2000-1032-Resolution No. 2000-086 Recorded 12/13/2000VOL: CJ2000 PAGE: 1032
RECORDED DOCUMENT
STATE OF OREGON
COUNTY OF DESCHUTES
*02000-1032 * Vol -Page Printed: 12/13/2000 15:29:40
DO NOT REMOVE THIS CERTIFICATE
(This certificate constitutes a part of the original instrument in accordance with
ORS 205.180(2). Removal of this certificate may invalidate this certificate and affect
the admissibility of the original instrument into evidence in any legal proceeding.)
I hereby certify that the attached instrument was received
and duly recorded in Deschutes County records:
DATE AND TIME:
DOCUMENT TYPE:
Dec. 13, 2000; 1:06 p.m.
Resolution (CJ)
NUMBER OF PAGES: 64
MARY SUE PENHOLLOW
DESCHUTES COUNTY CLERK
KEYp�4U�NCpHED
[IEC 2000
6. 3,? I�_�j
"
EGTA-TOUNSEL
BEFORE THE BOARD OF COUNTY COMMISSIONERS FOR DESCHUTES COUN O(/, OREGON
A Resolution Adopting Deschutes County's Self-
00 OEC 13 Pi 1: 01
Insured Plan Document and Summary Plan Descrip-* o 1 "M! t t' ; L %
tion for Deschutes County for Medical, Dental, * GOUN1 Y CLE f�i
and Vision Benefits under Its Self -Insured Plan.
RESOLUTION NO. 2000-086
WHEREAS, the Board of County Commissioners of Deschutes County, Oregon developed a
program to provide a self-insured health plan in accordance with ORS 731.036; and
WHEREAS, the program was implemented with an effective date of August 1, 2000; and
WHEREAS, it is necessary for the Board of County Commissioners to adopt the Plan Document
and Summary Plan Description for Deschutes County; now, therefore,
BE IT RESOLVED BY THE BOARD OF COUNTY OF COMMISSIONERS OF DESCHUTES
COUNTY, OREGON as follows:
Section 1. That the Plan Document and Summary Plan Description for Deschutes County marked
Exhibit "A," attached hereto and by this reference incorporated herein, is hereby adopted as its health
insurance program pursuant to ORS 731.036.
Section 2. That the effective date of the Plan Document and Summary Plan Description for
Deschutes County adopted in Section 1 of this Resolution shall be effective August 1, 2000.
DATED this 6th Day of December 2000, nunc pro tunc as of August 1, 2000.
ATTEST:
Recording Secretary
THE BOARD OF COUNTY COMMISSIONERS
FOR DUCHUTES COI;�4TX, OREGON
A
DENNIS R.
TOM DEWOLF, Commissioner
RESOLUTION NO. 2000-086 (12/6/2000)
SALegal\BOCC Resolutions\2000\Reso 2000-086 - Self insured - Plan Document adoption.doc
PLAN DOCUMENT AND
SUMMARY PLAN:
DESCRIPTION FOR
DESCHUTES COUNTY
Effective
August 112000
Exhibit A
Eli
1�
INTRODUCTION
DESCHUTES COUNTY
EMPLOYEE BENEFIT PLAN
Welcome to the Employee Benefit Plan of Deschutes County. This health care Plan is designed to provide
comprehensive Medical, Dental and Vision coverage for our eligible active and retired employees and their
covered dependents. At the same time, the Plan has also been designed to encourage the careful use of
health care services.
This Plan Document was designed to assist you in understanding what benefits are available. Some terms
are defined in the Definition of Terms section beginning on page 28 of this document. Please take the time to
review this document carefully and become familiar with the benefits the Plan offers.
This Plan is administered by Administrators West. If you have questions regarding your coverage or
eligibility, we encourage you to contact Administrators West using the phone numbers shown below and a
representative will assist you.
Administrators West may be contacted at:
Administrators West
612 NE Savannah Drive, Suite 4
Bend, OR 97701
Phone: (800) 894-9221 Toll -Free
(541) 312-9144 in Bend
Fax: (541) 312-9149
Deschutes County Employee Benefit Plan
Table of Contents
Pre -Admission Notification ...................................................................................................................... 1
EmergencyMedical Condition .................................................................................................................
I
LargeCase Management ..........................................................................................................................
2
ClaimSubmission .....................................................................................................................................
2
Grievancesand Appeals ..........................................................................................................................
4
Summaryof Medical Benefits ..................................................................................................................
5
Summaryof Prescription Benefits ..........................................................................................................
8
Summaryof Dental Benefits ....................................................................................................................
9
Summaryof Vision Benefits ..................................................................................................................
10
Vision Plan Limitations and Exclusions ...............................................................................................
10
Descriptionof Medical Benefits ............................................................................................................
I I
Medical Plan Limitations and Exclusions ............................................................................................
19
Description of Prescription Benefits .....................................................................................................
23
Prescription Plan Limitations and Exclusions .....................................................................................
24
Description of Dental Benefits ...............................................................................................................
25
Dental Plan Limitations and Exclusions ...............................................................................................
27
Definitionof Terms .................................................................................................................................
28
Pre -Existing Conditions, HIPAA, and Portability .................................................................................
40
Enrollmentand Eligibility .......................................................................................................................
42
Retiree Enrollment and Eligibility ..........................................................................................................
47
Coordinationof Benefits ........................................................................................................................
49
Third Party Recovery Provision ............................................................................................................
51
COBRAContinuation .............................................................................................................................. 52
GeneralPlan Provisions .........................................................................................................................
54
Administration.........................................................................................................................................
56
Plan Participant's Rights Under the Employee Retirement income Security Act (ERISA) ..............58
(0
:7
PRE -ADMISSION NOTIFICATION
Pre -Admission Notification
Pre -Admission Notification is required for all'inpatient hospital admissions, skilled nursing facility admissions,
inpatient rehabilitation center admissions, inpatient pain center admissions, inpatient or residential chemical
dependency treatment, inpatient mental health treatment, hospice care, home health care, and organ and/or
tissue transplant services. The intent of this service is to promote the most cost-effective use of hospitalization
and health care without sacrificing the quality of medical care.
Administrators West must be contacted by the employee or dependent, the physician, or the facility 10
business days (or as soon as possible) before the admission date, or the date that treatment begins. Pre -
Admission Notification must be submitted in writing. If time is a factor, notification may be made by telephone
and then followed by written confirmation. In the case of an emergency, Administrators West must be
contacted within 48 hours of an emergency inpatient hospital admission.
Emergency Medical Condition
If the employee or covered dependent should experience an emergency medical condition, he or she should
seek medical attention from the nearest appropriate facility (physician's office, clinic, urgent care center,
hospital emergency room) or call 9-1-1.
Administrators West may be contacted at:
Administrators West
612 NE Savannah Drive, Suite 4
Bend, OR 97701
Phone: (800) 894-9221 Toll -Free
(541) 312-9144 in Bend
Fax: (541) 312-9149
Non -Notification Penalty
If Pre -Admission Notification is not obtained, benefits will be reduced as follows:
■ If the admission is determined to have been medically necessary after review of the medical records,
the Plan will deduct a maximum of $1,000 from the total eligible covered expenses as a penalty of non-
compliance with the Pre -Notification requirement. (The maximum penalty, if needed, shall be adjusted
so as not to reduce the benefit more than 50%.) This penalty applies per admission for those
procedures requiring Pre -Admission notification as listed above.
■ If, after review of the medical records, the Plan determines that the admission or treatment was not
medically necessary, all benefits relating to this admission or treatment will be denied.
■ Charges reviewed by Administrators West and reduced or denied as not medically necessary are not
eligible for payment under any other portion of this Plan.
Pre -Admission Notification does not waive or exclude any other terms or conditions in this Plan.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page I
LARGE CASE MANAGEMENT
Large Case Management is designed to help manage the care of patients who have catastrophic or •
extended -care illnesses or injuries. The primary objective of Large Case Management is to identify and
coordinate cost-effective medical care alternatives that meet accepted standards of medical practice. Large
Case Management also monitors the care of the patient, offers emotional support for the family and
coordinates communication among health care providers, patients and others.
These objectives are met through contractual benefits and non -contractual benefits (on an exception basis) to
patients who are eligible and voluntarily agree to the alternative plan.
Examples of conditions that may be appropriate for Large Case Management include, but are not limited to:
1. Terminal illnesses such as AIDS or cancer;
2. Chronic illnesses such as multiple sclerosis, renal failure, cardiac conditions and organ transplants;
3. Accidents requiring long-term rehabilitative care, such as head injuries;
4. Conditions requiring long-term IV (intravenous) therapy; or
5. Mental health disorders.
CLAIM SUBMISSION
Preferred Provider Network
Deschutes County has contracted with Providence Preferred of Oregon to provide a network of preferred
medical providers and hospitals throughout the service area. To determine if a provider is in the network, a
directory of preferred providers in the area is available from Deschutes County, or the covered person may
call the network directly. The dental and vision plans do not include a preferred provider network.
The preferred provider will submit Providence Preferred of Oregon claims directly to Providence Preferred of
Oregon.
Providence Preferred of Oregon providers submit claims to: •
Providence Preferred of Oregon
PO Box 3236
Portland, OR 97208-3236
Phone: (800) 638-0449 Toll -Free
Out -of -Area Providers, Non -Network Providers, Chiropractors, Dental Providers & Vision Providers
Claims received from out -of -area providers, non -network providers, chiropractors, dental providers and vision
providers must be submitted to Administrators West. No special claim forms are required. The only item
that is required for claim submission is an itemized billing statement that the covered person can obtain from
the health care provider. An itemized billing includes the following:
1. The employee's name, the employer's name, and the patient's name;
2. A description of the service(s), including the amount charged for each service or supply;
3. The diagnosis;
4. The date(s) of service;
5. The name, address, and telephone number of the physician or provider; and
6. The federal tax identification number and credentials (e.g., MD or DDS) of the physician or provider.
Out -of -Area providers, non -network providers, dental and vision providers submit claims to:
Administrators West
612 NE Savannah Drive, Suite 4
Bend, OR 97701
Phone: (800) 894-9221 Toll -Free
(541) 312-9144 in Bend
11
Deschutes County Employee Benefit Plan Effective August 1, 2000 page z
CLAIM SUBMISSION (CONTINUED)
Requests for Additional Information
40 Sometimes additional information is required to complete the processing of a claim. If this occurs,
Administrators West will send the employee an inquiry indicating the information needed. As soon as
Administrators West receives the requested information, processing of the claim will be continued.
•
To help avoid this type of delay, certain information can be included with the original claim submission. For
example, if another health plan is the primary plan for a claim, please attach a copy of the other plan's
explanation of benefits so we may coordinate the benefits. If the claim involves an accidental injury, please
provide a brief description of the accident including the date, place, and circumstances surrounding the
accident.
Out -of -Area Providers
Those individuals that do not have access to PPO providers in Oregon for medically necessary treatment, as
well as those retirees living out of state, may take advantage of the Out -of -Area benefit level. Benefits are
paid at the PPO benefit level, but are subject to Usual, Customary and Reasonable (UCR) in the geographical
area where the services are furnished.
Timely Filing of Claims
All claims should be filed within 90 days from the date of service. Claims filed over 12 months from the date
of service are not eligible for benefits and will be denied.
Payment of Claims
Administrators West is responsible for processing all benefit claims under this Plan.
Administrators West will process the claim within a reasonable time after it is received. The Plan has the
right to secure independent medical evidence and to require such other evidence as it deems necessary to
determine available benefits.
Denial of Claims
If Administrators West denies a claim, in whole or in part, the employee will receive a written notification
setting forth:
1. The specific reason or reasons for the denial;
2. Specific reference to pertinent Plan provision(s) on which the denial is based;
3. A description of any additional material or information necessary for the claimant to complete the claim
for appeal, and an explanation of why such material or information is necessary; and
4. Appropriate information regarding the steps to be taken if the employee wishes to appeal Administrators
West's decision.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 3
GRIEVANCES AND APPEALS
If the subscriber believes that a policy, action, or decision made by Administrators West is incorrect, he or l
she may contact the Customer Service Department. If Administrators West cannot resolve the concern to
the subscriber's satisfaction, he or she may file a formal written grievance or appeal.
Grievances
To file a grievance, the subscriber must submit a written statement to Administrators West, containing all
information necessary to explain the issue. Administrators West will respond in a timely manner to
acknowledge receipt of the grievance, and the member will be sent written notification of the decision made.
If the subscriber is not satisfied with the decision, he or she may appeal the decision within 60 days of the
date of the initial decision.
Appeals
An appeal is initiated when Administrators West receives a written request for reconsideration of a denied
claim. This written notice must be submitted within 60 days of receipt of the Plan's initial denial. The written
appeal should state the reason(s) that the subscriber believes the claim should not have been denied, and it
should also include any additional facts and/or documents that may support the appeal. The covered person
may also ask additional questions or make comments, and may review pertinent documents.
Administrators West will respond in a timely manner to acknowledge receipt of the appeal and will notify the
employee of their decision in writing, generally within 60 days after it is submitted. If extended review is
needed, Administrators West will notify the employee, explaining the delay.
The plan may secure independent medical evidence, and may require such other evidence as it deems
necessary to determine available benefits.
If the decision on appeal affirms the initial denial of the claim, the notice will set forth:
1. The specific reason or reasons for the denial; and
2. Specific reference to pertinent Plan provision(s) on which the denial is based.
If the subscriber is not satisfied with Administrators West's determination on the initial appeal, he or she may
appeal a second time. To do so, a written request for review, containing additional information that may
affect the decision, must be submitted within 60 days of receipt of the notification on the first appeal. The
subscriber may also request a personal interview with a representative of the Plan.
If the subscriber wishes to seek other assistance from the Oregon Insurance Division, assistance is available:
By Calling: (503) 947-7984
By Writing: Oregon Insurance Division
Consumer Protection Unit
350 Winter Street, N.E., Room 440-2
Salem OR 97310
Through the Internet at: http://www.cbg.state.or.us/external/ins.
For further information about the procedures outlined here, please contact Customer Service at:
Administrators West
612 NE Savannah Drive, Suite 4
Bend, OR 97701
Phone: (800) 894-9221 Toll -Free
(541) 312-9144 in Bend
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 4
•.)
•
SUMMARY OF MEDICAL BENEFITS
The following is a summary of medical benefits. For additional coverage details, please refer to the
Description of Medical Benefits beginning on page 11. All benefits are subject to the Usual, Customary
and Reasonable (UCR) allowance and to all Medical Plan Limitations and Exclusions as described
beginning on page 19 of this document.
Lifetime Maximums
Individual.................................................................................................................................. $2,000,000
OrganTransplant........................................................................................................................ $250,000
TMJ (Temporomandibular Joint Disorder)................................................................................... $2,000
DiabeticEducation............................................................................................................................. $120
Calendar Year Deductible (Paid by member only where specified in Summary)
Individual............................................................................................................................................ $100
Family.................................................................................................................................................. $300
Out -of -Pocket Maximum (includes deductible)
Individual(per calendar ear .................................. $600
BENEFIT
PREFERRED
DESCRIPTION
PROVIDER*
Allergy Injections
$5 co -pay, then 100% - no deductible
Allergy Serum
80% after deductible
Ambulance
100%, subject to limitations - no deductible
Limited to 400 miles per condition
Chemotherapy/Rad lotion Thera
100% - no deductible
Chiropractic Treatment
100%, subject to limitations - no deductible
Limited to $8 per visit
Limited to 10 visits per calendar year
Chiropractic x-ray and laboratory limited to $100per
calendar year
Dental Injury within 120 days of accident
80% after deductible
Diabetic Education
100%, subject to limitations - no deductible
Limited to $120 per lifetime
Diagnostic X -Ray and Laboratory
100% first $100 per accident, then deductible, then 80%
Accident
Illness
100% first $100 per calendar year, then deductible,
then 80%
Durable Medical Equipment/Supplies
80% after deductible
Emergency Room 80% after deductible
Home Health Care 100%, subject to limitations - no deductible
Limited to two visits per day, 180 visits per calendar year
Hospice 100%, subject to limitations - no deductible
Limited to $15,000 per lifetime
Hospital
Inpatient
$100 per day co -pay, then 100% - no deductible
Maximum co -pay $300 per calendar year
Outpatient Surgery/Observation
100% - no deductible
Admission Testin�c ____
__ _.___100% - no deductible_
_Pre _
Infusion Thera
100% - no deductible
* Services furnished by non-preterrea proviaers ano our01-tUME P1VV1UW1A aIv ��..,��• — --, .I
and Reasonable (UCR) allowance. Non -Preferred and out of area providers, however, may bill the
covered person for any balances over UCR.
Deschutes County Employee Benefit Plan
Effective August 1, 2000 page 5
SUMMARY OF MEDICAL BENEFITS (CONTINUED)
BENE{ ° ' PREFERRED
DESCRIP ' ION PROVIDER*
Maternity Covered the same as any other condition.
Coverage includes eligible employee, Refer to appropriate Benefit Description (Hospital,
spouse, same-sex domestic partner and Physician Services, etc.)
Mental Health Care/Chemical Dependency
Mental Health Care- Adult
Inpatient
$100 per day co -pay, then 100% - no deductible
Maximum co -pay $300 per calendar year
Subject to limitations and maximum co -pay
Limited to 15 days per 24 -month period
Residential Treatment/Partial Hospitalization
$100 per day co -pay, then 100% - no deductible
Maximum co -pay $300 per calendar year
Subject to limitations and maximum co -pay
Limited to 17 days per 24 -month period
Outpatient
$15 co -pay, then 100% - no deductible
Limited to 34 visits per 24 -month period
P ...... ..... P .. ......................................................................
Sub'ect to limitations
..._..J.........t.................................n ............................................................ ............
Mental Health Care- Child/Adolescent
Inpatient
$100 per day co -pay, then 100% - no deductible
Maximum co -pay $300 per calendar year
Subject to limitations and maximum co -pay
Limited to 16 days per 24 -month period
Residential Treatment/Partial Hospitalization
$100 per day co -pay, then 100% - no deductible
Maximum co -pay $300 per calendar year
Subject to limitations and maximum co -pay
Limited to 20 days per 24 -month period
Outpatient
$15 co -pay, then 100% - no deductible
Limited to 34 visits per 24 -month period
Subjec...... .................. .._....................... ....................................................__.
Chemical Dependency — Adult
Inpatient
$100 per day co -pay, then 100% - no deductible
Maximum co -pay $300 per calendar year
Subject to limitations and maximum co -pay
Limited to 13 days per 24 -month period
Residential Treatment/ Partial Hospitalization
$100 per day co -pay, then 100% - no deductible
Maximum co -pay $300 per calendar year
Subject to limitations and maximum co -pay
Limited to 19 days per 24 -month period
Outpatient
$15 co -pay, then 100% - no deductible
Limited to 25 visits er 24 -month period......................................................................................................_...................._Subject._to...limitations..........................................................
....... P ...................... ... .. ..
......... ...........
Chemical Dependency — Child/Adolescent
Inpatient
$100 per day co -pay, then 100% - no deductible
Maximum co -pay $300 per calendar year
Subject to limitations and maximum co -pay
Limited to 27 days per 24 -month period
Residential Treatment/Partial Hospitalization
$100 per day co -pay, then 100% - no deductible
Maximum co -pay $300 per calendar year
Subject to limitations and maximum co -pay
Limited to 26 days per 24 -month period
Outpatient
$15 co -pay, then 100% - no deductible
Limitedto 36 visits.... per 24 -month period.,. ......................................................................................................................Subject
............................ P...
to...limitations..................._....................................................................
.__........._._...................................
iia combined diagnosis of mental health
disorder and chemical dependency is given,
allowance will be calculated based on the Mental Health Care benefit
Office Surgery
100% - no deductible
Includes surgical suite, supplies'
* Services furnished by non -preferred providers and out-ot-area providers are suoleci io usuai, customary
and Reasonable (UCR) allowance. Non -Preferred and out of area providers, howev6r, may bill the
covered person for any balances over UCR.
Deschutes County Employee Benefit Plan Effective August 1, 2000
page 6
0))
0
to
SUMMARY OF MEDICAL BENEFITS (CONTINUED)
BENEFIT
_ PREFERRED
DESCRIPTION
PROVIDER*
Organ and/or Tissue Transplant Covered the same as any other condition.
24 -month waiting period applies Refer to appropriate Benefit Description (Hospital,
Limited to $250,000 per lifetime Physician Services, etc.)
Donor expenses limited to $5,000 per trans lant Subject to limitations
Physician Office Visits $15 co -pay, then 100% - no deductible
Physician Services 100% - no deductible
Preventive Care (Routine)
Routine Exam 100%, subject to limitations - no deductible
Includes routine x-ray and lab services
Limitations:
Age two through 18, one exam per three-year period, up to $50
Age 19 through 34, one exam per five-year period, up to $140
Age 35 through 59, one exam per two-year period, up to $140
Age 60 and over, one exam per calendar ear, u to $140
9...................._................................................................................_.......................................................Y....................P....................................................................................................................................................................................................................._....
Routine Immunizations all ages) 100% - no deductible
Preventive Women's Health Care
Examination 100%, subject to limitations - no deductible
Includes routine pelvic exam, breast exam, pap smear
Limited to once per calendar ear
P......................................................Y......................................................................__........................................................................_.................................................................................................................................
Routine Mammogram 100%, subject to limitations - no deductible
Frequency limitations:
Age 35 through 39, one mammogram
Age 40 through 49, one mammogram per two-year period
Age 50 and over, one mammogram per calendar year
Rehabilitation Therapy 1 80%, subject to limitations - no deductible
Includes physical, occupational and speech therapy
Outpatient limited to 30 visits per calendar year
Inpatient limited to 30 days per calendar year
Skilled Nursing Facility
100% - no deductible
Supplemental Accident Benefit
100% of first $500 per accident, then refer to appropriate
Services within 90 days of injury
Benefit Description (Hospital, Physician Services, etc.)
Excludes chiropractic and dental treatment
Temporomandibular Joint Disorder (TMJ)
50%, subject to limitations - no deductible
Limited to $2 000 per lifetime
Therapeutic Injections
80% after deductible
Well Baby Care
$15 co -pay, then 100%, subject to limitations - no
Birth to age two
deductible
Limited to eight visits
All Other Covered Services
80% after deductible
* Services furnished by non -preferred providers and out -of -area providers are subject to Usual, Customary
and Reasonable (UCR) allowance. Non -Preferred and out of area providers, however, may bill the
covered person for any balances over UCR.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 7
SUMMARY OF MEDICAL_ BENEFITS (CONTINUED)
A six-month exclusion period applies to treatment of allergies, asthma, elective procedures, otitis media,
removal of tonsils or adenoids, sterilization and pre-existing conditions. A pre-existing condition is any injury,
illness, or related condition (except pregnancy), for which a covered person received medical care, advi(-e,
diagnosis or treatment, or has taken prescribed drugs or medicines during the six consecutive months
immediately preceding the enrollment date.
A 24 -month exclusion period applies to treatment for organ and/or tissue transplants.
Credit for Prior Coverage
The duration of the exclusion periods listed above will be reduced by the amount of time the employee had
prior "creditable coverage", if:
a) Creditable coverage was still in effect on the covered person's enrollment date in the Plan; or
b) Creditable coverage ended no more than 63 days prior to the covered person's enrollment date in the
Plan.
For more information, please refer to the Pre -Existing Conditions, HIPAA and Portability section of this
document beginning on page 40.
Open Enrollment
Applications for late enrollees will be accepted during the Open Enrollment Period from July 18t to July 31st
for an August 1st effective date.
For more information, please refer to the Enrollment and Eligibility section of this document beginning on
page 42.
SUMMARY OF PRESCRIPTION BENEFITS
PRESCRIPTION 13ENEFIT
GENERIC*
SINGLE-
MULTI -
SOURCE
SOURCE
BRAND NAME*
13RAND NAME*
Express Scripts Select Participating
$10 co -pay (or
$10 co -pay (or
$10 co -pay (or
Pharmacy
20% of retail,
20% of retail,
20% of retail,
Limited to 34 -day supply
whichever is
whichever is
whichever is
greater) then
greater) then
greater) then
100%
100%
100%
Certifax/Walgreen's Mail -Order Program
$20 co -pay (or
$20 co -pay (or
$20 co -pay (or
Limited to 100 -day supply
20% of retail,
20% of retail,
20% of retail,
whichever is
whichever is
whichever is
greater) then
greater) then
greater) then
100%
100%
1 100%
Expenses Submitted by Member
50% co -pay
50% co -pay
50% co -pay
Note: If the physician prescribes a generic drug, but a brand name drug is purchased, the covered person
must pay the co -payment plus the difference in the generic and brand name cost.
* Prescription co -payments and coinsurance amounts do not apply to the out-of-pocket maximum.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 8
A
•
•
SUMMARY OF DENTAL BENEFITS
The following is a summary of dental benefits. For additional coverage details, please refer to the Description
of Dental Benefits beginning on page 25. All benefits are subject to all Medical Plan Limitations and
Exclusions as described beginning on page 19 of this document. Dental benefits are also subject to
the Dental Plan Limitations and Exclusions as described beginning on page 27 of this document.
AnnualDeductible.......................................................................................................................................... $0
Maximum Dental Benefit (per calendar year)......................................................................................... $1,500
Maximum Orthodontia Benefit (per lifetime)......................................................................................... $1,000
BENEFIT DESCRIPTION
BENEFIT LEVEL
BENEFIT LEVEL
FIRST YEAR OF
SECOND/ SUBSEQUENT.
COVERAGE
OF COVERAGE
Preventive Services
80% of UCR
_YEARS
100% of UCR
Exam, office visit, x-rays, cleaning, fluoride
treatment
Basic Services
80% of UCR
100% of UCR
Restorations (fillings), periodontal services,
endodontics (root canal therapy),
extractions, periodontal surgery, oral
surgery
Major Services
80% of UCR
100% of UCR
Full and partial dentures, crowns bridges
Orthodontia Services
50%
50%
Approved treatment plan required before
treatment starts
Plan Maximum
The maximum benefit payable under the Plan for covered dental benefits during a calendar year is $1,500
per covered person.
Estimate of Benefits
If dental care will be extensive (over $300), the dentist is encouraged to submit a pre-treatment estimate of
benefits. This will assist the covered person and the dentist in understanding the benefits in advance, as the
Plan will determine its liability for the proposed treatment, and will notify the employee and the provider of the
benefits available. A pre-treatment estimate is not a guarantee of coverage or payment. Final benefit
payment will depend on the covered person's eligibility and the Plan benefits available at the time of service.
Deschutes County Employee Benefit Plan
Effective August 1, 2000
page 9
SUMMARY OF VISION BENEFITS
The followino is a summary of vision benefits. All benefits are subject to all Medical Plan Limitations and
Exclusions as described beginning on page 19 of this document, as well as the Vision Plan
Limitations and Exclusions shown below.
Eligible vision expenses are covered when performed by a licensed ophthalmologist, optometrist or optician.
6ENEFIf:01ESCAIPTION
BENEFIT LEVEL
Eye Exam
$25 co -pay, then 100%
Limited to one exam per calendar year
Lenses
Limited to one pair of lenses, (or a 12 -month supply of
disposable contact lenses) per calendar year
Pin .gle...vision lenses._. _ ...................................
..............................................__........._.............................._.......
............................... $100 per air
. .... ......... .........p .......... .......... ... ................................................... .....
Bifocal lenses.............................................................. ... ....
........................................................................................................................_....................................................................._.................
$140 er air
P............P.......................................................................
Trifocal lenses
$180 er air
.....................................................................................................................................................................................
Lenticular lenses ............ ......................_. . .
$220 per pair
Contact lenses (in lieu of lenses)
Medically necessary (following cataract surgery or if needed
$200 per pair
to correct vis...........................................on to 20!70 or better)
......................................................................................_......_................I........ .
........................................... __............................................................................
Cosmetic (including disposable lenses
(' g p )
$190 per pair
(or per 12 -month supply of disposable
lenses
Frames
$90
Limited to one frame per calendar year
Radial Keratotomy $250 per eye
Limited to $500 lifetime maximum
Benefit includes all surgical procedures that alter the refractive character of the eye, including but not
limited to, radial keratotomy, myopic keratomimleusis and other surgical procedures of the refractive
keratoplasty type which cures or reduces myopia or astigmatism. This includes reversals or revisions
of the surgical procedure and any complications of all of the aforementioned procedures.
VISION PLAN LIMITATIONS AND EXCLUSIONS
To assure coverage at a reasonable cost, and to prevent unnecessary use of services, the following
limitations and exclusions have been incorporated.
1. Additional charge for tinted lenses.
2. Charges for vision training or subnormal vision aids.
3. Charges for lenses ordered without a prescription.
4. Charges for any eye examination required by an employer as a condition of employment, or which an
employer is required to provide under a labor agreement, or which any law or government requires.
5. Charges for orthoptics (eye muscle exercises).
6. Charges for vision care services for which benefits are provided under any other portion of the Plan, or
under any other medical or vision care expense benefit plan carried or sponsored by Deschutes County,
whether benefits are payable as to all or only part of the expenses.
7. Charges for vision care services for which benefits are provided under any worker's compensation law or
any other law of similar purpose, whether benefits are payable as to all or only part of the expeinses.
8. Drugs or medications of any kind.
9. Treatment, care, or supplies for which a charge was incurred before the person was covered under the
Plan, or after termination of coverage.
Deschutes County Employee Benefit Plan Effective August 1, 2000
page 10
•
DESCRIPTION OF MEDICAL BENEFITS
Annual Deductible
The deductible amount for each covered person is the amount of covered expenses which must be incurred
in a calendar year before benefits are payable for covered medical expenses incurred during the remainder of
that year, as shown in the Summary of Medical Benefits. A copy of all bills must be submitted to
Administrators West for verification and record keeping so that benefit payment may begin as soon as
possible.
Family Limit on Deductible
The maximum deductible amounts to be applied each calendar year to a covered employee and his or her
covered dependents will not be more than the family limit as shown in the Summary of Medical Benefits.
Deductible Carryover
If claims incurred during the last three months of a calendar year are applied to the deductible, but the
deductible for that calendar year is not fully satisfied, the amount applied to the deductible will be carried
forward and will be used to help satisfy the deductible for the following calendar year. Please note that the
deductible carryover provision does not apply if the deductible is satisfied.
Plan Maximum
This Plan provides a cumulative maximum for medical benefits of $2,000,000 for each person covered by the
Plan. Persons previously covered by the Plan shall have this maximum reduced by any amounts previously
paid.
After the maximum for medical benefits has been paid for any Plan member, no additional benefits will be
paid.
Out -of -Pocket Maximum
This Plan provides for a maximum dollar amount that a participant will pay for covered medical expenses in
any one benefit period, unless otherwise specified in the Summary of Medical Benefits.
The following charges do not apply to the out-of-pocket maximum:
(. 1. Charges not covered at all by the Plan;
�l 2. Pre -Admission Notification penalty as explained on page 1;
3. Prescription co -payments; and
4. Dental and vision expenses.
Covered Expenses
Covered medical expenses means the usual, customary and reasonable (UCR) expenses incurred by a
covered person for the following hospital or other medical services which are:
1. Ordered by a physician;
2. Medically necessary for the treatment of an illness or injury;
3. Not of a luxury or personal nature;
4. Not excluded under Medical Plan Limitations and Exclusions beginning on page 19; and
5. Incurred while the person is covered under the Plan.
Allowable Amount - Preferred Providers vs. Non -Preferred Providers
The important difference between the benefits for preferred providers and non -preferred providers is the
balance that the covered person may be required to pay. Preferred providers will not charge any balances for
covered expenses over the amount allowed by the Preferred Provider Organization. Non -preferred providers,
however, may bill the covered person for any balances over UCR.
(0
Deschutes County Employee Benefit Plan Effective August 1, 2000 page i i
DESCRIPTION OF MEDICAL BENEFITS (CONTINUED)
Medical Expenses
If a covered person incurs covered medical expenses as the result of an illness or injury covered by The Plan,���
the Plan will pay benefits as shown in the Summary of Medical Benefits.
The following are covered expenses under the Plan. Benefits for these covered expenses will be payable as
shown in the Summary of Medical Benefits.
1. Allergy Treatment
a) Charges for allergy testing, injections, and serums.
2. Ambulance
a) Charges for professional ground or air ambulance service, when medically necessary, to the nearest
hospital or emergency care facility equipped to treat a condition which can be classified as an
emergency medical condition, or between medical facilities if medically necessary, subject to the
maximum shown in the Summary of Medical Benefits.
3. Ambulatory Surgical Center
a) Charges made by an ambulatory surgical center or a minor emergency medical clinic.
4. Anesthesia
a) Charges for the cost and administration of an anesthetic.
5. Birthing Center
a) Charges for birthing suite, room and board, and other medically necessary services or supplies.
b) Expenses for home birth are not covered.
6. Blood or Blood Components
a) Charges for the processing and administration of blood or blood components, but not for the actual
cost of the blood or blood components, if replaced.
7. Chemical Dependency Treatment
a) Charges for chemical dependency treatment, subject to the maximums shown in the Summary of
Medical Benefits. Covered expenses include:
i) Inpatient services rendered by a licensed general hospital or a freestanding inpatient facility while
the covered person is confined as an inpatient in the hospital or facility;
ii) Outpatient services rendered in an outpatient setting in a licensed general hospital, a physician's
or psychologist's office, or an alcoholism or drug treatment center;
iii) Covered services rendered by a physician or psychologist. Please refer to "Physician" in the
Definition of Terms section of this document for a description of the providers who qualify as a
physician under the Plan; and
iv) Medical and psychiatric evaluations, inpatient room and board (including detoxification), group
and individual psychotherapy, behavior therapy, recreation therapy and family therapy for the
covered person and the covered person's family.
b) If a combined diagnosis of chemical dependency and mental illness is given, benefits are based on
the Mental Health Care benefit.
8. Chemotherapy/Radiation Therapy
a) Charges for chemotherapy and/or radiation therapy or treatment.
9. Chiropractic Care
a) Charges for chiropractic care, rendered by licensed chiropractor, subject to the maximum shown in
the Summary of Medical Benefits.
10. Cosmetic Surgery
a) Charges for cosmetic surgery for pWl the following situations:
i) Treatment of an accidental bodily injury;
ii) The surgical correction of a congenital anomaly in a child under age 18 ,who is a covered
dependent; or
iii) Reconstructive breast surgery following a mastectomy.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 12
i,
DESCRIPTION OF MEDICAL BENEFITS (CONTINUED)
11. Dental Care
(to a) Charges for treatment of accidental injuries to sound and natural teeth within 120 days of the injury,
(unless a delay is medically necessary). Covered expenses include replacement of missing or
damaged teeth; removal of cysts and tumors; incision of sinuses, salivary glands or ducts; or
frenectomy. Charges for the removal of stitches or post-operative examinations are not covered.
12. Diabetic Education
a) Charges for initial instruction and/or training in diabetic care, when performed in an outpatient setting
of a hospital, subject to the maximum shown in the Summary of Medical Benefits.
13. Diagnostic X -Ray and Laboratory
a) Charges for x-rays, microscopic tests and laboratory tests, outpatient pre -admission testing prior to a
hospital admission, and amniocentesis.
14. Durable Medical Equipment
a) Charges for rental or purchase, if economically justified, of a wheelchair, hospital bed, ventilator, or
other durable medical equipment required for therapeutic use, subject to the maximum shown in the
Summary of Medical Benefits.
b) This benefit does not cover the purchase or rental of supplies of common use such as: exercise
cycles; air purifiers; air conditioners; water purifiers; hypoallergenic pillows; mattresses and
waterbeds; motorized transportation equipment; escalators or elevators; saunas; steam baths;
swimming pools; blood pressure kits; and humidifiers, even if obtained upon the recommendation of
a physician.
15. Emergency Medical Care
a) Emergency care is covered as any other covered medical condition under this Plan. In order to be
eligible for benefits, the emergency care provided must be a covered service under this Plan. Prior
authorization notification or physician referral is not required prior to receiving emergency medical
care; however Pre -Admission Notification requirements will apply. If the employee or dependent
covered under this Plan needs immediate assistance for a medical emergency, he or she should
seek medical attention from the nearest appropriate facility (physician's office, clinic, urgent care
center, hospital emergency room) or call 9-1-1.
16. Home Health Care
a) Charges made by a home health care agency for care in accordance with a home health care plan,
subject to the maximum shown in the Summary of Medical Benefits. Covered expenses include:
i) Part-time or intermittent nursing care by a registered nurse, a licensed practical nurse, a licensed
vocational nurse, or public health nurse who is under the direct supervision of a registered nurse;
ii) Home health aide services; and
iii) Medical supplies, drugs and medicines prescribed by a physician, and laboratory services
provided by or on behalf of a hospital, but only to the extent that they would have been covered
under the Plan if the person had remained in the hospital.
b) Specifically excluded from coverage under the home health care benefit are the following:
i) Services and supplies not included in the home health care plan;
ii) Services of a person who ordinarily resides in the home of the covered person, or is a close
relative of the covered person;
iii) Services of any social worker;
iv) Transportation services;
v) Custodial care and housekeeping; and
vi) Charges for services in excess of the maximum shown on the Summary of Medical Benefits.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 13
DESCRIPTION OF MEDICAL BENEFITS (CONTINUED)
17. Hospice Care
a) Charges relating to hospice care provided to a covered person with a life expectancy of six months or
less, subject to the maximum shown in the Summary of Medical Benefits. Covf red hospice
expenses include:
i) Room and board for confinement in a hospice;
ii) Ancillary services furnished by the hospice while the covered person is confined therein, including
rental of durable medical equipment which is used solely for treating an illness or injury;
iii) Medical supplies and medicines prescribed by the attending physician, but only to the extent such
items are necessary for pain control and management of the terminal condition;
iv) Physician's services and/or nursing care by a registered nurse, a licensed practical nurse, or a
licensed vocational nurse;
v) Home health aide services;
vi) Charges for home care furnished by a hospital or home health care agency, under the direction
of a hospice, including custodial care if it is provided during a regular visit by a registered nurse, a
licensed practical nurse, or a home health aide;
vii) Medical social services by licensed or trained social workers, psychologists, or counselors;
viii) Nutrition services provided by a licensed dietitian;
ix) Respite care; and
x) Bereavement counseling, which is a supportive service provided by the hospice team to a
covered person in the deceased's immediate family following a terminally ill covered person's
death.
Is. Hospital
a) Charges for services and supplies furnished by a hospital on an inpatient or outpatient basis.
Covered hospital expenses include:
i) The actual room and board expenses incurred for a ward or semi -private room;
ii) The expense incurred for medically necessary confinement in an intensive care unit, cardiac care
unit, or burn unit;
iii) Miscellaneous hospital services and supplies furnished during a hospital confinement;
iv) Outpatient hospital services and supplies, except for take-home drugs and medicines; and
v) Emergency room expenses.
19. Hospitalization for Dentistry
a) When hospitalization is required for a dental procedure because of a concurrent hazardous medical
condition such as serious blood dyscrasia, unstable diabetes, or severe cardiovascular disease,
charges for the hospital, anesthesiologist and physician's assistant will be allowed under the Medical
Plan. Such dental procedures include but are not limited to:
i) Multiple extractions;
ii) Removal of unerupted teeth;
iii) Vestibuloplasty; and
iv) Alveolectomy under general anesthesia.
b) Charges for the dentist's services are not covered under the Medical Plan.
20. Immunizations (all ages)
a) Charges for routine immunizations.
21. Infusion Therapy
a) Charges for services and supplies for the administration of a home infusion therapy regimen when
ordered by a physician and provided by an accredited home infusion therapy agency, subject to the
maximum shown in the Summary of Medical Benefits.
22. Maternity
a) Charges for maternity care, on the same basis as any other condition covered under the Plan.
Deschutes County Employee Benerit Plan Effective August 1, 2000 page 14
1))),))
•
27. Organ and/or Tissue Transplants
a) Pre -authorization is a requirement for organ transplants. Coverage for expenses incurred in
connection with any organ or tissue transplant listed in this provision will be subject to referral to and
pre -authorization by the Plan.
b) As soon as reasonably possible, but in no event more than ten days after a covered person's
attending physician has indicated that the covered person is a potential candidate for a transplant, the
covered person or his or her physician should contact Administrators West for a pre -authorization. A
comprehensive treatment plan must be developed for the Plan's medical review, and must include
such information as: the diagnosis; the nature of the transplant; the setting of the procedure; any
secondary medical need for the procedure; and a description and the estimated cost of the proposed
transplant. All potential transplant cases will be assessed for appropriateness through Large Case
Management.
c) The term covered expenses with respect to transplants includes the reasonable and customary
expenses for services and supplies which are covered under the Plan or are specifically identified as
covered only under this provision, which are medically necessary and appropriate to the transplant,
subject to the maximums shown in the Summary of Medical Benefits. Covered expenses include:
i) Charges incurred in the evaluation, screening and candidacy determination process;
Organ and/or Tissue Transplants continued next page
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 15
DESCRIPTION OF MEDICAL BENEFITS (CONTINUED)
23. Medical Supplies
a)
Charges for dressings, sutures, casts, splints, trusses, crutches, braces, or other necessary medical
supplies; and
b)
Medically necessary diabetic supplies.
24. Mental Health Treatment
a)
Charges for mental health treatment, subject to the maximum shown in the Summary of Medical
Benefits. Such expenses include:
i) Inpatient services rendered in a licensed general hospital; and
ii) Outpatient services rendered by a physician. Please refer to "Physician" in the Definition of Terms
section of this document for a description of the providers who qualify as a physician under the
Plan.
b)
If a combined diagnosis of chemical dependency and mental illness is given, benefits are based on
the Mental Health Care benefit.
c)
The Plan specifically excludes:
i) Intentionally self-inflicted injury, regardless of mental health disorder;
ii) Education, counseling, job training or care for learning disorders or behavioral problems, whether
or not services are rendered in a facility which also provides medical care and/or mental health
treatment; and
iii) Mental health treatment for conditions relating to academic related problems, adult antisocial
behavior, childhood or adolescent antisocial behavior or adjustment, marital or family counseling,
occupational counseling, and phase -of -life problem or other life circumstance problem.
25. Nursing
a)
Services
Charges for nursing care by a covered provider who is not a close relative and who does not reside in
the covered person's home, when the attending physician certifies that nursing care is medically
necessary.
ie 26. Occupational Therapy
a) Charges for services rendered by an occupational therapist under the prescription of a physician, in a
home setting, a facility or institution whose primary purpose is to provide medical care for an illness
or injury, or a freestanding duly licensed outpatient therapy facility, subject to the maximum shown in
the Summary of Medical Benefits under "Rehabilitation Therapy".
b)
Therapy that is intended to address primarily vocational rehabilitation issues (e.g., return -to -work
skills) is not covered by the Plan.
•
27. Organ and/or Tissue Transplants
a) Pre -authorization is a requirement for organ transplants. Coverage for expenses incurred in
connection with any organ or tissue transplant listed in this provision will be subject to referral to and
pre -authorization by the Plan.
b) As soon as reasonably possible, but in no event more than ten days after a covered person's
attending physician has indicated that the covered person is a potential candidate for a transplant, the
covered person or his or her physician should contact Administrators West for a pre -authorization. A
comprehensive treatment plan must be developed for the Plan's medical review, and must include
such information as: the diagnosis; the nature of the transplant; the setting of the procedure; any
secondary medical need for the procedure; and a description and the estimated cost of the proposed
transplant. All potential transplant cases will be assessed for appropriateness through Large Case
Management.
c) The term covered expenses with respect to transplants includes the reasonable and customary
expenses for services and supplies which are covered under the Plan or are specifically identified as
covered only under this provision, which are medically necessary and appropriate to the transplant,
subject to the maximums shown in the Summary of Medical Benefits. Covered expenses include:
i) Charges incurred in the evaluation, screening and candidacy determination process;
Organ and/or Tissue Transplants continued next page
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 15
DESCRIPTION OF MEDICAL BENEFITS (CONTINUED)
27. Organ and/or Tissue Transplants (continued)
ii) Charges for organ procurement, including donor expenses not covered under the donor's plan of
benefits;
iii) Charges for organ procurement from a non -living donor for costs involved in removing,
preserving, and transporting the organ;
iv) Charges for organ procurement from a living donor for costs involved in screening the potential
donor, transporting the donor to and from the site of the transplant, medical expenses associated
with removal of the donated organ and the medical services provided to the donor in the interim
and for follow-up care;
v) Charges incurred for organ transplantation;
vi) If the transplant procedure is a bone marrow transplant, coverage will be provided for the cost
involved in the removal of the person's own bone marrow (autologous), or donated marrow
(allogenic). Coverage will also be provided for the costs of treatment and storage of the marrow
up to the time of reinfusion, and for search charges to identify an unrelated match;
vii) Charges incurred for follow up care, including immuno -suppressant therapy; and
viii) Charges for transportation to and from the site of the covered organ transplant procedure for the
recipient and one other individual, or in the event that the recipient or the donor is a minor, two
other individuals.
d) Covered donor expenses include:
i) Medical expenses of the donor to the extent that the expenses are not covered elsewhere under
the Plan or any other benefit plan covering the donor, Medical expenses benefits for a donor
who is not a participant under the Plan are limited to a maximum benefit of $5,000 per transplant;
or
ii) If the donor is a covered person under the Plan but the recipient is not, no benefits are available;
however, complications and unforeseen effects from a covered person's organ donation will be
covered as any other condition.
28. Oxygen
a) Charges for oxygen and other gases and their administration. P
1 29. Parenteral Nutrition (Intravenous Feeding)
!i a) Charges for hyperalimentation or total parenteral nutrition (TPN) for persons recovering from surgery,
or preparing for surgery.
I 30. Physician
a) Charges for the services of a legally qualified physician for medical care and/or surgical treatment
including office or home visits, hospital inpatient and outpatient care, examinations, clinical care and
surgical opinion consultations. Please refer to "Physician" in the Definition of Terms section of this
document for a description of the providers who qualify as a physician under the Plan.
I 31. Physical Therapy
a) Charges for services rendered by a physical therapist under the prescription of a physician, in a home
setting, a facility or institution whose primary purpose is to provide medical care for an illness or
injury, or at a freestanding, duly licensed outpatient therapy facility, subject to the maximum shown in
the Summary of Medical Benefits under "Rehabilitation Therapy'.
32. Preventive Care
a) Charges for preventive care (age two and over), subject to the maximum shown in the Summary of
Medical Benefits. Covered expenses include:
i) Physical exam; and
ii) Appropriate x-ray and laboratory tests.
b) Charges for well baby care or well child care (birth to age two), subject to the maxiinum shown in the
Summary of Medical Benefits. Covered expenses include:
i) Routine pediatric care; and
ii) Appropriate x-ray and laboratory tests.
c) Immunizations are covered separately under the "Immunizations" benefit.
i Deschutes County Employee Benefit Plan Effective August 1, 2000 page 16
A a.
J
40
DESCRIPTION OF MEDICAL BENEFITS (CONTINUED)
33. Prosthetics
a) Charges for an artificial limb or eye to replace a missing body part or a non-functioning organ. The
loss of the body part or an organ's function must have resulted from an illness or injury, a surgery, or
a congenital anomaly of a child.
b) Repair or replacement will be covered when made necessary due to physiological changes.
c) This benefit includes coverage for the first contact lens to replace the lens of an eye that is surgically
extracted.
34. Rehabilitation Therapy
a) Charges for services rendered by a physician, or a therapist under the prescription of a physician, in
a home setting, a facility or institution whose primary purpose is to provide medical care for an illness
or injury, or a freestanding, duly licensed outpatient therapy facility, subject to the maximum shown in
the Summary of Medical Benefits.
35. Second Surgical Opinion
a) Charges for a second surgical opinion, when performed by a physician not financially or otherwise
associated with the physician recommending surgery. A third surgical opinion will be allowed if the first
two opinions are conflicting.
36. Skilled Nursing Facility
a) Charges incurred for confinement in a skilled nursing facility, subject to the maximums shown in the
Summary of Medical Benefits. Covered charges include:
i) Room and board for confinement in a skilled nursing;
ii) Ancillary services furnished by the skilled nursing facility while the covered person is confined
therein, including rental of durable medical equipment which is used solely for treating an illness
or injury;
iii) Physical, occupational and speech therapy; and
iv) Oxygen and other gas therapy.
b) No benefits will be provided for: custodial care; maintenance; non-medical self-help; recreational,
vocational or educational therapy; mental health care; chemical dependency rehabilitative treatment;
and gym or swim therapy.
c) Services must begin within seven days of discharge from a hospital confinement of at least three days
due to the same or related condition(s), and must be ordered by the attending physician.
37. Speech Therapy
a) Charges for services rendered by a speech therapist under prescription of a physician in a home
setting, a facility or institution whose primary purpose is to provide medical care for an illness or
injury, or a freestanding duly licensed outpatient therapy facility, subject to the maximum shown in the
Summary of Medical Benefits.
38. Sterilization
a) Charges for voluntary surgical reproductive sterilization.
Note: Dependent children are not eligible for this benefit.
39. Surgical Procedures
a) Charges for medically necessary surgery. When two or more surgical procedures are performed
during the same operation, the eligible expenses are calculated as follows:
i) When multiple or bilateral surgical procedures which increase the time and amount of patient
care are performed, the eligible expense is the UCR fee for the major procedure, plus the lesser
of 50% of the UCR fee for each of the secondary procedures, or the actual fee charged.
ii) When an incidental procedure is performed through the same incision, the eligible expense is the
UCR fee for the major surgical procedure only. Examples of incidental propedures include
excision of a scar or appendectomy, when performed in the course of a more major operation.
iii) When an assistant surgeon is required to render technical assistance at an operation, the eligible
expense for such services shall be limited to 20% of the UCR fee for the surgical procedure.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 17
DESCRIPTION OF MEDICAL BENEFITS (CONTINUED)
40. Temporomandibular Joint Disorder (TMJ) Treatment
a) Charges for treatment of temporomandibular joint disorder, including conditions of structures linking
the jaw, skull, and the complex of muscles, nerves and other tissues related to the
temporomandibular joint, subject to the maximum shown in the Summary of Medical Benefits.
Covered charges include, but are not limited to diagnostic x-ray services; oral surgery;
transcutaneous electrical nerve stimulation (TENS); and any appliance that is attached to, or rests
on, the teeth.
41. Therapeutic Injection
a) Injectable medication, allergy serum, chemotherapy, blood products or other substances intended for
injection (but not those included with home health services, home infusion therapies, hospitalization,
or the participating pharmacy benefit) are covered as listed in the Summary of Benefits.
42. Well Newborn Nursery Care
a) Hospital expenses for room, board and other healthy newborn care furnished to a covered newborn
dependent while the mother is receiving medically necessary treatment in an inpatient facility. If an
inpatient co -payment applies, only one co -payment is taken for both the mother's and the newborn's
expenses.
b) A newborn infant will be automatically added to the Plan for 31 days after the date of birth. In order to
continue coverage for a newborn beyond that time, an enrollment application must be submitted.
Please refer to the Enrollment and Eligibility section of this document.
Deschutes County Employee Benefit Plan Effective August 1, 2000 Page 18
MEDICAL PLAN LIMITATIONS AND EXCLUSIONS
Six -Month Exclusion Period
This Plan will not pay toward expenses for the following conditions, services and supplies during the first six
months following the enrollment date. The six-month exclusion period applies to:
■ Allergies;
■ Asthma;
• Elective procedures (procedures that can reasonably be postponed for the exclusion period);
■ Otitis media (inner or middle ear infection);
• Removal of tonsils or adenoids, with or without myringotomy;
■ Sterilization; or
■ Pre-existing conditions (any condition for which medical advice, diagnosis, care or treatment was
recommended or received during the six-month period immediately preceding the subscriber's enrollment
date. Pregnancy does not constitute a pre-existing condition.)
24 -Month Exclusion Period - Transplants
This Plan will not pay toward expenses for organ and/or tissue transplants during the first 24 months following
the enrollment date. For a description of transplant -related services, refer to "Organ and/or Tissue
Transplants" on page 15.
Prior Coverage Credit
If the member was covered under a previous health benefit plan, and was continuously insured with a 63 -day
(or less) break in coverage before the enrollment date under this Plan, the exclusion periods will be reduced
by one day for every day of enrollment under the previous policy. The enrollment date is the employee's date
of hire, or in the case of employees and/or dependents who are enrolled subsequent to the original eligibility
date (late enrollees), the first day of the waiting period or the actual date benefits begin, whichever is earlier.
Limitations and Exclusions
Certain services and supplies are not covered at all under the Plan; other expenses are limited or are only
covered under certain conditions. Please read this section thoroughly. Please note: Additional limitations
and exclusions are listed beginning on page 10 under Vision Plan Limitations and Exclusions, on
page 27 under Dental Plan Limitations and Exclusions, and on page 24 under Prescription Plan
Limitations and Exclusions.
1. Acupressure; acupuncture; faith healing services; or reflexology, even if a covered provider performs
services.
2. Adoption expenses or any expenses related to surrogate parenting.
3. Any illness or injury arising out of an act of military service; declared or undeclared war; riot; insurrection
or invasion; commission of a felony; or in the course of illegal activity by a covered employee or
dependent, including expenses resulting from or occurring: (1) during the commission of a crime by the
covered person; or (2) while engaged in an illegal act, illegal occupation or aggravated assault. This
exclusion includes charges for the care of inmates while in the custody of any state or federal law
enforcement authority, in jail, or in prison.
4. Any illness or injury sustained as a result of being engaged in an activity primarily for wage, profit, or gain,
or which could entitle the covered person to a benefit under the Workers' Compensation Act or similar
legislation.
5. Benefits payable under any automobile medical, personal injury protection, automobile no-fault,
homeowner, commercial premises coverage, or similar contract or insurance when such contract or
insurance is issued to, or makes benefits available to, the covered person. This also includes treatment
of illness or injury for which a third parry is liable.
6. Biofeedback.
7. Charges covered by any city, county, state or federal law, except Medicaid.
8. Charges for broken appointments; telephone calls; completion of forms; and medical records.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 19
MEDICAL PLAN LIMITATIONS AND EXCLUSIONS (CONTINUED)
9. Charges for services furnished in a hospital or program operated by a government agency or authority,
unless the covered person is a veteran of the armed forces, in which case covered services and supplies f
which are furnished by the Veterans' Administration of the United States, and which are not service -
related are eligible for benefits.
10. Charges for services rendered by a physician, nurse, or licensed therapist who is a close relative of the
covered person, or who resides in the same household as the covered person.
11. Charges for travel, except as specifically included, even if recommended by a physician.
12. Charges for treatment in excess of the least costly service or supply that will produce an acceptable
result, in the opinion of the Plan.
13. Charges for which a claim was not submitted to the Plan Administrator within 12 months of the date of
service.
14. Charges incurred in connection with care, treatment, or operations that are performed for cosmetic
purposes, except as specifically included.
15. Charges incurred prior to the effective date of coverage under the Plan, or after coverage is terminated.
16. Charges which the covered person is not, in the absence of this coverage, legally obligated to pay, or for
which a charge would not ordinarily be made in the absence of this coverage.
17. Complications arising from any non -covered surgery or treatment.
18. Convalescent or custodial services, regardless of where such services are provided, except as
specifically included under the Home Health Care and Hospice Care benefits.
19. Dental expenses, except as specifically included or as covered by the Dental Plan.
20. Drugs, medicines, or supplies which do not require a physician's prescription; anorexiants (weight -loss
drugs); fertility drugs; vitamins and nutritional supplements that do not require a physician's prescription;
drugs to promote hair growth; smoking cessation products; impotence treatments; and drugs prescribed
for cosmetic purposes (e.g., Retin-A for any diagnosis except acne).
21. Duplication of benefits provided by any other program sponsored by Deschutes County.
22. Education; counseling; job training; or care for learning disorders or behavioral problems, whether or not
services are rendered in a facility that also provides medical and/or mental health treatment.
23. Experimental procedures or drugs; research studies; or any services or supplies not considered legal in
the United States and its territories.
24. Eye examinations, except as provided under vision benefits, unless such treatment is due to an illness or
accidental injury.
25. Family planning (except sterilization and oral birth control.)
26. Genetic counseling or testing for any condition.
27. Growth hormones and growth hormone conditions, other than growth hormone deficiency in children,
failure in children secondary to chronic renal insufficiency prior to transplant, or for the promotion of
wound healing in persons with severe, active burns while hospitalized. Growth hormone for the treatment
of these listed conditions is covered when all Plan provisions (including Medical Necessity) are met.
28. Hearing tests and devices, both internal and external, including implantable hearing aids and surgical
procedures to implant them, unless necessitated by damage to the natural ear as a result of an injury.
29. Home birth, and related expenses.
30. Hospital late discharge fees for the purpose of patient, family, or physician convenience.
31. Hospitalization ordered solely due to the patient's age, apprehension, or emotional state; or for the
convenience of the patient, family, or physician.
32. Hypnosis or hypnotherapy.
33. Inpatient confinement primarily for x-rays, laboratory, diagnostic study, physiotherapy, hydrotherapy,
medical observation, convalescent or rest care; or any medical examination or test not connected with an
active illness or injury.
Deschutes county Employee Benefit Plan Effective August 1, 2000 page 20
MEDICAL PLAN LIMITATIONS AND EXCLUSIONS (CONTINUED)
34. Intentionally self-inflicted injury or illness, whether sane or insane.
35. Learning disabilities including, but not limited to dyslexia; tongue thrust; stuttering or stammering; and
speech and articulation disorders.
36. Maintenance care. Unless specifically included elsewhere, the Plan does not provide benefits for
services and supplies intended primarily to maintain a level of physical or mental function.
37. Marriage or family therapy.
38. Massage, massage therapy or Rolfing.
39. Mental examinations or psychological testing and evaluations not provided as an adjunct to treatment or
diagnosis of a mental disorder, including, but not limited to: mental examinations for the purpose of
adjudication of legal rights, administrative awards or benefits, or corrections or social service placement;
or for any use except as a diagnostic tool for the provision of mental health or chemical dependency
treatment as provided by the Plan.
40. Mental health treatment for conditions relating to academic -related problems, adult antisocial behavior,
childhood or adolescent antisocial behavior or adjustment, marital problems, occupational problems,
parent-child problem and other family circumstances, and phase -of -life problem or other life circumstance
problem.
41. Mental retardation.
42. Naturopathic and homeopathic treatment.
43. Non-medical self-help programs such as "Outward Bound" or "Wilderness Survival"; recreational or
educational therapy.
44. Non-surgical treatment of the feet, including but not limited to: callus or corn paring or excision; toenail
trimming; any manipulative procedure for weak or fallen arches, flat or pronated foot or foot strain;
impression casting for appliances; orthotics; orthopedic shoes and supports.
45. Obesity or weight control treatment.
46. Organ and/or tissue transplants, except as specifically approved by the Plan.
47. Preventive (routine) care, except as specifically included in the Description of Medical Benefits.
48. Private nursing services.
49. Procedures to diagnose infertility or to restore or enhance fertility; artificial insemination; in -vitro
i fertilization.
50. Purchase or rental of supplies of common use such as: exercise cycles; air purifiers; air conditioners;
water purifiers; hypoallergenic pillows; mattresses and waterbeds; motorized transportation equipment;
escalators or elevators; saunas; steam baths; swimming pools; blood pressure kits; and humidifiers. This
exclusion applies even if supplies of common use are obtained upon the recommendation of a physician.
51. Self-help or training programs (e.g. smoking cessation, weight control, general fitness).
52. Services or supplies that are not medically necessary for the treatment of an active illness or injury; are in
excess of UCR; or are not recommended and approved by a physician.
53. Services or supplies to diagnose, rule out, or treat paraphilia as defined by the most current version of the
Diagnostic and Statistical Manual of Mental Disorders.
54. Services or supplies which constitute personal comfort or beautification items; television or telephone
use; charges incurred in connection with custodial care, education or training; or expenses actually
incurred by other persons.
55. Services required by state law as a condition of obtaining or maintaining a driver's license.
56. Services, supplies, or treatment not commonly Find customarily recognized throughout the physicians'
profession or by the American Medical Association as generally accepted and medically necessary for
the diagnosis and/or treatment of an active illness or injury. Charges for procedures, surgical or
otherwise, which are specifically listed by the American Medical Association as having no medical value.
57. Sleep disorders- services, supplies or treatment of sleep disorders.
•
Deschutes county Emptoyee Benefit Plan Effective August 1, 2000 page 21
MEDICAL PLAN LIMITATIONS AND EXCLUSIONS (CONTINUED)
56. Social and cultural rehabilitation.
59. Sterilization for dependent children, including complications.
60. Treatment by a provider who has not shown proficiency in the procedure, based on experience and
satisfactory outcomes in an acceptable number of cases; or who is practicing outside the scope of his or
her license, registration, or certification as required by the state in which the provider is practicing.
61. Treatment of a mental illness for which there is no effective cure.
62. Treatment of sexual disorders and/or dysfunction including, but not limited to impotency and frigidity; and
penile implants. This exclusion includes all physician examinations and diagnostic x-ray or laboratory
studies and related expenses.
63. Treatment of transsexualism; gender dysphoria; or sexual reassignment or change and related
expenses.
64. Treatment that is court-ordered or related to deferred prosecution; deferred or suspended sentencing; or
driving rights.
65. Vision therapy or training regardless of the diagnosis.
Charges that are not specifically described as covered services are excluded. It is further intended
that benefits only be provided when such services are medically necessary, and required in the
diagnosis and treatment of an Illness or injury.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 22
i
i
•
DESCRIPTION OF PRESCRIPTION BENEFITS
The Prescription Drug Plan includes Express Scripts Participating Pharmacies, and the Certifax Mail -Order
Program.
Generic Substitution
Over 400 commonly prescribed drug products are now available in a generic form at an average cost of 50%
less than the name -brand products. This Plan encourages the use of generic prescription drugs. By law,
generic drugs must meet the same standards of safety, purity, strength and effectiveness as name -brand
drugs. Since name -brand drugs are often two to three times more expensive than generic drugs, use of
generics with this benefit will save money, and the covered person is encouraged to ask his or her physician
to prescribe a generic whenever possible.
If a generic drug is prescribed but the covered person purchases a name -brand drug, the covered person will
be required to pay both the co -payment, plus the difference in cost between the generic and the name -brand
drug.
Payment Schedule
The covered person must pay a co -payment for each prescription filled, as shown in the Summary of
Prescription Benefits.
Covered Expenses
The following expenses are covered under the Prescription Drug Plan, provided that all Plan provisions are
met:
1. Legend drugs. Legend drugs are those
drugs which cannot be purchased without a
prescription written by a physician or dentist;
2. Allergy extracts or other injectable drugs
intended for use in a physician's office or
settings other than home use;
3. Ritalin;
4. Insulin and diabetic supplies;
5. Fluoride products;
6. Peridex;
7. Migraine therapy;
8. Injectable medications, including Imitrex, bee
sting kits, Glucagon, growth hormones,
Lupron, and interferons;
9. Acne treatments, including Retin-A, through
age 24, and Accutane;
10. Antibiotics;
11. Vitamins and minerals requiring a physician's
prescription;
12. Hemanitics (iron preparations) requiring a
physician's prescription;
13. Anabolic steroids;
14. Psychotherapeutic drugs;
15. Alcoholism and chemical dependency
medications;
16. AIDS treatment;
17. Immunosupressant agents;
18. Chemotherapy agents;
19. Laxatives;
20. Compound medications which include at
least one legend drug;
21. Syringes and needles; and
22. Oral contraceptives.
Prescriptions Purchased Without the Express Scripts Benefit
If a prescription is purchased at an Express Scripts Participating Pharmacy but the participant does not utilize
his or her Express Scripts benefit at the time of the prescription purchase, or if a prescription is purchased at
a non -participating pharmacy, the employee must file a claim with Express Scripts using their claim form. A
50% co -payment will be taken. ,
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 23
DESCRIPTION OF PRESCRIPTION BENEFITS (CONTINUED)
Mail -Order Information
For an existing prescription, provide Certifax with the information requested on the initial order form and a
Certifax pharmacist will transfer the existing prescription to the Certifax Mail -Order pharmacy. The physician
can also telephone in refill prescriptions in order to save time. Refills can be ordered over the telephone with
a credit card by calling (800) 635-3070. The physician can also telephone or fax new prescriptions to Certifax
if the participant has previously provided credit card payment information. Certifax pharmacists automatically
call the physician for refills when the prescriptions expire.
Pharmacists are available for counseling Monday through Friday from 7:00 AM to 5:00 PM, Pacific Time, at:
(800) 635-3070
Certifax maintains a quick turnaround time. Orders which do not require a conversation with either the
participant or the physician prior to dispensing will be filled and mailed within one or two days. Prescriptions
that require communication with either the participant or the physician will not be filled until all questions have
been answered.
Summary
In order to best utilize the prescription benefits, continue to have non -maintenance prescriptions (prescribed
for an urgent illness or injury) filled at an Express Scripts Participating Pharmacy. However, when ordering
maintenance medications (those taken on a regular or long-term basis such as heart, allergy, diabetes or
blood pressure medications), use the Certifax Mail -Order Program.
PRESCRIPTION PLAN LIMITATIONS AND EXCLUSIONS
Dispensing Limitations
The Prescription Drug Plan will cover the amount normally prescribed by a physician, not to exceed a 34 -day
supply for prescriptions purchased at the pharmacy, or a 100 -day supply for prescriptions purchased through
the Mail -Order Program.
Limitations and Exclusions
a The following expenses are not covered, or benefits are specifically limited. Some of the excluded items and
products may be covered under the Medical Plan (e.g., therapeutic devices or support garments), please
p refer to the Description of Medical Benefits portion of this document.
J
1. Non -legend drugs (non-prescription drugs); 10. Administration or injection of drugs;
` 2. Anorexiants; 11. Immunization agents, biological sera, blood, or
blood plasma;
3. Fertility drugs;
+ + 12. Vitamins and fluoride (except those which by
4. Contraceptive devices other than oral law require a prescription order);
i'
5. Cosmetic indications (e.g. drugs to promote 13. Drugs prescribed for weight loss or treatment
growth of hair); of obesity (including, but not limited to
'i
i.
6. Smoking cessation products; amphetamines); and
i 7. Viagra and other medications for impotence; 14. Drugs dispensed in a facility (drugs dispensed
to the employee or covered dependent while a
8. Ostomy supplies; patient in a hospital, skilled nursing facility,
9. Drugs with no proven therapeutic indication; nursing home, or other health care institution.)
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 24
f' i
•
DESCRIPTION OF DENTAL BENEFITS
When dental care is necessary, the Plan covers the following Preventive, Basic and Major Services. All
benefits are subject to the Plan limitations and exclusions. Dental benefits are also subject to the
Dental Plan Limitations and Exclusions as described beginning on page 27 of this document.
Transfer of Care
If care is transferred from one dentist to another during a course of treatment, the Plan will only pay benefits
up to the amount it would have paid had only one dentist rendered service.
Alternate Course of Treatment
In all cases in which there are optional techniques of treatment that will produce an acceptable result in the
opinion of the Plan, the Plan shall be liable for the amount of the treatment carrying the lesser fee.
General Dental Plan Provisions
Benefits will only be paid for claims incurred while the covered person is eligible under the Plan. A claim is
incurred at the time of treatment (for crowns and prosthetic devices the claim is incurred when the device is
seated).
The Plan has the right to request a second opinion for any treatment prior to benefit payment.
PREVENTIVE SERVICES
The following Preventive Services are covered. The percentage level is determined by the employee's length
of coverage, please refer to the Summary of Dental Benefits on page 9 of this document.
1. Diagnostic oral exam.
2. Prophylaxis (or cleaning) of the teeth.
3. Topical application of fluoride.
4. Bitewing x-rays.
5. Full -mouth (or panorex) x-ray.
6. Space maintainers for children, when used to maintain space for eruption of permanent teeth. Space
maintainers used in conjunction with orthodontia treatment are covered only under the Orthodontia
Services benefit.
7. Emergency exams and treatment for the relief of dental pain.
8. Application of pit and fissure sealants.
9. Initial orthodontic exam.
10. Examination for a Statement Certifying Oral Health. Oregon State law requires this certificate before
most care furnished by a denturist.
BASIC SERVICES
The following Basic Services are covered. The percentage level is determined by the employee's length of
coverage, please refer to the Summary of Dental Benefits on page 9 of this document.
1. Amalgam, synthetic, or plastic restorations (fillings) necessary to restore the structure of teeth broken
down by decay or injury. The charge for a composite or plastic restoration placed on a posterior (back)
tooth will be reduced to the amalgam allowance for the same procedure. The charge for gold
restorations will be reduced to the amalgam allowance for the same procedure.
2. Root canal therapy and other endodontic treatment
3. Palliative treatment (emergency treatment primarily for relief, not cure).
4. Periodontal procedures, including scaling and root -planing, gingival curettage, periodontal maintenance
procedures, gingivectomy, gingivoplasty, osseous surgery, mucogingival surgery.
5. General anesthesia (excluding nitrous oxide) and its administration in connection with complex oral
surgery, major periodontics procedures, fractures or dislocations, or due to a concurrent medical
condition.
BASIC SERVICES continued next page
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 25
41
r,
DESCRIPTION OF DENTAL BENEFITS (CONTINUED)
BASIC SERVICES (continued)
6. Extraction of teeth, surgical extraction of impacted molars, 11
7. Oral surgery.
8. Dental x-rays not included in Preventive Services.
9. Antibiotics administered by a dentist or physician.
MAJOR SERVICES
The following Major Services are covered. The percentage level is determined by the employee's length of
coverage, please refer to the Summary of Dental Benefits on page 9 of this document.
1. Crowns, inlays and onlays necessary to restore the structure of teeth broken down by decay or injury
when the tooth cannot be restored with filling materials such as amalgam, silicate or plastic. Crowns,
inlays or onlays on the same tooth are covered once in a five-year period.
2. Initial installation of fixed and removable bridgework (including wing attachments, inlays and crowns as
abutments).
3. Replacement of existing fixed and removable bridgework. Replacement of existing bridgework is
covered only once every five years, and only then if it is unserviceable and cannot be made serviceable.
No benefits will be provided for lost or stolen prosthetic devices.
4. Initial installation of full or partial dentures. Charges for adjustments of prosthetic devices made within six
months of installation are not covered.
5. Replacement of existing full or partial dentures. Replacement of an existing prosthetic device is covered
only once every five years and only then if it is unserviceable and cannot be made serviceable. No
benefits will be provided for lost or stolen prosthetic devices. Charges for adjustments of prosthetic
devices made within six months of installation are not covered.
6. Installation of precision attachments for removable dentures.
i 7. Addition of clasp or rest to existing partial removable denture.
` 8. Relining of dentures.
9. Repair and recementing of crowns, inlays, bridgework and dentures.
10. Prosthetic services provided by a denturist must be accompanied by a Statement Certifying Oral Health
from a dentist or physician, except when services are to repair a denture or to replace a denture that was
placed within 12 months prior.
11. Bruxism splints and night guards.
12. Periodontal splints.
ORTHODONTIA SERVICES
The Dental Plan will pay 50% of the initial banding fee, or down payment. Any eligible balances remaining, up
to the maximum shown in the Summary of Dental Benefits, will be pro -rated over the prescribed treatment
period. The initial orthodontic exam is covered under Preventive Services.
Replacement andior repair of orthodontic appliances prescribed under the treatment plan are not covered.
Before benefits are payable, the Plan must approve an Orthodontic Treatment Plan. The Orthodontic
Treatment Plan is a report written by the covered person's orthodontist listing proposed services. This report
must include the total orthodontic charge, the initial banding fee, and the estimated length of required
treatment. It must be based on an examination which takes place while the person is covered by this Dental
Plan, and it must show a diagnosis indicating an abnormal occlusion which can be corrected by orthodontic
care.
In order for the Plan to pay for covered services, especially in cases where treatment is! already under way
when coverage begins or ends, all orthodontic treatment must be performed while the person is covered
under this Dental Plan and it cannot exceed the length of time prescribed in the treatment plan.
Deschutes County Employee Benefit Plan Effective August 1, 2000
page 26
DENTAL PLAN LIMITATIONS AND EXCLUSIONS
There are certain items specific to the Dental Plan that are not covered, these are listed below. Please refer
to the Medical Plan Limitations and Exclusions beginning on page 19 for additional limitations and
exclusions.
1. Any expenses covered by the Medical or other portions of the Plan.
2. Appliances or restorations to correct vertical dimension or occlusion or to break habits, (with the
exception of bruxism splint, night guard, or periodontal splint, which are covered Major Services).
3. Charges for broken appointments; completion of charts or forms; or patient management.
4. Dental implants, including any appliance and/or crown and the surgical insertion or removal of the
implant.
5. Duplicate bridge or denture or any other duplicate dental appliance, unless the existing denture is an
immediate temporary denture and replacement by a permanent denture is completed within 12 months
from the date of the initial installation of the temporary denture. Permanent appliances that replace
temporary appliances are limited to the maximum UCR allowance for the permanent appliance.
6. Gnathological recordings (recording of jaw movement and positions).
7. Gold, when billed separately.
B. Hospital costs or any additional fees charged by the dentist because the patient was hospitalized.
9. Myofunctional therapy.
10. Nitrous oxide (N20) or any other sedative or analgesic, except general anesthesia or intravenous
sedation when done in conjunction with open cutting procedures.
11. Oral hygiene instruction; dietary instruction; sterilization and contamination control; plaque control
programs; home fluoride kits; or dental care appliances.
12. Periodontal probing or charting, when billed separately.
13. Personalization of dentures.
14. Precision or semi -precision attachments, except as specifically provided for in the Plan.
15. Prescription drugs are payable only under the medical benefits when medically necessary for the
treatment of infection or pain, except as listed in the Summary of Dental Benefits.
(� 16. Rebasing or relining a denture within six months of the date of initial placement, or for the performance
of such service more often than once in any two-year period.
17. Replacement and/or repair of orthodontic appliances.
18. Replacement .dental appliance or prosthetic device, crown, cast restoration or fixed bridge placed within
five years of the prior placement date.
19. Replacement of lost or stolen appliances.
20. Services begun prior to the covered person's effective date on the Plan.
21. Services for cosmetic or aesthetic reasons including, but not limited to laminates; restorations due to
misalignment or discoloration of teeth; and bleaching.
22. Services or supplies for which payment could be obtained in whole or in part if the covered person had
applied for payment under any city, county, state or federal law except Medicaid.
23. Services or supplies that are not necessary for the treatment of the dental condition being treated.
24. Services rendered by a dentist beyond the scope of his or her license.
25. Services that are not included in the list of covered dental services.
26. Study models.
27. Treatment of TMJ (Temporomandibular Joint Disorder).
28. Treatment that is not generally recognized as tested and accepted dental practice by the American
Dental Association (ADA).
29. Upper or lower jaw augmentation or reduction procedures (orthognathic surgery) regardless of illness or
injury.
Charges that are not specifically described as covered services are excluded. It is further intended
that benefits only be provided when such services are necessary, and required in the diagnosis and
treatment of a dental condition.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 27
mss:_------------
DEFINITION OF TERMS
Accidental Injury
An injury is a definite impairment of function or traumatic injury to a body structure resulting from unintentional )�
causes beyond the control of the injured party. Diagnoses which are not definite injuries, such as sprains,
strains, pulled muscles, etc., can be considered as an accident, if the claim clearly indicates how the injury
occurred. Accident cases will be considered as an illness case after ninety days from the date of injury.
Allowable Charge
For preferred providers, the "Allowable Charge" is the fee that the provider has agreed to accept as full
payment for medically necessary covered services. The amount that preferred providers have agreed to
accept as full payment for medically necessary covered services is determined by the preferred agreements
with the providers. Preferred providers will seek payment from the Contract Administrator when they furnish
covered services to a covered employee or dependent. The covered person will be responsible only for any
applicable deductible, coinsurance, expenses in excess of stated benefit maximums, and charges for
services or supplies not covered by the Plan.
For non -preferred providers, the "Allowable Charge" is the fee that the Contract Administrator finds is the
Usual, Customary and Reasonable (UCR) fee for medically necessary covered services. This amount will not
be more than the provider's actual charge. The covered person is responsible for any amount that exceeds
the UCR allowance.
Ambulatory Surgical Center
An institution or facility, either freestanding or as a part of a hospital with permanent facilities, equipped and
operated for the primary purpose of performing surgical procedures, to which a person is admitted, and from
which a person is discharged within a 24-hour period. An office that is maintained by a physician for the
practice of medicine or dentistry, or for the primary purpose of performing terminations of pregnancy will not
be considered to be an ambulatory surgical center.
Amendment
A formal document that changes the provisions of the Plan Document, duly signed by the authorized person
or persons as designated by the Plan Administrator.
Approved Treatment Plan
A written outline of proposed treatment, which is submitted by the attending physician to the Contract
Administrator for review and approval.
Benefit Percentage
That portion of eligible expenses to be paid by the Plan in accordance with the coverage provisions as stated
in the Plan. It is the basis used to determine any out-of-pocket expenses in excess of the annual deductible,
which are to be paid by the employee.
Benefit Period
The time period shown on the Summary of Medical, Dental and Vision Benefits. The benefit period will
terminate on the earliest of the following dates:
1. The last day of the period so established;
2. The day the maximum lifetime benefit applicable to the covered person becomes payable; or
3. The day the covered person ceases to be eligible for coverage.
Benefits
The covered medical, surgical or hospital, dental and vision benefits set forth in the Plan.
Birthing Center
A properly licensed facility which meets all of the following criteria:
1. It is mainly engaged in providing care for childbirth, including prenatal and postpartum care;
2. It keeps complete medical records on all patients;
3. It has a utilization review plan;
4. It requires that a physician examine the patient at least once before delivery;
Birthing Center continued next page
Deschutes County Employee Benefit Plan
Effective August 1, 2000 page 28
111 I
DEFINITION OF TERMS (CONTINUED)
Birthing Center (continued)
�l 5. It requires that a physician perform any necessary surgical procedure;
6. It contains at least the following equipment, and has trained personnel to operate that equipment:
a) A fetal monitor,
b) An incubator, and
c) A resuscitator.
7. It does not keep any patient for more than 24 hours of inpatient care; and
6. It has a written agreement in force with at least one hospital for immediate transfer of patients who
require treatment in a hospital.
9. This Plan does not cover expenses related to home birth.
(6b
Calendar Year
The period of 12 consecutive months which starts each January 1 at 12:01 a.m. and ends on the following
December 31 at midnight.
Chemical Dependency
A condition characterized by a physiological or psychological dependence, or both, on alcohol or a state -
regulated controlled substance. Chemical dependency is further characterized by a frequent or intense
pattern of pathological use to the point that the user:
1. Loses self-control over the amount and circumstances of use
2. Develops symptoms of tolerance, or psychological and/or physiological withdrawal if use is reduced or
stopped; and/or
3. Substantially impairs or endangers his or her health or substantially disrupts his or her social or economic
function.
Chemical dependency includes alcohol and drug psychoses and alcohol and drug dependence syndromes.
Dependence upon tobacco, nicotine and caffeine are not included in this definition.
Chemical Dependency Treatment Facility
Any public or private treatment facility providing services for the treatment of chemical dependency, which
meets all of the following criteria:
1. It is accredited by the Joint Commission on Accreditation of Hospitals (JCAHO) or is licensed by the
appropriate state licensing authority as a Chemical Dependency Treatment Center;
2. It is operated chiefly for the treatment of chemical dependency and it provides a program for diagnosis,
evaluation and effective treatment.of alcoholism and/or chemical dependency;
3. It provides detoxification services;
4. It provides infirmary -level medical services, or has an arrangement with a hospital in the area to provide
any medical services which may be required;
5. It is at all times supervised by a staff of physicians;
6. It provides 24-hour skilled nursing care by licensed nurses who are directed by a full-time registered
nurse;
7. It prepares and maintains a written plan of treatment, which is supervised by a physician, for each patient
based on the patient's medical, psychological and social needs.
Chiropractic Care/Spinal Manipulation
Skeletal adjustments, manipulation or other treatment in connection with the detection and correction by
manual or mechanical means of structural imbalance or subluxation in the human body. Such treatment is
done by a chiropractor to remove nerve interference resulting from, or related to, distortion, misalignment or
subluxation of or in the vertebral column.
Close Relative
The spouse, mother, father, sister, brother, daughter, son, father-in-law or mother-in-law of the covered
person.
Co -Payment
The amount a participant is obligated to pay to a provider, in addition to deductible expenses (except for
prescription co -pays, which are in addition to the deductible and the out-of-pocket amount).
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 29
tli
DEFINITION OF TERMS (CONTINUED)
COBRA Beneficiary
Any former employee or dependent covered under the Plan, who is continuing participation under the
provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) and its amendments.
Complication of Pregnancy
1. Direct:
a) Hyperemesis gravidarum (pernicious vomiting during pregnancy), eclampsia of pregnancy (toxemia
with convulsions), severe antepartum hemorrhaging due to premature labor, cesarean section for
ectrauterine pregnancy; or
b) Spontaneous termination of pregnancy which occurs during a period of gestation in which a viable
birth is not possible.
2. Indirect:
a) Bodily or mental disorder whose diagnosis is distinct from pregnancy but which is adversely affected
by pregnancy or is caused by pregnancy, such as acute nephritis, nephrosis, cardiac
decompensation and similar medical and surgical conditions of comparable severity; or
b) Therapeutic abortion necessary as part of the treatment of severe bodily or mental disorder included
in (1) above.
In no event shall "Complication of Pregnancy" include cesarean section delivery as an alternative to vaginal
delivery after the 35th week of pregnancy; false labor; occasional spotting; physician -prescribed rest; morning
sickness; pre-eclampsia; or similar conditions associated with the management of a difficult pregnancy, but
not constituting a classifiable and distinct complication of pregnancy.
Contract Administrator
The person or firm employed by Deschutes County to provide consulting service to Deschutes County in
connection with the operation of the Plan and any other functions, including the processing and payment of
claims. The Contract Administrator for the Plan is Administrators West.
Contributory
The term "Contributory" means the employee is required to pay a portion of the Plan cost in order to be
eligible to participate in the Plan.��
Cosmetic Procedure
A procedure performed solely for the improvement of a covered person's appearance or well being, rather
than for the improvement or restoration of bodily function.
Covered Person
An employee, a dependent or a participating COBRA beneficiary meeting the eligibility requirements for
coverage as specified in the Plan, and properly enrolled in the Plan. The term may also include retirees if
such coverage is provided under the Plan.
Creditable Coverage
Health care coverage, which includes group coverage (including Federal employee health benefit plans and
peace corps), individual coverage (including student health plans), Medicaid, Medicare, Champus, Indian
Health Service or tribal organization coverage, state high-risk pool coverage and public health plans.
Creditable coverage is used to determine the reduction that may apply to a participant' s pre-existing
conditions and eligibility for coverage in the Oregon portability program.
Custodial Care
Care or service, wherever furnished and by whatever name called, which is designed primarily to assist a
covered person, whether or not totally disabled, in the activities of daily living. Such activities include, but are
not limited to bathing; dressing; feeding; preparation of special diets; assistance in walking or in getting in and
out of bed; and supervision of medication which can normally be self-administered.
Deductible
A specified dollar amount of covered expenses that must be incurred during a calendar year before other
covered expenses can be considered for payment.
Deschutes County Employee Benefit Plan
Effective August 1, 2000 page 30
0
DEFINITION OF TERMS (CONTINUED)
Dental Care
Any treatment, operation, procedure or service performed by a dental practitioner, which is accepted as or
defined as dentistry and meets the standards of dental practice accepted by the American Dental
Association.
Dental Hygienist
A person who is licensed to practice dental hygiene and who is practicing within the scope of an applicable
license.
Dentist
A licensed Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DMD) practicing within the scope of
the applicable license, or a licensed dental practitioner authorized by the license to perform the particular
dental service rendered.
Denturist
A person who is licensed to make, fit and repair dentures, and who is practicing within the scope of the
applicable license.
Dependent
An employee's: (1) spouse who is not legally separated from the employee; (2) eligible same-sex domestic
partner; (3) unmarried child under age 23 who is dependent upon the employee or qualified domestic partner
for full or partial support (at least 50%); or (4) unmarried child age 23 or older who is incapable of self-
sustaining employment and dependent upon the employee for support due to a mental or physical illness or
handicap. Proof of disability must be submitted to the Pian.within 31 days of the date that the child turns 23
or the date that the coverage would have terminated due to the child's age.
The term "child" includes: (1) the employee's or qualified domestic partner's natural child; (2) adopted child or
a child placed for adoption with the employee or qualified domestic partner; (3) stepchild living in the
employee's home, or a nonresident stepchild if there is a Qualified Medical Child Support Order that requires
the spouse or qualified domestic partner to provide health insurance coverage; and (4) children related to the
employee or qualified domestic partner by blood or marriage for whom the employee is the legal guardian
(the employee will need to provide a court order showing legal guardianship).
If the employee has a child who is incapable of self-support because of a physical handicap or mental
retardation, that child may be eligible to remain enrolled even though he or she is over age 23. To be eligible,
the handicap must have occurred before the child's 23rd birthday. The employee must certify to the Plan that
these conditions have been met before the child's 23rd birthday.
Upon enrollment, and periodically as required by the Plan, the employee must provide documentation that his
or her dependents meet these requirements, in the form of tax records, physician's report, court order, etc.
The term "Dependent" does not include a member of any armed forces (unless he or she is an active duty
member for 30 days or less per year); an employee of Deschutes County; or any person who has permanent
residence outside of the United States.
Donor
An individual who provides the organ for a transplant recipient.
Durable Medical Equipment (DME)
Medical equipment that is:
1. Able to withstand repeated use;
2. Primarily and customarily used to serve a medical purpose; and
3. Not generally useful to a person in the absence of illness or injury.
Examples of "Durable Medical Equipment" include a wheelchair, a hospital bed, and a ventilator.
Deschutes County Employee Benefit Plan
Effective August 1, 2000
page 31
-F
DEFINITION OF TERMS (CONTINUED)
Election Period (COBRA)
The 60 -day period during which a qualified beneficiary who would lose coverage as a result of a qualifying
event may elect COBRA Continuation Coverage. This 60 -day period begins no later than the date of
termination of coverage as a result of a qualifying event, and ends not earlier than 60 days after the later of:
(1) the date of termination of coverage; or (2) the date of receipt of notice of the right to elect COBRA
Continuation Coverage under the Plan.
Elective Surgical Procedure/Elective Surgery
A non -emergency surgical procedure which is scheduled at the covered person's convenience without
endangering the life of the person or without causing serious impairment to the person's bodily functions.
Emergency Medical Condition
A medical condition that manifests itself by symptoms of sufficient severity that a prudent layperson
possessing an average knowledge of health and medicine would reasonably expect that failure to receive
immediate medical attention would place the health of a person in serious jeopardy.
Employee
Any person who is rendering personal services on a full-time or part-time basis to Deschutes County for
compensation, excluding any employee who is not regularly scheduled to work at least 20 hours per week, or
an eligible retiree.
This definition does not include temporary or contract employees.
Employer
Deschutes County.
Enrollment Date
The employee's date of hire, or in the case of employees and/or dependents who are enrolled subsequent to
the original eligibility date, the first day of the waiting period or the actual date benefits begin, whichever is
earlier.
ERISA
The Employee Retirement Income Security Act of 1974 or any provision or section thereof which is herein
specifically referred to as such act, provision or section, as amended from time to time.
Experimental or Investigative
Any treatment, procedure, facility, equipment, drug or drug usage, device or supply not accepted as standard
treatment of the condition being treated by the general medical community, or any such items requiring
federal or other governmental agency approval not granted at the time services were rendered. Such
agencies include but are not limited to the American Medical Association and/or the Food and Drug
Administration.
Eye Examination
An inspection of the internal and external appearance of the eye, eye movement, visual acuity, visual fields,
color vision, glaucoma and a refraction test, to assess whether glasses or contact lenses are necessary.
Family and Medical Leave Act of 1993 (FMLA)
The "Family and Medical Leave Act of 1993" provides for a leave of absence to be granted to an eligible
participant by the employer in accordance with Public Law 103-3 for: the birth or adoption of the employee's
child; the placement in the employee's care of a foster child; the serious health condition of the employee's
spouse, eligible same-sex domestic partner, child or parent; or the employee's own disabling health condition.
This Act applies to public employers of any size or private sector with 50 or more employees for at least 20
work weeks in the current or preceding calendar year.
Family and Medical Leave Act of 1993 (FMLA) continued next page
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 32
i;j
DEFINITION OF TERMS (CONTINUED)
Family and Medical Leave Act of 1993 (FMLA) (continued)
10 The following are some definitions identified by the FMLA:
1. "Eligible": An individual who has been employed by the employer for at least 12 months, has performed
at least 1,250 hours of service during the previous 12 -month period, and has worked at a location where
at least 50 employees are employed by the employer within 75 miles.
2. "Serious Health Condition": An illness, injury, impairment, or physical or mental condition which involves:
(a) inpatient care in a hospital, hospice or residential medical care facility; or (b) continuing treatment by a
health provider.
These definitions are listed as a guide only, and the actual wording of the FMLA, as amended, shall
supersede these definitions.
Family Status Change
A status change brought about by the occurrence of one or more of the following events: birth or adoption of
a child; divorce; marriage; death of a spouse or eligible same-sex domestic partner; involuntary reduction in
employment hours; involuntary loss of a spouse's or eligible same-sex domestic partner's employment due to
layoff; or employer termination.
Family Unit
A covered employee and those persons covered under the Plan as the covered employee's dependents.
Fiduciary
Deschutes County, the Board of Directors, or the Plan Administrator, but only with respect to the specific
responsibilities of each with respect to the administration of the Plan.
Full -Time Employment
A basis whereby an employee is employed by Deschutes County for a minimum of 40 hours per week. Such
work may occur either at the usual place of business. of Deschutes County or at a location to which the
business of Deschutes County requires the employee to travel, and for which he or she receives regular
earnings from Deschutes County.
Generic Drug
A prescription drug that has the equivalency of the brand name drug, with the same use and metabolic
disintegration. This Plan will consider a generic drug to be a Food and Drug Administration approved generic
pharmaceutical which is dispensed according to the professional standards of a licensed pharmacist and
clearly designated by the pharmacist as generic.
Home Health Care Agency
A public or private agency or organization which specializes in providing medical care and treatment in the
home, which meets all of the following criteria:
1. It is primarily engaged in and licensed by the Community Health Accreditation Program (CHAP) to
provide skilled nursing services and other therapeutic services;
2. It has policies established by a professional group associated with the agency or organization. This
professional group must include at least one physician and at least one registered nurse to govern the
services provided, and it must provide for full-time supervision of such services by a physician or
registered nurse;
3. It maintains a complete medical record on each patient; and
4. It has a full-time administrator.
Home Health Care Plan
A program for care and treatment of a patient established and approved by the patient's attending physician,
which is in lieu of continued confinement as an inpatient in a hospital which would be required in the absence
of the services and supplies provided as part of the home health care plan.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 33
-4-,-ft-
DEFINITION OF TERMS (CONTINUED)
Hospice Care
A program providing a coordinated set of services rendered at home, in outpatient settings, or in an
institutional setting for a person suffering from a condition that has a terminal prognosis. A hospice must
have an interdisciplinary group of personnel that includes at least one physician and one registered nurse,
and it must maintain central clinical records on all patients. A hospice must meet the standards of the
National Hospice Organization (NHO) and applicable state licensing requirements.
Hospital
A public or private institution which meets all of the following criteria:
1. It is approved as a hospital by the Joint Commission on the Accreditation of Health Care Organizations
(JCAHO) or the American Osteopathic Association;
2. It is primarily engaged in providing, for compensation from its patients and on an inpatient basis,
diagnostic and therapeutic facilities for the surgical and medical didgnosis, treatment, and care of injured
and sick persons by or under the supervision of a staff of physicians. If primarily a facility for the
treatment of mental health conditions or substance abuse, the facility must have a bona fide arrangement
by contract or otherwise with a hospital to perform such surgical procedures as may be required;
3. It continuously provides 24-hour per day nursing service by registered nurses under the supervision of
physicians; and
4. It is not, other than incidentally, a place for rest, the aged, a nursing home, a hotel, or the like.
Illness
j A bodily disorder, disease, physical illness, or psychiatric disorder of a covered person.
Incurred Date
The "Incurred Date" for services is:
1. The date the service or procedure is performed or the supplies are furnished, except for the following
situations:
a) For dental appliances or changes to dental appliances, crowns, bridges, or cast restorations, the date
on which the appliance, crown, bridge, or restoration is seated.
b) For root canal therapy, the date on which the pulp chamber is opened for therapy.
Incurred Expenses
Those covered services and supplies furnished to a covered person.
Injury
A condition caused by accidental means, which results in damage to the patient's body from an external
force.
Inpatient
Confinement as a registered bed patient in a hospital, skilled nursing facility, hospice, or freestanding
chemical dependency treatment center.
Legend Drug
A drug or medication which cannot be purchased without a prescription written by a physician or dentist. See
"Prescription Drug".
Lifetime
The length of time an employee or dependent is covered under the Plan (or a prior plan sponsored by
Deschutes County). Under no circumstances does "Lifetime" mean the entire life of the covered person.
Mental Health CarefTreatment
Treatment for mental health disorders or conditions, as accepted by the general psychiatric community.
Deschutes County Employee Benefit Plan Effective August 1, 2000
page 34
DEFINITION OF TERMS (CONTINUED)
Medically Necessary
1,9 Health care services, supplies, or treatment which, in the judgment of the attending physician, are appropriate
and consistent with the diagnosis and which, in accordance with generally accepted medical standards, could
not have been omitted without adversely affecting the patient's condition or the quality of medical care
rendered. All of these criteria must be met. Because a physician recommends or approves certain care
does not necessarily mean that it is medically necessary.
Medicarel'Medicare Benefits
All benefits under Parts A and/or B of Title XVIII of the Social Security Act of 1965, as amended from time to
time.
Mental Health Disorder
Mental disorders, mental illnesses, psychiatric illnesses, mental conditions and psychiatric conditions,
(whether of organic or non-organic, biological or non -biological, chemical or non -chemical origin and
irrespective of cause, basis or inducement). This includes, but is not limited to the following conditions:
psychoses; neurotic disorders; schizophrenic disorders; affective disorders; personality disorders; and
psychological or behavioral abnormalities associated with transient or permanent dysfunction of the brain or
related neuro -hormonal systems.
Mental Health Treatment Facility
An administratively distinct governmental, public, private or independent unit or part of such unit which meets
all of the following criteria:
1. It provides psychiatric services and care, and is at all times supervised by a staff of physicians;
2. It provides 24-hour skilled nursing care by licensed nurses who are directed by a full-time registered
nurse;
3. It prepares and maintains a written plan of treatment for each patient based on medical, psychological
and social needs; and
4. It meets appropriate licensing standards.
Midwife
A licensed professional midwife or a professional person deemed by state law to be the same as a legally
qualified midwife, who assists in the delivery of newborns.
This plan does not cover expenses related to home birth.
Newborn Nursery Care
The fee charged by a hospital for room and board for a newborn child, while the mother is hospital -confined
following delivery.
Non -Emergency Hospital Admission
A hospital admission (including normal childbirth) which may be scheduled at the convenience of the covered
person without endangering the person's life or without causing serious impairment to the person's bodily
functions.
Nurse
An individual who has received specialized nursing training, who is authorized to use the designation RN
(Registered Nurse), LPN (Licensed Practical Nurse), or LVN (Licensed Vocational Nurse), and who is duly
licensed by the state or regulatory agency responsible for such license in the state in which the individual
performs the nursing services.
Occupational Therapy
A program of care that focuses on the physical, cognitive and perceptual disabilities which influence a
person's ability to perform functional tasks. The therapist evaluates the patient's ability to use his or her
fingers and hands (fine motor skills), perceptual skills, cognitive functioning, and eye -band coordination.
Therapy sessions may also involve physical movement exercises. Functional tasks also may be used. The
therapist may also perform splinting of the patient's arms or hands and may provide the patient with special
equipment. Therapy that is intended to address primarily vocational rehabilitation issues (e.g., return -to -work
skills) is not considered occupational therapy under the Plan.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page m5
DEFINITION OF TERMS (CONTINUED)
Out -of -Pocket Maximum
The maximum dollar amount a participant will pay for covered medical expenses in any benefit period, unless
otherwise specified in the Summary of Medical Benefits.
Outpatient
Medical services rendered to a person who is not confined as a registered bed patient in a hospital, skilled
nursing facility, hospice or freestanding chemical dependency treatment center.
Part -Time Employment
A basis whereby an employee is employed by Deschutes County for a minimum of 20 hours per week. Such
work may occur either at the usual place of business of Deschutes County or at a location to which the
business of Deschutes County requires the employee to travel, and for which he or she receives regular
earnings from Deschutes County
Partial Hospitalization
Care provided for at least three hours, but less than 12 hours in any 24-hour period at a hospital, without
which the person would require inpatient care.
Physical Therapy
A plan of care provided to return a patient to the highest level of motor functioning possible. The physical
therapist extensively evaluates the patient's muscle tone, movement, balance, endurance, ability to ambulate,
and ability to plan motor movements, strength and coordination. If the patient requires special equipment
(such as a wheelchair, walker or splint) the therapist determines the correct size and type of equipment for
the specific patient. The therapist constructs a program of exercises and movements to maximize the
patient's motor skills.
Physician
A legally licensed medical or dental doctor or surgeon, an osteopath, a chiropractor, a podiatrist, a licensed
psychologist or psychiatrist to the extent that same, within the scope of their license, are permitted to perform
services provided in the Plan. The term "Physician" also includes a certified licensed nurse -midwife, a nurse
practitioner, and a state -licensed clinical social worker, when referred by a doctor of medicine or osteopathy.
Plan
The Plan Document and all amendments and/or riders or waivers now or hereafter attached, signed by the
Plan Sponsor.
Plan Administrator
Deschutes County, which is responsible for the day-to-day functions and arrangements of the Plan. The Plan
Administrator may employ persons or firms to process claims and perform other Plan -related services.
Plan Sponsor
Deschutes County.
Plan Year
An annual period beginning on January 1 and ending on December 31, or upon termination of the Plan,
whichever occurs earlier.
Pre -Admission Testing
Services rendered to a covered person on an outpatient basis, which is medically necessary prior to a
scheduled inpatient confinement at the same facility.
Pre -Existing Condition
Any injury, illness, or related condition (except pregnancy), for which a covered person received medical care,
advice, diagnosis or treatment, or has taken prescribed drugs or medicines during the six consecutive
months immediately preceding the enrollment date.
Preferred Provider
A provider who is part of a network of providers contracted to accept a negotiated rate as payment in full for
services rendered.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 36
DEFINITION OF TERMS (CONTINUED)
Preferred Provider Organization (PPO)
A network of preferred providers and hospitals throughout a service area.
Pregnancy
The condition of being pregnant, and all conditions and/or complications resulting therefrom.
Prescription Drug
Any state or federal legend drug requiring a prescription and dispensed by a licensed pharmacist.
Psychiatric Treatment Facility
See "Mental Health Treatment Facility'.
Qualified Beneficiary (COBRA)
An individual who, on the day before a qualifying event, is a covered person under the Plan. A child born to
the covered member or who is placed for adoption with the covered member during a period of COBRA
Continuation Coverage is also a qualified beneficiary.
Qualifying Event (COBRA)
Any of the following events which result in the loss of coverage for a qualified beneficiary:
1. The death of the covered employee;
2. The termination (except for the reason of gross misconduct) or reduction in hours of the covered
employee's employment;
3. The divorce or legal separation of the covered employee from the employee's spouse;
4. The covered employee becoming entitled to benefits under Title XVIII of the Social Security Act
(Medicare);
5. A dependent child ceasing to be a covered dependent under the terms of the Plan;
6. Deschutes County filing for Chapter 11 reorganization.
Recipient
A person who receives an organ transplant from an organ donor.
(' (� Rehabilitation Facility
A legally operating institution, or distinct part of an institution, which has a transfer agreement with one or
more hospitals, which is primarily engaged in providing comprehensive multi -disciplinary physical restorative
services, hospital and rehabilitative inpatient care, and is duly licensed by the appropriate government agency
to provide such services. This definition does not include institutions which provide only minimal care,
custodial care, ambulatory or part-time care services, or an institution which primarily provides treatment of
mental health disorders, chemical dependency or tuberculosis, unless such facility is licensed, certified or
approved as a rehabilitation facility for the treatment of medical conditions, drug addiction or alcoholism in the
jurisdiction where it is located, or is accredited as such a facility by the Joint Commission on the Accreditation
of Health Care Organizations (JCAHO) or the Commission for the Accreditation of Rehabilitation Facilities.
Retiree
A retired employee of Deschutes County, who meets all of the following criteria:
1. The employee has been enrolled in the Plan (or a prior plan sponsored by the employer) for at least 24
consecutive months immediately prior to retirement, unless otherwise indicated by a management/labor
agreement;
2. The employee will be receiving benefits from PERS (Public Employee Retirement System) or from a
similar retirement plan offered by the employer.
Second Surgical Opinion
The opinion of a second physician or surgeon who is financially independent from a physician who is
recommending surgery, to determine the medical advisability of a person undergoing a plenned surgical
procedure. If the second opinion does not confirm that the planned surgical procedure is medically advisable,
then this definition shall also include a third surgical opinion.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 37
DEFINITION OF TERMS (CONTINUED)
Skilled Nursing Facility
A public or private institution, or distinct part thereof, which meets all of the following criteria:
1. It is approved by the Joint Commission on the Accreditation of Health Care Organizations (JCAHO)
and/or Medicare;
2. It provides nursing services by licensed staff under the 24-hour direction of a registered nurse;
3. It maintains a complete medical record for each patient;
4. Skilled nursing or skilled rehabilitation services are provided on a daily basis by appropriately licensed
personnel; and
5. The facility is not a place for rest, the aged, drug addicts, alcoholics, the mentally incapacitated, or for the
care of mental health disorders; nor is the facility meant for custodial care which is provided for the
primary purpose of assisting an individual in meeting the basic activities of daily living.
Speech Therapy/Pathology
A program of care which evaluates the patient's motor -speech skills, expressive and receptive language
skills, writing and reading skills, and determines if the person requires an extensive hearing evaluation by an
audiologist. The therapist also evaluates the patient's cognitive functioning as well as his or her social
interaction skills, such as the ability to maintain eye contact and initiate conversation. Therapy may also
involve developing the patient's speech, listening and conversational skills, and higher-level cognitive skills
such as understanding abstract thought, making decisions, sequencing, etc. Therapy may be considered
medically appropriate even for patients who do not have apparent speech problems, but who do have deficits
in higher-level language functioning as a result of trauma or identifiable organic disease process.
Substance Abuse
See "Chemical Dependency'.
Substance Abuse Treatment Facility
See "Chemical Dependency Treatment Facility'.
Surgical Procedure
The term "Surgical Procedure" means, but is not limited to cutting; suturing; treating burns; reduction of
fracture; reduction of dislocation; manipulation of a joint under general anesthesia; electocauterization;
paracentesis; application of plaster casts; administration of pneumothorax; endoscopy; injection of sclerosing
solution; arthroscopic procedures; and urethral dilation.
Temporomandibular Joint Disorder/Dysfunction (TMJ) Treatment
The treatment of temporomandibular joint Qaw) disorders, including conditions of structures linking the
jawbone and skull and the complex of muscles, nerves and other tissues related to the temporomandibular
joint.
Total Disability (Totally Disabled)
A, physical state of a covered person resulting from an injury or illness which wholly prevents the person:
1. In the case of an employee: from engaging in any and all business or occupation and from performing
any and all work for compensation or profit; or
2. In the case of a dependent, a COBRA beneficiary, or a retiree: from performing the normal activities of a
person for that age and sex in good health.
UCR
Usual, Customary and Reasonable.
Usual, Customary and Reasonable (UCR)
The lesser of:
1. The usual fee - the charge most frequently made for the covered services or supplies by a covered health
care provider;
2. The customary fee - the charge made for covered services or supplies by those of similar professional
standing in the same geographic area; or
3. The reasonable fee - the charge determined by considering the complexity involved, the degree of
professional skill required, and other pertinent factors, if (1) and (2) above cannot be easily determined.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 38
DEFINITION OF TERMS (CONTINUED)
Visit
' Each instance of treatment, consultation, therapy, or related session given by a health care provider.
Waiting Period
The period of time which an employee must satisfy before becoming eligible for coverage under the Plan.
Please refer to the Enrollment and Eligibility section of this document for information on the waiting period.
El
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 39
PRE-EXISTING CONDITIONS, HIPAA, AND PORTABILITY
Pre -Existing Conditions
No benefits are provided for any pre-existing condition during the first six consecutive months immediately
following the covered person's enrollment date, including complications of a pre-existing condition, even in
the case of a medical emergency. The enrollment date is the employee's date of hire, or in the case of
employees and/or dependents who are enrolled subsequent to the original eligibility date (late enrollees), the
first day of the waiting period or the actual date benefits begin, whichever is earlier.
A pre-existing condition is any injury or illness, except for pregnancy, for which a covered person received
medical care, treatment, consultation, diagnosis, services, or took prescribed medicines within the six months
immediately preceding the enrollment date. A condition is diagnosed when the physician tells a patient that
he or she has a condition, or when an entry is made in the medical record, even if the person sought
treatment for a different condition.
Any time accumulated toward satisfaction of the pre-existing condition limitation under a previous Deschutes
County plan will be counted toward the satisfaction of the pre-existing condition limitation of the Plan, as long
as there has been no lapse in coverage.
Coverage Under a Qualifying Prior Plan (HIPAA)
Prior periods of coverage may shorten or eliminate Deschutes County's six-month pre-existing condition
exclusion period. Credit will be given for all days on which the covered person had qualifying health care
coverage prior to joining the Deschutes County Plan. Days of prior coverage are "credited" by reducing, day -
for -day, the six-month pre-existing condition exclusion period the covered person would otherwise be
required to satisfy under the Plan. More specifically, Deschutes County's six-month pre-existing condition
exclusion period will be shortened one day for each day that the covered person had "creditable coverage"
under another health plan, provided that there has not been a 63 -day (or longer) lapse in coverage
immediately prior to the enrollment date. Creditable coverage includes coverage under a group health plan,
individual health insurance, a state health benefits risk pool, Medicare, Medicaid, and certain other coverage.
Coverage which the person may have had as a dependent, (e.g., under a spouse's or a parent's plan) will
qualify for this purpose.
In order for the six-month pre-existing condition exclusion period to be shortened as described, the covered
person must show that he or she had prior creditable coverage under another group health plan, an individual
health insurance policy, a state health benefits risk pool, Medicare, Medicaid, etc. To demonstrate to us that
there is creditable coverage, the covered person must provide a "Certificate of Creditable Coverage" from the
prior plan. Most group health plans, health insurers and HMOs are required to provide these certificates upon
request. The certificate will tell how long the person had coverage under the prior plan, when it ended, and
any waiting period satisfied.
Portability of Health Insurance (Oregon)
The 1995 Oregon Legislature passed Senate Bill 152 to make group health insurance "portable". "Portability"
means that ongoing coverage is now available if the participant was enrolled in a group plan for at least six
months prior to termination of coverage.
To qualify for portability coverage, the participant must meet all of the following criteria:
+, 1. He or she must be an Oregon resident;
2. The participant must apply for portability coverage within 63 days of losing group coverage; and
3. He or she must. not be eligible to remain enrolled in the prior group coverage, not be eligible for Medicare
coverage, and not be enrolled in another health insurance plan.
To qualify under the Oregon rules, the participant must meet one of the following criteria:
1. He or she must be enrolled in Oregon -based group coverage for at least six months; or
2. He or she must be enrolled in non -Oregon -based group coverage for at least six months, while residing in
Oregon.
If the prior group coverage was a self-insured plan, the participant must exhaust all ktate or federal
continuation coverage (commonly referred to as COBRA) before electing portability coverage.
Portability of Health Insurance (Oregon) continued next page
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 40
PRE-EXISTING CONDITIONS, HIPAA, AND PORTABILITY (CONTINUED)
Portability of Health Insurance (Oregon) (continued)
The participant has a choice between two portability plans:
1. A Prevailing Benefit plan, with coverage that is similar to most group plans; or
2. A Low Cost plan, with higher deductibles and co -payments.
Because Deschutes County Employee Benefit Plan is a self-funded health care plan, portability coverage is
provided by the Oregon Medical Insurance Pool (OMIP):
Highlights of Portability
• The Oregon rules for portability coverage took effect on January 1, 1997.
■ Portability plans cannot restrict coverage for pre-existing conditions.
■ Premium rates must match typical community rates.
■ The current health plan must provide a "Certificate of Creditable Coverage" when the group coverage
ends. This helps determine the participant's eligibility for portability coverage.
■ After the participant enrolls, he or she can keep the portability plan even if other coverage is obtained
(except if portability coverage is provided by OMIP and the participant becomes eligible for Medicare).
Questions & Answers
"What is `Oregon -based group coverage?"
For groups that purchase health insurance, the group policy must be issued in Oregon. For example, if an
employer has headquarters in another state and has a national group policy, that policy would not be Oregon -
based. However, if the same employer offers coverage in a local HMO plan, that plan would be Oregon -
based. For plans sponsored by a "self-insured" group (in accordance with federal provisions), the sponsoring
group must be located in Oregon.
"Are premium rates identical for everyone who elects the same portability plan?"
No. The same average rate applies to everyone on the plan, but the average rate is adjusted to reflect each
participant's age and family enrollment status.
"Do I have a choice of insurance companies when I elect portability?"
No. You must obtain coverage from the same insurer that provided your group plan, or from OMIP.
"Does a period of coverage under federal or state continuation count toward the six-month
qualification period for portability?"
Yes
"if I enroll In a portability plan within the 63 days allowed, when does the coverage begin?"
It is retroactive to the day following the termination of your group coverage. Your premiums must be paid
back to that date, also.
"Can I enroll my family In my portability coverage?"
Yes, if they were covered by your prior group plan and you include them when you first enroll for portability.
You may not enroll a family member at a later date, unless it is a new family member.
"After I enroll, can I switch my coverage between the Prevailing and Low Cost portability plans?"
You can switch to lower coverage (from the Prevailing to the Low Cost plan), but to switch up in coverage
(from the Low Cost to the Prevailing Plan) you must submit an application and be approved by the insurer or
OMIP.
"What if I lose group coverage because my employer goes out of business or cancels the group plan
for all employees?"
Portability coverage would still be available from the insurer that provided the group plan or OMIP.
"Where can I get more information?"
■ If you have lost coverage in the group plan, and your COBRA continuation coverage is about to run out
(for the Deschutes County Employee Benefit Plan or other self-insured plan) contact Regence Blue Cross
Blue Shield at (800) 848-7280. This company administers the program for the Oregon Medical Insurance
Pool (OMIP).
■ If you have general questions about portability coverage, or problems obtaining or using such coverage,
contact the Health Programs Unit of the Insurance Division at (503) 947-7985.
I�
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 41
ENROLLMENT AND ELIGIBILITY
Employee Enrollment
To be eligible for coverage under the Plan, an employee must meet th• lowing criteria:, !
■ He or she must be a full-time or part-time employee regularly Juled to work at least 20 hours per
week, and be eligible for the Deschutes County Plan;
■ He or she must be a resident of the United States; and
He or she must have satisfied the waiting period.
■ The Plan does not allow "dual Deschutes County coverage" for married couples and same-sex domestic
partners, except for COIC employees, who may have dual coverage. See Coordination of Benefits on
page 49 for further explanation.
The employee's coverage will begin on the effective date, provided that all other Plan requirements are met.
Waiting Period
An employee will not be covered under the Plan until the waiting period is satisfied. The waiting period is
satisfied for employees on the first day of the month following one full month of employment.
Enrollment Requirements
An employee has 31 days from the end of the waiting period to make application for enrollment to the Plan in
order to be eligible for coverage under the Plan. If the employee desires dependent coverage, eligible
dependents must also be enrolled at that time. If the employee does not have eligible dependents at the time
of initial enrollment but acquires eligible dependents at a later date, they must be enrolled within 31 days of
the date they become dependents of the employee.
Part -Time to Full -Time Conversion
Part-time employees who waive coverage, and then become full-time employees or have a significant
increase in work hours (minimum of 25%), may elect to enroll in the Plan at that time. Coverage will become
effective on the first day of the month following application.
Waiver of Coverage and Special Enrollment Rights
Waiver of Coverage:
■ If the employee declines enrollment for self or dependents at the time of initial eligibility, he or she is
requested to sign a Waiver of Coverage. The Waiver of Coverage states that coverage under another
group health plan or other health insurance is the reason for declining enrollment, and the employee is
asked to identify that coverage. If the employee fails to complete the Waiver of Coverage, neither the
employee nor his or her dependents will be entitled to the following Special Enrollment Rights.
Special Enrollment Rights:
• If the employee declines enrollment for self or dependents (including spouse or eligible same-sex
domestic partner) because of other health coverage, in the future the employee may be allowed to enroll
himself or herself, as well as dependents, in the Plan, provided that a Waiver of Coverage was completed
at the time of initial eligibility, and the employee requests enrollment within 31 days after the other
coverage ends.
The employee and/or eligible dependents will be considered eligible to enroll under this Plan on the date the
other plan ends when the following occurs:
■ The exhaustion of federal COBRA or Oregon State continuation; or
• Loss of eligibility due to legal separation, divorce, death, termination of employment or reduction in hours,
or termination of employer contributions. Loss of eligibility does not include a voluntary termination of
coverage, a loss for failure of the person to pay premiums on a timely basis or termination of coverage for
cause, such as making a fraudulent claim.
■ If the employee declined coverage when initially eligible and subsequently marries, he or she may apply
for coverage under this Plan on behalf of self, spouse, and any eligible dependent children provided that
the application is made within 31 days of marriage.
Waiver of Coverage and Special Enrollment Rights coptinued next page
Deschutes County Employee Benefit Plan
Effective August 1, 2000
page 42
El
ENROLLMENT AND ELIGIBILITY (CONTINUED)
Waiver of Coverage and Special Enrollment Rights (continued)
■ If the employee declined coverage when initially eligible and subsequently acquires a new dependent
child by birth, adoption, or placement for adoption, he or she may apply for coverage under this Plan on
behalf of self, spouse and eligible dependent children including the newly acquired child provided that the
application is made within 31 days of the birth, adoption, or placement.
■ If the employee declined coverage for a spouse and/or dependent child, he or she may enroll the spouse
and/or dependent child, provided that the application is made within 31 days after a court has issued an
order for the employee to provide such coverage.
■ Failing to meet the above criteria, an eligible employee and/or eligible dependents who were not enrolled
during the initial eligibility period may enroll during the Open Enrollment Period.
Late Enrollment (Late Enrollee)
If the employee waives coverage and later wants to enroll but does not meet the criteria described above, he
or she is considered a "late enrollee" and may apply for benefits during the Open Enrollment Period shown in
the Summary of Medical Benefits.
Terminations/Changes in Enrollment
The Plan Sponsor must be notified within 31 days prior to a termination or a change in the employee or
dependent's coverage; for example a dependent child who reaches the maximum dependent age, divorce of
a spouse, termination of domestic partnership, etc.
Dependent Enrollment
Eligible dependents may also be covered under the Plan. Eligible dependents include:
• The employee's lawful spouse;
• The employee's qualified same-sex domestic partner;
■ The employee's or qualified domestic partner's natural child*;
■ The employee's or qualified domestic partner's adopted child or a child placed for adoption with the
employee or qualified domestic partner*;
■ A stepchild living in the employee's home, or a nonresident stepchild if there is a Qualified Medical Child
Support Order that requires the spouse or qualified domestic partner to provide health insurance
coverage*;
■ Child(ren) related to the employee or qualified domestic partner by blood or marriage for whom the
employee is the legal guardian (the employee will need to provide a court order showing legal
guardianship).*
* Eligible dependent children must be under 23 years of age, unmarried, and dependent upon the
employee, spouse or qualified domestic partner for full or partial support (at least 50%). Upon
enrollment, and periodically as required by the Plan, the employee must provide documentation that his
or her dependent children meet these requirements, in the form of tax records, court order, etc.
With approval, an otherwise eligible dependent child who is incapable of self-sustaining employment due to a
disability and who relies upon the employee for primary support and maintenance (at least 50%) may
continue under the Plan after reaching age 23, as long as the employee continues to be covered under the
Plan. The employee must provide documentation in the form of a physician's letter which shows that the
dependent child meets these requirements.
Qualified Same -Sex Domestic Partner
To be eligible for benefits, the employee's same-sex domestic partner must meet all of the following
requirements:
■ The employee and domestic partner must be at least 18 years of age;
■ The domestic partners share a close personal relationship and are responsible for each other's common
welfare;
Qualified Same -Sex Domestic Partner continued next page
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 43
ENROLLMENT AND ELIGIBILITY (CONTINUED)
Qualified Same -Sex Domestic Partner (continued)
■ The domestic partners share the same permanent residence, with the intent to continue doing so
indefinitely;
■ The domestic partners are jointly financially responsible for basic living expenses such as food, shelter
and medical expenses;
• The domestic partners are of the same sex;
• Neither domestic partner is legally married to anyone else, nor has had another qualifying domestic
partnership within the 30 days immediately prior to application; and
■ The domestic partners are not related by blood closer than would bar marriage in the state of Oregon.
New Dependents
If new dependents are acquired, the following rules apply:
New Spouse and Stepchild(ren)
A new spouse and eligible stepchild(ren) are eligible from the date of marriage, provided that an
application for enrollment is submitted prior to the first day of the month in which the marriage takes
lace. If the enrollment application is submitted after the first day of the month in which the marriage
takes place, but within 31 days of the marriage, coverage will take effect on the first day of the month
following the marriage.
New Same -Sex Domestic Partner and Domestic Partner's Child(ren)
A new qualified same-sex domestic partner and his or her eligible child(ren) are eligible from the date that
the qualified domestic partnership is established by execution of an Affidavit of Domestic Partnership,
provided that an application for enrollment is submitted prior to the first day of the month in which the
Affidavit of Domestic Partnership is executed. If the enrollment application is submitted after the first day
of the month in which the Affidavit of Domestic Partnership is approved, but within 31 days of execution
of the Affidavit of Domestic Partnership, coverage will take effect on the first day of the month following
receipt and approval of the enrollment.
■ Newborn Infant(s)
The employee's or enrolled dependent's newborn child will be covered for 31 days after the date of birth.
In the case of a newborn of a male dependent, the Plan must have proof of paternity. In order to
continue coverage for a newborn beyond the initial 31days, an enrollment application must be submitted
within that 31 -day period.
■ Adopted Child(ren)
An adopted child will be automatically added to the Plan for 31 days after the date that he or she is placed
with the employee for adoption or the employee has a legal obligation for total or partial support of the
child. In order to continue coverage for an adopted child beyond that time, an enrollment application
must be submitted within that 31 -day period.
Qualified Medical Child Support Order
Section 609(a) of ERISA requires medical benefit plans to honor the terms of a Qualified Medical Child
Support Order (QMCSO). The order must be a judgment, order or decree (including approval of a divorce
settlement agreement) related to child support, alimony, or the division of marital property, issued pursuant to
state law (including certain state Medicaid laws). Agreements made by the parties but not formally approved
by a court are not acceptable.
When a QMCSO exists for dependent children covered under this Plan, the employee must provide a copy to
the Plan for documentation purposes.
Deschutes County Employee Benefit Plan Effective August f, 2000 page 44
ENROLLMENT AND ELIGIBILITY (CONTINUED)
Loss of Employed Eligibility
If an employee is no longer eligible, his or her coverage and the coverage of all dependents will end on the
earliest of the following dates:
■ On the last day of the month the employee's active service terminates;
• On the last day of the month the employee ceases to be in a class eligible for coverage;
• On the first day of the month for which the employee fails to make any required contribution; or
■ On the termination date of the Plan.
Employees who lose coverage may be eligible for the COBRA Continuation Plan. Please see page 52 of this
document for information on COBRA Continuation of Coverage.
Loss of Dependent Eligibility
Coverage ends for the spouse of an employee on the last day of the month that the marriage is legally
dissolved (by divorce or legal separation).
Coverage ends for a qualified same-sex domestic partner on the last day of the month that the domestic
partnership is dissolved.
Coverage ends for a dependent child on the last day of the month in which the child no longer meets the
eligibility requirements of the Plan.
A covered person who loses coverage may be eligible for the COBRA Continuation Plan. Please see page 52
of this document for information on COBRA Continuation of Coverage. An eligible employee or dependent is
required to notify the Plan Administrator within 60 days of any qualifying event of which the Plan Administrator
would not otherwise be aware such as divorce, legal separation, or loss of eligible dependent status, to be
eligible for COBRA Continuation. Please see page 52 of this document for information on COBRA
Continuation.
Rehire Following termination or Lay -Off
If an employee is laid -off or terminates employment and then returns to employment within six months of the
last day of work, coverage will be reinstated on the first day of the month following or coinciding with the
employee's return to employment.
Strike or Lockout
If an employee is employed under a collective bargaining agreement and involved in a work stoppage
because of a strike or lockout, coverage may be continued for up to six months. The employee must pay the
full premium, including any part usually paid by the employer, directly to the union or trust that represents him
or her. The union or trust must continue to pay the premiums on the due date. Coverage cannot be
continued if fewer than 75% of those normally enrolled continue coverage or if the employee or dependent(s)
otherwise lose eligibility under the Plan.
This six months of continued coverage is in lieu of and not in addition to any continuation of coverage
provisions of the Plan.
Workers' Compensation Claim
If the employee is no longer eligible due to an illness or injury for which he or she has filed a Workers'
Compensation claim, coverage can be continued for up to six months after the employee's eligibility ends, or
until the employee obtains full-time employment with another employer, whichever happens first. The
employee must pay his or her premium through the group on a timely basis in order to maintain coverage
during this period.
This six months of continued coverage is in lieu of and not in addition to any continuation of coverage
provisions of the Plan.
Deschutes County Employee Benefit Plan
Effective August 1, 2000 page 45
ENROLLMENT AND ELIGIBILITY (CONTINUED)
Employee and/or Dependents Covered in Error
Any employee and/or dependent who is enrolled in error under the Plan, or who is enrolled in violation of any
of the terms of the Plan, shall not be entitled le any benefits thereunder. The Plan shall have the right to
recover from any employee and/or dependent the cost of any benefits furnished while such an employee
and/or dependent was enrolled in error. The Plan shall make proper adjustments for any contributions paid
under such circumstances.
Family and Medical Leave Act (FMLA)
The Family and Medical Leave Act (FMLA) applies only to groups which employ 50 or more employees
during each of 20 or more calendar work weeks in the current or preceding calendar year, and which are
required by federal law to comply with FMLA provisions. Under this provision, eligible employees may receive
up to 12 weeks of leave during a 12 -month period, as provided by FMLA, under the following circumstances:
• The birth of the employee's child;
■ The placement of a child with the employee for adoption or foster care;
■ Care for the employee's seriously ill spouse, parent or child; or
■ The employee's own serious physical or mental health condition.
Eligible employees and covered dependents may continue coverage under the Plan during the FMLA leave.
Please contact the Personnel Department at Deschutes County for more detailed information on FMLA
IeaveS.
31
0
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 46
RETIREE ENROLLMENT AND ELIGIBILITY
Retired Employees and Their Dependents
Retirees, including their enrolled dependents, are eligible to continue coverage under the Plan after
retirement, as long as they apply for coverage within 31 days of retirement, and if all of the following criteria
are met:
■ The employee has been enrolled in the Plan (or a prior plan sponsored by the employer) for at least 24
consecutive months immediately prior to retirement, unless otherwise indicated by a management/labor
agreement;
■ The employee will be receiving benefits from PERS (Public Employee Retirement System) or from a
similar retirement plan offered by the employer; and
■ Retirees are not eligible to continue dental benefits unless they have 30 or more years of service with
Deschutes County.
Only those dependents who were enrolled under the Plan at the time the employee retired are eligible to
continue coverage under the Plan as the retiree's dependents,
Dependent coverage under the Plan is not extended to a new spouse, new same-sex domestic partner, or
new dependent children, (except a newborn child,) acquired after an employee's retirement becomes
effective; nor to a surviving spouse or qualified same-sex domestic partner who is receiving retirement
benefits earned by an employee who died before taking retirement.
A newborn child is eligible and will be enrolled at birth if family coverage is available under the Plan.
Loss of Eligibility - Retiree
If a retiree is no longer eligible, his or her coverage will end on the earliest of the following dates:
■ On the last day of the month that the retiree dies;
■ On the last day of the month that the retiree reaches age 65;
• On the first day of the month for which the retiree fails to pay any required premium payments;
■ On the last day of the month for which the employee voluntarily terminates enrollment; or
i ■ On the first day of the month that the retiree becomes entitled to Medicare.
A covered retiree who loses coverage may be eligible for the COBRA Continuation Plan. Please see page 52
of this document for information on COBRA Continuation of Coverage. An eligible employee or dependent is
required to notify the Plan Administrator within 60 days of any qualifying event of which the Plan Administrator
would not otherwise be aware such as divorce, legal separation, or loss of eligible dependent status, to be
eligible for COBRA Continuation. Please see page 52 of this document for information on COBRA
Continuation.
Loss of Dependent Eligibility — Retiree
The spouse or same-sex domestic partner of a retiree is no longer eligible and his or her coverage will end on
the earliest of the following dates:
• The last day of the month that he or she is granted a decree of divorce, or termination of domestic
partnership;
■ The last day of the month that he or she voluntarily terminates enrollment, either individually or through
the retiree;
• The last day of the month that he or she reaches age 65; or
■ The first day of the month that he or she becomes eligible for Medicare.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 47
RETIREE ENROLLMENT AND ELIGIBILITY (CONTINUED)
Eligibility will end for a dependent child of a retired employee on the last day of the month in which the child is
otherwise no longer considered to be a dependent as defined by the Plan, or voluntarily terminates
enrollment, either individually or through the retiree.
A disabled dependent child, as defined by the Plan, may remain covered after reaching age 23, as long as at
least one parent (the retiree, spouse or same-sex domestic partner) continues to be enrolled. Eligibility for a
disabled dependent child will end on the first day of the month in which he or she becomes eligible for
Medicare.
A covered person who loses coverage may be eligible for the COBRA Continuation Plan. Please see page 52
of this document for information on COBRA Continuation of Coverage. An eligible employee or dependent is
required to notify the Plan Administrator within 60 days of any qualifying event of which the Plan Administrator
would not otherwise be aware such as divorce, legal separation, or loss of eligible dependent status, to be
eligible for COBRA Continuation. Please see page 52 of this document for information on COBRA
Continuation.
Voluntary Termination of Retiree Coverage
A retiree and his or her dependents who voluntarily terminate coverage may not, under any circumstances,
re -enroll for coverage under the Plan.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 48
01)j)
COORDINATION OF BENEFITS
Coordination of Benefits Provision
The Coordination of Benefits provision applies to the Medical, Dental and Vision Plan when the employee or
covered dependents have health care coverage under more than one plan. This provision allows the Plan to
coordinate its benefits with similar benefits paid by other plans.
This provision is applicable when the total benefits which would be payable in the absence of any coordination
of benefits provision under the Plan and under other plans covering an individual combine to exceed the
allowable expenses incurred. The Plan will not pay more than it would have paid without this provision.
The Plan does not allow "dual Deschutes County coverage", except for COIC employees, how may have dual
coverage. When both spouses, (or an employee and qualified same-sex domestic partner) are covered as
employees of Deschutes County, they are not allowed to cover each other. Eligible dependent children may be
covered under one parent's plan, but not "double covered" under both.
Defined Terms
Other Plan is a plan providing benefits and services in connection with health care and treatment which meets
the following criteria:
1. Toward the cost of which an employer makes contributions or for which an employer takes payroll
deductions; or
2. Under or through action of any government or tax -supported program.
Allowable Expense is any necessary, reasonable and customary item of expense that is allowed under the
plan covering the individual with respect to whom a claim is made.
Order of Benefit Determination
When a covered person is enrolled under two or more policies, an order of benefit determination will be made
regarding which plan will pay first. The order of benefit determination is as follows:
1. The plan which does not have a Coordination of Benefits provision will be primary;
2. The plan covering a person as the employee or insured of the policy will be primary;
(� 3. For a dependent child when there has been no divorce, the policy of the parent whose birthday falls
earliest in the calendar year will be primary; or
4. For a dependent child when there has been a divorce or separation between the natural parents the
benefits will be determined in the following order:
a) The plan of the parent indicated in a court decree as having responsibility for health benefits;
b) The plan of the custodial parent (the natural parent with custody);
c) The plan of the custodial stepparent (the stepparent with custody);
d) The plan of the non-custodial parent (the natural parent without custody);
e) The plan' of the non-custodial stepparent (the stepparent without custody).
5. For a retired or laid -off person and his or her dependents, the benefits of the Plan will pay after the
benefits of any other plan covering such person as an active employee or dependent unless the other
plan does not have a provision regarding retired or laid -off employees. If the other plan does not have
this provision then this provision does not apply.
If none of the above determines which plan is primary, the plan which has been in effect the longest will be
primary.
Coordination with Medicaid
The Plan must honor any assignment of rights on behalf of participants and beneficiaries required under the
Medicaid rules.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 49
COORDINATION OF BENEFITS (CONTINUED)
Qualified Medical Child Support Order
Section 609(a) of ERISA requires medical benefit plans to honor the terms of a Qualified Medical Child GO)
Support Order (QMCSO). The order must be a judgment, order or decree (including approval of a divorce
settlement agreement) related to child support, alimony, or the division of marital property, issued pursuant to
state law (including certain state Medicaid laws). Agreements made by the parties but not formally approved
by a court are not acceptable.
When a QMCSO exists for dependent children covered under this Plan, the employee must provide a copy to
the Plan for documentation purposes.
Medicare
An active employee age 65 or over and his or her dependent spouse or qualified same-sex domestic partner
age 65 and over, who are covered under the Plan are entitled to benefits under the Plan on the same basis
as active employees and their dependents under the age of 65. This Plan will pay as the primary plan, as
described in the Coordination of Benefits section of this document, to the extent that an employer-sponsored
health plan is required by federal TEFRA (Tax Equity and Fiscal Responsibility Act of 1982) and ADEA (Age
Discrimination in Employment Act of 1967) laws.
The Plan also provides benefits primary over Medicare, to the extent that an employer-sponsored health plan
is required to by federal DEFRA (Deficit Reduction Act of 1984) laws, for covered persons who are entitled to
Medicare because of a disability, kidney transplants or renal dialysis or ESRD (End Stage Renal Disease).
For all other covered persons entitled to Medicare, the Plan will be the secondary plan to Medicare.
Correction of Payments
If another plan makes payments that the Plan should have made under this coordination provision, the Plan
can reimburse the other plan directly. Any such reimbursement payment will count as benefits paid under the
Plan and the Plan will be released from its liability to the covered person regarding them.
Right of Recovery
If the Plan makes payments that should have been made by another plan, the Plan will have the right to
recover payments from the person to or for whom they were made, or from insurance companies or other
organizations. The covered person involved must sign any documents that are necessary to enforce the
rights of the Plan under this provision.
Excess Coverage
This provision applies when a covered employee or dependent incurs medical or dental expenses for which
the covered employee or dependent is eligible to receive medical, dental or disability replacement benefits
from a plan of liability insurance, property insurance, casualty insurance or property/casualty insurance,
including but not limited to:
1. Motor vehicle plan;
2. Homeowner's plan;
3. Renter's insurance plan; or
4. Boat owner's plan.
When payments are available under another plan or policy, the Deschutes County Employee Benefit Plan
shall pay excess benefits only. The Plan shall always be considered the secondary carrier regardless of the
individual's election under such policies.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 50
THIRD PARTY RECOVERY PROVISION
Right of Subrogation and Refund
This provision applies when a covered person incurs medical, dental or vision expenses for injuries or
illnesses that may be caused by the act or omission of a third party. In such circumstances, the covered
person or beneficiary may have a claim against that third party, or insurer, for payment of the medical, dental
or vision expenses. Accepting benefits under the Plan for those incurred medical, dental or vision expenses
automatically assigns to the Plan any rights the covered person or beneficiary may have to recover payments
from any third party or insurer. This subrogation right allows the Plan to pursue any claim which the covered
person or beneficiary has against any third party, or insurer, whether or not the covered person or beneficiary
chooses to pursue that claim. The Plan may make a claim directly against the third party or insurer, but in
any event, the Plan has a lien on any amount recovered by the covered person or beneficiary, whether or not
designated as payment for medical expenses. This lien shall remain in effect until the Plan is repaid in full.
The covered person:
• Automatically assigns to the Plan his or her rights against any third party or insurer when this provision
applies; and
• Must repay to the Plan the benefits paid on his or her behalf out of the recovery made from the third party
or insurer.
For any amount subject to subrogation or refund, the covered person or beneficiary agrees to recognize the
Plan's right to subrogation and refund. These rights provide the Plan with a priority over any funds paid by a
third party to a covered person relative to the injury or illness, including a priority over any claim for non-,
medical, dental or vision attorney fees, or other costs and expenses.
Notwithstanding its priority to funds, the Plan's subrogation and refund rights, as well as the rights assigned to
it, are limited to the extent to which the Plan has made, or will make, payment for medical, dental or vision
expenses, as well as any costs and fees associated with the enforcement of its rights under the Plan.
When a right of recovery exists, the covered person or beneficiary will execute and deliver all required
to, instruments and papers as well as doing whatever else is needed to secure the Plan's right of subrogation as
a condition to having the Plan make payments. In addition, the covered person or beneficiary will do nothing
prejudice the right of the Plan to subrogate.
11
Defined Terms
Recovery
Money paid to the covered person or beneficiary by way of judgment, settlement, or otherwise to compensate
for losses caused by the injuries or illness, whether or not said losses reflect medical, dental or vision
expenses covered by the Plan. The right of refund also applies when a covered person recovers under an
uninsured or underinsured motorist plan, homeowner's plan, renter's plan, medical malpractice plan or any
liability plan.
Subrogation
The Plan's right to pursue the covered person's claims for medical, dental or vision against the third party.
Refund
Repayment to the Plan for medical, dental or vision benefits that it has paid for care and treatment of the
injury or illness.
Assignment of Rights as a Condition to the Plan Making Payment
The covered person must assign to the Plan his or her rights to any recovery arising out of or related to any
act or omission which caused or contributed to the injury or illness for which such benefits are to be paid.
The scope of this assignment is consistent with the amount subject to subrogation or refund set forth above.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 51
COBRA CONTINUATION
Consolidated Omnibus Budget Reconciliation Act (COBRA)
An eligible employee, retiree or dependent whose coverage has been terminated for any qualifying event
listed below has the right to continue on the Plan for the length of time indicated below, provided that he or
she was eligible for benefits on the day immediately preceding the termination date. A child born to a covered
employee or who is placed for adoption with a covered employee during a period of COBRA Continuation
Coverage is also a qualified beneficiary. The Plan is required by federal law to provide this option. The time
period for continuation is available as indicated below, in conjunction with the corresponding qualifying event.
An election to continue or decline coverage must be made within 60 days of the qualifying event, or 60 days
from the date notice is made by the Plan of the right to continue coverage.
If COBRA Continuation Coverage is elected, coverage will continue as though termination of employment or
loss of eligible status had not occurred. Any deductibles or benefit maximums accumulated prior to the loss
of eligibility will be retained. The Plan is not permitted to apply additional waiting periods, or pre-existing
condition limitations.
The full cost of providing such coverage, plus a 2% administrative fee, shall be charged to any person
continuing under the Plan. This cost is determined at the beginning of each Plan Year and shall remain in
effect for the remainder of the Plan Year. If a covered person elects COBRA Continuation Coverage, he or
she is responsible for making timely payments to Deschutes County. There will not be a monthly billing
statement from Deschutes County sent to participants.
An 16 -month continuation shall be available to covered employees and/or dependents in the event of one of
the following qualifying events:
1. A covered employee terminates employment for any reason (except gross misconduct); or
2. A covered employee loses eligibility to participate in the Plan due to reduction of scheduled work hours.
A 29 -month continuation shall be available to qualified beneficiaries in the event the qualified beneficiary is
disabled at the time the covered employee terminates employment or becomes disabled at any time during
the first 60 days of COBRA Continuation Coverage. If the individual entitled to the disability extension has
non -disabled family members who are entitled to COBRA Continuation Coverage, those non -disabled family
members are also entitled to the 29 -month disability extension. The Plan may charge 150% of the full cost of
the applicable premium from the 19th month through the 29th month for providing such coverage for disabled
individuals. The extended continuation will end the month that begins more than 30 days from the final
determination that the qualified beneficiary is no longer disabled.
A 36 -month continuation shall be available to covered dependents, (spouse and/or child), in the event of any
one of the following qualifying events:
1. The covered employee's death;
2. Divorce or legal separation from a covered employee;
3. A covered dependent child's loss of eligibility to participate in the Plan; or
4. A covered dependent's loss of eligibility to participate in the Plan due to the covered employee becoming
eligible for Medicare as a result of total disability, or choosing Medicare in place of the Plan at age 65.
A qualified beneficiary has 60 days from the date he or she is notified of these rights, pursuant to a qualifying
event, to elect coverage. Once the COBRA election has been made, the employee or dependent has 45
days to pay the retroactive premium(s) back to the date coverage would otherwise have ended under the
Plan.
An eligible employee or dependent is required to notify the Plan within 60 days of any qualifying event of
which the Plan would not otherwise be aware, such as divorce; legal separation; or loss of eligible dependent
status. The Plan must notify an eligible employee or dependent of his or her right to continue,coverage within
14 days of the qualifying event, or the date notification is made to the Plan.
The eligible employee or dependent is also required to provide the Plan with the information that is needed to
meet its obligation of providing notice and continuation of coverage.
Deschutes County Employee Benefit Plan Effective August 1, 2000 . page 52
4
COBRA CONTINUATION (CONTINUED)
/• Continuation of coverage shall not be provided beyond whichever of the following dates is first to occur:
(\ 1. The date the maximum continuation period expires for the qualifying event;
2. The date the Plan is terminated for all active employees;
3. The date the eligible qualified beneficiary fails to make timely payment of contributions, within a minimum
of 30 days, to continue coverage;
4. The date the eligible employee or dependent becomes covered under any other group health plan which
has no pre-existing condition limitation, or benefit exclusions not excluded under the Plan. If the new
Plan has a pre-existing condition limitation or a benefit exclusion not excluded under the Plan, COBRA
Coverage may be continued, up to the maximum period, depending on the corresponding qualifying
event which resulted in COBRA Continuation, or until the pre-existing condition limitation or benefit
exclusion is satisfied. However, benefits from the Plan will be determined after any benefits available
through the other group plan;
5. If the qualified beneficiary has creditable coverage under the Plan, which would be credited under the
other group plan, COBRA Continuation may be reduced due to the creditable coverage. If the qualified
beneficiary has 18 months of creditable coverage, COBRA Continuation may not be available; or
6. The date the employee becomes eligible for Medicare.
(6
t6
Deschutes County Employee Benefit Plan Effective August 1, 2000 page xs
GENERAL PLAN PROVISIONS
Entire Plan
The Plan, including amendments and attached papers, if ati./, constitutes the entire contract of coverage. No d)
change in the Plan shall be valid unless approved by an executive officer of the Plan Sponsor and unless
such approval is amended or attached to the Plan. The Plan Administrator has the sole authority to amend
the Plan. No other individual has the authority to change the Plan or waive any of its provisions.
Representations, Not Warranties
All statements made by the employee, the Plan or covered persons shall be considered representations and
not warranties. All such statements will be made in good faith without any intention of fraud. No statement
made while applying for coverage will cancel coverage or reduce benefits unless it is in a written document
signed by the Plan or covered person. A copy of the document must be given to the person noted.
Transfer of Benefits
A covered person transferring to the Plan from other policies shall be subject to the provisions of the Plan
upon transfer. Benefits received under the previous plan are included in determining the benefits available
under the Plan and not to increase the benefits available.
Special Rights Upon Childbirth
This Plan under Deschutes County may not restrict benefits for any hospital length of stay in connection with
childbirth for the mother or newborn child following a normal vaginal delivery to less than 48 hours, or restrict
benefits for any hospital length of stay in connection with childbirth for the mother or newborn child following a
cesarean section to less than 96 hours. This Plan may not require that a provider obtain authorization from
the Plan for prescribing any length of stay. The minimum stay requirements do not apply if the mother and
her physician make the decision to discharge.
Right to Examine Records
It is specifically understood and agreed that each covered person,'by enrolling in the Plan, is granted the right
to examine all medical, dental and other records pertaining to any cases for which the benefits of the Plan are
claimed.
Legal Action to Enforce the Plan
No legal procedure to enforce any of the provisions of the Plan may be instituted by the employee or family
members during a period of 60 days after the due and proper notice of intent to do so. No legal procedure
shall be brought against the Plan Sponsor and/or the Contract Administrator after the expiration of three
years from the original date of illness or injury.
Fraudulent Claims
If a covered person claims benefits for which no care, service, or supply is received, the claims will be denied.
If benefits are paid in error under the Plan, the Plan will be entitled to recover such amounts. See " Recovery
of "Benefits Paid in Error" below.
Recovery of Benefits Paid in Error
If the Plan mistakenly makes a payment for a person to which that person is not entitled, or if the Plan pays a
person who is not eligible for payment at all, the Plan has the right to recover the payment from the person or
anyone else who benefited from it, including a provider of service.
Any covered person who is enrolled in error under the Plan or who is enrolled in violation of any of the terms
and conditions of the Plan shall not be entitled to any Plan benefits, but the Plan shall make proper
adjustment to cover any contributions paid under such circumstances. The Plan shall have the right to
recover from any person the cost of any benefits furnished while such person was enrolled in error.
Deschutes County Employee Benefit Plan
M
Effective August i, Zvuu
P"ya '7v
(6
(1
0
GENERAL PLAN PROVISIONS (CONTINUED)
Venue
All suits or legal proceedings brought against Deschutes County by an employee or anyone claiming any right
under the Plan must be filed:
1. Within 12 months of the date the Contract Administrator denied, in writing, the rights or benefits claimed
under the Plan; and
2. In the State of Oregon, in Deshutes County.
All suits or legal proceedings brought by Deschutes County will be filed within the appropriate statutory period
of limitation, and venue may lie, at our option, in the State of Oregon, in Deshutes County.
Administrators West and/or Deschutes County Not Liable for Quality of Medical Care
A covered person has the sole right to choose his or her health care provider. Administrators West and/or
the Plan is not responsible for the quality of medical care a person receives since all those who provide care
do so as independent contractors. Administrators West and/or the Plan cannot be held liable for any claim or
damages connected with injuries suffered by a covered person while receiving medical services or supplies.
Right to Receive and Release Necessary Information
Certain facts are needed to apply provisions of the Plan. The Plan has the right to decide which facts it
needs. It may obtain required facts from, or give them to, any other organization or person. The Plan need
not notify or obtain consent of any person to do this. Each person claiming benefits under the Plan must give
the Plan any facts it needs to process the claim.
Funding
The procedure and method for funding the Plan is for the Plan Sponsor to pay benefits and administration
fees from its general assets, after a payroll deduction from employees, where required. To the extent that the
annual aggregate contribution made by the Plan Sponsor from its own funds exceeds the annual cost of the
Plan, such excess contributions will be retained by the Plan Sponsor, as permitted by law, in its own assets
and shall not become an asset of the Plan.
No Verbal Modifications
The enrollee shall not rely on any oral statement from an employee of the Plan Administrator or Claims
Administrator, including but not limited to a customer representative, to:
1. Modify or otherwise affect the benefits, limitations and exclusions, or other provisions of the Plan; or
2. Increase, reduce, waive or void aray coverage or benefits under the Plan.
In addition, such oral statement shall not be used in the prosecution or defense of a claim under the Plan.
Any written or oral verification received from the Plan Administrator or Claims Administrator is based upon
eligibility information and Plan benefits, which are subject to change; therefore, any verification should not be
interpreted as a guarantee of coverage or payment for any services rendered or otherwise provided to an
enrollee.
Governing Law
To the extent that state law governs the Plan, the interpretation and validity of the Plan will be governed by
the laws of the state of Oregon, without regard to its conflict of laws rules.
Hold Harmless In the Event of Non -Payment
Under state law, providers contracting with a health care service contractor such as Providence Preferred of
Oregon to provide services to its members, agree to look only to the health care service contractor for
payment of the part of an expense which is covered by the Plan, and may not bill a participant in the event the
health care service contractor fails to pay the provider, for whatever reason. The provider may bill the
covered person for applicable coinsurance, co -payments and deductibles, and for non -covered expenses
except as may be restricted in the provider contract.
Deschutes County Employee Benefit Plan Effective August 1, 2000
page 55
ADMINISTRATION
Delegation of Fiduciary Responsibility
The Plan Administrator shall be responsible for the administration of the Plan; however, the Plan ))1'
Administrator may delegate to any person or entity any of his/her powers or duties under the Plan. Such
delegation shall be in writing and, to the extent of any such delegation, the delegate shall become the named
fiduciary responsible for the administration of the Plan. A named fiduciary can appoint others to carry out
fiduciary responsibilities (other than a trustee) under the Plan. These other persons become fiduciaries
themselves and are responsible for their acts under the Plan. To the extent that the named fiduciary
allocates its responsibility to other persons, the named fiduciary shall not be liable for any act or omission of
such person unless either: (1) the named fiduciary has violated its stated duties under ERISA in appointing
the fiduciary, establishing the procedures to appoint the fiduciary or continuing either the appointment of the
procedure; or (2) the named fiduciary breached its fiduciary responsibility under Section 405(a) of ERISA.
A Contract Administrator is not a fiduciary under the Plan by virtue of paying claims in accordance with the
Plan's rules as established by the Plan Administrator.
Contract Administrator
The Contract Administrator shall provide services in connection with the operation of the Plan including such
functions as specified in writing in the Administration Agreement. The Contract Administrator is
Administrators West.
Administrative Functions
The Plan Administrator shall adopt such rules for the administration of the Plan, as he or she considers
desirable, provided that they do not conflict with the Plan, and may construe the Plan, correct defects, supply
omissions, and reconcile inconsistencies to the extent necessary to effectuate the Plan.
Records and Reports
The Plan Administrator shall keep a record of all proceedings and actions insofar as they relat6 to the Plan,
and shall maintain all such books of account, records, and other data as shall be necessary to administer the
Plan properly and to meet the disclosure and reporting requirements of ERISA and the Internal. Revenue
Service Code. The Plan Administrator shall maintain records that contain all relevant data pertaining to ,
covered employees or dependents and their rights under the Plan. Such records as may pertain solely to a
particular covered employee or dependent shall be made available for examination by such covered
employee or dependent. The Plan Administrator shall make a copy of the Plan available to each covered
employee or dependent, upon such covered employee or dependent request.
Contracts for Necessary Services
The Plan Administrator may contract for legal, advisory, accounting, clerical and other services to carry out
the Plan. The costs of such services and other administrative expenses shall be approved and paid by the
Plan.
Indemnification
The Plan shall indemnify any employee to whom it has delegated fiduciary duties against any and all claims,
losses, damages, expenses and liabilities arising from responsibilities in connection with the Plan, unless the
same is determined to be due to gross negligence or willful misconduct.
Non -Discrimination in Administration
All rules, decisions and designations by the Plan Administrator under the Plan shall be made in a non-
discriminatory manner and persons similarly situated shall be treated alike.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 56
ADMINISTRATION (CONTINUED)
Recovery of Benefits Paid in Error - Liability of the Plan
1 , Neither the Plan, nor any of the officers, employees or their delegates shall be liable for any loss due to their
errors or omissions in the administration of the Plan, unless the loss is due to the gross negligence or willful
misconduct of the party charged to exercise a fiduciary responsibility. Such responsibility must be exercised
with the care, skill, prudence and diligence under the circumstances then prevailing that a prudent person,
acting in a like capacity and familiar with such matters, would use in the conduct of an enterprise of a like
character and with like aims.
Amendment and Termination
The Plan shall be subject to amendment at any time hereafter by the Plan Administrator, with the approval of
the Plan in the event that the Plan Administrator and the Plan are not one in the same.
This Plan may be terminated at any time hereafter by action of the board of the Plan, which action shall be
communicated in writing to the Plan Administrator in the event the Plan Administrator and the Plan are not
one in the same.
11
The amendment, termination, or discontinuance of the Plan shall not adversely affect any right of any covered
employee or dependent to benefits under the provisions of the Plan arising prior to such amendment or
termination.
.Right to Terminate Employment
The establishment and maintenance of the Plan shall not confer upon any employee the right to continue in
the employ of the Plan Sponsor. The Plan Sponsor expressly reserves the right to terminate the employment
of any employee, whether or not a covered employee, whenever the interests of the Plan Sponsor, in its sole
judgment, may so require.
Law Governing Construction
All questions pertaining to the interpretation, administration, validity and effect of the provisions of the Plan
shall be determined in accordance with the laws of the State of Oregon to the extent they are not preempted
by ERISA and/or other federal law.
Cancellation of the Plan
If the Plan is canceled, coverage ends for all participants on the date that the Plan ends.
Amendments
In the event that any amendment or rider shall be affixed to the Plan which alters, increases, decreases, or in
any way changes the benefits specified in the Plan, such amendment or rider shall be subject to all other
terms and conditions of the Plan, except as specifically provided in such amendment or rider. No consent of
any participant or any other person referred to in the Plan shall be required.
Miscellaneous
To the full extent permitted by law, all rights and benefits occurring under the Plan shall be exempt from
execution, attachment, garnishment or other legal or equitable process, for the debts or liabilities of any
employee.
This Plan is not in lieu of, and do not affect, any requirement for coverage by Workers' Compensation
insurance.
No failure to enforce any provision of the Plan shall affect the Plan's right thereafter to enforce such provision,
nor shall such failure affect its right to enforce any other provision of the Plan.
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 57
PLAN PARTICIPANT'S RIGHTS UNDER THE EMPLOYEE RETIREMENT
INCOME SECURITY ACT (ERISA)
As a participant in your employer's Plan, you are entitled to certain rights and protections under the Erl; 40yee
Retirement Income Security Act of 1974 (ERISA).
Plan Description
ERISA requires that certain information be furnished to each participant in an employee benefit Plan. Your
document is the Summary Plan Description for the purposes of ERISA.
Name of Plan:
Deschutes County
Employee Benefit Plan
Employer Tax ID Number:
93-6002292
Plan Number:
502
Group Number:
1128
Type of Plan:
Medical, Dental and Vision
Type of Administration:
Contracted administration by:
Administrators West
612 NE Savannah Drive, Suite 4
Bend, OR 97701
(541) 312-9144
Plan Administrator:
Deschutes County
1130 NW Harriman
Bend, OR 97701
(503) 385-1408
Plan Sponsor and Fiduciary:
Deschutes County
1130 NW Harriman
Bend, OR 97701
(503) 385-1408
Agent for Legal Services:
Deschutes County
1130 NW Harriman
Bend, OR 97701
(503) 385-1408
Sources of Contributions to the Plan: Employer and Employee
Plan's Fiscal Year Ends: July 31
Deschutes County Employee Benefit Plan Effective August 1, 2000 page 58
IA
•
•
•
PARTICIPANT'S RIGHTS UNDER THE EMPLOYEE RETIREMENT
INCOME SECURITY ACT (ERISA) (CONTINUED)
ERISA provides that all Plan participants shall be entitled to:
Examine, without charge, at the Plan Administrator's office all Plan documents and copies of all
documents filed by the Plan with the U.S. Department of Labor, such as the annual reports and Plan
descriptions.
2. Obtain copies of all Plan documents and other Plan information upon written request to the Plan
Administrator. The Plan Administrator may make a reasonable charge for the copies.
3. Receive a summary of the Plan's annual financial report. The Plan Administrator is required by law to
furnish each participant with a copy of this summary financial report.
In addition to creating rights for Plan participants, ERISA imposes obligations upon the persons who are
responsible for operation of an employee benefit Plan. The people who operate the Plan, called "fiduciaries"
of the Plan, have a duty to do so prudently and in the interest of Plan participants and beneficiaries.
No one, including the employer or any other person, may fire an employee or otherwise discriminate against
an employee to prevent him or her from obtaining a benefit or exercising his or her rights under ERISA.
If a claim for a benefit is denied in whole or in part, the Plan participant must receive a written explanation of
the reason for the denial. The Plan participant has the right to have the Plan Administrator review and
reconsider the claim.
Under ERISA, there are steps an employee can take to enforce the above rights. For instance, if the
employee requests material from the Plan and does not receive them within 30 days, they may file suit in
federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay
the Plan participant up to $110 per day until the Plan participant receives the material, unless the materials
were not sent because of reasons beyond the control of the administrator.
If a Plan participant has a claim for benefits which is denied in whole or in part, they may file suit in a state or
federal court. If a Plan fiduciary misuses Plan money, or if the employee is discriminated against by asserting
his or her rights, the Plan participant may seek assistance from the U.S. Department of Labor or he or she
may file suit in a federal court. The court may order the person or corporation sued to pay these costs and
fees. If the Plan participant loses, the court may order the Plan participant to pay these costs and fees: for
example, if it finds the court case is frivolous.
If you have any questions about this statement or your rights under ERISA, you should contact the nearest
office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone
directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration,
U.S. Department of Labor, 200 Constitution Avenue NW, Washington, DC 20210.
Deschutes County Employee Benefit Plan
Effective August 1, 2000
page 55
Plan Arranged By:
PACIFIC BENEFIT RESOURCES (PBR)
JOHN HUFFMAN AND THOMAS EVERTS
19330 INNES MARKET ROAD
BEND, OR 97701
PHONE: (541) 382-3464
(800) 800-5595
FAX: (541) 382-0937
r
Plan Administered By:
ADMINISTRATORS WEST
t. 612 NE Savannah Drive, Suite 4
Bend, OR 97701
PHONE: (800) 894-9221
. (541) 312-9144
:'. FAX: (541) 312-9149
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