(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.
(i) Coverage shall be provided to each employee, each employee's spouse and all unmarried dependent members of the employee's family to age twenty-three (23). Spouses who are both employed by the City must jointly elect only one coverage: Traditional or HMO. 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 they shall be exempt from this joint election requirement. Where the spouse of a City employee is employed by a different employer and he or she desires to waive his or her employer's plan in favor of City coverage, the City is not obligated to place the spouse on the City's plan. In cases of demonstrated hardship due to excessive co- premiums (e.g., 40% co-premiums or premium payments equaling 30% or more of earnings), special consideration will occur.
(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.
(b) The following health care cost containment procedures shall be effective for all employees:
(i) Second surgical opinions, pre-admission notification or certification, emergency care limitations, 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. Failure to follow the procedures shall result in only eighty percent (80%) coverage for necessary care.
(ii) 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.
(iii) 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 (22) visits per year at fifty percent (50%) co-insurance.
(iv) Coverage for drug and alcoholism treatment is limited as follows. Inpatient care shall be maintained at a maximum of thirty-one (31) days per calendar year. Coverage is limited to a maximum of twenty-five thousand dollars ($25,000.00) lifetime benefits for all inpatient and outpatient care. Inpatient coverage shall be at one hundred percent (100%) for an individual's first admission, seventy-five percent (75%) for a second admission, and fifty percent (50%) for a third admission. No coverage shall be provided beyond three (3) admissions per lifetime or thirty-one (31) days per calendar year. Outpatient coverage shall be expanded to a maximum of two thousand five hundred dollars ($2,500.00) per calendar year at fifty percent (50%) co-insurance. Employees using drug and alcoholism treatment benefits must use the City employee assistance program.
(v) The panel of providers, and/or Preferred Provider Organization (P.P.O), selected by the City for managing and providing nervous and mental, drug and alcohol treatment must be utilized. The City will request proposals toward a managed care plan for this purpose with an effective date of June 1, 1999. The Union shall have a seat on the selection committee, but the right of final selection is reserved to the City. The Schedule of Benefits in effect as of February 9, 1999 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:
(i) There shall be a five hundred dollar ($500.00) annual per person maximum on chiropractic care and a one thousand three hundred dollar ($1,300.00) annual per person maximum on physical therapy, both subject to the major medical deductible ($100/individual and $200/family) and co-insurance (80%/20%).
(ii) Major medical benefits shall be paid to a lifetime maximum of one million dollars ($1,000,000.00) per person with a one hundred dollar ($100.00) individual and two hundred dollar ($200.00) family deductible and 80%/20% co-payment; provided that coverage for nervous and mental, drug and alcoholism treatment is limited per paragraph (b)(iii) and (iv).
(iii) There shall be a one hundred dollar ($100.00) 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 Noon, or on a Sunday.
(d) Effective June 1, 1994 the availability of a Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) shall be discontinued. All employees, including those in the Traditional Plan, shall thereafter be enrolled in the Consortium Plan. Consortium Plan coverage and benefits shall be at the Traditional Plan levels as of June 30, 1993 except as otherwise provided here or in the plan document. Consortium Plan Medical Providers shall be restricted to those hospitals, physicians, and other care providers designated in the plan as developed by the City in conjunction with the Cost Containment Committee. It is understood that the City is currently utilizing the hospital and ancillary providers panels through the Cooperative Health Network (CHN). It is further understood that the CHN physicians' panel may be implemented by the City without further consultation with the Cost Containment Committee. However, the schedule of benefits shall not be diminished.
(e) The Cost Containment Committee shall be formed from among representatives of the various Bargaining Units and representatives of the City and shall be maintained. 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. Changed coverage or benefits, such as increased deductibles, limitations on coverage, and contributions from employees;
3. Increased claims control, such as coordination of benefits, subrogation, worker's compensation deferral, patient audits, and claims audits;
4. Alternate delivery systems, such as preferred provider organizations for specific benefits and direct provider 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 Committee shall meet regularly, on at least a monthly basis, and attendance shall be required. Actions taken in the absence of a bargaining unit representative shall be binding upon that bargaining unit.
The Committee shall develop annual goals, objectives, and timetables directly aimed at reducing health care costs. Sub- committees 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 established timeframes shall be critically reviewed by the Committee. If the City, in its sole discretion, is dissatisfied with progress in meeting goals and objectives or with the Committee's action or inaction on 1, 3, 4, and/or 5 measures listed above, the City may take such actions as it deems necessary to exact cost containment. Changes in measure 2 must be by agreement of the parties.
(f) The Union releases the City from any obligation to expend monies currently in the healthcare savings fund created pursuant to former paragraph (g) of this section on future cost increases or for wellness programming. The Union further releases the City from any obligation to consult with the Cost Containment Committee relative to the transfer or expenditure of those funds.
(g) Coverage for well baby care, pap tests, and office visits shall be offered to all employees enrolled under conventional coverage as follows:
(i) Well baby care limited to routine examinations and immunizations for an infant until the infant's 1st birthday;
(ii) Pap tests as well as office fee will be paid in full once every twelve (12) months;
(iii) Office visits for routine wellness, services and treatment of illness or injury rendered in the physician's 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 (i), (ii), and (iii) shall be paid on the same basis as other covered services (e.g. usual, customary, and reasonable). Payment for services under Part (G)(i) and (iii) will be made for the first one hundred 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 the federally specified limits have been met) and for office visits. The fifteen dollar ($15.00) 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.
(h) 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: $50.00 per person per year maximum payment of $1,000.00 per year.
Maximum lifetime benefit for Type C Services for any covered person $1,000.00. Coverage limited to dependent children under age 19.
This program shall continue in effect for the duration of this agreement.
(i) 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); a fifteen dollar ($15.00) co-payment for tier 2 drugs (preferred brand name drugs); and a thirty dollar ($30.00) co-payment for tier 3 (non-preferred brand name drugs). This program will include a generic drug substitution option. The City shall select the provider for the formulary drug program, who shall group drugs according to determinations made by the provider's therapeutic committee as it deems necessary. The City may select an alternative carrier at its option.
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.
The coverages herein for dental and prescription drug shall be under either an individual or family contract as may be appropriate. The selection of the insurance carrier to provide the coverages herein is the exclusive right of the City.
(j) A reopener over the terms of this section may occur upon ten (10) days notice by the City if the City's percentage rise in medical services costs in the year 2000 is more than seven percent (7%) greater than the industry actuarial trend for Northwest Ohio. The base cost for this purpose will be the average annual full-time equivalent employee cost for medical services for the combined calendar years 1998 and 1999. In calculating the City's percentage rise, claims for an individual that total more than twenty-five thousand dollars ($25,000.00) shall be excluded from consideration from both the base cost and the year 2000 cost. If agreement cannot be reached within thirty (30) days after commencement of the reopener, the parties shall select an arbitrator using the selection procedure set forth in Section 2117.23, "Arbitration". The arbitrator shall conduct a hearing and render a decision following the provisions of the Ohio Public Employee Collective Bargaining Law at Section 4117.14(G), notwithstanding the provisions of 4117.14(D)(1).
In consideration for the right to reopen on this basis during the term of the 1999 Collective Bargaining Agreement, the City shall not exercise its rights under Paragraph (E) above to take such actions as it deems necessary to exact cost containment through measures 1, 3, 4, and/or 5. The existence of this reopener provision, or this clause of that provision, does not prevent the parties from agreeing through the Cost Containment Committee or otherwise to cost containment measures during the term of this agreement.
(k) As a condition of continued coverage under the terms of this section, covered employees shall, beginning January 1, 2009, be responsible for premium payments in accordance with the following schedule: single employees receiving coverage under this section shall pay a monthly premium of twenty-five dollars ($25.00); a single employee with one (1) dependent shall pay a monthly premium of forty dollars ($40.00) per month; an employee with more than one dependent (e.g. family coverage) shall pay a monthly premium of fifty-five dollars ($55.00) per month. Any employee eligible to receive coverage may waive such coverage in accordance with the provisions of subsection (b) (2) of this section. The 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 (1) premium payment based on the level of coverage selected. The birthday rule and spousal exclusion language in Section 2117.107(a) continue to apply to coverage option.
(Ord. 183-10. Passed 4-20-10.)