HomeMy WebLinkAboutCORRESPONDENCE - RFP - P928 CONSULTING SERVICES TO REVIEW MARKET ANALYSIS AND EMPLOYEE BENEFITS PRACTICES (3)City of Fort Collins Group Health Plan 1
PPO Summary Plan Description, 1/1/04
SUMMARY PLAN DESCRIPTION
CITY OF FORT COLLINS GROUP HEALTH PLAN
PREFERRED PROVIDER OPTIONS
PPO 1 AND PPO 2
EFFECTIVE DATE: JANUARY 1, 2004
City of Fort Collins Group Health Plan 2
PPO Summary Plan Description, 1/1/04
CITY OF FORT COLLINS
PPO OPTIONS
SUMMARY PLAN DESCRIPTION
TABLE OF CONTENTS
SECTION PAGE
Schedule of Benefits 3
Introduction 4
Eligibility 5
Enrollment 5
COBRA Continuation of Benefits 8
Family and Medical Leave Act (FMLA) 10
Newborns’ and Mothers’ Health Protection Act 10
Women’s Rights and Cancer Health Act 11
Coverage during Leave for Military Service 11
Cost Containment Features 11
Benefit Provisions 13
Covered Expenses 14
Maximum Benefits 19
General Exclusions and Limitations 19
How to Claim Benefits 23
Appeals 27
Definitions 27
Other Important Information 32
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SCHEDULE OF BENEFITS
CITY OF FORT COLLINS GROUP HEALTH PLANS
PPO OPTIONS 1 AND 2
Plan Benefits are based on a calendar year, January 1 – December 31.
Charges for Eligible Covered Services Option 1 Option 2
Deductible/person/year
Preferred Provider $ 750 $ 200
Non-Preferred Provider $1,500 $ 500
Coinsurance Paid by Plan
Preferred Provider 80% 80%
Non-Preferred Provider 60% R&C 60% R&C
Annual Individual Out-of-Pocket Maximum (including Deductible)
Preferred Provider 2004: $2,000 2004: $1,450
Non-Preferred Provider 2004: $2,750 2004: $2,000
Preferred Provider charges are not applied to Non-Preferred Provider Deductibles or Out-of-Pocket
Maximums, and vice versa.
Family Out-of-Pocket Maximum is met when two covered persons each satisfy the individual Out-of-
Pocket Maximum.
Failure to obtain required precertification: benefits reduced to 50% of eligible charges.
Maximum Benefit per Participant (all Plan options combined, $2,000,000
including POS)
Annual Maximum Benefit per Medicare-Eligible
Retiree (all Plan options combined including $100,000 (includes $5,000 for
POS) prescription drugs)
Prescription Drugs: Benefits are paid according to a separate benefit formula, which is the same for both
Options 1 and 2. Amounts paid for prescription drugs are not included in meeting Deductible/
Coinsurance requirements for non-prescription charges. The Plan uses a preferred list of medications to
determine the level of benefit paid.
Deductible/person/year $50
Copayment for up to 30-day Supply
Generic $ 8 or 10% of total charge, whichever is greater.
Preferred Brand $15 or 20% of total charge, whichever is greater.
Non-preferred Brand $30 or 30% of total charge, whichever is greater.
Copayment for 90-day Mail Order Supply
Generic $16
Preferred Brand $30
Non-Preferred Brand $60
All eligible charges are subject to the Deductible requirement. The Plan Participant is responsible for charges in excess of
Reasonable and Customary (R&C) charges. This schedule is for illustrative purposes only, and is not a substitute for the complete
Summary Plan Description (SPD) or Plan Document. This SPD is an integral part of the formal Plan Document. No Participant shall
accrue any rights because of any statement in or omission from this Schedule. Benefit provisions and Employee contribution
amounts are subject to change. Consult the full SPD for benefit restrictions and limitations.
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INTRODUCTION
This Summary Plan Description (SPD) describes benefits in effect January 1, 2004. The City of Fort
Collins Health Plan (“Plan”) is self-funded, so that the City of Fort Collins (“City”) provides direct funding
for claims payment and administrative costs. If an individual’s claims exceed $120,000 in a Plan Year
(this amount is subject to change), excess charges are paid through a separate stop-loss insurance
contract. Plan administration is conducted by 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, or PBM).
The Plan provides you and your enrolled Dependents with coverage for a variety of eligible services.
Under this Plan, you have the option of enrolling in a high ($750 for PPO 1) or low ($200 for PPO 2)
Deductible option. The Plan is a PPO (Preferred Provider Organization) Plan, which enables you to use
Preferred or Non-Preferred Providers. Generally, claim payment is based solely on whether the provider
is Preferred or Non-preferred. Only under extraordinary circumstances, such as Emergency situations,
might charges incurred through a Non-Preferred Provider be paid on a Preferred Provider basis.
Therefore, it is necessary that you confirm, even in Emergency situations, Preferred Provider Status
before any charges are incurred. Higher Deductibles and Coinsurance maximums are applied to services
obtained from Non-Preferred Providers.
Preferred Providers agree to provide services for reduced fees; therefore, you generally save money
when you use a Preferred Provider. Non-Preferred Providers do not enter into such agreements;
therefore, your cost for using these providers may be higher. Nonetheless, the choice of provider is yours,
but you are responsible for verifying with your provider whether he/she is a Preferred Provider in
order to avoid unnecessary charges. 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.
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 Summary Plan Description (SPD) and become familiar with the terms,
conditions and limitations of the Plan in order to avoid benefit reductions.
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 and any applicable law, the
applicable law shall govern. As Plan Sponsor, the City relies on guidance from the Third Party
Administrator (TPA), 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 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; contributions are subject to change.
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 Participants, 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.
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PPO Summary Plan Description, 1/1/04
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, and Retiree.
An eligible contract Employee is anyone whose specific employment contract states that he/she is eligible
for City-sponsored medical insurance. An eligible Retiree is an Employee who retires after completing ten
or more years of covered service with the City or other agency listed in the paragraph above; 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 eligible your Spouse and eligible Dependent children, as defined on page 28 of this
booklet. No other persons are eligible for enrollment.
Grandchildren, including children born to a Dependent child of the Employee, are not eligible for
coverage, unless the Employee adopts or assumes legal guardianship of the grandchild.
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 25-26
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.
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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. To retain the ability to enroll
under the Special Enrollment provisions, an Employee who waives coverage must state in writing the
reason coverage is being waived.
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 Plan is
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
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 a Qualified Medical Child
Support Order.
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PPO Summary Plan Description, 1/1/04
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 6). If you enroll a
Dependent after the initial thirty-one (31) day eligibility period, the Dependent will be subject to the pre-
existing condition limitation (see page 14), except in the case of Special Enrollment (see page 6).
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.
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 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 on page 8.
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.
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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. This notice gives only a summary
of your COBRA Continuation Coverage rights. 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; the cost is 102% of the premium equivalent for active
Employees.
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
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
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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.
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. Your cost is 150% of the
premium equivalent for active Employees.
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
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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.
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 Hospital 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
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the mother, from discharging the mother or her newborn child earlier than 48 hours (or 96 hours, if
applicable).
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 more
information, call your 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 or coverage as
provided USERRA if greater.
When you are honorably 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 provides value in exchange for our health care
dollars, the Plan uses several cost containment techniques. Failure to comply with the Plan’s cost
containment requirements could result in additional cost to you. Failure to obtain a required
preauthorization reduces benefits to 50%. These cost containment features include:
Preferred Provider network
Hospital pre-admission certification program
Utilization review/case management
Prescription benefit management
Hospital self-audit program
The Preferred Provider Network enables the Plan to contract with certain providers for negotiated fees
that are generally lower than fees in the open market. If you select a provider who belongs to the
Preferred Provider network, the Plan’s savings are passed along to you in the form of lower Coinsurance
costs. You are certainly free to use any provider you wish; however, your use of Non-Preferred Providers
will require generally that you pay a larger portion of the cost for services. The Plan utilizes the One
Health Plan Managed Care Network for Preferred Providers. Call your provider directly to determine
whether he/she is a Preferred Provider. The One Health Plan Directory is always subject to change, and
may not reflect the most current information. You may also check the One Health Plan website:
www.onehealthplan.com.
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The Hospital Pre-Admission Certification Program requires each inpatient Hospital stay (Preferred or
Non-preferred) to be precertified BEFORE you go to the Hospital. This precertification program is
administered by One Health Plan. If you do not precertify your inpatient Hospital admission, your
inpatient Hospital benefits will be to 50% of eligible Charges.
Non-Emergency Hospital Admissions When your Physician recommends an inpatient Hospital
stay, you must call One Health Plan at 1-800-850-1899. Be prepared to identify yourself as a
Participant in the City of Fort Collins Group Health Plan, and provide your name and 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
the 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 Hospital 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 a Hospital 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. Please remember: One Health Plan
determines only whether a service is appropriate, and not whether a service is actually covered by
the Plan. Please call Great-West, Inc. to verify whether a specific service is covered by the Plan.
Maternity Admissions and Care Remember to precertify with One Health Plan your maternity
admission. Otherwise, your benefits will be reduced to 50% of eligible Charges.
Prescription Benefit Management To help contain the cost of prescription drugs, the Plan has entered
into an agreement with a Prescription Benefit Manager, Advance PCS.
One of the services Advance PCS provides is called “preferred drugs”; with this program, Great-
West 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.
When you purchase medications from a participating pharmacy, use your identification card for quick
service.
For maintenance medications, a lower cost mail order prescription program is also available (see
page 17).
Hospital Self-Audit You can help the Plan contain health care costs by participating in this program. If
you receive a Hospital bill and you believe you are being charged for services or items you did not
receive, contact Great-West immediately and let them know your concerns. Then, call Human Resources
to obtain a Hospital Self-Audit form. If an overpayment has been prevented, you will receive 50% of
the amount saved to a maximum payment of $2,000.
City of Fort Collins Group Health Plan 13
PPO Summary Plan Description, 1/1/04
BENEFIT PROVISIONS
The Plan offers you two benefit Plan options from which to choose. Under either option of the Plan you
may use any Hospital or Physician you wish, including Non-Preferred (Non-PPO) Providers; however, you
generally receive a greater level of benefit for some expenses when you use a Preferred (PPO) Provider
who has entered into a contractual fee agreement. The Plan contracts with One Health Plan to provide a
Preferred Provider network. However, because the network directory is subject to change, you should
verify with your provider that he/she is a Preferred Provider before you obtain services.
Separate Accounting Preferred Provider and Non-Preferred Provider charges are accounted for
separately under the Plan; Preferred Provider charges are not applied toward Non-Preferred Provider
Deductibles and Out-of-Pocket Maximums and vice versa.
Benefit payments for services rendered by out-of-network Non-Preferred Providers are based on
Reasonable and Customary (R&C) charges that represent the prevailing rate in a geographic area.
Charges in excess of R&C limits are not covered by the Plan. In addition, you may refer yourself to a
specialist without a referral from your primary care Physician. Amounts that you pay for Deductible
charges or Coinsurance payments may be reimbursable through the City’s Health Care Flexible Spending
Account; please see the separate brochure for information on this Plan.
Deductible charges are paid on a calendar year basis, and apply to all covered expenses. There are
separate Deductibles for Preferred Provider and Non-Preferred Provider charges. Amounts paid for
Preferred Provider charges are not applied to the Non-Preferred Provider Deductible, and vice versa. 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.
The prescription drug Deductible is separate, and is not included for purposes of this Deductible.
Coinsurance is the percentage of covered charges you pay after satisfying your Deductible.
Coinsurance payments for Preferred Provider services are different from payments for Non-Preferred
Provider services. If you use a Preferred Provider, the Plan pays 80% of the provider’s contracted fee,
and you pay the remaining 20%. If you use a Non-Preferred Provider, the Plan pays 60% of R&C
charges and you pay the remaining 40% 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.
A Copayment is the fixed dollar amount you pay for prescription drugs, unless your cost of that drug is
subject to a percentage of the total cost.
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, the Plan will pay 100% of excess eligible charges for the balance of the Plan Year. There are
separate out-of-pocket maximums for Preferred Provider and Non-Preferred Provider charges. Amounts
paid toward the Preferred Provider Out-of-Pocket Maximum are not applied to the Non-Preferred Provider
Out-of-Pocket Maximum, and vice versa. The family Out-of-Pocket Maximum is satisfied when two family
members each satisfy the individual Out-of-Pocket Maximum. Amounts paid for prescription drugs are
not counted toward meeting this annual Out-of-Pocket Maximum. 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.
OPTION 1
Preferred Providers After you satisfy the calendar year Deductible of $750 per person in eligible
Preferred Provider charges, the Plan pays 80% and you pay 20% Coinsurance for additional covered
City of Fort Collins Group Health Plan 14
PPO Summary Plan Description, 1/1/04
charges. After meeting your Out-of-Pocket Maximum, the Plan will pay 100% of eligible Preferred
Provider charges for the remainder of the calendar year. Your individual maximum out-of-pocket cost per
year is:
2004: $2,000 ($750 Deductible + $1,250 Coinsurance)
Non-Preferred Providers After satisfying a separate calendar year Deductible of $1,500 per person in
eligible Non-Preferred Provider charges, the Plan pays 60% of R&C charges and you pay 40% of R&C
charges, plus charges over R&C limits. After meeting your Out-of-Pocket Maximum, the Plan will pay
100% of eligible R&C charges for the remainder of the calendar year. Your individual maximum out-of-
pocket cost per year is:
2004: $2,750 ($1,500 Deductible + $1,250 Coinsurance)
OPTION 2
Preferred Providers After you satisfy the calendar year Deductible of $200 per person in eligible
Preferred Provider charges, you pay 10% Coinsurance for additional covered charges. After meeting
your Out-of-Pocket Maximum, the Plan will pay 100% of eligible R&C charges for the remainder of the
calendar year. Your maximum out-of-pocket cost per calendar year is:
2004: $1,450 ($200 Deductible + $1,250 Coinsurance)
Non-Preferred Providers After satisfying a separate calendar year Deductible of $500 per person in
eligible Non-Preferred Provider charges, you pay 40% of R&C Coinsurance for additional covered
charges. After meeting your Out-of-Pocket Maximum, the Plan will pay 100% of eligible R&C charges for
the remainder of the calendar year. Your out-of-pocket cost per calendar year is:
2004: $2,000 ($750 Deductible + $1,250 Coinsurance)
Benefit Maximum For active Participants and Retiree Participants not eligible for Medicare, the Plan will
pay up to $2,000,000 in covered 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 $2,000,000 maximum.
The benefit maximum is an aggregate, and applies to all periods of coverage under the Plan, including
the Point-of-Service Options and including charges from both Preferred and Non-Preferred Providers.
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 expenses.
Payment for Non-Preferred Provider services is limited by Reasonable and Customary (R&C) amounts;
charges over and above R&C limits are your responsibility. References to maximum benefits include all
benefits received at any time of participation under Option 1, Option 2, from either PPO or Non-PPO
Providers and benefits provided in any way under the Point-of-Service Options.
Pre-existing Conditions are defined as conditions for which you have received medical treatment or
have incurred expenses within the three months immediately preceding your effective date of coverage
under the Plan. Generally, pre-existing conditions are not covered during the first six months of coverage
under the Plan; however, if no treatment is received for the pre-existing condition during the first three
months of participation under the Plan, the pre-existing condition shall be eligible for reimbursement
under the Plan. For purposes of the Plan, the pre-existing condition limitation does not apply to
pregnancy, newborn Dependent children or adopted Dependent children who have been enrolled within
thirty-one (31) days of the eligibility date under this Plan, or for adopted children placed for adoption or
children qualifying under a Qualified Medical Child Support Order.
City of Fort Collins Group Health Plan 15
PPO Summary Plan Description, 1/1/04
The Health Insurance Portability and Accountability Act (HIPAA) places limits on pre-existing condition
limitations. If you and your eligible Dependents had creditable coverage under another plan and did not
experience a break in coverage, that period of prior coverage is counted toward meeting the 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 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; all expenses are subject to
Deductible and Coinsurance requirements. Without required preauthorization, benefits reduce to 50%
OUTPATIENT SERVICES
Physician Office Visits, including self-referral to specialists, for the diagnosis and treatment of covered
illness or injury.
Immunizations and Injections are covered for the treatment of illness or accidental bodily injury.
Routine Physical Exams are not covered, except to the extent provided under the guidelines for
mammography, pap smears, prostate screening and sigmoidoscopy (see below). Charges incurred for
routine laboratory and x-ray procedures are not covered.
Second/Third Surgical Opinions provided by a specialist or board certified surgeon who acts only as a
consultant. Second and third surgical opinions are not covered for: cosmetic or dental Surgery; minor
Surgery that may be performed in a Physician’s office; and Medicare-eligible Participants who refuse to
comply with Medicare’s second surgical opinion program.
Outpatient Surgery for the treatment of illness or accidental bodily injury is covered as an alternative to
inpatient admission. Covered expenses include eligible charges made by a Hospital or Outpatient
Surgical Center for the use of its outpatient facilities. Coverage of colonoscopy is based on Medical
Necessity and family history. Preauthorization is required to avoid benefit reduction to 50%.
Maternity Care includes Physician Charges for Pre-natal, Delivery and Post-natal Care.
Nursery Fees for newborn children when Medically Necessary.
Well-child Care Routine Pediatric Visits, including immunizations. Benefits are paid up to $350 for
charges incurred before the covered child’s first birthday, and $175 for charges incurred on or after the
covered child’s first birthday but before the second birthday. Services must be received within the
timeframes specified. Delays in obtaining Physician appointments do not warrant extensions.
Outpatient Diagnostic X-Ray and Laboratory: charges in addition to Physician office visit charges for
Medically Necessary X-ray and laboratory examinations for the diagnosis and treatment of an illness or
accidental bodily injury, including blood tests, allergy tests, basal metabolism determination,
electrocardiograms, thyroid profiles, electroencephalograms. Routine X-ray and laboratory procedures
are not covered. For colonoscopy, see Outpatient Surgery.
City of Fort Collins Group Health Plan 16
PPO Summary Plan Description, 1/1/04
Routine Mammography: the following guidelines apply to mammography - Participants age 35-39: one
baseline exam; Participants age 40-49: one screening every two years; Participants age 50 and over: one
screening each year; or any Medically Necessary screening due to family history, regardless of age.
Prostate Screening and Sigmoidoscopy: the following guidelines shall apply to prostate screening
(PSA): men age 40 and under: one screening; men age 41-49: one screening every two years; men age
50 and over: one screening each year. These same guidelines also apply to sigmoidoscopy for all
Participants, including women. Any Medically Necessary prostate screening and sigmoidoscopy due to
family history is provided regardless of age or gender. For colonoscopy, see Outpatient Surgery.
Pap Smears are provided annually for routine screening.
Hearing tests and audiograms for the purpose of diagnosing illness or accidental bodily injury.
Speech and Hearing Therapy (including diagnostic testing) to improve speech and hearing ability or loss
due to developmental disorders or deficiencies due to illness or injury. Benefits in excess of $500 must
be pre-approved by the Plan. Benefits are payable up to an aggregate limit of $5,000 per Participant; this
maximum includes any and all benefits received at any time from Preferred and Non-Preferred Providers
under Option 1 and Option 2 combined.
Short-Term Occupational and Physical Therapy Performed on an Outpatient Basis is provided for
up to two consecutive months, when prescribed by a Physician in whose judgement significant
improvement can be obtained. Additional benefits must be certified by the attending Physician as
Medically Necessary. Occupational Therapy may be performed by a properly accredited Occupational
Therapist (OT) or a Certified Occupational Therapy Assistant (COTA). Physical Therapy may be
performed by a Physician or a registered physical therapist.
Chiropractic Services are covered up to one visit per day to a maximum of thirty visits per Participant
per calendar year.
Acupuncture is covered when Medically Necessary and administered by a licensed medical doctor (MD).
Prescription Drugs are provided on an outpatient basis through Advance PCS, which is affiliated with
Great-West Health Care, and benefits are the same for Options 1 and 2. Questions about outpatient
prescription drug claims should be addressed to Great-West Health Care
After satisfaction of a separate calendar year Deductible of $50 per person, you pay only a
Copayment for each prescription during the balance of that calendar year. One Copayment is required
for each thirty-day supply of a prescription drug, to a maximum 100 tablets. You should remember that
discounts are available through participating pharmacies and through the mail order prescription drug
program.
The Plan utilizes a preferred drug list to determine the amount you pay for your medications. Your
Copayment is based solely on whether your medication is generic, a preferred brand or a non-preferred
brand. Greater savings are generally available by using generic medications; consult with you Physician
to determine whether a generic medication would be appropriate for your treatment.
Under the “Preferred Drug” program, Great-West Health Care is required by the Plan to suggest (but not
to require) the use of lower cost alternative medications that might be appropriate for your care. Only
those medications prescribed for the treatment of a covered condition are eligible for coverage. The
preferred drug list is subject to change periodically, and a drug’s classification may change
during a Plan Year.
Under our 3-tier formulary structure, your Copayments are:
generic: you pay the greater of $8 or 10% of the total cost.
City of Fort Collins Group Health Plan 17
PPO Summary Plan Description, 1/1/04
preferred brand: you pay the greater of $15 or 20% of the total cost.
non-preferred brand: you pay the greater of $30 or 30% of the total cost.
Mail Order Program: by utilizing the prescription drug mail order program, you may purchase a three-
month supply of your maintenance medication for two Copayments per medication. Mail order
prescriptions are not subject to Deductible charges and are not subject to a percentage of the
medication’s cost. A maintenance medication is a prescription that is taken for at least 90 consecutive
days for the treatment of a chronic condition, e.g., blood pressure, cholesterol or birth control, etc.. Acute
care medications (e.g., antibiotics) are not eligible for the mail order program. Remember to place your
mail order prescription in time to avoid an interruption in the supply of your medication. Additional
information is available at the Human Resources Office. Mail order Copayments per medication are:
generic: $16
preferred brand: $30
non-preferred brand: $60
Outpatient Mental Health care is provided, up to a maximum of thirty visits per person per calendar year.
Services are also available through the separate Employee Assistance Program (EAP). You may reach
the EAP at 1-800-284-1819.
Outpatient Substance Abuse Treatment is covered to a maximum of $2,000 per covered person per
calendar year; these benefits are included in the combined lifetime maximum benefit of $25,000 per
Participant for inpatient plus outpatient Substance Abuse services. The aggregate benefit maximum shall
include all eligible charges incurred under any portion of the Plan, including charges incurred under
Option 1 and/or Option 2, and charges incurred with Preferred and/or Non-Preferred Providers. Services
are also available through the separate Employee Assistance Program (EAP). You may reach the EAP at
1-800-284-1819.
INPATIENT/HOSPITAL SERVICES
Inpatient Hospital Admissions are covered for the Medically Necessary services prescribed by a
Physician. Covered charges include: semi-private room and board (a private room is provided if
Medically Necessary); confinement in an Intensive Care Unit; operating room, delivery room and recovery
room charges; nursing and other professional care charges; inpatient X-ray, laboratory, EKG, therapeutic
and diagnostic services; the administration of blood and blood plasma; medications; Physical Therapy,
casts and dressings. Preauthorization is required, or benefits are reduced to 50%.
Newborn Nursery Charges are provided, subject to Medical Necessity.
Inpatient Physician services are provided, including Physicians’ and surgeons’ services, surgical
assistants and anesthesia. When Medically Necessary, coverage of assistant surgeon’s fees is provided
up to 20% of the surgeon’s fee; coverage of Medically Necessary Physician Assistant fees is provided up
to 10% of the surgeon’s fee.
Emergency Room Services are provided for the treatment of accidental injury or the sudden and
unexpected onset of a condition requiring immediate medical or surgical care. Without immediate
treatment, Emergency situations could result in a more serious health condition or death. Emergency
Room services are not provided as a convenience. Conditions that do not require immediate attention
but could wait for treatment by your personal Physician are not considered emergencies. The Plan is not
authorized to pay Emergency benefits for non-Emergency situations; therefore, the improper use of
Emergency services could result in substantial charges for which you alone would be responsible.
Inpatient Mental Health Services are covered up to a lifetime maximum of 100 days per Participant.
Two days of partial hospitalization shall equal one day of hospitalization for purposes of the maximum
days permitted. Preauthorization is required, or benefits are reduced to 50%.
City of Fort Collins Group Health Plan 18
PPO Summary Plan Description, 1/1/04
Inpatient Treatment of Substance Abuse is covered up to $25,000 per lifetime per Participant. This
benefit maximum shall include also any payment for outpatient treatment of Substance Abuse. The
aggregate benefit maximum shall include all eligible charges incurred under any portion of the Plan,
including charges incurred under Option 1 and/or Option 2, and charges incurred with Preferred and/or
Non-Preferred Providers. Preauthorization is required, or benefits are reduced to 50%.
OTHER SERVICES
Ambulance Service is provided when Medically Necessary for transportation to the Hospital and to
transfer from one Hospital to another for inpatient care.
Home Health Care is covered when prescribed by a Physician, pre-certified by One Health Plan
Managed Care and provided by health care professionals for care related to a condition for which you
might otherwise be hospitalized. The Plan provides coverage for Medically Necessary services and
supplies furnished on a visiting basis in a private residence by a certified Home Health Care provider.
Such covered services and supplies include: professional nursing services, supervised home health
aide services, physical/occupational/speech/respiratory/ rehabilitation therapy, medical services and
supplies provided by or through a Home Health Care agency, and nutrition counseling provided by or
under the supervision of a registered dietitian. One home health visit per day is provided, up to 100 visits
per calendar year. Each visit of four hours or less shall count as one visit. For Visits exceeding four
hours, each four hours or portion thereof shall be considered a separate visit.
Hospice Care is covered, if a Physician certifies that you or one of your covered Dependents is terminally
ill. For purposes of this section, a Terminally Ill Patient is a patient who is expected to live 180 days or
less; this limitation may be recertified when Medically Necessary. Covered services include: inpatient
confinement in a hospice facility; Physician services; physical/occupational/speech/hearing/respiratory/
inhalation therapy or a home health aide supervised by a registered nurse or specialized rehabilitative
therapist; professional services provided by (or under the supervision of) a registered nurse; prescription
drug therapy for pain control; eligible Durable Medical Equipment and Medically Necessary supplies;
nutrition counseling by a nutritionist or dietitian; homemaker services; medical social services; emotional
support services; bereavement counseling by a licensed social worker or pastoral counselor (up to $250);
Respite Care to immediate family members on a short-term basis so that the Terminally Ill Patient may
remain an outpatient.
Skilled Nursing Facility services following an inpatient hospitalization are provided for Medically
Necessary care prescribed by a Physician; the Physician must certify that these services are Medically
Necessary and provided in lieu of hospitalization. Services of a private duty nurse or Physician are not
included. Plan benefits are payable for up to 60 days per confinement at 50% of the immediately
preceding Hospital’s semi-private room rate; if the Hospital does not have semi-private rooms, the limit is
45% of the daily charge for its lowest rate private room. Separate confinements due to the same or
related illness or injury are considered a single confinement, unless separated by complete recovery.
Durable Medical Equipment (DME) is designed for repeated use for a medical purpose, and is not
useful to a person in the absence of illness or injury. Purchase of DME is covered if rental is more
expensive. DME includes, but is not limited to, wheelchairs, Hospital beds, respirators, glucose monitors
or other similar equipment. Replacement of DME must be Medically Necessary and pre-authorized by
Great-West. However, the following items are not covered: air conditioners, humidifiers, dehumidifiers, air
purifiers and other similar items.
Appliances, Prosthetics and Supplies are covered when Medically Necessary and prescribed by a
Physician. Such items include but are not limited to: original prosthetic devices and Medically Necessary
replacements; splints, trusses, braces, crutches; oxygen; and hearing aids. The maximum benefit paid for
hearing aids is $750 per Participant every five years.
Outpatient casts, dressings and orthotics are covered when Medically Necessary and prescribed by a
Physician. The maximum benefit for covered orthotics is $250 per Participant.
City of Fort Collins Group Health Plan 19
PPO Summary Plan Description, 1/1/04
Footcare services are provided for Medically Necessary non-surgical treatment of chronic foot conditions.
There is a maximum benefit of $500 per Participant. A separate maximum of $250 per Participant is
payable for orthotics prescribed by a Physician.
MAXIMUM BENEFITS
The following benefit maximums are in effect for covered Medically Necessary charges received from
either Preferred or Non-Preferred Providers combined, and also includes any benefits received from the
Point-of-Service Plans. The aggregate benefit maximum per Participant is $2 million, under all PPO and
POS options, and Preferred and Non-Preferred Providers. Specific benefit maximums are listed below.
Benefit Maximums per Participant
1. 100 days for inpatient mental health treatment.
2. $25,000 per Participant for inpatient and outpatient Substance Abuse treatment combined under all
portions of the Plan, including Options 1 and/or 2 and Preferred and/or Non-Preferred Providers.
3. $5,000 per Participant for speech and hearing therapy.
4. $250 per Participant who is an immediate family member for Hospice bereavement benefits.
5. $500 per Participant for Medically Necessary, non-surgical treatment of chronic foot conditions.
6. $250 per Participant for orthotics prescribed by a Physician.
Calendar Year Benefit Maximums Per Participant
1. Thirty (30) visits for outpatient mental health disorders.
2. Thirty (30) visits per year for chiropractic treatment.
3. 100 Home Health Care visits.
4. 180 days for Hospice Care.
5. $2,000 for outpatient Substance Abuse.
6. $100,000 in benefits paid for each Medicare-eligible Retiree medical Plan Participant, including
$5,000 per year for covered prescription medications.
GENERAL EXCLUSIONS AND LIMITATIONS
The following expenses are not covered by the Plan, even though they may be Medically Necessary and
prescribed by a Physician.
1. Any charge not listed specifically as a covered expense.
2. Charges for medical expenses which are not prescribed by or provided by a Physician or other
covered provider.
City of Fort Collins Group Health Plan 20
PPO Summary Plan Description, 1/1/04
3. Charges exceeding Reasonable and Customary limits.
4. Expenses for which a Participant is entitled or could have been entitled to any benefits provided by
any governmental agency.
5. Expenses a Participant would not be obligated to pay, if the Participant were not covered under this
Plan.
6. Expenses for treatment that is not Medically Necessary.
7. Charges incurred before the Participant’s effective date of coverage.
8. Services and supplies resulting from illness or injury arising out of and occurring in the course of
employment.
9. Eye examinations or refractions, eye glasses, contact lenses or fitting of eye glasses or contact
lenses.
10. Medical benefits for dental services and supplies, unless for treatment of accidental damage to sound
natural teeth and expenses are incurred within one year of the date of the Accident.
11. Cosmetic, plastic or reconstructive Surgery, unless needed after an injury you have sustained while
covered by the Plan or because of a congenital disease or anomaly of a Dependent child covered
since birth which results in a functional defect or if needed for reconstructive Surgery following a
mastectomy or other Medically Necessary treatment that results in disfigurement.
12. Custodial Care, medical care or treatment and service or supply charges made by a nursing home,
rest home, convalescent home or similar establishment, except as specifically described herein.
13. Accidental injury or illness resulting from any act of war (declared or undeclared), except as required
by law.
14. Accidental injury or illness resulting from the release of nuclear energy, except when used for medical
treatment of a sickness or injury of a Participant under direction and prescription of a Physician.
15. Accidental injury or illness resulting from or occurring during the commission of a felony by a
Participant.
16. Expenses for learning deficiencies and special education, whether or not related to a mental disorder.
17. Expenses for milieu therapy or recreational therapy.
18. Orthopedic shoes or supportive devices for the feet, or non-Medically Necessary orthotics, which do
not require a Physician’s prescription, except as otherwise provided herein.
19. Services and supplies designed to facilitate conception, such as artificial insemination, in-vitro
fertilization and embryo transplantation; services for the treatment of sexual impotency; services for
the reversal of surgically induced infertility.
20. Humidifiers, air conditioners, exercise equipment, whirlpools, health spa or club memberships, or
swimming pools, whether or not prescribed by a Physician.
21. Intentionally self-inflicted injury or illness, including overdose of medication, unless the Participant is
under psychiatric care or immediately seeks psychiatric care.
22. Transsexual Surgery.
City of Fort Collins Group Health Plan 21
PPO Summary Plan Description, 1/1/04
23. Services that are provided by a person who ordinarily lives with the Participant or is a member of the
Participant’s immediate family, either by blood or through law.
24. Non-surgical treatment for the removal of corns or the trimming of callus or toenails, and strapping,
but not including Medically Necessary Surgery and Medically Necessary treatment of the feet for
peripheral or vascular disease or diabetes, except as otherwise provided herein.
25. Weight loss, weight control programs, physical fitness programs or treatment (including Surgery) for
obesity, except morbid obesity as defined and when pre-authorized. Surgical treatment of morbid
obesity is excluded in any event.
26. Charges incurred for a pre-existing condition, except as described on page 14.
27. Charges for orthoptics or vision training.
28. Laetrile, enzymes and food supplements.
29. Treatment or services in connection with Premenstrual Syndrome (PMS).
30. Charges in connection with radial keratotomy, including all laser eye Surgery and automated
keratoplasty.
31. Chelation therapy.
32. Experimental or Investigative procedures as described in this SPD.
33. Insulin pumps, monitoring devices and other devices, other than pacemakers, that can be
permanently implanted.
34. Travel expenses for a Participant or a Physician.
35. Preparation of medical reports or itemized bills.
36. Telephone consultations.
37. Wigs and artificial hairpieces.
38. Personal convenience items, education materials, and classes.
39. Court ordered classes or treatments.
40. Lamaze classes.
41. Vocational rehabilitation.
42. Treatment or services not consistent with the diagnosis.
43. Treatment of growth hormone deficiency, except when determined Medically Necessary by medical
review.
44. Implantable and/or inflatable prosthesis and replacement of breast implants, except following a
mastectomy.
45. Smoking cessation substances, programs and devices.
City of Fort Collins Group Health Plan 22
PPO Summary Plan Description, 1/1/04
46. Massage therapy rendered by a massage therapist, unless directly supervised by a licensed physical
therapist; self-help and stress management; and exercise stress testing.
47. Expenses for Occupational Therapy that retrains an individual for a job or career, Physical Therapy or
speech therapy except as outlined under the section of this booklet entitled “Covered Expenses.”
48. Replacement of Durable Medical Equipment or prosthetic devices, unless Medically Necessary.
49. Examinations or consultations for or in connection with cosmetic purposes.
50. Charges for Hospital, surgical and related expenses incurred by a person for whom Medicare is
primary payer, when the person does not comply with Medicare’s mandatory Second Surgical Option
Program.
51. Elective abortions, except when necessary for the mother’s welfare or necessary due to severe
chromosomal abnormalities or malfunctions not compatible with life.
52. Treatment of pain, limitation of motion and other functional defects of the jaw and TMJ.
53. Charges in connection with the alleviation of chronic pain in excess of the charges that would be
payable to a Physician or Hospital.
54. Charges in connection with biofeedback, unless prescribed by a licensed Medical Doctor (M.D.) and
performed by a covered provider for a covered diagnosis, or hypnotherapy.
55. Any charges incurred through Medicare private contracting arrangements.
56. Charges for human organ and/or tissue transplants, including but not limited to, donor screening,
acquisition and selection, organ or tissue removal, transportation, transplantation, post operative
services and drugs or medicines, and charges related to nonhuman (Xenografted) organ and/or
tissue transplants or implants, except heart valves; charges related to high dose chemotherapy with
autologous or allogenic bone marrow transplantation; except charges related to the transplantation of
the kidney or the cornea. This exclusion does not limit in any way the Organ and Bone Marrow
Transplant benefits which may be available through a separate insurance contract.
57. Acupuncture, unless performed by a licensed medical doctor (M.D.).
58. Certain outpatient prescription charges are not covered, including but not limited to: drugs or
medications that are procurable without a Physician’s written prescription; immunization agents,
biological sera, blood or blood plasma; Minoxidil (Rogaine) for the treatment of alopecia; infertility
medications; injectable allergy extracts; dietary supplements; anorectics for individuals over age
twenty-five (25); charges for the administration or injection of any drug; therapeutic devices, or
appliances, including needles, syringes, support garments, appliances, prosthetics, bandages, heat
lamps, braces, splints, and other non-drug items, regardless of intended use; smoking cessation aids;
medications used to treat impotence; drugs labeled “Caution – limited by federal law to investigational
use,” or Experimental drugs, even though a charge is made to a Participant. There are other
outpatient medications which also require prior authorization. This means a letter would need to be
written by the prescribing Physician indicating a diagnosis and the name of the medication. This list
includes but is not limited to: growth hormones; drugs used to treat cosmetic indications;
immunosuppressants and drugs used for chemotherapy. For information on preauthorizations, call
Great-West Health Care directly.
59. Charges resulting from excluded charges, including but not limited to complications.
City of Fort Collins Group Health Plan 23
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HOW TO CLAIM BENEFITS
Preferred Providers (PPO)
To claim Preferred Provider benefits under the PPO option, 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 PPO 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 PPO 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.
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 for the Deductible and Coinsurance not paid
by the Plan. If a Preferred Provider requires full payment at the time of service, you should contact One
Health Plan Customer Service at 1-800-663-8081.
Hospital Claims. PPO 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 Hospital 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 PPO option. Be certain to
complete all necessary forms presented to you. The Hospital will send the claim directly to the Claims
Administrator for payment, and payment will be made directly to the Hospital.
Remember: you are responsible for specifying that you seek benefits under the Plan’s PPO option. If
you do not, benefits may be paid on a non-PPO basis and you will be responsible for additional charges
that are not covered or paid by the Plan.
Non-Preferred Providers
A claim for Non-Preferred Provider Hospital, medical, surgical and prescription drug expenses or
questions relating to the payment of a claim should be directed to the Claims Administrator. You will need
to complete the required claim form and obtain invoices from your providers. Upon receipt of this
information, file the claim directly with the Claims Administrator at the following address:
Great-West Health Care
PO Box 11111
Fort Scott, KS 66701
To file a claim for Non-Preferred 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. 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 at the address shown above. Bills should include the following
information on the provider’s letterhead stationery:
name of the individual for whom expenses were incurred;
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PPO Summary Plan Description, 1/1/04
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 participating pharmacy or a non-participating 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, you do not have to submit an additional claim form if your bills are for a continuing disability and
you have filed a claim within the past three calendar months. Mail to Great-West any further itemized bills
with diagnosis and breakdown of charges for any medical or Hospital services covered by the Plan as
soon as you receive them. Be sure that your name, date of birth, social security number and address
appear on the bills.
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 Hospital 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
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. 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. You should submit a copy of your EOB when filing claims under the separate medical
Flexible Spending Account.
Reporting Changes by Participants
It is important that the Claims Administrator or the City’s Human Resources Department be notified
whenever a change in any of the following occurs:
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PPO 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. Questions about Plan provisions should be directed
to Great-West Health Care
Plan Provisions: if you have any questions about specific Plan provisions or claim payments, you should
contact Great-West Health Care at 1-800-663-8081; be sure to have the Employee’s social security
number handy.
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. Benefits
payable under another plan include the benefits that would have been made payable had a claim been
filed.
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.
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.
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PPO Summary Plan Description, 1/1/04
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
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 an individual’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. Future benefits could be
suspended until recovery is made.
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
Prior to July 1, 2003, the State of Colorado required no fault automobile insurance, including medical
coverage. The Plan assumed that Participants are covered for the required level of medical insurance
City of Fort Collins Group Health Plan 27
PPO Summary Plan Description, 1/1/04
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 exceeded the required level of coverage,
this Plan would 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. 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.
Claims Administrator means the organization responsible for calculating and preparing benefit
payments for the Plan.
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PPO Summary Plan Description, 1/1/04
Coinsurance means the amount, expressed as a percentage, of a covered expense that is paid by the
Participant.
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.
Custodial Care means care, including confinement, which is given to a patient when there is no active
plan of treatment to improve the patient’s physical, functional or medical condition; or when there is an
active plan of treatment, the patient has attained his/her maximum level of physical, functional or mental
ability, and the plan of treatment cannot be reasonably expected to significantly improve the person’s
condition. “Custodial Care” includes, but is not limited to, care primarily given to help the patient in the
activities of a normal daily life. The determination that care is “Custodial Care” in no way implies that the
care or confinement is not required by the patient; it only means that no benefits for such are payable by
the Plan.
Deductible means a specified amount of money that the Participant is responsible for paying prior to
receiving reimbursement of a covered expense.
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 an accredited high school, college, university or vocational, technical or trade school on a full-
time basis); 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. Grandchildren,
including children of Dependent children, are not eligible for coverage unless the Employee assumes
legal guardianship of or adopts the grandchild. Proof of dependency status may be required from time to
time by the Employer.
Durable Medical Equipment (DME) means medical equipment that is designed for repeated use, is used
primarily to serve a medical purpose, and is not useful to a person without an illness or injury. DME must
be prescribed by a Physician and must be Medically Necessary. Examples of Durable Medical
Equipment include wheelchairs, Hospital beds, glucose monitors and respirators. Convenience items
such as air conditioners, humidifiers or air purifiers are not considered DME, even if prescribed by a
Physician as Medically Necessary.
Emergency means the sudden and unexpected onset of a medical condition with acute symptoms of
such severity that the absence of immediate medical attention could: place the Participant’s health in
serious jeopardy; result in the serious impairment of bodily functions; or result in serious dysfunction of
any bodily organ or part.
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PPO Summary Plan Description, 1/1/04
Employee means all classified Employees, unclassified management Employees, contractual Employees
whose specific employment contracts state that 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.
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.
Experimental/Investigative means any treatment, procedure, facility, equipment, drug, device, or supply
not accepted as standard medical practice in Colorado. In addition, if a federal or other government
agency approval is required for use of any items and such approval was not granted at the time service
were administered, the service is Experimental. To be considered standard medical practice and not
Experimental or Investigative, treatment must meet all five of the following criteria:
a technology must have final approval from the appropriate regulatory government bodies; and
the scientific evidence as published in peer-reviewed literature must permit conclusions concerning
the effect of the technology on health outcomes; and
the technology must improve the net health outcome; and
the technology must be as beneficial as any established alternatives; and
The improvement must be attainable outside the Investigative settings.
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 medical, health care and other services prescribed by a Physician for Terminally Ill
Patients to meet special physical and emotional needs so that the hospice patient may remain at home,
whenever possible. A hospice agency must be licensed by the state in which it is located and must meet
certification requirements, as required by Medicare.
Hospital means an institution primarily engaged in providing medical, diagnostic and surgical facilities for
the care and treatment of sick and injured persons on an inpatient basis, and which provides such
facilities under the supervision of a staff of Physicians and with a 24-hour-a-day nursing service by
registered nurses. A Hospital does not include any institution which is used principally as a rest facility,
nursing facility, convalescent facility or facility for the aged.
Intensive Care Unit means a section or wing within a Hospital that is operated for critically ill patients and
provides special supplies, equipment and supervision and care by a registered nurse or other trained
Hospital personnel.
Medically Necessary, Medical Necessity means tests, treatments, services or supplies provided by a
Hospital, Physician or other provider that the Plan determines to be:
appropriate for the symptoms or diagnosis and treatment of the Participant’s condition, disease,
illness or injury;
provided for the diagnosis or the direct care and treatment of the Participant’s condition, disease,
illness, or injury;
in accordance with standards of good medical practice within the medical community;
City of Fort Collins Group Health Plan 30
PPO Summary Plan Description, 1/1/04
not primarily for the convenience of the Participant, the Participant’s family or the Participant’s
provider;
the most appropriate level of services or supplies which can be provided safely.
The fact that a Physician or any other health care provider may order or recommend services, supplies or
treatment does not, of itself, make them Medically Necessary or establish Medical Necessity.
Medicare means the program of health care for the aged, end-stage renal disease (ESRD) beneficiaries,
and Disabled established by Title XVIII of the Social Security Act of 1965, as amended.
Non-Preferred Provider means any provider who has not contracted with the Plan to provide covered
services to Participants.
Occupational Therapy means the use of educational, vocational and rehabilitative techniques to improve
a patient’s functional ability to live independently.
Outpatient Surgical Center is a surgical facility, which is an appropriately licensed provider with an
organized staff of Physicians that meets all of the following criteria:
has permanent facilities and equipment for the primary purpose of performing surgical procedures on
an outpatient basis; and
provides treatment by or under the supervision of Physicians and nursing services whenever the
patient is in the facility; and
does not provide inpatient accommodations; and
is not a facility used primarily as an office or clinic for the private practice of a Physician or other
professional provider.
Participant means each eligible Employee, Retiree, Dependent and Qualified Beneficiary who is enrolled
to receive benefits from the Plan.
Physical Therapy means the use of physical agents to treat a disability resulting from disease or injury.
Examples of such physical agents include heat, cold, electrical currents, ultrasound, ultraviolet radiation,
massage (other than massage therapy) and therapeutic exercise.
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 that 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 Sponsor means The City of Fort Collins.
Plan Year means the fiscal period that begins January 1 and ends December 31 each year.
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PPO Summary Plan Description, 1/1/04
Preferred Provider means any Plan-recognized provider, corporation, organization or entity that has
contracted with the Plan to provide covered services to Participants.
Qualified Beneficiary means a Participant who becomes eligible for Continuation Coverage.
Qualifying Event means an occurrence that triggers a person’s right to Continuation Coverage under the
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, as amended.
Reasonable and Customary (R&C) means those charges for Medically Necessary services, supplies
and treatment that do not exceed the general level of charges made by others of similar standing in the
locality where the charge is incurred. The Plan bases its R&C amounts on data compiled by the Health
Insurance Association of America (HIAA).
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.
Respite Care means care that is furnished to a Participant when confined as an inpatient so that the
family unit may have relief from the stress of the care of the Participant.
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. Except for disabled Retirees, Retirees who elect COBRA cannot enroll for Retiree coverage
after the COBRA benefit period expires.
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.
Substance Abuse means intentional habitual and excessive misuse of alcohol or drugs resulting in the
need for medical treatment.
Surgery means the medical diagnosis and treatment of injury, deformity and disease by manual and
instrumental operations performed by a Physician.
Terminally Ill Patient means a Participant with a life expectancy of six months or less as certified in
writing by a Physician.
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PPO Summary Plan Description, 1/1/04
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 Claims Administrator, you
may address correspondence to:
Benefits Administrator
Human Resource Department
City of Fort Collins
PO Box 580
Fort Collins, CO 80522-0580
Phone: (970) 221-6535
Claims Administrator: Claims Administration is conducted by Great-West Health Care, which pays
claims, administers the participating 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 should be addressed to:
Great-West Health Care
PO Box 11111
Fort Scott, KS 66701
Phone: 800-663-8081
Group Number: 359613
If one or more of your providers does 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.