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HomeMy WebLinkAboutHBFMA - Fire Management Association - 2002-04-15I 'Le. %9 No NNNf W41 �M Council/Agency Meeting Held: 6�_N -a2 Deferred/Continued to: -� \Approved ❑ Conditionally Approved ❑ Denied PV( y Clef1 Signature Council Meeting Date: APRIL 15, 2002 Department ID Number: AS-02-011 O r CITY OF HUNTINGTON BEACH REQUEST FOR ACTION SUBMITTED TO: HONORABLE MAYOR AND CITY COUNCIL ME RS �� S2 SUBMITTED BY: RAY SILVER, CITY ADMINISTRATOR PREPARED BY: WILLIAM P. WORKMAN, ASSISTANT CITY ADMINISTRATOR CLAY MARTIN, DIRECTOR OF ADMINISTRATIVE SERVICES SUBJECT: ADOPT RESOLUTION NO. -�6oa 3a AMENDING THE MEMORANDUM OF UNDERSTANDING BETWEEN THE CITY AND THE HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Statement of Issue, Funding Source, Recommended Action, Alternative Action(s), Analysis, Environmental Status, Attachment(s) Statement of Issue: Should the City and the Huntington Beach Fire Management Association enter into a new Memorandum of Understanding covering the period of December 22, 2001 through December 20, 2002? Funding Source: Funding is included in the Fiscal Year 2001/2002 budget in account number 10040101.79100. The total annual cost to implement the Memorandum of Understanding with the Huntington Beach Fire Management Association is $35,000. The total cost for Fiscal Year 2001/2002 is $28,000. Recommended Action: Adopt Resolution No. ;3,� , a resolution approving and implementing the Memorandum Beach Fire Management Association (FMA) and through 12/20/02. Alternative Action(s): of the City Council of Huntington Beach of Understanding between the Huntington the City of Huntington Beach for 12/22/01 Reject the resolution and maintain the current salary and benefits of the Huntington Beach Fire Management Association. REQUEST FOR ACTION MEETING DATE: APRIL 15, 2002 DEPARTMENT ID NUMBER: AS-02-011 Analysis: Representatives of the City and the Huntington Beach Fire Management Association (FMA) have completed the meet and confer process with agreement on a new Memorandum of Understanding (MOU) for the period of December 22, 2001 through December 20, 2002. The agreement includes a three percent salary increase for Battalion Chiefs and a five percent salary increase for Division Chiefs effective March 2, 2002. FMA has agreed to the following City proposals: standardized tuition reimbursement and bilingual skill pay language, direct deposit required for all employees, a labor/management committee to redesign the City's performance evaluation forms, and new fleet management language. The City has agreed to cover all medical and dental premium increases for the 2002 calendar year and to lower the dependent coverage start date for full time employees from one year to the first of the month after one month of employment. To insure the success of the new JD Edwards payroll system, both the City and FMA agreed to covert all pay rates to either hourly or bi-weekly rates. Attachment(s): Summary of salary and benefit changes 2. Resolution to adopt Memorandum of Understanding, including Exhibit A, Memorandum of Understanding between the City of Huntington Beach and the Huntington Beach Fire Management Association for December 22, 2001 through December 20, 2002 it%. 2aa,2--3d 3. 1Legislative Draft of the Memorandum of Understanding between the City of Huntington Beach and the Huntington Beach Fire Management Association for December 22, 2001 through December 20, 2002 RCA Author: William McReynolds H:\RCA's\2002 FMA MOU.dot -2- 4/5/2002 9:00 AM ATTACHMENT #1 SUMMARY OF SALARY AND BENEFIT CHANGES FOR THE FIRE MANAGEMENT ASSOCIATION •'° Term • The period of December 22, 2001 through December 20, 2002. ❖ Salary 3% increase for Battalion Chiefs and 5% increase for Division Chiefs effective March 2, 2002 (the first pay period in the month in which the association agreed to the new MOU). ❖ Health Year 2002 Premiums The City's contribution to medical, dental and vision shall be no more than the premium maximum for employee only, employee plus one, and employee plus family. Dependent coverage start date lowered for full time employees from one year to the first of the month after thirty days of employment. °:• Management Issues • Tuition Reimbursement — Standardized • Bilingual Skill Pay — Standardized and only for specified languages • Direct Deposit Required of All Employees • Employee Performance Evaluations to be Redesigned by Labor/Management Committee • New Fleet Management Language - approval of City Administrator for City vehicles to be taken home • All Pay Rates Changed to Hourly or Bi-Weekly ATTACHMENT #2 RESOLUTION NO. 2002-32 - A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF HUNTINGTON BEACH APPROVING AND IMPLEMENTING THE MEMORANDUM OF UNDERSTANDING BETWEEN THE HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION (FMA) 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 Fire Management Association, 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 ; 2002. ATTEST: City Clerk dy-ZZ-a APPROVED AS TO FORM: City Attorney INITIAT ND PROVE Director Administrative Se ices 02reso/fma/4/4/02 Res. No. 2002-32 Ex. A FIRE MANAGEMENT ASSOCIATION Res. No.2002-32 MEMORANDUM OF UNDERSTANDING Ex. A TABLE OF CONTENTS Page PREAMBLE................................................................................................................................................................. I ARTICLEI — TERM OF MOU................................................................................:................................................1 ARTICLE II — REPRESENTATIONAL UNIT........................................................................................................I ARTICLEIII — SEVERABILITY.............................................................................................................................I ARTICLE IV — SALARY SCHEDULES AND RETIREMENT............................................................................. 2 A. MONTHLY COMPENSATION...................................................................................................................................2 B. PERS PICKUP........................................................................................:..............................................................2 C. SELF FUNDED SUPPLEMENTAL RETIREMENT BENEFIT..........................................................................................2 D. MEDICAL INSURANCE UPON RETIREMENT............................................................................................................2 E. PUBLIC EMPLOYEES' RETIREMENT SYSTEM REIMBURSEMENT AND REPORTING..................................................3 1. Level III Survivors Benefits.............................................................................................................................3 2. Rollover...........................................................................................................................................................3 F. DIRECT DEPOSIT...................................................................................................................................................3 ARTICLEV — SPECIAL PAY...................................................................................................................................3 A. EDUCATIONAL TUITION........................................................................................................................................3 B. HOLIDAY PAY-IN-LIEU.........................................................................................................................................4 C. BILINGUAL SKILL PAY..............................................................:...........................................................................5 ARTICLEVI — UNIFORMS......................................................................................................................................5 ARTICLE VII — WORK SCHEDULE/COMPENSATORY PAY/TIME OFF.....................................................5 A. WORK SCHEDULE ................................ :................................................................................................................ 5 B. ADMINISTRATIVE LEAVE/COMPENSATORY PAY...................................................................................................5 ARTICLE VIII — HEALTH AND OTHER INSURANCE BENEFITS .................................................................5 A. HEALTH................................................................................................................................................................6 1. Medical............................................................................................................................................................6 2. Dental..............................................................................................................................................................6 3. Vision...............................................................................................................................................................6 B. ELIGIBILITY CRITERIA AND COST.........................................................................................................................6 1. Cit>> Paid Medical and Dental Insurance - Dependents....................................................I.............................6 2. City's Contribution to Health Insurance Premiums ...................... :................................................................. 6 3. .Section 125 Plan..............................................................................................................................................7 C. LIFE AND ACCIDENTAL. DEATH AND DISMEMBERMENT................................................................:.......................7 D. LONG TERM DISABILITY INSURANCE....................................................................................................................7 E. MISCELLANEOUS..................................................................................................................................................8 1. City Paid Premiums I417ile on Medical Disabilitv.......................................................... .................... :............ 8 2. Insurance and Benefits Advisory Committee...................................................................................................8 01-02 FMA MOU i 04/02/02 8:31 AM FIRE MANAGEMENT ASSOCIATION Res. No. 2002-32 MEMORANDUM OF UNDERSTANDING Ex. A TABLE OF CONTENTS Page 3. Health Plan Over-Payments............................................................................................................................8 ARTICLE IX - LEAVE BENEFITS........................................................................................................................10 A. GENERAL LEAVE................................................................................................................................................10 1. Accrual..........................................................................................................................................................10 2. Eligibility and Approval................................................................_...............................................................10 3. Conversion to Cash.......................................................................................................................................10 B. SICK LEAVE......................................................................................................................................................... I 1 C. BEREAVEMENT LEAVE........................................................................................................................................ I ARTICLE X — CITY RULES...................................................................................................................................13 A. PERSONNEL RULES.............................................................................................................................................13 ARTICLEXI -- MISCELLANEOUS......................................................................................................................30 A. VEHICLE POLICY.................................................................................................................................................30 B. DEFERRED COMPENSATION LOAN PROGRAM.....................................................................................................30 ARTICLE XII — CITY COUNCIL APPROVAL...................................................................................................31 LIST OF MOU EXHIBITS.......................................................................................................................................32 EXHIBIT A - FIRE MANAGEMENT ASSOCIATION SALARY SCHEDULE ................................................ 33 EXHIBIT B - RETIREE SUBSIDY MEDICAL PLAN ............................................... .........34 ................................ EXHIBIT C — EMPLOYEE HEALTH PLAN BROCHURE................................................................................42 EXHIBIT D - DELTA CARE (PMI) DENTAL PLAN BROCHURE..................................................................43 EXHIBIT E - DELTA DENTAL PLAN BROCHURE.........................................................................................44 EXHIBIT F - SAFEGUARD DENTAL PLAN BROCHURE...............................................................................45 EXHIBIT G - VISION (VSP) PLAN BROCHURE...............................................................................................46 01-02 FMA MOU ii 04/02/02 8:31 AM Res. No. 2002-32 MEMORANDUM OF UNDERSTANDING Ex.A BETWEEN THE CITY OF HUNTINGTON BEACH, CALIFORNIA (Herein Called CITY) AND THE HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION (Hereinafter Called ASSOCIATION) 11102FI II- 014 WHEREAS the designated representative of the City of Huntington Beach and the Huntington Beach Fire Management Association have met and conferred in good faith with respect to salaries, benefits and other terms and conditions of employment for the employees represented by the Association; Except as expressly provided herein, the adoption of this Memorandum of Understanding shall not change existing terms and conditions of employment, which have been established for the classification represented by the Huntington Beach Fire Management Association. 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 on December 20, 2002. ARTICLE II — REPRESENTATIONAL UNIT It is recognized that the Huntington Beach Fire Management Association is the employee organization which has the right to meet and confer in good faith with the City on behalf of represented employees of the Huntington Beach Fire Department within the classification titles of Fire Division Chief and Fire Battalion Chief as outlined in Exhibit A attached hereto and incorporated herein. ARTICLE III — 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 be 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. MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A ARTICLE IV — SALARY SCHEDULES AND RETIREMENT A. Monthly Compensation Employees shall be compensated at hourly rates by job type and pay grade during the term of this Agreement as set out in Exhibit A attached hereto and incorporated herein unless expressly provided for in other articles of this Memorandum of Understanding. B. PERS Pickup Each employee covered by this Agreement shall be reimbursed bi-weekly in an amount equal to 9% of the employee's base salary and special pay 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. C. Self Funded Supplemental Retirement Benefit Employees hired prior to August 17, 1998 are eligible for the Self Funded Supplemental Retirement Benefit, which provides that: 1. 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, 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 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). 2. Employees hired on or after August 17, 1998 shall not be eligible for this benefit referenced in A.1.a. herein above. D. 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 01-02 FMA MOU 04/02/02 8:31 AM 2 MEMORANDUM OF UNDERSTANDING Res. No.2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A Retirees retiring after approval of this MOU may participate in the Retiree Medical Plan, attached hereto as Exhibit B, or the HMO Plan currently being offered to retirees, based upon the eligibility requirements described in Exhibit B. 2. 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. E. Public Employees' Retirement System Reimbursement and Reporting 1. Level III Survivors Benefits Unit employees shall be covered by the 1959 PERS Level III Survivor Benefit. 2. Rollover No unit employee shall be allowed to continue the rollover benefit provided in Article XI (13)(2) of the 1991/1993 Management Employees Organization MOU beyond January 31, 1994. F. Direct Deposit All FMA represented employees shall be required to utilize direct deposit of payroll checks effective April 26, 2002. ARTICLE V — 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 an 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 01-02 FMA MOU 04/02/02 8:31 AM 3 MEMORANDUM OF UNDERSTANDING Res,. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A 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. B. Holiday Pay -In -Lieu Employees shall be compensated by the City in lieu of the ten listed holidays at the rate of 3.0768 hours multiplied by the employee's hourly salary rate set forth in Exhibit A, payable each and every pay period. The following are the recognized legal holidays under this MOU: 1. New Year's Day (January 1) 2. Martin Luther King's Birthday (third Monday in January) 3. President's 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. Friday after Thanksgiving 10. Christmas Day (December 25) 11. Any day declared by the President of the United States to be a national holiday, or by the Governor of the State of California to be a state holiday, and adopted as an employee holiday by the City Council of Huntington Beach. Holidays which fall on Sunday shall be observed the following Monday, and those falling on Saturday shall be observed the preceding Friday. Employees designated by the Fire Chief who are required to work regular shifts on the above listed holidays as set forth in this Article, shall not be entitled to time off or overtime. Subject to State Law and Regulations, compensation paid as a result of Article VB shall be reportable to PERS as salary. 01-02 FMA MOU 04/02/02 8:31 AM 4 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A C. Bilingual Skill Pay Permanent employees who are qualified to use Spanish, Vietnamese, or Sign Language skills 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. I Such employees shall receive the additional five percent (5%) for every bi-weekly pay period that the assignment is in effect. In order to be qualified for said compensation, employee's language proficiency will be tested and certified by the Human Resources Officer or designee. ARTICLE VI — UNIFORMS The 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 VII - WORK SCHEDULE/COMPENSATORY PAY/TIME OFF A. Work Schedule Members assigned to non -suppression staff assignments shall work four (4) days per week, ten (10) hours each day, meal times to be included during the ten hour shift. B. Administrative Leave/Compensatory Pay 1. Members working suppression duties earn compensatory pay or compensatory time off, on an hour for hour. basis, for hours worked in addition to their regular schedule, subject to the limitations contained in Article VII.B 3. below. 2. Members shall work thirty-five (35) hours of non -suppression overtime in a calendar year, before earning compensatory pay or compensatory time off, on an hour for hour basis, for hours worked in excess of their regular normal work schedule. 3. Compensatory Pay a. Compensatory pay is paid at the 40 hours straight time rate for each hour. b. Compensatory time earned can be converted to cash at the member's 40-hour straight time rate. c. Maximum accrual shall be 120. hours. ARTICLE Vill — HEALTH AND OTHER INSURANCE BENEFITS 01-02 FMA MOU 04/02/02 8:31 AM 5 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A 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 E) and a prepaid dental insurance plan comparable to the Delta Care Plan (Group Policy #4002, Exhibit D). 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 VIII.132. for dependent health and dental insurance effective the first of the month following one month of employment. For purposes of determining continuous service, there shall be no accrual of hours for the period of time an employee is on a non -pay status for a complete pay period. 2. City's Contribution to Health Insurance Premiums Monthly Premium City Plan Health Net Delta Dental Delta Care Safeguard VSP (Vision) Single $ 280.51 $ 236.51 $ 41.31 $ 23.00 $ 16.20 $ 17.58 Two Party 554.70 517.79 78.92 39.11 29.16 17.58 Family (3 or more) 679.15 682.46 112.10 59.81 37.22 17.58 01-02 FMA MOU 04/02/02 8:31 AM 6 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Res. No. 2002-32 Ex. A c. 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. 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. d. Medical Cash -Out: Employees covered by a medical program outside of a City -provided program (evidence of which must be supplied to Administrative Services Department, Employee Benefits), 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. 3. Section 125 Plan Employees may utilize this. plan, which allows employees to use pre-tax salary to pay for regular childcare, 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, 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. 01-02 FMA MOU 04/02/02 8:31 AM 7 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex.A 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 benefit 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. 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 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. 01-02 FMA MOU 04/02/02 8:31 AM 8 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A 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. 01-02 FMA MOU 04/02/02 8:31 AM 9 MEMORANDUM OF UNDERSTANDING Res. No.2oo2-s2 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A ARTICLE IX - LEAVE BENEFITS A. General Leave 1. Accrual Employees accrue general 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. Generalleave 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 on a 40-hour schedule shall not accrue general leave in excess of six hundred hours (600), 56-hour members shall not accrue general leave in excess of eight hundred and forty hours (840). 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. Medical Premium Conversion Employees electing to participate in the City's group medical plan after retirement may cause the premiums to be paid by the City out of any available funds due and owing them under terms of the agreement for unused sick leave or general leave benefits upon retirement. 01-02 FMA MOU 04/02/02 8:31 AM 10 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A B. Sick Leave 1. Accrual No employee shall accrue sick leave after December 24, 1999. 2. Credit Employees assigned to FMA 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 the employee's assignment to FMA. 4. Family Sick Leave Forty (40) Hour Employees — 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 forty (40) hours per calendar year. Twenty -Four (24) Hour Employees — Twenty-four (24) hour shift employees shall be entitled to charge up to three (3) shifts per calendar year of sick leave for family sick leave. 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 industrial or non -industrial 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 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 current 40-hour equivalent rate of pay for fifty percent (50%) of all unused, accumulated sick leave. The maximum number of hours paid off at termination will be a total of 720 hours. Example: Employee has 1920 hours of accured sick leave. 1920 hours multiplied by 50% equals 960 hours. Maximum pay off is 720 hours. 01-02 FMA MOU 04/02/02 8:31 AM 11 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A Pay off equals 720 hours multiplied by the employee's current 40-hour equivalent pay rate. 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 40- hour equivalent 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 FMA MOU 04/02/02 8:31 AM 12 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A C. Bereavement Leave Employees shall be entitled to bereavement leave not to exceed two (2) work shifts for employees on a 24-hour work schedule or three (3) working days in case of death in the immediate family. "Immediate family is defined as spouse, father, stepfather, mother, stepmother, sisters, brothers, stepsisters, stepbrothers, mother-in-law, father-in-law, children, stepchildren, grandchildren and grandparents of the employee or spouse. D. Paternity Leave Fathers may utilize accumulated sick leave in addition to general leave and compensatory time, 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 X — 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. b) 5-14 — Promotional Exams 01-02 FMA MOU 04/02/02 8:31 AM 13 MEMORANDUM OF UNDERSTANDING Res. No.2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A Promotional examinations may be conducted whenever, in the opinion of the Human Resources Officer, r 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 contendere, 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 his/her 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 FMA MOU 04/02/02 8:31 AM 14 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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 the 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 FMA MOU 04/02/02 8:31 AM 15 MEMORANDUM OF UNDERSTANDING Res. No.2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A 5. Rule 14 — Additional Pay and Pay Adjustments a) 14-6 — 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 01-02 FMA MOU 04/02/02 8:31 AM 16 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION. Ex.A defined above. Industrial accident Leave compensation will terminate on the earliest of the following: 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 (10) days of the claim or such commencement. The City retains its rights of subrogation in all such instances. b) 18-19 — Maternity Leave 01-02 FMA MOU 04/02/02 8:31 AM 17 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATIONRes. No. 2002-32 . A 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 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 the 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. 01-02 FMA MOU 04/02/02 8:31 AM 18 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex..A 2) Step 5 — Personnel Board Hearing Hearing. As soon as practicable thereafter, the Personnel Director 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 -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 — Disciplinary 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. 01-02 FMA MOU 04/02/02 8:31 AM 19 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex.A 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. 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 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. 01-02 FMA MOU 04/02/02 8:31 AM 20 MEMORANDUM OF UNDERSTANDING Res. No.2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex.A 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 an appeal to the Personnel Commission. 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. 01-02 FMA MOU 04/02/02 8:31 AM 21 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A 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: 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 modification(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. 01-02 FMA MOU 04/02/02 8:31 AM 22 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A 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. 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 Personnel 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. 01-02 FMA MOU 04/02/02 8:31 AM 23 MEMORANDUM OF UNDERSTANDING Res. No. A02-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A 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 senioremployee. 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: 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 bumping 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. 01-02 FMA MOU 04/02/02 8:31 AM 24 MEMORANDUM OF UNDERSTANDING Res. No.2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A 2. Order of Layoff 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. 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 Personnel 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 rights. 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 Personnel Director in writing if the employee intends to exercise the employee's bumping rights, if any, pursuant to Part 2, Bumping Rights. 01-02 FMA MOU 04/02/02 8:31 AM 25 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A 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 be 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 Personnel Director 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 Personnel Director 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 employee notifies the Personnel Director 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 Personnel Director's 01-02 FMA MOU 04/02/02 8:31 AM 26 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A 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 Personnel Director's decision, the employee may appeal pursuant to the provisions of Sections 3 and 4 below. b) Reinstatement/Re-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 possess the necessary qualifications to successfully perform the duties of the lower position may appeal the decision. The appeal shall be filed with the Personnel Director 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 Hearin 1) Upon receipt of an appeal, the Personnel Director 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 01-02 FMA MOU 04/02/02 8:31 AM 27 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A 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. 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 (5) 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. 5) Re-employment lists shall be available to HBMEA 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 after layoff in the manner and amount set forth in existing 01-02 FMA MOU 04/02/02 8:31 AM 28 MEMORANDUM OF UNDERSTANDING Res. No.2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A 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. 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. 01-02 FMA MOU 04/02/02 8:31 AM 29 MEMORANDUM OF UNDERSTANDING Res. No.2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A ARTICLE XI -- MISCELLANEOUS A. Vehicle Policy 1. Approval is required by the City Administrator or his designee.for any City vehicle to be taken home by a FMA employee. 2. The auto allowance for qualifying members shall.be one -hundred sixty-one dollars and fifty-three cents ($161.53) bi-weekly. 3. The monthly automobile allowance shall not be reduced during the term of this agreement. 4. Eligibility for automobile allowance shall be determined in accordance with the Administrative Regulation, Vehicle Use Policy and the City's Fleet Management Program. 5. Unit members agree to all provisions of the City's Fleet Management Program dated August 1999. B. Deferred Compensation Loan Program Unit members may borrow up to 50% of their deferred compensation funds for critical needs such as medical costs, college tuition, or purchase of a home, pursant to program standards and regulations. 01-02 FMA MOU 04/02/02 8:31 AM 30 MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A ARTICLE XII — CITY COUNCIL APPROVAL It is the understanding of the City and the Association that this Memorandum of Understanding is of no force or effect whatsoever unless and until adopted by Resolution of the City Council of the City of Huntington Beach. IN WITNESS WHEREOF, the parties hereto have executed this Memorandum of Understanding this �4'1 day of Ate_, 2002. HUNTINGTON BEACH CITY OF HUNTINGTON BEACH FIRE MANAGEMENT SOCIATION Ray Sil r Je(cqde<Pelletier City Administrator FMA President , - / William Workman Assistant City Adminis L Clay Dire( / Gregory i s ator FMA Vice P sident ran Duane Olsor}�/ P of Administrative Services Baraaininatkmmittee APPROVED AS TO FORM: argaining 44 2- �... Gail Hutton City Attorney mittee 01-02 FMA MOU 04/02/02 8:31 AM 31 FIRE MANAGEMENT ASSOCIATION MEMORANDUM OF UNDERSTANDING FMA LIST OF MOU EXHIBITS EXHIBITS SUBJECT A Class/Salary Schedule B Retiree Medical Plan and Subsidy Program C Employee Health Plan D Delta Care (PMI) Dental Plan E Delta Dental — Dental Plan F Safeguard Dental — Dental Plan G Vision Service Plan Res. No. 2002-32 Ex. A MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A EXHIBIT A - FIRE MANAGEMENT ASSOCIATION SALARY SCHEDULE Effective March 2, 2002 Step Job Code Classification Range A B C D E 0031 Fire Battalion Chief 577 38.78 40.91 43.16 45.53 48.03 0026 Fire Division Chief 609 45.47 47.97 50.61 53.39 56.33 01-02 FMA MOU 04/02/02 8:31 AM 33 MEMORANDUM OF UNDERSTANDING Res. No.2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A EXHIBIT B — 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 MEMORANDUM OF UNDERSTANDING Res. No.2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A EXHIBIT B — RETIREE SUBSIDY MEDICAL PLAN CONTINUED 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: 01-02 FMA MOU 35 04/02/02 831 AM MEMORANDUM OF UNDERSTANDING Res. No.2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A EXHIBIT B — RETIREE SUBSIDY MEDICAL PLAN CONTINUED Maximum Monthly Payment for Retirements After: Years of Service Subsidy 10 $ 121 11 136 12 151 13 166 14 1-81 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 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 FMA MOU 36 04/02/02 8:31 AM MEMORANDUM OF UNDERSTANDING Res. No.2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A INDEMNITY HEALTH PLAN, EMPLOYEES/RETIREES This summary lists only those benefit provisions that differ between active and subsidized Retiree Plans. 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. vGA0 13nn4 City Plan - Employees Non -Subsidized Retirees City Plan - Subsidized Benefits' COBRA -eligibles Retirees Deductible per person Deductible per family Maximum Out of Pocket Coinsurance PPO EPO $200 $500 $2000 per person $4000 per family YEAR 2002 90% of UCR 70% of UCR 200 $500 $2,000 per person $4000 per family 90% of UCR 70% of UCR 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. MEMORANDUM OF UNDERSTANDING Res. No.2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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. MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A EXHIBIT B — RETIREE SUBSIDY MEDICAL PLAN CONTINUED 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 includes Managed Health Network (MHN), Prescription Card System (PCS), Orange County Foundation for Medical Care (OCFMC). 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. 01-02 FMA MOU 39 04/02/02 8:31 AM MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Ex. A EXHIBIT B — RETIREE SUBSIDY MEDICAL PLAN CONTINUED b. HealthNet. c. Part A of Medicare for those retirees not eligible for paid Part 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: 01-02 FMA MOU 40 04/02/02 8:31 AM MEMORANDUM OF UNDERSTANDING Res. No. 2002-32 HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION E"• A EXHIBIT B — RETIREE SUBSIDY MEDICAL PLAN CONTINUED 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: 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 FMA MOU 41 04/02/02 8:31 AM Res. No. 2002-32 Ex. A EXHIBIT C — EMPLOYEE HEALTH PLAN BROCHURE A copy of the Employee Health Plan Brochure may be obtained from the Risk Management OR See City Clerk Vault File No. 720.20 Res. No. 2002-32 Ex. A EMPLOYEE IiV-5-11 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 y Reasonable charges. o N m O k O k N Revised April 2001. D N TABLE OF CONTENTS Highlights of the Employee Health Plan CoPaymcnt and Bencfit Percentages Definitions Persons Covered and Effective Dates Preferred Provider and Exclusive Provider Organization Deductibles and Out of Pocket Expenses Covered Medical Expenses Prescriptions Chiropractic and Physical Therapy Preventive Medical Care Well Baby Care General Exclusions and Limitations When You Have a Claim Claims Payment and Appeals Coordination with Other Plans Termination of Coverage Highlights of the Employee Health Plan 1 The Employee Health Plan was created for the purpose of providing medi- 2 cal benefits for eligible employees and their eligible dependents. 3 This section is intended only as A brief summary of the Plan's benefits. All maximums are per person unless specifically noted as per family. G Please refer to the subsequent sections for a more detailed description of covered expenses and benefits exclusions and limitations. Eligible Employees 8 A permanent City employee 10 Eligibility Date (See Persons Covered and Effective Dates section for enrollment details 12 and effective dates) 12 Open Enrollment The open enrollment period is the month of November. Coverage for a 12 participant enrolling during Open Enrollment will be effective Jan. 1. 12 Lifetime Maximum Benefit The lifetime maximum benefit is $1,000,000. This is the absolute limit on 13 what the Plan will pay for each participant's covered expenses. 15, Calendar Year Maximum Benefit The calendar year maximum benefits listed below are the limits on what 15 this Plan will pay for each participant's covered expenses in a calendar year for the corresponding type of benefit: 16 Mental/Emotional Disorder and or Substance Abuse: 17 Administered by Managed Health Network. No benefits available through the Employee Health Plan. Refer to MHN brochures for further informa- tion. Inpatient Hospitalization 100 days (during each period of disability) y Chiropractic Care $2,000 or 24 visits o l (whichever occurs first) o i � N Wellness Benefit $200 per year D N I Deductible: Per Person $250 Per Family $500 Out of Pocket: Per Person $2,000 Per Family $4,000 (Deductibles and Out of Pocket apply per calendar year) NOTE: The out of pocket expenses do not include any charges that ex- ceed Usual, Customary and Reasonable rates, any expenses for treatment of a mental/emotional disorder and/or substance abuse, charges for pre- scription drugs or the EPO copayments. Copayment and Benefit Percentage Benefits EPO% Description Annual Deductible None PPO% Non PPO% $250/$500 $250/$500 Office Visits $5 copay 90% 70% UCR Wellness No charge $200 max $200 max Inpatient $150 copay 90% 70% Hospitalization (day 1-4) then 100% Emergency Services $5 copay 90% 70% Outpatient Services $5 copay 90% 70% Durable Medical $5 copay ` 90% 70% Equipment Prescription -pharmacy $5 generic/$8 brand Prescription —mail order $4 generic/$6 brand 2 Definitions Calendar Year A period of twelve months commencing January 1 and ending December 31 of the same 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 treatment to reduce their disability and to enable them to live without cus- todialcare. Emergency A sudden, unexpected, acute illness or injury that, without immediate medical treatment, could result in death or cause impairment to bodily functions. Extended Care or Skilled Nursinp, Facility A licensed facility operating pursuant to law which is primarily engaged in providing skilled nursing care on an inpatient basis during the convales- 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 term include a facility that is primarily: e A rest home, retirement home or home for the aged 9 A school or similar institution - - Engaged in the care and treatment of substance abuse, or of mentally ill or senile persons • Engaged in custodial care Hospital An institution operated pursuant to law that is accredited by the appropri- ate national regulatory body for hospital accreditation. It must be primar- 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- cians and with 24 hour a day nursing services by registered graduate nurses. The definition of hospital shall not include any institution or part thereof which is used principally as a rest facility,extended care facility, y . nursing facility or facility for the aged. Z 0 N Inpatient r„ o A person who is confined in a hospital as a registered bed patient and who'n w is charged at least one day's room and board by the hospital. a N 3 Medical Necessary or Medical -Necessity Describes medical treatment that: • Is appropriate and consistent with the diagnosis • Is in accordance with accepted medical standards, it would not have been omitted without adversely affecting the patient's condition or the quality of medical care rendered . • Is not primarily custodial care Mental Health Disorder Any disorder characterized by abnormal functioning of the mind or emotions and in which psychological, intellectual, emotional or behav- ioral disturbances are the dominate features. Mental health disorders include mental disorders, mental illnesses, psychiatric illnesses, mental conditions and psychiatric conditions, whether organic or non -organic, whether biological, non -biological, genetic, chemical, or non -chemical origin, and irrespective of cause, basis or inducement. Nurse A licensed Registered Nurse (R.N.) or licensed Practical Nurse (LPN) or licensed Vocational Nurse (LVN) who does not live with the patient and is not a member of the family. Outl2atien 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. Phygician A duly licensed Doctor of Medicine (M.D.), Osteopath, Podiatrist, Chi- ropractor or any other practitioner providing a covered service and act- ing within the scope of his/her license. 4 Plan Administrator The Risk Management Division is the Plan Administrator for purposes of this Plan's claims administration. Retiree Any retired employee of the City who (a) has retired on a service or dis- ability retirement and (2) is not eligible for Medicare, and (3) has not at- tained age 65. Usual, Customary and Reasonable Charges made for medical services or supplies essential to the care of the participant will be considered reasonable and customary if they are the amount normally charged by the provider for similar services and supplies and do not exceed the amount ordinary charged by most providers of com- parable services and supplies in the geographic area where the services or supplies are received. Whether charges are reasonable and customary shall be determined by the Plan Administrator or its agent in its sole dis- cretion by use of any customary or accepted method. In determining whether charges are reasonable and customary, the Plan Administrator will give due consideration to the nature and severity of the condition be- ing treated and any medical complications or unusual circumstances that require additional time, skill or expertise. Persons Covered and Effective Date Those eligible are; All permanent employees and their spouses Their unmarried children to age 19 Unmarried children from age 19 to 25 if. (a) A full time student, or (b) Lives at home and is dependent upon his/her parent for at least 50% of his/her support New permanent employees are eligible to participate in the Employee Health Plan on the first of the month following 30 days from the date of hire. Effective Date of Dependent Coverage Check with the Human Resources Division when you want to enroll a new spouse or new child. Appropriate forms must be completed within 60 days of marriage, birth of a child or when the employee becomes legally responsible for an adopted child. Dependent coverage will be effective on the date of marriage, date of birth or the newborn child or the date of adoption or the date of placement of an adopted child in your home. Preferred Provider Organization (PPO) Exclusive Provider Organization (EPO) The Preferred Provider Organization (PPO) and Exclusive Provider Or- ganization (EPO) is a statewide network of physicians, hospitals and other health care providers established specifically to provide comprehensive medical service to Plan participants at reduced rates. As a participant in the Plan, you will receive a directory of providers that belong to the PPO and EPO networks. If you choose the PPO/EPO option, please follow the procedures for its use carefully. If your doctor refers you to another provider, make sure that the new provider is also an EPO or PPO before services arc rendered. 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 the time of your visit. PPO providers are required to submit their medical bills to the Employee Health Plan first. The Employee Health Plan will then calculate the Usual, Customary and Reasonable (UCR) rate and then 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 - payment and deductible if applicable. Change in Family Status If you go to an EPO, the provider may request payment of the $5 copay at Once you are enrolled in the Employee Health Plan, you must notify the the time of your visit. You are not responsible for any other charges other Plan Administrator or Human Resources Division within 60 days of any than the $5 copay. If you are admitted to a hospital, your copay will be family status change,. such as a newborn baby, or when you no longer need 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 ends. CD y Z 0 N O mC) X N Deductibles and Out of Pocket Expenses Deductibles and out of pocket expenses represent the portion that the par- ticipant pays for covered expenses. Tlus section generally describes these cost sharing provisions of the Plan. Calendar Year Deductible The calendar year deductible is the amount of covered expenses incurred by a participant during a calendar year for which no benefits will be paid. After you, or a covered dependent, has satisfied the calendar year deducti- 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. Three Month Carryover 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 y certain covered charges will be increased to a full one hundred percent J (1001/6). The one hundred percent (100%) will continue until the end of 1 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 mentaVemotional disorder and/or substance abuse, charges for prescription drugs, charges that exceed Usual, Customary and Reason- able charges, or the EPO copaymcnts. Family Out of Pocket Expense If the dollar amount of the family out of pocket expense amount, shown in the Highlights section, is satisfied by the combined covered expenses ap- plied to the individual out of pocket expense amount of several covered family members, no additional out of pocket expense 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 individ- ual out of pocket expense amount no additional covered expenses for that person will be counted towards the family out of pocket expense amount. z 0 N 0 N DN Covered Medical Expenses List of Covered Medical Expenses The following expenses are covered by the Plan. Reimbursement is based upon the lifetime maximum and calendar year limits, benefit percentages and other limitations previously described in the Highlights section. 1. Charges for services and supplies used in the administration of anesthesia, when not duplicated in the hospital charges. 2. Transportation by a professional ambulance service to a local hospital or convalescent facility for inpatient care, if medically necessary, or to the nearest hospital for emergency care. Ex- penscs for transportation by air will be covered only if an air am- bulance is medically necessary. The first $50 of charges will be paid at 100%. 3. Rental or durable medical equipment when such equipment is deemed medically necessary, including, but not limited to, a wheelchair, hospital bed, respirator, and equipment for the ad- ministration of oxygen. Such equipment may be purchased, if, in the judgment of the Plan Administrator, purchase of the equip- mcnt would be less expensive than rental or the equipment is not available for rental. 4. Hospital room and board, at the semi -private hospital room and board rate. If medical necessity requires an intensive care or in- termediate care unit, die Plan will cover the room and board rate charged by the hospital. 5. Other hospital services and supplies furnislied by the hospital for 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 and dispensed by a licensed pharmacist. 10. X-ray and. radium treatments, and treatments with other radioac- tive substances. 10 11. Speech therapy by a qualified speech therapist. The therapy must be to restore or rehabilitate speech loss due an. illness or in- jury, or due to surgery for an illness or injury. If speech loss is due to a congenital anomaly, surgery to correct the anomaly must have been performed prior to therapy. 12. Elective surgery for sterilization, including tubal ligation and va- sectomy. 13. Medical supplies necessary for treatment including but not lim- ited to, an electronic heart pacemaker, surgical dressings, casts, splints, and crutches. 14. Surgeon's fees for the performance of surgical procedures, in- cluding necessary related postoperative care by a physician, sub- ject to the reasonable and customary fees in the area 15. Wellness care (see Highlights section for details) 16. Chiropractic and Physical Therapy subject to Plan limitations 17. Occupational Therapy performed by a licensed occupational therapist and ordered by a physician. It must be considered pro- gressive therapy, not maintenance therapy, and must not be per- formed for the purpose of vocational rehabilitation. Covered ex- penses do not include either recreational programs or supplies used in occupational therapy. 18. Emergency services. In the event of emergency services, the Plan will pay at the PPO rate for Non PPO providers. Emergency service is defined as follows: services which are immediately required to treat a sudden serious and unexpected illness or in- jury, including services to alleviate pain associated with sudden, serious and unexpected illness and/or injury. N DN 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 $S for each generic drug prescription or $8 for each brand name drug prescription. No payments for any prescription drug shall be made Occupational Injuries or Illnesses. Any illness or injury arising out through the Employee Health Plan. Prescription drugs are available by mail of, or in the course of, employment is excluded. order at a cost of $4 for generic and $6 for brand name prescriptions. Claims Unnecessary 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- 2 times a week for the second month Bcnefitsare provided as follows: 3 times a week for the first month tcd due to an emergency or if surgery is performed within 24 hours. Once a week for the third month Excess of Usual. Customary 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 Hearing Aids, Examinations to determine the need for, or the proper Benefits will be provided to a maximum of 24 treatments per year or $2,000, adjustment of hearing aids, are excluded. 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 - Preventive Medical Care justment of, eyeglasses or contact lenses are excluded. Radial kcmtot- omy, Lasik and similar procedures are also excluded. Benefits will be provided up to $200 per person for preventive medical care Cosmetic Surgery. Charges in connection with cosmetic surgery arc per year. This care shall include preventive medical options such as an an- nual physical exam, PAP tests ,flu shots, chest x-rays, EKG, PSA and other excluded unless performed for the correction of functional disorders as a result of accidental injury occurring while the individuals are diagnostic tests if certified by the physician that such procedures are in- covered. eluded 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 1. Hospital admissions primarily for diagnostic study when in- 7 patient care would not otherwise have been required. y Three well baby examinations for an infant for the first year of life will be z 2. Custodial care o allowed subject to the $200 maximum benefit. All innoculations for infants/ 3. Personal or convenience items o children will be provided and coverage is not limited to the $200 maximum 4. Services or supplies not connected with the care and treat- x N benefit, merit of an actual illness, disease or injury D N 12 13 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Any illness or injury due to war, declared or undeclared, or any act of war is excluded Any means of artificial fertilization, including but not limited to artificial insemination, in -vitro fertilization or gamete intra- fallopian transfer Reversing prior surgical stcrili7mtion procedures Any charges for weight control or weight reduction program No benefits will be provided for any condition of pregnancy for dependent daughters. Sales tax on prescription drugs or on any other covered item No benefits will be provided for any mental health care. Mental health services are provided by Managed Health Network Treatment, services, equipment; new technology, drugs, proce- dures or supplies considered experimental or investigational at the time the procedure is performed or service or supply is pro- vided Air conditioners, dehumidifiers, air purifiers, arch supports, cor- rective or orthopedic shoes, heating pads, hot water bottles, home enema equipment, etc. are not covered. Any items for which the participant is not legally required to pay, or for which a charge would not have been made if the participant did not have this coverage. Benefits available under the Plan may be reduced or eliminated based upon the coordination of benefits or subrogation rules. Charges for failure to keep a scheduled visit, completion of claim forms or providing supplemental information. Charges for vitamins (except pre -natal vitamins), minerals, nutri- tional or food supplements or any other over the counter item. Any charges not. listed in 'Covered Expenses" Nursing Facility. Any services furnished by an institution which is primarily a place of rest, a place for the aged, a nursing or con- valescent home or any institution of like character, unless other- wise specifically provided for herein. Smoking cessation program. 14 When you have a Claim Before submitting a claim for medical expenses, review this brochure and the bills you have accumulated. Be sure you are submitted itemized bills for which benefits are payable. Save all of your bills, including those being accumulated to satisfy a de- ductible. In most instances they will serve as evidence of your claim. Submit the original bill, not a copy. Each bill must be complete and item- ized and should show the patient's full name, date or dates of service, na- ture of the illness or injury, and type of service provided. Claim forms are available in the Risk Management oii'ice. A separate claim form is re- quired for each family member. Please mail all completed forms to: City of Huntington Beach Employee Health Plan Risk Management Division 2000 Main Street Huntington Beach, CA 92648 All claims must be received no later thart 12 months from the date of ser- vice. Claims submitted after this time period will be rejected. Claims Payment and Appeals Notice of Decision A notice of decision will be sent to you within 30 days after receipt of a properly completed claim. If there is some reason your claim cannot be processed within that time, you will be given notice of the reason for the delay. Claim Anneal 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 documentation, will be submitted to Medical Review for review by physt- N 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 N than 120 days after receipt of the request. g DN 15 Coordination with Other Plans The Employee Health Plan contains a provision to prevent double pay- ment for covered expenses. This provision works by coordinating the benefits under this Plan wide other similar plans under which a person is covered, so the total benefits available will not exceed one hundred per- cent of allowable expenses. This provision is commonly called "Coordination of Benefits". When a claim is made, the primary plan (as described below) pays its benefits without regard to any other plans. The secondary plans adjust their benefits so that the total benefits available will not exceed the allow- able expenses. No plan pays more than it would otherwise pay without this coordination provision. A plan without a coordination of benefits provision is always die primary plan. If ail plans have such a provision: (1) the plan covering the patient directly (e.g., employee or retiree), rather than as a dependent, is primary and the others secondary: (2) if a child is covered under both parents' plans, the parent whose birthday falls earlier in die year is primary, or, if both parents have the same birthday, the plan covering the parent longer is primary, but when the parents are separated or divorced_, their plans pay in this order: (a) the plan of the parent with custody of the child; (b) the plan of the parent not having custody of the child (c) the plan of the spouse of the parent with custody of the child; , aid (d) the plan of the spouse of the parent not leaving custody of flee 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- mine which plan is primary, the allowable expenses shall be shared equally between the plans. 16 Termination of Coverage Coverage will terminate for an employee on the last day of the month in which employment terminates. Coverage for a dependent will cease on the earliest of the following: • Last day of the month in which the employee's coverage termi- nates • Date the dependent enters active service with the armed forces • Date the dependent ceases to be an eligible dependent For a dependent spouse, on the date of divorce • For dependent child/children, the date of the child's marriage or attainment of the maximum age limit of 25. Continuation of Benefits If a covered employee ceases active employment due to an authorized leave of absence, participation may, be continued'under COBRA or Family and Medical Leave Act (FMLA). Please refer any questions regarding the continuation of health insurance coverage to the Employee Benefits Divi- sion of the City of Huntington Beach. m z 0 N O m O 17 St w DN i� ORANGE COUNTY O C z 0 0 ZONE FOR MEDICAL CARE Res. No. 2002-32 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 bJEEDICAL CARE, (OCFMC) P.O. Box 1297 Orange, CA 92856-0297 (714) 978-5048 (800) 345-8643 Thank you for using the Orange County Foundation for Medical Care. Providers current as of 7-2-01 Res. No. 2002-32 Ex. A ,Y MEDiC.4 s o� 0' A ® 2 unded 1889 -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. 2002-32 NA LE F CONTENTS Ex. 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 .......... I. ..............8 RADIOLOGY/IMAGING FACILITIES ........................10 REHABILITATION FACILITIES .............................12 SKILLED NURSING FACILITIES ...........................12 URGENT CARE CENTERS ........ ...... ........... .12 PARTICIPATING PROVIDERS .............................15 INDEX............ ....... ..........................87 Res. No. 2002-32 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. HOVE' 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 your visit. 2 n N 7 - _ _ F 7 if' f � f Res. No. 2002-32 . Ex. A Benefits at a glance Bent Copaymen; 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 Surgery Covered In Full Emergency room services (waived if admitted) $35 Prescription drugs $3 Level I generic (per prescription) $5 Level II brand name For more information, set Principal benefits and Coverage,' page 3. This disclosure is only a summary ofyour health plan. Your Evidence of Coverage (EOC), which you will receive after you enroll contains the exact teens and conditions ofyour Health Net coverage. You should also consult the Plan Contract (issued to your employer) to determine governing contractual provisions. It is important for you to carefully read this document and your EOC thoroughly once received, especially those sections that apply to those with special health care needs. Res. No. 2D02-32 Ex. A Table of contents Delivering choices ..................................... 2 How the plan works......:...................I........ 2 Selection of physicians and Physician Groups How to choose a physician HMO specialist access How to enroll Principal benefits and coverage ................. 3 Services and copayments/coinsurance Limitsof Coverage .................................... 6 What's not covered Behavioral health services. ......................... 7 What's covered Continuation of treatment Health Net and your EAP What's not covered Prescription drug program ....................... 8 Prescriptions By Mail Drug Program The Health Net Recommended Drug List: Level I drugs (primarily generic) and Level II drugs (primarily brand name) What's covered What's not covered Benefits and coverage..............................11 What you pay for services Coverage for newborns Emergencies SB ID: 1%79 1 Exclusions and limitations Extension of benefits Confidentiality and release of member information Payment of fees and charges....................13 Prepayment fees Other charges Coordination of benefits Reimbursement provisions Provider referral and reimbursement disclosure Utilization management processes Termination of provider Second opinions Facilities... ............................... .. .15 Physician Group transfers Renewing, continuing or ending coverage ................................................16 Renewal provisions Individual continuation of benefits Termination of benefits If you have a disagreement with our plan........................................................17 Member grievance and appeals process Arbitration Delivering choices When it comes to your health care, the best decisions are made with the best choices. Health Net of California, Inc. (Health Net) provides you with ways to help you receive the care you deserve. This brochure answers. basic questions about this versatile plan. If you have further questions, just contact our Member Services department at 1-800-522-0088. Our friendly, knowledgeable representatives will be glad to help. Please read the following information so you will know from whom or whatgroup ofproviden health care may be obtained . Selection of physicians and Physician Groups 9 When you enroll with Health Net, you choose a contracting Physician Group. From your Physician Group, you select one doctor to provide basic health care; this is your Primary Care Physician. (See your Directory of Contracting Physician Groups for detailed information about physicians and Physician Groups in the Health Net network.) ,JV Whenever you or a covered family member needs health care, your Primary Care Physician will provide the medically necessary treatment. Specialist care is also available through your Health Net plan, when authorized in advance through your Primary Care Physician or Physician Group. You do not have to choose the same Physician Group or Primary Care Physician for all members of your family. Physician Groups, with names of physicians and specialists, are listed in the Health Net Directory of contracting Physician Groups. How to choose a physician Selecting a Primary Care Physician is important to the quality of care you receive. To ensure you are Res. No. 2002-32 Ex. A comfortable with your choice, we suggest the following. ,fl Discuss any important health issues with your selected Physician Group. ,v Do the same with the Health Net Coordinator at the Physician Group, and ask for referral specialist policies and hospitals used by the Physician Group. ,o To ensure that you and your family members have adequate access to medical care, select a doctor located within 30 miles of your home or work. HMO specialist access Health Net offers Rapid Access®, a service that makes it easy for you to quickly connect with a specialist in Health Net's network. Ask your group or check your Directory of contracting Physician Groups to see if your Physician Group allows "self -referrals" or "direct referrals" to specialists within the same group. Self - referral allows you to contact a specialist directly for consultation and evaluation. Direct referral allows your doctor to refer you directly to a specialist — without the need for Physician Group authorization. Information about your Physician Group's referral policies is also available to you on our Internet web site, www.healthnet.com. How to enroll We have enclosed an enrollment form in the enrollment packet. If a form is not included, please obtain one from your employer. Then, just complete the enrollment form and return it to your employer. Some Hospitals and other providers do not provide one or more of the following services that may be covered under your Evidence of Coverage and that you or your family member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion. You should obtain more information before you enroll. Call your prospective doctor, medical group, independent practice association, or clinic, or call Health Net's Member Services Department at 1-800-522-0088 to ensure that you can obtain the health care services that you need. 2 Res. No. 2002-32 Ex. A Principal benefits and coverage Yearly maximum copayment One member, $1500 Two members, $3000 Family (three members or more), $4500 Payments for services not covered by this plan will not be applied to the yearly maximum copayment. You will need to continue making payments for any additional ben ef is as described in the Additional Plan Benef &"section of this brochure. Services and copayments/coinsurance The following shows the services and copayments/coinsurance required for this plan. Preventive care' Adult and Child preventive care Periodic health evaluations X-ray and laboratory procedures Vision screenings and examinations Hearing screenings and examinations Immunizations Standard immunizations Immunizations required for job or foreign travel Visit to physician Visit to physician for treatment of Severe Mental lllness or Serious Emotional Disturbances of a Child 4 Vuit to facility Specialist consultations Allergy testing Injection services, including allergy injection services Maternity and pregnancy Prenatal and postnatal office visits Maternity care in hospital or skilled nursing facility Genetic testing of fetus Normal delivery, cesarean section, newborn inpatient care Treatment of complications of pregnancy, including medica*necessary abortions Physician visit to hospital for care of mother and newborn Circumcision of newborn males Elective abortions Covered In Full' Covered In Full Covered In Full Covered In Full Covered In Full 20% Covered In Full Covered In Full Covered In Full Covered In Full Covered In Full Covered In Full Covered In Full Covered In Full Cover ed In Full Covered In Full Covered In Full Covered In Full Covered In Full $150 Emergency and urgent care Emergency room (professional and facility charges) $355 Urgent care center (professional and facility charges) $355 Ambulance Covered In Full Air ambulance Covered In Full Surgery' Surgeon or assistant surgeon services Covered In Full Anesthetics Covered In Full 3 Services and copayments/coinsurance (continued) Res. No. 2oEX A Organ and bone marrow transplants (nonexperimental and noninvestigational) Hospital and skilled nursing facility stays Semi -private hospital room or intensive care unit with ancillary services (unlimited, except for non -severe mental illness and chemical dependency treatment) 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) ` Skilled nursing facility stay (100 day maximum each Calendar Year) Physician visit to hospital or skilled nursing facility Reproductive health Infertility services and supplies Hospitalization for infertility services Injections related to infertility services (Injections for Infertility are not covered if used in connection with services which are not covered.) Injectable contraceptives (including but not limited to Depo Provera) Sterilisation Vasectomy Tubal ligation Other services Physician home visit Home health visits Hospice services Rehabilitative therapy (includes physical, speech, occupational, and pulmonary rehabilitation and cardiac rehabilitation therapy) Durable medical equipment Covered In Full Covered In Full Covered in Full Covered In Full Covered In Full 50% 50% 50% Covered In Full $50. $150 $10 $106 Covered In Full Covered In Full 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 0 Res. No. 2002-32 Services and copayments/coinsurance (continued) Ex. A `Self -referrals are allowed for Obstetrician and Gynecological services includingpreventive care, pregnancy and gynecological ailments. Copayment requirements may differ dependingending on the service provided Refer to Principal benef is and coverages. " ' Surgery includes surgical reconstruction ofa breast incident to a mastectomy, including surgery to restore symmetry; also includes prothesu and treatment of physical complications at all stages of mastectomy, including lymphedemas. While Health Net and your Physician Group will determine the most appropriate services, the length of hospital stay wid be determined solely by your Physician. sProvided on the basis ofage, medical need and health status 'Please refer to the. Behavioral health services "section of this brochure for the definitions of Severe Mental Nness and Serious Emotional Disturbances ofa Child and for non -severe mental disorder benefits. S Copayments for emergency room or urgent care center visits will not apply if receive cart from a facility owned and operated by your medical group or if you are admitted as an inpatient directly from the emergency room or urgent care center. A visit to one ofyour medical group s facilities will be considered an office visit and the office visit copayment; ifany will apply. 6Copayments are required for each day on which home health visits occur on and after the 31st calendar day ofthe treatment plan. 5 Limits • ! Coverage What's not covered Limitations and exclusions Acupuncture p Allergy desensitizing serum p Artificial insemination for reasons not related to infertility p Conception by medical procedures (IVF, GIFT, and ZIFT) p Corrective or support appliances or supplies p Cosmetic services and supplies p Custodial or live-in care p Dental services p Disposable supplies for home use Eyeglasses and contact lenses Experimental or investigational procedures, except as set out under the "If you have a disagreement with our plan" section of this brochure 19 Food supplements p Genetic testing and diagnostic procedures, except for prenatal diagnosis of fetal genetic disorders in cases of high risk pregnancy p Hearing aids p Non -eligible institutions p Orthoptics (eye exercises) p Norplant and Norplant kits, unless medically necessary p Orthotic items for the foot p Personal or comfort items ,V Physical examinations for nonpreventive purposes p Pregnancy under surrogate arrangement when compensation is obtained for the surrogacy f� Private -rooms when hospitalized, unless medically necessary Res. No. 2002-32 Ex. A i p Private -duty nursing for hospital patients p Refractive eye surgery p Reversal of surgical sterilization p Routine physical examinations p Services performed by an immediate relative p Services and supplies not authorized according to procedures Health Net and the contracting Physician Group have established p Services received before effective date or after termination of coverage, except as specifically stated in Extension of Benefits in member's Evidence of Coverage p Sex change services p Treatment of jaw joint disorders or surgical procedures to reduce or realign the jaw, unless medically necessary p Treatment of obesity, weight reduction or weight management, except for treatment of morbid obesity as determined by Health Net The above is a partial list of the principal exclusions and limitations applicable to the medical portion of your Health Net plan. The Evidence of Coverage which you will receive if you enroll in this plan, will contain a fiill list. Note that specific items excluded above may be covered under this plan if your employer has purchased them as supplemental benefits. Additional. benefits The following plan benefits show the copayments required for optional benefits available with your plan. For a more complete description of copayments, and exclusions and limitations of service, please see your plan's Evidence of Coverage. 6 Res. No. 2002-32 Ex. A Behavioral health O services Health Net contracts with Managed Health Network, a specialized health care service plan which provides behavioral health services through a personalized, confidential and affordable mental health and chemical dependency care program. Just call the toll -free number shown on your Health Net ID Card before receiving care. What's covered Non severe Mental Disorders*** Inpatient (30-day Covered in full* maximum each Calendar Year) Outpatient (20 visit $30** maximum each (Individual session) Calendar Year) $15** (Group session) Severe Mental Illness and Serious Emotional Disturbances o a Child Inpatient Covered in full Outpatient Covered in full Chemical Dependency Rehabilitation Inpatient (30-day Covered in fiill* maximum each Calendar Year) Outpatient (20 visit $30** maximum each (Individual session) Calendar Year) $15** (Group session) Acute Care Detoxification Covered in full * Inpatient admission means any admission to a hospital day treatment program, residential treatment center or structured out program. In addition, inpatient mental health and chemical dependency are limited to a combined maximum number ofdays each Calendar Year. **Applicable only for outpatient counseling defined as individual office visits and group therapy sessions Group sessions are equal to half ofan individual session and count towards the visit m avimum. A misted appointment may result in a copayment 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 Calendaryear. ***The mental disorder copayments and day or visit limits will not apply for Severe Mental Illness or Serious Emotional Disturbances of a Child as defined below. Services for these conditions require whatever copayment would be required if the services were provided for a medical condition. Refer to the Principal benefits and coverage"section to determine the applicable copayment. All other mental disorders will be subject to. the copayments shown above.. Serious Emotional Disturbances of a Child Serious Emotional Disturbances of a Child is when a child under the age of 18 has one or more Mental Disorders identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, other than a primary substance use disorder or a developmental disorder, that result in behavior inappropriate to the child's age according to expected developmental norms. In addition, the child must meet one or more of the following: • As a result of the Mental Disorder, the child has substantial impairment in at least two of the following areas: self -care, school functioning, family relationships, or ability to function in the community; and either (i) the child is at risk of removal from home or has already been removed from the home or (ii) the Mental Disorder and impairments have been present for more than six months or are likely to continue for more than one year; • The child displays one of the following: psychotic features, risk of suicide or risk of violence due to a Mental Disorder; and/or • The child meets special education eligibility requirements under Chapter 26.5 (commencing with Section 7570) of Division 7 of Title 1 of the Government Code. Severe Mental Illness Severe Mental Illness includes schizophrenia, schizoaffective disorder, bipolar disorder (manic- depressive illness), major depressive disorders, panic disorder, obsessive -compulsive disorders, pervasive developmental disorder, autism, anorexia nervosa, and bulimia nervosa. 7 Continuation of treatment If you are in treatment for a mental health or chemical dependency problem, call the telephone number shown on your Health Net ID,card to receive assistance in transferring your care to a network provider. Health Net and your EAP If your employer offers an Employee Assistance Program (EAP), Health Net's mental health and chemical dependency program works in coordination with your company's EAP. You may be able to obtain a referral to a network provider from either the mental health and chemical dependency program or with the assistance of your EAP counselor. What's not covered Services or supplies excluded under behavioral health services may be covered under the medical benefits portion of your plan. Consult your plan's Evidence of Coverage for more information. Limitations and exclusions (In addition to the exclusion and limitations listed below, mental health and chemical dependency benefits are subject to the plan's general exclusions and limitations.) Congenital and/or organic disorders, including organic brain disease and mental retardation, except for some conditions when the level of severity meets the criteria of severe mental illness or serious emotional disturbances of a child as described in the Evidence of Coverage Experimental or investigational therapies 9 Marriage counseling, except when rendered in connection with services provided for a treatable mental disorder Nontreatable mental disorders 9 Private -duty nursing Services related to educational and professional purposes 9 Smoking cessation, weight reduction, obesity, stammering, sleeping disorders or stuttering Res. No. 2002-32 Ex. A ,o State hospital treatment, except as the result of an emergency or urgently needed care. ,o Stress, except when rendered in connection with services provided for treatable mental disorder IV Treatment of detoxification in newborns y1 Treatment, testing or screening of learning disabilities, except for some conditions when the level of severity meets the criteria of severe mental illness or serious emotional disturbances of a child as described in the Evidence of Coverage 10 Care for mental health care as a condition of parole or probation, or court -ordered testing for mental disorders, except when such services are medically necessary and subject to the plan's day or visit limits. Remember. This is only a summary. Please consult your Evidence of Coverage for specific information regarding your plan. Prescription drug program Health Net is contracted with many major pharmacies including Longs, Rite Aid, Sav-On, and Walgreens, and those located in the Albertson, BeLkir, Raley's, Ralphs, Safeway, Save Man and Vons/Pavilions supermarket chains. There are many other neighborhood pharmacies that are also part of our network. For a complete and up-to-date list of participating pharmacies, call Health Net Member Services. Prescriptions By Mail Drug Program If your prescription is for a maintenance medication (a drug that you will be taking for an extended period), you have the option of filling it through our convenient Prescriptions By Mail Drug Program. This program allows you to receive up to a 90-consecutive-calendar-day supply of maintenance medications. For complete information, call Health Net Member Services at 1-800-522-0088. W The Health Net Recommended Drug List: Level I drugs (primarily generic) and Level II drugs (primarily brand name) The Health Net Recommended Drug List is the approved list of medications covered for illnesses and conditions. .It was developed to identify the safest and most effective medications for Health Net Members while attempting to maintain affordable pharmacy benefits. We specifically suggest to all Health Net contracted Primary Care Physicians and specialists that they refer to this list when choosing drugs for patients who are Health Net members. When your physician prescribes medications listed in the Recommended Drug List, it ensures that you are receiving a high quality prescription medication that is also of high value. The Recommended Drug List is updated regularly, based on input from the Health Net Pharmacy and Therapeutics (P&T) Committee. These committee members are actively practicing physicians of various medical specialties and clinical pharmacists. Voting members are recruited from contracting Physician Groups throughout California based on their experience, knowledge and expertise..In addition, the P&T Committee frequently consults with other medical experts to provide additional input to the Committee. Updates to the Recommended Drug List are made as new clinical information and new drugs become available. The drug usage guidelines are reviewed and updated as new clinical information becomes available. In order to keep the List current, the P&T Committee evaluates clinical effectiveness, safety and. overall value through: • Medical and scientific publications • Relevant utilization experience • Physician recommendations To obtain a copy of Health Net's most current Recommended Drug List, please visit our web site at www.healthnet.com, or call Member Services at 1- 800-522-0088. 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 Res. No. 2002-32 Ex A authorization, Health Net will evaluate the information submitted and make a determination as based on established clinical criteria for the particular medication. The criteria used for prior authorization are developed and based on input from the Health Net P&T Committee as well as physician specialist experts. Your physician may contact Health Net to obtain the usage guidelines for specific medications. If authorization is denied by Health Net, you will receive written communication including the specific reason for denial. If you disagree with the decision, you may appeal the decision. The appeal may be submitted in writing, by telephone or through e-mail. We must receive the appeal within 60 days of the date of the denial notice. Please refer to your Health Net Evidence of Coverage for details regarding your right to appeal. To submit an appeal: • Call Health Net Member Services at 1-800- 522-0088 • Visit www.healthnet.com for information on e- mailing Member Services • Write to: Health Net Member Services P.O. Box 10348 Van Nuys, CA 91410-0348 What's covered Outpatient prescription medication: Recommended Drug List $3 for Level I drugs $5 for Level II drugs when generic equivalent is not commercially available $5 for Level II drugs when generic equivalent is commercially available, plus the difference in cost between the brand name drug and the generic equivalent. . Res. No. 2002-32 Ex A Note: ,6 Prescription drug refills are covered, up to a 30- consecutive-day supply per prescription at a Health Net contracted pharmacy for one copayment. ,o If the pharmacy's usual and customary charge is less than the applicable copayment, the Member will pay the pharmacy's usual and customary charge. Mail order drugs are covered up to a 90- consecutive-calendar-day supply. The Member is responsible for twice the applicable retail pharmacy copayment. However, when the retail pharmacy copayment is a percentage, the mail order copayment is the same percentage as the retail pharmacy copayment. 9 Drugs prescribed for treating organically based sexual dysfunction are subject to a 50% copayment. (Limited to two doses per week or eight tablets per month.) * A7 Oral drugs prescribed for treating infertility are subjectto a 50% copayment. 9 Oral contraceptives are covered. Vaginal contraceptives (diaphragms and cervical caps) are limited to one prescription per calendar year. Refer to your plan's Evidence of Coverage for information on contraceptives covered under the medical benefit. ,© The Level II drug copayment applies for each 30- day supply of insulin and diabetic supplies (including but not limited to -blood glucose monitoring strips, pen delivery system, insulin needles and syringes) listed on the Recommended Drug List. Lancets are dispensed at no charge. See Diabetic equipment under the "Principal benefits and coverage" section of this brochure for additional benefit information. 9 Diabetic supplies (blood glucose testing strips, lancets, needles and syringes) are packaged in 50, 100 or 200 unit packages. Packages cannot be "broken" (i.e. opened in order to dispense the product in quantities other than those packaged). What's not covered Limitations and exclusions (In addition to the exclusion and limitations listed below, prescription drug benefits are subject to the plan's general exclusions and limitations.) ,o Allergy serum*** p Contraceptives such as, contraceptive foams, abortifacients or menstrual induction drugs p Cosmetics, health or beauty aids, or drugs prescribed for cosmetic reasons, including drugs prescribed for baldness or to eliminate wrinkles ,9 Devices or appliances Drugs that are appetite suppressants or are indicated for and prescribed for body weight reduction, except when prescribed for the treatment of morbid obesity as an alternative to surgery and approved by Health Net Drug products that help you reduce or quit smoking or for nicotine addiction (e.g., nicotine patches) 10 Drugs or medicines administered by a physician or physician's staff member** Drugs prescribed for non -organically based sexual dysfunction, including drugs that establish, maintain, or enhance sexual function or satisfaction ,7 Experimental drugs (those that are labeled "Caution - Limited by the Federal Law to investigational use only"), except as set out under the "If you have a disagreement with our plan" section of this brochure ,9 Hypodermic needles or syringes, except for insulin needles, syringes and pen devices ,6 Immunizing agents, injections (except for insulin), agents for surgical implantation, biological sera, blood, blood derivatives or blood plasma** 9, Individual doses of medication dispensed in plastic, unit dose, or foil packages unless . medically necessary or only available in that form ,v Limits on quantity, dosage and treatment duration may apply to some drugs 10 Over-the-counter drugs, equipment, supplies or drugs where there is a non-prescription equivalent available, except for drugs and supplies used for the treatment or management of diabetes , 7 Oxygen" Prescription drugs filled at pharmacies that are not in the Health Net pharmacy network except in emergency or urgent care situations Prescription drugs prescribed by a physician other than your Primary Care Physician or specialist you have received authorization to see, except in emergency or urgent care situations ,v Replacement of lost, stolen or damaged medications Services or supplies for which there is no charge, or for which you are not legally required to pay fJ Supply amounts (for any number of days) which exceed the Food and Drug Administration's or Health Net indicated usage guidelines *Must be approved by Health Net and your Physician Group. **These items are covered under the medical coverage portion of your plan ***These items are covered under the medical coverage portion of your plan only if your employer has purchased the coverages This is only a summary. Consult your plan's Evidence of Coverage to determine the exact terms and conditions of your coverage Benefits ! coverage What you pay for services The comprehensive benefits of your Health Net plan are described in the "Principal benefits and coverage" section. Please take a moment to look it over. Coverage for newborns Children born after your date of enrollment are automatically covered at birth. To continue coverage, Res. No. 2002-32 Ex. A the child must be enrolled through your employer before the 30d day of the child's life. If Health Net does not receive a newborn's enrollment form within 30 days of the child's birth: * coverage will end the 31 st day after birth; and ,v you will have to pay your Physician Group for A medical care provided after the 30th day of your baby's life. Emergencies Health Net covers emergency and urgently needed care throughout the world. If you are injured, feel severe pain, begin active labor or experience an unexpected illness that a reasonable person with an average knowledge of health and medicine would believe requires immediate treatment to prevent serious threat to your health (including Severe Mental Illness and Serious Emotional Disturbances of a Child), seek care where it is immediately available. Depending on your circumstances, you may seek this care by going to your physician group (medical) or the Behavioral Health Administrator (mental illness and chemical dependency), to the nearest emergency facility or by calling 911. You are encouraged to use appropriately the 911 emergency response system, in areas where the system is established and operating, when you have an emergency medical condition (including Severe Mental Illness and Serious Emotional Disturbances of a Child) that requires an emergency response. All ambulance and ambulance transport services provided as a result of a 911 call will be covered, if the request is made for an emergency medical condition (including Severe Mental Illness and Serious Emotional Disturbances of a Child). 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 Physician Group (medical) or the Behavioral Health Administrator (mental illness and chemical dependency), otherwise, it will not be covered by Health Net. Exclusions and limitations. For information on exclusions and limitations applicable to all of the services and benefits provided 11 under this plan, please review the "Principal benefits and coverage" section of this brochure. This plan does not cover any medical treatment you received before coverage begins under this plan or any services you may receive after your coverage under this plan ends. For further information, please refer to the Evidence of Coverage. Extension of benefits If you or a covered family member is totally disabled when your employer ends its group services agreement with Health Net, we will cover the treatment for the disability until one of the following occurs: a maximum of 12 consecutive months elapses from the termination date g available benefits are exhausted the disability ends ,PY the member becomes enrolled in another plan that covers the disability If you are hospitalized on the date your coverage ends, you will be covered until the discharge date. If you are not hospitalized, your application for an extension of benefits for disability must be made to Health Net within 90 days after your employer ends its agreement with us. We will require medical proof of the total disability at specified intervals. Confidentiality and release of member information Health Net knows that personal information in your medical records is private. Therefore, we protect your personal health information in all settings. As part of the application or enrollment form, Health Net members sign a routine consent to obtain or release their medical information. This consent is used by Health Net to ensure notification to and consent from members for present and future routine needs for the use of personal health information. This consent includes the obtaining or release of all records pertaining to medical history, services rendered or treatment given to all subscribers and members under the plan for the purpose of review, Res. No. 2002-32 Ex. A investigation or evaluation of an application, claim, appeals (including the release to an independent reviewer organization) or grievance, or for preventive health or health management purposes. We will not release your medical records or other confidential information to anyone such as employers or insurance brokers, who is not authorized to have that information. We will only release information if you give us special consent in writing. The only time we would release such information without your special consent is when we have to comply with a law, court order, or subpoena. Often, Health Net is required to comply with aggregated measurement and data reporting requirements. In those cases, we protect your privacy by not releasing any information that identifies our members. Technology assessment New technologies are those procedures, drugs or devices that have recently been developed for the treatment of specific diseases or conditions, or are new applications of existing procedures, drugs or devices. New technologies are considered investigational or experimental during various stages of clinical study as safety, and effectiveness are evaluated and the technology achieves acceptance into the medical standard of care. The technologies may continue to be considered investigational or experimental if clinical study has not shown safety or effectiveness or if they are not considered standard care by the appropriate medical specialty. Approved technologies are integrated into Health Net Benefits. Health Net determines whether new technologies should be considered medically appropriate, or investigational or experimental, following extensive review of medical research by appropriately specialized physicians. Health Net requests review of new technologies by an independent, expert medical reviewer in order to determine medical appropriateness or investigational or experimental status of a technology. or procedure. The expert medical reviewer also advises Health Net when patients require quick determinations of coverage, when there is no guiding principle for certain technologies, or .when the complexity of a patient's medical condition requires expert evaluation. 12 Payment of fees and charges Prepayment fees Your employer will pay Health Net your monthly premiums for all enrolled family members. Check with your employer regarding any share that you may be required to pay. If your share ever increases, your employer will inform you in advance. Other charges You are responsible for payment of your share of the cost of services covered by this plan. Amounts paid by you are called copayments or coinsurance, which are described in the "Principal benefits and coverage" section of this brochure. Beyond these charges the remainder of the cost of covered services will be paid by Health Net. When the total amount of copayments you pay equals the maximum copayment liability limit shown in the Evidence of Coverage, you will not have to pay additional copayments for the rest of the year for most services provided or authorized by your Physician Group. Certain copayments paid will not be applied to the maximum copayment liability limit. Additionally, copayments for any covered supplemental benefits purchased by your employer, such as prescription drugs or eyewear, will also not be applied to the limit with the exception of copayments for diabetic supplies. Please read the Evidence of Coverage for more information. Coordination of benefits When you are covered by another group health plan, Health Net will coordinate benefits with that plan. In doing so, we will comply with state laws that govern this activity. Both coverages combined will pay no more than the expenses that were incurred. Medicare coordination When, according to federal law, Medicare is the primary payor, Health Net or your Physician Group will coordinate payment with Medicare. If you have Res. No. 2002-32 questions about Medicare eligibility rules, contact A your local Social Security office. Liability of subscriber or enrollee for payment If you receive health care services from doctors without receiving required authorization from your Primary Care Physician or Physician Group (medical) or the Behavioral Health Administrator (mental illness and chemical dependency), you are responsible for payment of expenses for these services. Remember services are only covered when provided or authorized by a Primary Care Physician or Physician Group, except for emergency or out -of - area urgent care. Consu'_t the Directory of Contracting Physician Groups for a full listing of Health Net -contracted physicians. Third -parry liability If you receive medical services under this plan because of an injury caused by someone else and that person compensated you for the injury, you will be required to reimburse Health Net. or your Physician Group for medical services received as a result of the injury. Continuity of care If you are receiving ongoing medical care at the time of your enrollment with Health Net, and you are concerned about transferring your care to your selected Physician Group, we may temporarily cover all or part of your expenses for services from a provider not affiliated with Health Net under the following situations: p if medical services provided by your current physician or other provider are not covered by Health Net ,O if changing providers right away may have a negative effect on your health If you feel that your medical condition might require special attention as you switch to Health Net, tell your employer or a Health Net representative prior to enrollment, and no later than 15 days from the effective date of your Health Net coverage. To request a copy of our continuity of care policy, . please call Member Services at 1-800-522-0088. 13- Medically necessary care All services that are medically necessary will be covered by your Health Net plan (unless specifically excluded under the plan). All covered services or supplies are listed in your Evidence of Coverage booklet; any other services or supplies are not covered. Reimbursement provisions Payments that are owed by Health Net for services provided by or through your Physician Group will never be your responsibility. If you have out-of-pocket expenses for covered services, call out Member Services department for a claim form and instructions. You will be reimbursed for these expenses less any required copayment. (Remember: you do not need to submit claims for medical services provided by your Primary Care Physician or Physician Group.) If you receive emergency services not provided or directed by your Physician Group (medical) or the Behavioral Health Administrator (mental illness and chemical dependency), you may have to pay at the time you receive service. To be reimbursed for these charges, you should obtain a complete statement of the services received and, if possible, a copy of the emergency room report. Please contact Member Services to obtain claim forms, and to find out whether you should send the completed form to your Physician Group (medical) or the Behavioral Health Administrator (mental illness and chemical dependency) or to Health Net. Claims must be received by Health Net within one year of the date of service to be eligible for - reimbursement. Provider referral and reimbursement disclosure If you are considering enrolling in our plan, you are entitled to ask if the plan has special financial arrangements with our physicians that can affect the use of referrals and other services you may need. Health Net uses financial incentives and various risk sharing arrangements when paying providers. To get this information, call Health Net's Member Services at 1-800-522-0088, your physician or your Primary Care Physician and request information about our physician payment arrangements. Res. No. 2002-32 Ex. A Utilization management processes Utilization Management is an important component of health care management. Through the processes of pre -authorization, concurrent and retrospective review and care management, we evaluate the services provided to our members to be sure they are medically necessary and appropriate for the setting and time. This oversight helps to maintain Health Nees high quality medical management standards. Pre Authorization Certain proposed services may require an assessment prior to approval. Evidence -based criteria are used to evaluate that the procedure is medically necessary and planned for the appropriate setting (i.e., inpatient, ambulatory surgery, etc.). Concurrent Review This process continues to authorize inpatient and certain outpatient conditions on a concurrent basis while following a member's progress, such as during inpatient hospitalization or while receiving outpatient home care services. Discharge Planning This component of the concurrent review process ensures that planning is done for a member's safe discharge in conjunction with the physician's discharge orders and to authorize post hospital services when needed. Retrospective Review This medical management process assesses the appropriateness of medical services on a case -by -case basis after the services have been provided. It is usually performed on cases where pre -authorization was required but not obtained. Care or Case Management Nurse Care Managers provide assistance, education and guidance to members (and their families) through major acute and/or chronic long-term health problems. The care managers work closely with members and their physicians and community resources. If you would like additional information regarding Health Net's Utilization Management Process, please call Member Services at 1-800-522-0088. 14 Termination of provider If Health Nees contract with a Physician Group or other provider is terminated, Health Net will transfer any affected members to another contracted Physician Group or provider to ensure that care continues. Health Net will pay for services or supplies your plan covers, until Health Net has been able to arrange medically appropriate care by another provider. In addition, the member may elect continued care if at the time of termination the member was receiving care for: 9 an acute or serious chronic condition ,o a high -risk pregnancy ,V a pregnancy that has reached the second trimester If you would like more information on how to request continued care, please contact Health Net's Member Services department at 1-800-522-0088. Second opinions You have the right to request a second opinion when: ,v Your Primary Care Physician or a referral Physician gives a diagnosis or recommends a treatment plan that you are not satisfied with, or ,fl You are not satisfied with the result of treatment you have received, or ,o You are diagnosed with, or a treatment plan is recommended for, a condition that threatens loss Of life, limb, or bodily function, or a substantial impairment, including but not limited to a serious chronic condition, or 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 Net's second opinion policy, contact the Member Services Department at 1-800-522-0088. Res. No. 2002-32 Ex. A Facilities Health care services for you and eligible members of your family will be provided at: p the facilities of the Physician Group you selected' at enrollment; or p a nearby Health Net- contracted hospital, if hospitalization is required Many Health Net contracting Physician Groups have either a physician on call 24 hours a day or an urgent care center available to offer access to care at all times. The Physician Group you choose will also have a contractual relationship with local hospitals (for acute, subacute and transitional care) and skilled nursing facilities. These are listed in your Directory of contracting Physician Groups. Physician Group transfers You may switch doctors within the same Physician Group at any time. You may also transfer to another Physician Group monthly. Simply contact Health 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 I of the second following month. Transfer requests will generally be honored, unless you are more that three months pregnant, confined to a hospital, in a surgery follow-up period or receiving treatment for an acute illness. (However, Health Net may approve transfers under these conditions for certain unusual or serious circumstances.) 15 Res. No. 2002-32 Ex. A Renewing, continuing or ending coverage Renewal provisions The contract between Health Net and your employer is usually renewed annually. If your contract is amended or terminated, your employer will notify you in writing. Individual continuation of benefits If your employment with your current employer ends, you and your covered family members may qualify for continued group coverage under COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985). If you are over age 60, an additional period of coverage may be available under state law. For more information, ask your employer. Also, if you become ineligible for group coverage, you may convert from group coverage to a type of individual coverage called conversion coverage. Application must be made within 31 days of the date group coverage ends. Please contactMember Services for information about conversion plan coverage. Furthermore, you may be eligible for continued coverage for a disabling condition (for up to 12 months) if your employer terminates its agreement 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: fJ the agreement between the employer covered under this Health Net plan and Health Net ends fl the employer covered under this Health Net plan fails to pay subscription charges fJ you cease to either live or work within Health Net's service area ,o you no longer work for the employer covered under this Health Net plan Also, coverage under this Health Net plan may be terminated for an enrollee who: ,7 acts in a disruptive manner while receiving care 9 allows someone else to use his or her Health Net identification card p fails to make appropriate copayments or payment for noncovered services A knowingly provides incorrect information to Health Net or to his or her Health Net doctor p refuses to establish and maintain a relationship with his or her doctor to assure continuity of health care and appropriate use of covered services Note: If the person involved in any of the above activities is the enrolled employee, coverage under this plan will terminate as well for any covered dependents. If the employer covered under this Health Net plan does not pay appropriate subscription charges, benefits will end on the last day for which subscription charges have been made, unless: you apply for conversion coverage within 31 days of that date y� you are hospitalized (coverage will continue until you are discharged from the hospital) ,v you are totally disabled and apply for an extension of benefits for the disabling condition within 90 days 16 If you have a disagreement with our plan The California Department of Managed Health Care is responsible for regulating health care service plans. The Department has a toll -free telephone number (1- 888-HMO-2219) to receive complaints regarding health plans. The hearing and speech impaired may use the California Relay Service's toll -free numbers (1-800-735-2929 [TTY] or 1-888-877-5378 [TTY]) to contact the Department. The Department's Internet web site (http://www.hmohelp.ca.gov) has complaint forms and instructions online. If you have a grievance against your health plan, you should first telephone your plan at (1-800-522-0088) and use the plan's grievance process before contacting the Department. If you need help with a grievance that has not been satisfactorily resolved by. your plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. The plan's grievance process and the Department's complaint review process are in addition to any other 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.O. 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 appeal 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 Res. No. 2002-32 Ex. A function. Health Net must notify you of the status of your grievance no later than three days from receipt of the grievance. In addition, you can request an independent medical review of disputed health care services from the Department of Managed Health Care if you believe that health care services eligible for coverage and payment under the plan was improperly denied, modified or delayed by Health Net or one of its contracting providers. Also, if Health. Net denies. your appeal of a denial for lack of medical necessity, or denies or delays coverage for requested treatment involving experimental or investigational drugs, devices, procedures or therapies, you can request an independent medical review of Health Net's decision from the Department of Managed Health Care if you meet eligibility criteria set out in the Evidence of Coverage. Arbitration If you are not satisfied with the result of the grievance and appeals process, you.may submit the problem to binding arbitration. Health. Net uses binding arbitration to settle disputes, excluding medical malpractice. When you enroll in Health Net, you agree to submit any disputes to arbitration, in lieu of a jury or court trial. 17 o Ol .�—.. �71 ;C !'J +C .. , N;f,(/i 51 Rai i rv,ro;�•�c�u f i rl � .. � � �'� t�ll 'U. T1i •'j( � ��r �14 �jf� 'Rf, rf�)q�Q •�y�'I It rljr I A0=1 t�t�A��i y�b �� �M�}. ,y1�{J yt''h4bt rl�,1 •. O at , lst 1 ro � a r • ro N ,i I `0 r t �i S,.t` t e r I,I..A� 1 -, �i =i r+ t{r !•,y {�t!•1•aWel�.!'�'M51 �11, 'I +'lti'tIN 1� ro O .1 r S3k 1 ;kl.Olk yl�i�t 111��.11 � F'�iy�t r .? f-1 . tit �j���'i,{1 7? v Fit •� �f} - 4.. I .�.l � +r; � 11 {.•f`�'1'r 4�}:t�li 6��a .hlt C•F ttr��� �,.,. y ,,, Q ,, 1; r '. a I r ref,{ t, r l •: H I , t� �` t I ..Y' +;s r psi {Ifd°:tt 'stf •'1 {I t t-• - ti tri>�(i: sl st i' - ri •1�} .'.1 Y' i 0 f�l. ,r !,, r. ... . K I. ..� .�i,ii� sr v n �..'l.°}3* I . ! d,�:��.�i�Ri�u.�; �{il.�•�.?'.';t y'c � x�i: ;ki�t�..�; . X (D y Z O N O N DN rCur1'"'n N I. I -Pt 777 r 74jv 5! 1' r-�w A ' Y "Wr 41 5. rP "i", io Table of contents Res. No. 2002-32 Ex. A t Choosing your doctor and physician group.. 3 Based on the availability of your current doctor Based on where the doctor's office is located Based on the doctor's physician group affiliation Based on the doctor's hospital affiliation Based on affiliation with a particular specialist How to complete your enrollment form .... 4 Some frequently asked questions ......... 4 What is a Participating Physician Group? What is Rapid Access*? How is a referral specialist different from -a Primary Care Physician? What is an affilite office and how does it affect my selection of a Primary Care Physician? What's the difference between emergency care and urgent care? How can I get a list of.Sub-Acute Care Facilities? .How can the Health Net Coordinator help me? Should I choose a doctor who is close to home or close to work? When can I .change to a new doctor? How can I obtain information on doctors who are in the Health Net network? How Health Net works ................ 7 How to receive care About your Health Net ID card Hospitalization Questions? ............................ 7 Health Net HMO service area ............. 8 Primary Care Physicians by city ............ 9 If you're looking for doctors and physician groups in your area, check this listing Participating Physician Group index ...... 253 Detailed information about Health Net's contracted physician groups, in alphabetical order by group name Hospital index 355 A list of hospitals in alphabetical order by name Specialist index ...................... 361 A list of available specialists and their affiliated Participating Physician Groups, in alphabetical. order, by specialty Primary Care Physician index ......... 499 A list of all Primary Care Physicians affiliated with Health Net, arranged in alphabetical order Glossary of terms ..................... 515 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 Disclosure Form and Summary of Benefits. 1 Res. No. 2002-32 Ex. A EXHIBIT D — DELTA CARE (PMI) DENTAL PLAN BROCHURE A copy of the Delta Care (PMI) Brochure may be obtained from the Risk Management Division OR See City Clerk Vault File No. 720.20 01-02 FMA MOU 43 04/02/02 8:31 AM Res. No. 2002-32 Ex. A ®ELTACARE ` Dental HMO Prosram Administered by: Private Medical -Care, Inc. 12898 Towne Center Drive Cerritos, CA 90703 DeltaCare is a dental program that provides you and your family with quality dental benefits at an affordable cost. The DeltaCare program is designed to encourage you and your family to visit the dentist regularly to maintain your dental health. To receive your DeltaCare benefits, you select a primary care network dentist when you enroll. The DeltaCare network consists of private practice dental offices that have been carefully screened for quality. Whii�ALITY Res. No. 2002-32 • Eligibility for you and your family Ex. A If you meet your group's eligibility requirements for dental coverage, you can enroll in the DeltaCare program. You may also enroll eligible dependents, including your lawful spouse and unmarried children (which includes stepchildren and legally adopted and foster children to the age limit specified by your group). Contact your benefits administrator if you have any questions. 0 Easy enrollment To enroll in the DeltaCare program, simply complete an enrollment form indicating your choice of dentist (from the list of network dental offices) and the name of your group. Return this form as directed by your benefits administrator. • How your DeltaCare program works Your selected primary care network dentist will take care of the 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 number and address of your network dentist. Simply call the dentist to make an appointment. ✓ Extensive benefits for you and your family. ✓ No restrictions on pre-existing conditions, except for Under 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'for a list of your benefits. Please note: Dental services that are not performed by your network CONVENIENCEdentist must be prior authorized by PMI to be covered by your ✓ No claim forms to complete DeltaCare program. ✓ Easy access to specialty care ✓. Expanded business hours for toll -free customer • Provisions for emergency care service, from-6:00 a.m. to 6:00 p.m., Pacific Time Under 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 ✓ No deductibles or annual dollar maximum dental expenses incurred in each 12-month period. ✓ Out-of-pocket costs are clearly defined ✓ Out -of -area dental emergency coverage up to $100 each 12-month period 1. Prophylaxis is limited to one treatment each six-month period (in- cludes periodontal maintenance following active therapy); 2. Full maxillary and/or mandibular dentures inccuding immediate den- tures are not to exceed one each in any five year period from initial placement; 3. Partial dentures are not to be replaced within any five-year period from initial placement, unless necessary due to natural tooth loss where the addition or replacement of teeth to the existing partial is not feasible; 4. Crown(s) and bridges are not to be replaced within any five-year period from initial placement; 5. Denture relines are limited to one per denture during any 12 con- secutive months; 6. Periodontal treatments (root planinglsubgingival curettage) are lim- ited to four quadrants during any 12 consecutive months; 7. Full mouth debridement (gross scale) is limited to one treatment dur- ing any 12 consecutive month period; 8. Bitewing x-rays are limited to not more than one series of four films in any six-month period; 9. Fun mouth x-rays are limited to one set every 24 consecutive months; 10. Sealant benefits include the application of sealants only to permanent first and second molars with no decay, with no restorations and with the occlusal surface intact, for first molars up to age nine and second molars up to age fourteen. Sealant benefits do not include the repair or replacement of a sealant on any tooth within three years of its apprication.. ® Exclusions The following services are not covered benefits of this program: 1. General anesthesia and the services of a special anesthesiology 2. Cosmetic dental care; 3. Dental conditions arising out of and due to enrollee's employment or for which Workers' Compensation is payable. Services which are provided to the enrollee by State government or agency thereof or are provided without cost to the enrollee by any municipality, county or other subdivision, except as provided in Section 1373(a) of the Cali- fornia Health and Safety Code; 4. Treatment required by reason of war; 5. Dental services performed in a hospital and related hospital fees; 6. Treatment of fractures and dislocations; 7. Loss or theft of fixed and removable prosthetics (crowns, bridges, full or partial dentures); 8. Dental expenses incurred in connection with any dental procedures started after termination of eligibility for coverage; 9. Any service that is not specifically listed as a covered expense; 10. Dental expenses, incurred in connection with any dental procedure started prior to enrollee's eligibility with the DeltaCare program. Ex- ample: teeth prepared for crowns, root canals in progress, orthodon- tic treatment; 11. Congenital malformations (e.g., congenitally missing teeth, supernumerary); 12. Cysts and malignancies; 13. Dispensing of drugs not normally supplied in a dental office; 14. Accidental injury. Accidental injury is defined as damage to the hard and soft tissues of the oral cavity resulting from forces external to the mouth. Damages to the hard and soft tissues of the oral cavity from normal masticatory (chewing) function will be covered at the normal schedule of benefits; 15. Cases which, in the professional judgment of the attending dentist, a satisfactory result cannot be obtained, or where the prognosis is poor or guarded; 16. Dental services received from any dental office other than the assigned DeltaCare office, unless expressly authorized in writing by DeltaCare or as cited under "Provisions for Emergency Care 17. Prophylactic removal of impactions (asymptomaticlnonpathological); 18. `Specialist consultations' for noncovered benefits; 19. Implant placement or removal, appliances placed on or services associated with implants, including but not limited to prophylaxis and periodontal treatment. 20. Crown lengthening procedures. • Summary of Orthodontic Limitations and Exclusions The program provides coverage for orthodontic treatment plans provided through DeltaCare Network orthodontists. The start-up fees and the cost to the enrollee for the treatment plan are fisted in the Description of Benefits and Copayments, subject to the following: 1. Orthodontictreatmentmust be provided by a DeltaCare orthodontist. 2. Plan benefits cover 24 months of usual and customary orthodontic treatment. 3. Should an enrollee's coverage be canceled or terminated for any reason, and at the time of cancellation or termination be receiving any orthodontic treatment, the enrollee and not DeltaCare will be responsible for payment of balance due for treatment provided after cancellation or termination. In such a case the enrollee's payment shall be based on amaximum of $2,300for dependent children to age 19 and $2,500 for covered full time students and adults. The amount will be prorated over the number of months to completion of the treatment and, will be payable bythe enrollee on such terms and conditions as are arranged between the enrollee and the orthodontist. Start-up fees are included in these amounts. 4. Start-up fees coverthe initial examination, diagnosis, consultation and the retention phase of treatment of up to two years maximum. This includes initial construction, placement and adjustments to retainers and office visits for a maximum period of two years. The following services are not covered.- 1. Pre, mid- and post- treatment records which include cephalometric x- rays, tracings, photographs and study models; 2. Lost, stolen or broken orthodontic appliances, functional appliances, headgear, retainers and expansion appliances; 3. Retreatment of orthodontic cases; 4. Treatmentthatextends more than 24months from the point ofbanding dentition wiillbesubject to an office visitcharge at orthodontisf s usual, customary and reasonable fee; 5. Treatment in progress at inception of eligibility; 6. Transfer after banding has been initiated. • 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 nearly 30 years. PMI contracts with network dentists, works with your group to design your benefits program and handles all customer service inquiries. Today, more than a million enrollees are covered by DeltaCare programs. ® What is the difference between PMI and Delta? PMI administers DeltaCare dental HMO programs and is an affiliate of Delta Dental Plan of California. ® How do I know if my dentist is a PMI dentist? When you enroll in DeltaCare, you select a primary care dentist from the list of DeltaCare network dentists. With more than 2,500 general and specialist dentists, the DeltaCare network is one of the largest in California. • My dentist is a Delta dentist but is not on the list of DeltaCare network dentists. Can I still receive treatment from this dentist? No, you must receive treatment from your selected DeltaCare network dentist. Please note that Delta dentists are not necessarily DeltaCare dentists. ® How do l know DeltaCare dentists provide quality care? DeltaCare dentists are reviewed for quality, availability and safety before joining the network. PMI maintains quality standards by visiting each network dental office every three months. • Do my family members receive treatment from the same DeltaCare network dentist? Yes, you and all eligible dependents receive care from the same primary care network dentist. DENTAL HEALTH PLAN An Arrilime of Dcln Dalai Plan of Uifomia If you have any questions or need additional information, call or write to: PMI Dental Health Plan 12898 Towne Center Drive Cerritos, CA 90703 (800) 422-4234 or visit our website at www.deltadentalca.org Note: THIS IS ONLY A BRIEF SUMMARY OF THE PLAN. The Group Dental Service Contract must be consulted to determine the exact terms and conditions of coverage. An Evidence of Coverage will be sent to you 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 at (800) 422-4234. DeltaCare dentist? Two to four weeks is a reasonable amount of time to wait for a routine, non -urgent appointment. If you require a specifictime, you may have to wait longer. In addition, most DeltaCare dentists are in private group practices, which means greater appointment availability and extended office hours. • 1 have a pre-existing dental condition. Can I still join DeltaCare? Yes, treatment for pre-existing conditions such as extracted teeth is not excluded under the DeltaCare program. However, benefits are not provided for any dental treatment started before joining the program (that is, work in progress, such as preparations for crowns, root canals, impressions for dentures and orthodontic treatment). i How does the DeltaCare program encourage preventive care? Your DeltaCare program is designed to encourage regular visits to the dentist by having no copayments (fees you pay to the network dentist) on most diagnostic and preventive services. See the enclosed Description of Benefits and Copayments." • Does my DeltaCare program cover specialists'services? Yes. Your primary care network dentist will coordinate your specialty care needs with an approved network specialist. There is no additional charge to you for receiving care from a specialist. 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, other than the applicable copayment. If you or your dependent is assigned to a dental school clinic for specialty services, those services may be provided by a dentist, a dental student, a clinician or a dental instructor. • Can I change my primary care network dentist? Yes. You may change network dentists by notifying PMI either by phone or in writing, or by visiting our website (www.dettadentalca.org). If you contact us by the 21 st of the month, the change will become effective the first of the following month. • What if I have questions about my DeltaCare program? Call PMI Customer Relations at (800) 422-4234. We have multilingual representatives available from 5 a.m. to 6 p.m., Monday through Friday. Our Customer Relations representatives have worked in dental offices and can answer benefits questions, as well as arrange office transfers and urgent care referrals. 09101 SCCA700 aonEnmese � � coax P" 2930,2931 Crown —prefabricated stainless steel— primary/permanent........................................ No Cost 2950 Crown buildup (restorative material and pins) ........................ No Cost 2952 Cast post and core* (in addition to crown) ..................................... No Cost 2954 Prefabricated post and core (n addition to crown) ..................................... No Cost 5110,5120 Denture -complete maxillary or mandibular (upper or lower) ...................... No Cost 5130,5140 Immediate denture --maxillary or mandibular (upper or lower) ....................... No Cost 5213,5214 Denture -maxillary or mandibular (upper or lower) partial with metal lingual or palatal bar, clasps and acrylic saddles, and acrylic base or cast metal framework and teeth ..................... No Cost 5410 Adjust complete denture —maxillary .................... No Cost 5411 Adjust complete denture —mandibular ................ No Cost 5421 Adjust partial denture —maxillary ......................... No Cost 5422 Adjust partial denture —mandibular ..................... No Cost 5510 Repair broken complete denture base..No Cost 5520 Replace missing or broken teeth — complete denture (per tooth) ......................... No Cost 5610 Repair resin denture base .................................. No Cost 5620 Repair cast framework ....................................... No Cost 5630 Repair or replace broken clasp .......................... No Cost 5640 Replace broken teeth (per tooth) ....................... No Cost 5650 Add tooth to existing partial denture ................... No Cost 5660 Add clasp to existing partial denture ................... No Cost 5730 Reline complete maxllary denture (chairside)..........................................:........... No Cost 5731 Reline complete mandibular denture (chairside)...................................................... No Cost 5740 Reline maxillary partial denture (chairside)...................................................... No Cost 5741 Reline mandibular partial denture (chairside)...................................................... No Cost 5710 Rebase complete maxillarydenture ................... No Cost 5711 Rebase complete mandibular denture ............... No Cost 5720 Rebase maxillary partial denture ........................ No Cost 5721 Rebase mandibular partial denture .................... No Cost 5750 Ret'ine complete maxillary denture (lab) ............. No Cost 5751 Reline complete mandibular denture (lab) .......... No Cost 5760 Reline maxillary partial denture (lab) .................. No Cost 5761 Reline mandibular partial denture Qab) .............. No Cost 5820 Interim partial denture (maxillary) ....................... No Cost 5821 Interim partial denture (mandibular) ................... No Cost 5850,5851 Tissue conditioning —per denture ........................ No Cost 6210 Pontic--cast high noble metal* ............................ No Cost 6211 Pontic—cast predominantly base metal ............... No Cost 6212 Pontic--cast noble metal ..................................... No Cost 6240 Pontic--porcelain fused to high noble metet..... No Cost 6241 Pontic—porcelain fused to predominantly base metalt ............................ No Cost 6242 Pontic—porcelain fused to noble metalt ............. No Cost 6750 Crown —porcelain fused to high noble metal*t.... No Cost 6751 Crown --porcelain fused to predominantly base metalt ............................No Cost 6752 Crown —porcelain fused to noble metalt............. No Cost 6790 Crown —full cast high noble metal* ...................... No Cost 6791 Crown --full cast predominantly base metal......... No Cost 6792 Crown —full cast noble metal ............................... No Cost 6930 Recement bridge (fixed partial denture) ............. No Cost 6940 Stress breaker, per unit (in addition to mixed partial denture, retainer) ...................... No Cost 6970 Cast post and core* (includes canal preparation) ........................... No Cost 6972 Prefabricated post and core buildup (including canal preparation, restorative material and any pins) ...........:...... No Cost *Base ornoble metal is the benefit High noble metal (precious), r7used, wig be charged to the enrollee at the addidonallaboratorycost ofthe high noble metal. This applies to crowns, bridges, cast and post cores, kdays and onlays. t Porcelain on molars is considered optional treatment VIL ENDODONTICS 3110,3120 Pulp capping (direct(ndirect) .............................. No Cost 3220 Therapeutic pulpotomy (excluding final restoration) ............................ No Cost 3310 Root canal therapy —anterior (excluding final restoration) ............................ No Cost 3320 Root canal therapy —bicuspid (excluding final restoration) ............................ No Cost 3330 Root canal therapy —molar (excluding final restoration) ............................ No Cost 3410 Apicoedomy/periradicular surgery —anterior....... No Cost 3421 Apicoedomy/pe6radicular surgery — bicuspid (first root) ......................................... No Cost 3425 ApicoectomylpeNradicular surgery — molar (first root) ............................................. No Cast 3426 Apicoectomy/pedradicular surgery (each additional root) ........................ No Cost 3430 Retrograde filling, per root ................................. No Cost 3450 Root amputation, per root .................................. No Cost VIIL ADJUNCTIVE GENERAL SERVICES 9110 Palliative (emergency) treatment of dental pain.. No Cost 9211 Regional block anesthesia .................................. No Cost 9212 Trigeminal division block anesthesia ................... No Cost 9215 Local anesthesia ................................................ No Cost 9310 Consultation (diagnostic services provided by dentist or physician other than practitioner providing treatment) ....................................... No Cost 9440 Office visit after regularly scheduled hours ........... $ 20.00 0125 Failed appointment without 24 hour notification, per 15 minutes of appointment time ................ $10.00 DL ORTHODONTICS Start-up fees (excluding records) ............................................. $250.00 Dependent children to age 19.................................................. $500.00 Adults and covered full-time students ....................................... $500.00 Any procedure not listed is available on a fee -for -service basis. These services are performed as needed and deemed necessary by your attending DettaCare network dentist subject to the limitations, exclusions and governing administrative policies of the program. c ' Eper � I. DIAGNOSTIC Office visit, per visit (in addition to other services) ......................... No Cost 0120 Periodic oral evaluation ...................................... No Cost 0140 Limited oral evaluation —problem focused ........... No Cost 0150 Comprehensive oral evaluation .......................... No Cost 0160 Detailed and extensive oral evaluation problem focused ............................................ No Cost 0210 Intraoral radiographs - complete series (including bitewings) ............. No Cost 0220,0230 Intraoral periapical film ....................................... No Cost 0240 Intraoral occlusal film .......................................... No Cost 0270, 0272,0274 Bitewing radiograph(s)....................................... No Cost 0330 Panoramic film ................................................... No Cost It. PREVENTIVE 1110,1120 Prophylaxis (cleaning)—adult/child 1 per 6 month period ..................................... No Cost 1201 Topical application of fluoride, including prophylaxis (to age 19) 1 per 6 month period ..................................... No Cost 1203 Topical application of fluoride, excluding prophylaxis (to age 19) 1 per 6 month period ..................................... No Cost 1330 Oral hygiene instructions .................................... No Cost 1351 Sealant, per tooth .............................................. No Cost 1510 Space maintainer -fixed —unilateral .................... No Cost 1515 Space maintainer —fixed —bilateral ...................... No Cost 1520 Space maintainer —removable —unilateral ........... No Cost 1525 Space maintainer —removable —bilateral ............. No Cost 1550 Recementation of space maintainers ................. No Cost III. RESTORATIVE (Fillings) (Includes indirectpulp capping, bases, Aners and acid etch procedures) 2110 Amalgam —one surface, primary ......................... No Cost 2120 Amalgam —two surfaces, primary ....................... No Cost 2130 Amalgam —three surfaces, primary ..................... No Cost 2131 Amalgam —four or more surfaces, primary........................................................... No Cost 2140 Amalgam —one surface, permanent ................... No Cost 2150 Amalgam —two surfaces, permanent ............:..... No Cost 2160 Amalgam —three surfaces, permanent ............... No Cost 2161 Amalgam — four or more surfaces, permanent ................. No Cost 2330 Resin —one surface anterior ............................... No Cost 2331 Resin —two surface anterior ................................ No Cost 2332 Resin —three surface anterior ............................. No Cost 2335 Resin —four or more surfaces or involving incisal angle (anterior) ................. No Cost 2336 Composite resin crown, anterior —primary.......... No Cost 2940 Sedative filling .................................................... No Cost 2951 Pin retention —per tooth, in addition to restoration ................................. No Cost IV. ORAL SURGERY (Includes preoperative and postoperative evaluations and treatment under local anesthetic) 7110,7120 Single tooth extractionleach additional ............... No Cost 7130 Root removal —exposed roots ............................. No Cost 7210 Surgical removal of erupted tooth ...................... No Cost 7220 Removal of impacted tooth —soft tissue .............. No Cost 7230 Removal of impacted toothpartialty bony ............ No Cost 7240,7241 Removal of impacted tooth completely bony ............................................. No Cost 7250 Surgical removal of residual tooth roots (cutting procedure) ....................... No Cost 7266 Biopsy of oral tissue —soft ................................... No Cost 7310 Alveoloplastyinconjunction with extractions, per quadrant ........................ No Cost 7320 Alveoloplasty not in conjunction with extractions, per quadrant ........................ No Cost 7470 Removal of exostosis-maxilla or mandible .......... No Cost 7510 Incision and drainage of abscess— intraoral soft tissue ......................................... No Cost 7960 Frenulectomy—(frenectomyorfrenotomy) separate procedure ....................................... No Cost V. PERIODONTICS (Includes preoperative and postoperative evaluations and treatment undera !oral anesthetic) 4210 Gingivectomy or gingivoplasty, per quadrant....... No Cost 4211 Ging'nrectomyorgingiivoplasty, per tooth (fewer than six teeth) ...................... No Cost 4220 Gingival curettage surgical, per quadrant ........... No Cost 4240 _ Gingival flap procedures including root planing (per quadrant) ............................ No Cost 4260 Osseous surgery, flap entry and closure, per quadrant .................................................. No Cost 4341 Periodontal scaling and root planing, per quadrant .................................................. No Cost 4355 Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis ........... . .................................... No Cost 4910 Periodontalmaintenance (following active therapy) ................................ No Cost VL PROSTHETICS (Crowns, bridges and dentures) 2510 Inlay —one surface —base metal noble ................. No Cost 2520,6520 Inlay —two surfaces —base metal noble ............... No Cost 2530,6530 Inlay --three or more surfaces — base metal noble ............................................ No Cost 2543,6543 Onlay-4hree surfaces —base metal noble ........... No Cost 2544,6544 Onlay—four or more surfaces — base metal noble ....... . ................................... No Cost 2710 Crown —resin (laboratory) .................................. No Cost 2740 Crown—porcelainlceramict................................ No Cost 2750 Crown -porcelain fused to high noble metal*t.... No Cost 2751 Crown —porcelain fused to predominantly base rnetalt ............................ No Cost 2752 Crown —porcelain fused to noble metalt............. No Cost 2790 Crown —full cast high noble metal* ...................... No Cost 2791 Crown —fun cast predominantly base metal ......... No Cost 2792 Crown full cast noble metal ............................... No Cost 2810 Crown-3/4 cast metal noble .............................. No Cost 2910 Recement inlay .................................................. No Cost 2920 Recement crown ................................................ No Cost ®ELTACARE Open Offices AGOURA HILLS #125501 AGOURA DENTAL GROUP 29525 CANWOOD ST STE 250 (818) 991-9852 FIT I (SP TA) (� ALHAMBRA #000647 MOHAMMAD DABBOUSI DOS 401 N GARFIELD AVE (626) 570-0974 FIT I (SP TA AR) PARTICIPATING DENTAL OFFICES Second Quarter 2002 - Southern California ANAHEIM #235001 SMILES FOR ORANGE COUNTY 9672 BALL ROAD (714) 772-0102 FIT 2 (SP) ANAHEIM #256401 DRS ANTHONY AND NAOMI WONG 3356 W BALL ROAD STE 215 (714) 995.3051 Ffr 2 (SP CH) ANAHEIM HILLS #3C2201 ANAHEIM HILLS DENTAL GROUP 5731 A SANTA ANA CNYN RD (714) 998.2956 FIT I (SP) APPLE VALLEY #00510t ASPEN DENTAL GROUP 15995 TUSCOLA RD STE 201 (760) 242-2620 F/T I (TA RU) DEr?AL HEALTH PLAN A- AIrb- of Ddn Dnw Pt- .( Cali — Volume 1 A U A #3C6801 APPLE DENTAL 891 EARROW HWY STE B (626) 332-4788 F!r 2 (SP TA) BAKERSFIELD #131001 STEPHEN KANN DDS 1919 G STREET (661) 323-8585 F/T 1 ALHAMBRA #0S160I ANAHEIM #25650I 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 EUC ID ST 20162 HWY 18 STE L 2721 H ST (626) 284-5113 (714) 999-5050 (760) 946-1466 (661) 324-9709 F/T 2 P/T I (CH SP VI) FIT 2 PR 2 (SP CH) FIT I (KO SP) F/T I ALHAM13RA #00O201 NADIR YAZDANI DDS 747 S GARFIELD AVE (626) 289-6815 FIT 2 L1k ALHAMBRA #118001 ALHAMBRA FAMILY DENTISTRY 600 W MAIN STREET STE 102 (626) 2824119 F/T I (SP AA) & ALTA LOMA #198801 CARNELIAN FAMILY DENTISTRY 6626 CARNELIAN ST (909) 987-4113 F/T I (SP CH) ALTA LOMA #359101 JEFFREY LLOYD DDS 9310 BASELINE ROAD (909) 989-1868 F/r 1 (SP) ANAHEIM #183601 NANDINI MURTHY DDS 1655 W BROADWAY STE 9 (714) 774-2638 F/r 1 (SP) ANAHEIM #188001 DANNY THOMAS DDS 601 S ELICUD ST (714) 778-4700 FIT I P/T I (VI SP RU) ANAHEIM #I C0301 UNIVERSAL CARE DENTAL 1808 W LINCOLN STE 201 (714) 780.5665 FIT 1 PIT i (SP TA VI) & ANAHEIM #i C7301 MANHAR MISTRY DDS INC 303 N EAST ST (714) 772-0770 FIT I (SP) c-Vl - ANAHEIM #258301 DALWANI AND DHOLAKIYA 815 N EUCUD STREET (714) 758-0791 F/T 4 (SP CH JA) (T+ ANAHEIM #274701 ANAHEIM OPEN 7 DAYS DENTAL 637 N EUCLID ST (714) 772-2893 FIT 5 PIT i (SP CH A AR JA) & ANAHEIM I #2C1801 VILLAGE DENTAL GROUP 1210 S BROOKHURST ST (714) 535-7500 F/T 1 PIT 2 ANAHEIM #364201 DAE HUR DDS 40 E ORANGETHORPE (714) 870.6611 FIT I (KO) ANAHEIM #3C5201 ANAHEIM FAMILY DENTAL OFFICE 2170 W LINCOLN AVENUE (714) 535-3933 FIT 2. (SP) ANAHEIM #3C6001 PREFERRED DENTAL CARE 2207 S HARBOR BOULEVARD (714) 971-7800 FIT 2 PIT I (SP EI) ANAHEIM HILLS #000219 STAR DENTAL CARE 5031 E ORANGETHORPE AVE B2 (714) 693-1889 F/T 1 ANAHEIM HILLS #352101 SUNSHINE DENTAL OFFICE 8285 E SANTA ANA CYN RD 115 (714) 974-5599 FIT 1 P/r I (SP EI) APPLE VALLEY #2C5001 APPLE VALLEY DENTAL 18245 HIGHWAY 18 STE 4 (760) 242-2977 FIT I (SP) ARCADIA #196501 ARCADIA DENTAL CENTER 75 N SANTA ANITA BLVD 215 (626) 447-5126 FIT 4 (CH) ARCADIA #386201 WIWAM HOUSTON DDS 25 N SANTA ANITA AVE SUITE E (626) 254-1948 F/T I P/T 1 ARCADIA #3C8201 ANDREW LIM DDS 1043 W HUNTINGTON DRIVE (626) 445-9660 FIT I (KO SP) Ok ARLETA #000223 FAMILY DENTISTRY 9069 12 WOODMAN AVENUE (818) 893-8799 FIT 2 .(SP) RA LETA #198601 WOODMAN FAMILY DENTISTRY 8725 WOODMAN AVE (818) 891.6670 F/r 1 (SP) ARTESIA #000733 SARAH CUPINO DMD 12146 SOUTH STREET SUITE E (562) 924-1007 FIT I (SP TA) C1i ARTESIA #112201 SIOE HWA ONG DDS INC 17906 S PIONEER (562) 860-9612 FIT I P/T 2 (SP TA) Lk BAKERSFIELD #IC5601 G STREET FAMILY DENTAL 2611 G ST (661) 859-0192 F/T BALDWIN PARK #057801 DAVID KUTNER DMD 13734 RAMONA BLVD (626) 960-6616 FIT I PIT: I (SP KO) 6% BANNING #169501 ADRIAN ACOSTA DDS 4240 W RAMSEY AVE (909) 849-4484 F/T 2 (SP RU) BAR STOW #000301 GENTLE DENTAL CARE 113 E MOUNTAIN VIEW (760) 256.2896 FIT 1 (SP) BELL GARDENS #328401 MARKETPLACE DENTAL OFFICE 6815 EASTERN AVE STE AI (323) 560-2595 FIT I (SP) Lk BELL GARDENS #372001 JIN WEI CHU DDS 6526 EASTERN AVE (323) 771-3949 FIT 2 (SP) BELLFLOWER #185501 GERALD SANDARG DDS 17024 S CLARK AVE STE C (562) 925-7436 FIT I (SP) BELLFLOWER #IC0901 UNIVERSAL CARE DENTAL 17660 LAKEWOOD BLVD (562) 461-1ISO FIT 2 PIT 2 (SP VI) C}i I The wheelchair symbol indicates functional accessibility for individuals with limited mobility. Information regarding dental office accessibility for patients with mobility impairments is available by calling PMI's Customer Relations department at (800) 422-4234. Res. No. 2002-32 Ex. A EXHIBIT E — 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 FMA MOU 44 04/02/02 8:31 AM 7 BENEFIT HIGHLIGHTS FOR CITY OPHUNTINGTON M DELTA PR EMWI E' R ,MTAYiT6 'h4��,ELPREMIER% S"5, SE Man4ge�.F�c-for-Scvicc;P'ogram k.X;4 freed dentist .,,T hp,program .p. 1y p, �perqentage, or cov ABoUT DELTAPREMIER chargedbrlymhatPefta: etermMine&.is't lt mtt, 4, 14)iXf �W The DeltaPrem ­,ier,plan,allows� you to,'­,�� ! ,i rp ,�ppoointment;,Dbring��oue..;,fv, t", 4op';ohis:pag ,VV.. h 'k Visit.any licensed. dentistM "Lqj, Yo.u(c,hpipq:•- t -;,�,'Change dent sts,at 11.�46 I �ny,time V o Go to aAental f:your choice o r a! list' q imy r r. specialist 0 'ol- Delia, dentist w;wR ):dental',6are'anywheTe".'I"n'th"e,world""l�'*�,�4,�'.I V eceIVE 14 !&.,:�.site,a -www.d"'e'ita'-de"*n't'alcioeg"*,br.�calliour.. J""I 4nc If pi if bu ,D , asAa coplate "JiE .c the., eltaPremier,pan;,yoU'rpay.,.visitan licens ed YJ, iad�6'�trator-,w 4k! 'den �4 � - 2q�i: V" , " e. I '�­22,000, dental c '�920/6'of all tlsti'stat4wide.-�Fare Delta �D Under q, )fficesAn Catifornia- 0110�,.��,)' ',t.YDu-'can:alsoMe�v, yo6r,�ellgiblllty'�and, benefits.;In 'dentists.':T.her6are�several.adyantages.to choosing a Delta "A, . ". ­�5�4,­,.­�.,,Jnq u ing,remaini an paxim m;al ri'g`d6d6ctible� "d" u I di �'kave!the�'Info�matlonjaxed toyou� �-,':'Or you can DELTA' DENT 0 You may. ave.to corr P1 Claim'formp are .completed, and h ipletqand!Yo­,, ­v Delta �bentp an� of Cal if9mlaoffers y6u,what' r submitted for you at no submit your own clalr orms'or pay,�� Delta DlfferencOr,-, Here :s'.�:what m­a'Ke6 US,uniquo J, a�servl�e fee.­'�! ;(A, V. We prenegotiate:dentists "fees .: Delia 1denti',, c h n.it. 'nnt rarfifiarl'thn dentistsdentists:..lowest fees usua y.,phKge in,,t eiro fffoer Your riantit's'f havn'hpnn'1.-.,,�,�.'­, M certified by'Delta as.usua l, ` fees", you are re Comment customary,,aiqd reasonable you!re.L, ;differen.celfyourtd.,entistchargeg".'�,�.,.!! ',;determlnes: responsible only ,for ,the .pat patient z-_ more: han Delta 's,preap )roved -fees, "M _4 siona ou h 3� may,be char nly,the, You have to pay t 9qn ica charged patienV iv, lity, -'share* -at,thejimeipf,treatTent '_,pt1he,jime,: f a5'd aitjoct� 0i p �tpqatmept,, A Ali" reimbursement burs e men !i�rt,, Delta!s portion,-!.X�­ j 'These' A a ro,jqs . ...... ... XI; ' r De to for dental 1 -Patient share'is the copaymentany deductible and any amount over the annual maximum." Some P.1Som6:,6xamP/qS 0 es�no,�;'­. yW y services may not.be covered, please refer to your EvidenceofCoverag6, tservic covered are cosmetic dentistry, eXperimentalp.toceduresapd.se(Wcesto.correct .conger �; ..malformations.,,1 ...... �P�,% Te S y- ox" Q 0 jL J j' -Itj; s share rr,p R NO 4729.: r,fami DELT, 11 ­ hlat.- , ­ Delta',,o,; p & fdHT* FOMC17 BENEFITT."HIGHL r .V..�%.ir..PRI'NCIP-AUt$ ,ENEFITSyi Y}J-',WHO" 4 0. nDEDUCTIBLES."AND­" -.BENEFITS MAXIMU .4 bi4d NOSTICAN D'PR EVEN ;BENEFITS*'` vavexarn hatio .. .... z -Ic ea 'nihg9;N-,'rSys1;;examination I psyj,4lUonde� eea,tmenti..spaii nrialn.taIhers,1�s'piJcIali§t- onsulti 0_4 . . . . . . IC�BENEFiTS':t"" 'T'l lndsr6 tiI ntl( m n reatrnent;gd I i1l-' +I OROW 7JA'bRTS T 'AND;01 W _, ?� E` RESTORATIONS 4 "t " , N ,I-,PROSTHODONTlb:'BENEFIT! bridge$', pa. IaWenturesfull d 4�) 4, ORTHODONTIC,BENEFITS*' eligin wder d ,and I ')en entchil re D ENTAUACI DENT-- BENEFIT! ­-*Plea.4e, refer WyourEvic exarnpleivi 116adoha,, covered in,a"ealohdar'yeiir,.iI j, 7. i ,dependbiii".6hildr-dri'lo ag­6,19'a'n , d full:; 11? ,time pa. d­'� P um , bevel n J el idart46&'1IS'1S'1 000be ��y.GROUPI N044729 Ali &VICIES', MAVAW' T N.- 0- r. -C 0' 6 , +',j ,g�,'i!'# r3.AIthoughy�oy� pI *. 6VrJ66qqbUtherstbommonl,.needed : ' servicb��sbme+sdrvico§are,not �6�6red:. If you are. unsure : �,­-""o-Wheth6ir a particulairproc'edure' lst`6Vbr'ed;�, or hoW:itnUchof It is �,,,paidjor,byyoUr. plan',, check, withDelt4bef ore, proceeding V ervices for. njUries`dr'cohdit I on s covered -Cohpensatiorpr;'T7p1QyyVS;Ua 111TY LawQ,��"., Cusrblic burgeryordEhti�tr ,or,sevices lo.correct l,, congenital malo ald a n I al, prr6c,"e, d di 'a a 415 4 Therapeutic 6rugis;,"'peemLIV or pal N, osplal" MiSt or.extra;pharges-TO rI, .. E*V- P4XivxtrA;661 ihftd; Implants -i''�'b.,�,;4!�Jreatnent related to the "VTh ek P re cc;6 iii g I n f 66ii at I to in" I a! n otil into r ii mia ry(p I ain'd 6S C . . ri'ptl'onli','nor.-is-.,It,uesigned;i'16',s6rVb,'i6'a*nt'.,','-,,',%'., -of. Co� f E41d66c'e'. erage; or,t Wp aw Plan. This lf'y6u.6'aV6'ipeclfic-qU 41; tio,ri.a.ragardIng. struirtiire,�.,ilr�itati6iniior,oxbitiilons;- consult the Evldence�ot�; -yoverage. or,contactDeliti i:*CU6fdM6r,and 'M6M b6rSe ,"" et �":�.VeJartme"NW-t�mIt G W LTA NZ& T V g" 6f CA 3 I. W O.:3ox vp r. San Francisco,,1C tt -77—llie6ir. , or customertser,vlcd and el g 't 0 a ,TDELrA'CS(888-335-8227)or. benefita..i..�JI. For'onlino oefa'xed ellglibility/beri6Ms information em6nta.�!,.i" -,:"%,i%AW.deltadentalca.orgorr;,-,- tt DELTA CS:(888-335-8227) and press S r. a Iladentists Fo tofl)elta�`:t*1'_�.!.,,..�,t�.,,i.. .'(800) (D 7 4 AREA -DR (800-42 .3237) or deitadentaica .org z (Group 472 -P)(Mister Rev. 60) C) v, Res. No. 2002-32 DELTA DENTAL® Delta Dental Plan of California Combined Evidence of Coverage and Disclosure Form Res. No. 2002-32 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 Coverage\Disclosure form should be read completely and carefully and individuals with special health care needs should read.carefully those sections that apply to them (see CHOOSING YOUR DENTIST section). You have a right to review it prior to your enrollment. 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 furnished 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 94120 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 This Combined Evidence of Coverage and Disclosure Form constitutes only a summary of the dental plan. The dental Contract must be consulted to determine the exact terms and conditions of coverage.- - 1 Res. No. 2002-32 Ex. A TABLE OF CONTENT'S 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..........................................................8 DEDUCTIBLES......................................................9 COVERED FEES....................................................9 CHOOSING YOUR DENTIST...............................9 CONTINUITY OF CARE.....................................10 PUBLIC POLICY PARTICIPATION BY ENROLLEES..................................................10 SAVING MONEY ON YOUR DENTAL BILLS...................................................10 YOUR FIRST APPOINTMENT ...........................10 PREDETERMINATIONS..................................... i 1 PAYMENT............................................................11 IF YOU HAVE QUESTIONS ABOUT SERVICES FROM A DELTA DENTIST.............12 2 Res. No. 2002-32, Ex. A DEFINITIONS Certain words that you will see in this booklet have specific meanings. These definitions should make your dental program easier to understand. Attending Dentist's Statement - a form used by your dentist to request payment for dental treatment or predetermination for proposed dental treatment. Benefits - those dental services available under the Contract and which are described in this booklet.. Contract - the written agreement between your employer or sponsoring group and Delta to provide dental Benefits. The Contract, together with this booklet, forms the terms and conditions of the Benefits you are provided. Covered Services - those dental services to which Delta will apply Benefit payments, according to the Contract. Delta Dentist - a Dentist who has a signed agreement with Delta or a Participating Plan, agreeing to provide services under the terms and conditions established by Delta or the Participating Plan. Dependent - a Primary Enrollee's Dependent who is eligible to enroll for Benefits in accordance with the conditions of eligibility outlined in this booklet. Effective Date - the date this program starts. Enrollee - a Primary Enrollee or Dependent enrolled to receive Benefits or a person who chooses to pay for OPTIONAL CONTINUATION OF COVERAGE. Maximum - the greatest dollar amount Delta will pay for covered procedures in any calendar year and lifetime for Orthodontic Benefits. Premiums - the money paid to Delta each month for you and your Dependents' dental coverage. Participating Plan— Delta and any other member of the Delta Dental Plans Association with whom Delta contracts for assistance in administering your Benefits. Primary Enrollee - any group member or employee who is eligible to enroll for Benefits in accordance with the conditions of eligibility outlined in this booklet. Single Procedure - a dental procedure to which Delta has assigned a separate procedure number; for example, a three -surface amalgam restoration of one permanent tooth (procedure 02160) or a complete upper denture, including adjustments for a six- month period following installation (procedure 05110). Usual, Customary and Reasonable (UCR) - A Usual fee is the amount which an individual dentist regularly charges and receives for a given service or the fee actually charged, whichever is less. A Customary fee is within the range of Usual fees charged and received for a particular service by dentists of similar training in the same geographic area. A Reasonable fee schedule is reasonable if it is Usual and Customary. Additionally, a specific fee to a specific patient is Reasonable if it is justifiable considering special circumstances, or extraordinary difficulty, of the case in question. WHO IS COVERED? All present and future regular employees are required to enroll and will become eligible to receive Benefits on the first day of the month following 30 days of continuous employment. New Dependents should be enrolled as soon as they become Dependents, and they will then immediately be covered for dental Benefits. Res. No. 2002-32 Ex. A You are not eligible if you are not reporting to work on a regular basis and are not actively employed. Coverage resumes on the first day of the month after you return to active employment, report to work regularly and amounts due to Delta for coverage have been paid. But, coverage can continue without interruption if your employer continues to report you as a Primary Enrollee and amounts due Delta for your coverage continue to be paid. Family and Medical Leave Act of 1993 You can continue your coverage if you take.a leave governed by the Family and Medical Leave Act of 1993. If you do not continue your coverage during the governed leave, it will be reinstated at the same Benefit level you received before your leave. Uniformed Services Employment and Re- employment Rights Act of 1994 You can continue coverage for up to 18 months, if you take a leave governed by the Uniformed Services Employment and Re-employment Rights Act of 1994. If you make this election, you must submit any Premiums necessary, which may include administrative costs, to your employer. If you do not continue your coverage during a military leave, it will be reinstated at the same Benefit level you received before your leave. WHO ARE YOUR ELIGIBLE DEPENDENTS? • Your legal spouse; Your unmarried dependent children until their 19th birthday; Your unmarried dependent children until their 23rd birthday if enrolled full-time in an : accredited school, college or university, or live at home and are dependent upon parent(s) for at least 50% of their support; • An unmarried dependent child aged 19 or older who is incapable of self-support because of a physical or mental handicap that occurred before he or she turned 19, if the child is mostly dependent on you for support. Proof of this handicap must be given to Delta or your employer within 31 days, if it is requested. Proof will not be required more than once a year after the child has reached age 21. "Dependent children" also means stepchildren, adopted children, children placed for adoption and foster children, provided that they are dependent upon you for support and maintenance. Dependent coverage is also extended to any child who is recognized under a Qualified Medical Child Support Order (QMCSO). No Dependent in the military service is eligible. ENROLLING YOUR DEPENDENTS A payroll deduction is required for your enrolled Dependents. Your group can only provide coverage for your Dependents if at least half of the Primary Enrollees who have Dependents enroll all of them in this program. Your Dependents must be enrolled when you first become eligible or on the first day of the month after they become Dependents. However, Dependents who are covered under another group dental program are not required to enroll under this Delta program. If the other coverage ends, the Dependents may enroll under this program within 30 days of the loss of the other coverage. Proof of prior coverage is required. Dependent children up to four years of age may be enrolled at the beginning of any Contract year including the Contract year immediately following their fourth birthday. If you drop coverage for your Dependents, you may not re -enroll them in this program. COVERAGE COSTS Your employer pays Delta monthly Premiums for coverage of you and your enrolled Dependents. Res. No. 2002-32 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 imposed 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 $1,000 for each you qualify for and pay for OPTIONAL Enrollee in each calendar year. Payment for 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. 2002-32 Ex. A II. EQ BASIC BENEFITS - 85% Oral surgery - extractions and certain other surgical procedures, including pre- and post- operative care V. Restorative - amalgam, silicate or composite VI (resin) restorations (fillings) for treatment of carious lesions (visible destruction of hard tooth structure resulting from the process of dental decay) Endodontic - treatment of the tooth pulp Periodontic - treatment of gums and bones that support the teeth Sealants - topically applied acrylic, plastic or composite material used to seal developmental grooves and pits in teeth for the purpose of preventing dental decay Adjunctive General Services - general anesthesia; office visit for observation; office visit after regularly scheduled hours; therapeutic drug injection; treatment of post- surgical complications (unusual circumstances); limited occlusal adjustment CROWNS, JACKETS, INLAYS, ONLAYS AND CAST RESTORATION BENEFITS - 85% Crowns, Jackets, Inlays, Onlays and Cast Restorations are Benefits only if they are provided to treat cavities which cannot be restored with amalgam, silicate or direct composite (resin) restorations. IV. PROSTRODONTIC BENEFITS - 60% Construction or repair of fixed bridges, partial dentures and complete dentures are Benefits if provided to replace missing, natural teeth. ORTHODONTIC BENEFITS - 60% Procedures using appliances or surgery to straighten or realign teeth, which otherwise would not function properly. DENTAL ACCIDENT BENEFITS - 100% Any services which would be covered under other Benefit categories (subject to the same limitations and exclusions) are covered instead by your dental accident coverage when -they are provided for conditions caused directly by external, violent and accidental means. LINIITATIONS 1. Only the first two oral examinations, including office visits for observation and specialist consultations, or combination thereof, in a calendar year are Benefits while you are eligible under any Delta program. Oral examinations provided by a California dentist are Benefits only when the dentist is a Delta Dentist with an accepted fee on file with Delta. 2. Full -mouth x-rays are a Benefit once in a five-year period while you are eligible under any Delta program. 3. Bitewing x-rays are provided on request by the dentist, but no more than twice in any calendar year for children to age 18 or once in any calendar year for adults age 18 and over, while you are eligible under any Delta program- 4. Diagnostic casts are a Benefit only when made in connection with subsequent orthodontic treatment covered under this 6 Res. No. 2002-32 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 6. 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. Res. No. 2002-32 Ex A 13. If orthodontic treatment is begun before you 3 become eligible for coverage, Delta's payments will begin with the first payment due to the dentist following your eligibility date. 14. Delta's orthodontics payments will stop when the first payment is due to the dentist 4. following either a loss of eligibility, or if treatment is ended for any reason before it is completed. 15. X-rays and extractions that might be necessary for orthodontic treatment are not covered by Orthodontic Benefits, but may be covered under Diagnostic and Preventive or 5 Basic Benefits. 16. Delta will pay Dental Accident Benefits when services are provided within 180 days following the date of accident and shall not include any services for conditions caused by an accident occurring before your eligibility date. EXCLUSIONS/SERVICES WE DO NOT COVER Delta covers a wide variety of dental care expenses, but there are some services for which we do not provide Benefits. It is important for you to know what these services are before you visit your dentist. Delta does not provide benefits for: 1. Services for injuries covered by Workers' Compensation or Employer's Liability Laws. 2. Services which are provided to the Enrollee by any Federal or State Governmental Agency or are provided without cost to the Enrollee by any municipality, county or other political subdivision, except Medi-Cal benefits. 7. Services for cosmetic purposes or for conditions that are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth and teeth that are discolored or lacking enamel. Services for restoring tooth structure lost from wear (abrasion, erosion, attrition, or abfraction), for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth. Examples of such treatment are equilibration and periodontal splinting. Any Single Procedure, bridge, denture or other prosthodontic service which was started before the Enrollee was covered by this program. Prescribed drugs, or applied therapeutic drugs, premedication or analgesia. Experimental procedures. 8. Charges by any hospital or other surgical or treatment facility and any additional fees charged by the Dentist for treatment in any such facility. 9. Anesthesia, except for general anesthesia given by a dentist for covered oral surgery procedures. 10. Grafting tissues from outside the mouth to tissues inside the mouth ("extraoral grafts"). 11. Implants (materials implanted into or on bone or soft tissue) or the repair or removal of implants, except as provided under LIMITATIONS. Res. No. 2002-32 Ex. A 12. Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw) joints or associated muscles, nerves or tissues. 13. Replacement of existing restoration for any purpose other than active tooth decay. 14. Intravenous sedation, occlusal guards and complete occlusal adjustment. 15. Charges for replacement or repair of an orthodontic appliance paid in part or in full by this program. You must pay the first $25 of Covered Services for each Enrollee in your family in each calendar year, up to a limit of $75 per family. COVERED FEES It is to your advantage to select a dentist who is a Delta Dentist, since a lower percentage of the dentist's fees may be covered by this program if you select a dentist who is not a Delta Dentist. A list of Delta Dentists (see DEFINITIONS) is available in a directory at your group benefits office, or by calling 1-800-427-3237. Payment to a Delta Dentist will be based on the applicable percentage of the lesser of the Fee Actually Charged, or the accepted Usual, Customary and Reasonable Fee that the dentist has on file with Delta. Payment to a dentist located outside the United States will be based on the applicable percentage of the lesser of the Fee Actually Charged, or the fee which satisfies the majority of Delta's dentists. Payment to a dentist outside of California who agrees to be bound by Delta's rules in the administration of the program will be based on the applicable percentage of the lesser of the Fee Actually Charged or the Customary Fee for corresponding services for Delta Dentists in California. Payment to a California dentist, or an out-of-state dentist, who is not a Delta Dentist will be based on the applicable percentage of the lesser of the Fee Actually Charged, or the fee which satisfies the majority of Delta's Dentists. CHOOSING YOUR DENTIST PLEASE REAL) THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. More than 18,000 dentists in active practice in California are Delta Dentists. You are free to choose any dentist for treatment, but it is to your advantage to choose a Delta Dentist. This is because his or her fees are approved in advance by Delta. Delta Dentists have treatment forms on hand and will complete and submit the forms to Delta free of charge. If you go to a non -Delta Dentist, Delta cannot assure you what percentage of the charged fee may be covered. Claims for services from non -Delta Dentists may be submitted to Delta at the address listed on page 1. Dentists located outside the United States are not Delta Dentists. Claims submitted by out -of -country dentists are translated by Delta staff and the currency is converted to U.S. dollars. Claims submitted by out -of -country dentists for patients residing in California are referred to Delta's Quality Review department for processing Delta may require a clinical examination to determine the quality of the services provided, and Delta may decline to reimburse you for Benefits if the services are found to be unsatisfactory. A list of Delta Dentists can be obtained by calling 1-800427-3237. This list will identify those dentists who can provide care for individuals who have mobility impairments or have special health Res. No. 2002-32 Ex. A care needs. You can obtain specific information about Delta Dentists by using our web site — w%vw.deltadentalca.org or calling the Delta Customer and Member Service Department at the number shown on page 1. A printed list of the Delta Dentists in your area is also available by calling 1-800427-3237. Services may be obtained from any licensed dentist during normal office hours. Emergency services are available in most cases through an emergency telephone exchange maintained by the local dental society which is listed in the local telephone directory. Services from dental school clinics may be provided by students of dentistry or instructors who are not licensed by the state of California. Delta shares the public and professional concern about the possible spread of HIV and other infectious diseases in the dental office. However, Delta cannot ensure your dentist's use of precautions against the spread of such diseases, or compel your dentist to be tested for HIV or to disclose test results to Delta, or to you. Delta informs its panel dentists about the need for clinical precautions as recommended by recognized health authorities on this issue. If you should have questions about your dentist's health status or use of recommended clinical precautions, you should discuss them with your dentist. CONTINUITY OF CARE If you are undergoing a course of treatment and your dentist no longer is a Delta Dentist, you may continue to receive treatment from that dentist. PUBLIC POLICY PARTICIPATION BY ENROLLEES Delta's Board of Directors includes Enrollees who participate in establishing Delta's public policy regarding Enrollees through periodic review of Delta's Quality Assessment program reports and communication from Enrollees. Enrollees may submit any suggestions regarding Delta's public policy in writing to: Delta Dental Plan of California, Customer and Member Service Department, P. O. Box 7736, San Francisco, CA 94120. SAVING MONEY ON YOUR DENTAL BILLS You can keep your dental expenses down by practicing the following: 1. Comparing the fees of different dentists; 2. Using a Delta Dentist; 3. Having your dentist obtain predetermination from Delta for any treatment over $300; 4. Visiting your dentist regularly for checkups; 5. Following your dentist's advice about . regular brushing and flossing; 6. Avoiding putting off treatment until you have a major problem; and 7. By learning the facts about overbilling. Under this program, you must pay the dentist your copayment share (see YOUR BENEFITS). You may hear of some dentists who offer to accept insurance payments as "full payment." You should know that these dentists may do so by overcharging your program and may do more work than you need, thereby increasing program costs. You can help keep your dental Benefits intact by avoiding such schemes. YOUR FIRST APPOINTMENT During your first appointment, be sure to give your dentist the following information: 1. Your Delta group number (on the front of this booklet); 2. The employer's name; 10 Res. No. 2002-32 Ex. A . 3. Primary Enrollee's social security number (which must also be used by Dependents); 4. Primary Enrollee's date of birth; 5. Any other dental coverage you may have. PREDETERMINATIONS After an examination, your dentist will talk to you about treatment you may need. The cost of treatment is something you may want to consider. If the service is extensive and involves crowns or bridges, or if the service will cost more than $300, we encourage you to ask your dentist to request a predetermination. A predetermination does not guarantee payment. It is an estimate of the amount Delta will pay if you are eligible and meet all the requirements of your program at the time the treatment you have planned is completed. In order to receive predetermination, your dentist' must send an Attending Dentist's Statement to us listing the proposed treatment. Delta will send your dentist a Notice of Predetermination which estimates how much you will have to pay. After you review the estimate with your dentist and decide to go ahead with the treatment plan, your dentist returns the statement to us for payment when treatment has been completed. Computations are estimates only and are based on what would be payable on the date the Notice of Predetermination is issued if the patient is eligible. Payment will depend on the patient's eligibility and the remaining annual Maximum when completed services are submitted to Delta. Predetermining treatment helps prevent any misunderstanding about your financial responsibilities. If you have any concerns about the predetermination, let us know before treatment begins so your questions can be answered before you incur any charges. Delta will pay Delta Dentists directly. Our agreement with our Delta Dentists makes sure that you will not be responsible to the dentist for any money we owe. However, if for any reason we fail to pay a dentist who is not a Delta Dentist, you may be liable for that portion of the cost. If you have selected a non -Delta Dentist, Delta will .pay you. Payments made to you are not assignable (in other words, we will not grant requests to pay non -Delta Dentists directly). Delta does not pay Delta Dentists any incentive as an inducement to deny, reduce, limit or delay any appropriate service. If you wish to know more about the method of reimbursement to Delta Dentists, you may call Delta's Customer and Member Service Department for more information. Payment for claims exceeding $500 for services provided by dentists located outside the United States may; at Delta's option, be conditioned upon a clinical evaluation at Delta's request (see Second Opinions). Delta will not pay Benefits for such services if they are found to be unsatisfactory. Payment for any Single Procedure which is a Covered Service will only be made upon completion of that procedure. Delta does not make or prorate payments for treatment in progress or incomplete procedures. The date the procedure is completed governs the calculation of any Deductible (and determines when a charge is made against any Maximum) under your program. If there is a difference between what your dentist is charging you and what Delta says your portion should be, or if you are not satisfied with the dental work you have received, contact Delta's Customer and Member Service Department. We may be able to help you resolve the situation. Delta may deny payment of any Attending Dentist's Statement for services submitted more than six 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. 2002-32 Ex. A that dentist for the amount which would have been payable by Delta (unless you failed to advise the dentist of your eligibility at the time of treatment). The process Delta uses to determine or deny payment for services are distributed to all Delta Dentists. They describe in detail the dental procedures covered as Benefits, the conditions under which coverage is provided, and the limitations and exclusions applicable to the program. Claims are reviewed for eligibility and are paid according to these processing policies. Those claims which require additional review are evaluated by Delta's dentist consultants. If any claims are not covered, or if limitations or exclusions apply to services you have received from a Delta Dentist, you will be notified by an adjustment notice on the Notice of Payment or Action. You may contact Delta's Customer and Member Service Department for more information regarding Delta's processing policies. IF YOU HAVE. QUESTIONS ABOUT SERVICES FROM A DELTA DENTIST. If you have questions about the services you receive from a Delta Dentist, we recommend that you first discuss the matter with your dentist. If you continue to have concerns, call our Quality Review Department at 1-888-335-8227. If appropriate, Delta can arrange for you to be examined by one of our consulting dentists in your area. If the consultant recommends the work be replaced or corrected, Delta will intervene with the original dentist to either have the services replaced or corrected at no additional cost to you or obtain a refund. In the latter case, you are free to choose another dentist to receive your full Benefit. SECOND OPINIONS Delta obtains second opinions through Regional Consultant members of its Quality Review Committee who conduct clinical examinations, prepare objective reports of dental conditions, and evaluate treatment that is proposed or has been provided. Delta will authorize such an examination prior to treatment when necessary to make a Benefits determination in response to a request for a Predetermination of treatment cost by a dentist. Delta will also authorize a second opinion after treatment if an Enrollee has a complaint regarding the quality of care provided. Delta will notify the Enrollee and the treating dentist when a second opinion is necessary and appropriate, and direct the Enrollee to the Regional Consultant selected by Delta to perform the clinical examination. When Delta authorizes a second opinion through a Regional Consultant, we will pay for all charges. Enrollees may otherwise obtain second opinions about treatment from any dentist they choose, and claims for the examination or consultant may be submitted to Delta for payment. Delta will pay such claims in accordance with the Benefits of the program. This is only a summary of DeIta's policy on second opinions. A copy of Delta's formal policy is available from Delta's Customer and Member Service Department upon request. ORGAN AND TISSUE DONATION Donating organ and tissue provides many societal benefits. Organ and tissue donation allows recipients of transplants to go on to lead fuller and more meaningful lives. Currently, the need for organ transplants far exceeds availability. If you are interested in organ donation, please speak to your physician. Organ donation begins at the hospital when a patient is pronounced brain dead and identified as a potential organ donor. An organ procurement organization will become involved to coordinate the activities. COMPLAINT PROCEDURE, CLAIMS APPEAL AND ARBITRATION If you have any questions about the services you receive from a Delta Dentist, we recommend that you first discuss the matter with your dentist. If you continue to have concerns, call our Quality Review Department at t-888-335-8227. 12 Res. No. 2002-32 Ex. A We will provide notification if any dental services or claims are denied, in whole or in part, stating the specific reason or reasons for denial. If you have a question or complaint regarding eligibility, the denial of dental services or claims, the policies, procedures and operations of Delta, or the quality of dental services performed by a Delta Dentist, you may contact us at the telephone number shown on page 1. You have 60 days after you receive notice of denial to appeal. If you write, you must include the name of the patient, the group name and number, the Primary Enrollee's name and social security number or identification number and your telephone number on all correspondence. You should also include a copy of the treatment form, Notice of Payment and any other relevant information. Clearly explain your complaint and send it to us at the address shown on page 1. We will review your complaint and will resolve the matter within 30 days of receipt or inform you of the pending status of the complaint if more information or time is needed to resolve the matter. We will respond within three days of receipt to complaints involving severe pain and imminent and serious threat to a patient's health. The California Department of Managed Health Care is responsible for regulating health care service plans. The department has a toll -free number 1-888-HMO-2219 to receive complaints regarding health plans. The hearing and speech impaired may use the California Relay Service's toll -free telephone numbers 1-800-735-2929 (TTY) or 1-888-877-5378 (TTY) to contact the department. The department's Internet web site (http://www.hmohelp.ca.gov) has complaint forms and instructions online. If you have a grievance against the plan, you should first telephone the plan at 1-888-335-8227 and use the plan's grievance process before contacting the department. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by the plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. The plan's grievance process and the department's complaint review process are in addition to any other 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. Disputes relating to your plan, including claim denials, may be settled by arbitration if they cannot be settled by this complaint process. Arbitration will follow the Commercial Rules of the American Arbitration Association (AAA). You can begin this process by giving written notice to each party (for example, Delta and your dentist) with whom you want to arbitrate, explaining the dispute and the amount involved, if any, and the solution you wish. You must then file two copies of the notice with the Association's regional office in Los Angeles or San Francisco, along with the fee required by the Association. In the event of extreme hardship on the part of an Enrollee or subscriber, and upon an application for relief presented to the AAA, Delta shall assume all or.a portion of the arbitration fees and expenses as determined by the AAA in accordance with procedures established and administered by the AAA. IF YOU HAVE ADDITIONAL COVERAGE It is to your advantage to let your dentist and Delta know if you have dental coverage in addition to this Delta program. Most dental carriers cooperate with one another to avoid duplicate payments, but still allow you to make use of both programs - sometimes paying 100% of your dental bill. For example, you might have some fillings which cost $100: If the primary carrier usually pays 80% for these services, it would pay $80. The secondary carrier might usually pay 50% for this service. In this case, since payment is not to exceed the entire fee charged, the secondary carrier pays the remaining $20 only. Since this method pays 100% of the bill, you have no out-of-pocket expense. Be sure to advise your dentist of all programs under which you have dental coverage and have him or her complete the dual coverage portion of the Attending Dentist's Statement, so that you will 13 Res. No. 2002-32 Ex. A receive all benefits to which you are entitled. For further information, contact the Delta Customer and Member Service Department at the number'in the USING THIS BOOKLET section. OPTIONAL CONTINUATION OF COVERAGE (COBRA OR CAI, -COBRA) The federal Consolidated Omnibus Budget Reconciliation Act (or COBRA, pertaining to certain employers having 20 or more employees) and the California Continuation Benefits Replacement Act (or Cal -COBRA, pertaining to employers with 2-19 employees), both required continued health care coverage be made available to "Qualified Beneficiaries" who lose health care coverage under the group plan as a result of a "Qualifying Event". You or your Dependents may be entitled to continue coverage under this program, at the Qualified Beneficiary's expense, if certain conditions are met. The period of continued coverage depends on the Qualifying Event. M41211121# (AWK The meaning of key terms used in this section are shown below. Qualified Beneficiary means: 1. you and/or your Dependents who are enrolled in the Delta plan on the day before the Qualifying Event, or 2. a child who is born to or placed for adoption with you during the period of continued coverage, provided such child is enrolled within 30 days of birth or placement for adoption. Qualifying Event means any of the following events which, except for the election of this continued coverage, would result in a loss of coverage under the dental plan: Event 1. the termination of employment (other than termination for gross misconduct), or the reduction in work hours, by your employer; Event 2. 1your death; Event 3. your divorce or legal separation from your spouse; Event 4. your Dependents' loss of dependent status under the plan, and Event 5. as to your Dependents only, your entitlement to Medicare. You means the Primary Enrollee. PERIODS OF CONTINUED COVERAGE Qualified Beneficiaries may continue coverage for 18 months following the month in which Qualifying Event 1 occurs. This 18 month period can be extended for a total of 29 months, provided: 1. a determination is made under Title II or Title XVI of the Social Security Act that an individual is disabled on the date of the Qualifying Event or becomes disabled at any time during the fast 60 days of continued coverage; and 2. notice of the determination is given to the employer during the initial 18 months of continued coverage and within 60 days of the date of the determination. This period of coverage will end on the first day of the month that begins more than 30 days after, the date of the final determination that the disabled individual is no longer disabled. You must notify the employer within 30 days of any such determination. If, during the 18 months continuation period resulting from Qualifying Event 1, your Dependents, who are Qualified Beneficiaries, experience Qualifying Events 2, 3, 4, or 5, they may 14 Res. No. 2002-32 Ex. A choose to extend coverage for up to a total of 36 months (inclusive of the period continued under Qualifying Event 1). Your Dependents, who are Qualified Beneficiaries, may continue coverage for 36 months following the occurrence of Qualifying Events 2, 3, 4 or 5. Under federal COBRA law only, when an employer has filed for bankruptcy under Title H, United States Code, benefits may be substantially reduced or eliminated for retired employees and their. Dependents, or the surviving spouse of a deceased retired employee. If this benefit reduction or elimination occurs within one year before or one year after the filing, it is considered a Qualifying Event. If you are the retiree, and you have lost coverage because of this Qualifying Event, you may choose to continue coverage until your death. Your Dependents who have lost coverage because of this Qualifying Event may choose to continue coverage for up to 36 months following your death. Premiums for each month since the loss of coverage. Failure to pay the required Premiums within the 45 days will result in the loss of the right to continue coverage, any Premiums received after that will be returned to the Qualified Beneficiary. CONTINUED COVERAGE BENEFITS The Benefits under the continued coverage will be the same as those provided to active employees and their Dependents who are still enrolled in the dental plan. If the employer changes the coverage for active employees, the continued coverage will change as well. Premiums will be adjusted to reflect the changes made. TERMINATION OF CONTINUED COVERAGE A Qualified Beneficiary's coverage will terminate at the end of the month in which any of the following events first occurs: ELECTION OF CONTINUED COVERAGE L Your employer will notify Delta in writing within 30 days of Qualifying Event 1. A Qualified Beneficiary must notify Delta in writing within 60 days of Qualifying Events 2, 3, 4, or 5 or within 60 days of receiving the election notice from the employer. Otherwise, the option of continued coverage will be lost. Within 14 days of receiving notice of a Qualified Event, Delta will provide a Qualified Beneficiary with the necessary benefits information, monthly Premiums charge, enrollment forms, and instructions to allow election of continued coverage. 2. 3. 4. A Qualified Beneficiary will than have 60 days to give Delta written notice of the election to continue coverage. Failure to provide this written notice of election to Delta within 60 days will result in the 5 loss of the right to continue coverage. the allowable number of consecutive months of continued coverage is reached; failure to pay the required Premiums in a timely manner; the employer ceases to provide any group dental plan to its employees; the individual first obtains coverage for dental Benefits, after the date of the election of continued coverage, under another group health plan (as an employee or Dependent) which does not contain or apply any exclusion or limitation with respect to any pre-existing condition of such a person, if that pre-existing condition is covered under this program; entitlement to Medicare; or. 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. 2002-32 Ex A of the date when a Qualified Beneficiary becomes so eligible. Once continued coverage ends, it cannot be reinstated. TERNU NATION 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 under 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 Res. No. 2002-32 Ex. A EXHIBIT F — SAFEGUARD DENTAL PLAN BROCHURE A copy of the Safeguard Dental Brochure may be obtained from the Risk Management Division m See City Clerk Vault File No. 720.20 01-02 FMA MOU 45 04/02/02 8:31 AM SG55 Schedule Of Benefits Res. No. The following is a schedule of our SG85 Managed Care Dental Plan which offers comprehensive care with low copayments and access to our extensive network of primary care dentists. This symbol "•: " next to any clause indicates that your state may have a minor variation to the provision. If the provision has a ❖, see page 4 for information that may be specific to your state. Glossary of Terms Diagnostic Services: Evaluation of a patient's dental needs based on observation, examination, x-rays and other tests. The diagnosis is then linked to treatment plan for the patient. Preventive Services: This category includes dental cleanings; oral hygiene instructions to promote good home care and prevent dental disease; fluoride applica- tion to strengthen teeth; sealants to prevent tooth decay; and space maintainers to prevent tooth move- ment. Restorative Treatment: These procedures restore teeth to normal form and function and are usually comprised of materials that are metal (dental amalgam) as well as white - tooth colored materials (composites). Crowns: Restorations of the teeth that usually cover the remaining tooth structure to strengthen the tooth and replace lost tooth structure. Crowns are made in a variety of materials including metals, porcelain, and porcelain with metal. Endodontics: These procedures treat the diseased "inside" of the tooth, or nerve and eliminate any infection which may be present. Following endodontic (root canal) treatment, a crown is usually needed to strengthen the weakened tooth. Perlodontics: Procedures related to treatment of the supporting structures of the teeth (gums, underlying bone) including scaling beneath the gum and sometimes surgery to allow for a healthy environment to retain the teeth. Prosthetics: Procedures related to the replacement of teeth with removable appliances like dentures or partial dentures. Bridges: The replacement of missing teeth with attached or fixed replacements including the crowns on either side of the space. Oral Surgery: Surgery to remove teeth, reshape portions of the bone in the mouth, or biopsy suspect areas of the mouth. Orthodontics: Braces and other procedures to straighten the teeth. NOTE: N/C = No Charge Member Code Service Cooavment Diagnostic Treatment 120 Periodic oral evaluation 140 Limited oral evaluation - problem focused 150 Comprehensive oral evaluation (incl. Pedo screening psr) 9491 Office visit fee - per visit 210 X-rays intraoral = complete series - incl. Bitewings (once every 3 years) 220 X-rays intraoral - periapical - first film 230 X-rays intraoral - periapical - each additional film 240 X-rays intraoral - occlusal film 250 X-rays extraoral - first film 260 X-rays extraoral - each additional film 270 X-rays bitewing - single film 272 X-rays bitewmgs -two films 274 X-rays bitewings - four films 330 X-rays panoramic film 460 Pulp vitality tests 470 Diagnostic casts Preventive Services Procedures identified with an asterisk (*) are limited to 1 every 6 months. (ARiZONA members see ❖' on pg. 4) =0 Prophylaxis- adult* =0 Prophylaxis -child* 1201 Topical application of fluoride (incl. Prophylaxis) -child* 1203 Topical application of fluoride (excl. Prophylaxis) - child* 1204 Topical application of fluoride (excl. Prophylaxis) - adult* 1205 Topical application of fluoride (ncl. Prophylaxis) - adult* 1330 Orel hygiene instructions 1351 Sealant -per tooth 1510 Space maintainer- fixed- unilateral 1515 Space maintainer -fixed- bilateral 1520 Space maintainer- removable- unilateral 1525 Space maintainer- removable- bilateral 1550 Recementation of space maintainer Restorative Treatment 2110 Amalgam - one surface, primary 2120 Amalgam - two surfaces, primary 2130 Amalgam - three surfaces, primary 2131 Amalgam - four or more surfaces, primary 2140 Amalgam - one surface, permanent 2150 Amalgam - two surfaces, permanent 2160 Amalgam -three surfaces, permanent 2161 Amalgam - four or more surfaces, permanent 2330 Resin - one surface, anterior 2331 Resin -two surfaces, anterior 2332 Resin -three surfaces, anterior N/C N/C N/C $5 WC N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C $5 $20 $20 $20 $20 $5 N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C SGSS SafeGuard Heann Plans Member Services (800) 880-1800 SG85 Code Service Member Cooavment Code Res. No. 2(Aan3j6r Service CoPe"ent 2335 Resin - four or more surfaces 6970 Cast post & core in addition to bridge retainer $25 safeGuard Health or involving incisal angle, anterior N/C 6971 Cast post as part of bridge retainer $25 Plans 2336 Composite resin crown, anterior - primary $30 6972 Prefab. Post and core in addition to - A` 2380 Resin - one surface, posterior - primary $15 bridge retainer $25 2381 Resin - two surfaces posterior - primary $20 6973 Core build up for retainer, incl. Any pins $15 2382 Resin -three or more surfaces, posterior- Endodontics primary $30 All procedures exclude final restoration 2385 Resin - one surface, posterior- permanent $65 3110 Pulp cap- direct (excl. Final restoration) N/C 2386 Resin -two surfaces, posterior- permanent $75 3120 Pulp cap- irect (excl. Final restoration) N/C 2387 Resin -three or more surfaces, posterior- 3220 Therapeuticpulpotorry N/C permanent $80 3230 Pulpal therapy with resorbable filling - primary anterior tooth $5 Crowns / Fixed Bridges - Per Unit 3240 Pulpal therapy with resorbable filling - • Replacement Limit 1 every 5 years. primary posterior tooth $10 • Procedures identified by an asterisk (*) involve the additional cost 3310 Root canal - anterior - per tooth $70 of noble/high noble metal. • Cases involving 7 or more crown and/or fixed bridge units in the 3320 Root canal - bicuspid - per tooth $80 same treatment plan require additional $125 member fee per unit 3330 Root canal - ist molar- per tooth $150 for all crown/bridge units in addition to copay. 3340 Root canal - 2nd or 3rd molar - per tooth $150 • $75 fee per crown/bridge unit above copay for porcelain on molars. 3346 Retreatment of root canal - anterior 2510 Inlay - metallic - one surface* $85 (by report) - per tooth $80 2520 Inlay -metallic -two surfaces* $85 3347 Retreatment of root canal - bicuspid 2530 Inlay - metallic - three or more surfaces* $85 (by report) - per tooth $100 2543 Onlay - metallic - three surfaces* $85 3348 Retreatment of root canal - ist molar 2544 Onlay - metallic - four or more surfaces* $85 (BY report) -per tooth $160 2740 Crown porcelain/ceramic substrate $225 3349 Retreatment of root canal - 2nd 27SO Crown porcelain fused to high noble metal* $85 or 3rd molar (by report) - per tooth $160 2751 Crown porcelain fused to 3351 Apexification/recalcification - initial visit $65 predominantly base metal $85 3352 Apexification/recalcification - interim visit $65 27S2 Crown porcelain fused to noble metal* $85 3353 Apexification/recalcification - final visit $65 2790 Crown full cast high noble metal* $85: 3410 Apicoectomy/periradicularsurgery- anterior $90 2791 Crown full cast predominantly base metal $85 3421 Apicoectomy/pedradicular surgery- bicuspid - 2792 Crown full cast noble metal* $85 1st root $90 2810 Crown 3/4 cast metallic* S85 3425 Apicoectomy/pedradicularsurgery- 2910 Recement inlay N/C 1st, 2nd, or 3rd molar- ist root $90 2920 Recement crown N/C 3426 Apicoectomy/pedradicular surgery- 2930 Prefabricated stainless steel crown - each additional root $90 primary tooth N/C 3430 Retrograde filling - per root $90 2931 Prefabricated stainless steel crown - 3450 Root amputation - per root $95 permanent tooth N/C 3920 Hemisection- incl.Rootremoval 2940 Sedative filling N/C (excl. Root canal therapy) $90 2950 Core buildup, incl. Any pins $15 2951 Pin retention -per tooth, in addition to Periodontics — restoration $10 4210 Ging'rvectonry/gingivoplasty- per quadrant $35 2952 Cast post & core in addition to crown $25 4240 Gingival flap procedure, 2954 Prefabricated post & core in addition incl. Root planing -per quadrant $150 to crown $25 4249 Clinical crown lengthening - hard tissue $125 i 29SS Post removal (not in conj. With endo therapy) $10 4260 Osseous surgery 6210 Pontic- cast high noble metal* $85 (incl. Flap entry and closure) - per quadrant $150 6211 Pontic- cast predominantly base metal $85 4270 Pedicle soft tissue graft procedure $250 6212 Pontic- cast noble metal* $85 4271 Free soft tissue graft procedure 6240 Pontic- porcelain fused to high noble metal* $85 (incl. Donor site surgery) $250 6241 Pontic- porcelain fused to 4273 Subep'rthelial connective tissue predominantly base metal $85 graft procedure - (incl. Donor site surgery) $300 6242 Pontic- porcelain fused to noble metal* $85 4274 Distal or proximal wedge procedure - 6750 Crown - porcelain fused to high noble metal* $85 separate procedure $50 6751 Crown - porcelain fused to 4341 Periodontal scaling and root planing - predominantly base metal _ $85 per quadrant $15 $15 6752 Crown - porcelain fused to noble metal* $85 4355 Full mouth debridement 6780 Crown- 3/4 cast high noble metal* $85 4381 Localized site - specific therapy $60 6790 Crown- full cast high noble metal* $85 4910 Periodontal maintenance 6791 Crown- full cast predominantly base metal $85 procedures -following active 6792 Crown- full cast noble metal* $85 surgery (2 in a 12 month period) $15 6930 Recement bridge N/C Member Services (800) 880-1800 Member Code Service Coaavment Removable Prosthodontics Replacement Limit 1 Every 5 years. Procedures identified with a double asterisk (**) are limited to 1 every 24 months. Includes up to 3 adjustments within 6 months of delivery. 5110 Complete upper denture 5120 Complete lower denture 5130 Immediate upper denture 5140 Immediate lower denture 5211 Upper partial - resin base (incl. Clasps, rests & teeth) 5212 Lower partial - resin base (incl. Clasps, rests & teeth) 5213 Upper partial - cast metal base with resin saddles (incl clasps, rests & teeth)* . 5214 Lower partial - cast metal base with resin saddles.(incl. Clasps, rests & teeth)* 5410 Adjust complete denture - upper 5411 Adjust complete denture - lower 5421 Adjust partial denture - upper 5422 Adjust partial denture - lower 5510 Repair broken complete denture base 5520 Replace missing or broken teeth 5610 Repair resin denture base 5620 Repair cast framework 5630 Repair or replace broken clasp 5640 Replace broken teeth - per tooth 5650 Add tooth to existing partial denture 5660 Add clasp to existing partial denture 5710 Rebase complete upper denture 5711 Rebase complete lower denture 5720 Rebase upper partial denture 5721 Rebase lower partial denture 5730 Reline complete upper denture (chairside)* 5731. Reline complete lower denture (chairside)* 5740 Reline upper partial denture (chairside)* * 5741 Reline lower partial denture (chairside)** 5750 Reline complete upper denture (laboratory)* 5751 Reline complete lower denture (laboratory)** 5760 Reline upper partial denture (laboratory)** 5761. Reline lower partial denture (laboratory)* * 5820 Interim partial denture (maxillary) 5821 Interim partial denture (mandibular) 5850 Tissue conditioning (maxillary) 5851 Tissue conditioning (mandibular) Oral Surgery Includes routine -postoperative visits / treatment. Surgical removal of impacted teeth - (not covered unless pathology [disease] exists). Surgical removal of wisdom tooth/third molar for orthodontic reasons only is not covered. 7110 Extraction - single tooth 7120 Extraction - each additional tooth 7130 Root removal- exposed roots 7210 Surgical removal of erupted tooth 7220 Extraction - removal of impacted tooth - soft tissue 7230 Extraction - removal of impacted tooth - partially bony $100 $100 $100 $100 $100 $100 $125 $125 N/C N/C N/C N/C $10 $10 $10 $10 $10 $10 $10 $10 $35 $35 $35 $35 $20 $20 $20 $20 $35 $35 $35. $35 $35 $35 $10 $10 N/C N/C N/C $15 $15 $60 bWo. 2 Code Service Coaavment 7240 Extraction - removal of impacted tooth - completey bony $90 7241 Extraction - removal of impacted tooth - completely boM with unusual surgical complications $130 7250 Surgical extraction - removal of residual tooth roots $50 7270 Tooth reimplantation and/or stabilization $110 7280 Surgical exposure of impacted. unerupted tooth for orthodontic reasons $175 7285 Biopsy of oral tissue- hard N/C 7286 Biopsy of oral tissue- soft N/C 7310 Alveoplasty in conjunction with extractions - per quadrant N/C 7320 Alveoplasty not in conjunction with extractions - per quadrant N/C 7960 Frenulectomy (frenectomy or frenotomy) - separate procedure N/C 7971 Excision of pedcoronal gingiva $40 Adjunctive General Services Sill) Palliative (emergency) treatment of dental pain -minor procedures N/C 9215 Local anesthesia N/C 9310 Consultation (diagnostic service provided by dentist other than practitioner providing treatment) N/C 9430 Office visit for observation (during regularly scheduled hours) N/C 9440 Office visit- after regularly scheduled hours $20 9630 Medicinal application/irrigation per visit : $15 9951 Occlusion adjustment • limited N/C 9952 Occlusion adjustment -complete N/C 9999 Broken appointment (less than 24-hour notice) $10 Orthodontics 8660 Consultation N/C 8999 Orthodontic treatment plan & records (pre/post x-rays, photos, study models) $250 $020 Limited orthodontic treatment of the transitional dentition (up to 24 months) $725 8030 Limited orthodontic treatment of the adolescent dentition (up to 24 months) $725 8040 Limited orthodontic treatment of the adult dentition (up to 24 months) $725 8070 Comprehensive orthodontic treatment of the transitional dentition (full treatment case up to 24 months - incl. Fixed/removable appliances) $1450 8080 Comprehensive orthodontic treatment of the adolescent dentition (full treatment case up to 24 months - Incl. Fused/removable appliances) $1450 8096 Comprehensive orthodontic treatment of the adult dentition (full treatment case up to 24 months - incl. Fixed/removable appliances) $1450 8680 Retention phase (incl. Fee for fixed/removable retainers & monthly visits for 24 mos.) $250 SG85 safeGuard Health Plans Member Services (800) 880-1800 SGSS SafeGuard Health Plans rs Exclusions 1. Services performed by a dentist or dental specialist, not contracted with SafeGuard Health Plans without prior approval by SafeGuard Health Plans (SGHP), (except for out of area emergency services). (ARIZONA members see z below) 2. Any dental services, or appliances which are determined to be not reasonable and/or necessary for maintaining or improving the member's dental health, as determined by the SGHP network dentist. 3. Any procedures not specifically listed as a covered benefit in the Schedule of Benefits. 4. Dental procedures or services performed solely for cosmetic purposes or solely for appearance. 5. Orthognathic surgery. S. General anesthesia or IV sedation unless otherwise listed as a covered benefit on the schedule of benefits. 7. Any inpatient/outpatient hospital charges of any kind including dentist and/or physician charges, prescriptions or medications. 8. Replacement of dentures, crowns, appliances or bridgework that have been lost, stolen, or damaged due to abuse, misuse, or neglect. 9. Treatment of malignancies, cysts, or neoplasms. 10. Procedures, appliances, or restorations whose main purpose is to change the vertical dimension of occlusion, correct congenital, developmental, or medically induced dental disorders including, but not limited to treatment of myofunctional, myoskeletal, or temporomandibular joint disorders unless otherwise specified as an orthodontic benefit on the schedule of benefits. (COLORADO members see :•3 below) 11. Dental implants and services associated with the placement of implants, prosthodontic restoration of dental implants, and specialized implant maintenance services. 12. Precision attachments. 13. Any dental procedure or treatment unable to be performed in the dental office due to the general health or physical limitations of the member including, but not limited to physical or emotional resistance, inability to visit the dental office, or allergy to commonly utilized local anesthetics. 14. Dental procedures initiated prior to the member's eligibility under this benefit plan or started after the member's termination from the Plan. 15. Dental services provided for or paid by a federal or state government agency or authority, political subdivision, or other public program other than Medicaid or Medicare. (ARIZONA members see 4.•' below) 16. Dental Services relating to injuries which are self-inflicted. (TEXAS members see ees below) 17. Dental Services required while serving in the Armed Forces of any country or international authority or relating to a declared or undeclared war or acts of war. 18. Services considered unnecessary or experimental in nature. 19. Dental procedures or appliances for minor tooth guidance or for the control of harmful habits. Limitations 1. Prophylaxis: Once every six months 2. Fluoride treatment: Once every six months up to age" 18. 3. Full -mouth X-rays: Once every three years 4. Dentures (full or partial}: Replacement only after 5 years have elapsed following arrypnor provision of sucti dentures under SafeGuar�rrt 3ap2 Replacements will be a benefit only if the existing dI i5 unsatisfactory and can not be made satisfactory as determined by the SafeGuard contracted general dentist. 5. Sealants: Plan benefit applies to primary and permanent molar teeth, within four years of eruption. Orthodontic Exclusions and Limitations 1. Orthodontic treatment must be provided by a participating SafeGuard provider. It. Plan benefits shall cover 24 months of usual and customary orthodontic treatment and an additional 24 months of reten- tion. Treatment extending beyond such time periods will be subject to a per -office -visit charge of $25. Ill. The following are not included as orthodontic benefits: 1. repair or replacement of lost or broken appliances 2. retreatmertt of orthodontic cases 3. treatment in progress at inception of eligibility 4. inteiceptive or phase 1 orthodontics 5. changes in treatment necessitated by an accident 6. treatment involving: a. maxillo-facial surgery, myofunctional therapy, cleft palate, micrognathia, macroglossia (COLORADO members see 6 below) b. surgically exposing impacted teeth (i.e. maxillary cuspids) c. hormonal imbalances or other factors affecting growth or developmental disturbances d. treatment related to temporomandibular joint disorders e. lingually placed direct bonded appliances and arch Wires ('invisible braces') f. functional appliances that are used in conjunction with fixed appliances IV. The retention phase of treatment shall include the construction, placement, and adjustment of retainers. Notes •:•' Arizona Members Only Procedures identified with an asterisk (*) are limited to 1 every 6 months, or more frequently if medically necessary. ❖Z Arizona Members Only Services performed by a dentist or dental specialist, not contracted with SafeGuard Health Plans without prior approval by SafeGuard Health Plans (SGHP), (except for emergency services ). 413 - Colorado Members Only Procedures, appliances, or restorations whose main purpose is to change the vertical dimension of occlusion, correct, developmental, or medically induced dental disorders including, but not limited to treatment of myofunctional, myoskeletal, or temporomandibular joint disorders unless otherwise specified as an. orthodontic benefit on the schedule of benefits. •:•` Arizona Members Only Exclusion #15 is not applicable in Arizona ❖S Texas Members Only Exclusion #16 is not applicable in Texas 46 Colorado Members Only maxrllo-facial surgery, myofunctional therapy, micrognathia, macrogiossia Member Services (800) 880-1800 ELs9.8 SafeGuard Res. No. 2002-32 Directory Of Participating Dentists Dental HMO w PROVLST We give you more to smile aboutSM Enrollment Kit Res. No. 2002-32 Dental Plan Ex. A S xuard i SG-EC)r-3= We give you more to smile about"" About Our Network of Dentists SafeGuard contracts with private practice dentists in your community. All contracted Primary Care Dentists and Specialists are thoroughly evaluated prior to being accepted into our network. This extensive screening includes a verification of the dentist's license and supporting credentials. Each Primary Care Dentist also undergoes an on -site inspection to make sure the facility, equipment and office practices meet SafeGuards high standards and regulatory requirements. In addition, the dental office staff receives ongoing training on the administration of SafeGuard's Plan and our expectations with regard to serving our members. SafeGuard reviews all Primary Care Dental offices as part of our ongoing Quality Management Program. You can be confident that the SafeGuard network dentist you select is well prepared to meet your dental needs. Should you ever wish to transfer to another Primary Care Dentist, you may do so at any time by contacting SafeGuard's Member Services Department toll -free at (800) 880.1800. SafeGuard Advantages Here are just a few of the reasons why you should enroll with SafeGuard... • No claim forms. No deductibles. No annual maximums. • More than 190 dental procedures covered. • Many procedures at low or no copayment. • Multi -state network of pre-screened Primary Care Dentists and Specialists. • Network Primary Care Dentists participate in periodic Quality assessment reviews. • Family members can each select their own network Primary Care Dentist. • Change dentist selection any time. • Adult and child orthodontics. • Specialty care benefits at reduced fees. • Benefits for tooth -colored fillings. • Emergency Care available 24 hours a day, 7 days a week. • Call us toll -free at (800) 880-1800 with any questions. 2 Res. No. 2002-32 Ex. A Welcome To SafeGuard The companies of SafeGuard Health Plans, Inc. ("SafeGuard") have been providing dental benefits for over 25 years. As one of the nation's largest providers of dental benefits, we have partnered with an extensive network of Primary Care Dentists and Specialists to serve your dental care needs. At SafeGuard, our members are our first priority, and we continually strive to improve the value of our services to you. How Your Plan Works Enrolling in your SafeGuard Plan is easyl Just select a Primary Care Dentist for yourself and each enrolled family member from our extensive network. The dentist you choose must be listed in the SafeGuard Directory of Participating Dentists. Once your coverage begins, you may schedule an appointment directly with your selected Primary Care Dentist who will provide all of your general dental care. Should you require more involved treatment, your Primary Care Dentist may refer you to a contracted SafeGuard Specialist. When you receive care from either your selected Primary Care Dentist or a Specialist, you will pay the applicable copayment described on your Schedule of Benefits enclosed with this brochure. Your copayment will either be a fixed dollar amount at your Primary Care Dentist or a percentage discount off the dentist's usual fees at a Specialist. Regardless, your copayment will be significantly less than the fees you would be charged if you were not enrolled in the SafeGuard Plan. You don't have to worry about filing claim forms, meeting deductibles or exceeding maximums. There are none with SafeGuard! 1 Ll i r 0 Res. No. 2002-32 Ex. A Res. No. 2002-32 Ex. A EXHIBIT G — VISION (VSP) PLAN BROCHURE A copy of the Vision (VSP) Brochure may be obtained from the Risk Management Division X . See City Clerk Vault File No. 720.20 01-02 FMA MOU 46 04/02/02 8:31 AM _,ON SERVICE PLAN Benefit Summaryfor CITY OF HUNTINGTON BEACH • AkiERICA's First CHOICE IOR EYECARE BENEFITS: COPAYMENT: Examination Single Vision Lenses Bifocal Lenses Trifocal Lenses Lenticular Lenses Frametzl Tint Contact Lenses (3) Necessary Elective Examination Lenses Frame Examination and/or Materials Services from a VSP Participating Provider Paid -in -Full Paid -in -Full Paid -in -Full Paid -in -Full Paid -in -Full VSP fully covers a wide selection of attractive frames. Paid -in -Full Once every 12 months Once every 12 months Once every 12 months S10.00 Services from a Non -Participating Provider up to $ 40.06 up to $ 40.00 up to $ 60.00 up to $ 80.00 up to $125.00 up to $ 45.00 up to $ 5.00 (Instead of a complete pair of prescription glasses) Paid -in -Full less copayment up to $210.00 up to $ 105.00 up to $105.00 Obtaining services from a VSP doctor: When you want to obtain vision care services, call a VSP doctor to make an appointment. For details on how you locate a VSP doctor, contact your benefits representative or call VSP at 800-877-7195 to request a VSP doctor listing. Make sure you identify yourself as aVSP member, and be prepared to provide the covered member's social security number. The VSP doctor will contact VSP to verify your eligibility and plan coverage, and will also obtain authorization for services and materials. If you are not currently eligible for services, the VSP doctor is responsible for communicating this to you. VSP will pay the doctor directly for covered services and materials. Obtaining services from an out -of network provider: Services and materials obtained from an out -of -network provider will be reimbursed up to amounts on the above schedule less any copayments. For out -of -network reimbursement, pay the entire bill when you receive services, then send your itemized receipts and full patient and member information to VSP. Claims must be submitted to VSP within six months from your date of service. Please keep a copy of the information for your records and send the originals to the following address: Vision Service Plan, Out - of -Network Provider Claims, P.O. Box 997100, Sacramento, CA 95899-7100. ADDITIONAL BENEFITS: Laser Vision Correction: VSP's Laser VisionCareSM program is also available to those covered under this VSP WellVision® Plan. It is designed to provide members with a discount off laser surgery when obtained through VSP contracted doctors, surgeons and laser centers. This program includes the two most common laser vision correction procedures, laser -assisted in -situ keratomileusis (LASIK) and photorefractive keratectomy (PRK). Call your VSP doctor to check if he or she is participating in the program. Doctors can also be located on VSP's Web site at www.vsp.com or by calling 888-354-4434. 1 When an exam and/or materials are received from a VSP doctor, the patient will have no out-of-pocket expense other than the copayment, unless optional items are selected. Optional items include, but are not limited to, oversize lenses (61 mm or larger), coated lenses, no -line multifocal lenses, treatments for cosmetic reasons or a frame that exceeds the plan allowance. VSP doctors offer valuable savings including a 20 percent discount on non -covered pairs of prescription glasses (lenses and frame). Services must be received within 12 months from the same VSP doctor who provided your last covered eye exam You can also save 15 percent off the cost of your contact lens exam when you receive contact lens services from VSP. (This discount does not apply to the contact lens materials). Your VSP benefit provides guaranteed savings whether you choose a frame that is covered in full or one that exceeds the plan allowance. If you choose a frame valued at more than the plan's allowance, the difference you'll pay is based on VSP's low, discounted member, pricing. Have your doctor help you choose the best frame for you based on your VSP coverage. The allowance is in addition to the 15 percent discount on the contact lens exam. The allowance is applied to both the contact lens exam (fitting and evaluation) and the contact lenses. Any costs exceeding this allowance are the patient's responsibility. The contact lens exam is a special exam for ensuring proper fit of your contacts and evaluating your vision with the contacts. Medically necessary contact lenses must be prescribed by your doctor (as required for certain medical conditions) and approved by VSP. THIS IS ONLY A SUMMARY FOR FURTHER INFORMATION, SEE YOUR EMPLOYER'S BENEFIT REPRESENTATIVE VISIONSERh7CE PLAN CUSTOMER SERVICE (800) 877-7195 Visit our Web site at http://www.vsp.Com VSP makes it easy to use your eye care benefits and to maintain your eye health. Just follow the steps below and you will be on your way to quick and easy eye care. 1. Consult your benefits information, available from your benefats representative VSP supplies your benefits representative with information that outlines your cover- age plus listings of VSP doctors. Visit your benefits representative to review your coverage and locate a VSP doctor before scheduling an appointment. 2. Find a VSP doctor If you do not have a VSP doctor, simply find' one by: • using our doctor directory service at www.vsp.com, or • calling 1-800-877-7195. VSP's member service center offers tvvo ways to find a doctor near your home or office — member service or our automated telephone system. To speak to a member service representa- tive, call between 9 a.m. and 9 p.m., East- ern Standard Time, Monday through Friday. r .. AME RICAS FIRWCHOICE FOR EYECARF Use your telephone key pad after hours and on weekends to verify your coverage or locate a doctor. 3. Set an appointment with your VSP doctor Once you've found a doctor, call the office to make an appointment. Provide the following. • Your name and that you're a VSP member. • Your VSP member group or employer. • Your Social Security number or other identification number. • Your date of birth. If you are making an appointment for a dependent, provide the member's name, member's Social Security number and dependents date of birth. Your doctor will obtain authorization for services. If you are not eligible, the doctor will notify you. Keep your scheduled appointment and make any copayments. You are responsible for additional costs from cosmetic options or non -covered services. VSP and your doctor will take care of the rest. Its that simple! You dont need to read an extensive manual or obtain permission to access your VSP benefits. Remember, the next time you're eligible for eye care through VSP, it's Easy as 1, 2, 3! 114it our Web site at uuzc.isp.con: , Usion SenicePlan is an Equal Oppor7unity and Afj'trmatitwAction employer. eas),T asl,� VSP 3 c00382 Answers anytime, anywhere Information sources especially for you Your information needs aren't constricted to 8 am-5 pm right? Whose are really? That's why, at Vision Service Plan (VSP), we make sure the information you need is only a click or a phone call away. Click or Call Looking for a VSP doctor? Got a question about your vision benefits? Access VSP.com or call Member Services and find the answers. With these easy -to -use systems, you'll find information on: • Locating a VSP doctor near you • How to use your eye care benefits • Eye care coverage information • Answers to frequently asked questions about your eye care coverage • Important eye care and health information including the importance of a thorough eye exam, information about vision difficulties and links to vision and general wellness Web sites 2002-32 x. A AIERIGA'9 EIRST EHOIC[ GOR'EY ECA RE, ., It couldn't be easier To reach our Internet site, simply go to www.vsp.com and follow the member links. For Member Services, dial 1-800-877-7195 and listen to the easy -to -follow instructions, or you can always talk directly to a Member Service Representative by simply pressing "0" to be transferred. Member Services Representatives are available Monday through Friday, 6:00 am to 6:00 pm PST. E; i i VSservices 0 /00 Vision Service Plan is an Equal Opportuniry and Affirmative Action emploN er. #507 Welcome to the Finding a VSP Doctor Nation's Premier Eyeeare Health ]Plan! Yot.tr VSP Benefits at a Glance As a Vision Service Plan member, you. Dave: Great access to doctors We have the nation's largest eyecare doctor network, with thousands of doctors located in metropolitan as well as rural areas. Excellent health protection All of our plans provide a thorough eye examination, which is important to your overall health. Eye examinations can detect and diagnose numerous medical problems, including diabetes, glaucoma, high blood pressure and certain cancers. Iliglt quality We were one of the first eyecare health plans to use stringent National Committee for Quality Assurance guidelines to credential all of our doctors. These guidelines are increasingly becoming the national benchmark for evaluating the quality of health plans. VSP benefits are designed to protect your visual wellness. Consequently, you may have to pay extra if you choose certain cosmetic or elective eyewear options. Before selecting your eyewear, ask your doctor what is fully covered by your VSP plan. The following summarizes the main benefits of your plan. BENEFIT FREQUENCY CO -PAY FROM VSP DOCTOR FROM OUT -OF -NETWORK PROVIDER Examination 12 months' Lenses' 12 months' Frame' 12 months' Contact Lenses'" Medically Necessary' 12 months' Elective 12 months' Covered Covered up to $40 Covered Covered up to $40/single vision Covered up to $60/bifocal $10 for Covered up to $80/trifocal covered benefit Covered up to $125/lenticular (services & materials) A wide selection of attractive frames Covered up to $45 are covered in full Covered Covered up to $210 None Covered up to $105 Covered up to $105 1 Based on your last date of service. 2 Your plan provides a 20 percent discount on non -covered complete pairs of prescription glasses when provided by a VSP doctor. 3 Patients choosing contacts use their eligibility for a frame and lenses. 4 Your plan includes a 15 percent discount off of the VSP doctor's professional services when buying contact lenses. Materials are provided at the customary fees. 5 Medically necessary contact lenses must be prescribed by a VSP doctor for certain conditions. Your VSP doctor. must get prior approval from VSP for.medically necessary contact lenses. You can easilyfind ind a VSP doctor by: • Asking your organization's benefits representative • Calling the VSP Customer Service phone number • Logging on to the VSP Web site at www.vsp.com, and using the Doctor Directory Services From an Out -of -Network Provider Typically, more than 90 percent of our patients receive care from VSP doctors. If you wish to see an out -of -network provider, VSP will reimburse you up to the amount allowed under your plan's out -of -network provider reimbursement rate. Be aware that your out -of -network provider reimbursement rate does not guarantee full payment, and VSP cannot guarantee patient satisfaction when services are received from an out -of -network provider. If your plan allows such reimbursements, pay the entire bill when you see the out -of -network provider and gather the following information: • The provider's bill, including a detailed list of the services you received • The covered member's VSP member identification number (usually the Social Security number) • The covered members name, phone number and address • The name of the organization that provides your VSP coverage • Your name, date of birth, phone number and address • Your relationship to the covered VSP member (such as "self," "spouse," "child," etc.) Claims must be filed with VSP within six months after seeing the provider. Please keep a copy of the information for your records and send the originals to: Vision Service Plan Attn.: Out -of -Network Provider Claims P.O. Box 997100 N Sacramento, CA 95899-7100 0 N 0 a City of Huntington Beach N 00105162 #40404 6/99 M Res. No. 2002-32 Ex. A Policyowner:. STANDARD INSURANCE COMPANY A Stock Life Insurance Company 900 SW Fifth Avenue Portland, Oregon 9.7204-1282 (503) 321-7000 People. Not jux1 Pokier. CERTIFICATE: GROUP LIFE INSURANCE City of Huntington Beach Policy Number. 332175-XX Effective Date: February 1,1995 A Group Policy has been issued to the Policyowner. We certify that you will be insured as provided by the terms of the Group Policy. If your coverage is changed by an amendment to the Group Policy, we will provide the Policyowner with a revised Certificate or other notice to be given to you. This policy includes an Accelerated Benefit. The receipt of this benefit maybe taxable and may affect your eligibility for Medicaid or other government benefits or entitlements. You should consult your personal tax and/or legal advisor before you apply for an Accelerated Benefit. Possession of this Certificate does not necessarily mean you are insured. You are insured only if you meet the requirements set out in this Certificate. "We", "us" and "our" mean Standard Insurance Company. "You" and "your" mean the Member. All other defined terms appear with the initial letter capitalized. Section headings, and references to them, appear in boldface type. President GC190-LTE es Printed on recyded pope- Res. No. 2002-32 Ex A CALIFORNIA, LIFE AND HEALTH INSURANCE GUARANTEE ASSOCIATION ACT SUMMARY DOCUMENT AND DISCLAIMER Residents of. California who purchase life and health insurance and annuities should know that the insurance companies licensed in this state to write these types of insurance are members of the California Life and Health Insurance Guarantee Association ("CLHIGA'). The purpose of this Association is to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Guarantee Association will assess its other member insurance companies for the money to pay the claims of the insured persons who live in this state and, in some cases, to keep coverage in force. The valuable extra protection provided by these insurers through the Guarantee Association is not unlimited, however, as noted below, and is not a substitute for consumers' care in selecting insurers. The California Life and Health Insurance Guarantee Association may not provide coverage for this policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in California. You should not rely on coverage by the Association in selecting an insurance company or in selecting an insurance policy. Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk, such as a variable contract sold by prospectus. Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the. existence of the guarantee association to induce you to purchase any }rind of insurance policy. Policyholders with additional questions should first contact their insurer or agent or may then contact. The California Life and Health Insurance Guarantee Association PO Box 17319 Beverly Hills CA 90209-3319 OR Consumer Services Division California Department of Insurance 300 S Spring St,14th Fl Los Angeles CA 90013 The state law that provides for this safety -net coverage is called the California Life and Health Guarantee Association Act. Below is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations under the Act or the rights or obligations of the Association. COVERAGE Generally, individuals will be protected by the California Life and Health Insurance Guarantee Association if they live in this state and hold a life or health insurance contract, or an annuity, or if they are insured under a group insurance contract, issued by a member insurer. The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state. Res. No. 2002-32 Ex. A EXCLUSIONS FROM COVERAGE However, persons holding such policies are not protected by this Guarantee Association if: Their insurer was not authorized to do business in this state when it issued the policy or contract; Their policy was issued by a health care service plan. (HMO, Blue Cross, Blue Shield), a charitable organization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company, an insurance exchange, or a grants and annuities society-, They are eligible for protection under the laws of another state. This may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insureds who live outside that state. The Guarantee Association also does not provide coverage for. Unallocated annuity contracts; that is, contracts which are not issued to and owned by an individual and which guarantee rights to group contract holders, not individuals; Employer or association plans, to the extent they are self -funded or uninsured; Any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as a variable contract sold by prospectus; Any policy of reinsurance unless an assumption certificate was issued; Interest rate yields that exceed an average rate; Any portion of a contract that provides dividends or experience rating credits. LDUIPS ON AMOUNT OF COVERAGE The Act limits the Association to pay benefits as follows: 80% of what the insurance company would owe under a policy or contract up to $100,000 in cash surrender values, $100,000 in present value of annuities, or $250,000 in life insurance death benefits. A maximum of $250,000 for any one insured life no matter how many policies and contracts there were with the same company, even if the policies provided different types of coverages. A maximum of $200,000 of the contractual obligations that the health insurance company would owe were it not insolvent. The maximum may increase or decrease annually based upon changes in the health care cost component of the consumer price index. I' 01 6 1 t N 6 &1111410):4_t Member insurers are required to recoup assessments paid to the Association by way of a surcharge on premiums charged for health insurance policies to which the Act applies. Res. No. 2002-32 Ex. A CAIMORNIA NOTICE OF COMPLAINT PROCEDURE Should any dispute arise about your premium or about a claim that you have filed, write to the company that issued the group policy. If the problem is not resolved, you may also write to the State of California, Department of Insurance, Consumer Services Division, 300 S. Spring Street, 14th FL, Los Angeles, CA 90013, or call toll -free 1-800-927-HELP (4357). This notice of complaint procedure is for information only and does not become a part or condition of this group policy/certificate. Res. No. 2002-32 Ex A Table of Contents COVERAGE FEATURES GE�«Et�l�.POLICY Ii4�ORMATION ............................................................................ � BECOMING INSURED ..................................................................... IR���8I�O� _2 SCHEDULE OFINSURANCE -_----_--'--------�2 REDUCTIONS INI�JGD�J�VQ�____ �OTHER PROVISIONS ________,_________^_______^_______________-__'3 LIFE INSURANCE__^^_^__~____.___-_^__'__-_ ......... A- Insuring Clause & ....................................................................................................... BLAmoont OyLife Insurance _____,______________-____-__'-----'---'--'. 4 C. In I��/Insurance _.___._______________________�__________-4 D. Suicide Exclusion: Life Insurance ......................................................................... 4 E. When Life Insurance Becomes EOective_____________________ F. When Life Insurance Ends _.________________________-_-,_-'_-'---'-'. 5 G. Reinstatement 0fLife Insurance ......................................................................... 5 ACTIVE WORK PROVISIONS __~__.__________.____~______________________^. 6 STfM CONTINUATION_____________.____________,_____________'.. 6 WAIVEROF PREMIUM 6 ................................................................................................... ACCELERATED BENEFIT 8 ................................................................................... RIGHT TO CONVERT .................................................... 9 CLAIMS ________.................. 18 ` �� .............................I3ALLOCATION ` OF AUTHORITY ................................... _____________..________^_-_-''I4 TIME ACTIONS ____________�_______________--_---.--.--14 INCONTESTABILITY PROVISIONS .............................................................................. l4 Res. No. 2002-32 Ex. A Index of Defined Terms The page number shown below is where the term is defined. For terms defined by an entire section, the page number below is the page on which that section begins. Accelerated Benefit, 8 Proof Of Loss,11 Active Work, Actively At Work, 6 AD&D Insurance, 15 Annual Earnings, 15 Qualifying Event; 9 Qualifying Medical Condition, 8 Beneficiary, 12 Class Definition,1 Contributory, 15 Conversion Period, 9 Dependents Life Insurance, 15 Eligibility Waiting Period, 15 Recipient,13 Right To Convert, 9 schedule, I Sickness, 16 Spouse, 16 Strike Continuation, 3 Supplemental Life Insurance, 16 Employer(s),1 Totally Disabled, 7,10 Evidence Of Insurability„ 16 Waiting Period (for Waiver of Premium), 7 Group Policy, 16 Waiver Of Premium, 6 Group Policy Effective Date, 1 Group Policy Number, 1 you, your (for Right To Convert),10 Injury, 16 Insurance (for Accelerated Benefit), 9 Insurance (for Right To Convert), 9 Insurance (for Waiver of Premium), 7 Leave of Absence Provision, 3 Life Insurance, 16 Maximum Conversion Amount, 3 Member, 1 Minimum Time Insured, 3 Noncontributory, 16 Nursing Home, 9 Physician, 9, 16 Policyowner, 1 Pregnancy, 16 Prior Plan, 16 Res. No. 2002-32 Ex. A COVERAGE FEATURES This section contains many of the features of your group life insurance. Other provisions, including exclusions and limitations, appear in other sections. Please refer to the text of each section for full details. The Table of Contents and the Index of Defined Terris help locate sections and definitions. GENERAL POLICY INFORMATION Group Policy Number: Type of Insurance Provided: Life Insurance: Accidental Death And Dismemberment (AD&D) Insurance: Supplemental Life Insurance Dependants Life Insurance Policyowner. Employer(s): Group Policy Effective Date: 332175-XX Yes Not applicable Not applicable Not applicable City of Huntington Beach City of Huntington Beach February 1,1995 State of Issue: California BECOMING INSURED To become insured for Life Insurance you must: (a) Be a Member; (b) Complete your Eligibility Waiting Period; and (c) Meet the requirements in Life Insurance and Active Work Provisions. The requirements for becoming insured for coverages other than Life Insurance are set out in the text. Definition of Member. You area Member if you are one of the following. 1. An active member of, or in a class represented by the Police Management Association, the Management Employee Organization or the Fire Management Association regularly working at least 20 hours each week; or 2. An active Non -Associated employee of the Employer regularly working at least 20 hours each week; or 3. An Elected Department Head (City Treasurer, City Attorney or City Clerk) You are not a Member if you are: 1. A temporary or seasonal employee; or 2. A full time member of the armed forces of any country. Class Definition: Class 1: Management Employees Organization Members, Fire Management Association Members, Non -Associated Members, Elected Department Heads or City Council Members 0 Printed 10/25/01 1 332175-Xx Life Res. No. 2002-32 Ex. A Class 2: Police Management Association Members Eligibility Waiting Period: Plan 1 insurance: You are eligible on the first day as a Member. Plan 2 insurance: e: You are eligible on the first day of the calendar month after becoming a Member. Evidence Of Insurability Required for. a. Late application for Contributory insurance. b. Reinstatements if required. c. Members eligible but not insured under the Prior Plan. d. For all plan 2 Life Insurance. e. For becoming insured for any amount - greater than the amount for which you were insured under the Prior Plan, if your insurance under the Prior Plan was limited because you did not provide evidence of insurability or because your evidence of insurability was not approved. PREMIUM CONTRIBUTIONS Life and AD&D Insurance Plan 1: Noncontributory Plan 2: Contributory SCHEDULE OF INSURANCE You will become insured under Plan 1 if you meet the requirements to become insured under the Group Policy You may only become insured under Plan 2 if you are a Class 1 member and meet the requ drements to become insured for Plan 2 Life Insurance under the Group Policy. Plan 2 is a Contributory. Plan requiring premium contributions from Members. Life Insurance: Plan 1: Class 1: $45,000 Class 2: $40,000 Plan 2: Class 1: $25,000 Class 2: $25,000 . REDUCTIONS IN INSURANCE If you reach an age shown below, the amount of insurance will be the amount determined from the Schedule of Insurance, multiplied by the appropriate percentage below. Life and AD&D Insurance Age Percentage 70 through 74 65% 75 or over 50%v Printed 10/25/01 2 332175-XX-Life Res. No. 2002-32 Ex. A OTHER PROVISIONS Waiver Of Premium: Yes Limits on Right To Convert if Group Policy terminates or is amended: Minimum Time Insured: Maximum Conversion Amount: Suicide Exclusions: Leave of Absence Provision: Strike Continuation: Annual Earnings based on: 5 years $2,000 Apply to: Plan 2 Life Insurance 60 days of a scheduled leave of absence. Yes. The Strike Continuation premium percentage is 120% of the Premium Rate. Earnings in effect on your last full day of Active Work. Printed 10/25/01 3 332175-XX-Life Res. No. 2002-32 Ex. A LIFE INSURANCE A. Insuring Clause If you die while insured for Life Insurance, we will pay benefits according to the terms of the Group Policy after we receive satisfactory Proof Of Loss. B. Amount Of Life Insurance See the Coverage Features for the amount of your Life Insurance. C. Changes In Life Insurance Subject to 1 and 2 below, a change in your Life Insurance will become effective on the first day of the calendar month coinciding with or nest following the date of change in classification, age, Annual Earnings, or other factor shown in the Coverage Features. 1. All increases in your Life Insurance are subject to the Active Work Provisions. 2. Insurance which exceeds any Guarantee Issue Amount shown in the Coverage Features will become effective on the date we approve your Evidence Of Insurability. D. Suicide Exclusion: Life Insurance The Coverage Features states which Life Insurance plan is subject to this suicide exclusion. If your death results from suicide or other intentionally self-inflicted Injury, while sane or insane, 1 and 2 below apply. 1. The amount payable will exclude the amount of your Life Insurance which is subject to this suicide exclusion and which has not been continuously in effect for at least 2 years on the date of your death, including time you were insured under your Employer's group life insurance program with a prior carrier. 2. We will refund all premiums paid for that portion of your Life Insurance which is excluded from payment under this suicide exclusion. E. When Life Insurance Becomes Effective The Coverage Features states whether your Life Insurance is Contributory or Noncontributory. 1. Noncontributory Life Insurance Subject to the Active Work Provisions, your Noncontributory Life Insurance becomes effective on the date you become eligible. 2. Contributory Life Insurance You must apply in writing for Contributory Life Insurance and agree to pay premiums. Subject to the Active Work Provisions, your Life Insurance becomes effective on: a. The date you become eligible, if you apply on or before that date; b. The date you apply, if you apply within 31 days after you become eligible; or c. The first day of the month after we approve your Evidence Of Insurability, if you apply more than 31 days after you become eligible (late application). 3. Insurance Subject To Evidence Of Insurability Subject to the Active Work Provisions, insurance subject to Evidence Of Insurability becomes effective on the date we approve Evidence Of Insurability. Printed 10/25/01 4 332175-XX Life Res. No. 2002-32 Ex. A 4. Takeover Provisions a. If you were insured under the Prior Plan on the day before the effective date of your Employer's coverage under the Group Policy, your Eligibility Waiting Period is waived on the effective date of your Employer's coverage under the Group Policy. b. You must submit satisfactory Evidence Of Insurability to become insured for Life Insurance if you were eligible under the Prior Plan for more than 31 days but were not insured. F. When Life Insurance Ends Life Insurance ends automatically on the earliest of- 1. The date the last period ends for which you made a premium contribution, if your insurance is Contributory; 2. The date the Group Policy terminates; 3. The date your employment terminates; and 4. The date you cease to be a Member. However, if you cease to be a Member because you are working less than the required minimum number of hours, your Life Insurance will be continued with premium payment during the following periods, unless it ends under 1 through 3 above. a. While your Employer is paying you at least the same Annual Earnings paid to you immediately before you ceased to be a Member. b. While your ability to work is limited because of Sickness, Injury, or Pregnancy. c. During the first 60 days of a temporary layoff. d. During a leave of absence if continuation of your insurance under the Group Policy is required by a state -mandated family or medical leave act or law. e. During any other scheduled leave of absence approved by your Employer in advance and in writing and lasting the Leave Of Absence Period shown in the Coverage Features. G. Reinstatement Of Life Insurance If your Life Insurance ends, you may become insured again as a new Member. However, 1 through 4 below will apply. I. If your Life Insurance ends because you cease to be a Member, and if you become a Member again within 90 days, the Eligibility Waiting Period will be waived. 2. If your Life Insurance ends because you fail to make a required premium contribution, you must provide Evidence Of Insurability to become insured again. 3. If you exercised your Right To Convert, you must provide Evidence Of Insurability to become insured again. 4. If your insurance ends because you are on a federal or state -mandated family or medical leave of absence, and you become a Member again immediately following the period allowed, your insurance will be reinstated pursuant to the federal or state -mandated family or medical leave act or law. u.LF.129x Printed 10/25/O1 5 332175-XX-Life Res. No. 2002-32 Ex. A ACTIVE WORK PROVISIONS If you are incapable of Active Work because of Sickness, Injury or Pregnancy on the day before the scheduled effective date of your insurance or an increase in your insurance, your insurance or increase will not become effective until the day after you complete one full day of Active Work as an eligible Member. Active Work and Actively At Work mean performing the material duties of your own occupation at your Employer's usual place of business. You will also meet the Active Work requirement if: 1. You were absent from Active Work because of a regularly scheduled day off, holiday, or vacation day, 2. You were Actively At Work on your last scheduled work day before the date of your absence; and 3. You were capable of Active Work on the day before the scheduled effective date of your insurance or increase in your insurance. U.AW.02 STRIKE CONTINUATION Insurance may be continued for up to 6 months while you are absent from Active Work because of a strike, lockout or other general work stoppage caused by a labor dispute. Rules 1 through 4 below will apply. 1. When your compensation is suspended or terminated because of a work stoppage, your Employer will immediately notify you in writing of your rights under this provision. Your Employer will mail the notice to you at your last address on record with the Employer. 2. You must pay the entire premium for your insurance, including the Employer's share, if any, to your Employer on or before each Premium Due Date. 3. The premiums for your insurance during the work stoppage will equal a percentage of the premium rate in effect on the date the work stoppage began (see Coverage Features). We may change premium rates during the work stoppage according to the terms of the Group Policy. 4. Insurance continued under this provision will end on the earliest of: a. Any Premium Due Date if you fail to make the required premium contribution to your Employer on or before that date. b. The date you have been absent from Active Work for 6 months. c. On the date you begin full-time employment with another employer. d. At our option, on any Premium Due Date if less than 75% of the Members eligible to continue insurance under this provision make the required premium payment to the Employer. U.SK01 WAIVER OF PREMIUM A: Waiver Of Premium Benefit Insurance will be continued without payment of premiums while you are Totally Disabled if- 1. You become Totally Disabled while insured under the Group Policy and under age 60; 2. You complete your Waiting Period; and Printed 10/25/01 6 332175-XX-Life Res. No. 2002-32 Ex. A 3. You give us satisfactory Proof Of Loss. B. Definitions For Waiver Of Premium 1. Insurance means all your insurance under the Group Policy, except AD&D Insurance. 2. Totally Disabled means that, as a result of Sickness, accidental Injury, or Pregnancy, you are unable to perform with reasonable continuity the. material duties of any gainful occupation for which you are reasonably fitted by education, training and experience. 3. Waiting Period means the 180 consecutive day period beginning on the date you become Totally Disabled. Waiver Of Premium begins when you complete the Waiting Period. C. Premium Payment Premium payment must continue until the later of 1. The date you complete your Waiting Period; and 2. The date we approve your claim for Waiver Of Premium. D. Refund Of Premiums We will refund up to 12 months of the premiums that were paid for Insurance after the date you become Totally Disabled. E. Amount Of Insurance The amount of Insurance continued without payment of premium is the amount in effect on the day before you become Totally Disabled, subject to the following: 1. Insurance will be reduced or terminated according to the Group Policy provisions in effect on the day before you become Totally Disabled. 2. The amount of Supplemental Life Insurance on your Spouse will be the lesser of a. The amount in effect on the day before you become Totally Disabled; and b. The amount in effect one year before the date you become Totally Disabled. 3. If you receive an Accelerated Benefit, Insurance will be reduced according to the Accelerated Benefit provision. F. Effect Of Death During The Waiting Period If you die during the Waiting Period and are otherwise eligible for Waiver Of Premium, the Waiting Period will be waived. G. Termination Or Amendment Of The Group Policy Insurance will not be affected by termination or amendment of the Group Policy after you become Totally Disabled. R When Waiver Of Premium Ends Waiver of Premium ends on the earliest of: 1. The date you cease to be Totally Disabled; 2. 90 days. after the date we mail you a request for additional Proof Of Loss, if it is not given; 3. The date you fail to attend an examination or cooperate with the examiner, 4. With respect to the amount of Insurance which an insured has converted, the effective date of the individual life insurance policy issued to the insured; and 5. With respect to your Supplemental Life Insurance, the date you reach age 70. Printed 10/25/01 7 332175-XX-Life Res. No. 2002-32 Ex. A ACCELERATED BENEFIT A. Accelerated Benefit u.WP21 If you qualify for Waiver Of Premium and incur a Qualifying Medical Condition while you are insured under the Group Policy, we will pay an Accelerated Benefit to you according to the terms of the Group Policy after we receive satisfactory Proof Of Loss. Qualifying Medical Condition means: 1. You are terminally ill, with a life expectancy of less than 12 months; or 2. You are permanently confined to a Nursing Home and have been in residence there for at least 60 days.. We may have you examined at our expense in connection with your claim for an Accelerated Benefit. Any such examination will be conducted by one or more Physicians of our choice. B. Application For Accelerated Benefit You must have at least $10,000 of Insurance in effect to be eligible. You must apply for. an Accelerated Benefit. To apply you must give us satisfactory Proof Of Loss on our forms. Proof Of Loss must include a statement from a Physician that you have a Qualifying Medical Condition. C. Amount Of Accelerated Benefit You may receive an Accelerated Benefit of up to 50% of your Insurance. The maximum Accelerated Benefit is $250,000. The minimum Accelerated Benefit is $5,000 or 10% of your Insurance, whichever is greater. If the amount of your Insurance is scheduled to reduce within 24 months following the date you apply for the Accelerated Benefit, your Accelerated Benefit will be based on the reduced amount. If your Insurance is scheduled to end within 24 months following the- date you apply for the Accelerated Benefit, you will not be eligible for the Accelerated Benefit. You may elect an Accelerated Benefit once in your lifetime. The Accelerated Benefit will be paid to you in a lump sum. If you recover from your Qualifying Medical Condition after receiving an Accelerated Benefit, we will not ask you for a refund. D. Effect On Insurance And Other Benefits The amount of your Insurance after payment of the Accelerated Benefit will be: 1. The amount of your Insurance as if no Accelerated Benefit had been paid; minus 2. The amount of the Accelerated Benefit; minus 3. An interest charge calculated as follows: A times B times C divided by 365 = interest charge. A = The amount of the Accelerated Benefit. B = The monthly average of our variable policy.loan interest rate. C = The number of days from payment of the Accelerated Benefit to the earlier of (1) the date you die, and (2) the date you have a Right To Convert. Your AD&D Insurance, if any, is not affected by payment of the Accelerated Benefit. Printed 10/25/01 8 332175-XX-Life Res. No. 2002-32 Ex. A E. Exclusions No Accelerated Benefit will be paid if: 1. All or part of your Insurance must be paid to your Child(ren), or your Spouse or former Spouse as part of a court approved divorce decree, separate maintenance agreement, or property settlement agreement. 2. You are married and live in a community property state unless you give us a signed written consent from your Spouse. 3. You have made an assignment of all or part of your Insurance unless you give us a signed written consent from the assignee. 4. You have filed for bankruptcy, unless you give us written approval from the Bankruptcy Court for payment of the Accelerated Benefit. 5. You are required by a government agency to use the Accelerated Benefit to apply for, receive, or continue a government benefit or entitlement. 6. You have previously received an Accelerated Benefit under the Group Policy. F. Definitions For Accelerated Benefit Insurance with respect to Qualifying Medical Condition 1. means your Life Insurance and Supplemental Life Insurance, if any, under the Group Policy. Insurance with respect to Qualifying Medical Condition 2. means your Life Insurance and does not include your Supplemental Life Insurance, if any, under the Group Policy. Nursing Home means a licensed institution operated for the purpose of providing. nursing care and treatment for individuals which provides 24-hour nursing services under the direction and supervision of a Physician. Physician means a licensed M.D. or D.O., other than yourself, acting within the scope of the license. UA&82 RIGHT TO CONVERT A. Right To Convert You may buy an individual policy of life insurance without Evidence of Insurability if: 1. Your Insurance ends or is reduced due to a Qualifying Event; and 2. You apply in writing and pay us the first premium during the Conversion Period. Except as limited under C. Limits On Right To Convert, the maximum amount you have a Right To Convert is the amount of your Insurance which ended. B. Definitions For Right To Convert 1. Conversion Period means the 31-day period after the date of any Qualifying Event. 2. Insurance means all your insurance under the Group Policy, including insurance continued under Waiver Of Premium, but excluding AD&D Insurance. 3. Qualifying Event means. termination or reduction of your Insurance for any reason except: a. The Member's failure to make a required premium contribution. b. Payment of an Accelerated Benefit. Printed 10/25/01 9 332175-XX-Life Res. No. 2002-32 4. You and your mean any person insured under the Group Policy. 5. Totally Disabled means that, as a result of Sickness, accidental Injury, or Pregnancy, you are unable to perform with reasonable continuity the material duties of any gainful occupation for which you are reasonably fitted by education, training and experience. C. Limits On Right To Convert If your Insurance ends or is reduced because of termination or amendment of the Group Policy, 1 and 2 below will apply. 1. You may not convert Insurance which has been in effect for less than the Minimum Time Insured. See Coverage Features. 2. The maximum amount you have a Right To Convert is the lesser of: a. The amount of your Insurance which ended, minus any other group life insurance for which you become eligible during the Conversion Period; and b. The Maximum Conversion Amount. See Coverage Features. However, if your Insurance ends or is reduced because of termination or amendment of the Group Policy, the limitations in 1 and 2 above will not apply to you provided that: 1. You are Totally Disabled on the date of such termination or reduction of your Insurance; and 2. You are not covered under a Waiver of Premium Benefit. D. The Individual Policy You may select any form of individual life insurance policy we issue to persons of your age, except: L. A term insurance policy; 2. A universal life policy; 3. A policy with disability, accidental death, or other additional benefits; or 4. A policy in an amount less than the minimum amount we issue for the form of life insurance you select. The individual policy of life insurance will become effective on the day after the end of the Conversion Period. We will use our published rates for standard risks to determine the premium. E. Death During The Conversion Period If you die during the Conversion Period, we will pay a death benefit equal to the maximum amount you had a Right To Convert, whether or not you applied for an individual policy. The benefit will be paid according to the Benefit Payment And Beneficiary Provisions. LLRC.17 CLAIMS A. Filing A Claim Claims should be filed on our forms. If we do not provide our forms within 15 days after they are requested, the claim may be submitted in a letter to us. B. Time Limits On Filing Proof Of Loss Proof Of Loss must be provided within 90 days after the date of the loss. If that is not possible, it must be provided as soon as reasonably possible, but not later than one year after that 90-day period. Printed 10/25/01 10 332175-XX-Life Res. No. 2002-32 Ex. A Proof Of Loss for Waiver Of Premium must be provided within 12 months after the end of the Waiting Period. We will require further Proof Of Loss at reasonable intervals, but not more often than once a year after you have been continuously Totally Disabled for two years. If Proof Of Loss is filed outside these time limits, the claim will be denied. These limits will not apply while the Member or Beneficiary lacks legal capacity. C. Proof Of.Loss Proof Of Loss means written proof that a loss occurred: 1. For which the Group Policy provides benefits; 2. Which is not subject to any exclusions; and 3. Which meets all other conditions for benefits. Proof Of Loss includes any other information we may reasonably require in support of a claim. Proof Of Loss must be in writing and must be provided at the expense of the claimant. No benefits will be provided until we receive Proof Of Loss. D. Investigation Of Claim We may have you examined at our expense at reasonable intervals. Any such examination will be conducted by specialists of our choice. We may have an autopsy performed at our expense, except where prohibited by law. E. Time Of Payment We will pay benefits within 60 days after Proof Of Loss is satisfied. F. Notice Of Decision On Claim The claimant will receive a written decision on a claim within a reasonable time after we receive the claim. If the claimant does not receive our decision within 90 days after we receive the claim, the claimant will have an immediate right to request a review as if the claim had been denied. If we deny any part of the claim, the claimant will receive a written notice of denial containing 1. The reasons for our decision; 2. Reference to the parts of the Group Policy on which our decision is based; 3. A description of any additional information needed to support the claim; and 4. Information concerning the claimant's right to a review of our decision. G. Review Procedure If all or part of a claim is denied, the claimant must request a review in writing within 60 daysafter receiving notice of the denial. The claimant may send us written comments or other items to support the claim, and may review any nonprivileged information that relates to the request for review. We will review the claim promptly after we receive the request. We will send notice of our decision within 60 days after we receive the request, or within 120 days if special circumstances require an extension. We will state the reasons for our decision and refer to the relevant parts of the Group Policy. u.cLo1 Printed 10/25/01 11 332175-XX Life Res. No. 2002-32 Ex. A ASSIGNMENT The rights and benefits under the Group Policy cannot be assigned. u.As.o1 BENEFIT PAYMENT AND BENEFICIARY PROVISIONS A- Payment Of Benefits Benefits payable because of your death will be paid to the Beneficiary you name. Benefits payable because of your Spouse's death will be paid to the beneficiary your Spouse names. See B through E of this section. The benefits below will be paid to you if you are living. 1. AD&D Insurance dismemberment benefits. 2. Dependents Life Insurance benefits payable because of the death of your insured Child. 3. Accelerated Benefits. Any AD&D Insurance dismemberment benefits which are unpaid at your death will be paid to, the Beneficiary you name to receive Life Insurance benefits. Benefits payable because of the death of your Child which are unpaid at your death will be paid in equal shares to the first surviving class of the classes below. 1. The children of the Child. 2. The parents of the Child. 3. The brothers and sisters of the Child. 4. Your estate. B. Naming A Beneficiary Beneficiary means a person named to receive death benefits. One or more Beneficiaries may be named. Two or more surviving Beneficiaries will share equally, unless specified otherwise. Beneficiaries may be changed at any time without the consent of a Beneficiary. Your Beneficiary designation must be the same for Life Insurance and AD&D Insurance death benefits. Your Beneficiary designations for Fife Insurance and your Supplemental Life Insurance may be different. Your Spouse's Beneficiary designations for Dependents Life Insurance on your Spouse and for Supplemental Life Insurance on your Spouse may be different. A Beneficiary designation must be in writing and: 1. Must be dated and signed by the person malting the designation; 2. Must be delivered to the Policyowner or Employer during the lifetime of the person making the designation; 3. Must relate to the insurance provided under the Group Policy; and 4. Will take effect on the date it is delivered to the Policyowner or Employer. If we approve it, a signed and dated designation under the Prior Plan will be accepted as your Beneficiary designation under the Group Policy. Printed 10/25/01 12 332175-XX-Life Res. No. 2002-32 Ex. A C. Simultaneous Death Provision If a Beneficiary dies on the same day you or your Spouse die, or within 15 days thereafter, benefits will be paid as if that Beneficiary had died first, unless Proof Of Loss with respect to that death is delivered to us before the date of the Beneficiary's death. D. No Surviving Beneficiary If no designation is made or no Beneficiary survives, benefits will. be paid in equal shares to the first surviving class of the classes below. 1. With respect to your death: a. Your spouse. b. Your children. c. Your parents. d. Your brothers and sisters. e. Your estate. 2. With respect to your Spouse's death: a. You. b. Your Spouse's children. c. Your Spouse's parents. d. Your Spouse's brothers and sisters. e. Your Spouse's estate. E. Methods Of Payment Recipient means a person who is entitled to benefits under this Benefit Payment and Beneficiary Provisions section. 1. Lump Sum If the amount payable to a Recipient is less than $10,000, we will pay it in a lump sum. 2. Standard Secure Access Checking Account If the amount payable to a Recipient is $10,000 or more, we will deposit it into a Standard Secure Access checking account which: a. Bears interest; b. Is owned by the Recipient; c. Is subject to the terms and conditions of a confirmation certificate which will be given to the Recipient; and d. Is fully guaranteed by us. 3. Installments Payment to a Recipient may be made in installments if: a. The amount payable is $10,000 or more; b. The Recipient chooses; and c. We agree. Printed 10/25/01 .13 1 332175-XX-Life I Res. No. 2002-32 Ex. A To the extent permitted by law, the amount payable to the Recipient willnot be subject to any legal process or to the claims of any creditor or creditor's representative. usa1s ALLOCATION OF ALTMORITY Except for those functions which the Group Policy specifically reserves to the Policyowner, we have full and exclusive authority to control and manage the Group Policy, to administer claims, and to interpret the Group Policy and resolve all questions arising in the administration, interpretation, and application of the Group Policy. Our authority includes, but is not limited to: 1. The right to resolve all matters when a review has been requested; 2. The right to establish and enforce rules and procedures for the administration of the Group Policy and any claim under it; 3. The right to determine: a. Eligibility for insurance; b. Entitlement to benefits; c. Amount of benefits payable; d. Sufficiency and the amount of information we may reasonably require to determine a., b., or c., above. Subject to the review procedures of the Group Policy, any decision we make in the exercise of our authority is conclusive and binding. TIME LDHTS ON LEGAL ACTIONS No action at law or in equity may be brought until 60 days after we have been given Proof Of Loss. No such action may be brought more than three years after the earlier of. 1. The date we receive Proof Of Loss; and 2. The time within which Proof Of Loss is required to be given. uno1 INCONTESTABILITY PROVISIONS A. Incontestability Of Insurance Any statement made to obtain insurance is a representation and not a warranty. No misrepresentation will be used to reduce or deny a claim unless: 1. The insurance would not have been approved if we had known the truth; and Printed 10/25/01 14 332175-XX-Life Res. No. 2002-32 Ex. A 2. We have given you or any other person claiming benefits a copy of the signed written instrument which contains the misrepresentation. We will not use a misrepresentation to reduce or deny a claim after the insured's insurance has been in effect for two years. B. Incontestability Of Group Policy Any statement made by the Policyowner or Employer to obtain the Group Policy is a .representation and not a warranty. No misrepresentation by the Policyowner or Employer will be used to deny a claim or to deny the validity of the Group Policy unless: 1. The Group Policy would not have been issued if we had known the truth; and 2. We have .given the Policyowner or Employer a copy of a written instrument ment signedby the Policyowner or Employer which contains the misrepresentation. The validity of the Group Policy will not be contested after it has been in' force for two years, except for nonpayment of premiums. uw.oI DEFINMONS AD&D Insurance means accidental death and dismemberment insurance, if any, under the Group Policy. Annual Earnings means your annual rate of earnings from your Employer. Your Annual Earnings will be based on your earnings in effect on your last full day of Active .Work unless a different date applies (see . Coverage Features). Annual Earnings includes: 1. Contributions you make through a salary reduction agreement with your Employer to: a. An IRC Section 401(k), 403(b), 408(k) or 457 deferred compensation arrangement; or b. An executive nonqualified deferred compensation arrangement. 2. Shift differential pay. 3. Amounts contributed to your fringe benefits according to a salary reduction agreement under an IRC Section 125 plan. Annual Earnings does not include: 1. Bonuses. 2. Commissions. 3. Overtime pay. 4. Your Employer's contributions on your behalf to any deferred compensation arrangement or pension plan. 5. Any other extra compensation. Contributory means you pay all or part of the premium for insurance. Dependents Life Insurance means dependents life insurance, if any, under the Group Policy. Eligibility Waiting Period means the period you must be a Member before you become eligible for insurance. See Coverage Features. Printed 10/25/01 15 332175-XX Life Res. No. 2002-32 Ex. A Evidence Of Insurability means an applicant must: 1. Complete and sign our medical history statement; 2. Sign our form authorizing us to obtain information about the applicant's health; 3. Undergo a physical examination, if required by us, which may include blood testing, and 4. Provide any additional information about. the applicant's insurabilitythat we may reasonably require. Group Policy means the group life insurance policy issued by us to the Policyowner and identified by the Group Policy Number. Injury means an injury to your body. Life Insurance means life insurance under the Group Policy. Noncontributory_ means the Policyowner or Employer pays the entire premium for insurance. Physician means a licensed M.D. or D.O., other than yourself, acting within the scope of the license. Pregnancy means your pregnancy, childbirth, or related medical conditions, including complications of pregnancy. Prior Plan means your Employer's group life insurance plan in effect on the day before the effective date of your Employer's coverage under the Group Policy and which is replaced by the Group Policy. Sickness means your sickness, illness, or disease. Spouse means a person to whom you are legally married. Spouse does not include a person who is a full-time member of the armed forces of any country. Supplemental Life Insurance means supplemental life insurance, if any, under the Group Policy. L1.DF.18 Printed 10/25/01 16 332175-XX Life GROUP INSURANCE CERTIFICATE BANKERS LIFE AND CASUALTY COMPANY 222 Merchandise Mart Plaza Chicago, Illinois 60654-2011 (Herein Called the Company) HEREBY CERTIFIES that a Group Accident Policy has been issued to the Policyholder shown below. The insurance is subject in every respect to the terms of the policy, which alone constitutes the contract under which payments are made. Certain terms of the policy are recited on this and the following pages of this Certificate. POLICYHOLDER CITY OF HUNTINGTON BEACH POLICY NO:: SR 83, 557B—IA Huntington Beach, California CERT.NO.: INSURED PERSON: Class IA Employee, as defined below. EFFECTIVE DATE: As defined on Certificate Page IPE. BENEFITS: COVERAGE A: ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE Employee: $45,000.00 Principal Sum COVERAGE B: All Eligible Employees: SEAT BELT BENEFIT The limit of coverage for an Insured Employee shall be an additional 10% of his/her Principal Sum coverage to a maximum benefit of $10,000.00. "Class IA Employee" shall mean all active full-time employees and permanent Part-time employees working 20 or more hours per week under age eighty (80) represented by the Management Employees Organization and the Non -Associated Employees, City Council Members and Elected City Officials under age eighty and not contained in Classes I, II, III or IV. All periods of time under the Policy begin and end at the address of the Policyholder. BANKERS LIFE AND CASUALTY COMPANY President (This certificate replaces any and all insurance certificates and riders that may have been issued previously by Bankers Life and Casualty Company to the Person under the numbered Group Accident policy). =Z�D 226-C Cert.Rev./1-96 Res. No. 2002-32 AS RESPECTS COVERAGE A DEFINITION OF WORDS IN 'THE POLICY Ex. A "Injury" shall mean bodily injury caused by an accident which occurs while the policy is in force and while the Person sustaining such injury is insured under the policy and which results directly and independently of all other causes in a loss covered by the policy AS RESPECTS COVERAGE B "Injury" shall mean -bodily, injury caused solely by an automobile* accident that occurs while the policy is in forte and while the Insured Person sustaining such injury 'xis insured under the policy and that occurs in the United States or Canada, while the Insured Person is properly wearing the unaltered seat belt or lap and shoulder restraint installed by the manufacturer of the automobile* or a.seat belt or lap and shoulder restraint provided by such manufacturer and installed by an authorized dealer of such manufacturer. If such occupant is a child, the restraint must be one approved by the National Highway Traffic Safety Administration, prop- erly,secured, and utilized as recommended by its manufacturer for children of like age and weight. *"Automobile" means a private passenger land motor vehicle of pleasure design. Automobile includes vans, four-wheel drive vehicles, self-propelled motor homes and trucks with a factory -rated load capacity of 2,000 pounds or less, but excludes custom -fabricated specialty vehicles. An automobile does not in- clude any vehicle used for farming, commercial business, military business, racing or any type of competitive speed event. "Person" shall mean an employee (as defined on the.Certificate.Face Page) sRD/226 SR 83,557B (3/96) DP (Cal) NOTICE AND PROQF OF CLAIM Res. No. 200 L Ex. A A Written notice of injury upon which claim may be based must be given to the Company within thirty days of the date of the commencement of the first loss for which benefits arising out of each such injury may be claimed except notice in the case of Permanent Total Disability shall be governed by notice provisions as contained under Permanent Total Disability insurance provisions. Notice given by or in behalf of the Person sustaining the loss to the Company at its Home Office or to any Authorized agent of the Company, with particulars sufficient to identify the Person shall be deemed to be notice to the Company. Failure to furnish notice within the time provided in the polity shall not invalidate any claim if it shall be shown not to have been reasonably possible to furnish such notice and that such notice was furnished as soon as was reasonably possible. The Company, upon receipt of the notice required by the policy, will furnish to the Person sustaining the loss such forms as are usually furnished by it for filing proof of loss. If such forms are not so furnished within fifteen days after the Company receives such notice, the Person sustaining the loss shall be deemed to have complied with the requirements of the policy as to proof of loss upon submitting- within the time fixed in. the policy for filing. proofs of loss, written proof covering the occurrence, character and extent of the loss for which claim is made. Affirmative proof of loss must be furnished to the Company, in case of claim for loss for which the policy provides any periodic payment contingent upon continuing loss, within 90 days after the termination of the period for which the Company is liable, and in case of claim for any other loss, -within 90 days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reason- ably possible to give proof within such time, provided such proof is furnished.as soon as reasonably possible and in no event, except in the absence of legal capacity of the Person sustaining the loss, later than one year from the time proof is otherwise required. PHYSICAL EXAMINATION AND AUTOPSY The Company, at its own expense, shall have the right and opportunity to examine the person of any Person whose injury is the basis of claim when and as often as it may reasonably require during the pendency of a claim hereunder, and to make an autopsy, including disenterment if necessary, in case of death where it is not forbidden by law. PAYMENT OF CLAIM Subject to due proof of loss, all indemnities for loss for which the policy provides payment will be paid to the Person sustaining the loss as they accrue and any balance remaining unpaid at termination of the period of liability will be paid to the Person sustaining the loss immediately upon receipt of due proof. Benefits for loss of life on the Person are payable to the beneficiary designated by the Person. LEGAL PROCEEDINGS No action at law or in equity shall be brought to recover on the policy prior to the expiration of sixty days after proof of loss has been filed in accordance with the requirements of the policy, nor shall such action be brought at all unless brought within three years from expiration of the time within which proof of loss is required by this policy. EXPOSURE AND DISAPPEARANCE If by reason of an accident covered by the policy a Person shall be unavoidably exposed to the elements and as the result of such exposure shall suffer a loss for which indemnity is otherwise payable hereunder, such loss will be covered under the terms of the policy. If the body of a .Person has not been found within one year after the date of disappearance as the result of the sinking or wrecking of the aircraft in which the Person was riding at the time of the accident and under such circumstances as would otherwise be covered hereunder, it will be presumed that the Person suffered loss of life resulting from bodily injury caused solely by an accident. WORKMEN'S COMPENSATION NOT AFFECTED The polity is not in lieu of and does not affect any requirement for coverage by workmen's compensation insurance. SRD/226 GP2 SR 83,557B BENEFICIARY Res. No. 2002-32 The amount payable by reason of the accidental death of an Employee shall be paid to tRY0 A beneficiary or beneficiaries designated in writing by the Employee. An Employee may des— ignate a beneficiary, or change his/her designation of beneficiary, from time to time by written request filed with the Policyholder or with the Company at its Home Office. Such designation or change shall take effect as of the date of execution of such re— quest, whether or not the Employee be living at the time of such filing, but without prejudice to the Company on account of any payments made by it before receipt of such request at its Home Office. Except as may be otherwise specifically provided by the Employee, if any designated ben— eficiary predeceases the Employee, the share which such beneficiary would have received if surviving the Employee shall be payable equally to the remaining designated benefici— ary or beneficiaries, if any, who survive the Employee. If no beneficiary is designated or surviving at the death of the Employee, the amount payable shall be paid to the es— tate of the Employee. All other indemnities are payable to the Insured Person suffering the loss. MAXIMUM LIMIT OF INDEMNITY Notwithstanding the limit of indemnity specified for each Person, the Company's limit of indemnity under the policy for all losses arising out of any one accident is unlimited. In the event this limit of indemnity for any one accident is insufficient to pay the full amount of indemnity for each Person, then the amount of indemnity paid for each Person shall be in the proportion that the limit of indemnity for any one accident bears to the total amount of insurance that would have been payable except for such limit of. indemnity. EXCLUSIONS The policy does not cover loss caused boor resulting directly or indirectly from anyone or more of the following: (1) suicide or self-destruction or any attempt thereat, while sane or insane; (2) bodily infirmity, sickness or disease; (3) medical or surgical treatment (except medical surgical treatment made necessary solely by injury); (4) declared or undeclared war or any act thereof, (5) accidents occurring while serving on active duty in any type of Military Services of any country or international authority (any premium paid to be returned by the Company pro rata for any such period of active duty): (6) injury sustained v. Nile engaged in or taking part in aeronautics and;or aviation of any description or resulting from being in an aircraft except in consequence of riding as a passenger, and not as an operator or crew member, in or on, boarding or disembarking from any aircraft having a current and valid airworthiness certificate or any transport type aircraft operated by the Military Airlift Command (MAO of the United States of America or by any similar air transport service of any duly constituted governmental authority of the recognized government of any nation anywhere in the world. The term "airworthiness certificate" is defined as an N Standard or NC Airworthiness Certificate issued by the Federal Aviation Administration of the United States of America, or any equivalent certificate issued by the jurisdictional agency or authority of the recognized government of any nation anywhere in the world. notwithstanding anything to the contrary stated in (5) above, coverage shall apply while the Person covered hereunder is a member of an Organized Reserve Corps or National Guard Unit and; (a) in attendance at annual field training, cruise, or other active duty or training of less than thirty days (except that while attending a service school the coverage will extend for the duration of the school even though in excess of thirty days), or is enroute directly to or from such training; or (b) participating in a properly authorized periodic inactive duty training assembly or any other inactive duty training authorized by appropriate unit orders; or (c) participating as a member of his unit or detachment in an authorized parade, exhibition or ceremony by official orders. SRD!226 SR 83,557B GP3 A Res. No. 2002-32 EMPLOYEE ELIGIBILITY. Each Employee becomes eligible foi the insurance applicable to his classification 56 Set forth below: 1. On the Effective Date of the Policy; or 2. On the date of hire, if later. EMPLOYEE EFFECTIVE DATE. The insurance hereunder for an eligible Employee shall become effective as set forth below: I. On the date of "EMPLOYEE ELIGIBILITY" as shown above. EMPLOYEE TERMINATION DATE. The insurance of any Employee insured hereunder shall terminate at the ear- liest time indicated below: 1. On the date of termination of the policy; or 2. On the date ending the period for which the last premium payment is made for his/her insurance; or 3. On the date he/she is no longer an eligible employee as defined for insurance under the policy; or 4. On the date the policy is amended to terminate the class of persons to which he/she belongs or the benefits applicable to his/her class of persons. SRD/226 SR 83,557B IPE B Res. No. 2002-32 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE' A If a Person, while insured, sustains an injury which results in one of the following losses WITHIN365 DAYS OF THE DATE OF THE ACCIDENT, the Company will pay for Loss of Life............................................................. The Principal Sum Loss of both hands or both feet ............................................. The Principal Sum Loss of one hand and one foot .............................................. The Principal Sum Loss of the entire sight of both eyes ................... ....................... The Principal Sum Loss of speech and hearing ................................................. The Principal Sum Loss of the entire sight of one eye and one hand or one foot ................................................ The Principal Sum Loss of one hand or one foot ....................................... One -Half The Principal Sum Loss of the entire sight of one eye ................................... One -Half The Principal Sum Loss of speech or hearing......... .... ... . .............. One -Half The Principal Sum Loss of thumb and index finger (of the same hand) ........................................... One -Quarter The Principal Sum If a person, while insured, sustains an injury to the spinal cord which continues for twelve (12) consecutive months and which results in one of the following losses WITHIN 365DAYS OF THE DATE OF THE ACCIDENT, the Com- pany will pay for Quadriplegia (Total paralysis of both upper and lower limbs) ................. Triplegia (Total paralysis of three limbs) ........:.................... . Paraplegia (Total paralysis .......................... The Principal Sum .............. Three -Quarters The Principal Sum of both upper or lower limbs) ................ . ........... .... One -Half The Principal Sum Uniplegia (Total paralysis of a single limb) .................. One -Quarter The Principal Sum Indemnity payable under this provision will not be paid under any circumstances for more than one of the losses, the greatest, sustained by the Person as the result of any one injury. Occurrence of any one of the losses for which indemnity is payable under this provision shall at once terminate all insurance under the policy as to the Person sustaining the loss, but such termination shall be without prejudice to any claim arising out of the accident causing such loss and to the insurance provided hereunder as to any other Person. "Loss," used with reference to hand or foot, means complete severance through or above the wrist or ankle joint, as used with reference to eye, means irrecoverable loss of the entire sight thereof, as used with reference to speech and hearing means entire and irrecoverable and, as used with reference to thumb and index finger, means complete severance through or above metacarpophalangeal joints, and as used with reference to Quadriplegia, Triplegia, Paraplegia and Uniplegia means permanent, complete and irreversible as determined by competent medical authority. SRD/226 ADTIQ-2 SR 83,557B Res. No. 2002-32 Ex. A r STANDARD INSURANCE COMPANY A Stock Life Insurance Company 900 SW Fifth Avenue Portland, Oregon 97204-1282 (503) .321-7000 Dedicated to Excellence . . CERTIFICATE: CROUP LONG TERM DISABILITY INSURANCE Policyowner. City of Huntington Beach Policy Number. 332175XX-LTD Effective Date: February 1,1995 A Group Policy has been issued to the Policyowner. We certify that you will be insured as provided by the terms of the Group Policy. If your coverage is changed by an amendment to the Group Policy, we will provide the Policyowner with a revised Certificate or other notice to be given to you. Possession of this Certificate does not necessarily mean you are insured. You are insured only if you meet the requirements set out in this Certificate. Defined Terms are printed with their first letters capitalized. "We", "us" and "our" mean Standard Insurance Company. "You" and "your" mean the insured person. All other defined terms appear with the initial letter capitalized. Section headings, and references to them, appear in boldface type. GP190-LTD President Printed on n9eycSer3 paper. Res. No. 2002-32 Ex. A CAI"ORNIA LIFE AND HEALTH INSURANCE GUARANTEE ASSOCIATION ACT SUM11ARY DOCUMENT AND DISCLAIMER. Residents of California who purchase life and health insurance and annuities should know that the insurance companies licensed in this state to write these types of insurance are members of the California Life and Health Insurance Guarantee Association ("CIMGA'). The purpose of this Association is to assure that policyholders will be protected, within limits, in the . unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Guarantee Association will assess its other member insurance companies for the money to pay the claims of the insured persons who live in this state and, in some cases, to keep coverage in force. The valuable extra protection provided by these insurers through the Guarantee Association is not unlimited, however, as noted below, and is not a substitute for consumers' care in selecting insurers. The California Life and Health Insurance Guarantee Association may not provide coverage for this policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in California_ You should not rely on coverage by the Association in selecting an insurance company or in selecting an insurance policy. Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer or for. which you have assumed the risk, such as a variable contract sold by prospectus. Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the guarantee association to induce you to purchase any kind of insurance policy. Policyholders with additional questions should first contact their insurer or agent or may then contact: The California Life and Health Insurance Guarantee Association PO Box 17319 Beverly Hills CA 90209-3319 OR Consumer Services Division California Department of Insurance 300 S Spring St, 14th Fl Los Angeles CA 90013 The state law that provides for this safety -net coverage is called the California Life and Health Guarantee Association Act. Below is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations under the Act or the rights or obligations of the Association. COVERAGE Generally, individuals will be protected by the California Life and Health Insurance Guarantee Association if they live in this state and hold a life or health insurance contract, or an annuity, or if they are insured under a group insurance contract, issued by a member insurer. The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state. Res. No. 2002-32 Ex. A EXCLUSIONS FROM COVERAGE However, persons holding such policies are not protected by this Guarantee Association if - Their insurer was not authorized to do business in this state when it issued the policy or contract; Their policy was issued by a health care service plan (HMO, Blue Gross, Blue Shield), a charitable organization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company, an insurance exchange, or a grants and annuities society; They are eligible for protection under the laws of another state. This may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insureds who live outside that state. The Guarantee Association also does not provide coverage for. Unallocated annuity contracts; that is, contracts which are not issued to and owned by an individual and which guarantee rights to group contract holders, not individuals; Employer or association plans, to the extent they are self -funded or uninsured; Any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as a variable contract sold by prospectus; Any policy of reinsurance unless an assumption certificate was issued; Interest rate yields that exceed an average rate; Any portion of a contract that provides dividends or experience rating credits. LIlVIITS ON AMOUNT OF COVERAGE The Act limits the Association to pay benefits -as follows: LIFE -AND ANNUITY BENEFITS 80% of what the insurance company would owe under a policy or contract up to $100,000 in cash surrender values, $100,000 in present value of annuities, or $250,000 in life insurance death benefits. A maximum of $250,000 for any one insured life no matter how many policies and contracts there were with the same company, even if the policies provided different types of coverages. f of ���M�• A maximum of $200,000 of the contractual obligations that the health insurance company would owe were it not insolvent. The maximum may increase or decrease annually based upon changes in the health care cost component of the consumer price index. PREMIUM SURCHARGE Member insurers are required to recoup assessments paid to the Association by way of a surcharge on premiums charged for health insurance policies to which the Act applies. Res. No. 2002-32 Ex. A CALIFORNIA NOTICE OF COMPLAINT PROCEDURE Should any dispute arise about your premium or about a claim that you have filed, write to the company that issued the group policy. If the problem is not resolved, you may also write to the State of California, Department of Insurance, Consumer Services Division, 300 S. Spring Street, 14th FL, Los Angeles, CA 90013, or call toll -free 1-800-927-HELP (4357). This notice of complaint procedure is for information only and does not become a part or condition of this. group policy/certificate. Res. No. 2002-32 Table of Contents COVERAGEFEATURES ........... ....................................................................................... I GENERAL POLICY INFORMATION ----.---_----------------_---'---.-.I BECOD&INGI08lIDED.............................................................................................. I PREMIUM CONTRIBUTIONS .--.----------'--'---_-'-----...'-----------2 SCHEDULE OF ---'----------'--'----------------'---'---'. 2 DISABILITY PROVISIONS -----__--'.----'_-'-`-'.-.'-.-----------.-----j2 EXCLUSIONS AND LIMITATIONS ----------------_---------'_-------.8 DEDUCTIBLE INCOD&E.------..-'-----------------------------------..3 OTHER PROVISIONS ----.----------------'----'-----------'----'----3 INSURINGCLAUSE ......................................................................................................... 4 DEFIN IT ON OF DISABILITY ........................................................................................ 4 RETURN TOWORK INCENTIVE -__-.-.----_---'..-.--'_'_.__-.'.......................... 5 REASONABLE, ACCOMMODATION EXPENSE BENEFIT ......................................... S TEMPORARYRECOVERY .............................................................. ................................ 5 WHEN LTD BENEFITS END .......................................................................................... 8 PREDISABILITYEARNINGS .......................................................................................... 6 DEDUCTIBLEINCOME ................................................................................................... J EXCEPTIONS TO DEDUCTIBLE INCOME ................................................................... 0 RULES FOR DEDUCTIBLE INCOME ............................................................................ S SURVIVORS BENEFIT ................................ WAIVEROFPREMIUM ................................................................................................... 1O BENEFITS AFTER INSURANCE ENDS K}RI8CHANGED ........................................ 2O EFFECT OFNEW DISABILITY ...................................................................................... lD EXCLUSIONS --'--.-.----.---_-.--'--_--------_-----------.--------1u LIMITATIONS __.___..__._.__.__________._________-''_-_----_'_,.^-_---_----11 'CLAIMS ......................................................______________'--_--'--_--_--'~^_--__-.^I1 ALLOCATION OF AUTHORITY .._.__,_____-'---.-_-_.----_--_-_-__-----'1Q 9�]�E LI28IT8OI�I�CC�\L AX}9I0l�8-------------'--------------------......... 13 I"wOmTEoT/uBRITzPROVISIONS .............................................................................. ^= CONTINUITY OF COVERAGE ........................................................................................ 14 WHEN YOUR INSURANCE BECOMES EFFECTIVE .................................................. 14 ACTIVE WORK PROVISIONS ......................................................................................... 16 WHEN YOUR INSURANCE ENDS ................................................................................. 16 REINSTATEMENT OF INSURANCE ............................................................................. 16 Res. No. 2002-32 Ex. A Index of Defined Terms The page number shown below is where the term is defined. For terms defined by an entire section, the page number below is the page on which that section begins. Active Work, Actively At Work,15 Material Duties, 4 Allowable Period, 6 Maximum Benefit Period, 2,17 Any Occupation Definition of Disability, 4 Maximum LTD Benefit, 2 Any Occupation Income Level, 2 Member,1 Any Occupation Period, 2 Mental Disorder,11 Minimum LTD Benefit, 2 Benefit Waiting Period, 2, 17 Noncontributory, 17 . Class Definition, 1 Contributory, 17 Own Occupation, 4 CPI-W,17 Own Occupation Definition Of Disability, 4 Own Occupation Income Level, 2 Own Occupation Period, 2 Deductible Income, 7 Disability,4 Disabled, 4 Partial Disability, 4 Physical Disease, 17 Physician, 17 Eligibility Waiting Period, 17 Policyowner,1 Employer(s),1 Predisability Earnings, 6 Evidence of Insurability, 17 Preexisting Condition,11 Exclusion Period, 3 Preexisting Condition Period, 3 Pregnancy, 17 Prior Plan, 17 Group Policy, 17 Proof Of Loss,12 Group Policy Effective Date, 1 Group Policy Number,1 Hospital, it Indexed PredisabMV Earnings, 17 Injury, 17 Reasonable Accommodation Expense Benefit, 3, 5 Return To Work Incentive, 5 Salary Continuation Offset, 3 Temporary Recovery, 6 Leave of Absence Period, 3 LTD Benefit, 17 War, 10 Work Earnings, 5 Res. No. 2002-32 Ex. A COVERAGEFEATURES This section contains many of the features of your long term disability (LTD) insurance. Other provisions, including exclusions, limitations, and Deductible Income, appear in other sections. Please refer to the textof each section for full details. The Table of Contents and the Index of Defined Terms help locate sections and definitions. GENERAL POLICY INFORMATION Group Policy Number. 332175XX-LTD Policyowner. City of Huntington Beach Employer(s): City of Huntington Beach Group Policy Effective Date: February 1,1995 Policy Issued In: California BECOMING INSURED To become insured you must: (a) Be a Member, (b) Complete your Eligibility Waiting Period; and (c) Meet the requirements in Active Work Provisions and When Your Insurance Becomes Effective. Definition of Member. You are a Member if you are a citizen or resident of the United States or Canada and one of the following- Class Definition: Eligibility Waiting Period: Evidence Of Insurability Printed 10/25/01 1. An active member of a class represented by the Police Management Association, the . Management Employee Organization or the lire Management Association regularly working at least 20 hours each week; or 2. An active Non -Associated employee of the Employer regularly working at least 20 hours each week; or 3. An Elected Department Head (City Treasurer, City Attorney or City Clerk) and Non -Associated Members You are not a Member if you are: 1. A temporary or seasonal employee; or 2. A full time member of the armed forces of any country. Class 1: Police Management Association Members Class 2:. Management Employees Organization Members Class 3: Fire Management Association Members Class 4: Non -Associated Members Class 5: Elected Department Heads You are eligible on the first day as a Member. Required: a. For late application for Contributory insurance. . -1- 332175XX-LTD Res. No. 2002-32 Ex. A Insurance is: LTD Benefit: Maximum: Minimum: Benefit Waiting Period. Maximum Benefit Period - Age b. For reinstatements if required. c. For Members eligible but not insured under the Prior Plan. d. For becoming insured for any amount greater than the amount for which you were insured under the Prior Plan, if your insurance under the Prior Plan was limited because you did not provide evidence of insurability or because your evidence of insurability was not approved. PREMIUM CONTRIBUTIONS .Noncontributory SCHEDULE OF INSURANCE 66 2/3% of the first $18,750 of your Predisability Earnings, reduced by Deductible Income. $12,500 before reduction by Deductible Income. $50 Class 1 and 5: 60 days Class 2, 3 and 4: 30 days Determined by your age when Disability begins, as follows:: Maximum Benefit Period 61 or younger .................................................. To age 65, or 3 years 6 months, if longer. 62 ...................................................................... 3 years 6 months 63 ...................................................................... 3 years 64 ...................................................................... 2 years 6 months 65 ...................................................................... 2 years 66 ...................................................................... I year 9 months 67 ...................................................................... 1 year 6 months 68 ...................................................................... 1 year 3 months 69 or older .......................................................1 year Own Occupation Period: Any Occupation Period: Partial Disability. Own Occupation Income Level: Any Occupation Income Level: DISABILITY PROVISIONS The first 24 months for which LTD Benefits are paid. From the end of the Own Occupation Period to the end of the Maximum Benefit Period. Covered 80% of your Indexed Predisability Earnings. 66 2t3% of your Indexed Predisability Earnings. See Definition of Disability for more information. Printed 10/25101 1 - 2 - 332175XX-LTD Res. No. 2002-32 Ex. A EXCLUSIONS AND LIMITATIONS Preexisting Condition Exclusion: Yes Preexisting Condition Period: The 90 day period just before your insurance becomes effective. Exclusion Period: 12 months See Exclusions and Limitations for this and other exclusions and limitations. DEDUCTIBLE INCOME Social Security Offset: Full offset Salary Continuation Offset: Sick Pay or other salary continuation paid to you by your Employer, but not including vacation pay. See Deductible Income for this and other Deductible Income. Survivors Benefit Amount: Estate Payment Allowed: Leave of Absence Period: Continuity of Coverage: Reasonable Accommodation Expense Benefit: Predisability Earnings based on: Printed 10/25/01 OTHER PROVISIONS A lump sum equal to 3 times your LTD Benefit without reduction by Deductible Income. No 30 days or less. Yes The expenses incurred for the reasonable accommodation or $500, whichever is less. Earnings in effect on your last full day of Active Work - 3 - 332175XX LTD . Res. No. 2002-32 Ex. A INSURING CLAUSE If you become Disabled while insured under the Group Policy, we will pay LTD Benefits according to the terms of the Group Policy after we receive satisfactory Proof Of Loss. LT.IC.01 DEFMTION OF DISABILITY You are Disabled if you meet one of the following definitions during the period it applies: A- Own Occupation Definition of Disability; B. Any Occupation Definition of Disability; or C. Partial Disability Definition. A. Own Occupation Definition Of Disability During the Benefit Waiting Period and the Own Occupation Period you are required to be Disabled only from your Own Occupation. You are Disabled from your Own Occupation if, as a result of Physical Disease, Injury, Pregnancy or Mental Disorder, you are unable to perform with reasonable continuity the Material Duties of your Own Occupation. Own Occupation means any employment, business, trade, profession, calling or vocation that involves Material .Duties of the same general character as: your regular and ordinary employment with the Employer. Your Own Occupation is not limited to your job with your Employer. Material Duties means the essential tasks, functions and operations, and the skills, abilities, knowledge, training and experience, generally required by employers from those engaged in a particular occupation. B. Any Occupation Definition Of Disability During the Any Occupation Period you are required to be Disabled from all occupations. You are Disabled from all occupations if, as a result of Physical Disease, Injury, Pregnancy or Mental Disorder, you are unable to perform with reasonable continuity the Material Duties of any gainful occupation for which you are reasonably fitted by education, training and experience. C. Partial Disability Definition 1. During the Benefit Waiting Period and the Own Occupation Period, you are Partially Disabled when you work in your Own Occupation but, as a result of Physical Disease, Injury, -Pregnancy or Mental Disorder, you are unable to earn more than the Own Occupation Income Level. 2. During the Any Occupation Period, you are Partially Disabled when you work in an occupation but, as a result of Physical Disease, Injury, Pregnancy or Mental Disorder, you are unable to earn more than the Any Occupation Income Level in that occupation and in all other occupations for which you are reasonably fitted under the Any Occupation Definition of Disability. You may work in another occupation while you meet the Own Occupation Definition of Disability. If you are Disabled from your Own Occupation, there is no limit on your Work Earnings in another occupation. Your Work Earnings may be Deductible Income. See Return To Work Incentive and Deductible Income. Your Any Occupation Period, Any Occupation Income Level, Own Occupation Period, and Own Occupation Income Level are shown in the Coverage Features. Printed 10/25/01 - 4 - 332175XX-LTD Res. No. 2002-32 Ex. A LT.DD.O1 X RETURN TO WORK INCENTIVE A. During The Benefit Waiting Period You may serve your Benefit Waiting Period while working, if you meet either the Own Occupation Definition of Disability or the Partial Disability Definition. B. After The Benefit Waiting Period You are eligible for the Return To Work Incentive on the first day you work after the Benefit Waiting Period if LTD Benefits are payable on that date. The Return To Work Incentive changes 12 months after that date, as follows: 1. During the first 12 months, your Work Earnings will be Deductible Income as determined below: a. Determine the amount of your LTD Benefit as if there were no Deductible Income, and add your Work Earnings to that amount. b. Determine 100% of your Indexed Predisability Earnings. c. If a_ is greater than b., the difference will be Deductible Income. 2. After those first 12 months, one half of your Work Earnings will be Deductible Income. Work Earnings means your gross monthly earnings from work you perform while Disabled, including earnings from your Employer, any other employer, or self-employment. Work Earnings will not include any renewal commissions, overwriting renewal commissions, or service fees .received on business sold before you become Disabled. LTIM.09 REASONABLE ACCOMMODATION F P'ENSE BENEFIT If you are Disabled and return to work in any occupation for any employer, not including self employment, as a result of a reasonable accommodation made by such employer, we will pay that employer a Reasonable Accommodation Expense Benefit as shown in the Coverage Features. The Reasonable Accommodation Expense Benefit is payable only if the reasonable accommodation is approved by us in writing prior to its implementation. LT.RA01 y M r , 1, *--! You may temporarily recover from your Disability, and then become Disabled again from the same cause or causes, without having to serve a new Benefit Waiting Period. Temporary Recovery means you cease to be Disabled.forno longer than the applicable Allowable Period: A. Allowable Periods 1. During the Benefit Waiting Period: a total of 30 days of recovery. 2. During the Maximum Benefit Period: 180 days for each period of recovery. Printed 10/25/01 1 - 5 - 332175XX-LTD Res. No. 2002-32 Ex. A B. Effect Of Temporary Recovery If your Temporary Recovery does not exceed the Allowable Periods, 1 through 5 below will apply. 1. The Predisability Earnings used to determine your LTD Benefit will not change. 2. The period of Temporary Recovery will not count toward your Benefit Waiting Period, your Maximum Benefit Period or your Own Occupation Period. 3. No LTD Benefits will be payable for the period of Temporary Recovery. 4. No LTD Benefits will be payable after benefits become payable to you under any other group long term disability insurance policy under which you become insured during your period of Temporary Recovery. 5. Except as stated above, the provisions of the Group Policy will be applied as if there had been no interruption of your Disability. LT.TKOB � 01 1 191 1 Your LTD Benefits end automatically on the earliest of 1 through 4 below. 1. The date you are no longer Disabled. 2. The date your Maximum Benefit Period ends. 3. The date you die. 4. The date benefits become payable under any other group long term disability insurance policy under which you become insured during a period of Temporary Recovery. LTSC-01 PREDISABMXYY EARNINGS Your Predisability Earnings will be based on your earnings in effect on your last full day of Active Work unless a different date applies (see the Coverage Features). Any subsequent change in your earnings will not affect your Predisability Earnings. Predisability Earnings means your monthly rate of earnings from your Employer, including: 1. Contributions you make through a salary reduction agreement with your Employer to: a. An Internal Revenue Code (IRC) Section 401(k), 403(b), 408(k), or 457 deferred compensation arrangement; or b. An executive nonqualified deferred compensation arrangement. 2. Shift differential pay. 3. Amounts contributed to your. fringe benefits according to a salary reduction agreement under an IRC Section 125 plan. Predisability Earnings does not include: 1. Bonuses. 2. Commissions. Printed 10/25/01 - 6 - 332175XX LTD Res. No. 2002-32 Ex. A 3. Overtime pay. 4. Your Employer's contributions on your behalf to any deferred compensation arrangement or pension plan. 5. Any renewal commissions, overwriting renewal commissions, or service fees. 6. Any other extra compensation. If you are paid on an annual contract basis, your monthly rate of earnings is one -twelfth (1/12th) of your annual contract salary. If you are paid hourly, your monthly rate of earnings is based on your hourly pay rate multiplied by the number of hours you are regularly scheduled to work per month, but not more than 173 hours. If you do not have regular work hours, your monthly rate of earnings is based on the average number of hours you worked per month during the. preceding 12 calendar months (or during your period of employment if less than 12 months), but not more than 173 hours. LTYV24 DEDUCTIBLE INCOME Subject to Exceptions To Deductible Income, Deductible Income means: 1. Sick pay or other salary continuation as shown in the Coverage Features. 2. Your Work Earnings, as described in the Return To Work Incentive. 3. Any amount. you receive or are eligible to receive because of your disability under any workers' compensation law or similar law, including amounts for partial or total disability, whether permanent, temporary, or vocational 4. Any amount you, your spouse, or your children under age 18 receive or are eligible to receive because of your disability or retirement under. a. The Federal Social Security Act; b. The Canada Pension Plan; c. The Quebec Pension Plan; or d. Any similar plan, act, or law. Benefits your spouse or children receive or are eligible to receive because of your disability are Deductible Income regardless of marital status, custody, or place of residence. The Coverage Features states which one of the following options applies to your Social Security benefits. a. Full offset: Both the primary benefit (the benefit awarded to you) and dependents benefits are Deductible Income. b. Primary offset: Primary benefits are Deductible Income, but dependents benefits are not. c. Partial dependents offset: Primary benefits are Deductible Income. Dependents benefits are Deductible Income as determined below: (U) Determine the amount of your LTD Benefit as if there were no Deductible Income, and add your dependents benefits to that amount. (2) Multiply your Predisability Earnings by the dependents limit. Printed 10/25/01 - 7 - 332175XX LTD Res. No. 2002-32 Ex. A (3) If (1) is greater than (2), the difference will be Deductible Income. 5. Any amount you receive or are eligible to receive because of your disability under any state disability income benefit law or similar law. 6. Any amount you receive or are eligible to receive because of your disability under any other group insurance coverage. 7. Any disability or retirement benefits you receive or are eligible to receive under your Employer's retirement plan, including a public employee retirement system, a state teacher retirement system, and a plan arranged and maintained by a union or employee association for the benefit of its members. If any of these plans has two or more payment options, the option which comes closest to providing you a monthly income for life with no survivors benefit will be Deductible Income, even if you choose a different option. 8. Any amount. you receive by compromise, settlement, or other method as a result of a claim for any of the above, whether disputed or undisputed. LTA1.02 Deductible Income does not include: 1. Any cost of living increase in any Deductible Income other than Work Earnings, if the increase becomes effective while you are Disabled and while you are eligible for the Deductible Income. 2. Reimbursement for hospital, medical, or surgical expense. 3. Reasonable attorneys fees incurred in connection with a claim for Deductible Income. 4. Benefits from any individual disability insurance policy. 5. California Workers' Compensation benefits for permanent total or permanent partial disability. 6. Early retirement benefits under the Federal Social Security Act which are not actually received. 7. Group credit or mortgage disability insurance benefits. 8. Accelerated death benefits paid under a life insurance policy. 9. Benefits from a through h below: a. Profit sharing plan. b. Thrift or savings plan. c. Deferred compensation plan. d. Plan under IRC Section 401(k), 408(k), or 457. e. Individual Retirement Account (IRA). f. Tag Sheltered Annuity (TSA) under IRC Section 403(b). g. Stock ownership plan. h. Keogh (HR-10) plan. LT.M.06 Printed 10/25/01 -8- 332175XX LTD Res. No. 2002-32 Ex A RULES FOR DEDUCTIBLE INCOME A Monthly Equivalents Each month we will determine your LTD Benefit using the Deductible Income for the same monthly period, even if you actually receive the Deductible Income in another month. If you are paid Deductible Income in a lump sum or by a method other than monthly, we will determine your LTD Benefit using a prorated amount. We will use the period of time to which the Deductible Income applies. If no period of time is stated, we will use a reasonable one. B. Your Duty To Pursue Deductible Income You. must pursue Deductible Income for which you may be eligible. We may ask for written documentation of your pursuit of Deductible Income. You must provide it within 60 days after we mail you our request. Otherwise, we may reduce your LTD Benefits by the amount we estimate you would be eligible to receive upon proper pursuit of the Deductible Income. C. Pending Deductible Income We will not deduct pending Deductible Income until it becomes payable. You must notify us of the amount of the Deductible Income when it is approved. You must repay us for the resulting overpayment of your claim. D. Overpayment Of Claim We will notify you of the amount of any overpayment of your claim under any group disability insurance policy issued by us. You must immediately repay us. You will not receive any LTD Benefits until we have been repaid in full. In the meantime, any LTD Benefits paid, including the Minimum LTD Benefit, will be applied to reduce the amount of the overpayment. We may charge you. interest at the legal rate for any overpayment which is not repaid within 30 days after we first mail you notice of the amount of the overpayment. LTAU.01 AAA 10,' • • If you die while LTD Benefits are payable, we will pay a Survivors Benefit according to 1 through 4 below. 1. The amount of the Survivors Benefit is shown in the Coverage Features. 2. The Survivors Benefit will first be applied to reduce any overpayment of your claim. 3. The Survivors Benefit will be paid at our option to any one or more of the following. a. Your surviving spouse; b. Your surviving unmarried children under age 25; or c. Any person providing the care and support of any of them. 4. If you are not survived by a spouse or an unmarried child underage: 25, no Survivors Benefit will be paid unless payment to your estate is allowed as stated in the Coverage Features. LT.SB.01 Printed 10/25/01 1 - 9 - 332175XX-LTD Res. No. 2002-32 Ex. A Your insurance will continue without payment of premiums while LTD Benefits are payable. LT.WP.01. INSURANCEBENEFITS AFTER 1ENDS .y 1. Your right to receive LTD Benefits for a period of Disability which begins while you are insured will not be affected by: 1. Termination of the Group Policy after you become Disabled; 2. Termination of your insurance while the Group Policy remains in force; or 3. Any amendment to the Group Policy approved after the date you -become Disabled. LT akol If a period of Disability is extended by a new cause while LTD Benefits are payable, LTD Benefits will continue while you remain Disabled. However, 1 and 2 apply. 1. LTD Benefits will not continue beyond the end of the original Maximum Benefit Period. 2. All provisions of the Group Policy, including the Exclusions and Limitations sections, will apply to the new cause of Disability. L .ND.01 EXCLUSIONS A. War You are not covered for a Disability caused or contributed to by War or any act of War. War means declared or undeclared war, whether civil or international, and any substantial armed conflict between organized forces of a military nature. B. Intentionally Self -Inflicted Injury You are not covered for a Disability caused or contributed to by an intentionally self-inflicted Injury, while sane or insane. C. Preexisting Condition I. Definition I Preexisting Condition means a mental or physical condition for which you have done any of the following at any time during the Preexisting Condition Period shown in the Coverage Features: a- Consulted a Physician; b. Received medical treatment or services; or c. Taken prescribed drugs or medications. Printed 10/25/O1 - 10 - 332175XX-'LTD Res. No. 2002-32 Ex. A 2. Exclusion You are not covered for a Disability caused or contributed to by a Preexisting Condition or medical or surgical treatment of a Preexisting Condition unless, on the date you become Disabled, you: a. Have been continuously insured under the Group Policy for the entire Exclusion Period shown in the Coverage Features; and b. Have been Actively At Work for at least one full day after the end of the Exclusion Period. LIMTATIONS A. Care Of A Physician LT.DL01 You must be under the ongoing care of a Physician during the Benefit Waiting Period. No LTD Benefits will be paid for any period of Disability when you are not under the ongoing care of a Physician. B. Mental Disorder Payment of LTD Benefits is limited to 24 months for each period of continuous Disability caused or contributed to by a Mental Disorder. However, if you are confined in a Hospital at the end of the 24 months, this limitation will not apply while you are continuously confined. Mental Disorder means a mental, emotional, behavioral, psychological, personality, cognitive, mood or stress -related abnormality, disorder, disturbance, dysfunction or syndrome, regardless of cause, including and biological or biochemical disorder or imbalance of the brain. Mental Disorder includes, but is not limited to, bipolar affective disorder, organic brain syndrome, schizophrenia, psychotic illness, manic depressive illness, depression and depressive disorders, or anxiety and anxiety disorders. Hospital means a legally operated hospital providing full- time medical care and treatment under the direction of a full-time staff of licensed Physicians. Rest homes, nursing homes, convalescent homes, homes for the aged, and facilities primarily affording custodial, educational, or rehabilitative care are not Hospitals. C. Alcohol Use, Alcoholism Or Drug Use Payment of LTD Benefits is limited to 24 months during your entire lifetime for a Disability caused or contributed to by your use of alcohol, alcoholism, use of any drug, including hallucinogens, or drug addiction. LT.LMABx CLAIMS A. Filing A Claim Claims should be filed on our forms. If you do not receive our forms within 15 days after you ask for them, you may submit your claim in a letter to us. The letter .should include the date disability began, and the cause and nature of the disability. B. Time Limits On Filing Proof Of Loss You must give us Proof Of Loss within 90 days after the end of the Benefit Waiting Period. If you cannot do so, you must give it to us as soon as reasonably possible, but not later than one year after that 90 day Printed 10/25/01 - 11- 332175XX-LTD Res. No. 2002-32 Ex. A period. If Proof Of Loss is filed outside these time limits, your claim will be denied. These limits will not apply while you lack legal capacity. C. Proof Of Loss Proof Of Loss means written proof that you are Disabled and entitled to LTD Benefits. Proof Of Loss must be provided at your expense. D. Documentation At your expense, you must submit completed claims statements, your signed authorization for us to obtain information, and any other items we may reasonably require in support of your claim. If you do not provide the documentation within 60 days after we mail you our request, your claim may be denied. E. Investigation Of Claim We may investigate your claim at any time. At our expense, we may have you examined at reasonable intervals by specialists of our choice. We may deny or suspend LTD Benefits if you fail to attend an examination or cooperate with the examiner. F. Time Of Payment We wi11 pay LTD Benefits within 60 days after you satisfy Proof Of Loss. LTD Benefits will be paid to you at the end of each month you qualify for them. LTD Benefits remaining unpaid at your death will be paid to the person(s) receiving the Survivor Benefit. If no Survivor Benefit is paid, the unpaid LTD Benefits will be paid to your estate. G. Notice Of Decision On Claim You will receive a written decision on your claim within a reasonable time after we receive your claim. If you do not receive our.decision within 90 days after we receive your claim, you will have an immediate right to request a review as if your claim had been denied. If we deny any part of your claim, you will receive a written notice of denial containing. 1. The reasons for our decision; 2. Reference to the parts of the Group Policy on which our decision is based; 3. A description of any additional information needed to support your claim; and 4. Information concerning your right to a review of our decision. IL Review Procedure You must request in writing a review of a denial of all or part of your claim within 60 days after you receive notice of the denial. When you request a review, you may send us written comments or other items to support your claim. You may review any non -privileged information that relates to your request for review. We will review your claim promptly after we receive your request. We will send you a notice of our decision within 60 days after we receive your request, or within 120 days if special circumstances require an extension. We will state the reasons for our decision and refer you to the relevant parts of the Group Policy. I. Assignment The rights and benefits under the Group Policy are not assignable. LT.CL01 Printed 10/25/01 -12 - 33217M-LTD Res. No. 2002-32 Ex. A Except for those functions which the Group Policy specifically reserves to the Policyowner, we have full and exclusive authority to control and manage the Group Policy, to administer claims, and to interpret the Group Policy and resolve all questions arising in the administration, interpretation, and application of the Group Policy. Our authority includes, but is not limited to: 1. The right to resolve all matters when a review has been requested; 2. The right to establish and enforce rules and procedures for the administration of the Group Policy and any claim under it; 3. The right to determine: a. Eligibility for insurance; b. Entitlement to benefits; c. Amount of benefits payable; d. Sufficiency and the amount of information we may reasonably require to determine a., b., or c., above. Subject to the review procedures of the Group Policy, any decision we make in the exercise of our authority is conclusive and binding. LTAL01 TOM S ON ■ -.GAL ACTIONS IONS No action at law or in equity may be brought until 60 days after you have given us Proof Of Loss. No such action may be brought more than three years after the earlier of. 1. The date we receive Proof Of Loss; and 2. The end of the period within which Proof Of Loss is required to be given. LT.TL01 111 , . K9. ` 0111 VWd U19.411VA r , 1; . A. Incontestability Of Member's Insurance Any statement you make to obtain insurance is a representation and not a warranty. No misrepresentation by you will be used to reduce or deny your claim or contest the validity of your insurance unless: 1. Your insurance would not have been approved if we had known the truth; and 2. We have given you a copy of a written instru*nent signed by you which contains your misrepresentation_ Printed 10/25/01 1 -13 - 332175XX-LTD Res. No. 2002-32 Ex. A After your insurance has been in effect for two years, we will not use a misrepresentation by you to reduce or deny your claim, unless it was a fraudulent misrepresentation. B. Incontestability Of Group Policy Any statement made by the Policyowner or Employer to obtain the Group Policy is a representation and not a warranty. No misrepresentation by the Policyowner or Employer will be used to deny a claim or to deny the validity of the Group Policy unless: 1. The Group Policy would not have been issued if we had known the truth; and 2. We have given the Policyowner or Employer a copy of a written instrument signed by the Policyowner or Employer which contains the misrepresentation. The validity of the Group Policy will not be contested after it has been in force for two years, except for nonpayment of premiums or fraudulent misrepresentations. LT.MA1 CONTINUITY OF COVERAGE If your Disability is subject to the Preexisting Condition Exclusion, LTD Benefits will be payable if: 1. You were insured under the Prior Plan on the day before the effective date of your Employer's coverage under the Group Policy; 2. You became insured under the Group Policy when your insurance under the Prior Plan ceased; 3. You were continuously insured under the Group Policy from the .effective date of your insurance under the Group Policy through the date you became Disabled from the Preexisting Condition; and 4. Benefits would have been payable under the Prior Plan if it had remained in force, taking into account the preexisting condition exclusion, if any, of the Prior Plan. Payment of your LTD Benefit will be under the terms of the Prior Plan or the Group Policy, whichever pays less. LT.cc.09 The Coverage Features states whether your insurance is Contributory or Noncontributory. A Noncontributory Insurance Subject to the Active Work Provisions, your Noncontributory insurance becomes effective on the date you become eligible. B. Contributory Insurance You must apply in writing for Contributory insurance and agree to pay premiums. Subject to the Active Work Provisions, your insurance becomes effective on: 1. The date you become eligible, if you apply on or before that date; 2. The date you apply, if you apply within 31 days after you become eligible; or Printed 10/25/01 - 14 - 332175XX-LTD . Res. No. 2002-32 Ex. A 3. The date we approve your Evidence Of Insurability, if you apply more than 31 days after you become eligible (late application). C. Insurance Subject To Evidence Of Insurability Subject to the Active Work Provisions, insurance subject to Evidence Of Insurability becomes effective on the date we approve Evidence Of Insurability. D. Takeover Provisions 1. If you were insured under the Prior Plan on the day before the effective date of your Employer's coverage under the Group Policy, your Eligibility Waiting Period is waived on the effective date of your Employer's coverage under the Group Policy. 2. You must submit satisfactory Evidence Of Insurability to become insured for insurance if you were eligible for innsurance under the Prior Plan for more than 31 days but were not insured. LT.EF.o3 ACTIVE WORK PROVISIONS A. Active Work Requirement If you are incapable of Active Work because of Physical Disease, Injury, Pregnancy or Mental Disorder on the day before the scheduled effective date of your insurance, your insurance will not become effective until the day after you complete one full day of Active Work as an eligible Member. Active Work and Actively At Work mean performing the Material Duties of your Own Occupation at your Employer's usual place of business. You will also meet the Active Work requirement if; 1. You were absent from Active Work because of a regularly scheduled day off, holiday, or vacation day; 2. You were Actively At Work on your last scheduled work day before the date of your absence; and 3. You were capable of Active Work on the day before the scheduled effective date of your insurance. B. Changes In Insurance This Active Work requirement also applies to any increase in your insurance. However, if you return to Active Work during a period of Disability or Temporary Recovery (see Temporary Recovery), you will not qualify for any change in insurance caused by a change in: 1. Your status as a member of a class; 2. The rate of earnings used to determine your Predisability Earnings; or 3. The terms of the Group Policy. MAWAS WHEN YOUR, INSURANCE ENDS. Your insurance ends automatically on the earliest of Printed 10/25/01 1 -15 - 332175XX LTD Res. No. 2002-32 Ex. A 1. The date the last period ends for which you made I a premium contribution, if your insurance is Contributory. 2. The date the Group Policy terminates. 3. The date your employment terminates. 4. The date you cease to be a Member. However, if you cease to be a Member because you are not working the required minimum number of hours, your insurance will be continued during the following periods, unless it ends under 1 through 3 above. a. While your Employer is paying you at least the same Predisability Earnings paid to you immediately before you ceased to be a Member. b. During the Benefit Waiting Period and while LTD Benefits are payable. c. During a leave of absence if continuation of your insurance under the Group Policy is required by a state -mandated family or medical leave act or law. d. During any other leave of absence approved by your Employer in advance and in writing and scheduled to last the Leave Of Absence Period shown in the Coverage Features. LT.EN28 If your insurance ends, you may become insured again as a new Member. However, the following will apply. 1. If your insurance ends because you cease to be a Member, and if you become a Member again within 90 days, the Eligibility Waiting Period will be waived. 2. If your insurance ends because you fail to make a required premium contribution, you must provide Evidence Of Insurability to become insured again. 3. If your insurance ends because you are on a federal or state mandated family or medical leave of absence, and you become a Member again immediately following the period allowed, your insurance will be reinstated pursuant to the federal or state mandated family or medical leave act or law. 4. The Preexisting Conditions Exclusion will be applied as if there had been no break in coverage in the following instances: a. If you become insured again within 90 days. b. If required by federal or state mandated family or medical leave act or law and you become insured again immediately following the period allowed under the family or medical leave act or law. MSE01 Benefit Waiting Period means the period you must be continuously Disabled before LTD Benefits become payable. No LTD Benefits are payable for the Benefit Waiting Period. See Coverage Features. Contributory means you pay all or part of the premium for your insurance. Printed 10/25/01 - 16 - 332175XX LTD Res. No. 2002-32 Ex. A CPI-W means the Consumer Price Index for Urban Wage Earners and Clerical Workers published by the United States Department of Labor. If the CPI-W is discontinued or changed, we may use a comparable index. Where required, we will obtain prior state approval of the new index. Eligibility Waiting Period means the period you must be a Member before you become eligible for insurance. See Coverage Features. Providing Evidence Of Insurability means you must: 1. Complete and sign our medical history statement; 2. Sign our form authorizing us to obtain information about your health; 3. Undergo a physical examination, if required by us, which may include blood testing, and 4. At your expense, provide any additional information about your insurability that we may reasonably require. Group Policy means the group long term disability insurance policy issued by us to the Policyowner and identified by the Group Policy Number. Indexed Predisability Earnings means your Predisability Earnings adjusted by the rate of increase in the CPI-W. During your first year of Disability, your Indexed Predisability Earnings are the same as your Predisability Earnings. Thereafter, your Indexed Predisability Earnings are determined on each anniversary of your Disability by increasing the previous year's Indexed Predisability Earnings by the rate of increase in the CPI-W for the prior calendar year. The maximum adjustment in any year is 10%. Your Indexed Predisability Earnings will not decrease, even if the CPI-W decreases. Injury means an injury to your body. LTD Benefit means the monthly benefit payable to you under the terms of the Group Policy. Maximum Benefit Period means the longest period for which LTD Benefits are payable for any one period of continuous Disability, whether from one or more causes. It begins at the end of the Benefit Waiting Period. No LTD Benefits are payable after the end of the Maximum Benefit Period, even if you are still Disabled. See Coverage Features. Noncontributory means the Policyowner or Employer pays the entire premium for your insurance. Physical Disease means a physical disease entity or process that produces structural or functional changes in your body as diagnosed by a Physician. Physician means a licensed medical professional, other than yourself, acting within the scope of the license. Pregnancy means your pregnancy, childbirth, or related medical conditions, including complications of pregnancy. Prior Plan means your Employer's group long term disability insurance plan in effect on the day before the effective date of your EmpIoyer's coverage under the Group Policy and which is replaced by the Group Policy. LTAF.O6 Printed 10/25/01 1 -17 - 332175XX-LTD Res. No. 2002-32 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 e�x��v City Clerk and ex-officio Clerk of the City Council of the City of Huntington Beach, California ATTACHMENT #3 FIRE MANAGEMENT ASSOCIATION MEMORANDUM OF UNDERSTANDING TABLE OF CONTENTS of iPes�Vq. �- Page PREAMBLE................................................................................................................................................................. I ARTICLE I — TERM OF MOU.................................................................................................................................1 ARTICLE II — REPRESENTATIONAL UNIT........................................................................................................I ARTICLE III — SEVERABILITY.............................................................................................................................2 ARTICLE IV — SALARY SCHEDULES AND RETIREMENT............................................................................. 2 A. MONTHLY COMPENSATION...................................................................................................................................2 B. PERS PICKUP.......................................................................................................................................................3 C. SELF FUNDED SUPPLEMENTAL RETIREMENT BENEFIT..........................................................................................3 D. MEDICAL INSURANCE UPON RETIREMENT............................................................................................................3 E. PUBLIC EMPLOYEES' RETIREMENT SYSTEM REIMBURSEMENT AND REPORTING..................................................4 1. Level 4111 Survivors Benefits.......................................................................................................................... 4 2. Rollover.....................................................................................:.....................................................................4 F. DIRECT DEPOSIT...................................................................................................................................................4 ARTICLE V — SPECIAL PAY..........................................................................................................................:........4 A. EDUCATIONAL TUITION........................................................................................................................................4 B. HOLIDAY PAY-IN-LIEU.........................................................................................................................................5 C. BILINGUAL SKILL PAY..........................................................................................................................................6 ARTICLE VI — UNIFORMS......................................................................................................................................6 ARTICLE VII — WORK SCHEDULE/COMPENSATORY PAY/TIME OFF.....................................................6 A. WORK SCHEDULE.................................................................................................................................................6 B. ADMINISTRATIVE LEAVE/COMPENSATORY PAY...................................................................................................6 ARTICLE VIII — HEALTH AND OTHER INSURANCE BENEFITS.................................................................7 A. HEALTH................................................................................................................................................................7 1. Medical............................................................................................................................................................7 2. Dental..............................................................................................................................................................7 3. 41tk-n Vision..................................................................................................................................................8 B. ELIGIBILITY CRITERIA AND COST.........................................................................................................................8 1. City Paid Medical and Dental Insurance - Dependents.................................................................................. 8 2. City's Contribution to Health Insurance Premiums........................................................................................8 3. ................................... Section 125 Plan..................................................................................... ....................10 C. LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT......................................................................................10 D. LONG TERM DISABILITY INSURANCE..................................................................................................................10 E. MISCELLANEOUS................................................................................................................................................11 1. City Paid Premiums While on Medical Disability......................................................................................... II 2. Insurance and Benefits Advisory Committee................................................................................................. I I 01-02 FMA MOU Draft i 04/01/02 10:04 AM FIRE MANAGEMENT ASSOCIATION MEMORANDUM OF UNDERSTANDING TABLE OF CONTENTS Page 3. Health Plan Over-Payments..........................................................................................................................11 Vi,-do of W- alth PL v........................................ :....................... 11 ARTICLE IX - LEAVE BENEFITS........................................................................................................................12 A. GENERAL LEAVE................................................................................................................................................12 1. Accrual..........................................................................................................................................................12 2. Eligibility and Approval................................................................................................................................12 Z. C-hor-L Rodo. to !'_pniarwl 7omwz 12 3. Conversion to Cash...................................................................................................................................13 B. SICK LEAVE........................................................................................................................................................13 C. BEREAVEMENT LEAVE........................................................................................................................................15 ARTICLEX — CITY RULES...................................................................................................................................15 A. PERSONNEL RULES.............................................................................................................................................15 ARTICLE XI -- MISCELLANEOUS......................................................................................................................33 A. VEHICLE POLICY.................................................................................................................................................33 B. DEFERRED COMPENSATION LOAN PROGRAM.....................................................................................................33 ARTICLE XII — CITY COUNCIL APPROVAL...................................................................................................34 LISTOF MOU EXHIBITS.......................................................................................................................................35 EXHIBIT A - FIRE MANAGEMENT ASSOCIATION SALARY SCHEDULE ................................................ 36 EXHIBIT B — RETIREE SUBSIDY MEDICAL PLAN........................................................................................37 EXHIBIT C — EMPLOYEE HEALTH PLAN BROCHURE................................................................................46 EXHIBIT D — DELTA CARE (PMI) DENTAL PLAN BROCHURE..................................................................47 EXHIBIT E — DELTA DENTAL PLAN BROCHURE.........................................................................................48 EXHIBIT F — SAFEGUARD DENTAL PLAN BROCHURE...............................................................................49 EXHIBIT G — VISION (VSP) PLAN BROCHURE..........................................................:....................................50 01-02 FMA.MOU Draft ii 04/01/02 10:04 AM MEMORANDUM OF UNDERSTANDING BETWEEN. THE CITY OF HUNTINGTON BEACH, CALIFORNIA (Herein Called CITY) AND THE HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION (Hereinafter Called ASSOCIATION). PREAMBLE WHEREAS the designated representative of the City of Huntington Beach and the Huntington Beach Fire Management Association have.met and conferred in good faith with respect to salaries, benefits and other terms and conditions of employment for the employees represented by the Association; Except as expressly provided herein, the adoption , of this Memorandum of Understanding shall not change existing terms and conditions of employment, which have been established for the classification represented ,by the Huntington Beach Fire Management Association. NOW THEREFORE, .this Memorandum of Understanding is made, to become effective BeGember 25, 1999 December 22,.2001 and it is agreed as follows: ARTICLE I — TERM OF MOU This Agreement shall be in effect for a period of twe one (2 1) years commencing OesembeF25,1999 December 22, 2001 and ending at midnight on Oesember 2- , 1999 December 20, 2002. ARTICLE II REPRESENTATIONAL UNIT It is recognized that the Huntington Beach Fire Management Association is the employee organization which has the right to meet and confer in good faith with the City on behalf of represented employees of the Huntington Beach Fire Department within the classification titles of Fire Division Chief and Fire Battalion Chief as outlined in Exhibit A attached hereto and incorporated herein. WZT MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION ft-M. . .. . - UUMIA 11.101"I IA. -. - .- .im . MR— r -. .. ARTICLE III — 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 be 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 IV — SALARY SCHEDULES AND RETIREMENT A. Monthly Comoensatoon Employees shall be compensated at „ ORthl�ysa,a� hourly rates by Glassifination title Job type and salary rang pay grade during the term of this Agreement as set out in Exhibit A attached hereto and incorporated herein unless expressly provided for in other articles of this Memorandum of Understanding. 01-02 FMA MOU Draft 04/01/02 10:04AM 2 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION B. PERS Pickup Each employee covered by this Agreement shall be reimbursed weeks bi-weekly in an amount equal to 9% of the employee's base salary and special pay 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. C. Self Funded Supplemental Retirement Benefit Employees hired prior to August 17, 1998 are eligible for the Self Funded Supplemental Retirement Benefit, which provides that: 1. In the event a member elects Option #2 (Section 21333) or Option #3 (Section 21334) of the Public Employees' Retirement Law, the City shall paythe 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, 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 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). 2. Employees hired on or after August 17, 1998 shall not be eligible for this benefit referenced in A.1.a. herein above. D. 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 Retirees retiring after approval of this MOU may participate in the Retiree Medical Plan, attached hereto as Exhibit B, or thief the. HMO Plans currently being offered to retirees, based upon the eligibility requirements described in Exhibit B. 2. 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 01-02 FMA MOU Draft 04/01/02 10:04 AM 3 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION agreement for unused sick leave and general leave benefits upon retirement. E. Public Employees' Retirement System Reimbursement and Reporting 1. Level 4 III Survivors Benefits Unit employeesshall be covered by the 1959 PERS Level 4 III Survivor Benefit. 2. Rollover No unit employee shall be allowed to continue the rollover benefit provided in Article XI (B)(2) of the 1991/1993 Management Employees Organization MOU beyond January 31, 1994. F. Direct Deposit All FMA represented employees shall be required to utilize direct deposit of payroll checks effective April 26, 2002. A. Educational Tuition ARTICLE V — SPECIAL PAY 112 Fates than the University of California, GaA :se Ism +LrA employee- 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 01-02 FMA MOU Draft 04/01/02 10:04 AM 4 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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 an a degree with approval from their Department Head and the Human Resources. Officer prior to April 15, 2002. Education costsshall 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. B. Holiday Pay -In -Lieu Employees shall be compensated by the City in lieu of the ten listed holidays at the rate of of 3.0768 hours multiplied by the employee's monthly hourly salary rate set forth in Exhibit A, payable each and every pay period. The following are the recognized legal holidays under this MOU: 1. New Year's Day (January 1) 2. Martin Luther King's Birthday (third Monday in January) 3. President's 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. Friday after Thanksgiving 10. Christmas Day (December 25) 11. Any day declared by the President of the United States to be a national holiday, or by the Governor of the State of California to be a 01-02 FMA MOU Draft 04/01/02 10:04 AM 5 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION state holiday, and adopted as an employee holiday by the City Council of Huntington Beach. Holidays which fall on Sunday shall be observed the following Monday, and those falling on Saturday shall be observed the preceding Friday. Employees designated by the Fire Chief who are. required to work regular shifts on the above listed holidays , as set forth in this Article, shall not be entitled to time off or overtime. Subject to State Law and Regulations, compensation paid as a result of Article VB shall be reportable to PERS as salary. C. Bilingual Skill Pay Permanent employees who are qualified to use Spanish, Vietnamese, or Sign Language skills 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 every bi-weekly pay period that the assignment is in effect. In order to be qualified for said compensation, employee's language proficiency will be tested and certified by. the Human Resources Officer or designee. ARTICLE VI,— UNIFORMS The 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 VII — WORK SCHEDULE/COMPENSATORY PAY/TIME OFF A. Work Schedule Members assigned to non -suppression staff assignments shall work four (4) days per week, ten (10) hours each day, meal times to be included during the ten hour shift. B. Administrative Leave/Compensatory Pay 1. Members working suppression duties earn compensatory pay or compensatory time off, on an, hour for hour basis, for hours worked in addition to their regular schedule, subject to the limitations contained in Article VII.B 3. below. 01-02 FMA MOU Draft 04/01/02 10:04 AM 6 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 2. Members shall work thirty-five (35) hours of non -suppression overtime in a calendar year, before earning compensatory pay or compensatory time off, on an hour for hour basis, for hours worked in excess of their regular normal work schedule. 3. Compensatory Pay a. Compensatory pay is paid at the 40 hours straight time rate for each hour. b. Compensatory time earned .can be. or administrative leave converted to cash at the member's 40 hour straight time rate. c. Maximum accrual shall be 120 hours. ARTICLE VIII — 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.; eXGent that in the yeaF 2000 he Occnnietion agrees that only one I- MQ may he offered b. The coverage and benefits provided under the City Health Plan shall be as set forth in the Plan Document revised OGtober 1, 1998 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. The plan shall he modified_effeGtiye lane rani 'Ir 2001 as follows: -EVENT�� - -WE vRe-OpeneF — The City and-AssGGiation agFee to meet and nnnfer on , 20 2. Dental 01-02 FMA MOU Draft 04/01/02 10:04 AM 7 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION The City shall provide an indemnity dental insurance plan comparable to Delta Dental Plan (Group Policy #4729, Exhibit E) and a prepaid dental insurance plan comparable to the Delta Care Plan (Group Policy #4002, Exhibit D). 3. GP#Gat 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 VIII.132. for dependent health and dental insurance effective the first of the month following the MORth during whinh the employee nmm�lo�oc��r� /'l ) R7V-77'7{7' ITCT-Q Ql"ll7 PTTTTVfT[TT� -' � � year of full tiMe—sends- service -with the city one month of employment. For, purposes of determining continuous. service, there shall be no accrual of hours for the period of time an employee is on a non -pay status for a complete pay period. 2. City's Contribution to Health Insurance Premiums A0 • :,sue T--..-�--- - - --- - - STATA .. ... Monthly Delta Delta VSP Premium City Plan Health Net Dental Care Safeguard (Vision)> Single; $ 280.51 $ 236.51 $ 41.31 $ 23.00 $ 16.20 $ 17.58 Two Party 554.70 517.79 78.92 39.11 29.16 17.58 Family (3 or more) 679.15 682.46 112.10 59.81 37.22 17.58 01-02 FMA MOU Draft 04/01/02 10:04 AM 8 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION . ._ ._ ..NE.. c. Year 2-0" 2002 Premiums: The will GORtrih„te two_thir-ds of the inrreace in the hr�ni„m� to the the event that all otheremployee groups agreeto one HMO or the year 2001; and the y shall nontribute one hhundrroepeFGentt of t�h�ernI►��^ Prremi„ Grease in the year 2001. The Gity shall on+rih„+e the full GGSt of the premium �m for dentaldentaland vision for theyear 2001 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. 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. 01-02 FMA MOU Draft 04/01/02 10:04 AM 9 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION d. Medical Cash -Out: LEf er.t* cjan��r 2000, if an a Employees is covered by a medical program outside of a City -provided program (evidence of which must be supplied to Administrative Services Department, Personnel Division Employee. Benefits), 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. 3. Section 125 Plan €ffes+eApril 1,2000, a Employees may begin utilize +rig this plan, which 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 as additional amounts of life insurance and . accidental death and dismemberment insurance to the extent provided by the City's current providers $100,000. 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, vaGation pay general leave, 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 $10,00012,500 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 01-02 FMA MOU Draft 04/01/02 10:04 AM 10 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION for three (3) months beyond death Administrative Services Department. E. Miscellaneous A copy of the plan is on file in the 1. City Paid Premiums While on Medical Disability When an employee is off xwork 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. 2. Insurance and Benefits Advisory Committee The City and the Association agree to establish 'participate in a city- wide joint labor and management insurance and benefits advisory committee to discuss and study issues relating to insurance 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-MGnt*Weekly Salary Warrant The employee's bi-n4Gnthlyweekly salary warrant shall be reduced by one-half of the amount of the bi4nonV#yweekIy over -payment, (e.g., if $75. The employee's bi-monthly salami payment shall he redUGed by $37.50). 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. 01-02 FMA MOU Draft 04/01/02 10:04 AM 11 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION -..-. OW I . .. ARTICLE IX - LEAVE BENEFITS A. General Leave 1. Accrual and aGati�Teave, and-the_Long-Tcr�rmDisability. InsuranGe,waiting perinrl droll he redUG 60 �s instead .e .Employees will cii7urrvcT uv J—rrr.7ccr ucrG accrue,+ng general leave at the accrual rates outlined below. General leave may be used for any purpose, including vacation, sick leave, and personal leave. the —employee's —general —leave asssunte#esti�esember 25, 1999, General leave shall -be aGGrued as fn_l1A_4Af6,. 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 after 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. Ewe Dese�ber 25999,, Members on a 40-hour schedule shall not accrue general leave in excess of six hundred hours (600), 56-hour members shall not accrue general leave in excess of eight hundred and forty hours (840). Employees may not use their general leave to advance their separation date on retirement or other separation from employment. 01-02 FMA MOU Draft 04/01/02 10:04 AM 12 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 4 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. 5- 4. Medical Premium Conversion Employees electing to participate in the City's group medical plan after retirement may cause the premiums to be paid by the City out of any available funds , due and owingthem under terms of the agreement for unused sick leave or general leave benefits upon retirement. B. Sick Leave 1. Accrual No employee shall accrue sick leave after December 24, 1999. 2. Credit -...1-•-J--- ....--. r..-. ----...--• - -,. --- -•.--..•-- -•-`•---• --- --- --.-.. SiGk leave aesFued asGfDesember 24, 1999 Employees assigned to FMA shall carry forward their sick leave balance and shallno longer accrue sick leave -credit. 3. Usage Employees may use accrued sick leave for the same purposes for which it was used prior to gem er-25, 1999. the employee's assignment to FMA. 4. Family Sick Leave Forty (40) Hour Employees - Sick leave may be used for an absence due to illness of the employee's spouse or child when theemployee's presence is required at home, provided that such absences shall be limited to forty (40) hours per calendar year. Twenty -Four (24) Hour Employees - Twenty-four (24) hour shift employees shall be entitled to charge up to three (3) shifts per calendar year of sick leave for family sick leave. 5. Pav 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: 01-02 FMA MOU Draft 04/01/02 10:04 AM 13 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION At involuntary termination by reason of industrial or non -industrial 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 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. .tU ".)W. AVAPIsm. Upon termination for any other reason, employees shall be compensated at their current 40-hour equivalent rate of pay for fifty percent (50%) of all unused, accumulated sick leave. The maximum number of hours paidoff at termination will be a total of 720 hours. Example: Employee has 1920 hours of accured sick leave. 1920 hours multiplied by 50% equals 960 hours. Maximum pay off is 720 hours. Pay off equals 720 hours multiplied by the employee's current 40-hour equivalent pay rate. 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 40- hour equivalent 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 01-02 FMA MOU Draft 04/01/02 10:04 AM 14 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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. Sisk leave may he fnr -n ohg_enne due to the illne6s of trheerplleyee s spouse OF nhild when -the -employee's preseRse�required at home provided that absenGeSshall�mited to fide (5) days per C. Bereavement Leave Employees shall be entitled to bereavement leave not to exceed two (2) work shifts for employees on a 24-hour work schedule or three (3) working days in case of death in the immediate family. "Immediate family" is defined as spouse, father, stepfather, mother, stepmother, sisters, brothers, stepsisters, stepbrothers, mother-in-law, father-in-law, children, stepchildren, grandchildren and grandparents of the employee or spouse. D. Paternity Leave E�entive_ jaRuary 1,2$90, f Fathers may utilize accumulated sick leave in addition to general leave and compensatory time, 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 X - 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 01-02 FMA MOU Draft 04/01/02 10:04 AM 15 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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. b) 5-14 — Promotional Exams Promotional examinations may be conducted whenever, in the opinion of the personnel ' rlireGte 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 01-02 FMA MOU Draft 04/01/02 10:04 AM 16 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION contendere, 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 his/her position for physical or psychological reasons, such department head shall consult with the Perms el—DiTestor Human Resources Officer regarding such belief. If the Dorsennel Dirontor 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 - The department head shall review the medical or psychological report and shall consult with the personnel Dirontor 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 01-02 FMA MOU Draft 04/01/02 10:04 AM 17 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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 the PersG^, el DicestGF 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. 5. Rule 14 —Additional Pay and Pay Adjustments a) 14-6 — Salary Advancements to Meet Recruiting Problems or to Give Credit for Prior Service. Application for Other Advancements The Department Head, through the Peel Dicestgr 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 Personnel Dirontor 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 01-02 FMA MOU Draft 04/01/02 10:04 AM 18 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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 Auty 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: 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 01-02 FMA MOU Draft 04/01/02 10:04 AM 19 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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 (10) 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 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 Personnel DireGtnr 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. 01-02 FMA MOU Draft 04/01/02 10:04AM 20 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 7. Rule 19 — Grievance Procedure Non-DisciDlinary 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 the Personnel Director 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 rer- S-On gel Di- rester 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 Personnel firm+or Human Resources Officer. 2) Step 5 — Personnel Board Hearing Hearing. As soon as practicable thereafter, the Personnel Director 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 -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. 01-02 FMA MOU Draft 04/01/02 10:04 AM 21 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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 — Disciplinary 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. 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: 01-02 FMA MOU Draft 04/01/02 10:04 AM 22 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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 submitted to the Personnel D*reGto Human Resources Officer. 2) Hearing As soon as practicable thereafter, the Personnel Direster 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 gall 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 Personnel Di ester 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 an appeal to the Personnel Commission. 01-02 FMA MOU Draft 04/01/02 10:04 AM 23 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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 Commissionpursuant 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 Personnel Dir-eGter 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 FMA MOU Draft 04/01/02 10:04 AM 24 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION ■ _ .. . ,,. .. ,,. ... ..- .- .. it I .. e jee e i- . ,. W Mo. Wd ;. .. 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: 01-02 FMA MOU Draft 04/01/02 10:04 AM 25 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 1. The Human Resources Officer shall give written notice of the proposed modification(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. 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 01-02 FMA MOU Draft 04/01/02 10:04 AM 26 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIDE MANAGEMENT ASSOCIATION Personnel 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 employeeswhohave'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 im the class designated for staff reduction within a department subject to the following: 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 01-02 FMA MOU Draft 04/01/02 10:04 AM 27 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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 bumping 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 Layoff 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. 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 01-02 FMA MOU Draft 28 04/01/02 10:04 AM MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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 Personnel 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 rights. c) The notice of layoff shall include the reason for the layoff,. the effective date of the layoff, the employee's hire date rand 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 Personnel Director 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 be 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 Personnel Director 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 Personnel Director 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 employee notifies the Personnel Director of the dispute. Within five (5) calendar days after the dispute is reviewed, the employee shall be notified in writing of the decision. 01-02 FMA MOU Draft 04/01/02 10:04 AM 29 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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 underA 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 Personnel Director'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 Personnel Director's decision, the employee may appeal pursuant to the provisions of Sections 3 and 4 below. b) Reinstatement/Re-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 possess the necessary qualifications to successfully perform the duties of the lower position may appeal the decision. The appeal shall be filed with the Personnel Director within five (5) calendar days of the 01-02 FMA MOU Draft 04/01/02 10:04 AM 30 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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. Personnel Director.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. 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. 01-02 FMA MOU Draft 04/01/02 10:04 AM 31 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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 (5) 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. 5) Re-employment lists shall be available to HBMEA and affected employees upon reasonable request, 6) Qualification appeals involving reemployment rights shall be resolved in the same manner as that identified 1 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 FMA MOU Draft 04/01/02 10:04 AM 32 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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 XI -- MISCELLANEOUS A. Vehicle Policy 1. Approval is required by the City Administrator or his designee for any City vehicle to be taken home by a FMA employee. 2. The auto allowance for qualifying members shall be one - hundred sixty-one dollars and fifty-three cents ($161.53) bi-weekly. 3. The monthly automobile allowance shall not be reduced during the term of this agreement. 3- 4: Eligibility for automobile allowance shall be determined in accordance with the Administrative Regulation, Vehicle Use Policy and the City's Fleet Management Program. 4 5. Unit members agree to all provisions of the City's Fleet Management Program dated August 1999. B. Deferred Compensation Loan Program EffeGtive januaFy 1,=000, -u Unit members may borrow up to 50% of their deferred compensation funds for critical needs such as medical costs, college tuition, or purchase of a home, pursant to program standards and regulations. 01-02 FMA MOU Draft 04/01/02 10:04 AM 33 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION ARTICLE XII — CITY COUNCIL APPROVAL It is the understanding of the City and the Association that this Memorandum of Understanding is of no force or effect whatsoever unless and until adopted by Resolution of the City Council of the City of Huntington Beach. IN WITNESS WHEREOF, the parties hereto have executed this Memorandum of Understanding this day of , 2WQ 2002. CITY OF HUNTINGTON BEACH Ray Silver City Administrator William Workman Assistant City Administrator Clay Martin Director of Administrative Services APPROVED AS TO FORM: Gail Hutton City Attorney HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION Jacques Pelletier FMA President Gregory Wiggins FMA Vice President Duane Olson Bargaining Committee Mick Terich Bargaining Committee 01-02 FMA MOU Draft 04/01 /02 10:04 AM 34 FIRE MANAGEMENT ASSOCIATION MEMORANDUM OF UNDERSTANDING FMA LIST OF MOU EXHIBITS EXIiIBITS SUBJECT A I Class/Salary Schedule B Retiree Medical Plan and Subsidy Program C Employee Health Plan D Delta Care (PMI) Dental Plan E Delta Dental — Dental Plan F Safeguard Dental — Dental Plan G Vision Service Plan MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION EXHIBIT A - FIRE MANAGEMENT ASSOCIATION SALARY SCHEDULE fife^+1ue DeGernber 25, °,r999 Effective March 2, 2002 Step Job Code Classification Range, A B C D E 0031 Fire Battalion Chief 677 38.78 40.91 43.16 45.53 48.03 0026 Fire Division Chief 609 45.47 47.97 50.618 53.39 56.33 01-02 FMA MOU Draft 04/01/02 10:04 AM 36 MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION EXHIBIT B — RETIREE.SUBSIDY MEDICAL PLAN An employee who has retired from the City shall beentitled 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. .. 7=Me-LaUQ.-a--& .._N.J. ".01"! 00-412-201�01 W... mr-TWUMM. el- MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION EXHIBIT B — RETIREE SUBSIDY MEDICAL PLAN CONTINUED ._ .. .. _. .- 4- 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 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: 01-02 FMA MOU Draft 38 04/01/02 10:04 AM MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION EXHIBIT B — RETIREE SUBSIDY MEDICAL PLAN CONTINUED 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 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 FMA MOU Draft 39 04/01/02 10:04 AM MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION INDEMNITY HEALTH PLAN, EMPLOYEES/RETIREES This summary lists only those benefit provisions that differ between active and subsidized Retiree Plans. 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. Benefits' Deductible per person Deductible per family Maximum Out of Pocket Coinsurance PPO I 1�"!9 as-14; l YEAR 2000 2001 City Plan - Employees Non -Subsidized Retirees COBRA -eligibles $450 $200 $450 $500 $40W 2000 per person $24= 4000 per family YEAR 2004 2002 90% of UCR 70% of UCR City Plan - Subsidized Retirees 200 $500 $45W 2,000 per person $3000 4000 per family 90% of UCR 60 70% of UCR Note: Retirees who elect to participate in Health Net or shall be entitled to benefits of the program chosen. This summary ligs only those benefit provisions that differ hAhmpt;n ;aQt*v;i 2nd s-lbi;47sul Ri;tirpp P12ns; ThA Employee Health Plan DnnurnAnt for detailed questions about speGifi hAni;fits Renefits are subjent to modifir-ation through the meet and Gonfer prc)Ges6-. ' 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. MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION 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. Personnel 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. MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION EXHIBIT B — RETIREE SUBSIDY MEDICAL PLAN CONTINUED 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 includes Managed Health Network (MHN), Prescription Card System (PCS), Orange County referred Pr-eyide Foundation for Medical Care (OCFMC). 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: 01-02 FMA MOU Draft 42 04/01/02 10:04 AM MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION EXHIBIT B — RETIREE SUBSIDY MEDICAL PLAN CONTINUED a. Retiree Subsidy Medical Plan. b. HealthNet. c. Part A of Medicare for those retirees not eligible for paid Part 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. 01-02 FMA MOU Draft 43 04/01/02 10:04 AM MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION EXHIBIT B — RETIREE SUBSIDY MEDICAL PLAN CONTINUED 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: 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 p, R el Employee Benefits in accordance with provisions of the Memorandums of Understanding. 01-02 FMA MOU Draft 44 04/01/02 10:04 AM MEMORANDUM OF UNDERSTANDING HUNTINGTON BEACH FIRE MANAGEMENT ASSOCIATION EXHIBIT B — RETIREE SUBSIDY MEDICAL PLAN CONTINUED 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 FMA MOU Draft 45 04/01/02 10:04 AM EXHIBIT C — EMPLOYEE HEALTH PLAN BROCHURE A copy of the Employee Health Plan Brochure may be obtained from the InsuFaRGe and Benefits- Division Risk Management EXHIBIT D — DELTA CARE (PMI) DENTAL PLAN BROCHURE A copy of the Delta Care (PMI) Brochure may be obtained from the Percnnnol division Employee Benefits Division 01-02 FMA MOU Draft 47 04/01/02 10:04 AM EXHIBIT E — DELTA DENTAL PLAN BROCHURE A copy of the Delta Dental Plan Brochure may be obtained from the Personnel Division Employee Benefits Division 01-02 FMA MOU Draft 48 04/01/02 10:04 AM EXHIBIT F — SAFEGUARD DENTAL PLAN BROCHURE A copy of the Safeguard Dental Brochure may be obtained from the PorSORRel D'V'650n Employee Benefits Division 01-02 FMA MOU Draft 49 04/01/02 10:04 AM EXHIBIT G — VISION (VSP) PLAN BROCHURE A copy of the Vision (VSP) Brochure may be obtained from the Personnel division Employee Benefits Division 01-02 FMA MOU Draft 50 04/01/02 10:04 AM KUAAutnor: vviiiiam MCKeynoias RCA ROUTING SHEET INITIATING DEPARTMENT: ADMINISTRATIVE SERVICES SUBJECT: APPROVAL OF. MEMORANDUM OF UNDERSTANDING BETWEEN -THE CITY AND THE HUNT[NGTON -BEACH . FIRE MANAGEMENT ASSOCIATION COUNCIL MEETING DATE: April 15, 2002 RCA ATTACHMENTS STATUS Ordinance (w/exhibits & legislative draft if applicable) Not Applicable. Resolution (w/exhibits & legislative draft if applicable) Attached Tract Map, Location Map and/or other Exhibits Not Applicable Contract/Agreement (w/exhibits if applicable) (Signed in full by the City Attorney) Attached Subleases, Third Party Agreements, etc. (Approved as to form by City Attorney) Not Applicable Certificates of Insurance (Approved by the City Attorney) Not Applicable Financial Impact Statement (Unbudget, over $5,000) Not Applicable Bonds (If applicable) Not Applicable Staff Report (If applicable) Not Applicable Commission, Board or Committee Report (if applicable) Not Applicable Findings/Conditions for Approval and/or Denial Not Applicable > 6 " t EXPLANATION FOR MISSING ATTACHMENTS EX KI A v^T!0N,.,qj.F0.-R RETURN- OF FEW- U A r" SO4)" Please Find Attached: Complete Original Exhibits C — G of Res. No. 2002-32 and Additional Information Re: Employee Life Insurance Benefits Accidental Death Insurance Benefits Long -Term Disability Insurance Benefits FMA Mod Na �- 37• ors �i' ls-t7Z Fell � y 6