HomeMy WebLinkAbout20212718.tiffRESOLUTION
RE: APPROVE OPERATIONAL PLAN DOCUMENTS FOR DENTAL REIMBURSEMENT
PLAN AND VISION CARE REIMBURSEMENT PLAN
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 Operational Plan Documents for the
Dental Reimbursement Plan and the Vision Care Reimbursement Plan for the County of Weld,
State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf
of the Department of Human Resources, commencing September 20, 2021, with further terms
and conditions being as stated in said plans, and
WHEREAS, after review, the Board deems it advisable to approve said plans, a copies of
which are attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County, Colorado, that the Operational Plan Documents the for Dental Reimbursement Plan
and the Vision Care Reimbursement Plan for the County of Weld, State of Colorado, by and
through the Board of County Commissioners of Weld County, on behalf of the Department of
Human Resources, be, and hereby is, approved.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 20th day of September, A.D., 2021.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST: dettA4/O�s....effo:ok.
Weld County Clerk to the Board
BY:
Deputy Clerk to the Boar
APPROVED A
Moren
Chair
Stev
4
Scames, Pro-Te
retryL.. Buy
(fly. ...
ike Freeman
County orney
Date of signature: 10/14
on Saine
CC:NR(yR/sDF/DS)
talS/2l
2021-2718
PE0033
BOARD OF COUNTY COMMISSIONERS
PASS -AROUND REVIEW
PASS -AROUND TITLE: County Dental & Vision Operational Plan Documents
DEPARTMENT: Human Resources DATE: 8/24/21
PERSON REQUESTING: Patti Russell
Brief description of the problem/issue:
Our County Vision and Dental Operational plans had not been updated for many years. Accordingly, HR,
Accounting, Ryan Rose, Don Warden and an outside legal team updated these plans, ensured that they were
in compliance with all applicable laws. We also worked with our Broker, Shirazi & Associates as well.
The attached documents are the final version of the update for these employee benefits.
What options exist for the Board? (include consequences, impacts, costs, etc. of options):
1. Approve the changes and updates made by the teams mentioned above. These cleaned up versions
updated the plans to what our practices are and should be.
2. Don't approve — we would need to go back and start over.
Recommendation:
Staff recommends approving the authorization.
Approve
Recommendation
Perry L. Buck
Mike Freeman
Scott K. James, Pro -Tern
Steve Moreno, Chair
Lori Saine
Schedule
Work Session Other/Comments:
2021-2718
0912U ZU 0033
WELD COUNTY
DENTAL REIMBURSEMENT PLAN
OPERATIONAL PLAN DOCUMENT
Amended and Restated Effective September 20, 2021
TABLE OF CONTENTS
DENTAL REIMBURSEMENT PROGRAM
SUMMARY OF REIMBURSEMENTS
DEFINITIONS
ELIGIBILITY AND EFFECTIVE DATES
COORDINATION OF BENEFITS
DENTAL EXPENSE BENEFIT REIMBURSEMENTS
DENTAL LIMITATIONS
HOW TO FILE A CLAIM
PAYMENTS
CLAIMS PAYMENTS MADE IN ERROR
RECOVERY AND SUBROGATION
TIMELY SUBMISSION OF CLAIMS
FACILITY OF PAYMENT
APPEL OF CLAIM DENIAL
LEGAL ACTIONS
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DENTAL REIMBURSEMENT PLAN
Weld County agrees to provide for employees during continuance of this Dental Care
Reimbursement Plan (hereinafter referred to as the "Plan"), the benefits hereinafter described,
in the event they and/or their eligible dependent(s) incur dental expenses covered by this Plan.
The Plan is subject to all the terms, provisions and conditions recited on following pages hereof.
Weld County originally caused this Plan to take effect as of 12:01 A.M., Mountain Time, on
January 1, 1991, at Greeley, Colorado, and has amended and restated the Plan effective as of
12:01 A.M. Mountain Time, on September 20, 2021, at Greeley Colorado.
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SUMMARY OF DENTAL REIMBURSEMENTS
FOR ACTIVE EMPLOYEES AND DEPENDENTS
WELD COUNTY
Maximum Reimbursement
Annual $1,000 per Covered Person and/or family per
Calendar Year.
Deductible Not applicable
Reimbursement
Class I
Preventative
Class II
Restorative/Endodontic/
Prosthodontic
100% of Covered Expenses Incurred once per
calendar year
50% of Covered Expenses Incurred for second
prophylaxis and oral exam during calendar
year.
50% of Covered Expenses Incurred.
Reimbursement under this Plan will be made only after the Covered Person has paid the bill in
full. The reimbursement will be calculated based on the amount paid for services regardless of
any discounts provided by the dental provider.
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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 provide coverage under any benefit
unless specifically provided.
GENERAL DEFINITIONS
Amendment means a formal document changing the provisions of the Plan and signed by
the representatives of Weld County. Amendments apply to all Covered Persons, including
those persons who are covered before the amendment becomes effective, unless
otherwise specified.
Calendar/Plan Year means the twelve (12) month period beginning on each January 1st
and ending on the following December 31st.
Common -Law Marriage means a marriage recognized under applicable state law but for
which the individuals who are recognized as married have not obtained a marriage license
and they have not had a formal marriage ceremony. Only a small number of states
recognize common law marriage. For an employee of Weld County to be eligible for
dependent medical coverage, the common-law marriage must be recognized by the state
in which the employee resides.
Employer means Weld County.
Medicare means Title XVIII of the United States Social Security Act as amended.
Plan means the benefits and provisions as described herein for payment.
Plan Administrator means Weld County Human Resources and Accounting Department.
Subrogation means the transfer of one's liabilities for another's; in this case the temporary
assumption of the claimant's liabilities by the Plan prior to repayment by the party of
primary liability. This Plan contains a subrogation clause and the claimant is obligated to
obtain any monies available from third parties to reduce the Plan's claim losses.
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DENTAL DEFINITIONS
Covered Expense means only those Usual, Customary, and Reasonable charges made
for Medical Care and supplies which most Physicians would consider to be necessary for
treatment of an Injury or Illness which are not reimbursed in any other manner.
Dentally Necessary means any service or supply for treatment or diagnosis of dental
disease or Injury which is ordered by the attending Dentist and consistent with the Injury
or disease of the Covered Person.
Diagnostic Charges means the actual cost charged for X-ray or laboratory examinations
of the Covered Person or his/her dependent which are made or recommended by a Dentist
for diagnostic purposes.
Expense Incurred means only the fees and prices regularly and customarily charged for
the dental services and supplies generally furnished for cases of comparable nature and
severity in the particular geographical area concerned. Any agreement as to fees or
charges made between the individual and the Dentist 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
or except that such charge will be deemed incurred:
a. with respect to fixed bridgework, crowns, inlays, on lays or gold restorations, on
the first date of preparation of the tooth or teeth involved,
b. with respect to full or partial dentures, on the date the impression was taken, and
c. with respect to endodontics, on the date the tooth was opened for root canal
therapy.
Injury means a condition which results independently of Illness and all other causes,
and is a result of an externally violent force.
Medical Care means the amount paid for the diagnosis, cure, mitigation, treatment or
prevention of a disease, including the amounts paid for Medicines and Drugs, and such
other expenses as meet the requirements of Section 213(d) of the code and the
Regulations thereunder, or any other guidance by the U.S. Department of Treasury paid
exclusively for certain dental care expenses as set forth in the "Covered Dental Expense"
section of this Plan.
Medicines and Drugs means only drugs or biologicals which are legally procured, which
are generally accepted as falling within the category of medicines and drugs, and which
require the prescription of a physician for their use by an individual or over-the-counter
medicines or drugs considered expenditure for medical care in Rev. Ruling 2003-102, or
any subsequent guidance.
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Usual, Customary and Reasonable means the following:
a. The Usual charge is the most consistent charge by a Physician or provider 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.
c. A charge is Reasonable when it meets the customary criterion as determined by the
American Dental Association; or it may be Reasonable if, upon review, it merits special
consideration based on the nature and extent of treatment of the particular case.
Note: Colorado Department of Health Care Policy and Financing shall be the basis for
claim reimbursement at "Usual, Customary and Reasonable" levels, where the procedure
is performed.
PROVIDER DEFINITIONS
Hospital means only an institution constituted and operated pursuant to law, engaged in
providing on an out -patient basis at the patient' s expense, diagnostic and therapeutic
facilities for the surgical and medical diagnosis, treatment and care of injured and sick
individuals, by or under the supervision of a licensed Physician; and providing 24 -hour -a -
day services by registered nurses. The term "Hospital " shall not include an institutional
part thereof, which is other than incidentally a place for rest, a place for the aged, or a
place for drug addicts. However, an institution specializing in the care and treatment of
mentally ill patients which would qualify under this definition as a Hospital , except solely
for the fact that it lacks organized facilities on its premises for major surgery, shall
nevertheless be deemed a Hospital under the Plan with respect to room and board
charges only.
Physician means a person acting within the scope of his/her license and holding the
degree of Doctor of Dental Surgery (D. D.S.), or Doctor of Medical Dentistry (D.M.D.), who
is legally entitled to practice dentistry in all its branches under the laws of Colorado, or
under the laws of the State or jurisdiction where the services are rendered. For the
purposes of this policy, the term Physician shall also include a Doctor of Medicine (M.D.)
or Doctor of Osteopathy (D.O.) who is licensed to perform the particular dental service
rendered.
PARTICIPATION DEFINITIONS
Active Service means 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 workdays only if the employee was performing in the customary
manner all of the regular employment duties on the preceding scheduled workday.
Contribution means the amount payable by the Employer or the amount payable by the
Employer/employee jointly for participation in the benefits of the Plan.
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Covered Dependents means 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 twenty-six (26). The term "children" shall include natural
children, adopted children, foster children, grandchildren and stepchildren 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 dependent coverage for eligible
children, but not both.
Covered Dependent shall also include a dependent child after age twenty-six provided the
child is (1) incapable of self-sustaining employment by reason of mental or physical
handicap.
Proof of such incapacity must be furnished to the Plan Administrator by the Covered
Person within the thirty-one (31) days prior to the child's twenty-six (26) birthday. The
Plan Administrator may require, at reasonable intervals, subsequent proof of the child's
disability.
Covered Employee means a regular full-time or part-time employee of Weld County who
is working an average of twenty (20) hours per week and eligible for health plan benefits.
Covered Person means a Covered Employee or a Covered Dependent.
ELIGIBILITY AND EFFECTIVE DATES
Eligibility
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, 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 Plan Administrator.
d. An open -enrollment period will be scheduled in the fall 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 described herein, otherwise his/her
effective date will be deferred until return to Active Service.
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Loss of Benefits
Except in the case of certain health care continuation rights under federal law, a Covered
Person's coverage shall automatically terminate on the earliest of the following dates:
a. The end of the month during which the Covered Person ceases to be a member
of the classes of persons eligible for coverage.
b. The end of the month following the last premium deduction taken from Covered
Person's pay.
c. The date the Plan terminates.
Enrollment
Coverage for new Covered Employees and their Covered Dependents shall begin on the
first day of the month following the first full month's pay period after their date of hire. For
existing employees, the Employer will have an open enrollment will be conducted annually
during the Fall.
Late Entrants — For 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, coverage will begin on the date of approval by the Plan
Administrator.
Note: If an eligible employee and/or dependent loses coverage under another group
sponsored Plan or Program, he/she may be covered under this Plan if application for such
coverage is made within thirty-one (31) days of the loss of the prior coverage.
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.
Uniformed Services Reemployment Rights
A Covered Employee's right to continued participation in a group health plan during leaves
of absence for active military duty is protected by the Uniformed Services Employment
and Reemployment Rights Act (USERRA). Accordingly, if a Covered Employee is absent
from work due to a period of active duty in the military for less than thirty-one (31) days,
his or her plan participation will not be interrupted. If the absence is for more than thirty
(30) days and not more than twelve (12) weeks, he or she may continue to maintain their
coverage under the Plan by paying premiums in the manner specified by the Employer.
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If the Covered Employee does not elect to continue to participate in the Plan during an
absence for military duty that is more than thirty (30) days, or if he or she revokes a prior
election to continue to participate for up to twelve (12) weeks after his or her military leave
began, the Covered Employee and his or her Covered Dependents will have the
opportunity to elect continuation coverage under this Plan for up to the twenty-four (24) -
month period that begins on the first day of his or her leave of absence. Covered
Employees must pay the premiums for continuation coverage with after-tax funds, subject
to the rules that are set out the Plan.
USERRA continuation coverage is considered alternative coverage for purposes of
COBRA. Therefore, if the Covered Person elects USERRA continuation coverage,
COBRA coverage will generally not be available.
Leave under Family Medical Leave Act or Similar Law
If a Covered Employee takes a leave of absence (i) for his or her own serious health
condition, (ii) to care for family members with a serious health condition, (iii) to care for a
newborn or adopted child, (iv) to care for an injured or ill covered service member of the
Armed Forces, (v) due to a qualifying exigency arising out of a covered service member's
active duty, or (vi) pursuant to any applicable law or regulation providing for similar leave
as a result of a national or public health emergency, the Covered Employee may be able
to continue his or her health coverage under the Plan. If you the Covered Employee drops
health coverage during the leave, he or she can also have health coverage reinstated on
the date he or she returns to work assuming the Covered Employee pays any contributions
required for the coverage.
COORDINATION OF BENEFITS:
If any individual covered under this Plan is also Covered under other plans, the benefits
payable under this Plan will be coordinated with benefits payable under other plans,
subject to plan maximums and limitations stated in the Summary of Dental
Reimbursements.
1. If there is another dental reimbursement plan in force through the spouse of a Covered
Employee, the Weld County Dental Reimbursement Plan will provide primary benefits
for the Covered Employee only. Secondary benefits will be provided for the Covered
Dependents.
2. If there is a dental insurance plan in force through the spouse of a Covered Employee,
the Weld County Dental Reimbursement Plan will provide secondary benefits for the
Covered Employee and Covered Dependents.
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DENTAL EXPENSE BENEFIT REIMBURSEMENTS FOR
ACTIVE EMPLOYEES AND COVERED DEPENDENTS
Coverage Provision
If a Covered Person incurs eligible dental expenses, the Plan will pay benefits at the
Copayment rate as specified in the Summary of Reimbursements for such expense
which is not covered by any other dental coverage, up to the Maximum Benefit as
specified in the Summary of Benefits.
Maximum Annual Benefits
The Maximum Benefit as shown in the Summary of Reimbursements is the maximum
amount of benefit reimbursement 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 dental coverage.
Covered Dental Expense
Covered dental expenses shall mean the following Dentally Necessary charges by a
Physician for the prevention of dental disease, treating injured or diseased teeth, and
the treatment of supporting bone or tissue, not to exceed the maximum specified in the
Summary of Reimbursements.
CLASS I SERVICES
Preventative
a. oral examination — one (1) - per Calendar Year
b. Prophylaxis - one (1) per Calendar Year.
c. Topical application of fluorides, including prophylaxis - one (1) per Calendar Year
d. Bitewings, as part of a routine exam - one (1) set per Calendar Year.
e. Single films, as part of a routine exam - (up to thirteen [13]).
f. Entire denture series, as part of a routine exam - fourteen [14] or more films (no more
than one (1) series in a twenty-four [24] consecutive month period).
g. Full -mouth x-ray as part of a routine exam.
h. Consultation with another Dentist.
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CLASS II SERVICES
a. Dental x-rays to diagnose a symptom
b. Space maintainers
c. Diagnostic tests or laboratory exams excluding any services for orthodontic procedures
d. Microscopic examination
e. Biopsy and examination of oral tissue
f. Emergency or palliative services
g. Extractions, other Oral Surgery, and related General Anesthesia not covered by the
Health Plan
h. Periodontics
i. Endodontics
j. Injectable antibiotic drugs when administered by the attending Dentist
k. Crowns, inlays, and overlays
I. Repair of crowns, inlays, on lays, bridgework, or dentures
m. Relining or rebasing dentures
n. Prosthodontics
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DENTAL LIMITATIONS
The Plan does not cover:
• dental care not included in the list of defined eligible expenses; or
• dental care, which is not customarily performed, or which is experimental in nature. By
experimental, we mean: the use of any Treatment, procedure, facility, equipment, drug, or
drug usage device or supply which we determine is not acceptable standard dental
Treatment of the condition being treated. Any such items requiring federal or other
governmental agency approval which was not granted at the time the services were
rendered will also be considered experimental. In making the determination as to whether
dental care is experimental, we will rely on the advice of the general dental community
including, but not limited to dental consultants and dental journals and/or regulations
• charges for oral hygiene instruction, a plaque control program, tobacco counseling,
dietary instruction, or other educational services
• charges for house or hospital calls for dental services and for hospitalization costs
(e.g. facility -use fees)
• charges for prescription and non-prescription drugs, vitamins, or dietary supplements
• charges for medical exams prior to oral surgery
• charges for procedures that are:
o part of a service but are reported as separate services;
o reported in a Treatment sequence that is not appropriate;
o or misreported or that represent a procedure other than the one reported
charges for Treatment that is not Dentally Necessary or not deemed to be within
generally accepted
• standards of dental Treatment. If no clear or generally accepted standards exist, or there
are varying positions within the professional community, the determination will be made
by us
• charges for completion of claim forms or failure to keep appointments
• charges for any of the following:
o dental care resulting from war or an act of war, or any involvement in any period
of any type of armed conflict (this does not include acts of terrorism);
o active participation in a war (declared or undeclared);
o active military duty;
o dental care resulting from any injury which is self-inflicted or not caused by an
accident;
o dental care resulting from active Participation in a Riot; Rebellion, or Insurrection;
o dental care resulting from the commission or attempted commission of an assault,
felony or other criminal act.
o dental care arising out of or in the course of employment for pay or profit or which
is covered by Workers' Compensation or a similar law, or for which the Insured is
entitled to payment under an automobile insurance policy. Benefits paid by us
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would be in excess to the third -party benefits and therefore, we would have the
right of recovery for any benefits paid in excess.
o Covered Dental Expenses Incurred while insurance is not in force under the Policy
• charges for incomplete Treatment (e.g. patient does not return to complete Treatment)
and charges for temporary services (e.g. temporary restorations).
• charges for care, Treatment, services, or supplies to the extent that any benefit is
provided by Medicare.
• charges which are not customarily made when there is no insurance, or charges for
which there is no legal obligation to pay.
• charges for Treatment performed outside the United States except for a Maximum
Benefit of $100 for emergency dental Treatment performed outside the United States.
• procedures which are elective.
• procedures that we determine are cosmetic in nature.
• replacement or repair of lost, stolen or damaged prosthetic or orthodontic appliances.
• specialized procedures and techniques (e.g. precision or semi -precision attachments,
copings, over dentures or customized prostheses or attachments).
• a fixed bridge that replaces the extracted portion of a hemisected tooth.
• duplicate dentures, prosthetic devices or any other duplicative device.
• charges for bridges, partial or full dentures, inlays, onlays, crowns, implant crowns and
other laboratory prepared restorations if they can, as determined by us, be satisfactorily
restored with an amalgam or composite filling.
• the initial placement of implants, bridges, or partial or full dentures to replace teeth
missing on the effective date of the Insured's coverage under the Policy, including
congenitally missing teeth except for Treatment for cleft lip and cleft palate for
Dependent Children. Benefits will be payable for Covered Dental Expenses for bridges,
or dentures if the prosthesis includes the initial replacement of a Functioning Natural
Tooth that is extracted by a Dentist while the Insured is covered under the Policy except
that the replacement of:
o an extracted tooth will not be considered a Covered Dental Expense if it was an
abutment to an existing prosthesis;
o those teeth extracted while an Insured is covered under the Policy will be
considered a Covered Dental Expense; and
o teeth missing on an Insured's effective date will not be considered a Covered
Dental Expense.
• Benefit reimbursements will be payable for Covered Dental Expenses for implants,
implant crowns, bridges, or partial or full dentures, to replace a tooth that was extracted
while the Insured was covered under the Prior Plan. Such extraction must have occurred
within the preceding 12 months and have been a covered expense under the Prior Plan.
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No reimbursements will be payable for any expenses that are payable under the Prior
Plan's extension of benefits provision.
• charges for replacement of bridges, partial or full dentures, inlays, onlays, crowns,
implant crowns and other laboratory prepared restorations if they can, as determined by
us, be satisfactorily repaired and restored to function.
• charges for pulp caps.
• charges for diagnostic casts.
• charges for Treatment of fractures and dislocations of the jaw.
• charges for Treatment of malignancies or neoplasms.
• charges for desensitizing medications.
• administration of nitrous oxide or other agent to control anxiety.
• charges for occlusal adjustments.
• charges for periodontal splinting of teeth by any method.
• charges for orthodontic Treatment except for Treatment for cleft lip and cleft palate for
Dependent Children.
• charges for retention of orthodontic relationships.
• charges for Treatment or appliances whose primary purpose is to: change or maintain
vertical dimension;
• alteration or restoration of occlusion, except for occlusal adjustment in conjunction with
periodontal surgery;
• bite registration, or bite analysis;
• treat attrition or abrasion.
• charges for diagnostic services and Treatment of jaw joint problems by any method.
Examples of these jaw joint problems are temporomandibular joint disorders or other
conditions of the joint linking the jawbone and the complex muscles, nerves and other
tissues related to the joint.
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HOW TO FILE A CLAIM
Electronic filing is encouraged. Form (electronic and paper) and instruction can be found on the
county intranet or internet via the following links:
https://my.weldgov.com/Employee-Resources/Accounting-and-Payroll
https://my.weldgov.com/Employee-Resources/Human-Resources/Benefits/Dental
Internet:https://www.weldgov.com/Government/Departments/Human-Resources/Employee-
Benefits#section-3
Copy of the bill with detail of services received and proof of payment must be attached.
All incomplete submissions will be returned.
Payment of claims: you will receive notification when claim is processed for payment.
Payment will be direct deposited to the primary bank account linked to the employee's payroll
deposit.
Paper claims can be routed to or left at the Accounting Department. If mailed submit to:
Weld County Accounting Department
PO Box 758
Greeley, CO 80632
PAYMENTS
Whenever payments which should have been made under this Plan in accordance with the
provisions of this Plan have been made under any other plans, the Plan 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 benefits
paid under this Plan; and to the extent of these payments, the Employer will be fully discharged
from liability under this Plan.
CLAIMS PAYMENTS MADE IN ERROR
If payments in excess of the correct amount due are made, the Plan may recover all excess
amounts paid. Recovery will be made by reducing or suspending future Plan payments, or by
requiring the Covered Person to pay back the overpayment in full, or in installments, until the
overpayment is recovered.
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RECOVERY AND SUBROGATION
Whenever payments have been made by the Plan Administrator in excess of the maximum
amount of payment necessary to Satisfy the intent of the Coordination of Benefit provisions, Plan
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 Plan of any Expense Incurred for Hospital , surgical,
medical, or dental services, and medical supplies for the benefit of a Covered Person or a Covered
Dependent, this Plan 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, pl an or other entity regarding the payment of such
Expense Incurred.
TIMELY SUBMISSION OF CLAIMS
Claims must be submitted within thirty (30) days of date service or last working day of January,
of the following year, by noon, whichever is earlier. Claims exceeding five hundred dollars ($500),
that will not be paid in full within thirty (30) days may be eligible for partial payment reimbursement.
Contact the Accounting Department within the thirty (30) days for details.
FACILITY OF PAYMENT
Whenever, in the Plan Administrator's opinion, a person entitled to receive any payment of a
benefit or installment thereof hereunder is under a legal disability or is incapacitated in any way
so as to be unable to manage the person's financial affairs, the Plan Administrator may direct the
Employer to make payments to such person or the person's legal representative or to a relative
or friend of such person for such person's benefit, or the Plan Administrator may direct the
Employer to apply the payment for the benefit of such person in such manner as the Administrator
considers advisable. Any payment of a benefit or installment thereof in accordance with the
provisions of this Section shall be a complete discharge of any liability for the making of such
payment under the provisions of the Plan.
APPEAL OF CLAIM DENIAL
If a Covered Employee has reason to believe a claim has not been settled properly, or a claim
has been improperly denied, the following process applies:
1. Contact the Controller in writing within thirty (30) days to ask for a second review. If the
result of this review is not satisfactory, then:
2. Request a review in writing from the CIO/Director of Administrative Services 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
Controller. You should include documents or records you wish for the CIO/Director of
Administrative Services to review along with your written request for review. 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 Plan Documents upon which this
declination is based. The decision of the CIO/Director of Administrative Services is final,
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conclusive, and binding. If the Covered Employee still believes the claim is improperly
denied per the Plan Documents, he/she has a legal right to take whatever appropriate
action he/she believes is necessary.
LEGAL ACTIONS
All claim review and appeal procedures discussed herein must be exhausted before any legal
action is brought. If, after you have exhausted the claim review and appeals procedures discussed
herein, you want to bring a legal action you must do so by the earlier of the date that is (i) three
(3) years year after the date you are notified of the final decision on your appeal; or (ii) the date
that is three (3) years from the date a cause of action accrued. A cause of action "accrues" when
you know or should know that the Employer has clearly denied or otherwise repudiated your claim.
If you do not bring a legal action within this time period, you lose any rights to bring such an action
against the Employer.
If you fail to file a request for review in accordance with the claim review procedures outlined in
this Plan, you shall have no right of review and shall have no right to bring action in any court.
The denial of the claim shall become final and binding on all persons for all purposes.
PLAN IS NOT AN EMPLOYMENT CONTRACT
The Plan will not be construed as a contract for or of employment.
AMENDMENT AND TERMINATION
This Plan is established with the intention of being maintained for an indefinite period of time.
However, the Employer reserves the right at any time and from time to time to terminate or amend
in whole or in part any or all of the provisions of this Plan. No such amendment or termination
shall operate or be construed so as to deny or abridge any Covered Employee's rights to benefits
accrued hereunder prior to the date requisite action is taken by the Employer with respect to said
amendment or termination.
RIGHT TO OFFSET FUTURE PAYMENTS
In the event a payment or the amount of a payment is made erroneously to an individual, the Plan
shall have the right to reduce future payments payable to or on behalf of such individual by the
amount of the erroneous or excess payment. This right to offset shall not limit the right of the
Plan to recover an erroneous or excess payment in any other or correction methods permitted
under applicable IRS guidance.
RIGHT TO RECOVER PAYMENTS
Whenever a payment has been made by the Plan, including erroneous payments, in a total
amount in excess of the amount payable under the Plan, irrespective of to whom paid, the Plan
shall have the right to recover such payments, to the extent of the excess, from the person to or
for whom the payment was made using any method permitted under applicable IRS guidance.
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MISREPRESENTATION OR FRAUD
A Covered Employee who receives Benefits under the Plan on behalf of him/herself and/or any
other person as a result of false, incomplete, or incorrect information or a misleading or fraudulent
representation may be required to repay all amounts paid by the Plan with respect to such
individual(s) and may be liable for all costs of collection, including attorney's fees and court costs,
to the extent permitted by law. The Plan Administrator shall decide such matters on a case -by -
case basis.
DISCRIMINATION
Nothing herein contained shall be deemed to allow the Employer or the Administrator to treat any
Covered Employee under the Plan differently than any other similarly -situated Covered Employee
under the Plan in similar circumstances, it being the intention that this Plan shall be administered
uniformly with respect to all Covered Employees.
The effective date of this Amended and Restated Plan Document is September 20, 2021.
IT IS AGREED BY WELD COUNTY that the provisions contained in this Plans Operational
Document are acceptable and will be the basis for the administration of said Employer 's
Employee Benefit Plan described herein.
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WELD COUNTY
VISION CARE REIMBURSEMENT PLAN
OPERATIONAL PLAN DOCUMENT
Amended and Restated Effective September 20, 2021
TABLE OF CONTENTS
VISION CARE REIMBURSEMENT PLAN
SUMMARY OF VISION CARE BENEFIT REIMBURSEMENTS
DEFINITIONS
ELIGIBILITY AND EFFECTIVE DATES
COORDINATION OF BENEFITS
VISION CARE EXPENSE REIMBURSEMENTS
GENERAL LIMITATIONS
HOW TO FILE A CLAIM
PAYMENTS
CLAIMS PAYMENTS MADE IN ERROR
RECOVERY AND SUBROGATION
TIMELY SUBMISSION OF CLAIMS
FACILITY OF PAYMENT
APPEAL OF CLAIM DENIAL
LEGAL ACTIONS
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VISION CARE REIMBURSEMENT PLAN
Weld County agrees to provide for employees during continuance of this Vision Care
Reimbursement Plan (hereinafter referred to as the "Plan"), the benefits hereinafter described,
in the event they and/or their eligible dependent(s) incur vision care expenses covered by this
Plan.
The Plan is subject to all the terms, provisions and conditions recited on following pages hereof.
Weld County originally caused this Plan to take effect as of 12:01 A.M., Mountain Time, on
January 1, 1986, at Greeley, Colorado, and has amended and restated the Plan effective as of
12:01 A.M., Mountain Time, on September 20, 2021, at Greeley Colorado.
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SUMMARY OF VISION CARE BENEFIT REIMBURSEMENTS
FOR ACTIVE EMPLOYEES AND DEPENDENTS
WELD COUNTY
Maximum Reimbursement $300 per Covered Person per Calendar Year.
$600 per family, combined members, per
Calendar Year.
Deductible Not applicable
50% of Covered Expenses Incurred.
Reimbursement under this Plan will be made only after the Covered Person has paid the bill in
full. The reimbursement will be calculated based on the amount paid for services regardless of
any discounts.
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DEFINITIONS
Terms as used herein shall be deemed to define terms that may be used in the wording of the
Operational Plan Document. These definitions shall not be construed to provide coverage under
any benefit unless specifically provided.
GENERAL DEFINITIONS
Amendment means a formal document changing the provisions of the Plan and signed
by the representatives of Weld County. Amendments apply to all Covered Persons,
including those persons who are covered before the amendment becomes effective,
unless otherwise specified.
Calendar/Plan Year means the twelve (12) month period beginning on each January 1st
and ending on the following December 31st.
Common -Law Marriage means a marriage recognized under applicable state law but for
which the individuals who are recognized as married have not obtained a marriage
license and they have not had a formal marriage ceremony. Only a small number of
states recognize common law marriage. In order for an employee of Weld County to be
eligible for dependent coverage, the common-law marriage must be recognized by the
state in which the employee resides.
Employer means Weld County.
Medicare means Title XVIII of the United States Social Security Act, as amended.
Plan means the benefits and provisions as described herein for payment.
Plan Administrator means Weld County Human Resources and Accounting Department.
Subrogation means the transfer of one's liabilities for another's; in this case the
temporary assumption of the claimant's liabilities by the Plan prior to repayment by the
party of primary liability. This Plan contains a subrogation clause and the claimant is
obligated to obtain any monies available from third parties to reduce the Plan's claim
losses.
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VISION DEFINITIONS
Covered Expense means only those Usual, Customary, and Reasonable charges made
for Medical Care and supplies which most Physicians would consider to be necessary
for treatment of a refractive error and are prescribed by the attending Physician which
are not reimbursed in any other manner.
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 concerned. 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 complications therefrom, except that if
the dependent recovers for a period of three months and throughout such period is
capable of resuming the normal activities 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.
Medical Care means the amount paid for the diagnosis, cure, mitigation, treatment or
prevention of a disease, including the amounts paid for Medicines and Drugs, and such
other expenses as meet the requirements of Section 213(d) of the code and the
Regulations thereunder, or any other guidance by the U.S. Department of Treasury paid
exclusively for certain vision care expenses as set forth in the "Covered Vision Expense"
section of this Plan .
Medicines and Drugs shall mean only drugs or biologicals which are legally procured,
which are generally accepted as falling within the category of medicines and drugs, and
which require the prescription of a physician for their use by an individual or over-the-
counter medicines or drugs considered expenditure for medical care in Rev. Ruling
2003-102, or any subsequent guidance.
Total Disability means that the Covered Employee is prevented, solely because of a
non -occupational Injury or non -occupational disease, from engaging in his or her 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.
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Usual, Customary and Reasonable means the following:
a. The Usual charge is the most consistent charge by a Physician or provider 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.
c. A charge is Reasonable when it meets the customary criterion 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 means 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
workdays only if the employee was performing in the customary manner all of the regular
employment duties on the preceding scheduled workday.
Contribution means the amount payable by the Employer or the amount payable by the
Employer/employee jointly for participation in the benefits of the Plan.
Covered Dependent(s) means the spouse of a Covered Employee and/or a Covered
Employee's child who is under the age of twenty-six (26) who is/are eligible as provided
herein and enrolled in the Plan by a Covered Employee. The term "children" shall include
natural children, adopted children, foster children, grandchildren 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 dependent coverage for eligible
children, but not both.
Covered Dependent shall also include a dependent child after age twenty-six (26)
provided the child is incapable of self-sustaining employment by reason of mental or
physical handicap.
Proof of such incapacity must be furnished to the Program Administrator by the Covered
Person within the thirty-one (31) days prior to the child' s twenty-six (26) birthday. The
Plan Administrator may require, at reasonable intervals, subsequent proof of the child's
disability.
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Covered Employee means a regular full-time or part-time employee of Weld County who
is working an average of twenty (20) hours per week, is eligible for health benefits, and
has enrolled in the Plan.
Covered Person means a Covered Employee or a Covered Dependent.
ELIGIBILITY AND EFFECTIVE DATES
Eligibility
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. 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, the
coverage will begin on the date of approval of the Plan Administrator.
d. An open -enrollment period will be scheduled in the fall 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 described herein, otherwise his/her
effective date will be deferred until return to Active Service.
Loss of Benefits
Except in the case of certain health care continuation rights under federal law, a Covered Person's
coverage shall automatically terminate on the earliest of the following dates:
a. The end of the month during which the Covered Person ceases to be a member
of the classes of persons eligible for coverage.
b. The end of the month following the last premium deduction taken from Covered
Person's pay.
c. The date the Plan terminates.
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Enrollment
Coverage for new Covered Employees and their Covered Dependents shall begin on the
first day of the month following the first full month's pay period after their date of hire. For
existing employees, the Employer will have an open enrollment will be conducted annually
during the Fall.
Late Entrants — For 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, coverage will begin on the date of approval by the Plan
Administrator.
Note: If an eligible employee and/or dependent loses coverage under another group
sponsored Plan or Program, he/she may be covered under this Plan, if application for such
coverage is made within thirty-one (31) days of the loss of the prior coverage.
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.
Uniformed Services Reemployment Rights
A Covered Employee's right to continued participation in a group health plan during leaves
of absence for active military duty is protected by the Uniformed Services Employment
and Reemployment Rights Act (USERRA). Accordingly, if a Covered Employee is absent
from work due to a period of active duty in the military for less than thirty-one (31) days,
his or her plan participation will not be interrupted. If the absence is for more than thirty
(30) days and not more than twelve (12) weeks, he or she may continue to maintain their
coverage under the Plan by paying premiums in the manner specified by the Employer.
If the Covered Employee does not elect to continue to participate in the Plan during an
absence for military duty that is more than thirty (30) days, or if he or she revokes a prior
election to continue to participate for up to twelve (12) weeks after his or her military leave
began, the Covered Employee and his or her Covered Dependents will have the
opportunity to elect continuation coverage under this Plan for up to the twenty-four (24) -
month period that begins on the first day of his or her leave of absence. Covered
Employees must pay the premiums for continuation coverage with after-tax funds, subject
to the rules that are set out the Plan.
USERRA continuation coverage is considered alternative coverage for purposes of
COBRA. Therefore, if the Covered Person elects USERRA continuation coverage,
COBRA coverage will generally not be available.
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Leave under Family Medical Leave Act or Similar Law
If a Covered Employee takes a leave of absence (i) for his or her own serious health
condition, (ii) to care for family members with a serious health condition, (iii) to care for a
newborn or adopted child, (iv) to care for an injured or ill covered service member of the
Armed Forces, (v) due to a qualifying exigency arising out of a covered service member's
active duty, or (vi) pursuant to any applicable law or regulation providing for similar leave
as a result of a national or public health emergency, the Covered Employee may be able
to continue his or her health coverage under the Plan. If you the Covered Employee drops
health coverage during the leave, he or she can also have health coverage reinstated on
the date he or she returns to work assuming the Covered Employee pays any contributions
required for the coverage.
COORDINATION OF BENEFITS:
If any individual covered under this Plan is also Covered under other plans, the benefits
payable under this Plan will be coordinated with benefits payable under other plans,
subject to plan maximums and limitations stated in the Summary of Vision Benefits
Reimbursements.
1. If there is another vision reimbursement plan in force through the spouse of a Covered
Employee, the Weld County Vision Reimbursement Program will provide primary
benefits for the Covered Employee only. Secondary benefits will be provided for the
Covered Dependents.
2. If there is a vision insurance plan in force through the spouse of a Covered Employee,
the Weld County Vision Reimbursement Program will provide secondary benefits for
the Covered Employee and Covered Dependents.
VISION CARE EXPENSE BENEFIT REIMBURSEMENTS
ACTIVE EMPLOYEES AND COVERED DEPENDENTS
Coverage Provision
If a Covered Person incurs eligible vision care expenses, the Plan will pay benefits at the
Copayment rate as specified in the Summary of Benefit Reimbursements 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 Benefit Reimbursements.
Maximum Annual Benefits
The Maximum Benefit as shown in the Summary of Benefit Reimbursement is the
maximum amount of reimbursements available for any covered family during a Calendar
Year, whether or not there has been an interruption in coverage.
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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 maximum specified in the
Summary of Benefit Reimbursements, and limited to one each per year:
1. Examination, including refraction, and contact fittings.
2. Prescription lenses, including single vision, bifocal, trifocal, and contacts one set per
year, or a 12 -month supply of disposable contacts one time per year.
3. Frames one set a year for prescription lenses
4. Photo gray lenses in prescription glasses
5. Prescription sunglasses
6. Prescription safety glasses
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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 individual 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. charges a Covered Person would not be required to pay if there were no Plan benefits; or
8. charges for broken appointments; or
9. expenses for services which were not recommended or prescribed by a Physician; or
10. any Expense Incurred as a result of an act of war, whether declared or undeclared; or
11. any expense that is covered by another vision or health plan; or
12. any expense that is covered under the Weld County Health Plan; or
13. any expenses for duplicate eyewear; or
14. any expense in connection with surgical treatment of refractive errors; or
15. sunglasses, plain or
16. any expense for provider provided benefits for discounted service rates
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The Plan does not cover (continued):
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.
19. any charges for prescription and non-prescription drugs, vitamins or dietary supplements
20. any accessories purchased for glasses/contacts
HOW TO FILE A CLAIM
Electronic filing is encouraged. Form (electronic and paper) and instruction can be found on the
county intranet or internet via the following links:
https://my.weldgov.com/Employee-Resources/Accountinq-and-Payroll
https://my.weldgov.com/Employee-Resources/Human-Resources/BenefitsNision
Internet:https://www.weldgov.com/Government/Departments/Human-Resources/Employee-
Benefits#section-4
Copy of the bill with detail of services received and proof of payment must be attached.
All incomplete submissions will be returned.
Payment of claims: you will receive notification when claim is processed for payment.
Payment will be direct deposited to the employee's primary bank account linked to their payroll
deposit.
Paper claims can be routed to or left at the Accounting Department. If mailed submit to:
Weld County Accounting Department
PO Box 758
Greeley, CO 80632
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PAYMENTS
Whenever payments which should have been made under this Plan in accordance with the
provisions of this Plan have been made under any other plans, the Plan 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 benefits
paid under this Plan; and to the extent of these payments, the Employer will be fully discharged
from liability under this Plan.
CLAIMS PAYMENTS MADE IN ERROR
If payments in excess of the correct amount due are made, the Plan may recover all excess
amounts paid. Recovery will be made by reducing or suspending future Plan payments, or by
requiring the Covered Person to pay back the overpayment in full, or in installments, until the
overpayment is recovered.
RECOVERY AND SUBROGATION
Whenever payments have been made by the Plan Administrator in excess of the maximum
amount of payment necessary to satisfy the intent of the Coordination of Benefit provisions, the
Plan 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 Plan 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, power's, 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.
TIMELY SUBMISSION OF CLAIMS
Claims must be submitted within 30 days of service date or last working day of January the
following year, by noon, whichever is earlier.
FACILITY OF PAYMENT
Whenever, in the Plan Administrator's opinion, a person entitled to receive any payment of a
benefit or installment thereof hereunder is under a legal disability or is incapacitated in any way
so as to be unable to manage the person's financial affairs, the Administrator may direct the
Employer to make payments to such person or the person's legal representative or to a relative
or friend of such person for such person's benefit, or the Administrator may direct the Employer
to apply the payment for the benefit of such person in such manner as the Administrator
considers advisable. Any payment of a benefit or installment thereof in accordance with the
provisions of this Section shall be a complete discharge of any liability for the making of such
payment under the provisions of the Plan
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APPEAL OF CLAIM DENIAL
If a Covered Employee has reason to believe a claim has not been settled properly, or a claim
has been improperly denied, the following process applies:
1. Contact the Controller in writing within (30) days to ask for a second review. If the result
of this review is not satisfactory, then:
2. Request a review, in writing, from the CIO/Director of Administrative Services 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
Controller. You should include documents or records you wish for the CIO/Director of
Administrative Services to review along with your written request for review. 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 Plan Documents
upon which this declination is based. The decision of the CIO/Director of Administrative
Services is final, conclusive, and binding. If the Covered Employee still believes the
claim is improperly denied per the Plan Documents, he/she has a legal right to take
whatever appropriate action he/she believes is necessary.
LEGAL ACTIONS
All claim review and appeal procedures discussed herein must be exhausted before any legal
action is brought. If, after you have exhausted the claim review and appeals procedures discussed
herein, you want to bring a legal action you must do so by the earlier of the date that is (i) three
(3) years year after the date you are notified of the final decision on your appeal; or (ii) the date
that is three (3) years from the date a cause of action accrued. A cause of action "accrues" when
you know or should know that the Employer has clearly denied or otherwise repudiated your claim.
If you do not bring a legal action within this time period, you lose any rights to bring such an action
against the Employer.
If you fail to file a request for review in accordance with the claim review procedures outlined in
this Plan, you shall have no right of review and shall have no right to bring action in any court.
The denial of the claim shall become final and binding on all persons for all purposes.
PLAN IS NOT AN EMPLOYMENT CONTRACT
The Plan will not be construed as a contract for or of employment.
AMENDMENT AND TERMINATION
This Plan is established with the intention of being maintained for an indefinite period of time.
However, the Employer reserves the right at any time and from time to time to terminate or amend
in whole or in part any or all of the provisions of this Plan. No such amendment or termination
shall operate or be construed so as to deny or abridge any Covered Employee's rights to benefits
accrued hereunder prior to the date requisite action is taken by the Employer with respect to said
amendment or termination.
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RIGHT TO OFFSET FUTURE PAYMENTS
In the event a payment or the amount of a payment is made erroneously to an individual, the Plan
shall have the right to reduce future payments payable to or on behalf of such individual by the
amount of the erroneous or excess payment. This right to offset shall not limit the right of the
Plan to recover an erroneous or excess payment in any other or correction methods permitted
under applicable IRS guidance.
RIGHT TO RECOVER PAYMENTS
Whenever a payment has been made by the Plan, including erroneous payments, in a total
amount in excess of the amount payable under the Plan, irrespective of to whom paid, the Plan
shall have the right to recover such payments, to the extent of the excess, from the person to or
for whom the payment was made using any method permitted under applicable IRS guidance.
MISREPRESENTATION OR FRAUD
A Covered Employee who receives Benefits under the Plan on behalf of him/herself and/or any
other person as a result of false, incomplete, or incorrect information or a misleading or fraudulent
representation may be required to repay all amounts paid by the Plan with respect to such
individual(s) and may be liable for all costs of collection, including attorney's fees and court costs,
to the extent permitted by law. The Plan Administrator shall decide such matters on a case -by -
case basis.
DISCRIMINATION
Nothing herein contained shall be deemed to allow the Employer or the Administrator to treat any
Covered Employee under the Plan differently than any other similarly -situated Covered Employee
under the Plan in similar circumstances, it being the intention that this Plan shall be administered
uniformly with respect to all Covered Employees.
The effective date of this Amended and Restated Plan Document is September 20, 2021.
IT IS AGREED BY WELD COUNTY that the provisions contained in this Plans Operational
Document are acceptable and will be the basis for the administration of said Employer's
Employee Benefit Plan described herein.
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