1984-011-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.RESOLUTION NO. 1984 -11
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 a minor amendment to the
aforesaid 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 111984 Amendments" to the aforesaid
Agreement on behalf of the Town.
PASSED AND ADOPTED by the Town Council of the Town of Los Gatos, Cali-
fornia, at a regular meeting held this 17th day
of January , 1984, by the following vote:
AYES: COUNCILMEMBERS Joanne Benjamin Eric D
Carl on. Terrence J Daily Brent N
NOES: COUNCILMEMBERS
ABSENT: COUNCILMEMBERS
ABSTAIN: COUNCILMEMBERS
SIGNED:
MAYOR OF THE TOWI %OF LOS GATOS
ATTEST:
CLER OF THE TOWN OF LOS ATOS
GROUP —EDICAL AND HOSPITAL SERVICE 6 - 9EEMENT
FACE SHEET - PAGE TWO
AMENDMENTS AND ADDITIONAL PROVISIONS: Group No. 931
1984 Amendments
Section 2 -A(2) of the Service Agreement relating to eligibility of
Family Dependents is superseded by the amendment titled "Coverage of
Family Dependents ".
Section F of the Benefit Schedule is superseded by the attached amendment titled
"Prescription Plan 3 ".
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:
1. BASIC RATE STRUCTURE
Subscriber
Subscriber with one Family Dependent
Subscriber with two or more Family Dependents
2. VARIABLES RELATING TO MEDICARE STATUS
• 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
• For each Member (up to 3 per Family Unit) entitled to benefits under both
Parts A and B of Medicare who has assigned Part B benefits to Health Plan:
Subscriber
Subscriber's spouse (or child if there is no spouse)
Other Family Dependents
3. RATES APPLICABLE TO EMPLOYEES AFFECTED BY TEFRA
$
65 28
Add $
64.28
Add
Add $_
— 0 —
Subtract s-----2O
- 56
Subtract $
20 56
Subtract $
14.09
Total
$ 65.28
$ 129.56
$_ 187.37
In compliance with the Tax Equity and Fiscal Responsibility Act of 1982, Subscribers age 65 through 69 (and their spouses age 65
through 69) employed by groups in which the employer has 20 or more employees and who elect this coverage, pay the Basic Rates
described in Paragraph I above and not the Medicare variables described in Paragraph 2.
LIMIT ON SUPPLEMENTAL CHARGES for calendar year 1984:
For one Member of a Family Unit $ 670.00
For two Members of a Family Unit $ 1,340.00
For three or more Members of a Family Unit $ 1,925.00
OPEN ENROLLMENT PERIOD: Applications made during the Open Enrollment Period February
provide coverage effective March 1
Date Accepted
/ — Cif- 3
Executed at Oakland, California to take effect
19 ��
asof T °arch 1,_1984
Group Town of LOS Gatos
P.O. Box 949 Date December 28, 19K
Los Gatos, CA 95030
KAISER FOUNDATION HEALTH PLAN, INC.,
J } A California nonprofit corporation
Group Representativ
By:
Authorized Representative, Northern California
By:
HMO F51 -84 854 SS Coll ME? - -C CL-N dr3 dep9 MIR 44.72/43.72
F U TI
HEALTH PLAN, INC.
A Nonprofit Corporation
Northern California Region
n717ti�L MIS]
COVERAGE COVERAGE OF FAMILY DEPENDENTS
The first paragraph of Section 2 -A(2) of the Service Agreement is amended to read as follows:
(2) Family Dependents. To be a Family Dependent a person must be:
(a) The Subscriber's spouse; or
(b) A dependent child of the Subscriber or the Subscriber's spouse and either:
(i) Unmarried and under age 24; or
(ii) Over age 24 and incapable of self-sustaining employment by reason of mental retardation or phys.
ical handicap incurred prior to age 24, and chiefly dependent upon the Subscriber or the Subscriber's
spouse for support and maintenance, with proof of incapacity and dependency furnished annually if
requested by Health Plan ;or
(c) Any other unmarried dependent child under age 24 entirely supported by and permanently residing in
the Subscriber's household.
08073 1/77 Dep. 9 -9+
POUMMATION
"HALT`-✓ PLATY, 11VC.
A Nonprofit Corporation
Northern California Region
• �. ', . t
Section F of the Benefit Schedule is amended to read as follows:
F. PRESCRIBED MEDICATIONS, IMMUNIZATIONS, AND CERTAIN OTHER SUPPLIES.
1. Prescribed Medications.
(a) Administered to Members.
(t) While Hospitalized. During hospitalization specified in this Benefit Schedule, all
prescribed medications, injeetables, 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
(ii)
prescription is required by law.
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 1 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 OAomy 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.
PP3 1 -82