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Home My WebLink AboutRES 880231 - Contract Share Health PlanPage-,. of 2 A RESOLUTION APPROVING A CONTRACT BETWEEN THE CITY OF GEORGETOWN, TEXAS ffiD SHARE HEALTH PLAN OF TEXAS i INC. , A HEALTH MAINTENANCE ORGANIZATION (HMO),r TO PROVIDE AN OPTIONAL HMO HEALTH CARE PLAN FOR THE CITY OF GEORGETOWN EMPLOYEES AND DEPENDENTS AND AUTHORIZING THE MAYOR TO EXECUTE SAME AND THE CITY SEC TO ATTEST. WHEREAS, the City of Georgetown, Texas has a personnel policy that provides. health care insurance to the City's full-time employees and eligible dependents; and WHEREAS, Federal Law requires that a Health Maintenance Organization Plan be offered as an option to employees; and . i WHEREAS, the City of Georgetown has received proposals from qualified HMOs, Share Health Plan of Texas, Inc., Texas Health Plans, Inc., and Travelers Ins rance; and WHEREAS, the City of -Georgetown and Share Health Plan of Texas, Inc. desire to enter into a contract to provide an optional Health Maintenance organization plan to city's full-time employees and eligible dependents; NOW THEREFORE BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF GEORGETOWN TEXAS; SECTION I. That the City Council of the City of Georgetown finds that the cecitals set forth above are true and correct and are incorporated herein. - SECTION II. That the City Council approves the contract between,the City of Georgetown and share Health Plan of Texas, Inc. for a Health Maintenance Organi- zation Plan which contract is attached hereto and incorporated herein, as if fully set forth at length. SECTION III. That the contract shall be for a period of September 1, 1981 through September30, 1989. 5ECTION IV. That the Mayor is hereby authorized to sign the contract and the City Secretary 1s.,authorized to attest. Passed and Approved the 12 day of July, 1981 APPROVED: Tim, "Kenr6edy, May R,ESOLTJTION NO. Tons I Page 2 -'Of 2 wp� Leta I lloughby, Cit retll 110MORSMUM WOVIVIRWO-4 0 TO: nayor and Council FROM: q4vnise Lebowitz, Personnel Administrator THROUGH. artley Sappington, Director of Community Services SUBJECT: Share Health Plan Contract - Health Maintenance Organization The City of Georgetown was approached by three Health Maintenance Organi- zations requesting that we offer their health insurance program to our employees as an option to our conventional health insurance program. Fed- eral legislation has mandated that if we do not offer such a program and we are petitioned to do so, then we can be mandated to offer a HMO to our employees. The City has chosen to voluntarily comply with this federal mandate. Below is a. brief overview of the proposals submitted by Share Health Plans, Texas Health Plans and Travelers Insurance; included is a basic benefit profile. EMP.ONLY $ 81.42 $ 80.88 $ 78.00 EMP.& SPOUSE $170.14 $181.98 $187.21 EMP.& CHILDREN $157.99 $165.81 $156.01 EMP.& FAMILY $255.18 $254.77 $257.41 BENEFIT SUMMARY - CO PAYMENT REQUIREMENTS Office visit $ 0.00 Specialist Mmergency Room $ 20.00 at Hospital e •g $ 10.00 $ 10.00 $ 10.00 $ 15.00 $ 50.00 per day $150.00 per $250 s • $ 25.00 $ 25.00 $ 5.00 $ 5.00 Maternity $ 0.00 $ 10.00 lst visit Only $ 15.00 Ea. Dr. Visit **Travelers Insurance has withdrawn their proposal as of 6129/88. They advised that there would be an increase in the above proposed rates and that due to the amount of the needed employee contribution, they feel that their interest would not be secure enough to allow them to offer us an HMO plan. It is our opinion that Share Health Plan is the best HMO for the money. This plan requires no or little co-payment by the employee for almost equal and sometimes less cost than the others offer. Share provides a good phy� 8ician base in Georgetown and the service area of Austin and Round Rock. Attached is a listing of those participating physicians in Georgetown. As you will note in the contract terms, Share Health Plans has agreed to a 13 month contract for fiscal year 88/89. Share Health Plans coverage does not provide life or accidental death and dismemberment insurance as does our conventional program currently provided by American General Insurance. American General Insurance has agreed to allow those employees who wish to elect the HMO option to purchase life and accidental death and dismemberment insurance from American General at our regular group rate. Employees will be given a full briefing in a series of meetings which will be conducted by City Staff with participation by Share Health Plan and American General representatives to explain the benefits of both programs. Employees will be advised that they must pay for costs of the HMO program which is in excess of single or dependent coverage cost of the conventional insurance program through a payroll deduction plan4 A resolution is being presented to you for consideration whichi if passed, would allthorize the mayor to execute on behalf of the City of Georgetown the contract with Share Health Plans and affirming the City Councills agreement to offer a health maintenance organization as a health coverage option to the employees of the City of Georgetown. FAMILY PRACTICE Kenneth Ar stro g, M.D. 2300 Round Rock Avenue # 105 Round Rock, Texas 78681 255-6669 Office Hours: Mon.,Tues.,Thurs.,Fri.: 8:15 - 5:00 Wednesday: 8:15 - 12 noon Open every other Saturday until moon Douglas Beold, M.D. Georgetown Medical Clinic 2100 Scenic Drive Georgetown, Texas 78627 255-4454 Office Hours: Mon. through Fri.: 8 am to 12 noon 2 pm to 5 pm Stephen. Benold, M.D. Georgetown Medical Clinic 2100 Scenic Drive Georgetown, Texas 78627 255-4454 Office Hours: Mon. through Fri.: 8 am to 12 noon 2 pm to 5 pm Thomas Bomfalk, M.D. Georgetown Medical Group 2100 Scenic Drive Georgetown, Texas 78627 255-4454 Office Hours: Mon. through Fri.: 8 am to 12 noon 2 pm to 5 pm Jim Donovan, M.D. Georgetown Medical Group 2100 Scenic Drive Georgetown, Texas 78627 255-4454 Office Hours: Mon. through Fri. 8 am to 5 pm Saturday: 8 am to 12 noon Hal Gaddy, M.D. Georgetown Medical Group 2100 Scenic Drive Georgetown, Texas 78627 255-4454 Office Hours Mon. through Fri.: 8 am to 5 pm Saturday: 8 am to 12 noon, Richard S. Moon, M.D. Brewster & Curry Florence, Texas 76527 793-2651 Office Hours: Mon.,Tues.,Wed.,Thurs�.: 9 am to 12 noon 2 pm to 5 pm Thurs. and Sat.: 9 am to 12 noon Richard Pearce, M.D. Georgetown Medical Group 2100 Scenic Drive Georgetown, Texas 78627 255-4454 Office Hours: Mon. through Fri.: 8 am to 5 pm Saturday 8 am to 12 noon James L. Shepherd, M.D. Georgetown Medical Group 2100 Scenic Drive Georgetown, Texas 78627 255-4454 Office Hours: Mon. through Fri.: 8 am to 5 pm Saturday: 8 am to 12 noon John R. Webb, M.D. Georgetown Medical Group 2100 Scenic Drive Georgetown, Texas 78627 255-4454 Office Hours: Mon. through Fri.: 8 am to 5 pm Saturday. 8 am to 12 noon WILLIAMSON COUNTY Family Practice (continued) Greg Willis, M.D. 805 N. University Avenue Georgetown, Texas 78626 869-4714 Office Hours Mon. - Fri. 8:30 - 5:00 INTERNAL MEDICINE Michael Nacol, M.D. 1504 Leander Road Georgetown, Texas 78626 863-7811 Office Hours: Mon. through Fri.: 8 am to 5 pm Saturday: 8 am to 12 noon Susan Srovan, M.D. 116 West Davilla Granger, Texas 76530 859-2500 Office Hours: Mon. through Fri.: 8:30 am to 4:30 pm Doris Hoslla, M.D. 1520-B Leander Road Georgetown, Texas 78626 863-7586 Office Hours: Mon. through Fri.: 9:30 am to 12 noon 1:30 pm to 4:30 pm i Share physicians use various hospitals according to servfoes needed and location. The following is a list of Share Plan Hospitals in the service area. If you need to go to the hospital, your Share primary care physician will coordinate your hospital care through one of these hospitals. Brackenridge Hospital Round Rock Community Hospital 1500 East Avenue 2400 Round Rock Avenue Austin, Texas 78705 Round Rock, Texas 78681 Georgetown Hospital St. David's Community Hospital 2000 Scenic Drive 919 East 32nd Street %Georgetown, Texas 78626 Austint Texas 78705 Hays Memorial Hospital Seton Medical Center interstate Highway 35 North 1201 West 38th Street San Marcos, Texas 78666 Austin, Texas 78705 Holy Cross Hospital South Austin Medical Center 2600 E. Martin Luther King Blvd. 901 West Ben White Blvd. Austin, Texas 78702 Austin, Texas 78745 John's Community Hospital 305 Mallard Lane Taylor, Texas 76574 NORIME: Shoal Creek Hospital (Mental Health & Chemical Dependency) 3501 Mills Avenue Austin, Texas 78705 Share Health Plan of Texas, Inc. 3520 Executive Center Drive, Suite 100 Austin, Texas 78731 Telephone- (512) 477-4273 a copy of which shall be attached to and made a part of said CONTRACT. •a i[M •a 57.rjs� Ural %ROM .007.40 CkX: State Texn -Zip 786-92-0-4-09- 2. The contract shall be effective 12-01 A.M. Central Time on SeptwbQrz 1 0 4a 8- A minimum of five (5) contracts from five (5) eligible employees is required as a condition for the acceptance of this applicat n. 4. Coverage Basis: --2m Contributory Non-Conthbutory 5. An employee of the ENROLLING GROUP who meets the eligibility requirements for coverage under the ENROLLING GROUP'S REGULAR PLAN OF HEALTH BENEFITS will be eligible for coverage under this CONTRACT as stated in Section 2.1. @M= CGCMKTAPI 187 The parties agree that the "Addendum" which is attached hereto is incorporated into theis agreement as if fully set forth in length. 6. N Health Care Services (Benefits): xx Covered 1 54 -1 *F MA 1am i. .• W A.W6 TWO 14 and 15 of the Enrolling Group Contract IMM RNWWW+ •= 6 -xx- Covered Subscriber 5"T7WW%%r1�M% Subscriber + Family (1) Minimum of five enrollment contxacts (2) Dual Choice offering - (3) Thirteen wnth contract period $ 81.02 $ 170.14 $ 157.99 $ 255.18 Medicare — Active (Age 65-69) $ Retiree $ I 1111 . I * 11 ; .. . automatically renewed at the end of each" ING GROUP as providedherein. The first CONTRACT PERIOD shall comme as•the effective date and sha terminate at 12-00 P.M. Central Time, on Septenber 30 , m,�unless terminated before this date SHARE or the ENROLUNG GROUP. This CONTRACT shall continue in force only for the period for whicc Premiums are paid, subject to a thirty-one (31) day grace period. execute this CONTRACT this -day• Share Health Plan of Texas, Inc. Signature will be obtained ly by June 28th Council Meeting. By President Em COUNTY OF WILLIAMSON § AGREEMENT BETWEEN CITY OF GEORGETOWN AND STATE OF TEXAS SHARE HEALTH PLAN OF TEXAS ADDENDUM TO ENROLLING GROUP CONTRACT The parties, Share and City of Georgetown/Enrollingagree to the following term and condition as part of Enrolling group Contract. The last sentence of Section 7.1 (b) Step 2. of the contract is amended to read as follows: "If resolution is not achieved at this level, impartial] arbitration, as outlined below, may be commenced if bot parties, SHARE AND MEMBER, desire arbitration." Signature will be obtained by June 28th Council Meeting. My: President of SHARE By: Tim Kennedy Mayor, City of Georgetown 0 r,� 0 -, SHARE HEALTH PLAN OF TEXAS, INC. 815 Brazos Street, Suite 500 Austin, Texas 78701 Telephone; (512) 477-4273 ENROLLING GROUP CONTRACT/SUBSCRIBER'S SUBSCRIPTION CERTIFICATE This ENROLLING GROUP CONTRACT/SUBSCRIBER'S SUB- SCRIPTION CERTIFICATE (hereinafter called the "CONTRACT"), entered into by and between SHARE Health Plan of Texas, Inc. (here- after referred to as "SHARE"), a Texas Corporation and the Applicant named in the Application for an Enrolling Group Contract (hereafter referred to as "ENROLLING GROUP"), sets forth the basis on which eligible persons and their family dependents, if any, are provided with s coverage for prepaid health care services and benefits, to the extent described herein. SHARE will arrange to provide such services and benefits through i contractual arrangements with participating physicians, hospitals, and other health care providers during the term of this CONTRACT, sub- ject, however, to all of the provisions and conditions set forth in this CONTRACT. The SUBSCRIBERS and their QUALIFIED DEPENDENTS are enti- tled to services and benefits hereinafter set forth commencing with the effective date stated in the Enrollment Application. This ENROLLING GROUP CONTRACT/SUBSCRIBER'S SUB- SCRIPTION CERTIFICATE is issued subject to the terms and condi- tions as set forth in this CONTRACT on the subsequent pages. THIS CONTRACT CONTAINS AN ARBITRATION PROVISION IN SECTION 7, COMPLAINT PROCEDURE. .(:EGC385 T40 28 TX-EGC385-T40-1 INTRODUCTION SHARE Health Plan of Texas, Inc. (referred to as "SHARE") is a Texas Corporation, authorized to operate a Health Maintenance Organiza- tion under the Texas Health Maintenance Organization Act, Article 20A, Vemonls Texas Civil Statutes. In consideration of the Application TABLE OF CONTENTS of the ENROLLING GROUP and SUBSCRIBER, and the payment of SECTION 1 DEFINITIONS 3 the monthly Premiums by or on behalf of the SUBSCRIBER, SHARE agrees to arrange to provide prepaid health care services and bene - SECTION 2 ELIGIBILITY, ENROLLMENT AND EFFECTIVE - fits to the SUBSCRIBER and QUALIFIED DEPENDENTS, if any, in DATE 5 accordance with this CONTRACT. SECTION 3 PAYMENT FOR SERVICES g INTERPRETATION SECTION 4 RENEWAL AND TERMINATION OF In order to provide the advantages of an organized and planned health CONTRACT 10 care delivery system, SHARE arranges care on a direct service basis SECTION 5 TERMINATION OF INDIVIDUAL COVERAGE 10 rather than an indemnity basis. SHARE will arrange to provide the health care services described in this CONTRACT. The interpretation SECTION 6 CONVERSION 10 of this CONTRACT shall be guided by the direct service arrange- ments of SHARE with the objective of promoting comprehensive health SECTION 7 COMPLAINT PROCEDURE 11 care. SECTION 8 RELEASE OF INFORMATION 12 SECTION 9 COORDINATION OF BENEFITS AND SECTION 1 SUBROGATION 13 DEFINITIONS SECTION 10 GENERAL PROVISIONS 15 The following definitions apply to all provisions of this CONTRACT, SECTION 11 CLAIM PROVISION 16 CONSULTING PHYSICIAN: means any physician other than a PRI - SECTION 12 SELECTION OF PRIMARY CARE PHYSICIAN 17 MARY CARE PHYSICIAN with whom a PRIMARY CARE PH,YSI- CIAN has arranged and authorized the provision of health services SECTION 13 BASIC HEALTH CARE SERVICES INSIDE THE to MEMBERS. SERVICE AREA 18 CONTRACT PERIOD:. means the period of time from the effective SECTION 14 BASIC INPATIENT HOSPITAL SERVICES date of this CONTRACT through the effective date of termination of INSIDE THE SERVICE AREA 21 this CONTRACT during which the CONTRACT is in effect, unless terminated earlier by SHARE or the ENROLLING GROUP as pro - SECTION 15 HEALTH CARE AND INPATIENT HOSPITAL vded herein. SERVICES OUTSIDE OF SERVICE AREA 23 EMPLOYEE: means an individual who is in the employment of the SECTION 16 EXCLUSIONS 23 ENROLLING GROUP or a partner or participant in the ENROLL- ING GROUP and is entitled by agreement, contract, or other estab- lished standard to participate in group benefits arranged by the EN- ROLLING GROUP ° ENROLLING GROUP: means an industry, corporation,com an p y, partnership, union, enterprise, or other defined or otherwise legally constituted group of individuals which enters into an ENROI=LING GROUP CONTRACT with SHARE to allow its EMPLOYEES the op- portunity of selecting SHARE'S prepaid health services and benefits. ENROLLING GROUP CONTRACTOR CONTRACT: means the Con- tract executed by SHARE and the ENROLLING GROUP which de- scribes the costs, procedures, benefits, conditions, limitations, exclu- sions, and other obligations to which MEMBERS are subject under the prepaid health care services and benefits provided in such con- tract. TX-EGC385-T40-2 Ij TX-EGC385-T40-3 #PEN ENROLLMENT PERIOD: means a period of time -determined by RE and the ENROLLING GROUP during which time employ- ees •.' the ENROLLINGri andtheirQUALIFIED DEPEN- DENTS out evidence of insurab lity or of good health. PARTICIPATING FACILITIES: means any facilities which have con - for #treatmentof PARTICIPATING HEALTH CARE PROFESSIONAL: professional health care provider who contracts with SHARE for the care and treatment of MEMBERS. PHYSICIAN: means any physician who is duly licensed and qualified to practice within the scope of the license under the law of the juris- diction in which treatment is received. s TX-EGC385-T40-4 PLAN: means SHARE. # # .:.. i • e. ,. is � � � � _.. "_ #... #..; suppliesI Oil services or supplies in th raphic area where in - provided. and made a part of I is CONTRACT is y • paymentshave been received in accordanceCONTRACT pendents of the SUBSCRIBER. SECTION 2 ELIGIBILITY, ENROLLMENT, • i EFFECTIVE DATE PI& • 'i ! •. is - i i. i is � i `:• M-. :•. 0 1A Ott! a •,#.• # !__y_ _.•, ;.•. .r i -^a • .fs•-..♦ a a # •.. s t # a # '� a -e • ,•:a •:.._#. #. #. # # • -#. '# • •:' '. # #.. . '# i # • - ... .}�... # ,...... •:.. .• # — •-. a •. ._ . .. • .... #... .j a } the SERVICE AREA to students are subject to coverage under SECTION 3 Section 15- HEALTH CARE AND INPATIENT HOSPITAL PAYMENT FOR SERVICES SERVICES OUTSIDE OF SERVICE AREA. 3.1 Premium. payment for services covered by this CONTRACT 2.9 Medicare eligibility: shall be made as follows: The ENROLLING GROUP and SUB - a. An ENTITLED INDIVIDUAL under the Federal Medicare SCRIBER, if applicable, shall remit to SHARE monthly, the specified full premium. A grace period of thirty-one (31) days Program who is a SUBSCRIBER aged sixty-five (are is allowed for each payment other than the first, during which through sixty-nine (69) or the spouse aged sixty-five (65) through sixty-nine (69) of such a SUBSCRIBER may con- period coverage remains in force. The ENROLLING GROUP _ tinue coverage or become eligible for coverage, at the is liable to SHARE for all payments due for the time this COW TRACT is in force. The payment due will be subject to a late option of the SUBSCRIBER, for as long as the SUB- SCRIBER continues actively at work and otherwise meets payment charge at the annual rate of eighteen (18) percent of the eligibility requirements described in Section 2.1. any amount unpaid after the due date. b. A MEMBER who attains the age of sixty-five (65) or who 3.2 The monthly Premium rate shall be effective for the CON- TRACT PERIOD and shall be subject to revision thereafter on Medicare (um o recipient of years) is otherwise ell Disability Security Disability fora minimum of two (2} years} a yearly basis effective as of the anniversary date of this CON- wh not qualify under paragraph (a} of this section TRACT. Notice of a revision in the Premium rate shall be pro - vided to the ENROLLING GROUP not less than thirty (30) days may qualify for continued eligibility' if he or she obtains may . prior to the effective date of such revision, Parts A and B of the Medicare coverage. After Medicare benefits become effective, a SHARE MEMBER may con- 3.3 The first monthly Premium is due and payable on or before the tinue to receive care through the PLAN; however, the effective date of this CONTRACT and the succeeding Premi- MEMBER must assign to the persons or organizations ums are due in full and payable on or before the first day of actually providing services or supplies the right to collect each succeeding month. the applicable Medicare benefits. 2.10 A SUBSCRIBER'S coverage shall become effective on the later 3.4 The ENROLLING GROUP agrees to remit the entire Premium to SHARE on a monthly basis and assumes responsibility for of the following dates: collection of the contributory portion from the SUBSCRIBER, a. The Effective Date of this CONTRACT or if any. For coverage that is first dffective prior to the sixteenth (16th) day of the month, the entire monthly Premium shall be b. The date of his or her eligibility, according to the eligibility due. For coverage first effective after the fifteenth (15th) day of requirements of the ENROLLING GROUP for coverage if the month, no Premium will be charged until the following month. an Enrollment Application is made and received by SHARE For coverage terminated prior to the sixteenth (16th) day of the within thirty -ane (31) days of such eligibility date. month, no Premium shall be due. For coverage terminated after 2 a with respect to his or her QUAL- .11 A SUBSCRIBER'S coverage P the fifteenth (15th) day of the month, the entire monthly pre - mium shall be due; IFIED DEPENDENTS will become effective on the later of the following dates: 3.5 All copayments specified in the benefits schedule of this CON- a. The effective date of the SUBSCRIBER'S coverage; or TRACT are payable in addition to the Premium. Copayments specified for physician services, if any, shall be paid at the time b. .For a person joining the SUBSCRIBER UNIT other than of service. Copayments for services other than physician visits a newborn child, coverage shall commence on the date may be billed by SHARE or the Provider and shall be payable of the SUBSCRIBER'S written Enrollment Application for by the SUBSCRIBER within thirty (30) days of the receipt of QUALIFIED DEPENDENT'S coverage, if application is such statements; made and received by SHARE within thirty-one (31) days 3.6 PENALTY FOR NONPAYMENT OF COPAYMENTS of the QUALIFIED DEPENDENT'S eligibility dale: c. A newborn child is covered from birth but will not remain Copayments shall be paid at the time of service. SHARE re- serves the right to bill the SUBSCRIBER for copaymentswhich a covered dependent beyond thirty-one (31) days unless were not paid by the SUBSCRIBER or QUALIFIED DEPEN- the SUBSCRIBER has submitted an Enrollment Appli- DENTS at the time the service was rendered. cation requesting that coverage continue and has made any required Premium contribution. IF IT IS NECESSARY FOR SHARE TO BiLL THE SUB- SCRIBER, SHARE WiLL IMPOSE AN ADDITIONAL $8,00 SERVICE CHARGE TO DEFRAY THE COST OF BILLING. TX-EGC385-T40-8 2 's IR TX -EG 0385-T40-9 SECTION 4 RENEWAL AND TERMINATION OF CONTRACT 4.1 RENEWAL: This CONTRACT shall l5e renewed automatically I rom year to year unless otherwise terminated as provided below, SECTION 5 DIVIDU 5.1 The coverage of a SUBSCRIBER or QUALIFIED DEPEN- DENT shall automatically be terminated for the following reasons: (a) Termination of eligibility pursuant to Section 2 of this CONTRACT (b) Termination of this CONTRACT pursuant to Sections 4.2 and 4.3 of this CONTRACT o r.a I- $lie (a) Nonpayment of any amount due SHARE as a contribution for coverage under this CONTRACT, if any, or any copay- ment charges when due, if any. (b) Use of the MEMBER'S SHARE identification card by any other person with the knowledge and permission of the .,'MEMBER. (c) A materially false statement or misrepresentation by the SUBSCRIBER on the Enrollment Application. 5.3 The services and benefits provided to MEMBERS under this CONTRACT shall cease at 12:00 midnight, Central Time, -on the effective date of termination of coverage. SECTION 6 CONVERSION 6.1 Effective Date of Conversion Coverage The Effective Date of Coverage for the conversion policies de- scribed below shall be the Effective Date of Termination of this CONTRACT Ron W g47= Meq Dilj-.] q �Sgil rol A] jot;YA T�Z*'Witaq SHARE Health Plan of Texas, Inc. 815 Brazos Street, Suite 500 Austin, Texas 78701 steps until a satisfactory resolution is achieved. (a) Informal Administrative Review Process. Step 1. The written complaint must be submitted to the Membership Services Department at the corporatp office of SHARE at the address stated above. If possible, the Membership Services Department will resolve the com- plaint informally through meetings, conferences, or by phone either directly with the MEMBER or through his/ her authorized representative, Step 2. Complaints not resolved in Step 1 above will be referred to the Medical Director or administrative director, as appropriate, for resolution. A recommended resolution will be de to the MEMBER within 30 days after the written complaint is submitted to the Membership Serv- ices Department. TX-EGC365-T40-10 TX-EGC385-T40-11 (b) Formal Review Process. Step 1. It the issue is not resolved satisfactorily during the Informal Administrative Review Process, the complainant may notify SHARE in writing requesting a formal hearing before the Complaint Review Committee of i of Directors of SHARE. Within 30 days of such notification, this Committee will convene the hearing. Oral and writtpn testimony may be presented at the hear- ing by SHARE staff members� the MEMBER, and other persons as deemed necessary by.the Complaint Review Committee or the MEMBER. SHARE staff persons in- volved in the complaint will be available for questioning by the MEMBER. The Committee will notify the MEMBER in writing of its findings within 30 days of the conclusion of the hearing. Step 2. If the issue is not resolved satisfactorily by the Complaint Review Committee, the complainant may no- tify SHARE in writing requesting a review by the Board of Directors of SHARE. Within 30 days of such notification, the Board will render its final decision. This is the final step within the Plan. If resolution is not achieved at this level, impartial arbitration, as outlined below, may be commenced if either party, SHARE or the MEMBER, de- sires arbitration. 19113= Any complaint which remains unresolved after consider- ation through the Informal Administrative Review Process and the Formal Review Process may be submitted to ar- bitration, pursuant to Texas Arbitration Act, Articles 224- 238, Vernorfs Annotated Texas Statutes. The cost of ar- bitration, which does not include attorney fees, shall be shared equally by SHARE and the MEMBER. deems to be,necessary for such purposes—Any person claim- ing, benefits under this CONTRACT shall furnish to SHARE such information as may be necessary to implemeht this provision, 9.3 Information from medical records of MEMBERS and informa- tion received under Sections 8.1 and 8.2 above shall be kept confidential. This information, except as reasonably necessary in connection wiih the administration of this CONTRACT, may not be disclost;& without the consent of MEMBERS. SECTIOA 9 COORDINATION OF BENEFITS AND SUBROGATION W019ME30= . . . . . . . . . . . No 45KA-61fti0b. rill I ef its or services will be determined in the following order: (a) The health benefit plan which has no provision for Coor- dination of Benefits. (b) The health benefit plan w0ich covers the person a's other than a QUALIFIED DEPENDENT (c) The health benefit plan which covers the person as a de- pendent of a male person. (d) The health benefit plan which covers the person as a de- pendent of a female person. (e) In the case of a dependent child of divorced or separated SECTION 8 parents, Primary Responsibility shall be decided by the RELEASE OF INFORMATION following guidelines and these guidelines shall supersede (c) and (d) of this section 9.1. If there is a court decree 8.1 By execution of the application for coverage and execution of which establishes financial responsibility for benefit cov- this CONTRACT each SUBSCRIBER and QUALIFIED DE- erage of the child, the health benefit plan whicq covers PENDENT shall have waived any claims of privilege or Confl- the child as a dependent of the parent which is respo dentiality With respect to medical information reasonably hec- ble under the court decree will be determined to have essary to administer this CONTRACT and each SUBSCRIBER Primary Responsibility before any other plan; otherwise, -and QUALIFIED DEPENDENT hereby gives allthority to any Primary Responsibility will be determined in the following doctor, hospital or clinic to give to SHARE any and all reports, order: records, chartsi or x-rays. (1) The health benefit plan which covers the child as a 8.2 For the purposes of determining the applicability of and admin - dependent of the parent with custody will be deter- istering this CONTRACT the SUBSCRIBER and QUALIFIED mined before a plan which covers the child as a de - DEPENDENT hereby give authority to SHARE, without the ad- pendent of a stepparent or a parent without custody ditional consent of or notice to any person, to release or obtain from any insurance company, physician, hospital, or other or- (2) The health benefit ' plan which covers the child as a ganization or person, any medical information with respect to dependent of a stepparent will be determined before SUBSCRIBER or QUALIFIED DEPENDENT which SHARE a plan which covers the child as a dependent of the parent without custody. TX-EGC385-T-40-12 TX-EGC385-T40-13 (f) If (a) through (e) do not establish a Primary Responsibil- ity, then such responsibility is that of the health benefit plan which has covered the person for the longer period of time, For the purpose of this section, Primary Responsibility means the obligation of the health benefit plan to reim- burse the benefits or services first, with any eligible health care services or expenses then not covered to be as- surned by wNchever health benef it plan is not considered to be of Primary Responsibility. If any group contract does not contain provisions estab- lishing the same rules as are set forth above regarding Coordination of Benefits, then the benefits Under this CONTRACT will not be increased by virtue of that Coor- dination of Benefits limitation. It shall be the obligation of any MEMBER claiming benefits under this CONTRACT to notify SHARE of the existence of a I other group con- tracts, as well as the benefits payable under any such coverage. 9.2 Third -Party Actions MIN W. 1111F.W.W.1 MR. NOW WIN I i �Nffil 111.1. 11 1 (01,41 - extent the MEMBER is entitled to recover compensation or Awriollig 1614,1011111111 WI MEMBER, 9.3 Other Health Services •- '. ; care services shall be secondary TX-EGC385-T40-14 SECTION 10 GENERAL PROVISIONS 10.1 It is expressly understood that SHARE does not itself under- take to furnish any health service benefits. SHARE arranges with professional providers of care for the services received by MEMBERS under this CONTRACT SHARES obligation is ited to arranging health services through contracts with such providers of care. 10.2 No rights under this CONTRACT are assignable by any MEM- BER, and any such attempted assignment shall be void. =NWINN 11,161 IN oil 10.6 Indemnity in the form of cash will not be paid to any SAARV MEMBER except as follows: ♦.. • •. ..!" • . is •. a o SECTION CLAIM PROVISION 1 i.1 Reimbursement of Claims Received by Members If a MEMBER receives an invoice for benefits or services cov- ered under this CONTRACT, the MEMBER shall forward the unpaid invoice to SHARE for adjudication a: is if appropriate, payment. SHARE will make payment for covered benefits and services, minus any MEMBER copayments, directly to the pro- vider. •' • of ! •'. which the MEMBER is responsible and the MEMBER will directly reimburse the provider. also inform BER if the claim is denied. Claims must be submitted in writing on a formapproved by obtain ap- proved forms by calling or SHARE Health Plan of Texas, Inc. Brazos815 tC Austin, Texas 1; Telephone: 11.2 Reimbursement ofClaimsPaid by s^. It is not anticipated that a MEMBER will make paymenti other than the copayments required, to any other person or institu- nd services which aro covered under this CONTRACT provided, • o _that if the MEMBER • SHARE written proof •' payment such person or institution with respect to benefits and services covered under this CONTRACT, payment with respect to said services will be paid to the MEMBER, but without prejudice tt SHARE'S right to seek recovery of any payment made by I! before receipt of such evidence. Claims must be made in Writ- ing on a form approved by SHARE. . i • # MEMBERIf a charge is made to a which are covered underproof of such charge, in the formof #'•: bill is notice of payment received, must be furnished to 61 s. after the performance of the service. 11A Failure to Fumish Proofof Failure to furnish proof within the required time shall not inval- idate or reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible. All such charges will be paid within sixty is) days of receipt of proof sectionMEMBER is notified of the need for a longer time pursuant to Examination115 SHARE, at its own expense, shall have the rightto examine the person whose sickness or injury is the basis of a claim when A so often# •requiredurind the pendency of the claim. 11.6 Action on Claims will be acted on within sixty (60) days unless the MEM - notified of ' # for a longeri nied, a written notice will contain the reason for the denia6 11.7 Review If a claim is denied, a SUBSCRIBER may obtain a review of the denial through the Member Complaint Procedure (Section 11.8 Limitation of Actions (a) No action at law or equity shaJI be brought under this Sec- tion against SHARE: (1) prior to the expiration of the sixty (60) day period immediately following the date on which written proof of t" or oss upon which the action is brought . provisions of this Section,,. furnished; SHARE, or (2) later than three (3) years after the expiration of the period of time in which such proof of charge or loss is required under this Section to be furnished to CONTRACT(b) No liability shall be imposed upon SHARE other than for the benefits and services specifically covered in this SELECTIONSECTION 12 OF 12.1 MEMBERS shall be entitled to the services provided hereun- der, when such services are provided, authorized, or arranged by a PRIMARY CARE PHYSICIAN. A MEMBER enrolls iWith a PRIMARY CARE PHYSICIAN • uses the services of MARY CARE PHYSICIAN. 12.2 After initial selection of a MEMBER'S PRIMARY CARE PHY- SICIAN is made on the Enrollment Application, selection may be changed not more frequently than monthly by completing ? form and obtaining authorization from the PLAN. The form may be obtained by calling or writing SHARE: TX-EGG385-T40-16 TX-EGC385-T40-17 SHARE Health Plan of Texas, Inc. 815 Brazos Street, Suite 500 Austin, Texas 78701 Telephone: (512) 477-4273 12.3 The PRIMARY CARE PHYSICIAN shall, when deemed nec- essary, refer the MEMBER for appropriate care to a CON- SULTING PHYSICIAN or PARTICIPATING HEALTH CARE PROFESSIONAL. Such referrals must be allthorized in ad- yance by the PRIMARY CARE PHYSICIAN. SECTION 13 T ill Q @'TCaWW'1WL dt STUR MIME N115 piduutj 0 werneo necessary 2nd.- 1 13.1 Diagnosis and Treatment. Services of PRIMARY CARE PHY- SICIAN, CONSULTING PHYSICIANS, and other PARTICIPAT- ING HEALTH CARE PROFESSIONALS for diagnosis and treatment of illness or injury. 1011Q..... 13.3 Home Health Care (a) Visits by Home Health Agency personnel in t , he MEM- BER'S home if a PRIMARY CARE PHYSICIAN deter- mines such visits are medically necessary, which visits shall include part-time or periodic home nursing care by a nurse or services which consist primarily of caring for the patient. (b) , Medicines, medical supplies, drugs and dressings fur- 'nished in connection with such visits. (c) In addition to services for renal dialysis at a PARTICIPAT- ING FACILITY, renal dialysis may be performed in the MEMBER'S home. THERE 18 A $10 PER VISIT MEMBER COPAYMENT 13.4 Preventive Health Services Medical examinations; minations; well child care; family planning services including permanent sterilization; infertility evaluations and consultations; immunizations and inoculations. 13.5 Mental Health Services ceed twenty (20) visits per twelve (12) month period. THERE IS A $20.00 PER VISIT MEMBER COPAYMENT 13.6 Alcohol and Chemical Dependency Diagnosis and medical treatment for the detoxification of al- coholism or chemical dependency when provided or author- ized by a PRIMARY CARE PHYSICIAN. 13.7 In -Area Emergency Care Twenty-four hours a day, and seven days per week, emergency care for a Medical Emergency furnished by or under the order of a PRIMARY CARE PHYSICIAN (such order for emergency care will be made retroactively if justified by the Medical Emergency). In the case of a Medical Emergency within the SERVICE AREA, MEMBERS should first contact their PRIMARY CARE PHY- SICIAN. If MEMBERS are unable to contact their PRIMARY CARE PHYSICIAN, then MEMBERS should go directly to a PARTICIPATING HOSPITAL or FACILITY. If MEMBERS are un- able to reach a PARTICIPATING HOSPITAL or FACILITY, then MEMBERS should proceed directly to the nearest hospital or medical facility. (a) Medical Emergency means the sudden onset of ari illness or an accidental bodily injury, treated in an emergency ward, Outpatient department, or when admitted to a HOS- PITAL as a bed patient, all of which are subject to the following additional requirements: (1) The condition so treated must have required treat- ment of such immediate nature that the MEMBER'S life or health might have been jeopardized had he been taken instead to a treatment location where the services of PRIMARY CARE PHYSICIANS would be available, or (2) The MEMBER, if an adult, must have been In shock, or have been unconscious as a result of the accident or illness, or (3) The MEMBER, if a minor, must have been alone or without the presence of an adult member of his fam- ily or his legal guardian. (b) At PLAN designated HOSPITALS. The Member Copayment applies for all emergency serv- ices, except if the visit results in direct admission as a HOSPITAL inpatient. MEMBERS are required to notify the PLAN or their PRIMARY CARE PHYSICIAN within 48 hours of such an admission. TX-EGC385-T40-19 PLAN or their PRIMARY CARE PHYSICIAN within 48 hours of such an admission. THE MEMBER SHALL PAY 20016 OF THE FIRST $1,000 OF ELIGIBLE MEDICAL AND FACIUTY EXPENSES IN- CURRED; THEREAFTER, THE PLAN SHALL PAY 100% OF ELIGIBLE MEDICAL AND FACILITY EXPENSES. THERE IS A MINIMUM $20.00 PER"VISIT MEMBER CORAYMENT If admitted as an inpatient in a non -PARTICIPATING FA- CILITY MEMB6� are required tonoti' the PLAN or their PRIMARY CARE PHYSICIAN within 48' hours of such an admission. (d) The PLAN shall also pay the REASONABLE AND CUS- TOMARY CHARGE for land ambulance transportation (obtained in a Medical Emergency) to PARTICIPATING FACILITIES, if the accident or emergency illness oc- curred within the SERVICE AREA, or to the nearest HOS- PITAL where care and treatment can be rendered, if the accident or emergency illness occurred within the SERV- ICE AREA, if approved or authorized by a PRIMARY CARE PHYSICIAN or PLAN personnel. (e) Claims for any services and benefits covered under this Section should be submitted by the MEMBER in.accord- ance with the Claim Provision specified in Section 11. 13.8 Accidental Dental The PLAN shall pay 80% of the REASONABLE AND CLIS- TOMARY CHARGES of a physician, dentist, or dental, or oral surgeon, for surgical procedures or dental services performed or rendered. The diagnosis and determination of benefits uh- der this Section must be made within thirty (30) days after the date of an accident defined as external trauma to the mouth causing accidental injury which occurs on or after the effective date of the MEMBER'S coverage. This service is limited to (1) treatment of any natural teeth injured in the accident, including replacement of such natural teeth, or (2) treatment of a frac- tured jaw. Authorization must be received from the MEMBER'S PRIMARY CARE PHYSICIAN. 13.9 Prosthetic Devices and Durable Medical Equipment .The PLAN shall pay 80% of the REASONABLE AND CUS- TOMARY CHARGES incurred only for the following when au- thorized by a PRIMARY CARE PHYSICIAN: (a) Purchase or repair of artificial limbs, artificial eyes, breast protheses, and other authorized prostheses. (b) The purchase or repair of cardiac pacemakers and artifi- cal heart valves. (c) Rental or purchase of durable medical equipment de- signed primarily for use in a HOSPITAL for therapeutic purposes. (d) Rental or purchase of wheelchairs, trusses, braces, canes, and crutches. 13.10 Rehabilitation Services Rehabilitation services, including physical therapy, limited to conditions determined by a PRIMARY CARE PHYSICIAN to be subject to significant clinical improvement through relatively short-term therapy, not to exceed 90 days. More extensive re- habilitation services and specialized physical medicine shall be arranged by PLAN personnel, but payment for such serv- ices shall be the responsibility of the MEMBER. 13.11 Medications Medications, injectables, radioactive materials, allergy treat- ment materials, and dressings and casts prescribed and ad- ministered by a PRIMARY CARE PHYSICIAN or by a CON- SULTING OWSULTING PHYSICIAN upon referral by a PRIMARY CARE PHYSICIAN. 13.12 Maternity Care 1ENTS. 13.13 Reconstructive Surgery 13.14 Eye Care Routine vision examinations, including refractions, to,deter- mine the need for vision correction limited to once every twenty- four (24) months. Ophthalmologic services as medically nec- essary by a PRIMARY CARE PHYSICIAN or CONSULTING PHYSICIAN upon referral by a PRIMARY CARE PHYSICIAN. CONTRACT TX-EGC385-T40-20 I TX-EGC385-T40-21 14.1 For Illness, Injury, Maternity When admitted by a PRIMARY CARE PHYSICIAN or by a CONSULTING PHYSICIAN under the authorization of a PRI- MARY CARE PHYSICIAN to a HOSPITAL, NONACUTE CARE FACILITY, or hospice, all charges for a semi -private room (un- less a private room is medically necessary) and for all other HOSPITAL, facility or hospice services. Other HOSPITAL, fa- cility, or hospice services does not mean a) the service of a physician for which an identifiable fee is charged, (b) televi- sion, telephone, beauty or barber service, or other personal items or services if the cost of which is not included in the standard room rate, or (c) take-home items. Private room accommodations shall be provided only if consid- ered medically necessary by a PRIMARY CARE PHYSICIAN. If a MEMBER occupies private accommodations not consid- ered medically necessary by a PRIMARY CARE PHYSICIAN, the MEMBER shall be entitled to an allowance toward the reg- ular charge of the HOSPITAL for bed, board and general nurs- ing service in the private room occupied of an amount equal to the HOSPITAL'S most common charge for its semi -private accommodations. 14.2 Other Medical Facility 14.3 Mental Health Services (a) Inpatient services and supplies, at the rate of semi -pri- vate accommodations, not to exceed fourteen (14) days for crisis intervention. (b) Services provided in an approved Psychiatric Day Treat- ment Facility under the direction of a PRIMARY CARE PHYSICIAN, authorized CONSULTING PHYSICIAN, or authorized PARTICIPATING HEALTH CARE PROFES- SIONAL. Benefits shall count as one-half of one day of inpatient mental health services. A combination of bene- fits for these services and inpatient services shall not ex- ceed the maximum benefit of fourteen (14) days for crisis intervention. (c) Services, not to exceed fourteen (14) days for crisis in- tervention, of a PRIMARY CARE PHYSICIAN or'author- ized CONSULTING PHYSICIAN, or other authorized PARTICIPATING HEALTH CARE PROFESSIONAL, while the MEMBER is confined as a bed patient in an approved mental health facility or program or as a patient in an ap- proved Psychiatric Day Treatment Facility. 14.4 Alcohol and Chemical Dependency SECTION 15 VEALTY 15.1 When MEMBER isoutside of the SERVICE AREA and urgent care for any medical and hospital service which would be pro- vided by the PLAN within the SERVICE AREA is required, the MEMBER should go to the nearest medical facility equipped to render appropriate care. Claims for any services and benefits covered under this Se tion should be submitted by the MEMBER in accordance w the Claim Proon speed in Section 11. 15.2 This Section includes only those services which are furnish, before the MEMBER'S conditionpermits the MEMBER to i turn to the SERVICE AREA where the MEMBER could recei services at the direction or authorization of a PRIMARY CAF PHYSICIAN. This Section •- •. ' equired to return the MEMBER to the PLAN'S SERVICE ARE to receive necessary services if allthorized by the PLAN PRIMARY CARE PHYSICIAN. This Section does not inclo services in connection with conditions as a result of which tra� has been advised against for health reasons such as nece sary surgery, pending delivery, or treatment in process by PRIMARY CARE PHYSICIAN, authorized CONSULTIN PHYSICIAN or authorized PARTICIPATING HEALTH CAF PROFESSIONAL. MEMBERS must notify SHARE ortheir PRIMARY CARE PH SICIAN within forty-eight (48) hours of the emergency incide if the dent results in hospitalization. SECTION 16 EXCLUSIONS 16.1 The following services or benefits are not covered by SHARE: a. Services or medical supplies not performed, prescribed, directed, or authorized by a PRIMARY CARE PHYSICIAN. b. Dental preventive, therapeutic, and restorative proce- dures and surgery, except treatment of any natural teeth injured in an accident. TX-EGC385-T40-22 I TX-EGC385-T40-23 c. Cosmetic or plastic surgery except reconstructive sur- gery to correct a congenital disease or anomaly which has resulted in a functional defect, or when performed to correct a condition resulting from accidental injury or in- cidental to surgery if such accident or surgery occurs on or after the eff ective date of the MEMBER'S coverage. d. Custodialor •ut routine nursing pro- vided :#e primarily for ofthe MEMBER and not based upon the assessment of a PRIMARY CARE PHYSICIAN ihat the MEMBER will improve significantly in a reasonable and generally predictable period of time (examples would include, but not be limited to, mental retardation or chronic brain syndromes). e. Expenses for purchase, repair, or rental of prosthetic de- vices or durable medical equipment, except as included as a Basic Health Service. im- plants; procedures, or ••related • sex transformation. g. Medical or surgical procedures, pharmacological re- gimes, or HOSPITAL facilities not generally accepted by the medical profession in the United States. h. Services forvisual therapy. I. Hearing aids, orthopedic shoes, orthodontic appliances, j. Immunizations #: inoculations forpurposes. k. Long term habilitation or rehabilitation therapy such as occupational, recreational or educaflonal therapy, or other formsof f:. 'f Re- habilitationincluding physical therapy, ited to conditions determined by a PRIMARY CARE PHY- SICIAN to be subject to significant clinical improvement through short-termtherapy,hot to exceed •. ,. days. Any surgery or HOSPITAL charges for the purpose of weight reduction unless in the opinion of the PRIMARY CARE PHYSICIAN the weight is causing a serious im- minent health threat to the MEMBER. m. Benefits otherwise provided inthis CONTRACT which the PLAN is unable to provide because of any taw or'regula- tion of federal, state, or local government or any action taken by any agency of federal, state or local government in reliance on said law or regulations. n. Personal comfort items or services. o. Services which are not medically necessary; physical ex- aminations for obtaining or continuing employment, for governmental licensing or for securing insurance cover- age, or other services or supplies which are not, in the judgment im- provement of i Services outside the PLAN SERVICE AREA which: (1) would not be provided by the PLAN within the SERVICE AREA, (2) Were fumished after the MEMBER'S condition •ul permit MEMBER y return to the SERVICE AREA, or (3) were connected with conditions as a result of which travel had been advised against because of health reasons such as necessary surgery, pending delivery, or treatment in process by authorized CONSULTING PHYSICIAN or allthorized PARTICIPATING HEALTH CARE PROFESSIONAL. q. Payment for services covered, in whole or in part, under the Workers!Compensation or .i :.•n. whether or not the MEMBER claims compensation. r. Services which are required •. f•'treatedthrough••. eral, state, or local government program. - s. Payment for •^ no legal obligation to pay. in- duced infertility u. Structured sex therapy programs and/or treatment for sex offenders. Sex therapy may be routinely provided as an adjunct to related treatment. v, Nicotine dependency related services. w. Inpatient codepenclencydefined as Inpatient ices for a MEMBER companion of the MEMBER who is in treatment. x. Court ordered placements for of mental Illness when such orders are inconsistent with the PRIMARY CARE PHYSICIAN'S recommendationor i'.. y :o TX-EGC385-T40-24 TX-EGG385-T40-25