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264819 WH17E - CITV C�LERK PINK - FINANCE COUl1C11 CANAR��- p.EPARTMENT GITY OF SAINT PALIL File NO. �� BLUE,,% - MAI;OR ��,�� - uncil esolution � � Presented By � ,I Referred To Committee: Date Out of Committee By Date WHEREAS, the City of Saint Paul presently provides group hospital and medical coverage programs for its employees and employees of Independent School District No. 625; and WHEREAS, a recently formed Health Maintenance Organization, Ramsey Health Plan, Inc. , has t�ubmitted a proposed alternative plan for such hospital and medical coverage; and WHEREAS, the proposed rates for such plan are as follows: l. Employee Coverage Employee premium $25.80 Family premium $71.50 2. Early Retirees (Under age 65) Retiree $25.80 Retiree and dependents $71.50 3. Regular Retirees Retiree $14.00 Retiree and dependents $24.00 4. Regular Retiree (Not on Medicare) Retiree $25.80 Retiree and dependents $71.50 5. Retiree & Spouse (One Adult on f�"ec7'icare $54.00 COUNCILMEN Requested by Department of: Yeas Nays Christensen Hozza In Favor Levine Rcedler Against BY Sylvester Tedesco President Hunt Form Ap�d by Attorney Adopted by Council: Date � 1 Certified Passed by Council Secretary BY � By Approved by Mayor: Date Approved by Mayor for Submission to Council By By WHI7E - CITY CLERK � PINK - FINANCE COUI1C11 � CANARj_�j�EPARTMENT GITY OF SAINT PAITL File NO. �� BLUE � - MAY,OR � � . � � Council Resolution Presented By Referred To Committee: Date Out of Committee By Date WHEREAS, the Health and Welfare Insurance Advisory Committee reviewed the above proposal and recommends that it be accepted; now, therefore, be it RESOLVED, That the City Council hereby authorizes and directs the proper City officials to enter into the contract between the City of Saint Paul and Ramsey Health Plan, Inc. attached hereto; and be it FURTHER RESOLVED, That the City and Independent School District No. 625 shall pay $22.85 toward the costs of dependent monthly premium costs and the employee shall pay the balance of the monthly: premium cost in the amount of $22.85; and be it FINALLY RESOLVED, That the City Clerk shall be instructed to send a copy of this resolution to Ramsey Health Plan, Inc. COUI�TCILMEN Requested by Department of: Y eas N ays Christensen Hozza �_ In Favor Levine l Rcedler � Against By Sylvester Tedesco President Hunt Adopted by Council: Date �C 3 1 �9�4 Form App oved y City orn y Certified s d b� ouncil ecretary � gY � By Approve a or: �974 Approved by Mayor for Submission to Council By By .� � Y vr�:�� - � �� v {` � 1 � ,� n � , z�= _ ` "r j 'a'L� ,c> a " �., � � � � ��3� � � r ��1� - t �� . �. • , ` I /. . ' �� . � . �. ; � � . , � r . . �, � .. . ; . . �� ,, -.. � � .,�� ' t ,�r� �s�x � ... . { . . �, ' �. . . . � � , . �� ' t .,, " .'.. . �� .. ' .._ . - �. ,;,,. " �•v. ''� � , �..; : t� .. . , � t�.'. . �� .. r . . � , `...� ' ' . . , �.`' . ' . .'� . , � �' '�q i� �� . . . � . � � . � p. ' 1 �� . � � . - . . � 'a, ( � i � � _ � - .. � - � r e�� . � . -. r� . �. . � � . .. . . - _ - f ''+.,::. . . ..� . .; ., ,,. ., . �. � . . . .. . . " . .' . . . .. ' ' ' a ��. 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'�'. � �, �}5�� t� � . . . � . � ' � � � -� - . v�T� ��:�� . �� . � , . � . . .. , �� . -:' �.- ; . . . - .. , .. . ,�� r� \ �� , , : - , : „ � �t��,�� %'s . . , i, , ,� . - � x�:� � :;� ,' . _ ;; - � . � . -� .. . . . . . , �. ..;�;- n rs 4� �a3�,,,E'� ,. r �� a � � ... 7:�. . '� ... . . . � - '�� . � .� m'�' L^`'y �. . -. . . ' � � ._ . '- . . ... � - � . . . . - � � .. . . �.wc��-.,r � a -:i. .... - r s� . � ' • ' ' t . ��.." .-d l:7'7;.a.� RANiSEY HEALTIi PLAN BENEFITS AGREEMENT GROUP CONTRACT . CITY OF SAINT PAUL This Agreement entered into this day of , 1974, between the City of Saint Paul and Independent School District #625, pol.itical subaivisions of the State of l�linnesota, hereinafter called the "Sponsors" and Ramsey healtn Plan, Inc. , herein called "Plan", to provide fo-r the Sponso-rs ` employ�es, herein called "Eniployees", who enrol7. hereunder health ben�fits set forth in the schedule in accordance with the �ollowing co�di- tions: Benefits- The benefits to be provicled shall be as set fort:� in Part �I, the evidence of bene�its attached hereto ancl made a part of this Agreement hereunder. This certificate shall be furnished to each Employee enrolled hereunder. It is und�rstooa and agreed that portions o� the cove-rage � calling for out of area benefits are underwritten by Mid America Mutual Life Insurance Company, 2021 East Hennepin Avenue, Hennepin Square, Minneapolis, Minnesota. See Exhibit to Part II. � 1. Term: All benefits furnished by the Plan shall become ef�ective on January Z, 1975 and will continue until. December 31, 1975 and be renewecl from year to year thereafter at tne option of th� City. The Plan, however, reserves the right to change the. schedule of prertium rates .applicable to this health benefit agreement upan aelivery of notice of such change in writing to the City on or before the first day of September preceding the �irst aay of January upon which the proposed new preium rates are to become effective. In the event of such notification, tr.e City sr,all notify the Plan prior to the following December Ist of its acqui- escence or decis�on to termi�ate the contract as of the following December 31. 2. Payments- The amount of each payment due shall be the aggregate of the several amounts with respect to ,each �iployee enrolI.ed here- y , � � �� under at the time such payment falls c3ue; and the .amount so pay- . able with respect to each employee shall be determined according to the benefits for which the employee is enrollecl and the rates applicable to such benefits. Such payments shall be �made on or before the last day of the month, for each month benefits are in force, with respect to all persons enrollecl r.ereunder at the time such payment falls c1ue. Monthly payments for these bene�its snall be as follows: Structure Premiu:;� F�inployee 25.80 nnployee and family 71 .50 Retiree (under age 65) 25.80 Reti -ree and spouse (both under age 65) 71 .50 Retiree (eligible fo-r meclicare) 14.00 Retire�e and spouse (with Medica-re A and B) 24.00 � Retiree and spouse (not eligible for Medicare) 71 .50 Retiree and family (one aault on Medicare A and B) 54.00 Benefits for a new emnloyee or for additional or increased benefits for an existing empl.oyee, which becomes effective on or before tne �15th day of any month shall be provided on the basis of pay:�er,t for the full month, whereas benefits for an existir.g e:ap�oyee or for additional or increased benefits for an existing em�loyee which become effecti�e after the 15th day o� any month, s��all be provided for the balance of such month without paynent therefor. 3. Grace Period and Termination: A grace period of 31 days after the payment due aate witizout interest charge during which the benefits shall continue in force, shall be granted for any payment aue af�er the initial pay:�;er�t provided the Sponso-r has not previously given written notice to the Plan that the benefits for all enrolled l��loyees a-re to be ter,ninated as of the date of such payment. If the Sponsor fails to make payment within the grace period, the benefits for 'all enrolled employees shall be terminated at t:e ena of such grace period. But the Sponsor shall nevertheless be liable to the Plan for all payments due and unpaid, together wii.Y�. payments for the grace period. If, however, written notice is given by the Sponsor to the Plan during the grace period that tr.e -2- . benefits for all enrolled employees are to be terminated before the expiration of the grace period, such benefits shall be terminatecl as of the date specified by the Sponsor or the daLe of receipt of such written �notice by the Plan, whichever is the later date, and the Sponsor shall be liabile to the Plan for t:e pro-rata payment for the period commencing wizh the last payment date due and ending with the date or such termination. The termination of benefits shall not prejuclice any claim originating prior to the date of such termination. � 4. EliQibility of IInnloYees: The Sponsor, through its counsel, siiall have sole responsibi- lity for determining (a) the various classes of employees elibigle for enrollment under this agreement; (b) the date upon whic'r. such Etnnployees shall become eligible for benefits; and (c) the ccn- tinuation of eligibility hereunder as reflected in City Council � Resolution C.F. Nos. 231269 and 235219 and amenaments thereto, and the Plan shall be bound by such determination. � Benefits for any �nployee shall become effective upon r�is eligibiZity date provided prior written application for en-rollment is made. If written appiication is not made until after such eligibility date but within 31 aay s thereafter, benefits become effective on the application date. If application is made ma-re than 31 days after the eligibility aate, benefits shall become effective on the date satisfactory evidence of good health is furnished in writing by such E�iployee to the Plan. If any employee is not actively at work on the date his benefits would otherwise become effective, such benefits snall not become effective until the date he returns to active -reguia-r work. � On or before the last day of each month while this P.greemen� is in force, the City shall furnish to its ad,-:�inistrative agency the names of employees to be adaed to or deleted from the list of employees eligible to receive benefits under this Agreement. 5. Number of �nplovees Elictible: The number of eligible IInployees (excluding dependents) at the date of this application is active �nployees and Retired �nployees as follows: -3- . ��: � � ��:� ��. Retixee (eligible for mec3icare) Retiree and spouse (with nedicare A & B} � Retiree and spouse (not eligible for medicare) Retiree and family (one adult on medicare) � 6. Eliqibility of Em�lov�e Depen�ents: An IInployee with deper.dents may enroll for �amily ber�efits. In such event benefits for such d�pendents shall become effective on the same date as ao the employees benefits. A dep�:�de,.�c acquirecl after the effective enrollment date of an gnployee who is enrolled for family benefits shall become eligible for benefits on the date he becomes a dependent. �n Employee enrolled �o-r IInployee benefits only who later acquires a dependent, may by � making written application to the Plan, enroll for family ber.efits which shall become effective on the date of application provided such application is received by the Plan within 31 days �fter the date such person becomes a dependent. �f written application is not made until after 31 days from the date such person beco:.les a dependent, benefits s.ha11 become effective on the aate satis- factory evidence of good �iealth is furnished in writing for suc:� dependent. (It is understood that a dependent m�y be brought under the Plan regarc7less of insurability during open enrollme:�t periods and alsa following the sixth month of ernployee' s employ;zer.t. ) If an enrolled dependent is confinecl in a hospital on the date that his benefits would otherwise become effective, such benefits shall not become effective until such c7ependent ceGses to be so confined, except in the case of a new born chiZd who remains hospital confined following birth because of disease, injury, premature birth or congenital abnormality. A c7epenclent shall mean an Employee' s (a) spouse, and (b) unmarried children to the age 19, or to 25 years o� age if regularly attenaing school at an accredited institu�ior. and dependent upon employee for more than one-nalf of their s�pno-r�, � and (c) unmarried children of ar�y� age who beginning p-rio-r �o the termination ages specified above are incapable of s�lf-sustaini:�g employment by reason of inental disability or physical handicap and are chieily dependent upon the employce i'or sunport and main- tenance provided written proof of such incapacity ana dependency is furnishec3 RHP within 31 days of the date their coverage would otherwise terminate. The Plan will within one month prior to the �... . -4- � � , loss of dependency status of uny dependent, inform the �nployee . by mail of such penaing loss of dependency status. This notifica- tion 5hall contain info�raation regaraing the metho� of retaining dependency status by reason o� menLal disabi�ity or physical handicap, the dependent status as a student or through use of the conversion clause to an inaividual contract. 7. Ternination oi' I:�dividaa� }3enefits: The benefits of. any �ployee shall cease on wnicnever o� tne following s:�all first occur: (a) the failure of Sponsor �o �a1r Plan the charge for hea�tn care services Gs set forth in �aragrapn 1 ancl 2; (b) the termir.ation of Plan as set forth i:. pa•rag�aph i; - (c) the last c7ay of tr.e ;�ionthly period coincident with or r.ext . following the date of employemtn ter;nination except tha� (1) A member on leave of absence approved by the City, or lay-off, shall remain eligible for benefits hereunder for a period not to exc�ed twelve (12) consecutive months during� such leave of absence or I.ay-off 'Ay making the requi�ed p:.emium pay:ner.t di-rectly to t:�e administravite agency, anc7 (2) Eligib'ility shall not cease solely on account of a member becoming totally disabled while covered nere- unc7er; � (d) failure of the employee to make payments properly required to be due from him; (e) the giving by the IInployee of �alse ar.d material health status information when such informatian has been sought at times as set forth in paragraph 4 and 6 herein; and (f) the member moving out of the service area. A dependent benefit hereunaer shall cease on whichever the following shall first occur. (a) The date on which such person' s dependency ceases as � set forth in paragraph 6. (b) The date on which Ehiployee' s benefits terminate as set forth by State Iaw and City Council action. Termination of any benefits shall be effective thirty (30) � days following notice of mailed notice to IInployce. Sponsor snall provide the names of any employees whose benefits are about to -5- ` . . • �� ter.tinate and Plan agrees to then notify saicl Employees. 5ponsor, or . its agent, shall continue to remit premiums to Plan �or periods of coverGge extencled beyond termination up to six months. . 8. • Conversion Clause: Any employee or dependent wY�,ose eligibility for benefits hereunde-r terminates shall be entitled to have issued to him withou� eviclence of insurability an individual �lan providi�g benefits as customarill issued to indiviaual me,-nbers and co�;version . of group benetits providecl writ�en applicaticn there��r a•.:d p�yr;�ent of the first premium thereo:� is made to the Plan within �hi�ty-o:e (31) days after the date o� such employee' s or dependen`' s 'ene�i�s . hereuncler terninate. 9. Re-Obening of Enrollment: In the event of cnange of ca-rriers or on the annive�sa-ry date of this contract for health benefits, there shall be a re-open�ng of enrollment wherein employees can elect the indemnity or p'l2�alC� health plan of tY�.eir choice without evidence of ir.surabilit�. Approved as to fOrm and CITY OF SAINT PAUL execution this , c7ay of 1974. BY . BAMSEY HEALTH PLAN, INC. Attorney: � BY Q.^� Its Presi ent INDEPEi�]DENT SCHOOi� DISTRIC� -�G25 � ' BY -6- � i •. , � � . , . �, EVIDEIvTCE OF COVERAGE . • IN RAMSEY HEALTH PLAN, INC. (RHP) • RHP provides prepaid health services to Plan Participants and, upon additional payment, to eligible dependents of Pa rticipa;�ts. I. DEFINITIONS ; A. Confinement "Confinement" sha11 mean (1) one continuous hospitalization, or (2) a series of two or more hospitalizations for the same conditior., - as defined herein, in which each hospitaliza- tion is separated fronl the previous one by less than 90 days. B. Same Condition "Same Condition" means sickness or accidental bodily injury that is relatea to former sick- nes�s or accidental bodily injury in that it is (a) with�n the same ascertainab.Ze diagr.osis or set of diagnosis of the former sicicness or (b) within the scope of complications of tr,e � former sickness or accident bodily injury. C. Medical Emergency "Medical Emergency" as used herein r�eans an acute disability, either medical or as a result of injuries occurring spontar.eously and unexpectedly and demanding immediate attention. D. Co-Payments "Co-Payments" are those amounts required to be paid by the Plan Participants or Eligibie covered dependent to supplement prepaynent � for an item or service provided by RHP. E. Service Area "Service Area" includes Ramsey, nor�hern Dakota, Washington and southern Ano:{a counties in accord with a specific Service � Area map available in the RHP office. F. Plan � Participant "Plan Participant" is the person to whom this Evidence of Coverage has been issued. � . � � � � � ��:� G. Eligible Dependents A dependent shall mean an Employee ' s (a) . spouse, and (b) unmarried children to age nineteen (19) or to twenty-five (25) years _ of age if regularly attending school at an • accredited institution and depend�nt u�on the Employee for more than one-half (%) of their support, and (c) unmarried chilaran to any age who, beginning prior to t::e te rmination age (s) specified above , are . incapable of seif-sustaining employ�«ent by reason of inental disabili�y of physicai handicap and are chiefly dependent upon the Employee for support and maintenanca pro- - vided wrizten proof of such incapaci�y and depenc3ency is �urnisned RFiP within thirty- one (31) days of the date their coverage woula othezwise terminate. This written proof shall contain information rega-rai:�g the method of retaining dependency status by reason of inental disability or physical nandicap, the depende:�t' s s�a-�us as a student, or through use of the conversion clause, to an individual contract. Hospital Services: , Services are provided at St. Paul Ramsey , Hospital, St. Paul, Minnesota. II. BEI`TEFITS- Hospital- A. Room and Board Semi-private room and board in a hospital or convalescent nursing facility, provided at no additional charge for 365 days per confinement. . B. Aospital Se�rvices Provided at no additional charge for 365 days. C. Ambulance No charge. D. Anesthetist No cha rge. ..2_ � . � E. Custodial Care Not covered. F. Limitation In addition to othe r limitations stated, hospital benefits for alcoholism, mental or • emotional, chemical dependency or drug adaic- tion are limited to 73 days per calendar year. Applianees & Equipment- A. Corrective When prescribed by an RHP physiciar., a�e Appliances & covered aver $50.00 per individual (maximum Artificial $150.00 per family) each calendar yea-r to a Aids iifetime maxi�um of $5,000.00. B. Hearing Aids Not covered. Kidney Machines: Covered only to the extent that present Medicare rules pe-rmit pa rtial assistance in the cost of the use of these machines. RHP and the Plan Participant will join in the presentation of any necessary claims ;o � Medicare. The Plan participant is respon- sible for a co-payment equal to any balance � due after application of the Medicare benefits. Radiation Therapy: .No charge. Physical Thera�v_: No charge. Choice of Doctor: Services a re provided by licensed physicians associated with RHP.. Whenever possible, Plan Participants shall be per.nitted to be seen � by the RHP physician of their choice. Doctor Call Benefits : A. In Office Provided at no additional charge. B. In Home � $5.00 co-payment charge ($7.00 if between . 9:00 p.m. and 7:00 a.m. ) made for home call by an RHP physician within the service area. C. In Hospital Provided at no additional charge. -3- . �, � � . - . �� Routine Physical Exams: No charge. Suraery: A. Surgeon No charge. B. Assistant Surc�eon No charge. Maternity A. Doctor No charge. B. Hospital No charge if conception oecurs a) a�ter the effective date of coveraga and b) a�ter t�.e Plan Participan` or dependent becom,es eligible for coverage and elects dependent' s coverage. This p-rovision and the applicabl� provision fo-r benefits for Out-of-Area � Emergency Care will be waived for employees or eligible dependents who apply for coverage during eligibility periods upon cor,lmencer;�ent of employment of �he Plan Participant or during pe riods of open en•rollment. When the group te��tninates, these benefits terminate. C. Newborn Infant Covered at birth if Plan Participant has purchased coverage for eligible dependents. D. Marital Status These benefits cover Plan Participants and covered eligible dependents irrespective o� � marital status. DiaQnostic X-ray and Lab: A. Hospital � In-Patient � No charge. ' B. RHP Clinic No charge. Mental s; Emotional: A. In-Patient Mental and emotional hospital care is provided -4- for up to 73 days when unde r the ca re of an RHP physician. B. Out-Patient Diagnosis and treatment are fully covered under care of an RFiP physician, cr as referred by an RHP physician; five visits pe r year at no additional charg�; the next ten visits at ` $15.04 co-payment per visit; additional visits at $25.00 co-payment per vis��. Vision Care- A. Examination Vision analysis and eye examinations are covered the same as any other office visit. B. Eyeglasses EyegZasses, repairs and ler.s replaceme;�t are not covered, but optician' s sezvices a-re available at the RHP Clinic for Plan Pa rti- cipant's use if desired. C. Contact Lenses Not covered except as incidental to eye surgery. Prescription If prescribed by RHP physicians, druc,s will Druqs: be provided at zhe RF,P clinic at a co-�a �«e:t of $.50 per prescription up to a 34-day supply. The usual and cuszomary cos� of prescriptions for drugs written by an RHP physician and filled at a public pha��.acy � is covered after a $2 .00 deductible per • prescription for up to a 34-day supply. Claims for reimbursement shall be subMizted after $25.00 or 6 months, whichever occurs first. Immunizations: No charge AlleraY Testina: A co-payment is required to cover the cost of allergy se rum used. Chiropractic Care: Not covered. In Area Emeraency Emergency care is included for treatment at Care: RFiP clinic, and after hours at the Emergency Room at St. Paul Ramsey Hospital. If within the Service Area of the RHP clinic, jou may receive eme rgency health care services from . e. -5- - . � . . . ��.�� . ( any licensed hospital and/or physician when, for reason o� medical necessity and not � convenience, you are unable to obtain those services directly from RHP. Call the RHP . clinic as soon as possible. Out of Area Emerc,�encY Care: If a Plan Participant or covered eligible dependent is trav�iing out ot the Service Area, R�:P will pay, on a co-payment �asis, indemnity benefits as set forth in t:-�is section. A. Hospital Care I. Hospitalization - Daily semi-priva�z room and boa rd up to 365 days per , confinemen�. 2. Other Hospital Services - Up �0 365 days per confinement. 4. Pregnancy - Same as sickness. 5. Limitations: - a. Benefits for hospitalization fo� mental deficiency, psychogenic dis- � orders o-r tuberculosis are limi�ed to 70 days fo-r each period of con�ineme.t. b. Benefits for hospitalization for alcoholism, chemical dependency or c3rug addiction are limited to 73 days in each calendar year. B. Medical anc7 Surgical 1. Surgical Expense Benefits - The amou:�t Benefits actually charged fo-r any su•rgical operation performed, not to exceed �he allowa:�ce - listed in the Schedule of Bene�its . (I= that amount exceeds that allowance, a ao-payment is required. ) If two operatio:�s are performed at the sam� surgical session, the benefit shall not exceed 150 percent �� of the maximum allowed for the greater of . the allowances provided in the Schedule of Benefits. -6- � � � � 2. Office and In-Hospital Visit Benzfit - The amount actually charged for hospital � visits by a licensed physician during a hospital confinement or visits to a . licensed physician' s office, not to . exceed the allowawance listed iri t:ze Schedule of Benefits. (If that amount exceeds that allowance, a co-pay�ent is requi-red. ) 3. Anesthetist Benefit - The amount ac�ualZy oharged for the admir.istratior, of anesthesia by a licensed phys�cian, othe-r than the surgzon, in connection with . surge ry, not to exceed the al�owance listed in the Schedule of Benefits . (I� that amount exceeds that allowance, a co-payment is required. ) 4. Diagnostic X-Ray and Laboratory Be�efit - � The amount actually charged fo� laboratory ar x-ray examinatior. when .::ot co:.L�;.�d as a bed patient in a hospital, and wnzn such examinations are ordered by a Iicensed physician, not to exceed the allowance - listed in the Schedule of Benefits . (If that amount exceeds that all.owance, a co-payment is required. ) 5. Accidental Medical Ber.efit - In additia� to benefits listed above in this sectic;z 1 through 4, the amount actually cha rged as a result of an acciden;.al boGil.y injury for thz following services: a. medi.cal services b. local ambulance service c. anesthetic drugs d. x-rays � e. laboratory tests f. dressings and pharmaceutic�ls g. diathe rmy h. ultraviolet or heat treatments -7- • � � � � � � �� subject to a co-payment provision which � requires the person receiving such services to pay any amounts for such services when the aggregate charge exceeds $100.00. ' 6. Obstetrical Benefit - The amount actually charged fo-r care a-risir,r, from a p�ecnar.cy, includi�g miscarriage or abortion, pro- vided the test of zligible depe:�fi�;�ts (see definitions) has been met and the appropriate p-repayment made, not to exceed the followir.g co-payment scheaule: a. co-payraent of all charges for nis- carriage or abortion which exceed $75.00; and , b. co-payment of all charges for � obstetrical delivery which exczed $125.00 and caesarean section which exceed $200.00. 7. Schedule of Benefits - This section imposes certain limitations in the indemnity benefi�s which a-re praviGed. In the Surgical Expense Benefit, the Office and In-Hospital Benefit, zhe Anesthetic Benefit and the Diagnostic X-ra.y and Laboratory Benefit subsections, charges will be paid, as set for�h, not � � to exceed the Schedule of Benefits. This S�hedule of Benefits is deterr.tined by multiplying a point value, called the 1964 California Relative Value Study, times $6.00. The California Relative � Value Study of 1964 is a standard �or i measuring the relativz compl�xity o� ' various physician services by assigning a value index to each service. :ore difficult serviees are assigned higher -8- � � ' . . . . � . : � . . . , r • . ' • ' • numbers. As an e:ia:�ple, tr,e value sa� ' . ' • � � on the proc�dure or" �i1e rar.zoval o� �:.e • ' ' .• . appendix (appendecto.:,y) is �0 and, ` thererore, �he ir.�e,:�nity �•rouic p�ovida _ �• . � �o�c up to $2�0.0� (40 ti $6.OQ = $?�0. 00) . Com:non e:�a.;�p:.es o� o�he� units oi v�luz � are s�t fort:� ir. the �011o��i..:� sc:.aa::�a: , 0£fice Visits - *'.�dici.ne Relative Do:Ia:s Value �11o;��d ...Routine, new patient or new �istory & exam $ 2.0 $ 12 �..Initial (or subsec,uent) oizice visit, cor,��lete diagnositic history and pnysicai e.:arsination, new patient or ;.iajor i2ln�ss, including initiation . of diag:�osis and treat:..ent pro�ra.:LS . ,•, _, 6.0 , . .... 36 .. ...Follow up oifice visit, routine Z.0 6 ...Folioc�� up o:fice visit n2cessitatir.b professional - • Care over and above routine visit _ 1.5 9 Flospit2l. Visits - Lledicine ' ••� � � .. . .1.'Xniti�l hospi:.al visit, r�utine nistory and paysical •. . . � exa�ination, includin� initiation oi diagnostic and ' tredtnent prograc:s and prapa�a;.ion o� iiospitai records 3.0 1S ...Follow up hospital visit, ro�:tine 1.0 6 ...Fo21ow up nospit�l visit, necessitating care over and '� • above routir.e visit 2.0 ' I2 ...Consultation by a physician �ahose opinion is requested � by another physician, requirin? ii:.tited exa:�i:.ation o� � a given syste7 but r.ot requirin? a co.:;pletz ciaonostic hi.story and e::ar�inatioz, nor�e, of=ice or �ospical 3.0 1S ...Consultation requirino nore eltensive examin�tion S.0 30 ...Consultation requiring corap2ete dia6nostic history � ' and examination 7.0 42 Sur�ical . • ' - Y.epair - Sa��Ie . � ...4:ounds, recent , up to 22 incnes . 2.0 12 : ...For cach BC:CI lt lOi1�1 incil add 1.0 6 . Rcpair - conplex (i.�. , reconstructive sur�ery, � . eomplic�ted wounci closare, skin grafts, etc.) . � ...Up to s inctl, �orehe�d, ch�:e?:s, chin, nouth, neck • Axilla, geni[alia, nands, feet • B.0 �a8 ...Eycli.ds, nase, ears, lips � '. . 10.0 60 ...� iiich to 1 inch - scalp, arms, legs _ , 10.0 GO ...1 inch to 3 inchcs - scalp, arMS, legs �� . .22.0 . 132 • ti: . ....'. . . :. .. .. . . . .. _ .. ' . r.,-9- � • . e. , � � ,� , +� . . � �� . . . ,��g . . . . . . . . � . � � . � :} � � . • ReZativc �oilars E�S . • VaI� uC_ Allowed ...Initial treat�zent, first degree, wheze no �ore � • than Iocal treat�:.ent necessary $ Z�5 $ c� ...I?ressings, initial or subsequen� under anesthesia, small 4.0 24 ...tilith major debride�ent, per hour i0.0 60 Fractures ' ...Fiuc,erus, suroica�, neck, sinple :e�uiring manipulative re:uctioa 30.0 ISO ...Elbow, pror.erial end of ulna witn dislocation of radial head, si:^ple, colse� reciuction 20.0 I20 ...Fem,ur, neck, si:��1e or co��ou:.d, opan redection $a.� :�5� ...�n'�cle, binnzlleaiar, sic�le clos�d reduction , 30.0 I&0 . Othe. � ... Gall Bladder &�� , �80 ..�.Drainaoe oz abscess of external audi:.ory can�l 2.0 12 • . ' ' ...Ofioscopy �Eaitn :ezoval o� foreign body in external auditory auditory canal 2�.0 12 ...Y.emoval of foreign bodX from surzaee of cornea 2.0 12 � This list is not aII inclusive but is presented as represen- . tative af inedical. benefits provided �or out-of-urea e�ergencies. SASED OY Z964 C�,LIF0�2.\:11 F.EI�TIVE V�LIJE STUDIES - . . ... � . . . : ' --10- � • . . . , . , . . • . t C. Out of Area . Insurance Certain of your out of area benefits are . covered by a policy of insurance written, at no add�.tional prepayment to you, with MidAmerica Life Insurance Company of Minneapolis. Claims for benefits will be processed on your behalf and with your assistance by RHP personnel subject to the following requirements: 1. Notice of Claims - written r.otice o� claim must be given to the Company within 20 days af�er the occur-rence or , commencement of any loss covered by the policy, or as soon the reafter as is reasonably possible. Notice giver. by � and on behalf of the insured or the beneficiary to the company a4 its Home Office in Minneapolis, Minnesota, or to any authorized agent of the company, with in�ormation sufficien to identify the insured, shall be deemed notice to the company. � � 2. Claim Forms - The company, upon receipt of a notice of claim, will furnish to � � the claimant such forms as are usually furnished by it for filing proofs o� � loss. If such forms a re not furnished within 15 days afte r the giving of such notice, the claimant shall be deemed to have eomplied� with the require�er.ts of this polic1 as to proof of loss upon � submitting, within the tirae fixed i:� �hE policy for filing praofs of loss, written proof covering the occurience, . the character and tr.e extent of the loss fos which claim is made. ' 3. Proofs of Loss - Written p-roof of loss � must be furnished to the comnar,y at its said office within 90 days after the date of such loss. Failure to furnish such proof within the time required shall not �� -11- . . . . . �� invalidate nor reduce any claim if it was not reasonably possible ta give proof within such time, provided such proof is furnished as soon as �reasonably possible and in no event, except in the absence of legal capacity, later than ' one year from the ti;ne proof is ozner- wise required. 4. Time of Paymenc of Claims - Indemr,it;.es payable under �his policy wiil be paid immediately upon receipt of due w-ritten proof of such loss. 5. Lega1 Action - No legal action shall be brought to recover on benefits g-ranted in this document prio� to the expiratio:� of 60 days afte r the proof o� loss has been filed in accordance with the require- � � ments set fo�h above. No legal action shall be brought at all unless brought withir. three years �ro�:, th� exp��uti�:� � of the time within which the p roof o� � loss is required as stated above . � Exclusions: Cosmetic surgery other than restcrative surgery; rest cures and custodial ca-re; transplantation of organs (kidney transpian4s and renal dialysis are covered to the ex�e:�t of Medica re benefits available) ; se rvices of � physicians or other provider5 �aho are not �I • associated with Ramsey Health Plan, Inc. , I� unless authorized by the Ramsey �ieal�h Plan 'i Medical Director; dental care (such as repair �� and restoration) and dental surge ry are ex- cluded, except that which is required by reason of accidental injury to sound natural teeth, excision of tumors and exostoces, and � treatment of diseases of the jaw, cheek or gum; Te rmination of Coveraqe: A. The coverages afforded a Plan Participun�c and eligible dependents, if covered, can -12- , be terminated only fo-r the following reasons: . 1. Failure of RHP to be paid ::he . charge for health care coverages; ' 2 . Termination of RHP; 3. Termination of the group plan; 4. Plan Participant moving out of the Service Area; 5. Plan Participant moving o�t o� an eligible group; 6. Failure of the Plan Pa rticinar.t to make any required co-payments; � 7. A Plan Participant giving fa�se, material information at the `im,e of enrollmeizt relat�ve to tna � Participant' s (or eligib�e depen- dent' s, if cove-red) health status. Termination for this reason sr,all be limited to a period within 6 months of the date of the �artici- pant' s enrollment or renewal of _ coverages; or 8. Attainment by a covered eligible � � dependent of a Plan Participant attaining the maximum age, unless mentally disabled o-r physically handicapped as provided in Eliqi'ple Dependents. definition. Conversion: You may convert to an Individual Program, as specified by RHP, upon termir.ation of groun coverage, without proof of insurability. The form of this Program is avaiiable ror inspection by writing or calling the RHP clinic. -13- � � �� Identification: Each Plan Participant shall present an authorizec7 identification card at �he time RHP health services or care is requested. Coordination - of Benefits & In the event you have coverage under a health � SubroQation: benefit plan (including Health Insurance for ' the Aged undar Social Security, called Medicare) in addition to this Plar., the amounts payable under this Plan wiii be raducea if the other plan must pay first, to tr.e exte:.t that the total amount pay�ble under aii plan� � during a claim d�terr,iina�ion pe-riod snall . not exceed lOG/ of the al�owabie expenses. The claim dete-tmination period shall �e a calendar year. The order in which said plans will pay benefits shall be dete;.,ained as follows: (a) a plan without a Coordination of Benefit provision sY�.all pay benatizs before a plan with such provis ion, (b) a pla:� cove r- � ing a person as a subscriber, policy owner, certificate holder o-r simiZar sta�us shail pay benefits befo-re a plar. cove.�ing t�.e same person as a depzndent; (c) a plan cove-rir.g a person as a dependent of a female person; (d) when several plans cover a persor. as a subscriber, policy owner, certificate holde�.,: or similar status, the plan with tne ea-rliest effective date shall pay before a pla:. with a later effective date. Allowable expenses are those expenses at least a �ortion of which are covered by one of the plans involved. In the event you are entitled to payment for care rendered on account o� inju��y or aisease ; (1) arising out of and in the course o� you-r � employment, or (2) , arising f-rom injury or - illness through thz act or omission o� a third person, the Plan is entitled to reimbursement for the reasonable value of the ca re and services furnisned, to the ex�ent of compensable benefits or damages recove rable. The Plan is entitled to d�termine whet:�er and to what extent you have indemnity or -14- other coverage. In cases under the Workmen' s Compensation Act, or similar law, the employer . � or his ca rrie r have the prior obligation to provide services or indemnification. The Plan shall be subrogated to your rights . against the third persons or your employer to the extent of the reasonable value of such ca re and se rvices including the righ` to bring suit in your name. In the even� you a re entitled to receive � care ar.d se��vices in a hospital or medical institutio:� awned or operated by a natior.al or sta te government or any agency thereof, . such government or agency has the p-rior obligation to provide such care and services. In the event you receive care or services arising directly or indirectly f•rom ,wa r or any act attribu�ed thereto and the r.ational or�state gove-rnment o-r any agency thereof provides for such care or services, such government or agency has the prior obligation to provide tne same. Complaints: You may present any complaints ycu may have about the health care you rece-ived. If you wish to use this system, follow tnis pracedure: A. Written complaints should be addressed �a: Ramsey Health �lan, Inc. Membership Se-rvices Committee 640 Jackson S�reet St. Paul, Minnesota 55101 . where they will be considered and you will ',�e contacted within 3 working days of the � receipt of your complaint. B. Any complaint not resolved atter an : informal discussion will, upon Plan _ . Participant request, 'pe heard within 90 days before the full Membership Servic�s Committee at which there may be received testimony or explanations or other • -15- '\ . � � �� . . �� information from Plan Participant, staff persons, administrators or other - � persons as deemed necessary. Within 30 da�s r"rom the hearing, written notice af findings snall be given the . complainant. �I C. Any complaint yet unresolved shall be su'Aject to arbitration accordinC to the provisions of Chapte-r 572 or 1iinr.eso�a Statutes, the cosi: of which shall. be borne by Ra�nsey HeaZth Plan, unless tr.e P1an Pa rticipant elects to litigate his . complaint prior to subraission to arbi- tration. D. Neutral arbitrator(s} shall be selected . by the Chief Judge of the Dis�rict Court in and for Ramsey County. Plan Participant Opinions: Pian Pa-rticipan� opir�ior. may be expressed to the Membership Se�vices Conmit�ee or �he � Board of Direc�ors by no�ifying the RHP Administrato� at 225-7867 and asking to appear. Boa� � Directors: . PZan Participants have the right to annually nominate and to elect members for the Board of Directors oi RHP. Call the clinic for a copy of the Bylaws provision applicable to such right. . Gove rnmenta 1 Reaulations: Providing health care se-rvices to yau �y RHP is gove rned by Federal, State ar.d muni- � cipal laws and regulations. The StGte oi Minnesota, through its Department of H2a1t,1, � maintains a regulatory unit to gov�rn the conduct of RHP. Inquiries with res�ect to � the regulation and conduct of RHP may be directed to: Health Maintenance Organization Unit � Minnesota Depar�ment of Health 717 S. E. Delaware Street Minneapolis, Minnesota 55440 -16- o � � , . , I SCHEDUi�E OF BENEFITS . , - Section II . A. Definitions 1. "Act" means the Health Niaintenance Act of 1973, Minnesota Laws 1973, Chapter 670, Minnesota Statutes, Chapter 62D. 2. "Complaint" tne�ans any written enrollee grievance against a health maintenance organization or provider a rising out of the provision of health care se rvices, and which has been filed by an . enrollee or his representative in accordance with Minn. Reg. 370 and is not or is not yet the cause or subject of an enrollee election to litigate. 3. "Comprehensive Health Maintenance Service" means a group of services which includes at least all of the types of se rvices defined below: (a) "Em. erqencV Care" means professional health serv'ices immediately necessary to preserve life or stabilize health. (b) "In-patient Hospital Ca re" means necessary hospital services affording residential treatment to patients. Such services shall include room and board, drugs and medicine, dressings, nursing care, X-rays, and laboratory examination, and other usual and customary hospital services. . � �� ` � � � � � �� (c) "In-patient Phvsician Care" means those health services performed,� prescribecl or supervised by pr.ysicians .� within a hospital, for registered bed patients therein; which services shall include diagnostic and therapeutic care . (d) "Out- atient Health Services" means ambulatory care including health supervision, preventive, aiagnostic and therapeutic services, including diagnostic radiologic, treatment of alcohol and other chemical dependency, treatment of inental and emotional conditions, provision of prescription . drugs and other supportive treatment. (e) "Preventive Health Services" cneans heal�r. education, health supervision including evaluation and follow-up, ' immunization and early disease detection. 4. "In A rea Services" are those services provided within the geographical areas se rved by the health maintenance organiza- tion as describecl in its application for a certificate of authority and any subsequent changes therein filed. 5. "Out of A rea Health Ca re Services" are those services provided outside of the health maintenance organization' s geographic service area, as such a rea is described in the health maintenance organization' s application for a certificate of authority, and any subsequent changes the rein filed. . .. _2- . �. . . : ,��g�9 6. "Provide" as that word is used in Minn. Stat. §62D.09 means to send by United States postal service, by alte rnative ca rrier, or by other method to the place of residence or employ- ment of each enrollee or, if such enrollee is a member of a specified group covered by a health maintenance contract, to the office of the authorized representat�,ve of any such group. - 7. "Formal Procedural Requirements" means those rules governing the conduct of administrative hea rings applicabie to and affecting the rights, duties and privileges of each party . � to a "contested case" , as such te rm is defined and as such rules are set forth in Minnesota Statutes, Chapter 15. 8. "Enrollee Co-payr,tent Provision" means those contract clauses requiring charges to enrollees, in addition to fixed, prepaid sums, to supplement the cost of providing covered compre- hensive health maintenance services; "enrollee co-payment provi- sions" also means the difference between an indemnity benefit and the charge of a provider for health services rendered. 9. "Summary of Current Evidence of Ccveraae" means wrizten notice to be provided to enrollee by eve-ry health maintenance organization as prescribed in the Act. Such notice shall describe changes in health maintenance contract coverage but need not necessarily be specific as to changes respecting the coverage of . e. -3- � . . any individual enrollee. 10. "Open Enrollment" means the acceptance for ceverage by health plans of group enrollees without rega rd to underwriting restrictions, and coverage of individual or non-group en�ollees with rega rd only to those underwriting restrictions-germissible under Minn. Stat. §62D.10, Subd. 2 . 11. "Period of Confinement" means a period of time specified � in a health maintenance contract relating to the amount of days of in-patient hospital care and defining a period cluring which an � � enrollee may not receive any in-patient hospital care in orde r to become er.t:.tle� to a renswed period of hospital coverage. This term means the same as "spell of illness" and similar terms as they may be used in provisions to limit hospital care. B. Services Provided by Ramsey Health Plan, Tnc. 1. Such eomprehensive health maintenance services shall include but need not be limited to: (a) emergency in area health care services which are - available twenty-four (24) hours a day, seven (7) days a week; (b) are provided either directly through Ramsey Health Plan, Inc. ; (c) are provided by a physi- cian and other licensed and ancillary health personnel, -4- � . : �� as appropriate, readily available at all times; and (cl) cover enrollees requiring such services but who, for reasons of inedicai. necessity and not convenience, are unable to o'Atain them directly from Ramsey F-:aaith Plan, Inc. 2. Out-of-area services include out-of-area emergency care; 3. All in-patient hospital care except as exclusions o:: limitations are hereafter permitted; 4. All in-patient physicians care except as exclusions or - limitations are hereafter permitted; 5. All out-patient health services except as exclusions or limitations are hereafter permitted; ancl 6. Preventive health services. C. Limitations and/or Exclusions. The following limitatior�s unon ancl/or exclusions from the foregoing comprehensive health maintenance services are: l. Corrective appl'iances, artificial aids and nursinq � services are limited to a co-payment as follows: If a member requires any of the following services, . appliances or equipment ana has expended $50. 00 ($150 maximum per family) for such items c7uring any one calendar year, RHP will pro- vide such adaitional services, appliances, or equipment, in excess -5- , � of $50.00, as may be required during that year, witnout further ex;nense to the member.. Visiting nurse services, or other licensed nursir.g � service, such as special Guty nursinr at nome or in a legally constitu�ecl and opera�ed hospital, as may �e deemed necessary �y the at�ending R� p�ysic�.an. Hospital beds, crutches, wheelchairs, belts, t��:sses, lamps, artificial eyes anu lim'r�s ar.d ot:^.er �rost.et�c appliances (except dental nrosthetic ap�liances) , orthopecic appliances and incontinence app�iances, as are prescribed by the a�tending RHP pizysician. RHP wi1.1, however, pay for dental prosthetic a�pli- ances in the event of accidental injury to sound natural teeth. Oxygen ancl the renta? o� equipment for the aa.ministra- tion of oxygen, when prescribed by tne attending R�� physician. � 2. Cosmetic surgery other than restorative surgery is :�ot - covered. � • 3. Dental care (such as renair and restoration) and ce:�t�: surgery are excluded, except that wnicn is required by reason o� accidental injury to sound natural teetn, excision of tu.mors anc� exostoces, and treatment of diseases of the jaw, c:zeek or gum. . -6- . � � � � ` - ��,:�.�°�� 4. Eyeglasses, repairs and lens replacement ,are availabl.e at a reduced cost. Contact lenses are not provided except as incidental to eye surge ry. ' 5. Kidney transplant and renal dialysis are provided, but benefits are coordinated with other medical coverages (no age requirement) . ' 6. Custodial and/or domiciliary care are not covered. 7. Injuries while incur-recl on military duty are not covzred to the extent that such care is, in fact, covered in another program of coverage. 8. Home physician care benefits are provided subject to a $5.00 co-payment ($7.00 if between 9:00 p.m. and 7: OO� a.m. ) made for home call by an RHP physician within the Service area. 9. There is no coverage �or serv.ices and other items r.ot prescribed, recommended or approved by an RHP physician. 10. There i.s no coverage for maternity hospital care for an employee or an enrolled dependent if conception occurs prior� to the effective date of coverage. This provision will be waived _ for employees or eligible dependents who apply during pe-riods of open enrollment. � � � 11. Mental and emotional in-patient hospital care is limited to 73 days ana to treatment under the care of an RHP physician. -7- ' Out-patient diagnosis and treatment are fully covered under care of an RHP physician, or as referred by an RFiP physician; five visits per year at no additional charge; next ten visits at $15.00 co-payment per visit, additional visits at $25.00 co- payment per visit. 12. I£ prescribed by an RHP physician, drugs will be pro- vided at the RFIP clinic at a co-payment of $.50 per prescription up to a 34-day supply. The usual and customary cost of prescrip- tions for arugs written by an RHP physician and filled •at a . public pharmacy is covered co-payment basis of $2 .00 per presc rip- ;� tion for up to a 34-day supply. i 13. In-patient hospital care is limited to semi-private se Hosnital . � room and board and hospital service in St. Paul - Ram y ,, or a convalescent nursing facility at no charge foY 365 days per confinement, except for certain conditions as noted he rein. 14. Hospital benefits for mental or emotional, a7.coholism, chemical dependency or drug addiction are limited to 73 days per , calenda r year. , � 15. Chiropractic care is not covered. 16o Hearinq aids are not provided. 17. Kidney machines are provided only to the extent of reimbursement from Medicare. -8- ✓ . : �� . 18. There will be a charge for allergy serum to cover its cost. . 19. Experimental transplantation of organs is not covared. 20. There is no coverage for services of physicians or other providers who a-re not associated with Ramsey Health Plan, Inc. , unless authorizea by the Ramsey Health Plan Medical Director. • 21. Out-of-area benefits are providec3 on an indemnity basis. See Exhibit to this Part II Section and applicable portion of Part III. D. P,iscellaneous � (1) Coordination of Benefits and Sub roqation: In the event the employee or enrolled dependent have coverage under a health benefit plan (including Health Insurance for the Aged under Social Security, callea Medicare) in addition to this Plan, the amounts payable under this Plan will be reduced if the other plan must pay first, to the extent that the total amount payable unde•r all : plans during a claim determination period shall not exceed lOG% � � of the allowable expenses. The claim determination period shall be a calendar yea r. The order in which said plans will pay bene- fits shall be determined as follows: (a) a plan without a Coordination of Benefit provision shall pay benefits before a -9- ` ; - w plan with such provision, (b) a plan covering a person as a sub- scriber, a policy owner, certificate holder or similar status shall pay benefits before a plan covering the same person as a dependent; (c) a plan covering a pe rson as a dependent of a female pe rosn; (d) when several plans cover a person as a sub- scriber, policy owner, certificate holder or similar sta�us, the plan with the ea rliest effective date shall pay before a �la;� with a later effective date. Allowable expenses are those ex- penses at least a portion of which are covered by one of the plans involved. In the event the employee or enrolled dependent are entitled � to payment for ca re rendered on account of injury or disease (1) arising out of and in the course of his employment, or (2) arising from injury or illness through the act or nmission of a third person, the Plan is entitled to reimbursement for the reasonable value of the care and services furnished, to the extent of compensable benefits or damages recoverable. The Plan � is entitled to determine whether and to what extent he has in- � demnity or other coverage. In cases under the Workmen' s Co:�per.- sation Act, or similar law, the employer or his carrie r have the prior obligation to provide services or indemnification. The Plan shall be subrogated to his rights against the third persons . ..-10- , ', � . - ; �� or his employe r to .the extent of the reasonable value .of such care and services includ�ng the right to b-ring suit in ais name. In the event the employee or enrolled dependent receive care or services arising directly or indirectly from war or �ny act attributed thereto and the national or state gover:�rlen� o-r any agency thereof provides for such ca-re or services, such government or agency has the prior obligation to provide the same. ' (2) Investiqa�ion: RFiP is empowered to make such necessary � investigation as is necessary to effect coordination of bener"its and sub rogation. -11- . . i � � � � � . � . � . . ' -� ��1� or a:��.a � ' � • HOSPITAL, N�DICAL, StJRGICAL INDLYLL1iITY BE�rEF'IT The Company will pay zhe follo��ing benefits when a person is (a) traveling outside of the geographic area served bf the Ra.�`ns�y ;iealth PJ_an Medical ' Center, away �ram h�s pe��.nent plwce. oi residence, and requires e�.re s'or _ � � a medical emer�ency, or (b) is �emporarily residin,�, outsid� of t:�e Service Area and �.way �rom his pernanent_ place o� :esidence for at least 30 •iays but less than one year and is treated for a sickness or accidental bodily in�ury. , HOSPI'�AI,IZE1TIOi1 BENE:'ITS , . ' Da.ily Roc:: ?enei it - T::E arc�ount actually char�ed by the 'r.ospital to a Pz:son �or room �.nd �o��d �or e�ch day duri�� each �eriod o� . eor�fine::,e:,;:, bu� not �o exceed the fu�1 ser��-pr�vat� roor,; cost o: • ' the average se:;i-private roor� cost if confined in o�'r.er -tnan a • semi-pr�vate roon for each day so con�ined up to a maximw;► o� 305 days. � . Other �;os�ital Serv�r_es - �he amount ac�tual]_y cr�ar�ed by �r�e hospi�cal to a Pe-rso.l �or all necessa:y services, supplies, d�-�ugs, ::eciica�ior.s . a.nd pr�a�„aceuticals provided by t��e nospitai, other �r.an daily hospital rocm, �tensive care or syecisl nursinb care, or �or acmir.- is�raiion of an anesthetic, which �n.e Pe-rson receives and uses durin;; � such conl�nemen� and wnicn a-re �rescrioed by a physician and necessa�y in the trea�r�ent of such Person. Intensive Care 3er_efit - Tne amount actua.liy charged by the hospital to a Person ior tre c.a.iiy use o� inzensive care facilities up to t'r�e maximu� of 30 cla.ys for each hospital adraission. � P:e�.�c,y y�ne�'it - B�r.Qiits �or �reCnancy arz pwid the sarne as a�f � other sic=ti�ess excep� t�at such ber.efi�s are p�.;fable onl�� if a Pzrson i�s been continuously insurea ior at least nine i�ont��s prior • . to ter�.ina�ion of pre�.wncy. A nine mon�h extensic,n oi benefi�s is . . provided following tei^x►ination of coverage. ' Eh'T�A?SIO':`? OF BE��r ITS ' . If a Person who has oeen t�tall,y �,r,d cont�nuously disabled from the - � date of ter:�ination of nis covera.ge is hospitalized wi�.�:�.:� �0 dcLjrS o° - such date, the s�e hos��ta�l ber.eTits will �e psyable ��- such con- finemer.: as would have been payaole "r�ad cove:age not �e�::inated. I�L'iI'I'ATIO?.'S The max:xi:� nospitalization benefit fo: an out of area e:r,ergency is �10,000.00. � . Bznefits for hosp�tali�ation for mental deficiency, psyc'r.o�enic dis- • orners or tuberculosis are limited to 70 d:.�ys �or each �e-riod of • confiner.ient. � • Bene�its for hospitalization for alcoholism, chemical dependency or dru� addiction are limiLed to 73 days in each calendar ��ar. "Hospital" � { . . � � . � .� � . . . f . � _ . • ��g.�� as used in this particular bene�it lir,�itation shall include a licensed , residential prL�ary,treatment cenl:er f'or trea.tment oi alcoholi�r., chemical de�endency, or d.�-u� addiction when confineme:�t therein is pursuant to dia�nosis or recoit�;,endation by a doc�or of inedicine. . . . . ., MEDIC�IL, SURGICAL B�,iVEFITS , S�1r�ical E�p°nse Beneiit - The 2ssount actually charged for loss incurred oy a Person ur.der eitY:er (a) or (�) above fo� �ny surgical opera�ion perfo::,ed on sucn Person by � physician, not to exceed the allow�,.nce �or such ope:ation listed in the 196�+ Cali�ornia Relative �Value Studies deterrnined by :,iulti�lyin� the Units of • Relative Value by a u:�it Value r a.c�or oi �y6.00. - � � If ti�ro or more sur�ica�. operations are p�rfo�ed in the course os" a sir.�;le incis�on, by ti'r.e s�s;,e sux•�i.cal appro�.c:� or ir� the sa:�e � . operatiJe fiel�, na ...ent s;7a11 be made ior ttze largest be.efit _ � provided in t'r.e i9o�+ Cali�ornia Relative Value Studies for any one • such operatio:z. ' • If two or r,.ore surgical operations are perforr�ed at the• same operative � session in separate opera�;ive iields and. tr�rough separat� ir�cisions, payz:�,ent will �e made ior the surgical operation providing �he larjes� max�:wm paymen� as set fox•th in the ig64 c�.�iz o-r:.ia Relative Va�ue Studies plus 7� oi the sum or the r�.a.xi�lum pay:�en�s for the other sur�ical operations as se� £orth in said Studies. � In no event shall t'r.e total amount payable ur�der this benefi� for aI1 surgical op�r�tio:,s perioi;:�ed on t;e Person as the �e�::�1.t of (�.) cr (b) above exceed 15C o of the maxi�:u� �nounZ as sta�ed in tc.e 1G6� CaZiforni�. �elativz Value Szudies. Office a.^.d In-I?ospi��il �Tisit B°nefit - The ��ount �.ctt:a.11y char�ed for • loss incu-rrea oy a P•�rson u�der ei�her (a) or (b) �.bove io� (1) nospical visits by a phfsic�an (o�her tnan a resident p�ysician oi a^y hospital) . during such Persoh's hospital co:_finer�er�� or (2} for sucn Pe-rson's visi�s to a physici�.n's o�yice, r,ot �to e�ceed �:�e allo�f-ance zor sucn visits as � . listed in the 196�+ Cal�forn�a Relazive Value Stuciies d��err.�ined 'oy multipl;ji:�g tr.� Units of.Relative Val�.e �y a Unit Value .4actor o� $6.00. No benefits shall be p3yable �or any visit r.:ade in con^�ction with a , sur�ical operatior. or in connection with a pregnancy or any complicat:.on or sequel�.e thereoi. � . • Anesthetist Ber.efi� - ihe �saount �.ctual=�y charged ior loss irlcurred 'c;� a Persor: l,;nder eit�er (�.) or (b) above ior tre ad:-�ini��t��;ion o° anesthesia by a �ny�ici�.n in conr.ect�on «ith sucn Per��c_:`s surgery, no� • to exceed the allok*wi.ce ior sucn aa*��nistra�ion oi a-r.e.-�Y:esia as 1is�ed , in the 1Go�+ California Rela�ive Value Studies dete-ri;:ine : by multi�iy�r.� � the Units o� Relative Vaiue by a linit Value Factor of �:`.,�.00. Tnia beneiit is only payable to:�rard tr.e expense of a physic��.: o�ner tnan trie � ' sur�eon wno pe:ior:ns the surbery. ' , , Dia�ostic X-Ra;� C�d_ I��.bcr�.tor�f B°r.ei it - The �mount aclaally charged •� for loss incurreu. oy a Person unaer ei�L'ner (a} or (b) �'::ove, up to � a maxir.n;.;� of �50.00, for laboratory or x-ray e;caminations made while such Person is not confined as a bed pstient in a hospi�al and when ' t ` + ��. ... . . . . � . ' such exar,�inations are ordered by a physician. No benefit i�s payable 4��'�� . fo: dental x-rays. � � � .;�� - The amount actually char�ed for loss ! Acc.�..-ntal �iedic�l P�e�efit �ove, up � incurred 'u;� w P°r�on unuer either (a) or (b) a to a maximum , � , of $100.00 for t:�e i.olio�aing serivices rer,dered as a result of ��nf one f accidental bod�ly injury sustained by such Pzrson, or its complications ; or sequeiae: :aedical services, local �abulance service, anesthetic, drugs, ; x-rays, laooratory te'sts, dressings and pharmaceuticals, diatherniy, � ultravi.olet, or r�eat �reatments. t , put-Patien� EY�ense Benefit - Tr.e a.mount actually charged for loss ! incur.ed oy �. Per�on una=r ei�her (a) or (�) above for the followir.� � out-patie::c services rer�:e:ed such Persor� in �ne out-patient department oi a hospi�al: er:��gency roo:�, anestnezic, operating room, druos, dressings :.r�d pnar.naczuticals, :�-r�.ys and laooratory tilOY•lc. Obs�e�rical Bene�it - The �coun� actually charged for loss incu-rred bf � � a Perso:� ��:itihir. �ne limi�ts oi i?ie iollowir.� schedule ior such Person's � � care arising fro:a a pre�ancy, ynclu�ir.o a��scar-riage or aoortion, prov�.�°d such Perso:� has been contir.uously i:�surea for at least nine months prior to te�ination of pregnancy. � � ?5.00 - �iiscarriage or �bortion u�der (a) or (b) above. � �125.00 - Obs�etrical Delivery under (b) above - no . obstetrical delivery beneiit unde-r (aj• �200.00 - Caesarean Section under (b) above - no caesarean section oenefit un�er (a) . • . � � • D�"INITS0�7S � . . "perio� oi Confinement" sr.all mean (1) one continuous hospitalization, or (2) a series o� tTao or ::ore hospizal�zati^ns f'or tl�z sa.:�e condition, ' � as defined herein, in wnich each hospitalization is sepurated �rom tne previous ore by less than 90 ciays• . "Sa�ne Condition" means siclmess or accidental bodily injury tnat is reZated to for�e-r sicl�ess or accidental 'oodily injury in that it is • (a) within �he. sa.s.ne ascertainable dia6nosis or set of' diabmoses of . � the former sick:�ess or (b) within the scope of cor.:pl�ca,iqr.s or seqkelae . of the fo�rier sich-riess o-r acciaental bodily injury. . "�edical �ergency" a� used herein raeans an acute disab�_1i�y, either medical or as a resul� oi i:�juries occu:ring spor.taneou�ly ar.d une:c- pectedly and demancing ir.�ediate atter,tion. - "Service A:ea" as used herein z:�eans that area within a �� rr.ile radius ' • of a Ramsey Health Plan NI°dical Center ur.less otnerwis� noted by ter:;�s • of the gr�up ap�lication. • � COORDIZJATION OF BENEFITS • � The Coordi:.ation of B°nefits provision is intended to prevent payi;�ent of benefit;s which exceed expenses. It applies when a Person covered by r � ' y� . . - . �� . . . Ramsey Health Plan i� also covered by 'another health plan or plans. When more tha.n one such plan exists, one nonmslly p�ys its benefits in full and the other pays a reduced benefit. In apolying the Coordination of Benefits provision i�ic�l.merica will �.lwa,ys either pay its benefits in full • or a reduced a.mount� which, when added to the beneiits by the•other plan . � ' or plans, will equal 100� o� the allowable expenses. ' ' � DEPENDLI�TTS � � � � � Spouse and all ur.married children under 19 years of age or to age 25 � if a student, �,.-�arried and depender� on the e.-nployee. To a:�y aqe if � � an unn�arr�ed de�endent cniid T.1dJ physica�ly ha:�dicapped or mentally � retarded nefore re�,chinb aoe 19, or if a stude:t, age 25. EXCLUSIOVS Benefits are r.ot paid for (1) claims arising d�-rectly or indirectly fro:� insurrecti�n, war, or arly �.ct attri'outed tY:ereto; (2) ser�,�ices or facilities p-rovided 'oy a nospi�cai or medical i�stitution o�tined or • operated ny a na�ional or state ;overn.;,er:t or any agency thereoi, i:.nless charges for sucr. services are i.:.posed against the P�-raon; (3) cases �. payable un�er �Tor�c:an`s Co:.ipensatior. or �nployer's Liability �c�s; (�+) cosr�e�ic surgerf; (7) attempted suicide; (o) rest cures and custodi•al ' care; (7) transplantation of organs; or (8) dia�ostic woric when cur��ve � treatment is not given ciuring hosp�tal coniineT.ent.