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HomeMy WebLinkAboutC32510 - 2yr Renewal - Vision Service PlanCONTRACT NO. C32510 CITY OF PALM DESERT HUMAN RESOURCES DEPARTMENT STAFF REPORT REQUEST: By minute motion: Approve a two year renewal to Vision Service Plan agreement, Contract no.C32510, through June 30, 2018 with rate change, and authorize the Mayor to execute. SUBMITTED BY: Lori Carney, Human Resources Manager CASE NOS. N/A DATE: July 14, 2016 CONTENTS: Staff Report Vision Service Plan Agreement Recommendation: By Minute Motion approve renewal to Vision Service Plan Agreement, Contract No. C32510, through June 30, 2018, and authorize the Mayor to execute. Background: The City receives broker services from Wells Fargo Insurance for dental, vision, life and disability insurance. Wells Fargo negotiates rates and contracts on our behalf as part of a municipal pool consisting of over 100 agencies. Pursuant to our negotiated labor agreement (M.O.U. expires June 30, 2017) the City provides vision benefits to employees and their dependents. Renewal of the current contract provides continuity of benefits in accordance with the agreement. The City approved a contract with Vision Service Plan to provide employee vision benefits on May 8, 2008 and has continued the contract through June 30, 2016, in accordance with the terms of our labor agreement. We received this contract renewal from Wells Fargo in late June, too late for the June 30, 2016 Council Meeting. Wells Fargo has negotiated an amendment to the VSP contract for one year beginning July 1, 2016. The amendment includes a slight increase in cost per employee, from $30.88 to $31.81. The plan provides a "composite" rate, equal for each employee regardless of family size. Staff has requested that Wells Fargo provide "what if' quotes Staff Report Vision Service Plan Contract Renewal July 14, 2016 Page 2 of 2 showing the impact of setting premiums by family size and these showed that composite rating remains the most cost effective system. The City would likely experience increased costs if it were to leave the municipal pool and seek a plan on the open market. Timinq: The current M.O.U. with the employees group expires June 30, 2017. Changes to the structure of the benefits plans must be negotiated with the employees group. Fiscal Analysis This is a cost increase of $0.93 per employee, per month. The total cost, including the increase, is approximately $43,000.00 annually, which has been budgeted for the FY 2016/17. Submitted 7 y: Lgfi Carney, Director of Human Resources Approval: J in McCarthy, ity M nager Janeore, Finance Director CONTRACT NO. C32510 • • VSysiencr,„ VISION SERVICE PLAN 3333 QUALITY DRIVE RANCHO CORDOVA, CALIFORNIA 95670 GROUP VISION CARE PLAN Group Name CITY OF PALM DESERT Plan Number 00408001 State of Delivery CALIFORNIA Effective Date JULY 1, 2016 Plan Term TWENTY-FOUR (24) MONTHS Premium Due Date FIRST DAY OF MONTH In consideration of the statements and agreements contained in the Group Application and in consideration of payment by the Group of the premiums as herein provided, VISION SERVICE PLAN ("VSP") agrees to provide certain individuals under this Group Vision Care Plan ("Plan") the benefits provided herein, subject to the exceptions, limitations and exclusions hereinafter set forth. This Plan is delivered in and governed by the laws of the state of delivery and is subject to the terms and conditions recited on the subsequent pages hereof, including any Exhibits or state -specific Addenda, which are a part of this Plan. i Kate Renwick -Espinosa, President VSP-PLAN-5/07 06/29/16 Ank CONTRACT NO. C32510 VISION SERVICE PLAN GROUP VISION CARE PLAN TABLE OF CONTENTS I. DEFINITIONS.............................................................................................................. 1 II. TERM, TERMINATION, AND RENEWAL................................................................... 3 III. OBLIGATIONS OF VSP.............................................................................................. 4 IV. OBLIGATIONS OF THE GROUP................................................................................ 6 V. OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN ............................. 8 VI. ELIGIBILITY FOR COVERAGE................................................................................... 11 VII. CONTINUATION OF COVERAGE.............................................................................. 14 VIII. ARBITRATION OF DISPUTES.................................................................................... 15 IX. NOTICES.....................................................................................................................16 X. MISCELLANEOUS......................................................................................................17 EXHIBIT A SCHEDULEOF BENEFITS........................................................................... 19 SCHEDULE OF PREMIUMS......................................................................... 27 ADDENDUM ADDITIONAL BENEFIT - COVERED CONTACT LENSES ........................... 28 ADDENDUM FOR THE STATE OF CALIFORNIA...................................................................... 31 CONTRACT NO. C32510 I. DEFINITIONS Key terms used in this Plan are defined: 1.01. BENEFIT AUTHORIZATION: Authorization from VSP identifying the individual named a Covered Person of VSP, and identifying those Plan Benefits to which Covered Person is entitled. 1.02. CONFIDENTIAL MATTER: All confidential information concerning the medical, personal, financial or business affairs of Covered Persons obtained while providing Plan Benefits hereunder. 1.03. COPAYMENTS: Any amounts required to be paid by or on behalf of a Covered Person for Plan Benefits which are not fully covered. 1.04. COVERED PERSON: An Enrollee or Eligible Dependent who meets VSP's eligibility criteria and on whose behalf Premiums have been paid to VSP, and who is covered under this Plan. 1.05. ELIGIBLE DEPENDENT: Any legal dependent of an Enrollee of Group who meets the criteria for eligibility established by Group and approved by VSP in Article VI of this Plan under which such Enrollee is covered. 1.06. EMERGENCY CONDITION: A condition, with sudden onset and acute symptoms, that requires the Covered Person to obtain immediate medical care, or an unforeseen occurrence calling for immediate, non -medical action. 1.07. ENROLLEE: An employee or member of Group who meets the criteria for eligibility specified under Article VI. ELIGIBILITY FOR COVERAGE. 1.08. EXPERIMENTAL NATURE: Procedure or lens that is not used universally or accepted by the vision care profession, as determined by VSP. 1.09. GROUP: An employer or other entity which contracts with VSP for coverage under this Plan in order to provide vision care coverage to its Enrollees and their Eligible Dependents. 1.10. GROUP APPLICATION: The form signed by an authorized representative of the Group to signify the Group's intention to have its Enrollees and their Eligible Dependents become Covered Persons of VSP. 1.11. GROUP VISION CARE PLAN (also, "THE PLAN' ): The Plan issued by VSP to a Group, under which its Enrollees or members, and their Eligible Dependents are entitled to become Covered Persons of VSP and receive Plan Benefits in accordance with the terms of such Plan. CONTRACT NO. C32510 1.12. MEMBER DOCTOR: An optometrist or ophthalmologist licensed and otherwise qualified to practice vision care and/or provide vision care materials who has contracted with VSP to provide vision care services and/or vision care materials on behalf of Covered Persons of VSP. 1.13. NON-MEMBER PROVIDER: Any optometrist, optician, ophthalmologist, or other licensed and qualified vision care provider who has not contracted with VSP to provide vision care services and/or vision care materials to Covered Persons of VSP. 1.14, PLAN BENEFITS: The vision care services and vision care materials which a Covered Person is entitled to receive by virtue of coverage under this Plan, as defined in the Schedule of Benefits attached hereto as Exhibit A. 1.15. RENEWAL DATE: The date when the Plan shall renew, or terminate if proper notice is given. 1.16. SCHEDULE OF BENEFITS: The document, attached hereto as Exhibit A to this Plan, which lists the vision care services and vision care materials which a Covered Person is entitled to receive under this Plan. 1.17. SCHEDULE OF PREMIUMS: The document, attached hereto as Exhibit B, which states the payments to be made to VSP by or on behalf of a Covered Person to entitle him/her to Plan Benefits. 2 CONTRACT NO. C32510 II. TERM, TERMINATION, AND RENEWAL 2.01. Plan Term: This Plan is effective on the Effective Date and shall remain in effect for the Plan Term. At the end of the Plan Term, the Plan shall renew on a month to month basis unless either party notifies the other in writing, at least sixty (60) days before the end of the Plan Term that such party is unwilling to renew the Plan. If such notice is given, the Plan shall terminate at 11:59 p.m. on the last day of the Plan Term unless the parties agree on its renewal of the Plan. If the Plan continues on a month to month basis after the Plan Term, either party may terminate the Plan upon thirty (30) days advance notice to the other party. If VSP issues written renewal materials to Group at least sixty (60) days before the end of the Plan Term and Group fails to accept the new terms and/or rates in writing prior to the end of the Plan Term, this Plan shall terminate at 11:59 p.m. on the last day of the Plan Term. 2.02. Early Termination Provision: The Premium rate payable by Group to VSP under this Plan is based on an assumption that VSP will receive these amounts over the full Plan Term in order to cover costs associated with greater vision utilization that tends to occur during the first portion of a Plan Term. If Group terminates this Plan before the end of the Plan Term or before the end of any subsequent renewal terms, for any reason other than material breach by VSP, Group will remain liable to VSP for the lesser amount of any deficit incurred by VSP or the payments which Group would have paid for the remaining term of this Plan, not to exceed one year. A deficit incurred by VSP will be calculated by subtracting the cost of incurred and outstanding claims, as calculated on an incurred date basis with a claim run -out not to exceed six months from the date of termination, from the net premiums received by VSP from Group. Net premiums shall mean premiums paid by Group minus any applicable retention amounts and/or broker commissions. Group agrees to pay VSP within thirty-one (31) days of notification of the amount due, CONTRACT NO. C32510 III. OBLIGATIONS OF VSP 3.01. Coveraqe of Covered Persons: VSP will enroll for coverage each eligible Enrollee and his/her Eligible Dependents, if dependent coverage is provided, all of who shall be referred to upon enrollment as "Covered Persons." To institute coverage, VSP may require Group to complete, sign and forward to VSP a Group Application along with information regarding Enrollees and Eligible Dependents, and all applicable premiums. (Refer to VI. ELIGIBILITY FOR COVERAGE for further details.) Following the enrollment of the Covered Persons, VSP will provide Group with Member Benefit Summaries for distribution to Covered Persons. Such Member Benefit Summaries will summarize the terms and conditions set forth in this Plan. 3.02. Provision of Plan Benefits: Through its Member Doctors (or through other licensed vision care providers where a Covered Person is eligible for, and chooses to receive Plan Benefits from a Non -Member Provider) VSP shall provide Covered Persons such Plan Benefits listed in the Schedule of Benefits, Exhibit A hereto, subject to any limitations, exclusions, or Copayments therein stated. Benefit Authorization must be obtained prior to a Covered Person obtaining Plan Benefits from a Member Doctor. When a Covered Person seeks Plan Benefits from a Member Doctor, the Covered Person must schedule an appointment and identify himself as a VSP Covered Person so the Member Doctor can obtain Benefit Authorization from VSP. VSP shall provide Benefit Authorization to the Member Doctor to authorize the provision of Plan Benefits to the Covered Person. Each Benefit Authorization will contain an expiration date, stating a specific time period for the Covered Person to obtain Plan Benefits. VSP shall issue Benefit Authorizations in accordance with the latest eligibility information furnished by Group and the Covered Person's past service utilization, if any. Any Benefit Authorization so issued by VSP shall constitute a certification to the Member Doctor that payment will be made, irrespective of a later loss of eligibility of the Covered Person, provided Plan Benefits are received prior to the Benefit Authorization expiration date. VSP shall pay or deny claims for Plan Benefits provided to Covered Persons, less any applicable Copayment, within a reasonable time but not more than thirty (30) calendar days after VSP has received a completed claim, unless special circumstances require additional time. In such cases, VSP may obtain an extension of fifteen (15) calendar days of this time limit by providing notice to the claimant of the reasons for the extension. 4 CONTRACT NO. C32510 3.03. Provision of Information to Covered Persons: Upon request, VSP shall make available to Covered Persons necessary information describing Plan Benefits and how to use them. A copy of this Plan shall be placed with Group and also will be made available at the offices of VSP for any Covered Persons. VSP shall provide Group with an updated list of Member Doctors' names, addresses, and telephone numbers for distribution to Covered Persons twice a year. Covered Persons may also obtain a copy of the Member Doctor directory through contacting VSP's Customer Service Department's toll -free Customer Service telephone line, VSP's Web site at www.vsp.com, or by written request. 3.04. Preservation of Confidentiality: VSP shall hold in strict confidence all Confidential Matters and exercise its best efforts to prevent any of its employees, Member Doctors, or agents, from disclosing any Confidential Matter, except to the extent that such disclosure is necessary to enable any of the above to perform their obligations under this Plan, including but not limited to sharing information with medical information bureaus, or complying with applicable law. Covered Persons and/or Groups that want more information on VSP's Confidentiality policy may obtain a copy of the policy by contacting VSP's Customer Service Department or VSP's Web site at www.vsp.com. 3.05. Emergencv Vision Care: When vision care is necessary for Emergency Conditions, Covered Persons may obtain Plan Benefits by contacting a Member Doctor or Non -Member Provider. No prior approval from VSP is required for Covered Person to obtain vision care for Emergency Conditions of a medical nature. However, services for medical conditions, including emergencies, are covered by VSP only under the Acute EyeCare and Supplemental Primary EyeCare Plans. If Group has not purchased one of these plans, Covered Persons are not covered by VSP for medical services and should contact a physician under Covered Persons' medical insurance plan for care. For emergency conditions of a non -medical nature, such as lost, broken or stolen glasses, the Covered Person should contact VSP's Customer Service Department for assistance. Reimbursement and eligibility are subject to the terms of this Plan. 191 CONTRACT NO. C32510 IV. OBLIGATIONS OF THE GROUP 4.01. Identification of Eliqible Enrollees: An Enrollee is eligible for coverage under this Plan if he/she satisfies the enrollment criteria specified in Paragraph 6.01(a) and/or as mutually agreed to by VSP and Group, By the Effective Date of this Plan, Group shall provide VSP with eligibility information, in a mutually agreed upon format and medium, to identify all Enrollees who are eligible for coverage under this Plan as of that date. Thereafter, Group shall supply to VSP by the last day of each month, eligibility information sufficient to identify all Enrollees to be added to or deleted from VSP's coverage rosters for the next month. The eligibility information shall include designation of each Enrollee's family status if dependent coverage is provided. Upon VSP's request, Group shall make available for inspection records regarding the coverage of Covered Persons under this Plan. 4.02. Payment of Premiums: By the last day of each month, Group shall remit to VSP the premiums payable for the next month on behalf of each Enrollee and Eligible Dependents, if any, to be covered under this Plan. The Schedule of Premiums incorporated in this Plan as Exhibit B provides the premium amount for each Covered Person. Only Covered Persons for whom premiums are actually received by VSP shall be entitled to Plan Benefits under this Plan and only for the period for which such payment is received, subject to the grace period provision below. If payment for any Covered Person is not received on time, VSP may terminate all rights of such Covered Person. Such rights may be reinstated only in accordance with the requirements of this Plan. VSP may change the premiums set forth in Exhibit B (Schedule of Premiums) by giving Group at least sixty (60) days advance written notice, No change will be made during the Plan Term unless there is a change in the Schedule of Benefits or there is a material change in Plan terms or conditions, provided any such change is mutually agreed upon in writing by VSP and Group. Notwithstanding the above, VSP may increase premiums during a Plan Term by the amount of any tax or assessment not now in effect but subsequently levied by any taxing authority, which is attributable to premiums VSP received from Group. 0 CONTRACT NO. C32510 4.03. Grace Period: Group shall be allowed a grace period of thirty-one (31) days following the premium payment due date to pay premiums due under this Plan. During said grace period, this Plan shall remain in full force and effect for all Covered Persons of Group. VSP will consider late payments at the time of Plan renewal. Such payment may impact Group's premium rates in future Plan Terms. If Group fails to make any premiums payment due by the end of any grace period, VSP may notify Group that the premiums payment has not been made, that coverage is canceled and that Group is responsible for payment for all Plan Benefits provided to Covered Persons after the last period for which premiums were paid in full, including the grace period through the effective date of termination. Group shall also be responsible for any legal and/or collection fees incurred by VSP to collect amounts due under this Plan. 4.04. Distribution of Required Documents: Group shall distribute to Enrollees any disclosure forms, plan summaries or other material required to be given to plan subscribers by any regulatory authority. Such materials shall be distributed by Group no later than thirty (30) days after the receipt thereof, or as required under state law. M CONTRACT NO. C32510 V. OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN 5.01. General: By this Plan, Group makes coverage available to its Enrollees and their Eligible Dependents, if dependent coverage is provided. However, this Plan may be amended or terminated by agreement between VSP and Group as indicated herein, without the consent or concurrence of Covered Persons. This Plan, and all Exhibits, Riders and attachments hereto, constitute VSP's sole and entire undertaking to Covered Persons under this Plan. As conditions of coverage, all Covered Persons under this Plan have the following obligations: 5.02. Comment for Services Received: Where, as indicated in Exhibit A (Schedule of Benefits), Copayments are required for certain Plan Benefits, Copayments shall be the personal responsibility of the Covered Person receiving the care and must be paid to the Member Doctor the date services are rendered. 5.03. Obtaininq Services from Member Doctors: Benefit Authorization must be obtained prior to receiving Plan Benefits from a Member Doctor. When a Covered Person seeks Plan Benefits, the Covered Person must select a Member Doctor, schedule an appointment, and identify himself as a Covered Person so the Member Doctor can obtain Benefit Authorization from VSP. Should the Covered Person receive Plan Benefits from a Member Doctor without such Benefit Authorization, then for the purposes of those Plan Benefits provided to the Covered Person, the Member Doctor will be considered a Non -Member Provider and the benefits available will be limited to those for a Non -Member Provider, if any. 5.04. Submission of Non -Member Provider Claims: If Non -Member Provider coverage is indicated in Exhibit A (Schedule of Benefits), written proof (receipt and the Covered Person's identification information) of all claims for services received from Non -Member Providers shall be submitted by Covered Persons to VSP within three hundred sixty-five (365) days of the date of service. VSP may reject such claims filed more than three hundred sixty-five (365) days after the date of service. Failure to submit a claim within this time period, however, shall not invalidate or reduce the claim if it was not reasonably possible to submit the claim within such time period, provided the claim was submitted as soon as reasonably possible and in no event, except in absence of legal capacity, later than one year from the required date of three hundred sixty-five (365) days after the date of service. CONTRACT NO. C32510 5.05. Complaints and Grievances: Covered Persons shall report any complaints and/or grievances to VSP at the address given herein. Complaints and grievances are disagreements regarding access to care, quality of care, treatment or service. Complaints and grievances may be submitted to VSP verbally or in writing. A Covered Person may submit written comments or supporting documentation concerning his complaint or grievance to assist in VSP's review. VSP will resolve the complaint or grievance within thirty (30) days after receipt. 5.06. Claim Denial Appeals: If, under the terms of this Plan, a claim is denied in whole or in part, a request may be submitted to VSP by Covered Person or Covered Person's authorized representative for a full review of the denial. Covered Person may designate any person, including his/her provider, as his/her authorized representative. References in this section to "Covered Person" include Covered Person's authorized representative, where applicable. a) Initial Appeal: The request must be made within one hundred eighty (180) days following denial of a claim and should contain sufficient information to identify the Covered Person for whom the claim was denied, including the VSP Enrollee's name, the VSP Enrollee's Member Identification Number, the Covered Person's name and date of birth, the provider of services and the claim number. The Covered Person may review, during normal working hours, any documents held by VSP pertinent to the denial. The Covered Person may also submit written comments or supporting documentation concerning the claim to assist in VSP's review. VSP's determination, including specific reasons for the decision, shall be provided and communicated to the Covered Person within thirty (30) calendar days after receipt of a request for appeal from the Covered Person or Covered Person's authorized representative. b) Second Level Appeal: If the Covered Person disagrees with the response to the initial appeal of the claim, the Covered Person has a right to a second level appeal. Within sixty (60) calendar days after receipt of VSP's response to the initial appeal, the Covered Person may submit a second appeal to VSP along with any pertinent documentation. VSP shall communicate its final determination to the Covered Person in compliance with all applicable state and federal laws and regulations and shall include the specific reasons for the determination. c) Other Remedies: When Covered Person has completed the appeals process stated herein, additional voluntary alternative dispute resolution options may be available, including mediation, or Group should advise Covered Person to contact the U.S. Department of Labor or the state insurance regulatory agency for details. Additionally, under the provisions of ERISA (Section 502(a)(1)(8)) [29 U.S.C. 1132(a)(1)(B)], Covered Person has the right to bring a civil action when all available levels of review of denied claims, including the appeals process, have been completed, the claims were not approved in whole or in part, and Covered Person disagrees with the outcome. E CONTRACT NO. C32510 5.07. Time of Action: No action in law or in equity shall be brought to recover on the Plan prior to the Covered Person exhausting his/her grievance rights under this Plan and/or prior to the expiration of sixty (60) days after the claim and any applicable invoices have been filed with VSP. No such action shall be brought after the expiration of six (6) years from the last date that the claim and any applicable invoices were submitted to VSP, in accordance with the terms of this Plan. 5.08. Insurance Fraud: Any Group and/or person who intends to defraud, knowingly facilitates a fraud or submits an application or files a claim with a false or deceptive statement, is guilty of insurance fraud. Such an act is grounds for immediate termination of the Plan for the Group or individual that committed the fraud. 10 CONTRACT NO. C32510 VI. ELIGIBILITY FOR COVERAGE 6.01. Eligibility Criteria: Individuals will be accepted for coverage hereunder only upon meeting all the applicable requirements set forth below. (a) Enrollees: To be eligible for coverage, a person must: coverage are: (1) currently be an employee or member of the Group, and (2) meet the criteria established in the coverage criteria mutually agreed upon by Group and VSP. (b) Eligible Dependents: If dependent coverage is provided, the persons eligible for dependent (1) the legal spouse of any Enrollee, and (2) any child of an Enrollee, including any natural child from the moment of birth, legally adopted child from the moment of placement for adoption with the Enrollee, or other child for whom a court holds the Enrollee responsible; and who has not yet attained the age of 26 years, or (3) as further defined by Group. If a dependent, unmarried child prior to attainment of the prescribed age for termination of eligibility becomes, and continues to be, incapable of self-sustaining employment because of mental or physical disability, that Eligible Dependent's coverage shall not terminate so long as he remains chiefly dependent on the Enrollee for support and the Enrollee's coverage remains in force; PROVIDED that satisfactory proof of the dependent's incapacity can be furnished to VSP within thirty-one (31) days of the date the Eligible Dependent's coverage would have otherwise terminated or at such other times as VSP may request proof, but not more frequently than annually. 6.02. Documentation of Eligibility: Persons satisfying the coverage requirements under either of the above criteria shall be eligible if: (a) for an Enrollee, the individual's name and Social Security Number have been reported by Group to VSP in the manner provided hereunder, and (b) for changes to an Eligible Dependent's status, the change has been reported by the Group to VSP in the manner provided herein. As stated in Paragraph 4.01 above, VSP may elect to audit Group's records in order to verify eligibility of Enrollees and dependents and any errors. Subject to the terms of Paragraph 4.03 above, only persons on whose behalf premiums have been paid for the current period shall be entitled to Plan Benefits hereunder. If a clerical error is made, it will not affect the coverage a Covered Person is entitled under the Plan. CONTRACT NO. C32510 6.03. Retroactive Eligibility Chanqes: Retroactive eligibility changes are limited to sixty (60) days prior to the date notice of any such requested change is received by VSP. VSP may refuse retroactive termination of a Covered Person if Plan Benefits have been obtained by, or authorized for, the Covered Person after the effective date of the requested termination. 6.04. Chanqe of Participation Requirements, Contribution of Fees, and Eliqibilitv Rules: Composition of the Group, percentage of Enrollees covered under the Plan, and Group's contribution and eligibility requirements, are all material to VSP's obligations under this Plan. During the term of this Plan, Group must provide VSP with written notice of changes to its composition, percentage of Enrollees covered, contribution and eligibility requirements. Any change which materially affects VSP's obligations under this Plan must be agreed upon in writing between VSP and Group and may constitute a material change to the terms and conditions of this Plan for purposes of Paragraph 4.02. Nothing in this section shall limit Group's ability to add Enrollees or Eligible Dependents under the terms of this Plan. 12 CONTRACT NO. C32510 6.05. Change in Family Status: In the event Group is notified of any change in a Covered Person's family status [by marriage, the addition (e.g., newborn or adopted child) or deletion of Dependent, etc.] Group shall provide notice of such change to VSP via the next eligibility listing required under Paragraph 4.01. If notice is given, the change in the Covered Person's status will be effective on the first day of the month following the change request, or at such later date as may be requested by or on behalf of the Covered Person. Notwithstanding any other provision in this section, a newborn child will be covered during the thirty-one (31) day period after birth, and an adopted child will be covered for the thirty-one (31) day period after the date the Enrollee or Enrollee's spouse acquires the right to control that child's health care. To continue coverage for a newborn or adopted child beyond the initial thirty-one (31) day period, the Group must be properly notified of the Enrollee's change in family status and applicable premiums must be paid to VSP. 13 CONTRACT NO. C32510 Vn. CONTINUATION OF COVERAGE 7.01. COBRA: The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that, under certain circumstances, health plan benefits available to an Enrollee and his or her Eligible Dependents be made available for purchase by said persons upon the occurrence of a COBRA -qualifying event. If, and only to the extent, COBRA applies, VSP shall make the statutorily -required continuation coverage available for purchase in accordance with COBRA. 14 CONTRACT NO. C32510 Vill. ARBITRATION OF DISPUTES 8.01. Dispute Resolution: Any dispute or question arising between VSP and Group or any Covered Person involving the application, interpretation, or performance under this Plan shall be settled, if possible, by amicable and informal negotiations. This will allow such opportunity as may be appropriate under the circumstances for fact-finding and mediation. If any issue cannot be resolved in this fashion, it shall be submitted to arbitration. 8.02. Procedure: The procedure for arbitration hereunder shall be conducted pursuant to the Rules of the American Arbitration Association. 8.03. Choice of Law: If any matter arises in connection with this Plan which becomes the subject of arbitration or legal process, the law of the State of Delivery of the Plan shall be the applicable law. 15 CONTRACT NO. C32510 IX. NOTICES 9.01. Required Notices: Any notices required under this Plan to either Group or VSP shall be in written format. Notices sent to Group will be sent to the address or email address shown on the Group's Application unless otherwise directed by the Group. Notices sent to VSP shall be sent to the address shown on the first page of this Plan. Notwithstanding the above, any notices may be hand -delivered by either party to an appropriate representative of the other party. The party effecting hand -delivery bears the burden to prove delivery was made, if questioned. 16 CONTRACT NO. C32510 X. MISCELLANEOUS 10.01. Entire Plan: This Plan, the Group Application, the Evidence of Coverage, and all Exhibits, Riders and attachments hereto, and any amendments hereto, constitute the entire agreement of the parties and supersedes any prior understandings and agreements between them, either written or oral. Any change or amendment to the Plan must be approved by an officer of VSP and attached hereto to be valid. No agent has the authority to change this Plan or waive any of its provisions. Communication materials prepared by Group for distribution to Enrollees do not constitute a part of this Plan. 10.02. Indemnity: VSP agrees to indemnify, defend and hold harmless Group, its shareholders, directors, officers, agents, employees, successors and assigns from and against any and all liability, claim, loss, injury, cause of action and expense (including defense costs and legal fees) of any nature whatsoever arising from the failure of VSP, its officers, agents or employees, to perform any of the activities, duties or responsibilities specified herein. Group agrees to indemnify, defend and hold harmless VSP, its members, shareholders, directors, officers, agents, employees, successors and assigns from and against any and all liability, claim, loss, injury, cause of action and expense (including defense costs and legal fees) of any nature whatsoever arising or resulting from the failure of Group, its officers or employees to perform any of the duties or responsibilities specified herein. 10.03. Liability: VSP arranges for the provision of vision care services and materials through agreements with Member Doctors. Member Doctors are independent contractors and responsible for exercising independent judgment. VSP does not itself directly furnish vision care services or supply materials. Under no circumstances shall VSP or Group be liable for the negligence, wrongful acts or omissions of any doctor, laboratory, or any other person or organization performing services or supplying materials in connection with this Plan. 10.04. Assiqnment: Neither this Plan nor any of the rights or obligations of either of the parties hereto may be assigned or transferred without the prior written consent of both parties hereto except as expressly authorized herein. 10.05. Severability: Should any provision of this Plan be declared invalid, the remaining provisions shall remain in full force and effect. 10.06. Governinq Law: This Plan shall be governed by and construed in accordance with applicable federal and state law. Any provision that is in conflict with, or not in compliance with, applicable federal or state statutes or regulations is hereby amended to conform with the requirements of such statutes or regulations, now or hereafter existing. 17 CONTRACT NO. C32510 10.07. Gender: All pronouns used herein are deemed to refer to the masculine, feminine, neuter, singular, or plural, as the identity(ies) of the person(s) may require. 10.08. Equal Opportunity: VSP is an Equal Opportunity and Affirmative Action employer. 10.09. Grievances/Complaints: The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (800) 877-7195 and use your health plan's grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. The Department also has a toll -free telephone number (1-888-HMO-2219), a TDD line (1-877-688-9891) for the hearing impaired and its Internet Web site (http://www.hmohelp.ca.gov) has complaint forms online. The plan's grievance process and the Department's complaint review process are in addition to any other dispute resolution procedures that may be available to Covered Persons, and the failure to use these procedures does not preclude Covered Person's use of any other remedy provided by law. 10.10. Communication Materials: Communication materials created by Group which relate to this vision care Plan must adhere to VSP's Member Communication Guidelines distributed to Group by VSP. Such communication materials may be sent to VSP for review and approval prior to use. VSP's review of such materials shall be limited to approving the accuracy of Plan Benefits and shall not encompass or constitute certification that Group's materials meet any applicable legal or regulatory requirements, including but not limited to, ERISA requirements. 18 CONTRACT NO. C32510 EXHIBIT A VISION SERVICE PLAN SCHEDULE OF BENEFITS Signature Plan GENERAL This Schedule lists the vision care services and vision care materials to which Covered Persons of VSP are entitled, subject to any Copayments and other conditions, limitations and/or exclusions stated herein. If Plan Benefits are available for Non -Member Provider services, as indicated by the reimbursement provisions below, vision care services and vision care materials may be received from any licensed optometrist, ophthalmologist, or dispensing optician, whether Member Doctors or Non -Member Providers. This Schedule forms a part of the Plan or Policy to which it is attached. When Plan Benefits are received from Member Doctors, benefits appearing in the first column below are applicable subject to any Copayments as stated below. When Plan Benefits are available and received from Non -Member Providers, the Covered Person is reimbursed for such benefits according to the schedule in the second column below less any applicable Copayments. COPAYMENT The benefits described herein are available to each Covered Person subject only to payment of the applicable Copayment by the Covered Person. Copayments are required for Plan Benefits received from Member Doctors and Non -Member Providers. Covered Persons must also follow the proper procedures for obtaining Benefit Authorization. A Copayment amount of $10.00 shall be payable by the Covered Person to the Member Doctor at the time services are rendered, PLAN BENEFITS VISION CARE SERVICES Eve Examination MEMBER DOCTOR BENEFIT Covered in Full' NON-MEMBER PROVIDER BENEFIT Up to $ 50.00* Complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of corrective eyewear where indicated. Subsequent regular eye examinations every 12 months. `Less any applicable Copayment. 19 CONTRACT NO. C32510 VISION CARE MATERIALS MEMBER DOCTOR NON-MEMBER BENEFIT PROVIDER BENEFIT Lenses Single Vision Covered in full* Up to $ 50.00* Bifocal Covered in full* Up to $ 75.00* Trifocal Covered in full* Up to $ 100.00* Lenticular Covered in full* Up to $ 125.00* Available once every 12 months. Frames Covered up to Plan Up to $ 70.00* Allowance* Available once every 24 months. *Less any applicable Copayment. Frame allowance may be applied towards non-prescription sunglasses for post PRK, LASIK, or Custom LASIK patients. Lenses and frames include such professional services as are necessary, which shall include: • Prescribing and ordering proper lenses; • Assisting in the selection of frames; • Verifying the accuracy of the finished lenses; • Proper fitting and adjustment of frames; • Subsequent adjustments to frames to maintain comfort and efficiency; • Progress or follow-up work as necessary. 20 CONTRACT NO. C32510 CONTACT LENSES Contact lenses are available once every 12 months in lieu of all other lens and frame benefits available herein. When contact lenses are obtained, the Covered Person shall not be eligible for lenses and frames again for 12 months. Necessary - Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Member Doctor or Non -Member Provider. Prior review and approval by VSP are not required for Covered Person to be eligible for Necessary Contact Lenses. Elective - MEMBER DOCTOR BENEFIT Professional Fees and Materials Covered in full* MEMBER DOCTOR BENEFIT Elective Contact Lens fitting and evaluation** services are covered in full once every 12 months, after a maximum $60.00 Copayment. Materials Up to $130.00 NON-MEMBER PROVIDER BENEFIT Professional Fees and Materials Up to $250.00* NON-MEMBER PROVIDER BENEFIT Professional Fees and Materials Up to $105.00 *Subject to Copayment **15% discount applies to Member Doctor's usual and customary professional fees for contact lens evaluation and fitting. 21 CONTRACT NO. C32510 LOW VISION BENEFIT The Low Vision benefit is available to Covered Persons who have severe visual problems that are not correctable with regular lenses. Supplementary Testing MEMBER DOCTOR BENEFIT Covered in Full NON-MEMBER PROVIDER BENEFIT Up to $125.00 Complete low vision analysis/diagnosis, which includes a comprehensive examination of visual functions, including the prescription of corrective eyewear or vision aids where indicated. Supplemental Care Aids 75% of Cost 75% of Cost Subsequent low vision aids. Copayment for Supplemental Aids: 25% payable by Covered Person. Benefit Maximum The maximum benefit available is $1000.00 (excluding Copayment) every two years. NON-MEMBER PROVIDER BENEFIT Low Vision benefits secured from a Non -Member Provider are subject to the same time limits and Copayment arrangements as described above for a Member Doctor. The Covered Person should pay the Non -Member Provider his full fee. The Covered Person will be reimbursed in accordance with an amount not to exceed what VSP would pay a Member Doctor in similar circumstances. NOTE: There is no assurance that this amount will be within the 25% Copayment feature. PA CONTRACT NO. C32510 EXCLUSIONS AND LIMITATIONS OF BENEFITS Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional limitations. Covered Persons may obtain details regarding frame brand availability from their VSP Member Doctor or by calling VSP's Customer Care Division at (800) 877-7195. PATIENT OPTIONS This Plan is designed to cover visual needs rather than cosmetic materials. When the Covered Person selects any of the following extras, the Plan will pay the basic cost of the allowed lenses or frames, and the Covered Person wi►I pay the additional costs for the options. • Optional cosmetic processes. • Anti -reflective coating. • Color coating. • Mirror coating. • Scratch coating. • Blended lenses. • Cosmetic lenses, • Laminated lenses. • Oversize lenses. • Polycarbonate lenses. • Photochromic lenses, tinted lenses except Pink #1 and Pink #2. • Progressive multifocal lenses. • UV (ultraviolet) protected lenses. • Certain limitations on low vision care. • A frame that costs more than the Plan allowance. • Contact lenses (except as noted elsewhere herein). NOT COVERED There is no benefit for professional services or materials connected with: • Orthoptics or vision training and any associated supplemental testing; plano lenses (less than a f .50 diopter power); or two pair of glasses in lieu of bifocals; • Replacement of lenses and frames furnished under this Plan which are lost or broken, except at the normal intervals when services are otherwise available; • Medical or surgical treatment of the eyes; • Corrective vision treatment of an Experimental Nature; • Costs for services and/or materials above Plan Benefit allowances; • Services and/or materials not indicated on this Schedule as covered Plan Benefits. VSP MAY, AT ITS DISCRETION, WAIVE ANY OF THE PLAN LIMITATIONS IF, IN THE OPINION OF VSP's OPTOMETRIC CONSULTANTS, IT IS NECESSARY FOR THE VISUAL WELFARE OF THE COVERED PERSON. 23 CONTRACT NO. C32510 PLAN BENEFITS AFFILIATE PROVIDERS GENERAL Affiliate Providers are providers of Covered Services and Materials who are not contracted as Member Doctors but who have agreed to bill VSP directly for Plan Benefits provided pursuant to this Schedule. However, some Affiliate Providers may be unable to provide all Plan Benefits included in this Schedule. Covered Person should discuss requested services with their provider or contact VSP Customer Care for details. COPAYMENT A Copayment amount of $10.00 shall be payable by the Covered Person at the time services are rendered. COVERED SERVICES AND MATERIALS EYE EXAMINATION- Covered in full* once every 12 months** Comprehensive examination of visual functions and prescription of corrective eyewear. LENSES - Covered in full* once every 12 months** Spectacle Lenses (Single, Lined Bifocal, or Lined Trifocal ) FRAMES - Covered up to the Plan allowance* once every 24 months** CONTACT LENSES ELECTIVE Elective Contact Lenses (materials only) are covered up to $130.00 once every 12 months. Elective Contact Lens fitting and evaluation services are covered in full once every 12 months, after a maximum $60.00 Copayment. NECESSARY Necessary Contact Lenses are covered up to $250.00* once every 12 months** Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor. Contact Lenses are provided in place of spectacle lens and frame benefits available herein. *Less any applicable Copayment. **Beginning with the first date of service, When contact lenses are obtained, the Covered Person shall not be eligible for lenses and frames again for 12 months. 24 CONTRACT NO. C32510 LOW VISION Professional services for severe visual problems not correctable with regular lenses, including: Supplemental Testing: Up to $125.00t -Includes evaluation, diagnosis and prescription of vision aids where indicated. Supplemental Aids: 75% of Affiliate Provider's fee up to $1000.00t tMaximum benefit for all Low Vision services and materials is $1000.00 every two (2) years and a maximum of two supplemental tests within a two-year period Low Vision Services are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor. 25 CONTRACT NO. C32510 EXCLUSIONS AND LIMITATIONS OF BENEFITS 1. Exclusions and limitations of benefits described above for Member Doctors shall also apply to services rendered by Affiliate Providers. 2. Services from an Affiliate Provider are in lieu of services from a Member Doctor or a Non -Member Provider. 3. VSP is unable to require Affiliate Providers to adhere to VSP's quality standards. 4. Where Affiliate Providers are located in membership retail environments, Covered Persons may be required to purchase a membership in such entities as a condition of obtaining Plan Benefits. 9 CONTRACT NO. C32510 EXHIBIT B VISION SERVICE PLAN SCHEDULE OF PREMIUMS Signature Plan VSP shall be entitled to receive premiums for each month on behalf of each Enrollee and his/her Eligible Dependents, if any, in the amounts specified below: $ 31.81 per month for each eligible Enrollee (includes coverage for Eligible Dependents) NOTICE: The premium under this Plan is subject to change upon renewal (after the end of the Initial Plan Term or any subsequent Plan Term), or upon change of the Schedule of Benefits or a material change in any other terms or conditions of the Plan. 27 CONTRACT NO. C32510 ADDENDUM VISION SERVICE PLAN ADDITIONAL BENEFIT - COVERED CONTACT LENSES BENEFITS Persons covered under this additional benefit are entitled to contact lenses which are referred to by VSP as "covered" as opposed to those which are defined as "Necessary" under the standard coverage. A Covered Persons may receive professional services and the contact lenses associated therewith from a Member Doctor, if in the opinion of the Member Doctor the patient can successfully wear contact lenses. This Plan covers the initial fitting period of up to 90 days. This may be extended at the discretion of the doctor. THIS BENEFIT DOES NOT AFFECT, NOR IS IT AFFECTED BY, THE COVERED PERSON'S ELIGIBILITY FOR SPECTACLE LENSES AND FRAMES UNDER THE REGULAR PLAN. B For each Covered Person seeking services under this benefit, there shall be a Copayment as follows: TYPE OF LENS FITTING AMOUNT OF COPAYMENT Disposable contact lenses, $ 50.00 including daily disposable contact lenses BECAUSE OF THE UNIQUE NATURE OF FITTING CONTACT LENSES, EXPERIENCE HAS SHOWN THAT THERE MUST BE SUBSTANTIAL PATIENT MOTIVATION. THERE IS ALSO SIGNIFICANT TIME INVOLVED ON THE DOCTOR'S PART - WHETHER OR NOT THE PROCEDURE IS SUCCESSFUL. FOR THESE REASONS, THE COPAYMENT IS NOT REFUNDABLE TO THE COVERED PERSON IN ANY CASE. C While the professional contact lens services received under this program is essentially prepaid for most types of fittings, there are certain additional features, such as artistically painted contact lenses, for which the Covered Person may be required to make an additional payment. EXCLUSIONS The following items are not covered under this Plan: • Orthokeratology • Replacement of lost or damaged lenses • Modifications of lenses • Routine maintenance such as polishing Refitting (change in lens design) after the initial fitting - this will be the responsibility of the Covered Person NON-MEMBER PROVIDERS Covered contact lens services secured from a doctor who is NOT a member of the VSP panel are subject to the same time limits and Copayments described herein. The Covered Person should pay the NonMember Provider his full fee. Covered Persons will be reimbursed in accordance with a schedule as shown in the Schedule of Benefits below. THERE IS NO ASSURANCE THAT THE SCHEDULE WILL BE SUFFICIENT TO PAY FOR THE SERVICES RECEIVED. CONTACT LENSES, ONCE FURNISHED UNDER THIS PLAN, CAN BE REPLACED ONLY WITH PRIOR AUTHORIZATION BY VSP, BUT IN NO EVENT MORE FREQUENTLY THAN EVERY 12 MONTHS. 28 CONTRACT NO. C32510 COVERED CONTACT LENS SCHEDULE OF BENEFITS Covered - Covered contact lenses are provided as an additional benefit under the plan. MEMBER DOCTOR BENEFIT Professional Fees and Materials Covered in full* NON-MEMBER PROVIDER BENEFIT Professional Fees and Materials Up to $250.00* *Subject to Copayment. COVERED CONTACTS ARE PROVIDED UNDER THIS PLAN EVERY 12 MONTHS. 29 CONTRACT NO. C32510 PLAN BENEFITS AFFILIATE PROVIDERS GENERAL Affiliate Providers are providers of Covered Services and Materials who are not contracted as Member Doctors but who have agreed to bill VSP directly for Plan Benefits provided pursuant to this Schedule. However, some Affiliate Providers may be unable to provide all Plan Benefits included in this Schedule. Covered Persons should discuss requested services with their provider or contact VSP Customer Care for details. COPAYMENT A Copayment amount of $50.00 shall be payable by the Covered Person at the time services are rendered. The Copayment shall be required for professional services related to the fitting of contact lenses and is not refundable to the Covered Person regardless of whether or not the fitting is successful. COVERED SERVICES AND MATERIALS CONTACT LENSES Contact Lenses are covered in full* once every 12 months.** This benefit does not affect, nor is it affected by, the Covered Person's eligibility for spectacle lenses and frames under any other VSP Plan. *Less any applicable Copayment. **Beginning with the first date of service. EXCLUSIONS AND LIMITATIONS OF BENEFITS 1. Exclusions and limitations of benefits described above for Member Doctors shall also apply to services rendered by Affiliate Providers. 2. Services from an Affiliate Provider are in lieu of services from a Member Doctor or a Non -Member Provider. 3. VSP is unable to require Affiliate Providers to adhere to VSP's quality standards. 4. Where Affiliate Providers are located in membership retail environments, Covered Persons may be required to purchase a membership in such entities as a condition of obtaining Plan Benefits. 30 CONTRACT NO. C32510 ADDENDUM VISION SERVICE PLAN THE CALIFORNIA CONTINUATION BENEFITS REPLACEMENT ACT OF 1997 (CAL -COBRA) Pursuant to California Health and Safety Code Section 1366.25, the following section is hereby incorporated into the Group Vision Care Plan, if, and only to the extent Cal -COBRA applies to the parties to this Plan: The California Continuation Benefits Replacement Act of 1997 (Cal -COBRA) requires health care service plans providing contracted coverage to employers with 2 to 19 eligible employees to offer continuation coverage for purchase by qualified beneficiaries upon the occurrence of a qualifying event. VSP and Group are subject to the following obligations in connection with continuation coverage: 1. Group agrees to provide VSP with notice of any employee who has had a "qualifying event", within 31 days of the qualifying event. A "qualifying event" means any of the following events that, but for the election of continuation coverage provided thereunder, would result in a loss of coverage under the group benefit plan to a qualified beneficiary: • The death of the covered employee. • The termination or reduction of hours of the covered employee's employment, except that termination for gross misconduct does not constitute a qualifying event. • The divorce or legal separation of the covered employee from the covered employee's spouse. • The loss of dependent status by a dependent enrolled in the group benefit plan. • With respect to a dependent only, the covered employee's eligibility for coverage under Title XVIII of the United States Social Security Act (Medicare). Within 14 days of receipt of the foregoing notice of a qualifying event from Group, VSP will send to the qualified beneficiary's last known address, as provided by Group, the necessary benefits information, premium information, enrollment forms, and instructions to allow the qualified beneficiary to formally elect continuation coverage. 2. Group agrees to notify qualified beneficiaries currently receiving continuation coverage, whose continuation coverage will terminate under one group benefit plan prior to the end of the period the qualified beneficiary would have remained covered under Cal -COBRA, as specified in Health and Safety Code Section 1366.27, a minimum of 30 days prior to the termination, of the qualified beneficiary's ability to continue coverage under a new group benefit plan for the balance of the period the qualified beneficiary would have remained covered under the prior group benefit plan. Group agrees to provide qualified beneficiaries subject to this paragraph with the necessary benefits information, premium information, enrollment forms, and instructions to allow the qualified beneficiary to continue coverage. This information shall be sent to the qualified beneficiary's last known address, as provided by the plan currently providing continuation coverage to the qualified beneficiary. 31 CONTRACT NO. C32510 2016 Renewal Schedule Effective July 1, 2016 Dental Dental PPO Vision Vision Plan Life and AD&D Basic Employee Life Basic Employee AD&D Disability Employee $ 45.75 Employee $ 45.75 ? Delta Dental I Employee +1 $ 86.27 Employee +1 $ 86.27 July 1, 2018 Family $ 145.67 I Family $ 145.67 VSP Composite i $ 30.88 i Composite $ 31.81 July 1, 2018 The Standard j $0.20 / $1,000 The Standard $0.025 / $1,000 $0.20 / $1,000 $0.025 / $1,000 i Short Term Disability The Standard ! $0.74 - $1.21 j $0.74 - $1.21 i 4 i' Long Term Disability i The Standard $.89 / $100 CP $.89 / $100 CP I + i Employee Assistance Program ! i EAP* ( Anthem $1.50 / PEPM I $1.50 / PPPM * 2016/201.7 EAP renewal rate is not yet available. 2015/2016 rates shown as a place holder July 1, 2018 July 1, 2018 July 1, 2018 July 1, 2018 I July 1, 2017 14