HomeMy WebLinkAbout07/31/02 AGENDA FILE
239 4th Street · Bremerton, WA 98337 · Phone (360) 478-5280 · Fax (360) 478-5251
CITY COUNCIL MEETING AGENDA
JULY 31, 2002
1. PRE-COUNCIL STUDY SESSION: 5:00-5:30 P.M.
A. General Council Business
2. CALL TO ORDER: 5:30 P.M.
A. Pledge of Allegiance
B. Invocation
3. CONSENT AGENDA
A. Minutes of Meeting - July 24, 2002 (#AB02-147) (
B. Resolution No. 2869, setting a Hearing Date of August 21, 2002 for Vacating a
portion of the alley located between Warren Avenue & Park Avenues, and between
4th & 5th Streets (#AB02-148)
C. U.S. Department of Justice Local Law Enforcement Block Grant (LLEBG) FY 2002 /'~
(#AB02-149)
4. CLAIMS/CHECK REGISTERS
5. COUNCIL MEMBER REPORTS
6. MAYOR'S REPORT
7. PUBLIC RECOGNITION - Comments limited to 3-minutes
8. NEW BUSINESS
A. Appointment of Pro & Con Committees for Local Voter's Pamphlet on Public Safety
Bond Issue (#AB02-150)
B. Contract Renewals between the City and KPS Health Plans for Employee Medical
Coverage (#AB02-151 )
9. PUBLIC HEARINGS - RESOLUTIONS & ORDINANCES
A. Resolution No. 2870, regarding Recovery of Fees for the Removal of Vegetation on
the List of Properties (#AB02-152)
10. ADJOURNMENT OF MEETING
E-mail: citycouncil@ci.bremerton.wa.us · Web: www. ci.bremerton.wa.us
CITY COUNCIL MEETING
JULY 31, 2002
SPEAKERS LIST
If you wish to make an announcement, inform the Council of an issue, or ask a general question...Please
provide information be/ow so staff will be able to contact you.
Thank you.
NAME ADDRES S/TELEPHONE TOPIC
2.
o
Reminder: The next Council Meeting will be held on Wednesday, August 142
A Monthly Study Session will be held on Wednesday, August 7th
The City Council passed a resolution last week placing a Public Safety Bond
Issue in the amount of 12.979 Million on the September 17, 2002 ballot. In order to
participate in the County Voters Pamphlet we must appoint a committee to write a
statement in support of the bond issue and a committee to write a statement in opposition
to the bond issue. If you wish to serve on the committee to write the statement in
opposition to the bond issue please contact the ~nc:~! office no later than 5:00 p.m.
tomorrow Thursday August 1st. The phone number is 478-53,8~. 5"~._c~ O
The proposed committee in support of the bond issue is:
Mayor Cary Bozeman
Chief Rob Forbes
Chief A1 Duke
Stacey Tucker
Alan Martin
Jerry Reid
The committee will select a chairman and the three names to appear in the voters'
pamphlet.
PROCLAMATION
WHEREAS, the City of Bremenon applied and was selected as a World
Changers Project site for the fourth consecutive year; and
WHEREAS, over 250 young adults have raised their own funds to come to
Bremerton during the week of July 29-August 2, 2002; and
WHEREAS, these young people will paint, put on new roofs, and do yard
work on the homes of 22 low income families; and
VqHEREAS, the community, area businesses and churches have come together
to support the City of Bremerton with this worthwhile project;
NOW, THEREFORE, I, Cary Bozeman, Mayor of the City of Bremerton, do
hereby proclaim July 29 - August 2, 2002 as
WORLD CHANGERS WEEK
in Bremerton and call upon all citizens of our City to join us in recognizing these young
adults in their positive efforts to assist our citizens.
SIGNED this 31 st day of July 2002.
Cary Bozeman, Mayor
AGENDA BILL
BREMERTON CITY COUNCIL
1. SUBJECT: FORAGENDA OF: JULY 31, 2002
ORIGINATING DEPT: CITY COUNCIL
MINUTES OF MEETING- JULY 24, 2002 ORIGINATOR: CAROL ARENDS, PRESIDENT
DATE SUBMITTED: JUkY 25, 2002
2. CLEARANCES: (Comment on back ifnecessary) 3. EXHIBITS:
ENDORSEMENT ~ INFORMATION ~] APPROVED FOR SUBMITTAL BY
cou3% PR~S~r,[NT:
MAYOR:
4. SUMMARY STATEMENT AND REQUIREMENT FOR COUNCIL ACTION:
5. RECOMMENDATION:
6. RESPONSIBLE OFFICIAL:
ENFORCEMENT OFFICIAL:
EXPIRATION DATE:
REVIEW DATE:
7. NOTICE OF ACTION:
PULLED [--] TABLED [-] APPROVED [~ DISAPPROVED [--] AMENDED [--] DATE:
COUNCIL DIRECTIVE:
JA
8. AGENDA BILL NO.: Q¢'~ "' / ~( 7
/
9. IMPACT OF NON-PASSAGE:
10. IMPACT ON STAFFING, BUDGETS, FACILITIES, EQUIPMENT OR OTHER RESOURCES:
11. RESEARCH SOURCES:
TAPE #1844 UNAPPROVED DRAFT
CITY COUNCIL MEETING MINUTES
July 24, 2002
The weekly meeting of the City Council of the City of Bremerton was called to order in the City Council
Chambers, 239 4th Street, Bremerton, Washington, Wednesday, July 24, 2002, at 5:30 P.M., with
Council President Carol Arends presiding. Council members present were Mike Short, Will Maupin, Eric
Younger, Mike Shepherd, Ed Rollman, Daren Nygren, Cecil McConnell, and Wayne Olsen. Also present
were City Attorney Roger Lubovich; Deputy City Clerk Paula Johnston; and Council Assistant Christine
Grenier Ellingson.
The meeting opened with the Pledge of Allegiance led by Council Member Cecil McConnell, followed
by the invocation provided by Council President Carol Arends.
Council President Arends made the following announcements:
(1) The regular Pre-Council Session, which was open to the public, was held in the Council Conference
Room to discuss general Council business from 5:00 to 5:30 P.M.
CONSENT AGENDA A. Minutes of Meeting- July 10, 2002 (#AB02-141)
B. Minutes of Meeting - July 17, 2002 (#AB02-142)
#0025 M/S/C/U (McConnell/Olsen) Move to approve Consent Agenda as presented.
CLAIMS/CHECK REGISTERS
Vouchers audited and certified by the auditing officer as required by RCW 42.24.080, and those
expense reimbursement claims certified as required by RCW 42.24.090 have been recorded on a listing
that had been made available to the Council.
#0050 M/S/C (Younger/McConnell) On July 24, 2002 the Council approved payment for those vouchers
included and further described as follows: Check numbers 270316 through 273123 in the amount of
$923,664.27; and Regular Payroll in the amount of $924,980.46 for the period ending July 15, 2002.
Voted in favor of the Motion: McConnell, Nygren, Rollman, Shepherd, Younger, Maupin, Short, Arends
Abstained: Olsen
Motion Carried: 8-Yes; 1-Abstention
COUNCIL MEMBER REPORTS
Mike Short reported on meetings he attended with transportation representatives and officials in Seattle.
The estimated cost for downtown transportation improvements in Seattle is approximately $11.9 billion
which includes viaduct improvements, seawall upgrades at the ferry dock, and tunnel construction.
Eric Younger discussed a law seminar he attended yesterday that covered shoreline regulations and
permitting issues.
Mike Shepherd thanked the citizens who attended his 4th Annual District 5 picnic last Saturday at
Evergreen Rotary Park; assured the public that staff is working on the odor problem at the lift station
located at Park Avenue & Washington Street; and announced that sidewalk construction will be ongoing
during the summer between High Avenue and Hewitt Avenue on 10t~ Street.
Ed Rollman announced the next Concert of the Boardwalk would be held Friday from 6:00 to 8:00 P.M.
TAPE #1844
City Council Reg. Mtg. Minutes
July 24, 2002
Page 2 of 6
Daren Ny.qren commented on the District 3 meeting held last night; and informed citizens that they may
contact Marilyn Waibel in Community Development at 478-5375 to obtain information on the "Down
Payment Assistance Program" or "Low-Interest Home Rehabilitation Loan Program".
Carol Arends will be attending Puget Sound Regional Council Executive Board Meeting and Operations
Committee Meeting in Seattle tomorrow.
MAYOR'S REPORT
Mayor Bozeman asked that Gene Sampley, Director of Public Works & Utilities, provide an update on
the sewage spill. The spill is estimated to be between 250,000-350,000 gallons that occurred over the
course of a week and was due to contractor failure to install a plug on a pipe that interconnected the
sewerline. Clean up has begun and the storm water line has been cleaned.
Mayor Bozeman additionally briefed the Council on the following issues:
· Announced that an Interim Finance Director would be selected by next week, and then the position
for Director would be filled at a later time.
· Would like to introduce the City's new lobbyist at an upcoming committee meeting.
· Announced that there is a proposal being considered which would facilitate ferry traffic movement to
Burwell Street via a tunnel. Funding is available to assist the city in the overall cost. On a side note,
some funding may also be available to assist in fast ferry wake research.
PUBLIC RECOGNITION
Allen Shute thanked Lori Smith and Paula Johnston for helping him in recent weeks; pointed out that
there are drug houses across from his residence and he would like action; and emphasized the need for
more cops to be on the streets to address the drug issue and to look at the problem of speeding
motorists.
Don Larson announced that some plum seedlings and Douglas fir trees are available to plant.
Volunteers are committed for the planting projects; has explained that in speaking Jim Trainer,
Community Forester, there is interest in setting up an agreement with the City of Bremerton so that trees
would be watered in right-of-way areas. He may be reached at 373-7593 to make arrangements.
Gerard Krye, of VCW Post #239, announced that flags should be flown at half-staff from sunrise to
sunset on Saturday, July 27 for National Korean War Armistice Day. He reminded the public that any
flags that are no longer flyable may be brought to VFW Post #239 at 190 South Dora Avenue for proper
disposal.
H. Emily Mosha¥ announced that Gracey Kelley had passed away and was a Iongtime volunteer for the
Admiral Theater and very active with the West Sound Arts Council. The funeral service will be held at
Miller Wood Lawn Mortuary on Friday at 11:00 A.M. with a reception immediately following the service.
NEW BUSINESS
8A- 2003 CDBGIHOME POLICY PLAN (#AB02-143): Debbie Peavler- Stewart, Administrative
Analyst, stated that as an Entitlement Community under the Community Block Grant Program, the City
of Bremerton is required to solicit the input of citizens in the use of CDBS and HOME Funds. Attached
is the draft 2003 CDBG/HOME Policy Plan and schedule. The Plan identifies the CDBG rules and
regulations, as well as the City's proposed allocation process for CDBG and HOME funds. The Plan
TAPE #1844
City Council Reg. Mtg. Minutes
July 24, 2002
Page 3 of 6
was made available to the public for comment from June 11 to July 23, and a public meeting to discuss
the plan was held on June 25, 2002. A technical assistance meeting to discuss the elements of the
application was held on July 23. According to the plan, applications will be accepted until August 22.
The City received two comments from Kitsap Community Resources (KCR) relative to the draft plan.
KCR recommends expanding housing services to include homeowners and providing a two-year funding
cycle for public service grants. Another comment was received following submission of the documents
to Council and the comment provided support for a one-year funding cycle.
Larry Eyer, Director of KCR, provided an overview of the services KCR provides and emphasized that
current arrangements disallow the use of CDBG funds to make improvements on rental properties.
Changes in the program would allow the rentals to be improved and would encourage home ownership
for the elderly and those individuals who fall under the Iow-income bracket. Some of the services
include weatherization that will ultimately improve energy efficiency.
Allen Shute asked why the improvements should benefit slumlords. Mr. £¥er answered that the goal is
to lower energy costs and the benefit goes to the tenant not the landlord. Will Maupin asked where
that issue is addressed in the plan. Ms. Peavler-Stewart directed the Council to Part 2, Page 7 of the
2003 Policy Plan. In that segment it is specified that CDBG funds will not be used for private rental
housing. Services like weatherization, rehabilitation projects, and increasing opportunities for the
homeless are included in the plan.
Ed Rollman asked how many housing units would be available to the homeless and what was the
estimated cost. Ms. Pearler-Stewart would provide that information at a later time. Mr. Rollman asked
why the amount of $50,000 is set aside for code enforcement and if the amount is for expected
violations. Ms. Pearler-Stewart clarified that the amount is for the salary of the building inspector.
Daren Nwren asked if other cities' policies have been reviewed. Ms. Peavler-Stewart answered that
the policies generally allow use of funds on rental housing. It is at the discretion of the individual
jurisdiction to decide the best use of the funds.
Cecil McConnell asked for clarification on use of funds for capital projects. Ms. Peavler-Stewart
responded that the capital projects would include parks projects, curb cuts, sidewalk repairs, and
Admiral Theater improvements.
Mike Shepherd commented that the intent of the program was to offer help to those individuals who
really need the help and to provide incentives for home ownership. Ms. Peavler-Stewart stated that
world changers, habitat for humanity, KCR, revolving loan, and down-payment assistance programs are
all intended to improve home ownership levels in the City of Bremedon.
Wayne Olsen pointed out that there are homes that are already owned which need attention. He
emphasized that homeowners should receive first consideration for funding assistance.
Mike Short commented that the program should continue to assist Iow-income homeowners. In
addition, improving the rental properties may help in the short term but when the renter leaves the
landlord may raise rent to compensate for improvements made with that assistance. Mr. Eyer clarified
that there is a restriction on owners so the rent can not be raised.
Mr. Maupin asked that the issue be decided tonight but that Council consider an amendment to address
the assistance to rental properties issue. Paula Johnston clarified that an amendment can be made
after the Main Motion, and if the amendment survives the vote then the amendment becomes part of the
Main Motion.
TAPE #1844
City Council Reg. Mtg. Minutes
July 24, 2002
Page 4 of 6
Mayor Bozeman expressed his support for passage of this policy but emphasized that there is a limit on
the resources available. He emphasized that there is a need for home ownership considering the high
rate of rentership in order to improve the neighborhoods.
Mr. McConnell stated that the funding should be provided to those who truly demonstrate a need rather
than choosing not to do the work.
President Arends provided comments in support of the efforts made towards home ownership.
Mr. Younger proposed that a Study Session be held to discuss the renter issue and the breakdown of
fund usage. Ms. Peavler-Stewart specified that HOME funds goes towards the down-payment
assistance program and that $50,000 is available for weatherization and $100,000 is available for World
Changers and home rehabilitation program.
#1560 M/S/C/U (Maupin/Olsen) Move to approve the 2003 CDBG/HOME Policy Plan
9A - RESOLUTION NO. 2866, PROPOSING A PUBLIC SAFETY BOND ISSUE FOR SUBMISSION
TO PRIMARY ELECTION (#AB02-144): Mayor Bozeman announced that the Resolution would allow
the public to vote at the September 17, 2002 Primary Election on a proposition which would authorize
the City to acquire additional police patrol vehicles; acquire four additional fire trucks, apparatus and
related equipment; construct, remodel and equip a new Fire Station and Police and Court facility with
related offices. To issue no more than $12.979 million of unlimited tax general obligation bonds
maturing within 25 years to pay the costs of such construction and acquisition and levy annual excess
property taxes to pay and retire the bonds. This amounts to approximately $0.59/$1,000 assessed
property value in the first year of the bond issue to $0.33/$1,000 assessed property value in the final
year. For the individual homeowner whose property is valued at $100,000 this equated to $4.90 per
month in 2003 property taxes decreasing to $2.74 per month in 2027.
Mayor Bozeman encouraged support for the bond issue, and emphasized that it has been 10 years
since the last major capital improvements were done.
Fire Chief Al Duke summarized that there is a need for a new fire station and new fire engines, and
would like for the citizens to have the opportunity to decide on whether or not to fund these
improvements and purchases.
Police Chief Rob Forbes established that this bond would allow the Police Department to come
together in one place and not be fragmented. He outlined the needs of his department such as new
patrol vehicles, additional office and storage space for seizures.
Allen Shute believes that the City needs more money, and given the high percentage of rental
properties in the City, property owners should have to pay for public safety.
All Council Members offered their support for the bond...
Mr. Shepherd addressed the concern over having more officers available by stating that there is the
possibility of including those needs in the next budget.
Council Member Daren Nygren left the meeting at 6:32 P.M. and returned at 6:35 P.M.
Wayne Olsen asked for clarification on how the funds would be spent. Mayor Bozeman answered that
the individual purchases will be discussed at appropriate times since there is flexibility on equipment
purchases.
TAPE #1844
City Council Reg. Mtg. Minutes
July 24, 2002
Page 5 of 6
Cecil McConnell asked that Council be involved in process of choosing the locations of the fire station,
and police and courts buildings. Mayor Bozeman confirmed that the Council would be notified of any
negotiations and plans for public safety buildings, and further clarified that the final decision will be made
by Council for the actual location for those buildings.
Wayne Olsen agreed that there is a need for more officers. He cautioned that salaries should not be
included in bonds since there is the risk that voters may not approve the bond, and the positions would
then be unfunded.
#2350 M/S/C/U (Younger/Olsen) Move to approve Resolution No. 2866 providing for the submission to
the registered voters of the City at the September 17, 2002 primary election a ballot proposition for
Public Safety purposes in the amount of $12.979 million.
9B - RESOLUTION NO. 2867 IMPOSING OFF-PREMISES SIGNS MORATORIUM (#AB02-145):
Chris Hugo, Director of Community Development, pointed out that there are no provisions in the code
for off premises signs, defined as signs that advertise a business, profession, product, event, activity, or
service that is not related to a use or activity conducted or offered on the premises or at the location
where the sign is located.
There is a need for an off premises signs ordinance to protect the public's interest in maintaining the
aesthetics of the community, because in many cases these types of signs contribute to visual clutter.
The proposed moratorium will provide up to six (6) months to conduct a public process to create the
necessary siting and design standards.
There were no comments from the public.
City Attorney Roger Lubovich clarified for Council Members that if the resolution were passed then a
public hearing would need to be held within 60 days. The proposed hearing date is included in the
motion for this item.
#2610 M/S/C/U (Shepherd/Rollman) Move to pass Resolution No. 2867, with the Public Hearing
scheduled for August 14, 2002.
9C - RESOLUTION NO. 2868, IMPOSING MORATORIUM ON APPLICATIONS FOR WIRELESS
COMMUNICATIONS FACILITIES (#AB02-146): Chris Hugo, Director of Community Development, said
that staff has received several applications for wireless communications facilities (towers, antennae) this
year. More applications are anticipated. Since there is very little language in the Comprehensive Plan
and no standards in the Zoning Code to guide the permitting and siting of wireless facilities, it is difficult
to regulate these facilities in a consistent manner. In addition, applications that are handled
administratively in other jurisdictions must be handled as Special Use Permits in Bremerton due to the
City's lack of detailed regulations.
There is a need for a wireless communication facilities ordinance, both to give applicants some
predictability in the permitting process, and to protect the public's interest in maintaining the aesthetics of
the community, because in many cases the public feels that these facilities are unsightly. The proposed
moratorium will provide up to six (6) months to conduct a public process to create the necessary siting
and design standards.
Mr. Hugo added that the demand for towers has remained high. The question is how to accommodate
the industry without impacting property values. The moratorium would allow time to develop standards
for the cellular phone towers.
TAPE #1844
City Council Reg. Mtg. Minutes
July 24, 2002
Page 6 of 6
There were no comments from the public.
#2915 M/S/C/U (Shepherd/McConnell) Move to pass Resolution No. 2868, with the Public Hearing
scheduled for August 14, 2002.
With no further business, the meeting was adjourned at 6:54 P.M.
Prepared and Submitted by:
CHRISTINE GRENIER ELLINGSON
Council Assistant
Attest:
PAULA JOHNSTON, Deputy City Clerk
CAROL ARENDS, City Council President
City of Bremerton
CA/PJ/Is/cge
c: Normal Distribution
File
AGENDA BILL
BREMERTON CITY COUNCIL
1. SUBJECT: RESOLUTION# ~, ~~ FOR AGENDA OF: July 31, 2002
SETTING A HEARING DATE OF A~!GUST 21, ORIGINATING DEPT: .PW&U Engineering Division
2002 FOR VACATING A PORTION OF THE ALLEY ORIGINATOR Michael C Mecham, City Engin~e_.~,./~
LOCATED BETWEEN WARREN AND PARK DATE SUBMITTED: July 19, 2002
AVENUES AND BETWEEN 4TM ANI~] 5TM ~TRE~ETS.
2. · CLEARANCES: (comment on back~r~c~
Directo~tilities
City Attorney ~ ~:~' B. Site Map. ~! ~/~.
Director, Community Development ~ ~ . /-] 7t-~//_ .fi/F(./
Council Budget & Finance Commj~e~
Operations Committee ~~~~~ It:/v '(7
ENOORSE~ ~~--~__2~TION APPROVED BY COUNCIL PRUSlDENT FOR SUBM~TT.
MAYOR ~ COUNCIL PRESIDENT ~ .~/"~
4. SUMMARY STATEMENT AND REQUIREMENT FOR COUNCIL ACTION:
The City received a petition from KPS Health Plans to vacate a portion of the alley located between Warren and
Park Avenues and between 4th and 5th Streets. This right-of-way consists of a paved alley that abuts the
applicant's properties and is utilized as access to those properties. The vacation is being requested by KPS Health
Plans to develop the site for additional parking. An ingress and egress easement will be granted by KPS Health
Services to the City of Bremerton further to the east on the property to allow continued access to the existing alley,
which is not to be vacated. The City Council is being requested to establish a hearing date of August 21, 2002, to
consider the proposed vacation. Staff recommends passage of the proposed Resolution.
8. RECOMMENDATION:
That the City Council pass Resolution # ~,~se~in~g~a hearing date of August 21, 2002, for vacating a portion of
the alley located between Warren and Park*Avenues and between 4th and 5th Streets.
9. RESPONSIBLE OFFICIAL: City Engineer
ENFORCEMENT OFFICIAL: N/A
EXPIRATION DATE:
REVIEW DATE:
10. NOTICE OFACTION
PULLED TABLED APPROVED DISAPPROVED
COUNCIL DIRECTIVE DATE:
11. AGENDA BILL NO:
2. CLEARANCE COMMENTS:
5. IMPACT ON NON-PASSAGE:
The heating on the right-of-way vacation will not occur, and the rights-of-way will not be considered for vacation.
6. IMPACT ON STAFFING~ BUDGETS~ FACILITIES~ EQUIPMENT OR OTHER RESOURCES:
Staffing: No impact.
Budget: No impact
Facilities/Equipment: No impact
7. RESEARCH SOURCES
BMC 11.20 Vacation of Public Rights-of- Way
RCW 35. 79 Streets
T:\Vacations\KPS Alley\Agenda Bill and Resolution for Hearing Date
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SEAL[ CITY OF BREMERTON EXHIBIT MAP
HOR~Z~/SO DEPARTMENT OF PUBUC WORKS
~ U~LI~ES KPS VACATION OF PORTION OF ALLEY
PLOT 1/1 ENClNEERIN6 DI~SlON BETWEEN 4TH AND 5TH STREET
DRAWING NO. D~WN BY: TH DESIGN BY: 6F CHECKED BY: LK SHE~1
DATE 7/2~/02 DATE 7/22/02 DATE 7/2]/02 1 OF
~ I~$OI~ION of the City Council of the City of
Bremerton~ Washington, cstablishin~ a hearin~ date for the
proposed vacation of a portion of the alley located between Warren
and Park Avenues and between 4th and 5th Streets.
WHEREAS, a petition has been received to vacate a portion of the alley located
between Warren and Park Avenues and between 4th and 5th Streets; NOW THEREFORE,
THE CITY COUNCIL OF THE CITY OF BREMERTON, WASHINGTON,
DOES HEREBY RESOLVE AS FOLLOWS:
SECTION1. A public hearing will be held on August 21, 2002, at 5:30 p.m. or
later at the Bremerton City Hall, 239 Fourth Street, Bremerton, Washington, to take public
comment or consider written objections to the vacation.
SECTION 2. Severabili_ty. If any one or more sections, subsections, or
sentences of this Resolution are held to be unconstitutional or invalid, such decision shall not
affect the validity of the remaining portion of this Resolution and the same shall remain in full
force and effect.
SECTION 3. Effective Date. This Resolution shall take effect and be in force
immediately upon its passage.
PASSED by the City Council of the City of Bremerton, Washington this __
day of ,2002.
CAROL ARENDS, Council President
APPROVED AS TO FORM: ATTEST:
KATHLEEN MCCLUSKEY, City Clerk
R:\LEGAL\Resolutions\Warren & Park vacation.doc
1
Alley Vacation - Public Hearing
AGENDA BILL
BREMERTON CITY COUNCIL
1. SUBJECT: U.S. Department of Justice Local Law FOR AGENDA:
Enforcement Block Grant (LLEBG) FY 2002 ORIGINATING DEPT: Police
ORIGINATOR: Tim Sholtis
DATE SUBMITTED: July 17, 2002
2. CLEARANCES:~C~mment on back if necessary) 2. EXHIBIT__S:
Treasurer-- '
Operations Committee C'"~air
Budget and Fisca~'/omm~t[e~
Chief of Police .~/,~t~
4, SUMMARY STATEMENT AND REQUIREMENT FOR COUNCIL ACTION: The Department of
Justice awarded the City of Bremerton $72,068.00 through the LLEBG formula program. The City has a cash
match of $8,008.00 over the grant period October 1, 2001 to September 30, 2003. The funding is used for
police vehicle purchases. Council needs to formally accept the grant,
5. RECOMMENDATION: Recommend that the City Council approve accepting this Local Law Enforcement
Block Grant for $72,068.00, and comply with the special conditions according to grant administration.
6. RESPONSIBLE OFFICIAL:
ENFORCEMENT OFFICIAL: Chief Forbes
EXPIRATION DATE: 9/30/03
REVIEW DATE:
7. NOTICE OF ACTION:
PULLED [-'] TABLED [--] APPROVED ~-] DISAPPROVED [-'] AMENDED [--] DATE:
COUNCIL DIRECTIVE:
8. AGENDA BILL NO.: O~-- /Z/~ ?
9. IMPACT OF NON-PASSAGE:
The City of Bremerton will not use federal funding.
10. IMPACT ON STAFFING~ BUDGETS~ FACILITIES~ EQUIPMENT OR OTHER RESOURCES:
The funds are used towards the purchase of police vehicles.
11. RESEARCH SOURCES:
~,~,~,~ U.S. Department of Justice
Office of Justice Programs
Bureau o. f Justice Assistance
Office of the Director Washington, D.C. 20531
July 6, 2002
Mr. Bozeman
Mayor, Bremerton City
239 4th Street
Bremerton, WA 98337-1812
RE: Fiscal Year 2002 Local Law Enforcement Block Grants Program
Dear Mr. Bozeman:
I am pleased to inform you that I have approved the application for funding under the Bureau of
Justice Assistance's (BJA) Fiscal Year 2002 Local Law Enforcement Block Grants (LLEBG)
Program in the amount of $72,068 for Bremerton City. The purpose of the LLEBG Program is to
reduce crime and improve public safety. This Block Grant Award may be used for any of the
purpose areas described in the statute.
Enclosed you will find the Grant Award and Special Conditions documents. If you have any
programmatic questions regarding this award, please contact BJA's State and Local Assistance
Division at (202) 514-6638. In addition, all financial questions regarding this award should be
directed to the Office of the Comptroller, Customer Service Division at (800) 458-0786.
I look forward to a continuing partnership with Bremerton City in furtherance of this important
criminal justice program.
Sincerely yours,
Richard Nedelkoff
Director
Attachments
U.S. Department of Justice
Office of Justice Programs
Office for Civil Rights
Washington, D.C. 20531
July 6, 2002
Mr. Bozeman
Mayor, Bremerton City
239 4th Street
Bremerton, WA 98337-1812
Dear Grant Recipient:
Congratulations on your recent award. Because you have submitted Certified
Assurances that your agency is in compliance with applicable civil rights laws, this
office has determined that you have met this requirement in the Department of Justice
regulations governing recipients of Federal financial assistance (see 28 C.F.R. sec.
42.204, Applicants' Obligations). As Director of the Office for Civil Rights (OCR),
Office of Justice Programs, I would like to offer you my assistance in completing the
conditions of these Assurances, specifically Nos. 13, 14, and 15, as the grant goes
forward.
As you know, equal opportunity for the participation of women and minority
individuals in employment and services provided under programs and activities
receiving Federal financial assistance is required by law. Therefore, if there has been a
federal or state court or administrative agency finding of discrimination against your
agency, please forward a copy of such order or consent decree, as required by
Assurance No. 14, to OCR at the U.S. Department of Justice, Office of Justice
Programs, Office for Civil Rights, 810 Seventh Street, N.W., Room 8136, Washington,
D.C. 20531.
Additional Instructions For Grantees Receiving $500,000 Or More:
1. In accordance with Assurance No. 15, each grantee that receives $500,000 or more (or
$1,000,000 in an 18- month period), and has 50 or more employees, must submit an
Equal Employment Opportunity Plan (EEOP)within 60 days from the date of this letter
to OCR at the above address. ~
2. Alternatively, the grantee may choose to complete an EEOP Short Form, in lieu of
sending its own comprehensive EEOP, and return it to OCR within 60 days of the date
of this letter. This easy-to-follow EEOP Short Form reduces paperwork and
preparation time considerably and will ensure a quicker OCR review and approval.
The enclosed Seven-Step Guide to the Design and Development of an EEOP (which
includes an EEOP Short Form) will assist you in completing this requirement.
Please be reminded that the above requirements apply to primary grantees and to each
3. of their subgrantees or contractors that meet the criteria outlined in this letter.
Therefore, all primary grantees should apprise subgrantees of these responsiblities and
those meeting the criteria should send their EEOPs or EEOP Short Forms directly to the
Office for Civil Rights within 60 days of the date of their award.
NOTE: If agency has under 50 employees, regardless of amount of award, no EEOP is
required; however, grantee must return applicable portion of Certification Form to OCR
within 60 days.
PURSUANT TO THE SPECIAL CONDITION REGARDING EEOPs GOVERNING THIS
AWARD, RECIPIENT ACKNOWLEDGES THAT FAILURE TO SUBMIT AN
ACCEPTABLE EEOP IS A VIOLATION OF ITS CERTIFIED ASSURANCES AND
MAY RESULT IN SUSPENSION OF DRAWDOWN OF FUNDS UNTIL EEOP HAS
BEEN APPROVED BY THE OFFICE FOR CIVIL RIGHTS.
Additional Instructions For Grantees Receiving $25,000 Or More, But Under $500,000:
4. Pursuant to Department of Justice regulations, each grantee that receives $25,000 or
more and has 50 or more employees is required to maintain an Equal Employment
Opportunity Plan (EEOP) on file for review by OCR upon request. (However, if the
grantee is awarded $1,000,000 in an eighteen (18) month period, it must submit an
acceptable EEOP to OCR.) Please complete the applicable section of the attached
Certification Form and return it to OCR within 60 days of the date of this letter.
NOTE: If agency has under 50 employees, regardless of amount of award, no EEOP is
required; however, grantee must return applicable portion of Certification Form to OCR
within 60 days.
If you have akeady submitted an EEOP as part of another award from the Office of Justice Programs (OYP) or
the Office of Community Oriented Policing Services (COPS) within this grant period, or if you have certified that
no EEOP is required, it is not necessary for you to submit another at this time. Simply send a copy of the letter
you received from OCR showing that your EEOP or certification is acceptable.
Additional Instructions For Grantees Receiving Under $25,000:
5. A recipient of under $25,000 is not required to maintain or submit an Equal
Employment Opportunity Plan (EEOP) in accordance with Assurance No. 15. No
Certification is required.
Instructions for All Grantees:
6. In addition, all recipients, regardless of their type, the monetary amount awarded,
or the number of employees in their workforce, are subject to the prohibitions against
discrimination in any funded program or activity. Therefore, OCR investigates
complaints by individuals or groups alleging discrimination by a recipient of OJP
funding; and may require ali recipients, through selected compliance reviews, to submit
data to ensure their services are delivered in an equitable manner to all segments of the
service population and their employment practices are in compliance with equal
employment opportunity requirements. 2
If you have any questions, please call OCR at (202) 307-0690. Additional information and
technical assistance on the civil rights obligations of grantees can be found at:
http://www.ojp.usdoj.gov/ocr/.
Sincerely,
Michael L. Alston
Acting Director, Office for Civil Rights
cc: Grant Manager
Financial Analyst
The employment practices of certain Indian Tribes are not covered by Title VII of the Civil Rights Act of 1964, 42
U.S.C. sec. 2000e.
U.S. DEPARTMENT OF JUSTICE AWARD
OFFICE OF JUSTICE PROGRAMS
B,S [2 NI, ovc COOPERATIVE AOREEMENT
CHECK APPROPRIATE BOX
1. GRANTEE NAME AND ADDRESS (Including Zip Code) 4. AWARD NUMBER: 2002-LB-BX-1203
Bremerton City
239 4th Street
Bremerton, WA 98337-1812 5. PROJECT PERIOD: FROM 10/01/2001 TO 09/30/2003
BUDGET PERIOD: FROM 10/01/2001 TO 09/30/2003
IA. GRANTEE IRS/VENDOR NO. 916001231 6. AWARD DATE 07/06/2002 7. ACTION
2. SUBGRANTEE NAME AND ADDRESS (Including Zip Code) 8. SUPPLEMENT NUMBER
Initial
Supplemental
2A. SUBGRANTEE IRS/VENDOR NO. 9. PREVIOUS AWARD AMOUNT ~0.00
FY 2002 Lccal Law Enforcement Block Grants ~111 ~OT~LAL ~RD
12. SPECIAL CONDITIONS (Check, if applicable)
THE ABOVE GRANT PROJECT IS APPROVED SUBJECT TO SUCH CONDITIONS OR LIMITATIONS AS ARE SET FORTH
ON THE ATTACHED 6 PAGES
13. STATUTORY AUTHORITY FOR GRANT
TITLE 1 OF THE OMNIBUS CRIME CONTROL AND SAFE STREETS ACT OF 1968.
42 U.S.C. 3701, ET. SEQ., AS AMENDED
TITLE 2 OF THE JUVENILE JUSTICE AND DELINQUENCY PREVENTION ACT OF 1974
42 U.S.C. 5601, ET. SEQ., AS AMENDED
VICTIMS OF CRIME ACT OF 1984, 42 U.S.C. 10601, ET. SEQ., PUBLIC LAW 98-473, AS AMENDED
OTHER (Specify): Fiscal Year 2002, Departments of Coimnerce, Justice, and State, lhe Judiciary, and Related Agencies Appropriations Act (Pub. L. No.
107-77)
14. FUTURE FISCAL YEAR(S) SUPPORT:
SECOND YEAR'S BUDGET PERIOD: N/A
AMOUNT OF FUNDS: N/A TYPE OF FUNDS:
THIRD YEAR'S BUDGET PERIOD: N/A
AMOUNT OF FUNDS: N/A TYPE OF FUNDS:
15. METHOD OF PAYMENT
THE GRANTEE WILL RECEIVE CASH VIA A LE'I'TER OF CREDIT ~.~ YES LX~
NO
AGENCY APPROVAL ~ GRANTEE ACCEPTANCE I/ll'
16. TYPED NAME AND TITLE OF APPROVING OJP OFFICIAL 18. TYPED NAME AND TITLE OF AUTHORIZED GRANTEE OFFICIAL
Richard Nedelkoff Cury Bozeman
Director Mayor
Bureau of Justice Assistance
17. SIGNATURE OF APPROVING OIP OFFICIAL 19. SIGNATURE OF AUTHORIZED GRANTEE I
19A. DATE
AGENCY USE ONLY
20. ACCOUNTING CLASSIFICATION CODES 21. L 18M 14
FISCAL FUND BUD. DIV.
YEAR CODE ACT. OFC. REG. SUB. POMS LI02U01203
X B LI 80 00 00 i I
OIP FORM 41~0/2 (REV. 587) PREVIOUS EDITIONS ARE OBSOLETE
U.S. DEPARTMENT OF JUSTICE AWARD CONTINUATION
OFFICe OF JUSnCE PROO~MS SHEET
[] N, o vt Ct COOPERA VEAOREEM
CHECK APPROPRIATE BOX
PROIECT NUMBER: 2002-LB-BX-1203 AWARD DATE 07/06/2002
SPECIAL CONDITIONS
1. The recipient agrees to comply with the financial and administrative requirements set forth in the current edition of the
Office of Justice Programs (OJP) Financial Guide.
2. The recipient agrees to comply with the organizational audit requirements of OMB Circular, A-133, Audits of States,
Local Governments and Non-Profit Organizations, as further described in OJP's Financial Guide, Chapter 19.
3. The recipient acknowledges that failure to submit an acceptable Equal Employment Opportunity Plan (if recipient is
required to submit one pursuant to 28 CFR 42.302), that is approved by the Office of Civil Rights, is a violation of its
Certified Assurances and may result in suspension or termination of funding, until such time as the recipient is in
compliance.
4. The recipient agrees that federal funds under this award will be used to supplement but not supplant state or local
funds, pursuant to section 101 (g) of H.R. 728, 104th Cong. (1995).
5. The recipient shall submit one copy of all reports and proposed publications resulting from this agreement twenty (20)
days prior to public release. Any publications (written, visual, or sound), whether published at the recipient's or
government's expense, shall contain the following statement: (NOTE: This excludes press releases, newsletters, and
issue analysis.)
"This project was supported by Grant No. 2002-LB-BX-1203 awarded by the Bureau of Justice Assistance, Office
of Justice Programs, U.S. Department of Justice. Points of view in this document are those of the author and do not
necessarily represent the official position or policies of the U.S. Department of Justice."
6. The recipient agrees to provide information required for any national evaluation conducted by the U.S. Department of
Justice.
7. The recipient agrees, if the funds are used for the hiring and employing of new, additional law enforcement officers
and/or support personnel, as described in the applicable purpose area of Subpart A section 101(a)(2) of H.R. 728,
104th Cong. (1995), that the recipient unit of local government will achieve a net gain in the number of law
enforcement officers who perform non-administrative public safety service. If the funds are used for the hiring and
employing of new, additional law enforcement officers and/or support personnel, the unit of local government will
establish procedures to give members of the Armed Forces who, on or after October 1, 1990, were or are selected for
involuntary separation (as described in section 1141 of Title 10, United States Code), approved for separation under
section 1174a or 1175 of such title, or retired pursuant to the authority provided under section 4403 of the Defense
Conversion, Reinvestment, and Transition Assistance Act of 1992 (division D of Public Law 102-484; 10 U.S.C.
1923 note), a suitable preference in the employment of persons as additional law enforcement officers or support
personnel.
O~P FORM 4000/2 (REV. 587) PREVIOUS EDITIONS ARE OBSOLETE
u.s. DE~'ART~E~r OF JUSTXCE AWARD CONTINUATION
O~F~CE OF JUS~CE PROOf, MS SHEET
CHECK ~PROP~A~ BOX
PRO,CT NUMBER: 2~2-LB-BX- 1203 AWARD DA~ 07~6/2~2
SPECIAL CONDITIONS CONTINUED
8. The recipient agrees this award document constitutes the obligation of federal funds for use by the recipient in
execution of the program or project covered by the award. Such obligation may be terminated without further cause if
the recipient fails to affirm its timely utilization of the award by accepting the award and special conditions within 45
calendar days from the date of award.
9. The recipient agrees to submit the Request for Drawdown via the Internet system within 90 calendar days from the
date of award, or to have all funds deobligated for redistribution during the next funding cycle.
10. Local recipients agree to one 24 month obligation and expenditure period, as established at the approval of the
Request for Drawdown. All funds must be expended by the end of this 24 month period with no exceptions.
11. Local recipients are required to establish a trust fund account. This fund may not be used to pay debts incurred by
other activities beyond the scope of the Local Law Enforcement Block Grants Program. The recipient also agrees to
obligate and expend the grant funds in the trust fund (including any interest earned) during the 24 month period.
Grant funds (including any interest earned) not expended by the end of the 24 month period must be returned to the
Bureau of Justice Assistance (BJA) by the end of the 27th month, along with the final submission of the Financial
Status Report (SF-269A).
12. The recipient agrees to submit one final progress report via the Internet system at the end of the 24 month obligation
and expenditure period.
13. The recipient agrees, if funds are used by the recipient or subrecipient for enhancing security, that the recipient or
subrecipient - -
(a) has an adequate process to assess the impact of any enhancement of a school security measure that is undertaken
under subparagraph (B) of section 101(a)(2), on the incidence of crime in the geographic area where the enhancement
is undertaken;
(b) will conduct such an assessment with respect to each such enhancement; and,
(c) will submit to the Bureau of Justice Assistance (BJA) an annual assessment report via the Internet system.
14. The recipient agrees to comply with 28 CFR Part 23 if federal funds are used to support Criminal Intelligence
Systems.
OJP FORM 4000/2 (REV. 587) PREVIOUS EDITIONS ARE OBSOLETE
u.s. DE~^R*~E~ OF ~U$~CE AWARD CONTINUATION '
OFFICE OF JUSTICE PROGRAMS SHE ET
CHECK APPROPRIA~ BOX
PRO~ NUMBER: 2002-LB-BX-1203 AWARD DA~ 07~6/2~2
SPECIAL CONDITIONS CONTINUED
15. The recipient agrees to assist BJA in complying with the National Environmental Policy Act (NEPA) and other related
federal environmental impact analyses requirements in the use of these grant funds, either directly by the recipient or
by a subrecipient. Accordingly, prior to obligating grant funds, the recipient agrees to first determine if any of the
following activities will be related to the use of the grant funds. The recipient understands that this special condition
applies to its following new activities, whether or not they are being specifically funded with these grant funds. That
is, as long as the activity is being conducted by the recipient, a subrecipient, or any third party, and the activity needs
to be undertaken in order to use these grant funds, this special condition must first be met. The activities covered by
this special condition are:
1. New construction;
2. Minor renovation or remodeling of a property either (a) listed on or eligible for listing on the National Register of
Historic Places or (b) located within a 100-year flood plain;
3. A renovation, lease, or any proposed use of a building or facility that will either (a) result in a change in its basic
prior use or (b) significantly change its size; and,
4. Implementation of a new program involving the use of chemicals other than chemicals that are (a) purchased as an
incidental component of a funded activity and (b) traditionally used, for example, in office, household, recreational, or
educational environments.
Application of This Special Condition to Recipient's Existing Programs or Activities:
For any of the recipient's or its subrecipient's existing programs or activities that will be funded with these grant
funds, the recipient, upon specific request from BJA, agrees to cooperate with BJA in any preparation by BJA of a
national or program environmental assessment of that funded program or activity.
16. The recipient agrees to ensure that the State Information Technology Point of Contact receives written notification
regarding any information technology project funded by this grant during the obligation and expenditure period. This
is to facilitate communication among local and state governmental entities regarding various information technology
projects being conducted with these grant funds. In addition, the recipient agrees to maintain an administrative file
documenting the meeting of this requirement. For a list of State Information Technology Points of Contact, go to
http://www.ojp.usdoj.gov/ec/states.htm
17. The recipient agrees to provide and expend a 10 percent cash match (calculated as 1/9 of the federal award amount)
before the end of the 24 month obligation and expenditure period. The recipient is reminded that the matching funds
are auditable under Special Condition 4/2 and will be binding to the recipient.
OJP FORM 4000/2 (REV. 587) PREVIOUS EDITIONS ARE OBSOLETE
U.S. DEPARTMENT OF JUSTICE AWARD CONTINUATION
OFFICE OF JUSTICE PROGRAMS SHEET
[] B,S [] NH OVC COOPER^ VE^OREE
CHECK APPROPRIA~_. BOX
PROJECT NUMBER: 2002-LB-BX-1203 AWARD DATE 07/06/2002
SPECIAL CONDITIONS CONTINUED
18. The recipient agrees that prior to the obligation or expenditure of any LLEBG funds, at least one (1) public hearing
will be held regarding the proposed use(s) of the grant funds. The recipient must also provide verification to BJA, via
the Internet system, of the public hearing. At the hearing, persons shall be given an opportunity to provide written and
oral views to the recipient on the proposed use(s) of the grant funds. The recipient will hold the public hearing at a
time and place that allows and encourages public attendance and participation. The recipient may not request a
drawdown of funds until these requirements are met and the formal budget allocations are adopted by the recipient.
19. The recipient agrees that prior to the obligation or expenditure of any LLEBG funds, a previously designated or newly
established advisory board will meet to discuss the proposed use(s) of the grant funds. The recipient will designate the
advisory board to make nonbinding recommendations on the use(s) of funds under the LLEBG Program. Membership
on the advisory board must include a representative from the following though it may be broader:
a) the local police department or sheriffs department;
b) the local prosecutor's office;
c) the local court system;
d) the local school system; and,
e) a local nonprofit, educational, religious, or community group active in crime prevention or drug use prevention or
treatment.
The recipient may not request a drawdown of funds until these requirements are met and the formal budget allocations
are adopted by the recipient.
20. The recipient has certified it is not in compliance with the Public Safety Officers' Health Benefits Provision of the
Fiscal Year 2002, Departments of Commerce, Justice, and State, the Judiciary, and Related Agencies Appropriations
Act (Pub. L. No. 107-77). Therefore, the recipient will receive not more than 90 percent of the eligible award amount
(or, if less than the eligible amount was requested, of that amount). This provision makes no allowances for a unit of
local government to come into compliance during the life of the grant; consequently BJA will not consider requests to
adjust the reduced award amount.
21. The recipient agrees that funds provided under this award may not be used to operate a "pay-to-stay" program in any
local jail. The recipient further agrees not to subaward funds to local jails which operate "pay-to-stay" programs.
OJP FORM 4000/2 (REV. 587) PREVIOUS EDITIONS ARE OBSOLETE
2,3
U.S. DEPARTMENT OF JUSTICE AWARD CONTINUATION
OFFICE OF JUSTICE PROGRAMS S H E ET
CHECK APPROPRIATE BOX
PROJECT NUMBER: 2002-LB-BX- 1203 AWARD DATE 07/06/2002
SPECIAL CONDITIONS CONTINUED
22 . Mitigation of Health, Safety, and Environmental Risks
a. General Requirement: The grantee agrees to comply with Federal, State, and local environmental,
health, and safety laws and regulations applicable to the investigation and closure of clandestine
methamphetamine laboratories and the removal and the disposal of the chemicals, equipment, and wastes
used in or resulting from the operations of these laboratories.
b. Specific Requirements: The grantee understands and agrees that any program or initiative involving
either the identification, seizure, or closure of clandestine methamphetamine laboratories, hereafter referred
to as the "Program", can result in adverse health, safety, and environmental impacts to (1) the law
enforcement and other governmental personnel involved; (2) any residents, occupants, users, and neighbors
of the site of a seized clandestine laboratory; (3) the seized laboratory site's immediate and surrounding
environment; and (4) the immediate and surrounding environment of the site(s) where any remaining
chemicals, equipment, and wastes from a seized laboratory's operations are placed or come to rest.
Therefore, the grantee further agrees that in order to avoid or mitigate the possible adverse health, safety,
and environmental impacts of its Program, it will (1) include the nine, below listed protective measures or
components within its Program; (2) provide for their adequate funding to include funding, as necessary,
beyond that provided by this grant agreement; and (3) implement these protective measures throughout the
life of this grant agreement. In so doing, the grantee understands that it may implement these protective
measures directly through the use of its own resources and staff or may secure the qualified services of
other agencies, contractors, or other qualified third parties.
1. Provide medical screening of personnel assigned or to be assigned by the grantee to the seizure or
closure of clandestine methamphetamine laboratories;
2. Provide Occupational Safety and Health Administration (OSHA) required initial and refresher training
for law enforcement officials and other personnel assigned by the grantee to either the seizure or the closure
of clandestine methamphetamine laboratories;
3. As determined by their specific duties, equip personnel assigned to the Program with OSHA required
protective wear and other required safety equipment;
4. Assign properly trained personnel to prepare a comprehensive contamination report on each closed
laboratory;
OJP FORM 400012 (REV. 587) PREVIOUS EDITIONS ARE OBSOLETE
u.s. DE,^RT~,~ OF ~UST~¢E AWARD CONTINUATION
OFFICE OF JUST[CE PROGRAMS SHE ET
~ O~ ~ BJA ~ OJ~P ~ GRA~ PAGE 7 OF7
C~CK APPROPRIA~ BOX
PRO~ ~: 2~2-LB-BX-1203 AW~ DA~ 07/0&2~2
SPECIAL CONDITIONS CONTINUED
5. Employ qualified disposal contractors to remove all chemicals and associated glassware, equipment, and
contaminated materials and wastes from the site(s) of each seized clandestine laboratory;
6. Dispose of the chemicals, equipment, and contaminated materials and wastes removed from the sites of
seized laboratories at properly licensed disposal facilities or, when allowable, properly licensed recycling
facilities;
7. Monitor the transport, disposal, and recycling components of subparagraphs numbered 5. and 6.
immediately above in order [o ensure proper compliance;
8. Have in place and implement an inter-agency agreement or other form of commitment with a
responsible state environmental agency that provides for that agency's (i) timely evaluation of the
environmental conditions at and around the site of a closed clandestine laboratory and (ii) coordination with
the responsible party, property owner, or others to ensure that any residual contamination is remediated, if
necessary, and in accordance with existing state and federal requirements; and
9. Include among the personnel involved in seizing clandestine methamphetamine laboratories, or have
immediate access to, qualified personnel who can respond to the potential health needs of any of the
offender(s)' children or other children present or living at the seized laboratory site. Response actions should
include, at a minimum and as necessary, taking children into protective custody, immediately testing them for
methamphetamine toxici[y, and arranging for any necessary follow-up medical tests, examinations, or health
care.
c. Additional Requirements: As part of the Request for Drawdown process, the Grantee shall submit a brief
description of its project sufficient for the Office of Justice Programs (OJP) to determine whether any additional
compliance with federal environmental statutes and regulations needs to occur prior to [be issuance of LLEBG
funds. Furthermore, once LLEBG funds are issued, the Grantee shall notify OJP if the project changes
significantly from the description in the Request for Drawdown, or if significant new information is revealed
during the course of the expenditure of LLEBG funds so that OJP can determine whether any additional
environmental analyses need [o be completed.
OJP FORM 400012 (REV. 587) PREVIOUS EDITIONS ARE OBSOLETE
AGENDA BILL
BREMERTON CITY COUNCIL
1. SUBJECT: FOR AGENDA OF: 7/31/02
ORIGINATING DEPT: City Council
Appointment of Pro and Con ORIGINATOR: City Council
Committees For Local Voters' Pamphlet DATE SUBMITTED: 7/25/02
2. CLEARANCES: 3. EXHIBITS:
ENDORSEME~ INk,MATiN.__ APPROVED BY COUNCIL PRESIDENT FOR SUBMITTAL:
MAYOR [_.~-~/--~ ~ ~ COUNCIL PRESIDENT ~~.J/~-~G~_~" ~
4. SUMMARY STATEMENT AND REQUIREMENT FOR COUNCIL ACTION:
Last Wednesday the City Council passed the resolution placing the Public
Safety Bond Levy on the September 17, 2002 Primary Election.
If the City desires to participate in the local voters pamphlet it must
appoint persons known to favor the measure to serve on the committee
advocating approval and shall, whenever possible, appoint persons known to
oppose the measure to serve on the committee advocating rejection. No
committee shall have more than three members; however a committee may seek
the advice of any person or persons in preparing their statements.
Statements for and against measures shall not exceed 200 words. Statements
must be submitted to the county auditor by August 5th.
(The names of those recommended to serve on the committees will be placed
in council mailboxes early next week)
8. RECOMMENDATION:
Motion to approve Voter Pamphlet Pro and Con Statement Committees.
9. RESPONSIBLE OFFICIAL: City Council
ENFORCEMENT OFFICIAL: N/A
EXPIRATION DATE:N/A
REVIEW DATE: N/A
10. NOTICE OF ACTION
PULLED TABLED APPROVED DISAPPROVED AMENDED
COUNCIL DIRECTIVE:
Date:
11. AGENDA BILL NO:
2. CLEARANCE COMMENTS (cont.):
SUMMARY STATEMENT (cont.):
5. IMPACT ON NON-PASSAGE:
6. IMPACT ON STAFFING, BUDGETS, FACILITIES, EQUIPMENT OR OTHER RESOURCES
None.
7. RESEARCH SOURCES:
AGENDA BILL
BREMERTON CITY COUNCIL
1. SUBJECT: FOR AGENDA OF: July 31, 2002
Contract renewals between the City and KPS Healthplans ORIGINATING DEPT: Huma~R~r~
for employee medical coverage ORIGINATOR: Carol Conle~
DATE SUBMITTED: July 26, 2002
2. CLEARANCES: (Comment on back if necessary) 3. EXHIBITS:
· Confirmation letter from Willis of
m~~c'2,~.- Seattle to KPS on behalf of the City.
· Contract w/Premium rates
City Atto
City Treasurer: ~ -t~ . J~
ENDORSEM,~2~T [ ] IN?~) ..Ri~ATION [ ] APPROVED BY COUNCIL PRESIDENT FOR SUBMITTAL:
4. SUMMARY STATEMENT AND REQUIREMENT FOR COUNCIL ACTION:
This action in necessary to formally renew our contracts with KPS Health Plans for 2002 to provide coverage for
those employees enrolled in KPS Health Plans. The rates reflect an increase of 15.4 % over 2001 rates, and the
policies were renewed "as is", with no additional benefits. The current budget includes funding to cover the cost of
the rate increases. The delay in bringing this before Council was due to KPS converting our contract and benefits
booklets to their standardized form. Both the new contract and benefit booklets were reviewed by staff, our
benefits consultants, Willis of Seattle, and the City Attorney's office for content and correctness. We received the
final revised contracts for execution and benefits booklets from KPS on July 16, 2002.
8. RECOMMENDATION:
1. Motion to approve renewal of the contracts between the City and KPS Health Plans for 2002 and authorize the
Mayor to execute same.
9. RESPONSIBLE OFFICIAL: Carol Conley ~ ~
ENFORCEMENT OFFICIAL: Carol Conley
EXPIRATION DATE: 12/31/2002
REVIEW DATE: 09/01/2002
10. NOTICE OF ACTION:
PULLED [ ] TABLED [ ] APPROVED [ ] DISAPPROVED[] AMENDED [ ] DATE:
COUNCIL DIRECTIVE:
(OVER)
2. CLEARANCE COMMENTS:
5. IMPACT OF NON-PASSAGE:
Failure of the Council to approve this contract renewal would result is no medical coverage for those
employees who elected KPS to provide their healthcare.
6. IMPACT ON STAFFING~ BUDGETS~ FACILITIES~ EQUIPMENT OR OTHER RESOURCES:
The cost of renewing these contracts is based on the premium rates as attached, times the # of employees
and dependents covered in each category, less any contributions they are required to make towards the cost
of coverage. Sufficient funds are available in the 2002 budget to cover the cost of these contracts.
7. RESEARCH SOURCES:
Telephone: (206) 386-7400
Fax: (206) 386-7960
Website: Www.willis~com
Direct Line: (206) 386-7430
E-mail: Kathy.autry(~willis.com
January 17, 2002
Ms. Joyce Wilson
KPS Health Plan
400 Warren Avenue
Bremerton, WA 98337-0039
Re: City of Bremerton
January 1, 2002 Renewal
Dear Joyce:
We are writing on behalf of the City of Bremerton to confirm their renewal with KPS effective
January 1, 2002.
The City has elected to renew all policies "as is" for the next policy year. As you know the City has
a "Maintenance of Benefits" clause with the unions and has agreed that all benefits will remain
unchanged effective with this renewal.
The City has elected against raising the individual stop loss from $75,000 to $100,000 as proposed
by KPS. This will remain at $75,000.
They have also elected not to choose a refunding contract with KPS at this time.
The renewal increase is 15.4%; the actual rates are attached for your review.
Please send the renewal through for processing. Please prepare an updated contract for delivery to
the City.
We would also like to request a 120-renewal notice of next year's renewal. We also would like to
continue to pursue written Performance Guarantees from KPS for the City.
Joyce, please feel free to contact us if you have any questions.
Sincerely,
Kathy Autry
Assistant Vice President
Benefits Group
Willis of Seattle, Inc.
505 Fifth Avenue South
Suite 200
P. O. Box 34201 (Zip 98124)
Seattle, WA 98104
2002 renewal confirmation letter\l 3 0
KPS Health Plans, In Rehabilitation
400 Warren Avenue
P.O. Box 339
Bremerton, WA 98331-0039
Attachment B
Premium Rates and Underwriting Criteria
For
City of Bremerton
Premium Rates
lanARates LEOFFI ~ Active, ~=RegUlar& Sous ~st~-~ 2"a Child &
: : ,:, , LI=U~r ,I/~ctwe p e ! ~nlla OIA D~Pe~dents
$50 Deductible/Person
$100/Famity 282.42 205.08 227.33 102.67 82.63
pla"A , Retirees Under SpouSe Ii!Child
0iA, D~pe~en~
$50 Deductible/Person
$100/Family 739.04 404.87 101.01 80.73
$100 Deductible/Person
$300/Family N/A 177.34 198.64 90.37 70.32
: PI : :~t 2n~ Child &
an BRates LEOFF IRet~rees Spouse 1 Chdd OtA D ~d~nts
$100 Deductible/Person
$300/Family N/A 336.27 85.48 69.11
Additional Financial Arrangements:
Individual Stop Loss at $75,000 - $6.72pmpm charge
Administrative Expense- $22.32pmpm
Statutory Reserve Charge - $2.25pmpm
2003 Administration Increase Maximum - 5% from 2002 figure of $22.32 pmpm to $23.44pmpm for
contract year 2003
Underwriting Criteria
The Premium rates quoted above for this Group Plan are based on the following underwriting criteria.
KPS reserves the right to withdraw or rerate this offering if Group falls outside the scope of these criteria.
Active, full-time Employees must work a minimum of thirty (30) hours per week unless otherwise
negotiated and agreed by both KPS and Group.
:> Subject to prior KPS approval, two (2) or more health insurance carriers, including KPS, may
provide coverage to Group's Employees.
> Subject to prior KPS approval, Group may select multiple KPS health plan offerings.
The minimum level of participation required is seventy-five percent (75%) of eligible Employees,
excluding those employees that may be on an HMO plan.
Unless otherwise approved by KPS, no more than twenty-five percent (25%) of Group's eligible
Employees may reside outside of the KPS service area. The KPS service area is defined as
Kitsap, Jefferson, Mason, Clallam, Thurston, Grays Harbor, Pierce and King counties.
KPS reserves the right to rerate Group in the event actual enrollment fluctuates by ten percent
(10%) or more from the census provided to KPS by Group at the time Group was initially rated.
City of Bremerton
Medical Rate Analysis
PLAN B PLAN B PLAN B ~ ~?~,i~'. i,, PLAN B
LEOFF I Active $244.75 N/A $282.42 N/A $301.81 N/A $336.60 N/A
!Regular & LEOFF II Active $177.73 $153.69 $205.08 $177.34 $219.49 $189.98 $244.43 $211.37
:Spouse $197.01 $172.15 $227.33 $198.64 $243.28 $212.75 $270.95 $236.76
1st Dependent $88.98 $78.32 $102.67 $90.37 $110.19 $97.25 $122.38 $107.71
2nd & all other Dependents $71.61 $60.94 $82.63 $70.32 $88.99 $75.89 $220.86 $191.52
LEOFF I Retirees Under 65 $614.07 N/A $739.04 N/A $788.17 N/A $844.43 N/A
LEOFF I Retirees Over 65 N/A N/A N/A N/A N/A N/A N/A N/A
Spouse $336.56 $291.42 $404.87 $336.27 $432.67 $432.67 $462.88 $462.88
1st Dependent $84.14 $74.08 $101.01 $85.48 $108.92 $108.92 $115.71 $115.71
2nd & all other Dependents $67.29 $59.89 $80.73 $69.11 $87.34 $87.34 $208.26 $208.26
Monthly Premium $48,267.15 $53,802.37 $56,628.17 $62,081.44 $60,~47.02 $66,582.22 $68,355.02 $76,937.51
Annual Premium $579,205.80 $645,628.44 $679,538.04 $744,977.28 $726,564.24 $798,986.64 $820,260.24 $923,250.12
Combined Annual Premium $1,224,834 $1,424,515 $1,525,551 $1,743,510
Increase over Current 16. 30% 24.55% 42.35%
Assumptions** PLAN A PLAN B
LEOFF I Active 15
Regular & LEOFF II Active 72 129
Spouse 37 128
1st Dependent 35 98
2nd and all other Dependents 36 70 25 46
LEOFF I Retirees Under 65 29
LEOFF I Retirees Over 65
Spouse 3
1st Dependent
2nd and all other Dependents
* ~In approximate number of enrolled employees was used itt calculating the overall monthly premium. ~4ctual rates will be based on final enrollment.
Prepared by Willis of Seattle, Inc.
KPS Health Plans, In Rehabilitation
400 Warren Avenue
P.O. Box 339
Bremerton, WA 98331-0039
CITY OF BREMERTON - COVERAGE CONTRACT- PLAN A
Group Name: City of Bremerton Group Number: 21001-21006
Effective Date: 1/1/2002
Renewal Month: January
Open Enrollment December
This Coverage Contract includes the following:
Attachment A- Benefits Booklet
Attachment B - Premium Rates and Underwriting Criteria
Riders: N/A
Optional Riders: Occupational Injury Coverage - LOEFF !
Employees only
Endorsements: N/A
KPS Health Plans, In Rehabilitation, hereinafter referred to as KPS, is a duly licensed health care
services contractor (HC$C) in Washington State. In its capacity as an HCSC, KPS agrees to underwrite
and provide the benefits and services described in Attachment A, Benefits Booklet, to the eligible
employees, and their eligible Dependents, of the above-named Group, provided the Group, its eligible
employees and their eligible Dependents, meet and comply with the provisions of this Contract.
Contract Form: BREMA-22900-2002
TABLE OF CONTENTS
DEFINITIONS ................................................................................................................................ 1
CONTRACT EXAMINATION PERIOD ................................................................................................. 3
EFFECTIVE DATE, DURATION AND RENEWAL .................................................................................. 3
PREMIUM PAYMENT PROVISIONS ................................................................................................... 3
Payment Due Date/Grace Period ............................................................................................................. 3
Premium Rate Adiustments ...................................................................................................................... 3
Premiums Paid by Subscribers/Dependents ............................................................................................ 4
Premium Refunds ..................................................................................................................................... 4
ELIGIBILITY AND ENROLLMENT ....................................................................................................... 4
Group Eligibility ......................................................................................................................................... 4
Subscriber/Dependent Eligibility Requirements ....................................................................................... 4
Enrollment ................................................................................................................................................. 4
Enrollment Under Special Circumstances ................................................................................................ 5
When Coverage Begins ............................................................................................................................ 5
Coverage Waiting Periods (This section does not apply to LEOFF I Employees) .................................. 6
TERMINATION Of COVERAGE ......................................................................................................... 6
Continuity of Coverage ............................................................................................................................. 6
Termination of Group Contract ................................................................................................................. 7
Re-Enrollment/Reinstatement .................................................................................................................. 7
Termination of Enrollee Coverage ............................................................................................................ 7
Continuation of Inpatient Coverage .......................................................................................................... 8
Continuation of Coverage for a Disabled Child ........................................................................................ 8
CONTINUATION OF COVERAGE ...................................................................................................... 9
Coverage During a Labor Dispute ............................................................................................................ 9
Continuation of Group Coverage .............................................................................................................. 9
COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) ....................................................... 9
Individual Conversion Coverage ............................................................................................................. 10
COORDINATION OF BENEFITS (COB) ........................................................................................... 10
General Provision ................................................................................................................................... 10
Definitions ............................................................................................................................................... 10
Claim Determination Period .................................................................................................................... 11
Effect on Benefits .................................................................................................................................... 11
Order of Benefit Determination ............................................................................................................... 11
Facility of Payment ................................................................................................................................. 12
Right of Recovery ................................................................................................................................... 12
Right to Receive and Release Information ............................................................................................. 12
Disclosure of Coordination ..................................................................................................................... 12
KPS' RIGHT OF RECOVERY ......................................................................................................... 12
Limitations and Exclusions ..................................................................................................................... 12
Third Party Liability: Reimbursement and Subrogation .......................................................................... 13
Collection and Reimbursement by Enrollee (or the Enrollee's Representative) .................................... 13
Subrogation: Assignment of Third Party Claim to KPS .......................................................................... 14
Trust and Cooperation Between the Enrollee (or the Enrollee's Representative) and KPS .................. 14
Agreement to Arbitrate ............................................................................................................................ 14
Recovery of Claims Payments ............................................................................................................... 14
SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS ......................................................................... 15
SubscribeflDependent Liability ............................................................................................................... 15
KPS Privacy Policy ................................................................................................................................. 15
COMPLAINTS AND APPEALS PROCESS ......................................................................................... 16
Complaints .............................................................................................................................................. 16
Standard Appeals Process ..................................................................................................................... 16
Expedited Appeals Process .................................................................................................................... 17
GENERAL TERMS AND CONDITIONS ............................................................................................. 17
Applicable Law ........................................................................................................................................ 17
Assignment of Benefits ........................................................................................................................... 17
35
Binding Agreement ................................................................................................................................. 17
Confidentiality ......................................................................................................................................... 17
Contract Modifications ............................................................................................................................ 18
Coverage Limits ...................................................................................................................................... 18
Entire Agreement .................................................................................................................................... 18
Equity of Application ............................................................................................................................... 18
False or Misleading Information ............................................................................................................. 18
Force Majeure ......................................................................................................................................... 18
Group Cooperation ................................................................................................................................. 18
Headings ................................................................................................................................................. 19
Limitation of KPS Liability ....................................................................................................................... 19
Notices .................................................................................................................................................... 19
Severability ............................................................................................................................................. 19
Third Party Beneficiaries ........................................................................................................................ 19
Waiver of Breach .................................................................................................................................... 19
DEFINITIONS
Child means any one of the following:
(i) An unmarried natural Child, adopted Child, stepchild or other legally designated ward under the
Limiting Age who is primarily dependent upon the Subscriber or the Subscriber's Spouse for
support;
(ii) An unmarried Child under the Limiting Age who is legally entitled to receive medical coverage as
a result of a court order binding either the Subscriber or the SubscribeFs Spouse, regardless of
whether or not the Subscriber or Subscriber's Spouse has legal custody of the Child;
(iii) An unmarried Child who has reached the Limiting Age, or is older than the Limiting Age, is
incapable of self-sustaining employment due to developmental disability or physical handicap,
and is primarily dependent upon the Subscriber or the Subscriber's Spouse for support and
maintenance (see Continued Eligibility for a Disabled Dependent)
Contract means this documents and any other attachments, exhibits, riders or endorsements listed on
the title page or otherwise described herein, and any subsequent amendments or modifications to the
Contract or its attachments, exhibits, riders or endorsements.
Contract Renewal Month means the calendar month specified on the face page of this Group Policy
during which, each year, Group may renew its coverage under this Group Plan.
Covered Benefit or Service means those Medically Necessary services described in Attachment A,
Benefits Booklet, which a Covered Person is entitled to receive.
Eligible Dependent means the legal Spouse or Child of a LEOFF I or LEOFF II law enforcement officer.
Eligible Employee means:
(a) LEOFF I employees who are full-time law enforcement officers or firefighters hired prior to
October 1, 1977, and who are members of the LEOFF system as defined in Sections (3) and (4),
CH 131, Law of 1972, 1~ Ex. Session; or
(b) LEOFF II employees who are full-time law enforcement officers or firefighters hired on or after
October 1, 1977, and who are not members of the LEOFF system as defined in Sections (3) and
(4), CH 131, Law of 1972, 1st Ex. Session.
Enrollee means a person enrolled in this Group Plan.
Group means the employer entity, association or other group that has entered into this Contract with
KPS.
Group Plan means this KPS Group Plan.
Group Master Application means the application form completed by Group and submitted to KPS prior
to securing coverage under this Group Plan. The Group Master Application identifies the size,
participation and contribution eligibility requirements applicable to Group.
Limiting Age for Dependents means the age shown in the Benefits Summary section of the Benefits
Booklet.
Non-Participating Provider/Facility means any Provider or Facility not contracted directly with KPS, or
indirectly through First Choice Health Network or MultiPlan.
Open Enrollment Period means the thirty-one (31) day period, or some other period agreed to by both
KPS and Group, beginning one (1) month prior to Group's Renewal Month, or at some other mutually
agreeable time, but at least annually. During the Open Enrollment Period, Subscribers may add or delete
Eligible Dependents, and all eligible Employees and their Eligible Dependents have the opportunity to
select from alternative health plans offered by Group.
Premium means the periodic payment made by, or on behalf of the Enrollee, in accordance with the
terms of this Group Contract.
Premium Due Date means the first day of each month of coverage.
Provider means a licensed or certified health care practitioner acting within the scope of his/her license
or certificate.
City of Bremerton Plan A - 2002 ~,~ Page 1
Renewal Month see Contract Renewal Month.
Spouse means an individual who is living in a marital relationship with the Subscriber. The marital
relationship must be legally recognized by the State of Washington.
Subscriber means the pdmary person, generally the Employee, enrolled in this Group Plan.
Page: 2 3 i~ City of Bremerton Plan A - 2002
CONTRACT EXAMINATION PERIOD
GroUp may return this Contract to KPS within ten (10) days of the date it is received, if, after examination,
Group is not satisfied with the Contract for any reason. Upon receipt of the returned Contract, KPS will
refund to Group any pre-paid Premiums. The Contract shall subsequently be deemed null and void.
EFFECTIVE DATE~ DURATION AND RENEWAL
This Contract shall begin at 12:01 a.m. Pacific Time on the Effective Date (as indicated on the title page),
and shall remain in effect until the Contract Renewal Month unless terminated according to the provisions
set forth herein.
Thereafter, this Contract may be renewed automatically at 12:01 a.m. on the same date (month and day)
in subsequent calendar years unless otherwise terminated according to the provisions set forth herein.
PREMIUM PAYMENT PROVISIONS
Payment Due Date/Grace Period
The initial Premium payment is due and payable to KPS on or before the Effective Date of this Contract.
Thereafter, Premium payments are due and payable on or before the first day of every month ("Premium
Due Date") for which coverage is provided. A roster of current enrollment and enrollment changes
must accompany each Premium payment.
A ten (10) day grace period following the Premium Due Date is allowed, during which time this Contract
shall not be terminated. However, KPS may, at its sole discretion, elect to extend the grace period for up
to sixty (60) days from the Premium Due Date, or cancel this Contract immediately, without notice to
Group, if payment is not received by the end of the grace period.
If KPS elects to immediately cancel this Contract due to non-payment of Premium, the effective date of
cancellation will be retroactive to the last day of the month for which payment was received. No further
liability for claims will accrue to KP$. No person enrolled in this Group Plan shall be entitled to benefits
during any calendar month for which the Premium paid on his/her behalf was not received by KPS.
Premium Rate Adjustments
The Premium rates applicable to this Group Plan are defined in Attachment B - Premium Rates and
Underwriting Criteria. Rates are guaranteed until the Contract Renewal Month each Calendar Year.
Notwithstanding the foregoing, KPS reserves the right to revise the rates as follows:
As part of the annual Contract renewal process;
As a result of any state or federal law or regulation which imposes an additional tax, new tax or
other assessment on KPS revenue; and
> In the event there is a material change in the basis upon which KPS assumed risk under this
Contract. Such changes may include false or misleading information presented by Group,
changes in the benefits or other Contract terms required by statute or regulation, adverse claims
or underwriting experience, or fluctuations of ten percent (10%) or more in the number of enrolled
Subscribers and/or Dependents. KP$ will give Group sixty (60) days prior written notice of any
change in Premium rates not associated with the annual renewal process.
KPS will give Group thirty (30) days prior written notice of rate increases associated with the annual
Contract renewal process.
City of Bremerton Plan A - 2002 Page 3
Premiums Paid by Subscribers/Dependents
In certain instances, Subscribers and their enrolled Dependents may be required to self-pay their
Premiums in order to continue coverage. Those instances include:
~ Strikes, lockouts and other labor disputes which cause a disruption in Employee benefits; and
~ When the Subscriber and/or Dependent(s) elects to continue coverage under a COBRA provision
or other coverage continuation provision available under this Group Policy.
Group is required to collect self-paid Premiums and forward payments to KPS on or before the Premium
Due Date.
Premium Refunds
KPS will refund to Group any Premium paid in advance for periods after the termination date of this
Group Plan.
In the case of ineligible persons enrolled in this Group Plan, KPS will refund to Group any Premium paid
during a period of ineligibility which is in excess of claim payments made on behalf of the ineligible
person(s) during the period of ineligibility not to exceed three (3) months of Premium payments.
ELIGIBILITY AND ENROLLMENT
Group Eligibility
In order to be eligible to participate in this Group Plan, Group must continuously meet all eligibility,
participation, Group size, contribution and other requirements specified in the Group Master Application
form.
KPS reserves the right to audit Group's employment, payroll and eligibility records to ensure that Group
continues to meet its participation requirements, and to ensure that eligible Employees and their eligible
Dependents are properly enrolled in this Group Plan.
Subscriber/Dependent Eligibility Requirements
Active, full-time LEOFF I and LEOFF II Employees, as defined in the Definitions section are eligible to
enroll in this Group Plan.
Eligible Dependents of an active, full-time LEOFF I or LEOFF II law enforcement officer, as defined in the
Definitions section, are also eligible to enroll in this Group Plan.
The Child of a Dependent, other than the Child of the Subscriber's Spouse, is not eligible to enroll in this
Group Plan.
Enrollment
Premium if applicable, must all applications for
payments,
accompany
coverage
Current LEOFF I and LEOFF II Employees, including Dependents of active, full-time LEOFF I and LEOFF
II law enforcement officers, are initially eligible to apply for coverage beginning on the effective date of the
Group Policy. Application for coverage must be made within thirty-one (31) days of initial eligibility.
New LEOFF II Employees, including Dependents of active, full-time LEOFF I and LEOFF II law
enforcement officers, are initial eligible to apply for coverage on the first day of the first full month
following their first day of employment. Application for coverage must be made within thirty-one (31) days
of initial eligibility.
A new Spouse and the Spouse's Child{ran) are initially eligible to apply for coverage as of the date of
marriage. Application for coverage must be made within thirty-one (31) days of initial eligibility.
Page: 4 City of Bremerton Plan A - 2002
Newborn and Adopted Children are initially eligible to apply for coverage as follows:
~> A natural newborn Child is eligible as of the date of birth and is covered automatically for a period
of three weeks. In order for coverage to continue after the initial three (3) week period, the Child
must qualify as a Dependent and be enrolled in this Group Plan within sixty (60) days of birth;
~> Adopted Children are eligible (i) on the date of their adoption, (ii) on the date the Employee or
Spouse assumes legal obligation for total or partial support in anticipation of adoption, or (iii) on
the date the Employee or Spouse acquires partial or complete legal custody. Application for
coverage must be submitted within sixty (60) days of the date of placement for adoption.
In the case of court-ordered coverage, a Dependent Child becomes initially eligible on the date the
Subscriber or Spouse receives the order to provide medical coverage for the Child, even if neither the
Subscriber nor the Spouse is the custodial parent. Application for coverage must be submitted within
thirty-one (31) days of the date of the order.
Employees and their Dependents who do not enroll when they are initially eligible must wait until the next
Open Enrollment Pedod except in certain circumstances (see Enrollment Under Special
Circumstances).
Enrollment Under Special Circumstances
Loss of Other Coverage
Employees and their Dependents who, when they were initially eligible to enroll, declined coverage in this
Group Plan, in writing, based on existing coverage under another health plan, may apply for coverage
under this Group Plan if they lose eligibility for coverage under their other health plan, or if the other
health plan terminates. Employees and their eligible Dependents must apply for coverage within thirty-
one (31) days of losing coverage under their prior plan, or wait until the next Open Enrollment Period. A
Dependent may not enroll unless the Employee also enrolls.
Marriage, Birth or Adoption
Employees who, when they were initially eligible to enroll, declined coverage in this Group Plan, may
subsequently apply for coverage for themselves and their eligible Dependents before the next Open
Enrollment Period in the event they acquire Dependents as a result of marriage, birth of a Child, adoption,
or placement for adoption. Application for enrollment must be received by KPS within thirty-one (31) days
following the date of marriage, or within sixty (60) days following the date of birth, adoption or placement
for adoption, or wait until the next Open Enrollment Period.
Court-Ordered Coverage
Employees who, when they were initially eligible to enroll, declined coverage in this Group Plan, may
subsequently apply for coverage for themselves and their eligible Dependents before the next Open
Enrollment Period in the event they are required to provide health care coverage for a Dependent Child
as a result of a court order. Application for enrollment must be received within thirty-one (31) days
following the date of the court order, or wait until the next Open Enrollment Period.
When Coverage Begins
Coverage for new Enrollees begins on their date of initial eligibility provided they enrolled in this Group
Plan within the specified time limits (see Enrollment) and any applicable Premium amounts have been
paid.
A newborn Child who meets eligibility requirements is covered automatically for a period of three (3)
weeks from the date of birth, provided either the female Subscriber, or male Subscriber's Spouse, is
eligible for maternity coverage under this Group Plan at the time of the Child's birth. Coverage will not
extend beyond that time unless the Child is enrolled within sixty (60) days of the date of birth. Any
applicable Premium amount must accompany the enrollment application.
Coverage for an adopted child is retroactive to the date the child was legally placed for adoption, provided
the Child was enrolled within sixty (60) days from the date of placement, and provided any applicable
Premium amount has been paid by the Premium Due Date.
City of Bremerton Plan A - 2002 Page 5
Coverage Waiting Periods (This section does not apply to LEOFF I Employees)
Pre-Existing Conditions
KPS imposes a three (3) month waiting period before providing coverage for a pre-existing condition. A
"Pre-existing Condition" is any condition about which, during the three (3) month period immediately
before enrolling in this Group Plan, an Enrollee received medical advice, or for which his/her Provider
recommended or provided treatment. "
:-'"-"- '= i'rl '!'__ I!l'rI IIIr --
However, this waiting period may be reduced as follows:
> By the number of months the Enrollee was covered under a prior plan with similar benefits.
However, the prior period of coverage may not be counted if sixty-three (63) or more days have
elapsed since the date the prior coverage ended and the date the Enrollee enrolled in this Group
Plan. Any time during which the Enrollee was in a probationary or affiliation period will not be
taken into account in determining the sixty-three (63) day break; or
> By the number of months the Enrollee was continuously covered under a prior plan at any time
during the three (3) month period immediately preceding the effective date of coverage of this
Group Plan, provided the prior plan had similar benefits.
For purposes of this Contract, similar benefits means a health plan with an actuarial value of at least
seventy-five percent (75%) of the value of the benefits provided under this Group Plan.
To request a waiver of the waiting period, the Enrollee must submit a Certificate of Creditable Coverage
from the prior health plan carrier with his/her enrollment application. In lieu of a Certificate of Creditable
Coverage, the Enrollee must provide all of the following information:
The name of the prior health plan carrier;
The dates of coverage under the prior plan;
Proof of coverage under the prior plan which documents the coverage period(s).
There are no waiting periods for:
Pregnancy;
Formulas necessary for the treatment of phenylketonuria (PKU)
Prescription drugs included in the Pharmacy Benefit; or
A newborn Child or an adopted Child whose effective date of coverage is the date of birth or
placement for adoption.
Transplant Procedures
KP$ provides coverage for transplant procedures only after an Enrollee has been continuously covered
under this Group Plan for six (6) months. This transplant waiting period applies to the transplant
procedure as well as any pre- and post-transplant care directly related to a transplant you receive while
covered under this Group Plan. If the Enrollee was covered under another KPS plan immediately prior to
enrolling in this Group Plan, KPS may credit to this Group Plan the portion of the transplant waiting period
which was satisfied under the prior plan.
TERMINATION OF COVERAGE
Continuity of Coverage
Continuity of coverage under this Contract is guaranteed to all eligible Enrollees provided Group
continues to meet eligibility requirements and continues to pay applicable Premium payments on a timely
basis.
Page: 6 City of Bremerton Plan A - 2002
Termination of Group Contract
This Group Policy may be terminated if any of the following occurs:
Group fails to make full Premium payments;
Group violates, or refuses to comply with, the terms and conditions of this Contract;
Group violates or refuses to comply with any published KPS policies and procedures which have
been approved by the Insurance Commissioner;
~' there is a change to, or implementation of, federal or state laws which prohibits the continued
offering of this Group Plan; or
KPS replaces this Group Plan. In this case, the replacement plan will (i) include the services
covered under the replaced Plan; (ii) be offered to Group's eligible Employees and their Eligible
Dependents; and (iii) not significantly limit access to the kind of services covered under the
replaced Plan.
In addition, Group may terminate this Contract, at any time, by providing forty-five (45) days written notice
to KPS.
If this Group Contract terminates, for any reason, coverage for all Enrollees will end automatically on the
effective date of termination, or on the last day of the last month for which Group paid the Premium,
whichever occurs first. KPS will refund to Group any Premium paid in advance for periods after the
termination date.
In the case of termination or non-renewal of this Group Policy, Group shall be responsible for providing
the following information to all affected Employees and their Dependents:
~* The effective date of termination of coverage; and
> The reason(s) for termination or non-renewal.
Re-Enrollment/Reinstatement
If this Group Policy has been cancelled by KPS due to non-payment of Premium, Group automatically
forfeits all rights to guaranteed renewal of coverage afforded under the Health Insurance Portability and
Accountability Act (HIPAA) of 1996. Any decision to reinstate or reenroll Group is at the sole discretion of
KPS.
If Group voluntarily cancels this Group Policy prior to the Open Enrollment Period, KPS may, at its sole
discretion, impose up to a twelve (12) month waiting period before Group is eligible to reapply for
coverage.
Termination of Enrollee Coverage
Coverage for an individual Enrollee under this Group Plan will end if any one of the following events
occurs:
Non-payment of any Premium amount, when Premium payment is the responsibility of the
Enrollee;
Non-payment of any Deductible or Copayment amounts owed to KPS by the Enrollee;
The Enrollee loses eligibility for coverage under this Group Plan;
The Enrollee commits a fraudulent act with regard to KPS and this Group Plan;
The Enrollee behaves in a manner that is threatening, disruptive or abusive toward a KPS
employee or a Provider;
The Enrollee refuses to comply with the terms and conditions of this Group Plan as described in
this Group Policy and the Benefits Booklet;
The Enrollee voluntarily disenrolls from this Group Plan;
Thero is a change in either state or federal laws which no longer permits KPS from offering this
Group Plan; or
> This Group Policy is terminated.
City of Bremerton Plan A - 2002 Page 7
Additionally, Dependent coverage ends if:
The Subscriber is no longer employed or no longer meets eligibility requirements;
The Subscriber dies;
The Subscriber and Spouse divorce; or
The Child reaches the Limiting Age or marries.
Coverage ends on the last day of the month in which the Enrollee was eligible for coverage, provided all
applicable Premium amounts have been paid. In the case of non-payment of Premium, coverage ends on
the last day of the month for which KPS received a Premium payment.
Upon termination of coverage either KPS or Group shall issue a Certificate of Creditable Coverage
certifying the period(s) during which the Enrollee was enrolled in this Group Plan.
An Enrollee who loses coverage under this Group Plan may be eligible to continue coverage or enroll in
an individual conversion plan (see Continuation of Coverage).
A Subscriber who voluntarily disenrolls from this Group Plan while still an Employee will not be eligible to
re-enroll in the Group Plan until the first day of the month after one full year from the date of
disenrollment. See Enrollment Under Special Circumstances for exceptions to this policy.
Continuation of Inpatient Coverage
An Enrollee who is receiving care as an inpatient in an Accredited General Hospital or other approved
facility on the date that coverage would otherwise end, is eligible to continue receiving benefits under this
Group Plan provided the following conditions are met:
> KPS pre-authorized the inpatient care (see Prior Authorization of Inpatient Care); and
:~ All applicable Premium amounts continue to be paid.
KPS will continue to provide benefits until one of the following events occurs:
The Enrollee cease to be an inpatient;
Three (3) consecutive months have elapsed since the date on which coverage would otherwise
have ended;
The Enrollee has exhausted the inpatient benefits offered under this Group Plan (annual renewal
of benefits does not apply under this provision);
The KPS Medical Director determines that inpatient care is no longer Medically Necessary;
The Enrollee enrolls in another KPS plan or in any other health plan which provides inpatient
hospital benefits; or
~, Non-payment of Premium amounts
The Enrollee is not eligible for the extended coverage described herein if, when this Group Policy ends:
~ The Enrollee is covered under any other group or individual medical plan with similar
inpatient benefits; or
:~ The Enrollee is eligible for continuation of coverage under COBRA or any other continuation
provision.
Continuation of Coverage for a Disabled Child
A Dependent Child who has reached the Limiting Age remains eligible for coverage under this Group
Plan provided both of the following conditions are met:
> The Child is primarily dependent upon the Subscriber or the Subscriber's Spouse for support; and
> The Child is incapable of self-sustaining employment due to developmental disability or physical
handicap.
Proof of the Child's dependence must be submitted to KPS within thirty-one (31) days of the date the
Child reaches the Limiting Age. Thereafter, KPS may require resubmission of proof of the Child's
continuing dependence. Generally this proof is requested annually after the two-year period following the
Child's attainment of the Limiting Age.
Page: 8 City of Bremerton Plan A - 2002
A disabled Child will continue to be eligible for coverage until any one of the following events occurs:
Failure to submit proof of the Child's continuing dependence as a result of disability or physical
handicap;
KPS determines that the Child is no longer developmentally disabled or physically handicapped
(based on the evidence submitted);
The Subscriber is no longer covered under this Group Plan;
Non-payment of Premium; or
KPS terminates the Group Policy.
Coverage for a disabled Child ends on the last day of the month in which the disabled Child is eligible for
coverage, provided any applicable Premium amounts have been paid. In the case of non-payment of
Premium, coverage ends on the last day of the month for which KPS received a Premium payment.
A Dependent who is no longer eligible for coverage as a disabled Child may be eligible for coverage
under COBRA or a KPS conversion plan (see Continuation of Coverage).
CONTINUATION OF COVERAGE
Coverage During a Labor Dispute
In the event of a strike, lockout or other labor dispute which causes a disruption of health care
compensation benefits or wages, Subscribers and their enrolled Dependents may elect to continue
coverage under this Group Plan, for a period not to exceed six (6) months, by self-paying their Premiums.
During this period of continued coverage, benefits and Premium may not be altered from that of the
existing Group Plan.
The Subscriber is required to pay any applicable Premium directly to Group. Group is required to remit
Premium to KPS in accordance with the Premium Due Date and grace periods defined in this Contract.
Failure, on the part of the Subscriber, to make Premium payments will result in termination of coverage as
of the last day of the month for which Premium was paid. Coverage terminated for non-payment of
Premium will not be reinstated.
This provision does not apply to Subscribers and their enrolled Dependent(s) who are eligible to continue
coverage under COBRA or any other continuation of coverage provision.
Continuation of Group Coverage
Subscribers and their enrolled Dependents who lose eligibility for coverage under this Group Plan may
elect to extend their coverage for a period not to exceed three (3) month except (i) in the case of a strike,
lockout or other labor dispute, or (ii) when employment was terminated for gross misconduct. Application
for coverage must be made within thirty-one (31) days of the date coverage under the Group Plan
terminated. During this period of continued coverage, benefits and Premium may not be altered from that
of the existing Group Plan.
The Subscriber is required to pay any applicable Premium directly to Group. Group is required to remit
Premium to KPS in accordance with the Premium Due Date and grace periods defined in this Contract.
Failure, on the part of the Subscriber, to make Premium payments will result in termination of coverage as
of the last day of the month for which Premium was paid. Coverage terminated for non-payment of
Premium will not be reinstated.
COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985)
Employers who are required by law to comply with the provisions of the 1985 COBRA act must notify all
eligible Employees, and their eligible Dependents, who lose eligibility for coverage under this Group Plan
of their right to continue coverage under this provision.
Eligible individuals are required to apply for continued coverage within sixty (60) days of the date
coverage under this Group Plan ends. Group is required to notify KPS of each individual's election of
COBRA continuation coverage within sixty (60) days of that election. Failure on the part of the eligible
individual to make a timely election, or failure on the part of Group to provide KPS with timely notification
City of Bremerton Plan A - 2002 Page 9
of the election, will be interpreted by KPS as a waiver of the individual's right to continue coverage under
this provision. Failure by Group to provide timely notification to KPS may not, in all cases, eliminate
Group's obligation to provide continuation coverage. It will, however, eliminate any obligation on the part
of KPS to provide continuation coverage under this Contract.
Individual Conversion Coverage
Employees who are under age sixty-five (65) may be entitled to transfer to a KPS Individual Conversion
Plan if:
They are not otherwise eligible for coverage under Medicare;
They are currently eligible for continuation of Group coverage but have elected not to enroll in the
Group Plan;
~ Coverage under this Group Plan or a COBRA continuation plan has terminated (for any reason
except non-payment of Premium, when it is the individual's responsibility to pay the Premium); or
~' If this Group Policy terminates and Group does not provide other health care coverage to its
Employees.
Application for coverage must be made within thirty-one (31) days of the date coverage under this Group
Plan, or other KPS continuation or COBRA plan ends. Applicable Premium payments for the first month
of coverage must be submitted with the enrollment application
Dependents are separately eligible to apply for coverage under this option in the event they cease to be
eligible for coverage under the Group Plan due to the death of the Subscriber, or if the Subscriber and
Spouse divorce.
When an Enrollee enrolls in a conversion plan, he/she loses certain protections guaranteed under the
Health Insurance Portability and Accountability Act (HIPAA) of 1996. Most notably, if the Enrollee wants
to transfer to a non-conversion individual plan, he/she could be denied coverage based on a previous or
existing health condition. If the Enrollee does qualify for coverage under a non-conversion individual plan,
his/her coverage will be subject to any waiting periods for pre-existing conditions. For more information,
please contact KPS Member Services.
Employees who are age sixty-five (65) or older when coverage under the Group Plan terminates may be
eligible for coverage under a Medicare Supplement Plan. To determine Employee eligibility for a
Medicare Supplement Plan, please contact KPS Member Services.
COORDINATION OF BENEFITS (COB)
General Provision
Benefits are provided under this KPS Group Plan only to the extent that Subscribers and their enrolled
Dependent(s) could not have received benefits for the same service(s) under any other Plan, had a claim
for benefits been made. The purpose of this COB provision is to ensure that the sum of claim benefits
paid by KP$ and all other Plans under which Subscribers and their Dependent(s) are covered does not
exceed 100% of the Allowable Expense. All of the benefits provided under this KPS Group Plan are
subject to this COB provision.
Definitions
"Allowable Expense" means the usual, customary or reasonable charge for any necessary health care
service or supply when the service or supply is a covered benefit, at least in part, under any of the Plans
involved. When a Plan provides benefits in the form of services rather than cash payments, the
reasonable cash value of each service provided shall be considered an Allowable Expense. The
difference between the cost of a private Hospital room and the cost of a semi-private Hospital room is not
considered an Allowable Expense under the above definition unless your stay in a private Hospital room
is considered to be Medically Necessary under at least one of the Plans involved.
Page: 10 City of Bremerton Plan A - 2002
"Plan" means a policy or contract which provides benefits or services for, or because of, medical or dental
care, through one of the following:
This KPS Group Plan;
Any group, individual or blanket disability insurance policy;
Any group or individual contractual prepayment or indemnity plan such as those issued by health
care service contractors, health maintenance organizations or other health carriers or health
insurers;
Any labor-management trusteed plan or labor organization plan;
Any employer organization plan or employee benefit organization plan;
Any governmental program;
Any insurance coverage required or provided by statute, including automobile policies which
provide medical benefits; or
> Any other similar source.
The term "Plan" does not include accident-only coverage, including athletic injuries, for school-age
children from kindergarten through twelfth grade (K through 12), or for college students, either on a 24-
hour basis or on a "to and from school" basis.
Each of the Plans under which you and/or your Dependents are covered, and each benefit payable under
those Plans, is considered separately when benefits are coordinated under this provision.
Claim Determination Period
The claim determination period means a Calendar Year.
Effect on Benefits
If, during a claim determination period, your Allowed Expenses incurred under this KPS Greup Plan are
more than the sum of the benefits that would be payable under this KPS Group Plan in the absence of
this COB provision plus the benefits that would be payable under all other Plans in the absence therein of
similar COB provisions, then the benefits payable under this KPS Group Plan will be reduced so that the
sum of such reduced benefits plus all the benefits payable for corresponding Allowable Expenses under
all other Plans, does not exceed the total of such Allowable Expenses.
Order of Benefit Determination
When more than one Plan contains a COB provision, the decision as to which Plan is the primary Plan is
made in the following order:
The Plan which covers the person as a Subscriber rather than as a Dependent is primary;
When a Dependent Child is covered under more than one Plan, the Plan of the parent whose
date of birth (month and day only) occurs earlier in a Calendar Year is primary, except when the
Child's parents are legally divorced or separated.
>, When the parents of a covered Dependent Child are divorced or separated and there is no court
decree which establishes financial responsibility for the medical or dental expenses of the
Dependent Child, then benefits for the Child's Covered Expenses are determined as follows:
· the Plan of the parent with custody is primary, provided the parent with custody has not
remarried;
· if the parent with custody has remarried, the order for determining the primary Plan is:
(i) the Plan of parent with custody;
(ii) the Plan of the step-parent;
(iii) the Plan of the parent without custody.
Notwithstanding the above, if the court has determined which parent is financially responsible for the
health care of the Dependent Child, then the Plan of that parent is always the primary Plan.
City of Bremerton Plan A - 2002 Page 11
When the above rules do not establish an order of determination, then the Plan which has covered the
person for the longer period shall be primary, except that:
~. The benefits of the Plan which covers the person, on whose expenses the claim is based, as a
laid-off or retired Subscriber, or a Dependent of such a Subscriber, shall be determined after the
benefits of the Plan which covers that person as a Subscriber (other than as a laid-off or retired
Subscriber), or the Dependent of such a Subscriber; and
~. If either of the Plans does not have a provision regarding laid-off or retired Subscribers, which
results in each Plan determining its benefits after the other, then the above provision shall not
apply.
If none of the above rules applies, the Plan that has covered the person for the longest period of time
shall be considered the primary Plan.
Facility of Payment
Whenever another Plan makes payments which should have been provided under this KPS Group Plan
and in accordance with this COB provision, KPS may, at its sole discretion, choose to reimburse the Plan
making such other payments, the amount necessary to satisfy the intent of this COB provision. ,&ny
amount paid under this subsection shall be considered as benefits paid under this KPS Group Plan, and
KPS shall be fully discharged from liability to the extent of such payments.
Right of Recovery
Whenever KPS makes payments that are in excess of the maximum amount of payment necessary to
satisfy this COB provision, KPS shall have the right to recover the excess payment amount from the
Enrollee, from the Provider, or from another Plan, as applicable.
Right to Receive and Release Information
As a condition of receiving benefits under this KPS Group Plan, Subscribers and their enrolled
Dependent(s) agree to provide KPS with any necessary information, and authorize KPS to release to or
obtain from any other insurer, organization or person, any information necessary to administer this COB
provision.
Disclosure of Coordination
Failure on the part of Subscribers and their enrolled Dependents to cooperate with KPS regarding this
COB provision could result in the loss of benefits under this Group Plan.
KPS recommends that Subscribers and their enrolled Dependent(s) submit claims to KPS, and each
other plan, at the same time to help minimize delays and facilitate claims payment.
KPS' RIGHT OF RECOVERY
Limitations and Exclusions
Coverage under this plan is excluded for expenses incurred or services rendered if your illness or injury is
caused (or alleged by you to be caused) by another party, to the extent that benefits are available under
the terms of any other insurance coverage or source of payment, including but not limited to:
Vehicle medical, personal injury protection ("PIP"), no-fault, uninsured or underinsured motorist,
workers' compensation insurance or benefits and third party liability insurance, or similar contract
of insurance;
)' Homeowner's, property or any other insurance policy (except for individual or group health
insurance); or
)~ An agreement, judgment or settlement pursuant to which a third party pays or agrees to pay for
the costs of such services from assets other than a policy of insurance.
Page: 12 City of Bremerton Plan A - 2002
This exclusion applies whenever any such contract of insurance, agreement, judgment or settlement is
issued to or provides benefits for you, whether or not you assert a claim against the responsible third
party or its insurers.
Third Party Liability: Reimbursement and Subrogation
In consideration for KPS' agreement to advance medical expenses involving a claim against a third party
or its insurers, you agree to make a claim against the responsible party and its insurers for any and all
amounts advanced by KPS. By providing benefits under this provision, KPS is fulfilling its obligations
under this Group Contract. However, by so doing, KPS does not waive any rights to reimbursement or
subrogation. Provided, the benefits of this plan will be advanced to you if you are injured by a third party,
before compensation is recovered from the third party or its insurers, only under the following conditions:
You, and your representative(s), must fully cooperate with KPS in recovering payment of medical
bills paid, and to be paid by KPS, from the parties who allegedly caused the injury or illness,
including but not limited to their liability insurance carriers, any applicable PIP, uninsured or
underinsured motorist policy, homeowners policy, workers compensation or any other reachable
assets of the responsible party or parties;
You notify KPS, in writing, of the details of the injury or illness, the names and addresses of the
parties believed to be responsible and the names and addresses of the responsible party's
insurers, if known;
Any claim or lawsuit filed by you against the third party or the third party's insurer(s) must include
a demand for repayment of benefits paid by, or to be paid, by KPS on your behalf; or
~ You must agree to assign to KPS your right to recover compensation for medical costs paid
(subrogation), or to be paid, by KPS as a result of injuries caused by the third party responsible
for the injury.
~ You must agree to reimburse KPS for the cost of medical care provided by KPS as a result of the
injury, from the settlement, judgment, insurance proceeds or other recovery obtained by you from
any third party or its insurers.
Collection and Reimbursement by Enrollee (or the Enrollee's Representative)
If you elect to demand payment for KPS' medical costs from the responsible third party, you must:
Notify KPS in advance of any settlement, mediation, arbitration or trial;
Inform the responsible third party and its insurer(s) of the amount of the lien asserted by KPS, for
the recovery of benefits paid on your behalf, against any recovery or potential recovery obtained
by you;
Obtain prior consent from KPS before compromising or settling claims involving medical costs
paid by KPS;
~ Not enter into any agreement with the responsible third party or its insurer(s), or do anything else
that would release KPS' lien or prejudice our subrogation or reimbursement rights, without first
obtaining express prior written consent from KPS;
~ Reimburse KP$ for that portion of the settlement, award or judgment that is compensation for
medical bills paid and to be paid by us.
If you obtain a settlement or recovery for less than the insurance policy limits or reachable assets of the
liable party, you are obligated to reimburse KPS for the full amount of benefits paid on your behalf after
you have been fully compensated for your loss. If, however, you obtain a settlement or recovery that is
equal to or greater than the liable party's insurance policy limits or reachable assets, you are only
obligated to reimburse KPS in the amount that is left after you have been fully compensated for your loss.
You, or your representative(s), must obtain a written agreement from KPS prior to settling any claim if you
want KPS to share, on an equitable basis, any reasonable attorney fees incurred by you in pursuit of any
subrogation or reimbursement claim. In the absence of a prior written agreement, KPS, at its sole
discretion, will determine whether or not to reduce our reimbursement amount in order to share, on an
equitable basis, any reasonable attorney fees incurred by you. However, such a reduction will only be
considered if KPS has benefited from the services of your attorney. In no event will KPS' reimbursement
be reduced by more than twenty percent (20%) to offset attorney fees incurred by you, and KPS will not
pay for costs incurred by you.
Page 13
City of Bremerton Plan A - 2002 _,
?
Subrogation: Assignment of Third Party Claim to KPS
If you elect to assign your rights to KPS to pursue a claim seeking recovery from a responsible third party
or its insurer(s), you and your representative(s) must cooperate fully with KPS in pursuing the claim
against the responsible parties. Such cooperation includes, among other things:
Providing evidence and testimony consistent with the testimony in the case against the
responsible parties;
~ Refusing to assist the responsible parties, in any way, in defending against a claim brought
by KPS; and
~> Cooperating with KPS by not taking any action that might release, limit, reduce, or otherwise
prejudice our efforts to pursue a claim against any responsible third party.
Trust and Cooperation Between the Enrollee (or the Enrollee's Representative) and KPS.
You and your representative(s) must deal in good faith with KPS by adhering to all of the conditions set
forth in this Section. In turn, KPS agrees to cooperate with you and your representative(s) in your effort to
recover reimbursement, and will advance payments on your behalf for injuries or medical conditions
caused, or asserted by you to be caused, by any third party. You and your representative(s) must
cooperate fully with KPS in protecting, preserving, and recovering the amounts KPS has paid or will pay
on your behalf under this Group Plan. Failure to cooperate may result in the denial of coverage for injuries
or conditions caused, or asserted by you to be caused by any third party, to the extent that coverage or
payment for such injuries or illnesses is, or would have been, available under the terms of any other
insurance coverage or source of payment.
Agreement to Arbitrate
Any dispute which arises between you and KPS as a result of the preceding recovery provisions shall be
settled through arbitration. Both you and KPS shall be bound by the decisions of the arbitration
proceedings.
Disputes will be presented to, and resolved by, a single arbitrator, in accordance with the current rules of
the American Arbitration Association. Either you or KPS may demand arbitration by serving notice of this
demand on the other. Each party to the arbitration agrees to bear its own costs and to share equally in
the fees of the arbitrator. This agreement to resolve disputes through arbitration is in effect as of the
effective date of the Group Policy, and shall remain in effect until the dispute between us has been
resolved.
Recovery of Claims Payments
Ineligible Persons
If KPS knowingly or unknowingly makes any payment on behalf of an individual who for any reason was
not eligible to receive the services and benefits provided herein, KPS is entitled to full reimbursement
from such ineligible individual or from a Subscriber who applied for the ineligible benefits on behalf of
such individual.
If KPS knowingly or unknowingly receives Premium payment on behalf of an individual who for any
reason was not eligible to receive the services and benefits provided herein, KPS reserves the right to
refund any Premium payment(s) in excess of claims paid for the time the individual was ineligible, and
shall have the right to recover the cost of any benefit furnished while such individual was improperly
enrolled in this Group Plan.
Incorrect Claim Payment
KPS is entitled to full reimbursement from the payee for any incorrect claim payment. The term "incorrect
claim payment" includes but is not limited to the following:
> Payment to the wrong Provider;
> Payment of an incorrect amount;
), Payment for a service that is not a Covered Benefit or Service;
> Duplicate payment for the same service;
> Payment on behalf of the wrong Enrollee.
Page: 14 City of Bremerton Plan A - 2002
SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS
Subscriber/Dependent Liability
Subscribers and their Eligible Dependents who are enrolled in this Group Plan are liable for the following
costs:
Deductible
Copayments
Charges for non-covered services
Coinsurance, up to the Coinsurance Stoploss limit defined in the Benefits Booklet
Charges incurred after an annual or lifetime maximum benefit for a specific service or supply has
been exhausted (such as the annual maximum benefit for durable medical equipment)
Y Charges in excess of the amount paid by KPS to non-participating Providers
If KPS fails to reimburse a Participating Provider for the cost of Medically Necessary Covered Services
provided in accordance with the terms of this Contract, neither the Enrollee nor Group shall be required to
compensate the Participating Provider for such services beyond the limit of Deductibles, Copayments or
Coinsurance amounts specified in the Benefits Booklet.
KPS will continue to reimburse a Participating Provider for Medically Necessary Covered Services
rendered to an Enrollee after the Participating Provider's contract with KPS has ended, for such time as
the Enrollee remains covered under this Group Contract, until (i) the Enrollee's course of treatment has
been completed, or (ii) the care of the Enrollee has been appropriately transferred to another Participating
Provider. The KPS Medical Director is responsible for determinations regarding the completion of a
course of treatment and the transfer of patient care.
KPS Privacy Policy
Privacy Policy
The State of Washington enacted RCW 48.43.505 which implements the federal Gramm-Leach-Bliley Act
(P.L.102-106), sections 501(b) and 505(b)(2), and expands the requirements to cover the protection of
health information privacy. This law requires health insurance carriers in Washington State to provide its
Enrollees with information regarding privacy policies and procedures. The following is our privacy notice
to our Enrollees.
Non-Public Personal Information means information about our Enrollees that KPS collects in conjunction
with providing health care products or services to our Enrollees. Non-public Personal Information does
not include information that is available from public sources such as telephone directories or government
records.
KPS collects the following types of Non-public Personal Information about our Enrollees:
Information provided by Enrollees on coverage application forms and any other forms
completed as a result of enrollment in a KPS Health Plan;
), Information we receive from health care Providers or other companies, such as other health
insurance companies, related to medical claims and billing; and
> General information about the health care services received by Enrollees, such as the quality
and availability of services.
KPS does not disclose Non-public Personal Information about our Enrollees or former Enrollees to
anyone, except as permitted or required by law. KPS restricts access to Non-public Personal Information
about our Enrollees to only those employees who need to know that information in order to provide
products and services to our Enrollees. KPS maintains physical, electronic and procedural safeguards
that comply with federal regulations to guard all Non-public Personal Information.
City of Bremerton Plan A - 2002 Page 15
KPS' Right to Receive and Release Medical Information
As a condition of receiving the benefits and services provided under this Contract, Subscribers and their
enrolled Dependents, including their heirs, executors, administrators and assigns, authorize the Provider,
Hospital, other health care insurers, organizations or persons to:
(i) Release to KPS any medical information necessary for the administration of this Contract;
(ii) Allow the KPS Medical Director to examine, or have examined, any medical, hospital or other
facility records pertaining to the Enrollee; and
(iii) Present medical, hospital or other facility records pertaining to the Enrollee in any civil action in
which KPS is a party, expressly waiving any objections to such presentation.
COMPLAINTS AND APPEALS PROCESS
Complaints
All Enrollees have the right to contact KPS whenever they have a question, complaint or concern
regarding benefits, access to care or how to arrange for care, any KPS Participating Provider, the service
they receive from KPS, or any other issue related to this Group Plan or KPS. In the event an Enrollee has
a complaint, KPS Member Services Representatives are available Monday through Friday, from 8:00 a.m.
until 5:00 p.m. Pacific Time, except on nationally recognized holidays. If the complaint cannot be resolved
by a Member Services Representative, Enrollees may choose to file a complaint, or request an appeal, if
they are not satisfied with the Member Services response.
The following steps outline the procedure for filing a complaint:
EITHER
A KPS Member Services will
The service provided by KPS Send a written statement of work with the Enrollee and try
the complaint to: to resolve the complaint over
Eligibility
KPS Health Plans the phone. Otherwise, KPS will
Coverage or Benefits Attn: Complaint Resolution send a written response within
Claims Payment PO Box 339 30 days of receiving the
Bremerton, WA 98337 complaint.
Access to Care
Quality of Care OR Complaints about Participating
Providers are investigated
KPS Participating Providers Call KPS Member Services at thoroughly and are reviewed
360-478-6796 periodically.
or toll free at 1-800-552-7114
Standard Appeals Process
Enrollees have the right to appeal any decision regarding a complaint or any aspect of their health care
coverage which is not in their favor. Such decisions could affect:
The service received from KPS;
Access to health care services or Providers;
Eligibility for coverage;
Benefit coverage;
Termination of coverage under this Group Plan (except termination for non-payment of
Premium);
~. Non-payment of a claim, either completely or partially;
Page: 16 City of Bremerton Plan A - 2002
>. A denial or modification of a request for pre-authorization of any health care service or
supply; or
> A denial of a request for coverage of an experimental or investigational service or supply.
To file an appeal, the Enrollee, his/her designated representative, or his/her Provider may either call or
write KPS at the phone number or address listed above. Any documentation supporting the Enrollee's
position may be included with the appeal.
KPS will notify the Enrollee in writing that the request has been received. Included with that notice is
additional information regarding the Appeals Process and the Enrollee's rights and responsibilities during
an appeal. An Enrollee has the right to send his/her appeal directly to an Independent Review
Organization (IRO) if KPS does not respond to him/her within the allotted time period, as follows:
Decisions Regarding: Days to Respond:
Service-Related Appeals 30 Days
Denials of Experimental and/or Investigational Procedures 20 Days
or Supplies
All other Adverse Determinations 14 Days
Expedited Appeals Process
If the Enrollee's health care Provider, or the KPS Medical Director, reasonably determines that the
Enrollee's life, health, or ability to regain maximum function would be jeopardized by following the
Standard Appeals Process, KPS will bypass its internal appeals process and forward the appeal directly
to an Independent Review Organization (IRO) within 72 hours after it is received. If KPS expedites the
appeal, the Enrollee will receive notice of this action.
GENERAL TERMS AND CONDITIONS
Applicable Law
This Contract shall be governed by, and construed in accordance with, the laws of the State of
Washington. Venue for this Contract shall be Kitsap County.
Assignment of Benefits
The benefits of this Contract shall accrue to Subscribers and their enrolled Dependents. Neither this
Contract, nor its payments or Covered Benefits and Services are assignable to a third party. KPS
reserves the right to make benefit payments to the Subscriber, the Provider, or jointly, as KPS deems
necessary and appropriate, subject to federal and/or state laws.
Binding Agreement
This Contract is binding on KPS and Group, and their respective executors, administrators, successors
and assigns. By election of coverage or payment of applicable Premiums, or if Group's Subscribers or
their enrolled Dependents seek the services provided under this Contract, all of the terms, covenants and
conditions contained herein shall become valid and binding on Group and its Subscribers and enrolled
Dependents, notwithstanding the failure of Group to sign this Contract.
This Contract shall not bind KPS until (i) it has been executed by a person authorized by KPS, and (ii) an
executed copy has been delivered to Group.
Confidentiality
The underwriting and financial terms of this Contract are confidential and shall not be disclosed except as
is necessary for the performance of this Contract, or as required by law.
City of Bremerton Plan A - 2002 Page 17
Contract Modifications
Except as set forth under Premium Rate Adjustments, KP$ reserves the right to modify the provisions
of this Contract, or the services described in the Benefits Booklet, upon forty-five (45) days written notice
to Group. Group may elect to reject such modifications by providing KPS with fifteen (15) days written
notice. However, rejection of a modification will result in the termination of this Contract as of the last day
of the month for which Premium payment has been received. Lack of notification of rejection by Group
shall be interpreted as acceptance of the modification and this Contract will be renewed as modified.
No modification of this terms of this Contract shall be binding upon KPS unless endorsed, in writing, and
signed by an authorized officer of KPS. Such endorsement shall be deemed a part of this Contract,
effective as of the effective date of the endorsement. Any amendment or Contract modification required
by law or regulation shall become effective as of the effective date required by such law or regulation.
Coverage Limits
The Covered Benefits and Services offered under this Contract are subject to the coverage limits and
maximums set forth in the attached Benefits Booklet.
Entire Agreement
This Contract, together with Attachment A: Benefits Booklet; Attachment B: Premium Rates and
Underwriting Criteria; and any riders and/or endorsements attached hereto, constitute the entire
agreement. This Contract supersedes all previous communications, representations or agreements,
either verbal or written between KPS and Group, with respect to the subject matter herein.
Equity of Application
This Contract is intended to apply equally to all Enrollees.
False or Misleading Information
If Group provides statements or other information on the Group Master Application form, or any other
form required by KPS, that affects the acceptability of Group for coverage, or the risk assumed by KPS for
providing coverage, KPS may, at its sole discretion, elect to immediately terminate this Group Contract
and recover any claims and/or administrative costs from Group, Enrollee, or any other person(s)
responsible for providing the false or misleading information.
Force Majeure
In the event KPS is unable to perform its obligations hereunder by reason of fire, casualty, lockout, strike,
labor condition, riot, war, act of God or by ordinance, law, order or decree of any legally constituted
authority, then this Contract may, at the option of KPS, be suspended. During any period of suspension,
KPS shall not be required to perform any service hereunder, nor shall KPS be liable for any damages
arising from any event which precipitated the suspension. If this Contract is suspended pursuant to this
provision, any obligation by Group and/or an Enrollee to make Premium payments shall also be
suspended for the same period of time.
Group Cooperation
Group agrees to cooperate with KPS in the administration of this Contract by:
(i) Advising Subscribers and their enrolled Dependents of policies and procedures applicable to this
Group Plan;
(ii) Providing Subscribers and their enrolled Dependents with a Benefits Booklet, ID cards and any
applicable notices or other information regarding this Group Plan;
(iii) Providing information about Enrollees which is relevant to the determination of eligibility, claim
reimbursement, coordination of benefits or other information required for the administration of this
Contract; and
Page: 18 City of Bremerton Plan A - 2002
(iv) Making appropriate payroll deductions, if applicable, to facilitate Premium payment.
Headings
The headings of sections and paragraphs in this Contract are for convenience and reference purposes
only and do not affect in any way the meaning or interpretation of any provision of this Contract.
Limitation of KPS Liability
Nothing contained within or omitted from this Contract shall be construed as a promise by KPS to..perform
any service hereunder. In no case shall KPS be liable for any negligence or other wrongful act or
omission of any Provider, Hospital or other facility, or their employees, or any other person. Nothing in this
provision shall be construed as relieving KPS from liability for failure to make any payments required to
be made under the terms of this Contact.
Nothing in this Contract shall be construed to require KPS to provide coverage for services rendered to
any person after the termination of coverage for such person, or after the termination of this Contract.
Notices
Any notice which may affect the provisions of this Contract shall be deemed delivered to Group when
deposited in the United States mail with prepaid postage, addressed to Group at the most recent address
listed for Group. Any notice which may affect the provisions of this Contract shall be deemed delivered to
KPS when deposited in the United States mail with prepaid postage, addressed to KPS at the following
address: P.O. Box 339, Bremerton, WA 98337-0039.
Any requirement of KPS to provide notice to Enrollees shall be fulfilled when Group has received such
notice. It is the responsibility of Group to disseminate notices to Enrollees within thirty-one (31) days of
receipt.
Severability
If any term, provision, endorsement or condition of this Contract is deemed invalid or unenforceable by a
court of competent jurisdiction, the same shall be deemed severable from this Contract. However, the
remainder of this Contract shall remain in full force and effect and shall in no way be affected, impaired or
invalidated as a result of such decision.
Third Party Beneficiaries
There are not third party beneficiaries to this Contract.
Waiver of Breach
Waiver of a breach of any provision of this Contract shall not be deemed to be a waiver of any other
breach of the same or different provision.
City of Bremerton Plan A - 2002 Page 19
KPS Health Plans, In Rehabilitation
400 Warren Avenue
P.O. Box 339
Bremerton, WA 98331-0039
CITY OF BREMERTON - COVERAGE CONTRACT- PLAN B
Group Name: City of Bremerton Group Number: 21010, 21014
Effective Date: 1/1/2002
Renewal Month: January
Open Enrollment December
This Coverage Contract includes the following:
Attachment A- Benefits Booklet
Attachment B - Premium Rates and Underwriting Criteria
Riders: N/A
Optional Riders: N/A
Endorsements: N/A
KPS Health Plans, In Rehabilitation, hereinafter referred to as KPS, is a duly licensed health care
services contractor (HCSC) in Washington State. In its capacity as an HCSC, KPS agrees to underwrite
and provide the benefits and services described in Attachment A, Benefits Booklet, to the eligible
employees, and their eligible Dependents, of the above-named Group, provided the Group, its eligible
employees and their eligible Dependents, meet and comply with the provisions of this Contract.
Contract Form: BREMB-22900-2002
TABLE Of CONTENTS
DEFINITIONS ................................................................................................................................
CONTRACT EXAMINATION PERIOD ................................................................................................. 3
EFFECTIVE DATE, DURATION AND RENEWAL .................................................................................. 3
PREMIUM PAYMENT PROVISIONS ................................................................................................... 3
Payment Due Date/Grace Period ............................................................................................................. 3
Premium Rate Adjustments ...................................................................................................................... 3
Premiums Paid by Subscribers/Dependents ............................................................................................ 4
Premium Refunds ..................................................................................................................................... 4
ELIGIBILITY AND ENROLLMENT ....................................................................................................... 4
Group Eligibility ......................................................................................................................................... 4
Subscriber/Dependent Eligibility Requirements ....................................................................................... 4
Enrollment ................................................................................................................................................. 4
Enrollment Under Special Circumstances ................................................................................................ 5
When Coverage Begins ............................................................................................................................ 5
Coverage Waiting Periods ........................................................................................................................ 6
TERMINATION OF COVERAGE ......................................................................................................... 6
Continuity of Coverage ............................................................................................................................. 6
Termination of Group Contract ................................................................................................................. 7
Re-Enrollment/Reinstatement .................................................................................................................. 7
Termination of Enrollee Coverage ............................................................................................................ 7
Continuation of Inpatient Coverage .......................................................................................................... 8
Continuation of Coverage for a Disabled Child ........................................................................................ 8
CONTINUATION OF COVERAGE ...................................................................................................... 9
Coverage During a Labor Dispute ............................................................................................................ 9
Continuation of Group Coverage .............................................................................................................. 9
COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) ....................................................... 9
Individual Conversion Coverage ............................................................................................................. 10
COORDINATION OF BENEFITS (COB) ........................................................................................... 10
General Provision ................................................................................................................................... 10
Definitions ............................................................................................................................................... 10
Claim Determination Period .................................................................................................................... 11
Effect on Benefits .................................................................................................................................... 11
Order of Benefit Determination ............................................................................................................... 11
Facility of Payment ................................................................................................................................. 12
Right of Recovery ................................................................................................................................... 12
Right to Receive and Release Information ............................................................................................. 12
Disclosure of Coordination ..................................................................................................................... 12
KPS' RIGHT OF RECOVERY ......................................................................................................... 12
Limitations and Exclusions ..................................................................................................................... 12
Third Party Liability: Reimbursement and Subrogation .......................................................................... 13
Collection and Reimbursement by Enrollee (or the Enrollee's Representative) .................................... 13
Subrogation: Assignment of Third Party Claim to KPS .......................................................................... 14
Trust and Cooperation Between the Enrollee (or the Enrollee's Representative) and KPS .................. 14
Agreement to Arbitrate ............................................................................................................................ 14
Recovery of Claims Payments ............................................................................................................... 14
SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS ......................................................................... 15
Subscriber/Dependent Liability ............................................................................................................... 15
KPS Privacy Policy ................................................................................................................................. 15
COMPLAINTS AND APPEALS PROCESS ......................................................................................... 16
Complaints .............................................................................................................................................. 16
Standard Appeals Process ..................................................................................................................... 16
Expedited Appeals Process .................................................................................................................... 17
GENERAL TERMS AND CONDITIONS ............................................................................................. 17
Applicable Law ........................................................................................................................................ 17
Assignment of Benefits ........................................................................................................................... 17
Binding Agreement ................................................................................................................................. 17
Confidentiality ......................................................................................................................................... 17
Contract Modifications ............................................................................................................................ 17
Coverage Limits ...................................................................................................................................... 18
Entire Agreement .................................................................................................................................... 18
Equity of Application ............................................................................................................................... 18
False or Misleading Information ............................................................................................................. 18
Force Majeure ......................................................................................................................................... 18
Group Cooperation ................................................................................................................................. 18
Headings ................................................................................................................................................. 18
Limitation of KPS Liability ....................................................................................................................... 19
Notices .................................................................................................................................................... 19
Severability ............................................................................................................................................. 19
Third Party Beneficiaries ........................................................................................................................ 19
Waiver of Breach .................................................................................................................................... 19
DEFINITIONS
Child means any one of the following:
(i) An unmarried natural Child, adopted Child, stepchild or other legally designated ward under the
Limiting Age who is primarily dependent upon the Subscriber or the Subscriber's Spouse for
support;
(ii) An unmarried Child under the Limiting Age who is legally entitled to receive medical coverage as
a result of a court order binding either the Subscriber or the Subscriber's Spouse, regardless of
whether or not the Subscriber or Subscriber's Spouse has legal custody of the Child;
(iii) An unmarried Child who has reached the Limiting Age, or is older than the Limiting Age, is
incapable of self-sustaining employment due to developmental disability or physical handicap,
and is primarily dependent upon the Subscriber or the Subscriber's Spouse for support and
maintenance (see Continued Eligibility for a Disabled Dependent)
Contract means this documents and any other attachments, exhibits, riders or endorsements listed on
the title page or otherwise described herein, and any subsequent amendments or modifications to the
Contract or its attachments, exhibits, riders or endorsements.
Contract Renewal Month means the calendar month specified on the face page of this Group Policy
during which, each year, Group may renew its coverage under this Group Plan.
Covered Benefit or Service means those Medically Necessary services described in Attachment A,
Benefits Booklet, which a Covered Person is entitled to receive.
Eligible Dependent means the legal Spouse or Child of an Eligible Employee, or the legal Spouse or
Child of an active, full-time LEOFF I or LEOFF II firefighter.
Eligible Employee means an active, full-time Employee who is not a LEOFF I or LEOFF II Employee:
Enrollee means a person enrolled in this Group Plan.
Group means the employer entity, association or other group that has entered into this Contract with
KPS.
Group Plan means this KPS Group Plan.
Group Master Application means the application form completed by Group and submitted to KPS prior
to securing coverage under this Group Plan. The Group Master Application identifies the size,
participation and contribution eligibility requirements applicable to Group.
LEOFF I Employee means an active, full-time law enforcement officer or firefighter hired prior to October
1, 1977, and who is a member of the LEOFF system as defined in Sections (3) and (4), CH 131, Law of
1972, 1st Ex. Session.
LEOFF II Employee means an active, full-time law enforcement officer or firefighter hired on or after
October 1, 1977, and who is not a member of the LEOFF system as defined in Sections (3) and (4), CH
131, Law of 1972, 1st Ex. Session.
Limiting Age for Dependents means the age shown in the Benefits Summary section of the Benefits
Booklet.
Non-Participating Provider/Facility means any Provider or Facility not contracted directly with KPS, or
indirectly through First Choice Health Network or MultiPlan.
Open Enrollment Period means the thirty-one (31) day period, or some other period agreed to by both
KPS and Group, beginning one (1) month prior to Group's Renewal Month, or at some other mutually
agreeable time, but at least annually. During the Open Enrollment Period, Subscribers may add or delete
Eligible Dependents, and all eligible Employees and their Eligible Dependents have the opportunity to
select from alternative health plans offered by Group.
Premium means the periodic payment made by, or on behalf of the Enrollee, in accordance with the
terms of this Group Contract.
Premium Due Date means the first day of each month of coverage.
City of Bremerton Plan B 2002 ~-~ Page I
Provider means a licensed or certified health care practitioner acting within the scope of his/her license
or certificate.
Renewal Month see Contract' Renewal Month.
Spouse means an individual who is living in a marital relationship with the Subscriber. The marital
relationship must be legally recognized by the State of Washington.
Subscriber means the primary person, generally the Employee, enrolled in this Group Plan.
Page: 2 (3 0 City of Bremerton Plan B 2002
CONTRACT EXAMINATION PERIOD
Group may return this Contract to KPS within ten (10) days of the date it is received, if, after examination,
Group is not satisfied with the Contract for any reason. Upon receipt of the returned Contract, KPS will
refund to Group any pre-paid Premiums. The Contract shall subsequently be deemed null and void.
EFFECTIVE DATE~ DURATION AND RENEWAL
This Contract shall begin at 12:01 a.m. Pacific Time on the Effective Date (as indicated on the title page),
and shall remain in effect until the Contract Renewal Month unless terminated according to the provisions
set forth herein.
Thereafter, this Contract may be renewed automatically at 12:01 a.m. on the same date (month and day)
in subsequent calendar years unless otherwise terminated according to the provisions set forth herein.
PREMIUM PAYMENT PROVISIONS
Payment Due Date/Grace Period
The initial Premium payment is due and payable to KPS on or before the Effective Date of this Contract.
Thereafter, Premium payments are due and payable on or before the first day of every month ("Premium
Due Date") for which coverage is provided. A roster of current enrollment and enrollment changes
must accompany each Premium payment.
A ten (10) day grace period following the Premium Due Date is allowed, dudng which time this Contract
shall not be terminated. However, KPS may, at its sole discretion, elect to extend the grace period for up
to sixty (60) days from the Premium Due Date, or cancel this Contract immediately, without notice to
Group, if payment is not received by the end of the grace period.
If KPS elects to immediately cancel this Contract due to non-payment of Premium, the effective date of
cancellation will be retroactive to the last day of the month for which payment was received. No further
liability for claims will accrue to KPS. No person enrolled in this Group Plan shall be entitled to benefits
during any calendar month for which the Premium paid on his/her behalf was not received by KPS.
Premium Rate Adjustments
The Premium rates applicable to this Group Plan are defined in Attachment B - Premium Rates and
Underwriting Criteria. Rates are guaranteed until the Contract Renewal Month each Calendar Year.
Notwithstanding the foregoing, KPS reserves the right to revise the rates as follows:
As part of the annual Contract renewal process;
As a result of any state or federal law or regulation which imposes an additional tax, new tax or
other assessment on KPS revenue; and
~ In the event there is a material change in the basis upon which KPS assumed risk under this
Contract. Such changes may include false or misleading information presented by Group,
changes in the benefits or other Contract terms required by statute or regulation, adverse claims
or underwriting experience, or fluctuations of ten percent (10%) or more in the number of enrolled
Subscribers and/or Dependents. KPS will give Group sixty (60) days prior written notice of any
change in Premium rates not associated with the annual renewal process.
KPS will give Group thirty (30) days prior written notice of rate increases associated with the annual
Contract renewal process.
City of Bremerton Plan B 2002 (~ ( Page 3
Premiums Paid by Subscribers/Dependents
In certain instances, Subscribers and their enrolled Dependents may be required to self-pay their
Premiums in order to continue coverage. Those instances include:
), Strikes, lockouts and other labor disputes which cause a disruption in Employee benefits; and
), When the Subscriber and/or Dependent(s) elects to continue coverage under a COBRA provision
or other coverage continuation provision available under this Group Policy.
Group is required to collect self-paid Premiums and forward payments to KPS on or before the Premium
Due Date.
Premium Refunds
KPS will refund to Group any Premium paid in advance for periods after the termination date of this
Group Plan.
In the case of ineligible persons enrolled in this Group Plan, KPS will refund to Group any Premium paid
during a period of ineligibility which is in excess of claim payments made on behalf of the ineligible
person(s) during the period of ineligibility not to exceed three (3) months of Premium payments.
ELIGIBILITY AND ENROLLMENT
Group Eligibility
In order to be eligible to participate in this Group Plan, Group must continuously meet all eligibility,
participation, Group size, contribution and other requirements specified in the Group Master Application
form.
KPS reserves the right to audit Group's employment, payroll and eligibility records to ensure that Group
continues to meet its participation requirements, and to ensure that eligible Employees and their eligible
Dependents are properly enrolled in this Group Plan.
Subscriber/Dependent Eligibility Requirements
Active, full-time Employees, as defined in the Definitions section, and their Eligible Dependents, are
eligible to enroll in this Group Plan.
Eligible Dependents of active, full-time LEOFF I or LEOFF II firefighters, as defined in the Definitions
section, are also eligible to enroll in this Group Plan.
The Child of a Dependent, other than the Child of the Subscriber's Spouse, is not eligible to enroll in this
Group Plan.
Enrollment
Premium payments, if applicable, must accompany all applications for coverage
Current Employees and their Dependents, including Dependents of active, full-time LEOFF I and LEOFF
II firefighters, are initially eligible to apply for coverage beginning on the effective date of the Group Policy.
Application for coverage must be made within thirty-one (31) days of initial eligibility.
New Employees and their Dependents, including Dependents of active, full-time LEOFF I and LEOFF II
firefighters, are initially eligible to apply for coverage on the first day of the first full month following their
first day of employment. Application for coverage must be made within thirty-one (31) days of initial
eligibility.
A new Spouse and the Spouse's Child(ten) are initially eligible to apply for coverage as of the date of
marriage. Application for coverage must be made within thirty-one (31) days of initial eligibility.
Page: 4 ~, ~ City of Bremerton Plan B 2002
Newborn and Adopted Children are initially eligible to apply for coverage as follows:
;> A natural newborn Child is eligible as of the date of birth and is covered automatically for a period
of three weeks. In order for coverage to continue after the initial three (3) week period, the Child
must qualify as a Dependent and be enrolled in this Group Plan within sixty (60) days of birth;
> Adopted Children are eligible (i) on the date of their adoption, (ii) on the date the Employee or
Spouse assumes legal obligation for total or partial support in anticipation of adoption, or (iii) on
the date the Employee or Spouse acquires partial or complete legal custody. Application for
coverage must be submitted within sixty (60) days of the date of placement for adoption.
In the case of court-ordered coverage, a Dependent Child becomes initially eligible on the date the
Subscriber or Spouse receives the order to provide medical coverage for the Child, even if neither the
Subscriber nor the Spouse is the custodial parent. Application for coverage must be submitted within
thirty-one (31) day~ of the date of the order.
Employees and their Dependents who do not enroll when they are initially eligible must wait until the next
Open Enrollment Period except in certain circumstances (see Enrollment Under Special
Circumstances).
Enrollment Under Special Circumstances
Loss of Other Coverage
Employees and their Dependents who, when they were initially eligible to enroll, declined coverage in this
Group Plan, in writing, based on existing coverage under another health plan, may apply for coverage
under this Group Plan if they lose eligibility for coverage under their other health plan, or if the other
health plan terminates. Employees and their eligible Dependents must apply for coverage within thirty-
one (31) days of losing coverage under their prior plan, or wait until the next Open Enrollment Period. A
Dependent may not enroll unless the Employee also enrolls.
Marriage, Birth or Adoption
Employees who, when they were initially eligible to enroll, declined coverage in this Group Plan, may
subsequently apply for coverage for themselves and their eligible Dependents before the next Open
Enrollment Period in the event they acquire Dependents as a result of marriage, birth of a Child, adoption,
or placement for adoption. Application for enrollment must be received by KPS within thirty-one (31) days
following the date of marriage, or within sixty (60) days following the date of birth, adoption or placement
for adoption, or wait until the next Open Enrollment Period.
Court-Ordered Coverage
Employees who, when they were initially eligible to enroll, declined coverage in this Group Plan, may
subsequently apply for coverage for themselves and their eligible Dependents before the next Open
Enrollment Period in the event they are required to provide health care coverage for a Dependent Child
as a result of a court order. Application for enrollment must be received within thirty-one (31) days
following the date of the court order, or wait until the next Open Enrollment Period.
When Coverage Begins
Coverage for new Enrollees begins on their date of initial eligibility provided they enrolled in this Group
Plan within the specified time limits (see Enrollment) and any applicable Premium amounts have been
paid.
A newborn Child who meets eligibility requirements is covered automatically for a period of three (3)
weeks from the date of birth, provided either the female Subscriber, or male Subscriber's Spouse, is
eligible for maternity coverage under this Group Plan at the time of the Child's birth. Coverage will not
extend beyond that time unless the Child is enrolled within sixty (60) days of the date of birth. Any
applicable Premium amount must accompany the enrollment application.
Coverage for an adopted child is retroactive to the date the child was legally placed for adoption, provided
the Child was enrolled within sixty (60) days from the date of placement, and provided any applicable
Premium amount has been paid by the Premium Due Date.
City of Bremerton Plan B 2002 ~o3 Page 5
Coverage Waiting Periods
Pre-Existing Conditions
KPS imposes a three (3) month waiting period before providing coverage for a pre-existing condition. A
"Pre-existing Condition" is any condition about which, during the three (3) month period immediately
before enrolling in this Group Plan, an Enrollee received medical advice, or for which his/her Provider
recommended or provided treatment. Genetic information shall not be treated as a pre-existing condition
unless there has been a diagnosis of the condition related to the specific genetic information.
However, this waiting period may be reduced as follows:
~' By the number of months the Enrollee was covered under a prior plan with similar benefits.
However, the pdor period of coverage may not be counted if sixty-three (63) or more days have
elapsed since the date the prior coverage ended and the date the Enrollee enrolled in this Group
Plan. Any time during which the Enrollee was in a probationary or affiliation period will not be
taken into account in determining the sixty-three (63) day break; or
~. By the number of months the Enrollee was continuously covered under a prior plan at any time
during the three (3) month period immediately preceding the effective date of coverage of this
Group Plan, provided the prior plan had similar benefits.
For purposes of this Contract, similar benefits means a health plan with an actuarial value of at least
seventy-five percent (75%) of the value of the benefits provided under this Group Plan.
To request a waiver of the waiting period, the Enrollee must submit a Certificate of Creditable Coverage
from the prior health plan carder with his/her enrollment application. In lieu of a Certificate of Creditable
Coverage, the Enrollee must provide all of the following information:
The name of the prior health plan carrier;,
The dates of coverage under the prior plan;
Proof of coverage under the prior plan which documents the coverage period(s).
There are no waiting periods for:
Pregnancy;
Formulas necessary for the treatment of phenylketonuria (PKU)
Prescription drugs included in the Pharmacy Benefit; or
A newborn Child or an adopted Child whose effective date of coverage is the date of birth or
placement for adoption.
Transplant Procedures
KPS provides coverage for transplant procedures only after an Enrollee has been continuously covered
under this Group Plan for six (6) months. This transplant waiting period applies to the transplant
procedure as well as any pre- and post-transplant care directly related to a transplant you receive while
covered under this Group Plan. If the Enrollee was covered under another KPS plan immediately prior to
enrolling in this Group Plan, KPS may credit to this Group Plan the portion of the transplant waiting period
which was satisfied under the prior plan.
TERMINATION OF COVERAGE
Continuity of Coverage
Continuity of coverage under this Contract is guaranteed to all eligible Enrollees provided Group
continues to meet eligibility requirements and continues to pay applicable Premium payments on a timely
basis.
Page: 6 ~ ¢ City of Bremerton Plan B 2002
Termination of Group Contract
This Group Policy may be terminated if any of the following occurs:
Group fails to make full Premium payments;
Group violates, or refuses to comply with, the terms and conditions of this Contract;
Group violates or refuses to comply with any published KPS policies and procedures which have
been approved by the Insurance Commissioner;
> there is a change to, or implementation of, federal or state laws which prohibits the continued
offering of this Group Plan; or
> KPS replaces this Group Plan. In this case, the replacement plan will (i) include the services
covered under the replaced Plan; (ii) be offered to Group's eligible Employees and their Eligible
Dependents; and (iii) not significantly limit access to the kind of services covered under the
replaced Plan.
In addition, Group may terminate this Contract, at any time, by providing forty-five (45) days written notice
to KPS.
If this Group Contract terminates, for any reason, coverage for all Enrollees will end automatically on the
effective date of termination, or on the last day of the last month for which Group paid the Premium,
whichever occurs first. KPS will refund to Group any Premium paid in advance for periods after the
termination date.
In the case of termination or non-renewal of this Group Policy, Group shall be responsible for providing
the following information to all affected Employees and their Dependents:
> The effective date of termination of coverage; and
> The reason(s) for termination or non-renewal.
Re-Enrollment/Reinstatement
If this Group Policy has been cancelled by KPS due to non-payment of Premium, Group automatically
forfeits all rights to guaranteed renewal of coverage afforded under the Health Insurance Portability and
Accountability Act (HIPAA) of 1996. ,&ny decision to reinstate or reenroll Group is at the sole discretion of
KPS.
If Group voluntarily cancels this Group Policy prior to the Open Enrollment Period, KPS may, at its sole
discretion, impose up to a twelve (12) month waiting period before Group is eligible to reapply for
coverage.
Termination of Enrollee Coverage
Coverage for an individual Enrollee under this Group Plan will end if any one of the following events
occurs:
Non-payment of any Premium amount, when Premium payment is the responsibility of the
Enrollee;
Non-payment of any Deductible or Copayment amounts owed to KPS by the Enrollee;
The Enrollee loses eligibility for coverage under this Group Plan;
The Enrollee commits a fraudulent act with regard to KPS and this Group Plan;
The Enrollee behaves in a manner that is threatening, disruptive or abusive toward a KPS
employee or a Provider;
The Enrollee refuses to comply with the terms and conditions of this Group Plan as described in
this Group Policy and the Benefits Booklet;
The Enrollee voluntarily disenrolls from this Group Plan;
There is a change in either state or federal laws which no longer permits KPS from offering this
Group Plan; or
~. This Group Policy is terminated.
City of Bremerton Plan B 2002 (0 ~ Page 7
Additionally, Dependent coverage ends if:
The Subscriber is no longer employed or no longer meets eligibility requirements;
The Subscriber dies;
The Subscriber and Spouse divorce; or
The Child reaches the Limiting Age or marries.
Coverage ends on the last day of the month in which the Enrollee was eligible for coverage, provided all
applicable Premium amounts have been paid. In the case of non-payment of Premium, coverage ends on
the last day of the month for which KPS received a Premium payment.
Upon termination of coverage either KPS or Group shall issue a Certificate of Creditable Coverage
certifying the period(s) during which the Enrollee was enrolled in this Group Plan.
An Enrollee who loses coverage under this Group Plan may be eligible to continue coverage or enroll in
an individual conversion plan (see Continuation of Coverage).
A Subscriber who voluntarily disenrolls from this Group Plan while still an Employee will not be eligible to
re-enroll in the Group Plan until the first day of the month after one full year from the date of
disenrollment. See Enrollment Under Special Circumstances for exceptions to this policy.
Continuation of Inpatient Coverage
An Enrollee who is receiving care as an inpatient in an Accredited General Hospital or other approved
facility on the date that coverage would otherwise end, is eligible to continue receiving benefits under this
Group Plan provided the following conditions are met:
>' KPS pre-authorized the inpatient care (see Prior Authorization of Inpatient Care); and
>' All applicable Premium amounts continue to be paid.
KPS will continue to provide benefits until one of the following events occurs:
The Enrollee cease to be an inpatient;
Three (3) consecutive months have elapsed since the date on which coverage would otherwise
have ended;
The Enrollee has exhausted the inpatient benefits offered under this Group Plan (annual renewal
of benefits does not apply under this provision);
The KPS Medical Director determines that inpatient care is no longer Medically Necessary;
The Enrollee enrolls in another KPS plan or in any other health plan which provides inpatient
hospital benefits; or
~' Non-payment of Premium amounts
The Enrollee is not eligible for the extended coverage described herein if, when this Group Policy ends:
~ The Enrollee is covered under any other group or individual medical plan with similar
inpatient benefits; or
~ The Enrollee is eligible for continuation of coverage under COBRA or any other continuation
provision.
Continuation of Coverage for a Disabled Child
A Dependent Child who has reached the Limiting Age remains eligible for coverage under this Group
Plan provided both of the following conditions are met:
>, The Child is primarily dependent upon the Subscriber or the Subscriber's Spouse for support; and
>, The Child is incapable of self-sustaining employment due to developmental disability or physical
handicap.
Proof of the Child's dependence must be submitted to KPS within thirty-one (3'1) days of the date the
Child reaches the Limiting Age. Thereafter, KPS may require resubmission of proof of the Child's
continuing dependence. Generally this proof is requested annually after the two-year period following the
Child's attainment of the Limiting Age.
Page: 8 ~o City of Bremerton Plan B 2002
A disabled Child will continue to be eligible for coverage until any one of the following events occurs:
Failure to submit proof of the Child's continuing dependence as a result of disability or physical
handicap;
KPS determines that the Child is no longer developmentally disabled or physically handicapped
(based on the evidence submitted);
The Subscriber is no longer covered under this Group Plan;
Non-payment of Premium; or
KPS terminates the Group Policy.
Coverage for a disabled Child ends on the last day of the month in which the disabled Child is eligible for
coverage, provided any applicable Premium amounts have been paid. In the case of non-payment of
Premium, coverage ends on the last day of the month for which KPS received a Premium payment.
A Dependent who is no longer eligible for coverage as a disabled Child may be eligible for coverage
under COBRA or a KPS conversion plan (see Continuation of Coverage).
CONTINUATION OF COVERAGE
Coverage During a Labor Dispute
In the event of a strike, lockout or other labor dispute which causes a disruption of health care
compensation benefits or wages, Subscribers and their enrolled Dependents may elect to continue
coverage under this Group Plan, for a period not to exceed six (6) months, by self-paying their Premiums.
During this period of continued coverage, benefits and Premium may not be altered from that of the
existing Group Plan.
The Subscriber is required to pay any applicable Premium directly to Group. Group is required to remit
Premium to KPS in accordance with the Premium Due Date and grace periods defined in this Contract.
Failure, on the part of the Subscriber, to make Premium payments will result in termination of coverage as
of the last day of the month for which Premium was paid. Coverage terminated for non-payment of
Premium will not be reinstated.
This provision does not apply to Subscribers and their enrolled Dependent(s) who are eligible to continue
coverage under COBRA or any other continuation of coverage provision.
Continuation of Group Coverage
Subscribers and their enrolled Dependents who lose eligibility for coverage under this Group Plan may
elect to extend their coverage for a period not to exceed three (3) month except (i) in the case of a strike,
lockout or other labor dispute, or (ii) when employment was terminated for gross misconduct. Application
for coverage must be made within thirty-one (31) days of the date coverage under the Group Plan
terminated. During this period of continued coverage, benefits and Premium may not be altered from that
of the existing Group Plan.
The Subscriber is required to pay any applicable Premium directly to Group. Group is required to remit
Premium to KPS in accordance with the Premium Due Date and grace periods defined in this Contract.
Failure, on the part of the Subscriber, to make Premium payments will result in termination of coverage as
of the last day of the month for which Premium was paid. Coverage terminated for non-payment of
Premium will not be reinstated.
COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985)
Employers who are required by law to comply with the provisions of the 1985 COBRA act must notify all
eligible Employees, and their eligible Dependents, who lose eligibility for coverage under this Group Plan
of their right to continue coverage under this provision.
Eligible individuals are required to apply for continued coverage within sixty (60) days of the date
coverage under this Group Plan ends. Group is required to notify KPS of each individual's election of
COBRA continuation coverage within sixty (60) days of that election. Failure on the part of the eligible
individual to make a timely election, or failure on the part of Group to provide KPS with timely notification
of the election, will be interpreted by KPS as a waiver of the individual's right to continue coverage under
City of Bremerton Plan B 2002 ~'7 Page 9
this provision. Failure by Group to provide timely notification to KPS may not, in all cases, eliminate
Group's obligation to provide continuation coverage. It will, however, eliminate any obligation on the part
of KPS to provide continuation coverage under this Contract.
Individual Conversion Coverage
Employees who are under age sixty-five (65) may be entitled to transfer to a KPS Individual Conversion
Plan if:
They are not otherwise eligible for coverage under Medicare;
They are currently eligible for continuation of Group coverage but have elected not to enroll in the
Group Plan;
> Coverage under this Group Plan or a COBRA continuation plan has terminated (for any reason
except non-payment of Premium, when it is the individual's responsibility to pay the Premium); or
> If this Group Policy terminates and Group does not provide other health care coverage to its
Employees.
Application for coverage must be made within thirty-one (31) days of the date coverage under this Group
Plan, or other KPS continuation or COBRA plan ends. Applicable Premium payments for the first month
of coverage must be submitted with the enrollment application
Dependents are separately eligible to apply for coverage under this option in the event they cease to be
eligible for coverage under the Group Plan due to the death of the Subscriber, or if the Subscriber and
Spouse divorce.
When an Enrollee enrolls in a conversion plan, he/she loses certain protections guaranteed under the
Health Insurance Portability and Accountability Act (HIPAA) of 1996. Most notably, if the Enrollee wants
to transfer to a non-conversion individual plan, he/she could be denied coverage based on a previous or
existing health condition. If the Enrollee does qualify for coverage under a non-conversion individual plan,
his/her coverage will be subject to any waiting periods for pre-existing conditions. For more information,
please contact KPS Member Services.
Employees who are age sixty-five (65) or older when coverage under the Group Plan terminates may be
eligible for coverage under a Medicare Supplement Plan. To determine Employee eligibility for a
Medicare Supplement Plan, please contact KPS Member Services.
COORDINATION OF BENEFITS (COB)
General Provision
Benefits are provided under this KPS Group Plan only to the extent that Subscribers and their enrolled
Dependent(s) could not have received benefits for the same service(s) under any other Plan, had a claim
for benefits been made. The purpose of this COB provision is to ensure that the sum of claim benefits
paid by KPS and all other Plans under which Subscribers and their Dependent(s) are covered does not
exceed 100% of the Allowable Expense. All of the benefits provided under this KPS Group Plan are
subject to this COB provision.
Definitions
"Allowable Expense" means the usual, customary or reasonable charge for any necessary health care
service or supply when the service or supply is a covered benefit, at least in part, under any of the Plans
involved. When a Plan provides benefits in the form of services rather than cash payments, the
reasonable cash value of each service provided shall be considered an Allowable Expense. The
difference between the cost of a private Hospital room and the cost of a semi-private Hospital room is not
considered an Allowable Expense under the above definition unless your stay in a private Hospital room
is considered to be Medically Necessary under at least one of the Plans involved.
Page: 10 (o9 City of Bremerton Plan B 2002
"Plan" means a policy or contract which provides benefits or services for, or because of, medical or dental
care, through one of the following:
This KPS Group Plan;
Any group, individual or blanket disability insurance policy;
Any group or individual contractual prepayment or indemnity plan such as those issued by health
care service contractors, health maintenance organizations or other health carriers or health
insurers;
Any labor-management trusteed plan or labor organization plan;
Any employer organization plan or employee benefit organization plan;
Any governmental program;
Any insurance coverage required or provided by statute, including automobile policies which
provide medical benefits; or
> Any other similar source.
The term "Plan" does not include accident-only coverage, including athletic injuries, for school-age
children from kindergarten through twelfth grade (K through 12), or for college students, either on a 24-
hour basis or on a "to and from school" basis.
Each of the Plans under which you and/or your Dependents are covered, and each benefit payable under
those Plans, is considered separately when benefits are coordinated under this provision.
Claim Determination Period
The claim determination period means a Calendar Year.
Effect on Benefits
If, during a claim determination period, your Allowed Expenses incurred under this KP$ Group Plan are
more than the sum of the benefits that would be payable under this KPS Group Plan in the absence of
this COB provision plus the benefits that would be payable under all other Plans in the absence therein of
similar COB provisions, then the benefits payable under this KPS Group Plan will be reduced so that the
sum of such reduced benefits plus all the benefits payable for corresponding Allowable Expenses under
all other Plans, does not exceed the total of such AIIowable Expenses.
Order of Benefit Determination
When more than one Plan contains a COB provision, the decision as to which Plan is the primary Plan is
made in the following order:
The Plan which covers the person as a Subscriber rather than as a Dependent is primary;
When a Dependent Child is covered under more than one Plan, the Plan of the parent whose
date of birth (month and day only) occurs earlier in a Calendar Year is primary, except when the
Child's parents are legally divorced or separated.
~ When the parents of a covered Dependent Child are divorced or separated and there is no court
decree which establishes financial responsibility for the medical or dental expenses of the
Dependent Child, then benefits for the Child's Covered Expenses are determined as follows:
· the Plan of the parent with custody is primary, provided the parent with custody has not
remarried;
· if the parent with custody has remarried, the order for determining the primary Plan is:
(i) the Plan of parent with custody;
(ii) the Plan of the step-parent;
(iii) the Plan of the parent without custody.
Notwithstanding the above, if the court has determined which parent is financially responsible for the
health care of the Dependent Child, then the Plan of that parent is always the primary Plan.
City of Bremerton Plan B 2002 Page 11
When the above rules do not establish an order of determination, then the Plan which has covered the
person for the longer period shall be primary, except that:
> The benefits of the Plan which covers the person, on whose expenses the claim is based, as a
laid-off or retired Subscriber, or a Dependent of such a Subscriber, shall be determined after the
benefits of the Plan which covers that person as a Subscriber (other than as a laid-off or retired
Subscriber), or the Dependent of such a Subscriber; and
>. If either of the Plans does not have a provision regarding laid-off or retired Subscribers, which
results in each Plan determining its benefits after the other, then the above provision shall not
apply.
If none of the above rules applies, the Plan that has covered the person for the longest period of time
shall be considered the pdmary Plan.
Facility of Payment
Whenever another Plan makes payments which should have been provided under this KPS Group Plan
and in accordance with this COB provision, KPS may, at its sole discretion, choose to reimburse the Plan
making such other payments, the amount necessary to satisfy the intent of this COB provision. Any
amount paid under this subsection shall be considered as benefits paid under this KPS Group Plan, and
KPS shall be fully discharged from liability to the extent of such payments.
Right of Recovery
Whenever KPS makes payments that are in excess of the maximum amount of payment necessary to
satisfy this COB provision, KPS shall have the right to recover the excess payment amount from the
Enrollee, from the Provider, or from another Plan, as applicable.
Right to Receive and Release Information
As a condition of receiving benefits under this KP$ Group Plan, Subscribers and their enrolled
Dependent(s) agree to provide KPS with any necessary information, and authorize KPS to release to or
obtain from any other insurer, organization or person, any information necessary to administer this COB
provision.
Disclosure of Coordination
Failure on the part of Subscribers and their enrolled Dependents to cooperate with KPS regarding this
COB provision could result in the loss of benefits under this Group Plan.
KPS recommends that Subscribers and their enrolled Dependent(s) submit claims to KPS, and each
other plan, at the same time to help minimize delays and facilitate claims payment.
KPS' RIGHT OF RECOVERY
Limitations and Exclusions
Coverage under this plan is excluded for expenses incurred or services rendered if your illness or injury is
caused (or alleged by you to be caused) by another party, to the extent that benefits are available under
the terms of any other insurance coverage or source of payment, including but not limited to:
Vehicle medical, personal injury protection ("PIP"), no-fault, uninsured or underinsured motorist,
workers' compensation insurance or benefits and third party liability insurance, or similar contract
of insurance;
~. Homeowner's, property or any other insurance policy (except for individual or group health
insurance); or
~ An agreement, judgment or settlement pursuant to which a third party pays or agrees to pay for
the costs of such services from assets other than a policy of insurance.
Page: 12 City of Bremerton Plan B 2002
This exclusion applies whenever any such contract of insurance, agreement, judgment or settlement is
issued to or provides benefits for you, whether or not you assert a claim against the responsible third
party or its insurers.
Third Party Liability: Reimbursement and Subrogation
In consideration for KP$' agreement to advance medical expenses involving a claim against a third party
or its insurers, you agree to make a claim against the responsible party and its insurers for any and all
amounts advanced by KPS. By providing benefits under this provision, KPS is fulfilling its obligations
under this Group Contract. However, by so doing, KP$ does not waive any rights to reimbursement or
subrogation. Provided, the benefits of this plan will be advanced to you if you are injured by a third party,
before compensation is recovered from the third party or its insurers, only under the following conditions:
You, and your representative(s), must fully cooperate with KPS in recovering payment of medical
bills paid, and to be paid by KPS, from the parties who allegedly caused the injury or illness,
including but not limited to their liability insurance carriers, any applicable PIP, uninsured or
underinsured motorist policy, homeowners policy, workers compensation or any other reachable
assets of the responsible party or parties;
You notify KPS, in writing, of the details of the injury or illness, the names and addresses of the
parties believed to be responsible and the names and addresses of the responsible party's
insurers, if known;
Any claim or lawsuit filed by you against the third party or the third party's insurer(s) must include
a demand for repayment of benefits paid by, or to be paid, by KP$ on your behalf; or
), You must agree to assign to KPS your right to recover compensation for medical costs paid
(subrogation), or to be paid, by KPS as a result of injuries caused by the third party responsible
for the injury.
:> You must agree to reimburse KPS for the cost of medical care provided by KPS as a result of the
injury, from the settlement, judgment, insurance proceeds or other recovery obtained by you from
any third party or its insurers.
Collection and Reimbursement by Enrollee (or the Enrollee's Representative)
If you elect to demand payment for KP$' medical costs from the responsible third party, you must:
Notify KPS in advance of any settlement, mediation, arbitration or trial;
Inform the responsible third party and its insurer(s) of the amount of the lien asserted by KPS, for
the recovery of benefits paid on your behalf, against any recovery or potential recovery obtained
by you;
Obtain prior consent from KPS before compromising or settling claims involving medical costs
paid by KPS;
>, Not enter into any agreement with the responsible third party or its insurer(s), or do anything else
that would release KPS' lien or prejudice our subrogation or reimbursement rights, without first
obtaining express prior written consent from KPS;
:> Reimburse KPS for that portion of the settlement, award or judgment that is compensation for
medical bills paid and to be paid by us.
If you obtain a settlement or recovery for less than the insurance policy limits or reachable assets of the
liable party, you are obligated to reimburse KPS for the full amount of benefits paid on your behalf after
you have been fully compensated for your loss. If, however, you obtain a settlement or recovery that is
equal to or greater than the liable party!s insurance policy limits or reachable assets, you are only
obligated to reimburse KPS in the amount that is left after you have been fully compensated for your loss.
You, or your representative(s), must obtain a written agreement from KPS prior to settling any claim if you
want KPS to share, on an equitable basis, any reasonable attorney fees incurred by you in pursuit of any
subrogation or reimbursement claim. In the absence of a prior written agreement, KPS, at its sole
discretion, will determine whether or not to reduce our reimbursement amount in order to share, on an
equitable basis, any reasonable attorney fees incurred by you. However, such a reduction will only be
considered if KPS has benefited from the services of your attorney. In no event will KPS' reimbursement
be reduced by more than twenty percent (20%) to offset attorney fees incurred by you, and KPS will not
pay for costs incurred by you.
City of Bremerton Plan B 2002 '~ I Page 13
Subrogation: Assignment of Third Party Claim to KPS
If you elect to assign your rights to KPS to pursue a claim seeking recovery from a responsible third party
or its insurer(s), you and your representative(s) must cooperate fully with KPS in pursuing the claim
against the responsible parties. Such cooperation includes, among other things:
Providing evidence and testimony consistent with the testimony in the case against the
responsible parties;
> Refusing to assist the responsible parties, in any way, in defending against a claim brought
by KPS; and
> Cooperating with KPS by not taking any action that might release, limit, reduce, or otherwise
prejudice our efforts to pursue a claim against any responsible third party.
Trust and Cooperation Between the Enrollee (or the Enrollee's Representative) and KPS.
You and your representative(s) must deal in good faith with KPS by adhering to all of the conditions set
forth in this Section. In turn, KPS agrees to cooperate with you and your representative(s) in your effort to
recover reimbursement, and will advance payments on your behalf for injuries or medical conditions
caused, or asserted by you to be caused, by any third party. You and your representative(s) must
cooperate fully with KPS in protecting, preserving, and recovering the amounts KPS has paid or will pay
on your behalf under this Group Plan. Failure to cooperate may result in the denial of coverage for injuries
or conditions caused, or asserted by you to be caused by any third party, to the extent that coverage or
payment for such injuries or illnesses is, or would have been, available under the terms of any other
insurance coverage or source of payment.
Agreement to Arbitrate
Any dispute which arises between you and KPS as a result of the preceding recovery provisions shall be
settled through arbitration. Both you and KPS shall be bound by the decisions of the arbitration
proceedings.
Disputes will be presented to, and resolved by, a single arbitrator, in accordance with the current rules of
the American Arbitration Association. Either you or KPS may demand arbitration by serving notice of this
demand on the other. Each party to the arbitration agrees to bear its own costs and to share equally in
the fees of the arbitrator. This agreement to resolve disputes through arbitration is in effect as of the
effective date of the Group Policy, and shall remain in effect until the dispute between us has been
resolved.
Recovery of Claims Payments
Ineligible Persons
If KPS knowingly or unknowingly makes any payment on behalf of an individual who for any reason was
not eligible to receive the services and benefits provided herein, KPS is entitled to full reimbursement
from such ineligible individual or from a Subscriber who applied for the ineligible benefits on behalf of
such individual.
If KPS knowingly or unknowingly receives Premium payment on behalf of an individual who for any
reason was not eligible to receive the services and benefits provided herein, KPS reserves the right to
refund any Premium payment(s) in excess of claims paid for the time the individual was ineligible, and
shall have the right to recover the cost of any benefit furnished while such individual was improperly
enrolled in this Group Plan.
Incorrect Claim Payment
KPS is entitled to full reimbursement from the payee for any incorrect claim payment. The term "incorrect
claim payment" includes but is not limited to the following:
> Payment to the wrong Provider;
> Payment of an incorrect amount;
> Payment for a service that is not a Covered Benefit or Service;
> Duplicate payment for the same service;
> Payment on behalf of the wrong Enrollee.
Page: 14 City of Bremerton Plan B 2002
SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS
Subscriber/Dependent Liability
Subscribers and their Eligible Dependents who are enrolled in this Group Plan are liable for the following
costs:
Deductible
Copayments
Charges for non-covered services
Coinsurance, up to the Coinsurance Stoploss limit defined in the Benefits Booklet
Charges incurred after an annual or lifetime maximum benefit for a specific service or supply has
been exhausted (such as the annual maximum benefit for durable medical equipment)
~. Charges in excess of the amount paid by KPS to non-participating Providers
If KPS fails to reimburse a Participating Provider for the cost of Medically Necessary Covered Services
provided in accordance with the terms of this Contract, neither the Enrollee nor Group shall be required to
compensate the Participating Provider for such services beyond the limit of Deductibles, Copayments or
Coinsurance amounts specified in the Benefits Booklet.
KPS will continue to reimburse a Participating Provider for Medically Necessary Covered Services
rendered to an Enrollee after the Participating Provider's contract with KPS has ended, for such time as
the Enrollee remains covered under this Group Contract, until (i) the Enrollee's course of treatment has
been completed, or (ii) the care of the Enrollee has been appropriately transferred to another Participating
Provider. The KPS Medical Director is responsible for determinations regarding the completion of a
course of treatment and the transfer of patient care.
KPS Privacy Policy
Privacy Policy
The State of Washington enacted RCW 48.43.505 which implements the federal Gramm-Leach-Bliley Act
(P.L.102-106), sections 501(b) and 505(b)(2), and expands the requirements to cover the protection of
health information privacy. This law requires health insurance carriers in Washington State to provide its
Enrollees with information regarding privacy policies and procedures. The following is our privacy notice
to our Enrollees.
Non-Public Personal Information means information about our Enrollees that KPS collects in conjunction
with providing health care products or services to our Enrollees. Non-public Personal Information does
not include information that is available from public sources such as telephone directories or government
records.
KPS collects the following types of Non-public Personal Information about our Enrollees:
Information provided by Enrollees on coverage application forms and any other forms
completed as a result of enrollment in a KPS Health Plan;
> Information we receive from health care Providers or other companies, such as other health
insurance companies, related to medical claims and billing; and
;> General information about the health care services received by Enrollees, such as the quality
and availability of services.
KPS does not disclose Non-public Personal Information about our Enrollees or former Enrollees to
anyone, except as permitted or required by law. KP$ restricts access to Non-public Personal Information
about our Enrollees to only those employees who need to know that information in order to provide
products and services to our Enrollees. KPS maintains physical, electronic and procedural safeguards
that comply with federal regulations to guard all Non-public Personal Information.
City of Bremerton Plan B 2002 Page 15
KPS' Right to Receive and Release Medical Information
As a condition of receiving the benefits and services provided under this Contract, Subscribers and their
enrolled Dependents, including their heirs, executors, administrators and assigns, authorize the Provider,
Hospital, other health care insurers, organizations or persons to:
(i) Release to KPS any medical information necessary for the administration of this Contract;
(ii) Allow the KPS Medical Director to examine, or have examined, any medical, hospital or other
facility records pertaining to the Enrollee; and
(iii) Present medical, hospital or other facility records pertaining to the Enrollee in any civil action in
which KPS is a party, expressly waiving any objections to such presentation.
COMPLAINTS AND APPEALS PROCESS
Complaints
All Enrollees have the right to contact KPS whenever they have a question, complaint or concern
regarding benefits, access to care or how to arrange for care, any KPS Participating Provider, the service
they receive from KPS, or any other issue related to this Group Plan or KPS. In the event an Enrollee has
a complaint, KPS Member Services Representatives are available Monday through Fdday, from 8:00 a.m.
until 5:00 p.m. Pacific Time, except on nationally recognized holidays. If the complaint cannot be resolved
by a Member Services Representative, Enrollees may choose to file a complaint, or request an appeal, if
they are not satisfied with the Member Services response.
The following steps outline the procedure for filing a complaint:
EITH ER
A KPS Member Services will
The service provided by KPS Send a written statement of work with the Enrollee and try
Eligibility the complaint to: to resolve the complaint over
KPS Health Plans the phone. Otherwise, KPS will
Coverage or Benefits Attn: Complaint Resolution send a written response within
Claims Payment PO Box 339 30 days of receiving the
Bremerton, WA 98337 complaint.
Access to Care
Quality of Care OR Complaints about Participating
Providers are investigated
KPS Participating Providers Call KPS Member Services at thoroughly and are reviewed
360-478-6796 periodically.
or toll free at 1-800-552-7114
Standard Appeals Process
Enrollees have the right to appeal any decision regarding a complaint or any aspect of their health care
coverage which is not in their favor. Such decisions could affect:
The service received from KPS;
Access to health care services or Providers;
Eligibility for coverage;
Benefit coverage;
Termination of coverage under this Group Plan (except termination for non-payment of
Premium);
Non-payment of a claim, either completely or partially;
A denial or modification of a request for pre-authorization of any health care service or
supply; or
> A denial of a request for coverage of an experimental or investigational service or supply.
Page: 16 ~.! City of Bremerton Plan B 2002
-/?
To file an appeal, the Enrollee, his/her designated representative, or his/her Provider may either call or
write KPS at the phone number or address listed above. Any documentation supporting the Enrollee's
position may be included with the appeal.
KPS will notify the Enrollee in writing that the request has been received. Included with that notice is
additional information regarding the Appeals Process and the Enrollee's rights and responsibilities during
an appeal. An Enrollee has the right to send his/her appeal directly to an Independent Review
Organization (IRO) if KPS does not respond to him/her within the allotted time period, as follows:
Decisions Regarding: Days to Respond:
Service-Related Appeals 30 Days
Denials of Experimental and/or Investigational Procedures or Supplies 20 Days
All other Adverse Determinations 14 Days
Expedited Appeals Process
)f the Enrollee's health care Provider, or the KPS Medical Director, reasonably determines that the
Enrollee's life, health, or ability to regain maximum function would be jeopardized by following the
Standard Appeals Process, KPS will bypass its internal appeals process and forward the appeal directly
to an Independent Review Organization (IRO) within 72 hours after it is received. If KPS expedites the
appeal, the Enrollee will receive notice of this action.
GENERAL TERMS AND CONDITIONS
Applicable Law
This Contract shall be governed by, and construed in accordance with, the laws of the State of
Washington. Venue for this Contract shall be Kitsap County.
Assignment of Benefits
The benefits of this Contract shall accrue to Subscribers and their enrolled Dependents. Neither this
Contract, nor its payments or Covered Benefits and Services are assignable to a third party. KPS
reserves the right to make benefit payments to the Subscriber, the Provider, or jointly, as KPS deems
necessary and appropriate, subject to federal and/or state laws.
Binding Agreement
This Contract is binding on KPS and Group, and their respective executors, administrators, successors
and assigns. By election of coverage or payment of applicable Premiums, or if Group's Subscribers or
their enrolled Dependents seek the services provided under this Contract, all of the terms, covenants and
conditions contained herein shall become valid and binding on Group and its Subscribers and enrolled
Dependents, notwithstanding the failure of Group to sign this Contract.
This Contract shall not bind KPS until (i) it has been executed by a person authorized by KPS, and (ii) an
executed copy has been delivered to Group.
Confidentiality
The underwriting and financial terms of this Contract are confidential and shall not be disclosed except as
is necessary for the performance of this Contract, or as required by law.
Contract Modifications
Except as set forth under Premium Rate Adjustments, KPS reserves the right to modify the provisions
of this Contract, or the services described in the Benefits Booklet, upon forty-five (45) days written notice
to Group. Group may elect to reject such modifications by providing KPS with fifteen (15) days written
notice. However, rejection of a modification will result in the termination of this Contract as of the last day
City of Bremerton Plan B 2002 Page 17
of the month for which Premium payment has been received. Lack of notification of rejection by Group
shall be interpreted as acceptance of the modification and this Contract will be renewed as modified.
No modification of this terms of this Contract shall be binding upon KPS unless endorsed, in writing, and
signed by an authorized officer of KPS. Such endorsement shall be deemed a part of this Contract,
effective as of the effective date of the endorsement. Any amendment or Contract modification required
by law or regulation shall become effective as of the effective date required by such law or regulation.
Coverage Limits
The Covered Benefits and Services offered under this Contract are subject to the coverage limits and
maximums set forth in the attached Benefits Booklet.
Entire Agreement
This Contract, together with Attachment A: Benefits Booklet; Attachment B: Premium Rates and
Underwriting Criteria; and any riders and/or endorsements attached hereto, constitute the entire
agreement. This Contract supersedes all previous communications, representations or agreements,
either verbal or written between KPS and Group, with respect to the subject matter herein.
Equity of Application
This Contract is intended to apply equally to all Enrollees.
False or Misleading Information
If Group provides statements or other information on the Group Master Application form, or any other
form required by KPS, that affects the acceptability of Group for coverage, or the risk assumed by KPS for
providing coverage, KPS may, at its sole discretion, elect to immediately terminate this Group Contract
and recover any claims and/or administrative costs from Group, Enrollee, or any other person(s)
responsible for providing the false or misleading information.
Force Majeure
In the event KPS is unable to perform its obligations hereunder by reason of fire, casualty, lockout, strike,
labor condition, riot, war, act of God or by ordinance, law, order or decree of any legally constituted
authority, then this Contract may, at the option of KPS, be suspended. During any period of suspension,
KPS shall not be required to perform any service hereunder, nor shall KPS be liable for any damages
arising from any event which precipitated the suspension. If this Contract is suspended pursuant to this
provision, any obligation by Group and/or an Enrollee to make Premium payments shall also be
suspended for the same period of time.
Group Cooperation
Group agrees to cooperate with KPS in the administration of this Contract by:
(i) Advising Subscribers and their enrolled Dependents of policies and procedures applicable to this
Group Plan;
(ii) Providing Subscribers and their enrolled Dependents with a Benefits Booklet, ID cards and any
applicable notices or other information regarding this Group Plan;
(iii) Providing information about Enrollees which is relevant to the determination of eligibility, claim
reimbursement, coordination of benefits or other information required for the administration of this
Contract; and
(iv) Making appropriate payroll deductions, if applicable, to facilitate Premium payment.
Headings
The headings of sections and paragraphs in this Contract are for convenience and reference purposes
only and do not affect in any way the meaning or interpretation of any provision of this Contract.
Page: 18 City of Bremerton Plan B 2002
Limitation of KPS Liability
Nothing contained within or omitted from this Contract shall be construed as a promise by KPS to perform
any service hereunder. In no case shall KPS be liable for any negligence or other wrongful act or
omission of any Provider, Hospital or other facility, or their employees, or any other person. Nothing in this
provision shall be construed as relieving KPS from liability for failure to make any payments required to
be made under the terms of this Contact.
Nothing in this Contract shall be construed to require KPS to provide coverage for services rendered to
any person after the termination of coverage for such person, or after the termination of this Contract.
Notices
Any notice which may affect the provisions of this Contract shall be deemed delivered to Group when
deposited in the United States mail with prepaid postage, addressed to Group at the most recent address
listed for Group. Any notice which may affect the provisions of this Contract shall be deemed delivered to
KP$ when deposited in the United States mail with prepaid postage, addressed to KPS at the following
address: P.O. Box 339, Bremerton, WA 98337-0039.
Any requirement of KPS to provide notice to Enrollees shall be fulfilled when Group has received such
notice. It is the responsibility of Group to disseminate notices to Enrollees within thirty-one (31) days of
receipt.
Severability
If any term, provision, endorsement or condition of this Contract is deemed invalid or unenforceable by a
court of competent jurisdiction, the same shall be deemed severable from this Contract. However, the
remainder of this Contract shall remain in full force and effect and shall in no way be affected, impaired or
invalidated as a result of such decision.
Third Party Beneficiaries
There are not third party beneficiaries to this Contract.
Waiver of Breach
Waiver of a breach of any provision of this Contract shall not be deemed to be a waiver of any other
breach of the same or different provision.
City of Bremerton Plan B 2002 Page 19
KPS Health Plans, In Rehabilitation
400 Warren Avenue
P.O. Box 339
Bremerton, WA 98331-0039
CITY OF BREMERTON - COVERAGE CONTRACT- PLAN B
Group Name: City of Bremerton Group Number: 21010, 21014
Effective Date: 1/1/2002
Renewal Month: January
Open Enrollment December
This Coverage Contract includes the following:
Attachment A - Benefits Booklet
Attachment B - Premium Rates and Underwriting Criteria
Riders: N/A
Optional Riders: N/A
Endorsements: N/A
This Contract is entered into and delivered in the State of Washington and is governed by Washington
State laws, except to the extent state laws are preempted by federal law.
Signature by a qualified Group representative or payment of the Premium shall constitute acceptance of
the terms and conditions set forth herein.
FOR KPS: FOR GROUP:
Elizabeth A. Gilje, President Signature
Print Name
Title
Date
KPS Health Plans, In Rehabilitation
400 Warren Avenue
P.O. Box 339
Bremerton, WA 98331-0039
CITY OF BREMERTON - COVERAGE CONTRACT- PLAN B
Group Name: City of Bremerton Group Number: 21010, 21014
Effective Date: 1/1/2002
Renewal Month: January
Open Enrollment December
This Coverage Contract includes the following:
Attachment A - Benefits Booklet
Attachment B - Premium Rates and Underwriting Criteria
Riders: N/A
Optional Riders: N/A
Endorsements: N/A
This Contract is entered into and delivered in the State of Washington and is governed by Washington
State laws, except to the extent state laws are preempted by federal law.
Signature by a qualified Group representative or payment of the Premium shall constitute acceptance of
the terms and conditions set forth herein.
FOR KPS: FOR GROUP:
Elizabeth A. Gilje, President Signature
Print Name
Title
Date
7?
KPS Health Plans, In Rehabilitation
400 Warren/Avenue
P.O. Box 339
Bremerton, WA 98331-0039
Attachment B
Premium Rates and Underwriting Criteria
For
City of Brernerton
Premium Rates
~ tV ~ Reg lar& us 1s~ i 2 Child.&
Plan ARates: LEOFFI Actl !e ,.E~F~ii ~iYe :Spo e Ch Id Oi/~' '..
i /, uepenaents
$50 Deductible/Person
282.42 205.08 227.33 102.67 82.63
$100/Family
Pian A Rates: Spouse ~i Chi!d 01A2~3 eC~dtni
$50 Deductible/Person
$100/Family 739.04 404.87 101.01 80.73
=: :: Active EEOFF II Act v := = OiA Dependents
$100 Deductible/Person
$300/Family N/A 177.34 198.64 90.37 70.32
$100 Deductible/Person
$300/Family N/A 336.27 85.48 69.11
Additional Financial Arrangements:
Individual Stop Loss at $75,000 - $6.72pmpm charge
Administrative Expense- $22.32pmpm
Statutory Reserve Charge- $2.25pmpm
2003 Administration Increase Maximum - 5% from 2002 figure of $22.32 pmpm to $23.44pmpm for
contract year 2003
Underwriting Criteria
The Premium rates quoted above for this Group Plan are based on the following underwriting criteria.
KPS reserves the right to withdraw or rerate this offering if Group falls outside the scope of these criteria.
Active, full-time Employees must work a minimum of thirty (30) hours per week unless otherwise
negotiated and agreed by both KPS and Group.
> Subject to prior KPS approval, two (2) or more health insurance carriers, including KPS, may
provide coverage to Group's Employees.
> Subject to prior KPS approval, Group may select multiple KPS health plan offerings.
The minimum level of participation required is seventy-five percent (75%) of eligible Employees,
excluding those employees that may be on an HMO plan.
Unless otherwise approved by KPS, no more than twenty-five percent (25%) of Group's eligible
Employees may reside outside of the KPS service area. The KPS service area is defined as
Kitsap, Jefferson, Mason, Clallam, Thurston, Grays Harbor, Pierce and King counties.
KPS reserves the right to rerate Group in the event actual enrollment fluctuates by ten percent
(10%) or more from the census provided to KPS by Group at the time Group was initially rated.
KPS Health Plans, In Rehabilitation
400 Warren Avenue
P.O. Box 339
Bremerton,-WA 98331-0039
City of Bremerton - Coverage Contract -
UNDER 65 LEOFF I RETIREES (SUBSCRIBERS ONLY)
Group Name: City of Bremerton Group Number: 21001-21000
Effective Date: 1/1/2002
Renewal Month: January
Open Enrollment December
This Coverage Contract includes the following:
Attachment A - Benefits Booklet
Attachment B - Premium Rates and Underwriting Criteria
Riders: N/A
Optional Riders: N/A
Endorsements: N/A
KPS Health Plans, In Rehabilitation, hereinafter referred to as KPS, is a duly licensed health care
services contractor (HCSC) in Washington State. In its capacity as an HCSC, KPS agrees to underwrite
and provide the benefits and services described in Attachment A, Benefits Booklet, to the eligible
employees, and their eligible Dependents, of the above-named Group, provided the Group, its eligible
employees and their eligible Dependents, meet and comply with the provisions of this Contract.
Contract Form: BREMC-22900-2002
TABLE OF CONTENTS
DEFINITIONS .......................................................................................................... 1
CONTRACT EXAMINATION PERIOD ....................................................................................... i ...... 3
EFFECTIVE DATE, DURATION AND RENEWAL .................................................................................. 3
PREMIUM PAYMENT PROVISIONS ................................................................................................... 3
Payment Due Date/Grace Period ............................................................................................................. 3
Premium Rate Adjustments ...................................................................................................................... 3
Premiums Paid by Subscribers/Dependents ............................................................................................ 4
Premium Refunds ..................................................................................................................................... 4
ELIGIBILITY AND ENROLLMENT ....................................................................................................... 4
Group Eligibility ......................................................................................................................................... 4
Subscriber/Dependent Eligibility Requirements ....................................................................................... 4
Enrollment ................................................................................................................................................. 4
Enrollment Under Special Circumstances ................................................................................................ 5
When Coverage Begins ............................................................................................................................ 5
TERMINATION OF COVERAGE ......................................................................................................... 5
Continuity of Coverage ............................................................................................................................. 5
Termination of Group Contract ................................................................................................................. 5
Re-Enrollment/Reinstatement .................................................................................................................. 5
Termination of Enrollee Coverage ............................................................................................................ 6
Continuation of Inpatient Coverage .......................................................................................................... 6
Continuation of Coverage for a Disabled Child ........................................................................................ 7
CONTINUATION OF COVERAGE ...................................................................................................... 7
COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) ....................................................... 7
Individual Conversion Coverage ............................................................................................................... 8
COORDINATION OF BENEFITS (COB) ............................................................................................. 8
General Provision ..................................................................................................................................... 8
Definitions ................................................................................................................................................. 8
Claim Determination Period ...................................................................................................................... 9
Effect on Benefits ...................................................................................................................................... 9
Order of Benefit Determination ................................................................................................................. 9
Facility of Payment ................................................................................................................................. 10
Right of Recovery ................................................................................................................................... 10
Right to Receive and Release Information ............................................................................................. 10
Disclosure of Coordination ..................................................................................................................... 10
KPS' RIGHT OF RECOVERY ......................................................................................................... 10
Limitations and Exclusions ..................................................................................................................... 10
Third Party Liability: Reimbursement and Subrogation .......................................................................... 11
Collection and Reimbursement by Enrollee (or the En rollee's Representative) .................................... 11
Subrogation: Assignment of Third Party Claim to KPS .......................................................................... 12
Trust and Cooperation Between the Enrollee (or the F:nrollee's Representative) and KPS .................. 12
Agreement to Arbitrate ............................................................................................................................ 12
Recovery of Claims Payments ............................................................................................................... 12
SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS ......................................................................... 1 3
SubscribedDependent Liability ............................................................................................................... 13
KPS Privacy Policy ................................................................................................................................. 13
COMPLAINTS AND APPEALS PROCESS ......................................................................................... 14
Complaints .............................................................................................................................................. 14
Standard Appeals Process ..................................................................................................................... 15
Expedited Appeals Process .................................................................................................................... 15
GENERAL TERMS AND CONDITIONS ............................................................................................. 1 5
Applicable Law ........................................................................................................................................ 15
Assignment of Benefits ........................................................................................................................... 15
Binding Agreement ................................................................................................................................. 15
Confidentiality ......................................................................................................................................... 16
Contract Modifications ............................................................................................................................ 16
Coverage Limits ...................................................................................................................................... 16
Entire Agreement .................................................................................................................................... 16
Equity of Application ............................................................................................................................... 16
False or Misleading Information ............................................................................................................. 16
Force Majeure ......................................................................................................................................... 16
Group Cooperation ................................................................................................................................. 17
Headings ................................................................................................................................................. 17
Limitation of KPS Liability ....................................................................................................................... 17
Notices .................................................................................................................................................... 17
Severability ............................................................................................................................................. 17
Third Party Beneficiaries ........................................................................................................................ 17
Waiver of Breach .................................................................................................................................... 17
DEFINITIONS
Child means any one of the following:
(i) An unmarried natural Child, adopted Child, stepchild or other legally designated ward under the
Limiting Age who is primarily dependent upon the Subscriber or the Subscriber's Spouse for
support;
(ii) An unmarried Child under the Limiting Age who is legally entitled to receive medical coverage as
a result of a court order binding either the Subscriber or the Subscriber's Spouse, regardless of
whether or not the Subscriber or Subscriber's Spouse has legal custody of the Child;
(iii) An unmarried Child who has reached the Limiting Age, or is older than the Limiting Age, is
incapable of self-sustaining employment due to developmental disability or physical handicap,
and is primarily dependent upon the Subscriber or the Subscriber's Spouse for support and
maintenance (see Continued Eligibility for a Disabled Dependent)
Contract means this documents and any other attachments, exhibits, riders or endorsements listed on
the title page or otherwise described herein, and any subsequent amendments or modifications to the
Contract or its attachments, exhibits, riders or endorsements.
Contract Renewal Month means the calendar month specified on the face page of this Group Policy
during which, each year, Group may renew its coverage under this Group Plan.
Covered Benefit or Service means those Medically Necessary services described in Attachment A,
Benefits Booklet, which a Covered Person is entitled to receive.
Eligible Dependent means the Subscriber's legal Spouse or Child.
Eligible Employee means a retired LEOFF I Employee who is under age 65 and who is eligible for a
Premium contribution by his/her payroll office.
Enrollee means a person enrolled in this Group Plan.
Group means the employer entity, association or other group that has entered into this Contract with
KPS.
Group Plan means this KPS Group Plan.
Group Master Application means the application form completed by Group and submitted to KPS prior
to securing coverage under this Group Plan. The Group Master Application identifies the size,
participation and contribution eligibility requirements applicable to Group.
LEOFF I Employee means a full-time law enforcement officer or firefighter hired prior to October 1, 1977,
who is a member of the LEOFF system as defined in Sections (3) and (4), CH 131, Law of 1972, 1st Ex.
Session.
Limiting Age for Dependents means the age shown in the Benefits Summary section of the Benefits
Booklet.
Non-Participating Provider/Facility means any Provider or Facility not contracted directly with KPS, or
indirectly through First Choice Health Network or MultiPlan.
Open Enrollment Period means the thirty-one (31) day period, or some other period agreed to by both
KPS and Group, beginning one (1) month prior to Group's Renewal Month, or at some other mutually
agreeable time, but at least annually. During the Open Enrollment Period, Subscribers may add or delete
Eligible Dependents, and all eligible Employees and their Eligible Dependents have the opportunity to
select from alternative health plans offered by Group.
Premium means the periodic payment made by, or on behalf of the Enrollee, in accordance with the
terms of this Group Contract.
Premium Due Date means the first day of each month of coverage.
Provider means a licensed or certified health care practitioner acting within the scope of his/her license
or certificate.
Renewal Month see Contract Renewal Month.
City of Bremerton Plan C -2002 Page 1
Spouse means an individual who is living in a marital relationship with the Subscriber. The marital
relationship must be legally recognized by the State of Washington.
Subscriber means the primary person, generally the Employee, enrolled in this Group Plan.
Page: 2 City of Bremerton Plan C 2002
CONTRACT EXAMINATION PERIOD
Group may return this Contract to KPS within ten (10) days of the date it is received, if, after examination,
Group is not satisfied with the Contract for any reason. Upon receipt of the returned Contract, KPS will
refund to Group any pre-paid Premiums. The Contract shall subsequently be deemed null and void.
EFFECTIVE DATE~ DURATION AND RENEWAL
This Contract shall begin at 12:01 a.m. Pacific Time on the Effective Date (as indicated on the title page),
and shall remain in effect until the Contract Renewal Month unless terminated according to the provisions
set forth herein.
Thereafter, this Contract may be renewed automatically at 12:01 a.m. on the same date (month and day)
in subsequent calendar years unless otherwise terminated according to the provisions set forth herein.
PREMIUM PAYMENT PROVISIONS
Payment Due Date/Grace Period
The initial Premium payment is due and payable to KPS on or before the Effective Date of this Contract.
Thereafter, Premium payments are due and payable on or before the first day of every month ("Premium
Due Date") for which coverage is provided. A roster of current enrollment and enrollment changes
must accompany each Premium payment.
A ten (10) day grace period following the Premium Due Date is allowed, during which time this Contract
shall not be terminated. However, KPS may, at its sole discretion, elect to extend the grace period for up
to sixty (60) days from the Premium Due Date, or cancel this Contract immediately, without notice to
Group, if payment is not received by the end of the grace period.
If KPS elects to immediately cancel this Contract due to non-payment of Premium, the effective date of
cancellation will be retroactive to the last day of the month for which payment was received. No further
liability for claims will accrue to KPS. No person enrolled in this Group Plan shall be entitled to benefits
during any calendar month for which the Premium paid on his/her behalf was not received by KPS.
Premium Rate Adjustments
The Premium rates applicable to this Group Plan are defined in Attachment B - Premium Rates and
Underwriting Criteria. Rates are guaranteed until the Contract Renewal Month each Calendar Year.
Notwithstanding the foregoing, KPS reserves the right to revise the rates as follows:
As part of the annual Contract renewal process;
As a result of any state or federal law or regulation which imposes an additional tax, new tax or
other assessment on KPS revenue; and
> In the event there is a material change in the basis upon which KPS assumed risk under this
Contract. Such changes may include false or misleading information presented by Group,
changes in the benefits or other Contract terms required by statute or regulation, adverse claims
or underwriting experience, or fluctuations of ten percent (10%) or more in the number of enrolled
Subscribers and/or Dependents. KPS will give Group sixty (60) days prior written notice of any
change in Premium rates not associated with the annual renewal process.
KPS will give Group thirty (30) days prior written notice of rate increases associated with the annual
Contract renewal process.
City of Bremerton Plan C -2002
~7 Page3
Premiums Paid by Subscribers/Dependents
In certain instances, Subscribers and their enrolled Dependents may be required to self-pay their
Premiums in order to continue coverage. Those instances include:
~ Strikes, lockouts and other labor disputes which cause a disruption in Employee benefits; and
~> When the Subscriber and/or Dependent(s) elects to continue coverage under a COBRA provision
or other coverage continuation provision available under this Group Policy.
Group is required to collect self-paid Premiums and forward payments to KPS on or before the Premium
Due Date.
Premium Refunds
KPS will refund to Group any Premium paid in advance for periods after the termination date of thL5
Group Plan.
In the case of ineligible persons enrolled in this Group Plan, KPS will refund to Group any Premium paid
during a period of ineligibility which is in excess of claim payments made on behalf of the ineligible
person(s) during the period of ineligibility not to exceed three (3) months of Premium payments.
ELIGIBILITY AND ENROLLMENT
Group Eligibility
In order to be eligible to participate in this Group Plan, Group must continuously meet all eligibility,
participation, Group size, contribution and other requirements specified in the Group Master Application
form.
KPS reserves the right to audit Group's employment, payroll and eligibility records to ensure that Group
continues to meet its participation requirements, and to ensure that eligible Employees and their eligible
Dependents are properly enrolled in this Group Plan.
Subscriber/Dependent Eligibility Requirements
Retired LEOFF I Employees, as defined in the Definitions section, are eligible to enroll in this Group
Plan.
As of March 1, 2001, Dependents of retired LEOFF I EmPloyees are no longer eligible to enroll in this
Group Plan. Dependents who enrolled prior to March 1, 2001, may remain on this Group Plan.
Enrollment
Premium payments, if applicable, must accompany all applications for coverage
Currently retired LEOFF I Employees are initially eligible to apply for coverage beginning on the effective
date of this Group Policy. Application for coverage must be made within thirty-one (31) days of initial
eligibility.
Newly retired LEOFF I Employees are initially eligible to apply for coverage on their effective date of
retirement. Application for coverage must be made within thirty-one (31) days of initial eligibility.
Retired LEOFF I Employees who do not enroll when they are initially eligible may not apply for coverage
at a later date except in certain circumstances (see Enrollment Under Special Circumstances).
Page: 4 City of Bremerton Plan C 2002
Enrollment Under Special Circumstances
Retired LEOFF I Employees who, when they were initially eligible to enroll, declined coverage in this
Group Plan, in writing, based on existing coverage under another health plan, may apply for coverage
under this Group Plan if they lose eligibility for coverage under their other health plan, or if the other
health plan terminates. Retired LEOFF I Employees mu st apply for coverage within thirty-one (31) days of
losing coverage under their prior plan.
When Coverage Begins
Coverage for new Enrollees begins on their date of initial eligibility provided they enrolled in this Group
Plan within the specified time limits (see Enrollment) and any applicable Premium amounts have been
paid.
TERMINATION OF COVERAGE
Continuity of Coverage
Continuity of coverage under this Contract is guaranteed to all eligible Enrollees provided Group
continues to meet eligibility requirements and continues to pay applicable Premium payments on a timely
basis.
Termination of Group Contract
This Group Policy may be terminated if any of the following occurs:
Group fails to make full Premium payments;
Group violates, or refuses to comply with, the terms and conditions of this Contract;
Group violates or refuses to comply with any published KPS policies and procedures which have
been approved by the Insurance Commissioner;
~ there is a change to, or implementation of, federal or state laws which prohibits the continued
offering of this Group Plan; or
KPS replaces this Group Plan. In this case, the replacement plan will (i) include the services
covered under the replaced Plan; (ii) be offered to Group's eligible Employees and their Eligible
Dependents; and (iii) not significantly limit access to the kind of services covered under the
replaced Plan.
In addition, Group may terminate this Contract, at any time, by providing forty-five (45) days written notice
to KPS.
If this Group Contract terminates, for any reason, coverage for all Enrollees will end automatically on the
effective date of termination, or on the last day of the last month for which Group paid the Premium,
whichever occurs first. KPS will refund to Group any Premium paid in advance for periods after the
termination date.
In the case of termination or non-renewal of this Group Policy, Group shall be responsible for providing
the following information to all affected Employees and their Dependents:
> The effective date of termination of coverage; and
~ The reason(s) for termination or non-renewal.
Re-Enrollment/Reinstatement
If this Group Policy has been cancelled by KPS due to non-payment of Premium, Group automatically
forfeits all rights to guaranteed renewal of coverage afforded under the Health Insurance Portability and
Accountability Act (HIPAA) of 1996. Any decision to reinstate or reenroll Group is at the sole discretion of
KPS.
If Group voluntarily cancels this Group Policy prior to the Open Enrollment Period, KPS may, at its sole
discretion, impose up to a twelve (12) month waiting period before Group is eligible to reapply for
coverage.
City of Bremerton Plan C -2002 (~ Page 5
Termination of Enrollee Coverage
Coverage for an individual Enrollee under this Group Plan will end if any one of the following events
occurs:
Non-payment of any Premium amount, when Premium payment is the responsibility of the
Enrollee;
Non-payment of any Deductible or Copayment amounts owed to KPS by the Enrollee;
The Enrollee loses eligibility for coverage under this Group Plan;
The Enrollee commits a fraudulent act with regard to KPS and this Group Plan;
The Enrollee behaves in a manner that is threatening, disruptive or abusive toward a KPS
employee or a Provider;
The Enrollee refuses to comply with the terms and conditions of this Group Plan as described in
this Group Policy and the Benefits Booklet;
The Enrollee voluntarily disenrolls from this Group Plan;
There is a change in either state or federal laws which no longer permits KPS from offering this
Group Plan; or
> This Group Policy is terminated.
Additionally, Dependent coverage ends if:
The Subscriber is no longer employed or no longer meets eligibility requirements;
The Subscriber dies;
The Subscriber and Spouse divorce; or
The Child reaches the Limiting Age or marries.
Coverage ends on the last day of the month in which the Enrollee was eligible for coverage, provided all
applicable Premium amounts have been paid. In the case of non-payment of Premium, coverage ends on
the last day of the month for which KPS received a Premium payment.
Upon termination of coverage either KPS or Group shall issue a Certificate of Creditable Coverage
certifying the period(s) during which the Enrollee was enrolled in this Group Plan.
An Enrollee who loses coverage under this Group Plan may be eligible to continue coverage or enroll in
an individual conversion plan (see Continuation of Coverage).
A Subscriber who voluntarily disenrolls from this Group Plan is no longer eligible to re-enroll.
Continuation of Inpatient Coverage
An Enrollee who is receiving care as an inpatient in an Accredited General Hospital or other approved
facility on the date that coverage would otherwise end, is eligible to continue receiving benefits under this
Group Plan provided the following conditions are met:
~ KPS pre-authorized the inpatient care (see Prior Authorization of Inpatient Care); and
~' All applicable Premium amounts continue to be paid.
KPS will continue to provide benefits until one of the following events occurs:
The Enrollee cease to be an inpatient;
Three (3) consecutive months have elapsed since the date on which coverage would otherwise
have ended;
The Enrollee has exhausted the inpatient benefits offered under this Group Plan (annual renewal
of benefits does not apply under this provision);
The KPS Medical Director determines that inpatient care is no longer Medically Necessary;
The Enrollee enrolls in another KPS plan or in any other health plan which provides inpatient
hospital benefits; or
~ Non-payment of Premium amounts
Page: 6 City of Bremerton Plan C 2002
The Enrollee is not eligible for the extended coverage described herein if, when this Group Policy ends:
> The Enrollee is covered under any other group or individual medical plan with similar
inpatient benefits; or
> The Enrollee is eligible for continuation of coverage under COBRA or any other continuation
provision.
Continuation of Coverage for a Disabled Child
A Dependent Child who has reached the Limiting Age remains eligible for coverage under this Group
Plan provided both of the following conditions are met.'
~ The Child is primarily dependent upon the Subscriber or the Subscriber's Spouse for support; and
~ The Child is incapable of self-sustaining employment due to developmental disability or physical
handicap.
Proof of the Child's dependence must be submitted to KPS within thirty-one (31) days of the date the
Child reaches the Limiting Age. Thereafter, KPS may require resubmission of proof of the Child's
continuing dependence. Generally this proof is requested annually after the two-year period following the
Child's attainment of the Limiting Age.
A disabled Child will continue to be eligible for coverage until any one of the following events occurs:
Failure to submit proof of the Child's continuing dependence as a result of disability or physical
handicap;
KPS determines that the Child is no longer developmentally disabled or physically handicapped
(based on the evidence submitted);
The Subscriber is no longer covered under this Group Plan;
Non-payment of Premium; or
KPS terminates the Group Policy.
Coverage for a disabled Child ends on the last day of the month in which the disabled Child is eligible for
coverage, provided any applicable Premium amounts have been paid. In the case of non-payment of
Premium, coverage ends on the last day of the month for which KPS received a Premium payment.
A Dependent who is no longer eligible for coverage as a disabled Child may be eligible for coverage
under COBRA or a KPS conversion plan (see Continuation of Coverage).
CONTINUATION OF COVERAGE
COBRA (Consolidated Omnibus Budget Reconciliation Act - '1985)
Employers who are required by law to comply with the provisions of the 1985 COBRA act must notify all
eligible Employees, and their eligible Dependents, who lose eligibility for coverage under this Group Plan
of their right to continue coverage under this provision.
Eligible individuals are required to apply for continued coverage within sixty (60) days of the date
coverage under this Group Plan ends. Group is required to notify KPS of each individual's election of
COBRA continuation coverage within sixty (60) days of that election. Failure on the part of the eligible
individual to make a timely election, or failure on the part of Group to provide KPS with timely notification
of the election, will be interpreted by KPS as a waiver of the individual's right to continue coverage under
this provision. Failure by Group to provide timely notification to KPS may not, in all cases, eliminate
Group's obligation to provide continuation coverage. It will, however, eliminate any obligation on the part
of KPS to provide continuation coverage under this Contract.
City of Bremerton Plan C -2002 Page 7
Individual Conversion Coverage
Employees who are under age sixty-five (65) may be entitled to transfer to a KPS Individual Conversion
Plan if:
They are not otherwise eligible for coverage under Medicare;
They are currently eligible for continuation of Group coverage but have elected not to enroll in the
Group Plan;
~ Coverage under this Group Plan or a COBRA continuation plan has terminated (for any reason
except non-payment of Premium, when it is the individual's responsibility to pay the Premium); or
~ If this Group Policy terminates and Group does not provide other health care coverage to its
Employees.
Application for coverage must be made within thirty-one (31) days of the date coverage under this Group
Plan, or other KPS continuation or COBRA plan ends. Applicable Premium payments for the first month
of coverage must be submitted with the enrollment application
Dependents are separately eligible to apply for coverage under this option in the event they cease to be
eligible for coverage under the Group Plan due to the death of the Subscriber, or if the Subscriber and
Spouse divorce.
When an Enrollee enrolls in a conversion plan, he/she loses certain protections guaranteed under the
Health Insurance Portability and Accountability Act (H1PAA) of 1996. Most notably, if the Enrollee wants
to transfer to a non-conversion individual plan, he/she could be denied coverage based on a previous or
existing health condition. If the Enrollee does qualify for coverage under a non-conversion individual plan,
his/her coverage will be subject to any waiting periods for pre-existing conditions. For more information,
please contact KPS Member Services.
Employees who are age sixty-five (65) or older when coverage under the Group Plan terminates may be
eligible for coverage under a Medicare Supplement Plan. To determine Employee eligibility for a
Medicare Supplement Plan, please contact KPS Member Services.
COORDINATION OF BENEFITS (COB)
General Provision
Benefits are provided under this KPS Group Plan only to the extent that Subscribers and their enrolled
Dependent(s) could not have received benefits for the same service(s) under any other Plan, had a claim
for benefits been made. The purpose of this COB provision is to ensure that the sum of claim benefits
paid by KPS and all other Plans under which Subscribers and their Dependent(s) are covered does not
exceed 100% of the Allowable Expense. All of the benefits provided under this KPS Group Plan are
subject to this COB provision.
Definitions
"Allowable Expense" means the usual, customary or reasonable charge for any necessary health care
service or supply when the service or supply is a covered benefit, at least in part, under any of the Plans
involved. When a Plan provides benefits in the form of services rather than cash payments, the
reasonable cash value of each service provided shall be considered an Allowable Expense. The
difference between the cost of a private Hospital room and the cost of a semi-private Hospital room is not
considered an Allowable Expense under the above definition unless your stay in a private Hospital room
is considered to be Medically Necessary under at least one of the Plans involved.
Page: 8 City of Bremerton Plan C 2002
"Plan" means a policy or contract which provides benefits o~' services for, or because of, medical or dental
care, through one of the following:
This KPS Group Plan;
Any group, individual or blanket disability insurance policy;
Any group or individual contractual prepayment or indemnity plan such as those issued by health
care service contractors, health maintenance organizations or other health carriers or health
insurers;
Any labor-management trusteed plan or labor organization plan;
Any employer organization plan or employee benefit organization plan;
Any governmental program;
Any insurance coverage required or provided by statute, including automobile policies which
provide medical benefits; or
~. Any other similar source.
The term "Plan" does not include accident-only coverage, including athletic injuries, for school-age
children from kindergarten through twelfth grade (K through 12), or for college students, either on a 24-
hour basis or on a "to and from school" basis.
Each of the Plans under which you and/or your Dependents are covered, and each benefit payable under
those Plans, is considered separately when benefits are coordinated under this provision.
Claim Determination Period
The claim determination period means a Calendar Year.
Effect on Benefits
If, during a claim determination period, your Allowed Expenses incurred under this KPS Group Plan are
more than the sum of the benefits that would be payable under this KPS Group Plan in the absence of
this COB provision plus the benefits that would be payable under all other Plans in the absence therein of
similar COB provisions, then the benefits payable under this KPS Group Plan will be reduced so that the
sum of such reduced benefits plus all the benefits payable for corresponding Allowable Expenses under
all other Plans, does not exceed the total of such Allowable Expenses.
Order of Benefit Determination
When more than one Plan contains a COB provision, the decision as to which Plan is the primary Plan is
made in the following order:
The Plan which covers the person as a Subscriber rather than as a Dependent is primary;
When a Dependent Child is covered under more than one Plan, the Plan of the parent whose
date of birth (month and day only) occurs earlier in a Calendar Year is primary, except when the
Child's parents are legally divorced or separated.
~> When the parents of a covered Dependent Child are divorced or separated and there is no court
decree which establishes financial responsibility for the medical or dental expenses of the
Dependent Child, then benefits for the Child's Covered Expenses are determined as follows:
· the Plan of the parent with custody is primary, provided the parent with custody has not
remarried;
· if the parent with custody has remarried, the order for determining the primary Plan is:
(i) the Plan of parent with custody;
(ii) the Plan of the step-parent;
(iii) the Plan of the parent without custody.
Notwithstanding the above, if the court has determined which parent is financially responsible for the
health care of the Dependent Child, then the Plan of that parent is always the primary Plan.
City of Bremerton Plan C -2002 Page 9
When the above rules do not establish an order of determination, then the Plan which has covered the
person for the longer period shall be primary, except that:
> The benefits of the Plan which covers the person, on whose expenses the claim is based, as a
laid-off or retired Subscriber, or a Dependent of such a Subscriber, shall be determined after the
benefits of the Plan which covers that person as a Subscriber (other than as a laid-off or retired
Subscriber), or the Dependent of such a Subscriber; and
> if either of the Plans does not have a provision regarding laid-off or retired Subscribers, which
results in each Plan determining its benefits after the other, then the above provision shall not
apply.
If none of the above rules applies, the Plan that has covered the person for the longest period of time
shall be considered the primary Plan.
Facility of Payment
Whenever another Plan makes payments which should have been 3rovided under this KPS Group Plan
and in accordance with this COB provision, KPS may, at its sole discretion, choose to reimburse the Plan
making such other payments, the amount necessary to satisfy the intent of this COB provision. Any
amount paid under this subsection shall be considered as benefits paid under this KPS Group Plan, and
KPS shall be fully discharged from liability to the extent of such payments.
Right of Recovery
Whenever KPS makes payments that are in excess of the maximum amount of payment necessary to
satisfy this COB provision, KPS shall have the right to recover the excess payment amount from the
Enrollee, from the Provider, or from another Plan, as applicable.
Right to Receive and Release Information
As a condition of receiving benefits under this KPS Group Plan, Subscribers and their enrolled
Dependent(s) agree to provide KPS with any necessary information, and authorize KPS to release to or
obtain from any other insurer, organization or person, any information necessary to administer this COB
provision.
Disclosure of Coordination
Failure on the part of Subscribers and their enrolled Dependents to cooperate with KPS regarding this
COB provision could result in the loss of benefits under this Group Plan.
KPS recommends that Subscribers and their enrolled Dependent(s) submit claims to KPS, and each
other plan, at the same time to help minimize delays and facilitate claims payment.
KPS' RIGHT OF RECOVERY
Limitations and Exclusions
Coverage under this plan is excluded for expenses incurred or services rendered if your illness or injury is
caused (or alleged by you to be caused) by another party, to the extent that benefits are available under
the terms of any other insurance coverage or source of payment, including but not limited to:
Vehicle medical, personal injury protection ("PIP"), no-fault, uninsured or underinsured motorist,
workers' compensation insurance or benefits and third party liability insurance, or similar contract
of insurance;
> Homeowner's, property or any other insurance policy (except for individual or group health
insurance); or
> An agreement, judgment or settlement pursuant to which a third party pays or agrees to pay for
the costs of such services from assets other than a policy of insurance.
Page: 10 City of Bremerton Plan C 2002
This exclusion applies whenever any such contract of insurance, agreement, judgment or settlement is
issued to or provides benefits for you, whether or not you assert a claim against the responsible third
party or its insurers.
Third Party Liability: Reimbursement and Subrogation
In consideration for KPS' agreement to advance medical expenses involving a claim against a third party
or its insurers, you agree to make a claim against the responsible party and its insurers for any and all
amounts advanced by KPS. By providing benefits under this provision, KPS is fulfilling its obligations
under this Group Contract. However, by so doing, KPS does not waive any rights to reimbursement or
subrogation. Provided, the benefits of this plan will be advanced to you if you are injured by a third party,
before compensation is recovered from the third party or its insurers, only under the following conditions:
You, and your representative(s), must fully cooperate with KPS in recovering payment of medical
bills paid, and to be paid by KPS, from the parties who allegedly caused the injury or illness,
including but not limited to their liability insurance carriers, any applicable PIP, uninsured or
underinsured motorist policy, homeowners policy, workers compensation or any other reachable
assets of the responsible party or parties;
You notify KPS, in writing, of the details of the injury or illness, the names and addresses of the
parties believed to be responsible and the names and addresses of the responsible party's
insurers, if known;
Any claim or lawsuit filed by you against the third party or the third party's insurer(s) must include
a demand for repayment of benefits paid by, or to be paid, by KPS on your behalf; or
~ You must agree to assign to KPS your right to recover compensation for medical costs paid
(subrogation), or to be paid, by KPS as a result of injuries caused by the third party responsible
for the injury.
~ You must agree to reimburse KPS for the cost of medical care provided by KPS as a result of the
injury, from the settlement, judgment, insurance proceeds or other recovery obtained by you from
any third party or its insurers.
Collection and Reimbursement by Enrollee (or the Enrollee's Representative)
If you elect to demand payment for KPS' medical costs from the responsible third party, you must:
Notify KPS in advance of any settlement, mediation, arbitration or trial;
Inform the responsible third party and its insurer(s) of the amount of the lien asserted by KPS, for
the recovery of benefits paid on your behalf, against any recovery or potential recovery obtained
by you;
Obtain prior consent from KPS before compromising or settling claims involving medical costs
paid by KPS;
~ Not enter into any agreement with the responsible third party or its insurer(s), or do anything else
that would release KPS' lien or prejudice our subrogation or reimbursement rights, without first
obtaining express prior written consent from KPS;
~ Reimburse KPS for that portion of the settlement, award or judgment that is compensation for
medical bills paid and to be paid by us.
If you obtain a settlement or recovery for less than the insurance policy limits or reachable assets of the
liable party, you are obligated to reimburse KPS for the full amount of benefits paid on your behalf after
you have been fully compensated for your loss. If, however, you obtain a settlement or recovery that is
equal to or greater than the liable party's insurance policy limits or reachable assets, you are only
obligated to reimburse KPS in the amount that is left after you have been fully compensated for your loss.
You, or your representative(s), must obtain a written agreement from KPS prior to settling any claim if you
want KPS to share, on an equitable basis, any reasonable attorney fees incurred by you in pursuit of any
subrogation or reimbursement claim. In the absence of a prior written agreement, KPS, at its sole
discretion, will determine whether or not to reduce our reimbursement amount in order to share, on an
equitable basis, any reasonable attorney fees incurred by you. However, such a reduction will only be
considered if KPS has benefited from the services of your attorney. In no event will KPS' reimbursement
City of Bremerton Plan C -2002 Page 11
be reduced by more than twenty percent (20%) to offset attorney fees incurred by you, and KPS will not
pay for costs incurred by you.
Subrogation: Assignment of Third Party Claim to KPS
If you elect to assign your rights to KPS to pursue a claim seeking recovery from a responsible third party
or its insurer(s), you and your representative(s) must cooperate fully with KPS in pursuing the claim
against the responsible parties. Such cooperation includes, among other things:
Providing evidence and testimony consistent with the testimony in the case against the
responsible parties;
> Refusing to assist the responsible parties, in any way, in defending against a claim brought
by KPS; and
Cooperating with KPS by not taking any action that might release, limit, reduce, or otherwise
prejudice our efforts to pursue a claim against any responsible third party.
Trust and Cooperation Between the Enrollee (or the Enrollee's Representative) and KPS.
You and your representative(s) must deal in good faith with KPS by adhering to all of the conditions set
forth in this Section. In turn, KPS agrees to cooperate with you and your representative(s) in your effort to
recover reimbursement, and will advance payments on your behalf for injuries or medical conditions
caused, or asserted by you to be caused, by any third party. You and your representative(s) must
cooperate fully with KPS in protecting, preserving, and recovering the amounts KPS has paid or will pay
on your behalf under this Group Plan. Failure to cooperate may result in the denial of coverage for injuries
or conditions caused, or asserted by you to be caused by any third party, to the extent that coverage or
payment for such injuries or illnesses is, or would have been, available under the terms of any other
insurance coverage or source of payment.
Agreement to Arbitrate
Any dispute which arises between you and KPS as a result of the preceding recovery provisions shall be
settled through arbitration. Both you and KPS shall be bound by the decisions of the arbitration
proceedings.
Disputes will be presented to, and resolved by, a single arbitrator, in accordance with the current rules of
the American Arbitration Association. Either you or KPS may demand arbitration by serving notice of this
demand on the other. Each party to the arbitration agrees to bear its own costs and to share equally in
the fees of the arbitrator. This agreement to resolve disputes through arbitration is in effect as of the
effective date of the Group Policy, and shall remain in effect until the dispute between us has been
resolved.
Recovery of Claims Payments
Ineligible Persons
If KPS knowingly or unknowingly makes any payment on behalf of an individual who for any reason was
not eligible to receive the services and benefits provided herein, KPS is entitled to full reimbursement
from such ineligible individual or from a Subscriber who applied for the ineligible benefits on behalf of
such individual.
If KPS knowingly or unknowingly receives Premium payment on behalf of an individual who for any
reason was not eligible to receive the services and benefits provided herein, KPS reserves the right to
refund any Premium payment(s) in excess of claims paid for the time the individual was ineligible, and
shall have the right to recover the cost of any benefit furnished while such individual was improperly
enrolled in this Group Plan.
Page: 12 City of Bremerton Plan C 2002
Incorrect Claim Payment
KPS is entitled to full reimbursement from the payee for any incorrect claim payment. The term "incorrect
claim payment" includes but is not limited to the following:
Payment to the wrong Provider;
Payment of an incorrect amount;
Payment for a service that is not a Covered Benefit or Service;
Duplicate payment for the same service;
Payment on behalf of the wrong Enrollee.
SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS
Subscriber/Dependent Liability
Subscribers and their Eligible Dependents who are enrolled in this Group Plan are liable for the following
costs:
Deductible
Copayments
Charges for non-covered services
Coinsurance, up to the Coinsurance Stoploss limit defined in the Benefits Booklet
Charges incurred after an annual or lifetime maximum benefit for a specific service or supply has
been exhausted (such as the annual maximum benefit for durable medical equipment)
~> Charges in excess of the amount paid by KPS to non-participating Providers
If KPS fails to reimburse a Participating Provider for the cost of Medically Necessary Covered Services
provided in accordance with the terms of this Contract, neither the Enrollee nor Group shall be required to
compensate the Participating Provider for such services beyond the limit of Deductibles, Copayments or
Coinsurance amounts specified in the Benefits Booklet.
KPS will continue to reimburse a Participating Provider for Medically Necessary Covered Services
rendered to an Enrollee after the Participating Provider's contract with KPS has ended, for such time as
the Enrollee remains covered under this Group Contract, until (i) the Enrollee's course of treatment has
been completed, or (ii) the care of the Enrollee has been appropriately transferred to another Participating
Provider. The KPS Medical Director is responsible for determinations regarding the completion of a
course of treatment and the transfer of patient care.
KPS Privacy Policy
Privacy Policy
The State of Washington enacted RCW 48.43.505 which implements the federal Gramm-Leach-Bliley Act
(P.L.102-106), sections 501(b) and 505(b)(2), and expands the requirements to cover the protection of
health information privacy. This law requires health insurance carriers in Washington State to provide its
Enrollees with information regarding privacy policies and proc=~dures. The following is our privacy notice
to our Enrollees.
Non-Public Personal Information means information about our Enrollees that KPS collects in conjunction
with providing health care products or services to our Enrollees. Non-public Personal Information does
not include information that is available from public sources such as telephone directories or government
records.
City of Bremerton Plan C -2002 Page 13
KPS collects the following types of Non-public Personal Information about our Enrollees:
Information provided by Enrollees on coverage application forms and any other forms
completed as a result of enrollment in a KPS Health Plan;
> Information we receive from health care Providers or other companies, such as other health
insurance companies, related to medical claims and billing; and
General information about the health care services received by Enrollees, such as the quality
and availability of services.
KPS does not disclose Non-public Personal Information about our Enrollees or former Enrollees to
anyone, except as permitted or required by law. KPS restricts access to Non-public Personal Information
about our Enrollees to only those employees who need to know that information in order to provide
products and services to our Enrollees. KPS maintains physical, electronic and procedural safeguards
that comply with federal regulations to guard all Non-public Personal Information.
KPS' Right to Receive and Release Medical Information
As a condition of receiving the benefits and services provided under this Contract, Subscribers and their
enrolled Dependents, including their heirs, executors, ad ministrators and assigns, authorize the Provider,
Hospital, other health care insurers, organizations or persons to:
(i) Release to KPS any medical information necessary for the administration of this Contract;
(ii) Allow the KPS Medical Director to examine, or have examined, any medical, hospital or other
facility records pertaining to the Enrollee; and
(iii) Present medical, hospital or other facility records pertaining to the Enrollee in any civil action in
which KPS is a party, expressly waiving any objections to such presentation.
COMPLAINTS AND APPEALS PROCESS
Complaints
All Enrollees have the right to contact KPS whenever they have a question, complaint or concern
regarding benefits, access to care or how to arrange for care, any KPS Participating Provider, the service
they receive from KPS, or any other issue related to this Group Plan or KPS. In the event an Enrollee has
a complaint, KPS Member Services Representatives are available Monday through Friday, from 8:00 a.m.
until 5:00 p.m. Pacific Time, except on nationally recognized holidays. If the complaint cannot be resolved
by a Member Services Representative, Enrollees may choose to file a complaint, or request an appeal, if
they are not satisfied with the Member Services response.
The following steps outline the procedure for filing a complaint:
EITHER
A KP$ Member Services will
The service provided by KPS Send a written statement of work with the Enrollee and try
the complaint to: to resolve the complaint over
Eligibility
KPS Health Plans the phone. Otherwise, KPS will
Coverage or Benefits Attn: Complaint Resolution send a written response within
Claims Payment PO Box 339 30 days of receiving the
Bremerton, WA 98337 complaint.
Access to Care
Quality of Care OR Complaints about Participating
Providers are investigated
KPS Participating Providers Call KPS Member Services at thoroughly and are reviewed
360-478-6796 periodically.
or toll free at 1-800-552-7114
Page: 14 f~ City of Bremerton Plan C 2002
Standard Appeals Process
Enrollees have the right to appeal any decision regarding a complaint or any aspect of their health care
coverage which is not in their favor. Such decisions could affect:
The service received from KPS;
Access to health care services or Providers;
Eligibility for coverage;
Benefit coverage;
Termination of coverage under this Group Plan (except termination for non-payment of
Premium);
Non-payment of a claim, either completely or partially;
A denial or modification of a request for pre-authorization of any health care service or
supply; or
> A denial of a request for coverage of an experimental or investigational service or supply.
To file an appeal, the Enrollee, his/her designated representative, or his/her Provider may either call or
write KPS at the phone number or address listed above. Any documentation supporting the Enrollee's
position may be included with the appeal.
KPS will notify the Enrollee in writing that the request has been received. Included with that notice is
additional information regarding the Appeals Process and the Enrollee's rights and responsibilities during
an appeal. An Enrollee has the right to send his/her appeal directly to an Independent Review
Organization (IRO) if KPS does not respond to him/her within the allotted time period, as follows:
Decisions Regarding: Days to Respond:
Service-Related Appeals 30 Days
Denials of Experimental and/or Investigational Procedures 20 Days
or Supplies
All other Adverse Determinations 14 Days
Expedited Appeals Process
If the Enrollee's health care Provider, or the KPS Medical Director, reasonably determines that the
Enrollee's life, health, or ability to regain maximum function would be jeopardized by following the
Standard Appeals Process, KPS will bypass its internal appeals process and forward the appeal directly
to an Independent Review Organization (IRO) within 72 hours after it is received. If KPS expedites the
appeal, the Enrollee will receive notice of this action.
GENERAL TERMS AND CONDITIONS
Applicable Law
This Contract shall be governed by, and construed in accordance with, the laws of the State of
Washington. Venue for this Contract shall be Kitsap County.
Assignment of Benefits
The benefits of this Contract shall accrue to Subscribers and their enrolled Dependents. Neither this
Contract, nor its payments or Covered Benefits and Services are assignable to a third party. KPS
reserves the right to make benefit payments to the Subscriber, the Provider, or jointly, as KPS deems
necessary and appropriate, subject to federal and/or state laws.
Binding Agreement
This Contract is binding on KPS and Group, and their respective executors, administrators, successors
and assigns. By election of coverage or payment of applicable Premiums, or if Group's Subscribers or
City of Bremerton Plan C -2002 ,~ Page 15
7
their enrolled Dependents seek the services provided under this Contract, all of the terms, covenants and
conditions contained herein shall become valid and binding on Group and its Subscribers and enrolled
Dependents, notwithstanding the failure of Group to sign this Contract.
This Contract shall not bind KPS until (i) it has been executed by a person authorized by KPS, and (ii) an
executed copy has been delivered to Group.
Confidentiality
The underwriting and financial terms of this Contract are confidential and shall not be disclosed except as
is necessary for the performance of this Contract, or as required by law.
Contract Modifications
Except as set forth under Premium Rate Adjustments, KPS reserves the right to modify the provisions
of this Contract, or the services described in the Benefits Booklet, upon forty-five (45) days written notice
to Group. Group may elect to reject such modifications by providing KPS with fifteen (15) days written
notice. However, rejection of a modification will result in the termination of this Contract as of the last day
of the month for which Premium payment has been received. Lack of notification of rejection by Group
shall be interpreted as acceptance of the modification and this Contract will be renewed as modified.
No modification of this terms of this Contract shall be binding upon KPS unless endorsed, in writing, and
signed by an authorized officer of KPS. Such endorsement shall be deemed a part of this Contract,
effective as of the effective date of the endorsement. Any amendment or Contract modification required
by law or regulation shall become effective as of the effective date required by such law or regulation.
Coverage Limits
The Covered Benefits and Services offered under this Contract are subject to the coverage limits and
maximums set forth in the attached Benefits Booklet.
Entire Agreement
This Contract, together with Attachment A: Benefits Booklet; Attachment B: Premium Rates and
Underwriting Criteria; and any riders and/or endorsements attached hereto, constitute the entire
agreement. This Contract supersedes all previous communications, representations or agreements,
either verbal or written between KPS and Group, with respect to the subject matter herein.
Equity of Application
This Contract is intended to apply equally to all Enrollees.
False or Misleading Information
If Group provides statements or other information on the Group Master Application form, or any other
form required by KPS, that affects the acceptability of Group for coverage, or the risk assumed by KPS for
providing coverage, KPS may, at its sole discretion, elect to immediately terminate this Group Contract
and recover any claims and/or administrative costs from Group, Enrollee, or any other person(s)
responsible for providing the false or misleading information.
Force Majeure
In the event KPS is unable to perform its obligations hereunder by reason of fire, casualty, lockout, strike,
labor condition, riot, war, act of God or by ordinance, law, order or decree of any legally constituted
authority, then this Contract may, at the option of KPS, be suspended. During any period of suspension,
KPS shall not be required to perform any service hereunder, nor shall KPS be liable for any damages
arising from any event which precipitated the suspension. If this Contract is suspended pursuant to this
provision, any obligation by Group and/or an Enrollee to make Premium payments shall also be
suspended for the same period of time.
Page: 16 /,, City of Bremerton Plan C 2002
Group Cooperation
Group agrees to cooperate with KPS in the administration of this Contract by:
(i) Advising Subscribers and their enrolled Dependents of policies and procedures applicable to this
Group Plan;
(ii) Providing Subscribers and their enrolled Dependents with a Benefits Booklet, ID cards and any
applicable notices or other information regarding this Group Plan;
(iii) Providing information about Enrollees which is relevant to the determination of eligibility, claim
reimbursement, coordination of benefits or other information required for the administration of this
Contract; and
(iv) Making appropriate payroll deductions, if applicable, to facilitate Premium payment.
Headings
The headings of sections and paragraphs in this Contract are for convenience and reference purposes
only and do not affect in any way the meaning or interpretation of any provision of this Contract.
Limitation of KPS Liability
Nothing contained within or omitted from this Contract shall be construed as a promise by KPS to perform
any service hereunder. In no case shall KPS be liable for any negligence or other wrongful act or
omission of any Provider, Hospital or other facility, or their employees, or any other person. Nothing in this
provision shall be construed as relieving KPS from liability for failure to make any payments required to
be made under the terms of this Contact.
Nothing in this Contract shall be construed to require KPS to provide coverage for services rendered to
any person after the termination of coverage for such person, or after the termination of this Contract.
Notices
Any notice which may affect the provisions of this Contract shall be deemed delivered to Group when
deposited in the United States mail with prepaid postage, addressed to Group at the most recent address
listed for Group. Any notice which may affect the provisions of this Contract shall be deemed delivered to
KPS when deposited in the United States mail with prepaid postage, addressed to KPS at the following
address: P.O. Box 339, Bremerton, WA 98337-0039.
Any requirement of KPS to provide notice to Enrollees shall be fulfilled when Group has received such
notice. It is the responsibility of Group to disseminate notices to Enrollees within thirty-one (31) days of
receipt.
Severability
If any term, provision, endorsement or condition of this Contract is deemed invalid or unenforceable by a
court of competent jurisdiction, the same shall be deemed severable from this Contract. However, the
remainder of this Contract shall remain in full force and effect and shall in no way be affected, impaired or
invalidated as a result of such decision.
Third Party Beneficiaries
There are not third party beneficiaries to this Contract.
Waiver of Breach
Waiver of a breach of any provision of this Contract shall not be deemed to be a waiver of any other
breach of the same or different provision.
City of Bremerton Plan C -2002 /, ~) ( Page 17
KPS Health Plans, In Rehabilitation
400 Warren Avenue
P.O. Box 339
Bremerton, WA 98331-0039
City of Bremerton - Coverage Contract-
UNDER 65 LEOFF I RETIREES (SUBSCRIBERS ONLY)
Group Name: City of Bremerton Group Number: 21001-21006
Effective Date: 1/1/2002
Renewal Month: January
Open Enrollment December
This Coverage Contract includes the following:
Attachment A- Benefits Booklet
Attachment B - Premium Rates and Underwriting Criteria
Riders: N/A
Optional Riders: N/A
Endorsements: N/A
This Contract is entered into and delivered in the State of Washington and is governed by Washington
State laws, except to the extent state laws are preempted by federal law.
Signature by a qualified Group representative or payment of the Premium shall constitute acceptance of
the terms and conditions set forth herein.
FOR KPS: FOR GROUP:
Elizabeth A. Gilje, President Signature
Print Name
Title
Date
KPS Health Plans, In Rehabilitation
400 Warren Avenue
P.O. Box 339
Bremerton, WA 98331-0039
City of Bremerton - Coverage Contract-
UNDER 65 LEOFF I RETIREES (SUBSCRIBERS ONLY)
Group Name: City of Bremerton Group Number: 21001-21006
Effective Date: 1/1/2002
Renewal Month: January
Open Enrollment December
This Coverage Contract includes the following:
Attachment A- Benefits Booklet
Attachment B - Premium Rates and Underwriting Criteria
Riders: N/A
Optional Riders: N/A
Endorsements: N/A
This Contract is entered into and delivered in the State of Washington and is governed by Washington
State laws, except to the extent state laws are preempted by federal law.
Signature by a qualified Group representative or payment of the Premium shall constitute acceptance of
the terms and conditions set forth herein.
FOR KPS: FOR GROUP:
Elizabeth A. Gilje, President Signature
Print Name
Title
Date
!o3
KPS Health Plans, In Rehabilitation
400 Warren Avenue
P.O. Box 339
Bremerton, WA 98331-0039
Attachment B
Premium Rates and Underwriting Criteria
For
City of Brernerton
Premium Rates
plan:A Rates EEOFF I Active sPOUse O/~ph~d tnls
$50 Deductible/Person
$100/Family 282.42 205.08 227.33 102.67 82.63
,~ OiA D~P~dents
$50 Deductible/Person
$100/Family 739.04 404.87 101.01 80.73
an I~l~a=es upouse .;~,nua OIA Dep~:dents
: .. : : : ACtive: ,,,,:.LEOFF!,!~ACtiVe,, : : ~: : : : ::
$100 Deductible/Person
$300/Family N/A 177.34 198.64 90.37 70.32
p ~ st ~ 2 Child
lan B Rates LEOFF I Retirees . Spouse I Child _~,~ ~ ~;
$100 Deductible/Person
$300/Family N/A 336.27 85.48 69.11
Additional Financial Arrangements:
Individual Stop Loss at $75,000 - $6.72pmpm charge
Administrative Expense- $22.32pmpm
Statutory Reserve Charge- $2.25pmpm
2003 Administration Increase Maximum - 5% from 2002 figure of $22.32 pmpm to $23.44pmpm for
contract year 2003
Underwriting Criteria
The Premium rates quoted above for this Group Plan are based on the following underwriting criteria.
KPS reserves the right to withdraw or rerate this offering if Group falls outside the scope of these criteria.
Active, full-time Employees must work a minimum of thirty (30) hours per week unless otherwise
negotiated and agreed by both KPS and Group.
~ Subject to prior KPS approval, two (2) or more health insurance carriers, including KPS, may
provide coverage to Group's Employees.
:~ Subject to prior KPS approval, Group may select multiple KPS health plan offerings.
The minimum level of participation required is seventy-five percent (75%) of eligible Employees,
excluding those employees that may be on an HMO plan.
Unless otherwise approved by KPS, no more than twenty-five percent (25%) of Group's eligible
Employees may reside outside of the KPS service area. The KPS service area is defined as
Kitsap, Jefferson, Mason, Clallam, Thurston, Grays Harbor, Pierce and King counties.
KPS reserves the right to rerate Group in the event actual enrollment fluctuates by ten percent
(10%) or more from the census provided to KPS by Group at the time Group was initially rated.
to5
AGENDA BILL
BREMERTON CITY COUNCIL
1. SUBJECT_ .~__blic Hearing ~4~70 FOR AGENDA OF: July 31,, 2002
Resolution #._a~,.~~, regarding re~o~r~'offees for ORIGINATING DEPT.: Fire Dept.
removal ofvege~tion on the listed properties. ORIGINATOR: Al Duke
DATE SUBMITTED:
2. CLEARANCES,..' ,(Comment on back if 3. EXHIBITS:
Fire Chief: { ~ 1. Resolution #
City Clerk: ~_,_~,0r.t-~-~ 2. Property Ide~ication List
City Atty: . ~ 7)
..... ~ -~- ~ ..~ 3. Photos
ENDORSEME~..~ IN?~N __ APPROVED BY COUNCIL PRESIDENT FOR SUBMITTAL:
4. SUMMARY STATEMENT AND REQUIREMENT FOR COUNCIL ACTION:
Ordinance #4584 declares that it is ~mlawful and a nuisance to allow, continue, or maintain grass and weeds exceeding
twelve (12) inches in height, shrubs, brush, vines or trees which constitute a fire hazard or provide a harborage for rats,
rodents or horticultural pests, or noxious and poisonous plants. The listed properties are currently in violation of the
ordinance and pursuant to Section 9.14 of the Bremerton Municipal Code. The legal requirements for notice were met.
Council is asked to approve the removal of the nuisance vegetation on the property and collection of the costs incurred by
personal judgment against the owner and a lien against the property.
RECOMMEND*TION:~-7 ~' g ~J~O
I move that Council pass Resolution ~, ordering that the nuisance vegetation on the
properties identified by the attached listingbe~[~moved by the City with fees incurred collected as
reasonable abatement costs, which shall become a personal judgment against the owner and a lien
against the property] t~' ~tft~e~(
9. RESPONSIBLE OFFICIAL: A! Duke
ENFORCEMENT OFFICIAL: A! Duke
EXPIRATION DATE: N/A
REVIEW DATE: N/A
10. NOTICE OF ACTION
PULLED TABLED APPROVED DISAPPROVED AMENDED _~_~
COUNCIL DIRECTIVE: DATE:
11. AGENDA BILL NO.:
2. CLEARANCE COMMENTS:
5. IMPACT OF NON-PASSAGE:
Ordinance #4584 would not be enforced and nuisance vegetation would continue to thrive in the
City of Bremerton.
6. IMPACT ON STAFFING~ BUDGETS~ FACILITIES~ EQUIPMENT OR OTHER RESOURCES-
The City's revolving abatement fund would suffer the deficit of not collecting these funds.
7. RESEARCH SOURCES:
N/A
RESOLUTION NO. ~ ~
A RESOLUTION of thc City Council of the City of
Brcmcrton, Washington, approving nuisance vegetation abatement
on thc properties listed in Exhibit A and determining means of
collection of costs incurred for its removal.
WHEREAS, the City of Bremerton passed ordinance #4584 in February of 1997, which
declares certain vegetation a public nuisance, a fire hazard and a menace to public health,
safety and welfare and requiring its abatement; and
WHEREAS, Section 9.14 of the Bremerton Municipal Code allows the City to
remove nuisance vegetation and recoup the costs by personal judgment against the property
owner and as a lien against the property; and
WHEREAS, the City Council is charged with determining whether the vegetation
is a nuisance and whether it shall be removed and has considered the report filed by the Building
Official and any protests or objections filed; NOW THEREFORE,
THE CITY COUNCIL OF THE CITY OF BREMERTON, WASHINGTON,
DOES HEREBY RESOLVE AS FOLLOWS:
SECTION 1. That the vegetation show to exist on the properties listed in
Exhibit A attached hereto and incorporated herein is hereby declared to be a nuisance.
SECTION2. That the City of Bremerton will exercise its right to remove said
nuisance vegetation and recapture abatement fees by pursuing a personal judgment against the
property owner and filing a lien against the property.
SECTION 3. Severabilit~. If any one or more sections, subsections, or
sentences of this Resolution are held to be unconstitutional or invalid, such decision shall not
affect the validity of the remaining portion of this Resolution and the same shall remain in full
force and effect.
Declaration of Nuisance
SECTION 4. Effective Date. This Resolution shall take effect and be in force
immediately upon its passage.
PASSED by the City Council of the City of Bremerton, Washington this __
day of ,2002.
CAROL ARENDS, Council President
APPROVED AS TO FORM: ATTEST:
'~)GER A. -~UBOVICH, City Attorn' ye-~" KATHLEEN MCCLUSKEY, City Clerk
R:\LEGAL\Resolutions\Nuisance (2867).doc
Declaration of Nuisance
WEED ABATEMENT LISTING
JULY 31, 2002
ADDRESS OWNER
1. 802 Broadway Ave. Angelo Jones
802 Broadway Avenue
Bremerton, WA 98337
2. 1704 N. Callow Ave. Bank of America, N.A.
I0I E. Main St.
Louisville, KY 40202
. 2107 N. Callow Ave. Shirlee A. Harrison
~z~r2ezYt//__ P.O. Box 202783
Denver, CO 80220-8783
4 107 S. Cambrian Ave. Santiago Saavedra
107 S. Cambrian Avenue
Bremerton, WA 98312
5. 241 S. Cambrian Ave. Gary Atnip
1232 Audrey Avenue
Bremerton, WA 98312
6. 3021 Eagle St. Alvina Kratcha
651 Finley Gulch
Colville, WA 99114
7. 3107 Eagle St. Alvina Kratcha
651 Finley Gulch
Colville, WA 99114
8. 2222 Eastview Ave. Mitzi Grade
7697 Beardsley Avenue NW
Gig Harbor, WA 98335-8379
9. 2711/2713 Hefner St. James B. Hartstrom
P.O. Box 838
Cemralia, WA 98531
EXHIBIT A
I 0. 602 Sheridan Rd. Daniel and Paula Milovich
518 Sheridan Road
Bremerton, WA 98310
11. 1014 Veneta Ave. D.K. Shaw
1014 Veneta Avenue
Bremerton, WA 98337
12. 1014 Warren Ave. Mrs. George A. Perkins
1014 Warren Avenue
Bremerton, WA 98310
. 1300 Blk Warren Ave. Jewell and Patricia Severson
P.O. Box 475
~ gE'--O"~/~O/2/9p~ Bremerton, WA 98337-0116
EXHIBIT A
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