(a) GENERAL PROVISIONS: The City shall continue to provide hospital, medical, surgical, major medical outpatient diagnostic laboratory services, prescription drug, dental care and benefits under the terms and conditions set forth below. Coverage will be in accord with any mandatory requirements of Federal law. In the event of any conflict between mandatory requirements of Federal law and the City's health benefits plan, the Federal law will prevail.
(i) Coverage shall be provided to each employee, each employee's spouse, and all dependent members of the employee's family to age twenty-six (26) or other age as determined by applicable state or federal law. Spouses who are both employed by the City must jointly elect only one coverage. A new election may occur at open enrollment, or due to circumstances such as a job status change, layoff or other separation of one of the spouses, death, or divorce.
Where the spouse of a City employee has health care coverage through a different employer, the spouse must enroll in his/her employer's plan. Dependents shall be covered as provided by the "Birthday Rule", as that term is defined in the Summary Plan Document (SPD). Coordination of benefits shall be provided so that coverage is extended to the spouse and dependents that is not provided by the other employer's plan. Special consideration will be given to cases of demonstrated hardship due to excessive premiums based on spousal income. An "excessive premium" is identified in the following circumstances: (a) A spouse whose gross base income is less than $30,000 who is required to pay 30% or more of their premium cost for "employee only" primary coverage; (b) A spouse whose gross base income is more than $30,001 but less than $50,000 must accept their employer's plan for "employee only" coverage. However, if the spouse is required to pay 40% or more of their premium cost for "family" coverage, the eligible dependents may be eligible to enroll in this Plan as primary and the spouse may be eligible for coverage under this Plan as secondary; (c) A spouse whose gross base income is more than $50,001 must accept their employer's plan coverage and must carry any eligible dependents in accordance with the "Birthday Rule". The spouse and dependents may be eligible for secondary coverage through this Plan.
(ii) Coverage for this purpose shall be furnished through the insurance carrier(s) selected exclusively by the City on a fair fee basis until such time as some other insurer may be selected or the City determines that it would be in its best interest to self insure these benefits.
(iii) Full-time employees covered by another health care program due to marriage, or other reasons may waive their City of Toledo coverage and receive twenty-five thousand dollars ($25,000.00) in additional life insurance coverage. This shall also be extended to those employees whose spouses are also employed by the City.
(b) The following cost sharing plan and cost coverage restrictions shall be effective for all employees:
(i) There shall be a one thousand dollar ($1000.00) annual per person maximum on chiropractic care subject to the major medical deductible ($100/individual and $200/family) and co-insurance (80%/20%).
(ii) There shall be a two hundred dollar ($200.00) co-pay for all emergency room visits, which shall be waived if the individual is admitted. An employee who is not admitted but is referred to the emergency room by his or her primary care physician, or by an urgent care facility, or by a tele-medicine service, may appeal the payment of one-half (1/2) of the co-pay. Such appeal will be decided by the City's third-party administrator for health care, with any further appeal to be made to the Health Care Cost Containment Committee, whose decision shall be final.
(iii) There shall be a monthly co-premium paid by each employee for coverage under this section, depending on the type of coverage selected. Coverage selections are: single coverage (employee only); single +1 coverage (employee plus one (1) dependent); family coverage (employee plus two (2) or more dependents).
Employees will pay the following monthly co-premiums:
Single: $94
Single +1: $160
Family: $166
The co-premium payments will be made by payroll deduction on a pre-tax basis. Spouses who are both employed by the City of Toledo will only pay one co-premium based on the type of coverage selected. The "Birthday Rule" and the spousal exclusion language in Section 2101.32(a) continue to apply to coverage options.
(iv) Upon any future increases in monthly co-premiums that apply, uniformly, to all City of Toledo bargaining units covered under the City of Toledo's health benefits plan, the monthly co-premiums for employees covered under this Chapter shall increase to reflect the same monthly co-premiums. Such increase shall have the same effective date as that agreed to by the bargaining units.
(v) Office visits rendered in the physician's office shall be subject to a ten dollar ($10.00) co-payment, which shall be counted toward the individual's major medical deductible;
(c) The City shall continue to provide a major dental program which provides the following:
Type A Services: Preventative 100%
Type B Services: Major and minor restorative 80%
Type C Services: Orthodontia 60%
Deductible for Type B Services: fifty dollars ($50.00) per person per year; maximum payment of one thousand three hundred dollars ($1,300.00) per year.
Maximum lifetime benefit for Type C Services for any covered person: one thousand three hundred dollars ($1,300.00); coverage limited to dependent children under age 19.
(d) The City shall provide a prescription drug program with a zero dollar ($0) employee co-pay for generic drug prescriptions (Tier 1), a fifteen dollar ($15.00) employee co-pay for preferred brand prescriptions (Tier 2), and a thirty dollar ($30.00) employee co-pay for non-preferred brand prescriptions (Tier 3). This program shall include a generic drug mandate. The City may select an alternative pharmacy benefit manager at its option.
(e) The selection of the insurance carrier to provide all coverages herein is the exclusive right of the City.
(f) The City shall provide a vision care plan, which will contain a deductible plan. The City may select a carrier or become a self insurer as it deems necessary.
(Ord. 504-20. Passed 12-15-20.)