(A) General Provisions:
The City will provide hospital, medical, surgical, major medical outpatient diagnostic laboratory services, prescriptive drug, dental care and benefits under the terms and conditions set forth below:
(1) Coverage shall be provided to each employee, each employee's spouse, and all unmarried dependent members of the employee's family in accordance with the plan document. Spouses who are both employed by the City must jointly elect one coverage. A new election may occur after an open enrollment due to circumstances such as layoff, or other separation of one of the spouses, death or divorce. Where spouses who are both employed have dependents from prior marriages for whose hospitalization coverage they are responsible shall be exempt from this joint requirement.
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". Co-ordination of benefits shall be provided so that coverage is extended to the spouse and dependents that is provided by the other employer's plan. In case of demonstrated hardship due to excessive co-premiums (i.e. 40% co-premiums or premium payments equaling 30% or more of earnings) special consideration will occur.
(2) Coverage for this purpose shall be furnished through the insurance carriers selected exclusively by the City on a fair fee or other basis until such time as some other insurer may be selected or the City determines that it would be in its best interest to insure these benefits. The Association shall receive advance notice of and the reasons for the change in carriers.
(3) Coverage shall be provided at the levels existing as of December 31, 1999 except as set forth herein.
(B) The following health care cost containment procedures shall be effective for all employees enrolled under traditional coverage:
(1) Second surgical opinions, pre-admission notification or certification emergency care limitations, concurrent review, post-admission concurrent review, outpatient surgery, continued treatment and technological review, medical case management, planned discharge and other procedures as may be established under the medical review programs established by the City shall be followed.
(2) Full time employees covered by another employer's health care program due to marriage or other reasons may waive their City of Toledo coverage and receive twenty-five thousand dollars ($25,000) in life insurance coverage. This shall also be extended to those employees whose spouses are also employed by the City.
(3) Coverage for nervous and mental treatment is limited as follows: inpatient care shall be maintained at a maximum of thirty-one (31) days per calendar year. Outpatient coverage shall be expanded to a maximum of twenty-two visits per year at fifty (50%) percent co-insurance.
(4) Coverage for drug and alcoholism treatment is limited to a maximum of twenty-five thousand dollars ($25,000) lifetime benefits for all in-patient and out-patient care. In-patient care shall be maintained at a maximum of thirty-one (31) days per calendar year. Out-patient coverage shall be expanded to a maximum of twenty-five hundred dollars ($2,500) per calendar year at fifty percent (50%) co-insurance. Employees using drug and alcohol treatment programs must use the Fire Department Employee Assistance Program when one is available. The Co-operative health network or other such agency selected by the City for managing health care must be used by employees to certify coverage for drug and alcohol treatment for themselves or their dependents.
Treatment of alcoholism and drug addiction. In addition to coverage for nervous/mental diseases or disorders, coverage for inpatient treatment of alcoholism and drug abuse is limited to thirty-one (31) days per calendar year for each covered person following that covered person's admission to a hospital.
Once combined in-patient /out-patient maximum of twenty-five thousand ($25,000) has been met for alcohol and drug care, no further in-patient benefits will be available. Coverage is limited to a lifetime maximum of twenty-five thousand dollars ($25,000). Covered services for a covered person's first admission will be paid at one hundred percent (100%) of the provider's reasonable charge. A second admission will be paid at seventy-five percent (75%) of the provider's reasonable charge. A third admission will be paid at fifty percent (50%) of the provider's reasonable charge. After three admissions per lifetime, no further inpatient benefits are available.
(5) The panel of providers and PPP selected by the City for managing and providing nervous and mental, drug and alcohol treatment must be utilized. The City may request proposals toward a managed care plan for this purpose with an effective date of June 1, 2000 or thereafter. The selection shall be by mutual agreement. The schedule of benefits in effect as of December 31, 2000 shall be maintained, without additional co-pays or deductibles.
(C) The following cost sharing plan and cost coverage restrictions shall be effective for all employees enrolled under conventional coverage.
(1) There shall be a five hundred dollar ($500.00) annual per person maximum on chiropractic care in 2003 which shall increase to a one thousand dollar ($1,000.00) maximum effective in 2005 and a thirteen hundred dollar ($1,300.00) annual per person maximum on physical therapy, both subject to the major medical deductible (one hundred dollar ($100.00)/individual and two hundred dollar ($200)/family) and co-insurance 80%/20%.
(2) Major Medical benefits shall be paid to a lifetime maximum of the one million dollars ($1,000,000) per person with one hundred dollars ($100.00)/individual and two hundred dollar ($200.00)/family deductible and 80%/ 20% co-payment; provided that coverage for nervous mental, drug and alcoholism is limited per paragraph (B)(3) and (4).
(3) There shall be a sixty-five dollar ($65.00) co-pay for all emergency room visits, which shall be waived if the individual is admitted or if the visit is between the hours of 8:00 p.m. and 9:00 a.m. or on a Saturday after 12:00 p.m. noon or a Sunday.
There shall be a monthly co-premium paid by each employee for hospitalization, prescriptive drug and dental insurance. Employees will pay the following monthly co-premiums:
Single Coverage | Single + 1 Coverage | Family Coverage | |
Effective with the first full pay period of January 2012 | $48 | $80 | $92 |
Effective with the first full pay period of January 2013 | $71 | $120 | $129 |
Effective with the first full pay period of January 2014 | $94 | $160 | $166 |
The co-premiums will be made by payroll deduction on a pre-tax basis. Spouses who are both employed by the City of Toledo will pay one co-premium payment based on the level of coverage selected. The "Birthday Rule" and the "Spousal Exclusion" language in Part A of this section continue to apply to coverage options.
(D) The Cost Containment Committee shall be maintained from among the representatives of the various bargaining units, including the Toledo Fire Chiefs Association. The Committee shall develop other cost containment measures, which shall include: 1.) enhanced managed care, such as pre-certification, concurrent review, and utilization review; 2.) changes of coverage or benefits such as increased deductibles, limitations on coverage and contributions from employees; 3.) increased claims control, such as co-ordination of benefits, subrogation, workers compensation deferral, patient audits and claim audits; 4.) negotiations and 5.) development of a participative employee plan by which employees will be encouraged to contain costs, audit bills, correct lifestyles, maintain wellness and undertake other cost saving measures. The Cost Containment Committee shall meet regularly on at least a monthly basis and attendance shall be required. The Cost Containment Committee shall develop annual goals, objectives and timetables directly aimed at reducing health care costs. Subcommittees may be formed as deemed necessary by the co-chairpersons to study issues, develop reasonable solutions and report back to the committee. Goals and objectives not met within the established time frames shall be critically reviewed by the Cost Containment Contract as they affect TFCA shall be permitted unless the authorized to do so by the TFCA through its president. In the event any change in benefits is required by either federal or state law, the TFCA and City shall negotiate the replacement language. If no agreement is reached, the matter shall be subject to interest arbitration. The parties shall use a panel of seven arbitrators with experience in interest arbitration.
(E) The Association releases the City from any obligation to add or to expend moneys currently in the Healthcare Savings fund created pursuant to former paragraph (f) of this section on future cost increases or wellness programming. The Association further releases the City from any obligation to consult with the Cost Containment Committee relative to the transfer or expenditure of those funds. Annual reports from third party administrators of the City's health and benefits, including any such reports showing costs and cost reductions, shall be shared with the Cost Containment Committee.
(F) Coverage for all well baby care, pap tests, and office visits shall be offered to all employees enrolled under the Co-operative Health Network coverage.
(i) Well baby care is limited to routine examinations and immunizations for an infant until the infant's first birthday.
(ii) Pap tests as well as office fees will be paid in full once every twelve months.
(iii) Office visits for routine services rendered in the physicians office including physical examinations and family planning shall be subject to a fifteen dollar ($15.00) co-payment, which shall be counted toward the individual’s major medical deductible.
Fees that the physician charges for the services under paragraphs (1), (2) and (3) shall be paid on the same basis as other covered services (e.g. usual, customary and reasonable; payments for services under part (F) (1) and (3) of 100% will be made for the first one hundred and twenty-five dollars ($125.00) per single contract or three hundred dollars ($300.00) per family per calendar year collectively for well baby care (after federally specified limits have been met) and for office visits. The fifteen dollar office visit co-pay shall not be counted toward the $125/300 limits. After deductibles are reached, payment shall then be under the major medical plan; provided however, that the bill shall be reduced by the fifteen dollar ($15.00) office visit co-pay before the 80%/20% co-payment formula is applied.
(G) The City shall provide a three tier closed formulary prescriptive drug purchase program with a co-payment structure of a six dollar ($6.00) co-payment for Tier 1 drugs (generics); fifteen dollar ($15) co-payment for Tier 2 drugs (preferred brand name drugs); and a thirty dollar ($30) co-payment for Tier 3 (non-preferred brand name drugs). This program will include a generic drug substitution option and shall select the provider for the formulary drag program, who shall group drugs according to determinations made by the provider's therapeutic committee as it deems necessary.
The City may implement managed care for the prescriptive drug program. This would allow for an evaluation of the interaction of an individual's different prescriptions on a voluntary basis. Recommendations could then be made to the individual and his/her physician for more effective drug therapy.
(H) The City shall continue to provide a major dental plan which provides the following:
Type A services: Preventative 100%
Type B Services: Major and Minor Restorative - 80%
Deductible for Type B Services Fifty Dollars per person per year. Maximum payment of $1,000.00
Type C Services: Orthodontia: - 60%
Maximum lifetime benefit for Type C Services for any covered person $1,000.00 coverage limited to dependent children under age 19
Such benefit shall continue in effect for the life of this agreement. The city, however, may select an alternative carrier or become self-insured as it deems necessary. The coverage to be provided to each employee shall be either an individual or family contract, as may be appropriate. The selection of insurance carrier to provide the coverage herein is the exclusive right of the City.
(I) Vision care: Beginning in July 2000, the City shall contribute fifteen dollars ($15.00) per employee per month for vision care benefits to the Toledo Fire Chiefs Association. Said shall be used by the Association to purchase whatever vision care benefits they will buy. The city shall no responsibility relative to the administration of this Vision Care Plan.
(J) The city agrees to all conditions and terms relating to the hospitalization-prescriptive drug - dental insurance shall be maintained at less than the highest minimum standards in effect as of the effective date of this agreement (per the Fact-finders report and acceptance by the union and City Council). It is further agreed that any terms or conditions agreed to that are in excess of those established shall not be reduced.