(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) 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 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 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.
(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 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).
(iii) There shall be 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.
(iv) As a condition of continued coverage under the terms of this section, covered employees shall, beginning the first full pay period in January, 2013, be responsible for premium payments in accordance with the following schedule: Single employees receiving coverage under this section shall pay a monthly premium of forty-eight dollars ($48) per month; a single employee with one (1) dependent (e.g. "single + 1" coverage) shall pay a monthly premium of eighty dollars ($80) per month; an employee with more than one dependent (e.g. family coverage) shall pay a monthly premium of ninety-two dollars ($92) per month. Any employee eligible to receive coverage may waive such coverage.
Effective the first full pay period in June, 2013 the monthly premiums will be increased as follows: Single employees receiving coverage under this section shall pay a monthly premium of seventy-one dollars ($71) per month; a single employee with one (1) dependent shall pay a monthly premium of one hundred twenty dollars ($120) per month; an employee with more than one dependent (e.g. family coverage) shall pay a monthly premium of one hundred twenty-nine dollars ($129) per month.
Effective the first full pay period in June, 2014 the monthly premiums will be increased as follows: Single employees receiving coverage under this section shall pay a monthly premium of ninety-four dollars ($94) per month; a single employee with one (1) dependent shall pay a monthly premium of one hundred sixty dollars ($160) per month; an employee with more than one dependent (e.g. family coverage) shall pay a monthly premium of one hundred sixty six dollars ($166) per month.
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 payment based on the level of coverage selected. The "Birthday Rule" and the spousal exclusion language in subsection (a) of this section continue to apply to coverage options.
(d) Medical providers shall be restricted to those hospitals, physicians, and other care providers designated in the plan as developed by the City.
(e) 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 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). Payment for services under part (e)(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 ten dollar ($10.00) 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 ten dollar ($10.00) office visit co-pay before the 80%/20% co-payment formula is applied.
(f) 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.
(g) The City shall provide a prescriptive drug purchase program with a deductible of twenty percent (20%) of the cost for each brand name prescription, up to a maximum deductible of eight dollars ($8.00), and a two dollar ($2.00) deductible for generic drug prescriptions. This program will include a generic drug substitution option. 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.
(h) 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.