HomeMy WebLinkAboutCORRESPONDENCE - RFP - P928 CONSULTING SERVICES TO REVIEW MARKET ANALYSIS AND EMPLOYEE BENEFITS PRACTICES (2)City of Fort Collins Group Health Plan 1
POS Summary Plan Description, 1/1/04
SUMMARY PLAN DESCRIPTION
CITY OF FORT COLLINS GROUP HEALTH PLAN
POINT-OF-SERVICE PLANS
POS 1 AND POS 2
EFFECTIVE DATE: JANUARY 1, 2004
City of Fort Collins Group Health Plan 2
POS Summary Plan Description, 1/1/04
CITY OF FORT COLLINS GROUP HEALTH PLAN
POINT-OF-SERVICE (POS) PLANS: POS 1 and POS 2
SUMMARY PLAN DESCRIPTION
TABLE OF CONTENTS
SECTION PAGE
Schedule of Benefits 3
Introduction 5
Eligibility 6
Enrollment 7
COBRA Continuation of Benefits 9
Family and Medical Leave Act (FMLA) 11
Newborns’ and Mothers’ Health Protection Act 12
Women’s Rights and Cancer Health Act 12
Coverage during Leave for Military Service 12
Cost Containment Features 12
Benefit Provisions 14
Covered Expenses 15
POS 1 – Covered Network Expenses 15
POS 1 – General Exclusions and Limitations 31
POS 2 - Covered Non-Network Expenses 34
POS 2 - General Exclusions and Limitations 44
General Limits 47
Maximum Benefits 47
How to Claim Benefits 47
Appeals 52
Definitions 52
Other Important Information 60
City of Fort Collins Group Health Plan 3
POS Summary Plan Description, 1/1/04
SCHEDULE OF BENEFITS
City of Fort Collins
Point of Service (POS) Options 1 and 2
POS 1 is an EPO/HMO Plan Design.
POS 2 Network Benefits are paid as POS 1; Non-network benefits are paid by the Plan as a percentage
of Reasonable and Customary (R&C) Rates. Obtain required precertifications to avoid benefit
reductions
POS 1 and POS 2 POS 2 Non-network Services
Covered Service Network - YOU Pay After Deductible, Plan Pays
Calendar Year Deductible None $200 individual; $400 family
Annual Out-of-Pocket Max $2,500 individual; $5,000 family $2,500 individual; $5,000 family
Physician Office Visit* $15/PCP visit; $30/specialist visit 70% R&C
Preventive Care $15/visit 70% R&C
Maternity Care (Physician) $100 70% R&C
Allergy Testing/Treatment $15/PCP visit; $30/specialist visit 70% R&C
Allergy Injections $10/visit if no physician seen 70% R&C
Diagnostic X-Ray & Lab $15 70% R&C
Infertility Services 50% Not covered
Emergency Room $100/visit 50% R&C
Emergency Services after $25/visit 50% R&C
hours in a Physician’s Office
or Urgent Care
Ambulance $50/episode 70% R&C
Hospital Inpatient $500/admission 70% R&C (50% without precertification)
Hospital Outpatient (includes $100/visit 70% R&C (50% without precertification)
ambulatory surgery)
Physical/Occupational/ $15/visit; 20 visits/ 70% R&C to maximum $500 per type of
Speech Therapy condition maximum therapy
Mental Health**
Inpatient $50/day to max 45 days/ 50% R&C to max 45 days/year, or 90
year. $25/partial day to partial days/year. Combined max not to
max 90 partial days/year. exceed equivalent of 45 full days/year.
Combined max not to $1,000/year maximum for inpatient
exceed 45 full days/year. Physician charges. Precertification required.
Outpatient None for visits 1-5; $30/visit 70% R&C to $1,000 maximum/year
thereafter.
Alcohol/Substance Abuse
Inpatient $50/day to max 21 days/ 50% R&C to max 45 days/year. One
year. One course of course of treatment/year; two courses
treatment/year; two courses/ per lifetime. $1,000 max/year for in-
lifetime. patient Physician charges. Precertification
required.
*OB/GYNs are considered Primary Care Physicians (PCPs).
** Coverage for biologically based mental illness is no less extensive than the Coverage for any other physical illness.
City of Fort Collins Group Health Plan 4
POS Summary Plan Description, 1/1/04
POS 1 and POS 2 POS 2 Non-network Services
Covered Service Network - YOU Pay After Deductible, Plan Pays
Outpatient Substance/Alcohol None for visits 1-5; $30/visit 70% R&C to max $500/year
Abuse thereafter.
Skilled Nursing Facility None; maximum 120 days/ 70% R&C to max 30 days when
year. preauthorized; 50% without precertification.
Home Health Care None 70% R&C to max 60 days/year.
Hospice Care None Inpatient: 100% R&C; 50% without precert-
ification
Outpatient: 70% R&C to max $55/day
up to 270 days.
Durable Medical Equipment None; max benefit $1,500/ 70% R&C to max $1,000/year, included
(DME) year, including oxygen. Network maximum of $1,500/year.
Chiropractic $15/visit to max 20 visits/year. Covered as Physical Therapy
Prescription Drugs $8 for generic Applicable Network copay, plus 30%
(30-day supply) $15 for preferred brand of remaining cost.
$30 for non-preferred brand
Mail Order provides a 3-month
supply for 2 monthly copays.
Maximum Benefit $2,000,000/person/lifetime. $1,000,000/person/lifetime, included
This maximum includes any in the $2,000,000/person/lifetime
benefits received from any maximum under POS 1 Network
portion of the City of Fort benefits.
Collins Health Plan, including
the PPO Options.
Retirees under age 65 Same benefits as active Same benefits as active Employees.
Employees.
Retirees over age 65 $100,000 annual maximum, $100,000 annual maximum, including
including $5,000/year for $5,000 for prescription drugs. This
prescription drugs. maximum includes any Network
benefits received.
Note: This summary is for illustrative purposes, and is not a substitute for the full Summary Plan
Description. No Participant shall accrue any rights because of any statement in or omission from this
summary. Different benefit maximums may be applied to POS 1 and POS 2 benefits.
Be sure to use Network Providers to receive the highest level of covered benefits; otherwise, you may be
responsible for excess benefit costs. Non-network charges exceeding R&C Limits are the responsibility
of the Participant. Obtain required preauthorizations to avoid benefit reductions; call Great-West Health
Care for details: 1-800-663-8081.
Benefit provisions along with Employee cost sharing and contributions are subject to change.
City of Fort Collins Group Health Plan 5
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INTRODUCTION
This Summary Plan Description (SPD) describes Point-of-Service (POS) benefits in effect January 1,
2003, and is an integral part of the formal health Plan Document. The City of Fort Collins Group Health
Plan (Plan) is self-funded, which means that the City of Fort Collins (City) provides direct funding for
claims payment and administrative costs. If during a Plan Year, an individual’s claims exceed $120,000 in
eligible charges (this amount is subject to change), excess charges are paid through a separate stop-loss
insurance contract. The Plan Supervisor is Great-West Health Care, which pays claims, manages the
provider network through One Health Plan, performs utilization review/case management services and
provides prescription drug benefits through Advance PCS, a Prescription Benefit Manager (PBM).
This SPD describes the two Point-of-Service (POS) Plans provided through Great-West Health Care:
POS 1 is an HMO-type plan that provides Coverage with fixed-dollar Copayments; however, you must
select a Primary Care Physician (PCP) and use Network Providers; referrals to specialists are not
required. Non-Network Providers are usually not covered, except under limited and extraordinary (e.g.,
emergency) circumstances. Some Network services require preauthorization by One Health Plan.
POS 2 offers you the opportunity to use Network Providers like an HMO. You must select a PCP;
however, you also have the freedom of choice to use non-Network Providers, subject to an annual
Deductible and Coinsurance. Some non-Network services require preauthorization by One Health Plan.
Network Providers agree to provide services for reduced fees; therefore, you generally save money
when you use a Network Provider. Non-Network Providers do not enter into such agreements;
therefore, your cost for using these providers may be higher. Nonetheless, the choice of provider is
yours. Network Providers may elect to discontinue their participation in the network; therefore, you are
responsible for verifying with your provider that he/she is a Network Provider. This is especially
important now that referrals from PCPs to specialists are no longer required; be careful that your
specialists are members of the Network. Using a non-Network Provider generally will result in you paying
a larger portion of incurred charges. Only under rare circumstances, such as emergencies, can you
receive Network benefits for non-Network charges. Non-Network Providers may apply for Network status
directly with One Health Plan at www.onehealthplan.com.
It is important to remember that not all Medically Necessary services prescribed by a Physician are
Covered Services under the Plan. The decision to seek medical attention should not be based solely on
available Plan Coverage. The use of certain Network and non-Network services may require
preauthorization to avoid benefit reductions and additional cost to you.
It is your responsibility to enroll for the Plan that best meets your needs and to understand the
provisions of the Plan you select. Before a crisis situation arises, you and your enrolled Dependents
should take time to read this SPD and become familiar with the terms, conditions and limitations of the
Plan in order to avoid benefit reductions and additional cost to you.
The Plan shall be administered in accordance with applicable governmental rules and regulations, and in
a nondiscriminatory manner. In the event of a discrepancy between the Plan, this SPD and any
applicable law, the applicable law shall govern. As Plan Sponsor, the City relies on guidance from the
Plan Supervisor, which handles the daily administration of Plan provisions. The City has complete
authority to establish standards of proof and to interpret the Plan as it pertains to any claim dispute. The
decisions of the City or its designee are final and binding with regard to claims disputes.
Funding The Plan is part of a cafeteria plan, as defined by Section 125 of the Internal Revenue Code.
Funding is provided by Employer and Employee contributions. Payroll-deducted employee contributions
are made on a pre-tax basis, which reduces your taxable income. Employee contribution amounts are
subject to change.
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Plan Amendment/Termination Although the City intends to maintain the Plan indefinitely, the City
reserves the right to amend or terminate the Plan in whole or in part at any time. This right of
amendment/termination shall apply to all Participant groups, including Retirees. Significant changes to
Plan provisions will be communicated usually during the annual Open Enrollment, and therefore may not
appear in this SPD. You should retain those announcements for future use in conjunction with this SPD.
Plan Document Shall Govern The information contained in this SPD is intended to be accurate and
complete. However, the SPD is intended to be a summary. In the event that the Plan Document provides
more comprehensive provisions that are not specifically addressed by the SPD, the Plan Document shall
govern. The Plan Document is available for inspection at the Human Resources Office. To review the
Plan Document, please call 970-221-6535 and schedule an appointment.
ELIGIBILITY
Who is eligible for Employee Coverage?
Eligible full-time Employees are required to enroll for medical Coverage, unless they provide written proof
that they are covered by another medical benefit plan. Employees of the City of Fort Collins, the Poudre
Fire Authority, the Downtown Development Authority, or the Northern Front Range Transportation and Air
Quality Planning Council who are regularly scheduled to work 20 hours or more per week in the following
categories are eligible for Coverage: unclassified management, classified Employee, eligible contract
Employee, eligible hourly Employee with benefits and Retiree. An eligible contract Employee is anyone
whose specific employment contract states that he/she is eligible for City-sponsored medical insurance.
Hourly Employees with benefits are eligible to enroll only for POS 1 Coverage; an hourly Employee with
benefits is an Employees whose job code falls between 2000 and 2399 and who works on a scheduled
basis at least 30 hours per week for 26 weeks or more in a 12-month period)
An eligible Retiree is an Employee who retires after completing ten or more years of Covered Service with
the City and is able to file for receipt of retirement benefits; at the time of retirement, the Retiree is given
the option to elect COBRA Coverage or Retiree health insurance Coverage. Except for disabled
Retirees, Retirees who elect COBRA upon retirement cannot enroll for Retiree Coverage after the
COBRA benefit period expires.
Who is eligible to be enrolled for Dependent Coverage?
You may enroll your legal Spouse and eligible Dependent Children, as defined on page 54 of this booklet.
No other persons are eligible for enrollment. Grandchildren, including children born to an enrolled
Dependent Child of the Employee, are not eligible for Coverage, unless the Employee adopts or assumes
legal guardianship of the grandchild. Proof of dependency status must be provided as required by the
Plan. Divorced Spouses are not eligible for Coverage, but may be eligible for COBRA Continuation
Coverage (see page 9). Charges incurred by a divorced Spouse will be the responsibility of the
Employee, and future benefit payments could be withheld until inappropriately paid charges are recovered
by the Plan.
When are you eligible for Coverage?
You are eligible for Coverage on the first day of the month following completion of 30 calendar days
continuous service as an eligible Employee, unless your absence is due to a disability, illness or injury.
Special rules apply to married staff members.
If an Employee and Spouse are both eligible Employees, each Employee may enroll in the Plan option of
his/her choice, or each may enroll as an Employee and as a Dependent. Dependent children will be
enrolled primarily under the parent whose birthday falls earlier in the calendar year; however, they may be
enrolled under both parents. Benefits will be coordinated in accordance with the rules for Coordination of
Benefits on pages 50-51.
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POS Summary Plan Description, 1/1/04
ENROLLMENT
When must enrollment be completed?
Enrollment must be completed within 31 calendar days of the date you become eligible for Coverage.
What if you miss your enrollment deadline?
If you miss your enrollment deadline, you cannot enroll until the next following Open Enrollment Period,
unless you experience an involuntary loss of other group Coverage or qualify for “Special Enrollment” as
outlined in this section.
Enrollment of Newborn Children
Newborn children must be enrolled just like any other Dependent if claims are to be paid. Within thirty-
one (31) calendar days from birth, call the Human Resources Department and provide the name, sex and
birth date of the newborn child. Newborns are covered automatically for the first thirty-one (31) calendar
days of life. If enrollment of the newborn will result in additional premium (for example, if you are
changing from Employee + Spouse to Employee + Family Coverage), the newborn must be enrolled
within the first thirty-one (31) calendar days following birth for Coverage to continue past the first thirty-
one (31) calendar days. If such enrollment is not completed as required, Coverage will cease at the end
of the thirty-first day, and the newborn will not be able to be enrolled until the next Open Enrollment.
Involuntary loss of other group coverage can occur for a variety of reasons; for example, if: you were
covered under your Spouse’s plan and that coverage ends due to your Spouse’s termination of
employment, layoff or reduction in hours; you get divorced and are no longer eligible for coverage as your
Spouse’s Dependent; your Spouse dies or your Spouse’s employer terminates its plan. If you experience
an involuntary loss of other group coverage, you may enroll for Coverage through the City during the first
31 days following the loss of coverage. Simply provide a statement from your former plan listing the
people who were covered and the date coverage ended. After expiration of the 31-day period, you may
not enroll until the next open enrollment.
Special enrollment is permitted for Employees or Dependents who originally declined Coverage if they:
1. had other coverage, which they later lost because of separation/divorce, termination of
employment or reduction in the hours of the Employee or of his/her Spouse, death or the cessation of
contributions for their coverage by another employer (unless it was for cause or failure to pay
Employee contributions on time), or
2. were on COBRA continuation of benefits coverage, but their COBRA eligibility has expired, or
3. did not initially enroll and later gains a new Dependent as a result of marriage, birth, adoption or
placement for adoption, in which case the Employee is entitled to special enrollment along with the
Dependent(s), including the new child.
A person eligible for special enrollment has thirty-one (31) calendar days from the date of the occurrence
of the above listed events to enroll, and shall become a Participant on the first day of the month following
receipt of the properly completed enrollment form, except that in the event of special enrollment as the
result of birth, adoption or placement for adoption of a child, the person enrolling shall become a
Participant upon the date of birth or placement for adoption of the child.
How is enrollment completed?
At your benefits orientation, you received a packet of forms and information describing the available
benefit options. After you have reviewed the benefit information and you have determined which Plans
are best suited to you and your family, complete the appropriate enrollment application, and return the
completed form to Human Resources. You should confirm your enrollment by referring to the entries on
your pay stub. If these entries do not appear on your pay stub on or after your enrollment date, you
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should contact Human Resources immediately. Remember: enrollment must be completed within 31
calendar days of the date on which you first become eligible.
When does Coverage begin?
For new eligible Employees, Coverage begins on the first day of the month following the completion of
thirty (30) consecutive days of service, unless your absence is due to a disability, illness or injury. Of
course, enrollment must be completed within thirty-one (31) days of the initial eligibility date. For
example, if your first day of employment is March 15 and you enroll for Coverage during the initial
eligibility period, your Coverage will go into effect on May 1.
Enrollment conducted during the annual Open Enrollment Period is effective on the first day of the
following Plan Year, which begins January 1.
Dependent Coverage begins the same day that your Coverage begins. In the event that you acquire an
eligible Dependent after you have already enrolled, those Dependents must be enrolled within thirty-one
(31) days of their initial eligibility date. Newborns are eligible for Coverage from date of birth; children
placed for adoption are eligible from date of placement; and children for whom you acquire the legal
responsibility to provide Coverage are eligible from the date stipulated by Qualified Medical Child Support
Order.
Please Remember: Be sure to contact Human Resources whenever you acquire a new Dependent you
wish to enroll for Coverage. Otherwise, Coverage could be delayed until the next Open Enrollment.
Changing Your Coverage
Generally, your group health plan choices must stay in effect from the date your elections take effect until
the end of the Plan Year on December 31. However, if you experience a qualifying change in status
during the year, you may add or drop Coverage within 31 days from the date the event occurs. For
example, if you get married on June 13 and you wish to enroll your Spouse for Coverage, your Spouse
is eligible for Coverage on June 13, and must be enrolled within 31 days of your date of marriage.
If you have a child, the child must be enrolled within 31 days of birth.
If you do not register your change within the thirty-one (31) day period, you must wait until the next open
enrollment to make that change, except in the case of special enrollment (see page 7).
Qualifying changes in status include changes in your:
legal marital status – an event that changes your legal marital status, including marriage, divorce,
annulment or death of a Spouse;
number of Dependents – an event that changes the number of your eligible Dependents, including
birth, death, adoption or placement for adoption, or a child reaching maximum age or losing student
status;
employment status - termination of employment, commencement of/return from unpaid leave of
absence, or any other change in the employment status of you, your Spouse or Dependent that
affects an individual’s eligibility for Coverage under a Plan;
residence - a change in your residence or the residence of your Spouse or Dependent that impacts
plan eligibility.
It is important to remember that such qualifying changes do not automatically enable you to change your
enrollment option(s); rather, the change in status must cause you, your Spouse or a Dependent to lose or
gain Coverage under this plan, or under the plan of your Spouse’s or Dependent’s employer. In addition,
your election must be on account of and correspond with the change in status. For example, if you get
married you may enroll your new Spouse for Coverage, but you may not change plans.
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In addition, an annual Open Enrollment period is held, usually during late October and early November.
During this time, you may change your Coverage to another plan offered by the City or terminate your
Coverage. Information is distributed to each department. Retired and COBRA Participants may also
change Coverage during the annual open enrollment; however, a Retiree who elects Option 1 at
retirement may not switch Coverage later to another option.
When does Coverage end?
Coverage ends on the last day of the month in which you terminate employment or you elect to terminate
Coverage due to a qualified change in family status. For a Dependent, Coverage ends on the last day of
the month in which the Dependent ceases to be eligible for participation under the Plan. For example, if
a Dependent child attains age 19 on March 15 and is not a full-time student at an accredited institution,
the child’s Coverage ends March 31. Participants who cease to be eligible for Coverage may be eligible
for COBRA continuation of benefits. See the COBRA section below.
Coverage for a divorced Spouse ends on the last day of the month in which the divorce becomes final.
No charges incurred by a divorced Spouse or other Dependent after the Coverage termination date will
be reimbursed by the Plan, and will be the responsibility of the Employee. If benefits are paid improperly
on behalf of an ineligible Dependent, the Plan retains the right to suspend benefits until those improperly
paid benefits are recovered.
Divorced Spouses may be eligible for COBRA continuation of benefits Coverage. Please see the next
section for more information about this continuation of benefits provision.
COBRA CONTINUATION OF BENEFITS
This notice contains important information about your right to COBRA Continuation Coverage, which is a
temporary extension of Coverage under the Plan. The right to COBRA Continuation Coverage was
created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).
COBRA Continuation Coverage can become available to you and to other members of your family who
are covered under the Plan when you would otherwise lose your group health Coverage. This notice
generally explains COBRA Continuation Coverage, when it may become available to you and your
family, and what you need to do to protect the right to receive it. Additional information is available
from the Plan Administrator.
The Plan Administrator is the City’s Benefits Administrator, Human Resources Department, City of Fort
Collins, PO Box 580, Fort Collins, Colorado 80522-0580, telephone (970) 221-6535. The Plan
Administrator is responsible for administering COBRA Continuation Coverage.
COBRA Continuation Coverage
COBRA Continuation Coverage is a continuation of Plan Coverage when Coverage would otherwise end
because of a life event known as a “Qualifying Event.” Specific Qualifying Events are listed later in this
notice. COBRA Continuation Coverage must be offered to each person who is a “Qualified Beneficiary.”
A Qualified Beneficiary is someone who will lose Coverage under the Plan because of a Qualifying Event.
Depending on the type of Qualifying Event, Employees, Spouses of Employees and Dependent children
of Employees may be qualified beneficiaries. Under the Plan, qualified beneficiaries who elect COBRA
must pay for COBRA Continuation Coverage.
If you are an Employee, you will become a Qualified Beneficiary if you will lose your Coverage under the
Plan because either one of the following Qualifying Events happens:
1. your hours of employment are reduced, or
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2. your employment ends for any other reason than your gross misconduct.
If you are the Spouse of an Employee, you will become a Qualified Beneficiary if you will lose your
Coverage under the Plan because any of the following Qualifying Events happens:
1. your Spouse dies;
2. your Spouse’s hours of employment are reduced;
3. your Spouse’s employment ends for any reason other than his or her gross misconduct;
4. your Spouse becomes enrolled in Medicare (Part A, Part B, or both); or
5. you become legally divorced or legally separated from your Spouse.
Your Dependent children will become qualified beneficiaries if they will lose Coverage under the Plan
because any of the Qualifying Events happens:
1. the parent-Employee dies;
2. the parent-Employee’s hours of employment are reduced;
3. the parent-Employee’s employment ends for any other reason than his or her gross misconduct;
4. the parent-Employee becomes enrolled in Medicare (Part A, Part B, or both);
5. the parents become divorced or legally separated; or
6. the child stops being eligible for Coverage under the plan as a “Dependent child.”
Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a Qualifying
Event. If a proceeding in bankruptcy is filed with respect to The City of Fort Collins and that bankruptcy
results in the loss of Coverage of any retired Employee covered under the Plan, the retired Employee is a
Qualified Beneficiary with respect to the bankruptcy. The retired Employee’s Spouse, surviving Spouse,
and Dependent children will also be qualified beneficiaries if bankruptcy results in the loss of their
Coverage under the Plan.
The Plan will offer COBRA Continuation Coverage to qualified beneficiaries only after the Plan
Administrator has been notified that a Qualifying Event has occurred. When the Qualifying Event is the
end of employment or reduction of hours of employment, death of the Employee, commencement of a
proceeding in bankruptcy with respect to the Employer, or enrollment of the Employee in Medicare (Part
A, Part B or both), the Employer must notify the Plan Administrator of the Qualifying Event within 30 days
following the date Coverage ends.
For the other Qualifying Events (divorce or legal separation of the Employee and Spouse or a Dependent
child’s losing eligibility for Coverage as a Dependent child), you must notify the Plan Administrator within
60 days after the Qualifying Event. You must send this notice to Ms. Gwen Feit, Benefits Technician, in
the Human Resources Department. Additional documentation or information may be required, depending
on the Qualifying Event.
Once the Plan Administrator receives notice that a Qualifying Event has occurred, COBRA Continuation
Coverage will be offered to each of the qualified beneficiaries. For each Qualified Beneficiary who elects
COBRA Continuation Coverage, COBRA Continuation Coverage will begin on the date the Plan
Coverage would otherwise have been lost.
COBRA Continuation Coverage is a temporary continuation of Coverage. When the Qualifying Event is
the death of the Employee, enrollment of the Employee in Medicare (Part A, Part B or both), your divorce
or legal separation or a Dependent child losing eligibility as a Dependent child, COBRA Continuation
Coverage lasts for up to 36 months.
When the Qualifying Event is the end of employment or reduction of the Employee’s hours of
employment, COBRA continuation lasts for up to 18 months. There are two ways in which this 18-month
period of COBRA Continuation Coverage can be extended.
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Disability extension of 18-month period of Continuation Coverage.
If you or anyone in your family covered under the Plan is determined by the Social Security
Administration to be disabled at any time during the first 60 days of COBRA Continuation
Coverage and you notify the Plan Administrator in a timely fashion, you and your entire family
can receive up to an additional 11 months of COBRA Continuation Coverage, for a total of 29
months. You must make sure that the Plan Administrator is notified of the Social Security
Administration’s determination within 60 days of the date of determination and before the end of
the 18-month period of COBRA Continuation Coverage. This notice should be sent to Ms. Gwen
Feit, Benefits Technician, Human Resources Department. You will need to provide a copy of the
Social Security Administration’s written notice of determination.
Second Qualifying Event extension of 18-month period of Continuation Coverage
If your family experiences another Qualifying Event while receiving COBRA Continuation Coverage, the
Spouse and Dependent children in your family can get additional months of COBRA Continuation
Coverage, up to a maximum of 36 months. This extension is available to the Spouse and Dependent
children if the former Employee dies, enrolls in Medicare (Part A, Part B or both), or gets divorced or
legally separated. The extension is also available to a Dependent child when that child stops being
eligible under the Plan as a Dependent child. In all of these cases, you must make sure that the Plan
Administrator is notified of the second Qualifying Event within 60 days of the second Qualifying
Event. This notice must be sent to: Ms. Gwen Feit, Benefits Technician, Human Resources
Department. Additional information and documentation may be required, depending on the
nature of the Qualifying Event.
If You Have Questions
If you have questions about your COBRA Continuation Coverage, you should contact Ms. Gwen Feit,
Benefits Technician, Human Resources Department; or you may contact the nearest Regional or District
Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA). Addresses
and phone numbers of Regional and District EBSA Offices are available through EBSA’s web site at
www.dol.gov/ebsa.
Keep Your Plan Informed of Address Changes
In order to protect your family’s rights, you should keep the Plan Administrator informed of any
changes in the addresses of family members. You should also keep a copy for your records of any
notices you send to the Plan Administrator.
FAMILY AND MEDICAL LEAVE ACT (FMLA)
If you are on a leave of absence that qualifies under the provisions of FMLA, you will remain eligible for
plan benefits during your leave of up to 12 weeks. However, during FMLA leave, you must continue to
pay the premiums you paid (if any) before your leave began.
If you are on a paid leave that runs concurrently with your FMLA leave, your premiums will continue to be
deducted from your paycheck. If you are on an unpaid FMLA leave, you need to make arrangements
with Human Resources for the payment of your required premium. Premium payment is due on the first
day of each month of Coverage. If premiums are not paid within 30 days of the due date, Coverage will
be terminated retroactively to the end of the month in which premiums were paid last. Coverage will be
reinstated upon your return from leave without a waiting period, but no Coverage is provided for the
period you failed to pay required premiums.
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If you elect not to return to work at the end of your FMLA leave, you must repay to the City the premiums
paid on your behalf during your leave, unless you cannot return due to circumstances beyond your
control.
If you elect not to return to work at the end of your FMLA leave, you may elect COBRA continuation of
benefits as described previously. Your benefit continuation period begins at the time you inform the City
of your decision not to return to work.
NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT
Under federal law, the Plan may not restrict benefits for any length of stay in connection with childbirth for
the mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96
hours following a caesarian section. Also, the Plan may not require that a provider obtain authorization
from the Plan for prescribing a length of stay not in excess of the stipulated periods. In addition, the Plan
is prohibited under federal law from requiring a health care provider to obtain authorization from the Plan
in order to prescribe a length of stay not in excess of 48 hours (or 96 hours). However, federal law does
not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from
discharging the mother or her newborn child earlier than 48 hours (or 96 hours, if applicable). For
additional information, call the Benefits Administrator at (970) 221-6535.
WOMEN’S RIGHTS AND CANCER HEALTH ACT
In accordance with this federal law, the Plan shall provide benefits for Reconstructive Surgery following a
mastectomy, surgery and reconstruction of the other breast to produce a symmetrical appearance, and
prostheses and physical complications of all stages of mastectomy, including lymphedemas. For
additional information, contact the Benefits Administrator at (970) 221-6535.
COVERAGE DURING LEAVE FOR MILITARY SERVICE
If you enter the Uniformed Services as defined by the Uniformed Services Employment and
Reemployment Rights Act (USERRA) of 1994, your Coverage under the Plan shall be continued for up to
30 days. If you enter service with the Uniformed Services for more than 30 days, Coverage under the
Plan shall terminate, and you will be entitled to elect COBRA continuation of Coverage.
When you are discharged from the Uniformed Services, your Coverage under the Plan will be reinstated
immediately upon your return to work with the City, provided you return to work within certain time
periods. If your period of service was between thirty and 180 days, you must return to work with the City
within 14 days of your discharge in order for your Coverage to be reinstated immediately upon return to
work. If your period of service was more than 180 days, you must return to work with the City within 90
days of your discharge in order for your Coverage to be reinstated immediately upon your return to work.
If the former active Employee is hospitalized for or convalescing from any illness or injury caused by
active duty, the time Limits to submit the application for reemployment are extended to the end of the
period necessary to recover and in no case beyond two (2) years.
COST CONTAINMENT FEATURES
To help maintain a cost-effective benefit program that will continue to meet our health care needs, the
Plan uses several cost containment techniques. Failure to comply with the Plan’s cost containment
requirements could result in additional cost to you. These cost containment features include:
City of Fort Collins Group Health Plan 13
POS Summary Plan Description, 1/1/04
the One Health Plan provider network
pre-admission certification program
utilization review/case management
prescription benefit management
The One Health Plan Network enables the Plan to contract with certain providers for negotiated fees
that are generally lower than fees in the open market. The Plan utilizes the One Health Plan Managed
Care Provider Network. Call your provider directly to determine whether he/she is a Network Provider.
The One Health Plan Directory is always subject to change, and may not reflect the most current
information. You may access a directory at the One Health Plan website: www.onehealthplan.com. POS
1 Participants must use Network Providers. POS 2 Participants may use Network Providers for the same
Copayments, but they may also use non-Network Providers and pay a generally higher portion of costs.
The Hospital Pre-Admission Certification Program requires each inpatient Hospital stay (Network or
non-network) to be precertified by your Network Physician before you go to the Hospital. You are
responsible for non-Network precertifications. One Health Plan administers this program.
Non-emergency Hospital Admissions When your Physician recommends an inpatient Hospital
stay, you should call One Health Plan at 1-800-663-8081 to verify precertification. Be prepared to
identify yourself as a Participant in the City of Fort Collins Group Health Plan # 359613, and provide
your name and the Employee’s Social Security number. If the hospitalization is for a covered
Dependent, provide the Dependent’s name and date of birth. You also need to provide the name of
your attending Physician, the name of the Hospital, and the date and reason for the proposed
hospitalization. One Health Plan will discuss the proposed hospitalization with your Physician and, if
possible, recommend appropriate cost-effective alternatives, such as outpatient surgery.
Emergency Admissions In case of an emergency, obtain the care you need immediately. If you are
admitted overnight, call One Health Plan within 48 hours (72 hours if you are admitted on a
weekend). If you are unable to make the call yourself, have a family member or friend call on your
behalf. Please familiarize your family members or a friend with this requirement so that you can avoid
a reduction in benefits.
Utilization Review seeks to provide the proper level of Medically Necessary care appropriate to a
patient’s condition; if warranted, adjustments to the treatment plan can be made. The Plan uses several
utilization review techniques:
Continued Stay Review If your stay is expected to last longer than the approved period, call One
Health Plan to request an extension. One Health Plan in consultation with your Physician may
authorize additional days that are necessary because of your condition.
Medical Case Management When One Health Plan is notified of an admission for a serious illness
or injury, they assign a medical case manager to monitor your treatment. The medical case manager
is usually a Registered Nurse. Case managers work with the Physician and the patient’s family to
see that quality care and appropriate treatment are received. Case managers may also recommend
alternative forms of appropriate treatment.
Maternity Admissions and Care Remember to confirm with One Health Plan that your maternity
admission has been precertified properly.
Prescription Benefit Management To help contain the cost of prescription drugs, Great-West Health
Care utilizes a Prescription Benefit Manager (PBM) called Advance PCS.
One of the services Advance PCS provides is called “preferred drugs”; with this program, Advance
PCS suggests to Physicians the use of lower cost medications that might be appropriate for your
treatment. This program suggests but does not require the use of lower cost medications.
City of Fort Collins Group Health Plan 14
POS Summary Plan Description, 1/1/04
When you purchase medications from a Network pharmacy, use your plan identification card for quick
service.
For maintenance medications, a lower cost mail order prescription program is also available (see
page 23). Questions about prescription drugs should be addressed to One Health Plan at 1-800-663-
8081.
BENEFIT PROVISIONS
The Plan offers you two POS benefit plan options from which to choose. POS 1 is a self-funded HMO;
you must select a Primary Care Physician (PCP), obtain and use Network Providers; referrals to
specialists are not required. POS 1 requires that you make fixed-dollar Copayments at the time services
are provided. Remember, POS 1 is a self-funded HMO. The annual out-of-pocket maximum you will pay
under POS 1 is $2,500 per individual and $5,000 per family; however, it would be unusual for anyone to
reach the out-of-pocket maximum under POS 1 due to the low Copayment requirements. To avoid
unnecessary charges, it is your responsibility to confirm with each of your providers that he/she is a
Network Provider. If you accidentally receive services from a non-Network Provider, the fact that you did
not know the provider’s status does not relieve you of your responsibility to pay additional charges.
POS 2 is a self-funded Point-of-Service (POS) Plan. You must choose a PCP, and if you elect to follow
the requirements of POS 1 you will make the same Copayments as POS 1. There are certain restrictions
in using non-Network Providers; call One Health Plan for details. However, if you elect not to follow the
requirements of POS 1, your benefits will be subject to an individual annual Deductible of $200 ($400 per
family), after which benefits are paid at 70% of the Reasonable and Customary (R&C) Charge for the
area in which services are rendered. You are responsible for confirming whether or not a provider is a
Network Provider. Using a non-Network Provider will generally result in larger charges to you. Charges
in excess of R&C Limits are your responsibility.
Deductible charges under POS 2 are paid on a calendar year basis, and apply to eligible non-
network covered expenses. If you incur any Deductible charges during the last three months of a
Plan Year, those charges will also be applied to your Deductible requirement for the following Plan
Year. If more than one covered family member is injured during a common Accident, only one
Deductible will need to be met for medical expenses related to that Accident. Amounts you pay for
ineligible charges (including charges in excess of R&C Limits) are not applied toward meeting your
Deductible requirement or any out-of-pocket maximum.
Coinsurance is the percentage of covered charges you pay after satisfying your Deductible.
Coinsurance payments for non-Network Provider services are different from fixed-dollar Copayments
for Network Provider services. If you use a Non-Network Provider, the Plan pays 70% of R&C
charges and you pay the remaining 30% of R&C charges, plus any charges in excess of R&C levels.
Charges in excess of R&C amounts are not covered by the Plan; therefore they are not applied
toward your Deductible or out-of-pocket maximum amounts.
The Annual Out-of-Pocket Maximum is the most you will pay for eligible charges during a Plan
Year, and is comprised of your Deductible plus your Coinsurance payments. Once you satisfy the
out-of-pocket maximum of $2,500 per person or $5,000 per family, the Plan will pay 100% of
excess eligible R&C charges for the balance of the Plan Year. Amounts paid for any charges not
covered by the Plan or costs exceeding specific benefit maximums do not apply to the Out-of-Pocket
Maximum.
Benefit Maximum For active Participants and Retiree Participants not eligible for Medicare, the Plan
will pay up to $2,000,000 in covered Network charges for you and each of your eligible covered
Dependents. For retired Participants eligible for Medicare, the Plan will pay up to $100,000 in
covered charges per calendar year, including $5,000 per year in prescription drug charges, up to the
City of Fort Collins Group Health Plan 15
POS Summary Plan Description, 1/1/04
$2,000,000 Network maximum. The benefit maximum for all Participants applies to all periods of
Coverage under the Plan, including the PPO Options and any non-Network charges. Non-Network
charges are paid up to $1,000,000, which is included in the aggregate $2,000,000 maximum benefit.
COVERED EXPENSES
The Plan covers a wide variety of Medically Necessary services that are prescribed by a Physician.
However, not all services are covered even if they are determined Medically Necessary and prescribed
by your Physician. Your decision to seek and obtain medical care should not be determined solely by the
availability of insurance Coverage. In addition, the Plan reimburses only for eligible Covered Services.
Payment for non-Network Provider services under POS 2 is limited by Reasonable and Customary
(R&C) amounts; charges over and above R&C Limits are your responsibility. References to maximum
benefits include benefits received at any time of participation under any Plan option, including the PPO
Options. Refer to the Schedule of Benefits (pages 3-4) for benefit payment amounts.
There are no pre-existing condition Exclusions or limitations under either POS 1 or POS 2. Nonetheless,
we are required to provide the following information. The Health Insurance Portability and Accountability
Act (HIPAA) places Limits on pre-existing condition limitations. If you and your eligible Dependents had
creditable under another plan and did not experience a break in coverage, that period of prior coverage is
counted toward meeting a pre-existing condition limitation. For HIPAA purposes, a break in coverage is
defined as a period of 63 days or more without health coverage. To use Creditable Coverage toward
meeting your pre-existing condition limitation, you must present a Certificate of Creditable Coverage,
which you obtain from your prior Employer or health plan provider.
Work related illness and injury Work related illness or injury are not covered by the Plan if: the
Participant fails to file a Workers’ Compensation claim within the filing period allowed by the law; the
Participant obtains care which is not authorized by Workers’ Compensation; the Participant obtains care
from a provider not authorized by the Employer; the Employer fails to carry the required Workers’
Compensation insurance, in which case the Employer becomes liable for any work-related illness or injury
expenses; the Participant fails to comply with any other provisions of the law. Questions about Workers
Compensation should be addressed to the Risk Management Department, at (970) 221-6708.
The following services are covered by the Plan when Medically Necessary and prescribed by a Physician.
The amount you will be required to pay may depend on whether you are enrolled for POS 1 or POS 2.
You are responsible for determining whether or not your providers are Network Providers.
POS 1
COVERED NETWORK SERVICES
POS 1 requires the use of Network Providers, except under extraordinary circumstances, such as
emergencies. Most services require that you pay a fixed-dollar amount to your Network Provider at the
time service is rendered. Always verify with your provider that he/she participates in the One Health Plan
Network. Otherwise, you may be responsible for all charges incurred through non-Network Providers.
Remember: your Dependents must remember your Social Security Number in order to verify Coverage at
a provider’s office. Referrals to specialists are no longer required.
If a Covered Service is not available through a Network Provider, the Plan Supervisor’s Medical Director
shall have the discretion to authorize the use of a non-Network Provider. In such a case, the non-
Network Provider would be reimbursed at the contracted network fee and you would be responsible for
your Copayment and charges that exceed the contracted network fee. Whether a Covered Service is
available through a Network Provider shall be determined solely by the Plan Supervisor’s Medical
Director.
City of Fort Collins Group Health Plan 16
POS Summary Plan Description, 1/1/04
CLINICS
Pain Clinics are covered for chronic conditions to a maximum benefit of $2,000 per person per lifetime.
Pain centers, facilities, clinics, or centers involved in treatment of pain are not covered for inpatient care.
Convenience items and meals are not covered. Pain centers, facilities, clinics, or centers involved in
treatment of pain are not covered for inpatient care.
Lymphadema Clinics are covered when necessary for the treatment of complications of breast cancer
following mastectomy.
Clinics not covered include special service clinics, centers, or programs on an inpatient or outpatient
basis, unless they are specifically listed as covered. Clinics not covered include, but are not limited to,
clinics, centers or programs for: disassociated disorders; eating disorders; headaches; lactation; long-
term brain injury; post-traumatic stress; premenstrual syndrome (PMS); senior services; stress
management.
DIETARY AND DIABETES COUNSELING
Diabetes Counseling, medication management, and self-management skills instruction is covered for
Participants diagnosed with diabetes or those with special management needs.
Dietary Counseling is covered for one session per Plan Year when regulation of the diet is a significant
part of the treatment program for a pathological state or illness. Dietary counseling for obesity, including
weight management programs, is not covered.
DURABLE MEDICAL EQUIPMENT
Durable Medical Equipment (DME) is covered based on medical criteria up to $1,500 per person per
Plan Year. At the Plan’s discretion, equipment may be rented or purchased. Covered DME includes:
Apnea monitors Bilirubin lights or blankets
Bone stimulators Continuous passive motion machines (CPM)
Eye prosthetics Feeding pumps
Glucose monitors Hospital beds
Insulin pump supplies (including cartridges,
extension tubing, batteries, infusion sets, and
customary dressings provided by the pump supplier
to secure fusion sets
Lymphadema pumps
Nebulizers Oxygen and related equipment
Positive airway pressure devices (C-PAP) (Bi-PAP) Peak flow meters
Suction machines Traction equipment
Ventilators Wheelchairs
DME Limits: make sure that your Physician prescribes DME through a Network Provider. A list of
Network DME Providers is available from One Health Plan.
$1,500 per Covered Person per year.
One glucose meter per Covered Person per lifetime.
One peak flow meter per Covered Person per lifetime.
City of Fort Collins Group Health Plan 17
POS Summary Plan Description, 1/1/04
Preauthorized external extremity prosthetics up to $1,500 if the prosthesis will restore function to the
extremity; applicable to the DME maximum. Coverage for prosthetic arms and legs is based on
criteria and is not subject to the DME maximum of $1,500. However, the Covered Person is
responsible for 20% of the eligible charge for these items.
Not covered: penile prostheses and prostheses for cosmetic purposes.
Insulin pumps are covered, based on medical criteria, and are not subject to the benefit maximum.
Authorization: DME, including oxygen, must be authorized for a specified period of time in advance
and in writing by the Plan. The authorization will specify whether purchase or rental is approved.
After the initial authorized period of Coverage, continuation is subject to written reauthorization in
advance for another specified period.
Orthopedic Braces are covered up to $500 per person per year, when prescribed by Network
Physician and obtained from a Network Provider. Fitting and adjustment of covered braces is
provided. Repair or replacement of covered braces is provided, unless necessitated by misuse. The
Plan may replace or repair a covered brace at its discretion. Each $1 paid for orthopedic braces shall
reduce by $1 the amount available for podiatric shoe inserts as shown below. Covered braces must
meet all of the following criteria:
they are required to support or correct a defect of form or function or a permanently non-
functioning or malfunctioning body part, and
they are medically approved and in general use for the specific condition, and
they are primarily and customarily used either as an alternative to surgery or to speed recovery of
a patient who has had surgery, and
they can withstand repeated use, and
they are not generally useful to a patient in the absence of an injury or illness.
Not Covered: dental braces, braces used as aids in sports and activities, corsets and other non-
rigid appliances.
Podiatric Shoe Inserts for persons with diabetes with historical ulcers or presence of pre-ulcerous
lesions and documented neuropathy. In addition, for Covered Persons with persistent plantar facitis,
or when documented neuropathy who have documented failure of commercial over-the-counter
inserts when used as a trial prior to, or in lieu of, surgery.
Benefits are limited to $500 per person per year. Each $1 paid for podiatric shoe inserts shall
reduce by $1 the amount available for orthopedic braces, as shown above.
Not Covered: orthotic devices for podiatric use and arch support.
EMERGENCY SERVICES
Ambulance Service is covered when Medically Necessary, either by ground or air, and when the
destination is an Acute Care facility.
Not covered: ambulance service provided due to the absence of another medically appropriate form
of transportation or for the Covered Person’s convenience.
Medical Emergencies Emergency Services are provided when necessary to screen and stabilize a
Covered Person in cases where a prudent person acting reasonably believes that an Emergency Medical
Condition exists. The Participant or a family member should notify the Participant’s PCP of the episode
by the following business day. If the Participant is admitted to a Hospital as an inpatient directly from the
emergency room, the emergency room Copayment is waived.
City of Fort Collins Group Health Plan 18
POS Summary Plan Description, 1/1/04
Important Note: Emergency Services are NOT to be used for your convenience or the convenience of
your Physician. Unauthorized use of an emergency facility will be reviewed by the Plan. Payment of
claims may be denied, and those claims may become the Participant’s personal responsibility.
Not covered:
follow-up care in the emergency facility;
emergency visits made in non-life or limb threatening situations without the Participant’s PCP’s
authorization, which will result in the Participant being liable for the entire charge for the visit and
any unauthorized care resulting from it;
emergency room services obtained during normal Physician office hours, except in the event of a
life or limb threatening emergency or when preauthorized the he Participant’s PCP.
Medical Emergencies and Urgent Care Outside the Plan Network
Ambulance for Medically Necessary air or ground ambulance service under emergency conditions arising
from an Accident, acute illness or injury and when the destination is an Acute Care facility.
Medical Emergencies: Emergency Services necessary to screen and stabilize a Covered Person in
cases when a prudent layperson acting responsibly, believes that an Emergency Medical Condition
exists. Medically Necessary emergency or urgent care would include:
Reasonable charges for Hospital services that are Covered Services.
Reasonable charges for professional services that are Covered Services, including sales tax in
states where such tax is allowed by law.
Ambulance service resulting from an Accident, Acute Condition, or injury.
Reasonable charges for transportation authorized by the Plan to return the Covered Person to a
Network Hospital, less the cost of the person’s normal return trip.
There are two Copayment levels for Emergency Services:
the higher Copayment applies when Covered Services are obtained in a Hospital emergency
room.
the lower Copayment applies when Covered Services are obtained in a Physician’s office outside
normal business hours or in an urgent care facility.
If a Participant is admitted as an inpatient to a Hospital directly from the emergency room, the
emergency Copayment is waived. The Plan must be notified within forty-eight (48) hours, or as soon
as practical after the Hospital admission outside of the Plan Network.
Follow-up Care to Emergency Services outside of the Plan Network is covered to a maximum of $400
per Participant per Plan Year.
A claim paid and/or submitted by a Covered Person for a Covered Service must be submitted to the
Plan within twelve (12) months after the date of the service, or reimbursement will not be made.
Claims can be submitted by providing an itemized statement to the Plan’s administrative service
provider at the address shown at the back of this booklet.
EYE EXAMINATIONS/EYEGLASSES
Preventive Care: routine visual acuity exams are covered as part of covered periodic health
appraisals.
Routine Examinations: are covered, including refractions to determine the prescription for corrective
lenses, eyeglasses or contact lenses, once in every twelve (12) months at Plan designated facilities.
City of Fort Collins Group Health Plan 19
POS Summary Plan Description, 1/1/04
Limit: one routine exam per Covered Person per year
Not Covered: fitting contact lenses, vision therapy, radial keratotomy, keratomileusis and excimer
laser surgery.
Eyeglasses: when prescribed following cataract surgery with an intra ocular lens implant. Eyeglasses
must be obtained through Network Providers providers.
Limits:
$125 per pair of eyeglasses
One (1) pair of eyeglasses per surgery
Two (2) pairs of eyeglasses per lifetime
Not Covered:
Eyeglasses or contact lenses other than following cataract surgery as described above.
Special treatment for eyeglasses, including, but not limited to, tinting and scratch
resistant coatings.
FAMILY PLANNING
Voluntary family planning to include: family planning counseling; information on birth control; IUDs and
implantable contraceptive devices, including their insertion and removal; diaphragms and cervical caps,
including their fitting; costs related to two (2) elective abortions per lifetime; pre- and post-abortion
counseling; surgical procedures causing permanent sterilization, including vasectomies and tubal
ligations.
Not covered: pregnancy test kits and ovulation kits; reversal of voluntary sterilization and
related procedures
Infertility: limited infertility services to the extent preauthorized and based on criteria established by the
Plan including testing artificial insemination, appropriate medical advice, and instruction in accordance
with accepted medical practice.
Limits:
treatment for infertility is covered only for persons who have been diagnosed as biologically
infertile in accordance with accepted medical practice;
twelve (12) artificial inseminations per pregnancy.
if after twelve (12) attempts, the Participant fails to become pregnant, no additional
inseminations will be covered.
Not Covered:
In vitro fertilization (test tube babies), the Gamete Intrafallopian Transfer (G.I.F.T.) procedure,
the Zygote Intrafallopian Transfer (Z.I.F.T.) procedure, Artificial Reproductive Technology
(A.R.T.), other ovum transplant procedures, surrogate parentage, drug therapy for infertility
and related costs of each.
Procedures considered to be experimental/investigational
The cost related to donor sperm and ova (collection, preparation, storage, etc.)
Infertility services for Covered Persons who have undergone a voluntary sterilization
procedure.
HEARING TESTS
City of Fort Collins Group Health Plan 20
POS Summary Plan Description, 1/1/04
Preventive Care: examinations to determine the need, if any, for hearing correction are covered.
Not Covered: hearing aids and evaluation for hearing aids.
HOME HEALTH CARE
Nursing Care Services: Skilled Nursing Care at home, when prescribed by a Network Provider and
deemed Medically Necessary for treatment of a covered illness or injury. Home Health Care services are
provided only when and as long as the following two conditions are met simultaneously:
The Participant’s Network Provider prescribes a specific home care plan to provided and sets forth
the length of time deemed Medically Necessary to complete the treatment plan. This plan must be
approved in writing by the Plan and periodically reviewed and reauthorized by the Plan or an agent
acting on the Plan’s behalf.
The services are provided by a Medicare certified home health agency selected or approved by the
Plan.
Not covered: custodial and Maintenance Care; homemaker services.
Periodic assessment visits by either a Physician or a licensed nurse to determine the patient’s condition,
progress, and Level of Care needs.
Limit: After the period of specified time in the prescribed treatment plan, continuation of care
depends on the Participant’s status for Medical Necessity.
Therapy (Physical, Occupational, and/or Speech) are covered as part of Home Health Care only for
treatment of Acute Conditions that are subject to significant improvement within two (2) months of when
treatment begins and the Participant is homebound.
Training for Home Care is provided on a one-time basis for a family member, household resident, or
nonprofessional person employed by the patient or family. This training covers the services necessary to
the custodial or maintenance levels of care.
HOSPICE CARE
Hospice Care is covered when provided under the direction of the Participant’s Primary Care Physician,
who certifies that the Participant is in the terminal states of illness, with a life expectance of approximately
six (6) months or less. The Physician mush submit a written plan of care. When preauthorized by the
Plan Supervisor, services covered in home or Hospice facility include:
Nursing care provided by or under the supervision of a registered nurse
Home health aide services under the supervision of an RN or specialized rehabilitative therapist
Respiratory therapy and inhalation services
Nutrition counseling by a nutritionist or dietician
Physical therapy, occupational therapy, speech therapy and audiology
Individual, family, and caregiver counseling
Medical social services
Bereavement support services for the Participant’s family
Continuous home care or short-term inpatient care provided in a Network hospice inpatient unit, , or
Skilled Nursing Facility as required for pain control or symptom management
Inpatient Hospice Care will be provided based on medical criteria established by the Plan
Medical supplies ordinarily furnished by the Hospice agency, including prescription drugs and
biologicals
City of Fort Collins Group Health Plan 21
POS Summary Plan Description, 1/1/04
Respite Care, up to five (5) continuous days per occurrence
Coverage of these services will not prevent the Plan from reevaluating the Participant’s status and
subsequently redetermining the status of care.
Not Covered:
Services and supplies related to the terminal condition that are not part of Hospice Care
Services of a caregiver other than as provided by the Hospice agency as part of this benefit,
including, but not limited to, someone who lives in the Participant’s home or someone who is a
relative of the Participant
Domestic or housekeeping services that are unrelated to the Participant’s care
Services that provide a protective environment where no professional skill is required, such as
companionship or sitter services
Services not directly related to the medical care of the Participant, including but not limited to:
Estate planning, drafting of will, or other legal services
Funeral counseling or funeral arrangements or services
Food services, such as Meals on Wheels
Transportation services, except covered benefits for
HOSPITAL CARE
Covered Services include: semi-private room and board, Physician visits, surgeon’s fees,
anesthesiologist’s fees, surgical assistant fees (when Medically Necessary), operating and recovery room
charges, general nursing care, Intensive Care services, laboratory, pathology, radiology, radiation therapy,
respiratory therapy, physical therapy, occupational therapy, speech therapy, oxygen and other gases,
drugs, medications and biologicals as prescribed, and coordinated discharge planning services. Be sure
that inpatient hospitalizations are precertified by One Health Plan.
Not covered: take home drugs, special blood handling fees, storage of cord blood, experimental/
investigational or cosmetic implants, penile implants, Private Duty Nursing, personal comfort and
convenience items (including, but not limited to, television, telephone, guest meals, articles for personal
hygiene, etc.), private room except when Medically Necessary, take-home supplies.
INJECTABLES - OUTPATIENT
Outpatient injectables are covered when approved by the Food and Drug Administration (FDA) for the
given diagnosis or protocol, when oral administration of prescribed medication is not medically
appropriate.
Services include administration, supplies and medical monitoring when administered in the Physician’s
office or through an authorized home infusion company.
Outpatient injectables that can be obtained by the Participant through a pharmacy, or can be self-
administered, whether obtained at the pharmacy or not, must be preauthorized and are subject to the
applicable Copayment. A Copayment will be collected for up to a 30-day supply of medications, course of
therapy or treatment of an acute episode, whichever is shorter. No more than a thirty (30) day supply will
be dispensed at one time.
LABORATORY/PATHOLOGY
Laboratory and pathology services, including preventive diagnostic services, are covered in accordance
with criteria established by the Plan.
City of Fort Collins Group Health Plan 22
POS Summary Plan Description, 1/1/04
MEDICAL FOODS
Medical foods, for the purpose of this benefit, refer exclusively to prescription metabolic formulas and
their modular counterparts, obtained through a pharmacy. Medical Foods are specifically designated and
manufactured for the treatment of Inherited Enzymatic Disorders caused by Single Gene Defects.
Coverage for Inherited Enzymatic Disorders caused by Single Gene Defects shall include, but not be
limited to, the following diagnosed conditions: Phenylketonuria, Maternal Phenylketonuria, Maple Syrup
Urine Disease, Tyrosinemia, Homocystinuria, Histidinemia, Urea Cycle Disorders, Hyperlysinemia,
Glutaric Acidemias, Methylmalonic Acidemia, and Propionic Acidemia. Covered care and treatment of
such conditions shall include, to the extent Medically Necessary, medical foods for home use for which a
Network Physician has issued a written, oral or electronic prescription.
The maximum age to receive this benefit for Phenylketonuria is twenty-one (21) years of age; except that
the maximum age to receive this benefit for Phenylketonuria for women who are child-bearing age is
thirty-five (35) years of age.
Limit: Medical Foods will be subject to a 50% Copayment by the Participant.
MENTAL HEALTH SERVICES
A PCP referral is not required to obtain Medically Necessary mental health services; however, Covered
Services must be provided by a Network Provider.
Inpatient Mental Health Care: Medically Necessary inpatient mental health care is covered up to forty-five
(45) days per Participant per Plan Year, or ninety (90) days of partial hospitalization per Participant per
Plan Year. Partial hospitalization is defined as treatment for at least three (3) but not more than twelve
(12) hours in a 24-hour period. For the purpose of computing the period for which benefits are payable,
each two days of partial hospitalization care shall reduce by one day the forty-five days available for
inpatient care, and each day of inpatient care shall reduce by two days the ninety days available for
partial hospitalization care.
Outpatient Mental Health Care: Medically Necessary outpatient mental health care is covered. The
number of visits allowed and any Coverage of services necessary to fulfill the designated treatment
program in addition to those services listed here are based on Medical Necessity as determined by the
Network Provider.
Biologically-Based Mental Illnesses: Care for schizophrenia, schizoafective disorder, bipolar affective
disorder, major depressive disorder, specific obsessive-compulsive disorder, and panic disorder shall be
covered as any other physical illness and shall not be subject to the limitations of Mental Health Services
described below.
Mental Health Services Not Covered: In addition to excluded Therapies/Rehabilitation services listed
separately in this booklet, the following services are not covered by the Plan:
Confinement, treatment, service or supply that is not authorized, except in the event of an emergency.
Confinement, treatment, service or supply that is not ordinarily provided for the specific treatment
which was authorized.
Confinement, treatment, service or supply obtained through or required by a governmental program.
Weight control programs and treatment for addictions to tobacco, nicotine or food.
Treatment or psychological testing for any reading or learning disorder, mental retardation, or other
developmental disorders as defined by the Diagnostic and Statistical Manual Disorders-IV (DSM-IV).
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POS Summary Plan Description, 1/1/04
Counseling for adoption, custody, family planning or pregnancy in the absence of a DSM-IV
diagnosis.
Counseling associated with or in preparation for a sex change operation.
Sexual therapy programs, including therapy for sexual addiction, the use of sexual surrogates and
sexual treatment.
Vocational, pastoral or spiritual counseling.
Dance, poetry, music or art therapy, except as part of a treatment program in an inpatient setting.
Non-organic therapies including, but not limited to, bioenergetics therapy, confrontation therapy,
crystal healing therapy, educational remediation, Eye Movement Desensitation Reprocessing, guided
imagery, marathon therapy, primal therapy, rolfing, sensitivity training, training psychoanalysis,
transcendental meditation and Z therapy.
Organic therapies including, but not limited to, aversion therapy, carbon dioxide therapy,
environmental ecological treatment or remedies, herbal therapies, homodialysis for schizophrenia,
vitamin or orthomolecular therapy, narcotherapy with LSD, and sedative action electrostimulation
therapy.
Surgery or acupuncture as a mental health benefit.
Laboratory fees as mental health benefit for outpatient treatment plans.
Services which are not Medically Necessary for the treatment of mental health disorders.
Services that are required by a court order as part of parole or probation, or instead of incarceration
which are not Medically Necessary.
Long-term insight-oriented psychotherapies that regress the Covered Person emotionally or
behaviorally.
Personal enhancement, self actualization therapy or other similar treatment plans.
Services provided by a non licensed provider.
Neurological services and tests, including, but not limited to, EEGs, PET scans, beam scans, MRIs,
skull x-rays and lumbar punctures. These services must be preauthorized by the PCP.
Treatments which do not meet the national standards for mental health professional practice.
Medical treatment for eating disorders.
Treatment sessions by telephone or computer Internet services.
Evaluation or treatment for education, professional training, employment investigations, fitness for
duty evaluations or career counseling.
OUTPATIENT PRESCRIPTION DRUGS
Outpatient prescription drugs are covered for the Medically Necessary treatment of covered illness or
injury. Benefits are based solely on whether the medication is generic, preferred brand or non-preferred
brand. Therefore, if you need to take a non-preferred brand name medication because other medications
are not effective, you will pay the non-preferred brand Copayment. The preferred brand list is subject to
periodic review and may be changed in the future. Consequently, your future Copayments are also
subject to change if a medication’s classification changes.
Outpatient medications are dispensed for up to a 30-day supply; however, quantity limitations may be set
as medically appropriate. The Plan reserves the right to require precertification or prior authorization in
determining Medical Necessity. One Copayment is required for each prescription unit. Copayments for
up to a 30-day supply are:
Generic: $ 8
Preferred Brand: $15
Non-Preferred Brand $30
The mail order program enables you to purchase a three-month supply of maintenance medications for
two monthly Copayments. Maintenance medications are those medications that are taken for at least 90
days, and include, but are not limited to, medications treating such conditions as high blood pressure,
City of Fort Collins Group Health Plan 24
POS Summary Plan Description, 1/1/04
high cholesterol, birth control, etc. To use the mail order program, complete the appropriate order form
and attach your Physician’s 90-day prescription authorizing three refills.
Eligible prescription drugs include:
drugs that can be dispensed only upon the written prescription of a Physician or other prescriber who
is authorized to prescribe that drug under applicable State law;
compounded medication that is made up of at least one prescription drug
all compound drugs require preauthorization
diabetic supplies, insulin, glucagon kits and glucose testing strips
immunosupressants to prevent organ rejection
oral birth control medications, diaphragms, and cervical caps that require a Physician’s prescription
by law.
Medications/Refills – Other Quantities
Prepackaged units such as tubes, vials and inhalers are dispensed for one (1) applicable Copayment per
prepackaged unit at a Plan pharmacy; one (1) Copayment per two (2) prepackaged units of the same
medication, including strength, through the mail-order pharmacy.
Insulin is limited to two (2) vials of the same kind of insulin per applicable Copayment at a Plan pharmacy,
or up to three (3) vials of the same kind of insulin per applicable Copayment through the mail-order
pharmacy.
Insulin syringes and needles, when used with covered insulin products, are limited to one (1)
prepackaged unit for one (1) applicable Copayment at a Plan pharmacy, or two (2) prepackaged units
through the mail-order pharmacy.
Glucose and ketone test strips and lancets on the Preferred Drug List are dispensed in the
manufacturer’s trade-size package and are subject to the applicable Copayment per trade-size package
unit. Coverage of glucose and ketone test strips is limited to 200 strips per thirty (30) days. Coverage of
lancets is limited to 200 units per thirty (30) days.
Delivery Charge If the Plan pharmacy routinely charges all of its customers for delivery service, the
Participant must pay the delivery charge in addition to the applicable Copayment.
Prescription Drugs While Traveling If you are traveling away from home, experience an emergency
situation and cannot use a Plan pharmacy, you may be able to obtain a seven (7) day supply of
medication; antibiotics may be dispensed in up to a fourteen (14) day supply. However, you will need to
make the normal applicable Copayment. Prescription medications already taken on a regular basis
obtained while traveling will be covered only when filled and processed electronically at a Network
pharmacy. You may obtain information on Network pharmacies outside of Colorado by contacting One
Health Plan.
PHYSICIAN SERVICES
Physician Office visits are covered for the Medically Necessary treatment of non-work related illness or
injury, periodic health appraisals, allergy treatments and materials, immunizations provided in accordance
with recommendations by the American Academy of Pediatrics and the Centers for Disease Control
immunization guidelines, immunizations recommended for travel by the Centers for Disease Control
immunization guidelines, well-baby/well-child care, charges in connection with a second or third surgical
opinion, and outpatient surgical procedures in the office or in a licensed outpatient surgical facility
(including the Medically Necessary services of an anesthesiologist and/or surgical assistant).
Not Covered:
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POS Summary Plan Description, 1/1/04
Examinations for employment, licensing, insurance, adoption purposes or examination or
treatment ordered by a court of law.
Expenses for medical reports, including preparation and presentation.
Expenses for examinations and treatment conducted for the purpose of medical research.
Immunizations that are recommended because of increased risk due to type of employment.
Charges for services not administered in accordance with established medical practice.
PREGNANCY/MATERNITY/NEWBORN SERVICES
Newborn: Hospital care and services for newborn infants of Participants is covered. No inpatient
Copayment, if applicable, will apply to the newborn if he/she is discharged with the mother, if the mother
is a Participant. However, any applicable inpatient Copayment will apply if the newborn remains
hospitalized after the mother’s discharge, or if the mother is not covered under the Plan.
Delivery: Hospital obstetrical delivery care and services are provided. Normal delivery is generally
considered to be within five (5) weeks of the expected due date. Travel within five (5) weeks of the
expected due date is discouraged, due to potential health hazards. If you do travel during this time and
your child is born at a Hospital other than the Hospital at which the delivery is precertified (see page 13),
delivery charges are not be covered. See page 12 for information on the Newborns’ and Mothers’ Health
Protection Act. Separate copayments are required for Physician’s services and Hospital charges.
Not covered:
home delivery
delivery at a Non-Network Hospital
charges incurred by a newborn child of a Dependent child
charges incurred if your child is delivered while you are travelling within five weeks of your due date
POSTPARTUM
Complete Hospital and outpatient postpartum care and services are provided to female Participants. The
office visit Copayment applies to postpartum visits in the Physician’s office.
Mothers and newborns released from the Hospital in accordance with Plan guidelines are entitled to one
(1) visit by a registered nurse as well as the services of a homemaker for four (4) hours on two (2) days
within thirty (30) days following delivery. The homemaker may perform such duties as grocery shopping,
preparing meals, laundry and light housekeeping.
PRENATAL SERVICES
Prenatal care and services are provided for female Participants. If criteria established by the Plan
Supervisor are met, Medically Necessary amniocentesis may also be covered. The Network Provider
must request this procedure and provide necessary information to the Plan.
Not covered:
any procedure intended solely for sex determination
birthing classes.
RADIOLOGY
Medically Necessary radiological services, such as electrocardiography (EKG), electroencephalography
(EEG), and the use of radioactive isotopes, are covered for Participants. Preventive diagnostic services
City of Fort Collins Group Health Plan 26
POS Summary Plan Description, 1/1/04
are also covered, in accordance with criteria established by the Plan Supervisor. This includes, but is not
limited to, mammograms, chest x-rays, electrocardiograms and laboratory services.
SKILLED NURSING FACILITY/COMPREHENSIVE REHABILITATION FACILITY/EXTENDED CARE
Skilled Nursing Facility, extended care facility and comprehensive Rehabilitation Facility or unit services
are covered only on order of the Network PCP when approved by the Plan and only when significant
measurable improvement can be anticipated. Services include accommodations, meals, general nursing
care, medical supplies and equipment ordinarily furnished by the facilities and all prescribed biologicals.
Benefits are provided up to 120 days each Plan Year at approved facilities. The Participant’s status may
also be reevaluated and, if it is determined that the status of the care is no longer acute, it may not be
covered.
Not covered:
Custodial Care, Maintenance Care
convalescent care
care for chronic conditions
Private Duty Nursing
personal comfort or convenience items (e.g., television, telephone, etc.)
private room (except when Medically Necessary).
SUBACUTE CARE FACILITIES
Subacute Care Facility services are covered following hospitalization, and include accommodations,
meals, general nursing care, medical supplies and equipment ordinarily furnished by the facility and
prescribed drugs and biologicals.
Subacute Care Facility services are provided up to sixty (60) days per Plan Year at an approved
Subacute Care Facility.
SUBSTANCE ABUSE
A PCP referral is not required to obtain mental health services, but all benefits must be referred by and be
administered by a Network Provider.
Alcohol-Drug Rehabilitation: Medically Necessary treatment may be either inpatient or outpatient or a
combination of both if authorized by a Network mental health provider. Benefits are provided up to one
course of treatment per Plan Year, to a maximum of two courses of treatment per Participant during
his/her lifetime.
Not covered:
rapid anesthesia opiate detoxification
services that are not Medically Necessary for the treatment of Substance Abuse disorders.
services that are required by a court order as part of parole or probation, or instead of incarceration,
which are not Medically Necessary
Methadone maintenance or treatment
Detoxification: services for detoxification are limited to removal of the toxic substance or substances from
the system, including diagnosis, evaluation and care of emergency or acute medical conditions.
Inpatient Alcohol-Drug Rehabilitation: alcohol-drug inpatient rehabilitation services are provided at a
facility designated by the Plan. Inpatient services are those services provided to Participants who reside
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POS Summary Plan Description, 1/1/04
for the course of their treatment at the program site. Services are covered at the designated facility up to
a maximum of twenty-one (21) days per Plan Year, or until the Network Provider has determined
satisfactory completion of the inpatient program, whichever is less.
Outpatient Alcohol-Drug Rehabilitation: alcohol-drug rehabilitation services are provided at a facility
designated by the Plan. Outpatient services are those services provided to Participants who are living at
home and receiving services at the program site on an ambulatory basis. The number of visits allowed is
based on Medical Necessity as determined by the Network Provider.
SURGERY
Medically Necessary surgical services are provided in the Hospital, Physician’s office, or in a licensed
outpatient surgical facility. This includes the services of a surgical assistant and anesthesiologist with
surgical services when Medically Necessary. You must obtain precertification of non-Network surgery.
Breast Surgery: Reconstructive Surgery to the extent preauthorized following a mastectomy shall include
reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the
unaffected breast to produce a symmetrical appearance, surgically implanted breast prostheses and
Coverage of physical complications resulting from the mastectomy, including lymphademas. The cost of
surgical bras, including external prostheses, in lieu of reconstructive breast surgery will be covered to the
extent preauthorized, with a maximum benefit of $500 per Participant per Plan Year.
Oral and Dental Surgery: oral surgery and certain medical service charges associated with dental
services will be covered only for emergency treatment received within twenty-four (24) hours of the
occurrence of accidental injury to the jaw or mouth. During an inpatient admission for a covered dental
problem, medical consultation and diagnostic procedures ordered by the medical consultant related to a
strictly medical condition are covered. Follow-up dental restoration procedures are not covered.
Covered Services for oral and dental surgery also include
treatment for tumors of the mouth when cancer is suspected
treatment of congenital conditions of the jaw that may be demonstrated to cause actual significant
deterioration in the Covered Person’s physical condition because of inadequate nutrition or
respirationand anesthesia charges associated with dental services to the extent preauthorized by the
Plan Supervisor upon determination that a medical condition or other criteria requires such services
to be obtained in a medical facility
cleft lip, cleft palate, or any condition or illness that is related to or developed as a result of the cleft lip
or cleft palate will be considered to be compensable for Coverage under the provisions of Colorado
law for newborn children born with cleft lip or cleft palate or both. The following care and treatment is
covered to the extent Medically Necessary and when ordered by a Network Provider:
oral and facial surgery, surgical management and follow-up care by plastic surgeons and oral
surgeons
prosthetic treatment such as obturators, speech appliances, and feeding appliances
Medically Necessary orthodontic treatment
Medically Necessary prosthodontics treatment
habilitative speech therapy
otolaryngology treatment
audiological assessments and treatment
If a dental policy is in effect at the time of the birth, or is purchased after the birth of a child with cleft lip or
cleft palate or both, no benefit under the Plan will be provided for any orthodontics or dental care as
needed as a result of the cleft lip or cleft palate or both.
Oral surgery not covered: orthognathic surgery; metallic bone cylinder implants (bone screws).
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POS Summary Plan Description, 1/1/04
Plastic, Reconstructive or Cosmetic Surgery: these services are covered if the surgery is performed as
soon as medically feasible and it is Medically Necessary for either of the following reasons:
to repair an injury sustained while the Participant is covered by the Plan and repair is initiated within
one (1) year following the injury
the correction of a congenital defect that substantially impairs major organ function, or leads to
progressive deterioration of health of a covered Dependent child.
Surgery Not Covered:
Plastic, reconstructive or cosmetic surgery, including skin lesions that are removed for cosmetic
purposes. Exceptions for Reconstructive Surgery must be approved by the Plan and will be
considered only when performed primarily to improve the physical health and function of the patient.
Any non-Covered Services received prior to written approval will not be reimbursed by the Plan and
will be the responsibility of the Participant.
Reconstructive nasal surgery, including rhinoplasty.
Revision of a previous procedure performed for cosmetic purposes including, but not limited to, breast
augmentation.
Surgical treatment for morbid obesity, even in cases that meet the standards of Medical Necessity.
Reconstructive Surgery that does not correct or materially improve a physiological function.
THERAPIES/REHABILITATION
Cardiac: a short-term Cardiac Rehabilitation program is covered, based on criteria established by the
Plan Supervisor at an approved facility for short-term follow-up of Acute Care for a myocardial infarct or
cardiac revascularization procedure. This benefit is an extension of the treatment for an inpatient Acute
Care episode and must begin within two (2) months of discharge from the Acute Care facility. Benefits
are paid to a maximum of $1,000 within a ninety (90) day period.
Chemotherapy: outpatient injectable chemotherapy is covered, when oral administration of prescribed
medication is not medically appropriate. Services and materials for chemotherapy are covered.
Hemodialysis: all necessary services for hemodialysis for chronic renal disease and for kidney
transplants, including training and expendable medical supplies, are covered.
Occupational/Physical: short-term, outpatient occupational and physical therapy by licensed therapists
who are Network Providers or approved by the Plan Supervisor are covered. This short-term, outpatient
physical therapy is for treatment of Acute Conditions that are subject to significant improvement within
two (2) months of when treatment begins. Benefits are paid up to twenty (20) sessions combined for
physical and occupational therapy per Acute Condition. Prior written authorization of an approved
treatment plan by the Plan Supervisor is required. The Participant’s status may be reevaluated and, if it is
determined that the condition is no longer acute, it may not be covered.
Physical and occupational therapy are covered for the care and treatment of congenital defects and birth
abnormalities for children up to age five (5) without regard to whether the condition is acute or chronic
and without regard to whether the purpose of the therapy is to maintain or improve functional capacity.
Benefits are paid to a maximum of 20 sessions per Plan Year.
Radiation Therapy: services for radiation therapy are covered when Medically Necessary.
Respiratory Therapy: respiratory therapy by a licensed respiratory therapist on an outpatient basis is
limited to emergency care.
Speech Therapy: services of licensed speech therapists who are Network Providers or approved by the
Plan are covered. This therapy is covered only for the short-term rehabilitation required immediately
following these acute episodes: accidental brain injury (not occurring during birth), and injury or surgery
City of Fort Collins Group Health Plan 29
POS Summary Plan Description, 1/1/04
directly affecting the larynx and/or vocal cords or for treatment of vocal cord nodules in lieu of surgery.
Also, for treatment of speech delay in three- to five-year-old patients, secondary to persistent otitis media
or serous otitis media documented as persisting longer than six (6) months with documented bilateral
twenty-five (25) decibel hearing loss. The goal of this therapy is significant improvement of a Participant’s
condition within two (2) months. Benefits are provided to a maximum of twenty (20) sessions per Acute
Condition, and require prior written authorization of an approved treatment plan by the Plan Supervisor.
The Participant’s status may be reevaluated and, if it is determined that the condition is no longer acute, it
may not be covered.
Not Covered: speech therapy related to a developmental or communicational delay.
Speech therapy for the care and treatment of congenital defects and birth abnormalities for children up to
age five (5) are also covered, without regard to whether the condition is acute or chronic and without
regard to whether the purpose of the therapy is to maintain or to improve functional capacity. Benefits are
provided up to twenty sessions per Plan Year.
Therapies/Rehabilitations Not Covered:
Special evaluation and/or therapy for:
behavioral disorders
communication delay, except as specified elsewhere in this booklet
learning disability
mental retardation and related conditions
motor dysfunction
multiple handicaps
perceptual disorders
post-traumatic stress
pulmonary rehabilitation
sensory deficit
sex addiction
speech, except as specifically listed as a Covered Service
vision
Special evaluations and therapies, including:
behavioral training
biofeedback, except as covered under pain clinics
cognitive therapy
coma stimulation
developmental and neuroeducational testing or treatment
educational studies
hearing therapy
hypnotherapy
myofunctional therapy
neuromuscular rehabilitation for chronic conditions
psychological testing
sleep therapy
vision therapy/orthoptics
vocational rehabilitation
TRANSPLANTS
This Plan covers only cornea and kidney transplants. Other transplants may be covered under a
separate contract. Please contact Human Resources for additional information.
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POS Summary Plan Description, 1/1/04
All necessary services for covered transplants at designated transplant facilities are covered to the extent
preauthorized and based on medical criteria established by the Plan. Covered Services include the
directly related, reasonable medical and expenses of the donor.
Donor screening charges are covered for immediate family members to include Spouses, parents,
children, siblings and, if appropriate, grandparents.
Coverage will be restricted to transplant services provided to the donor and recipient only when the
recipient is a Participant. Neither the Plan nor the Network Providers will be responsible to furnish a
donor or to assure the availability or capacity of designated facilities.
Transplant Guidelines:
Any request for a covered transplant, except cornea transplants, must be made in writing to the Plan.
The Plan will issue a written response within thirty (30) days.
Written preauthorization of any covered transplant benefit must be given prior to the initiation of
services.
The Plan will not cover services received prior to issuance of the Plan’s written preauthorization.
TREATMENT ALTERNATIVES
Treatment alternatives and limited adaptations to Coverage under the Plan are reserved to the sole
discretion of the Plan. While the Plan Documents are the definitive statement of the Plan’s legal
obligation to provide benefits, experience has shown that there may be unusual and extraordinary
circumstances that are not contemplated by the Plan. Therefore, the Plan specifically reserves the right,
at its sole discretion and based on prudent business and medical judgment (with the input of the Plan
Supervisor’s Medical Director), to adapt the Coverage and benefits set forth in the Plan.
Such decisions will be made exclusively by the Plan based on the medical and cost effectiveness of
alternatives, probable outcome of a Medically Necessary Service, and consultation with the Participant or
the Participant’s representative. The fact that the Plan makes an adaptation to the Plan will not require or
act as precedent requiring that it make future adaptations in similar or other situations, or otherwise be
prevented from administering the Plan in strict accordance with its terms.
In addition, the plan may, at its sole discretion, reevaluate and discontinue any adaptation granted under
this provision if it determines that the original basis for granting the adaptation is no longer valid and
supportive of the adaptation or is no longer likely to lead to measurable improvement in the health of the
Participant.
Any request for Coverage of treatment alternatives and/or limited adaptations to the Plan must be made
in writing by a Network Physician or a Participant to the Plan. The Coverage decision will be made by
the Plan Administrator. The Plan will provide a written response; only services specifically authorized and
received after the Covered Person’s receipt of the written response will be covered. The Plan
Administrator shall have the sole discretionary authority to interpret the Plan and determine all questions
arising in the administration, interpretation, and application of the Plan, and all such determinations shall
be final, conclusive and binding.
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POS 1
GENERAL EXCLUSIONS AND LIMITATIONS
The following services are not covered by the Plan:
1. Any service that is:
not specifically listed as a Covered Service under the Plan, even though provided or referred by a
Network Physician.
not reasonably and Medically Necessary, even if listed as a Covered Service.
not required in accordance with accepted standards of medical, surgical, or psychiatric practice,
even though provided or referred by a Network Physician.
not selected by the Plan Administrator.
required only for the convenience of the Participant or the Participant’s Physician.
any service provided by a non-Network Provider, unless authorized in advance by the Plan, or in
case of emergency.
2. Services that the Plan has no legal obligation to cover:
free clinics
government free programs
any charge made solely because the Participant has the benefit covered by the Plan
services and supplies paid for directly or indirectly by any local, State or Federal Government
agency, except when the Participant would have a legal obligation to pay for the services
3. All medical and Hospital care associated with conditions for which preauthorization by the Plan
Supervisor’s Medical Director is required and was not received; and/or for which treatment by
Network Physicians or Hospital was required but was not so provided.
4. Expenses for medical and/or Hospital services incurred prior to Coverage under the Plan or services
provided after the Plan Coverage or eligibility terminates.
5. Braces and artificial limbs, except as provided specifically by the Plan. Artificial aids, prosthetic
devices, corrective appliances and breast pumps.
6. Medical supplies including, on an outpatient basis, enteral feeding substance and infant formula, and
medical foods, except as provided elsewhere in this booklet.
7. Total parenteral nutrition (TPN), except when the need for TPN results from a condition diagnosed
after the date of Plan enrollment and preauthorized based on criteria established by the Plan.
8. Acupuncture.
9. Sex transformation procedures, services and supplies.
10. Sexual dysfunction or inadequacy medications, procedures, services, supplies, including penile
implants/prosthesis except testosterone injections for documented low testosterone levels. Coverage
of testosterone injections is based on criteria established by the Plan.
11. Post-mortem testing.
12. Charges for missed appointments in Providers’ offices and/or charges incurred when scheduled
services are canceled by the Participant.
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POS Summary Plan Description, 1/1/04
13. Services that Participants are entitled to as a result of class action or special group settlements, for
example, Agent Orange treatment programs and asbestosis indemnifications. If specific treatment
facilities are not stipulated by the responsible agency or group, the Plan will provide the services
contingent on either coordination of benefits or the Subrogation rights described in this booklet.
14. Special blood handling fees and storage of cord blood.
15. Take-home drugs.
16. Gene manipulation therapy.
17. Expenses of treating complications resulting from services that are not Covered Services.
18. Personal comfort or convenience items or services obtained or rendered in or out of a Hospital or
other facility, such as television, telephone, guest meals, articles for personal hygiene, and any other
similar incidental services and supplies.
19. Services rendered by a provider with the same legal residence as the Participant, or a member of the
Participant’s family, including Spouse, brother, sister, parent or child.
20. Custodial maintenance, convalescent and/or domiciliary care, Respite Care (except as specifically
provided by the Plan), rest cures, whether furnished in the home or in an institution, including a
nursing home or similar facility.
21. Travel or transportation expenses (except ambulance service as specifically provided under the Plan),
even though prescribed by a Physician or to reach a Network or designated Plan facility.
22. Cosmetic Procedures and services performed for cosmetic reasons, whether or not due to a medical
condition, except as specifically provided under the Plan.
23. Elective voluntary enhancement procedures, services, supplies, and medications, including, but not
limited to, weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes,
anti-aging and mental performance.
24. New procedures, services, supplies and medications until they are reviewed for safety, efficacy and
cost effectiveness and approved as covered by the Plan.
25. Treatment or care for maxillary and mandibular osteotomies, and jaw or orthognathic conditions.
26. Orthognathic surgery and associated costs of each related to the treatment for misalignment or
similar malfunction of the jaw joint, commonly known as temporomandibular joint problems or TMJ
syndrome.
27. Surgical treatment of morbid obesity, including complications arising from such treatment.
28. Charges, including complications, resulting from the Participant incurring excluded charges and
services.
29. Dental Services Not Covered (these include but are not limited to): general dental services and dental
x-rays, including treatment on or to the teeth or gums; any services customarily provided by a general
dentist, an oral surgeon or any other dental specialist; any procedure involving osteotomy of the jay;
periodontal treatment and/or surgery; treatment or care for overbite or underbite; treatment or care for
maxillary and mandibular osteotomies, and jaw or orthognathic conditions; dental prosthetics and
metallic bone cylinder implants (bone screws); Hospital costs for dental surgery or other dental
reasons; orthodontic treatment, orthognathic surgery and associated costs of each related to the
City of Fort Collins Group Health Plan 33
POS Summary Plan Description, 1/1/04
treatment for misalignment or similar malfunction of the jaw joint, commonly known as
temporomandibular joint problems or TMJ syndrome.
30. Experimental, Investigational, Unproven, Unusual, or Not Customary Treatments, Procedures,
Devices and/or Drugs.
31. The following treatments, procedures, devices and/or drugs are specifically excluded from Coverage
under the Plan:
orthomolecular medicine
holistic medicine
environmental medicine
chelation therapy, unless Medically Necessary for the treatment of metal poisoning
cytotoxin testing
hair analysis
colonics
gene manipulation therapy
autologous bone marrow transplants and chemotherapy requiring a bone marrow transplant for
stage I and stage IV breast cancer, ovarian cancer and other solid tumors
transplants not specifically listed as covered
medications that are experimental, investigative, or used in ways not approved by the Food and
Drug Administration (FDA), including those prescribed for:
use in dosage forms not commercially available
use by routes of administration not approved by the FDA
naturopathic services
megavitamin therapy
32. The following are not covered prescription drug benefits:
convenience dosage forms: unit dose, individual packets, etc.
diabetic supplies, except as specifically listed as a covered benefit
dietary products, nutritional products and food supplements, except as specifically listed as a
covered benefit
drugs administered by a Physician or Physician’s staff, unless specifically listed as a covered
benefit
drugs administered while the Participant is receiving skilled care as an inpatient in a Skilled
Nursing. Facility or Extended Care Facility, unless specifically listed as a covered benefit
elective or voluntary enhancement procedures, services, supplies and medications including but
not limited to: weight loss, hair growth, sexual performance, athletic performance, cosmetic
purposes, anti-aging, and mental performance
medications that are Experimental, Investigational, or used in ways not approved by the FDA.
drug therapy for infertility
drugs determined by the Plan to be ineffective, duplicative or to have preferred therapeutic
alternatives available
any prescription drug prescribed in connection with a service excluded under the Plan
non-drug supplies, such as stockings, support garments and other therapeutic devices or
appliances, even though a prescription may be required, except as specifically listed as a covered
benefit
medications (except insulin) which can be obtained without a prescription or have a
nonprescription therapeutic equivalent, unless specified by the Plan’s Preferred Drug List.
Progesterone and Estrogen Products, specifically compounded progesterone and estrogen
products, including progesterone suppositories
medications when used for purpose(s) of recreation and/or travel, other than those medications
recommended for travel by guidelines established by the Centers for Disease Control
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POS Summary Plan Description, 1/1/04
saline and medications for irrigation
prescription medication for the treatment of sexual dysfunction, including erectile dysfunction,
impotence and anorgasmy or hyporgasmy
smoking cessation drugs and/or aids
drugs received from a Hospital, Skilled Nursing Facility, convalescent home or similar facility for
take-home use
immunizations, except oral typhoid , unless specifically listed as a covered benefit
vitamins and minerals, except when requiring a prescription for a Medically Necessary vitamin or
mineral
medications recommended because of increased risk due to type of employment
GENERAL LIMITS
Cumulative Benefits. Any service provided to a Participant or Dependent during a Plan Year is limited
cumulatively to these benefits covered in the Plan. No change in a Participant’s status may increase any
restriction or limitation on the number of services or benefits a Participant can receive during a Plan Year.
Circumstances Beyond the Plan’s Control. If, due to circumstances not reasonably within the control of
the Plan, such as complete or partial destruction of facilities, war, riot, civil insurrection, labor disputes,
disability of a significant part of the Physician network, or similar causes, the rendition or provision of
benefits covered hereunder is delayed or rendered impractical, Hospitals and Physicians associated with
the Plan will make a good faith effort to provide benefits covered hereunder, but neither the Plan,
Hospitals, nor any Physician associated with the Plan will have any other liability or obligation on account
of such delay or failure to provide covered benefits.
Major Disaster or Epidemic. If a major disaster or epidemic occurs, Physicians and Hospitals will provide
medical and Hospital services and arrange extended care services and home health services as far as is
practical according to their best judgement. These services will be within the limitation of available
facilities and personnel, but neither the Plan, Hospitals nor any Physician associated with the Plan has
any liability or obligation for delay or failure to provide or arrange for any such services to the extent the
disaster or epidemic causes unavailability of facilities or personnel.
POS – 2
COVERED NON-NETWORK SERVICES
The following services are covered when Medically Necessary as non-Network expenses under POS 2;
Network expenses for POS 2 are covered in the same manner as under POS 1. Please be aware that
not all non-Network expenses are covered in the same manner as Network expenses, and that different
benefit limitations/Exclusions may apply to non-Network services.
Some services that are available from Network Providers may NOT be available through non-Network
Providers. The Plan may determine Medical Necessity by using precertification programs as
appropriate. Through the precertification process, the Plan may encourage that certain services be
directed to, and performed at, the most cost effective setting. Covered non-network expenses require
satisfaction of the annual Deductible and the payment of Coinsurance amounts, as specified in the
Schedule of Benefits. If you have questions about your payment responsibility, you should call Great-
West Health Care directly at: 1-800-663-8081.
ALCOHOL-DRUG ABUSE
Alcohol-Drug Rehabilitation A course of treatment, either inpatient or outpatient rehabilitation or a
combination of both, if preauthorized by the Plan. The rehabilitation benefit applies when the Participant
completes the full course of treatment as outlined by the provider, including detoxification and
rehabilitation. Benefits are provided for one course of treatment per Plan Year, to a maximum of forty-five
City of Fort Collins Group Health Plan 35
POS Summary Plan Description, 1/1/04
(45) days for inpatient care or ninety (90) days of partial hospitalization per Plan Year. For the purpose of
computing the benefit period, two partial hospitalization visits will be the equivalent of one inpatient day;
each two days of partial hospitalization care shall reduce by one day the forty-five days available for
inpatient care, and each day of inpatient care shall reduce by two days the ninety days available for
partial hospitalization care. Each day of confinement for alcohol detoxification or rehabilitation will reduce
by one (1) day the number of days available for inpatient psychiatric care and will reduce by two (2) days
the number of partial hospitalization days available.
Not covered:
maintenance or aftercare following a rehabilitation program
alcoholism and drug addiction treatment on court order as a condition of parole or probation
nutritional based therapy for alcoholism or other chemical dependency
Detoxification Inpatient services are provided for detoxification, limited to the removal of the toxic
substance from the system, together with diagnosis, evaluation, and care of emergency or acute medical
conditions.
Inpatient Alcohol-Drug Rehabilitation Inpatient rehabilitation services are provided at a Hospital or alcohol
treatment center. Inpatient services are those services provided to Participants who reside for the course
of their treatment program at the program site. Benefits for Physician visits (including psychologist visits)
during a period of inpatient confinement for alcohol-drug dependency or mental and nervous disorders is
$1,000 per Plan Year. A maximum of forty-five (45) inpatient days or ninety (90) partial hospitalization
days are provided per Plan Year, less the number of days devoted to inpatient detoxification during the
Plan Year, or until the provider determines that the Participant has satisfactorily completed the inpatient
program, which ever is less. Each two days of partial hospitalization shall reduce by one day the forty-
five days available for inpatient care, and each day of inpatient care shall reduce by two days the ninety
days available for partial hospitalization care.
Outpatient Alcohol-Drug Rehabilitation Outpatient rehabilitation services are provided to Participants who
are maintaining their place of residence at home and receiving services at the program site on an
ambulatory basis. Services are covered to a maximum benefit of $500 per Plan Year, or until the provider
has deemed satisfactory completion of the outpatient program, whichever is less.
DIETARY AND DIABETES COUNSELING
Dietary Counseling One dietary counseling session per year is provided when regulation of the diet is a
significant part of the treatment program for a pathological state or illness.
Not covered: dietary counseling for obesity, including weight reduction programs.
Diabetes Counseling Dietary counseling, medication management and self-management skills instruction
is provided for Participants diagnosed with diabetes or those with special management needs.
DURABLE MEDICAL EQUIPMENT
Durable Medical Equipment (DME), including oxygen is to enable a patient who otherwise would have to
be treated in an Acute Care or rehabilitative facility to be cared for outside such an institution. At the
Plan’s discretion, this equipment may be rented or purchased. Benefits are provided up to $1,000 per
Participant per Plan Year, and this amount is applied to the $1,500 limit for Network charges. Coverage
of external extremity prosthetics will be considered under the provisions regarding Treatment Alternatives,
up to $1,000 applicable to the DME maximum. Penile prostheses or prostheses for cosmetic purposes
are specifically excluded by the Plan.
City of Fort Collins Group Health Plan 36
POS Summary Plan Description, 1/1/04
DME, including oxygen, must be authorized by the Plan for a specified period of time in advance and in
writing. The authorization will specify whether purchase or rental is approved. After the initial authorized
period of Coverage, continuation is subject to written reauthorization in advance for another specified
period of Coverage.
Orthopedic Braces Orthopedic braces are covered when prescribed by a Physician and preauthorized by
the Plan. Such braces must meet all of the following criteria:
they are required to support or correct a defect of form or function or a permanently non-functioning
or malfunctioning body part, and
they are medically approved and in general use for the specific condition, and
they are primarily and customarily used either as an alternative to surgery or to speed recovery of a
patient who has had surgery, and
they can withstand repeated use, and
they are not generally useful to a patient in the absence of an injury or illness.
Fitting and adjustment of covered braces is also provided. Repair or replacement of covered braces is
provided, unless necessitated by misuse or covered by any other insurance plan or arrangement. At its
discretion, the Plan may replace or repair a covered brace.
Coverage is provided up to $250 per Participant per Plan Year. Coverage under this benefit applies to the
$1,000 annual DME benefit maximum.
Not covered: dental braces, orthotic devices for podiatric use and arch support, braces used as aids
in sports and activities, corsets and other non-rigid appliances.
EMERGENCIES
Ambulance Medically Necessary air and ground ambulance services are covered when the destination is
an Acute Care facility. Ambulance service provided due to the absence of another medically appropriate
form of transportation or for the Participant’s convenience is specifically excluded under the Plan.
Medical Emergencies Emergency Services are covered when necessary to screen and stabilize
Participants in cases where a prudent layperson acting reasonably believes that an Emergency Medical
Condition exists. Medical emergencies are generally covered as Network services.
FAMILY PLANNING
Surgical procedures causing permanent sterilization, including vasectomies and tubal ligations, are
covered by the Plan, as are costs related to a maximum of two (2) elective abortions per Participant per
lifetime. No other non-network family planning services are covered by the Plan.
HOME HEALTH CARE
Medically Necessary Home Health Care services are provided when preauthorized by the Plan. Services
are covered only when Medically Necessary as alternatives to hospitalization or in place of
hospitalization. Covered Services may include medical social services, nutritional counseling by a
nutritionist or dietitian, intermittent part-time Skilled Nursing Care, physical therapy, occupational therapy
and speech therapy,, audiology, respiratory therapy and inhalation therapy.
Covered benefits are provided up to sixty (60) visits by a Home Health Care agency per Participant per
Plan Year. Each visit of four (4) hours or less from a Home Health Care agency team is considered a
City of Fort Collins Group Health Plan 37
POS Summary Plan Description, 1/1/04
single visit. One-time training is provided for a caregiver covering the services necessary to the custodial
or maintenance levels of care.
Physical, occupational, and speech therapy are covered as part of Home Health Care only if the patient is
homebound and are subject to the limitations explained in the section entitled “Therapies/Rehabilitation”.
Home health aide services must be under the supervision of a registered nurse or a licensed
occupational, physical, or speech therapist.
Not covered: services for personal comfort or convenience, such as homemaker services; custodial and
Maintenance Care and Private Duty Nursing, even if Medically Necessary.
HOSPICE CARE
Services are provided when preauthorized by the Plan, and when the Participant’s Physician certifies that
the Participant has a life expectancy of six (6) months or less. Benefits may exceed six (6) months if the
Participant lives beyond the prognosis for life expectancy, in which case the benefits will continue for an
additional three (3) successive months. Under no circumstances will covered benefits exceed a total of
nine (9) months.
Covered Hospice services may include:
nursing care provided by or under the supervision of a registered nurse
home health aide services under the supervision of a registered nurse or specialized rehabilitative
therapist
respiratory therapy and inhalation services
nutrition counseling by a nutritionist or dietitian
Physical therapy, occupational therapy, speech therapy and audiology
individual, family and caregiver counseling
medical social services
bereavement – to a maximum $500
continuous home care or short-term inpatient care provided in a Hopsice unit, Hospital, Skilled
Nursing Facility as required for pain control or symptom management. Benefits are paid up to thirty
(30) days and require preauthoriztion by the Plan. Each day of care counts toward the maximum
benefit period
medical supplies ordinarily furnished by the hospice agency, including prescription drugs and
biologicals
Respite Care as a short-term inpatient stay which may be necessary for the patient in order to give
temporary relief to the person who regularly assists the patient with home care. Benefits are provided
up to five (5) days in a row per occurrence
Hospice Care Limits:
the Coverage of these services will not prevent the Plan from reevaluating the Participant’s status and
subsequently reconfirming the status of care
the maximum benefit for Hospice Care, including Respite Care, is $5,000 per three-month hospice
benefit period during which services are provided on a regular basis
the maximum daily benefit for home Hospice Care, including Respite Care, is $55
Not covered as part of Hospice Care:
services and supplies that are not part of Hospice Care
services of a caregiver who lives in the Participant’s home or is a member of the Participant’s family
domestic or housekeeping services that are unrelated to the Participant’s medical care
services that provide a protective environment where no professional skill is required, such as
companionship or sitter services
services not related directly to the medical care of the Covered Person, including but not limited to
estate planning, drafting of wills or other legal services; funeral counseling or funeral arrangements or
City of Fort Collins Group Health Plan 38
POS Summary Plan Description, 1/1/04
services; food services such as Meals on Wheels; transportation services, except covered benefits for
necessary professional ambulance services
HOSPITAL CARE
Hospital care includes: semi-private room and board, nursing care, use of operating and specialized
treatment rooms, use of Intensive Care facilities, surgical and anesthetic supplies furnished by the
Hospital as a regular service, laboratory, pathology, radiology, radiation therapy, physical therapy,
occupational therapy, speech therapy, oxygen, other gases, drugs, medications and biologicals as
prescribed, blood and blood plasma, administration of blood and blood plasma, coordinated discharge
planning services, outpatient services Medically Necessary for outpatient medical and surgical treatment,
pacemakers, replacement joints and permanent replacement lenses following cataract surgery that are
Medically Necessary and must be implanted by surgical means.
Not covered: take-home drugs, products derived in whole or in part from blood or blood plasma (including
special handling fees), experimental or cosmetic implants, penile implants, all implants not specifically
listed as covered, Custodial Care, Maintenance Care, Private Duty Nursing, personal comfort and
convenience items, private room (except when Medically Necessary) and take home supplies.
INJECTABLES
Outpatient injectables are covered only when oral administration of prescribed medication is not medically
appropriate and when the injectable is approved by the FDA for the given diagnosis or protocol. Services
include administration, supplies and medical monitoring when administered in the Physician’s office.
Before obtaining outpatient injectables, contact Human Resources for the special order form.
MEDICAL FOODS
Medical foods for the purpose of this benefit refer exclusively to prescription metabolic formulas and their
modular counterparts obtained through a pharmacy. Medical foods are specifically designated and
manufactured for the treatment of Inherited Enzymatic Disorders caused by Single Gene Defects.
Coverage for Inherited Enzymatic Disorders caused by Single Gene Defects shall include, but not be
limited to, the following diagnosed conditions: Phenylketonuria, Maternal Phenylketonuria, Maple Syrup
Urine Disease, Tyrosinemia, Homocystinuria, Histidinemia, Urea Cycle Disorders, Hyperlysinemia,
Glutaric Acidemias, Methylmalonic Acidemia,, and Propionic Acidemia. Covered care and treatment of
such conditions shall include, to the extent Medically Necessary, medical foods for home use for which a
Network Physician has issued a written, oral, or electronic prescription.
The maximum age to receive this benefit for Phenylketonuria is twenty-one (21) years of age; except that
the maximum age to receive this benefit for Phenylketonuria for women who are of child-bearing age is
thirty-five (35) years of age.
Benefits for medical foods are subject to a fifty (50) percent Copayment.
MENTAL HEALTH SERVICES/PSYCHIATRIC CARE
Inpatient psychiatric care up to forty-five (45) days for per Plan Year or ninety (90) partial hospitalization
days per Plan Year. Partial hospitalization is defined as treatment for at least three (3) hours but not more
than twelve (12) hours in a 24-hour period. Maximum amount payable for Physician visits (including
psychologist visits) during a Participant’s confinement for alcohol dependency or mental and nervous
City of Fort Collins Group Health Plan 39
POS Summary Plan Description, 1/1/04
disorders is $1,000 per Participant per Plan Year. Benefits are paid to a maximum of forty-five (45) days
for inpatient care per Plan Year or ninety (90) partial hospitalization days per Plan Year or a combination
of inpatient care plus partial hospitalization not to exceed the aggregate value of forty-five (45) days of
inpatient care.
Two partial hospitalization days will be the equivalent of one inpatient day. Each two days of partial
hospitalization care shall reduce by one day the forty-five days available for inpatient care, and each day
of inpatient care shall reduce by two days the ninety days available for partial hospitalization care. Each
day of confinement for alcohol detoxification or rehabilitation will reduce by one (1) day the number of
days available for inpatient psychiatric care and will reduce by two (2) days the number of partial
hospitalization days available.
Outpatient Psychiatric Care Services include individual and group psychotherapy sessions for Medically
Necessary treatment of mental and nervous conditions. Outpatient psychiatric services are limited to a
maximum amount payable of $1,000 per Participant per Plan Year.
Not Covered
court-ordered psychiatric therapy or psychiatric therapy as a condition of parole or probation.
psychological testing of a Participant that is requested by or for a third party.
counseling for borderline intellectual functioning, for occupational problems, or for activities of an
educational nature; counseling related to consciousness raising.
vocational or religious counseling.
developmental disorders, including but not limited to, developmental reading, arithmetic, language, or
articulation disorders.
IQ testing.
lifestyle and personal growth counseling.
early infant stimulation.
counseling for autism.
counseling for transsexualism.
cognitive skills rehabilitation.
psychotherapy credited toward earning a degree or required for education purposes.
psychosurgery.
OBSTETRICAL CARE
Obstetrical care for female Participants is provided in connection with normal pregnancy and childbirth.
Medically Necessary treatment necessitated by complications of pregnancy are also covered.
Not Covered: home delivery, any procedure intended solely for sex determination, birthing classes and
delivery charges if travelling within five weeks of due date.
OTHER INSTITUTIONS
Services of other institutions may be covered, but only on order of the attending Physician and only when
significant, measurable improvement can be anticipated. Services include accommodations, meals,
general nursing care, medical supplies and equipment ordinarily furnished by the facilities, and prescribed
drugs and biologicals.
Benefits are provided up to thirty (30) days per Plan Year. The Participant’s status may be reevaluated
and, if it is determined that the status of the care is no longer acute, the services may not be covered.
Not Covered:
expenses of chronic, custodial, or Maintenance Care.
City of Fort Collins Group Health Plan 40
POS Summary Plan Description, 1/1/04
chronic or Maintenance Care, Private Duty Nursing, and Respite Care (except as may be provided as
Hospice Care).
convalescent care.
Private Duty Nursing.
personal comfort or convenience items, such as telephone or television.
private room, except when Medically Necessary.
Care provided to a Participant may be Custodial Care, even though all of the following apply:
the Participant is under a Physician’s care or supervision.
services are being prescribed to support and generally maintain the Participant’s condition, provide
for the Participant’s comfort, or assure the manageability of the Participant.
services are being provided by a registered nurse or other licensed provider.
PHYSICIAN SERVICES
Allergy Treatment Outpatient allergy evaluation and allergy treatment materials are covered.
Exams and Consultation (Office, In/Outpatient) Physician’s services including time for visits and
examinations relating to an illness or injury. These services include consultation and personal attendance
with the patient in the Physician’s office, or in a Hospital or other institution. Physician’s visits to the
Participant’s home when Medically Necessary and only if the Participant is too ill or disabled to go to the
Physician’s office. Medical consultation services, including charges made by a Physician for a second
surgical opinion.
Not covered: expenses for medical reports, including preparation and presentation; expenses for
examinations conducted for the purpose of medical research.
Foot Conditions Treatment of weak, strained, flat, unstable or imbalanced feet. Treatment for
metatarsalgia or bunion, cutting or removing one or more corns, calluses, toenails, removal of part or all
of one or more nail roots for treatment of a metabolic or peripheral vascular disease. Surgical or
nonsurgical treatment of subluxations of the foot. Subluxations of the foot are partial displacements or
dislocations of joint surfaces, tendons, ligaments, or muscles of the foot. Benefits are paid to a maximum
of $500 per Participant per Plan Year.
Not covered: corrective or supportive devices, appliances, or shoes; routine foot care or routine
hygiene care.
Prostate Cancer Screening Prostate cancer screening to include a prostate-specific antigen blood test
and digital rectal examination. Prostate cancer screening is not subject to a Deductible. Coverage is
subject to the following guidelines: screening once a year for men over the age of 50; screening once a
year for men over the age of 40 who are in high-risk categories as determined by a Physician.
Well-Baby/Well-Child Care Well-baby and/or well-child care, including immunizations, in a Physician’s
office for Participants up to age thirteen (13).
PRESCRIPTION DRUGS
Prescription drugs may be obtained from a non-network pharmacy. However, in addition to the
Copayment required for network benefits, you will pay an additional 30% of the medication’s total cost.
As with Network benefits, covered medications are subject to change. Coverage of a medication at any
time is not a guarantee of future Coverage. Copayments are subject to change due to periodic changes
in the Preferred Brand Drug Listing.
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POS Summary Plan Description, 1/1/04
RADIOLOGY
Radiological, laboratory and other services, such as electrocardiography (EKG), electroencephalography
(EEG), and the use of radioactive isotopes when used in the diagnosis of actual or suspected illness or
injury. Therapeutic radiological services, including radiation therapy and radioactive isotope therapy.
Screening by low-dose mammography for the presence of breast cancer in adult female Participants.
Coverage of mammograms is not subject to a Deductible. Coverage is subject to the following guidelines:
annual screening for women over age 40; screening as indicated for women with risk factors for breast
cancer as determined by a Physician.
Not Covered: preventive diagnostic screening of all kinds, except for the covered benefits relating to
screening by low-dose mammography
SURGERY
Breast Surgery: The cost of reconstructive breast surgery following a mastectomy, to include
reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the
unaffected breast to produce a symmetrical appearance; surgically implanted breast prostheses;
Coverage of physical examinations resulting from the mastectomy, including lymphedemas. The cost of
surgical bras, including external prostheses, when preauthorized and when in lieu of reconstructive breast
surgery is covered for two (2) surgical bras initially following breast surgery; one replacement bra is
covered up to $500 per Participant every twenty-four (24) months.
Oral and Dental Surgery: Oral surgery and certain medical service charges for dental services will be
covered only as follows: emergency treatment received within twenty-four (24) hours of the occurrence of
accidental injury to the jaw or mouth (no follow-up dental restoration procedures are covered); medical
consultation and diagnostic procedures during an inpatient admission for a covered dental problem when
ordered by the medical consultant related to a strictly medical condition; treatment for tumors of the
mouth when cancer is suspected; treatment of congenital conditions of the jaw that may be demonstrated
to cause actual significant deterioration of the Participant’s physical condition because of inadequate
nutrition or respiration; cleft lip, cleft palate, or any condition or illness that is related to or developed as a
result of the cleft lip or cleft palate shall be considered compensable for Coverage to the extent required
by Colorado law; for newborn children born while covered under the Plan with cleft lip or cleft palate or
both, the following care and treatment are provided to the extent Medically Necessary and when ordered
by a Physician:
oral and facial surgery, surgical management, and follow-up care by plastic surgeons and oral
surgeons.
prosthetic treatment such as obturators, speech appliances and feeding appliances
Medically Necessary orthodontic treatment
Medically Necessary prosthodontic treatment
habilitative speech therapy
otolaryngology treatment
audiological assessments and treatment
Plastic, Reconstructive or Cosmetic Surgery Services will be covered if the surgery is performed as soon
as medically feasible and it is Medically Necessary for any of the following reasons:
to repair an injury sustained while the Participant is covered by the Plan and repair is initiated within
one (1) year following the injury;
reconstruction that is incidental to or is required as a result of surgery necessitated by injury
sustained or illness commenced while the patient is a Participant;
City of Fort Collins Group Health Plan 42
POS Summary Plan Description, 1/1/04
the correction of a congenital defect that substantially impairs major organ function, or leads to a
progressive deterioration of health of a covered child.
Surgical Services Surgical services in the Hospital, Physician’s office, or in an ambulatory surgical center.
This may include when Medically Necessary: a surgical assistant when medically appropriate as
determined by the Plan; services of an anesthesiologist or anesthetist.
Surgery Not Covered:
expenses of plastic, reconstructive or cosmetic surgery, including but not limited to, skin lesions that
are removed for cosmetic purposes. Exceptions for Reconstructive Surgery must be approved in
writing by the Plan and will be considered only when Medically Necessary and performed primarily to
improve the physical health and function of the patient;
reconstructive nasal surgery, including rhinoplasty;
revision of a previous procedure performed for cosmetic purposes including, but not limited to, breast
augmentation;
Reconstructive Surgery which does not correct or materially improve a physiological function;
surgical treatment for obesity, and complications arising from surgical treatment for obesity;
orthognathic surgery;
metallic bone cylinder implants (bone screws);
if a dental insurance policy is in effect at the time of the birth, or is purchased after the birth of a child
with cleft lip or cleft palate or both, no benefit under the Plan shall be provided for any orthodontics or
dental care needed as a result of the cleft lip or cleft palate or both.
THERAPIES/REHABILITATION
Cardiac Short-term Cardiac Rehabilitation program for the short-term follow-up of Acute Care for a
myocardial infarct or cardiac revascularization procedure. This benefit is an extension of the treatment for
an inpatient Acute Care episode and must begin within two (2) months of discharge from the Acute Care
facility. Benefits are paid to a maximum of $1,000 within a ninety-(90) day period.
Chemotherapy Physician services and materials for chemotherapy. Outpatient injectable chemotherapy
when oral administration of prescribed medication is not medically appropriate. Chemotherapy requiring
a bone marrow transplant for breast cancer and other solid tumors is not covered.
Hemodialysis All necessary services for hemodialysis for chronic renal disease, including training and
expendable medical supplies required for home dialysis and dialysis at hemodialysis facilities. Covered
benefits are provided only at hemodialysis facilities that are approved for participation in the Medicare
program.
Occupational/Physical/Speech Short-term, occupational and speech therapy, including evaluation,
treatment or therapy to correct or adjust any structural imbalance, distortion, subluxation or misplaced
body tissue of any kind. Speech therapy is a covered benefit only for the short-term rehabilitation
required immediately following these acute episodes: stroke, accidental brain injury (not occurring during
birth), and surgery involving the larynx. The Participant’s status may be reevaluated and, if it is
determined that the condition is no longer acute, any subsequent therapy will not be covered. Short-term
outpatient therapy is defined for purposes of this benefit as resulting in significant improvement of a
Participant’s condition within a period of two (2) months. Benefits paid for a procedure billed as a
“manipulation” or other form of physical therapy will be applied toward the benefit limit for physical
therapy. Benefits are paid up to $500 per Participant Per Plan Year each for physical, occupational and
speech therapy.
Occupational/Physical/Speech therapy is covered for the care and treatment of congenital defects and
birth abnormalities for children up to age five (5), without regard to whether the condition is acute or
chronic and without regard to whether the purpose of the therapy is to maintain or to improve functional
City of Fort Collins Group Health Plan 43
POS Summary Plan Description, 1/1/04
capacity. Otherwise, speech therapy related to a developmental or communication delay is not covered.
Benefits are paid up to twenty (20) sessions of each type of therapy per year.
Radiation Therapy Service for Medically Necessary radiation therapy are covered.
Therapies/Rehabilitation Not Covered
Special evaluation and/or therapy for: behavior disorders; communication delay; learning disability;
mental retardation and related conditions; motor dysfunction; multiple handicaps; perceptual
disorders; personal goal fulfillment; post-traumatic stress; sensory deficit; sex addiction; speech
(except as specifically listed as a covered benefit); vision.
Special evaluations and therapies, including: behavioral training; bereavement support, except as
part of Hospice Care; biofeedback; cognitive therapy; coma stimulation; developmental and
neuroeducational testing or treatment; educational studies; hearing therapy; hypnosis or
hypnotherapy; myofunctional therapy; neuromuscular rehabilitation for chronic conditions;
psychological testing; respiratory therapy; sleep therapy; vision therapy/orthoptics; vocational
rehabilitation.
TRANSPLANTS
Covered Transplants Necessary services for covered transplants at designated facilities. Covered
Services include directly related, reasonable medical and Hospital expenses of the donor. Coverage will
be restricted to transplant services provided to the donor and recipient only when the recipient is a
Participant. The Plan will not be responsible for furnishing a donor or for assuring the availability capacity
of designated transplant facilities.
Cornea Cornea transplants are covered by the Plan
Kidney All necessary services for kidney transplants, including the directly related, reasonable medical
and Hospital expenses of a donor for a current Participant and transplant services provided to a recipient
who is a Participant.
Skin Grafts Skin grafts are covered, unless performed for cosmetic purposes.
Transplants Not Covered Any organ or tissue transplant or artificial organ not specifically listed as a
covered benefit. Transplants not covered include but are not limited to: bone marrow, heart, heart-lung,
liver, lung, multiple organs, pancreas. Transplants not covered by the Plan may be covered through a
separate insurance contract. Please call Human Resources for additional information.
TREATMENT ALTERNATIVES
Treatment alternatives and limited adaptations to Coverage under the Plan are reserved to the sole
discretion of the Plan. Such decisions will be made exclusively by the Plan based upon the medical and
cost effectiveness of alternatives, probable outcome of a Medically Necessary Service, and consultation
with the Participant or the Participant’s representative. The fact that the Plan makes an adaptation to the
Plan will not require or act as a precedent requiring that it make future adaptations in similar or other
situations, or otherwise be prevented from administering the Plan in strict accordance with its terms.
In addition, the Plan may, at its sole discretion, reevaluate and discontinue any adaptation granted under
this provision if it determines that the original basis for granting the adaptation is no longer valid and
City of Fort Collins Group Health Plan 44
POS Summary Plan Description, 1/1/04
supportive of the adaptation or is no longer likely to lead to measurable improvement in the health of the
Participant.
Any request for Coverage of treatment alternatives and/or limited adaptations to the Plan must be made
in writing, by a Physician or a Participant to the Plan. The Coverage decision will be made by the Plan,
which will provide a written response; only services specifically authorized and received after the
Participant’s receipt of the written response will be covered. The Plan shall have the sole discretionary
authority to determine all questions arising in the administration, interpretation and application of this
provision, and all such determinations shall be final, conclusive and binding.
POS 2
GENERAL EXCLUSIONS AND LIMITATIONS
Network benefits are subject to POS 1 Exclusions and Limitations. The Limitations and Exclusions shown
here apply to non-network services.
1. Any service that is:
not specifically identified as a covered benefit by the Plan;
not reasonably and Medically Necessary, even if otherwise covered by the Plan
not required in accordance with accepted standards of medical, surgical or psychiatric practice
not selected by the City as part of the group Coverage under the Plan.
required only for the convenience of the Participant or the Participant’s Physician.
2. Services and supplies paid for directly or indirectly by any local, State or Federal Government agency,
except when the Participant would have a legal obligation to pay for the services.
3. Expenses for medical and/or Hospital services incurred prior to the effective date for the Participant or
after termination of Coverage under the Plan.
4. Expenses in excess of reasonable and customary (R&C) limits.
5. Expenses for services that were not recommended by a Physician, or not accompanied by a
diagnosis of an illness or injury from the Physician who ordered the service for which the expenses
were incurred.
6. Expenses of procedures, therapies, services, and supplies related to sex transformation, reversal of
sex transformation, and sexual dysfunctions or inadequacies, including penile implants or any
prosthesis for impotency.
7. Expenses of health education, patient education, wellness promotion exercise or fitness programs,
fitness education or training, or recreation. or any similar program or service.
8. Expenses of vitamins, minerals, or nutrient supplements; or for any procedures for determining
vitamin or mineral deficiencies.
9. Expenses for missed appointments and/or charges incurred when scheduled services are canceled
by the Participant, telephone consultations, personal comfort items, or the completion of claim forms.
10. Expenses resulting from military service for any country or organization, including service with military
forces as a civilian whose duties do not include combat.
11. Expenses resulting from committing, attempting, or taking part in a felony, or expenses incurred while
the Participant is incarcerated or serving a term of imprisonment or involuntary confinement.
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12. Expenses of services or supplies provided by a Hospital owned and operated by the United States
government or any state government, unless an expense must be paid by the Participant in the
absence of insurance. This Exclusion is not applicable to Colorado-supported institutions treating
mental illness, mental retardation, or both and nervous disorders if such charges for treatment are
customarily charged to nonindigent patients by such state institutions.
13. Expenses of medical care or treatment given by any member of the Participant’s family, a relative, or
anyone normally residing with the Participant. Expenses that the Participant is not obligated to pay
(e.g., free clinics or services which the Participant received as a professional courtesy) or charges
that would not have been made had the Plan not been in force; expenses for services which were not
actually provided.
14. Expenses resulting from any injury arising out of, or in the course of, any work for wage or profit
(whether or not with the Employer). Expenses resulting from any illness or injury for which the
Participant is eligible for or entitled to benefits under workers’ compensation statutes or any similar
laws.
15. Expenses to the extent that the Participant receives, or is entitled to receive, payment for such
expenses through any governmental program, except as described under the sections entitled
“Coordination of Benefits” and “Subrogation”.
16. Expenses for which payment is not lawful in the jurisdiction where the Participant’s is living when the
expenses are incurred. Expenses for services that are not within the scope of the provider’s license
in the jurisdiction where the services are provided.
17. Braces and artificial limbs, except as specifically listed as a covered expense under the Plan.
Artificial aids, prosthetic devices, corrective appliances, breast pumps and medical supplies,
including, on an outpatient basis, enteral feeding substance and infant formula.
18. Expenses of treating complications resulting from services that are not covered benefits or are
excluded from Coverage (such as, but not limited to, experimental procedures or surgery for obesity).
19. Expenses incurred on order of a court or as a condition of parole or probation.
20. Services that the Participant is entitled to as a result of class action or special group settlements, e.g.,
Agent Orange treatment programs and asbestosis indemnification funds. If specific treatment
facilities are not stipulated by the responsible agency or group, the Plan will pay for eligible charges
contingent on coordination of benefits or Subrogation rights.
21. Expenses resulting from any intentionally self-inflicted injury or illness.
22. Acupuncture expenses.
23. Dietary counseling for obesity, including weight reduction programs.
24. Enteral feeding substance, hyperalimentation solution, total parenteral nutrition, and infant formula on
an outpatient basis, medical foods, except as listed specifically as a covered expense.
25. Hearing aids and all examinations for prescribing, fitting, or adjusting hearing aids; cochlear implants
and all associated supplies and expenses.
26. Growth hormones.
27. Health appraisals, check-ups and immunizations for children and adults, except as specifically
provided by the Plan.
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POS Summary Plan Description, 1/1/04
28. Medical report expenses, including preparation and presentation.
29. Routine exams, such as physical, premarital, school, employment, insurance, licensing, adoption, and
camp exams, flight physicals and examination and treatment ordered by a court.
30. Travel expenses or transportation other than professional ambulance service.
31. Well-baby care, except as specifically provided by the Plan.
32. Wigs, hair implants, and similar supplies and procedures, even if there is a medical reason for the
Participant’s loss of hair.
33. Custodial, chronic, maintenance, convalescent, and/or domiciliary care, Private Duty Nursing and
Respite Care (except as specifically provided by the Plan through Hospice Care), rest cures, whether
furnished in the home or in an institution, including nursing home or similar facility.
34. Post-mortem testing.
35. Products derived in whole or in part from blood or blood plasma, and special blood handling fees.
36. Personal comfort or convenience items or services obtained or rendered in our out of a Hospital or
other facility, such as television, telephone, guest meals, articles for personal hygiene and any other
similar incidental services and supplies.
37. Cosmetic Procedures and services performed for cosmetic reasons, whether or not due to a medical
condition, including but not limited to the treatment of hair loss, except as specifically provided by the
Plan.
38. Elective or voluntary enhancement procedures, services, supplies, and medications including, but not
limited to weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes,
anti-aging, and mental performance.
39. New procedures, services, supplies and medications until they are reviewed for safety, efficacy, and
cost effectiveness and approved as covered by the Plan.
40. Treatment or care for maxillary and mandibular osteotomies, and jaw or orthognathic conditions.
41. Orthognathic surgery and associated costs of each related to the treatment for misalignment or
similar malfunction of the jaw joint, commonly known as termporomandibular joint problems or TMJ
syndrome.
42. Special Service Clinics, centers or programs on an inpatient or outpatient basis. This includes but is
not limited to clinics, centers or programs for: lactation; senior service; headaches; eating disorders;
smoking cessation; personal goal-fulfillment therapy; premenstrual syndrome (PMS); stress
management; inpatient or outpatient services of facilities, clinics, or centers that specialize in, or
advertise their services for, the treatment of pain.
43. Dental services not covered include, but are not limited to:
general dental services and dental x-rays, including treatment on or to the teeth or gums;
any services customarily provided by a general dentist, an oral surgeon, or any other dental
specialist;
any procedure involving osteotomy of the jaw;
periodontal treatment and/or surgery;
treatment or care of overbite or underbite;
City of Fort Collins Group Health Plan 47
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treatment or care for maxillary and mandibular osteotomies, and jaw or orthognathic conditions;
dental prosthetics, orthognathic surgery, and metallic bone cylinder implants (bone screws);
expenses for dental care in the treatment for misalignment or similar malfunction of the jaw joint,
commonly known as temporomandibular joint problems or TMJ syndrome, including but not
limited to splint therapy. Covered Services related to the treatment of TMJ must be preauthorized
and are limited to $500 per Participant per Plan Year.
Hospital costs for dental surgery or other dental reasons, except for those listed specifically as
covered by the Plan.
44. Treatments, procedures, devices and/or drugs which shall be deemed excluded as Experimental,
Investigational, unproven, unusual, or not customary. The Plan shall have the discretionary authority
to interpret this provision and determine all questions arising in the administration, interpretation and
application of this provision, including determining what procedures, devices or drugs are
Experimental, Investigational, unusual, not customary or unproven. All such determinations shall be
final, conclusive and binding. Examples of experimental treatments, procedures, devices and/or
drugs include but are not limited to:
orthomolecular medicine;
holistic medicine;
environmental medicine;
chelation therapy, unless Medically Necessary for the treatment of metal poisoning;
cytotoxin testing;
hair analysis;
colonics;
gene manipulation therapy;
medications that are experimental, investigative, or used in ways not approved by the Food and
Drug Administration (FDA);
naturopathic services;
megavitamin therapy.
45. Vision services, except as specifically listed as a Covered Service.
46. Surgical treatment of morbid obesity, and treatment of any complications arising from such surgery.
GENERAL LIMITS
Benefits for any service provided a Participant during a Plan Year are limited cumulatively to the benefits
covered by the Plan. The benefits a Participant can receive in a Plan Year will not increase due to a
change in the Participant’s status or a change from group Coverage to Continuation Coverage.
MAXIMUM BENEFITS
The benefit maximums are in effect for covered Medically Necessary charges received from either
Network or non-Network Providers combined. The aggregate lifetime benefit maximum under all Plan
Options (POS, PPO, Network and non-Network Providers) per Participant is $2 million. Specific benefit
maximums for particular services are shown under the sections entitled “Covered Expenses”. Medicare-
eligible Retirees are covered for up to $100,000 in covered expenses per year, including $5,000 for
prescription drugs.
HOW TO CLAIM BENEFITS
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POS Summary Plan Description, 1/1/04
For all Plans, you will need to provide the Employee’s Social Security Number. For purposes of
confidentiality, this number is NOT shown on identification cards.
POS 1 BENEFITS
To claim benefits under the POS 1, you must first select a provider who is a member of the One Health
Plan provider network. Before services are obtained, verify with your provider whether he/she is a
Preferred Provider; otherwise, you may be responsible for additional charges.
Medical Claims (Physician Services). At the time you call a Physician for an appointment, you should
confirm that he/she is a member of the Network. When you arrive at the Physician’s office, you must
follow certain specific steps to ensure that the office staff recognizes you as a POS patient. Either
present your health plan identification card, or follow these two steps:
First, identify yourself (or your Dependent) to the receptionist as a Participant in the City of Fort
Collins Group Health Plan.
Second, you must specify that you are seeking benefits through the Plan’s POS option. You should
inform the Physician’s staff that the City of Fort Collins Group Health Plan participates with One
Health Plan. This information is listed on your health plan identification card. Don’t forget that you
will also need to provide the Employee’s Social Security Number, which is no longer shown on your
identification card.
The Physician’s office will file on your behalf the claim with the claims administrator, and payment will be
made directly to the Physician. The Physician may bill you only for your required Copayment. If a
Network Provider requires full payment at the time of service, you should contact One Health Plan
Customer Service at 1-800-663-8081.
Hospital Claims. Hospital admissions must be in a facility contracting with One Health Plan. When
admitted on an inpatient or outpatient basis, present your plan identification card to the admitting office,
identify yourself (or your Dependent) as a Participant in the City of Fort Collins Group Health Plan, and
inform the admitting office that you are seeking benefits through the Plan’s POS option. Be certain to
complete all necessary forms presented to you. The Hospital will send the claim directly to the Plan
Supervisor for payment, and payment will be made directly to the Hospital. Be sure to let the Hospital
and any other providers know that your Coverage is through One Health Plan for Network benefits.
POS 2 (non-Network) Providers
A claim for non-Network Provider, Hospital, medical, surgical and prescription drug expenses or questions
relating to the payment of a claim should be directed to the Plan Supervisor. You will need to complete
the required claim form and obtain invoices from your providers. Claim forms are available on-line at
www.onehealthplan.com; you’ll need to register as a member. Upon receipt of this information, file the
claim directly with the Plan Supervisor at the following address:
Great-West Health Care, Inc.
O Box 11111
Fort Scott, KS 66701
To file a claim for non-Network providers, follow these four simple steps:
First, obtain the proper claim form from the City’s Human Resources Department. Complete the form in
its entirety to avoid claim processing delays, and be sure to sign your form. Also, remember that claims
need to be filed under the Employee’s Social Security Number. A completed and signed form is required
for each person for whom a claim is submitted. Be sure to attach an itemized billing, and mail the
completed claim form to Great-West Health Care at the address shown above. Bills should include the
following information on the provider’s letterhead stationery:
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POS Summary Plan Description, 1/1/04
name of the individual for whom expenses were incurred;
Physician bills should show the date of service, the diagnosis and the charge for each
treatment;
nurse’s bills should show the date of service, the place and the hours of duty, the charge per
day and the nurse's signature;
bills for other medical expenses such as oxygen, blood and X-rays on the provider’s billing
letterhead, and should show the charges and the date the expense was incurred;
prescription drug bills should show the date of purchase and the name of the drug(s) for all
prescription drugs purchased at a Network pharmacy or a non-network pharmacy.
Second, if the claim information is complete as submitted and the claim is approved, payment will be
made to you or the providers, depending on whether you have assigned benefits. If you assign benefits
to the provider, payment will be made directly to the provider. If you have already paid the provider, do
not assign benefits and payment will be made directly to you.
Third, if your claim form is incomplete, Great-West Health Care will contact you or the provider for the
required information.
Fourth, benefits will be paid by the Plan only if notice of claim is made within 90 days from the date on
which covered charges were first incurred. In no event shall benefits be allowed if notice of claim is made
beyond a fifteen month period immediately following the date on which expenses were incurred, unless
the City in its sole discretion determines that extenuating circumstances prevented timely filing of a claim.
All claims must be filed in writing by completing such procedures as required. Such procedures may
include the submission of documents and additional information. Any bills will usually contain all of the
necessary information. However, Physician bills are sometimes incomplete. Claim payments may be
expedited by having such bills prepared clearly and correctly by the provider before they are submitted.
Frequently, delays in claim payment are the result of inaccurate or incomplete claims.
Proof of Claim
The Plan, at its own expense, shall have the right and opportunity to examine the person of any
Participant when and so often as it may reasonably require during the pendency of any claim, and also
the right and opportunity to an autopsy in case of death where it is not forbidden by law. Proof of claim
forms, as well as other forms, and method of administration and procedure will be determined solely by
the Plan.
Explanation of Benefits (POS 2 Only)
After your claim has been processed, you will receive in the mail from Great-West an Explanation of
Benefits (EOB), which notifies you of the manner in which your claim was handled. If payment was made
to a provider, the amount of the payment will be shown on the EOB, together with an accounting of all the
charges rendered. If no payment has been made, the EOB will provide you with the reason payment has
been reduced or denied. The EOB will specify the amount you are required to pay. If you have any
questions about information contained on any EOB, please call Great-West. If an EOB shows a charge
for a service you did not receive, please notify Great-West immediately. Please use your EOB when filing
claims through the medical Flexible Spending Account.
Reporting Changes by Participants
It is important that the City’s Human Resources Department be notified whenever a change in any of the
following occurs:
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POS Summary Plan Description, 1/1/04
a change in your address, so that records are kept up-to-date if you need to be contacted about any
matter concerning your benefit Coverage; or
any change in your family status, such as marriage or divorce, birth of a child, the marriage of or the
loss of Dependent student status by a Dependent child, or the death of any Dependent. Charges
incurred by any ineligible Dependent will be your responsibility.
If You Need Assistance
Eligibility: if you have any questions about eligibility for Coverage under the Plan, please do not hesitate
to contact the Human Resources Office at 221-6535.
Plan Provisions: if you have any questions about specific Plan provisions (including prescription drugs),
requirements or claim payments, you should contact Great-West Health Care at 1-800-663-8081.
Coordination of Benefits
Coordination of Benefits applies to persons who are covered by more than one group health plan so that
each plan pays its proper share of benefits. If you or any of your Dependents are covered by another
group insurance plan, you will need to provide information regarding other Coverage when you file a
claim. If this Plan pays secondary to another plan of benefits, the benefits paid by this Plan are reduced
so that the benefits payable under all plans do not exceed 100% of the eligible charges incurred.
If you or any of your covered Dependents are covered by a motor vehicle policy which provides for
Coverage of medical expenses resulting from accidental injury, claims should be submitted first to those
other policies for payment. Benefits payable by the Plan shall be reduced by the benefits payable by
those other polices. Only after benefits have been determined by those other policies should claims be
submitted to the Plan. If benefits have been paid out by the Plan, the Plan shall have the right to recover
from you, the motor vehicle insurer the value of benefits that should have paid by those plans. At its
discretion, the Plan reserves the right to suspend future benefit payments in order to recover benefits that
should have been paid by other plans.
If there are two group plans providing Coverage for you and your eligible Dependents, a determination
must be made as to how the plans coordinate payment, and which plan pays first. These are the general
guidelines that are used to determine which plan pays first:
A. Employee/Dependent Rule
1. The plan which covers the Participant as an Employee pays first.
2. The plan which covers the Participant as a Dependent pays second.
B. Dependent children of parents NOT separated or divorced
1. The plan which covers the parent whose birthday falls earlier in the year pays first; the
plan which covers the parent whose birthday falls later in the year pays second. The birthday
order is determined by month and day, and not by year of birth.
2. If both parents have the same month and day of birth, the plan which covered the
parent longer will pay first; the plan which covered the parent for a shorter period of
time pays second.
C. Dependent children of separated or divorced parents
1. The plan of the parent with custody of the child pays first.
2. The plan of the Spouse of the parent with custody (i.e., the stepparent) pays second.
3. The plan of the parent not having custody of the child pays third.
4. The plan of the Spouse of the parent not having custody pays fourth.
5. However, if there is a court decree which would otherwise establish financial responsibility for
medical or other health care expenses with respect to the child, the plan which covers the parent
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POS Summary Plan Description, 1/1/04
with such financial responsibility shall be determined before the benefits of any other plan which
covers the child as a Dependent.
D. Active/Inactive
1. The plan which covers the Participant as an active Employee or Dependent of an active
Employee pays first.
2. The plan which covers the Participant as a retired or otherwise inactive Employee or
Dependent of a retired or otherwise inactive Employee pays second.
E. Longer/Shorter
1. If the rules cited above cannot adequately determine the order of benefits, then the plan
which has covered the patient for a longer period of time will pay first.
F. COBRA
1. When a Participant’s Coverage under this Plan is COBRA Coverage, this Plan will determine its
benefits after benefits are determined on a primary basis under the other plan.
In no event will benefits received from this Plan and all other plans combined exceed the total of eligible
charges incurred.
For purposes of coordination of benefits, the Plan may obtain claim information from any individual or
organization. In addition, any Participant claiming benefits from the Plan shall furnish the Plan with any
information the Plan may require. If any overpayment is made by the Plan because of a Participant’s
failure to report other Coverage or any other reason, the Plan has the right to recover such excess
payment from any individual to whom or for whom overpayments were made. The Plan reserves the right
to suspend future benefit payments in order to recover such overpayments.
Coordination of Benefits with Medicare
Benefits under the Plan are not designed to duplicate any benefit to which you are entitled under the
Social Security Act. If you and/or one of your covered Dependents are covered by Medicare, special
rules about the order of payment apply, and benefits will be coordinated in compliance with current federal
regulation.
The Plan pays first and Medicare pays second when you are an active
Employee and you or your covered Dependent is enrolled for Medicare. When the Plan pays first, you
receive the same benefits as all other covered Participants.
Medicare pays first and the Plan pays second when you are not an active Employee and you or your
covered Dependent are entitled to Medicare, regardless of whether you have actually enrolled in
Medicare Part A or Part B. Benefits are payable by the Plan without regard to entitlement to Medicare as
an End Stage Renal Disease (ESRD) beneficiary for the first 30 months of Medicare entitlement. Benefits
are payable after Medicare benefits whether or not you or your Spouse is eligible for Medicare as an
ESRD beneficiary, or you or your Spouse are disabled at any age.
If you have any questions about Medicare benefits, you should contact your local Social Security office.
HMO Coordination of Benefits
HMOs have special provisions for coordinating benefits. If you are an HMO Participant, you should
contact the HMO regarding these provisions.
No Fault Insurance
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POS Summary Plan Description, 1/1/04
Prior to July 1, 2003, the State of Colorado requires no fault automobile insurance, including medical
Coverage. The Plan assumes that Participants are covered for the required level of medical insurance
under an automobile policy, and will not pay any charges that should be covered by automobile
insurance. If the medical Coverage under the automobile policy exceeds the required level of Coverage,
this Plan will coordinate benefits with those Coverages in effect. The Plan does not coordinate benefits
relating to any other person injured in a motor vehicle Accident if the injured person is a non-owner
operator, passenger or pedestrian or any other person not covered by No Fault Automobile Insurance.
After July 1, 2003, this requirement is lifted. Injuries to Participants may be covered by the Plan, provided
those charges are eligible for Coverage under the Plan. Injuries to persons not participating in the Plan
are not covered. Therefore, you should consult your personal insurance agent to determine what
adjustments should be made to your automobile insurance policy.
Subrogation (The Right to Third Party Payment)
If the Plan pays benefits to you or a covered Dependent that are later determined to be the legal
responsibility of another person or company, the Plan has the right to recover these payments from you.
You will be asked to sign a Subrogation form at the time of claim. You should know that the Plan will be
refunded for any payments you receive from the Plan which have also been paid to you by a third party.
This right of Subrogation applies also to payments that are received through homeowners’ insurance. In
the event of a Participant’s death or incapacity, the responsibility for reimbursing the Plan shall be
assumed by the Participant’s guardian or estate. Failure to comply with these Subrogation requirements
may, at the Plan’s discretion, result in the forfeiture of benefits under the Plan. The Plan reserves the
right to suspend future benefit payments in order to recover benefits paid by a third party.
Fraudulent Claims Plan Participants are responsible for the accuracy of the claims submitted for
themselves and their eligible Dependents. Anyone who knowingly submits a fraudulent claim under the
Plan will forfeit immediately Coverage under the Plan and will be subject to disciplinary action, up to and
including termination of employment. Submission of fraudulent claims may also result in criminal and/or
civil liability.
APPEALS
If you disagree with the manner in which a claim has been processed because you believe Plan
provisions have been misapplied, the Plan provides for a specific appeals procedure.
First, call Great-West Health Care, and ask them to explain the manner in which your claim was handled.
You should have your Explanation of Benefits with you for reference.
Second, if you still disagree with the result of your claim processing, contact the City’s Human Resources
Department to confirm the information provided by Great-West Health Care.
Third, if you still disagree with the outcome of your claim’s disposition, you may submit a written appeal
to the City’s Benefits Administrator. Be sure to include the specific reason why you believe the Plan’s
provisions were misapplied. Such an appeal must be made within sixty (60) days from the date shown on
the denial or reduction of benefits. In your written appeal, state the specific reasons for your
disagreement with the disposition of your claim. You will receive a written response to your appeal as
soon as possible, but not later than 120 days after receipt of your appeal by the Benefits Administrator.
The written response will include specific reference to Plan provisions applicable to your appeal. The
decision of the City or its designee with respect to your appeal will be final and binding on all parties.
DEFINITIONS
Accident means an unexpected event that could not have been foreseen and that causes physical injury
to the Participant.
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POS Summary Plan Description, 1/1/04
Acute Care means a pattern of health care in which a patient is treated for an acute (immediate and
severe) episode of illness, for the subsequent treatment of injuries to an Accident or other trauma, or
during recovery from surgery. Acute Care is usually given in a Hospital by specialized personnel using
complex and sophisticated technical equipment and materials. Unlike Chronic Care, Acute Care is often
necessary for only a short time.
Acute Condition means an immediate and severe episode of illness or the treatment of injuries related
to an Accident or other trauma, or during recovery from surgery.
Administrative Agreement means the agreement between the Plan Sponsor and the Plan Supervisor
for the provision of administrative services. This agreement is part of the Plan Documents.
Cardiac Rehabilitation means a structured program provided to individuals following acute cardiac
episodes. Cardiac Rehabilitation services are provided on an outpatient basis.
Chronic Care means a pattern of care that focuses on long-term care of individuals with chronic (long-
standing, persistent) diseases or conditions. It includes care specific to the problem as well as other
measures to encourage self-care, to promote health, and to prevent loss of function.
Coinsurance means the amount, expressed as a percentage, of a covered expense that is paid by the
Participant
Common Law Marriage means evidence of cohabitation as husband and wife, and general reputation
that the two individuals are living together as husband and wife and claiming to be such. By general
reputation is meant the understanding among the neighbors and acquaintances with whom the parties
associate in their daily lives, that they are living together as husband and wife, and not that they are
merely living together.
Common Law Spouse means a party to a Common Law Marriage.
Continuation Coverage means Coverage which may be available to a terminated Participant, as
mandated or required by Section 10-17-135 C.R.S., Title X, Consolidated Omnibus Budget Reconciliation
Act of 1985, as amended, or any other applicable law.
Copayment means the amount, expressed as a fixed-dollar figure, of a covered expense that is paid by
the Participant.
Cosmetic Procedures means those procedures which change physical appearance, but which do not
correct or materially improve a physiological function, and therefore are not Medically Necessary.
Coverage means the right of a Participant to receive services under the Plan, subject to the terms,
limitations and Exclusions of the Plan.
Covered Person means any individual meeting the definition of a Participant.
Covered Service means a Medically Necessary service that is specifically provided for under the
provisions of the Plan. A Covered Service must always be Medically Necessary, but not every Medically
Necessary service is a Covered Service. For example, some elements of custodial or Maintenance Care,
which are excluded from Coverage, may be Medically Necessary, but nevertheless are not covered.
Creditable Coverage means coverage provided under Medicare or Medicaid; an Employee welfare
benefit plan or group health insurance or health benefit plan; an individual health benefit plan; a state
health benefits risk pool (including, but not limited to, the Colorado uninsurable health insurance plan); or
Chapter 55 of Title 10 of the United States Code, a medical care program of the federal Indian health
Service or of a tribal organization, a health plan offered under Chapter 89 of Title 5, United States Code, a
City of Fort Collins Group Health Plan 54
POS Summary Plan Description, 1/1/04
public health plan, or a health benefit plan under Section 5(e) of the federal “Peace Corps Act” [22 U.S.C.
Sec 2504(e)]; and there was no gap in coverage of more than sixty-three (63) days between such
individual policies and the most recent coverage ended not more than ninety (90) days prior to the
effective date of this Coverage.
Custodial Care means any skilled or non-skilled health services, or personal comfort or convenience
related services, which provide general maintenance, supportive, preventive and/or protective care.
Custodial Care:
does not seek a cure.
can be provided in any setting.
may be provided between periods of acute or intercurrent health care needs.
is care provided to an individual whose health services requirements are stabilized and whose current
medical condition is not expected to significantly and objectively improve or progress over a specified
period of time.
Custodial Care may include the supervision or participation of a Physician, licensed nurse, or registered
therapist as necessary or desirable service. The mere participation of these professionals does not
preclude the services as being custodial in nature. If the nature of the services can be safely and
effectively performed by a trained non-medical person, the services are custodial. Further, Custodial
Care and the nature of those services are not altered by the availability of the non-medical person.
Custodial Care may also be referred to as maintenance, domiciliary, respite, and/or convalescent care.
Deductible means a specified amount of money that the Participant is responsible for paying prior to
receiving reimbursement of a Covered Service.
Dependent means the Employee’s legal Spouse and never-married natural children from birth, or never-
married legally adopted children, until the end of the month in which they attain age nineteen (twenty-five
if attending on a full-time basis an accredited high school, college, university or vocational, technical or
trade school); and
never-married step children residing with the Employee in a regular parent-child relationship; never-
married adopted children (from date of placement); never-married children for whom the Employee
has assumed legal guardianship; and
any child incapable of self-sustaining employment by reason of mental or physical impairment, who
resides with the Employee and who became incapable of self-support prior to having attained age
nineteen (notification of such impairment must be submitted to the claims administrator within thirty-
one days after the date the Dependent child’s Coverage would otherwise terminate); and
or any child for whom the Employee or Spouse is responsible for medical or other health care
benefits under a Qualified Medical Child Support Order.
No other persons are eligible to be a Dependent for purposes of Coverage under the Plan. If a
Dependent child of an Employee gives birth, that child is not eligible for Coverage under the Plan unless
the Employee assumes legal guardianship of the grandchild or adopts the grandchild. Proof of
dependency status may be required from time to time by the Employer.
Designated Transplant Facility means a facility selected by the Plan Supervisor to provide covered
transplant benefits.
Durable Medical Equipment means items of medical equipment owned or rented that are placed in the
home of the patient to facilitate treatment and/or rehabilitation. Generally, these are items that can
withstand repeated use, are primarily and customarily used to serve a medical purpose, and are usually
not useful to an individual in the absence of illness or injury.
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POS Summary Plan Description, 1/1/04
Effective Date of Coverage means the date that Coverage under the Plan becomes effective. The
Effective Date of Coverage for the Plan is stated in this Summary Plan Description.
Emergency Medical Condition means an event or medical condition which the Participant, acting as a
prudent layperson, reasonably believes threatens his or her life or limb in such a manner that a need for
immediate medical care is created to prevent death or serious impairment of health.
Emergency Services means inpatient and outpatient services that are furnished by a provider qualified
to furnish Emergency Services, and that are needed to evaluate or stabilize an Emergency Medical
Condition.
Employee means all classified Employees, unclassified management Employees, contractual Employees
whose specific employment contracts state they are eligible for Employer-sponsored medical insurance
as long as such Employees are regularly scheduled to work at least 20 or more hours per week. In
addition, certain hourly (with benefits) Employees are eligible for benefits, provided their job codes fall
within the range 2000-2399 and they work at least 30 hours per week for 26 weeks or more in a 12-month
period.
Employer means the City of Fort Collins, Colorado; the Poudre Fire Authority; the Downtown
Development Authority; and the Northern Front Range Transportation and Air Quality Planning Council.
Exclusion means any provision of the Plan whereby Coverage for a specific service or condition is
entirely eliminated regardless of Medical Necessity.
Experimental, Investigational, Unproven, Unusual, or Not Customary Treatments, Procedures,
Devices, and/or Drugs Not Covered means treatments, procedures, devices and/or drugs that:
cannot be lawfully marketed without the approval of the Food and Drug Administration (FDA) or other
governmental agency and such approval has not been granted at the time of its use or proposed use,
or
is the subject of a current investigational new drug or new device application on file with the FDA, or
is being administered for non FDA-approved indications, or
is being provided pursuant to a Phase I or Phase II clinical trial or as the experimental or research
arm of a Phase III clinical trial, or
is being provided pursuant to a written protocol which describes among its objectives determinations
of safety, toxicity, effectiveness or effectiveness in comparison with conventional alternatives, or
is being delivered or should be delivered subject to the approval and supervision of an Institutional
Review Board (IRB) as required and defined by federal regulations, particularly those of the FDA or
the Department of Health and Human Services (HHS), or
the predominant opinion among experts as expressed in the published authoritative literature is that
further research is necessary in order to define safety, toxicity, effectiveness or effectiveness
compared with conventional alternatives, or
is not a covered benefit under Medicare as determined by the Centers for Medicare and Medicaid
Services (CMS) of HHS, or
is Experimental, Investigational, Unproven, Unusual or Not Customary or is not generally acceptable
medical practice in the predominant opinion of independent experts, or
City of Fort Collins Group Health Plan 56
POS Summary Plan Description, 1/1/04
a majority of a representative sample of not less than three health insurance or benefit providers or
administrators consider the requested treatment, procedure, device or drugs to be Experimental,
Investigational, Unproven, Unusual or Not Customary based upon criteria and standards regularly
applied by the industry, or
is not experimental or investigational in itself pursuant to the above, and would not be Medically
Necessary, but for being provided in conjunction with the provision of a treatment, procedure, device
or drug which is Experimental, Investigational, Unproven, Unusual or Not Customary.
Home Health Care means Medically Necessary services prescribed by a Physician in lieu of inpatient
confinement in a Hospital, convalescent nursing home, or a Skilled Nursing Facility; such services must
be provided through an organization or agency which meets the requirements of Medicare.
Hospice Care means a system, both inpatient and outpatient, of supportive and palliative family-centered
care designed to assist the terminally ill individual to be comfortable and to maintain a satisfactory lifestyle
through the terminal phases of dying.
Hospital means an institution licensed and operated pursuant to law which is primarily engaged in
providing health services on an inpatient basis for the cure and treatment of injured or sick individuals
through medical, diagnostic and surgical facilities (including a surgical facility which has a bona fide
arrangement, by agreement or otherwise, with an accredited Hospital to perform such surgical
procedures) by, or under the supervision of, a staff of Physicians and which has twenty-four (24) hour
nursing services. A Hospital is not primarily a place of rest or Custodial Care of the aged, and is not a
nursing home, convalescent home or similar institution. A Network Hospital is one that is accredited as a
by the Joint Commission on Accreditation of Health Care Organizations (JCAHCO) and maintains
contractual agreements with the Plan Supervisor.
Intensive Care means constant, complex, detailed health care requiring special training and provided in
various acute, life threatening conditions.
Level of Care means the intensity of effort required to diagnose, treat, preserve, or maintain any
Participant’s current physical or emotional status. Depending on what the current Level of Care is
determined to be, from time to time, the Plan will have complete, limited or no responsibility to provide the
services appropriate to that level. Redetermination of Status and the appropriate Level of Care will be
made by the Network Primary Care Physician and the Plan Supervisor. Terms commonly used to identify
Levels of Care include, but are not limited to: acute, chronic, emergency, rehabilitation, intensive,
custodial, domiciliary, maintenance, skilled nursing, Private Duty Nursing, and hospice.
Lifetime Maximum means the maximum total aggregate dollar amount payable by the Plan for benefits
on behalf of any Participant during the Participant’s lifetime. This total aggregate dollar amount includes
all benefits received from any portion of the City of Fort Collins Group Health Plan, including POS and
PPO.
Limits means any provision, other than an Exclusion, which restricts Coverage under the Plan,
regardless of Medical Necessity.
Location of Care means the setting in which Covered Services, appropriate for the Participant’s current
Level of Care, are provided. Terms commonly used to identify locations of care include, but are not
limited to: Physician’s office, outpatient department or facility, emergency room or facility, general/Acute
Care Hospital, rehabilitation Hospital, psychiatric Hospital, specialty Hospital, Skilled Nursing Facility, and
home.
Maintenance Care means all services that are provided solely to maintain a patient’s condition at the
level to which it has been restored or stabilized, and from which level no significant practical improvement
can be expected.
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POS Summary Plan Description, 1/1/04
Medical Director means the Physician so named by the Plan Supervisor as the Medical Director, or his
or her designee.
Medically Necessary means an intervention that is a covered category of service and is not specifically
excluded. An intervention may be medically indicated yet not be a covered benefit or meet the definition
of Medically Necessary. An intervention is Medically Necessary if, as recommended by the treating
Physician and determined by the Medical Director of the Plan Supervisor or the Network medical group, it
is all of the following:
(a) a health intervention for the purpose of treating a medical condition; and
(b) the most appropriate supply or level of service, considering potential benefits and harms to the
Participant; and
(c) known to be effective in treating the medical condition. For existing interventions, effectiveness is
determined first by scientific evidence, then by professional standards, then by expert opinion. For
new interventions, effectiveness is determined by scientific evidence; and
(d) if more than one health intervention meets the requirements of (a) through (c) above, furnished in the
most cost-effective manner which may be provided safely and effectively to the Covered Person.
In applying the above definition of Medical Necessity, the following terms shall have the following
meanings:
i. A health intervention is an item or service delivered or undertaken primarily to treat (that is,
prevent diagnose, detect, treat or palliate) a medical condition or to maintain functional ability. A
medical condition is a disease, illness, injury, genetic or congenital defect, pregnancy, or a
biological condition that lies outside the range of normal, age-appropriate human variation. A health
intervention is defined by the intervention itself, the medical condition and the patient indications for
which it is being applied.
ii. Effective means that the intervention can reasonably be expected to produce the intended results
and to have expected benefits that outweigh potential harmful effects.
iii. Scientific evidence consists primarily of controlled clinical trials that either directly or indirectly
demonstrate the effect of the intervention on health outcomes. If controlled clinical trials are not
available, observational studies that suggest a causal relationship between the intervention and
health outcomes can be used. Such studies do not by themselves demonstrate a causal
relationship unless the magnitude of the effect observed exceeds anything that could be explained
either by the natural history of the medical condition or potential experimental biases. For existing
interventions, the scientific evidence should be considered first and, to the greatest extent possible,
should be the basis for the determinations of Medical Necessity. If no scientific evidence is
available, professional standards of care should be considered. If professional standards of care do
not exist, or are outdated or contradictory, decisions about existing interventions should be based on
expert opinion. Giving priority to scientific evidence does not mean that Coverage of existing
interventions should be denied in the absence of conclusive scientific evidence. Existing
interventions can meet the definition of Medical Necessity in the absence of scientific evidence if
there is a strong conviction of effectiveness and benefit expressed through up-to-date and
consistent professional standards of care or, in the absence of such standards, convincing expert
opinion.
iv. A new intervention is one which is not yet in widespread use for the medical condition and patient
indications being considered. New interventions for which clinical trails have not been conducted
because of epidemiological reasons (i.e., rare or new diseases or orphan populations) shall be
evaluated on the basis of professional standards of care. If professional standards of care do not
exist, or are outdated or contradictory, decisions about such new interventions should be based on
convincing expert opinion.
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POS Summary Plan Description, 1/1/04
v. An intervention is considered cost effective if the benefits and harms relative to costs represent an
economically efficient use of resources for patients with this condition.
Medicare means Part A (Hospital coverage) and Part B (Physician coverage) of the insurance program
established by Title XVIII, United States Social Security Act, as later amended, 42 U.S.C. Sections 1394,
et seq.
Network Provider means any Physician, Physician specialist, Skilled Nursing Facility, individual,
organization, agency or other provider who/which has entered into a contractual arrangement with the
Plan Supervisor for the provision of Covered Services to Participants in accordance with the Plan. The
Plan Supervisor may contract with a provider for a specified member, a specified period of time and/or a
specified service. In that case, the provider is a Network Provider only for the service(s) contracted
and/or for the designated period.
Open Enrollment Period means the period of time designated by the Employer during which Employees
may enroll for Coverage under the Plan and enrolled Employees amend their Coverage elections.
Participant means each eligible Employee, Retiree, Dependent and Qualified Beneficiary who is enrolled
to receive benefits from the Plan.
Physician means Physician and surgeon (M.D. or D.O) licensed to practice medicine in the state in which
he or she practices. The term Physician may include a dentist, podiatrist, chiropractor, certified nurse
midwife or nurse practitioner. Physician may also include licensed psychologists, licensed clinical social
workers or clinical specialist psychiatric registered nurses to the extent they are rendering services which
they are legally qualified and licensed to perform, and licensed practitioners rendering counseling and
therapy services under the direction and supervision of a licensed psychologist or M.D.
Physician Assistant means an individual who is qualified to provide patient services under the
supervision and responsibility of a Physician, and is currently certified by the state in which he or she
practices.
Plan means the City of Fort Collins Group Health Plan, as amended from time to time.
Plan Administrator means The City of Fort Collins.
Plan Documents means the legal documents encompassing the provisions of the Plan. These include
this summary plan description, the annual open enrollment booklet, the administrative services agreement
between the City of Fort Collins and the Plan Supervisor, the stop loss insurance contract between the
City and the stop loss insurance carrier, The City of Fort Collins Flexible Benefits Plan document and The
City of Fort Collins Group Health Plan Document.
Plan Sponsor means the City of Fort Collins.
Plan Supervisor means the entity retained by the City of Fort Collins for purposes of administering the
Plan’s provisions.
Plan Year means the period that begins January 1 and ends December 31 each year.
Preferred Drug List means a listing of brand name prescription medications that are provided by a
network pharmacy for a Copayment of $15 per thirty-day supply (to 100 tablets) or $30 per three-month
supply through the mail order prescription drug program. This list is subject to change by the Plan
Supervisor.
Primary Care Physician means a Physician so designated by the Plan Supervisor who:
supervises, coordinates and provides medical care to Covered Persons; and
maintains continuity of patient care.
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POS Summary Plan Description, 1/1/04
Private Duty Nursing means full-shift continuous attention of a licensed nurse.
Qualified Beneficiary means a Participant who becomes eligible for Continuation Coverage.
Qualifying Event means an occurrence which triggers a person’s right to continuation of Coverage under
the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended.
Reasonable and Customary (R&C) Charges means the amount of a provider’s bill that can be
reasonably justified by the circumstances involved. Such circumstances include the Level of Care and
experience needed, the prevailing or common cost of the supplies and services and any other factors that
determine value. The determination and application of R&C Charges is made by the Plan Supervisor.
Reconstructive Surgery means surgery performed on abnormal structures of the body, caused by
congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally
performed to improve function, but may also be done to approximate normal appearance.
Redetermination of Status means the right and process by which the Plan Supervisor may review the
Level of Care to identify changes in a Participant’s status and prognosis. This may result in a different
determination of Level of Care and a different level of the Plan’s responsibility for covered benefits. Each
such determination will supersede earlier determinations and the Plan’s obligation for Coverage provided.
Rehabilitation Facility means a facility that is recognized by the Plan and licensed or certified to perform
rehabilitative health care services by the state or jurisdiction where services are provided. Services of
such a facility must be among the Covered Services recognized by the Plan.
Rehabilitative Care means the restoration of an individual to normal or near-normal function following a
disabling disease, injury or addiction.
Respite Care means the provision of infrequent and temporary substitute care in a patient’s home or
licensed facility for the purpose of relieving the patient’s family or other caregiver for unforeseen
emergencies and the daily demands of care for the patient.
Retiree means an Employee who has ten (10) or more years of eligible service completed with the
Employer in a classified position or an unclassified management position, and who is eligible to file for
receipt of retirement benefits, or who is totally and permanently disabled and has ten (10) or more years
of eligible service completed with the Employer in a classified position or unclassified management
position and has exhausted his/her COBRA continuation period.
Skilled Nursing Care means those home health services that:
can only be provided by an RN or LPN;
can produce the best possible and most timely outcome for a disease process and/or treatment
regimen according to a professional assessment and plan;
cannot be made available outside of the home because of the immediate home-bound nature of the
Covered Person;
can furnish reliable information to the Network Physician and the Plan Supervisor’s Medical Director
sufficient for proper determination of the status of the Participant’s condition and the Level of Care
required of that condition.
Skilled Nursing Facility means a lawfully operated institution for the care and treatment of persons
convalescing from an accidental bodily injury or illness which provides room and board and 24-hour
nursing service by licensed nurses and is under the full-time supervision of a legally qualified Physician or
a registered nurse.
Spouse means a husband or wife, as recognized by Colorado state law.
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POS Summary Plan Description, 1/1/04
Subacute Care Facility means a facility which provides a pattern of health care in which a patient is
treated for an ongoing condition as a result of an acute injury or illness. A subacute facility specializes in
care which does not require acute hospitalization but is more intensive than can be provided in a Skilled
Nursing Facility.
Subrogation means the assumption by a third party of another’s legal right to collect a debt or damages.
Substance Abuse means intentional habitual and excessive misuse of alcohol or drugs resulting in the
need for medical treatment.
Terminally Ill Patient means a Participant with a life expectancy of six months or less as certified in
writing by a Physician.
OTHER IMPORTANT PLAN INFORMATION
Plan Sponsor: The City of Fort Collins is the sponsor of this self-funded health Plan. If you have
questions about eligibility or if you wish to appeal a claim decision made by the Plan Supervisor you may
address correspondence to:
Benefits Administrator
Human Resource Department
City of Fort Collins
PO Box 580
Fort Collins, CO 80522
Phone: (970) 221-6535
Plan Supervisor: Great-West Health Care is the designated Plan Supervisor, which pays claims,
administers the provider network through One Health Plan, provides utilization review and case
management services, and provides prescription drug benefits through AdvancePCS. Questions about
specific plan provisions or particular claims, including prescription drugs, should be addressed
to:
Great-West Health Care
PO Box 11111
Fort Scott, KS 66701
Phone: 800-663-8081
Group Number: 359613
Provider Credentialing: If any of your providers do not participate currently with the One Health Plan
Network, you may wish to encourage your provider(s) to join the network. Information for prospective
providers is available at www.onehealthplan.com, along with the application to join the network.