the general plan information section is amended to read ... · o septoplasty o spinal cord...

The General Plan Information Section is AMENDED to read:

The Plan shall take effect for each participating employer on the effective date shown on the cover, unless a different date is set forth above.

The Plan is a legal entity. Legal notice may be filed with, and legal process served upon, the City Attorney.

This Plan believes it is a "non-grandfathered health plan" under the Patient Protection and Affordable Care Act (the Affordable Care Act).

The Your Costs Section is AMENDED to read:

The Plan contains a limit for the amount of out-of-pocket expense you must pay toward covered expenses, shown in the "Schedule ofBenefits", and your out-of-pocket expense limit may be higher for non-PPO network providers than for PPO network providers. Please note, however, that not all covered expenses are eligible to accumulate toward your out-of-pocket expense limit. .These types of expenses include:

" Any penalty

The following is REMOVED from the Exclusions and Limitations section:

., Pre-existing conditions. Related to a pre-existing condition except as specifically provided under this Plan and as required by law.

Other changes to the City of Wisconsin Rapids Employee Welfare Benefit plan (the "Plan") document (the "PD") and summary plan description (the "SPD," and collectively with the PD, the "plan documents") is listed as follows:

• Pre-existing conditions limitations have been removed. • Plan B will adopt all Women's Health Mandates under PPACA. The HSA plan is required to

include these provisions as a new plan established after August I, 2012. «> Copayments wiJI accumulate toward out of pocket maximums " Preventive benefits are frequency based • City of Wisconsin Rapids Employee Welfare Benefit plan document will be one booklet with Plan

B and HSA schedules, and benefit descriptions.

All other provisions of the plan documents shalJ remain unchanged.

PLAN SPONSOR

B~~ Title: H (L DLV"e.L..::f-o{"'

Date: }0 · .;1) ·) 2

r:~~:~;/ I /

,.• . City of Wisconsin RFtpids

, Amendment # 2 to

Plan Document and Summary Plan Description • <

Effective January 1, 2014

This Amendment #2 to the PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION (''the Plan"), made by City of Wisconsin Rapids (the "Company" or the "Plan Sponsor") effective July I, 1988 and restated July I, 2006 and January I, 2012, is effective as of January I, 2.0 I 4. This Amendment modifies the Plan and any addenda thereto as follows:

1) The following is Added to the GENERAL PLAN INFORMATION: ' Master Plan Document

Unless otherwise noted, the Summary Plan Description shall constitute the Master Plan Document for alJ matters addressed herein.

2) The following are Added to the HIPAA PRIVACY PRACTICES: e The Plan may not dis9Jose protected health information that is genetic

information under the Genetic Information Nondiscrimination Act ("GINA") for underwriting purposes.

e You have the right to restrict certain disclosures of protected health information to a health plan where you pay out ofpocket in full for the health care item or service.

~~> You have the right to be notified following a breach of unsecured protected health information.

Al1 other provisions of the plan documents shal1 remain unchanged.

IN WITNESS WHEREOF, the Plan Sponsor has caused this Amendment to be executed.

PLAN SPONSOR

B~ Name: ~ ~l.A.("""'iD '

Date: \ · d\• \* Title: \.4~ ~"bv-/'l-%6 U ~c::R>r

,.

Tbe City of Wisconsin Rapids Employee Medical Plan

Amendment #3 to PJ&n Document and Summary Plan Description

Tbe City of Wisconsln Rapids Employee Medical Benefit Plan (the ''Plan") plan document (the "PD") and summ(ll'y plan description (the "SPD," and collectively with the PD, the "plan documents") are hereby amended as follows:

~ffective: January 1, 2015

The "Medical Care )!smefit" Section is amended tn include the following;

Preventive Care Benefit Covered expenses include these listed services for preventive care for each covered person, subject to any limits described in the "Schedule of Benefits" section. The preventive care benefit includes services that have a rating of' A' or 'B' in the current recommendations of the United ~tates Preventive Services Task Force, immunizations that are recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, and preventive care and screenings for infants, children, adolescents and women by the Health Resources and Services Administration. The Affordable Care Act (ACA) has a specific list of immunizations and well exams that are required to be covered at 100% with no member cost sharing. To view a list of the recommended preventive care services for adults and children please visit https://www.s~curityhealth.orgtpreventivebene:fits

The "Schedule of Begefits" Section the following portion is amended to reag as follows for the HSA Plan:

~;y.~~~RiSP.P'osi6Uit1Ct"S:'; ::; ':.t~~ · · · In ne:tw9rk · ' SQ.Vt Of netWork Deductible $1J300 individual $ltJOO individual The individual deductible does not apply $216oo family $216oo family under a family plan. One or more members of the family must meet the family deductible before benefits will be paid,

Coinsurance J.O% 20%

Annual out of pocket $1,900 individual $~1500 individual (Deductible & coinsurance) S3,Boo family ss,ooo family

In-network amounts accumulate to the out-of- Only the family limit above applies Only the family limit above network out-of-pocket maximum. Out-of- to a two-person or a family plan. applies to a two-person or a network amounts accumulate to the in- family plan. network, out-of-pocket maximum . .

r l

Tbe "Schedule ofJ!!nefits" Section tbe following portion is am~nded tu.t,tUL@s follows for flru!..D.J.

;\'f.O.V~ll~$"P~Ilsi~iti1:ies .' ..:< · ln·netwQrl{ .: ~.O.vh.ifhetwork Deductible S750 individual $750 individual

$1,500 employee+ :1 $1,500 employee+ 1

Sl.,875 family $11875 family I

Coinsurance 10% 20%

Annual QUt of pocket $:1.,150 individual u,sso individual (Deductible, colnsurance, 'medical copays, and $2.300 employee + 1 f31lOO employee+ 1

prescription co pays) $21875 family ~3,875 family

In-network amounts accumulate to the out-of-network out-of-pocket maximum. Out-of· network amounts accumulate to the in-network, out-of-pocket rnilxlmum.

Common Accident Deductible: When two or more covered persons in one family incur covered expenses due to the same accident, only one deductible per calendar year will be applied to the total of all covered expenses incurred as a result of that accident.

All other provisions of the plan documents shall remain unchanged.

:~-~-=---=~:.._so-·R_1_· _.B_k ___ _ Title: ____ <Jt __ tc_,s_u_.·~-"'-'~-----Date: _ _____;J~ . ..!...:/J_o.:..;_!ts-'~·----

The City of Wisconsin Rapids Employee Medical Plan

Amendment#4 to Plan Document and Summary Plan Description Schedule of Benefits

The City of Wisconsin Rapids Employee Medical Benefit Plan (the "Plan") plan document (the "PD") and summary plan description (the "SPD," and collectively with the PD, the "plan documents") are hereby amended as follows:

Effective: January 1, 2016

The section entitled Schedules of Benefits the following is added for each plan:

Precertification Reql]ired ·.· Contact Hines and Associates at 8oo.483.5984 or www.orecertcare.com

• All Inpatient hospitalizations • Skilled Nursing Facility and Residential Stays • Transplants • Physical, Occupational, and Speech therapy after ~o visits per calendar year • Second Surgical Opinions • Outpatient surgery including:

o Abdominoplasty

o ~-i!rp_rl_I~l!~.LR~Iei!se ...... ·-o Cosmetic/Reconstructive Surgery o Hip Replacement o Infuse Bone Graft o Knee Replacement o Panniculectomy o Port Wine Stain- Abnormal Vascular Lesion Treatment o Reduction Mammoplasty o Rhinoplasty o Septoplasty o Spinal Cord Stimulator

The section entitled Cost Containment Provisions is removed in its entirety and replaced with the following:

Pre-certificatiQn Program

Through the Plan's Pre-certification Program, it is possible to work with your attending physician to arrange for care in a setting that is more comfortable for you, such as your home, and to save both you and the Plan unnecessary expense.

The program works by establishing a communication among you, your attending physician and the Pre-certification Program administrator (Hines & Associates) to discuss the proposed course of treatment and any options that may be available for your treatment. Medical management

determines whether the treatment is considered medically necessary, which is one of the required elements for reimbursement under the plan. The medical manager does not establish your eligibility for coverage under the Plan, nor does it approve the services for coverage or reimbursement under the Plan. Those responsibilities rest with the Plan Administrator.

Because communication is the basis for the program, the Plan requires that you contact the medical management at least 1 working day before any of the following services are performed. For emergency and urgent admissions, you must contact medical management within 2 working days following the admission. The contact may be made by you, a friend or family member, or your physician or facility; however, it is important that you understand that it is your responsibility to make sure that the contact has been made. Failure to contact the Program administrator will result in a penalty reducing the benefits otherwise payable.

You are responsible for notifying medical management at 800.483.5984 or www.precertcare.com before you receive the following services:

All Inpatient hospitalizations Occupational Therapy, Physical Therapy, or Speech Therapy after 10 visits per calendar

year Second Surgical Opinion Skilled Nursing Facility and Residential Stays Transplants

• Outpatient Surgery fucluding: o Abdominoplasty o CarpeTfunnefR.dease o Cosmetic/Reconstructive Surgery o Hip Replacement o Infuse Bone Graft o Knee Replacement o Panniculectomy o Port Wine Stain - Abnormal Vascular Lesion Treatment o Reduction Mammoplasty o Rhinoplasty o Septoplasty o Spinal Cord Stimulator

Utilization Management

Utilization management is designed to assist covered persons in making informed medical care decisions resulting in the delivery of appropriate levels of Plan benefits for each proposed course of treatment. These decisions are based on the medical information provided by the patient and the patient's physician. The patient and his or her physician determine the course of treatment. The assistance provided through these services does not constitute the practice of medicine. Payment of Plan benefits is not determined through these processes. The utilization management program is administered by Hines & Associates.

Concurrent Review

Once the service has been pre-certified, the on-going review of the course of treatment becomes the focus of the Program. Working directly with your physician, medical management will identify and approve the most appropriate and cost-effective setting for the treatment as it progresses.

Medical management will not interfere with your course of treatment or the physician-patient relationship. All decisions regarding treatment and use of facilities will be yours and should be made independently of this Program.

A pre-certification, utilization management or concurrent review determination by the Plan under this provision will not be a guarantee of eligibility, coverage or benefits. All benefit determinations will be based upon the provisions of this Plan and the decision of the Plan Administrator in its sole discretion.

Penalty If you fail to notify the Pre-certification Program administrator within the time periods described in this section for emergency and non-emergency inpatient care, the benefits that otherwise would be available for the facility's expenses under the Plan will be reduced as follows:

• Covered expenses will be reduced by $250.00 per admission, and this amount will not accumulate toward any out-of-pocket expense limits.

Any amount of reduction due to a penalty will not accumulate toward any out-of-pocket expense limits under the Plan.

A pre-certification or concurrent review determination under this section will not be a guarantee of eligibility, coverage or benefits. All benefit detenninations will be based upon the provisions of this Plan and the decision of the Plan Administrator in its sole discretion.

Pre-determination of Medical/Surgical Benefits

This is a service offered by the Plan to help you determine, in advance, whether a proposed treatment will be a covered expense under the Plan. It is a voluntary provision, and you are under no obligation to obtain pre-approval of your treatment. However, you are encouraged to use this service to avoid incurring non-covered expenses for which you will be responsible. In order to evaluate the proposed treatment, the Plan Administrator will require detailed medical information from your physician, including:

The identity of the patient (including date of birth and sex); • The diagnosis code (ICD-'9);

The procedure code (CPT); and • The amount of the proposed charge.

This information should be submitted to:

Security Administrative Services PO Box 8000

Marshfield WI 54449 800.570.8760

Types of serviCes which are recommended for predetermination include the following:

• Blepharoplasty • Rhinoplasty • Virtual Colonoscopy • Varicose Vein Treatment • Other services that may be viewed as cosmetic, experimental or investigational,

or not medically necessary

You will receive a written response with the Plan Administrator's determination, which you may furnish to your physician if you so desire. A pre-determination under this section will not be a guarantee of eligibility, coverage or benefits. All benefit determinations will be based upon the provisions of this Plan and the decision of the Plan Administrator in its sole discretion.

Do not delay seeking medical care for any covered person who has a serious condition that may jeopardize his life or health in order to pre-determine benefits. Pre-determination of benefits is not recommended under these circumstances.

Case Management Program

In-certain CircumstanceS, especially -Ill the case-o-ra very serious 1Hness-or-Tnjucy,-the Plan may make available its Case Management Program services to the covered person. This is strictly a voluntary program; no covered person is obligated to participate and benefits will not be adversely affected.

Case managers are medical professionals who will work with your attending physician to identify alternate courses of tre~tment and the best way to -use your benefit dollars. They can be of invaluable assistance in locating resources to assist in your recovery.

If you are selected as a candidate for case management, you will be contacted by a case manager who will then work with you and your physiCian throughout the course of treatment. If you have any questions about the Case Management Program, please feel free to contact Hines & Associates at 800.483.5984.

Condition I Disease Management

Condition I Disease Management is another voluntary program offered to plan participants through Medical Management. This is an educational program for people with certain chronic conditions where the person's self-management and lifestyle choices greatly impact the quality and total cost of their health care. The role of the disease management nurses is to work with the covered person, the family, and the health care providers, to educate the covered member on the management of their condition in order to promqte healthier lifestyle choices and better condition management efforts in order to reduce exacerbations and/or complications.

Members are identified for this program by analyzing claims data, as well as information received in the precertification process.

• ·0"

The conditions that are part of this program are: Asthma

• Chronic Obstructive Pulmonary Disease (chronic bronchitis or emphysema) • Congestive Heart Failure

Coronary Artery Disease Degenerative Joint Disease/Arthritis

• Diabetes

An educational program for Healthy Pregnancy is also offered to any pregnant health plan member.


The City ofWisconsin Rapids Employee Medical Plan


The City of Wisconsin Rapids Employee Medical Benefit Plan (the "Plan") plan document (the "PD") and summary plan description (the "SPD," and collectively with the PD, the "plan documents") arc hereby amended as follows:

Effective: July 1, 2016

The "Schedule of Benefits" Section the following portion is amended to read as follows for each plan:

Precertification Required Contact Hines and Associates at 800.483.5984 or www.precertcare.com

e All inpatient hospitalizations e Skilled Nursing Facility and Residential Stays • Transplants • Physical, Occupational, and Speech therapy after 15 visits per calendar year • Second Surgical Opinions • Outpatient surgery including:

o Abdominoplasty o Carpel Tunnel Release o Cosmetic/Reconstructive Surgery o Hip Replacement o Infuse Bone Graft o Knee Replacement o Panniculectomy o Port Wine Stain- Abnormal Vascular Lesion Treatment o Reduction Mammoplasty o Rhinoplasty o Septoplasty o Spinal Cord Stimulator

---- ---·----

The "Medical Care Benefit" Section is amended to read as follows:

Preventive Care Benefit

I ____ .,_j

Covered expenses include these listed services for preventive care for each covered person, subject to any limits described in the "Schedule of Benefits" section.

• Immunizations (including zostavax (shingles) vaccine, for covered persons age 50 or older)


PLAN SPONSOR

By'~-h--<_r-,~~ Title: \-+?-- 0\ ( e.L•:f·c:,(

Date: q.. · ) 0 · ' le

The City of Wisconsin Rapids Employee Medical Plan


The City of Wisconsin Rapids Employee Medical Benefit Plan (the "Plan") plan document (the "PD") and summary plan description (the "SPD," and collectively with the PD, the "plan documents") are hereby amended as follows:

Effective: October 5, 2016

The section entitled Eligibility for Participation; subsection "Effective Date oflndividual Coverage" the following is removed:

1. Contributory Coverage. Coverage for which the employee pays for part of the coverage. The employee must apply for such coverage and cannot elect medical and not dental coverage. The employee must elect both medical and dental coverage. All applications must be made to the employer on approved forms. A person's coverage shall become effective as follows:

a. The first of the month following the date thirty calendar days of active work are completed.

b. If the employee applies for coverage on or before the eligibility date, the effective date shall be the eligibility date.

c. If the employee applies for coverage after the first 31 days of eligibility, the employee may not enroll until the next open enrollment period of September 15th through October 15th for an effective date of January 1st.

d. If the employee applies for coverage after prior termination due to failure to pay for the coverage or due to a prior request to terminate, the employee must wait until the next annual open enrollment period of September 15th through October 15th for an effective date of January I st of each year.

e. If an employee marries while his coverage is in force, and he applies for dependent coverage within 31 days ofthe marriage his spouse's effective date shall be the date of the marriage.

And replaced with:

2. Contributory Coverage. Coverage for which the employee pays for part of the coverage. The employee must apply for such coverage. All applications must be made to the employer on approved forms. A person's coverage shall become effective as follows:

a. The frrst of the month following the date thirty calendar days of active work are completed.

b. If the employee applies for coverage on or before the eligibility date, the effective date shall be the eligibility date.

d. If the employee applies for coverage after the first 31 days of eligibility, the employee may not enroll until the next open enrollment period of October 15th through November 15th for an effective date of January I st.

f. If the employee applies for coverage after prior termination due to failure to pay for the coverage or due to a prior request to terminate, the employee must wait until the next annual open enrollment period of October 15111 through November 15th for an effective date ofJanuary 1'1 of each year.

g. If an employee marries while his coverage is in force, and he applies for dependent coverage within 31 days of the marriage his spouse's effective date shall be the date of the marriage.

The section entitled Eligibility for Participation; subsection "What if I do not enroll during my original eligibility period and later decide to apply for coverage?" the following is removed:

You and your dependents may enroll for coverage during the Plan's annual open enrollment period, which is the period between September 15 through October 15th in each calendar year. If you or your dependents enroll during an open enrollment period, coverage will be effective at 12:01 A.M. on the first day of January, unless you have not satisfied the waiting period. In that case, coverage for you and your eligible dependents will be effective on the first day of the month following your completion of the waiting period.

And replaced with:

You and your dependents may enroll for coverage during the Plan's annual open enrollment period, which is the period between October 15 through November 15th in each calendar year. If you or your dependents enroll during an open enrollment period, coverage will be effective at 12:01 A.M. on the first day of January, unless you have not satisfied the waiting period. In that case, coverage for you and your eligible dependents will be effective on the first day of the month following your completion of the waiting period.


PLAN SPONSOR

By~~~~ Title : \A~ CJ~_+D--v

Date: \ () · I d-· I \Q

the general plan information section is amended to read ... · o septoplasty o spinal cord...

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