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HomeMy WebLinkAboutVSP VISION SERVICES PLAN - CONTRACT - RFP - P682 BENEFITSVISION SERVICE PLAN GROUP VISION CARE PLAN ADMINISTRATIVE SERVICES PROGRAM TABLE OF CONTENTS TITLE PAGE I DEFINITIONS 1 II TERM, TERMINATION, AND RENEWAL 4 III OBLIGATIONS OF VSP 5 IV OBLIGATIONS OF THE GROUP 7 V OBLIGATIONS OF COVERED PERSONS UNDER THIS PLAN 9 VI ELIGIBILITY FOR COVERAGE 11 VII CONTINUATION OF COVERAGE 14 VIII ARBITRATION OF DISPUTES 15 DX NOTICES 16 X MISCELLANEOUS 17 ATTACHMENTS EXHIBIT A - SCHEDULE OF BENEFITS EXHIBIT B - SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE -11- ASPPLAN 1/96 V OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN 501 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 Consent or concurrence of the Covered Persons is not necessary This Plan, and all Exhibits attachments and amendments, constitute VSP's sole and entire undertaking to Covered Persons under tlus 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 on the date the services are rendered 5 03 Authorization of Services A Covered Person must receive Benefit Authorization before receiving Plan Benefits from a Member Doctor Such Benefit Authorization is received by contacting a Member Doctor or 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 5 04 Complaints and Gnevances, Tune of Action Covered Person shall report any complaints and/or grievances to VSP at the address given herein No action in law or in equity shall be brought to recover on the Plan 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 three (3) 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 505 Insurance Fraud Any person who with intent to defraud or knowing that he is facilitating a fraud against an insurer submits an application or files a claim containing a false or deceptive statement, is guilty of insurance fraud 10 A OnY 1 11 1n1 506 Claun Denial If, under the provisions of an employee's vision care plan, a claim for benefits is demed in whole or part, a request in writing, may be submitted to VSP for a full review of the denial The written request must be made within sixty (60) days following the denial of benefits The request should contain sufficient information to identify the employee or dependent whose benefits were denied This includes the name of the VSP member social security number, patient's name and patient's date of birth The member, upon request to VSP may review during normal working hours, any documents in the possession of VSP pertinent to the denial The member may submit written comments concerning the claim submission winch might affect the denial unless special circumstances require an extension of time Upon completion of the review by VSP, the employee will be advised, in writing, of the final disposition of the claim within sixty (60) days after receipt of a request to review, unless special circumstances require an extension of tune for processing, in which case a decision shall be rendered as soon as possible but not later than one hundred twenty (120) days after receipt of a request for review -10- A On"T ♦ LT � ink VI ELIGIBILITY FOR COVERAGE 601 Eligibility Cntena 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 the 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 unmarred child of an Enrollee, including any natural child from the moment of birth, or 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 and 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 mstitution (3) as further defined by Group If a dependent unmarred child, prior to attainment of the prescribed age for termination of eligibility, becomes and continues to be, mcapable 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 a dependent and the Enrollee's coverage remains in force, PROVIDED satisfactory proof of the dependent's mcapacity can be furnished to VSP within thirty-one (31) days of the date dependent's coverage would have otherwise terminated At such other times, 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 -11- (a) in the case of an Enrollee, the individuals name and Social Security Number has been reported by the Group to VSP in the manner provided hereunder, and (b) in the case of changes to a dependent's status the change has been reported by the Group to VSP in the manner provided herein As indicated in Paragraph 4 05 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 premiums have been paid for the current period, or Grace Periods outlined above in Paragraph 4 04 Dependents will be covered through the end of the month in which the dependent child reaches age 19 or 25 whichever is applicable If a clerical error is made it will not affect the coverage to which the Covered Person is entitled under the Plan 6 03 Change of Participation Requirements Contnbution of Fees and Eligibihtv Rules Composition of the Group percentage of Enrollees covered under the Plan, and eligibility requirements, are material to VSP's obligations under this Plan During the term of this plan Group may not change its composition, percentage of Enrollees covered, or eligibility requirements in any way which affects VSP's obligations hereunder unless VSP consents to such change in writing VSP may require Group to make written request for any such change at least sixty (60) days prior to the proposed effective date of the change Nothing herein shall linut Group's ability to add Enrollees and/or Eligible Dependents in accordance with the terms of this Plan 604 Change in Family Status In the event of any change in a Covered Person's family status (by marriage the addition (e g , newborn or adopted child) or deletion of dependent children etc ) written notice is to be given to VSP within durty-one (31) days If such notice is given the change in the Covered Person's status will become effective on the first day of the month following the request for change or at a requested later date A newborn will be covered for thirty-one (31) days after birth -12- 6 05 Family and Methcal Leave Act The federal Family and Medical Leave Act of 1993 (FMLA), requires that under certain circumstances health plan benefits available to an eligible participant and his or her 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 participant 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 -13- ASPPLAN 1/96 VU CONTINUATION OF COVERAGE 701 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 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 -14- ASPPLAN 5/98 VIII ARBITRATION OF DISPUTES 801 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 atrucable 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 802 The procedure for arbitration hereunder shall be conducted pursuant to the Rules of the American Arbitration Association -15- ASPPLAN 1/96 IX NOTICES 901 Any notices required 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 parry to an appropriate representative of the party with the burden being on the parry effecting such hand - delivery to prove if questioned, that such delivery was made -16- ASPPLAN 1/96 X MISCELLANEOUS 10 01 Entire Plan This Plan, the Group Application the Evidence of Coverage 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 1002 Indemntty 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 1003 Liability 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 Right to Reject Claims VSP reserves the right to reject any and all claims for services or benefits which are filed with it more than one hundred eighty (180) days after completion of services 10 05 Assignment Neither this Plan nor any of the rights or obligations of either of the parties may be assigned or transferred consent of both parties except as noted herein, without the prior written -17- ASPPT AN 1'7/QA 1006 Severability Should any provision of this Plan be declared invalid the remaining provisions shall remain in full force and effect 1007 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 1008 Gender All pronouns used herem are deemed to refer to the masculine, feminine, neuter, singular, or plural, as the identity(ies) of the person(s) may require 1009 Year 2000 VSP agrees that it will be Year 2000 compliant Year 2000 compliance is defined as the ability to provide contracted services without interruptions due to date information and its processing, up to, through, and beyond the Year 2000 Group shall be responsible for ensuring that information it submits to VSP by electronic transfer or magnetic media shall contain the number of digits necessary to fully and distinctly identify the year and not contain any invalid dates Group shall hold VSP harmless for any errors that occur because information provided by the Group does not meet this format requirement 1010 Communication Materials All communication materials created by Group which relate to this vision care plan must be approved in advance of mailing to Enrollees by VSP M ASPPLAN 6/98 VISION SERVICE PLAN GROUP VISION CARE PLAN 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 101 ADMINISTRATIVE FEE The payments made to VSP by or on behalf of Group in consideration of administrative services rendered 102 ADMINISTRATIVE SERVICES PROGRAM A group vision care plan whereby Group pays VSP for the Plan Benefits in addition to a monthly Administrative Fee 103 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 104 ANISOMETROPIA A condition of unequal refractive state for the two eyes one eye requiring a different lens correction than the other 105 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 106 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 107 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 109 ELIGIBLE DEPENDENT Any legal dependent of an Enrollee of Group who meets the criteria for eligibility established by Group and approved by VSP in Article VI of this Plan under which such Enrollee is covered -1- ASPPLAN 1/96 VISION SERVICE PLAN SCHEDULE OF BENEFITS PLAN B GENERAL This Schedule lists the vision care services and vision care materials to winch Covered Persons of VSP are entitled, subject to any Copayments and other conditions, limitations and/or exclusions stated herein 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 Policy or Certificate to winch it is attached When Plan Benefits are received from Member Doctors, benefits appeanng in the fast column below are applicable subject to any Copayment as stated below When Plan Benefits are 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 Copayment In either event, Copayments are payable to the Member Doctor or Non -Member Provider at the time the services are rendered and materials are supplied PLAN BENEFITS VISION CARE SERVICES Vision Examination MEMBER DOCTOR BENS Covered in Full NON-MEMBER BENEFIT Up to $ 30 00 Complete urinal vision analysis which includes an appropriate examination of visual functions, including the prescription of corrective eyewear where indicated Subsequent regular vision exammations every twelve (12) months -1- VISION CARE MATERIALS MEMBER DOCTOR NO BENEFIT BE FIT 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 $ 60 00 Available every twelve (12) months Frame Covered up to Up to $ 30 00 Plan Allowance Available every twenty-four (24) months Lenses and frames include such professional services as are necessary, which shall include 1 Prescribing and ordering proper lenses, 2 Assisting in the selection of frames, 3 Venfymg the accuracy of finished lenses, 4 Proper fitting and adjustment of frames, 5 Subsequent adjustments to frames to maintain comfort and efficiency, 6 Progress or follow-up work as necessary ADDITIONAL DISCOUNT Each Covered Person shall be entitled to receive a discount toward the purchases of additional complete pairs of prescription glasses (lenses, lens options, and frames) Additionally, the Covered Person shall be entitled to receive a discount off the Member Doctor's professional fees for contact lenses 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 -2- CONTACT LENSES In lieu of all other Plan Benefits available hereunder and when a prescription change is warranted but in no event more than once in any twelve (12) month period Necessary - Contact lenses together with necessary professional services will be provided, with prior authorisation, only under one of the following circumstances • Following cataract surgery • To correct extreme visual acuity problems that cannot be corrected with spectacle lenses • Certain conditions of Anisometropia • Keratoconus MEMBER DOCTOR NON-MEMBER BENEFIT RE— Exam and Materials Up to $ 30 00 toward exam Covered in Full Up to $150 00 toward contact Subject to Copayment lens evaluation fee, fittmg if any costs and materials Elective - Contact lenses for purposes other than under the circumstances above MEMBER DOCTOR NON-MEMBER BENEFIT BENEFIT Exam Covered in Full Subject to Copayment if any Materials Allowance* Up to $ 30 00 toward exam Up to $80 00 toward contact lens evaluation fee, fitting costs and materials *Materials allowance toward contact lens evaluation fee, fitting costs and materials and equivalent under the program to spectacle lenses and frame COPAYMENT The benefits described herein are available to each Covered Person from any participating Member Doctor at no cost to the Covered Person The Covered Person must follow the proper procedures by obtaining Benefit Authorization THERE SHALL BE A COPAYMENT OF FIFTEEN DOLLARS ($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 FIFTEEN DOLLAR ($15 00) COPAYMENT PAYABLE AT THE TIME THE MATERIALS ARE ORDERED HOWEVER, THE COPAYMENT FOR MATERIALS SHALL NOT APPLY TO ELECTIVE CONTACT LENSES -3- 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 BENEFIT Covered in Full NON-MEMBER BENEFIT Complete low vision analysis and diagnosis which includes a comprehensive examination of visual functions, mcludmg the prescription of corrective eyewear or vision aids where indicated Supplemental Care 75 % of Cost Subsequent low vision therapy as Visually Necessary or Appropriate Copayment 75% of the authorized benefits payable by VSP and 25% payable by Covered Person Benefit Maximum The maximum benefit available is $1000 00 (excluding copayment) every two years * NON-MEMBER BENEFrr 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 Covered Person will be reimbursed in accordance with an amount not to exceed what VSP would pay a Member Doctor in similar cuaumstances NOTE There is no assurance that this amount will be within the 25 % copayment feature Es EXCLUSIONS AND LIMITATIONS OF BENEFITS PATIENT OPTIONS This Policy is designed to cover visual needs rather than cosmetic materials When a 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 1 Blended lenses 2 Contact lenses (except as noted elsewhere herem) 3 Oversize lenses 4 Photochromrc lenses, tinted lenses except Pink #1 and Pink #2 5 Progressive multrfocal lenses 6 The coating of the lens or lenses 7 The laminating of the lens or lenses 8 A frame that costs more than the Plan allowance 9 Certam hmrtations on low vision care 10 Cosmetic lenses 11 Optional cosmetic processes 12 UV (ultraviolet) protected lenses NOT COVERED There is no benefit for professional services or materials connected with Orthoptics or vision training and any associated supplemental testing, piano lenses (less than a t 38 diopter power), or two pair of glasses in lieu of bifocals, 2 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, 4 Any eye examination, or any corrective eyewear, required by an employer as a condition of employment 5 Corrective vision treatment of an experimental nature such as, but not limited to, RK and PRK Surgery 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 -5- VISION SERVICE PLAN SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE 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 WAIVED ADMINISTRATIVE FEE $2 15 PER ELIGIBLE EMPLOYEE, PER MONTH NOTICE The amount due under this Plan is subject to change, upon renewal, after the end of the Initial Plan Term or any subsequent Plan Term, or upon change of the Schedule of Benefits or a change in any other terms or conditions of the Plan RESOLUTION 96-132 -- Page 1 of 2 RESOLUTION 96 132 OF THE COUNCIL OF THE CITY OF FORT COLLINS APPROVING THE PURCHASE OF VARIOUS INSURANCE FOR THE BENEFITS PROGRAM FROM SUN LIFE OF CANADA FHP HEALTH PLAN VISION SERVICE PLAN AND DELTA DENTAL PLAN WHEREAS Sun Life of Canada FHP Health Plan Vision Service Plan and Delta Dental Plan provide insurance options needed by the City and and WHEREAS the City is in need of these insurance options for its employee benefits program, WHEREAS funds have been allocated in the 1997 budget for such purpose and WHEREAS Section 8-160 (d) (1) b of the Code of the City of Fort Collins authorizes the Purchasing Agent to negotiate the purchase of supplies and services without utilizing a competitive process where the Purchasing Agent determines that although there exists more than one (1) responsible source a competitive process cannot reasonably be used or if used will result in a substantially higher cost to the City will otherwise injure the City's financial interest or will substantially impede the City's administrative junctions or the delivery of services to the public and WHEREAS the Purchasing Agent has made such a determination and has submitted the requisite justification for that determination to the City Manager for approval, and WHEREAS, the City Manager has reviewed and approved the determination that for this acquisition should be exempted from the competitive purchasing requirements and WHEREAS, Section 8-160 (d) (3) requires approval of this purchasing method by the City Council for items costing more than Fifty Thousand Dollars ($50 000) prior to acquisition and WHEREAS the Council has considered the Purchasing Agent's justification for determining that circumstances are appropriate for application of City Code Section 8-160(d)(1)b , and agrees with that determination NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF FORT COLLINS that the Purchasing Agent is hereby authorized to contract for the following insurance coverages as exceptions to the City s competitive purchasing requirements (a) Life and Accidental Death and Dismemberment and Long Term Disability Insurance from Sun Life of Canada in an amount estimated to be $274,000 (b) Stop Loss Insurance from FHP Health Care in an amount estimated to be $120 000 (c) Vision Insurance from Vision Service Plan in an amount estimated to be $68,000 and (d) Dental Insurance from Delta Dental Plan in amount estimated to be $35 000 RES&=ION 96-132 -- Page 2 of 2 Passed and adopted at a regular meeting of the City Council hcicj7this 5th Al otNovember, A D 1996 —Mayor ATTEST C/ � ,A City Clerk 1 10 EMERGENCY CONDITION A condition which requires the Covered Person or Eligible Dependents to seek immediate vision care either from a Member Doctor or Non-VSP Member Provider 1 11 ENROLLEE An employee or member of Group who meets the criteria for eligibility specified under VI ELIGIBILITY FOR COVERAGE 1 12 EXPEREWENTAL 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 or members, and their Eligible Dependents are entitled to become Covered Persons of VSP and receive Plan Benefits in accordance with the terms of such Plan 1 16 KERATOCONUS A developmental or dystrophic deformity of the cornea in which it becomes coneshaped due to a thinning and stretching of the tissue in its central area 1 17 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 18 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 Ma ASPPLAN 10/97 1 19 PLAN ADMINISTRATOR The person specifically so designated on the application or if an administrator is not so designated, the Group The Plan Administrator shall have the authority to control and manage the operation and administration of the Plan on behalf of the Group 120 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 m the Schedule of Benefits attached hereto as Exhibit A 121 RENEWAL DATE The date on which the Plan shall renew, or expire if proper notice is given 122 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 123 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/her to Plan Benefits 124 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 -3- e onnr ♦ XT . 1n1 II TERM, TERMINATION, AND RENEWAL 201 This Plan shall become effective on the date previously stated, 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 parry notifies the other in writing, at least sixty (60) days before the end of the Plan Term, that the parry is unwilling to renew the Plan If such notice is given, the Plan will expire at 12 00 midnight on the last day of the Plan Term, unless the parties reach mutual agreement on its renewal 202 In the event of termination of this Plan by either parry, Group agrees to provide funds for payment pursuant to benefit authorizations issued prior to the termination date, provided such benefit authorizations are fled with VSP within six (6) months after termination of this Plan me ASPPLAN 1/96 III OBLIGATIONS OF VSP 301 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 premiums (Refer to VI ELIGIBILITY FOR COVERAGE for further details ) Following enrollment VSP will provide Vision Care Brochures for Covered Persons Such Brochure 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 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 When a Covered Person desires to receive Plan Benefits from a Member Doctor the Covered Person shall contact VSP or the Member Doctor VSP shall provide Benefit Authorization to the Member Doctor or to the eligible Covered Person for use in receiving Plan Benefits from a Member Doctor Benefit Authorization shall be issued by VSP in accordance with the latest eligibility information furnished by Group and 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 so issued in error Covered Persons are required to obtain the Benefit Authorization prior to obtaining Plan Benefits in cases in which the Covered Person obtains Plan Benefits from a Member Doctor (See Section 5 03 for further details) -5- ASPPLAN 1/96 VSP shall reimburse Member Doctors for Plan Benefits provided to Covered Persons or reimburse Covered Persons for Plan Benefits received from Non -Member Providers, less any applicable copayment, within a reasonable time but not more than forty-five (45) days after VSP has received the completed claim from either Member Doctor or Covered Person VSP shall furnish to Group on a monthly basis, a list of all benefits paid pursuant to this Plan 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 Person's care and are subject to review by VSP Any objections of a Covered Person regarding such decisions may be made to VSP 3 04 Provision of Information to Covered Persons VSP will make available to Covered Persons necessary information describing Plan Benefits and procedures A copy of this Plan will be placed with Group It will also be available at the offices of VSP for copying or inspection by Covered Persons VSP shall provide Covered Persons an updated list of the Member Doctors' names, addresses, and telephone numbers 3 05 Preservation of Confidenttality 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 3 06 Emergency Vision Care In emergency cases when vision care is necessary, Covered Persons may obtain Plan Benefits by contacting a Member Doctor or Non -Member Provider Reimbursement is subject to the same provisions as stated elsewhere herein la ASPPLAN 1/96 IV OBLIGATIONS OF THE GROUP 4 01 Identification of Ehsible 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 VSP with a listing in a form approved by VSP, of all of its Enrollees who are eligible for coverage under this Plan The listing will include designation of family status for each such Enrollee if dependent coverage is provided Group will supply to VSP, on or before the last day of each month a listing of all Enrollees to be added to or deleted from VSP's coverage rosters for the coming month 4 02 Clanns 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 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 VSP may change the Administrative Fee shown on the attached Schedule of Advance Payment and Administrative Fee Exhibit B by giving the Group at least one hundred and twenty (120) days advance written notice Change will not be made more often than once during any twelve (12) month period unless there is a change in the Schedule of Benefits or a change in any other terms and conditions of the Plan -7- ASPPLAN 2/99 Notwithstanding the above, VSP reserves the right to increase amounts due hereunder 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 Penod 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 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 all Plan Benefits provided to Covered Persons after the last period for which amounts due were fully paid, including the grace period 4 05 Other Information to be Provided Group shall furmsh to VSP monthly listings of new Enrollees terminations of eligibility and changes in the family status of covered Enrollees Such information shall be supplied in a form specified by VSP Group shall, when requested, make available for inspection by VSP records having a bearing on the coverage of Covered Persons under this Plan 4 06 Distribution of Requi ed 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 to Enrollees no later than thirty (30) days after receipt so ASPPLAN 1/96