1985-008-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. 1985 -8
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 agreement 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 "1985 Amendments" to the aforesaid Agreement on
behalf of the Town.
PASSED AND ADOPTED by the Town Council of the Town of Los Gatos,
California, at a regular meeting held this 22nd day of
January, 1985, by the following vote:
AYES: COUNCILMEMBERS Eric D. Carlson, Terrence J. Daily,
Thomas J. Ferrito, Brent N. Ventura,
and Mayor Joanne Benjamin
NOES: COUNCILMEMBERS None
ABSENT: COUNCILMEMBERS None
ABSTAIN: COUNCILMEMBERS
SIGNED: G2.rrt r�'
k r't_. x' }ti ate--'
MAYOR OF THE TOWN 0 LOS G{�fOS
r
ATTEST:
CLERK OF THE TOWN OF LOSOS
Ae�A COPT 70 c's ?^ail �TUIWZD, PLEA
cni rnin.QT /QN
•' � `' A Nonprofit Corporation
HEALTH PLAN, PLAN, INC. P rP
Northern California Region
GROUP MEDICAL AND HOSPITAL SERVICE AGREEMENT
AMENDMENT
Group No.- � 931
The Group Medical and Hospital Service Agreement between Kaiser Foundation Health Plan, Inc. and The Group named below is
amended as follows:
See attached "1985 Amendments"
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:
L BASIC RATE STRUCTURE $ 72,44
Subscriber Add $ 71 44
Subscriber with one Family Dependent Add $
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 Add S '0'
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: Subtract $ 23.10
Subscriber .2—
Subscriber's spouse (or child if there is no spouse) Subtract $ lc • �b
Other Family Dependents
y0. 69W.1 �
3. RATE VARIABLE APPLICABLE TO EMPLOYERS OF 20 OR MORE PERSONS
Federal law applicable to employers of 20 or more employees requires a choice between this plan and Medicare as the primary
coverage by the following: (a) Subscribers age 65 through 69, (b) Subscribers age 65 through 69 and their spouses age 65 through
69, and (c) Spouses age 65 through 69 of Subscribers under age 65. Those who elect coverage under this Agreement are charged
the Basic Rates described in Paragraph I above, and not the Medicare variables described in Paragraph 2.
LIMIT ON SUPPLEMENTAL CHARGES for calendar year 1985:
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=
Group Town of Los Gatos
P. O. Box 949
Los Gatos, OA 95030
Group Repfesentative f}v'rD P li'iORA
$ 725.00
$ 1.450.00
S 2,090.00
Executed at Oakland, California to take effect
as of March 1, 1985
December 27, 1984
KAISER FOUNDATION HEALTH PLAN, INC.,
, ll A California nonprofit corporation
By:
(�J"�
Authorized Representative, Northern California
By: 854 SS poll MH —C C7rN dr 3 dep 9 M/R 49.34/48.34 ;f)
HMO FS 1.85
!CAISER
FOUNOAT ION
1985 AMTS
C'�• ��• 1:�� Y• � : •.'t' Y• `Is' M' • t!' Gs 16
1. Section 1 -N is amended as follows:
"N. Service Area: That geographical area within a radius of
thirty miles of any Hospital or Medical Office within the following
sixteen Northern California counties: Alameda, Amador, Contra Costa, E1
Dorado, Marin, Napa, Placer, Sacramento, San Francisco, San Mateo, Santa
Clara, Solano, Sonoma, Sutter, Yolo and Yuba, and that portion of San
Joaquin County within a thirty mile radius of any Hospital or Medical
Office in Sacramento."
2. Section 2- A(2) (c) is amended by adding the following phrase to the end
of the sentence:
"and for whom the Subscriber or Subscriber's spouse is (or was
before the person's 18th birthday) the guardian."
3. Section 4-C(2) is amended as follows:
0(2) Special Provision for Members Age 65 through 69 Who Elect
the Group's Health Plan As Primary Coverage. Members age 65 through 69
who are entitled to Medicare benefits but who elect to have the Group's
health plan as their primary health coverage pursuant to the applicable
provisions of Federal law will be considered, for purposes of rates and
benefits under this Agreement, in the same category as Members under age
65 who are not entitled to Medicare benefits."
4. Section 6 -A(6) is retitled and amended as follows:
"(6) Eq)erimental or Investigational Services. Any treatment,
procedure, drug or drug usage, facility or facility usage, equipment or
equipment usage, device or device usage, or supplies (each of which is
hereafter called a "Service ") which Health Plan, after consultation with
Medical Group, determines to be experimental or investigational. A
Service is experimental or investigational if:
(a) The Service is not recognized in accord with generally
accepted medical standards as being safe and effective for use in
the treatment of the condition in question, whether or not the
Service is authorized by law for use in testing or other studies on
human patients; or
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Birth control pills and devices are not covered except as specified in
Section F.
Medical Services for diagnosis and treatment of involuntary
infertility are provided upon payment of the registration charge, if
any, specified in Section A -2. X -ray and laboratory procedures in
conjunction with family planning and infertility treatment are provided
in accord with Section D, and medications are provided in accord with
Section F.
EION: In vitro fertilization,
related to conception by artificial
insemination is covered."
3. Section I is amended as follows:
ovum transplants and other services
means, except artificial
1. Surgery and Prosthetic Devices Following Fastectcmy. If all
or part of a breast is surgically removed for medically necessary
reasons, reconstructive surgery and a prosthetic device incident to the
mastectomy are provided, subject to the payment of applicable
Supplemental Charges, if any. A Physician determines whether
reconstructive surgery is medically feasible, and the extent to which
further reconstructive surgery is necessary. Replacement will be made
when a prosthesis is no longer functional. Custom made prostheses will
be provided when necessary.
2. Cosmetic Surgery Following Accidents or Surgery. Cosmetic
surgery to correct a significant disfigurement resulting from an injury
or surgery is provided, subject to the payment 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."
Section J is retitled and amended as follows:
-J. HMMTAT.VSIS AND KIERW 'IItAbUMMUS, LIVER '1RAHMAN1'S, AND BONE
MARROW TRAWSP ANl'S
1. Semodialysis and Kidney Transplants. Subject to the terms
and conditions in paragraph 5 of this provision:
(a) Medical and hospital services for hemxlialysis for renal
disease are provided in accord with this Benefit Schedule.
Hemodialysis for chronic conditions is provided only in facilities
approved for participation in the Medicare program. Medical Group
determines whether a condition is chronic or acute. Equipment,
training and medical supplies required for home dialysis are
provided without charge.
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obligation is limited to paying for covered services provided prior
to such determination.
(d) Neither Health Plan, Medical Group nor Physicians
undertake to provide a kidney or bone marrow donor or a donor organ
or to assure the availability of a donor or of a donor organ or the
availability or capacity of referral facilities approved by Medical
Group.
(e) Except for covered, medically necessary ambulance
service, neither transportation nor living expenses are covered for
the Member,.for his or her family, or for a donor."
5. Section M, TREATMENT FOR ALCJOBDLISM, DFM ABUSE AND DREG ADDICTION, is
amended by adding a new Item 3 under the paragraph titled "Exclusions':
113. Care in a specialized alcoholism, drug abuse or drug addiction
treatment center."
6. The second paragraph of Section P, HEALTH EDUCATION, is amended by
changing the words "anti - smoking" to "stop - stroking"
7. The second paragraph of Section R, SERVICE BENEFITS IN OTHER HFALTH PLAN
REGIONS, is amended as follows:
"Health Plan, either directly or through related organizations,
conducts direct - service medical and hospital care programs in the Los
Angeles and San Diego areas in California, in the Cleveland area in
Ohio, in the Denver area in Colorado, in Portland, Oregon, and vicinity,
Washington, D.C., and vicinity, and on the islands of Oahu and Maui,
Hawaii, in the Dallas area in Texas, and in the Hartford area in
Connecticut, and in the Raleigh area of North Carolina. A description
of such other Regions and a list of their contracting hospitals and
medical office facilities may be obtained at the Health Plan Office."
8. Section S -2, Continuing or Follow-up Treatment, is amended by adding to
the end of the second sentence the phrase, ",except that Health Plan, at
its option, may continue to cover inpatient care in lieu of transferring
the Member to a Hospital."
4. Section T, LIMIT ON SUPPLEMENTAL CHARGES, is amended by changing the
phrase in the last sentence from, "contraceptive devices referred to in
Section H -2," to "contraceptive devices referred to in Section F, ".
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