1982-085-Authorizing the Town Manger To Execute An Amendment To The Group Medical And Hospital Service Agreement Between The Town And Kaiser Foundation Health Plan, Inc.RESOLUTION NO. 1982 -85
A RESOLUTION OF THE TOWN OF LOS GATOS AUTHORIZING
THE TOWN MANAGER TO EXECUTE AN AMENDMENT TO THE
GROUP MEDICAL AND HOSPITAL SERVICE AGREEMENT
BETWEEN THE TOWN AND KAISER FOUNDATION HEALTH
PLAN, INC.
WHEREAS, the Town of Los Gatos and Kaiser Foundation Health Plan, Inc.
entered into a Group Medical and Hospital Service Agreement;
and
WHEREAS, the parties now wish to enter into an amendment to the afore-
said Agreement;
NOW, THEREFORE, BE IT RESOLVED BY THE TOWN COUNCIL OF THE TOWN OF
LOS GATOS that the Town Manager is hereby authorized to
execute the attached " "1982 Amendments with Prescription
Plan 3, PERS Retirees," to the aforesaid Agreement on behalf
of the Town.
PASSED AND ADOPTED by the Town Council of the Town of Los Gatos at a
regular meeting held this 3rd day of Naay
1982, by the following vote:
AYES: COUNCIL MEMBERS Ruth Cannon, Thomas J.
Ferrito, N;arLyn J. Rasmussen, Brent N.
Ventura and Peter W. Siemens
NOES: COUNCIL MEMBERS None
ABSENT: COUNCIL MEMBERS
ABSTAIN: COUNCIL MEMBERS None
r /
SIGNED:
(MAYOR OF THE TOWN OF LOS GATOS
ATTEST:
CLERK F THE TOWN OF LOS GP S
J
A Nonprofit Corporation
Northern California Region
Group No. 61— 931 (PERS Retirees)
The Group Medical and Hospital Service Agreement between Kaiser Foundation Health Plan, Inc. and the Group named below is
amended as follows:
See attached 111982 Amendments with Presc'TOtion'P,lan 3"
The monthly payments are changed to, _ti hpse sllavn below.
rr
COVERAGE: All Subscribers have "__S_=' Coverage. All Family Dependents have "_S_" Coverage.
MONTHLY PAYMENTS: The monthly payments per Family Unit required under this Agreement are shown below
Basic Rate Structure
Total
Subscriber
$ 46.16 $ 46.16
Subscriber with one Family Dependent
Add $ 46. 16 $ 92.32
Subscriber with two or more Family Dependents
Add $ 4.1 .08 $ 1-33.40
Variables to Basic Rate Structure
For each dependent child age 19 to 24 in a family of
four or more Members
Add $ 23.08
For each Member age 65 or older who is (a) not entitled to
benefits under Part B of Medicare, or (b) entitled to benefits
under Part B of Medicare but has not assigned such benefits
to Health Plan.
Add $ —0—
For each Member (up to 3 per Family Unit) entitled to bene-
fits under both Parts A and B of Medicare who has assigned
Part B benefits to Health Plan:
Subscriber
Subtract
Subscriber's spouse (or child if there is no spouse)
Subtract $ 11.46
Other Family Dependents
Subtract $ 6.38
LIMIT ON SUPPLEMENTAL CHARGES for calendar year 1952:
For one Member of a Family Unit
For two Members of a Family Unit
For three or more Members of a Family Unit
Date Accepted .. J _ G , 19 'F%
Group Town of Los Getog— Retirees
P.O. Box 949
Los Gatos, CA 95030
1
Group Repre ntative/ W+ R?6k-2D
La
H08311 + 1 -92
$ 500.00
$ 1,000.00
$ 1,440.00
Executed at Oakland, Callornia to take effect
as of July 1 1982
Date
KAISER FOUNDATION HEALTH PLAN, INC.,
A California nonprofit corporation
By: �� e
Authorized Representative, Northern California
861 SS PAR MB -C dr3 dep9k MAR 34.70
FL
k
� CUIVOATIDIV
HEALTH PL.4M, INC.
1924 BROADWAY, OAKLAND, CALIFORNIA • PHONE 6456035
MAILING ADDRESS- P.O. SOX 12916. OAKLAND, CALIFORNIA 94604
IMPORTANT NOTICE REGARDING RETIREES
Group 61 (PEAS)
The enclosed Amendment to our Group Medical and Hospital Service
Agreement pertaining to monthly charges for retirees covers the
twelve -month period commencing July 1, 1982.
We will be notifying all retirees who are enrolled in our Plan
of the increase by direct mail to their homes.
This will no doubt affect you in one of the three following
situations:
1) if you have already made arrangements with the Public
Employees' Retirement System in Sacramento (PERS) to
handle the deductions of Health Plan periodic payments
from your retirees' retirement checks, then this Amend-
ment is to inform you of the new amounts that will
automatically be deducted from the retirees' warrants
effective July 1, 1982;
2) if you have not made arrangements with PERS and desire
to do so in the future, it will be necessary for you
to submit a copy of the enclosed Amendment to PERS
with your request. There are minimal charges by PERS
for this administrative service;
3) if your retirees do not receive their retirement payments
from PERS, the attached does not apply. Please notify
us so that we can discontinue sending you information
concerning PERS.
Please sign and return a copy of the Amendment if 1) or 2) above
is applicable. If you require additional information, your
Health Plan Representative is available to assist you.
KAISER FOUNDATION HEALTH PLAN, INC.
Enc.
61 -AMD.
4-82
AOSS
J"C7 //VZ7AT9 ®1!!
HEALTH PLAN, INC.
L+ &` l .
._
1. GROUP MEDICAL AND HOSPITAL SERVICE AGREEMENT
1. Section 1, DEFINITIONS.
Section O, House Call Area, is deleted and Sections P, Q, R and S are re- lettered O, P, Q and R.
2. Section 2, ELIGIBILITY, ENROLLMENT AND COVERAGE.
A. The second paragraph of Section 2 -13(l), Newly Eligible Persons, is amended to read:
"Any person who thereafter newly attains eligibility to become a Family Dependent, such as a new
spouse or newborn or newly adopted child, may be enrolled by Subscriber's submitting a change of enroll-
ment form to Group within 30 days. A newborn child of a Family Dependent other than the Subscriber's
spouse may be enrolled only if the newborn child is eligible under Section 2- A(2)(c)."
B. Section 2 -C(1), Newly Eligible Persons, is amended by deleting the period at the end of the second
sentence and adding the words, "if enrolled in accord with Section 2 -B(1) above."
C. Section 2 -C(2), Newborns, is amended by adding the words "from birth" after the word
"provided ".
3. Section 3, RELATIONS AMONG PARTIES AFFECTED BY AGREEMENT.
A fifth paragraph is added to this Section, as follows:
"The contracts between Health Plan and Medical Group and Health Plan and Hospitals provide that
Members shall not be liable for any amounts owed Medical Group or Hospitals by Health Plan. However,
should Health Plan fail to pay a non - contracting provider the Member may be liable for the cost of any such
services."
4. Section 4, RATES AND PAYMENT.
A new sentence is added after the second sentence in the first paragraph of Section 4 -A, Monthly
Payments, as follows:
"If Group fails to make payments when due, upon renewal the Base Payment may include an additional
charge."
5. Section 5, SERVICES AND BENEFITS.
The second paragraph of Section 5 -A, Within the Service Area, is amended to read:
"Choice of Physician and Hospital. Within the Service Area, covered services are available only from
Medical Group, Hospitals and in Skilled Nursing Facilities, and neither Health Plan, Hospitals, Medical
Group nor any Physician has any liability or obligation on account of any service or benefit sought or receiv-
ed by any Member from any other doctor, hospital or skilled nursing facility, or other person, institution or
organization, unless such services are covered under Sections Q or S -1(a) of the applicable Benefit
Schedule(s)."
6. Section 6, EXCLUSIONS, LIMITATIONS AND REDUCTIONS.
A. Section 6 -A(3), Cosmetic Services, is amended to read:
"(3) Cosmetic Services. Plastic surgery or other services which are indicated primarily for
cosmetic purposes, except as provided in Section I of the Benefit Schedule(s)."
B. Section 6 -A(5), Certain Physical Examinations, is amended by deleting the period at the end of the
sentence and adding, "; premarital examinations are covered."
C. Section 6 -A(9), Corrective Appliances and Artificial Aids, is amended to read:
"(9). Corrective Appliances and Artificial Aids. Artificial aids and corrective appliances, such as
braces, prosthetic devices, hearing aids, corrective lenses and eyeglasses, except that:
(a) Physicians provide the services necessary to determine the need therefor and attempt to
make arrangements whereby they may be obtained at reasonable rates;
(b) Prosthetic devices following mastectomy are provided in accord with Section I -1;
(c) Permanent internally implanted devices which are not experimental and are generally and
customarily available in Northern California, such as pacemakers and hip joints, are
covered; and,
(d) Prosthetic devices and cataract lenses are provided at no charge to Members with Medicare
Part B."
7. Section 8, ARBITRATION OF CLAIMS.
Section 8 -13, Initiating Arbitration Proceedings, is amended by changing the street address of the
Oakland Main Branch of Bank of America from 1200 Broadway to 2000 Broadway.
8. Section 9, TERM AND TERMINATION.
Section 9 -B(3), Furnishing Incorrect or Incomplete Information, is amended as follows:
"(3) Furnishing Incorrect or Incomplete Information. Members warrant that all information con-
tained in applications, questionnaires, forms or statements submitted to Health Plan incident to
enrollment under this Agreement or the administration hereof is true, correct and complete. Members
agree to advise Health Plan of any change in family or Medicare coverage status that affects eligibility
for membership. If a Member knowingly furnishes incorrect or incomplete information or subse-
quently fails to inform Health Plan of changes of eligibility status of dependents, then the rights of the
Member and all other Members of the Family Unit may be terminated effective immediately upon
written notice."
II. BENEFIT SCHEDULE(S)
1. Section A, MEDICAL CARE; IN HOSPITAL, OFFICE AND SKILLED NURSING FACILITY.
The paragraph titled, "Exclusion:" in Section A -2(b), Preventive Services, is amended by deleting the
period at the end of the sentence and adding, "; premarital examinations are covered."
2. Section C, HOUSE CALLS.
The first sentence of this Section is amended to read:
"Necessary house calls by Physicians and by visiting nurses when prescribed by a Physician' are provided
within the Service Area."
3. Section F is amended to read as follows:
"F. PRESCIZIBED MEDICATIONS, IMMUNIZATIONS AND CERTAIN OTHER SUPPLIES.
1. Prescribed Medications.
(a) Administered to Members.
(i) While Hospitalized. During hospitalization specified in this Benefit Schedule, all
prescribed medications, injectables, radioactive materials used for therapeutic purposes,
allergy test materials and allergy treatment materials are provided without charge.
(ii) In Medical Offices, Emergency Departments, and on House Calls. All prescribed
medications, injectables, radioactive materials used for therapeutic purposes, allergy test
materials and allergy treatment materials administered at Medical Offices, at Hospital emer-
gency departments, and on house calls are provided without charge.
(b) Purchased by Members. Members may purchase covered medications and accessories for
$1.00 for each prescription unless the quantity prescribed exceeds both (i) the smallest therapeutic
package made by the manufacturer, and (ii) 34 days'supply (or one cycle of a contraceptive drug).
Each prescription refill is provided on the same basis as the original prescription. If the prescrip-
tion or refill is for a quantity greater than the limits described above, the charge is an additional
$1.00 for each multiple of such quantity or fraction thereof, except that the charge is only $1.00
for each 100 nitroglycerin, phenobarbital or thyroid U.S.P. tablets if they are prescribed by a
physician or dentist in quantities of 100 or more.
The following medications and accessories are covered only when prescribed by physicians or
dentists and obtained at pharmacies in Hospitals and designated Medical Offices. The scheduled
hours of operation of such pharmacies will be provided to Group on request.
(i) Drugs for which a prescription is required by law.
(ii) Additional drugs and accessories:
(1) Diabetic supplies:
(A) insulin;
(B) sugar test tablets, sugar test tape, acetone test tablets and Benedict's solution or
equivalent.
(2) Compounded dermatological preparations (ointments and lotions which must be
prepared by a pharmacist in accord with a physician's prescription).
(3) Elixir Terpin Hydrate, N.F.
(4) Prescribed antacids.
(5) Diaphragms.
2. Needles and Syringes. Disposable needles and syringes in quantities needed for injecting prescribed
medications are provided without charge.
3. Immunizations. Immunizations generally available in Northern California which were developed
and in general use for specific diseases on April I of the year immediately preceding the year in which this
Agreement became effective or was last renewed are provided without charge. A list of diseases for which
immunizations are covered is available at Health Plan Offices.
4. Dressings, Casts and Ostomy Supplies. During hospitalization specified in Section B, and at
Medical Offices, Hospital emergency departments and on house calls, prescribed dressings, casts and
ostomy supplies are provided without charge. Ostomy supplies for home use are provided at no charge.
5. Amino Acid Modified Products. Prescribed amino acid modified products used in the treatment of
congenital errors of amino acid metabolism are provided without charge during hospitalization and for
self- administered use."
4. Section H, FAMILY PLANNING AND INFERTILITY STUDIES.
The first paragraph of this Section is amended to read:
"Family planning counseling, including pre- abortion and post- abortion counseling and information on
birth control, is provided upon payment of the registration charge, if any, specified in Section A -2. Birth
control pills and diaphragms are provided in accord with Section F. Other contraceptive . devices are pro-
vided at reasonable charges."
5. Section I, COSMETIC SURGERY AND PROSTHETIC DEVICES FOLLOWING MASTECTOMY.
A. The existing paragraph is numbered and titled as follows:
"]. Surgery and Prosthetic Devices Following Mastectomy."
B. A new Section 1 -2, Cosmetic Surgery Following Accidents or Surgery, is added as follows:
^2. Cosmetic Surgery Following Accidents or Surgery. Cosmetic surgery to correct a significant
disfigurement resulting from an injury or surgery (other than mastectomy) is provided, subject to the pay-
ment of applicable supplemental charges, if any. A Physician determines the medical feasibility of surgery
and whether the surgery can reasonably be expected to correct the condition."
6. Section R, SERVICE BENEFITS IN OTHER HEALTH PLAN REGIONS AND IN THE AREA
SERVED BY KAISER/ PRUDENTIAL HEALTH PLAN.
The first paragraph of this Section is amended to read:
"If a Member is temporarily in another Health Plan Region, or in the geographical area served by
Kaiser/ Prudential Health Plan, the Member may obtain hospital and medical services from physicians and
hospitals that have a contractual arrangement with Health Plan or a related organization or Kaiser /Pruden-
tial Health Plan."
7. Section T, LIM1T ON SUPPLEMENTAL CHARGES.
The phrase "cosmetic services referred to in Section I," is added before the words "Extended Care Ser-
vices" in the next to last line.