HomeMy WebLinkAboutAGMT - Vision Service Plan I
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VSP
P.O.Box 997100•Sacramento•California 95899.9989
(800)852.7600
Attn: Inside Sales
All applicable questions must be completed accurately and in detail to avoid delay.
1 _ ; ° CLIENTs N rtiFfiVrA4T.1
e .S117,11140 ikpr-r-Sn,Witiait.t.-ai1t;t411141.
1. Full legal name of client as it appears on the policy: City of Seal Beach
Address:211 81h Street
City:Seal Beach County: Orange State: CA Zip:90740
Telephone: (562)431-2527 Fax:(562)431-4067
Principal Contact: Andy Tse Title:Personnel Manager E-mail: atse @ci.seal-beach.ca.us
Client is headquartered in state of (if different from above).
2. Who should we contact with payment questions?Andy Tse Title:
Telephone: ( ) Fax: ( ) E-mail:
3. Who should we contact with eligibility questions?Andy Tse Title:
Telephone: ( ) Fax:( ) E-mail:
4. Who is the Benefit Administrator responsible for the overall administration of the plan(if not principal contact)?
Name: Title:
Telephone: ( ) Fax: ( ) E-mail:
If multiple benefits administrators are at other locations,please attach separate piece of paper, with name(s), address(es),
telephone, and fax numbers.
5. What is your Standard Industry Code(SIC)?9111
What is the nature of your business?City
6. Membership updates will be made via a secure Internet site. Do you have Internet access?Yes
Employers without Internet access for making membership updates will be contacted by VSP to review other options.
7a. Names of separate divisions that will be covered by this plan:
NAME:
N/A
5/06 Small Client Online Application
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16. Client has purchased Enhancements or Specialty Care: ❑Yes Z No
❑Covered Contact Lenses ❑Second Pair of Glasses ❑Vision Therapy ❑Primary EyeCare ❑Safety EyeCare
❑Computer VisionCare ❑ Preferred Laser VisionCare(available on a self-funded basis only to clients with 200+enrolled
employees) ❑ Scratch Coating ❑Anti-Reflective Coating ❑Progressive Lenses ❑Elective Contact Lenses$135
Allowance
Frame Buy-up: ❑ $130 ❑$140 ❑$150 (Retail Frame Allowance)
Additional Information
(Enhancements or Specialty Care benefit service frequency must match the base plan)
17. FOR FULLY INSURED PROGRAMS:
RATES:
Employee only or composite rate basis $9.46
Two,Three or Four-rate basis $ 13.56
$24.40
Termination Clause
The City of Seal Beach has the right to withdraw from this contract if the City provides written notice to
VSP 30 days prior to the termination date. VSP can also cancel this contract with the City of Seal Beach
under the Same terms.
Note:A minimum number of enrolled employees is required. Membership is due with the receipt of the application to ensure
qualification for coverage and acceptance by VSP.
18. FOR SELF-INSURED PROGRAMS:
Administrative Fee: Fixed fee or Percent of claims
Prefunding(Advance Payment):Amount if Group is an Administrative Service Program
$ (per covered employee-as quoted)x (number of employees)_$
19. Requested effective date(The effective date should not precede date of receipt of this application by VSP.)
This policy will become effective on the first day of January, 2008 provided that all of the following has been completed prior
to this effective date:
A. Application has been received and accepted by VSP.
B. Membership has been received and accepted by VSP, including the required information of all employees that will be
covered under this policy showing name,member ID number,and number of dependents, if applicable.
20. This agreement will continue in force 24 months from the effective date.Rates are based on the assumption that VSP will receive
these amounts over the full plan term.
21. 5500 Report Information: Fiscal Year N/A through N/A. 5500 Report will be sent to the person named as the principal contact.A
copy of the report may also be sent to your broker and/or your third party administrator.
Please send an additional copy to:N/A
22. Prior VSP coverage: ❑Yes ®No
If yes,prior client name:
23. Names of affiliates or subsidiaries with VSP coverage under a separate contract:
N/A
5/06 Small Client Online Application
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7b. Will a separate billing be needed for the above divisions? ❑ Yes ®No
Billing address(if applicable):
Firm/Organization:
Address:
City: State: Zip:
Telephone: ( ) Fax:( ) E-mail:
7c. If Self-Funded Program,do claims billings and administrative fee billings go to the same person? ❑Yes ❑No
(If no,please supply contact, title, address, telephone, and fax number for each type of billing)
8. Send employee benefit information*to: Client's Benefit Administrator
*Any non-VSP-created information outlining coverage or plan details must be reviewed by VSP prior to distribution to members.
9. Number of employees eligible for benefits 86
Does this represent the total number of employees in the company? ®Yes ❑No(fill in total number)
10. Dependents: Eligible dependents are the covered employee's spouse and unmarried dependent children until they reach their
23 birthday(also includes an unmarried child if incapable of self-support because of physical or mental incapacity that
commenced prior to reaching the above age),or their 23 birthday, if attending school full time.
Dependents other than employee's spouse&children: ❑parents ❑domestic partners(all)
❑domestic partners(same sex only) ❑domestic partner's children
11. The third party administrator(if applicable):
Firm:
Address: E-mail:
City: State: Zip:
Telephone:( ) Fax:(
Contact: Title:
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The rates listed must support the plan design and benefit selected and must meet all eligibility requirements.Please refer to your VSP
provided rate sheet for details or contact your VSP Account Executive.Any discrepancies may preclude acceptance by VSP.
12. Benefit Year: (Select One)
❑ Service Year(from last date of service)
®Calendar Year(available for clients with January 1 effective dates only)
13. Is vision benefit: ®Core ❑Voluntary ❑Packaged with medical and/or dental
14. Plan Type:VSP Signature Plan
*A minimum number of enrolled employees may apply.
15. Frequency of Service: B(12/12/24)
Co-Payment: $20 Total co-payment(applies to exam and eyewear)OR Split$ Exam/$ Eyewear
5/06 Small Client Online Application
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The undersigned client hereby applies for vision care coverage through VSP.
It is understood that:
A. All future employees will be covered when they become eligible,or offered VSP coverage if voluntary.
B. Coverage will terminate for an employee on the last day of the month in which employment terminates.
C. Member past service for clients previously covered by VSP will carry over and remain in force.
D. This agreement will continue in force 24 months from the effective date. Rates are based on the assumption that VSP will
receive these amounts over the full plan term.
This application signed this 11 fn-day of,{,ge , 20o1
Firm/Organization:City of Seal Beach
Name: Title: Mil9 N. '2 /CZ7y IVAt22&(
Signature: ez-le- r' I
-
Any person who knowingly and with intent to injure,defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
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®The broker/consultant indicated below is hereby designated Broker of Record by the above signed employer
Legal Firm Name:ABD Insurance& Financial Services
Address:21250 Hawthorne Blvd.,Suite 600
City:Torrance County: Los Angeles State:CA Zip:90503
Telephone:(310)543-9995 Fax:(310)543-9905
Contact:Liesel Collins Title:Account Manager E-mail: Ijc @abdi.com
Broker Assistant Name: Elizabeth Sapien E-mail: eal@abdi.com
Taxpayer I.D.#:770570678
Commission Checks Payable to:Firm Name
Name:
Address:
City: County: State: Zip:
This application signed this 24 day of October,2 07
By State Licensed Agent: y - , (/,/ Title:Account Manager
PLEASE SEND A COPY OF AGENT/BROKER LICENSE TO VSP
IF NOT CURRENTLY ON FILE WITH VSP.
5/06
Small Client Online Application
RECEIVED
FEB 2 3 2012 j iFAR O
ill
Wells Fargo Insurance Services USA,Inc.
CADOI#0D08408 "ii•!,: ManaOar Offke
21250 Hawthorne Blvd -
Suite boo
Torrance,CA 90503-5506
Tel 310 543-9995
Fax 310 543
February 22, 2012
Nancy Ralsten
City of Seal Beach
211 Eighth Street
Seal Beach, CA 90740
RE: VISION SERVICE PLAN #30006227
CONTRACT AND EVIDENCE OF COVERAGE
EFFECTIVE JANUARY 1, 2012
Dear Nancy,
Enclosed is the Vision Service Plan Contract for the City of Seal Beach effective
January 1, 2012 through December 31, 2014. We have determined that the
benefits, rates, and contract period are correct in terms of the purchase. There is
no signature required for this contract; please retain this copy for your files.
Also enclosed is the 2012 Evidence of Coverage for distribution to employees. If
you have any questions, please do not hesitate to contact myself or Kristin.
Sincerely,
Mitzi Baum,
Account Manager
Together we'll go far
4,,
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tl S '
Vision Care for Life
VISION SERVICE PLAN
3333 QUALITY DRIVE
RANCHO CORDOVA, CALIFORNIA 95670
GROUP VISION CARE PLAN
Group Name CITY OF SEAL BEACH
Plan Number • 30006227
State of Delivery CALIFORNIA
Effective Date JANUARY 1, 2012
Plan Term TWENTY-FOUR(24)MONTHS
Premium Due Date FIRST DAY OF MONTH
In consideration of the statements and agreements contained in the Group Application and in consideration of
payment by the Group of the premiums as herein provided, VISION SERVICE PLAN ("VSP") agrees to provide certain
individuals under this Group Vision Care Plan ("Plan")the benefits provided herein, subject to the exceptions, limitations and
exclusions hereinafter set forth. This Plan is delivered in and governed by the laws of the state of delivery and is subject to
the terms and conditions recited on the subsequent pages hereof, includi any Exhibits or state-specific Addenda, which
are a part of this Plan.
IM^ utsm. °
Jim McGrann, President, VSP Vision Care
VSP-PLAN5A07 01/30/12 Jah
VISION SERVICE PLAN
GROUP VISION CARE PLAN
TABLE OF CONTENTS
I. DEFINITIONS 1
II. TERM, TERMINATION, AND RENEWAL 3
III. OBLIGATIONS OF VSP 4
IV. OBLIGATIONS OF THE GROUP 6
V. OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN 8
VI. ELIGIBILITY FOR COVERAGE 11
VII. CONTINUATION OF COVERAGE 14
VIII. ARBITRATION OF DISPUTES 15
IX. NOTICES 16
X. MISCELLANEOUS 17
EXHIBIT A
SCHEDULE OF BENEFITS 19
EXHIBIT B
SCHEDULE OF PREMIUMS 24
ADDENDUM
ADDITIONAL BENEFIT- PRIMARY EYECARE PLAN 25
ADDENDUM
FOR THE STATE OF CALIFORNIA 28
•
DEFINITIONS
Key terms used in this Plan are defined:
1.01. BENEFIT AUTHORIZATION: Authorization from VSP identifying the individual named a Covered Person
of VSP, and identifying those Plan Benefits to which Covered Person is entitled.
1.02. CONFIDENTIAL MATTER: All confidential information concerning the medical, personal, financial or
business affairs of Covered Persons obtained while providing Plan Benefits hereunder.
1.03. COPAYMENTS: Any amounts required to be paid by or on behalf of a Covered Person for Plan Benefits
which are not fully covered.
1.04. COVERED PERSON: An Enrollee or Eligible Dependent who meets VSP's eligibility criteria and on whose
behalf Premiums have been paid to VSP, and who is covered under this Plan.
1.05. ELIGIBLE DEPENDENT: Any legal dependent of an Enrollee of Group who meets the criteria for eligibility
established by Group and approved by VSP in Article VI of this Plan under which such Enrollee is covered.
1.06. EMERGENCY CONDITION: A condition, with sudden onset and acute symptoms, that requires the
Covered Person to obtain immediate medical care, or an unforeseen occurrence calling for immediate, non-medical action.
1.07. ENROLLEE: An employee or member of Group who meets the criteria for eligibility specified under Article
VI. ELIGIBILITY FOR COVERAGE.
1.08. EXPERIMENTAL NATURE: Procedure or lens that is not used universally or accepted by the vision care
profession, as determined by VSP.
1.09. GROUP: An employer or other entity which contracts with VSP for coverage under this Plan in order to
provide vision care coverage to its Enrollees and their Eligible Dependents.
1.10. GROUP APPLICATION: The form signed by an authorized representative of the Group to signify the
Group's intention to have its Enrollees and their Eligible Dependents become Covered Persons of VSP.
1.11. GROUP VISION CARE PLAN (also, "THE PLAN"): The Plan issued by VSP to a Group, under which its
Enrollees or members, and their Eligible Dependents are entitled to become Covered Persons of VSP and receive Plan
Benefits in accordance with the terms of such Plan.
1
1.12. MEMBER DOCTOR: An optometrist or ophthalmologist licensed and otherwise qualified to practice vision
care and/or provide vision care materials who has contracted with VSP to provide vision care services and/or vision care
materials on behalf of Covered Persons of VSP.
1.13. NON-MEMBER PROVIDER: Any optometrist, optician, ophthalmologist, or other licensed and qualified
vision care provider who has not contracted with VSP to provide vision care services and/or vision care materials to
Covered Persons of VSP.
1.14. PLAN BENEFITS: The vision care services and vision care materials which a Covered Person is entitled
to receive by virtue of coverage under this Plan, as defined in the Schedule of Benefits attached hereto as Exhibit A.
1.15. RENEWAL DATE: The date when the Plan shall renew, or terminate if proper notice is given.
1.16. SCHEDULE OF BENEFITS: The document, attached hereto as Exhibit A to this Plan, which lists the vision
care services and vision care materials which a Covered Person is entitled to receive under this Plan.
1.17. SCHEDULE OF PREMIUMS: The document, attached hereto as Exhibit B, which states the payments to
be made to VSP by or on behalf of a Covered Person to entitle him/her to Plan Benefits.
2
II.
TERM, TERMINATION, AND RENEWAL
2.01. Plan Term: This Plan is effective on the Effective Date and shall remain in effect for the Plan Term. At the
end of the Plan Term, the Plan shall renew on a month to month basis unless either party notifies the other in writing, at
least sixty (60) days before the end of the Plan Term that such party is unwilling to renew the Plan. If such notice is given,
the Plan shall terminate at 11:59 p.m. on the last day of the Plan Term unless the parties agree on its renewal of the Plan. If
the Plan continues on a month to month basis after the Plan Term, either party may terminate the Plan upon thirty (30) days
advance notice to the other party.
If VSP issues written renewal materials to Group at least sixty (60) days before the end of the Plan Term and Group
fails to accept the new terms and/or rates in writing prior to the end of the Plan Term, this Plan shall terminate at 11:59 p.m.
on the last day of the Plan Term.
2.02. Early Termination Provision: The Premium rate payable by Group to VSP under this Plan is based on an
assumption that VSP will receive these amounts over the full Plan Term in order to cover costs associated with greater
vision utilization that tends to occur during the first portion of a Plan Term. If Group terminates this Plan before the end of
the Plan Term or before the end of any subsequent renewal terms, for any reason other than material breach by \/SP,
Group shall be liable for the lesser of any deficit incurred by VSP or the remaining payments which Group would have paid
for the full term of this Agreement. A deficit incurred by VSP will be calculated by subtracting the cost of incurred and
outstanding claims, as calculated on an incurred date basis with a claim run-out not to exceed six months from the date of
termination, from the net premiums received by VSP from Group. Net premiums shall mean premiums paid by Group minus
any applicable retention amounts and/or broker commissions. Group agrees to pay VSP within thirty-one (31) days of
notification of the amount due.
3
III.
OBLIGATIONS OF VSP
3.01. Coverage of Covered Persons: VSP will enroll for coverage each eligible Enrollee and his/her Eligible
Dependents, if dependent coverage is provided, all of who shall be referred to upon enrollment as "Covered Persons." To
institute coverage, VSP may require Group to complete, sign and forward to VSP a Group Application along with information
regarding Enrollees and Eligible Dependents, and all applicable premiums. (Refer to VI. ELIGIBILITY FOR COVERAGE
for further details.)
Following the enrollment of the Covered Persons, VSP will provide Group with Member Benefit Summaries for
distribution to Covered Persons. Such Member Benefit Summaries will summarize the terms and conditions set forth in this
Plan.
3.02. Provision of Plan Benefits: Through its Member Doctors (or through other licensed vision care providers
where a Covered Person is eligible for, and chooses to receive Plan Benefits from a Non-Member Provider) VSP shall
provide Covered Persons such Plan Benefits listed in the Schedule of Benefits, Exhibit A hereto, subject to any limitations,
exclusions, or Copayments therein stated. Benefit Authorization must be obtained prior to a Covered Person obtaining Plan
Benefits from a Member Doctor. When a Covered Person seeks Plan Benefits from a Member Doctor, the Covered Person
must schedule an appointment and identify himself as a VSP Covered Person so the Member Doctor can obtain Benefit
Authorization from VSP. VSP shall provide Benefit Authorization to the Member Doctor to authorize the provision of Plan
Benefits to the Covered Person. Each Benefit Authorization will contain an expiration date, stating a specific time period for
the Covered Person to obtain Plan Benefits. VSP shall issue Benefit Authorizations in accordance with the latest eligibility
information furnished by Group and the Covered Person's past service utilization, if any. Any Benefit Authorization so
issued by VSP shall constitute a certification to the Member Doctor that payment will be made, irrespective of a later loss of
eligibility of the Covered Person, provided Plan Benefits are received prior to the Benefit Authorization expiration date.
VSP shall pay or deny claims for Plan Benefits provided to Covered Persons, less any applicable Copayment,
within a reasonable time but not more than thirty (30) calendar days after VSP has received a completed claim, unless
special circumstances require additional time. In such cases, VSP may obtain an extension of fifteen (15) calendar days of
this time limit by providing notice to the claimant of the reasons for the extension.
4
3.03. Provision of Information to Covered Persons: Upon request, VSP shall make available to Covered
Persons necessary information describing Plan Benefits and how to use them. A copy of this Plan shall be placed with
Group and also will be made available at the offices of VSP for any Covered Persons. VSP shall provide Group with an
updated list of Member Doctors' names, addresses, and telephone numbers for distribution to Covered Persons twice a
• year. Covered Persons may also obtain a copy of the Member Doctor directory through contacting VSP's Customer Service
Department's toll-free Customer Service telephone line, VSP's Web site at www.vsp.com, or by written request.
3.04. Preservation of Confidentiality: VSP shall hold in strict confidence all Confidential Matters and exercise
its best efforts to prevent any of its employees, Member Doctors, or agents, from disclosing any Confidential Matter, except
to the extent that such disclosure is necessary to enable any of the above to perform their obligations under this Plan,
including but not limited to sharing information with medical information bureaus, or complying with applicable law. Covered
Persons and/or Groups that want more information on VSP's Confidentiality policy may obtain a copy of the policy by
contacting VSP's Customer Service Department or VSP's Web site at www.vsp.com.
3.05. Emergency Vision Care: When vision care is necessary for Emergency Conditions, Covered Persons
may obtain Plan Benefits by contacting a Member Doctor or Non-Member Provider. No prior approval from VSP is required
for Covered Person to obtain vision care for Emergency Conditions of a medical nature. However, services for medical
conditions, including emergencies, are covered by VSP only under the Acute EyeCare and Supplemental Primary EyeCare
Plans. If Group has not purchased one of these plans, Covered Persons are not covered by VSP for medical services and
should contact a physician under Covered Persons' medical insurance plan for care. For emergency conditions of a
non-medical nature, such as lost, broken or stolen glasses, the Covered Person should contact VSP's Customer Service
Department for assistance. Reimbursement and eligibility are subject to the terms of this Plan.
5
Iv.
OBLIGATIONS OF THE GROUP
4.01. Identification of Eligible Enrollees: An Enrollee is eligible for coverage under this Plan if he/she satisfies
the enrollment criteria specified in Paragraph 6.01(a) and/or as mutually agreed to by VSP and Group. By the Effective
Date of this Plan, Group shall provide VSP with eligibility information, in a mutually agreed upon format and medium, to
identify all Enrollees who are eligible for coverage under this Plan as of that date. Thereafter, Group shall supply to VSP by
the last day of each month, eligibility information sufficient to identify all Enrollees to be added to or deleted from VSP's
coverage rosters for the next month. The eligibility information shall include designation of each Enrollee's family status if
dependent coverage is provided. Upon VSP's request, Group shall make available for inspection records regarding the
coverage of Covered Persons under this Plan.
4.02. Payment of Premiums: By the last day of each month, Group shall remit to VSP the premiums payable for
the next month on behalf of each Enrollee and Eligible Dependents, if any, to be covered under this Plan. The Schedule of
Premiums incorporated in this Plan as Exhibit B provides the premium amount for each Covered Person. Only Covered
Persons for whom premiums are actually received by VSP shall be entitled to Plan Benefits under this Plan and only for the
period for which such payment is received, subject to the grace period provision below. If payment for any Covered Person
is not received on time, VSP may terminate all rights of such Covered Person. Such rights may be reinstated only in
accordance with the requirements of this Plan.
VSP may change the premiums set forth in Exhibit B (Schedule of Premiums) by giving Group at least sixty (60)
days advance written notice. No change will be made during the Plan Term unless there is a change in the Schedule of
Benefits or there is a material change in Plan terms or conditions, provided any such change is mutually agreed upon in
writing by VSP and Group.
Notwithstanding the above, VSP may increase premiums during a Plan Term by the amount of any tax or
assessment not now in effect but subsequently levied by any taxing authority, which is attributable to premiums VSP
received from Group.
6
•
4.03. Grace Period: Group shall be allowed a grace period of thirty-one (31) days following the premium
payment due date to pay premiums due under this Plan. During said grace period, this Plan shall remain in full force and
effect for all Covered Persons of Group. VSP will consider late payments at the time of Plan renewal. Such payment may
impact Group's premium rates in future Plan Terms.
If Group fails to make any premiums payment due by the end of any grace period, VSP may notify Group that the
premiums payment has not been made, that coverage is canceled and that Group is responsible for payment for all Plan
Benefits provided to Covered Persons after the last period for which premiums were paid in full, including the grace period
through the effective date of termination. Group shall also be responsible for any legal and/or collection fees incurred by
VSP to collect amounts due under this Plan.
4.04. Distribution of Required Documents: Group shall distribute to Enrollees any disclosure forms, plan
summaries or other material required to be given to plan subscribers by any regulatory authority. Such materials shall be
distributed by Group no later than thirty(30) days after the receipt thereof, or as required under state law.
•
•
7
V.
OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN
5.01. General: By this Plan, Group makes coverage available to its Enrollees and their Eligible Dependents, if
dependent coverage is provided. However, this Plan may be amended or terminated by agreement between VSP and
Group as indicated herein, without the consent or concurrence of Covered Persons. This Plan, and all Exhibits, Riders and
attachments hereto, constitute VSP's sole and entire undertaking to Covered Persons under this Plan.
As conditions of coverage, all Covered Persons under this Plan have the following obligations:
5.02. Copayment for Services Received: Where, as indicated in Exhibit A (Schedule of Benefits), Copayments
are required for certain Plan Benefits, Copayments shall be the personal responsibility of the Covered Person receiving the
care and must be paid to the Member Doctor the date services are rendered.
5.03. Obtaining Services from Member Doctors: Benefit Authorization must be obtained prior to receiving Plan
Benefits from a Member Doctor. When a Covered Person seeks Plan Benefits, the Covered Person must select a Member
Doctor, schedule an appointment, and identify himself as a Covered Person so the Member Doctor can obtain Benefit
Authorization from VSP. Should the Covered Person receive Plan Benefits from a Member Doctor without such Benefit
Authorization, then for the purposes of those Plan Benefits provided to the Covered Person, the Member Doctor will be
considered a Non-Member Provider and the benefits available will be limited to those for a Non-Member Provider, if any.
5.04. Submission of Non-Member Provider Claims: If Non-Member Provider coverage is indicated in Exhibit
A (Schedule of Benefits), written proof(receipt and the Covered Person's identification information) of all claims for services
received from Non-Member Providers shall be submitted by Covered Persons to VSP within three hundred sixty five (365)
days of the date of service. VSP may reject such claims filed more than three hundred sixty five (365) days after the date of
service.
Failure to submit a claim within this time period, however, shall not invalidate or reduce the claim if it was not
reasonably possible to submit the claim within such time period, provided the claim was submitted as soon as reasonably
possible and in no event, except in absence of legal capacity, later than one year from the required date of three hundred
sixty five (365) days after the date of service.
5.05. Complaints and Grievances: Covered Persons shall report any complaints and/or grievances to VSP at
the address given herein. Complaints and grievances are disagreements regarding access to care, quality of care,
treatment or service. Complaints and grievances may be submitted to VSP verbally or in writing. A Covered Person may
submit written comments or supporting documentation concerning his complaint or grievance to assist in VSP's review.
VSP will resolve the complaint or grievance within thirty (30) days after receipt.
8
5.06. Claim Denial Appeals: If, under the terms of this Plan, a claim is denied in whole or in part, a request may
be submitted to VSP by Covered Person or Covered Person's authorized representative for a full review of the denial.
Covered Person may designate any person, including his/her provider, as his/her authorized representative. References in
this section to "Covered Person" include Covered Person's authorized representative,where applicable.
a) Initial Appeal: The request must be made within one hundred eighty (180) days following denial
of a claim and should contain sufficient information to identify the Covered Person for whom the claim was denied, including
the VSP Enrollee's name, the VSP Enrollee's Member Identification Number, the Covered Person's name and date of birth,
the provider of services and the claim number. The Covered Person may review, during normal working hours, any
documents held by VSP pertinent to the denial. The Covered Person may also submit written comments or supporting
documentation concerning the claim to assist in VSP's review. VSP's determination, including specific reasons for the
decision, shall be provided and communicated to the Covered Person within thirty (30) calendar days after receipt of a
request for appeal from the Covered Person or Covered Person's authorized representative.
b) Second Level Appeal: If the Covered Person disagrees with the response to the initial appeal of
the claim, the Covered Person has a right to a second level appeal. Within sixty (60) calendar days after receipt of VSP's
response to the initial appeal, the Covered Person may submit a second appeal to VSP along with any pertinent
documentation. VSP shall communicate its final determination to the Covered Person in compliance with all applicable
state and federal laws and regulations and shall include the specific reasons for the determination.
c) Other Remedies: When Covered Person has completed the appeals process stated herein,
additional voluntary alternative dispute resolution options may be available, including mediation, or Group should advise
Covered Person to contact the U.S. Department of Labor or the state insurance regulatory agency for details. Additionally,
under the provisions of ERISA (Section 502(a)(1)(B)) [29 U.S.C. 1132(a)(I)(B)], Covered Person has the right to bring a civil
action when all available levels of review of denied claims, including the appeals process, have been completed, the claims
were not approved in whole or in part, and Covered Person disagrees with the outcome.
5.07. Time of Action: No action in law or in equity shall be brought to recover on the Plan prior to the Covered
Person exhausting his/her grievance rights under this Plan and/or prior to the expiration of sixty (60) days after the claim
and any applicable invoices have been filed with VSP. No such action shall be brought after the expiration of six (6) years
from the last date that the claim and any applicable invoices were submitted to VSP, in accordance with the terms of this
Plan.
5.08. Insurance Fraud: Any Group and/or person who intends to defraud, knowingly facilitates a fraud or
submits an application or files a claim with a false or deceptive statement, is guilty of insurance fraud. Such an act is
9
• grounds for immediate termination of the Plan for the Group or individual that committed the fraud.
10
VI.
ELIGIBILITY FOR COVERAGE
6.01. Eligibility Criteria: Individuals will be accepted for coverage hereunder only upon meeting all the
applicable requirements set forth below.
(a) Enrollees: To be eligible for coverage, a person must:
(1) currently be an employee or member of the Group, and
(2) meet the criteria established in the coverage criteria mutually agreed upon by Group and VSP.
(b) Eligible Dependents: If dependent coverage is provided, the persons eligible for dependent
coverage are:
(1) the legal spouse of any Enrollee, and
(2) any unmarried child of an Enrollee, including any natural child from the moment of birth, or
legally adopted child from the moment of placement for adoption with the Enrollee, or other child for whom a court holds the
Enrollee responsible; and
(A) for whose support the Enrollee is legally responsible and who has not yet attained the
age of 23 years.
(3) as further defined by Group.
If a dependent, unmarried child prior to attainment of the prescribed age for termination of eligibility becomes, and
continues to be, incapable of self-sustaining employment because of mental or physical disability, that Eligible Dependent's
coverage shall not terminate so long as he remains chiefly dependent on the Enrollee for support and the Enrollee's
coverage remains in force; PROVIDED that satisfactory proof of the dependent's incapacity can be furnished to VSP within
thirty-one (31) days of the date the Eligible Dependents coverage would have otherwise terminated or at such other times
as VSP may request proof, but not more frequently than annually.
11
6.02. Documentation of Eligibility: Persons satisfying the coverage requirements under either of the above
criteria shall be eligible if:
(a) for an Enrollee, the individual's name and Social Security Number have been reported by Group to VSP
in the manner provided hereunder, and
(b) for changes to an Eligible Dependent's status, the change has been reported by the Group to VSP in
the manner provided herein. As stated in Paragraph 4.01 above, VSP may elect to audit Group's records in order to verify
eligibility of Enrollees and dependents and any errors. Subject to the terms of Paragraph 4.03 above, only persons on
whose behalf premiums have been paid for the current period shall be entitled to Plan Benefits hereunder. If a clerical error
is made, it will not affect the coverage a Covered Person is entitled under the Plan.
6.03. Retroactive Eligibility Changes: Retroactive eligibility changes are limited to sixty (60) days prior to the
date notice of any such requested change is received by VSP. VSP may refuse retroactive termination of a Covered
Person if Plan Benefits have been obtained by, or authorized for, the Covered Person after the effective date of the
requested termination.
6.04. Change of Participation Requirements, Contribution of Fees, and Eligibility Rules: Composition of
the Group, percentage of Enrollees covered under the Plan, and Group's contribution and eligibility requirements, are all
material to VSP's obligations under this Plan. During the term of this Plan, Group must provide VSP with written notice of
changes to its composition, percentage of Enrollees covered, contribution and eligibility requirements. Any change which
materially affects VSP's obligations under this Plan must be agreed upon in writing between VSP and Group and may
constitute a material change to the terms and conditions of this Plan for purposes of Paragraph 4.02. Nothing in this section
shall limit Group's ability to add Enrollees or Eligible Dependents under the terms of this Plan.
•
12
6.05. Change in Family Status: In the event Group is notified of any change in a Covered Person's family
status by marriage, the addition (e.g., newborn or adopted child) or deletion of Dependent, etc.] Group shall provide notice
of such change to VSP via the next eligibility listing required under Paragraph 4.01. If notice is given, the change in the
Covered Person's status will be effective on the first day of the month following the change request, or at such later date as
may be requested by or on behalf of the Covered Person. Notwithstanding any other provision in this section, a newborn
child will be covered during the thirty-one (31) day period after birth, and an adopted child will be covered for the thirty-one
(31) day period after the date the Enrollee or Enrollee's spouse acquires the right to control that child's health care. To
continue coverage for a newborn or adopted child beyond the initial thirty-one (31) day period, the Group must be properly
notified of the Enrollee's change in family status and applicable premiums must be paid to VSP.
•
13
VII.
CONTINUATION OF COVERAGE
7.01. COBRA: The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that, under
certain circumstances, health plan benefits available to an Enrollee and his or her Eligible Dependents be made available
for purchase by said persons upon the occurrence of a COBRA-qualifying event. If, and only to the extent, COBRA applies,
VSP shall make the statutorily-required continuation coverage available for purchase in accordance with COBRA.
•
14
VIII.
•
ARBITRATION OF DISPUTES
8.01. Dispute Resolution: Any dispute or question arising between VSP and Group or any Covered Person
involving the application, interpretation, or performance under this Plan shall be settled, if possible, by amicable and
informal negotiations. This will allow such opportunity as may be appropriate under the circumstances for fact-finding and
mediation. If any issue cannot be resolved in this fashion, it shall be submitted to arbitration.
8.02. Procedure: The procedure for arbitration hereunder shall be conducted pursuant to the Rules of the
American Arbitration Association.
8.03. Choice of Law: If any matter arises in connection with this Plan which becomes the subject of arbitration
or legal process, the law of the State of Delivery of the Plan shall be the applicable law.
15
IX.
NOTICES
9.01. Required Notices: Any notices required under this Plan to either Group or VSP shall be in written format.
Notices sent to Group will be sent to the address or email address shown on the Group's Application unless otherwise
directed by the Group. Notices sent to VSP shall be sent to the address shown on the first page of this Plan.
Notwithstanding the above;any notices may be hand-delivered by either party to an appropriate representative of the other
party. The party effecting hand-delivery bears the burden to prove delivery was made, if questioned.
•
•
16
•
X.
MISCELLANEOUS
10.01. Entire Plan: This Plan, the Group Application, the Evidence of Coverage, and all Exhibits, Riders and
attachments hereto, and any amendments hereto, constitute the entire agreement of the parties and supersedes any prior
understandings and agreements between them, either written or oral. Any change or amendment to the Plan must be
approved by an officer of VSP and attached hereto to be valid. No agent has the authority to change this Plan or waive any
of its provisions. Communication materials prepared by Group for distribution to Enrollees do not constitute a part of this
Plan.
10.02. Indemnity: VSP agrees to indemnify, defend and hold harmless Group, its shareholders, directors, officers,
agents, employees, successors and assigns from and against any and all liability, claim, loss, injury, cause of action and
expense (including defense costs and legal fees) of any nature whatsoever arising from the failure of VSP, its officers,
agents or employees, to perform any of the activities, duties or responsibilities specified herein. Group agrees to indemnify,
defend and hold harmless VSP, its members, shareholders, directors, officers, agents, employees, successors and assigns
from and against any and all liability, claim, loss, injury, cause of action and expense (including defense costs and legal
fees) of any nature whatsoever arising or resulting from the failure of Group, its officers or employees to perform any of the
duties or responsibilities specified herein.
10.03. Liability: VSP arranges for the provision of vision care services and materials through agreements with
Member Doctors. Member Doctors are independent contractors and responsible for exercising independent judgment.
VSP does not itself directly furnish vision care services or supply materials. Under no circumstances shall VSP or Group be
liable for the negligence, wrongful acts or omissions of any doctor, laboratory, or any other person or organization
performing services or supplying materials in connection with this Plan.
10.04. Assignment Neither this Plan nor any of the rights or obligations of either of the parties hereto may be
assigned or transferred without the prior written consent of both parties hereto except as expressly authorized herein.
10.05. Severability: Should any provision of this Plan be declared invalid, the remaining provisions shall remain
in full force and effect.
10.06. Governing Law: This Plan shall be governed by and construed in accordance with applicable federal and
state law. Any provision that is in conflict with, or not in compliance with, applicable federal or state statutes or regulations
. is hereby amended to conform with the requirements of such statutes or regulations, now or hereafter existing.
17
10.07. Gender: All pronouns used herein are deemed to refer to the masculine, feminine, neuter, singular, or
plural, as the identity(ies)of the person(s) may require.
10.08. Equal Opportunity: VSP is an Equal Opportunity and Affirmative Action employer.
10.09. Grievances/Complaints: The California Department of Managed Health Care is responsible for regulating
health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at
(800) 877-7195 and use your health plan's grievance process before contacting the Department. Utilizing this grievance
procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a
grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance
that has remained unresolved for more than 30 days, you may call the Department for assistance.
The Department also has a toll-free telephone number (1-888-HMO-2219), a TDD line (1-877-688-9891) for the
hearing impaired and its Internet Web site (http://www.hmohelp.ca.gov) has complaint forms online. The plan's grievance
process and the Department's complaint review process are in addition to any other dispute resolution procedures that may
be available to Covered Persons, and the failure to use these procedures does not preclude Covered Person's use of any
other remedy provided by law.
10.10. Communication Materials: Communication materials created by Group which relate to this vision care
Plan must adhere to VSP's Member Communication Guidelines distributed to Group by VSP. Such communication
materials may be sent to VSP for review and approval prior to use. VSP's review of such materials shall be limited to
approving the accuracy of Plan Benefits and shall not encompass or constitute certification that Group's materials meet any
applicable legal or regulatory requirements, including but not limited to, ERISA requirements.
18
EXHIBIT A
VISION SERVICE PLAN
SCHEDULE OF BENEFITS
Signature Plan
GENERAL
This Schedule lists the vision care services and vision care materials to which Covered Persons of VSP are entitled, subject
to any Copayments and other conditions, limitations and/or exclusions stated herein. If Plan Benefits are available for
Non-Member Provider services, as indicated by the reimbursement provisions below, vision care services and vision care
materials may be received from any licensed optometrist, ophthalmologist, or dispensing optician, whether Member Doctors
or Non-Member Providers. This Schedule forms a part of the Plan or Policy to which it is attached.
When Plan Benefits are received from Member Doctors, benefits appearing in the first column below are applicable subject
to any Copayments as stated below. When Plan Benefits are available and received from Non-Member Providers, the
Covered Person is reimbursed for such benefits according to the schedule in the second column below less any applicable
Copayments.
COPAYMENT
The benefits described herein are available to each Covered Person subject only to payment of the applicable Copayment
by the Covered Person. Copayments are required for Plan Benefits received from Member Doctors and Non-Member
Providers. Covered Persons must also follow the proper procedures for obtaining Benefit Authorization.
A Copayment amount of $20.00 shall be payable by the Covered Person to the Member Doctor at the time services are
rendered.
PLAN BENEFITS
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
VISION CARE SERVICES
Eye Examination Covered in Full* Up to $ 50.00*
Complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of
corrective eyewear where indicated.
Subsequent regular eye examinations every 12 months.
*Less any applicable Copayment.
19
VISION CARE MATERIALS
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Lenses
Single Vision Covered in full* Up to $ 50.00*
Bifocal Covered in full* Up to $ 75.00`
Trifocal Covered in full* Up to $ 100.00*
Lenticular Covered in full` . Up to $ 125.00*
Available once every 12 months.
Frames Covered up to Plan Up to $ 70.00*
• Allowance*
Available once every 24 months.
`Less any applicable Copayment.
Frame allowance may be applied towards non-prescription sunglasses for post PRK, LASIK, or Custom LASIK patients.
Lenses and frames include such professional services as are necessary, which shall include:
• Prescribing and ordering proper lenses;
• Assisting in the selection of frames;
• Verifying the accuracy of the finished lenses;
• Proper fitting and adjustment of frames;
• Subsequent adjustments to frames to maintain comfort and efficiency;
• Progress or follow-up work as necessary.
20
CONTACT LENSES
Contact lenses are available once every 12 months in lieu of all other lens and frame benefits available herein. When
contact lenses are obtained, the Covered Person shall not be eligible for lenses and frames again for 12 months.
Necessary-
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered
Person's Member Doctor or Non-Member Provider. Prior review and approval by VSP are not required for Covered Person
to be eligible for Necessary Contact Lenses.
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Professional Fees and Materials Professional Fees and Materials
Covered in full* Up to $210.00`
Elective
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Elective Contact Lens fitting and
evaluation**services are covered in full
once every 12 months, after a $60.00
Copayment.
Materials Professional Fees and Materials
Up to $130.00 Up to $105.00
`Subject to Copayment
"15%discount applies to Member Doctor's usual and customary professional fees for contact lens evaluation and fitting.
21
LOW VISION BENEFIT
The Low Vision benefit is available to Covered Persons who have severe visual problems that are not correctable with
regular lenses.
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Supplementary Testing Covered in Full Up to $125.00
Complete low vision analysis/diagnosis, which includes a comprehensive examination of visual functions, including the
prescription of corrective eyewear or vision aids where indicated.
Supplemental Care Aids 75%of Cost 75%of Cost
Subsequent low vision aids.
Copayment for Supplemental Aids: 25%payable by Covered Person.
Benefit Maximum
The maximum benefit available is $1000.00 (excluding Copayment) every two years.
NON-MEMBER PROVIDER BENEFIT
Low Vision benefits secured from a Non-Member Provider are subject to the same time limits and Copayment arrangements
as described above for a Member Doctor. The Covered Person should pay the Non-Member Provider his full fee. The
Covered Person will be reimbursed in accordance with an amount not to exceed what VSP would pay a Member Doctor in
similar circumstances. NOTE: There is no assurance that this amount will be within the 25% Copayment feature.
22
EXCLUSIONS AND LIMITATIONS OF BENEFITS
Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional
limitations. Covered Persons may obtain details regarding frame brand availability from their VSP Member Doctor or by
calling VSP's Customer Care Division at (800) 877-7195.
PATIENT OPTIONS
This Plan is designed to cover visual needs rather than cosmetic materials. When the Covered Person selects any of the
following extras, the Plan will pay the basic cost of the allowed lenses or frames, and the Covered Person will pay the
additional costs for the options. •
• Optional cosmetic processes.
• Anti-reflective coating.
• Color coating.
• Mirror coating.
• Scratch coating.
• Blended lenses.
• Cosmetic lenses.
• Laminated lenses.
• Oversize lenses.
• Polycarbonate lenses.
• Photochromic lenses, tinted lenses except Pink#1 and Pink#2.
• Progressive multifocal lenses.
• UV (ultraviolet) protected lenses.
• Certain limitations on low vision care.
• A frame that costs more than the Plan allowance.
• Contact lenses (except as noted elsewhere herein).
NOT COVERED
There is no benefit for professional services or materials connected with:
• Orthoptics or vision training and any associated supplemental testing; piano lenses (less than a ± .50 diopter power); or
two pair of glasses in lieu of bifocals;
• Replacement of lenses and frames furnished under this Plan which are lost or broken, except at the normal intervals
when services are otherwise available;
• Medical or surgical treatment of the eyes;
• Corrective vision treatment of an Experimental Nature;
• Costs for services and/or materials above Plan Benefit allowances;
• Services and/or materials not indicated on this Schedule as covered Plan Benefits.
VSP MAY, AT ITS DISCRETION, WAIVE ANY OF THE PLAN LIMITATIONS IF, IN THE OPINION OF VSP's
OPTOMETRIC CONSULTANTS, IT IS NECESSARY FOR THE VISUAL WELFARE OF THE COVERED PERSON.
•
23
•
EXHIBIT B
VISION SERVICE PLAN
SCHEDULE OF PREMIUMS
Signature Plan
VSP shall be entitled to receive premiums for each month on behalf of each Enrollee and his/her Eligible Dependents, if
any, in the amounts specified below:
$ 9.84 per month for each eligible Enrollee without Eligible Dependents.
$ 14.10 per month for each eligible Enrollee with one Eligible Dependent.
$ 25.37 per month for each eligible Enrollee with two or more Eligible Dependents.
NOTICE: The premium under this Plan is subject to change upon renewal (after the end of the Initial Plan Term or any
subsequent Plan Term), or upon change of the Schedule of Benefits or a material change in any other terms or conditions of
the Plan.
24
ADDENDUM
VISION SERVICE PLAN
ADDITIONAL BENEFIT• PRIMARY EYECARE
Primary Eyecare is designed for the detection, treatment, and management of ocular conditions and/or systemic conditions
which produce ocular or visual symptoms. Under the plan, Member Doctors provide treatment and management of urgent
and follow-up services. Primary Eyecare also involves management of conditions which require monitoring to prevent future
vision loss.
The Member Doctor is responsible for advising and educating patients on matters of general health and prevention of
ocular, as well as systemic disease. If consultation, treatment, and/or referral are necessary, it is the responsibility of the
Member Doctor as a Primary Eyecare Professional, to manage and coordinate on behalf of the patient to assure
appropriateness of follow-up services.
SYMPTOMS
Examples of symptoms which may result in a patient seeking services on an urgent basis under the Primary Eyecare Plan
include, but are not limited to:
ocular discomfort or pain recent onset of eye muscle dysfunction
transient loss of vision ocular foreign body sensation
flashes or floaters pain in or around the eyes
ocular trauma swollen lids
diplopia red eyes
CONDITIONS
Examples of conditions which may require management under the Primary Eyecare Plan, include, but are not limited to:
ocular hypertension macular degeneration
glaucoma corneal abrasion
retinal nevus corneal dystrophy
cataract blep haritis
pink-eye sty
PROCEDURES FOR OBTAINING PRIMARY EYECARE SERVICES
1. To obtain Primary Eyecare Services, the Covered Person contacts a Member Doctor's office and makes an
appointment. If necessary, the Covered Person may call VSP's Customer Service Department first to determine the
nearest location of a Member Doctor's office.
2. If urgent care is necessary, the Covered Person may be seen by a Member Doctor immediately.
3. The Covered Person pays the applicable Copayment to the Member Doctor at the time of each Primary Eyecare office
visit.
4. When the Member Doctor has completed the services, he will fill out the necessary paperwork and mail it to VSP. VSP
will pay the Member Doctor directly according to VSP's agreement with the Doctor.
•
25
COPAYMENT
The benefits described herein are available to each Covered Person from any participating Member Doctor at no cost to the
Covered Person except there shall be a Copayment amount of $20.00 payable by the Covered Person to the Member
Doctor at the time of each Primary Eyecare office visit.
EXCLUSIONS AND LIMITATIONS OF BENEFITS
The Primary Eyecare Plan is designed to cover Primary Eyecare services only, There is no coverage provided under the
Plan for the following:
1. Costs associated with securing materials such as lenses and frames.
2. Orthoptics or vision training and any associated supplemental testing.
3. Surgical or pathological treatment.
4. Any eye examination, or any corrective eye wear, required by an employer as a condition of employment.
5. Medication.
6. Pre and post-operative services.
REFERRALS BY THE MEMBER DOCTOR
The Member Doctor will refer the patient to another doctor under the following conditions:
1. If the patient requires additional services which are covered by the Primary Eyecare Plan but are not provided in his
office, the Member Doctor will refer the patient to another Member Doctor or to the major medical physician whose
offices provide the necessary services.
2. If the patient requires services beyond the scope of the Primary Eyecare Plan, the Member Doctor will refer the patient
back to the major medical physician.
3. If the patient requires emergency services beyond.the scope of the Primary Eyecare Plan, the Member Doctor will make
a"STAT" (emergency) referral by calling either another Member Doctor or the major medical physician.
26
DEFINITIONS
Blepharitis - Inflammation of the eyelids.
Cataract-A cloudiness of the lens of the eye obstructing vision.
Conjunctiva - The mucous membrane that lines the inner surface of the eyelids and is continued over the forepart of the
eyeball.
Corneal Abrasion - Irritation of the transparent part of the coat of the eyeball.
Corneal Dystrophy- A disorder involving nervous and muscular tissue of the transparent part of the coat of the eyeball.
Diplopia-The observance by a person of seeing double images of an object.
Eye Muscle Dysfunction - A disorder or weakness of the muscles that control eye movement.
Glaucoma - A disease of the eye marked by increased pressure within the eyeball which causes damage to the optic disc
and gradual loss of vision.
Flashes or Floaters- The observance by a person of seeing flashing lights and/or spots.
Macula- A small, yellowish area lying slightly lateral to the center of the retina that constitutes the region of maximum visual
acuity.
Macular Degeneration- Degeneration of the macula.
Ocular-Of or relating to the eye or the eyesight.
Ocular Hypertension - Unusually high blood pressure within the eye.
Ocular Conditions-Any condition, problem, or complaint relating to the eyes or eyesight.
Ocular Trauma-A forceful injury to the eye due to a foreign object, e.g., fist, baseball, racquetball, auto accident, etc.
Pink-eye-An acute, highly contagious, conjunctivitis (inflammation of the conjunctiva).
Retinal Nevus - A pigmented birthmark on the sensory membrane lining the eye which receives the image formed by the
lens.
Sty-An inflamed swelling of the fatty material at the margin of the eyelid.
Systemic Condition- Any condition or problem relating to a person's general health.
Transient Loss of Vision -Temporary loss of vision.
27
•
ADDENDUM
VISION SERVICE PLAN
THE CALIFORNIA CONTINUATION BENEFITS
REPLACEMENT ACT OF 1997 (CAL-COBRA)
Pursuant to California Health and Safety Code Section 1366.25, the following section is hereby incorporated into the Group
Vision Care Plan, if, and only to the extent Cal-COBRA applies to the parties to this Plan:
The California Continuation Benefits Replacement Act of 1997 (Cal-COBRA) requires health care service plans providing
contracted coverage to employers with 2 to 19 eligible employees to offer continuation coverage for purchase by qualified
beneficiaries upon the occurrence of a qualifying event. VSP and Group are subject to the following obligations in
connection with continuation coverage:
1. Group agrees to provide VSP with notice of any employee who has had a "qualifying event", within 31 days of the
qualifying event. A "qualifying event" means any of the following events that, but for the election of continuation coverage
provided thereunder, would result in a loss of coverage under the group benefit plan to a qualified beneficiary:
• The death of the covered employee.
• The termination or reduction of hours of the covered employee's employment, except that termination for gross
misconduct does not constitute a qualifying event.
• The divorce or legal separation of the covered employee from the covered employee's spouse.
• The loss of dependent status by a dependent enrolled in the group benefit plan.
• With respect to a dependent only, the covered employee's eligibility for coverage under Title XVIII of the United States
Social Security Act(Medicare).
Within 14 days of receipt of the foregoing notice of a qualifying event from Group, VSP will send to the qualified
beneficiary's last known address, as provided by Group, the necessary benefits information, premium information,
enrollment forms, and instructions to allow the qualified beneficiary to formally elect continuation coverage.
2. Group agrees to notify qualified beneficiaries currently receiving continuation coverage, whose continuation
coverage will terminate under one group benefit plan prior to the end of the period the qualified beneficiary would have
remained covered under Cal-COBRA, as specified in Health and Safety Code Section 1366.27, a minimum of 30 days prior
to the termination, of the qualified beneficiary's ability to continue coverage under a new group benefit plan for the balance
of the period the qualified beneficiary would have remained covered under the prior group benefit plan. Group agrees to
provide qualified beneficiaries subject to this paragraph with the necessary benefits information, premium information,
enrollment forms, and instructions to allow the qualified beneficiary to continue coverage. This information shall be sent to
the qualified beneficiary's last known address, as provided by the plan currently providing continuation coverage to the
qualified beneficiary.
•
28
r rout Vision Care ' lan
. s
Vision Care for Life
EVIDENCE OF COVERAGE
DISCLOSURE FORM
Provided by:
VISION SERVICE PLAN
3333 Quality Drive, Rancho Cordova, CA 95670
(916) 851-5000 (800) 877-7195
THIS EVIDENCE OF COVERAGE AND DISCLOSURE FORM DISCLOSES THE TERMS AND CONDITIONS OF
COVERAGE. PLEASE READ THE FORM COMPLETELY AND CAREFULLY. INDIVIDUALS WITH SPECIAL
HEALTHCARE NEEDS SHOULD CAREFULLY READ THOSE SECTIONS THAT APPLY TO THEM. ALL APPLICANTS
HAVE A RIGHT TO REVIEW THE EVIDENCE OF COVERAGE AND DISCLOSURE FORM PRIOR TO ENROLLMENT.
CARISK-00890 01/30/12 Jah
To be filled in by employer in the event this document is used to develop a Summary Plan Description:
NAME OF EMPLOYER:
NAME OF PLAN:
PRINCIPAL ADDRESS:
EMPLOYER I.D.#:
PLAN#:
PLAN ADMINISTRATOR:
ADDRESS:
PHONE NUMBER:
REGISTERED AGENT FOR SERVICE OF LEGAL PROCESS, IF DIFFERENT FROM PLAN ADMINISTRATOR:
ADDRESS:
THIS EVIDENCE OF COVERAGE AND DISCLOSURE FORM CONSTITUTES ONLY A SUMMARY OF THE TERMS AND CONDITIONS OF
COVERAGE. THE PLAN CONTRACT ITSELF SHOULD BE CONSULTED TO DETERMINE GOVERNING TERMS AND CONDITIONS OF
COVERAGE.
DEFINITIONS:
ADDITIONAL BENEFIT The document attached to this Evidence of Coverage„ when purchased by Group, which lists selected vision
RIDER care services and vision care materials that a Covered Person is entitled to receive by virtue of the Plan.
ANISOMETROPIA A condition of unequal refractive state for the two eyes, one eye requiring a different lens correction than the
other.
BENEFIT AUTHORIZATION Authorization issued by VSP identifying the individual named as a Covered Person of VSP, and identifying
those Plan Benefits to which a Covered Person is entitled.
COPAYMENTS Any amounts required to be paid by or on behalf of a Covered Person for Plan Benefits which are not fully
covered.
COVERED PERSON An Enrollee or Eligible Dependent who meets VSP's eligibility criteria and on whose behalf Premiums have
been paid to VSP, and who is covered under this plan.
ELIGIBLE DEPENDENT Any legal dependent of an Enrollee of Group who meets the criteria for eligibility established by Group and
approved by VSP under section VI. ELIGIBILITY FOR COVERAGE of the Group Plan document maintained by
your Group Administrator under which such Enrollee is covered.
EMERGENCY CONDITION A condition, with sudden onset and acute symptoms, that requires the Covered Person to obtain immediate
medical care, or an unforeseen occurrence requiring immediate, non-medical action.
ENROLLEE An employee or member of Group who meets the criteria for eligibility specified under section VI. ELIGIBILITY
FOR COVERAGE of the Group Plan document maintained by your Group Administrator.
EXPERIMENTAL NATURE Procedure or lens that is not used universally or accepted by the vision care profession, as determined by
VSP.
GROUP An employer or other entity which contracts with VSP for coverage under this plan in order to provide vision
care coverage to its Enrollees and their Eligible Dependents.
1
KERATOCONUS A development or dystrophic deformity of the cornea in which it becomes coneshaped due to a thinning and
stretching of the tissue in its central area.
MEMBER DOCTOR An optometrist or ophthalmologist licensed and otherwise qualified to practice vision care and/or provide vision
care materials who has contracted with VSP to provide vision care services and/or vision care materials on
behalf of Covered Persons of VSP.
NON-MEMBER PROVIDER Any optometrist, optician, ophthalmologist, or other licensed and qualified vision care provider who has not
contracted with VSP to provide vision care services and/or vision care materials to Covered Persons of VSP.
PLAN BENEFITS • The vision care services and vision care materials which a Covered Person is entitled to receive by virtue of
coverage under this plan, as defined on the enclosed insert or in the Schedule of Benefits attached as Exhibit
A to the Group Plan document maintained by your Group Administrator.
PREMIUMS The payments made to VSP by or on behalf of a Covered Person to entitle him/her to Plan Benefits, as stated
in the Schedule of Premiums attached as Exhibit B to the Group Plan document maintained by your Group
Administrator.
RENEWAL DATE The date on which this plan shall renew or terminate if proper notice is given.
SCHEDULE OF BENEFITS The document, attached as Exhibit A to the Group Plan document maintained by your Group Administrator,
which lists the vision care services and vision care materials which a Covered Person is entitled to receive by
virtue of this plan.
SCHEDULE OF PREMIUMS The document, attached as Exhibit B to the Group Plan document maintained by your Group Administrator,
which states the payments to be made to VSP by or on behalf of a Covered Person to entitle him/her to Plan
Benefits.
•
2
ELIGIBILITY FOR COVERAGE
Enrollees: To be eligible for coverage, a person must currently be an employee or member of the Group, and meet the criteria established in the
coverage criteria mutually agreed upon by Group and VSP.
Eligible Dependents: If dependent coverage is provided, the persons eligible for coverage as dependents shall include the legal spouse of any
Enrollee, and any unmarried child of an Enrollee who has not attained the limifing age as shown on the enclosed insert, including any natural child
from the moment of birth, legally adopted child from the moment of placement for adoption with the Enrollee, or other child for whom a court holds
the Enrollee responsible.
A dependent, unmarried child over the limiting age as shown on the enclosed insert may continue to be eligible as a dependent if the child is
incapable of self-sustaining employment because of mental or physical disability, and chiefly dependent upon the Enrollee for support and
maintenance.
ANNUAL ENROLLMENTIDISENROLLMENT
Except for new Enrollees joining this plan, Enrollees and Eligible Dependents shall have the right to become covered or cancel coverage once each
year during the thirty (30) day period beginning sixty (60) days prior to the anniversary of the effective date of this plan (or as may otherwise be
allowed by mutual agreement between the Group and VSP). Any such coverage or cancellation of coverage may be accomplished only by Group
giving VSP written notice thereof on behalf of the Enrollee or Eligible Dependent before the end of the prescribed thirty(30)day period and will take
effect on the anniversary date following receipt of such notice.
PREMIUMS
Your Group is responsible for payments to VSP of the periodic charges for your coverage. You will be notified of your share of the charges, if any,
by your Group. The entire cost of the program is paid to VSP by your Group.
3
•
PROCEDURES FOR USING THIS PLAN
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE
MAY BE OBTAINED.
1. When you desire to obtain Plan Benefits from a Member Doctor, you should contact a Member Doctor or VSP. A list of names, addresses, and
phone numbers of Member Doctors in your geographic location can be obtained from your Group, Plan Administrator, or VSP. If this list does
not cover the geographic area in which you desire to seek services, you may call or write the VSP office nearest you to obtain one which does.
2. If you are eligible for Plan Benefits, VSP will provide Benefit Authorization directly to the Member Doctor. If you contact a Member Doctor
directly, you must identify yourself as a VSP member so the doctor knows to obtain Benefit Authorization from VSP.
3. When such Benefit Authorization is provided by VSP and services are performed prior to the expiration date of the Benefit Authorization, this will
constitute a claim against this plan in spite of your termination of coverage or the termination of this plan. Should you receive services from a
Member Doctor without such Benefit Authorization or obtain services from a provider who is not a Member Doctor, you are responsible for
payment in full to the provider.
4. You pay only the Copayment (if any) to the Member Doctor for the services covered by this plan. VSP will pay the Member Doctor directly
according to their agreement with the doctor. VSP reimburses its Member Doctors on a fee-for-service basis. There are no incentives or
financial bonuses paid to Member Doctors for services covered under this plan.
Note: If you are eligible for and obtain Plan Benefits from a Non-Member Provider, you should pay the provider his full fee. You will
be reimbursed by VSP in accordance with the Non-Member Provider reimbursement schedule shown on the enclosed insert, less any
applicable Copayments.
5. In emergency conditions, when immediate vision care of a medical nature such as for bodily trauma or disease is necessary, Covered Person
can obtain covered services by contacting a Member Doctor(or Out-of-Network Provider if the attached Schedule of Benefits indicates Covered
Person's Plan includes such coverage). No prior approval from VSP is required for Covered Person to obtain vision care for Emergency
Conditions of a medical nature. However, services for medical conditions, including emergencies, are covered by VSP only under the Acute
EyeCare and Primary EyeCare Plans. If coverage for one of these plans is not indicated on the attached Schedule of Benefits or Addendum,
Covered Person is not covered by VSP for medical services and should contact a physician under Covered Person's medical insurance plan for
care. For emergency conditions of a non-medical nature, such as lost, broken or stolen glasses, the Covered Person should contact VSP's
Customer Service Department for assistance.
Emergency vision care is subject to the same benefit frequencies, plan allowances, Copayments and exclusions stated herein. Reimbursement
to Member Doctors will be made in accordance with their agreement with VSP.
6. In the event of termination of a Member Doctor's membership in VSP,VSP will remain liable to the Member Doctor for services rendered to you
at the time of termination and permit Member Doctor to continue to provide you with Plan Benefits until the services are completed or until VSP
makes reasonable and appropriate arrangements for the provision of such services by another authorized doctor.
BENEFIT AUTHORIZATION PROCESS
VSP authorizes Plan Benefits according to the latest eligibility information furnished to VSP by Covered Person's Group and the level of coverage
(i.e. service frequencies, covered materials, reimbursement amounts, limitations, and exclusions) purchased for Covered Person by Group under this
Plan. When Covered Person requests services under this Plan, Covered Person's prior utilization of Plan Benefits will be reviewed by VSP to
determine if Covered Person is eligible for new services based upon Covered Person's Plan's level of coverage. Please refer to the attached
Schedule of Benefits for a summary of the level of coverage provided to Covered Person by Group.
A. Appeals: If VSP denies the doctor's request for prior authorization, the doctor, Covered Person or the Covered Person's authorized
representative may request an appeal of the denial. Please refer to the section on Claim Appeals, below, for details on how to request an
appeal. VSP shall provide the requestor with a final review determination within thirty (30) calendar days from the date the request is
received. A second level appeal, and other remedies as described below, is also available. VSP shall resolve any second level appeal
within thirty (30) calendar days. Covered Person may designate any person, including the provider, as Covered Person's authorized
representative.
For more information regarding VSP's criteria for authorizing or denying Plan Benefits, please contact VSP's Customer Service Department.
4
BENEFITS AND COVERAGES
Through its Member Doctors, VSP provides Plan Benefits to Covered Persons, subject to the limitations, exclusions, and Copayment(s) described
herein. When you wish to obtain Plan Benefits from a Member Doctor, you should contact the Member Doctor of your choice, identify yourself as a
VSP member, and schedule an appointment. If you are eligible for Plan Benefits, VSP will provide Benefit Authorization for you directly to the
Member Doctor prior to your appointment.
IMPORTANT: The benefits described below are typical services and materials available under most VSP plans. However, the actual Plan
Benefits provided to you by your Group may be different. Refer to the attached Schedule of Benefits and/or Disclosure to determine your
specific Plan Benefits.
1. Eye Examination: A complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of
corrective eyewear where indicated. Each Covered Person is entitled to a Eye Examination as indicated on the enclosed insert.
2. Lenses: The Member Doctor will order the proper lenses necessary for your visual welfare. The doctor shall verify the accuracy of the finished
lenses. Each Covered Person is entitled to new lenses as indicated on the enclosed insert.
3. Frames: The Member Doctor will assist in the selection of frames, properly fit and adjust the frames, and provide subsequent adjustments to
frames to maintain comfort and efficiency. Each Covered Person is entitled to new frames as indicated on the enclosed insert.
4. Contact lenses: Unless otherwise indicated on the enclosed insert, contact lenses are available under this Plan in lieu of all other lens and
frame benefits described herein.
When you obtain Necessary contact lenses from a Member Doctor, professional fees and materials will be covered as indicated on the
enclosed insert.
When Elective contact lenses are obtained from a Member Doctor, VSP will provide an allowance toward the cost of professional fees and
materials. A 15%discount shall also be applied to the Member Doctor's usual and customary professional fees for contact lens evaluation and
fitting. Contact lens materials are provided at the Member Doctor's usual and customary charges.
5. If you elect to receive vision care services from one of the Member Doctors, Plan Benefits are provided subject only to your payment of any
applicable Copayment. If your Plan includes Non-Member Provider coverage and you choose to obtain Plan Benefits from a Non-Member
Provider, you should pay the Non-Member Provider his full fee. VSP will reimburse you in accordance with the reimbursement schedule shown
on the enclosed insert, less any applicable Copayment. THERE IS NO ASSURANCE THAT THE SCHEDULE WILL BE SUFFICIENT TO PAY
FOR THE EXAMINATION OR THE MATERIALS. Availability of services under the Non-Member Provider reimbursement schedule is subject to
the same time limits and Copayments as those described for Member Doctor services. Services obtained from a Non-Member Provider are in
lieu of obtaining services from a Member Doctor and count toward plan benefit frequencies.
6. Low Vision Services and Materials(applicable only if included in your Plan Benefits outlined on the enclosed insert): The Low Vision Benefit
provides special aid for people who have acuity or visual field loss that cannot be corrected with regular lenses. If a Covered Person falls within
this category, he or she will be entitled to professional services as well as ophthalmic materials including but not limited to supplemental testing,
evaluations, visual training, low vision prescription services, plus optical and non-optical aids, subject to the frequency and benefit limitations as
outlined on the enclosed insert. Consult your Member Doctor for details.
COPAYMENT
The benefits described herein are available to you subject only to your payment of any applicable Copayment(s) as described in this booklet and on
the enclosed insert.ANY ADDITIONAL CARE, SERVICE AND/OR MATERIALS NOT COVERED BY THIS PLAN MAY BE ARRANGED BETWEEN
YOU AND THE DOCTOR.
5
•
EXCLUSIONS AND LIMITATIONS OF BENEFITS
Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional limitations. Covered
Persons may obtain details regarding frame brand availability from their VSP Member Doctor or by calling VSP's Customer Care Division
at(800)877-7195.
This Plan is designed to cover visual needs rather than cosmetic materials. If you select any of the following extras,this Plan will pay the
basic cost of the allowed lenses or frames, and you will be responsible for the additional costs for the options, unless the extra is defined
as a Plan Benefit in the enclosed Schedule of Benefits insert.
• Optional cosmetic processes.
• Anti-reflective coating.
• Color coating.
• Mirror coating.
• Scratch coating.
• Blended lenses.
• Cosmetic lenses.
• Laminated lenses.
• Oversize lenses.
• Polycarbonate lenses.
• Photochromic lenses, tinted lenses except Pink#1 and Pink#2.
• Progressive multifocal lenses.
• UV(ultraviolet)protected lenses.
• Certain limitations on low vision care.
NOT COVERED
There is no benefit under this plan for professional services or materials connected with:
• Orthoptics or vision training and any associated supplemental testing; piano lenses(less than ±.50 diopter power); or two pair of glasses in lieu
of bifocals.
• Replacement of lenses and frames furnished under this plan which are lost or broken except at the normal intervals when services are
otherwise available.
• Medical or surgical treatment of the eyes.
• Corrective vision treatment of an Experimental Nature.
• Costs forservices and/or materials above Plan Benefit allowances indicated on the enclosed insert.
• Services/materials not indicated as covered Plan Benefits on the enclosed insert.
LIABILITY IN EVENT OF NON-PAYMENT
In the event VSP fails to pay the provider,you shall not be liable for any sums owed by VSP other than those not covered by the policy.
6
COMPLAINTS AND GRIEVANCES
If Covered Person ever has a question or problem, Covered Person's first step is to call VSP's Customer Service Department. The Customer Service
Department will make every effort to answer Covered Person's question and/or resolve the matter informally. If a matter is not initially resolved to the
•satisfaction of a Covered Person, the Covered Person may communicate a complaint or grievance to VSP orally or in writing by using the complaint
form that may be obtained upon request from the Customer Service Department. Complaints and grievances include disagreements regarding
access to care, or the quality of care, treatment or service. Covered Persons also have the right to submit written comments or supporting
documentation concerning a complaint or grievance to assist in VSP's review. VSP will resolve the complaint or grievance within thirty(30)days after
receipt.
Claim Payments and Denials
A. Initial Determination: VSP will pay or deny claims within thirty(30) calendar days of the receipt of the claim from the Covered Person or
Covered Person's authorized representative. In the event that a claim cannot be resolved within the time indicated VSP may, if necessary, extend
the time for decision by no more than fifteen (15)calendar days.
B. Request for Appeals: If a Covered Person's claim for benefits is denied by VSP in whole or in part, VSP will notify the Covered Person in
writing of the reason or reasons for the denial. Within one hundred eighty(180) days after receipt of such notice of denial of a claim, Covered Person
may make a verbal or written request to VSP for a full review of such denial. The request should contain sufficient information to identify the Covered
Person for whom a claim for benefits was denied, including the name of the VSP Enrollee, Member Identification Number of the VSP Enrollee, the
Covered Person's name and date of birth, the name of the provider of services and the claim number. The Covered Person may state the reasons
fhe Covered Person believes that the claim denial was in error. The Covered Person may also provide any pertinent documents to be reviewed.
VSP will review the claim and give the Covered Person the opportunity to review pertinent documents, submit any statements, documents, or written
arguments in support of the claim, and appear personally to present materials or arguments. Covered Person or Covered Person's authorized
representative should submit all requests for appeals to:
VSP
• Member Appeals
3333 Quality Drive
Rancho Cordova, CA 95670
(800)877-7195
VSP's determination, including specific reasons for the decision, shall be provided and communicated to the Covered Person within thirty (30)
calendar days after receipt of a request for appeal from the Covered Person or Covered Person's authorized representative.
When Covered Person has completed all appeals mandated by the Employee Retirement Income Security Act of 1974 ("ERISA"), additional
voluntary alternative dispute resolution options may be available, including mediation and arbitration. Covered Person should contact the U. S.
Department of Labor or the State insurance regulatory agency for details. Additionally, under ERISA (Section 502(a)(1)(B)) [29 U.S.C.
1132(a)(1)(B)], Covered Person has the right to bring a civil (court) action when all available levels of denied claims, including the appeal process,
have been completed, the claims were not approved in whole or in part,and Covered Person disagrees with the outcome.
C. Review by the Department of Managed Health Care: The California Department of Managed Health Care is responsible for regulating
health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at(800) 877-7195 and use
your health plan's grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights
or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily
resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance.
The Department also has a toll-free telephone number(1-888-HMO-2219), a TDD line (1-877-688-9891)for the hearing impaired and its Internet
Web site (http://www.hmohelp.ca.gov)has complaint forms online. The plan's grievance process and the Departments complaint review process are
in addition to any other dispute resolution procedures that may be available to Covered Persons, and the failure to use these procedures does not
preclude Covered Person's use of any other remedy provided by law.
ARBITRATION
Any dispute or question arising between VSP and Group or any Covered Person involving the application, interpretation, or performance under this
plan shall be settled, if possible, by amicable and informal negotiations. This will allow such opportunity as may be appropriate under the
circumstances for fact-finding and mediation. If any issue cannot be resolved in this fashion, it shall be submitted to arbitration. The procedure for
arbitration hereunder shall be conducted pursuant to the Rules of the American Arbitration Association.
7
•
TERMINATION OF BENEFITS
Terms and cancellation conditions of this plan are shown on the enclosed insert. Plan Benefits will cease on the date of cancellation of this plan
whether the cancellation is by Group or by VSP due to non-payment of Premium. If service is being rendered to you as of the termination date of
this plan, such service shall be continued to completion, but in no event beyond six(6) months after the termination date of this plan.
INDIVIDUAL CONTINUATION OF BENEFITS
This program is available to groups of a minimum of ten (10) employees and is, therefore, not available on an individual basis. When a Group
terminates its coverage, individual coverage is not available for Enrollees of the Group who may desire to retain their coverage.
THE CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1985 (COBRA)
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that, under certain circumstances, health plan benefits available to
an eligible Enrollee and his or her Eligible Dependents be made available for purchase by said persons upon the occurrence of a COBRA-qualifying
event. If, and only to the extent COBRA applies, VSP shall make the statutorily-required continuation coverage available for purchase in accordance
with COBRA.
•
•
8
VISION SERVICE PLAN
3333 Quality Drive
Rancho Cordova, CA 95670
Group Name: CITY OF SEAL BEACH
Plan Number 30006227
Effective Date: JANUARY 1, 2012
Plan Term: TWENTY-FOUR (24)MONTHS
VISION CARE PLAN
DISCLOSURE FORM AND EVIDENCE OF COVERAGE
PLAN ADMINISTRATOR: Nancy Ralsten
(Name)
211 8th St
(Address)
Seal Beach, CA 90740-6305
(City, State, Zip)
MONTHLY PREMIUM: YOUR GROUP IS RESPONSIBLE FOR PAYMENT TO VISION SERVICE
PLAN OF THE PERIODIC CHARGES FOR YOUR COVERAGE. YOU WILL
BE NOTIFIED OF YOUR SHARE OF THE CHARGES, IF ANY, BY YOUR
GROUP.
ELIGIBILITY: ENROLLEES & ELIGIBLE DEPENDENTS: UNMARRIED DEPENDENT
CHILDREN ARE COVERED TO AGE 23. THE WAITING PERIOD IS THE
SAME AS YOUR OTHER HEALTH BENEFITS.
PLAN AND SCHEDULE: SIGNATURE PLAN
EXAMINATION: ONCE EVERY 12 MONTHS.
LENSES: ONCE EVERY 12 MONTHS.
FRAMES: ONCE EVERY 24 MONTHS.
TERM, TERMINATION AND RENEWAL: AFTER THE PLAN TERM, THIS PLAN WILL CONTINUE ON A MONTH TO
MONTH BASIS OR UNTIL TERMINATED BY EITHER PARTY GIVING THE
OTHER SIXTY(60) DAYS PRIOR WRITTEN NOTICE
TYPE OF ADMINISTRATION: BENEFITS ARE FURNISHED UNDER A VISION CARE PLAN PURCHASED
BY THE GROUP AND PROVIDED BY VISION SERVICE PLAN(VSP)
UNDER WHICH VSP IS FINANCIALLY RESPONSIBLE FOR THE PAYMENT
OF CLAIMS.
VSP'S ADDRESS IS: VISION SERVICE PLAN
3333 QUALITY DRIVE
RANCHO CORDOVA, CA 95670
9
•
SCHEDULE OF BENEFITS
GENERAL
This Schedule and any Additional Benefit Rider(s), when purchased by Group, attached hereto list the vision care services and vision care materials
to which Covered Persons of VSP are entitled, subject to any Copayments and other conditions, limitations and/or exclusions stated herein. If Plan
Benefits are available for Non-Member Provider services as indicated by the reimbursement provisions below, vision care services and vision care
materials may be received from any licensed optometrist, ophthalmologist, or dispensing optician, whether Member Doctors or Non-Member
Providers.
When Plan Benefits are received from Member Doctors, benefits appearing in the first column below are applicable subject to any Copayment(s) as
stated below. When Plan Benefits are available and received from Non-Member Providers,-you are reimbursed for such benefits according to the
schedule in the second column below less any applicable Copayment.
•
PLAN BENEFITS MEMBER DOCTOR BENEFIT NON-MEMBER PROVIDER BENEFIT
VISION CARE SERVICES
Vision Examination Covered in Full* Up to$ 5000*
VISION CARE MATERIALS
Lenses
Single Vision Covered in Full* Up to$ 50.00*
Bifocal Covered in Full* Up to$ 75.00*
Trifocal Covered in Full* Up to$ 100.00*
Lenticular Covered in Full* Up to$ 125.00*
Frames Covered up to Plan Allowance* Up to$ 70.00*
Frame allowance may be applied towards non-prescription sunglasses for post PRK, LASIK, or Custom LASIK patients.
CONTACT LENSES
Necessary
Professional Fees and Materials Covered in Full* Up to$ 210.00*
Elective Materials Professional Fees
• and Materials
Up to$130.00 Up to$ 105.00
Elective Contact Lens fitting and evaluation**
services are covered in full once every 12
months, after a$60.00 Copayment.
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Member Doctor
or Non-Member Provider. Prior review and approval by VSP are not required for Covered Person to be eligible for Necessary Contact Lenses.
When contact lenses are obtained, the Covered Person shall not be eligible for lenses and frames again for 12 months.
*Subject to Copayment,if any.
**15%discount applies to Member Doctor's usual and customary professional fees for contact lens evaluation and fitting.
10
COPAYMENT
A Copayment amount of$20.00 shall be payable by the Covered Person to the Member Doctor or Non-Member Doctor at the time services are
rendered.
LOW VISION
Professional services for severe visual problems not corrected with regular lenses, including:
Supplemental Testing Covered in Full Up to$125.00
(includes evaluation, diagnosis and prescription of vision aids where indicated)
Supplemental Aids 75%of cost 75%of cost
Maximum allowable for all Low Vision benefits of$1000.00 every two(2)years.
THIS EVIDENCE OF COVERAGE CONSTITUTES ONLY A SUMMARY OF THE VISION PLAN. THE VISION PLAN DOCUMENT MUST BE
CONSULTED TO DETERMINE THE EXACT TERMS AND CONDITIONS OF COVERAGE.
•
11
•
•
•
Exhibit C
ADDITIONAL BENEFIT RIDER
PRIMARY EYECARE PLAN
GENERAL
This Rider lists additional vision care benefits to which Covered Persons of VISION SERVICE PLAN ("VSP") are entitled, subject to any applicable
Copayments and other conditions, limitations and/or exclusions stated herein. This Rider forms a part of the Policy and Evidence of coverage to
which it is attached.
The Primary EyeCare Plan is designed for the detection, treatment and management of ocular conditions and/or systemic conditions that produce
ocular or visual symptoms. Under the Plan, Member Doctors provide treatment and management of urgent and follow-up services. Primary EyeCare
also involves management of conditions that require monitoring to prevent future vision loss.
The Member Doctor is responsible for advising and educating patients on matters of general health and prevention of ocular disease. If consultation,
treatment, and/or referral are necessary, it is the responsibility of the Member Doctor as a Primary EyeCare professional, to manage and coordinate
on behalf of the patient to assure appropriateness of follow-up services.
Covered Persons with the following symptoms and/or conditions (see DEFINITIONS, below)will be covered for certain Primary EyeCare services in
accordance with the optometric scope of licensure in the Member Doctor's state. This Rider forms a part of the Policy and Evidence of Coverage to
which it is attached.
SYMPTOMS
Examples of symptoms which may result in a patient seeking services on an urgent basis under the Primary EyeCare Plan include, but are not
limited to:
• ocular discomfort or pain • recent onset of eye muscle dysfunction
• transient loss of vision • ocular foreign body sensation
• flashes or floaters • pain in or around the eyes
• ocular trauma • swollen lids
• diplopia • red eyes
CONDITIONS
•
Examples of conditions which may require management under the Primary EyeCare Plan include, but are not limited to:
• ocular hypertension • macular degeneration
• retinal nevus • corneal dystrophy
• glaucoma • corneal abrasion
• cataract • blepharitis
• pink-eye • sty
See schedule below for Plan Benefits, payments and/or reimbursement subject to any Copayment(s)as stated.
12
PROCEDURES FOR OBTAINING PRIMARY EYECARE SERVICES
To obtain Primary EyeCare Services, the Covered Person contacts a Member Doctor's office and makes an appointment. If necessary, the Covered
Person may first call VSP's Customer Service Department to determine the location of the nearest Member Doctor's office.
If urgent care is necessary, the Covered Person may be seen by a Member Doctor immediately.
The Covered Person pays the applicable Copayment to the Member Doctor at the time of each Primary EyeCare office visit, and for any additional
services not covered by the Plan.
Upon completion of the services, the Member Doctor will submit the required claim information to VSP. VSP will pay the Member Doctor directly in
accordance with VSP's agreement with the doctor.
See schedule below for Plan Benefits, payments and/or reimbursement subject to any Copayment(s)as stated.
•
COPAYMENT
A Copayment amount of$20.00 shall be payable by the Covered Person at the time of each Primary EyeCare office visit.
REFERRALS BY THE MEMBER DOCTOR
The Member Doctor will refer the Covered Person to another doctor under the following circumstances:
If the Covered Person requires additional services which are covered by the Primary EyeCare Plan but can not be provided in the Member Doctor's
office, the doctor will refer the Covered Person to another Member Doctor or to the Group's major medical physician whose offices provide the
necessary services.
If the Covered Person requires services beyond the scope of the Primary EyeCare Plan, the Member Doctor will refer the Covered Person to the
Group's major medical physician.
If the Covered Person requires emergency services beyond the scope of the Primary EyeCare Plan, the Member Doctor will make an urgent referral
by calling either another Member Doctor or the Group's major medical physician.
EXCLUSIONS AND LIMITATIONS OF BENEFITS
The Primary EyeCare Plan is designed to cover Primary EyeCare services only.There is no coverage provided under the Plan for the following:
• Costs associated with securing materials such as lenses and frames.
• Orthoptics or vision training and any associated supplemental testing.
• Surgical or pathological treatment.
• Any eye examination, or any corrective eyewear required by an employer as a condition of employment.
• Medication.
• Pre-and post-operative services.
• Services and/or materials not indicated on this Rider as covered Plan Benefits.
•
13
DEFINITIONS
Blepharitis Inflammation of the eyelids.
Cataract A cloudiness of the lens of the eye obstructing vision.
Conjunctiva The mucous membrane that lines the inner surface of the eyelids and is continued
over the forepart of the eye.
Corneal Abrasion Irritation of the transparent, outermost layer of the eye.
Corneal Dystrophy A disorder involving nervous and muscular tissue of the transparent, outermost layer
of the eye.
Diplopia The observance by a person of seeing double images of an object
Eye Muscle Dysfunction A disorder or weakness of the muscles that control the eye movement.
Flashes or Floaters The observance by a person of seeing flashing lights and/or spots.
Glaucoma A disease of the eye marked by increased pressure within the eye which causes
damage to the optic disc and gradual loss of vision.
Macula The small, sensitive area of the central retina, which provides vision for fine work and
reading.
Macular Degeneration An acquired degenerative disease which affects the central retina.
Ocular Of or pertaining to the eye or the eyesight.
Ocular Conditions Any condition, problem, or complaint relating to the eyes or eyesight.
Ocular Hypertension Unusually high blood pressure within the eye.
Ocular Trauma A forceful injury to the eye due to a foreign object.
Pink eye An acute, highly contagious inflammation of the conjunctiva.
Retinal Nevus A pigmented birthmark on the sensory membrane lining the eye that receives the
image formed by the lens.
Systemic Condition Any condition or problem relating to a person's general health.
Sty An inflamed swelling of the fatty material at the margin of the eyelid.
Transient Loss of Vision Temporary loss of vision.
•
•
14
VS Vision Care for Life
CONTINUATION COVERAGE UNDER CAL-COBRA
If you are covered under a group policy providing coverage to 2 to 19 eligible employees, you may be eligible to purchase continued coverage under
this group vision plan under California Health and Safety Code Section 1366.20 et seq. (Cal-COBRA).
You may qualify for Cal-COBRA continuation coverage if you lose coverage for one of the following reasons:
a. The death of the covered employee.
b. The termination of employment or reduction in hours of the covered employee's employment, except that termination for gross misconduct
does not constitute a qualifying event.
c. The divorce or legal separation of the covered employee from the covered employee's spouse.
d. The loss of dependent status by a dependent enrolled in the group benefit plan.
e. Wth respect to a covered dependent only, the covered employee's entitlement to benefits under Title XVIII of the United States Social
Security Act(Medicare).
As a condition of receiving benefits, you must notify VSP within 60 days of the loss of coverage for one of the foregoing reasons. FAILURE TO
NOTIFY VSP WITHIN THE REQUIRED 60 DAY PERIOD WILL DISQUALIFY YOU FROM RECEIVING CONTINUATION COVERAGE.
You must request the continuation in writing and deliver the written request to VSP by first class mail or other reliable means of delivery within the 60
day period following the later of(1)the date your coverage under the group benefit plan terminated or will terminate by reason of a qualifying reason,
or(2)the date you were sent notice from the group benefit plan or VSP of eligibility to continue coverage under Cal-COBRA.
In order to continue receiving coverage under this plan, you are responsible for making all of the required premium payments in accordance with the
terms and conditions of the plan contract. The first premium payment must be made to VSP by first-class mail, certified mail or other reliable means
of delivery including personal delivery, express mail, or private courier within 45 days of the date you provided written notice to VSP of your election
of continuation of benefits. The first premium payment must equal an amount sufficient to pay any required premiums and all premiums due. Failure
to submit the correct premium amount within the 45 day period will disqualify you from receiving continuation coverage.
Notice: If the contract between VSP and the employer is terminated prior to the date your continuation coverage would terminate pursuant to the
Cal-COBRA statute, you may elect continuation coverage under the employer's subsequent group benefit plan, if any, for the balance of the period
you would have remained covered under this plan. However, continuation coverage shall terminate if you fail to comply with the requirements
pertaining to enrollment in and payment of premiums to the new benefit plan within 30 days of receiving notice of termination of the prior group
benefit plan.
All notices to VSP must be sent to:
VISION SERVICE PLAN
Attn: COBRA Administration
3333 Quality Drive
Rancho Cordova, CA 95670
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