HomeMy WebLinkAboutVSP - CONTRACT - RFP - P902 BENEFITS (2)VISION SERVICE PLAN INSURANCE COMPANY
3333 Quality Drive
Rancho Cordova, California 95670
GROUP VISION CARE PLAN
ADMINISTRATIVE SERVICES PROGRAM
Group Name CITY OF FORT COLLINS COLORADO MUNICIPAL
CORPORATION
Plan Number 12063997
State of Delivery COLORADO
Effective Date JANUARY 1, 2004
Plan Term TWENTY-FOUR (24) MONTHS
Administrative Fee Due Date FIRST DAY OF MONTH
In consideration of the statements and agreements contained in the Group
Application and in consideration of payment by Group of the administrative fees and other
amounts due as herein provided, VISION SERVICE PLAN INSURANCE COMPANY
("VSP") agrees to provide certain individuals under this Group Vision Care Plan ("Plan")
the benefits provided herein, subject to the exceptions, limitations and exclusions hereinafter
set forth. This Plan is delivered in and governed by the laws of the State of Delivery and is
subject to the terms and conditions recited on the subsequent pages hereof, which are a part
of this Plan.
Gary Brooks, Senior Vice President, Operations
i
VSP-GVCP-ASP-6/99 DDM 10/16/03 Lsl
IV. OBLIGATIONS OF THE GROUP
4.01. Identification of Elieible Enrollees: An Enrollee is eligible for coverage under
this Plan, if he satisfies the enrollment criteria specified in Paragraph 6.01(a) and/or as mutually
agreed to by VSP and Group. Group shall provide monthly eligibility information to VSP in a
mutually agreed upon format and medium to identify all Enrollees who are eligible for coverage
under this Plan. Group will supply to VSP, on or before the last day of each month, eligibility
information sufficient to identify all Enrollees to be added to or deleted from VSP's coverage rosters
for the coming month. The eligibility information shall include designation of family status for each
such Enrollee, if dependent coverage is provided. Group shall, when requested, make available for
inspection by VSP records having a bearing on the coverage of Covered Persons under this Plan.
4.02. Claims Amounts and Advance of Payment: Group shall provide all funds
necessary to pay the Claims Amount associated with Covered Persons pursuant to this Plan. In
order to assure timely and adequate payment, Group agrees to make an Advance Payment as
outlined on the attached Schedule of Advance Payment and Administrative Fee, Exhibit B. This
Advance Payment is an estimate of the Claims Amount for one (1) month. Group agrees to pay the
actual Claims Amounts on a monthly basis within ten (10) days after receipt of VSP's statement.
The Advance Payment amount may be adjusted each Plan Term if the average of monthly Claims
Amount increases or decreases. The parties agree that such Advance Payment is reimbursable to
the Group upon termination of this Plan, after the Group's indebtedness to VSP and/or its benefit
providers has been satisfied. However, amounts paid to VSP as Advance Payment shall not be
considered assets of the Group, and need not be held in trust by VSP.
3
4.03. Administrative Fee: Additionally, on or before the first day of each month, Group
shall remit to VSP an Administrative Fee as outlined on the attached Schedule of Advance Payment
and Administrative Fee, Exhibit B. Change will not be made to the Administrative Fee during any
Plan Term unless there is a change in the Schedule of Benefits or a material change in any other
terms and conditions of the Plan, provided any such change is mutually agreed upon in writing
between VSP and Group.
Notwithstanding the above, VSP reserves the right to increase amounts due hereunder
during a Plan Term by the amount of any tax or assessment not now in effect which is subsequently
levied by any taxing authority, which is attributable to the amount due VSP from Group.
4.04. Grace Period: Group shall be allowed a grace period of thirty-one (31) days
following the due date for making any payment of amounts due under this Plan. During the grace
period, this Plan will remain in full force and effect for all Covered Persons. Late payments will be
considered by VSP at the time of Plan renewal and may impact Group's Advance Payment and
Administrative Fees in future Plan Terms.
If Group fails to make any payment of amounts due by the end of any grace period, VSP
may notify Group that the payment of amounts due has not been made, that coverage is canceled
and that the Group is responsible for payment for the Claims Amount associated with Plan Benefits
provided to Covered Persons after the last period for which amounts due were fully paid, including
the grace period and through the effective date of the termination. Group shall also remain
responsible for payment, in accordance with Paragraph 2.02, of any Claims Amount associated with
Benefit Authorizations outstanding at the time of termination, and for any legal and/or collection
fees incurred by VSP in collecting amounts due under this Plan.
4.05. Distribution of Required Documents: Group agrees to distribute to Enrollees any
disclosure forms, plan summaries or other materials that may be required to be given to plan
subscribers by any regulatory authority. Such materials shall be distributed by Group no later than
thirty (30) days after receipt or as otherwise required under state law.
E
V. OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN
5.01. General: By this Plan, Group makes coverage available to its Enrollees and their
Eligible Dependents, if dependent coverage is provided. This Plan may be amended or terminated
by agreement between VSP and Group as otherwise indicated herein. Consent or concurrence of
Covered Persons for any such amendment or termination is not necessary. This Plan, and all
Exhibits, attachments and amendments, constitute VSP's sole and entire undertaking to Covered
Persons under this Plan.
All Covered Persons under this Plan shall have the following obligations as a condition of
their coverage.
5.02. Copayments for Services Received: Where, as indicated on the Schedule of
Benefits, Exhibit A hereto, Copayments are required for certain Plan Benefits, these Copayments
shall be the personal responsibility of the Covered Person receiving the care and must be paid to the
Member Doctor (or Non -Member Doctor if Non -Member Provider benefits are indicated on the
attached Schedule of Benefits at Exhibit A) on the date the services are rendered.
5.03. Obtaining Services from Member Doctors: Benefit Authorization must be
obtained prior to receiving Plan Benefits from a Member Doctor. When a Covered Person desires
to receive Plan Benefits from a Member Doctor, the Covered Person must select a Member Doctor,
schedule an appointment, and identify himself as a Covered Person in order for the Member Doctor
to obtain Benefit Authorization from VSP. Should the Covered Person receive Plan Benefits from a
Member Doctor without such Benefit Authorization, then for the purposes of those Plan Benefits
provided to the Covered Person, the provider will be considered a Non -Member Provider and the
benefits available will be limited to those for a Non -Member Provider, if any.
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5.04. Submission of Non -Member Provider Claims: All claims for services received
from Non -Member Providers (if Non -Member Provider coverage is indicated on the attached
Schedule of Benefits at Exhibit A) shall be submitted by Covered Persons to VSP within one
hundred eighty (180) days of the date of service. VSP reserves the right to reject such claims which
are filed more than one hundred eighty (180) days after the date of service. Failure to submit a
claim within one hundred eighty (180) days, however, shall not invalidate or reduce the claim if it
was not reasonably possible to submit the claim within such time period, provided the claim was
submitted as soon as was reasonably possible and in no event, except in absence of legal capacity,
later than one year from the required date.
5.05. Complaints and Grievances: Covered Persons shall report any complaints and/or
grievances to VSP at the address given herein. Complaints and grievances are disagreements
regarding access to care, quality of care, treatment or service. Complaints and grievances may be
submitted to VSP verbally or in writing. A Covered Person may submit written comments or
supporting documentation concerning his/her complaint or grievance to assist in VSP's review.
VSP will resolve the complaint or grievance within thirty (30) days after receipt, unless special
circumstances require an extension of time. In that case, resolution shall be achieved as soon as
possible, but not later than one hundred twenty (120) days after VSP's receipt of the complaint or
grievance. If VSP determines that resolution cannot be achieved within thirty (30) days, VSP will
notify the Covered Person of the expected resolution date. Upon final resolution, VSP will notify
the Covered Person of the outcome in writing.
5.06. Claim Denial Appeals: If, under the terms of this Plan, a claim is denied in whole
or in part, a request may be submitted to VSP by Covered Person or Covered Person's authorized
representative for a full review of the denial. Covered Person may designate any person, including
his/her provider, as his/her authorized representative. References in this section to "Covered
Person" include Covered Person's authorized representative, where applicable.
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a) Initial Appeal: The request must be made within one hundred eighty (180)
days following denial of a claim and should contain sufficient information to identify the Covered
Person for whom the claim was denied, including the VSP Enrollee's name, the VSP Enrollee's
Member Identification Number, the Covered Person's name and date of birth, the provider of
services and the claim number. The Covered Person may review, during normal working hours,
any documents held by VSP pertinent to the denial. The Covered Person may also submit written
comments or supporting documentation concerning the claim to assist in VSP's review. VSP's
response to the initial appeal, including specific reasons for the decision, shall be provided and
communicated to the Covered Person as follows:
Prior Authorization for Visually Necessary or Appropriate Services:
within thirty (30) calendar days after receipt of a request for an appeal from the Covered Person.
2. Denied Claims for Services Rendered: within thirty (30) calendar
days after receipt of a request for an appeal from the Covered Person.
b) Second Level Appeal: If the Covered Person disagrees with the response to
the initial appeal of the claim, the Covered Person has a right to a second level appeal. Within sixty
(60) calendar days after receipt of VSP's response to the initial appeal, the Covered Person may
submit a second appeal to VSP along with any pertinent documentation. VSP shall communicate its
final determination to the Covered Person in compliance with all applicable state and federal laws
and regulations and shall include the specific reasons for the determination.
c) Other Remedies: When Covered Person has completed the appeals process
stated herein, additional voluntary alternative dispute resolution options may be available, including
mediation, or Group should advise Covered Person to contact the U.S. Department of Labor or the
state insurance regulatory agency for details. Additionally, under the provisions of ERISA Section
502(a)(1)(B), Covered Person has the right to bring a civil action when all available levels of review
of denied claims, including the appeals process, have been completed, the claims were not approved
in whole or in part, and Covered Person disagrees with the outcome.
12
5.07. Time of Action: No action in law or in equity shall be brought to recover on the
Plan prior to the Covered Person exhausting his grievance rights as described in Paragraphs 5.05
and 5.06 above and/or prior to the expiration of sixty (60) days after the claim and any applicable
invoices have been filed with VSP. No such action shall be brought after the expiration of six (6)
years from the last date that the claim and any applicable invoices may be submitted to VSP, in
accordance with the terms of this Plan.
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VI. ELIGIBILITY FOR COVERAGE
6.01. Eligibility Criteria: Individuals will be accepted for coverage hereunder only
upon meeting all the applicable requirements set forth below.
(a) Enrollees: To be eligible for coverage, a person must:
(1) currently be an employee or member of the Group, and
(2) meet the criteria established in the coverage criteria mutually agreed
upon by Group and VSP.
(b) Eligible Dependents: If dependent coverage is provided, the persons
eligible for coverage as dependents shall include:
(1) the legal spouse of any Enrollee, and
(2) any unmarried child of an Enrollee, including any natural child from the
moment of birth, legally adopted child from the moment of placement for adoption with the
Enrollee, or other child for whom a court holds the Enrollee responsible; and
(A) for whose support the Enrollee is legally responsible and who
has not yet attained the age of 19 years, or
(B) who is chiefly dependent upon the Enrollee for support, has not
yet attained the age of 25 years, and is currently enrolled as a full-time student in good standing
actively pursuing a degree or certificate at a recognized educational institution.
(3) as further defined by Group.
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If a dependent unmarried child, prior to attainment of the prescribed age for termination of
eligibility, becomes and continues to be, incapable of self-sustaining employment because of mental
or physical disability, that Eligible Dependent's coverage shall not terminate. Coverage will
continue as long as he remains chiefly dependent on the Enrollee for support and the Enrollee's
coverage remains in force; PROVIDED satisfactory proof of the dependent's incapacity can be
furnished to VSP within thirty-one (31) days of the date the Eligible Dependent's coverage would
have otherwise terminated, and at such other times as VSP may request proof, but not more
frequently than annually.
6.02. Documentation of Eligibility: Persons satisfying the requirements for coverage
under either of the above classes shall be eligible if
(a) in the case of an Enrollee, the individual's name and Social Security Number
have been reported by the Group to VSP in the manner provided hereunder, and
(b) in the case of changes to an Eligible Dependent's status, the change has been
reported by the Group to VSP in the manner provided herein. As indicated in Paragraph 4.01
above, VSP may elect to inspect the Group's records in order to verify eligibility of Enrollees and
dependents. Plan Benefits will be available only to persons on whose behalf applicable amounts
due have been paid for the current period, or Grace Periods outlined above in Paragraph 4.04. If a
clerical error is made, it will not affect the coverage to which the Covered Person is entitled under
the Plan.
6.03. Retroactive Efigibifity Changes: Retroactive eligibility changes are limited to
sixty (60) days prior to the date notice of any such requested change is received by VSP. If
coverage is retroactively terminated for an individual, Group shall remain responsible for the
Claims Amount associated with any Plan Benefits provided to that individual pursuant to the
Benefit Authorization issued by VSP in reliance on the latest eligibility information available to
VSP at the time of such Benefit Authorization.
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6.04. Chance of Participation Requirements Contribution of Fees, and Efijibility
Rules: Composition of the Group, percentage of Enrollees covered under the Plan, and Group's
contribution and Group's eligibility requirements are all material to VSP's obligations under this
Plan. During the term of this Plan, Group must provide VSP with written notice of changes to its
composition, percentage of Enrollees covered, contribution or eligibility requirements. Any such
change which materially affects VSP's obligations hereunder must be mutually agreed upon in
writing between VSP and Group and may constitute a material change to the terms and conditions
of this Plan for purposes of Paragraph 4.03. Nothing in this section shall limit Group's ability to add
Enrollees and/or Eligible Dependents in accordance with the terms of this Plan.
6.05. Change in Family Status: In the event Group is notified of any change in a
Covered Persons family status (by marriage, the addition (e.g., newborn or adopted child) or
deletion of dependent children, etc.) Group shall provide notice of such change to VSP via the next
eligibility listing required under Paragraph 4.01. If such notice is given, the change in the Covered
Person's status will be effective on the first day of the month following the request for change, or at
a requested later date. Notwithstanding any other provision in this section, a newborn child will be
covered for thirty-one (31) days after birth and an adopted child will be covered for thirty-one (31)
days after the date the Enrollee or Enrollee's spouse acquires the right to control the health care of
the child. To continue coverage for a newborn or adopted child beyond the initial thirty-one (31)
day period, the Group must be properly notified of the Enrollee's change in family status and
applicable amounts due must be paid to VSP on behalf of the child.
6.05. Family and Medical Leave Act: The federal Family and Medical Leave Act of
1993 (FMLA), requires that under certain circumstances health plan benefits available to an eligible
Enrollee and his or her Eligible Dependents be made available during certain periods of leave.
Benefits will be available at the level and under the conditions coverage would have been provided
if the eligible Enrollee had not gone on leave. If, and only to the extent, FMLA applies to the
parties to this Plan, VSP shall make the statutorily -required continuation coverage available based
on the eligibility information provided by the Group.
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VII. CONTINUATION OF COVERAGE
7.01. COBRA: The Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA) requires that under certain circumstances health plan benefits available to an eligible
Enrollee and his or her Eligible Dependents be made available to said persons upon the termination
of employment of said Enrollee, or the termination of the relationship between said Enrollee and his
or her dependents. If, and only to the extent, COBRA applies to the parties to this Plan, VSP shall
make the statutorily -required continuation coverage available in accordance with COBRA.
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TABLE OF CONTENTS
TITLE PAGE
I.
DEFINITIONS
I
II.
TERM, TERMINATION, AND RENEWAL
4
III.
OBLIGATIONS OF VSP
5
IV.
OBLIGATIONS OF THE GROUP
g
V.
OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN
10
VI.
ELIGIBILITY FOR COVERAGE
14
VII.
CONTINUATION OF COVERAGE
17
VIII.
ARBITRATION OF DISPUTES
18
IX.
NOTICES
19
X.
MISCELLANEOUS
20
EXHIBIT A 22
SCHEDULE OF BENEFITS 22
EXHIBIT B 27
SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE 27
VIII. ARBITRATION OF DISPUTES
8.01. Dispute Resolution: Any dispute or question arising between VSP and Group or
any Covered Person involving the application, interpretation, or performance under this Plan shall
be settled, if possible, by amicable and informal negotiations. This will allow such opportunity as
may be appropriate under the circumstances for fact-finding and mediation. If any issue cannot be
resolved in this fashion, it shall be submitted to arbitration.
8.02. Procedure: The procedure for arbitration hereunder shall be conducted pursuant to
the Rules of the American Arbitration Association in effect at the time of the dispute.
8.03. Choice of Law: Question(s) and dispute(s) hereunder are to be resolved by
arbitration. However,.if there are any matters arising in connection with this Plan which do become
the subject of legal process, the applicable law shall be that of the State of delivery of this Plan.
IN
IX. NOTICES
9.01. Any notices to be given under this Plan to either the Group or VSP shall be in
writing and delivered by United States First Class Mail. Notices sent to the Group will be mailed to
the address shown on the Group Application. Notices sent to VSP shall be sent to the address
shown on this Plan. Any notices may be hand -delivered by either party to an appropriate
representative of the party, with the burden being on the party effecting such hand -delivery, to
prove, if questioned, that such delivery was made.
19
X. MISCELLANEOUS
10.01. Entire Plan: This Plan, the Group Application, and all Exhibits and attachments,
and any amendments hereto, constitute the entire understanding between the parties and supersedes
any prior understandings and agreements between them, either written or oral. Any change or
amendment to the Plan must be approved by an officer of VSP and attached to be valid. No agent
has the authority to change this Plan or waive any of its provisions. Communication materials
prepared by Group for distribution to Enrollees do not constitute a part of this Plan.
10.02. Indenmity: VSP agrees to indemnify, defend and hold harmless Group, its
shareholders, directors, officers, agents, employees, successors and assigns from and against any
and all liability, claim, loss, injury, cause of action and expense (including defense costs and legal
fees) of any nature whatsoever arising from the failure of VSP, its officers, agents or employees, to
perform any of the activities, duties or responsibilities specified herein. Group agrees to indemnify,
defend and hold harmless VSP, its members, shareholders, directors, officers, agents, employees,
successors and assigns from and against any and all liability, claim, loss, injury, cause of action and
expense (including defense costs and legal fees) of any nature whatsoever arising or resulting from
the failure of Group, its officers or employees to perform any of the duties or responsibilities
specified herein.
10.03. Liability: VSP arranges for the provision of vision care services and materials
through agreements with Member Doctors, who are independent contractors responsible for
exercising independent judgement. VSP does not itself directly furnish vision care services or
supply materials. Under no circumstances shall VSP or Group be liable for the negligence,
wrongful acts or omissions of any doctor, laboratory, or any other person or organization
performing services or supplying materials in connection with this Plan.
10.04. Assignment: Neither this Plan nor any of the rights or obligations of either of the
parties may be assigned or transferred, except as noted herein, without the prior written consent of
both parties.
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10.05. Severability: Should any provision of this Plan be declared invalid, the remaining
provisions shall remain in full force and effect.
10.06. Governina Law: This Plan shall be governed by and construed in accordance with
applicable federal and state law. Any provision that is in conflict with, or not in compliance with,
applicable federal or state statutes or regulations is hereby amended to conform with the
requirements of such statutes or regulations, now or hereafter existing.
10.07. Gender: All pronouns used herein are deemed to refer to the masculine, feminine,
neuter, singular, or plural, as the identity(ies) of the person(s) may require.
10.08. Communication Materials: All Communication materials created by Group
which relate to this vision care Plan must adhere to VSP's Member Communication Guidelines,
distributed to Group by VSP. Such communication materials may be sent to VSP for review and
approval in advance of mailing to Enrollees. VSP's review of such materials shall be limited to
approving the accuracy of Plan Benefits and shall not encompass or constitute certification that
Group's materials meet any applicable legal or regulatory requirements, including, but not limited
to, ERISA requirements.
21
EXHIBIT A
VISION SERVICE PLAN INSURANCE COMPANY
SCHEDULE OF BENEFITS
ENHANCED PLAN B
GENERAL
This Schedule lists the vision care services and vision care materials to which Covered Persons
of VISION SERVICE PLAN INSURANCE COMPANY ("VSP") are entitled, subject to any
Copayments and other conditions, limitations and/or exclusions stated herein. If Plan Benefits
are available for Non -Member Provider services, as indicated by the reimbursement provisions
below, vision care services and vision care materials may be received from any licensed
optometrist, ophthalmologist, or dispensing optician, whether Member Doctors or Non -Member
Providers. This Schedule forms a part of the Plan or Certificate to which it is attached.
When Plan Benefits are received from Member Doctors, benefits appearing in the first column
below are applicable subject to any Copayments as stated below. When Plan Benefits are
available and received from Non -Member Providers, the Covered Person is reimbursed for such
benefits according to the schedule in the second column below less any applicable Copayments.
COPAYMENT
The benefits described herein are available to each Covered Person subject only to payment of
the applicable Copayment by the Covered Person. Copayments are required for Plan Benefits
received from Member Doctors and Non -Member Providers. Covered Persons must also follow
the proper procedures for obtaining Benefit Authorization.
The applicable Copayment for Covered Persons under this Plan is:
There shall be a Copayment of $15.00 for the examination payable by the Covered Person to the
Member Doctor at the time services are rendered. If materials (lenses and frames) are provided,
there shall be an additional $15.00 Copayment payable at the time the materials are ordered.
However, the Copayment for materials shall not apply to elective contact lenses.
PLAN BENEFITS
VISION CARE SERVICES
Eye Examination
MEMBER DOCTOR
BENEFIT
Covered in Full*
NON-MEMBER
PROVIDER BENEFIT
Up to $ 30.00*
Complete initial vision analysis which includes an appropriate examination of visual functions,
including the prescription of corrective eyewear where indicated.
Subsequent regular eye examinations every 12 months.
*Less any applicable Copayment.
22
VISION CARE MATERIALS
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Lenses
Single Vision
Covered in Full*
Up to $
30.00*
Bifocal
Covered in Full*
Up to $
40.00*
Trifocal
Covered in Full*
Up to $
50.00*
Lenticular
Covered in Full*
Up to $
80.00*
Available every 12 months.
Frames
Available every 24 months.
*Less any applicable Copayment.
Covered up to Plan Up to $ 30.00*
Allowance*
Lenses and frames include such professional services as are necessary, which shall include:
• Prescribing and ordering proper lenses;
• Assisting in the selection of frames;
• Verifying the accuracy of the finished lenses;
• Proper fitting and adjustment of frames;
• Subsequent adjustments to frames to maintain comfort and efficiency;
• Progress or follow-up work as necessary.
23
CONTACT LENSES
Contact lenses are available once every 12 months in lieu of all other lens and frame benefits
available herein. When contact lenses are obtained, the Covered Person shall not be eligible for
lenses and frames again for 12 months.
Visually Necessary — When Visually Necessary contact lenses are obtained from a Member
Doctor, they will be covered in full with prior authorization from VSP. When Visually
Necessary contact lenses are obtained from a Non -Member Provider, VSP will provide an
allowance toward the cost as outlined below. Coverage for Visually Necessary contact lenses
regardless of whether they are obtained from a Member Doctor or Non -Member Provider are
subject to review and authorization from VSP's Optometric Consultants.
MEMBER DOCTOR
BENEFIT
Professional Fees and
Materials — Covered in Full*
NON-MEMBER
PROVIDER BENEFIT
Professional Fees and
Materials — Up to $250.00*
Elective - Contact lenses for other than Visually Necessary circumstances:
MEMBER DOCTOR
BENEFIT
NON-MEMBER
PROVIDER BENEFIT
Professional Fees** and Professional Fees and
Materials —Covered up to $100.00 Materials— Up to $80.00
*Less any applicable Copayment
**Additional discount applies to Member Doctor's
contact lens evaluation and fitting (see section on
usual and customary professional fees for
Additional Discounts below)
24
ADDITIONAL DISCOUNT
Each Covered Person shall be entitled to receive a discount of twenty percent (20%) toward the
purchase of additional complete pairs of prescription glasses (lenses, lens options, and frames)
from a Member Doctor. Additional pair means any complete pair of prescription glasses
purchased beyond the benefit frequency allowed under this Plan.
Additionally, Covered Persons shall be entitled to receive a discount of fifteen percent (15%) off
Member Doctor professional fees for elective contact lens evaluations and fittings. Discounts are
applied to the Member Doctor's usual and customary fees for such services and are available
within twelve (12) months of the covered eye examination from the Member Doctor who
provided the covered eye examination. Contact lens materials are provided at the doctor's usual
and customary charges. Additional discounts noted on this schedule are subject to change as
deemed appropriate by VSP with prior notification to the Group.
LOW VISION BENEFIT
The Low Vision benefit is available to Covered Persons who have severe visual problems that
are not correctable with regular lenses and is subject to prior approval by VSP Consultants.
Supplementary Testing
MEMBER DOCTOR NON-MEMBER
BENEFIT BENEFIT
Covered in Full Up to $125.00
Complete low vision analysis and diagnosis which includes a comprehensive examination
of visual functions, including the prescription of corrective eyewear or vision aids where
indicated.
Supplemental Care Aids 75% of Cost 75% of Cost
Subsequent low vision aids as Visually Necessary or Appropriate.
Copayment for Supplemental Aids: 25% payable by Covered Person.
Benefit Maximum
The maximum benefit available is $1000.00 (excluding Copayment) every two years.
NON-MEMBER PROVIDER BENEFIT
Low Vision benefits secured from a Non -Member Provider are subject to the same time limits
and Copayment arrangements as described above for a Member Doctor. The Covered Person
should pay the Non -Member Provider his full fee. The Covered Person will be reimbursed in
accordance with an amount not to exceed what VSP would pay a Member Doctor in similar
circumstances. NOTE: There is no assurance that this amount will be within the 25%
Copayment feature.
25
EXCLUSIONS AND LIMITATIONS OF BENEFITS
PATIENT OPTIONS
This Plan is designed to cover visual needs rather than cosmetic materials. When the Covered
Person selects any of the following extras, the Plan will pay the basic cost of the allowed lenses,
and the Covered Person will pay the additional costs for the options.
• Blended Lenses.
• Oversize lenses.
• Cosmetic lenses.
• Optional cosmetic processes.
• Progressive multifocal lenses.
• UV (ultraviolet) protected lenses.
• The coating of the lens or lenses.
• The laminating of the lens or lenses.
• Certain limitations on low vision care.
• A frame that costs more than the Plan allowance.
• Contact lenses (except as noted elsewhere herein).
• Photochromic lenses; tinted lenses except Pink #1 and Pink #2.
NOT COVERED
There is no benefit for professional services or materials connected with:
• Orthoptics or vision training and any associated supplemental testing; plano lenses (less than
a f.38 diopter power); or two pair of glasses in lieu of bifocals;
• Replacement of lenses and frames furnished under this Plan which are lost or broken, except
at the normal intervals when services are otherwise available;
• Medical or surgical treatment of the eyes;
• Corrective vision treatment of an Experimental Nature;
• Costs for services and/or materials above Plan Benefit allowances;
• Services and/or materials not indicated on this Schedule as covered Plan Benefits.
VSP MAY, AT ITS DISCRETION, WAIVE ANY OF THE PLAN LIMITATIONS IF, IN THE
OPINION OF VSP'S OPTOMETRIC CONSULTANTS, IT IS NECESSARY FOR THE
VISUAL WELFARE OF THE COVERED PERSON.
FM
EXHIBIT B
VISION SERVICE PLAN INSURANCE COMPANY
SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE
ENHANCED PLAN B
VSP shall be entitled to receive amounts due for each month on behalf of each Enrollee and
his/her Eligible Dependents, if any in the amounts specified below:
ADVANCE PAYMENT: $0000000000
ADMINISTRATIVE FEE: $1.64 PER ELIGIBLE ENROLLEE
NOTICE: The amount due under this Plan is subject to change upon renewal (after the end of
the Plan Term or any subsequent Plan Tenn) or upon change of the Schedule of Benefits or a
material change in any other terms or conditions of the Plan.
27
I. DEFINITIONS
Key terms used in this Plan are defined and shall have the meaning set forth as follows,
unless the context of a term's usage clearly requires otherwise.
1.01 ADMINISTRATIVE FEE: The payments made to VSP by or on behalf of Group
in consideration of administrative services rendered.
1.02. ADMINISTRATIVE SERVICES PROGRAM: A group vision care plan
whereby Group pays VSP for the Plan Benefits in addition to a monthly Administrative Fee.
1.03. ADVANCE PAYMENT: The amount paid in advance to VSP by or on behalf of
Group to cover the estimated benefit costs of Group for one (1) month.
1.04. BENEFIT AUTHORIZATION: Authorization issued by VSP identifying the
individual named as a Covered Person of VSP, and identifying those Plan Benefits to which
Covered Person is entitled.
1.05. CLAIMS AMOUNT: Total charges for benefits delivered, including the cost of
professional services and ophthalmic materials, charges for VSP services related to materials
purchased, and taxes.
1.06. CONFIDENTIAL MATTER: All confidential or personal information
concerning the medical, personal, financial or business affairs of Covered Persons acquired in the
course of providing Plan Benefits hereunder.
1.07. COPAYMENTS: Any amounts required to be paid by or on behalf of a Covered
Person for Plan Benefits which are not fully covered.
1.08. COVERED PERSON: An Enrollee or Eligible Dependent who meets VSP's
eligibility criteria and who is covered under this Plan.
1.09. ELIGIBLE DEPENDENT: Any legal dependent of an Enrollee of Group who
meets the criteria for eligibility established by Group and approved by VSP in Article VI of this
Plan under which such Enrollee is covered.
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1.10. EMERGENCY CONDITION: A condition, with sudden onset and acute
symptoms, that requires the Covered Person to obtain immediate medical care, or an unforeseen
occurrence calling for immediate, non -medical action.
1.11. ENROLLEE: An employee or member of Group who meets the criteria for
eligibility specified under VI. ELIGIBILITY FOR COVERAGE.
1.12. EXPERIMENTAL NATURE: Procedure or lens that is not used universally or
accepted by the vision care profession, as determined by VSP.
1.13. GROUP: An employer or other entity which contracts with VSP for coverage
under this Plan in order to provide vision care coverage to its Enrollees and their Eligible
Dependents.
1.14. GROUP APPLICATION: The form signed by an authorized representative of
the Group to signify the Group's intention to have its Enrollees and their Eligible Dependents
become Covered Persons of VSP.
1.15. GROUP VISION CARE PLAN (also, "THE PLAN"): The Plan provided by
VSP in favor of a Group, under which its Enrollees, and their Eligible Dependents are entitled to
become Covered Persons of VSP and receive Plan Benefits in accordance with the terms of such
Plan.
1.16. MEMBER DOCTOR: An optometrist or ophthalmologist licensed and otherwise
qualified to practice vision care and/or provide vision care materials who has contracted with VSP
to provide vision care services and/or vision care materials on behalf of Covered Persons of VSP.
1.17. NON-MEMBER PROVIDER: Any optometrist, optician, ophthalmologist, or
other licensed and qualified vision care provider who has not contracted with VSP to provide vision
care services and/or vision care materials to Covered Persons of VSP.
1.18. PLAN BENEFITS: The vision care services and vision care materials which a
Covered Person is entitled to receive by virtue of coverage under this Plan, as defined in the
Schedule of Benefits attached hereto as Exhibit A.
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1.19. RENEWAL DATE: The date on which the Plan shall renew, or terminate if
proper notice is given.
1.20. SCHEDULE OF BENEFITS: The document, attached hereto as Exhibit A,
which lists the vision care services and vision care materials which a Covered Person is entitled to
receive by virtue of this Plan.
1.21. SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE:
The document, attached hereto as Exhibit B, which states the payments to be made to VSP by or on
behalf of a Covered Person to entitle him to Plan Benefits.
1.22. VISUALLY NECESSARY OR APPROPRIATE: Services and materials
medically or visually necessary to restore or maintain a patient's visual acuity and health and for
which there is no less expensive professionally acceptable alternative, as determined by VSP.
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U. TERM, TERMINATION, AND RENEWAL
2.01. This Plan shall become effective on the Effective Date and shall remain in effect for
the Plan Term. At the end of the Plan Term, it will renew on a month to month basis unless either
party notifies the other in writing, at least sixty (60) days before the end of the Plan Term, that the
party is unwilling to renew the Plan. If such notice is given, the Plan will terminate at 12:00
midnight on the last day of the Plan Term, unless the parties reach mutual agreement on its renewal.
If the Plan continues on a month to month basis after the Plan Term, either Party may thereafter
terminate the Plan upon thirty (30) days advance written notice to the other party.
If VSP issues written renewal materials to Group at least sixty (60) days before the end of
the Plan Term and Group fails to accept the new terms and/or rates in writing prior to the end of the
Plan Term, this Plan shall terminate at 12:00 midnight on the last day of the Plan Term as noted
above.
2.02. In the event of termination of this Plan by either party, Group agrees to provide
funds for payment of the Claims Amount associated with Plan Benefits provided pursuant to
Benefit Authorizations issued prior to the Plan termination date, provided claims for such Plan
Benefits are filed with VSP within six (6) months after termination of this Plan.
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III.OBLIGATIONS OF VSP
3.01. Coverage of Covered Persons: VSP will enroll each eligible Enrollee and his
Eligible Dependents, if dependent coverage is provided, all of whom shall be referred to as
"Covered Persons." To institute coverage, Group may be required to complete and sign a Group
Application and forward such application to VSP, along with information regarding Enrollees and
Eligible Dependents, and applicable amounts due. (Refer to VI. ELIGIBILITY FOR COVERAGE
for further details.)
Following enrollment, VSP will provide Group with Vision Care Brochures for Covered
Persons. Such Brochures will summarize the terms and conditions of this Plan.
3.02. Provision of Plan Benefits: Through its Member Doctors (or through other
licensed vision care providers in cases where a Covered Person is eligible for, and chooses to
receive Plan Benefits from a Non -Member Provider) VSP shall provide Covered Persons such Plan
Benefits listed in the Schedule of Benefits, Exhibit A hereto, as may be Visually Necessary or
Appropriate, subject to any limitations, exclusions, or Copayments therein stated.
Benefit Authorization must be obtained prior to a Covered Person obtaining Plan Benefits
from a Member Doctor. When a Covered Person desires to receive Plan Benefits from a Member
Doctor, the Covered Person must schedule an appointment and identify himself as a VSP Covered
Person in order for the Member Doctor to obtain Benefit Authorization from VSP. VSP shall
provide Benefit Authorization to the Member Doctor to authorize the provision of Plan Benefits to
the Covered Person. Each Benefit Authorization will contain an expiration date, allowing a specific
period of time for the Covered Person to obtain Plan Benefits. Benefit Authorization shall be issued
by VSP in accordance with the latest eligibility information furnished by Group and the Covered
Person's past service utilization, if any. Any Benefit Authorization so issued by VSP shall
constitute a certification to the Member Doctor that payment will be made. VSP shall not be held
liable to Group for any Benefit Authorization issued in error in reliance on the latest eligibility
information available to VSP as provided by the Group.
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VSP shall pay or deny claims for Plan Benefits provided to Covered Persons, less any
applicable Copayment, within a reasonable time but not more than thirty (30) calendar days after
VSP has received a completed claim, unless special circumstances require additional time. In such
cases, VSP may obtain an extension of fifteen (15) calendar days of this time limit by providing
notice to the claimant of the reasons for the extension.
3.03. Determination of Visual Necessity: Plan Benefits are covered only when they are
deemed Visually Necessary or Appropriate for the proper treatment of a Covered Person's
condition. Questions involving necessity or appropriateness of treatment shall be decided by the
doctor responsible for the Covered Persons care and are subject to review and final determination
by VSP. Any objections of a Covered Person regarding such decisions may be made to VSP in
accordance with VSP's grievance procedures (See Paragraphs 5.05 and 5.06).
3.04. Provision of Information to Covered Persons: Upon request, VSP will make
available to Covered Persons necessary information describing Plan Benefits and procedures. A
copy of this Plan will be placed with Group. The Plan will also be available at the offices of VSP
for copying or inspection by Covered Persons. VSP shall provide Group with an updated list twice
annually of Member Doctors' names, addresses, and telephone numbers for distribution to Covered
Persons. Covered Persons may also obtain a copy of the latest Member Doctor list by contacting
VSP's Customer Service Department in writing or via the toll -free Customer Service telephone line,
or by visiting VSP's Web site at www.vsp.com.
3.05. Preservation of Confidentiality: VSP will hold in strict confidence all
Confidential Matters. VSP will also exercise its best efforts to prevent any of its employees,
Member Doctors, or agents, from disclosing any Confidential Matter. An exception would be if
disclosure is necessary to enable any of the above to perform their obligations under this Plan,
including but not limited to sharing information with medical information bureaus, or as may
otherwise be required by law. Covered Persons and/or Groups that want more information on
VSP's Confidentiality Policy may obtain a copy of the policy by contacting VSP's Customer
Service Department or by visiting VSP's Web site at www.vsp.com.
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3.06. Emergency Vision Care: When vision care is necessary for Emergency
Conditions, Covered Persons may obtain Plan Benefits by contacting a Member Doctor or Out -of -
Network Provider. No prior approval from VSP is required for Covered Person to obtain vision
care for Emergency Conditions of a medical nature. However, services for medical conditions,
including emergencies, are covered by VSP only under the Acute EyeCare and Supplemental
Primary EyeCare Plans. If Group has not purchased one of these plans, Covered Persons are not
covered by VSP for medical services and should contact a physician under Covered Persons'
medical insurance plans for care. For emergency conditions of a non -medical nature, such as lost,
broken or stolen glasses, the Covered Person should contact VSP's Customer Service Department
for assistance. Reimbursement and eligibility are subject to the terms of this Plan.
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