(A) General Provisions
The City shall continue to 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 to age twenty-three (23) or other age as determined by applicable state or federal law.
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". 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. In cases 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 carrier(s) 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, 2002 except as set forth in paragraphs (b) and (c) 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 ($25,000.00) in additional 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 percent (50%) co-insurance.
(4) Coverage for Drug and Alcoholism treatment is limited to a maximum of twenty-five thousand dollars ($25,000.00) lifetime benefits for all in-patient and out-patient care. Inpatient care shall be maintained at a maximum of thirty-one (31) days per calendar year. 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 twenty-five hundred dollars ($2,500.00) per calendar year at fifty percent (50%) co insurance. Employees using drug and alcohol treatment programs must use the Police Department Employee Assistance Program when one is available.
(5) The panel of providers and/or P.P.O. selected by the City for managing and providing nervous and mental, drug and alcohol treatment must be utilized. The City has the right to 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 of both parties. 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:
(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 maximum effective July 1 of 2004, 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/individual) and two hundred dollar ($200.00/family) and co-insurance (80%/20%).
(2) 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 is limited per paragraph (b)(3) and (4).
(3) There shall be a sixty-five dollars ($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 noon, or on a Sunday.
(4) 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 July 2012 | $48 | $80 | $92 |
Effective with the first full pay period of July 2013 | $71 | $120 | $129 |
Effective with the first full pay period of July 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) Effective March 1, 1994, the availability of 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 December 31, 1993 except as otherwise provided herein. 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 cooperation with the Cost Containment Committee. It is understood that the City will now be utilizing the hospital, physicians, and ancillary providers panels through the Western Lake Erie Employer's Cooperative (WLEC)/Cooperative Health Network (CHN).
(E) The Cost Containment Committee formed from among the representatives of the various bargaining units, including the Association, 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) changes of coverage or benefits, such as increased deductibles, limitations on coverage, and contributions from employees; 3) increased claims control, such as coordination of benefits, subrogation, workers' compensation deferral, patient audits, and claim audits; 4) alternate delivery systems such as preferred provider organizations for specific benefits and direct provider negotiations; and 5) development of participative employee plan by which employees will be encouraged to contain costs, audit bills, correct lifestyles, maintain wellness, and undertake other cost savings measures. The committee shall meet regularly on at least a monthly basis and attendance shall be required. The 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 Committee. No changes in benefits during the term of the contract as they affect TPPA shall be permitted unless the TPPA representative on the Cost Containment Committee is authorized to do so by the TPPA through its president. In the event any change in benefits is required by either federal or state law, the TPPA and City shall negotiate the replacement language. If no agreement is reached, the matter shall be subject to an interest arbitration. The parties shall use a panel of seven arbitrators with experience in interest arbitration.
(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. Annual reports from third party administrators of the City's health benefits, including any such reports showing costs and cost reductions, shall be shared with the Cost Containment Committee.
(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 immunization for an infant until the infant's first birthday.
(ii) Pap tests as well as office fee will be paid in full once every twelve (12) months.
(iii) Office visits for routine services rendered in the physicians office, including physical examinations and family planning shall be subject to a ten dollar ($10.00) 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). Payments for services under part (G)(i) and (iii) of 100% will be made for the first three hundred ($300.00) per single contract or six hundred ($600.00) per family per calendar year. The ten-dollar ($10.00) office visit co-pay shall not be counted toward the $300/$600 limits. After deductibles are reached, payment shall then be under the major medical plan; provided, however, that the bill shall be reduced by the ten dollar ($10.00) office visit co-pay before the 80%/20% co-payment formula is applied.
(H) 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 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.
(I) 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 $50.00 per person per year maximum payment of $1,300.00 per year.
Type C Services: Orthodontia 60%
Maximum lifetime benefit for Type C Services for any covered person $1,300.00 coverage limited to dependent children under age 19.
Such benefit shall continue in effect for the duration 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 the insurance carrier to provide the coverage herein is the exclusive right of the City.
(J) 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 Police Patrolman's Association. Said amount shall be used by the Association to purchase whatever vision care benefits they will buy. The City shall have no responsibility relative to the administration of this vision care plan.
(K) The City agrees that all conditions and terms relating to the hospitalization-prescriptive drug-dental insurance shall be maintained at not less than the highest minimum standards in effect as of the effective date of this agreement as found in 2129.101 "Duration of Agreement". It is further agreed that any terms or conditions agreed to that are in excess of those established herein shall not be reduced.