AP 12-06-07SOUTH TAHOE PUBLIC UTILITY DISTRICT
"Basic Services for a Complex World"
REGULAR BOARD MEETING AGENDA
Thursday, December 6, 2007
2:00 P.M.
District Board Room
1275 Meadow Crest Drive, South Lake Tahoe, California
Richard Solbri•, General Mana•er Paul Sciuto, Assistant Mana•er
Eric W. Schafer, President
Duane Wallace, Director
BOARD MEMBERS
Mary Lou Mosbacher, Director
1. CALL TO ORDER REGULAR MEETING — PLEDGE OF ALLEGIANCE
6. PRESENTATION
a. Report on the 2007 Fiscal Year Financial Statement Audit
(Larry Mace, Partner, Grant Thornton, LLP)
James R. Jones, Vice President
Kathleen Farrell, Director
2. COMMENTS FROM THE AUDIENCE (Short non - agenda items that are within the subject
matter jurisdiction of the District. Five - minute limit. No action will be taken.)
3. CORRECTIONS TO THE AGENDA OR CONSENT CALENDAR
4. ADOPTION OF CONSENT CALENDAR (Any item can be discussed and considered
separately upon request.)
5. CONSENT ITEMS BROUGHT FORWARD FOR ACTION / DISCUSSION
7. ITEMS FOR BOARD ACTION REQUESTED BOARD ACTION
a. Consideration of Request to Appear Before Customer Request to Waive Sewer
Pg. 39 the Board and Water Fees on Vacant Lot
(Del Lafountain, Lisa Coyner)
REGULAR BOARD MEETING AGENDA — DECEMBER 6, 2007
c. Plan Document for Employees' Benefit Plan
Pg. 51 (Nancy Hussmann)
d. Employee Benefits Plan 2008 Renewal
Pg. 53 (Nancy Hussmann, Rhonda McFarlane)
e. Check Signing Authority
Pg. 59 (Rhonda McFarlane)
8. BOARD MEMBER STANDING COMMITTEE REPORTS
(Discussions may take place; however, no action will be taken)
a.
b.
c.
d.
b. 2:30 P.M. PUBLIC MEETING
Pg. 41 Indian Creek Reservoir TMDL Oxygenation
Project
(Ivo Bergsohn)
Water & Wastewater Operations Committee (Jones / Farrell)
Finance Committee (Wallace / Schafer)
Executive Committee (Schafer / Jones)
Planning Committee (Mosbacher / Schafer)
PAGE — 2
(1) Hold a Public Meeting to Take
Public Comments on the Initial Study
and Negative Declaration of Environ-
mental Impact; and (2) Certify the
Negative Declaration of Environment
Impact
Approve Updated Plan Document
(1) Renew Excess Insurance Policy
with Gerber Life Insurance Co.;
(2) Approve Funding Level for Plan
in the Amount of $1,600 per
Employee Per Month;
(3) Approve COBRA Rates for 2008
as Follows: Single Dental $80;
Family Dental $185; Single Medical
$650; Family Medical $1,600
Adopt Resolution No. 2840 -07 to
Designate Authorized Signatories of
All District Bank Accounts,
Superseding Resolution No. 2590
f. Payment of Claims Approve Payment in the Amount
Pg. 63 of $1,694,948.98
9. EL DORADO COUNTY WATER AGENCY REPRESENTATIVE REPORT
10. BOARD MEMBER REPORTS (Discussions may take place; however, no action will be taken)
11. GENERAL MANAGER REPORT (Discussions may take place; however, no action will be taken)
a. Corp of Engineers Meeting re: 219 Funding
b. Prop. 50 Grant
12. STAFF / ATTORNEY REPORTS (Discussions may take place; however, no action will be taken)
REGULAR BOARD MEETING AGENDA- DECEMBER 6, 2007
13. NOTICE OF PAST AND FUTURE MEETINGS / EVENTS
Past Meetings / Events
11/20/07 — Finance Committee Meeting
11/27/07 —11 /30/07 ACWA Fall Conference
11/28/07 — ECC (Employee Communications Committee) Meeting
12/03/07 — Water and Wastewater Operations Committee
14. CLOSED SESSION (Closed Sessions are not open to the public)
PAGE -3
Future Meetings / Events
12/12/07 — 9:00 a.m. — El Dorado County Water Agency Meeting in Shingle Springs
12/17/07 — 4:00 p.m. — Water and Wastewater Operations Committee Meeting at District
12/18/07 — 9:00 a.m. — Alpine County Supervisors Regular Meeting in Markleeville
12/20/07 — 2:00 p.m. — STPUD Regular Board Meeting at District
12/24/07 — Union Holiday — District Office Closed
12/25/07 — Christmas Holiday — District Office Closed
a. Pursuant to Government Code Section 54956.9(a) /Conference with Legal Counsel —
Pg. 79 Existing Litigation re: Meyers Landfill Site: United States of America vs. El Dorado
County and City of South Lake Tahoe and Third Party Defendants, Civil Action No.
S -01 -1520 LKK GGH, United States District Court for the Eastern District of CA
15. ACTION / REPORT ON ITEMS DISCUSSED DURING CLOSED SESSION
16. ADJOURNMENT (To the next regular meeting, December 20, 2007, 2:00 p.m.)
The South Tahoe Public Utility District Board of Directors regularly meets the first and third Thursday of each month. A complete
agenda packet, including all backup information is available for review at the meeting and at the District office during the hours of
8:00 a.m. — 5:00 p.m., Monday through Friday. Items on this agenda are numbered for identification purposes only and will not
necessarily be considered in the order in which they appear on the agenda. Designated times are for particular items only. Public
Hearings will not be called to order prior to the time specified.
Public participation is encouraged. Public comments on items appearing on the agenda will be taken at the same time the agenda
items are heard; comments should be brief and directed to the specifics of the item being considered. Comments on items not on
the agenda can be heard during "Comments from the Audience;" however, action cannot be taken on items not on the agenda.
Please provide the Clerk of the Board with a copy of all written material presented at the meeting.
The meeting location is accessible to people with disabilities. Every reasonable effort will be made to accommodate participation of
the disabled in all of the District's public meetings. If particular accommodations for the disabled are needed (i.e., disability- related
aids, or other services), please contact the Clerk of the Board at 530.544.6474, extension 6203, at least 24 hours in advance of the
meeting.
ITEMS
a. Dump Truck and Water Service Truck
Pg. 1 (Randy Curtis)
b. Surplus Vehicle and Equipment
Pg. 3 (Linda Brown, Randy Curtis)
c. Temporary Help — Finance Department
Pg. 5 (Debbie Henderson)
d.
Pg. 7
e.
Pg. 11
AB 303 Groundwater Assistance Program
Application
(Lynn Nolan)
457 Deferred Compensation Plan Provider
Agreement
(Nancy Hussmann)
CONSENT CALENDAR
December 6, 2007
f. 2008 Washington, D.C. Legislative Advocacy
Pg. 13 Services
(Dennis Cocking)
g. 2008 California Legislative Advocacy Services
Pg. 29 (Dennis Cocking)
REQUESTED ACTION
Authorize Staff to Advertise for Bids
for One (1) 5/6 Yard Dump Truck,
and One (1) 1 '/z ton 4x4 Water
Service Truck
Authorize First Capitol Auction,
Inc., to Sell District Surplus Vehicle
and Equipment at Public Auction
Approve Extending the Contract with
Accounting Temps, for a Temporary
Employee through June 2008, in an
Amount Not to Exceed $30,000
Adopt Resolution No. 2841 -07 to
Submit a Grant Application for Funds
Authorize Staff to Enter into a
Contract with Great West Life to
Provide Administrative and Record -
keeping Services for the District's
Deferred Compensation Plan
(1) Authorize Execution of Contract
with ENS Resources, Inc., in the
Amount of $74,390.40; and
(2) Authorize Execution of Contract
with Crosspointe Partners, L.L.C., in
the Amount of $66,000.00
Authorize Execution of Contract with
Suter, Wallauch, Corbett and
Associates, in the Amount of
$30,000
CONSENT CALENDAR — DECEMBER 6, 2007
h. Approve Regular Board Meeting Minutes:
Pg. 35 November 1, 2007
(Kathy Sharp)
Approve Minutes
South Tahoe Public Utility District • 1275 Meadow Crest Drive • South Lake Tahoe, CA 96150
Phone 530.544.6474 • Facsimile 530.541.0614 • www.stpud.us
PAGE -2
TO:
youth Tahoe
Pubfie Utility District
1273 Meadow Crest Drive •Soud+ 1
Mane 530 54 6474•f +x 530 541- 0014•www.a dies
BOARD AGENDA ITEM 4a
Board of Directors
FROM: Randy Curtis, Manager of Field Operations
MEETING DATE: December 6, 2007
ITEM — PROJECT NAME: Dump Truck and Water Service Truck.
REQUESTED BOARD ACTION: Authorize staff to advertise for bids for one (1) 5/6
yard dump truck, and one (1) 1 '/2 ton 4x4 water service truck.
DISCUSSION: The dump truck is to replace Truck #56 which is a 1990 5/6 yard dump
truck with 43,704 miles. This vehicle is currently in Alpine County being utilized as an on
farm only vehicle. The 1 1/2 ton water service truck is to replace the current water service
Truck #77, which is a 2001 model year with 116,939 miles. This vehicle is used by the
District's water service employee, and stand -by personnel for emergency call outs.
SCHEDULE: As soon as possible
COSTS:
ACCOUNT NO: Truck #56 — 1005-8887; Truck #77 — 2005 -8856
BUDGETED AMOUNT REMAINING: 1005 -8887— $60,000; 2005 -8856 — $40,000
ATTACHMENTS:
CONCURRENCE WITH REQUESTED ACTION: GENERAL MANAGER: YES /g I NO
CHIEF FINANCIAL OFFICER: YES Plikr We- NO
-1-
CATEGORY: Sewer & Water
James IC. Jaw
Mary Lau Mosi etbr
Duane Wm Nor..
Eric So Iteivr
South Taho
Public Utility District
1275 Mose low Ora Drive • South Lai Tahoe • CA
Mona 530 74* Fax 530 50-0614*wwws4pu4ue
BOARD AGENDA ITEM 4b
TO: Board of Directors
FROM: Linda Brown, Purchasing Agent
Randy Curtis, Manager of Field Operations
MEETING DATE:' December 6, 2007
ITEM — PROJECT NAME: Surplus Vehicle and Equipment
REQUESTED BOARD ACTION: Authorize First Capitol Auction Inc. to sell District
surplus vehicle and equipment at public auction.
DISCUSSION: This would be our second sale with First Capitol Auction which is
located in Vallejo, has an excellent reputation, and offers terms similar to its
competitors.
The surplus equipment (which has been replaced by new equipment) includes:
(1) Truck 74 -1994 Ford Aerostar Van, VIN 5053, mileage —81,000
(2) Ingersoll -Rand trailer- mounted Air Compressor 1974 model G150,
S/N 00479U 74 211 Does not meet County & State Air Board emission
regulations
First Capitol will complete required vehicle smog testing, and perform minor vehicle
repairs with District approval. A vehicle which cannot pass smog certification without
substantial repairs will be sold to dealers only. Staff believes that selling through a
professional auctioneer, is the best option for the sale of this surplus equipment.
SCHEDULE: As soon as possible
COSTS: Income less 8% commission
ACCOUNT NO: Various
BUDGETED AMOUNT REMAINING: N/A
ATTACHMENTS: None
rr+eraf Miinver
IIIkAaMt�y
Directors
Ked+wen Farrel
Jenks R. Josses
Mary toy Matioctsr
Puma %Wm*
Eric Schtskr
Linda Brown
Randy Curtis
December 6, 2007
Page 2
CONCURRENCE WITH REQUESTED ACTION:
GENERAL MANAGER: YES 4 4 NO
CHIEF FINANCIAL OFFICER: YES ' "'fr 4YYC NO
-
CATEGORY: General
TO:
South Tahoe
Public Utility District
BOARD AGENDA ITEM 4c
Board of Directors
FROM: Debbie Henderson, Accounting Manager
MEETING DATE: December 6, 2007
ITEM — PROJECT NAME: Temporary Help — Finance Department
REQUESTED BOARD ACTION: Approve extending the contract with Accounting
Temps, for a temporary employee through June 2008, in an amount not to exceed
$30,000.
DISCUSSION: The Finance Committee has conceptually approved a 1 /2 time position
for grant assistance and authorized an additional 1 /2 time position for miscellaneous
accounting duties, through the end of June 2008. This extension will allow time to
explore other options to address current workload issues. Approval of this item also
includes funds for the current temporary employee to be enrolled in CaIPERS when
1,000 hours is reached in the current fiscal year, as required by CaIPERS rules.
SCHEDULE:
COSTS: Not to exceed $30,000
ACCOUNT NO: 1039 - 4405/2039 -4405
BUDGETED AMOUNT REMAINING: 1039 -4405 <7,011 >; 2039 -4405 $12,541
ATTACHMENTS:
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: Sewer & Water
GENERAL MANAGER: YES )4.9 NO
CHIEF FINANCIAL OFFICER: YES F'. t-- NO
-5-
Kahtsen Farr#!
Jams C. Jane.
May Lai
Dam %Um
Eric &hew
South Taho
Public Utility District
BOARD AGENDA ITEM 4d
?hang 530 544-6474' Fax
TO: Board of Supervisors
FROM: Lynn Nolan, Grant Coordinator
MEETING DATE: December 6, 2007
ITEM — PROJECT NAME: AB 303 Groundwater Assistance Program Application
REQUESTED BOARD ACTION: Adopt Resolution No. 2841 -07 to submit a grant
application for funds.
DISCUSSION: The District's Land Application Manager and engineering staff are
planning to submit an application for $250,000 to the Department of Water Resources
2007 AB 303 Groundwater Assistance Program Funds. These funds are to be used for
the development of nutrient management plans (NMP's) for Diamond Valley Ranch and
the six private ranches that utilize the District's effluent for irrigation. These plans are an
important groundwater management tool for the implementation of the Alpine County
Groundwater Management Plan, to ensure water quality standards are maintained in
District influenced areas.
The District is currently seeking proposals from qualified consulting firms to provide
engineering and planning services to develop these NMP's.
SCHEDULE: Application due December 11, 2007
COSTS: No costs are associated with this item.
ACCOUNT NO: N/A
BUDGETED AMOUNT REMAINING: N/A
ATTACHMENTS: Resolution No. 2841 -07
CONCURRENCE WITH REQUESTED ACTION:
GENERAL MANAGER: YES NO
CHIEF FINANCIAL OFFICER: YES NO
-
CATEGORY: Sewer
[Amuxe
KatMben Farrel
James R. Jones
Mary Lau
Mans Wallace
Eric Sdiefer
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A RESOLUTION OF THE BOARD OF DIRECTORS
OF THE SOUTH TAHOE PULBIC UTILITY DISTRICT
TO SUBMIT A GRANT APPLICATION PURSUANT TO AB303
GROUNDWATER ASSISTANCE PROGRAM FUNDS
NOW, THEREFORE BE IT RESOLVED, by the Board of Directors of the South
Tahoe Public Utility District that:
1. Application be made to the California Department of Water Resources for
a Local Groundwater Assistance Grant pursuant to the Water Security,
Clean Drinking Water, Coastal and Beach Protection Act of 2002 (Water code Section
79560 et seq.); and
2. If the application is successful, the District will enter into an agreement to
receive a grant for a Nutrient Management Plan for Diamond Valley Ranch and the six
private ranches that receive effluent for irrigation.
BE IT FURTHER RESOLVED, the District's Land Application Manager is hereby
authorized and directed to prepare the necessary data, conduct investigations, file such
application, and execute a grant agreement with California Department of Water
Resources.
WE, THE UNDERSIGNED, do hereby certify that the above and foregoing
Resolution was duly adopted and passed by the Board of Directors of the South Tahoe
Public Utility District at a regularly scheduled meeting held on the 6th day of December,
2007, by the following vote:
AYES:
NOES:
ABSENT:
ATTEST:
Kathy Sharp, Clerk of the Board
RESOLUTION NO. 2841-07
-9-
Eric W. Schafer, Board President
South Tahoe Public Utility District
TO:
FROM:
MEETING DATE: December 6, 2007
SCHEDULE:
COSTS:
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATTACHMENTS:
South Tahoe
Public Utility District
Directors
K+t811en Farrel
Jana, It ,Ipnes
Mary Lou MaaMeher
Puma WaSoca
F.& 8duefer
1275 MoM,w Cre. C)v1 • South Lake 53 Tahoe. CA 00 gi-n
Mute r Ie � 544-64740 I Fax !'0014' weevatruAue
BOARD AGENDA ITEM 4e
Board of Directors
Nancy Hussmann, Human Resources Director
ITEM — PROJECT NAME: 457 Deferred Compensation Plan Provider Agreement
REQUESTED BOARD ACTION: Authorize staff to enter into a contract with Great
West Life to provide administrative and recordkeeping services for the District's
Deferred Compensation Plan.
DISCUSSION: The Retirement Benefits Committee (comprised of Union and
Management employees) decided to go out for proposal for the provider of
administrative and recordkeeping services for the 457 Deferred Compensation Plan, in
part because our plan with John Hancock is terminating in June, 2008, and the
committee wanted to allow them the opportunity to bid on deferred compensation plan
services. Request for Proposals were sent out to twelve providers on August 27, 2007,
and six proposals were received by the September 14, 2007 deadline. All members of
the committee reviewed the extensive proposals, and the top three proposers were
invited to an interview on October 17, 2007. Great West Life is the District current
provider of Deferred Compensation Plan services, and along with ICMA -RC and John
Hancock, were interviewed on October 17, 2007. After discussion of the benefits of
each provider, the committee voted to retain Great West Life as the provider for the
District's Deferred Compensation Plan.
Staff has requested some amendments to the current agreement, including
performance standards, which are being considered by Great West Life, and is
therefore requesting that the Board authorize staff to enter into the agreement with
Great West once a mutually agreed upon Agreement is reached.
—11—
Nancy Hussmann
December 6, 2007
Page 2
CONCURRENCE WITH REQUESTED ACTION:
GENERAL MANAGER: YES
CHIEF FINANCIAL OFFICER: YES
-12-
NO
NO
CATEGORY: General
TO:
youth Tahoe
Public Utility District
BOARD AGENDA ITEM 4f
Board of Directors
Drive+South ti Tage•CA 9el5O - 7Ao1
Phone 3O544-6474.Fax 530 541-0614
FROM: Dennis Cocking, District Information Officer
MEETING DATE: December 6, 2007
ITEM — PROJECT NAME: 2008 Washington, D.C. Legislative Advocacy Services
REQUESTED BOARD ACTION: (1) Authorize execution of contract with ENS
Resources, Inc., in the amount of $74,390.40; and (2) Authorize execution of contract
with Crosspointe Partners, L.L.C., in the amount of $66,000.00.
DISCUSSION: ENS Resources, Inc. (Eric Sapirstein and David French) and
Crosspointe Partners, L.L.C. (Jeff Fedorchak), have effectively advocated on the
District's behalf regarding federal governmental matters since 1997. Both firms have
submitted their proposals for ongoing legislative advocacy in Washington, D.C. Please
see attached proposals and scope of work.
SCHEDULE:
COSTS: $74,390.40 ENS /$66,000.00 Crosspointe
ACCOUNT NO: 50/50 27 -4405
BUDGETED AMOUNT REMAINING: 1027 -4405 - $36,574; 2027 -4405 - $36,574
ATTACHMENTS: Proposals and Scope of Work
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: General
GENERAL MANAGER: YES 4Z .I4 NO
CHIEF FINANCIAL OFFICER: YES O
-13-
Director.
Kett' lran farts.
Jaws R Jones
Mary Law Mookacher
Puma Walisea
&lc Schafer
ENS
. - (R650WRCBS) --
SCOPE OF SERVICES
FOR CONTINUATION OF
WASHINGTON REPRESENTATION
ON BEHALF OF
THE SOUTH TAHOE PUBLIC UTILITY DISTRICT
SOUTH LAKE TAHOE, CALIFORNIA
SUBMITTED BY
ENS RESOURCES, INC.
November 14, 2007
ENS Resources. Inc.
1747 Pennsylvania Avenue. N.W. / Suite 420
Washington, D.C. 20006 / Telephone (202)466-3755
Telefax: (202) 466 -3787
www.ensresnrces.com
I. INTRODUCTION
ENS Resources, Inc. (ENS), proposes to continue providing Washington representation
services to the South Tahoe Public Utility District ( STPUD). ENS will maintain and
expand its work on behalf of STPUD with an emphasis on water quality and water supply
policy issues identified by STPUD as priority areas of interest. This work will involve
liaison with the congressional delegation, key federal agencies tasked with
implementation of natural resources and water qualitypolicies, and key congressional
committees with jurisdiction over environment, public health and resource protection.
We will continue to build on our past successes.
ENS will work with STPUD officials to review its existing federal priorities and develop
a strategy to guide implementation of the identified federal priorities. Past years' efforts
have focused on issues affecting water supply and resolution of disputes related to special
use permits. We understand that STPUD continues to be interested in these issues, but
would like to direct attention toward water quality matters. Given this area of interest,
we propose to expand our activities with an emphasis on regulatory matters, as they
impact the management and operation of STPUD's wastewater treatment system.
As in past years, the following can summarize our proposed approach:
• Developing and implementing a strategy to secure appropriate authorizations of
program assistance supporting STPUD operations;
• Assisting STPUD in developing environmental initiatives to utilize district
properties located in Alpine County;
• Supporting STPUD develop approaches to support regional initiatives related to
water quality improvement projects authorized through the U.S, Army Corps of
Engineers;
• Developing a strategy to secure authorization of federal support of C -Line
infrastructure replacement;
• Monitoring legislative initiatives related to wilderness designations;
• Providing regulatory support on matters impacting STPUD operations;
• Supporting, through research resolution of pending litigation related to the Myers
Landfill dispute or other matters; and
• Providing general monitoring of legislative and regulatory initiatives initiated at
the federal level.
We would continue to provide support on issues as identified by STPUD related to
maintaining the effective and efficient delivery of water and water quality services.
Mr. Schafer
November 14, 2007
Page 2
II. SCOPE OF SERVICES
ENS proposes to continue our current level of services as provided during the past year.
This will include periodic updates by telephone, emails, and memoranda on matters
determined to be a priority for STPUD. In the course of conducting these
responsibilities, we will continue to base our activities within three areas. These are:
• Legislative Liaison
• Executive Branch Liaison
• Washington -based association liaison
A. Legislative Liaison
1. Work with STPUD to identify goals and objectives that would serve as
the federal priorities;
2. Develop a strategy for STPUD to review that would implement a
program to achieve goals and objectives;
3. Maintain and expand congressional liaison on behalf of STPUD
focusing on water quality and infrastructure policy;
4. Monitor the status of legislative proposals and initiatives of interest to
STPUD and provide recommendations on how to respond to such
initiatives;
5. Draft as appropriate legislative communications and supporting
materials for STPUD consideration and use to achieve goals and .
objectives;
6. Draft analyses, talking papers, and related briefing materials on matter
of interest;
7. Arrange, coordinate and attend meetings between elected and
appointed policymakers and STPUD officials; and
8. Provide periodic updates on the status of STPUD priorities and other
matters that could directly or indirectly affect STPUD priorities.
B. Executive Branch Liaison and Representation
1. Collaborate with STPUD on defining issues of interest within the
federal regulatory arena and develop a regulatory advocacy program
focusing upon water quality issues;
2. Establish an expanded liaison network with key federal agencies
including U.S. Environmental Protection Agency, Department of the
Interior and Department of Agriculture, and the related independent
agencies;
3. Monitor federal agency activities and report to STPUD on potential
impacts of activities on STPUD activities;
4. Support STPUD officials in developing communications to federal
agencies related to federal initiatives affecting STPUD operations; and
5. Arrange, coordinate and attend meetings between. STPUD and federal
regulatory officials to discuss matters of interest to STPUD.
-17-
Mr. Schafer
November 14, 2007
Page 3
C. Washington -based Association Liaison
ENS will continue to maintain contact with key trade associations officials located in
Washington. This will be supplemented by our working relationships with individual
advocates that represent water and wastewater agencies. Our liaison will included
such organizations as the Association of California Water Agencies, National
Association of Clean Water Agencies, California Association of Sanitation Agencies,
Association of Metropolitan Water Agencies, WateReuse Association and American
Water Works Association. We would, as appropriate, also work with the national
public interest organizations like the National Association of Counties and National
League of Cities.
Our activities in this area may involve:
III. BUDGET
1. Attendance and participation in meetings to review regulatory or
legislative initiatives for impact on STPUD's goals and objectives and
to identify concerns that, SSTPUD may have with a group's position or
strategy;
2. Securing letters of support for STPUD goals and objectives; and
3. Identification of opportunities for STPUD to work with groups on
initiatives in furtherance of STPUD goals and objectives
ENS proposes to carryout its representation services agenda on an annual budget similar
to its current agreement. The only change would involve a 5% cost of living adjustment
to accommodate recent increases in the delivery of services. Expenses would be limited
to an amount not to exceed $250 in any one - month period. However, we, do not expect .
that this level would be reached except when extraordinary activities occur. We would
bill out -of -town travel as an additional cost under this agreement subject to STPUD's
prior approval for such travel activities.
A. Professional Services
A retainer of $ 6,199.20 per month would be charged for services as described in
Section II. This retainer would cover all time expended by ENS staff in
connection with the scope of services.
B. Expenses
As noted we will endeavor to limit our monthly expenses as we have
accomplished during the past contract period. Any expenses that are expected to
exceed the monthly cap will be identified to STPUD. for approval to incur such
costs.
Mr. Schafer
November 14, 2007
Page 4
IV. TERMS OF AGREEMENT
ENS and STPUD agree to the following terms:
The term of this agreement shall be January 1, 2008 through December 31, 2008. Either
party may terminate this agreement provided written notice of termination is provided
thirty days prior to such termination. In the event that such agreement is terminated,
STPUD shall reimburse ENS for all reasonable costs incurred prior to the date of
termination. Such costs shall be reimbursed within thirty days of the date of termination.
A ENS shall continue to provide monthly invoices detailing activities initiated
pursuant to the Scope of Services of this agreement.
B. ENS will provide its best efforts, working with STPUD, to support identified
project priorities.
C. ENS designates Eric Sapirstein as the lead official for contract management.
D. STPUD designates the General Manager or his designee as the primary contact
for ENS.
E. STPUD agrees to pay ENS a monthly retainer in this agreement. STPUD further
agrees to reimburse ENS for expenses consistent with the budget. Such retainer
will be payable no later than the 15` day of the month for which such services
will be provided. Expenses will be billed on a monthly basis and will be due
within thirty days of such invoicing.
F. ENS will register as. the Washington representative and comply with any
additional requirements imposed on such registrant as they occur.
G. STPUD will be provided periodic written updates (through email or fax) detailing
issues of general interest to STPUD as well as specific areas of focus. Such
updates will be provided not less than monthly.
Mr. Scnafer
November 14, 2007
Page 5
If you agree with the terms oftlris agreement, please complete and si1P1 below. Return
one executed. agreement to our office. The second copy is for your file. If YOu have any
questions, please give me a call. Again, we look forward to another productive year on
behalf of the South Tahoe Public Utility District.
ACCEPTED BY:
TITLE:
DATE:
-20-
CROSSPOINTE Partners LLC
"Strategic Counsel for Business, Government & Nonprofit Organizations"
November 19, 2007
Mr. Dennis Cocking
District Information Officer
South Tahoe Public Utility District
1275 Meadow Crest Drive
South Lake Tahoe, CA 96150
Dear Dennis:
It is with mixed emotion that I must announce to you and the Board that this second half
of the 1 10th Congress will need to be my last in representing the District's legislative and
regulatory interests in Washington, DC. It has been an honor to work with all of you and
to help identify and meet the needs of the District and its customers.
My practice has been moving more toward the corporate setting, helping Fortune 500
companies identify and address risk as it relates to their brand and bottom line. As more
companies focus on risk I see the trend continuing.
As a result, I need to begin a more structured and reasonable exit from some of the
congressional lobbying activities I have been involved with over time but do so in a way
that makes sense and does not jeopardize any ofthe work we are in the midst of
addressing. I also believe on a personal level that after all these years of working
together, departing in a way that is reasonable and is done with integrity and reflects the
spirit and success of the relationship is a necessity.
As you know, we are closing on this first half ofthe 1 10th Congress. In January, the
second half begins with all the same bills still in play exactly where they were left. Given
the appropriations backlog and promised presidential veto on most of these bills, we may
start back in January having to close out the remaining bills that did not get done.
So while it is illogical and inappropriate to leave at halftime when we have key items in
play, it does make sense to make the end of the second half a logical departure point. I
wanted to be sure to alert you and the Board with such advance notice out of respect and
courtesy for our many years together.
Crosspointe Partners LLC
Fair Oaks Business Plaza
11350 Random Hills Road; Ste 800
FairfaJt; ~22030
CROSSPOINTE Partners LLC
"Strategic Counsel for Business, Government & Nonprofit Organizations"
We have had some remarkable achievements together and they are well documented.
Together, we:
o Secured $lm for an export pipeline
oRe-wrote the landmark Lake Tahoe Restoration Act - perhaps the biggest piece of
legislation to impact the area in modern history
o Ensured MTBE was an issue receiving the highest levels of congressional
attention and oversight
o Secured a $1 million dollar authorization and later appropriation for MTBE
remediation
o Secured federal relocation cost funding that will total millions of dollars in
savmgs
o Saved ratepayers $17 million dollars in beating back a USFS mandated pipeline
o Secured $1 million dollars for expanding waterlines in key tract areas to provide
greater fire protection to the Tahoe NatL Forest
Maybe our most important achievement to date has been the less tangible one - meeting
with members of Congress, personal staff and committee staff to formally introduce
STPUD, advance our issues, protect our interests and refute and rebut comments of our
once-vocal opponents. Through ACW A and others, we joined neighboring (and
sometimes rival) communities as part of trade associations and developed an overall
presence on Capitol Hill and in key regulatory bodies. Today, key stakeholder groups
know ofSTPUD; our presence and ability to make things happen when need be. I'm not
sure the price you put on that but there is real value in it.
We still have some work to do in this last remaining session and I look forward to
pursuing our agenda and securing additional funding for fire protection in particular.
Again, please express my gratitude to the Board for their trust and support. Working
with them, you and ENS Resources we have made a formidable team and have the
success metrics to show for our efforts. We did not just mark our time here but made a
tangible difference for the District and for its customers that can be measured. That is
most gratifying.
Let's finish the second half of this Congress strong.
cJtff
Jeff Fedorchak
Crosspointe Partners LLC
Fair Oaks Business Plaza
11350 Random Hills Road; Ste 800
Fairfax,a0\-22030
CROSSPOINTE Partners LLC
"Strategic Counsel for Business, Government & Nonprofit Organizations"
2008 CONSULTING SERVICES AGREEMENT
This Agreement is entered into between Crosspointe Partners LLC (CP) and the South
Tahoe Public Utility District ("Client").
1. Services. CP agrees to provide Client with the services described in the Statement of
Work ("SOW") attached to this Agreement as Schedule A. Client may cancel or suspend the
SOW at any time upon 3D-day written notice to CPo Upon receipt of a cancellation or
suspension notice, CP agrees to discontinue providing services immediately.
2. Additional Services. Client may request services in addition to those described in the
SOW by submitting a proposed SOW to CP, describing the specific additional tasks that
Client would like CP to perform. CP will review the proposed SOW and prompdy notify
Client in writing that it intends to accept, reject, or request changes to the proposed SOW
for additional services.
3. Compensation. Client agrees to pay CP at the rates, fees or prices listed in the Rate
Sheet attached to this Agreement as Schedule B. If Client requests and CP agrees to a
change to the SOW or to provide additional services, Client agrees to pay CP for any
additional time and costs incurred by such change, if any, provided that the price of the
change or additional services are mutually agreed upon in advance by the parties in writing.
4. Expenses. Unless otherwise agreed, Client agrees to pay Cp's reasonable, direct
expenses incurred in perfonning the work described by this Agreement. Such expenses
include trave~ meals, lodging and incidental expenses. Client reserves the right to reject any
expense that is not reasonable in amount and/or that is not direcdy related to CP's work for
Client.
5. Payment. CP will invoice Client monthly for both the fees to be incurred by CP in
the current month and for any expenses incurred by CP in the prior month. CP will attach
to its invoice receipts evidencing all expenses incurred Unless otherwise agreed, Client will
pay CP within thirty (30) days following receipt of CP's invoice.
6. Independent Contractor. This is not a contract or an agreement for employment.
The relationship between the parties created by this Agreement is that of an independent
contractor. CP represents and agrees that it is and will at all times acts as an independent
contractor to Client under this Agreement. By this Agreement, CP and Client do not
become partners, joint ventures, associates, affiliates, parent, subsidiary, employee or agent
of the other. CP is not authorized to bind Client in any way or to represent Client other
than as set forth in this Agreement.
Crosspointe Partners LLC
Fair Oaks Business PI82a
11350 Random Hills Road; Ste 800
Fairfax,2Wr 22030
CROSSPOINTE Partners LLC
"Strategic Counsel for Business, Government & Nonprofit Organizations"
7. Term. This Agreement will commence upon its execution by both parties and
continue for one year. Either party may terminate this Agreement upon thirty (30) days
advance written notice to the other, provided that any such termination by CP will not
terminate. release or discharge CP from its obligations to provide its services pursuant to any
on-going task. Client may terminate a task at any time upon advance written notice to CPo
Upon termination of the Agreement or any task. Client will pay CP for work done up
through the day of termination of the task.
8. Compliance with Laws. CP certifies that it is duly registered in and in compliance
with the laws of the state in which it is incorporated and/or does business and will in the
performance of this Agreement comply with all applicable federal, state and local laws and
regulations. No payments to third parties will be made in violation of applicable federal law.
Upon request. CP will provide Client with the information listed in IRS Form W-9 Request
for Taxpayer Identification and Certification.
9. Confidential Information. CP and Client each acknowledge that one may provide
the other during the term of this Agreement with information that is confidential and
proprietary to the providing party or its customers. CP and Client each agree not to
reproduce. transfer or disclose to any person or entity any information confidential and
proprietary to the providing party or its customers. Confidential and proprietary
information includes but is not limited designs. formulae. trade secrets. computer programs.
in whole or part. in both object and source code. hardware configurations. system
documentation. source materials. schematics. blueprints. manuals. names and identities of
customers and prospective customers. proposals, financial data. sales data and marketing
data. CP and Client each will take such steps as are reasonably necessary to safeguard
confidential and proprietary information to assure that no unauthorized disclosures are
made. CP and Client each will promptly report to the providing party any prohibited action
regarding the disclosure of confidential and proprietary information of which either CP or
Client, as a receiving party. becomes aware and further will take such steps as may reasonably
be requested by the providing party to prevent such disclosure. Upon termination of this
Agreement for any reason. CP and Client will promptly deliver to the other. as the providing
party. all information confidential and proprietary to the providing party. CP's and Client's
obligations will survive any termination or expiration of this Agreement and will continue in
perpetuity.
11. Limitation of Liability. IN NO EVENT WIlL EITHER CLIENT OR CP BEšLIABLE TO THE OTHER IN CONTRACT, TORT OR OTHERWISE FOR ANY
CONSEQUENTIAL. EXEMPLARY, SPECIAL. PUNITIVE OR INCIDENTAL
DAMAGES THAT ARE IN ANY WAY RELATED TO THIS AGREEMENT.
12. Arbitration. Any dispute that arises between the parties with regard to this
Agreement will be submitted to binding arbitration for resolution. Any arbitration will be
conducted in the metropolitan Washington. D.C.. area in accordance with the then effective
arbitration rules of the American Arbitration Association.
Crosspointe Partners LLC
Fair Oaks Business Plaza
11350 Random Hills Road; Ste 800
FairfitK~'4A 22030
CROSSPOINTE Partners LLC
"Strategic Counsel for Business, Government & Nonprofit Organizations"
13. Notices. All notices required to be given under this Agreement will be delivered by
mail to the addresses set forth in the preamble to the Agreement
14. General. The headings of paragraphs and sections of this Agreement are inserted for
convenience only and will not be deemed to be part of the terms of this Agreement. This
Agreement may be amended only in writing signed by all the parties. The laws of the
Commonwealth of Virginia will govern this Agreement. The provisions of this Agreement
are severable, and if any provision becomes or is declared invalid or unenforceable, all other
provisions will remain in effect. This Agreement represents the entire Agreement of the
parties and supersedes all prior and contemporaneous oral and written communications
between the parties relating to this Agreement. Neither Client nor CP has made any other
representations or promises of any kind to the other.
By Crosspointe Partners LLC
By South Tahoe Public Utility District
Signature: Signature:
Name: Name:
Tide: Title:
Date: Date:
Crosspointe Partners LLC
Fair Oaks Business Plaza
11350 Random Hills Road; Ste 800
FairfiHt,2l&r 22030
CROSSPOINTE Partners LLC
"Strategic Counsel for Business, Government & Nonprofit Organizations"
SCHEDULE A
STATEMENT OF WORK
In conjunction with the South Tahoe Public Utility District team, Crosspointe agrees to
engage the following issues in the 2008 calendar year:
AUTHORIZATIONS
· C-Line - Authorization to fund study on hydropower generation and new
technologies demonstration
APPROPRIATIONS
· Any necessary follow up from FY '08 appropriations cycle on water line funding
(ie.. should a continuing resolution push the bill into January-February of2008
and that bill be pursued to closure before the FY '09 bill will be taken up)
· New FY '09 Appropriation language of at least $1 million to allow funding for
the expansion of water lines for fire protection
IMPACT ISSUE TRACKING
· S. 493 - The California Wild Heritage Act (Boxer) which designates certain
public land (nearly 74,000 acres including lands within the Tahoe National
Forest) as wilderness and certain rivers as wild & scenic in California. Our
attention needs to be on M&O access to our existing and potential future facilities
· HR2421- Clean Water Restoration Act (Oberstar) which amends the Federal
Water Pollution Control Act to clarify jurisdiction over waters of the United
States. Specifically, the bill reaffirms Congressional intent (as now defined by
this new Congress); and defines exactly what waters are subject to the Clean
Water Act. The term "navigable" will be dropped from waterways under the
jurisdiction of the CWA therefore opening the broadest possible definition and
therefore regulation
· Myers Landfill- Stay apprised of final arrangements and alignment agreements;
keep congressional offices aware of ongoing status and interaction with USFS
· ESA - Ensure any review allows for continued access to aging water & sewer
infrastructure; Identify opportunities to reduce or eliminate costly, duplicative
and/or scientifically questionable studies currently required before moving
forward with infrastructure projects
Crosspointe Partners LLC
Fair Oaks Business Plaza
11350 Random Hills Road; Ste 800
Fairfax,a&t-22030
CROSSPOINTE Partners LLC
"Strategic Counsel for Business, Government & Nonprofit Organizations"
GENERAL
· Representation of District interests before Congress, government agencies, trade
associations, stakeholder groups and coalitions
· Arrange meetings with any ofthe above groups for District Board and/or
professional staffmembers during DC visits
· Maintain regular communication (via Board designee Dennis Cocking) and
continue joint work with ENS Resources
Crosspointe Partners LLC
Fair Oaks Business Plaza
11350 Random Hills Road; Ste 800
Fairf'ax; Jl?r-22030
CROSSPOINTE Partners LLC
"Strategic Counsel for Business, Government & Nonprofit Organizations"
SCHEDULE B
STATEMENT OF FEES
There shall be no changes in the current contractual amounts paid for services. As
compensation for services rendered under this Agreement, STPUD shall compensate CP at a
fee of $66,000.00 annually; to be paid in monthly installments of $5,500.00 over a 12-month
period from January through December 2008.
Crosspointe Partners LLC
Fair Oaks Business Plaza
11350 Random Hills Road; Ste 800
Fa~,2Q\-22030
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South Tahoe
Public Utility DistrIct
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BOARD AGENDA ITEM 4g
TO:
FROM:
Board of Directors
Dennis Cocking, District Information Officer
MEETING DATE:
December 6, 2007
ITEM - PROJECT NAME: 2008 California Legislative Advocacy Services
REQUESTED BOARD ACTION: Authorize execution of contract with Suter, Wallauch,
Corbett and Associates, in the amount of $30,000.
DISCUSSION: Suter, Wallauch, Corbett and Associates (formerly Lynn M. Suter and
Associates), have effectively advocated on the District's behalf on state legislative
matters since 1997. They have submitted their proposal for ongoing legislative
advocacy in Sacramento. Please see attached proposal and scope of work
SCHEDULE:
COSTS: $30,000
ACCOUNT NO: 50/5027-4405
BUDGETED AMOUNT REMAINING: 1027-4405 - $36,574; 2027-4405 - $36,574
ATTACHMENTS: Proposal and Scope of Work
CONCURRENCE WITH REQUESTED ACTION:
GENERAL MANAGER: YES
CHIEF FINANCIAL OFFICER: YES
CATEGORY: General
-29-
1iI.};~:i; - S.u.ter.~allaUCh.COrbett
':';:;:~:\;,'& Associates
: '..'~' '':' .. .
II..... .-.... . Government Relations
October 29, 2007
Mr. Dennis Cocking
South Tahoe Public Utility District
. '1275 Meadow Crest Drive
Sputll.L~e Tahoe, CA 96150
R;E: Scope of Service - Contract Renewal
,'!J
Dear Mr. Cocking:
\
\
Thank you for the opportunity to continue our relationship under our new name Suter,
Wallauch, Corbett and Associates for legislative advocacy services. Having worked
together on a contract basis for many years, Lynn M. Suter & Associates has joined
forces with Michael Y. Corbett & Associates to fonn Suter, Wallauch, Corbett &
Asseciates (SWCA).
SWCA has successfully served as the South Tahoe Public Utilities District's (STPUD)
legislative representative in the State Capitol for several years, and has developed a
s.trong relationship with STPUD's staff and with members of the District's legislative
delegation.
This year SWCA was successful in updating existing law to bring the compensation rate
for board members that serve on Public Utility District on par with those that serve on
Water District boards. This long over due changes was accomplished by amending AB
490, Chapter #213, Statutes of 2007, to include the PUD provisions. Assemblywoman
Loni Hancock originally introduced AB 490 to address board compensation issues
relating to transit operators in her district. However, given the similarity ofthePUD
p,rovisions with the other issues in the bill and the lack of opposition to the PUD
language, she agreed with our request to add the PUD compensation language.
We propose to continue the existing relationship with Steve Wallauch as the primary
contact person, managing the day-to-day needs ofSTPUD's legislative program. Lynn
Suter will continue her contribution to the political and policy process, and Michael
Corbett is a valuable resource where his areas of expertise touch upon related issues. All
other SWCA advocates and staff are available resources to STPUD, as needed.
'Attached is an outline of services that SWCA has historically provided, and will continue
to provide, for the STPUD. We .are happy to discuss any additions or changes to our
.c;llrrent activities, and understand that specific adjustments are always necessary in
~yolving political situations.
1127 1 ph Street, Suite 512 .. Sacramento, CA 95814.. Telephone 916/442-0412' Facsimile 916/444-0383
www.sw~~ocates.com
,~ l1S7-M
Contract Term and Fees: SWCA will perform the activities listed for a fee of
$30,000.00 per year covering the period January 1,2008 through December 31,2008.
This fee shall include ordinary expenses of doing business such as postage, telephone and
travel. Travel other than Sacramento and South Lake Tahoe and extraordinary expenses
shall be reimbursed with prior approval of STPUD.
Quarterly Reporting Requirements: SWCA agrees to abide by all statutes and
regulations applying to lobbying activities in California, to file timely reports with the
Secretary of State's Office pursuant to state disclosure requirements, and SWCA agrees
to provide to STPUD the information necessary for the District's disclosure
responsibilities with the Secretary of State.
Thank you for your past confidence, and we look forward to continuing our relationship
with the STPUD. If you have any questions please give us a call.
Sin1elY,
~7
StevenT. w~
2
-32-
Scope of Services
In this proposal SWCA outlines services that would be provided to the South Tahoe
Public Utility District (STPUD). The goal of these activities is to provide STPUD with
the most coordinated and seamless service possible in furtherance of its state legislative
and administrative needs.
. SWCA advocates maintain regular communication with designated key contacts
regarding STPUD's sponsored bills and positions.
. SWCA provides updates on Capitol activities and the status oflegislation of
importance to the STPUD, and in addition, STPUD receives Budget Updates
when events warrant.
i.' SWCA analyses and distributes legislation and amendments to bills as needed for
STPUD.
. SWCA writes letters on all positions taken by the STPUD Board for every
committee hearing and to the Governor and delivers them personally to legislative
and administrative offices.
. SWCA maintains a data base that electronically tracks all bills with a Board
position, as well as those bills that are monitored on behalf of STPUD.
. SWCA meets with STPUD's legislative delegation, as well as Legislators from
other areas, to present STPUD's legislative issues, and then works closely with
them throughout the year.
. SWCA testifies at legislative hearings on all bills in which the STPUD has an
interest and position and before all Budget Subcommittees on relevant issues.
. SWCA keeps Legislators informed through correspondence, personal contact,
staff contact, and other means of STPUD's legislative and budget issues.
. SWCA schedules meetings between STPUD personnel and Legislators when
issues demand their expertise.
. SWCA negotiates with other delegations, and other local entities for amendments
sought by STPUD, and actively works against passage of bills STPUD opposes.
. SWCA provides background for legislative staff and new members on STPUD
issues.
. SWCA participates in strategy meetings on policy and budget issues with
leadership staff in both Houses and both parties, as well as with other advocate
groups, to further STPUD's legislative goals.
3
-33-
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SOUTH TAHOE PUBLIC UTILITY DISTRICT
"Basic Services for a Complex World"
'./
Richard Solbrig, General Manager
Eric W. Schafer, President
Paul Sciuto, Assistant Manai:.
BOARD MEMBERS James R. Jones, Vice President
Duane Wallace, Director
Mary Lou Mosbacher, Director Kathleen Farrell, Director
REGULAR MEETING OF THE BOARD OF DIRECTORS
SOUTH TAHOE PUBLIC UTILITY DISTRICT
NOVEMBER 1, 2007
MINUTES
The Board of Directors of the South Tahoe Public Utility District met in a regular session,
November 1, 2007, 2:00 P.M., District Office, 1275 Meadow Crest Drive, South Lake
Tahoe, California.
BOARD OF DIRECTORS:
President Schafer, Directors Wallace, Jones, Farrell,
Mosbacher
ROLL CALL
STAFF:
Solbrig, Sciuto, Sharp, McFarlane, Cocking, Ryan,
Hammond, Torney, Brown, Curtis, Barnes, Eidam,
Coyner, R. Johnson, Pinkel, Attorney Herrema
GUESTS:
John Runnels, Julie Threewit, Mike McFarlane
Staff requested that Action Item b. (Engineering CORRECTIONS TO THE AGENDA
Department 2008 Project Priority List) be removed OR CONSENT CALENDAR
from the agenda, and placed on a future agenda for
consideration.
Moved Wallace / Second Farrell / Passed Unanimously CONSENT CALENDAR
to approve the Consent Calendar as submitted:
a. Keller Booster Station Pumps and Motors - Awarded
bid to the lowest responsive, responsible bidder,
Simonds Machinery Co., in the amount of
$30,321.76;
b. Adopted new Purchasing Policy;
-35-
REGULAR BOARD MEETING MINUTES - NOVEMBER 1, 2007
PAGE - 2
c. Upper Dressler Ditch Phase 1 Project - Approved
Change Order No.1 to T&S Construction Co., Inc.,
in the amount of $5,766.70;
d. 2007 Glen Road and Gardner Mountain Waterline
Replacement Project - Approved Change Order
No.2 to Marv McQueary Excavating, Inc., in the
amount of $87,136.92;
e. Sewer Capacity Fees - Accepted proposal from
Municipal Financial Services to develop an update
to the sewer capacity charge, in an amount not
to exceed $23,000;
f. Approved Regular Board Meeting Minutes:
October 18, 2007.
CONSENT CALENDAR
(continued)
ITEMS FOR BOARD ACTION
A work plan and schedule for the sewer collection
system is required by the State Water Resources
Control Board, so they can develop a regulatory
mechanism to provide a consistent statewide
approach for reducing sanitary sewer overflows.
Randy Curtis gave a PowerPoint presentation cover-
ing aspects of the plan, including: goals, organizational
charts, staffing, notification and reporting procedures,
overflow emergency response plan, legal authority,
operation and maintenance, fats/oils/grease control
program, design and construction schedules, system
evaluations and capacity assurance plan, monitoring/
measurement and program modifications, internal
management audits, and the communications program.
Moved Jones / Second Farrell/ Passed Unanimouslv
to approve the schedule and work plan as presented.
Moved Farrell/ Second Mosbacher / Passed
Unanimously to approve payment in the amount of
$1,471,511.69.
Water and Wastewater Operations Committee: The
committee met October 29. Minutes of the meeting
are available upon request.
Director Wallace reported that the agency is trying to
secure 40,000 acre feet of water to accommodate
agricultural needs. Several issues raised by Georgetown
Divide PUD must be resolved before any more progress
can be made.
-36-
SEWER SYSTEM MANAGEMENT
PLAN
PAYMENT OF CLAIMS
BOARD MEMBER STANDING
COMMITTEE REPORTS
EL DORADO COUNTY WATER
AGENCY PURVEYOR
REPRESENTATIVE REPORT
REGULAR BOARD MEETING MINUTES - NOVEMBER 1, 2007
PAGE. 3
Director Mosbacher reported the bid process is under-
way for 2008 cattle grazing at the Diamond Valley
Ranch.
Director Schafer reported he was the Board represen-
tative at the ECC (Employee Communications
Committee) meeting on October 31 . He was happy to
see increased attendance at the meeting.
General Manager: Richard Sol brig reported on three
items:
1) The CTC (California Tahoe Conservancy) has
taken a new position that public agencies should no
longer receive grant funding for BMPs (Best Manage-
ment Practices) on private parcels. In response to
this decision, staff will look into the intent behind
the grant program to be sure nothing has gone awry,
and if it has, will work to get it back on track with
the original intentions.
2) The District's second application for Proposition 50
funding was denied. Apparently the application rater
did not assign credits appropriately, so staff will
request reconsideration.
3) The District received an "emergency" request from
City of South lake Tahoe council members and staff
to immediately open the water valve between the
District's waterline and the 14" line the developer
installed to provide fire protection for motels on
Cedar Ave. District staff is not sure why they felt
it was an emergency since they have fire protection
from Lakeside Mutual Water Company - the
same protection that has been provided for the past
30 years - and anew, high volume District hydrant
on the convention center site. The City attorney,
though, was very concerned regarding the potential
for being sued for not providing the fire protection
that was available in the event of a fire. District
crews opened the valve 15 minutes later to charge
the line and fire hydrants as requested.
3: 15 - 3:25 P.M.
3:30 P.M.
-37-
BOARD MEMBER REPORTS
GENERAL MANAGER REPORTS
MEETING BREAK AND ADJOURN-
MENT TO CLOSED SESSION
RECONVENED TO REGULAR
SESSION
REGULAR BOARD MEETING MINUTES - NOVEMBER 1, 2007
PAGE. 4
ACTION I REPORT ON ITEMS DISCUSSED DURING CLOSED SESSION
No reportable Board action.
Pursuant to Government Code
Section 54956.9(a)/Conference
with Legal Counsel - Existing
Litigation re: Meyers Landfill Site:
United States of America vs. EI
Dorado County and City of South
Lake Tahoe and Third Party
Defendants, Civil Action No.
S-01-1520 LKK GGH, U.S. District
Court for the Eastern District of Ca.
3:30 P.M.
ADJOURNMENT
Eric W. Schafer, Board President
South Tahoe Public Utility District
ATTEST:
Kathy Sharp, Clerk of the Board
South Tahoe Public Utility District
-38-
Action Item 7a
SOUTH TAHOE PUBLIC UTILITY DISTRICT
.1275 Meadow Crest Drive, South Lake Tahoe, CA 96150.
· Phone 530.544.6474. Facsimile 530.541.0614 ·
NOTE: COMPLETION OF THE ABOVE INFORMATION IS VOLUNTARY AND NOT A PRECONDITION FOR ATTENDANCE.
REQUEST TO APPEAR BEFORE THE BOARD
(Use Separate Sheet if Necessary)
1.
Name:
Del Lafountain
2. Street Address: 948 Normuk Street
3. Mailing Address: Box 16473. South Lake Tahoe. CA 96151
4.
Phone No: 530.318.0426
Date:
Nov. 24. 2007
5.
Date I wish to appear before Board:
Thursday. December 6. 2007
6. I have discussed this matter with a member of District staff: Ves X No
If "Ves": Name/Department of District contact: Christene. Lisa. Kathy
7.
Staff Introduction:
Mr. Lafountain contacted the District concernina waiYine water
and sewer service charees because house is not built yet.
8. Customer Comments: Lot is vacant - no utilities are connected. The County issued a
non-comoliance letter years aao and made us tear out the foundation.
9. Action I am requesting Board take: Consider removine oneoina fees that have
been billed to me.
10.
Staff Comments / Recommendation:
Board has oreviously uoheld Administrative
Code Sections 6.1.2 and 6.1.3 as the District has no control over how lone it takes to
build a home after water/sewer connection has been insoected and "finaled."
-39-
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1275 ~~0rM.5outh Labl TahoI.CA9615O-7401
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BOARD AGENDA ITEM 7b
TO:
Board of Directors
FROM:
Ivo Bergsohn, Hydro-Geologist
MEETING DATE:
December 6, 2007
ITEM - PROJECT NAME: Indian Creek Reservoir TMDL Oxygenation Project
REQUESTED BOARD ACTION: 2:30 p.m. PUBLIC MEETING
REQUESTED BOARD ACTION: (1) Hold a Public Meeting to take public comments on
the Initial Study and Negative Declaration of Environmental Impact; and (2) Certify the
Negative Declaration of Environmental Impact.
DISCUSSION: At 2:30 p.m. open the meeting to receive public input on the Initial Study
and Negative Declaration of Environmental Impact for the Indian Creek Reservoir TMDL
Oxygenation Project. After the close of the meeting and response to comments by staff,
the Board may certify the Negative Declaration of Environmental Impact and approve
the project.
SCHEDULE: N/A
COSTS: N/A
ACCOUNT NO: 1029-8605/ICTMDL
BUDGETED AMOUNT REMAINING:
ATTACHMENTS: Certification of the Negative Declaration of Environmental Impact,
IS/ND for Indian Creek Reservoir Oxygenation Project - Responses to Written
Comments Memorandum (dated November 26,2007) and Notice of Determination.
CONCURRENCE WITH REQUESTED ACTION:
GENERAL MANAGER: YES~ NO
CHIEF FINANCIAL OFFICER: YES~ NO
CATEGORY: Sewer
-41-
SOUTH TAHOE PUBLIC UTILITY
DISTRICT
INDIAN CREEK RESERVOIR TMDL
OXYGENATION PROJECT
State Clearinghouse Number: 2007102083
FINAL
ENVIRONMENTAL
DOCUMENTATION PACKAGE
December 6, 2007
-43-
1
SOUTH TAHOE PUBLIC UTILITY DISTRICT
INDIAN CREEK RESERVOIR TMDL OXYGENATION PROJECT
CERTIFICATION OF THE NEGATIVE
DECLARATION OF ENVIRONMENTAL IMPACT
SOUTH TAHOE PUBLIC UTiliTY DISTRICT
INDIAN CREEK RESERVOIR
TMDL OXYGENATION PROJECT
Whereas a Mitigated Negative Declaration was prepared dated October 12,2007 on the project
which includes: A brief description of the Project; the location of the project; findings that the
project will not have a significant effect on the environment and; an Initial Study documenting
the potential impacts, incorporated mitigation measures and information supporting the finding
of no significant impact;
Whereas the Negative Declaration was circulated through the California Office of Planning and
Research and to responsible agencies and the interested public from October 15, 2007 through
November 19, 2007 and comment letters were received from:
California Department of Water Resources Division of Safety of Dams (11/09/07);
California Department of Transportation (11/19/07);
Whereas the Negative Declaration was noticed to adjacent property owners on October 15,2007;
Whereas the written comments received during the Public Review period were considered and
accompanying responses were prepared on November 26, 2007;
Whereas the Negative Declaration was presented at a Public Meeting on December 6, 2007;
Now therefore, at the December 6, 2007 Regular Meeting, the South Tahoe Public Utility District
Board finds "that upon review of the initial study and comments received that there is no
substantial evidence that the Project will have a significant impact on the environment."
-44-
PAGE 1
SoutVt TCtVtOe
Ri.c~Clrcl soLbrtg
c;eV'l-tYCll MCl V\,Clgey
Board Members
Katl1LeeY\. Farrell
Ja~ R.JOV\.tS
Marl:1 LolA. MosbClcl1er
DIA.ClV\.t walLace
6ri.c scl1afer
pubLLc vttLLLtkj Dtsbict
MtltVto yet vu;{ UltVt
Date:
November 26, 2007
To:
Board of Directors n
Ivo Bergsohn ). -f!J ·
IS/ND for Indian Creek Reservoir Oxygenation Project - Responses to
Written Comments
From:
Subject:
The following are responses to comments that were received by the South Tahoe Public
Utility District on the Indian Creek Reservoir TMDL Oxygenation Project, dated October
12,2007. A total of two comments were received. The two comments are summarized
below followed by responses. Copies of the comments received, are attached to this
memorandum.
Comment #1 - Mike Zumot, Acting Chief Division of Safety of Dams, California
Department of Water Resources - The proposed project is located adjacent to the
dam which is under State jurisdiction for safety. The proposed project may require
excavation into the dam embankment to install pipelines and conduits. If the excavation
required is more than a few feet into the embankment, an alteration application may be
required.
Response - This comment is not in response to the environmental analysis
provided in the initial study, however this is a permitting issue. If prior to
construction it is determined the depth of excavation is more than a few feet, an
alteration application will be submitted to the CA Department of Water
Resources, Division of Safety of Dams. Trenches for buried conduit and piping
installations would be properly backfilled with granular material in maximum 8-
inch lifts and compacted to 90% to 95% relative compaction.
-45-
ISIND for Indian Creek Reservoir Oxygenation Project-
STPUD Responses to Written Comments
Page 2
November 26, 2007
Comment #2 - Kathleen Zahniser McClaflin, Associate Transportation Planner,
CA Department of Transportation - The project has no impacts on traffic. The
Washoe Tribe of California and Nevada is a federally recognized tribe located within the
area, and should be consulted with early in the process to determine impacts this
project may have on the project.
Response - The District and the environmental documentation staff consulted
with the Washoe Tribe of California and Nevada on 19 October 2007 to discuss
the project and potential impacts to known archeological sites within the vicinity.
The Tribe also has been provided copies of the Initial Study for their review and
comment.
cc: AVl-Cler$ I-tCllA.ge, I-tCllA.ge "Bn.(.ec~ A$$oci.t:lte$
R. solbrLg
F~le
South Tahoe Public Utility District. 1275 Meadow Crest Drive, South Lake Tahoe, CA 96150
Phone 530.544.6474. Facsimile 530.541.0614. www.stpud.us
-46-
STATE OF CAlIFORNIA- THE RESOURCES AGENCY
DEPARTMENT OF WATER RESOURCES
1416 NINTH STREET. P.O. BOX 942836
SACRAMENTO. CA 94236-0001
(916) 653-5791
NOV 9 'Sf!
Mr. Ivo Bergsohn
South Tahoe Public Utility District
1275 Meadow Crest Drive
South Lake Tahoe, California 96150
Initial Study/Environmental Checklist of South Tahoe Public Utility District Indian Creek
Reservoir TMDL Oxygenation Project, October 2007
Alpine County .
Dear Mr. Bergsohn:
The Division of Safety of Dams has reviewed the Initial Study/Environmental Checklist
report for the proposed Indian Creek Reservoir TMDL Oxygenation Project involving
Indian Creek Dam, No.1062, which is currently under State jurisdiction for safety.
Based on the information provided, we find the proposed project may require
excavation into the upstream portion of the embankment dam to install pipelines and
conduits. As long as the trench excavations are shallow and are backfilled properly,
this work should not significantly affect the dam or its appurtenances. If the excavation
is more than a few feet into the embankment, however, an alteration application may be
required.
If you have any questions or need additional information, you may contact Office
Engineer Chuck Wong at (916) 227-4601 or Acting Regional Engineer Aspet
Ordoubigian at (916) 227-4625.
Sincerely,
4(6~or
Mike Zumot, Acting Chief
Division of Safety of Dams
cc: Ms. Nadell Gayou
Resources Agency Project Coordinator
Environmental Review Section, DPLA
901 P Street
Sacramento, California 95814
Governor's Office of Planning
and Research
State Clearinghouse
Post Office Box 3044
Sacramento, California 95812-3044
-47-
(vo Bergsohn
From:
Sent:
To:
Subject:
Kathleen McClaflin [kathleen_mcclallin@dot.ca.gov]
Monday, November 19, 20073:05 PM
Ivo Bergsohn
$0 Tahoe PUD Indian Crk Res TMDL Oxy proj Comments
Mr. Bergsohn,
This email is to thank you for the opportunity to review and comment on the Notice of Intent
(NOI). The South Tahoe Public Utility District (PUD) proposes to implement a Hypolimnetic
oxygengation System (HOS) to improve water quality in Indian Creek Reservoir and comply with
total maximum daily load requirements. The project is located off Diamond Valley Road and State
Route 89 in Alpine County near Woodfords.
This project has No Impacts to traffic.
The Washoe Tribe of California and Nevada is a federally recognized
tribe located within the area, please ensure that early consultation
takes place with the Tribe and input from the Native American community
occurs for any potential impacts of this proposed project.
Kathleen Zahniser McClaflin
Associate Transportation Planner
Alpine and Amador County IGR Coordinator District Native American Liaison Department of
Transportation Office of Rural Planning and Administration
1976 E. Charter Way
Stockton, CA 95205
209-948-7647 209-948-7164
-'/8-
Notice of Determination
Form C
To: ~
Office of Planning and Research
PO Box 3044, 1400 Tenth Street, Room 212
Sacramento, CA 95812-3044
From: (Public Agency) South Tahoe Public
Utility District, 1275 Meadow Crest Drive
South Lake Tahoe, CA 96150
(Address)
~
County Clerk
County of Alpine
P.O. Box 158
Markleeville, CA 96120
Subject:
Filing of Notice of Determination in compliance with Section 21108 or 21152 of the Public Resources Code.
Indian Creek Reservoir TMDL Oxygenation Project
Project Title
2007102083
State Clearinghouse Number
(If submitted to Clearinghouse)
Ivo Bergsohn
Lead Agency
Contact Person
530.543.6204
Area Code/felephonelExtension
Indian Creek Reservoir, NW 1/4, SE 1/4, Section 4, T 10 N, R 20 E, Alpine County, CA
Project Location (include county)
Project Description:
Project will entail the construction and operation of an in-reservoir hypolimnetic
oxygenation system to achieve compliance with TMDL water quality numeric targets. The
system will include construction of a 460 sf equipment building west of the main dam,
installation of a submerged oxygenation equipment skid within the reservoir and
submerged connecting oxygen supply and power lines.
This is to advise that the South Tahoe Public Utility District has approved the above described project on
l2J Lead Agency 0 Responsible Agency
December 6, 2007 and has made the following determinations regarding the above described project:
(Date)
1. The project [[]will llJwill not] have a significant effect on the environment.
2. 0 An Environmental Impact Report was prepared for this project pursuant to the provisions of CEQA.
III A Negative Declaration was prepared for this project pursuant to the provisions of CEQA.
3. Mitigation measures [Dwere l;ZIwere not] made a condition of the approval of the project.
4. A statement of Overriding Considerations [[]was ~as not] adopted for this project.
5. Findings [lZJwere []were not] made pursuant to the provisions ofCEQA.
This is to certify that the final EIR with comments and responses and record of project approval is available to the General Public at:
Not Applicable
Signature (Public Agency)
Date
Title
Date received for filing at OPR:
January 2004
26
-49-
~t~...1Ir'
..............
South Tahoe
Public Utility District
0Irect.0rt
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MatyI.Q\.l~
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frlc ScMfIr
1275 ~~ Dri\e .South....,.~.CA961fX)..1AI01
PI10re 530 544-6414-Fmc 5SOf541-0614.www.trt.pud' us
BOARD AGENDA ITEM 7c
TO:
Board of Directors
FROM:
MEETING DATE:
Nancy Hussmann, Human Resources Director
December 6, 2007
ITEM - PROJECT NAME: Plan Document for Employees' Benefit Plan
REQUESTED BOARD ACTION: Approve updated Plan Document
DISCUSSION: The Plan Document for the District's Employees' Benefit Plan is
reviewed periodically and updated to comply with current law and other Plan changes
that have taken place since the last publication. Additionally, this year, staff has had the
new Third Party Administrator, CDS Group Health, review the document and make
recommendations for changes. The attached redline/strikeout version of the updated
Plan Document indicates the changes staff is recommending for the 2008 Plan Year.
One item in the Plan Document, the Wellness Guidelines, starting on page 23, are
being reviewed by the Wellness Committee, comprised of shop stewards, management
representatives, and Dr. Greg Bergner, as a consultant. The Wellness Committee is
meeting on December 5th to determine if there are any changes needed to these
guidelines. A copy of any updated changes to the Wellness Guidelines will hopefully be
distributed at the Board Meeting on December 6th.
SCHEDULE:
COSTS:
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATTACHMENTS: Plan Document & Summary Plan Description for S.T.P.U.D.
Employees' Benefit Plan. Due to its length, additional copies can be requested from the
Board Clerk.
CATEGORY: General
CONCURRENCE WITH REQUESTED ACTION:
GENERAL MANAGER: YES~ NO
CHIEF FINANCIAL OFFICER: YES~ NO
-51-
\.,
\.,
Plan Document
and
Summary Plan Description
For
South Tahoe Public Utility District
Employees' Benefit Plan
\..,
Implemented January 1, 1997
Updated January 1, 1998
Updated May 12, 2000
Updated January 1,2004
Updated January 1, 2007
Updated January 1,2008
lntroduetion
This document is a description of the South Tahoe Public Utility District Employees'
Benefit Plan (the Plan). The Plan described is designed to protect Plan Participants
against catastrophic health expenses, as well as for more routine medical, dental, and
prescription needs.
This Plan is intended to provide the Employee and eligible dependents health insurance
coverage for preventive care, routine services and minor injuries and illnesses, in addition
to providing covemge for catastrophic illness or injury. This Plan can ease financial
burdens by providing reimbursement for the great majority of covered expenses.
This document summarizes the Plan rights and benefits for covered Employees and their
Dependents and is divided into the following parts:
..J
.J
.J
\.,
Table of Contents
Section Paee #
Soecial Notices
Newborns & Mothers Health Protection Act and
Women's Health & Cancer Rights Act.....................................................~.......................1
COBRA Notification Procedures
Provides an overview of the COBRA Notification Requirements ...................................1
Dermed Terms
Defines those Plan terms that have a specific meaning ....................................................1
Eligibility, Funding, Effective Date, and Termination
Explains eligibility for coverage under the Plan, fimding of the Plan,
and when the coverage takes effect and terminates ..........................................................8
Schedule of Benefits
Provides an outline of the Plan reimbursement formulas,
as well as payment limits on certain services .................................................................16
WeIlness Program Guidelines..... ............... ..... ................ ............................................ .22
'-'
Notes for Schedule of Benefits, Benefit Descriptions &
Benefit Limits
Explains when the benefit applies, the types of charges covered,
and the limits applicable for certain conditions or treatment methods ...........................26
Prescription Drug Benefit
Provides an outline of the Plan reimbursement formulas as well as
payment limits regarding prescription drugs ..................................................................35
Dental Benefits
Provides an outline of the Plan reimbursement formulas as well as
payment limits on certain dental services .......................................................................39
Medical Management Services
Explains the methods used to curb unnecessary and excessive charges
This part should be read carefully since each Participant is required
to take action to assure that the maximum payment levels under the Plan
are paid. ....... ........ .............................. ............ ....................................................... .........45
Case Management Services
Explains voluntary program where catastrophic conditions are monitored
\., and care coordinated to provide the most appropriate level of care ...............................49
Table of Contents - Continued
Section Pae:e #
Plan Exclusions
Shows what charges are not covered..............................................................................50
.J
Claim Provisions
Explains the rules for filing claims .................................................................................54
Claim Denials
Explains the provisions when a claim is denied in whole or in part...............................62
Appeal Procedures
Explains the process for appealing a denied claim .........................................................63
Coordination of Benefits
Shows the Plan payment order when a person is covered under
more than one plan ............ ............ ........ ............ .... ........ ..... .......... ...................... ........... ..65
Subrogation and Reimbursement Provisions
Explains the Pan's rights to recover payment of charges when a Covered Person has a
claim against another person because of injuries sustained............................................69
COBRA Continuation Options . . ..i
Explains when a person's coverage under the Plan ceases, .."
and the continuation options which are available ...........................................................74
USERRA Continuation Coverage
Explains continuation coverage for a covered Employee and covered
Dependents who lose coverage due to service in the Uniformed Services..................... 79
Plan Amendment Regarding HIP AA Privacy Compliance
Explains the provisions of the Health Insurance Portability
and Accountability Act of 1996 ......................................................................................81
Responsibilities for Plan Administration
Outlines the duties and responsibilities of the Plan Administrator.................................85
General Plan Information
Provides general plan information as required by federal law .......................................87
Attachments
Attachment 1
Attachment 2
Attachment 3
Authorization for Release of Claim Information 89
Claim Appeal Release of Medical Information Form 90
Release of Medical Information Authorization
for Request for Plan Exception 91
..J
\.,
\.,
\."
Special Notices
Stated on Paee 32 of Plan Doc - but required to be on front Daee Der Federal Law
The Newborns and Mothers Health Protection Act
Group health plans and helath insurance issuers generally may not. under Federal law.
restrict benefits for any hospital length of stay in connection with childbirth for the
mother or newborn child to less than 48 hours following a vaginal delivery. or less than
96 hours following a cesarean delivery. However. Federal law generally does not
prohibit the mother's or newborn's attending provider. after consulting with the mother.
from discharging the mother or her newborn earlier than 48 hours (or 96 hours as
applicable). In any case. plans and issuers may not. under Federal law. require that a
provider obtain authorization from the plan or the issuer for prescribing a length of stay
not in excess of 48 hours (or 96 hours).
Stated on pafle 28 of Plan Doc, but required bv Federal law to be on front page
The Women's Health and Cancer Rie:hts Act
Under Federal law. the heatlh benefits of most plans must include coverage for the
following post-mastectomy services and supplies when provided in a manner determined
in consultation between the attending physician and the patient:
1.
Reconstruction of the breast on which a mastectomy has been performed.
2. Surgery and reconstruction of the other breast to produce symmetrical
appearance.
3. Breast prostheses. and
4. Physical complications of all stages of mastectomy. including lymphedemas.
Plan participants must be notified. upon enrollment and annually thereafter. of the
availability of benefits required due to the Women's Health and Cancer Rights Act
(WHCRA).
Required bv Federal law to have an overview at front of document
COBRA Notification Procedures
Notice Responsibilities
It is a Plan participant's responsibility to provide the following Notices relating to
COBRA Continuation Coverage:
Notice of Divorce or Separation - Notice of the occurrence of a Qualifying Event that is
a divorce or legal separation of a covered Employee from his or her spouse.
Page 1 of3
Notice of Child's Loss of Dependent Status - Notice of a ~ualifying Event that is:a"
child's loss of Dependent status under the Plan (e.g.. a Dependent child reaching the ..""
maximum age limit).
Notice of a Second OuaIifvine: Event - Notice of the occurrence of a second Qualifying
Event after a Qualified Beneficiary has become entitled to COBRA coverage with a
maximum duration of 18 (or 29) months.
Notice Ree:ardine: Disabilitv - Notice that:
1. A Qualified Beneficiary entitled to receive COBRA Continuation Coverage
with a maximum duration of 18 months has been determined by the Social
Security Administration (SSA) to be disabled at any time during the first 60
days of continuation coverage. or
2. A Qualified Beneficiary as described in "1." Has subsequently been
determined by the SSA to no longer be disabled.
Notification Procedures
Notification must be made in accordance with the following procedures. Any individual
who is either the covered Employee. a Qualified Beneficiasry with respect to the
Qualifying Event. or any representative acting on behalf of the covered Employee or
Qualified Beneficiary may provide the Notice. Notice by one individual shall satisfy any
responsibility to provide Notice on behalf of all related Qualified Beneficiaries with
respect to the Qualifying Event.
..J
Form or Means of Notification - Notification of the Qualifying Event must be provided
to the District's Human Resources Department.
Content - Notification must include any official documentation showing evidence that a
Qualifying Event has occurred. such as a copy of a divorce decree. a child's birth
certificate. a copy of the Social Security Administration's disability determination. etc.
Delivery of Notification - Notification must be received by the District's Human
Resources Department.
Time Requirements for Notification - Should an event occur (as described in Notice
Responsibilities above). the Emplovee. other Qualified Beneficiary. or a representative
acting on behalf of any such person must provide Notice to the designated recipient
within a certain time frame.
In the case of divorce. legal separation or a child losing dependent status. Notice must be
delivered within 60 days from the later of:
1.
2.
The date of the Qualifying Event.
The date health plan coverage is lost due to the event. or
wi
Page 2 of3
\.,
'-'
\.
3. The date the Qualified Beneficiary is notified of the obligation to provide Notice
through the Summary Plan Description or the Plan Sponsor's General COBRA Notice. If
Notice is not received within the 60-dav oeriod. COBRA Continuation Covera2e will
not be available. except in the case of a loss of coverage due to foreign competition
where a second COBRA election period may be available - see "Effect of the Trade Act"
in the COBRA Continuation Coverage section of this Plan Document.
If an Emplovee or Qualified Beneficiary is determined to be disabled under the Social
Security Act. Notice must be delivered within 60 days from the later of:
1. The date of the determination.
2. The date of the Qualifying Event.
3. The date coverage is lost as a result of the Qualifying Event. or
4. The date the covered Employee or Qualified Beneficiary is advised of the Notice
obligation through the Plan Document or the Plan Sponsor's General COBRA Notice.
Also, Notice must be provided within the 18-month COBRA coverage period.
Page 3 of3
'Refined ~
The following terms have special meanings and when used in this Plan will be
capitalized.
,J
Active Employee is an Employee who performs all of the duties ofhis or her job with
the Employer on a full-time basis.
Ambulatory Surgical Center is a licensed facility that is used mainly for performing
outpatient surgery, has a staff of Physicians, has continuous Physicians and nursing care
by registered nurses (R.N.s) and does not provide for overnight staYs.
Baseline shall mean the initial Test Results to which the results in future years will be
compared in order to detect abnormalities.
Rirthing Center means any freestah4alg health facility, place, professional office or
institution which is not a Hospital or in a Hospital, where births occur in a home-like
atmosphere. This facility must be licensed and operated in accordance with the laws
pertaining to Birthing Centers in the jurisdiction where the facility is located.
The Birthing Center must provide facilities for obstetrical delivery and short-term
recovery after delivery in compliance with the Mothers and Newborns Protection Act;
provide care under the full-time supervision of a Physician and either a registered nurse . ...
(R.N.) or a licensed nurse-midwife; and have a written agreement with a Hospital in the ..,
same locality for immediate acceptance of patients who develop complications or require
pre- or post-delivery confinement.
Calendar Year means January 1st through December 31st of the same year.
COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as
amended.
Claims Administrator/Contract Administrator - A company that oerforms all
functions reasonably related to the administration of one or more benefits of the Plan
(e.g.. processing of claims for payment in accordance with the terms and conditions of
the Benefit Document and an administration agreement between the Contract
Administrator and the Plan Sponsor.
Cosmetic Surgery means medically unnecessary surgical procedures, usually, but not
limited to, plastic surgery directed toward preserving beauty or correcting scars, bums or
disfigurements.
Covered Person is an Employee, Dependent, or Active Board Member who is covered
under this Plan.
~
Page 1 of 95
\.,
Custodial Care is care (including room and board needed to provide that care) that is
given principally for personal hygiene or for assistance in daily activities and can,
according to generally accepted medical standards, be performed by persons who have no
medical training. Examples of Custodial Care are help in walking and getting out of bed;
assistance in bathing, dressing, feeding; or supervision over medication which could
normally be self-administered.
Dentist is a person who is properly trained and licensed to practice dentistry and who is
practicing within the scope of such license.
Durable Medical Equipment means equipment which (a) can withstand repeated use;
(b) is primarily and customarily used to serve a medical purpose; (c) generally is not
useful to a person in the absence of an Illness or Injury and (d) is appropriate for use in
the home.
Employee means a person who is an Active, regular Employee of the Employer,
regularly scheduled to work for the Employer in an Employee/Employer relationship.
-..
Experimental and/or Investigational means services, supplies, care and treatment
which do not constitute accepted medical practice properly within the range of
appropriate medical practice under the standards of the case and by the standards of a
reasonably substantial, qualified, responsible, relevant segment of the medical
~mmunity or government oversight agencies at the time services were rendered.
The Plan Administrator, or hislher designee, must make an independent evaluation of the
experimental/non-experimental standings of specific technologies.> The Plan
Administrator, or hislher designee shall be guided by reasonable interpretation of Plan
provisions. The decisions shall be made in good faith and rendered following a detailed
factual background investigation of the claim and the proposed treatment. The Plan
Administrator, or his/her designee will be guided by the following principles:
1. If the drug or device cannot be lawfully marketed without approval of the U.S.
Food and Drug Administration and approval for marketing has not been given at
the time the drug or device is furnished; or
2. If the drug, device, medical treatment or procedure, or the patient informed
consent document utilized with the drug, device, treatment or procedure, was
reviewed and approved by the treating filcility's Institutional Review Board or
other body serving a similar fimction, or if the federa1law requires such review or
approval; or
3.
If Reliable Evidence shows that the drug, device, medical treatment or procedure
is the subject of on-going phase I or phase II clinical trials, is the research,
experimental, study or investigational arm of on-going phase ill clinical trials, or
is otherwise under study to determine its maximum tolerated dose, its toxicity, its
\.,
Page 2 of95
safety, its efficacy or its efficacy as compared with a standard means of1reatment
or diagnosis; or ...J
4. If Reliable Evidence shows that the prevailing opinion among experts regarding
the drug, device, medical treatment or procedure is that further studies or clinical
trials are necessary to determine its maximwn tolerated dose, its toxicity, its
safety, its efficacy or its efficacy as compared with a standard means of treatment
or diagnosis.
Reliable Evidence shall mean only published reports and articles in the
authoritative medical and scientific literature; the written protocol or protocols
used by the treating facility or the protocol(s) of another facility studying
substantially the same drug, device, medical treatment or procedure; or the written
informed consent used by the treating facility or by another facility studying
substantially the same drug, device, medical1reatment or procedure.
Family Unit is the covered Employee and the family members who are covered as
Dependents under the Plan.
Generic Drug means a Prescription Drug which has the equivalency of the brand name
drug with the same use and metabolic disintegration. This Plan will consider as a
Generic Drug any Food and Drug Administration-approved generic pharmaceutical
dispensed according to the professional standards of a licensed pharmacist and clearly
designated by the pharmacist as being generic. .J
Home Health Care Agency is an organization that meets all of these tests: its main
function is to provide Home Health Care Services and Supplies; it is federally certified as
a Home Health Care Agency; and it is licensed by the state in which it is located, if
licensing is required.
Home Health Care Services and Supplies include: part-time or intermittent nursing
care by or under the supervision of a registered nurse (R.N.); part-time or intermittent
home health aide services provided through a Home Health Care Agency (this does not
include general housekeeping services); physica4 occupational and speech therapy;
medical supplies; and laboratory services by or on behalf of the Hospital.
Hospice Agency is an organi7.ation where its main fimction is to provide Hospice Care
Services and Supplies and it is licensed by the state in which it is located, if licensing is
required.
Hospice Care Plan is a plan of terminal patient care that is established and conducted by
a Hospice Agency and supervised by a Physician.
Hospice Care Services and Supplies are those provided through a Hospice Agency and
under a Hospice Care Plan and include inpatient care in a Hospice Unit or other licensed
facility, home care, and family counseling during the bereavement period. J
Page 3 of 95
\.., Hospice Unit is a facility or separate Hospital Unit, that provides ~tment under a
Hospice Care Plan and admits at least two unrelated persons who are expected to die
within six months.
Hospital is an institution which is engaged primarily in providing medical care and
treatment of sick and injured persons on an inpatient basis at the patient's expense and
which fully meets these tests: it is accredited as a Hospital by the Joint Commission on
Accreditation of Healthcare Organizations; it is approved by Medicare as a Hospital; it
maintains diagnostic and therapeutic facilities on the premises for surgical and medical
diagnosis and treatment of sick and injured persons by or under the supervision of a staff
of Physicians; it continuously provides on the premises 24.hour.a-day nursing services
by or under the supervision of registered nurses (R.N.s); and it is operated continuously
with organized facilities for operative surgery on the premises.
The definition of "Hospital" shall be expanded to include the following:
. A facility operating legally as a psychiatric Hospital or residential treatment
facility for mental health and licensed as such by the state in which the facility
operates.
.
A facility operating primarily for the treatment of Substance Abuse if it meets
these tests: maintains permanent and full-time facilities for bed care and full-time
confinement of at least 15 residential patients; has a Physician in regular
attendance; continuously provides 24.hour a day nursing service by a registered
nurse (R.N.); has a full-time psychiatrist or psychologist on the staff; and is
primarily engaged in providing diagnostic and therapeutic services and facilities
for treatment of Substance Abuse.
\"
Illness is, for all persons: Sickness, disease, or Pregnancy.
Injury means an accidental physical injury to the body caused by unexpected external
means.
Intensive Care Unit is defined as a separate, clearly designated service area which is
maintained within a Hospital solely for the care and treatment of patients who are
critically ill. This also includes what is referred to as a "coronary care unif' or an "acute
care unit". It has: facilities for special nursing care not available in regular rooms and
wards of the Hospital; special life saving equipment which is immediately available at all
times; at least two beds for the accommodation of the critically ill; and at least one
registered nurse (R.N.) in continuous and constant attendance 24 hours a day.
\.,.
Lifetime is a word that appears in this Plan in reference to benefit maximums and
limitations. Lifetime is understood to mean while covered under this Plan. Under no
circumstances does Lifetime mean during the lifetime of the Covered Person.
Page 4 of 95
Medical Care Facility means a Hospital, or a facility that treats one or more specific
ailments or any type of Skilled Nursing Facility.
,J
Medical Emergency means a sudden onset of a condition with acute symptoms requiring
immediate medical care and includes such conditions as heart attacks, cardiovascular
accid.<mts, poisonings, loss of consciousness or respiration, convulsions or other such
acute medical conditions.
Medically Necessary care and treatment is recommended or approved by a Physician; is
consistent with the patient's condition or accepted standards of good medical practice; is
medically proven to be effective treatment of the condition; is not performed mainly for
the convenience of the patient or provider of medical services; is not conducted for
research purposes; and is the most appropriate level of services which can be safely
provided to the patient.
All of these criteria must be met; merely because a Physician recommends or approves
certain care does not mean that it is Medically Necessary.
Medicare is the Health Insurance for the Aged and Disabled program under Title xvm
of the Social Security Act, as amended.
Mental Disorder means any disease or condition that is classified as a mental Disorder
in the cmrent edition of Intemational Classification of Diseases. published by the u.s.
Department of Health and Human Services or is listed in the current edition of Diagnostic ..J
and Statistical Manual of Mental Disorders. published by the American Psychiatric
Association.
Morbid Obesity is a diagnosed condition in which the body weight exceeds the
medically recommended weight by either 100 pounds or is twice the medically
recommended weight in the most recent Metropolitan Life Insurance Co. tables for a
person of the same height, age, and mobility as the Covered Person.
No-Fault Auto Insurance is the basic reparations provision of a law providing for
payments without determining fault in connection with automobile accidents.
Outpatient Care is treatment including services, supplies and medicines provided and
used at a Hospital under the direction of a Physician to a person not admitted as a
registered bed patient; or services rendered in a Physician's office, laboratory or X-ray
facility, an Ambulatory Surgical Center, or the patient's home.
Pharmacy means a licensed establishment where covered Prescription Drugs are filled
and dispensed by a pharmacist licensed under the laws of the state where he or she
practices.
Physician means a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of
Dental Surgery (D.D.S.), Doctor of Podiatry (D.P.M.), Doctor of Chiropractic (D.C.), ..",;
Page 5 of95
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Audiologist, Certified Nurse Anesthetist, Licensed Professional Counselor, Licensed
Professional Physical Therapist, Midwife, Occupational Therapist, Optometrist (O.D.),
Physiotherapist, Psychiatrist, Psychologist (ph.D.), Speech Language Pathologist and any
other practitioner of the healing arts who is licensed and regulated by a state or federal
agency and is acting within the scope ofhis or her license.
Plan or Plan Program means South Tahoe Public Utility District Employees' Benefit
Plan, which is a benefits plan for certain employees of South Tahoe Public Utility
District, and is described in this document.
Plan Participant is any Employee or Dependent who is covered under this Plan.
Plan Year is the 12-month period beginning on the effective date of the Plan.
Pregnancy is childbirth and conditions associated with Pregnancy, including
complications.
\.,
Preferred Provider Organization (PPO) means the currently designated networks of
discounting providers for which the Plan provides financial incentive to plan participants.
Selection of PPO providers by participants results in the highest plan benefits. The Plan
may enter into other discounting arrangements with non-PPO designated providers.
When a participant uses one of these providers, benefits will be paid at the non-PPO
percentage, however the non-PPO co-insurance will be payable on a smaller (e.g.,
negotiated) amount.
Prescription Drug means any of the following: a drug or medicine which, Wlder federal
law, is required to bear the legend: "Caution: federal law prohibits dispensing without
prescription"; injectable insulin, Imitrex, Glucagon, prescribed Bee Sting Kits for allergic
Covered Persons, or other approved injectables as defined in the Prescription Drug
section; hypodermic needles or syringes, but only when dispensed upon a written
prescription of a licensed Physician. Such Drug must be Medically Necessary in the
treatment of a Sickness or Injury.
Sickness is, for all persons: nlness, disease or Pregnancy.
Skilled Nuning Facility is a facility that fully meets all of these tests:
1. It is licensed to provide professional nursing services on an inpatient basis to
persons convalescing from Injury or Sickness. The service must be rendered by a
registered nurse (R.N.) or by a licensed practical nurse (L.P.N.) under the
direction of a registered nurse (R.N.). Services to help restore patients to self-care
in essential daily living activities must be provided.
2.
Its services are provided for compensation and under the full-time supervision of
a Physician.
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Page 6 of 95
3.
It provides 24-hour per day nursing services by licensed nurses, under the
direction of a full-time registered nurse.
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4. It maintains a complete medical record on each patient.
5. It has an effective utilization review plan.
6. It is not, other than incidentally, a place for rest, the aged, dmg addicts,
alcoholics, mental retardates, Custodial or educational care or care of Mental
Disorders.
7. It is approved and licensed by Medicare.
This term also applies to charges incwred in a facility referring to itself as an extended
care facility, convalescent nursing home or any other similar nomenclature.
Spinal Manipulation/Chiropractic Care means skeletal adjustments, manipulation or
other treatment in connection with the detection and correction by manual or mechanical
means of structural imbalance or subluxation in the human body. Such treatment is done
by a Physician to remove nerve interference resulting from, or related to, distortion,
misalignment or subluxation of, or in, the vertebral column. Massage therapy is not
included as a covered benefit.
Substance Abuse is the condition caused by regular excessive compulsive drinking of
alcohol and/or physical habitual dependence on drugs that results in a chronic disorder
affecting physical health and/or personal or social functioning. This does not include
dependence on tobacco and ordinary caffeine-contJlining drinks.
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Temporomandibular Joint (TMJ) syndrome is the treatment of jaw joint disorders
including conditions of structures Jinlcine the jaw bone and skull and the complex of
muscles, nerves and other tissues related to the temporomandibular joint.
Usual, Customary and Reasonable Charge (VCR) is a charge which is not higher than
the usual charge made by the provider of the care or supply and does not exceed the usual
charge made by most providers of like service in the same area. This test will consider
the nature and severity of the condition being treated. It will also consider medical
complications or unusual circumstances that require more time, skill or experience. For
services, supplies or fees where publications of Usual, Customary, and Reasonable
Charges are not available, the Claims Administrator shall survey local or nearest
geographic providers of the same service to determine the allowable Usual, Customary,
and Reasonable Charges lrtiJi7.ing applicable local resources.
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Page 7 of 95
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EIiIDbilitv. Fundinll. Effective Date & Termination Provisions
EIi2ibilitv
Eligible Classes of Employees
The following Classes of Employees are considered eligible classes of Employees:
1. All Active Full-Time Employees of the Employer. An Employee is considered to
be Full-Time ifhe or she normally works at least 20 hours per week and is on the
regular payroll of the Employer for that work.
2. Active members of the Board of Directors.
3. Those persons formerly covered under the Board/Management insurance plan
prior to 1/1/96, who are not otherwise classified in # 1 or #2 above.
4. Any other persons who become eligible in accordance with the Memorandum of
Understanding in effect at the time they would otherwise be considered ineligible.
Eligibility Requirements for Employee Coverage
A person is eligible for Employee coverage on the first day of the Calendar month
following date of hire.
Eligible Classes of Dependents
Dependent is anyone of the following persons:
1. A covered Employee's Spouse and unmarried children from birth to the limiting
age of 19 years. However, a Dependent child will continue to be covered after
age 19, provided the child is a full-time student at an accredited school, primarily
dependent upon the covered Employee for support and maintenance, is unmarried
and under the limiting age of25. When the child reaches either limiting age,
coverage will end on the last day of the child's birthday month.
The term "Spouse" shall mean the person recognized as the covered Employee's
husband or wife under the laws of the state where the covered Employee lives.
The Plan Administrator may require documentation proving a legal marital
relationship.
The term "children" shall include natural children, adopted children or Step-
children who reside in the Employee's household, including those with court
order that mandates dependent coverage. However, if a dependent is enrolled in a
mandatory full-time (40 hour/week) unpaid internship as a mandatory
Page 8 of 95
requirements of their degree program, and such unpaid internship results in
enrollment in less than 12 units, such dependent shall continue to be eligible for ..J
coverage for that semester. Satisfactory documentation of same will be required
to be provided to the Plan Administrator, and shall include verification from the
accredited school.
The phrase "primarily dependent upon" shall mean dependent upon the covered
Employee for support and maintenance as defined by the Internal Revenue Code
and the covered Employee must declare the child as an income tax deduction or
have a court order mandating that employee provide dependent coverage. The
Plan Administrator may require documentation proving dependency, including
birth certificates, tax records or initiation of legal proceeding severing parental
rights,
2. A covered Dependent child who is incapable of self-sustaining employment by
reason of mental retardation or physical handicap, primarily dependent upon the
covered Employee for support and maintenance, unmarried, and covered under
the Plan when reaching the limiting age. The Plan Administrator may require, at
reasonable intervals during the two years following the Dependent's reaching the
limiting age, subsequent proof of the child's disability and dependency.
After such two-year period, the Plan Administrator may require subsequent proof
not more than once each year. The Plan Admini~tor reserves the right to have
such Dependent examined by a Physician of the Plan Admini~tor's choice, at J
the Plan's expense, to determine the existence of such incapacity.
These persons are excluded as Dependents:
1. Other individuals living in the covered Employee's home, but who are not eligible
as defined;
2. The legally separated or divorced former Spouse of the Employee;
3. Any person who is on active duty in any military service of any country.
If a person covered under this Plan changes status from Employee to Dependent or
Dependent to Employee, and the person is covered continuously under this Plan before,
during, and after the change in status, credit will be given for all amounts applied to
maximums.
Ifboth husband and wife are Employees, their children will be covered as Dependents of
both.
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Page 9 of 95
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Eligibility Requirements for Dependent Coverage
A family member of an Employee will become eligible for Dependent coverage on the
fIrst day that the family member satisfies the requirements for Dependent coverage.
At any time, the Plan may require proof that a Spouse or a child qualifies or continues to
qualify as a Dependent as defined by this Plan.
Fundin2
Cost of the Plan
South Tahoe Public Utility District pays the entire cost of Employee and Dependent
coverage under this Plan.
Enrollment
Enrollment Requirements
An eligible Employee or eligible Board Member must enroll for coverage by filling out
and signing an enrollment application. The covered Employee or Board Member is
required to enroll for Dependent coverage also, including coverage for newborn children.
\.,. Enrollment Requirements for Newborn Children
A newborn child of a Plan Participant is covered under the parent's coverage for routine
nursery care covered under this Plan. For coverage of Sickness or Injury, including
Medically Necessary care and treatment of congenital defects, birth abnormalities or
complications resulting from prematurity, the newborn child must be enrolled as a
Dependent under this Plan within 31 days of the child's birth in order for non-routine
coverage to take effect from birth.
If the child is not enrolled within 31 days of birth, the enrollment will be considered a
Late Enrollment.
Timely and Late Enrollments
An enrollment is either "timely'" or "late":
1. Timely Enrollment - The enrollment will be ''timely'" if the completed form is
received by the Plan Administrator no later than 31 days after the person becomes
eligible for the coverage.
2.
Late Enrollment - Late enrollment is accepted at the next Annual Enrollment
Period.
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Page 10 of 95
Effective Date
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Effective Date or Employee Coverage
An Employee or Board Member will be covered under this Plan as of the first day of the
calendar month following the date that the Employee or Board Member satisfies all of the
following:
1. Eligibility Requirement
2. The Enrollment Requirements of the Plan
Effective Date or Dependent Coverage
A Dependent will be covered under this Plan on the first date that the Dependent satisfies
all of the following:
1. Eligibility Requirement
2. Enrollment Requirements of the Plan
Coverage for a subsequent Dependent is effective, upon enrollment, as follows:
1.
For a spouse, the date of marriage;
J
2. For a newborn child, the date of birth;
3. For an adopted child, the date of adoption or placement for adoption;
4. For any other child, the date the child becomes a Dependent.
Enrollment Periods
The Initial Eligibility Period is the 31-day period which begins on the date the Employee
or Board Member is first eligible under this Plan. The District must offer enrollment
during that time and advise the employee of the deadline.
Employees and/or Dependents who are not enrolled during the Initial Eligibility Period,
or a Special Enrollment Period, through the Employee's election or omission, must wait
until the next Annual Enrollment Period to enroll for coverage.
The Annual Enrollment Period is designated by the Employer as December of each year.
It is held before the start of each Plan Year. During this period, all eligible Employees
and Dependents can enroll for coverage.
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Page 11 of 95
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Special Enrollment Periods are available to certain persons who have lost other coverage
and to certain dependents.
A Special Enrollment Period is available to a covered Employee's spouse or minor child
if a court orders that coverage must be provided under this Plan and the request for
enrollment is made within 30 days after the issuance of the order.
A Special Enrollment Period is available to a person who meets each of the following
conditions:
2. The Employee or Dependent was covered under a group health plan or had health
insurance coverage or was covered under no-share-of-cost Medi-Cal coverage at
the time coverage under this Plan was previously offered to the Employee or
Dependent.
3. The Employee stated in writing, at the time coverage was previously offered, that
the other coverage was the reason for declining enrollment under this Plan. The
Employer must have requested the statement and provided the Employee with
notice of this requirement (and its consequences) at that time. If the Employer
cannot produce the signed waiver form at the time the person wants to enroll, the
provision does not apply.
4. The Employee's or Dependent's prior coverage was one of the following:
\.,
A.
COBRA continuation which was exhausted.
B. Non-COBRA coverage which was terminated either as a result ofloss of
eligibility for the coverage (including as a result of legal separation,
divorce, death, termination of employment, or reduction in the number of
hours of employment) or employer contributions towards such coverage
where terminated.
C. The Employee requests enrollment under this Plan not later than 31 days
after the date of the end of COBRA continuation, termination of coverage,
or termination of Employer contribution.
A Special Enrollment Period is available to Subsequent Dependents. The Dependent
Special Enrollment Period is the 31-day period which begins with the date the person
becomes a dependent.
~
If a Subsequent Dependent is enrolled, the Employee must enroll at the same time if not
already covered. In addition, any of the Employee's other Dependents may be enrolled at
the same time, if not already covered, subject to the same enrollment requirements.
"Subsequent Dependent" includes a spouse or child of an eligible Employee whose
coverage is ordered by the court. The request for enrollment must be made within 30
days after issuance of the order.
Page 12 of95
Qualified Medical ChDd Support Qrden
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In the event a court order provides that coverage under the Plan or some portion thereof,
must be provided for your minor child, the following rules will apply:
1. You must submit the order in a timely manner to the Plan Administrator. The
Plan Administrator will notify you and your child that the order has been received
and what procedures will be used to determine if the order is a qualified medical
child support order within the meaning of Section 609 of ERISA. The Plan
Administrator will decide whether the order is qualified and notify the Participant
and the Participant's child of that decision.
2. If the Plan Administrator determines that the order is qualified, the Plan
Administrator shall permit an alternate recipient (as defined in ERISA Section
609(a)(2)(C)) to designate a representative for recipient of copies of notices that
are sent to the alternate recipient with respect to the medical child support order.
3. If the Plan Administrator determines that the circumstances surrounding the court
order constitutes and/or satisfies the change in family status requirements under
the Plan, then you will be permitted to change your election of benefits under the
Plan Programs.
Termination of Coverae:e
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When Employee Coverage Terminates
Employee or Board Member's coverage will terminate on the earliest of these dates
(except in certain circumstances, a covered Employee may be eligible for COBRA
continuation coverage. For a complete explanation of when COBRA continuation
coverage is available, what conditions apply, and how to select it, see the section entitled
COBRA Continuation Option):
1. The date the Plan is terminated.
2. The last day of the calendar month in which the covered Employee ceases to be in
one of the Eligible Classes. This includes death or termination of employment of
the covered Employee. (See the COBRA Continuation Option)
Continuation During Periods of Employer-Certified Disability,
Leave of Absence or Layoff
A person may remain eligible for a limited time if active, full-time work ceases due to
disability, leave of absence or layoff. Limited eligibility shall be determined by the
negotiated Memorandum of Understanding between the applicable employee group and
the District.
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Page 13 of 95
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While continued, coverage will be that which was in force on the last day worked as an
Active Employee. However, ifbenefits reduce for others in the class, they will also
reduce for the continued person.
Continuation During Family and Medical Leave
Regardless of the established leave policies mentioned above, this Plan shall at all times
comply with the Family and Medical Leave Act of 1993 as promulgated in regulations
issued by the Department of Labor.
During any leave taken under the Family and Medical Leave Act, the Employer will
maintain coverage under this Plan on the same conditions as coverage would have been
provided if the covered Employee had been continuously employed during the entire
leave period.
If Plan coverage terminates during the FMLA leave, coverage will be reinstated for the
Employee and his or her eligible Dependents if the Employee returns to work in
accordance with the terms of the FMLA leave. Coverage will be reinstated only if the
person(s) had coverage under this Plan when the FMLA leave started, and will be
reinstated to the same extent that it was in force when that coverage terminated.
Rehiring a Terminated Employee
...., A terminated Employee who is rehired will be treated as a new hire and will be required
to satisfy all Eligibility and Enrollment requirements, with the exception of an Employee
returning to work directly from COBRA coverage. An Employee returning to work
directly from COBRA coverage does not have to satisfy the employment waiting period.
Employees on Military Leave
Employees going into or returning from military service will have Plan rights mandated
by the Uniformed Services Employment and Re-employment Rights Act. These rights
include up to 18 months of extended health care coverage upon payment of the entire cost
of coverage plus a reasonable administration fee and immediate coverage with no pre.
existing conditions exclusions applied in. the Plan upon return from service. These rights
apply only to Employees and their Dependents covered under the Plan before leaving for
military service.
Plan exclusions and waiting periods may be imposed for any Sickness or Injury
determined by the Secretary of V eterans Affairs to have been incurred in, or aggravated
during, military service.
When Dependent Coverage Terminates
\..
A Dependent's coverage will terminate on the earliest of these dates (except in certain
circumstances, a covered Dependent may be eligible for COBRA continuation coverage.
Page 14 of95
For a complete explanation of when COBRA continuation coverage is available, what
conditions apply, and how to select it, see the section entitled COBRA Continuation
Option):
1. The date the Plan is terminated.
2. The date that the Employee's or Board Member's coverage under the Plan
terminates for any reason including death (See the COBRA Continuation Option).
3. The date Dependent coverage is terminated under the Plan.
4. On the last day of the month that follows the first date that he or she ceases to be a
Dependent as defined by the Plan (See eligibility for dependents).
Page 15 of95
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Sehedule of Benefits
VerificatioD of Eligibility
Call ("99) 892 4912 00lID 455-4236 or (775) 352-6900
to verify eligibility for Plan benefits before the charge is incurred
Medical Benefits
Note: The following non-emer~encv services must be pre-certified or
reimbursement from the Plan will be reduced:
.
.
.
.
.
.
.
\r .
.
.
.
.
Hospitalizations;
MRI (on second or subsequent tests per year, eKe..nlteB ordered
dYriBg BR -Asit)
CT/CA T 8eaBB;
8ubstaRee AbuselMeDtal Disorder Treatmeats (exeept the first
three visits per Calelldai- Year);
Skilled Nursing Facility stays;
Home Health Care;
Hospiee Care;
Durable Medical Equipment exceeding $3.000;
Physical, Speeeh aOOIor Oeeupational 'I11ef8py;
Carwae R-eha9ilitatiOB Thempy;
Outpatient Surgical Procedures performed in an ambulatory
surgical center. hospital. or free-standing surgical center; and
Prosthetics.
Please see the Medical Management section in this booklet for details.
Participating Provider Organization (PPO)
This Plan has entered into an agreement with certain Hospitals, Physicians and other
health care providers, which are called Participating Providers. Because these
Participating Providers have agreed to charge reduced fees to persons covered under the
Plan, the Plan can afford to reimburse a higher percentage of their fees.
Therefore, when a Covered Person uses a Participating Provider, that Covered Person
will receive a higher payment from the Plan than when a Non-Participating Provider is
used. It is the Covered Person's choice as to which Provider to use.
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The District will reimburse the following providers, who currently are not participants in
the self-insured plan preferred provider organizatio~ as if they were participants in the
self-insured plan preferred provider organi7.ation:
Page 16 of95
Jose A irre, MD
Catherine Aisner, PhD'J .
Ma ie Che MD
Ton Cruz
Thomas Dicke , MFCC
Timoth Do Ie, MD
Lee Van E s, MD
William Everts, MD
Robert Flie ler, MD
Ron Gemberlin , MD
Colleen Carr Hurwitz, MA
Ned Jaleel, MD
M. Mack, Chiro ractor
Practice
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Additional information about this option, as well as a list of Participating Providers will
be given to covered Employees and updated as needed.
Members who use a non-network Physician will need to file their own claim and make
sure treatment is approved by the applicable Cost Management Services.
Members who use a non-network provider for large claims may receive a negotiated
discount to reduce claims costs. as?re their aRt afpaeket eKpeases rellu0es by a ..",J
00mpaay the Distriet e9Btraets ".'lith tEl leElRee aut af setwark elaims eests. This eempaBY
is refefi'es tEl as a "Sileat PP.Q". The "SHE PP.Q" pJlegraBl aegatiates eifeedy with the
aRt of BeWlark pl8vftler 16 reduee the amaRBt billetl. The Participant is not responsible
for any negotiated discount obtained. however charges will be paid at the non-PPO
benefit level. 'Nrite off aegariateEl by tile Silest PPO. The serviees aegetiateEl by the
Sileat PPO are eeasidefeEl BOB aetwerk Pf6'\iSefS \lBEler this PlaB, therefefe, the e~Vleres
member is respeasible for pre wlHmeat appfaval fer kespHal admi59iees 8ft<! IM'gery
eutsie:le the PllysieiaB's affiee.
Allowable Covered Expenses
All medical benefits are subject to allowable covered expense guidelines. Network
providers have agreed to negotiated rates a set fee selleEkHe. Members are not
responsible for expenses over the negotiated rates seI1eElules ameum for covered services.
Members are responsible for any applicable co-pays, deductibles, and coinsurance. For
non-network providers, the allowable covered expense is determined by usual and
customary charge guidelines. The usual and customary charge for each service or supply
received will be the lesser of the fee usually charged by a provider and the fee usually
charged by other providers in the same geographical area (Tahoe, Reno, Sacramento) for
these services and supplies.
When Participants utilize the services of a PPO network facility, such as hospital,
emergency room, and/or diagnostic medical imaging facility, for which there are no
network physicians, benefits will be paid at the higher PPO benefit leveL Additionally,
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Page 17 of 95
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in the event an employee is required to utilize a non-network facility due to medical
necessity ~ when there is no availability at a comparable network facility, benefits will be
paid at the higher PPO benefit level.
Deductibles/Co-Pavments Pavable bv Plan Participants
Deductibles and Co-Payments
Deductibles and co-payments are dollar amounts that the Covered Person must pay
before the Plan pays.
A deductible is an amount of money that is paid once a Calendar Year per Covered
Person. Typically~ there is one deductible amount per Plan and it must be paid before any
money is paid by the Plan for any covered service. This is an amount of covered charges
for which no benefits will be paid. Before benefits can be paid in a Calendar Y ear~ a
Covered Person must meet the deductible shown below. Each January 1st, a new
deductible amount is required. Deductibles do not accrue toward the 100% maximum
out-of-pocket payment.
A co-payment is a smaller amount of money that. is paid each time a particular service is
used. Typically~ there may be co-payments on some services and other services will not
have any co-payments. Co-payments do not accrue toward the 100% maximum out-of-
pocket payment.
Deductible Three-Month Carryover
Covered expenses incurred in, and applied toward the deductible in October, November
and December will be applied toward the deductible in the next Calendar Year.
Family Unit Limit
When the dollar amount shown in this Schedule of Benefits has been incurred by
members of a Family Unit toward their Calendar Year deductibles~ the deductibles of all
members of that Family Unit will be considered satisfied for that year.
Deductible for a Common Accident
This provision applies when two or more Covered Persons in a Family Unit are injured in
the same accident. These persons need not meet separate deductibles for treatment of
injuries incurred in this accident; instead, only one deductible for the Calendar Year in
which the accident occurred will be required for them as a unit.
Page 18 of95
Incentives for Wellness Program
Plan participants are encouraged to participate in the recommended Wellness Program
outlined in this Plan Document with the goal of prevention and/or early detection of
potential illnesses. Different Deductibles, Co.Pays, and Out of Pocket Maximums shall
apply to Plan Participants who follow the Wellness Program guidelines than to those who
do not follow the Wellness Program guidelines, as follows:
J
Out of Pocket
Deductible Co-Pay Maximum
Wellness Program PPO: $1000 Single
Guidelines $100 Single $2000 Family
Followed $200 Family $10 per office visit Non-PPO:
$1500 Single
$3000 Familv
Wellness Program PPO: $2000 Single
Guidelines Not $250 Single $4000 Family
Followed $500 Single + 1 $20 per office visit Non-PPO:
$750 Family $3000 Single
(See Note below) $6000 Family
Note: If the employee and all eligible dependents comprising the Family Unit, fail to
participate in the recommended annual wellness testing program, the Family Unit's
annual co-pays, deductibles, and out of pocket maximum will be increased for the
subsequent year.
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The Calendar Year Deductible is waived for Second Surgical Opinions.
Maximum Out.of-Pocket Payments, per Calendar Year
The Plan will pay the percentage of covered charges designated in the Schedule of
Benefits until the above amounts of out-of-pocket payments are reached, at which time
the Plan will pay 100% of the remainder of covered charges for the rest of the Calendar
Year, unless stated otherwise.
The charges for the following do not apply to the 100% benefit limit and are never paid at
100%
. Deductible(s)
. Outpatient mental treatment charges
. Outpatient substance abuse treatment charges
. Cost containment penalties
. Co-payments
Medical Benefits
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Page 19 of95
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Medical Benefits apply when covered charges are incurred by a Covered Person for care
of an Injury or Sickness and while the person is covered for these benefits under the Plan.
Benefit Payment
Each Calendar Year, benefits will be paid for the covered charges of a Covered Person.
Payment will be made at the rate shown under Percentage Payable in the Schedule of
Benefits. No benefits will be paid in excess of the Maximum Benefit Amount or the
"Benefit Limits" of the Plan.
Maximum Benefit Amounts
The Maximum Benefit Amount is shown in the Schedule of Benefits. It is the total
amount of benefits that will be paid under the Plan for all covered charges incurred by a
Covered Person
Lifetime, while covered .... ...... ............................ ........... ...... .......... .... ......... ......$2,000,000
There are other maximums on individual benefits. These follow under Benefit Limits.
Schedule of Benefits
% Co-Pay Co-Payor
Benefit Payable % Payable or Co-Ins Co-Ins
Benefit Type Limits PPO Non-PPO PPO NonPPO
Acupuncture! 52 visits 90% 70% 10% 30%
combined
with
chiropractic
Ambulance:l Per trip 90% 90% 10% 10%
max
ChiropracticJ 52 visits 90% 70% $10 30%
combined
with
acupuncture
Durable Medical 90% 70% 10% 30%
Equipment4
Emergency Room' 90% 70% $50/10% 30%
Home Health Careo 100 visits 900J'o 700fo 10% 30%
per year
Hospice Care I $15,000 per 90% 700fo 1 OOJ'o 300.10
lifetime
Hospital CarelServices6 90% 70% 10% 30%
Immunizations'J 100% 700fo $10 30%
Page 20 of 95
% eO-Pay . Co-Payor
Benefit Payable % Payable or Co-Ins Co-Ins
Benefit TYDe Limits PPO Non-PPO PPO NonPPO
Injury to or Care of 90% 70% l00A. 30%
Mouth, Teeth & Gums10
Mastectomyll 90% 7 WA>> 10% 30%
Mental Health- 30 dayslyr 90% 70% l00A. 30%
Inpatientl2
Mental Health-Outotll 100% 70% $10 30%
Occupational Therapyl-' $1,500/yr 90% 70% 10% 30%
Or~an Transplantl4 100% 70% $10 30%
Other Medical Services 90% 70% lOOA. 30%
& Supplies1S
Out of Area Medical 800,10 80% 200,10 200,10
Emer~encies
Outpatient Care & 90% 70% 100,10 30%
Services
Physical TherapylO $1,500/yr 90% 70% 10% 30%
Physician 90% 70% 10% 30%
CarelServices17
Physician's Office 100% 70% $10 30%
Visitl8
Pregnancy-Employee, 90% 70% 10% 30%
Spouse or Covered
Childl9
ProstheticslOrthoticszu 90% 70% 10% 30%
Wellness Program Care 100% SOOA. -0- 200,10
(See Wellness Program
Guidelines)
Child Wellness Program 100% 80% -0- 20%
Care (See Wellness Program
Guidelines )21
Wellness Program 100% 80% -0- 200,10
Testing (See Wellness
Program GUideIineS)21
Second Surgical 100% 100% -0- -0-
Opinion22
Skill~l~ursing 100 days 90% 70% 10% 30%
Facilit 3
Substance Abuse $20,000 90% 70% 10% 30%
Treatment-Inpatien~ lifetime
Substance Abuse Included 100% 70% up to $75 $10 30%
Treatement-Outof4 Above
Ur~ent Care Center 100% 70% $10 300,10
Page 21 of95
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Covered Charges
Covered charges are the Usual and Reasonable Charges that are incurred for the
following items of service and supply. These charges are subject to the "Benefit Limits"
of this Plan. A charge is incurred on the date that the service or supply is performed or
furnished.
WeUness Program Guidelines
Plan Participants are encouraged to be proactive in seeking out medical testing and
wellness information for the prevention and early diagnosis of potential illnesses. It is
the Plan Participant's responsibility to meet the Wellness Program Guidelines in order to
qualify for the lower co-pays, deductibles, and out of pocket maximums. The Wellness
Program's two-tier structure will become effective January 1,2008. There is no change
to current benefit levels prior to that date.
Well care and wellness testing will be paid at 100% for PPO providers and at 80% for
non-PPO providers, and will not be subject to the annual deductible. If a participant's
physician recommends a more frequent exam and/or testing than the frequency described
herein, due to medical history or physical e~ such extra exams and/or testing will not
be paid at 100%, but will be paid at the applicable PPO or Non-PPO benefit level for
regular medical care. If a participant's physician states that due to health history and/or
exam, a particular test or exam is not needed as :frequently as is indicated herein, the
participant must have the physician put such recommendation in writing and submit it to
the Plan's Claims Administrator no later than the last day of the Calendar Year, so that
there is no reduction in benefits for the following year.
Benefit levels for new employees hired between January 1st and June 30th, and their
dependents, or new Adult Dependents, will be at the lower deductibles, co-pays, and out-
of pocket maximums until January 1st of the following year. During this time, the
employee and/or their dependents must meet the Wellness Program Guidelines. Benefit
levels for new employees hired between July 1st and December 31 st, and their dependents
or new Adult Dependents, will be at the lower deductibles, co-pays, and out-of-pocket
maximum until January 1 st following their one-year anniversary. During this time period,
the employee and/or their dependents must meet the Wellness Program Guidelines. Any
new employees and/or their dependents failing to meet the deadlines as stated above, will
then be subject to the higher deductibles, co-pays, and out-of pocket maximums for the
subsequent calendar year.
The annual/bi-annual physical exams that are cmrently required for employees
possessing a commercial license and/or who wear respirators, will be replaced by the full
physical exams that are part of the Wellness Program Guidelines.
The table below summarizes the We11ness Progmm Guidelines that are to be followed in
order to qualify for the lower deductible, co-pay and out of pocket maximums:
Page 22 of 95
Wellness Prolmlm Guidelines
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Child WeOness Guidelines
Children through 18 years of age shall receive a minimum of one annual physical exam,
and young children may receive more than one well-child ex~ up to the Frequency
Limits listed below. Benefit is payable at 100% with no deductible or co-pay for PPO
Providers and 80010 payable for non-PPO providers. Coverage includes the following
routine services, as recommended by the physician:
1. Physical Exam
2. Laboratory blood tests
3. Urinalysis
4. X-rays
5. Immunizations (See Immunization Requirements, below)
WeD Child Care
Calendar Year
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Child Immunization Reauirements
(Per CB.FeBt 2006 CDC Recommendations
Immunization 18t Dose 2Da Dose 3ra Dose 4m DoselBooster
Diptheria, 2 months 4 months 6 months Between 15 and 18 months. Can
Tetanus, Pertussis be given as early as 12 months
(DTPIDTaP) as long as 6 months have passed
since third dose. Fourth dose
should be given at the latest
between 4-6 years.
Tetanus and If If If 11-18 years: One booster dose if
Diptheria (Td) previously previously previously the child has completed the
completed completed completed DTPIDTaP series and has not yet
received a booster for any
reason.
Hepatitis A 12 months 23 months Nla
(Hep A)
Given at least 6
months apart
Hepatitis B Birth 1-2 months 6-18 2-18 years: Three dose series
(Hep B) months given to all children under 18
who didn't get the vaccine as
infants
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Page 23 of 95
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Immunization lit Dose 280 Dose 3nl Dose 418 DoseJBooster
H. influenzae type 2 months 4 months 6 months
b (Rib) or between
12-15
months
MeaslesIMumps, Between One month N/a Second dose is typically given
Rubella (MMR) 12-15 after fll'St between 4-6 years, and should
months dose be given by 11-12 years at the
lastest.
Pneumococcus 2 months 4 months 6 months 12-15 months
(PCV7)
Chickenpox 12-24 N/a N/a Can be given up to age 13 in a
(Varicella, Var) months child who has not contracted
chickenpox
Rotavirus (RV) 2-3 months 4-10 weeks 6-8 months All three doses should be given
after the no later than 8 months.
first dose
Polio (IPV) 2 months 4 months Between 6- Between 4-6 years
Injectable Polio 18 months
Vaccine
Meningococcal Age 13-15 Age 18
Ad ItW Un P
G od liD
u e ess ro !!:ram we es
Exam, Test or Procedure Frequency 18-25 26-39 40-49 50-64 65+
Physical Exam, including
abdomen, breasts, heart, Annually
height, weight, neck, X X X X X
pelvic, rectal, testicles &
groin, vision/color,
hearing (forced whisper)
Blood Pressure Annually X X X X X
Rectal Exam Annually X X X X X
Rectal Exam of Prostate Annually X X X
Hemoccult (Stool occult Annually X X X
blood)
Blood Test & Urinalysis Every 5 years X X
Fasting chemistry panel Every 2 years X
Annually X X
Complete Lipid Profile Every 3 Years X X
Thyroid-Stimulating Every 3 years X X
Hormone (TSH)
TB Skin/Quantiferon Test Every 5 years X X X X X
Page 24 of 95
, "
Exam. Test or Procedure FrequeKY 18--25 26-39 40-49 50-64 65+
Baseline Age 30
EKG Every 4 years X
Every 3 years X X
Colonoscopy Every 10 years X X
Bone Mineral Density
Test Every 3 yrs post X X
Women menopausal
Men At least One X
Women Only
Pap/Pelvic Annually X To 30
Every 2 years 31+ X X
Mammogram Baseline 35-39
Every 2 years X
Annually X X
HPV immunization series Ages 19-26 X To 26
Men Only
PSA Blood Test Annually X X
Testicles & Groin Exam Every 3 years X X
Adult Immunization Guidelines
an accordance with Cal'feBt 2006 CDC Recommendations)
Immunization Frequency or Booster
Diptheria & Tetanus Toxoid Every 10 years at 30, 40, 50, 60, etc
Influenza (flu) Annually if over 65
Pneumovax (pneumonia shot) Once over age 65
Page 25 of 95
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Notes for Schedule of Benefits
Benefit Descriptions & Benefit Limits
1.
Acupuncture: PPO is payable at 900A and Non-PPO is payable at 7OOA, up to a
maximum of 52 visits per Calendar Year, combined with Chiropractic services.
2.
Ambulance: Covered Charges are for local Medically Necessary professional
land or air ambulance service. A charge for this item will be a Covered Charge
only if the service is to the nearest Hospital or Skilled Nursing Facility where
necessary treatment can be provided, or the transfer from a non-PPO hospital to a
PPO hospital. if approved by Universal Health Network. l>ut iB &:BY eveRt, Be
more tlteB SO miles from the plaee sf piekup, UBless 1M PIaB .A..ElsHBistfater fiftds
a loager trip ~1:8B Medieally Neeessary. ;\selaBee Seniee is limited to the
U8U8:l8Be! ReeseBableGftafge per Trip. The Per Trip Maximum for Ambulance
Services is paid at 90% subjeet to tile tJeual &:Be! R-ea58B:aMe Charge.
3.
Chiropractic: PPO is payable at 90% and non-PPO is payable at 70% up to a
maximum of 52 visits per Calendar Year, combined with Acupuncture services.
Spinal manipulation/Chiropractic services will be paid as shown in the Schedule
of Benefits, but does not include massage therapy.
4.
Durable Medical Equipment: Covered charges include rental of durable
medical or surgical equipment if deemed Medically Necessary up to the amount
of purchase price. These items may be bought rather than rented, but only if
agreed to in advance by the Plan Administrator.
5.
Emergency Room: If emergeaey e8fe is a_eEl, ge te tile Be8fest medieel
faeility. CS~Ief8ge fer emergeaey eare is a"l8ilable 7 days a week, 24 haUlS a day.
For Non-Emergency visits to the Emergency Room, a $50 co-pay will be charged
in addition to the regular Calendar Year deductible before benefits are paid at
either 90% (PPO) or 700Al (Non-PPO). For Emergency visits, or if the Covered
Person is admitted directly from the emergency room to the Hospital because of a
Medical Emergency, this $50 co-payment will be waived and the Plan will apply
only the Calendar Year deductible before paying benefits at either 90% or 70%.
Medical Emergency means a sudden onset of a condition with acute symptoms
requiring immediate medical care and includes, but is not limited to, such
conditions as heart attacks, cardiovascular accidents, poisonings, loss of
consciousness or respiration, convulsions or other such acute medical conditions.
Home Health Care Services and Supplies: Home Health Care benefits payable
are limited to a Calendar Year maximum of 100 visits.
Charges for home health care services and supplies are covered only for care and
treatment of an Injury or Sickness when Hospital or Skilled Nursing Facility
Page 26 of 95
confmement would otherwise be required. The diagnosis, care and treatment . ..
must be certified by the attending Physician and be contained in a Home Health .."
Care Plan. Benefit payment for nursing, home health aide and therapy services is
subject to the Home Health Care limit shown in the Schedule of Benefits.
A home health care visit will be considered a periodic visit by either a nurse or
therapist, as the case may be, or four hours of home health aide services.
7. Hospice Care Services and Supplies: The Benefit payment Limit for Hospice
Care is limited to $15,000 per Lifetime. Charges for hospice care services and
supplies are covered only when the attending Physician has diagnosed the
Covered Person's condition as being terminal, determined that the person is not
expected to live more than six months, and placed the person under a Hospice
Care Plan.
8. Hospital Care and Services: The Daily Limit for Hospital Room and Board is
the semi~private room rate. The Daily Limit for the Intensive Care Unit is the
Hospital's ICU charge. The Daily Limit for Skilled Nursing Facility is the
facility's Usual and Reasonable Charge, with a maximum number of 100 days
payable per Calendar Year.
Covered charges include the medical services and supplies furnished by a
Hospital or Ambulatory Surgical Center or a Birthing center. Covered charges for
room and board will be payable as shown in the Schedule of Benefits. After 23
observation hours, a confinement will be considered an inpatient confinement.
J
Room charges made by a Hospital having only private rooms will be paid at 80%
of the average private room rate. The 20% coinsurance paid by the Employee
will count toward the out-of-pocket maximum.
9. Immunizations: Immunizations received by a PPO are paid at 1000.10.
Immunizations received from a Non-PPO are payable at 70%.
10. Injury to or Care of Mouth, Teeth and Gums: Charges for injury to or care of
the mouth, ~ gums and alveolar processes will be covered charges under
Medical Benefits only if that care is for the following oral surgical procedures:
A. Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and
floor of the mouth.
B. Emergency repair due to Injury to sound natural teeth. This repair must be
made within 12 months from the date of an accident and the accident must
have occwred while the person was covered under the Plan.
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Page 27 of 95
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c.
Surgery needed to correct accidental injuries to the jaws, cheeks, lips,
tongue floor and roof of the mouth when the Injuries occurred while
covered under the Plan.
D. Excision of benign bony growths of the jaw and bard palate.
E. External incision and drainage of cellulitis.
F. Incision of sensory sinuses, salivary glands or ducts.
G. Removal of impacted teeth.
No charge will be covered under Medical Benefits for dental and oral surgical
procedures involving orthodontic care of the teeth, periodontal disease and
preparing the mouth for the fitting of or continued use of dentures.
11. Women's Health and Cancer Rights Act. Under the Women's Health and
Cancer Rights Act, a group health plan participant or beneficiary who is receiving
benefits in connection with a mastectomy, and who elects breast reconstruction in
connection with the mastectomy is entitled to coverage for the following:
\.,
A.
Reconstruction of the breast on which the mastectomy has been
performed;
B. Surgery and reconstruction of the other breast to produce a symmetrical
appearance; and
c. Prostheses and treatment of physical complications at all stages of
mastectomy, including lymphedemas.
Coverage for these benefits Of services will be provided in a manner determined
in consultation with the participant's attending physician. Additionally, coverage
for the mastectomy-related benefits or services required under the Women's
Health Law will be subject to the same deductibles and coinsurance or co-
payment provisions that apply with respect to other medical or surgical benefits
provided under the group medical plan.
Your rights to benefits in this Plan are subject to amendment, modification, or
termination in accordance with the Plan Eligibility and Participation Section of
this Plan, and the applicable provisions. Any amendment, modification or
termination of a Program will also be an amendment, modification or termination
of this Plan.
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12. Mental Health Inpatient and Outpatient: Covered charges for care and
treatment of Mental Disorders will be limited as follows:
Page 28 of 95
A. All treatment is subject to the benefit payment maximums shown in the
Schedule of Benefits.
B. Physician's visits are limited to one treatment per day.
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C. Psychiatrists (.M.D.), psychologists (ph.D) or counselors (MFCC, LCSW)
may bill the Plan directly. Other licensed mental health practitioners must
bill the Plan through these professionals. Inpatient Mental Health - PPO
or Non-PPO is limited to 30 days per Calendar year and 60 days per
lifetime.
D. Outpatient mental health co-payment is applied per office visit. Non-PPO
outpatient treatment is limited to 66 visits per Calendar Year. Outpatient
charges for Mental Disorders will not be counted in accumulating covered
charges toward the 100% payment percentage of other charges, nor will
outpatient charges be subject to the lOOO!c. payment.
13. Occupational Therapy: Benefit payable is limited to $1,500 per Calendar Year.
Covered charges include occupational therapy performed by a licensed
occupational therapist. Therapy must be ordered by a Physician, result from an
Injury or Sickness that occurred while covered under the Plan and improve a body
function. Covered expenses do not include recreational programs, maintenance
therapy or supplies used in occupational therapy. .J
14. Organ Transplant - Covered Transplant Procedures:
Organ and tissue transplants are covered except those which are classified as
"Experimental and/or Investigational". Percentage payable in a network facility
is 1 00%. Percentage Payable in a Non-Network Facility is 70% with an
Unlimited Maximum Out-Of-Pocket.
Charges for the reasonable travel expenses of the Covered Person's immediate
family to the designated transplant facility will be covered when pre..authorized,
up to a maximum of $10,000 per transplant.
OrRan TransDlant Covetalle Limits
Charges otherwise covered under the Plan that are incurred for the care and
treatment due to an organ or tissue transplant are subject to these limits:
A. Charges made by a Hospital or a Physician's fee for organ transplants are
treated as covered charges when incurred as a recipient only, except as
provided below.
B.
Covered charges will be paid at lOOO!c. for transplants done at a designated
transplant facility. Covered charges for transplants performed at a non-
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Page 29 of95
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network facility will be paid at 700fct and such non-network charges are
subject to an unlimited maximum out-of-pocket limit
c.
Charges made by a Hospital or a physician's fee for a donor will be paid at
100% if the organ transplant is performed at a designated transplant
facility and such charges are pre-authorized. When the donor bas medical
coverage, his or her plan will pay first. The benefits under this Plan will
be reduced by those payable under the donor's plan. Donor charges
include those for:
. Evaluating the organ;
. Removing the organ from the donor; and
. Transportation of the organ from within the United States and Canada
to the place where the transplant is to take place.
D. The Plan covers a Covered Person's charges as a donor, only when the
recipient is either an immediate family member of the Covered Person, or
is also a Covered Person. Immediate family is defined as mother, father,
natural or adopted child, grandparent, grandchild, brother or sister. Such
donor charges will be paid at 100% if the organ transplant is done at a
designated transplant facility and such charges are pre-authorized by
Hometown Health Providers.
~
15. Other Medical Services and Supplies: These services and supplies not
otherwise included in the items above are covered as follows:
A. Anesthetic; oxygen; blood and blood derivatives that are not donated or
replaced; intravenous injections and solutions. Administration of these
items is included.
B. Cardiac rehabilitation as deemed Medically Necessary provided services
are rendered (a) under the supervision of a Physician; (b) in connection
with a myocardial infarction, coronary occlusion or coronary bypass
surgery; (c) initiated within 12 weeks after other treatment for the medical
condition ends; and (d) in a Medical Care Facility as defined by this Plan.
C. Radiation or Chemotherapy and treatment with radioactive substances.
The materials and services of technicians are included.
D. Initial contaet lenses or glasses required following cataract surgery.
E. Laboratory Studies
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F.
Prescription Drugs (as defined).
Page 30 of 95
G.
Private. Duty Nundng Care. The private duty nursing care by a licensed
nurse (R.N., L.P.N., or L.V.N.). Covered charges for this service will be
included to this extent:
J
. Inpatient Nuning Care. Charges are covered only when care is
Medically Necessary or not Custodial in nature and the Hospital' s
Intensive Care Unit is filled or the Hospital has no Intensive Care Unit.
. Outpatient Nursing Care. The only charges covered for Outpatient
nursing care are those shown below, under Home Health Care Services
and Supplies. Outpatient private duty nursing care on a shift-basis is
not covered.
. Smoking Cessation. Costs for medically supervised classes and/or
cessation supplies to a maximum of three programs per participant
lifetime. Proof of mandatory attendance shall be provided to the
Claims Administrator (firsT- :\4miBiMtem).
H.
Speech Therapy by a licensed speech therapist. Therapy must be ordered
by a Physician and follow either: (i) surgery for correction of a
congenital condition of the oral cavity, throat or nasal complex (other than
a frenectomy) of a person born while covered under the Plan; (ll) an
Injwy; or (iii) a Sickness that is other than a learning or Mental Disorder.
J
I. Sterilization procedures.
J. Surgical dressings, splints, casts and other devices used in the reduction
of fractures and dislocations.
K. Diagnostic x-rays.
16. Physical Therapy: Covered charges are for physical therapy by a licensed
physical therapist. The therapy must be in accordance with a Physician's exact
orders as to type, frequency and dmation and to improve a body function. If
recommended and prescribed by a Physician due to Medical Necessity as a result
of serious illness, physical therapy performed by a certified exercise trainer may
be payable upon written request to the Plan Administrator.
Physical Therapy benefits payable are limited to $1,500 per Calendar Year.
Physical Therapy Annual Maximum may be extended to a maximum of $2,400
per Calendar Year due to lumbar or cervical spinal stenosis, if Physical Therapy
benefits are used in lieu of Occupational Therapy benefits.
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Page 31 of95
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Physical Therapy Annual Maximum may be extended to a maximum of 20 visits
up to $1,725.00 per Calendar Year when medically necessary and pre-authorized
by HHP, for the treatment of chrondromalacia patellae.
Physical Therapy Annual Maximum may be extended to a maximum of $3,000
per year due to anterior lumbar discectomy and interbody fusion followed by
posterior decompression and fusion with instrumentatio~ when medically
necessary and pre-approved hy HHP, if Physical Therapy benefits are used in lieu
of Occupational Therapy benefits.
17. Physician Care. The professional services of a Physician for surgical or medical
services. Covered charges for Physician Care and Services includes services
received in office; other than office visit charge, Inpatient ServiceslTreatment,
Outpatient Serviceslfreatment and Surgical ServiceslProcedures.
18. Physician's Office Visit: Co-pay applies to Physician's Office Visit only. All
other services provided in physician's office are payable at 90% after satisfying
deductible, unless specified elsewhere in the Plan. The Plan covers only one
office visit charge per visit to the physician's office.
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19. Pregnancy Benefits: For Normal Delivery - 48 hour inpatient hospital stay is
approved. For Caesarean Section: 96-hour inpatient hospital stay is approved. A
shorter length of stay may be approved if the decision is made by participant and
attending physician. The Usual and Reasonable Charges for the care and
treatment of Pregnancy are covered the same as any other Sickness for covered
Employee, covered Spouse or Dependent child.
Group health plans and health insurance issuers offering group insurance
coverage genera1ly may not, under Federal law (the Newborns' and Mothers'
Health Protection Act of 1996 (NMHPA)) restrict benefits for any hospital length
of stay in connection with childbirth for the mother or newborn child to less than
48 hours following a normal vaginal delivery, or less than 96 hours following a
caesarean section, or require that a provider obtain authorization from the plan or
the insurance issuer for prescribing a length of stay not in excess of the above
periods.
20. Prosthetics/Orthotics: Benefits are payable for covered charges for the initial
purchase, fitting, repair and replacement of fitted prosthetic devices which replace
body parts or for the initial pmchase, fitting, repair and replacement of orthotic
appliances such as braces, splints or other appliances which are required for
support for an injured or deformed part of the body as a result of a disabling
congenital condition or an Injury or Sickness that occurred while covered under
the Plan.
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21. Charges for ChDd WeDness Program Care. Routine well newborn nursery care
is room, board and other normal care for which a Hospital makes a charge.
Page 32 of95
The Usual and Reasonable Charge made by the Hospital for routine nursery care ..,J
provided as shown below after the newborn child's birth will be considered as
covered charges under the Plan.
This coverage is only provided if a parent is a Covered Person who was covered
under the Plan at the termination of the Pregnancy and the newborn child is an
eligible Dependent and is neither injured nor ill.
Charges for Wellness Program Care. The benefit is limited to the Usual and
Reasonable Charges made by a Physician for the first pediatric visit to the
newborn child after birth while Hospital confined.
22. Second Surgical Opinion: Deductible is waived and benefit is payable at 100%
for second surgical opinion.
23. Skilled Nursing Facility Care. The room and board and nursing care furnished
by a Skilled Nursing Facility will be payable if and when:
a The patient is confined as a bed patient in the facility;
b. The attending Physician certifies that the confinement is needed for further
care of the condition that caused the Hospital confinement; and
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c. The attending Physician completes a treatment plan which includes a
diagnosis, the proposed course of treatment and the projected date of
discharge from the Skilled Nursing Facility.
d. Covered charges for a Covered Person's care in these facilities is limited
to the covered daily charge limit shown in the Schedule of Benefits and
for other charges incurred for necessary medical care on a day for which
Room and Board benefits are payable.
Covered services are limited to the first 100 days of confinement each Calendar
Year.
24. Substance Abuse Inpatient and Outpatient:
Covered charges for care and treatment of Substance Abuse will be limited as
follows:
a. All treatment is subject to the benefit payment maximums shown in the
Schedule of Benefits.
b. Physician's visits are limited to one treatment per day.
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Page 33 of95
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c. Psychiatrists (M.D.), psychologists (ph.D) or counselors (MFCC, LCSW)
may bill the Plan directly. Other licensed mental health practitioners must
bill the Plan through these professionals.
d. Inpatient Substance Abuse Treatment limited to $10,000 maximum per
Calendar Year, for PPO and Non-PPO. Lifetime maximum for inpatient
and outpatient Substance Abuse treatment combined is $20,000.
e. Outpatient Substance Abuse Treatment is paid at 100% after $10 co-pay
for PPO, and limited to $10,000 maximum per Calendar Year for PPO or
Non-PPO. Non-PPO outpatient Substance Abuse Treatment is paid at
70% up to a maximum of $75 per visit. Outpatient charges for Substance
Abuse will not be counted in accumulating covered charges toward the
100% payment percentage of other charges, nor will Non-PPO outpatient
charges be subject to the 100% payment.
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Page 34 of 95
Prescription Drat! Benefit
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In an effort to reduce the costs of the prescription drug plan, effective January 1,
2007, the following changes will be implemented to the Prescription Drug Plan,
so that Plan Participants can have control over how much they spend on
prescription medications, thereby assisting the Plan in controlling costs as well.
Pharmacy Drug Charge
Participating pharmacies have contracted with the Plan to charge Covered Persons
reduced fees for covered Prescription Drugs. PhanBaCare Maaagemen.t Servioes,
IDe:, Catalyst RX is the administrator of the pharmacy drug plan effective January
1. 2008.
Co-Payment
The co-payment is applied to each covered pharmacy drug charge and is shown in
the Prescription Drug Plan Schedule of Benefits. The co-payment amount is not a
covered charge under the Medical Plan. Anyone prescription is limited to the
greater of a 30-day supply or a l00-writ dose.
If a drug is purchased from a non-participating pharmacy, or a participating
pharmacy when the Covered Person's ID card is not used, the amount payable in
excess of the co-payment will be the ingredient cost and dispensing fee.
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Mail Order Drug Benefit Option
The mail order drug benefit option is available for maintenance medications
(those that are taken for long periods of time, such as drugs sometimes prescribed
for heart disease, high blood pressure, asthma, etc). Because of volume buying,
PhermaCare Ma8agemeBt SetViees, me., ill ees.jUBetiOB with PhermaC8fe Difeet,
the mail order pharmacy, is able to offer Covered Persons significant savings on
their prescriptions.
Co-Payment
The co-payment is applied to each covered mail order prescription charge and is
shown in the Prescription Drug Plan Schedule of Benefits. It is not a covered
charge under the Medical Plan. Anyone prescription is limited to the greater of a
90-day supply or a 300-writ dose.
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Page 35 of95
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Prescription Drug Benefit
Schedule of Benefits
Brand Name
when no generic
available, or
when noted
Bledieally
Deeessary
Purchase Generic Brand Name "Dispense as
Location (Generic Available) Written" for
Brand Name
Retail Pharmacy
See Note (1) $5.00 $45.00 $5.00
Mail Service for
Maintenance
Medication (See $10.00 $75.00 $10.00
Note (2)
Retail Pharmacy
for Maintenance $20.00 $75.00 $20.00
Medication
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Notes:
(1)
(2)
Retail Pharmacy is for short-term use; l00-unit dose or 30 day supply
or if prescription is unavailable by mail service
Maintenance Medication is a 90 day supply or a 300 unit dose, is taken
longer than 60 days for a long term or chronic condition, and is
purchased through the mail order service. A maintenance medication
does not require frequent dosage adjustments, and is prescribed to treat
a long-term condition such as birth control or chronic condition such
as arthritis, diabetes and/or high blood pressure. Ask your physician if
you will be taking a prescribed medication longer than 60 days. If you
purchase a maintenance medication at a retail pharmacy after the
second (2~ fill, you will be charged the applicable Retail Pharmacy
Maintenance Service co-payment described above for the usual 30
day, 100 unit dose retail prescription.
Covered Prescription Drugs
1.
-.
All drugs prescribed by a Physician that require a prescription either by
federal or state law, except injectables. The following injectables will be
covered: Insulin, Imitrex, Glucagon, Copaxin for multiple sclerosis,
Enbrel for the treatment of psoriasis and/or rheumatoid arthritis, Injectable
DHE for migraines, injectable Depo- Testosterone and prescribed Bee
Sting Kits for allergic Covered Persons.
Page 36 of 95
2.
All compounded prescriptions containing at least one prescription
ingredient in a therapeutic quantity.
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3. Insulin when prescribed by a Physician.
4. Retin-A, when Medically Necessary for persons over the age of 19.
5. Gleevec for treatment of Chronic Myeloid Leukemia (CML).
6. Ritalin for treatment of Narcolepsy.
7. Strattera, when Medically Necessary for persons over the age of 19, for
the diagnosis of Attention Deficit Disorder.
Limits to this Benefit
This benefit applies only when a Covered Person incurs a covered Prescription
Drug charge. The covered drug charge for anyone prescription will be limited to:
1. Refills only up to the number of times specified by a Physician.
2.
Refills up to one year from the date of order by a Physician.
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Expenses Not Covered
This benefit will not cover a charge for any of the following:
1. A charge excluded under Medical Plan Exclusions.
2. A drug or medicine that can legally be bought without a written
prescription. This does not apply to injectable insulin.
3. Devices of any type, even though such devices may require a prescription.
These include (but are not limited to) therapeutic devices, artificial
appliances, braces, support garments, or any similar device.
4. Immunization agents or biological sera.
5. A drug or medicine labeled: "Caution -limited by federal law to
investigational use".
6. Experimental drugs and medicines, even though a charge is made to the
Covered Person.
7.
Any charge for the administration of a covered Prescription Drug.
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Page 37 of 95
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8.
Any drug or medicine that is consumed or administered at the place where
it is dispensed,
9. A drug or medicine that is to be taken by the Covered Person, in whole or
in part, while Hospital confined. This includes being confined in any
institution that has a facility for the dispensing of drugs and medicines on
its premises.
10. A charge for Prescription Drugs which may be properly received without
charge under local, state, or federal programs.
11. A charge for hypodermic syringes and/or needles, injectables or any
prescription directing administration by injection (other than ins.
Imi1re'4 Glucagon, Copaxin, or prescribed Bee Sting Kits for allergic
Covered Persons).
12. A charge for Prescription Drugs for smoking cessation (i.e., nicotine gum),
except for a medically supervised program including prescription for
Chantix. up to three programs per participant lifetime.
13. A charge for infertility medication.
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14.
A charge for smoking deterrent patches.
15. A charge for Crinone will not be covered, unless prescribed for the
purpose of assisting in the continuation of an existing pregnancy.
New FDA approved drugs are evaluated by our pharmacy benefit management
company. Oversight and final approval are given by the pharmacy benefit
manager and the Plan Administrator. Some drugs may have dispensing limits
which are primarily based on FDA recommendations.
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Page 38 of95
~ntal Benefits
Calendar Year Deductible for Class B (Basic) and Class C (Major) Serviees
Per person............................................................................................................... ..$25 .00
Per FaInily Unit..... ............ ............... ................................ ...................................... ..$50.00
Dental Percentage Payable
Class A Services - Preventive .......................................................100% (No Deductible)
Class B Services - Basic................................................................... 800.10 after deductible
Class C Services - Major .................................................................. 80% after deductible
Participants and their families are encouraged to obtain their routine dental exams and
cleanings twice per year, with the goal of reducing the number of Basic and Major dental
services needed and utilizing the Plan in a cost effective manner. The District's self-
insured plan therefore implements this Preventive Dental Program to provide incentives
to employees to obtain preventive dental care.
P tiv D tiP
reven e en a r02l1lm
Cl:lITeBt 2007 Dental Preventive Dental Program Preventive Dental Program
Benefits Payable Guidelines Followed Guidelines
Not Followed
Preventative (Exam & Preventive - 3 or 4 Oral Minimum of 3 oral exams
Cleaning) Exams & Cleanings every 6- and cleanings not received
Paid at 100%, with No 8 months during the previous during the previous two year
Deductible two-year period (JaR 2Q06 period (JeB 2006 Je 20gB).
J882OO8) Each exam/cleaning paid at
100% with no deductible 100% with no deductible
Basic Dental Services (as Basic Dental Services as Basic Dental Service as
defined below) defined below defined below continued to
,.. .. Paid at 80% Continued to be paid at 80% be paid at 80%
Major Dental Services as If follow above preventive, If preventive not followed
defmed below - elil'fefttly Major dental services will be Major services will be paid at
Paid at 80% paid at 80%. Participants 50%.
with full dentures need only
obtain one oral exam prior to
January 2008 and then one
oral exam per year
thereafter, to qualify for the
80% benefit for Major
servIces.
Page 39 of 95
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Exams and cleanings will be an on-going requirement in order to maintain the 8001'0 rate
for Major dental work.
New hires only: No benefits are payable for Class C (Major) Services in the first 12
months of the Covered Person's coverage under the Plan.
Maximum Benefit Amount
Per Person per Calendar Year ..................................................................................$2,000
This benefit applies when covered dental charges are incurred by a person while covered
under this Plan.
Deductible
Deductible Amount: This is an amount of dental charges for which no benefits will be
paid. Before benefits can be paid in a Calendar Year, a Covered Person must meet the
deductible shown in the Schedule of Benefits.
Family Unit Limit: When the dollar amount shown in the Schedule of Benefits has been
incurred by members of a Family Unit toward their Calendar Year deductibles, the
deductibles of all members of that Family Unit will be considered satisfied for that year.
Benefit Payment
Each Calendar Year benefits will be paid to a Covered Person for the dental charges in
excess of the deductible. Payment will be made at the rate shown under Dental
Percentage Payable in the Schedule of Benefits. No benefits will be paid in excess of the
Maximum Benefit Amount.
Dental Charges
Dental charges are the Usual, Customary and Reasonable Charges made by a Dentist or
other Physician for necessary care, appliances or other dental material listed as a covered
dental service.
A dental charge is incurred on the date the service or supply for which it is made is
performed or furnished. However, there are times when one overall charge is made for
all or part of a course of treatment In this case, the Claims Administrator will apportion
that overall charge to each of the separate visits or treatments. The pro rata charge will
be considered to be incurred as each visit or treatment is completed.
Page 40 of 95
C-overed Dental Serviees
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Class A Services: ................................. Preventive and Diagnostic Dental Procedures
The limits on Class A Services are for routine services. If dental need is present, this
Plan will consider for reimbursement services performed more frequently than the limits
shown.
1. Routine oral exams. This includes the cleaning and scaling of teeth. Limit of two
exams per Covered Person each Calendar Year.
2. One bitewing x-ray series every Calendar Year.
3. One full mouth x-ray every five Calendar Years.
4. One fluoride treatment for covered Dependent children under age 19 each
Calendar Year.
5. Dental sealants for covered Dependent children under age 19.
6.
Space maintainers for covered Dependent children under age 19 to replace
primary teeth.
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7. Emergency palliative treatment for pain.
Class B Serviees: .....................................................................Basie Dental Proeedures
1. Dental x-rays not included in Class A.
2. Oral surgery. Oral surgery is limited to removal of~ preparation of the
mouth for dentures and removal of tooth-generated cysts of less than ~ inch.
3. Periodontics (gum trea1ments)
4. Endodontics (root canals).
5. Extractions. This service includes local anesthesia and routine post-operative
care.
6. Recementing bridges, crowns, or inlays.
7.
Fillings, other than gold.
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Page 41 of95
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8.
General anesthetics, upon demonstration ofMedica1 Necessity.
9. Antibiotic drugs.
Class C Senriees..................................................................... Major Dental Proeedures
1. Gold restorations, including inlays, onlays and foil fillings. The cost of gold
restorations in excess of the cost for amalgam, synthetic porcelain or plastic
materials will be included only when the teeth must be restored with gold.
2. Installation of crowns.
3. Installing precision attachments for removable dentures.
4. Installing partial, full or removable dentures to replace one or more natural teeth
that were extracted while the person was covered for this benefit. This service
also includes all adjustments made during a six-month period following the
installation.
5. Addition of clasp or rest to existing partial removable dentures.
6.
Initial installation of fixed bridgework to replace one or more natural teeth which
were extracted while the person was covered for these benefits. Initial installation
of fixed bridgework will be covered for one or more natural teeth if the adult
permanent teeth are missing due to congenital birth defect.
7. Repair of crowns, bridgework, and removable dentures.
8. Rebasing or relining of removable dentures.
9. Replacing an existing removable partial or full denture or fixed bridgework;
adding teeth to an existing removable partial denture; or SliMing teeth to existing
bridgework to replace newly extracted natural teeth. However, this item will
apply only if one of these tests is met:
A. The replacement or addition of teeth is required because of one or more
natural teeth being extracted after the person is covered under these
benefits.
B.
The existing denture or bridgework was installed at least five years prior
to its replacement and cannot currently be made serviceable. Replacement.
dentures will be allowed earlier than 5 years if deemed medically
necessary due to dental oral health being compromised and the existing
dentures cannot be made serviceable.
Page 42 of 95
c.
The existing denture is of an immediate temporary nature. Further,
replacement by permanent dentures is required and must take place within
12 months from the date the temporary denture was installed.
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10. Night guards are covered for night grinding only. They are not covered for
orthodontics.
Voluntary Predetermination of Benefits
Before starting a dental treatment for which the charge is expected to be $300 or more, a
predetermination of benefits fonn should be submitted.
A regular dental claim form is used for the predetermination of benefits. The covered
Employee fills out the Employee section of the form and then gives the form to the
Dentist. The Dentist must itemize all recommended services and costs and attach all
supporting x-rays to the form.
The Dentist should send the fonn to the Claims Administrator at this address:
FirsTier f..ElmiBilHfatef&, IBe.
P.O. BeI{ 19338
Rime, NV 895 11
(8QG) 892 4912
FaK: (775) 78ft 9ft37
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CDS Group Health
P.O. Box 50190
Sparks. NY 89435-0190
(800) 455-4236
The Claims Administrator will notify the Dentist of the benefits payable under the Plan.
The Covered Person and the Dentist can then decide on the course of treatment, knowing
in advance an estimate of how much the Plan will pay.
Alternate Treatment
Many dental conditions can be treated in more than one way. This Plan has an "alternate
treatment" clause which governs the amount of benefits the Plan will pay for treatments
covered under the Plan. If a patient chooses a more expensive treatment than is needed to
correct a dental problem according to accepted standards of dental practice, the benefit
payment will be based on the cost of the treatment which provides professionally
satisfactory results at the most cost-effective level.
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Page 43 of95
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For example, if a regular amalgam filling is sufficient to restore a tooth to health,
and the patient and the Dentist decide to use a gold filling on any tooth, or a
composite filling on posterior teeth, the Plan wiD base its reimbursement on the
Usual, Customary and Reasonable Charge for an amalgam filling. The patient will
pay the difference in cost.
Exclusions
A charge for the following is not covered:
1. Services that are excluded under Medical Plan Exclusions.
2. Services that, to any extent, are payable under any medical expense benefits of the
Plan.
3. Services which are not included in the list of covered dental services.
4. Crowns for teeth that are restorable by other means or for the purpose of
Periodontal Splinting.
5.
Crowns, fillings or appliances that are used to connect (splint) teeth, or change or
alter the way the teeth meet, including altering the vertical dimension, restoring
the bite (occlusion) or are Cosmetic.
6. Implants, including any appliances and/or crowns which are actually implants and
the surgical insertion or removal of implants and any expense specifically related
to examination for or preparation for implants.
1. Replacement of lost or stolen appliances.
8. Orthodontic treatment and orthognatic surgery
9. Personalization of dentures.
10. Oral hygiene, plaque control programs or dietary instructions.
Page 44 of95
M~I'M'D_ement Serviees
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Medical Management Services Phone Number:
HemetewB Health Pr-ev-iders Universal Health Network/Nevada Preferred Professionals
(800) 336 0123 (800) 776-6959
The patient or family member must call this number to receive certification of certain
Medical Management services. This call must be made at least 48 hours in advance of
services being rendered or within 24 hours after an emergency.
Any reduced reimbunement due to failure to follow medical management
procedures will not accrue toward the 100% maximum out-of-pocket payment.
Utilization Review
Utilization review is a program designed to help ensure that all Covered Persons receive
necessary and appropriate health care while avoiding unnecessary expenses.
It is the Employee's or Covered Person's responsibility to make certain that the
compliance procedures of this program are completed. To minimi7e the risk of reduced
benefits, the Covered Person should contact Medical Management Services to make
certain that the hospital or attending physician has initiated the necessary procedures.
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Also, any prior authorization is not a guarantee of coverage. The Utilization Review
Program is designed to determine whether or not a proposed course of1reatment is
Medically Necessary and appropriate. Benefits under the plan will depend upon the
person's eligibility for coverage and the Plan's limitations and exclusions.
The Program Consists of:
1. Pre-certification of the Medical Necessity for the following non-emergency
services before medical services are provided:
Hospitalizations
MRI (only on 2nd and any subsequent MRI in the calendar year, .L .. . ........ ... T! ~)
CT; C}..T ge&ftB
Home Health Care
";"" I . . , ~_ 4 .t:..~" .~ . 'T_ -,
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. n.
~...
...... . . ..I .
,
Outpatient surgical procedures performed in an ambulatory surgical center. hospital. or free-
standinl! surl!ical center
Durable Medical Equipment exceedinQ $3.000
Continued on next oat!'e
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Page 45 of 95
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. Prosthetics
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2. Retrospective Review of the Medical Necessity of the listed services provided on
an emergency basis;
3. Concurrent Review, based on the admitting diagnosis, of the listed services
requested by the attending Physician; and
4. Certification of Services and planning for discharge from a Medical Care
Facility or cessation of medical treatment
The purpose of the program is to determine:
1. The medical necessity of the care
2. The appropriate location for the care to be provided
3. If admitted to the hospital, the appropriate length of stay.
If a particular course of treatment or medical service is not certified, it means that the
Plan will not consider that course of treatment as appropriate for the maximum
reimbursement under the Plan.
In order to maTimi7.e Plan reimbunement, please read the following provisions
carefully.
Here's How the Program Works:
Pre-Certification
Before a Covered Person enters a Medical Care Facility on a non-emergency basis or
receives other listed medical services, Medical Management Services will, in conjunction
with the attending Physician, certify the care as appropriate for Plan reimbursement A
non-emergency stay in a Medical Care Facility is one that can be scheduled in advance.
The Utilization Review Program is set in motion by a telephone call from the Covered
Person. Contact Medical Management Services at:
HemetowB Health PrevideN
(no) ]a, 0113
Universal Health Network/Nevada Preferred Professionals
(800) 776-6959
at least 48 hours before the services are scheduled to be rendered, with the following
information:
Page 46 of 95
1.
2.
3.
4.
5.
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6.
7.
The name of the patient and relationship to the Covered Employee
The name, Social Security Number and address of the Covered Employee
The name of the Employer
The name and telephone number of the attending Physician
The name of the Medical Care Facility, proposed date of admission, and proposed
length of stay
The diagnosis and/or type of surgery
The proposed rendering of listed medical services.
If there is an emergency admission to the Medical Care Facility, the patient, patient's
family member, Medical Care Facility or attending Physician must contact Hem.etevlB
Health Pl'8"liders Universal Health Network within 24 hours of the first business day
after the admission.
If a Physician does not get pre-treatment authorization, or if a Covered Person does not
follow these pre-certification procedures, benefit payment will be reduced by 50%. This
reduction of benefits cannot be applied toward the deductible or out-of-pocket maximum.
It is the Covered Person's responsibility to ensure that these procedures are followed.
IF THE COVERED PERSON DOES NOT RECEIVE AUTHORIZATION
AS EXPLAINED IN THIS SECfION,
THE BENEFIT PAYMENT WILL BE REDUCED BY 50%
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Concurrent Review; Discharge Planning
Concurrent review of a course of treatment and discharge planning from a Medical Care
Facility are parts of the utilization review program. Medical Management Services will
monitor the Covered Person's Medical Care Facility stay or use of other medical services
and coordinate with the attending Physician, Medical Care Facilities and Covered Person
either the scheduled release or an extension of the Medical Care Facility stay or extension
or cessation of the use of other medical services.
If the attending Physician feels that it is Medically Necessary for a Covered Person to
receive additional services or to stay in the Medical Care Facility for a greater length of
time than has been pre-certified, the attending Physician must request the additional
services or days.
Second and/or Third Opinion Program
Certain surgical procedures are performed either inappropriately or unnecessarily. In
some cases, surgery is only one of several treatment options. In other cases, surgery will
not help the condition. In order to prevent unnecessary or potentially harmful surgical ...i
treatments, the second and/or third opinion program fulfills the dual purpose of protecting .""
the health of the Plan's Covered Persons and protecting the financial integrity of the Plan.
Page 47 of 95
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Benefits will be provided for a second (and third, if necessary) opinion consultation to
determine the Medical Necessity of an elective surgical procedure. An elective surgical
procedure is one that can be scheduled in advance; that is, it is not an emergency or of a
life-threatening nature. Benefits will be payable as described in the Schedule of Benefits.
The patient may choose any board-certified specialist who is not an associate of the
attending Physician and who is affiliated in the appropriate specialty.
While &BY surgieal treatmeBt is aUsweti a sees&<! apiBi9B; the feUewiBg preeetlwes 8fe
eMS fer '/:lhieh surgery is afteR perfermeel \.:hen ether veatmeats are a"JIJi:lilWe, &Bel wmeh
RJflYiN a seeeBtl epHHes:
. .
r . 1'__11 .. ". ~ . 1'.
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Pre state 9l:lrget')' SalpiBge eetHtefeetemy (reme....at of
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-- . .:- .
Please refer to the "Claims Procedures" section of this booklet for information on
submitting and appealing a Medical Management decision.
Page 48 of95
Case,'~nal!ement
~
The Case Management (eM) Program helps Members with serious Illnesses manage
their health care. The goal of the eM program is to develop alternative treatment plans
that will help the Member obtain the type of care needed outside of a Hospital setting.
Members who choose to participate in the program are assigned a case mAnager to help
coordinate care.
Case Management is a process performed by H0met0Wll Health Universal Health
Network Registered Nurses and Social Workers who coordinate services for members,
both in the inpatient setting as well as services in the ambulatory setting. Many of these
services require prior authorization to confirm benefit coverage and medical necessity.
After an admission to a facility, }{ell\et(ylJB Heakk Universal Health Network Case
Managers monitor the member's progress, with the attending physician, to assure the
appropriate level of care is maintained and services utilized are delivered in a quality,
cost-effective manner using national standards (Interqual criteria, Milliman & Robertson)
and HometowB Healtli Universal Health Network custom community guidelines.
These Case Managers work with the attending physician and community resources to
develop a plan of treatment per the benefit level of the plan.
Note:
Case Management is a voluntary service. There are no reductions of benefits or
penalties if the patient and family choose note to participate. Each treatment plan is
individually tailored to a specific patient and should not be seen as appropriate or
recommended for any other patient, even one with the same diagnosis.
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Page 49 of 95
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Plan Exclusions
Note:
All exclusions related to Prescription Drugs are shown in the Prescription Drug
Plan. All exclusions related to Dental are shown in the Dental Plan.
For all Medical Benefits shown in the Schedule of Benefits, a charge for the
following is not covered:
Abortion. Services, supplies, care or treatment in connection with an abortion unless the
life of the mother is endangered by the continued Pregnancy or the Pregnancy is the
result of rape or incest.
Complications of non-covered treatments. Care, services or treatment required as a
result of complications from a treatment not covered under the Plan, except when
Medically Necessary due to complications arising out of previous surgery, up to $1,000
per Calendar Year and $2,000 while covered under the Plan.
Cosmetic Services. Care and treatment provided for cosmetic reasons. This exclusion
will not apply if the care and treatment is for repair or damage from an accident that
occurred while the person was covered under the Plan.
-..... Reconstroctive breast surgery following a Medically Necessary mastectomy is covered.
Custodial Care. Services or supplies provided mainly as a rest cure, maintenance or
Custodial Care.
Educational or Vocational Testing. Services for educational or vocational testing or
training.
Excess Charges. The part of an expense for care and treatment of an Injury or Sickness
that is in excess of the Usual, Customary and Reasonable Charge.
Exercise Programs. Exercise programs for treatment of any conditio~ except for
Physician prescribed and supervised programs, including cardiac rebabilitatio~
occupational or physical therapy covered by this Plan.
Experimental or not MedicaJly Necessary. Care and treatment that is either
ExperimentallInvestigational or not Medically Necessary.
Eye Care. Radial keratotomy or other eye surgery to correct near-sigbtedness. Also,
routine eye e~8U1in;:ltions, including refractions, lenses for the eyes and exams for their
fitting. This exclusion does not apply to aphakic patients and soft lenses or sclera shells
intended for use as corneal bandages.
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Page 50 of 95
Foot Care. Treatment of~eak, strained, flat, unBtabIe or unbalanced feet, metatarsalgia j
or bunions (except orthotics up to $200 per Calendar Year, and open. cutting operationsj, .."
and treatment of corns, calluses or toenails (unless needed in treatment of a metabolic or
peripheral-vascular disease).
Government Coverage. Care, treatment or supplies furnished by a program or agency
funded by any government. This does not apply to Medicaid or when otherwise
prohibited by law.
Hair Loss. Care and treatment for hair loss including wigs, hair transplants or any drug
that promises hair growth, whether or not prescribed by a Physician.
Hearing Aids and Exams. Charges for services or supplies in connection with hearing
aids or exams for their fitting.
Hospital Employees. Professional services billed by a Physician or nurse who is an
employee of a Hospital or Skilled Nursing Facility and paid by the Hospital or facility for
the service.
Illegal Acts. Charges for services received as a result of Injury or Sickness caused by or
contributed to by taking part in the commission of a felony.
Infertility. Diagnosis, care and treatment for infertility, artificial insemination or in vitro .. j
fertilization. .."
Massage Therapy. Charges for any condition, except when prescribed by a Physician
following trigger point injection treatment due to inflammation of the myofascia of the
muscle. Such prescription sball designate type, frequency and duration of Medica1lly
Necessary massage therapy.
No Charge. Care and treatment for which there would not have been a charge if no
coverage had been in force.
Non-Emergency Hospital Admissions. Care and treatment billed by a Hospital for non~
Medical Emergency admissions on a Friday or a Saturday. This does not apply if surgery
is performed within 24 hours of admi~ion.
No Obligation to Pay. Charges incurred for which the Plan has no legal obligation to
pay.
No Physician Recommendation. Care, treatment, services or supplies not
recommended and approved by a Physician; or treatment, services or supplies when the
Covered Person is not under the regular care of a Physician. Regular care means ongoing
medical supervision or treatment which is appropriate care for the Injury or Sickness.
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Page 51 of95
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Not Specified as Covered. Services, treatments and supplies which are not specified as
covered under this Plan.
Obesity. Care and treatment of obesity, weight loss or dietary control whether or not it
is, in any case, a part of the treatment plan for another Sickness. Medically Necessary
charges for Morbid Obesity will be covered.
OccupationaL Care and treatment of an Injury or Sickness due to or aggravated by
employment with any employer or self-employment.
Penonal Comfort Items. Personal comfort items or other equipment, such as, but not
limited to, air conditioners, air-purification units, humidifiers, electric heating units,
orthopedic mattiesses, blood pressure instnnnents, scales, elastic bandages or stockings,
nonprescription drugs and medicines, and first-aid supplies and non-hospital adjustable
beds.
~
Relative Giving Services. Professional services performed by a person who ordinarily
resides in the Covered Person's home or is related to the Covered Person as a Spouse,
parent, chil~ brother or sister, whether the relationship is by blood or exists in law.
Replacement Braces. Replacement of braces of the leg, arm, back, neck, or artificial
arms or legs, unless there is sufficient change in the Covered Person's physical condition
to make the original device no longer functional.
Routine Care. Charges for routine or periodic examinations, screening examinations,
evaluation procedures, preventive medical care, or treatment or services not directly
related to the diagnosis or treatment of a specific Injury, Sickness or pregnancy-related
condition which is known or reasonably suspected, unless such care is specifically
covered in the Schedule of Benefits.
Self-Infticted. Any loss due to intentionally self-inflicted Injury, while sane or insane.
Services Before Coverage. Care, treatment or supplies for which a charge was incurred
before a person was Covered under this Plan.
Sex Changes. Care, services or treatment for non-congenital transsexualism, gender
dysphoria or sexual reassignment or change. This exclusion includes medications,
implants, hormone therapy, surgery, medical or psychiatric treatment.
Sleep Disorden. Care and treatment for sleep disorders unless deemed Medically
Necessary.
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Smoking Cessation. Care and treatment for smoking cessation programs, including
smoking deterrent patches that is in excess of three times per participant lifetime and is
not medically supervised.
Page 52 of 95
Surgical Steri~D .Reve..waL Care and treatment for eversal of surgical stetili:zation.
Temporomandibular Joint Syndrome. All diagnostic and trea1ment services related to
the treatment of jaw joint problems including temporomandibular joint (1MJ) syndrome.
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War. Any loss that is due to a declared or wuieclared act of war.
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Page 53 of 95
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Claims Procedures ~iea~
(How to Submit a Claim)
It is the intent of the Plan Administrator that the following claims procedures comply
with the United States Department of Labor ("DOL") regulation 29 CPR ~ 2560.503-1.
llft<! .the Bmpleyee RetiremeBtlBesme Seeurity set sf 1974t 85 ameBdeEl ("ERISt..'t).
Where any provision is in conflict with the DOL's claims procedure regulations, ERISA,
ef any other applicable law, such law shall control.
Administrative Processes and Safe2uards
Same language as before. iust moved to beginning of section
The Plan requires that claims determinations be made in accordance with govemin~
documents of the Plan and that they be applied consistently with respect to similarly
situated Claimants. The claims procedures will not be administered in a way that unduly
inhibits or hampers the initiation or processing of claims or claims appeals.
~
Authorized Representative Mav Act for Claimant
Same language as before. iust moved to beginning of section
Anv of the following actions which can be done by the Claimant can also be done by an
authorized representative actinr on the Claimant's bebalf. The Claimant may be required
to provide reasonable proof of such authorization. For an urSlent claim a health care
professional with knowl~e of a Claimant's medical condition. will be oennitted to act
as the authorized ret>resentative of the Claim~nt "Health care professional" means a
physician or other health care professional licensed. accredited or certified to perform
specified health services consistent with state law.
Benefit Determinations
Same language as before. iust moved to beginning of section
Uoon the Claims Administrator's receipt of a written claim for benefits and Pursuant to
the procedures described herein. the Claims Administrator will review the claim
submission. proof of claim. and all associated and/or applicable information provided by
the Claim~nt and Slathered ~ntly by the Claims Administrator in llizht of the Plan
Document through which benefits of the Plan are paid. Further. the Claims
Administrator will assure that all benefit determinations are applied consistently to
similarly-situated Plan particiDants b~ maintaill~ll~ ~pro~ claim and benefit records
which shall be reviewed periodically and on a case-by-case basis to determine past
practices in similar claim situatio~. ShoYlJi, the qqiro~ Administrator at any time durinQ:
its review perj.od ~termine thN additional infol'IDatjon is reauired from the Emoloyee or
CJ~jmant. the Claims Administrator will request such necessary information from the
Emoloyee. The C~ Administrator will make every effort to make its benefit
determination in as reaso~le a time frame as P9ssible.
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Page 54 of 95
Submitting a Cia...
.J
A claim is a request for a benefit determination which is made, in accordance with the
Plan's procedures, by a Claim~t or his authorized representative. A claim must be
received by the person or organh'.ational unit customarily responsible for handling benefit
matters on behalf of the Plan so that the claim review and benefit deterinination process
can begin. A claim must name the Plan. a specific Claimant, a specific health condition
or symptom or diagnostic code. and a specific treatment, service or supply (Qr
procedure/revenue codes) for which a benefit or benefit determination is requested. the
date of service. the amount of charges. the address (location) where services are received.
and provider name. address. phone number and tax identification number.
For purposes of the Plan, the Plan Administrator, at its discretion, may contract with
other entities to handle claims communications and benefit determinations for the Plan.
Such other entities may include a third party claims administrator payet', a managed care
organization, or a pharmacy benefit manager. Contact information for such entities is
provided below.
There are two types of claims: (1) Pre-Service Claims, and (2) Post-Service Claims:
Same language as before that was in chart format. just moved here and stated more
clearly
1. A Pre-Service Claim is a written or oral reauest for Innatient Hosnital .j
benefits where the terms of the Plan condition benefits. in whole or in narl on ...
prior approval of the proposed care (e.g.. a utilization review requirement).
See the Medical Manuement PnwntmnJtilization Review section for that
information.
A Pre-Service Claim should be submitted to:
Universal Health Network/NPP
P.O. Box 30007
Reno. NV 89520-3007
Important: A Pre-Service Claim is onlv for the purposes of asses sine: the Medical
Necessity and appropriateness of care and delivery settine:. A determination on a
Pre-Service Claim is not a e:uarantee of benefits from the Plan. Plan benefit
payments are subiect to review upon submission of a claim to the Plan after medical
services have been received. and are subiect to all related Plan provisions. includine:
exclusions and limitations.
Note: Requests for benefit determination and requests for Plan approval where prior
approval is desired but not required should be directed to CDS Group Health. the
Claims Administrator as identified in the "Post-Service Claim" information below. or call
(775) 352-6900.
.J
Page 55 of 95
\.
Same language as before that was in chart. lust moved here and stated more clearly
2. A Post Service Claim is a written reauest for benefit determination after a
service has been rendered and expense has been incurred. Proof of loss for a
Post Service Claim must be submitted to the claims office within 45 dayfi
twelve (12) months after the date a service is rendered. Failure to furnish such
proof within the time required will not invalidate nor reduce any claim if it
can be shown that it was not reasonably possible to give proof within such
time. provided such proof is furnished as soon as reasonably possible. It is the
Claimant's responsibility for timely submission of all claims.
A Post Service Claim should be submitted to:
CDS Group Health
P.O. Box 50190
Sparks. NV 89435-0190
Note: Proof of loss for a claim has not been "furnished" unless and until the Claims
Administrator has received all information they reasonably deem necessary to allow
processing of the claim. This includes responding to reasonable requests for completion
of forms. providing additional information about the claim. or providing of documents in
support of the claim. If satisfactory proof of loss is not furnished within the 12-month
period after chare:es are incurred. benefits will not be available.
~
Note: In accordance with federal law, the Centers for Medicare and Medicaid Services
(CMS) have three (3) years to submit claims when CMS has paid as the primary plan and
the Plan should have been primary.
Assieoments to Providers
Same language as before. moved to this section
All Eligible Expenses reimbursable under the Plan will be paid to the covered Employee
except that:
1. Assignments of benefits to Hospitals, Physicians, or other providers of service
will be honored,
2. The Plan may pay benefits directly to providers of service unless the Covered
Person requests otherwise, in writing, within the time limits for filing proof of
loss, and
3. The Plan may make benefit payments fOf a child covered by a Qualified
Medical Child Support Order (a QMCSO) directly to the custodial parent or
legal guardian of such child.
Note: Benefit payments on behalf of a Covered Person who is also covered by a state's
Medicaid program will be subject to the state's right to reimbursement for benefits it has
paid on behalf of the Covered Perso~ as created by an assignment of rights made by the
Covered Person or his beneficiary as may be required by the state Medicaid plan.
'-' Furthermore, the Plan will honor any subrogation rights that a state may have gained
Page 56 of 95
from a Medicaid-eligible benefioiary due to the state's haviil.JW&i<l.'-~,bcnefits that
were payable under the Plan. '
~
Sf'.. Notet
These CIa.s 'reeedures address the,p,rieds witkia wlHehlJea~fit determiRatioas
lDustlJedeeided, Botpldd. B:..,.,..eets lDut.'.dewitltia N8S8B8lJle
perieds ef tiBte feIIewiBg 8m appre'.~ asl.....ed It)t ERISA.
There are twe types fir elaims:
1. Pre Serviee Claims, aad
2. Past 8erviee Claims
Pre Serviee ClaHBs Post Sertiee Chlims
A Pre Servise Claimie a \vfltte9Feml A Past Serviee CI8iat iea wRUea N'illest
feEJUest rorheaetit 4eteRBiBati9ll where the fer beaeftt t!etel'fl:1iaatiea after a servise has
teABS af the PI8B eoo4maa heBefits, iB heea feBdered ~'~e'has heea
'.~:liele at in par.., 0B prier 8J1Pl8va1 af the iB88ffeEl. A Pest Serviee Claim :&l1wt he
EI € utir'. . submitted 10 the eIaims ames "mtBiB 4 S
prepese eare. e.g~a ' ImtieB ftWlty.y
re'i~t). See the Ned_I days aftlie Elate eharges far the serAee
MtmacemeatP.....1bltJtiliMti8B were iaeun:eEl.
Red,,,, seeUaa fer fitrtker iBfemtaHaa
regaMiBg prier appmvel efthe'J1f8P9Bed.
e&fe:
~
Pre Seniee Claim.
Pf'8eedlH'e fOF SalJlllittiRg . CIeim
P08t Sen_ Claim
Preeedare fer SuIJIIIittiBg . Claim
.\ Pre Serviee Claim should he 9Q~ed.
far heaefit determiBatieB ta:
fo. Pest Seniee Claim sheuW he su9miUed.
tef
HelDetewB llealtk PFeViders
(800) ~U 9123
FiPsTier fadmiBistftten, me.
P.O. ..Be. 19~~8
ReRo, NY 89511
Please fefer 1a the "MeElieaJ. MaB&gemeBt
SenieesflJtilisMaB &e'l'ne\\''' semoR :fer
Blare iBfermati9B.
NMet
lB aeeaFElanee "1mB fedefallaw, the CeatefS fer Me<:f.isare 8BEI MeeieaidServiees (eMS)
have three (3) yeam 1a suhmlt elaims whea MeElieare has paid. as die primary pl8B 8BEI the
Plea skeDlt! ..,e heea pAmety.
AssigBIBeats to Previders
~
Page 57 of 95
\.,
\.,
\.,
All Bl-igible BKpeftBes reimbufsahle tWIer the Plan '.viii be paid te the COVeFe8 Eml'loyee
eKeept dlat:
1. ..\ssignmeatsof beaefits te Hospitals, PkyeieiBBS ar edier Pf&1'$ef8 sf serviee vAll
be Belt0fed;
2. The PIlla -.y pay benefits ttireetly te pt(WiElem of sen_ aalesstBe C&\~
PemeB reElllestB edler\'.ise,iB '.vritiBg, withHttke time liiBisfer.g }:tfeaf of
lass;aad
3. ThePIM -.y make beBefit paymeBts far 8 e&iW eO\'ereti by a ~d Medieal
Child Suppett Order (QMCSO) tlireetly ta the .eustedial pareBter legal g1:1ardian
sf sueh. eliikl.
Benefits due to MY Netw<<k pl'cYlider wiR be eeBSidered "assigBed" te SBeB pmviEier aatl
'.ViR be paid ttireetly to suek pl'9YiEler, whetker at Jlet a wmteB 89SigBmes.t efbeBefits was
eMel:tted. .
Netet
Besent paymems 8R behalf ef a Cavere4 PersoB '.'Jhe is alse ecy:ered by a state's
Me4ieeid J'l8gpam will be subjeette the state's right ta reimlnlfS8IIleBt fer MaeHS it Bas
paid as beheJ:f of the Ca....~e4PefSE)Jl, as efe8ted by &Il assigtHBeatof rights _e~' t:ke
Cavered PefSOS Of his heaefieiMy, as may Be le<faked by thes.te Medieeidples..
FU1'tkemtere, die .PJ:an '."Jill MBM aay 9U~gatieR rights that a state may havegaiaed
Rem a Medieaid eligible beaefieiary due lothe state's ha"liBg paid Medie8Wheaefits that
t'.W8 payaWe \lAdei' die PIa&.
aaims Tillie UIIlits ..d ..\Dew.e.
Forgreup Ile&kB pI8ftB subjeet to die Employee RetiMttettt !Beame Seeurity ..AS
(BRI8f.), tile ehatt below sets fefth die time limits aaEI aD&W&Ilees wlHeli apply te the
PleB aBti a ClaimaBt vA. respeet teelaim filiBgs, eti-iQistraU8B atl4 h.aJl8Bt
deteaBiBafteBs (i.e., hew tluieldy tBe PI8B m&st fe8l'8B4te eleims aetiees, filiBgs, aad
eIaims appeal&, aBEI Raw !Buell time is aIIewed for ClaimeRts to NSf'SB&, em). Iftkefe is
MY VafteRee betv:eeti diefoHawiBg iBfermatiea aatltlle iBteftEled ~ afthe
le'" tile lev- '~1i1l prevail
...., .. .... .
TllePe are he types af .'Pfe S8l'\4een C1eimB~ as fella\vs:
1. UPleat Claim
Afi ''ufgeBt elaim" is aa ami at WRtteB yetlllest fer beo.efit determiBatiaB where
tile 4eeisiaa "f9uld result in eit:her ae tile faJle?:liBg if deeide4 ":1itBiB tile time
fmmes fer Bes. 1:1l'geBt elaims:
I",.
Serious jeopardy ta the CIaimaBt's life ar health, er die amlity te regaiB
mMimum iURetiaa, ar
Page 58 of 95
B.
1ft die jllcfgmeBt ef Ii PkysieiaB kBewle4geah1e alteu$ the CJaiptll"t's
a~tiOB, Be\'ere.peie. that. eealEr Rat he adefluately managed witBeHt the
eare er watmellt-hemg elaimed.
.,J
All Beeessary mel1Batioti iBeladiag the PIM'S haBdfulg ef aft appeal9haR he
tFaftsmiUedhetweea the Plaaaad tke Claittumthytelepkeae, feesimHe ar ether
a'lailable aBd similarlf epediuaus metlteds.
Whether a elaiBl is urgeJlt ':JilI generally be deeiEled By MilHtividlHll aetiBg OR
hehalf of the PIM Md atfIYiag the judgJBeBt fta pl84eBt lcly,ersea whe
possesses &B ave. klte".vledge. afhealtB ... medieiae~ Hewev<<, if a PhysieiaB
familiar "-'litH tHe OIaitBeat~s eeaditi9l1 deeities that tHe elatm <HweJ.'r:esurgeateare,
the PIM must defer te tile PliysieiM' s j1lClgmeat.
2. C8DealTeBt Care Cia'"
A. 4'eOBellReRt eare a.aim" is a Cleimaftt's feEt_at te .~ a previeusly
apflraved aagemg eeurse aft:featmeBt (e.g., tddBey dialysis) heyaad the aPl*l'fled
J:'Ieftod af time ar Buml3eref treatmeBtB. Aft adve.f8e elaim deei$ieR fer eeBeut'fElRt
eafe dees net iftehule a heB.efif redueaeaar Elesial due fa Plaa ameBdtBeBt ar
termiftatiaa
3.
NeD tJpgeat Claim
..J
~\ "ooB urgent elaim" is &BY elaim fer a beBefit U:BEIer this Plaa that is Ret a Pre
Seniee Claim, Urgent CareC.aim, ar CeeutfeBt Care Claim.
The feUo'.viBg 0l18ft iBdieates tHe lespeeft.ve Time Limits aatI Alle\':aaees fer eaeh
'6 fttHieEI GI' It. ..
1 e lHBL...ew/tty.
....... -... .
un.. ... . " . ... . T-. Li8lit .r ...'\De,,'..e
Claimtmt makes IBitial IIIetI'IIfJ11se Claim WHlHB 8:8t mere thaB 24 hellf'B (aB4 as
R..est S90Jl88peSsmle takiBg iftte aeeeUflt the
medieel eK-igeaeies), VI&B _tiftes ClaimaBt
0f material Reeded te eemplete the etaim
Ief.l1le8t NaOOeatiaa may he efallHllesB
GI . ..
~fflnM 1etI1:IestB a wntteB Boaee.
ClaiftlQAt ~.viU have a reflS0B8.bte periea sf
time, I:lUt Bet le88 tkaa 48 hems ta previae
the N~d iBfeRB6UeB to eamplete die
~
PIM IeeeWes CtHffJIlelillK IBfermatieB PIaB B0tifies ClaimaBt, ill ~.~aitiB.g 9f
eleetfeBieally, ef He helleBt determiBatiaB
as saaR as pa~le aBtI set later tkaa 48
l1eUfS after 1ke earlier eft (1) reeeipt sf the
. . . ... . ""''' 4.L_ .. _&'
.J
Page 59 of95
-.
\.
\.,
-
ame ClaHBatit was aIIw.ved to pmvi4e tlie
..... . - ...
ClaimaBt makes 1Bi1ial C8IffJ1Iete Claim WttIHs.s.etJBef8 thaB 12 BeufS (&BS as
ReflUeBt 988ft as..pee$j91e tekiftg. ime Bese.t $e
me4ieal ~ie~), PlEmMlpallds with
\vfttteJler. eleetFi:)tHEl beae&. ~ti.6a
Oml B&ti.ee Baa be ~VeB hl aElditielllO
"y9JfitteBer ele*aaieft~e. WriUea ar
eleeveai0aeHeeef abMet'k <leBial ar
~ll.(aa "a4veme heoefrt
deteRBiMtk>B") must he l*'0viEled ta the
CI~ Qat later thaR 3 .Y8 after lHl af8l
lletifi~B.
ClaimaBt Af'Peals See "..'\tJpeal Pi:aeeaures" sullseetiaB. AD
a.PPe8:l fer 8ft. BfgeBt elaim. may ae JB8EIe
..;....It.. __ :_ . .
.
Pltm fespellds te f..ppeel Witlmt set mere dian 72 Ileum (S\das
seeR as paBSiWe takiBg da Bee0U1lt the
me4ieal exigeBeies) atler feeeipt ef
~.. , . .
.
Netef.
VIhefe the '~ime Limit for ..'\R9W8BOO".slatett ahe"l' refileets "ar saeBer ifpassible", tMs
phrase BlEl8BS 1I:Iat &B eerYer respease lBBY he re~ takiag Bite aeea8S:t the medieal
eKigeBeies.
Speeiel Netel
The Besefit DetetmiBatieB time &ames stated 88\'8 shell hegiR at tile time a eleim is
flied ill 110eer<iaaee with the preeedares ef the pI&, 9.vitheut regani to whether aU the
iBfermatioB Beeessary te mak-e a lJeaefit 8etermiM1i9B 110eempBBies t:ke filiBg.
COBeUFreBt Care asia
.......- ... . ....... . -. . Time 1._1 Dr AD8W8Bee
Pltm makes &B l\threme Claim PIaB lletWeS ClaiMaPt efBiteBt to reEltlee er 6eBY
DeeisiOB lJeaefits "eleN 8IIY NElBetiea sr termiBati.eB ef NBeftts
iB maee BB4 previEles eBe1:tgB time to eIlew the. CIB:im8Bt
te appeal aml ebteiBa ietertnmauea 88 ~yy lJeleN
tlie eeeefit is fed8eetl er termiBate4. .:\8)'ieeiBieB -Nidi
th tialE · Eli' .
. e peteB. . e mv~g empties te eBg01Bg eare
wWeI1 is .~ Neeessary, is m"1eet to the UrgeRt
Claim rules.
ClaimaBt ReftUests BKteBsiea Pl&B B0tifies ClaimaBt ef its benefit determisatiaB
fer UfgeBt Care ":lithia Bet mere .. 24 keurs after reeeipt ef the
reEftleBt (1HlG as SeeR as ~98Bible takiBg iBte &ee9Uftt the
.. . . '" ... _ L . -'....
Page 60 of 95
least 24 litlillfS ,pllitir ,..tm!I~..imtiaaa-'th.e 'fJre:oAously . . j
appre~._ peried. tlif~ erlFeaUBeBt.()tken.Jise, the ,..",
PlaB's BeHfieaB8R lIW9t~_eiBaeeetdaaee 'llith the
time alte.::aaees fer .P~ad. afaB urgeBt, pre serviee, or
... . ".. .
"8_. ~ ." -. ... .
CIeimaJlt makes laitial
hte8Mf1lete Gleim Re(}uest
PIe Reeei'les CtHnplethrg
IafeflllaB9fi
ClaimaBt mak.eslBitial
CtmIplete Claim Re(}uest
.n.' ... .
no.....
...
..
.
1IIo.1,....y -. .
6 ,__
T.el.-'t er..\It~e
. . ~..J '. ,~..L'L . ~1, .
-,,- ....' ~- -- - -..-....
reEluel9t,PIen ae$iese~ 0f8Dy 8f ift~mitiB:g, af
~ needed to 001Bplete the elQimtefIllest.
CJ4i~QJ:K may fEHI_a-.vriUeB aetifieatiea ' Claim&Bt
has at least 4S days RElm reeeipt af 91leB aeaee to
_"_:'t- .... _,..
WitIHB 1 S days, PIaa tespOOds \..41:11 ..wittea 9r
eleetfeBie Belt.t determiaatioa. IS BEWitieBtll daYB
may Be allo:'.~ .>>ith:Ml Beaee te Claim&at see
de&Hti9B af'1Wl~e"Belwll.
WItIHB 15 days,'P.lIafEl~_ tvith -.vftUea9r
eleetmB:ie BeI:lefitdetermilulti9a. 15 aaditioBSl days
may Be alla.:;edwilt fultBeDee te ClAi~8at see
tiefiBiiee af~.ti.ee"Mlaw.
Cl" _'" ".t.'
~
. . .,1\..1. ^
. ~
.
DeIiBifteB ef "FaR'Neee" feF~. G.... Pre .iewiee 'Qeims
"Full Netiee" IBeaB5 that BeBee is ,revideEl tetlle CJaime$ tle&$rihiBg the eifeumstaBees
fe(}uiriBg tile 8*teBsiaa af time eEl.t:ke date By vlhiehdle Plaa 'SKpeet.9 te Nader a
E1eeiBioa 8ueli eJGeasiea must be Reeessary due 18 JIIBttefs aeyeBEllte e6Rtlel af the Pie
8BEl aaHfieatiea m1:1flt aeeur prier te tile expimti9R of flt:eiBitiall S day PeRod.
Ifl the ease ef ey eJrtessieB as eutliBed aBave, tile BeRee af eJAeBsieB whieh is previtled
te the Employee ar ClaimaBt shell speemeaDy explejB tile staBtlards es wftieli eatitlemeat
te 8 heaefit is Based, th.e UB:reSah_ issues that pfeveat a EleeisioB 8ft the eleim, aBd the
aElditi0B81 iBfarmatisB Beed_ ttl fespallti te these iS8lleS. Wltefe tke Pis ~~",dmiBi9tf8ter ,
feEJuifes atfElitieB&l iBfenmm9R arb Bmpleyee at Claimaat, the Plaa "'~A4miBi9t:fater
must afferti tile Emplayee 8f CJa""m,t at least 4 S days te previEle Ite speeitie
iBform&aeB. IB sueR ease, tkeheaefit 4etermiBaa0B periafl..vill he teUetl (S\tSpeBde6)
from tile Elate ea wBielt aetHieeti8B ef 1:ke eKteBBies is seat te Its Emplayee ar ClaimaBt
lIBtY the date Oft ..vBielt the respeBSe ta the le<iUe8t fer ~ iBfeRllfttiOft is made.
Pest Serviee Claim
I~~I~ I
~~i:-~~_~~"lG~(ed~~WaR
J
Page 61 of95
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eleim Nflaest. lBe PI_may elfteB4this periaEI f0l' up - to
IS _)'5 witk fuU DB_ tcHhe CI&iRleat see aetiftiti0B
ef ''filII ttetiee" he Jew. Cf4dmAN has at 'Mast · 4SQayB to
. . . . .- ... .
.
Phm Reeeives C8llfJJleIiIIg 'Atithbl30 days, Pltm Qf)pt6"/es 0l' 4~elaim. 1 S
1ftfe1lll6tiaB additi9ftfll days may he a41ewea vlllt iWJ.- Beti.e to
Claimel _ seec!ejditi&ll $.f''lWl80tlee"belCWl.
. .,',.,.-,", -'.
CWmaBt makes Iftkial WitIBs.30. efreeeiviBg tk8 $~P"'~ves ar
C9111p1ete Claim Request seales eIaim~ ISaa4fti9Bll:ldaYSlBaytJe.el:l.ewes-\V:itlt
full ootiee te CWmaBt see defiBitiea ef~ ooUee"
bela'" ,
y..
...... .. . cL " " .
.
PlaB Re9J1aoos to A al \\{khiB 00 says after Heei}'t af .,eat 69 adtBftesal
~..ppe
days may he aU:e\\'eEI '."lith fullaetifieati8B te ClaimaBt
see Elefiftiti9B sf "full Jletiee" hele-v;.
DefiBifieB af"FuII Natiee~fer Pest Semee CI8im8
"PmI aetiee" lBeaBB that aetiee is prevlaedte the CIaime&tEleaeribiBgtke eifeamstanees
teq1HrlBg the eKteBsiaB at'tiste ami ile Sate hy wlHeh 1he PI8fl 0K:peet8 te feset a
seei9iea--Suek emeBSieamust he l1eeessary S9 temattef9'heyeBEltheeeatfel efd1e-PleB
aDd aetifieati9B te ClaimaBt IIlll9t eeeur prier tel the eKpifatiea. eftlte iBitiel 39 Sayar 60
Sayperiet:l.
IB the ease of 8flY eX;teasiea as eutliBea ee",e, the --aetiee ef eKteBsiaa whisk is pmviEled
to tlte 8mpla)'i!le at GlaimaBt -shall Sfteeifieally eJEPlaiBtke 9tftB(Ieras eft -jlkieh eatitlemem
to aheaefit is hase&, the lHIfeS8lveQ ~ dmt preveat a EleeisisB ea. .!aim, aB8 the
a4ditkmal iBfermeH0B aee4etlte respeM to thase is9aes. Where ile CJ8ims
~A"d.iRi8trator reEfllU'es ad._ iBfeaBatieB. at. 8mpleyee at CI..-8Dt,tfte Claims
~A~t mBSt a:ffer41ke Empleyee-er GJ9i~at leest 4' Says te pre"Ade die
speeifie WeABtHiea IB saek esse; the heaefit EleteImiBatieR perle. 'WiD "$ teUe4
(9U5peade4) WJB die ~ 8ft mtiek aeUfieaaaB afthe exteftsieB is seat te 1he8etplay.e
er Claimaat lIfttiI die date 9ft ...JhieIl ile re9pease te the feEJlIest fer aEklitieMI iBfemHlSeB
is made.
Moved to beginning of section f.il.iRiAN.lve Preeuses IBd SafepllNs
The Plaa requires 1Bat elaims SeteRBiBatieBB he BHHIe iRaeeeraaaee ...Jitk g&\.entiBg
aaetHBeBts af ile Plan eEl tliat dley he applied e9B9isteBtly wi. respeet tel similarly
SHuateEl Cleimaats. The elaims pmeet:Iu.Ms '.viII Jl0t ~e tlffR:linistereEl iRe way dtat 1:1Baaly
i:Bhimts at hampem tile iBitiatieB 91' pteee8BiBg af eleims al elaims apJge81s.
J.dIdterked RepNlleBtadve May 1M fer Claimaat
Aity of die above aeuOBS \"AHek e8fl he SeRe by 1:I1e Cleimaftt e8fl alse hedeBe ~ 8fl
81:ltBeMea lepFeseatatP/e aetiag 9ft the CIfli~aBt'9 hehaIf. The ClaimaBt may he rectllifea
to pm"tide fe&SaDalHe pmef ef suek autkerimtioa Fer 8ft Ulgent elaim, a heal+.h eafe
Page 62 of95
~
pl'afessieBBlt .nithk:aEv.vlesge sf a GlaimaBt's medieal OOBEIiooa,. win he permitted to set .. Jt
as the a11tkefi:zes represeatatk~eefthe CJ$i~AlJt. "Heel.~. prefes~" me. a ..",
pIlysieiao. er ether kealtk eaN prefessklBellieeBSe&, aeere&test at eerti:fiaQ to perferm
speeified heeItl1 serviees e9BSisteat ....Ath stete law.
SeReIt Oete"'atie8:S
Upaa the Claims f..iJmiBistmter's ree. af a '.vrittea eIaim, fer heaefits aa8pliflRJ8Bt ta
tile pmeeaures deseriheslleteiB,tke Cl~ Mmint!itfatef \ViII fe'~wtlte elaHB
SllhMissiea; prasf af slaim, 8$I.aD esseei$e8 &IUIIer~We.iBtbl6llH0apF&".idedby
tile CI~,"IIRt aBdgatllered iMe~Yhy tile ~l~ElmiBiMteriftHght aftlle Plett
DaeunteBt'tkreagh w8iek heaefits af. Plea aN ..d. .FUrtliett me 01_
..A;.-dfRinif&tmter will.as9Ufe that aIlhettelt det8ffJii9aU&8B ate ~liedee.isteDdy to
simtlatJy 8itlJates Plaa pameipaatshylBBintaieiftg .~rieteeleim $ltl heaetit reeords
'.Viii. $IHtll be reviewed periaE1ieeD.r CHld.CJfi a _e 'hy ease.is to determh1epast
.pIlleUees ifl ~ elaim .situatiOBB.. De~tiait efMs le\i&V/s sksII he made
aveilaNe te tile Bmployee ar ClaimaBt upea re'tRest. 8k&ukI die Gl$:ims .:\Elministfatar at
.y time El8fiflg its revi&".\' p~ed. s.mHlte that atWitieaal infe~8Il is requifed from
the Rmpl~e ar CJeiRJ8Bt,d1eCleims ..A...dministfater 'WiD ~uestsueBaeeessalY
~D hmthe ElBpleyee er CJf\iRlapt. The Claims f.:dmiBi...... wHlmake e....ery
eftelt U) make its heaefit EletetmHtatiaa ifl as reasaMhle a time frame 89 pessi.hle.
Calealatiac TilBe Pwieds
J
Far heaefit tIetermiBatioBt the pmad eftime '.vitlHft whiek 1RfeIl. deteRRiBaSeB is NEftHreS
begiBB at.the time 8 eIaim isfi1e8 iR aeeer8aBee ',vith die PIe's ~epraeeElweB,
\.lftheut regeN to wkether aU tkeiBl8Ml8tiaB Deeessat'y to malte a },eBefit aetefmi~etieB
aeeem,P88ies the fiJiag. Is. theevemthet &B eKteB4ed peried af tiftleiBpemHbs due te a
ClaimaBtts fail_ta Emit tile aeeessary infermaSeD, the penes f0l'melEiBg the
~B will be telletl (suspeBf:ie4) Hem die Elate eft wWek the. aetiiieaS9B af the
eKteBSiea is seat te the CJ~.~t UBtil the Elate aD wlHeJi 1ke Cleim8Bt resp9BEls te the
request fer a4sitiesal iBfet:matiaB.
WriUeB or EledroBie Netiees
The Pl&B shall pre":ise a Cleim8Bt ylidt vmuea af eleetmBie aoofieatiea of &BY beaefit
rec:taetieB ar deBial. WritteB 81' "eele !lease af &B appHved heftefit m-ast be
pra.:idetI aBly fer Pfi Seme8 heseHt tletermiBatiOBB.
''NoBee" er "ootifieatiaa" meass the Eleliyery er fumisBiBg ef iBfeffti&tiaa Hi a m&ftIler
that satisfies the staB6afEls ef29 CFR 2S20.194h 1 (IJ) as apprepriate with respeet to
material reEJ.1Hfes to he fumiehed er maee availMle te &B iBtIividual. ..\By eleetmBie
aotifieaseB shaD semply ".'lith tile staB8aras af29 CFR 2S29.l94h 1 (e)(l )(1), (ii)(iii), aBd
(iv) ana 2S2G.194h 1(8)(2)(1) &Bd (ii).
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Page 63 of 95
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Claims Denials
If a elei:&l is wh.aUy ar J'8ftiaUy t!eaieEl (see Note), the ClajJ;NI~ '.viR begi",~ vmttefl ar
ele_e. llaUBeatioa af saeh. Eleaiel witlHa *e -time frames re<<iukeeEl-tty law (See Claims
Time Limim aBd AlIaw&BeEls). The aeaee ...lill _11:1. tile fallowing aad wUI be
pl'EWide<l Hi a maBBer The Claims Administrator shall provide adequate notice in writing
to any Claimant whose claims for benefits. under this Plan have been denied. written in a
manner intended to be understood by the Claimant. including:
1. The specific reason(s) for the denial~ tleeisiea.8 retllieEler deay beaefltB;
2.
Specific reference to the Plan provision(s) on which the denial is based; as \".~ as
itleB.tifieatioB of &BE:i aeeess to ass guitleliftes,ruleB~8B.tlprOteeel5 v:meh. W~fe
relied UpOB ift makiBg tlte deeisioa. Whefea Plaauti!iMs' a speeiie ia.temal flJIe
ar preteeeJ., tile aetieeJlla;Y eitker set :forth the pteteeel8rs.kKIe a statemeat flat
a eopy af saeI1 pra,teeel",viU be fumisl1etl to the ChuRtflRt er his atHherized
represeatative free sf ehatge anti BpOO ref.lll89t. f.. aotWeatiea aftlemel at beaetit
rettueaOR llasea oa Medieal Neeessity Of eXfM.vimelltal treaBBeBt 8f 8*er similar
gelusiee or limit ~ <<plain tBe seiestifie 9f elisieal jlldgmellt af lBe Plaaift
applyiBg tile teaBS aft1le PI8ft to the ClAh~_t's mecieel e~eB, or must
ise1uE1e a BtatemeBt dHlt- -SQeh eKi"lanatiaa "Nillbe J1f0videElte tkeClaimsftt Bee of
eharge llpOft re<<iaElst;
\.,
3. A description of any additional information needed for further review of the
claim~ and to ehaBge tile .eisiee aM 8ft explasatieB of'Miy it is Reeeed;
4. An explanation of the Plan's review procedure. ElesefipUoa ef*e Pkm's
pmeetiUfes 8Bd time-limits fer appealed eleims. A EleBiel of 8B 8fgeat elaim mllSt
deseriBe the expeEliWEI appeal Pftleess ror 1lfgeat lleaI4h elaims. L'\B 1lf8t'at eleim
EIeftial may be Illtlde emlly totlte ClaimaBt ita ":JritteB ar eleekeBie BOtifieat:iOft is
fumisked to tBe ClaimaBt ":lidHB 3 tlayfi after tile 9f8l B:&tifieetieB.
Further. the Claims Administrator shall afford a reasonable opportunity to any Claimant
whose claim for benefits has been denied for a full and fair review of the decision
denying the claim by the person designated by the Plan Administrator for that purpose.
\r
Netet
fa. elaim Eleaial, or 8ft "a&".~eme ),eaefit Elet0fftliBatioa" meass &BY of the fella\vmgl a
EIeaial, reElueaa~ teffB:imtt:ieB ef a heaefit, 0f a failure 10 previ4e ar mak-e paymeBt - (ia
wkele 9f is paR) fer a be.aefit, iBeluEliBg &BY S\:leh EIeBiaI, reHeft~ tellBiBatieB af failure
to ptavi. or mak-e payftleat "is hasetl OR a E1eterm:iltati8fl ef a partieiJWlt' B or
beaefieiery' B eJ..igi9illty to peRieipate is a pia&, &BEl iflelllEliBg a EleRial, retlBeaeB ar
tel'miAfUieB ef a heaefH, or a feihJfe to Pf8vitle Sf make paymes.tt Hi ".vkele er ill F"t far
a MaefitresultiBg Uem the applieatiaa of 8IlY ~eBle:vie.l." as well as a feRUle te
ea..ref 8ft item ar serviee fer ".vhieh. henetHs are odtelwise previdecllleeaase it is
Page 64 of95
<!~d to he eKj)eriBleBtal af Hwe.~9.aalerBetMectieally~ 01' ~
apprepriate. DtlBial eta e_ fer ~te ebtai$ a }lrier appreval..WlElet~eB ""'"
thatwamdMak. e\1taiBiBg sueh prier 8flP!eVali$,."le at ~".-~eatieB sftae
prief.~Val p~ess ealdd _&8S~YJe0par~.lIfe er leal. efdle l'8tleJ!t (e~g.t the
patiest lsuaee.ei9lt8 aRd is iB Mati etimBlediate eare at_ ti$ej fIl<<Iieal treatmeB.t is
r~) is ~ahiWted.
Appeal Procedures
New language more accurately reflects actual practice for the last 10 years.
If a claim has been denied in whole or in part by the Claims Administrator. the Claimant
may appeal the determination of that claim under the lowest review level indicated
below. If the denial is uoheld. Claimant may appeal to the next highest level of review.
until the entire appeals process has been exhausted.
Level I: REVIEW OF THE CLAIM BY THE CLAIMS ADMINISTRATOR:
The Claimant may submit an appeal letter referencing the claim to the Claims
Administrator. The Claimant shall have this opportunity to present additional
information and/or documentation supporting this appeal. The Claims Administrator will
review the claim for appropriateness based on the Plan Document. and if needed for
medical interpretation or clarification. request a Physician review. Appeal letter and
additional information and/or documentation must be submitted within sixty (60) days of
the claim denial to:
CDS Group Health
ATTN: Claims Mana2er
1625 East Prater Way. Buildin2 C. Suite 101
P.O. Box 50190
Sparks. NV 89435-0190
J
The Claims Administrator will render a decision within sixty (60) days of receipt of the
appeal letter and will notify the Claimant in writing of the findings.
Level II: PLAN ADMINISTRATOR REVIEW:
If after completing Level I. the Claimant is dissatisfied with the Claim Administrator
decision. the Claimant may submit a written appeal to the Plan Administrator for review
and/or Request for Plan Exception. The appeal shall contain all information and/or
documentation the Claimant would like reviewed by the Plan Administrator and shall
include a signed Authorization for Release of Medical Information for Claim
Appeal/Request for Plan Exception form. The written appeal must be submitted within
sixty (60) days of the Level I decision to:
South Tahoe Public Utility District
General Mana2erIPlan Administrator
The Claimant will be notified in writing of the Plan Administrator's decision within sixty..
(60) days of the date the decision was made. ..",
Page 65 of 95
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Pre-CertificationlPrior Authorization Appeals
If the pre-certification of a service or procedure has not been approved by Universal
Health Network. and the service or procedure has not vet been rendered. a Claimant may
appeal the determination under the lowest review level indicated below. If the
determination is upheld. Claimant may appeal to the next highest level of review until the
entire appeals process is exhausted. If the service or procedure has been rendered.
Claimant will need to follow the "Claims Appeals" procedures outlined above.
Level I: REVIEW OF THE CLAIM BY THE UTILIZATION REVIEW FIRM:
The Claimant may submit an appeal letter referencing the determination to Universal
Health Network. The Claimant shall have this opportunity to present additional
information and/or documentation supporting this appeal. The Medical Director will
review.the information to determine medical necessity. Appeal letter and additional
information and/or documentation must be submitted within thirty (30) days of the
original determination to:
Universal Health NetworklNPP
P.O. Box 30007
Reno. NV 89520-3007
The Medical Director will render a decision within thirty (30) davs of the date the appeal
letter was received and will notify the Claimant in writing of his/her findings.
Level II: PLAN ADMINISTRATOR REVIEW:
If after completing Level I. the Claimant is dissatisfied with the Medical Director
decision. the Claimant may submit a written appeal and Request for Plan Exception to the
Plan Administrator for hislher review. The appeal shall contain all information and/or
documentation the Claimant would like reviewed by the Plan Administrator. including a
signed Release of Information for Request for Plan Exception form. The written appeal
must be submitted within thirty (30) days of the Level I decision to:
South Tahoe Public Utility District
A TTN: General ManaeerlPlan Administrator
1275 Meadow Crest Drive
South Lake Tahoe. CA 96150
The Claimant will be notified in writing of the Plan Administrator's decision within thirty
(30) davs of the date the decision was made.
'iI_IRR Ai',e..l aad Appeal Review
WHhia 1 gO Gays af teeehiBg aetitle ef 8 elaim retlaeUeB af Elenial~ a ClaimaBt may
allpeallHs etaim, ill writiBg~ to aRe'll tleeisieB maker (8:11 8~8te NaaieEl FiEkieiary ef
tile PlaB ,vile is Reither the iBElivi4uel -:Ale maEie die iBiael ae-:eree BeBeBt EleteftBiBatieB
Page 66 of 95
B0l' a mmordiBate ef1ke iBitial Eleeisiea _<<) aad Ile may suhmit IieW ~~
(eommeats, ooeamems, Nee., ete.,)iR supp0rt efWs appeal.
.,jj
Ia eNei' fe ..,eal au. .dveN, he.-4,.enaiaad8B,
. 0..........11..... .,.........,
ill wfttia~ tettle '111I A........tel\
htreSJl0Bfle to hiB appeal,.the CIQiJR8Rtis eBlitleEl teBfaR SfHlfilir leVie-"/: of tile elaim
e d' . d · ~.. f~' tfte' .tieI d ..'
8ft . a aev: eelSl8B 8ftaet SUIIp . a fe\'I~V e\'. '. er JBI .' .' EletBl8a\V8B
reasonable. ..A.. ''fuJIBB.d fairRWiev/' tak-es iRk> BeliJemlt allee$$eJits, OOe\HBeBts, reeems
aDd o1ller $ennatiea sublBiUed by the Cl~t rela~ to the elai$.
f..tS'HeB time as theClaimaatappeBls a EleBied el_lie will heJH'EWi~ upoa request
and free ef eharge, with aeeElff9 16' sad 09f'ies sf aU. deel:HBeBtS, Feeertls aB4 ether
~a rele'l8ftt k> IHs eIeim forbe&efits, 'tvit8auttegflfEl t0 ,,"At:etIter.. PIafl relied
oa the mateRel. TIt, PlaB wiD else &eele&e tlie bftIBf3fief ey me8ieBlat heaItB
pFofessiOBals eoli9\lkeEl as JHtrt af 1ke elaimproee9S,,,'Jkether Of aet BUell iefetmatiea was
submitted af eeasiElered iRthe iBitial beaefit EletermieMioo.
Fer appeal of a denial based ill whole or in part ORa medieaI juegmeBt, ifleladiBg
EletemHBatieas 'lAth legar6 te wkather apattieular 1N8tmeat, drug er eiler'itemiB
eltf'erimeatal, iBvestigati9aal, er I10t MedieaUyNe~ er 4fl~;, .dttJ. Pie
/;.A.iRi9t$ter sBaU eeBSUltwHk e~t~_epl'(lfessieBftl. has
~pftate 1fai8iBg aa4 'expelieaee ill 1Ile field efllHldieiae iIlvehretlia .. medieal
j1lC:igmeat SHeil .flf0fessi08Bl BHISt he iB<Ietlemieatef 8Ilyliealth eere pretessieaal
iB'liJWeEliB the iBitialdeeisi9fl te .uee er deay beBefits. "Health safepl8fessioaa!"
meaas a l'hysieiaB ar atBerkeeltheare pmfessieMllieessea, BeeN~ ar semRed to
perferm speeified healdt seniees eeBSi9lertt vMh state law.
.J
Deei8iBB 8B Appeal
..A.. cleeisioB '.vith regard ta the elaim appeal ?/ill he 1B8EIe widHB tile allt)1'l{M time frame
(see Claims Time Limits ..... ..\HM\~.Be~. If spee_ eireumstaBees ",rftieh &Fe eat ef
tile PlaB~B e9Btfel, require all messiea eftime, 'lJIHte aetiee efthe eKteBsi8B '.vitI he
fumisBeEI to the Claimaat prier t01he temiAaUeB 8fthe iBitiaRy allev.reEl time. The
eX:teBei8B aeuee 'lnD explaifl tile st'ee- eifeum.staftees requiriag all eJiteBsiea aad the
date the Pie eKpeets to reader the fiBalEleeisi8B. Ne elfteasi8B is peBBHted for urgeat
elaims.
The Eleeisiea ea appeal vAIl he ill wfitiBg er hy eleetfeBie aetHieati8B. If tile tleeisiea is
to e8BMue te rec:fuee Of EIeay hellefits, 1Ile aoufieatiea will ~ pre'AtleEl ill a lBBBIler
eale\ilaW to he lHlttemtoed by the Claim88t aad will iBelude:
1. The speeiHe 18aseB(fij fer tlte deeisi8a;
2.
R-efereaee 16 the pertiBeBt Pie pftlvisiellS 8a wm. the deeisiea is hased;
...J
Page 67 of95
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3.
.A.. atatemeat that die Claim9flt is eBtitled te reeei~..-e, 1:JpGBA.Wil1:le$t &BEl free at
eharge, fe8B9aahle ~ te a&4l eepies sf aIltleetHMf1tS,N~ aa4edter
iBfefJBQUeBfelel'lBfttte the eleus. "Rele\"8ftf' ~~elliflelll_.a d9~t,
leet;)r'eF t;)tker iftfomlfl1i~ tvhielt: (1) was NIW ... Bt ~ the u81\efit
detetmiB4tiea; (2) "N8$ su&mitted~eessi<l_detgeB.eRtt$diRtkee9\1fS~ af'~
the heBefit detetmift81:km, ~er B&t it wasfeUeda~et(~).4~s
eempliaBee vAth tIte~i~i_tWepf8ee8Ses_~.'~\JiNd' in ~"Jdlag
tkeheaetit <l~.. The.PIaB ""Jill else ..lese.y da8lHBeJl:tS that ","Jete
ere.tea er reeeived By the Plas. Eluriftg the 8pfJeal preeess;
4. WeIltifieatiGB af MYBlElEliesl sr voeat:ieB81 eKpeRs whese ad"liee ,vas ohtaiBed iB
OOMeeU9R with tile iBitial elaim <leBial, wltether or Bet tile aFAee was relied \lpes
iB J'l9frilag tile iBitiel deeisie&;
5. IdetHifieaaeB ef &BEl aeeess to MY guitleliBe&, roles, 9t preteeels ""dii. ",,,,,efe
relied \If)es iB ~ tile deeisi8B. A. ootifieaUes ef deeial ef heaefit redaeft9B
hasedoB Medieal Neeessity er eKperimeBtal treatmeator etlter similar eKeltIsioo
Of l~t must eKplaiadleseieBtifie sr eliBieal jvttgmeBt sf the Plea iB applyiBg tile
ter$9 eftke PlaB te tIte ClaimaBt'smetlieal eireumstaBees, er BHlstiBelu4e a
stateBieRt that 9lle1t ~B 'Will he pretoiEle<t te tile ClaimsBt free at elwge
llpSB fe<illest.
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Page 68 of 95
Coordination of Benefits
~
Coordination of the benefit plans
Coordination of benefits sets out roles for the order of payment of covered Charges when
two Of more plans - including Medicare - are paying. When a Covered Person is
covered by this Plan and another pIan, or the Covered Person's Spouse is covered by this
Plan and by another plan, or the couple's Covered children are covered under two or
more plans, the plans will coordinate benefits when a claim is received.
The plan that pays first according to the rules will pay as if there were no other plan
involved. The secondary and subsequent plans will pay the balance of the claim after the
primary plan has paid. Deductible(s) and co-pay(s) shall not be taken when this plan is
the secondary plan. (corrects language to reflect actual practice) up te eaeIi 0Jle's plaa
fel'fBBla. The taW re~SleBt wHlBeV<< he lDere thaa die see9B(f8ry (or seSeElllMt)
,plan's fo_. 5(;)% or 8Qq4. sr 1 (;)Q.4J4. \vBetewr it may he. The helaaee Ellie, if any, is
the respeBSihRity of the C&"/ered :Pe.f$eB.
Benefit Plan
This provision will coordinate the medical and dental benefits of a benefit plan. The term
benefit plan means this Plan or anyone of the following plans:
1.
Group or group-type plans, including franchise or blanket benefit plans.
.J
2. Blue Cross and Blue Shield group plans.
3. Group practice and other group prepayment plans.
4. Federal government plans or programs. This includes Medicare.
5. Other plans required or provided by law. This does not include Medicaid or any
benefit plan like it that, by its terms, does not allow coordination.
6. No Fault Auto Insurance, by whatever name it is called, when not prohibited by
law.
Allowable Charge
For a charge to be allowable it must be a Usual, Customary, and Reasonable Charge and
at least part of it must be covered under this Plan.
In the case of HMO (Health Maintenance Oreani7-6hon) plans: This Plan will not
consider any charges in excess ofwbat an HMO provider has agreed to accept as . "",j
payment in full. Also, when an HMO pays its benefits first, this Plan will not consider as ....,
Page 69 of 95
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an allowable charge, any charge that would have been covered by the HMO had the
Covered Person used the services of an HMO provider.
In the case of service type plans where services are provided as benefits, the reasonable
cash value of each service will be the allowable charge.
AutomobDe Limitations
When medical payments are available under vehicle insurance, the Plan shall pay excess
benefits only, without reimbursement for vehicle plan deductibles. This Plan shall
always be considered the secondary carrier regardless of the individual's election under
PIP (personal Injury Protection) coverage with the auto carrier.
Benefit Plan Payment Order
When two or more plans provide benefits for the same allowable charge, benefit payment
will follow these rules.
1. Plans that do not have a coordination provision, or one like it, will pay:first. Plans
with such a provision will be considered after those without one.
2.
Plans with a coordination provision will pay their benefits by these rules up to the
allowable charge.
A. The benefits of the plan which covers the person as an employee, member,
or subscriber (that is, other than as a dependent) are determined before
those of the plan which covers the person as a dependent; except that: if
the person is also a Medicare beneficiary, and as a result of the rule
established by Title xvm of the Social Security Act and implementing
regulations, Medicare is:
1. Secondary to the plan covering the person as a dependent, and
2. Primary to the plan covering the person as other than a dependent
(e.g., a retired employee),
Then the benefits of the plan covering the person as a dependent are
determined before those of the plan covering that person as other than a
dependent
B.
If both husband and wife are Employees, benefits covering the person as
an Employee are determined before benefits covering the person as a
Dependent After determining benefits for the person as an Employee,
Internal Coordination of Benefits will apply, and benefits will be
determined for the person as a Dependent
Page 70 of95
Benefits for children covered as Dependents of both Employee Spouses
will be determined in accordance with the Dependent rules below and
coordinated internally.
.J
C. The benefits of a benefit plan which covers a person as an Employee who
is neither laid off nor retired are determined before those of a benefit plan
which covers that person as a laid-off or Retired Employee. The benefits
of a benefit plan which covers a person as a Dependent of an Employee
who is neither laid off nor retired are determined. before those of a benefit
plan which covers a person as a Dependent of a laid-off or Retired
Employee. If the other benefit plan does not have this rule, and if, as a
resul~ the plans do not agree on the order of benefits, this rule does not
apply.
D. The benefits of a benefit plan which covers a person as an Employee who
is neither laid off nor retired or a Dependent of an Employee who is
neither laid off nor retired are determined before those of a plan which
covers the person as a COBRA beneficiary.
E. When a child is covered as a Dependent and the parents are not separated
or divorced, these rules will apply:
1.
The benefits of the benefit plan of the parent whose birthday falls
earlier in a year are determined before those of the benefit plan of
the parent whose birthday falls later in that year.
.J
2. If both parents have the same birthday, the benefits of the benefit
plan which has covered the patient for the longer time are
determined before those of the benefit plan which covers the other
parent.
F. When a child's parents are divorced or legally separated, these rules will
apply:
1. This rule applies when the parent with custody of the child has not
remarried. The benefit plan of the parent with custody will be
considered before the benefit plan of the parent without custody.
2. This rule applies when the parent with custody of the child has
remarried. The benefit plan of the parent with custody will be
considered first. The benefit plan of the stepparent that covers the
child as a Dependent will be considered next. The benefit plan of
the parent without custody will be considered last.
3.
This rule will be in place of items (1) and (2) above when it
applies. A court decree may state which parent is financially
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Page 71 of 95
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responsible for medical and dental benefits of the child. In this
case, the benefit plan of that parent will be considered before other
plans that cover the child as a Dependent.
4.
If the specific terms of the court decree state that the parents shall
share joint custody, without stating that one of the parents is
responsible for the health care expenses of the child, the plans
covering the child shall following the order of benefit
determination rules outlined above when a child is covered as a
Dependent and the parents are not separated or divorced.
G. If there is still a conflict after these rules have been applied, the benefit
plan which has covered the patient for the longer time will be considered
first.
3. Medicare will pay primary, secondary, or last, to the extent stated in federal law.
When Medicare is to be the primary payer, this Plan will base its payment upon
benefits that would have been paid by Medicare under Parts A and B, regardless
of whether or not the person was enrolled under both of these parts.
Claims Determination Period
Benefits will be coordiDatOO on a Calendar Year basis. This is called the claims
determination period.
Right to Receive or Release Necessary Information
To make this provision work, this Plan may give or obtain needed information from
another insurer or any other organi7.a.tion or person. This information may be given or
obtained without the consent of or notice to any other person. A Covered Person will
give this Plan the information it asks for about other plans and their payment of allowable
charges.
Facility of Payment
This Plan may repay other plans for benefits paid that the Plan Administrator determines
it should have paid. That repayment will count as a valid payment under this Plan.
Right of Recovery
This Plan may pay benefits that should be paid by another benefit plan. In this case, the
Plan may recover the amount paid from the other benefit plan or the Covered Person.
That repayment will count as a valid payment under the other benefit plan.
Page 72 of95
Further, this Plan may pay benefits that.are later found to be greater than the allowable
charge. In this case, the Plan may recover the amount of the overpayment from the
source to which it was paid.
..j
Subroeation and Reimbursement Provisions
Ri2ht of Subrontion and Refund
When this provision appHes:
The Covered Person may incur medical or dental charges due to injuries, sickness,
disease or disability which may be ~ in whole or in p~ by or resulting from the
acts or omissions of a third party, or from the acts or omissions of Plan Participant where
any insurance coverage, no-faul~ uninsured motori~ underinsured motori~ medical
payment provision or other insumnce policies or funds ("Coverage") exist In such
circumstances, the Covered Person may have a claim against that third party, or insurer,
for payment of the medical or dental charges and the Plan will conditionally advance
payment or extend credit of medical benefits as a courtesy in such situations.
Payment Conditions
1.
Plan Partici~ his or her attorney, and/or legal guardian of a minor or
incapacitated individual( s) agrees, by accepting benefits under this Plan for those
incurred medical or dental expenses, to maintain in trust and without dissipation
one hundred percent (1 ()()OAt) of the amount paid for benefits by the Plan, or the
full extent of payment received, less reasonable attorney's fees, when recovered
from anyone or combination of first and third party sources.
oJ
2. By accepting benefits under the Plan, the Plan Participant recognizes this property
right or equitable interest of the Plan in any cause of action the Plan Participant
may have or the proceeds thereof and allows the Plan to pursue any claim which
the Covered Person has against any third party, or insurer, whether or not the
Covered Person chooses to pursue that claim.
3. The Plan may make a claim directly against the third party or insurer. In the
event a Plan Participant settles, recovers, or is reimbursed by any third party or
Coverage, the Plan bas the first priority right of recovery and a first lien on any
amount recovered by the Covered Person whether or not designated as payment
for medical expenses, and shall be paid before any other claims for the Plan
Participant as the result of the illness or injury. This lien shall remain in effect
until the Plan is repaid in full. Said right and/or lien may be filed with any person
or 0~tli7~tion responsible, or potentially responsible, to the Plan Participant for
indemnification, the Plan Participant's attorney, or the Court.
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Page 73 of 95
\.
4.
If the Plan Participant fails to reimburse the Plan for all benefits paid or to be
paid, less reasonable attorney' fees, as a result of said injury or condition, out of
recovery or reimbursement received, the Plan Participant will be liable for any
and all expenses (whether fees or costs) associated with the Plan's attempt to
recover such money from the Plan Participant.
5. The Plan requires written co~nt for any fees or costs associated with a Plan
Participant pursuing a claim against any Coverage. The Plan Participant agrees to
hold the Plan harmless against any unreasonable claims made against the Plan by
the attorneys retained by the Plan Partic~ however these rights of subrogation
and reimbursement shall apply without regard to whether any separate written
acknowledgement of these rights is issued by the Plan and signed by the Plan
Participant
6. This provision shall not limit any other remedies of the Plan provided by law.
These rights of subrogation and reimbursement shall apply without regard to the
location of the event that led to or caused the applicable sickness, injury, disease,
or disability.
The Covered Penon:
1.
As a condition to participating in and receiving benefits under the Plan,
automatically agrees to assign to the Plan any and all claims, causes of action or
rights that they have or that may arise against any person, corporation and/or other
entity, third party or insurer when this provision applies and to any Coverage for
which the Covered Person claims an entitlement to benefits under this Plan,
regardless of how classified or cha.racteriud.
~
2. To promptly reimburse the Plan for any benefits paid on his or her behalf out of
the recovery made from the third party or insurer, when such recovery through
settlement, judgmen~ award or other payment is received;
3. To cooperate with the Plan or its agents in defining, verifying and protecting its
rights of subrogation and reimbursement and to do nothing to prejudice the Plan's
rights of subrogation and reimbursement.
4. To provide the Plan with pertinent information regarding the injury or sickness,
including various forms of documentation, accident reports, settlement reports
and any other requested additional information;
5. To take such action, furnish such information and assistance, and execute such
documents as the Plan may require to facilitate enforcement of its subrogation and
reimbursement rights.
41.
Page 74 of95
Amount Subject to Subrogation or Refund
..J
1. The Covered Person agrees to recognize the Plan's right to subrogation and
reimbursement. These rights provide the Plan with a priority over any funds to
recover 10001<<. of the benefits paid by a third party to a Covered Person relative to
the Injury or Sickness, with reasonable deduction for non-medical or dental
charges, attorney fees, or other costs and expenses, without regard to whether the
Plan Participant is fully compensated by hislher net recovery from all sources.
This obligation exists whether or not thejudgment or settlement specifically
designates the recovery or a portion of it as including medical, disability, or other
expenses, and exists regardless of how classified or characterized. If the Plan
Participant's net recovery is less than the benefits paid, then the Plan is entitled to
be paid all of the net recovery achieved, less reasonable attorney's fees.
2. Notwithstanding its priority to funds, the Plan's subrogation and refund rights, as
well as the rights assigned to i~ are limited to the extent to which the Plan has
made, or will make, payments for medical or dental charges as well as any costs
and fees associated with the enforcement of its rights under the Plan.
Assignment of Rights
1.
As a condition to the Plan making payments for any medical or dental charges,
the Covered Person must assign to the Plan his or her rights to any recovery
arising out of or related to any act or omission that caused or contributed to the
Injury or Sickness for which such benefits are to be paid. The scope of this
assignment is consistent with the amount subject to subrogation or refund set forth
above.
vJ
2. If the Covered Person decides to pursue a third party or any Coverage available to
them as a result of the said injury or condition, when a right of recovery exists, the
Covered Person agrees to include the Plan's subrogation claim in that action and
will execute and deliver all required instruments and papers as well as doing
whatever else is needed to secure the Plan's right of subrogation as a condition to
having the Plan make payments. In addition, the Covered Person will do nothing
to prejudice the right of the Plan to subrogate. If the Covered Person fails to
include the Plan's subrogation claim in that action, the Plan will be legally
presumed to be included in such action or recovery.
3. In the event the Plan Participant fails to make a claim against or pursue damages
against:
A. The responsible party, its insurer, or any other source on behalf of that
party;
B. Any first part insurance through medical payment coverage or personal
injury protection;
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Page 75 of95
~
'-'
2.
~
C. The Plan Participant's uninsured or underinsured motorist coverage;
D. Any policy or contract of insurance from any insurance company or
guarantor of a third party;
E. Workers' Compensation or other liability insurance company; or
F. Any other source, including but not limited to crime victim restitution
funds, any medical, disability or other benefit payments, and no-fault or
school insurance coverages,
Then the Plan Participant authorizes the Plan to pursue, sue, compromise or settle
any such claims in their name, to execute any and all documents necessary to
pursue said claims in their name, and agrees to fully cooperate with the Plan in the
prosecution of any such claims, and assigns all rights to the Plan or its assignee to
pursue a claim and the recovery of all expenses from any sources listed above.
4.
If at the time of injury, sickness, disease or disability there is available, or
potentially available based on information known or provided to the Plan or to the
Plan Participan~ any other Coverage, including but not limited to judgment at law
or settlements, the benefits under this Plan shall apply only as excess insurance
over such other sources of indemnifications. The Plan's benefits shall be excess
to the parties listed above.
5.
The Plan may, in its own name, or in the name of the Plan Participant or their
personal representative, commence a proceeding or pursue a claim against such
other third person for the recovery of all damages in the full extent of the value of
any such benefits or services furnished or payment advanced or credit extended
by the Plan.
6. In the event the Plan Participant is a minor as that term is defined by applicable
law, the minor's parents or court-appointed guardian, as the case may be, shall
take and cooperate in any and all action requested by the Plan to seek and obtain
any requisite court approval in order to bind the minor and his or her estate
insofar as the subrogation and reimbursement provisions are concerned. If the
minor's parents or court-appointed guardian fail or refuse to take such action, any
court costs or legal fees incurred by the Plan associated with obtaioiJlg such
approval, shall be paid by the minor's parents or court-appointed guardian.
Language Interpretation and Severability
1. The Plan Administrator retains sole, full and final discretionary authority to
construe and interpret the language of this provision, to determine all questions of
fact and law arising under this provision, and to ~lJ1jnlster the Plan's
subrogation/reimbursement rights.
In the event that any section of this provision is considered invalid or illegal for
any reason, said invalidity or illegality shall not affect the rero$Jinine sections of
this provision and Plan. The section shall be fully severable. The Plan shall be
Page 76 of95
construed and enforced as if such invalid or illegal sections had never been
inserted in the Plan.
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Defined Terms
1. Recovery means monies paid to the Covered Person by way of judgment,
sett1emen~ or otherwise to compensate for all losses caused by the Injuries or
Sickness whether or not said losses reflect medical or dental charges covered by
the Plan.
2. Subrogation means the Plan's right to pursue the Covered Person's claims for
medical or dental charges against the other person.
3. Refund means repayment to the Plan for medical or dental benefits that it has
paid toward care and treatment of the Injury or Sickness.
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Page 77 of95
\"
COBRA Continuation Options
To provide options for individuals who lose health coverage from an employer-sponsored
insurance plan, the FedemI Government enacted the Consolidated Omnibus Budget
RecOnciliation Act of 1985 (Public Law 99-272, Title X), commonly known as COBRA.
The following will explain your rights under the law and what should be done if you (or a
covered dependent) experience a COBRA "qualifying event". A qualifying event is an
event that occurs whereby an employee or covered dependent would no longer be eligible
to continue under a group health plan. We request that you and your covered dependents
take the time to read this important notification.
COBRA Law
~
With a few exceptions, employers with twenty or more employees that provide health
benefits are required to offer employees (and/or their covered dependents) the right to a
temporary extension of group insurance (called "continuation coverage") upon
experiencing a qualifying event. An individual experiencing a qualifying event is
referred to as a "qualified beneficiary" and receives many of the rights granted to
similarly situated active employees as it relates to group insurance plans. It is the
emolovee's resoonsibility to notify the Plan Admlni.trator Immedlatelv uoon
exoeriencine: . QUa6fvin1l event. so that the Plan Adminatntor may effeetuate the
required notification within the required time frames. See definition of Qualifying
Events, below.
Continuation coverage is different from converting to individual coverage after
termination of employment. The major advantages of COBRA are that participants will
receive the same group plan benefits as a similarly situated active employee and will be
charged the company's group rate (plus a maximum. of two percent as an administrative
fee). These COBRA rates may (or may not) be less than the premiums charged under a
conversion policy so it is recommended that you contact the insurer directly to receive a
quote. With many conversion policies, benefits are reduced and premiums are based
upon the age and sex of the converting members. Another difference is that COBRA
allows for covered dependents to independently continue their health coverage and retain
COBRA rights throughout their continuation time ftame.
Employer and Qualified Beneficiary's Responsibilities
\.,.
When you or your covered dependent experience a qualifying event, you will be sent a
notification explaining your rights to elect COBRA continuation coverage. The Plan
Administrator shall provide this notification through its third party COBRA
administrator, within fourteen days from the date of the qualifying event (or as soon as
administratively possible ). Yon or vour d~ntlent have the resoonsiJJility to notify
the third oartv COBRA .dmini.trator ofvour desire to continue covere:e within
IiItv (60) daVI from the later of the date of notification or loss of covene:e. Upon
acceptance you or your dependent will be notified of any enrollment forms that must be
completed. Keep in mind, qualified beneficiaries who elect continuation coverage
Page 78 of 95
are responsible for premiums back to the date termination from the plan would
have occurred.
...J
If you or a covered dependent experience a qualifying event and do not receive a
qualifying event notification in a timely fashion, you are requested to contact the Plan
Administrator immediately. Even if you elect not to continue coverage, it is vital you
have the information necessary to make an informed decision.
The Employer will know when certain qualifying events (i.e., reduced work hours,
employment termination and death of an employee) occur. Y@u fAfl vow covered
deoendents wiD be resoonsible for notilrintr the Plan Adp"..istrator or hislher
desimte of a div~fC!, fml se~ntio", Medjeare enfi:tleme,t or when a de~ndent
loses hislher "dependent status". .. You or vour de"ndenUs} have sixtv (60) dars to
notify the Plan Administrator or tits clajtmee of fhese QVaJifriD2: events. If the Plan
Administntor OJ: IY! ~~i&wt! if not ,.tUJ!4.lt!tJW! tJ!iI tie, h~~ (;2DM
continuation eannot be offered. In order to take advantage of the disability extension
described below, you must also notify us within sixty days of a determination by Social
Security that you or a dependent are "disabled".
COBRA Qualifying Events
Listed below are qualifying events for which you and/or your covered dependents are
able to continue coverage under COBRA. As sho~ the maximum continuation
coverage time frame depends upon the qualifying event experienced. To be considered a .,j
qualified beneficiary, you or your dependent must have been enrolled on the group plan
on the day prior to the qualifying event. One exception to this rule is when a child is born
to (or placed for adoption with) an employee during the COBRA continuation period.
These children will receive all the rights of a qualified beneficiary throughout the
COBRA continuation period.
Divorce or Ie on
Employee is entitled to Medicare but
d ndents are not
Dependent child who no longer meets the
lan's definition of a "de nt"
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Page 79 of 95
\.
Disability Extension
If the qualifying event is an employee's termination or reduction in work hours and you
or a covered dependent are determined to be "disabled~~ by Social Security (under Title
XI or Title XVI) either before that qualifying event or within sixty days of such even~
you and your covered dependents are eligible for an additional eleven months of
coverage (yielding a total of29 months). For this extension to apply, evidence of
disability under the Social Security Act must be provided to the Plan Administrator
within the initial eighteen month continuation coverage time frame and within sixty days
from the date of Social Security's determination.
Multiple Qualifying Events
~
If you experience a qualifying event that entitles you and your covered dependents to less
than thirty-six months of continuation coverage (including the disability extension
described above) and during your period of continuation coverage your covered
dependents experience a second (or "multiple") qualifying even~ the period of
continuation coverage for your covered dependents may be extended under COBRA from
eighteen months (or twenty-nine months if disabled) to thirty-six months. The maximum
continuation period is thirty-six months regardless of how many qualifying events your
covered dependents experience. It is your responsibility, or the responsibility of your
covered dependents to notify the Plan Administrator within sixty days of the
multiple qualifying event. Employees who experience a reduction in work hours
followed by a terrnlJ1~tion of employment shall only be eligible for eighteen months of
continuation coverage under COBRA.
Family and Medical Leave Ad
Under the Family and Medical Leave Act of 1993 (FMLA), eligible employees have the
right to take up to twelve weeks of unpaid leave to care for themselves or a specified
relative. If you elect to take this leave and later notify the company that you will not be
returning, you have the ability to continue your coverage for eighteen months from the
date benefits are terminated on account of your failure to return to work. Please refer to
the District's Family Care and Medical Leave Policy for complete details regarding
benefits status during this type of leave.
Re-Enrollment after a FMLA Leave
If any or all of an Employee's coverages end while the Employee is on a FMLA leave,
the Employee can re-enroll for coverage when he or she returns to work from the FMLA
leave.
'-'
The Employee and any Dependents will be considered timely enrollees if the Employee
re-enrolls within thirty one.(31) days from the date he or she returns to work. Any
waiting period will be applied as if there had been no break in coverage.
Page 80 of 95
COBRA Termination
..J
Although COBRA continuation coverage has a maximum time frame, you may
voluntarily terminate coverage at any time by notifying the Plan Administrator in
advance. In addition, COBRA states that continuation coverage will end for one or more
of the following reasons:
1. The District terminates all of its health plans for similarly situated active
employees.
2. COBRA premiums are not paid in a timely manner.
3 . You and/or your Covered Dependents become covered under another group plan
after electing continuation coverage and that plan does not exclude a pre-existing
medical condition affecting you or your dependents.
4. You become entitled to Medicare (meaning enrolled in Parts A and/or B) after
you have elected continuation coverage under COBRA. However, your
dependent's continuation coverage may be extended to thirty-six months upon
notifying the Plan Ad.m:inis1rator of your Medicare entitlement.
5.
You or a Covered Dependent are enrolled in a plan that requires you to live in the
plan's "Service Area" or visit contracted providers and you move out of that
service area. However, if another plan is available to similarly situated active
employees who move from the service area, coverage under that plan will be
offered to you.
~
6. You file fraudulent claims or engage in other activities for which a similarly
situated active employee would be terminated "for cause".
7. A "disabled" participant is determined by Social Security to be no longer disabled
during the eleven month extension. In that case, the entire family unit will be
terminated from. COBRA.
Premium Costs
The cost of continuation coverage will be determined at the time of the qualifying event.
Your cost will be the amount determined by the District for similarly situated active
employees under the Plan, plus a 2% admiujstration fee. An employee who is deemed to
be disabled and who elects the disability extension may be charged a 50% administration
fee during the eleven month extension. (If the disabled employee does not elect the
disability extension or tero1jn~tes coverage before the extension would ordinarily end,
hisIher covered dependent's administration fee will be reduced to 2%). If the District's
"premium" funding increases or decreases, the COBRA participant's premiums will be
adjusted accordingly. Premium rates for the plan are set for twelve month periods based "filii
upon the Plan Year.
Page 81 of95
,
\.., If you elect to continue coverage under COBRA, you will be granted an initial forty-five
day grace period to make your payment. Your first payment must include the premiums
for coverage retroactively to the date you or your covered dependents would have lost
coverage if you hadn't elected to continue coverage. Subsequent premium payments will
have a thirty-day grace period. If premiums are not received within the allotted grace
period, COBRA coverage will be terminated back to the date for which premiums were
applied.
Coverage under COBRA
Since COBRA is a continuation of benefits, your benefits will remain the same as prior to
the qualifying event. If the District elects to change plans and/or benefits, you will be
eligible to enroll in the changed plan and will therefore receive the same benefits as
similarly situated active employees. If your Plan has deductibles and co~insurance
maximums, these amounts will be based upon expenses incurred prior to the qualifying
event by only those family members electing to continue under the plan.
COBRA participants who move from the plan's service area may lose coverage under the
group health plan (as would a similarly situated active employee). If the District offers a
plan that would provide coverage in the new area, the COBRA participant will be offered
the right to enroll in that plan.
\., Open Enrollment
COBRA participants are offered the same rights as similarly situated active employees
during open enrollment They may change plans and add/delete eligible dependents.
Although part of the family unit, dependents (other than newborn children and adopted
children of the employee) added during open enrollment will not have the same COBRA
rights as the initial qualified beneficiaries. The District's open enrollment may vary from
year to year, so feel free to contact the Plan Administrator for further information on open
enrollment.
Tnde Act 0(2002
On August 6, 2002, the Trade Act of 2002 was signed into law expandinf the benefits
available to workers displaced by import competition or shifts of production to other
countries. The Trade Act of 1974 initially offered benefits (known as "trade adjustment
assistance") which expired September 30, 2001. The Trade Act of 2002 extended this
period to September 30, 2007 and offers qualified workers a tax credit of up to 65% of
COBRA health insurance premiums for both them and their family.
\"
To be eligible for the tax credit, you must be currently receiving trade adjustment
assistance or considered an "eligible PBOC pension recipient", paying premiums for
qualified health insurance, not receiving other coverage and not in prison. The law also
creates a second "election period" for individuals not electing COBRA coverage upon
Page 82 of 95
their loss of employment if they are within the six months immediately after their group
health plan coverage ended. For further information on the Trade act of 2002, please .j
visit the website at www.cobralaw.com/trade-act.
Health Insurance Portability and Accountability Act of 1996 (IDP AA)
The scope ofHIPAA is to eliminate barriers for individuals (mainly people with pre-
existing medical conditions that would have difficulty obtaining immediate coverage)
who lose coverage and want to find a replacement plan. The law limits a plan's "pre-
existing condition limitation time frame" to twelve months for newly enrolling
individuals and provides credit for prior medical coverage, including COBRA
continuation coverage. When you termin~ from a group medical plan, you will receive
a Certificate of Coverage that illustrates your prior coverage. This certificate should be
shown to a new employer to receive one month credit for every month of prior coverage.
If there is a break in coverage greater than sixty-three (63) days, the new employer does
not have to provide any prior coverage credit. (Individuals receiving trade adjustment
assistance and who enroll in COBRA during the "second election period" shall receive
creditable covemge even with a break in coverage larger than sixty-three days.)
In addition, if you elect COBRA and keep your coverage for the maximum continuation
period available to yo~ you may be eligible for coverage under an individual plan
(through an insurer of your choice) on a guaranteed issue basis without any pre-existing
condition limitations.
.J
Questions Regarding COBRA
COBRA is complex, placing certain requirements on both the employer and the qualified
beneficiary. It is designed to provide temporary health insurance with a defined
termination date. Hyou have any questions regarding this notification of your
COBRA rights, please feel free to contact Conea at (866) 262-7277.
Continuation of Coverage Under USERRA
If your Service ends due to a qualified military leave of absence you may be eligible to
continue coverage under this provision, subject to payment of contributions.
The Uniformed Services Employment and Reemployment Rights Act of 1994
(USERRA) established requirements that Employers must meet for certain Employees
who are involved in the Uniformed Services. In addition to the rights under COBRA
continuation of coverage, you are entitled under USERRA to continue the coverage yu
had under the group for Medical, Prescription Drug and Dental.
"Service in the Uniformed Services" means the performance of active duty in the
Uniformed Services under competent authority which includes W\ining, full-time
National Guard duty and the time necessary for a person to be absent from employment
.II
Page 83 of95
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-..,
\.,
for an examination to determine the fitness of the person to perform any of the assigned
duties.
When a covered Employee takes a leave for Service in the Uniformed Services,
USERRA coverage for the covered Employee and covered Dependents for whom
coverage is elected, begins the day after the Employee and covered Dependents lose
coverage under the Plan and it continues for a maximum period of up to 24 months.
If you are entitled to COBRA continuation coverage, both COBRA and USERAA
coverage are concurrent. This means both COBRA coverage and USERRA coverage
will begin upon commencement of the employee's leave. The administrative policies and
procedures described for COBRA continuation coverage will also apply to USERAA
coverage. In some instances, COBRA coverage may continue longer. Additional
information on COBRA continuation coverage is described in this Plan Document.
If coverage under USERRA is elected, the covered Employee and covered Dependents
will be required to pay up to 102% of the applicable group rate. However, if your
Uniformed Service leave of absence is less than 31 days, you are not required to pay
more than the amount that you pay as an active Employee for that coverage.
Page 84 of95
,rJall Amendment Re2an~liDI!.ml-M PrlvacvComnlianee
" For the
So e Oct
Em~l~~' BeoefijPlan
..J
Introduction
The South Tahoe Public Utility District (plan Sponsor) sponsors the South Tahoe Public
Utility District Employees' Benefit Plan (the Plan). Members of the District's workforce
may have access to the individually identifiable health information of Plan participants
for administrative functions of the Plan. When this health information is provided from
the Plan to the Plan Sponsor, it is Protected Health Information (PHI).
The Health Insurance Portability and Accountability Act of 1996 (HIP AA) and its
implementing regulations restrict the Plan Sponsor~ s ability to use and disclose pm. The
following lllP AA definition ofPID applies to this Plan Amendment:
Protection Health Information: Protected health information means information
that is created or received by the Plan and relates to the past, presen~ or future
physical or mental health or condition of a participant; the provision of health care
to a participant; or the past, presen~ or future payment for the provision of health
care to a participant; and that identifies the participant or for which there is a """
reasonable basis to believe the information can be used to identify the participant.
Protected health information includes information of persons living or deceased.
The Plan Sponsor shall have access to pm from the Plan only as permitted under this
Plan Amendment or as otherwise required or permitted by lllP AA.
Provision of Protected Health Information to Plan SDOBIOr
Permitted Disclosure of EnrollmentlDis-Enrollment Information
The Plan (or a health insurance issuer or HMO with respect to the Plan) may disclose to
the Plan Sponsor information on whether the individual is participating in the Plan, or is
enrolled in or has dis-enrolled from a health insurance issuer or HMO offered by the
Plan.
Permitted Us. and Disclosure of SDl"1IIary Health Information
The Plan (or a health insurance issuer or HMO with respect to the Plan) may disclose
Summary Health Information (defined below) to the Plan Sponsor, provided the Plan
Sponsor requests the Summary Health Information for the purpose of:
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Page 8S of9S
\"
1.
Obtaining premium bids from health plans for providing health insurance
coverage under the plan; or
2. modifying, amending, or terminating the Plan.
Summary Health Information: Summary health information means information
that (a) summarizes the claims history, claims expenses or type of claims
experienced by individuals for whom a plan sponsor had provided health benefits
under a Health Plan; and (b) from which the information described at 42 CFR ~
164.514(bX2)(I) has been deleted, except that the geographic information
described in 42 CFR ~164.514(bX2)(i)(B) need only be aggregated to the level of
a five-digit zip code.
Permitted and Required Uses and Disclosure of
Protected Health Information for
Plan Administration Purposes
'-'
Unless otherwise permitted by law, and subject to the conditions of disclosure described
under "Conditions of Disclosure for Plan Administration Purposes". and obtaining
written certification pursuant to "Certification of Plan Sponsor", the Plan (or a health
insurance issuer of HMO on behalf of the Plan) may disclose PHI to the Plan Sponsor,
provided the Plan Sponsor uses or discloses such PIll only for Plan administration
purposes.
Plan Administration Purposes: Plan adminilrtrative purposes means
oomhlistration functions performed by the Plan Sponsor on behalf of the Plan,
such as quality assurance, claims processing, utili7J1tion trends, auditing, and
monitoring. Plan admini~tion functions do not include functions performed by
the Plan Sponsor in connection with any other benefit or benefit plan of the plan
of the Plan Sponsor, and they do not include any employment related functions.
Notwithstanding the provisions of this Plan to the contrary, in no event shall the Plan
Sponsor be permitted to use or disclose PIll in a manner that is inconsistent with 45 CFR
~ 164.504(f).
Conditions of Disclosure for Plan Admtnllltration Purposes
Plan Sponsor agrees that with respect to any PIll (other an enrollmentldis-enrollment
information and Summary Health Information, which are not subject to these restrictions)
disclosed to it by the Plan (or a health insurance issuer or HMO on behalf of the Plan)
Plan Sponsor shall:
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Page 86 of 95
1.
Not use or further disclose the Pill other than as permitted or required by the Plan
or as required by law.
'.I
2. Ensure that any agen~ including a subcontractor, to whom it provides Pill
received from the Plan agrees to the same restrictions and conditions that apply to
the Plan Sponsor with respect to PHI.
3. Not use or disclose the PHI for employment-related actions and decisions or in
connection with any other benefit or employee benefit plan of the Plan Sponsor.
4. Report to the Plan any use or disclosure of the information that is inconsistent
with the uses or disclosures provided for, of which it becomes aware.
5. Make available PHI to comply with HIP AA's right to access in accordance with
45 CPR ~ 164.524.
6. Make available PHI for amendment and incorporate any amendments to PHI in
accordance with 45 CFR ~ 164.526.
7. Make available the information required to provide an accounting of disclosures
in accordance with 45 CFR ~ 164.528.
8.
Make its internal practices, books, and records relating to the use and disclosure
of Pill received from the Plan available to the Secretary of Health and Human
Services for purposes of determining compliance by the Plan with HIP AA's
privacy requirements.
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9. If feasible, return or destroy all PHI received from the Plan that the Plan Sponsor
still maintains in any form and retain no copies of such information when no
longer needed for the purposes for which disclosure was made, except that, if
such return or destruction is not feasible, limit further uses and disclosure to those
purposes that make the return or destruction of the information infeasible.
1 O. Ensure that the adequate separation between Plan and Plan Sponsor (Le., the
''firewall''), required in 45 CPR ~ 504(t)(2)(iii), is satisfied.
Adequate Sepantion Between Plan and Plan Sponsor
The Plan Sponsor shall allow the General Manager (as Plan Administrator), Human
Resources Director (as Plan Coordinator) and Chief Financial Officer and/or Accounting
Manager (to conduct internal audit of the Plan's expenses and payment of claims), access
to the Pill. No other persons shall have access to and use Pill to the extent necessary to
perform the Plan 3{1ministration functions that the Plan Sponsor performs for the Plan. In
the event that any of these specified employees do not comply with the provisions of this . ..,j
Section, that employee shall be subject to disciplinary action by the Plan Sponsor for ..",
Page 87 of95
\r
\.,
\.
non-compliance, pursuant to the Plan Sponsor's employee discipline and termination
procedures.
CertUICation of Plan Sponsor
The Plan (or a health insurance issuer or HMO with respect to the Plan) shall disclose
PHI to the Plan Sponsor only upon the receipt of a certification by the Plan Sponsor that
the Plan has been amended to incorporate the provisions of 45 CFR ~ 164.504(f)(2Xii),
and that the Plan Sponsor agrees to the conditions of disclosure set forth in the preceding
paragraphs of this Section.
Page 88 of95
ResponsibjJjtimif2tlJ~ Admilistratic!p
..J
Plan Administrator
South Tahoe Public Utility District Employees' Benefit Plan is the benefit plan for
Employees of South Tahoe Public Utility District. The Plan Administrator, also called
the Plan Sponsor is an individual appointed by the South Tahoe Public Utility District to
be Plan Administrator and serve at the convenience of the Employer. If the Plan
Administrator resigns, dies or is otherwise removed from the position, South Tahoe
Public Utility District shall appoint a new Plan Administrator as soon as reasonably
possible.
The Plan Administrator sha1l9dminister this Plan in accordance with its terms and
establish its 'policies, interpretations, practices, and procedures. It is the express intent of
this Plan that the Plan Administrator shall have maximum legal discretionary authority to
construe and intetpret the'terms and provisions of the Plan, to make determinations
regarding issues which relate to eligibility for benefits, to decide disputes which may
arise relative to a Plan Participant's rights, and to decide questions of Plan intetpretation
and those of fact relating to the Plan. The decisions of the Plan Administrator will be
final on all interested parties.
Duties of the Plan Adminifltrator
..J
1. To admin;ster the Plan in accordance with its terms.
2. To interpret the Plan, including the right to remedy possible ambiguities,
inconsistencies or omissions.
3. To decide disputes which may arise relative to a Plan Participant's rights.
4. To prescribe procedures for filing a claim for benefits and to review claim denials.
5. To keep and maintain the Plan documents and all other records pertaining to the
Plan.
6. To appoint a Claims Administrator to pay claims.
7. To delegate to any person or entity such powers, duties and responsibilities as it
deems appropriate.
Plan Administrator Compensation
The Plan Administrator serves without compensation; however, all expenses for Plan
administration, including compensation for hired services, will be paid by the Plan.
.J
Page 89 of 95
\.., Claims Administrator is not a Fiduciary
A Claims Administrator is not a fiduciary under the Plan by virtue of paying claims in
accordance with the Plan's rules as established by the Plan Administrator.
Funding the Plan and Payment of Benefits
The cost of the Plan is funded as follows:
1. For Employee and Dependent Coverage:
A. Funding is derived solely from the funds of the Employer.
2. Benefits are paid directly from the Plan through the Claims Administrator.
Plan is not an Employment Contract
The Plan is not to be construed as a contract for or of employment.
Clerical Error
\..
Any clerical error by the Plan Administrator or an agent of the Plan Administrator in
keeping pertinent.records or a delay in making any changes will not invalidate coverage
otherwise validly in force or continue coverage validly terminated. An equitable
adjustment of contributions will be made when the error or delay is discovered.
If, due to a clerical error, an overpayment occurs in a Plan reimbursement amoun~ the
Plan retains a contractual right to the overpayment. The person or institution receiving
the overpayment will be required to return the incorrect amount of money. In the case of
a Plan Participant, if it is requested, the amount of overpayment will be deducted from
future benefits payable.
Self-Funded Benefits
Medical, Prescription Drug, Dental and Vision Benefits
The Plan Administrator has complete authority to control and manage the Plan. The Plan
Administrator has full discretion to determine eligibility, to interpret the Plan, and to
determine whether a claim should be paid or denied, according to the provisions of the
Plan as set forth in this booklet. The Employer is fully responsible for the self-funded .
benefits. The Claims Administrator processes claims and provides other services to the
Employer related to the self-funded benefits. The Claims Administrator does not insure
or guarantee the self-funded benefits.
\..,
Page 90 of 95
General Plan Information
,~
The Plan will provide benefits, in accordance with the applicable requirements of federal
laws, such as COBRA, HIP AA (the Health Insurance Portability and Accountability Act
of 1996), the NMHP A (The Newborns' and Mothers' Health Protection Act of 1996),
and the WHCRA (The Women's Health and Cancer Rights Act of 1998).
The Plan will also provide benefits as required by any qualified medical child support
order, as defined in ERISA ~ 609(a), and provide benefits to dependent children placed
with participants or beneficiaries for adoption under the same terms and conditions as
apply in the case of dependent children who are natural children or participants of
beneficiaries, in accordance with ERISA ~609( c).
Your right to benefits under this Plan will be determined under each Program in which
you participate. Your rights to benefits in this Plan or any Program are subject to
amendmen~ modification or termination in accordance with the Plan Eligibility and
Participant Section of this Plan, and the applicable provisions of each Program. Any
amendmen~ modification or termination of a Program will also be an amendment,
modification or termination of this Plan.
Amendment or Termination of this Plan
The Employer fully intends to maintain this Plan indefinitely. However, it reserves the .A
right to terminate, suspend, discontinue or amend the Plan at any time upon advance ..",
notice to all Participants, subject to the terms of the applicable MOU.
Changes in the Plan may occur in any or all parts of the Plan including benefit coverage,
deductibles, maximums, co-payments, exclusions, limitations, definitions, eligibility and
the like.
If the Plan is terminated, the rights of Covered Persons are limited to covered charges
incurred before terl:nination.
Funding
All benefits paid under the Plan are paid in cash from the general assets of the District.
No Employees have any righ~ title, or interest whatever in or to any investment reserves,
accounts, or funds that the District may purchase, establish, or accumulate to aid in
providing Benefits under the Plan. Nothing contained in the Plan, and no action taken
under its provisions, creates a trust or fiduciary relationship of any kind between the
District and an Employee or any other person. Neither an Employee nor a beneficiary of
an Employee acquires any interest greater than that of an unsecured creditor.
Type of Plan
The Plan provides medical, dental, and prescription drug benefits.
.,J
Page 91 of95
\., Type of Administration
The Plan is a self-funded welfare plan and the administration is provided through a third
party Claims Administrator
Plan Name
South Tahoe Public Utility District Employees' Benefit Plan
Plan Number
901
Plan Effective Date
January 1, 1997
Plan Year
January 1 through December 31 sf
The Plan has been amended several times since its original effective date. See the title
page for all amendment dates.
Employer Information
South Tahoe Public Utility District
1275 Meadow Crest Drive
South Lake Tahoe, CA 96150
(530) 544-6474
Plan Administrator
General Manager
South Tahoe Public Utility District
1275 Meadow Crest Drive
South Lake Tahoe, CA 96150
(530) 543-6201
\.,
Claims Administrator
CDS Group Health
1625 East Prater Way. Building C. Suite 101
P.O. Box 50190
Reno.~ 89435-0190
(800) 455-4236
Trustee(s)
Board of Directors
South Tahoe Public Utility District
1275 Meadow Crest Drive
South Lake Tahoe, CA 96150
Plan Coordinaton
Nancy Hussmann; Rhonda McFarlane
South Tahoe Public Utility District
1275 Meadow Crest Drive
South Lake Tahoe, CA 96150
(530) 543-6222 or 543-6211
Agent of Legal Process
General Manager/Plan Administrator
South Tahoe Public Utility District
1275 Meadow Crest Drive
South Lake Tahoe, CA 96150
(530) 5343-6201
The Plan Trustees reserve the right to change Claims Administrator and/or Plan
Administrator at their discretion.
The Plan and its attachments constitute the written Plan Document required by ERISA
~402.
\..,
Page 92 of 95
Attachment 1
...,J
Authorization for Release of Claim Information
Claim Assistance
I, , hereby authorize the staff of CDS
Group Health, claims administrator for the South Tahoe Public Utility Distri~ to release
to Nancy Hussmann, Plan Coordinator, information regarding
This release of information is for the purpose of allowing the Plan Coordinator to assist
me with claim processing questions and to assist in resolving any billing and/or claim
discrepancies.
Specifically, I authorize the staff of CDS Group Health, to provide Nancy Hussmann,
Plan Coordinator, with billing and/or claim processing information, which may include
diagnosis and/or medical information, that will assist in determining the appropriate
action needed regarding the above c1aim(s).
This authorixation will expire 60 days after the date of my signatme on this
Authorization, after which date CDS Group Health is no longer authorized to discuss my
current medical claims information with the Plan Coordinator, unless a new
Authorization is signed by me.
J
I understand that the District shall not use any information contained in or obtained as a
result of this Medical Information Release against me in any District personnel action
(promotion, demotion, layoff: or disciplinary determination). I further understand that a
copy of this signed authorixation will be provided to me upon my request.
Signature:
Date:
Print Name:
Original:
Cc:
Plan Coordinator
Employee
Claims Administrator
..J
Page 93 of 95
\..,
\...
\.
Attachment 2
Authorimtion for Release Of Claim Information
For Claim Anneal
I, , hereby authorize the staff of CDS Group
Health, Claims Administrator for the South Tahoe Public Utility District, to release
information regarding
to the Human Resources Director (plan Coordinator) and/or General Manager (plan
Administrator).
This release of information is for the purpose of allowing the Plan Administrator and/or
Coordinator to assist me with appealing the denial of the above claim.
Specifically, I authorize the Claims Administrator to provide the General Manager (plan
Administrator) and/or Human Resources Director (plan Coordinator) with billing and/or
claim processing information, which may include diagnosis and/or medical information,
that will assist in determining the appropriate action needed regarding the above claim(s).
This authorization will expire 60 days after the date of my signature on this
Authorization, after which date Claims Administrator is no longer authorized to discuss
my current medical condition with the Plan Administrator and/or Coordinator, unless a
new Authorization is signed by me. I understand that the District shall not use any
information contained in or obtained as a result of this Medical Information Release
against me in any District personnel action (promotion, demotion, layoff: or disciplinary
determination). I further understand that a copy of this signed authorization will be
provided to me upon my request.
Signature:
Date:
Print Name:
Original:
Cc:
Plan Administrator
Plan Coordinator
Employee
Claims Administrator
Page 94 of 95
Attachment 3
.J
Authorization for
Release of Medical Information
Th
Claims Administrator and Plan Administrator
Request for Plan Exception
I, ~ hereby authorize the staff of
CDS Group Health and/or Medical Provider, to release to the Human Resources Director
and/or Geneml Manager (plan Coordinator and Plan Administrator) for the South Tahoe
Public Utility Distri~ information regarding
This release of information is for the purpose of allowing the Plan Admini~trator to make
an informed decision regarding my Request for Plan Exception. I understand that the
Claims Administrator will consult with the Plan Administrator and that any information
released pursuant to this Authorization may be shared with the Plan Administrator for
purposes of decision regarding the requested plan exception.
Specifically, I authorize Provider to inform the Claims Administrator of any medical ..J
information bearing upon my Request for Plan Exception, including when relevan~ my
current diagnosis, recommended course of action, and medical information relevant to the
recommended course of action, including any documents, test results, x-rays, etc. I
further specifically authorize the Claims Administrator to share this information with the
Plan Administrator. I further authorize Provider, Claims Administrator and/or Plan
Administrator to release this information to any third party qualified to review such
claims which may be consulted by Claims Administrator and/or Plan Administrator for
purposes of obtaining a recommendation or opinion regarding my Request for Plan
Exception.
This authorization will expire 60 days after the date of my signature on this
Authorization, after which date Provider is no longer authorized to discuss my current
medical condition with the Claims Admini~tor. I understand that the District shall not
use any information contained in or obtained as a result of this Medical Information
Release against me in any personnel (promotion or demotion or layoff determination) or
District disciplinary action. I further understand that a copy of this signed authorization
will be provided to me upon my request.
Signature:
Date:
Original:
Cc:
Claims Administrator
Plan Coordinator, Plan Administrator, Employee
..J
Page 95 of 95
~........
................
South Tahoe
Public Utility District
0Ir<<;t.cn
~ F..,...
Jamft It .Jon/Ilt
MtIy t,QU ~
Duanct~
EIfc~
1275 ~a.t.0rIve. South ~ Tahc>>-CA 96150-1<401
PhcnJ530!S44-6414. Fax 580 !541-o614.WWW.stputus
BOARD AGENDA ITEM 7d
TO:
Board of Directors
FROM:
Nancy Hussmann, Human Resources Director
Rhonda McFarlane. Chief Financial Officer
MEETING DATE:
December 6, 2007
ITEM - PROJECT NAME: Employee Benefits Plan 2008 Renewal
REQUESTED BOARD ACTION: (1) Renew Excess Insurance Policy with Gerber Life
Insurance Company; (2) Approve funding level for plan in the amount of $1 ,600 per
employee per month; (3) Approve COBRA rates for 2008 as follows: Single Dental $70;
Family Dental $185; Single Medical $650; Family Medical $1,600.
DISCUSSION: BB&H Benefit Designs, Inc., the District's consultant for the self-insured
Employee Benefits Plan, went out for proposal for the Excess Insurance company for
the Plan. Currently the District has a policy with Gerber Life Insurance Company.
Renewal proposals that were received indicated that renewing with Gerber would result
in only a 9.2% increase in fixed costs, versus 26.7-67.2% increase with other carriers.
Staff met with the Finance Committee who concurs that renewing with Gerber is most
cost effective.
Staff also met with the Finance Committee regarding the funding level per employee per
month for the Employee Benefits Plan. The District experienced a higher than normal
claims costs in 2007, due in part to initiating the Wellness Program. Inflation trending
was utilized to determine the appropriate level of funding required to meet anticipated
claims in 2008. Staff anticipates that Wellness costs will decrease in 2008, since many
of the tests required are not annual tests. Therefore, staff believes that the current
$1,600 per employee, per month, is adequate to cover anticipated claims in 2008.
The Employee Benefits Plan provides, as required by federal law, for continuation of
coverage in the event of termination or loss of dependent status. Participants electing
COBRA continuation coverage pay the applicable COBRA rate plus a 2% administrative
fee. Each year, applicable COBRA rates are established consistent with the prior year's
actual claim experience, in conjunction with the current Plan renewal issues. As
required under COBRA regulations, a two-tier rate structure must be provided, and
participants can elect to continue coverage for either medical or dental, or both.
-53-
Nancy Hussmann
Rhonda McFarlane
December 6, 2007
Page 2
Based upon recommendation from BB&H Benefit Designs, and taking into account the
current year's claim experience, renewal quotes and estimated claims liability for 2008,
these COBRA rates will accurately cover actual COBRA costs.
SCHEDULE: December 6,2007, Notify BB&H of Board decision; Notify CDS Group
Health of COBRA rates.
COSTS: $2,188,800
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATTACHMENTS: Stop Loss Renewal Comparison, BB&H Memo re COBRA Rates
CONCURRENCE WITH REQUESTED ACTION:
GENERAL MANAGER: YES~ NO
CHIEF FINANCIAL OFFICER: YES~ NO
-54-
CATEGORY: General
-..
South Tahoe Public UtIlity District
Stop Loss Renewal
Elf 1/1_
Volume Gerber Gerber TransAmenca Canada Life RE Moulton
Current Renewal Proposal Proposal Proposal
Specific Stop Loss MedIRx MedIRx MedIRx MedIRx MedIRx
Specific Level $65,000 $65.000 $65,000 $65,000 $65,000
lifetime Maximum $2,000,000 $2,000,000 $2.000,000 $2,000,000 $2,000,000
ContJact Type 15/12 15112 15/12 15/12 15112
Premiums
Single 22 $54.62 $59.92 $90.30 $80.46 $93.53
Family 96 $133.84 $146.27 $227.56 $168.84 $201.28
Monlhly Cost $14,050.28 $15,360.16 $23,832.36 $17,978.76 $21,380.54
Annual Cost $168,603.36 $184.321.92 $285,988.32 $215,745.12 $256,566.48
Aggregate Stop Loss MEidIRx MedIRx MedIRx MedIRx MedIRx
Margin 125% 125% 125% 125% 125%
Centrad Type 15112 15112 15/12 15112 15112
Monthly Cumulative
Maximum Reimbursement $1,000,000 $1,000,000 $1,000,000 $1,000,000 $1,000,000
Pl8mium
Single 118 $9.45 $10.11 $12.86 $10.50 $8.46
Monthly Cost $1,096.20 $1,1n.76 $1,491.76 $1,218..00 $981.36
Annual Cost $13,154.40 $14,073.12 $17,901.12 $14,616.00 $11,776.32
Total Stop loss Annual FIXed Cost $181,757.76 $198.395.04 $303,889.44 $230,361.12 $268,342.80
$ Difference $16,637.28 $122.131.&8 $48,603.36 $86,515.04
% DIffenmce 9.2% 67.2% 2&.7% 47.6%
ClaIms Liability
AggIegafe Fac:Ior
Single 22 $563.30 $669.03 $636.13 $806.02 $887.88
Family 96 $1,399.81 $1,662.55 $1,604.56 $1,767.05 $1,910.75
Monthly Uability $146,n4.36 $174,323.46 $168,045.82 $187,369.24 $202,965.36
Annuall.iablllty $1,761,292.32 $2,091 ,881.52 $2,016,549.84 $2,248.430.88 $2,435,584.32
$ Differ8nce $330,588.20 $255,257 .S2 $487,138.56 $674,292.00
% Difference 18.8% 14.5% 27.7% 38.3%
Rud plus Claims liability $1.943.050.08 $2,290,278..56 $2,328,439.28 $2,478,782.00 $2,703,927.12
$ DIfference $347,226.48 $377'-.20 $535,741.92 $760,877.04
% DifferelICe 17.1% 1tA% 27..6% 39.2%
-55-
To:
From:
cc:
Date:
Re:
Nancy Hussmann, S. Tahoe Pubk Ufifity District
Deb Babineau, OB55630
SooziBrooks
11/27/2007
2008 COBRA Rates 8. Funding levels
Memo
benefit designs
,",.,..ala "'''IU!'
As requested, please find attached the COBRA rates for 2008. The stop loss renewal
should be finalized in mid-Oecember, and if there ore any material changes to the
factors and fees proposed, the cobra rates should change. The stop loss renewal is
based on the claims experience through 10/31/07. Based on the update of claims we
received from Firstier (11/1/07-11/15/07), it does not appear that the stop loss renewal will
change. However, if claims deteriorate in the second half of November, then a change
will probably be proposed by the stop loss carrier. Gerber.
last year we recommended a change in methodology. This recommendation was
based on the fact that the covered population of 116 employees does not produce
creditable claims experience year to year. Therefore, we recommended using 85% of
the stop loss attachment factor proposed by the stop loss carrier, and then added the
fixed cost (factored employee/dependent when a super composite rate is charged). For
2008 we used this methodology in providing annual cobra rates.
Because the dental is not included in the stop loss, we used actual claims trended at
7.6% and then added the administration fees.
Please let me know if you hove any questions.
. Page 1
80 1 Garden Street, Suite 301
Santa Babara, CA 93101
Tele: 805-962-2868
Fax: 805-962-9268
-56-
S. Tahoe Public Utility District
COBRA Rates - Plan Year 2008
Spec stop Loss $65k
Claims dental medical
employee 62.7 6 568.68
family 104.60 1,413.17
fixed costs dental medical
employee - ssl 57.16
family - ssl 139.55
employee - admin & asf 1.06 14.78
family - admin & asl 2.82 39.41
Trended Claims 7.60% no trend
employee 68.36 568.68
family 113.93 1 ,413.17
supercomposite 151.91 1,255.72
cobra rates (2% not added)
employee
family
supercomposite
69.42
185.11
164.02
640.61
1 ,592.13
1 ,418.05
11/27/2007
2008 cobra rates with 651c ssl.xls
-57-
~..,...,.
..............
South Tahoe
Puk7Uc UtUityDlstrict
Dll-oc;t;ore
~FMdI
JImcIrlJ III Jolw
Mpyl.ou~
1>uarlIJ~
Erlc~.
1275 ~~.South... rat.-CAge1f5O.7<401
n.onego544. 6474.Fax530541-Ce14.www~
BOARD AGENDA ITEM 7e
TO:
Board of Directors
FROM:
Rhonda McFarlane, Chief Financial Officer
MEETING DATE:
December 6,2007
ITEM - PROJECT NAME: Check Signing Authority
REQUESTED BOARD ACTION: Adopt Resolution No. 2840-07 to designate authorized
signatories of all District bank accounts, superseding Resolution No. 2590.
DISCUSSION: As a matter of law and good policy the Board of Directors approves
payment of claims at each Board meeting. Upon Board approval, staff releases checks
to the payees. Checks are printed on a laser printer with a facsimile signature. Control
over the check stock, micro toner ink, and access to necessary computer software is
tightly controlled to avoid misappropriation of funds. Several positions are involved in
the automated check signing process to ensure proper internal controls are in place.
The only checks manually signed are emergency checks that usually involve a TRPA
permit deadline. In those cases, two of the authorized check signers manually sign the
check. In addition, the District has in place "Payee Positive Pay." This is a banking tool
that requires transmission of a computer file to the bank prior to releasing checks. The
computer file lists the check date, check numbers, check amounts and payees. The
check must match the computer file exactly or it will not be honored without proper
authorization.
At one time the District had minimal financial staff and needed the Board of Directors to
sign checks in order to have adequate internal controls over funds. Because the District
has evolved due to both having necessary staff for segregation of duties, and also due
to technology like "Payee Positive Pay," the Chief Financial Officer recommends the
administrative function of check signing be assigned to appropriate staff.
Request is made to have check signers on the District's bank accounts be designated
as any two of the following managers: General Manager, Assistant General Manager,
Chief Financial Officer and Executive Services Manager. Delegating this authority to
these positions will provide for effiCiency and safety over District funds. None of these
positions have computer access to input data into the general ledger. The District's
outside auditor and the District's Finance Committee concur with this recommended
change.
-59-
Rhonda McFarlane
December 6, 2007
Page 2
SCHEDULE: Effective upon approval.
COSTS: Some savings in staff time.
BUDGETED AMOUNT REMAINING: N/A
ATTACHMENTS: Resolution No. 2840-07
CONCURRENCE WITH REQUESTED ACTION:
GENERAL MANAGER: YES~ NO
CHIEF FINANCIAL OFFICER: YES~ NO
CATEGORY: General
-60-
1
2
3
4
5
RESOLUTION NO. 2840-07
A RESOLUTION OF THE BOARD OF DIRECTORS OF THE
SOUTH TAHOE PUBLIC UTILITY DISTRICT
TO DESIGNATE AUTHORIZED SIGNATORIES OF ALL
DISTRICT BANK ACCOUNTS
SUPERSEDING RESOLUTION NO. 2590
6
WHEREAS, at each board meeting of the South Tahoe Public Utility District the
7
Board Directors review and authorize payment of claims.
8
9
WHEREAS, strong internal controls are in place for check issuance, including
10
physical controls, computer software access controls, segregation of duties, and Payee
11
12
Positive Pay.
13
WHEREAS, check signing is an administrative function best delegated to senior
14
management staff.
15
16
WHEREAS, financial institutions require the Board of Directors designate the
17 appropriate positions allowed to withdraw funds from all accounts by check, draft, or
18
other items, for and on behalf of the South Tahoe Public Utility District.
19
20
NOW THEREFORE BE IT RESOLVED by the Board of Directors of the South
Tahoe Public Utility District, a public agency in the County of EI Dorado, State of
22 California that any two of the following designated positions are authorized to withdraw
23 funds from all accounts by check, draft, or other items, for and on behalf of the South
24 Tahoe Public Utility District: General Manager, Assistant General Manager, Chief
21
25
Financial Officer and Executive Services Manager.
26 1/1
27 1/1
28 11/
29 11/
30 11/
-61-
1 Resolution No. 2840-07
2 Page 2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
WE, THE UNDERSIGNED, do hereby certify that the above and foregoing
Resolution was duly adopted and passed by the Board of Directors of the South Tahoe
Public Utility District at a regularly scheduled meeting held on the 6th day of
December, 2007, by the following vote:
AYES:
NOES:
ABSENT:
Eric W. Schafer, Board President
South Tahoe Public Utility District
ATTEST:
Kathy Sharp, Clerk of the Board
-62-
PAYMENT OF CLAIMS
FOR APPROVAL
December 6, 2007
Payroll 11/21/07
Total Payroll
BNY Western Trust Company
FirstTier Administrators...health care pmts
Hatch & Parent-legal services
LaSalle Bank
Total Vendor EFT
Accounts Payable Checks-Sewer Fund
Accounts Payable Checks-Water Fund
Accounts Payable Checks-Self-funded Ins
Accounts Payable Checks-Grant Fund
Total Accounts Payable
Grand Total
Pavroll EFTs & Checks
EFT
EFT
EFT
CHK
EFT
EFT
CHK
EFT
CHK
CHK
EFT
CHK
AFLAC Medical & Dependent Care
CA Employment Taxes & W/H
Federal Employment Taxes & W/H
CalPERS Contributions
John Hancock Pension Loan Pmts
Great West Deferred Comp
Stationary Engineers Union Dues
United Way Contributions
CA State Disbursement Unit
CA State Franchise Tax Board
Employee Direct Deposits
Employee Paychecks
Adjustments-prior period correction
Total
-63-
11/21/07
3,151.31
12,482.06
79,618.02
25,598.66
2,442.46
15,314.05
2,077.04
86.00
460.15
15.00
192,684.90
11,580.10
0.00
345,509.75
345,509.75
345,509.75
288,598.88
47,520.54
34,340.16
156,572.80
527,032.38
431,193.67
336,648.80
15,444.38
39,120.00
822,406.85
1,694,948.98
Vendor Name
A -1 CHEMICAL INC
ACCOUNTEMPS
ACCOUNTEMPS
User: LAVERNE
Report: OH_PMT_CLAIMS_V2
Department / Proi Name
GEN & ADMIN
FINANCE
FINANCE
PAYMENT OF CLAIMS
Description Acct# / Pro' Code Amu Check Num Tvoe
OFFICE INVENTORY 1000 - 0428 499.99
Check Total: 499.99 AP -00068139 MW
CONTRACT SERVICE 1039 - 4405 1,764.00
CONTRACT SERVICE 2039 - 4405 1,764.00
Check Total: 3,528.00 AP -00068140 MW
AFLAC GEN & ADMIN SUPP INS W/H 1000 - 2532 829.72
Check Total: 829.72 AP -00068141 MW
ALESSI, SUSAN CUSTOMER SERVICE - WTR CNSRV INCNT WTR CONS EXPENSE 2038 - 6660 - WCNCTV 250.00
Check Total: 250.00 AP -00068142 MW
ALPEN SIERRA COFFEE COMPANY FINANCE OFC SUPPLY ISSUE 1039 - 6081 278.50
Check Total: 278.50 AP -00068143 MW
ALPINE METALS HEAVY MAINT GROUNDS & MNTC 1004 - 6042 169.71
Check Total: 169.71 AP -00068144 MW
ARAMARK UNIFORM SERVICES GEN & ADMIN UNIFORM PAYABLE 1000 - 2518 1,266.31
i Check Total: 1,266.31 AP-00068145 MW
rn
AROPERP PUMPS OPERATING PERMIT 1002 - 6650 575.00
Check Total: 575.00 AP -00068146 MW
AT &T GEN & ADMIN SIGNAL CHARGES 1000 - 6320 32.96
Check Total: 32.96 AP -00068149 MW
AT &T /CALNET 2 PUMPS TELEPHONE 1002 - 6310 0.19
AT &T /CALNET 2 PUMPS TELEPHONE 2002 - 6310 0.19
Check Total: 0.38 AP -00068147 MW
AT &T/MCI GEN & ADMIN TELEPHONE 1000 - 6310 15.65
AT &T/MCI PUMPS TELEPHONE 1002 - 6310 17.79
AT &T/MCI OPERATIONS TELEPHONE 1006 - 6310 21.68
AT &T /MCI INFORMATION SYS TELEPHONE 1037 - 6310 82.80
AT &T/MCI CUSTOMER SERVICE TELEPHONE 1038 - 6310 7.17
AT &T /MCI GEN & ADMIN TELEPHONE 2000 - 6310 15.64
AT &T/MCI PUMPS TELEPHONE 2002 - 6310 17.78
AT &T/MCI INFORMATION SYS TELEPHONE 2037 - 6310 82.79
Page: 1 Current Date: 11/29/2007
Current Tune: 12:03:12
PAYMENT OF CLAIMS
Vendor Name Department 1 Prol Name Description Acct# / Prof Code Amount Check Num Type
AT &T/MCI CUSTOMER SERVICE TELEPHONE 2038 - 6310 7.17
Check Total: 268.47 AP -00068148 MW
AUERBACH ENGINEERING CORP ENGINEERING - UPPER DRESSLER DRSSLR DTCH,UPR 1029 - 7062 - DRSSLR 280.00
Check Total: 280.00 AP- 00068150 MW
AWARDS OF TAHOE ADMINISTRATION INCNTV & RCGNTN 1021 - 6621 17.40
AWARDS OF TAHOE ADMINISTRATION INCNTV & RCGNTN 2021 - 6621 17.40
Check Total: 34.80 AP -00068151 MW
AWWA QUALSERVE OPERATIONS DUES /MEMB /CERT 1006 - 6250 71.00
Check Total: 71.00 AP -00068152 MW
BARNES, SHELLY CUSTOMER SERVICE - WTR CONS PROG WTR CONS EXPENSE 2038 - 6660 - WCPROG 100.00
Check Total: 100.00 AP -00068153 MW
BAY AREA COATING CONSULTANTS UNDERGROUND REP - ANGORA FIRE 07 G CONTRACT SERVICE 2001 - 4405 - FANG07 9,875.00
Check Total: 9,875.00 AP -00068154 MW
BAY TOOL & SUPPLY INC GEN & ADMIN SHOP SUPPLY INV 1000 - 0421 176.82
c
Check Total: 176.82 AP -00068155 MW
BErJIETT, DAVID CUSTOMER SERVICE - WTR CNSRV INCNT WTR CONS EXPENSE 2038 - 6660 - WCNCTV 75.00
Check Total: 75.00 AP -00068156 MW
BENTLY AGROWDYNAMICS OPERATIONS SLUDGE DISPOSAL 1006 - 6652 2,358.79
Check Total: 2,358.79 AP- 00068157 MW
BING MATERIALS UNDERGROUND REP PIPE/CVRS /MHLS 2001 - 6052 1,250.26
Check Total: 1.250.26 AP -00068158 MW
BROWN & CALDWELL CONSULTANTS DIAMOND VLY RNCH GROUNDS & MNTC 1028 - 6042 1,488.38
BROWN & CALDWELL CONSULTANTS ENGINEERING - ICR TMDL O2SYS/TMDL,ICR 1029 - 8605 - ICTMDL 2,704.59
BROWN & CALDWELL CONSULTANTS ENGINEERING - COLL SYS MASTER COLL SYS MST PLN 1029 - 8721 - CSMSPL 81,324.85
Check Total: 85,517.82 AP -00068159 MW
BUREAU OF LAND MANAGEMENT DIAMOND VLY RNCH LAND & BUILDINGS 1028 - 5010 4,700.00
Check Total: 4,700.00 AP -00068160 M W
CALIF BOARD OF EQUALIZATION GEN & ADMIN SHOP SUPPLY INV 1000 - 0421 45.17
CALIF BOARD OF EQUALIZATION PUMPS BEECHER PS UPGR 1002 - 8630 15.81
CALIF BOARD OF EQUALIZATION EQUIPMENT REP GENERATORS 1005 - 6013 6.98
User: LAVERNE
Page: 2 Current Date: 11/29/2007
Report: OH PMT_CLAIMS V2 Current Time: 12:03:12
Vendor Name
CALIF BOARD OF EQUALIZATION
CALIF BOARD OF EQUALIZATION
CALIF BOARD OF EQUALIZATION
CALIF BOARD OF EQUALIZATION
CALIF WATER RESOURCES CTRL BD OPERATIONS
CALIF WATER RESOURCES CTRL BD OPERATIONS
CALIFORNIA OVERNIGHT
CALIFORNIA OVERNIGHT
CALLIAN, JERALEE
CAMPBELL AUD, NANCI
0
CAMPBELL AUD, NANCI
CAMPMOR
CAMPMOR
CARDINALE
CARDINALE
CAROLLO ENGINEERS
CAROLLO ENGINEERS
CHARTER ADVERTISING/DESIGN
CHARTER ADVERTISING/DESIGN
CLARK PLUMBING HEATING & A/C
Department / Prof Name
LABORATORY
PUMPS
PUMPS
LABORATORY
LABORATORY
LABORATORY
CUSTOMER SERVICE - WTR CNSRV INCNT WTR CONS EXPENSE
PUMPS
PUMPS
GEN & ADMIN
FINANCE
EQUIPMENT REP
EQUIPMENT REPAIR
ELECTRICAL SHOP
ELECTRICAL SHOP
FINANCE
FINANCE
DIAMOND VLY RNCH
PAYMENT OF CLAIMS
User: LAVERNE Page: 3
Report: OH_PMT_CLAIMS_V2
Description
LAB SUPPLIES
WELLS
PUMP STATIONS
LAB SUPPLIES
TRAVEL/MEETINGS
OPERATING PERMIT
POSTAGE EXPENSES
POSTAGE EXPENSES
SAFETY/EQUIP/PHY
SAFETY/EQUIP/PHY
SHOP SUPPLY INV
INV/FRT/DISCOUNT
AUTOMOTIVE
AUTOMOTIVE
TRAVEUMEETINGS
TRAVEUMEETINGS
PRINTING
PRINTING
GROUNDS & MNTC
Acct# I Proi Code
1007 - 4760
2002 - 6050
2002 - 6051
2007 - 4760
1006 - 6200
1006 - 6650
1007 - 4810
2007 - 4810
2038 - 6660 - WCNCTV
Check Total:
1002 - 6075
2002 - 6075
1000 - 0421
1039 - 6077
1005 - 6011
2005 - 6011
1003 - 6200
2003 - 6200
1039 - 4920
2039 - 4920
1028-6042
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
Current Date: 11/29/2007
Current Time: 12:03:12
A oun Check Num Type
6.42
86.13
2.30
6.44
169.25 AP -00068161 MW
170.00
170.00 AP -00068162 MW
46,143.00
46,143.00 AP -00068163 MW
179.36
27.00
206.36 AP -00068164 MW
250.00
250.00 AP- 00068165 MW
104.00
104.00
208.00 AP -00068166 MW
582.84
6.99
589.83 AP-00068167 MW
32.33
32.32
64.65 AP -00068168 MW
104.00
156.00
260.00 AP- 00068169 MW
4,437.50
4,437.50
8,875.00 AP- 00068170 MW
249.50
Vendor Name
CWEA
DELARIVA, MITCH
DICK'S FULLER -
DICK'S FULLER -
DICK'S FULLER -
DIONEX CORP
EL DORADO COUNTY
EMPIRE SAFETY & SUPPLY
rn
ENT IX INC
ENTRIX INC
ENTRIX INC
ENTRIX INC
ETS
FERGUSON ENTERPRISES INC.
FERGUSON ENTERPRISES INC.
FERGUSON ENTERPRISES INC.
FERGUSON ENTERPRISES INC.
FISHER SCIENTIFIC
FISHER SCIENTIFIC
Department / Proi Name
ENGINEERING
CUSTOMER SERVICE - WTR CONS PROG WTR CONS EXPENSE
HEAVY MAINT
OPERATIONS
OPERATIONS
LABORATORY
ENGINEERING - SUT WELL REDRILL
UNDERGROUND REP
ENGINEERING
ENGINEERING
ENGINEERING
ENGINEERING
LABORATORY
PUMPS
HEAVY MAINT
PUMPS
PUMPS
LABORATORY
LABORATORY
- WTRLN,GRD MTN
- SUT WELL REDRILL
- WELL, BAYVIEW
- SUT WELL REDRILL
PAYMENT OF CLAIMS
Description
User: LAVERNE Page: 4
Report: OH PMT_CLAIMS V2
TRAVEL/MEETINGS
GROUNDS & MNTC
BUILDINGS
GROUNDS & MNTC
REPL ION CHRMATG
SUT WELL REDRILL
SAFETY/EQUIP /PHY
WTRLN, GARD MTN
SUT WELL REDRILL
WELL, BAYVIEW
CORR PILOT SUTWL
MONITORING
SHOP SUPPLIES
SECONDARY EQUIP
WELLS
SHOP SUPPLIES
LAB SUPPLIES
LAB SUPPLIES
Acct# / Prol Code
2029 - 6200
Check Total:
Check Total:
2038 - 6660 - WCPROG
Check Total:
1004 - 6042
1006 - 6041
1006 - 6042
1007 - 8822
1007-4760
2007-4760
Check Total:
Check Total:
2029 - 8463 - RWSUTR
Check Total:
Check Total:
Check Total:
Current Date: 11/29/2007
Current Time: 12:03:12
Amount Check Num I PQ
249.50 AP -00068171 MW
66.00
66.00 AP- 00068172 MW
1,200.00
1,200.00 AP- 00068173 MW
47.79
144.44
205.88
398.11 AP -00068174 MW
47,543.98
47,543.98 AP -00068175 MW
68.00
68.00 AP -00068176 MW
2001 - 6075 772.57
Check Total: 772.57 AP- 00068177 MW
2029 - 7065 - GMWL07 1,605.50
2029 - 8463 - RWSUTR 15,030.27
2029 - 8574 - BAYWEL 466.70
2029 - 8717 - RWSUTR 8,281.51
Check Total: 25,383.98 AP -00068178 MW
1007 - 6110 700.00
Check Total: 700.00 AP -00068179 MW
1002 - 6071 33.73
1004 - 6022 187.05
2002 - 6050 22.51
2002 - 6071 33.73
277.02 AP -00068180 MW
537.40
750.16
1,287.56 AP -00068181 MW
Vendor Name
FUSCO, TINA
GERBER LIFE INSURANCE COMPANY
GFOA
GFOA
GFS CHEMICAL
GFS CHEMICAL
GIBSON, HARRY
GRAINGER
GRAINGER
GRAINGER
cn
GRAANGER
HAEN CO INC, THOMAS
HAEN CO INC, THOMAS
HAEN CO INC, THOMAS
HAEN CO INC, THOMAS
HARTFORD, THE
HARTFORD, THE
SELF FUNDED INS
FINANCE
FINANCE
LABORATORY
LABORATORY
HEAVY MAINT
HEAVY MAINT
HEAVY MAINT
OPERATIONS
GEN & ADMIN -
ENGINEERING
GEN & ADMIN -
ENGINEERING
GEN &ADMIN
GEN & ADMIN
LPPS SEISMIC UPG
- LPPS SEISMIC UPG
SUT WELL REDRILL
- SUT WELL REDRILL
PAYMENT OF CLAIMS
Department / Proi Name Descriotion
CUSTOMER SERVICE - WTR CNSRV INCNT WTR CONS EXPENSE
User: LAVERNE Page: 5
Report: OH_PMT_CLAIMS_V2
EXCESS INSURANCE
ADVISORY
ADVISORY
LAB SUPPLIES
LAB SUPPLIES
CUSTOMER SERVICE - WTR CNSRV INCNT WTR CONS EXPENSE
PRIMARY EQUIP
FILTER EQ/BLDG
SMALL TOOLS
GROUNDS & MNTC
CONST RETAINAGE
LPPS IMPRVMNTS
CONST RETAINAGE
SUT WELL REDRILL
LIFE INS
LTD, UNION
HAUGE BRUECK ASSOCIATES LLC ENGINEERING - ICR TMDL O2SYS/TMDL,ICR
HELVIG, PAUL CUSTOMER SERVICE - WTR CNSRV INCNT WTR CONS EXPENSE
HIGH SIERRA BUSINESS SYSTEMS ADMINISTRATION SERVICE CONTRACT
Acct# / Pro' Code
2038 - 6660 - WCNCTV
Check Total:
100.00 AP- 00068182 MW
3000 - 6744 14,929.38
14,929.38 AP- 00068183 MW
1039 - 4440 207.50
2039 - 4440 207.50
415.00 AP -00068184 MW
1007 - 4760 127.84
2007 - 4760 82.95
210.79 AP -00068185 MW
150.00
150.00 AP -00068186 MW
1004 - 6021 420.01
1004 - 6023 50.28
1004 - 6073 121.22
1006 - 6042 243.62
Check Total: 835.13 AP -00068187 MW
1000 - 2605 - LPSEIS - 818.30
1029 - 8720 - LPSEIS 8,183.00
2000 - 2605 - RWSUTR - 16,687.62
2029 - 8463 - RWSUTR 166,876.20
Check Total: 157,553.28 AP -00068188 MW
1000 - 2512 1,962.09
1000 -2539 1,758.62
Check Total: 3,720.71 AP -00068189 MW
Check Total:
Check Total:
Check Total:
2038 - 6660 - WCNCTV
Check Total:
1029 - 8605 - ICTMDL
Check Total:
2038 - 6660 - WCNCTV
Check Total:
1021-6030
Current Date: 11/29/2007
Current Time: 12:03:12
ount Check Num Tye
100.00
6,523.95
6.523.95 AP -00068190 MW
350.00
350.00 AP- 00068191 MW
173.32
Vendor Name
HIGH SIERRA BUSINESS SYSTEMS
HIGH SIERRA SOUNDS
HIGH SIERRA SOUNDS
HUGO BONDED LOCKSMITH
HUGO BONDED LOCKSMITH
HUGO BONDED LOCKSMITH
HUGO BONDED LOCKSMITH
HUGO BONDED LOCKSMITH
HUSSMANN, NANCY
HUSSMANN, NANCY
HYD & NATIVE AMER BANK
rn
'.o
INSTY- PRINTS INC
INSTY - PRINTS INC
INSTY - PRINTS INC
INSTY - PRINTS INC
INSTY - PRINTS INC
INSTY- PRINTS INC
INSTY- PRINTS INC
INTERNATIONAL INSTITUTE OF
INTERNATIONAL INSTITUTE OF
INTERSTATE SAFETY & SUPPLY
INTERSTATE SAFETY & SUPPLY
User: LAVERNE
Report: OH_PMT_CLAIMS_V2
Department / Proi Name
ADMINISTRATION
ADMINISTRATION
ADMINISTRATION
PUMPS
EQUIPMENT REP
UNDERGROUND REP
PUMPS
EQUIPMENT REPAIR
HUMAN RESOURCES
HUMAN RESOURCES
UNDERGROUND REP
OPERATIONS
DIO
ENGINEERING
ENGINEERING - EFFLUENT EVAL
DIO
ENGINEERING
CUSTOMER SERVICE - WTR CONS PROD
ADMINISTRATION
ADMINISTRATION
GEN & ADMIN
GEN & ADMIN
PAYMENT OF CLAIMS
Description
SERVICE CONTRACT
INCNTV & RCGNTN
INCNTV & RCGNTN
PUMP STATIONS
AUTOMOTIVE
SHOP SUPPLIES
PUMP STATIONS
AUTOMOTIVE
TRAVEUMEETINGS
TRAVEUMEETINGS
INFILTRTN /INFLOW
TRAVEUMEETINGS
PRINTING
PRINTING
REP EXP PUMPS
PRINTING
PRINTING
WTR CONS EXPENSE
DUES/MEMB /CERT
DUES/MEMB /CERT
SHOP SUPPLY INV
SAFETY INVENTORY
Page: 6
Acct# I Prol Code
2021 - 6030
1021 - 6621
2021 - 6621
1002 - 6051
1005 - 6011
2001 - 6071
2002 - 6051
2005 - 6011
1022 - 6200
2022 - 6200
1001 - 6055
1021 - 6250
2021 - 6250
1000 - 0421
1000 - 0425
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
1006 - 6200
1027 - 4920
1029 - 4920
1029 - 8676 - EFFLEV
2027 - 4920
2029 - 4920
2038 - 6660 - WCPROG
Check Total:
Check Total:
Check Total:
Current Date: 11/29/2007
Current Time: 12:03:12
Amount Check Num Tvoe
173.32
346.64 AP -00068192 MW
300.00
300.00
600.00 AP- 00068193 MW
5.12
21.55
23.44
5.12
21.55
76.78 AP -00068194 MW
177.76
177.75
355.51 AP -00068195 MW
32,381.25
32.381.25 AP -00068196 MW
760.03
685.35
209.26
457.62
685.36
209.25
436.43
3.443.30 AP -00068197 MW
87.50
87.50
175.00 AP- 00068198 MW
486.33
119.54
605.87 AP- 00068199 MW
Vendor Name
IVES TRAINING GROUP
J&L PRO KLEEN INC
J&L PRO KLEEN INC
JATCO INC
KAHL COMMERCIAL INTERIORS INC
KAISER PERMANENTE
KELLEY EROSION CONTROL INC
KENKO UTILITY SUPPLY INC
v
KIVINIS CLUB OF LAKE TAHOE
KRLT & KOWL RADIO
LAKE TAHOE EYE CARE
LAKE TAHOE EYE CARE
LAKE TAHOE EYE CARE
LAKE TAHOE SOUTH SHORE
LAKE TAHOE SOUTH SHORE
LAKE TAHOE SOUTH SHORE
LAKE TAHOE SOUTH SHORE
User: LAVERNE
Report: OH_PMT_CLAIMS_V2
Department / Proi Name
EQUIPMENT REP
FINANCE
FINANCE
ENGINEERING
CUSTOMER SERVICE
SELF FUNDED INS
EXPORT PIPELINE - B LINE REVEG
HEAVY MAINT
DIO - PR EXP- EXTERNAL
DIO - WTR CONS PROG
OPERATIONS
ELECTRICAL SHOP
ELECTRICAL SHOP
ADMINISTRATION
DIO - PR EXP- EXTERNAL
ADMINISTRATION
DIO - PR EXP- EXTERNAL
PAYMENT OF CLAIMS
Description
SHOP SUPPLIES
JANITORIAL SERV
JANITORIAL SERV
OFFICE SUPPLIES
FILE CAB, INSPEC
CLAIMS
BLINE REVEG
EXPORT/FRCE MAIN
PUB RELATIONS
WTR CONS EXPENSE
SAFETY /EQUIP/PHY
SAFETY/EQUIP /PHY
SAFETY/EQUIP/PHY
DUES/MEMB /CERT
PUB RELATIONS
DUES/MEMB /CERT
PUB RELATIONS
Page: 7
Acct# / Proi Code
1005 - 6071
1039 - 6074
2039 - 6074
1029 - 4820
1038 - 8744
3000 - 6745
9098 - 8736 - BLNVEG
Check Total:
1004 - 6047
1027 - 6620 - PREEXT
Check Total:
2027 - 6660 - WCPROG
Check Total:
1006 - 6075
1003 - 6075
2003 - 6075
1021 - 6250
1027 - 6620 - PREEXT
2021 - 6250
2027 - 6620 - PREEXT
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
Current Date: 11/29/2007
Current Time: 12:03:12
Amount Check Num I n
658.06
658.06 AP- 00068200 MW
1,603.50
1,603.50
3,207.00 AP- 00068201 MW
111.37
111.37 AP -00068202 MW
1,717.02
1,717.02 AP -00068203 MW
515.00
515.00 AP -00068204 MW
39,120.00
39.120.00 AP -00068205 MW
3,840.21
3,840.21 AP- 00068206 MW
484.09
484.09 AP -00068207 MW
4,220.00
4,220.00 AP- 00068208 MW
65.00
65.00 AP -00068210 M W
84.00
84.00
168.00 AP -00068211 MW
100.00
25.00
100.00
25.00
PAYMENT OF CLAIMS
Vendor Name Department / Proi Name Description Acct# / Prot Code Amount Check Num Type
Check Total: 250.00 AP- 00068212 MW
LAKESIDE NAPA PUMPS SHOP SUPPLIES 1002 - 6071 43.42
LAKESIDE NAPA PUMPS SMALL TOOLS 1002 - 6073 11.91
LAKESIDE NAPA HEAVY MAINT FILTER EQ/BLDG 1004 - 6023 7.31
LAKESIDE NAPA HEAVY MAINT BUILDINGS 1004 - 6041 31.03
LAKESIDE NAPA HEAVY MAINT GROUNDS & MNTC 1004 - 6042 149.99
LAKESIDE NAPA HEAVY MAINT SHOP SUPPLIES 1004 - 6071 108.25
LAKESIDE NAPA EQUIPMENT REP AUTOMOTIVE 1005 - 6011 786.18
LAKESIDE NAPA EQUIPMENT REP GENERATORS 1005 - 6013 600.10
LAKESIDE NAPA EQUIPMENT REP SMALL TOOLS 1005 - 6073 517.19
LAKESIDE NAPA DIAMOND VLY RNCH GROUNDS & MNTC 1028 - 6042 248.31
LAKESIDE NAPA UNDERGROUND REP SMALL TOOLS 2001 - 6073 22.94
LAKESIDE NAPA PUMPS SHOP SUPPLIES 2002 - 6071 36.99
LAKESIDE NAPA PUMPS SMALL TOOLS 2002 - 6073 11.91
LAKESIDE NAPA EQUIPMENT REPAIR AUTOMOTIVE 2005 - 6011 878.78
1
LAKESIDE NAPA EQUIPMENT REPAIR GENERATORS 2005 - 6013 221.02
i
Check Total: 3.675.33 AP -00068213 MW
LIVE WIRE MEDIA PARTNERS DIO - WTR CONS PROG WTR CONS EXPENSE 2027 - 6660 - WCPROG 672.00
Check Total:
LONG, WES DIAMOND VLY RNCH DUES/MEMB /CERT 1028 - 6250 93.95
Check Total: 93.95 AP -00068215 MW
LOOMIS FARGO & CO. FINANCE CONTRACT SERVICE 1039 - 4405 267.07
LOOMIS FARGO & CO. FINANCE CONTRACT SERVICE 2039 - 4405 267.06
Check Total:
MACAN, JULIANA
MAXHIMER, JOHN W
MAXHIMER, JOHN W
MC MASTER CARR SUPPLY CO
User: LAVERNE
CUSTOMER SERVICE - WTR CNSRV INCNT WTR CONS EXPENSE 2038 - 6660 - WCNCTV 250.00
Check Total: 250.00 AP -00068217 MW
PUMPS TRAVEUMEETINGS 1002 - 6200 48.50
PUMPS TRAVEUMEETINGS 2002 - 6200 48.50
Check Total: 97.00 AP -00068218 MW
PUMPS SHOP SUPPLIES 1002 - 6071 359.37
Page: 8 Current Date: 11/29/2007
Report: OH_PMT_CLAIMS_V2 Current Time: 12:03:12
672.00 AP-00068214 MW
534.13 AP- 00068216 MW
Vendor Name Department / Prol Name
MC MASTER CARR SUPPLY CO HEAVY MAINT
MC MASTER CARR SUPPLY CO PUMPS
MC MASTER CARR SUPPLY CO PUMPS
MEEKS BUILDING CENTER UNDERGROUND REP SMALL TOOLS 1001 - 6073 60.95
MEEKS BUILDING CENTER PUMPS PUMP STATIONS 1002 - 6051 15.00
MEEKS BUILDING CENTER PUMPS SHOP SUPPLIES 1002 - 6071 10.78
MEEKS BUILDING CENTER PUMPS SMALL TOOLS 1002 - 6073 194.04
MEEKS BUILDING CENTER ELECTRICAL SHOP SHOP SUPPLIES 1003 - 6071 65.44
MEEKS BUILDING CENTER HEAVY MAINT PRIMARY EQUIP 1004 - 6021 54.39
MEEKS BUILDING CENTER HEAVY MAINT FILTER EQ/BLDG 1004 - 6023 38.08
MEEKS BUILDING CENTER HEAVY MAINT BUILDINGS 1004 - 6041 598.29
MEEKS BUILDING CENTER HEAVY MAINT GROUNDS & MNTC 1004 - 6042 243.01
MEEKS BUILDING CENTER HEAVY MAINT SHOP SUPPLIES 1004 - 6071 30.05
MEEKS BUILDING CENTER HEAVY MAINT SMALL TOOLS 1004 - 6073 387.28
MEEKS BUILDING CENTER DIAMOND VLY RNCH FENCE, DVR 1028 - 8689 203.86
ME&S BUILDING CENTER UNDERGROUND REP SMALL TOOLS 2001 - 6073 13.37
MEEKS BUILDING CENTER PUMPS WELLS 2002 - 6050 10.66
MEEKS BUILDING CENTER PUMPS PUMP STATIONS 2002 - 6051 11.37
MEEKS BUILDING CENTER PUMPS SHOP SUPPLIES 2002 - 6071 10.78
MEEKS BUILDING CENTER PUMPS SMALL TOOLS 2002 - 6073 194.03
Check Total: 2,141.38 AP -00068220 MW
MUNIQUIP INC PUMPS PUMP STATIONS 1002 - 6051 651.37
Check Total: 651.37 AP -00068221 MW
MURDOCK, HENRY CUSTOMER SERVICE - WTR CNSRV INCNT WTR CONS EXPENSE 2038 - 6660 - WCNCTV 325.00
Check Total: 325.00 AP-00068222 MW
MY OFFICE PRODUCTS GEN & ADMIN OFFICE INVENTORY 1000 - 0428 1,312.40
MY OFFICE PRODUCTS CUSTOMER SERVICE OFFICE SUPPLIES 1038 - 4820 1.38
MY OFFICE PRODUCTS FINANCE OFFICE SUPPLIES 1039 - 4820 19.08
MY OFFICE PRODUCTS CUSTOMER SERVICE OFFICE SUPPLIES 2038 - 4820 1.38
User: LAVERNE
PAYMENT OF CLAIMS
Description Acct# / Proi Code Amount Check Num Type
BUILDINGS 1004 - 6041 28.78
SHOP SUPPLIES 2002 - 6071 441.44
SMALL TOOLS 2002 - 6073 945.47
Check Total: 1,775.06 AP -00068219 MW
Page: 9 Current Date: 11/29/2007
Report: OH_PMT CLAIMS_V2 Current Time: 12:03:12
PAYMENT OF CLAIMS
Vendor Name Denartmeot / Pro! Name Description Acct# / Proi Code Amount Check Num TAM
MY OFFICE PRODUCTS FINANCE OFFICE SUPPLIES 2039 - 4820 19.08
Check Total: 1,353.32 AP- 00068223 MW
NELS TAHOE HARDWARE HEAVY MAINT SHOP SUPPLIES 1004 - 6071 12.90
Check Total: 12.90 AP -00068224 MW
NEVADA GENERATOR SYSTEMS EQUIPMENT REP GENERATORS 1005 - 6013 100.40
Check Total: 100.40 AP -00068225 MW
NEWARK IN ONE ELECTRICAL SHOP WELLS 2003 - 6050 446.85
Check Total: 446.85 AP -00068226 MW
NOLAN, LYNN FINANCE - WTRLN/WATER CNSV TRAVEUMEETINGS 2039 - 6200 - PRP502 124.87
Check Total: 124.87 AP -00068227 MW
NORTON, LARRY B ELECTRICAL SHOP TRAVEUMEETINGS 1003 - 6200 91.18
NORTON, LARRY B ELECTRICAL SHOP TRAVEUMEETINGS 2003 - 6200 91.18
Check Total: 182.36 AP -00068228 MW
NOVALYNX CORP LABORATORY LAB SUPPLIES 1007 - 4760 80.81
NOVALYNX CORP LABORATORY LAB SUPPLIES 2007 - 4760 88.07
w Check Total: 168.88 AP 00068229 MW
OFFICE MAX ADMINISTRATION OFFICE SUPPLIES 1021 - 4820 13.30
OFFICE MAX ENGINEERING OFFICE SUPPLIES 1029 - 4820 38.89
OFFICE MAX CUSTOMER SERVICE OFFICE SUPPLIES 1038 - 4820 23.82
OFFICE MAX ADMINISTRATION OFFICE SUPPLIES 2021 - 4820 13.29
OFFICE MAX ENGINEERING OFFICE SUPPLIES 2029 - 4820 38.90
OFFICE MAX CUSTOMER SERVICE OFFICE SUPPLIES 2038 - 4820 23.86
Check Total: 152.06 AP -00068230 MW
PDM STEEL DIAMOND VLY RNCH GROUNDS & MNTC 1028 - 6042 1,304.74
Check Total: 1,304.74 AP- 00068231 MW
PERKS PLUMBING & HEAT INC, L A HEAVY MAINT GROUNDS & MNTC 1004 - 6042 1,230.00
Check Total: 1,230.00 AP -00068232 MW
PIONEER AMERICAS LLC OPERATIONS HYPOCHLORITE 1006 - 4755 11,589.23
Check Total: 11.589.23 AP -00068233 MW
PRAXAIR 174 HEAVY MAINT SHOP SUPPLIES 1004 - 6071 372.63
User: LAVERNE
Page: 10 Current Date: 11/29/2007
Report: OH_PMT_CLAIMS_V2 Current Time: 12:03:12
Vendor Name
RADIO SHACK
RADIO SHACK
RADIO SHACK
RADIO SHACK
RADIO SHACK
RED WING SHOE STORE
RED WING SHOE STORE
RHP MECHANICAL SYSTEMS
RSN SPORTS NETWORK
SACRAMENTO BEE, THE
SCHLANGE, PAUL
SCHWAB TIRES, LES
SCHWAB TIRES, LES
SCOTTYS HARDWARE
SEARS, R
SHANNON, MICHAEL
SHARP, KATHY
SHARP, KATHY
User: LAVERNE
Report: OH_PMT_CLAIMS_V2
Department / Proi Name
PUMPS
INFORMATION SYS
PUMPS
ELECTRICAL SHOP
INFORMATION SYS
DIAMOND VLY RNCH
UNDERGROUND REP
EQUIPMENT REP
DIO - WTR CONS PROG
ENGINEERING - EFFLUENT EVAL
DIAMOND VLY RNCH
EQUIPMENT REP
EQUIPMENT REPAIR
PUMPS
CUSTOMER SERVICE
CUSTOMER SERVICE
ADMINISTRATION
ADMINISTRATION
PAYMENT OF CLAIMS
Description
OFFICE SUPPLIES
DIST.COMP SPPLIS
OFFICE SUPPLIES
SHOP SUPPLIES
DIST.COMP SPPLIS
SAFETY/EQUIP /PHY
SAFETY/EQUIP/PHY
GENERATORS
WTR CONS EXPENSE
REP EXP PUMPS
DUES /MEMB /CERT
AUTOMOTIVE
AUTOMOTIVE
WELLS
- WTR CNSRV INCNT WTR CONS EXPENSE
- WTR CNSRV INCNT WTR CONS EXPENSE
TRAVELIMEETINGS
TRAVEL/MEETINGS
Acct# I Proi Code
1002 - 4820
1037 - 4840
2002 - 4820
2003 - 6071
2037 - 4840
1028 - 6075
2001 - 6075
1005-6013
1028-6250
1005 - 6011
2005 - 6011
2002-6050
1021 - 6200
2021 - 6200
Check Total:
Check Total:
Check Total:
Check Total:
2027 - 6660 - WCPROG
Check Total:
1029 - 8676 - EFFLEV
Check Total:
Check Total:
Check Total:
Check Total:
2038 - 6660 - WCNCTV
Check Total:
2038 - 6660 - WCNCTV
Check Total:
Check Total:
Page: 11 Current Date: 11/29/2007
Current Time: 12:03:12
moun
372.63 AP- 00068234 MW
26.93
18.63
26.93
10.75
18.62
101.86 AP -00068235 MW
164.86
164.86
329.72 AP -00068236 MW
245.14
245.14 AP -00068237 MW
4,175.00
4,175.00 AP- 00068238 MW
922.60
922.60 AP -00068239 MW
56.25
56.25 AP- 00068240 MW
2,256.76
1,526.36
3,783.12 AP -00068241 MW
32.31
32.31 AP -00068242 MW
250.00
Check Num Type
250.00 AP -00068243 MW
250.00
250.00 AP -00068244 MW
53.35
53.35
106.70 AP -00068245 MW
PAYMENT OF CLAIMS
Vendor Name Department / Proi Name Description Acct# / Prot Code Amount Check Num Type
SHORTRIDGE, LAURA CUSTOMER SERVICE - WTR CNSRV INCNT WTR CONS EXPENSE 2038 - 6660 - WCNCTV 750.00
Check Total: 750.00 AP -00068246 MW
SIERRA CHEMICAL CO PUMPS HYPOCHLORITE 2002 - 4755 1,957.43
Check Total: 1,957.43 AP -00068247 MW
SIERRA ENVIRONMENTAL LABORATORY MONITORING 1007 - 6110 380.00
Check Total: 380.00 AP -00068248 MW
SIERRA NEVADA CLASSIFIEDS DIAMOND VLY RNCH PRINTING 1028 - 4920 73.24
Check Total: 73.24 AP -00068249 MW
SIERRA PACIFIC POWER GEN & ADMIN ELECTRICITY 1000 - 6330 60,120.50
SIERRA PACIFIC POWER GEN & ADMIN ST LIGHTING EXP 1000 - 6740 8.67
SIERRA PACIFIC POWER GEN & ADMIN ELECTRICITY 2000 - 6330 28,448.93
Check Total: 88,578.10 AP -00068250 MW
SIERRA SPRINGS UNDERGROUND REP SUPPLIES 1001 - 6520 40.28
SIERRA SPRINGS PUMPS SUPPLIES 1002 - 6520 2.69
SIERRA SPRINGS ELECTRICAL SHOP SUPPLIES 1003 - 6520 13.42
SIERRA SPRINGS HEAVY MAINT SUPPLIES 1004 - 6520 40.28
SIERRA SPRINGS EQUIPMENT REP SUPPLIES 1005 - 6520 13.43
SIERRA SPRINGS OPERATIONS SUPPLIES 1006 - 6520 40.28
SIERRA SPRINGS DIAMOND VLY RNCH SUPPLIES 1028 - 6520 13.43
SIERRA SPRINGS CUSTOMER SERVICE SUPPLIES 1038 - 6520 13.43
SIERRA SPRINGS UNDERGROUND REP SUPPLIES 2001 - 6520 40.28
SIERRA SPRINGS PUMPS SUPPLIES 2002 - 6520 10.74
SIERRA SPRINGS ELECTRICAL SHOP SUPPLIES ., 2003 - 6520 13.42
SIERRA SPRINGS EQUIPMENT REPAIR SUPPLIES 2005 - 6520 13.43
SIERRA SPRINGS CUSTOMER SERVICE SUPPLIES 2038 - 6520 13.43
Check Total: 268.54 AP -00068251 MW
SMITH, GREG PUMPS STANDBY ACCOMODA 1002 - 6083 31.69
Check Total: 31.69 AP -00068252 MW
SOUTH SIDE AUTO BODY EQUIPMENT REPAIR AUTOMOTIVE 2005 - 6011 1,628.91
Check Total: 1,628.91 AP- 00068253 MW
User: LAVERNE
Page: 12 Current Date: 11/29/2007
Report: OH PMT_CLAIMS_V2 Current Time: 12:03:12
Vendor Name
SOUTH TAHOE NEWSPAPER AGENCY
SOUTH TAHOE NEWSPAPER AGENCY
SOUTH TAHOE REFUSE
SOUTH TAHOE REFUSE
SOUTHWEST GAS
SOUTHWEST GAS
STANTEC CONSULTING INC
STANTEC CONSULTING INC
STANTEC CONSULTING INC
STANTEC CONSULTING INC
STANTEC CONSULTING INC
SUTITUTE PERSONNEL &
SUBSTITUTE PERSONNEL &
SUTER ASSOCIATES, LYNN M.
SUTER ASSOCIATES, LYNN M.
SWAIN, CAROL
SWAIN, CAROL
TAHOE ASPHALT INC
TAHOE BLUEPRINT
TAHOE BLUEPRINT
TAHOE BLUEPRINT
User: LAVERNE
Report: OH_PMT_CLAIMS_V2
Department / Proi Name
ADMINISTRATION
ADMINISTRATION
DIO - PR EXP- EXTERNAL
DIO - PR EXP- EXTERNAL
GEN &ADMIN
GEN & ADMIN
ENGINEERING -
ENGINEERING -
ENGINEERING -
ENGINEERING -
ENGINEERING -
UNDERGROUND REP
OPERATIONS
DIO
DIO
INFORMATION SYS
INFORMATION SYS
UNDERGROUND REP
EFFLUENT EVAL
DVR EIR
WTRLN,GRD MTN
HWY 50 WTR W2Y
WTRLN, GLEN RD
ENGINEERING - EFFLUENT EVAL
ENGINEERING - WTRLN,AL TAHOE
ENGINEERING - WTRLN, TATA
PAYMENT OF CLAIMS
Description
SUBSCRIPTIONS
SUBSCRIPTIONS
PUB RELATIONS
PUB RELATIONS
NATURAL GAS
NATURAL GAS
REP EXP PUMPS
DIAM VLY MP /EIR
WTRLN, GARD MTN
WTLN HWY50 WIN/Y
WTLN, GLEN RD
CONTRACT SERVICE
CONTRACT SERVICE
CONTRACT SERVICE
CONTRACT SERVICE
TRAVEL/MEETINGS
TRAVEUMEETINGS
PIPE/CVRS/MHLS
REP EXP PUMPS
WTLN, AL TAHOE
WTRLN, TATA LN
Acct# / Proi Code
1021 - 4830
2021 - 4830
Check Total:
1027 - 6620 - PREEXT
2027 - 6620 - PREEXT
Check Total:
1000 - 6350
2000 - 6350
Check Total:
1029 - 8676 - EFFLEV
1029 - 8725 - DVREIR
2029 - 7065 - GMWL07
2029 - 8355 - H5OWWY
2029 - 8714 - GLENWL
Check Total:
1001 - 4405
1006 - 4405
1027 - 4405
2027 - 4405
1037 - 6200
2037 - 6200
2001-6052
Check Total:
Check Total:
Check Total:
Check Total:
1029 - 8676 - EFFLEV
2029 - 8811 - ATWLO8
2029 - 8866 - TATAWL
Check Total:
Page: 13 Current Date: 11/29/2007
Current Time: 12:03:12
Amount Check Num "mg
54.63
54.63
109.26 AP - 00068254 MW
162.50
162.50
325.00 AP -00068255 MW
114.07
64.40
178.47 AP -00068256 MW
845.50
24,920.09
420.37
5,687.50
48,419.92
80,293.38 AP- 00068257 MW
1,932.00
2,838.00
4,770.00 AP -00068258 MW
1,225.00
1,225.00
2,450.00 AP -00068259 MW
239.56
239.56
479.12 AP -00068260 MW
735.00
735.00 AP -00068261 MW
11,264.73
374.97
445.16
12,084.86 AP -00068262 MW
Vendor Name
Tahoe Daily Tribune
Tahoe Daily Tribune
Tahoe Daily Tribune
Tahoe Daily Tribune
TAHOE MOUNTAIN NEWS
TAHOE PRINTING
TAHOE PRINTING
TAHOE SAND & GRAVEL
TAHOE VALLEY ELECTRIC SUPPLY
TAHOE YOUTH & FAMILY SERV
TUSTIN LOCK AND SAFE
TUSTIN LOCK AND SAFE
UNITED RENTALS INC
USA BLUE BOOK
USA BLUE BOOK
VANGUARD VAULTS
VANGUARD VAULTS
VERIZON
VWR CORPORATION
Department / Proi Name
ADMINISTRATION
ADMINISTRATION
DIO - PR EXP- EXTERNAL
DIO - WTR CONS PROG
DIO - WTR CONS PROG
ADMINISTRATION
ADMINISTRATION
UNDERGROUND REP
PUMPS
DIO - WTR CONS PROG
INFORMATION SYS
INFORMATION SYS
UNDERGROUND REP
PUMPS
PUMPS
ADMINISTRATION
ADMINISTRATION
DIAMOND VLY RNCH
LABORATORY
PAYMENT OF CLAIMS
PRINTING
PRINTING
User: LAVERNE Page: 14
Report: OH_PMT_CLAIMS_V2
Description
SUBSCRIPTIONS
SUBSCRIPTIONS
PUB RELATIONS
WTR CONS EXPENSE
WTR CONS EXPENSE
PIPE /CVRS /MHLS
PUMP STATIONS
WTR CONS EXPENSE
DIST.COMP SPPLIS
DIST.COMP SPPLIS
SMALL TOOLS
BEECHER PS UPGR
WELLS
OFFICE SUPPLIES
OFFICE SUPPLIES
TELEPHONE
LAB SUPPLIES
Acct# I Proi Code
1021 - 4830
2021 - 4830
2027 - 6620 - PREEXT
2027 - 6660 - WCPROG
Check Total:
2027 - 6660 - WCPROG
Check Total:
1021 - 4920
2021 - 4920
2001-6052
1002 - 6051
2027 - 6660 - WCPROG
Check Total:
1037 - 4840
2037 - 4840
2001-6073
1002 - 8630
2002 - 6050
1021 - 4820
2021 - 4820
1028-6310
1007-4760
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
Current Date: 11/29/2007
Current Time: 12:03:12
Amount Check Num I Re
61.75
61.75
1,722.00
2,995.00
4,840.50 AP -00068263 MW
325.00
325.00 AP -00068264 MW
42.66
42.65
85.31 AP -00068265 MW
1,728.48
1,728.48 AP -00068266 MW
14.55
14 AP -00068267 MW
500.00
500.00 AP -00068268 MW
387.82
383.82
771.64 AP- 00068269 MW
1,488.25
1,488.25 AP -00068270 MW
249.15
1,134.87
1,384.02 AP -00068271 MW
231.00
231.00
462.00 AP 00068272 MW
194.90
194.90 AP- 00068273 MW
55.57
Vendor Name
VWR CORPORATION
WEDCO INC
WESTERN ENVIRONMENTAL
WESTERN EXTERMINATOR COMPANY
WESTERN NEVADA SUPPLY
WESTERN NEVADA SUPPLY
WESTERN NEVADA SUPPLY
WESTERN NEVADA SUPPLY
WESTERN NEVADA SUPPLY
WESTERN NEVADA SUPPLY
WE §TERN NEVADA SUPPLY
co
WINZLER & KELLY CONSULT ENGRS
WINZLER & KELLY CONSULT ENGRS
ZEE MEDICAL INC
Department / Prol Name
LABORATORY
ELECTRICAL SHOP
LABORATORY
HEAVY MAINT
UNDERGROUND REP
PUMPS
HEAVY MAINT
HEAVY MAINT
HEAVY MAINT
UNDERGROUND REP
CUSTOMER SERVICE
ENGINEERING - EFFLUENT EVAL
ENGINEERING - LPPS SEISMIC UPG
OPERATIONS
PAYMENT OF CLAIMS
User: LAVERNE Page: 15
Report: OH_PMT_CLAIMS_V2
Description
LAB SUPPLIES
SECONDARY EQUIP
MONITORING
BUILDINGS
PIPE/CVRS/MHLS
PUMP STATIONS
PRIMARY EQUIP
BUILDINGS
SHOP SUPPLIES
PIPE /CVRS /MHLS
WATER METERS
REP EXP PUMPS
LPPS IMPRVMNTS
SAFETY/EQUIP/PHY
Acct# / Proi Code
2007 - 4760
1003 - 6022
1007 - 6110
1004 - 6041
1001 - 6052
1002 - 6051
1004 - 6021
1004 - 6041
1004 - 6071
2001 - 6052
2038 - 6045
1006-6075
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
1029 - 8676 - EFFLEV
1029 - 8720 - LPSEIS
Check Total:
Check Total:
Grand Total:
Current Date: 11/29/2007
Current Time: 12:03:12
Amount Check Num I
13.67
69.24 AP- 00068274 MW
25.59
25.59 AP- 00068275 MW
120.00
120.00 AP -00068276 MW
370.00
370.00 AP -00068277 MW
2,626.41
887.93
26.70
8.49
23.64
4,537.95
13,071.55
21,182.67 AP -00068278 MW
28,709.00
1,372.00
30,081.00 AP -00068279 MW
64.86
64.86 AP -00068280 MW
822,406.85
~..., ~,...
.....tt......
South Tahoe
Public Utility District
I:llroerore
~ FIImlI
.hlmM It.~
Mal)'Lou ~
0wIN ~
EI1c Sdu6r
127!5.~en.t Drtve..Sot.rth1*~.CA 9615()..'1401
~680544-6414.Fax5!O!541-0014.www.s.udlfS
BOARD AGENDA ITEM 14a
TO:
FROM:
Board of Directors
Richard H. SOlbrig, General Manager
MEETING DATE: December 6, 2007
ITEM - PROJECT: Conference with Legal Counsel - Existing Litigation
REQUESTED BOARD ACTION: Direct staff.
DISCUSSION: Pursuant to Section 54956.9(a) of the California Government Code,
Closed Session may be held for conference with legal counsel regarding existing
litigation: Meyers Landfill Site - United States of America vs. EI Dorado County and City
of South Lake Tahoe and Third Party Defendants, Civil Action No. S-01-1520 LKK
GGH, United States District Court for the Eastern District of California.
SCHEDULE:
COSTS:
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATTACHMENTS:
CONCURRENCE WITH REQUESTED ACTION:
GENERAL MANAGER: YES ACH) NO
CHIEF FINANCIAL OFFICER: YES~NO
CATEGORY: Sewer
-79-
INDIAN CREEK RESERVOIR
DL OXYGENATION PROJECT
NEGATIVE D O
ENVIRONMENTAL IMPACT
• Mid 1980s: ICR identified as an impaired waterbody.
• 2000: Draft amendments to Water Quality Control Plan
- Includes ICR TMDL and TMDL implementation plan
• 2001: TMDL Tech Support Document Developed
- http: / /www.swrcb.ca.gov /rwgcb6 /tmdl /indianckresindex.htm
• 2002: Water Quality Control Plan Amendments
Indicator
Interim Target (2013)
Final Target (2024)
Total Phosphorus
(P)
<0.04 mg /L, annual mean
<0.02 mg /L, annual mean
Dissolved Oxygen
(DO)
30 -day avg.— 6.5 mg /L
7 -day min. — 5.0 mg /L
1 -day min. —4.0 mg /L
>7.0 mg /L
Secchi Depth
Summer mean > 2 meters
Chlorophyll a
Summer mean < 10 mg /cu meter
Trophic State
Index
Composite index < 45 units
• Early 1970s — Present:
C✓fWater - Quality Monitoring
• 2004
Olnternal Phosphorus Control Plan
• 2005
Q ICR Sediment Studies
QConceptual Design
• 2006 -07:
0319(h) Grant Funding
— Planning & Design
— CEQA/NEPA Documentation
• July - August 2007
11Perform environmental review
[Prepare draft Initial Study /Negative Declaration
(IS /ND)
• October 12, 2007
I IS /ND — COMPLETED
• October 15 — November 19, 2007
[Public Notice of Availability
I1Public Review
• December 6, 2007
I?lPublic Meeting
❑ Consideration of Negative Declaration
INDIAN CREEK RESERVOIR
South Tahoe Public Utility District
Site Area
•Alpine County,
southeast Diamond
Valley;
• BLM Lands;
• E 1/2 Sect. 4, TION,
R20E;
• LP Land Preserve
Zone
• Equipment Building
• 0 Generation
System
• Underwater 0
Delivery Skid
• Submerged 4 -inch
power and 0
conveyance lines
1.7
P
i
r,
NOM 0111•30MINI/OR
• Less Than Significant — Mitigation
Incorporated
— AESTHETICS
• Visual Impact
• CA DIVISION OF SAFETY OF DAMS
"Based on the information provided, we find
the proposed project may require
excavation into the upstream portion of
the embankment dam to instal! pipelines
and conduits. As long as the trench
excavations are shallow and are backfilled
properly, this work should not significantly
affect the dam or its appurtenances."
• CALTRANS
"The Washoe Tribe of California and Nevada is a
federally recognized tribe located within the
area, please ensure that early consultation
takes place with the Tribe and input from the
Native American community occurs for any
potential impacts of this proposed project."
Accept the ICR TMDL Oxygenation
Project Initial Study
DCertify Negative Declaration of
Environmental Impact with written
comments and responses to comments
ElFile Notice of Determination
~
~ ~OL.J 10/b/6l
(Pc
Adult WeUness Proe:ram Guidelines
Effective January 1,2007: PPO Paid at 100% (Non-PPO paid @ 80%) no deductible or co-pay.
Treating MD's medical opinion supersedes these Guidelines. MD may determine that certain procedures are not medicallv indic
Exam, Test or Procedure Frequency 18-25 26-39 40-49 50-64 65+
Comprehensive Physical Exam, including such
items as abdomen, breasts, heart, height,
weight, neck, pelvic, rectal, testicles & groin, Annually X X X X X
vision/color, hearing (forced whisper), blood
pressure, rectal exam, prostate rectal exam,
hemoccult (stool occult blood), testicles and
groin
Blo88 PFessure X X X X X
Reetal EKam AiHlually X X X
Reetal Exam 9f~ostate X X X
Hem966t:lk (Stool 866alt blood) X X X
Fasting Complete Blood +est Count (CRC), Every 5 years X X
Complete Metabolic Panel (CMP) & Chemical Every 2 years X
Urinalvsis "'.' . --, Annuallv X X
Complete Fasting Lipid Profile Every 3 X X
Years
Thvroid-Stimulatin~ Ronnone (TSID Everv 3 vears X X
TB SkinlQYaRtifeFea Test Every 5 vears X X X X X
RestingEKG Baseline Age 30
Resting EKG Every 4 years X
Stress EKG Every 3 years X X
Colonoscopy Every 10 X X
years
Bone Mineral Density +est Assessment
(Central or Peripheral; CT not cov'd as Every 3 yrs X X
Wellness) post
Women menopausal
Men At least One X
Women Only
Pap/Pelvic Annually X To 30
Everv 2 vears 31+ X X
Mammogram Baseline 35-39
Every 2 years X
Annuallv X X
HPV immunization series A~es 9-26 X To 26
Men Only
PSA Blood Test Annually X X
Testi61es & Grein EH:Bl T,. .,., X X X X X
ated.
Adult Immunization Guidelines
an accordanee with Current 2006 CDC Recommendations)
Immunization
DiptBeria & T etaJ.m5 Toxoid
Tetanus (Td) or Tda if indicated
or Booster
Eve
Influenza (flu)
Annuall if over M 50
Pneumovax neumonia shot)
Once over e 65
.,
.. .
Child WeUness Guidelines
Children through 18 years of age shall receive a minimum of one annual physical exam, and young children
may receive more than one well-child exam, up to the Frequency Limits listed below. Benefit is payable at
1000,10 with no deductible or co-pay for PPO Providers and 80% payable for non-PPO providers. Coverage
includes the following routine services, as recommended by the physician: Physical Exam, Laboratory blood
tests, Urinalysis, X-rays, Immunizations (See Immunization Requirements, below)
Limits
Fr uen Limit
Seven visits
Three visits
One visit r Calendar Year
Child Immunization Reouirements
() )er Current 2CJO() CDC Recommendations
Immunization 18t Dose 2114 Dose 3n1 Dose 401 Dose/Booster
Diptheria, Tetanus, 2 months 4 months 6 months Between 15 and 18 months. Can be given as
Pertussis (DTPIDTaP) early as 12 months as long as 6 months have
passed since third dose. Fourth dose should
be given at the latest between 4-6 years.
Tetanus and Diptheria If If previously If previously 11-18 years: One booster dose if the child
(Td) previously completed completed has completed the DTPIDTaP series and has
completed not yet received a booster for any reason.
Hepatitis A 12 months 23 months N/a
(Hep A)
Given at least 6
months apart
HepatitisB Birth 1-2 months 6-18 months 2-18 years: Three dose series given to all
(Hep B) children under 18 who didn't get the vaccine
as infants
H. influenzae type b 2 months 4 months 6 months
(Hib) or between
12-15 months
MeasleslMumps, Between One month N/a Second dose is typically given between 4-6
Rubella (MMR) 12-15 after fIrSt years, and should be given by 11-12 years at
months dose the latest.
Pneumococcus 2 months 4 months 6 months 12-15 months
(PCV7)
Chickenpox 12-24 N/a N/a Can be given up to age 13 in a child who has
(Varicella, Var) months not contracted chickenpox
Rotavirus (RV) 2-3 4-10 weeks 6-8 months All three doses should be given no later than
months after the fust 8 months.
dose
Polio (IPV) 2 months 4 months Between 6- Between 4-6 years
Injectable Polio 18 months
Vaccine
Menin2ococcal Age 13-15 Age 18
Females - HPV Ages 9-26
immunization series