HomeMy WebLinkAboutDoc 655 - Employee Health Plan Amend 14Deschutes County Board of Commissioners
1300 NW Wall St., Suite 200, Bend, OR 97701-1960
(541) 388-6570 -Fax (541) 385-3202 -www.deschutes.org
AGENDA REQUEST & STAFF REPORT
For Board Business Meeting of December 11,2013
DATE: December 2,2013.
FROM: Danielle FegleylRonda Connor Human Resources 541-385-3215
TITLE OF AGENDA ITEM:
Consideration of Board approval and County Administrator signature of Amendments 14 and 15 to the
Deschutes County Employee Benefit Plan.
PUBLIC HEARING ON THIS DATE? No.
BACKGROUND AND POLICY IMPLICATIONS:
Authorizing County Administrator signature of Amendments 14 and 15 to the health benefit plan.
Amendment 14 incorporates prescription co-pay changes as voted upon by the Board at their June 5
2013 meeting. Amendment 14 also incorporates the Patient Protection and Affordable Care Act
mandates for our non-grandfathered plan. These are updating the preventive care coverage
requirements, expanding women's health coverage to include, breast pumps and sterilization charges,
expanding the durable medical equipment payment limitations, and clarifying the level III grievance
procedure in the plan. Amendment 15 changes the employee title permitted to receive protected health
information from Personnel Services Manager to Human Resources Director.
FISCAL IMPLICATIONS:
An estimated $500,000 in savings related to the prescription drug changes.
RECOMMENDATION & ACTION REQUESTED:
County Administrator signature of Amendments 14 and 15.
ATTENDANCE: Danielle Fegley and Ronda Connor.
DISTRIBUTION OF DOCUMENTS:
Please return documents to Ronda Connor.
Deschutes County 1 August 1, 2013
AMENDMENT #14
TO THE
PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION
FOR
DESCHUTES COUNTY EMPLOYEE BENEFIT PLAN
Effective: August 1, 2013
1. AMEND the following ELIGIBILITY provision in the ELIGIBILITY, FUNDING,
EFFECTIVE DATE AND TERMINATION PROVISIONS section as follows:
Eligibility Requirements for Employee Coverage. A person is eligible for Employee coverage
from the first day that he or she:
(1) Is a full-time or part-time, Active Employee of the Employer, who is regularly scheduled to
work at least 20 hours per week.
Note: If a part-time Employee’s hours are reduced by a County-approved, temporary
reduction in hours, coverage will continue without interruption.
(2) Is a Retired Employee of the Employer. A Retired Employee must have been enrolled as an
active employee in the Plan (or a prior plan sponsored by the Employer) for at least 24
consecutive months immediately prior to retirement, unless otherwise indicated by a
management/labor agreement. The Retired Employee must be receiving benefits from the
Public Employee Retirement System (PERS) or from a similar retirement Plan offered by
the Employer. Retired Employees are not eligible to continue dental benefits unless
they have 30 or more years of service with Deschutes County. Retired
Employees must elect Retiree coverage within 30 days of the date of their
retirement to be eligible for this coverage.
(3) Is in a class eligible for coverage.
(4) Completes the employment Waiting Period of one month as an Active Employee. A
"Waiting Period" is the time between the first day of employment as an eligible Employee
and the first day of coverage under the Plan. The Waiting Period is counted in the Pre-
Existing Conditions exclusion time. In the case of weekends and holidays, if the Employee
starts on the first business day of the month, he or she will be treated as having been hired
on the first day of the calendar month or the first shift of the month for certain classes of
Employees.
2. AMEND the following PART-TIME TO FULL-TIME CONVERSION provision in the
ELIGIBILITY, FUNDING, EFFECTIVE DATE AND TERMINATION PROVISIONS
section as follows:
Part-Time to Full-Time Conversion. Part-time Employees who waive coverage and
then become full-time Employees or have a significant increase in work hours
(minimum of 25%), may elect to enroll in the Standard Plan at that time. Coverage will
Deschutes County 2 August 1, 2013
become effective on the first day of the month following 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.
Coverage will become effective the first day of the calendar month following or
coinciding with the Employee is considered a full-time Employee.
Full-Time to Part-Time Conversion. Full-time Employees who were 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. 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.
3. AMEND the following PLAN OPTIONS provision in the SCHEDULE OF BENEFITS section
as follows:
PLAN OPTIONS
Standard Plan
The Standard Plan option is available to all Employees (and Retired Employees).
High Deductible Plan*
The High Deductible Plan option is only available to Retirees and those Employees considered part-
time Employees.
* This High Deductible Plan option does not satisfy the statutory requirements with
respect to deductibles and maximum out-of-pocket expenses set forth by the U.S.
Department of Treasury for contribution to a Health Savings Account.
Deschutes County 3 August 1, 2013
4. AMEND the following benefits listed under the PREVENTIVE CARE benefit in the
SCHEDULE OF BENEFITS section as follows:
STANDARD PLAN
Preventive Care
Routine Well Care 100%, no deductible applies 80%, no deductible applies
Routine well care services will include, but will not be limited to the following services as recommended
by the U.S. Preventive Services Task Force and Health Resources and Services Administration at
https://www.healthcare.gov/what-are-my-preventive-care-benefits/
Routine physical examination; routine office visit; prostate screening; x-rays; laboratory tests; nutrition
counseling; routine screenings; immunizations/flu shots; colonoscopy/ sigmoidoscopy; bone density
scans.
Routine Well Baby Care
Ages Birth to age 2 100%, no deductible applies 10
visits maximum
80%, no deductible applies 10
visits maximum
Routine well baby services will be subject to frequency limitations as determined by the U.S. Preventive
Services Task Force and Health Resources and Services Administration (HRSA) at
https://www.healthcare.gov/what-are-my-preventive-care-benefits/
and will include, but will not be limited to, the following routine services:
Routine office visits; routine physical exam; history; developmental assessment; anticipatory
guidance; routine laboratory tests and x-rays; pediatric vision and hearing screening; flu shots and
immunizations to include the schedule for immunizations recommended by the immunization practices
advisory committee of the U.S. Department of Health and Human Services.
"Developmental assessment" and "anticipatory guidance" mean the services described in the Guidelines
for Health Supervision II, published by the American Academy of Pediatrics.
Preventive Care
Preventive Women’s Health Care 100%, no deductible 80%, no deductible
Includes: Office visits, well-women visits, mammograms, gynecological exam, Pap smear, counseling for
sexually transmitted infections, human papillomavirus (HPV) testing, counseling and screening for human
immune-deficiency virus (HIV), interpersonal and domestic violence, contraceptive methods and
counseling as prescribed, sterilization procedures, patient education and counseling for all women with
reproductive capacity, screening for gestational diabetes in Pregnant female Covered Persons,
breastfeeding support, supplies, and counseling in conjunction with each birth.
Preventive women’s health care benefits will be subject to frequency limitations as determined by the U.S.
Preventive Services Task Force (USPSTF) and Health Resources and Services Administration (HRSA) at
https://www.healthcare.gov/what-are-my-preventive-care-benefits/
Deschutes County 4 August 1, 2013
HIGH DEDUCTIBLE PLAN
Preventive Care
Routine Well Care 100%, no deductible applies 80%, no deductible applies
Routine well care services will include, but will not be limited to the following services as recommended
by the U.S. Preventive Services Task Force and Health Resources and Services Administration at
https://www.healthcare.gov/what-are-my-preventive-care-benefits/
Routine physical examination; routine office visit; prostate screening; x-rays; laboratory tests; nutrition
counseling; routine screenings; immunizations/flu shots; colonoscopy/ sigmoidoscopy; bone density
scans.
Routine Well Baby Care
Ages Birth to age 2 100%, no deductible applies 10
visits maximum
80%, no deductible applies 10
visits maximum
Routine well child services will be subject to frequency limitations as determined by the U.S. Preventive
Services Task Force and Health Resources and Services Administration (HRSA) at
https://www.healthcare.gov/what-are-my-preventive-care-benefits/
and will include, but will not be limited to, the following routine services:
Routine office visits; routine physical exam; history; developmental assessment; anticipatory
guidance; routine laboratory tests and x-rays; pediatric vision and hearing screening; flu shots and
immunizations to include the schedule for immunizations recommended by the immunization practices
advisory committee of the U.S. Department of Health and Human Services.
"Developmental assessment" and "anticipatory guidance" mean the services described in the Guidelines
for Health Supervision II, published by the American Academy of Pediatrics.
Preventive Care
Preventive Women’s Health Care 100%, no deductible 80%, no deductible
Includes: Office visits, well-women visits, mammograms, gynecological exam, Pap smear, counseling for
sexually transmitted infections, human papillomavirus (HPV) testing, counseling and screening for human
immune-deficiency virus (HIV), interpersonal and domestic violence, contraceptive methods and
counseling as prescribed, sterilization procedures, patient education and counseling for all women with
reproductive capacity, screening for gestational diabetes in Pregnant female Covered Persons,
breastfeeding support, supplies, and counseling in conjunction with each birth.
Preventive women’s health care benefits will be subject to frequency limitations as determined by the U.S.
Preventive Services Task Force (USPSTF) and Health Resources and Services Administration (HRSA) at
https://www.healthcare.gov/what-are-my-preventive-care-benefits/
Deschutes County 5 August 1, 2013
5. ADD the following NUTRITIONAL EDUCATION COUNSELING benefit in the
SCHEDULE OF BENEFITS section as follows:
STANDARD PLAN
Nutritional Education Counseling 100%, no deductible 80%, no deductible
HIGH DEDUCTIBLE PLAN
Nutritional Education Counseling 100%, no deductible 80%, no deductible
6. AMEND the following ALTERNATIVE CARE benefit in the SCHEDULE OF BENEFITS
section as follows:
STANDARD PLAN
Alternative Care 100% after $15 copayment, no deductible applies; $45 massage
therapy per visit maximum $1,500 per Calendar Year combined
maximum
Includes: Chiropractic treatment, naturopathic treatment, massage therapy, and acupuncture.
HIGH DEDUCTIBLE PLAN
Alternative Care 100% after $15 copayment, no deductible applies; $45 massage
therapy per visit maximum; $1,500 per Calendar Year combined
maximum
Includes: Chiropractic treatment, naturopathic treatment, massage therapy, and acupuncture.
7. AMEND the following PRESCRIPTION DRUG BENEFITS provision listed in the
SCHEDULE OF BENEFITS section as follows:
PRESCRIPTION DRUG BENEFITS
Prescription copayments and coinsurance amounts do not apply toward the out-of-pocket maximum.
Pharmacy Option - Northwest Pharmacy Services (800) 998-2611 – Limited to a 30-day supply
Generic Drugs
Copayment ........................................................................................................... $20
Reimbursement .................................................................................................... 100%
Deschutes County 6 August 1, 2013
Formulary Drugs
Copayment ........................................................................................................... Greater of 20% or $50
up to a maximum of
$100
Reimbursement .................................................................................................... 100%
Non-Formulary Drugs
Copayment ........................................................................................................... Greater of 20% or $75
up to a maximum of
$125
Reimbursement .................................................................................................... 100%
Expense Submitted by Employee – Limited to a 30-day supply
Copayment ........................................................................................................... 50%
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 in the Schedule of Benefits.
Mail Order Prescription Drug Option – WellPartner (877) 935-5797 – Limited to a 100-day supply
Generic Drugs
Copayment ........................................................................................................... $40
Reimbursement .................................................................................................... 100%
Formulary Drugs
Copayment ........................................................................................................... Greater of 20% or
$100 up to a maximum
of $200
Reimbursement .................................................................................................... 100%
Non-Formulary Drugs
Copayment ........................................................................................................... Greater of 20% or
$150 up to a maximum
of $300
Reimbursement .................................................................................................... 100%
Deschutes County 7 August 1, 2013
Note: If the Physician prescribes a Generic drug, but a brand name drug is purchased, the Covered
Person must pay the copayment plus the difference in the Generic and brand name cost.
The following will be covered at 100%, no copayment required.
(1) Physician-prescribed tobacco cessation products. Limited to a 168-day supply per Calendar
Year of generic nicotine replacement products (nicotine patch, gum, lozenges) and a 168-day
supply per Calendar Year of Physician-prescribed generic medications (Zyban, Chantix).
(2) Physician-prescribed folic acid (generic or over-the-counter (OTC)) for all female Covered
Persons with reproductive capacity.
(3) Physician-prescribed over-the-counter (OTC) contraceptives (such as female condoms,
spermicides and sponges) for all female Covered Persons with reproductive capacity.
(4) Physician-prescribed aspirin (generic only) to prevent cardiovascular disease (CVD) in adult
men and women. Note: quantity limitations will apply.
(5) Physician-prescribed iron supplements for asymptomatic covered Dependent children aged 6 to
12 months who are at increased risk for iron deficiency anemia.
(6) Physician prescribed fluoride supplements for covered Dependent children ages 5 years and
under.
8. AMEND the following provision to the ALTERNATIVE CARE section of the COVERED
CHARGES section as follows:
(ii) Benefits are provided for:
− Office visits to providers of chiropractic, acupuncture, naturopathic
medicine and massage therapy; and
− Diagnostic x-rays (except CT scans) and laboratory services ordered by a
chiropractor.
9. ADD the following CRANIOFACIAL ANOMALY provision to the COVERED CHARGES
section as follows:
Craniofacial anomaly. “Craniofacial anomaly” shall include any congenital anomaly affecting the
face or head, including but not limited to cleft palate, cleft lip, craniosynostosis, craniofacial
microsomia and Treacher Collins syndrome.
Covered Charges will include Hospital, surgical or dental services, coverage of dental and
orthodontic services for the treatment of craniofacial anomalies if the services and treatment is
deemed Medically Necessary to improve or restore function.
10. ADD the following BREAST PUMP provision to the COVERED CHARGES section as
follows:
Breast pump supplies and rental of a breast pump. The purchase of a standard electric breast pump
or a manual breast pump for initiation or continuation of breastfeeding (within 45 days prior to the
Covered Person’s due date or the first 12 months following delivery) may be bought rather than
rented, with the cost not to exceed the actual acquisition cost of the item to the Covered Person if
Deschutes County 8 August 1, 2013
the Covered Person were to purchase the item directly. The acquisition cost of the item may be
prorated over a 6 month period, subject to prior approval by the Plan Administrator.
Rental of a heavy duty/hospital grade breast pump may be considered medically necessary only for
the period of time that a newborn remains inpatient in the Hospital. Purchase of these a heavy
duty/hospital grade breast pumps is not considered medically necessary or a Covered Charge under
this Plan.
For covered women using a breast pump from a prior pregnancy, a new set of breast pump supplies
may be covered with each subsequent pregnancy. Replacement standard electric breast pumps
maybe covered every 3 Calendar Years following a subsequent pregnancy.
11. AMEND the following, DURABLE MEDICAL EQUIPMENT benefit as described in the
COVERED CHARGES provisions of the MEDICAL BENEFITS section as follows:
(k) Durable Medical Equipment (DME). Charges for Durable Medical Equipment and
supplies necessary for the maintenance and operation of the Durable Medical Equipment
that meet all of the following criteria:
Medically Necessary;
Prescribed by a Physician for outpatient use;
Is NOT primarily for the comfort and convenience of the Covered Person;
Does NOT have significant non-medical uses (i.e. air conditioners, air filters,
humidifiers, environmental control devices).
If more than one item of Durable Medical Equipment can meet a Covered Person’s needs,
Plan benefits are only available for the least cost alternative as determined by the Plan
Administrator. Benefits are not available for certain convenience or luxury features that are
considered non-standard.
Rental of a Durable Medical Equipment item will be a Covered Charge up to a maximum
of the lesser of 24 months or the warranty period of the item, commencing on the date the
item is first delivered to the Covered Person.
A Durable Medical Equipment item may be purchased, rather than rented, with the cost not
to exceed the actual acquisition cost of the item to the Covered Person if the Covered
Person were to purchase the item directly. The acquisition cost of the item may be prorated
over a 6 month period, subject to prior approval by the Plan Administrator.
Replacement of a Durable Medical Equipment item, rented or purchased, will be a Covered
Charge limited to once every 4 calendar years.
Subject to prior approval of the Plan Administrator, replacement for a purchased
Durable Medical Equipment item may be available for damage beyond repair with
normal wear and tear, when repair costs exceed the acquisition cost, or when a change
in the Covered Person’s medical condition occurs sooner than the 4 calendar year
period.
Subject to prior approval of the Plan Administrator, replacement for a rented Durable
Medical Equipment item may be available when a change in the Covered Person’s
medical condition occurs sooner than the 4 calendar year period.
Repair of a Durable Medical Equipment item including the replacement of essential
accessories such as hoses, tubing, mouth pieces, etc., are Covered Charges only when
necessary to make the item serviceable and the total estimated repair and replacement costs
Deschutes County 9 August 1, 2013
do not exceed the acquisition cost of the item. Rental charges for a temporary replacement
Durable Medical Equipment item are Covered Charges up to a maximum of two
consecutive months. Requests to repair a Durable Medical Equipment item are not subject
to the 4 calendar year limit.
The Plan Administrator may require documentation, including but not limited to the
make and model number of the Durable Medical Equipment item, the acquisition cost
to the provider, and documentation to support Medical Necessity.
12. ADD the following NUTRITIONAL EDUCATION BENEFIT in the COVERED CHARGES
section as follows:
Nutritional Education Benefit. Care, treatment, and services when provided by
Physician, or a registered dietician, up to the limits as stated in the Schedule of Benefits.
This benefit will not include weight loss medications or nutritional supplements whether
or not prescribed by a Physician.
13. REPLACE the following USUAL AND REASONABLE CHARGE definition in the
DEFINITIONS section as follows:
Allowable Charge means the charge for a treatment, service, or supply that is the lesser of: 1) the
charge made by the provider that furnished the care, service, or supply; 2) the negotiated amount
established by a provider network arrangement or other discounting or negotiation arrangement; 3)
the reasonable and customary charge for the same treatment, service, or supply furnished in the
same geographic area by a provider of like service as further described below; or 4) an amount
equivalent to the following:
1. For specialty drugs, the lesser of AWP minus 10% or the amount set by the Plan’s
prescription drug service vendor;
2. For inpatient or outpatient facility claims, an amount equivalent to 200% of the Medicare
equivalent allowable.
The reasonable and customary charge shall mean an amount equivalent to the 90th percentile of a
commercially available database, or such other cost or quality-based reimbursement methodologies
as may be available and adopted by the Plan. If there are insufficient charges submitted for a given
procedure, the Plan will determine an Allowable Charge based upon charges made for similar
services. Determination of the reasonable and customary charge will consider the nature and
severity of the condition being treated, medical complications or unusual circumstances that require
more time, skill or experience, and the cost and quality data for that provider.
For Covered Services rendered by a Physician, Hospital or Ancillary Provider in a geographic area
where applicable law dictates the maximum amount that can be billed by the rendering provider, the
Allowable Charge shall mean the amount established by applicable law for that Covered Service.
The Plan Administrator or its designee has the discretionary authority to determine an Allowable
Charge, including establishing the negotiated terms of a provider arrangement as the Allowable
Charge even if such negotiated terms do not satisfy the lesser of test described above.
Deschutes County 10 August 1, 2013
14. AMEND the following EXCESS CHARGES provision in the PLAN EXCLUSIONS section as
follows:
Excess charges. The part of an expense for care and treatment of an Injury or Sickness that is in
excess of the Allowable Charge.
15. AMEND the following GOVERNMENT COVERAGE provision in the PLAN EXCLUSIONS
section as follows:
Government coverage. Care, treatment or supplies furnished by a program or agency funded
by any government. This does not apply to Medicaid, hospitals or mental health and
developmental disability programs owned or operated by the State of Oregon, or
when otherwise prohibited by law.
16. DELETE the following SEX CHANGES provision in the PLAN EXCLUSIONS section as
follows:
Sex changes. Care, services or treatment for non-congenital transsexualism, gender dysphoria
or sexual reassignment or change. This exclusion includes medications, implants, hormone
therapy, surgery, medical or psychiatric treatment.
17. AMEND the following ORTHOGNATHIC SURGERY provision in the DENTAL PLAN
EXCLUSIONS section as follows:
(15) Orthognathic surgery. Surgery to correct malpositions in the bones of the jaw, except as
specifically stated as a benefit under this Plan.
18. AMEND the following COVERED PRESCRIPTION DRUGS provision in the
PRESCRIPTION DRUGS section as follows:
Covered Prescription Drugs
The following will be covered at 100%, no copayment required.
(1) Physician-prescribed tobacco cessation products. Limited to a 168-day supply per Calendar
Year of generic nicotine replacement products (nicotine patch, gum, lozenges) and a 168-day
supply per Calendar Year of Physician-prescribed generic medications (Zyban, Chantix).
(2) Physician-prescribed folic acid (generic or over-the-counter (OTC)) for all female Covered
Persons with reproductive capacity.
(3) Physician-prescribed over-the-counter (OTC) contraceptives (such as female condoms,
spermicides and sponges) for all female Covered Persons with reproductive capacity.
(4) Physician-prescribed aspirin (generic only) to prevent cardiovascular disease (CVD) in adult
men and women. Note: quantity limitations will apply.
Deschutes County 11 August 1, 2013
(5) Physician-prescribed iron supplements for asymptomatic covered Dependent children aged 6 to
12 months who are at increased risk for iron deficiency anemia.
(6) Physician prescribed fluoride supplements for covered Dependent children ages 5 years and
under.
19. AMEND the following LIMITS TO THIS BENEFIT provision in the PRESCRIPTION
DRUGS section as follows:
Limits To This Benefit
The Prescription Drug Plan will cover the amount normally prescribed by a Physician, not to exceed a 30-
day supply for prescriptions purchased at the pharmacy, or a 100-day supply for prescriptions purchased
through the Mail-Order Program.
20. AMEND the following PORTABILITY OF HEALTH INSURANCE (Oregon) provision in the
TERMINATION OF COVERAGE section as follows:
Cover Oregon. If a Covered Person's medical coverage under this Plan terminates and the Covered Person
has exhausted continuation coverage (COBRA), he or she may be eligible for coverage through Cover
Oregon.
For information on Cover Oregon and the options available for individuals and families, visit:
coveroregon.com.
21. AMEND the following provisions within the COMPLAINTS AND GRIEVANCES provision
in the CLAIMS PROCEDURES section as follows:
COMPLAINTS AND GRIEVANCES
A Plan Participant has the right to ask questions and voice complaints or file Grievances. Our goal is to
listen, resolve your problems, and improve our service to you. To provide you an opportunity to resolve
problems that may occur, please follow the following procedures. While the Plan is not a Group Health Plan
subject to the provisions the Employee Retirement Income Security Act of 1994 (ERISA), these procedures
will nonetheless fulfill in all respects the requirements concerning internal claims and appeals found in
Section 2719 of the Public Health Service Act, as added by Section 1001 of the Affordable Care Act (PHS
Act Section 2719), implementing guidance concerning PHS Act Section 2719 as provided by the
Department of Treasury (26 CFR §54.9815-2719T), the Department of Health and Human Services (45 CFR
§147.136), and the Department of Labor (29 CFR §2590.715-2719), and relevant Oregon regulatory
requirements.
The Complaint Procedure
A complaint is an expression of dissatisfaction that is about a specific problem encountered by a Plan
Participant, or about a decision by the Plan, and that includes a request for action to resolve the problem or
change the decision.
When the Plan Participant has a complaint, he or she should call the Claims Administrator. The Claims
Administrator will send the Plan Participant a letter to acknowledge receipt of the complaint within seven
(7) days of its receipt.
Deschutes County 12 August 1, 2013
A Plan Participant has the right to voice complaints about:
Availability, delivery or quality of health care services, including a claim for benefits before or after
services are rendered;
Claims payment, handling, or reimbursement for health care services (Please also refer to the Notice
of Adverse Benefit Determination section set forth above.); or
Matters pertaining to the Plan.
If the Plan Participant’s complaint cannot be resolved at the time of your call, the Plan will: Gather more
information or records when necessary;
Conduct a review; and
Notify the Plan Participant of the outcome and the reasons for the decision.
If the Plan Participant has questions regarding the complaint procedure, please contact the Claims
Administrator for assistance in filing a complaint. If the Plan Participant is not satisfied with the Plan’s
decisions, the Plan Participant may seek assistance from the Department of Consumer and Business Services
at any time.
If the Plan Participant has questions regarding the complaint procedure, please contact the Claims
Administrator for assistance in filing a complaint. If the Plan Participant is not satisfied with the Plan’s
decisions, the Plan Participant may seek assistance from the Department of Consumer and Business Services
at any time.
Other assistance may be available from the Oregon Insurance Division:
By Calling: (503) 947-7984
By Writing: Director of the Department of Consumer and Business Services Consumer
Protection Unit, 350 Winter Street, N.E., Room 440-2, Salem, OR 97310
On the Internet at: http://www.cbs.state.or.us/external/ins
The Grievance Procedure
If the Plan Participant’s complaint is not satisfactorily resolved, the Plan Participant may submit a
Grievance. A Grievance means a written complaint submitted by or on behalf of a Plan Participant
regarding: 1) the availability, delivery or quality of health care services, including a complaint regarding an
adverse determination made pursuant to utilization review, 2) claims payment, handling or reimbursement
for health care services, or 3) matters pertaining to the Plan. The Plan Participant may include additional
supporting information, even if not initially submitted with the Claim. The Claims Administrator must
receive your Grievance within:
If regarding a Post-Service Claim, 180 days of the date the Plan Participant is notified of the
outcome of the compliant review (or the Initial Benefit Determination if the Plan Participant did not
file a complaint);
Deschutes County 13 August 1, 2013
If regarding a Pre-Service Claim, 30 days of the date the Plan Participant is notified of the outcome
of the compliant review (or the Initial Benefit Determination if the Plan Participant did not file a
complaint);
If regarding a Concurrent Care Claim, 15 days of the date the Plan Participant is notified of the
outcome of the compliant review (or the Initial Benefit Determination if the Plan Participant did not
file a complaint.
If the Plan Participant has questions regarding the Grievance procedure, please contact the Claims
Administrator who can provide assistance in filing a Grievance.
If the Plan Participant is not satisfied with the Plan’s decisions, the Plan Participant may seek
assistance from the Department of Consumer and Business Services at any time.
Should the Claims Administrator (for a Level I Review) or the Plan Administrator (for a Level II review),
elect to have an independent external review performed or if a Level III Review is requested by a Plan
Participant, such review will be assigned to an independent review organization (IRO) that is chosen by
Claims Administrator on a random basis.
Send all Grievances to:
Employee Benefit Management Services, Inc.
P.O. Box 21367
Billings, MT 59104
22. AMEND the following LEVEL III provision within the COMPLAINTS AND GRIEVANCES
provision in the CLAIMS PROCEDURES section as follows:
LEVEL III:
A Plan Participant may, by written application to the Plan, obtain an external review by an independent
review organization for a Level III Grievance on an Adverse Benefit Determination that involves one or
more of the following:
Whether a course or plan of treatment is Medically Necessary.
Whether a course or plan of treatment is Experimental or Investigational.
A rescission of coverage.
A Plan Participant shall apply in writing for external review of an adverse decision by the Plan not later than
180 days after receipt of the Plan's final written decision following Steps I and II of this Grievance procedure.
A Plan Participant is eligible for external review only if the following requirements have been met:
The Plan Participant must have signed a waiver granting the independent review organization access
to the medical records of the Plan Participant.
The Plan Participant must have exhausted all review rights through Level I and Level II of the
Plan’s Grievance procedure before submitting a request for a Level III external review. The Plan
may waive the requirement of compliance with the internal Grievance procedure and have a dispute
referred directly to external review upon the Plan Participant’s written consent.
Deschutes County 14 August 1, 2013
The Plan Participant must provide accurate and complete information to the independent review
organization in a timely manner.
The Plan agrees to be bound by the results of the Level III external review.
23. AMEND the following EMERGENCY MEDICAL CARE provision listed under the
COVERED CHARGES section in the MEDICAL BENEFITS section as follows:
(l) Emergency Medical Care. Emergency care for a Medical Emergency is covered as any other
covered medical condition under this Plan, subject to the requirements of ORS 743A.012. Prior
authorization notification or Physician referral is not required prior to receiving emergency medical
care. If the Employee or Dependent covered under this Plan needs immediate assistance for a
medical emergency, he or she should seek medical attention from the nearest appropriate facility
(Physician's office, clinic, urgent care center, Hospital emergency room) or call 9-1-1.
I, _______________________________________, certify that I am the _______________________________
Name Title
of the Plan Sponsor/Administrator for the above named Health Plan, and further certify that I am authorized
to sign this Amendment. I have read and agree with the above change to the Plan and am hereby authorizing
its implementation as of the effective date stated above.
Signature: ______________________________________
Print Name: ____________________________________
Date: __________________________________________