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HomeMy WebLinkAboutO-2004-2777 e e, ORDmAllCll NO. 2004~177 ~ 0 rnril 0 ~ ~S~~;X~~~=~RI:O~G ~~~:~~ ~BR~~~~MB: ~-r: ~ i1D~ eJ MEDICAL PLAN, EFFECTIVE JAHl1ARY 1, 2005, ADOPTING nHEALTH SERVICE PLAN DESIGNn OPTIONS, APPROVING AN EMPLOYBB CONTRIBUTION SCHEDULE, APPROPRIATING THE SUM OF $130,000.00, TO Fl1HD SAID ADMINISTRATIVE SBRVICES AGREEMBNTS, MAICING VARIOUS FINDINGS AND PROVISIONS RELATING TO THE SUBJECT, FINDING COMPLIANCE WITH THE OPEN MEETINGS LAW, AND PROVIDING AN EFFECTIVE DATE HEREOF. BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF LA PORTE: Section 1. The City Council hereby approves and authorizes an agreement with Humana Insurance Company, for administrative services of the City's Employee Medical Fund Plan, a copy of which agreement is on file in the office of the City Secretary. The City Manager is hereby authorized to execute such document and all related documents on behalf of the City of La Porte. The City Secretary is hereby authorized to attest to all such signatures and to affix the seal of the City to all such documents. City Council appropriates the sum of $130,000.00 from City of La Porte Employee Health Services Fund Account No. 014-6144-515-6011, to fund said administrative services agreement for the 2005 calendar year, subject to network cost guarantee. Section 2. The City Council approves and adopts the four plan design options recommended by Humana Insurance Company, for the City of La Porte Employee Medical Fund (Coverage First 1500, Coverage First 1000, PPO 500 AND PPO 300), in form attached hereto and incorporated herein by this reference. Council also approves and adopts the Employee contribution Schedule by Plan Design effective January 1, 2005, with 20% of plan cost shared with employees, in form attached hereto and incorporated herein by this reference. e e Section 3. The City Council officially finds, determines, recites, and declares that a sufficient written notice of the date, hour, place and subject of this meeting of the City council was posted at a place convenient to the public at the City Hall of the City for the time required by law preceding this meeting, as required by the Open Meetings Law, Chapter 551, Texas Government Code; and that this meeting has been open to the public as required by law at all times during which this ordinance and the subject matter thereof has been discussed, considered and formally acted upon. The City Council further ratifies, approves and confirms such written notice and the contents and posting thereof. Section 5. This Ordinance shall be effective from and after its passage and approval, and it is so ordered. PASSED AND APPROVED, this 27th of September, 2004. CITY OF LA PORTE By: Alton Porter, Mayor ATTEST: Martha A. Gillett, city Secretary AP~td &h Knox W. Askins, City Attorney 2 . ,...e... Hum ana' .C:~ v.e r ~ g:~'F irs t~ ~ P P:.~' ,sum.m~'ry of.B~nefits _~~"tJ~. ~ TEXAS CoverageFirst 1000 Plan 35, Option 84 Plan pays for services from PARTICIPATING providers Plan pays for services from NONPARTICIPATING providers Up-Front Benefit · Annual member benefit (Applies Allowance to medical services received from participating providers only. Does not apply to member copayments, mental health services or Rx benefits.) $500 per calendar year per member Not applicable Annual Deductible · Individual $1,000 $2,000 (per calendar year) (copayments do · Family $3,000 $6.000 not apply) Preventive Care · Routine immunizations (birth to 100% 100% age 7) · Routine immunizations (age 7 to 100% after deductible 70% after deductible age 18) · Annual routine mammography · Annual routine Pap smears · Routine adult lab and X-rays · Annual routine adult physical 100% after $20 copayment per 70% after deductible examinations (16 years and visit to a Level One participating above; excludes lab and X-ray) physician or $35 copayment per · Routine child physical visit to a Level Two participating examinations (up to age 16; physician * includes lab and X-ray) Physician Services · Office visits (excludes diagnostic 100% after $20 copayment per 70% after deductible lab and X-ray, outpatient surgery) visit to a Level One participating · Prenatal benefit (office visit physician or $35 copayment per copayment applies to first visit visit to a Level Two participating only) physician * · Allergy testing (covered as part of office visit) · Diagnostic tests, lab and X-rays 80% after deductible 60% after deductible · Allergy serum · Inpatient services · Outpatient services (includes surgery) · Physician visits to emergency room (1) · Allergy injections 100% after $5 copayment per 70% after deductible visit Coverage First PPO combines the cost-saving incentives of a modern health plan with freedom of choice and an annual benefit allowance. When you see participating providers, you receive the highest level of benefits available under your plan. At the same time, you retain the flexibility to see any physician. TX-10434-HH 1/04 e e CoverageFirst 1000 Plan pays for services from plan pays for services from Plan 35, Option 84 PARTICIPATING providers NONPARTICIPATING providers Hospital Services · Inpatient care (semiprivate room 100% after $100 co payment 70% after deductible and board, nursing care, leU) (2) per day for first five days per admission, and after deductible · Outpatient surgery - facility (2) 100% after $ 50 copayment per 70% after deductible procedure after deductible · Outpatient nonsurgical (including 80% after deductible 60% after deductible diagnostic lab and X-ray) · Emergency room (1) 100% after $100 copayment 70% after deductible per visit after deductible (copayment is waived if admitted) Prescription Drugs · Rx4 See attached rider, if applicable Other Medical · Skilled nursing facility (up to 80% after deductible 60% after deductible Services 60 days per calendar year) · Home health care (up to 100 visits per calendar year) (2) · Durable medical equipment (2) · Physical, speech and hearing therapy (2), (5) · Ambulance (1) · Private duty nursing (inpatient hospital only) · Hospice (2) · Transplant services (2), (3) 100% after deductible 70% after deductible Mental Health · Inpatient (up to 30 days per 100% after $100 copayment 70% after deductible Services (4) calendar year) (2) per day for first five days per admission · Inpatient professional services 80% 60% · Outpatient (up to 30 visits per calendar year) -Individual sessions 100% after a $20 copayment 70% per visit - Group sessions 100% after a $1 0 copayment 70% per visit Serious · Inpatient (up to 45 days per Covered the same as any Covered the same as any Mental Illness calendar year) (2) other illness other illness · Outpatient (up to 60 visits per calendar year) Chemical Dependency · Inpatient (2) Covered the same as any Covered the same as any (lifetime maximum of · Outpatient other illness other illness three separate series of treatments for each insured person) * Level One participating physicians include family practitioner, general practitioner, pediatrician or internist and Level Two contains any other participating physician. Please contact Customer Service for details. e CoverageFirst 1000 Plan 35, Option 84 Plan pays for services from PARTICIPATING providers e Plan pays for services from NONPARTICIPATING providers Maximum · Individual Out-Of-Pocket Expense Limit · Family (per calendar year) (excludes deductibles and copayments) $2,000 $6,000 $4,000 $12,000 Lifetime Maximum Benefit $1,000,000 Payments - Plan benefits are paid based on reasonable charges, as defined in your Certificate. Participating providers agree to accept reasonable charges, as listed in negotiated payment schedules, as payment in full. For services rendered by nonparticipating physicians, the member is responsible for charges exceeding a fee schedule selected by your employer and defined in your Certificate. For services from other nonparticipating providers, the member is responsible for amounts exceeding reasonable charges, as defined in your Certificate. Participating primary care and .,ecialist physicians and other :oviders in Humana's networks are . not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. Emergency care services received while out of the service area are covered at the participating provider level. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) Emergency care provided by a nonparticipating provider will be covered at the participating provider level. (2) Prior authorization required in order to receive these benefits. (3) Transplant services do not apply toward the maximum out-ot-pocket expense limit. (4) Any out-at-pocket expense for the treatment ot mental health services does not apply towards any out-of-pocket expense limits except for serious mental illness. (5) Subject to certain limitations and exclusions. Refer to the Certificate for additional information. TIle III1W/IIzt ~f benifits pWIJided depends UpOIl the plall selected. Premiums U,ilIl'llry IIccoTdin.~ ta tl1(' selectioll made. For .,?eneml questiollS about the plan. (orttaa. YOIIT betl!!fits admil1isr'12tar. Limitat and o n s This is a partial and summarized list of nitations and exclusions. Your group ..lay have specific limitations and exclusions not included on this list. Please check your Certificate for this complete listing. The Certificate is the document upon which benefit paynlent will be determined. Unless stated mhenvise. no coverage will be provided for the foUowing simacions. 'I. A sickness or injury which is covered under any Workers' Compensation or similar law. 2. Sickness or injury tor which the insured person is in any way paid or entitled to payment or care and treannent by or through a government program, other than Medicaid or as othcnvise provided by Texas law. 3. Education or training; medical services pro\'ided by the insured person's parent. spouse, brother. sister or child. 4. Investigational or experimental drugs or substances not approved by Humana or by the Food and Drug Administration. 5. Tre.atment, services. supplies or surgery that is not medically necessary. 6. Purchase or fitting of hearing aids, implantable hearing devices or advice on their care, unless provided by rider. TX-l0434-HH 1/04 e Exclusions 7. Weekend nonemergency hospital admissions. S. In-vitro fertilization. unless our In- Vitro Fertilization Rider is included in the Group Policy; any medical or surgical treatment of infertility; infertility evaluations; sex change services or reversal of elective sterilization. 9. Plastic, cosmetic or reconstructive surgery, unless a functional impairment is present or if required to correct a congenital defect. birth abnormality of a newborn or for breast reconstruction or as othenvise stated in the certificate. 10. Services and supplies for dental care, treatment of teeth or periodontium or oral surgery. unless the expenses a. are medically necessary diagnostic and/ or surgical treatment of the temporomandibular Gaw or craniomandibular) joint; b. are for the surgical removal of a tumor or lesions in the mouth; or c. are incurred in connection with an injury to sound natural teeth or jaw. except injuries resulting from biting or chewing, sustained while the person is covered by the Group Policy. For an injury. the care and treatment must be provided within tile 12 month period beginning on the date of the injury. Also. the insured person must remain covered ~~~~:- Insured by Humana Insurance Company @2004 Humana Inc. e under the Group Policy during the 12 month period while the care and treatment is being received. We will not cover any treatment related to the preparation or the fitting of denmres. including dental implants. 11. Any service, supply or treamlent connected with custodial care. l2. Sickness or injury caused by the insured person's: a. engaging in an illegal occupation; or b. commission of or an attempt to commit a criminal act. 13. Any treatment to reduce obesity, including, but not limited to. surgical procedures. 14. .Elective abortion unless: a. the physician certifies in writing that the pregnancy would endanger the life of the mother: or b. the pregnancy is a result of rape or incest: or c. the services are received to treat medical complications due to the abortion. 15. Vision analysis. testing or orthoptic n-aining or the purchase of eyeglasses or contact lenses. 16. Care and treatment of complications of noncovered procedures. unless required by state law. e e. _. Hum a n a' cov~ ~~'~Z;~'~s~~~;~6's~~~::~'~fB~rtefit.'. , ~~ ~ ~ ~ TEXAS CoverageFirst 1500 Plan 35, Option 100 Plan pays for services from PARTICIPATING providers Plan pays for services from NONPARTICIPATING providers Up-Front Benefit · Annual member benefit (Applies Allowance to medical services received from participating providers only. Does . not apply to member copayments, mental health services or Rx benefits.) $500 per calendar year per member Not applicable Annual Deductible · Individual $1.500 $3,000 (per calendar year) (copayments do · Family $4.500 $9,000 not apply) Preventive Care . Routine immunizations (birth to 100% 100% age 7) · Routine immunizations (age 7 to 100% after deductible 70% after deductible age 18) · Annual routine mammography · Annual routine Pap smears · Routine adult lab and X-rays · Annual routine adult physical 100% after $20 copayment per 70% after deductible examinations (16 years and visit to a Level One participating above; excludes lab and X-ray) . physician or $35 copayment per · Routine child physical visit to a Level Two participating examinations (up to age 16; physician* includes lab and X-ray) Physician Services · Office visits (excludes diagnostic 100% after $20 copayment per 70% after deductible lab and X-ray, outpatient surgery) visit to a Level One participating · Prenatal benefit (office visit physician or $35 copayment per copayment applies to first visit visit to a Level Two participating only) physician * · Allergy testing (covered as part of office visit) · Diagnostic tests. lab and X-rays 80% after deductible 60% after deductible · Allergy serum · Inpatient services · Outpatient services (includes surgery) · Physician visits to emergency room (1) · Allergy injections 100% after $5 copayment per 70% after deductible visit Coverage First PPO combines the cost-saving incentives of a modern health plan with freedom of choice and an annual benefit allowance. When you see participating providers, you receive the highest level of benefits available under your plan. At the same time, you retain the flexibility to see any physician. TX-23441-HH 1/04 e e CoverageFirst 1500 Plan pays for services from Plan pays for services from plan 35, Option 100 PARTICIPATING providers NONPARTICIPATING providers Hospital Services · Inpatient care (semiprivate room 100% after $100 co payment 70% after deductible and board, nursing care, leU) (2) per day for first five days per admission, and after deductible · Outpatient surgery - facility (2) 100% after $50 copayment per 70% after deductible procedure after deductible · Outpatient nonsurgical (including 80% after deductible 60% after deductible diagnostic lab and X-ray) · Emergency room (1) 100% after $1 00 copayment 70% after deductible per visit after deductible (copayment is waived if admitted) Prescription Drugs · Rx4 See attached rider, if applicable Other Medical . Skilled nursing facility (up to 80% after deductible 60% after deductible Services 60 days per calendar year) · Home health care (up to 100 visits per calendar year) (2) · Durable medical equipment (2) . Physical, speech and hearing therapy (2), (5) . Ambulance (1) . Private duty nursing (inpatient hospital only) · Hospice (2) · Transplant services (2), (3) 100% after deductible 70% after deductible Mental Health · Inpatient (up to 30 days per 100% after $100 copayment 70% after deductible Services (4) calendar year) (2) per day for first five days per admission · Inpatient professional services 80% 60% · Outpatient (up to 30 visits per calendar year) -Individual sessions 100% after a $20 copayment 70% per visit - Group sessions 100% after a $10 copayment 70% per visit Serious · Inpatient (up to 45 days per Covered the same as any Covered the same as any Mental Illness calendar year) (2) other illness other illness . Outpatient (up to 60 visits per calendar year) Chemical Dependency · Inpatient (2) Covered the same as any Covered the same as any (lifetime maximum of · Outpatient other illness other illness three separate series of treatments for each insured person) * level One participating physicians include family practitioner, general practitioner, pediatrician or internist and level Two contains any other participating physician. Please contact Customer Service for details. e CoverageFirst 1500 Plan 35, Option 100 Plan pays for services from PARTICIPATING providers e Plan pays for services from NONPARTICIPATING providers Maximum · Individual Out-Of-Pocket Expense Limit · Family (per calendar year) (excludes deductibles and copayments) $3.000 $9,000 $6,000 $18.000 Lifetime Maximum Benefit u,ooo,ooo Payments - Plan benefits are paid based on reasonable charges. as defined in your Certificate. Participating providers agree to accept reasonable charges. as listed in negotiated payment schedules. as payment in full. For services rendered by nonparticipating physicians. the member is responsible for charges exceeding a fee sc/:1edule selected by your employer and defined in your Certificate. For services from other nonparticipating providers. the member is responsible for amounts exceeding reasonable charges. as defined in your Certificate. Participating primary care and -pecialist physicians and other roviders in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent I " contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. Emergency care services received while out of the service area are covered at the participating provider level. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) Emergency care provided by a nonparticipating provider will be covered at the participating provider level. (2) Prior authorization required in order to receive these benefits. (3) Transplant services do not apply toward the maximum out-of-pocket expense limit. (4) Any out-of-pocket expense for the treatment of mental health services does not apply towards any out-of-pocket expense limits except for serious mental illness. (5) Subject to certain limitations and exclusions. Refer to the Certificate for additional information. '17Ie alllOl/llt oj benifits pTOlJided depends I/pOll the plan selected. Premiums U.'i/ll'tlty according to the selection /IIade. For general questiol/s abol/t the plan, conTact 1'O/4r benefits adminisrrator. limitations and This is a partial and summarized list of nitations and exclusions. Your group .,lay have specific limitations and exclusions not included on this list. Please check your Certificate for this complete listing. The Certificate is the document upon which benefit payment will be determined. Unless stated otherwise, no coverage will be provided tor the following sinIatiollS. I. A sickness or injury which is covered under any Workers' Compensation or similar law. 2. Sickness or injury tor which the insured person is in any wny paid or entitled to payment or care and treatmenr by or through a governmenr program, ocher than Medicaid or as otherwise provided by Tex.1s law. 3. Education or training; medical services provided by che insured person's parent, spouse, brother, sister or child. 4. Investigational or experimental drugs or substances nor approved by Humana or by the Food and Drug Administration. =>. Treatment, sen'ices. supplies or surgery chat is not medically necessary. 6. Purchase or fitting of hearing aids, implantable hearing devices or advice on their care, unless provided by rider. TX-23441-HH 1/04 e Exclusions 7. Weekend non emergency hospital awnissions. 8. In-vitro tertilization. unless our In- Viero Fercilization Rider is included in the Group Policy; any medical or surgical treatment of intertility; infertility evaluations; sex change services or reversal of elective sterilization. 9. Plastic. cosmetic or reconstructive surgery. unless a functional impaimlenc is presenr or if required to correct a congenital defect. birth abnormalicy of a newborn or for breast reconstruction or as otherwise stated in the certificate. 10. Services and supplies for dental care, treannent of teeth or periodontium or otal surgery, unless the e)..-penses a. are medically necessary diagnostic and/or surgical treamlent of the temporomandibular Gaw or craniomandibular) joint; b. are for the surgical removal of a tumor or lesions in che mouth; or c. are incurred in connection with an injury to sound natural teeth or jaw, ex.cept injuries resulting from biting or che\\'<ing, sustained while the person is covered by the Group Policy. For all injury, the care and treatment must be provided within the '12 monch period beginning on che date of the injury. Also. the insured person must remain covered f l!!2.~~:_. Insured by Humana Insurance Company @2004 Humana Inc. e under che Group Policy during the 12 month period while the care and treannent is being received. We will not cover any trearmenc related co che preparation or the titting of dentures. including dental implants. 11. Any service, supply or treatment connected with .custodial care. 12. Sickness or injury caused by the insured person's: a. engaging in an illegal occupation: or b. commission of or an attempt to commit a criminal act. 13. Any treatment to reduce obesit)" including, but not limited to. surgical procedures. 14. Elective abortion unless: a. the physician certifies in writing that the pregnancy would endanger the life of the mocher: or b. the pregnancy is a result of rape or incest; or c. the services are received to treat medical complications due to the abortion. '15. Vision analysis, testing or orthoptic training or che purchase of eyeglasses' or concact lenses. 16. Care and treatment of complications of noncovered procedures. unless required by state law. . ~. . '.' . ~ . ',' It ".___ _..~ .__~._~._ h.... ';" ", :.-~ .~. ..-- :-'~'~:,;":~~~.' .':: ,':-:-: :"':'. :'~-~_:'::'., '.' . .,. - .;'." ,:",:!~..::~..t-i.: 1.t ........ ;.11 ~.... .'l Su'miTiary -of.Ben.e.f.its . '. '.. ,. .....-:. .. -. '-. :': ,'. ',". .".. - ;' ..... . , ; ". HumanaPPO --c - ~.. ~~~.~-==-"t~r=-~r~- ,"-,..,.,.,.,=--=-=r-~-"----r ,'- ~~-~ .~....,--.--~-- ~- ~ ,oil ~ i:~~~:~ 1~~~~~~.~~~t~~~~5f~~~~t~~U~~~(~~1t~1~r.t:?::~~~~~~~;;;{~,~::~:f;~;11 ~:;t~f~~j~'~<'~ff\~i~~l~~lt?~~-r;~~s~~~:~l ZJ__ "","""~_~,1!.;~~~~",-~"""",.:;(i!i;,;~~,..:....r~_K.e:.A~':l.:__....._~,,,~u.........tl_l.,.,::l..!;:_..c.1.J,u~ .ii_;~~~-...:.:-->~ .,. " .. ...~.. . . . ". TEXAS PPO 300 Plan pays for services at Plan pays for services at Plan 44, Option 5 PARTICIPATING providers NONPARTICIPATING providers Preventive Care · Routine immunizations (birth to 100% 100% age 7) · Routine immunizations (age 7 to 100% after deductible 70% after deductible age 78) · Annual routine mammogram · Annual routine Pap smear - Routine adult lab and X-ray · Annual routine adult physical 100% after $20 copayment per 70% after deductible examinations (16 years and visit to a Level One participating above: excludes lab and X-ray) physician or $35 copayment per · Routine child physical visit to a Level Two participating examinations (up to age 76; physician * includes lab and X-ray) Physician · Office visits (includes diagnostic 100% after $20 co payment per 70% after deductible Services lab/X-ray, allergy testing) (excludes visit to a Level One participating outpatient surgery) physician or $35 copayment per · Prenatal care (office visit visit to a Level Two participating copayment applies to first visit physician * only) - Allergy serum 90% after deductible 60% after deductible · Inpatient services - Outpatient services (includes surgery) - Physician visits to emergency room (1) · Allergy injections 100% after $5 copayment 70% after deductible per visit Hospital -Inpatient care (semiprivate room 100% after $ 1 50 copayment per 70% after deductible Services and board, nursing care, leU) (2) day for first five days per admission, and after deductible - Outpatient surgery - facility (2) 100% after $50 co payment per 70% after deductible procedure after deductible · Outpatient nonsurgical (including 90% after deductible 60% after deductible diagnostic lab and X-ray) · Emergency room (1) 100% after $1 00 copayment per 70% after deductible visit after deductible (copayment waived if admitted) Prescription Drugs · Rx4 See attached rider. if applicable Other Medical - Skilled nursing facility (up to 60 90% after deductible 60% after deductible Services days per calendar year) HumanaPPO combines the cost-saving incentives of a modern health plan with freedom of choice. When you see participating providers, you receive the highest level of benefits available under your plan. At the same time, you retain the flexibility to see any physiCian. TX-23443-HH 1/04 tit e PPO 300 Plan 44, Option 5 Plan pays for services at PARTICIPATING providers Plan pays for services at NONPARTICIPATING providers Other Medical - Home health care (up to 100 90% after deductible 60% after deductible Services (cont.) visits per calendar year) (2) - Durable medical equipment (2) - Physical, speech and hearing therapy (2), (5) - Ambulance (1) - Private duty nursing (inpatient hospital only) - Hospice (2) - Transplant selVices (2), (3) 100% after deductible 70% after deductible Mental Health -Inpatient (up to 30 days per 100% after $150 copayment per 70% after deductible Services' (4) calendar year) (2) day for first five days per admission -Inpatient professional selVices 90% 60% - Outpatient (up to 30 visits per calendar year) - Individual sessions 100% after a $35 copayment 70% per visit - Group sessions 100% after a $20 copayment 70% per visit Serious Mental -Inpatient (up to 45 days per Covered the same as any Covered the same as any Illness calendar year) (2) other illness other illness - Outpatient (up to 60 visits per calendar year) Chemical -Inpatient (2) Covered the same as any Covered the same as any Dependency - Outpatient other illness other illness Services (lifetime maximum of three separate series of treatments for each insured person) Annual Deductible - Individual $300 $600 (per calendar year) (copayments do not - Family $900 $1,800 apply) Maximum - Individual $2,500 $5,000 Out-Of-Pocket Expense Limit - Family $7,500 $15,000 (per calendar year) (excludes deductibles and copayments) Lifetime Maximum $~,OOO,OOO Benefit * Level One participating physicians include family practitioner, general practitioner, pediatrician or internist and Level Two contains any other participating physician. Please contact Customer SelVice for details. Payments - Plan benefits are paid based on reasonable charges. as defined in your r:ertificate. Participating providers agree to .:cept reasonable charges. as listed in negotiated payment schedules. as payment in full. For seNlces rendered by nonparticipating physicians. the member is responsible for charges exceeding a fee schedule selected by your employer and defined in your Certificate. For seNices from other nonparticipating providers. the member is responsible for amounts exceeding reasonable charges, as defined in your Certificate. Participating primary care and specialist physicians and other providers in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent e contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. Emergency services received while out of the seNice area are covered at participating provider level. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) Emergency care provided by a nonparticipating provider will be covered at the participating provider level. e (2) Prior authorization required in order to receive these benefits. (3) Transplant seNices do not apply toward the maximum out-of-pocket expense limit. (4) Any out-of-pocket expense for the treatment of mental health services does not apply towards any out-of-pocket expense limits except for serious mental illness. (5) Subject to certain limitations and exclusions. Refer to the Certificate for additional information. Tht~ amr)l4nr of heruifits providt'd depends llJ1tlll dIe plan selected. Premiums will lIar)' accordit(~ to the selection made. Ftlr ~~e/leml questions about the plan, Cl.llltOa )/our benefits odmi/listrmor. limitations and This is a partial and summarized list of limitations and exclusions. Your group may have specific limitations and exclusions not included on this list. Please check your Certificate for 'Us complete listing. The Certificate is .le document upon which benefit payment will be determined. Unless stated orhenvise, no coverage will be provided tor the followi.ng situations. I. A sickness or injury which is coven:d under any Workers' Compensation or similar law. 2. Sicknes.~ or injury tor which the insured person is in any w:lY paid or emided co paymem or care and treacment by or through a governmem program. other than Medicaid or as othen\.>ise provided by Texas law: 3. Education or training; medical services provided by the insured person"s parent, spouse, brother, sister or child. {. Investigational or experimental drugs or substances not approved by Humana or by the Food and Dl'l1gAdminisrration. 5. Treaunent, services, supplies or surgery that is noc medically necessary. 6. Purchase or fitting of hearing aids, implanClble hearing devices or advice on their care, unless provided by rider. 7. Weekend nonemergency hospica.l admissions. TX-23443-HH 1/04 Exclusions 8. In-vitl'O fertilization, unless our In- Vio"O Fertilization Rider is included in che Group Policy; any medical or surgical t:re:ltment of infertility; infertility evaluations; sex change services or reversal of elective the certificate. 9. Plastic, cosmetic or reconstructive surgery, unless a timctional impairment is present or if required to correct a congenit::ll defect, birth abnomlality of a newborn or for breast reconstruction or as odlenvise stated in the certificace. 10. Services and supplies for dental care, treatment of teeth or periodontiwn or oral surgery, unless the expenses a. are medically necessary diagnostic andlor surgical t:re:louent of the cempol'Omandibular Gaw or cr:miomandibular) joint: b. are fOl' che surgical remoV'dl of a nlmor 01" lesions in the mouth; or c. are incurred in connection "vith an injury to sound namral teeth or jaw, except injuries resulting from biting or chewing, sust.-uned while the person is covered by the Group Policy. For an injury, the care and treannent mUSt be provided within the 12 month period t.~~- Insured by Humana Insurance Company @2004 Humana Inc. beginning on the date of the iI1iury. Also. the insured person must remain covered under the Group Policy dming the 'J 2 month period while the care and O'eaonent is being received. We will not cover any treannent related to the preparation or the fitting of denmres, including dental imp.lants. 11. Any service, supply oi' treaunent connected with custodial care. 12. Sickness or injury caused by dle insured person's: a. engaging in an megal occupation; or b. commission of or an attempt to commit a criminal act. '13. Any treaOnem to reduce obesity, including, but nO[ limiced to, surgical procedures. 14. Elective abortion unless: a. the physician certifies in writing that dle pregnancy \vouJd endanger the life of the mother; or b. the pregnancy is a result of rape or incest; or c. the services are received to treat medical complications due to dle abortion. 15. Vision analysis, testing or orthoptic training or the purchase of eyt:'g1asses or contact lenses. 16. Care and treamlent of complications of non covered procedures, wuess required by state law; ., ... ~. ...:. .,.. . - ;- ....- '--'" .... ..' . ' " ,'.' " - - - : : .4 It . .... _ '-'04_ . '.' __. ...._.._ .-0- _.--.-. , - ~ . ..: . :.:;l ',' .. ., . " -,::'.. '.' . H u.m a.".a PPO .'su.~'":1ai"y'o(:~.~'~~:f.i~:s. ......-;:\:; , . .. ":. ;. ,~~:. " ... .~. t' . ". :-. " ." " ~ ~. . :. 1r~..,:; 11.. ~~~~~~~~~'77~~A~~;1"'l::;:::-':1< ':;J\~['i'j:"e~;'l\~,~:-';:,--;~~-/~ ::f':~~::.~~.i:~~~n;i:lt~l:itt, "'":,1~';\~lJ:~,~~~.9J ~i: 1 1'"'~t"~~"1;f;\~., ~,~~~~it~~.11f~'!.:h:}~_1l..\r~:,l::t,~.Jk~!i \i~'~i~i;~~~-~~'l\~~..\; J....fL>< :':'~..E.c~~:~~itrr:_ !.\.~i;::.~ffi,;'\):...t<.'1~:lt~~t- ;_.tJ')';..-~-rt"~ $_ ~ ::.:.:~~lE";i~~,;8~~r-~~V:.:J.;.:l2~""":':"" ~~.3o<~".;~~c..:;""'~L:::;"...~..~~~l.::."Wj:!~~~~~~n~~ ~;,,:~,~~;:..~ TEXAS PPO 500 Plan pays for services at Plan pays for services at Plan 44, OP.tion 3 PARTICIPATING providers NONPARTICIPATING providers Preventive Care · Routine immunizations (birth to 100% 100% age 7) · Routine immunizations (age 7 to 100% after deductible 70% after deductible age 18) · Annual routine mammogram · Annual routine Pap smear · Routine adult lab and X-ray · Annual routine adult physical 100% after $25 copayment per 70% after deductible examinations (16 years and visit to a Level One participating above; excludes lab and X-ray) physician or $40 copayment per · Routine child physical visit to a Level Two participating examinations (up to age 16; physician* includes lab and X-ray) Physician Services · Office visits (includes diagnostic 100% after $25 copayment per 70% after deductible lab/X-ray. allergy testing) (excludes visit to a Level One participating outpatient surgery) physician or $40 copayment per · Prenatal care (office visit visit to a Level Two participating copayment applies to first visit physician * only) · Allergy serum 80% after deductible 50% after deductible · Inpatient services · Outpatient services (includes surgery) · Physician visits to emergency room (1) · Allergy injections 100% after $ 5 copayment per 70% after deductible visit Hospital Services · Inpatient care (semiprivate room 100% after $250 copayment per 70% after deductible and board, nursing care, leU) (2) day for first five days per admission, and after deductible · Outpatient surgery - facility (2) 100% after $1 00 copayment per 70% after deductible procedure after deductible · Outpatient nonsurgical (including 80% after deductible 50% after deductibie diagnostic lab and X-ray) · Emergency room (1) 100% after $150 copayment per 70% after deductible visit after deductible (copayment waived if admitted) Prescription · Rx4 See attached rider, if applicable Drugs Other Medical · Skilled nursing facility (up to 60 80% after deductible 50% after deductible Services days per calendar year) HumanaPPO combines the cost-saving incentives of a modern health plan with freedom of choice. When you see participating providers, you receive the highest level of benefits available under your plan. At the same time, you retain the flexibility to see any physician. TX-10410-HH 1/04 e e PPO 500 Plan 44, Option 3 Plan pays for services at PARTICIPATING providers Plan pays for services at NONPARTICIPATING providers Other Medical - Home health care (up to 700 80% after deductible 50% after deductible Services (cont.) visits per calendar year) (2) - Durable medical equipment (2) - Physical, speech and hearing therapy (2), (5) - Ambulance (1) - Private duty nursing (inpatient hospital only) - Hospice (2) - Transplant seNices (2), (3) 100% after deductible 70% after deductible Mental Health -Inpatient (up to 30 days per 100% after $250 copayment per 70% after deductible Services (4) calendar year) (2) day for first five days per admission -Inpatient professional seNices 80% 50% - Outpatient (up to 30 visits per calendar year) - Individual sessions 100% after a $40 copayment per 70% visit - Group sessions 100% after a $25 copayment per 70% . visit Serious Mental -Inpatient (up to 45 days per Covered the same as any Covered the same 'as any Illness calendar year) (2) other illness other illness - Outpatient (up to 60 visits per calendar year) Chemical -Inpatient (2) Covered the same as any Covered the same as any Dependency - Outpatient other illness other illness Services (lifetime maximum of three separate series of treatments for each insured person) Annual - Individual $500 $1,000 Deductible (per calendar year) - Family $1,500 $3,000 (copayments do not apply) Maximum - Individual $3,000 $6,000 Out-Of-Pocket Expense Limit (per - Family $9,000 $18,000 calendar year) (excludes deductibles and copayments) Lifetime Maximum Sf,OOO,OOO Benefit * Level One participating physicians include family practitioner, general practitioner, pediatrician or internist and Level Two contains any other participating physician. Please contact Customer SeNice for details. Payments - Plan benefits are paid based on reasonable charges. as defined in your ':ertificate. Participating providers agree to .:cept reasonable charges, as listed in negotiated payment schedules. as payment in full. For services rendered by nonparticipating physicians. the member is responsible for charges exceeding a fee schedule selected by your employer and defined in your Certificate. For services from other nonparticipating providers. the member is responsible for amounts exceeding reasonable charges. as defined in your Certificate. Participating primary care and specialist physicians and other providers in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent e contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. Emergency services received while out of the service area are covered at participating provider level. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) Emergency care provided by a nonparticipating provider will be covered at the participating provider level. e (2) Prior authorization reqUired in order to receive these benefits, (3) Transplant services do not apply toward the maximum out-of-pocket expense limit. (4) Any out-of-pocket expense for the treatment of mental health services does not apply towards any out-of-pocket expense limits except for serious mental illness. (5) Subject to certain limitations and exclusions. Refer to the Certificate for additional information. TIle amourlt of bemftts provided depends upon the plan selected. Prel/liums lIIilI /lQry aa:ordil~1t to the selection made. For .t:e/lero1 questions about the plan, ',I/Itart }'Qllr ben~fits admillistrrrtor. limitations and This is a partial and summarized list of limitations and exclusions. Your group may have specific limitations and exclusions not included on this list. Please check your Certificate for '-lUs complete listing. The Certificate is .e document upon which benefit payment will be determined. Unless stated othen.vise, no coverage will be provided tor the foUowing situations. 1. A sickness or injury which is covered under any'Workers' Compensation or similar law. 2. Sickness or mjury for which the insured person is in :my way paid or entitled to payment or care and treaonenr by or through a government program, other th.m Medicaid or as othen.vise provided by Texas law. 3. Education or training; medical services provided by the insured person's parent, spouse, brother, sister or child. 4. Investigational or experimental drugs or substances not approved by Humana or by the Food and Drug Administration. 5. Treatment, services. supplies or surgery 'that is not medically necessary. 6. Purchase or fitting of hearing aids. implantable hearing devices or advice on their care, unless provided by rider. 7. Weekend non emergency hospital admissions. "- TX-1 041 O-HH 1/04 Exclusions 8. In-vitro fertiJiz,'ltion. unless our In-Vitro Fertilization Rider is included in the Group Policy; any medical or surgical treatment of intertility; infertility evaluations; se.'C change services or reversal of elective sterilization. 9. Plastic, cosmetic or reconstructive surgery, unless a functional impairment is present or if required to correct a congenital defect, birth abnormality of a newborn or for breast reconstruction or as otherwise stated in the certificate. 10. Services and supplies for dental care. treatment of teeth or periodontium or ora] surgery. unless the expenses :1. are medically necessary diagnostic and/or surgical rreatmem of the temporomandibular Gaw or craniomandibular) joint; b. are for the surgical remov:tl of a nImor or lesions in the mouth: or c. are incun'ed in connection with an injury to sound natural teeth or jaw. except injuries resulting from biting or che\ving, sustained while the person is covered by the Group Policy. For an. illjUry. the care and treatment must be provided ,vithin the 12 month period beginning on the date of the injury. ~l!}L~_ Insured by Humana Insurance Company @2004 Humana Inc. Also, the insured person must remain covered under the Group Policy during the 12 month period while the care and treatment is being received. We V\rj]] not covet any treamlent related to the preparation or the fitting of dentures, including dental implants. 11. Any service, supply or treamlent connected \\'ith custodial care. 12. Sickness or injury caused by the insured person's: a. engaging in an illegal occupation: or b. commission of or an attempt to cOIllmit a criminal act. 13. Any treatment to reduce obesity, including, but not limited to, surgical procedures. 14. Elective abortion unless: a. the physician certifies in writing that the pregnancy would endangel' the life of the mother; or b. the pregnancy is a result of rape or incest; or c. the services are received to treat medical complications due to the abortion. t 5. Vision analysis. testing or orthoptic training or the purchase of eyeglasses or contact lenses. 16. Care and treatment of complications of non covered pl"Ocedures. unless required by state law. ... ....... . . . . . :1 .~ . '" :. : .. .:. ~. ~ . . Hum a naP P O' R x 4 . pre~crip'tion .D.r~g' co~erag~ : .,:;:: level One - $10. level Two - $25. [ev~1 Three - :$50, level' Four _: 2~.% .r. ';. How the Rx4 structure works Covered prescnpaon drugs are assigned to one of four difterem levels with corresponding copaymem amounts. The levels are organized as ,follows: . Level One: low-est copaymem for low COSt generic and brand-name drugs. . Level Two: higher copayment tor higher cost generic and br:md-name drugs. . Level Three: higher copaymem than Level Two tor higher cost. mostly brand-name drugs that may have generic or brand-name alternatives on Levels One or Two. . Level Four: highest copayrnent for high-technology drugs (cerrain br:md-name drugs, biOtechnology drugs and self-administered injectable medications). . Medications may be moved from one level to a clifterent level during the plan year. Please check Ollr Web site or contact Customer Service for the most up-to-date information. Some drugs in all levels may be subject co dispensing limit::ltions. based on age, gender, duration or quantity. Additionally, some Level Four drugs may need prior authorization in order to be covered. In these cases. your physician should conract Humana Clinical Pharmacy Review at '1-800-555-CLIN (2546). Members can visit Hum:ma's Web site, W\vw;humana.com, to obtain intormation about tl1eir prescription drug and corresponding benefits and for possible lower cost alternatives, or they can call Humana's Customer Service with questions or to request a Humana Rx4 Drug List by mail. We will also work with physicians and pharmacists to eAl'lain the Rx4 strucnn-e. For a complete listing of participating pharmacies, please refer to our Web site or your participating provider directory. Coverage at participating pharmacies When you present your membership card at a participating pharmacy, you are req\lired to make a copayment for each prescription based on the currem assigned level of the drug. Drugs assigned to: Copayment per prescription or refill Level One: S10 Level Two: $25 Level Three: 550 Level Four: 25%* of the total required payment to the dispensing pharmacy per prescription or refill. * The total maximum our-of-pocket copaymem costs for drugs in Level Four is limited to $2.500 per calendar year, per member. . If the dispensing pharmacy's charge is less than the con-esponding copaymenr, YOll will only be responsible fur the lower amount. . Your copayments for covered prescription drugs are made on a per prescription or refiU basis and will not change ifHumana receives any reo'Ospective volume discounts or prescription drug rebates. There are no claim torms to file if you use a participating pharmacy and present your membership card with each prescription. Nonparticipating pharmacy coverage * YOll may also purchase prescribed medications from a nonparticipating pharmacy.You will be required to pay for your prescriptions according to the following rule. . You pay 100 percent of the dispensing pharmacy's charges. You file a claim torm with Humana (address is on the back of ID card). - Claim is paid at 70 percent of the dispensing pharmacy's charges. after they are first reduced by the applicable copaymem. . Your copayments for covered prescription drugs are made on a per prescription or refill basis and will not change ifHumana recei"lr-cs any retrospective volume discounts or prescription drug rebates. * In Georgia. the nonparticipating benefits are paid the same as the participating benefits. per st::lte regulation. Coverage specifics GN-12140-HH 5/03 Your coverage includes the tollowi.l1g: . A 30-day supply or the amount prescribed. whichever is less. for each pl-escription or refill. . Contraceptives. . Certain self-administered injectable drugs and related supplies approved by Humana. . Certain dnlg5, medicines or medications that, under tederal or st::lte law; may be dispensed only by prescription from a physician. Mail-order benefit e e For your convenience. you may receive a maximum 90-day supply per prescription or refill through the mai.l (maximum 30-day supply for self-administered injeccable drugs). The same requirements apply when purchasing medications through a participating mail-order pharmacy as apply when purchasing in person at a pharmacy. Members can call Customer Service or visit our 'Web site for more information, including mail-order torms. Definition of terms . Drug List: a list of prescription drugs, medicines. medications and supplies specified by Humana. This list identifies drugs as Level One, Level Two, Level Three or Level Four and indicates applicable dispensing limits and/or any prior authorization requirements. (This list is subject to change,) . Copayment: the amoul1t to be paid by the member coward the COSt of each separate prescription or refill of a covered drug when dispensed by a pharmacy. . Nonparticipating pharmacy: a pharmacy which has not been designated by Humana as a participating pharmacy. . Participating pharmacy: a pharmal:y which has entered into an agreement with Humana or which has been designared by HU111,111a to provide services to all covered persons. Participating pharmacy designation by Hlunana may be limited to specified services. Limitations and exclusions { "' GN-12140-HH 5/03 Unless specifically stated otherwise, no coverage is provided for the following: . Any portion of a prescription or refill that exceeds a 30-day supply for a medication - 90-&y supply for a prescription or refill pO-day supply for self-administered injectables) purchased through mail order. . Prescription refills in excess of the number specified by the physician's original order or dispensed more than one year from the cL'lte of the original order . The administration of a covered medication . Immunizing agents or biological serums or allergy e:-..'"rnlcts (may be covered under the medical plan) . Infertility drugs (except where required b)' law) . Drug delivery implants . Any drug, medicine or medication labeled "Caution -limited by federal law to investigational use" or any experime.ncal drug, medicine or medication, even though a charge is, or may be. made to the member . Any costs related to the mailing, sending or delivery of prescription drugs . Any drug used for weight concrol (except where required by law) . Any drug prescribed for a nOJlcovered sickness or injury . Abortifacients (drugs used to induce abortions) . Any drug prescribed for impOtence and/or sexual dysfimction, e.g. Viagra . Injectable drugs. including but not limited to immunizing agents, biological sera, blood, blood plasma or self-adm.inistered injectable dl"Ugs not approved by Humana . Dietary supplements, except for amino acid mod.ified preparations and low-protein modified food products necessary tor the treatment of inherited metabolic diseases. This is only a partial list of limitations and exclusions. Please refer to the Certificate of Coverage/Insurance for complete details regarding prescription drug coverage. RJL~- Insured by Humana Health Insurance Company of Florida, Inc., Humana Insurance Company. Human3 Health Plan, Inc., or Humana Insurance of Puerto Rico, Inc. @2003 Humana Inc. HWl1anaPPO The Welch Comoan Assumptions: 1. Humana Smart Suite plan design. 2. Rate differentials based on Humana book of business. 3. Enrollment assumptions based on Humana plan experience. 4. Employee and total premiums are based on previously stated projections of expected costs. Schedule C 20% Subs Coverage 1st - $1,500 Deductible Employee Only 23 Employee & Spouse 8 Employee and Children 8 Employee and Family 22 .overage 1st - $1,000 Deductible Employee Only 54 Employee & Spouse 6 Employee and Children 6 Employee and Family 16 PPO - $500 Deductible Employee Only 22 Employee & Spouse 23 Employee and Children 24 Employee and Family 58 PPO - $300 Deductible Employee Only 33 Employee & Spouse 13 Employee and Children 13 Employee and Family 31 e 360 Total Monthly Funding Total Annual Funding Employee/Employer % Proposed Premiums and Contributions Current Total Employer Employee Employee Premium Contribution Contributions Contribution Change I $452.20 $429.17 $14.65 $0.00 $14.65 $581.64 $429.17 $105.00, $104.00 $1.00 $530.40 $429.17: $95.24 $86.67 $8.57 $632.86 $429.17 $120.69 $112.67 $8.02 , $487.88 $429.17 ~ $22.70 $0.00 $22.70 $627.51 $429.17 ' $130.34 $104.00 $26.34 $572.24 $429.17; $120.07. $86.67 $33.40 $682.77 $429.17. $155.60' $112.67 $42.93 : $508.39 $429.17, $50.23: $0.00 $50.23 $653.91 $429.171 $165.74 $104.00 $61.74 $596.31 $429.17; $155.15, $86.67 $68.48 $711.49 $429.17; $185.32' $112.67 $72.65 $554.31 $429.17: $79.14i $0.00 $79.14 $712.95 $429.171 $225.79' $104.00 $121.79 $650.16 $429.17! $215.99' $86.67 $129.32 $775.73 $429.17: $239.56 $112.67 $126.89 I j i I $219,551 $154.500: $44,982, $23,929 $21,053 $2,634,610 $1.854,001 $539,787: $287,151 $252,636 100% 70% 20% I $36.53 $104.21 $99.69 $110.57 Per Check $23.18 $76.50 $71.61 $85.53 $10.48 $60.16 $55.42 $71.82 $6.76 $48.46 $43.96 $55.70 City of La Porte Premium and Contribution Projection Effective January 1. 2005 e e REQUEST FOR CITY COUNCIL AGENDA ITEM Agenda Date Requested: 09-27-04 Appropriation Requested By: Shl'rri Samp~nn Source of Funds: Medical Fund Department: BURl~R R.esourc:es Account Number: 014-6144-515-6061 Report: Resolution: Ordinance: x Amount Budgeted: $3,403,235; Exhibits: Ordinance Amount Requested: $3,403,23; Exhibits: Summary of Benefits Budgeted Item: YES NO Exhibits: Premium and C.ontrihutinn PrQjedion SUMMARY & RECOMMENDATION The City of La Porte is self-funded for medical benefits for employees, retirees and their dependents To ensure the City was receiving the best rates and service for its employees, a consultant was used in March of this year to formulate a request for proposal and test the market. Additionally, our employees have had numerous customer service related problems with TML. The RFP requested services for health plan claims administration, utilization review and large case management, preferred provider network, disease management, pharmacy benefit management, COBRA and HIP AA administration. 18 Responses were received for some or all components of the RFP. After an initial evaluation by the Benefit Consultant, two companies were chosen for presentations to the Chapter 172 Board members, Aetna and Humana. Each company was asked to provide information regarding health plan claim administration, utilization review and large case management, preferred provider network, disease management, pharmacy benefit management, HIP AA and COBRA administration. Both companies had current clients and past clients that were willing to supply favorable references. Aetna and Humana both offered substantial savings on the network discounts, compared to TML and their average 30% discount. Aetna claimed to have discounts averaging over 50% and Humana claimed to have discounts averaging at 49%. Human offered new plan designs that are experiencing less than average annual increases to their health benefit costs. The Humana Plan designs also offered similar PPOs to the City's current plan design. The Chapter 172 Board of Trustees is recommending that Council authorize the City Manager to negotiate a 3 year contract with Humana, beginning January 01,2005, for Administrative Services of the City's medical plan. This proposal includes adopting the 4 plan design options Humana recommends for the City of La Porte (Coverage First 1500, Coverage First 1000, PPO 500 and PPO 300). Action Required bv Council: Authorize City Manager to award bid to Humana, to administer the City's Medical Plan; adopt 4 plan designs proposed by Humana; and increase the employee contributions to compromise 20% of Plan expenses. dOl~,JQ~~ Debra Feazelle, City Manager. l' ~ ,),1dl + Date e e 11tf;/-r'1 ORDINANCE NO. 2004- d-ol17 AN ORDINANCE AUTHORIZING AND APPROVING AN AGREEMENT WITH BUMAHA INSURANCE COMPANY, FOR ADMINISTRATIVE SERVICES OF THE CITY' S MEDICAL PLAN, BFFECTIVE JAHl1ARY 1, 2005, ADOPTING nHEALTH SERVICE PLAN DESIGNn OPTIONS, APPROVING AN EMPLOYEE CONTRIBUTION SCHEDULE, APPROPRIATING THE SUM OF $130,000.00, TO Fl1HD SAID ADMINISTRATIVE SERVICBS AGREEMENTS, MAKING VARIOUS FINDINGS AND PROVISIONS RELATING TO THE SUBJECT, FINDING COMPLIANCE WITH THE OPEN MEETINGS LAW, AND PROVIDING AN EFFECTIVE DATE HEREOF. BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF LA PORTE: Section 1. The City council hereby approves and authorizes an agreement with Humana Insurance Company, for administrative services of the City's Employee Medical Fund Plan, a copy of which agreement is on file in the office of the City Secretary. The City Manager is hereby authorized to execute such document and all related documents on behalf of the City of La Porte. The City Secretary is hereby authorized to attest to all such signatures and to affix the seal of the city to all such documents. City Council appropriates the sum of $130,000.00 from City of La Porte Employee Health Services Fund Account No. 014-6144-515-6011, to fund said administrative services agreement for the 2005 calendar year, subject to network cost guarantee. Section 2. The City Council approves and adopts the four plan design options recommended by Humana Insurance Company, for the City of La Porte Employee Medical Fund (Coverage First 1500, Coverage First 1000, PPO 500 AND PPO 300), in form attached hereto and incorporated herein by this reference. Council also approves and adopts the Employee Contribution Schedule by Plan Design effective January 1, 2005, with 20% of plan cost shared with employees, in form attached hereto and incorporated herein by this reference. e e Section 3. The City Council officially finds, determines, recites, and declares that a sufficient written notice of the date, hour, place and subject of this meeting of the City Council was posted at a place convenient to the public at the City Hall of the City for the time required by law preceding this meeting, as required by the Open Meetings Law, Chapter 551, Texas Government Code; and that this meeting has been open to the public as required by law at all times during which this ordinance and the subject matter thereof has been discussed, considered and formally acted upon. The City Council further ratifies, approves and confirms such written notice and the contents and posting thereof. Section 5. This Ordinance shall be effective from and after its passage and approval, and it is so ordered. PASSED AND APPROVED, this 13th of September, 2004. CITY OF LA PORTE By: Alton Porter, Mayor ATTEST: Martha A. Gillett, City Secretary rx;;~~ Knox W. Askins, City Attorney 2 e e ~... - ~~~ . - -" -..... . -.";- ... ", . -~. - .'.-:' . - '.- - _........~-:-::.. ~'. :i:-:''' ~ '""':".-' - :'.~ '~:7':-:-'-'''".-7:: ".:- ::=_-.... :.:.~..:~. :~.; ,,- -~ . 'f - ',. ". _ - "-'..- . 7"-' -". ~~-:;. . . .,.;. .' '. ...:. .:->. . ..:. :-:').:' ;<;".'.-.::..:..;::.t.:......~. "~'.....::~:..::' :~c..:.::~;:S.:.~.,~...iL.:f:~:: ":::'. ',~ ,-' :" ,.::'.,:~:,' '. ' H u nt~ 11 ~-. .~~.v~.;~a:g::'f;f~~t~t~~..J~'.~;Q.;::s.:.~.~.:~;~;~~.,9f.~~~e.fi~.S '~.., '. :. '. ..' ..:. .~ .." ......J-A.:..':~.. ~..:.,~.....,'~.:. ;'~I~"." :<..:....:'";~ ..~. .~:"",'.;.~..;.:'1::" ~.' .. ~ ::~.. ~Fi2!~0\],~;~~~if~1:~;:;:-bJ!r.;..~~D~~r.r~1:~~>I~'-;,..;;n1~~~~'i\~~:r~~~:~ff~~'0,,~;eJ . . , ik..-,~ '"r "1Pt., ",,' c, ~ ~~t. ",!~'"!?-y.,~.~, ~w;:'-"");.'i.. ?~fl'1'?"'''t~.l- ":'"",,1'; "i!i,"-a'';.1.&,(r~,ih''.t;, ...._s3;r;..'j(,~:.t;{)1",4:: -'~~ , L - Lit-~l....::;~..:~~-=~~~":.J"-~...:.:'i.f2:tt:.Jjf~.~.-tUl ~~-8';.;....i' ).,:"""'~~.w'.";;~~:l"<'Eft~.:. f:~_~~;~l...",-,-" U"'.:ti;a.>,~ ~l.i;:iLL..::'1~~~ n.:~~ TEXAS CoverageFirst 1000 Plan pays for services from Plan pays for services from Plan 35, Option 84 PARTICIPATING providers NONPARTICIPATING providers Up-Front Benefit · Annual member benefit (Applies $500 per calendar year Not applicable Allowance to medical services received from per member participating providers only. Does not apply to member copayments, mental health services or Rx benefits.) Annual Deductible · Individual $1,000 $2,000 (per calendar year) (copayments do · Family $3,000 $6,000 not apply) Preventive Care · Routine immunizations (birth to 100% 100% age 7) · Routine immunizations (age 7 to 100% after deductible 10% after deductible age 18) · Annual routine mammography · Annual routine Pap smears · Routine adult lab and X-rays · Annual routine adult physical 100% after $20 copayment per 10% after deductible ( examinations (16 years and visit to a Level One participating above; excludes lab and X-ray) physician or $35 copayment per · Routine child physical visit to a Level Two participating examinations (up to age 16; physician * includes lab and X-ray) Physician Services · Office visits (excludes diagnostic 100% after $20 copayment per 10% after deductible lab and X-ray, outpatient surgery) visit to a Level One participating · Prenatal benefit (office visit physician or $35 copayment per copayment applies to first visit visit to a Level Two participating only) physician * · Allergy testing (covered as part of office visit) · Diagnostic tests, lab and X-rays 80% after deductible 60% after deductible · Allergy serum · Inpatient services · Outpatient services (includes surgery) · Physician visits to emergency room (1) · Allergy injections 100% after $5 copayment per 10% after deductible visit CoverageFirst PPO combines the cost-saving incentives of a modern health plan with freedom of choice and an annual benefit allowance. When you see participating providers, you receive the highest level of benefits available under your plan. At the same time, you retain the flexibility to see any physician. TX-10434-HH 1/04 e e CoverageFirst 1000 Plan pays for services from Plan pays for services from Plan 35, Option 84 PARTICIPATING providers NONPARTICIPATING providers Hospital Services · Inpatient care (semiprivate room 100% after $100 copayment 70% after deductible and board, nursing care, leU) (2) per day for first five days per admission, and after deductible · Outpatient surgery - facility (2) 100% after $50 copayment per 70% after deductible procedure after deductible · Outpatient nonsurgical (including 80% after deductible 60% after deductible diagnostic lab and X-ray) · Emergency room (1) 100% after $100 copayment 70% after deductible per visit after deductible (copayment is waived if admitted) Prescription Drugs · Rx4 See attached rider, if applicable Other Medical · Skilled nursing facility (up to 80% after deductible 60% after deductible Services 60 days per calendar year) · Home health care (up to 100 visits per calendar year) (2) · Durable medical equipment (2) · Physical, speech and hearing therapy (2), (5) · Ambulance (1) · Private duty nursing (inpatient hospital only) · Hospice (2) C · Transplant services (2), (3) 100% after deductible 70% after deductible Mental Health · Inpatient (up to 30 days per 100% after $1 00 copayment 70% after deductible Services (4) calendar year) (2) per day for first five days per admission · Inpatient professional services 80% 60% · Outpatient (up to 30 visits per calendar year) -Individual sessions 100% after a $20 copayment 70% per visit - Group sessions 100% after a $10 copayment 70% per visit Serious · Inpatient (up to 45 days per Covered the same as any Covered the same as any Mental Illness calendar year) (2) other illness other illness · Outpatient (up to 60 visits per calendar year) Chemical Dependency · Inpatient (2) Covered the same as any Covered the same as any (lifetime maximum of · Outpatient other illness other illness three separate series of treatments for each insured person) ( * Level One participating physicians include family practitioner, general practitioner, pediatrician or internist and Level Two contains any other participating physician. Please contact Customer Service for details. e CoverageFirst 1000 Plan 35, Option 84 Plan pays for services from PARTICIPATING providers e Plan pays for services from NONPARTICIPATING providers Maximum · Individual Out-Of-Pocket Expense Limit · Family (per calendar year) (excludes deductibles and copayments) $2,000 $6,000 $4,000 $12,000 Lifetime Maximum Benefit $1,000,000 Payments - Plan benefits are paid based on reasonable charges, as defined in your Certificate. Participating providers agree to accept reasonable charges, as listed in negotiated payment schedules, as payment in full. For services rendered by nonparticipating physicians, the member is responsible for charges exceeding a fee schedule selected by your employer and defined in your Certificate. For services from other nonparticipating providers, the member is responsible for amounts exceeding reasonable charges, as defined in your Certificate. Participating primary care and (. - .,ecialist physicians and other :oviders in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent c contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. Emergency care services received while out of the service area are covered at the participating provider level. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) Emergency care provided by a nonparticipating provider will be covered at the participating provider level. (2) Prior authorization required in order to receive these benefits. (3) Transplant services do not apply toward the maximum out-of-pocket expense limit. (4) Any out-of-pocket expense for the treatment of mental health services does not apply towards any out-of-pocket expense limits except for serious mental illness. (5) Subject to certain limitations and exclusions. Refer to the Certificate for additional information. TIle al1l01lllt of benf!fits proJlided depetlds IIpOll the plall selected. Premiums willl'flry according lI.J the selectipll made. For g'!tIeral questip,lS abolll the plait. conraa YOllf belzqifs administrator. limitations and " This is a partial and summarized list of ( nitations and exclusions. Your group ..lay have specific limitations and exclusions not included on this list. Please check your Certificate for this complete listing. The Certificate is the document upon which benefit payment will be determined. ( Unless stated othen\oise. no coverage will be provided for the following simatiollS. 1 . A sickness or injury which is covered under any Workers' Compensation or similar law. 2. Sickness or injury tor which the insured person is in any way paid or entitled to payment or care and treatment by or through a government program, other than Medicaid or as othe.rwise provided by Texas law. 3. Education or training; medical services provided by the insured person's parent, spouse, brother, sister or child. 4. Investigational or experimental drugs or substances not approved by Humana or by the Food and Drug Administration. 5. Treatment, services. supplies or surgery that is not medically necessary. 6. Purchase or fitting of hearing aids, implantable hearing devices or advice 011 their care, unless provided by rider. ( TX-10434-HH 1/04 e Exclusions 7. Weekend nonemergency hospital admissions. 8. In-vitro fertilization. unless our In-Vim) Fertilization Rider is included in the GI'OUP Policy; any medical or surgical treatmen r of infertility; infertility evaluations; sex change services or reversal of elective sterilization. 9. Plastic, cosmetic or reconstructive surgery, unless a functional impairment is present or if required to correcr a congenital defect. birth abnormality of a newborn or for breast reconstruction or as otherwise scared in the certificate. 10. Services and supplies for dental care, treatment of teeth or periodontium or oral surgery, unless the e~l'enses a. are medically necessary diagnostic and/or surgical treatment of the temporomandibular Gaw or craniomandibular) joint; b. are for the surgical removal of a. nmlOr or lesions in the mouth; or c. are incurred in connection with an injury to sound natural teeth or jaw, except injuries resulting from biting or chewing, sustained while the person is covered by the Group Policy. For an. injury, the care and treaonent must be provided within the 12 month period beginning on the date of the injury. Also. the insured person must remain covered '" Ff2...~~;~ Insured by Humana Insurance Company @2004 Humana Inc. e under the Group Policy durin.g the 12 month period while the care and treatment is being received. We will not cover any treaonent related to the preparation or the fitting of deumres. including dental implants. 11. Any senri.ce, supply or treatment connected with custodial care. 12. Sickness or injury caused by the insured persons: a. engaging in an illegal occupation; or b. commission of or an attempt to commit a criminal act. 13. Any treatment to reduce obesity, including, but not limited to. surgical procedures. 14. Elective abortion unless: a. the physician certifies in writing tllat the pregnancy would endanger the life of the mother: or b. the pregnancy is a result of rape or incest; or c. the services are received to treat medical complications due to the a borrion. 15. Vision analysis. testing or orthoptic training or the purchase of eyeglasses or contact lenses. 16, Care and treatment of complications of noncovered procedures. unless required by state law. e e ... -.~~-". -;--. . :":.-:.~_.. } ~~:::r::-r ;;'~ff~~'~.J~?~?t~:~~~;~~~;:f~~f.!.~;~~t~~;:~;B.~.~~F"~'Jf?-4r:::~:}:~;'~:~ ..},:.~ -:~:'~/..:.-':.'~~ .~~ .~ u.:~:~'.n. ~', :~':~:v~~'t~~-.~-:':~.lt;:$~~--~' :~J.!~~P\:~~~.-~:~:~:'~:~ ._~~~..:,~hef:~.t.s ::':. .~. ..,.:.......,... :'..'.~' "~'...~ .:~ ", ...~.;.:.;:..:. .:!~.;~'::.~...,;:~.~ --i' h..:..... .: ...........;.,:,.~...;_. ".:.<J .;." 0' -:'" ...."r ' :-----:-r . . I ( r - ~ ~.. ~~,:;;'E~~~.~~;-"!~ ~~r-;lTe:;~:; 71~~."7'"U~~;;~j~<:~: .~~J ~ '~r 7i:'7;.f~';?~2:---:,-~ "'i3'~ ~~'l'j't.~j.1'..~r;;~F~71T~~4 !"_ .[1 ~ ~i lli~~~~ni:~j~1?i1i!filll~b~i~?0~~1t:~:~~;l~l,-;:~:,.:~~~ry~~t:~~~~!:k;;i~~~~~~Si~1~~~fe.:~irti~1 TEXAS CoverageFirst 1500 Plan pays for services from Plan pays for services from Plan 35, Option 100 PARTICIPATING providers NONPARTICIPATING providers Up-Front Benefit · Annual member benefit (Applies $500 per calendar year Not applicable Allowance to medical services received from per member participating providers only. Does not apply to member copayments, mental health services or Rx benefits.) Annual Deductible · Individual $1,500 $3,000 (per calendar year) (copayments do · Family $4,500 $9,000 not apply) Preventive Care · Routine immunizations (birth to 100% 100% age 7) · Routine immunizations (age 7 to 100% after deductible 70% after deductible age 18) · Annual routine mam.mography · Annual routine Pap smears · Routine adult lab and X-rays · Annual routine adult physical 100% after $20 copayment per 70% after deductible r' examinations (16 years and visit to a Level One participating " above; excludes lab and X-ray) physician or $35 copayment per · Routine child physical visit to a Level Two participating examinations (up to age 16; physician * includes lab and ~-ray) Physician Services · Office visits (excludes diagnostic 100% after $20 copayment per 70% after deductible lab and X-ray, outpatient surgery) visit to a Level One participating · Prenatal benefit (office visit physician or $35 copayment per copayment applies to first visit visit to a Level Two participating only) physician * · Allergy testing (covered as part of office visit) · Diagnostic tests, lab and X-rays 80% after deductible 60% after deductible · Allergy serum · Inpatient services · Outpatient services (includes surgery) · Physician visits to emergency room (1) · Allergy injections 100% after $5 copayment per 70% after deductible visit (, '-. CoverageFirst PPO combines the cost-saving incentives of a modern health plan with freedom of choice and an annual benefit allowance. When you see participating providers, you receive the highest level of benefits available under your plan. At the same time, you retain the flexibility to see any physician. TX-23441-HH 1/04 . e CoverageFirst 1500 Plan pays for services from Plan pays for services from Plan 35, Option 100 PARTICIPATING providers NONPARTICIPATING providers -- Hospital Services · Inpatient care (semiprivate room 100% after $1 00 copayment 10% after deductible and board, nursing care, leU) (2l per day for first five days per admission, and after deductible · Outpatient surgery - facility (2l 100% after $50 copayment per 10% after deductible procedure after deductible · Outpatient nonsurgical (including 80% after deductible 60% after deductible diagnostic lab and X-ray) · Emergency room (1) 100% after $1 00 copayment 10% after deductible per visit after deductible (copayment is waived if admitted) Prescription Drugs · Rx4 See attached rider, if applicable Other Medical · Skilled nursing facility (up to 80% after deductible 60% after deductible Services 60 days per calendar year) · Home health care (up to 700 visits per calendar year) (2) · Durable medical equipment (2) · Physical. speech and hearing therapy (2), (5) · Ambulance (1) · Private duty nursing (inpatient hospital only) · Hospice (2l ( · Transplant services (2), (3) 100% after deductible 70% after deductible Mental Health · Inpatient (up to 30 days per 100% after $1 00 copayment 70% after deductible Services (4) calendar year) (2) per day for first five days per admission · Inpatient professional services 80% 60% · Outpatient (up to 30 visits per calendar year) -Individual sessions 1 PO% after a $20 co payment 70% per visit - Group sessions 100% after a $10 copayment 70% per visit Serious · Inpatient (up to 45 days per Covered the same as any Covered the same as any Mental Illness calendar year) (2) other illness other illness · Outpatient (up to 60 visits per calendar year) Chemical Dependency · Inpatient (2) Covered the same as any Covered the same as any (lifetime maximum of · Outpatient other illness other illness three separate series of treatments for each insured person) ( * Level One participating physicians include family practitioner, general practitioner, pediatrician or internist and Level Two contains any other participating physician. Please contact Customer Service for details. . ~.. CoverageFirst 1500 Plan 35, Option 100 Plan pays for services from PARTICIPATING providers e Plan pays for services from NONPARTICIPATING providers Maximum · Individual Out-Of-Pocket Expense Limit · Family (per calendar year) (excludes deduct;bles and copayments) $3.000 $9,000 $6.000 $18.000 Lifetime Maximum Benefit u.ooo.ooo Payments - Plan benefits are paid based on reasonable charges. as defined in your Certificate. Participating providers agree to accept reasonable charges. as listed in negotiated payment schedules, as payment in full. For services rendered by nonparticipating physicians. the member is responsible for charges exceeding a fee schedule selected by your employer and defined in your Certificate. For services from other nonparticipating providers, the member is responsible for amounts exceeding reasonable charges. as defined in your Certificate. Participating primary care and (,. -pecialist physicians and other roviders in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent (, contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. Emergency care services received while out of the service area are covered at the participating provider level. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) Emergency care provided by a nonparticipating provider will be covered at the participating provider level. (2) Prior authorization required in order to receive these benefits. (3) Transplant services do not apply toward the maximum out-of-pocket expense limit. (4) Any out-of-pocket expense for the treatment of mental health services does not apply towards any out-of-pocket expense limits except for serious mental illness. (5) Subject to certain limitations and exclusions. Refer to the Certificate for additional information. n,e al1l011llt if benifjts prol'ided depends IIpCI/I the plall selected. Premiums will mry according to the selection made. For general qr4estiolls abollt the plall. contact: your bell4its adminisrrator; limitations and ," This is a partial and summarized list of (" nitations and exclusions. Your group .<lay have specific limitations and exclusions not included on tlIis list. Please check your Certificate for this complete listing. The Certificate is the document upon which benefit payment ~;ll be determined. Unless srated otherwise, no coverage will be provided for the foUowing situations. I. A sickness or injury which is covered undel' <lnyWorkers. Compensation or similar law. Sickness or injury for ,"vhich the insured person is in any way paid or entitled to payment or care and treatment by or through a government program, other than Medicaid or as otherwise provided byTex.1S law. Education or training; medical services provided by the insured person's parent, spouse, brother, sister or child. Investigational or experimental drugs or substances not approved by Humana or by the Food and Drug Administration, Treatment, services. supplies or surgery that is not medically necessary. Purchase or fitting of hearing aids, implantable hearing devices or advice 011 their care, unless provided by rider. 2. 3. 4. :>. 6. l. (~ TX-23441-HH 1/04 e Exclusions 7. 'Weekend nonemergency hospital admissions, 8. In-vin-o fertilization. unless our In-Vitro Fertilization Rider is included in the Gmup Policy; any medical or surgical treatment of infertility; infertility evaluations; sex change services or reversal of elective sterilization. 9. Plastic. cosmetic or reconstructive surgery. unless a functional inlpairment is present or if required to correct a congenital defect, birth abnormality of a newborn or for breast reconstruction or as otherwise stated in the certificate. 10. Services and supplies for dental care, treatment of teeth or periodontium or oral surgery, unless the e)..-penses a. are medically necessary diagnostic and/or surgical n'eannent of the temporomandibular Gaw or craniomandibular) joint; b. are for the surgical removal of a n1ll1Or or lesions in the mouth; or c. are incurred in connection with an injury to sound natural teeth or jaw, exce.pt injuries resulting from biting or chC"l.\>ing, sustained while the person is covered by the Group PoliC}~ For an injury, the care and treatment must be pl-o\'ided within the 12 month period beginning on the date of the injury. Also, the insured person must remain covered }~Ff..TL~~:m_ Insured by Humana Insurance Company @2004 Humana Inc. e under the Group Policy during the 12 month period while the care and treatment is being received. We ,""ill not cover any treannent related to the preparation or the fitting of dentures. including dental implants. II. Any service, supply or treaonent connected with custodial care. 12. Sickness or injury caused by the insured person's: a. engaging in an illegal occupation: or b. commission of or an attempt to commit a criminal act. 13. Any n'eatment to reduce obesity, including, but not limited to. surgical procedures. 14. Elective abortion unless: a. the physician certifies in writing that the pregnancy would endanger the life of the mother; or b. the pregnancy is a result of rape or incest; or c. the services are received to treat medical complications due to the abortion. 15, Vision analysis, testing or orthoptic training or the purchase of eyeglasses or contact lenses. 16. Care and treannent of complications of noncovered procedures. unless required by state law. e e :-: ~ ~ ;': ~:~~:. ::~ <.-;:':: ~10.~;~~<:H~~.~~W~~:~~~s~'~~'~~;~~~i~~~~~J~~:'!Y:!.f?1Q?~f.~;~~;':;i-;:;~~~:I~:~7~~;~~~R Hum ai..a p.'p O:'~iJjrt:ni~~r:'}i::,~;f~~~.~:~'ii.i~'.";;.>t:~~r>::..~~~::'\.:~:.~1~\=.,I':~:'~ :'''};' ;'::'., ~':: .:.,.. . -.'~':,:' ....... :.:- ~ '. . '. '.' ".,' (~.~-< ,:..~.~::-~'~~..;r..~fc..~- : ~.:,:.~<:~~.:~}ff; .~.~;:h..'~.~~~:J~-:~~~~)i~:/::,<;.~5<~.. :.,)~;.)~:':: .' .:.::: :,~.<.-/: '>. '.'~ .,'" . ~.. t::~~~L~~L~~~c.l~ ~~~~' ~:?!'j ~~~;~:-1:=)~ :~~ "'~' 3_J:Y~~D~~~ ~f~-3/~~i~~~;Z:~lg;~~~*~~~~f~ TEXAS PPO 300 Plan pays for services at Plan pays for services at Plan 44, Option 5 PARTICIPATING providers NONPARTICIPATING providers Preventive Care · Routine immunizations (birth to 100% 100% age 7) · Routine immunizations (age 7 to 100% after deductible 70% after deductible age 18) · Annual routine mammogram · Annual routine Pap smear · Routine adult lab and X-ray · Annual routine adult physical 100% after $20 copayment per 70% after deductible examinations (16 years and visit to a Level One participating above; excludes lab and X-ray) physician or $35 copayment per · Routine child physical visit to a Level Two participating examinations (up to age 16; physician* includes lab and X-ray) Physician · Office visits (includes diagnostic 100% after $20 copayment per 70% after deductible Services lab/X-ray, allergy testing) (excludes visit to a Level One participating outpatient surgery) physician or $35 copayment per · Prenatal care (office visit visit to a Level Two participating copayment applies to first visit physician * only) ,'- · Allergy serum 90% after deductible 60% after deductible \ · Inpatient services · Outpatient services (includes surgery) · Physician visits to emergency room (1) · Allergy injections 100% after $5 copayment 70% after deductible per visit Hospital · Inpatient care (semiprivate room 100% after $1 50 copayment per 70% after deductible Services and board, nursing care, leU) (2) day for first five days per admission, and after deductible · Outpatient surgery - facility (2) 100% after $50 copayment per 70% after deductible procedure after deductible · Outpatient nonsurgical (including 90% after deductible 60% after deductible diagnostic lab and X-ray) · Emergency room (1) 100% after $1 00 copayment per 70% after deductible visit after deductible (copayment waived if admitted) Prescription Drugs · Rx4 See attached rider, if applicable Other Medical · Skilled nursing facility (up to 60 90% after deductible 60% after deductible Services days per calendar year) {, HumanaPPO combines the cost-saving incentives of a modern health plan with freedom of choice. When you see participating providers, you receive the highest level of benefits available under your plan. At the same time, you retain the flexibility to see any physician. TX-23443-HH 1/04 e . PPO 3 DO Plan 44, Option 5 Plan pays for services at PARTICIPATING providers Plan pays for services at NONPARTICIPATING providers ( Other Medical - Home health care (up to 700 90% after deductible 60% after deductible Services (cant.) visits per calendar year) (2) - Durable medical equipment (2) - Physical, speech and hearing therapy (2), (5) - Ambulance (1) - Private duty nursing (inpatient hospital only) - Hospice (2) - Transplant services (2), (3) 100% after deductible 70% after deductible Mental Health -Inpatient (up to 30 days per 100% after $1 50 co payment per 70% after deductible Services (4) calendar year) (2) day for first five days per admission -Inpatient professional services 90% 60% - Outpatient (up to 30 visits per calendar year) - Individual sessions 100% after a $35 copayment 70% per visit - Group sessions 100% after a $20 copayment 70% per visit Serious Mental -Inpatient (up to 45 days per Covered the same as any Covered the same as any Illness calendar year) (2) other illness other illness - Outpatient (up to 60 visits per calendar year) - Chemical -Inpatient (2) Covered the same as any Covered the same as any Dependency - Outpatient other illness other illness Services (lifetime maximum of three separate series of treatments for each insured person) Annual Deductible - Individual $300 $600 (per calendar year) (copayments do not - Family $900 $1,800 apply) . Maximum - Individual $2,500 $5.000 Out-Of-Pocket Expense Limit - Family $7,500 $15,000 (per calendar year) (excludes deductibles and copayments) Lifetime Maximum $~,OOO,OOO Benefit * Level One participating physicians include family practitioner. general practitioner. pediatrician or internist and Level Two contains any other participating physician. Please contact Customer Service for details. ( '. Payments - Plan benefits are paid based on reasonable charges. as defined in your ,. . '":ertificate. Participating providers agree to I .:cept reasonable charges. as listed in negotiated payment schedules. as payment in full. For services rendered by nonparticipating physicians, the member is responsible for charges exceeding a fee schedule selected by your employer and defined in your Certificate. For services from other nonparticipating providers. the member is responsible for amounts exceeding reasonable charges, as defined in your Certificate. Participating primary care and specialist physicians and other providers in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent e contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. Emergency services received while out of the service area are covered at participating provider level. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) Emergency care provided by a nonparticipating provider will be covered at the participating provider level. e (2) Prior authorization required in order to receive these benefits. (3) Transplant services do not apply toward the maximum out-of-pocket expense limit. (4) Any out-of-pocket expense for the treatment of mental health services does not apply towards any out-of-pocket expense limits except for serious mental illness. (5) Subject to certain limitations and exclusions. Refer to the Certificate for additional information. The amol/nt l![ beruifirs pro/Jided depellds 14}J<1Il the plnu selected. Premiul1ls ulillllal"J' accordiuK to the selection made. Hlr general questions about the p/IlII, colltner )'our beuifits adl1linistrator. limitations and This is a partial and summarized list of limitations and exclusions. Your group may have specific limitations and exclusions not included on this list. Please check your Certificate for ('- ",is complete listing. The Certificate is . .Ie document upon which benefit payment will be determined. Unless stated otherwise, 110 coverage will be provided for the following sinlations. 1. A sickness or injury which is covered u.nder any Workers' COmpens.1tion or similar law. 2. Sickness or injury for which the insured person is in any way paid or entitled to paymem or care and tre2tment by or through a govemment progr:nil. other than Medicaid or as otherwise provided by Texas law. 3. Education or training; medical services provided by the insured person's parent, spouse, brother, si~ter or child. 4. Investigational or experimental drugs or substances not approved by Humana or by the Food and Drug Administration. 5. Treaunent, services, supplies or surgery that is not medically necessary. 6. Purchase or fitting of hearing aids, implantable hearing devices or advice on their care, unless provided by rider. 7. Weekend nonemergency hospital admissions. ( , TX-23443-HH 1/04 Exclusions 8. In-vitro fertilization, unless our In-Vitro Fertilization Rider is included in the Group Policy; any medical or surgical ueatment of infettility; infertility evaluations; sex change services or reversal of elective the certificate. 9. Plastic, cosmetic or reconstructive surgery, unless a functional impairment is present or if required to correct a congenital defect, birth abnormality of a newborn or for breast reconstruction or as otherwise stated in the certificate. 10. Services and supplies for dental care, treatment of teeth or periodontiwll or oral surgery; unless the expenses a. are medically necessary diagnostic and/or surgical treamlent of the temporomandibular Gaw or craniomandibular) joint: b. are for the surgical removal of a tumor or lesions in the mouth; or c. are incurred in connection with an injury to sound namral teeth or jaw. except injuries resulting from biting or chewing, sust:tined while the person is covered by the Group Policy. For an injury, the care and treatment must be provided within the 12 month period ~ l!2.~~_ Insured by Humana Insurance Company @2004 Humana Inc. beginning on the cL1te of the injury. Also, the insured person must remain covered under the Group Policy during the 12 month period while the care and treatment is being received. We 'willnot cover any treannent related to the preparation or the fitting of denmres, including dental implants. 11. Any service, supply or m:amlent connected with custodial care. 12. Sickness or injury caused by the insured person's: a. engaging in an iUegal occupation; or b. commission of or an attempt to conU1ut a criminal act. 13. Any treatment to reduce obesity, including, but not limited to, surgical procedures. 14. Elective abortion unless: a. the physician certifies in writing that the pregnancy would endanger the life of the mother; or b. the pregnancy is a result of rape or incest; or c. the services are received to treat medical complications due to the abortion. 15. Vision analysis, testing or orthoptic training or the purchase of eyeglasses or contact lenses. 16. Care and treatment of complications of noncovered procedures, unless required by state la"v. e e -. '. '-, ::~.'~ ~' :;;: ~'.'-~~;;~~;~ ;:~~~~'~~~f~;J~~f~~Hrf%;:~~{rt::!:t!~:~.)~t~{l:fi:,;:::::~{;;;:~:':: Hum a n. a P:P 0:. Sl!:I!J;~aj!:y.':'Q:t!te.r:t.~~f~IJ$,'.':\<:-r6.~:. .... :; >:'~.';=... :'~':'~"l ::. .;:.":' .'. .: .... :.;. . ..... . . . '. '. .. I ~ '.:' ~ . :": :., ~:~~t;.r. ..~ :~. ~~~ ':~:;: .?~_'~::.1<.~": j-. '.~ '~: :~;:' .;~ i" I:~':[~. :,'t:o'~ ':~"~;"~:: .. :'..": ~: ~-.,,~~ 7;.~" ":: J'~' . '. . .~ ~ . '.' =. . ~. : ",: - . ~.. i;A:~i~l:~~-~ ;:,,_:lJ -~= _:-~.:~-~:' :~;~'. :~:/~-." _~,~,:~ ::.~~,-~~:~~'::~. J:';i~~~~~ri~~Efil~~~t~~~ TEXAS PPO 500 Plan pays for services at Plan pays for services at Plan 44, Option 3 PARTICIPATING providers NONPARTICIPATING providers Preventive Care · Routine immunizations (birth to 100% 100% age 7) · Routine immunizations (age 7 to 100% after deductible 70% after deductible age 18) · Annual routine mammogram · Annual routine Pap smear · Routine adult lab and X-ray · Annual routine adult physical 100% after $25 copayment per 70% after deductible examinations (16 years and visit to a Level One participating above; excludes lab and X-ray) physician or $40 copayment per · Routine child physical visit to a Level Two participating examinations (up to age 76; physician* includes lab and X-ray) Physician Services · Office visits (includes diagnostic 100% after $25 copayment per 70% after deductible lab/X-ray, allergy testing) (excludes visit to a Level One participating outpatient surgery) physician or $40 copayment per · Prenatal care (office visit visit to a Level Two participating copayment applies to first visit physician * only) ( · Allergy serum 80% after deductible 50% after deductible · Inpatient services · Outpatient services (includes surgery) · Physician visits to emergency room (1) · Allergy injections 100% after $5 copayment per 70% after deductible visit Hospital Services · Inpatient care (semiprivate room 100% after $250 copayment per 70% after deductible and board, nursing care, leU) (2) day for first five days per admission. and after deductible · Outpatient surgery - facility (2) 100% after $1 00 copayment per 70% after deductible procedure after deductible · Outpatient nonsurgical (including 80% after deductible 50% after deductible diagnostic lab and X-ray) · Emergency room (1) 100% after $150 copayment per 70% after deductible visit after deductible (copayment waived if admitted) Prescription · Rx4 See attached rider, if applicable Drugs Other Medical · Skilled nursing facility (up to 60 80% after deductible SO% after deductible Services days per calendar year) (, - HumanaPPO combines the cost-saving incentives of a modern health plan with freedom of choice. When you see participating providers, you receive the highest level of benefits available under your plan. At the same time, you retain the flexibility to see any physician. TX-1 041 O-HH 1/04 It e PPO 500 Plan 44, Option 3 Plan pays for services at PARTICIPATING providers Plan pays for services at NONPARTICIPATING providers c Other Medical - Home health care (up to 100 80% after deductible 50% after deductible Services (cont.) visits per calendar year) (2) - Durable medical equipment (2) - Physical, speech and hearing therapy (2), (5) - Ambulance (1) - Private duty nursing (inpatient hospital only) - Hospice (2) - Transplant services (2), (3) 100% after deductible 70% after deductible Mental Health -Inpatient (up to 30 days per 100% after $250 copayment per 70% after deductible Services (4) calendar year) (2) day for first five days per admission -Inpatient professional services 80% 50% - Outpatient (up to 30 visits per calendar year) - Individual sessions 100% after a $40 copayment per 70% visit - Group sessions 100% after a $25 copayment per 70% visit Serious Mental -Inpatient (up to 45 days per Covered the same as any Covered the same as any Illness calendar year) (2) other illness other illness - Outpatient (up to 60 visits per calendar year) Chemical -Inpatient (2) Covered the same as any Covered the same as any Dependency - Outpatient other illness other illness Services (lifetime maximum of three separate series of treatments for each insured person) Annual - Individual $500 $1,000 Deductible (per calendar year) - Family $1,500 $3,000 (copayments do not apply) Maximum - Individual $3,000 $6,000 Out-Of-Pocket Expense Limit (per - Family $9,000 $18,000 calendar year) (excludes deductibles and copayments) Lifetime Maximum U,OOO,OOO Benefit l * Level One participating physicians include family practitioner, general practitioner, pediatrician or internist and Level Two contains any other participating physician. Please contact Customer Service for details. Payments - Plan benefits are paid based on reasonable charges. as defined in your ':ertificate. Participating providers agree to :cept reasonable charges. as listed in negotiated payment schedules. as payment in full. For services rendered by nonparticipating physicians. the member is responsible for charges exceeding a fee schedule selected by your employer and defined in your Certificate. For services from other nonparticipating providers. the member is responsible for amounts exceeding reasonable charges. as defined in your Certificate. Participating primary care and specialist physicians and other providers in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent e contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. Emergency services received while out of the service area are covered at participating provider level. To be covered, expenses must .be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) Emergency care provided by a nonparticipating provider will be covered at the participating provider level. e (2) Prior authorization required in order to receive these benefits, (3) Transplant services do not apply toward the maximum out-of-pocket expense limit. (4) Any out-of-pocket expense for the treatment of mental health services does not apply towards any out-of-pocket expense limits except for serious mental illness. (5) Subject to certain limitations and exclusions. Refer to the Certificate for additional information. The amount of bellljits prollided depends upon the plan selected. Premiums will var)' according to the selection made. For ge/lerol questions about the plan, 'lllltQct )'ollr ben~fits administmtor. limitations and This is a partial and summarized list of limitations and exclusions. Your group may have specific limitations and exclusions not included on this list. Please check your Certificate for ( - ~~is complete listing. The Certificate is . ,e document upon which benefit . payment will be determined. Unless stated otherwise, no coverage will be provided for the follm,ving situations. 1. A sickness or injury which is covered under any Workers' Compensation or similar law. 2. Sickness or InjUry for which the insured person is in any way paid 01: entitled [0 paymcm or care and treatment by or through a government program, other than Medicaid or as otherwise provided by Texas law. 3. Education or training; medical services provided by the insured person's parent, spouse, brother, sister or child. 4. Investigational or experimental drugs or subst:mces not approved by Humana or by the Food and Dnlg Administration. =>. Treaonel1t, services. supplies or surgery 'that: is not medically necessary. 6. Purchase or fitting of hearing aids, implantable hearing devices or advice on their care, unless provided by rider. 7. Weekend nonemergency hospital admissions. \.- TX-10410-HH 1/04 Exclusions 8. In-vitro fertilization, unless our In-Vitro Fertilization Rider is included in the Group Policy; any medical or surgical treaollent of infertility; infertility evaluatiol1S; sex change services or reversal of elective sterilization. 9. Plastic, cosmetic or reconstructive surgery, unless a functional impairment is present or if required to correct a congenital defect, birth abnormality of a newborn or for breast reconstruction or as otherwise stated in the certificate. 10. Services and supplies for dental care, treatment of teeth or periodontium or oral surgery. unless the expenses a. are medically necessary diagnostic and/or surgical. treatment of the temporomandibular Gaw or craniomandibular) joint; b. are for the surgical removal of a nJmor or lesions in the mouth; or c. are incuned in connection with an injwy to sound natural teeth or jaw, except injuries resulting from biring or che\.ving, sustained while the person is covered by me Group Policy. For an injury. the care and treatment must be provided within the 12 month period beginning on the date of the injury. RJL~~- Insured by Humana Insurance Company @2004 Humana Inc. Also, the insured person must remain covered under the Group Policy during the 12 month period while the care and treamlent is being received. We will not cover any o-eatment related to the preparation or the fitting of dentures, including dental implants. 11. Any service, supply or trearnlent connected with custodial care. 12. Sickness or injury caused by the insured person's: a. engaging in an illegal occupation: or b. commission of or an attempt to conmut a cril1unal act. 13. Any treatment to reduce obesity, including, but not limited to, surgical procedures. 14. Elective abortion unless: a. the physician certifies in writing that the pregnancy would endanger tile life of the mother; or b. the pregnancy is a result of rape or incest; or c. the services are received to treat medical complications due to the abortion. 15. Vision analysis. testing or orthoptic training or the purchase of eyeglasses or contact lenses. 16. Care and treatment of complications of noncovered procedures. unless required by state law. e e "~o~:i'67~lIb?'ii~~~~~~~~~(f.~~WP;.~-;'-B7;;~i:::? Level One:- $1 0, ~~Y~~:}W~~~;;~:~ri-~~~~l ~~re~f/~~,~;{~vfr~~ur"~;~~;%;:~::.::':._ . .;". '. ..:~' <. - .~. .' : "'~;.i: I ; '{" ~.. ~}~~~~~;;F"~.:1~I~).m1TI1~ff~~:-:n..){iT{:~"TI5:~wf;~~*b:~~~~:;,r~~:~~;;j:~~~~:'w.}]fi;~~51!:'..~u..~ 1 I ;,.~' h..~ Jt'~'~~~~~:!rt!ht'~!ikTh?~~~~~~~~J!:;~~t~~1kt~$~;\-~H~~~"~Fi1id!!1~f ~1;~r~:t!iJ;'~J,ft~P\:~~~~ifj~ How the Rx4 structure works Covered prescription drugs are assigned to one of four difterent levels ""ith corresponding copaymenr amounts. The levels are organized as follo'''15: . Level One: lowest copaymellt for ]ow COSt generic and brand-name dl1.lgs. . Level Two: higher copayment for higher cost generic and br:l11d-name drugs. . Level Three: higher copaymem than Level Two for higher cost, mostly brand-name drugs that may have generic or brand-name alternatives on Levels One or Two. . Level Four: highest copayment for high-technology drugs (certain brand-name drugs, biotechnolog)' drugs and self-administered injectable medications). . Medications may be moved from one level to a different level during the plan year. Please check our Web site or contact Customer Service for the most up-to-date information. Some drugs in all levels may be su bject to dispensing limitations, based on age, gender, duration or q'uantity. Additionally, some Level Four cInlgs may need prior authorization in order to be covered. In these cases. your physician should contact Humana Clinica] Pharmacy Review at 1-800-555-CLIN (2546). Members can visit.Humana'sWeb site, www.humana.com.to obt.'lin information about their prescription drug and corresponding benefits and for possible lower cost alternatives, or they can call Humana's Customer Service with questions or to request a Humana Rx4 Drug List by mail. We will also work with physicians and pharmacists to eA-plain the Rx4 structure. For a complete listing of participating pharmacies, please refer to our Web site or your participating provider directof)~ Coverage at participating pharmacies ( When you present your membership card at a participating pharmacy, you are required to make a copayment for each prescription based on the cw'rent assigned level of the drug. Drugs assigned to: Copayment per prescription or refill Leve] One: SlO Le"e1 Two: S25 Level Three: S50 Level Four: 25%* of the total required payment to the dispensing pharmacy per prescription or refill. * The total maximum out-of-pocket copayment costs for drugs in Level Four is limited to $2,500 per calendar year, per member. . If the dispensing pharmacy's charge is less than the corresponding copayment, you v.riJl only be responsible for the lower amount. . Your copayments for covered prescription drugs are made on a per prescription or refill basis and will not change ifHumana receives any retrospective volume discounts or prescription drug rebates. There are 110 claim torms to file if you use a participating pharmacy and preseot YOllr membership card VI>ith each prescription. Nonparticipating pharmacy coverage* You may aL~o purchase prescribed medications trom a nonparticipating pharmacy.You will be required to pay for your prescriptions according to the following rule. . You pay '100 percent of the dispensing pharmacy's charges. You file a claim form with Humana (address is on the back ofID card). - Claim is paid at 70 percent of the dispensing pharrnacy's charges. after they are first reduced by the applicable copayment. . Your copayments for covered prescription dnJgs are made on a per prescription or refill basis and will nor challge ifHumana receives any retrospective volume discounts or prescription dnlg rebates. * In Georgia. the nonparticipating benefits are paid the same as the participating benefits, per state reguJation. Coverage specifics c GN-12140-HH 5/03 Your coverage includes the following: . A 30-day supply or the amount prescribed. whichever is less. for each prescription or refill. . Contraceptives. . Certain self-administered injectable drugs and related supplies approved by Humana. . Certain drugs, medicines or medications that, under tederal or st.'1te law, may be dispensed only by prescription from a physician. .' I Mail-order benefit e e For YOw' convenience, you may receive a rn.:oomum 90-day supply per prescription or refill through the mail (nm..-imum 3D-day supply for self-administered injectable drugs). The same requirements apply when purchasing medications through a participating mail-order pharmacy as apply when purchasing in person at a pharmacy, Members can call Customer Service or v;sit our Web site for more information, including mail-order forms. Definition of terms . Drug List: a list of prescription drugs, medicines. medications and supplies specified by Humana. This list identifies drugs as Level One, Level Two, Level Three or Level Four and indicates applicable dispensing limits and/or any prior authorization requirements. (This list is subject to change.) . Copayment: the amount to be paid by the member to\vard the cost of each separate prescription or refill of a covered drug when dispensed by a pharmacy. . Nonparticipating pharmacy: a pharmacy which has not been designated by Humana as a participating pharmacy. . Participating pharmacy: a pharmacy which has entered into an agreement with Humana or which has been designated by Humana to provide services to all covered persons. Participating pharmacy designation by Humana may be limited to specified services. Limitations and exclusions C' Unless specifically stated otherwise, no coverage is provided for the following: . Any portion of a prescription or refill that exceeds a 30-day supply for a medication - 90-day supply for a prescription or refill (30-day supply for self-administered injecr.1hles) purchased through mail order. . Prescription refills in excess of the number specified by the physician's original order or dispensed mOI1~ than one year from the date of the original order . The administration of a covered medication . lm111wlizing agents or biological sej-um.~ or allergy e:l\.."tracts (may be covered under the medical plan) . Infertility drugs (except where required by law) . Drug delivery implants . Any drug, medicine or medication labeled "Caution - limited by federal law to investigational use" or any e"."perimental drug, medicine. or medication, even though a charge is, or may be, made to the member . Any COSts related to the mailing, sending or delivery of prescription drugs . Any drug used for weight control (except where required by law) . Any drug prescribed for a noncovered sickness or injury . Abormacients (drugs used to induce abortions) . Any drug prescribed for impotence and/or sexual dysfunction, e.g.Viagra . Injectable drugs. including but not limited to inununizing agents, biological sera, blood, blood plasma or self-administered injectable drugs not approved by Humana . Dietary supplements, except for amino acid modified preparations and low-protein modified food products necessary tor the treatment of inherited metabolic diseases. This is only a partial list of limitations and exclusions. Please refer to the Certificate of Coverage/Insurance for complete details regarding prescription drug coverage. ~ l!2.~_ ....~- Insured by Humana Health Insura.nce Company of Florida, Inc., Humana rnsurance Company, Humana. Health Plan, rnc., or Humana rnsurance of Puerto Rico, rnc, GN-12140-HUi 5/03 ~2003 Humana Inc. HumanaPPO City of La Porte Premium and Contribution Projection Effective January 1, 2005 Proposed Premiums and Contributions --current Employee Contribution Per Check $6.76 $48.46 $43.96 $55.70 e $10.48 $60.16 $55.42 $71.82 $22.70 $26.34 $33.40 $42.93 $0.00 $104.00 $86.67 $112.67 $23.18 $76.50 $71.61 $85.53 $50.23 $61.74 $68.48 $72.65 $0.00 $104.00 $86.67 $112.67 $36.53 $104.21 $99.69 $110.57 $79.14 $121.79 $129.32 $126.89 $0.00 $104.00 $86.67 $112.67 e $21,053 $252,636 an Assumptions: 1. Humana Smart Suite plan design. 2. Rate differentials based on Humana book of business. 3. Enrollment assumptions based on Humana plan experience. 4. Employee and total premiums are based on previously stated projections of expected costs. The Welch Com Change $14.65 $1.00 $8.57 $8.02 $23,929 $287,151 Schedule C 20% $0.00 $104.00 $86.67 $112.67 Employer Contribution $429.17 $429.17 $429.17 $429.17 Total Premium $452.20 $581.64 $530.40 $632.86 Subs 23 8 8 22 Coverage 1st - $1,500 Deductible Employee Only Employee & Spouse Employee and Children Employee and Family $487.88 $627.51 $572.24 $682.77 54 6 6 16 Coverage 1st - $1,000 Deductible Employee Only Employee & Spouse Employee and Children Employee and Family $429.17 $429.17 $429.17 $429.17 $508.39 $653.91 $596.31 $711.49 22 23 24 58 PPO - $500 Deductible Employee Only Employee & Spouse Employee and Children Employee and Family $429.17 $429.17 $429.17 $429.17 $554.31 $712.95 $650.16 $775.73 33 13 13 31 PPO - $300 Deductible Employee Only Employee & Spouse Employee and Children Employee and Family 360 54,500 $1,854,001 70% $1 $219,551 $2,634,610 1'00% Total Monthly Funding Total Annual Funding Employee/Employer % . e Due to the volume of this contract, a copy is available for your review in the City Secretary's Office - - ..~.,. _.~~ .....:: .... . 1i, - , ~ .. ;, e e REQUEST FOR CITY COUNCIL AGENDA ITEM Agenda Date Requested: 08-23-04 Appropriation Requested By: Shprri Samp~nn Source of Funds: Medical Find Department: KumaR Reliour~eli Account Number: 014-6144-515-6061 Report: Resolution: Ordinance: x Amount Budgeted: $~,403,23~ Exhibits: Ordinance Amount Requested: $3,403,23; Exhibits: Schedule A Budgeted Item: YES NO Exhibits: SUMMARY & RECOMMENDATION The City of La Porte is self-funded for medical benefits for employees, retirees and their dependents To ensure the City was receiving the best rates and service for its employees, a consultant was used in March of this year to formulate a request for proposal and test the market. Additionally, our employees have had numerous customer service related problems with TML. The RFP requested services for health plan claims administration, utilization review and large case management, preferred provider network, disease management, pharmacy benefit managmenet, COBRA and HIP AA administration. 18 Responses were received for some or all components of the RFP. After an initial evaluation by the Benefit Consultant, two companies were chosen for presentations to the Chapter 172 Board members, Aetna and Humana. Each company was asked to provide information regarding health plan claim administration, utilization review and large case management, preferred provider network, disease management, pharmacy benefit management, HIP AA and COBRA administration. Both companies had current clients and past clients that were willing to supply favorable references. Aetna and Humana both offered substantial savings on the network discounts, compared to TML and their average 30% discount. Aetna claimed to have discounts averaging over 50% and Humana claimed to have discounts averaging at 49%. Human offered new plan designs that are experiencing less than average annual increases to their health benefit costs. The Human plan design also offered similar PPOs to the City's current plan design. The Chapter 172 Board of Trustees is recommending that Council authorize the City Manager to negotiate a 3 year contract with Humana, beginning January 01, 2005, for Administrative Services of the City's medical plan. This proposal includes adopting the 4 plan design options Humana recommends for the City of La Porte (Coverage First 1500, Coverage First 1000, PPO 500 and PPO 300). This recommendation also includes the increase of employee contributions by plan design effective January 01, 2005 (Contribution Schedule with 20% of plan cost shared with employees attached). e e Action Required bv Council: Authorize City Manager to negotiate a 3 year contract with Humana, to administer the City's Medical Plan. Adopt 4 plan designs proposed by Humana and increase the employee contributions to comprise 20% of Plan expenses. Date 17/0'+ (