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HomeMy WebLinkAboutContract 37688 T R), NO S16RR No. 889000 ADMINISTRATIVE SERVICES AGREEMENT AGREEMENT NUMBER ASA-889000 This Administrative Services Agreement(hereinafter"Services Agreement")is made and entered into by and between Aetna Life Insurance Company on behalf of itself and its affiliated health maintenance organizations("HMOs")(collectively"Aetna")and City of Fort Worth(hereinafter"Customer"). WHEREAS,Customer has established a self-funded employee health benefits plan(the"Plan")for certain eligible individuals described in Appendix I of this Services Agreement;and WHEREAS,pursuant to the Plan,Customer wishes to make available one or more coverage products offered by the HMOs(the "Products"),as specified in Appendix I of this Services Agreement;and WHEREAS,Aetna has arranged to provide integrated administration of these Product(s)and,if requested by the Customer,has also agreed to provide certain supplemental administrative services and Products not available through the HMOs; WHEREAS,Aetna will administer the Plan as a self insured plan using the negotiated rates,network rules and policies,and contracts for its Products. THEREFORE,in consideration of the mutual covenants and promises stated herein and other good and valuable consideration, the parties hereby enter into this Services Agreement. This Services Agreement includes and incorporates by reference the attached Service and Fee Schedule,General Conditions Addendum,Description of Services Addendum,National Advantage Program Addendum,and Appendices. Customer hereby elects to receive the Services for Products/Programs designated in the Service and Fee Schedule as well as any supplemental Services identified therein. The corresponding Service Fees effective for the period beginning January 1,2005 and ending December 31,2005 are specified in the Service and Fee Schedule,which shall be amended for future periods,in accordance with Section 3 of the General Conditions Addendum,to reflect the Services elected and corresponding Service Fees for such periods. The HMOs include the following entities to the extent that Plan beneficiaries elect coverage under Products offered in geographic areas served by such entity:Aetna Health Inc. (CT),Aetna Health Inc.(ME),Aetna Health Inc. (MA),Aetna Health Inc. (NH), Aetna Health Inc.(NY),Aetna Health Inc.(DE),Aetna Health Inc.(NJ),Aetna Health Inc.(PA),Aetna Health Inc. (MD),Aetna Health Inc. (FL),Aetna Health Inc. (TN),Aetna Health Inc. (GA),Aetna Health of the Carolinas Inc.,Aetna Health Inc.(LA), Aetna Health Inc.(CO),Aetna Health of Illinois Inc.,Aetna Health Inc.(MI),Aetna Health Inc.(MO),Aetna Health Inc. (OH), Aetna Health Inc. (OK),Aetna Health Inc. (TX),Aetna Health Inc.(AZ),Aetna Health Inc.(WA).Aetna Life Insurance Company is authorized to represent the HMOs for purposes of the execution and administration of this Services Agreement, including receipt of any notices to Aetna required hereunder. This Services Agreement(including incorporated attachments)constitutes the complete and exclusive contract between the parties and supersedes any and all prior or contemporaneous oral or written communications or proposals not expressly included herein. No modification or amendment of this Services Agreement shall be valid unless in writing signed by a duly authorized representative of Aetna and a duly authorized representative of Customer. By executing this Services Agreement,Customer acknowledges and agrees that it has reviewed all terms and conditions incorporated into this Services Agreement and intends to be legally bound by the same. OFFICIAL RECORD CITY SECRETARY FT.WORTH, TX ASA Page 1 The Effective Date of this Services Agreement shall be January 1,2005. IN WITNESS WHEREOF,the parties hereto have caused this Services Agreement to be executed by their duly authorized representatives. CITY OF FORT WORTH AETNA LIFE INSURANCE COMPANY ("CUSTOMER") ("AETNA") By: By: Name: Karen T. MontOomecy Ronald A.Williams Title: Assistant City Manager/CFO President Date: ! � Address: 1000 Throckmorton St. City:_ Fort Worth Financial Verification: /4L m• 7Jj- State: Texas Zip: 76102 OR ® ALITY: SSIST T CITY ATTORNEY - 2 0123/ C - 2 � 'ZZ�' C - 2oog1 C -22S�v A ested by Marty Hendrix, Ci Secretary OFFICIAL RECORD CITY SECRETA, ASA Page 2 FT C . SERVICE AND FEE SCHEDULE This Service and Fee Schedule is an attachment to Services Agreement Number ASA-889000 between Aetna and Customer(as identified therein)and is incorporated into the Services Agreement by reference. Customer hereby elects to receive the Services for Products/Programs designated below. The corresponding Service Fees effective for the period beginning January 1,2005 and ending December 31,2008 are specified below. It shall be amended for future periods,in accordance with Section 3 of the General Conditions Addendum to reflect the Services elected and corresponding Service Fees for such periods. MEDICAL PRODUCTS Services Aetna ChoiceTM Indemnity POS II Medical (Medicare Direct I. Administration Services Included Included II. Patient Management Services Precertification Included Not Included Concurrent Review/ Discharge Planning Included Not Included Case Management Included Not Included National Medical Excellence/ Institutes of Excellence Included Not Included Behavioral Health Not Included Not Included Focused Psychiatric Review N/A N/A Healthy Outlook Program Comprehensive Not Included Not Included Informed HealthLine: 1-800# Included Included Moms-To-Babies Maternity Management ProgramTM Not Included Not Included Simple Steps To A Healthier LifeTM Not Included Not Included MedQuerys''4 Included Not Included SFS Page 3 MEDICAL PRODUCTS Indemnity Services Aetna ChoiceTM Medical/Medicare POS lI Direct M. Network Access Services Included N/A Total Fee (Per Employee Per Month) First Services Agreement Period $31.60 $21.37 (01/01/2005 thru 12/31/2005) Second Services Agreement Period $32.55 $22.01 (01/01/2006 thru 12/31/2006) Third Services Agreement Period $33.85 $22.89 (01/01/2007 thru 12/31/2007) Fourth Services Agreement Period POS H-$34.86 Indemnity-$23.57 (01/01/2008 thru 12/31/2008) MedQuery-$1.00 MedQuery-not included Fifth Services Agreement Period POS H-$35.90 $24.27 (01/01/2009 thru 12/31/2009) MedQuery-$1.00 MedQuery-not included Sixth Services Agreement Period POS II-$36.97 $24.99 (01/01/2010 thru 12/3 1/2010) MedQuery-$1.00 MedQuery-not included IV.Aetna Subrogation Program 27%of recovered amount will be retained for administrative expenses V. NationalAdvantage Program Included Included (NAP) National Advantage- Not Included Not Included Facility Charge Review (NAP-FCR) National Advantage Access Fee: 30%of Aggregate Savings- Fee will be included in Plan Benefit Funding Request from Bank. SFS Page 4 PHARMACY PRODUCTS Services Aetna Pharmacy Management I. Administration Services Included II. Network Access Services Included 111. Aetna Subrogation Program 27%of recovered amount will be retained for administrative expenses Aetna also may adjust Service Fees effective as of the date on which any of the following occurs. (1) If,for any product: • There is a 15%decrease in the number of Employees by product or in aggregate from the number assumed in Aetna's quotation of May 4,2004,i.e. 1,174 Retired Employees for Indemnity Medical/MedicareDirect;5,993 Employees for Aetna Choicer"'POS II Medical;7,166 Employees for Pharmacy,or from any subsequently reset assumptions. • The member-to-employee ratio falls outside the range in the table below. Product Assumed Member-to- Range Employee Ratio Choice POS II 1 1.94 1.8-1.99 • The number of processed claim transactions(PCTs)from the ratio per employee is greater than 31.5 or less than 27.6. The assumed PCTs per employee for Choice POS II is 28.6 PCTs. A processed claim transaction,or PCT,for medical benefits is any transaction with respect to a benefit request for expenses incurred or expected to be incurred by one claimant in any one calendar year for a major line of coverage,including but not limited to benefit payment,benefit denial,pended request or decision on an appeal of a denied benefit request. • The number of manually processed claim transactions(PCTs)per Employee is greater than 17.4 or less than 13.5. The assumed manually processed PCTs per Employee is 17.2. This number is based on the predicted PCT volume and an assumed book of business auto-adjudication rate. • The maximum account structure exceeds 300 units per product. Account structure determines the reporting format. Maximum total account structure includes Experience Rated Groups,controls,suffixes,billing and claim accounts. (2) Medicare Direct enrollment-If Medicare Direct is not offered to any over age 65 Medicare eligible retirees,there will be an additional per employee,per month charge. It is assumed that any Medicare-eligible retiree over age 65 will be enrolled in the Medicare Direct program. (3) Change in Plan-A material change in Plan is initiated by Customer or by legislative action that modifies the Plan's benefits and Aetna's obligations and/or responsibilities under this agreement,and such fee change is disclosed to the City prior to implementation of any change. SFS Page 5 (4) Change in Claim Administration-A material change in claim payment requirements or procedures,account structure,or any other change materially affecting the manner or cost of paying benefits,other than a material change initiated or caused solely by Aetna. Late Payment Charges If Customer fails to provide funds on a timely basis to cover benefit payments as provided in Section 5 of the General Conditions Addendum,and/or fails to pay Service Fees on a timely basis as provided in Section 3 of such Addendum,Aetna will assess a late payment charge. The per annum charge for 2005 will be as follows: (i) late funds to cover benefit payments(e.g.,late wire transfers): 9%annual rate (ii) late payments of Service Fees: 9%annual rate In addition,Aetna will make a charge to recover its cost of collection,including reasonable attorneys'fees. Aetna will provide ninety(90)days prior written notice to Customer of the late payment charges for subsequent years. SFS Page 6 GENERAL CONDITIONS ADDENDUM This General Conditions Addendum is an attachment to Services Agreement Number ASA-889000 between Aetna and Customer (as identified therein)and is incorporated into the Services Agreement by reference. Definitions: In this General Conditions Addendum and in all attachments to the Services Agreement: (A) "Plan(s)"means only the portions of the Customer's employee benefit plan(s)that are described in Appendix I. (B) "Employee"means only a person in those classes of employees and retirees that are specifically described in Appendix I, including employees and retirees of subsidiaries and affiliates of Customer who are reported,in writing,to Aetna for inclusion in the Services Agreement. (C) "Dependent"means only a person in a class described in Appendix I as a dependent of an employee. (D) "Members"means Employees and Dependents covered under the Plan. (E) "Bank"means the bank selected by Aetna on which benefit payment checks are drawn in satisfaction of a claim for Plan benefits. (F) The term"Payment Due Date" shall have the meaning set forth in Section 3 of this General Conditions Addendum. (G) "Product"means a health benefit plan arrangement such as an indemnity,point of service(POS),preferred provider organization(PPO)or exclusive provider organization(EPO)arrangement. (I) The term"Service Fees"shall have the meaning set forth in Section 3 of this General Conditions Addendum. (I) The term"Services Agreement Period"shall have the meaning set forth in Section 2 of this General Conditions Addendum. (J) The term"Services" shall have the meaning set forth in Section 1 to this General Conditions Addendum. The following are the terms and conditions under which Aetna agrees to perform Services for Customer: 1. Purpose. Customer will purchase and Aetna will provide to Customer the services designated in the Services Agreement and such other services Customer requests of Aetna and Aetna agrees in writing to perform,as described in the Service and Fee Schedule and the Description of Services Addendum with respect to the Plan(s)(the"Services"). 2. Term. The initial Services Agreement Period is from 01/01/2005 through 12/31/2005;the second Services Agreement Period is from 01/01/2006 through 12/31/2006;the third Services Agreement Period is from 01/01/2007 through 12/31 2007;the fourth Services Agreement Period is from 01/01/2008 through 12/31/2008. Those periods and all subsequent year to year renewals that shall automatically occur unless either party gives notice as provided in Section 4 herein. The automatic renewal thereafter shall be referred to as"Services Agreement Periods." 3. Service Fees; Renewals. The Service Fees payable by Customer to Aetna for the Services shall be determined in accordance with the Service and Fee Schedule identified in the Services Agreement. No Services other than those identified in the Service and Fee Schedule are included in the Service Fees. The Services to be provided by Aetna and the Service Fees may be adjusted annually on the anniversary of the Effective Date(the"Contract Anniversary")by Aetna subject to the terms of the Service and Fee Schedule. Aetna shall give Customer 180 days prior written notice of such adjustments in Services and Service Fees. Aetna also may adjust the Service Fees at other times in accordance with the terms and conditions of the Service and Fee Schedule. Aetna shall submit to Customer a statement for each month this Services Agreement is in effect showing the Service Fees for that month. Customer shall pay Aetna the amount of the Service Fees no later than thirty-one(3 1)calendar days following the first calendar day of the month in which the services are provided(the"Payment Due Date"). GCA Page 7 Customer shall reimburse Aetna for additional expenses incurred by Aetna and agreed to by the parties on behalf of the Plan or Customer which are necessary for the administration of the Plan,including,but not limited to,special hospital audit fees,fees paid or expenses incurred to recover Plan assets and customized printing fees and for any other services performed which are not Services under the Services Agreement. All overdue amounts shall be subject to the late charges set forth in the Service and Fee Schedule. Following the close of a Service Agreement Period,Aetna will prepare and submit to the Customer a report showing the Service Fees paid. 4. Termination. The Services Agreement may be terminated by Aetna or the Customer as follows: (A) Legal Prohibition-If any state or other jurisdiction enacts a law which prohibits the continuance of this Services Agreement,or an existing law is interpreted to so prohibit the continuance of this Services Agreement,the Services Agreement shall terminate automatically as to such state or jurisdiction on the effective date of such law or interpretation;provided,however,that if only a portion of the Services Agreement is prohibited by such law,only that portion of the Services Agreement shall be affected,and the Services Agreement shall be construed in all respects as if such invalid or unenforceable provision were omitted. (B) Customer Termination-Customer may terminate the Services Agreement with respect to all Employees (including their Dependents)or any group of Employees included under the Services Agreement or any subsidiary or affiliate of Customer that is covered under the Services Agreement by giving Aetna at least thirty-one(31)days written notice stating when,after the date of such notice,such termination shall become effective. (C) Aetna Termination- (1) Aetna may terminate the Services Agreement by giving to Customer at least 180 days written notice stating when,after the date of such notice,such termination shall become effective. (2) If Customer fails to respond to Aetna's or the Bank's initial request to provide funds to the Bank for the payment of checks or other payments approved and recorded by Aetna,Aetna shall have the right to cease processing of benefit payment requests and suspend other Services until the requested funds have been provided. Aetna may terminate the Services Agreement immediately upon transmission of notice to Customer by mail,facsimile transmission or other means of communication(including electronic mail)if(a) Customer fails to provide the requested funds within(5)business days of such notice by Aetna,or(b)Aetna reasonably determines that Customer will not meet its obligation to provide such funds within such five(5) business days. (3) If Customer fails to pay Service Fees by the Payment Due Date,Aetna shall have the right to suspend Services until the charges have been paid. Aetna may terminate the Services Agreement immediately upon transmission of notice to Customer by mail,facsimile transmission or other means of communication (including electronic mail)if(a)Customer either fails to pay such charges within five(5)business days of such notice of unpaid Service Fees by Aetna,or(b)Aetna reasonably determines that Customer will not meet its obligation to pay such charges within such five(5)business days. (4) Any acceptance by Aetna of funds or Service Fees described in paragraphs(2)or(3)above,after the grace periods specified therein have elapsed and prior to any action by Aetna to suspend Services or terminate the Services Agreement,shall not constitute a waiver of Aetna's right to suspend Services or terminate the Services Agreement in accordance with this section with respect to any other failure of Customer to meet its obligations hereunder. GCA Page 8 (D) Responsibilities on Termination-Upon termination of the Services Agreement,Aetna will continue to process runoff claims for Plan benefits that were incurred prior to but not processed as of the termination date which are received by Aetna not more than twelve(12)months following the termination date. The Service Fee for such activity is included in the Service Fee described in Section 3 of this General Conditions Addendum. The procedures and obligations described in the Services Agreement,to the extent applicable,shall survive the termination of the Services Agreement and remain in effect with respect to such claims. Benefit payments processed by Aetna with respect to such claims which are pended or disputed will be handled to their conclusion by Aetna and the procedures and obligations described in the Services Agreement,to the extent applicable,shall survive the expiration of the twelve(12)month period. Requests for benefit payments received after such twelve(12)month period will be returned to the Customer or,upon its direction,to a successor administrator at the Customer's expense. Customer will be liable for all Plan benefit payments made by Aetna in accordance with the preceding paragraph (D)following the termination date or which are outstanding on the termination date. Customer will continue to fund benefit payments through the banking arrangement described in Section 5 of this General Conditions Addendum and agrees to instruct its bank to continue to make funds available until all outstanding benefit payments have been funded by the Customer or until such time as mutually agreed upon by Aetna and Customer(e.g.,Customer's wire line and bank account from which the Bank requests funds must remain open for one(1)year after runoff processing ends,two(2)years after termination). Upon termination of the Services Agreement and provided all Service Fees have been paid,Aetna will release to Customer or to a successor administrator,in Aetna's standard format,all claim data,records,and files within a reasonable time period following the termination date. All reasonable costs associated with the release of data, records,and files from Aetna to Customer shall be paid by Customer. Subsidiaries and affiliates of Customer who are covered under the Services Agreement may be terminated by Customer giving timely written notice to Aetna. 5. Funding of Plan Benefits. Benefit payments and related charges of any amount payable under the Plan shall be made by check drawn by Aetna payable through the Bank or by electronic funds transfer or other reasonable transfer method. Customer,by execution of the Services Agreement,expressly authorizes Aetna to issue and accept such checks on behalf of Customer for the purpose of payment of Plan benefits and other related charges. Customer agrees to provide funds through its designated bank sufficient to satisfy all Plan benefits and related charges upon notice from Aetna or the Bank of the amount of payments made by Aetna. Customer agrees to instruct its bank to initiate an ACH credit on the day the Customer receives a request for value in the Bank's account the next business day equal to such liability. As used herein, "Plan benefits"means payments under the Plan,excluding copayments,coinsurance,or deductibles required by the Plan. A stop payment will be made on all outstanding benefit payment checks(checks which have not been presented for payment) on the sooner of: (A) one(1)year following the date Aetna completes its runoff processing obligations. (B) the date the Customer ceases to fund benefit payments. For any calendar month,the maximum payment to be made to the Bank to fund Plan benefit payments and related charges is described below. Plan benefit payments and related charges in a calendar month which exceed the maximum payment for the month will be carved forward to be funded by Customer in future calendar months of the current Services Agreement Period, except that for the last calendar month of the Services Agreement Period,Customer is liable for any benefit payments which exceed the maximum payment for that month. GCA Page 9 The maximum payment for any calendar month shall be equal to(i) less(ii)where: (i) shall be equal to the product of(A)and(B)where: (A) equals the sum of the number of employees as indicated by Aetna records at the beginning of each calendar month of the Services Agreement Period up to and including the current calendar month(provided the sum shall not be less than the number of calendar months up to and including the current calendar month times the number of employees as indicated by Aetna records as of the beginning of the first Services Agreement month),times (B) the maximum benefit payment factor. This factor shall be determined by Aetna and shall be effective as of the first calendar month of a Services Agreement Period. The maximum benefit payment factor may be changed at such other times as the Aggregate Stop Loss Factor under Contractual Liability Insurance Policy No. SL-889000 is adjusted. (ii) shall equal the Plan benefit payments funded by Customer during the preceding calendar months of the Services Agreement Period. On the termination date,in addition to the liabilities described in Section 4,Customer is liable for and must provide funds to the Bank equal to the difference between: (i) the total amount of benefit payments by Aetna during the Services Agreement Period;and (ii) the amount of benefit payments by Aetna during the Services Agreement Period for which Customer has provided funds up to the date of termination. 6. Customer's Responsibilities. Customer shall supply Aetna in writing or by electronic medium acceptable to Aetna with all information regarding the eligibility of Members including but not limited to the identification of any Sponsored Dependents defined in Appendix I and shall notify Aetna by the tenth day of the month following any changes in Plan participation. Aetna has no responsibility for determining whether an individual meets the definition of a Sponsored Dependent. Aetna shall not be responsible in any manner,including but not limited to,any obligations set forth in Section 12 below,for any delay or error caused by the Customer's failure to furnish accurate eligibility information in a timely fashion. Customer shall provide Aetna with all Plan documents at least thirty(30)days prior to the Effective Date or such other date as may be mutually agreed upon by the parties. Customer shall notify Aetna in writing of any changes in Plan documents or Plan benefits at least thirty(30)days prior to the effective date of such changes. Aetna shall have thirty(30)days following receipt of such notice to inform Customer of whether it will administer such proposed changes. Appendix I hereto shall be deemed to be automatically modified to reflect such proposed changes if Aetna either agrees to administer the changes as proposed or fails to object to such changes within thirty(30)days of receipt of the foregoing notice. The description of Plan benefits in Appendix I may otherwise be amended only by mutual written agreement of the parties. Aetna may charge reasonable additional fees relating to any increase in cost to administer the Plan because of changes which Aetna agrees to administer,provided that Aetna has given Customer prior written notice specifying the amount of increase in fees. If the Aetna Pharmacy Management(APM)plan is terminated by the City of Fort Worth,Aetna reserves the right to adjust the fees being charged the Customer. Within a reasonable period of time following Customer's receipt of Aetna's request,Customer shall provide Aetna with such information reasonably related to administration of the Plan as Aetna may request from time to time. Aetna is entitled to rely on the information most recently supplied by Customer in connection with Aetna's Services and its other obligations under the Services Agreement. Aetna shall not be responsible for any delay or error caused by Customer's failure to furnish correct information in a timely manner. Customer agrees that it will provide Aetna with a copy of its Summary Plan Description(SPD),as finally approved by the Customer,so that Aetna may reconcile any potential differences that may exist among the SPD,the description of Plan benefits in Appendix I and Aetna's internal policies and procedures. Notwithstanding the foregoing,in no event shall Aetna have the authority to unilaterally modify the SPD,plan document,or description of benefits in Appendix I. In the event that Aetna discovers a potential discrepancy among the SPD and the description of Plan benefits in Appendix I,or the Plan,Aetna agrees to notify the Customer of such differences. Customer agrees that it is responsible for satisfying any and all Plan reporting and disclosure requirements imposed by law. GCA Page 10 7. Services. Aetna shall perform the Services set forth in the Service and Fee Schedule and the Description of Services Addendum identified in the Services Agreement.Customer acknowledges that Aetna may utilize the services of external reviewers or contractors in performing these services. 8. Standard of Care. Aetna will discharge its obligations under the Services Agreement with that level of reasonable care which a similarly situated administrator of claims would exercise under similar circumstances. 9. Fiduciary Duty. It is understood and agreed that the Customer retains complete authority and responsibility for the Plan, its operation,and the benefits provided thereunder,and that Aetna is empowered to act on behalf of Customer in connection with the Plan only to the extent expressly stated in the Services Agreement or as agreed to in writing by Aetna and Customer. Customer and Aetna agree that Aetna will be the"appropriate named fiduciary"of the Plan for the first two levels of appeal for purpose of reviewing denied claims under the Plan. In exercising such fiduciary responsibility,Aetna will have discretionary authority to determine entitlement to Plan benefits as determined by the Plan documents for each claim received and to construe the terms of the Plan. If the denial is upheld in the second level of appeal,then Aetna will inform the Member of his right to appeal to the Customer for final review. Customer shall be the"appropriate named fiduciary"of the Plan for the final appeal. Customer has the sole and complete authority to determine eligibility of persons to participate in the Plan. 10. Records. All documents,records,reports,and data, including data recorded in Aetna's data processing systems ("Documentation"),related to the receipt,processing,and payment of claims,including all claim histories,shall at all times be the property of Customer,subject to Aetna's right to possession and use during the continuance of the Services Agreement and Aetna's right to maintain such Documentation in such form and at such locations as Aetna normally maintains such Documentation. Customer acknowledges and agrees that Aetna or one of its affiliates or authorized agents shall have the right to use Documentation for legitimate Plan or health related purposes such as:claims payment and fraud prevention; preventive health,early detection,and disease management programs;coordination of patient care;quality improvement/management assessment;utilization review and management; fulfilling certain state and federal requirements; HEDIS and similar data collection and reporting;accreditation by the National Committee for Quality Assurance and other accrediting organizations;and statistical research. Upon reasonable prior written request,subject to the provisions of Sections 11 and 17 hereof,and as permitted by law or regulation,the benefit payment information contained in the Documentation shall be made available to Customer or,at Customer's request,to a third party designated by Customer for inspection during regular business hours at the place or places of business where it is maintained by Aetna,for purposes related to the administration of the Plan. Aetna may assess a charge to recover costs in connection with documentation requests which are excessively repetitive or burdensome. Such Documentation will be kept by Aetna for seven(7)years after the year in which a claim is paid,unless Aetna turns such Documentation over to Customer or a designee of Customer. 11. Audit rights. (A) General Guidelines-For the purpose of this contract,an "audit"is defined as performing a review of claim transactions for the purpose of assessing the accuracy of benefit determinations. Audits must be commenced within two(2)years following the period being audited. Audits of performance guarantees must be commenced in the year following the period to which the performance guarantee results apply. The size of the audit sample may not exceed 400 claim transactions,without Aetna's written consent and the payment of fees as assessed by Aetna. Audit samples that exceed 400 claim transactions will be assessed a fee of$50.00 per claim transaction for audits performed during 2005. The fee is subject to change,based on applicable rates in force at the time any future audits are performed. To the extent practicable,Aetna will provide an estimate of such fees to Customer prior to the Customer incurring additional fees. GCA Page 11 Audits must be performed at the location where Customer's claims are processed,or at the closest Aetna office to the Customer in the United States. Notwithstanding the foregoing,in the event and to the extent that the Customer's claims are processed in a location outside the continental United States,Aetna will provide copies,at Aetna's own expense,of all documents that the Customer reasonably requests to review in connection with an audit. Aetna is not responsible for paying Customers'audit fees or the costs associated with the audit. Customer shall pay Aetna fees for any audit which(i)cannot be completed within a five(5)day period,(ii)contains a sample size in excess of 400 claim transactions,or(iii)otherwise creates exceptional administrative demands upon Aetna. To the extent practicable,Aetna will provide estimates of such fees to Customer prior to the Customer incurring additional fees. Any requested payment from Aetna resulting from the audit must be based upon documented findings,agreed to by both parties,and must be solely due to Aetna's actions or inactions. (B) Auditor Qualifications and Requirements-Customer retains the sole discretion to select an individual to conduct audits on its behalf. Such individual selected by the Customer shall perform his/her review in accordance with published administrative safeguards and procedures against unauthorized use or disclosure(in the audit report or otherwise)of any individually identifiable information(including health care information)contained in the information to be audited. Such individual will not make or retain any record of provider negotiated rates included in the audited transactions,or payment identifying information concerning treatment of drug or alcohol abuse, mental/nervous or HIV/AIDS or genetic markers,in connection with any audit. Auditors may not be compensated on the basis of a contingency fee or a percentage of overpayments identified,in accordance with the provisions of Section 8.207 through 8.209 of the International Federation of Accountants(IFAC)Code of Ethics For Professional Accountants(Revised 2004). Audits of any services are subject to any related proprietary and confidentiality requirements protecting the nature of the data. (C) Audit Coordination-The account representative must be contacted to initiate an audit. The representative will identify an audit coordinator who will have day-to-day responsibility for coordinating and facilitating the audit. Customer will provide reasonable advance notice of its intent to audit and will complete an Audit Request Form providing information reasonably requested by Aetna. Further,Customer or its representative will provide the account representative at least four(4)weeks advance notice of the audit,with a complete and accurate listing of the transactions to be pulled for the audit and identification of the potential auditor. Notification requirements may exceed four weeks for unusual audit requests,including but not limited to audits involving large sample sizes(e.g.,greater than 400 transactions). Aetna will communicate these requirements to Customer upon receipt of the completed Audit Request Form. No audit may commence until the Audit request Form is completed and executed by the Customer and auditor. Aetna recommends that any auditor being considered by the Customer be identified to Aetna as soon as possible so that any potential conflicts or past relationships or issues may be determined. (D) Identification of Audit Sample-Prior to the audit,the auditors will provide a listing of the transactions selected for testing and the specific service for which each item is being tested,unless otherwise specified in Appendix II- Performance Guarantees-Medical,Appendix II-A-Discount Guarantees,Appendix 11-B-RX Rebate Guarantees, Appendix H-C-Medical Management Guarantees. The sample must be based on a statistical random sampling methodology(e.g.,systematic random sampling,simple random sampling,stratified random sampling). Aetna reserves the right to review and approve the sample size,the objectives of the audit and the sampling methodology proposed by the auditors. (E) Closing Meeting-The auditors will provide their draft audit findings to Aetna,in writing,before a final audit report is presented to Customer. This draft will provide the basis for discussions between Aetna and the auditors to resolve disagreements and summarize the audit findings. GCA Page 12 (F) Audit Reports- Aetna will have a right to review the final draft Audit Report,before delivery to the Customer. Auditors shall provide Aetna with a copy of the final audit report delivered to Customer and Aetna shall have the right to include with the final Audit Report a supplementary statement containing facts that Aetna considers pertinent to the audit. Unless auditors are compliant with paragraphs(E)and(F),the audit will not be completed and its results are presumed invalid. 12. Recovery of Overpayments. The parties will cooperate fully to make reasonable efforts to recover overpayments of benefits under the Plan. If it is determined that any payment has been made by Aetna to or on behalf of an ineligible person or if it is determined that more than the appropriate amount has been paid,Aetna shall undertake good faith efforts to recover the erroneous payment. For the purpose of this provision,"good faith efforts"means that Aetna will contact the responsible party twice via letter,phone,email or other means to try to make the recovery. If those efforts are unsuccessful in obtaining recovery,Aetna may use an outside vendor,collection agency or attorney to pursue recovery. Except as stated in this section,Aetna has no other obligation with respect to the recovery of overpayments. Overpayment recoveries made through third party recovery vendors,collection agencies,or attorneys are credited to Customer net of fees charged by them. This process does not preclude Customer from pursuing indemnification in accordance with Section 13(A)if the overpayment results from actions by Aetna that would otherwise obligate Aetna to indemnify Customer pursuant to that Section. For the purposes of Sections 11 and 13,overpayments must be determined by direct proof of specific claims. Indirect or inferential methods of proof—such as statistical sampling,etc.—may not be used to determine overpayments. In addition, application of software or other review processes that analyze claims in a manner different from the claim determination and payment procedures and standards used by Aetna may not be used to determine overpayments. Customer may not seek collection,or use a third party to seek collection,of overpayment from contracted providers pursuant to audits conducted in accordance with Sections 11 and 13,since all such recoveries are subject to the terms and provisions of the providers'contracts with Aetna. For the purpose of determining whether a provider has or has not been overpaid, Customer agrees that the rates paid to contracting providers for Covered Services shall be governed by Aetna's contracts with those providers,and shall be effective upon the loading of those contract rates into Aetna's systems,but no later than three (3)months after the effective date of the providers'contracts. Customer may not seek collection,or use a third party to seek collection,of overpayments identified pursuant to an audit conducted in accordance with Sections 11 and 13,from parties other than contracted providers as described above until Aetna has had a reasonable opportunity to recover the overpayments. 13. Indemnification. (A) Aetna shall indemnify and hold harmless Customer,its directors,officers,employees(acting in the course of their employment,but not as Members),and agents for that portion of any loss,liability,damage,expense,settlement,cost, or obligation(including reasonable attorneys' fees)(i)which was caused solely and directly by the willful misconduct, criminal conduct,breach of the Services Agreement,fraud,breach of fiduciary responsibility,failure to comply with Section 8 above,or failure to comply with any applicable state or federal law by Aetna or Aetna's subcontractor or agent,that is related to or arising out of the Services provided under the Services Agreement: (ii)resulting from any assessments and penalties incurred by Customer by reason of Aetna's failure to provide the Services contemplated hereunder,and any interest thereon;or(iii)in connection with the use or further disclosure of member identifiable information by Aetna or Aetna's subcontractor or agent. GCA Page 13 (B) Except as provided in(A)above,Customer shall indemnify and hold harmless Aetna,its affiliates and their respective directors,officers,employees,and agents for that portion of any loss,liability,damage,expense,settlement,cost,or obligation(including reasonable attorney's fees):(i)which was caused solely and directly by Customer's willful misconduct,criminal conduct,breach of the Services Agreement,fraud,breach of fiduciary responsibility,or negligence,related to or arising out of the Services Agreement or Customer's role as employer or Plan sponsor;(ii) resulting from taxes,assessments incurred by Aetna by reason of Plan benefit payments made or Services performed hereunder,and,so long as Aetna has performed in accordance with Section 8 above,any interest and penalties thereon, provided that Customer shall not be required to pay any net income,franchise or other tax,however designated,based upon or measured by Aetna's net income,receipts,capital,or net worth;(iii)in connection with the release or transfer of Member-identifiable information to Customer or a third party designated by Customer,or the use or further disclosure of such information by Customer or such third party;(iv)resulting from the inclusion of third party vendor information on identification cards as required or requested by the Customer;or(v)resulting from or arising out of claims,demands,or lawsuits brought against Aetna in connection with Services provided under the Services Agreement. (C) The party seeking indemnification under(A)or(B)above must notify the indemnifying party within 30 days in writing of any actual or threatened action,suit,or proceeding to which it claims such indemnification applies. Failure to so notify the indemnifying party shall not be deemed a waiver of the right to seek indemnification,unless the actions of the indemnifying party have been prejudiced by the failure of the other party to provide notice within the required time period. The indemnifying party may then take steps to be joined as a party to such proceeding,and the party seeking indemnification shall not oppose any such joinder. Whether or not such joinder takes place,the indemnifying party shall provide the defense with respect to claims to which this Section applies and in doing so shall have the right to control the defense and settlement with respect to such claims. The party seeking indemnification may assume responsibility for the direction of its own defense at any time, including the right to settle or compromise any claim against it without the consent of the indemnifying party, provided that in doing so it shall be deemed to have waived its right to indemnification except in cases where the indemnifying party has declined to defend against the claim. (D) Customer and Aetna agree that: (i)Aetna does not render medical services or treatments to Members;(ii)neither Customer nor Aetna are responsible for the health care that is delivered by contracting health care providers; (iii)health care providers are solely responsible for the health care they deliver to Members;(iv)health care providers are not the agents or employees of Customer or Aetna;and(v)the indemnification obligations of(A)or(B)above do not apply to any portion of any loss,liability,damage,expense,settlement,cost,or obligation caused by the acts or omissions of health care providers with respect to Members. (E) The indemnification obligations under(A)above shall not apply to that portion of any loss,liability,damage,expense, settlement,cost,or obligation caused by Aetna's act or omission undertaken at the direction of Customer(other than services described in the Services Agreement),and the indemnification obligations under(B)above shall not apply to that portion of any loss,liability,damage,expense,settlement,cost,or obligation caused by Customer's act or omission undertaken at the direction of Aetna. (F) The indemnification obligations under this Section 13 shall terminate upon the termination of this Agreement,except with respect to any matter concerning a claim that has been asserted by notice to the other party either at the time of such termination or within the applicable statute of limitations relating to such claim. GCA Page 14 14. Defense of Claim Litigation. In the event of a legal,administrative or other action("action")arising out of the administration,processing or determination of a claim for Plan benefits,the party designated in this document as the fiduciary which rendered the decision in the appeal last exercised by the Member which is being appealed to the court ("appropriate named fiduciary")shall undertake the defense of such action at its expense and settle such action when in its reasonable judgment it appears expedient to do so. If the other party is also named as a party to such action,the appropriate named fiduciary will defend the other party PROVIDED the action relates solely and directly to actions or failure to act by the appropriate named fiduciary and there is no conflict of interest between the parties. Customer agrees to pay the amount of Plan benefits included in any judgment or settlement in such action. The other party shall not be liable for any other part of such judgment or settlement,including but not limited to legal expenses and punitive damages,except to the extent provided in Section 13 above. 15. Remedies. Neither party shall be liable to the other for any consequential,incidental,or punitive damages whatsoever. 16. Dispute Resolution. (a) Informal Dispute. In the event of a dispute,the parties shall first attempt in good faith to promptly resolve any dispute arising out of or relating to this Agreement,except for temporary,preliminary,or permanent injunctive relief or any other form of equitable relief granted by a court of competent jurisdiction,by negotiation between executives who have authority to settle the controversy and who are at a higher level of management than the persons with direct responsibility for administration of the contract. Any party shall give the other party written notice of any dispute not resolved in the normal course of business,including the prescribed period to cure alleged breaches of contract. Within ten(10)business days after delivery of the notice,the receiving party shall submit to the other a written response. The notice and the response shall include(a)a statement of each party's position and a summary of arguments supporting that position,and(b)the name and title of the executive who will represent that party and of any other person who will accompany the executive. Within thirty(30)calendar days after the delivery of the disputing party's notice,the executives of both parties shall meet at the mutually convenient time and place,and thereafter attempt to resolve the dispute. All reasonable requests for information made by one party to the other will be honored to the extent practicable. To the extent permitted by applicable law,all negotiations pursuant to this provision are confidential and shall be treated as compromise and settlement negotiations for purposes of applicable rules of evidence. (b) Mediation. If the dispute is not resolved by negotiation between executives within thirty(30)calendar days after the initial meeting between the executives under subsection(a)above,the parties may,upon mutual written consent, endeavor to settle the dispute by mediation under the then current American Arbitration Association(AAA) Mediation Procedures. Unless otherwise agree,the parties will select a mutually agreed upon mediator from AAA Panels of Mediators with specific expertise in employee benefits or similar subject. Each party shall be liable for its own costs and the parties will share equally in the costs of the mediator. GCA Page 15 17. Confidentiality. (A) Each party acknowledges that performance of the Services Agreement may involve access to and disclosure of data, rates,procedures,materials,lists,systems,and other information(collectively"Confidential Information")belonging to the other. The parties further acknowledge and agree that Aetna operates in a highly regulated and competitive environment and that the unauthorized disclosure or use of Confidential Information will cause irreparable harm and significant injury to Aetna which will be difficult to measure with certainty or to compensate through monetary damage. Accordingly,the parties agree that injunctive or other equitable relief shall be appropriate in the event of any breach by Customer,or their agents related to Confidential Information,in addition to such other remedies as may be available to Aetna at law.No Confidential Information shall be disclosed to any third party other than representatives of such party who have a need to know such Information,provided that such representatives are informed of the confidentiality provisions hereof and agree to abide by them. All such Information must be maintained in strict confidence. In addition,each party will maintain the confidentiality of medical records and confidential patient information as required by law. Upon termination of the Services Agreement,each party,upon the request of the other,will return or destroy all copies of all of the other's Confidential Information in its possession or control except to the extent such Information must be retained pursuant to applicable law,provided,however,that Aetna may retain copies of any such Information it deems necessary for the defense of litigation concerning the services it provided under the Services Agreement. Customer agrees that Aetna may make lawful references to Customer in its marketing activities and in informing health care providers as to the organizations and plans for which Services are to be provided. Each party will execute and cause its employees and agents to execute any documents the other reasonably requires in connection with this confidentiality provision. (B) In addition to the provisions of the foregoing paragraph(A),any information with respect to Aetna's or any of its affiliate's fees or specific rates of payment to health care providers,and any information which may allow determination of such fees or rates,and any of the terms and provisions of the health care providers'agreements with Aetna or its affiliates are deemed to be Aetna's Confidential Information. No disclosure of any such information may be made or permitted to Customer or to any third party whatsoever,including,but not limited to,any broker, consultant,auditor,reviewer,administrator,or agent unless(i)Aetna has consented in writing to such disclosure and (ii)each such recipient has executed a confidentiality agreement in form satisfactory to Aetna's counsel. (C) Customer acknowledges that compliance with the provisions of the foregoing paragraphs(A)and(B)are necessary to protect the business and good will of Aetna and its affiliates and that any actual or prospective breach will irreparably cause damage to Aetna or its affiliates for which money damages may not be adequate. Customer therefore agrees that if Customer breaches or attempts to breach paragraphs(A)or(B)hereof,Aetna or an affiliate shall be entitled to obtain temporary,preliminary,and permanent equitable relief,without bond,to restrain such breaches,together with any and all other legal and equitable remedies available under applicable law or under the Services Agreement. Aetna shall be entitled to recover from Customer the attorneys'fees and costs Aetna expends in any action related to such breach or attempted breach. 18. Relationship of the Parties. It is understood and agreed that Aetna is an agent with respect to claim payments and an independent contractor with respect to all other Services being performed pursuant to the Services Agreement. Aetna makes no guarantee and disclaims any obligation to make any specific health care providers or any particular number of health care providers available for use by Members or that any level of discounts or savings will be afforded to or realized by Customer, the Plan,or Members. 19. Subcontractors. The work to be performed by Aetna under the Services Agreement may,at its discretion,be performed directly by it or wholly or in part through a subsidiary or affiliate or under a contract with an organization of its choosing. Aetna will remain liable for Services under the Services Agreement. 20. Advancement of Funds. If,in the normal course of business under the Services Agreement,Aetna,or any other financial organization with which Aetna has a working arrangement,chooses to advance any funds,Customer shall reimburse Aetna or such other financial organization for such payment. In no event shall such advances by Aetna or any other financial organization be construed as obligating Aetna or such organization to make further advances,or to assume liability of Customer for the payment of Plan benefits. GCA Page 16 21. Communications. Aetna and Customer shall be entitled to rely upon any communication believed by them to be genuine and to have been signed or presented by the proper party or parties. Neither party shall be bound by any notice,direction,requisition or request unless and until it shall have been received in writing at(i)in the case of Aetna, 151 Farmington Avenue,Hartford,Connecticut 06156,Attention: Employer Services Team Leader,Aetna,(ii)in the case of Customer,at the address shown below,or(iii)at such other address as either party specifies for the purposes of the Services Agreement by notice in writing addressed to the other party. Notices or communications shall be sent by mail,facsimile transmission,or other means of communication. In the case of Aetna: Address: Aetna Inc. 2777 Stemmons Freeway,Ste 300 Dallas,TX 75207 Attn: Account Executive(Deborah Collins,Email-CollinsDD@aetna.com) Facsimile Number: 214-200-8932 In the case of the City of Fort Worth Address: City of Fort Worth 1000 Throckmorton Fort Worth,TX 76102 Attn:Manager of Benefits(as of 1-1-05--Robert Molloy,Email-MolloyR@ci.fort-worth.tx.us) Facsimile Number: 817-392-8869 Each party will provide timely notification in writing to the other party of any change in the contact information shown above. 22. Employee Notices. Customer agrees to furnish each Employee covered by the Plan written notice,satisfactory to Aetna, that Customer has complete financial liability for the payment of Plan benefits. Customer agrees to indemnify Aetna and hold Aetna harmless against any and all loss,damage,and expense(including reasonable attorneys' fees)sustained by Aetna as a result of any failure by Customer to give such notice. 23. Force Majeure. Aetna shall not be liable for any failure to meet any of the obligations or provide any of the services or benefits specified or required under the Services Agreement where such failure to perform is due to any contingency beyond the reasonable control of Aetna,its employees,officers,or directors. Such contingencies include,but are not limited to: acts or omissions of any person or entity not employed or reasonably controlled by Aetna,its employees,officers or directors; acts of God;fires;wars;accidents;labor disputes or shortages;governmental laws,ordinances,rules,regulations,or the opinions rendered by any Court,whether valid or invalid. 24. Non-Aetna Networks If Aetna is requested by Customer to arrange for network services to be provided for Employees and their Dependents in a geographic area where Aetna does not have a network of providers under contract to provide those services,Aetna may contract with another network of non-contracted providers("non-Aetna networks")to provide the requested services. With respect to the services provided by providers who are not under contract to Aetna or any of its subsidiaries("non-Aetna providers"),Customer acknowledges and agrees that,any other provisions of the Services Agreement notwithstanding: 1. Aetna does not credential,monitor,or oversee the providers or the administrative procedures or practices of any non- Aetna networks; 2. No particular discounts may, in fact,be provided or made available by any particular providers; 3. Such providers may not necessarily be available,accessible,or convenient; 4. Any performance guarantees appearing in the Services Agreement shall not apply to services delivered by non-Aetna providers or networks; 5. Neither non-Aetna providers nor non-Aetna networks are to be considered contractors or subcontractors of Aetna; and GCA Page 17 6. Such providers are providers in private practice,are neither agents nor employees of Aetna,and are solely responsible for the health care services they deliver. Customer further agrees that,if Aetna subsequently establishes its own contracted provider network in a geographic area where services are being provided by a non-Aetna network,Aetna may terminate the non-Aetna network contract,and begin providing services through a network that is subject to the terms and provisions of the Services Agreement. Customer acknowledges that such conversion may cause disruption,including the possibility that a particular provider in a non-Aetna network may not be included in the replacement network. 25. Health Insurance Portability And Accountability Act(HIPAA)Compliance In accordance with the services being provided under the Services Agreement,Aetna will have access to,create,and/or receive certain Protected Health Information("PHI"as defined in Appendix A),thus necessitating a written agreement that meets the applicable requirements of the privacy and security rules promulgated by the Federal Department of Health and Human Services("HHS"). Customer and Aetna mutually agree to satisfy the foregoing regulatory requirements through Appendix A to the Services Agreement. As of the effective dates set forth therein,the provisions of Appendix A supercede any other provision of the Services Agreement,which may be in conflict with such Appendix on or after the applicable effective date. 26. Miscellaneous. The Services Agreement shall be governed by,and interpreted in accordance with,applicable federal law. To the extent such federal law does not govern,the Services Agreement shall be governed by Texas law and the courts in such state shall have sole and exclusive jurisdiction of any dispute related hereto or arising hereunder. No delay or failure of either party in exercising any right hereunder shall be deemed to constitute a waiver of that right. There are no intended third party beneficiaries of the Services Agreement. This Section and Sections 3 through 12 and 14 through 17 shall survive termination of the Services Agreement. The provisions of Section 13 shall survive termination only to the extent stated therein. The headings in the Services Agreement are for reference only and shall not affect the interpretation or construction of the Services Agreement. GCA Page 18 DESCRIPTION OF SERVICES ADDENDUM This Description of Services Addendum is an addendum to Services Agreement Number ASA-889000 between Aetna and Customer(as identified therein)and is incorporated into the Services Agreement by reference. Subject to the terms and conditions of the Services Agreement,the Services available from Aetna are described below. Unless otherwise agreed in writing,only the Services selected by Customer in the Service and Fee Schedule(as modified by Aetna from time to time pursuant to Section 3 of the General Conditions Addendum)will be provided by Aetna. Additional Services may be provided at Customer's written request under the terms of the Services Agreement. I. Administration Services: A. Member and Claim Services: 1. Requests for Plan benefit payments for claims shall be made to Aetna on forms or other appropriate means approved by Aetna. Such forms(or other appropriate means)may include a consent to the release of medical,claims,and administrative records and information to Aetna. Aetna will process and pay the claims for Plan benefits incurred after the Effective Date using Aetna's normal claim determination,payment,and audit procedures,and applicable cost control standards in a manner consistent with the terms of the Plan and the Services Agreement. With respect to any Member who makes a request for Plan benefits which is denied on behalf of the Customer,Aetna will notify said Member of the denial and of said Plan Member's right of review of the denial in accordance with applicable state and federal law. 2. Whenever it is determined that benefits and related charges are payable under the Plan,Aetna will issue a payment of such benefits and related charges on behalf of the Customer. Funding of benefits and related charges shall be made as provided in Section 5 of the General Conditions Addendum. 3. Where the Plan contains a coordination of benefits clause,antiduplication clause,or provision(s)reducing benefits for injuries or illness caused or alleged to be caused by third parties,Aetna will administer all claims consistent with such provisions and any information concurrently in its possession as to duplicate coverage or the cause of the injury or illness. Aetna shall have no obligation to recover sums owed to the Plan by virtue of the Plan's rights to coordinate where the claim was incurred prior to the Effective Date. Aetna has no obligation to bring actions based on subrogation or lien rights,unless Subrogation Services are included herein,in which event its obligations are governed by Article IV of this Description of Services Addendum. B. Plan Sponsor Services: 1. Aetna will assign an Account Executive to the Customer's account. The Account Executive will be available to assist the Customer in connection with the general administration of the Plan,ongoing communications with the Customer and administration,and record-keeping systems for ongoing operation of the Plan. 2. Upon request by the Customer and consent by Aetna,Aetna will implement amendments or modifications to the Customers Plan. A charge may be assessed for implementing such amendment or modification. The Customer's administration services fees,as set forth in the Service and Fee Schedule,will be revised if the foregoing amendments or modifications increase Aetna's costs, provided that Aetna provides written notice to the Customer of such fee increases in accordance with Section 6 of the General Conditions Addendum. DSA Page 19 3. Aetna will provide the following reports to the Customer for no additional charge: (a) Monthly/Quarterly/Annual Accounting Reports-Aetna shall prepare the following accounting reports in accordance with the benefit-account structure for use by the Customer in the financial management and administrative control for the Plan benefits: (i) a monthly listing of funds requested and received for payment of Plan benefits; (ii) a monthly reconciliation of funds requested to claims paid within the benefit-account structure; (iii)a monthly or quarterly or annual listing of paid benefits; (iv) quarterly or annual standard claim analysis report. (b) Annual Accounting Reports-Aetna shall prepare standard annual accounting reports for each major benefit line under the Plan for the Services Agreement Period that include the following: (i) forecast of claim costs; (ii) accounting of experience;and (iii)calculation of Customer reserve. Any additional reporting formats and the price for any such reports shall be mutually agreed upon by the Customer and Aetna. 4. Aetna shall develop and install all agreed upon administrative and record keeping systems,including the production of employee identification cards. 5. Aetna shall design and install a benefit-account structure separately by class of Employees,division, subsidiary, associated company,or other classification desired by the Customer. 6. Aetna shall provide plan design and underwriting services in connection with benefit revisions,additions of new benefits,and extensions of coverage to new Employees and their Dependents. 7. Aetna shall provide cost estimates and actuarial advice for benefit revisions,new benefits,and extensions of coverage being co sidered by Customer. 8. Upon request of th Customer,Aetna will provide the Customer with information reasonably available to Aetna which is reasonabl necessary for the Customer to prepare reports for the United States Internal Revenue Service and Department of Labor. 9. (a) Upon request f the Customer,Aetna shall prepare and distribute to employees an Aetna standard Plan description, in luding benefit revisions,additions of new benefits,and extension of coverage under the Plan. If the Customer lects to have an Aetna non-standard Plan description,Aetna will provide a custom Plan description wii In all costs borne by the Customer. Notwithstanding the foregoing,Customer shall review and approve all Ph descriptions and make or request Aetna to make any revisions thereto prior to distribution of any Plan desc ption,and to consult with the Customer or its designated representatives,at its discretion,with said review an approval; or (b) Upon request f the Customer,Aetna will review the Customer prepared employee Plan descriptions, subject to the Customer's final and sole authority regarding benefits and provisions in the self-insured portion of the Plan. The Customer acknowledges its responsibility to review and approve all Plan descriptions and any revisions thereto,and to consult the Customer's legal counsel,at its discretion,with said review and approval. DSA Page 20 Aetna shall have no responsibility or liability for the content of any of Customer's Plan documents,regardless of the role Aetna may have played in the preparation of such documents. If the Customer requires both preparation(a)and review(b),there may be an additional charge. 10. Upon request by the Customer,Aetna will arrange for the printing of Plan descriptions,with all costs borne by the Customer. 11. Upon request by the Customer,Aetna will arrange for the custom printing of forms and identification cards,with all costs borne by the Customer. H. Patient Management Services: A. Precertification: 1. Inpatient Precertification: A process for collecting information prior to an inpatient confinement.Proposed treatment plans are reviewed. The goals of this process are: a. Assessment of the level and quality of the services provided; b. Determination of the coverage of the proposed treatment; c. Identification of care and treatment alternatives,when appropriate;and d. Identification of members for referral to specialized programs,such as Disease Management,Case Management,or the prenatal program;and e. Determination of the initial length of stay. The request for services is reviewed against a set of criteria established by clinical experts and administered by trained staff. Those cases not meeting criteria are subject to further review by the medical director or a specialist in the appropriate area prior to final determination. Inpatient Precertification involves medical,surgical,behavioral health,inpatient hospice,and skilled nursing facility admissions. 2. Outpatient Precertification: A process for reviewing selected ambulatory procedures,surgeries,diagnostic tests, home health care,and durable medical equipment. The goals of this process are: a. Assessment of the level and quality of the services provided; b. Determination of the coverage of the proposed treatment; c. Identification of care and treatment alternatives,when appropriate;and d. Identification of members for referral to specialized programs. The request for services is reviewed against a set of criteria established by clinical experts and administered by trained staff. Those cases not meeting criteria are subject to further review by the medical director or a specialist in the appropriate area prior to final determination. B. Concurrent Review: This is a program in which Aetna monitors a patient's progress toward recovery after a patient is admitted to a hospital. This program focuses on the timely delivery of services and confirms the necessity of continued inpatient care. Appropriate alternatives to continued inpatient care may be identified. DSA Page 21 C. Discharge Planning: This is an interdisciplinary process that assists Members as their medical condition changes and as they transition from the inpatient setting. The discharge planning process begins upon identification of the Members' post discharge needs(which may occur during the registration,precertification,or concurrent review process). This program may include evaluation of alternate care settings and identification of care needed after discharge. The goal is to provide continuing quality of care and to avoid delay in discharge due to lack of outpatient support. D. Case Management: This program focuses on improving health and wellness. Case Management is a process of identifying persons at high risk for problems associated with complex healthcare needs,assessing opportunities to coordinate care,and identifying treatment options to improve quality of care,quality of life,and control costs. Case Managers generally assist Members in managing their illnesses,coordinate a series of intensive interventions designed to alter the natural history of a specific illness and facilitate the accessibility of resources. By integrating the record of a Member's contact with the medical delivery system,Case Managers can focus internal and external resources in an effort designed to improve the individual Member's clinical condition. E. National Medical Excellence Program: This program was created to help arrange for access to effective care for Members with particularly difficult conditions requiring transplants or complex cardiac,neurosurgical,or other procedures,when the needed care is not available in a Member's service area. The program utilizes a national network of experienced providers and facilities selected based on their volume of cases and outcomes. The National Medical Excellence Unit provides specialized Case Management through the use of nurse case managers,each with procedure and/or disease specific training. F. Behavioral Health: This program provides immediate 24-hour access to mental health benefits through a dedicated 1- 800 number. Calls are received by a direct services team which verifies eligibility and then transfers the call to a behavioral health clinician. The clinician performs an assessment,determines medical necessity and appropriate level of care,and then facilitates a referral to a network provider. Local professionals may perform concurrent review and case management. G. Focused Psychiatric Review(FPR): This is a program which provides phone-based utilization review of inpatient behavioral health admissions intended to contain confinements to appropriate lengths,assure medical necessity and appropriateness of care,and reduce costs. FPR is integrated with Inpatient Precertification. H. Healthy Outlook Program: This program directs focused support and resources toward Members within a defined disease population,as determined by Aetna. The goal of this program is to provide disease management services for Members with chronic conditions,in an effort to improve health status and quality of life. This program identifies Member populations at risk for certain chronic diseases,with a focus on education for the Member and provider to maximize positive health outcomes. This program offers individual disease management focused on assisting Member to identify and address health risk factors associated with their chronic condition. It also offers Members the opportunity to order educational materials that contain information about certain chronic diseases or conditions(e.g.,asthma, congestive heart failure,coronary artery disease,diabetes, low back pain,depression). I. INFORMED HEALTH Line: For products other than any Aetna Health Fund product(s)elected,this service includes a toll-free 24-hour/7 day health information hotline through which Members can speak with registered nurses about a variety of health topics. The service includes a self-help handbook,entitled INFORMED HEALTH Handbook(or INFORMED HEALTH Handbookfor Health Aging). The nurses can contribute to informed healthcare decision-making and optimal patient/provider relationships through coaching and support. The nurses cannot diagnose,prescribe treatment or give medical advice but they can provide Members with information on a broad spectrum of health issues, including self-care,prevention,chronic conditions,and complex medical situations. For any Aetna Health Fund product(s)elected,this service includes a toll-free 24-hour/7 day health information line through which Members can speak with registered nurses about a variety of health topics. The nurses encourage informed health care decision-making and optimal patient/provider relationships through coaching and support. Members can also call to listen to their topic of interest through a new audio health library,available in English and Spanish. The nurses cannot diagnose,prescribe or give medical advice. DSA Page 22 J. Moms-To-Babies Maternity Management ProgramTM: Moms-To-Babies Maternity Management ProgramTM provides services that complement covered maternity benefits including access to obstetrical nurse case management,a pregnancy risk survey,educational materials for both expectant mothers and fathers,the Smoke-free Moms-to-BeTM smoking cessation program and more. Case management nurses help coordinate services for Members provided by the obstetrician,perinatologists,any other needed specialists,and hospitals or other facilities. K. Simple Steps To A Healthier Life®: Aetna InteliHealth Inc. ("Aetna InteliHealth"),a Delaware corporation and an indirect wholly-owned subsidiary of Aetna Inc.and an affiliate of Aetna Life Insurance Company("Aetna")(Aetna InteliHealth and Aetna are collectively referred to as"InteliHealth"),has developed an internet-based comprehensive management information resource,known as"Simple Steps To A Healthier Life"(the"Life Program")and located at www.simnlesteuslife.com,to be hosted by Aetna InteliHealth and designed for the eligible employees and dependants of subscribing employers(the"Users"). The Life Program is an online service that offers advice relating to disease prevention,condition education,behavior modification and health promotion programs that may contribute to the health and productivity of employees. The Life Program allows Users to create a health risk assessment profile that generates a personalized health action plan. The health action plan identifies certain potential risks and directs participants to personalized programs and services encouraging healthy lifestyle changes. L. MedQuerysM The MedQuery program is a data-mining initiative,aimed at turning Aetna's data into information that physicians can use to improve clinical quality and patient safety. Through the program,Aetna's data is analyzed and the resulting information gives physicians access to a broader view of an Aetna member's clinical profile. The data which fuels this program includes claims history,current medical claims,pharmacy,physician encounter reports,and patient demographics. Data is mined on a weekly basis and compared with evidence-based treatment recommendations to find possible errors,gaps,omissions(meaning perhaps that certain accepted treatment regimens may be absent)or comissions in care(meaning,for example,drug-to-drug or drug-to-disease interactions.) When MedQuery identifies an Aetna member whose data indicates that there may be an opportunity to improve care,outreach is made to the treating physician based on the apparent urgency of the situation. HI. Network Access Services: A. Aetna shall provide Members with access to Aetna's network hospitals,physicians and other health care providers ("Network Providers")who have agreed to provide services at agreed upon rates and are participating in the Plan covering the Members. B. Aetna reserves the right to set a minimum plan benefit design structure for in-area network claims to which Customer must comply in order to participate in Aetna's Network Program. C. Aetna will provide Customer with physician directories in an amount up to 100%of eligible Employees plus 20%of the current enrolled Employees. Customer shall pay the costs of providing any additional directories which it requests. N. Subrogation Services: Aetna will provide assistance to Customer for subrogation services,some or all of which may be delegated to an organization of Aetna's choosing in accordance with Section 18 of the General Conditions Addendum. Aetna or its contracted representative shall retain a percentage of any monies collected to recover reasonable expenses incurred while pursuing subrogation recoveries. Reasonable expenses include but are not limited to(a)collection agency fees,(b)police and fire reports,(c)asset checks,(d)locate reports,and(e)attorneys' fees. Aetna shall advise Customer if the pursuit of recovery requires formal litigation. In such event, Customer shall have the option to instruct Aetna to cease further action toward recovery. Aetna will credit net recoveries to Customer's accounting. DSA Page 23 Aetna has the exclusive discretion:(a)to decide whether to pursue potential recoveries on subrogated claims;(b)to determine the reasonable methods used to pursue recoveries on subrogated claims,subject to the provision with respect to formal litigation above;and(c)to decide whether to accept any settlement offer relating to a subrogation claim. If no monies are recovered as a result of the subrogation pursuit,no fees or expenses incurred by Aetna or its contracted representative for subrogation activities will be charged to Customer. If Customer notifies Aetna of its election to terminate the Services provided by Aetna,all claims identified for potential subrogation recovery prior to the date notification of such election is received(i.e.,pending claims)shall be handled to conclusion by Aetna and shall be governed by the terms of this provision,unless otherwise mutually agreed DSA Page 24 NATIONAL ADVANTAGE PROGRAM ADDENDUM The National Advantage Program("NAP')is an addendum to Services Agreement Number ASA-889000 between Aetna and Customer(as identified herein)and is incorporated into the Services Agreement by reference. I. National Advantage Program A. Summary NAP provides access to contracted rates for many medical claims that would otherwise be paid as billed under indemnity plans,the out-of-network portion of managed care plans,or for emergency/medically necessary services not provided within the network. When available,these contracted rates will produce savings for the Customer. Aetna contracts with several national third-party vendors to access their contracted rates. In addition,a significant number of Aetna directly-contracted rates are available for members with indemnity benefits. Aetna will access third- party vendor rates where Aetna directly-contracted rates are not available. If no contracted rate is available,Aetna(or one of its vendors)will attempt to negotiate an Ad-Hoc Rate(case specific discount)with non-NAP participating providers for certain larger claims or will apply Facility Charge Review,as applicable and as described below. B. Claim Submission/Payment Process Providers should bill Aetna directly for Covered Services. The Member should not make payment at the time of service. When the Provider submits the claim,Aetna will process it at the contracted rate(when applicable)and reflect the contracted amount in any explanation of payments made that the Member and Provider receives. The Member would then be responsible for any applicable coinsurance,deductible or non-covered service,based upon the plan of benefits. Because claims must be paid within specific timeframes in order to take advantage of the negotiated arrangements,the bulk payment feature will be eliminated for affected claims,and payments will be issued on a daily basis. II. National Advantage Program—Facility Charge Review Facility Charge Review is an optional component of NAP. It is only available in conjunction with the National Advantage Program,and is not available separately. A. Summary Where a contracted rate is not available under NAP,the Facility Charge Review Program provides reasonable charge allowances for most inpatient and outpatient facility claims under Members' indemnity plans and the out-of-network portion of Members' managed care plans or for emergency/medically necessary services not provided within the network. When utilized,these reasonable charges will produce savings for the Customer. B. Claim Submission/Payment Process When an inpatient or outpatient facility claim exceeds a threshold(currently$1,000)and Aetna does not have access to a contracted rate,Aetna will forward the claim to its Facility Charge Review vendor for review.The billed charges will be reviewed for financial reasonableness for the geographic area where the service was provided. Payment to the facility will be based on the Reasonable Charge Amount.Any excess will be considered not covered as it exceeds the reasonable charge(as defined under the Plan). Though many facilities accept the Reasonable Charge Amount as payment in full,there may be circumstances where facilities may not accept the determination of the reasonable charge and may balance bill the Member. In the event that a Member is balance billed,the vendor for the Facility Charge Review Program has a review process and will initiate negotiations with the facility in an attempt to come to a mutually agreeable payment amount. However, should the vendor be unable to negotiate a mutually agreeable rate,consistent with the terms of the Member's plan of benefits,the Member may be responsible for any charges in excess of the reasonable charge. NAP Addendum Page 25 When an inpatient or outpatient facility claim is reduced based on the Reasonable Charge Amount,the Member will receive a letter alerting them to the possibility of balance billing. The letter will ask the Member to contact the vendor in the event that the Member is balance billed,in order to obtain information about the review process. The explanation of benefits that the Member receives from Aetna,if applicable,will also indicate that the amount paid is based upon the Reasonable Charge Amount and will request that the Member contact the vendor should the member be balance billed. The amount actually paid to the provider under the Facility Charge Review Program will be used as the basis for the calculation of the Member's coinsurance and deductibles. III. Terms and Conditions A. Customer Charges For Provider Payments Subject to the terms herein,Aetna agrees that for Covered Services rendered by a Provider for which Aetna has a) accessed a contracted rate,or b)negotiated an Ad-Hoc rate,or c)applied a Reasonable Charge Amount for facility services,Customer shall be charged the amount paid to the Provider. This amount shall be equal to the contracted rate, Ad-Hoc Rate,or Reasonable Charge Amount less any payments made by the Member in accordance with the Plan. B. Access Fees 1. As compensation for the services provided by Aetna under NAP for savings achieved,Customer shall pay an Access Fee to Aetna as described in the Service and Fee Schedule(excluding Aggregate Savings with respect to claims for which Aetna is liable for funding,e.g.,claims in excess of an individual or aggregate stop loss point). 2. Access Fees shall be paid by the Bank to Aetna via wire transfer or such other reasonable transfer method agreed upon by Aetna and the Bank. The Customer agrees to provide funds through its designated bank sufficient to satisfy the Access Fee in accordance with the banking agreement between the Customer and the Bank,i.e.,Access Fees will be included in the request from the Bank for payment/funding of claims. 3. Aetna shall provide a quarterly report of Aggregate Savings and Access Fees. Access Fees may be included with claims in other reports. C. ID Cards For most products/plans,Customer must inform Members of the availability of NAP and Aetna will distribute ID cards with a NAP logo. Further,a Customer's Plan document language defining reasonable charge or recognized charge must conform to Aetna requirements. Aetna shall provide Information regarding participating Providers on DocFind®, Aetna's online provider listing,on our website at www.Aetna.com or by other comparable means. D. Definitions As used herein: "Access Fee"means the amount(s)to be paid by Customer to Aetna for access to the savings provided under NAP. "Ad-Hoc Rate"means the rate which was negotiated for a specific claim in the absence of a pre-negotiated contracted rate with a Provider. "Aggregate Savings"means the difference between(i)the amount which would have been due or otherwise paid to Providers for Covered Services without the benefit of NAP,and(ii)the amount due Providers for Covered Services as a result of NAP. "Covered Services"means the health services subject to NAP for which charges are paid pursuant to the Plan. "Member"means a person who is eligible for coverage as identified and specified under the terms of the Plan. NAP Addendum Page 26 "Plan"means the portion of Customer's employee welfare benefit plan,which provides medical benefits to Members as administered by Aetna. "Providers"means those physicians,hospitals and other health care providers whose services are available at a savings under NAP. "Reasonable Charge Amount"means the amount determined by Aetna(or its chosen vendor)to be a reasonable charge for a service in the geographic area where the service was provided to the Member. E. Customer Acknowledgements Customer acknowledges that: 1. The NAP listing of Providers includes Providers that are(i)participating by virtue of direct contracts with Aetna and its affiliates,and(ii)participating by virtue of Aetna's contracts with unaffiliated third parties that have contracts with Providers,and provide Aetna with access to these contracted rates for the purpose of NAP. 2. Aetna does not guarantee(a)any particular discounts or any level of discount will be made available through providers listed as participating in NAP;(b)any obligation to make any specific Providers or any particular number of Providers available for use by Plan participants. Aetna does not credential,monitor or oversee those Providers who participate through third party contracts.Providers listed as participating in NAP may not necessarily be available or convenient. 3. Aetna is not responsible for the acts or omissions of any provider listed as participating in NAP. All such providers are providers in private practice,are neither agents nor employees of Aetna,and are solely responsible for the health care services they deliver. 4. The following claim situations may not be eligible for NAP: • Small claims(currently certain claims below$151 and claims below$1000 for which there is no contracted rate). • Claims involving Medicare or coordination of benefits(COB). • Certain claims that have already been paid directly by the Member. • Claims of physicians under non-indemnity plans. F. General Provisions 1. Aetna's aggregate cumulative liability to the Customer for all losses or liabilities arising under or related to NAP, regardless of the form of action,shall be limited to the Access Fees actually paid to Aetna by the Customer for services rendered. 2. The terms and conditions of this Addendum shall remain in effect for any claims incurred prior to the termination date that are administered by Aetna after the termination date. Except as provided herein,this Addendum is subject to all of the provisions of the Services Agreement,provided,however,in the event of any conflict between this Addendum and the Services Agreement,the terms of this Addendum shall govern. NAP Addendum Page 27 APPENDIX A HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT(HIPAA) THIS APPENDIX is an attachment to Services Agreement Number ASA-889000 between Aetna and Customer (as identified therein) in its own capacity and in its capacity as the plan sponsor of its group health plan (the "Plan") is incorporated into the Services Agreement by reference. In conformity with the regulations at 45 C.F.R.Parts 160-164(the"Privacy and Security Rules")Aetna will under the following conditions and provisions have access to,maintain,transmit,create and/or receive certain Protected Health Information: 1. Definitions. The following terms shall have the meaning set forth below: (a) C.F.R. "C.F.R."means the Code of Federal Regulations. (b) Designated Record Set. "Designated Record Set"has the meaning assigned to such term in 45 C.F.R. 164.501. (c) Electronic Protected Health Information. "Electronic Protected Health Information"means information that comes within paragraphs 1(i)and 1(ii)of the definition of"Protected Health Information",as defined in 45 C.F.R. 160.103, (d) Individual. "Individual"shall have the same meaning as the term"individual"in 45 C.F.R. 160.103 and shall include a person who qualifies as personal representative in accordance with 45 C.F.R. 164.502(g). (e) Protected Health Information. "Protected Health Information"shall have the same meaning as the term"Protected Health Information",as defined by 45 C.F.R. 160.103,limited to the information created or received by Aetna from or on behalf of Customer. (f) Required By Law. "Required By Law"shall have the same meaning as the term"required by law"in 45 C.F.R. 164.103. (g) Secretary. "Secretary"shall mean the Secretary of the Department of Health and Human Services or his designee. (h) Security Incident. "Security Incident"has the meaning assigned to such term in 45 C.F.R. 164.304. (i) Standard Transactions. "Standard Transactions"means the electronic health care transactions for which HIPAA standards have been established,as set forth in 45 C.F.R.,Parts 160-162. 2. Oblizations and Activities of Aetna (a) Aetna agrees to not use or disclose Protected Health Information other than as permitted or required by this Appendix or- as Required By Law. (b) Aetna agrees to use appropriate safeguards to prevent use or disclosure of the Protected Health Information other than as provided for by this Appendix. (c) Aetna agrees to mitigate,to the extent practicable,any harmful effect that is known to Aetna of a use or disclosure of Protected Health Information by Aetna in violation of the requirements of this Appendix. (d) Aetna agrees to report to Customer any Security Incident or any use or disclosure of the Protected Health Information not allowed by this Appendix of which it becomes aware. (e) Aetna agrees to ensure that any agent,including a subcontractor,to whom it provides Protected Health Information received from,or created or received by Aetna on behalf of Customer agrees to the same restrictions and conditions that apply through this Appendix to Aetna with respect to such information. (f) Aetna agrees to provide access,at the request of Customer,and in the time and manner designated by Customer,to Protected Health Information in a Designated Record Set,to Customer or,as directed by Customer,to an Individual in order to meet the requirements under 45 C.F.R. 164.524. (g) Aetna agrees to make any amendment(s)to Protected Health Information in a Designated Record Set that the Customer directs or agrees to pursuant to 45 C.F.R. 164.526 at the request of Customer or an Individual,and in the time and manner designated by Customer. (h) Aetna agrees to make(i)internal practices,books,and records,including policies and procedures,relating to the use and disclosure of Protected Health Information received from,or created or received by Aetna on behalf of,Customer,and (ii)policies,procedures,and documentation relating to the safeguarding of Electronic Protected Health Information available to the Secretary, in a time and manner designated by the Secretary,for purposes of the Secretary determining Customer's compliance with the Privacy and Security Rules. (i) Aetna agrees to document such disclosures of Protected Health Information as would be required for Customer to respond to a request by an Individual for an accounting of disclosures of Protected Health Information in accordance with 45 C.F.R. 164.528. (j) Aetna agrees to provide to Customer the information collected in accordance with this section to permit Customer,to respond to a request by an Individual for an accounting of disclosures of Protected Health Information in accordance with 45 C.F.R. 164.528. ASA-HIPAA Page 28 (k) With respect to Electronic Protected Health Information,Aetna shall implement administrative,physical,and technical safeguards that reasonably and appropriately protect the confidentiality,integrity,and availability of the Electronic Protected Health Information that it creates,receives,maintains,or transmits on behalf of Customer,as required by 45 C.F.R Part 164,Subpart C. (1) With respect to Electronic Protected Health Information,Aetna shall ensure that any agent,including a subcontractor,to whom it provides Electronic Protected Health Information,agrees to implement reasonable and appropriate safeguards to protect it. (m) If Aetna conducts any Standard Transactions on behalf of Customer,Aetna shall comply with the applicable requirements of 45 C.F.R Parts 160-162. 3. Permitted Uses and Disclosures by Aetna 3.1 General Use and Disclosure Except as otherwise provided in this Appendix,Aetna may use or disclose Protected Health Information to perform its obligations under the Agreement,provided that such use or disclosure would not violate the Privacy and Security Rules if done by Customer or the minimum necessary policies and procedures of Customer. 3.2 Specific Use and Disclosure Provisions (a) Except as otherwise provided in this Appendix,Aetna may use Protected Health Information for the proper management and administration of Aetna or to carry out the legal responsibilities of Aetna. (b) Except as otherwise provided in this Appendix,Aetna may disclose Protected Health Information for the proper management and administration of Aetna,provided that disclosures are Required by Law,or Aetna obtains reasonable assurances from the person to whom the information is disclosed that it will remain confidential and used or further disclosed only as Required by Law or for the purpose for which it was disclosed to the person,and the person notifies Aetna of any instances of which it is aware in which the confidentiality of the information has been breached. (c) Except as otherwise provided in this Appendix,Aetna may use Protected Health Information to provide data aggregation services to Customer as permitted by 45 C.F.R 164.504(e)(2)(i)(B). (d) Aetna may use Protected Health Information to report violations of law to appropriate Federal and State authorities, consistent with 45 C.F.R 164.5020)(1). 4. Obligations of Customer 4.1 Provisions for Customer to Inform Aetna of Privacy Practices and Restrictions (a) Customer shall notify Aetna of any limitation(s)in its notice of privacy practices of Customer in accordance with 45 C.F.R § 164.520,to the extent that such limitation(s)may affect Aetna's use or disclosure of Protected Health Information. (b) Customer shall provide Aetna with any changes in,or revocation of,permission by Individual to use or disclose Protected Health Information,to the extent that such changes affect Aetna's use or disclosure of Protected Health Information. (c) Customer agrees that it will not furnish or impose by arrangements with third parties or other Covered Entities or Business Associates special limits or restrictions to the uses and disclosures of its PHI that may impact in any manner the use and disclosure of PHI by Aetna under the Services Agreement and this Appendix,including,but not limited to,restrictions on the use and/or disclosure of PHI as provided for in 45 C.F.R. 164.522. 4.2 Permissible Requests by Customer Customer shall not request Aetna to use or disclose Protected Health Information in any manner that would not be permissible under the Privacy and Security Rules if done by Customer. ASA-HIPAA Page 29 5. Term and Termination (a) Term.The provisions of this Appendix shall take effect(i)with respect to 45 C.F.R.Part 164,Subpart E(the"Privacy Rule"),on the effective date of the Agreement,and(ii)with respect to 45 C.F.R. 164, Subpart C(the"Security Rule"), the later of(1)April 21,2005 or the compliance date applicable to the Customer under the Security Rule,if different than April 21,2005,and(2)the effective date of the Agreement,and shall terminate when protections are extended to Protected Health Information,in accordance with Section 5(c)of this Appendix. (b) Termination for Cause. Without limiting the termination rights of the parties pursuant to the Agreement and upon Customer's knowledge of a material breach by Aetna,Customer shall either: (i) provide an opportunity for Aetna to cure the breach or end the violation or terminate the Agreement, if Aetna does not cure the breach or end the violation within the time specified by Customer; (ii) immediately terminate the Agreement,if cure of such breach is not possible; (iii) if neither termination nor cure are feasible,Customer shall report the violation to the Secretary. (c) Effect of Termination. The parties mutually agree that it is essential for Protected Health Information to be maintained after the expiration of the Services Agreement for regulatory and other business reasons.The parties further agree that it would be infeasible for Customer to maintain such records because Customer lacks the necessary system and expertise. Accordingly,Customer hereby appoints Aetna as its custodian for the safe keeping of any record-containing PHI that Aetna may determine it is appropriate to retain.Notwithstanding the expiration of the Services Agreement,Aetna shall extend the protections of this Appendix to such Protected Health Information,and limit further use or disclosure of the Protected Health Information to those purposes that make the return or destruction of the Protected Health Information infeasible. 6. Miscellaneous (a) Regulatory References. A reference in this Appendix to a section in the Privacy and Security Rules means the section as in effect or as amended,and for which compliance is required. (b) Amendment. Upon the enactment of any law or regulation affecting the use or disclosure of Protected Health Information,the safeguarding of Electronic Protected Health Information,or the publication of any decision of a court of the United States or any state relating to any such law or the publication of any interpretive policy or opinion of any governmental agency charged with the enforcement of any such law or regulation,either party may,by written notice to the other party,amend the Agreement and this Appendix in such manner as such party determines necessary to comply with such law or regulation. If the other party disagrees with such amendment, it shall so notify the first party in writing within thirty(30)days of the notice.If the parties are unable to agree on an amendment within thirty(30)days thereafter, then either of the parties may terminate the Agreement on thirty(30)days written notice to the other party. (c) Survival. The respective rights and obligations of Aetna under sections 5(c)and 6 of this Appendix shall survive the termination of this Appendix. (d) Interpretation. Any ambiguity in this Appendix shall be resolved in favor of a meaning that permits Customer to comply with the Privacy and Security Rules. (e) No third party beneficiary. Nothing express or implied in this Appendix or in the Agreement is intended to confer,nor shall anything herein confer,upon any person other than the parties and the respective successors or assigns of the parties,any rights,remedies,obligations,or liabilities whatsoever. (f) Governing Law. This Appendix shall be governed by and construed in accordance with the same internal laws as that of the Agreement. The parties hereto have executed this Appendix with the execution of the Agreement. ASA-HIPAA Page 30 No. 889000 Appendix I Plan of Benefits describing benefits payable in connection with Administrative Services Agreement No.ASA-889000 An Agreement between Aetna Life Insurance Company and City of Fort Worth ASA Page 31 207754 Index Section I Appendix Contents Section II Eligibility ASA Page 32 209342 Section I Appendix Contents This Appendix consists of the following only: The provisions of the Appendix Face Page,the Index,and the following Sections I and H;and The provisions found in the document(s)listed in this Section I. As used in this Appendix: The words"you"and"your"in any document included in the Appendix,will mean a covered Employee. The word"Employer"(initially capitalized)as used in this Appendix means the Customer or any other Employer included in this Agreement. A"Document"consists of: The Summary Plan Description("SPD")which describes the Plan's benefit provisions,administrators,claim procedures and the participant's rights under ERISA. Any Amendment("Amend.")issued to support or amend the Summary Plan Description. The Document(s)included in this Appendix are as follows: Identification Issue Date Effective Date Eligible Group and/or Type of Coverage Aetna Choice October 1,2007 January 1,2005 Active Employees-Aetna Choice POS 11(Basic Plan, Basic Plus Plan, Select Plan) Aetna Traditional October 1,2007 January 1,2005 Retirees-Traditional Choice Plan ASA Page 33 207755 Section H Eligibility Eligible Classes All classes of employees of an Employer are eligible except those who are: Part-time; Temporary; Substitute;or In a class for which a document is not listed in Section I of this Appendix. An employee is eligible only for the coverages shown in the Summary Plan Description("SPD")applicable to his class. If an Employer is a partnership or proprietorship,each of its natural-person partners,or the proprietor,will be deemed to be an employee. This applies only if the person is actively engaged in and giving his time on a mostly full-time basis to the conduct of the Employer's business. ASA Page 34 207756 Appendix II Performance Guarantees - Medical In total,Aetna will place 15% of the annualized administrative service fee at risk through Performance Guarantees. The annualized administrative service fee will be calculated at the beginning of each of the three contract periods and will be based on the total number of employees actually enrolled in the Medical plans on January 1 of the first,second and third contract year. This guarantee does not apply to non-Aetna benefits or networks. The guarantees described herein will be effective for a period of 12 months and will run from January 1,2005 to December 31, 2005 (hereinafter"guarantee period"). The performance guarantees shown below will apply to the self-funded Choice POS 11 and Indemnity Medical plans administered under the Administrative Services Only Agreement("Services Agreement").These guarantees do not apply to non-Aetna benefits or networks(e.g.,passive networks,customer specific networks,and/or the Rural PPO network). Summary of Performance Standards and Penalties Performance Category 7Minimum Standard Proposed Penalty Implementation n Implementation Average evaluation score 2.0% of 3.0 or higher n ID Card Production&Distribution ID cards mailed within 15 1.0% business days of receiving eligibility file Account Management Overall Account Management Average evaluation score 2.0% of 3.0 or higher Claim Administration n Turnaround Time 80.0%of claims processed 2.0% within 12 calendar days n Financial Accuracy 99.0% 2.0% n Payment Incidence Accuracy 96.0% 1.5% Total Claim Accuracy 90.0% 1.5% Telephone Response Time Telephone Service Factor 75.0%within 30 seconds 3.0% Total 15.0% ASA-Appendix II Page 35 Appendix II-A Discount Guarantees Medical Aetna has placed 10%of the gross fees at risk with a Choice POS H Discount Guarantee. In Year 1 (January 1,2005 to December 31,2005),Aetna will guarantee the savings that result from negotiated arrangements with providers participating in our Choice POS II. These savings will be calculated on an aggregate basis,taking the weighted average of the network discounts based upon the actual enrollment by network. Rebate Guarantee Aetna has agreed to guarantee a specified level of the manufacturer volume discounts it receives based on actual utilization of formulary drugs under contract(see separate Rebate Guarantee Document). Depending on City of Fort Worth members' utilization,the rebates retained by Aetna under the proposed Rebate Guarantee may exceed the standard rebate share percentage. Medical Management Guarantee Aetna has placed fees at risk on the following medical management: Performance Category Minimum Standard Proposed Penalty Care Management n Compliance/Clinical Execution 90%of cases targeted for discharge $0.25 PEPM Discharge Planning planning will have activity documented,as evidenced by e- TUMS discharge notes documented in that episode of care. n Compliance/Clinical Execution 90%of cases accepted for CM will $0.25 PEPM Case Management have a documented case management plan within that case management event. n Touch Rates 90%of all Aetna Book of Business $0.25 PEPM members with PULSE scores of 13+ and 1 flag and will be screened for Case Management n Integration 95%of all Aetna Book of Business $0.25 PEPM members with hospital claims greater than or equal to 75K will have one PM intervention ASA-Appendix II-A Page 36 Appendix II-B RX RebateGuarantees Rebate Guarantee: During the January 1,2005 through December 31,2005 policy period,Aetna guarantees to City of Fort Worth a return of$1.77 per retail script and$5.88 per MOD script subject to the terms and conditions of this document. The mature rebate payable to City of Fort Worth for purposes of this guarantee will be realized no later than 16 months following the end of the guarantee period. A rebatable script is defined as any formulary prescription transaction that results in a rebate return being produced by Aetna's contracted pharmaceutical manufacturers. Conditions of Guarantees: The following conditions apply to these guarantees: This guarantee only applies to the managed pharmacy claims dispensed during the guarantee period and will remain in force during the January 1,2005 through December 31,2005 policy period. • Aetna reserves the right to make appropriate changes to this guarantee if there are any changes to the current or proposed benefit plans and plan design(Aetna has assumed a triple copay plan design),if there are significant changes in the population(i.e.geographic,demographic,or eligible mix),if there exists movement of a significant drug from a brand to a generic status,or if there is a change in government laws or regulations which have a significant impact on pharmacy claim costs. • A total of 7,166 employees are expected to be enrolled in the APM product. A change of greater than 10%of this enrollment may allow Aetna to revisit the structure or conditions of this guarantee,or revoke this guarantee. • Valid scripts(excludes rejects/denials)of 25.4 per employee per year are projected for the guarantee period. Should actual scripts be+/- 15%from this assumption,this guarantee may be revised or adjusted. • Aetna reserves the right to terminate this guarantee prior to the end of any policy period for which it is offered if(a)there is any legal,legislative or regulatory action that materially affects or could affect the manner in which Aetna conducts its rebate program,(b)any material manufacturer volume discount contracts with Aetna are terminated or modified in whole or in part, (c)the rebates actually received under any material manufacturer volume discount contract is less than the level of rebates assumed in the contracts by Aetna for the applicable policy period • If(a)City of Fort Worth terminates the Agreement prior to the date the APM rebate check is issued,or(b)the Agreement is terminated by Aetna for City of Fort Worth's failure to meet its obligations to fund benefits or pay medical or pharmacy administrative fees under the Agreement,Aetna will be entitled to deduct deferred administrative fees or other plan expenses due to the termination date from any rebate check due City of Fort Worth following the termination date. • Validation of this guarantee will be on or after we have collected 90 percent of rebates for the policy period,expected within 16 months following the end of the guarantee period. This is necessary due to the time lag in the drug manufacturers' invoicing process. • The script count used to validate this guarantee will be reported using pharmacy data from Aetna's Integrated Informatics database. Scripts will exclude rejected claims or reversals/denied claims. • If there is any legal action,law or regulation which prohibits or could prohibit the continuance of the Rebate Program or an existing law is interpreted to prohibit the program,the program and guarantee shall terminate automatically as to the state or jurisdiction of such law or regulation on the effective date of such law,regulation or interpretation. ASA-Appendix II-B Page 37 Appendix H-C Medical ManagementGuarantees Patient Safety MedQuery Aetna is willing to place the current MedQuery fee($1.00 PEPM)at risk. There is no payout should the reported savings equal$1.00 PEPM. Should the savings be less than$1.00 PEPM,the penalty will be$1.00 PEPM less the achieved savings. Standard reports(which will include a savings calculation)will be provided on a regular basis. This guarantee will be reconciled once every year,assumes a minimum enrollment of 7,000 employee lives,and assumes Aetna will have access to pharmacy data for employees enrolled in our medical programs. For example,assuming a population of 7,000 employees,the annual cost of the program would be$84,000($1.00 x7,000 x12). If actual savings in the fast year is$60,000,Aetna will return$24,000($84,000-$60,000)in administrative fees. ASA-Appendix II-C Page 39 City of Fort worth Health Benefit Plan Summary Plan Description Aetna Group Number: 889000 Aetna Choice POS II Plan — Basic Plan - - Basic Plus Plan - - Select Plan — Effective: January 1, 2005 Restated: October 1, 2007 Table of Contents Introduction....................................................................................................................... 1 Your Health Care Coverage............................................................................................2 Benefits Assistance and Resources.................................................................................. 3 Eligibility............................................................................................................................ 5 ActiveEmployees........................................................................................................... 5 Dependents of Active Employees................................................................................... 5 Retirees and Vested Employees............................................. Dependents of Retirees and Vested Employees.............................................................. 9 Enrollment....................................................................................................................... 11 Important Plan Terms.................................................................................................... 13 Howthe Plan Works....................................................................................................... 15 In-Network and Out-of-Network Benefits.................................................................... 15 Finding Network Providers........................................................................................... 16 Pre-certification............................................................................................................... 18 Summaryof Benefits ....................................................................................................20 BasicPlan......................................................................................................................21 BasicPlan......................................................................................................................21 BasicPlan......................................................................................................................23 BasicPlus Option..........................................................................................................24 SelectOption.................................................................................................................27 SelectOption.................................................................................................................28 SelectOption.................................................................................................................29 What the Medical Plan Covers......................................................................................30 PreventiveCare............................................................................................................. 30 HospitalServices .......................................................................................................... 31 EmergencyCare............................................................................................................ 32 Skilled Nursing/Convalescent Care............................................................................ 32 HomeHealth Care......................................................................................................... 33 HospiceCare................................................................................................................. 34 Short-Term Rehabilitation............................................................................................ 35 Chiropractic Care (Spinal Manipulation)...................................................................... 36 FamilyPlanning............................................................................................................ 36 Mental Health and Substance Abuse Treatment........................................................... 37 OralSurgery.................................................................................................................. 38 Durable Medical Equipment.........................................................................................38 Diabetic Equipment, Supplies and Education............................................................... 39 OtherCovered Expenses............................................................................................... 39 Prescription Drug Benefits.............................................................................................40 RetailPharmacy............................................................................................................40 Mail Order Prescriptions...............................................................................................40 What the Prescription Drug Program Covers ...............................................................41 What the Prescription Drug Program Does Not Cover.................................................41 Women's Health Provisions...........................................................................................42 The Newborns' and Mothers' Health Protection Act...................................................42 The Women's Health and Cancer Rights Act...............................................................42 i SpecialPrograms ........................................ ...............................................................43 The National Medical Excellence Program®(NME).................................................... InformedHealth®Line..................................................................................................45 What the Medical Plan Does Not Cover.......................................................................46 Coordination With Other Plans ....................................................................................50 Claimsand Benefit Payment.......................................................................................... 53 FilingClaims.................................................................................................................53 When You Disagree With a Claim Decision................................................................55 WhenCoverage Ends .....................................................................................................61 ForEmployees..............................................................................................................61 ForDependents.............................................................................................................61 Continuing Coverage under COBRA...........................................................................62 Continuing Coverage During an FMLA Leave............................................................64 Your Privacy Under HIPAA..........................................................................................66 OtherPlan Provisions..................................................................................................... 67 Typeof Coverage..........................................................................................................67 Multiple Employers and Misstatement of Fact.............................................................67 Glossary...........................................................................................................................68 ii Introduction The medical plan described in this booklet is an important employee benefit designed to help keep good health care affordable for you and your family. It provides benefits for preventive care and access to special programs that focus on helping you stay healthy, plus the coverage you need when an illness or injury strikes. This Benefits Summary describes your benefits as well as your rights and responsibilities when accessing care through the City of Fort Worth Health Benefit Plan. To take full advantage of all that your plan offers, it's important to know how the plan works—and how to make it work for you. Reading this booklet is a great place to start. In This Booklet This Summary Plan Description describes the City of Fort Worth Aetna Choice POS II Medical Plan options effective January 1, 2005. It describes the main features of the plan—who is eligible for coverage, what is covered and not covered, what to do when you need care, how the plan pays benefits, and when coverage ends. To understand what certain important words in bold type mean, turn to the Glossary at the back of the booklet. The words "we," "us,"and "our" in this document refer to the City of Fort Worth. The words "you" and "your' refer to people who are covered persons as defined in the Eligibility section of this booklet. The term Plan Administrator refers to the City of Fort Worth. Your Contribution to the Benefit Costs The Plan may require you to contribute to the cost of coverage. A copy of the active employee rates is available on the City of Fort Worth's intranet site and/or in the Benefits Division of the Human Resources office. Contact your City of Fort Worth Benefits Representative for information about any part of this cost you may be responsible for paying. Important Notices The plan described in this booklet is administered by Aetna Life Insurance Company of Hartford, Connecticut(referred to as "Aetna"). The benefits are effective only while you are covered under the plan. This summary contains information about the Basic, Basic Plus and Select Plans. Ifyou have coverage under the Traditional Plan,you should read the appropriate Summary Plan Description for that plan. 1 Your Health Care Coverage The plan covers medically necessary health care expenses as well as certain preventive care expenses that are incurred while your coverage is in effect. An expense is incurred on the day you receive a health care service or supply. The plan does not pay benefits for expenses incurred before your coverage starts or after it ends, even if the expenses were incurred because of an accident, injury or disease that occurred, began or existed while your coverage was in effect. When a single charge is made for a series of services, each service will be assigned a pro rata(evenly divided) share of the expense. Aetna will determine the pro rata share. Only the pro rata share of the expense will be considered as incurred on the date of the health care service. Outcome of Covered Services and Supplies Aetna is not responsible for and makes no guarantees concerning the outcome of the covered services and supplies you receive. 2 Benefits Assistance and Resources When you need help, answers or information,here are some resources available to you. Tele one Web Site �#etna 1VfemberfSenrices j g Claim stetus, c©vexed ser�,l�ce"s and;bene t 0,66,Is,`pet�%OM Previdersq emplacement JD carrols;:`access tes eciel rams • Active Employees 888-398-4467 • Retirees 888-397-4537 Aetna Navigator at • COBRA 800-429-9526 www.aetna.com • Aetna On-site Representative 817-392-7780 City of Fort WocW HR/Ernployee benefits Adtlress i3nd.farriil stattis`can es' City of Fort Worth Benefits Office Lower Level 817-392-8577 Intranet site 1000 Throckmorton Street www.cfwnet.org/benefits/ Fort Worth, TX 76102 Aetna Maims Submission Address Aetna P.O. Box 14586 Lexington, KY 40512-4586 ID Cards When you enroll in the plan,you receive an ID card. If you cover your spouse,you will receive an additional card for your spouse. The ID card shows: • The name and identification number of each covered family member • The Aetna Member Services telephone number and address • Information about the plan's pre-certification requirement, including the telephone number to call(complete information about prior notification can be found in the Pre-certification section of this booklet) • The telephone number for the Behavioral Health Coordinator who must coordinate any treatment for alcoholism,drug abuse or a mental disorder - NAP FORTWorli Aee CITY C7 rMI WAIN CHOICETM POS II �--���-') wrrrwwnic u--om���xn V ID mt74f 73l54 �s�tt.'s,a,swra a,ux c2 � Front of ID Card vt >_F;,I TEaT Fir`: 12 LLC:TIC6 ,E1313.E t£'IS r£SJ;CE� .EL5 3PL.ii6 ,:n 5 22 C.i: �4�FLFGEi re75,'. 971! 3 wwea� aetaa.CPa Mental healtV substoace abuse coverage: precertification or quections call 1-800-424.4047. PCP cepay applies to your selected PCP, the specialist cooppa.�� applies to all other participating physicians, REFER114LS,ARE NOT REOUIRED. For services that require precertificotion, call the number on the fromt of this card. In an emerges ej, call the local �r�---��/) hotline (e: 911) or go to the nearest eaergemcy facility. V Notify coverage is i &force, promptly after tled to p. n bes Back of ID Card subjctis in force, members are entitled to plan benefits. subject to exclusions and limitations. For eligibilitrr,benefit information, call meaber services. Participating doctors mad hospitals are independent Providers and are neither agents nor emploiees of Aetna. Ion underwritten or administered by Aetna Life Insurance Co. This card does not guarantee coverage. AETNA P.O. BU€ 14566 LUJINTON KY 4051Z-4586 Aetna NavigatorTm Aetna Navigator is Aetna's self-service website that you can visit for health and benefits information, self-service features, interactive tools and more. After a simple registration process,you can use Aetna Navigator to verify eligibility information, check benefits and claim status, and as your gateway to: • DocFindo, Aetna's online provider directory that gives you the most recent information on Aetna's network doctors, hospitals and other providers. You can learn about each provider's credentials and practice, including education,board certification,languages spoken, office location and hours, and parking and handicapped access. In DocFind, choose"Aetna Choice POS II" from the list of Aetna Open Access plans to find network providers in your area. • Intelihealth®,Aetna's health website that you can search for topics from specific health conditions and their treatment to developments in disease prevention,wellness and fitness. • Healthwise Knowledgebase, an innovative decision-support tool that provides information on thousands of health-related topics to help you make better decisions about health care and treatment options. • Health History Report,an easy-to-understand,printable summary of doctor visits, tests, treatments and other health-related activity. Visit Aetna Navigator at www.aetna.com. 4 Eligibility These are eligibility rules for active employees and their spouses and dependents who have permanent residency within the United States for participation in the City's group health benefits program. These rules may be amended from time to time. Please contact the Human Resources Department for the latest revision of this information. Active Employees 1. Employees must be permanent employees occupying positions budgeted for at least half-time (0.5 A.P. —20 hours) or working in a full-time position (1.0 A.P.) at least 20 hours per week on a regular basis or otherwise as authorized by the City. 2. In order to continue eligibility, employees must remain current with the biweekly contribution required to effect the employee's choice of coverage. Failure to do so will result in loss of coverage for the employee and his/her dependents. 3. An employee's and his eligible dependent's coverage becomes effective on the first day of the month coincident with or immediately following one (1) month of continuous service and will remain in effect after termination of employment through the end of the month for which payment is made for health coverage. 4. Employees who choose not to participate in the City's group health program may waive participation. The employee will be required to sign a waiver of coverage to do so and will not be allowed to enroll in the City's program until the next open enrollment period unless there is a qualifying change in status. Such enrollment will be subject to any conditions then in effect for new employees. 5. If an employee waives coverage and re-enrolls at any future point, he/she and his/her eligible dependents will be subject to any eligibility requirements then in effect. 6. The value of any benefits or services provided by the City's plan(s) will be coordinated with any group plan or coverage under governmental programs, including Medicare, to assure that the covered person receives coverage while avoiding double recovery. 7. Services and benefits for military service-connected disabilities for which the covered person is legally entitled and for which facilities are reasonably available, shall in all cases be provided before the benefits of the City's plan(s). Dependents of Active Employees 1. To be eligible to enroll as a dependent, a person must be: a. the spouse of an enrolled employee, or 5 b. dependent of an enrolled employee who is an unmarried natural child, foster child, stepchild, legally adopted child or child under the employee's legal guardianship or custodianship, residing with the employee or with the employee's present or former spouse who is: (i) under nineteen (19) years of age; or (ii) under twenty-three (23) years of age, primarily dependent on the employee for financial support and attending an accredited college, university, trade or secondary school on a full-time basis,which has, in writing, verified the attendance, or c. a dependent of an enrolled employee who is an unmarried natural child, foster child, stepchild, legally adopted child or child under the employee's legal guardianship or custodianship, residing with the employee or the employee's present or former spouse, who is nineteen (19) years of age or older but incapable of self-sustaining employment because of mental retardation or physical handicap that commenced prior to age nineteen (19) (or commenced prior to age twenty- three (23) if the child was attending a recognized college or university, trade or secondary school on a full-time basis when such incapacity occurred) and primarily dependent on the employee for support and maintenance. Such dependent child must have been enrolled under the City's benefit plan either prior to attaining nineteen(19) years of age or twenty-three (23) years of age under the conditions of the previous sentence. The employee must give the City proof of the incapacity and dependency within thirty-one (31) days before the dependent child's attainment of the limiting age and from time to time thereafter as the City deems appropriate. d. a child of an enrolled employee's unmarried dependent child provided that(1) the child is under age twenty-five (25), (2) the employee provides more than one-half the child's support, (3)the child is considered to be the employee's dependent for federal income tax purposes, (4)the child is the grandchild of the employee and (5) the child resides in the employee's home. If the child is eligible for coverage by the employee, the coverage will be available as already described provided appropriate notices and contribution payments have been timely. e. a surviving unmarried spouse of a peace office or fire fighter who has died in the course of the individual's duty performed in the individual's position as the result of exposure to a risk that is inherent in the duty or to which the general public is not customarily exposed until the date the surviving spouse remarries or the date the surviving spouse becomes eligible for group health coverage through another employer or the date the surviving spouse becomes eligible for federal Medicare benefits, whichever occurs first(Section 615.074 or the Texas Government Code), or f. a surviving dependent who is a minor child of a peace officer or fire fighter who has died in the course of the individual's duty performed in the individual's position as a result of exposure to a risk that is inherent in the duty or to which the 6 general public is not customarily exposed until the date the child reaches the age of 18 years or the date the child becomes eligible for group health coverage through another employer, whichever first occurs (Section 615.074 of the Texas Government Code), or g. a surviving dependent who is not a minor child of a peace officer or fire fighter who has died in the course of the individual's duty performed in the individual's position as a result of exposure to a risk that is inherent in the duty or to which the general public is not customarily exposed until the date the dependent marries or the date the dependent becomes eligible for group health coverage through another employer, whichever first occurs (Section 615.074 of the Texas Government Code), or 2. Coverage takes effect for dependents as follows: a. no dependent can be covered before the date the member becomes covered. b. a newly acquired dependent other than a newborn child shall be covered as of the first day on which the dependent meets all applicable eligibility requirements, provided that any dependent confined at home or confined in a hospital or confined in any other medical institution on the day that person would otherwise become covered will become covered on the first day such dependent is not confined. c. member's eligible spouse and/or other dependents who lose coverage due to the spouse's or former spouse's loss of coverage due to loss of employment or reduction in hours or employer or carrier discontinuation of group medical coverage will be allowed to enroll in the City's plan within thirty-one (31) days of such loss of coverage only if the member has current coverage on him/herself and subject to the following condition: (i) proof of loss of employment and/or coverage must be verified (ii) the spouse and/or other dependents eligible for participation in the City's plan must have been enrolled through the spouse's or former spouse's group plan at the time of loss of coverage. d. newborn children of a member, a member's spouse, and/or the member's unmarried dependent shall be covered for an initial period of thirty-one(31) days from the date of birth and shall continue to be so covered after that time only if, prior to the expiration of such thirty-one (31) day period, member notifies the Human Resources Department with an application submitted for such newborn child. e. a newly adopted child, including a newborn, shall be covered as if the child were a newly acquired eligible dependent. The thirty-one (31) day period for submission of an application shall commence on the earlier of the date upon which such child commences residence with the member or when the adoption 7 becomes legal, and coverage shall begin on the earlier date provided the application is submitted on a timely basis. Retirees and Vested Employees 1. Persons who have retired as either regular, disability or early retirees and are receiving pension disbursements from the City of Fort Worth Retirement System (Retirement) are eligible to participate in the City-sponsored group health care plan provided the retiree made an election for retiree coverage within 60 days of his/her retirement. If a retired person fails to enroll himself/herself and his/her then eligible dependents within sixty (60) days of his/her loss of coverage as an active employee, he/she and his/her eligible dependents will not be eligible to enroll in the City's plan at any future time. Persons hired on or after October 5, 1988 will be required to contribute towards the cost of their group health benefit at a cost established by the City of Fort Worth. Persons whose active employment began prior to October 5, 1988 will have afforded to them at least one group health care plan option which requires no cost participation for their own basic coverage. The retiree may be required to make contributions to obtain benefits above the basic coverage at amounts set by the City Council or to cover any dependents. 2. Persons who resign after five (5)years of credited service in Retirement and who remain vested in the City's pension program but who have not yet begun to receive distributions are eligible to participate in the City-sponsored group health care plan. Persons vested in Retirement who have not yet begun taking distribution of pension benefits must pay 100% of the cost of their coverage and that of their eligible dependents at the premium equivalent for active employees until the vested employee is eligible to receive a pension distribution, at which time the cost of participation is as described under 1. above. If a vested person fails to enroll himself/herself and his/her then-eligible dependents within sixty (60) days of his/her loss of coverage as an active employee, he/she and his/her eligible dependents will not be eligible to enroll in the City's plan at any time in the future. 3. Medicare will be the primary payer for benefits for covered retirees and/or their covered spouses and/or other covered dependents who are eligible for Medicare Part A. Benefits for all Medicare-eligible covered retirees and their Medicare-eligible covered dependents, regardless of the date of coverage under Medicare, will be paid as if the enrollee subscribes to both Part A and Part B of Medicare. 8 NOTE: A covered retiree's election not to enroll in Part B of Medicare has the potential to expose the covered retiree to significant expense at the time of claim. The same is true of the covered Medicare-eligible dependents of the retiree. Dependents of Retirees and Vested Employees 1. To be eligible to enroll as a dependent, a person must be: a. either the spouse of a covered retired or vested employee, or b. the surviving spouse of a covered retired or vested employee at the time of the employee's retirement or at the time of the employee's election of coverage as a vested employee. c. a dependent unmarried natural child, foster child, stepchild, legally adopted child or child under the covered retired or vested employee's legal guardianship or custodianship, residing with the covered retired or vested employee or with the covered retired or vested employee's present or former spouse who is: • under nineteen (19) years of age, or • under twenty-three (23)years of age, primarily dependent on the covered retired or vested employee for financial support and attending an accredited college, university, trade, or secondary school on a full time basis, which has, in writing, verified said attendance, or d. a dependent unmarried natural child, foster child, stepchild, legally adopted child or child under the covered retired or vested employee's legal guardianship or custodianship, residing with the covered retired or vested employee or with the covered retired or vested employee's present or former spouse,who is nineteen (19) years of age or older but incapable of self-sustaining employment because of mental retardation or physical handicap commenced prior to age nineteen (19) (or commenced prior to age twenty-three (23) if such child was attending a recognized college or university, trade or secondary school on a full-time basis when such incapacity occurred) and primarily dependent upon the Enrollee for support and maintenance. Such dependent child must have been enrolled under the City's benefit plan either prior to attaining nineteen (19) years of age or twenty-three (23)years of age under the conditions of the previous sentence. The covered retired or vested employee shall give the City proof of such incapacity and dependency within thirty-one (31) days before the dependent child's attainment of the limiting age and from time to time thereafter as the City deems appropriate, or e. the dependents of an active, retired, or vested employee who are entitled to receive survivor pension benefits through the City of Fort Worth and who were enrolled as dependents on the covered active, vested, or retired employee's plan at the time of the 9 employee's death provided they enroll within sixty(60) days of the death of the covered active, retired, or vested employee, or f. dependents who became covered after the date the retired or vested employee became covered as an active employee but prior to the date of the Member's retirement provided they are enrolled on or before the covered retired or vested employee's date of retirement except certain newborn children, or g. a newborn child of a covered retired or vested employee, or a spouse of a covered retired or vested employee, and/or of a covered retiree's covered unmarried dependent child that results from a pregnancy that existed at the time of the covered retired or vested employee's date of retirement shall be covered for an initial period of thirty-one (31) days from the date of birth, and shall continue to be so covered after that time only if, prior to the expiration of such thirty-one (31) day period,the covered retired or vested employee notifies the Human Resources Department with an application submitted for such newborn child. Newborn children of a covered retired or vested employee, of a covered retired or vested employee's spouse, and/or of the retiree's covered unmarried dependent from a pregnancy that occurs after retirement, shall be covered for a period of thirty-one (3 1) days from the date of birth only. Retired employees are required to make a contribution for the cost of their dependent's coverage as set forth by the City Council and as may be amended from time to time. Survivors are required to make contribution for the cost of their coverage as set forth by the City Council and as may be amended from time to time. Method of Payment Retirees who participate in the cost of their own health coverage and who pay for eligible dependent coverage authorize deductions for the required participation through deductions from their monthly pension checks. Retirees whose monthly pension checks are insufficient to pay the premium must arrange a payment plan with the Human Resources Department to make supplemental payments to maintain the desired coverage. Arrangements are to be made for monthly payments in advance. In cases of extreme hardship, supplemental payment monthly in advance may be granted. If a retired employee falls into arrears in required contributions, he/she will be notified and will be allowed to correct the arrearage. If the arrearage continues 45 days after notification, coverage for all dependents will be terminated and the retiree's health benefits reduced to the "no cost participation required" level of benefits if the retiree is eligible for such a plan or terminated if any payment by the retiree is required to keep coverage in effect. 10 Enrollment When to Enroll Who Can Enroll Begin Date Initial Enrollment Period Eligible persons may enroll Coverage begins on the date themselves and their dependents. identified by the Plan The Initial Enrollment Period is Administrator, if the Plan the first period of time when Administrator receives the eligible persons can enroll. completed enrollment form and any required contribution through payroll deduction for coverage within 31 days of the date the eligible person becomes eligible to enroll. Open Enrollment Period Eligible persons may enroll The Plan Administrator determines themselves and their dependents. the Open Enrollment Period. Coverage begins on the date identified by the Plan Administrator if the Plan Administrator receives the completed enrollment form and any required contribution within 31 days of the date the eligible person becomes eligible to enroll. New Eligible Persons New eligible persons may enroll Coverage begins on the first day themselves and their dependents. of the month coincident with or immediately following one(1) calendar month of continuous service if the Plan Administrator receives the properly completed enrollment form and any required contribution for coverage within 31 days of the date the new eligible person becomes eligible to enroll and if the participant pays any required contribution to the Plan Administrator for coverage. Adding New Dependents Participants may enroll Coverage begins on the date of dependents who join their family the event if the Plan Administrator because of any of the following received the completed enrollment events: form and any required contribution for coverage within 31 days of the • Birth event that makes the new • Legal adoption dependent eligible. • Placement for adoption • Marriage • Legal guardianship • Court or administrative order 11 When to Enroll Who Can Enroll Begin Date Special Enrollment Period A special enrollment period Event Takes Place (for example, applies to an eligible person and a birth or marriage). Coverage An eligible person and/or any dependents when one of the begins on the date of the event if dependent may also be able to following events occurs: the Plan Administrator receives enroll during a special the completed enrollment form and enrollment period. A special • Birth any required contribution within 31 Enrollment period is not • Legal adoption days of the event. available to an eligible person . Placement for adoption and his or her dependents if . Marriage Missed Initial Enrollment Period coverage under the prior plan or Open Enrollment Period. was terminated for cause or A special enrollment period Coverage begins on the day because premiums were not applies for an eligible person immediately following the day paid on a timely basis. and/or dependent who did not coverage under the prior plan enroll during the initial enrollment ends if the Plan Administrator period or open enrollment period if receives the completed enrollment the following are true: form and any required contribution within 31 days of the date • The eligible person and/or coverage under the prior plan dependent had existing health ended. coverage under another plan at the time they had an opportunity to enroll during the initial enrollment period or open enrollment period; and • Coverage under the prior plan ended because of any of the following: — Loss of eligibility(including, without limitation, legal separation, divorce or death. — The employer stopped paying the contributions. — In the case of COBRA continuation coverage, the coverage ended. 12 Important Plan Terms You share in the cost of your care by making payroll contributions and paying deductibles, co-payments and coinsurance. These terms are explained below and specific amounts and coinsurance percentages are shown in the Summary of Benefits chart for the medical option you elected. The Summary of Benefits can be found later in this booklet. Calendar Year Deductible: The calendar year deductible is the part of covered expenses you pay each year before the plan starts to pay benefits. Expenses for both in-network and out-of-network care are applied to the appropriate deductible during the year. Once you meet the individual deductible, the plan starts to pay benefits. Each January 1, you start over with a new deductible. -------------------------------------------------------------------------------------------------------------------- Note: Lots of services on our plan do not require you to meet a deductible = Refer to the Schedule of Benefits for the plan in which you are enrolled. -------------------------------------------------------------------------------------------------------------------- Family Deductible: Once the sum of covered expenses applied toward the individual deductibles for you and any covered dependents reaches the family limit, you and your dependents will all be considered to have met your separate individual deductible limits for the rest of the year. Coinsurance: Once you meet the plan year deductible,the plan pays part of your covered expense and you pay the rest. The part you pay is called coinsurance. Coinsurance Limit: The plan puts a limit on the dollar amount you pay for covered expenses out of your own pocket—called the out-of-pocket maximum. A separate out- of-pocket maximum applies for in-network and out-of-network expenses. Once your share of covered expenses (excluding the deductible) reaches the individual out-of-pocket maximum,the plan pays 100%of covered expenses for the rest of the plan year, except for co-pays. Each January 1, you start over with a new out-of-pocket maximum. -------------------------------------------------------------------------------------------------------------------- Important: Co-pays, pre-certification penalty amounts and any expenses reimbursed at 50% do not apply toward the out-of-pocket maximum. -------------------------------------------------------------------------------------------------------------------= Family Coinsurance Limit: Once the sum of amounts applied toward the individual out- of-pocket maximums for you and your family members reaches the family out-of-pocket maximum,the play pays 100%of covered expenses for all covered family members for the rest of the plan year, except for co-pays. Co payments (also called co pays): For certain types of expenses, you pay a co- payment. A co-pay is a flat fee that you pay for a covered service or supply. In many cases, the co-pay is all you pay; there is no need to meet the plan year deductible or pay coinsurance. 13 Lifetime Maximum Benefits: The lifetime maximum benefits are the most the plan will pay for out-of-network and substance abuse benefits for a covered person in his or her lifetime. There is one overall Lifetime Maximum Benefit per person which continues to accumulate per individual regardless of the medical plan option you enroll in. This means that if you change from one option to another, your accumulated expenses will move to the new plan. 14 How the Plan Works The City of Fort Worth offers three medical plan options: • Basic • Basic Plus • Select All three plans are variations of the Aetna Choice POS II Plan. They differ as to deductible, coinsurance and co-pay amounts, but cover the same medical expenses and include the same special programs, services and features. Under each plan, you have the freedom to choose your doctor or health care facility when you need health care. How that care is covered and how much you pay for your care out of your own pocket depend on whether the expense is covered by the plan and whether you choose an in-network provider or an out-of-network provider(see below). In-Network and Out-of-Network Benefits You and your covered family members can receive care from in-network doctors and facilities—those that belong to Aetna's network. To be selected as a network provider, a doctor or other healthcare provider must meet certain standards in a process called credentialing. The credentialing process looks at factors such as education, residency, board certification and licensing, and admitting privileges to determine whether or not a provider may participate in the network. The providers in the network represent a wide range of services, from basic, routine care (general practitioners,pediatricians, internists, OBBYNs), to specialty care (cardiologists, urologists), to health care facilities (hospitals, skilled nursing facilities). When they join the network, the providers agree to provide services or supplies at negotiated charges. If you use an in-network provider, you'll pay less out of your own pocket for your care. You won't have to fill out claim forms because your network provider will file claims for you. In addition, your provider will make the necessary telephone call to start the pre- certification process when you must be hospitalized or need certain treatments or procedures. If you use an out-of-network provider (for other than emergency services), you'll pay more out of your own pocket for your care. The plan generally pays a lower benefit level for covered expenses, up to what Aetna considers the reasonable and customary amount for a given health service. A reasonable and customary charge is the provider's usual charge or the charge Aetna determines to be appropriate or most common for a given service or supply in a specific geographic area. The out-of-network provider's fee for a given service may be more than 15 the reasonable and customary amount, as determined by Aetna. In this case,the plan's benefit applies only to the part of the charge that is reasonable and customary. You must pay the difference. Any charges over the reasonable and customary charge do not count toward your deductible or out-of-pocket limit. You'll also be required to file your own claims and make the telephone call required for pre-certification. The Summary of Benefits charts that follow later in this booklet show how each option's level of coverage differs when you use in-network versus out-of-network providers. -------------------------------------------------------------------------------------------------------------------- Important: All day and visit maximums in the plan are combined maximums between in- and out-of-network care unless stated otherwise. Finding Network Providers To find a network provider in your area: — Use DocFind at www.aetna.com. Choose "Aetna Choice POS II" from the list of Aetna Open Access plans. You can search the online directory for a specific doctor,type of doctor or all the doctors in a given zip code and/or travel distance. — Call Aetna Member Services. A Member Services representative can help you find an in-network provider in your area. The Member Services toll-free number is printed on your ID card. Your Primary Care Physician (PCP) You may decide to choose a primary care physician(PCP) for routine care such as checkups, health screenings and care for everyday health problems. A PCP can be a general practitioner, family practitioner, internist, pediatrician or an OB/GYN. You can choose a different PCP for each member of the family if you like. And you can change your PCP at any time. You are not required to choose a PCP. But we encourage you to develop a relationship with a primary doctor. Here's why we think it's a good idea: • Your PCP may be your personal health care manager. He or she gets to know your personal health history and health care needs, and maintains all of your records. Your PCP also can recommend a specialist when you need care that he or she can't provide. This can be very helpful, since it's often hard to choose the right specialist. • Your network provider takes care of pre-certification. This is an approval process that's required for certain types of care. You are required to obtain pre-certification if receiving care from a non-network provider. • Although the plan does not require referrals, your PCP can help you find the right kind of specialist when you need one. 16 Specialists Specialists are doctors such as oncologists, cardiologists, allergists, chiropractors, neurologists or podiatrists. When you need specialty care, you can make an appointment directly with any licensed specialist. No referral is required Remember, you'll pay less out of your own pocket when you use a network provider. You can find a network specialist the same way you find a PCP. -------------------------------------------------------------------------------------------------------------------, Remember to use DocFind at www.aetna.com to finding-network providers in your area. Choose "Aetna Choice POS II" from the list of Open Access plans when prompted. 17 Pre-certification In order to receive certain benefits from the plan,you must follow the pre-certification rules described in this section. Pre-certification is a review of inpatient admissions and other care to determine whether the requested care is covered under your plan. This review takes place before the admission and before the care is provided. Pre-certification starts with a telephone call to Member Services at the number listed on your ID card. If you receive care from an in-network provider, he or she will make this call for you. If you receive care from an out-of-network provider,you will be required to make the call. If you don't make the call when you are required to, or if Aetna doesn't certify the care requested, a penalty may be applied to your covered charges. This means your out-of-pocket cost will be higher. The services listed in the following chart must be pre-certified: Penalty fir Failure FTYP' e of Service When to Pre-certifyetify lnpafYent Care Hospital Confinements I • Non-emergency admission: at least 14 Covered expenses Other Confinements days prior to admission reduced by 50% i Skilled Nursing Facility Urgent admission: before you are • scheduled to be admitted • Home Health Care Emergency admission: within 48 hours • Hospice Care or as soon as reasonably possible Behavioral Health Confinements Emergency admission: within 48 hours Benefits will be paid (mental health/substance I of admission at the out-of-network abuse) level 18 Type of Service Wheri to Pre-certify Penalty for Failure _ to Pre-certify Procedures and — Treatments • Allergy Immunotherapy If due to an Emergency condition: Covered expenses • Bunionectomy • Before the procedure or treatment is reduced by 50% • Carpal Tunnel Surgery performed • Colonoscopy • Within 48 hours (72 hours if performed • CAT Scan—spine on a Friday or Saturday) • Coronary Angiography • Dilation/Curettage If due to an Non-emergency condition: • Hemorrhoidectomy 14 days before the procedure or • Knee Arthroscopy treatment is performed or as soon as • Laparoscopy(pelvic) reasonably possible before performed • MRI—Knee • MR[—Spine • Septorhinoplasty • Tympanostomy Tube • Upper GI Endoscopy The plan pays benefits for covered medical expenses only. If a service or supply you receive is not covered by the plan, benefits will not be paid for it—whether or not it has been pre-certified. 19 Summary of Benefits The Summary of Benefits charts in this section show the deductibles, coinsurance, out-of- pocket maximums and lifetime maximum, as well as benefits for the major types of covered expenses for the Basic,Basic Plus and Select medical options. -------------------------------------------------------------------------------------------------------------------- Remember to refer to the appropriate summary for the plan option you elected— Basic, Basic Plus or Select. The sections, What the Plan Covers and What the Plan Does Not Cover include more detail about specific services and supplies. The information in these sections applies to all three medical plan options except as noted. Here are some important points to remember about your benefits: 1. The plan pays different benefits for in-network and out-of-network care. 2. The plan pays out-of-network benefits based on reasonable and customary charges. 3. Pre-certification may be required for certain types of care. 20 Basic Plan Plan Features In-Network Out-of-Network Lifetime Maximum Unlimited $1,000,000 Preventive Care Services • Routine Physical Exams—Adults 100% after$25 co-pay; 60% after deductible Includes Immunizations not subject to deductible (one exam per calendar year age 18 and older • Routine Well-Child Visits 100%after$25 co-pay; 60% after deductible Includes Immunizations not subject to deductible (7 exams in first 12 months of life; 2 exams 13—24 months; one exam per calendar year thereafter to age 18 • Routine OB/GYN Exam 100% after$25 co-pay 60% after deductible (one routine exam per calendar year, not subject to deductible including Pap smear and related lab expenses) • Routine Mammography 100% no deductible or co-pay 601/6 after deductible (one routine mammogram per calendar year for females age 40 and older • Colonoscopy 80% no deductible first 60% after deductible (one every 10 years) procedure, 80% after deductible thereafter • Routine Sigmoidoscopy 80% after deductible 60% after deductible one every 5 ears • Routine Digital Rectal Exam (DRE) 100% no deductible or co-pay 60% after deductible and Prostate Antigen Test (PSA) (one per year for males age 45 and over, or earlier as a result of family history) • Vision Exam with Refraction 100% after$25 co-pay; 60% after deductible one exam per 24 months not subject to deductible Physician Services • Office Visits 100% after$25 co-pay 60% after deductible • Physician In-Hospital Services 80% after deductible 60% after deductible • Other Physician Services 80% after deductible 60% after deductible Allergy Testing 100% after$25 co-pay; 60% after deductible not subject to deductible Allergy Injections 100% after$25 co-pay; 60% after deductible not subject to deductible (co-pay waived if no physician encounter Maternity • Prenatal and postnatal visits 100%after$25 co-pay for 60% after deductible initial visit only; all visits thereafter covered in full 21 Basic Plan Plan Features In-Network Benefits Out-of-Network Benefits Hospital Services • Inpatient Coverage 80% after deductible 60% after deductible • Outpatient Coverage 80% after deductible 60% after deductible • Emergency Room 100%after$125 co-pay; 100%after$125 co-pay; (includes related physician, surgery, not subject to deductible not subject to deductible imaging and lab services) (co-pay waived if admitted) (co-pay waived if admitted) • Non-Emergency Use of the 50% after deductible 50% after deductible Emergency Room Ambulance 80% after deductible 80% after deductible Urgent Care Center 100%after$50 copay 60% after deductible Diagnostic X-ray and Laboratory • Freestanding Facility 100% no deductible 60% after deductible • Hospital Inpatient or Outpatient 80%after deductible 60% after deductible • Radiologist, Anesthesiologist, 100% after$25 co-pay in 60% after deductible Pathologist Services office, otherwise 80%after deductible Complex Imaging 80%after deductible 60% after deductible MRI, PET, &CAT scans Skilled Nursing Facility 80% after deductible 60% after deductible (up to 60 days per calendar ear Home Health Care 80% after deductible 60% after deductible (up to 60 visits per calendar ear Hospice Care 80% after deductible 60% after deductible combined 360 days per lifetime Short-Term Rehabilitation 100%after$25 co-pay; 60% after deductible (physical, occupational and speech not subject to deductible therapy. Up to 60 visits per calendar ear Chiropractic Care 100%after$25 co-pay in 60% after deductible (up to 24 visits per calendar year) office, otherwise 80%after deductible Durable Medical Equipment 80% after deductible 60% after deductible Mental Health and Alcohol and Drug Abuse • Inpatient Care 80% after deductible 60% after deductible (up to 30 days per calendar year. Up to 3 series of treatment for alcohol and drug abuse per lifetime • Outpatient Care 100% after$25 co-pay; 60% after deductible (up to 30 visits per calendar ear not subject to deductible Calendar Year Deductible • Individual $750 $2,000 • Family $1,500 $4,000 Out-of-Pocket Maximum • Individual $2,000 $8,000 • Family $4,000 $16,000 22 Basic Plan Prescription Drugs In-Network Benefits Out-of-Network Benefits Calendar Year Deductible • Individual $50 • Family $150 Retail Pharmacy (30-day supply) • Generic 100% after deductible and 60% after deductible and $10 co-pay $10 co-pay • Brand Formulary 100% after deductible and 60% after deductible and $30 co-pay $30 co-pay • Brand Non-Formulary 100% after deductible and 60% after deductible and $50 co-pay $50 co-pay Mail Order Pharmacy (90-day supply) • Generic 100% after deductible and Not covered $25 co-pay • Brand Formulary 100%after deductible and Not covered $75 co-pay • Brand Non-Formulary 100%after deductible and Not covered $125 co-pay 23 Basic Plus Option Plan Features In-Network Out-of-Network Lifetime Maximum Unlimited $1,000,000 Preventive Care Services • Routine Physical Exams—Adults 100%after$20 co-pay; 65% after deductible Includes Immunizations not subject to deductible (one exam per calendar year age 18 and older • Routine Well-Child Visits 100%after$20 co-pay; 65% after deductible Includes Immunizations not subject to deductible (7 exams in first 12 months of life; 2 exams 13—24 months; one exam per calendar year thereafter to age 18 • Routine OB/GYN Exam 100% after$20 co-pay; 65% after deductible (one routine exam per calendar year; not subject to deductible including Pap smear and related lab expenses) • Routine Mammography 100% no deductible or co-pay 65% after deductible (one routine mammogram per calendar year for females age 40 and older • Colonoscopy 85% no deductible first 65% after deductible (one every 10 years) procedure, 85% after deductible thereafter • Routine Sigmoidoscopy 85% after deductible 65% after deductible one every 5 ears • Routine Digital Rectal Exam (DRE) 100% no deductible or co-pay 65% after deductible and Prostate Antigen Test (PSA) (one per year for males age 45 and over, or earlier as a result of family history) • Vision Exam with Refraction 100% after$20 co-pay; 65% after deductible one exam per24 months not subject to deductible Physician Services • Office Visits 100%after$20 co-pay 65% after deductible • Physician In-Hospital Services 85% after deductible 65% after deductible • Other Physician Services 85% after deductible 65% after deductible Allergy Testing 100%after$20 co-pay; 65% after deductible not subject to deductible Allergy Injections 100% after$20 co-pay; 65% after deductible not subject to deductible (co-pay waived if no physician encounter Maternity • Prenatal and postnatal visits 100% after$20 co-pay for 65% after deductible initial visit only; all visits thereafter covered in full 24 Basic Plus Option Plan Features In-Network Benefits Out-of-Network Benefits Hospital Services • Inpatient Coverage 85% after deductible 65% after deductible • Outpatient Coverage 85% after deductible 65% after deductible • Emergency Room 100% after$100 co-pay; 100% after$100 co-pay; (includes related physician, surgery, not subject to deductible not subject to deductible imaging and lab services) (co-pay waived if admitted) (co-pay waived if admitted) • Non-Emergency Use of the 50% after deductible 50% after deductible Emergency Room Ambulance 85% after deductible 85% after deductible Urgent Care Center 100%after$50 copay 60% after deductible Diagnostic X-ray and Laboratory • Freestanding Facility 100% no deductible 65% after deductible • Hospital Inpatient or Outpatient 85% after deductible 65% after deductible • Radiologist, Anesthesiologist, 100% after$20 co-pay 65% after deductible Pathologist Services in office, otherwise 85% after deductible Complex Imaging 80% after deductible 60% after deductible MRI, PET, & CAT scans Skilled Nursing Facility 85% after deductible 65% after deductible (up to 60 days per calendar ear Home Health Care 85% after deductible 65% after deductible (up to 60 visits per calendar ear Hospice Care 85% after deductible 65% after deductible combined 360 days per lifetime Short-Term Rehabilitation 100% after$20 co-pay; 65% after deductible (physical, occupational and speech not subject to deductible therapy. Up to 60 visits per calendar ear Chiropractic Care 100% after$20 co-pay 65% after deductible (up to 24 visits per calendar year) in office, otherwise 85% after deductible Durable Medical Equipment 85% after deductible 65% after deductible Mental Health and Alcohol and Drug Abuse • Inpatient Care 85% after deductible 65% after deductible (up to 30 days per calendar year. Up to 3 series of treatment for alcohol and drug abuse per lifetime • Outpatient Care 100% after$20 co-pay; 65% after deductible (up to 30 visits per calendar ear not subject to deductible Calendar Year Deductible • Individual $500 $1,500 • Family $1,000 $3,000 Out-of-Pocket Maximum • Individual $2,000 $4,000 • Family $4,000 $8,000 25 Basic Plus Option Prescription Drugs In-Network Benefits Out-of-Network Benefits Calendar Year Deductible • Individual $25 • Family $75 Retail Pharmacy (30-day supply) • Generic 100%after deductible and 65% after deductible and $8 co-pay $8 co-pay • Brand Formulary 100%after deductible and 65% after deductible and $25 co-pay $25 co-pay • Brand Non-Formulary 100%after deductible and 65% after deductible and $45 co-pay $45 co-pay Mail Order Pharmacy (90-day supply) • Generic 100%after deductible and Not covered $20 co-pay • Brand Formulary 100% after deductible and Not covered $62.50 co-pay • Brand Non-Formulary 100%after deductible and Not covered $112.50 co-pay 26 Select Option Plan Features In-Network Out-of-Network Lifetime Maximum Unlimited $1,000,000 Preventive Care Services • Routine Physical Exams—Adults 100%after$15 co-pay; 70% after deductible Includes Immunizations not subject to deductible (one exam per calendar year age 18 and older • Routine Well-Child Visits 100% after$15 co-pay; 70% after deductible Includes Immunizations not subject to deductible (7 exams in first 12 months of life; 2 exams 13—24 months; one exam per calendar year thereafter to age 18 • Routine OB/GYN Exam 100%after$15 co-pay; 70% after deductible (one routine exam per calendar year, not subject to deductible including Pap smear and related lab expenses) • Routine Mammography 100% no deductible or co-pay 70% after deductible (one routine mammogram per calendar year for females age 40 and older • Colonoscopy 90% no deductible first 70% after deductible (one every 10 years) procedure, 90% after deductible thereafter • Routine Sigmoidoscopy 90% after deductible 70% after deductible one every 5 ears • Routine Digital Rectal Exam (DRE) 100% no deductible or co-pay 70% after deductible and Prostate Antigen Test (PSA) (one per year for males age 45 and over, or earlier as a result of family history) • Vision Exam with Refraction 100% after$15 co-pay; 70% after deductible one exam per 24 months not subject to deductible Physician Services • Office Visits 100% after$15 co-pay 70% after deductible • Physician In-Hospital Services 90%after deductible 70% after deductible • Other Physician Services 90% after deductible 70% after deductible Allergy Testing 100%after$15 co-pay; 70% after deductible not subject to deductible Allergy Injections 100% after$15 co-pay; 70% after deductible not subject to deductible (co-pay waived if no physician encounter Maternity • Prenatal and postnatal visits 100% after$15 co-pay for 70% after deductible initial visit only; all visits thereafter covered in full 27 Select Option Plan Features In-Network Benefits Out-of-Network Benefits Hospital Services • Inpatient Coverage 90% after deductible 70% after deductible • Outpatient Coverage 90% after deductible 70% after deductible • Emergency Room 100% after$75 co-pay; 100% after$75 co-pay; (includes related physician, surgery, not subject to deductible not subject to deductible imaging and lab services) (co-pay waived if admitted) (co-pay waived if admitted) • Non-Emergency Use of the 50% after deductible 50% after deductible Emergency Room Ambulance 90% after deductible 70% after deductible Urgent Care Center 100% after$35 copay 60% after deductible Diagnostic X-ray and Laboratory • Freestanding Facility 100% no deductible 70% after deductible • Hospital Inpatient or Outpatient 90% after deductible 70% after deductible • Radiologist,Anesthesiologist, 100%after$15 co-pay 70% after deductible Pathologist Services in office, otherwise 90% after deductible Complex Imaging 80% after deductible 60% after deductible MRI, PET, & CAT scans Skilled Nursing Facility 90% after deductible 70% after deductible (up to 60 days per calendar ear Home Health Care 90% after deductible 70% after deductible (up to 60 visits per calendar ear Hospice Care 90% after deductible 70% after deductible combined 360 days per lifetime Short-Term Rehabilitation 100% after$15 co-pay; 70% after deductible (physical, occupational and speech not subject to deductible therapy. Up to 60 visits per calendar ear Chiropractic Care 100% after$15 co-pay 70% after deductible (up to 24 visits per calendar year) in office, otherwise 90% after deductible Durable Medical Equipment 90% after deductible 70% after deductible Mental Health and Alcohol and Drug Abuse • Inpatient Care 90% after deductible 70% after deductible (up to 30 days per calendar year. Up to 3 series of treatment for alcohol and drug abuse per lifetime • Outpatient Care 100% after$15 co-pay; 70% after deductible (up to 30 visits per calendar ear not subject to deductible Calendar Year Deductible • Individual $250 $750 • Family $500 $1,500 Out-of-Pocket Maximum • Individual $2,000 $4,000 • Family $4,000 $8,000 28 Select Option Prescription Drugs In-Network Benefits Out-of-Network Benefits Retail Pharmacy (30-day supply) • Generic 100% after deductible and 70% after deductible and $6 co-pay $6 co-pay • Brand Formulary 100% after deductible and 70% after deductible and $20 co-pay $20 co-pay • Brand Non-Formulary 100% after deductible and 70% after deductible and $35 co-pay $35 co-pay Mail Order Pharmacy (90-Jay supply) • Generic 100% after deductible and Not covered $15 co-pay • Brand Formulary 100% after deductible and Not covered $50 co-pay • Brand Non-Formulary 100%after deductible and Not covered $87.50 co-pa 29 What the Medical Plan Covers While the Summary of Benefits charts outline the deductibles, coinsurance, out-of-pocket maximums, age, frequency and lifetime maximums for the major types of covered expenses, this section further describes the services and supplies covered under the medical plans. It also describes limits and exclusions that may apply to a specific type of expense. Although a service may be listed as a covered benefit, it will not be covered unless it is medically necessary for the prevention, diagnosis or treatment of your illness or condition or considered covered preventive care as specifically outlined. Refer to the Glossary for a definition of"necessary." Preventive Care Routine Physical Exams The plan covers charges made by a physician for a routine physical exam given to you, your spouse or your dependent child. Included as part of the exam are: — X-rays, lab and other tests given in connection with the exam; and — Materials for giving immunizations for infectious disease and testing for tuberculosis. A physical exam for your dependent child must include at least: — A review and written record of the patient's complete medical history; — A check of all body systems; and — A review and discussion of exam results with the patient or with the parent or guardian. If an exam is given to diagnose or treat an injury or disease, it is not considered a routine physical exam. The plan does not cover(as part of any routine physical exam): — Services to the extent they are covered under any other part of this plan. — Services covered to any extent under any other group plan sponsored by The City of Fort Worth. — Services to diagnose or treat a suspected or identified injury or disease. — Exams given while the person is confined in a hospital or other facility for medical care. — Services not provided by a physician or under the direct supervision of a physician. — Medicines, drugs, appliances, equipment or supplies. — Psychiatric,psychological, personality, or emotional testing or exams. — Any employment-related exams. — Premarital exams. 30 Vision Exams with Refractive Services The plan included benefits for one (1) complete eye exam every 24 months performed by a qualified ophthalmologist or optometrist. There is no coverage for eyewear or contact lenses. This plan provision does not cover charges for: — Exams which do not include refraction (exams for diagnosis or treatment of a medical problem may be covered under another plan provision); — Any service or supply provided while not covered under the plan; — Any exams given while confined in the hospital or facility for medical care; or — Any exam required by an employer as a condition of employment, or which an employer is required to provide under a labor agreement or government law. — Drugs or medicines; — Any service or supply that does not meet professionally accepted standards. Hospital Services Inpatient Hospital Expenses The plan covers charges made by a hospital for room and board and other hospital services and supplies for a person confined as an inpatient. Room and board charges are covered up to the hospital's semi-private room rate. (A semi-private room is one with two or more beds.) Room and board charges include: • Services of the hospital's nursing staff, • Admission fees; • General and special diets; and • Sundries and supplies. The plan also pays for other services and supplies provided during an inpatient stay, such as: • Physician and surgeon services; • Operating and recovery rooms; • Intensive or special care facilities; • Radiation therapy,physical therapy and occupational therapy; • Oxygen and oxygen therapy; • X-rays, lab tests and diagnostic services; • Medication; and • Social services planning. -------------------------------------------------------------------------------------------------------------------- Remember that inpatient hospital stays require pre-certification. -------------------------------------------------------------------------------------------------------------------- 31 Outpatient Hospital Expenses The plan covers charges made by a hospital for hospital services and supplies provided to a person who is not confined as an inpatient. Charges include: • Professional fees; • Services and supplies furnished by the hospital on the day of a treatment,procedure or test; • Services of an operating physician for surgery, related pre- and post-operative care, and administration of an anesthetic; and • Services of any other physician for the administration of a general anesthetic. Emergency Care Emergency Room The plan covers emergency care provided in a hospital emergency room while a person is not a full-time inpatient. The care must be for an emergency condition. The plan benefits are reduced for non-emergency care provided in a hospital emergency room. An emergency condition means a recent and severe medical condition— including but not limited to severe pain—which would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that failure to get immediate medical care could result in: — Placing the person's health in serious jeopardy; or — Serious impairment to bodily function; or — Serious dysfunction of a body part or organ; or — Serious jeopardy to the health of the fetus in the case of a pregnant woman. Ambulance The plan covers charges for a professional ambulance to transport a person from the place where he/she is injured or becomes ill to the first hospital where treatment is given. When, in a medical emergency, the first hospital does not have the required services, transportation to another hospital is also covered. Skilled Nursing / Convalescent Care The plan covers charges made by a skilled nursing facility (convalescent facility) for the services and supplies listed below. These must be provided to a person while confined to convalesce from a disease or injury. 32 — Room and board, including charges for services (such as general nursing care) made in connection with room occupancy. Any charge for room and board in a private room that exceeds the hospital's semi-private room rate is not covered. — Use of special treatment rooms. — X-ray and lab work. — Physical, occupational or speech therapy. — Oxygen and other gas therapy. — Other medical services provided by a skilled nursing facility. This does not include private or special nursing, physician services, drugs, biologicals, solutions, dressings, casts and other supplies. The plan pays benefits for up to 60 days for skilled nursing services per calendar year. The maximum is a combined limit for in- and out-of-network care. Convalescent facility care does not include charges for treatment of: — Drug addiction; — Chronic brain syndrome; — Alcoholism; — Mental retardation; or — Any other mental disorder. -------------------------------------------------------------------------------------------------------------------- Remember that inpatient admissions to a skilled nursing facility require pre-certification. -------------------------------------------------------------------------------------------------------------------- Home Health Care The plan covers home health care expenses when care is provided by a home health care agency as part of a home health care plan, and the care is provided to a covered person in his or her home. Home health care expenses are charges for: — Part-time or intermittent care by an R.N. or L.P.N., if an R.N. is not available. — Part-time or intermittent home health aide services for patient care. — Physical, occupational and speech therapy. — The following services, to the extent they would have been covered if the person had been confined to a hospital or convalescent facility: — Medical supplies; — Drugs and medicines prescribed by a physician; and — Lab services provided by or for a home health care agency. The plan covers up to 60 home health care visits per calendar year. Each visit by a nurse or therapist is one visit. Each visit of up to 4 hours by a home health aide is one visit. 33 The plan does not cover home health care charges for: — Services or supplies that are not part of the home health care plan; — Services of a person who usually lives with you or is a member of your family or your spouse's family; — Services of a social worker; or — Transportation. -------------------------------------------------------------------------------------------------------------------- Remember that home health care requires pre-certification. -------------------------------------------------------------------------------------------------------------------- Hospice Care The plan covers hospice care that is provided as part of a hospice care program for a person with a prognosis of six months or less to live. Hospice care coverage is described below. Facility Expenses The plan covers charges made by a hospice facility, hospital or convalescent facility on its own behalf for: — Room and board, and other services and supplies provided to a person while a full-time inpatient for pain control and other acute and chronic symptom management. (The plan covers charges for room and board up to the facility's semi-private room rate.) • Services and supplies provided on an outpatient basis. Other Hospice Care Agency Expenses The plan covers charges made by a hospice care agency for: — Part-time or intermittent nursing care by an R.N. or L.P.N. for up to 8 hours in any one day. — Medical social services under a physician's direction. These include: — Assessment of the person's social, emotional and medical needs, and the home and family situation; — Identifying community resources available to the person; and — Helping the person make use of these resources. — Psychological and dietary counseling. — Consultation or case management services provided by a physician. — Physical and occupational therapy. — Part-time or intermittent home health aide services for up to 8 hours in any one day. These services consist mainly of caring for the person. — Medical supplies. — Drugs and medicines prescribed by a physician. 34 Charges made by a physician for consulting or case management services, and charges made by a physical or occupational therapist are also covered if- - The provider is not an employee of a hospice care agency; and — A hospice care agency is still responsible for the person's care. Home Health Care Agency Expenses As part of its hospice care coverage, the plan covers home health care agency expenses for: — Physical and occupational therapy. — Part-time or intermittent home health aid services for up to 8 hours in any one day. These consist mainly of caring for the person. — Medical supplies. — Drugs and medicines prescribed by a physician. — Psychological and dietary counseling. The plan limits coverage for bereavement counseling and respite care to a maximum of 3 visits within 3 months. Respite care is care provided when the person's family or usual caretaker can't or won't care for the person. The plan's hospice care benefit does not include coverage for: — Funeral arrangements. — Pastoral counseling. — Financial or legal counseling, including estate planning and the drafting of a will. — Homemaker or caretaker services. These are services not entirely related to the care of a person and include sitter or companion services for the person who is ill or other family members; transportation; housecleaning and home maintenance. ------------------------------------------------------------------------------------------------------------------- Remember that inpatient hospice care requires pre-certification. -------------------------------------------------------------------------------------------------------------------- Short-Term Rehabilitation The plan covers charges made by a hospital or licensed health care facility; a physician; or a licensed or certified physical, occupational or speech therapist for short-term rehabilitation on an outpatient basis. Short-term rehabilitation is therapy expected to result in the improvement of a body function (including speech) which was lost or impaired because of- - An injury, — A disease, or — Major congenital abnormalities such as cleft lip and cleft palate, cerebral palsy, hearing impairment, autism and developmental disabilities in children. 35 The plan covers physical, occupational or speech therapy provided to a person who is not confined as an inpatient in a hospital or other facility for medical care. Therapy will be expected to result in significant improvement of the person's condition within 60 days from the date therapy begins. The plan covers up to 60 visits per person per calendar year combined in-and out-of-network. Speech therapy to treat a congenital abnormality is covered for children to age 6, limited to 3 times per week. This benefit does not cover short-term rehabilitation when: — Any therapy, service or supply for the treatment of a condition which ceases to be therapeutic treatment and is instead administered to maintain a level of functioning to prevent a medical problem from occurring or recurring; — Services are received while a person is confined in a hospital or other medical facility for medical care; — Rehabilitation services are covered under any other part of this plan or any plan sponsored by The City of Fort Worth. — Services are provided by a physical, occupation or speech therapist who lives in the patient's home or is a family member of the patient or his/her spouse; — Services are not performed by a physician or under his/her direct supervision; — It is for special education, including lessons in sign language,to teach a person whose ability to speak has been lost or impaired,to function without that ability. — Services are not provided in accordance with a specific treatment plan that details the treatment to be provided and the frequency and duration of treatment; provides for ongoing reviews; and is renewed only if therapy is still necessary. Chiropractic Care (Spinal Manipulation) The plan covers expenses for chiropractor care to treat any condition caused by or related to biomechanical or nerve conduction disorders of the spine. Benefits are paid for up to 24 visits per calendar year combined in- and out-of-network. This maximum does not apply to expenses incurred: — While the person is a full-time inpatient in hospital; — For treatment of scoliosis; — For fracture care; or — For surgery. This includes pre- and post-surgical care provided or ordered by the operating physician. Family Planning Pregnancy Coverage The plan pays benefits for pregnancy-related expenses on the same basis as it would for an illness. For inpatient care of a mother and newborn child, benefits will be payable for a minimum of- - 48 hours after a vaginal delivery; and — 96 hours after a cesarean section. 36 Pre-certification is not required for the first 48 hours of hospital confinement after a vaginal delivery or 96 hours after a cesarean delivery. Any days of confinement over these limits must be pre-certified. You, your doctor or other health care provider can request pre-certification by calling the number on your ID card. To be covered, expenses must be incurred while covered by the plan. Any pregnancy benefits payable by a previous group medical plan will be subtracted from benefits payable under this plan. Infertility Coverage The plan covers services to diagnose and treat an underlying medical condition which causes infertility when provided by or under the direction of a physician. Mental Health and Substance Abuse Treatment The plan covers expenses for inpatient and outpatient treatment of alcoholism or drug abuse, and mental disorders as explained below. Hospital If a person is a full-time inpatient in a hospital, the plan covers: • Treatment for the medical complications of alcoholism or drug abuse. "Medical complications" include cirrhosis of the liver, delirium tremens or hepatitis. • Effective treatment of alcoholism or drug abuse. • Treatment of mental disorders. Treatment Facility If a person is a full-time inpatient in a treatment facility, the plan covers certain expenses for the effective treatment of alcoholism, drug abuse or mental disorders. These expenses are: • Room and board, up to the facility's semi-private room rate; and • Other necessary services and supplies. Outpatient Treatment The plan also covers effective treatment of alcoholism, drug abuse or mental disorders on an outpatient basis. Benefit Maximums • For inpatient care, the plan covers up to 30 days per calendar year for mental health and substance abuse treatment. 37 • For substance abuse, the plan includes a lifetime maximum of 3 series of treatment per lifetime which includes rehabilitation, detoxification, residential care and partial confinement expenses. • For outpatient care, the plan covers up to 60 visits per calendar year for mental health and substance abuse treatment. Each of these maximums is a combined limit for in- and out-of-network care. Oral Surgery The plan covers treatment of the mouth,jaws and teeth as follows: • Surgery needed to: — Treat an accidental injury; — Remove cysts, tumors or other diseased tissues; — Alter the jaw,jaw joints or bite relationships to treat TMJ when appliance therapy cannot result in functional improvement. This benefit does not cover charges: • For surgery to remove teeth (whether or not routine); • For periodontal treatment; • To remove, repair, replace, restore or reposition teeth lost or damaged in the course of biting or chewing; • To repair, replace or restore fillings, crowns, dentures or bridgework • Non-surgical treatment of infections or diseases; • For dental cleaning, in-mouth scaling, planning or scraping; • For myofunctional therapy (muscle training therapy to correct or control harmful habits). Durable Medical Equipment The plan covers durable medical equipment(such as wheelchairs, walkers, crutches) as follows: • Rental of durable medical equipment. Instead of rental, the plan may cover purchase of this equipment if Aetna is shown that long-term use of it is planned and that it either can't be rented or would cost less to purchase than to rent; • Repair of purchased durable medical equipment; • Replacement of purchased durable medical equipment if Aetna is shown that it is needed because of a change in the person's physical condition, or if it is likely to cost less to purchase a replacement than to repair existing equipment or rent similar equipment. 38 Diabetic Equipment, Supplies and Education The plan covers the following services, supplies, equipment and training for the treatment of diabetes: • Diabetic education; • Insulin preparations; • Insulin infusion pumps; • Needles and syringes; • Injection aids; • Blood glucose monitors and test strips; • Lancets; • Prescribed oral medications for controlling blood sugar level; • Alcohol swaps; • Glucose agents; • Glucagon emergency kits or injectable glucagon; • Self-management training provided by a qualified health care provider; and • Orthotic devices, orthopedic shoes and replacement inserts. Other Covered Expenses The plan also covers: • Charges made by a physician. • Charges for drugs and medicines which, by law, require a physician's prescription, but only while a person is confined as an inpatient. • Charges for diagnostic lab work and x-rays; x-ray, radium and radioactive isotope therapy; and anesthetics and oxygen. • Charges for surgical treatment of morbid obesity. • Charges for diabetic education. • Artificial limbs and eyes. Not included are such things as eyeglasses, vision aids, hearing aids and communication aids. • Anesthetics and oxygen. 39 Prescription Drug Benefits Outpatient prescription drugs prescribed by a physician to treat an illness or injury are covered. To receive maximum benefits there are two ways to fill prescriptions: at an in-network retail pharmacy or by mail order through Aetna RX Home Delivery. The amount you pay for your prescription depends on whether the drug is generic or brand-name, or if it is in the formulary. Although you may also fill a prescription at an out-of-network retail pharmacy,the benefits you receive will be reduced. The formulary is a list of preferred drugs that includes both brand-name and generic drugs. You can reduce your co-payment by using a covered drug that appears on the formulary. You can find Aetna's formulary online at www.aetna.com/formulary or call Member Services at the number on your ID card to request a printed formulary guide. Retail Pharmacy You may fill your prescription for up to a 30-day supply at a retail pharmacy. The benefit level for prescriptions obtained at out-of-network retail pharmacies is lower than the benefit level for prescriptions obtained at in-network retail pharmacies. You can find a list of in_networkpharmacies using the DocFind tool on Aetna Navigator._) Mail Order Prescriptions If you take medications on a regular basis, you may order up to a 90-day supply through Aetna Rx Home Delivery, Aetna's mail order drug service. Aetna Rx Home Delivery is easy-to-use and saves you money. To order by mail, send your original prescription, together with an order form and payment of the applicable coinsurance amount to Aetna. Order forms are available online at www.aetnarxhomedelivery.com. Your doctor can also fax a prescription and order form to 866-681-5166. Refills can be ordered by mail, online at www.aetnarxhomedelivery.com or by phone toll free at 800-227-5720. The address is P.O. Box 829518, Pembroke Pines, FL 33082- 9913. 40 What the Prescription Drug Program Covers The following prescription drug expenses are covered: — Federal legend drugs—drugs that require a label stating: "Caution: Federal law prohibits dispensing without a prescription"; — Compounded medications, of which at least one ingredient is a federal legend drug; — Any other drug which, under applicable state law, may be dispensed only upon a physician's written prescription; — Insulin needles and syringes; — Insulin; — Contraceptive drugs; — Drugs to treat erectile dysfunction, up to 6 tablets per month. What the Prescription Drug Program Does Not Cover The following prescription drug expenses are not covered: — Any drug that does not, by federal law, require a prescription, such as an over-the- counter drug or equivalent over-the-counter product, even when a prescription is written for it; — A device of any type (such as a spacer or nebulizer) used in connection with a prescription drug; — Any drug entirely consumed when and where it is prescribed; — Administration or injection of any drug; — More than the number of refills specified by the prescribing doctor; — Any refill of a drug dispensed more than one year after prescribed, or as permitted by law where the drug is dispensed; — Oral and injectable fertility drugs; — Immunization agents; — Smoking cessation aids; — Nutritional supplements. 41 Women's Health Provisions Federal law affects how certain health conditions are covered. Your rights under these laws are described below. The Newborns' and Mothers' Health Protection Act Federal law generally prohibits restricting benefits for hospital lengths of stay to less than 48 hours following a vaginal delivery and less than 96 hours following a caesarean section. However, the plan may pay for a shorter stay if the attending provider (physician, nurse midwife or physician assistant) discharges the mother or newborn earlier, after consulting with the mother. Also, federal law states that the plan may not, for the purpose of benefits or out-of-pocket costs,treat the later portion of a hospital stay in a manner less favorable to the mother or newborn than any earlier portion of the stay. Finally, federal law states that a plan may not require a physician or other health care provider to obtain authorization of a length of stay up to 48 hours or 96 hours, as described above. However,pre-certification may be required for more than 48 or 96 hours of confinement. The Women's Health and Cancer Rights Act The Women's Health and Cancer Rights Act requires that the following procedures be covered for a person who receives benefits for a medically necessary mastectomy and decides to have reconstructive surgery after the mastectomy: • Reconstruction of the breast on which a mastectomy has been performed; • Surgery and reconstruction of the other breast to create a symmetrical (balanced) appearance; • Prostheses; and • Treatment of physical complications of all stages of mastectomy, including lymphedemas. This coverage will be provided in consultation with the attending physician and the patient, and will be subject to the same annual deductibles and coinsurance provisions that apply to the mastectomy. For answers to questions about the plan's coverage of mastectomies and reconstructive surgery, call Aetna's Member Services at the number on your ID card. 42 Special Programs As participants in this plan, you and your covered family members can take advantage of the special care, discount, vision and fitness programs described in this section. These services, discounts and programs are not underwritten by Aetna, but are made available to you and your family as part of your plan. The National Medical Excellence Program® (NME) The National Medical Excellence (NME) Program®helps you and covered family members receive care from nationally recognized doctors and facilities specializing in organ transplants and certain other treatments. For patients who take part in this program,the plan pays benefits for covered medical expenses incurred for the NME procedures and treatment types listed in this section. In addition,the plan pays a benefit for travel and lodging expenses when the patient is directed to care at a facility more than 100 miles from his/her home. Institutes of ExceffenceTm Network The Institutes of Excellence Network supports the NME program. It is Aetna's network of health care facilities for transplants and transplant-related services, including evaluation and follow-up care. Aetna selects hospitals for the network based on successful clinical outcomes, quality of care standards and agreement with Aetna's contractual terms. These facilities have been contracted on a transplant-specific basis and are,therefore, considered preferred only for specific transplant types. The plan pays in- network benefits for transplant-related services, including evaluation,transplant and follow-up care,when patients use an Institutes of Excellence participating facility that has been specifically contracted by Aetna for their transplant type. Transplants performed outside of the Institutes of Excellence Network will be paid at the out-of- network level. Note: Aetna requires pre-certification at the time of evaluation for transplant services. You can find a list of Institutes of Excellence facilities at DocFind or from Member Services at the number on your ID card. NME Procedure and Treatment Types • Heart transplant • Lung transplant • Liver tranplant • Bone marrow transplant • Heart/lung transplant • Kidney transplant • Pancreas transplant • Kidney/pancreas transplant 43 Travel Expenses "Travel expenses" are expenses for transportation between the patient's home and the medical facility where he or she receives services in connection with a procedure or treatment listed above. Also included are expenses incurred by a companion for transportation to and from an NME patient's home and the medical facility where he or she receives services. These expenses must be approved in advance by Aetna. Lodging Expenses These are expenses for lodging away from home while a patient is traveling between his or her home and the medical facility where services are provided. The plan covers the patient's lodging expenses up to $50 per person, per night. Also covered are a companion's expenses for lodging away from home: • While traveling with an NME patient between the patient's home and the medical facility where services are provided; or • When the patient needs a companion's help to receive services from the medical facility on an inpatient or outpatient basis. The plan covers a companion's lodging expenses up to $50 per person, per night. For the purpose of determining N IE travel or lodging expenses, the hospital or other temporary residence to which a patient must travel while receiving treatment or after discharge at the end of treatment, will be considered the patient's home. Travel and Lodging Maximum The plan pays up to $10,000 per episode of care for travel and lodging expenses incurred in connection with a procedure or treatment. Benefits will be paid only for expenses incurred during the period that begins on the day a covered person becomes an NME patient and ends on the earlier to occur of the following: • One year after the day the procedure is performed; • The date the patient stops receiving services from the facility in connection with the procedure. 44 Limitations Travel and lodging expenses include only those expenses described in this section. No other type of expense covered under this plan will be considered a travel or lodging expense. In addition,the plan covers travel and lodging expenses for just one companion unless the patient is a minor in which case up to two companions over age 18 are allowed. Informed Health° Line At any time, you can call 1-800-556-1555 to speak to Informed Health Line nurses. Our registered nurses are experienced in providing information on a variety of health topics. While the nurses don't diagnose problems, prescribe or give advice, they can: • Help you understand health issues and treatment choices, • Give you some good questions to ask your doctor, and • Tell you about the latest research on certain treatments and procedures, and explain their risks and benefits. The nurses can help you make sense of your health issues and communicate better with your doctor. They'll give you the facts you need to make decisions and choices you can feel good about. Informed Health Line also includes an audio health library that gives you an easy way to access reliable health information from any touchtone phone, 24 hours a day, in English or Spanish. 45 What the Medical Plan Does Not Cover This section contains a general list of charges not covered under the plan. These excluded charges will not be used when figuring benefits. (Remember, limitations and exclusions for specific types of health care expenses are contained in the section, What the Medical Plan Covers.) Exclusions listed in this section will not apply if coverage is required by law. Also, if a benefit is prohibited by the law of the jurisdiction where a person lives, it will not be paid. General Exclusions The plan does not cover charges: • For services and supplies Aetna determines are not necessary for the diagnosis, care or treatment of the disease or injury involved—even if they are prescribed, recommended or approved by a physician or dentist. • For care, treatment, services or supplies not prescribed, recommended or approved by a physician or dentist. • For services of a resident physician or intern. • Made only because you have health coverage. • You are not legally obligated to pay. • That are not reasonable and customary charges, as determined by Aetna. • In excess of the negotiated charge for a given service or supply given by a network provider. Experimental or Investigational Except as provided below, the plan does not cover drugs, devices, treatments or procedures that are experimental or investigational. A drug, device, treatment or procedure is considered experimental or investigational if: • It requires approval by a governmental authority(including the U.S. Food and Drug Administration)prior to use, but such approval has not been granted; or • It is the subject of a written protocol used by any facility for research, clinical trials, or other tests or studies to evaluate its safety, effectiveness, toxicity or maximum tolerated dose, as evidenced in the protocol itself or in the written consent form used by the facility; or • It is a type of drug, device or treatment that is the subject of a Phase I or Phase II clinical trial or the experimental or research arm of a Phase III clinical trial, as these Phases are defined in regulations and other official actions and publications issued by the FDA and the Department of Health and Human Services; or • It has not been proven safe and effective under generally accepted standards of medical practice. 46 "Generally accepted standards of medical practice" are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, or otherwise consistent with physician specialty society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors. However,your plan will pay for experimental or investigational drugs, devices, treatments or procedures if all of the following conditions are met: • You have been diagnosed with a cancer or a condition that is likely to cause death within one year; • Standard therapies have not been effective or do not meet the definition of medically necessary; • Aetna determines, based on at least two documents of medical and scientific evidence that you would likely benefit from the treatment; and • You are enrolled in a clinical trial that meets all of these criteria: — The drug, device, treatment or procedure to be investigated has been granted investigational new drug (IND) or Group c/treatment IND status, — The clinical trial has passed independent scientific scrutiny and has been approved by an Institutional Review Board that will oversee the investigation, — The clinical trial is sponsored by the National Cancer Institute("NCI") or similar national organization (e.g. Food&Drug Administration, Department of Defense) and conforms to the NCI standards, — The clinical trial is not a single institution or investigator study unless the clinical trial is performed at an NCI-designated cancer center, and — You are treated according to the protocol. Government and Armed Forces The plan does not cover charges (to the extent allowed by law) for services and supplies: • Provided,paid for, or for which benefits are provided or required because of a person's past or present service in the armed forces of a government. • Provided, paid for, or for which benefits are provided or required under any governmental law. This exclusion will not apply to "no fault" auto insurance if it is: — Required by law; and — Provided on an individual basis; and — Included in the definition of"other plan" in the section, Coordination With Other Plans. This exclusion also will not apply to a plan established by government for its own employers or their dependents, or to Medicaid. 47 Education and Training The plan does not cover charges for: • Services, treatment, education testing or training related to learning disabilities or developmental delays. • Education, special education or job training, whether or not this is provided in a facility that also provides medical or psychiatric treatment. Reproductive and Sexual Health The plan does not cover charges for: • Therapy, supplies or counseling for sexual dysfunction or inadequacies that don't have a physiological or organic basis. • Sex change surgery or treatment of gender identity disorders. • Reversal of a sterilization procedure. • Voluntary abortion. • Drugs used to treat erectile dysfunction, impotence or sexual dysfunction or inadequacy. This exclusion applies whether or not the drug is delivered in oral, injectable or topical forms (including but not limited to gels, creams, ointments and patches). (See the Prescription Drug Benefits section for information on coverage for such prescription drugs.) Mental Health The plan does not cover charges for: • Marriage, family, child, career, social adjustment, pastoral or financial counseling. • Treatment of health care providers who specialize in mental health and receive treatment as part of their training in that field. • Primal therapy, rolfing or psychodrama. Custodial and Protective Care The plan does not cover charges for: • Care provided to create an environment that protects a person against exposure that can make his or her disease or injury worse. • Custodial care; that is, care provided to help a person in the activities of daily life. 48 Cosmetic Procedures Regardless of whether the service is provided for psychological or emotional reasons, the plan does not cover charges for: • Plastic surgery; • Reconstructive surgery; • Cosmetic surgery; or • Other services that improve, alter or enhance appearance, whether or not for psychological or emotional reasons . . . . . . except when needed: • To improve the function of a part of the body that: — Is not a tooth or a structure that supports the teeth; and — Is malformed as a result of a severe birth defect(such as cleft lip, or webbed fingers or toes), disease, or surgery performed to treat a disease or injury. • As part of reconstruction following an accidental injury. Surgery must be performed in the calendar year of the accident that caused the injury, or in the next calendar year. • As part of reconstruction following a mastectomy. Other Services and Supplies The plan also does not cover: • Acupuncture except when used in lieu of anesthesia; • Wigs; • Blood, blood plasma or other blood derivatives or substitutes, and any related services including processing, storage or replacement costs, and the services of blood donors; • Disposable outpatient supplies including sheaths, bags, elastic garments, bandages, syringes, blood or urine testing supplies, unless specifically provided under What the Medical Plan Covers; • Food items, nutritional supplements, vitamins, medical foods and formulas, even if they are the sole source of nutrition; • Household improvements and equipment, including the purchase or rental of exercise equipment, air purifiers, central or unit air conditioners, water purifiers, hypo- allergenic pillows, mattresses, waterbeds, ramps, elevators, handrails, stair glides and swimming pools; • Injectable drugs, if there is an alternative oral drug; • Recreational therapy; • Services and supplies provided for personal comfort or convenience, or for the convenience of any other person, including a provider. 49 Coordination With Other Plans If you have coverage under other group plans or receive payments for an illness or injury caused by another person,the benefits you receive from this plan may be adjusted. This may mean a reduction in benefits under the plan. Coordination of Benefits Provision The plan coordinates with benefits available through other group plans and/or fault no- fault automobile coverage. "Other group plans" include any other plan of dental or medical coverage provided by: — Group insurance or any other arrangement of group coverage for individuals, whether or not the plan is insured; and — "No-fault" and traditional "fault" auto insurance, including medical payments coverage provided on other than a group basis, to the extent allowed by law. To find out if benefits under this plan will be reduced,Aetna must first determine which plan pays benefits first. The following chart outlines the order in which plans pay for each circumstance described: If: Then: one plan has a coordination of benefits (COB) ... the plan without a COB provision provision, and the other plan does not, determines its benefits before the plan that has such a provision. one plan covers the person as a dependent, ...the plan that covers a person as an and the other plan covers the person as an employee determines its benefits before the employee, plan that covers the person as a dependent. the person is eligible for Medicare and is not ... the Medicare Secondary Payer rules will actively working, apply. Under the Medicare Secondary Payer rules,the order of benefits will be determined as follows: • The plan that covers the person as a dependent of a working spouse will pay first; • Medicare will pay second; and • The plan that covers the person as a retired employee will pay third. a child's parents are not divorced or separated, ... the plan of the parent whose birthday occurs earlier in the calendar year pays the child's expenses first. When both parents' birthdays occur on the same day, the plan that has covered the parent the longest pays first. If the other plan doesn't have the parent birthday rule,the other plan's COB rule applies. 50 a child's parents are separated or divorced, If there is a court decree that states that the parents will share joint custody of a dependent child, without stating that one of the parents is responsible for the health care expenses of the child, the parent birthday rule, above, applies. • If a court decree gives financial responsibility for the child's medical, dental or other health care expenses to one of the parents, the plan covering the child as that parent's dependent determines its benefits before any other plan that covers the child as a dependent. • If there is no such court decree, the order of benefits will be determined as follows: -the plan of the natural parent with whom the child resides, -the plan of the stepparent with whom the child resides, -the plan of the natural parent with whom the child does not reside, or -the plan of the stepparent with whom the child does not reside. a person has coverage as an active employee ... the plan that covers the person as an active or as the dependent of an active employee, employee or as the dependent of an active and also has coverage as a retired or laid-off employee is primary. employee, a person is covered under a federal or state ... the benefits of a plan that covers a person right of continuation law(such as COBRA), under a right of continuation under federal or state laws will be determined after the benefits of any other plan that is not a mandated continuation plan. the above rules do not establish an order of the plan that has covered the person for the payment, longest time will pay benefits first. If the other plan pays first, the benefits paid under this plan will be reduced. Aetna will calculate the reduced amount as follows: — 100% of allowable expenses,minus — Benefits payable from your other plan(s). If other plan(s) provide benefits in the form of services rather than cash payments, the cash value of the services will be used in the calculation. 51 Right to Receive and Release Information Certain facts about health care coverage and services are needed to apply the plan's COB rules and to determine benefits under this and other plans. Aetna has the right to release or obtain any information and make or recover any payments it considers necessary in order to administer this provision. Facility of Payment Any payment made under another plan may include an amount which should have been paid under this plan. If so,Aetna may pay that amount to the organization, which made that payment. That amount will then be treated as though it were a benefit paid under this plan. Aetna will not have to pay that amount again. The term "payment made"means reasonable cash value of the benefits provided in the form of services. Right of Recovery If the amount of the payment made by Aetna is more than it should have paid under this COB provision, it may recover the excess from one or more of the persons it has paid or for whom it has paid, or from any other person or organization that may be responsible for the benefits or services provided for the covered person. The"amount of payment made" includes the reasonable cash value of any benefits provided in the form of services. 52 Claims and Benefit Payment This section explains the rules and provisions that affect claim filing and processing, and payment of benefits. Keeping Records of Expenses It's important to keep records of medical expenses for yourself and all covered family members. These will be required when you file a claim for benefits. Of particular importance are: • Names and addresses of physicians; • The dates on which expenses are incurred; and • Copies of all medical bills and receipts. Filing Claims If you use an in-network provider, your provider will generally file the claim for services provided. If you use an out-of-network provider,you must file a claim to be reimbursed for covered expenses. To file a claim, you complete a claim form. (Claim forms are available on Aetna Navigator at www.aetna.com or by calling Aetna Member Services.) The form contains instructions on how and when to file a claim, as well as the address to which you should send your completed form. ------------------------------------------------------------------------------------------------------------------- Claims should be submitted to: Aetna P.O. Box 14586 Lexington, KY 40512-4586 -----------------------------------•-------------------------------------------------------------------------------J All claims must be filed promptly. The deadline for filing a claim is 12 months after the date you incurred a covered expense. If,through no fault of your own,you are unable to meet this deadline,your claim will still be accepted if you file as soon as possible. However, if a claim is filed more than two years after the deadline, it will not be covered unless you are legally incapacitated. You can file claims for benefits and appeal adverse claim decisions yourself or through an authorized representative. An"authorized representative" is a person you authorize, in writing,to act on your behalf. The plan will also recognize a court order giving a person authority to submit claims on your behalf, except that in the case of a claim involving urgent care, a health care professional with knowledge of your condition may always act as your authorized representative. 53 If your claim is denied in whole or in part, you will receive a written notice of the denial from Aetna. The notice will explain the reason for the denial and the review procedures. Turn to the section, When You Disagree With a Claim Decision, for more information about appeals. Time Frames for Claim Processing Aetna will make a decision on your claim. For concurrent care claims, Aetna will send you written notification of an affirmative benefit determination. For other types of claims, you may only receive written notice if Aetna makes an adverse benefit determination. Aetna will provide you with written notices of adverse benefit determinations within the time frames shown in the following chart. These time frames may be extended under certain limited circumstances. The notice you receive from Aetna will provide important information that will assist you in making an appeal of the adverse benefit determination, if you wish to do so. Please see When You Disagree With a Claim Decision for more information about appeals. Type of Claim Response Time Urgent care claim: a claim for medical care or As soon as possible, but not later treatment where delay could: than 72 hours • Seriously jeopardize your life or health, or your ability to regain maximum function; or • Subject you to severe pain that cannot be adequately managed without the requested care or treatment. Pre-service claim: a claim for a benefit that requires 15 calendar days Aetna's approval of the benefit in advance of obtaining medical care (pre-certification). Concurrent care claim extension: a request to extend • Urgent care claim-as soon as a previously approved course of treatment. possible, but not later than 24 hours, provided the request was received at least 24 hours prior to the expiration of the approved treatment. • Other claims- 15 calendar days Concurrent care claim reduction or termination: a With enough advance notice to allow decision to reduce or terminate a course of treatment you to appeal that was previously approved. Post-service claim: a claim for a benefit that is not a 30 calendar days pre-service claim. Extensions of Time Frames The time periods described in the chart may be extended, as follows: 54 — For urgent care claims: If Aetna does not have sufficient information to decide the claim,you will be notified as soon as possible (but no more than 24 hours after Aetna receives the claim)that additional information is needed. You will then have at least 48 hours to provide the information. A decision on your claim will be made within 48 hours after the additional information is provided. — For non-urgent pre-service and post-service claims: The time frames may be extended for up to 15 additional days for reasons beyond the plan's control. In this case,Aetna will notify you of the extension before the original notification time period has ended. If you fail to provide the information,your claim will be denied. If an extension is necessary because Aetna needs more information to process your post service claim,Aetna will notify you and give you an additional period of at least 45 days after receiving the notice to provide the information. Aetna will then inform you of the claim decision within 15 days after the additional period has ended (or within 15 days after Aetna receives the information, if earlier). If you fail to provide the information, your claim will be denied. Payment of Benefits Benefits will be paid as soon as Aetna receives the necessary proof to support the claim. All benefits are payable to you. However,Aetna has the right to pay any benefits directly to your physician or other care provider. This will be done unless you tell Aetna otherwise by the time you file the claim. -------------------------------------------------------------------------------------------------------------------- If your claim is denied in whole or in part,you will receive a written notice of the denial from Aetna. The notice will explain the reason for the denial and the review procedures. More information about appeals follows later in this section. =--------------------------------------------------- ------------------------------------------------------------- When You Disagree With a Claim Decision The Appeal Process Aetna will send you written notice of an adverse benefit determination. The notice will give the reason for the decision and will explain what steps you must take if you wish to appeal. The notice will also tell you about your rights to receive additional information that may be relevant to the appeal. Requests for appeal must be made in writing within 180 days from the receipt of the notice. However, appeals of adverse benefit determinations involving urgent care may be made orally. -------------------------------------------------------------------------------------------------------------------- Written requests for appeal may be sent to: Aetna P.O. Box 14586 - --Lexington, KY 40512-4586 --- - - - ---- --------------------------------------- 55 The plan provides for two levels of appeal plus an option to seek external review of the adverse benefit determination. If you are dissatisfied with the outcome of your level one appeal and wish to file a level two appeal, your appeal must be filed no later than 60 days following receipt of the level one notice of adverse benefit determination. The following chart summarizes some information about how appeals are handled for different types of claims. Type of Claim Level One Appeal Level Two Appeal Response Time Response Time Urgent care claim: a claim for medical 36 hours 36 hours care or treatment where delay could: • Seriously jeopardize your life or Review provided by Review provided by health, or your ability to regain Aetna personnel not Aetna personnel not maximum function; or involved in making the involved in making the • Subject you to severe pain that adverse benefit adverse benefit cannot be adequately managed determination. determination. without the requested care or treatment. Pre-service claim: a claim for a benefit 15 calendar days 15 calendar days that requires Aetna's approval of the benefit in advance of obtaining medical Review provided by Review provided by care. Aetna personnel not Aetna personnel not involved in making the involved in making the adverse benefit adverse benefit determination. determination. Concurrent care claim extension: a Treated like an urgent Treated like an urgent request to extend a previously approved care claim or a pre- care claim or a pre- course of treatment. service claim depending service claim depending on the circumstances. on the circumstances. Post-service claim: a claim for a benefit 30 calendar days 30 calendar days that is not a pre-service claim. Review provided by Review provided by Aetna personnel not Aetna personnel not involved in making the involved in making the adverse benefit adverse benefit determination. determination. You may also choose to have another person (an authorized representative) make the appeal on your behalf by providing written consent to Aetna. In the case of an urgent care claim or a pre-service claim, a physician familiar with the case may represent you in the appeal. -------------------------------------------------------------------------------------------------------------------- If the Level One and Level Two appeals uphold the original adverse benefit determination for a medical claim, you may have the right to pursue an external review of your claim. See External Review for more information. -------------------------------------------------------------------------------------------------------------------- S6 Voluntary Appeals You may file a voluntary appeal after the standard appeals process has been exhausted. The voluntary appeal should be made to the City of Fort Worth. You must complete all levels of the standard appeal process before you can appeal to the City of Fort Worth. You, or your authorized representative, must request the voluntary level of review within 60 days after you receive the final denial notice under the standard appeal proves. If you file a voluntary appeal, any applicable statute of limitations will be suspended while the appeal is pending. Since this level of appeal is voluntary, you are not required to pursue it before initiating legal action. You must submit your voluntary appeal to the City of Fort Worth in writing and include: • The reason for the appeal; • Copies of all past correspondence with Aetna(including your Explanation of Benefits; and • Any applicable information that you have not yet sent to Aetna. The City of Fort Worth has the right to obtain information from Aetna that is relevant to your claim. The City of Fort Worth will review your appeal and make a decision within 60 days after you file your appeal. If the City of Fort Worth reviewer needs more time, the reviewer may take an additional 60 days. You will be notified in advance of this extension. The City of Fort Worth's reviewer will notify you of the final decision on your appeal electronically or in writing. The notice will give you the reason for the decision and the Plan provisions upon which the decision was based. All decisions by the City of Fort Worth will be final and binding. Claim Fiduciary The City of Fort Worth has discretionary authority to review all denied claims for benefits under the medical plan. This includes, but is not limited to, determining whether hospital or medical treatment is, or is not, medically necessary. In exercising its responsibilities, the City of Fort Worth has discretionary authority to: — Determine whether, and to what extent, you and your covered dependents are entitled to benefits; and — Construe any disputed or doubtful terms of the plan. 57 Aetna has the right to adopt reasonable policies, procedures, rules and interpretations of the plan to promote orderly and efficient administration. Aetna may not abuse its discretionary authority by acting arbitrarily and capriciously. The City of Fort Worth is responsible for making reports and disclosures required by applicable laws and regulations. Subrogation and Reimbursement As used throughout this provision, the term Responsible Party means any party actually, possibly, or potentially responsible for making any payment to a Covered Person due to a Covered Person's injury, illness or condition. The term Responsible Party includes the liability insurer of such party, or any insurance coverage. For purposes of this provision, the term Insurance Coverage refers to any coverage providing medical expense coverage or liability coverage including, but not limited to, uninsured motorist coverage, underinsured motorist coverage,personal umbrella coverage, medical payments coverage, workers compensation coverage, no-fault automobile insurance coverage or any first party insurance coverage. For purposes of this provision, a Covered Person includes anyone on whose behalf the plan pays or provides any benefit including, but not limited to, the minor child or dependent of any plan member or person entitled to receive any benefits from the plan. Subrogation Immediately upon paying or providing any benefit under this plan, the plan shall be subrogated to (stand in the place of) all rights of recovery a Covered Person has against any Responsible Party with respect to any payment made by the Responsible Party to a Covered Person due to a Covered Person's injury, illness or condition to the full extent of benefits provided or to be provided by the plan. Reimbursement In addition, if a Covered Person receives any payment from any Responsible Party or Insurance Coverage as a result of an injury, illness or condition,the plan has the right to recover from, and be reimbursed by,the Covered Person for all amounts this plan has paid and will pay as a result of that injury, illness or condition, up to and including the full amount the Covered Person receives from any Responsible Party. Constructive Trust By accepting benefits (whether the payment of such benefits is made to the Covered Person or made on behalf of the Covered Person to any provider) from the plan, the Covered Person agrees that if he/she receives any payment from any Responsible Party as a result of an injury, illness or condition, he/she will serve as a constructive trustee over 58 the funds that constitute such payment. Failure to hold such funds in trust will be deemed a breach of the Covered Person's fiduciary duty to the plan. Lien Rights Further, the plan will automatically have a lien to the extent of benefits paid by the Plan for the treatment of the illness, injury or condition for which Responsible Party is liable. The lien shall be imposed upon any recovery whether by settlement,judgment or otherwise, including from any Insurance Coverage, related to treatment for any illness, injury or condition for which the plan paid benefits. The lien may be enforced against any party who possesses funds or proceeds representing the amount of benefits paid by the Plan including, but not limited to,the Covered Person; the Covered Person's representative or agent;Responsible Party;Responsible Party's insurer, representative agent; and/or any other source possessing funds representing the amount of benefits paid by the plan or the City of Fort Worth. First-Priority Claim By accepting benefits (whether the payment of such benefits is made to the Covered Person or made on behalf of the Covered Person to any provider) from the plan, the Covered Person acknowledges that this plan's recovery rights are a first priority claim against all Responsible Parties and are to be paid to the plan before any other claim for the Covered Person's damages. This plan shall be entitled to full reimbursement on a first-dollar basis from any Responsible Party's payments, even if such payment to the plan will result in a recovery to the Covered Person which is insufficient to make the Covered Person whole or to compensate the Covered Person in part or in whole for the damages sustained. The plan is not required to participate in or pay court costs or attorney fees to any attorney hired by the Covered Person to pursue the Covered Person's damage claim. Applicability to All Settlements and Judgments The terms of this entire subrogation and right of recovery provision shall apply and the plan is entitled to full recovery regardless of whether any liability for payment is admitted by any Responsible Party and regardless of whether the settlement or judgment received by the Covered Person identifies the medical benefits the plan provided or purports to allocate any portion of such settlement or judgment to payment of expenses other than medical expenses. The plan is entitled to recover from any and all settlements or judgments, even those designated as pain and suffering, non-economic damages and/or general damages only. Cooperation The Covered Person shall fully cooperate with the plan's efforts to recover its benefits paid. It is the duty of the Covered Person to notify the plan within 30 days of the date when any notice is given to a party, including an insurance company or attorney, of the 59 Covered Person's intention to pursue or investigate a claim to recover damages or obtain compensation due to injury, illness or condition sustained by the Covered Person. The Covered Person and his/her agents shall provide all information requested by the plan, the Claims Administrator or its representative including, but not limited to, completing and submitting any applications or other forms or statements as the plan may reasonable request. Failure to provide this information may result in the termination of health benefits for the Covered Person or the institution of court proceedings against the Covered Person. The Covered Person shall do nothing to prejudice the plan's subrogation or recovery interest or to prejudice the plan's ability to enforce the terms of this plan provision. This includes, but is not limited to, refraining from making any settlement or recovery that attempts to reduce or exclude the full cost of all benefits provided by the plan. The Covered Person acknowledges that the plan has the right to conduct an investigation regarding the injury, illness or condition to identify any Responsible Parry. The plan reserves the right to notify Responsible Parry and his/her agents of its lien. Agents include, but are not limited to, insurance companies and attorneys. Interpretation In the event that any claim is made that any part of this subrogation and right of recovery provision is ambiguous or questions arise concerning the meaning or intent of any of its terms,the Claims Administrator for the plan shall have the sole authority and discretion to resolve all disputes regarding the interpretation of this provision. Jurisdiction By accepting benefits (whether the payment of such benefits is made to the Covered Person or made on behalf of the Covered Person to any provider) from the plan, the Covered Person agrees that any court proceeding with respect to this provision may be brought in any court of competent jurisdiction as the plan may elect. By accepting such benefits, the Covered Person hereby submits to each such jurisdiction, waiving whatever rights may correspond to him/her by reason of his/her present or future domicile. 60 When Coverage Ends Your coverage under this plan can end for a number of reasons. This section explains how and why your coverage can be terminated, and how you may be able to continue coverage after it ends. For Employees Your coverage under this plan ends at the end of the period for which contributions were made following the date: — Your employment stops; — The coverage described in this booklet is terminated under the group contract; — You are no longer in an eligible class for all or part of your coverage; or — You fail to make any required contribution. For Dependents Your dependent's coverage will end on the earliest to occur of the following events: — When all dependents' coverage under the group contract is terminated; — When a dependent becomes covered as an employee (a person cannot be covered as both an employee and a dependent); — The end of the month when he or she no longer meets the plan's definition of a dependent(see the Eligibility section); or • When your coverage terminates. -------------------------------------------------------------------------------------------------------------------- A notice of your rights to continue coverage will be sent to the last address provided to the City's Human Resources. ------------------------------------------------------------------------------------------------------------------ 61 Continuing Coverage under COBRA Under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), you and your dependents have the right to continue health coverage if it ends for the reasons ("qualifying events") described below. You may continue only the plan coverage in effect at the time and must pay required premiums. Qualifying Events and Continuation Periods The chart below outlines: • The qualifying events that trigger the right to continue coverage; • Those eligible to elect continued coverage; and • The maximum continuation period. Qualifying Event Covered Persons Maximum Causing Eligible for Continuation Loss of Coverage- Continued'Coverage Period Termination of active employment You 18 months (except for gross misconduct) Your spouse Your dependent children Reduction in work hours You 18 months Yourspouse Your dependent children Termination of active employment due to You 24 months military leave (USERRA) Your spouse Your dependent children Divorce or legal separation Your spouse 36 months Your dependent children Children no longer qualify as eligible for Your dependent children 36 months dependent coverage Your death Your spouse 36 months Your dependent children The required premium for the 18- or 36-month continuation period may be up to 102%of the plan cost. Disability Extension The 18-month continuation period may be extended for an additional 11 months if you or your covered dependents qualify for disability status under Title II or XVI of the Social Security Act during the 18-month continuation period. The additional 11 months of continued coverage is available for the disabled individual and any family member of the disabled person. The City of Fort Worth must be notified of a determination of disability within 60 days of the date of the determination and before the end of the 18-month continuation period. 62 The required premiums for the 18''through 29th month of continued coverage may be up to 150%of the plan cost. Multiple Qualifying Events If your spouse or dependent children experience a second qualifying event during the 18- or 29-month continuation period, their maximum continuation period can be extended to 36 months. Electing Continued Coverage The City of Fort Worth will notify Aetna who will give you detailed information about how to continue coverage under COBRA at the time you or your dependents become eligible. You or your dependents will need to elect continued coverage within 60 days of the"qualifying event" or the date of your COBRA notice, if later. The election must include an agreement to pay required premiums. Your dependents will need to notify the City of Fort Worth within 60 days of a divorce or legal separation or loss of dependent child eligibility, or the date coverage ends due to those circumstances, if later. Acquiring New Dependents During Continuation If you acquire any new dependents during a period of continuation (through birth, adoption or marriage), they can be added for the remainder of the continuation period if: • They meet the definition of an eligible dependent; • You notify The City of Fort Worth within 31 days of their eligibility; and • You pay the additional required premiums. When COBRA Continuation Ends Continued coverage ends on the first of the following events: • The end of the maximum COBRA continuation period; • Failure to pay required premiums; • Coverage under another group plan that does not restrict coverage for preexisting conditions; • The City of Fort Worth no longer offers a group health plan; • You or your dependents die. When you or a family member on COBRA becomes enrolled in Medicare, continued City of Fort Worth plan coverage is secondary to Medicare. 63 Other Continuation Provisions If this plan contains any other continuation provisions, contact the City of Fort Worth for information on how they may affect COBRA continuation provisions. Continuing Coverage During an FMLA Leave If the City of Fort Worth grants you an approved family or medical leave of absence in accordance with the Family and Medical Leave Act of 1993 (FMLA), you may continue coverage for yourself and your eligible dependents during your approved leave. You must agree to make any required contributions. If the City of Fort Worth grants you an approved FMLA leave for longer than the period required by FMLA, the City of Fort Worth will determine how your coverage will be continued. At the time you request the leave, you must agree to make any contributions required to continue coverage. If the plan has reduction rules that apply because of age or retirement, those rules will apply while you are on FMLA leave. When Continued Coverage Ends Coverage will end at the first to occur of the following: — The date you fail to make any required contribution; — The date The City of Fort Worth determines that your approved FMLA leave is terminated; or — The date the coverage involved discontinues for your eligible class. However, coverage for health expenses may be available to you under another plan sponsored by the City of Fort Worth. Any coverage being continued for a dependent will not be continued beyond the date it would otherwise terminate. COBRA Continuation Coverage After a Terminated Leave If health coverage ends because your approved FMLA leave is considered terminated by The City of Fort Worth, you may, on the date of such termination, be eligible for continuation coverage under COBRA. COBRA coverage will be available on the same terms as though your employment terminated, other than for gross misconduct, on such date. If this plan provides any other continuation of coverage (for example, upon termination of employment, death, divorce or ceasing to be a defined dependent), you (or your eligible dependents) may be eligible for such continuation on: 64 — The date The City of Fort Worth determines that your approved FMLA leave is at an end; or — The date of the event for which the continuation is available. Acquiring a New Dependent During an FMLA Leave If you acquire a new dependent while your coverage is continued during an approved FMLA leave, the dependent will be eligible for the continued coverage on the same terms as would be applicable if you were actively at work, not on an approved FMLA leave. 65 Your Privacy Under HIPAA The Health Insurance Portability and Accountability Act(HIPAA) of 1996 gives you certain rights of privacy concerning your health information. The regulation designates certain medical information as Protected Health Information (PHI). PHI is any information that could be used to identify you as an individual in electronic, printed or spoken form. PHI consists of information that relates to past, present or future health or physical or mental conditions. You have the right to: • Receive notice of your privacy rights,policies and procedures; • Obtain access to your PHI; • Amend your PHI; • Authorize use and disclosure of your PHI; • Receive an accounting of uses and disclosures of your PHI; • Receive communications by an alternative means or at an alternative location. Your health care providers must obtain your written consent to use or disclose your PHI for any purpose other than: • Treatment; • Payment; • Health care operations; or • As required by a national public health initiative, law enforcement investigations and other such laws (e.g., Occupational Safety and Health Administration regulations). There are also times when your PHI may be used or disclosed without your consent. These permitted uses include disclosure: • To you; • In case of an emergency where your provider cannot get authorization; • When treatment is required by law; • Where language barriers exist but consent can be inferred; • Pursuant to an authorization from you; • To business associates(consultants and other entities who contract with the City of Fort Worth and comply with the privacy rules); and • When all information that could identify you is removed from your PHI. You may be asked to authorize your PHI for another purpose. When you grant this authorization, your PHI is still protected from use and disclosure by any party other than the one(s) to whom you grant written authorization, and from use and disclosure by authorized parties for any purpose other than the one you specifically authorized. 66 Other Plan Provisions Type of Coverage Only non-occupational (not job-related) accidental injuries and non-occupational diseases are covered under this plan. Coverage for services and supplies applies only if they are provided to a person at the time he or she is covered under the plan. Multiple Employers and Misstatement of Fact You cannot receive multiple coverage under this plan because you are connected with more than one employer. If there is a misstatement of fact that affects your coverage under this plan, the true facts will be investigated to determine the coverage that applies. Assignment of Coverage Coverage may be assigned (signed over to another person) only with Aetna's written permission. 67 Glossary The terms that appear in bold print throughout this booklet are defined in this section. Brand-Name Drug This is a prescription drug protected by trademark registration. Companion This is a person who needs to be with an NME patient to enable him or her: • To receive services in connection with an NME (National Medical Excellence) procedure or treatment on an inpatient or outpatient basis; or • To travel to and from the facility where treatment is given. Co-pay/Co-payment This is a flat fee, which represents a portion of the applicable expense. (Co-payments for your City of Fort Worth medical and prescription drug plan do not accumulate towards your out-of-pocket maximum.) Custodial Care This means services and supplies— including room and board and other institutional care —provided to help a person in the activities of daily life. The person does not have to be disabled. Such services and supplies are custodial care no matter who prescribes, recommends or performs them. Durable Medical Equipment This is equipment—and the accessories needed to operate it—that is: • Made to withstand prolonged use; • Made for and mainly used in the treatment of a disease or injury; and • Suited for use in the home. 68 Effective Treatment of Alcoholism or Drug Abuse This means a program of alcoholism or drug abuse therapy that is prescribed and supervised by a physician and either: • Has a follow up therapy program directed by a physician on at least a monthly basis; or • Includes meetings at least once a month with organizations devoted to the treatment of alcoholism or drug abuse. Detoxification(treating the aftereffects of a specific episode of alcohol or drug abuse) and maintenance care (providing an alcohol- and/or drug-free environment) are not considered "effective treatment." Emergency Admission This means a hospital admission where the physician admits the person to the hospital or treatment facility right after the sudden and, at that time, unexpected onset of a change in the person's physical or mental condition: — Which requires confinement right away as a full-time inpatient; and — For which, if immediate inpatient care were not given, could (as determined by Aetna), reasonably be expected to result in: — Placing the person's health in serious jeopardy; or — Serious impairment to bodily function; or — Serious dysfunction of a body part or organ; or — Serious jeopardy to the health of the fetus (in the case of a pregnant woman). Emergency Care This means the treatment given in a hospital's emergency room to evaluate and treat medical conditions of a recent onset and severity—including but not limited to severe pain—which would lead a prudent layperson,possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that failure to get immediate medical care could result in: • Placing the person's health in serious jeopardy; or • Serious impairment to bodily function; or • Serious dysfunction of a body part or organ; or • Serious jeopardy to the health of the fetus (in the case of a pregnant woman). 69 Emergency Condition This means a recent and severe medical condition—including but not limited to severe pain—which would lead a prudent layperson,possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in: • Placing the person's health in serious jeopardy; or • Serious impairment to bodily function; or • Serious dysfunction of a body part or organ; or • Serious jeopardy to the health of the fetus (in the case of a pregnant woman). Some examples of emergency conditions include: • Serious injury, severe pain or infection; • Poisoning; • Uncontrollable bleeding; • Sudden change of vision; • Chest pain; • Sudden weakness or trouble talking; • Major burns; • Spinal injury; • Difficulty breathing; • Broken bones. Home Health Care Agency This is an agency that: • Mainly provides skilled nursing and other therapeutic services; and • Is associated with a professional group (of at least one physician and one R.N.) which makes policy; and • Has full-time supervision by a physician or an R.N.; and • Keeps complete medical records on each person; and • Has an administrator; and • Meets licensing standards. Home Health Care Plan This is a plan that provides for care and treatment in a person's home. It must be: • Prescribed in writing by the attending physician; and • An alternative to confinement in a hospital or convalescent facility. 70 Hospice Care This is care provided to a terminally ill person by or under arrangements with a hospice care agency. The care must be part of a hospice care program. Hospice Care Agency This is an agency or organization that: • Has hospice care available 24 hours a day. • Meets any licensing or certification standards established by the jurisdiction where it is located. • Provides: — Skilled nursing services; and — Medical social services; and — Psychological and dietary counseling. — Provides, or arranges for, other services which include: — Physician services; and — Physical and occupational therapy; and — Part-time home health aide services which mainly consist of caring for terminally ill people; and — Inpatient care in a facility when needed for pain control and acute and chronic symptom management. • Has at least the following personnel: — One physician; and — One R.N.; and — One licensed or certified social worker employed by the agency. • Establishes policies about how hospice care is provided. • Assesses the patient's medical and social needs. • Develops a hospice care program to meet those needs. • Provides an ongoing quality assurance program. This includes reviews by physicians, other than those who own or direct the agency. • Permits all area medical personnel to utilize its services for their patients. • Keeps a medical record on each patient. • Uses volunteers trained in providing services for non-medical needs. • Has a full-time administrator. Hospice Care Facility This is a facility, or distinct part of one,which: • Mainly provides inpatient hospice care to terminally ill persons. • Charges patients for its services. • Meets any licensing or certification standards established by the jurisdiction where it is located. • Keeps a medical record on each patient. • Provides an ongoing quality assurance program including reviews by physicians other than those who own or direct the facility. 71 • Is run by a staff of physicians. At least one staff physician must be on call at all times. • Provides 24-hour-a-day nursing services under the direction of an R.N. • Has a full-time administrator. Hospice Care Program This is a written plan of hospice care,that: • Is established by and reviewed from time to time by the person's attending physician and appropriate hospice care agency personnel. • Is designed to provide palliative (pain relief) and supportive care to terminally ill people and supportive care to their families. • Includes an assessment of the person's medical and social needs, and a description of the care to be given to meet those needs. Hospital This is a place that: • Mainly provides inpatient facilities for the surgical and medical diagnosis, treatment, and care of injured and sick persons. • Is supervised by a staff of physicians. • Provides 24-hour-a-day R.N. service. • Is not mainly a place for rest, for the aged, for drug addicts, for alcoholics, or a nursing home. • Charges for its services. In-Network Care This is a health care service or supply furnished by: • A person's primary care physician (PCP) or any other network provider; • Any health care provider who is not a network provider when there is an emergency condition and travel to an in-network provider is not possible. • An out-of-network urgent care provider when travel to an in-network urgent care provider for treatment is not feasible. Care recommended and approved by the Behavorial Health Care Center is also considered in-network care. 72 In-Network Provider This is a health care provider who has contracted to furnish services or supplies for a negotiated charge, but only if the provider is, with Aetna's consent, included in the directory or DocFind as an in-network care provider for: • The service or supply involved; and • The class of employees to which you belong. L.P.N. This means a licensed practical nurse. Mental Disorder This is a disease commonly understood to be a mental disorder whether or not it has a physiological or organic basis. Treatment for mental disorders is usually provided by or under the direction of a mental health professional such as a psychiatrist,psychologist or psychiatric social worker. Mental disorders include (but are not limited to): • Alcoholism and drug abuse • Schizophrenia • Bipolar disorder • Pervasive mental developmental disorder(autism) • Panic disorder • Major depressive disorder • Psychotic depression • Obsessive compulsive disorder For the purposes of benefits under this plan, mental disorder will include alcoholism and drug abuse only if there is no separate benefit for the treatment of alcoholism and drug abuse. Necessary A service or supply is necessary if Aetna determines that it is appropriate for the diagnosis, care, or treatment of the disease or injury involved. To be appropriate, the service or supply must: • Be care or treatment, as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the person's overall health condition; • Be a diagnostic procedure, indicated by the health status of the person, and be as likely to result in information that could affect the course of treatment as, and no 73 more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the person's overall health condition; and • As to diagnosis, care and treatment be no more costly (taking into account all health expenses incurred in connection with the service or supply) than any alternative service or supply to meet the above tests. In determining if a service or supply is appropriate under the circumstances, Aetna will take into consideration: • Information provided on the person's health status; • Reports in peer-reviewed medical literature; • Reports and guidelines published by nationally recognized health care organizations that include supporting scientific data; • Generally recognized professional standards of safety and effectiveness in the United States for diagnosis, care or treatment; • The opinion of health professionals in the generally recognized health specialty involved; and • Any other relevant information brought to Aetna's attention. The following services or supplies are not considered necessary: • Those that do not require the technical skills of a medical, mental health or dental professional; or • Those provided mainly for the personal comfort or convenience of the person, any person who cares for him or her, any person who is part of his or her family, any healthcare provider or health care facility; or • Those provided only because the person is an inpatient on any day when the person's disease or injury could safely and adequately be diagnosed or treated while not confined as an inpatient; or • Those provided only because of the setting, if the service or supply could safely and adequately be furnished in a physician's or a dentist's office or other less costly setting. Negotiated Charge This is the maximum charge an in-network provider has agreed to make for any service or supply for the purpose of benefits under this plan. Non-Occupational Disease A non-occupational disease is a disease that does not: • Result from(or in the course of) any work for pay or profit; or • Result in any way from a disease that does. 74 A disease will be considered non-occupational regardless of its cause if proof is provided that the person: • Is covered under any type of workers' compensation law; and • Is not covered for that disease under such law. Non-occupational Injury A non-occupational injury is an accidental bodily injury that does not: • Result from (or in the course of) any work for pay or profit; or • Result in any way from an injury that does. Out-of-Network Provider This is a health care provider who does not belong to Aetna's network and has not contracted with Aetna to furnish services or supplies at a negotiated charge. Physician The following practitioners are recognized as legally qualified physicians when they are rendering a covered service: • Medical Doctor(M.D.) • Doctor of Osteopathy (D.O.) • Doctor of Dental Surgery (D.D.S.) or Dentist (D.D.S.) • Podiatrist (D.P.M.), (D.S.C.) • Doctor of Chiropractic (D.C.) • Licensed Professional Counselor(L.P.C.) • Optometrist(O.D.) • Psychologist(Ph.D.), (Ed. D.) • Social Worker(M.S.W.) Prescription Drugs Any of the following: • A drug, biological or compounded prescription which, by federal law, may be dispensed only by prescription and which is required to be labeled "Caution: Federal Law prohibits dispensing without prescription". • An injectable contraceptive drug prescribed to be administered by a paid health care professional. • An injectable drug prescribed to be self-administered or administered by another person except someone who is acting within his or her capacity as a paid health care professional. 75 • Disposable needles and syringes purchased to administer a covered injectable prescription drug. Primary Care Physician (PCP) This is a network provider who is: • Chosen by a covered person from the provider directory or at DocFind online; • Responsible for a person's ongoing health care R.N. This means a registered nurse. Room and Board Charges Charges made by an institution for room and board and other necessary services and supplies. The charges must be regularly made at a daily or weekly rate. If a hospital or other health care facility doesn't identify the specific amounts charged for room and board charges and other charges, Aetna will assume that 40%of the total is the room and board charge, and 60%is other charges. Semi-Private Room Rate This is the room and board charge that an institution applies to the most beds in its semi- private rooms with 2 or more beds. If there are no such rooms, Aetna will figure the rate. It will be the rate most commonly charged by similar institutions in the same geographic area. Skilled Nursing Facility This is an institution that: • Is licensed to provide, and does provide, the following on an inpatient basis for persons convalescing from disease or injury: — Professional nursing care by a R.N., or by a L.P.N. directed by a full-time R.N.; and — Physical restoration services to help patients to meet a goal of self-care in daily living activities. • Provides 24-hour-a-day nursing care by licensed nurses directed by a full-time R.N. • Is supervised full-time by a physician or R.N. • Keeps a complete medical record on each patient. • Has a utilization review plan. 76 • Is not mainly a place for rest, for the aged, for drug addicts, for alcoholics, for people who are mentally retarded, for custodial or educational care, or for care of mental disorders. • Charges for its services. Specialist A specialist is a physician who practices in any generally accepted medical or surgical subspecialty, and provides care that is not considered routine medical care. A physician who practices in such a subspecialty and provides routine medical care that could be provided by a PCP will not be considered a specialist for the purposes of applying this plan's co-pay provisions. Terminally 111 This is a medical prognosis of 6 months or less to live. Treatment Facility(Alcoholism or Drug Abuse) This is an institution that: • Mainly provides a program for diagnosis, evaluation and effective treatment of alcoholism or drug abuse. • Makes charges. • Meets licensing standards. • Prepares and maintains a written plan of treatment for each patient. The plan must be based on medical, psychological and social needs, and must be supervised by a physician. • Provides, on the premises, 24 hours a day: — Detoxification services needed with its effective treatment program. — Infirmary-level medical services. Also, it provides, or arranges with a hospital in the area for, any other medical services that may be required. — Supervision by a staff of physicians. — Skilled nursing care by licensed nurses directed by a full-time R.N. CCG CFW CPOS II SPD-06-0598(10/07) 77 City of Fort Worth Health Benefit Plan Summary Plan Description Aetna Group Number: 889000 Aetna Traditional Plan For Retirees, Survivors and Dependents who are eligible for Medicare Part A or Medicare Part A and Part 8 Effective: January 1, 2005 Restated: October 1, 2007 This page intentionally left blank. ii Table of Contents Introduction....................................................................................................................... 1 Your Health Care Coverage ............................................................................................ 2 Benefits Assistance and Resources.................................................................................. 3 Eligibility............................................................................................................................ 5 Retirees ........................................................................................................................... 5 Dependents of Retirees and Vested Employees.............................................................. 5 ImportantPlan Terms...................................................................................................... 8 How the Plan Works for Medical Services Not Covered by Medicare........................ 9 The National AdvantageTM Program............................................................................... 9 Summaryof Benefits ...................................................................................................... 9 What the Medical Plan Covers...................................................................................... 13 PhysicianServices ........................................................................................................ 13 HospitalServices ........................................................................".....I............................ 14 EmergencyCare............................................................................................................ 15 Skilled Nursing/Convalescent Care............................................................................ 16 HomeHealth Care......................................................................................................... 16 HospiceCare................................................................................................................. 17 Short-Term Rehabilitation............................................................................................ 19 Chiropractic Care (Spinal Manipulation)...................................................................... 20 FamilyPlanning............................................................................................................ 20 Mental Health and Substance Abuse Treatment........................................................... 20 OralSurgery.................................................................................................................. 21 Durable Medical Equipment......................................................................................... 22 Diabetic Equipment, Supplies and Education............................................................... 22 Other Covered Expenses............................................................................................... 23 Prescription Drug Benefits............................................................................................. 24 RetailPharmacy............................................................................................................ 24 Mail Order Prescriptions............................................................................................... 24 What the Prescription Drug Program Covers ............................................................... 25 What the Prescription Drug Program Does Not Cover................................................. 25 Women's Health Provisions........................................................................................... 26 The Newborns' and Mothers' Health Protection Act................................................... 26 The Women's Health and Cancer Rights Act...............................................................26 SpecialPrograms ............................................................................................................ 27 The National Medical Excellence Program® (NME).................................................... 27 InformedHealth®Line.................................................................................................. 29 What the Medical Plan Does Not Cover....................................................................... 30 Coordination With Other Plans .................................................................................... 34 Claims and Benefit Payment.......................................................................................... 36 FilingClaims................................................................................................................. 36 When You Disagree With a Claim Decision................................................................ 39 WhenCoverage Ends ..................................................................................................... 45 ForRetired Employees ................................................................................................. 45 ForDependents............................................................................................................. 45 Continuing Coverage under COBRA ........................................................................... 45 iii Your Privacy Under HIPAA.......................................................................................... 48 Other Plan Provisions..................................................................................................... 49 Typeof Coverage.......................................................................................................... 49 Multiple Employers and Misstatement of Fact............................................................. 49 Glossary ........................................................................................................................... 50 iv Introduction The medical plan described in this booklet is an important employee benefit designed to help keep good health care affordable for you and your family. It provides benefits for preventive care and access to special programs that focus on helping you stay healthy, plus the coverage you need when an illness or injury strikes. This Benefits Summary describes your benefits as well as your rights and responsibilities when accessing care through the City of Fort Worth Health Benefit Plan. To take full advantage of all that your plan offers, it's important to know how the plan works—and how to make it work for you. Reading this booklet is a great place to start. In This Booklet This Summary Plan Description describes the City of Fort Worth Aetna Traditional Indemnity Medical Plan option effective January 1, 2005. It describes the main features of the plan—who is eligible for coverage, what is covered and not covered, what to do when you need care, how the plan pays benefits, and when coverage ends. To understand what certain important words in bold type mean, turn to the Glossary at the back of the booklet. The words "we," "us," and "our" in this document refer to the City of Fort Worth. The words "you" and "your' refer to people who are covered persons as defined in the Eligibility section of this booklet. The term Plan Administrator refers to the City of Fort Worth. Your Contribution to the Benefit Costs The Plan may require you to contribute to the cost of coverage. A copy of the rates is available in the Benefits Division of the Human Resources office. Contact your City of Fort Worth Benefits Representative for information about any part of this cost you may be responsible for paying. Important Notices The plan described in this booklet is administered by Aetna Life Insurance Company of Hartford, Connecticut (referred to as "Aetna"). The benefits are effective only while you are covered under the plan. This summary contains information about the Traditional Plan. If you have coverage under the Basic, Basic Plus or Select Plan,you should read the appropriate Summary Plan Description for that plan. 1 Your Health Care Coverage The plan covers medically necessary health care expenses as well as certain preventive care expenses that are incurred while your coverage is in effect. An expense is incurred on the day you receive a health care service or supply. The plan does not pay benefits for expenses incurred before your coverage starts or after it ends. When a single charge is made for a series of services, each service will be assigned a pro rata(evenly divided) share of the expense. Aetna will determine the pro rata share. Only the pro rata share of the expense will be considered as incurred on the date of the health care service. Outcome of Covered Services and Supplies Aetna is not responsible for and makes no guarantees concerning the outcome of the covered services and supplies you receive. 2 Benefits Assistance and Resources When you need help, answers or information,here are some resources available to you. Telephone Web Site Aetna Member Servjces) Claret statris,�"Vovered services,`and 6eneft levels, aetwark�rnv,ders, eplacemenf!D carats; access 10'S ecral ra rams .. • Active Employees 888-398-4467 • Retirees 888-397-4537 Aetna Navigator at • COBRA 800-429-9526 www.aetna.com • Aetna On-site Representative 817-392-7780 Clty of Fort llVorth HR/E rnployee Benefits 4;, ;4ddiess-and Tamil status than es City of Fort Worth Benefits Office Lower Level 817-392-8577 --- 1000 Throckmorton Street Fort Worth, TX 76102 :Aetna,Ciaims'sutimiss on-Address -777777777 Aetna P.O. Box 14586 Lexington, KY 40512-4586 ID Cards When you enroll in the plan,you receive an ID card. If you cover your spouse,you will receive an additional card for your spouse. The ID card shows: • The name and identification number of each covered family member • The Aetna Member Services telephone number and address MAP F4RrWoRni CITY 6f MET S1f y*1 CHOICETM PQS II nrm pm%i P—i own ID W1141 73954 M .670..Dom a+W;.icwz W. 0; C.� TT__T PCP: '40 ;LsCT10% 1[004CD Front of ID Card 1EnEEk lnul�S 1%b Z%"47 as b S.4L ntre'.Dm CALL 1-SEE 672.AS2 SP:b n-O? eX�DF.PF.Hr-k M&4 ONE 3 r+:•.-V Aetna.con Y cntal health i'substance ebuse cweroge: precertification or qu ez .one cell 1-800-i_i-4047. PCP co-pay applies to •:our selected FCF, the specialist copPe,• apPpPlies to ell other participating ph_sicians. REFERFokL� APE IJOT REQUIREC�. For services that require precertification, call the number on the front of this card. In an eaergene.,, call the local Back of ID Card hotline b 911 or go to the nearest emergency facili t:. Ilotii Yeaber 3erriceg prom the after treatment. °While ' corerage i in force, members are entitled to plan benefits. subject to ea elusions end limitations. For eligibility-:benefit information, call Member Serrices. Forticipating doctors and hospitals ore independent providers and are neither agents nor enplo.;ees of Aetna. Plan underc•:ritten or administered 1; Aetna Life Insurance Co. This card does not guarantee coferage. AETIhi F.O. BOX 14586 LE€IIJGTOIJ t-f 41,512.4586 ter. Aetna NavigatorTm Aetna Navigator is Aetna's self-service website that you can visit for health and benefits information, self-service features, interactive tools and more. After a simple registration process, you can use Aetna Navigator to verify eligibility information, check benefits and claim status, and as your gateway to: • DoeFind°, Aetna's online provider directory that gives you the most recent information on Aetna's network doctors, hospitals and other providers. You can learn about each provider's credentials and practice, including education, board certification, languages spoken, office location and hours, and parking and handicapped access. In DocFind, choose "Aetna Choice POS II" from the list of Aetna Open Access plans to find network providers in your area. • Intelihealth9,Aetna's health website that you can search for topics from specific health conditions and their treatment to developments in disease prevention, wellness and fitness. • Healthwise°Knowledgebase, an innovative decision-support tool that provides information on thousands of health-related topics to help you make better decisions about health care and treatment options. • Health History Report, an easy-to-understand, printable summary of doctor visits, tests, treatments and other health-related activity. Visit Aetna Navigator at www.aetna.com. 4 Eli ibilit These are eligibility rules for retired employees and their spouses and dependents who have permanent residency within the United States for participation in the City's group health benefits program. These rules may be amended from time to time. Please contact the Human Resources Department for the latest revision of this information. Retirees Specific Rule for Enrollment in the Traditional Plan A City of Fort Worth retiree and eligible dependent(s) or eligible surviving dependent(s) of a retiree must be enrolled in Medicare Part A or Part A and Part B*. An eligible Retiree is one: 1. Who has retired and is receiving pension disbursements from the City of Fort Worth Retirement System; or 2. Who has vested, but who has not elected to begin distribution. NOTE: If an eligible retiree fails to enroll and add eligible dependents within sixty (60) days of loss of coverage as an active employee, the retiree and eligible dependents will not be eligible to enroll in the City's plan at any time in the future. * A covered retiree's election not to enroll in Part B of Medicare has the potential to expose the covered retiree to significant expense at the time of claim. The same is true of the covered Medicare-eligible dependents of the retiree. An eligible retiree enrolled only in Medicare Part B must enroll in one of the City's Choice POS II Plans. They are Basic, Basic Plus and Select. The retiree cannot enroll in the Traditional Choice Plan. Dependents of Retirees and Vested Employees The following rules determine dependent eligibility for the City's health plan. A dependent is only eligible for the Traditional Plan if he or she satisfies these rules and is also enrolled in Medicare Part A only or Medicare Part A and Part B. If a dependent satisfies the following rules but is not covered by Medicare, the dependent would be eligible for coverage under one of the City's POS plans. 1. To be eligible to enroll as a dependent, a person must be: a. either the spouse of a covered retired, or 5 b. the surviving spouse of a covered retired or vested employee at the time of the employee's retirement or at the time of the employee's election of coverage as a vested employee. c. a dependent unmarried natural child, foster child, stepchild, legally adopted child or child under the covered retired or vested employee's legal guardianship or custodianship, residing with the covered retired or vested employee or with the covered retired or vested employee's present or former spouse who is: • under nineteen (19) years of age, or • under twenty-three (23) years of age, primarily dependent on the covered retired or vested employee for financial support and attending a state accredited college, university, trade, or secondary school on a full time basis, which has, in writing, verified said attendance, or d. a dependent unmarried natural child, foster child, stepchild, legally adopted child or child under the covered retired or vested employee's legal guardianship or custodianship, residing with the covered retired or vested employee or with the covered retired or vested employee's present or former spouse, who is nineteen (19) years of age or older but incapable of self-sustaining employment because of mental retardation or physical handicap commenced prior to age nineteen (19) (or commenced prior to age twenty-three (23) if such child was attending a recognized college or university, trade or secondary school on a full-time basis when such incapacity occurred) and primarily dependent upon the Enrollee for support and maintenance. Such dependent child must have been enrolled under the City's benefit plan either prior to attaining nineteen (19) years of age or twenty-three (23) years of age under the conditions of the previous sentence. The covered retired or vested employee shall give the City proof of such incapacity and dependency within thirty-one (31) days before the dependent child's attainment of the limiting age and from time to time thereafter as the City deems appropriate, or e. the dependents of a retired employee who are entitled to receive survivor pension benefits through the City of Fort Worth and who were enrolled as dependents on the retired employee's plan at the time of the employee's death provided they enroll within sixty (60) days of the death of the covered retired employee, or f. dependents who became covered prior to the date of the Member's retirement provided they are enrolled on or before the covered retiree's date of retirement except certain newborn children, or 6 g. a newborn child of a covered retired employee, or a spouse of a covered retired employee, and/or of a covered retiree's covered unmarried dependent child that results from a pregnancy that existed at the time of the covered retired or vested employee's date of retirement shall be covered for an initial period of thirty-one(31) days from the date of birth, and shall continue to be so covered after that time only if, prior to the expiration of such thirty-one (31) day period, the covered retired or vested employee notifies the Human Resources Department with an application submitted for such newborn child. Newborn children of a covered retired employee, of a covered retired employee's spouse, and/or of the retiree's covered unmarried dependent from a pregnancy that occurs after retirement, shall be covered for a period of thirty-one (31) days from the date of birth only. Retired employees are required to make a contribution for the cost of their dependent's coverage as set forth by the City Council and as may be amended from time to time. Survivors are required to make contribution for the cost of their coverage as set forth by the City Council and as may be amended from time to time. Method of Payment Retirees who participate in the cost of their own health coverage and who pay for eligible dependent coverage authorize deductions for the required participation through deductions from their monthly pension checks. Retirees whose monthly pension checks are insufficient to pay the premium must arrange a payment plan with the Human Resources Department to make supplemental payments to maintain the desired coverage. Arrangements are to be made for monthly payments in advance. In cases of extreme hardship, supplemental payment monthly in advance may be granted. If a retired employee falls into arrears in required contributions, he/she will be notified and will be allowed to correct the arrearage. If the arrearage continues 45 days after notification, coverage for all dependents will be terminated and the retiree's health benefits reduced to the "no cost participation required" level of benefits if the retiree is eligible for such a plan or terminated if any payment by the retiree is required to keep coverage in effect. 7 Important Plan Terms Depending upon your years of service with the City, you may share in the cost of your care by making premium contributions. In addition, you may also be required to pay coinsurance. The plan pays part of your covered expense and any amount paid by you is called coinsurance. The member's coinsurance percentage for the Traditional Plan is generally 10%. However, this 10% coinsurance may be reduced or even eliminated if Medicare has made a payment on your claim. The plan puts a limit on the dollar amount you pay for covered expenses out of your own pocket—called the coinsurance out-of-pocket maximum. The coinsurance out-of- pocket maximum is shown in the Summary of Benefits that can be found later in this booklet. Once your share of covered expenses reaches the individual out-of-pocket maximum, the plan pays 100% of covered expenses for the rest of the plan year. Each January 1, you start over with a new coinsurance out-of-pocket maximum. 8 How the Plan Works for Medical Services Not Covered by Medicare Your health plan is Aetna's Traditional Indemnity Plan. With this indemnity plan, you and your covered family members have the freedom to receive care from any licensed physician, hospital or other heath care provider. There are no network providers for this plan. When you visit a health care provider, remember to show your Aetna ID card. You may be required to pay for your care at the time you receive it or you may be billed later. Either way, once you have an itemized bill for your care, you must file a claim for reimbursement from the plan. The plan pays a certain percentage of your covered expenses (generally 90%) and you pay the rest. The plan generally pays a benefit for covered expenses up to what Aetna considers the reasonable and customary amount for a given health service. A reasonable and customary charge is the provider's usual charge or the charge Aetna determines to be appropriate or most common for a given service or supply in a specific geographic area. A provider's fee for a given service may be more than the reasonable and customary amount, as determined by Aetna. In this case, the plan's benefit applies only to the part of the charge that is reasonable and customary. You must pay the difference. Any charges over the reasonable and customary charge do not count toward your coinsurance out-of-pocket limit. The National Advantage TM Program You may lower your out of pocket costs by visiting doctors or facilities that participate in Aetna's National Advantage Program(NAP) network. NAP doctors and facilities have agreed to accept negotiated rates for certain covered services. If you visit a NAP doctor or facility, you may receive a discount off billed charges. When you visit a NAP provider, allow the provider to submit the claim. After your claim is processed at the discounted rate, you'll be billed for any applicable coinsurance or non- covered service. Visit DocFind at www.aetna.com to find participating NAP doctors and facilities. Summary of Benefits The Summary of Benefits chart in this section shows the coinsurance, coinsurance out-of- pocket maximum, benefits and benefit limits for the major types of covered expenses. The sections, What the Plan Covers and What the Plan Does Not Cover include more detail about specific services and supplies. 9 Summary of Benefits Plan Features Member Responsibility Calendar Year Deductible None Coinsurance Out-of-Pocket Maximum • Individual $2,000 • Family $4,000 Lifetime Maximum Unlimited Covered Expense Plan Pays Physician Services • Office Visits 90% • In-Hospital Physician Services 90% • Other Physician Services 90% Preventive Care Services • Routine Physical Exams 90% Includes Immunizations six visits first year of life; two visits 13—24 months of life, one visit per calendar year thereafter for children and adults • Routine OB/GYN Exam 90% (one routine exam per calendar year, including Pap smear and related lab expenses) • Routine Mammography 90% (one routine mammogram per calendar year for females age 40 and older • Routine Digital Rectal Exam (DRE) and 90% Prostate Antigen Test(PSA) (one per calendar year for males age 40 and over • Routine Vision Exam with Refraction Services 90% (one exam per 24 months Allergy Testing 90% Allergy Injections 90% Maternity • Prenatal and postnatal visits 90% 10 Summary of Benefits Covered Expense Plan Pays Hospital Services • Inpatient Facility 100% • Sariatric Surgery 100% (precertified and approved by the City of Fort Worth • Outpatient Facility 100% • Emergency Room 100% (physicians, surgery, anesthesia, lab and x-ray) • Non-Emergency Use of the Emergency Room 50% Ambulance 90% Diagnostic X-ray and Laboratory • Hospital 100% • Independent Lab Facility 90% Skilled Nursing/Convalescent Facility 100% (up to 120 days per ear) Home Health Care 90% (up to 120 visits per ear Hospice Care 100% (combined 360 days per ear Short-Term Rehabilitation 90% (physical, occupational and speech therapy. Up to 60 visits per ear Chiropractic Care 90% (up to 30 visits per ear) Durable Medical Equipment 90% Mental Health and Alcohol and Drug Abuse • Inpatient Care 100% (up to 30 days per calendar ear) • Outpatient Care 90% (up to 60 visits per calendar ear) Alcohol and Drug Abuse Lifetime Maximum 3 courses of treatment per lifetime 11 Summary of Benefits -Prescription Drugs Plan Feature Member Responsibility Calendar Year Deductible • Individual $50 • Family $150 Covered Expense Plan Pays " Retail Pharmacy (30-day supply) • Generic 100% after deductible and $10 member co-pay • Brand Formulary 100% after deductible and $30 member co-pay • Brand Non-Formulary 100% after deductible and $50 member co-pay Mail Order Pharmacy (90-day supply) • Generic 100% after deductible and $25 co-pay • Brand Formulary 100% after deductible and $75 co-pay • Brand Non-Formulary 100% after deductible and $125 co-pay 12 What the Medical Plan Covers While the Summary of Benefits charts outline the deductibles, coinsurance, out-of-pocket maximums, age, frequency and lifetime maximums for the major types of covered expenses, this section further describes the services and supplies covered under the medical plans. It also describes limits and exclusions that may apply to a specific type of expense. Although a service may be listed as a covered benefit, it will not be covered unless it is medically necessary for the prevention, diagnosis or treatment of your illness or condition or considered covered preventive care as specifically outlined. Refer to the Glossary for a definition of"necessary." Physician Services Routine Physical Exams The plan covers charges made by a physician for a routine physical exam given to you, your spouse or your dependent child. Included as part of the exam are: • X-rays, lab and other tests given in connection with the exam; and • Materials for giving immunizations for infectious disease and testing for tuberculosis. A physical exam for your dependent child must include at least: • A review and written record of the patient's complete medical history; • A check of all body systems; and • A review and discussion of exam results with the patient or with the parent or guardian. If an exam is given to diagnose or treat an injury or disease, it is not considered a routine physical exam. The plan does not cover (as part of any routine physical exam): • Services to the extent they are covered under any other part of this plan. • Services covered to any extent under any other group plan sponsored by The City of Fort Worth. • Services to diagnose or treat a suspected or identified injury or disease. • Exams given while the person is confined in a hospital or other facility for medical care. • Services not provided by a physician or under the direct supervision of a physician. • Medicines, drugs, appliances, equipment or supplies. • Psychiatric, psychological, personality, or emotional testing or exams. • Any employment-related exams. • Premarital exams. 13 Vision Exams for Refractive Services The plan included benefits for one (1) complete refraction eye exam every 24 months performed by a qualified ophthalmologist or optometrist. There is no coverage for eyewear or contact lenses. This plan provision does not cover charges for: • Exams which do not include refraction (exams for diagnosis or treatment of a medical problem may be covered under another plan provision); • Any service or supply provided while not covered under the plan; • Any exams given while confined in the hospital or facility for medical care; or • Any exam required by an employer as a condition of employment, or which an employer is required to provide under a labor agreement or government law. • Drugs or medicines; • Any service or supply that does not meet professionally accepted standards. Other Physician Services The plan covers physician home and office visits for the treatment of illness or injury. Other physicians' services are also covered including those for: • Inpatient physician visits; • Second surgical opinions; • Allergy testing and treatment; • Radiation therapy and chemotherapy; • Cardiac rehabilitation; and • Pregnancy-related care. Hospital Services Inpatient Hospital Expenses The plan covers charges made by a hospital for room and board and other hospital services and supplies for a person confined as an inpatient. Room and board charges are covered up to the hospital's semi-private room rate. (A semi-private room is one with two or more beds.) Room and board charges include: • Services of the hospital's nursing staff; • Admission fees; • General and special diets; and • Sundries and supplies. 14 The plan also pays for other services and supplies provided during an inpatient stay, such as: • Physician and surgeon services; • Operating and recovery rooms; • Intensive or special care facilities; • Radiation therapy, physical therapy and occupational therapy; • Oxygen and oxygen therapy; • X-rays, lab tests and diagnostic services; • Medication; and • Social services planning. Outpatient Hospital Expenses The plan covers charges made by a hospital for hospital services and supplies provided to a person who is not confined as an inpatient. Charges include: • Professional fees; • Services and supplies furnished by the hospital on the day of a treatment, procedure or test; • Services of an operating physician for surgery, related pre- and post-operative care, and administration of an anesthetic; and • Services of any other physician for the administration of a general anesthetic. Emergency Care Emergency Room The plan covers emergency care provided in a hospital emergency room while a person is not a full-time inpatient. The care must be for an emergency condition. The plan benefits are reduced for non-emergency care provided in a hospital emergency room. An emergency condition means a recent and severe medical condition— including but not limited to severe pain—which would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that failure to get immediate medical care could result in: • Placing the person's health in serious jeopardy; or • Serious impairment to bodily function; or • Serious dysfunction of a body part or organ; or • Serious jeopardy to the health of the fetus in the case of a pregnant woman. 15 Ambulance The plan covers charges for a professional ambulance to transport a person from the place where he/she is injured or becomes ill to the first hospital where treatment is given. When, in a medical emergency,the first hospital does not have the required services, transportation to another hospital is also covered. Skilled Nursing / Convalescent Care The plan covers charges made by a skilled nursing facility (convalescent facility) for the services and supplies listed below. These must be provided to a person while confined to recover from a disease or injury. • Room and board, including charges for services (such as general nursing care) made in connection with room occupancy. Any charge for room and board in a private room that exceeds the hospital's semi-private room rate is not covered. • Use of special treatment rooms. • X-ray and lab work. • Physical, occupational or speech therapy. • Oxygen and other gas therapy. • Other medical services provided by a skilled nursing facility. This does not include private or special nursing, physician services, drugs, biologicals, solutions, dressings, casts and other supplies. The plan pays benefits for up to 120 days for skilled nursing services per calendar year. Convalescent facility care does not include charges for treatment of. • Drug addiction; • Chronic brain syndrome; • Alcoholism; • Mental retardation; or • Any other mental disorder. Home Health Care The plan covers home health care expenses when care is provided by a home health care agency as part of a home health care plan, and the care is provided to a covered person in his or her home. 16 Home health care expenses are charges for: • Part-time or intermittent care by a R.N. or L.P.N., if a R.N. is not available. • Part-time or intermittent home health aide services for patient care. • Physical, occupational and speech therapy. • The following services, to the extent they would have been covered if the person had been confined to a hospital or convalescent facility: — Medical supplies; — Drugs and medicines prescribed by a physician; and — Lab services provided by or for a home health care agency. The plan covers up to 120 home health care visits per calendar year. Each visit by a nurse or therapist is one visit. Each visit of up to 4 hours by a home health aide is one visit. The plan does not cover home health care charges for: • Services or supplies that are not part of the home health care plan; • Services of a person who usually lives with you or is a member of your family or your spouse's family; • Services of a social worker; or • Transportation. Hospice Care The plan covers hospice care that is provided as part of a hospice care program for a person with a prognosis of six months or less to live. Hospice care coverage is described below. Facility Expenses The plan covers charges made by a hospice facility, hospital or convalescent facility on its own behalf for: • Room and board, and other services and supplies provided to a person while a full- time inpatient for pain control and other acute and chronic symptom management. (The plan covers charges for room and board up to the facility's semi-private room rate.) • Services and supplies provided on an outpatient basis. 17 Other Hospice Care Agency Expenses The plan covers charges made by a hospice care agency for: • Part-time or intermittent nursing care by a R.N. or L.P.N. for up to 8 hours in any one day. • Medical social services under a physician's direction. These include: — Assessment of the person's social, emotional and medical needs, and the home and family situation; — Identifying community resources available to the person; and — Helping the person make use of these resources. — Psychological and dietary counseling. • Consultation or case management services provided by a physician. • Physical and occupational therapy. • Part-time or intermittent home health aide services for up to 8 hours in any one day. These services consist mainly of caring for the person. • Medical supplies. • Drugs and medicines prescribed by a physician. Charges made by a physician for consulting or case management services, and charges made by a physical or occupational therapist are also covered i£ • The provider is not an employee of a hospice care agency; and • A hospice care agency is still responsible for the person's care. Home Health Care Agency Expenses As part of its hospice care coverage, the plan covers home health care agency expenses for: • Physical and occupational therapy. • Part-time or intermittent home health aid services for up to 8 hours in any one day. These consist mainly of caring for the person. • Medical supplies. • Drugs and medicines prescribed by a physician. • Psychological and dietary counseling. The plan limits coverage for bereavement counseling and respite care to a maximum of 3 visits within 3 months. Respite care is care provided when the person's family or usual caretaker can't or won't care for the person. 18 The plan's hospice care benefit does not include coverage for: • Funeral arrangements. • Pastoral counseling. • Financial or legal counseling, including estate planning and the drafting of a will. • Homemaker or caretaker services. These are services not entirely related to the care of a person and include sitter or companion services for the person who is ill or other family members;transportation; housecleaning and home maintenance. Short-Term Rehabilitation The plan covers charges made by a hospital or licensed health care facility; a physician; or a licensed or certified physical, occupational or speech therapist for short-term rehabilitation on an outpatient basis. Short-term rehabilitation is therapy expected to result in the improvement of a body function(including speech) which was lost or impaired because of: • An injury, • A disease, or • Major congenital abnormalities such as cleft lip and cleft palate, cerebral palsy, hearing impairment, autism and developmental disabilities in children. The plan covers physical, occupational or speech therapy provided to a person who is not confined as an inpatient in a hospital or other facility for medical care. Therapy will be expected to result in significant improvement of the person's condition within 60 days from the date therapy begins. The plan covers up to 60 visits per person per calendar year. This benefit does not cover short-term rehabilitation when: • Any therapy, service or supply for the treatment of a condition which ceases to be therapeutic treatment and is instead administered to maintain a level of functioning to prevent a medical problem from occurring or recurring; • Services are received while a person is confined in a hospital or other medical facility for medical care; • Rehabilitation services are covered under any other part of this plan or any plan sponsored by The City of Fort Worth. • Services are provided by a physical, occupation or speech therapist who lives in the patient's home or is a family member of the patient or his/her spouse; • Services are not performed by a physician or under his/her direct supervision; • It is for special education, including lessons in sign language, to teach a person whose ability to speak has been lost or impaired, to function without that ability. • Services are not provided in accordance with a specific treatment plan that details the treatment to be provided and the frequency and duration of treatment;provides for ongoing reviews; and is renewed only if therapy is still necessary. 19 Chiropractic Care (Spinal Manipulation) The plan covers expenses for chiropractor care to treat any condition caused by or related to biomechanical or nerve conduction disorders of the spine. Benefits are paid for up to 30 visits per calendar year combined in- and out-of-network. This maximum does not apply to expenses incurred: • While the person is a full-time inpatient in hospital; • For treatment of scoliosis; • For fracture care; or • For surgery. This includes pre- and post-surgical care provided or ordered by the operating physician. Family Planning Voluntary Sterilization The plan covers charges for a vasectomy or tubal ligation performed by a physician or hospital. The plan does not cover charges for the reversal of a sterilization procedure. Pregnancy Coverage The plan pays benefits for pregnancy-related expenses on the same basis as it would for an illness. For inpatient care of a mother and newborn child,benefits will be payable for a minimum of: • 48 hours after a vaginal delivery; and • 96 hours after a cesarean section. To be covered, expenses must be incurred while covered by the plan. Any pregnancy benefits payable by a previous group medical plan will be subtracted from benefits payable under this plan. Infertility Coverage The plan covers services to diagnose and treat an underlying medical condition which causes infertility when provided by or under the direction of a physician. Mental Health and Substance Abuse Treatment The plan covers expenses for inpatient and outpatient treatment of alcoholism or drug abuse, and mental disorders as explained below. 20 Hospital If a person is a full-time inpatient in a hospital, the plan covers: • Treatment for the medical complications of alcoholism or drug abuse. "Medical complications" include cirrhosis of the liver, delirium tremens or hepatitis. • Effective treatment of alcoholism or drug abuse. • Treatment of mental disorders. Treatment Facility If a person is a full-time inpatient in a treatment facility, the plan covers certain expenses for the effective treatment of alcoholism, drug abuse or mental disorders. These expenses are: • Room and board, up to the facility's semi-private room rate; and • Other necessary services and supplies. Outpatient Treatment The plan also covers effective treatment of alcoholism, drug abuse or mental disorders on an outpatient basis. Benefit Maximums • For inpatient care, the plan covers up to 30 days per calendar year for mental health and substance abuse treatment. • For substance abuse,the plan includes a lifetime maximum of 3 series of treatment per lifetime which includes rehabilitation, detoxification, residential care and partial confinement expenses. • For outpatient care, the plan covers up to 60 visits per calendar year for mental health and substance abuse treatment. Oral Surgery The plan covers treatment of the mouth,jaws and teeth as follows: • Surgery needed to: — Treat an accidental injury; — Remove cysts, tumors or other diseased tissues; — Alter the jaw,jaw joints or bite relationships to treat TMJ when appliance therapy cannot result in functional improvement. 21 This benefit does not cover charges: • For surgery to remove teeth(whether or not routine); • For periodontal treatment; • To remove, repair, replace, restore or reposition teeth lost or damaged in the course of biting or chewing; • To repair, replace or restore fillings, crowns, dentures or bridgework • Non-surgical treatment of infections or diseases; • For dental cleaning, in-mouth scaling,planning or scraping; • For myofunctional therapy (muscle training therapy to correct or control harmful habits). Durable Medical Equipment The plan covers durable medical equipment (such as wheelchairs, walkers, crutches) as follows: • Rental of durable medical equipment. Instead of rental, the plan may cover purchase of this equipment if Aetna is shown that long-term use of it is planned and that it either can't be rented or would cost less to purchase than to rent; • Repair of purchased durable medical equipment; • Replacement of purchased durable medical equipment if Aetna is shown that it is needed because of a change in the person's physical condition, or if it is likely to cost less to purchase a replacement than to repair existing equipment or rent similar equipment. Diabetic Equipment, Supplies and Education The plan covers the following services, supplies, equipment and training for the treatment of diabetes: • Diabetic education; • Insulin preparations; • Insulin infusion pumps; • Needles and syringes; • Injection aids; • Blood glucose monitors and test strips; • Lancets; • Prescribed oral medications for controlling blood sugar level; • Alcohol swaps; • Glucose agents; • Glucagon emergency kits or injectable glucagon; • Self-management training provided by a qualified health care provider; and • Orthotic devices, orthopedic shoes and replacement inserts. 22 Other Covered Expenses The plan also covers: • Charges for drugs and medicines which, by law, require a physician's prescription, but only while a person is confined as an inpatient. • Charges for diagnostic lab work and x-rays; x-ray, radium and radioactive isotope therapy; and anesthetics and oxygen. • Artificial limbs and eyes. Not included are such things as eyeglasses, vision aids, hearing aids and communication aids. • Anesthetics and oxygen. • Inpatient and outpatient charges for the surgical treatment of morbid obesity if precertified and approved through the City of Fort Worth. 23 Prescription Drug Benefits Outpatient prescription drugs prescribed by a physician to treat an illness or injury are covered. To receive maximum benefits there are two ways to fill prescriptions: at an in-network retail pharmacy or by mail order through Aetna RX Home Delivery. The amount you pay for your prescription depends on whether the drug is generic or brand-name, or if it is in the formulary. Although you may also fill a prescription at an out-of-network retail pharmacy,the benefits you receive will be reduced. The formulary is a list of preferred drugs that includes both brand-name and generic drugs. You can reduce your co-payment by using a covered drug that appears on the formulary. You can find Aetna's formulary online at www.aetna.com/formulary or call Member Services at the number on your ID card to request a printed formulary guide. -- Retail Pharmacy You may fill your prescription for up to a 30-day supply at a pharmacy that belongs to Aetna's pharmacy network. There is no benefit for prescriptions obtained at out-of-network retail pharmacies. You can find a list of in-network pharmacies using the DocFind tool on Aetna Navigator. Mail Order Prescriptions If you take medications on a regular basis, you may order up to a 90-day supply through Aetna Rx Home Delivery, Aetna's mail order drug service. Aetna Rx Home Delivery is easy-to-use and saves you money. To order by mail, send your original prescription, together with an order form and payment of the applicable coinsurance amount to Aetna. Order forms are available online at www.aetnarxhomedelivery.com. Your doctor can also fax a prescription and order form to 866-681-5166. Refills can be ordered by mail, online at www.aetnarxhomedelivery.com or by phone toll free at 800-227-5720. The address is P.O. Box 829518, Pembroke Pines, FL 33082- 9913. 24 What the Prescription Drug Program Covers The following prescription drug expenses are covered: • Federal legend drugs—drugs that require a label stating: "Caution: Federal law prohibits dispensing without a prescription"; • Compounded medications, of which at least one ingredient is a federal legend drug; • Any other drug which,under applicable state law, may be dispensed only upon a physician's written prescription; • Insulin needles and syringes; • Insulin; • Contraceptive drugs; • Drugs to treat erectile dysfunction, up to 6 tablets per month. What the Prescription Drug Program Does Not Cover The following prescription drug expenses are not covered: • Any drug that does not, by federal law, require a prescription, such as an over-the- counter drug or equivalent over-the-counter product, even when a prescription is written for it; • A device of any type(such as a spacer or nebulizer) used in connection with a prescription drug; • Any drug entirely consumed when and where it is prescribed; • Administration or injection of any drug; • More than the number of refills specified by the prescribing doctor; • Any refill of a drug dispensed more than one year after prescribed, or as permitted by law where the drug is dispensed; • Oral and injectable fertility drugs; • Immunization agents; • Smoking cessation aids; • Nutritional supplements. 25 Women's Health Provisions Federal law affects how certain health conditions are covered. Your rights under these laws are described below. The Newborns' and Mothers' Health Protection Act Federal law generally prohibits restricting benefits for hospital lengths of stay to less than 48 hours following a vaginal delivery and less than 96 hours following a caesarean section. However, the plan may pay for a shorter stay if the attending provider (physician, nurse midwife or physician assistant) discharges the mother or newborn earlier, after consulting with the mother. Also, federal law states that the plan may not, for the purpose of benefits or out-of-pocket costs, treat the later portion of a hospital stay in a manner less favorable to the mother or newborn than any earlier portion of the stay. Finally, federal law states that a plan may not require a physician or other health care provider to obtain authorization of a length of stay up to 48 hours or 96 hours, as described above. However, pre-certification may be required for more than 48 or 96 hours of confinement. The Women's Health and Cancer Rights Act The Women's Health and Cancer Rights Act requires that the following procedures be covered for a person who receives benefits for a medically necessary mastectomy and decides to have reconstructive surgery after the mastectomy: • Reconstruction of the breast on which a mastectomy has been performed; • Surgery and reconstruction of the other breast to create a symmetrical (balanced) appearance; . • Prostheses; and • Treatment of physical complications of all stages of mastectomy, including lymphedemas. This coverage will be provided in consultation with the attending physician and the patient, and will be subject to the same annual deductibles and coinsurance provisions that apply to the mastectomy. For answers to questions about the plan's coverage of mastectomies and reconstructive surgery,call Aetna's Member Services at the number on your ID card. 26 Special Programs As participants in this plan, you and your covered family members can take advantage of the special care, discount, vision and fitness programs described in this section. These services, discounts and programs are not underwritten by Aetna, but are made available to you and your family as part of your plan. The National Medical Excellence Program® (NME) The National Medical Excellence (NME) Program®helps you and covered family members receive care from nationally recognized doctors and facilities specializing in organ transplants and certain other treatments. For patients who take part in this program, the plan pays benefits for covered medical expenses incurred for the NME procedures and treatment types listed in this section. In addition, the plan pays a benefit for travel and lodging expenses when the patient is directed to care at a facility more than 100 miles from his/her home. Institutes of ExcellenceTm Network The Institutes of Excellence Network supports the NME program. It is Aetna's network of health care facilities for transplants and transplant-related services, including evaluation and follow-up care. Aetna selects hospitals for the network based on successful clinical outcomes, quality of care standards and agreement with Aetna's contractual terms. These facilities have been contracted on a transplant-specific basis and are, therefore, considered preferred only for specific transplant types. The plan pays benefits at the plan's regular coinsurance for transplant-related services, including evaluation, transplant and follow-up care, when patients use an Institutes of Excellence participating facility that has been specifically contracted by Aetna for their transplant type. Transplants performed outside of the Institutes of Excellence Network will be also paid at the plan's regular coinsurance. You can find a list of Institutes of Excellence facilities at DocFind or from Member Services at the number on your ID card. NME Procedure and Treatment Types • Heart transplant • Lung transplant • Liver transplant • Bone marrow transplant • Heart/lung transplant • Kidney transplant • Pancreas transplant • Kidney/pancreas transplant 27 Travel Expenses "Travel expenses" are expenses for transportation between the patient's home and the medical facility where he or she receives services in connection with a procedure or treatment listed above. Also included are expenses incurred by a companion for transportation to and from an NME patient's home and the medical facility where he or she receives services. These expenses must be approved in advance by Aetna. Lodging Expenses These are expenses for lodging away from home while a patient is traveling between his or her home and the medical facility where services are provided. The plan covers the patient's lodging expenses up to $50 per person,per night. Also covered are a companion's expenses for lodging away from home: • While traveling with an NME patient between the patient's home and the medical facility where services are provided; or • When the patient needs a companion's help to receive services from the medical facility on an inpatient or outpatient basis. The plan covers a companion's lodging expenses up to $50 per person, per night. For the purpose of determining NME travel or lodging expenses, the hospital or other temporary residence to which a patient must travel while receiving treatment or after discharge at the end of treatment, will be considered the patient's home. Travel and Lodging Maximum The plan pays up to $10,000 per episode of care for travel and lodging expenses incurred in connection with a procedure or treatment. Benefits will be paid only for expenses incurred during the period that begins on the day a covered person becomes an NME patient and ends on the earlier to occur of the following: • One year after the day the procedure is performed; • The date the patient stops receiving services from the facility in connection with the procedure. Limitations Travel and lodging expenses include only those expenses described in this section. No other type of expense covered under this plan will be considered a travel or lodging expense. In addition, the plan covers travel and lodging expenses for just one companion unless the patient is a minor in which case up to two companions over age 18 are allowed. 28 Informed Health° Line At any time, you can call 1-800-556-1555 to speak to Informed Health Line nurses. Our registered nurses are experienced in providing information on a variety of health topics. While the nurses don't diagnose problems, prescribe or give advice,they can: • Help you understand health issues and treatment choices, • Give you some good questions to ask your doctor, and • Tell you about the latest research on certain treatments and procedures, and explain their risks and benefits. The nurses can help you make sense of your health issues and communicate better with your doctor. They'll give you the facts you need to make decisions and choices you can feel good about. Informed Health Line also includes an audio health library that gives you an easy way to access reliable health information from any touchtone phone, 24 hours a day, in English or Spanish. 29 What the Medical Plan Does Not Cover This section contains a general list of charges not covered under the plan. These excluded charges will not be used when figuring benefits. (Remember, limitations and exclusions for specific types of health care expenses are contained in the section, What the Medical Plan Covers.) Exclusions listed in this section will not apply if coverage is required by law. Also, if a benefit is prohibited by the law of the jurisdiction where a person lives, it will not be paid. General Exclusions The plan does not cover charges: • For services and supplies Aetna determines are not necessary for the diagnosis, care or treatment of the disease or injury involved—even if they are prescribed, recommended or approved by a physician or dentist. • For care, treatment, services or supplies not prescribed, recommended or approved by a physician or dentist. • For services of a resident physician or intern. • Made only because you have health coverage. • You are not legally obligated to pay. • That are not reasonable and customary charges, as determined by Aetna. Experimental or Investigational Except as provided below, the plan does not cover drugs, devices, treatments or procedures that are experimental or investigational. A drug, device, treatment or procedure is considered experimental or investigational if: • It requires approval by a governmental authority (including the U.S. Food and Drug Administration)prior to use, but such approval has not been granted; or • It is the subject of a written protocol used by any facility for research, clinical trials, or other tests or studies to evaluate its safety, effectiveness, toxicity or maximum tolerated dose, as evidenced in the protocol itself or in the written consent form used by the facility; or • It is a type of drug, device or treatment that is the subject of a Phase I or Phase II clinical trial or the experimental or research arm of a Phase III clinical trial, as these Phases are defined in regulations and other official actions and publications issued by the FDA and the Department of Health and Human Services; or • It has not been proven safe and effective under generally accepted standards of medical practice. 30 "Generally accepted standards of medical practice" are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, or otherwise consistent with physician specialty society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors. However, your plan will pay for experimental or investigational drugs, devices, treatments or procedures if all of the following conditions are met: • You have been diagnosed with a cancer or a condition that is likely to cause death within one year; • Standard therapies have not been effective or do not meet the definition of medically necessary; • Aetna determines, based on at least two documents of medical and scientific evidence that you would likely benefit from the treatment; and • You are enrolled in a clinical trial that meets all of these criteria: — The drug, device, treatment or procedure to be investigated has been granted investigational new drug (IND) or Group c/treatment IND status, — The clinical trial has passed independent scientific scrutiny and has been approved by an Institutional Review Board that will oversee the investigation, — The clinical trial is sponsored by the National Cancer Institute ("NCI") or similar national organization(e.g. Food& Drug Administration, Department of Defense) and conforms to the NCI standards, — The clinical trial is not a single institution or investigator study unless the clinical trial is performed at an NCI-designated cancer center, and — You are treated according to the protocol. Government and Armed Forces The plan does not cover charges (to the extent allowed by law) for services and supplies: • Provided, paid for, or for which benefits are provided or required because of a person's past or present service in the armed forces of a government. • Provided, paid for, or for which benefits are provided or required under any governmental law. This exclusion will not apply to "no fault" auto insurance if it is: — Required by law; and — Provided on an individual basis; and — Included in the definition of"other plan" in the section, Coordination With Other Plans. This exclusion also will not apply to a plan established by government for its own employees or their dependents, or to Medicaid. 31 Education and Training The plan does not cover charges for: • Services, treatment, education testing or training related to learning disabilities or developmental delays. • Education, special education or job training, whether or not this is provided in a facility that also provides medical or psychiatric treatment. Reproductive and Sexual Health The plan does not cover charges for: • Therapy, supplies or counseling for sexual dysfunction or inadequacies that don't have a physiological or organic basis. • Sex change surgery or treatment of gender identity disorders. • Reversal of a sterilization procedure. • Voluntary abortion. • Drugs used to treat erectile dysfunction, impotence or sexual dysfunction or inadequacy. This exclusion applies whether or not the drug is delivered in oral, injectable or topical forms (including but not limited to gels, creams, ointments and patches). Mental Health The plan does not cover charges for: • Marriage, family, child, career, social adjustment, pastoral or financial counseling. • Treatment of health care providers who specialize in mental health and receive treatment as part of their training in that field. • Primal therapy,rolfing or psychodrama. Custodial and Protective Care The plan does not cover charges for: • Care provided to create an environment that protects a person against exposure that can make his or her disease or injury worse. • Custodial care; that is, care provided to help a person in the activities of daily life. 32 Cosmetic Procedures Regardless of whether the service is provided for psychological or emotional reasons, the plan does not cover charges for: • Plastic surgery; • Reconstructive surgery; • Cosmetic surgery; or • Other services that improve, alter or enhance appearance, whether or not for psychological or emotional reasons . . . . . . except when needed: • To improve the function of a part of the body that: — Is not a tooth or a structure that supports the teeth; and — Is malformed as a result of a severe birth defect (such as cleft lip, or webbed fingers or toes), disease, or surgery performed to treat a disease or injury. • As part of reconstruction following an accidental injury. Surgery must be performed in the calendar year of the accident that caused the injury, or in the next calendar year. • As part of reconstruction following a mastectomy. Other Services and Supplies The plan also does not cover: • Acupuncture except when used in lieu of anesthesia; • Wigs; • Blood, blood plasma or other blood derivatives or substitutes, and any related services including processing, storage or replacement costs, and the services of blood donors; • Disposable outpatient supplies including sheaths, bags, elastic garments, bandages, syringes, blood or urine testing supplies, unless specifically provided under What the Medical Plan Covers; • Food items, nutritional supplements, vitamins, medical foods and formulas, even if they are the sole source of nutrition; • Household improvements and equipment, including the purchase or rental of exercise equipment, air purifiers, central or unit air conditioners, water purifiers, hypo- allergenic pillows, mattresses,waterbeds, ramps,elevators, handrails, stair glides and swimming pools; • Injectable drugs, if there is an alternative oral drug; • Recreational therapy; • Services and supplies provided for personal comfort or convenience, or for the convenience of any other person, including a provider. 33 Coordination With Other Plans The Traditional Choice Plan is offered by the City of Fort Worth primarily for its Medicare Retirees. The retirees and their eligible dependents (usually a spouse) must be enrolled in Medicare Part A or Medicare Parts A and B to qualify for this plan. For medical services covered by Medicare, most of Part A services are covered at 100%. Part B medical services including the deductible are covered at 90%. Enrollee is subject to 10% of the Part B medical services including the deductible. However, amounts paid by Medicare for a service may reduce, or even eliminate,the 10% coinsurance. Coordination of Benefits Provision The Coordination of Benefits (COB) for the Traditional Plan and other coverage works as follows: A. Enrollee has Medicare and not enrolled in any other plan other than the Traditional Choice Plan. Medicare is primary, Traditional Plan is secondary. B. Enrollee has Medicare and is actively employed and enrolled in employer's plan. Current employer's plan is primary, Medicare is secondary, and the Traditional Plan pays third. C. Enrollee has Medicare, but covered under a working spouse plan. The working spouse plan is primary, Medicare is secondary, and the Traditional Plan pays third. D. Enrollee has Medicare and Tricare. Medicare is primary, Traditional Plan is secondary, and Tricare pays third. E. Enrollee has Medicare and retirement health coverage from another employer. Medicare is primary,the company that the enrollee retired from first would generally be secondary and the other plan would pay third. The enrollee should contact the Benefits Office of each plan to confirm which would be secondary. Medical Services Not Covered by Medicare The Traditional Plan will be primary in all coverage possibilities above except B and E. The coinsurance amount for the enrollee is generally 10% and the coinsurance out-of- pocket maximum for the calendar year is $2,000. 34 Right to Receive and Release Information Certain facts about health care coverage and services are needed to apply the plan's COB rules and to determine benefits under this and other plans. Aetna has the right to release or obtain any information and make or recover any payments it considers necessary in order to administer this provision. Facility of Payment Any payment made under another plan may include an amount which should have been paid under this plan. If so, Aetna may pay that amount to the organization, which made that payment. That amount will then be treated as though it were a benefit paid under this plan. Aetna will not have to pay that amount again. The term "payment made" means reasonable cash value of the benefits provided in the form of services. Right of Recovery If the amount of the payment made by Aetna is more than it should have paid under this COB provision, it may recover the excess from one or more of the persons it has paid or for whom it has paid, or from any other person or organization that may be responsible for the benefits or services provided for the covered person. The "amount of payment made" includes the reasonable cash value of any benefits provided in the form of services. 35 Claims and Benefit Payment This section explains the rules and provisions that affect claim filing and processing, and payment of benefits. Keeping Records of Expenses It's important to keep records of medical expenses for yourself and all covered family members. These will be required when you file a claim for benefits. Of particular importance are: • Names and addresses of physicians; • The dates on which expenses are incurred; and • Copies of all medical bills and receipts. Filing Claims Medicare Direct Each enrollee that submits a copy of their Medicare card to the City's Human Resources Benefits Division will be enrolled into Aetna's Medicare Direct. This enrollment will alert Medicare that Aetna is the Enrollee's secondary payer. All providers accepting the Medicare allowable amount are required to file the initial claim with Medicare. After Medicare has paid its share of the expenses submitted by the provider (Part B medical services only), Medicare forwards your remaining expenses directly to Aetna. This process is transparent and a benefit to the enrollee. Not Enrolled in Medicare Direct You must file a claim to be reimbursed for covered expenses. To file a claim, you complete a claim form. (Claim forms are available on Aetna Navigator at www.aetna.com or by calling Aetna Member Services.) The form contains instructions on how and when to file a claim, as well as the address to which you should send your completed form. ------------------------------------------------------------------------------------------------------------------- Claims should be submitted to: Aetna P.O. Box 14586 Lexington, KY 40512-4586 ----------------------------------------------------------------------------------------------------------------- ' When you visit a NAP provider, allow the provider to submit the claim. After your claim is processed at the discounted rate, you'll be billed for any applicable coinsurance or non- covered service. 36 All claims must be filed promptly. Your deadline for filing a claim is 12 months after the date you incurred a covered expense. If, through no fault of your own, you are unable to meet this deadline, your claim will still be accepted if you file as soon as possible. However, if a claim is filed more than two years after the deadline, it will not be covered unless you are legally incapacitated. You can file claims for benefits and appeal adverse claim decisions yourself or through an authorized representative. An"authorized representative" is a person you authorize, in writing, to act on your behalf. The plan will also recognize a court order giving a person authority to submit claims on your behalf, except that in the case of a claim involving urgent care, a health care professional with knowledge of your condition may always act as your authorized representative. If your claim is denied in whole or in part, you will receive a written notice of the denial from Aetna. The notice will explain the reason for the denial and the review procedures. Turn to the section, When You Disagree With a Claim Decision, for more information about appeals. Time Frames for Claim Processing Aetna will make a decision on your claim. For concurrent care claims, Aetna will send you written notification of an affirmative benefit determination. For other types of claims, you may only receive written notice if Aetna makes an adverse benefit determination. Aetna will provide you with written notices of adverse benefit determinations within the time frames shown in the following chart. These time frames may be extended under certain limited circumstances. The notice you receive from Aetna will provide important information that will assist you in making an appeal of the adverse benefit determination, if you wish to do so. Please see When You Disagree With a Claim Decision for more information about appeals. 37 Type of Claim Response Time Urgent care claim: a claim for medical care or As soon as possible, but not later treatment where delay could: than 72 hours • Seriously jeopardize your life or health, or your ability to regain maximum function; or • Subject you to severe pain that cannot be adequately managed without the requested care or treatment. Pre-service claim: a claim for a benefit that requires 15 calendar days Aetna's approval of the benefit in advance of obtaining medical care (pre-certification). Concurrent care claim extension: a request to extend Urgent care claim -as soon as a previously approved course of treatment. possible, but not later than 24 hours, provided the request was received at least 24 hours prior to the expiration of the approved treatment. • Other claims - 15 calendar days Concurrent care claim reduction or termination: a With enough advance notice to allow decision to reduce or terminate a course of treatment you to appeal that was previously approved. Post-service claim: a claim for a benefit that is not a 30 calendar days pre-service claim. Extensions of Time Frames The time periods described in the chart may be extended, as follows: • For urgent care claims: If Aetna does not have sufficient information to decide the claim, you will be notified as soon as possible (but no more than 24 hours after Aetna receives the claim) that additional information is needed. You will then have at least 48 hours to provide the information. A decision on your claim will be made within 48 hours after the additional information is provided. • For non-urgent pre-service and post-service claims: The time frames may be extended for up to 15 additional days for reasons beyond the plan's control. In this case, Aetna will notify you of the extension before the original notification time period has ended. If you fail to provide the information, your claim will be denied. If an extension is necessary because Aetna needs more information to process your post service claim, Aetna will notify you and give you an additional period of at least 45 days after receiving the notice to provide the information. Aetna will then inform you of the claim decision within 15 days after the additional period has ended (or within 15 days after Aetna receives the information, if earlier). If you fail to provide the information, your claim will be denied. 38 Payment of Benefits Benefits will be eligible for payment as soon as Aetna receives the necessary proof to support the claim. All benefits are payable to you or the provider. If your claim is denied in whole or in part, you will receive a written notice of the denial from Aetna. The notice will explain the reason for the denial and the review procedures. More information about appeals follows later in this section. When You Disagree With a Claim Decision The Appeal Process Aetna will send you written notice of an adverse benefit determination. The notice will give the reason for the decision and will explain what steps you must take if you wish to appeal. The notice will also tell you about your rights to receive additional information that may be relevant to the appeal. Requests for appeal must be made in writing within 180 days from the receipt of the notice. However, appeals of adverse benefit determinations involving urgent care may be made orally. ------------------------------------------------------------------------------------------------------------------ Written requests for appeal may be sent to: Aetna P.O. Box 14586 Lexington, KY 40512-4586 The plan provides for two levels of appeal plus an option to seek external review of the adverse benefit determination. If you are dissatisfied with the outcome of your level one appeal and wish to file a level two appeal, your appeal must be filed no later than 60 days following receipt of the level one notice of adverse benefit determination. The following chart summarizes some information about how appeals are handled for different types of claims. 39 Type of Claim Level One Appeal Level Two Appeal Response Time Response Time Urgent care claim: a claim for medical 36 hours 36 hours care or treatment where delay could: • Seriously jeopardize your life or Review provided by Review provided by health, or your ability to regain Aetna personnel not Aetna personnel not maximum function; or involved in making the involved in making the • Subject you to severe pain that adverse benefit adverse benefit cannot be adequately managed determination. determination. without the requested care or treatment. Pre-service claim: a claim for a benefit 15 calendar days 15 calendar days that requires Aetna's approval of the benefit in advance of obtaining medical Review provided by Review provided by care. Aetna personnel not Aetna personnel not involved in making the involved in making the adverse benefit adverse benefit determination. determination. Concurrent care claim extension: a Treated like an urgent Treated like an urgent request to extend a previously approved care claim or a pre- care claim or a pre- course of treatment. service claim depending service claim depending on the circumstances. on the circumstances. Post-service claim: a claim for a benefit 30 calendar days 30 calendar days that is not a pre-service claim. Review provided by Review provided by Aetna personnel not Aetna personnel not involved in making the involved in making the adverse benefit adverse benefit determination. determination. You may also choose to have another person (an authorized representative) make the appeal on your behalf by providing written consent to Aetna. In the case of an urgent care claim or a pre-service claim, a physician familiar with the case may represent you in the appeal. ------------------------------------------------------------------------------------------------------------------ If the Level One and Level Two appeals uphold the original adverse benefit determination for a medical claim, you may have the right to pursue an external review of your claim. See External Review for more information. - - - -------------------------------- ---------- 40 Voluntary Appeals You may file a voluntary appeal after the standard appeals process has been exhausted. The voluntary appeal should be made to the City of Fort Worth. You must complete all levels of the standard appeal process before you can appeal to the City of Fort Worth. You, or your authorized representative, must request the voluntary level of review within 60 days after you receive the final denial notice under the standard appeal proves. If you file a voluntary appeal, any applicable statute of limitations will be suspended while the appeal is pending. Since this level of appeal is voluntary, you are not required to pursue it before initiating legal action. You must submit your voluntary appeal to the City of Fort Worth in writing and include: • The reason for the appeal; • Copies of all past correspondence with Aetna(including your Explanation of Benefits; and • Any applicable information that you have not yet sent to Aetna. The City of Fort Worth has the right to obtain information from Aetna that is relevant to your claim. The City of Fort Worth will review your appeal and make a decision within 60 days after you file your appeal. If the City of Fort Worth reviewer needs more time, the reviewer may take an additional 60 days. You will be notified in advance of this extension. The City of Fort Worth's reviewer will notify you of the final decision on your appeal electronically or in writing. The notice will give you the reason for the decision and the Plan provisions upon which the decision was based. All decisions by the City of Fort Worth will be final and binding. Claim Fiduciary The City of Fort Worth has discretionary authority to review all denied claims for benefits under the medical plan. This includes, but is not limited to, determining whether hospital or medical treatment is, or is not, medically necessary. In exercising its responsibilities, the City of Fort Worth has discretionary authority to: • Determine whether, and to what extent, you and your covered dependents are entitled to benefits; and • Construe any disputed or doubtful terms of the plan. 41 Aetna has the right to adopt reasonable policies,procedures,rules and interpretations of the plan to promote orderly and efficient administration. Aetna may not abuse its discretionary authority by acting arbitrarily and capriciously. The City of Fort Worth is responsible for making reports and disclosures required by applicable laws and regulations. Subrogation and Reimbursement As used throughout this provision, the term Responsible Party means any party actually, possibly, or potentially responsible for making any payment to a Covered Person due to a Covered Person's injury, illness or condition. The term Responsible Party includes the liability insurer of such party, or any insurance coverage. For purposes of this provision, the term Insurance Coverage refers to any coverage providing medical expense coverage or liability coverage including, but not limited to, uninsured motorist coverage, underinsured motorist coverage, personal umbrella coverage, medical payments coverage, workers compensation coverage, no-fault automobile insurance coverage or any first party insurance coverage. For purposes of this provision, a Covered Person includes anyone on whose behalf the plan pays or provides any benefit including, but not limited to, the minor child or dependent of any plan member or person entitled to receive any benefits from the plan. Subrogation Immediately upon paying or providing any benefit under this plan, the plan shall be subrogated to (stand in the place of) all rights of recovery a Covered Person has against any Responsible Party with respect to any payment made by the Responsible Party to a Covered Person due to a Covered Person's injury, illness or condition to the full extent of benefits provided or to be provided by the plan. Reimbursement In addition, if a Covered Person receives any payment from any Responsible Party or Insurance Coverage as a result of an injury, illness or condition, the plan has the right to recover from, and be reimbursed by, the Covered Person for all amounts this plan has paid and will pay as a result of that injury, illness or condition, up to and including the full amount the Covered Person receives from any Responsible Party. 42 Constructive Trust By accepting benefits (whether the payment of such benefits is made to the Covered Person or made on behalf of the Covered Person to any provider) from the plan, the Covered Person agrees that if he/she receives any payment from any Responsible Party as a result of an injury, illness or condition, he/she will serve as a constructive trustee over the funds that constitute such payment. Failure to hold such funds in trust will be deemed a breach of the Covered Person's fiduciary duty to the plan. Lien Rights Further,the plan will automatically have a lien to the extent of benefits paid by the Plan for the treatment of the illness, injury or condition for which Responsible Party is liable. The lien shall be imposed upon any recovery whether by settlement,judgment or otherwise, including from any Insurance Coverage, related to treatment for any illness, injury or condition for which the plan paid benefits. The lien may be enforced against any party who possesses funds or proceeds representing the amount of benefits paid by the Plan including, but not limited to, the Covered Person; the Covered Person's representative or agent; Responsible Party; Responsible Party's insurer, representative agent; and/or any other source possessing funds representing the amount of benefits paid by the plan or the City of Fort Worth. First-Priority Claim By accepting benefits (whether the payment of such benefits is made to the Covered Person or made on behalf of the Covered Person to any provider) from the plan, the Covered Person acknowledges that this plan's recovery rights are a first priority claim against all Responsible Parties and are to be paid to the plan before any other claim for the Covered Person's damages. This plan shall be entitled to full reimbursement on a first-dollar basis from any Responsible Party's payments, even if such payment to the plan will result in a recovery to the Covered Person which is insufficient to make the Covered Person whole or to compensate the Covered Person in part or in whole for the damages sustained. The plan is not required to participate in or pay court costs or attorney fees to any attorney hired by the Covered Person to pursue the Covered Person's damage claim. Applicability to All Settlements and Judgments The terms of this entire subrogation and right of recovery provision shall apply and the plan is entitled to full recovery regardless of whether any liability for payment is admitted by any Responsible Party and regardless of whether the settlement or judgment received by the Covered Person identifies the medical benefits the plan provided or purports to allocate any portion of such settlement or judgment to payment of expenses other than medical expenses. The plan is entitled to recover from any and all settlements or judgments, even those designated as pain and suffering, non-economic damages and/or general damages only. 43 Cooperation The Covered Person shall fully cooperate with the plan's efforts to recover its benefits paid. It is the duty of the Covered Person to notify the plan within 30 days of the date when any notice is given to a party, including an insurance company or attorney, of the Covered Person's intention to pursue or investigate a claim to recover damages or obtain compensation due to injury, illness or condition sustained by the Covered Person. The Covered Person and his/her agents shall provide all information requested by the plan, the Claims Administrator or its representative including,but not limited to, completing and submitting any applications or other forms or statements as the plan may reasonable request. Failure to provide this information may result in the termination of health benefits for the Covered Person or the institution of court proceedings against the Covered Person. The Covered Person shall do nothing to prejudice the plan's subrogation or recovery interest or to prejudice the plan's ability to enforce the terms of this plan provision. This includes, but is not limited to, refraining from making any settlement or recovery that attempts to reduce or exclude the full cost of all benefits provided by the plan. The Covered Person acknowledges that the plan has the right to conduct an investigation regarding the injury, illness or condition to identify any Responsible Party. The plan reserves the right to notify Responsible Party and his/her agents of its lien. Agents include, but are not limited to, insurance companies and attorneys. Interpretation In the event that any claim is made that any part of this subrogation and right of recovery provision is ambiguous or questions arise concerning the meaning or intent of any of its terms, the Claims Administrator for the plan shall have the sole authority and discretion to resolve all disputes regarding the interpretation of this provision. Jurisdiction By accepting benefits (whether the payment of such benefits is made to the Covered Person or made on behalf of the Covered Person to any provider) from the plan,the Covered Person agrees that any court proceeding with respect to this provision may be brought in any court of competent jurisdiction as the plan may elect. By accepting such benefits, the Covered Person hereby submits to each such jurisdiction, waiving whatever rights may correspond to him/her by reason of his/her present or future domicile. 44 When Coverage Ends Your coverage under this plan can end for a number of reasons. This section explains how and why your coverage can be terminated, and how you may be able to continue coverage after it ends. For Retired Employees Your coverage under this plan ends at the end of the period for which contributions were made following the date: • You terminate your coverage; • The coverage described in this booklet is terminated under the group contract; • You are no longer in an eligible class for all or part of your coverage; or • You fail to make any required contribution. For Dependents Your dependent's coverage will end on the earliest to occur of the following events: • When all dependents' coverage under the group contract is terminated; • When a dependent becomes covered as an employee of the City of Fort Worth (a person cannot be covered as both an employee and a dependent); • The end of the month when he or she no longer meets the plan's definition of a dependent (see the Eligibility section); or • When your coverage terminates. Continuing Coverage under COBRA Under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), you and your dependents have the right to continue health coverage if it ends for the reasons ("qualifying events") described below. You may continue only the plan coverage in effect at the time and must pay required premiums. Qualifying Events and Continuation Periods The chart below outlines: • The qualifying events that trigger the right to continue coverage; • Those eligible to elect continued coverage; and • The maximum continuation period. 45 Qualifying Event` Covered Persons :< Maximum e. " Causing Eligible for° Contmuatiion Loss of C ?; ,' nneCoaeraa erod,Cotu Povera , Divorce or legal separation Your spouse 36 months Your dependent children Children no longer qualify as eligible for Your dependent children 36 months dependent coverage Your death Your spouse 36 months Your dependent children The required premium for the 18- or 36-month continuation period may be up to 102% of the plan cost. Disability Extension The 18-month continuation period may be extended for an additional 11 months if you or your covered dependents qualify for disability status under Title II or XVI of the Social Security Act during the 18-month continuation period. The additional 11 months of continued coverage is available for the disabled individual and any family member of the disabled person. The City of Fort Worth must be notified of a determination of disability within 60 days of the date of the determination and before the end of the 18-month continuation period. The required premiums for the 18'h through 29 h month of continued coverage may be up to 150% of the plan cost. Multiple Qualifying Events If your spouse or dependent children experience a second qualifying event during the 18- or 29-month continuation period, their maximum continuation period can be extended to 36 months. Electing Continued Coverage The City of Fort Worth will notify Aetna who will give you detailed information about how to continue coverage under COBRA at the time you or your dependents become eligible. You or your dependents will need to elect continued coverage within 60 days of the"qualifying event"or the date of your COBRA notice, if later. The election must include an agreement to pay required premiums. Your dependents will need to notify the City of Fort Worth within 60 days of a divorce or legal separation or loss of dependent child eligibility, or the date coverage ends due to those circumstances, if later. 46 When COBRA Continuation Ends Continued coverage ends on the first of the following events: • The end of the maximum COBRA continuation period; • Failure to pay required premiums; • Coverage under another group plan that does not restrict coverage for preexisting conditions; • Coverage by Medicare; • The City of Fort Worth no longer offers a group health plan; • You or your dependents die. Other Continuation Provisions If this plan contains any other continuation provisions, contact the City of Fort Worth for information on how they may affect COBRA continuation provisions. 47 Your Privacy Under HIPAA The Health Insurance Portability and Accountability Act (HIPAA) of 1996 gives you certain rights of privacy concerning your health information. The regulation designates certain medical information as Protected Health Information (PHI). PHI is any information that could be used to identify you as an individual in electronic, printed or spoken form. PHI consists of information that relates to past, present or future health or physical or mental conditions. You have the right to: • Receive notice of your privacy rights,policies and procedures; • Obtain access to your PHI; • Amend your PHI; • Authorize use and disclosure of your PHI; • Receive an accounting of uses and disclosures of your PHI; • Receive communications by an alternative means or at an alternative location. Your health care providers must obtain your written consent to use or disclose your PHI for any purpose other than: • Treatment; • Payment; • Health care operations; or • As required by a national public health initiative, law enforcement investigations and other such laws (e.g., Occupational Safety and Health Administration regulations). There are also times when your PHI may be used or disclosed without your consent. These permitted uses include disclosure: • To you; • In case of an emergency where your provider cannot get authorization; • When treatment is required by law; • Where language barriers exist but consent can be inferred; • Pursuant to an authorization from you; • To business associates (consultants and other entities who contract with the City of Fort Worth and comply with the privacy rules); and • When all information that could identify you is removed from your PHI. You may be asked to authorize your PHI for another purpose. When you grant this authorization, your PHI is still protected from use and disclosure by any party other than the one(s) to whom you grant written authorization, and from use and disclosure by authorized parties for any purpose other than the one you specifically authorized. 48 Other Plan Provisions Type of Coverage Only non-occupational (not job-related) accidental injuries and non-occupational diseases are covered under this plan. Coverage for services and supplies applies only if they are provided to a person at the time he or she is covered under the plan. Multiple Coverage and Misstatement of Fact You cannot be covered under this plan as both a retiree and as a dependent. If there is a misstatement of fact that affects your coverage under this plan, the true facts will be investigated to determine the coverage that applies. Assignment of Coverage Coverage may be assigned(signed over to another person) only with Aetna's written permission. 49 Glossary The terms that appear in bold print throughout this booklet are defined in this section. Brand-Name Drug This is a prescription drug protected by trademark registration. Companion This is a person who needs to be with an NME patient to enable him or her: • To receive services in connection with an NME (National Medical Excellence) procedure or treatment on an inpatient or outpatient basis; or • To travel to and from the facility where treatment is given. Co-pay/Co-payment This is a flat fee, which represents a portion of the applicable expenses. Custodial Care This means services and supplies—including room and board and other institutional care —provided to help a person in the activities of daily life. The person does not have to be disabled. Such services and supplies are custodial care no matter who prescribes, recommends or performs them. Durable Medical Equipment This is equipment—and the accessories needed to operate it—that is: • Made to withstand prolonged use; • Made for and mainly used in the treatment of a disease or injury; and • Suited for use in the home. 50 Effective Treatment of Alcoholism or Drug Abuse This means a program of alcoholism or drug abuse therapy that is prescribed and supervised by a physician and either: • Has a follow up therapy program directed by a physician on at least a monthly basis; or • Includes meetings at least once a month with organizations devoted to the treatment of alcoholism or drug abuse. Detoxification (treating the aftereffects of a specific episode of alcohol or drug abuse) and maintenance care (providing an alcohol-and/or drug-free environment) are not considered"effective treatment." Emergency Admission This means a hospital admission where the physician admits the person to the hospital or treatment facility right after the sudden and, at that time, unexpected onset of a change in the person's physical or mental condition: • Which requires confinement right away as a full-time inpatient; and • For which, if immediate inpatient care were not given, could (as determined by Aetna), reasonably be expected to result in: • Placing the person's health in serious jeopardy; or • Serious impairment to bodily function; or • Serious dysfunction of a body part or organ; or • Serious jeopardy to the health of the fetus (in the case of a pregnant woman). Emergency Care This means the treatment given in a hospital's emergency room to evaluate and treat medical conditions of a recent onset and severity—including but not limited to severe pain—which would lead a prudent layperson,possessing an average knowledge of medicine and health,to believe that his or her condition, sickness or injury is of such a nature that failure to get immediate medical care could result in: • Placing the person's health in serious jeopardy; or • Serious impairment to bodily function; or • Serious dysfunction of a body part or organ; or • Serious jeopardy to the health of the fetus (in the case of a pregnant woman). 51 Emergency Condition This means a recent and severe medical condition—including but not limited to severe pain—which would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in: • Placing the person's health in serious jeopardy; or • Serious impairment to bodily function; or • Serious dysfunction of a body part or organ; or • Serious jeopardy to the health of the fetus (in the case of a pregnant woman). Some examples of emergency conditions include: • Serious injury, severe pain or infection; • Poisoning; • Uncontrollable bleeding; • Sudden change of vision; • Chest pain; • Sudden weakness or trouble talking; • Major burns; • Spinal injury; • Difficulty breathing; • Broken bones. Home Health Care Agency This is an agency that: • Mainly provides skilled nursing and other therapeutic services; and • Is associated with a professional group (of at least one physician and one R.N.)which makes policy; and • Has full-time supervision by a physician or a R.N.; and • Keeps complete medical records on each person; and • Has an administrator; and • Meets licensing standards. 52 Home Health Care Plan This is a plan that provides for care and treatment in a person's home. It must be: • Prescribed in writing by the attending physician; and • An alternative to confinement in a hospital or convalescent facility. Hospice Care This is care provided to a terminally ill person by or under arrangements with a hospice care agency. The care must be part of a hospice care program. Hospice Care Agency This is an agency or organization that: • Has hospice care available 24 hours a day. • Meets any licensing or certification standards established by the jurisdiction where it is located. • Provides: • Skilled nursing services; and • Medical social services; and • Psychological and dietary counseling. • Provides, or arranges for, other services which include: • Physician services; and • Physical and occupational therapy; and • Part-time home health aide services which mainly consist of caring for terminally ill people; and • Inpatient care in a facility when needed for pain control and acute and chronic symptom management. • Has at least the following personnel: • One physician; and • One R.N.; and • One licensed or certified social worker employed by the agency. • Establishes policies about how hospice care is provided. • Assesses the patient's medical and social needs. • Develops a hospice care program to meet those needs. • Provides an ongoing quality assurance program. This includes reviews by physicians, other than those who own or direct the agency. • Permits all area medical personnel to utilize its services for their patients. • Keeps a medical record on each patient. • Uses volunteers trained in providing services for non-medical needs. • Has a full-time administrator. 53 Hospice Care Facility This is a facility, or distinct part of one, which: • Mainly provides inpatient hospice care to terminally ill persons. • Charges patients for its services. • Meets any licensing or certification standards established by the jurisdiction where it is located. • Keeps a medical record on each patient. • Provides an ongoing quality assurance program including reviews by physicians other than those who own or direct the facility. • Is run by a staff of physicians. At least one staff physician must be on call at all times. • Provides 24-hour-a-day nursing services under the direction of a R.N. • Has a full-time administrator. Hospice Care Program This is a written plan of hospice care,that: • Is established by and reviewed from time to time by the person's attending physician and appropriate hospice care agency personnel. • Is designed to provide palliative (pain relief) and supportive care to terminally ill people and supportive care to their families. • Includes an assessment of the person's medical and social needs, and a description of the care to be given to meet those needs. Hospital This is a place that: • Mainly provides inpatient facilities for the surgical and medical diagnosis, treatment, and care of injured and sick persons. • Is supervised by a staff of physicians. • Provides 24-hour-a-day R.N. service. • Is not mainly a place for rest, for the aged, for drug addicts, for alcoholics, or a nursing home. • Charges for its services. L.P.N. This means a licensed practical nurse. 54 Mental Disorder This is a disease commonly understood to be a mental disorder whether or not it has a physiological or organic basis. Treatment for mental disorders is usually provided by or under the direction of a mental health professional such as a psychiatrist, psychologist or psychiatric social worker. Mental disorders include (but are not limited to): • Alcoholism and drug abuse • Schizophrenia • Bipolar disorder • Pervasive mental developmental disorder(autism) • Panic disorder • Major depressive disorder • Psychotic depression • Obsessive compulsive disorder For the purposes of benefits under this plan, mental disorder will include alcoholism and drug abuse only if there is no separate benefit for the treatment of alcoholism and drug abuse. Necessary A service or supply is necessary if Aetna determines that it is appropriate for the diagnosis, care, or treatment of the disease or injury involved. To be appropriate, the service or supply must: • Be care or treatment, as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the person's overall health condition; • Be a diagnostic procedure, indicated by the health status of the person, and be as likely to result in information that could affect the course of treatment as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the person's overall health condition; and • As to diagnosis, care and treatment be no more costly (taking into account all health expenses incurred in connection with the service or supply) than any alternative service or supply to meet the above tests. 55 In determining if a service or supply is appropriate under the circumstances, Aetna will take into consideration: • Information provided on the person's health status; • Reports in peer-reviewed medical literature; • Reports and guidelines published by nationally recognized health care organizations that include supporting scientific data; • Generally recognized professional standards of safety and effectiveness in the United States for diagnosis, care or treatment; • The opinion of health professionals in the generally recognized health specialty involved; and • Any other relevant information brought to Aetna's attention. The following services or supplies are not considered necessary: • Those that do not require the technical skills of a medical,mental health or dental professional; or • Those provided mainly for the personal comfort or convenience of the person, any person who cares for him or her, any person who is part of his or her family, any healthcare provider or health care facility; or • Those provided only because the person is an inpatient on any day when the person's disease or injury could safely and adequately be diagnosed or treated while not confined as an inpatient; or • Those provided only because of the setting, if the service or supply could safely and adequately be furnished in a physician's or a dentist's office or other less costly setting. Non-Occupational Disease A non-occupational disease is a disease that does not: • Result from(or in the course of) any work for pay or profit; or • Result in any way from a disease that does. A disease will be considered non-occupational regardless of its cause if proof is provided that the person: • Is covered under any type of workers' compensation law; and • Is not covered for that disease under such law. 56 Non-occupational Injury A non-occupational injury is an accidental bodily injury that does not: • Result from (or in the course of) any work for pay or profit; or • Result in any way from an injury that does. Physician The following practitioners are recognized as legally qualified physicians when they are rendering a covered service: • Medical Doctor (M.D.) • Doctor of Osteopathy (D.O.) • Doctor of Dental Surgery (D.D.S.) or Dentist(D.D.S.) • Podiatrist(D.P.M.), (D.S.C.) • Doctor of Chiropractic (D.C.) • Licensed Professional Counselor(L.P.C.) • Optometrist(O.D.) • Psychologist(Ph.D.), (Ed. D.) • Social Worker(M.S.W.) Prescription Drugs Any of the following: • A drug, biological or compounded prescription which, by federal law, may be dispensed only by prescription and which is required to be labeled "Caution: Federal Law prohibits dispensing without prescription". • An injectable contraceptive drug prescribed to be administered by a paid health care professional. • An injectable drug prescribed to be self-administered or administered by another person except someone who is acting within his or her capacity as a paid health care professional.. • Disposable needles and syringes purchased to administer a covered injectable prescription drug. R.N. This means a registered nurse. 57 Room and Board Charges Charges made by an institution for room and board and other necessary services and supplies. The charges must be regularly made at a daily or weekly rate. If a hospital or other health care facility doesn't identify the specific amounts charged for room and board charges and other charges, Aetna will assume that 40% of the total is the room and board charge, and 60% is other charges. Semi-Private Room Rate This is the room and board charge that an institution applies to the most beds in its semi- private rooms with 2 or more beds. If there are no such rooms, Aetna will figure the rate. It will be the rate most commonly charged by similar institutions in the same geographic area. Skilled Nursing Facility This is an institution that: • Is licensed to provide, and does provide, the following on an inpatient basis for persons convalescing from disease or injury: — Professional nursing care by a R.N., or by a L.P.N. directed by a full-time R.N.; and — Physical restoration services to help patients to meet a goal of self-care in daily living activities. • Provides 24-hour-a-day nursing care by licensed nurses directed by a full-time R.N. • Is supervised full-time by a physician or R.N. • Keeps a complete medical record on each patient. • Has a utilization review plan. • Is not mainly a place for rest, for the aged, for drug addicts, for alcoholics, for people who are mentally retarded, for custodial or educational care, or for care of mental disorders. • Charges for its services. Terminally I// This is a medical prognosis of 6 months or less to live. 58 Treatment Facility(Alcoholism or Drug Abuse) This is an institution that: • Mainly provides a program for diagnosis, evaluation and effective treatment of alcoholism or drug abuse. • Makes charges. • Meets licensing standards. • Prepares and maintains a written plan of treatment for each patient. The plan must be based on medical, psychological and social needs, and must be supervised by a physician. • Provides, on the premises, 24 hours a day: — Detoxification services needed with its effective treatment program. — Infirmary-level medical services. Also, it provides, or arranges with a hospital in the area for, any other medical services that may be required. — Supervision by a staff of physicians. — Skilled nursing care by licensed nurses directed by a full-time R.N. CCG CFW TC SPD-06-0598(10/07) 59 Page 1 of 3 City of Fort Worth, Texas Mayor and Council Communication COUNCIL ACTION: Approved on 6/22/2004 DATE: Tuesday, June 22, 2004 LOG NAME: 14AETNA REFERENCE NO.: C-20123 SUBJECT: Award of Contract for the Administration of Group Medical Benefits and Purchase of Specific and Aggregate Stop Loss Insurance to AETNA Life Insurance Company RECOMMENDATION: It is recommended that the City Council authorize the City Manager to enter into a contract with Aetna Life Insurance Company (Aetna) for administration of the City's self-funded group medical benefit program including COBRA and stop-loss insurance effective January 1, 2005 through December 31, 2005, with three one-year options for renewal. DISCUSSION: United Healthcare Insurance Company (UHC) has been the medical benefit administrator for the City of Fort Worth's group medical coverage for employees, retirees, and the eligible dependents since October 1, 2001. The contract with UHC expires December 31, 2004. In January 2004, an Ad Hoc Selection Committee was formed with the Human Resources Director, Karen Marshall, as chair and other members including John Kerr - Police Officers' Association, Don Westmoreland - Firefighters' Association, Sally - McCoy Librarians' Association, Dinah Horton - Public Events, Ann Bracey - Retiree, Barbara Smith - Association of City Employees and Jimmy Young - Medicare Eligible Retiree. This Committee was active in both the preparation of the Request for Proposals (RFP) and the analysis of the proposals submitted. On February 6, 2004, an RFP was issued requiring interested vendors to submit proposals by March 4, 2004. The RFP was designed to solicit proposals on 1) Third Party Administrative Services (TPA) for a self funded plan, 2) Fully Insured PPO, HMO, and POS options, 3) Pharmacy Benefit Management Programs (PBM), which require a separate prescription program from the medical plan and 4) Medicare Supplement program for Retirees eligible for Medicare. The Committee considered several factors in evaluating proposals including price competitiveness, the organization's ability to administer plans with various plan designs, evaluation of provider network, qualifications of the organization's staff, satisfaction and complaint records, MWBE participation, and responsiveness to customer service issues. Aetna received the highest rating from a selection of thirty-one (31) submissions. Aetna's broad provider network would result in a very low disruption rate with minimum changes to the members' current doctors and hospitals. In its presentation to the City, Aetna emphasized enhanced customer service, case management and use of technology to assist physicians in providing better care at a lower cost. Aetna has committed to maintaining a designated customer service team for the City of Fort Worth and providing a walk-in customer service center in Arlington. Aetna will guarantee performance incentives for the plan http://apps.cfwnet.org/council_packet/Reports/mc_print.asp 6/26/2008 Page 2 of 3 based on the specific needs of the City. The associated cost and fees for plan administration and re-insurance is a follows: A. Administration of Benefits $32.50 per subscriber per month for active employees and Non-Medicare eligible retirees, for the period of January 1, 2005, through December 31, 2005. . $22.27 per subscriber per month for Medicare eligible retirees, for the period of January 1, 2005, through December 31, 2005. B. Stop-loss Insurance 18/12 . Specific stop-loss insurance will ensure the City of Fort Worth is not liable for claims above $350,000 paid on any plan member during 2005. The cost of this coverage is $18.35 per month for each active employee and for each Non-Medicare eligible retiree. . Aggregate stop-loss insurance will ensure the City of Fort Worth is not liable for any claims of plan members after the total claims paid has exceeded 125 percent of expected claims. The cost for this re-insurance is $1.10 per employee and retiree per month. C. COBRA Administration Monthly Processing for COBRA continuants $ 11 per enrollment Qualifying Event Notice $ 12 per notice A summary of the cost for administrative fees, specific stop loss and aggregate stop loss is provided below: Proposed Rates Proposed Costs Administrative Fees January-December 2005 Active and Non-Medicare Retirees $32.30 $2,358,720.00 Medicare Retirees $22.27 $302,086.00 Specific Stop-Loss $18.35 $1,341,204.00 Aggregate $1.10 $95,383.00 Total $74.02 $4,097,394.00 These figures were based on anticipated enrollment of 4,923 employees, 1,125 Non-Medicare eligible retirees and 1,178 Medicare eligible retirees. Overall, the expected fixed administrative costs for Aetna are within the requested budget for FY 04-05. It is anticipated that the Health Benefit Advisory Committee will make a recommendation to the City Manager on premium contribution rates, plan design, and a Medicare supplement plan by July 2004. Open enrollment for the 2005 medical plan is scheduled to begin October 1, 2004. http://apps.cfwnet.org/council_packet/Reports/mc_print.asp 6/26/2008 Page 3 of 3 FISCAL INFORMATION/CERTIFICATION: The Finance Director certifies that funds are available in the current operating budget, as appropriated, of the Group Health Insurance Fund. TO Fund/Account/Centers FROM Fund/Account/Centers FE85 534830 0148520 $9.00 FE85 534840 0148520 $0.00 FE85 534850 0148520 $0.00 FE85 534830 0148540 $0.00 FE85 534840 0148540 JQ.00 FE85 534850 0148540 $4,097,394.00 Submitted for City Manager's Office by: Charles Boswell (6183) Originating Department Head: Karen Marshall (7783) Additional Information Contact: Mark Washington (8058) http://apps.cfwnet.org/council_packet/Reports/mc_print.asp 6/26/2008 ,. Page 1 of 2 City of Fort Worth, Texas Mayor and Council Communication COUNCIL ACTION: Approved on 12/20/2005 DATE: Tuesday, December 20, 2005 LOG NAME: 14AETNA REFERENCE NO.: C-21220 SUBJECT: Authorize Renewal of Contract with Aetna Life Insurance for Administration of the City's Self-Funded Group Health Benefit Program RECOMMENDATION: It is recommended that the City Council authorize the City Manager to execute the first (of three) one-year contract renewal options with Aetna Life Insurance for administration of the City's self-funded group health benefit program beginning January 1, 2006 and expiring December 31, 2006. DISCUSSION: The City's health benefits program is self-funded and utilizes a third party administrator to process claims. Aetna has been the third party administrator of group health benefits for the City of Fort Worth since January 1, 2005, (M&C C-20123). The original contract provides for three options to renew the contract for a one-year term. Aetna was selected as the administrator of the health plan as a result of an RFP process including the use of an employee advisory committee throughout the process. Since Aetna became the administrator of the plan, the claims experience has improved. There was no increase in premiums in the FY 05-06 budget and member satisfaction has also increased. The associated cost and fees for plan administration and re-insurance is as follows: Administration Fee -Aetna will receive a monthly administrative fee of $32.55 per employee or retiree who is not eligible for Medicare and $22.01 for each retiree eligible for Medicare. During calendar year 2006, the City is expected to pay Aetna $2,893,441 in administrative fees. These figures represent an increase of 4.7% over the administrative fees for 2005. This increase is partly the result of the new reports related to Medicare Part D that Aetna will supply. These reports are expected to assist the City in receiving over $500,000 in subsidies from Medicare in 2006. Aetna will also administer the COBRA program, prepare detailed quarterly files and use its Med Query Predictive modeling program to help lessen claims and to improve the quality of life of some members. Stop Loss Premium - Specific Stop Loss coverage will protect the health plan from additional costs once benefits of $350,000 have been paid on an individual. Aggregate Stop Loss coverage will provide up to $3,000,000 in benefits if claims exceed 125% of the expected claims. The City is expected to pay Aetna $1,338,788 in stop loss premiums in 2006. This represents a 28.2% increase over the premiums paid in 2005. However, most of the increase is due to improvements in the terms of the specific stop loss contract in terms of which claims will be included under the coverage. This change provides additional protection for the plan against individuals who incur large claims. AON Consulting assisted in the evaluation of the proposed premiums. http://apps.cfwnet.org/council_packet/R.eports/mc_print.asp 6/26/2008 Page 2 of 2 Aetna is in compliance with the City's M/WBE Ordinance by providing 30% M/WBE participation on their discretionary spending. The City's M/WBE goal on this project is 25%. Summary of Aetna's Costs: Item Cost Administration Fee $2,893,441.00 Stop Losss Premiums 1,338,788.00 Total $4,232,229.00 FISCAL INFORMATION/CERTIFICATION: The Finance Director certifies that funds are available in the current operating budget, as appropriated, of the Group Health Insurance Fund. TO Fund/Account/Centers FROM Fund/Account/C enters FE85 534830 0148520 $2,415,956.00 FE85 534840 0148520 $1,115,927.00 FE85 534830 0148540 $477,485.00 FE85 534840 0148540 $222,860.00 Submitted for City Manager's Office by: Richard Zavala (Acting) (6222) Originating Department Head: Karen Marshall (7783) Additional Information Contact: Bob Molloy (7787) http://apps.cfwnet.org/council_packet/Reports/mc_print.asp 6/26/2008 • Page 1 of 2 City of Fort Worth, Texas Mayor and Council Communication COUNCIL ACTION: Approved on 12/19/2006 DATE: Tuesday, December 19, 2006 LOG NAME: 14AETNA REFERENCE NO.: C-21907 SUBJECT: Authorize Renewal of Contract with Aetna Life Insurance for Administration of the City's Self-Funded Group Health Benefit Program RECOMMENDATION: It is recommended that the City Council authorize the City Manager to execute the second of three one-year renewal options with Aetna Life Insurance (Aetna) for administration of the City's self-funded group health benefit program beginning January 1, 2007, and expiring December 31, 2007. DISCUSSION: The City's health benefits program is self-funded and utilizes a third party administrator to process claims. Aetna has been the third party administrator of group health benefits for the City of Fort Worth since January 1, 2005. The original contract provides for three options to renew the contract for a one-year term. Aetna was selected as the administrator of the health plan as a result of a competitive process including the use of an employee advisory committee. Since Aetna became the administrator of the plan on January 1, 2005, the claims experience has been better than it had been under the prior administrator. There was no increase in employee or City contribution rates in the FY 05-06 budget, and there is no increase in the FY 06-07 budget. The associated cost and fees for plan administration and re-insurance are as follows: Administration Fee - Aetna will receive a monthly administrative fee of $34.85 per employee or retiree who is not eligible for Medicare and $22.89 for each retiree eligible for Medicare. During calendar year 2007, the City is expected to pay Aetna $3,031,488 in administrative fees. Stop Loss Premium - Specific Stop Loss coverage will protect the health plan from additional costs once benefits of $350,000 have been paid for an individual. Aggregate Stop Loss coverage will provide up to $5,000,000 in benefits if actual claims exceed 125% of the expected claims. The City is expected to pay Aetna $1,315,596 in stop loss premiums in 2007. AON Consulting assisted in the evaluation and negotiation of the proposed stop loss premiums. Summary of Aetna's Proposed Costs Administration Fee $3,031,488 Stop Loss Premiums $1,315,596 Total $4,347,084 http://apps.cfwnet.org/council_packet/Reports/mc_print.asp 6/26/2008 ' , Page 2 of 2 The total projected twelve-month cost of $4,347,084 represents a 10.7 percent increase in cost from the previous year primarily due to more catastrophic/larger claims that expected. However, only nine months of the projected costs, $3,260,313.00, will be paid in fiscal year 2006-07. The remaining three months costs of $1,086,771.00 will be paid in FY2007-08. Aetna Life Insurance Company is in compliance with the City's M/WBE Ordinance. FISCAL INFORMATION/CERTIFICATION: The Finance Director certifies that the funds are available in the current operating budget as appropriated, of the Group Health and Life Insurance Fund. TO Fund/Account/Centers FROM Fund/Account/Centers FE85 534830 0148520 $1,647,765.75 FE85 534840 0148520 $625,850.25 FE85 534830 0148540 $794,404.50 FE85 534830 0148540 $192,292.50 Submitted for City Manager's Office by: Karen Montgomery (6222) Originating Department Head: Karen Marshall (7783) Additional Information Contact: Bob Molloy (7787) http://apps.cfwnet.org/council_packet/Reports/mc_print.asp 6/26/2008 Page 1 of 2 City of Fort Worth, Texas Mayor and Council Communication COUNCIL ACTION: Approved on 12/18/2007 DATE: Tuesday, December 18, 2007 LOG NAME: 141NSURANCE REFERENCE NO.: C-22590 SUBJECT: Authorize Execution of Contract Renewal with Aetna Life Insurance for Administration of the City's Self-Funded Group Health Benefit Program RECOMMENDATION: It is recommended that the City Council authorize the City Manager to execute the third of three, one-year contract renewal options with Aetna Life Insurance for administration of the City's self-funded group health benefit program beginning January 1, 2008, and expiring December 31, 2008, for a total cost not to exceed $4,819,356. DISCUSSION: The City's health benefits program is self-funded and utilizes a third party administrator to process claims. Aetna Life Insurance (Aetna) has been the third party administrator of group health benefits for the City of Fort Worth since January 1, 2005. Since Aetna became the administrator of the Plan the claims experience has been better than national and local trends, but there has been an upward trend in claims in 2006 and 2007. The original contract provides for three options to renew the contract for a one-year term. The associated cost and fees for plan administration and re-insurance during calendar year 2008 is as follows: Administration Fee - Aetna will receive a monthly administrative fee of $35.86 per employee or retiree who is not eligible for Medicare and $23.57 for each retiree eligible for Medicare. During calendar year 2008, the City is expected to pay Aetna $3,226,558 in administrative fees. These monthly fees represent an increase of three percent over the administrative fees for calendar year 2007. Stop Loss Premium - Specific Stop Loss coverage protects the health plan from additional costs once benefits for an individual have exceeded an attachment point. Currently the Plan has an attachment point of $350,000. Aggregate Stop Loss coverage will provide up to $3,000,000 in benefits if actual claims exceed 125 percent of the expected claims. The City is expected to pay a maximum amount of $1,592,798 in stop loss premiums in calendar year 2008. Summary of Expected Charges from Aetna during Calendar Year 2008 Administration Fee $3,226,558.00 Stop Loss Premiums $1,592,798.00 Total $4,819,356.00 Aetna Life Insurance company is in compliance with the City's M/WBE ordinance. http://apps.cfwnet.org/council_packet/Reports/mc_print.asp 6/26/2008 Page 2 of 2 FISCAL INFORMATION/CERTIFICATION: The Finance Director certifies that the funds are available in the current operating budget as appropriated, of the Group Health and Life Insurance Fund. (Amounts shown below are the expected cost for FY07-08 (75 percent of the calendar year amounts). TO Fund/AccountlCenters FROM Fund/AccounVCenters FE85 534830 0148520 $1,764,540.36 FE85 534830 0148540 $655,377.84 FE85 534840 0148540 $227,306.52 FE85 534840 0148520 $967,291.92 Submitted for City Manager's Office by: Karen Montgomery (6222) Originating Department Head: Karen Marshall (7783) Additional Information Contact: Bob Molloy (7787) http://apps.cfwnet.org/council_packet/Reports/mc_print.asp 6/26/2008