(A) Definitions. For the purpose of this section, the following definitions shall apply unless the context clearly indicates or requires a different meaning.
COINSURANCE. The portion of eligible expenses in excess of the deductibles that is the employee’s responsibility and is specified as the coinsurance level. If the employee’s COINSURANCE for care received during a calendar year reach the individual coinsurance maximum, no further coinsurance will be required for care he or she receives during the remainder of that calendar year.
DEDUCTIBLE. The individual deductible is the amount of eligible expenses that an employee must incur and be responsible for paying in a calendar year before insurance provider will make any payments for benefits.
EMPLOYEE. A full-time employee of the city who is enrolled on the city’s group health insurance policy.
NETWORK PROVIDER. A provider of medical care who is registered as a participating provider and listed in the provider directory.
NON-NETWORK PROVIDER. A provider of medical care who is not registered with the insurance provider.
PROVIDER. A hospital, ambulatory surgical center, home health care agency, skilled nursing facility, supplier of ambulance services or durable medical equipment, home infusion therapy care provider and home respiratory therapy care provider, physician, or other licensed health care professionals licensed to render care which is a benefit under the health insurance certificate.
(B) Reimbursement.
(1) Employees of the city shall be reimbursed, up to a maximum of $500, for the coinsurance of the insurance that is used.
(2) When the coinsurance level is 20%, maximum $500, for all care received from network providers and ambulance services related to an emergency medical condition, the city will reimburse the employee 100% of the coinsurance at the 20% level.
(3) When the coinsurance level is 50%, maximum $1,250, for all care received from non-network providers, the city will only reimburse the employee for that part that would be equal to the 20% coinsurance; which is 40% of the coinsurance at the 50% level.
(4) Reimbursement requests must be submitted to the City Clerk and include the original insurer explanation of benefits showing the claim processing detail and the original medical bill. The City Clerk will make copies of the originals and return the originals to the employee.
(5) All reimbursement requests must be approved and signed by the Mayor prior to reimbursement.
(6) Coinsurance used by covered dependents of employees will be the responsibility of the employee.
(Ord. 06-001, passed 2-21-2006)