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Home My WebLink AboutCity Council - 2002-31 RESOLUTION NO. 2002-31 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF HUNTINGTON BEACH APPROVING AND IMPLEMENTING THE MEMORANDUM OF UNDERSTANDING BETWEEN THE HUNTINGTON BEACH MANAGEMENT EMPLOYEES' ORGANIZATION(MEO) AND THE CITY OF HUNTINGTON BEACH FOR 12/22/01 THROUGH 12/20/02 The City Council of the City of Huntington Beach does resolve as follows: The Memorandum of Understanding between the City of Huntington Beach and the Huntington Beach Management Employees' Organization ("MEO"), a copy of which is attached hereto as EXHIBIT "A" and by reference made a part hereof, is hereby approved and ordered implemented in accordance with the terms and conditions thereof; and the City Administrator is authorized to execute this Agreement. Such Memorandum of Understanding shall be effective for the term December 22, 2001, through December 20, 2002. PASSED AND ADOPTED by the City Council of the City of Huntington Beach at a regular meeting thereof held on the 15th day of April 204L. j L&a 14A444', Mayor ATTEST: APPROVED AS TO FORM: 4XI �"' t z,-/�� City Clerk ay- oZ City Attorney I ILlo t REVIEWED AND APPROVE INITIATED AND OVED: City Administrator '� Director o dministrative Services O l resolmeo-emp/]2/12/0l Res.No.2002-31 Ex.A M E O M O U Res-No.2002-31 TABLE OF CONTENTS Ex.A PREAMBLE .................................................................................................................................................................................3 ARTICLEI-TERM OF MOU...................................................................................................................................................3 ARTICLE II-REPRESENTATIONAL UNIT/CLASSIFICATIONS....................................................................................3 ARTICLE III-ARTICLE NUMBER RESERVED..................................................................................................................4 ARTICLE IV-EXISTING CONDITIONS OF EMPLOYMENT ..........................................................................................4 ARTICLEV-SEVERABILITY.................................................................................................................................................4 ARTICLE VI-SALARY SCHEDULE...........................................................................................................................I..........4 ARTICLEVII-SPECIAL PAY.................................................................................................................................................5 A. EDUCATIONAL TUITION ...........................................................................................................................5 B. BILINGUAL PAY.....................................................................................................................................................................5 ARTICLEVIII-UNIFORMS.....................................................................................................................................................6 ARTICLE IX-HOURS OF WORK/OVERTIME/ADMINISTRATIVE LEAVE................................................................6 A. OVERTIME............................................................................. .....6 B. ADMINISTRATIVE LEAVE.......................................................................................................................................................6 ARTICLE X-HEALTH AND OTHER INSURANCE BENEFITS .......................................................................................6 A. HEALTH............... ..........................................................................................................................6 . ...................................... 1. Medical..............................................................................................................................................................................6 2: Dental...............................................................................................................................................................................6 3. Vision......................................................... ...................................................................................................................... 7 B. ELIGIBILITY CRITERIA AND COST............--..........................................................................................................................7 1. City Paid Medical and Dental Insurance-Dependents...................................................................................................7 2. City's Contribution to Health Insurance Premiums..................................................................................... .................. 7 a. Year 2002 Premiums.............. .......................................................................................................................................................7 b. Medical Cash-Out...........................................................................................................................................................................7 3. Section 125 Plan.................................................................. .....................8 C. LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT.........................................................................................................S D. LONG TERM DISABILITY INSURANCE.....................................................................................................................................S E. MISCELLANEOUS ...................................................................................................................S L City Paid Premiums While On Medical Disability--•............................................................................................... .......8 2- Insuance Benefits Advisory Committee............................................................................................................................9 3. Health Plan Over-P ments.............................................................................................................................................9 a. Reduction of Employee's Bi-Monthly Salary Warrant...................................................................................................................9 b. Notice of Ineligible Dependents.....................................................................................................................................................9 C. Twelve Month Recovery Period.....................................................................................................................................................9 ARTICLE XI-RETIREMENT BENEFITS .............................................................................................................................9 A. BENEFITS....................................................................................................... ........9 1. Self FundedSup�lementalRetirementBeneft •.............................................................................................................9 2. Medical Insurance for Retirees......................................................................................................................................10 a. Medical Insurance Upon Retirement....................................................................................................... ......................10 b. Premiums Paid Upon Retirement By Use of Unused Sick Leave Benefits................................................................................... 10 B. PUBLIC EMPLOYEES' RETIREMENT SYSTEMREImBURSEMENT AND REPORTING.................................................................10 1. Employee's Contribution.. .......................................................................................10 2. Rollover.......................................................................................... ...............................................................................10 01-02 MEO MOU Final i 04104/02 5:40 PM M E O M O V Res-No.2002-31 TABLE OF CONTENTS Ex.A 3. Two Percent at Age 55 Formula................................... .....11 4. PER.S'Level 3 Survivors Benefits............................... ................................................................. .. ..........................11 ARTICLEXII-LEAVE BENEFITS .......................................................................................................................................11 A. GENERAL LEAVE.................................................................................................................................................................11 LAcerual...........................................................................................................................................................................1] 2. Eligibility and Approval.................................................................................................................................................11 3. Conversion to Cash..............................................................................................:.........................................................11 4, One Week Minimum vacation Requirement...................................................................................................................11 B. HOLIDAYS............................................................................................................................................................................12 C. SICK LEAVE.........................................................................................................................................................................12 D. BEREAVEMENT LEAVE.......................................................................................................................................................-14 E. PATERNITY LEAVE...............................................................................................................................................................14 ARTICLEXIII-CITY RULES................................................................................................................................................14 ARTICLEXIV-MISCELLANEOUS ........................................................................ ........................................................30 A. PHYSICAL EXAM[NATION.....................................................................................................................................................30 B. VEHICLE POLICY..................................................................................................................................................................30 C. DEFERRED COMPENSATION LOAN PROGRAM......................................................................................................................30 ARTICLE XV-CITY COUNCIL APPROVAL.....................................................................................................................31 EXHIBITA-MEO SALARY SCHEDULE ............................................................................................................................32 EXHIBIT B-DELTA DENTAL BROCHURE.......................................................................................................................34 EXHIBIT C-DELTA CARE PLAN BROCHURE ................................................................................................................35 EXHIBIT D-EMPLOYEE HEALTH PLAN BROCHURE .................................................................................................36 EXHIBIT E-RETIREE MEDICAL PLAN ............................................................................................................................37 RETIREESUBSIDY MEDICAL PLAN..................................................................................................................................37 SCHEDULEOF BENEFITS.....................................................................................................................................................38 A. Minimum Eligibility-for Benefits....................................................................................................................................38 B. Disability Retirees...............I.........I.................... .....................-....................................................................................38 C. Maximum Monthly Subsidy Payments......................................................................................:.....................................38 INDEMNITY HEALTH PLAN,EMPLOYEES/RETIREES' ...............................................................................................40 RETIREE SUBSIDY MEDICAL PLAN/MISCELLANEOUS PROVISIONS ....................................................................41 A. Eli gib ........................................................................................................................................................................41 B. Benefits...........................................................................................................................................................................42 C. Subsidies.........................................................................................................................................................................42 D. Medicare........................................................................................................................................................................43 E. Cancellation...................................................................................................................................................................43 EXHIBIT F-VEHICLE USE/ASSIGNMENT .......................................................................................................................45 EXHIBIT G-PHYSICAL EXAMINATION DESCRIPTION..............................................................................................46 01-02 MEO MOU Final ii 04/04/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A MEMORANDUM OF UNDERSTANDING Between THE CITY OF HUNTINGTON BEACH (Hereinafter called CITY) and THE HUNTINGTON BEACH MANAGEMENT EMPLOYEES' ORGANIZATION (Hereinafter called ORGANIZATION or MEO) PREAMBLE This Memorandum of Understanding is entered into by and between the City Of Huntington Beach, a Municipal Corporation of the State of California, herein called "City", and the Huntington Beach Management Employees' Organization, a California Organization, herein called "Association". WHEREAS, pursuant to California law, the City, acting by and through its designated representatives, duly appointed by the governing body of said city, and the representatives of the Association, a duly recognized employee association have met and conferred in good faith and have fully communicated and exchanged information concerning wages, hours, and other terms and conditions of employment for the period December 22, 2001 through December 20, 2002. WHEREAS, except as otherwise expressly provided herein, all terms and conditions of this Agreement shall apply to all employees represented by the Association, and WHEREAS, the representatives of the City and Association desire to reduce their agreements to writing, NOW THEREFORE, this Memorandum of Understanding is made, to become effective December 22, 2001 and it is agreed as follows. ARTICLE I - TERM OF MOU This Agreement shall be in effect for a period of one (1) year commencing December 22, 2001, and ending at midnight, December 20, 2002. The City and the Association agree to exchange proposals regarding a successor Memorandum of Understanding (MOU) on or prior to August 15, 2002. ARTICLE II - REPRESENTATIONAL UNIT/CLASSIFICATIONS A- It is recognized that Association is the employee association which has the right to meet and confer in good faith with the City on the behalf of employees whose 01-02 MEO MOU Final 3 04/04/02 9:40 PM MEO MOU Res.No.2002-31 Ex.A classifications are listed in Exhibit A, attached hereto and incorporated by reference herein. ARTICLE III -ARTICLE NUMBER RESERVED ARTICLE IV - EXISTING.CONDITIONS OF EMPLOYMENT Except as otherwise expressly provided herein, the adoption of this Memorandum of Understanding shall not change existing benefits and terms and conditions of employment which have been established in prior Memoranda of Understanding, and/or provided for in the Personnel and Departmental Rules of the City of Huntington Beach. ARTICLE V - SEVERABILITY If any section, subsection, sentence, clause, phrase or portion of this MOU or any additions or amendments thereof, or the application thereof to any person, is for any reason held to be invalid or unconstitutional by the decision of any court of competent jurisdiction, such decision shall not affect the validity of the remaining portions of this resolution or its application to other persons. The City Council hereby declares that it would have adopted this MOU and each section, subsection, sentence, clause, phrase or portion, and any additions or amendments thereof, irrespective of the fact that any one or more sections, subsections, sentences, clauses, phrases or portions, or the application thereof to any person, be declared invalid or unconstitutional. ARTICLE VI - SALARY SCHEDULE A. Salary Schedule 1. All MEO represented employees shall be required to utilize direct deposit of payroll checks effective April 26, 2002. 2. Permanent employees shall be compensated at hourly salary rates by job type and pay grade including three percent (3%) effective March 2, 2002 as set forth in Exhibit A attached hereto and incorporated herein by this reference. 3. Marine Safety Chief The salary range of the Marine Safety Chief shall be a minimum of 18% above the Marine Safety Lieutenant but shall be no higher than 15% below the Community Services Department Deputy Director. 01-02 MEO MOU Final 4 04/04/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A ARTICLE VII - SPECIAL PAY A. Educational Tuition: 1, Upon approval of the Department Head and the Human Resources Officer, permanent employees . may be compensated for courses from accredited educational institutions. Tuition reimbursement shall be limited to job related courses or job related educational degree objectives and requires prior approval by the Department Head and Human Resources Officer. 2, Education costs shall be reimbursed to permanent employees on the basis of a full refund for tuition, books, parking (if a required fee) and any other required fees upon presentation of receipts. However, the maximum reimbursement shall be not more than one thousand two hundred and fifty dollars ($1,250) in any fiscal year period. 3, If a permanent employee was enrolled in a degree with approval from their Department Head and the Human Resources Officer prior to April 15, 2002. Education costs shall be paid to employees on the basis of full refund for tuition, fees, books and supplies; provided, however, that maximum reimbursement shall be at the rates currently in effect in the University of California System. Employee may be compensated for actual cost of tuition, books, fees, at accredited educational institutions that charge higher rates than the University of California, if it can be demonstrated by the employee that said educational institutional presents the only accredited course or program within a reasonable commuting distance of the employee. 4, Reimbursements shall be made when the employee presents proof to the Human Resources Officer that he/she has successfully completed the course with a grade of"C" or better; or a "Pass" if taken for credit. 5. The City and the Association agree to convene an "Education Committee" that will consist of two individuals from the City and two individuals from the Association to meet on the topic of tuition reimbursement. The committee will meet between July 1, 2002 and August 30, 2002. The resulting committee report shall be a possible subject of negotiation in a successor MOU. B. Bilingual Pay: Permanent employees who are required by their Department Head to use Spanish, Vietnamese, or Sign Language skills as part of their job assignment, shall be paid an additional five-percent (5%) of their basic hourly rate in addition to their regular bi- weekly salary. Permanent employees may accept assignments utilizing bilingual skills in other languages on a short-term assignment with approval by the City Administrator. Such employees shall receive the additional five percent (5%) for 01-02 MEO MOU Final 5 04/04102 5:40 PM MEO MOU Res.No.2002-31 Ex.A every bi-weekly pay period that the assignment is in effect. In order to be eligible for said compensation, employee's language proficiency will be tested and certified by the Human Resources Officer or designee. ARTICLE VIII - UNIFORMS City agrees to provide uniforms to employees on active duty who are required to wear uniforms to the same extent as in the past. ARTICLE IX - HOURS OF WORK/OVERTIMEIADMINISTRATIVE LEAVE A. Overtime: Employees represented herein shall not be eligible for paid overtime compensation. B. Administrative Leave: All unit employees shall be entitled to 40 hours of administrative leave upon working forty (40) additional hours above their regular work schedule per calendar year. Such employee may earn additional administrative leave, on an hour for hour basis, for hours worked in excess of seventy-five (75) in a calendar year. Time off for Police Department fitness programs and flexible scheduling that is agreed .to between the employee and Department Head are exempt from the 75-hour provision. ARTICLE X - HEALTH AND OTHER INSURANCE BENEFITS A. Health 1. Medical a. The City shall continue to provide group medical benefits to all employees with coverage and benefits comparable to the group medical plans currently in effect. b. The coverage and benefits provided under the City Health Plan shall be as set forth in the Plan Document revised January 1, 1995 and modified from time to time to comply with changes in law requirements or the City's stop- loss re-insurance and developments in medicine. 2. Dental The City shall provide an indemnity dental insurance plan comparable to Delta Dental Plan (Group Policy #4729, Exhibit B) and a prepaid dental insurance plan comparable to the Delta Care Plan (Group Policy #4002, Exhibit B). 01-02 MEO MOU Final 6 04/04/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A 3. Vision The City shall provide a Vision Care Plan for employees and their dependents comparable to the group plan currently in effect. B. Eligibility Criteria and Cost 1. City Paid Medical and Dental Insurance - Dependents The City will assume payment, subject to the limitations set forth in Article X.B.2. for dependent health and dental insurance effective the first of the month following one month of employment. 2. City's Contribution to Health Insurance Premiums a. Year 2002 Premiums The City "caps" its contributions toward employee monthly health insurance premiums by category (single, two-party, family) and plan (medical, dental, vision) at the rate in effect January 1, 2002 for the year ending December 31, 2002. Monthly Delta Delta VSP Premium City Plan Health Net Dental Care Safeguard (Vision) Single 280.51 236.31 41.31 23.00 16.20 17.58 Two-Party 554.70 517.79 78.92 39.11 29.16 17.58 Family 679.15 682.46 112.10 59.81 37.22 17.58 (3 or more) The City will reimburse employees represented by the association the cost of medical and dental premiums paid by the employee for the period of March 2, 2002 through April 12, 2002. All medical and dental reimbursements shall be subject to all applicable state and federal taxes. b. Medical Cash-Out If an employee is covered by a medical program outside of a City-provided program (evidence of which must be supplied to Administrative Services Department, Risk Management Division), they may elect to discontinue City medical coverage and receive ninety two dollars and thirty-one cents ($92.31) bi-weekly to deposit into their Deferred Compensation account or any other pre-tax program offered by the City. 01-02 MEO MOU Final 7 04104/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A 3. Section 125 Plan This plan allows employees to use pre-tax salary to pay for regular child care, adult dependent care and/or medical expenses. C. Life and Accidental Death and Dismemberment Each employee under age sixty-five (65) shall be provided with $45,000 life insurance and $45,000 accidental death and dismemberment insurance paid for by the City. Each employee shall have the option, at his or her own expense, to purchase additional amounts of life insurance and accidental death and dismemberment insurance to the extent provided by the City's current providers. Evidence of insurability is contingent upon total participation in additional amounts. D. Long Term Disability Insurance This program provides, for each incident of illness or injury, a waiting period of thirty (30) calendar days, during which the employee may use accumulated sick leave, general leave pay, or the employee may elect to be in a non-pay status. Subsequent to the thirty (30) day waiting period, the employee will be covered by an insurance plan paid for by the City, providing 66 2/3 percent of the first $12,500 of the employee's basic monthly earnings. The maximum benefit period for disability due to accident or sickness shall be to age 65. Days and months refer to calendar days and months. Benefits under the plan are integrated with sick leave, Worker's Compensation, Social Security and other non- private program benefits to which the employee may be entitled. Disability is defined as: "The inability to perform all of the duties of regular occupation during two years, and thereafter the inability to engage in any employment or occupation for which he is fitted by reason of education, training or experience." Rehabilitation benefits are provided in the event the individual, due to disability, must engage in another occupation. Survivor's benefits continues plan payment for three (3) months beyond death. A copy of the plan is on file in the Administrative Services Department. E. Miscellaneous 1. City Paid Premiums While on Medical Disability When an employee is off work without pay for reason of medical disability, the City shall maintain the City paid employee's insurance premiums during the period the employee is in a non-pay status for the length of said leave, not to exceed twenty-four (24) months. 01-02 MEO MOU Final 8 04/04/02 5:40 PM MEO MOU Res. No.2002-31 Ex.A 2. Insurance and Benefits Advisory Committee The City and the Association agree to participate in a citywide joint labor and management insurance and benefits advisory committee to discuss and study issues relating to insurance and benefits available for employees. 3. Health Plan Over-Payments Unit members shall be responsible for accurately reporting the removal of ineligible dependents from health plan coverages. The City shall have the right to recover any premium paid by the City, including premiums to its self-insured plan, on behalf of ineligible dependents. Recovery of such over-payments shall be made as follows: a. Reduction of Employee's Bi- Weekly Salary Warrant The employee's bi-weekly salary warrant shall be reduced by one-half of the amount of the bi-weekly over-payment. Such reduction shall continue until the entire amount of the over-payment is recovered. b. Notice of Ineligible Dependents The City shall use its best efforts to advise all unit members of their obligation to report changes in the status of dependents, which affect their eligibility. c. Twelve Month Recovery Period The City shall be entitled to recover a maximum of twelve (12) months of premium over-payments. Neither the employee nor the dependent shall be liable to the City other than as provided herein. ARTICLE XI - RETIREMENT BENEFITS A. Benefits 1. Self Funded Supplemental Retirement Benefit Employees hired prior to August 17, 1998 are eligible for the Self-Funded Supplemental Retirement Benefit, which provides that: a. In the event a member elects Option #2 (Section 21456) or Option #3 (Section 21457) of the Public Employees' Retirement Law, the City shall pay the difference between such elected option and the unmodified allowance which the member would have received for his or her life alone. This payment shall be made only to the member, shall be payable by the City during the life of the member, and upon that member's death, the City obligation shall cease. The method of funding this benefit shall be at the sole discretion of the City. This benefit is vested for employees covered by this agreement. (Note: The options provide the allowance is payable to the 01-02 MEO MOU Final 9 04/04/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A member until his or her death, and then either the entire allowance (Option #2) or one-half of the allowance (Option #3) is paid to the beneficiary for life.) b. Employees hired on or after August 17, 1998 shall not be eligible for this benefit referenced in A.1:a. herein above. 2. Medical Insurance for Retirees a. Medical Insurance Upon Retirement Upon retirement, whether service or disability, each employee shall have the following options in regards to medical insurance under City sponsored plans: 1) With no change in benefits, retirees can stay in any of the plans offered by the City, at the retiree's own expense, for the maximum time period required by Federal Law (COBRA), or 2) Retirees retiring after approval of this MOU may participate in the Retiree Medical Plan, attached hereto as Exhibit E, or the HMO Plan currently being offered to retirees, based upon the eligibility requirements described in Exhibit E. b. Premiums Paid Upon Retirement By Use of Unused Leave Benefits Employees electing to participate in the City's group health insurance program after retirement may cause the premiums to be paid by the City out of any available funds due and owing them under the terms of this agreement for unused sick leave and general leave benefits upon retirement. B. Public Employees' Retirement System Reimbursement and Reporting 1. Employee's Contribution Each employee covered by this Agreement shall continue to be reimbursed once bi-weekly in an amount equal to 7% of the employee's base salary (9% for safety employees) as a pickup of the employee's contribution, or portion of such contribution, to the Public Employees' Retirement System. The above PERS pickup is not base salary but is done pursuant to Section 414(h)(2) of the Internal Revenue Code. 2. Rollover No unit employee shall be allowed to continue the rollover benefit provided in Article XI(B)(2) of the 1991/1993 MOU beyond January 31, 1994. 01-02 MEO MOU Final 10 04/04/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A 3. Two Percent at Age 55 Formula Unit employees shall be covered by the two percent at age 55 formula (2% @ 55) as identified in Section 21354. 4. PERS Level 3 Survivors Benefits Unit employees shall be covered by the 1959 Level 3 Survivors Benefits. ARTICLE KII - LEAVE BENEFITS A. General Leave 1. Accrual Employees accrue leave at the accrual rates outlined below. General leave may be used for any purpose, including vacation, sick leave, and personal leave. Years of Service General Leave Allowance First through Fourth Year 176 Hours Fifth through Ninth Year 200 Hours Tenth through Fourteenth Year 224 Hours Fifteenth Year and Thereafter 256 Hours 2. Eligibility and Approval General leave must be pre-approved except for illness, injury or family sickness, which may require a physician's statement for approval. Accrued general leave may not be taken prior to six (6) months' service except for illness, injury or family sickness. General leave accrued time is to be computed from hiring date anniversary. Members shall not be permitted to take general leave in excess of actual time earned. Members shall not accrue general leave in excess of six hundred hours (600)- Employees may not use their general leave to advance their separation date on retirement or other separation from employment. 3. Conversion to Cash Once during each fiscal year, each employee shall have the option to convert into a cash payment or deferred compensation up to a total of one hundred twenty (120) hours of earned general leave benefits. The employee shall give two (2) weeks advance notice of his/her desire to exercise such option. 4. One Week Minimum Vacation Requirement The Deputy City Treasurer shall take a minimum of one week, (i.e., five consecutive work days) paid vacation each calendar year. 01-02 MEO MOU Final 11 04104/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A B. Holidays The following are paid holidays: 1. New Year's Day 2. Martin Luther King Jr., (third Monday in January) 3. Presidents Day (third Monday in.February 4. Memorial Day (last Monday in May) 5. Independence Day (July 4) 6. Labor Day (first Monday in September) 7. Veteran's Day (November 11) 8. Thanksgiving Day (fourth Thursday in November) 9. The Friday after Thanksgiving 10. Christmas Day (December 25) 11. Any day declared by the President of the United States to be a national holiday and adopted as an employee holiday by the City Council of Huntington Beach. Holidays which fall on Saturday shall be observed the preceding Friday, and those falling on Sunday shall be observed the following Monday. C. Sick Leave 1. Accrual — No employee shall accrue sick leave after December 24, 1999. 2. Credit —Employees assigned to MEO shall carry forward their sick leave balance and shall no longer accrue sick leave credit. 3. Usage — Employees may use accrued sick leave for the same purposes for which it was used prior to December 25, 1999, 4. Family Sick Leave — Sick leave may be used for an absence due to illness of the employee's spouse or child when the employee's presence is required at home, provided that such absences shall be limited to five (5) days per calendar year. 5. Pay Off At Termination a. Employees covered by this agreement and on the payroll on November 20, 1978 shall be entitled to the following sick leave payoff plan: At involuntary termination by reason of disability, or by death, or by retirement, employees shall be compensated at their then current rate of pay for seventy-five percent (75%) of all unused sick leave accumulated as of 01-02 MEO MOU Final 12 04/04/02 5.40 PM MEO MOU Res.No.2002-31 Ex,A July 1, 1972, plus fifty percent (50%) of unused sick leave accumulated subsequent to July 1, 1972, up to a maximum of 720 hours of unused, accumulated sick leave, except as provided in paragraph 4 below. Upon termination for any other reason, employees shall be compensated at their then current rate of pay for fifty percent (50%) of all unused, accumulated sick leave, up to a maximum of 720 hours of such accumulated sick leave. b. Employees hired after November 20, 1978 shall be entitled to the following sick leave payoff plan: Upon termination, all employees shall be paid, at their then current salary rate, for twenty-five percent (25%) of unused, earned sick leave to 480 hours accrued, and for thirty-five percent (35%) of all unused, earned sick leave in excess of 480 hours, but not to exceed 720 hours, except as provided in paragraph 4 below. c. Except as provided in paragraph 4 below, no employee shall be paid at termination for more than 720 hours of unused, accumulated sick leave. However, employees may utilize accumulated sick leave on the basis of "last in, first out" meaning that sick leave accumulated in excess of the maximum for payoff may be utilized first for sick leave, as defined in Personnel Rule 18- 8. d. Employees who had unused, accumulated sick leave in excess of 720 hours as of July 5, 1980, shall be compensated for such excess sick leave remaining on termination under the formulas described in paragraphs 1 and 2 above. In no event shall any employee be compensated upon termination for any accumulated sick leave in excess of the "cap" established by this paragraph (i.e., 720 hours plus the amount over 720 hours existing on July 5, 1980). Employees may continue to utilize sick leave accrued after that date in excess of such "cap" on a "last in, first out" basis. e. To the extent that any "capped" amount of excess sick leave over 720 hours is utilized, the maximum compensable amount shall be correspondingly reduced. (Example: Employee had 1,000 hours accumulated. Six months after July 5, 1980, employee has accumulated another 48 hours. Employee is then sick for 120 hours. Employee's maximum sick leave "cap" for compensation at termination is now reduced by 72 hours to 928 hours.) f. Employees electing to participate in the City's group health insurance program after retirement may cause the premiums to be paid by the City out of any available funds due and owing them under the terms of this agreement for unused sick leave benefits upon retirement. 01-02 MEO MOU Final 13 04/04/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A D. Bereavement Leave Employees shall be entitled to bereavement leave not to exceed twenty-four (24) work hours in each instance of death in the immediate family. Immediate family is defined as father, mother, sister, brother, spouse, children, grandfather, grandmother, stepfather, stepmother, step grandfather, step grandmother, grandchildren, stepsisters, .stepbrothers, mother-in-law, father-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepchildren, or wards of which the employee is the legal guardian. E. Paternity Leave Fathers may utilize accumulated sick leave in addition to leave and administrative leave, or take unpaid leave, to care for their newborn or adopted child (or children if more than one is born or adopted at the same time) up to a total of 160 hours annually. ARTICLE XIII - CITY RULES A. Personnel Rules The City and the Association agree to implement the following rules and accordingly revise the Personnel Rules as described herein: 1. Rule 5 — Recruitment and Examination Procedure a) 5-4 — Order of Certification Whenever certification is to be made, the eligibility lists, if active and not exhausted shall be used in the following order: 1) Re-employment list 2) Promotional list 3) Employment List If fewer than five (5) names of persons willing to accept appointment are on the list from which certification is to be made, then additional eligibles shall be certified from the various lists next lower in order of preference until five (5) names are certified. If there are fewer than five (5) names on such lists, there shall be certified the number thereon. In such case, the appointing authority may demand certification of five (5) names and examinations shall be conducted until five (5) names may be certified. In the event the appointing authority does not choose to appoint from the five (5) names certified, a new examination may be requested. In the event another examination is conducted, those names shall be merged with others already on the list in order of scores. 01-02 MEO MOU Final 14 04/04102 5:40 PM MEO MOU Res.No.2002-31 Ex.A b) 5-14 — Promotional Exams Promotional examinations may be conducted whenever, in the opinion of the Human Resources Officer, after consultation with the department head, the need of the service so requires; provided, however, a promotional examination may not be given unless there are two (2) or more candidates eligible. Only employees who meet the requirements for the vacant position may compete in promotional examinations. Promotional examinations may include any of the selection techniques, or any combination thereof, mentioned in Section 5-13. Additional factors including, but not limited to, performance rating and length of service may be considered. A promotional employment list shall be established after the administration of a promotional examination, and such list shall contain the name(s) of those that passed the examination. 2. Rule 7 — Discipline a) 7-2 — Causes for Discipline 12) Possession, use or sale of illegal narcotics or habit-forming drugs, while on-duty or on City property. 14) Conviction of any felony or a misdemeanor with a job nexus. A plea or.verdict of guilt, or a conviction following a plea of nolo contenders, is deemed to be a conviction within the meaning of this section. 15) Participating in an unlawful strike, work stoppage, slowdown, or using or attempting to use sick leave to accomplish the same purpose as a strike, work stoppage, or slowdown. 3. Rule 8 — Termination a) 8-1 — Medical Examination; Evaluation of Employee's Work Capacity. Demotion, Transfer or Termination of Appointment At any time a department head has reasonable cause to believe that an employee may not be able to perform the duties of hislher position for physical or psychological reasons, such department head shall consult with the Human Resources Officer regarding such belief. If the Human Resources Officer concurs, the department head may order the employee to submit to a medical or psychological examination. The employee shall be offered the opportunity, in writing, to select from a panel of three to five physicians or psychologists to conduct the examination. The cost of such examination shall be paid by the City and, to the extent practicable, shall be scheduled during the work hours with no loss of pay. 01-02 MEO MOU Final 15 04/04/02 5.40 PM MEd MOU Res.No.2002-31 Ex_A The department head shall review the medical or psychological report and shall consult with the Human Resources Officer regarding the physician's assessment of the employee's ability to perform the duties of his/her position. Any decision regarding such employee shall be made in accordance with the Americans with Disabilities Act. Notwithstanding any other provision of this rule, an employee being evaluated for medical or psychological fitness to perform the duties of his/her position may apply for another position in the competitive service for which he/she has qualified. If such employee is qualified and can perform the duties of a lower paying vacant position for which he/she has applied, he/she will be placed in such position, without competitive examination, subject to the approval of the department head. (The City and Association agree to meet biannually to discuss the 8-1 process). b) 8-3 — Layoff in Accordance with Length of Service The City and the Association agree that the first sentence in Personnel Rule 8-3 shall be modified to read as follows: Layoff shall be made in accordance with the relative length of the last period of continuous service of the employees in the class of layoff, provided, however, that no permanent employee shall be laid off until all temporary, acting and probationary employees in the competitive service holding positions in the same class are first laid off. c) 8-11 — Re-Employment With the approval of Human Resources Officer, an employee who has resigned in good standing from the competitive service may be re- employed to his/her former position, if vacant, or to a vacant position in the same or comparable class within one (1) year from date of resignation in accordance with Rule 5-21. If such re-employment commences within ninety days Of the effective date of resignation, the employee shall not be considered a new employee for vacation and seniority purposes. 4. Rule 12 — Classification Plan a) 12-10 — Temporary Employees Employment on a basis other than permanent or probationary to a permanently budgeted position not to exceed 1000 hours in any twelve (12) month period. Employees occupying temporary positions shall not be included in the competitive service and shall not be subject to these rules and regulations. 01-02 MEO MOU Final 16 04/04/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A 5. Rule 14 —Additional Ppy and Pgy Adjustments a) 1,4-6 — Salary Advancements to Meet Recruiting Problems or to Give Credit for Prior Service. Application for Other Advancements The Department Head, through the Human Resources Officer and with the approval of the City Administrator may make an appointment at any step above the minimum salary rate to classes or positions in order to meet recruiting problems to obtain a person who has extraordinary qualifications, or to give credit for prior city service in connection with appointments, promotions, reinstatements, transfers, reclassifications, or demotions. Salary adjustments within the salary range for the class, other than merit salary adjustments authorized by Section 14-1, may be approved by the City Administrator, upon recommendation of the department head through the Human Resources Officer. Such recommendation shall include the reason(s) for the adjustment, whether the advancement is to be permanent or temporary, and an effective date. 6. Rule 18 —Attendance and Leaves a) 18-16 — Industrial Accident Leave In the event a permanent employee, who is a miscellaneous member of the Public Employees' Retirement System (PERS), is temporarily totally disabled as a result of an injury or illness arising out of and in the course of employment and covered by the State of California Workers' Compensation Insurance and Safety Act, resulting light duty assignments due to the injury or illness or absences from work shall be considered Industrial Accident Leave as that term is defined by this rule. A permanent employee eligible for Industrial Accident Leave shall receive compensation from the City in an amount equal to the employee's regular rate of salary during such period of temporary total disability. Benefits received under this rule shall be in lieu of statutory Workers' Compensation benefits. Industrial Accident Leave shall continue during all absences resulting from the injury or illness, including those absences attributable to doctor's appointments, therapy, or other follow-up medical visits, but in no case exceeding one year of accumulated absences attributable to the same injury or illness. In the event an employee is temporarily, totally disabled by coinciding qualifying injuries or illnesses, periods of absences shall be applied concurrently to all qualifying injuries or illnesses. Industrial Accident Leave compensation shall begin on the first day an eligible employee is absent due to a qualifying injury or illness as defined above. Industrial accident Leave compensation will terminate on the earliest of the following: 01-02 MEO MOU Final 17 04/04/02 5:40 PM MEO MOO Res.No.2002-31 Ex.A 1) The date upon which the injury or illness giving rise to eligibility for compensation under this rule is declared permanent and stationary by a treating or examining physician; or 2) The date PERS approves an application for disability retirement benefits filed by the employee or by the City; or 3) The employee receives thirty (30) days advance notice and refuses to submit to a medical examination ordered by PERS pursuant to Government Section 21154 or otherwise refuses to cooperate with PERS in determining whether the employee is incapacitated for the performance of duty; or 4) The employee receiving Industrial Accident Leave Compensation applies for service-connected retirement benefits; or 5) The employment of the affected employee is otherwise separated. If an injured worker remains temporarily disabled after receiving one year of Industrial Accident Leave for accumulated absences or light duty work attributable to the same injury or illness, the employee will receive temporary total disability benefits as specified by the State of California Workers' Compensation Insurance and Safety Act. Any period of time during which an employee is absent from work by reason of injury or illness for which he or she is entitled to receive Industrial Accident Leave compensation will not constitute a break in continuous service for the purposes of salary adjustments, sick leave, vacation accruals, and length of service computation. In the event an employee who is receiving or has received Industrial Accident Leave compensation makes a claim or initiates legal action against a third party for allegedly causing or contributing to the injury or illness resulting in the inability to work, the employee is required to notify in writing the City's Risk Management Division of the claim or commencement of such action within ten (1 a) days of the claim or such commencement. The City retains its rights of subrogation in all such instances. b) 18-19 — Maternity Leave The City and the Association agree to modify the present Personnel Rule 18-19 Maternity Leave to read as follows: "A permanent employee shall be entitled to a leave of absence without pay due to inability to work due to pregnancy. The employee will be entitled to use available sick leave during this period. Said leave must be requested in writing from the Department Head and must include written notification from the employees physician stating the last day the employee may work and the estimated duration of 01-02 MEO MOU Final 18 04/04/02 5:40 PM MEO MOu Res,No.2002-31 Ex.A leave. The employee must obtain written authorization to return to work from the attending physician. Said authorization must be filed with the Department Head and the Human Resources Officer." c) 18-20 — Leave of Absence without Pay The City and the Association agree that the following sub-paragraph "C" shall be added to Personnel Rule 18-20. Leave of Absence without Pay: Leave of absence without pay, for medical disability reasons, shall be restricted to six (6) months. 7. Rule 19 — Grievance Procedure Non-Disciplinary Matters a) 19-5 Grievance Procedure 1) Step 4 — City Administrator If the grievance is not settled under Step 3, the grievance may be presented to the City Administrator in accordance with the following procedure: Within fifteen (15) days after the time the decision is rendered under Step 3 above, a written statement of the grievance shall be filed with Human Resources Officer who shall act as hearing officer and shall set the matter for hearing within fifteen (15) days thereafter and shall cause notice to be served upon all interested parties. The Human Resources Officer, or his representative, shall hear the matter de novo and shall make recommended findings, conclusions and decision in the form of a written report and recommendation to the City Administrator within five (5) days following such hearing. The City Administrator may, in his discretion, receive additional evidence or argument by setting the matter for hearing within ten (10) days following his receipt of such report and causing notice of such hearing to be served upon all interested parties. Within five (5) days after receipt of report, or the hearing provided for above, if such hearing is set by the City Administrator, the City Administrator shall make written decision and cause such to be served upon the employee or employee organization and the Human Resources Officer. 2) Step 5 — Personnel Board Hearing Hearing. As soon as practicable thereafter, the Human Resources Officer shall set the matter for hearing before a hearing officer either selected by mutual consent of the parties or from a list provided by the Personnel Commission. Ratification of the hearing officer selected by mutual consent of the parties, if from a list approved by the Personnel Commission, shall not require separate approval or- 01-02 MEO MOU Final 19 04104/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A ratification by the Personnel Commission. The hearing officer shall hear the case and make recommended findings, conclusions and decision in the form of a written report and recommendation to the Personnel Commission. In lieu of the hearing officer process, the Personnel Commission may agree to hear a case directly upon submission of the case by mutual consent of the parties. 8. Rule 20 -Disciplinary Procedure and Appeal a) 20-1- Purpose The purpose of this rule is to provide a procedure for recommending and imposing discipline against City employees, and a means by which an employees may administratively appeal any such disciplinary action. b) 20-2 — Disci lina Procedures 1) Notice„of Proposed Adverse Action For disciplinary demotions, suspensions or dismissals, an employee shall be served a written Notice of Proposed Adverse Action by the employee's department head, Or his/her designee, or by certified mail, prior to the proposed disciplinary action taking effect. The notice shall state the reasons for and charges upon which the proposed action is based, and the effective date of the action the right to respond and the employer's right to representation. A copy of all materials upon which the proposed action is based shall be attached to the notice. 2) Employee's Right to Respond The employee shall be given a minimum of ten (10) calendar days to respond orally and/or in writing to the charges upon which the proposed action is based. The employee's response shall be made to and/or before his/her department head. 3) Time Off The employee shall be given reasonable time off with pay to attend disciplinary meetings. 4) Final Notice of Decision After an employee has responded to or waived his/her right to respond to the proposed adverse action, the employee shall be served with a final Notice of Decision from his/her department head. The final written Notice of Decision shall state whether or not the proposed action shall be taken or modified, and the reasons therefore and effective date or the action. 01-02 MEO MOU Final 20 04/04102 5:40 PM MEO MOU Res.No.2002-31 Ex.A c) 20-3 —Appeal to Personnel Commission Disciplinary action involving the termination, suspension, demotion or other reduction in pay may be appealed to the Personnel Commission for de novo hearing and final determination in accordance with the following procedure: 1} Request for Appeal Within five (5) days after the employee's receipt of a final Notice of Discipline, a written request for an appeal to the Personnel Commission shall be submitted to the Human Resources Officer. 2) Hearing As soon as practicable thereafter, the Human Resources Officer shall set the matter for hearing before a hearing officer. The hearing officer shall hear the case without the Board and shall make recommended findings, conclusions and decision in the form of a written report and recommendation to the Board. 3) Final Decision The Board shall consider the written report and recommendations of the hearing officer and after due deliberation in executive session, shall render a decision in the matter which shall be final and binding on all parties,and from which there shall be no further appeal. d) 20-4 — Supplemental Hearing by Personnel Board 1) The Board may, in its sole discretion, after it has received the written report and recommendation of the hearing officer, set the matter for private hearing for the purpose of receiving additional evidence or argument. In the event the Board sets a private hearing for such purposes, the Human Resources Officer shall give written notice to all parties concerned in such matter. 2) The Board, following a consideration of the hearing officer's written report and recommendation and deliberation thereon and any supplemental hearing before the Board, shall make findings, conclusions and decisions which shall be final and binding on all parties and from which there shall be no further appeal. e) 20-5 — Employee Status on Pending Appeal Notwithstanding the provisions of Rule 7, Section 7-4 (Suspension with Pay), the disciplinary action shall be effective pending an appeal to the Personnel Commission. 01-02 MEO MOU Final 21 04/04/02 5:40 PM MEO MOU Res.No_2002-31 Ex.A 9. Rule 21 —Grievance Procedures - General a) 21-7 Hearing Officers The hearing officer provided for in Rules 19 and 20 shall be from a list provided by the Personnel Commission or one selected by mutual consent of the parties. b) 21-12 Time. Extension of The City and the employee, or employee organization may, by mutual consent, extend the time period within which an act must occur in the processing of grievances. c) 21-13, Time Extension, Grievances The City and the employee, or employee organization may, by mutual consent, extend the time periods within which an act must occur in the processing of grievances. B. Employer-Employee Relations Resolution 1. Modification of Section 7 — Decertification and Modification a) The City and the Association desire to maintain labor stability within the representational unit to the greatest extent possible, consistent with the employee's right to select the representative of his or her own choosing. For these purposes, the parties agree that this Agreement shall act as a bar to appropriateness of this unit and the selection of the representative of this unit, except during the month of August prior to the expiration of this Agreement. Changes in bargaining unit shall not be effective until expiration of the MOU Except as may be determined by the Personnel Commission pursuant to the procedures outlined below. This provision shall modify and supersede the time limits, where inconsistent, contained in Section 7 of the current Employer-Employee Relations Resolution of the City of Huntington Beach. b) The City and the Association have agreed to a procedure whereby the City, by and through the Human Resources Officer, would be entitled to propose a Unit Modification. The Association and the City agree to jointly recommend a modification of the City of Huntington Beach Employer- Employee Relations Resolution (Resolution Number 3335) upon the City's having completed its obligation to meet and confer on this issue with all other bargaining units. The proposed changed to the Employer-Employee Relations Resolution is as follows: 01-02 MEO MOU Final 22 04104/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A 7.3 Human Resources Officer Motion of Unit Modification - The Human Resources Officer may propose, during the same period for filing a petition for decertification, that an established unit be modified in accordance with the following procedure: 1. The Human Resources Officer shall give written notice of the proposed modi#ication(s); to any affected employee organization and any affected employees. 2. The Personnel Commission shall hold a meeting concerning the proposed modification(s) at which time all affected employee organizations and employees shall be heard; 3. Thereafter, the Personnel Commission shall determine the composition of the appropriate unit or units and shall give written notice of such determination to the affected employee organizations and any affected employees. The City Administrator, employee organization or employee aggrieved by' an appropriate unit determination of the Personnel Commission may, within ten (10). days of notice thereof, request a review of such determination by the City Council. Within thirty (30) days of receipt of a request to review a unit determination of the Personnel Commission the City Council shall review the matter. The City Council's decision shall be final. 4. Except as provided otherwise in this MOU, the salary, benefit and working conditions specified by this MOU shall be provided to employees in classifications listed in Exhibit A and have completed or are in the process of completing a probationary period in a permanent position in the competitive service in which the employee regularly works twenty hours or more per week. C. Rules Governing Layoff, Reduction in Lieu of Layoff and Re-Employment 1. Part 1 — Layoff Procedure a) General Provisions 1) Whenever it is necessary, because of lack of work or funds to reduce the staff of a City department, employees may be laid off pursuant to these rules. 01-02 MEO MOU Final 23 04/04/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A 2) Whenever an employee is to be separated from the competitive service because the tasks assigned are to be eliminated or substantially changed due to management-initiated changes, including but not limited to automation or other technological changes, it is the policy of the City that steps be taken by the Human Resources Division on an interdepartmental basis to assist such employee in locating, preparing to qualify for, and being placed in other positions in the competitive service. This shall not be construed as a restriction on the City government in effecting economies or in making organizational or other changes to increase efficiency. 3) A department shall reduce staff by identifying which positions within the department are to be eliminated. 4) The employee who has the least City-wide service credit in the class within the department shall have City-wide transfer rights in the class pursuant to Part 1, Section 3, Transfer or Reduction to Vacancies in Lieu of Layoffs, or within the occupational series pursuant to Part 2, Bumping Rights. 5) If a deadline within this procedure falls on a day that City Hall is closed, the deadline shall be the next day City Hall is open. b. Service Credit 1) Service credit means total time of full-time continuous service within the City at the time the layoff is initiated, including probation, paid leave or military leave. Permanent part-time employees earn service credit on a pro-rata basis. 2) Except as required by law, leaves of absence without pay shall not earn service credit. 3) As between two or more employees who have the same amount of service credit, the employee who has the least amount Of service in class shall be deemed to be the least senior employee. c. Transfer or Reduction to Vacancies in Lieu of Layoff 1) In lieu of layoff, a transfer within class shall be offered to an employee(s) with the least amount of service credit in the class designated for staff reduction within a department subject to the following: 01-02 MEO MOU Final 24 04/04/02 5:40 PM MEO MOU Res.No.2002-31 Ex,A a) The employee has the necessary qualifications to perform the duties of the position. b) The employee shall be given the opportunity, in order of service credit, to accept a transfer to a vacant position in the same class within the City, provided the employee has the necessary qualifications to perform the duties of the position. . c) if no position in the same class is vacant, the employee shall be given the opportunity, in order of service credit, to transfer to the position in the same class that is held by an incumbent in another department with the least amount of service credit whose position the employee has the necessary qualifications to perform. 2) If an employee(s) is not eligible for transfer within the employee's class, the employee shall be offered, in order of service credit, a reduction to a vacant position in the next lower class within the City in the occupational series in lieu of layoff provided the employee has the necessary qualifications to perform the duties of the position. 3) If the employee refuses to accept a transfer or reduction pursuant to A. or B., above, the employee shall be laid off. d) If the employee(s) in the class with the least amount of service credit is in the position(s) to be eliminated or displaced by transfer, the employee shall be offered Dumping rights, pursuant to Part 2, Service Credit. e) Any employee who takes a reduction to a position in a. lower class within the occupational series in lieu of layoff shall be placed on the reinstatement/reemployment list(s) pursuant to Part 3., Reemployment. 2. Order of La off a) Prior to implementing a layoff, vacant positions that are authorized to be filled shall be identified by citywide occupational series. if the employee refuses to accept a position pursuant to Section 3., above, the employee shall be laid off. b) No promotional probationary employee or permanent employee within a class in the department shall be laid off until all temporary, nonpermanent part-time and non-promotional probationary employees in the class are laid off. Permanent employees whose positions have been eliminated may exercise citywide bumping rights to a lower class in the occupational series pursuant to Part 2. 01-02 MEO MOU Final 25 04104/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A c) When a position in a class and/or occupational series is eliminated, any employee in the class who is on authorized leave of absence or is holding a temporary acting position in another class shall be included for determining order of service credit and be subject to these layoff procedures as if the employee was in his or her permanent position. 3. Notification of Employees a) The Human Resources Division shall give written notice of layoff to the employee by personal service or by sending it by certified mail to the last known mailing address at least fifteen (15) calendar days prior to the effective date of the layoff. Normally notices will be served on employees personally at work. b) Layoff notices may be initially issued to all employees who may be subject to layoff as a result of employees exercising voluntary reduction/bumping rig hts. c) The notice of layoff shall include the reason for the layoff, the effective date of the layoff, the employee's hire date and the employee's service credit ranking. The notice shall also include the employee's right to bump the person in a lower class with the least service credit within the occupational series provided the employee possesses the necessary qualifications to successfully perform the duties in, the lower class and the employee has more service credit than the incumbent in the lower class. d) The written layoff notice given to an employee shall include notice that he or she has seven (7) calendar days from the date of personal service, or date of delivery of mail if certified, to notify the Human Resources Officer in writing if the employee intends to exercise the employee's bumping rights, if any, pursuant to Part 2, Bumping Rights. e) Whenever practicable, any employee with the least amount of service credit in a lower class within an occupational series which is identified for work force reduction shall also be given written notice that such employee may Pe bumped pursuant to Part 2. This notice shall include the items referred to in C., above. f) If an employee disagrees with the City's computation of service credit or listed date of hire, the employee shall notify the Human Resources Officer as soon as possible but in no case later than five (5) calendar days after the personal service or certified mail delivery. Disputes regarding date of hire or service credit shall be jointly reviewed by the Human Resources Officer and the employee and/or the employee's representative as soon as possible, but in no case later than five (5) calendar days from the date the 01-02 MEO MOU Final 26 04/04/02 5:40 PM MEO MOV Res.No.2002-31 Ex.A employee notifies the Human Resources Officer of the dispute. Within five (5) calendar days after the dispute is reviewed, the employee shall be notified in writing of the decision. 4. Part 2 — Bumping Rights a) Voluntary Reduction or Bumping in Lieu of Layoff 1) A promotional probationary employee or permanent employee who receives a layoff notice may request a reduction to a position in a lower class within the occupational series provided the employee possesses the necessary qualifications to perform the duties of the position. 2) Employees electing reduction under A above, shall be reduced to a position authorized to be filled in a lower class within the employee's occupational series. The employee may reduce to a lower class in his/her occupational series by: 1) filling a vacancy in that class, or 2) if no vacancy exists, displacing the employee in the class with the least service credit whose position the employee has the necessary qualifications to perform. A displaced employee shall have bumping rights. 3) An employee who receives a layoff notice must exercise bumping rights within seven (7) calendar days of receipt of the notice as specified in Part 1. Failure to respond within the time limit shall result in a reputable presumption that the employee does not intend to exercise any right of reduction or bumping to a lower class. The employee must carry the burden of proof to show that the employee's failure to respond within the time limits was reasonable. If the employee establishes that failure to respond within the time limit was reasonable, to the Human Resource Officer's satisfaction, the employee shall be permitted to exercise bumping rights but shall not be reinstated to a paid position until the employee to be bumped has vacated the position. If the employee disagrees with the Human Resource Officer's decision, the employee may appeal pursuant to the provisions of Sections 3 and 4 below. b) ReinstatemenURe-employment Lists Any employee who takes a reduction to a position in a lower class within the occupational series in lieu of layoff shall be placed on tile reinstatement/re-employment list pursuant to Part 3, Re-employment. c) Qualifications Appeal Any employee who is denied a reduction to a position in a lower class within the occupational series on the basis that the employee does not 01-02 MEO MOU Final 27 04/04102 5:40 PM MEO MOU Res.No.2002-31 Ex.A possess the necessary qualifications to successfully perform the duties of the lower position may appeal the decision. The appeal shall be filed with the Human Resource Officer within five (5) calendar days of the employee's receipt of written notice of the decision and reason(s) for denial. The employee's appeal shall be in writing and shall include supporting facts or documents supporting the appeal d) Qualifications Appeal Hearing 1) Upon receipt of an appeal, the Human Resource Officer shall contact a mediator from the California State Mediation and Conciliation Service to schedule a hearing within two (2) weeks after receipt of the appeal. If the California State Mediation and Conciliation Service is not available within that time frame, the parties shall mutually select a person who is available within the time frame. If the California State Mediation and Conciliation Service and the person mutually selected are not available within tile time frame, the parties shall select the earliest date either is available to conduct the hearing. The parties shall split the cost, if any, of the hearing officer. In addition, the parties shall meet within three (3) workdays to attempt to resolve the dispute. If the dispute remains unresolved, the parties shall endeavor in good faith to submit to the hearing officer a statement of all agreed upon facts relevant to the hearing. 2) Appeal hearings shall be limited to two (2) hours, except as otherwise agreed by the parties or directed by the hearing officer. 3) The hearing officer shall attempt to resolve the dispute by mutual agreement if possible. If no agreement is reached, the hearing officer shall render a decision at the conclusion of the hearing which shall be final and binding 5. Part 3 — Re-employment a) Re-employment 1) Employees who are laid off or reduced to avoid layoff shall have their names placed upon a reemployment list, for each class in the occupational series, in seniority order at or below the level of the class from which laid off or reduced. 2) Names of persons placed on the reemployment lists shall remain on the list for two (2) years from the date of layoff or reduction. 01-02 MEO MOU Final 28 04/04/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A 3) Vacancies shall be filled from the reemployment list for a class, starting at tile top of the list, providing that the person meets the necessary qualifications for tile position. 4) Names of persons are to be removed from the reemployment list for a class if on two (2) occasions they decline an offer of employment or on two (2) occasions fail to respond to offers of employment in a particular class within five (a) calendar days of receipt of written notice of an offer. Any employee who is dismissed from the City service for cause shall have his or her name removed from all re-employment lists. a) Re-employment lists shall be available to HBMEO and affected employees upon reasonable request, 6) Qualification appeals involving reemployment rights shall be resolved in the same manner as that identified in Part 2., Section 4. b) Status on Re-employment 1) Persons re-employed from layoff within a two (2) year period from the date of layoff shall receive the following considerations and benefits: a) Service credit held upon layoff shall be restored, but no credit shall be added for the period of layoff. b) Prior service credit shall be counted toward sick leave and vacation accruals. c) Employees may cash in sick leave upon layoff or at any time after layoff in the manner and amount set forth in existing Memoranda of Understanding for that employee's unit. Sick leave shall be paid to an employee when the reemployment list(s) expire(s), if not previously paid. d) Upon reinstatement the employee may have his or her sick leave re-credited by repayment to the City the cashed amount. Sick leave accumulation of less than 480 hours shall be restored upon reemployment. e) The employee shall be returned to the salary step of the classification held at the time of the layoff and credited with the time previously served at that step prior to being laid off. f) The probationary status of the employee shall resume if incomplete. 01-02 MEO MOU Final 29 04104/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A 2) Employees who have been reduced in class to avoid layoff and are returned within two (2) years to their former class shall be placed at the salary step of the class they held at the time of reduction and have their merit increase eligibility date recalculated. ARTICLE XIV - MISCELLANEOUS A. Physical Examination Employees covered by this agreement shall be provided, once every two years, with a city paid physical examination. Said exam shall be comprehensive in nature and shall include: 1. A complete medical history, physical exam, laboratory testing and review of results by a physician. (See Exhibit G, Physical Exam Description.) 2. A stress EKG will be provided for employees forty (40) years of age or older. No more than one-half of the eligible employees shall receive examinations in any one fiscal year. B. Vehicle Policy 1. Approval is required by the City Administrator or his designee for any City vehicle to be taken home by a MEO employee. 2. The auto allowance for qualifying employees shall be one hundred sixty one dollars and fifty-three cents ($161.53) bi-weekly. 3. No unit employee shall have their automobile allowance eliminated until the City's Fleet Management Policy is re-negotiated. 4. Eligibility for automobile allowance shall be determined in accordance with the City's Fleet Management Program dated August, 1999. C. Deferred Compensation Loan Program Employees may borrow up to 50% of their deferred compensation funds for critical needs such as medical costs, college tuition, or purchase of a home. 01-02 MEO MOU Final 30 04/04/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A ARTICLE XV - CITY COUNCIL APPROVAL It is the understanding of the City and the Association that this Memorandum of Understanding is of no force or effect unless and until adopted by resolution of the City Council of the City of Huntington Beach. .IN WITNESS WHEREOF, the p r ttiep hereto have executed this Memorandum of Understanding this JS day of L , 2002. HUNTINGTON BEACH CITY OF HUNTINGTON BEACH MANAGEMENT EMPLOYEES A Municipal Corporation ORGANIZATION By. By. Ray SKer %s'Duftin, M O President City Administrator By: By: William P. Workman Assista ty Admi ator By: By: Clay rtin Michael Mudd, Board Member Director of Administrative Services By: By: Bev rade , Bo d Member Paul Crost MEO Negotiator APPROVED AS TO FORM a By: �� Gail utton City Attorney 01-02 MEO MOU Final 31 04/04102 5:40 PM MEO MOU Res.No.2002-31 Ex.A EXHIBIT A CITY OF HUNTINGTON BEACH MANAGEMENT EMPLOYEES' ORGANIZATION SALARY SCHEDULE EFFECTIVE MARCH 2, 2002 . Job Type Description Pay Grade A B C D E 0028 Accountant, Principal 526 30.06 31.71 33.45 35.29 37.23 0025 Admin Analyst 491 25.24 26.63 28.09 29.63 31.26 0084 Admin Analyst, Principal 538 31.91 33.67 35.52 37.47 39.53 0089 Admin Analyst, Sr 519 29.03 30.63 32.31 34.09 35.96 0078 Assistant City Attorney 608 45.24 47.73 50.36 53.13 56.05 0132 Assistant City Clerk 467 22.39 23.62 24.92 26.29 27.74 0024 City Engineer 611 45.92 48.45 51.11 53.92 56.89 0069 Civil Engineer, Associate 536 31.59 33.33 35.16 37.09 39.13 0096 Civil Engineer, Principal 555 34.73 36.64 38.65 40.78 43.02 0092 Claims Supervisor 529 30.51 32.19 33.96 1 35.83 37.80 0065 Community Services Mgr 536 31.59 33.33 35.16 37.09 39.13 0097 Construction Manager 551 34.05 35.92 37.90 39.98 42.18 0085 Contract Administrator 519 29.03 30.63 32.31 34.09 35.96 0045 Criminalist Supervisor 543 32.72 34.52 36.42 38.42 40.53 0070 Criminalist, Chief 571 37.63 39.70 41.88 44.19 46.61 0081 Deputy City Attorney i 524 29.75 31.39 33.12 34.94 36.86 0080 Deputy City Attorney II 561 35.79 37.76 39.84 42.03 44.34 0079 Deputy City Attorney I II 589 41.15 43.41 45.80 48.32 50.98 0068 Deputy City Engineer 583 39.93 42.13 44.45 46.90 49.48 0090 Deputy City Treasurer 567 36.88 38.91 41.05 43.31 45.69 0027 Dpty Dir of Recr/ Bch Dvlprnt 595 42.40 44.73 47.19 49.79 52.53 0035 Dpty Director of PW's 611 45.92 48.45 51.11 53.92 56.89 0039 Econ Dev. Proj Mgr 542 32.56 34.35 36.24 38.23 40.33 0037 Econ Dev. Proj Mgr, Asst 511 27.89 29.42 31.04 32.75 34.55 0055 Finance Officer 591 41.57 43.86 46.27 48.81 51.49 0130 Fire Protection Analyst 519 29.03 30.63 32.31 34.09 35.96 0131 FireMed Coordinator 519 29.03 30.63 32.31 34.09 35.96 0184 GIS Manager 536 31.59 33.33 35.16 37.09 39.13 0023 Housing/Redev. Mgr 562 35.97 37.95 40.04 42.24 44.56 0088 Info Syst Analyst, Principal 559 35.43 37.38 39.44 41.61 43.90 0087 Info Systems Analyst V 550 33.88 35.74 37.71 39.78 41.97 0038 Info Systems Manager 587 40.76 43.00 45.36 47.85 50.48 0067 Info Systems Mgr, Police 568 37.07 39.11 41.26 43.53 45.92 0075 Inspection Manager 1 555 1 34.73 36.64 38.65 1 40.78 43.02 01-02 MEO MOU Final 32 04104/02 9:40 PM MEO MOU Res.No.2002-31 Ex.A EXHIBIT A CITY OF HUNTINGTON BEACH MANAGEMENT EMPLOYEES' ORGANIZATION SALARY SCHEDULE EFFECTIVE MARCH 2, 2002 Job Type Description Pay Grade A B C D E 0076 Inspctr Plb/Mech Princpl 508 27.49 29.00 30.59 32.27 34.04 0072 Inspctr, Electrical Princpl 508 27.49 29.00 30.59 32.27 34.04 0251 Investigator 491 25.24 26.63 28.09 29.63 31.26 0158 Landscape Architect 519 29.03 30.63 32.31 34.09 35.96 0095 Law Office Manager T 495 25.75 27.17 28.66 30.24 31.90 0077 Librarian, Sr 482 24.13 25.46 26.86 28.34 29.90 0066 Library Services M r 540 32.24 34.01 35.88 37.85 39.93 0030 Maint Operations Mgr 565 36.51 38.52 40.64 42.87 45.23 0032 Marine Safety Div Chief 561 35.79 37.76 39.84 42.03 44.34 0441 Ngrhbrhd Prsvtn P m Mgr 562 35.97 37.95 40.04 42.24 44.56 0098 Permit & Plan Check Mgr 564 36.32 38.32 40.43 42.65 45.00 0099 Plan Checker, Building Sr 550 33.88 35.74 37.71 39.78 41.97 0071 Planner, Associate 511 27.89 29.42 1 31.04 32.75 34.55 0074 Planner, Principal 562 35.97 37.95 140.04 42.24 44.56 0036 Planner, Senior 542 32.56 34.35 1 36.24 38.23 40.33 0022 Police Com Mgr 522 29.47 31.00 32.80 34.60 36.50 0040 PTL Operations Manager 557 35.07 37.00 39.04 41.19 43.46 0083 Prchsing/Cntrl Svcs Mgr 528 30.36 32.03 33.79 35.65 37.61 0043 Real Estate Svcs Mgr 570 37.25 39.30 41.46 43.74 46.15 0093 Real Property Agent 542 32.56 34.35 36.24 38.23 40.33 0094 Records Admin Police 522 29.47 31.09 32.80 34.60 36.50 0054 Risk Manager 570 37.25 39.30 41.46 43.74 46.15 0042 Sprntndnt, Rec/Hmn Svcs 561 35.79 1 37.76 39.84 42.03 44.34 0044 Sprvsr, Beach Operations 521 29.33 30.94 32.64 34.43 36.32 0047 Sprvsr, Building Maint 521 29.33 30.94 32.64 34.43 36.32 0073 Sprvsr, Comb/Strctrl Insp 527 30.21 31.87 33.62 35.47 37.42 0048 Sprvsr, Mechanical Maint 521 29.33 30.94 32.64 34.43 36.32 0049 Sprvsr, Park Maintenance 521 29.33 30.94 32.64 34.43 36.32 0133 Sprvsr, Prkg/Cmping Fac 508 27.49 29.00 30.59 32.27 34.04 0046 Sprvsr, Recreation Senior 508 27.49 29.00 30.59 32.27 34.04 0050 Sprvsr, St & Sewer Maint 521 29.33 30.94 32.64 34.43 36.32 0051 Sprvsr, Tr, Lnd, Pst Cntrl 521 29.33 30.94 32.64 34.43 36.32 0052 Sprvsr, Water Dist 521 29.33 30.94 32.64 34.43 36.32 0053 Sprvsr, Water Production 521 29.33 30.94 32.64 34.43 36.32 0086 Systems Analyst 512 28.02 29.56 31.19 32.91 34.72 0034 Trffc Engineer, Associate 537 31.75 33.50 35.34 37.28 39.33 0033 Transportation Manager 580 39.36 41.52 43.80 1 46.21 1 48.75 0041 Water Operations Mgr 585 40.34 142-56 1 44.99__i 47.37 149.98 01.02 MEO MOU Final 33 04/04/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A EXHIBIT B DELTA DENTAL PLAN BROCHURE A copy of the Delta Dental Plan Brochure may be obtained from the Risk Management Division OR See City Clerk Vault File No. 720.20 01-02 MEO MOU Final 34 04/04102 9:40 PM r 'a i w: 5 '4.ai.r +;_ v��_ r�.hr:R..s+;�i :i}:�''1.„ � r b. Y 'r I'Sh y I.� f; •,T f ,,. j.Ytii r- 4 +- -+, �'.- -4. . },i `!•. sI :., r. �p +: 1"4: ,I.• ;l %!'.Y 'I,�r �. 'ti`F.'. -J i,l4- � T:u`.Fr b y; n. y._ kV.'' .. � ' ,i, ? ..Lh�...'rj.. .{.,�Y, •1r,�. :`6'SG• ;'B: .Sl k,.�. '�', 'nJ{ ,i':i� �,,.'c fr r -bk'�,�i i rt f„fry ., f, 1•s'.,.r, dd;a { 1 9:':rr ( r�' der .Yk . : , 1 `;E r "A H:µ � ;:d �, d� da �, .'R , � ;GROURN0.�4129 BENEFiTn HIGHLIGHTS'FOR��CITuY�:OF:,HUNTINGTC}N SE C � �.�•1 �-r � ,.�. Y�r. ,.: ,�,. � � y'.. � r, �:! i"D' d at,?µ'4'. :�.::- `�.' •. ., I+. ,,tC., ,:, .vrr -t! : `' •ez. ,f - -ia- !- ..rA.'. S' 'F.r -.�.'r,,. -- :_ '.�-+'fi' e ,..r:£•....r jX ,� "' a•_,:c-�` ; r<:,,. .. ',N -;t': s. ' '1': " .a t vac's.: ?/aR.- T``-...rz �gyn.,. .:�s}�C' .s' ,r , S'+ .,�,r�..-. .•...T" !�. 'ax:-• ri >,_ :: l +^ 3?k � d: "�... r' 'S• _4. -t.; _str` �:i:., _ _3 Ar, r 'a fs y: ,, r s,. •.,'; '->i., -t a c•SI �• .._: �:-'.r, .`au, :n a,. .� ">: : ..is } ,,. � rrr 5 a z- ^� 1'-'>zk.. - =t s F: :.eke ^b']irv:. c. <.,' ,i !c 'L�,.�±5� ,.� nr ;f;- } r, '•r r `k rl v '�l -r , � k� -Y ,:'+t1 ✓ _7� i,+,Tt >< t s .�`:r,n ,1; � 'fit r 4 - •"' +1_:�'- Y '��•,. f `�Fy r p..I. ��M"`,.r 3 K1/ h ��,_ '.i A. I'..- 4 � 1'I p r TO T PR , IEltr „�,Di1 LTAPREMIER IS EASY >'r, ,• t ,r. �+. -,'.7:-1 e t w;F s y,*• r,, .3• , _?ry..r~.:s^«ae r k r'.. + ,r„y !.r ,SJI°: y7 i- rt �.�� .�1 O n i�. � -Y F .r`5i A,•,':J _ `4':W :"S. s^ ;�•• sTv r 5� ;i J_ q' J5. ,k,',: 'i .r:. :4i t. .Y. rr,, i 4 'r„ -•r"-.r, �:, -M ..f.Y' rl :: !kr'^L:, T' .L�{4- F¢,.x.r w.: i 1 ,T: t -ti e}, }.-k S• r Y4k: - f,y', a e for- aryl I'r6 raiYs. _: + �. � €. .. h m choosa:a licensed { T :. �. a ptan wit frsf#do io any, r:: ty' "a_ ,. 7 ,. Y � s t l]eltaPreniier Is a'fee for-Servl�c ":. r V. as r ,, '�x:. , - f �: Vered S81ViCe5,,..OU'ma ;be Y. ..J i� 3 - dentist TFie:.rograin pays'a percentage, a co ,Y, Y, � r. Y n :'F-" * ? s:t v I e ermines is jhe_ atlBnt&ilaC Y : �, l ». „,', charged only wh2ti;De to d t p :&3bu 'DELTAPREWE'R a .., a ., t ., ,<..,}n �'14.' t.-. F`.'=P;, .b :Pr 7 r+. ^ �` - �.:,>' .•,p r. a, .x' ro- + zee + St'O< ry G :r', a.. 'r ,s._y45 ::*F''-: ,adr, ".;, ra' ,. ..,f..- :r *:� �.S -:�1...- tl',�'r �:Y_F�''., .:t r.r y - G,eJ ^':.:_ ._ ,..r�:: f. +rb 7 +�_ xF .,:, :w .,; .. s , : ` hake anE ,m^ke art'f� _. >� ,_,.� • , � ..,,41; p, xir{� �,. •�, �:, .•,To useAha an,'usfcall tfie denfaf"officeyof your;c a 1:. :5. 73r e'' Y'r.4'T :,i7.'c y_ _-`.; Ij,--r` ` '+r :t, - ',�f�'•� The Qeltal?reMleri lan:alfows:. auto.: : . ,.. -:' ir. ,u.. -.. ...,..R ,. number 1 P Y, �� €41 a in :nurkn ourft st a ointment ive our dentist out°group; -�i::'4, ,r �"•" e.. T' '�'F,.:�+-:. ,,�•- r,a. ':sl. YR'"•-"w.-y- .. • appp invent. g.'Y r Pf? ,g ;:Y „Y k., �, .,. py f this` 'a a :and the: rlma 'onrollee s:snclal"security�G. :. «Y'!-', •, .:;r;f .+- rY1.ir`.r ,t.f:4 s 1, .rr?„,,.r} s;,r,w�„';,t's+�`it�i,,which 18'at'the-toI P-9 r. ,P rY ..�, �,s� M,n i 'Ifrc n ed,d°entiSt�ot;your ohoice,t 1.:�. �, f}b j• �ti{.'a�. t,, Wr ♦. r1fiSt an $ �:, }:' p,- w Y r' nr. 1 r'� number. 4•,,;, t L' F �.��'' �,3:'} r?..�tk, 'Chan"s',denti6te&t an'.,tlrrra 4'+ f 3 '(��!.' � Y. j,- ' r�� -�M '� -.( �•� 9'.. ys'.:i4' �t.y.. �!'.'K q,w:. J' :4. ,r j�f r� „vr a.d7"n•:, � '� f -�x. a:. .-� ..z:,•:r�; 1 �. .r:, yy,.,�� .�i.. .�'Ca,. r a Go''t a;dentai:s eciallst of:. bur,choice.:-f�. 7t F u ,, _ ,M, �: r s a ch' a dentist dlrWb: ;ori odr web , �,�� o P Y, � ��:� ,: _ � -,;� �3,.,,Form list�of=Delta dentists in your•a ea, a r ,t „ry to � '-' _$ - ",��. Receive`derifa`i` are; , f�ere`tn tfie' +rorld �,� :a fi. , i:our. I-r auto ated tale' hone servlce`at - a a.Y�!!. _. M -..�;pyy.zysites#wwwtleltadsntalcaorg or"caltol # eo; m p„ , r ``34 .5, 4J :;,,s- w..i,r rs''" r' , -�:#� 't- ;tr-r' r ��'�(c ssr.'S. ':f •c- 6a�'":, r. 1 c�F d .fib .x.' a• "T ! q? >' y . 3 �- _r, f : ..x.b. �r r eft fi s' G ` ` ?rx ' 800 t4-AREA=DR`8U=427=3237):You'can,alsoicheck.G++ith you _'k,:�,5;rRrv'4z_ �.... ;.,.+- -•-:r ,... .-'-! ,n,. ,.. :ryr.' -, :,� h'4+• -f.: i•!t v- a[a:,•¢, '�..'ifs 1 {� :.n. I >+ x ,'. i^ .. .�.",ia. :..1...., .• -••1..'.• 9{.f 5 r a ..�, 3 e m iete llst of;Delta-dentists.r `a ad has a o. p ;e F k I a :vlslt'a licensed':denlist: au wlsh.kNeariy��t,:1t Undar.the 1�eltaPrem eripa rou°m Y �1Y w . f :, ,Ir :.s..,, :-y '.:ice.{.r ..;,y -r� ..,'f' Y_. i�T ��ti N.r .. -.'...,,, w t,4. :..:�•.-:22 000'dent'al ofticas irZ',Cekiiarniat*92 f:of all-dentksts'satatawidH are'Delta r» w : IE I ilif and`benefits'Information,on`our;rvveb:site, ., �.. ._... . ..,. >:: � ..;You'can-,alsomew,.your,e g b . y. dentists;There'are.seYeral:advanta es;.to;:Choosing a l?eltarderatist ;` , 'sr,, F i I and maximum:amounts foc ou'and, our; 9, ;.,.. =t.. . K..,. , <:N., rv:.1�r i*ncludmg [ernainmgFdeduct b e Y Yfamily. .,,, r6�'i_., r.� .s, n ,..; ..s"ti,,„ ' ..•z ,.°.... .. - . ._.. .:».. , ,. ..•.y � � �, faxe eta you callln`'toll free; 668'DELTA �7 -A. � �':You:can ha►is'the information A. p:YQ . +ir'ff`- "''.:. .. •., %,....- .... _�':_^ !'•+T�-',{� } •' :yy. .^ - .: y1;rY :s` ' .a• ti 1: -°mot •f'$:i• k ? .' y DI*LTA DENTIST-r4 r NOf3��1ELTA.DENTIST �.1F{ t38=335 6227), r �,5 'r ::•r�dY,I},Fx:�34�•+ y', �.�wd.a.f ,X+7•� ,iy�,:,:�- �; �h+ rrj-�ti:�.. r A..yY•. t,,W:t -•. : y .�.�. _...: -�, ,.'.:.7'y. ,iY� _ ._f-. ...Y, 1:.'::.. :i...:r, .. .; r''Clalm ormssara'.comnnl�te 'arid,: ;,_ Yaia>ma ,have tp5eornplet and�e � " � y QeI+a:Derital Plan"of-Califorriia'offer's; a what;no,othar dental pfarr'`c'an-The r'• -i -.r. ,Y.�.: ::"4 ,;y ... y:� .:; t :(t,Y ;,;.�., submitted for`• oU at:no~char b.,_,W ;submit. our;own claim forms or a x; y g Y 'Delta Qiff e�°`Fie uniqu Ysr r>_ R y r;,, _ erenc re s vuhat makes us a � a Y� q.;''}," h;:.s_:•�, w?e ,f?C�'r�- -a.:"+Y 'y!': Hst,: 1:, r -.:. ,. ..1% tiAt:- �j` a'service,ee., r �";� h d rti x„ r ^,r,E�,� '� .,.r, a ur.`,. a �,�r .= -y rl,.� .r�' 'w ks%.:.• rf�:s??'"'v�!'�` ,�' :h:)'?. -.,. w,. �eC �yj. 'e,� �¢ .i.�� '� ie � .r'..r�- -•Yr': ii#eti�,r.-ode'"''-: r`.x r"','_ _M`�k.' l.dy_",fir; r'"t 1. !a..':.'s'TS g_,r:;�c. 6 t t,.,., •.;"A� `1''"" y`= ,♦ rWe p egoJrare'dentists fees'Delta�dentist5�agree,'to chargo-you.ins .. ..i ., :,.: .s.,, :. , ', �. .p>.,.r- ;;e,'•, :.[.: .m..,, x,t-' Jam - -, •,;.:,.rk 1' -61 •,;• . �` arry -Y,t.,yy.. :ty s ,;;.r, Y. -vbx •-L,'G 1�+t'ti ! l, .a..r Y. -,, 7, €>• r�:, :sa s. ..t.:r��` d.ln'their ofiflce;' 1 :� .. `cr +..'�.' ! ,. �a lowest usi1a11y`ch'arge ' �",r b I a.his naf ertlfied Your,dentlst'i4bes have,been.,.r�, N' a t a f y p •_ m'Co a meat w. certified by;Delta,:as usual,��?re :, , ass ou are res onsibfe forthe 1,.' ., , ,° : :. P..Y, s;are guaranteed.`Delta'dentists,charge you-only what Delta customary;and reasonable 'you r� x :difference:lf„your dentist charges � :'determine •to be our share of;ttle treatment`cost.;lf.youfa.,ohare'is20 res nslble,onl 'for tfie patient � more:;than Qelta s rea roved fees ,, y ro "n.. u a 0- ercent of the,.Delta-a roved fee and no."morays Y k,Yo ,P Y.2 PP -�,..-...f- '3.:;.,t. •K;:: idi.*. :y, t .i. 4'� -,P p p- w c..i :. , -ds¢ s»�<- ...,. :. }L' ';. a - ,. ,w .,, r :r-,'Yr::r. H.- '+x 6 4 X< ,{ti ✓.:1 tr�.+'.! ri.'w•,,�n w'q i v •Share 'r:r..- Myv., ie `''P,:.w: ':.. ..a^::.. ;Y r'-••i�^ r '4-•..-•°._-.T r��:t -'s 'sa. ,-z< r,t' - a t Fta. �:: rv,3�.'.f� -,�:e {ar,„ �':;,• i- t' $1 :r a t, ;--rtYn^.Y r r::�:,•a r S- ..>- „r-:. °r " '� r M1 '1 + ♦ y`We`requlrworofessforial'feeatmenr'srandards?.Qelta dentisfs must.meet ,,1• r5=4-' i 4:- "'v +'Y'�.f ; - w5 - �y r'�✓e r r- E :A.''A ' �s ssibhai:standards'for.hY9-iene;.radiation-safety and other areas'related�- . ,You,may be ch'argedyoniy ft-zl) tlent You may have to-pay_the;entire b111 'to uallt' care;, ;,h share*;at:the'time.of treaiment,knoi <`at the time of.treatment and:waut or q Y Delta's''portion ` ; reimbursement: 1 , r one in three Californians counts on Delta or dental care benefits' one t at rPatianf share" .Is the Copaymenf:anydeducHbJe'arrcf sny amount Over the.annual ma�rlmum Some : r "services may nof'be covered;please refer.to your Svidance'of Coverage.'Some examples of Services not a,, covered are cosmetic dentfsfiyi'.expe4menfal procedures a+id services to rrecf co,rgenital- " matlormations. , r. y z 0 r � - f - ! m� +r: ^jdk i:'tY=.ri:� -.r•.f. '!xa„�k'Y/; Y'`T--` ,"''�y_4;,_at"�v �'-?� .E�., ..�'• s •�µ'�`.' o n�'>t,.'�'.�•�,. .r�t s->r '� :?.: '-x•.�'' .»a-f�, .a ,�f.•s ,r --.^ F ,:a• � r .�..:- 4.� qia�:-�; -t :•:rrer i�.' tl lr.l��S'e��. ',,r'�F�1.•�' ,, r bw �' ',Pri' ..,��r- rF.f q k(rq:....x�'ttiP_. •*F ..r,• �'.,� -r� r� `' � r � w� 1 H NMI :r "WORM PR1NC1fAAL BENEITS:QND COVERED SERVICES* "#SERVICES THAT ARE /VOTCOVERED 5r Aiihough your plan`covers many of"the most-commoniy needed y` WHO'S COVERED Primary enrollee and.spouse as well as aetvices,;some:services`are not-covered if you are unsure dependent children Wage 19 and Lull, ;' ,whethej'a particular'procedure iacovered';?or�hov{Imuch pi it is�`�,�• "2 w r i f 'b ou cheo wit :Dgta:be o.e rbceadln :'` time students to ale, 5 x.,, a d ar, y y .,pla h f .p ;9. , a' !�}L'fir v r ,.,�•,'� tk r�. r� w" sx a h r2'�.'�p_ .-�, ; :#1 rx ``t,,""tt .� .�: � J.$, ,.t x'a {3'.,,5. ny4�,{ �.n N.i. r '1*' 'j: r - n - The:followin 'a a tint co. a e t o-: in �' y� , M :.k' �.�,wS. "e'k 4,.l�•. '� ✓ ? '� ",?� °fa aa^' r..ti +Ln'* f sA ? A a � °�Serv`ces o 'n u es r.;co dltl n ;c ue ed,unde , ork DEDUCTIBLE$:AND , °r• stirs ,.fir �e �:f.t 1r1, ,. s ..4 ..,:• ,� ,� 4 $25 per person, ?6 per.tamily'per.., ? , # ,y 1 �,, ,'' f BENEFITS MAXIMUM �� .�::C; r x , k�CoCraperls L#0 or,;En loyer,,s1igtiili ysLaws. b. .� ! , :Calendar ear-The:n"iaxi- urri;benefit-., Y k �A:�•.,rf�-w .-t s�r 4G ; ;;;... •. y :5'3'., rypf4 a k2'+ } '. "S:r(r 1,�•!+„ :af.dy fY 4 "'i'a,,trA"t- .KY,�'.�L: YV,S B,t�Y.. u. �r.V��Q�'"� I.lQ VI2PMpW `der CalBrrdaOOO p� F �� a��,r�,��'•�r�",a� M� -t' p,' xa• Y I 'L.1 - y y y J ;.. , ,,�, :ri dl '•.r J , , 3. e_ .§'.>' `a' '� ! L kS �i -. ,-: : � f, erson ;1 . ;' ,cQn'g'e i}}aaI4�alformaf igna &;� `�, }_. 4 �s p ��^ r 1. .n'g'e YiTd€: i qly �-+ZS'.Hr �}.%>r t -j hf�{ a-"", : ws ;' ... ` a' r! ? ' }� '�'� 3d4 � �t=xpeximental p�oc Idures ��- b w -r' 4. ��!' {' �:.. .1'a,M _'Yw!a -:i..aa'H� � ^�,s.,;'�',�r :'.7�P-,�F+,:., .�I .e,�.•. [y I 116V6 �.n'.a:;�- s s_' remedica I. nor t1a n re rs.;,� '.x- . ,+k,-J�•;tl'' •`Y�''• •r `S'1.4 DIAGNOSTIC AND':PREVEN... x a :: :85%:of.Dalta dentist' 'fee �1 r � y r"fa,e� w , S aI.;� D�rrewftra G Q$5".0 B��I�al`tC t r' 4 �'Sc• ��( ` *7r-`2', ;ae3i' .#'�a. t'1?`"OF:'�tlC? .P;e ..gc,. r 2 F a BENEFITS K ,oralr am��iations, gt - ��F, :.!. � k � s#i se oap ol"g f �r1e then of r�surge Y claanlrtgs!r%rayE;,a a, r�atib90. t s �.` ¢ e :{.. :r n� ; 4. r ; :r oV�l. i �' ., f`. � , ,.. �: u q ;�a' k �± 1` -� •.d:0�� rc"lft.5 n'1 I$rIt$-rar�I� a{1 , `r,,.°r ,��,•,` . r� %„ ' "�3 y� S�. ;�+` 2ryls�k�` "o-'.h9 $r"'�� Jn� �°ti .` t".�` "bio s fluoride tre�iment s�ace i J �� .�: � "�. � ,� �.��. p ylk C,..I? d f fr eky,s S,, 5.7.�we� q;�N ;a k,' '71 Ms: z �,, �:a 4 q +1GEf�' 1. -...aA+�i eat a 'relate Ito, a,te` Oro..a bular.Oi maintai�iers,.Speciallst`consultations ,a , q , P a� ,!•- :, '. , ^;.� ;, �, e ,Ay - -ka si�.�J 1wr r.i�+` "` ,d +:`i �d+, k .., �„ = A.��'y� q r•yi y'yek/yy*reC9dllt[y I tormatjQ s',r,�ot me dAd•f0 'Usk as n i ✓�, 4i% •5 ,. - �{Y''b"�Yy�. y4' .[Ip. .li•1SYk;a0.l�j4 r^.Y,.j,. r .. l:pr . -y�..,,�..�q.ti:r,r•J 7rr,_ l�� aBASIGMENEFITB" �aral su a su land sc I Ii n' naa I It'[tesl no d�to se e' s a rK . , `;, .{ ...EY x .. 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'+.'.: .+d -y :- :;rr�• .:,7, , a +x� 5 ' � r J �5 � v f. �r��s y,„ .ts- � ;,�+ �, ,.3-• � ,� s� �. � Res.No.2002-31 DELTA QENTAV Ex.A Delta Dental Plan of California For Employees of CITY OF HUNTINGTON BEACH i i Group Number i 4729 i I I Combined Evidence of Coverage and Disclosure Form Res.No.2002-31 Ex.A USING THIS BOOKLET A STATEMENT DESCRIBING OUR POLICIES AND PROCEDURES FOR PRESERVING THE This booklet has been written with you in mind. It CONFIDENTIALITY OF MEDICAL RECORDS is designed to help you make the most of your Delta IS AVAILABLE AND WILL BE FURNISHED TO dental program. This combined Evidence of YOU UPON REQUEST. Coverage/Disclosure form discloses the terms and conditions of your coverage, The Combined Evidence of CoveragelDisclosure This Combined Evidence of Coverage form should be read completely and carefully and and Disclosure Form constitutes only a individuals with special health care needs should summary of the dental plan. The dental read carefully those sections that apply to them(see. Contract must be consulted to determine CHOOSING YOUR DENTIST section). You have the exact terms and conditions of a right to review it prior to your enrollment. coverage. Please read the"DEFINITIONS" section. It will explain to you any words which have special or technical meanings under your group Contract. A copy of the Contract will be famished upon request. Please read this summary of your dental Benefits carefully. Keep in mind that YOU means the ENROLLEES whom Delta covers. WE,US and OUR always refers to Delta Dental Plan of California(Delta). If you have any questions about your coverage that are not answered here,please check with your personnel office, or with Delta. DELTA DENTAL PLAN OF CALIFORNIA P.O. Box 7736 San Francisco, California 94124 For claims, eligibility and benefits inquiries, or additional information, call Delta's Customer and Member Service Department toll-free at: 1-888-335-8227. Or contact us on the Internet at: e-mail: cros@delta.org web site: www.deltadentalca.org 1 Res.No.2002-31 Ex.A TABLE OF CONTENTS DEFINITIONS.........................................................3 SECOND OPINIONS............................................12 WHO IS COVERED?..............................................3 ORGAN AND TISSUE DONATION...................12 WHO ARE YOUR ELIGIBLE COMPLAINT PROCEDURE,CLAIMS DEPENDENTS?......................................................4 APPEAL AND ARBITRATION...........................12 ENROLLING YOUR DEPENDENTS....................4 IF YOU HAVE ADDITIONAL COVERAGE..........................................................13 COVERAGE COSTS ..............................................4 OPTIONAL CONTINUATION WHEN YOU ARE NO LONGER OF COVERAGE....................................................14 COVERED ..............................................................5 CANCELING THIS PROGRAM ...........................5 YOUR BENEFITS ..................................................5 LIMITATIONS........................................................6 EXCLUSIONS/SERVICES WE DO NOTCOVER ..........................................................5 DEDUCTIBLES ........ ............................................9 COVERED FEES....... ............................................9 CHOOSING YOUR DENTIST......................... .....9 CONTINUITY OF CARE.....................................10 PUBLIC POLICY PARTICIPATION BYENROLLEES..................................................10 SAVING MONEY ON YOUR DENTALBILLS ...................................................10 YOUR FIRST APPOINTMENT...........................10 PREDETERMINA'TIONS.....................................11 PAYMENT............................................................I I IF YOU HAVE QUESTIONS ABOUT SERVICES FROM A DELTA DENTIST.............12 2 Res.No.2002-31 Ex.A DEFINITIONS Participating Plan—Delta and any other member of the Delta Dental Plans Association with whom Certain words that you will see in this booklet have Delta contracts for assistance in administering your specific meanings. These definitions should make Benefits. your dental program easier to understand. Primary Enrollee- any group member or Attending Dentist's Statement- a form used by employee who is eligible to enroll for Benefits in your dentist to request payment for dental treatment accordance with the conditions of eligibility or predetermination for proposed dental treatment. outlined in this booklet. Benefits-those dental services available under the Single Procedure- a dental procedure to which Contract and which are described in this booklet. Delta has assigned a separate procedure number; for example, a three-surface amalgam restoration of one Contract-the written agreement between your permanent tooth(procedure 02160)or a complete employer or sponsoring group and Delta to provide upper denture, including adjustments for a six- dental Benefits. The Contract, together with this month period following installation(procedure booklet, forms the terms and conditions of the 05110). Benefits you are provided. Usual,Customary and Reasonable(UCR)- Covered Services- those dental services to which Delta will apply Benefit payments,according to the A Usual fee is the amount which an individual Contract. dentist regularly charges and receives for a given service or the fee actually charged,whichever is Delta Dentist-a Dentist who has a signed less. agreement with Delta or.a Participating Plan, agreeing to provide services under the terms and A Customary fee is within the range of Usual fees conditions established by Delta or the Participating charged and received for a particular service by Plan. dentists of similar training in the same geographic area Dependent- a Primary Enrollee's Dependent who is eligible to enroll for Benefits in accordance with A Reasonable fee schedule is reasonable if it is the conditions of eligibility outlined in this booklet. Usual and Customary. Additionally, a specific fee to a specific patient is Reasonable if it is justifiable Effective Date-the date this program starts. considering special circumstances, or extraordinary difficulty, of the case in question. Enrollee- a Primary Enrollee or Dependent enrolled to receive Benefits or a person who WHO IS COVERED? chooses to pay for OPTIONAL CONTINUATION OF COVERAGE. All present and future regular employees are required to enroll and will become eligible to Maximum-the greatest dollar amount Delta will receive Benefits on the first day of the month pay for covered procedures in any calendar year and following 30 days of continuous employment. lifetime for Orthodontic Benefits. New Dependents should be enrolled as soon as they Premiums-the money paid to Delta each month become Dependents, and they will then immediately for you and your Dependents' dental coverage. be covered for dental Benefits. 3 Res.No.2002-31 Fx A You are not eligible if you are not reporting to work physical or mental handicap that occurred before on a regular basis and are not actively employed. he or she turned 19, if the child is mostly Coverage resumes on the first day of the month dependent on you for support. Proof of this after you return to active employment,report to handicap must be given to Delta or your work employer within 31 days, if it is requested. Proof will not be required more than once a year regularly and amounts due to Delta for coverage. after the child has reached age 21. have been paid. But, coverage can continue without interruption if your employer continues to report "Dependent children"also means stepchildren, you as a Primary Enrollee and amounts due Delta adopted children, children placed for adoption and for your coverage continue to be paid. foster children,provided that they are dependent upon you for support and maintenance. Family and Medical Leave Act of 1993 Dependent coverage is also extended to any child You can continue your coverage if you take a leave who is recognized under a Qualified Medical Child governed by the Family and Medical Leave Act of Support Order(QMCSO). 1993. If you do not continue your coverage during the governed leave,it will be reinstated at the same No Dependent in the military service is eligible. Benefit level you received before your leave. ENROLLING YOUR DEPENDENTS Uniformed Services Employment and Re- employment Rights Act of 1994 A payroll deduction is required for your enrolled Dependents.Your group can only provide coverage You can continue coverage for up to 18 months,if for your Dependents if at least half of the Primary you take a leave governed by the Uniformed Services Enrollees who have Dependents enroll all of them Employment and Re-employment Rights Act of in this program. 1994. If you make this election,you must submit any Premiums necessary,which may include Your Dependents must be enrolled when you first administrative costs,to your employer.If you do not become eligible or on the first day of the month continue your coverage during a military leave,it will after they become Dependents. However, be reinstated at the same Benefit level you received Dependents who are covered under another group before your leave. dental program are not required to enroll under this Delta program. If the other coverage ends, the WHO ARE YOUR ELIGIBLE DEPENDENTS? Dependents may enroll under this program within 30 days of the loss of the other coverage. Proof of • Your legal spouse; prior coverage is required. • Your unmarried dependent children until their Dependent children up to four years of age may be 19th birthday; enrolled at the beginning of any Contract year including the Contract year immediately following • Your unmarried dependent children until their their fourth birthday.If you drop coverage for your 23rd birthday if enrolled full-time in an Dependents,you may not re-enroll them in this accredited school, college or university, or live program. at home and are dependent upon parent(s)for at least 50% of their support; COVERAGE COSTS • An unmarried dependent child aged 19 or older Your employer pays Delta monthly Premiums for who is incapable of self-support because of a coverage of you and your enrolled Dependents. 4 Res.No.2002-31 Ex,A You do not pay for your own coverage but a payroll Procedures begun while the Contract was in effect deduction is made for monthly Premiums required which are otherwise Benefits under the Contract. for your Dependent's coverage. If this program is canceled, you and your The amount of Premiums may change at each Dependents have no right to renewal or renewal of the Contract between your employer and reinstatement of your Benefits. Delta. Premiums will not increase during the contract year unless new taxes or tax rates are YOUR BENEFITS unposed upon Delta for this program or unless there is an agreement between your employer and Delta Your dental program covers several categories of to change the Premiums rate. Benefits,when the services are provided by a licensed dentist, and when they are necessary and WHEN YOU ARE NO LONGER COVERED customary under the generally accepted standards of dental practice. After you have satisfied any 1. If you stop working for your employer,your deductible requirements,Delta will provide dental coverage will end on the last day of payment for these services at the percentage the month in which you stop working,unless indicated up to a Maximum of S1,000 for each you qualify for and pay for OPTIONAL Enrollee in each calendar year. Payment for j CONTINUATION OF COVERAGE. Your Orthodontic Benefits for Enrollee is limited to a Dependents' coverage ends when yours lifetime Maximum of$3,000. An agreement does, or as soon as they are no longer between your employer and Delta is required to Dependents, unless they choose to pay_for change Benefits during the term of the contract. OPTIONAL CONTINUATION OF COVERAGE. The following Benefits are limited to the applicable percentages of dentist's fees or allowances specified 2. When the Contract between Delta and your below. You are required to pay the balance of any employer is discontinued or canceled,your such fee or allowance,known as the"patient coverage ends immediately. copayment." If the dentist discounts, waives or rebates any portion of the patient copayment to the CANCELING THIS PROGRAM Enrollee,Delta only provides as Benefits the applicable allowances reduced by the amount that Delta may cancel this program only on an such fees or allowances are discounted,waived or anniversary date(period after the program first rebated. takes effect or at the end of each renewal period thereafter), or any time your group does not make I. DIAGNOSTIC AND PREVENTIVE payment as required by the Contract. BENEFITS-85% If you believe that this program has been terminated Diagnostic- oral examinations(including or not renewed due to your health status or initial examinations,periodic examinations requirements for health care services (or that of your and emergency examinations);x-rays; Dependents),you may request a review by the diagnostic casts; examination of biopsied California Director of the Department of Managed tissue;palliative(emergency)treatment of Health Care. dental pain; specialist consultation If the Contract is terminated for any cause,Delta is Preventive -prophylaxis (cleaning); fluoride not required to predetermine services beyond the treatment; space maintainers termination date or to pay for services provided after the termination date, except for Single 5 Res.No.2002-31 Ex.A II. BASIC BENEFITS-85% V. ORTHODONTIC BENEFITS - 60% Oral surgery- extractions and certain other Procedures using appliances or surgery to surgical procedures, including pre- and post- straighten or realign teeth, which otherwise operative care would not function properly. Restorative- amalgam,silicate or composite VI DENTAL ACCIDENT BENEFITS - (resin)restorations (fillings) for treatment of 100% carious lesions(visible destruction of hard tooth structure resulting from the process of Any services which would be covered under dental decay) other Benefit categories(subject to the same limitations and exclusions) are covered Endodontic -treatment of the tooth pulp instead by your dental accident coverage when they are provided for conditions Periodontic-treatment of gums and bones caused directly by external,violent and that support the teeth accidental means. Sealants-topically applied acrylic,plastic or MUTATIONS composite material used to seal developmental grooves and pits in teeth for 1. Only the first two oral examinations, the purpose of preventing dental decay including office visits for observation and specialist consultations, or combination Adjunctive General Services - general thereof, in a calendar year are Benefits while anesthesia;office visit for observation; you are eligible under any Delta program. office visit after regularly scheduled hours; Oral examinations provided by a California therapeutic drug injection; treatment of post- dentist are Benefits only when the dentist is surgical complications (unusual a Delta Dentist with an accepted fee on file circumstances); limited occlusal adjustment with Delta. M. CROWNS,JACKETS, INLAYS, 2. Full-mouth x-rays are a Benefit once in a ONLAYS AND CAST RESTORATION five-year period while you are eligible under BENEFITS-85% any Delta program. Crowns,Jackets, Inlays, Onlays and Cast 3. Bitewing x-rays are provided on request by Restorations are Benefits only if they are the dentist,but no more than twice in any provided to treat cavities which cannot be calendar year for children to age 18 or once restored with amalgam, silicate or direct in any calendar year for adults age 18 and composite(resin)restorations. over,while you are eligible under any Delta program. IV. PROSTHODONTIC BENEFITS -60% 4. Diagnostic casts are a Benefit only when Construction or repair of fixed bridges, made in connection with subsequent partial dentures and complete dentures are orthodontic treatment covered under this Benefits if provided to replace missing, program- natural teeth. 6 Res.No.2002-31 Ex.A 5. Only the first two cleanings, fluoride 10. Delta will pay its percentage of the dentist's treatments,or Single Procedures which fee for a standard partial or complete denture include cleaning, or combination thereof, in up to a maximum fee allowance. This fee a calendar year are Benefits while you are allowance is the fee that would satisfy the eligible under any Delta program. majority of Delta's Dentists. A standard partial or complete denture is one made from b. Sealant Benefits include the application of accepted materials and by conventional sealants only to permanent first molars up to methods. The maximum fee allowance is age nine and second molars up to age 14 if revised periodically,as dental fees change. they are without caries(decay), or If your dentist's accepted fee on file with restoration on the occlusal surface. Sealant Delta for a partial or complete denture is Benefits do not include the repair or higher than this maximum allowance,you replacement of a sealant on any tooth within must pay that portion of his or her fee that three years of its application. exceeds Delta's allowance in addition to your portion of the allowance. 7. Direct composite(resin)restorations are Benefits on anterior teeth and the facial 11. Implants (appliances inserted into bone or surface of bicuspids. Any other posterior soft tissue in the jaw,usually to anchor a direct composite(resin)restorations are denture) are not covered by your program. optional services and Delta's payment is However,if implants are provided along limited to the cost of the equivalent with a covered prosthodontic appliance, amalgam restorations. Delta will allow the cost of a standard partial or complete denture toward the cost of the 8. Crowns,Jackets;Inlays,Onlays and Cast implants and the prosthodontic appliances Restorations are Benefits on the same tooth when the prosthetic appliance is completed. only once every five years,while you are If Delta makes such an allowance,we will eligible under any Delta program,unless not pay for any replacement for five years Delta determines that replacement is following the completion of the service. required because the restoration is unsatisfactory as a result or poor quality of 12. If you select a more expensive plan of care,or because the tooth involved has treatment than is customarily provided,or experienced extensive loss or changes to specialized techniques, an allowance will be tooth structure or supporting tissues since made for the least expensive,professionally the replacement of the restoration. acceptable, alternative treatment plan. Delta will pay the applicable percentage of the 9. Prosthodontic appliances are Benefits only lesser fee for the customary or standard once every five years,while you are eligible treatment and you are responsible for the under any Delta program,unless Delta remainder of the dentist's fee. determines that there has been such an extensive loss of remaining teeth or a change For example: a crown where a silver filling in supporting tissues that the existing would restore the tooth; or a precision appliance cannot be made satisfactory. denture where a standard denture would Replacement of a prosthodontic appliance suffice. not provided under a Delta program will be made if it is unsatisfactory and cannot be made satisfactory. 7 Res. No.2002-31 Ex.A 13. If orthodontic treatment is begun before you 3. Services for cosmetic purposes or for become eligible for coverage,Delta's conditions that are a result of hereditary or payments will begin with the first payment developmental defects, such as cleft palate, due to the dentist following your eligibility upper and lower jaw malformations, date. congenitally missing teeth and teeth that are discolored or lacking enamel. 14. Delta's orthodontics payments will stop when the first payment is due to the dentist 4. Services for restoring tooth structure lost following either a loss of eligibility,or if from wear(abrasion, erosion, attrition, or treatment is ended for any reason before it is abfraction),for rebuilding or maintaining completed. chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the 15. X-rays and extractions that might be teeth. Examples of such treatment are necessary for orthodontic treatment are not equilibration and periodontal splinting. covered by Orthodontic Benefits,but may be covered under Diagnostic and Preventive or 5. Any Single Procedure,bridge, denture or Basic Benefits. other prosthodontic service which was started before the Enrollee was covered by 16. Delta will pay Dental Accident Benefits this program. when services are provided within 180 days following the date of accident and shall not 6. Prescribed drugs, or applied therapeutic include any services for conditions caused drugs,premedication or analgesia. by an accident occurring before your. eligibility date. 7. Experimental procedures. EXCLUSIONS/SERVICES WE DO NOT 8. Charges by any hospital or other surgical or COVER treatment facility and any additional fees charged by the Dentist for treatment in any Delta covers a wide variety of dental care expenses, such facility. but there are some services for which we do not provide Benefits. It is important for you to know 9. Anesthesia, except for general anesthesia what these services are before you visit your dentist. given by a dentist for covered oral surgery procedures. Delta does not provide benefits for: 10. Grafting tissues from outside the mouth to 1. Services for injuries covered by Workers' tissues inside the mouth("extraoral grafts'). Compensation or Employer's Liability Laws. 11. Implants(materials implanted into or on bone or soft tissue) or the repair or removal 2. Services which are provided to the Enrollee of implants, except as provided under by any Federal or State Governmental LIMITATIONS. Agency or are provided without cost to the Enrollee by any municipality,county or other political subdivision, except Medi-Cal benefits. 8 Res.No.2002-31 Ex.A 12. Diagnosis or treatment by any method of corresponding services for Delta Dentists in any condition related to the California. temporomandibular{jaw)joints or associated muscles,nerves or tissues. Payment to a California dentist,or an out-of-state dentist, who is not a Delta Dentist will be based on 13. Replacement of existing restoration for any the applicable percentage of the lesser of the Fee purpose other than active tooth decay.: Actually Charged, or the fee which satisfies the majority of Delta's Dentists. 14. Intravenous sedation, occlusal guards and complete occlusal adjustment. CHOOSING YOUR DENTIST 15. Charges for replacement or repair of an PLEASE READ THE FOLLOWING orthodontic appliance paid in part or in full INFORMATION SO YOU WILL KNOW by this program. FROM WHOM OR WHAT GROUT'OF i PROVIDERS HEALTH CARE MAY BE DEDUCTIBLES OBTAINED. You must pay the first$25 of Covered Services for More than 18,000 dentists in active practice in each Enrollee in your family in each calendar year, California are Delta Dentists. You are free to up to a limit of$75 per family. choose any dentist for treatment,but it is to your advantage to choose a Delta Dentist. This is COVERED FEES because his or her fees are approved in advance by Delta. Delta Dentists have treatment forms on hand It is to your advantage to select a dentist who is a and will complete and submit the forms to Delta Delta Dentist, since a lower percentage of the free of charge. dentist's fees may be covered by this program if you select a dentist who is not a Delta Dentist. if you go to a non-Delta Dentist,Delta cannot assure you what percentage of the charged fee may A list of Delta Dentists(see DEFINITIONS) is be covered. Claims for services from non-Delta available in a directory at your group benefits Dentists may be submitted to Delta at the address office,or by calling 1-800-427-3237. listed on page 1. Payment to a Delta Dentist will be based on the Dentists located outside the United States are not applicable percentage of the lesser of the Fee Delta Dentists. Claims submitted by out-of-country Actually Charged, or the accepted Usual, dentists are translated by Delta staff and the Customary and Reasonable Fee that the dentist has currency is converted to U.S. dollars. Claims on file with Delta. submitted by out-of-country dentists for patients residing in California are referred to Delta's Quality Payment to a dentist located outside the United Review department for processing Delta may States will be based on the applicable percentage of require a clinical examination to determine the the lesser of the Fee Actually Charged, or the fee quality of the services provided, and Delta may which satisfies the majority of Delta's dentists. decline to reimburse you for Benefits if the services are found to be unsatisfactory. Payment to a dentist outside of California who agrees to be bound by Delta's rules in the A list of Delta Dentists can be obtained by calling administration of the program will be based on the 1-800-427-3237. This list will identify those applicable percentage of the lesser of the Fee dentists who can provide care for individuals who Actually Charged or the Customary Fee for have mobility impairments or have special health 9 Res.No.2002-31 Ex.A care needs. You can obtain specific information policy in writing to:Delta Dental Plan of California, about Delta Dentists by using our web site— Customer and Member Service Department,P. O. www.deltadentalca.org or calling the Delta Box 7736, San Francisco, CA 94120. Customer and Member Service Department at the number shown on page 1. A printed list of the SAVING MONEY ON YOUR DENTAL BILLS Delta Dentists in your area is also available by calling 1-800427-3237. You can keep your dental expenses down by practicing the following: Services may be obtained from any licensed dentist during normal office hours. Emergency services are l. Comparing the fees of different dentists; available in most cases through an emergency telephone exchange maintained by the local dental 2. Using a Delta Dentist; society which is listed in the local telephone directory. 3. Having your dentist obtain predetermination from Delta for any treatment over$300; Services from dental school clinics may be provided by students of dentistry or instructors who are not 4. Visiting your dentist regularly for checkups; licensed by the state of California. S. Following your dentist's advice about Delta shares the public and professional concern regular brushing and flossing; about the possible spread of HN and other infectious diseases in the dental office. However, 6. Avoiding putting off treatment until you Delta cannot ensure your dentist's use of have a major problem; and precautions against the spread of such diseases,or compel your dentist to be tested for HIV or to 7. By learning the facts about overbilling. disclose test results to Delta, or to you. Delta Under this program, you must pay the informs its panel dentists about the need for clinical dentist your copayment share(see YOUR precautions as recommended by recognized health BENEFITS). You may hear of some authorities on this issue. If you should have dentists who offer to accept insurance questions about your dentist's health status or use of payments as"full payment." You should recommended clinical precautions,you should know that these dentists may do so by discuss them with your dentist. overcharging your program and may do more work than you need,thereby CONTINUITY OF CARE increasing program costs. You can help keep your dental Benefits intact by avoiding If you are undergoing a course of treatment and such schemes. your dentist no longer is a Delta Dentist,you may continue to receive treatment from that dentist. YOUR FIRST APPOINTMENT PUBLIC POLICY PARTICIPATION BY During your first appointment,be sure to give your ENROLLEES dentist the following information: Delta's Board of Directors includes Enrollees who 1. Your Delta group number(on the front of participate in establishing Delta's public policy this booklet); regarding Enrollees through periodic review of Delta's Quality Assessment program reports and 2. The employer's name; communication from Enrollees. Enrollees may submit any suggestions regarding Delta's public 10 Res.No.2002-31 Ex.A 3. Primary Enrollee's social security number PAYMENT (which must also be used by Dependents); Delta will pay Delta Dentists directly. Our 4. Primary Enrollee's date of birth; agreement with our Delta Dentists makes sure that you will not be responsible to the dentist for any S. Any other dental coverage you may have. money we owe. However,if for any reason we fail to pay a dentist who is not a Delta Dentist, you may PREDETERMINATIONS be liable for that portion of the cost. if you have selected a non-Delta Dentist,Delta will pay you. After an examination,your dentist will talk to you Payments made to you are not assignable(in other about treatment you may need. The cost of words,we will not grant requests to pay non-Delta treatment is something you may want to consider. Dentists directly). If the service is extensive and involves crowns or bridges, or if the service will cost more than $300, Delta does not pay Delta Dentists any incentive as we encourage you to ask your dentist to request a an inducement to deny,reduce, limit or delay any predetermination. appropriate service. If you wish to know more about the method of reimbursement to Delta A predetermination does not guarantee payment. Dentists,you may call Delta's Customer and It is an estimate of the amount Delta will pay if Member Service Department for more information. you are eligible and meet all the requirements of your program at the time the treatment you have Payment for claims exceeding$500 for services planned is completed. provided by dentists located outside the United States may, at Delta's option,be conditioned upon a In order to receive predetermination,your dentist' clinical evaluation at Delta's request(see Second must send an Attending Dentist's Statement to us Opinions). Delta willnot pay Benefits for such listing the proposed treatment. Delta will send your services if they are found to be unsatisfactory. dentist a Notice of Predetermination which estimates how much you will have to pay. After Payment for any Single Procedure which is a you review the estimate with your dentist and Covered Service will only be made upon decide to go ahead with the treatment plan, your completion of that procedure. Delta does not make dentist returns the statement to us for payment when or prorate payments for treatment in progress or treatment has been completed. incomplete procedures. The date the procedure is completed governs the calculation of any Computations are estimates only and are based on Deductible(and determines when a charge is made what would be payable on the date the Notice of against any Maximum)under your program. Predetermination is issued if the patient is eligible. Payment will depend on the patient's eligibility and If there is a difference between what your dentist is the remaining annual Maximum when completed charging you and what Delta says your portion services are submitted to Delta should be, or if you are not satisfied with the dental work you have received,contact Delta's Customer Predetermining treatment helps prevent any and Member Service Department. We may be able misunderstanding about your financial to help you resolve the situation. responsibilities. If you have any concerns about the predetermination, let us know before treatment Delta may deny payment of any Attending Dentist's begins so your questions can be answered before Statement for services submitted more than six you incur any charges. months after the date the services were provided. If a claim is denied due to a Delta Dentist's failure to make a timely submission,you shall not be liable to 11 Res.No.2002-31 Ex.A that dentist for the amount which would have been Delta will authorize such an examination prior to payable by Delta(unless you failed to advise the treatment when necessary to make a Benefits dentist of your eligibility at the time of treatment). determination in response to a request for a Predetermination of treatment cost by a dentist. The process Delta uses to determine or deny Delta will also authorize a second opinion after payment for services are distributed to all Delta treatment if an Enrollee has a complaint regarding Dentists. They describe in detail the dental the quality of care provided. Delta will notify the procedures covered as Benefits,the conditions Enrollee and the treating dentist when a second under which coverage is provided, and the opinion is necessary and appropriate, and direct the limitations and exclusions applicable to the Enrollee to the Regional Consultant selected by program. Claims are reviewed for eligibility and Delta to perform the clinical examination. When are paid according to these processing policies. Delta authorizes a second opinion through a Those claims which require additional review are Regional Consultant,we will pay for all charges. evaluated by Delta's dentist consultants. If any claims are not covered, or if limitations or Enrollees may otherwise obtain second opinions exclusions apply to services you have received from about treatment from any dentist they choose,and a Delta Dentist,you will be notified by an claims for the examination or consultant may be adjustment notice on the Notice of Payment or submitted to Delta for payment. Delta will pay such Action. You may contact Delta's Customer and claims in accordance with the Benefits of the Member Service Department for more information program. regarding Delta's processing policies. This is only a summary of Delta's policy on IF YOU HAVE QUESTIONS ABOUT second opinions. A copy of Delta's formal policy SERVICES FROM A DELTA DENTIST is available from Delta's Customer and Member Service Department upon request. If you have questions about the services you receive from a Delta Dentist,we recommend that you first ORGAN AND TISSUE DONATION discuss the matter with your dentist. If you continue to have concerns, call our Quality Review Donating organ and tissue provides many societal Department at 1-888-335-8227. If appropriate, benefits. Organ and tissue donation allows Delta can arrange for you to be examined by one of recipients of transplants to go on to lead fuller and our consulting dentists in your area. If the more meaningful lives. Currently, the need for consultant recommends the work be replaced or organ transplants far exceeds availability. If you are corrected, Delta will intervene with the original interested in organ donation, please speak to your dentist to either have the services replaced or physician. Organ donation begins at the hospital corrected at no additional cost to you or obtain a when a patient is pronounced brain dead and refund. In the latter case, you are free to choose identified as a potential organ donor. An organ another dentist to receive your full Benefit. procurement organization will become involved to coordinate the activities. SECOND OPINIONS COMPLAINT PROCEDURE,CLAIMS Delta obtains second opinions through Regional APPEAL AND ARBITRATION Consultant members of its Quality Review Committee who conduct clinical examinations, If you have any questions about the services you prepare objective reports of dental conditions, and receive from a Delta Dentist, we recommend that evaluate treatment that is proposed or has been you first discuss the matter with your dentist. If you provided. continue to have concerns, call our Quality Review Department at 1-888-335-8227. 12 Res.No.2002-31 Ex.A We will provide notification if any dental services resolution procedures that may be available to you, or claims are denied, in whole or in part,stating the and your failure to use these processes does not specific reason or reasons for denial. If you have a preclude your use of any other remedy provided by question or complaint regarding eligibility, the law. denial of dental services or claims,the policies, procedures and operations of Delta, or the quality of Disputes relating to your plan, including claim dental services performed by a Delta Dentist,you denials,may be settled by arbitration if they cannot may contact us at the telephone number shown on be settled by this complaint process. Arbitration page 1. You have 60 days after you receive notice will follow the Commercial Rules of the American of denial to appeal. If you write,you must include Arbitration Association(AAA). You can begin this the name of the patient, the group name and process by giving written notice to each party(for number,the Primary Enrollee's name and social example,Delta and your dentist)with whom you security number or identification number and your want to arbitrate, explaining the dispute and the telephone number on all correspondence. You amount involved, if any, and the solution you wish. should also include a copy of the treatment form, You must then file two copies of the notice with the Notice of Payment and any other relevant Association's regional office in Los Angeles or San information. Clearly explain your complaint and Francisco,along with the fee required by the send it to us at the address shown on page 1. Association. We will review your complaint and will resolve the In the event of extreme hardship on the part of an matter within 30 days of receipt or inform you of Enrollee or subscriber, and upon an application for the pending status of the complaint if more relief presented to the AAA, Delta shall assume all information or time is needed to resolve the matter. or a portion of the arbitration fees and expenses as We will respond within three days of receipt to determined by the AAA in accordance with complaints involving severe pain and imminent and procedures established and administered by the serious threat to a patient's health. AAA. The California Department of Managed Health Care IF YOU HAVE ADDITIONAL COVERAGE is responsible for regulating health care service plans. The department has a toll-free number It is to your advantage to let your dentist and Delta 1-888-HMO-2219 to receive complaints regarding know if you have dental coverage in addition to this health plans. The hearing and speech impaired may Delta program. Most dental carriers cooperate with use the California Relay Service's toll-free one another to avoid duplicate payments,but still telephone numbers 1-800-735-2929 CITY) or allow you to make use of both programs- 1-888-877-5378(TTY)to contact the department. sometimes paying 100%of your dental bill. For The department's Internet web site example,you might have some.fillings which cost (http://www.hmohelp.ca.gov)has complaint forms $100. If the primary carrier usually pays 80%for and instructions online. If you have a grievance these services, it would pay$80. The secondary against the plan, you should first telephone the plan carrier might usually pay 50% for this service. In at 1-888-335-8227 and use the plan's grievance this case, since payment is not to exceed the entire process before contacting the department. If you fee charged, the secondary carrier pays the need help with a grievance involving an emergency, remaining$20 only. Since this method pays 100% a grievance that has not been satisfactorily resolved of the bill,you have no out-of-pocket expense. by the plan, or a grievance that has remained unresolved for more than 30 days,you may call the Be sure to advise your dentist of all programs under department for assistance. The plan's grievance which you have dental coverage and have him or process and the department's complaint review her complete the dual coverage portion of the process are in addition to any other dispute Attending Dentist's Statement, so that you will 13 Res.No,2002-31 Ex.A receive all benefits to which you are entitled. For misconduct), or the reduction in further information, contact the Delta Customer and work hours,by your employer, Member Service Department at the number in the USING THIS BOOKLET section. Event 2. your death; OPTIONAL CONTINUATION OF Event 3. your divorce or legal separation from COVERAGE (COBRA OR CAL-COBRA) your spouse; The federal Consolidated Omnibus Budget Event 4. your Dependents' loss of dependent Reconciliation Act(or COBRA,pertaining to status under the plan, and certain employers having 20 or more employees) and the California Continuation Benefits Event 5. as to your Dependents only, your Replacement Act(or Cal-COBRA,pertaining to entitlement to Medicare. employers with 2-19 employees),both required continued health care coverage be made available to You means the Primary Enrollee. "Qualified Beneficiaries"who lose health care coverage under the group plan as a result of a PERIODS OF CONTINUED COVERAGE "Qualifying Event". You or your Dependents may be entitled to continue coverage under this program, Qualified Beneficiaries may continue coverage for at the Qualified Beneficiary's expense,if certain 18 months following the month in which Qualifying conditions are met. The period of continued Event 1 occurs. coverage depends on the Qualifying Event. This 18 month period can be extended for a total of DEFINITIONS 29 months,provided: The meaning of key terms used in this section are 1. a determination is made under Title II or shown below. Title XVI of the Social Security Act that an individual is disabled on the date of the Qualified Beneficiary means: Qualifying Event or becomes disabled at any time during the first 60 days of continued 1. you and/or your Dependents who are coverage;and enrolled in the Delta plan on the day before the Qualifying Event,or 2. notice of the determination is given to the employer during the initial 18 months of 2. a child who is bom to or placed for adoption continued coverage and within 60 days of with you during the period of continued the date of the determination. coverage,provided such child is enrolled within 30 days of birth or placement for This period of coverage will end on the first day of adoption. the month that begins more than 30 days after the date of the final determination that the disabled Qualifying Event means any of the following individual is no longer disabled. You must notify events which, except for the election of this the employer within 30 days of any such continued coverage,would result in a loss of determination. coverage under the dental plan: If,during the 18 months continuation period Event 1. the termination of employment resulting from Qualifying Event 1,your (other than termination for gross Dependents,who are Qualified Beneficiaries, experience Qualifying Events 2,3,4,or 5,they may 14 Res.No.2002-31 Ex.A choose to extend coverage for up to a total of 36 Premiums for each month since the loss of months(inclusive of the period continued under coverage. Failure to pay the required Premiums Qualifying Event 1). within the 45 days will result in the loss of the right to continue coverage,any Premiums received after Your Dependents,who are Qualified Beneficiaries, that will be returned to the Qualified Beneficiary. may continue coverage for 36 months following the occurrence of Qualifying Events 2,3, 4 or 5. CONTINUED COVERAGE BENEFITS Under federal COBRA law only,when an employer The Benefits under the continued coverage will be has filed for bankruptcy under Title H,United States the same as those provided to active employees and Code,benefits may be substantially reduced or their Dependents who are still enrolled in the dental eliminated for retired employees and their plan. If the employer changes the coverage for Dependents,or the surviving spouse of a deceased active employees,the continued coverage will retired employee. If this benefit reduction or change as well. Premiums will be adjusted to elimination occurs within one year before or one reflect the changes made. year after the filing, it is considered a Qualifying Event. If you are the retiree,and you have lost TERN19NATION OF CONTINUED coverage because of this Qualifying Event,you may COVERAGE choose to continue coverage until your death. Your Dependents who have lost coverage because of this A Qualified Beneficiary's coverage will terminate at Qualifying Event may choose to continue coverage the end of the month in which any of the following for up to 36 months following your death. events first occurs: ELECTION OF CONTINUED COVERAGE 1. the allowable number of consecutive months of continued coverage is reached; Your employer will notify Delta in writing within 30 days of Qualifying Event 1. A Qualified 2. failure to pay the required Premiums in a Beneficiary must notify Delta in writing within 60 timely manner, days of Qualifying Events 2, 3,4, or 5 or within 60 days of receiving the election notice from the 3. the employer ceases to provide any group employer. Otherwise, the option of continued dental plan to its employees; coverage will be lost. 4. the individual first obtains coverage for Within 14 days of receiving notice of a Qualified dental Benefits,after the date of the election Event,Delta will provide a Qualified Beneficiary of continued coverage, under another group with the necessary benefits information,monthly health plan(as an employee or Dependent) Premiums charge,enrollment forms,and which does not contain or apply any instructions to allow election of continued coverage. exclusion or limitation with respect to any pre-existing condition of such a person, if A Qualified Beneficiary will than have 60 days to that pre-existing condition is covered under give Delta written notice of the election to continue this program; coverage. Failure to provide this written notice of election to Delta within 60 days will result in the 5. entitlement to Medicare; or loss of the right to continue coverage. 6. the individual becomes eligible for coverage A Qualified Beneficiary has 45 days from the under the federal COBRA law. The written election of continued coverage to pay the employer shall notify Delta within 30 days initial Premiums to Delta, which includes the 15 Res.No.2002-31 Ex.A of the date when a Qualified Beneficiary becomes so eligible. Once continued coverage ends,it cannot be reinstated. TERMINATION OF THE EMPLOYER'S DENTAL CONTRACT If the dental Contract between the employer and Delta terminates prior to the time that the continuation coverage would otherwise terminate, the employer shall notify a Qualified Beneficiary under Cal-COBRA either 30 days prior to the termination or when all Enrollees are notified, whichever is later, of the ability to elect continuation coverage under the employer's subsequent dental plan, if any. The continuation coverage will be provided only for the balance of the period that a Qualified Beneficiary would have remained covered under the Delta program had such program with the former employer not terminated. The employer shall notify the successor plan in writing of the Qualified Beneficiaries receiving continuation coverage so they may be notified of how to continue coverage. The continuation coverage will terminate if a Qualified Beneficiary fails to comply with the requirements pertaining to enrollment in,and payment of Premiums to the new group benefit plan. OPEN ENROLLMENT CHANGE OF COVERAGE A Qualified Beneficiary under Cal-COBRA may elect to change continuation coverage during any subsequent open enrollment period,if the employer has contracted with another plan to provide coverage to its active employees. The continuation coverage cinder the other plan will be provided only for the balance of the period that a Qualified Beneficiary would have remained covered under the Delta program. 16 MEO MOU Res. No.2002-31 Ex.A EXHIBIT C DELTA DENTAL CARE PLAN BROCHURE A copy of the Delta Care Plan Brochure may be obtained from the Risk Management Division OR See City Clerk Vault File No. 720.20 01-02 MEO MOU Final 35 04104/02 5:40 PM Res. No.2002-31 41 DELTACARE ' x.A Dental HMO Program x. �"M _ tf. � � . +� �Np .y s ^•e t� v .i Administered by: 1 Private Medical-Care, Inc. f 12898 Towne Center Drive ` Cerritos, CA 90703 Res.No.2002-31 "1111MWO • Eligibility for you and your family Ex.A If you meet your group's eligibility requirements for dental coverage, DeltaCare is a dental program that you can enroll in the DeltaCare program.You may also enroll eligible dependents,including your lawful spouse and unmarried children provides you and your family with (which includes stepchildren and legally adopted and foster children quality dental benefits at an affordable to the age limit specified by your group). Contact your benefits cost. The.DeltaCare program is administrator if you have any questions. designed to encourage you and your family to visit the dentist regularly to • Easy enrollment maintain your dental health. To enroll in the DeltaCare program,simply complete an enrollment form indicating your choice of dentist(from the list of network dental To receive your DeltaCare benefits, you offices)and the name of your group.Return this form as directed by select a primary care network dentist your benefits administrator. when you enroll.The DeltaCare network consists of private practice How your DeltaCare program works dental offices that have been carefully Your selected primary care network dentist will take we of the screened for quality. dental care needs for your family.If you require treatment from a specialist,your primary care network dentist will handle the referral for you. After you have enrolled,you will receive a PMI membership card and an Evidence of Coverage that fully describes the covered benefits of your dental program.The membership card will have the telephone 1 number and address of your network dentist.Simply call the dentist to make an appointment. +r Extensive benefits for you and your family No restrictions on pre-existing conditions, except for tinder the DeltaCare program,many services are covered at no work in progress cost,while others have copayments(fees you pay your network ✓ Large,stable network of dentists,so you can enjoy a dentist)for certain procedures.See the"Description of Benefits and long-term relationship with your dentist. Copayments°far a list of your benefits. Please note:Dental services that are not performed by your network CONVENIENCEdentist must be prior authorized by PM to be covered by your DeltaCare program. No claim forms to complete Easy access to specialty care J Expanded business hours for toll-free customer • provisions for emergency care service,from 6:00 a.m,to 6:00 p.m.,Pacific Time Linder your DeltaCare program,you are covered for out-of-area dental emergencies(35 or more miles from your primary care network dentist).Your program pays up to$100 for emergency J No deductibles or annual dollar maximum dental expenses incurred in each 12-month period. ✓ Cut-of-pocket costs are dearly defined ✓ Cut-of-area dental emergency coverage up to$100 each 12-month period LIMITATIONSAND es.No.2002-31 EXCLUSIONS OF Ex.A • Limitations of Benefits 1. Prophylaxis is limited to one treatment each six-month period (in- 13.Dispensing of drugs not normally supplied in a dental office; cludes periodontal maintenance following active therapy); 14,Accidental injury. Accidental injury is defined as damage to the hard 2. Full maxillary and/or mandibular dentures inlcuding immediate den- and soft tissues of the oral cavity resulting from forces external to the tures are not to exceed one each in any five year period from initial mouth. Damages to the hard and soft tissues of the oral cavity from placement; normal masticatory(chewing)function will be covered at the normal 3. Partial dentures are not to be replaced within any five-year period schedule of benefits; from initial placement, unless necessary due to natural tooth loss 15.Cases which,in the professional judgment of the attending dentist,a where the addition or replacement of teeth to the existing partial is not satisfactory result cannot be obtained,or where the prognosis is poor feasible; or guarded; 4. Crown(s) and bridges are not to be replaced within any five-year 16.Dental services received from any dental office other than the assigned period from initial placement; DekaCare office,unless expressly authorized in writing by DeltaCare 5. Denture relines are limited to one per denture during any 12 con- or as cited under"Provisions for Emergency Care"; secutive months; 17.Prophylactic removal of impactions(asymptomaticlnonpathologicg; 6. Periodontal treatments(root planingisubgingival curettage)are lim- 18."Specla!'ist consultations"for noncovered benefits; Red to four quadrants during any 12 consecutive months; 19.Implant placement or removal, appliances placed on or services 7. Full mouth debridement(gross scale)is limited to one treatment dur- associated with implants,including but not limited to prophylaxis and ing any 12 consecutive month period; periodontal treatment. 8. Bitewing x-rays are limited to not more than one series of four films in 20.Crown lengthening procedures. any six-month period; • Summary of Orthodontic Limitations and Exclusions 9. Full mouth x-rays are limited to one set every 24 consecutive months; 10.Sealant benefrtsinclude the application°fseaianfs only topermanent Theprogramprevidescoveragefororthodontictreatmentpfansprovided first and second molars with no decay,with no restorations and with through DeltaCare Network orthodontists.The start-up fees and the cost the occlusal surface intact,for first molars up to age nine and second to the enrolleeforthe treatment plan are listed lithe DescrlptionofBenefits molars up to age fourteen.Sealant benefits do not include the repair and Copayments,subject to the fallowing: or replacement of a sealant on any tooth within three years of its 1. Orthodontic treatment must be provided byaDeltaCareorthodontist. application. 2- Plan benefits cover 24 months of usual and customary orthodontic i Exclusions treatment. Thefollowingservices are notcovered benefits of this program:- 3. Should an enrollee's coverage be canceled or terminated for any reason,and atthe time ofcancellation orterminati°n be receiving any 1. General anesthesia and the services of special anesthesiologist orthodontictreatment,the enrollee and not DeltaCarewill be responsible 2 Cosmetic dental care; for payment of balance due for treatment provided after cancellation or termination. In such a case the enrollee's payment shall be based 3. Dental conditions arising out of and due to enrollee's employment or on a maximum of$2,300 for dependent children to age 19 and$2,500 for which Workers'Compensation is payable. Services which are for covered full timestudents and adults.The amount will be prorated provided to the enrollee by State government or agency thereof or over the number of months to completion of the treatment and,will be are provided without cost to the enrollee by any municipality,county or payable bythe enrollee on such terms and conditions as arearrang ed other subdivision,except as provided in Section 1373(a)of the Cali- between the enrollee and the orthodontist.Start-upfees are included fornia Health and Safety Code; in these amounts. 4. Treatment required by reason of war; 4. Start-up fees cover the initial examination,diagnosis,consultation and 5. Dental services performed in a hospital and related hospital fees; the retention phase of treatment of up to two years maximum. This includes initial construction,placement and adjustments to retainers 6. Treatment of fractures and dislocations; and office visits for a maximum period of two years. 7. Loss or theft of fixed and removable prosthetics(crowns,bridges,full The following serYlces are not covered.• or partial dentures); 1. Pre,mid-and post-treatment records which include cephalometricx- 8. Dental expenses incurred in connection with any dental procedures rays,tracings,photographs and study models; started after termination of eligibility for coverage; 2. last,stolen or broken orthodontic appliances,functional appliances, 9. Any service that is not specifically listed as a covered expense; headgear,retainers and expansion appliances; 10.Dental expenses incurred in connection with any dental procedure 3. Retreatment of orthodontic cases; started prior to enrollee's eligibility with the DeltaCare program.Ex- 4. Treatmentthat extends morethan 24 months from the point of banding ample:teeth prepared for crowns,root canals in progress,orthodon- dentition will be subject to an office visit charge at orthodontist's usual, he treatment; customary and reasonable fee; 11.Congenital malformations (e.g., congenitally missing teeth, 5. Treatment in progress at inception of eligibility; supernumerary); 12.Cysts and malignancies; 6. Transfer after banding has been initiated. 2-31 FF GETTING TO KNO��- Ex.A LOUR DeltaCare PROGRAM • What is PMI? • How long does it take to get an appointment with a PMI is a dental HMO that has administered DeltaCare programs for DeltaCare dentist? nearly 30 years.PMI contracts with network dentists,works with Two to four weeks is a reasonable amount of time to wait for a your group to design your benefits program and handles all routine,non-urgent appointment.If you require a specific time,you customer service inquiries.Today,more than a million enrollees may have to wait longer.In addition,most DeltaCare dentists are in are covered by DeltaCare programs. private group practices,which means greater appointment • What is the difference between PMI and Delta? availability and extended office hours. PMI administers DeltaCare dental HMO programs and is an I have a pre-existing dental condition.Can I still join: affiliate of Delta Dental Plan of Califomia. DeltaCare? 0 Now do I know if my dentist is a PMI dentist? Yes,treatment for pre-existing conditions such as extracted teeth is not excluded under the DeltaCare program. When you enroll in DeltaCare,you select a primary care dentist However,benefits are not provided for any dental treatment from the list of DeltaCare network dentists.With more than 2,500 started before joining the program(that is,work in progress,such general and specialist dentists,the DeltaCare network is one of the as preparations for crowns,root canals,impressions for dentures largest in California. and orthodontic treatment). 0 My dentist is a Delta dentist but Is not on the list of • How does the DeltaCare program encourage preventive DeltaCare network dentists.Can I still receive treatment care? from this dentist? Your DeftaCare program is designed to encourage regular visits to No,you must receive treatment from your selected DeltaCare the dentist by having no copayments(fees you pay to the network network dentist.Please Hate that Delta dentists are not necessarily dentist)on most diagnostic and preventive services. See the DeltaCare dentists. enclosed"Description of Benefits and Capayments" 0 How do I know DeltaCare dentists provide quality 0 Does my DeltaCare program cover specialists'services? care? Yes.Your primary care network dentist will coordinate your DeltaCare dentists are reviewed for quality,availability and safety specialty care needs with an approved network specialist. There before joining the network.PMI maintains quality standards by is no additional charge to you for receiving care from a specialist. visiting each network dental office every three months. If there's no network specialist within your service area,PMI will authorize a referral to an out-of-network specialist at no extra cost, Do my family members receive treatment from the same other than the applicable copayment.If you or your dependent is DeltaCare network dentist? assigned to a dental school clinic for specialty services,those services may be provided by a dentist,a dental student,a clinician Yes,you and all eligible dependents receive care from the same or a dental instructor. primary care network dentist. Can I change my primary care network dentist? Yes.You may change network dentists by notifying PM1 either by ® DENTAL HEALTH PLAN phone or in writing,or by visiting our websfte A AM—ofW.DaumM- uirami, {www.deftadentalca.oral. If you contact us by the 21 st of the Ifyou have any questions or need additional information,call or write to: month,the change will become effective the first of the following PMI Dental Health Plan month. 128s&Cerritos,CA 9t77Q3 Towne Center Drive 0 What if I have questions about my DeltaCare program? (800)422-4234 Call PMI Customer Relations at(800)422-4234.We have or visit our website at www.defadentaica.org_ multilingual representatives available from 5 a.m.to 6 p.m., Note-THIS tS ONLY A BRIEF SUMMARY OF THE PLAN. Monday through Friday.Our Customer Relations representatives The Group,Dental Service Contract must be consulted to determine the exact have worked in dental offices and can answer benefits questions, terms and conditions of coverage.An Evidence of Coverage will be sent to you as well as arrange office transfers and urgent care referrals. upon enrollment. If you wish to review an Evidence of Coverage prior to enrollment,you may request a copy by calling PMI's Customer Relations Department M(8W)422-4234. 09/0 r SCCA700 1 . , Res.No.2002-31 Ex.A Cxiaa E'er C4ft Pays 2930,2931 Crown--prefabricated stainless steel— 6752 Crown--porcelain fused to noble metalt.............No Cost primary/permanent........................................No Cost 6790 Crown--full cast high noble metsP......................No Cost 2950 Crown buildup 6791 Crown--full cast predominantly base metal.........No Cost (restorative material and pins).......................:No Cost 6792 Crown--full cast noble metal...............................No Cost 2952 Cast post and core' 6936 Recement bridge(fixed partial denture).............No Cost (in addition to crown) ....................................6 No Cost 6g40 Stress breaker,per unit (in addition to 2954 Prefabricated post and core mixed partial denture,retainer)......................No Cost (in addition to crown) ......».............................No Cost 6970 Cast post and core* 5110,5120 Denture—complete maxillary (incktdes canal preparation)...........................No Cost or mandibular(upper or lower)......................No Cost 6972 Prefabricated post and core buildup 5130,5140 Immediate denture—maxillary (including canal preparation, or mandibular(upper or lower).......................No Cost restorative material and any pins) .................No Cost 5213,5214 Denture—maxillary or mandibular (upper or lower)partial with metal *Base ornoble metal is the benefrt. NighnobkmeW(preciars),ifused, lingual or palatal bar,clasps and wilbe charged to the enrollee at the addidonallaboraiorycost of the high acrylic saddles,and acrylic base or noble metal This applies to crowns,bridges,cast and post cores,inlays cast metal framework and teeth.....................No Cost and onlays. 5410 Adjust complete denture—maxillary....................No Cast 5411 Adjust complete denture--mandibular ................No Cost t Porcelain on molars is considered optionaltreatment 5421 Adjust partial denture--maxillary........................No Cost 5422 Adjust partial denture--mandibular.....................No Cost Vll. ENDODONTtCS 5510 Repair broken complete denture base..No Cost 3110,3120 Pulp capping(directlindirect)..............................No Cost 5520 Replace missing or broken teeth 3220 Therapeutic pulpatorny complete denture(per tooth) . ....................No Cost (excluding final restoration) ..........................,No Cost 5610 Repair resin denture base..................................No Cost 3310 Root canal therapy--anterior 5620 Repair cast framework......................................No Cost (excluding final restoration) ...........................No Cost 5630 Repair or replace broken clasp..........................No Cost 3324 Root canal therapy--bicuspid 5640 Replace broken teeth(per tooth).......................No Cost (excluding final restoration) ............................No Cost 5650 Add tooth to existing partial denture...................No Cost 3330 Root canal therapy-molar 5660 Add clasp to existing partial denture...................No Cost (excludingfinal restoration .............No Cost 5730 Reline complete mmal denture }.ery ..... � �Y 34i0 Apicoectomylperiradicularsurgery--anterior.......No Cost (chairside)......................................................No Cost 3421 Apicoectomylperkedicular surgery 5731 Reline complete mandibular denture bicuspid(first root) ......No Cost ................................... (chairside)......................................................No Cost 3425 Apicoectomylperiradicular surgery-- 5740 Reline max0lary partial denture molar(first root) ..............No Cost > (chairside)......................................................No Cost 3426 Ap'icoektomylpedradicular 5741 Reline mandibular partial denture surgery(each additional root) ........................No Cost (chairside)........... ......................................No Cost 3430 Retrograde filling,per root.................................No Cost 5710 Rebase complete maxillary denture ...................No Cost 3450 Root amputation,per root..................................No Cost 5711 Rebase complete mandibular denture ...............No Cost 5720 Rebase maxillary partial denture........................No Cost Vitt. ADJUNCTIVE GENERAL SERVICES 5721 Rebase mandibular partial denture....................No Cost 9110 Pa lative(emergency)treatment of dental pain..No Cost 5750 Reline complete maxillary denture(lab) .............No Cost 9211 Regional block anesthesia..................................No Cost 5751 Reline complete mandibular denture Cab)..........No Cost 9212 Trigeminal division block anesthesia...................No Cost 5760 Reline maxillary partial denture(lab} .................No Cost 9215 Local anesthesia.................................................No Cost 5761 Reline mandibular partial denture p (lab)..............No Cast 9310 Consultation(diagnostic services provided by 5820 Interim partial denture(maxillary)......................No Cost dentist or physician other than practitioner 5821 Interim partial denture(mandibular)...................No Cost providing treatment).......................................No Cost 5850,5851 Tissue conditioning--per denture........................No Cost 9440 Office visa after regularly scheduled hours...........$20.00 6210 Pontic—cast high noble metal!............................ No Cost 0125 Failed appointment without 24 hour notification, 6211 Pontie--cast predominantly base metal...............No Cost per 15 minutes of appointment time................$10.00 6212 Pontic--cast noble metal...................................No Cost 6240 Pontic--porcelain fused to high noble metall.....No Cost DL ORTHODONTICS 6241 Pontic—porcelain fused to . Start-up fees(excluding records)............................................$250.00 predominantly base metalt............................No Cost Dependent children to age 19..................................................$500.00 6242 Pontic—porcelain fused to noble metalt .............No Cost Adults and covered full-time students.......................................$500.00 6750 Crown--porcelain fused to high noble rneW?t....No Cost 6751 Crown--porcelain fused to Any procedure not listed is available on a fee-for-service basis. predominantly base metalt............................No Cost TOWS Res.No.2002-31 Ex.A • � IF These services are performed as needed and deemed necessary by your attending DeltaCare network dentist subject to the limitations, exclusions and goveming administrative policies of the program. ADA ENIAN ADA EvAge codes Par cedes pap, I. DIAGNOSTIC 7130 Root removal—exposed roots.............................No Cost Office visit,per visa 7210 Surgical removal of erupted tooth......................No Cost (in addition to other services) .........................No Cost 7220 Removalof impacted tooth—soft tissue ..............No.Cost 0120 Periodic oral evaluation......................................No Cost 7230 Removal of impacted toothpartially bony............No Cost 0140 Limited oral evaluation--problem focused...........No Cost 7240,7241 Removalof impacted tooth 0150 Comprehensive oral evaluation..........................No Cost corTletelybony ............................................No Cost 0160 Detailed and extensive oral evaluation 7250 Surgical removal of residual problem focused ...........................................No Cost tooth roots(cutting procedure).......................No Cast 0210 Intraoral radiographs- 7286 Biopsy oforaltissue—soft...................................No Cost complete series(including bdewings) .............No Cost 7310 Alveoloplastyin conjunction 0220,0230 Intraoral periapical film.......................................No Cost with extradions,per quadrant........................No Cost 0240 Intraoral occlusal film..........................................No Cost 7320 Alveobplasty not in oonjunction 0270, with extras tlons,per quadrant........................No Cost 0272,0274 Mewing radiograph(s).......................................No Cast 7470 Removal of exostosis-maxilla or mandible..........No Cost 0330 Panoramic film...................................................No Cost 7510 Incision and drainage of abscess-- intraoralsofttissue....................... ..............»No Cost IL PREVENTIVE 7960 Frenule*my—(frenectomyorfrenotomy) 1110,1120 Prophylaxis(cleaning)--adulVJchild separate procedure .......................................No Cost 1 per 6 month period .....................................No Cost 1201 Topical application offluodde, V. PERIODONTICS including prophylaxis Po age 19) (includes preoperaMand postoperative evahratlons and beabrrent i per 6 month period .....................................No Cost under a kxW anesM94 1203 Topical application of fluoride, 4210 Gingiveadomy or gingivoplasty,per quadrant.......No Cost excluding prophylaxis(to age 19) 4211 Gingiiveo#rmyorging'rvoplasty, 1 per 6 month period .....................................No Cost per tooth(fewer than six teeth)......................No Cost 1330 Oral hygiene instructions....................................No Cost 4220 Gingival curettage surgical,per quadrant...........No Cost 1351 Sealant,per tooth .......................... . .....No Cost 4240 Gingivalflap procedures including 1510 Space maintainer--fixed--unilateral....................No Cost root planing(per quadrant)................ '...........No Cost 1515 Space maintainer--fixed--bilateral......................No Cost 4260 Osseous surgery,flap entry and closure, 1520 Space maintainer--removable--unilateral...........No Cast per quadrant..................................................No Cost 1525 Space maintainer--removable--bilateral.............No Cost 4341 Periodontal scaling and root planing, 1550 RecemenWon of space maintainers .................No Cost per quadrant..................................................No Cost 4355 Full mouth debridement to enable Ill. RESTORATIVE(iFitlings) comprehensive pedodonta!evaluation (lndudes indirect pulp rapping,bases,frners and acid etch procedures) and diagnosis.................................................No Cost 2110 Amalgamone surface,primary.........................No Cost 4910 Periodontal maintenance 2120 Ama*am--two surfaces,primary ......................No Cost (following active therapy) ..............................No CrOd 2130 Amalgam--three surfaces,primary.....................No Cast 2131 Amalgam—four or more surfaces, VI. PROSTHETICS primary...........................................................No Cast (Crowns,bridges and dentures) 2140 Amalgam--one surface,permanent ...................No Cost 2510 Inlay—one surface—base metal noble................No Cost 2150 Amalgam--two surfaces,permanent..................No Cost 2520,6520 Inlay—two surfaces--base metal noble ...............No Cost 2160 Amalgam--three surfaces,permanent...............No Cost 2530,6530 Inlay--three or more surfaces— 2161 Amalgam-- base metal noble............................................No Cost four or more surfaces,permanent .................No Cost 2543,6543 Onlay-three surfaces—base metal noble........—No Cost 2330 Resin—one surface anterior...............................No Cost 2544,6544 Onlay—four or more surfaces- 2331 Resin--two surface anterior................................No Cost base metal noble............................................No Cost 2332 Resin--three surface anterior.............................No Cast 2710 Grown—resin(laboratory) ..................................No Cost 2335 Resin--four or more surfaces 2740 Crown—porcelain(ceramict..............................No Cost or invohring incisal angle(anterior) .................No Cost 2750 Crown--porcelain fused to high noble metWt....No Cost 2336 Composite resin crown,anterior--primary..........No Cost 2761 Crown—porcelain fused to 2940 Sedative filling ..................................................No Cost predoWnardty base metalt............................No Cost 2951 Pin retention--per tooth, 2752 Crown—porcelain fused to noble metalt.............No Cost in addition to restoration.................................No Cost 2790 Crown—full cast high noble metal*......................No Cost 2791 Crown--full cast predominantly base metal.........No Cost IV ORAL SURGERY 2792 Crown—M cast noble metal..............................No Cost (lnctudes preoperative and postoperative evaluations and treatment 2810 Crown44 cast metal noble..............................No Cost underbcalanesthetic) 2910 Recement Way..................................................No Cast 7110,7120 Single tooth extractioNeach additional ...............No Cost 2920 Recement crown...............................................No Cost loxes 41 DELTACAR E' FERAL Mft AlJ PARTICIPATING DENTAL OFFICES � Dw �PiA� at Second Quarter 2002-Southern California Open Offices Volume I AGOURA HILLS -#125501 ANAHEIM #235001 ANAHEIM HILLS 93C2201 AZUSA #3G6801 AGOURA DENTAL GROUP SMILES FOR ORANGE COUNTY ANAH M HILLS DENTAL GROUP APPLE DENTAL 2952S CANWOOD ST STE 250 9672 BALL ROAD 5731 A SANTA ANA CNYN RD 891 E ARROW HWY STE B (818)991-9852 (714)772-0102 (714)998-2956 (626)332-4788 FIT I (SP TA) & FIT 2 (SP) FIT I (5P) FIT 2 (SP TA) ALHAMBRA #000647 ANAHEIM #2S6401 APPLE VALLEY #005101 BAKERSFIEL12 #131001 MOHAMMAD DABBOUSI DDS DRS ANTHONY AND NAOMIWONG ASPEN DENTAL GROUP STEPHEN KANN DOS 401 N GARFIELD AVE 3356 W BALL ROAD STE 215 ISM TUSCOLA RD STE 201 1919 G STREET (626)570-0974 (714)993-3051 (760)242-2620 (661)3234585 FIT I (SP TA AR) FIT 2 (SP CH) Ffr I (TA RU) FIT I ALHAMSRA 9051601 ANAHEIM #256501 APPLE VALLEY #128401 BAKERSFIELD #164101 DRS LEE AND YEE ANAHEIM FIRST FAMILY DENTAL SANG PAIK DDS SIAN POH DDS 157 N GARFIELD AVE 1161 N EUCLID ST 20162 HWY 18 STE L 2721 H ST (626)284-5113 (714)9995050 (7"946-1466 (661)324-9709 FIT 2 PIT I (CH SP VI) CEi FIT 2 PIT 2(SP CH) FIT i (KO SP) FIT I ALHAMBRA #00O201 ANAHEIM #258301 APPLEVA #2CS001 BAKERSFIELD #ICS601 NADIR YAZDANI DOS DALWANI AND DHOLAKTYA APPLEVALLEY DENTAL G STREET FAMILY DENTAL 747 5 GARFIELD AVE 815 N EUCLID STREET ISM HIGHWAY 18 STE 4 2611 G ST (626)289.6813 (714)75&0791 f760141--2977 (661)859-0191 FIT 2 C% FIT 4 (SP CH JA) r FIT 1 M FIT I ALHAMBFtA #1 1 Soo I ANAHEIM #274701 ARCADIA #196501 BALMMN PARK #057801 ALHAMBRA FAMILY DENTISTRY ANAHEIM OPEN 7 DAYS DENTAL ARCADIA DENTAL CENTER DAVID KUTNER DMD 600 W MAIN STREET STE 102 637 N EUCLID ST 7S N SkNTAANITA BLVD 215 13734 RAMONA BLVD (626)181-4119 (714)772-2693 (626)447-5126 (626)960=6616 FIT t (SPAR) L Ffr 5 PIT I (SP CH V1 AR JA) & FIT 4 Pi) FIT I PIT I (SP KO) c ALTA LOMA #198801 ANAHEIM #2C1801 ARCADIA #386201 BANNING #169S01 CARNELIAN FAMILY DENTISTRY VILLAGE DENTAL GROUP WILLIAM HOUSTON DDS ADRIAN ACOSTA DDS 6626 CARNELIAN ST 1210 S BROOKHURST ST 25 N SANTA ANITA AVE SUITE E 4240 W RAMSEY AVE (909)987-4113 (714)535-7500 (626)25"%8 (909)849-4484 FIT I (SP CH) FIT I PIT 2 Ch FIT I PIT I FfT 2 (SP RU) ALTA LOMA #359101 ANAH§jM #364201 ARM #3CS201 BARSTOW #000301 JEFFREY LLOYD DDS DAE HUR DDS ANDREW LIM DDS GENTLE DENTAL CARE 9310 BASELINE ROAD 40 E ORANGETHORPE 1041 W HUNTINGTON DRIVE 113 E MOUNTAIN VIEW (909)989-1868 (714)870-6611 (626)445-9660 (760)256-2896 FIT I (SP) FIT I (KO) FIT t (KO SP) (k FIT 1 (SP) ANAHEIM #183601 AUAHEIM #3CS201 tiTA #000223 BELL GARLIENS #328401 NANDINI MURTHY DDS ANAHEIM FAMILY DENTAL OFFICE FA1ILT DENTISTRY MARKETPLACE DENTAL OFFICE 1655 W BROADWAY STE 9 2170 W LINCOLN AVENUE 900 IR WOODMAN AVENUE 6815 EASTERN AVE Sn A 1 (714)774-2638 (714)535-3933 (8181893.8799 (323)560-2595 FfT I (SP) FIT (SP) FIT (SP') FIr 1 (SP) Atl6kfEIM #188001 ANAHEIM #3C6001 #198601 BELL 9AMEti #372001 DANNY TH OMAS DDS PREFERRED DENTAL CARE WOODMAN FAMILY DENTISTRY JIN WE) CHU DDS 601 S EUCLID ST n07 S HARBOR BOULEVARD 8nS WOODMAN AVE 6526 EASTERN AVE (714)77&0700 (714)971-7800 (818)891.6670 (323)771 3949 FfT I PIT t (VI SP RU) FIT 2 PIT I (SP EI) FfT I M FIT 2 (SP) AFL`! #IC0301 ANAHEIM HILLS #000219 ARTESIA #000733 IIELL.FLOWER #185501 UNIVERSAL CARE DENTAL STAR DENTAL CARE SAPM CUPINO DMD GERALD SANDARG DDS 1808 W LINCOLN STE 201 5031 E ORANGETHORPE AVE B2 12146 SOUTH STREET SUITE E 17024 S CLARK AVE STE C (714)780SW (714)6934889 (562)924-1007 (562)915-7436 FIT 1 Pfr I (SP TAVI) c*t FfT I Ffr 1 (SP TA) t Ffr 1 (SP) AHAHEI 4IC7301 ANAHEIM 1:11 S #152101 9112201 99LLELOWER #IC0901 MANHAR MISTRY DDS INC SUNSHINE DENTAL OFFICE SIDE FM ONG DDS INC UNIVERSAL CARE DENTAL 303 N EAST Sr 8285 E SANTA ANA CYN RD 115 17%4 S PIONEER 17660 LAKEWOOD BLVD (714)772-0770 (714)974.5599 (Sq 86&9612 (562)461-1180 FIT I (SP) FIT I Prr I (SP EI) FIT t FIT.2(SP TA) L1k FIT 2 PIT 2(SP VI) & I - The wheelchair symbol indicates funcWnal accessibility for individual uMnited mobill'dy.Irlformafim regarding dental office accessibility for patieds with mobility impairments is available by cAI RCS Customer ReWons department at(8OO)422-4234. MEO MOU Res.No.2002-31 Ex_A EXHIBIT D EMPLOYEE HEALTH PLAN BROCHURE A copy of the Employee Health Plan Brochure may be obtained from the Risk Management Division OR See City Clerk Vault File No. 720.20 01-02 MEO MOU Final 36 04/04/02 5:40 PM Res.No.2002-31 Ex-A v It f HUNTINGTON BEACH MEMBERSHIP HANDBOOK MEQ ASSOCIATION AND SUBSIDIZED ` RETIREE a!7��a"� r'�,:1r�':e.4Y^ry...iil..,'� ....... .��....zY :✓k�..-n�� .'aik��.�� EMPLOYEE HEALTH PLAN This booklet provides a brief description of the important features of your health insurance-coverage. It is not a contract and only the provisions of the Plan Document will control. Payments under this plan are based on Usual, Customary and Reasonable charges. 0 N d Revised April 2001 , TABLE OF CONTENTS Highlights of the Employee Health flan Highlights of the Employee Health Plan 1 The Employee Health Plan was created for the purpose of providing medi- cal benefits for eligible employees and their eligible dependents. CoPayment and Benefit Percentages 2 This section is intended only as a brief summary of the Plan's benefits. Definitions 3 All maximums are per person unless specifically noted as per famlly. Please refer to the subsequent sections for a more detailed description Persons Covered and Effective Dates 6 of covered expenses and benefits exclusions. and limitations. Preferred Provider and Exclusive Provider_ Organization 7 Eligible yegs Deductibles and Out of Pocket Expenses 14 A permanent City employee Eligibility Date Covered Medical Expenses 10 (See Persons Covered and Effective Dates section for enrollment details 12 and effective dates) Prescriptions Open Enrollment Chiropractic and Physical Therapy 12 The open enrollment period is the month of November. Coverage for a Preventive Medical Care 12 participant enrolling during Open Enrollment will be effective Jan. 1. Lifetime Maximum Benefit Well Baby Care 12 The lifetime maximum benefit is$1,000,000. This is the absolute limit on General Exclusions and Limitations 13 what the Plan will pay for each participant's covered expenses. 15 Calendar Year Maximum Benefit When You Have a Claim The calendar year maximum benefits listed below are the limits on what l5 this Plan will pay for each participant's covered expenses in a calendar Claims Payment and Appeals year for the corresponding type of benefit: Coordination with Other Plans 16 Mental/Emotional Disorder and or Substance Abuse: 17 Administered by Managed Health Network. No benefits available through Termination of Coverage the Employee Health Plan. Refer to MHN brochures for further in forma- tion. Inaatient Hospitalization 100 days (during each period of disability) Chiropractic Care $2,000 or 24 visits o (whichever occurs first) 0 Wellness Benefit $200 per year y w 1 Definitions Deductible: Per Person S250 Per Family $500 Calendar Year A period of twelve months commencing January l and ending December Out of Pocket: Per Person $2,000 31 of the same year. Per Family $4,000 (Deductibles and Out of Pocket apply per calendar year) Custodial Care Means services or supplies for persons who are'physically or mentally dis- abled but who are not currently receiving medical,surgical or psychiatric teed Usual, Customary and Reasonable rates, any expenses for treatment treatment to reduce their disability and to enable them to live without cus- of a menta!/emotional disorder and/or substance abuse,charges for pre- todial care. scription drags or the EPO copayments. Copsyment and Benefit Percentage Emergency A sudden,unexpected,acute illness or injury that,without immediate Benefits EPO% PPO% Non PPO% medical treatment,could result in death or cause impairment to bodily Description functions. Annual Deductible None $250/$500 $250/$500 Extended Care or Ski I led Nursing Facility A licensed facility operating pursuant to law which is primarily engaged in providing skilled nursing care on an inpatient basis during the convales- Qftl3ce Visits $5 copay 90% 70%UCR cent state of illness or injury under 24 hours a day supervision of a physi- cian or registered graduate nurse. Such a facility must maintain complete medical records on each patient and have established methods and proce- dures for the dispensing and administering of drugs. In no event shall the Wellness No charge $200 max $200 max term include a facility that is primarily: • A rest home,retirement home or home for the aged • A school or similar institution Inpatient S 150 copay 90% 70% • Engaged in the care and treatment of substance abuse,or of Hospitalization (day 1-4)then mentally ill or senile persons 100% • Engaged in custodial dare Emergency Services $5 copay 900/0 70% Hospital An institution operated pursuant to law that is accredited by the appropri- ate national regulatory body for hospital accreditation. It must be primar- Outpatient Services $5 copay 90% 70% ily engaged in providing medical,diagnostic and surgical facilities for the care and treatment of sick and injured individuals on an inpatient basis. It must also provide such facilities under the supervision of a staff of physi- Durable Medical $5 copay 90% 70% } cians and with 24 how a day nursing services by registered graduate Equipment nurses. The definition of hospital shall not include any institution or part thereof which is used principally as a rest facility,extended care facility, m Prescription-pharmacy $5 generivS$brand nursing facility or facility for the aged. z 0 In a i o Prescription—mail order $4 generic!$(brand A person who is confined in a hospital as a registered bed patient and who x N is charged at least one day's room and board by the hospital. n 3 2 Medical Necessary or Medical Necessity Plan Administrator Describes medical treatment that: The Risk Management Division is the Plan Administrator for purposes of • Is appropriate and consistent with the diagnosis this Plan's claims administration. Is in accordance with accepted medical standards,it would not have been omitted without adversely affecting the patient's Re free condition or the quality of medical care rendered Any retired employee of the City who(a)has retired on a service or dis- • is not primarily custodial care ability retirement and(2)is not eligible for Medicare,and(3)has not at- tained age 65. Mental Health Disorder Any disorder characterized by abnormal functioning of the mind or usual.Customary and Reasonable emotions and in which psychological, intellectual,emotional or behav- Charges made for medical services or supplies essential to the care of the ioral disturbances are the dominate features. Mental health disorders participant will be considered reasonable and customary if they are the include mental disorders,mental illnesses,psychiatric illnesses,mental amount normally charged by the provider for similar services and supplies conditions and psychiatric conditions,whether organic or non-organic, and do not exceed the amount ordinary charged by most providers of com- whether biological,non-biological,genetic,chemical,or non-chemical parable services and supplies in the geographic area where the services or origin,and irrespective of cause,basis or inducement. supplies are received. Whether charges are reasonable and customary shall be determined by the Plan Administrator or its agent in its sole dis- Nurse cretion by use of any customary or accepted method. In determining A licensed Registered Nurse(R.N.)or licensed Practical Nurse(LPN)or whether charges are reasonable and customary,the Plan Administrator licensed Vocational Nurse(LVN)who does not live with the patient and will give due consideration to the nature and severity of the condition be is not a member of the family, ing treated and any medical complications or unusual circumstances that require additional time,skill or expertise. Outpatim A person who is not admitted as an inpatient but who receives medical care. Outpatient Surgery Surgery performed on an outpatient basis at a hospital,ambulatory Sur- gical facility,or physician's office. An ambulatory surgical facility is defined as a licensed,specialized facility,within or outside the hospital facility that meets the following criteria: + Is established,equipped and operated in accordance with the applicable state laws and is primarily for the purpose of per- forming surgical procedures • Is operated under the supervision of a Medical Doctor(M.D.) who is devoted full time to such supervision ' • Requires,in all cases other than those requiring only local infiltration anesthetics,that a licensed anesthesiologist admin- ister the anesthetics and remain present through the surgery. z Physician ° N A duly licensed Doctor of Medicine(M.D.),Osteopath,Podiatrist,Chi- $ ropractor or any other practitioner providing a covered service and act- S n 2 Ing within the scope ofhislher license. 4 Persons Covered and Effective Date Preferred Provider Organization(PPO) Those eligible are: Exclusive Provider Organization(EPO) • All permanent employees and their spouses The Preferred Provider Organization(PPO)and Exclusive Provider Or- • Their unmarried children to age 19 ganization(EPO)is a statewide network of physicians,hospitals and other health care providers established specifically to provide comprehensive • Unmarried children from age 19 to 25 if: medical service to Plan participants at reduced rates. As a participant in (a) A full time student,or the Plan,you will receive a directory of providers that belong to the FPO (b) Lives at home and is dependent upon hislher and EPO networks. parent for at least 50%of his/her support If you choose the PPOIEPO option,please follow the procedures for its New permanent employees are eligible to participate in the Employee use carefully. If your doctor refers you to another provider,make sure that Health Plan on the first of the month fallowing 30 days from the date of the new provider is also an EPO or PPO before services are rendered. hire. Effective Date of Detendent Coverage The copayments and applicable benefit percentages are shown in the Highlights section. If you go to a PPO provider,do not pay for services at Check with the Human Resources Division when you went to enroll a new spouse or new child. Appropriate forms must be completed within 60 the time of your visit. PPO providers are required to submit their medical bills to the Employee Health Plan fir 'Me Employee Health Plan will days of marriage,birth of a child or when the employee becomes legally responsible for an adopted child. Dependent coverage will be e then calculate the Usual,Customary and ltcasonable(UCR)rate and then effective on the date of marriage,date of birth or the newborn child or the date of issue an Explanation of Benefits(EOB)to the PPO and the participant. The PPO provider will then issue a statement to the participant for the co- adoption or the date of placement of an adopted child in your home. payment and deductible if applicable. Change in Family Status If you o to an EPO,the provider may Once you are enrolled in the Employee Health Plan,you must notify the y g P y request payment of the$5 copay at Plan Administrator or Human Resources Division within 60 days of any the time of your visit. You are not responsible for any other charges other family status change,such as a newborn baby,or when you no longer need than the$5 co lay if you are admitted to a hospital,your copay will be a certain family member covered,or when a family member is no longer $150 per day to a maximum of$600 per period of hospitalization. eligible as defined by this Plan. Notice to Employees Waiving Coverage If you decide to decline coverage under this Plan for yourself or your Eli- gible Dependents for whatever reason,you must execute a waiver of cov- erage on a form provided by the Human Resources Division at the time coverage is declined,and return such form to Human Resources. If you are declining enrollment for yourself or your Eligible Dependents because of other health insurance coverage,you may,in the future,be able to enroll yourself or your Eligible Dependents in the Plan,provided that you request enrollment within thirty(30)days after your other coverage ;U ends. N O rn- x n3 6 7 a� Deductibles and Out of Pocket Expenses Family Out ofPocket-Ex prnse Deductibles and out of pocket expenses represent the portion that the par- If the dollar amount of the family out of pocket expense amount,shown in ticipant pays for covered expenses. This section generally describes these the Highlights section,is satisfied by the combined covered expenses ap- cost sharing provisions of the Plan. plied to the individual out of pocket expense amount of several covered family members,no additional out of pocket expense amount is required Calendar Year Deductible to be satisfied by the covered persons of that family for the remainder of The calendar year deductible is the amount of covered expenses incurred the calendar year.Once a covered family member has satisfied the individ- by a participant during a calendar year for which no benefits will be paid. r ual out of pocket expense amount no additional covered expenses for that After you,or a covered dependent,has satisfied the calendar year deducti- 6 person will be counted towards the family out of pocket expense amount ble, the Plan pays a certain percentage of the covered expenses for that individual during the rest of the calendar year. Deductible accumulation period is January 1 through December 31. Family Calendar Year Deductible If the dollar amount of the family calendar year deductible,shown in the Highlights section,is satisfied by the combined covered expenses applied to the individual deductibles of several covered family members,no addi- tional calendar year deductible amount is required to be satisfied by the covered persons of that family for the remainder of the calendar year. Once a covered family member has satisfied the individual deductible,no additional covered expenses for that person will be counted toward the family deductible. Thrm Month_ Mover Any covered expenses incurred in the last three months of the calendar year that are used to satisfy the calendar year deductible for that year will be applied towards to deductible for the following year. Out of Pocket Expenses Out of pocket expense is the amount of covered expenses you must pay after the satisfaction of the calendar year deductible before certain benefits begin to be paid at 100%. If,during the calendar year,your out of pocket expenses satisfy the out of pocket expense amount,the rate of payment for 4 certain covered charges will be increased to a full one hundred percent I (100%). The one hundred percent(100%)will continue until the end of that calendar year. You must satisfy your deductible plus your out of pocket amount before these benefits will be paid at 100%. In no event will this provision apply to the deductible,any expenses for treatment of a mental/emotional disorder and/or substance abuse,charges o for prescription drugs,charges that exceed Usual, Customary and Reason- able charges,or the EPO copayments. m N x , • A j 8 9 Covered Medical Expenses It. Speech therapy by a qualified speech therapist. The therapy List of Covered Medical B ses must be to restore or rehabilitate speech loss due an illness or in- The following expenses are covered b the Plan. Reimbursement is based jury,or due to surgery for y,illness or injury. If speech loss is y due to a congenital anomaly,surgery to correct the anomaly must upon the lifetime maximum and calendar year limits,benefit percentages have been performed prior to therapy. and other limitations previously described in the Highlights section, 12. Elective surgery for sterilization,including tubal ligation and va- sectomy. l. Charges for services and supplies used in the administration of 13. Medical supplies necessary for treatment including but not lira- anesthesia,when not duplicated in the hospital charges. ited to,an electronic heart pacemaker,surgical dressings,casts, 2. Transportation by a professional ambulance service to a local splints,and crutches. hospital or convalescent facility for inpatient care,if medically 14. Surgeon's fees for the performance of surgical procedures,in- necessary,or to the nearest hospital for emergency care. Ex- eluding necessary related postoperative care by a physician,sub- penses for transportation by air will be covered only if an air am- ject to the reasonable and customary fees in the area. bulance is medically necessary. The first$50 of charges will be 15. Wellness care(see Highlights section for details) paid at 100%. 16, Chiropractic and Physical Therapy subject to Plan limitations 3. Rental or durable medical equipment when such equipment is 17. Occupational Therapy performed by a licensed occupational deemed medically necessary, including,but not limited to,a therapist and ordered by a physician. It must be considered pro- wheelchair,hospital bed,respirator,and equipment for the ad- gressive therapy,not maintenance therapy,and must not be per- ministration of oxygen. Such equipment may be purchased,if, in formed for the purpose of vocational rehabilitation. Covered ex- the judgment of the Plan Administrator,purchase of the equip- penses do not include either recreational programs or supplies ment would be less expensive than rental or the equipment is not used in occupational therapy. available for rental. 19. Emergency services. In the event of emergency services,the 4. Hospital room and board,at the semi private hospital room and Plan will pay at the PPO rate for Non PPO providers. Emergency board rate. If medical necessity requires an intensive care or in- service is defined as follows: services which are immediately termediate care snit,the Plan will cover the room and board rate required to treat a sudden serious and unexpected illness or in- charged by the hospital. jury,including services to alleviate pain associated with sudden, S. Other hospital services and supplies furnished by the hospital for serious and unexpected illness and/or injury. medical care during confinement,exclusive of physician's and other professional services. 6. Radiology(x-rays)and laboratory charges in connection with treatment of an illness or injury. 7. Outpatient surgery charges for necessary services and supplies for surgical procedures performed on an outpatient basis at a hos- pital,ambulatory surgical facility,or physician's office,provided that benefits for such charges would be payable if the procedure were performed during a hospital confinement. 8. Physician's fees for medical care and treatment of an illness or injury covered under the terms of this Plan 9. Prescription drugs necessary for the treatment of an illness or in- jury,if obtainable only on a physician's written prescription andCD dispensed by a licensed pharmacist, 91 10. X-ray and,radium treatments,and treatments with other radioac. ° tive substances. o mo x ^a 10 11 n Prescriptions General Exclusions and Limitations All prescription drug payments shall be made through the Advance Prescrip- Benefits for the following shall not be covered: tion Card Service(PCS)and shall be on the basis of a copayment by the par- ticipant of$5 for each generic drug prescription or$8 for each brand name Occupational Injuries or Illnesses. Any illness or injury arising out drug prescription. No payments for any prescription drug shall be made of,or in the course of,employment is excluded. through the Employee Health Plan. Prescription drugs are available by mail order at a cost of$4 for generic and$6 for brand name prescriptions. Claims ILJanecessary Services or. Supplies, Any services or supplies not rea- forms are available in the Risk Management Office. sonably necessary for the medical care of the participant's illness or injury are excluded. Chiropractic and Physical Therapy Guidelines Weekend Admissions If admitted to the hospital on a Friday, Satur- day or Sunday,charges for these days will be excluded unless admit- Benefits are provided as follows: 3 times a week for the first month ted due to an emergency or if surgery is performed within 24 hours. 2 times a week for the second month Once a weep for the third month Excess of Usual,Cus!2MM and Reasonable. The portion of any 2 times a month for fourth month and charge for any services or supplies in excess of the reasonable and thereafter customary charge is excluded. These guidelines may be modified on an individual case-by-case basis pur- Mouth and Teeth Conditions. Treatment on or to the teeth,extraction suant to the recommendation of our Medical Advisor. of teeth,treatment of dental abscesses or granuloma,dental examina- tion or treatment of gingival tissues other than for tumors is excluded. Chiropractic Limitations Hearings. Examinations to determine the need for,or the proper adjustment of hearing aids,are excluded. Benefits will be provided to a maximum of 24 treatments per year or$2,000, whichever occurs first. Said limits are per person and commence January 1 Vision Care. Physicians services in connection with eye refractions of each year. or any other examinations to determine the need for,or the proper ad- justment of,eyeglasses or contact lenses are excluded. Radial keratot- Preventive Medical Care omy,Lasik and similar procedures are also excluded. Benefits will be provided up to$200 per person for preventive medical care Cosmetic Sureerv. Charges in connection with cosmetic surgery are per year. This care shall include preventive medical options such as an an- excluded unless performed for the correction of fimctional disorders nual physical exam,PAP tests,flu shots,chest x-rays,EKG,PSA and other as a result of accidental injury occurring while the individuals are diagnostic tests if certified by the physician that such procedures are in- covered. cluded under a routine physical examination and are not in connection with the diagnosis or treatment of any illness or disease. Other General Exclusions: Well Baby Exams I. Hospital admissions primarily for diagnostic study when in- patient care would not otherwise have been required. Three well baby examinations for an infant for the first year of life will be 2. Custodial care o aIIowed subject to the$200 maximum benefit. All inoculations for infants/ 3. Personal or convenience items children will be provided and coverage is not limited to the$200 maximum 4. Services or supplies not connected with the care and treat- o benefit, ment pf an actual illness,disease or injury D w 12 13 S. Any illness or injury due to war,declared or undeclared,or any act of war is excluded When you have a Claim 6. Any means of artificial fertilization,including but not limited to artificial insemination,in vitro fertilization or gamete intra- fallopian transfer Before submitting a claim for medical expenses,review this brochure and 7. Reversing prior surgical sterilization procedures the bills you have accumulated. Be sure you arc submitted itemized bills 8. Any charges for weight control or weight reduction program for which benefits are payable. 9. No benefits will be provided for any condition of pregnancy for dependent daughters. Save all of your bills,including those being accumulated to satisfy a de- 10. Sales tax on prescription drugs or on any other covered item ductible. In most instances they will serve as evidence of your claim. 11. No benefits will be provided for any mental health care. Mental Submit the original bill,not a copy. Each bill must be complete and item- health services are provided by Managed Health Network ized and should show the patient's full name,date or dates of service,na- 12. Treatment,services,equipment,new technology,drugs,proce- ture of the illness or injury,and type of service provided. Claim forms are daces oc supplies considered experimental or investigational at available in the Risk Management office. A separate claim form is re- the time the procedure is performed or service or supply is pro- quired for each family member. Please mail all completed forms to: vided 13. Air conditioners,dehumidifiers,air purifiers,arch supports,cor- City of Huntington Beach rective or orthopedic shoes,heating pads,hot water bottles,home Employee Health Plan enema equipment,etc.are not covered, Risk Management Division 14. Any items for which the participant is not legally required to pay, 2000 Main Street or for which a charge would not have been made if the participant Huntington Beach,CA 92648 did not have this coverage. 15, Benefits available under the Plan may be reduced or eliminated All claims must be received no later than 12 months from the date of ser- based upon the coordination of benefits or subrogation Hiles. vice. Claims submitted after this time period will be rejected. I6. Charges for failure to keep a scheduled visit,completion of claim forms or providing supplemental information. Claims Payment and Appeals 17. Charges for vitamins(except pre-natal vitamins),minerals,nutri- tional or food.supplements or any other over the counter item. Notice of Decision 18. Any charges not listed in`Covered Expenses" A notice of decision will be sent to you within 30 days after receipt of a 19. Nursing Facility. Any services furnished by an institution which properly completed claim If there is some reason your claim cannot be is primarily a place of rest,a place for the aged,a nursing or con- processed witldn that time,you will be given notice of the reason for the valcsccnt home or any institution of like character,unless other- delay. wise specifically provided for herein. 20. Smoking cessation program, Claim Auaeal Procedure If your claim is denied in whole or in part,you and your physician will be provided with written notification explaining the reason. If you have rea- son to believe that the denial of your claim was not correct under the terms of the Plan Document,a request for review must be made within 60 days from the notice of the claim denial. The claim,as well as all supporting ;u documentation,will be submitted to Medical Review for review by physi- 2 14 cians at the Foundation for Medical Care. You and your provider will be o notified in writing of the claim decision as soon as possible but not later than 120 days after receipt of the request, m$ x n" ..A 15 Coordination with Other Plans Termination of Coverage The Employee Health Plan contains a provision to prevent double pay- coverage will terminate for an employee on the last day of the month in ment for covered expenses. This provision works by coordinating the which employment terminates. Coverage for a dependent will cease on benefits under this Plan with other similar plans under which a person is the earliest of the fallowing: covered, so the total benefits available will not exceed one hundred per- • Last day of the month in which the employee's coverage termi- cent of allowable expenses. This provision is commonly called "Coordination of Benefits". Hates • Date the dependent enters active service with the armed forces When a claim is made,the primary plan(as described below)pays its ' • Date the dependent ceases to be an eligible dependent benefits without regard to any other plans. The secondary plans adjust • For a dependent spouse,on the date of divorce their benefits so that the total benefits available will not exceed the allow- • For dependent child/children,the date of the child's marriage or able expenses. No plan pays more than it would otherwise pay without attainment of the maximum age limit of 25. this coordination provision. A plan without a coordination of benefits provision is always the primary Continuation of Benefits. plan. 1f all plans have such a provision: (1)the plan covering die patient directly(e.g.,employee or retiree),rather than as a dependent,is primary If a covered employee ceases active employment'due to an authorized and the others secondary: (2)if a child is covered under both parents' nce,participation may be continues under COBRA or Family plans,the parent whose birthday falls earlier in the year is primary, or,if leave of abse both parents have the same birthday,the plan covering the parent longer is and Medical Leave Act(FMLA)• Please refer any questions regarding the primary,but when the parents are separated or divorced,their plans pay in continuation of Health insurance coverage to the Employee Benefits Divi- this order:(a)the plan of the parent with custody of the child;(b)the plan Sion of the City of Huntington Beach. of the parent not having custody of the child(c)the plan of the spouse of the parent with custody of the child;,and(d)the plan of the spouse of the parent not having custody of the child. When the order of benefits is not determined by the preceding paragraphs, the benefits of the plan covering the person as an employee who is actively employed(neither laid off'nor retired),are determined before those of a plan covering a person who is inactive. If the other plan does not have this provision and,as a result,the plans do not agree on the order of benefits, this provision is ignored. If none of the preceding provisions determine the order of benefits,the benefits of the plan that covered a person longer are determined first, If none of the preceding provisions of this section make it able to deter- ;U mine which plan is primary,the allowable expenses shall be shared }g equally between the plans. o N m b k 0 17 n 16 Res.No.2DO2-31 Ex.A ORANGE COUNTY PPO & EP0 . GUIDE To HEALTH CARE PROVIDERS . 2001 - 2002 D IRECToRY ORANGE COUNTY a■ FOR MEDICAL CARE Res.No.2002 31 Ex.A Dear Health Plan Member: On behalf of the Orange County Foundation for Medical Care, we are pleased to have the oppor- tunity to service your health plan needs. This directory was designed to assist you in choosing your health care provider, but appearance in this directory does not ensure coverage. It also does not constitute a recommendation of any provider,hospital, or other facility. The choice is yours. Every reasonable effort has been made to confirm the accuracy of this publication, however provider status is subject to change without prior notice. It is therefore, important to verify that your provider is currently participating in the network prior to receiving services. Some providers also participate at one location but not at others, and not every provider in a group'is contracted. Questions you may have regarding the use of this directory,provider participation in either network, pre-certification, or case management should be directed to: ORANGE COUNTY FOUNDATION FOR MEDICAL CARE;(OCFMC) P.O. Box 1297 Orange, CA 92856-0297 (714) 978-5048 (800) 345-8643 s 3 Thank you for using the Orange County Foundation for Medical Care. I Providers current as of 7-2-01 Res.No.2002-31 Ex.A • ti MEblC44�� v� p z R C The Orange County . Medical Association is the Advocate for Physicians , Patients , and the Highest Quality Medical Care for our Community . " OCMA is proud to be a strong partner and supporter in the efforts of the Orange County Foundation for Medical Care to ensure high quality patient care . Res.No.2002-31 TABLE OF CONTENTS E"A HOW TO USE THIS DIRECTORY . . . . . . . . . . . . . . . . .2 ACUTE HOSPITALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 AMBULATORY SURGERY CENTERS . . . . . . . . . . . . . . . . . . . . . . .4 BEHAVIORAL HEALTH FACILITIES . . . . . . . . . . . . . . . . . . . . . . . . . .4 DURABLE MEDICAL EQUIPMENT . . . . . . . . . . . . . . . . . . . . . . . . . .4 HOME HEALTH CARE AGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . .5 HOME INFUSION THERAPY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 HOSPICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 LABORATORY/PATHOLOGY FACILITIES . . . . . . . . . . . . . . . . . . . . .6 OTHER ANCILLARY FACILITIES . . . . . . . . . . . . . . . .8 PHYSICAL THERAPY FACILITIES . . . . . . . . . . . . . . ..• . . . . . . . . . .8 RADIOLOGY/IMAGING FACILITIES . . . . . . . .10 REHABILITATION FACILITIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 SKILLED NURSING FACILITIES .. . . . . . . . . . . . . . . . . . . . . . . .12 URGENT CARE CENTERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 PARTICIPATING PROVIDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 INDEX . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 Res.No.2002-31 Ex.A ORANGE COUNTY FOUNDATION FOR-MEDICAL CARE OCFMC The 2001-2002 Provider Directory contains providers for the Exclusive Provider Organization (EPO), Preferred Provider Organization (PPO) and Workers' Compensation networks. Please note that the, E = EPO,P=PPO and W=Workers' Comp. The (*) indi- cates the provider is board certified. The provider names in italics indicate that he/she is a member of the Orange County Medical Association. The participating providers are listed alphabetically by Specialty and then by City. HOW TO USE THIS DIRECTORY. 1. Determine your plan type: EPO, PPO or Workers' Comp. (Printed on your insurance identification card). 2. Select a provider applicable to your plan type. 3. Verify the current status of your provider(s). Provider status is subject to change with- out prior notice. Please be aware that it is your responsibility and in your best financial interest to verify current provider status. 4. Call the provider for your appointment. 5. Obtain Pre-Certification if required by your Health plan. Pre-certification may be required for particular services. Failure to notify OCFMC may result in denial of procedures, or reduction in benefits. 6. Contact your claims administrator to verify benefits or eligibility. Payment for services rendered by participating providers is subject to the terms, exclusions and limitations of your health plan. 7. Present your health plan identification card at your provider's office at the time of i your visit. 2 \f y F. 1 i !STM _ r 1. T+ a ■ r Or Nal R loom y:; i t SyLFr r r E Res.No.2002-31 Ex.A Benefits at a glance Benefit Copaymentt Visits to physician's office Covered In Full Visits to physician's office for treatment of Severe Mental Illness or Serious Emotional Disturbances of a Child Covered In Full Periodic health evaluations Covered In Full Maternity care Covered In Full Vision examinations Covered In Full Hearing examinations Covered In Full X-ray and lab procedures Covered In Full Hospitalization Covered In Full Hospitalization for treatment of Severe Mental Illness or Serious Emotional Disturbances of a Child Covered In Full r Surgery Covered In Full Emergency room services (waived if admitted) $35 Prescription drugs $3 Level I generic (per prescription) $5 Level II brand name t For more informatim sec Trineipal Lenefi&and Coverage," page-" This disclosure is only a summary of your health plan. Your Evidence of Coverage(TOO, which you will receive after you enroll contains the&=t terms and conditions ofyour Health Net coverage. You should also consult the Plan Contract(Awd to your employer) to determine governing contractual provisions It is important far you to carefuly read this document and your EOC thoroughly once reeeivez4 especially those sections that apply to those with special health care needs Res.No.2W2-31 Ex.A Table of contents Delivering choices..................................... 2 Exclusions and limitations How the plan works.................................. 2 Extension of benefits Selection of physicians and Physician Confidentiality and release of member Groups information How to choose a physician Payment of fees and charges.................... 13 HMO specialist access Prepayment fees How to enroll Other charges Principal benefits and coverage................. 3 Coordination of benefits Services and copaymentslcoinsurance Reimbursement provisions Limits of Coverage....................................6 Provider referral and reimbursement What's not covered disclosure Behavioral health services.........................7 Utilization management processes What's covered Termination of provider Continuation of treatment Second opinions Health Net and your EAP Facilities. ................................................15 What's not covered Physician Group transfers Prescription drug program .......................8 Renewing, continuing or ending Prescriptions By Mail Drug Program coverage................................................16 The Health Net Recommended Drug List: Renewal provisions Level I drugs (primarily generic) and Level Individual continuation of benefits II drugs (primarily brand name) Termination of benefits What's covered If you have a disagreement with our What's not covered plan........................................................17 Benefits and coverage.............................. 11 Member grievance and appeals process What you pay for services Arbitration Coverage for newborns Emergencies SS ID: 19679 1 Res.No,2002-31 Ex.A comfortable with your choice,we suggest the Delivering choices following. When it comes to your health care, the best decisions Discuss any important health issues with your are made with the best choices. Health Net of selected Physician Group. California, Inc. (Health Net) provides you with ways p Do the same with the Health Net Coordinator at to help you receive the care you deserve. This the Physician Group, and ask for referral specialist brochure answers basic questions about this versatile policies and hospitals used by the Physician plan. If you have further questions,just contact our Group. Member Services department at 1-800-522-0088. Our friendly, knowledgeable representatives will be A To ensure that you and your family members have glad to help. adequate access to medical rare, select a doctor located within 30 miles of your home or work. HMU specialist access Haw the plan warps Health Net offers Rapid Access®, a service that makes it easy for you to quickly connect with a specialist in Health Nees network. Ask your group or check your Please read the following information so you wit know Directory of contracting Physician Groups to see if ,from whom or what group ofproviden health care may your Physician Group allows "self-referrals" or "direct be obtained referrals"to specialists within the same group. Self- referral allows you to contact a specialist directly for Selection of physicians and Physician Groups - consultation and evaluation. Direct referral allows 9 When you enroll with Health Net, you choose a Your doctor to refer you directly to a specialist-- without the need for Physician Group authorization. contracting Physician Group. From your Information about your Physician Group,s referral Physician Group,you select one doctor to provide policies is also available to you on our Internet web basic health care; this is your Primary Care Physician. (See your Directory of Contracting site,www healthnet.cam. Physician Groups for detailed information about physicians and Physician Groups in the Health How to enroll Net network.) We have enclosed an enrollment form in the p Whenever you or a covered family member needs enrollment packet. If a form is not included,please health care,your Primary Care Physician will obtain one from your employer.Then,just complete provide the medically necessary treatment. the enrollment form and return it to your employer. Specialist care is also available through your Some Hospitals and other providers do not provide Health Net plan, when authorized in advance one or more of the following services that may be through your Primary Care Physician or Physician covered under your Evidence of Coverage and that Group. you or your family member might need: family 9 You do not have to choose the same Physician planning; contraceptive services, including Group or Primary Care Physician for all members emergency contraception; sterilization, including of your family. Physician Groups,with names of tubal ligation at the time of labor and delivery; physicians and specialists, are listed in the Health infertility treatments; or abortion. You should Net Directory of contracting Physician Groups. obtain more information before you enroll. Call your prospective doctor, medical group, independent practice association, or clinic, or call Health Net's How to choose a physician Member Services Department at 1-800-522-0088 to Selecting a Primary Care Physician is important to the ensure that you can obtain the health care services quality of care you receive. To ensure you are that you need. 2 Res.No.2002-31 Ex,A Principal benefits and. coverage Yearly mud mum eopayment One member,$1500 Two members,$3000 Family(three members or more),$4500 Paymentu for services not covered by this plan roili not be applied to the yearly maximum copayment You wild need to continue making payments for any additional benefits as described in the"Additional Plan Bemfsts'section of this brochure. Services and eopaymentslcoinsurance The following shows the services and copaymentslcoinsurance required for this plan. Preventive care' Adult and Child preventive care Periodic health evaluations Covered In Full3 X-ray and laboratory procedures Covered In Full Vision screenings and examinations Covered In Full Hearing screenings and examinations Covered In Full Immunizations Standard immunizations Covered In Full Immunizations required for job or foreign travel 20% Visit to physician Covered In Full Visit to physician for treatment of Severe Mental Abmss or Serious Emotional Disturbances of a Child a Covered In Full Visit to facility Covered In Full peels bt conmOtions Covered In Full Allege testing Covered In Full Injection services,including allergy injection services Covered In Full Maternity mxdpregnanq Prenatal and postnatal office visits Covered In Full Maternity care in hospital or skilled nursing facility Covered In Full Genetic testing of fetus Cover ed In Full Normal delivery,cesarean section,newborn inpatient care Covered In Full Treatment of complications of pregnancy,including medically-necessary abortions Covered In Full Physician visit to hospital for care of mother and newborn Covered In Full Circumcision of newborn males Covered In Full Elective abortions $150 Emergency mud urgent can Emergency room(professional and facility charges) $353 Urgent care center(professional and facility charges) $35s Ambulance Covered In Full Air ambulance Covered In Full Su Surgeon or assistant surgeon services Covered In Full Anesthetics C ered In F 3 Res.No.2002-31 Services and copayments/coinsurance (continued) Ex.A Organ and bone marrow transplants(nonexperi.mental and noninvestigational) Covered In Full Hospital and sUR nutting facility stays Semi-private hospital room or intensive cue unit with ancillary services(unlimited,except for non-severe mental illness and chemical dependency treatment) Covered In Full Semi-private hospital room or intensive care unit with ancillary services for treatment of Severe Mental Illness or Serious Emotional Disturbances of a Child(unlimited)4 Covered in Full Skilled nursing facility stay(100 day maximum each Calendar Year) Covered In Full Physician visit to hospital or skilled nursing Facility Covered In Full Repro Infertility services and supplies 50% Hospitalization for infertility services 50% Injections related to� ' 'ty services(Injections for Infertility are not covered if used in connection with services which are not covered) 50% Inje contraceptives(including but not limited to Depo Proves) Covered In Full Sterilization Vasectomy $50 Tubal ligation $150 Other sernua Physician home visit $10 Home health visits $106 Hospice services Covered In Full Rehabilitative therapy(includes physical,speech, occupational,and pulmonary rehabilitation and cardiac rehabilitation therapy) Covered In Full Durable medical equipment Covered In Full Diabetic equipment(coverage under the medical benefit includes blood glucose monitors,insulin pumps and podiatric devices)See the"Prescription drug program" section of this brochure for diabetic supplies benefit information. Covered In Full Prosthetic devices Covered In Full Blood, blood plasma,blood derivatives,and blood factors Covered In Full Nuclear medicine Covered In Full Chemotherapy Covered In Full Renal dialysis Covered In Full 4 Res.No.2002-31 Services and copaymentslcoinsurance (continued) Ex.A Self-referrals are allowed for Obstetrician and Gynecological services including preventive care,pregnancy and gynecological ailments Copayment requirements may differ depending on the service provided Refer to Principal bents and coverages 'Surgery includes surgical reconstruction ofa breast incident to a mastectmny including surgery to restore symrrmetryy also includesprothesir and treatment ofphysical complications at all stage ofmastectom including lymphedrrnas. fiilc Health Net and your Physician Group will determine the most appropriate services,the length of hospitalstay will be determined solely byyour Physician. a Provided on the basis of age,medical need and health status. 6Please refer to the "Behuvsoral health services"section ofthis brochure for the definitions of SevereMent>allUness and Serious Emotional Disturbances ofa Child and far non severe mental disorder benef tt S Capayments for emergency room or urgent care center visits will not apply ifyou receive care from a fadUty owned and operated by your medicalgroup or ifyou are admitted as an inpatient directly from the emergency room or urgent rare center.A visit to one ofyour medical group's facilities will be considered an office visit and the office visit copaymenA ifany will apply. 6Capayments are required far each day on which home health visits occur an and after t1e310 calendar day ofthe treatment plan. 5 Res.No.2002-31 Ex.A Limits of Covera e V Private-duty nursing for hospital patients 9 ,Q Refractive eye surgery ,s Reversal of surgical sterilization What's not covered Routine physical examinations Limitations and exclusions p Services performed by an immediate relative ,v Acupuncture p Services and supplies not authorized according Allergy desensitizing serum to procedures Health Net and the contracting Physician Group have established ,D Artificial insemination for reasons not related to infertility ,V Services received before effective date or after termination of coverage,except as specifically ,V Conception by medical procedures (IVF, GIFT, stated in Extension of Benefits in memberr's and ZIFT) Evidence of Coverage p Corrective or support appliances or supplies p Sex change series p Cosmetic services and supplies ,S Treatment of jaw joint disorders or surgical Custodial or live-in care procedures to reduce or realign the jaw, unless medically necessary f1 Dental services p Treatment of obesity,weight reduction or p Disposable supplies for home use weight management, except for treatment of ,o Eyeglasses and contact lenses morbid obesity as determined by Health Net ,V Experimental or invesdgational procedures, except as set out under the"If you have a The above is a partial list of the principal exclusions disagreement with our plan" section of this and limitations applicable to the medical portion of brochure your Health Net plan. The Evidence of Coverage 9 Food supplements which you will receive if you enroll in this plan, will contain a full list. Note that specific items excluded p Genetic testing and diagnostic procedures,except above may be covered under this plan if your for prenatal diagnosis of fetal genetic disorders in employer has purchased them as supplemental cases of high risk pregnancy benefits. ,o Hearing aids ,0 Non-eligible institutions ,V Orthoprics (eye exercises) d.dltlorial plan ,Q Norplant and Norplant kits, unless medically benefits necessary A Orthotic stems for the foot The following plan benefits show the copayments required for optional benefits available with your 9 Personal or comfort items plan. For a more complete description of ,V Physical examinations for nonpreventive purposes copayments, and exclusions and limitations of service, please see your plan's Evidence of Coverage. y� Pregnancy under surrogate arrangement when compensation is obtained for the surrogacy p Private-rooms when hospitalized, unless medically necessary 6 Res.No.2002-31 Ex.A Behavioral health **'The mental disorder capayments and day or visit limits will not apply for Severe Mental Illness or Serious Emotional Drtturbances services ofa Child as defined below. Services far thew conditions require whatever copayment would be required if the services were provided far a medirnl condition. Refer to the "Principal benefits and coverage"section to determine the applicable copayment.All Health Net Contracts with Managed Health Other mental disorders will be subject to the copayrnents shown Network, a specialized health care service plan above which provides behavioral health services through a personalized, confidential and affordable mental health and chemical dependency care program:Just Serious Emotional Disturbances of a Child call the toll-free number shown on your Health Serious Emotional Disturbances of a Child is Net ID Card before receiving care. when a child under the age of 1.8 has one or more Mental Disorders identified in the most recent What's covered edition of the Diagnostic and Statistical Manual of Nox-severe Mental Mental Disorders, other than a primary substance Disorders*** use disorder or a developmental disorder, that Inpatient(30-day Covered in full* result in behavior inappropriate to the child's age maximum each according to expected developmental norms. In Calendar Year) addition, the child must meet one or more of the Outpatient (20 visit $30** following: maximum each (Individual session) + As a result of the Mental Disorder, the child Calendar Year) $15** (Group has substantial impairment in at least two of session) the following areas: self-care, school Seven Mental Illness and functioning, family relationships, or ability to Serious Emotional function in the community; and either(i) the child is at risk of removal from home or has Inpatient Covered in full heady been removed from the home or(ii) Outpatient Covered in full the Mental Disorder and impairments have Cheasf`�D�bilitation��'i`S' Rehabilitation been present for more than six months or are Inpatient(30-day Covered in f dl* likely to-continue for more than one year; maximum each • The child displays one of the following: Calendar Year) psychotic features, risk of suicide or risk of Outpatient (20 visit $30** violence due to a Mental Disorder, and/or maximum each (Individual session) . The child meets special education eligibility Calendar Year) $15** (Group requirements under Chapter 26.5 session) (commencing with Section 7570) of Division Arute Care Detax fwation I Covered in full 7 of Title 1 of the Government Code. *Inpatient admission means any admission to a hospital day Severe Mental Illness treatmentprogram, residential treatment center or structured ouepatientprograrn. In addition, inpatient mental health and Severe Mental Illness includes schizophrenia, chemical dependency are limited to a combined maximum number schizoaffective disorder, bipolar disorder (manic- ofdays each Calendar Year. depressive illness), major depressive disorders, panic disorder, obsessive-compulsive disorders, "Applicableonly for outpatient counseling;defined as individual pervasive developmental disorder, autism, anorexia office visits and group therapy sessions Group sessions are equal to hafofan individual session and count towards the visit marrimum. nervosa, and bulimia nervosa. A mused appointment may result in a eapayment being charged and one of the counseling sessions being used. In addition, outpatient mental health and chemical dependency are limited to a combined maximum number of visits each Calendar year. 7 Res.No.2002-31 Ex.A State hospital treatment,except as the result of Continuation of treatment an emergency or urgently needed care- If you are in treatment for a mental health or ,� Sys, except when rendered in connection with chemical dependency problem, call the telephone services provided for a treatable mental disorder number shown on your Health Net ID card to receive assistance in transferring your care to a ,7 Treatment of detoxification in newborns network provider. y1 Treatment, testing or screening of learning disabilities, except for some conditions when the Health Net and your EAP level of severity meets the criteria of severe If your employer offers an Employee Assistance mental illness or serious emotional disturbances Program (EAP), Health Net's mental health and of a child as described in the Evidence of chemical dependency program works in coordination Coverage with your company's EAP.You may be able to p Care for mental health care as a condition of obtain a referral to a network provider from either parole or probation, or court-ordered testing for the mental health and chemical dependency program mental disorders, except when such services are or with the assistance of your EAP counselor. medically necessary and subject to the plan's day or visit limits. What's not covered Remember. This is only a summary. Please consult your Evidence of Coverage for specific Services or supplies excluded under behavioral health information regarding your plan. services may be covered under the medical benefits portion of your plan. Consult your plan's Evidence of Coverage for more information. Prescription: drug Limitations and excLusions (In addition to the exclusion and limitations listed program below, mental health and chemical dependency benefits are subject to the plan's general exclusions Health Net is contracted with many major and limitations.) pharmacies including Longs, Rite Aid, Sav-on, and Walgreens, and those located in the Albertsons, 9 Congenital and/or organic disorders, including BelAir, Raley's, Ralphs, Safeway, Save Marc and organic brain disease and mental retardation, VonslPavilions supermarket chains. There are many except for some conditions when the level of ocher neighborhood pharmacies that are also pan of severity meets the criteria of severe mental illness our network. For a complete and up-to-date list of or serious emotional disturbances of a child as pharmacies, call Health Net Member described in the Evidence of Coverage participating P Services. p Experimental or investigational therapies Marriagecounseling,except when rendered in Prescriptions B Mail D g P P Y �Program connection with services provided for a treatable If your prescription is for a maintenance mental disorder medication (a drug that you will be taking for an ,o Nontreatable mental disorders extended period), you have the option of filling it through our convenient Prescriptions By Mail Private-duty nursing Drug Program. This program allows you to receive 9 Services related to educational and professional up to a 90-consecutive-calendar-day supply of maintenance medications. For complete purposes information, call Health Net Member Services at 9 Smoking cessation, weight reduction, obesity, 1-800-522-0088. stammering, sleeping disorders or stuttering 8 Res.No.2002-31 Ex.A The Health Net Recommended Drug List:Level I authorization, Health Net will evaluate the drugs (primarily generic) and Level 11 drags information submitted and make a determination as (primarily brand name) based on established clinical criteria for the The Health Net Recommended Drug List is the particular medication. approved list of medications covered for illnesses and conditions. It was developed to identify the safest and The criteria used for prior authorization are most effective medications for Health Net Members developed and based on input from the Health Net while attempting to maintain affordable pharmacy P&T Committee as well as physician specialist benefits. experts. Your physician may contact Health Net to obtain the usage guidelines for specific medications. We specifically suggest to all Health Net contracted If authorization is denied by Health Net, you will Primary Care Physicians and specialists that they receive written communication including the refer to this list when choosing drugs for patients specific reason for denial.If you disagree with the who are Health Net members. When your physician decision,you may appeal the decision. prescribes medications listed in the Recommended Drug List, it ensures that you are receiving a high The appeal may be submitted in writing, by quality prescription medication that is also of high telephone or through e-mail. We must receive the value. appeal within 60 days of the date of the denial The Recommended Drug List is updated regularly, notice. Please refer to your Health Net Evidence of Coverage for details regarding your right to appeal. based on input from the Health Net Pharmacy and Therapeutics (P&T) Committee. These committee To submit an appeal: members are actively practicing physicians of various e Call Health Net Member Services at 1-800- medical specialties and clinical pharmacists. Voting 522-0088 members are recruited from contracting Physician . Visit www.healthnet.com for information on e- Groups throughout California based on their experience, knowledge and expertise. In addition, the mailing Member Services P&T Committee frequently consults with other • Write to: medical experts to provide additional input to the Health Net Member Services Committee. Updates to the Recommended Drug List P.O. Box 10348 are made as new clinical information and new drugs Van Nuys, CA 91410-0348 become available. The drug usage guidelines are reviewed and updated as new clinical information What's covered becomes available. In order to keep the List current, the P&T Committee evaluates clinical effectiveness, Outpatient prescription medication. safety and overall value through: Recommended Drug List •Medical and scientific publications $3 for Level I drugs •Relevant utilization experience $5 for Level II drugs when generic equivalent is not Physician recommendations commercially available To obtain a copy of Health Net's most current $5 for Level 11 drugs when generic equivalent is Recommended Drug List, please visit our web site at commercially available, plus the difference in cost www.healthnet.com, or call Member Services at 1- between the brand name drug and the generic 800-522-0088. equivalent. What is"prior authorization"? Some prescription medications require prior authorization. This means that your doctor must contact Health Net in advance to provide the medical reason for prescribing the medication. Upon receiving your physician's request for prior 9 Res.No.2002-31 Ex.A Note: (In addition to the exclusion and limitations listed below, prescription drug benefits are subject to the p Prescription drug refills are covered, up to a 30- plan's general exclusions and limitations.) consecutive-day supply per prescription at a Health Net contracted pharmacy for one copayment. p Allergy serum*** ,o If the pharmacy's usual and customary charge is ;v Contraceptives such as,contraceptive foams, less than the applicable copayment, the Member abordfacients or menstrual induction drugs will pay the pharmacy's usual and customary charge. ,o Cosmetics,health or beauty aids, or drugs prescribed for cosmetic reasons, including drugs ,7 Mail order drugs are covered up to a 90- prescribed for baldness or to eliminate wrinkles consecutive-calendar-day supply. The Member is responsible for twice the applicable retail .� Devices or appliances pharmacy copayment. However, when the retail ,�! Drugs that are appetite suppressants or are pharmacy copayment is a percentage, the mail indicated for and prescribed for body weight order copayment is the same percentage as the reduction,except when prescribed for the retail pharmacy copayment. treatment of morbid obesity as an alternative to Drugs prescribed for treating organically based surgery and approved by Health Net sexual dysfunction are subject to a 50% ,�! Drug products that help you reduce or quit copayment. (Limited to two doses per week or smoking or for nicotine addiction (e.g., nicotine eight tablets per month.) * patches) ,v Oral drugs prescribed for treating infertility are ,v Drugs or medicines administered by a physician subject to a 50% copayment. * or physician's staff member** A Oral contraceptives are covered. Vaginal ,9 Drugs prescribed for non-organically based contraceptives (diaphragms and cervical caps) are sexual dysfunction, including drugs that limited to one prescription per calendar year. establish, maintain, or enhance sexual function Refer to your plan's Evidence of Coverage for or satisfaction information on contraceptives covered under the medical benefit. Experimental drugs(those that are labeled "Caution-Limited by the Federal Law to 9 The Level lI drug copayment applies for each 30- investigational use only"), except as set out day supply of insulin and diabetic supplies under the"If you have a disagreement with our (including but not limited to blood glucose plan" section of this brochure monitoring strips, pen delivery system, insulin needles and syringes) listed on the Recommended A Hypodermic needles or syringes, except for Drug List. Lancets are dispensed at no charge. insulin needles, syringes and pen devices See Diabetic equipment under the "Principal 9 Immunizing agents, injections (except for benefits and coverage" section of this brochure insulin), agents for surgical implantation, for additional benefit information. biological sera, blood, blood derivatives or blood 9 Diabetic supplies (blood glucose testing strips, plasma** lancets, needles and syringes) are packaged in 50, . 10 individual doses of medication dispensed in 100 or 200 unit packages. Packages cannot be plastic,unit dose, or foil packages unless "broken" (i.e. opened in order to dispense the medically necessary or only available in that product in quantities other than those packaged). form ,¢ Limits on quantity, dosage and treatment What's not covered duration may apply to some drugs Limitations and exclusions 10 Res.No.2002-31 Ex.A y� Over-the-counter drugs, equipment, supplies or the child must be enrolled through your employer drugs where there is a non-prescription before the 30'day of the child's life. If Health Net equivalent available,except for drugs and supplies does not receive a newborn's enrollment form used for the treatment or management of diabetes within 30 days of the child's birth: ,v Oxygen** V coverage will end the 31st day afterbirth; and p Prescription drugs filled at pharmacies that are ,W you will have to pay your Physician Group for not in the Health Net pharmacy network except all medical we provided after the 30th day of in emergency or urgent care situations your baby's life. ;V Prescription drugs prescribed by a physician other than your Primary Care Physician or specialist Emergencies you have received authorization to see,except in Health Net covers emergency and urgently needed emergency or urgent care situations care throughout the world. If you are injured, feel ,W Replacement of lost, stolen or damaged severe pain,begin active labor or experience an medications unexpected illness that a reasonable person with an average knowledge of health and medicine would p Services or supplies for which there is no charge, believe requires immediate treatment to prevent or for which you are not legally required to pay serious threat to your health (including Severe ,V Supply amounts (for any number of days) which Mental illness and Serious Emotional Disturbances of a Child), seek care where it is immediately exceed the Food and Drug Administration's or Health Net indicated usage guidelines available. Depending on your circumstances,you may seek this care by going to your physician group (medical)or the Behavioral Health Administrator *Must be approved by Health Net and your Ngerician Group. (mental illness and chemical dependency), pe cy), to the nearest emergency facility or by calling 911. **These,items are covered under the medical coverage portion of your plan You are encouraged to use appropriately the 911 emergency response system, in areas where the system is established and operating,when you have ***These iurxr are covered under the medical coverage portion of an emergency medical condition (including Severe your plan only ifyour employer has purchased the coverage. Mental Illness and Serious Emotional Disturbances of a Child)that requires an emergency response. All This is only a summary. Consult your plan's ambulance and ambulance transport services Evidence of Coverage to determine the exact terms provided as a result of a 911 call will be covered, if and conditions of your coverage the request is made for an emergency medical condition (including Severe Mental Illness and Serious Emotional Disturbances of a Child). Benefit's and coverage All follow-up care (including Severe Mental Illness and Serious Emotional Disturbances of a Child} after the urgency has passed and your condition is stable, must be provided or authorized by your What you Pay for services Physician Group(medical) or the Behavioral Health The comprehensive benefits of your Health Net plan Administrator (mental illness and chemical are described in the "Principal benefits and coverage" dependency), otherwise,it will not be covered by section. Please take a moment to look it over. Health Net. Coverage for newborns Exclusions and limitations Children born after your date of enrollment are For information on exclusions and limitations automatically covered at birth.To continue coverage, applicable to all of the services and benefits provided 11 Res.No.2002-31 Ex.A under this plan, please review the "Principal benefits investigation or evaluation of an application, claim, and coverage" section of this brochure. appeals (including the release to an independent This plan does not cover any medical treatment you reviewer organization) or grievance, or for preventive received before coverage begins under this plan or health or health management purposes. any services you may receive after your coverage We will not release your medical records or other under this plan ends. For further information, please confidential.information to anyone such as refer to the Evidence of Coverage. employers or insurance brokers, who is not authorized to have that information. We will only Extension of benefits release information if you give us special consent in If you or a covered family member is totally disabled writing. The only time we would release such when your employer ends its group services information without your special consent is when agreement with Health Net, we will cover the we have to comply with a law, court order, or treatment for the disability until one of the following subpoena. Often, Health Net is required to comply occurs: with aggregated measurement and data reporting requirements. In those cases, we protect your privacy 9 a maximum of 12 consecutive months elapses by not releasing any information that identifies our from the termination date members. R available benefits are exhausted Technology assessment ,v the disability ends New technologies are those procedures, drugs or devices that have recently been developed for p the member becomes enrolled in another plan the treatment of specific diseases or conditions, or that covers the disability are new applications of existing procedures, drugs If you are hospitalized on the date your coverage or devices. New technologies are considered investigational or experimental during various ends,you will be covered until the discharge date. If you are not hospitalized, your application for an stages of clinical study as safety and effectiveness are evaluated and the technology achieves acceptance extension of benefits for disability must be made to into the medical standard of care.The technologies Health Net within 90 days after your employer ends may continue to be considered investigational or its agreement with us. We will require medical proof of the total disability at specified intervals. experimental if clinical study has not shown safety or effectiveness or if they are not considered standard care by the appropriate medical specialty. Confidentiality and release of member Approved technologies are integrated into Health information Net Benefits. Health Net knows that personal information in Health Net determines whether new technologies your medical records is private. Therefore, we should be considered medically appropriate, or protect your personal health information in all y settings. As part of the application or enrollment investigational or experimental, following extensive form, Health Net members sign a routine consent to review of medical research by appropriately obtain or release their medical information. This specialized physicians. Health Net requests review of consent is used by Health Net to ensure notification new technologies by an independent, expert medical to and consent from members for present and future reviewer in order to determine medical routine needs for the use of personal health appropriateness or investigational or experimental information. status of a technology or procedure. This consent includes the obtaining or release of all The expert medical reviewer also advises Health Net records pertaining to medical history, services when patients require quick determinations of rendered or treatment given to all subscribers and coverage,when there is no guiding principle for members under the plan for the purpose of review, certain technologies, or when the complexity of patients medical condition requires expert evaluation. 12 Res.No.2002-31 Ex.A Payment of fees and questions about Medicare eligibility rules, contact your local Social Security office. charges Liability of subscriber or enrollee for payment If you receive health care services from doctors without receiving required authorization from your Prepayment fees Primary Care Physician or Physician Group Your employer will pay Health Net your monthly (medical) or the Behavioral Health Administrator premiums for all enrolled family members. Check (mental illness and chemical dependency), you are with your employer regarding any share that you may responsible for payment of expenses for these be required to pay. If your share ever increases, your services. Remember services are only covered when employer will inform you in advance. provided or authorized by a Primary Care Physician or Physician Group,except for emergency or out-of- area urgent care. Consult the Directory of Other charges Contracting Physician Groups for a full listing of You are responsible for payment of your share of the Health Net-contracted physicians. cost of services covered by this plan. Amounts paid by you are called copayments or coinsurance, which Third-parry liability are described in the"Principal benefits and coverage" If you receive medical services under this plan section of this brochure- Beyond these charges the remainder of the cost of covered services will be paid because of an injury caused by someone else and by Health Net. that person compensated you for the injury,you will be required to reimburse Health Net or your When the total amount of copayments you pay Physician Group for medical services received as a equals the maximum copayment liability limit shown result of the injury. in the Evidence of Coverage,you will not have to pay additional copayments for the rest of the year for Continuity of rare most services provided or authorized by your If you are receiving ongoing medical rare at the time Physician Group. of your enrollment with Health Net, and you are Certain copayments paid will not be applied to the concerned about transferring your care to your maximum copayment liability limit.Additionally, selected Physician Group, we may temporarily cover copayments for any covered supplemental benefits all or part of your expenses for services from a purchased by your employer, such as prescription provider not affiliated with Health Net under the drugs or eyewear,will also not be applied to the limit following situations: with the exception of copayments for diabetic supplies. Please read the Evidence of Coverage for .� if medical services provided by your current more information. physician or other provider are not covered by Health Net Coordination of benefits ,e if changing providers right away may have a negative effect on your health When you are covered by another group health plan, If you feel that our medical condition might Health Net will coordinate benefits with that plan. In y y gh doing so,we will comply with state laws that govern require special attention as you switch to Health this activity. Both coverages combined will pay no Net,tell your employer or a Health Net more than the expenses that were incurred- representative prior to enrollment, and no later than 15 days from the effective date of your Health Net Medicare coordination coverage. When, according to federal law, Medicare is the To request a copy of our continuity of care policy, primary payor, Health Net or your Physician Group Please call Member Services at 1-800-522-0088. will coordinate payment with Medicare. If you have 13 Res.No.2002-31 Ex.A Medically necessary care Utilization management processes All services that are medically necessary will be Utilisation Management is an important component covered by your Health Net plan (unless specifically of health care management. Through the processes excluded under the plan). All covered services or of pre-authorization,concurrent and retrospective supplies are listed in your Evidence of Coverage review and care management,we evaluate the booklet; any other services or supplies are not services provided to our members to be sure they are covered. medically necessary and appropriate for the setting and time. This oversight helps to maintain Health Nees high quality medical management standards. Reimbursement provisions Payments that are owed by Health Net for services Pre Authorization provided by or through your Physician Group will Certain proposed services may require an assessment never be your responsibility. prior to approval. Evidence-based criteria are used If you have out-of-pocket expenses for covered to evaluate that the procedure is medically necessary services, call out Member Services department for a and planned for the appropriate setting(i.e-, claim form and instructions. You will be reimbursed inpatient, ambulatory surgery,etc.). for these expenses less any required copayment. Concurrent Review (Remember: you do not need to submit claims for This process continues to authorize inpatient and medical services provided by your Primary Care certain outpatient conditions on a concurrent basis Physician or Physician Group.) while following a member's progress, such as during If you receive emergency services not provided or inpatient hospitalization or while receiving directed by your Physician Group (medical) or the outpatient home care services. Behavioral Health Administrator (mental illness and Discharge Planning chemical dependency), you may.have to pay at the This component of the concurrent review process time you receive service. To be reimbursed for these ensures that planning is done for a member's safe charges,you should obtain a complete statement of discharge in conjunction with the physician's the services received and, if possible, a copy of the discharge orders and to authorize post hospital emergency room report. services when needed. Please contact Member Services to obtain claim Retrvspertive Review forms, and to find out whether you should send the This medical management process assesses the completed form to your Physician Group (medical) appropriateness of medical services on a case-by-case or the Behavioral Health Administrator (mental basis after the services have been provided. It is illness and chemical dependency) or to Health Net. usually performed on cases where pre-authorization CIaims must be received by Health Net within one was required but not obtained. year of the date of service to be eligible for Care or Corse ManAge»unt reimbursement. Nurse Care Managers provide assistance, education and guidance to members (and their families) Provider referral and reimbursement'disclosure through major acute and/or chronic long-term If you are considering enrolling in our plan,you are health problems. The care managers work closely entitled to ask if the plan has special financial with members and their physicians and community arrangements with our physicians that can affect the resources. use of referrals and other services you may need. If you would like additional information regarding Health Net uses financial incentives and various risk Health Nees Utilization Management Process, sharing arrangements when paying providers. To get please call Member Services at 1-800-522-0088. this information, call Health Nees Member Services at 1-800-522-0088,your physician or your Primary Care Physician and request information about our physician payment arrangements. 14 Res.No.2002-31 Ex.A Facilities Termination of provider i Health care services for you and eligible members of If Health Net's contract with a Physician Group or your family will be provided at: other provider is terminated, Health Net will transfer any affected members to another contracted .Q the facilities of the Physician Group you selected Physician Group or provider to ensure that care at enrollment, or continues. Health Net will pay for services or supplies ,g a nearby Health Net- contracted hospital, if your plan covers, until Health Net has been able to hospitalization is required arrange medically appropriate care by another provider. Many Health Net contracting Physician Groups have either a physician on call 24 hours a day or an In addition, the member may elect continued care if urgent care center available to offer access to care at at the time of termination the member was receiving all times care for. The Physician Group you choose will also have a p an acute or serious chronic condition contractual relationship with local hospitals (for p a high-risk pregnancy acute; subacute and transitional care) and skilled nursing facilities. These are listed in your Directory p a pregnancy that has reached the second trimester of contracting Physician Groups. `. If you would like more information on how to request continued care, please contact Health Net's Physician Group transfers Member Services department at 1-800-522-0088. You may switch doctors within the same Physician Group at any rime. You may also transfer to another Second opinions Physician Group monthly. Simply contact Health You have the right to request a second opinion when: Net by the 15'of the month to have your transfer effective by the 1 of the following month. If you call after the 15',your transfer will be effective the ,o Your Primary Care Physician or a referral 1"of the second following month. Physician gives a diagnosis or recommends a treatment plan that you are not satisfied with, or Transfer requests will generally be honored, unless you are more that three months pregnant, confined You are not satisfied with the result of treatment to a hospital, in a surgery follow-up period or you have received, or receiving treatment for an acute illness. (However, You are diagnosed with, or a treatment plan is Health Net may approve transfers under these recommended for, a condition that threatens loss conditions for certain unusual or serious of life, limb, or bodily function, or a substantial circumstances.) impairment, including but not limited to a serious chronic condition, or ,7 Your Primary Care Physician or a referral Physician is unable to diagnose your condition, or test results are conflicting. To obtain a copy of Health Nees second opinion policy, contact the Member Services Department at 1-800-522-0088. 15 Res.No.2002-31 Ex.A Also, coverage under this Health Net plan may be Renewing, terminated for an enrollee who: Q r ,6 acts in a disruptive manner while receiving care- continuing IV allows someone else to use his or her Health Net ending coverage identification card fails to make appropriate copayments or payment for noncovered services Renewal provisions p knowingly provides incorrect information to The contract between Health Net and your employer Health Net or to his or her Health Net doctor is usually renewed annually. If your contract is amended or terminated,your employer will notify IV refuses to establish and maintain a relationship you in writing. with his or her doctor to assure continuity of health care and appropriate use of covered services Individual continuation of benefits Note If the person involved in any of the above If your employment with your current employer activities is the enrolled employee, coverage under ends,you and your covered family members may this plan will terminate as well for any covered qualify for continued group coverage under COBRA dependents. (Consolidated Omnibus Budget Reconciliation Act of 1985). If you are over age 60,an additional period If the employer covered under this Health Net plan of coverage may be available under state law. For does not pay appropriate subscription charges, more information, ask your employer. benefits will end on the last day for which Also, if you become ineligible for group coverage, you subscription charges have been made, unless: may convert from group coverage to a We of you apply for conversion coverage within 31 individual coverage called conversion coverage. days of that date Application must be made within 31 days of the date �p you are hospitalized (coverage will continue group coverage ends. Please contact Member Services until you are discharged from the hospital) for information about conversion plan coverage. Furthermore,you may be eligible for continued ,v you are totally disabled and apply for an coverage for a disabling condition (for up to 12 extension of benefits for the disabling condition months) if your employer terminates its agreement within 90 days with Health Net. Please refer to the"Extension of benefits" section of this brochure for more information. Termination of benefits Health Net can terminate your coverage when: 9 the agreement between the employer covered under this Health Net plan and Health Net ends .0 the employer covered under this Health Net plan fails to pay subscription charges ,Q you cease to either live or work within Health Net's service area p you no longer work for the employer covered under this Health Net plan 16 Res.No.2002-31 Ex.A function. Health Net must notify you of the status If you have a of your grievance no later Than three days from receipt of the grievance. disagreement with In addition,you can request an independent medical review of disputed health care services from Q u r plan the Department of Managed Health Care if you believe that health care services eligible for coverage The California Department of Managed Health Care and payment under the plan was improperly denied, b d e is responsible for regulating health care service plans. modified or delayed Y Health Net or one of its contracting providers. n h atoll-free telephone number 1- g P The Department as p 888-HMO-2219) to receive complaints regarding if Health Net denies our appeal of a denial health plans. The hearing and speech impaired may Also, y Ape use the California Relay Service's toll-free numbers for lack of medical necessity, or denies or delays (1 800-735-2929 [TTY1 or 1-888-877-5378 coverage for requested treatment involving [TTY]) to contact the Department. The experimental or investigational drugs, devices, Department's Internet web site procedures or therapies,you can request an (http://www.hmohelp.ca.gov) has complaint forms independent medical review of Health Nees and instructions online. decision from the Department of Managed Health Care if you meet eligibility criteria set out in the If you have a grievance against your health Evidence of Coverage. plan,you should first telephone your plan at (1-800-522-0088) and use the plan's grievance Arbitration process before contacting the Department Ifyou If you are not satisfied with the result of the need help with a grievance that has not been grievance and appeals process, you.may submit the satisfactorily resolved by your plan, or a grievance problem to binding arbitration. Health Net uses that has remained unresolved for more than 30 days, binding arbitration to settle disputes, excluding you may call the Department for assistance.The medical malpractice. When you enroll in Health Alan's grievance process and the Department's Net, you agree to submit any disputes to arbitration, complaint review process are in addition to any other in lieu of a jury or court trial. dispute resolution procedures that may be available to you, and your failure to use these processes does not preclude your use of any other remedy provided by law. Member grievance and appeals process If you are dissatisfied with the quality of care that you have received or feel that you have been denied a service or claim in error, you may file a grievance or appeal. To file a grievance or appeal you may call or write to Health Net, P.Q. Box 10348,Van Nuys, CA 91410-0348, 1-800-522-0088. Health Net will acknowledge your grievance or appeal within five days. If we cannot resolve your grievance or yeA within 30 days we will contact you by the 30 day and inform you of the reason for the delay. You may also file an emergency appeal for conditions where there is an immediate and serious threat to your health, including severe pain or,the potential for loss of life, limb or major bodily 17 �a N X p W 0 N D Z a 0 tr� d+ iM /� r�t� k 4 � rJ In 'rxi Y. V V k F 1 k �r�� j' ;1 N � tyq ,i 7• �'G.;N�,t„'��+rKfd C d I Q�t a�3 :�y - f. w ,• -wrxt'-� �N�S ��r �n�y a. r ,� 40.J pp ij r x M I Vg �* d W. 77 JY v.T d ,x^' i?,faFf,4YV y74'4�;�u�� *^yr rij�t^ r4 S• ° r � { ✓a ��. \�[�h+a wi 8� � � w � }t f ,�f1�V� {� f!��3�1� � M ZNlq r P S,rtr a+y>• Fla (f '3.: �� s' 1 V J Y r�1 ,,� �"y'.. ra 15, a j2 s 5 r Y o ro Mf r a w t c � r�y. y >4, • � — Table of contents+ Res.No.2002-31 Ex.A Choosing your doctor and physician group . . 3 questions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Based on the availability of your current doctor Based on where the doctor's office is located Health Net HMO service area . . . . . . . . . . . . . 8 Based on the doctor's physician group affiliation Based on the doctor's hospital affiliation Primary Care Physicians by city . . . . . . . . . . . 9. Based on affiliation with a particular specialist If you're looking for doctors and physician groups in your area, check this listing How to complete your enrollment form . . . . 4 Participating Physician Group index . . . . . . 253 Some frequently asked questions . . . . . . . . . 4 Detailed information about Health Net's What is a Participating Physician Group? contracted physician groups, in alphabetical . What is Rapid Access? order by group name How is a referral specialist different from a Primary Care Physician? Hospital index . . . . . . . . . . . . . . . . . . . . . .. 355 What is an affilite office and how does it affect A list of hospitals in alphabetical order by name my selection of a Primary Care Physician? What's the difference between emergency care Specialist index . . . . . . . . . . . . . . . . . . . . . . 361 and urgent care? A list of available specialists and their affiliated How can I get a list of Sub-Acute Care Facilities? Participating Physician Groups, in alphabetical How can the Health Net Coordinator help me? order, by specialty Should I choose a doctor who is close to home or close to work? Primary Care Physician index . . . . . . . . : . . 499 j When can I change to a new doctor? A list of all Primary Care Physicians affiliated with I How can I obtain information on doctors who Health Net, arranged in alphabetical order are in the Health Net network? Glossary of terms . . . . . . . . . . . . . . . . . . . . . 515 5 How Health Net works . . . . . . . . . . . . . . . . . . 7 How to receive care About your Health Net 1D card Hospitalization Read about Rapid.Access,'Health Net's guide to accessing specialists quickly and easily. Use this directory to choose a Primary Care Physician and Participating Physician Group. For more details about your plan benefits and terms of your group's coverage, please refer to your E Disclosure Form and Summary of Benefits. i 1 MEO MOU Res.No.2002-31 Ex.A EXHIBIT E RETIREE SUBSIDY MEDICAL PLAN An employee who has retired from the City shall be entitled to participate in the City sponsored medical insurance plans and the City shall contribute toward monthly premiums for coverage in an amount as specified in accordance with this Plan, provided: A. At the time of retirement the employee has a minimum of ten (10) years of continuous City service or is granted an industrial disability retirement; and B. At the time of retirement, the employee is employed by the City; and C. Following official separation from the City, the employee is granted a retirement allowance by the California Public Employees' Retirement System. The City's obligation to pay the monthly premium as indicated shall be modified downward or cease during the lifetime of the retiree upon the occurrence of any one of the following: 1. During any period the retired employee is eligible to receive or receives health insurance coverage at the expense of another employer, the payment will be suspended. "Another.employer" as used herein means private employer or public employer or the employer of a spouse. As a condition of being eligible to receive the premium contribution as set forth in this plan, the City shall have the right to require any retiree to annually certify that the retiree is not receiving or eligible to receive any such health insurance benefits from another employer. If it is later discovered that a misrepresentation has occurred, the retiree will be responsible for reimbursement of those amounts inappropriately expended and the retiree's eligibility to receive further benefits will cease. 2. On the first of the month in which a retiree or dependent reaches age 65 or on the date the retiree or dependent can first apply and become eligible, automatically or voluntarily, for medical coverage under Medicare (whether or not such application is made) the City's obligation to pay monthly premiums may be adjusted downward or eliminated. Benefit coverage at age 65 under the City's medical plans shall be governed by applicable plan document. 3. In the event of the death of any employee, whether retired or not, the amount of the retiree medical insurance subsidy benefit which the deceased employee was receiving at the time of his/her death would be eligible to receive if he/she were retired at the time of death, shall be paid 01-02 MEO MOU Final 37 04/04102 5:40 PM MEO MOU Res.No.2002-31 Ex_A on behalf of the spouse or family for a period not to exceed twelve (12) months. SCHEDULE OF BENEFITS A. Minimum___Eligibility for. Benefits - With the exception of an industrial disability retirement, eligibility for benefits begin after an employee has completed ten (10) years of continuous service with the City of Huntington Beach. Said service must be continuous unless prior service is reinstated at the time of his/her rehire in accordance with the City's Personnel Rules. B. Disability Retirees - Industrial disability retirees with less than ten (10) years of service shall receive a maximum monthly payment toward the premium for health insurance of $121. Payments shall be in accordance with the stipulations and conditions which exist for all retirees. Payment shall not exceed dollar amount which is equal to the full cost of premium for employee only. C. Maximum Monthly Subsidy Payments - All retirees, including those retired as a result of disability whose number of years of service prior to retirement exceeds ten (10), shall be entitled to maximum monthly payment of premiums by the City for each year of completed City service as follows: Maximum Monthly Payment for Retirements After: Years of Service Subsidy 10 $ 121 11 136 12 151 13 166 14 181 15 196 16 211 17 226 18 241 19 256 20 271 21 286 22 300 23 315 24 330 25 344 Note: The above payment amounts may be reduced each month as dependent eligibility ceases due to death, divorce or loss of dependent child status. However, the amount shall not be reduced if such reduction would cause insufficient funds needed to pay the full premium for 01-02 MEO MOU Final 38 04/04/02 5:40 PM M E O MO U Res, No.2002-31 Ex_A the employee and the remaining dependents. In the event no reduction occurs and the remaining benefit premium is not sufficient to pay the premium amount for the employee and the eligible dependents, said needed excess premium amount shall be paid by the employee. 01-02 MEO MOU Final 39 04/04/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A INDEMNITY HEALTH PLAN, EMPLOYE ESIRETIREES' YEAR 2002 City Plan Employees Non-Subsidized Retirees City Plan - Subsidized Benefits? COBRA-eligibles Retirees Deductible per person $250 $250 Deductible per family $500 $500 Maximum Out of Pocket $2000 per person $2000 per person $4000 per family $4000 per family Note: Retirees who elect to participate in Health Net shall be entitled to benefits of the program chosen. This summary has been used to list only those benefit provisions that differ between active and subsidized Retiree Plans. Currently, there are no differences, however, this exhibit is not intended to require that future changes to active employee benefits be applied to retirees as well. The Employee Health Plan document should be consulted for detailed questions about specific benefits. Benefits are subject to modification through the meet and confer process. 04-02 MEO MOU Final 40 04/04/02 9:40 PM MEO MOU Res.No.2002-31 Ex.A RETIREE SUBSIDY MEDICAL PLAN/MISCELLANEOUS PROVISIONS A. Eligibility: 1. The effective start-up date of the Retiree Subsidy Medical Plan for the various employee groups shall be the first of the month following retirement date. 2. A retiree may change plans, add dependents, etc., during annual open enrollment. Employee Benefits shall notify covered retirees of this opportunity each year. 3. Years of service computed for the Retiree Subsidy Medical Plan are actual years of completed service with the City of Huntington Beach. 4. When a retiree is eligible for medical plan coverage at the expense of another employer due to post-retirement employment of the retiree or spouse of the retiree, the retiree and his/her spouse must take that coverage regardless of benefit level and shall be deleted from any City Plan coverage. Exceptions to this requirement are limited to the following: a. A retiree is.not required to enroll in such "other" medical plan coverage if there is significant disparity between the benefits provided by the "other" medical plan and the Retiree Subsidy Medical Plan as defined below. "Significant disparity" means coverage available under the "other" medical plan is restrictive or limited in one or more of the following ways: 1) No in-patient hospitalization coverage. 2) No major medical benefits 3) Annual deductible is $1,000 or greater per person. 4) Major medical benefits are paid at 60% or less of covered expenses. b. The Risk Manager will have the authority to provide additional exceptions following review of the "other ' medical plan policy. Exceptions will be made only if the "other" medical plan benefit provisions are comparable to the guidelines under B above. 01-02 MEO MOU Final 41 04IM02 9:40 PM MEO MOU Res. No.2002-31 Ex.A c. Miscellaneous Provisions: 1. Benefits provided under the Retiree Subsidy Medical Plan will be coordinated with the "other" medical plan as the primary carrier. 2. The City shall have the right to require any retiree to provide a copy of the "other" medical plan policy for review by the Risk Manager. 5. When a retiree becomes eligible for the other group coverage and then becomes no longer eligible, he/she may have the subsidy reinstated and regain Retiree Subsidy Medical Plan coverage. 6. Dependents of a retiree may follow him/her into the Retiree Subsidy Medical Plan or they may choose to exercise COBRA rights along with the retiree. 7. When a retiree becomes 65 and has eligible dependents under 65, said dependents are eligible to exercise COBRA rights. 8. When a retiree is under 65 and his/her spouse is over 65, the spouse is not covered. B. Benefits: 1. Retiree Subsidy Medical Plan inctudes Managed Health Network (MHN), Prescription Card System (PCS), Orange County Foundation for Medical Care (OCFMC) and Medical Stop Loss insurance. 2. City Plans are the primary payer for active employees age 65 and over, with Medicare the secondary payer. Retirees age 65 and over have no City Plan options and are eligible only for Medicare. 3. Premium payments are to be received at least one month in advance of the coverage period. C. Subsidies: 1. The subsidy payments will pay for: a. Retiree Subsidy Medical Plan. b. Health Net. c. Part A of Medicare for those retirees not eligible for paid Part A. 01-02 MEO MOU Final 42 04/04102 5:40 PM MEO MOU Res_No.2002-31 Ex.A 2. Subsidy payments will not pay for: a. Part B Medicare. b. Regular City Employee Indemnity Plan. c. Any other employee benefit plan. d. Any other commercially available benefit plan. e. Medicare supplements D. Medicare: 1. All persons are eligible for Medicare coverage at age 65. Those with sufficient credit quarters of Social Security will receive Part A of Medicare at no cost. Those without sufficient credited quarters are still eligible for Medicare at age 65, but will have to pay for Part A of Medicare if the individual elects to take Medicare. In all cases, Part B of Medicare is paid for by the participant. 2. When a retiree and his/her spouse are both 65 or over, and neither is eligible for paid Part A of Medicare, the subsidy shall pay for Part A for each of them or the maximum subsidy, whichever is less. 3. When a retiree at age 65 is eligible for paid Part A of Medicare and his/her spouse is not eligible for paid Part A, the spouse shall not receive subsidy. When a retiree at age 65 is not eligible for paid Part A of Medicare and his/her spouse who is also age 65 is eligible for paid Part A of Medicare, the subsidy shall be for the retiree's Part A only. E. Cancellation: 1. For retirees/dependents eligible for paid Part A of Medicare, the following cancellation provisions apply: a. Coverage for a retiree under the Retiree Subsidy Medical Plan will be eliminated on the first day of the month in which the retiree reaches age 65. If such retiree was covering dependents under the Plan, dependents will be eligible for COBRA continuation benefits effective as of the retiree's 65th birthday. b. Dependent coverage will be eliminated upon whichever of the following occasions comes first: 01-02 MEO MOU Final 43 04104/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A 1) After 36 months of COBRA continuation coverage, or 2) When the covered dependent reaches age 65 in the event such dependent reaches age 65 prior to the retiree reaching age 65. c. At age 65 retirees are eligible to-make application for Medicare. Upon being considered "eligible to make application", whether or not application has been made for Medicare, the Retiree Subsidy Medical Plan will be eliminated. 2. See provisions under "Benefits", "Subsidies", and "Medicare" for those retirees/dependents not eligible for paid Part A of Medicare. 3. Retiree Subsidy Medical Plan and COBRA participants shall be notified of non-payment of premium by means of a certified letter from Employee Benefits in accordance with provisions of the Memorandums of Understanding. 4. A retiree who fails to pay premiums due for coverage and is in arrears for sixty (60) days shall be terminated from the Plan and shall not have reinstatement rights. 01-02 MEO MOU Final 44 04104/02 5:40 PM MEO MOU Res.No.2002-31 Ex.A EXHIBIT F VEHICLE USE ASSIGNMENT ADMINISTRATIVE REGULATION See Administrative Regulations OR See City Clerk Vault File No. 720.20 01-02 MEO MOU Final 45 04104/02 5:40 PM Res.No.M2-31 Ex.A ASSIGNMENT AND USE OF CITY VEHICLES The following represents the requirements for the assignment and use of city vehicles. It first identifies the four categories in which a City Vehicle may be authorized and requirements and additional options that meet the City's standards. It also includes reimbursement for use of personal vehicles and requirements and use of city vehicles by volunteers. A. Category A — Exclusive with take-home authorization. Upon approval of the City Administrator and Department Head, assigned City vehicles may be taken home by employees whose residence is within twenty-five (25) miles of City Hall for uses as described below: 1. Executive Use: City Administrator and Department Heads. 2. Designated management positions, as outlined in Appendix A that they meet the following criteria including those prescribed within an MOU: a. They have received a permanent or probationary appointment to the management position, or are serving in an acting capacity in a management position im excess of sixty(60) days, and b. Assignment is approved by the City Administrator, and c. There is a higher than normal need for incumbents to use vehicles outside normal work hours (more than three (3) times per month), and d. There is a need to have a vehicle available for City business purposes on a constant and regular basis, and e. In addition, such employees must meet one of the following criteria: 1) Have routine and recurring duties to perform after or outside of normal working hours which require a return to work from home, or 2) Be subject to call out during non-duty hours for emergencies, field operations, or meetings if the actual frequency of calls and the importance of response times can be documented and justify the assignment of vehicle, or 3) Mileage driven on official City business exceeds an average of 300 miles per month, or Fleet Management Program-City of Huntington Beach Res.No.2002-31 Ex.A 4) Regularly and frequently supervise subordinates in the field and conduct City business in the field, outside of normal working hours, or 5) Duties require the employee to be away from his/her base workstation greater than fifty percent (50%) of his/her working time, on an average. 3. Emergency Response Employees - may include non-management positions - See Appendix B: a. Employees who are required to respond more than once per week on an average without delay in order to protect the public health, safety, and property. b. Employees who are required to carry special emergency equipment in their vehicles, which must be utilized on a regular and frequent basis. (A radio or car phone in and of itself does not constitute special emergency equipment.) 4. Appendix A: List of authorized "Category A" assignments where the employee has an option of an auto allowance or vehicle assignment. a. Auto Allowance: In lieu of "Category A" Exclusive Vehicle Assignment; employees may request an auto allowance. Authority for pertinent policies and procedure on auto allowances originate from the Charter of the City of Huntington Beach, Section 401. Policy and procedures are listed below: 1. The Department Head and City Administrator shall approve requests for auto allowance. 2. The City Administrator and Department Heads shall be responsible for determining if it is appropriate to use a private vehicle for City business. 3. Compensation is specified in the appropriate Memorandum of Understanding (MQU), plus the most recent IRS approved rate per mile for mileage above fifty (50) miles on any one trip. Travel/commute to and from the work site will be consistent with the Fair Labor Standards Act(FLSA). 4. Procedure to change from City vehicle to auto allowance: Fleet Mamagement Program-City of Huntington Beach Res.No.2002-31 Ex.A a. The employee shall request permission of his/her Department Head to change from using a City-assigned vehicle to receiving the auto allowance. b. The Department Head shall determine if it is appropriate to use a private vehicle for City. business, and if a City vehicle/equipments (i.e., radio) is necessary to the effective performance of the employee's duties. C. Department Head shall request approval to use a private vehicle for City business from the City Administrator via the Fleet Management Committee. d. If the Department Head and City Administrator via the Fleet Management Committee approve use of a private vehicle, funds for the auto allowance shall be included in the department's budget or, if necessary, transferred from the department's operating accounts to an auto allowance account. e. As part of the approval, a written memorandum of understanding shall be prepared to specify the uses and responsibilities of each. party. The memorandum (Auto Allowance Authorization Form, Appendix D) shall be executed by each party. f. After the effective date of this regulation, an employee who switches from a City vehicle to the auto allowance must elect to receive the auto allowance for a minimum period of three (3) years in order to allow the City the cost savings made possible by elimination of a City vehicle. This does not negate the ability of the Department Head or City Administrator to require the use of a City vehicle if it is necessitated by the job in their opinion. Conversely, an employee who switches from an auto allowance to a City vehicle must elect to keep the auto option for a minimum period of three (3) years in order to amortize the cost of the vehicle. The employee shall sign a statement acknowledging his/her agreement to these terms that shall be contained in the memo agreement as provided above. The general form of such memorandum agreement is attached hereto as Appendix D, Auto Allowance 'Authorization Form. g. The City vehicle previously used by the employee, or another similar type of vehicle, shall be declared surplus Fleet Management Program.City of Huntington Beach Res.No.2002-31 Ex.A and disposed of in accordance with Administrative Regulation AR 207, Surplus Disposal and/or Transfer, unless the City Administrator approves an exception. h. If an employee receiving an auto allowance chooses to be assigned a City vehicle instead, he/she must give ample notice to allow for budgeting the purchase of an additional vehicle if one is not available. No vehicle purchases will be approved for this purpose, which have not been formally budgeted separately as an addition to the City's fleet. i. If an employee is in a non-pay status (suspension, leave without pay, or no pay) on the payroll record for a period of two weeks or more in any month, the auto allowance will be suspended until the employee returns to an active pay status. If the allowance has been paid in advance, a pro- rated refund shall be due the City. B. Category B -- Exclusive without take-home authorization: City vehicles which are not to be taken home may be assigned to an employee or group of employees by a Department Head based on meeting one of the following criteria. 1. Monthly mileage driven exceeds an average of 300 miles per month and the vehicle is used for the purpose of supervision or inspection in the field, or 2. Duties require the employee to be away from his/her workstation greater than fifty percent(50%) of his/her working time on an average. C. Category C — Temporary Assignment with and without take-home authorization: Vehicles may be assigned to an employee or group of employees to provide transportation for a training opportunity, to complete a special project, to conduct seasonal work, or for other special, limited time purposes. Fleet Managers will issue vehicles to employees or groups of employees upon receipt of authorization by the employee's Department Head authorizing the activity and requesting a vehicle based on the availability of vehicles. Under this category, a vehicle might be assigned to an employee or a group of employees conducting a 30-day traffic study or a group of employees who are sent to a weeklong out- of-town training opportunity. The City Administrator or his/her designee shall approve temporary assignment of a vehicle to an employee if the vehicle is to be taken home by the employee. D. Category D — Shared Short Terns: Department and fleet pool vehicles are available for employees who require transportation to perform official City Fleet Management Program-City of Huntington Beach Res.No.2002-31 Fat-A business, but do not meet the criteria for an assigned City vehicle under Category A, B, or C above. Such pool vehicles shall be used in accordance with department policies that shall provide for the assignment of responsibility for the maintenance of the necessary records with respect to the use of pool vehicles These may be checked out on an as needed basis for the conduct of City business. A pool of vehicles shall be maintained by Fleet Managers to provide for the intermittent transportation needs of employees. A number of available vehicles shall be located at locations where employees normally conduct City business. A sign-out system will be established by each Fleet Manager or by each Department to record the name of the employee checking out the. vehicle, starting mileage, ending mileage, and destination. The person who maintains the keys and gas cards for these vehicles will be responsible for maintaining the sign-out of the pool vehicles. Reimbursement for Use of Personal"Vehicles Employees, upon authorization of their Department Head, may use their own vehicles on official City business and shall be reimbursed at the most recent IRS Allowance rate per mile driven on official City business. A. The Department Head will approve use of the private vehicle. The Department Head will be responsible for reviewing use of the vehicle and employee reimbursements. 1. Employees shalt submit monthly claims or in conjunction with approved travel expense submission for reimbursement to the Finance Officer through their Department Head on forms prescribed by the Finance Officer. 2. Employees shall not be reimbursed for commuting to and from work, except that employees who are required to attend scheduled meetings outside of normal working hours may be reimbursed for mileage required for use of personal vehicles when authorized by the Department Head. 3. The mileage reimbursement covers fuel, oil, tires, maintenance, depreciation, insurance, and all other costs of owning and maintaining an automobile. B. INSURANCE REQUIREMENTS FOR PRIVATE VEHICLES Private vehicles used on City business shall be insured by the individual employee by vehicle liability insurance at least equal to the minimum requirement of the California Vehicle Code. Fleet Management Program-City of Huntington Beach Res.No.2002-31 Ex.A A. Such requirements currently are: 1. $15,000 for single injury or death. 2. $30,000 for multiple injury or death. 3. $5,000 for property damage. Employees who do not meet the above requirements shall not be permitted to use private vehicles on City business until such requirements are met. B. City liability on use of private vehicle. If an employee uses his/her personal vehicle for City business, he/she must carry proof of automobile liability insurance. Personal auto insurance is primary insurance should an employee be involved in an accident in his/her own vehicle. The employee should contact his/her personal auto insurance agent for further instruction. The City's self-insured automobile liability coverage will be secondary to any other existing insurance. If an employee is required to use his/her personal vehicle for City business purposes and is involved in a non-fault accident incurring out-of-pocket expenses, the City will reimburse the employee for up to $500 to cover any applicable collision deductible or out-of-pocket expenses resulting from the collision. C.Family Members in City Vehicles The transportation of family members or others for personal business in a City vehicle is to be discouraged. However, in the event an employee, while engaged in personal business in a City vehicle, is involved in an automobile accident, the City will be primarily responsible for the resultant losses. In the event that the employee is determined to be at fault for the accident while on personal business, the City will subrogate against the employee's private automobile liability insurance carrier for recovery of the damage to the City's vehicle, any third party property damage as well as for bodily injury sustained by the passengers or third party. Use of Cif Vehicles by Volunteers 1. Prior to operating any City vehicle or equipment, all volunteers shall provide the Department Head or his/her designee with a current copy of their DMV driving record. The record shall be reviewed and approved by Fleet Management Program-City of Huntington Beach Res.No.2002-31 Ex.A the Department Head or his/her designee before the volunteer is permitted to drive a City vehicle. All approved DMV reports shall be filed and maintained by the respective department. 2. Use of City vehicles shall be limited to the Orange County area, unless previously approved by the Department Head or his/her designee. 3. The Department Head or his/her designee shall brief volunteer drivers on: a. The use of City vehicles, including accident procedures and policy, b. Fueling procedures, c. What to do in the event of a mechanical failure. Fleet Management Program-City of Huntington Beach Res.No.2002-31 Ex.A APPENDIX A AUTHORIZED CATEGORY A ASSIGNMENTS CURRENT AUTHORIZATIONS AS OF NOVEMBER 2000 CITY VEHICLE OR AUTO ALLOWANCE City Administrator All Appointed and Elected Department Heads Administration Police Assistant City Administrator Captain(4) Deputy City Administrator Lieutenant(12 positions) Director of Organizational Effectiveness Information Systems Manager Director of Communications & Special Projects Chief Criminalist Police Records Administrator Attorney's Office Police Communications Manager Building& Safety Public Works Inspection Manager Deputy Director of Public Works City Engineer Transportation Manager Community Services Park, Tree &Landscape Dep. Director Recreation/Beach Operations Manager Marine Safety Chief Water Operations Manager Supervisor Parking/Camping Facility Supervisor Water Production Supt. Recreation/Human Services Supervisor Building Maintenance Beach Operations Supervisor Recreation Supervisor Senior(2) Supervisor Park Maintenance Arts & Cultural Affairs Manager Supervisor Tree, Landscape, Pest Construction Manager Fire Maintenance Operations Manager Division Chief(2) Supervisor Water Distribution Fire Protection Analyst Supervisor Building Maintenance Supervisor Street/Sewer Maintenance Note: The following classifications are not authorized to have an auto allowance or City vehicle on a take-home basis. The incumbents in these classifications as of November 1, 1989 are, however, receiving auto allowance and will be allowed to continue receiving an auto allowance during their employment with the City. Department Classification Administrative Services Finance Officer Fleet Management Program-City of Huntington Beach Res.No.2002-31 Ex.A APPENDIX B EMERGENCY RESPONSE PERSONNEL Police Community Liaison-- 1 Sergeant Professional Standards Unit-2 Sergeants General Investigations- 3 Sergeants 17 Investigators Uniform Division- 4 K-9 Officers 2 SWAT Sergeants I Accident Investigations Officer 2 Motorcycle Sergeants 16 Motorcycle Officers r Public Works Inspectors (4) Crewleaders (9) Leadworkers (9) Sr. Water Inspectors (2) Fleet Management Program-City of Huntington Beach Res.No.2002-31 EX A APPENDIX C OTHER STAFF RECEIVING ALLOWANCE/TAKE-HOME VEHICLES BUILDING&SAFETY Supervising Combination/Structural Inspector(2) Plumbing/Mechanical Inspector Electrical Inspector Principal Inspector 111 (2) CITY ATTORNEY'S OFFICE City Attorney Investigator *Positions to be reviewed for possible placement on Appendix A Fleet Management Program•City of Huntington Beach Res.No_2002-31 Ex.A APPENDIX D CITY OF HUNTINGTON BEACH AUTOMOBILE ALLOWANCE AUTHORIZATION FORM In return for receiving an auto allowance, my private vehicle will be used fro City business where a vehicle is needed, including, but not limited to, transportation to meetings, field inspections, transporting equipment.or supplies, and any other uses for which a city vehicle would be used, whether within or outside of normal working hours. All maintenance, insurance, and other costs associated with the vehicle will be my responsibility. Circle Appropriate Choice AUTOMOBILE ALLOWANCE or CITY VEHICLE OPTION f I understand that if I switch from a City vehicle to the auto allowance, I must elect to receive the allowance for a minimum period of three years. I understand that if I switch from an auto allowance to a City vehicle, I must elect to keep the auto option fora. minimum period of three years. I have read the Automobile Allowance Administrative Regulation and understand the terms under which I am receiving the automobile allowance or City vehicle. APPROVED BY: Department Head Employee Director of Administrative Services City Administrator Fleet Management Committee Chair Department Fleet Manager Please check one: City vehicle not previously used. City vehicle was assigned to this department. (Attached is Equipment Report Form) Fleet Management Program-City of Huntington Beach MEO MOU Res. No.2002-31 Ex.A EXHIBIT G PHYSICAL EXAMINATION DESCRIPTION I. Complete Health History It. Complete Physical Examination by Physician III. Computer Printout: A. Physiological Tests- 1- Temperature 2. Height 3. Weight 4. Vision 5. Audiometry (Hearing Screening) 6. Blood Pressure 7. Pulse 8. Chest X-Ray 9. EKG 10. History 11. Tonometry (Glaucoma) for patients 35 and over. 12. Spirometry (Breathing) B. Laboratory Tests: 1. Blood Chemistry Screening Tests: SGPT Triglycerides SGOT Glucose Fasting LDH BUN Alk. Phosphatase Creatinine Total Bilirubin Uric Acid Total Protein Calcium Albumin-Serum Inorganic Phosphate Globulin Sodium Cholesterol Postassium 2. Complete Blood Count 3. Urinalysis 4. Stool Test for Blood 5. RPR 6. Pap Smear on Females 7. HDL IV. Examination Findings: A. Consultation with Physician B. Written Report of Findings 01-02 MEO MO Final 46 04104/02 5:40 PM Res. No. 2002-31 STATE OF CALIFORNIA COUNTY OF ORANGE } ss: CITY OF HUNTINGTON BEACH } I, CONNIE BROCKWAY, the duly elected, Qualified .City Clerk of the City of Huntington Beach, and ex-officio Clerk of the City Council of said City, do hereby certify that the whole number of members of the City Council of the City of Huntington Beach is seven; that the foregoing resolution was passed and adopted by the affirmative vote of at least a majority of all the members of said City Council at a regular meeting thereof held on the 15th day of April, 2002 by the following vote: AYES: Green, Dettloff, Bauer, Cook, Houchen, Winchell, Boardman NOES: None ABSENT: None ABSTAIN: None City Clerk and ex-officio C erk of the City Council of the City of Huntington Beach, California