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Home My WebLink About3158 +--------------------------------------------------------------------------+ ==Enter Search Criteria, Press Esc Key to Transmit =1= ==Press Del Key to Terminate Delete Mode =1= -- CHANGE Contract Transactions =1= =1= Contract Number 3158 =1= =1= =1= =1= =+= = =Vendor Name ==Subject =.=Departmen t =l=Status Code KPS HEALTH PLANS MEDICAL BENEFITS HUMAN RESOURCES EMP (FORMERLY KITSAP PHYSICIANS) - EMPLOYEES Comments FILE CLASSIFICATION CHANGED PER 11-2 MEDICAL INSURANCE PLANS C/o $450000.00 01/01/1990 12/31/2005 02/15/2005 -.- =1= =1= =1= =1= =1= =1= =1= =1= =1= $0.00 =1= Insurance Type Amount Amount Begin Date End Date Review Date =1= Insurance Total Insurance Review Date =f= =1= +--------------------------------------------------------------------------+ +--------------------------------------------------------------------------+ 9=Browse: Next Previous First Last Update Delete Restart X - Exit 9= tUPdate current record MAINTAIN Contract Transactions t 9= Contract Number 3158 9= 9= 9= 9=Vendor Name KPS HEALTH PLANS (FORMERLY KITSAP PHYSICIANS) 9= 9=Subject MEDICAL BENEFITS - EMPLOYEES 9= 9=Department HUMAN RESOURCES 9= tStatus Code EMP 9= Amount $450000.00 9= 9= Begin Date 01/01/1990 9= 9= Insurance End Date 12/31/2005 9= 9= Type Amount Review Date 11/01/2005 9= 9= 9= 9= 9= 9= 9= 9= Insurance Total $0.00 9= 9= Insurance Review Date 9= 9= 9= 9= Comments 9= 9= 9= 9= 9= +--------------------------------------------------------------------------+ I<pS Health Plans, \n Rehabilitation 400 Warren Avenue P.O. Box 339 Bremerton. W A 9B337 ~o039 CONlRACI ENOORscMENI T"is Eodorsemeot applies 10 the Group cootract lor Cit'i 01 BremedoO - plao ". I GroUP contract as shoWo 1. please re",se the folloWing language on page 5 0 your be\oW: court.Ordered coverage .' Plao io wr'"i09, maY subSequeotly applY emplOyees w\'1O declined initial eorollme1t.~t~s g;~~deo\S io toe eveot toeY are re~lfedd to lor cOverage lor \\\emseIVes and tOelf . IgI eodent C"ild as a result 01 a cou .or er. provide "ealt" care co""r~~ r~e~ested wit"io t"irtY.ooe (3\) da~ MPlicatlOn lor eorollOleot '11 b eff~te as 01 t"e court order. date 01 \\\e court order. Covera e W' e . \ ge ,n the Co'Vera 2. Please re"ise the folloWing angua 5 of )lour Group contract: A.. lNaitlng periods (ThiS sectioO does 001 applY to LEOFF \ EmplOyees) p EXisting condHions .1 .... . d 01 three (3) consecutNe mon\\\S be ore 'Iou mus\ \)e enrolled io t"is Group pI~o 1.0;. a P~~~dnion. "pre-e,isting coodition is any ;<'PS will provide. \)enelllS lor a pre eXiS ,n? dvice during tne toree (3) moot" """od cOndition lor ""''''" you receNed medIca ~rou plan or lor Which your proVIder imOledialely preceding eorollOlent ;" g;:~e\\c inl~rma\\o~ soall oat \)e traated as a pre- recommeoded or prov,ded traatOlen. d' . 01 \t1a cOndition ralated to tne spaollc a",.ting cOodition unless t"era has beeo a ,agnOSIS genatic iolormatlOO. b r 1 monthS 01 credi\3bla d d nowaver bj \t1a num a 0 . . T"is waiting ceriod may ba ra uce ' 'ara ro rams prior to yOUr enrollmant In \t11S covarage YOU "ave accrued undar o;~ar oaalto ~iod~ J o\\\er nealto covaraga aO Eorollee Group plan. .credllllbla coverage . mean:ri~S Toase include groUP neal\t1 coverage; 0I'i" Plan; ~ oigo ris~ pool; lederal or publIC oea t . P , . I covaraga ij it CO"eraga. 'IoU wll receive credIt lor p"or credl~:e toree (3) mooto~ ~ ~ \\1& waS cootioUOUS aod termloallld no more ao .' . 1'10 ~ enrollment in 10iS GrouP plan. to (3) OIon\t1 brea~ in coverage between your creoll will be g",eO ij lnere. was more \\\ao: e~~~o toi. Group plan. MY employer imposed prior plan aod ~enr~ :brea~ in coverage or credi\llble coverage. probatiooary celiod will oat be COnSl ere a\eC 13\\\.1- --- ~ l'W al.UeN W\-Id ~:neC .M/ 900'0 'L'0 fJenuer a.lNeu6\S W8P\S8.ld 'a\l\8 "\j 1.-\\8qez\\,3 ~-'fJ~ :Sd)\ 'l:i0~ "U\8.lal.\ I.\VO} 10S sUO!\!puoo pue sUlle\ .~\;o ,",ueld-e .100qSUOO lIe~s ",!W\u.sa,d.' doo)B pOlJ\leob e I.q OJO\euBIS I. W Sd)\ '\'le; leU.lew;O \u.W.leISSIW -pe'\Uo:) sl~\ .WU!UU'l\ 1.10\e!P"WW! 0\ 10.'. 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Q) ~~ <t "'g CCO- (.) ~E.~.o -- u.l t/l . '.c N I- or-' B. . provider Of Hospita\ ChOosing a .. roviders wnO contract directlY with \<.pS as well. as participating pro'i\ders Include tnOSe p N K (FC\-lN) pfOvidence prelefled pfO'i\de' F Cn. e \-lealtn etwor' ,d providers In tne IfS" OIC ,ne lol\owing list provides general loCO IOns an organiZation and lIIumPlan NetworK. ,ons - e'lst~ networKs 01 participating prov:ders. \-lowever,~;Z'~ 'and ,nurston counties. For a cuflent and FC\-lN contract Vli\I1 ro'i\ders In Gra ~ \<.pS at ;.BOO-55Z-7;;4, or visu our webslte at listing 01 providers In your area, please ca ~: th d of the "Choosing a pro"ider or Hospital" C. Add the folloWing language at e en section. , P vlder nO longe' partlclpales Vlith t<PS? What happens If "'Y ,0 .. ment wun \<.pS Vie will notilY 'JOu . . h to te",\lnate tMIf agree ' . \I your participating provIder Gooses. at lellst s"':-i (60) da'JO to ellMr (I) complete your 01 tne termination. ,ne notlllcatlon Will alloVl I r care to anotner partiCIpating provider. course 01 treatment, or (iI) appropnatelY ~rf"s er ~~~vlder wOo nas terminated tMlr agreement Nter tOO s'riri (60) da'JOd se~~c~ ~~;~~~CIP:~; provider \)eneft\ level. VlIIn \<.pS ",,\I \)e covere at e 0 o t I poCl<et costs sadion on page S: 3. please add the folloWing language to the '(our u.o' . d Reinstate",ent of Benefits \.lfetime t/oa",mum an bl benall 01 eacn Enrollee during tOO ,ne IlIetlme m""lmUm Is too tolal amount 01 \)eneflts par I=n~n VlUn KPS. \-loVleVer, eacn year, at IndWidual'S IlIetime under this GrouP. Plan and a~\ P;~rd~M \lIe"me ma,lmum. ,nlS reinstatement reneVIal, 1M reinstatement amount Villi be r~;o~e om""lmum sucn as organ transplants and sleep does not applY to benefits vJl\n a separate I elme disorders. $1,000,000 per E.nro\\ee u{etime M3)C.irnurn 6ene{it Up to $5,000 par Enrollee per calendar year "nnual Reinstatement 01 Beneflls 4. please re"lse the following benefit language in the ~ on page 11 of your Benefits Bool<let: . ' . r benel\t5 and se",lces. at the Indicated j{p5 pro.ldes tM following Medl,callY ~~~J are not subject to the annual Oeductlble, reimbursement percen\3ge. aenellts pal a 100% 100% 100% 100% See prolesslonal & \-los lIalSe",ices ~ ~ ~ N...... '0"'0 (") m )> 1>>"'0 co ""-J 1>>;;' . -- .' ", .....(1) cg ~ -g.!}l ~;!:: v v v v v v () (')"'0 f (f)"'O Ule CD ~. () ("))>0. en ~ !U~"O(f):I: (J) ,... - OO::T"O::T 00000. v. :::l tll ro ro CD W (1) ~ g tll a. ~ <: I>> ~ (I) Q: (ii' 3 <CD 0 a. 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'tI ::r;i 3m CD - 0 ~ ~ 0 r- 0 ;;! ::r -oS' < "" 0 l> '" ~Q rom CD 3" 0"> iD m OJ co z '" "- co ~ :i'-c IT S- CD 0 . '" '< ~ '< -::;: I ~. 3 ~'" r CD CD g}. m iii" 3. i>> 5" 0 " -co " o iU- - ?E g - m - '" 3 ::r '" ::J "to a. 6" "tl (ii" '< ~ CD '" co CD 3 0 00 c' < CD t 3 3 CD m "- ::r rr ~ '< n ::;: 0 '" " 00 III ::r - ::J ;:;: co c 0" - '" ::J . . KPS Health Plans, In Rehabilitation 400 Warren Avenue P.O. Box 339 Bremerton, WA 98337-:0039 CONTRACT ENDORSEMENT This Endorsement applies to the Group Contract for City of Bremerton - Under 65 LEOFF I Retirees 1. Please revise the following language in the Continuation of CoveraQe section, page 9 of your Group Contract: COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) If you lose eligibility for coverage under this Group Plan (except in the case of a labor dispute), you may be eligible to continue your coverage for a period of time specified by federal law and regulations then in effect. This continuation of coverage is referred to as COBRA and applies generally to groups of twenty (20) or more employees. Continuation of coverage under COBRA is not automatic. You must apply for continuation of your Group coverage within sixty (60) days of the effective d3te of tormination ofcover3ge under this Group Plan date your Group provides you a COBRA election notice. 2. Please delete the entire paragraph entitled "False and Misleading Information language in the General Terms and Conditions section, page 19 of you Group Contract and replace with the following: Misrepresentation, False or Fraudulent Information If the Group provides statements or other information on the Group Master Application form, or any other form required by KPS, that constitutes intentional misrepresentation or fraudulent misstatement of material fact, KPS may elect to immediately terminate this Contract. Signature by a qualified Group representative shall constitute acceptance of the terms and conditions set forth herein. FOR KPS: FO~ gc ~<A.~ ~ Elizabeth A. Gilje, President Si9~ 't?P 2'"EMt/""v March 24, 2005 1/1;21 Date Print Name /J1J1- if=n- Title . ?)~~5--- Date CITYRETGC-END-2005 . . KPS Health Plans, In Rehabilitation 400 Warren Avenue P.O. Box 339 Bremerton, WA 98337~0039 BENEFITS BOOKLET ENDORSEMENT This Endorsement applies to the Benefits Booklet for the City of Bremerton - Under 65 LEOFF I Retirees. 1. Please revise the following language in the How the Group Plan Works section, pages 3 & 4 of your Benefits Booklet: A. Choosing a Provider or Hospital Participating Providers include those Providers who contract directly with KPS as well as Providers in the First Choice Health Network (FCHN), Providence Preferred Provider Organization and MultiPlan Network. The following list provides general locations and networks of Participating Providers. However, exceptions may exist, for example, both KPS and FCHN contract with providers in Grays Harbor and Thurston counties. For a current listing of Providers in your area, please call KPS at 1-800-552-7114, or visit our website at www.kpshealthplans.com: C. Add the following language at the end of the "Choosing a Provider or Hospital" section. What happens if my Provider no longer participates with KPS? If your Participating Provider chooses to terminate their agreement with KPS, we will notify you of the termination. The notification will allow at least sixty (60) days to either (i) complete your course of treatment, or (ii) appropriately transfer your care to another Participating Provider. After the sixty (60) days, services received from a provider who has terminated their agreement with KPS will be covered at the Non-participating Provider benefit level. 2. Please add the following language to the Your Out-of-Pocket Costs section on page 7: Lifetime Maximum and Reinstatement of Benefits The lifetime maximum is the total amount of benefits payable on behalf of each Enrollee during the individual's lifetime under this Group Plan and any prior plans with KPS. However, each year, at renewal, the reinstatement amount will be restored toward the lifetime maximum. This reinstatement does not apply to benefits with a separate lifetime maximum such as organ transplants and sleep disorders. Lifetime Maximum Benefit $1,000,000 per Enrollee Annual Reinstatement of Benefits Up to $5,000 per Enrollee per Calendar Year CITYRETIREE-END-2005 . 3. Please revise the following benefit language in the Benefits Summary on pages 10 of your Benefits Booklet: KPS provides the following Medically Necessary benefits and services, at the indicated reimbursement percentage. Benefits paid at 1000/0 are not subject to the annual Deductible. Chemical Dependency $11,811 $12,500 maximum per 24 month period Inpatient care 100% 100% Outpatient care 100% 100% Colonoscopv and SiQmoidoscopv - not subiect to the See Professional & Hospital Services preventive care maximum or limit Sections 4. Please revise the following benefit language in the Description of Covered Benefits and Services section, pages 16,24 & 26 of your Benefits Booklet: A. Add the following new language before the Home Health and Hospice benefit: Colonoscopy and SiQmoidoscopy Services Coveraqe under this benefit includes screeninq and/or diaqnostic colonoscopy and siqmoidoscopy services when such services are recommended bv a physician, advanced reqistered nurse practitioner (ARNP) or licensed physician's assistant (PA). This benefit is not subiect to the preventive care limit. B. Phenylketonuria (PKU) Formulas Special dietary formulas. designed for use bY:J Child you and/or your Eliqible Dependents who Ha&-have been diagnosed with phenylketonuria are covered under this benefit. - ~."' C. Pharmacy Benefits Coverage Coverage under this benefit includes: >- Prescription drugs >- Insulin and diabetic supplies >- Self-administered drugs, including self-administered chemotherapy drugs >- Pre-authorized off-label use of prescription drugs >- Contraceptives >- Pre-natal vitamins (for you, as the Subscriber, or your enrolled Spouse only during the term of pregnancy) All drugs and supplies must be Medically Necessary for the condition, and must be prescribed by a Provider with prescriptive authority. Except in the case of a Medical Emergency, all prescriptions must be filled at a network pharmacy. We will also cover druqs dispensed at a hospital-based emerqency room. -- . pr. ~ ~;ytI~2~~~~! ~.:-'~ "'C'''-~''~. _ c' , i~~~!r .. . L-:......:..,~..-< . ,.. 5. Please revise the following exclusions in the Exclusions and Limitations section, pages 29 and 30 of your Benefits Booklet 17. Hearing aids, hearinq devices such as cochlear implants, and hearing exams. 29. Services for any occupational illness or injury arising out of, or in the course of, an activity pertaining to any trade, business, employment (including self-employment) or occupation for wage or profit. whether or not a proper and timely claim was filed for such benefits under another plan or policy. 6. Please revise the following language in the Continuation of CoveraQe section, page 31 of your Benefits Booklet: COBRA (Consolidated Omnibus Budget Reconciliation Act -1985) If you lose eligibility for coverage under this Group Plan (except in the case of a labor dispute), you may be eligible to continue your coverage for a period of time specified by federal law and regulations then in effect. 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Pharmacy Benefits Coverage Coverage under this benefit includes: y Prescription drugs y Insulin and diabetic supplies y Self-administered drugs, including self-administered chemotherapy drugs y Pre-authorized off-label use of prescription drugs y Contraceptives y Pre-natal vitamins (for you, as the Subscriber, or your enrolled Spouse only during the term of pregnancy) All drugs and supplies must be Medically Necessary for the condition, and must be prescribed by a Provider with prescriptive authority. Except in the case of a Medical Emergency, all prescriptions must be filled at a network pharmacy. We will also cover druas disoensed at a hosoital-based emerqencV room. 6. Please revise the following exclusions in the Exclusions and Limitations, section, pages 29 and 30 of your Benefits Booklet 17. Hearing aids. hearino devices such as cochlear implants.. and hearing exams. 29. Services for any occupational illness or injury arising out of, or in the course of, an activity pertaining to any trade, business, employment (including self-employment) or occupation for wage or profit. whether or not a orODer and timelv claim was filed for such benefits under, pnother olan or polic\/. 7. Please revise the foUowing language in the Continuation of Coveraae ,section, page 31 of your Benefits Booklet: COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) If you lose eligibility for coverage under this Group Plan (except in the case of a labor dispute), you may be eligible to continue your coverage for a period of time specified by federai law and regulations then in effect. This continuation of coverage is referred to as COBRA and applies generally to groups of twenty (20) or more employees. Continuation of coverage under COBRA is not automatic. You must apply for continuation of your Group coverage within sixty (60) days of the effocti'lc :!::~&-G~ ~':'~::H-ination ~~ ,:,,:,';or3g9 LlAEl-,:~ ~~;s. 12~~'..:~ 0?te vour GrouD orovides yOU a COBRA election notic~.' \ ENDORSEMENT No.: City of Bremerton 1 EFFECTIVE DATE: January 1, 2005 \ \BY~~.~ \ TITLE: ELIZABETH A. GlUE, PRESIDENT \ I J "0 -I C <0 ~-='" -;:l 3 (I) 0. _. (fl \) <0 C '(j '(j co"@ i. 3 '(j Ul:3 ~ ;:0 '(j '(j -;:l):> ~ -' -' {I) ....., -oU> (1)0 <.C -;:l .... " -I U> .....c IO!:!"' ro3 IP ~ C C 00" 0< Ul 0 7'\1'"1 ::s 0" <_......(1) .....ill --- 7' ~:3 2- ro '(6' 0:. ~ ti)' \1'"1 :::s..... :l. o\) (jl-oro 3 a ro..... $~ (I)~ ~ .,g (fl ~ 0 cc, 3' ';; a 0 0. -6~' :l. "'0 " ~"@ - -< 0 =5' 0 2-0 tll 0 tg.-@ {I) "'" "'0 o Ul ~ ~ ~ ~ -0 ro -;:l. -=' -< :::. Sl (1) CJ) -:;~ =:l:t1l(l) 3 5' ill~ ~~ o~ '3.... 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COBRPo.lC . lexce t in tOO case 01 a labor dispute), you \I you lose eligibility lor coverage under tniS Gr~uP Plan .od J tiroe speCified bY lederal laW and may be eligible to continUe your coverage 0; a ~:;~ge .is relerred to as COBRA and applies re9ulations tnen in eIIec\. lniS continuatiOn 0 co generallY to grouPS 01 twenty (20) or more employees. ( '/ou must applY lor continuation 01 your continuation 01 coverage under cOBRA is not autoroa iC. ' GrouP coverage witnln sl-M (60)~aYS 01 tn~OBRA election notice. ~ date our Grou roV\ <is ou a . 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Q) Q) 100M lD ~ ('il g Q) Q) "0 0) U i (!;S ::0- -oro <I).... Q) "0 15 .s::. Q) .s::. 0 > om 0) II) :I: (j)o.~('il (/)t/) 0 =>. x.c CU"O ~c <i. 00 u ..!C'Il r...: cD 0.. cu a... a. '<""" N Lt'i to 7. Please revise the following language in the Continuation of Coveraqe section, page 32 of your Benefits Booklet: COBRA (Consolidated Omnibus Budget Reconciliation Act -1985) If you lose eligibility for coverage under this Group Plan (except in the case of a labor dispute), you may be eligible to continue your coverage for a period of time specified by federal law and regulations then in effect. This continuation of coverage is referred to as COBRA and applies generally to groups of twenty (20) or more employees. Continuation of coverage under COBRA is not automatic. You must apply for continuation of your Group coverage within sixty (60) days of the effective data of termin:Jtion of covora€l~ :..:~~:k:::~ ~~:~ Gf.Gt:~ ~!::~ date vour Group provides vou a COBRA election notice. 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"C W E 03 (f) >. m Q,l Q) Q).s:: 2 Q,l .r:. ::J O)..Q 0,) Q) Ct:l __ Q) c..c Q) ~ a. ..c ..... rn Q) 00 ~.~ 5 c'~ e; rr ~ ~ ~ '0 ~:5 ~ s: 3::5 3: 8 W S :5;g l?.2 ~ 15 ~ ~ ~ ~ g- ~ ~ ~ 03 g ~ ~ ~ Ectl _Ct:l o~ _C....~ Q)0l-c: Q)O} _a'irno--.... u U C 9!.s:: C c:S: ~ Q) C Q) A A A :~ -w'- C 0 A A C :Q :: c"E .... ~ "- C1)Q)-'-uQ,lQ)>> "'CQ,l ...... 0} (j) '-Q)o.cQ)- .!~ =..c-:.c..c.s::Q).Q ....s::-g ~(ll..c~ gc g.s::uu"O~ U f- W S~;: S s;:n; 0 SE of; s~ :=8 11. S~~Sii 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 Group Plan, Subscribers and their enrolled Eligible 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 Eligible 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 Eligible 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 Group Plan is excluded for expenses incurred or services rendered if the Enrorlee's illness or injury is caused (or alleged by the Enrollee 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). 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. This exclusion applies whenever any such contract of insurance, agreement, judgment or settlement is issued to or provides benefits for the Enrollee, whether or not they assert a claim against the responsible third party or its insurers. Third Party Liability: Reimbursement and Subrogation As a condition of KPS' agreement to advance payment to the Enrollee or their Provider for medical expenses for illnesses or injuries caused (or alleged by the Enrollee to be caused) by another party, the Enrollee agrees to make a claim against, or otherwise pursue recovery from all responsible parties and their insurer(s) for all payments advanced to the Enrollee or their Provider by KPS. If the Enrollee does not make a claim or otherwise pursue recovery of KPS' payments, all such payments made by KPS may be denied or recouped. By providing benefits under this provision, KPS is fulfilling its obligations under this Group Plan. However, by so doing, KPS does not waive any rights to reimbursement or subrogation. Provided, the benefits of this Group Plan will be advanced to the Enrollee if they are injured by a third party, before compensation is recovered from the third party or its insurers, only under the following conditions: > The Enrollee, and their 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; Page: 12 OOrfJ 00"-": (f)>, >..>. ....-0 "'0 Q)+-' '- w::::'->...... >,."t::::WC>.+-<(f) Q.)Q) Q) >. Q) Q) ->, ::::l m U5 t .0 W .E Q.) "co (f) ~ E Ci3 Ctl 0 Q) E C ::::l 0 CO c a5 a.. ::0 ..c .s= .o.~ M ~ t E ..c 0 ~ "0 > . . ~ .~ a. 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E.!!1m::'::mo.", (!) t-= _ _ _ :I: t-m Notices Any notice that may affect the provisions of this Contract shall be deemed delivered to the Group when deposited in the United States mail with prepaid postage, addressed to the Group at the most recent address listed for the Group. Any notice that 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 the Group has received such notice. It is the responsibility of the 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 no 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. Page: 20 e Gl 0 - 0, ::J - e :;::; :c III <J) c: ell 0 5 l.l >- Cii .c .c: "0 III '" e E OJ ::J > oe 0 Ol Gl ,!!l ~ Q. "0 Gl e ell .c: - e:;i - Bell 0 Ol- e- .- <0 'E ell ..c Qj G.J ';:; ~-a E ~ 52 >- ';:; >- .. . lD 0 -..0 c.c o ._ Ol Ql"O ~Gl Ql Ql Z " e ~'" 01;; "" co c:t ~ ~li .c i= 0 ...J a OJ '~ <J) E ~.c: 0. ~ N " ~ .c Ql Ql .- 1:: ci a E Ql ..c ~ a; 0 I a ell "0 - CI.. +ol- e ~ ~ ::J Ql e .S Q) ~ 1) Z a e u Ol => 0 0 ~ ~ ell Ql e "0 en en tn :;::; ~ 0 '~ "0 ctl I- .... 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C ~ 0 . ~ 0 :E ~lIlcEE 0 'ta.m Cl I- ChC'aCDm U TABLE OF CONTENTS DEFINITIONS ................................................................................................................................ 1 CONTRACT EXAMINATION PERIOD ................................................................................................. 3 EFFECTIVE DATE, DURATION AND RENEWAL .................................................................................. 3 PREMIUM PAYMENT PROV SONS ......................... 3 Payment Due Date/Grace Pedod ............................................................................................................. 3 Premium Rate Adjustments ...................................................................................................................... 3 Premiums Paid by Subscribers/Dependents ............................................................................................ 4 Premium Refunds ..................................................................................................................................... 4 ELIGIBILITY AND ENROLLMENT ....................................................................................................... 4 Group Eligibility ......................................................................................................................................... 4 SubscribedDependent Eligibility Requirements ....................................................................................... 4 Enrollment ................................................................................................................................................ 4 Enrollment Under Special Cimumstances ................................................................................................ 5 When Coverage Begins ........................................................................................................................... 6 Coverage Waiting Periods (This section does not apply to LEOFF I Employees) .................................. 6 TERMINATION OF COVERAGE ......................................................................................................... 7 Continuity of Coverage ............................................................................................................................. 7 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 Dudng a Labor Dispute ............................................................................................................ 9 Continuation of Group Coverage ........................................................ ~ .................................................... 9 COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) .................................................... 10 Individual Conversion Coverage ............................................................................................................. 10 COORDINATION OF BENEFITS (COB) ........................................................................................... 11 General Provision ................................................................................................................................... 11 Definitions ............................................................................................................................................... 11 Claim Determination Period .................................................................................................................... 11 Effect on Benefits .................................................................................................................................... 11 Order of Benefit Determination ............................................................................................................... 12 Facility of Payment ................................................................................................................................. 12 Right of Recovery ................................................................................................................................... 12 Right to Receive and Release Information ............................................................................................. 12 Disclosure of Coordination .................................................................................................................... 13 KPS' RIGHT OF RECOVERY ......................................................................................................... 13 Limitations and Exclusions ..................................................................................................................... 13 Third Party Liability: Reimbursement and Subrogation .......................................................................... 13 Collection and Reimbursement by Enrollee (or the Enrollee's Representative) .................................... 14 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 ............................................................................................................................ 15 Recovery of Claims Payments .............................................................................................................. 15 SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS ......................................................................... 15 SubscribedDependent Liability ............................................................................................................... 15 KPS Privacy Policy ................................................................................................................................ 16 COMPLAINTS AND APPEALS PROCESS ............................................................... ~ ......................... 16 Complaints .............................................................................................................................................. 16 Standard Appeals Process .................................................................................................................... 17 Expedited Appeals Process .................................................................................................................... 17 GENERAL TERMS AND CONDITIONS ............................................................................................. 18 Applicable Law ....................................................................................................................................... 18 Assignment of Benefits .......................................................................................................................... 18 Binding Agreement ................................................................................................................................ 18 Confidentiality ......................................................................................................................................... 18 Contract Modifications ........................................................................................................................... 18 Coverage Limits ...................................................................................................................................... 18 Entire Agreement .................................................................................................................................... 18 Equity of Application .............................................................................................................................. 19 False or Misleading Information ............................................................................................................. 19 Force Majeure ......................................................................................................................................... 19 Group Cooperation ................................................................................................................................. 19 Headings ................................................................................................................................................. 19 Notices ................................................................................................................................................... 19 Severability ............................................................................................................................................. 19 Third Party Beneficiaries ........................................................................................................................ 20 Waiver of Breach .................................................................................................................................... 20 I ~o gJo .~c:"O cm 0>'''''''- .9.....; Qi'C ;; 64>.2l d :5~S.9 Q) CD ~ ........ nJ c: o~ .- ...... ~ V 4:::!:: .- .~ N ij: 0- CD ..c (f) Q) ~CD mm Qfj~ct1 ,,'" 0: - cD L..- rum ~ Q.'(j) Q) oo~ .o~Q3~'" ffi en Ol '" 0) Ol 0)- - Ol 0 a. c: 0 O"'C - c:... ._ ..c m "C m - <( '-' ~ ...... ..... 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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 0f 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 ara 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 payments, if applicable, must accompany all applications for coverage Current LEOFF I and LEOFF II Employees, including Dependents of active, full-time LEOFF I and LEOFF II law enfomement 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) ara 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 Bremerlon 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 if additional Premium is required, be enrolled in this Group Plan within sixty (60) days of birth; > Adopted Children ara 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. If additional Premium is required, the application for coverage must be submitted within sixty (60) days of the date of placement for adoption. NOTE: When additional Premium is not required, we encourage enrollment as soon as possible to prevent delays in claims processing. In the case of court-ordered covera,qe, 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 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. Mar~age, 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, if additional premium is required, following the date of birth, adoption or placement for adoption, or ~ the next Open Enrollment Period if these time frames are not met. NOTE: When additional Premium is not required, we encourage enrollment as soon as possible to prevent delays in claims processing. Court-Orderad 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. City of Bremerton Plan A - 2002 Page 5 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 pedod 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. If additional Premium is required, 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. If additional Premium is required, 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. NOTE: When additional Premium is not required, we encourage enrollment as soon as possible to prevent delays in claims processing. 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. 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 prior period of coverage may not be counted if sixty-three (63) or mom days have elapsed since the date the pdor coverage ended and the date the Enrollee enrolled Jn this Group Plan. Any time during which the Enrollee was in a probationary or affiliation pedod 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 dudng the three (3) month period immediately preceding the effective date of coverage of this Group Plan, provided the pdor 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 carder; The dates of coverage under the pdor 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. Page: 6 City of Bremerton Plan A - 2002 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 offedng 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 for[y-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 pdor to the Open Enrollment Pedod, 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; 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 refuses to comply with the terms and conditions of this Group Plan as described in this Group Policy and the Benefits Booklet; City of Bremerton Plan A - 2002 Page 7 The Enrollee voluntarily disenretls 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 disenrells from this Group Plan while still an Employee will not be eligible to re-enrell in the Group Plan until the first day of the month after one full year from the date of disenrollment. See Enrollroent Under Special Clrcurostances 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 othenvise 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. Page: 8 City of Bremedon Plan A - 2002 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 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 ara 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. 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I o ~.Q.s '>"'C~ E c: c:: ~~ 0 ~ >'>-::J CDa..~- o(jjE cuoe W5.9~~ j:ug. o a._.- C c: 0.2 0:= .... ~ ~e ~~;:E" ';;;:Q) J!l~g I - ~E..c "C:Jo_o"(jj..ca. ;;; lJ) c lJ) ~ '" 8 lJ)~en c( Q)w.g>.5: (],) um!! -s; 0.9 ::l '" f- f-C!) t) ~ :=w .2 0 ~ ~.E:O cu.=J!:?..c: Q) J2 (I) I 0:: >'Q)'- Q)C><(::]Q)om "tl '" c: ..c UJ C'J '- '" ~ 0 >-. . - L..... "0 >-",tll 0_'- - mo::-c ....~a.CIJ '> O~ !'l 0 '" c '" 5l CD_C:c:Q) ~ I tXI c..:9 Q) :9 (jj OJ os; G) Q,::J 0. "iic AA A A =-1;",:O::J ~ro!!!:cE 0_ 0 iIi o E 0>= _2' > 0 'is:5 U) 0 ~ :s c.ffiu a.oeno CD-en(/) a.:9:c 0> .-- 0 "- '- c E.!1! a._ _ Q)._ C. J: o'x:.c: E _2' '" '" o Wa:; 0 ill uO.SC5:5C>o woo <(a. 0 Oa;en -", Wa;~ 11. I I I 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. "Plan" means a policy or contract which provides benefits or servicas 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 previsions, 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. City of Bremerton Plan A - 2002 Page 11 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 divomed 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. 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 KP$ 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. Page: 12 City of Bremerton Plan A - 2002 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 ~oss 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. 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, KP$ does not waive any rights to reimbursement or subrogation. Provided, the benefits of this plan will be advanced to you if you ara injured by a third party, before compensation is recovered from the third party or its insurars, only under the following conditions: You, and your raprasentative(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 wdting, 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 dght to recover compensation for medical costs paid (subrogation), or to be paid, by KPS as a result of injuries caused by the third party rasponsible 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. City of Bremerton Plan A - 2002 Page 13 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 pdor consent from KPS before compremising 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 portJon 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 reimbureement 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 attomey 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' reimbursa'nent be reduced by more than twenty pereent (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 pureue a claim seeking recovery from a responsible third party or its insurer(s), you and your representative(s) must cooperate fully with KPS in pureuing the claim against the responsible parties. Such cooperation includes, among other things: Previding 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 Bet~veen 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 pretecting, 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 soume of payment. Page: 14 City of Brsmerton Plan A - 2002 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 bounri 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 urttil 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 proviried 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 Servic~e; 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 City of Bremerton Plan A- 2002 Page 15 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 Enmllees. Non-public Personal Information does not include information that is available from public soumes 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 cars 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, 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 cars, 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. Page: 16 City of Brernerton Plan A - 2002 The following steps outline the procedure for filing a complaint: EITHER KPS Member Services will worl~ The service provided by KPS Send a written statement of with the Enrollee and try to the complaint to: resolve the complaint over the Eligibility KPS Health Plans 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 investigafional 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 or Supplies 20 Days All other Adverse Determinations 14 Days Expedited Appeals Process If the Enrollee's health care Provider, or the KP$ Medical Director, reasonably determines that by following the Standard Appeals Process, the Enrollee's life, health, or ability to regain maximum function would be jeopardized, 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. City of Bremerton Plan A - 2002 Page 17 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 wrfften 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. Page: 18 City of Bremerton Plan A - 2002 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. 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. City of Bremerton Plan A - 2002 Page 19 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. Page: 20 City of Bremerton Plan A - 2002 KPS Health Plans, In Rehabilitation 400 Warren Avenue P.O. Box 339 Bremerton, WA 98337-0039 CITY OF BREMERTON - COVERAGE CONTRACT - PLAN A Group Name: City of Bremerton Group Number: 21001-21006 Effective Date: 1/1/2003 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 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: FO~ Eliz ' ' ' ' ' ~' Signature Print Name Title Date KPS Health Plans, In Rehabilitation 400 Warren Avenue P.O. Box 339 Bremerton, WA 98337-0039 CITY OF BREMERTON - COVERAGE CONTRACT - PLAN B Group Name: City of Bremerton Group Number: 21010, 21014 Effective Date: 1/1/2003 Renewal Month: January Open Enrollment December This Coverage Contract includes the following: Attachment A - Benefits Booklet Attachment B - Premium Rates and Underwriting Criteda 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 under~rite 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-22900-2003 TABLE OF CONTENTS DEFINITIONS ............................................................................................................. 1 CONTRACT EXAMINATION PERIOD ....... . ............. iiiiii 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 .... . ............................ ii 5 When Coverage Begins ............................................................................................................................ 6 Coverage Waiting Periods ........................................................................................................................ 6 TERMINATION OF COVERAGE ......................................................................................................... 7 Continuity of Coverage ............................................................................................................................ 7 Termination of Group Contract ..................................... . ............ 7 Re-Enrollment/Reinstatament .............................. 7 Continuation of Inpatient Coverage ...................................... 8 Continuation of Coverage for a Disabled Child .................. .iiii;;; ............... ;;'i;i;;;; 8 CONTINUATION OF COVERAGE ...................................................................................................... 9 Coverage During a Labor Dispute ............................................................................................................ 9 Continuation of Group Coverage .............................. 9 COBRA (Consolidated Omnibus Budget Reconciliation Act- 19~5)====================== ;il;;i';";;'"'i0 Individual Conversion Coverage .......................................................................................... 10 COORDINATION OF BENEFITS (COB) ............ . ..... "' ..iiiii 11 General Provision .................................................................................................................................. 11 Definitions .............................................................. 11 Claim Determinat on Per od .............................................. 11 Effect on Benefits .................................................................................................................................... 11 Order of Benefit Determination .................... . ................ 12 Facility of Payment ................................................................................................................................. 12 Right of Recovery ................................................................................................................................... 12 Right to Receive and Release Informat on ................................. 12 Disclosure of Coordination .................................................................................................................... 13 KPS' RIGHT OF RECOVERY ......................................................................................................... 13 Limitations and Exclusions ........................................................................ Third Party Liability: Reimbursement and Subrogation ......................... "iiii ......... 1 13 ....... 13 Collection and Reimbursement by Enrollee (or the Enrollee's Representative) ................................... 14 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 SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS ......... ' ....... 115 Subscriber/Dependent Liability ............................................................................................................... 15 KPS Privacy Policy ................................................................................................................................ 16 COMPLAINTS AND APPEALS PROCESS .... . .................. 16 Complaints ....................................................................................................................................... 16 Standard Appeals Process ....................................................................................... 17 GENERAL TERMS AND CONDITIONS ............................................................................................. 18 Applicable Law ................................................................................................................................. 18 Assignment of Benefits ......................... . ........................................... 1 18 Binding Agreement ................................................................................................................................. 18 Confidentiality ......................................................................................................................................... 18 Contract Modifications ............................................................................................................................ 18 Coverage Limits ...................................................................................................................................... 18 Entire Agreement ......................................................................................................... : ......................... 18 Equity of Application ............................................................................................................................... 18 False or Misleading Information ............................................................................................................. 19 Force Majeure ......................................................................................................................................... 19 Group Cooperation ................................................................................................................................. 19 Headings ................................................................................................................................................. 19 Notices .................................................................................................................................................... 19 Severability ............................................................................................................................................. 19 Third Party Beneficiaries ........................................................................................................................ 19 Waiver of Breach .................................................................................................................................... 20 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-sustainin9 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. Eligibfa 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 securin§ 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 firafighter 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, 1't 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, 1~t Ex. Session. Limiting Age for Dependents means the age shown in the Benefits Summa~/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 2003 Page 1 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 City of Bremerton Plan B 2003 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 pro-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 sola 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 aro 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 Y 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, 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 2003 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) dudng 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 ara properly enrolled in this Group Plan. Subscriber/Dependent Eligibility Requirements Active, full-time Employees, as defined in the Definitions section, and their Eligible Dependents, ara 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, ara 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, ara 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(ran) ara 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 2003 Newborn and Adooted 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 pedod of three weeks. In order for coverage to continue after the initial three (3) week period, the Child must qualify as a Dependent, and if additional Premium is required, 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, if additional Premium is required, the application for coverage must be submitted within sixty (60) days of the date of placement for adoption. NOTE: When additional Premium is not required, we encourage enrollment as soon as possible to prevent delays in claims processing. in the case of court-ordered covera,qe, 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 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 Pedod. 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, if additional premium is required, following the date of birth, adoption or placement for adoption, or ~, the next Open Enrollment Period if these time frames are not met. NOTE: When additional Premium is not required, we encourage enrollment as soon as possible to prevent delays in claims processing. 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. City of Bremerton Plan B 2003 Page 5 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 pedod 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. If additional Premium is required, 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. If additional Premium is required, 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. NOTE: When additional Premium is not required, we encourage enrollment as soon as possible to prevent delays in claims processing. Coverage Waiting Periods Pre-Existing Conditions KPS imposes a three (3) month waiting period before providing coverage for a pro-existing condition. A "Pro-extsting 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 pro-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 prior period of coverage may not be counted if sixty-three (63) or moro days have elapsed since the date the pdor coverage ended and the date the Enrollee enrolled in this Group Plan. Any time dudng which the Enrollee was in a probationary or affiliation pedod 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 pdor plan had $imilarbenefits. For purposes of this Contract, similar benefits means a health plan with an actuarial value of at least seventy-five pement (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 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. Page: 6 City of Bremerton Plan B 2003 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 pedods 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-EnrollmentJReinstatement 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; 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 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; City of Bremerton Plan B 2003 Page 7 > 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 divome; 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 othep, vise 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. Page: 8 City of Bremerton Plan B 2003 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 occum: 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. Dudng 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. City of Bremerton Plan B 2003 Page 9 COBRA (Consolidated Omnibus Budget Reconciliation Act - 1988) 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. 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 quality 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. Page: 10 City of Bremerton Plan B 2003 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 pdvate Hospital room is considered to be Medically Necessary under at least one of the Plans involved. "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 soume. 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 ara 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. City of Bremerton Plan B 2003 Page 11 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 divomed 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 pdmary 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. 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 pdmary, 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. 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. Page: 12 City of Bremerton Plan B 2003 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. 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 prevision, 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 respoflsible 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. City of Bremerton Plan B 2003 Page 13 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 aftomey. In no event will KPS' reimbursement be reduced by more than twenty pement (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. Page: 14 City of Bremerton Plan B 2003 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 dght 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. SUBSCRIBER/DEPENDENT LIABILITY AND J~IGHTS 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 falls 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. City of Bremerton Plan B 2003 Page 15 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. 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 ara 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. Page: 16 City of Bremerton Plan B 2003 The following steps outline the procedure for filing a complaint: EITHER KPS Member Services will work The service provided by KPS Send a written statement of with the Enrollee and try to Eligibility the complaint to: resolve the complaint over the KPS Health Plans 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. 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 dghts 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 If the Enrollee's health care Provider, or the KPS Medical Director, reasonably determines that by following the Standard Appeals Process, the Enrollee's life, health, or ability to regain maximum function would be jeopardized, 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. City of Bremerton Plan B 2003 Page 17 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 wdtten 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 raquired 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 ara 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. Page: 18 City of Bremerton Plan B 2003 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 suspensioll, 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 Subscribem and their enrolJed 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. Notices Any notice which may affect the provisions of this Contract shall be deemed delivered to Group when deposited Jn 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. City of Bremerton Plan B 2003 Page 19 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. Page: 20 City of Bremerton Plan B 2003 KPS Health Plans, In Rehabilitation 400 Warren Avenue P.O. Box 339 Brernerton, WA 98337-0039 CITY OF BREMERTON - COVERAGE CONTRACT - PLAN B Group Name: City of Bremerton Group Number: 21010, 21014 Effective Date: 1/1/2003 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: Fo~G : ~'-~ Elizabeth A. ~lje, Presl[ient ' ' Signatu~ Print Name Date /' KPS Health Plans, In Rehabilitation 400 Warren Avenue P.O. Box 339 Bremerton, WA 98337-0039 City of Bremerton - Coverage Contract - UNDER 65 LEOFF I RETIREES (SuBsCRIBERS ONLY) Group Name: City of Bremerton Group Number: 21001-21006 Effective Date: 1/1/2003 Renewal Month: January Open Enrollment December This Coverage Contract includes the following: Attachment A - Benefits Booklet Attachment B - Premium Rates and Underwriting Cdteria 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-22900-2003 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 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-Enrellment/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 .............................................................................................................. 7 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 ................................................................................................................................... 9 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 .......................................................................... 10 Collection and Reimbursement by Enrollee (or the Enrellee's Representative) .................................... 11 Subrogation: Assignment of Third Party Claim to KPS .......................................................................... 11 Trust and Cooperation Between the Enrollee (or the Enrollee's Representative) and KPS .................. 12 Agreement to Arbitrate ........................................................................................................................... 12 Recovery of Claims Payments ............................................................................................................... 12 SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS ......................................................................... 12 Subscriber/Dependent Liability ............................................................................................................... 12 KPS Privacy Policy ................................................................................................................................. 13 COMPLAINTS AND APPEALS PROCESS ......................................................................................... 14 Complaints .............................................................................................................................................. 14 Standard Appeals Process ..................................................................................................................... 14 Expedited Appeals Process ................................................................................................................... 15 GENERAL TERMS AND CONDITIONS ............................................................................................. 15 Applicable Law ....................................................................................................................................... 15 Assignment of Benefits .......................................................................................................................... 15 Binding Agreement ................................................................................................................................ 15 Confidentiality ........................................................................................................................................ 15 Contract Modifications ........................................................................................................................... 15 Coverage Limits ...................................................................................................................................... 16 Entire Agreement .................................................................................................................................... 16 Equity of Application .............................................................................................................................. 16 False or Misleading Information ............................................................................................................ 16 Force Majeure ......................................................................................................................................... 16 Group Cooperation ................................................................................................................................ 16 Headings ................................................................................................................................................. 16 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, dders 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, 1~ Ex. Session. Limiting Age for Dependents means the age shown in the Benefits Summary section of the Benefits Booklet. Non-ParUcipatlng 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 pedod, 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. Dudng 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 -2003 Page 1 Spouse means an individual who is living in a madtal 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 2003 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 cancerlation 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, or fluctuations of ten pement (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 wdtten notice of rate increases associated with the annual Contract renewal process. City of Brernerton Plan C -2003 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 Poticy. 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 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 J 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 2003 Enrollment Under Special Circumstances Retired LEOFF I Employees who, when they were initially eligible to enroll, declined coverage in this Group Plan, in wdting, 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 must apply for coverage within thirty-one (31) days of losing coverage under their pdor plan. When Coverage Begins Coverage for new Enm!lees 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 rsapply for coverage. City of Bremerton Plan C -2003 Page 5 Termination of Enrollee Coverage Coverage for an individual Enrollee under this Group PJan 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; 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 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 to-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 aro met: ~, KPS pro-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. Page: 6 City of Bremerton Plan C 2003 Continuation of Coverage for a Disabled Child A Dependent Child who has roached the Limiting Age remains eligible for coverage under this Group Plan provided both of the following conditions aro 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 rosult of disability or physical handicap; KP$ determines that the Child is no longer developmentally disabled or physically handicapped (based on the evidence submitted); The Subscriber is no longer coverod 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 Promium, coverage ends on the last day of the month for which KPS roceived a Promium 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 roquirod 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 aro required to apply for continued coverage within sixty (60) days of the date coverage under this Group Plan ends. Group is requirod to notify KPS of each individual's elec~n of COBRA continuation coverage within sixty (60) days of that election. Failuro on the part of the eligible individual to make a timely election, or failure on the part of Group to provide KPS with timely notifk~ation of the election, will be interpreted by KPS as a waiver of the individual's dght 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 ara 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 Promium, 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. City of 6remerton Plan C -2003 Page 7 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 ara 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 J 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 mom is considered to be Medically Necessary under at least one of the Plans involved. "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 soume. 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 prevision. Page: 8 City of Bremerton Plan C 2003 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 pdmary, 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 pdmary 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. 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 prevision 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. 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. City of Bremerton Plan C -2003 Page 9 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 undednsured 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. 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; Page: 10 City of Bremerton Plan C 2003 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 dght 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 KP$ 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 dghts, 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 pdor 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. 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. City of Bremerton Plan C -2003 Page 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 injudes 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 KP$ 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. SUBSCRIBERJDEPENDENT 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 Page: 12 City of Bremerton Plan C 2003 >. 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 Gremm-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 pdvacy. This law requires health insurance carriers in Washington State to provide its Enrollees with information regarding privacy policies and procedures. The following is our pdvacy 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. 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. City of Bremerton Plan C -2003 Page 13 COMPLAINTS AND APPEALS PROCESS Complaints All Enrollees have the dght 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: EITH R KPS Member Services will work The service provided by KPS Send a written statement of with the Enrollee and try to Eligibility the complaint to: resolve the complaint over the KPS Health Plans 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. 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 Enroltee's position may be included with the appeal. KPS will notify the Enrollee in writing that the request has been recaived. 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: Page: 14 City of Bremerton Plan C 2003 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 If the Enmllee's health care Provider, or the KPS Medical Director, reasonably detarmines that by following the Standard Appeals Process, the Enrollee's life, health, or ability to regain maximum function would be jeopardized, 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 dght to make benefit payments to the Subscriber, the Provider, or jointly, as KPS deems necessary and appropriate, subject to federal and/or state Paws. 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, apl 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 ara 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. City of Brernerton Plan C-2003 Page 15 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 adsing 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: 16 City of Bremeilon Plan C 2003 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 -2003 Page 17 KPS Health Plans, In Rehabilitation 400 Warren Avenue P.O, Box 339 Bremerton, WA 98337-0039 City of Bremerton - Coverage Contract - UNDER 65 LEOFF I RETIREES (SUBSCRIBERS ONLY) Group Name: City of Bremerton Group Number: 21001-21006 Effective Date: 1/1/2003 Renewal Month: January Open Enrollment December This Coverage Contract includes the following: Attachment A - Benefits Booklet Attachment B - Premium Rates and Underwriting Criteda 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: F~. · ~ Elizabeth A. I~lje, President Signature Print Name · Date ~/~/~ +Browse: Next Previous First Last Update Delete Restart X - Exit + +Retrieve the Next record + +Found: 21 Record(s) MAINTAIN Contract Transactions + + Contract Number 3158 + + + +Vendor Name KPS HEALTH PLANS (FORMERLY KITSAP PHYSICIANS) + +Subject MEDICAL BENEFITS - EMPLOYEES + +Department HUMAN RESOURCES + +Status Code EMP + + Amount $450000.00 + + Begin Date 01/01/1990 + + Insurance End Date 12/31/2002 + + Type Amount Review Date 09/01/2002 + + + + + + + + Insurance Total $0.00 + + Insurance Review Date + + + + Comments + + + + + KPS Health Plans, In Rehabilitation 400 Warren Avenue P.O. Box 339 Bremerto~, 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 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: FO ~ Elizabet~A. Gilje, President ~ Signature Caz'y Bozeman Print Name Mayor August 1, 2002 Dal~ 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: Cityof 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 (HCSC) in Washington State. In its capacity as an HCSC, KPS agrees to underwrite and provide the benefits and services decchbed 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 RENEVVAL .................................................................................. 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 Cimumstances ................................................................................................ 5 VVhen 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 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 ............................................................................................................................ 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 Broach .................................................................................................................................... 19 DEFINITIONS Child means any one of the following: (il 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 a LEOFF I or LEOFF II law enforcement officer. Eligible Employee means: (al LEOFF I employees who ara 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, 1'~ Ex. Session. Enro#ee 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 Benef'~s 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. Pramlum means the periodic payment made by, or on behalf of the Enrollee, in accordance with the terms of this Group Contract. Pramlum 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 ^ - 2002 Page 1 Renewal Month see Contract Renewal Month. Spotme 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 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 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 A - 2002 Page 3 Premiums Paid by SubscribersIDependents 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 > VVhen 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 pedod 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 ara properly enrolled in this Group Plan. SubscHberlDependent Eligibility Requirements Active, full-time LEOFF I and LEOFF II Employees, as defined in the Definitions section ara eligible to enroll in this Group Plan. Eligible Dependents of an active, full-time LEOFF I or LEOFF II law enfomement 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 payments, applicable, accompany applications coverage Premium if must all for Current LEOFF I al3d 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 coveraqe, 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 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 v/ithin 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 throe (3) month waiting period beforo providing coverage for a pre-existing condition. A "Pro-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 However, this waiting period may be reduced as follows: )~ By the number of months the Enrollee was coverod under a prior plan with similar benefits. However, the prior period of coverage may not be counted if sixty-three (63) or moro days have elapsed since the date the prior coverage ended and the date the Enrollee enrolled in this Group Plan. Any time dudng which the Enrollee was in a probationary or affiliation period will not be taken into account in determining the sixty-throe (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 proceding the effective date of coverage of this Group Plan, provided the pdor plan had s/milarbenefits. For purposes of this Contract, similar beneFSs 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 carder; The dates of coverage under the pdor 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 coverod 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 pdor 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 Peen 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-tive (45) days written notice to KPS. If this Group Contract terminates, for any reason, coverage for ail 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-EnrollmentJReinstatement If this Group Policy has been cancelled by KPS due to non-payment of Premium, Group automatically forfeits all rights to guaranteed renewal of coverege 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 Pedod, 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 Benetits 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 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 othenvise end, is eligible to continue receiving benefits under this Group Plan provided the following conditions ara 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 occura: 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 ara 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 KP$ 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. Dudng 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 fo 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 ceverege 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 ~vill, 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 (HIP,aA) 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 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 soume. 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 Detemfination When more than one Plan contains a COB provision, the decision as to which Plan is the pdmary Plan is made in the following order: The Plan which covers the person as a Subscriber rather than as a Dependent is pdmary; 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 pdmary, 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: (il the Plan of parent with custody; (ii) the Plan of the stap-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 pedod 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 prevision 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 KP$ 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: 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 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 t~enty pement (20%) to offset attorney fees incurred by you, and KPS will not pay for costs incurred by you. City of Bremerton Plan A - 2002 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 injudes or conditions caused, or asserted by you to be caused by any third party, to the extent that coverage or payment for such injudes 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 adses 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 RIGHTR 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 Stat~ 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 heeith 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. COItlPLAINTS AND APPEALS PROCESS Complaints All Enrollees have the dght 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 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 Bramerton, 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 dght 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 dghts and responsibilities dudng 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 ~vithin 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 Enrolise'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 KP$ 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, KPS reserves the right to modify the provisions of this Contract, or the services described in the Benefits Booklet, upon forty-five (45) days wdtten 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 ^: 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 KP$ 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, sthke, 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 tc~.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 recant 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. Severebility 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 Attachment B Premium Rates and Underwriting Criteria For City of Bremerton Premium Rates $50 Deductible/Person $100/Family 282,42 206.08 227.33 102.67 82.63 PI~RatI~; LEOFFIRetreebU~er$$ S~use ~Cllii¢1~ ~ ~ ~.~ $50 D~uctible/Person $100/Family 739,04 404.87 101.01 80.73 $100 Dedu~iblgPemon $300/Family N/A 177.34 198.64 90.37 70.32 PbnB Ra~ EEOFF L Re~!re~ S~use ~ Chi!~ $100 Deductible/Pemon $300/Family N/A 336.27 85.48 69.11 Additional Financial ~angements: > Individual Stop Loss at $75,000 - $6.72pmpm charge > Administrative Expense - $22.32pmpm > Statuto~ Rese~e Charge- $2.25pmpm > 2003 Administration Increase Maximum - 5% from 2002 figure of $22.32 pmpm to $23.44pmpm for ~ntmct year 2003 Unde~rlting Criteria The Premium rotes quoted above for this Group Plan am based on the following unde~riting criteria. KPS resewes the right to withdraw or mmte this offering if Group falls outside the scope of these criteria. > Active, full-time Employees must work a minimum of thi~y (30) houm per week unless othe~ise negotiated and agreed by both KPS and Group. > Subject to prior KPS approval, ~o (2) or mom health insuran~ ~iem, 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 (SuBscmaE;S 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 G~,~.~..._.z._~ Elizabeth A~Gilje, President" U Signature Cary Bozeman Print Name Mayo]~ Title Augus~c ~., 2002 Date KPS Health Plans, In Rehabilitation 400 Warren Avenue P.O. Box 339 Brernerton, 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 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 ................................................................................................................................ 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 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) ............................................................................................. 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 Enrollee's Representative) .................................... 1 Subrogation: Assignment of Third Party Claim to KPS .......................................................................... 12 Trust and Cooperation Between the Enrollee (or the Enrollee's Representative) and KPS .................. 12 Agreement to Arbitrate ............................................................................................................................ 12 Recovery of Claims Payments ............................................................................................................... 12 SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS ......................................................................... 13 Subscriber/Dependent Liability ............................................................................................................... 13 KPS Pdvacy Policy ................................................................................................................................. 13 COMPLAINTS AND APPEALS PROCESS ......................................................................................... 14 Complaints .............................................................................................................................................. 14 Standard Appeals Process ..................................................................................................................... 15 Expedited Appeals Process .................................................................................................................... 15 GENERAL TERMS AND CONDITIONS ............................................................................................. 15 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 Broach .................................................................................................................................... 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. Coverod 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 Brsmerton 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 nu]~ 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. PREltlIII~IM 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 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 for~vard 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 pedod of ineligibility which is in excess of claim payments made on behalf of the ineligible person(s) dudng the pedod of ineligibility not to exceed three (3) months of Premium payments. ELIGI~, ILITY 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 e{igible 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 L payments, applicable, accompany applications coverage J Premium if must all for 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 Emolovees 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 must 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 wilt 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 (HIP,AA) 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 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 divome; 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 KP$ 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 cars (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 ara 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 (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 pedods for pm-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 Ex=ense" 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 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 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 wilt 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 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 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 KPS1 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 pdor 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 share1 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 Breme~ton 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 ail 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 injudes 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 Ineli~ble 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. SUB~C~t, IBERJ0EPENDENT 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 arid 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 soumes 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, administrators and assigns, authorize the Provider, Hospital, other health care insurers, organizations or persons to: (i) ReleasetoKPSanymedicalinformationnecessaryfortheadministrationofthisContract; (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 Page: 14 City of Bremerton Plan C 2002 Standard Appeals Process Enrollees have the dght 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 pro-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 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 undem/riting 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, law1 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 pedod 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 prevision 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 sen/ices 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 previsions of this Contract shalt 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 Broach 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 338 Bremerton, WA 98331-0039 Attachment B Premium Rates and Underwriting Criteria For City of Bremerton Premium Rates $50 Deductible/Person $100/Family 282.42 205.08 227.33 102,67 82.63 $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 $100 Deductible/Person N/A 336.27 85.48 69.11 $300/Family 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 Cflterla The Premium rates quoted above for this Group Plan am 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 ~Narren Avenue P.O. Box 339 Brernerton, WA 98331-0039 CIT~ OF BREMERTON - COVER~OE 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: AttachmentA - 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. Elizabeth 4. Gilje, President Signature Ca~cy Bozeman Print Name Mayor Title Augusl: ~., 2002 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: Cityof Bmmerton 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 Cdteda 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 sen, ices 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 ................................................................................................................................ 1 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 Enrollea'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 Broach .................................................................................................................................... 19 DEF, INITIONS 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 (sea 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 I~onth 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. Coverod 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 I~a~cer &ppllcation 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, 1~t Ex. Session. LEOFF It 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, 1= Ex. Session. Limiting Age for Dependents means the age shown in the Beneflt~ Summary section of the Benefits Booklet. Non-Participating ProvlderlFacillty 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 pdmary person, generally the Employee, enrolled in this Group Plan. Page: 2 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 othenvise terminated according to the provisions set forth herein. PREMIyM PAYMENT PROVISIONS Payment Due D-ts/Grace Period The initial Premium payment is due and payable to KP$ on or before the Effective Date of this Contract. Tbe~ffer, Premium payments are due and payable on or before the first day of every month ("Premium Due Date") for which coverage is provided. A ro~ter of cun'ont enrollment and enrollment change~ must accompany each Premium payment. ^ ten (10) day grace pedod 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 pedod. 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 dudng any calendar month for which the Premium paid on his/her behalf was not received by KPS. Premium Rats Adjustments The Premium rates applicable to this Group Plen are defined in Attachment B - Premium Rates and UndenvHting 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 > th 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 unde~n*iting 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 Bmmerton 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: > Stdkes, 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 KP$ 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. ELIG~IBILITY 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 ti 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 ~1 fireflghtere, 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 Emr~ovses and their Desendents, including Dependents of active, full-time LEOFF I and LEOFF II firefightare, 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 Srx~use 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 Adooted Children ara 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 thrae (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 pdor 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 Pedod 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 Pedod. 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 Pramium amounts have been paid. A newborn Child who meets eligibility requiraments is coverad automatically for a period of thrae (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 Pramium 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 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 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-throe (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 pdor 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 Y 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 cenditions of this Group Plan as described in this Group Policy and the Benefits Booklet; The Enrollee voluntsdly 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 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. Covecage 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) dudng 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 ra--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 Clrcumstancee 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 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 Subscdbar 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, Subscdbars 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 Subscdbar 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 ara 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 stdke, 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 pedod of continued coverage, benefits and Premium may not be altered from that of the existing Group Plan. The Subscriber is mquirad 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 - t985) Employers who are required by law to comply with the previsions 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 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 cu~Tently 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. VVhen 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 pedods 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 exc, eed 100% of the Allowable Expense. All of the benefits provided under this KPS Group Plan are subject to this COB provision. Definitions "Allowable Expen~,eTM 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 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 ^liowed Expenses incurred under this KPS Group Plan are more than the sum of the benefits that would be payable under this KP$ Group Plan in the absence of this COB provision plus the benefits that would be peyable 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 p/us all the benefits payable for corresponding ^llowab]e Expenses under all other Plans, does not exceed the total of such ^liowable Expenses. Order of Benefit Detenninetion 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 pdmary, 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 KP$ 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. KP$' 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 parb~ 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 part7 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 Reimbursernant 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 pdor wdtten 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 pement (20%) to offset attorney fees incurred by you, and KPS will not pay for costs incurred by you. City of Bremerton Plan B 2002 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 injudes 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 adses 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 ara 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 fo raimburse a Participating Provider for the cost of Medically Necessary Coverad Services provided in accordance with the terms of this Contract, neither the Enrollee nor Group shall be requirad to compensate the Participating Provider for such services beyond the limit of Deductibles, Copayments or Coinsurance amounts specified in the Bener~s Booklet. KPS will continue to raimburse a Participating Provider for Medically Necessary Covered Services randered to an Enrollee after the Participating Provider's contract with KPS has ended, for such time as the Enrollee ramains covered under this Group Contract, until (i) the Enrollee's course of traatment has been completed, or (ii) the cera of the Enrollee has been appropriately transferred to another Participating Provider. The KPS Medical Director is rasponsible for determinations ragarding the completion of a course of treatment and the transfer of patient cara. 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 raquiraments to cover the protection of health information privacy. This law requires health insurance carriers in Washington State to provide its Enrollees with information regarding pdvacy policies and proceduras. The following is our privacy notice to our Enrollees. Non-Public Pe~onal Information means information about our Enrollees that KPS collects in conJunction with providing health care products or services to our Enraliees. 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 rasult of enrollment in a KPS Health Plan; > Information we receive from health cara Providers or other companies, such as other health insurance companies, related to medical claims and billing; and > General information about the health care services raceived by Enrollees, such as the quality and availability of services. KPS does not discicsa Non-public Personal Information about our Enrollees or former Enrollees to anyone, except as permitted or requirad by law. KPS rastricts 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 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 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 wdtten 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 frae 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 wdting that the request has peen 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 dght 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: Dectslons 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 If the Enrollee's health cam Provider, or the KPS Medical Director, reasonably determines that the Enroliae's lifo, 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 end/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 sat 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-fn/e (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 Co~tract, together with Attachment A: Benefits Booklet;, Attachment B: Premium Rates and Underwriting Criteria; and any alders and/or endorsements attached hereto, constitute the entire agreement. This Contract supersedes all previous communications, representations or agreements, either ver13al 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 dsk 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 fn3m any event which precipitated the suspension, tf 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 pedod 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 Brernerton 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 mede 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. Severabtlity 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 Attachment B Premium Rates and Underwriting Criteria For City of Bremerton Premium Rates $50 Deductible/Person 282.42 205.08 227.33 102.67 82.63 $100/Family $50 Deductible/Person $100/Family 739.04 404.87 101.01 80.73 ~nBP~ $100 Deductible/Person N/A 177.34 198.64 90.37 70.32 $300/Family $100 Deductible/Person N/A 336.27 85.48 69.11 $300/Family 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 $23.44pmpm for contract year 2003 Underwriting Criteria The Premium rates quoted above for this Group Plan ara based on the following underwriting criteria. KPS reserves the right to withdraw or rerate this offering if Group falls outside the scope of these criteria. Active, full-time Employees must work a minimum of thirty (30) hours per week unless otherwise negotiated and agreed by both KPS and Group. ~ Subject to prior KPS approval, two (2) or more health insurance carriers, including KPS, may provide coverage to Group's Employees. ~ Subject to prior KPS approval, Group may select multiple KPS health plan offerings. The minimum level of participation required is seventy-five pement (75%) of eligible Employees, excluding those employees that may be on an HMO plan. Unless otherwise approved by KPS, no more than twenty-five percent (25%) of Group's eligible Employees may reside outside of the KPS service area. The KPS service area is defined as Kitsap, Jefferson, Mason, Clallam, Thurston, Grays Harbor, Pierce and King counties. KP$ 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.