2018-16-Minutes for Meeting December 07,2017 Recorded 1/8/2018Recorded in Deschutes County
Nancy Blankenship, County Clerk
CommissionersJournal
AI**
CJ201 8-16
01/08/2018 8:44 13 AM
R11161111111111111111111 1 III
For Recording Stamp Only
Deschutes County Board of Commissioners
1300 NW Wall St., Bend, OR 97703-1960
(541) 388-6570 - Fax (541) 385-3202 - www.deschutes.org
DESCHUTES COUNTY BOARD OF COMMISSIONERS
Date: December 7, 2017
Present were Commissioners Tammy Baney, Anthony DeBone and Phil Henderson. Also present
were Tom Anderson, County Administrator; Erik Kropp, Deputy County Administrator; Scot
Langton, County Assessor; Todd Straughan, Senior Property Appraiser; Tana West, Assessment
Manager; Greg Rossi, Chief Cartographer; and Whitney Hale, P10.
The Board of County Commissioners held a field trip and site visit to the Deschutes County
Assessor's Office today for the round -three department update of activities and programs.
The meeting was held in the Assessor's office conference room.
Points of interest that were presented included the following:
• Tana West provided an overview of the Assessor's Office. Tana stated that there is an
increase in workload for assessing new construction. She noted that staff completed
over 6,300 inspections last year for new construction and received over 11,000
customer service calls.
• Toss Straughan discussed the challenge of hiring licensed appraisers.
• Scot Langton said that as the County continues to grow, staff will likely need to be
added.
• Scot Langton provided an overview of implementation of HB 2407, which was passed by
the State Legislature in 2017.
• Gregg Rossi passed out a chart showing the daily deed averages by month (attached).
He also heanded out a table of new subidivsions in FY 2016-2017 (attached).
Minutes Provided By:
{ //ten
Erik Kropp, Deputy County Administrator
DATED this Day of
Board of Commissioners.
ATT
Recording Secretary
2018 for the Deschutes County
(5-646,„
Anthony DeBone, Chair
Phili • G. Heng rson, Vice Chair
Tammy Baney, Corp nissioner
Chart of Daily Deed Averages by Month
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'MY SWROMSVON
18END DANTILI HEIGHTS
BEND CASCADE HEIGHTS PHASES 4 & 5
BEND BRDGES AT SHADOW GLEN PHASE 4A
BEND P[TT|GR[VVPLACE PHASE 3
'BEND ]ARBORACRES
BEND IBUNGALOWS AT NORTHWEST CROSSING CONDOMINJUM STAGE 2
BEND |TNA|LHEADATTETHEROVVPHASE 1
BEND MILEPOST 1
BEND !RIVER CAMP
BEND |ATRIUM ATTHE OLD MILL CONDOMINIUM
BEND TUSCANY PINES PHASE 3
BEND RIVERS EDGE VILLAGE NORTH RIVERFRONT
BEND EASTR|DGE
BEND TETHEROW VACATION HOMES PHASES |8&/|
BEND 'FIRST PLACE
BEND 'TREE FARM
!BEND 1REVERERENAGSAN[E
'BEND IROSENGARTH ESTATES PHASES 1-3
BEND 3ANDYSACRE
BEND |NORTHWEST CROSSING PHASE 29
BEND BEND TECH PARK CONDOMINtUMS
BEND ]0N[SFAK�W
BEND /BRANT[STATES
BEND CASCADE HEIGHTS PHASE 3
REDMOND COOK CROSSING CONDOMINIUM
REDMOND ORCHARD KNOLL
REDMOND SUMMIT CREST PHASE 4
'REDMOND TRIPLE RIDGE PHASE 1
REDMOND IGLENN MEADOW PHASE 11
!REDMOND /DQ5|D/ANTRAILS PHASE 1
S/STERS VILLAGE AT COLD SPRINGS PHASE 3
SISTERS CLEARPINE PHASE 2
TOTAL
NEW LOTS
6
391
301
391
7
13
11
24
21
9
35
20
31
15
13
50
6
41
5
16
1
31
2
20
2
8
27
49
16
29
33
23
672
Yellow indicates new subdivisions not located within city /irnits of Bend or Redmond.
21'..);12 A h
MY SLVSOODN 'NEW y,01 S
BEND STONE CREEK PHASE 2 49
'BEND BASECAMP PHASES 2 & 3 171
(BEND PACIFIC CASCADE HEIGHTS 141
BEND AWBREY TERRACE 6
'BEND !NORTHWEST CROSSING AT MCNEAL WAY 15
BEND 'NORTHWEST CROSSING PHASE 23 8
BEND SAGINAW VIEW CONDOMINIUMS 2
BEND BRIDGES AT SHADOW GLEN PHASE 4B, 5 & 6 65
BEND LAVA RIDGES PHASE 6 15
BEND RESERVE AT OLD MILL LANDING 2 4
BEND 'NORTHWEST CROSSING PHASE 27 63
BEND LEEHAVEN 59
BEND HIDDEN HILLS PHASE 3 22
BEND ROBAL ROAD RETAIL VILLAGE 7
BEND RIVERWALK 30
BEND AWBREY GLEN HOMESITES, PHASE EIGHT 61
BEND RIVER'S EDGE VILLAGE, THE POINTE 43
BEND POTTS COURT 6
LA PINE MELASHENKO 5
REDMOND CANYON RIM VILLAGE PHASE 8 191
REDMOND 27 ELM PHASE 1 21
REDMOND KAYLA VILLAGE 5
REDMOND BROOKTREE 68
REDMOND CROSSINGS AT METOLIUS 191
REDMOND OBSIDIAN TRAILS PHASE 2 301
REDMOND FAIRHAVEN VISTA PUD PHASE VI 361
REDMOND MAKENAVIEW ESTATES 131
REDMOND EMERALD VIEW ESTATES PHASE I 161
-(ES
Deschutes County Board of Commissioners
1300 NW Wall St, Bend, OR 97703
(541) 388-6570 — Fax (541) 385-3202 — https://www.deschutes.org/
AGENDA REQUEST & STAFF REPORT
For Board of Commissioners Business Meeting of December 27. 2017
DATE: December 12, 2017
FROM: Kathleen Hinman, Human Resources, 541-385-3215
TITLE OF AGENDA ITEM:
Consideration of Chair Signature of Document No. 2017-737, Amendment to Doc# 2012-622
Deschutes County/Medcor
RECOMMENDATION & ACTION REQUESTED:
Board approval of Document No. 2017-737 amending Contract 2012-622 by extending the
expiration term one year to December 31, 2018 and approving calendar year 2018 charges not
to exceed $1,364,500.00.
CONTRACTOR: Contractor/Supplier/Consultant Name: Medcor
AGREEMENT TIMEFRAME: Starting Date: 1/1/2018 Ending Date: 12/31/2018
BACKGROUND AND POLICY IMPLICATIONS:
In 2012 Deschutes County entered into a contract with Medcor for operation of the Deschutes
Onsite Clinic (DOC). Additional services were added through amendments in 2013, 2014, and
2016, including juvenile services.
The term of the original contract and amendments expires on 12/31/2017.
Document 2017-737 amends the original contract by extending the termination date to
December 31, 2018. It also modifies reporting metrics and authorizes calendar year 2018
charges.
FISCAL IMPLICATIONS: Annual budgeted expenditure of $1,364,500.00
ATTENDANCE: Kathleen Hinman, Director Human Resources and Trygve Bolken, Human
Resources Analyst.
DESCHUTES COUNTY DOCUMENT SUMMARY
(NOTE: This form is required to be submitted with ALL contracts and other agreements, regardless of whether the document is to be
on a Board agenda or can be signed by the County Administrator or Department Director. If the document is to be on a Board
agenda, the Agenda Request Form is also required. If this form is not included with the document, the document will be returned to
the Department. Please submit documents to the Board Secretary for tracking purposes, and not directly to Legal Counsel, the
County Administrator or the Commissioners. In addition to submitting this form with your documents, please submit this form
electronically to the Board Secretary.)
Please complete all sections above the Official Review line.
Date: 11/29/2017! Department: Human Resources!
Contractor/Supplier/Consultant Name: 1Medcod
Contractor Contact: Cody Seeger Contractor Phone #: 015-354-34451
Type of Document: Amendment to extend the Medcor contract (2012-622) through
12/31/2018.
Goods and/or Services: Modcor staffs the DOC and supplies the clinic with necessary
goods. Medocr also provides a staff of one as a wellness coordinator and provides
medical staff and medical supplies for the junvinille detention center.
Background & History: We have been under contract with Medcor since 2012 with
several ammendments following. This amendment will continue the contract through
2018. We anticipate going out to RFP in 2018.
Agreement Starting Date: 1/1/2018!
Annual Value or Total Payment: 01,364,500.001
Insurance Certificate Received check box)
Insurance Expiration Date:
Ending Date: 112/31/20181
Check all that apply:
(- RFP, Solicitation or Bid Process
Informal quotes (<$150K)
Exempt from RFP, Solicitation or Bid Process (specify — see DCC §2.37)
Funding Source: (Included in current budget? E Yes No
If No, has budget amendment been submitted?
Yes No
Is this a Grant Agreement providing revenue to the County? I 1 Yes ® No
Special conditions attached to this grant:
Deadlines for reporting to the grantor:
12/1/2017
If a new FTE will be hired with grant funds, confirm that Personnel has been notified that
it is a grant -funded position so that this will be noted in the offer letter: I 1 Yes I 1No
Contact information for the person responsible for grant compliance:
Name:
Phone #:
Departmental Contact and Title: rirygve Bolken Human Resources Analyst
Phone M1541-317-31541
Department Director Approval:
Signature
Date
Distribution of Document: Who gets the original document and/or copies after it has
been signed? Include complete information if the document is to be mailed.
Official Review:
C. nty Signature Required (check one):
OCC (if $150,000 or more) — BOARD AGENDA Item
0 County Administrator (if $25,000 but under $150,000)
0 Department Director - Health (if under $50,000)
El Department Head/Director (if under $25,000)
Legal Review
Document Number
Date
11/30/2017
DocuSign Envelope ID: D99B7ABE-AFBB-4A9F-84E5-CBEB3E92D11C
rn,
DESCHUTES COUNTY CONTRACT NO. 2017-737
(AMENDMENT TO DESCHUTES COUNTY CONTRACT NO. 2012-622)
Whereas the parties to this contract amendment are Medcor, Inc., and Deschutes County, a political
subdivision of the State of Oregon, and
Whereas the parties continue to operate pursuant to the terms of Contract No. 2012-622, as amended
by Documents Nos. 2013-355, 2013-476, 2013-511, 2014-636, 2016-143, and 2016-680 (together the
"Amended Agreement") and
Whereas the parties now desire to amend that Amended Agreement according to the terms of this
additional Amendment,
Now, therefore, in consideration of the mutual promises of the parties and other good and valuable
consideration, the sufficiency of which is hereby acknowledged, it is agreed by the parties as follows:
I. The Amended Agreement is further amended as follows:
• Contract No. 2012-622, as amended, is renewed for a term of one-year: termination
date of "December 31, 2017" is deleted and "December 31, 2018" is inserted in its
place.
• Monthly Contractor reports for the previous month are provided to the County no later
than the 10th of each month.
DS
tater than the 10th
• Medcor will provide the County with its Projected Budget/Charges for 2018 by no later
than January 31, 2018; the County will review the Projected Budget/Charges and
provide written approval or rejection within 30 days; in no event shall the Projected
Budget/Charges exceed $1,364,500.00.
11. All other terms and conditions in the Amended Agreement remain in full force and effect.
III DTssidlamendment is effective as of January 1, 2018.
pthys Vi,
.—fq1AC,1fl1?BOhAnA
For Medcor, Inc.
COO
Title
0))41,-,(6"-
DESCHUT S LINTY
Board Chair, Tammy B
CONTRACT NO. 2017-737
12/5/2017
Date Signed
Date Signed
7// 7
Page 1
oc 2017
DESCHUTES COUNTY CONTRACT NO. 2017-737
(AMENDMENT TO DESCHUTES COUNTY CONTRACT NO. 2012-622)
Whereas the parties to this contract amendment are Medcor, Inc., and Deschutes County, a political
subdivision of the State of Oregon, and
Whereas the parties continue to operate pursuant to the terms of Contract No. 2012-622, as amended
by Documents Nos. 2013-355, 2013-476, 2013-511, 2014-636, 2016-143, and 2016-680 (together the
"Amended Agreement") and
Whereas the parties now desire to amend that Amended Agreement according to the terms of this
additional Amendment,
Now, therefore, in consideration of the mutual promises of the parties and other good and valuable
consideration, the sufficiency of which is hereby acknowledged, it is agreed by the parties as follows:
I. The Amended Agreement is further amended as follows:
• Contract No. 2012-622, as amended, is renewed for a term of one-year: termination
date of "December 31, 2017" is deleted and "December 31, 2018" is inserted in its
place.
• Monthly Contractor reports for the previous month are provided to the County no later
than the 10th of each month.
• Quarterly myCatalyst reports for th' quarter are provided to the County no
later than the 10th of the mor4.' lendar quarter.
�Escti�
• Medcor will provide the ' � �� budget/Charges for 2018 by no later
than January 31, " ejected Budget/Charges and
provide writ' Yz 1 no event shall the Projected
Budge'
II.All othe- in full force and effect.
111. Th. n
(V �
acs �°
For Me. L5 I�o
7 x
Title
DESCHUTES COUN1
Board Chair, Tammy i
CONTRACT NO. 2017-737
Date Signed
Page 1
Certificate Of Completion
Envelope Id: D99B7ABEAFBB4A9F84E5CBEB3E92D11C
Subject: Please DocuSign: Medcor Contract Renewal 2017 - Deschutes County 122017.pdf
Source Envelope:
Document Pages: 1 Signatures: 1
Certificate Pages: 5 Initials: 1
AutoNav: Enabled
Envelopeld Stamping: Enabled
Time Zone: (UTC -06:00) Central Time (US & Canada)
Record Tracking
Status: Original
Dec 5, 2017 1 14:41
Signer Events
Ben Petersen
bpetersen@medcor.com
COO
Medcor
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted: Dec 5, 2017 1 15:12
ID: 38e17 bcc-d 715-4f78-9060-13a5598d b 8ae
In Person Signer Events
Editor Delivery Events
Agent Delivery Events
Intermediary Delivery Events
Certified Delivery Events
Carbon Copy Events
Patrick Looby
patrick.looby@med cor. com
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Matt Ford
Matthew.ford@medcor.com
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
marcy sheppard
marcy.sheppard @med cor. com
Medcor, Inc.
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Holder: Anne Marie Zembrzuski
azembrzuski@medcor.com
Signature
,—DocuSlgneu by:
f2t.tn, etftrs tn,
`-2318E4417BOA404 .
Using IP Address: 68.21.221.240
Signature
Status
Status
Status
Status
Status
COPIED
COPIED
COPIED
Status: Completed
Envelope Originator:
Anne Marie Zembrzuski
P.O. Box 550
McHenry, IL 60051
azembrzuski@medcor.com
IP Address: 68.21.221.240
Location: DocuSign
Timestamp
Sent: Dec 5, 2017 1 14:42
Viewed: Dec 5, 2017 1 15:12
Signed: Dec 5, 2017 1 15:12
Timestamp
Timestamp
Timestamp
Timestamp
Timestamp
Timestamp
Sent: Dec 5, 2017 1 15:12
Sent: Dec 5, 2017 1 15:12
Sent: Dec 5, 2017 1 15:12
Docu
Carbon Copy Events Status Timestamp
Not Offered via DocuSign
Notary Events Signature Timestamp
Envelope Summary Events Status Timestamps
Envelope Sent Hashed/Encrypted Dec 5, 2017 1 15:12
Certified Delivered Security Checked Dec 5, 2017 1 15:12
Signing Complete Security Checked Dec 5, 2017 1 15:12
Completed Security Checked Dec 5, 2017 1 15:12
Payment Events Status Timestamps
Electronic Record and Signature Disclosure
Electronic Record and Signature Disclosure created on: Dec 31, 2013 1 17:18
Parties agreed to: Ben Petersen
CONSUMER DISCLOSURE
From time to time, Medcor, Inc. (we, us or Company) may be required by law to provide to you
certain written notices or disclosures. Described below are the terms and conditions for providing
to you such notices and disclosures electronically through the DocuSign, Inc. (DocuSign)
electronic signing system. Please read the information below carefully and thoroughly, and if
you can access this information electronically to your satisfaction and agree to these terms and
conditions, please confirm your agreement by clicking the `I agree' button at the bottom of this
document.
Getting paper copies
At any time, you may request from us a paper copy of any record provided or made available
electronically to you by us. You will have the ability to download and print documents we send
to you through the DocuSign system during and immediately after signing session and, if you
elect to create a DocuSign signer account, you may access them for a limited period of time
(usually 30 days) after such documents are first sent to you. After such time, if you wish for us to
send you paper copies of any such documents from our office to you, you will be charged a
$0.00 per -page fee. You may request delivery of such paper copies from us by following the
procedure described below.
Withdrawing your consent
If you decide to receive notices and disclosures from us electronically, you may at any time
change your mind and tell us that thereafter you want to receive required notices and disclosures
only in paper format. How you must inform us of your decision to receive future notices and
disclosure in paper format and withdraw your consent to receive notices and disclosures
electronically is described below.
Consequences of changing your mind
If you elect to receive required notices and disclosures only in paper format, it will slow the
speed at which we can complete certain steps in transactions with you and delivering services to
you because we will need first to send the required notices or disclosures to you in paper format,
and then wait until we receive back from you your acknowledgment of your receipt of such
paper notices or disclosures. To indicate to us that you are changing your mind, you must
withdraw your consent using the DocuSign `Withdraw Consent' form on the signing page of a
DocuSign envelope instead of signing it. This will indicate to us that you have withdrawn your
consent to receive required notices and disclosures electronically from us and you will no longer
be able to use the DocuSign system to receive required notices and consents electronically from
us or to sign electronically documents from us.
All notices and disclosures will be sent to you electronically
Unless you tell us otherwise in accordance with the procedures described herein, we will provide
electronically to you through the DocuSign system all required notices, disclosures,
authorizations, acknowledgements, and other documents that are required to be provided or made
available to you during the course of our relationship with you. To reduce the chance of you
inadvertently not receiving any notice or disclosure, we prefer to provide all of the required
notices and disclosures to you by the same method and to the same address that you have given
us. Thus, you can receive all the disclosures and notices electronically or in paper format through
the paper mail delivery system. If you do not agree with this process, please let us know as
described below. Please also see the paragraph immediately above that describes the
consequences of your electing not to receive delivery of the notices and disclosures
electronically from us.
How to contact Medcor, Inc.:
You may contact us to let us know of your changes as to how we may contact you electronically,
to request paper copies of certain information from us, and to withdraw your prior consent to
receive notices and disclosures electronically as follows:
To contact us by email send messages to: rdooley@medcor.com
To advise Medcor, Inc. of your new e-mail address
To let us know of a change in your e-mail address where we should send notices and disclosures
electronically to you, you must send an email message to us at rdooley@medcor.com and in the
body of such request you must state: your previous e-mail address, your new e-mail address. We
do not require any other information from you to change your email address..
In addition, you must notify DocuSign, Inc. to arrange for your new email address to be reflected
in your DocuSign account by following the process for changing e-mail in the DocuSign system.
To request paper copies from Medcor, Inc.
To request delivery from us of paper copies of the notices and disclosures previously provided
by us to you electronically, you must send us an e-mail to rdooley@medcor.com and in the body
of such request you must state your e-mail address, full name, US Postal address, and telephone
number. We will bill you for any fees at that time, if any.
To withdraw your consent with Medcor, Inc.
To inform us that you no longer want to receive future notices and disclosures in electronic
format you may:
i. decline to sign a document from within your DocuSign session, and on the subsequent
page, select the check -box indicating you wish to withdraw your consent, or you may;
ii. send us an e-mail to rdooley@medcor.com and in the body of such request you must
state your e-mail, full name, US Postal Address, and telephone number. We do not need
any other information from you to withdraw consent.. The consequences of your
withdrawing consent for online documents will be that transactions may take a longer
time to process..
Required hardware and software
Operating
Systems:
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Screen
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-CES
Deschutes County Board of Commissioners
1300 NW Wall St, Bend, OR 97703
(541) 388-6570 — Fax (541) 385-3202 — https://www.deschutes.org/
AGENDA REQUEST & STAFF REPORT
For Board of Commissioners Business Meeting of December 27, 2017
DATE: December 12, 2017
FROM: Kathleen Hinman, Human Resources, 541-385-3215
TITLE OF AGENDA ITEM:
Consideration of Chair Signature of 2017-757, Amendment to Premise Health Contract 2012-
299
RECOMMENDATION & ACTION REQUESTED:
Board approval of 2017-757
CONTRACTOR: Contractor/Supplier/Consultant Name: Premise Health f/k/a Take Care
Employer Solutions, LLC
AGREEMENT TIMEFRAME: Starting Date: 5/30/2017 Ending Date: 12/31/2018
BACKGROUND AND POLICY IMPLICATIONS:
Premise Health staffs the DOC Pharmacy and supplies the pharmacy with necessary goods
and pharmacy dispensing information systems.
We have been under contract with Premise Health since 2012 for DOC Pharmacy services
since 2012 with one amendment (2013-539) following. This amendment will continue the
contract through 12/31/2018.
FISCAL IMPLICATIONS: 2018 budgeted expenditure of $2,153,695.00
ATTENDANCE: Kathleen Hinman, Director Human Resources and Trygve Bolken, Human
Resources Analyst
DESCHUTES COUNTY DOCUMENT SUMMARY
(NOTE: This form is required to be submitted with ALL contracts and other agreements, regardless of whether the document is to be
on a Board agenda or can be signed by the County Administrator or Department Director. If the document is to be on a Board
agenda, the Agenda Request Form is also required. If this form is not included with the document, the document will be returned to
the Department. Please submit documents to the Board Secretary for tracking purposes, and not directly to Legal Counsel, the
County Administrator or the Commissioners. In addition to submitting this form with your documents, please submit this form
electronically to the Board Secretary.)
Please complete all sections above the Official Review line.
Date: 112/1/20171 Department: 1Human Resources
Contractor/Supplier/Consultant Name: Premise Health1
Contractor Contact: Lindsey Kratzer Contractor Phone #: 1415-407-70931
Type of Document: Amendment to extend the Premise Health f/k/a Take Care
Employer Solutions LLC contract (2012-299) through 12/31/2018.
Goods and/or Services: Premise Health staffs the DOC Pharmacy and supplies the
pharmacy with necessary goods and pharmacy dispensing information systems.
Background & History: We have been under contract Premise Health since 2012
with one ammendment (2013-539) following. This amendment will continue the contract
through 2018.
Agreement Starting Date: 15/30/20171 Ending Date: 12/31/2018
Annual Value or Total Payment: $2,153,695.001
Insurance Certificate Received (check box)
Insurance Expiration Date:
Check all that apply:
RFP, Solicitation or Bid Process
Informal quotes (<$150K)
Exempt from RFP, Solicitation or Bid Process (specify — see DCC §2.37)
I I
I I
I I
Funding Source: (Included in current budget? X Yes 1 1 No
If No, has budget amendment been submitted?
Yes
No
Is this a Grant Agreement providing revenue to the County? Yes E No
Special conditions attached to this grant:
Deadlines for reporting to the grantor:
If a new FTE will be hired with grant funds, confirm that Personnel has been notified that
it is a grant -funded position so that this will be noted in the offer letter: Yes No
12/6/2017
Contact information for the person responsible for grant compliance:
Name:
Phone #:
Departmental Contact and Title: ITrygve Bolken Human Resources Analystj
Phone #: 541-317-3154
k
Department Director Approval: ii,Y1Ac% CA -1
Signature
2(
ri-
Date
Distribution of Document: Who gets the original document and/or copies after it has
been signed? Include complete information if the document is to be mailed.
Official Review:
Coo
nty Signature Required (check one):
BOCC (if $150,000 or more) — BOARD AGENDA Item
County Administrator (if $25,000 but under $150,000)
El Department Director - Health (if under $50,000)
El Department Head/Director (if under $25,000)
Legal Review
Document Number ail
t1J
Date )
12/6/2017
AMENDMENT NO. 2
TO
PHARMACY AGREEMENT CONTRACT
This Amendment No. 2 to the Pharmacy Agreement ("Amendment") is effective as of May
31, 2017 ("Effective Date"), and is made by and between PREMISE HEALTH
EMPLOYER SOLUTIONS, LLC f/k/a Take Care Employer Solutions, LLC, a Delaware
limited liability company, having its principal place of business at 5500 Maryland Way,
Suite 200, Brentwood, TN 37027 ("Premise Health") and DESCHUTES COUNTY,
OREGON, a municipal corporation ("Client"). Premise Health and Client are each
individually a "Party" and are collectively the "Parties."
RECITALS
WHEREAS, Premise Health and Client entered into that certain Pharmacy
Agreement Contract, effective May 30, 2012, as amended by that certain Document No.
2013-539, effective December 4, 2013 (collectively, the "Agreement");
WHEREAS, the Parties desire to amend certain terms of the Agreement.
NOW, THEREFORE, in consideration of the premises and mutual promises and
covenants set forth in this Amendment, and intending to be legally bound, Premise Health
and Client agree to the following:
AMENDMENTS
Section 5 — Term to the Agreement is hereby deleted in its entirety and replaced
with the following:
Term. The Term of this Agreement will expire on May 30, 2017 ("Initial Term").
Upon expiration of the Initial Term, this Agreement will renew and will terminate
December 31, 2018 ("Renewal Term"), unless terminated earlier in accordance
with the provisions of this Agreement. The Initial Term and Renewal Term are
collectively referred to as thc "Term".
2. The Agreement is further amended to replace references in the Agreement to "Take
Care Employer Solutions, LLC" or "Take Care" with references to "Premise Health
Employer Solutions, LLC" or "Premise Health".
3. Exhibit B — Proiected Implementation Budget and Proiected Operating Budget is
hereby deleted in its entirety and replaced with the attached hereto Exhibit B —
Budget 2017-20 I 8.
4. "Exhibit A, Statement of Work, Deschutes County Pharmacy" shall be amended
by adding a new Section 4.4 as stated below.
4.4 Variable Co -Pay Program — From time to time, but no less than quarterly,
Premise Health will identify certain pharmaceutical manufacturers saving and
coupon programs for which County and Participants may qualify ("Coupon
Optimization"). Premise Health shall provide County with a written summary of
such programs and the savings opportunities. To the extent County agrees to
modify its summary plan description for specified pharmaceuticals to include any
prerequisites to comply with Coupon Optimization program guidelines, Premise
Health will manage and remit such Coupon Optimization program for those eligible
pharmaceuticals. Premise Health shall retain 20% of total recoveries attributable
to the Coupon Optimization program. All remaining recoveries shall be
summarized and included on the monthly invoice provided by Premise Health to
County. County may, at its sole discretion, terminate the Program upon 30 days
written notice to Premise Health.
MISCELLANEOUS
1 . Effect of Amendment. Except as specifically amended hereby, all of the terms of
the Agreement shall remain in full force and effect.
2. Authority. Client and Premise Health hereby represent and warrant that they have
all necessary and required power and authority to enter into this Amendment and
that the execution and delivery of this Amendment by Client and Premise Health
has been duly authorized by all requisite corporate action and when executed and
delivered, this Amendment shall be valid and binding upon Client and Premise
Health.
3. Counterparts. This Amendment may be executed in one or more counterparts, each
of which shall be deemed an original, but all of which together shall constitute one
and the same instrument. Signature pages may be executed by "wet" signature or
electronic mark and the executed pages may be delivered using PDF or other similar
file types transmitted by electronic mail, cloud -based server, e -signature
technology or other similar electronic means and neither party shall contest the
validity of any properly delivered signature or mark.
IN WITNESS WHEREOF, Premise Health and Client have executed this
Amendment through their respective representatives to be effective as of the Amendment
Effective Date.
{Signature Page Follows}
2
DESCI t ;TES COUNTY, OREGON
13y;1'
Name: \ (fl
vvw \
Title: d (tstol
Date:
3
PREMISE IlEALTII EMPLOYER
SOLUTIONS, LLC
fly:
Name: Shannon Farrington
Tit le: Chief Financial Officer
DESCHUTES COUNTY, OREGON PREMISE HEALTH EMPLOYER
SOLUTIONS, LLC
By: il-h4 2 By:
Name: -T-mainq\I 4rw \/ Name: Shannon Farrington
Title: 130% 01 CNA tr 1 Title: Chief Financial Officer
Date: /(9-12 i .---7 Date:
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--k Deschutes County Board of Commissioners
1300 NW Wall St, Bend, OR 97703
(541) 388-6570 — Fax (541) 385-3202 — https://www.deschutes.org/
AGENDA REQUEST & STAFF REPORT
For Board of Commissioners Business Meeting of December 27, 2017
DATE: December 21, 2017
FROM: Kathleen Hinman, Human Resources, 541-385-3215
TITLE OF AGENDA ITEM:
Consideration of Board Signature of Document No. 2017-774, Third Party Agreement -
PacificSource
RECOMMENDATION & ACTION REQUESTED:
Staff recommends Board signature of Administrative Services Agreement document # 2017-
774 with PacificSource for TPA services in connection with the Deschutes County Employee
Health Benefit Plan.
CONTRACTOR: PacificSource
AGREEMENT TIMEFRAME: Starting Date: January 1, 2018 Ending Date: December 31,
2020
INSURANCE:
Insurance Certificate Required: Yes
Insurance Review Required by Risk Management: Yes
BACKGROUND AND POLICY IMPLICATIONS: In consideration of Deschutes County's
Acceptance and in consideration of payment of Administrative Services Fees in the amounts and at the
time required, PacificSource Health Plans, an Oregon non-profit corporation, and its subsidiary,
PacificSource Administrators, Inc., will provide administrative services for the Deschutes County
Employee Benefit Plan for each enrolled person in accordance with the provisions and subject to the
conditions of this Agreement.
FISCAL IMPLICATIONS: Costs for TPA are in annual budget.
ATTENDANCE: Preference is consent agenda as this agreement was discussed during
12/18/17 work session. Kathleen Hinman, HR Director and Trygve Bolken, HR Analyst will be
present to answer any questions.
DESCHUTES COUNTY DOCUMENT SUMMARY
(NOTE: This form is required to be submitted with ALL contracts and other agreements, regardless of whether the document is to be
on a Board agenda or can be signed by the County Administrator or Department Director. If the document is to be on a Board
agenda, the Agenda Request Form is also required. If this form is not included with the document, the document will be returned to
the Department. Please submit documents to the Board Secretary for tracking purposes, and not directly to Legal Counsel, the
County Administrator or the Commissioners. In addition to submitting this form with your documents, please submit this form
electronically to the Board Secretary.)
Please complete all sections above the Official Review line.
Date: 112/21/171 Department: 1Human Resources1
Contractor/Supplier/Consultant Name: 1PacificSourcel
Contractor Contact: 1Tony Kopki Contractor Phone #: 1866-540-11911
Type of Document: Third Party Administrative Services Agreement
Goods and/or Services: In consideration of Deschutes County's Acceptance and in
consideration of payment of Administrative Services Fees in the amounts and at the
time required, PacificSource Health Plans, an Oregon non-profit corporation, and its
subsidiary, PacificSource Administrators, Inc., will provide administrative services for
the Deschutes County Employee Benefit Plan for each enrolled person in accordance
with the provisions and subject to the conditions of this Agreement.
Background & History: PacificSource was awarded the services contract through
the RFP process in April 2017. PacificSource is assuming third party administration of
the County benefits plan effective 1/1/2018. They will be assuming the services
formerly administered by EBMS.
Agreement Starting Date: 11/1/2018
Annual Value or Total Payment: 003,990.00j
Insurance Certificate Received check box)
Insurance Expiration Date:
Check all that apply:
RFP, Solicitation or Bid Process
Informal quotes (<$150K)
Exempt from RFP, Solicitation or Bid Process (specify — see DCC §2.37)
x
Ending Date: 12/31/2020
Funding Source: (Included in current budget? Fl Yes I l No
If No, has budget amendment been submitted?
Yes
Is this a Grant Agreement providing revenue to the County?
Special conditions attached to this grant:
No
Yes No
12/21/2017
Deadlines for reporting to the grantor:
If a new FTE will be hired with grant funds, confirm that Personnel has been notified that
it is a grant -funded position so that this will be noted in the offer letter: Yes I I No
Contact information for the person responsible for grant compliance:
Name:
Phone #:
Departmental Contact and Title: 1Trygve Bolken Human Resources Analy0
Phone #:1541-317-31541
Department Director Approval:
Signature Date
Distribution of Document: Who gets the original document and/or copies after it has
been signed? Include complete information if the document is to be mailed.
Official Review:
County Signature Required (check one):
BOCC (if $150,000 or more) — BOARD AGENDA Item
❑ County Administrator (if $25,000 but under $150,000)
❑ Department Director - Health (if under $50,000)
❑ Department Head/Director (if under $25,000)
Legal Review
Document Number c9. 01
Date V9 -2,-( �� B
12/21/2017
NEVIab
Ili
LEGAL COUNSEL
PacificSource
THIRD PARTY ADMINISTRATIVE SERVICES AGREEMENT
No. G0037173
Deschutes County Contract No. 2017-xxx
This Third Party Administrative Services Agreement ("Agreement") is between PacificSource Health Plans,
an Oregon non-profit corporation, PacificSource Administrators, Inc., an Oregon Corporation, and
Deschutes County, Oregon, a political subdivision of the State of Oregon.
In consideration of Deschutes County's Acceptance and in consideration of payment of Administrative
Services Fees in the amounts and at the time required, PacificSource Health Plans, and its subsidiary,
PacificSource Administrators, Inc., will provide administrative services for the Deschutes County Employee
Benefit Plan for each enrolled person in accordance with the provisions and subject to the conditions of this
Agreement.
This Agreement, including all attachments, addendums, exhibits, PacificSource Stop Loss Policy (if
applicable), or amendments affixed hereto, shall constitute the entire contract between the Parties.
PacificSource Health Plans
P.O. Box 7068, Springfield, OR 97475-0068
PacificSource Administrators, Inc.
P.O. Box 7068, Springfield, OR 97475-0068
Pacificsource
1 ASA_Deschutes County _0118
DC 2017-7741.
Table of Contents
THIRD PARTY ADMINISTRATIVE SERVICES AGREEMENT No. G0037173 1
PacificSource Health Plans 1
PacificSource Administrators, Inc. ..... . ..... ..... .......—...... ......... . ..... ........ ........ 1
L RECITALS 4
IL INTRODUCTION 4
2.1 Effective Date and Term 4
2.2 Scope of Relationship 4
2.3 Definitions 5
III. RESPONSIBILITIES OF SPONSOR 5
3.1 Role of Sponsor 5
3.2 Funding and Services Charges 6
3.3 Information to PacificSource 6
3.4 Pian Documents 6
3.5 Financial Responsibility for Claims 7
3.6 Medical Records 7
3.7 HIPAA Privacy and Security 7
IV. RESPONSIBILITIES OF PACIFICSOURCE 7
4.1 Limited Scope of Responsibilities 7
4.2 Customer Service 7
4.3 Benefit Process and Payment 7
4.4 Bonding and Insurance Coverage 8
4.5 Reporting 8
4.6 Claims Appeals 8
4.7 Recordkeeping 8
4.8 Standard of Care; Erroneous Payments 9
4.9 Notices to Sponsor 9
4.10 Non-Discretionary Duties; Additional Duties 9
4.11 Subcontractors 9
V. PAYMENTS FOR HEALTH BENEFITS; SPONSOR'S FUNDING RESPONSIBILITY 9
5.1 Payment of Health Benefits 9
5.2 Prompt Payment 10
5.3 Funding of Benefits 10
VI. PACIFICSOURCE COMPENSATION 10
2 ASA_Deschutes County _0118
6.1 Service Charges 10
6.2 Billing of Charges 10
6.3 Payment of Charges 10
6.4 Compensation Disclosures 10
VII. INDEMNIFICATION AND HOLD HARMLESS 10
7.1 Indemnification by Sponsor 10
7.2 Indemnification by PacificSource Group 11
VIII. TERMINATION 11
8.1 Automatic 11
8.2 Discretionary 11
8.3 Limited Continuation Following Termination 11
8.4 Survival of Certain Provisions 11
IX. GENERAL PROVISIONS 12
9.1 Severability 12
9.2 Headings 12
9.3 Compliance and Non -Waiver 12
9.4 Amendment 12
9.5 Assignment 12
9.6 Audits 12
9.7 Non -Disclosure of Proprietary Information 12
9.8 Governing Law; Venue; Attorneys' Fees 13
9.9 Notices and Communications 13
9.10 Force Majeure 13
9.11 Participation with Health Improvement Entities 14
9.12 Enrollment Vendor 14
9.13 Complete Agreement 14
9.14 Opt -Out of Quality Improvement Measures 14
X. SIGNATURE 15
EXHIBIT 1: BUSINESS ASSOCIATE ADDENDUM 16
EXHIBIT II: COVERAGE SERVICES ADDENDUM 19
EXHIBIT III: COBRA ADMINISTRATION SERVICES ADDENDUM 22
EXHIBIT IV: DESCHUTES COUNTY ADDENDUM 23
3 ASA_Deschutes County _0118
This Agreemenis made by and between PacificSource Health Plans ("PacificSource") and PacificSource
Administrators, Inc. (''PSA") (collectively, "PacificSource Group") as Third Party Administrators providing
administrative services only, and Deschutes County, as Plan Sponsor ("Sponsor") of the Deschutes County
Employee Benefit Plan (the "Plan"). PacificSource Group and Sponsor shall be collectively referred to as
the "Parties."
1 RECITALS
1.1 Sponsor has established certain programs for the benefit of its employees, which may be
subject to the laws codified in ERISA, Health Care Reform, and in various other state and federal statutory
schemes.
1.2 PacificSource Group is in the business of assisting companies like Sponsor with the
administration of certain ministeriat functions for benefitpians.
1.3 Sponsor has requested PacificSource Group assist it, and act on its behalf, with respect to
a variety of administrative and ministerial functions, including making payment of certain benefits, providing
recordkeeping and other administrative services as described in this Agreement.
1.4 PacificSource Group is a business associate under HIPAA with regards to the services it
will provide herein and, to that extan8, has executed the Business Associate Addendum attached hereto as
Exhibit I.
NOW THEREFORE, in consideration of the mutual promises contained in this Agreement, Sponsor and
PacificSource Group agree as follows:
K INTRODUCTION
2.1 Effective Date arid Term
The effective date of this Agreement is January 1, 2018, or the date on which each party has signed this
Agreement, whichever is later. Untess extended or terminated eariier in accordance with the terms herein,
the Agreement shall terminate on December 31, 2020. After the initial term, this Agreement may be
renewed for successive one-year periods by the mutual, written agreement of the Parties.
2.2 Scope ofRelationship
Sponsor has the sole and final authority to eoteb|ioh, maintain, control, and manage the operation of the
Plan. PacificSource Group is and shall remain an independent contractor with respect to the services being
performed hereunder and shall not for any purpose be deemed an employee of Sponsor. Nor shall
PacificSource Group and Sponsor be deemed partnero, engaged in a joint venture, or governed by any
legal relationship other than that of independent contractor. PacificSource Group does not assume any
responsibility for the policy design of the Plan, the adequacy of its funding, or any act or omission or breach
of duty by Sponsor. Nor is PacificSource Group in any way to be deemed an inounar, undenmhter, or
guarantor with respect to any benefits payable under the Plan. With respect to payment of benefits,
PacificSource Group generally provides reimbursement services only and does not assume any financial
risk or obligation with respect to claims for benefits payable by Sponsor under the Plan. PacificSource
Group does not intend to be the "named fiduciary," "plan sponsor," or "plan administrator" (as such terms
are described in ER/8A, other applicable law, or the Plan documentation) or assume any of the
administrative duties or responsibilities commensurate with those designations.
Unless required by applicable |aw, nothing in this Agreement shall be deemed to (1) render the
PacificSource Group a party to the Plan; (2) confer upon PacificSource Group any authority or control
respecting management of the Plan, authority or responsibility in connection with administration of the Plan,
or responsibility for the terms or validity of the Plan; or (3) impose upon PacificSource Group any obligation
to any employee of Sponsor or any person who is participating in the Plan ("Participant") or otherwise
entitied to benefits through the PIan.
4
ASA_oeschmesCounty _0z18
2.3 Definitions
"Agreement" means this Administrative Services Only Agreement, including all Appendices hereto.
"Business Associate Addendum" means the separate agreement entered into between Sponsor and the
PacificSource Group (as business associate) to document compliance with HIPAA's privacy, security, and
electronic data interchange (EDI) requirements.
"COBRA" means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, including
regulations promulgated thereunder.
"Code" means the Internal Revenue Code of 1986, as amended, including regulations thereunder.
"ERISA" means the Employee Retirement Income Security Act of 1974, as amended, including regulations
thereunder.
"Effective Date" has the meaning given in Section 2.1.
"Electronic PHI" or "ePHI" is a type of PHI and has the meaning assigned to such term under HIPAA.
"Exhibits" means one or more documents added to this Agreement, and marked as exhibits, which are
incorporated by reference into and form part of this Agreement.
"Health Care Reform" means the Patient Protection and Affordable Care Act, (PPACA), as amended by
the Health Care and Education Reconciliation Act of 2010, (HCERA), and as further amended from time to
time, including regulations thereunder.
"HIPAA" means the Health Insurance Portability and Accountability Act of 1996, as amended, including
regulations thereunder.
"Named Fiduciary" means the named fiduciary as defined in ERISA §402(a)(1).
"Participant" has the meaning given in Section 2.2.
"Plan" means each portion of the Program through which benefits are provided, including the Health FSA
or DCAP, as applicable.
"Plan Administrator" means the administrator as defined in ERISA §3(16)(A).
"Program" has the meaning given in the Recitals and refers to the Plans collectively.
"Protected Health Information" or "PHI" has the meaning assigned to such term under HIPAA.
"Sponsor" means Deschutes County.
III. RESPONSIBILITIES OF SPONSOR
3.1 Role of Sponsor
(a) General. Sponsor has the sole authority and responsibility for the Plan and its operation,
including the authority and responsibility for establishing, administering, construing, and interpreting the
provisions of the Plan and making all determinations thereunder. Sponsor gives PacificSource Group the
authority to act on behalf of Sponsor in connection with the Plan, but only as expressly stated in this
Agreement or as mutually agreed in writing by Sponsor and PacificSource Group. All final determinations
as to a Participant's entitlement to Plan benefits are to be made by Sponsor, including any determination
5 ASA_Deschutes County _0118
upon appeal of a denied claim for Plan benefits. Sponsor is considered the Plan Administrator and Named
Fiduciary of the Plan benefits for purposes of ERISA.
(b) Responsibilities. Without limiting Sponsor's responsibilities described herein, except as
otherwise provided in this Agreement, it shall be Sponsor's sole responsibility (as Plan Administrator) and
duty to: ensure compliance with COBRA; perform required nondiscrimination testing; amend the Plans as
necessary to ensure ongoing compliance with applicable law; file any required tax or governmental returns
relating to the Plan(s); collect and forward any fees related to the Plans; determine if and when a valid
election change has occurred; make final determination on any Participant claim appeals; execute and
retain required Plan and claims documentation; and take all other steps necessary to maintain and operate
the Plans in compliance with applicable provisions of the Plans, ERISA, HIPAA, the Code, Health Care
Reform, and other applicable federal and state laws.
3.2 Funding and Services Charges
Sponsor shall pay PacificSource Group the service charges set forth in the Exhibits hereto, and as further
described in Sections 5.1 and 5.2. Sponsor shall promptly make any funds necessary available for payment
of benefits under the Plan. It is the Sponsor's intent that the Plan be operated to fall within an exception or
non -enforcement policy with respect to ERISA's trust requirement for plan assets. To the extent
PacificSource Group administers the remittance of fees or expenses for which Sponsor is responsible, such
as certain fees which may apply under Health Care Reform, Sponsor shall promptly make those funds
available to PacificSource Group for any required remittance.
3.3 Information to PacificSource
Sponsor shall furnish the information requested by PacificSource Group as determined necessary to
perform PacificSource Group's functions hereunder, including information concerning the Plan and the
eligibility of individuals to participate in and receive Plan benefits. Such information shall be provided to
PacificSource Group in the time and in the manner agreed to by Sponsor and PacificSource Group.
PacificSource Group shall have no responsibility with regard to benefits paid (or not paid) in error, or with
regard to failure to timely provide required notices or other communications, due to Sponsor's failure to
timely update such information. From time to time thereafter, at least as frequently as necessary to enable
Sponsor and PacificSource to discharge their respective responsibilities under applicable law,
PacificSource shall provide Sponsor with updated reports summarizing the eligibility data provided by
Sponsor by electronic medium (the "Reports") unless otherwise agreed by the Parties. The Reports shall
specify the effective date for each Participant who is added to or terminated from participation in the Plan.
Sponsor shall be responsible for ensuring the accuracy of its Reports, and bears the burden of proof in any
dispute with PacificSource relating to the accuracy of any Report. PacificSource shall have no liability to
Sponsor or any Participant as a consequence of an inaccurate Report, and PacificSource shall not have
any obligation to credit Sponsor for any claims expenses or administrative fees incurred or paid to
PacificSource as a consequence of Sponsor failing to review Reports for accuracy. PacificSource shall
assume that all such information is complete and accurate, and is under no duty to question the
completeness or accuracy of such information. With respect to any Plan subject to the HIPAA privacy rule,
such Reports shall be considered PHI, and when transmitted by or maintained in electronic media shall be
considered ePHI, subject to the privacy and security rules under HIPAA and the applicable separate
Business Associate Contract.
3.4 Plan Documents
Sponsor is responsible for the Plan's compliance with all applicable federal and state laws and regulations,
including amending Plan documents as necessary to comply with applicable law changes and reflect
changes to the benefit arrangements. Sponsor shall provide PacificSource Group with all relevant
documentation, including but not limited to, the Plan documents and any Plan amendments. To the best of
its ability, Sponsor will notify PacificSource Group of any changes to the Plan at least thirty (30) days before
the effective date of such changes. Sponsor acknowledges that PacificSource Group is not providing tax
or legal advice and that Sponsor shall be solely responsible for determining the legal and tax status of the
Program.
6 ASA_Deschutes County _0118
3.5 Financial Responsjbiljtv for Claims
Sponsor is responsible for payment of claims made pursuant to, and the benefits to be provided by, the
Plan. PacificSource Group does not insure or underwrite the liability of Sponsor under the Plan. Except for
(a) expenses required for PacificSource Group to be in the business of providing services under this
Agreement; and (b) expenses specifically assumed by PacificSource Group in this Agreement, Sponsor is
solely responsible for all expenses incident to the Plan.
3.6 Medical Records
Sponsor shall, if required by law or regulation, (a) notifeach Participant and provide each Participant with
an opportunity to opt out (if required); or (b) obtain from each Participant such written authorization for
release of any financial records and medical records which may be required in accordance with any and all
applicable state and federal laws (including HIPAA, HiTECH. ARRA, and the Gram -Leach -Bailey Act) to
permit Sponsor and/or PacificSource Group to perform their respective obligations under the terms of this
Agreement.
3.7 H|PAAPrivacy and Security
With respect to any arrangement under the Plan that is subject to the HIPAA privacy rule, Sponsor shall
provide PacificSource Group with the applicable notice of privacy practices (prepared by the Plan; not
prepared by PacificSource Gvoup), as well as any subsequent changes to such notices. Sponsor shall
provide PacificSource Group with certification that the applicable Plan document has been amended as
required by the privacy rule to permit disclosures of PHI to Sponsor for plan administration purposes and
that Sponsor agrees to the conditions set forth in applicable Plan documentation. Upon request, Sponsor
will provide a copy of any applicable Plan amendments to PacificSource Group. Other aspects of the HIPAA
privacy rule are reflected in the separate applicable Business Associate Addendum, Sponsor shall not
request PacificSource Group to use or disclose PHI in any manner that would not be permissible under the
privacy rule if done by Sponsor, except that PacificSource Group may use or disclose PHI for purposes of
data aggregation and the management and administrative activities of PacificSource Group, as provided in
the separate applicable Business Associate Addendum.
IV. RESPONSIBILITIES OF PACIFICSOURCE
4.1 Limited Scope ofResponsibilities
PacificSource Group's sole responsibilities shall be as described and enumerated in this Agreement, and
shall include any obligations listed in the Exhibits attached hereto. PacificSource Group generally provides
certain administrative and ministerial services for Sponsor, as more fully described in this Agreement.
PacificSource Group does not — under any circumstances — interpret the Plan or Plan documents.
Specifically, in regards to the administration of COBRA, PSA will perform the responsibilities provided in
Exhibit 111, attached hereto and ncorporatedherein.
4.2 Customer Service
PacificSource Group shall provide customer service personnel by telephone and e-mail during the hours of
8:00 a.m. to 5:00 p.m. Pacific Standard Time and Mountain Standard Time, Monday through Fhdoy,
excepting federally recognized holidays. PacificSource Group shall not be deemed in default of this
Agreement as a result of, nor held responsible for, any neoaation, interruption or delay in the performance
of its obligations hereunder due to causes beyond its reasonable control, including, but not limited to, natural
di000ter, act of God, labor oontnovemy, civil diaturbonoe, disruption of the public morheta, war or armed
cnnflict, or the inability to obtain sufficient materials or services required in the conduct of its business,
including Internet access, or any change in or the adoption of any law, judgment, ordecree.
4.3 Benefit Process and Pavment
PacificSource Group shall, on behalf of Sponsor, operate under the express terms of this Agreement and
the Plan. PacificSource Group shall accept and process claims of Participants received by PacificSource
Group for benefits under the Plan in accordance with the terms and conditions, including timeframes, of the
applicable Plan (as set forth in the Plan document) and applicable law. PacificSource Group shall initially
7
xSA_Desmme`County _0118
determine if persons covered by the Plan (as described in the Reports) are entitled to benefits under the
Plan, and shall adjudicate and pay Plan benefits to Participants, as set forth in this Section IV and Section
V, in accordance with Plan terms and in its usual and customary manner. PacificSource Group shall not
interpret any Plan document or provision, but shall process claims in accordance with the plan, written
terms of the Plan document(s). Where a claim is not paid in full, PacificSource Group shall provide written
denial notices in accordance with the terms and conditions, including timeframes, of the applicable Plan (as
set forth in the Plan document) and applicable law.
PacificSource Group shall have no duty or obligation with respect to claims incurred prior to the Effective
Date, if any, or Plan administration (or other) services arising prior to the Effective Date ("Prior
Administration"), if any, regardless of whether such services were/are to be performed prior to or after the
Effective Date. Sponsor agrees that: (a) PacificSource Group has no responsibility or obligation with respect
to claims incurred prior to the Effective Date and/or Prior Administration; (b) Sponsor will be responsible for
processing claims incurred prior to the Effective Date (including any run -out claims submitted after the
Effective Date) and maintaining legally required records of all claims incurred prior to the Effective Date and
Prior Administration sufficient to comply with applicable legal (e.g., IRS substantiation) requirements; and
(c) Sponsor shall indemnify and hold PacificSource Group harmless for any liability relating to claims
incurred prior to the Effective Date and/or Prior Administration.
4.4 Bonding and Insurance Coveraae
PacificSource Group has, and will maintain, an appropriate bond to act as a third party administrator
pursuant to this Agreement. This bond covers the handling of Sponsor's and Participants' money and must
protect such money from losses by dishonesty, theft, forgery or alteration, and unexplained disappearance.
Such bond shall be in an amount sufficient to at least satisfy the fidelity bonding requirement under ERISA
§412 and any other applicable bonding requirement(s). PacificSource Group shall also maintain business
liability coverage in the amount of at least $2 million PacificSource Group shall provide proof of such
bonding and business liability coverage upon Sponsor's request and shall notify Sponsor of any material
changes, including change of carrier, change in amount of coverage, or any other condition of coverage.
4.5 Reporting
PacificSource shall make available to Sponsor at least monthly via electronic medium (unless otherwise
agreed by the Parties) a master report showing the payment history and status of Sponsor claims and the
amounts and transactions of Sponsor accounts during the preceding month. PacificSource shall also make
available to Sponsor at least monthly via electronic medium a report showing individual payment history,
status of claims, and the amounts and transactions of the individual accounts during the preceding month.
4.6 Claims Appeals
PacificSource will provide one level of appeal review for Sponsor, and shall conduct such review in
accordance with its internal written procedures. PacificSource shall review any first level appeal filed by a
Participant to ensure the subject matter of the appeal was handled appropriately and in accordance with
the plain, written language of the Plan Document(s). If Sponsor allows Participants to pursue additional
levels of appeal, PacificSource shall forward any such appeal to Sponsor for review and determination.
PacificSource shall accept and forward any request for external review by a Participant to an appropriate
Independent Review Organization ("IRO") as required. PacificSource shall coordinate the review of the
appeal by the IRO, and shall inform the Participant of the outcome of the same. PacificSource shall
handle any such requests in accordance with its internal policies and procedures. Any fees associated
with such a review shall be passed through to Sponsor
4.7 Recordkeeping
PacificSource Group shall maintain, for the duration of this Agreement, the usual and customary books,
records and documents, including electronic records, that relate to the Program and its Participants that
PacificSource Group has prepared or that have otherwise come within its possession. These books,
records, and documents, including electronic records, are the property of Sponsor, and Sponsor has the
right of continuing access to them during normal business hours at PacificSource Group's offices with
8 ASA_Deschutes County _0118
reasonable prior notice. If this Agreement terminates, PacificSource Group shall deliver all such books,
records, and documents to Sponsor, subject to PacificSource Group's right to retain copies of any records
it deems appropriate. Sponsor shall be required to pay PacificSource Group reasonable charges for
transportation of such records.
Provided, however, that upon termination of this Agreement, PacificSource Group must comply with the
terms of the applicable separate Business Associate Addendum with respect to the destruction or return of
all PHI, including PHI that is in the possession of subcontractors or agents of PacificSourceGroup.
4.8 Standard of Care: Erroneous Payments
PacificSource Group shall use reasonable care and due diligence in the exercise of its powers and the
performance of its duties under this Agreement, provided that a higher standard of care will be exercised
where required by applicable law. If PacificSource makes any payment under this Agreement to an ineligible
person, on a claim that is later determined to be fraudulent, or if more than the correct amount is paid,
PacificSource shall promptly notify Sponsor and make diligent efforts to recover any payment made to or
on behalf of an ineligible person, fraudulent claim, or any overpayment. To the extent electronic payment
cards are used, PacificSource shall follow the Plan language and applicable legal requirements regarding
the efforts to be made. PacificSource will follow its established policies and procedures in pursuit of any
such erroneous payment, but will not be financially responsible for such erroneous payment even if it fails
to recover the amounts paid in error. PacificSource shall not be required to pursue any erroneous payment
that is for an amount of fifteen ($15) U.S. dollars or less.
4.9 Notices to Sponsor
PacificSource shall provide Sponsor with any and all notices, including those relating to privacy policies
and practices, as may be required by any applicable state and/or federal law.
4.10 Non -Discretionary Duties: Additional Duties
PacificSource Group and Sponsor agree that the duties to be performed by PacificSource Group under this
Agreement are non -discretionary. To the extent a question may arise regarding any Plan document or
provision thereof, PacificSource Group shall be entitled to rely on Sponsor's direction or interpretation. Any
additional duties agreed upon by PacificSource Group and Sponsor will not be effective unless specified in
writing and signed by both Parties.
4.11 Subcontractors
PacificSource Group may engage subcontractors to assist PacificSource Group in the performance of its
obligations under this Agreement. Subcontractors may include, among others, vendors of debit card
services. PacificSource Group guarantees the subcontractor's performance to the same degree as if the
PacificSource Group provided the services directly. PacificSource Group will ensure that, if necessary, a
Business Associate Addendum is in place with respect to applicable services provided by a subcontractor.
V. PAYMENTS FOR HEALTH BENEFITS; SPONSOR'S FUNDING RESPONSIBILITY
5.1 Payment of Health Benefits
Sponsor authorizes PacificSource to pay Plan benefits by checks written (or other draft payment or debit)
on one or more bank accounts established in the name of Sponsor for the payment of Plan benefits. This
account must be pre -funded by Sponsor in an amount to be determined by the Parties. Each week, or at
such other interval as may be agreed upon, PacificSource shall notify Sponsor of all amounts paid out of
the account and Sponsor pay not less than an equal amount into the account to replenish it. Sponsor shall
enter into any such agreements, and provide any such instructions, with its bank of choice that may be
necessary to implement this section.
PacificSource's duty to pay benefits is contingent upon Sponsor maintaining a sufficient level of funding in
the account to allow for payment of the same. In the event the account is overdrawn or has a balance of
zero, PacificSource shall have no duty or obligation to pay any benefit.
9 ASA_Deschutes County _0118
5.2 Prompt Payment
Payments for benefits under the terms of this Agreement may fall under the 'Prompt Pay' statute(s) of the
State of Oregon. PacificSource shall comply with any and all such Prompt Pay statute(s), including any
interest payments that may be required under those statute(s), unless Sponsor has received an exemption
from such statute(s), or can show that it is exempt under the explicit terms of the statute(s). Sponsor shall
provide PacificSource with any information reasonably requested by PacificSource detailing any claimed
exemption. In the absence of such evidence of exemption, PacificSource shall comply with any Prompt Pay
statute(s).
5.3 Funding of Benefits
Funding for any benefit payment to (or on behalf of) the Participants under the Plan, including but not limited
to, all benefits to Participants in accordance with the Plan, is the sole responsibility of Sponsor. Sponsor
agrees to accept liability for, and provide sufficient funds to satisfy, all payments to Participants or on their
behalf under the Plan, including claims for reimbursement for covered expenses as described in the
applicable Plan documents, if such expenses are incurred and the claim is presented for payment during
the term of this Agreement.
VI. PACIFICSOURCE COMPENSATION
6.1 Service Charges
The monthly service charges of PacificSource Group are described in (as applicable) Exhibit II.
PacificSource Group may change the amount of such charges by providing at least one hundred eighty
(180) days written or electronic notice to Sponsor. PacificSource Group may also change the monthly
service charges as of the date of any Plan change, or upon a change of 10% or more in the number of
enrolled members.
6.2 Billina of Charaes
All service charges of PacificSource Group, whether provided for in this or any other Section of Exhibit,
shall be billed separately from statements for payment of claims so that a proper accounting can be made
by Sponsor as to the respective amounts paid for claims and for administrative expenses.
6.3 Payment of Charges
All charges under this Section VI shall be determined by PacificSource Group and billed to Sponsor on a
monthly basis. Sponsor shall make payment to PacificSource Group within ten (10) business days of receipt
of notice of the amount due.
6.4 Compensation Disclosures
PacificSource shall disclose direct and indirect sources of compensation received by PacificSource, other
than the items discussed above, attributable to this Agreement as required by law. Total compensation
received by PacificSource for the performance of services under this Agreement, including direct and
indirect sources of compensation, may not exceed what is considered "reasonable" for purposes of ERISA's
prohibited transaction exemption for services to a plan.
VII. INDEMNIFICATION AND HOLD HARMLESS
7.1 Indemnification by Sponsor
Sponsor shall indemnify PacificSource Group and hold it harmless from and against all loss, liability,
damage, expense, attorney's fees, or other obligations resulting from, or arising out of, any act or omission
of Sponsor in connection with the Plan, or claim, demand, internal appeal, or lawsuit by Plan Participants
and beneficiaries against PacificSource Group in connection with benefit payments or services performed
(or not performed) hereunder. In addition, Sponsor shall indemnify PacificSource Group and hold it
harmless from and against any liability, expense, demand, or other obligation resulting from or arising out
10 ASA_Deschutes County _0118
of any premium charge, tax, or similar assessment (federal or state), for which the Plan or Sponsor is liable.
Sponsor shall also have the indemnification obligation described in Section4.3.
7.2 Indemnification by PacificSource Group
PacificSource Group shall indemnify Sponsor and hold it harmless from and against all loss, liability,
damage, expense, attorney's fees or other obligations resulting from, or arising out of, any act or omission
of PacificSource Group in connection with the Plan, or claim, demand, or lawsuit by Plan Participants and
beneficiaries against Sponsor in connection with benefit payments or services performed (or not performed)
by PacificSource Group hereunder. In addition, PacificSource Group shall indemnify Sponsor and hold it
harmless from and against any liability, expense, demand, or other obligation resulting from or arising out
of any premium charge, tax, or similar assessment (federal or state), for which the PacificSource Group is
solely liable.
VIII. TERMINATION
8.1 Automatic
Unless specifically agreed to otherwise in a written amendment to this Agreement, this Agreement shall
automatically terminate as of the earliest of the following: (1) the end of the term specified in Section 2.1,
or any subsequent renewal thereof; (2) the effective date of any legislation which makes the Plan and/or
this Agreement illegal; (3) the date either Party becomes insolvent, or bankrupt, or subject to liquidation,
receivership, or conservatorship; or (4) the termination date of the Plan, subject to any agreement between
Sponsor and PacificSource Group regarding payment of benefits after the Plan is terminated.
8.2 Discretionary
This Agreement may be terminated as of the earliest of the following: (1) by PacificSource upon failure of
the Sponsor to replenish the funds of the account referenced in Section 5.1 within ten (10) days following
notice of the same; (2) by PacificSource Group upon the failure of Sponsor to pay any charges within ten
(10) business days after they are due and payable as provided in Section VI; (3) by PacificSource Group
upon the failure of Sponsor to perform its obligations in accordance with this Agreement; (4) by Sponsor
upon the failure of PacificSource Group to perform its obligations in accordance with this Agreement or
upon termination of the Business Associate Contract; (5) by Sponsor if it is unable to agree to any
adjustment of price in accordance with Exhibit II; or (6) by Sponsor upon a 30 day written notice of
termination to PacificSource Group.
8.3 Limited Continuation Following Termination
If the Plan is terminated, Sponsor and PacificSource Group may mutually agree in writing as an amendment
to this Agreement that this Agreement shall continue for the purpose of payment of any Plan benefit,
expense, or claims incurred prior to the date of Plan termination. In addition, if this Agreement is terminated
while the Plan continues in effect, Sponsor and PacificSource may mutually agree in writing as an
amendment to this Agreement that this Agreement shall continue for the purpose of payment of any claims
for which requests for reimbursements have been received by PacificSource before the date of such
termination. If this Agreement is continued in accordance with this Section 8.3, Sponsor shall pay the
monthly service charges incurred during the period that this Agreement is so continued plus a final
termination fee equal to the final month's service charge.
8.4 Survival of Certain Provisions
Termination of this Agreement shall not terminate: (1) the rights or obligations of either Party arising out of
a period prior to such termination; (2) the indemnity, confidentiality, privacy, and security provisions of this
Agreement; (3) the duties and obligations imposed on PacificSource Group by the Business Associate
Addendum attached hereto as Exhibit I to the extent they survive this Agreement; and (4) any provision in
this Agreement or any Addendum which specifically provides for termination of this Agreement.
11 ASA_Deschutes County_0118
IX. GENERAL PROVISIONS
9.1 Severabilitv
If any term of this Agreement is declared invalid by a court, the same will not affect the validity of any other
provision, provided that the basic purposes of this Agreement are achieved through the remaining valid
provisions.
92 Headings
The headings of Sections and subsections contained in this Agreement are for reference purposes only
and shall not affect in any way the meaning or interpretation of this Agreement.
9.3 Compliance and Non -Waiver
Failure by Sponsor or PacificSource Group to insist upon strict performance of any provision of this
Agreement will not modify such provision, render it unenforceable, or waive any subsequent breach. No
waiver or modification of any of the terms or provisions of this Agreement shall be valid unless in each
instance the waiver or modification is made pursuant to the amendment provisions of Section 9.4, infra.
9.4 Amendment
This Agreement may only be amended by written agreement of the Parties.
9.5 Assignment
Neither Party can assign this Agreement without the other Party's written consent, which shall not be
unreasonably withheld.
9.6 Audits
Each Party shall be authorized to perform audits of the records of payment to all Participants and other data
specifically related to performance of the parties under this Agreement upon reasonable prior written notice
to the other. Audits shall be performed during normal working hours. Audits may be performed by an agent
of either Party, provided such agent signs an acceptable confidentiality agreement. Each Party agrees to
provide reasonable assistance and information to the auditors. Sponsor acknowledges and agrees that if it
requests an audit, it shall reimburse PacificSource Group for PacificSource Group's reasonable expenses,
including copying and labor costs, in assisting Sponsor to perform the audit.
9.7 Non -Disclosure of Proprietary Information
(a) General. Sponsor and PacificSource Group each acknowledge that in contemplation of
entering into this Agreement (and as a result of the contractual relationship created hereby), each Party
has revealed and disclosed, and shall continue to reveal and disclose to the other, information which is
proprietary and/or confidential information of such Party. Sponsor and PacificSource Group agree that each
Party shall: (1) keep such proprietary and/or confidential information of the other Party in strict confidence;
(2) not disclose confidential information of the other Party to any third parties or to any of its employees not
having a legitimate need to know such information; and (3) shall not use confidential information of the other
Party for any purpose not directly related to and necessary for the performance of its obligations under this
Agreement (unless required to do so by a court of competent jurisdiction or a regulatory body having
authority to require such disclosure).
(b) Confidential Information Defined. Information revealed or disclosed by a Party for any
purpose not directly related to and necessary for the performance of such Partys obligations under this
Agreement shall not be considered confidential information for purposes hereof: (1) if, when, and to the
extent such information is or becomes generally available to the public without the fault or negligence of
the Party receiving or disclosing the information; (2) if the unrestricted use of such information by the Party
receiving or disclosing the information has been expressly authorized in writing and in advance by an
authorized representative of the other Party; or (3) if required by applicable law. For purposes of this
Section, confidential information is any information in written, human -readable, machine-readable, or
electronically recorded form (and marked as confidential and/or proprietary, or words of similar import) and
12 ASA_Deschutes County _0118
information disclosed orally in connection with this Agreement and identified as confidential and/or
proprietary (or words of similar import); and programs, policies, practices, procedures, files, records, and
correspondence concerning the parties' respective businesses or finances. The terms and conditions of
this Section 9.7(b) shall survive the termination of this Agreement.
9.8 Governing Law: Venue; Attorneys' Fees
This Agreement is made and entered into and is to be governed by the laws of the State of Oregon
applicable to agreements made within such State, without regard to the conflicts of law principles of such
State. The Venue for all purposes in connection with this Agreement shall be the County of Lane, State of
Oregon. In the event any Party hereto reasonably retains counsel for the purpose of enforcing or preventing
the breach of this Agreement or any provision hereof, then the prevailing Party shall be entitled, in addition
to such other relief as may be granted, to be reimbursed by the non -prevailing Party for all costs and
expenses incurred thereby, including reasonable attorneys' fees.
9.9 Notices and Communications
(a) Notices. All notices provided for herein shall be sent by confirmed facsimile, or
guaranteed overnight mail, with tracing capability, or by first class United States mail, with postage prepaid,
addressed to the other Party at their respective addresses set forth below or such other addresses as either
party may designate in writing to the other from time to time for such purposes. All notices provided for
herein shall be deemed given or made when received.
(b) Addresses.
Sponsor's address for notices is:
Deschutes County
Attn: Kathleen Hinman
PO Box 6005
Bend, OR 97708-6005
Fax: 541-330-4626
PacificSource's address for notices is:
PacificSource Health Plans
Attn: Sales
110 International Way
Springfield, OR 97477
Fax: 541-225-3645
PSA's address for notices is:
PacificSource Administrators, Inc.
Attn: President and CEO
110 International Way
Springfield, OR 97477
Fax: 541-684-5575
(c) Communications. Sponsor agrees that PacificSource Group may communicate
confidential, protected, privileged or otherwise sensitive information to Sponsor through a named contact
designated by Sponsor ("Named Contact") and specifically agrees to indemnify PacificSource Group and
hold it harmless: (1) for any such communications directed to Sponsor through the Named Contact
attempted via telefax, mail, telephone, email, or any other media, acknowledging the possibility that such
communications may be inadvertently misrouted or intercepted; and (2) from any claim for the improper
use or disclosure of any PHI by PacificSource Group if such information is used or disclosed in a manner
consistent with its duties and responsibilities hereunder or under the separate applicable Business
Associate Addendum.
9.10 Force Maieure
All obligations of both Parties shall be suspended while, but only as long as, a Party is prevented by matters
beyond its reasonable control from complying with such obligations in whole or in part as by strikes,
lockouts, acts of God, explosion, flood, epidemics, unavoidable accidents, inability to obtain permits,
licenses, or any necessary governmental or private authorization, any local, state or federal law, regulation
or order or any other matters beyond the reasonable control of a Party, whether similar to the matters herein
13 ASA_Deschutes County _0118
specifically enumerated or not and whether foreseeable or unforeseeable; provided, however, that the Party
shall have, and continue to, in a timely and diligent manner to remedy such cause; and provided, however,
that performance shall be resumed within a reasonable time after such cause has been removed; and
provided further that neither Party shall be required, unwillingly, to adjust any labor disputes or to question
the validity or to refrain from judicially testing the validity of any local, state or federal order, regulation or
law.
9.11 Participation with Health Improvement Entities
PacificSource is a participating member with various entities that are devoted to improving public health.
From time to time, PacificSource may release any data in its possession to these entities, or to any third
party vendor employed by such an entity. PacificSource shall take all reasonable steps to ensure that any
such data is protected by data use and/or business associate agreements, as may be appropriate.
Execution of this Agreement by Sponsor shall serve as specific authorization for the release of such data
in accordance with this provision.
9.12 Enrollment Vendor
If the Sponsor elects to utilize an enrollment vendor to transmit enrollment and dis-enrollment information
to PacificSource, then the Sponsor hereby affirms that it has entered into a valid business associate
agreement with said vendor and that both the Sponsor and vendor are in compliance with the Health
Insurance Portability and Accountability Act, as amended. The Sponsor hereby requests and authorizes
PacificSource to exchange protected health information with said vendor for the purposes of enrollment
and dis-enrollment in this plan.
9.13 Complete Aareement
This Agreement, which includes Exhibit I: Business Associate Addendum, Exhibit II: Coverage Services
Addendum, and Exhibit III: COBRA Administration Services Addendum attached hereto, constitute the full
Agreement of the Parties with respect to the subject matter hereof and supersedes all prior and
contemporaneous agreements and representations between the Parties.
9.14 Opt -Out of Quality Improvement Measures
Sponsor will not be included in any quality improvement measures conducted by PacificSource, including
without limitation Health Effectiveness and Data Information Set, Consumer Assessment of Healthcare
Providers and Systems, and all National Committee for Quality Assurance accreditation activities. As such,
PacificSource will have no contact with Participants for any purpose under this section.
14 ASA_Deschutes County_0118
X. SIGNATURE
IN WITNESS WHEREOF, Sponsor and PacificSource Group have caused this Agreement to be executed
in their names by their undersigned officers, who are duly authorized to do so.
"Sponsor"
Deschuu my
By:
Print: ! /AV
Title:�l:
By:
Print:OP
�V501t( /
Title:&)Ot V\ J ��_ e. V► o w -
By:
Print:PhiI i t �`i . i-iViMQX & r '
Title: e:(l 1 1' M 1 *S, eilrVe' Y
"PacificSource"
PacificSource Health )ns
By:
Print:
Title: President and CEO
Kenneth P. Provencher
"PSA"
PacificSource Admipiostraors, Inc.
By.-'�'0
Print: Kenneth P. Provencher
Title: President and CEO
15 ASA_Deschutes County _0118
X. SIGNATURE
IN WITNESS WHEREOF, Sponsor and PacificSource Group have caused this Agreement to be executed
in their names by their undersigned officers, who are duly authorized to do so.
"Sponsor" "PacificSource"
Deschut- C.unty PacificSource Health Plans
By: � By:
Print:TO fl1Y\\I ,t y Print: Kenneth P. Provencher
�Ofl
Title: Ta, (/I u E Title: President and CEO
By: ar
Print:( U O V
\
CAL
Title:00n �i 1� '. 1 �O'+�
•%`
By; L
print:Ph iIi`". -HOnCian
Title: 02&) 1 1 OW is ( I vek.
"PSA"
PacificSource Administrators, Inc.
By:
Print: Kenneth P. Provencher
Title: President and CEO
15 ASA_Deschutes County _0118
EXHIBIT I: BUSINESS ASSOCIATE ADDENDUM
Between
Deschutes County
and
PacificSource Health Plans and PacificSource Administrators, Inc.
Sponsor and PacificSource Group intend to protect the privacy and provide for the security of PHI disclosed
to PacificSource Group pursuant to the Agreement in compliance with the Health Insurance Portability and
Accountability Act of 1996, as amended ("HIPAA"), and regulations promulgated thereunder (the "HIPAA
Regulations"), the American Recovery and Reinvestment Act of 2009, and regulations promulgated
thereunder, and other applicable laws, as further described below.
1. Definitions. Capitalized terms used herein without definition shall have the meanings assigned to such
terms in 45 CFR Parts 160 and 164.
2. Obligations of PacificSource Group
(a) Permitted Uses and Disclosures. PacificSource Group may use and/or disclose PHI only as
required to satisfy its obligations under the Agreement, as permitted herein, or required by law, but
shall not otherwise use or disclose PHI.
(b) Safeguards. PacificSource Group shall use commercially reasonable safeguards to prevent use or
disclosure of Plan Sponsor PHI other than as provided for by this Addendum, including encryption
of electronic PHI outside of a secured data center. PacificSource Group shall maintain a
comprehensive written information privacy and security program that includes administrative,
technical and physical safeguards that reasonably and appropriately protect the confidentiality,
integrity and availability of electronic PHI that it creates, receives, maintains, or transmits on behalf
of Plan Sponsor, as required by 45 CFR 164.314(a)(2)(i)(A).
(c) Reporting of Disclosures. PacificSource Group shall report to Plan Sponsor any use or disclosure
of Plan Sponsor PHI otherwise than as provided for by this Addendum of which PacificSource
Group becomes aware. PacificSource Group shall also report to Plan Sponsor any Security
Incident related to PHI of which PacificSource Group becomes aware.
(d) Mitigation. PacificSource Group agrees to mitigate, to the extent practicable, any harmful effect that
is known to PacificSource Group of a use or disclosure of PHI by PacificSource Group in violation
of this Addendum.
(e) PacificSource Group's Aaents. PacificSource Group shall ensure that any agents, including
subcontractors, to whom it provides PHI received from (or created or received by PacificSource
Group on behalf of) Plan Sponsor, agree to the same restrictions and conditions that apply to
PacificSource Group with respect to such PHI.
(f) Availability of Information to Plan Sponsor. PacificSource Group shall make available to Plan
Sponsor such information as Plan Sponsor may require to fulfill the obligations of Plan Sponsor to
provide access to, provide a copy of, and account for disclosures with respect to PHI pursuant to
HIPAA and the HIPAA Regulations, including, but not limited to, 45 CFR Section 164.524 and
164.528.
16 ASA_Deschutes County _0118
(g)
Amendment of PHI. PacificSource Group shall make Plan Sponsor PHI available to Plan Sponsor
as Plan Sponsor may require to fulfill Plan Sponsor obligations to amend PHI pursuant to HIPAA
and the HIPAA Regulations, including, but not limited to, 45 CFR Section 164.526 and
PacificSource Group shall, as directed by Plan Sponsor, incorporate any amendments to Plan
Sponsor PHI into copies of such PHI maintained by PacificSource Group.
(h) Internal Practices. PacificSource Group shall make its internal practices, books, and records
relating to the use and disclosure of PHI received from (or created or received by PacificSource
Group on behalf of) Plan Sponsor available to the Secretary for purposes of determining the
compliance of Plan Sponsor with HIPAA and the HIPAA Regulations.
(1)
Documentation and Accountina of Disclosures. PacificSource Group shall document disclosures of
PHI, and provide such information, as would be required for Plan Sponsor to respond to a request by
an Individual for an accounting of disclosures of PHI in accordance with 45 CFR Section 164.528.
(j) Notification of Breach. During the term of this Addendum, PacificSource Group shall notify Plan
Sponsor as soon as reasonably practical of any suspected act or actual breach of security, intrusion
or unauthorized use or disclosure of PHI and/or any actual or suspected use or disclosure of data
in violation of any applicable federal or state laws or regulations, and shall provide such information
as required under HIPAA. PacificSource Group shall take (i) prompt corrective action to cure any
such deficiencies and (ii) any action pertaining to such unauthorized disclosure required by
applicable federal and state laws and regulations.
3. Obligations of Plan Sponsor.
(a) Safeauards. Plan Sponsor shall be responsible for using appropriate safeguards to maintain and
ensure the confidentiality, privacy and security of PHI transmitted to PacificSource Group pursuant
to this Addendum, and in accordance with the standards and requirements of HIPAA and the HIPAA
Regulations until such PHI is received by PacificSource Group; at a minimum, Plan Sponsor shall
ensure that all electronic PHI is encrypted. Plan Sponsor shall be responsible to send any and all
notifications required under HI PAA.
(b) Notification of Limitations. Plan Sponsor shall notify PacificSource Group of any limitations in its
notice of privacy practices of Plan Sponsor in accordance with 45 CFR Section 164.520, to the
extent that such limitations may affect PacificSource Group's use or disclosure of PHI.
(c) Notice of Chanaes. Plan Sponsor shall notify PacificSource Group of any changes in, or revocation
of, permission by Individual to use or disclose PHI, to the extent that such changes may affect
PacificSource Group's use or disclosure of PHI.
(d) Notification of Restrictions. Plan Sponsor shall notify PacificSource Group of any restriction to the
use or disclosure of PHI that Plan Sponsor has agreed to in accordance with 45 CFR Section
164.522, after consultation with PacificSource Group, to the extent such restriction may affect
PacificSource Group's use or disclosure of PHI.
(e) Compliance. Plan Sponsor shall not act or fail to act in a manner that would cause PacificSource
Group to violate or not be in compliance with this Addendum, applicable state and federal laws,
including HIPAA. Employer acknowledges that it is not PacificSource Group's responsibility or
obligation to ensure that Plan Sponsor comply with any applicable state and/or federal laws.
4. Audits. Inspections and Enforcement. From time to time upon reasonable notice, upon reasonable
determination by Plan Sponsor that PacificSource Group has breached this Addendum; Plan Sponsor
may inspect the facilities, systems, books and records of PacificSource Group that pertain to the Plan
17 ASA_Deschutes County _0118
Sponsor to monitor compliance with this addendum. PacificSource Group shall promptly remedy any
violation of any term of this addendum and shall certify the same to Plan Sponsor in writing.
5. Termination.
(a) Reasonable Steps to Cure Breach. If Plan Sponsor knows of a pattern of activity or practice of
PacificSource Group that constitutes a material breach or violation of the PacificSource Group's
obligations under the provision of this Addendum or another arrangement and does not terminate
the Agreement pursuant to the termination provisions of the Agreement, then PacificSource Group
shall take reasonable steps to cure such breach or end such violation as applicable. If PacificSource
Group's efforts to cure such breach or end such violation are unsuccessful, Plan Sponsor shall
either (i) terminate the Agreement, if feasible, or (ii) if termination of this Addendum isnot feasible,
Plan Sponsor shall report PacificSource Group's breach or violation to the Secretary.
(b) Judicial or Administrative Proceedings. Either party may terminate the Agreement effective
immediately, if (i) the other party is named as a defendant in a criminal proceeding for a violation
of HIPAA or (ii) a finding or stipulation that the other party has violated any standard or requirement
of HIPAA or other security or privacy laws is made in any administrative or civil proceeding in which
the party has been joined.
(c) Effect of Termination. Upon termination of this Addendum for any reason, PacificSource Group
shall return or destroy all PHI received from (or created or received by PacificSource Group on
behalf of) Plan Sponsor that PacificSource Group still maintains in any form and shall retain no
copies of such PHI or, if the return or destruction is not feasible, it shall continue to extend the
protections of this Addendum to such information.
6. Amendment to Comply With Law. The parties acknowledge that state and federal laws relating to
Electronic Data Security and privacy may be evolving and that the amendment of this Addendum may
be required to provide for procedures to ensure compliance with such developments. The parties
specifically agree to take such action as is necessary to implement the standards and requirements of
HIPAA, the HIPAA Regulations, and other applicable laws relating to the security and confidentiality of
PHI.
7. No Third Party Beneficiaries. Nothing expressed or implied in this Addendum is intended to confer, nor
shall anything herein confer, upon any person other than Plan Sponsor, PacificSource Group and their
respective successors or assigns, anyrights, remedies, obligations or liabilities whatsoever.
8. Effect on Agreement. Except as specifically required to implement the purposes of this Addendum, or
to the extent inconsistent with this Addendum, all other terms of the Agreement shall remain in force
and effect.
9. Interpretation. This Addendum and the Agreement shall be interpreted as broadly as necessary to
implement and comply with HIPAA, HIPAA Regulations, and applicable state laws. The parties agree
that any ambiguity in this Addendum shall be resolved in favor of a meaning that complies and is
consistent with HIPAA and the HIPAA Regulations.
18 ASA_Deschutes County _0118
EXHIBIT II: COVERAGE SERVICES ADDENDUM
Between
Deschutes County
and
PacificSource Health Plans and PacificSource Administrators, Inc.
Policy Period: 01/01/2018 through 12/31/2020
I. INTRODUCTION
This Exhibit II: Coverage Services is effective as of the date noted in Section 2.1 of the Third Party
Administrative Services Agreement entered into by and between Deschutes County ("Plan Sponsor") and
PacificSource Health Plans ("PacificSource") and PacificSource Administrators, Inc. ("PSA") (collectively,
"PacificSource Group"), and to which this Exhibit is attached. In the event of any discrepancy or
contradiction between the terms of the Agreement and this Exhibit, the terms of this Exhibit shall control.
II. FEES
The fees and costs payable for the services provided under this Exhibit II shall be as follows:
Number of Participants on Effective Date 1091
Required Claim Fund Waived
Administrative Fees
Claims Administration
Medical
Dental
Vision
Other — COBRA Administration
Broker Fees
Coverage
Medical
Dental
Vision
Network Fees
Network
PSN Access Fee
First Choice Access Fee
First Health Access Fee
Advantage Dental Access Fee
Travel Wrap Network
First Choice
First Health
2018 PEPM
$28.20
$2.75
$0.90
$0.00
2018 PEPM
$0.00
$0.00
$0.00
2018 PEPM
$4.50
$4.50
$4.50
$1.25
2019 PEPM
$28.20
$2.75
$0.90
$0.00
2019 PEPM
TBD
TBD
TBD
2019 PEPM
TBD
TBD
TBD
TBD
FEE.
14% of Savings
13% of Savings
2020 PEPM
$28.20
$2.75
$0.90
$0.00
2020 PEPM
TBD
TBD
TBD
2020 PEPM
TBD
TBD
TBD
TBD
Travel Wrap programs are available for coverage when members travel outside of your chosen
network(s). The Fee's noted above are pass through costs.
19 ASA_Deschutes County _0118
Optional Programs
Programs Fee
ACS Quit for Life — Tobacco Cessation $ PEPM
Assist America — Global Emergency Services $ PEPM
Biometric Screening Pass Thru
Other:
Coordination of Benefits Included
III. PHARMACY
Pharmacy Benefit Manager (PBM) — n/a
Pharmacy Rebates
IV. INCLUDED SERVICES
Accept/Decline
_Decline
Decline
Decline
True/Intearated
True
n/a, Sponsor contracting with separate
vendor
24 Hour Nurseline
Condition Support and AccordantCare — Rare Disease Management
Monthly Reporting
Prenatal Management
Standard Identification Cards
Standard Plan Amendments
Standard Summary Plan document (SPD)
State Surcharge Reporting
Summary of Benefits and Coverage (SBC) (PacificSource coverage's only)
Utilization Review & Large Case Management
Wellness Programs
STANDARD ADDITIONAL FEES
Run -In Claims Processing
Run -Out Claims Processing
Custom Ad Hoc Reporting
Custom Programming*
Independent Medical Review (IMR)
Independent Review Organization (IRO)
SBC & SPD Printing and Shipping
Applicable taxes, surcharges and
assessments
*Custom Programming is defined as programming beyond implementation that 1) is specific to Customer's
operations or benefits; or 2) results in the need for system enhancements.
Not Available
Two months admin fees for 12 months of service
$175 per hour
$150 per hour
Pass through cost to Plan Sponsor
Pass through cost to Plan Sponsor
Pass through cost to Plan Sponsor
Pass through cost to Plan Sponsor
20 ASA_Deschutes County _0118
VI. PLAN CONTACT INFORMATION
• Any correspondence mailed to the Sponsor will be Deschutes County
mailed to: Attn: Kathleen Hinman
PO Box 6005
Bend, OR 97708-6005
Phone: (541) 385-3215
Fax: (541) 330-4626
E -Mail:
Kathleen.hinman@deschutes.org
• Any copy of correspondence and invoices mailed to the Deschutes County
Plan Administrator will be mailed to: Attn: Trygve Bolken
PO Box 6005
Bend, OR 97708-6005
Phone: (541) 385-3215
Fax: (541) 330-4626
E -Mail: trygve.bolken@deschutes.org
• Any correspondence mailed to PacificSource will be PacificSource Health Plans
mailed to: Attn: Sales
PO Box 7068
Springfield, OR 97475-0068
Phone: (541) 686-1242
Fax: (541) 485-0915
• Any Enrollment Information, billing information, and PacificSource Health Plans
payments mailed to PacificSource will be mailed to: Attn: Membership Services
PO Box 7068
Springfield, OR 97475-0068
Phone: (866) 999-5583
Fax: (541) 225-3642
E-mail:
membership@pacificsource.com
The Sponsor agrees to notify PacificSource within twenty-four (24) hours of any changes to the Plan
Contact Information contained in this Exhibit.
21 ASA_Deschutes County _0118
EXHIBIT III: COBRA ADMINISTRATION SERVICES ADDENDUM
Between
Deschutes County
and
PacificSource Administrators, Inc.
Sponsor has enrolled "qualified beneficiaries" for COBRA benefits, which PSA shall administer in
accordance with this Agreement and this Addendum, as further described below.
1. PLAN ADMINISTRATION
1.1. Beneficiary Notification
PSA shall provide qualified beneficiaries with notification of continuation rights within fourteen days of receiving
notice of a qualifying event from Sponsor. In addition, PSA will provide qualified beneficiaries with notice of
changes in plan provisions if it should become effective during the coverage period. All notifications provided
by PSA will include any and all statutorily required provisions and disclosures.
1.2. Collection of Premiums
PSA shall be responsible for the collection of premiums from qualified beneficiaries electing COBRA coverage
and for the distribution of the beneficiary's premiums to the Client.
1.3. Maintenance of Records
Notwithstanding anything to the contrary in this Agreement, PSA agrees to maintain sufficiently detailed
physical and/or computer records regarding qualified beneficiary notification and beneficiary election (or waiver)
of benefits. Periodically, PSA shall deliver a status report to Sponsor regarding the plan, which Sponsor is
responsible to review and advise PSA of any errors or discrepancies. PSA shall maintain and keep all records
including worksheets, receipts, and vouchers for seven (7) years after the documents to which they relate are
filed unless otherwise exempted. PSA shall transfer all records to successor plan administrator if requested by
Sponsor in writing.
1.4. Required Reporting
PSA shall provide any federal or state agency with required reports which contain information over which PSA
has control and that PSA generates in accordance with this Agreement.
1.5. Beneficiary Requests for lnformation
PSA shall furnish any qualified beneficiary with plan information upon the beneficiary's written request.
2. RESIGNATION AND REMOVAL
Notwithstanding any provision in this Agreement to the contrary, PSA may resign or may be removed by
Sponsor at any time, with or without cause. Such resignation or removal shall be accomplished by the giving
of sixty (60) days advance written notice, except in the event of gross negligence, criminal activities or such
other serious cause in which case Sponsor shall have the power to terminate this Agreement as of the date of
notice to PSA. Upon resignation or removal, Sponsor shall appoint a successor to whom PSA shall transfer all
documents and records held by PSA along with funds in custody of PSA.
22 ASA_Deschutes County _0118
EXHIBIT IV: DESCHUTES COUNTY ADDENDUM
Between
Deschutes County
and
PacificSource Health Plans and PacificSource Administrators, Inc.
1. Certification of Entity Status:
Pacific -Source Health Plans certifies under penalty of perjury (1) that it is an active Oregon non-profit
corporation; (2) that to the best of its knowledge it is not in violation of any tax laws described in ORS
305.380(4); (3) that it is responsible for any federal or state taxes applicable to any consideration and
payments paid to it der this Agreement; and (4) that it has discriminated against minority, women or
small busines
p/r}r rjs in obtaining any associated subcontracts.
f
Signature
President and CEO 1/2/18
Title & Date
2. Compliance Confirmation:
Conflicts of Interest
Pacific Source Health Plans (and as applicable, PSA) certifies under penalty of perjury that the following
statements are true to the best of its knowledge:
No federally appropriated funds have been paid or shall be paid, by or on behalf of it, to any person for
influencing or attempting to influence an officer or employee of any agency, a member of Congress, an
officer or employee of Congress, or an employee of a member of Congress in connection with the
awarding of any federal contract, the making of any federal grant, the making of any federal loan, the
entering into of any operative agreement, and the extension, continuation, renewal, amendment, or
modification o contract, grant, loan, or cooperative agreement.
Si nature
President and CEO 1/2/18
Title & Date
23
ASA_Deschutes County _0118
Deschutes County Board of Commissioners
1300 NW Wall St, Bend, OR 97703
*11-14-f (541) 388-6570 - Fax (541) 385-3202 - https://www.deschutes.org/
AGENDA REQUEST & STAFF REPORT
For Board of Commissioners Business Meeting of December 27, 2017
DATE: December 22, 2017
FROM: Kathleen Hinman, Human Resources, 541-385-3215
TITLE OF AGENDA ITEM:
Consideration of Board Approval of Deschutes County Group Medical Plan Document # 2017-
776
RECOMMENDATION & ACTION REQUESTED:,
Staff recommends Board authorize County Administrator (Plan Sponsor) signature of
Deschutes County Employee Benefits Dental Plan document # 2017-776 for the 2018 plan
year.
CONTRACTOR: Contractor/Supplier/Consultant Name: Benefits Plan to be administered By
PacificSource.
AGREEMENT TIMEFRAME: Starting Date: 1/1/2018 Ending Date: N/A
BACKGROUND AND POLICY IMPLICATIONS: Deschutes County has established the
Deschutes County Group Health Plan (referred to as the "Plan") to provide health care
coverage for Eligible Employees and their Dependents. Deschutes County is the Plan
Sponsor.This Plan Document contains both the written Plan Document and the Summary Plan
Description ("SPD"). This is the latest revision of the medical plan document that will be
administered by PacificSource, the new Third Party Administrator, and effective 1/1/2018.
FISCAL IMPLICATIONS: N/A
ATTENDANCE: Kathleen Hinman, Director Human Resources and Trygve Bolken, Human
Resources Analyst
DESCHUTES COUNTY DOCUMENT SUMMARY.
(NOTE: This form is required to be submitted with ALL contracts and other agreements, regardless of whether the document is to be
on a Board agenda or can be signed by the County Administrator or Department Director. If the document is to be on a Board
agenda, the Agenda Request Form is also required. If this form is not included with the document, the document will be returned to
the Department. Please submit documents to the Board Secretary for tracking purposes, and not directly to Legal Counsel, the
County Administrator or the Commissioners. In addition to submitting this form with your documents, please submit this form
electronically to the Board Secretary.)
Please complete all sections above the Official Review line.
Date: 112/21/171 Department: Human Resources1
Contractor/Supplier/Consultant Name: PacificSource1
Contractor Contact: !Tony Kopkil Contractor Phone #: 066-540-11911
Type of Document: Deschutes County Employee Medical Plan
Goods and/or Services: Deschutes County has established the Deschutes County
Group Health Plan (referred to as the or this "Plan") to provide health care coverage for
Eligible Employees and their Dependents. Deschutes County is the Plan Sponsor.This
Plan Document contains both the written Plan Document and the Summary Plan
Description ("SPD").
Background & History: This is the latest revision of the medical plan document that
will be administered by PacificSource, the new Third Party Administrator, effective
1/1/2018.
Agreement Starting Date: 11/1/20181 Ending Date: N
Annual Value or Total Payment:
Insurance Certificate Received (check box)
Insurance Expiration Date:
Check all that apply:
RFP, Solicitation or Bid Process
Informal quotes (<$150K)
Exempt from RFP, Solicitation or Bid Process (specify — see DCC §2.37)
I I
I I
Funding Source: (Included in current budget? X Yes
No
If No, has budget amendment been submitted? 1 1 Yes No
Is this a Grant Agreement providing revenue to the County? Yes [5<1 No
Special conditions attached to this grant:
Deadlines for reporting to the grantor:
12/21/2017
If a new FTE will be hired with grant funds, confirm that Personnel has been notified that
it is a grant -funded position so that this will be noted in the offer letter: Yes No
Contact information for the person responsible for grant compliance:
Name:
Phone #:
Departmental Contact and Title:
Phone #: 1541-317-3154!
Department Director Approval:
Trygve Bolken Human Resources Analysil
Signature
V2- \
Date
Distribution of Document: Who gets the original document and/or copies after it has
been signed? Include complete information if the document is to be mailed.
Official Review:
County Signature Required (check one):
111 BOCC (if $150,000 or more) — BOARD AGENDA Item
Li County Administrator (if $25,000 but under $150,000)
El Department Director - Health (if under $50,000)
El Department Head/Director (if under $25,000)
Legal Revie
Document Number
Date 12_
12/21/2017
Deschutes County
Group No.: G0037173
Plan Name: Medical Plan
Effective: January 1, 2018
With Third Party Administrative Services Provided By:
PacificSource
1 Deschutes County Plan Document_0118_Medical
ac
2017 7 6
This page left intentionally blank.
2 Deschutes County Plan Document_0118_Medical
INTRODUCTION
Deschutes County has established the Deschutes County Group Health Plan (referred to as
the or this "Plan") to provide health care coverage for Eligible Employees and their
Dependents. This Plan is established effective January 1, 2018 (the "Effective Date").
Deschutes County is the Plan Sponsor.
Any words or phrases used in this Plan Document that appear with an initial capital letter, or
which are in italics, are defined terms. All such words or phrases are defined in the Definitions
section of this Plan Document (see the Table of Contents for exact location). The Plan
Sponsor highly encourages you to read this Plan Document in its entirety and to ask any
questions you may have to ensure you understand your rights, responsibilities, and the
benefits available to you under the terms of this Plan.
Nature of the Plan
This Plan is an employee welfare benefit plan. This Plan is not governed by the Employee
Retirement Income Security Act ("ERISA"). This Plan is a self-insured medical plan intended
to meet the requirements of Sections 105(b), 105(h) and 106 of the Internal Revenue Code so
that the portion of the cost of coverage paid by the Employer, and any benefits received by a
Covered Individual through this Plan, are not taxable income to the Covered Individual. The
specific tax treatment of any Covered Individual will depend on the individual's personal
circumstances; the Plan does not guarantee any particular tax treatment. Covered Individuals
are solely responsible for any and all federal, state, and local taxes attributable to their
participation in this Plan, and the Plan expressly disclaims any liability for such taxes.
This Plan is "self-insured" which means benefits are paid from the Employer's general assets
and/or trust funds and are not guaranteed by an insurance company. The Plan Sponsor,
which is also the Plan Administrator, has contracted with the Third Party Administrator to
perform certain administrative services related to this Plan.
PacificSource Health Plans ("PacificSource") is the Third Party Administrator and will process
Claims, manage the network of Health Care Providers, answer medical benefit and Claim
questions, and to generally provide administrative services to the Plan. If anything is unclear
to you, please contact the Plan Sponsor or the Third Party Administrator at the number or
address available in this Introduction section.
Written Plan Document and SPD
This Plan Document contains both the written Plan Document and the Summary Plan
Description ("SPD"). It is very important to review this Plan Document carefully to confirm a
complete understanding of the benefits available, as well as your responsibilities, under this
Plan.
This Plan Document consists of several pieces, all of which work together. The Summary of
Benefits provides an overview of the key benefit provisions of the Plan and can give you a
general idea of what the Plan covers and how it works. However, it is important to read the
entire Plan Document, including the Definitions, to fully understand the Plan's coverage and
benefits.
3 Deschutes County Plan Document_0118_Medical
Non -Grandfathered Status of the Plan under Health Care Reform
The consumer protections of the Patient Protection and Affordable Care Act (PPACA) apply to
this Plan.
Questions regarding the Plan's status can be directed to the Plan Administrator.
You may also contact the U.S. Department of Health and Human Services at
healthreform.uov.
Retention of Fiduciary Duties
The Plan Sponsor has retained all fiduciary duties under the Plan, including all interpretations
of the Plan and the benefits and exclusions it contains. This means that the Plan Sponsor is
solely responsible for all final decisions regarding what benefits are or will be covered, both
now and in the future. The Plan Sponsor is solely responsible for the design of the Plan. Plan
Sponsor is solely responsible for setting any and all criteria used to determine enrollment and
eligibility.
Questions?
PacificSource's customer service representatives are available to answer questions or
concerns regarding the Plan. Phone lines are open from 8 a.m. to 5 p.m. Monday through
Friday (excluding holidays). PacificSource's customer service representatives are not
authorized to interpret or change the terms of the Plan.
For enrollment or eligibility questions, please contact us.
PacificSource Customer Service Team
Phone (888) 246-1370
Email cs@pacificsource.com
PacificSource Headquarters
110 International Way, Springfield, OR 97477
PO Box 7068, Springfield, OR 97475-0068
Phone (541) 686-1242 or (800) 624-6052
Website
PacificSource.com
As used in this Plan Document, the word `year' refers to the contract year, which is the 12 -
month period beginning January 1St and ending December 31St. The word lifetime as used in
this document refers to the period of time you or your eligible family members participate in
this Plan or any other plan offered by the Plan Sponsor.
Representations not warranties: In the absence of fraud, all statements made by the Plan
Sponsor will be considered representations and not warranties. No statement made for the
purpose of effecting coverage will void the coverage or reduce benefits unless it is contained
in a written document signed by the Ran Sponsor and a provided to a member.
Governing Law
This Plan must comply with applicable state and federal laws, including required changes
occurring after the Plan's Effective Date. Therefore, coverage is subject to change as required
by law.
Para asistirle en espanol, por favor Ilame el numero (866) 281-1464.
4 Deschutes County Plan Document_0118_Medical
CONTENTS
MEDICAL BENEFIT SUMMARIES 7
STANDARD PLAN INFORMATION 7
HIGH DEDUCTIBLE PLAN INFORMATION 11
VISION BENEFIT SUMMARY 15
CHIROPRACTIC MANIPULATION, ACUPUNCTURE, AND MASSAGE THERAPY
BENEFIT SUMMARY 18
PRESCRIPTION DRUG BENEFIT SUMMARY 19
ONSITE CLINIC — Deschutes County Onsite Clinic Pharmacy Services (541) 385-1071 19
RETAIL — Northwest Pharmacy Services (800) 998-2611 20
MAIL ORDER — WellPartner (877) 935-5797 21
BECOMING ELIGIBLE 23
ENROLLING DURING THE INITIAL ENROLLMENT PERIOD 24
ENROLLING NEW FAMILY MEMBERS 24
ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD 26
STATUS CHANGE 27
PLAN SELECTION PERIOD 29
WHEN COVERAGE ENDS 29
CONTINUATION OF COVERAGE 30
CONTINUATION DUE TO PLAN SPONSOR APPROVED PAID ADMINISTRATIVE LEAVE OF
ABSENCE, DISABILITY, OR LEAVE OF ABSENCE 30
USERRA CONTINUATION 30
COBRA CONTINUATION 31
CONTINUATION WHEN YOU RETIRE 33
USING THE PROVIDER NETWORK 34
PARTICIPATING PROVIDERS 35
NON -PARTICIPATING PROVIDERS 35
COVERAGE WHILE TRAVELING 37
FINDING PARTICIPATING PROVIDER INFORMATION 37
TERMINATION OF PROVIDER CONTRACTS 37
COVERED EXPENSES 38
PLAN BENEFITS 40
PREVENTIVE CARE SERVICES 40
PEDIATRIC SERVICES 43
HOSPITAL AND SKILLED NURSING FACILITY SERVICES 45
OUTPATIENT SERVICES 46
EMERGENCY SERVICES 47
MATERNITY SERVICES 48
MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES 48
HOME HEALTH AND HOSPICE SERVICES 50
DURABLE MEDICAL EQUIPMENT 51
TRANSPLANT SERVICES 52
OTHER COVERED SERVICES, SUPPLIES, AND TREATMENTS 54
COMMUNITY WELLNESS BENEFITS 58
PRESCRIPTIONS PURCHASED WITHOUT THE NORTHWEST PHARMACY SERVICES
BENEFIT 60
5 Deschutes County Plan Document_0118_Medical
BENEFIT LIMITATIONS AND EXCLUSIONS 63
EXCLUDED SERVICES 63
PREAUTHORIZATION 70
INDIVIDUAL BENEFITS MANAGEMENT 71
UTILIZATION REVIEW 71
CLAIMS PAYMENT 73
COORDINATION OF BENEFITS 75
THIRD PARTY LIABILITY 77
COMPLAINTS, GRIEVANCES, AND APPEALS 79
GRIEVANCE PROCEDURES 79
APPEAL PROCEDURES 79
HOW TO SUBMIT GRIEVANCES OR APPEALS 81
RESOURCES FOR INFORMATION AND ASSISTANCE 82
RIGHTS AND RESPONSIBILITIES 83
PRIVACY AND CONFIDENTIALITY 85
PLAN ADMINISTRATION 85
DEFINITIONS 87
6 Deschutes County Plan Document_0118_Medical
MEDICAL BENEFIT SUMMARIES
STANDARD PLAN INFORMATION
Group Name:
Group Number:
Plan Name:
Provider Network:
Deschutes County
G0037173
Standard
PSN
EMPLOYEE ELIGIBILITY REQUIREMENTS
Minimum Hour Requirement: 20 hours per week
Waiting Period for New Employees:
Deschutes County
Onsite Clinic Providers
PSN Providers and
Non -participating
Providers
Deschutes County
Onsite Clinic Providers
PSN Providers
Non -participating
Providers
Please note: Your actual costs for services provided by a non -participating provider may
exceed this Plan's out-of-pocket limit for non -participating services. In addition, non-
participating providers can bill you for the difference between the amount charged by the
provider and the amount allowed by the insurance company, and this amount is not counted
toward the non -participating out-of-pocket limit.
The member is responsible for the above deductible and the following amounts:
First day of the month following 30 days.
None
$500
None
$2,000
$4,000
None
$1,500
None
$6,000
$12,000
Service
Preventive Care
Well baby/Well child
care
Routine physicals
Well woman visits
Routine mammograms
Immunizations
Not Available
No Charge*
No Charge*
Not Available
No Charge*
PSN
Providers:
No Charge*
No Charge*
No Charge*
No Charge*
No Charge*
Non -participating
Providers:
20% co-insurance*
20% co-insurance*
20% co-insurance*
20% co-insurance*
20% co-insurance*
7 Deschutes County Plan Document_0118_Medical
Routine and diagnostic
colonoscopy
Prostate cancer
screening
Routine electron beam
tomography (EBT)
Professional Services
Office and home visits
Naturopath office visits
Specialist office and
home visits
Telemedicine visits
Office procedures and
supplies
Skin lesion removal in
the Physician's office
Surgery
Outpatient
rehabilitation and
habilitation services
Hospital Services
Inpatient room and
board
Inpatient rehabilitation
and habilitation
services
Skilled nursing facility
Outpatient Services
Outpatient
surgery/services
Advanced diagnostic
imaging
Diagnostic and
therapeutic radiology
and lab
Dialysis
Urgent and Emergency
Urgent care center
visits - Professional
Urgent care center
visits - Facility
Not Available
Not Available
Not Available
No Charge*
No Charge*
No Charge*
No Charge*
No Charge*
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
No Charge*
Not Available
Services
No Charge*
No Charge*
No Charge*
No Charge*
No Charge*
$25 co-pay/visit*
$25 co-pay/visit*
$25 co-pay/visit*
$25 co-pay/visit*
Deductible then
20% co-insurance
20% co-insurance*
Deductible then
20% co-insurance
Deductible then
20% co-insurance
Deductible then
$100 co-pay/admit plus
20% co-insurance
Deductible then
20% co-insurance
Deductible then
20% co-insurance
Deductible then
20% co-insurance
20% co-insurance*
20% co-insurance*
20% co-insurance*
$25 co-pay/visit*
Deductible then
20% co-insurance
20% co-insurance*
20% co-insurance*
20% co-insurance*
$25 co-pay/visit plus
20% co-insurance*
$25 co-pay/visit plus
20% co-insurance*
$25 co-pay/visit plus
20% co-insurance*
$25 co-pay/visit plus
20% co-insurance*
Deductible then
40% co-insurance
40% co-insurance*
Deductible then
40% co-insurance
Deductible then
40% co-insurance
Deductible then
$100 co-pay/admit plus
40% co-insurance
Deductible then
40% co-insurance
Deductible then
40% co-insurance
Deductible then
40% co-insurance
40% co-insurance*
40% co-insurance*
40% co-insurance*
$25 co-pay/visit plus
20% co-insurance*
Deductible then
20% co-insurance
8 Deschutes County Plan Document_0118_Medical
Emergency room visits
— medical emergency
Emergency room visits
— non -emergency
Not Available
Not Available
Ambulance, ground Not Available
Ambulance, air Not Available
Maternity Services**
Physician/Provider
services (global Not Available
charge)
Hospital/Facility
services
Mental Health/Chemical
Office visits
Inpatient care Not Available
Residential programs Not Available
Not Available
Deductible then
$100 co-pay/admit
plus
20% co-insurance^
Not Covered
Deductible then
20% co-insurance
Deductible then
20% co-insurance
88% co-insurance*
Deductible then
20% co-insurance
Dependency Services
No Charge* $25 co-pay/visit*
Other Covered Services
Allergy injections
Durable medical
equipment
Home health services
Chiropractic
manipulations,
acupuncture care, and
massage therapy
Transplants
Temporomandibular
Joint
No Charge*
Not Available
Not Available
Not Available
Not Available
Not Available
Deductible then
20% co-insurance
Deductible then
20% co-insurance
$5 co -pay*
Deductible then
20% co-insurance
Deductible then
20% co-insurance
$15 co -pay*
Deductible then
$100 co-pay/admit
plus
20% co-insurance^
Not Covered
Deductible then
20% co-insurance
Deductible then
20% co-insurance
Deductible then
40% co-insurance
Deductible then
40% co-insurance
$25 co-pay/visit plus
20% co-insurance*
Deductible then
40% co-insurance
Deductible then
40% co-insurance
$5 co -pay plus 20%
co-insurance
Deductible then
40% co-insurance
Deductible then
40% co-insurance
$15 co -pay*
Deductible then Deductible then
20% co-insurance 40% co-insurance
Deductible then Deductible then
50% co-insurance 50% co-insurance
This is a brief summary of benefits. Refer to the Plan Document for additional
information or a further explanation of benefits, limitations, and exclusions.
^ Co -pay applies to ER physician and facility charges only. Co -pay waived if admitted
into hospital.
Not subject to annual deductible.
Medically necessary services, medication, and supplies to manage diabetes during
pregnancy from conception through six weeks postpartum will not be subject to a
deductible, co -payment, or co-insurance.
**
9 Deschutes County Plan Document_0118_Medical
1
Additional Information
q: �rtrtt t:t ttb�C���
This Plan's deductible is the amount of money that you pay first, before this Plan starts to pay.
You'll see that many services, especially preventive care, are covered by the Plan without you
needing to meet the deductible. The individual deductible applies if you enroll without
dependents. If you and one or more dependents enroll, the individual deductible applies for
each member oniy untU the family deductible has been met. Deductibie expense is appiied to
the outofpocket limit.
Participating provider expense and non -participating provider expense apply together toward
your deductible.
the, 0�'��'���'
The out-of-pocket limit is the most you'll pay for covered medical expenses during the
calendar year. Once the out-of-pocket limit has been met, the Plan will pay 100 percent of
covered charges for the rest of that calendar year. The individual out-of-pocket limit applies
only if you enroll without dependents. If you and one or more dependents enroll, the individual
out-of-pocket limit applies for each member only until the family out-of-pocket limit has been
met. Be sure to check the Plan Document, as there are some charges, such as non-essential
heaith benefits, penaities, and balance biIIed amounts that do not count toward the out-of-
pooket|inmiL
Participating provider expense and non -participating provider expense apply together toward
your out-of-pocket Iimits.
lvmd (:)\h���(��`�`�
Payment to providers is based on the prevailing or contracted PacificSource fee
ailowance for covered services. Participating providers accept the fee allowance as
payment in fuji. Non -participating providers are ailowed to baiance bili any remaining
baiance that your pian did not cover. Services of non -participating providers could
result in out-of-pocket expense in addition to the percentage indicated.
Coverage of certain medical services and surgical procedures requires a benefit
determination by PacificSource before the services are performed. This process is
called 'preauthorization'. Preauthorization is necessary to determine if certain services
and supplies are covered under this Plan, and if you meet the Plan's eligibility
requirements. You'll find the most current preauthorization list on our website,
PocifiCS0unce.conl/nOeDOb8[/pr8GuthOrizGUOn.@Gpx.
10 Deschutes County Plan Oocumon0118_Medica|
HIGH DEDUCTIBLE PLAN INFORMATION
Group Name:
Group Number:
Plan Name:
Provider Network:
Deschutes County
G0037173
High Deductible
PS N
EMPLOYEE ELIGIBILITY REQUIREMENTS
Minimum Hour Requirement: 20 hours per week
Waiting Period for New Employees: First day of the month following 30 days.
Deschutes County
Onsite Clinic Providers
PSN Providers and
Non -participating
Providers
Deschutes County
Onsite Clinic Providers
PSN Providers
Non -participating
Providers
Please note: Your actual costs for services provided by a non -participating provider may
exceed this Plan's out-of-pocket limit for non -participating services. In addition, non-
participating providers can bill you for the difference between the amount charged by the
provider and the amount allowed by the insurance company, and this amount is not counted
toward the non -participating out-of-pocket limit.
The member is responsible for the above deductible and the following amounts:
None
$2,500
None
$5,000
$10,000
None
$5,000
None
$10,000
$20,000
Service
Preventive Care
Well baby/Well child
care
Routine physicals
Well woman visits
Routine mammograms
Immunizations
Routine colonoscopy
Not Available
No Charge*
No Charge*
Not Available
No Charge*
Not Available
PSN Non -participating
Providers: Providers:
No Charge*
No Charge*
No Charge*
No Charge*
No Charge*
No Charge*
20% co-insurance*
20% co-insurance*
20% co-insurance*
20% co-insurance*
20% co-insurance*
20% co-insurance*
11 Deschutes County Plan Document_0118_Medical
Prostate cancer
screening
Routine electron beam
tomography (EBT)
Professional Services
Office and home visits
Naturopath office visits
Specialist office and
home visits
Telemedicine visits
Office procedures and
supplies
Skin lesion removal in
the Physician's office
Surgery
Outpatient
rehabilitation and
habilitation services
Hospital Services
Inpatient room and
board
Inpatient rehabilitation
and habilitation
services
Skilled nursing facility
Outpatient Services
Outpatient
surgery/services
Advanced diagnostic
imaging
Diagnostic and
therapeutic radiology
and lab
Dialysis
Urgent and Emergency
Urgent care center
visits - Professional
Urgent care center
visits - Facility
Emergency room visits
— medical emergency
Not Available
Not Available
No Charge*
No Charge*
No Charge*
No Charge*
No Charge*
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
No Charge*
Not Available
Services
No Charge*
No Charge*
Not Available
No Charge* 20% co-insurance*
No Charge* 20% co-insurance*
$25 co-pay/visit*
$25 co-pay/visit*
$25 co-pay/visit*
$25 co-pay/visit*
Deductible then
20% co-insurance
20% co-insurance*
Deductible then
20% co-insurance
Deductible then
20% co-insurance
Deductible then
$100 co-pay/admit plus
20% co-insurance
Deductible then
20% co-insurance
Deductible then
20% co-insurance
Deductible then
20% co-insurance
20% co-insurance*
20% co-insurance*
20% co-insurance*
$25 co-pay/visit*
Deductible then
20% co-insurance
Deductible then
$100 co-pay/admit
$25 co-pay/visit plus
20% co-insurance*
$25 co-pay/visit plus
20% co-insurance*
$25 co-pay/visit plus
20% co-insurance*
$25 co-pay/visit plus
20% co-insurance*
Deductible then
40% co-insurance
40% co-insurance*
Deductible then
40% co-insurance
Deductible then
40% co-insurance
Deductible then
$100 co-pay/admit plus
40% co-insurance
Deductible then
40% co-insurance
Deductible then
40% co-insurance
Deductible then
40% co-insurance
40% co-insurance*
40% co-insurance*
40% co-insurance*
$25 co-pay/visit plus
20% co-insurance*
Deductible then
40% co-insurance
Deductible then
12 Deschutes County Plan Document_0118_Medical
Emergency room visits
— non -emergency
Ambulance, ground
Ambulance, air
Maternity Services**
Physician/Provider
services (global
charge)
Hospital/Facility
services
Mental Health/Chemical
Office visits
Inpatient care
Residential programs
Other Covered Services
Allergy injections
Durable medical
equipment
Home health services
Chiropractic
manipulations,
acupuncture care, and
massage therapy
Transplants
Temporomandibular
Joint
Not Available
Not Available
Not Available
Not Available
Not Available
plus
20% co-insurance^
Not Covered
Deductible then
20% co-insurance
Deductible then
20% co-insurance
88% co-insurance*
Deductible then
20% co-insurance
Dependency Services
No Charge*
Not Available
Not Available
No Charge*
Not Available
Not Available
Not Available
Not Available
Not Available
$25 co-pay/visit*
Deductible then
20% co-insurance
Deductible then
20% co-insurance
$5 co -pay*
Deductible then
20% co-insurance
Deductible then
20% co-insurance
$15 co -pay*
$100 co-pay/admit
plus
20% co-insurance^
Not Covered
Deductible then
20% co-insurance
Deductible then
20% co-insurance
Deductible then
40% co-insurance
Deductible then
40% co-insurance
$25 co-pay/visit plus
20% co-insurance*
Deductible then
40% co-insurance
Deductible then
40% co-insurance
$5 co -pay plus 20%
co-insurance
Deductible then
40% co-insurance
Deductible then
40% co-insurance
$15 co -pay*
Deductible then Deductible then
20% co-insurance 40% co-insurance
Deductible then Deductible then
50% co-insurance 50% co-insurance
This is a brief summary of benefits. Refer to the Plan Document for additional
information or a further explanation of benefits, limitations, and exclusions.
^ Co -pay applies to ER physician and facility charges only. Co -pay waived if admitted
into hospital.
* Not subject to annual deductible.
**
Medically necessary services, medication, and supplies to manage diabetes during
pregnancy from conception through six weeks postpartum will not be subject to a
deductible, co -payment, or co-insurance.
13 Deschutes County Plan Document_0118_Medical
Additional Information
V'tirtnt [; tr;��[���'�
This PIan's deductible is the amount of money that you pay first, beforthis PIan starts to pay.
You'll see that many services, especially preventive care, are covered by the PIan without you
needing to meet the deductible. The individual deductible applies if you enroll without
dependents. If you and one or more dependents enroll, the individual deductible applies for
each member only until the family deductible has been met. Deductible expense is applied to
the out-of-pocket limit.
Participating provider expense and non -participating provider expense apply together toward
your deductible.
(�[/�'
The out-of-pocket limit is the most you'll pay for covered medical expenses during the
calendar year. Once the out-of-pocket limit has been met, the Plan will pay 100 percent of
covered charges for the rest of that calendar year. The individual out-of-pocket limit applies
only if you enroll without dependents. If you and one or more dependents enroll, the individual
out-of-pocket limit applies for each member only until the family out-of-pocket limit has been
met. Be sure to check the Plan Dnounnent, as there are some charges, such as non-essential
health banafito, pena|tiea, and balance billed amounts that do not count toward the out-of-
pnoket limit.
Participating provider expense and non -participating provider expense apply together toward
your out-of-pocket limits.
r_t{(>\/tOo!`tt,
Payment to providers is based on the prevailing or contracted PacificSource fee
allowance for covered services. Participating providers accept the fee allowance as
payment in full. Non -participating providers are allowed to balance bill any remaining
balance that your plan did not cover. Services of non -participating providers could
result in out-of-pocket expense in addition to the percentage indicated.
(~�t_t;\WC'yy�.;.-5. t.,tr|1;
Coverage of certain medical services and surgical procedures requires a benefit
determination by PacificSource before the services are performed. This process is
called 'preauthorization'. Preauthorization is necessary to determine if certain services
and supplies are covered under this PIan, and if you meet the Plan's eligibility
requirements. You'IJ find the most current preauthorization Iist on our website,
P2CificSouroe.comin8mber/org8uthOriz@ti0n.GGpx.
14 Deschutes County Plan Dooumon(_0118_Medina|
VISION BENEFIT SUMMARY
The following shows the vision benefit available under this Plan for enrolled members for
all covered vision exams, lenses, and frames when performed or prescribed by a licensed
ophthalmologist or licensed optometrist. Co -payment and/or co-insurance for covered
charges do not apply to the medical plan's out-of-pocket limit.
If charges for a service or supply are less than the amount allowed, the benefit will be
equal to the actual charge. If charges for a service or supply are greater than the amount
allowed, the expense above the allowed amount is the member's responsibility and will
not apply toward the member's medical plan deductible or out-of-pocket limit.
Member Responsibility
Service/Supply
Enrolled Members Age 18 and Younger
Not Available
Eye exam
Vision hardware
(includes frame and
lenses)
Contacts in lieu of glasses
(includes fitting)
Not Available
Not Available
Enrolled Members Age 19 and Older
Eye exam
Frames
Single vision lenses
Bifocal lenses
Trifocal lenses
Progressive lenses
Lenticular lenses
Contacts in lieu of glasses
(includes fitting)
PSN
Providers:
No Charge*
No Charge* for
one pair per
calendar year
No Charge* for
one pair per
calendar year
Not Available $25 co-pay/visit*
No charge up to
Not Available $90 per calendar
year*
No charge up to
Not Available $100 per calendar
year*
No charge up to
Not Available $140 per calendar
year*
No charge up to
Not Available $180 per calendar
year*
No charge up to
Not Available $220 per calendar
year*
No charge up to
Not Available $220 per calendar
year*
No charge up to
Not Available $190 per calendar
year*
* Not subject to annual medical deductible
Non -participating
Providers:
No Charge*
No Charge* for one
pair per calendar
year
No Charge* for one
pair per calendar
year
$25 co-pay/visit* 1
No charge up to
$90 per calendar
year*
No charge up to
$100 per calendar
year*
No charge up to
$140 per calendar
year*
No charge up to
$180 per calendar
year*
No charge up to
$220 per calendar
year*
No charge up to
$220 per calendar
year*
No charge up to
$190 per calendar
year*
15 Deschutes County Plan Document_0118_Medical
Benefit Limitations: enrolled members age 18 and younger
• One vision exam every calendar year.
• One pair of glasses (frames and lenses) or contact lenses in lieu of glasses per calendar
year.
• Corrective eye surgery is covered up to a lifetime maximum of $250 per eye. This
includes reversals, revision, surgical procedures, and any complications.
Benefit Limitations: enrolled members age 19 and older
• One vision exam every calendar year.
• Lenses: One pair every calendar year.
• Frames: Once every calendar year.
• Contact lenses: Once every calendar year, in lieu of glasses. Contact lenses fitting is
included.
• Corrective eye surgery is covered up to a lifetime maximum of $250 per eye. This includes
reversals, revision, surgical procedures, and any complications.
Exclusions
• Special procedures such as orthoptics or vision training.
• Special supplies such as sunglasses (plain or prescription) and subnormal vision aids.
• Lens tint.
• Polycarbonate lenses for enrolled members age 19 and older.
• Plano contact lenses.
• Anti -reflective coatings and scratch resistant coatings.
• Replacement of lost, stolen, or broken lenses or frames.
• Duplication of spare eyeglasses or any lenses or frames.
• Nonprescription lenses.
• Visual analysis that does not include refraction.
• Services or supplies not listed as covered expenses.
• Eye exams required as a condition of employment, required by a labor agreement or
government body.
• Expenses covered under any workers' compensation law.
• Services or supplies received before this plan's coverage begins or after it ends.
16 Deschutes County Plan Document_0118_Medical
• Charges for services or supplies covered in whole or in part under any medical or vision
benefits provided by the employer.
• Medical or surgical treatment of the eye.
Important information about your vision benefits
This Plan includes coverage for vision services. To make the most of those benefits, it's
important to keep in mind the following:
Participating Providers
PacificSource is able to add value to your vision benefits by contracting with a network of
vision providers. Those providers offer vision services at discounted rates, which are
passed on to you in your benefits.
Paying for Services
Please remember to show your current member ID card whenever you use this Plan's
benefits. Our provider contracts require participating providers to bill us directly whenever
you receive covered services and supplies. Providers will verify your vision benefits.
Participating providers should not ask you to pay the full cost in advance. They may only
collect your share of the expense up front, such as co -payments and amounts over your
plan's allowances. If you are asked to pay the entire amount in advance, tell the provider
you understand they have a contract with PacificSource and they should bill
PacificSource directly.
Sales and Special Promotions (sales and promotions are not considered
insurance)
Vision retailers often use coupons and promotions to bring in new business, such as free
eye exams, two-for-one glasses, or free lenses with purchase of frames. Because
participating providers already discount their services through their contract with
PacificSource, this Plan's participating provider benefits cannot be combined with any
other discounts or coupons. You can use this Plan's participating provider benefits, or you
can use this Plan's non -participating provider benefits to take advantage of a sale or
coupon offer.
If you do take advantage of a special offer, the participating provider may treat you as an
uninsured customer and require full payment in advance. You can then send the claim to
PacificSource yourself, and we will reimburse you according to this Plan's non-
participating provider benefits.
17 Deschutes County Plan Document_0118_Medical
CHIROPRACTIC MANIPULATION, ACUPUNCTURE, AND
MASSAGE THERAPY BENEFIT SUMMARY
This benefit allows you to receive services from licensed providers for chiropractic
manipulations, acupuncture, and massage therapy for medically necessary treatment of
illness or injury. The service must be within the scope of the provider's license. Refer to
the Medical Benefit Summary for your deductible, co -payment and/or co-insurance
information.
Covered Services
• Acupuncture from a licensed provider when necessary for treatment of illness or injury.
• Chiropractic manipulations from a licensed provider for medically necessary treatment of
illness or injury.
• Massage therapy from a licensed provider. There is a $45 maximum benefit per visit for
massage therapy.
The combined benefit for all chiropractic manipulation, acupuncture care, and massage
therapy is limited to a maximum of $1,500 per person, per calendar year.
Excluded Services
• Any service or supply noted as being excluded or not otherwise covered by this Plan.
• Homeopathic medicines or homeopathic supplies.
18 Deschutes County Plan Document_0118_Medical
PRESCRIPTION DRUG BENEFIT SUMMARY
Prescription Drug Benefit Maximum Out -of -Pocket amounts
Standard Plan
High Deductible Plan
$1,200
$1,200
$3,600
$3,200
Prescription Drug benefit copayments/coinsurance will accumulate to the Prescription Drug
benefit maximum out-of-pocket amount until the out-of-pocket amount, as shown above, is
reached for the calendar year. Then, covered charges for Prescriptions Drug expenses
incurred by a covered person will be payable at 100% for the remainder of the calendar
year.
Prescription Drug copayments/coinsurance amounts do not apply toward the medical
maximum out-of-pocket amount.
Note: If the covered member's physician prescribes a generic drug, but a brand name
drug is purchased, the covered member must pay the copayment plus the difference in
the generic and brand name cost.
ONSITE CLINIC - DESCHUTES COUNTY ONSITE CLINIC
PHARMACY SERVICES (541) 385-1071
Limited to a 30 -day supply:
Copayment $2 copayment
Limited to a 90 -day supply:
Copayment $4 copayment $40 copayment $80 copayment I
Note: Prescriptions filled through the Deschutes Onsite Clinic Pharmacy are available
at a 30 -day or a 90 -day supply. Mail order maintenance medications are excluded in
certain locations.
Prescriptions for female contraceptives, tobacco cessation drugs or products, and
certain vaccines and immunizations are available at no cost to the Covered Person.
Formulary Non -Formulary
Drugs: Drugs:
$20 copayment
$40 copayment
For additional information regarding the Deschutes Onsite Clinic Pharmacy
Call: 541-385-1071
Or access their website at:
http://www.deschutes.orq/benefits/paqe/doc-pharmacy
19 Deschutes County Plan Document_0118_Medical
RETAIL - NORTHWEST PHARMACY SERVICES (800) 998-
2611
Retail Pharmacy Option — Limited to a 34 -day supply:
Limited to a 34 -day supply:
Copayment $20 copayment
Formulary
Drugs:
on -Formulary
Drugs:
Greater of
20% coinsurance or
$50 copayment up to
a maximum of $100
Greater of
20% coinsurance or
$75 copayment up to
a maximum of $125
Retail Pharmacy Option — Diabetes management for covered Pregnant
Women (i.e., diabetic medications and supplies):
Formulary
Drugs:
Non Formulary
Drugs:
Limited to a 34 -day supply:
Copayment No Charge
Retail Expense Submitted by Employee:
Formulary Druc
Limited to a 34 -day supply:
Non Formulary
•
Drugs:
Coinsurance 50% coinsurance
Note: If a drug is purchased from a non -participating pharmacy, or a participating
pharmacy when the covered person's ID card is not used, the covered person will be
required to pay 100% at the point of sale, no discount will be given, and the covered
person must submit the prescription receipt directly to Northwest Pharmacy Services
for reimbursement less any applicable copayment as shown above.
20 Deschutes County Plan Document_0118_Medical
MAIL ORDER - WELLPARTNER (877) 935-5797
Mail Order Pharmacy Option — Limited to a 100 -day supply:
Limited to a 100 -day supply:
Copayment $40 copayment
Formulary
Drugs:
Non -Formulary
Drugs:
Greater of
20% coinsurance or
$100 copayment up to
a maximum of $200
Greater of
20% coinsurance or
$150 copayment up to
a maximum of $300
Mail Order Pharmacy Option — Diabetes management for covered Pregnant
Women (i.e., diabetic medications and supplies):
.............................
Formulary
Drugs:
Limited to a 100 -day supply:
Copayment No Charge
Non -Formulary
Drugs:
The following will be covered at 100%, no copayment required:
• Physician -prescribed tobacco cessation products or medications. Limited to a 168 -day
supply per calendar year of nicotine replacement products (nicotine patch, gum,
lozenges) and a 168 -day supply per calendar year of physician -prescribed medications
(Zyban, Chantix).
• Physician -prescribed contraceptive methods (Food and Drug Administration (FDA)
approved) including by not limited to oral contraceptive medications, transdermals,
devices (diaphragms, cervical caps), vaginal contraceptives, and injectables. This also
includes physician -prescribed over -the- counter (OTC) contraceptives (such as female
condoms, spermicides, and sponges); for all covered female members with
reproductive capacity.
Refer to the medical section of this Plan Document, regarding additional coverage for
intrauterine devices (IUDs), and implantables.
• Additional Physician -prescribed medications as recommended by the U.S. Preventive
Services Task Force (USPSTF) grades A and B recommendations will be covered at
100%, no prescription copayment, coinsurance or deductible will be required, and will
only be available when utilizing a participating pharmacy.
Please note, the USPSTF grades A and B recommendations are subject to change as
new medications become available and other recommendations may change.
Coverage of new recommended medications will be available following the one (1)
year anniversary date of the adoption of the USPSTF grade A and B recommendation.
21 Deschutes County Plan Document_0118_Medical
Refer to the following link for more information regarding USPSTF grade A and B
recommendations or contact Northwest Pharmacy Services at (800) 998-2611, for
more information regarding which medications are available. Note: Age and/or
quantity limitations may apply.
http://www. uspreventiveservicestaskforce.ora/Paqe/Name/uspstf-a-and-b-
recommendations
Additional information on Prescription Drug coverage may be found in the Prescription
Drug Benefit section of this Plan Document.
22 Deschutes County Plan Document_0118_Medical
BECOMING ELIGIBLE
Who Pays for Your Benefits
Deschutes County shares the cost of employee and dependent coverage under this Plan with
the covered employees. This authorization must be filed out, signed and returned with the
enrollment application.
The level of any employee contributions is set by the Plan Sponsor. The Plan Sponsor
reserves the right to change the level of employee contribution.
In addition, the deductible and co -payments may also change periodically. You will be notified
by your Plan Sponsor of any changes in the cost this Plan's coverage before they take effect.
Employees
Your status as an Employee is determined by the employment records maintained by the Plan
Sponsor. Workers classified by the Plan Sponsor as independent contractors are not eligible
for coverage under this Plan under any circumstances. The Plan Sponsor decides the
minimum number of hours employees must work each week to be eligible for health benefits.
The Plan Sponsor may also require new employees to satisfy a waiting period called the
`probationary waiting period' before they are eligible for benefits. The Plan Sponsor's eligibility
requirements, including the length of the probationary waiting period are shown in your
Medical Benefit Summary. All employees who meet those requirements are eligible for
coverage.
Family members
While you are covered under this Plan, the following family members are also eligible for
coverage:
• Your legal spouse or your domestic partner.
• Your, your spouse's, or your domestic partner's natural or step children under age 26
regardless of the child's place of residence, marital status, or financial dependence on
you.
• Your, your spouse's, or your domestic partner's unmarried dependent children age 26 or
over who are mentally or physically disabled. To qualify as dependents, they must have
been continuously unable to support themselves since turning age 26 because of a mental
or physical disability. The Plan Sponsor requires documentation of the disability from the
child's physician, and will review the case before determining eligibility for coverage.
• A child placed for adoption with you, your spouse, or your domestic partner. `Placed for
adoption' means the assumption and retention by you, your spouse, or domestic partner of
a legal obligation for full or partial support and care of the child in anticipation of adoption
of the child. Coverage will continue assuming continued eligibility under this Plan unless
placement is disrupted prior to legal adoption and the child is removed from placement.
• A foster child placed with you, your spouse, or your domestic partner. Placed means an
individual who is placed by an authorized placement agency or by judgment, decree, or
other order of any court of competent jurisdiction. Coverage will continue assuming
23 Deschutes County Plan Document_0118_Medical
continued eligibility under this Plan unless placement is disrupted and the child is removed
from placement.
• A child placed in your, your spouse's, or your domestic partner's guardianship. To be
eligible for coverage, the child must be unmarried; not in a domestic partnership; under
age 19; and for whom you are the court appointed legal custodian or guardian with the
expectation the child will live in your household for at least a year.
No family or household members other than those listed above are eligible to enroll under
your coverage.
No person can be covered both as an employee and as a dependent, or as a dependent of
more than one employee. Separate enrollments for employees that are married or are in a
domestic partnership will not be allowed. The employee who is employed the longest with
Deschutes County must enroll his or her spouse, domestic partner and any other eligible
dependents.
However, if both the mother and father are Employees of COIC, their children will be covered
as Dependents of the mother and father.
In cases where the mother or father is an Employee of Deschutes County and the mother or
father is an Employee of COIC, their children will be covered as Dependents of the mother
and father.
Special Rules for Eligibility
At any time the Plan Administrator may require proof that a person qualifies, or continues to
qualify, as a dependent as defined by this Plan.
ENROLLING DURING THE INITIAL ENROLLMENT PERIOD
Once you satisfy the Plan Sponsor's probationary waiting period, and meet the hours required
for eligibility, you and your eligible family members become eligible for this Plan. Starting on
the date you become eligible, you and your family members have 31 days to enroll. The Plan
Sponsor calls this 31 day window the initial enrollment period. To enroll you must submit the
completed enrollment application to the Plan Sponsor.
If you miss your initial enrollment period, you will not be able to enroll in the Plan later in the
year, unless you have a special circumstance, called a `qualifying event'. (For more
information, see `Special Enrollment Periods' and 'Late Enrollment' under the Enrolling After
the Initial Enrollment Period section.)
Coverage for you and your enrolling family members begins after you satisfy the Plan
Sponsor's probationary waiting period. The length of the probationary waiting period is stated
in your Medical Benefit Summary. Coverage will only begin if the Plan Sponsor receives your
enrollment information, and forwards it to PacificSource.
Employees who were determined eligible for coverage during the applicable measurement
period (and their eligible dependents) may enroll in the Plan the first day of the first full
calendar month of the following stability period, as defined by the Afordable Care Act.
Employees will be credited for time previously satisfied toward the employment Waiting
Period.
ENROLLING NEW FAMILY MEMBERS
Newborns
24 Deschutes County Plan Document_0118_Medical
Your newborn child is eligible from the date of birth for 31 days. To enroll your child
beyond 31 days, the Plan Sponsor must receive your enrollment change within 31 days
of the child's birth. A claim for maternity care is not considered notification for the purpose
of enrolling a newborn child. The Plan Sponsor may ask for legal documentation to
confirm validity.
In the case of a newborn of a dependent child, they will be eligible for coverage only
during the 31 days following the birth. In order to enroll the child, guardianship must be
given to the employee on the Plan.
In the case of a newborn of a male dependent child, the employee must supply proof of
paternity (at the Plan's expense).
Adopted Children
Your adopted child is eligible from the date of birth, placement, or finalization for 31 days. To
enroll your child, the Plan Sponsor must receive your enrollment change within 31 days of the
birth, placement, or finalization. Coverage for your new family members will begin on the date
of birth, placement, or finalization. The Plan Sponsor may ask for legal documentation to
confirm validity. If your adopted child is older than age 18 at the time of placement or
finalization, they may not be enrolled in this Plan.
Foster Children
When a foster child is placed in your home, you have 31 days from the date of placement to
enroll them on the Plan. To enroll the child, the Plan Sponsor must receive your enrollment
change within 31 days of the placement. Coverage for your new family members will begin on
the date of placement. The Plan Sponsor may ask for legal documentation to confirm validity
Family Members Acquired by Marriage
If you marry, you have 31 days from the date of the marriage to add your new spouse and any
newly eligible dependent children on this Plan. The Plan Sponsor must receive your
enrollment change from you within 31 days of the marriage. If the enrollment change is
received prior to the date of marriage, coverage for your new family members will begin on the
date of marriage. If the enrollment form is received after the date of marriage but within the 31
day enrollment period, coverage will begin on the first day of the month after the date of the
marriage. The Plan Sponsor may ask for legal documentation to confirm validity.
Family Members Acquired by Domestic Partnership
If you and your domestic partner have been issued a Certificate of Registered Domestic
Partnership, your domestic partner and your partner's dependent children are eligible for
coverage during the 31 day enrollment period after the registration of the domestic
partnership. The Plan Sponsor must receive your enrollment change during the enrollment
period. Coverage for your new family members will then begin on the first day of the month
after the date of the registration of the domestic partnership. The Plan Sponsor may ask for
legal documentation to confirm validity.
Family Members Placed in Your Guardianship
If a court appoints you custodian or guardian of an eligible dependent child, you have 60 days
from the court appointment to enroll them on this Plan. The Plan Sponsor must receive your
enrollment change and any additional contribution from you within 31 days of the court
appointment. Coverage will then begin on the first day of the month after the date of the court
25 Deschutes County Plan Document_0118_Medical
appointment. The Plan Sponsor may ask for legal documentation to confirm validity. When
the court order terminates or expires, the child is no longer eligible for coverage under this
Plan.
Qualified Medical Child Support Orders
This Plan complies with qualified medical child support orders (QMCSO) issued by a state
court or state child support agency. A QMCSO is a judgment, decree, or order, including
approval of a settlement agreement, which provides for health benefit coverage for the child of
a member of this Plan.
If a court or state agency orders coverage for your spouse, domestic partner, or child, you
have 31 days from the date of the court order to enroll them in this Plan. The Plan Sponsor
must receive your enrollment change and any additional contribution from you within 31 days
of the court order. Coverage will become effective on the first day of the month after the date
of the court order. The Plan Sponsor may ask for legal documentation to confirm validity.
ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD
Returning to Work after a Layoff or Termination
If you are laid off or terminated, and then rehired by the Plan Sponsor within six months, you
will not have to satisfy another probationary waiting period.
Your health coverage will resume the first day of the month after you return to work and again
meet the Plan Sponsor's minimum hour requirement. If your family members were covered
before your layoff or termination, they can resume coverage at that time as well. You must re -
enroll your family members by submitting your enrollment change within the 31 day
enrollment.
Returning to Work after a Leave of Absence
If you return to work after a Plan Sponsor -approved leave of absence of six months or less,
you will not have to satisfy another probationary waiting period.
Your health coverage will resume the first day of the month after you return to work and again
meet the Plan Sponsor's minimum hour requirement. If your family members were covered
before your leave of absence, they can resume coverage at that time as well. You must re -
enroll your family members by submitting your enrollment application to the Plan Sponsor
within the 31 day initial enrollment period following your return to work.
Returning to Work after Family Medical Leave
If the Plan Sponsor employs 50 or more people, it is probably subject to the Family Medical
Leave Act (FMLA). To find out if you have rights under FMLA, contact your Human Resources
Department or health Plan Administrator. Under FMLA, if you return to work after a qualifying
FMLA medical leave, you will not have to satisfy another probationary waiting period under
this Plan. Your health coverage will resume the day you return to work and meet your
employer's minimum hour requirement. If your family members were covered before your
leave, they can resume coverage at that time as well. You must re -enroll your family
members by submitting an enrollment change to the Plan Sponsor within the 31 day initial
enrollment period following your return to work.
26 Deschutes County Plan Document_0118_Medical
STATUS CHANGE
Part-time to full-time conversion
Part-time employees who have waived coverage and then become a full-time employee or
have a significant increase in work hours (minimum of 25%), may elect to enroll in the
Standard Plan at that time. You may enroll by submitting an enrollment change to the Plan
Sponsor within the 31 days following the change in your employment status. Coverage is
effective the first of the month following the receipt of the application.
Part-time employees who are enrolled in the High Deductible Plan option who then become
full-time employees may either waive continuation of coverage or enroll in the Standard Plan
option at that time. You may enroll by submitting an enrollment change to the Plan Sponsor
within the 31 days following the change in your employment status. Coverage will become
effective the first day of the calendar month following or coinciding with the date the employee
is considered a full-time employee.
If a part-time employee's hours are reduced by a Deschutes County approved temporary
reduction in hours, coverage will continue without termination.
Full-time to part-time conversion
Full-time employees who have been covered under the Standard Plan and then become part-
time employees or have a significant decrease in work hours (minimum of 25%), may elect to
waive continuation of coverage or enroll in the High Deductible Plan option at that time. You
may enroll by submitting an enrollment change to the Plan Sponsor within the 31 days
following the change in your employment status. Coverage will become effective the first day
of the calendar month following or coinciding with the date the employee is considered a part-
time employee.
Full-time hourly employees who were covered under the Standard Plan and who experience a
change in job status to a part-time position of less than 20 hours per week while in a stability
period may continue coverage in the Standard Plan for 3 calendar months following the job
status change, if the employee continues to work in the part-time position and is on the
employer's payroll for that work. The employee may also choose to enroll in the High
Deductible Plan option at the time of the job status change. You may enroll by submitting an
enrollment change to the Plan Sponsor within the 31 days following the change in your
employment status. Coverage will become effective the first day of the calendar month
following or coinciding with the date the employee is considered a part-time employee.
Starting with the fourth calendar month, the employee's eligibility will be determined on a
month to month basis for the remainder of the stability period as defined by the Afordable
Care Act.
Employment transfer between COIC and Deschutes County
Employees who were employed by COIC and transfer their employment to Deschutes County
or vice versa, will not have to re -serve the probationary waiting period.
Special Enrollment Periods
You and your family members may decline coverage during your initial enrollment period. To
find out if this Plan allows employees to decline coverage, ask your Plan Sponsor. If you wish
to do so, you must submit a completed Waiver of Coverage form to the Plan Sponsor. You
and your family members may enroll in this Plan later if you qualify under the Special
Enrollment Rules below.
27 Deschutes County Plan Document_0118_Medical
Retirees and COBRA members may waive coverage for any reason. However, if they waive
coverage, they will not be able to re -enroll at a future date.
If you enroll during your initial enrollment period, your family members may decline coverage,
and they may enroll in the Plan later if they qualify under the Special Enrollment Rules below.
Employees are allowed to waive medical coverage and enroll in dental only if the employee
has an eligible waiver.
All special enrollment provisions assume that the employee has satisfied any probationary
periods required and each individual is eligible as stated in this Plan Document.
• Special Enrollment Rule #1
If you declined enrollment for yourself or your family members because of other health
coverage or there was a change in contribution, you or your family members may enroll in
the Plan later if the other coverage ends. To do so, you must submit a completed
enrollment application to the Plan Sponsor within 31 days after the other health coverage
ends (or within 60 days after the other health coverage ends if the other coverage is
through Medicaid or a State Children's Health Insurance Program). Coverage will begin
on the first day of the month following the receipt of the completed enrollment application.
• Special Enrollment Rule #2
If you acquire new family members because of marriage, domestic partnership, birth,
placement of foster child, or placement or finalization for adoption, you may be able to
enroll yourself and/or your eligible family members at that time. To do so, you must submit
a completed enrollment application to the Plan Sponsor within 31 days after the marriage,
qualification of the domestic partnership, birth, placement of foster child, or placement for
adoption. In the case of marriage or domestic partnership, coverage begins on the first
day of the month after the marriage or qualification of the domestic partnership. In the
case of birth, placement of foster child, placement or finalization for adoption, coverage
begins on the date of birth or placement. In the case of marriage, if the enrollment
application/change is received prior to the date of marriage, coverage will begin on the
marriage date.
• Special Enrollment Rule #3
If you or your family members become eligible for a premium assistance subsidy under
Medicaid or a state Children's Health Insurance Program (CHIP), you may be able to
enroll yourself and/or your family members at that time. To do so, you must submit a
completed enrollment application to the Plan Sponsor within 60 days of the date you
and/or your family members become eligible for such assistance. Coverage will begin on
the first day of the month after becoming eligible for such assistance.
Late Enrollment
If you did not enroll during your initial enrollment period and you do not qualify for a special
enrollment period, your enrollment will be delayed until the Plan's next designated open
enrollment period.
A 'late enrollee' is an otherwise eligible employee or family member who does not qualify for a
special enrollment period explained above, and who:
• Did not enroll during the initial enrollment period; or
• Enrolled during the initial enrollment period but discontinued coverage later.
28 Deschutes County Plan Document_0118_Medical
A late enrollee may enroll by submitting a completed enrollment application to the Plan
Sponsor during the open enrollment period. When you or your family members enroll during
the open enrollment period, coverage becomes effective the first day of the contract year.
The annual open enrollment period will be during a two week period in November determined
each year. Employees and their dependents who are late enrollees or who are otherwise
eligible for coverage under the Plan will be able to enroll in the Plan. Benefit choices for late
enrollees made during the open enrollment period will become effective January 1St. Plan
participants will receive detailed information regarding open enrollment from their employer.
PLAN SELECTION PERIOD
If the Plan Sponsor offers more than one benefit plan, you may choose another plan option
only upon this Plan's anniversary date. You may select a different plan option by completing a
selection form or application form and submitting it to the Plan Sponsor. Coverage under the
new plan option becomes effective on this Plan's anniversary date.
WHEN COVERAGE ENDS
If you leave your job for any reason or your work hours are reduced below the Plan Sponsor's
minimum requirement, coverage for enrolled individuals will end. Coverage ends on the last
day of the last month in which you worked full time. You may, however, be eligible to continue
coverage for a limited time. (See Continuation of Coverage section.)
Divorced Spouses
If you divorce, coverage for your spouse will end on the last day of the month in which the
divorce decree or legal separation is final. You must notify the Plan Sponsor of the divorce or
separation, and continuation coverage may be available for your spouse. If there are special
child custody circumstances, contact the Plan Sponsor. (See Continuation of Coverage
section.)
Dependent Children
When your enrolled child no longer qualifies as a dependent, their coverage will end on the
last day of the month they become ineligible. Please see e Eligibility in the Becoming Covered
section for information on when your dependent child is eligible. The Continuation of
Coverage section includes information on other coverage options for those children who no
longer qualify for coverage. (See Continuation of Coverage section.)
If two employees are covered under the Plan and the employee who is covering the
dependent children terminates coverage, the dependent child may be continued by the other
covered employee with no waiting period as long as coverage has been continuous.
Dissolution of Domestic Partnership
If you dissolve your domestic partnership, coverage for your domestic partner and their
children not related to you by birth or adoption will end on the last day of the month in which
the dissolution of the domestic partnership is final. You must notify your employer of the
dissolution of the domestic partnership. Domestic partners and their covered children are not
recognized as qualified beneficiaries under federal COBRA continuation laws. Domestic
partners and their covered children may not continue this Plan's coverage under COBRA
independent of the employee. See Continuation of Coverage section.
29 Deschutes County Plan Document_0118_Medical
CONTINUATION OF COVERAGE
Under applicable state and federal laws, you and your covered family members may
have the right to continue this Plan's coverage for a specified time. You and your family
members may be eligible if:
• Your employment ends or you have a reduction in hours;
• You take a leave of absence for military service;
• You divorce;
• You die;
• You become eligible for Medicare benefits if it causes a loss of coverage for your family
members; or
• Your children no longer qualify as dependents.
The following sections describe your rights to continuation under applicable state
and federal laws, and the requirements you must meet to enroll in continuation
coverage.
CONTINUATION DUE TO PLAN SPONSOR APPROVED PAID
ADMINISTRATIVE LEAVE OF ABSENCE, DISABILITY, OR
LEAVE OF ABSENCE
A person may remain eligible for a limited time if active, full-time work ceases due to disability,
employer -certified leave of absence, or paid administrative leave.
For disability or employer -certified leave of absence, this continuance will remain in effect until
the end of the three calendar month period that next follows the month in which the person
last worked as an active employee.
For paid administrative leave, continuance will remain in effect until the date the employer, in
its sole discretion, ends the continuance.
While continued, coverage will be that which was in force on the last day worked as an active
employee. However, if benefits reduce for others in the class, they will also reduce for the
continued person.
If you return to work after a Plan Sponsor -approved paid administrative leave of absence, you
will not have to satisfy another probationary waiting period.
USERRA CONTINUATION
If you take a leave of absence from your job due to military service, you have continuation
rights under the Uniformed Services Employment and Re-employment Rights Act (USERRA).
You and your enrolled family members may continue this Plan's coverage if you, the
employee, no longer qualify for coverage under the Plan because of military service.
Continuation coverage under USERRA is available for up to 24 months while you are on
military leave. If your military service ends and you do not return to work, your eligibility for
USERRA continuation coverage will end. Premium for continuation coverage is your
responsibility.
30 Deschutes County Plan Document_0118_Medical
The following requirements apply to USERRA continuation:
• Only family members who were enrolled in this Plan can take continuation. The only
exceptions are newborn babies and newly acquired eligible family members not covered
by another group health plan.
• To apply for continuation, you must submit a completed Continuation Election form to the
Plan Sponsor within 60 days after the last day of coverage under this Plan.
• You must pay continuation premium to the Plan Sponsor by the first of each month.
PacificSource cannot accept the premium directly from you.
• The Plan Sponsor must still be self-insured. If the Plan Sponsor discontinues this Plan,
you will no longer qualify for continuation.
SURVIVING OR DIVORCED SPOUSES OR DOMESTIC
PARTNERS
If your group has 20 or more employees, or this Plan has 20 or more subscribers, and you die,
divorce, or dissolve your domestic partnership, and your spouse or domestic partner is 55
years or older, your spouse or domestic partner may be able to continue coverage until
eligible for Medicare or other coverage. Dependent children are subject to the Plan's age and
other eligibility requirements. Some restrictions and guidelines apply; please see your Plan
Sponsor for specific details.
COBRA CONTINUATION
This Plan is subject to the continuation of coverage provisions of the Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA) as amended. To find out if you have continuation
rights under COBRA, ask your Human Resources Department or health Plan Administrator.
COBRA Eligibility
A 'qualifying event' is the event that causes your regular group coverage to end and makes
you eligible for continuation coverage. When the following qualifying events happen, you may
continue coverage for the lengths of time shown:
1 Qualifying Event
Employee's termination of employment or reduction in
hours
Employee's divorce
Employee's eligibility for Medicare benefits if it causes a
loss of coverage
Employee's death Spouse and children may continue for up to 36 months2
Child no longer qualifies as a dependent Child may continue for up to 36 months2
I If the employee or covered family member is determined disabled by the Social Security Administration within the
first 60 days of COBRA coverage, all qualified beneficiaries may continue coverage for up to 29 months.
2 The total maximum continuation period is 36 months, even if there is a second qualifying event. A second
qualifying event might be a divorce, death, or child no longer qualifying as a dependent after the employee's
termination or reduction in hours.
Continuation Period
Employee, spouse, and children may continue for up to
18 months
Spouse and children may continue for up to 36 months2
Spouse and children may continue for up to 36 months
If your family members were not covered prior to your qualifying event, they may enroll in the
continuation coverage while you are on continuation. They will be subject to the same rules
that apply to active employees, including the late enrollment waiting period.
31 Deschutes County Plan Document_0118_Medical
If your employment is terminated for gross misconduct, you and your family members are not
eligible for COBRA continuation.
Domestic partners and their covered children may not continue this Plan's coverage under
COBRA independent of the employee.
When Continuation Coverage Ends
Your continuation coverage will end before the end of the continuation period above if any of
the following occur:
• Your continuation premium is not paid on time.
• You become entitled to Medicare benefits.
• The Plan Sponsor discontinues this Plan and no longer offers a group health plan to any
of its employees.
• Your continuation period was extended from 18 to 29 months due to disability, and you are
no longer considered disabled.
Type of Coverage
Under COBRA, you may continue any coverage you had before the qualifying event. If the
Plan Sponsor provides both medical and dental coverage and you were enrolled in both, you
may continue both medical and dental. If the Plan Sponsor provides only one type of
coverage, or if you were enrolled in only one type of coverage, you may continue only that
coverage. If the Plan Sponsor offers more than one benefit plan to eligible employees, a
member electing COBRA may select enrollment for another plan at the time the member
elects COBRA coverage. Members electing COBRA may not add family members at this time
unless they otherwise qualify under the 'Special Enrollment' provisions of the Plan.
COBRA continuation benefits are always the same as your employer's current benefits. The
Plan Sponsor has the right to change the benefits of this Plan or eliminate the Plan entirely. If
that happens, any changes to the Plan will also apply to everyone enrolled in continuation
coverage.
Your Responsibilities and Deadlines
You must notify the Plan Sponsor within 60 days if you divorce, or if your child no longer
qualifies as a dependent. That will allow the Plan Sponsor to notify you or your family
members of your continuation rights.
When the Plan Sponsor learns of your eligibility for continuation, it will notify you of your
continuation rights and provide a Continuation Election form. You then have 60 days from that
date or 60 days from the date coverage would otherwise end, whichever is later, to enroll in
continuation coverage by submitting a completed Continuation Election form to the Plan
Sponsor. If continuation coverage is not elected during that 60 day period, coverage will end
on the last day of the last month you were an active employee, or when your family member
lost eligibility.
If you fail to provide the Plan Sponsor with the Continuation Election form in the required
timeframe, then the Plan Sponsor's obligation to provide you with COBRA coverage will end.
PacificSource does not accept any liability for any failure, on your part or the part of the Plan
Sponsor, to provide required notices or coverage.
32 Deschutes County Plan Document_0118_Medical
Continuation Premium
Enrolled individuals are responsible for the full cost of continuation coverage. The Plan
Sponsor uses the services of a third -party COBRA administrator to collect premium for
continuation coverage. Please see the Plan Sponsor for more information about the Plan's
COBRA administrator. The monthly premium must be paid to the Plan Sponsor's COBRA
administrator. You may make your first premium payment any time within 45 days after you
return your Continuation Election Form to the Plan Sponsor's COBRA administrator. After the
first premium payment, each monthly payment must reach the Plan Sponsor's COBRA
administrator within 30 days of your premium due date. If the COBRA administrator does not
receive your continuation premium on time, continuation coverage will end. If your coverage is
canceled due to a missed payment, it will not be reinstated for any reason. It is solely your
responsibility to ensure that the COBRA administrator receives the premium on time. Premium
rates are established annually and may be adjusted if the Plan's benefits or costs change.
Keep Your Plan Sponsor Informed of Any Address Changes
It is your responsibility to ensure that you keep the Plan Sponsor informed of any changes in
your mailing address, and the mailing address of any dependents covered by your health
coverage. You should also keep a copy of any notices you send to the Plan Sponsor along
with proof of transmission or mailing.
CONTINUATION WHEN YOU RETIRE
Continuation upon retirement is based on meeting all the retirement requirements set forth in
your employment agreement with your Plan Sponsor
• You must be receiving benefits from PERS (Public Employee Retirement System) or
from a similar retirement Plan offered by your Plan Sponsor;
• You must have been continuously covered under the group's Plan for at least 24
consecutive months prior to the retirement, unless otherwise indicated by a
management/labor agreement.
If you become eligible for PERS while enrolled in COBRA due not being at work because of
disability, you can elect to re -enroll as a retired employee only under this Pian. You must
request re -enrollment within 6 months of PERS eligibility.
Your continuation coverage will end when any one of the following occurs:
When a retired employee's coverage terminates. Retired employee coverage will terminate
on the earlies of these dates:
• The date the Plan is terminated;
• The date the covered retired employee's eligible class is eliminated;
• The first day of the calendar month the covered retired employee becomes eligible for
Medicare;
• The end of the period for which the required contribution has been paid if the charge for
the next period is not paid when, due; or
• As otherwise specified in the Eligibility section of the Plan.
33 Deschutes County Plan Document_0118_Medical
Your family member's continuation coverage will end when any one of the following
occurs:
When Dependent Coverage, of a Retired Employee, Terminates.
When a retired employee's coverage terminates under this Plan due to reaching age 65 or
becoming entitled to Medicare, his/her dependents may remain eligible for benefits until the
dependent's coverage terminates as outlined below. The Plan Sponsor must be notified that
the dependent coverage is to continue within 31 days of the retired employee's termination. A
retired employee's dependent's coverage will terminate on the earliest of these dates:
• The last day of the calendar month the Plan or dependent coverage under the Plan is
terminated;
• On the last day of the calendar month a covered spouse or domestic partner of a retired
employee loses coverage due to loss of dependency status. (See the Continuation of
Coverage section.)
• The first day of the month the covered dependent spouse or domestic partner becomes
entitled to Medicare;
• On the last day of the calendar month that a dependent child ceases to be a dependent as
defined by the Plan. (See the Continuation of Coverage section.)
• The end of the period for which the required contribution has been paid if the charge for
the next period is not paid when due; or
• As otherwise specified in the Eligibility section of the Plan.
WORK STOPPAGE
Labor Unions
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 contribution, 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 contributions 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.
USING THE PROVIDER NETWORK
This section explains how this Plan's benefits differ when you use a participating or non-
participating providers and explains how we apply the reimbursement rate. This information is
not meant to prevent you from seeking treatment from any provider if you are willing to take
increased financial responsibility for the charges incurred. Your network name is listed at the
beginning of the Medical Benefit Summary.
All healthcare providers are independent contractors. Neither the Plan Sponsor nor
PacificSource can be held liable for any claim for damages or injuries you experience while
receiving medical care.
34 Deschutes County Plan Document_0118_Medical
PARTICIPATING PROVIDERS
Participating providers contract with PacificSource to furnish medical services and supplies to
members enrolled in this Plan for a set fee. That fee is called the contracted allowable fee.
Participating providers agree not to charge more than the contracted allowable fee.
Participating providers bill PacificSource directly, and are paid directly. When you receive
covered services or supplies from a participating provider, you are only responsible for the
amounts stated in your Medical Benefit Summary. Depending on the terms of this Plan, those
amounts can include deductibles, co -payments, and/or co-insurance payments.
PacificSource contracts directly and/or indirectly with participating providers throughout
Oregon, Idaho, Montana, and communities in southwest Washington. They also have
agreements with nationwide provider networks. These providers outside the service area are
also considered PacificSource participating providers under this Plan.
It is not safe to assume that when you are treated at a participating medical facility, all
services are performed by participating providers. Whenever possible, you should arrange for
professional services such as surgery and anesthesiology, to be provided by a participating
provider. Doing so will help you maximize your benefits and limit your out-of-pocket expenses.
Risk -sharing Arrangements
By agreement, a participating provider may not bill a member for any amount in excess of the
contracted allowable fee. However, the agreement does not prohibit the provider from
collecting co -payments, deductibles, co-insurance, and amounts for non -covered services
from the member.
NON -PARTICIPATING PROVIDERS
When you receive services or supplies from a non -participating provider, your out-of-pocket
expense is likely to be higher than if you had used a participating provider. If the same
services or supplies are available from a participating provider to whom you have reasonable
access (explained in the next section), you may be responsible for more than the deductibles,
co -payments, and/or co-insurance amounts stated in your Medical Benefit Summary.
Allowable Fee for Non participating Providers
To maximize this Plan's benefits, always make sure your healthcare provider is a participating
provider on PacificSource's network. Do not assume all services at a participating facility are
performed by participating providers.
PacificSource, as your Third Party Administrator, bases payment to non -participating
providers on the `allowable fee' which is derived from several sources, depending on the
service or supply and the geographical area where it is provided. The allowable fee may be
based on data collected from the Centers for Medicare and Medicaid Services (CMS),
contracted vendor, other nationally recognized databases, or PacificSource, as documented in
PacificSource's payment policy.
In PacificSource's service area the allowable fee for professional services is based on
PacificSource's standard non -participating provider reimbursement rate. Outside the
PacificSource service area and in areas where members do not have reasonable access to a
participating provider through one of the third party provider networks, the allowable fee,
depending upon the service and supply, can be based on data collected from PacificSource or
other nationally recognized databases. If the service is based on the usual, customary, and
reasonable charge (UCR) PacificSource will utilize the 85th percentile. UCR is based on data
35 Deschutes County Plan Document_0118_Medical
collected for a geographic area. Provider charges for each type of service are collected and
ranked from Iowest to highest.hest. Charges at the 85th position in the ranking are considered to be
the 85th percentile.
To calculate the payment to non -participating providere. PacificSource determines the
allowable fee then subtracts the non -participating provider benefits shown in the 'Non-
participating Provider' column of your Medical Benefit Summary. The allowable fee is often
less than the non -participating provider's charge. In that case, the difference between the
allowable fee and the provider's billed charge is also your responsibility. That amount does not
count toward this Plan's out-of-pocket maximum. It also does not apply toward any
deductibles or co -payments required by the Plan. In any case, after any co -payments or
deductibles, the amount the Plan pays to a non -participating provider will not be less than 50
percent of the allowable fee for a like service or supply.
To maximize this Plan's benefits, pIese check with PacificSource before receiving care from
a non -participating provider. Their Customer Service team can help you Iocate a parUcipating
provider in your area.
Example of Provider Payment
The following illustrates how payment could be made for covered service in three different
settings: with a Tier One participating provider, Tier Two participating provider, and with a
non -participating provider. This is only an example; this Plan's benefits may be different.
|
/P[ovder'SUau8|dl@[0e
Billed charge after
negotiated provider
discounts
PacificSource's allowable
fee
Allowable fee less patient
co-insurance
Percent of payment
PacificSource's payment
Patient's responsibility:
Co-insurance
Patient's amount of
allowable fee
Difference between
allowable fee and billed
charge after discounts
Patient's total
responsibility to the
provider
Tier one Tier two Non -
Participating Participating participating
Provider Provider Provider
$100 $100 $120
$80
$70
$50
80% 70% | 50%
20%
30% 50%
$20 $30
$50
36 Deschutes County Plan Oouumont_118_Mndica|
COVERAGE WHILE TRAVELING
This Plan is powered by the network shown at the beginning of the Medical Benefit Summary.
You can save out of pocket expense by using a participating provider in your service area.
Your network covers Oregon, Idaho, Montana, southwest Washington, and eastern
Washington. When you need medical services outside of your network, you can save out-of-
pocket expense by using the participating providers identified on the website at
providerdirectory.pacificsource.com.
Nonemergency Care While Traveling
To find a participating provider outside the regions covered by your network, go to the
providerdirectory.pacificsource.com website. Nonemergency care outside of the United States
is not covered.
• If a participating provider is available in your area, the Plan's participating provider benefits
will apply if you use a participating provider.
• If a participating provider is available but you choose to use a non -participating provider,
this Plan's non -participating provider benefits will apply.
Emergency Services While Traveling
In medical emergencies (see the Covered Expenses — Emergency Services section of this
Plan Document), this Plan pays benefits at the participating provider level regardless of your
location. Your covered expenses are based on our allowable fee. If you are admitted to a
hospital as an inpatient following the stabilization of your emergency condition, your physician
or hospital should contact the PacificSource Health Services team at (888) 691-8209 as soon
as possible to make a benefit determination on your admission. If you are admitted to a non-
participating hospital, this Plan may require you to transfer to a participating facility once your
condition is stabilized in order to continue receiving benefits at the participating provider level.
FINDING PARTICIPATING PROVIDER INFORMATION
You can find up-to-date participating provider information:
• By asking your healthcare provider if they are a participating provider for your network.
• On the PacificSource website, providerdirectory.pacificsource.com. Go to 'Find a Doctor or
Drug' to easily look up participating providers, specialists, behavioral health providers, and
hospitals. You can also print your own customized directory.
• By contacting the PacificSource Customer Service Team, their staff can answer your
questions about specific providers.
TERMINATION OF PROVIDER CONTRACTS
PacificSource, on behalf of the Plan Sponsor, will use best efforts to notify you within 30 days
of learning about the termination of a provider's contractual relationship if you have received
services in the previous three months from such a provider when:
• A provider terminates a contractual relationship with PacificSource in accordance with the
terms and conditions of the provider's agreement;
37 Deschutes County Plan Document_0118_Medical
• A provider terminates a contractual relationship with an organization under contract with
PacificSource; or
• PacificSource terminates a contractual relationship with an individual provider or the
organization with which the provider is contracted in accordance with the terms and
conditions of the agreement.
Note: On the date a provider's contract with PacificSource terminates, they become a non-
participating provider and any services you receive from them will be paid at the percentage
shown in the `Non -participating Provider' column of your Medical Benefit Summary. To avoid
unexpected costs, be sure to verify each time you see your provider that they are still
participating in the network.
You may be entitled to continue care with an individual provider for a limited period of time
after the medical services contract terminates. Contact Customer Service for additional
information.
COVERED EXPENSES
Understanding Medical Necessity
This Plan provides comprehensive medical coverage when care is medically necessary to
treat an illness, injury, or disease. Be careful — just because a treatment is prescribed by a
healthcare professional does not mean it is medically necessary under the terms of this Plan.
Also remember that just because a service or supply is a covered benefit under this Plan does
not necessarily mean all billed charges will be paid.
Medically necessary services and supplies that are excluded from coverage under this Plan
can be found in the Benefit Limitations and Exclusions section of this Plan Document, as well
as the section on Preauthorization. If you ever have a question about this Plan's benefits,
contact the Plan Administrator or the PacificSource Customer Service team.
Understanding Experimental/Investigational Services
Except for specified Preventive Care services, the benefits of this Plan are paid only toward
the covered expense of medically necessary diagnosis or treatment of illness, injury, or
disease. This is true even though the service or supply is not specifically excluded. All
treatment is subject to review for medical necessity. Review of treatment may involve prior
approval, concurrent review of the continuation of treatment, post-treatment review or any
combination of these. For additional information, see `medically necessary' in the Definitions
section of this Plan Document.
Be careful. Your healthcare provider could prescribe services or supplies that are not covered
under this Plan. Also, just because a service or supply is a covered benefit does not mean all
related charges will be paid.
New and emerging medical procedures, medications, treatments, and technologies are often
marketed to the public or prescribed by physicians before FDA approval, or before research is
available in qualified peer-reviewed literature to show they provide safe, long term positive
outcomes for patients.
To ensure you receive the highest quality care at the lowest possible cost, PacificSource
reviews new and emerging technologies and medications on a regular basis and consults with
the Plan Sponsor about what procedures, technologies and medications should be covered
38 Deschutes County Plan Document_0118_Medical
under the terms of the Plan. The Plan Sponsor has sole and complete authority to determine
what is and is not covered under the terms of the Plan.
Eligible Healthcare Providers
This Plan provides benefits only for covered expenses and supplies rendered by a physician
(M.D. or D.O.), Nurse Practitioner, hospital or specialized treatment facility, durable medical
equipment supplier, or other licensed medical provider as specifically stated in this Plan
Document. The services or supplies provided by individuals or companies that are not
specified as eligible practitioners are not eligible for reimbursement under the benefits of this
Plan. For additional information, see 'practitioner', 'specialized treatment facility', and 'durable
medical equipment supplier' in the Definitions section of this Plan Document.
To be eligible, the provider must also be practicing within the scope of their license. For
example although an Optometrist is an eligible provider for vision exams, they are not eligible
to provide chiropractic services.
After Hours and Emergency Care
If you have a medical emergency, always go directly to the nearest emergency room, or call
911 for help.
If you're facing a non -life-threatening emergency, contact your provider's office, or go to an
urgent care facility. Urgent care facilities are listed in PacificSource's online provider directory
at providerdirectory.pacificsource.com. Simply enter your City and State or Zip code, and then
select Urgent Care in the 'Specialty Category' field.
Appropriate Setting
It is important to have services provided in the most suitable and least costly setting. For
example, if you go to the emergency room to have a throat culture instead of going to a
doctor's office or urgent care facility, it could result in higher out-of-pocket expenses for you.
Your Annual Out -of -Pocket Limit
This Plan has an out-of-pocket limit provision to protect you from excessive medical
expenses. The Medical Benefit Summary shows this Plan's annual out-of-pocket limits for
participating and/or non -participating providers. If you incur covered expenses over those
amounts, this Plan will pay 100 percent of eligible charges, subject to the allowable fee.
Your expenses for the following do not count toward the annual out-of-pocket limit:
• Charges over the allowable fee for services of non -participating providers;
• Incurred charges that exceed amounts allowed under this Plan;
• Prescription Drugs;
• Vision exams, hardware, or contact lenses.
• Charges not covered by the plan.
Charges that do not count toward the out-of-pocket limit, that are not covered by this Plan, or
that are over the allowable fee for services by non -participating providers, will continue to be
your responsibility even after the out-of-pocket or stop -loss limit is reached.
39 Deschutes County Plan Document_0118_Medical
Out-of-pocket limits are applied on a calendar year basis. If this Plan renews or is
modified mid calendar year, the previously satisfied out-of-pocket amount will be
credited toward the renewed difference between the increase and the amount you
have already satisfied under the prior Plan's requirement. If the out-of-pocket limit
decreases, any excess in the amount credited to the lower amount is not refundable.
PLAN BENEFITS
This Plan provides benefits for the following services and supplies as outlined on your Benefit
Summaries. These services and supplies may require you to satisfy a deductible, make a co-
payment, and/or pay co-insurance, and they may be subject to additional limitations or
maximum dollar amounts. For a medical expense to be eligible for payment, you must be
covered under this Plan on the date the expense is incurred. Please refer to your Medical
Benefit Summary and the Benefit Limitations and Exclusions section of this Plan Document for
more information.
PREVENTIVE CARE SERVICES
This Plan covers the following preventive care services when provided by a physician,
physician assistant, or nurse practitioner:
• Routine physicals including appropriate screening, radiology and laboratory tests, and
other screening procedures for members age 22 and older are covered according to the
schedule below. Screening exams and laboratory tests may include, but are not limited to,
blood pressure checks, weight checks, occult blood tests, urinalysis, complete blood
count, prostate exams, cholesterol exams, stool guaiac screening, EKG screens, blood
sugar tests, and tuberculosis skin test.
— Ages 22+: One exam every calendar year
Only laboratory tests and other diagnostic testing procedures related to the routine
physical exam are covered by this benefit. Any laboratory tests and other diagnostic
testing procedures ordered during, but not related to, a routine physical examination are
not covered by this preventive care benefit. Please see Outpatient Services in this section.
• Well woman visits, including the following:
One routine gynecological exam each calendar year for women 18 and over. Exams
may include Pap smear, pelvic exam, breast exam, blood pressure check, and weight
check. Covered lab services are limited to occult blood, urinalysis, and complete blood
count.
Routine preventive mammograms for women as recommended.
o There is no deductible, co -payment, and/or co-insurance for mammograms that
are considered `routine' according to the guidelines of the U.S. Preventive Services
Task Force.
o Diagnostic mammograms for any woman desiring a mammogram for medical
cause. The deductible, co -payment, and/or co-insurance stated in your Medical
Benefit Summary for `Outpatient Services – Diagnostic and therapeutic radiology
and lab' apply to diagnostic mammograms related to the ongoing evaluation or
treatment of a medical condition.
40 Deschutes County Plan Document_0118_Medical
— Pelvic exams and Pap smear exams for women 18 to 64 years of age annually, or at
any time when recommended by a women's healthcare provider.
— Breast exams annually for women 18 years of age or older or at any time when
recommended by a women's healthcare provider for the purpose of checking for lumps
and other changes for early detection and prevention of breast cancer.
Members have the right to seek care from obstetricians and gynecologists for covered
services without preapproval or preauthorization.
• Colorectal cancer screening exams and lab work including the following:
— A colonoscopy, including removal of polyps during the screening procedure if a
positive result on any fecal test assigned either a grade "A" or `B";
— A fecal occult blood test;
— A flexible sigmoidoscopy; or
— A double contrast barium enema.
A colonoscopy performed for routine screening purposes is considered to be a preventive
service according to the guidelines of the U.S. Preventive Services Task Force that have a
rating of 'A' or B' for age 50 and older. The deductible, co -payment, and/or co-insurance
stated in your Medical Benefit Summary for Participating Providers `Preventive Care –
Routine and diagnostic colonoscopy' applies to colonoscopies that are considered 'routine'
according to the guidelines of the U.S. Preventive Services Task Force. It is not safe to
assume that when you are treated at a participating medical facility, all services are
performed by participating providers. Whenever possible, you should arrange for
professional services such as surgery and anesthesiology to be provided by a participating
provider. Doing so will help you maximize your benefits and limit your out-of-pocket
expenses.
A colonoscopy performed for evaluation or treatment of a known medical condition is
considered to be Outpatient Surgery. The deductible, co -payment, and/or co-insurance
stated in your Medical Benefit Summary for `Preventive Care – Routine and diagnostic
colonoscopy' applies to colonoscopies related to ongoing evaluation or treatment of a
medical condition.
A colonoscopy performed for screening purposes on individuals at 'high risk' under age 50
is also considered a preventive service. An individual is at high risk for colorectal cancer if
the individual has:
Family medical history of colorectal cancer;
Prior occurrence of cancer or precursor neoplastic polyps;
Prior occurrence of a chronic digestive disease condition such as inflammatory bowel
disease;
Crohn's disease or ulcerative colitis; or
Other predisposing factors.
• Prostate cancer screening, including a digital rectal examination and a prostate-specific
antigen test.
41 Deschutes County Plan Document_0118_Medical
Well baby/well child care exams for members age 21 and younger according to the
following schedule:
— At birth: One standard in-hospital exam
— Ages 0-2: 12 additional exams during the first 36 months of life
— Ages 3-21: One exam every calendar/contract year
Only laboratory tests and other diagnostic testing procedures related to a well baby/well
child care exam are covered by this benefit. Any laboratory tests and other diagnostic
testing procedures ordered during, but not related to, a well baby/well child care exam are
not covered by this preventive care benefit. Please see Outpatient Services in this section.
• Age-appropriate childhood and adult immunizations for primary prevention of infectious
diseases as recommended and adopted by the Centers for Disease Control and
Prevention, American Academy of Pediatrics, American Academy of Family Physicians, or
similar standard-setting body. Benefits do not include immunizations for more elective,
investigative, unproven, or discretionary reasons (e.g. travel). Covered immunizations
include, but may not be limited to the following:
Diphtheria, pertussis, and tetanus (DPT) vaccines, given separately or together;
Hemophilus influenza B vaccine;
Hepatitis A vaccine;
Hepatitis B vaccine;
Human papillomavirus (HPV) vaccine;
Influenza virus vaccine;
Measles, mumps, and rubella (MMR) vaccines, given separately or together;
Meningococcal (meningitis) vaccine;
Pneumococcal vaccine;
Polio vaccine;
Shingles vaccine for ages 60 and over; or
Varicella (chicken pox) vaccine.
• Tobacco cessation program services are covered at no charge when services are
received from a participating provider.
Any Plan deductible, co -payment, and/or co-insurance amounts stated in your Medical Benefit
Summary are waived for the following recommended preventive care services when provided
by a participating provider:
• Services that have a rating of 'A' or '6' from the U.S. Preventive Services Task Force
(USPSTF);
• Immunizations recommended by the Advisory Committee on Immunization Practices of
the Centers for Disease Control and Prevention (CDC);
42 Deschutes County Plan Document_0118_Medical
• Preventive care and screening for infants, children, and adolescents supported by the
Health Resources and Services Administration (HRSA);
• Preventive care and screening for women supported by the HRSA that are not included in
the USPSTF recommendations.
The A and B list for preventive services can be found on the USPSTF website at:
http://www. uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/
The list of women's preventive services can be found on the HRSA website at:
http://www.hrsa.aov/womensquidelines2016/
For members who do not have Internet access, please contact PacificSource Customer
Service at the number shown on the first page of this Plan Document for a complete
description of the preventive services lists.
Current USPSTF recommendations include the January 2016 recommendations regarding
breast cancer screening, mammography, and prevention. Cancer risk -reducing medications
are covered according to the September 2013 USPSTF recommendations, at no cost, subject
to reasonable medical management.
PEDIATRIC SERVICES
This Plan covers the following services for individuals age 18 and younger. Coverage for
pediatric services will end on the last day of the month in which the enrolled individual turns
19:
• Routine vision examinations are covered on this Plan. Benefits are subject to the
deductible, limitations, co -payment, and/or co-insurance stated in your Vision Benefit
Summary.
• Vision hardware including lenses, frames and contact lenses are covered on this Plan.
Benefits are subject to the deductible, limitations, co -payment, and/or co-insurance stated
in your Vision Benefit Summary.
PROFESSIONAL SERVICES
This Plan covers the following professional services when medically necessary:
• Services of a physician (M.D., D.O., naturopathy, or other provider practicing within
the scope of their license), for diagnosis or treatment of illness, injury, or disease.
• Services of a licensed physician assistant under the supervision of a physician.
• Services of a nurse practitioner, including certified registered nurse anesthetist
(C.R.N.A.) and certified nurse midwife (C.N.M.), or other provider practicing within the
scope of their license, for medically necessary diagnosis or treatment of illness, injury, or
disease.
Urgent care services provided by a physician. 'Urgent care' means services for an
unforeseen illness, injury, or disease that requires treatment within 24 hours to prevent
serious deterioration of a patient's health. Urgent conditions are normally less severe than
medical emergencies. Examples of conditions that could need urgent care are sprains and
strains, vomiting, cuts, and headaches.
43 Deschutes County Plan Document_0118_Medical
Outpatient rehabilitation services provided by a licensed physical therapist,
occupational therapist, speech language pathologist, physician or other practitioner
licensed to provide physical, occupational, or speech therapy within the scope of the
provider's license. Services must be prescribed in writing by a licensed physician, dentist,
podiatrist, nurse practitioner, or physician assistant. The prescription must include site,
modality, duration, and frequency of treatment. Covered services are for the purpose of
restoring certain functional losses due to disease, illness, or injury only, and do not include
maintenance services. Total covered expenses for outpatient rehabilitation services,
including vision therapy, are limited to a maximum of 30 visits per calendar year and
subject to review for medical necessity, unless medically necessary to treat a mental
health diagnosis. Treatment of neurodevelopmental problems, and other problems
associated with pervasive developmental disorders for which rehabilitation services would
be appropriate are covered when criteria for individual benefits are met. Up to 30
additional visits will be allowed for head and spinal injury, cardiovascular accident, stroke
or major injury.
Services for speech therapy will only be allowed when needed to correct stuttering,
hearing loss, peripheral speech mechanism problems, and deficits due to neurological
disease or injury. Speech and/or cognitive therapy for acute illnesses and injuries are
covered up to one year post injury when the services do not duplicate those provided by
other eligible providers, including occupational therapists or neuropsychologists. This
exclusion does not apply if medically necessary as part of a treatment plan.
Outpatient pulmonary rehabilitation programs are covered when prescribed by a physician
for patients with severe chronic lung disease that interferes with normal daily activities
despite optimal medication management.
For related provisions, see 'motion analysis', 'vocational rehabilitation', and 'speech
therapy', and 'temporomandibular joint' under 'Excluded Services — Types of Treatments'
in the Benefit Limitations and Exclusions section of this Plan Document.
• Outpatient habilitation services provided by a licensed physical therapist, occupational
therapist, speech language pathologist, physician, or other practitioner licensed to provide
physical, occupational, or speech therapy services, within the scope of the provider's
license. Services must be prescribed in writing by a licensed physician, dentist, podiatrist,
nurse practitioner, or physician assistant. The prescription must include site, modality,
duration, and frequency of treatment. Total covered expenses for outpatient habilitation
services, including vision therapy, are limited to a combined maximum of 30 visits per
calendar year subject to review for medical necessity, unless medically necessary to treat
a mental health diagnosis. Treatment of neurodevelopmental problems, and other
problems associated with pervasive developmental disorders for which habilitation
services would be appropriate are covered when criteria for individual benefits are met. Up
to 30 additional visits will be allowed for head and spinal injury, cardiovascular accident,
stroke or major injury.
• Services of a licensed audiologist for medically necessary audiological (hearing)
services.
• Services of a dentist or physician to treat injury of the jaw or natural teeth. Services
must be provided within 120 days of the injury. Except for the initial examination, services
for treatment of an injury to the jaw or natural teeth require preauthorization to be covered.
• Services of a dentist or physician for orthognathic (jaw) surgery as follows:
44 Deschutes County Plan Document_0118_Medical
— When medically necessary to repair an accidental injury. Services must be provided
within 120 days after the accident; or
— For removal of a malignancy, including reconstruction of the jaw within 120 days after
that surgery.
• Services of a board-certified or board -eligible genetic counselor when referred by a
physician or nurse practitioner for evaluation of genetic disease.
• Treatment of temporomandibular joint syndrome (TMJ) for medical reasons only. All
TMJ -related services, including but not limited to diagnostic and surgical procedures, must
be medically necessary and preauthorized. Services are covered only when medically
necessary due to a history of advanced pathologic process (arthritic degeneration) or in
the case of severe acute trauma. Benefits for the treatment of TMJ and all related services
are subject to the deductible, co -payment, and/or co-insurance stated in the Medical
Benefit Summary under `Other Covered Services– Temporomandibular Joint'. Benefits are
limited to a lifetime maximum benefit of $2,000 per person.
• Medically necessary telemedical health services for health services covered by this Plan
when provided in person by a healthcare professional.
• Services for chiropractic manipulation, acupuncture, and/or massage therapy are
covered. See your Chiropractic Manipulation, Acupuncture, and/or Massage Therapy
Benefit Summary for benefit details.
HOSPITAL AND SKILLED NURSING FACILITY SERVICES
This Plan covers medically necessary hospital inpatient services. Charges for a hospital
room are covered up to the hospital's semi -private room rate (or private room rate, if the
hospital does not offer semi -private rooms). Charges for a private room are covered if the
attending physician orders hospitalization in an intensive care unit, coronary care unit, or
private room for medically necessary isolation. Coverage includes eligible services provided
by a hospital owned or operated by the state, or any state approved mental health and
developmental disabilities program.
In addition to the hospital room, covered inpatient hospital services may include (but are not
limited to):
• Anesthesia and post -anesthesia recovery;
• Dressings, equipment, and other necessary supplies;
• Inpatient medications;
• Intensive and/or specialty care units;
• Lab services provided by a hospital;
• Operating room;
• Radiology services; or
• Respiratory care.
The Plan does not cover charges for rental of telephones, radios, or televisions, or for guest
meals or other personal items.
45 Deschutes County Plan Document_0118_Medical
Services of skilled nursing facilities and convalescent homes are covered when
preauthorized by PacificSource. Services must be medically necessary. Confinement for
custodial care is not covered. Coverage is limited to semiprivate rates.
Inpatient rehabilitation services are covered when medically necessary to restore and
improve lost body functions after illness, injury, or disease. These services must be
consistent with the condition being treated, and must be part of a formal written treatment
program prescribed by a physician and subject to preauthorization by PacificSource. Total
covered expenses for inpatient rehabilitation services are limited to a maximum of 30 days per
calendar year subject to review for medical necessity, unless medically necessary to treat a
mental health diagnosis. Recreation therapy is only covered as part of an inpatient
rehabilitation admission.
Inpatient habilitation services are covered when medically necessary to help a person
keep, restore or improve skills and functioning for daily living related to skills that have been
lost or impaired because a person was sick, injured or disabled. These services must be
consistent with the condition being treated, and must be part of a formal written treatment
program prescribed by a physician and subject to preauthorization by PacificSource. Total
covered expenses for inpatient habilitation services are limited to a maximum of 30 days per
calendar year and are subject to review for medical necessity, unless medically necessary to
treat a mental health diagnosis. Recreation therapy is only covered as part of an inpatient
rehabilitation admission.
OUTPATIENT SERVICES
'Outpatient services are medical services that take place without being admitted to the
hospital.' This Plan covers the following outpatient services:
• Advanced diagnostic imaging procedures that are medically necessary for the
diagnosis of illness, injury, or disease. For purposes of this benefit, advanced diagnostic
imaging procedures include CT scans, MRIs, PET scans, CATH labs and nuclear
cardiology studies. In all situations and settings, benefits require preauthorization and are
subject to the deductibles, co -payments, and/or co-insurance stated in your Medical
Benefit Summary for Outpatient Services — Advanced diagnostic imaging. Please note that
the co -payment for these services is 'per test'. For example, if separate MRIs are
performed on different regions of the back, there will be a co -payment charged for each
region imaged.
• Diagnostic radiology and laboratory procedures provided or ordered by a physician,
nurse practitioner, alternative care practitioner, or physician assistant. These services may
be performed or provided by laboratories, radiology facilities, hospitals, and physicians,
including services in conjunction with office visits.
• Emergency room services. The emergency room benefit stated in your Medical Benefit
Summary covers only physician and hospital facility charges in the emergency room. The
benefit does not cover further treatment provided on referral from the emergency room.
Emergency medical screening and emergency services, including any diagnostic tests
necessary for emergency care (including radiology, laboratory work, CT scans and MRIs)
are subject to the deductibles, co -payments, and/or co-insurance stated in your Medical
Benefit Summary for either 'Outpatient Services — Diagnostic and Therapeutic Radiology
and Lab' or 'Outpatient Services - Advanced Diagnostic Imaging', depending on the
specific service provided.
Non -Emergency room services received from a Non -participating provider are not
covered.
46 Deschutes County Plan Document_0118_Medical
• Surgery and other outpatient services. Benefits are based on the setting where services
are performed.
— For surgeries or outpatient services performed in a physician's office, the benefit
stated in your Medical Benefit Summary for Professional Services – Office Procedures
and Supplies applies.
For surgeries or outpatient services performed in an ambulatory surgical center or
outpatient hospital setting, both the benefits shown on your Medical Benefit Summary
for Professional Services – Surgery and the Outpatient Services - Outpatient
Surgery/Services apply.
• Therapeutic radiology services, chemotherapy, and renal dialysis provided or
ordered by a physician. Covered services include a prescribed, orally administered
anticancer medication used to kill or slow the growth of cancerous cells. Absent a
contracted allowable fee amount based on the Medicare allowable, benefits for members
who are receiving renal dialysis are limited to 125 percent of the current Medicare
allowable amount for participating and non -participating providers. In all situations and
settings, benefits are subject to the deductibles, co -payments, and/or co-insurance stated
in your Medical Benefit Summary for Outpatient Services – Dialysis.
• Other medically necessary diagnostic services provided in a hospital or outpatient
setting, including testing or observation to diagnose the extent of a medical condition.
EMERGENCY SERVICES
For emergency medical conditions (see Definitions section), this Plan covers services and
supplies necessary to evaluate and treat an emergency condition.
Examples of emergency medical conditions include (but are not limited to):
• Convulsions or seizures;
• Difficulty breathing;
• Major traumatic injuries;
• Poisoning;
• Serious burns;
• Sudden abdominal or chest pains;
• Sudden fevers;
• Suspected heart attacks;
• Unconsciousness; or
• Unusual or heavy bleeding.
If you need immediate assistance for a medical emergency, call 911. If you have an
emergency medical condition, you should go directly to the nearest emergency room or
appropriate facility. Emergency and non -emergency services may be subject to the
deductible, co -payments and/or co-insurance stated in your Medical Benefit Summary. Non -
Emergency room services from a non -participating provider are not covered.
47 Deschutes County Plan Document_0118_Medical
If you are admitted to a non -participating hospital after your emergency condition is stabilized,
the Plan Sponsor may require you to transfer to a participating facility in order to receive
benefits at the participating provider level.
MATERNITY SERVICES
Maternity means, in any one pregnancy, all prenatal services including complications and
miscarriage, delivery, postnatal services provided within six weeks of delivery, and routine
nursery care of a newborn child. Maternity services are covered subject to the deductible, co-
payments and/or co-insurance stated in your Medical Benefit Summary.
Medically necessary services, medication, and supplies to manage diabetes during pregnancy
from conception through six weeks postpartum will not be subjected to a deductible, co-
payment, or co-insurance. Diabetic medication and supplies, (including needles, syringes,
test strips, insulin, etc.) are covered under the Prescription Drug benefit.
Services of a physician or other provider practicing within the scope of their license for
pregnancy. Services are subject to the same payment amounts, conditions, and limitations
that apply to similar expenses for illness.
Please contact the PacificSource Customer Service team as soon as you learn of your
pregnancy. Their staff will explain the Plan's maternity benefits.
This Plan provides routine nursery care of a newborn while the mother is hospitalized and
eligible for pregnancy -related benefits under this Plan if the newborn is also eligible and
enrolled in this Plan.
Special Information about Childbirth — This Plan covers hospital inpatient services for
childbirth according to the Newborns' and Mothers' Health Protection Act of 1996. This Plan
does not restrict the length of stay for the mother or newborn child to less than 48 hours after
vaginal delivery, or to less than 96 hours after Cesarean section delivery. Your provider is
allowed to discharge you or your newborn sooner than that, but only if you both agree. For
childbirth, your provider does not need to preauthorize your hospital stay.
MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES
This Plan covers medically necessary crisis intervention, diagnosis, and treatment of mental
health conditions and chemical dependency the same as any other illness. Refer to the
Benefit Limitations and Exclusions section of this Plan Document for more information on
services not covered by your Plan.
Providers Eligible for Reimbursement
A mental and/or chemical healthcare provider (see Definitions section of this Plan Document)
is eligible for reimbursement if:
• The mental and/or chemical healthcare provider is authorized for reimbursement under the
laws of this Plan's state of issuance; and
• The mental and/or chemical healthcare provider is accredited for the particular level of
care for which reimbursement is being requested by The Joint Commission or the
Commission on Accreditation of Rehabilitation Facilities; and
48 Deschutes County Plan Document_0118_Medical
• The patient is staying overnight at the mental and/or chemical healthcare facility (see
Definitions section of this Plan Document) and is involved in a structured program at least
eight hours per day, five days per week; or
• The mental and/or chemical healthcare provider is providing a covered benefit under this
Plan.
Eligible mental and/or chemical healthcare providers are:
• A program licensed, approved, established, maintained, contracted with, or operated by
the accrediting and licensing authority of the state wherein the program exists;
• A Medical or Osteopathic physician licensed by the State Board of Medical Examiners;
• A Psychologist (PhD) licensed by the State Board of Psychologists' Examiners;
• A Nurse Practitioner registered by the State Board of Nursing;
• A Licensed Clinical Social Worker (LCSW) licensed by the State Board of Clinical Social
Workers;
• A Licensed Professional Counselor (LPC) licensed by the State Board of Licensed
Professional Counselors and Therapists;
• A Licensed Marriage and Family Therapist (LMFT) licensed by the State Board of
Licensed Professional Counselors and Therapists;
• A Board Certified Assistant Behavior Analyst (BCaBA) licensed by the State Board of
Behavior Analysis;
• A Board Certified Behavior Analyst (BCBA) licensed by the State Board of Behavior
Analysis;
• A Board Certified Behavior Analyst, Doctoral level (BCBA-D) licensed by the State Board
of Behavior Analysis;
• A Behavior Analyst Interventionist (BAI) licensed by the State Board of Behavior Analysis;
and
• A hospital or other healthcare facility accredited by The Joint Commission or the
Commission on Accreditation of Rehabilitation Facilities for inpatient or residential care
and treatment of mental health conditions and/or chemical dependency.
Medica/ Necessity and Appropriateness of Treatment
• As with all medical treatment, mental health and chemical dependency treatment is
subject to review for medical necessity and/or appropriateness. Review of treatment may
involve pre -service review, concurrent review of the continuation of treatment, post-
treatment review, or a combination of these. PacificSource will notify the patient and
patient's provider when a treatment review is necessary to make a determination of
medical necessity.
• A second opinion may be required for a medical necessity determination. PacificSource
will notify the patient when this requirement is applicable.
• A hospital or other healthcare facility must notify PacificSource of an emergency
admission within two business days.
49 Deschutes County Plan Document_0118_Medical
• Medication management by a licensed physician (such as a psychiatrist) does not require
review.
• Treatment of substance abuse and related disorders is subject to placement criteria
established by the 'American Society of Addiction Medicine, Third Edition (ASAM)'.
Mental Health Parity and Addiction Equity Act of 2008
This Plan complies with all state and federal laws and regulations related to the Mental Health
Parity and Addiction Equity Act of 2008.
HOME HEALTH AND HOSPICE SERVICES
• This Plan covers home health services when preauthorized by PacificSource. Covered
services include services by a licensed Home Health Agency providing skilled nursing;
physical, occupational, and speech therapy; and medical social work services. Private
duty nursing is not covered. Benefits are limited to two visits per day, and a maximum of
180 days per calendar year.
Home infusion services are covered when preauthorized. This benefit covers parenteral
nutrition, medications, and biologicals (other than immunizations) that cannot be self-
administered. Benefits are paid at the percentage stated in your Medical Benefit Summary
for home health services.
This Plan covers hospice services when preauthorized. Hospice services including
respite care are intended to meet the physical, emotional, and spiritual needs of the
patient and family during the final stages of illness and dying, while maintaining the patient
in the home setting. Services are intended to supplement the efforts of an unpaid
caregiver. Hospice benefits do not cover services of a primary caregiver such as a relative
or friend, or private duty nursing. The Plan Sponsor has set the following criteria to
determine eligibility for hospice benefits:
The member's physician must certify that the member is terminally ill with a life
expectancy of less than six months;
— The member must be living at home;
A non -salaried primary caregiver must be available and willing
care to the member on a daily basis; and
The member must not be undergoing treatment of the terminal
direct control of adverse symptoms.
Only the following hospice services are covered:
Durable medical equipment, oxygen, and medical supplies;
Home nursing visits;
Home health aides when necessary to assist in personal care;
Home infusion therapy;
Home visits by a medical social worker;
Home visits by the hospice physician;
to provide custodial
illness other than for
50 Deschutes County Plan Document_0118_Medical
— Inpatient hospice care when provided by a Medicare -certified or state -certified program
when admission to an acute care hospital would otherwise be medically necessary;
— Medically necessary physical, occupational, and speech therapy provided in the home;
— Pastoral care and bereavement services;
— Prescription medications for the relief of symptoms manifested by the terminal illness;
— Respite care provided in a nursing facility to provide relief for the primary caregiver,
subject to a maximum of five consecutive days and to a lifetime maximum benefit of 30
days. A member must be enrolled in a hospice program to be eligible for respite care
benefits.
The member retains the right to all other services provided under this Plan, including
active treatment of non -terminal illnesses, except for services of another provider that
duplicate the services of the hospice team.
DURABLE MEDICAL EQUIPMENT
• This Plan covers prosthetic and orthotic devices that are medically necessary to restore
or maintain the ability to complete activities of daily living or essential job-related activities
and that are not solely for comfort or convenience. Benefits include coverage of all
services and supplies medically necessary for the effective use of a prosthetic or orthotic
device, including formulating its design, fabrication, material and component selection,
measurements, fittings, static and dynamic alignments, and instructing the patient in the
use of the device. Benefits also include coverage for any repair or replacement of a
prosthetic or orthotic device that is determined medically necessary to restore or maintain
the ability to complete activities of daily living or essential job-related activities and that is
not solely for comfort or convenience.
• This Plan covers durable medical equipment prescribed exclusively to treat medical
conditions. Covered equipment includes crutches, wheelchairs, orthopedic braces, home
glucose meters, equipment for administering oxygen, and non -power assisted prosthetic
limbs and eyes. Durable medical equipment must be prescribed by a licensed M.D., D.O.,
N.P., P.A., D.D.S., D.M.D., or D.P.M. to be covered. This Plan does not cover equipment
commonly used for nonmedical purposes, for physical or occupational therapy, or
prescribed primarily for comfort. Please see the Benefit Limitations and Exclusions section
for information on items not covered. The following limitations apply to durable medical
equipment:
This benefit covers the cost of either purchase or rental of the equipment for the period
needed, whichever is less. Repair or replacement of equipment is also covered when
necessary, subject to all conditions and limitations of the Plan. If the cost of the
purchase, rental, repair, or replacement is over $1,000, preauthorization by
PacificSource is required.
Only expenses for durable medical equipment, or prosthetic and orthotic devices that
are provided by a PacificSource contracted provider or a provider that satisfies the
criteria of the Medicare fee schedule for Suppliers of Durable Medical Equipment,
Prosthetics, Orthotics, Supplies (DMEPOS) and Other Items and Services are eligible
for reimbursement. Mail order or Internet/Web based providers are not eligible
providers.
51 Deschutes County Plan Document_0118_Medical
Purchase, rental, repair, lease, or replacement of a power -assisted wheelchair
(including batteries and other accessories) requires preauthorization by PacificSource
and is payable only in lieu of benefits for a manual wheelchair.
The durable medical equipment benefit also covers lenses to correct a specific vision
defect resulting from a severe medical or surgical problem, such as stroke,
neurological disease, trauma, or eye surgery other than refraction procedures.
Coverage is subject to the following limitations:
o The medical or surgical problem must cause visual impairment or disability due to
loss of binocular vision or visual field defects (not merely a refractive error or
astigmatism) that requires lenses to restore some normalcy to vision.
o The maximum allowance for glasses (lenses and frames), or contact lenses in lieu
of glasses, is limited to one pair per year. Other Plan limitations, such as
exclusions for extra lenses, other hardware, tinting of lenses, eye exercises, or
vision therapy, also apply.
o Benefits for subsequent medically necessary vision corrections to either eye
(including an eye not previously treated) are limited to the cost of lenses only.
o Reimbursement is subject to the deductible, co -payment, and/or co-insurance
stated in your Medical Benefit Summary for durable medical equipment and is in
lieu of, and not in addition to any other vision benefit payable.
The durable medical equipment benefit also covers hearing aids for members 18 years
of age or younger Coverage is limited to a maximum benefit of one hearing aid per
ear, every 48 months. For members age 19 and older, the benefit is limited to one
hearing aid per ear, up to a maximum dollar amount of $2,500 every 24 months.
Medically necessary treatment for sleep apnea and other sleeping disorders is covered
when preauthorized by PacificSource. Coverage of oral devices includes charges for
consultation, fitting, adjustment, follow-up care, and the appliance. The appliance must
be prescribed by a physician specializing in evaluation and treatment of obstructive
sleep apnea, and the condition must meet criteria for obstructive sleep apnea.
Manual and electric breast pumps are covered at no cost once per pregnancy when
purchased or rented from a participating licensed provider, or purchased from a retail
outlet. Hospital -grade breast pumps are not covered.
Wigs following chemotherapy or radiation therapy are covered up to a maximum
benefit of $150 per contract year.
Diabetic Supplies, (including needles, syringes, test strips, insulin, etc.) are covered under
the Prescription Drug benefit.
TRANSPLANT SERVICES
This Plan covers certain medically necessary organ and tissue transplants. it also covers the
cost of acquiring organs or tissues needed for covered transplants and limited travel expenses
for the patient, subject to certain limitations.
All pre -transplant evaluations, services, treatments, and supplies for transplant procedures
require preauthorization.
This Plan covers the following medically necessary organ and tissue transplants:
52 Deschutes County Plan Document_0118_Medical
• Bone marrow, peripheral blood stem cell and high -dose chemotherapy when medically
necessary;
• Heart;
• Heart – Lungs;
• Kidney;
• Kidney – Pancreas;
• Liver ;
• Lungs;
• Pancreas whole organ transplantation; or
• Pediatric bowel.
This Plan only covers transplants of human body organs and tissues. Transplants of artificial,
animal, or other non -human organs and tissues are not covered.
Expenses for the acquisition of organs or tissues for transplantation are covered only when
the transplantation itself is covered under this contract, and is subject to the following
limitations:
• Testing of related or unrelated donors for a potential living related organ donation is
payable at the same percentage that would apply to the same testing of a covered
recipient.
• Expense for acquisition of cadaver organs is covered, payable at the same percentage
and subject to the same limitations, if any, as the transplant itself.
• Medical services required for the removal and transportation of organs or tissues from
living donors are covered. Coverage of the organ or tissue donation is payable at the
same percentage as the transplant itself if the recipient is a Plan member.
— If the donor is not covered by this Plan, only those complications of the donation that
occur during the initial hospitalization are covered, and such complications are covered
only to the extent that they are not covered by another health plan or government
program. Coverage is payable at the same percentage as the transplant itself.
— If the donor is a Plan member, complications of the donation are covered as any other
illness would be covered.
• Transplant related services, including human leukocyte antigen (HLA) typing, sibling tissue
typing, and evaluation costs, are considered transplant expenses and accumulate toward
any transplant benefit limitations and are subject to PacificSource's provider contractual
agreements (See Payment of Transplant Benefits, below).
Travel and housing expenses for the recipient and one caregiver are limited to $200 per day,
up to a maximum of $10,000 per transplant. If the recipient is a child, travel and housing
expenses will be covered for the recipient and both parents, limited to $200 per day, up to a
maximum of $10,000 per transplant. Travel and living expenses are not covered for the donor.
Travel and housing expenses are not covered when transplant is received from non-
participating providers.
53 Deschutes County Plan Document_0118_Medical
Payment of Transplant Benefits
If a transplant is performed at a participating Center of Excellence transplantation facility,
covered charges of the facility are subject this Plan's deductibles (co-insurance and co-
payment amounts after deductible are waived). If the contract with the facility includes the
services of the medical professionals performing the transplant (such as physicians, nurse
practitioners, and anesthesiologists), those charges are also subject this Plan's deductibles
(co-insurance and co -payment amounts after deductible are waived). If the professional fees
are not included in the contract with the facility, then those benefits are provided according to
your Medical Benefit Summary.
Transplant services that are not received at a participating Center of Excellence and/or
services of non -participating medical professionals are paid at the non -participating provider
percentages stated in your Medical Benefit Summary. The maximum benefit payment for
transplant services of non -participating providers is 125 percent of the Medicare allowance.
OTHER COVERED SERVICES, SUPPLIES, AND
TREATMENTS
• This Plan covers services of a state certified ground or air ambulance when private
transportation is medically inappropriate because the acute medical condition requires
paramedic support. Benefits are provided for emergency ambulance service and/or
transport to the nearest facility capable of treating the condition. Air ambulance service is
covered only when ground transportation is medically or physically inappropriate.
Whenever possible, you should seek services from an air ambulance service that
participates in PacificSource's network of providers. Your participating provider
deductibles and co-insurance will apply when out -of -network ground or air ambulance is
part of medically necessary emergency services. Non -emergency medically necessary
travel, other than transportation by a licensed ambulance service, to the nearest facility
qualified to treat the patient's medical condition is covered when approved in advance by
PacificSource. Non -emergency ground or air ambulance travel requires preauthorization.
• This Plan covers biofeedback to treat migraine headaches or urinary incontinence when
provided by an otherwise eligible practitioner. Benefits are limited to a lifetime maximum of
ten sessions.
• This Plan covers blood transfusions, including the cost of blood or blood plasma.
• This Plan covers removal, repair, or replacement of breast prostheses due to a
contracture or rupture, but only when the original prosthesis was for a medically necessary
mastectomy. Preauthorization is required, and eligibility for benefits is subject to the
following criteria which have been set by the Plan Sponsor:
The contracture or rupture must be clinically evident by a physician's physical
examination, imaging studies, or findings at surgery;
This Plan covers removal, repair, and/or replacement of the prosthesis; and
Removal, repair, and/or replacement of the prosthesis is not covered when
recommended due to an autoimmune disease, connective tissue disease, arthritis,
allergenic syndrome, psychiatric syndrome, fatigue, or other systemic signs or
symptoms.
54 Deschutes County Plan Document_0118_Medical
• This Plan covers breast reconstruction in connection with a medically necessary
mastectomy. Coverage is provided in a manner determined in consultation with the
attending physician and patient for:
— All stages of reconstruction of the breast on which the mastectomy was performed;
— Surgery and reconstruction of the other breast to produce a symmetrical appearance;
— Prostheses; and
— Treatment of physical complications of the mastectomy, including lymphedema.
Benefits for breast reconstruction are subject to all terms and provisions of the Plan,
including deductibles, co -payments, and/or co-insurance stated in your Medical Benefit
Summary.
• This Plan covers cardiac rehabilitation as follows:
— Phase I (inpatient) services are covered under inpatient hospital benefits;
Phase II (short-term outpatient) services are covered subject to the deductible, co-
payment, and/or co-insurance stated in your Medical Benefit Summary for Diagnostic
and therapeutic radiology and lab. Benefits are limited to services provided in
connection with a cardiac rehabilitation exercise program up to a lifetime maximum of
36 visits and are reasonable and necessary.
Phase III (long-term outpatient) services are not covered.
• This Plan covers child abuse medical assessments which includes the taking of a
thorough medical history, a complete physical examination and interview by or under the
direction of a licensed physician or other licensed health care professional trained in the
evaluation, diagnosis and treatment of child abuse. Child abuse medical assessments are
covered when performed at a community assessment center. Community assessment
center means a neutral, child -sensitive community-based facility or service provider to
which a child from the community may be referred to receive a thorough child abuse
medical assessment for the purpose of determining whether the child has been abused or
neglected.
• Cochlear implants and bilateral cochlear implants are covered when medically
necessary.
• This Plan covers IUD, diaphragm, and cervical cap contraceptives and contraceptive
devices along with their insertion or removal. Contraceptive devices that can be obtained
over the counter or without a prescription, such as condoms are not covered.
• This Plan covers corneal transplants. Preauthorization is not required.
• In the following situations, this Plan covers cosmetic or reconstructive surgery:
— When necessary to correct a functional disorder; or
— When necessary due to a congenital anomaly; or
— When necessary because of an accidental injury, or to correct a scar or defect that
resulted from treatment of an accidental injury; or
55 Deschutes County Plan Document_0118_Medical
— When necessary to correct a scar or defect on the head or neck that resulted from a
covered surgery.
Cosmetic or reconstructive surgery is provided for one attempt and must take place within
18 months after the injury, surgery, scar, or defect first occurred unless determined
otherwise through medical necessity evaluation. Preauthorization by PacificSource is
required for all cosmetic and reconstructive surgeries covered by this Plan. For information
on breast reconstruction, see 'breast prostheses' and 'breast reconstruction' in this
section.
• This Plan covers dental and orthodontic services for the treatment of craniofacial
anomalies when medically necessary to restore function. Coverage includes but is not
limited to physical disorders identifiable at birth that affect the bony structure of the face or
head, such as a cleft palate, cleft lip, craniosynostosis, craniofacial microsomia and
Treacher Collins syndrome. Coverage is limited to the least costly clinically appropriate
treatment. Cosmetic procedures and procedures to improve on the normal range of
functions are not covered. See the exclusions for cosmetic/reconstructive services, dental
examinations and treatments, jaw surgery, and orthognathic surgery under the 'Excluded
Services' section.
• This Plan provides coverage for certain diabetic equipment, supplies and training as
follows:
Medications and diabetic supplies will be payable under the separate prescription drug
benefit section under this Plan.
This Plan covers outpatient and self-management training and education for the
treatment of diabetes, subject to the deductible, co -payment and/or co-insurance for
office visits stated in the Member Benefit Summary. To be covered, the training must
be provided by a licensed health care professional with expertise in diabetes.
This Plan covers medically necessary telemedical health services provided in
connection with the treatment of diabetes.
• This Plan covers dietary or nutritional counseling provided by a registered dietitian
under certain circumstances. It is covered under the diabetic education, or for
management of anorexia nervosa or bulimia nervosa as determined by a medical
necessity evaluation.
• This Plan covers nonprescription elemental enteral formula ordered by a physician for
home use. Formula is covered when medically necessary to treat severe intestinal
malabsorption and the formula comprises a predominant or essential source of nutrition.
Coverage is subject to the deductible, co -payment, and/or co-insurance stated in your
Medical Benefit Summary for durable medical equipment.
• This Plan covers routine foot care for patients with diabetes mellitus.
• Hospitalization for dental procedures is covered when the patient has another serious
medical condition that may complicate the dental procedure, such as serious blood
disease, unstable diabetes, or severe cardiovascular disease, or the patient is physically
or developmentally disabled with a dental condition that cannot be safely and effectively
treated in a dental office. Coverage requires preauthorization, and only charges for the
facility, anesthesiologist, and assistant physician are covered. Hospitalization because of
the patient's apprehension or convenience is not covered.
56 Deschutes County Plan Document_0118_Medical
This Plan covers treatment for inborn errors of metabolism involving amino acid,
carbohydrate, and fat metabolism for which widely accepted standards of care exist for
diagnosis, treatment, and monitoring, including quantification of metabolites in blood, urine
or spinal fluid or enzyme or DNA confirmation in tissues. Coverage includes expenses for
diagnosing, monitoring and controlling the disorders by nutritional and medical
assessment, including but not limited to clinical visits, biochemical analysis and medical
foods used in the treatment of such disorders. Nutritional supplies are covered subject to
the deductible, co -payment, and/or co-insurance stated in your Medical Benefit Summary
for durable medical equipment.
• Injectable drugs and biologicals administered by a physician are covered when
medically necessary for diagnosis or treatment of illness, injury, or disease. This benefit
does not include immunizations (See Preventive Care Services in this section) or drugs or
biologicals that can be self-administered or are dispensed to a patient.
This Plan covers maxillofacial prosthetic services when prescribed by a physician as
necessary to restore and manage head and facial structures. Coverage is provided only
when head and facial structures cannot be replaced with living tissue, and are defective
because of disease, trauma, or birth and developmental deformities. To be covered,
treatment must be necessary to control or eliminate pain or infection or to restore functions
such as speech, swallowing, or chewing. Coverage is limited to the least costly clinically
appropriate treatment, as determined by the physician. Cosmetic procedures and
procedures to improve on the normal range of functions are not covered. Dentures,
prosthetic devices for treatment of TMJ conditions and artificial larynx are also not
covered.
• For pediatric dental care requiring general anesthesia, this Plan covers the facility
charges of a hospital or ambulatory surgery center. Benefits are limited to one visit
annually and are subject to preauthorization by PacificSource.
• Post -mastectomy care is covered for hospital inpatient care for a period of time as
determined by the attending physician and, in consultation with the patient determined to
be medically necessary following a mastectomy, a lumpectomy, or a lymph node
dissection for the treatment of breast cancer.
• The routine costs of care associated with approved clinical trials are covered. For
more information, see 'routine costs of care' in the Definitions section of this Plan
Document. A 'qualified individual' is someone who is eligible to participate in an 'approved
clinical trial'. If a participating provider is participating in an approved clinical trial, the
qualified individual may be required to participate in the trial through that participating
provider if the provider will accept the individual as a participant in the trial.
Sleep studies are covered when ordered by a pulmonologist, neurologist,
otolaryngologist, internist, family practitioner, or certified sleep medicine specialist.
This Plan covers medically necessary therapy and services for the treatment of traumatic
brain injury.
This Plan covers tubal ligation and vasectomy procedures.
Obesity services (interventions) are covered when Plan Sponsor criteria is met.
Covered services include physician -directed intensive, multicomponent behavioral
interventions for weight management for covered members age 18 and older with a body
mass index (BMI) of 30 kg/m2 or higher. This benefit is limited to 26 visits per calendar
year. This benefit does not include surgery or other related services.
57 Deschutes County Plan Document_0118_Medical
• Routine vision examinations are covered for enrolled members age 19 and older on this
Plan. Benefits are subject to the deductibles, limitations, co -payment, and/or co-insurance
stated in your Vision Benefit Summary details.
• Vision hardware including lenses, frames and contact lenses are covered for enrolled
members age 19 and older. Benefits are subject to the deductible, limitations, co -payment,
and/or co-insurance stated in your Vision Benefit Summary for details.
• Electronic Beam Tomography (EBT) is a covered benefit.
• This Plan covers the medically necessary removal of benign skin lesions, such as but not
limited to, skin tags, benign seborrheic keratosis, sebaceous cysts, and vial warts.
• This Plan covers Weight Watchers benefits up to an annual maximum of $100 per
calendar year.
You must be enrolled in this Plan at the time of your first and last meeting to qualify for
reimbursement. You must complete a minimum of ten weeks during a consecutive four
month period during the contract year. Participation verification is required. To be eligible
for reimbursement, the 'Weight Watchers Reimbursement Request Form' must be
submitted within two months of the last Weight Watchers class attended. If you have
questions, please contact PacificSource's Customer Service team at (888) 249-1370 or
email cs@pacificsource.com.
COMMUNITY WELLNESS BENEFITS
This Plan covers Community Wellness Benefits when provided by a hospital that is a
preferred provider, up to an annual maximum of $150. Wellness topics usually include matters
such as maternity fitness and education, newborn care and parenting skills, nutrition and
healthy heart exercises or CPR skills.
Covered services include wellness -related classes; and printed materials required for the
class.
After you have completed the class, please provide PacificSource with proof of payment and a
completed Community Wellness Reimbursement Form for PacificSource to review for benefit
payment consideration based on the Plan Sponsor's criteria. You may obtain the Community
Wellness Reimbursement Form from the Plan Sponsor, or PacificSource's Customer Service
team.
PRESCRIPTION DRUG BENEFITS
This Plan includes prescription drug benefits through Northwest Pharmacy Services
Participating Pharmacies and the WellPartner Mail -Order Program.
This Plan will not exclude coverage of a particular drug for a particular indication based solely
on the grounds that the indication has not been approved by the FDA. Coverage for such
drug(s) is available if the State of Oregon Health Resources Commission has determined that
the drug is recognized as effective for the treatment of that indication in publications that the
Commission determines to be the equivalent to:
1. The American Hospital Formulary Services drug information;
2. "Drug Facts and Comparisons" (Lippincott -Raven Publishers);
3. The United States Pharmacopoeia drug information;
58 Deschutes County Plan Document_0118_Medical
4. Other publications that have been identified by the United States Secretary of Health
and Human Services as authoritative;
5. In the majority of the relevant peer-reviewed medical literature; or
6. By the United States Secretary of Health and Human Services.
Coverage of prescription drugs shall include coverage for medically necessary services
associated with the administration of that drug.
Nothing in this section requires coverage for any prescription drug if the United States Food
and Drug Administration has determined use of the drug to be contraindicated.
Nothing in this section requires coverage for experimental drugs not approved for any
indication by the United States Food and Drug Administration, except covered charges as
related to the Plan's clinical trials benefit.
CONTACT INFORMATION
Northwest Pharmacy Services
(800) 998-2611
www.nwpsrx.com
WellPartner Inc., Mail -Order Program
(877)935-5797
www.welloartner.com
WHERE TO SUBMIT PHARMACY CLAIMS
Northwest Pharmacy Services is the Retail Claims Administrator. Claims for retail pharmacy
expenses should be submitted to the Retail Claims Administrator at the address below:
Northwest Pharmacy Services
929 East Main Street, Suite 310
Puyallup, WA 98372-3124
WellPartner, Inc., is the Mail -Order Claims Administrator. Claims for mail-order pharmacy
expenses should be submitted to the Mail -Order Claims Administrator at the address below:
WellPartner, Inc.
Customer Service
P.O. Box 5909
Portland OR 97228-5909
GENERIC SUBSTITUION
Over 400 commonly prescribed drug products are now available in a generic form at an
average cost of 50% less than the brand name 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 brand name drugs. Since brand name drugs are often
two to three times more expensive than generic drugs, use of generics with this benefit will
59 Deschutes County Plan Document_0118_Medical
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 brand name drug though
the WellPartner Mail -Order Program, the covered person will be required to pay both the
copayment, plus the difference in cost between the generic and the brand name drug. If a
generic drug is prescribed but the covered person purchases a brand name drug through a
Northwest Pharmacy Services pharmacy, the covered person will be required to pay a higher
co -payment.
STEP THERAPY
Step therapy requires the covered person to try two "first step" medications first before moving
to a "second step" medication.
What happens when a medication is medically necessary but is part of a step therapy
protocol? If it is medically necessary to the covered person to receive a "second step"
medication before any "first step" medications have been tried, the covered person's physician
may contact Northwest Pharmacy Services toll-free at 1 (800) 998-2611 to request coverage
of the medication as a medical exception.
PAYMENT SCHEDULE
The covered person must pay a copayment for each prescription filled, as shown in the
Prescription Drug Benefit Summary.
PRESCRIPTIONS PURCHASED WITHOUT THE NORTHWEST
PHARMACY SERVICES BENEFIT
If a prescription is purchased at a Northwest Pharmacy Services Participating Pharmacy but
the participant does not utilize his or her Northwest Pharmacy Services benefit at the time of
the prescription purchase, or if a prescription is purchased at a non -participating pharmacy,
the member must file a claim with Northwest Pharmacy Services using their claim form; a 50%
copayment will be taken.
MAIL-ORDER INFORMATION
For an existing prescription, provide WellPartner Inc., with the information requested on the
initial order form and a WellPartner pharmacist will transfer the existing prescription to the
WellPartner Inc., Mail -Order Pharmacy. The physician can also telephone in refill
prescriptions to save time. Refills can be ordered over the telephone with a credit card by
calling (877) 935-5797. They physician can also telephone or fax new prescriptions to
WellPartner if the participant has previously provided credit card payment information.
WellPartner Inc., 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:OOpm,
Pacific Time, at (877) 935-5997.
WellPartner Inc., 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.
60 Deschutes County Plan Document_0118_Medical
SUMMARY
In order to best use the prescription benefits, continue to have non -maintenance prescriptions
(prescribed for an urgent illness or injury) filled at a Northwest Pharmacy Services
participating pharmacy. When ordering maintenance medications (those taken on a regular or
Tong -term basis such as heart, allergy, diabetes or blood pressure medications), it may be
more cost effective to use the WellPartner Mail -Order Program. The covered person should
call both their local retail pharmacist and WellPartner to verify which copayment will be Tess for
medications, since mail-order benefits are applied differently than retail pharmacy benefits.
COVERED PRESCRIPTION DRUGS
1. Legend drugs, (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
Note: Diabetic medications, including insulin, and other diabetic supplies (and when
prescribed by a physician) in connection with diabetes management for covered
pregnant women will be payable subject to first dollar coverage (i.e., no deductible or
copayment will apply) as shown in the Prescription Drug Benefit Summary.
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. Hematinics (iron preparations) requiring a physician's prescriptions.
13. Anabolic steroids.
14. Psychotherapeutic drugs.
15. Alcoholism and chemical dependency medications.
16. AIDS treatments.
17. Immunosuppressant agents.
18. Chemotherapy agents.
19. Laxatives requiring a physician's prescription.
61 Deschutes County Plan Document_0118_Medical
20. Compound medications which include at least one legend drug.
21. Syringes and needles.
22. Orally administered anti-cancer medications.
The following will be covered at 100%, no copayment required:
1. Physician -prescribed tobacco cessation products or medications. Limited to a 168 -day
supply per calendar year of nicotine replacement products (such as nicotine patch,
gum, lozenges) and a 168 -day supply per calendar year of physician -prescribed
medications (such as Zyban and Chantix).
2. Physician -prescribed contraceptive methods (Food and Drug Administration (FDA)
approved) including but not limited to oral contraceptive medications, transdermals,
devices (diaphragms, cervical caps), vaginal contraceptives, and injectables. This also
includes physician -prescribed over-the-counter (OTC) contraceptives (such as female
condoms, spermicides, and sponges); for all female covered persons with reproductive
capacity.
Refer to the medical benefits regarding additional coverage for intrauterine devices
(IUD), and implantables.
3. Additional physician -prescribed medications as recommended by the U.S. Preventive
Services Task Force (USPSTF) grades A and B recommendations will be covered at
100%, no prescription copayment, coinsurance or deductible will be required, and will
only be available when utilizing a participating pharmacy.
Please note, the USPSTF grades A and B recommendations are subject to change as
new medications become available and other recommendations change. Coverage of
new recommended mediations will be available following the one (1) year anniversary
date of the adoption of the USPSTF grade A and B recommendation.
Refer to the following link for more information regarding USPSTF grade A and B
recommendations or contact Northwest Pharmacy Services for more information
regarding which medications are available. Note: Age and/or quantity limitations may
apply.
http://www. uspreventiveservicestaskforce.orq/Pape/Name/uspstf-a-and-b-
recommendations
LIMITS TO THE PRESCRIPTION DRUG BENEFIT
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 up to a 100 -day
supply for prescriptions purchased through the Mail -Order Program.
Expenses Not Covered
1. No prescription. A drug or medicine that can legally be bought without a prescription.
This does not apply to insulin or to over-the-counter drugs prescribed by a physician
and as specifically stated as a covered benefit of this Plan.
2. Anorexiants.
3. Fertility drugs.
62 Deschutes County Plan Document_0118_Medical
4. Cosmetic indications.
5. Viagra and other medications for impotence.
6. Ostomy supplies.
7. Drugs with no proven therapeutic indication.
8. Administration or injection of drugs.
9. Immunization agents, biological sera, blood, or blood plasma.
10. Vitamins and fluoride (except those which by law require a prescription order).
11. Drugs prescribed for weight loss or treatment of obesity (including, but not limited to
amphetamines).
12. Drugs dispensed in a facility (drugs dispensed to the member while a patient in a
hospital, skilled nursing facility, nursing home, or other health care institution).
13. Medical exclusions. A charge associated with treatment or services excluded by this
Plan.
BENEFIT LIMITATIONS AND EXCLUSIONS
EXCLUDED SERVICES
Types of Treatment — This Plan does not cover the following:
• Abdominoplasty for any indication.
• Abortion — services, supplies, care or treatment in connection with an abortion unless the
life of the mother is endangered by the continued pregnancy or the pregnancy is the result
of rape or incest.
• Academic skills training. This exclusion does not apply if the program, training, or therapy
is part of a treatment plan for pervasive developmental disorder.
• Any amounts in excess of the allowable fee for a given service or supply.
• Aversion therapy.
• Benefits not stated — Services and supplies not specifically described as benefits under
the Plan and/or any endorsement attached hereto,
• Biofeedback (other than as specifically noted under the Covered Expenses — Other
covered Services, Supplies, and Treatment section).
• Charges for phone consultations, missed appointments, get acquainted visits, completion
of claim forms, or reports PacificSource needs to process claims unless otherwise
contracted.
• Charges over the usual, customary, and reasonable fee (UCR) — Any amount in excess of
the UCR for a given service or supply.
63 Deschutes County Plan Document_0118_Medical
• Charges that are the responsibility of a third party who may have caused the illness, injury,
or disease or other insurers covering the incident (such as workers' compensation
insurers, automobile insurers, and general liability insurers).
• Chelation therapy including associated infusions of vitamins and/or minerals, except as
medically necessary for the treatment of selected medical conditions and medically
significant heavy metal toxicities.
• Computer or electronic equipment for monitoring asthmatic, or similar medical conditions
or related data.
• Cosmetic/reconstructive services and supplies — (Except as specified in the Covered
Expenses — Other Covered Services, Supplies, and Treatments section.) Services and
supplies, including drugs, rendered primarily for cosmetic/reconstructive purposes (does
not apply to emergency services). Cosmetic/reconstructive services and supplies are
those performed primarily to improve the body's appearance and not primarily to restore
impaired function of the body, unless the area needing treatment is a result of congenital
anomaly or gender dysphoria.
• Court-ordered sex offender treatment programs.
• Day care or custodial care — Care and related services designed essentially to assist a
person in maintaining activities of daily living, e.g. services to assist with walking, getting
in/out of bed, bathing, dressing, feeding, preparation of meals, homemaker services,
special diets, rest crews, day care, and diapers. (This does not include rehabilitative or
habilitative services that are covered under the 'Professional Services' section.) Custodial
care is only covered in conjunction with respite care allowed under this Plan's hospice
benefit. For related provisions, see 'Hospital and Skilled Nursing Facility Services' and
'Home Health and Hospice Services' in the Covered Expenses section of this Plan
Document.
• Dental examinations and treatment — For the purpose of this exclusion, the term 'dental
examinations and treatment' means services or supplies provided to prevent, diagnose, or
treat diseases of the teeth and supporting tissues or structures. This includes services,
supplies, hospitalization, anesthesia, dental braces or appliances, or dental care rendered
to repair defects that have developed because of tooth loss, or to restore the ability to
chew, or dental treatment necessitated by disease. For related provisions, see
'hospitalization for dental procedures' under 'Other Covered Services, Supplies, and
Treatments' in the Covered Expenses section of this Plan Document.
• Drugs and biologicals that can be self-administered (including injectables) are excluded
from the medical benefit, except those provided in a hospital emergency room, or other
institutional setting, or as outpatient chemotherapy and dialysis, which are covered.
Covered drugs and biologicals that can be self-administered are otherwise available under
the pharmacy benefit, subject to the Plan requirements.
• Drugs or medications not prescribed for inborn errors of metabolism, diabetic insulin, or
autism spectrum disorder that can be self-administered (including prescription drugs,
injectable drugs, and biologicals), unless given during a visit for outpatient chemotherapy
or dialysis or during a medically necessary hospital, emergency room or other institutional
stay.
• Durable medical equipment available over the counter and/or without a prescription.
• Educational or correctional services or sheltered living provided by a school or halfway
house, except outpatient services received while temporarily living in a shelter.
64 Deschutes County Plan Document_0118_Medical
• Equine/animal therapy.
• Equipment commonly used for nonmedical purposes or marketed to the general public.
• Equipment used primarily in athletic or recreational activities. This includes exercise
equipment for stretching, conditioning, strengthening, or relief of musculoskeletal
problems.
• Experimental or investigational procedures — This Plan does not cover experimental or
investigational treatment. This means services, supplies, protocols, procedures, devices,
chemotherapy, drugs or medicines or the use thereof that are experimental or
investigational for the diagnosis and treatment of the patient. It includes treatment that,
when and for the purpose rendered: has not yet received full U.S. government agency
approval (e.g. FDA) for other than experimental, investigational, or clinical testing; is not of
generally accepted medical practice in this Plan's state of issuance or as determined by
medical advisors, medical associations, and/or technology resources; is not approved for
reimbursement by the Centers for Medicare and Medicaid Services; is furnished in
connection with medical or other research; or is considered by any governmental agency
or subdivision to be experimental or investigational, not reasonable and necessary, or any
similar finding.
An experimental or investigational service is not made eligible for benefits by the fact that
other treatment is considered by your healthcare provider to be ineffective or not as
effective as the service or that the service is prescribed as the most likely to prolong life.
When making benefit determinations about whether treatments are investigational or
experimental, this Plan relies on the above resources as well as: expert opinions of
specialists and other medical authorities; published articles in peer-reviewed medical
literature; external agencies whose role is the evaluation of new technologies and drugs;
and external review by an independent review organization. The Plan Sponsor retains
sole and complete authority to determine what services are covered under the terms of
this Plan.
The following will be considered in making the determination whether the service is in an
experimental and/or investigational status: whether there is sufficient evidence to permit
conclusions concerning the effect of the services on health outcomes; whether the
scientific evidence demonstrates that the services improve health outcomes as much or
more than established alternatives; whether the scientific evidence demonstrates that the
services' beneficial effects outweigh any harmful effects; and whether any improved health
outcomes from the services are attainable outside an investigational setting.
If you or your provider have any concerns about whether a course of treatment will be
covered, we encourage you to contact PacificSource's Customer Service Team. They will
arrange for medical review of your case against the criteria established by the Plan
Sponsor, and notify you of whether or not the proposed treatment will be covered.
Eye exercises and eye refraction - therapy, and procedures — Orthoptics, vision therapy,
and procedures intended to correct refractive errors.
Family planning — Services and supplies for artificial insemination, in vitro fertilization,
treatment of infertility, surgery to reverse voluntary sterilization.
Infertility includes— Services and supplies, surgery, treatment, or prescriptions, except
for medically necessary medication to preserve fertility during treatment with cytotoxic
chemotherapy.
65 Deschutes County Plan Document_0118_Medical
• Fitness or exercise programs and health or fitness club memberships.
• Food dependencies.
• Foot care (routine) — Services and supplies for corns and calluses of the feet, conditions of
the toenails other than infection, hypertrophy or hyperplasia of the skin of the feet, and
other routine foot care, except in the case of patients being treated for diabetes mellitus.
• Growth hormone injections or treatments, except to treat documented growth hormone
deficiencies.
• Hearing Aids for individuals 26 and over, including the fitting, provision or replacement of
hearing aids. Individuals age 19 to 25 must be enrolled in a secondary school or an
accredited education institution. This exclusion does not apply to cochlear implants.
• Homeopathic medicines or homeopathic supplies.
• Hypnotherapy.
• Immunizations when recommended for or in anticipation of exposure through travel or
work.
• Instructional or educational programs, except diabetes self-management programs unless
medically necessary.
• Jaw — Services or supplies for developmental or degenerative abnormalities of the jaw,
malocclusion, dental implants, or improving placement of dentures.
• Maintenance supplies and equipment not unique to medical care.
• Marital/partner counseling.
• Maternity charges incurred by a covered person acting as a Surrogate Mother are not
covered charges. For the purpose of this Plan, the newborn of a Surrogate Mother will not
be considered an eligible dependent if the Surrogate Mother has entered into a contract or
other understanding to which they relinquish the newborn to intended parents following the
birth.
• Mattresses and mattress pads are only covered when medically necessary to heal
pressure sores.
• Mental health treatments for conditions defined in the `Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM -5)', that are not attributable to a mental health
disorder or disease.
Mental illness does not include —relationship problems (for example, parent-child, partner,
sibling, or other relationship issues), except the treatment of children five years of age or
younger for parent-child relational problems, physical abuse of a child, sexual abuse,
neglect of a child, or bereavement.
The following are also excluded: court -mandated psychological evaluations for child
custody determinations; voluntary mutual support groups such as Alcoholics Anonymous;
adolescent wilderness treatment programs; mental examinations for the purpose of
adjudication of legal rights; psychological testing and evaluations not provided as an
adjunct to treatment or diagnosis of a stress management, parenting skills, or family
education; and assertiveness training.
66 Deschutes County Plan Document_0118_Medical
• Modifications to vehicles or structures to prevent, treat, or accommodate a medical
condition.
• Motion analysis, including videotaping and 3-D kinematics, dynamic surface and fine wire
electromyography, including physician review.
Myeloablative high dose chemotherapy, except when the related transplant is specifically
covered under the transplantation provisions of this Plan. For related provisions, see
`Transplant Services' in the Covered Expenses section of this Plan Document.
• Narcosynthesis.
• Naturopathic supplies.
• Nicotine related disorders, other than those covered through tobacco cessation program
services.
• Obesity or weight reduction control — Surgery or other related services or supplies
provided for weight reduction control or obesity (including all categories of obesity),
whether or not there are other medical conditions related to or caused by obesity. Obesity
screening and counseling are covered for children and adults; see the `obesity services
(interventions)' section under 'Other Covered Services'.
• Oral/facial motor therapy for strengthening and coordination of speech -producing
musculature and structures.
• Orthognathic surgery — Services and supplies to augment or reduce the upper or lower
jaw, except as specified under 'Professional Services' in the Covered Expenses section of
this Plan Document. For related provisions, see exclusions for `jaw' in this section.
• Orthopedic shoes, diabetic shoes and shoe modifications.
• Osteopathic manipulation, except for treatment of disorders of the musculoskeletal
system.
• Over-the-counter medications or nonprescription drugs. Does not apply to tobacco
cessation medications covered under USPSTF guidelines, which are covered under the
Prescription Drug benefit.
• Panniculectomy for any indication.
• Personal items such as telephones, televisions, and guest meals during a stay at a
hospital or other inpatient facility.
• Physical or eye examinations required for administrative purposes such as participation in
athletics, admission to school, or by an employer.
• Private nursing service.
• Programs that teach a person to use medical equipment, care for family members, or self-
administer drugs or nutrition (except for diabetic education benefit).
• Psychoanalysis or psychotherapy received as part of an educational or training program,
regardless of diagnosis or symptoms that may be present.
• Recreation therapy — Outpatient.
67 Deschutes County Plan Document_0118_Medical
• Rehabilitation — Functional capacity evaluations, work hardening programs, vocational
rehabilitation, community reintegration services, and driving evaluations and training
programs.
• Replacement costs for worn or damaged durable medical equipment that would otherwise
be replaceable without charge under warranty or other agreement.
• Scheduled and/or non -emergent medical care outside of the United States, unless, unless
specified in the Covered Expenses — Other Covered Services, Supplies, and Treatments
section for this Plan Document.
Screening tests — Services and supplies, including imaging and screening exams
performed for the sole purpose of screening and not associated with specific diagnoses
and/or signs and symptoms of disease or of abnormalities on prior testing (including but
not limited to total body CT imaging, CT colonography and bone density testing).This does
not include preventive care screenings listed under `Preventive Care Services' in the
Covered Expenses section of this Plan Document.
• Self-help or training programs.
• Sensory integration training. This exclusion does not apply if the program, training, or
therapy is part of a treatment plan for a pervasive developmental disorder.
• Services of providers who are not eligible for reimbursement under this Plan. An individual
organization, facility, or program is not eligible for reimbursement for services or supplies,
regardless of whether this Plan includes benefits for such services or supplies, unless the
individual, organization, facility, or program is licensed by the state in which services are
provided as an independent practitioner, hospital, ambulatory surgical center, skilled
nursing facility, durable medical equipment supplier, or mental and/or chemical healthcare
facility. To the extent PacificSource maintains credentialing requirements the practitioner
or facility must satisfy those requirements in order to be considered an eligible provider.
• Services or supplies provided by or payable under any plan or program established by a
domestic or foreign government or political subdivision, unless such exclusion is prohibited
by law.
• Services or supplies with no charge, or for which your employer or the Plan Sponsor has
paid for, or for which the member is not legally required to pay, or for which a provider or
facility is not licensed to provide even though the service or supply may otherwise be
eligible. This exclusion includes any services provided by the member, or by any licensed
medical professional that is directly related to the member by blood or marriage.
• Services required by state law as a condition of maintaining a valid driver license or
commercial driver license.
• Services, supplies, and equipment not involved in diagnosis or treatment but provided
primarily for the comfort, convenience, intended to alter the physical environment, or
education of a patient. This includes appliances like adjustable power beds sold as
furniture, air conditioners, air purifiers, room humidifiers, heating and cooling pads, home
blood pressure monitoring equipment, light boxes, conveyances other than conventional
wheelchairs, whirlpool baths, spas, saunas, heat lamps, tanning lights, and pillows.
• Sex reassignment — Procedures, services or supplies related to a sex reassignment
unless medically necessary to treat a mental health diagnosis.
68 Deschutes County Plan Document_0118_Medical
Sexual disorders – Services or supplies for the treatment of erectile or sexual dysfunction
unless defined in the 'Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'
(DSM -5).
Snoring – Services or supplies for the diagnosis or treatment of snoring and/or upper
airway resistance disorders, including somnoplasty, unless medically necessary to treat a
mental health diagnosis.
• Social skill training. This exclusion does not apply if the program, training, or therapy is
part of a treatment plan for a pervasive developmental disorder.
• Speech therapy – Oral/facial motor therapy for strengthening and coordination of speech -
producing muscles and structures, except as medically necessary in the restoration or
improvement of speech following a traumatic brain injury or for members diagnosed with a
pervasive developmental disorder.
• Sterilization of dependent children.
• Support groups.
• Training or self-help health or instruction.
• Transplants – Any services, treatments, or supplies for the transplantation of bone marrow
or peripheral blood stem cells or any human body organ or tissue, except as expressly
provided under the provisions of this Plan for covered transplantation expenses. For
related provisions see 'Transplant Services' in the Covered Expenses section of this Plan
Document.
• Treatment after coverage ends – Services or supplies a member receives after the
member's coverage under this Plan ends, except as follows:
— If this Plan is replaced by another health plan while the member is hospitalized, this
Plan will continue paying covered hospital expenses until the member is released or
benefits are exhausted, whichever occurs first.
• Treatment not medically necessary – Services or supplies that are not medically
necessary for the diagnosis or treatment of an illness, injury, or disease. For related
provisions, see 'medically necessary' in the Definitions section and 'Understanding
Medical Necessity' in the Covered Expenses section of this Plan Document.
• Treatment of any illness, injury, or disease resulting from an illegal occupation or
attempted felony, or treatment received while in the custody of any law enforcement other
than with the local supervisory authority while pending disposition of charges.
• Treatment of any work-related illness, injury, or disease, except in the following
circumstances:
You are the owner, partner, or principal of the Plan Sponsor, were injured in the course
of employment, and are otherwise exempt from the applicable state or federal workers'
compensation insurance program;
— The appropriate state or federal worker's compensation insurance program has
determined that coverage is not available for your injury. This exclusion includes any
illness, injury, or disease that is caused by any for-profit activity, whether through
employment or self-employment; or
69 Deschutes County Plan Document_0118_Medical
— If your employer is based in Oregon and a timely application for coverage has been
filed with the State Accident Insurance Fund or other Worker's Compensation Carrier
and you are waiting for a determination of coverage from that entity.
This Plan exception will also be waived for self-employed spouses or domestic partners.
Treatment prior to enrollment – Services or supplies a member received prior to enrolling
in coverage provided by this Plan, such as inpatient stays or admission to a hospital,
skilled nursing facility or specialized facility that began before the patient's coverage under
this Plan.
Unwilling to release information – Charges for services or supplies for which a member is
unwilling to release medical or eligibility information necessary to determine the benefits
payable under this Plan.
• Vocational rehabilitation, functional capacity evaluations, work hardening programs,
community reintegration services, and driving evaluations and training programs, except
as medically necessary in the restoration or improvement of speech following a traumatic
brain injury or for members diagnosed with a pervasive development disorder.
• War -related conditions – The treatment of any condition caused by or arising out of an act
of war, armed invasion, or aggression, or while in the service of the armed forces unless
not covered by the member's military or veteran's coverage.
PREAUTHORIZATION
Coverage of certain medical services and surgical procedures requires a benefit determination
before the services are performed. This process is called `preauthorization'. PacificSource will
utilize the criteria adopted by the Plan Sponsor and, where necessary, will coordinate review
with the Plan Sponsor, to render a determination based on the Plan.
Preauthorization is necessary to determine if certain services and supplies are covered under
this Plan, and if you meet the Plan's eligibility requirements.
Your medical provider can request preauthorization by making the request to the
PacificSource Health Services team. If your provider will not request preauthorization for you,
you may contact PacificSource yourself. In some cases, they may ask for more information or
require a second opinion before the Plan will authorize coverage.
Because of the changing nature of medicine, PacificSource continually reviews new
technologies and standards of medical practice. The list of procedures and services requiring
preauthorization is therefore subject to revision and update. The list is not intended to
suggest that all the items included are necessarily covered by the benefits of this Plan,
You'll find the most current preauthorization list on the PacificSource website,
Pacificsource.com/member/areauthorization.asox
When services are received from your participating provider, the provider is responsible for
contacting PacificSource to obtain preauthorization.
If your treatment is not preauthorized, you can still seek treatment, but you will be held
responsible for the expense if it is not medically necessary or is not covered by this Plan.
Remember, any time you are unsure if an expense will be covered, contact the PacificSource
Customer Service team.
70 Deschutes County Plan Document_0118_Medical
Notification of the Plan's benefit determination will be communicated by letter, fax, or
electronic transmission to the hospital, the provider, and you. If time is a factor, notification will
be made by telephone and followed up in writing.
PacificSource reserves the right to employ a third party to perform preauthorization
procedures on its behalf.
In a medical emergency, services and supplies necessary to determine the nature and extent
of the emergency condition and to stabilize the patient are covered without preauthorization
requirements. PacificSource must be notified of an emergency admission to a hospital or
specialized treatment center as an inpatient within two business days.
If your provider's preauthorization request is denied as not medically necessary or as
experimental, your provider may appeal our benefit determination. You retain the right to
appeal our benefit determination independent from your provider.
CASE MANAGEMENT
Case management is a service provided by Registered Nurses who are Certified Case
Managers and Licensed Behavioral Health Clinicians with specialized skills to respond to the
complexity of a member's healthcare needs. Case management services may be initiated by
PacificSource when there is a high utilization of health services or multiple providers, or for
health problems such as, but not limited to, transplantation, high risk obstetric or neonatal
care, open heart surgery, neuromuscular disease, spinal cord injury, or any acute or chronic
condition that may necessitate specialized treatment or care coordination. When case
management services are implemented, the Case Manager will work in collaboration with the
patient's provider, PacificSource Medical Director and, where necessary, the Plan Sponsor, to
enhance the quality of care and maximize available benefits of this Plan. A case manager may
authorize benefits for supplemental services not otherwise covered by this Plan. (See
Individual Benefits Management in this section.)
PacificSource reserves the right to employ a third party to assist with, or perform the function
of, case management.
INDIVIDUAL BENEFITS MANAGEMENT
Individual benefits management addresses, as an alternative to providing covered services,
PacificSource's consideration of economically justified alternative benefits. The decision to
allow alternative benefits will be made by on a case-by-case basis. The determination to cover
and pay for alternative benefits for a member shall not be deemed to waive, alter or affect the
Plan Sponsor's or PacificSource's right to reject any other or subsequent request or
recommendation. The Plan Sponsor may provide alternative benefits if PacificSource and the
member's attending provider concur in the request for and in the advisability of alternative
benefits in lieu of specified covered services, and, in addition, PacificSource concludes that
substantial future expenditures for covered services for the member could be significantly
diminished by providing such alternative benefits under the individual benefit management
program (See Case Management above).
UTILIZATION REVIEW
PacificSource has a utilization review program based on the criteria adopted by the Plan
Sponsor to determine coverage of hospital admissions. This program is administered by their
Health Services team. All hospital admissions are reviewed by PacificSource Case Managers,
who are all Registered Nurses or Licensed Behavioral Health Clinicians. Questions regarding
71 Deschutes County Plan Document_0118_Medical
medical necessity, possible experimental or investigational services, appropriate setting, and
appropriate treatment are forwarded to the PacificSource Medical Director for review and
benefit determination based on the criteria established by the Plan Sponsor.
PacificSource reserves the right to delegate a third party to assist with or perform the function
of utilization management.
Authorization of Hospital Admissions
When a Plan member is admitted to a hospital within the area covered by PacificSource's
provider networks (see the Using the Provider Network — Coverage While Traveling section),
the hospital calls PacificSource to verify the patient's eligibility and benefits. The hospital gives
PacificSource information about the patient's diagnosis, procedure, and attending physician
and they use this information to evaluate how long each patient is expected to remain
hospitalized.
This is called the `target length of stay.' PacificSource will use the target length of stay to
monitor the patient's progress and plan for any necessary follow-up care after the patient is
discharged.
The PacificSource Health Services team assigns the target length of stay based on the
patient's diagnosis and/or procedure, and any other criteria adopted by the Plan Sponsor. For
standard hospitalizations, they use written procedures that were developed based on the
following guidelines:
• American Society of Addition Medicine, Third Editions (ASAM);
• MCGTM;
• MCGTM Goal Length of Stay (GLOS)';
• Standard of practice in the State where the Plan was issued; and
• Any additional criteria adopted by the Plan Sponsor.
If they are unable to assign a target length of stay based on those guidelines, their Case
Manager contacts the hospital for more specific information about the case. They will then use
that information to assign a target length of stay for the patient.
Extension of Hospital Stays
if a patient's hospital stay extends beyond the targeted length of stay, a Case Manager
contacts the hospital to obtain current information about the patient's medical progress and
assign a new target length of stay or begin planning for the patient's discharge. The
PacificSource Medical Director may review the case to determine if extended hospitalization
meets coverage criteria as defined in the previous section.
Occasionally, patients choose to extend their hospital stay beyond the length the attending
physician considers medically necessary. Charges for hospital days and services beyond
those determined to be medically necessary are the member's responsibility.
Timeliness for Responding to Coverage Request
When PacificSource receives a request for coverage of an admission or extension of a
hospital stay, they are generally able to provide an answer that same day. If they do not have
enough information to make a benefit determination based on criteria, they may request
72 Deschutes County Plan Document_0118_Medical
further information, coordinate with the Plan Sponsor as necessary, and attempt to provide a
determination on the day they receive that information. If a member is discharged before they
receive the information we need, the case is reviewed retrospectively by the Case Manager
and the Medical Director for a determination regarding coverage.
Questions About Specific Utilization Review Decisions
If you would like information on how PacificSource reached a particular utilization review
benefit determination, please contact PacificSource's Health Services team by phone at (541)
684-5584 or (888) 691-8209, or by email at healthservices( PacificSource.com.
CLAIMS PAYMENT
How to File a Claim
When a participating provider treats you, your claims are automatically sent to PacificSource
and processed. All you need to do is show your member ID card to the provider.
If you receive care from a non -participating provider, the provider may submit the claim to
PacificSource for you. If not, you are responsible for sending the claim to them for processing.
Your claim must include a copy of your provider's itemized bill. It must also include your name,
ID number or social security number, group name, group number, and the patient's name. If
you were treated for an accidental injury, please include the date, time, place, and
circumstances of the accident.
All claims for benefits must be turned in to PacificSource within 90 days of the date of service.
If it is not possible to submit a claim within 90 days, turn in the claim with an explanation as
soon as possible. In some cases PacificSource may accept the late claim. The Plan will never
pay a claim that was submitted more than a year after the date of service.
All claims should be sent to:
PacificSource
Attn: Claims
PO Box 7068
Springfield, OR 97475-0068
Claim Handling Procedures
A claim for benefits under this Plan will be examined by PacificSource on a pre -service,
concurrent, and/or a post -services basis. Each time your claim is examined, a new claims
determination will be made regarding the category (pre -service, concurrent, or post -service)
into which the claim falls at that particular time. In each case, PacificSource, on behalf of the
Plan Sponsor, must render a claim determination within a prescribed period of time.
Pre -service review — This Plan subjects the receipt of benefits for some services or supplies
to a preauthorization review. Although a preauthorization review is generally done on a pre -
service basis, it may in some case be conducted on a post -service basis. Unless a response
is needed sooner due to the urgency of the situation, a pre -service preauthorization review will
be completed and notification made to you and your medical provider as soon as possible,
generally within two working days, but no later than 15 days within receipt of the request.
Urgent care review — If the time period for making a non -urgent care determination could
seriously jeopardize your life, health or ability to regain maximum function, or would subject
you to severe pain that cannot be adequately managed without the care or treatment that is
73 Deschutes County Plan Document_0118_Medical
proposed, a preauthorization review will be completed as soon as possible, generally within
24 hours, but no later than 48 hours of receipt of the request.
Concurrent care review — Inpatient hospital or rehabilitation facilities, skilled nursing
facilities, chemical dependency/substance abuse and psychiatric day treatment facilities,
partial hospitalization, and residential behavioral healthcare require concurrent review for a
benefit determination with regard to an appropriate length of stay or duration of service.
Benefit determinations will be made as soon as possible but no later than one working day of
receipt of all the information necessary to make such a determination.
Post -service claims — A claim determination that involves only the payment of
reimbursement of the cost of medical care that has already been provided will be made as
soon as reasonably possible but no later than 30 days from the day after receiving the claim.
Retrospective review — A claim for benefits for which the service or supply requires a
preauthorization review but was not submitted for review on a pre -service basis will be
reviewed on a retrospective basis within 30 working days after receipt of the information
necessary to make a claim determination.
Extension of time —If a claim cannot be paid within the stated timeframes because additional
information is needed, they will acknowledge receipt of the claim and explain why payment is
delayed. If they do not receive the necessary information within 15 days of the delay notice,
they will either deny the claim or notify you every 45 days while the claim remains under
investigation. No extension is permitted for urgent care claims.
Payment of claims — PacificSource, on behalf of the Plan, has the sole right to pay benefits
to the member, the provider, or both jointly. Neither the benefits of this Plan nor a claim for
payment of benefits under the Plan are assignable in whole or in part to any person or entity.
Adverse benefit determinations — A decision made to reduce or deny benefits applied on a
pre -service, post -service, or concurrent care basis may be appealed in accordance with the
Plan's Appeals procedures (See Complaints, Grievances, and Appeals section below).
Questions about Claims
If you have questions about the status of a claim, you are welcome to contact the
PacificSource Customer Service team. You may also contact Customer Service if you believe
a claim was denied in error. They will review your claim and this Plan's benefits to determine if
the claim is eligible for payment. Then PacificSource will either reprocess the claim for
payment, or contact you with an explanation.
Benefits Paid in Error
If PacificSource makes a payment to you that you are not entitled to, or pays a person who is
not eligible for payment, we may recover the payment. PacificSource, on behalf of the Plan
Sponsor, may also deduct the amount paid in error from your future benefits.
In the same manner, if PacificSource applies medical expense to the Plan's deductible that
would not otherwise be reimbursable under the terms of this Plan; PacificSource, on behalf of
the Plan Sponsor, may deduct a like amount from the accumulated deductible amount and/or
recover payment of the medical expense that would have otherwise been applied to the
deductibles. Examples of amounts recoverable under this provision include, but are not limited
to services of an excluded medical condition. The fact that a medical expense was applied to
the Plan's deductibles or a drug was provided under the Plan's prescription drug program
74 Deschutes County Plan Document_0118_Medical
does not in itself create an eligible expense or infer that benefits will continue to be provided
for an otherwise excluded condition.
COORDINATION OF BENEFITS
This is a summary of only a few of the provisions of this Plan to help you understand
coordination of benefits which can be very complicated. This is not a complete description of
all of the coordination rules.
Double Coverage
It is common for family members to be covered by more than one healthcare plan. This
happens, for example, when a husband and wife both work and choose to have family
coverage through both employers.
When you are covered by more than one health plan, the law permits your insurers to follow a
procedure called `coordination of benefits' to determine how much each should pay when you
have a claim. The goal is to make sure that the combined payments of all plans do not add up
to more than your covered healthcare expenses.
Coordination of benefits (COB) is complicated, and covers a wide variety of circumstances.
This is only an outline of some of the most common ones. If your situation is not described,
contact the PacificSource Customer Service team or contact the Division of Financial
Regulation.
Primary or Secondary?
You will be asked to identify all the plans that cover members of your family. PacificSource will
need this information to determine whether we are the `primary' or `secondary' benefit payer.
The primary plan always pays first when you have a claim.
Any plan that does not contain your COB rules will always be primary.
When This Plan is Primary
If you or a family member are covered under another plan in addition to this one, this Plan will
be primary when:
Your Own Expenses
• The claim is for your own health care expenses.
Your Spouse's or Domestic Partner's Expenses
• The claim is for your spouse or domestic partner, who is covered by this Plan.
Your Child's Expenses
• The claim is for the health care expenses of your child who is covered by this Plan; and
• You are married and your birthday is earlier in the year than your spouse's or your
domestic partner's, or you are living with another individual, regardless of whether or not
you have ever been married to that individual, and your birthday is earlier than that other
individual's birthday. This is known as the `birthday rule;' or
• You are separated or divorced and you have informed us of a court decree that makes
you responsible for the child's healthcare expenses; or
• There is no court decree, but you have custody of the child.
75 Deschutes County Plan Document_0118_Medical
Other Situations
The Plan will be primary when any other provisions of federal law require it to be.
How this Plan Pays Claims When it is Primary
When this Plan is the primary plan, we will pay the benefits in accordance with the terms of
this Plan, just as if you had no other healthcare coverage under any other plan.
How this Plan Pays Claims When it is Secondary
This Plan will be secondary whenever the rules do not require it to be primary.
When this Plan is the secondary plan, it does not pay until after the primary plan has paid its
benefits. This Plan will then pay part or all of the allowable expenses left unpaid, as explained
below. An `allowable expense' is a healthcare expense covered by one of the plans, including
copayments, coinsurance and deductibles.
• If there is a difference between the amounts the plans allow, this Plan will base its
payment on the higher amount. However, if the primary plan has a contract with the
provider, our combined payments will not be more than the amount called for in the
contract or the amount called for in the contract of the primary plan, whichever is higher.
• This Plan will determine its payment by calculating the amount it would have paid if it had
been primary, and apply that calculated amount to any allowable expense that is left
unpaid by the primary plan. This Plan may reduce its payment by any amount so that,
when combined with the amount paid by the primary plan, the total benefits paid do not
exceed the total allowable expense for your claim. This Plan will credit any amount it
would have paid in the absence of your other health care coverage toward this Plan's
deductible.
• If the primary plan covers similar kinds of healthcare expenses, but allows expenses that
this Plan does not cover, it may pay for those expenses.
• This Plan will not pay an amount the primary plan did not cover because you did not follow
its rules and procedures. For example, if your plan has reduced its benefit because you
did not obtain preauthorization, as required by that plan, this Plan will not pay the amount
of the reduction, because it is not an allowable expense.
Questions About Coordination of Benefits?
Contact Your Plan Sponsor, PacificSource's Customer Service team, or the Division of
Financial Regulation. (See `Information Available from the Division of Financial
Regulation' in the Resources for Information and Assistance section.)
Coordination with Medicare
• Employers with 20 or more employees: If you are Medicare eligible due to age, this Plan is
usually the primary payer and Medicare is secondary. This rule applies to you and your
enrolled individuals only if you are an active employee.
• Employers with 19 or fewer employees: If you are Medicare eligible due to age, this Plan
only pays the portion of covered charges that would not be paid by Medicare Parts A and
B. This rule applies regardless of whether you are actually enrolled in Medicare Parts A
and B. In other words, this Plan pays secondary for anyone eligible for Medicare Parts A
and B, even if they have not enrolled in Medicare.
If you are Medicare eligible due to age, and your employer has 19 or fewer employees,
and you have not applied for both Medicare Parts A and B, please contact the
PacificSource Membership Services team immediately. They may arrange to pay your
76 Deschutes County Plan Document_0118_Medical
claims without a reduction in benefits until your next opportunity to enroll in Medicare
coverage. You can reach Membership Services by phone at (541) 684-5583 or toll-free
(866) 999-5583, or by email at membership c(�PacificSource.com.
• Medicare eligibility due to age:
For employer groups with 20 or more employees, this Plan pays benefit without regard to
the benefits available from Medicare for active employees and their enrolled family
members.
For employer groups with 19 or fewer employees and for individuals on COBRA
continuation, the benefits of this Plan are paid after amounts payable by Medicare are
deducted. This limitation applies whether or not a Medicare -eligible individual is enrolled in
both Part A and Part B. In order to maximize the benefits available under this Plan and
avoid unnecessary out-of-pocket expense, a Medicare -eligible individual should enroll in
both Medicare Part A and Part B. PacificSource will notify those Medicare -eligible
individuals for whom Medicare becomes primary payer for their medical expense.
• Medicare disabled and end-stage renal disease (ESRD) patients: The rules above may
not apply to disabled people under 65 and ESRD patients enrolled in Medicare, please
see Medicare.gov for more information. For information on coordination of benefits in
those situations, please contact PacificSource.
THIRD PARTY LIABILITY
Third party liability means claims that are the responsibility of someone other than this Plan.
The liable party may be a person, firm, or corporation. Auto accidents and 'slip -and -fall'
property accidents are examples of common third party liability cases.
A third party includes liability and casualty insurance, and any other form of insurance that
may pay money to or on behalf of a member, including but not limited to uninsured motorist
coverage, under -insured motorist coverage, premises med-pay coverage, Personal Injury
Protection (PIP) coverage, homeowner's insurance, and workers' compensation insurance.
If you use this Plan's benefit for an illness or injury you think may involve another party,
contact PacificSource right away.
When PacificSource receives a claim that might involve a third party, it will send you a
questionnaire to help determine responsibility.
In all third party liability situations, this Plan's coverage is secondary. By enrolling in this Plan,
you automatically agree to the following terms regarding third party liability situations:
• If this Plan pays any claim determined to be the responsibility of another party, you will
hold the right of recovery against the other party in trust for the Plan.
• The Plan is entitled to full reimbursement for any paid claims if there is a settlement or
judgment from the other party. This is so regardless of whether the other party or insurer
admits liability or fault.
• The Plan may subtract a proportionate share of the reasonable attorney's fees you
incurred from the money you are to pay back to the Plan.
• The Plan may ask you to take action to recover medical expenses we have paid from the
responsible party. The Plan may also assign a representative to do so on your behalf. If
77 Deschutes County Plan Document_0118_Medical
there is a recovery, the Plan will be reimbursed for any expenses or attorney's fees out of
that recovery.
• If you receive a third party settlement, that money must be used to pay, in full, your related
medical expenses incurred both before and after the settlement. If you have ongoing
medical expenses after the settlement, the Plan may deny your related claims until the full
settlement (less reasonable attorney's fees) has been used to pay those expenses.
Motor Vehicle and Other Accidents
If you are involved in a motor vehicle accident or other accident, your related medical
expenses are not covered by this Plan if they are covered by any other type of insurance
policy.
The Plan may pay your medical claims from the accident if an insurance claim has been filed
with the other insurance company and that insurance has not yet paid.
By enrolling in this Plan, you agree to the terms in the previous section regarding third party
liability.
On -the -Job Illness or Injury and Workers' Compensation
This Plan does not cover any work-related illness, injury, or disease that is caused by any for-
profit activity, whether through employment or from self-employment. The only exceptions
would be if:
• You are the owner, partner, or principal of the Plan Sponsor, are injured in the course of
employment, and are otherwise exempt from the applicable state or federal workers'
compensation insurance program;
• The appropriate state or federal workers' compensation insurance program has
determined that coverage is not available for your injury; or
• You have timely filed an application for coverage with the appropriate state or federal
workers' compensation insurance program, such as Oregon's State Accident Insurance
Fund or other Worker's Compensation Carrier, and are awaiting a determination of
coverage from that entity.
• This Plan exception will also be waived for self-employed spouses or domestic partners.
Claims submitted for coverage under this section are processed in accordance with the terms
of this Plan.
If you are not the owner, partner, or principal of this group then the Plan may pay your medical
claims if a workers' compensation claim has been denied on the basis that the illness or injury
is not work related, and the denial is under appeal.
The contractual rules for third party liability, motor vehicle and other accidents, and on-the-job
illness or injury are complicated and specific. Please refer to your Plan Sponsor for complete
details, or contact the PacificSource Third Party Claims team.
Continuation of benefits after injury or illness covered by worker's compensation insurance.
Coverage under this Plan shall be available to eligible employees who are not actively working
and are receiving worker's compensation insurance payments. Contribution amounts/levels
will be the same as if the eligible employee was actively at work. This continuation of benefits
is administered in accordance with the coverage extension provision and with any state or
78 Deschutes County Plan Document_0118_Medical
federal continuation requirements. The eligible employee may maintain such coverage until
the earlier or:
• The employee takes full-time employment with another employer; or
• Twelve months from the date the employee first makes payment of contribution under this
provision. This twelve months of continued coverage is in lieu of, not in addition to, any
other continuation of insurance provision described in other sections.
COMPLAINTS, GRIEVANCES, AND APPEALS
Questions, Concerns, or Complaints
The Plan Sponsor understands that you may have questions or concerns about your benefits,
eligibility, the quality of care you receive, or how we reached a claim determination or handled
a claim. PacificSource will try to answer your questions promptly and give you clear, accurate
answers based on the criteria established by the Plan Sponsor.
If you have a question, concern, or complaint about your coverage, please contact the
Customer Service team. Many times the Customer Service team can answer your question or
resolve an issue to your satisfaction right away. If you feel your issues have not been
addressed, you have the right to submit a grievance and/or appeal in accordance with this
section.
GRIEVANCE PROCEDURES
If you are dissatisfied with the availability, delivery, or the quality of healthcare services; or
claims payment, handling or reimbursement for healthcare services, you may file a grievance
in writing. PacificSource will attempt to address your grievance, generally within 30 days of
receipt (See How to Submit Grievances or Appeals below).
APPEAL PROCEDURES
First Internal Appeal: If you believe the Plan Sponsor, or PacificSource acting on behalf of
the Plan Sponsor, has improperly reduced or terminated a healthcare item or service, or failed
or refused to provide or make a payment in whole or in part for a healthcare item or service,
that is based on any of the reasons listed below, you or your authorized representative (see
Definition section) may appeal (request a review) that decision. The request for appeal must
be made in writing and within 180 days of the adverse benefit determination (See How to
Submit Grievances or Appeals below). You may appeal if there is an adverse benefit
determination based on a:
• Denial of eligibility for or termination of enrollment in a healthcare plan;
• Rescission or cancellation of your coverage;
• Imposition of a source -of -injury exclusion*, network exclusion, annual benefit limit or other
limitation on otherwise covered services or items;
• Determination that a healthcare item or service is experimental, investigational or not
medically necessary, effective or appropriate; or
• Determination that a course or plan of treatment you are undergoing is an active course of
treatment for the purpose of continuity of care.
79 Deschutes County Plan Document_0118_Medical
* Source -of -injury exclusions cannot exclude injuries resulting from a medical condition or
domestic violence.
Any staff involved in the initial adverse benefit determination will not be involved in the internal
appeal.
You or your authorized representative may submit additional comments, documents, records
and other materials relating to the adverse benefit determination that is the subject of the
appeal. If an authorized representative is filing on your behalf, your appeal is not considered
to be filed until such time as PacificSource has received the 'Authorization to Use or Disclose
PHI' and the 'Designation of Authorized Representative' forms.
You may receive continued coverage under the Plan for otherwise covered services pending
the conclusion of the internal appeals process. If the Plan makes payment for any service or
item on your behalf that is later determined not to be a covered service or item, you will be
required to reimburse the Plan for the non -covered service or item.
Second Internal Appeal: If you are not satisfied with the first internal appeal decision, you
may request an additional review. Your appeal and any additional information not presented
with your first internal appeal should be forwarded to your Plan Sponsor within 60 days of the
first appeal response. You may send your request for appeal and any documentation to the
Plan Sponsor's address that appears in the section entitled "How to Submit Grievances or
Appeals."
Any staff involved in the first internal appeal determination will not be involved in the second
internal appeal.
Request for Expedited Response: If there is a clinical urgency to do so, you or your
authorized representative may request in writing or orally, an expedited response to an
internal or external review of an adverse benefit determination. To qualify for an expedited
response, your attending physician must attest to the fact that the time period for making a
non -urgent benefit determination could seriously jeopardize your life or health or your ability to
regain maximum function or would subject you to severe pain that cannot be adequately
managed without the healthcare service or treatment that is the subject of the request. If your
appeal qualifies for an expedited review and would also qualify for external review (See
External Independent Review below) you may request that the internal and external reviews
be performed at the same time.
External Independent Review: If your dispute with the Plan relates to an adverse benefit
determination that a course or plan of treatment is not medically necessary; is experimental or
investigational; is not an active course of treatment for purposes of continuity of care; or is not
delivered in an appropriate healthcare setting and with the appropriate level of care, you or
your authorized representative may request an external review by an independent review
organization (See How to Submit Grievances or Appeals below).
Your request for an independent review must be made within 180 days of the date of the
second internal appeal response. External independent review is available at no cost to you,
but is generally only available when coverage has been denied for the reasons stated above
and only after all internal grievance levels are exhausted. The Plan will pay for any cost
associated with the external independent review. You must submit your reauest for an
external review directly to your Plan Sponsor.
The Plan Sponsor, may at its discretion and with your consent, waive the requirements of
compliance with the internal appeals process and have a dispute referred directly to external
review. You shall be deemed to have exhausted internal appeals if the Plan Sponsor fails to
strictly comply with its appeals process and with state and federal requirements for internal
80 Deschutes County Plan Document_0118_Medical
appeals. If the Plan Sponsor fails to comply with the decision of the independent review
organization assigned under Oregon law, you have a private right of action (sue) against the
Plan Sponsor for damages arising from an adverse benefit determination subject to the
external review.
If you have questions regarding Oregon's external review process, you may contact the
Division of Financial Regulation at (503) 947-7984 or the toll-free message line at (888) 877-
4894.
Timelines for Responding to Appeals
You will be afforded two levels of internal appeal and, if applicable to your case, an external
review. PacificSource will acknowledge receipt of an appeal no later than seven days after
receipt. A decision in response to the appeal will be made within 30 days after receiving your
request to appeal.
The above time frames do not apply if the period is too long to accommodate the clinical
urgency of a situation, or if you do not reasonably cooperate, or if circumstances beyond your or
our control prevent either party from complying with the time frame. In the case of a delay, the
party unable to comply must give notice of delay, including the specific circumstances, to the
other party.
Information Available with Regard to an Adverse Benefit Determination
The final adverse benefit determination will include:
• A reference to the specific internal rule or guideline used in the adverse benefit
determination; and
An explanation of the scientific or clinical judgment for the adverse benefit determination, if
the adverse benefit determination is based on medical necessity, experimental treatment,
or a similar exclusion.
Upon request, the Plan Sponsor will provide you with any additional documents, records or
information that are relevant to the adverse benefit determination at no cost.
HOW TO SUBMIT GRIEVANCES OR APPEALS
Before submitting a grievance or appeal, we suggest you contact PacificSource's Customer
Service team with your concerns. You can reach it by phone or email at the contact
information found on the first page of this Plan Document. Issues can often be resolved at this
level. Otherwise, you may file a grievance or appeal by:
First Level Appeal Writing to:
PacificSource
Attn: Grievance Review
PO Box 7068
Springfield, OR 97475-0068
Emailing cs@PacificSource.com, with `Grievance' as the subject
Faxing (541) 225-3628
81 Deschutes County Plan Document_0118_Medical
Second Level Appeal Writing to:
Deschutes County
Attn: Trygve Bolken
PO Box 6005
Bend, OR 97708-6005
Emailing trygve.bolken@deschutes.org with "Grievance" or "Appeal" as the subject
Faxing (541) 330-4626
If you are unsure of what to say or how to prepare a grievance, please call PacificSource's
Customer Service team. They will help you through the grievance process and answer any
questions you have.
Assistance Outside PacificSource
You have the right to file a complaint or seek other assistance from the Division of Financial
Regulation. Assistance is available:
By calling (503) 947-7984 or the toll-free message line at (888) 877-4894
By writing to:
Division of Financial Regulation
Consumer Advocacy Unit
PO Box 14480
Salem, OR 97309-0405
Through their website at dfr.oregon.gov
Or by email at cp.ins@state.or.us
RESOURCES FOR INFORMATION AND
ASSISTANCE
Assistance in Other Languages
Plan members who do not speak English may contact PacificSource's Customer Service team
for assistance. PacificSource can usually arrange for a multilingual staff member or interpreter
to speak with them in their native language.
Information Available from PacificSource
The Plan makes the following written information available to you free of charge. You may
contact PacificSource's Customer Service team to request any of the following:
A directory of participating healthcare providers under this Plan;
Information about the drug list (also known as a formulary);
A description (consistent with risk -sharing information required by the Centers for
Medicare and Medicaid Services, formerly known as Health Care Financing
82 Deschutes County Plan Document_0118_Medical
Administration) of any risk -sharing arrangements the Plan or PacificSource has with
providers;
• A description of the Plan and/or PacificSource's efforts to monitor and improve the quality
of health services;
• Information about how PacificSource checks the credentials of its network providers and
how you can obtain the names and qualifications of your healthcare providers;
• Information about preauthorization and utilization review procedures; or
• Information about any healthcare plan offered by PacificSource.
Information Available from the Division of Financial Regulation about
PacificSource
The following consumer information is available from the Division Financial Regulation:
• The results of all publicly available accreditation surveys;
• A summary of our health promotion and disease prevention activities;
• Samples of the written summaries delivered to PacificSource policyholders;
• An annual summary of grievances and appeals against PacificSource;
• An annual summary of our utilization review policies;
• An annual summary of our quality assessment activities; and
• An annual summary of the scope of our provider network and accessibility of healthcare
services.
You can request this information by contacting the Division of Financial Regulation:
By writing to:
Division of Financial Regulation
Consumer Advocacy Unit
PO Box 14480
Salem, OR 97309-0405
By calling (503) 947-7984, or the toll-free message line at (888) 877-4894
Through their website at dfr.oregon.gov
Or by email at cp.ins@state.or.us.
RIGHTS AND RESPONSIBILITIES
The Plan and PacificSource are committed to providing you with the highest level of service in
the industry. By respecting your rights and clearly explaining your responsibilities under this
Plan, we will promote effective healthcare.
83 Deschutes County Plan Document_0118_Medical
Your Rights as a Member.
• You have a right to receive information about the Plan and PacificSource, our services,
our providers, and your rights and responsibilities.
• You have a right to expect clear explanations of this Plan's benefits and exclusions.
• You have a right to be treated with respect and dignity.
• You have a right to impartial access to healthcare without regard to race, religion, gender,
national origin, or disability.
• You have a right to honest discussion of appropriate or medically necessary treatment
options. You are entitled to discuss those options regardless of how much the treatment
costs or if it is covered by this Plan.
• You have a right to the confidential protection of your medical records and personal
information.
• You have a right to voice complaints about the Plan, PacificSource or the care you
receive, and to appeal decisions you believe are wrong.
• You have a right to participate with your healthcare provider in decision-making regarding
your care.
• You have a right to know why any tests, procedures, or treatments are performed and any
risks involved.
• You have a right to refuse treatment and be informed of any possible medical
consequences.
• You have a right to refuse to sign any consent form you do not fully understand, or cross
out any part you do not want applied to your care.
• You have a right to change your mind about treatment you previously agreed to.
Your Responsibilities as a Member;
• You are responsible for reading this Plan Document and all other communications from
the Plan and PacificSource, and for understanding this Plan's benefits. You are
responsible for contacting the Plan and/or PacificSource Customer Service team if
anything is unclear to you.
• You are responsible for making sure your provider obtains preauthorization for any
services that require it before you are treated.
• You are responsible for providing the Plan and PacificSource with all the information
required to provide benefits under this Plan.
You are responsible for giving your healthcare provider complete health information to
help accurately diagnose and treat you.
You are responsible for telling your providers you are covered by the Plan and showing
your member ID card when you receive care.
You are responsible for being on time for appointments, and calling your provider ahead of
time if you need to cancel.
84 Deschutes County Plan Document_0118_Medical
• You are responsible for any fees the provider charges for late cancellations or `no shows'.
• You are responsible for contacting the Plan or PacificSource if you believe you are not
receiving adequate care.
• You are responsible for supplying information to the extent possible that the Plan or
PacificSource needs in order to administer your benefits or your medical providers need in
order to provide care.
• You are responsible for following plans and instructions for care that you have agreed to
with your doctors.
• You are responsible for understanding your health problems and participating in
developing mutually agreed upon goals, to the degree possible.
PRIVACY AND CONFIDENTIALITY
The Plan and PacificSource have strict policies in place to protect the confidentiality of your
personal information, including your medical records. Your personal information is only
available to the staff members who need that information to do their jobs.
Disclosure outside the Plan and PacificSource is allowed only when necessary to provide your
coverage, or when otherwise allowed by law. Except when certain statutory exceptions apply,
the law requires us to have written authorization from you (or your representative) before
disclosing your personal information outside the Plan or PacificSource. An example of one
exception is that we do not need written authorization to disclose information to a designee
performing utilization management, quality assurance, or peer review on our behalf.
PLAN ADMINISTRATION
Name of Plan:
The Deschutes County Group Health Plan (the "Plan").
Name and Address of the Plan Sponsor:
Deschutes County
PO Box 6005
Bend, OR 97708-6005
Phone: (541) 385-3215
Fax: (541) 330-4626
Plan Number
502
Plan Sponsor's Employer Identification / Tax Identification Number:
93-6002292
Contract Year:
January 1 to December 31
85 Deschutes County Plan Document_0118_Medical
Type of Plan:
Group Health Plan (self-insured)
Type of Administration:
The Plan is administered by employees of the Plan Sponsor and under an administrative
services agreement with a third -party administrator.
Name and Address of Third Party Administrator:
PacificSource Health Plans
P.O. Box 7068
Springfield, OR 97475-0068
Phone: (888) 977-9299
Fax: (541) 684-5264
Name and Address of Designated Agent for Service of Legal Process:
Deschutes County
Attn: Tom Anderson, County Administrator
PO Box 6005
Bend, OR 97708-6005
Phone: (541) 385-3215
Fax: (541) 330-4626
Funding Method and Contributions:
This Plan is self-insured, meaning that benefits are paid from the general assets and/or trust
funds of the Plan Sponsor and are not guaranteed under an insurance policy or contract. The
cost of the Plan is paid with contributions by the Plan Sponsor and participating employees.
The Plan Sponsor determines the amount of contributions to the Plan, based on estimates of
claims and administration costs. The Plan Sponsor may purchase insurance coverage to
guard against excess loss incurred by allowed claims under the Plan, but such coverage is not
included as part of the Plan.
Plan Changes
The terms, conditions, and benefits of this Plan may change based on changes in law,
administrative decisions, or qualifying events. The following people have the authority to
accept or approve such changes or terminate this Plan:
• The Plan Sponsor's board of County Commisioners or other governing body;
• The owner or partners of the Plan Sponsor; or
• Anyone authorized by the above people to take such action.
The Plan Administrator is authorized to make Plan changes on behalf of the Plan Sponsor.
If this Plan terminates and the Plan Sponsor does not replace the coverage with another plan,
the Plan Sponsor is required by law to advise you in writing of the termination.
86 Deschutes County Plan Document_0118_Medical
Legal Procedures
You may not take legal action against the Plan Sponsor or PacificSource to enforce any
provision of the Plan until 60 days after your claim is properly submitted in accordance with
established procedures. Also, you must exhaust this Plan's claims procedures, and grievance
and appeals procedures, before filing benefits litigation. You may not take legal action against
the Plan Sponsor or PacificSource more than three years after the deadline for claim
submission has expired. No such action shall be brought against the Plan Sponsor or
PacificSource after the expiration of any applicable statutes of limitations.
DEFINITIONS
Wherever used in this Plan, the following definitions apply to the masculine and feminine and
singular plural forms of terms. For the purpose of this Plan, `employee' includes the employer
when covered by this Plan. Other terms are defined where they are first used in the text.
Accident means an unforeseen or unexpected event causing injury that requires medical
attention.
Advanced diagnostic imaging means diagnostic examinations using CT scans, MRIs, PET
scans, CATH labs, and nuclear cardiology studies.
Adverse benefit determination means the Plan Sponsor's denial, reduction, or termination
of a healthcare item or service, or the Plan Sponsor's failure or refusal to provide or to make a
payment in whole or in part for a healthcare item or service that is based on the Plan
Sponsor's:
• Denial of eligibility for or termination of enrollment in a health benefit plan;
• Rescission or cancellation of this Plan;
• Imposition of a source -of -injury exclusion*, network exclusion, annual benefit limit or other
limitation on otherwise covered items or services;
• Determination that a healthcare item or service is experimental, investigational, or not
medically necessary, effective, or appropriate; or
• Determination that a course or plan of treatment that a member is undergoing is an active
course of treatment for purposes of continuity of care.
Allowable fee is the dollar amount established for reimbursement of charges for specific
services or supplies provided by non -participating providers. PacificSource uses several
sources to determine the allowable fee. Depending on the service or supply and the
geographical area in which it is provided, the allowable fee may be based on data collected
from the Centers for Medicare and Medicaid Services (CMS), contracted vendors, other
nationally recognized databases, or PacificSource, as documented in PacificSource's
payment policy and adopted by the Plan Sponsor.
Ambulatory surgical center means a facility licensed by the appropriate state or federal
agency to perform surgical procedures on an outpatient basis.
Appeal means a written or verbal request from a member or, if authorized by the member, the
member's representative, to change a previous decision made by the Plan Sponsor
concerning;
87 Deschutes County Plan Document_0118_Medical
• Access to healthcare benefits, including an adverse benefit determination made pursuant
to utilization management;
• Claims payment, handling or reimbursement for healthcare services;
• Rescissions of member's benefit coverage by the Plan Sponsor; and
• Other matters as specifically required by law.
Approved clinical trials are Phase I, II, III, or IV clinical trials for the prevention, detection, or
treatment of cancer or another life-threatening condition or disease; or:
• Funded by the National Institutes of Health, the Centers for Disease Control and
Prevention, the Agency for Healthcare Research and Quality, the Centers for Medicare
and Medicaid Services, the United States Department of Defense or the United States
Department of Veterans Affairs;
Supported by a center or cooperative group that is funded by the National Institutes of
Health, the Centers for Disease Control and Prevention, the Agency for Healthcare
Research and Quality, the Centers for Medicare and Medicaid Services, the United States
Department of Defense or the United States Department of Veterans Affairs;
Conducted as an investigational new drug application, an investigational device exemption
or a biologics license application subject to approval by the United States Food and Drug
Administration; or
• Exempt by federal law from the requirement to submit an investigational new drug
application to the United States Food and Drug Administration.
Authorized representative is an individual who by law or by the consent of a person may act
on behalf of the person. An authorized representative must have the member complete and
execute an `Authorization to Use or Disclose PHI' form and a `Designation of Authorized
Representative' form, both of which are available at PacificSource.com, and which will be
supplied to you upon request. These completed forms must be submitted to PacificSource
before PacificSource can recognize the authorized representative as acting on behalf of the
member.
Behavioral health assessment means an evaluation by a behavioral health clinician, in
person or using telemedicine, to determine a patient's need for immediate crisis stabilization.
Behavioral health crisis means a disruption in an individual's mental or emotional stability or
functioning resulting in an urgent need for immediate outpatient treatment in an emergency
department or admission to a hospital to prevent a serious deterioration in the individual's
mental or physical health.
Benefit determination means the activity taken to determine or fulfill the Plan Sponsor's
responsibility for provisions under this Plan and provide reimbursement for healthcare in
accordance with those provisions. Such activity may include:
• Eligibility and coverage determinations (including coordination of benefits), and
adjudication or subrogation of health benefit claims;
• Review of healthcare services with respect to medical necessity (including underlying
criteria), coverage under this Plan, appropriateness of care, experimental/investigational
treatment, justification of charges; and
88 Deschutes County Plan Document_0118_Medical
• Utilization review activities, including precertification and preauthorization of services and
concurrent and retrospective review of services.
Calendar year means the 12 month period beginning January 1 of any year through
December 31 of the same year.
Cardiac rehabilitation refers to a comprehensive program that generally involves medical
evaluation, prescribed exercise, and cardiac risk factor modification. Education, counseling,
and behavioral interventions are sometimes used as well. Phase I refers to inpatient services
that typically occur during hospitalization for heart attack or heart surgery. Phase II refers to a
short-term outpatient program, usually involving ECG -monitored exercise. Phase III refers to a
long-term program, usually at home or in a community-based facility, with little or no ECG
monitoring.
Chemical dependency means the addictive relationship with any drug or alcohol
characterized by either a physical or psychological relationship, or both, that interferes with
the individual's social, psychological, or physical adjustment to common problems on a
recurring basis. Chemical dependency does not include addiction to, or dependency on,
tobacco products or foods.
Chemical dependency treatment facility means a treatment facility that provides a program
for the treatment of alcoholism or drug addiction pursuant to a written treatment plan approved
and monitored by a physician or addiction counselor licensed by the state; and is licensed or
approved as a treatment center by the department of public health and human services, is
licensed by the state where the facility is located.
Co-insurance means a defined percentage of the allowable fee for covered services and
supplies the member receives. It is the percentage the member is responsible for, not
including co -pays and deductible. The co-insurance the member is responsible for is listed in
the Benefit Summary.
Complaint means an expression of dissatisfaction directly to the Plan Sponsor or
PacificSource that is about a specific problem encountered by a member, or about a benefit
determination by the Plan Sponsor or an agent acting on behalf of the Plan Sponsor, including
PacificSource, and that includes a request for action to resolve the problem or change the
benefit determination. The complaint does not include an inquiry.
Congenital anomaly means a condition existing at or from birth that is a significant deviation
from the common form or function of the body, whether caused by a hereditary or
developmental defect or disease. The term significant deviation is defined to be a deviation
which impairs the function of the body and includes but is not limited to the conditions of cleft
lip, cleft palate, webbed fingers or toes, sixth toes or fingers, or defects of metabolism and
other conditions that are medically diagnosed to be congenital anomalies.
Contract year means a 12 -month period beginning on the date this Plan is issued or the
anniversary of the date this Plan was issued. The specific dates for the contract year
applicable to this Plan are reflected in the introductory section at the beginning of this Plan
Document. If changes are made to the Plan on a date other than the anniversary of issuance,
a new contract year may start on the date the changes become effective if so agreed by the
Plan Sponsor and PacificSource. A contract year may or may not coincide with a calendar
year.
Contracted allowable fee is an amount the Plan agrees to pay a participating provider for a
given service or supply through direct or indirect contract.
89 Deschutes County Plan Document_0118_Medical
Co -payment (also referred to as `co -pay') is a fixed up -front dollar amount the member is
required to pay for certain covered services. The co -pay applicable to a specific covered
service is listed under that specific benefit in the Benefit Summary.
Covered expense is an expense for which benefits are payable under by this Ran subject to
applicable deductibles, co -payments, co-insurance, out-of-pocket maximum, or other specific
limitations.
Deductible means the portion of the healthcare expense that must be paid by the member
before the benefits of this Plan are applied.
Dependent children means any natural, step, adopted or eligible child you, your spouse, or
your domestic partner are legally obligated to support or contribute support. This may include
eligible dependent children for which you are the court appointed legal custodian or guardian.
Eligible dependent children may be covered under the Plan only if they meet the eligibility
requirements of the Plan (See Becoming Covered – Eligibility section).
Domestic Partner means:
• Registered Domestic Partner means an individual of the same gender, age 18 or older,
who is joined in a domestic partnership, and whose domestic partnership is legally
registered in any state.
Durable medical equipment means equipment that can withstand repeated use; is primarily
and customarily used to serve a medical purpose rather than convenience or comfort; is
generally not useful to a person in the absence of an illness or injury; is appropriate for use in
the home; and is prescribed by a physician. Examples of durable medical equipment include
but are not limited to hospital beds, wheelchairs, crutches, canes, walkers, nebulizers,
commodes, suction machines, traction equipment, respirators, TENS units, and hearing aids.
Durable medical equipment supplier means a PacificSource contracted provider or a
provider that satisfies the criteria in the Medicare Qualify Standards for Suppliers of Durable
Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) and Other Items and
Services noted in this Plan Document.
Elective surgery or procedure refers to a surgery or procedure for a condition that does not
require immediate attention and for which a delay would not have a substantial likelihood of
adversely affecting the health of the patient.
Eligible employee means an employee who has met the Plan Sponsor's minimum eligibility
requirements as defined in the Medical Benefit Summary, and who is otherwise eligible for
coverage under the terms of this Plan.
Emergency medical condition means a medical condition:
• That manifests itself by acute symptoms of sufficient severity, including severe pain 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, or an unborn child in the case of a pregnant woman, in
serious jeopardy;
— Result in serious impairment to bodily functions; or
— Result in serious dysfunction of any bodily organ or part.
90 Deschutes County Plan Document_0118_Medical
With respect to a pregnant woman who is having contractions, for which there is
inadequate time to affect a safe transfer to another hospital before delivery or for which a
transfer may pose a threat to the health or safety of the woman or the unborn child.
That is a behavioral crisis.
Emergency medical screening exam means the medical history, examination, ancillary
tests, and medical determinations required to ascertain the nature and extent of an
emergency medical condition.
Emergency services means, with respect to an emergency medical condition:
• An emergency medical screening exam or behavioral health assessment that is within the
capability of the emergency department of a hospital, including ancillary services routinely
available to the emergency department to evaluate such emergency medical condition;
and
• Such further medical examination and treatment as are required under 42 U.S.C. 1395dd
to stabilize the patient to the extent the examination and treatment are within the capability
of the staff and facilities available at a hospital.
Employee means any individual employed by the Employer.
Employer generally means the Plan Sponsor unless otherwise noted.
Essential health benefits are services defined as such by the Secretary of the U.S.
Department of Health and Human Services. Essential health benefits fall into the following
categories:
• Ambulatory patient services;
• Emergency services;
• Hospitalization;
• Laboratory services;
• Maternity and newborn care;
• Mental health and substance use disorder services, including behavioral health treatment;
• Pediatric services, including oral and vision care.
• Prescription drugs;
• Preventive and wellness services and chronic disease management; and
• Rehabilitation and habilitation services and devices.
Experimental or investigational procedures means services, supplies, protocols,
procedures, devices, chemotherapy, drugs or medicines, or the use thereof, that are
experimental or investigational for the diagnosis and treatment of illness, injury, or disease.
• Experimental or investigational services and supplies include, but are not limited to,
services, supplies, procedures, devices, chemotherapy, drugs or medicines, or the use
thereof, which at the time they are rendered and for the purpose and in the manner they
are being used:
91 Deschutes County Plan Document_0118_Medical
— Have not yet received full U.S. government agency required approval (e.g., FDA) for
other than experimental, investigational, or clinical testing;
— Are not of generally accepted medical practice in this Plan's state of issue or as
determined by medical advisors, medical associations, and/or technology resources;
— Are not approved for reimbursement by the Centers for Medicare and Medicaid
Services;
— Are furnished in connection with medical or other research; or
— Are considered by any governmental agency or subdivision to be experimental or
investigational, not considered reasonable and necessary, or any similar finding.
• When making decisions about whether treatments are investigational or experimental, the
Plan Sponsor relies on the above resources as well as:
Expert opinions of specialists and other medical authorities;
Published articles in peer-reviewed medical literature;
External agencies whose role is the evaluation of new technologies and drugs; and
External review by an independent review organization.
• The following will be considered in making the determination whether the service is in an
experimental and/or investigational status:
Whether there is sufficient evidence to permit conclusions concerning the effect of the
services on health outcomes;
Whether the scientific evidence demonstrates that the services improve health
outcomes as much or more than established alternatives;
Whether the scientific evidence demonstrates that the services' beneficial effects
outweigh any harmful effects; and
Whether any improved health outcomes from the services are attainable outside an
investigational setting.
External appeal or review means the request by an appellant for an independent review
organization to determine whether or not the Plan Sponsor's internal appeal decisions are
correct.
Geographical area – PacificSource has direct and indirect provider contracts to offer services
to members in Oregon, Idaho, Montana, and bordering communities in southwest
Washington. PacificSource also has an agreement with a nationwide provider network to
offer services to members while traveling throughout the United States.
Global charge means a lump sum charge for maternity care that includes prenatal care, labor
and delivery and post -delivery care. Ante partum services such as amniocentesis,
cordocentesis, chorionic villus sampling, fetal stress test, and fetal non-stress test are not
considered part of global maternity services and are reimbursed separately.
Grievance means:
• A request submitted by a member or an authorized representative of a member;
92 Deschutes County Plan Document_0118_Medical
— In writing, for an internal appeal or an external review; or
— In writing or orally, for an expedited internal review or an expedited external review.
A written complaint submitted by a member or an authorized representative of a member
regarding:
— The availability, delivery, or quality of a healthcare service; or
— Claims payment, handling, or reimbursement for healthcare services and, unless the
member has not submitted a request for an internal appeal, the complaint is not
disputing an adverse benefit determination.
Habilitation services means healthcare services that help a person keep, learn or improve
skills and functioning for daily living. Examples include therapy for a child who isn't walking or
talking at the expected age. These services may include physical and occupational therapy,
speech-language pathology and other services for people with disabilities in a variety of
inpatient and/or outpatient settings.
Health benefit plan means any hospital expense, medical expense, or hospital or medical
expense policy or certificate, healthcare contractor or health maintenance organization
subscriber contract, or any plan provided by a multiple employer welfare arrangement or by
another benefit arrangement defined in the federal Employee Retirement Income Security Act
of 1974.
Hearing aids mean any non -disposable, wearable instrument or device designed to aid or
compensate for impaired human hearing and any necessary ear mold, part, attachments or
accessory for the instrument or device, except batteries and cords. Hearing aids include any
amplifying device that does not produce as its output an electrical signal that directly
stimulates the auditory nerve. For the purpose of this definition, such amplifying devices
include air conduction and bone conduction devices, as well as those that provide vibratory
input to the middle ear.
Home healthcare means services provided by a licensed home health agency in the
member's place of residence that is prescribed by the member's attending physician as part of
a written plan of care. Services provided by home healthcare include:
• Home health aide services;
• Hospice therapy;
• Medical supplies and equipment suitable for use in the home;
• Medically necessary personal hygiene, grooming and dietary assistance;
• Nursing;
• Occupational therapy;
• Physical therapy; and
• Speech therapy.
Homebound means the ability to leave home only with great difficulty with absences
infrequently and of short duration. Infants and toddlers will not be considered homebound
without medical documentation that clearly establishes the need for home skilled care. Lack of
93 Deschutes County Plan Document_0118_Medical
transportation is not considered sufficient medical criterion for establishing that a person is
homebound.
Hospital means an institution licensed as a `general hospital' or 'intermediate general
hospital' by the appropriate state agency in the state in which it is located.
Illness includes a physical or mental condition that results in a covered expense. Physical
illness is a disease or bodily disorder. Mental illness is a psychological disorder that results in
pain or distress and substantial impairment of basic or normal functioning.
Incurred expense means charges of a healthcare provider for services or supplies for which
a member becomes obligated to pay. The expense of a service is incurred on the day the
service is rendered, and the expense of a supply is incurred on the day the supply is
delivered.
Infertility means:
• Male: Low sperm counts or the inability to fertilize an egg; or
• Female: The inability to conceive or carry a pregnancy to 12 weeks.
Initial enrollment period means a period of days set by your employer that determines when
an individual is first eligible to enroll.
Injury means bodily trauma or damage that is independent of disease or infirmity. The
damage must be caused solely through external and accidental means and does not include
muscular strain sustained while performing a physical activity. (For muscular strain, see
definition of `illness'.)
Inquiry means a written request for information or clarification about any subject matter
related to the Plan.
Internal appeal means a review of an adverse benefit determination.
Leave of absence is a period of time off work granted to an employee by the Plan Sponsor at
the employee's request and during which the employee is still considered to be employed and
is carried on the employment records of the Plan Sponsor. A leave can be granted for any
reason acceptable to the Plan Sponsor, including disability and pregnancy.
Lifetime maximum or lifetime benefit means the maximum benefit that will be provided
toward the expenses incurred by any one person while the person is covered by the Plan. If
any covered expense that includes a lifetime maximum benefit amount is deemed to be an
`essential health benefit' as determined by the Secretary of the U.S. Department of Health and
Human Services, and such is determined to apply to the Plan, the lifetime maximum amount
will not apply to that covered expense in accordance with the standards established by the
Secretary.
Mastectomy is the surgical removal of all or part of a breast or a breast tumor suspected to
be malignant.
Medical supplies means items of a disposable nature that may be essential to effectively
carry out the care a physician has ordered for the treatment or diagnosis of an illness, injury,
or disease. Examples of medical supplies include but are not limited to syringes and needles,
splints and slings, ostomy supplies, sterile dressings, elastic stockings, enteral foods, drugs or
biologicals that must be put directly into the equipment in order to achieve the therapeutic
benefit of the durable medical equipment or to assure the proper functioning of this equipment
(e.g. Albuterol for use in a nebulizer).
94 Deschutes County Plan Document_0118_Medical
Medically necessary means those services and supplies that are required for diagnosis or
treatment of illness, injury, or disease and that are:
• Consistent with the symptoms or diagnosis and treatment of the condition;
• Consistent with generally accepted standards of good medical practice in this Plan's state
of issue, or expert consensus physician opinion published in peer-reviewed medical
literature, or the results of clinical outcome trials published in peer-reviewed medical
literature;
• As likely to produce a significant positive outcome as, and no more likely to produce a
negative outcome than, any other service or supply, both as to the illness, injury, or
disease involved and the patient's overall health condition;
Not for the convenience of the member or a provider of services or supplies; and
The least costly of the alternative services or supplies that can be safely provided. When
specifically applied to a hospital inpatient, it further means that the services or supplies
cannot be safely provided in other than a hospital inpatient setting without adversely
affecting the patient's condition or the quality of medical care rendered.
Services and supplies intended to diagnose or screen for a medical condition in the absence
of signs or symptoms, or of abnormalities on prior testing, including exposure to infectious or
toxic materials or family history of genetic disease, are not considered medically necessary
under this definition (See Excluded Services — Screening tests).
Member means an individual covered under this Plan.
Mental and/or chemical healthcare facility means a corporate or governmental entity or
other provider of services for the care and treatment of chemical dependency and/or mental or
nervous conditions which is licensed or accredited by The Joint Commission or the
Commission on Accreditation of Rehabilitation Facilities for the level of care which the facility
provides.
Mental and/or chemical healthcare program means a particular type or level of service that
is organizationally distinct within a mental and/or chemical healthcare facility.
Mental and/or chemical healthcare provider means a person that has met the applicable
credentialing requirements, is otherwise eligible to receive reimbursement under the Plan and
is:
• A healthcare facility;
• A residential program or facility where appropriately licensed or accredited by The Joint
Commission or the Commission on Accreditation of Rehabilitation Facilities;
• A day or partial hospitalization program;
• An outpatient service; or
• An individual behavioral health or medical professional authorized for reimbursement
under state law.
Mental or nervous condition means all disorders defined in the `Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition' (DSM -5).
95 Deschutes County Plan Document_0118_Medical
Non -participating provider is a provider of covered medical services or supplies that does
not directly or indirectly hold a provider contract or agreement with PacificSource.
Orthotic devices means rigid or semi rigid devices supporting a weak or deformed leg, foot,
arm, hand, back or neck or restricting or eliminating motion in a diseased or injured leg, foot,
arm, hand, back or neck. Benefits for orthotic devices include orthopedic appliances or
apparatus used to support, align, prevent, or correct deformities or to improve the function of
movable parts of the body. An orthotic device differs from a prosthetic in that, rather than
replacing a body part, it supports and/or rehabilitates existing body parts. Orthotic devices are
usually customized for an individual's use and are not appropriate for anyone else. Examples
of orthotic devices include but are not limited to Ankle Foot Orthosis (AFO), Knee Ankle Foot
Orthosis (KAFO), Lumbosacral Orthosis (LSO), and foot orthotics.
Participating provider means a physician, healthcare professional, hospital, medical facility,
or supplier of medical supplies that directly or indirectly holds a provider contract or agreement
with PacificSource.
Physical/occupational therapy is comprised of the services provided by (or under the
direction and supervision of) a licensed physical or occupational therapist.
Physical/occupational therapy includes emphasis on examination, evaluation, and intervention
to alleviate impairment and functional limitation and to prevent further impairment or disability.
Physician means a state -licensed Doctor of Medicine (M.D.) or a Doctor of Osteopathy
(D.O.).
Physician assistant is a person who is licensed by an appropriate state agency as a
physician assistant.
Plan Amendment is a written attachment that amends, alters or supersedes any of the terms
or conditions set forth in this Plan Document.
Practitioner means Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental
Surgery (D.D.S.), Doctor of Dental Medicine (D.M.D.), Doctor of Podiatry Medicine (D.P.M.),
Doctor of Chiropractic (D.C.), Doctor of Optometry (O.D.), Licensed Nurse Practitioner
(including Certified Nurse Midwife (C.N.M.) and Certified Registered Nurse Anesthetist
(C.R.N.A.)), Registered Physical Therapist (R.P.T.), Speech Therapist, Occupational
Therapist, Psychologist (Ph.D.), Licensed Clinical Social Worker (L.C.S.W.), Licensed
Professional Counselor (L.P.C.), Licensed Marriage and Family Therapist (LMFT), Licensed
Psychologist Associate (LPA), Physician Assistant (PA), Audiologist, Acupuncturist,
Naturopathic Physician, Licensed Massage Therapist, and Pharmacist.
Prescription drugs are drugs that, under federal law, require a prescription by a licensed
physician (M.D. or D.O.) or other licensed medical provider.
Prosthetic devices (excluding dental) means artificial limb devices or appliances designed to
replace in whole or in part an arm or a leg. Benefits for prosthetic devices include coverage of
devices that replace all or part of an internal or external body organ, or replace all or part of
the function of a permanently inoperative or malfunctioning internal or external organ, and are
furnished on a physician's order. Examples of prosthetic devices include but are not limited to
artificial limbs, cardiac pacemakers, prosthetic lenses, breast prosthesis (including
mastectomy bras), and maxillofacial devices.
Rehabilitation services means healthcare services and devices that help a person keep, get
back, or improve skills and functioning for daily living to overcome or recover from an illness or
diagnosis that is covered by this Plan. These services may include physical and occupational
96 Deschutes County Plan Document_0118_Medical
therapy, speech-language pathology, and other services for people with disabilities in a variety
of inpatient and/or outpatient settings.
Rescind or rescission means to retroactively cancel or discontinue coverage under a health
benefit plan or group or individual health insurance policy for reasons other than failure to
timely pay or required contributions toward the cost of coverage.
Routine costs of care mean medically necessary services or supplies which would normally
be covered by the Plan if the member were not enrolled in an approved clinical trial. Routine
costs of care do not include:
• The drug, device, or service being tested in the clinical trial unless the drug, device, or
service would be covered for that indication by the Plan if provided outside of a clinical
trial;
• Items or services required solely for the provisions of the drug, device, or service being
tested in the clinical trial;
• Items or services required solely for the clinically appropriate monitoring of the drug,
device, or service being tested in the clinical trial;
• Items of services required solely for the prevention, diagnosis, or treatment of
complications arising from the provision of the drug, device, or service being tested in the
clinical trial;
• Items or services that are provided solely to satisfy data collection and analysis needs and
that are not used in the direct clinical management of the patient;
• Items or services customarily provided by a clinical trial sponsor free of charge to any
participant in the clinical trial; or
• Items or services that are not covered by the Plan if provided outside of the clinical trial.
Skilled nursing facility or convalescent home means an institution that provides skilled
nursing care under the supervision of a physician, provides 24-hour nursing service by or
under the supervision of a registered nurse (R.N.), and maintains a daily record of each
patient. Skilled nursing facilities must be licensed by an appropriate state agency and
approved for payment of Medicare benefits to be eligible for reimbursement.
Source -of -injury exclusions means this Plan may exclude benefits for the treatment of
injuries based on the source of that injury, as long as the plan does not exclude benefits
otherwise provided for treatment of injury if the injury results from an act of domestic violence
or a medical condition.
Specialized treatment facility means a facility that provides specialized short-term or long-
term care. The term specialized treatment facility includes ambulatory surgical centers,
birthing centers, chemical dependency/substance abuse day treatment facilities, hospice
facilities, inpatient rehabilitation facilities, mental and/or chemical healthcare facilities, organ
transplant facilities, psychiatric day treatment facilities, residential treatment facilities, skilled
nursing facilities, substance abuse treatment facilities, and urgent care treatment facilities.
Specialty drugs are high dollar oral, injectable, infused or inhaled biotech medications
prescribed for the treatment of chronic and/or genetic disorders with complex care issues that
have to be managed. The major conditions these drugs treat include but are not limited to:
cancer, HIV/AIDS, hemophilia, hepatitis C, multiple sclerosis, Crohn's disease, rheumatoid
arthritis, and growth hormone deficiency.
97 Deschutes County Plan Document_0118_Medical
Specialty pharmacies specialize in the distribution of specialty drugs and providing
pharmacy care management services designed to assist patients in effectively managing their
condition.
Spouse means any individual who is legally married under current state law.
Stabilize means to provide medical treatment as necessary to ensure that, within reasonable
medical probability, no material deterioration of an emergency medical condition is likely to
occur during or to result from the transfer of the patient from a facility; and with respect to a
pregnant woman who is in active labor, to perform the delivery, including the delivery of the
placenta.
Step therapy means a program that requires the member to try lower-cost alternative
medications (Step 1 drugs) before using more expensive medications (Step 2 or 3 drugs). The
program will not cover a brand name, or second -line medication, until less expensive, first-
line/generic medications have been tried first.
Subscriber means an employee or former employee covered under the Plan. When a family
that does not include an employee or former employee is covered under the Plan, the oldest
family member is referred to as the subscriber.
Surgical procedure means any of the following listed operative procedures:
• Procedures accomplished by cutting or incision;
• Suturing of wounds;
Treatment of fractures, dislocations, and burns;
Manipulations under general anesthesia;
Visual examination of the hollow organs of the body including biopsy, or removal of tumors
or foreign body;
Procedures accomplished by the use of cannulas, needling, or endoscopic instruments; or
Destruction of tissue by thermal, chemical, electrical, laser, or ultrasound means.
Surrogate Mother means an adult woman who enters into an agreement to bear a child
conceived through assisted conception for intended parents.
Telemedical is the use of technology for exchange of information for diagnosis.
Third Party Administrator means an organization that processes claims and performs
administrative functions on behalf of a Plan Sponsor pursuant to the terms of a contract or
agreement. In the case of this Plan, the term Third Party Administrator refers solely to
PacificSource.
Tobacco cessation program means a program recommended by a physician that follows the
United States Public Health Services guidelines for tobacco cessation. Tobacco cessation
program includes education and medical treatment components designed to assist a person in
ceasing the use of tobacco products.
Tobacco use means use of tobacco on average four or more times per week within no longer
than the past six months. This includes all tobacco products. Tobacco use does not include
religious or ceremonial use of tobacco by American Indians and/or Alaska Natives.
98 Deschutes County Plan Document_0118_Medical
Urgent care treatment facility means a healthcare facility whose primary purpose is the
provision of immediate, short-term medical care for minor, but urgent, medical conditions.
Usual, customary, and reasonable fee (UCR) is the dollar amount established by
PacificSource, and adopted by the Plan Sponsor, for reimbursement of eligible charges for
specific services or supplies provided by non -participating providers. PacificSource uses
several sources to determine UCR. Depending on the service or supply and the geographical
area in which it is provided, UCR may be based on data collected from the Centers for
Medicare and Medicaid Services (CMS), contracted vendors, other nationally recognized
databases, or PacificSource, as documented in PacificSource's payment policy.
A non -participating provider may charge more than the limits established by the definition of
UCR. Charges that are eligible for reimbursement but exceed the UCR are the member's
responsibility (See Non -participating Providers in the Using the Provider Network section).
Waiting period means the period that must pass with respect to the individual before the
individual is eligible to be covered for benefits under the terms of the Plan.
Women's healthcare provider means an obstetrician, gynecologist, physician assistant,
naturopathic physician, nurse practitioner specializing in women's health, or certified nurse
midwife practicing within the applicable scope of practice.
99 Deschutes County Plan Document_0118_Medical
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100 Deschutes County Plan Document_0118_Medical
SIGNATURE PAGE
It is agreed by Deschutes County that the provisions of this document are correct and will
be the basis for the administration of the Plan.
The effective date of the Plan is January 1, 2018.
Dated this0.3-day of
By
Title
(7174(
YAM coaw-
mbeA1r .201
101 Deschutes County Plan Document_0118_Medical
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102 Deschutes County Plan Document_0118_Medical
DATE:
Deschutes County Board of Commissioners
1300 NW Wall St, Bend, OR 97703
(541) 388-6570 — Fax (541) 385-3202 — https://www.deschutes.org/
AGENDA REQUEST & STAFF REPORT
For Board of Commissioners Business Meeting of December 27. 2017
FROM: Kathleen Hinman, Human Resources, 541-385-3215
TITLE OF AGENDA ITEM:
Consideration of Board Approval of Deschutes County Group Dental Plan Document # 2017-
777
RECOMMENDATION & ACTION REQUESTED:
Staff recommends Board authorize County Administrator (Plan Sponsor) signature of
Deschutes County Employee Benefits Dental Plan document # 2017-777 for the 2018 plan
year.
CONTRACTOR: Contractor/Supplier/Consultant Name: Benefits Plan to be administered By
PacificSource.
AGREEMENT TIMEFRAME: Starting Date: 1/1/2018 Ending Date: N/A
BACKGROUND AND POLICY IMPLICATIONS: Deschutes County has established the
Deschutes County Group Health Plan (referred to as the "Plan") to provide health care
coverage for Eligible Employees and their Dependents. Deschutes County is the Plan
Sponsor.This Plan Document contains both the written Plan Document and the Summary Plan
Description ("SPD"). This is the latest revision of the dental plan document that will be
administered by PacificSource, the new Third Party Administrator, and effective 1/1/2018.
FISCAL IMPLICATIONS: N/A
ATTENDANCE: Kathleen Hinman, Director Human Resources and Trygve Bolken, Human
Resources Analyst
DESCHUTES COUNTY DOCUMENT SUMMARY
(NOTE: This form is required to be submitted with ALL contracts and other agreements, regardless of whether the document is to be
on a Board agenda or can be signed by the County Administrator or Department Director. If the document is to be on a Board
agenda, the Agenda Request Form is also required. If this form is not included with the document, the document will be returned to
the Department. Please submit documents to the Board Secretary for tracking purposes, and not directly to Legal Counsel, the
County Administrator or the Commissioners. In addition to submitting this form with your documents, please submit this form
electronically to the Board Secretary.)
Date: 112/21/17
Please complete all sections above the Official Review line.
Department: 1Human Resources
Contractor/Supplier/Consultant Name: 1PacificSourcel
Contractor Contact: 1Tony Kopkil Contractor Phone #: 1866-540-1191
Type of Document: Deschutes County Employee Dental Plan
Goods and/or Services: Deschutes County has established the Deschutes County
Group Health Plan (referred to as the or this "Plan") to provide health care coverage for
Eligible Employees and their Dependents. Deschutes County is the Plan Sponsor.This
Plan Document contains both the written Plan Document and the Summary Plan
Description ("SPD").
Background & History: This is the latest revision of the dental plan document that will
be administered by PacificSource, the new Third Party Administrator, effective 1/1/2018•
Agreement Starting Date: 11/1/20181
Annual Value or Total Payment:
Insurance Certificate Received (check box)
Insurance Expiration Date:
Check all that apply:
RFP, Solicitation or Bid Process
Informal quotes (<$150K)
Exempt from RFP, Solicitation or Bid Process (specify — see DCC §2.37)
1]
Ending Date:
N//
Funding Source: (Included in current budget? X Yes No
If No, has budget amendment been submitted?
Yes
Is this a Grant Agreement providing revenue to the County?
Special conditions attached to this grant:
Deadlines for reporting to the grantor:
II
No
Yes g No
12/21/2017
If a new FTE will be hired with grant funds, confirm that Personnel has been notified that
it is a grant -funded position so that this will be noted in the offer letter: 1 1 Yes No
Contact information for the person responsible for grant compliance:
Name:
Phone #:
Departmental Contact and Title:
Phone #: 541-317-31541
Department Director Approval:
Trygve Bolken Human Resources Analyst1
Signature
2.4 \
Date
Distribution of Document: Who gets the original document and/or copies after it has
been signed? Include complete information if the document is to be mailed.
Official Review:
County Signature Required (check one):
❑ BOCC (if $150,000 or more) — BOARD AGENDA Item
❑ County Administrator (if $25,000 but under $150,000)
❑ Department Director - Health (if under $50,000)
❑ Department Head/Director (if under $25,000)
Legal Review
Document Number 1
Date 7
l
12/21/2017
Deschutes County
Group No.: G0037173
Plan Name: Dental Plan
Effective: January 1, 2018
With Third Party Administrative Services Provided By:
PacificSource
Deschutes County Plan Document_0118_Dental
DC 2017 7 7
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Deschutes County Plan Document_0118_Dental
INTRODUCTION
Deschutes County has established the Deschutes County Group Dental Plan (referred to as the or
this "Plan") to provide dental care coverage for Eligible Employees and their Dependents. This Plan
is established effective January 1, 2018 (the "Effective Date"). Deschutes County is the Plan
Sponsor.
Any words or phrases used in this Plan Document that appear with an initial capital letter, or which
are in italics, are defined terms. All such words or phrases are defined in the Definitions section of
this Plan Document (See the Table of Contents for exact location). The Plan Sponsor highly
encourages you to read this Plan Document in its entirety and to ask any questions you may have
to ensure you understand your rights, responsibilities, and the benefits available to you under the
terms of this Plan.
Nature of the Plan
This Plan is an employee welfare benefit plan within the meaning of ERISA. This Plan is a self-
insured dental plan intended to meet the requirements of Sections 105(b), 105(h) and 106 of the
Internal Revenue Code so that the portion of the cost of coverage paid by the Employer, and any
benefits received by a Covered Individual through this Plan, are not taxable income to the Covered
Individual. The specific tax treatment of any Covered Individual will depend on the individual's
personal circumstances; the Plan does not guarantee any particular tax treatment. Covered
Individuals are solely responsible for any and all federal, state, and local taxes attributable to their
participation in this Plan, and the Plan expressly disclaims any liability for such taxes.
This Plan is "self-insured" which means benefits are paid from the Employer's general assets and/or
trust funds and are not guaranteed by an insurance company. The Plan Sponsor, which is also the
Plan Administrator, has contracted with the Third Party Administrator to perform certain
administrative services related to this Plan.
PacificSource Health Plans ("PacificSource") is the Third Party Administrator and will process
Claims, manage the network of Health Care Providers, answer dental benefit and Claim questions,
and to generally provide administrative services to the Plan. If anything is unclear to you, please
contact your Plan Sponsor or the Third Party Administrator at the number or address available in
this Introduction section.
Written Plan Document and SPD
This Plan Document contains both the written Plan Document and the Summary Plan Description
("SPD") required under ERISA. It is very important to review this Plan Document carefully to confirm
a complete understanding of the benefits available, as well as your responsibilities, under this Plan.
This Plan Document consists of several pieces, all of which work together. The Summary of
Benefits provides an overview of the key benefit provisions of the Plan and can give you a general
idea of what the Plan covers and how it works. However, it is important to read the entire Plan
Document, including the Definitions, to fully understand the Plan's coverage and benefits.
Deschutes County Plan Document_0118_Dental
Retention of Fiduciary Duties
The Plan Sponsor has retained all fiduciary duties under the Plan, including all interpretations of the
Plan and the benefits and exclusions it contains. This means that the Plan Sponsor is solely
responsible for all final decisions regarding what benefits are or will be covered, both now and in the
future. The Plan Sponsor is solely responsible for the design of the Plan. Plan Sponsor is solely
responsible for setting any and all criteria used to determine enrollment and eligibility.
Questions?
PacificSource's customer service representatives are available to answer questions or concerns
regarding the Plan. Phone lines are open from 8 a.m. to 5 p.m. Monday through Friday (excluding
holidays). PacificSource's customer service representatives are not authorized to interpret or
change the terms of the Plan.
For enrollment or eligibility questions, please contact the Plan Sponsor or PacificSource.
PacificSource Customer Service Team
Phone (888) 246-1370
Email dental@pacificsource.com
PacificSource Headquarters
110 International Way, Springfield, OR 97477
PO Box 7068, Springfield, OR 97475-0068
Phone (541) 686-1242 or (800) 624-6052
Website
PacificSource.com
As used in this Pian Document, the word 'year' refers to the contract year, which is the 12 -month
period beginning January 1st and ending December 31St. The word lifetime as used in this Plan
Document refers to the period of time you or your eligible family members participate in this Plan or
any other plan offered by the Plan Sponsor.
Representations not warranties: In the absence of fraud, all statements made by the Plan Sponsor
will be considered representations and not warranties. No statement made for the purpose of
effecting coverage will void the coverage or reduce benefits unless it is contained in a written
document signed by the Plan Sponsor and a provided to a member.
Governing Law
This Plan must comply with state and federal law, including required changes occurring after the
Plan's Effective Date. Therefore, coverage is subject to change as required by law.
Para asistirle en espanol, por favor Ilame el numero (866) 281-1464.
Deschutes County Plan Document_0118_Dental
CONTENTS
DENTAL BENEFIT SUMMARY A
ORTHODONTIC BENEFIT SUMMARY D
BECOMING ELIGIBLE 1
ENROLLING DURING THE INITIAL ENROLLMENT PERIOD 2
ENROLLING NEW FAMILY MEMBERS 3
PLAN SELECTION PERIOD 7
WHEN COVERAGE ENDS 7
CONTINUATION OF COVERAGE 8
CONTINUATION DUE TO PLAN SPONSOR APPROVED PAID ADMINISTRATIVE LEAVE OF
ABSENCE, DISABILITY, OR LEAVE OF ABSENCE 8
USERRA CONTINUATION 8
SURVIVING OR DIVORCED SPOUSES AND DOMESTIC PARTNERS 9
COBRA CONTINUATION 9
CONTINUATION WHEN YOU RETIRE 11
HOW TO USE YOUR PLAN 13
USING THE DENTAL ADVANTAGE NETWORK 13
COVERED EXPENSES 15
DENTAL PLAN BENEFITS 15
COVERED DENTAL SERVICES 15
CLASS I SERVICES 15
CLASS II SERVICES 16
CLASS III SERVICES 17
ORTHODONTIC SERVICES 17
BENEFIT LIMITATIONS AND EXCLUSIONS 18
EXCLUDED SERVICES 18
NECESSITY ACCORDING TO ACCEPTABLE DENTAL PRACTICE 21
INDIVIDUAL BENEFITS MANAGEMENT 21
CLAIMS PAYMENT 21
COORDINATION OF BENEFITS 23
THIRD PARTY LIABILITY 24
COMPLAINTS, GRIEVANCES, AND APPEALS 26
GRIEVANCE PROCEDURES 26
APPEAL PROCEDURES 26
HOW TO SUBMIT GRIEVANCES OR APPEALS 28
RESOURCES FOR INFORMATION AND ASSISTANCE 29
PLAN ADMINISTRATION 32
DEFINITIONS 34
Deschutes County Plan Document_0118_Dental
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Deschutes County Plan Document_0118_Dental
DENTAL BENEFIT SUMMARY
PLAN INFORMATION
Group Name: Deschutes County
Group Number: G0037173
Plan Name: Dental
Provider Network: Advantage Dental
EMPLOYEE ELIGIBILITY REQUIREMENTS
Minimum Hour Requirement: 20 hours per week
Waiting Period for New Employees: First day of the month following 30 days.
This dental Plan covers the following services when performed by a licensed dentist, dental
hygienist or denturist to the extent that they are operating within the scope of their license as
required under law in the state of issuance, and when determined to be necessary, usual, and
customary by the standards of generally accepted dental practice for the prevention or
treatment of oral disease or for accidental injury, including masticatory function (chewing of
food).
Advantage Network dentists contract with PacificSource to furnish dental services and
supplies for a set fee. That fee is called the contracted allowable fee. Participating providers
agree not to collect more than the contracted allowable fee. When you use an Advantage
Network dentist, you will pay only the participating provider amounts below. If you choose
not to use a participating dentist, or don't have access to them, reimbursement is based on
the 90th percentile of the usual, customary and reasonable fee (UCR). If charges exceed
the UCR fee, the excess charges are your responsibility.
$2,000 per person per calendar year. Applies to all covered services.
For members age 18 and younger, Class I Services do not apply towards the Annual
Benefit Maximum.
All Services: Services during the first year of eligibility will have 20% co-insurance, in
addition to the co -pay amounts listed below. In the second year of eligibility, the
member will only pay the co -pay amounts listed below.
A Deschutes County Plan Document_0118_Dental
The member is responsible for any amounts shown above, in addition to the following
amounts.
Service
Non -participating Providers
Class I Services
Examinations $15 co -pay $15 co -pay
Bitewing films, full mouth x-rays, $15 co -pay $15 co -pay
cone beam x-rays, and/or panorex
Dental cleaning (prophylaxis) $15 co -pay $15 co -pay
Topical fluoride
Fluoride varnish
Sealants
Space maintainers
Athletic mouth guards
Brush biopsies
Initial Orthodontic Exam
Class II Services
$15 co -pay $15 co -pay
$15 co -pay $15 co -pay
$15 co -pay $15 co -pay
$15 co -pay $15 co -pay
Not covered Not covered
$15 co -pay $15 co -pay
$15 co -pay $15 co -pay
Fillings $25 co -pay $25 co -pay
Dental cleaning (periodontal $25 co -pay $25 co -pay
maintenance)
Simple extractions $25 co -pay $25 co -pay
Periodontal scaling and root $25 co pay $25 co -pay
planing
Full mouth debridement $25 co -pay $25 co -pay
Complicated oral surgery $25 co -pay $25 co -pay
Pulp capping $25 co -pay $25 co -pay
Pulpotomy $25 co -pay $25 co -pay
Root canal therapy $25 co -pay $25 co -pay
Periodontal surgery $25 co -pay $25 co -pay
Tooth desensitization $25 co -pay $25 co -pay
Class III Services
Crowns $25 co -pay $25 co -pay
Replacement of existing
prosthetic device $25 co -pay $25 co -pay
Dentures $25 co -pay $25 co -pay
g Deschutes County Plan Document_0118_Dental
Bridges
$25 co -pay
$25 co -pay
Implants $25 co -pay $25 co -pay
This is a brief summary of benefits. Refer to the Plan Document for additional information or a further
explanation of benefits, limitations, and exclusions.
Additional Information`
•
The Annual Benefit Maximum is the maximum amount payable by this Plan for covered
services received each calendar year.
Coverage of certain dental services and surgical procedures requires a benefit determination
by PacificSource before the services are performed. This process is called `preauthorization'.
Preauthorization is necessary to determine if certain services and supplies are covered under
this Plan, and if you meet the Plan's eligibility requirements. You'll find the most current
preauthorization list on their website, PacificSource.com.
C Deschutes County Plan Document_0118_Dental
ORTHODONTIC BENEFIT SUMMARY
This Plan covers orthodontia for all eligible members.
The dollar amount listed below is the maximum benefit allowed for all orthodontic services
covered under this benefit, when prescribed by a licensed dentist or licensed orthodontist.
$2,000 per person
Limitations
50% co-insurance
Benefits for orthodontic covered services will be paid monthly on a pro -rated basis over the
length of the treatment. If the orthodontic treatment began before the patient was eligible for
this Plan, this Plan will continue to make payments toward the remaining balance due, as of
the patient's initial eligibility date. The above mentioned maximum will apply fully to this
amount. PacificSource's obligation, on behalf of the Plan Sponsor, to make payment for
orthodontic treatment ends when the patient's eligibility ends, or when treatment is terminated
before the case is completed.
Diagnostic casts are covered under the Orthodontic benefit.
Exclusions
• This Plan does not cover repair or replacement of orthodontic appliances furnished under
this program.
D Deschutes County Plan Document_0118_Dental
BECOMING ELIGIBLE
Who Pays for Your Benefits
Deschutes County shares the cost of employee and dependent coverage under this Plan with
the covered employees. This authorization must be filed out, signed and returned with the
enrollment application.
The level of any employee contributions is set by the Plan Sponsor. The Plan Sponsor
reserves the right to change the level of employee contribution.
In addition, the deductible and co -payments may also change periodically. You will be notified
by your Plan Sponsor of any changes in the cost this Plan's coverage before they take effect.
Employees
Your status as an Employee is determined by the employment records maintained by the Plan
Sponsor. Workers classified by the Plan Sponsor as independent contractors are not eligible
for coverage under this Plan under any circumstances. The Plan Sponsor decides the
minimum number of hours employees must work each week to be eligible for dental benefits.
The Plan Sponsor may also require new employees to satisfy a waiting period called the
'probationary waiting period' before they are eligible for benefits. The Plan Sponsor's eligibility
requirements, including the length of the probationary waiting period are shown in your Dental
Benefit Summary. All employees who meet those requirements are eligible for coverage.
Family members
While you are covered under this Plan, the following family members are also eligible for
coverage:
• Your legal spouse or your domestic partner.
• Your, your spouse's, or your domestic partner's natural or step children under age 26
regardless of the child's place of residence, marital status, or financial dependence on
you.
• Your, your spouse's, or your domestic partner's unmarried dependent children age 26
or over who are mentally or physically disabled. To qualify as dependents, they must
have been continuously unable to support themselves since turning age 26 because of
a mental or physical disability. The Plan Sponsor requires documentation of the
disability from the child's physician, and will review the case before determining
eligibility for coverage.
• A child placed for adoption with you, your spouse, or your domestic partner. 'Placed for
adoption' means the assumption and retention by you, your spouse, or domestic
partner of a legal obligation for full or partial support and care of the child in
anticipation of adoption of the child. Coverage will continue assuming continued
eligibility under this Plan unless placement is disrupted prior to legal adoption and the
child is removed from placement.
• A foster child placed with you, your spouse, or your domestic partner. Placed means
an individual who is placed by an authorized placement agency or by judgment,
decree, or other order of any court of competent jurisdiction. Coverage will continue
1 Deschutes County Plan Document_0118_Dental
assuming continued eligibility under this Plan unless placement is disrupted and the
child is removed from placement.
• A child placed in your, your spouse's, or your domestic partner's guardianship. To be
eligible for coverage, the child must be unmarried; not in a domestic partnership; under
age 19; and for whom you are the court appointed legal custodian or guardian with the
expectation the child will live in your household for at least a year.
No person can be covered both as an employee and as a dependent, or as a dependent of
more than one employee. Separate enrollments for employees that are married or are in a
domestic partnership will not be allowed. The employee who is employed the longest with
Deschutes County must enroll his or her spouse, domestic partner and any other eligible
dependents.
However, if both the mother and father are Employees of COIC, their children will be covered
as Dependents of the mother and father.
In cases where the mother or father is an Employee of Deschutes County and the mother or
father is an Employee of COIC, their children will be covered as Dependents of the mother
and father.
Special Rules for Eligibility
At any time the Plan Administrator may require proof that a person qualifies, or continues to
qualify, as a dependent as defined by this Plan.
ENROLLING DURING THE INITIAL ENROLLMENT PERIOD
Once you satisfy the Plan Sponsor's probationary waiting period, and meet the hours required
for eligibility, you and/or your eligible family members become eligible for this Plan. Starting on
the date you become eligible, you and your family members have 31 days to enroll. The Plan
Sponsor calls this 31 day window the initial enrollment period. To enroll you must submit the
completed enrollment application to the Plan Sponsor. The Plan Sponsor will send the
application to PacificSource.
If you miss your initial enrollment period, you will not be able to enroll in the Plan later in the
year, unless you have a special circumstance, called a 'qualifying event'. (For more
information, see 'Special Enrollment Periods' and 'Late Enrollment' under the Enrolling After
the Initial Enrollment Period section.)
Coverage for you and your enrolling family members begins after you satisfy the Plan
Sponsor's probationary waiting period. The length of the probationary waiting period is stated
in your Dental Benefit Summary. Coverage will only begin if the Plan Sponsor receives your
enrollment information, and forwards it to PacificSource.
Employees who were determined eligible for coverage during the applicable measurement
period (and their eligible dependents) may enroll in the Plan the first day of the first full
calendar month of the following stability period. Employees will be credited for time previously
satisfied toward the employment Waiting Period.
2 Deschutes County Plan Document_0118_Dental
ENROLLING NEW FAMILY MEMBERS
Newborns
Your newborn child is eligible from the date of birth for 31 days. To enroll your child
beyond 31 days, the Plan Sponsor must receive your enrollment change within 31 days
of the child's birth. A claim for maternity care is not considered notification for the purpose
of enrolling a newborn child. The Plan Sponsor may ask for legal documentation to
confirm validity.
In the case of a newborn of a dependent child, they will be eligible for coverage only
during the 31 days following the birth. In order to enroll the child, guardianship must be
given to the employee on the Plan.
In the case of a newborn of a male dependent child, the employee must supply proof of
paternity (at the Plan's expense).
Adopted Children
Your adopted child is eligible from the date of birth, placement, or finalization for 31 days. To
enroll your child, the Plan Sponsor must receive your enrollment change within 31 days of the
birth, placement, or finalization. Coverage for your new family members will begin on the date
of birth, placement, or finalization. The Plan Sponsor may ask for legal documentation to
confirm validity. If your adopted child is older than age 18 at the time of placement or
finalization, they may not be enrolled in this Plan.
Foster Children
When a foster child is placed in your home, you have 31 days from the date of placement to
enroll them on the Plan. To enroll the child, the Plan Sponsor must receive your enrollment
change within 31 days of the placement. Coverage for your new family members will begin on
the date of placement. The Plan Sponsor may ask for legal documentation to confirm validity
Family Members Acquired by Marriage
If you marry, you have 31 days from the date of the marriage to add your new spouse and any
newly eligible dependent children on this Plan. The Plan Sponsor must receive your
enrollment change from you within 31 days of the marriage. If the enrollment change is
received prior to the date of marriage, coverage for your new family members will begin on the
date of marriage. If the enrollment form is received after the date of marriage but within the 31
day enrollment period, coverage will begin on the first day of the month after the date of the
marriage. The Plan Sponsor may ask for legal documentation to confirm validity.
Family Members Acquired by Domestic Partnership
If you and your domestic partner have been issued a Certificate of Registered Domestic
Partnership, your domestic partner and your partner's dependent children are eligible for
coverage during the 31 day enrollment period after the registration of the domestic
partnership. The Plan Sponsor must receive your enrollment change during the enrollment
period. Coverage for your new family members will then begin on the first day of the month
after the date of the registration of the domestic partnership. The Plan Sponsor may ask for
legal documentation to confirm validity.
Family Members Placed in Your Guardianship
3 Deschutes County Plan Document_0118_Dental
If a court appoints you custodian or guardian of an eligible dependent child, you have 60 days
from the court appointment to enroll them on this Plan. The Plan Sponsor must receive your
enrollment change and any additional contribution from you within 31 days of the court
appointment. Coverage will then begin on the first day of the month after the date of the court
appointment. The Plan Sponsor may ask for legal documentation to confirm validity. When
the court order terminates or expires, the child is no longer eligible for coverage under this
Plan.
Qualified Medical Child Support Orders
This Plan complies with qualified medical child support orders (QMCSO) issued by a state
court or state child support agency. A QMCSO is a judgment, decree, or order, including
approval of a settlement agreement, which provides for health benefit coverage for the child of
a member of this Plan.
If a court or state agency orders coverage for your spouse, domestic partner, or child, you
have 31 days from the date of the court order to enroll them in this Plan. The Plan Sponsor
must receive your enrollment change and any additional contribution from you within 31 days
of the court order. Coverage will become effective on the first day of the month after the date
of the court order. The Plan Sponsor may ask for legal documentation to confirm validity.
ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD
Returning to Work after a Layoff or Termination
If you are laid off or terminated, and then rehired by the Plan Sponsor within six months, you
will not have to satisfy another probationary waiting period.
Your dental coverage will resume the first day of the month after you return to work and again
meet the Plan Sponsor's minimum hour requirement. If your family members were covered
before your layoff or termination, they can resume coverage at that time as well. You must re -
enroll your family members by submitting your enrollment change within the 31 day
enrollment.
Returning to Work after a Leave of Absence
If you return to work after a Plan Sponsor -approved leave of absence of six months or less,
you will not have to satisfy another probationary waiting period.
Your dental coverage will resume the day you return to work and again meet the Plan
Sponsor's minimum hour requirement. If your family members were covered before your leave
of absence, they can resume coverage at that time as well. You must re -enroll your family
members by submitting an enrollment change to the Plan Sponsor within the 31 day
enrollment period following your return to work.
Returning to Work after Family Medical Leave
If the Plan Sponsor employs 50 or more people, it is probably subject to the Family Medical
Leave Act (FMLA). To find out if you have rights under FMLA, contact your Human Resources
Department or dental Plan Administrator. Under FMLA, if you return to work after a qualifying
FMLA medical leave, you will not have to satisfy another probationary waiting period under
this Plan. Your dental coverage will resume the day you return to work and meet your
employer's minimum hour requirement. If your family members were covered before your
leave, they can also resume coverage at that time as well. You must re -enroll your family
4 Deschutes County Plan Document_0118_Dental
members by submitting an enrollment change to the Plan Sponsor within the 31 day
enrollment period following your return to work.
Status Change
Part-time to full-time conversion
Part-time employees who have waived coverage and then become a full-time employee or
have a significant increase in work hours (minimum of 25%), may elect to enroll in the
Standard Plan at that time. You may enroll by submitting an enrollment change to the Plan
Sponsor within the 31 days following the change in your employment status. Coverage is
effective the first of the month following the receipt of the application.
Part-time employees who are enrolled in the High Deductible Plan option who then become
full-time employees may either waive continuation of coverage or enroll in the Standard Plan
option at that time. You may enroll by submitting an enrollment change to the Plan Sponsor
within the 31 days following the change in your employment status. Coverage will become
effective the first day of the calendar month following or coinciding with the date the employee
is considered a full-time employee.
If a part-time employee's hours are reduced by a Deschutes County approved temporary
reduction in hours, coverage will continue without termination.
Full-time to part-time conversion
Full-time employees who have been covered under the Standard Plan and then become part-
time employees or have a significant decrease in work hours (minimum of 25%), may elect to
waive continuation of coverage or enroll in the High Deductible Plan option at that time. You
may enroll by submitting an enrollment change to the Plan Sponsor within the 31 days
following the change in your employment status. Coverage will become effective the first day
of the calendar month following or coinciding with the date the employee is considered a part-
time employee.
Full-time hourly employees who were covered under the Standard Plan and who experience a
change in job status to a part-time position of less than 20 hours per week while in a stability
period may continue coverage in the Standard Plan for 3 calendar months following the job
status change, if the employee continues to work in the part-time position and is on the
employer's payroll for that work. The employee may also choose to enroll in the High
Deductible Plan option at the time of the job status change. You may enroll by submitting an
enrollment change to the Plan Sponsor within the 31 days following the change in your
employment status. Coverage will become effective the first day of the calendar month
following or coinciding with the date the employee is considered a part-time employee.
Starting with the fourth calendar month, the employee's eligibility will be determined on a
month to month basis for the remainder of the stability period.
Employment transfer between COIC and Deschutes County
Employees who were employed by COIC and transfer their employment to Deschutes County
or vice versa, will not have to re -serve the probationary waiting period.
Special Enrollment Periods
You and your family members may decline coverage during your initial enrollment period. To
find out if this Plan allows employees to decline coverage, ask your Plan Sponsor. If you wish
to do so, you must submit a completed Waiver of Coverage form to the Plan Sponsor. You
5 Deschutes County Plan Document_0118_Dental
and your family members may enroll in this Plan later if you qualify under the Special
Enrollment Rules below.
Retirees and COBRA members may waive coverage for any reason. However, if they waive
coverage, they will not be able to re -enroll at a future date.
If you enroll during your initial enrollment period, your family members may decline coverage,
and they may enroll in the Plan later if they qualify under the Special Enrollment Rules below.
Employees are allowed to waive medical coverage and enroll in dental only if the employee
has an eligible waiver.
All special enrollment provisions assume that the employee has satisfied any probationary
periods required and each individual is eligible as stated in this Plan Document.
• Special Enrollment Rule #1
If you declined enrollment for yourself or your family members because of other health
coverage or there was a change in contribution, you or your family members may enroll in
the Plan later if the other coverage ends. To do so, you must submit a completed
enrollment application to the Plan Sponsor within 31 days after the other health coverage
ends (or within 60 days after the other health coverage ends if the other coverage is
through Medicaid or a State Children's Health Insurance Program). Coverage will begin
on the first day of the month following the receipt of the completed enrollment application.
• Special Enrollment Rule #2
If you acquire new family members because of marriage, domestic partnership, birth,
placement of foster child, or placement or finalization for adoption, you may be able to
enroll yourself and/or your eligible family members at that time. To do so, you must submit
a completed enrollment application to the Plan Sponsor within 31 days after the marriage,
qualification of the domestic partnership, birth, placement of foster child, or placement for
adoption. In the case of marriage or domestic partnership, coverage begins on the first
day of the month after the marriage or qualification of the domestic partnership. In the
case of birth, placement of foster child, placement or finalization for adoption, coverage
begins on the date of birth or placement. In the case of marriage, if the enrollment
application/change is received prior to the date of marriage, coverage will begin on the
marriage date.
• Special Enrollment Rule #3
If you or your family members become eligible for a premium assistance subsidy under
Medicaid or a state Children's Health Insurance Program (CHIP), you may be able to
enroll yourself and/or your family members at that time. To do so, you must submit a
completed enrollment application to the Plan Sponsor within 60 days of the date you
and/or your family members become eligible for such assistance. Coverage will begin on
the first day of the month after becoming eligible for such assistance.
Late Enrollment
If you did not enroll during your initial enrollment period and you do not qualify for a special
enrollment period, your enrollment will be delayed until the Plan's next designated open
enrollment period.
A `late enrollee' is an otherwise eligible employee or family member who does not qualify for a
special enrollment period explained above, and who:
• Did not enroll during the initial enrollment period; or
6 Deschutes County Plan Document_0118_Dental
• Enrolled during the initial enrollment period but discontinued coverage later.
A late enrollee may enroll by submitting a completed enrollment application to the Plan
Sponsor during the open enrollment period. When you or your family members enroll during
the open enrollment period, coverage becomes effective the first day of the contract year.
The annual open enrollment period will be during a two week period in November determined
anually. Employees and their dependents who are late enrollees or who are otherwise eligible
for coverage under the Plan will be able to enroll in the Plan. Benefit choices for late enrollees
made during the open enrollment period will become effective January 1St. Plan participants
will receive detailed information regarding open enrollment from their employer.
PLAN SELECTION PERIOD
If the Plan Sponsor offers more than one benefit plan, you may choose another plan option
only upon this Plan's anniversary date. You may select a different plan option by completing a
selection form or application form and submitting it to the Plan Sponsor. Coverage under the
new plan option becomes effective on this Plan's anniversary date.
WHEN COVERAGE ENDS
If you leave your job for any reason or your work hours are reduced below the Plan Sponsor's
minimum requirement, coverage for enrolled individuals will end. Coverage ends on the last
day of the last month in which you worked full time. You may, however, be eligible to continue
coverage for a limited time. (See Continuation of Coverage section).
Divorced Spouses
If you divorce, coverage for your spouse will end on the last day of the month in which the
divorce decree or legal separation is final. You must notify the Plan Sponsor of the divorce or
separation, and continuation coverage may be available for your spouse. If there are special
child custody circumstances, contact the Plan Sponsor. (See the Continuation of Insurance
section).
Dependent Children
When your enrolled child no longer qualifies as a dependent, their coverage will end on
the last day of the month they become ineligible. Please see Eligibility in the Becoming
Covered section for information on when your dependent child is eligible. The
Continuation of Coverage section includes information on other coverage options for
those children who no longer qualify for coverage.
If two employees are covered under the Plan and the employee who is covering the
dependent children terminates coverage, the dependent child may be continued by the other
covered employee with no waiting period as long as coverage has been continuous.
Dissolution of Domestic Partnership
If you dissolve your domestic partnership, coverage for your domestic partner and their
children not related to you by birth or adoption will end on the last day of the month in which
the dissolution of the domestic partnership is final. You must notify your employer of the
dissolution of the domestic partnership. Domestic partners and their covered children are not
recognized as qualified beneficiaries under federal COBRA continuation laws. Domestic
7 Deschutes County Plan Document_0118_Dental
partners and their covered children may not continue this Plan's coverage under COBRA
independent of the employee.
CONTINUATION OF COVERAGE
Under federal and/or state laws, you and your covered family members may have the
right to continue this Plan's coverage for a specified time. You and your family
members may be eligible if:
• Your employment ends or you have a reduction in hours.
• You take a leave of absence for military service.
• You divorce.
• You die.
• Your children no longer qualify as dependents.
The following sections describe your rights to continuation under applicable state
and/or federal laws, and the requirements you must meet to enroll in continuation
coverage.
CONTINUATION DUE TO PLAN SPONSOR APPROVED PAID
ADMINISTRATIVE LEAVE OF ABSENCE, DISABILITY, OR
LEAVE OF ABSENCE
A person may remain eligible for a limited time if active, full-time work ceases due to disability,
employer -certified leave of absence, or paid administrative leave.
For disability or employer -certified leave of absence, this continuance will remain in effect until
the end of the three calendar month period that next follows the month in which the person
last worked as an active employee.
For paid administrative leave, continuance will remain in effect until the date the employer, in
its sole discretion, ends the continuance.
While continued, coverage will be that which was in force on the last day worked as an active
employee. However, if benefits reduce for others in the class, they will also reduce for the
continued person.
If you return to work after a Plan Sponsor -approved paid administrative leave of absence, you
will not have to satisfy another probationary waiting period.
USERRA CONTINUATION
If you take a leave of absence from your job due to military service, you have continuation
rights under the Uniformed Services Employment and Re-employment Rights Act (USERRA).
Enrolled individuals may continue this Plan's coverage if you, the employee, no longer qualify
for coverage under the Plan because of military service. Continuation coverage under
USERRA is available for up to 24 months while you are on military leave. If your military
service ends and you do not return to work, your eligibility for USERRA continuation coverage
will end. Premium for continuation coverage is your responsibility.
8 Deschutes County Plan Document_0118_Dental
The following requirements apply to USERRA continuation:
• Only family members who were enrolled in the Plan can take continuation. The only
exceptions are newborn babies and newly acquired eligible family members not covered by
another group dental Plan.
• To apply for continuation, you must submit a completed Continuation Election Form to your
employer within 60 days after the last day of coverage under the Plan.
• You must pay continuation premium to the Plan Sponsor by the first of each month.
PacificSource cannot accept the premium directly from you.
• The Plan Sponsor must still be self-insured. If the Plan Sponsor discontinues this Plan, you
will no longer qualify for continuation.
SURVIVING OR DIVORCED SPOUSES AND DOMESTIC
PARTNERS
If your group has 20 or more employees, or your group dental plan has 20 or more
subscribers, and you die, divorce, or dissolve your domestic partnership, and your spouse or
domestic partner is 55 years or older, your spouse or domestic partner may be able to
continue coverage until eligible for Medicare or other coverage. Dependent children are
subject to the Plan's age and other eligibility requirements. Some restrictions and guidelines
apply; please see your employer for specific details.
COBRA CONTINUATION
This Plan is subject to the continuation of coverage provisions of the Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA) as amended. To find out if you have continuation
rights under COBRA, ask your Human Resources Department or dental Plan Administrator.
COBRA Eligibility
If, as an active employee, you were required to enroll in a medical plan as well as this dental
Plan, you may continue coverage under this dental Plan if you also continue coverage under
the medical plan. If, as an active employee, you enrolled in only the dental Plan, you may
continue coverage under this dental Plan according to the following:
A 'qualifying event' is the event that causes your regular group coverage to end and makes
you eligible for continuation coverage. When the following qualifying events happen, you may
continue coverage for the lengths of time shown:
1 Qualifying Event
Employee's termination of employment or
reduction in hours
Employee's divorce
Employee's eligibility for Medicare benefits if it
causes a loss of coverage
Employee's death
Child no longer qualifies as a dependent
Continuation Period
Employee, spouse, and children may continue
for up to 18 months'
Spouse and children may continue for up to 36
months2
Spouse and children may continue for up to 36
months
Spouse and children may continue for up to 36
months2
Child may continue for up to 36 months2
9 Deschutes County Plan Document_0118_Dental
If the employee or covered family member is determined disabled by the Social Security
Administration within the first 60 days of COBRA coverage, all qualified beneficiaries may
continue coverage for up to 29 months.
2 The total maximum continuation period is 36 months, even if there is a second qualifying
event. A second qualifying event might be a divorce, death, or child no longer qualifying as a
dependent after the employee's termination or reduction in hours.
If your family members were not covered prior to your qualifying event, they may enroll in the
continuation coverage while you are on continuation. They will be subject to the same rules
that apply to active employees, including the late enrollment waiting period.
If your employment is terminated for gross misconduct, you and your family members are not
eligible for COBRA continuation.
Domestic partners and their covered children may not continue this Plan's coverage under
COBRA independent of the employee.
When Continuation Coverage Ends
Your continuation coverage will end before the end of the continuation period above if any of
the following occur:
• Your continuation premium is not paid on time.
• You become entitled to Medicare benefits.
The Plan Sponsor discontinues this Plan and no longer offers a group dental Plan to any
of its employees.
• Your continuation period was extended from 18 to 29 months due to disability, and you are
no longer considered disabled.
Type of Coverage
Under COBRA, you may continue any coverage you had before the qualifying event. If the
Plan Sponsor provides both medical and dental coverage and you were enrolled in both, you
may continue both medical and dental. If the Plan Sponsor provides only one type of
coverage, or if you were enrolled in only one type of coverage, you may continue only that
coverage. If the Plan Sponsor offers more than one benefit plan to eligible employees, a
member electing COBRA may select enrollment for another plan at the time the member
elects COBRA coverage. Members electing COBRA may not add family members at this time
unless they otherwise qualify under the 'Special Enrollment' provisions of the Plan.
COBRA continuation benefits are always the same as your employer's current benefits. The
Plan Sponsor has the right to change the benefits of this dental Plan or eliminate the Plan
entirely. If that happens, any changes to the group dental Plan will also apply to everyone
enrolled in continuation coverage.
Your Responsibilities and Deadlines
You must notify the Plan Sponsor within 60 days if you divorce, or if your child no longer
qualifies as a dependent. That will allow the Plan Sponsor to notify you or your family
members of your continuation rights.
10 Deschutes County Plan Document_0118_Dental
When the Plan Sponsor learns of your eligibility for continuation, it will notify you of your
continuation rights and provide a Continuation Election form. You then have 60 days from that
date or 60 days from the date coverage would otherwise end, whichever is later, to enroll in
continuation coverage by submitting a completed Continuation Election form to the Plan
Sponsor. If continuation coverage is not elected during that 60 day period, coverage will end
on the last day of the last month you were an active employee or when your family member
lost eligibility.
If you fail to provide the Plan Sponsor with the Continuation Election form in the required
timeframe, then the Plan Sponsor's obligation to provide you with COBRA coverage will end.
PacificSource does not accept any liability for any failure, on your part or the part of the Plan
Sponsor, to provide required notices or coverage.
Continuation Premium
Enrolled individuals are responsible for the full cost of continuation coverage. The Plan
Sponsor uses the services of a third -party COBRA administrator to collect premium for
continuation coverage. Please see the Plan Sponsor for more information about the Plan's
COBRA administrator. The monthly premium must be paid to the Plan Sponsor's COBRA
administrator. You may make your first premium payment any time within 45 days after you
return your Continuation Election Form to the Plan Sponsor's COBRA administrator. After the
first premium payment, each monthly payment must reach the Plan Sponsor's COBRA
administrator within 30 days of your premium due date. If the COBRA administrator does not
receive your continuation premium on time, continuation coverage will end. If your coverage is
canceled due to a missed payment, it will not be reinstated for any reason. It is solely your
responsibility to ensure that the COBRA administrator receives the premium on time.
Premium rates are established annually and may be adjusted if the Plan's benefits or costs
change.
Keep Your Pian Sponsor Informed of Any Address Changes
It is your responsibility to ensure that you keep the Plan Sponsor informed of any changes in
your mailing address, and the mailing address of any dependents covered by your dental
coverage. You should also keep a copy of any notices you send to the Plan Sponsor along
with proof of transmission or mailing.
CONTINUATION WHEN YOU RETIRE
Continuation upon retirement is based on meeting all the retirement requirements set forth in
your employment agreement with your Plan Sponsor
• You must be receiving benefits from PERS (Public Employee Retirement System) or
from a similar retirement Plan offered by your Plan Sponsor;
• You must have been continuously covered under the group's Plan for at least 24
consecutive months prior to the retirement, unless otherwise indicated by a
management/labor agreement.
If you become eligible for PERS while enrolled in COBRA due not being at work because of
disability, you can elect to re -enroll as a retired employee only under this Plan. You must
request re -enrollment within 6 months of PERS eligibility.
11 Deschutes County Plan Document_0118_Dental
Your continuation coverage will end when any one of the foHowing occurs:
When a retired employee's coverage terminates, Retired employee coverage wiH terminate
on the earlies of these dates:
• The date the PIan is terminated;
• The date the covered retired employee's eligible class is eliminated;
• The first day of the calendar month the covered retired employee becomes eligible for
Medicare;
• The end of the period for which the required contribution has been paid if the charge for
the next period is not paid when, due; or
• As otherwise sin the Eligibiiity section of the PIan.
Your family member's continuation coverage will end when any one of the following
occurs:
When Dependent Coverage of a Retired Employee Terminates.
When a retired employee's coverage terminates under this Plan due to reaching age 65 or
becoming entitled to Medimana, his/her dependents may remain eligible for benefits until the
dependent's coverage terminates as outlined below. The PIan Sponsor must be notified that
the dependent coverage is to continue within 31 days of the retired employee's termination. A
retired employee's dependent's coverage will terminate on the earliest of these dates:
o The last day of the calendar month the Plan or dependent coverage under the Plan is
terminated;
• On the last day of the calendar month acovered spouse or domestic partner of a retired
employee loses coverage due to loss of dependency status. (See the Continuation of
Coverage section.)
• The first day of the month the covered dependent spouse or domestic partner becomes
entitled to Medicare;
o On the Iast day of the calendar month that a dependent child ceases to be a dependentoa
defined by the Plan. (See the Continuation of Coverage section.)
• The end of the period for which the required contribution has been paid if the charge for
the next period is not paid when due; or
^ As otherwise specified in the Eliibi|Uv8eoUonofthePlan.
WORK STOPPAGE
Labor Unions
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 contribution, including any part usually paid bvthe mrnp|oyer.
directly tothe union ortrust that represents hinmorher. The union ortrust nnu'tcontinue to
pay the contributions 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
12 Deschutes County Plan Oocument_O118_Donta|
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.
HOW TO USE YOUR PLAN
When you first visit your dentist after becoming covered under this Plan, let the office staff
know that PacificSource provides administrative services to this Plan. You will need to show
your member ID card, which contains your group number and benefit information. Most dental
offices will send the bills directly to PacificSource. Your dentist may submit claims and
treatment programs on a standard American Dental Association form. If your dentist has any
questions regarding billing procedures, they can call PacificSource toll-free at (866) 373-7053.
For extensive dental work, we recommend that your dentist submit a preauthorization request
to PacificSource. We then determine how much the Plan will pay toward the proposed
treatment and review the estimate with your dentist prior to treatment. If your covered family
members require extensive dental work, be sure your member ID number and group number
are included on their pre-treatment form for identification purposes.
USING THE DENTAL ADVANTAGE NETWORK
This section explains how this Plan's benefits differ when you use Dental Advantage Network
providers and non -participating providers. This information is not meant to prevent you from
seeking treatment from any provider if you are willing to take increased financial responsibility
for the charges incurred.
All dental care providers are independent contractors. Neither the Plan Sponsor nor
PacificSource can be held liable for any claim for damages or injuries you experience while
receiving dental care.
PARTICIPATING PROVIDERS
Participating providers contract with PacificSource, directly or indirectly, to furnish dental
services and supplies to members enrolled in this Plan for a set fee. That fee is called the
contracted allowable fee. Participating providers agree not to collect more than the contracted
allowable fee. When you receive covered dental services or supplies from a participating
provider, you are only responsible for the amounts stated in the Dental Benefit Summary.
Depending on your Plan, those amounts can include a deductible, co -payment, and/or co-
insurance payment.
NON -PARTICIPATING PROVIDERS
When you receive dental services or supplies from a non -participating provider, payment and
application of benefits are as follows:
• Eligible charges considered for payment to non -participating providers are based on the
allowable usual, customary, and reasonable (UCR) fee.
• PacificSource makes payment for non -participating providers at the percentage stated in
the Dental Benefit Summary. The non -participating provider's usual charge may exceed the
allowable UCR fee. The dollar amount PacificSource pays may be a lower percentage of
the provider's total charge than the non -participating provider co-insurance stated in the
Dental Benefit Summary.
13 Deschutes County Plan Document_0118_Dental
Example of Provider Payment
The following example shows how payment could be made to providers for a covered service
billed at $110 for a Class II procedure. This is only an example; this Plan's benefits may be
different:
In -network Out -of -network
Provider Provider
Provider's usual charge $110 $110
Provider discount $10 $0
PacificSource allowable fee $100 $100
Member's co-insurance 20% 20%
PacificSource's payment $80 $80
Member's amount of allowable fee $20 $20
Charges above allowable fee $0 $10
Member's total payment due to provider $20 $30
Percent of charge paid by PacificSource 80% 73%
Percent of charge paid by member 20% 27%
I
FINDING DENTAL ADVANTAGE NETWORK PROVIDER
INFORMATION
You can find up-to-date Dental Advantage Network provider information:
• Asking your dental care provider if they are a Dental Advantage Network provider for
PacificSource-backed dental plans.
• On the PacificSource website, PacificSource.com. go to 'Find a Doctor or Dentist' to easily
look up Dental Advantage providers. You can also print your own customized directory.
• By contacting the PacificSource Customer Service team. Their staff can answer your
questions about specific providers.
TERMINATION OF PROVIDER CONTRACTS
PacificSource will use best efforts to notify you within 30 days of learning about the
termination of a provider contractual relationship if you have received services in the previous
three months from such a provider when:
• A provider terminates a contractual relationship with PacificSource in accordance with the
terms and conditions of the agreement;
• A provider terminates a contractual relationship with an organization under contract with
PacificSource; or
• PacificSource terminates a contractual relationship with an individual provider or the
organization with which the provider is contracted in accordance with the terms and
conditions of the agreement.
Note: On the date a provider's contract with PacificSource terminates, they become a non-
participating provider and any services you receive from them will be paid at the percentage
shown in the "Non -participating Provider" column of your Dental Benefit Summary. To avoid
14 Deschutes County Plan Document_0118_Dental
unexpected costs, be sure to verify each time you see your provider that they are still
participating in the network.
Contact our Customer Service team for additional information.
COVERED EXPENSES
DENTAL PLAN BENEFITS
When this Plan pays for dental services, it actually pays the percentage of charges based on
reasonable and customary charges. A charge is reasonable and customary when it falls within
a general range of charges being made by most dental providers in your service area for
similar treatment of similar dental conditions. If the charge for a treatment or service is more
than the reasonable and customary charge in your service area, you may be required to pay
the difference. The reasonable and customary charge for dental expense is the `covered
charge' referred to in this Plan Document.
If you or your covered family member selects a more expensive treatment than is customarily
provided, this Plan will pay the applicable percentage of the lesser fee. You will be responsible
for the balance of the provider's charges. With the Advantage Network, participating dentists
agree to write off any charges over and above the negotiated, contracted fees for most
services. When you use a participating dentist in the Advantage Network, you will not be
responsible for any excess charges and will pay only the Plan's deductible and/or co-
insurance amount. If you choose not to use a participating Advantage Network dentist, or
don't have access to them, reimbursement will continue to be based on the contracted
allowable fee. If that non -participating dentist's fees exceed the contracted allowable fee, the
excess charges are also your responsibility.
Subject to all the terms of this Plan, incurred dental expense for the following services and
supplies are covered according to the Dental Benefit Summary. Benefits are eligible for
payment only to the extent a charge is, or would be, made for the least costly service or
supply appropriate to your dental treatment. Charges in excess of the least costly service or
supply appropriate for treatment or the contracted allowable fee are not covered under this
Plan and become your responsibility.
COVERED DENTAL SERVICES
This Plan covers the following services when performed by an eligible provider and when
determined to be necessary by the generally accepted standards of dental practice for the
prevention or treatment of oral disease or for accidental injury, including masticatory function
(chewing of food). Covered services may also be provided by a dental hygienist or denturist to
the extent that they are operating within the scope of their license as required under state law.
Covered dental services are organized into different classes, starting with preventive care and
advancing into specialized dental treatments.
CLASS I SERVICES
• Benefits for examinations (routine or other diagnostic exams) are covered. Separate
charges for review of a proposed treatment plan or for diagnostic aids, such as study
models and diagnostic lab tests (other than brush biopsies), are not covered. Problem
focused examinations are covered.
15 Deschutes County Plan Document_0118_Dental
• Benefits for a full mouth series x-rays, a cone beam x-ray, panorex, bite -wing films,
and periapical x-rays are covered.
• Benefits for dental cleaning (prophylaxis) are covered.
• Benefits for the topical application of fluoride are limited to two applications per calendar
year.
• Benefits for fluoride varnish applications are covered.
• Benefits for the application of sealants are covered.
• Benefits for space maintainers are covered.
• Benefits for brush biopsies are covered.
• Benefits for the initial Orthodontic exam is covered as Class I.
CLASS 11 SERVICES
• Benefits for dental cleaning (periodontal maintenance) are covered.
• Benefits for a composite, resin, or similar restoration in a posterior (back) tooth are
covered. A separate charge for anesthesia when used during restorative procedures is not
a covered benefit.
• Simple extractions of teeth and other minor oral surgery procedures are covered. A
separate charge for alveolectomy performed in conjunction with removal of teeth is not a
covered benefit.
• Benefits for periodontal scaling and root planing and/or curettage are covered.
• Benefits for full mouth debridement are covered.
• Complicated oral surgery procedures such as the removal of impacted teeth are limited
to procedures that have been preauthorized by PacificSource. A separate charge for
alveolectomy performed in conjunction with removal of teeth is not a covered benefit.
• Benefits for pulp capping are payable only when there is an exposure to the pulp. These
are direct pulp caps. Indirect pulp caps are not covered.
• Benefits for a pulpotomy are payable only for deciduous teeth.
• Benefits for root canal therapy on the same tooth are payable only for one charge in a 36
month period.
• Benefits for periodontal surgery are limited to procedures that have been preauthorized by
PacificSource and accompanied by a periodontal diagnosis and history of conservative
(non-surgical) periodontal treatment.
• Benefits for tooth desensitization are covered as a separate procedure from other dental
treatment.
• Core build-ups are only covered when used to restore a tooth that has been treated
endodontically (root canal).
16 Deschutes County Plan Document_0118_Dental
• Benefits for anesthesia services are limited to children age six or younger and patients
with mental disabilities that render them incapable of treatment in the dental office under
local anesthesia. This is limited to conscious sedation and single oral sedatives.
• Benefits for general anesthesia (including nitrous oxide) and its administration in
connection with complex oral surgery, major periodontics procedures, fractures or
dislocations, or due to a concurrent medical condition.
CLASS III SERVICES
• Benefits for crowns and other cast or laboratory -processed restorations are limited to the
restoration of any one tooth in a 60 month period. If a tooth can be restored with a material
such as amalgam or composite resin, covered charges are limited to the cost of amalgam or
non -laboratory composite resin restoration even if another type of restoration is selected by
the patient and/or dentist.
• Benefits for an initial cast partial denture, full denture, immediate denture, or
overdenture are limited to the cost of a standard full or cast partial denture. A separate
charge for denture adjustments and relines performed within six months of the initial
placement is not a covered benefit. Benefits for subsequent relines are provided only once
in a 12 month period. Cast restorations for partial denture abutment teeth or for splinting
purposes are not covered unless the tooth in and of itself requires a cast restoration.
• Benefits for initial fixed bridges or removable cast partials are covered. Benefits for
temporary full or partial dentures must be preauthorized by PacificSource.
• Benefits for the replacement of an existing prosthetic device are provided only when the
device being replaced is unserviceable, cannot be made serviceable, and has been in place
for at least 60 months.
• Benefits for the surgical placement and removal of implants are limited to once per lifetime
per tooth space. Services must be preauthorized by PacificSource to be covered. Benefits
include final crown and implant abutment over a single implant, final implant -supported
bridge abutment, and implant abutment, or pontic. An alternative benefit per arch of a
conventional full or partial denture for the final implant -supported full or partial denture
prosthetic device is available.
• Benefits for splints, night guards, or appliances used to increase vertical dimensions, restore the
occlusion, or correct habits such as tongue thrust and grinding teeth. Periodontal splinting
including crowns and bridgework used in conjunction with periodontal splinting.
ORTHODONTIC SERVICES
This Plan covers charges for orthodontia for all eligible individuals
The amount this Plan pays is outlined in the Orthodontic Benefit Summary.
Benefits for orthodontic covered services will be paid monthly on a pro -rated basis over the
length of the treatment. If the orthodontic treatment began before the patient was eligible for
this Plan, this Plan will continue to make payment toward the remaining balance due as of the
patient's initial eligibility date. The lifetime maximum amount stated in the Orthodontic Benefit
Summary will apply fully to this amount.
Diagnostic casts are covered under the orthodontic benefit.
17 Deschutes County Plan Document_0118_Dental
This Plan does not cover repair or replacement of orthodontic appliances furnished under this
program.
PacificSource's obligation, on behalf of the Plan Sponsor, to make payment for orthodontic
treatment ends when the patient's eligibility ends, or when treatment is terminated before the
case is completed.
BENEFIT LIMITATIONS AND EXCLUSIONS
EXCLUDED SERVICES
This Plan does not provide benefits in any of the following circumstances or for any of the
following conditions:
• Aesthetic dental procedures — Services and supplies provided in connection with dental
procedures that are primarily aesthetic, including bleaching of teeth and labial veneers.
• Alveoloplasty.
• Antimicrobial agents — Localized delivery of antimicrobial agents into diseased crevicular
tissue via a controlled release vehicle.
• Athletic activities — Any injuries sustained while competing or practicing for a professional or
semiprofessional athletic contest.
• Athletic mouth guards.
• Benefits not stated — Any services and supplies not specifically described as covered
benefits under the dental Plan.
• Biopsies or histopathologic exams — (except when related to tooth structure and
preauthorized).
• Bone replacement grafts for purposes other than to prepare sockets for implants after tooth
extraction.
• Charges for missed appointments.
• Collection of cultures and specimens.
• Comprehensive periodontal exams.
• Connector bar or stress breaker.
• Core build-ups are not covered unless used to restore a tooth that has been treated
endodontically (root canal).
• Cosmetic/reconstructive services and supplies — Procedures, appliances, restorations, or
other services that are primarily for cosmetic purposes (does not apply to emergency
services). This includes services or supplies rendered primarily to correct congenital or
developmental malformations, including but not limited to, peg laterals, cleft palate,
maxillary and mandibular (upper and lower jaw) malformations, enamel hypoplasia,
veneers, and fluorosis (discoloration of teeth). However, the replacement of congenitally
missing teeth is covered.
• Denture replacement made necessary by loss, theft, or breakage.
18 Deschutes County Plan Document_0118_Dental
• Diagnostic casts — Diagnostic casts (study models), occlusal appliance, gnathological
recordings, occlusal equilibration procedures, or similar procedures are only covered in
conjunction with the orthodontia benefit.
• Drugs and medications that are prescribed drugs and take-home medicine or supplies
distributed by a provider for any member. As well as premedication drugs, analgesics (for
example, nitrous oxide or non-intravenous sedation), and any other euphoric drugs, or any
take-home medicine or supplies distributed by a provider.
• Educational programs — Instructions and/or training in plaque control and oral hygiene.
• Experimental or investigational procedures — Services, supplies, protocols, procedures,
devices, drugs or medicines, or the use thereof that are experimental or investigational for
the diagnosis and treatment of the patient. An experimental or investigational service is not
made eligible for benefits by the fact that other treatment is considered by the member's
dental care provider to be ineffective or not as effective as the service or that the service is
prescribed as the most likely to prolong life.
• Fractures of the maxilla and mandible — Surgery, services, and supplies provided in
connection with the treatment of simple or compound fractures of the maxilla or mandible.
• General anesthesia except when administered by a dentist in connection with oral surgery
in his/her office.
• Gingivectomy, gingivoplasty, or crown lengthening in conjunction with crown preparation or
fixed bridge services done on the same date of service.
• Hospital charges or additional fees charged by the dentist for hospital treatment.
• Hypnosis.
• Indirect pulp caps are to be included in the restoration process, and are not a separate
covered benefit.
• Infection control — A separate charge for infection control or sterilization.
• Intra and extra coronal splinting — Devices and procedures for intra and extra coronal
splinting to stabilize mobile teeth.
• Mail order or Internet/Web based providers are not eligible providers.
• Occlusal adjustments.
• Orthodontic services — Repair or replacement of orthodontic appliances furnished under this
Plan.
• Orthognathic surgery — Surgery to manipulate facial bones, including the jaw, in patients
with facial bone abnormalities performed to restore the proper anatomic and functional
relationship to the facial bones.
• Periodontal probing, charting, and re-evaluations.
• Photographic images.
• Pin retention in addition to restoration.
• Precision attachments.
19 Deschutes County Plan Document_0118_Dental
• Pulpotomies on permanent teeth.
• Removal of clinically serviceable amalgam restorations to be replaced by other materials
free of mercury, except with proof of allergy to mercury.
• Services covered by the member's medical plan.
• Services for rebuilding or maintaining chewing surfaces due to teeth out of alignment or
occlusion, or for stabilizing the teeth.
• Services or supplies with no charge, or for the Plan Sponsor has paid, or for which you are
not legally required to pay, or which a provider or facility is not licensed to provide even
though the service or supply may otherwise be eligible. This exclusion includes any services
provided to you by any licensed professional that is directly related to you by blood or
marriage.
• Services otherwise available – These include but are not limited to:
— Services or supplies for which payment could be obtained in whole or in part if the
member applied for payment under any city, county, state, or federal law (except
Medicaid);
— Services or supplies the member could have received in a hospital or program
operated by a federal government agency or authority. Covered expenses for services
or supplies furnished to a member by the Veterans' Administration of the United States
that are not service -related are eligible for payment according to the terms of this Plan;
and
— Services or supplies for which payment would be made by Medicare.
• Services or supplies provided outside of the United States, except in cases of emergency.
• Sinus lift grafts to prepare sinus site for implants.
• Stress -breaking or habit -breaking appliances.
• Temporomandibular joint (TMJ) – Services or supplies for treatment of any disturbance of the
temporomandibular joint.
• Third party liability, motor vehicle liability, motor vehicle insurance coverage, workers'
compensation – Any services or supplies for illness or injury for which a third party is
responsible or which are payable by such third party or which are payable pursuant to
applicable workers' compensation laws, motor vehicle liability, uninsured motorist,
underinsured motorist, and personal injury protection insurance and any other liability and
voluntary dental payment insurance to the extent of any recovery received from or on behalf
of such sources.
• Tooth transplantation – Services and supplies provided in connection with tooth
transplantation, including re -implantation from one site to another and splinting and/or
stabilization. This exclusion does not relate to the re -implantation of a tooth into its original
socket after it has been avulsed.
• Treatment after coverage ends – Services or supplies provided after enrollment in this Plan
ends.
• Treatment not dentally necessary according to acceptable dental practice or treatment not
likely to have a reasonably favorable prognosis.
20 Deschutes County Plan Document_0118_Dental
• Treatment of any illness, injury, or disease resulting from an illegal occupation or attempted
felony, or treatment received while in the custody of any law enforcement other than with
the local supervisory authority while pending disposition of charges.
• Treatment prior to enrollment — Dental services began before you or your family member
became eligible for those services under this Plan.
• Unwilling to release information — Charges for services or supplies for which you are
unwilling to release dental or eligibility information necessary to determine the benefits
payable under this Plan.
• Vizilite.
• War -related conditions — The treatment of any condition caused by or arising out of an act
of war, armed invasion, or aggression, or while in the service of the armed forces that
occurred while on this.
NECESSITY ACCORDING TO ACCEPTABLE DENTAL
PRACTICE
The benefits of this Plan are paid only toward the covered expense of necessary diagnosis or
treatment according to acceptable dental practice. This is true even though the service or
supply is not specifically excluded. All treatment is subject to review for necessity according to
acceptable dental practice. Review of treatment may involve prior approval, concurrent review
of the continuation of treatment, post-treatment review or any combination of these. Just
because a dentist may prescribe, order, recommend, or approve a service or supply
does not, of itself, make the charge a covered expense.
The Plan has the right to arrange, at its expense, a second opinion by a provider of its choice,
and is not required to pay benefits unless that opinion has been rendered.
INDIVIDUAL BENEFITS MANAGEMENT
Individual benefits management addresses, as an alternative to providing covered services,
the Plan's consideration of economically justified alternative benefits. The decision to allow
alternative benefits will be made by the Plan on a case-by-case basis. The Plan's
determination to cover and pay for alternative benefits for a member shall not be deemed to
waive, alter or affect the Plan's right to reject any other or subsequent request or
recommendation. The Plan may elect to provide alternative benefits if the Plan and the
member's attending provider concur in the request for and in the advisability of alternative
benefits in lieu of specified covered services, and, in addition, the Plan concludes that
substantial future expenditures for covered services for the member could be significantly
diminished by providing such alternative benefits under the individual benefit management
program.
CLAIMS PAYMENT
How to File a Claim
When a participating provider treats you, your claims are automatically sent to PacificSource
and processed. All you need to do is show your member ID card to the provider.
If you receive care from a non -participating provider, the provider may submit the claim to
PacificSource for you. If not, you are responsible for sending the claim to them for processing.
21 Deschutes County Plan Document_0118_Dental
Your claim must include a copy of your provider's itemized bill. It must also include your nmnxa,
member ID number or social security number, group name, group number, and the patient's
name. If you were treated for an accidental injury, please include the date, time, p/oce, and
circumstances of the accident.
All claims for benefits must bmturned intoPacifin8Vuncewithin 80davmofthe date ofservice.
If it is not possible to submit claim within 90 days, turn in the claim with ' an explanation as
soon as possibe. In some cases PacificSource may accept the late claim if the PIan aliows.
This PIan will never pay a claim that was submitted more than a year after the date of service.
All claims should be sent to:
PacificSource Health Plan
Attn: Dental Claims
PO Box 7068
Springfield, OR 97475-0068
Claim Payment Practices
Unless additional information is needed to process your claim, Pmoific8ouromviU make every
effort to pay or deny your claim within 30 days of receipt. If a claim cannot be paid within 30
days of receipt because additional information is needed, PacificSource will acknowledge
receipt of the claim and explain why payment is delayed. If PacificSource does not receive the
necessary information within 15 days of the delay npdoe, they will either deny the claim or
notify you every 45 days while the claim remains under investigation.
The Plan may pay benefits to the nnunnbmr, the prov/der, or both jointly. Neither the benefits of
this Plan norm claim for payment of benefits under the Plan are assignable in whole or in part
to any person or entity.
Questions About Claims
If you have questions about the status of a claim, you are welcome to contact the
PacificSource Customer Service team. You may also contact Customer Service if you believe
a claim was denied in error. PacificSource will review your claim and the Plan benefits to
determine if the claim is eligible for payment. Then PacificSource will either reprocess the
claim for payment, or contact you with an explanation.
Benefits Paid in Error
If the Plan makes a payment to you that you are not entitled to, or pays a person who is not
eligible for payment, it may recover the payment. It may also deduct the amount paid in error
from your future benefits if the Plan receives an agreement from you in writing.
In the same manner, if the Plan applies dental expense to the Plan deductible that would not
otherwise be reimbursable under the terms of this Plan; it may deduct a like amount from the
accumulated deductible amount and/or recover payment of the dental expense that would
have otherwise been applied to the deductible. Examples of amounts recoverable under this
provision ino|uda, but are not limited to, services for an excluded dental condition. The fact
that a dental expense was applied to the Plan's deductible does not in itself create an eligible
expense or infer that benefits will continue to be provided for an otherwise excluded condition.
22 Deschutes County Plan Donumont_0118_Oents|
COORDINATION OF BENEFITS
This is a summary of only a few of the provisions of this dental Plan to help you understand
coordination of benefits which can be very complicated. This is not a complete description of
all of the coordination rules.
Double Coverage
It is common for family members to be covered by more than one dental plan. This happens,
for example, when a husband and wife both work and choose to have family coverage through
both employers.
When you are covered by more than one dental Plan, the law permits your plans to follow a
procedure called `coordination of benefits' to determine how much each should pay when you
have a claim. The goal is to make sure that the combined payments of all plans do not add up
to more than your covered dental care expenses.
Coordination of benefits (COB) is complicated, and covers a wide variety of circumstances.
This is only an outline of some of the most common ones. If your situation is not described,
contact the PacificSource Customer Service team or contact the Division of Financial
Regulation.
Primary or Secondary?
You will be asked to identify all the plans that cover members of your family. PacificSource will
need this information to determine whether the Plan is the `primary' or `secondary' benefit
payer. The primary plan always pays first when you have a claim.
Any plan that does not contain your COB rules will always be primary.
When This Plan is Primary
If you or a family member are covered under another plan in addition to this one, this Plan will
be primary when:
Your Own Expenses
• The claim is for your own dental expenses.
Your Spouse's or Domestic Partner's Expenses
• The claim is for your spouse or domestic partner, who is covered by this Plan.
Your Child's Expenses
• The claim is for the dental care expenses of your child who is covered by this Plan; and
• You are married and your birthday is earlier in the year than your spouse's or your domestic
partner's, or you are living with another individual, regardless of whether or not you have
ever been married to that individual, and your birthday is earlier than that other individual's
birthday. This is known as the `birthday rule;' or
• You are separated or divorced and you have informed us of a court decree that makes you
responsible for the child's dental care expenses; or
• There is no court decree, but you have custody of the child.
Other Situations
The Plan will be primary when any other provisions of federal law require it to be.
23 Deschutes County Plan Document_0118_Dental
How this Plan Pays Claims When it is Primary
When this Plan is the primary plan, we will pay the benefits in accordance with the terms of
the Plan, just as if you had no other dental care coverage under any other plan.
How this Plan Pays Claims When it is Secondary
This Plan will be secondary whenever the rules do not require it to be primary.
When this Plan is the secondary plan, it does not pay until after the primary plan has paid its
benefits. This Plan will then pay part or all of the allowable expenses left unpaid, as explained
below. An `allowable expense' is a dental care expense covered by one of the plans, including
copayments, coinsurance and deductibles.
• If there is a difference between the amounts the plans allow, this Plan will base its payment
on the higher amount. However, if the primary plan has a contract with the provider, our
combined payments will not be more than the amount called for in the contract or the
amount called for in the contract of the primary plan, whichever is higher.
• This Plan will determine its payment by calculating the amount it would have paid if it had
been primary, and apply that calculated amount to any allowable expense that is left unpaid
by the primary plan. This Plan may reduce its payment by any amount so that, when
combined with the amount paid by the primary plan, the total benefits paid do not exceed
the total allowable expense for your claim. This Plan will credit any amount it would have
paid in the absence of your other dental care coverage toward our own plan deductible.
• If the primary plan covers similar kinds of dental care expenses, but allows expenses that
this Plan does not cover, it may pay for those expenses.
• This Plan will not pay an amount the primary plan did not cover because you did not follow
its rules and procedures. For example, if your plan has reduced its benefit because you did
not obtain preauthorization, as required by that plan, this Plan will not pay the amount of the
reduction, because it is not an allowable expense.
THIRD PARTY LIABILITY
Third party liability means claims that are the responsibility of someone other than this Plan.
The liable party may be a person, firm, or corporation. Auto accidents and `slip -and -fall'
property accidents are examples of common third party liability cases.
A third party includes liability and casualty insurance, and any other form of insurance that
may pay money to or on behalf of a member, including but not limited to uninsured motorist
coverage, under -insured motorist coverage, premises med-pay coverage, Personal Injury
Protection (PIP) coverage, homeowner's insurance, and workers' compensation insurance.
If you use this Plan's benefit for an illness or injury you think may involve another party,
contact PacificSource right away.
When PacificSource receives a claim that might involve a third party, they will send you a
questionnaire to help determine responsibility.
In all third party liability situations, this Plan's coverage is secondary. By enrolling in this Plan,
you automatically agree to the following terms regarding third party liability situations:
• If this Plan pays any claim determined to be the responsibility of another party, you will
hold the right of recovery against the other party in trust for the Plan.
24 Deschutes County Plan Document_0118_Dental
• The Plan is entitled to reimbursement for any paid claims if there is a settlement or
judgment from the other party. This is so regardless of whether the other party or insurer
admits liability or fault.
• The Plan may subtract a proportionate share of the reasonable attorney's fees you
incurred from the money you are to pay back to the Plan.
• The Plan may ask you to take action to recover dental expenses we have paid from the
responsible party. The Plan may also assign a representative to do so on your behalf. If
there is a recovery, the Plan will be reimbursed for any expenses or attorney's fees out of
that recovery.
• If you receive a third party settlement, that money must be used to pay your related dental
expenses incurred both before and after the settlement. If you have ongoing dental
expenses after the settlement, the Plan may deny your related claims until the full
settlement (less reasonable attorney's fees) has been used to pay those expenses.
Motor Vehicle and Other Accidents
If you are involved in a motor vehicle accident or other accident, your related dental expenses
are not covered by this Plan if they are covered by any other type of insurance policy.
The Plan may pay your dental claims from the accident if a dental claim has been filed with
the other insurance company and that insurance has not yet paid.
By enrolling in this Pian, you agree to the terms in the previous section regarding third party
liability.
On -the -Job Illness or Injury and Workers' Compensation
This Plan does not cover any work-related illness, injury, or disease that is caused by any for-
profit activity, whether through employment or from self-employment. The only exceptions
would be if:
• You are the owner, partner, or principal of the Plan Sponsor, are injured in the course of
employment, and are otherwise exempt from the applicable, state or federal workers'
compensation insurance program;
• The appropriate state or federal workers' compensation insurance program has
determined that coverage is not available for your injury; or
• You have timely filed an application for coverage with the appropriate state or federal
workers' compensation insurance program, such as Oregon's State Accident Fund or
other Worker's Compensation carrier, and are awaiting a determination of coverage from
that entity.
Claims submitted for coverage under this section are processed in accordance with the terms
of this Plan.
If you are not the owner, partner, or principal of this group then the Plan may pay your dental
claims if a workers' compensation claim has been denied on the basis that the illness or injury
is not work related, and the denial is under appeal.
The contractual rules for third party liability, motor vehicle and other accidents, and on-the-job
illness or injury are complicated and specific. Please refer to your Plan Sponsor for complete
details, or contact the PacificSource Third Party Claims Department.
25 Deschutes County Plan Document_0118_Dental
This Plan will remain in effect upon timely payment of the full contribution until whichever of
the following events first occurs:
• The employee takes full-time employment with another employer; or
• Six months from the date the employee first makes payment under this provision.
COMPLAINTS, GRIEVANCES, AND APPEALS
Questions, Concerns, or Complaints
The Plan Sponsor understands that you may have questions or concerns about your benefits,
eligibility, the quality of care you receive, or how we reached a claim determination or handled
a claim. PacificSource will try to answer your questions promptly and give you clear, accurate
answers based on the criteria established by the Plan Sponsor.
If you have a question, concern, or complaint about your coverage, please contact
PacificSource's Customer Service Department. Many times their Customer Service team can
answer your question or resolve an issue to your satisfaction right away. If you feel your
issues have not been addressed, you have the right to submit a grievance and/or appeal in
accordance with this section.
GRIEVANCE PROCEDURES
If you are dissatisfied with the availability, delivery, or the quality of dental care services; or
claims payment, handling or reimbursement for dental care services; you may file a grievance
in writing. PacificSource will attempt to address your grievance, generally within 30 days of
receipt. (See How to Submit Grievances or Appeals below.)
APPEAL PROCEDURES
First Internal Appeal: If you believe the Plan Sponsor, or PacificSource acting on behalf of
the Plan Sponsor, has improperly reduced or terminated a dental care item or service, or
failed or refused to provide or make a payment in whole or in part for a dental care item or
service, that is based on any of the reasons listed below, you or your authorized
representative (See Definition section) may appeal (request a review) that decision. The
request for appeal must be made in writing and within 180 days of the adverse benefit
determination (See How to Submit Grievances or Appeals below). You may appeal if there is
an adverse benefit determination based on a:
Denial of eligibility for or termination of enrollment in a dental care plan;
• Rescission or cancellation of your coverage;
• Imposition of a source -of -injury exclusion*, network exclusion, annual benefit limit or other
limitation on otherwise covered services or items;
• Determination that a dental care item or service is experimental, investigational or not a
dental necessity, effective or appropriate; or
• Determination that a course or plan of treatment you are undergoing is an active course of
treatment for the purpose of continuity of care.
26 Deschutes County Plan Document_0118_Dental
* Source -of -injury exclusions cannot exclude injuries resulting from a medical or dental
condition or domestic violence.
Any staff involved in the initial adverse benefit determination will not be involved in the internal
appeal.
You or your authorized representative may submit additional comments, documents, records
and other materials relating to the adverse benefit determination that is the subject of the
appeal. If an authorized representative is filing on your behalf, your appeal is not considered
to be filed until such time as PacificSource has received the 'Authorization to Use or Disclose
PHI' and the `Designation of Authorized Representative' forms.
You may receive continued coverage under the Plan for otherwise covered services pending
the conclusion of the internal appeals process. If the Plan makes payment for any service or
item on your behalf that is later determined not to be a covered service or item, you will be
expected to reimburse the Plan for the non -covered service or item.
Second Internal Appeal: If you are not satisfied with the first internal appeal decision, you
may request an additional review. Your appeal and any additional information not presented
with your first internal appeal should be forwarded to your Plan Sponsor within 60 days of the
first appeal response. You may send your request for appeal and any documentation to the
Plan Sponsor's address that appears in the section entitled "How to Submit Grievances or
Appeals."
Any staff involved in the first internal appeal determination will not be involved in the second
internal appeal.
Request for Expedited Response: If there is a clinical urgency to do so, you or your
authorized representative may request in writing or orally, an expedited response to an
internal or external review of an adverse benefit determination. To qualify for an expedited
response, your attending physician must attest to the fact that the time period for making a
non -urgent benefit determination could seriously jeopardize your life, health, your ability to
regain maximum function or would subject you to severe pain that cannot be adequately
managed without the dental care service or treatment that is the subject of the request. If your
appeal qualifies for an expedited review and would also qualify for external review (See
External Independent Review below) you may request that the internal and external reviews
be performed at the same time.
External Independent Review: If your dispute with the Plan relates to an adverse benefit
determination that a course or plan of treatment is not medically necessary; is experimental or
investigational; is not an active course of treatment for purposes of continuity of care; or is not
delivered in an appropriate healthcare setting and with the appropriate level of care, you or
your authorized representative may request an external review by an independent review
organization (See How to Submit Grievances or Appeals below).
Your request for an independent review must be made within 180 days of the date of the
second internal appeal response. External independent review is available at no cost to you,
but is generally only available when coverage has been denied for the reasons stated above
and only after all internal grievance levels are exhausted. The Plan will pay for any cost
associated with the external independent review. You must submit your request for an
external review directly to your Plan Sponsor.
The Plan Sponsor, may at its discretion and with your consent, waive the requirements of
compliance with the internal appeals process and have a dispute referred directly to external
review. You shall be deemed to have exhausted internal appeals if the Plan Sponsor fails to
27 Deschutes County Plan Document_0118_Dental
strictly comply with its appeals process and with state and federal requirements for internal
appeals. If the Plan Sponsor fails to comply with the decision of the independent review
organization assigned under Oregon law, you have a private right of action (sue) against the
Plan Sponsor for damages arising from an adverse benefit determination subject to the
external review.
If you have questions regarding Oregon's external review process, you may contact the
Division of Financial Regulation at (503) 947-7984 or the toll-free message line at (888) 877-
4894.
Timelines for Responding to Appeals
You will be afforded two levels of internal appeal and, if applicable to your case, an external
review. PacificSource will acknowledge receipt of an appeal no later than seven days after
receipt. A decision in response to the appeal will be made within 30 days after receiving your
request to appeal.
The above time frames do not apply if the period is too long to accommodate the clinical
urgency of a situation, or if you do not reasonably cooperate, or if circumstances beyond your or
our control prevent either party from complying with the time frame. In the case of a delay, the
party unable to comply must give notice of delay, including the specific circumstances, to the
other party.
Information Available with Regard to an Adverse Benefit Determination
The final adverse benefit determination will include:
• A reference to the specific internal rule or guideline used in the adverse benefit
determination; and
• An explanation of the scientific or clinical judgment for the adverse benefit determination, if
the adverse benefit determination is based on dental necessity, experimental treatment, or
a similar exclusion.
Upon request, PacificSource will provide you with any additional documents, records or
information that are relevant to the adverse benefit determination.
HOW TO SUBMIT GRIEVANCES OR APPEALS
Before submitting a grievance or appeal, we suggest you contact PacificSource's Customer
Service team with your concerns. You can reach it by phone or email at the contact
information found on the first page of this Plan Document. Issues can often be resolved at this
level. Otherwise, you may file a grievance or appeal by:
First Level Appeal Writing to:
PacificSource
Attn: Grievance Review
PO Box 7068
Springfield, OR 97475-0068
Emailing cs@PacificSource.com, with `Grievance' as the subject
Faxing (541) 225-3628
28 Deschutes County Plan Document_0118_Dental
Second Level Appeal Writing to:
Deschutes County
Attn: Trygve Bolken
PO Box 6005
Bend, OR 97708-6005
Emailing trygve.bolken@deschutes.org with "Grievance" or "Appeal" as the subject
Faxing (541) 330-4626
If you are unsure of what to say or how to prepare a grievance, please call PacificSource's
Customer Service team. They will help you through the grievance process and answer any
questions you have.
Assistance Outside PacificSource
You have the right to file a complaint or seek other assistance from the Division of Financial
Regulation. Assistance is available:
By calling (503) 947-7984 or the toll-free message line at (888) 877-4894
By writing to:
Division of Financial Regulation
Consumer Advocacy Unit
PO Box 14480
Salem, OR 97309-0405
Through their website at http://dfr.oregon.gov
Or by email at cp.ins@state.or.us
RESOURCES FOR INFORMATION AND
ASSISTANCE
Assistance in Other Languages
Plan members who do not speak English may contact PacificSource's Customer Service team
for assistance. PacificSource can usually arrange for a multilingual staff member or interpreter
to speak with them in their native language.
Information Available from PacificSource
The Plan makes the following written information available to you free of charge. You may
contact PacificSource's Customer Service team to request any of the following:
• A directory of participating dental care providers under this Plan;
• A description (consistent with risk -sharing information required by the Centers for
Medicare and Medicaid Services, formerly known as Health Care Financing
Administration) of any risk -sharing arrangements the Plan or PacificSource has with
providers;
29 Deschutes County Plan Document_0118_Dental
• A description of the Plan and/or PacificSource's efforts to monitor and improve the quality
of dental services;
• Information about how PacificSource checks the credentials of its network providers and
how you can obtain the names and qualifications of your dental providers;
• Information about preauthorization and utilization review procedures; and
• Information about any dental plan offered by PacificSource.
Information and Assistance Available from the Division of Financial
Regulation about PacificSource
The following consumer information is available from the Division of Financial Regulation:
• The results of all publicly available accreditation surveys;
• A summary of our health promotion and disease prevention activities;
• Samples of the written summaries delivered to PacificSource policyholders;
• An annual summary of grievances and appeals against PacificSource;
• An annual summary of our utilization review policies;
• An annual summary of our quality assessment activities; and
• An annual summary of the scope of our provider network and accessibility of dental
services.
You can request this information by contacting the Division of Financial Regulation:
By calling (503) 947-7984 or the toll-free message line at (888) 877-4894
By writing to:
Division of Financial Regulation
Consumer Advocacy Unit
PO Box 14480
Salem, OR 97309-0405
Through their website at http://dfr.oregon.gov
Or by email at cp.ins@state.or.us
RIGHTS AND RESPONSIBILITIES
The Plan and PacificSource are committed to providing you with the highest level of service in
the industry. By respecting your rights and clearly explaining your responsibilities under this
Plan, we will promote effective dental care.
Your Rights as a Member.
• You have a right to receive information about the Plan and PacificSource, our services,
our providers, and your rights and responsibilities.
30 Deschutes County Plan Document_0118_Dental
• You have a right to expect clear explanations of this Plan's benefits and exclusions.
• You have a right to be treated with respect and dignity.
• You have a right to impartial access to dental care without regard to race, religion, gender,
national origin, or disability.
• You have a right to honest discussion of appropriate or dentally necessary treatment
options. You are entitled to discuss those options regardless of how much the treatment
costs or if it is covered by this Plan.
• You have a right to the confidential protection of your dental records and personal
information.
• You have a right to voice complaints about the Plan, PacificSource or the care you
receive, and to appeal decisions you believe are wrong.
• You have a right to participate with your dental care provider in decision-making regarding
your care.
• You have a right to know why any tests, procedures, or treatments are performed and any
risks involved.
• You have a right to refuse treatment and be informed of any possible dental
consequences.
• You have a right to refuse to sign any consent form you do not fully understand, or cross
out any part you do not want applied to your care.
• You have a right to change your mind about treatment you previously agreed to.
Your Responsibilities as a Member;
• You are responsible for reading this Plan Document and all other communications from
the Plan and PacificSource, and for understanding this Plan's benefits. You are
responsible for contacting the Plan and/or PacificSource Customer Service team if
anything is unclear to you.
• You are responsible for making sure your provider obtains preauthorization for any
services that require it before you are treated.
• You are responsible for providing the Plan and PacificSource with all the information
required to provide benefits under this Plan.
• You are responsible for giving your dental care provider complete health information to
help accurately diagnose and treat you.
• You are responsible for telling your providers you are covered by the Plan and showing
your member ID card when you receive care.
• You are responsible for being on time for appointments, and calling your provider ahead of
time if you need to cancel.
• You are responsible for any fees the provider charges for late cancellations or 'no shows'.
• You are responsible for contacting the Plan or PacificSource if you believe you are not
receiving adequate care.
31 Deschutes County Plan Document_0118_Dental
• You are responsible for supplying information to the extent possible that the Plan or
PacificSource needs in order to administer your benefits or your dental providers need in
order to provide care.
• You are responsible for following plans and instructions for care that you have agreed to
with your doctors.
• You are responsible for understanding your health problems and participating in
developing mutually agreed upon goals, to the degree possible.
PRIVACY AND CONFIDENTIALITY
The Plan and PacificSource have strict policies in place to protect the confidentiality of your
personal information, including your dental records. Your personal information is only
available to the staff members who need that information to do their jobs.
Disclosure outside the Plan and PacificSource is allowed only when necessary to provide your
coverage, or when otherwise allowed by law. Except when certain statutory exceptions apply,
the law requires your written authorization (or your representative) before disclosing your
personal information outside the Plan or PacificSource. An example of one exception is that
we do not need written authorization to disclose information to a designee performing
utilization management, quality assurance, or peer review on our behalf.
PLAN ADMINISTRATION
Name of Plan:
The Deschutes County Group Health Plan (the "Plan").
Name and Address of the Plan Sponsor:
Deschutes County
PO Box 6005
Bend, OR 97708-6005
Phone: (541) 385-3215
Fax: (541) 330-4626
Plan Number
502
Plan Sponsor's Employer Identification / Tax Identification Number:
93-6002292
Contract Year:
January 1 to December 31
Type of Plan:
Group Dental Plan (self-insured)
32 Deschutes County Plan Document_0118_Dental
Type of Administration:
The Plan is administered by employees of the Plan Sponsor and under an administrative
services agreement with a third -party administrator.
Name and Address of Third Party Administrator:
PacificSource Health Plans
P.O. Box 7068
Springfield, OR 97475-0068
Phone: (888) 977-9299
Fax: (541) 684-5264
Name and Address of Designated Agent for Service of Legal Process:
Deschutes County
Attn: Tom Anderson, County Administrator
PO Box 6005
Bend, OR 97708-6005
Phone: (541) 385-3215
Fax: (541) 330-4626
Funding Method and Contributions:
This Plan is self-insured, meaning that benefits are paid from the general assets and/or trust
funds of the Plan Sponsor and are not guaranteed under an insurance policy or contract. The
cost of the Plan is paid with contributions by the Plan Sponsor and participating employees.
The Plan Sponsor determines the amount of contributions to the Plan, based on estimates of
claims and administration costs. The Plan Sponsor may purchase insurance coverage to
guard against excess loss incurred by allowed claims under the Plan, but such coverage is not
included as part of the Plan.
Plan Changes
The terms, conditions, and benefits of this Plan may be changed from time to time. The
following people have the authority to accept or approve changes or terminate this Plan:
• The Plan Sponsor's board of directors or other governing body;
• The owner or partners of the Plan Sponsor; or
• Anyone authorized by the above people to take such action.
The Plan Administrator is authorized to make Pian changes on behalf of the Plan Sponsor.
If this Plan terminates and the Plan Sponsor does not replace the coverage with another
group Plan, the Plan Sponsor is required by law to advise you in writing of the termination.
Legal Procedures
You may not take legal action against the Plan Sponsor or PacificSource to enforce any
provision of the Plan until 60 days after your claim is properly submitted in accordance with
established procedures. Also, you must exhaust this Plan's claims procedures, and grievance
33 Deschutes County Plan Document_0118_Dental
and appeals procedures, before filing benefits litigation. No action shall be brought against the
Plan Sponsor or PacificSource after the expiration of any applicable statutes of limitations.
DEFINITIONS
Wherever used in this Plan, the following definitions apply to the masculine and feminine and
singular plural forms of terms. For the purpose of this Plan, `employee' includes the employer
when covered by this Plan. Other terms are defined where they are first used in the text.
Abutment is a tooth used to support a prosthetic device (bridges, partials or overdentures).
With an implant, an abutment is a device placed on the implant that supports the implant
crown.
Adverse benefit determination means the Plan's denial, reduction, or termination of a dental
care item or service, or the Plan's failure or refusal to provide or to make a payment in whole
or in part for a dental care item or service, that is based on this Plan's:
• Denial of eligibility for or termination of enrollment in a dental benefit Plan;
• Rescission or cancellation of a Plan or coverage;
• Imposition of a source -of -injury exclusion*, network exclusion, annual benefit limit or other
limitation on otherwise covered items or services;
• Determination that a dental care item or service is experimental, investigational, or not a
dental necessity, effective, or appropriate; or
• Determination that a course or plan of treatment that a member is undergoing is an active
course of treatment for purposes of continuity of care.
* Source -of -injury exclusions cannot exclude injuries resulting from a medical or dental
condition or domestic violence.
Allowable fee is the dollar amount established for reimbursement of charges for specific
services or supplies provided by non -participating providers. PacificSource uses several
sources to determine the allowable fee. Depending on the service or supply and the
geographical area in which it is provided, the allowable fee may be based on data collected
from Centers for Medicare and Medicaid Services (CMS), contracted vendors, other nationally
recognized databases, or PacificSource Health Plans, as documented in PacificSource's
payment policy and adopted by the Plan Sponsor.
Alveolectomy is the removal of bone from the socket of a tooth.
Amalgam is a silver -colored material used in restoring teeth.
Appeal means a written or verbal request from a member or, if authorized by the member, the
member's representative, to change a previous decision made by the Plan Sponsor
concerning;
• Access to dental care benefits, including an adverse benefit determination made pursuant
to utilization management;
• Claims payment, handling or reimbursement for dental care services;
• Rescissions of member's benefit coverage by the Plan Sponsor; and
• Other matters as specifically required by law.
34 Deschutes County Plan Document_0118_Dental
Authorized representative is an individual who by law or by the consent of a person may act
on behalf of the person. An authorized representative must have the member complete and
execute an `Authorization to Use or Disclose PHI' form and a 'Designation of Authorized
Representative' form, both of which are available at Pacificsource.com, and which will be
supplied to you upon request. These completed forms must be submitted to PacificSource
before PacificSource can recognize the authorized representative as acting on behalf of the
member.
Benefit determination means the activity taken to determine or fulfill the Plan Sponsor's
responsibility for provisions under this dental Plan and provide reimbursement for dental care
in accordance with those provisions. Such activity may include:
• Eligibility and coverage determinations (including coordination of benefits), and adjudication
or subrogation of dental benefit claims;
• Review of dental care services with respect to dental necessity (including underlying
criteria), coverage under the dental Plan, appropriateness of care,
experimental/investigational treatment, justification of charges; and
• Utilization review activities, including precertification and preauthorization of services and
concurrent and retrospective review of services.
Calendar year means the 12 month period beginning January 1 of any year through
December 31 of the same year.
Cast restoration includes crowns, inlays, onlays, and other restorations made to fit a patient's
tooth that are made at a laboratory and cemented onto the tooth.
Co-insurance means a defined percentage of the allowable fee or usual, customary and
reasonable fee for covered services and supplies the member receives. It is the percentage
the member is responsible for, not including co -pays and deductible. The co-insurance the
member is responsible for is listed in the Dental Benefit Summary.
Complaint means an expression of dissatisfaction directly to the Plan Sponsor or
PacificSource that is about a specific problem encountered by a member, or about a benefit
determination by the Plan Sponsor or an agent acting on behalf of the Plan Sponsor, including
PacificSource, and that includes a request for action to resolve the problem or change the
benefit determination. The complaint does not include an inquiry.
Composite resin is a tooth -colored material used in restoring teeth.
Contract year means a 12 month period beginning on the date the Plan is issued or the
anniversary of the date the Plan was issued. The specific dates for the contract year
applicable to this Plan are reflected in the introductory section at the beginning of this Plan
Document. If changes are made to the Plan on a date other than the anniversary of issuance,
a new contract year may start on the date the changes become effective if so agreed by the
Plan Sponsor and PacificSource. A contract year may or may not coincide with a calendar
year.
Contracted allowable fee is an amount the Plan Sponsor agrees to pay a participating
provider for a given service or supply through direct or indirect contract.
Co -payment (also referred to as 'co -pay') is a fixed up -front dollar amount the member is
required to pay for certain covered services. The co -pay applicable to a specific covered
service is listed under that specific benefit in the Dental Benefit Summary.
Covered expense is an expense for which benefits are payable under by this Plan subject to
applicable deductible, co -payment, co-insurance, or other specific limitations.
35 Deschutes County Plan Document_0118_Dental
Creditable coverage means a member's prior dental coverage that meets the following
criteria:
• There was no more than a 63 day break between the last day of coverage under the
previous plan and the first day of coverage under this Plan. The 63 day limit excludes the
employer's eligibility waiting period.
• The prior coverage was one of the following types of insurance: group coverage (including
Federal Employee Health Benefit Plans and Peace Corps), individual coverage (including
student health plans), Medicaid, Medicare, TRICARE, Indian Health Service or tribal
organization coverage, state high-risk pool coverage, and public health plans.
Curettage is the scraping and cleaning of the walls of a real or potential space, such as a
gingival pocket or bone, to remove pathological material.
Deductible means the portion of the dental expense that must be paid by the member before
the benefits of this Plan are applied.
Dental emergency means the sudden and unexpected onset of a condition, or exacerbation
of an existing condition, requiring necessary care to control pain, swelling or bleeding in or
around the teeth and gums. Such emergency care must be provided within 48 hours following
the onset of the emergency and includes treatment for acute infection, pain, swelling,
bleeding, or injury to natural teeth and oral structures. The emergency care does not include
follow-up care such as, but not limited to, crowns, root canal therapy, or prosthetic benefits.
Dentally necessary means those services and supplies that are required for diagnosis or
treatment of illness or injury and that are:
• Consistent with the symptoms or diagnosis and treatment or prevention of the condition;
• Consistent with generally accepted standards of good dental practice, or expert consensus
dentist opinion published in peer-reviewed dental literature, or the results of clinical outcome
trials published in peer-reviewed dental literature;
• As likely to produce a significant positive outcome as, and no more likely to produce a
negative outcome than, any other service or supply, both as to the disease or injury
involved and the patient's overall dental condition;
• Not for the convenience of the member or a provider of services or supplies; and
• The least costly of the alternative services or supplies that can be safely provided.
The fact that a dentist may recommend or approve a service or supply does not, of itself,
make the charge a covered expense.
Dental Provider or Dentist means a licensed doctor of dental surgery (D.D.S.) or a licensed
doctor of medical dentistry (D.M.D.)
Dependent children means any natural, step, adopted or eligible child you, your spouse, or
your domestic partner are legally obligated to support or contribute support. This may include
eligible dependent children for which you are the court appointed legal custodian or guardian.
Eligible dependent children may be covered under the Plan only if they meet the eligibility
requirements of the Plan. (See the Becoming Covered — Eligibility section.)
36 Deschutes County Plan Document_0118_Dental
Domestic partner means:
• Registered Domestic Partner means an individual of the same gender, age 18 or older,
who is joined in a domestic partnership, and whose domestic partnership is legally
registered in any state.
Eligible dental provider means a dentist, oral surgeon, endodontist, orthodontist,
periodontist, or pedodontist. Eligible provider may also include a denturist or dental hygienist
to the extent that they operate within the scope of their license.
Eligible employee means an employee who has met the Plan Sponsor's minimum eligibility
requirements as defined in the Dental Benefit Summary, and who is otherwise eligible for
coverage under the terms of this Plan.
Employee means any individual employed by the Employer.
Employer generally means the Plan Sponsor unless otherwise noted.
Enrollee means an employee, family member of the employee, or individual otherwise eligible
and enrolled for coverage under this Plan. In this Plan, enrollee is referred to as subscriber,
member, or you.
Exclusion period means a period during which specified conditions, treatments or services
are excluded from coverage.
External appeal or review means the request by an appellant for an independent review
organization to determine whether the Plan Sponsor's internal appeal decisions are correct.
Grievance means:
• A request submitted by a member or an authorized representative of a member;
— In writing, for an internal appeal or an external review; or
— In writing or orally, for an expedited internal review or an expedited external review.
• A written complaint submitted by a member or an authorized representative of a member
regarding:
— The availability, delivery, or quality of a dental care service;
— Claims payment, handling, or reimbursement for dental care services and, unless the
member has not submitted a request for an internal appeal, the complaint is not
disputing an adverse benefit determination.
Incurred expense means charges of a dental provider for services or supplies for which the
member becomes obligated to pay. The expense of a service is incurred on the day the
service is rendered, and the expense of a supply is incurred on the day the supply is
delivered.
Initial enrollment period means the period of days set by the Plan Sponsor that determines
when an individual is first eligible to enroll.
Inquiry means a written request for information or clarification about any subject matter
related to the Plan.
Internal appeal means a review of an adverse benefit.
Leave of absence is a period of time off work granted to an employee by the Plan Sponsor at
the employee's request and during which the employee is still considered to be employed and
37 Deschutes County Plan Document_0118_Dental
is carried on the employment records of the Plan Sponsor. A leave can be granted for any
reason acceptable to the Plan Sponsor, including disability and pregnancy.
Member means an individual covered under this Plan.
Non -participating provider is a provider of covered dental services or supplies that does not
directly or indirectly hold a provider contract or agreement with PacificSource.
Participating provider means a dentist, oral surgeon, endodontist, orthodontist, periodontist,
pedodontist denturist, or dental hygienist that directly or indirectly holds a provider contract or
agreement with PacificSource.
Periapical x-ray is an x-ray of the area encompassing or surrounding the tip of the root of a
tooth.
Periodontal maintenance is a periodontal procedure for patients who have previously been
treated for periodontal disease. In addition to cleaning the visible surfaces of the teeth (as in
prophylaxis) surfaces below the gum -line are also cleaned. This is a more comprehensive
service than a regular cleaning (prophylaxis).
Periodontal scaling and root planing means the removal of plaque and calculus deposits
from the root surface under the gum line.
Plan Amendment is a written attachment that amends, alters, or supersedes any of the terms
or conditions set forth in this Plan Document.
Prophylaxis is a cleaning and polishing of all teeth.
Pulpotomy is the removal of a portion of the pulp, including the diseased aspect, with the
intent of maintaining the vitality of the remaining pulpal tissue by means of a therapeutic
dressing.
Radiographic Image means any x-ray or computerized image of the teeth and jaws that
provides information for detecting, diagnosing, and treating conditions that can threaten oral
and general health. It includes cone beam x-rays, bitewing x-rays, single film x-rays, intraoral
x-rays, extraoral x-rays, panoramic x-rays, and cephalometric x-rays.
Rescind or rescission means to retroactively cancel or discontinue coverage under a dental
plan for reasons other than failure to timely pay required premiums or required contributions
toward the cost of coverage.
Restoration is the treatment that repairs a broken or decayed tooth. Restorations include, but
are not limited to, fillings and crowns.
Source -of -injury exclusions means this Plan may exclude benefits for the treatment of
injuries based on the source of that injury, as long as the plan does not exclude benefits
otherwise provided for treatment of injury if the injury results from an act of domestic violence,
medical or dental condition. Source of injury means objects, equipment, and other factors that
caused the injury or illness
Spouse means any individual who is legally married under current state law.
Subscriber means an employee or former employee covered under this Plan. When a family
that does not include an employee or former employee is covered under this Plan, the oldest
family member is referred to as the subscriber.
Third Party Administrator means an organization that processes claims and performs
administrative functions on behalf of the Plan Sponsor pursuant to the terms of a contract or
agreement. In the case of this Plan, the term Third Party Administrator refers solely to
PacificSource.
38 Deschutes County Plan Document_0118_Dental
Usual, customary, and reasonable fee (UCR) is the dollar amount based on charges being
made by dental providers in the same service area for similar treatment of similar dental
conditions. A usual, customary, and reasonable fee is based on provider billing data gathered
by PacificSource and adjusted to the 90th percentile. Usual, customary and reasonable fees
are reviewed by PacificSource annually.
A non -participating provider may charge more than the limits established by the definition of
UCR. Charges that are eligible for reimbursement but exceed the UCR are the member's
responsibility.
Waiting period means the period that must pass with respect to the individual before the
individual is eligible to be covered for benefits under the terms of this Plan.
39 Deschutes County Plan Document_0118_Dental
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40 Deschutes County Plan Document_0118_Dental
SIGNATURE PAGE
It is agreed by Deschutes County that the provisions of this document are correct and will
be the basis for the administration of the Dental Plan. The effective date of the Deschutes
County Dental Plan is January 1, 2018.
Dated this
2�- dayof 1 re\I
By --`V19r°
Title N Y r l �' Ici r
41 Deschutes County Plan Document_0118_Dental
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42 Deschutes County Plan Document_0118_Dental