AP 11-18-10SOUTH TAHOE PUBLIC UTILITY DISTRICT
REGULAR BOARD MEETING AGENDA
Thursday, November 18, 2010
2:00 P.M.
District Board Room
1275 Meadow Crest Drive, South Lake Tahoe, California
Richard Solbri , General Mana er Paul Sciuto, Assistant General Mana er
Dale Rise, President BOARD MEMBERS Mary Lou Mosbacher, Vice President
James R. Jones, Director Eric W. Schafer, Director Chris Cefalu, Director
1. CALL TO ORDER REGULAR MEETING - PLEDGE OF ALLEGIANCE
2. COMMENTS FROM THE AUDIENCE (This is an opportunity for members of the public to address the
Board on short non - agenda items that are within the subject matter jurisdiction of the District. Five
minute limit. No action can be taken on matters not listed on the agenda.)
3. CORRECTIONS TO THE AGENDA OR CONSENT CALENDAR
4. ADOPTION OF CONSENT CALENDAR (Any item can be removed to be discussed and considered
separately upon request. Comments and questions from members of the public, staff or Board can
be taken when the comment does not necessitate separate action.)
5. CONSENT ITEMS BROUGHT FORWARD FOR SEPARATE DISCUSSION / ACTION
6. ITEMS FOR BOARD ACTION REQUESTED BOARD ACTION
a. Ordinance No. 525 -10: Unreported Enact Ordinance No. 525-10
Pg. 17 Connections and Discharges Amending Section 4.6.7 of the
(Tim Bledsoe) Administrative Code Regarding
Unreported Connections and
Discharges
b. Headworks Replacement Phase II Project
Pg. 23 (Julie Ryan)
(1) Approve Staff's Recommended
List of Pre - Qualified General
Contractors and SCADA Integrators
for Bidding on the Headworks
Replacement Phase II Project; and
(2) Authorize Staff to Advertise for
Bids
REGULAR BOARD MEETING AGENDA - NOVEMBER 18, 2010 PAGE - 2
C. Employees' Benefit Plan
Pg. 25 (Nancy Hussmann)
d. Payment of Claims
Pg. 113
Update the Plan Document to
Reflect Changes Required by the
Recent Enactment of Health Care
Reform
Approve Payment in the Amount of
$1,721,696.05
7. BOARD MEMBER STANDING COMMITTEE REPORTS
(Discussions may take place; however, no action will be taken)
a. Water & Wastewater Operations Committee (Jones / Rise)
b. Finance Committee (Schafer / Cefalu)
C. Executive Committee (Rise / Mosbacher)
d. Planning Committee (Mosbacher / Schafer)
8. BOARD MEMBER AD HOC COMMITTEE REPORTS
a. Lukins Brothers Water Company Ad Hoc Committee (Jones / Schafer)
b. Management Contract Ad Hoc Committee (Rise / Schafer)
C. General Manager Contract Ad-Hoc Committee (Rise / Mosbacher)
9. EL DORADO COUNTY WATER AGENCY PURVEYOR REPRESENTATIVES REPORT
10. BOARD MEMBER REPORTS (Discussions may take place; however, no action will be taken.)
11. GENERAL MANAGER REPORT(S) (Discussions may take place; however, no action will be taken.)
a. New City Council Members Orientation
12. STAFF / ATTORNEY REPORT(S) (Discussions may take place; however, no action will be taken.)
a. Aspen Low Income Housing Project - Paul Hughes
13. NOTICE OF PAST AND FUTURE MEETINGS / EVENTS
Past Meetings / Events
11 /10 /10 - El Dorado County Water Agency Board Meeting
11 / 15/10 - Finance Committee Meeting
11/15/10- Water and Wastewater Operations Committee Meeting
Future Meeflngs / Events
11 /23/10 - 11:00 a.m. - Finance Committee Meeting at District
11 /25/10 & 11 /26/10 - Thanksgiving Holiday (District Office Closed)
11 /29/10 - 3:30 p.m. - Water and Wastewater Operations Committee Meeting
11 /30/10 - ACWA (Association of California Water Agencies) Conference through 12/3/10
11 /30/10 - 9:00 a.m. - Alpine County Supervisors Special Board Meeting in Markleeville
12/02/10 - 2:00 p.m. - STPUD Regular Board Meeting at District
12/07/10 - 9:00 a.m. - Alpine County Regular Board Meeting in Markleeville
12/07/10 - 8:00 a.m. - ECC (Employee Communication Committee) Meeting
Director Mosbacher is Board representative
12/08/10 - 10:00 a.m. - El Dorado County Water Agency Board Meeting in Shingle Springs
REGULAR BOARD MEETING AGENDA - NOVEMBER 18, 2010 PAGE - 3
14. CLOSED SESSION (The Board will adjourn to Closed Session to discuss items listed below. Closed
Session is not open to the public; however, an opportunity will be provided at this time if members
of the public would like to comment on any item listed. Three minute limit.)
a. Pursuant to Government Code Section 54956.9(a) /Conference with Legal Counsel
Pg. 127 Existing Litigation re: False Claims Act Case: United States, the States of California,
Delaware, Florida, Nevada, and Tennessee and the Commonwealths of
Massachusetts and Virginia ex rel. John Hendrix v. J -M Manufacturing Company, Inc.
and Formosa Plastics Corporation, U.S.A., Civil Action No. ED CV06- 0055 -GW, United
States District Court for the Central District of California
b. Pursuant to Government Code Section 54957.6(a) /Conference with
Pg. 129 Labor Negotiators
Agency Negotiators: Richard Solbrig /General Manager, Board of Directors
Employee Organization: Management Unit
C. Pursuant to Government Code Section 54957.6fa) /Conference with
Pg. 131 Labor Negotiators
Agency Negotiators: Richard Solbrig /General Manager, Board of Directors
Employee Organization: Stationary Engineers, Local 39
d. Pursuant to Government Code Section 54957.6(a) /Conference with
Pg. 133 Labor Negotiators
Unrepresented Employee Position: General Manager
Agency Negotiators: Executive Committee, Board of Directors
15. ACTION / REPORT ON ITEMS DISCUSSED DURING CLOSED SESSION
16. ADJOURNMENT (To the next regular meeting, December 2, 2010, 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. A recording of the meeting is retained for 30
days after minutes of the meeting have been approved. 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, but may occur slightly later
than the specified time.
Public participation is encouraged. Public comments on items appearing on the agenda will be taken at the some 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. Backup to any
agenda item(s) not included with the Board packet will be made available when finalized at the District office, at the
Board meeting, and upon request to the Clerk of the Board.
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.
M
19 so
CONSENT CALENDAR
NOVEMBER 18, 2010
ITEMS REQUESTED ACTION
a. Luther Pass Pump Station (LPPS) Standby Power (1) Approve Change Order No. 3 to
Pg. i ( Ivo Bergsohn) Sierra Nevada Construction, Inc., in
the Amount of $13,403.20; and
(2) Add Four (4) Calendar Days to
the Contract Time
b. 2010 Echo View Tank Sitework Project
Pg. 5 (Julie Ryan)
(1) Approve Change Order No. 1 for
KG Walters Construction Company,
as a Credit to the District in the
Amount of <$52,013.46 >; (2) Approve
the Partial Closeout Agreement and
Release of Claims; and (3) Authorize
Staff to File a Partial Notice of
Completion with the El Dorado
County Clerk
_:-f
South Tahoe Public Utility District ■ 1274 Meadow Crest Drive ■ South Lake Tahoe, CA 96150
Phone 530.544.6474 ■ Facsimile 530.541.0614 ■ www.stpud.us
Richard K Sow
S outh Chr1sQ6W
James R. Jones
Public Utility District
Dale Rlea
1275 Meadow Crest Drive - 5outh Lake Tahoe - CA 96150 -7401
i'hone 530 544 -6474 - Fax 530 541 -0614 - www.stpud.us
BOARD AGENDA ITEM 4a
TO: Board of Directors
FROM: No Bergsohn, Hydro-Geologist
MEETING DATE: November 18, 2010
ITEM - PROJECT NAME: Luther Pass Pump Station (LPPS) Standby Power Generation
Facility
REQUESTED BOARD ACTION: (1) Approve-Change Order No. 3 to Sierra Nevada
Construction, Inc., in the amount of $13,403.20; and (2) Add four (4) calendar days to
the contract time.
DISCUSSION: The itemized parts of Change Order No. 3 are as follows:
Item 1, in the amount of $760.00, is to remove concrete encasement surrounding a
4 -inch blow -off line connected to the B -line identified during excavation for the new
generator building. The District directed the contractor to remove the concrete
encasement to provide access to District crews for line abandonment. The added labor
and equipment costs required for this work is an extra work item that was not part of the
original contract documents.
Item 2, in the amount of $2,934.00, is to install rip -rap north of the generator building and
construct a cut -off wall, drain pipe and dry well in accordance with Information Bulletin
No. 4 - Grading Plan Modifications (July 19, 2010). The additional rip -rap is requested to
provide support for the native material between the north property line and the new
generator building. The cut -off wall, drain pipe and dry well are requested to protect
the footing beneath the retaining wall from saturation by routing drainage from the drip
line trench past the retaining wall to a dry well added at the west end of the wall. The`
added labor, equipment and materials required for these grading plan changes is an
extra work item that was not part of the original contract documents.
Item 3, in the amount of $9,595.00 and add four (4) calendar days to the contract time
is to: increase the length of the 12 -inch CMP culvert from 8 -feet to 36 -feet; furnish and
install a precast concrete headwall; and place additional rip rap in front of the fire
pump building in accordance with Information Bulletin No. 6 - (August 26, 2010). The
requested changes are needed to allow for grading improvements for construction
while maintaining adequate site drainage in front of the fire pump building. The added
labor, equipment and materials required for these plan changes are extra work that
-1-
No Bergsohn
November 18, 2010
Page 2
was not part of the original contract documents. The added calendar days will change
the project completion date from February 4, 2011, to February 8, 2011.
Item 4, in the amount of <$377.84 >, is a credit for elimination of the motor operator
requirement for the coiling door. Staff directed the engineer to remove the motor
operator and replace with a hand chain operator due to infrequent use of the coiling
door. The credit is the total cost difference between furnishing and installing a motor
operated coiling door and a hand chain operated coiling door in accordance with the
specifications.
Item 5, in the amount of <$1,315.00 >, is a credit for revegetation of barren areas
disturbed by construction activities at the site. The site plan requires the contractor to
revegetate all native and barren areas disturbed during construction. However, the -
Contract Documents did not include a revegetation specification and areas requiring
revegetation where not identified on the site plan. Therefore, District staff agreed to
share the costs for completion of this revegetation work in accordance with TRPA
permitting requirements. The credit represents the contractors fifty percent (50 %) share
of the site revegetation costs.
Item 6, in the amount of $1,807.04, is to pay the overtime premium for earthwork
performed on October 9 and 10, 2010. The District requested that the contractor
perform weekend work in order to satisfactorily complete all remaining earth disturbing
construction activities prior to the end of the TRPA grading season (October 15, 2010).
SCHEDULE: As soon as possible
COSTS: $13,403.20
ACCOUNT NO: 1029 - 8933 /RGLPPS
BUDGETED AMOUNT REMAINING: $ 665,261
ATTACHMENTS: Change Order No. 3 (November 18, 2010)
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: Sewer
GENERAL MANAGER: YES .
_ a NO
CHIEF FINANCIAL OFFICER: YES NO
-2-
CHANGE ORDER NUMBER 3
m Project: LPPS STANDBY POWER GENERATOR FACILITY Contractor: Sierra Nevada Construction. Inc.
Date: 11.18.2010
The Contract Shall Be Changed As Follows:
PO #: P22641
1) Increase $760.00 to remove concrete encasement surrounding the 4 -inch blow -off line at
the Luther Pass Pump Station for abandonment, as directed by the District (June 9, 2010).
The increase includes all additional labor and equipment costs for this work.
Total Item 1 is $760.00
2) Increase $2,934.00 to install 8 x 18" rip -rap north of the generator building and construct
a concrete cut -off wall, 4 -inch drain pipe and 3'x 3'x 2' dry well west of the drip line trench
in accordance with Information Bulletin #004 — Grading Plan Modifications (July 19, 2010).
The increase includes all additional labor, equipment and material costs for construction of
these modifications to the grading plan.
Total Item 2 Is $2,934.00
TOTAL FOR CHANGE ORDER NO.
Original Contract
3,
ITEMS 1 — 6 IS:
$2,027,007.00
$13 403.20
263 Calendar Days
Previous Change Order
$37 645.00
10 Calendar Days
Current Contract
$29064,652.00
273 Calendar Days
THIS CHANGE ORDER.
$13 403.20
4 Calendar Days
New Contract Total
$2,078
277 Calendar Days
Contractor agrees to make the herein - described
In contract price and/or contract time noted
described, unless specifically noted in individual
changes in accordance with the terms hereof. The ch
is full settlement for costs incurred because of the change
description(s).
Authorized By STPUD Board President
Date •
Date:
Accepted By Contractor
Date:
Reviewed By
-3-
ange
(s)
3) Increase $9,595.00 and add four(4) calendar days to the Contract Time to: increase the
length of the CMP culvert; furnish and install a precast concrete headwall; and install
additional rip rap in front of the fire pump building in accordance with Information Bulletin
#006 (August 26, 2010). The increase includes all additional labor, equipment and material
costs for this change and credit of $239.00 for the 12 -inch CMP culvert replaced in Drawing
C -103. The added calendar days will change the project completion date from February 4,
2011 to February 8, 2011.
Total Item 3 Is $9,595.00
4) Deduct $377.84 as a credit for elimination of the motor operator for the coiling door as
specified in Section 083323 — Coiling Doors (SD #20 review comments, August 13, 2010).
The credit represents the total cost difference between a motor operated coiling door and a
hand chain operated coiling door, complete and in- place, in accordance with the
specifications.
Total Item 4 Is <$377.84>
5) Deduct <$1,315.00> as a credit for revegetation of four areas totaling approximately
8,000 square feet of barren areas disturbed by construction activities. The credit represents
one -half of the total cost to complete revegetation work, performed on October 20, 2010, by
Kelley Erosion Control Services (KECS Invoice No. 1403).
Total Item 5 is <$1,315.00>
6) Increase $1,807.04 to pay the overtime premium for earthwork performed on October 9
and 10, 2010 to complete all remaining earth disturbing construction activities.
Total Item 6 is $1,807.04
-4-
wwwd Manager
RUMIM K 5olbeig
,5outh Tahoe C"CeNju
James X Jones
Public Utility Diotrict - ''' LW MOOM411"
Eftfthaftr
1275 Meadow Crest Drive • South lake Tahoe • CA 96150 -7401
Phone 530 544 -6474 - Fax 530 541 -0614 • www.stpud.u5
BOARD AGENDA ITEM 4b
TO: Board of Directors
FROM: Julie Ryan, Senior Engineer
MEETING DATE: November 18, 2010
ITEM - PROJECT NAME: 2010 Echo View Tank Sitework Project
REQUESTED BOARD ACTION: (1) Approve Change Order No. 1 for KG Walters
Construction Company, as a credit to the District in the amount of <$52, 013.46 >; (2)
Approve the Partial Closeout Agreement and Release of Claims; and (3) Authorize staff
to file a Partial Notice of Completion with the El Dorado County Clerk.
DISCUSSION: Change Order No. 1 addresses 3 work items that are beyond the scope
and or quantity defined in the Contract, 5 credits to the District for costs recovered
and /or work not performed, and a change to the contract time.
1. The project bid item for paving was calculated on Unit Price basis. An
additional 881 s.f. of paving was installed within the Project area for an
additional cost to the District of $5,286.00.
2. The Contract included a line item of $100,000.00 for drilling and blasting to be
performed on a Time & Materials basis. The level of effort required for drilling
and blasting was less than the Contract amount, resulting in a reduction in
this line item by $73, 523.15 to balance the Contract.
3. To improve operation of the Twin Peaks Zone in light of upcoming capital
improvements to the zone, staff requested that KG Walters install an altitude
valve at the Echo View Tanks. The additional work was performed on a Time
& Materials basis for a cost of $20, 415.63.
4. KG Walters has credited $348.00 to the District for the District's purchase of
site signage that was required by the Contract to comply with grant
requirements.
5. Prior to moving out of the site, KG Walters discovered an error in their
construction of the concrete ringwall foundation. To design a repair for the
foundation, the District consulted with Brown & Caldwell engineers. KG
Walters is providing a credit to the District for the cost of this design, in the
amount $4,731.27.
6. Also in response to the foundation modifications, the tank builder was
required (under separate contract) to modify the anchor chairs and tank
-5-
Julie Ryan
November 18, 2010
Page 2
drain. KG Walters is providing a credit to the District for the cost of these
modifications, in the amount $415.00.
7. In response to a requirement of our TRPA permit to limit access to the
unpaved road to the tank site, staff requested that KG Walter install bollards
at the bottom of the unpaved access. The cost to the District for this
additional work is $1,302.33.
8. Because Angora Tank (under separate contract) was not complete in
enough time for KG Walters to perform the site work prior to the end of
grading season, staff has directed them to return to Angora after May 1,
2011, to perform the work. As a result, the Contract Time is increased from
166 days to 477 days, for a new completion date of August 1, 2011.
KG Walters has completed the site work at the Echo View Tank Site. The work remaining
at Angora Tank Site to be completed in 2011 includes demolition of the old tank, site
grading and stabilization activities.
The District has approved all components of the contract work for the Echo View site.
Staff recommends approval of the Partial Closeout Agreement and Release of Claims,
and the filing of the Partial Notice of Completion with the El Dorado County Clerk.
SCHEDULE: As soon as possible
COSTS: <$52,013.46>
ACCOUNT NO: 2029 -8809
BUDGETED AMOUNT REMAINING: $331,622
ATTACHMENTS: Change Order No. 1, Partial Closeout Agreement and Release of
Claims, Partial Notice of Completion.
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: Water
GENERAL MANAGER: YES !I". NO
CHIEF FINANCIAL OFFICER: YES NO
-6-
CHANGE ORDER NUMBER 1
Project 2010 Echo View and Angora Site Work Proiect
+ �`e� •�sss• �'`�' Contractor KG Walters Construction Company, Inc.
Date: November 18, 2010 PO # P22801
The Contract Shall Be Changed As Follows:
A. Amend Bid Item 13, to reflect an 881 square foot increase in the Contract quantity for
area paved. The Contract unit price for this work remains $6.00 per square foot. This
increase in the Contract quantity results in a cost to the District in the amount
$5,286.00.
TOTAL FOR ITEM A IS $5,286.00
TOTAL FOR CHANGE ORDER NUMBER ISA +B +C +D +E +F +G +H.
<$52,013.46>
Original
Contract
$3889700.00
166 Calendar Days
Previous Change Order
$0.00
Current Contract
$3889700.00
166 Calendar Days
THIS CHANGE ORDER
<$52,013.46>
1 281 Calendar Days
New Contract Total 1
$336 .686.541 447
Calendar Days
Contractor agrees to make the herein - described changes in accordance with the terms hereof. The
change in contract price and/or contract time noted Is full settlement for costs incurred because of the
change(s) described, unless specifically noted in individual description(s).
Date:
Authorized By STPUD Board President
Date:
Accepted By Contractor
Date:
Reviewed By
-7-
B. Amend Bid Item 4, to reflect a reduction in the level of effort required for drilling and
blasting, which was performed on a Time & Materials Basis in accordance with the
Contract.. The cost to the District for drilling and blasting is $26,476.85 of the
$100,000.00 earmarked for Bid Item 4 in the Contract. These costs are detailed in
Quote #103, dated August 20, 2010. This reduction in effort results in a credit to the
District in the amount $73,523.15
TOTAL FOR ITEM B IS <$73,523.15>
C. Add Bid Item 22 to include all labor, equipment, materials and subcontractor costs
necessary to install an altitude valve on the Echo View Tank inlet/outlet pipe, as detailed
in Construction Directive #4, dated July 29, 2010. The additional cost for this work is
$20,415.63, as detailed in Change Order Quote #101 (attached).
TOTAL FOR ITEM C IS $20,415.63
D. Amend Bid Item 1 to include a credit to the District for all labor, equipment, and
material savings resulting from the District procurement of project signage required by
Section 00 74 00, Part 2.04, of the Contract. The credit for this item is $348.000, as
detailed on the Signs of Tahoe Invoice# 100532 (attached).
TOTAL FOR ITEM D IS <$348.00>
E. Amend Bid Item 11 to include a credit to the District for all labor, equipment,
materials and consultant costs necessary to design a repair for the Echo View Tank
foundation, as detailed in Construction Directive # 5, dated August 18, 2010. The credit
for this item is $4,731.27 of the $7,061.59 budget extension for this work as detailed in
the scope of work for Brown & Caldwell's Task Order # 8C (attached). Together with
Item F (below) this item addresses in full the costs incurred by the District for the repair
requested in Construction Directive #5.
TOTAL FOR ITEM E IS <$4,731.27>
F. Amend Bid Item 11 to include a credit to the District for the labor, equipment,
materials and subcontractor costs resulting from modifications to the anchor chairs and
tank drain at Echo View Tank, needed as result of the foundation error detailed in
Construction Directive #5, dated August 18, 2010. The credit for this item is $415.00, as
detailed in the quote (dated 10/22/2010) from the tank builder (attached). Together with
Item E (above) this item addresses in full the costs incurred by the District for the repair
requested in Construction Directive #5.
TOTAL FOR ITEM F IS <$415.00>
G. Amend Bid Item 12 to include all labor, equipment, materials and subcontractor costs
necessary to install security bollards at the Echo View Tank site, as detailed in
Construction Directive #6, dated August 18, 2010. The additional cost for this work is
$1,302.33, as detailed in Change Order Quote #102 (attached).
TOTAL FOR ITEM G IS $1,302.33
H. Change the Contract Time, identified in Section 007200, Part 2.04, of the Contract
Specifications, from one - hundred sixty -six (166) days to four - hundred forty -seven (447)
2
days to account for delays in performing the site work at Angora Tank, as described in
Construction Directive #7, dated October 11, 2010. Adding time to the Contract has the
potential to impact the cost for several items of the work, including, but not limited to,
additional bond /insurance costs, additional labor costs, fuel escalation, hazardous
material disposal fees, rental equipment charges, seed and revegetation materials, and
remobilization costs. The actual cost impact of the postponement on these work items
will not be known until just prior to starting the work. As such, the costs associated with
this extension to the Contract Time will be negotiated separately before the work
commences on or after May 1, 2011.
TOTAL FOR ITEM H IS $0.00
TOTAL FOR CHANGE ORDER #1 IS
A + B + C + D + E + F +G + H = <$52,013.46>
-9-
41
PARTIAL CLOSEOUT AGREEMENT AND RELEASE OF CLAIMS
THIS RTIAL CLOSEOUT AGREEMENT AND RELEASE OF CLAIMS (Agree/.Walters ade
in Sout Lake Tahoe, California, this day of November 2010 by and be outh
Tahoe P lic Utility DISTRICT, hereinafter referred to as "DISTRICT", and
Constructio Company, Inc., hereinafter referred to as "CONTRACTOR ".
KNOW ALL PERSONS BY THESE PRESENTS:
1. The DISTR T and NTRACTOR entered into that agreement r Purchase Order No.
P22801, for D TRICT CO project described as 2010 ECHO VIEW ND ANGORA WATER
TANKS REPLA \ DIS ITEWORK PROJECT on Apr 23, 2010 ( "Agreement ").
The Contract whrough Change Order No. 1 s approved by the parties,
pertaining to Puo. P22801 and dated Nov ber 18, 2010.
2. CONTRACTOR T agree that the total justed Contract price a nd time of
performance for ` er No. P22801, after a execution of the change order, is
as follows: N
Original Contract Price: $388, 00.00
Adjusted Contract Price: $336,6 .54
3. Other than the uncompleted portions
below, the DISTRICT and CONTRACT
any claims related thereto. /
project ( "Uncompleted Work "), described
h to close out the Agreement and release
The CONTRACTOR has not r�'After ed and the ISTRICT has not accepted any of the
work at the Angora Tank S May 1, 2 1 the CONTRACTOR will return to
Angora Tank Site to perform k. The DISTR T is withholding $72,500.00 for the
Uncompleted Work.
The withholding will be/released when the CONTRA OR completed the work at
Angora Tank Site to the satisfaction and accetp of the DISTRICT. The
CONTRACTOR shall mplete this Uncompleted Work pursu t to a schedule approved
by the DISTRICT a d no later than July 31, 2011. The 1 -ye warranty period for the
Uncompleted Wo shall commence upon the completion of the ork to the satisfaction
and acceptance the DISTRICT.
4. That the and igned, as the authorized representative of CONTRA OR, and for each
of its succe ors, assigns and partners, for an in consideration of Thre Hundred Eighty -
Eight Tho sand Seven Hundred Dollars and Zero Cents ($388,7N), the original
Contract mount, less Fifty -Two Thousand Thirteen Dollars and -Six Cents
($52,01 .46) for Contract Change Order No. 1, and less the wi holding for
Uncom leted Work receipt of which is acknowledged, does release d forever
disch ge the DISTRICT, and each of its successors, assigns, directors, office ,agents,
sery nts, volunteers and employees, from any and all rights, claims, causes f action,
de ands, debts, obligations, liabilities, actions, damages, costs and expenses (i eluding
b not limited to attorneys, paralegal and experts' fees, costs and expenses) an other
cl ims, which may be asserted against DISTRICT by reason of any matter or thing hich
was the subject matter of or basis for:
A. The performance of all terms and conditions of that certain agreement dated April
23, 2010 for Purchase Order No. P22801, DISTRICT project described as 2010
South Tahoe
Public Utility District
Memorandum
Date: November 18, 2010
To: Board of Directors
From: Julie Ryan, Senior Engineer
v vsSe^I I
�k -k7 -10
0 y 1 1 6
60ot'A ml�)
Richard Solbrig, General Manager
Board Members
Chris Cefalu
James R. Jones
Mary Lou Mosbacher
Dale Rise
Eric Schafer
Re: Modifications to KG Walter Partial Final Closeout Agreement
At the recommendation of Counsel, Staff has made minor modifications to the Partial
Final Closeout agreement for KG Walters work at the Echo View Tank Site. The
revised agreement is attached.
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
� OL &- Lt f � e f L& Ce hnt..if
PARTIAL CLOSEOUT AGREEMENT AND RELEASE OF CLAIMS
THIS PARTIAL CLOSEOUT AGREEMENT AND RELEASE OF CLAIMS (Agreement) is made
in South Lake Tahoe, California, this day of November 2010 by and between South
Tahoe Public Utility DISTRICT, hereinafter referred to 'as "DISTRICT", and K.G. Walters
Construction Company, Inc., hereinafter referred to as "CONTRACTOR ".
KNOW ALL PERSONS BY THESE PRESENTS:
The DISTRICT and CONTRACTOR entered into that agreement for Purchase Order No.
P22801, for DISTRICT project described as 2010 ECHO VIEW AND ANGORA WATER
TANKS REPLACEMENT — SITEWORK PROJECT on April 23, 2010 ( "Agreement").
The Contract was amended through Change Order No. 1 as approved by the parties,
pertaining to Purchase Order No. P22801 and dated November 18, 2010.
2. CONTRACTOR and DISTRICT agree that the total adjusted Contract price for Purchase
Order No. P22801, after the execution of the change order, is as follows:
Original Contract Price: $388,700.00
Adjusted Contract Price: $336,686.54
3. Other than the uncompleted portions of the project ( "Uncompleted Work "), described
below, the DISTRICT and CONTRACTOR wish to close out the Agreement and release
any claims related thereto.
The CONTRACTOR has not performed and the DISTRICT has not accepted any of the
Uncompleted Work at the Angora Tank Site. After May 1, 2011 the CONTRACTOR will
return to Angora Tank Site to perform the Uncompleted Work. The DISTRICT is
withholding $72,500.00 for the Uncompleted Work.
The withholding will be released when the CONTRACTOR completes the Uncompleted -
Work at Angora Tank Site to the satisfactiori and acceptance of the DISTRICT. The
CONTRACTOR shall complete this Uncompleted Work pursuant to a schedule approved
by the DISTRICT and no later than July 31, 2011. The 1 -year warranty period for the
Uncompleted Work shall commence upon the completion of the Uncompleted Work to
the satisfaction and acceptance of the DISTRICT.
4. That the undersigned, as the authorized representative of CONTRACTOR, and for each
of its successors, assigns and partners, for an in consideration of Three Hundred Eighty -
Eight Thousand Seven Hundred Dollars and Zero Cents ($388,700), the original
Contract amount, less Fifty -Two Thousand Thirteen Dollars and Forty -Six Cents
($52,013.46) for Contract Change Order No. 1, and less the withholding for
Uncompleted Work, receipt of which is acknowledged, does release and forever
discharge the DISTRICT, and each of its successors, assigns, directors, officers, agents,
servants, volunteers and employees, from any and all rights, claims, causes of action,
demands, debts, obligations, liabilities, actions, damages, costs and expenses (including
but not limited to attorneys, paralegal and experts' fees, costs and expenses) and other
claims, which may be asserted against DISTRICT by reason of any matter or thing which
was the subject matter of or basis for:
A. The performance of all terms and conditions of that certain agreement dated April
23, 2010 for Purchase Order No. P22801, DISTRICT project described as 20.10
ECHO VIEW AND ANGORA WATER TANKS REPLACEMENT — SITEWORK
PROJECT;
B. Change Order No. 1, as approved by the parties, pertaining to Purchase Order
No. P22801 and dated November 18, 2010;
with the exception of the Uncompleted Work.
5. Nothing contained in this Agreement shall waive or alter the rights, privileges, and
powers of the DISTRICT or the duties, liabilities and obligations of the CONTRACTOR
and its surety(ies) in respect to any portions of the Contract Documents for Purchase
Order No. P22801.
6. The DISTRICT has received the following claims from the CONTRACTOR: None.
Except as expressly provided in this section, the DISTRICT has received no other claims
from the CONTRACTOR.
7. Upon execution of this Agreement, the DISTRICT agrees to promptly record a NOTICE
OF PARTIAL COMPLETION with the El Dorado County Recorder. Upon completion of
the Uncompleted Work, the Parties shall enter into a Closeout Agreement and Release
of Claims, as to Uncompleted Work, and record a NOTICE OF COMPLETION with the
El Dorado County Recorder.
8. The current retention amount is: $ 13,209.33
Original Contract amount $388,700.00
Total Change Order Amount: $ (52,013.46)
Less: Amount Previously Paid:
(Request Nos. 1 thru 5) $250,977.21
Retainage $ 13,209.33
Withholding for Uncompleted Work: $ 72,500.00
BALANCE: $ -0-
The retainage will be released to the CONTRACTOR at the expiration of thirty -five (35)
calendar days after date of recording the NOTICE OF PARTIAL COMPLETION by El
Dorado County Recorder or when all stop notices have been released, whichever last
occurs. The release provided pursuant to this Agreement shall not apply to
CONTRACTOR'S right to the retention amount until and to the extent such amounts are
received by COTNRACTOR.
9. It is understood and agreed by CONTRACTOR that the facts with respect to which the
release provided pursuant to this Agreement is given may turn out to be other than or
different from the facts as now known or believed to be, and CONTRACTOR expressly
assumes the risk of the facts turning out to be different than they now appear, and
agrees that the release provided pursuant to this Agreement shall be, in all respects,
effective and not subject to termination or rescission by any such difference in fats and
CONTRACTOR expressly waives any and all rights it has or may have under California
Civil Code Section 1542, which provides as follows:
"A general release does not extend to claims which the creditor does not know
or suspect to exist in his favor at the time of executing the Release which if know
by him must have materially affected his settlement with the debtor."
10. The release made by the CONTRACTOR is not to be construed as an admission or
admissions of liability and the CONTRACTOR denies any such liability. CONTRACTOR
2
agrees that it will forever refrain and forebear from commencing, instituting or
prosecuting any lawsuit, action or other proceeding against the DISTRICT based on,
arising out of, or in any way connected with the subject matter of this release.
11. The CONTRACTOR releases the DISTRICT from all claims, other than any related to
the Uncompleted Work, including but not limited to those of its Subcontractors for all
delay and impact costs, if any.
12. The CONTRACTOR represents and warrants to the DISTRICT that the CONTRACTOR
has not assigned or transferred or purported to assign or transfer to any person, firm,
corporation, association or entity any of the rights, claims, warranties, demands, debts,
obligations, liabilities, actions, causes or action, damages, costs, expenses and other
claims and the CONTRACTOR agrees to indemnify and hold harmless the DISTRICT,
its successors, assigns, directors, officers, agents, servants, volunteers and employees,
from and against, without limitation, any and all rights, claims, warranties, demands,
debts, obligations, liabilities, actions, causes of action, damages, costs, expenses and
other claims, including but not limited to attorneys', paralegal and experts' fees, costs
and expenses arising out of or connected with any such assignment or transfer or
purported assignment or transfer.
13. The parties acknowledge that they have been represented by counsel of their own
choice in connection with the preparation and execution of this Agreement. The parties
acknowledge and represent that they understand and voluntarily consent and agree to
each and every provision contained in this Agreement.
14. The parties further acknowledge and represent that no promise, inducement or
agreement, not expressed in this Agreement, have been made and that this Agreement
contains the entire agreement among the parties and that the terms of the Agreement
are contractual and not a mere recital.
15. The persons executing this Agreement represent and warrant to the other party that the
execution and performance of the terms of this Agreement have been duly authorized by
all corporate, partnership, individual, or other entity requirements and that said persons
have the right, power, legal capacity and authority to execute and enter into this
Agreement.
SOUTH TAHOE PUBLIC UTILITY DISTRICT
RICHARD SOLBRIG, GENERAL MANAGER DATED
ATTEST: KATHY SHARP, CLERK OF BOARD DATED
K. G. WALTERS CONTRUCTION CO., INC.
By:
JOHN COLLINS, PROJECT MANAGER DATED
3
ECHO VIEW AND ANGORA WATER TANKS REPLACEMENT — SITEWORK
PROJECT;
B. Change Order No. 1, as approved by the parties, pertaining to Purchase Order
� No. P22801 and dated November 18, 2010; ,
the exception of the Uncompleted Work.
5. Nothin contained in this Agreement shall waive or alter the rights/for es, and
powers the DISTRICT or the duties, liabilities and obligations of the ACTOR
and its su ty(ies) in respect to any portions of the Contract Documeurchase
Order No. P22801.
6. The DISTRICT as received the following claims from the C TRACTOR: None.
Except as express rovided in this section, the DISTRICT has r ceived no other claims
from the CONTRAC R.
7. Upon execution of this A ement, the DISTRICT agrees promptly record a NOTICE
OF PARTIAL COMPLETIO with the El Dorado Coun ecorder. Upon completion of
the Uncompleted Work, the rties shall enter into a loseout Agreement and Release
of Claims, as to Uncompleted ork, and record a TICE OF COMPLETION with the
El Dorado County Recorder.
8. The current retention amount is:
Original Contract amount
Total Change Order Amount:
Less: Amount Previously Paid:
(Request Nos. 1 thru 5)
Retainage
Withholding for Uncompl
BALANCE:
0
$/14,796.29
388,700.00
$ (52,013.46)
$ 3,166.56
$ ,796.29
Work: $ 72, 00.00
$ 16,2 .69
The retainage will bp releas d to the CONTRACTOR t the expiration of thirty -five (35)
calendar days after date recording the NOTICE OF ARTIAL COMPLETION by El
Dorado County Recorde or when all stop notices have een released, whichever last
occurs. The releas provided pursuant to this Aglrhpment shall not apply to
CONTRACTOR'S to the retention amount until and to extent such amounts are
received by CO' N VC, TOR. t
It is understood nd agreed by CONTRACTOR that the facts wr respect to which the
release provid pursuant to this Agreement is given may tum o t to be other than or
different fro he facts as now known or believed to be, and CON RAC expressly
assumes risk of the facts turning out to be different than the now appear, and
agrees t t the release provided pursuant to this Agreement shall , in all respects,
effectiv and not subject to termination or rescission by any such Jiff ence in fats and
CON CTOR expressly waives any and all rights it has or may have nder California
Civil ode Section 1542, which provides as follows:
"A general release does not extend to claims which the creditor dohs not know
or suspect to exist in his favor at the time of executing the Release which if know
by him must have materially affected his settlement with the debtor."
10.
The release made by the CONTRACTOR is not to be construed as an admission or
admissions of liability and the CONTRACTOR denies any such liability. CONTRACTOR
-11-
2
agrees that it will forever refrain and forebear from commencing, instituting or
prosecuting any lawsuit, action or other proceeding against the DISTRICT based on,
arising out of, or in any way connected with the subject matter of this release.
11. The CONTRACTOR releases the DISTRICT from all claims, other than a y related to
\ the Uncompleted Work, including but not limited to those of its Subcont ctors for all
delay and impact costs, if any.
12. T e CONTRACTOR represents and warrants to the DISTRICT that e COTNRACTOR
ha not assigned or transferred or purported to assign or transfe o any person, firm,
corp tion, association or entity any of the rights, claims, warr ties, demands, debts,
obligati ,liabilities, actions, causes or actio/ es, c ts, expenses and other
claims and a CONTRACTOR agrees to inde h harmless the DISTRICT,
its successors, ssigns, directors, officers, agen , volunteers and employees,
from and agains , without limitation, any and , claims, warranties, demands,
debts, obligations, bilities, actions, causes oamages, costs, expenses and
other claims, includin but not limited to attornalegal and experts' fees, costs
and expenses arising ut of or connected wuch assignment or transfer or
purported assignment or nsfer.
13. The parties acknowledge th 7 dot they have een represented by counsel of their own
choice in connection with the p aration nd execution of this Agreement. The parties
acknowledge and represent that ey derstand and voluntarily consent and agree to
each and every provision contained is Agreement.
14. The parties further acknowledg . an represent that no promise, inducement or
agreement, not expressed in thi gree nt, have been made and that this Agreement
contains the entire agreement Mong the arties and that the terms of the Agreement
are contractual and not a mer recital.
15. The persons executing thi Agreement represen and warrant to the other party that the
execution and performs of the terms of this, g ement have been duly authorized by
all corporate, partners ' , individual, or other entity quirements and that said persons
have the right, pow legal capacity and author! to execute and enter into this
Agreement.
SOUTH TAHOE PUBLIC/UTILITY DISTRICT
RICHARD SOLBRIGIGENERAL MANAGER DA
ATTEST: KATHX SHARP, CLERK OF BOARD DATED
K. G. WALTEVS CONTRUCTION CO., INC.
(Print Name and Title)
-12-
DATED
3
RECORDING REQUESTED BY:
Heidi C. Baugh
South Tahoe Public Utility District
WHEN RECORDED MAIL TO:
SOUTH TAHOE PUBLIC UTILITY DISTRICT
1275 Meadow Crest Drive
South Lake Tahoe
CA 96150
APN: 33- 623 - 1 2 'NOTICE OF PARTS COMPLETION
ION
USE
NOTICE IS HEREBY GIVEN THAT:
1. The undersigned is OWNER or agent of the OWNER of the interest or estate stated below in the property hereinafter described.
2. The FULL NAME of the OWNER is South Tahoe Public Utility District
3. The FULL ADDRESS of the OWNER is 1275 Meadow Crest Drive, South Lake Tahoe, CA 96150
4. The NATURE OF THE INTEREST or ESTATE of the undersigned is: In fee.
(If other than fee, strike "in fee" and insert here, for example, "purchaser under contract of purchase," or "lessee."
5. The FULL NAMES and FULL ADDRESSES of ALL PERSONS, if any, WHO HOLD SUCH INTEREST or ESTATE with the undersigned as
JOINT TENANTS or as TENANTS IN COMMON are:
Name & Address
Name & Address
6. The FULL NAMES of FULL ADDRESSES OF THE PREDECESSORS in INTEREST of the undersigned if the property was transferred
subsequent to the commencement of the work of improvement herein referred to:
Name & Address
Name & Address
7. A work of improvement on the property hereinafter described was COMPLETED on 8/20 /2010.
8. The work of improvement completed is described as follows: 2010 Echo view and Angora Water Tank Replacement - SITEWORK.
9. The NAME OF THE ORIGINAL CONTRACTOR, if any, for such work of improvement is K. G. Walters Construction Co., Inc.
10. The street address of said property is 1045 Lamor Court.
11. The property on which said work of improvement was completed is in the City of South Lake Tahoe County of El Dorado, State of
Caldbmia, and is described as follows: (See Exhibit "A" )
As shown in Exhibit "A" attached hereto and made a part hereoff, 4M=4>nA'=Wd4W) =
DATE: November 18, 2010
SIGNATURE OF OWNER OR AGENT OF OWNER
VERIFICATION FOR INDIVIDUAL OWNER: Board President for So.Tahoe PUD
I, the undermined, declare under penalty of perjury under the laws of the State of Califomia that I am the owner of the aforesaid interest or estate in
the property described in the above notice; that I have read said notice, that I know and understand the contents thereof, and the fads stated therein
are true and correct.
DATE AND PLACE SIGNATURE OF OWNER NAMED IN PARAGRAPH 2
VERIFICATION FOR NOWINDIVIDUAL OWNER: -South Tahcia Public litility District
I, the undersigned, declare under penalty of perjury under the aws of State of Califoinla f oa rd Preside
of the aforesaid interest or estate in the property described in the above notice; that I have read the said notice, that I know and understand the
contents thereof, and that the fads stated therein are true and correct.
2010 at South Lake Tahoe, CA �I b1A7ff pE�p ��q�
DATE AND P Uale R1 OF Bo NrSJ P ING 0" pE ILF OF OWNER
rest en
South Tahoe Public Utility District
—13—
EXHIBIT "A"
Notice of Completion of a Portion of the
2010 ECHO VIEW AND ANGORA TANK REPLACEMENT - SITEWORK PROJECT known as
2010 ECHO VIEW TANK SITEWORK PROJECT
The site of the work is located at Assessor's Parcel No. 33- 623 -12, commonly
known as 1045 Lamor Court in the County of El Dorado, California.
The work to be performed consists of the installation of approximately 380 linear
feet of new 8" waterline, services, meters, fire hydrants, interties, valves and
associated work including paving, temporary erosion control and traffic control,
drilling and blasting, tank demolition, site grading, concrete tank foundation, and
retaining wall.
Notice of Completion of a Portion of the
2010 ECHO VIEW AND ANGORA TANK REPLACEMENT - SITEWORK PROJECT known as
2010 ECHO VIEW TANK SITEWORK PROJECT
EXHIBIT "A"
-14-
South Tahoe
Public Utility District
1275 Meadow Crest Drive - 5outh lake Tahoe - CA 96150 -7401
Phone 530 544 -6474 - Fax 530 541 -0614 - www.5tpud.u5
CERTIFICATION
I hereby certify that the foregoing is a full, true, and correct copy of the
Notice of Partial Completion that was approved by the Board of Directors of the
South Tahoe Public Utility District, County of El Dorado, State of California, and
executed by Board President, Dale Rise.
Date Approved:
Certified by:
Kathy Sharp, Clerk of the Board
-15-
1275 Meadow Crest Drive - South take Tahoe - CA 96150 -7401
Phone 530 544 -6474 - Fax 530 541 -0614 - www.stpud.u5
BOARD AGENDA ITEM 6a
TO: Board of Directors
FROM: Tim Bledsoe, Manager of Customer Service
MEETING DATE: November 18, 2010
ITEM - PROJECT NAME: Ordinance No. 525 -10: Unreported Connections and
Discharges
REQUESTED BOARD ACTION: Enact Ordinance No. 525 -10 amending Section 4.6.7 of the
Administrative Code regarding unreported connections and discharges.
DISCUSSION: Currently, the Administrative Code imposes a sewer connection fee, three
(3) years back charges and administrative fees and penalties on any property owners
whose property is discovered to have unreported sewer connections. Additionally, the
Administrative Code provides that if a property owner can provide sufficient proof to
the District that the unreported sewer connection(s) existed prior to their purchase of
the property they are only required to pay three (3) years of back charges and are not
required to pay a sewer connection fee or penalties.
The proposed amendment states that any property owner who can demonstrate the
unreported sewer connection existed prior to their purchase of the property will be
subject to no fees, charges or penalties, and will only be required to pay the
appropriate annual sewer service charge going forward.
SCHEDULE:
COSTS:
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATTACHMENTS: Ordinance No. 525 -10
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: Sewer
GENERAL MANAGER: YES NO
CHIEF FINANCIAL OFFICER: YES NO
-17-
Gen&W Manager
Ridwa H. S*de
South
James R Jones
Public Utility District .
arwumftbschw
MyCWOMW
1275 Meadow Crest Drive - South take Tahoe - CA 96150 -7401
Phone 530 544 -6474 - Fax 530 541 -0614 - www.stpud.u5
BOARD AGENDA ITEM 6a
TO: Board of Directors
FROM: Tim Bledsoe, Manager of Customer Service
MEETING DATE: November 18, 2010
ITEM - PROJECT NAME: Ordinance No. 525 -10: Unreported Connections and
Discharges
REQUESTED BOARD ACTION: Enact Ordinance No. 525 -10 amending Section 4.6.7 of the
Administrative Code regarding unreported connections and discharges.
DISCUSSION: Currently, the Administrative Code imposes a sewer connection fee, three
(3) years back charges and administrative fees and penalties on any property owners
whose property is discovered to have unreported sewer connections. Additionally, the
Administrative Code provides that if a property owner can provide sufficient proof to
the District that the unreported sewer connection(s) existed prior to their purchase of
the property they are only required to pay three (3) years of back charges and are not
required to pay a sewer connection fee or penalties.
The proposed amendment states that any property owner who can demonstrate the
unreported sewer connection existed prior to their purchase of the property will be
subject to no fees, charges or penalties, and will only be required to pay the
appropriate annual sewer service charge going forward.
SCHEDULE:
COSTS:
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATTACHMENTS: Ordinance No. 525 -10
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: Sewer
GENERAL MANAGER: YES NO
CHIEF FINANCIAL OFFICER: YES NO
-17-
ORDINANCE NO. 525-10
AN ORDINANCE OF THE SOUTH TAHOE PUBLIC UTILITY DISTRICT
AMENDING SECTION 4.6.7 OF THE ADMINISTRATIVE CODE REGARDING
CHARGES AND FEES FOR UNREPORTED SEWER CONNECTIONS
BE IT ENACTED by the Board of Directors of the South Tahoe Public Utility
District, County of El Dorado, State of California, as follows:
SECTION 1— POLICY AND PURPOSE
The purpose of this Ordinance is to adopt certain changes to the Administrative
Code regarding charges and fees for unreported sewer connections.
SECTION II — DEFINITIONS
For the purposes of this Ordinance, the terms used herein are defined as follows:
A. The District — The South Tahoe Public Utility District.
B. The Board — The Board of Directors of the South Tahoe Public Utility
District.
C. Administrative Code — The compilation and codification of all of the
Administrative, Water, Sewer, Street Lighting and Groundwater
Management Plan Ordinances of the District, which establish the authority
and the principles for the decisions of the District, and provide the public
with guidelines applicable to District operations.
SECTION III — FINDINGS
The Board of Directors of the South Tahoe Public Utility District, County of El
Dorado, State of California, make the following findings:
1. The District's Administrative Code imposes on property owners who have
installed but failed to report a sewer connection a sewer connection fee, three (3) years
back charges and several administrative fees and penalties.
2. However, the District's Administrative Code provides that if a property
owner can provide sufficient proof to the District that the unreported sewer
connections(s) existed prior to his or her purchase of the property, he or she is only
required to pay three (3) years of back charges and is not required to pay a sewer
connection fee or any administrative fees or penalties.
-19-
3. The proposed amendment is intended to reflect a change in the District's
policy toward property owners who can demonstrate to the District that the unreported
sewer connections(s) existed prior to their purchase of the property by removing the
requirement that three (3) years back charges be imposed on such property owners.
Under the new policy, any property owner who can demonstrate the unreported sewer
connection(s) existed prior to his or her purchase of the property will only be required to
pay the appropriate annual sewer service charge going forward.
4. The Board seeks to adopt this policy change because it does not wish to
require payment from property owners who unknowingly utilize unreported sewer
connections by requiring the collection of back charges from such property owners.
5. The Board has determined that it is in the best interest of the health and
safety of District residents to adopt an ordinance to amend certain provisions of the
Administrative Code regarding charges and fees for unreported sewer connections.
SECTION IV — AMEND SECTION 4.6.7 OF THE ADMINISTRATIVE CODE
Administrative Code Section 4.6.7 to be amended as follows:
Unreported Connections and Discharges. Upon discovery of the unreported
connections and discharges to the District sewer system, the District shall charge all
current charges and fees, including all current connection charges, plus a ten percent
(10 %) basic penalty, up to three (3) years back charges for current sewer service fees, a
ten percent (10 %) penalty on such back charges, and the current administrative fee for
unreported connections and discharges. (Refer to Schedule No. 2, Section 4.5.8.) The
owner of said property may, at his option, abate the unreported connection(s)
immediately or pay all of the above charges and fees. If the owner elects to abate the
unreported connection(s), the District may only charge up to three (3) years back charge
for current sewer service fees. If the owner can demonstrate sufficient proof to the
District Customer Service Manager or authorized representative that the unreported sewer
connection(s) existed prior to the purchase of such property by owner, then the District
shall not impose any sewer connection fee, back charges, administrative fees or penalties
as to the unreported connection(s). As to the unreported connection, the District will
charge the appropriate annual service charge beginning with the day the District
discovered the unreported sewer connections(s). (Refer to Schedule No. 6, Section
4.5.12.) If the owner fails to complete any of the above options, all charges and fees shall
be deemed charges for the purposes of collection and enforcement, and the property shall
be subject to disconnection procedures for delinquent charges as provided in Section 6.6.
Ordinance No. 525 -10
Unreported Sewer Connection Fees and Charges
Page 2
-20-
SECTION V — SEVERABILITY
If any section, subsection, subdivision, paragraph, sentence, clause or phrase of
this Ordinance and its implementing rules and regulations is for any reason held to be
unconstitutional or invalid, such decision shall not affect the validity of the remaining
portions of this Ordinance or the Administrative Code. The Board of Directors declares
and determines that it would have passed section, subsection, subdivision, paragraph,
sentence, clause or phrase thereof of this Ordinance and its implementing rules and
regulations and the Administrative Code irrespective of the fact that any one or more
sections, subsections, subdivisions, paragraphs, sentences, clauses or phrases may be
determined to be unconstitutional or invalid.
SECTION VI — EFFECTIVE DATE
This Ordinance amending the above referenced sections to the Administrative
Code shall take effect thirty days after its passage.
PASSED AND ADOPTED the Board of Directors of the South Tahoe Public
Utility District at its duly held regular meeting on the 18th day of November, 2010, by
the following vote:
AYES:
NOES:
ABSENT:
Dale Rise, President
South Tahoe Public Utility District
ATTEST:
Kathy Sharp, Clerk of the Board
Ordinance No. 525 -10
Unreported Sewer Connection Fees and Charges
Page 3
1275 Meadow Crest Drive • 5outh Lake Tahoe • CA 96150 -7401
Phone 530 544 -6474 • Fax 530 541 -0614 • www.stpud.us
BOARD AGENDA ITEM 6b
TO: Board of Directors
FROM: Julie Ryan, Senior Engineer
MEETING DATE: November 18, 2010
ITEM - PROJECT NAME: Headworks Replacement Phase II Project
REQUESTED BOARD ACTION: (1) Approve staff's recommended list of pre - qualified
General Contractors and SCADA Integrators for bidding on the Headworks
Replacement Phase II Project; and (2) Authorize staff to advertise for bids.
DISCUSSION: In response to the District's advertisement for pre - qualification of general
contractors for the Headworks Project, the District received 20 applications for pre -
qualification. After careful review, scoring and deliberation, staff recommends 16 of
the 20 applicants for pre - qualification to bid on the project. The pre - qualified general
contractors include the following firms, listed in alphabetical order:
1. Auburn Constructors, Inc.
2. C. Overaa & Co.
3. Cushman Contracting Corp.
4. C.W. Roen Construction Co.
5. Gateway Pacific Contractors, Inc.
6. GSE Construction Company, Inc.
7. KG Walters Construction Co., Inc.
8. Manito Construction, Inc.
9. Pacific Infrastructure
10. Pacific Mechanical Corp.
11. Proven Management, Inc.
12. Stanek Constructors, Inc.
13. Syblon Reid
14. Thomas Haen Co., Inc.
15. Western Water Constructors, Inc.
16. WM Lyles Co.
Disqualified contractors have until Thursday, November 11, 2010, to submit appeals to
the District for review. If needed, the District will hold an appeals hearing prior to the
-23-
General MnuWr
Rk:6 W H. 5o"
S out h
T ahoe
alucafAw
James K Jesus
Public Utility District
. `"ms'
1275 Meadow Crest Drive • 5outh Lake Tahoe • CA 96150 -7401
Phone 530 544 -6474 • Fax 530 541 -0614 • www.stpud.us
BOARD AGENDA ITEM 6b
TO: Board of Directors
FROM: Julie Ryan, Senior Engineer
MEETING DATE: November 18, 2010
ITEM - PROJECT NAME: Headworks Replacement Phase II Project
REQUESTED BOARD ACTION: (1) Approve staff's recommended list of pre - qualified
General Contractors and SCADA Integrators for bidding on the Headworks
Replacement Phase II Project; and (2) Authorize staff to advertise for bids.
DISCUSSION: In response to the District's advertisement for pre - qualification of general
contractors for the Headworks Project, the District received 20 applications for pre -
qualification. After careful review, scoring and deliberation, staff recommends 16 of
the 20 applicants for pre - qualification to bid on the project. The pre - qualified general
contractors include the following firms, listed in alphabetical order:
1. Auburn Constructors, Inc.
2. C. Overaa & Co.
3. Cushman Contracting Corp.
4. C.W. Roen Construction Co.
5. Gateway Pacific Contractors, Inc.
6. GSE Construction Company, Inc.
7. KG Walters Construction Co., Inc.
8. Manito Construction, Inc.
9. Pacific Infrastructure
10. Pacific Mechanical Corp.
11. Proven Management, Inc.
12. Stanek Constructors, Inc.
13. Syblon Reid
14. Thomas Haen Co., Inc.
15. Western Water Constructors, Inc.
16. WM Lyles Co.
Disqualified contractors have until Thursday, November 11, 2010, to submit appeals to
the District for review. If needed, the District will hold an appeals hearing prior to the
-23-
Julie Ryan
November 18, 2010
Page 2
November 18, 2010, meeting of the Board of Directors. Based on the results of the
appeals process, if needed staff will provide the Board with additions to the above list
of contractors for consideration prior to and at the Board meeting.
In response to the District's advertisement for pre - qualification of SCADA integrators for
the project, the District received 6 applications for pre - qualification. After careful
review, scoring and deliberation, staff recommends 4 of the 6 applicants for pre -
qualification to bid on the project. The pre - qualified SCADA integrators include the
following firms, listed in alphabetical order:
1. Carollo Systems, LLC
2. FluidlQs, LLC
3. MCC Control Systems
4. TESCO Controls, Inc.
Disqualified integrators have until Thursday, November 11, 2010, to submit appeals to
the District for review. If needed, the District will hold an appeals hearing prior to the
November 18, 2010, meeting of the Board of Directors. Based on the results of the
appeals process, if needed staff will provide the Board with additions to the above list
of integrators for consideration prior to and at the Board Meeting.
Carollo Engineers and District staff has finalized the bid documents. With Board
approval to bid, staff proposes to proceed with the project on the following schedule:
Advertise for Bid
Mandatory Pre -Bid Meeting
Bid Opening
Board Approval
Notice to Proceed
Contractor Mobilization
Project Complete
November 22, 2010
December 7, 2010
January 5, 2011
January 7, 2011
February 1, 2011
May 1, 2011
December 2012
The approximate cost to construct this project is expected to be on the order of
$9.1 million based on Carollo's Engineer's final bid estimate.
SCHEDULE: See above
COSTS: $9.1 million
ACCOUNT NO: 1029 -8033
BUDGETED AMOUNT REMAINING: $1,780,134
ATTACHMENTS: None
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: Sewer
GENERAL MANAGER: YES Add NO
CHIEF FINANCIAL OFFICER: YES NO
-24-
GG D
South Tahoe
Public Utility District
l I- tg--ID ► . n'1
Richard Solbrig, General Manager
Board Members
Chris Cefalu
James R. Jones
Mary Lou Mosbacher
Dale Rise
Eric Schafer
Memorandum
Date: November 18, 2010
To: Board of Directors
From: Julie Ryan, Senior Engineer
Re: Additional Contractors Pre - Qualified to Bid on Headworks Replacement Project.
The District received 2 appeals from General Contractors for the District to reconsider
their disqualification to bid on the Headworks Replacement Phase 2 Project. The
Appeals Panel, which consisted of Richard Solbrig and Paul Hughes from STPUD and
Brad Johnson from the Incline Village General Improvement District, met on
Wednesday, November 17, 2010, to review these apeals. Based on their review of the
appeals and deliberation, the Appeals Panel has recommended that the District qualify
Steve P. Rados, Inc., to bid as a General Contractor on the Headworks Replacement
Phase 2 Project.
The District also received 2 appeals from SCADA Integrators. The same Appeals Panel
reviewed these appeals on Wednesday, November 17, 2010. Based on their review of
the appeals and deliberation, the Appeals Panel has recommended that the District
qualify Ausenco PSI to bid as a SCADA Integrator on the Headworks Replacement
Phase 2 Project.
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
1275 Meadow Crest Drive - South Lake Tahoe - CA 96150 -7401
Phone 530 544-6474 - Fax 530 541 -0614 • wwmstpud.us
BOARD AGENDA ITEM 6c
TO: Board of Directors
FROM: Nancy Hussmann, Richard Solbrig
MEETING DATE: November 18, 2010
ITEM - PROJECT NAME: Employees' Benefit Plan
REQUESTED BOARD ACTION: Update the Plan Document to reflect changes required by
the recent enactment of Health Care Reform.
DISCUSSION: The District's Plan Document was reviewed by staff and also by our
consultants, BB&H Benefits Designs. BB&H Benefit Designs provided language for the
Plan Document that needed to be added and /or deleted due to the recent
enactment of Health Care Reform. The Union has reviewed the proposed changes and
concurs with the proposed language changes. The main items that needed to be
changed are: (1) Elimination of the lifetime maximum limit and (2) coverage of
dependents up to age 26. It is also determined that the District believes it is a
grandfathered plan under the law. The District also adjusted items in the Wellness
Guidelines, as recommended by a panel of physicians and agreed upon by the Union.
The updated Plan Document will be distributed to all District employees and Board
members at the December training conference, and a class will be held informing
employees of those changes.
SCHEDULE: Distribute to Board &'Employees 12/10/10
COSTS: N/A
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATTACHMENTS: Summary of Plan Document Changes; Redline /Strike -out version of Plan
Document
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: General
GENERAL MANAGER: YES NO
AFV
CHIEF FINANCIAL OFFICER: YES NO
-25-
General Manager
Rtciiard K so"
South
Chf-bCVf.*
Jatms R. Jones
P ublic Utility nietrict
UV W*Adw
` '' DAD n"
Eftfthaftr
1275 Meadow Crest Drive - South Lake Tahoe - CA 96150 -7401
Phone 530 544-6474 - Fax 530 541 -0614 • wwmstpud.us
BOARD AGENDA ITEM 6c
TO: Board of Directors
FROM: Nancy Hussmann, Richard Solbrig
MEETING DATE: November 18, 2010
ITEM - PROJECT NAME: Employees' Benefit Plan
REQUESTED BOARD ACTION: Update the Plan Document to reflect changes required by
the recent enactment of Health Care Reform.
DISCUSSION: The District's Plan Document was reviewed by staff and also by our
consultants, BB&H Benefits Designs. BB&H Benefit Designs provided language for the
Plan Document that needed to be added and /or deleted due to the recent
enactment of Health Care Reform. The Union has reviewed the proposed changes and
concurs with the proposed language changes. The main items that needed to be
changed are: (1) Elimination of the lifetime maximum limit and (2) coverage of
dependents up to age 26. It is also determined that the District believes it is a
grandfathered plan under the law. The District also adjusted items in the Wellness
Guidelines, as recommended by a panel of physicians and agreed upon by the Union.
The updated Plan Document will be distributed to all District employees and Board
members at the December training conference, and a class will be held informing
employees of those changes.
SCHEDULE: Distribute to Board &'Employees 12/10/10
COSTS: N/A
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATTACHMENTS: Summary of Plan Document Changes; Redline /Strike -out version of Plan
Document
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: General
GENERAL MANAGER: YES NO
AFV
CHIEF FINANCIAL OFFICER: YES NO
-25-
Summary Of Plan Document Changes
I . Introduction – Added wording that the Plan does not constitute an agreement
for employment.
2. Definitions – Page 3 & 5 - Definition of Dependent – referred to page 10, and
definition of Grandfathered Plan, according to Health Care Reform.
3. Definitions – Page 6 Eliminated definition for Lifetime, since Lifetime
maximums are now eliminated.
4. Page 10 – Eligible Classes of Dependents – changed after further clarification
was received by BB &H. Also, definition of dependent over 26 with disability
is addressed in #2 on page 11.
5. Age 26 Eligibility – Page 10 & 11, in accordance with Health Care Reform
interim final regulations. May enroll dependent children up to the age of 26
if they are not eligible to enroll in their employer's insurance, during Open
Enrollment, which is December 1 -31, for an effective date of January 1 ".
Corrected definition of Dependent exclusions – to comply with Health Care
Reform.
6. Page 15 – Employees on Military Leave – the rights include up to 24 months
instead of the previous 18 months of extended health care coverage.
7. Page 16 – Paragraph about Michelle's law – no longer applies due to health
care reform legislation.
8. Page 17 - Preferred Provider Organization — Explanation of Preferred
Provider Organization and that PPO Network providers will be provided upon
request.
9. Page 20 - Lifetime Maximum eliminated.
10. Page 21 & Pg 28 – Lifetime limit for Hospice eliminated – no more lifetime
limits can be imposed according to Health Care Reform.
11. Changes to Wellness Requirements – Pages 23 -26
a. Child requirements – slight changes to immunization requirements.
Eliminated Female HPV Immunization series.
b. Adult Requirements - Change physical frequency to every two years for
18 -25 and 26 -39; keep frequency at annually for 40-49 and older.
c. Delete requirement for Stress EKG's. Baseline required before Age 40.
d. Resting EKG frequency schedule changed for age 40 -65 +.
e. Change frequency schedule for Female Pap/Pelvic for Ages 21 -26
f. Change frequency schedule for Men's PSA Blood Test.
g. Changed Influenza & Pneumovax immunizations to Voluntary for adults.
h. Added note that frequency limits will be waived for first year of Health
Improvement Program (HIP) to enable employees to change
physical/bloodwork dates to earlier in the year. Labwork and lipid tests
will be paid at 100% the first year (2011) of the Health Improvement
Program, if the employee is participating in the HIP, (effort to reduce
duplication of services)
12. Page 32 - Added new Plan Exception for Physical Therapy, allowing $3000
per calendar year if medically necessary due to treatment of Medial
-27-
Patellofemoral Ligament Reconstruction and Medial Meniscus repair, when
used in lieu of Occupational Therapy benefits.
13. Smoking Cessation — Page 34 — 3 per lifetime limit eliminated due to Health
Care Reform.
14. Page 75 — General Plan Information — First Paragraph — changed to include all
applicable health care laws.
-28-
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
Updated January 1, 2010
Updated January 1, 2011
-29-
Introduction
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
coverage 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.
The Plan is not intended to be, and may not be construed as constitutine a contract or other
arranzement between ant individual and the District to the effect that the individual will be
employed for any soeciRc period of time
-30-
Table of Contents
Section Pa eg_#
Special Notices
Newborns & Mothers Health Protection Act and
Women's Health & Cancer Rights Act .......................................................... ............................... l
COBRA Notification Procedures
Provides an overview of the COBRA Notification Requirements ................. ..............................1
Defined Terms
Defines those Plan terms that have a specific meaning ................................. ............................... 4
Eligibility, Funding, Effective Date, and Termination
Explains eligibility for coverage under the Plan, funding of the Plan,
and when the coverage takes effect and terminates ....................................... .............................11
Schedule of Benefits
Provides an outline of the Plan reimbursement formulas,
as well as payment limits on certain services ................................................ .............................19
WellnessProgram Guidelines ..................................................................... .............................25
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 ........ ............................... 29
Prescription Drug Benefit
Provides an outline of the Plan reimbursement formulas as well as
payment limits regarding prescription drugs ............................................... ............................... 38
Dental Benefits
Provides an outline of the Plan reimbursement formulas as well as
payment limits on certain dental services .................................................... ............................... 42
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
arepaid ......................................................................................................... .............................48
Case Management Services
Explains voluntary program where catastrophic conditions are monitored
and care coordinated to provide the most appropriate level of cage ............ ............................... 52
-31-
Table of Contents — Continued
Section page #
Plan ]Exclusions
Shows what charges are not covered ........................................................... ...............................
53
Claim Provisions
Explains the rules for filing claims .............................................................. ...............................
57
Claim Denials
Explains the provisions when a claim is denied in whole or in part ............ ...............................
60
Appeal Procedures
Explains the process for appealing a denied claim ...................................... ...............................
60
Coordination of Benefits
Shows the Plan payment order when a person is covered under
morethan one plan ....................................................................................... ...............................
63
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 ........................ .............................67
COBRA Continuation Options
Explains when a person's coverage under the Plan ceases,
and the continuation options which are available ........................................ ...............................
72
USERRA Continuation Coverage
Explains continuation coverage for a covered Employee and covered
Dependents who lose coverage due to service in the Uniformed Services .. ...............................
77
Plan Amendment Regarding EIIPAA Privacy Compliance
Explains the provisions of the Health Insurance Portability
andAccountability Act of 1996 ................................................................... ...............................
79
Responsibilities for Plan Administration
Outlines the duties and responsibilities of the Plan Administrator .............. ...............................
83
General Plan Information
Provides general plan information as required by federal law ..................... ...............................
85
Attachments
Attachment 1 Authorization for Release of Claim Information
87
Attachment 2 Claim Appeal Release of Medical Information Form
88
Attachment 3 Release of Medical Information Authorization
for Request for Plan Exception
89
-32-
Special Notices
The Newborns and Mothers Health Protection Act
Group health plans and health 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).
The Women's Health and Cancer Rights Act
Under Federal law, the health 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).
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.
Notice of Child's Loss of Dependent Status — Notice of a Qualifying 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 Qualifying 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 IS (or 29) months.
Notice Regarding Disability — 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
Page 3of 79
2. A Qualified Beneficiary as described in "l." 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 Beneficiary 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.
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 Employee, 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. The date of the Qualifying Event,
2. The date health plan coverage is lost due to the event, or
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-day period, COBRA Continuation Coverage 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 Employee 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 of
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 2 of 79
-34-
Defined Terms
The following terms have special meanings and when used in this Plan will be capitalized
Active Employee is an Employee who performs all of the duties of his 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.$) 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.
Birthing Center means any freestanding 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 I' through December 31 ' of the same year.
COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.
Claims Administrator /Contract Administrator — A company that performs 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, burns or disfigurements.
Covered Person is an Employee, Dependent, or Active Board Member who is covered under this
Plan.
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.
Dependent — See page 10,
Page of 79
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 community or government oversight agencies at the
time services were rendered.
The Plan Administrator, or his/her designee, must make an independent evaluation of the
experimental/non- experimental standings of specific technologies. The Plan Administrator, or
his/her 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 facility's Institutional Review Board or other body serving a
similar function, or if the federal law 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 III clinical trials, or is otherwise under study to
determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as
compared with a standard means of treatment or diagnosis; or
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 maximum 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, medical
treatment or procedure.
Family Unit is the covered Employee and the family members who are covered as Dependents
under the Plan.
Page 4 of 79
-36-
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.
Grandfathered Status: The South Tahoe Public Utility District believes this Plan is a
" grandfathered health clan" under the Patient Protection and Affordable Care Act (the
Affordable Care Act). As Permitted by the Affordable Care Act, a erandfathered health plan
can preserve certain basic health coverage that was already in effect when that law was
enacted Being a grandfathered health Plan means that your Plan may not include certain
consumer Protections of the Affordable Care Act that apply to other Plans, for example the
ruairement for the Provision of Preventive health services without any cost sharing However,
grandfathered health Plans must complp with certain other consumer Protections in the
Affordable Care Act for example, the elimination of lifetime limits on benefits
Questions regardine which Protections apply and which protections do not apply to a
,erandfathered health plan and what might cause a plan to change from grandfathered health
plan status can be directed to the Plan Administrator at (530 -543 -6201) You may also contact
the U.S. Department of Health and Human Services at www healthrefornLeov
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 (RN.); part-time or intermittent home health aide
services provided through a Home Health Care Agency (this does not include general
housekeeping services); physical, occupational and speech therapy; medical supplies; and
laboratory services by or on behalf of the Hospital.
Hospice Agency is an organization where its main function 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.
Hospice Unit is a facility or separate Hospital Unit, that provides treatment 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
Page 5 of 79
-37-
premises 24- hour -a-day nursing services by or under the supervision of registered nurses (R.N.$);
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 unit" 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.
bi&fime is underAead to mean while eaver-ed under- this Plan. Ueder- ne eir-eumstanees dees
Lifetime ° n duf - in" `" ''` `' me e f the r d PeFsea. Deleted due to lifetime maximums
being eliminated See schedule of be fe!<ts
Medical Care Facility means a Hospital, or a facility that treats one or more specific ailments or
any type of Skilled Nursing Facility.
Medical Emergency means a sudden onset of a condition with acute symptoms requiring
immediate medical care and includes such conditions as heart attacks, cardiovascular accidents,
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.
Page 6 of 79
-38-
Medicare is the Health Insurance for the Aged and Disabled program under Title XVHI of the
Social Security Act, as amended..
Mental Disorder means any disease or condition that is classified as a mental Disorder in the
current edition of International Classification of Diseases published by the U.S. Department of
Health and Human Services or is listed in the current edition of Diagnostic 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.), 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 of his 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, under federal law, is
required to bear the legend: "Caution: federal law prohibits dispensing without prescription";
Page 7 of 79
-39-
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: Illness, disease or Pregnancy.
Skilled Nursing 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.
3. It provides 24 -hour per day nursing services by licensed nurses, under the direction of a
full -time registered nurse.
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, drug 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 incurred 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 - containing drinks.
Temporomandibular Joint (TMJ) syndrome is the treatment of jaw joint disorders including
conditions of structures linking the jaw bone and skull and the complex of muscles, nerves and
other tissues related to the temporomandibular joint.
Usual, Customary and Reasonable Charge (UCR) 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
Page 8 of 79
-40-
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 utilizing applicable local resources.
Page 9 of 79
-41-
Elisibility. Funding, Effective Date & Termination Provisions
Eligibility
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 if he 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 #I or #2 above.
4. Any other persons who become eligible in accordaiRce 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 any one of the following persons:
1. A covered Employee's Spouse, as derned; you or your Spouse's child who is under
are 26 and who is not eligible to enroll in an eligible enw1over- sponsored health plan
(as denned by law), including a natural cliild, stepchild, a legally adopted child a child
Qlaced for adoption or a child for whom you or your Spouse are the legal guardian.
ehild will eentiffue te be eever-ed after- age 19, provided the ehild is a full firae 9W&M
an aeoredited seheel, p6muily dependent open the eever-ed Employee for- suppeft and-
W* age of 25. A%eft the ehild r-ewhes
Individuals whose coverage ended or who were denied coverage (or were not eligible
for coverage), because the availability of dependent coverage of children ended before
attainment of age 26 are eligible to enroll in the District's Plan. Individuals may
request enrollment for such children for 30 days from the date of notice of Open
E_ nrollment. Open EnroUment period for the District is December I - 31. Enrollment
will then be effective January 1 of the following year. For more information, contact
the Plan Administrator at 530 -543 -6222.
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.
Page 10 of 79
-42-
Y.
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, umnaF6 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 Administrator reserves the right to have such
Dependent examined by a Physician of the Plan Administrator's choice, at 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 per-son who is on wtive duty in any failkapy serviee ef any ee Any dependent
who is on active duty in any military service in anv 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.
If both husband and wife are Employees, their children will be covered as Dependents of both.
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.
Page I I of 79
-43-
these
eeuft order- " man
_-eluding
wM
Y.
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, umnaF6 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 Administrator reserves the right to have such
Dependent examined by a Physician of the Plan Administrator's choice, at 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 per-son who is on wtive duty in any failkapy serviee ef any ee Any dependent
who is on active duty in any military service in anv 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.
If both husband and wife are Employees, their children will be covered as Dependents of both.
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.
Page I I of 79
-43-
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, umnaF6 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 Administrator reserves the right to have such
Dependent examined by a Physician of the Plan Administrator's choice, at 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 per-son who is on wtive duty in any failkapy serviee ef any ee Any dependent
who is on active duty in any military service in anv 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.
If both husband and wife are Employees, their children will be covered as Dependents of both.
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.
Page I I of 79
-43-
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.
Funding
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.
Effective Date
Effective Date of 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 of Dependent Coverage
Page 12 of 79
-44-
A Dependent will be covered under this Plan on the first date that the Dependent satisfies all of
the following:
I . 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;
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.
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 3 Q 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.
Page 13 of 79
-45-
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 of loss 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.
Qualified Medical Child Support Orders
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:
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(ax2XC)) 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 Coverage
When Employee Coverage Terminates
Page 14 of 79
-46-
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.
While continued, coverage will be that which was in force on the last day worked as an Active
Employee. However, if benefits 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 U
24 months of extended health care coverage upon payment of the entire cost of coverage plus a
Page 15 of 79
-47-
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 Veterans 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. 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).
Ift GeffiPfiftflee m4h Nfiehelle's Lay. GeveFage will be eaMinved for- Dependent Children who an'
ser-ieus illness or- if��. Sueh leave and ser-ieus ill most be doeumented by
et be teEminated befer-e the
weald ether-wise termktae (as indioated in items 13 above .
(Deleted due to legislative
chap es
Page 16 of 79
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Schedule of Benefits
Verification of Eligibility
Call (800) 455 -4236 or (775) 352 -6900
to verify eligibility for Plan benefits before the charge is incurred
Medical Benefits
Note: The following non - emergency services must be pre - certified or
reimbursement from the Plan will be reduced:
• Hospitalizations;
MRI (on second or subsequent tests per year,
• Skilled Nursing Facility stays;
• Home Health Care;
• Durable Medical Equipment exceeding $3,000;
• Outpatient Surgical'Procedures performed in an ambulatory surgical
center, hospital, or free - standing qurgical 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.
The Plan's current PPO is Nevada Preferred Professionals which covers areas of Northern
Nevada and bordering northern California (Tahoe) Provider lists are furnished upon reQUest,
without charge, as a separate document. Participants are responsible for ensuring that their
physician is currently a PPO provider before the visit as provider status changes often and
without notice to the Plan Administrator.
The District will reimburse the following providers, who currently are not participants in the self -
insured plan preferred provider organization, as if they were participants in the self-insured plan
preferred provider organization:
Page 17 of 79
-49-
Grandfathered Preferred Providers
Jose Aguirre, MD
Meddirect
Catherine Aisner, PhD
Alison Monroe, MD — Alpine Family Practice
Maggie Che MD
Tony Naccarato, DC
Tony Cruz
Viola Nungary, MFCC
Thomas Dickey, MFCC
i Larry Pappas MD
Timothy Doyle, MD
Jeanne Plumb, MD
Lee Van Epps MD
Reno Ortho Appliance
William Everts, MD
Renown — for Designated Trauma Center
Robert Flie ler, MD
Carol Scott, MD
Ron Gemberlin , MD
Winston Serrano, MD
Colleen Carr Hurwitz, MA
D. Thekekkara, MD Renown
Ned Jaleel, MD
UCD Medical Center
M. Mack, Chiropractor
UCD Medical Grou
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. The Participant is not responsible for any negotiated discount obtained,
however charges will be paid at the non -PPO benefit level.
Allowable Covered Expenses
All medical benefits are subject to allowable covered expense guidelines. Network providers
have agreed to negotiated rates. Members are not responsible for expenses over the negotiated
rates 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, 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- Payments Payable by Plan Participants
Deductibles and Co-Payments
Deductibles and co- payments are dollar amounts that the Covered Person must pay before the
Plan pays.
Page 18 of 79
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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 Year, a Covered Person must meet the
deductible shown below. Each January 1', 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.
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:
Page 59 19 of 79
Deductible
Co-Pay
Out of Pocket
Maximum
Wellness Program
PPO: $1000 Single
Guidelines Followed
$100 Single
$2000 Family
$200 Family
$10 per office visit
Non -PPO:
$1500 Single
$3000 Fami
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 Famil
Page 59 19 of 79
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.
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)
• Cost containment penalties
• Co- payments
Medical Benefits
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, Nle eeve -Red ........... ................... ... . ............. $2
The lifetime limit on the dollar value of benefits under the District's Plan no longer applies
Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are
eligible to enroll in the Plan during Open Enrollment (Dec 1 -311 for an effective date of
January I. For more information contact Ilse Plan Coordinator at 530 -543 -6222
There are other maximums on individual benefits. These follow under Benefit Limits.
Page 20 of 74
-52-
Schedule of Benefits
Page B of 79
% Payable
Co-Pay or
Co-Pay or Co-
Benefit
PPO
% Payable
Co-Ins
Ins Non -PPO
Benefit Type
Limits
Non -PPO
PPO
Acupuncture
52 visits
90%
70 0 N ,
10%
30%
combined
with
chiropractic
Ambulance
Per trip coax
90%
90%
10%
10 0 /0
Chiropractic
52 visits
90%
70%
10 0 /0
30%
combined
with
acupuncture
Durable Medical
90%
70%
10%
30%
ui mene
Emergency Room
90%
70%
$50110%
30%
Home Health Care
100 visits
90%
70%
10%
30%
r year
Hospice Care
6 15,000 P
lifetime
90%
70%
10%
30 0 /9
Hospital Care/Services
90%
70%
10%
30%
Immunizations
100%
70%
$10
30%
Injury to or Care of Mouth,
90%
70%
10%
30%
Teeth & Gums
Mastectom
90%
70%
10%
30%
Mental Health- atient
90%
70%
10%
30%
Mental Health-Ou t
100%
70%
$10
30%
Organ Trans lant
100%
70%
$10
30 0 /0
Other Medical Services &
90 0 /0
70%
10%
30%
Su lies'
Out of Area Medical
80%
80%
20%
20%
Emergencies
Outpatient Care &
90%
70%
10 11 /0
30 0 /6
Services
Physical The
$1,500/
90%
70%
10%
30%
Physician Care/Services
90%
70%
10%
30 /a
Physician's Office Visit
10
70%
$10
30%
Pregnancy- Employee,
90%
70%
10%
30%
Spouse or Covered Child
Prosthetics/Orthotics
90%
70%
10%
30%
Wellness Program Care
100 0 /0
80%
-0-
20%
(See Wellness Program
Guidelines)
Page B of 79
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.
Wellness 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 exam, 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 1' and June 30 and their dependents,
or new Adult Dependents, will be at the lower deductibles, co -pays, and out-of pocket maximums
until January I" 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 I' and December 31 ", and their dependents or new Adult Dependents, will be at the lower
deductibles, co -pays, and out -of- pocket maximum until January 1' following their one -year
anniversary. During this time period, the employee and/or their dependents must meet the
Page 22 of 79
-54-
% Payable
Co-Pay or
Co-Pay or Co-
Benefit
PPO
% Payable
Co -Ins
Ins Non -PPO
Benefit a
Limits
Non -PPO
PPO
Child Wellness Program
100 0 /0
80%
-0-
20%
Care (See Wellness
Program Guidelines 21
Wellness Program
100%
80%
-0-
20%
Testing (See Wellness
Program Guidelines)
Second Surgical Opinion
100%
100%
-0-
-0-
Skilled Nursin Facili
100 days
90%
70%
10%
30%
Substance Abuse
90%
70%
10%
30%
Treatment -In atient
Substance Abuse
100%
70%
$10
30%
Treatment-OUtpe
Urgent Care Center
100%
70% Islo
30%
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.
Wellness 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 exam, 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 1' and June 30 and their dependents,
or new Adult Dependents, will be at the lower deductibles, co -pays, and out-of pocket maximums
until January I" 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 I' and December 31 ", and their dependents or new Adult Dependents, will be at the lower
deductibles, co -pays, and out -of- pocket maximum until January 1' following their one -year
anniversary. During this time period, the employee and/or their dependents must meet the
Page 22 of 79
-54-
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 annuallbi- annual physical exams that are currently 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 Wellness Program Guidelines that are to be followed in order to
qualify for the lower deductible, co -pay and out of pocket maximums:
Wellness Program Guidelines
Child Wellness Guidelines
Children4 up to I8 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 100% with no deductible or co-pay for PPO Providers and 80%
payable for non -PPO providers. Covered charges include the following routine services, as
recommended by the physician: Physical Exam,
preventive non- 4aenostic Laboratory
and Urinalysis tests. and Immunizations (See Immunization Requirements, below)
Well Child Care Frennenev Limits
Age - -
Frequency Limit
1 St ye ar of life
Seven visits
2 year of life
Three visits
3 rd throw 18 ears of life
One visit per Calendar Year
Child Immunization Requirements
(Per 2006 CDC Reeommendstionc
Immunization
i Dose
2 Dose
3
4 th Dose/Booster
Diptheria,
2 months
4 months
6 months
Between 15 and 18 months. Can
Tetanus, Pertussis
be given as early as 12 months
(DTP/DTaP)
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
DTP/DTaP series and has not yet
received a booster for any
reason.
Immunization
1' Dose
2 Dose
3' Dose
4 Dose/Booster
Hepatitis A
12 months
23 months
N/A
Page J4 of 79
(Hep A)
Given at least 6
months apart
Hepatitis B (Hep
Birth
1 -2 months
6 -18
2 -18 years: Three dose series
B
months
p t iven to ail children under 18
who didn't set the vaccine as
infants,
H. influenzae type
2 months
4 months
6 months
b (Hib)
or between
12 -15
months
Measles/Mumps,
Between
One month
N/A
Second dose is typically given
Rubella (MMR)
12 -15
after first
between 4 -6 years, and should be
months
dose
given by 11 -12 years at the latest.
Pneumococcus
2 months
4 months
6 months
12 -15 months
CV7
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
Menin ococcal
Age 13 -15
Age 18
refailes 1
iam tinizati
series
Aes 9 26
Page 24 of 79
-56-
.muurt vv euness
rro ram liuiuewies
Exam Test or Procedure
Frequency
18 -25
26 -39
4049
50-64
65+
Comprehensive Physical Exam, including
such items as abdomen, breasts, heart, height,
Annually
X
X
X
weight, neck, visiontcolor, hearing (forced
&ea 2 Yrs
X
X
whisper), blood pressure, pelvic, rectal, testicles &
groin, prostate rectal exam, hemoccult (stool
occult blood ) testicals and grom
Fasting Complete Blood Count (CBC),
Every 5 years
X
X
Complete Metabolic Panel (CMP) &
Every 2 years
X
Chemical Urinalysis See Note
Annually
X
X
Fasting Lipid Profile a ee ote
Every 3 Years
X
X
Thyroid-Stimulating Hormone S
Every 3 years
X
X
TB Skin
Every 5 years
X
X
X
X
X
Exam, Test or Procedure
Frequency
18 -25
26 -39
4049
50-64
65+
Resting EKG
Baseline
X
Resting EKG
Every 4 years
X
Resting EKG
Every 3 vears
X
Colonoscopy
Every 10
X
X
ears
Bone Mineral Density Assessment
(Central or Perpheral; CT not cov'd as Wellnesss)
Every 3 yrs
X
X
Women
post menopausal
Men
At least One
X
Women Onl
Pap/Pelvic
Baseline
Age 21
Every 3 years
22 -26
X
X
E verp 2 years
X
Mammogram
Baseline
35 -39
Every 2 years
X
X
X
— Annually
X
Te26
Men Onl
PSA Blood Test
AantW
Eve Z ears
X
X
See Next pane for
Adult Immunization Guidelines
Page 25 of 79
Adult Immunization Gu „dines
an accordance with 2006 CDC Recommendations)
Immunization
Frequency or Booster
Tetanus Td or Tdap if indicated
Every 10 years at 30, 40, 50, 60, etc
Influenza flu
Volunta
Pneumovax (pneumonia shot
ever-age-6-5-Volunta
NOTE: In order to facilitate mr- iciyation in the - Health Improvement Program, and to
avoid duplication of mervices, enwl&W with physicaLOlood work late in the first calendar
year of the HIP (2011) can change their physical date and the blood work would be covered as
a wellness benefit, even if last lab draw was done 6 months earlier. Will waive frequency limit
the first Year (2011) ifpartk*atina in Health Improvement Program. In such case, Lab work
and Lipid Panel will be paid at 100%
Page 26 of 79
-58-
Notes for Schedule of Benefits
Benefit Descriptions & Benefit Limits
1. Acupuncture: PPO is payable at 90% and Non -PPO is payable at 70 %, 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. The Per Trip Maximum for Ambulance Services is paid at
90 %.
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: 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 70% (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' /o 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.
6. 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 confinement
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.
Page 27 of 79
-59-
7. Hospice Care Services and Supplies: The Benefit p"eFA Limit fer- 1409piee C.
limited to $15,000 pef Wet 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.
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 100 %. 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, teeth, 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
occurred while the person was covered under the Plan.
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 hard palate.
E. External incision and drainage of cellulitis.
F. Incision of sensory sinuses, salivary glands or ducts.
G. Removal of impacted teeth.
Page 28 of 79
-60-
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 or 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.
12. Mental Health Inpatient and Outpatient: Covered charges for care and treatment of
Mental Disorders will be limited as follows:
A. Treatment is covered the same as any other illness or injury and is subject to the
same co -pay and/or co- insurance.
B. 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.
C. Outpatient mental health co- payment is applied per office visit. Outpatient
charges for Mental Disorders will be counted in accumulating covered charges
toward the 100% payment percentage of other charges.
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.
Page 29 of 79
-61-
The Occupational Therapy benefit may be extended to a maximum of $3,000, when
combined with the annual Physical Therapy benefit, upon the recommendation of the
attending physician. The combined Occupational Therapy and Physical Therapy benefits
cannot exceed $3,000 per calendar year.
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 100 %.
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.
Organ Transplant Coverage 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 100% for transplants done at a designated
transplant facility. Covered charges for transplants performed at a non - network
facility will be paid at 70% 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 has 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:
Page 30 of 79
-62-
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 contact lenses or glasses required following cataract surgery.
E. Laboratory Studies
F. Prescription Drugs (as defined).
G. Private Duty Nursing 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:
♦ Inpatient Nursing 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.
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; (ii) an Injury; or (iii) a Sickness that is other
than a learning or Mental Disorder.
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 duration 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
Page 31_of 79
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. The Physical
Therapy benefits may be extended to a maximum of $3,000, when combined with the
annual Occupational Therapy benefit, upon the recommendation of the attending
physician. The combined Occupational Therapy and Physical Therapy benefits cannot
exceed $3,000 per Calendar Year.
Physical Therapy Annual Maximum may be extended to a maximum of $3,000 Per
year due to Medial Pateflofemoral Lieament Reconstruction and Medial Meniscus
repair, when medically necessary and pre - approved 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 Services/Treatment, Outpatient
Services/Treatment and Surgical Services/Procedures.
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.
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
generally 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 purchase, 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.
21. Charges for Child Wellness Program Care. Routine well newborn nursery care is
room, board and other normal care for which a Hospital makes a charge.
Page 32 of 79
-64-
The Usual and Reasonable Charge made by the Hospital for routine nursery care
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
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 fast 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.
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. Outpatient Substance Abuse Treatment is paid at 100% after $10 co -pay for PPO.
Non -PPO outpatient Substance Abuse Treatment is paid at 70 Outpatient
charges for Substance Abuse will be counted in accumulating covered charges
toward the 100% payment percentage of other charges.
Page 6� of 79
25. Foot Surgery — The Ossatron procedure for Plantar Fasciitis and bone spurs is an
authorized treatment under the Plan.
26. Smoking Cessation. Costs for medically supervised classes and/or cessation supplies to
shall be paid as any other illness.
Proof of mandatory attendance shall be provided to the Claims Administrator.
Page 34 of 79
-66-
Prescription Drug Benefit
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. 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 drag 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. Any one prescription is limited to the greater of a 30-day
supply or a 100 -unit 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.
Mail Order Drag 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, 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. Any one prescription is limited to the greater of a 90-day supply or a 300 -
unit dose.
Page 61 of 79
Prescription Drug Benefit
Schedule of Benefits
Notes:
a. Retail Pharmacy is for short-term use; 100 -unit dose or 30 day supply or if
prescription is unavailable by mail service
b. 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 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.
2. All compounded prescriptions containing at least one prescription ingredient in a
therapeutic quantity.
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 (GML).
Page 36 of 79
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Brand Name when
no generic
available, or when
noted
"Dispense as
Written" for
Purchase Location
Generic
Brand Name
Brand Name
Generic Available
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
Notes:
a. Retail Pharmacy is for short-term use; 100 -unit dose or 30 day supply or if
prescription is unavailable by mail service
b. 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 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.
2. All compounded prescriptions containing at least one prescription ingredient in a
therapeutic quantity.
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 (GML).
Page 36 of 79
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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.
S. Meridia is a covered medication when taken to counteract the side effects of anti -
psychotic medications.
Limits to this Benefit
This benefit applies only when a Covered Person incurs a covered Prescription Drug
charge. The covered drug charge for any one 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.
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.
S. 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.
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.
Page� of 79
11. A charge for hypodermic syringes and/or needles, injectables or any prescription
directing administration by injection (other than insulin, Imitrex, 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.
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.
Page 38 of 79
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Dental Benefits
Calendar Year Deductible for Class B (Basic) and Class C (Major) Services
Perperson ............................................................................................. ............................... $25.00
PerFamily Unit ..................................................................................... ............................... $50.00
Dental Percentage Payable
Class A Services — Preventive .......... ............................... ...........................100% (No Deductible)
Class B Services — Basic .................................................... ............................80% 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.
Preventive Dental Propram,
2007 Dental Benefits
Preventive Dental Program
Preventive Dental Program
Payable
Guidelines Followed
Guidelines
Not Followed
Preventative (Exam &
Preventive - 3 or 4 Oral Exams
Minimum of 3 oral exams and
Cleaning)
& Cleanings every 6 -8 months
cleanings not received during
Paid at 100 %, with No
during the previous two -year
the previous two year period.
Deductible
period.
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
defined below)
defined below
below continued to be paid at
Paid at 80%
Continued to be paid at 80%
80%
Major Dental Services as
If follow above preventive,
If preventive not followed
defined below —Paid at 80%
Major dental services will be
Major services will be paid at
paid at 80 %. Participants with
50 %.
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.
Exams and cleanings will be an on -going requirement in order to maintain the 80% 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
Page � of 79
PerPerson 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.
Covered Dental Services
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
Page 40 of 79
-72-
3. One full mouth x -ray every five Calendar Years.
4. One fluoride treatment for covered Dependent children under age 19 each Calendar Year.
S. Dental sealants for covered Dependent children under age 19.
6. Space maintainers for covered Dependent children under age 19 to replace primary teeth.
7. Emergency palliative treatment for pain.
ClassB Services: ................................................................................. Basic Dental Procedures
I . Dental x -rays not included in Class A.
2. Oral surgery. Oral surgery is limited to removal of teeth, preparation of the mouth for
dentures and removal of tooth- generated cysts of less than' /. inch.
3. Periodontics (gum treatments)
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.
8. General anesthetics, upon demonstration of Medical Necessity.
9. Antibiotic drugs.
Class C Services ........................ ............................... ..........................Major Dental Procedures
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.
Page 41 of 79
S. 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.
g. 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 adding 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.
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.
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 form 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 form to the Claims Administrator at this address:
CDS Group Health
P.O. Box 50190
Sparks, NV 89435 -0190
(800) 455 -4236
Pegg 4 42 of 79
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.
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 will 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.
7. 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 ,45 of 79
Medical Management Services
Medical Management Services Phone Number:
CDS Group Health Medical Management
P.O. Boa 50190
Sparks, NV 89435 -0190
8004554236 or 775 - 352 -6939
Fax: 775 - 352 -6992
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 reimbursement 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 minimize 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.
Also, any prior authorization is not a guarantee of coverage. The Utilization Review Program is
designed to determine whether or not a proposed course of treatment 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
ME (only on 2 and any subsequent MRI in the calendar year
Home Health Care
Outpatient surgical procedures performed in an ambulatory surgical center, hospital, or free - standing
surgical center
Durable Medical Equipment exceeding $3,000
Skilled Nursing Facility stays
Prosthetics
Page 44 of 79
-76-
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 maximize Plan reimbursement, 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:
CDS Medical Management
8004554236 ext. 6939 or 775 -352 -6939
ft: 775 - 352 -6992
at least 48 hours before the services are scheduled to be rendered, with the following
information:
1. The name of the patient and relationship to the Covered Employee
2. The name, Social Security Number and address of the Covered Employee
3. The name of the Employer
4. The name and telephone number of the attending Physician
5. The name of the Medical Care Facility, proposed date of admission, and proposed length
of stay
6. The diagnosis and/or type of surgery
7. The proposed rendering of listed medical services.
Page 4 5 of 79
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 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 SECTION,
THE BENEFIT PAYMENT WILL BE REDUCED BY 50%
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 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.
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.
Please refer to the "Claims Procedures" section of this booklet for information on submitting and
appealing a Medical Management decision.
Page 46 of 79
-78-
Case Management
The Case Management (CM) Program helps Members with serious Illnesses manage their health
care. The goal of the CM 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 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, 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 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.
Page 47 of 79
-79-
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.
Reconstructive 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 condition, except for Physician
prescribed and supervised programs, including cardiac rehabilitation, occupational or physical
therapy covered by this Plan.
Experimental or not Medically Necessary. Care and treatment that is either
ExperimentaVlnvestigational or not Medically Necessary.
Eye Care. Radial keratotomy or other eye surgery to correct near - sightedness. Also, routine eye
examinations, 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.
Foot Care. Treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or
bunions (except orthotics up to $200 per Calendar Year, and open cutting operations), and
treatment of corns, calluses or toenails (unless needed in treatment of a metabolic or peripheral -
vascular disease). The Ossotron procedure for the treatment of Plantar Fasciitis and bone spurs is
an approved surgical treatment procedure.
Page 48 of 79
-80-
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
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 shall designate type, frequency and duration of Medicallly 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 admission.
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.
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.
Personal Comfort Items. Personal comfort items or other equipment, such as, but not limited to,
air conditioners, air - purification units, humidifiers, electric heating units, orthopedic mattresses,
blood pressure instruments, scales, elastic bandages or stockings, nonprescription drugs and
medicines, and first -aid supplies and non - hospital adjustable beds.
Page ` 1 of 79
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, child, 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 - Inflicted. 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 Disorders. Care and treatment for sleep disorders unless deemed Medically Necessary.
Smoldng 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.
Surgical Sterilization Reversal. Care and treatment for eversal of surgical sterilization.
Temporomandibular Joint Syndrome. All diagnostic and treatment services related to the
treatment of jaw joint problems including temporomandibular joint (TMJ) syndrome.
War. Any loss that is due to a declared or undeclared act of war
Page 50 of 79
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Claims Procedures
(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 CFR § 2560.503 -1. Where any
provision is in conflict with the DOL's claims procedure regulations, or any other applicable law,
such law shall control.
Administrative Processes and SafeEaards
The Plan requires that claims determinations be made in accordance with governing 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 May Act for Claimant
Any of the following actions which can be done by the Claimant can also be done by an
authorized representative acting on the Claimant's behalf. The Claimant may be required to
provide reasonable proof of such authorization. For an urgent claim, a health care professional,
with knowledge of a Claimant's medical condition, will be permitted to act as the authorized
representative of the Claimant. "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
Upon 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 Claimant and gathered
independently by the Claims Administrator in light 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 participants by maintaining appropriate claim
and benefit records which shall be reviewed periodically and on a case -by -case basis to determine
past practices in similar claim situations. Should the Claims Administrator at any time during its
review period determine that additional information is required from the Employee or Claimant,
the Claims Administrator will request such necessary information from the Employee. The
Claims Administrator will make every effort to make its benefit determination in as reasonable a
time frame as possible.
Submitting a Claim
A claim is a request for a benefit determination which is made, in accordance with the Plan's
procedures, by a Claimant or his authorized representative. A claim must be received by the
person or organizational unit customarily responsible for handling benefit matters on behalf of the
Plan so that the claim review and benefit determination process can begin. A claim must name
the Plan, a specific Claimant, a specific health condition or symptom or diagnostic code, and a
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specific treatment, service or supply (or 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, 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:
1. A Pre- Service Claim is a written or oral request for Inpatient Hospital benefits
where the terms of the Plan condition benefits, in whole or in part, on prior approval
of the proposed care (e.g., a utilization review requirement). See the Medical
Management Program/Utilization Review section for that information.
A Pre - Service Claim should be submitted to:
CDS Group Health
P.O. Box 50190
Sparks, NV 89435-0190
Important: A Pre - Service Claim is only for the purposes of assessing the Medical Necessity
and appropriateness of care and delivery setting. A determination on a Pre - Service Claim
is not a guarantee of benefits from the Plan. Plan benefit payments are subject to review
upon submission of a claim to the Plan after medical services have been received, and are
subject to all related Plan provisions, including 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.
2. A Post Service Claim is a written request 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 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
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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 charges 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.
Assignments to Providers
All Eligible Expenses reimbursable under the Plan will be paid to the covered Employee except
that:
l . 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 for 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 Person, 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 from a Medicaid - eligible beneficiary
due to the state's having paid Medicaid benefits that were payable under the Plan.
Claims Denials
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;;
2. Specific reference to the Plan provision(s) on which the denial is based;
3 . A description of any additional information needed for further review of the claim; and;
4. An explanation of the Plan's review procedure.
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.
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Appeal Procedures
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 upheld, 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 Medical Management
P.O. Boa 50190
Sparks, NV 89435 -0190
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 Manager/Plan 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.
Pre- Certification/Prior 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 yet 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 determiaaiiou to:
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CDS Medical Management
P.O. Box 50190
Sparks, NV 89435 -0190
The Medical Director will render a decision within thirty (30) days 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 his/her 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
ATTN: General Manager/Plan 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)
days of the date the decision was made.
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Coordination of Benefits
Coordination of the benefit plans
Coordination of benefits sets out rules for the order of payment of covered Charges when two or
more plans — including Medicare — are paying. When a Covered Person is covered by this Plan
and another plan, 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.
Benefit Plan
This provision will coordinate the medical and dental benefits of a benefit plan. The term benefit
plan means this Plan or any one of the following plans:
I . Group or group -type plans, including franchise or blanket benefit plans.
2. Blue Cross and Blue Shield group plans.
I 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 Organization) plans: This Plan will not consider any
charges in excess of what an HMO provider has agreed to accept as payment in full. Also, when
an HMO pays its benefits first, this Plan will not consider as 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.
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Automobile 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 XVIII of the
Social Security Act and implementing regulations, Medicare is:
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.
Benefits for children covered as Dependents of both Employee Spouses will be
determined in accordance with the Dependent rules below and coordinated
internally.
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 result, the plans do not agree on the order
of benefits, this rule does not apply.
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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.
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:
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 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.
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Claims Determination Period
Benefits will be coordinated 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 organization 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.
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.
Subrogation and Reimbursement Provisions
Right of Subrogation and Refund
When this provision applies:
The Covered Person may incur medical or dental charges due to injuries, sickness, disease or
disability which may be caused, in whole or in part, 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-
fault, uninsured motorist, underinsured motorist, medical payment provision or other insurance
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 Participant, 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 (100°/6)
of the amount paid for benefits by the Plan, or the full extent of payment received, less
reasonable attorney's fees, when recovered from any one or combination of fast and third
party sources.
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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 has
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 organizationTesponsible, or potentially responsible, to the
Plan Participant for indemnification, the Plan Participant's attorney, or the Court.
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 consent 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 Participant, 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 Person:
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 characterized.
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,
judgment, 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.
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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.
Amount Subject to Subrogation or Refund
1. The Covered Person agrees to recognize the Plan's right to subrogation and
reimbursement. These rights provide the Plan with a priority over gay funds to recover
100% 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 his/her net recovery from all sources. This obligation exists whether or
not the judgment 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 it, 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.
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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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 fiords, 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 Participant,
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.
S. 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 famished 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 obtaining 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 administer the Plan's subrogation /reimbursement rights.
2. 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 remaining sections of this provision
and Plan. The section shall be fully severable. The Plan shall be construed and enforced
as if such invalid or illegal sections had never been inserted in the Plan.
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Defined Terms
L Recovery means monies paid to the Covered Person by way of judgment, settlement, 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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COBRA Continuation Options
To provide options for individuals who lose health coverage from an employer- sponsored
insurance plan, the Federal 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 employee's responsibility to notify the Plan Administrator immediately upon
experiencing a qualifying event. so that the Plan Administrator may effectuate 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 frame.
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). You
or your dependent have the responsibility to notify the third party COBRA administrator
of your desire to continue coverage within siw (60) days from the later of the date of
notification or loss of coverage. 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 are responsible for premiums back to the date termination from the
plan would have occurred.
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.
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The Employer will know when certain qualifying events (i.e., reduced work hours, employment
termination and death of an employee) occur. You and Your covered dependents will be
responsible for notifvine the Plan Administrator or his/her designee of a divorce, legal
separation, Medicare entitlement or when a dependent loses his/her "dependent status"
You or your depeadent(s) have sixty (60) days to notify the Plan Administrator or his
designee of these aualifvng events If the Plan Administrator or his designee is not notified
within this time frame, COBRA continuation cannot 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 shown, the maximum continuation coverage time frame
depends upon the qualifying event experienced. To be considered a 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.
Qualifying Events that Yield a Maximum of
Qualifying Events that Yield a Maximum of
18 Months Coverage
36 Months Coverage
(E xperienced by the Employee)
(Ea rienced by a Covered Dependent
Termination of employment (for reason other
Death of the employee
than "gross misconduct")
Reduction of employee's work hours
Divorce or legal separation
Employee is entitled to Medicare but
devendents are not
Dependent child who no longer meets the
Ian's definition of a "dependent"
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 event, you and your covered
dependents are eligible for an additional eleven months of coverage (yielding a total of 29
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 event, 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
Page 65 of 79
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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 termination of employment shall only be eligible for eighteen months of
continuation coverage under COBRA.
Family and Medical Leave Act
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 (3 1) 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.
COBRA Termination
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:
I . 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 Administrator 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.
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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% administration 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 terminates
coverage before the extension would ordinarily end, his/her 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 upon the Plan Year.
If you elect to continue coverage under COBRA, you will be granted an initial forty-five day
grace period to make your payment. Your fast 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.
Page 67 of 79
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Trade Act of 2002
On August 6, 2002, the Trade Act of 2002 was signed into law expanding 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 PBGC 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 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 visit the website at www.cobralaw.com/trade -act
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
The scope of HIPAA 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 terminate 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 coverage 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 you, 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.
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.
If you have any questions regarding this notification of your COBRA rights, please feel free
to contact Coneais 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
Page 68 of 79
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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 training, full -time National Guard duty and
the time necessary for a person to be absent from employment 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 it 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 69 of 79
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Plan Amendment Reeardine WAA Privacy Compliance
For the
South Tahoe Public Utility District
Emplovees' Benefit Plan
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 ( HIPAA) and its implementing
regulations restrict the Plan Sponsor's ability to use and disclose PHI. The following HIPAA
definition of PHI 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, present, or future physical or
mental health or condition of a participant the provision of health care to a participant; or
the past, present, 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 PHI from the Plan only as permitted under this Plan
Amendment or as otherwise required or permitted by HIPAA.
Provision of Protected Health Information to Plan Sponsor
Permitted Disclosure of Enrollment /Dis- 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 Uses and Disclosure of Summary 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:
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
Page 70 of 79
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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 ft2XI) 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 PHI only for Plan administration purposes.
Plan Administration Purposes: Plan administrative purposes means administration
functions performed by the Plan Sponsor on behalf of the Plan, such as quality assurance,
claims processing, utilization trends, auditing, and monitoring. Plan administration
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 PHI in a manner that is inconsistent with 45 CFR § 164.504(f).
Conditions of Disclosure for Plan Administration Purposes
Plan Sponsor agrees that with respect to any PHI (other an enrollment/dis- 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:
1. Not use or further disclose the PHI other than as permitted or required by the Plan or as
required by law.
2. Ensure that any agent, including a subcontractor, to whom it provides PHI 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 HIPAA's right to access in accordance with 45 CFR
§ 164.524.
Page 71 of 79
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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 PHI
received from the Plan available to the Secretary of Health and Human Services for
purposes of determining compliance by the Plan with HIPAA's privacy requirements.
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.
10. Ensure that the adequate separation between Plan and Plan Sponsor (i.e., the "firewall "),
required in 45 CFR § 504(f)(2xiii), is satisfied.
Adequate Separation 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 PHI. No other
persons shall have access to and use PHI to the extent necessary to perform the Plan
administration 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 Section, that employee shall
be subject to disciplinary action by the Plan Sponsor for non - compliance, pursuant to the Plan
Sponsor's employee discipline and termination procedures.
Certification 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 72 of 79
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Responsibilities for Plan Administration
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 shall administer 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 interpret 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 interpretation 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 Administrator
1. To administer the Plan in accordance with its terms.
2. To interpret the Plan, including the right to remedy possible ambiguities, inconsistencies
or omissions.
I 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.
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
Page 73 of 79
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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 amount, 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 74 of 79
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General Plan Information
,
With respect to component benefit Plans the Plan wX conwIv. , to the extent applicable, with
the requirements of all applicable laws, such as USERRA, COBRA, HIPAA, NMHPA,
CHIPRA, WHCRA, FMLA, MHPA, MHPAEA, HITECH Michelle's Law, and Title 1 of
GINA.
In accordance with Title I of the Genetic Information Nondiscrimination Act of 2008, in no
event shall the Plan or any of its insurers discriminate against any Participant on the basis of
genetic information with respect to eligibikty, premiums, or contributions
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 amendment,
modification or termination in accordance with the Plan Eligibility and Participant Section of this
Plan, and the applicable provisions of each Program. Any amendment, 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 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 termination.
Funding
All benefits paid under the Plan are paid in cash from the general assets of the District. No
Employees have any right, 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.
Page 75 of 79
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Type of Plan
The Plan provides medical, dental, and prescription drug benefits.
Type of Administration
The Plan is a self-funded welfare plan and the administration is provided through a third party
Claims Administrator
Plan Name Plan Number
South Tahoe Public Utility District Employees' Benefit Plan 901
Plan Effective Date Plan Year
January 1, 1997 January 1 through December 31 "
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
Claims Administrator
CDS Group Health
1625 East Prater Way, Building C, Suite 101
P.O. Box 50190
Reno, NV 89435 -0190
(800) 4554236
Plan Coordinators
Nancy Hussmann; Paul Hughes
South Tahoe Public Utility District
1275 Meadow Crest Drive
South Lake Tahoe, CA 96150
(530) 543 -6222 or 543 -6211
Plan Administrator
General Manager
South Tahoe Public Utility District
1275 Meadow Crest Drive
South Lake Tahoe, CA 96150
(530) 543 -6201
Trustee(s)
Board of Directors
South Tahoe Public Utility District
1275 Meadow Crest Drive
South Lake Tahoe, CA 96150
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 76 of 79
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Attachment 1
Authorization for Release of Cl 'm in
Claim Assistance
L hereby authorize the staff of CDS Group
Health, claims administrator for the South Tahoe Public Utility District, 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 claim(s).
This authorization will expire 60 days after the date of my signature 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.
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:
Print Name:
Original: Plan Coordinator
Cc: Employee
Claims Administrator
Date:
Page 77 of 79
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Attachment 2
Authorization for Release Of Claim Information
For Claim Appeal
1, , 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:
Print Name:
Original: Plan Administrator
Cc: Plan Coordinator
Employee
Claims Administrator
Date:
Page 78 of 79
-110-
Attachment 3
Authorization for
Release of Medical Information
To
Claims Administrator and Plan Administrator
Request for Plan Exception
11 hereby authorize the staff of CDS Group
Health and/or Medical Provider, to release to the Human Resources Director and/or General
Manager (Plan Coordinator and Plan Administrator) for the South Tahoe Public Utility District,
information regarding
This release of information is for the purpose of allowing the Plan Administrator 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 information
bearing upon my Request for Plan Exception, including when relevant, 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 fiuther 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 Administrator. 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:
Original: Claims Administrator
Cc: Plan Coordinator, Plan Administrator, Employee
Date:
Page 79 of 79
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PAYMENT OF CLAIMS
FOR APPROVAL
November 18, 2010
Payroll 11/2/10 429,064.30
Payroll 11 /16/10 425,214.44
Total Payroll 854,278.74
ADP 2,621.17
Banc of America 156,572.80
BNY Mellon Trust Company 0.00
Brownstein /Hyatt/Farber /Schreck legal services 0.00
CDS- health care payments 102,987.12
Union Bank 0.00
Total Vendor EFT 262,181.09
Accounts Payable Checks -Sewer Fund 299,790.74
Accounts Payable Checks -Water Fund 305,445.48
Accounts Payable Cheeks - Self - funded Insurance 0.00
Accounts Payable Checks - Grants Fund 0.00
Total Accounts Payable 605,236.22
Grand Total 1,721,696.05
Payroll
EFTS & Checks
11/2/10
11/16/10
EFT
AFLAC Medical & Dependent Care
833.42
0.00
EFT
CA Employment Taxes & W/H
19,101.36
18,640.61
EFT
Federal Employment Taxes & W/H
92,528.29
89,164.06
EFT
CalPERS Contributions
70,270.73
70,180.95
EFT
'Great West Deferred Comp
20,006.54
19,181.54
EFT
Stationary Engineers Union Dues
2,393.45
2,394.89
EFT
United Way Contributions
187.00
172.00
EFT
Employee Direct Deposits
215,545.72
218,082.80
EFT
Employee Garnishments
1,380.86
1,387.02
CHIC
Employee Paychecks
6,816.93
6,010.57
Total
429
425,214.44
-113-
PAYMENT OF CLAIMS
Vendor Name Department! Proj Name Description Acct# / Proj Cod@ Amount Check Num IYp
A -1 CHEMICAL INC GEN & ADMIN SHOP SUPPLY INV 1000 - 0421 64.68
A -1 CHEMICAL INC GEN & ADMIN JANIT /SUPPLY INV 1000 - 0422 977.96
Check Total: 1 AP 00077531 MW
ABC FIRE SERVICE HUMAN RESOURCES SAFETY PROGRAMS 1022 - 6079 282.16
ABC FIRE SERVICE HUMAN RESOURCES SAFETY PROGRAMS 2022 - 6079 282.16
Check Total: 564.34 AP 00077532 MW
ACCURATE PROCESS HUMAN RESOURCES PERSONNEL EXPENS 1022 - 6670 50.00
ACCURATE PROCESS HUMAN RESOURCES PERSONNEL EXPENS 2022 - 6870 50,00
Check Total: 100,00 AP MW
ACE HARDWARE OF 80 LAKE TAHOE ENGINEERING - UR SHOPS EVAL UR SHOP BLD EVAL 1029 - 7908 - URSHOP 11.10
Check Total: 11.10 AP 00077534 MW
AECOM TECHNICAL SERVICES INC ENGINEERING - IROQUOIS BSTR ST BSTR STN IROQ 2029 - 8967 - IQBSTR 3,393.00
Check Total: 3,393.00 AP 00077535 MW
AFLAC GEN & ADMIN SUPP INS WM 1000 - 2532 744.70
I
Check Total: 744.70 AP 00077536 MW
41 ELECTRIC MOTORS INC PUMPS PUMP, PONDEROSA 1002 - 7602 3,960.48
I Check Total:
3.960.48 AP 00077537 MW
ALPEN SIERRA COFFEE GEN & ADMIN OFC SUPPLY ISSUE 1000 - 6081 160.00
Check Total: 160,00 AP 00077538 MW
AMERICAS GEN & ADMIN PROPANE 1000 - 6360 369.97
Check Total: 369.97 AP 00077539 MW
AMERIPRIDE UNIFORM SERVICES GEN & ADMIN UNIFORM PAYABLE 1000 - 2518 882.16
Check Total: 882.16 AP 00077540 MW
ARETE SYSTEMS ENGINEERING CONTRACT SERVICE 1029.4405 800.62
ARETE SYSTEMS ENGINEERING CONTRACT SERVICE 2029 - 4405 800.63
ARETE SYSTEMS ENGINEERING - GIS SFTWR DEV ARETE, GIS 2029 - 8120 - GISSFT 6,536.25
Check Total: 8.137.50 AP MW
AT&T /CALNET 2 GEN & ADMIN TELEPHONE 1000 - 6310 473.74
AT &T /CALNET 2 GEN & ADMIN SIGNAL CHARGES 1000 - 6320 32.08
AT &TICALNET 2 PUMPS TELEPHONE 1002 - 6310 105.13
AT &T /CALNET 2 GEN & ADMIN TELEPHONE 2000 - 6310 473.74
User: THERESA
Page: 1 Current Date: 11 /10/2010
Report: OH_PMT_CLAIMS_BK Current Time: 11:56:35
Vendor I .
AT&T/CALNET 2
User: THERESA
Report: OH_PMT_CLAIMS_BK
Department/ Proj Name
PUMPS
PAYMENT OF CLAIMS
DIUMW Acct# / Proj Code
TELEPHONE 2002 -8310
IYpft
Page: 2 Current Date: 11/10/2010
Current Time: 11:56:35
Amount Check Nuts
103.31
Check Total: _LIME AP- 00077542 MW
AWARDS OF TAHOE ADMINISTRATION INCNTV & RCGNTN 1021 - 6621 34.48
AWARDS OF TAHOE ADMINISTRATION INCNTV & RCGNTN 2021 - 6621 34.47
Check Total: 66.98 AP- 00077543 MW
BAY TOOL & SUPPLY INC GEN & ADMIN SHOP SUPPLY INV 1000 - 0421 361.61
BAY TOOL & SUPPLY INC GEN & ADMIN SMALL TOOLS INV 1000 - 0423 817.99
Check Total: 1,179.60 AP- 00077544 MW
BENTLY AGROWDYNAMICS OPERATIONS SLUDGE DISPOSAL 1006 - 6652 2,0.38
Check Total: 2.068.38 AP- 00077545 MW
BEST & KRIEGER LLP ENGINEERING LEGAL - REGULAR 1029 - 4480 4,728.94
BEST & KRIEGER LLP ENGINEERING LEGAL - REGULAR 2029 - 4480 4,728.94
Check Total: 8,467,88 AP 00077546 MW
BING MATERIALS DIAMOND VLY FINCH GROUNDS & MNTC 1028 - 6042 243.04
BING MATERIALS UNDERGROUND REP PIPE/CVRSIMHLS 2001 - 6052 2,857.06
r Check Total: 3.100.10 AP- 00077547 MW
to
BIOMERIEX•VITEK LABORATORY LAB SUPPLIES 1007 - 4760 106.98
BIOMERIEX•VITEK LABORATORY LAB SUPPLIES 2007 - 4760 47.25
Check Total: 154.23 AP- 00077548 MW
BLUE RIBBON TEMP PERSONNEL UNDERGROUND REP CONTRACT SERVICE 2001 - 4405 1,984.48
BLUE RIBBON TEMP PERSONNEL ENGINEERING - WT METERING PRJ WTR METERING/NEW 2029.7078 - METERS 2,386.40
Check Total: 4.37048 AP- 00077549 MW
BROWN & CALDWELL CONSULTANTS ENGINEERING • ANGORA TNK REPL TANK, ANGORA 2029 - 7064 - ANGOTK 4,853.12
BROWN & CALDWELL CONSULTANTS ENGINEERING - ECHO TANK REPL TANK, ECHO 2029 - 8809 - ECHOTK 4,853.12
Check Total: 9.766.24 AP- 00077550 MW
CAUF BOARD OF EQUAUZATION FINANCE SUPPLIES 1039 - 6520 9.00
CAUF BOARD OF EQUAUZATION FINANCE SUPPUES 2039.6520 9.00
Check Total: 16,00 AP- 00077551 MW
CALIF DEPT OF HEALTH SERVICES PUMPS DUES/MEMB /CERT 1002 - 6250 170.00
Check Total: 170.00 AP- 00077552 MW
CAUF DEPT OF HEALTH SERVICES OPERATIONS DUES/MEMB/CERT 1006.6250 70.00
Vendor Name
CALIF DEPT OF HEALTH SERVICES UNDERGROUND REP
CALIF WATER RESOURCES CTRL BD OPERATIONS
DOMENICHELU & ASSOCIATES
User: THERESA
Department / Proj Namg
PAYMENT OF CLAIMS
Quahatian Acct# / Proj Code
DUES/MEMB/CERT 2001 •6250
DUES/MEMB/CERT 1006 - 6250
Check Total:
Check Total:
CAMPBELL CONSTRUCTION CO INC GEN & ADMIN - WT METERING PRJ CONST RETAINAGE 2000.2605 - METERS
CAMPBELL CONSTRUCTION CO INC ENGINEERING • WT METERING PRJ WTR METERING/NEW 2029 - 7078 - METERS
Check Total:
CASHMAN EQUIPMENT EQUIPMENT REP AUTOMOTIVE 1005.6011
ENGINEERING - DVR IRRIG IMPRVS DVR IRR FLDS PHI 1029 - 8161 - DVRIIP 25,139.32
Page: 3 Current Date: 11/10/2010
Report: OH_PMT_CLAIMS_BK Current Time: 11:56:35
Amount Check Num Type
50.00
120.00 AP 00077553 MW
170.00
170.00 AP 00077554 MW
- 4,587.43
45,874.29
41. 286.88 AP 00077555 MW
422.09
Check Total: x,09 AP 00077556 MW
CCH FINANCE SUBSCRIPTIONS 1039 - 4830 299.50
CCH FINANCE SUBSCRIPTIONS 2039 - 4830 299.50
Check Total: 599,00 AP 00077557 MW
CDW - G CORP INFORMATION SYS DIST.COMP SPPUS 1037.4840 145.21
COW - G CORP INFORMATION SYS DIST.COMP SPPLIS 2037 - 4840 145.19
1 Check Total: _MA AP 00077558 MW
rOCKING, DENNIS DIO OFFICE SUPPLIES 1027 - 4820 108.64
o►
COCKING, DENNIS DIO OFFICE SUPPLIES 2027 - 4820 108.64
Check Total: ;17.28 AP 00077559 MW
CWEA ELECTRICAL SHOP DUES/MEMB/CERT 1003 - 6250 217.00
Check Total: 217.00 AP 00077560 MW
DELL MARKETING L P INFORMATION SYS DIST.COMP SPPUS 1037 - 4840 1,082.15
DELL MARKETING L P INFORMATION SYS DIST.COMP SPPLIS 2037 - 4840 1,208.83
Check Total: 2.290.98 AP 00077561 MW
DIAMOND DITCH MUTUAL WATER DIAMOND VLY FINCH LAND & BUILDINGS 1028 - 5010 3,085.00
Check Total: 3.085.00 AP 00077562 MW
DIY HOME CENTER PUMPS SHOP SUPPLIES 1002 - 6071 5.53
DIY HOME CENTER HEAVY MAINT MOBILE EQUIP 1004 - 6012 21.51
DIY HOME CENTER UNDERGROUND REP SMALL TOOLS 2001 - 6073 90.97
DIY HOME CENTER PUMPS SHOP SUPPUES 2002 - 6071 5.52
Check Total: 123.53 AP 00077563 MW
User. THERESA
DOMENICHELLI a ASSOCIATES ENGINEERING - DVR IRR IMP UTL
GF$ CHEMICAL
Department / Pro' Name
PAYMENT OF CLAIMS
InmodotIgn Aced / Prol Coda
DVR IRR FLDS PHI 1029.8161 - DVRUTL
Check Total:
ENVIROMIENTAL EXPRESS LABORATORY LAB SUPPLIES 1007 - 4760
ENVIRONMENTAL EXPRESS LABORATORY LAB SUPPLIES 2007.4760
ERA LABORATORY LAB SUPPLIES 1007 - 4760
ERA LABORATORY LAB SUPPLIES 2007 - 4760
FAST PRINT DIO PRINTING 2027 - 4920
Check Total:
Check Total:
FEDEX HUMAN RESOURCES POSTAGE EXPENSES 1022 - 4810 7.97
FEDEX DIO POSTAGE EXPENSES 1027 - 4810 7.87
FEDEX ENGINEERING POSTAGE EXPENSES 1029 - 4810 3.98
FEDEX HUMAN RESOURCES POSTAGE EXPENSES 2022 - 4810 7.96
FEDEX DIO POSTAGE EXPENSES 2027.4810 7.86
I
PPE,DEX ENGINEERING POSTAGE EXPENSES 2029 - 4810 3.98
v
I Check Total: 3112 AP 00077568 MW
FERGUSON ENTERPRISES INC. HEAVY MAINT BUILDINGS 1004 - 6041 51.04
FERGUSON ENTERPRISES INC. HEAVY MAINT SHOP SUPPLIES 1004.6071 67.52
FERGUSON ENTERPRISES INC. ENGINEERING - UR SHOPS EVAL UR SHOP BLD EVAL 1029 - 7908 - URSHOP 481.72
FERGUSON ENTERPRISES INC. PUMPS WELLS 2002.6050 147.99
FERGUSON ENTERPRISES INC. PUMPS PUMP STATIONS 2002 - 6061 5.77
FERGUSON ENTERPRISES INC. HEAVY MAINTENANC BUILDINGS 2004 - 6041 61.00
Check Total: 815.04 AP 00077569 MW
GB GENERAL ENG CONTRACTOR INC UNDERGROUND REP PIPE/CVRS/MHLS 1001 •6052 3,108.25
GB GENERAL ENG CONTRACTOR INC UNDERGROUND REP PIPE/CVRSIMHLS 2001 •6052 9,047.75
GB GENERAL ENG CONTRACTOR INC ENGINEERING • IROQUOIS SUPPLY WTLN IROQ 2029 - 8166 - IQWTRL 1,956.25
Check Total: 14.112.25 AP 00077570 MW
GFOA FINANCE DUES/MEMB/CERT 1039.6250 80.00
GFOA FINANCE DUESIMEMBICERT 2039.6250 80.00
LABORATORY LAB SUPPLIES 1007.4760 137.30
Page: 4 Current Date: 11/10/2010
Report OH_PMT_CLAIMS BK Current Time: 11:56:35
Amount Cheek Num I
3,150.00
28.28942 AP 00077564 MW
426.26
339.50
766.76 AP 00077565 MW
34.60
67.61
102.21 AP 00077566 MW
202.33
Check Total: 202.33 AP- 00077567 MW
Check Total: 160.00 AP- 00077571 MW
Vendor Name
GFS CHEMICAL
GILL., DENISE
GLOBAL DATA SPECIALISTS
GLOBAL DATA SPECIALISTS
User: THERESA
PAYMENT OF CLAIMS
Department / ProJ Name Description Acct# / Proj Code Ajnount Check Num
Ina
LABORATORY LAB SUPPUES 2007 - 4760 201.15
Check Total: 338 AP 00077572 MW
CUSTOMER SERVICE - WTR CONS PROG WTR CONS EXPENSE 2038 - 6660 - WCPROG 200.00
Check Total: Y00,00 AP 00077573 MW
ELECTRICAL SHOP REP TELEM EQ TBD 1003 - 8107 4,566.67
ELECTRICAL SHOP SCADA UPGR FLD 3 2003.8054 8,623.33
Check Total: 13.190.00 AP 00077574 MW
GRAINGER GEN & ADMIN JANIT/SUPPLY INV 1000 - 0422 383.27
GRAINGER HEAVY MAINT SHOP SUPPLIES 1004 - 6071 82.41
GRAINGER EQUIPMENT REP GENERATORS 1005 - 6013 99.27
GRAINGER OPERATIONS SMALL. TOOLS 1006 - 6073 413.39
GRAINGER ENGINEERING - UR SHOPS EVAL UR SHOP BLD EVAL 1029 - 7908 - URSHOP 419.17
Check Total: 1 AP 00077575 MW
GRANT THORNTON LLP FINANCE AUDITING 1039 - 4470 6,779.75
GRANT THORNTON LLP FINANCE AUDITING 2039 - 4470 6,779.75
r
f• Check Total:
F+ 13,559,50 AP 00077376 MW
TIEAT BASIN UNIFED AIR POLL CTRL DIST DIAMOND VLY RNCH OPERATING PERMIT 1028 - 6650 393.56
Check Total: 393.56 AP 00077577 MW
GROVE MADSEN INDUSTRIES INC ELECTRICAL SHOP FILTER EQ/BLDG 1003 - 6023 123.55
GROVE MADSEN INDUSTRIES INC ELECTRICAL SHOP PUMP STATIONS 1003 - 6051 897.35
Check Total: 1 AP 00077578 MW
HACH CO LABORATORY LAB SUPPLIES 1007 - 4760 46.10
HACH CO LABORATORY LAB SUPPLIES 2007.4760 62.07
Check Total: 108.17 AP 00077579 MW
HARDY DIAGNOSTICS LABORATORY LAB SUPPUES 1007 - 4760 228.61
HARDY DIAGNOSTICS LABORATORY LAB SUPPLIES 2007 - 4760 241.14
Check Total: 469 AP 00077580 MW
HERTZOG, CYNTHIA CUSTOMER SERVICE • WTR CONS PROG WTR CONS EXPENSE 2038 - 6660 - WCPROG 200.00
Check Total: 200.00 AP 00077581 MW
HIGH SIERRA BUSINESS SYSTEMS FINANCE SERVICE CONTRACT 1039 - 6030 79.34
HIGH SIERRA BUSINESS SYSTEMS FINANCE SERVICE CONTRACT 2039 - 6030 79.34
Page: 5 Current Date: 11/10/2010
Report: OH_PMT_CLAIMS_BK Current Time: 11:56:35
Vytdot Nam*
HOME DEPOT CREDIT
HOME DEPOT CREDIT
HOME DEPOT CREDIT
IDEXX DISTRIBUTION CORP.
IDEXX DISTRIBUTION CORP.
INSITE LAND SURVEYS
INTEGRITY LOCKSMITH
INTERSTATE SAFETY & SUPPLY
INTERSTATE SAFETY & SUPPLY
TACK HENRY & ASSOC. INC
.LACK HENRY & ASSOC. INC
JONES, SARAH
KTHO RADIO
KTHO RADIO
LAB SAFETY SUPPLY
LAB SAFETY SUPPLY
LAKE TAHOE PLUMBING INC
LAVALLEE, PETER
User: THERESA
Report: OH PMT_CLAIMS BK
Dewy / Pro1 Name
DIAMOND VLY RNCH
DIAMOND VLY RNCH • SNOWSHOE
ENGINEERING • UR SHOPS EVAL
LABORATORY
LABORATORY
GEN & ADMIN
GEN & ADMIN
CUSTOMER SERVICE
CUSTOMER SERVICE
LABORATORY
LABORATORY
PAYMENT OF CLAIMS
GROUNDS & MNTC
DITCH -2 DITCH PIPING
UR SHOP BLD EVAL
LAB SUPPLIES
LAB SUPPLIES
ENGINEERING - WT METERING PRJ WTR METERING/NEW
PUMPS PUMP STATIONS
SHOP SUPPLY INV
SAFETY INVENTORY
SERVICE CONTRACT
SERVICE CONTRACT
CUSTOMER SERVICE • WTR CONS PROG WTR CONS EXPENSE
DIO - PR EXP- EXTERNAL PUB RELATIONS
DIO • PR EXP- EXTERNAL PUB RELATIONS
LAB SUPPUES
LAB SUPPUES
PUMPS PUMP STATIONS
ENGINEERING TRAVEL/ MEETINGS
Page: 6
Accts / ProI Code
1028 - 8042
1028 - 8131 - SNOPIP
1029 - 7908 - URSHOP
Check Total:
1007-4780
2007-4780
2029 - 7078 - METERS
Check Total:
1002 -8051
1000 - 0421
1000 - 0425
1038.6030
2038 - 6030
1007-4780
2007-4780
1002-8051
1029 - 6200
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
2038 - 8660 - WCPROG
Check Total:
1027 - 6620 - PREEXT
2027 - 6620 - PREEXT
Check Total:
Check Total:
Check Total:
Current Date: 11/10/2010
Current Time: 11:56:35
Amami Check Num Ix &
156.66 AP- 00077582 MW
70.91
121.71
20.49
213.11 AP 00077583 MW
337.12
114.55
451.67 AP MW
500.00
500.00 AP 00077585 MW
425.13
425.13 AP 00077586 MW
493.35
755.23
1.248.58 AP 00077587 MW
1,395.00
1,395.00
2.790.00 AP 00077588 MW
383.50
383.50 AP 00077589 MW
275.00
275.00
550.00 AP 00077590 MW
108.02
88.85
194.87 AP 00077592
222.00
222.00 AP 00077593
338.12
MW
MW
Vendor Nona
LAVALLEE, PETER
User. THERESA
Department / ProJ Name
ENGINEERING
PAYMENT OF CLAIMS
landiaan Acct# / Proj Code
TRAVEL/MEETINGS 2029 - 6200
Amount Check Num Ins
338.12
Check Total: 676.24 AP 00077594 MW
LEE, JEFF OPERATIONS TRAVEL/MEETINGS 1006.6200 139.20
Check Total: 13920 AP 00077595 MW
LES SCHWAB TIRES EQUIPMENT REP AUTOMOTIVE 1005 - 6011 57.50
Check Total: 57.50 AP 00077596 MW
ULLY'S TIRE SERVICE INC. EQUIPMENT REPAIR AUTOMOTIVE 2005 - 6011 2,313.60
Check Total: 2.313.60 AP 00077597 MW
LOOMIS FINANCE CONTRACT SERVICE 1039 - 4405 309.27
LOOMIS FINANCE CONTRACT SERVICE 2039 - 4405 309.27
Check Total: 618.54 AP 00077598 MW
MAIL FINANCE CUSTOMER SERVICE EQUIP RENT/LEASE 1038 - 5020 12330
MAIL FINANCE CUSTOMER SERVICE EQUIP RENT/LEASE 2038 - 5020 123.70
Check Total: 247.40 AP 00077599 MW
P fC MASTER CARR SUPPLY CO PUMPS PUMP STATIONS 1002.6051 956.37
lifp MASTER CARR SUPPLY CO PUMPS SHOP SUPPUES 1002.6071 577.26
O
MC MASTER CARR SUPPLY CO HEAVY MAINT MOBILE EQUIP 1004.6012 286.44
MC MASTER CARR SUPPLY CO ENGINEERING - UR SHOPS EVAL UR SHOP BLD EVAL 1029 - 7908 - URSHOP 1,334.16
MC MASTER CARR SUPPLY CO PUMPS SHOP SUPPUES 2002 - 6071 577.15
Cheek Total: 3.711.38 AP 00077602 MW
MSC INDUSTRIAL SUPPLY CO PUMPS SMALL TOOLS 1002 - 6073 101.75
MSC INDUSTRIAL SUPPLY CO PUMPS SMALL TOOLS 2002 - 6073 102.01
Check Total: 20316 AP 00077603 MW
MWH LABORATORIES LABORATORY MONITORING 2007 - 6110 20.00
Check Total: 20,00 AP 00077604 MW
NELS TAHOE HARDWARE PUMPS SMALL TOOLS 1002 - 6073 • 13.38
NELS TAHOE HARDWARE PUMPS WELLS 2002 - 6050 23.70
NELS TAHOE HARDWARE PUMPS SMALL TOOLS 2002 - 6073 13.37
Check Total: 50.45 AP 00077605 MW
NEVADA GENERATOR SYSTEMS INC EQUIPMENT REPAIR GENERATORS 2005 - 6013 349.35
Page: 7 Current Date: 11/10/2010
Report: OH_PMT_CLAIMS_BK Current Time: 11:56:35
Check Total: 349,35 AP 00077606 MW
MSOSILAINDR
NORTHWEST HYD. CONSULT INC
NORTHWEST HYD. CONSULT INC
NOVALYNX CORP
OFFICE DEPOT
ONTRAC
ONTRAC
OUTSIDE TELEVISION
OUTSIDE TELEVISION
PAPA Membership
TTERBILT TRUCK PARTS
PETERSON, JENNIFER
PETTY CASH
PETTY CASH
PETTY CASH
PETTY CASH
PETTY CASH
PETTY CASH
PETTY CASH
PIPEUNE SYSTEMS INC, PSI
PLASTI -FAB
User. THERESA
Report: OH_PMT_CLAIMS_BK
Dapsrtment /Prot Nama
ENGINEERING - CTC GRNT -BMPs
ENGINEERING - DEMO RALPH TANK
LABORATORY
GEN & ADMIN
LABORATORY
LABORATORY
010 - PR EXP- EXTERNAL
010 - PR EXP- EXTERNAL
DIAMOND VLY RNCH
EQUIPMENT REPAIR
ENGINEERING - WT METERING PRJ
INFORMATION SYS
INFORMATION SYS
CUSTOMER SERVICE
INFORMATION SYS
CUSTOMER SERVICE
CUSTOMER SERVICE
CUSTOMER SERVICE • WTR CONS PROG
OPERATIONS - SCADA IMPRVMTS
PAYMENT OF CLAIMS
Q91011000
. BMP PROJECTS
BMP PROJECTS
Page:
LABORATORY EQUIP
OFFICE INVENTORY
POSTAGE EXPENSES
POSTAGE EXPENSES
PUB RELATIONS
PUB RELATIONS
DUESIMEMB/CERT
GENERATORS
WTR METERING/NEW
OFFICE SUPPLIES
TRAVELIMEETINGS
OFFICE SUPPLIES
DIST.COMP SPPLIS
OFFICE SUPPUES
TRAVEL/MEETINGS
WTR CONS EXPENSE
PLNTSCADA SYSTEM
DIAMOND VLY RNCH - SNOWSHOE DITCH -2 DITCH PIPING
8
Acct# / Proi-Code
2029 - 8745 • CTCBMP
2029.8743 • DEMORT
Check Total:
Check Total:
Check Total:
1007-6025
1000 - 0428
1007 - 4810
2007 4810
Check Total:
1027 - 6620 - PREEXT
2027 - 6620 - PREEXT
Check Total:
1028.6250
2005 - 6013
1028 - 8131 - SNOPIP
Check Total:
Check Total:
2029.7078 - METERS
Check Total:
1037 - 4820
1037 - 6200
1038 - 4820
2037 - 4840
2038 -4820
2038 - 6200
2038 - 6660 - WCPROG
Check Total:
1006 - 8328 - SCADAM
Check Total:
Check Total: 11.742.50 AP 00077617 MW
Current Date: 11 /10/2010
Current Time: 11:56:35
Amount Check Num Inft
787.32
787.32
1.574.84 AP 00077607 MW
171.71
17121 AP 00077608 MW
295.24
295.24 AP 00077609 MW
34.00
23.50
57.50 AP 00077610 MW
730.63
730.62
1.461.25 AP 00077611 MW
40.00
40.00 AP 00077612 MW
218.30
218.30 AP 00077613 MW
62.50
62.50 AP 00077614 MW
7.07
7.50
31.95
7.06
31.94
7.50
25.00
118.02 AP-00077615 MW
6 AP- 00077616 MW
11,742.50
686.00
PAYMENT OF CLAIMS
Vendor Name Department / Pro) Name Description Acct# / Proj Code Amount Check Nunn Ip
POLYDYNE INC OPERATIONS POLYMER 1006.4720 16,058.02
Check Total: 16.058.02 AP 00077618 MW
POWER TRAC DIAMOND VLY RNCH SLOPE MOWER 1028.8129 23,658.60
Check Total: Y3.658.60 AP 00077619 MW
POWER TRAC DIAMOND VLY RNCH SLOPE MOWER 1028 - 8129 23,658.60
Check Total: 23,658.60 AP 00077620 MW
PRAXAIR 174 PUMPS SHOP SUPPLIES 1002 - 6071 55.17
PRAXAIR 174 HEAVY MAINT SHOP SUPPLIES 1004 - 6071 79.42
PRAXAIR 174 LABORATORY LAB SUPPLIES 1007.4760 60.40
PRAXAIR 174 PUMPS SHOP SUPPLIES 2002 - 6071 55.15
PRAXAIR 174 LABORATORY LAB SUPPLIES 2007 - 4760 60.39
Check Total: 310.53 AP 00077621 MW
PRO LEISURE ADMINISTRATION INCNTV & RCGNTN 1021 - 6621 44.18
PRO LEISURE ADMINISTRATION INCNTV & RCGNTN 2021 - 6621 44.18
I
Check Total: 88.38 AP 00077622 MW
*VEN BIOLOGICAL LABS LABORATORY LAB SUPPLIES 1007 - 4760 20.00
OVEN BIOLOGICAL LABS LABORATORY LAB SUPPLIES 2007 - 4760 38.45
Check Total: 58,15 AP 00077623 MW
RED WING SHOE STORE ENGINEERING SAFETY/EQUIP/PHY 1029 - 6075 90.13
RED WING SHOE STORE ENGINEERING SAFETY/EQUIP/PHY 2029 - 6075 90.12
Check Total: 180.25 AP 00077624 MW
RENNER EQUIPMENT CO DIAMOND VLY RNCH GROUNDS & MNTC 1028 - 6042 533.92
Check Total: 533.92 AP 00077625 MW
RENO DRAIN OIL SERVICE EQUIPMENT REP OIL & LUBE 1005 - 4630 80.00
RENO DRAIN OIL SERVICE EQUIPMENT REPAIR OIL & LURE 2005 - 4630 80.00
Check Total: 1611,00 AP 00077626 MW
REXEL NORCAL VALLEY - SACRAMENTO ELECTRICAL SHOP PRIMARY EQUIP 1003 - 6021 1,137.00
Check Total: 1.137.00 AP 00077627 MW
RIEGER, TIMOTHY .1 ENGINEERING TRAVEL/MEETINGS 1029 - 6200 39.17
RIEGER, TIMOTHY J ENGINEERING TRAVEL/MEETINGS 2029.6200 39.17
Check Total: 78.34 AP 00077628 MW
User: THERESA
Page: 9 Current Date: 11/10/2010
Report: OH_PMT CLAIMS_BK Current Time: 11:56:35
II006CAMDI
Round HUI CUD
User: THERESA
Department / Prot Name
GEN & ADMIN • USFS GRNT ADMIN
J AYMENT OF CLAIMS
SUSPENSE
Acct# / Proi Cod.
2000.2504 - SMOKEY
Check Total:
22.497,16 AP 00077629 MW
RUDY'S PLUMBING & HEATING INC ENGINEERING - WT METERING PRJ WTR METERING/NEW 2029.7078 • METERS 907.49
Check Total: -- 9Q7.49 AP 00077630 MW
RUIZ, JOSE UNDERGROUND REP TRAVEL/MEETINGS 1001 - 6200 158.00
Check Total: 158.00 AP 00077631 MW
SAFEWAY INC 09344 GEN & ADMIN UB SUSPENSE 1000 - 2002 8,103.24
Check Total: 8.103.24 AP 00077632 MW
SAFEWAY INC 09344 GEN & ADMIN UB SUSPENSE 1000 - 2002 30,253.33
Check Total: 30,253,33 AP 00077633 MW
SCOTTYS HARDWARE PUMPS PUMP STATIONS 1002.6051 17.54
SCOTTYS HARDWARE PUMPS WELLS 2002 - 6050 21.58
SCOTTYS HARDWARE PUMPS PUMP STATIONS 2002.6051 4.95
Check Total: 4,1,07 AP 00077634 MW
HERMAN, THERESA FINANCE TRAVEL/MEETINGS 1039 - 6200 49.20
glERMAN, THERESA FINANCE TRAVEL/MEETINGS 2039 - 6200 49.20
W
1 Check Total:
98.40 AP 00077635 MW
SIERRA CHEMICAL CO OPERATIONS HYPOCHLORITE 1006 - 4755 3,949.07
SIERRA CHEMICAL CO PUMPS HYPOCHLORITE 2002.4755 517.28
Check Total:
SIERRA NEVADA MEDIA GROUP EQUIPMENT REP REP TRK 46 1005.8179 30.65
SIERRA NEVADA MEDIA GROUP EQUIPMENT REP REP TRK 51 1005 - 8180 30.65
SIERRA NEVADA MEDIA GROUP EQUIPMENT REP REP TRK 49 1005 - 8181 30.64
SIERRA NEVADA MEDIA GROUP HUMAN RESOURCES ADS/LGL NOTICES 1022 - 4930 143.50
SIERRA NEVADA MEDIA GROUP DIO • PR EXP- EXTERNAL PUB RELATIONS 1027 - 6820 - PREEXT 375.00
SIERRA NEVADA MEDIA GROUP ENGINEERING - HEADWORKS HDWKS IMP PROJ 1029 - 8033 • HDWORK 373.29
SIERRA NEVADA MEDIA GROUP HUMAN RESOURCES ADS/LGL NOTICES 2022 - 4930 143.50
SIERRA NEVADA MEDIA GROUP 010 - PR EXP- EXTERNAL PUB RELATIONS 2027.6620 - PREEXT 375.00
SIERRA NEVADA MEDIA GROUP CUSTOMER SERVICE ADS/LGL NOTICES 2038.4930 414.50
Check Total: 1.916.73 AP 00077637 MW
SIERRA PACIFIC POWER GEN & ADMIN ELECTRICITY 1000.6330 66,204.27
SIERRA PACIFIC POWER GEN & ADMIN ST LIGHTING EXP 1000 - 6740 1,524.74
Page: 10 Current Date: 11/10/2010
Report: OH_PMT CLAIMS BK Current Time: 11:56:35
Amount Catcall= Ix
22,497.16
4.466.35 AP- 00077636 MW
Vendor Name
SIERRA PACIFIC POWER
SKELLY, CHRIS
SKELLY, CHRIS
SOUND STRATEGIES/OFC INC.
SOUND STRATEGIES/OFC INC.
SOUTHWEST GAS
SOUTHWEST GAS
SUBSTITUTE PERSONNEL &
SUBSTITUTE PERSONNEL &
SUBSTITUTE PERSONNEL &
SUBSTITUTE PERSONNEL &
SUBSTITUTE PERSONNEL &
TITUTE PERSONNEL &
SUBSTITUTE PERSONNEL &
SUBSTITUTE PERSONNEL &
SUBSTITUTE PIMONNEL &
SUBSTITUTE PERSONNEL &
SUBSTITUTE PERSONNEL &
SYSTEMS TECHNOLOGY ASSOCIATES INC,
SYSTEMS TECHNOLOGY ASSOCIATES INC,
SYSTEMS TECHNOLOGY ASSOCIATES INC,
Tahoe City PUD
TAHOE MOUNTAIN NEWS
TAHOE MOUNTAIN NEWS
User. THERESA
Report: OH_PMT_CLAIMS_BK
Department / Proj Name
GEN & ADMIN
INFORMATION SYS
INFORMATION SYS
DIO
DIO
GEN & ADMIN
GEN & ADMIN
UNDERGROUND REP
ENGINEERING
INFORMATION SYS
CUSTOMER SERVICE
ENGINEERING - J-M PIPE FAILURE
ENGINEERING
ENGINEERING - WT METERING PRJ
ENGINEERING - IROQUOIS SUPPLY
ENGINEERING - IROQUOIS BSTR ST
INFORMATION SYS
CUSTOMER SERVICE
INFORMATION SYS
INFORMATION SYS
INFORMATION SYS - IT STRATEGC PLN
GEN & ADMIN - USES GRNT ADMIN
D10 - PR EXP- EXTERNAL
DIO - PR EXP- EXTERNAL
PAYMENT OF CLAIMS
CONTRACT SERVICE
CONTRACT SERVICE
CONTRACT SERVICE
CONTRACT SERVICE
CONTRACT SERVICE
CONTRACT SERVICE
WTR METERING/NEW
WTLN IROQ
BSTR STN IROQ
CONTRACT SERVICE
CONTRACT SERVICE
SERVER, PHONE
SRVR, ENG
IS STRAG PLN IMP
SUSPENSE
PUB RELATIONS
PUB RELATIONS
Page: 11
Description
ELECTRICITY
TRAVEL/MEETINGS
TRAVEL/MEETINGS
CONTRACT SERVICE
CONTRACT SERVICE
NATURAL GAS
NATURAL GAS
Acct# / Proj Code
2000 - 6330
1037 - 6200
2037 - 6200
1027.4405
2027.4405
1000.6350
2000.6350
1001 -4405
1029.4405
1037 -4405
1038 - 4405
2029 - 4405 - MANVIL
2029 - 4405
2029 - 7078 • METERS
2029 - 8166 - IQWTRL
2029 - 8967 • IQBSTR
2037 - 4405
2038 -4405
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
1037 - 8040
2037 - 8071
2037 - 8960 - ITPLAN
Check Total:
2000.2504 - SMOKEY
Check Total:
1027 - 6620 - PREEXT
2027 - 6620 - PREEXT
Check Total:
Current Date: 11/10/2010
Current Time: 11:56:35
Amaunl Check Num Iypg
20,851.34
8,740.85
8,739.26
28,947.99
AP 00077638
88.580.35
92.50
92.50
185.00 AP 00077639
49.00
49.00
98.00
2,857.03
138.23
2.995.26 AP 00077641
2,111.20
- 196.07
195.60
195.60
- 112.04
- 168.06
1,550.14
292.44
47.80
195.60
195.60
AP- 00077640
4.192.21 AP 00077642
46.428.10 AP 00077643
85,681.97
85.681.97
162.50
162.50
AP- 00077644
325.00 AP- 00077645
MW
MW
MW
MW
MW
MW
MW
M W
TAHOE PRINTING
TAHOE PRINTING
TAHOE TRADING POST
TAHOE TRADING POST
TAHOE TRADING POST
TAHOE WEB HOST
TAHOE WEB HOST
TRANSFORMER TESTING & REPAIRS INC ELECTRICAL SHOP
TRPA
TRPA
gitPA
TURNER & ASSOCIATES INC
UNITED RENTALS INC
UNITED RENTALS INC
USP$- HASLER
USPS-HASLER
WECO INDUSTRIES INC
WEDCO INC
WESTERN BOTANICAL SERVICES
User: THERESA
OH_PMT_CLAIMS_BK
QtalUtIMUICIALNIMIn
ELECTRICAL SHOP
ELECTRICAL SHOP
UNDERGROUND REP
PUMPS
PUMPS
D10
D10
ENGINEERING
ENGINEERING
ENGINEERING - IROQUOIS SUPPLY
ENGINEERING - WT METERING PRJ
GEN & ADMIN
GEN & ADMIN
ELECTRICAL SHOP
ELECTRICAL SHOP
ENGINEERING • IROQUOIS SUPPLY
PAYMENT OF CLAIMS
Qua Non
OFFICE SUPPLIES
OFFICE SUPPLIES
SAFETY/EQUIP/PHY
PUMP STATIONS
PUMP STATIONS
CONTRACT SERVICE
CONTRACT SERVICE
PRIMARY EQUIP
OPERATING PERMIT
OPERATING PERMIT
WTLN IROQ
WTR METERING/NEW
DIAMOND VLY RNCH DITCH PIPING
DIAMOND VLY RNCH - SNOWSHOE DITCH -2 DITCH PIPING
POSTAGE PPD
POSTAGE PPD
SHOP SUPPLIES
PUMP STATIONS
WTLN IROQ
Page: 12
ACct* / Proj Code
1003 -4820
2003 - 4820
1001 - 6075
1002 - 6051
2002.6051
1027 - 4405
2027 - 4405
1003 -6021
1029 - 6650
2029 - 6650
1028 -8131
1000.0304
2000 - 0304
1003 -8071
1003 -6051
Check Total:
Check Total:
Check Total:
Check Total:
Check Total:
2029 - 8166 - IQWTRL
Check Total:
2029 - 7078 - METERS
Check Total:
1028 - 8131 - SNOPIP
Check Total:
Check Total:
Check Total:
Check Total:
2029.8166 - IQWTRL
Check Total:
Current Date: 11/10/2010
Current Time: 11:56:35
Amount Cheek Num
10.06
10.05
20 AP 00077646
276.39
5.36
8.38
287.15 AP 00077647
3,473.75
3,473.75
6.!47.50 AP 00077648
223.00
223.00 AP 00077649
2,060.00
2,060.00
4.120.00 AP 00077650
148.00
148,00 AP 00077651
762.50
762.50
334.76
129.90
AP- 00077652
464.86 AP- 00077653
1,000.00
1,000.00
2.000.00
160.00
AP- 00077654
160.00 AP- 00077655
432.83
432.1 AP
880.00
880.00 AP-00077657
PAYMENT OF CLAIMS
Vendor Name Department/ Proj Name Description Acct# / Proj Code Amount Check Num Int
WESTERN ENERGETIX INC GEN & ADMIN GASOLINE INV 1000.0415 3,924 26
WESTERN ENERGETIX INC EQUIPMENT REP OIL & LURE 1005.4630 793.11
WESTERN ENERGETIX INC DIAMOND VLY RNCH GASOLINE 1028 - 4610 1,325 66
WESTERN ENERGETIX INC DIAMOND VLY RNCH DIESEL 1028 - 4620 1,020.81
WESTERN ENERGETIX INC UNDERGROUND REP DIESEL 2001 - 4620 Y00.46
WESTERN ENERGETIX INC UNDERGROUND REP PROPANE 2001 - 6360 94.81
WESTERN ENERGETIX INC EQUIPMENT REPAIR OIL & LUBE 2005 - 4630 793.11
Check Total: 8,152.02 AP 00077658 MW
WESTERN ENVIRONMENTAL LABORATORY MONITORING 1007.6110 240.00
Check Total: 240.00 AP 00077659 MW
WESTERN NEVADA SUPPLY PUMPS SHOP SUPPLIES 1002.6071 3.55
WESTERN NEVADA SUPPLY HEAVY MAINT GROUNDS & MNTC 1004.6042 41.11
WESTERN NEVADA SUPPLY DIAMOND VLY RNCH GROUNDS & MNTC 1028 - 6042 16.13
WESTERN NEVADA SUPPLY GEN & ADMIN METERS,ETC INV 2000 - 0402 2,392.50
WESTERN NEVADA SUPPLY GEN & ADMIN BOXES/LIDS/INV 2000 - 0403 1,921.33
IIIIESTERN NEVADA SUPPLY GEN & ADMIN COUPLINGS INV 2000 - 0405 1,531.09
N
p� ESTERN NEVADA SUPPLY GEN & ADMIN REPAIR CLAP INV 2000.0406 - 1,576.88
WESTERN NEVADA SUPPLY GEN & ADMIN SADDLES INV 2000 - 0407 365.14
WESTERN NEVADA SUPPLY UNDERGROUND REP PIPE/CVRS/MHLS 2001 - 6052 3,296.11
WESTERN NEVADA SUPPLY PUMPS PUMP STATIONS 2002 - 6051 1,144.09
WESTERN NEVADA SUPPLY PUMPS RPRIMNTC WTR TKS 2002 - 6054 132.60
WESTERN NEVADA SUPPLY PUMPS SHOP SUPPLIES 2002 - 6071 3.54
Check Total: 9270.31 AP 00077660 MW
XEROX CORP UNDERGROUND REP OFFICE SUPPLIES 1001 - 4820 73.44
Check Total: 73,44 AP 00077661 MW
ZEE MEDICAL INC GEN & ADMIN SAFETY/EQUIP/PHY 1000 - 6075 409.85
ZEE MEDICAL INC GEN & ADMIN SAFETY/EQUIP/PHY 2000 - 6075 409.86
Check Total: 818.71 AP 00077662 MW
Grand Total: 605,236.22
User: THERESA
Page: 13 Current Date: 11/10/2010
Report: OH_PMT_CLAIMS_BK Current Time: 11:56:35
1275 Meadow Crest Drive • South Lake Tahoe • CA 96150 -7401
Phone 530 544 -6474 • Fax 530 541 -0614 • www.5tpud.us
BOARD AGENDA ITEM 14a
TO: Board of Directors
FROM: Richard Solbrig, General Manager
MEETING DATE: November 18, 2010
ITEM - PROJECT NAME: Conference with Legal Counsel - Existing Litigation
REQUESTED BOARD ACTION: Direct staff.
DISCUSSION: Pursuant to Section 54956.9(x) of the California Government code,
Closed Session may be held for conference with legal counsel regarding existing
litigation: False Claims Act Case: United States, the States of California, Delaware,
Florida, Nevada, and Tennessee and the Commonwealths of Massachusetts and
Virginia ex rel. John Hendrix v. J -M Manufacturing Company, Inc. and Formosa Plastics
Corporation, U.S.A., Civil Action No. ED CV06- 0055 -GW, United States District Court for
the Central District of California.
SCHEDULE:
COSTS:
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATTACHMENTS:
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: Water
GENERAL MANAGER: ES NO
CHIEF FINANCIAL OFFICER: YES NO
-127-
omww Manager
RWuW K SolbMg
out
Tahoe
Public Utility District
_
' �ry� owe M"
1275 Meadow Crest Drive • South Lake Tahoe • CA 96150 -7401
Phone 530 544 -6474 • Fax 530 541 -0614 • www.5tpud.us
BOARD AGENDA ITEM 14a
TO: Board of Directors
FROM: Richard Solbrig, General Manager
MEETING DATE: November 18, 2010
ITEM - PROJECT NAME: Conference with Legal Counsel - Existing Litigation
REQUESTED BOARD ACTION: Direct staff.
DISCUSSION: Pursuant to Section 54956.9(x) of the California Government code,
Closed Session may be held for conference with legal counsel regarding existing
litigation: False Claims Act Case: United States, the States of California, Delaware,
Florida, Nevada, and Tennessee and the Commonwealths of Massachusetts and
Virginia ex rel. John Hendrix v. J -M Manufacturing Company, Inc. and Formosa Plastics
Corporation, U.S.A., Civil Action No. ED CV06- 0055 -GW, United States District Court for
the Central District of California.
SCHEDULE:
COSTS:
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATTACHMENTS:
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: Water
GENERAL MANAGER: ES NO
CHIEF FINANCIAL OFFICER: YES NO
-127-
I'
1275 Meadow Great Drive - 5outh Lake Tahoe - CA 96150 -7401
Phone 530 544 -6474 - Fax 530 541 -0614 - www.stpud.u5
BOARD AGENDA ITEM 14b
ffll
FROM:
MEETING DATE:
ITEM - PROJECT NAME:
Board of Directors
Richard Solbrig, General Manager
November 18, 2010
Conference with Labor Negotiators
REQUESTED BOARD ACTION: Direct negotiators
DISCUSSION: Pursuant to Section 54957.6(a) of the California Government Code,
Closed Session may be held regarding contract negotiations.
Agency Negotiators: Richard Solbrig /General Manager and
Board of Directors
Employee Organization: STPUD Management Unit
SCHEDULE:
COSTS:
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATTACHMENTS:
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: Genera!
GENERAL MANAGER: YES Z NO
CHIEF FINANCIAL OFFICER: YES NO
-129-
WuW K 5olbrig
Tahoe
,5outh
James R Jones
public Utility niotria
Ay4WM0*A&"
MCW0 MW
1275 Meadow Great Drive - 5outh Lake Tahoe - CA 96150 -7401
Phone 530 544 -6474 - Fax 530 541 -0614 - www.stpud.u5
BOARD AGENDA ITEM 14b
ffll
FROM:
MEETING DATE:
ITEM - PROJECT NAME:
Board of Directors
Richard Solbrig, General Manager
November 18, 2010
Conference with Labor Negotiators
REQUESTED BOARD ACTION: Direct negotiators
DISCUSSION: Pursuant to Section 54957.6(a) of the California Government Code,
Closed Session may be held regarding contract negotiations.
Agency Negotiators: Richard Solbrig /General Manager and
Board of Directors
Employee Organization: STPUD Management Unit
SCHEDULE:
COSTS:
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATTACHMENTS:
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: Genera!
GENERAL MANAGER: YES Z NO
CHIEF FINANCIAL OFFICER: YES NO
-129-
1275 Meadow Cr*t Drive ,ii Smith Lake Tahoe • CA 96150
Phone 530 544 -6474 • Fax 530 541 -0614
BOARD AGENDA ITEM 14c
TO: Board of Directors
FROM: Richard Solbrig, General Manager
MEETING DATE: November 18, 2010
ITEM - PROJECT NAME: Conference with Labor Negotiators
REQUESTED BOARD ACTION: Direct negotiators
DISCUSSION: Pursuant to Section 54957.6(a) of the California Government Code,
Closed Session may be held regarding contract negotiations.
Agency Negotiators: Richard Solbrig /General Manager, Board of Directors
Employee Organization: Stationary Engineers, Local 39
SCHEDULE:
COSTS:
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATrAdHMikTS:
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: General
GENERAL MANAGER: YES Af dA p NO
CHIEF FINANCIAL OFFICER: YES NO
-131-
General Manager
Richard H. SolMig
Direct ors
O u
Tah
Chris Cefalu
James R. Jones
#emu bl i c Utility P i otri ct
Mar Lou Mo�a�
Dale Rise
Eric Schafer
1275 Meadow Cr*t Drive ,ii Smith Lake Tahoe • CA 96150
Phone 530 544 -6474 • Fax 530 541 -0614
BOARD AGENDA ITEM 14c
TO: Board of Directors
FROM: Richard Solbrig, General Manager
MEETING DATE: November 18, 2010
ITEM - PROJECT NAME: Conference with Labor Negotiators
REQUESTED BOARD ACTION: Direct negotiators
DISCUSSION: Pursuant to Section 54957.6(a) of the California Government Code,
Closed Session may be held regarding contract negotiations.
Agency Negotiators: Richard Solbrig /General Manager, Board of Directors
Employee Organization: Stationary Engineers, Local 39
SCHEDULE:
COSTS:
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATrAdHMikTS:
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: General
GENERAL MANAGER: YES Af dA p NO
CHIEF FINANCIAL OFFICER: YES NO
-131-
1275 Meadow Crest Drive • 5outh Lake Tahoe • CA 96150 -7401
Phone 530 544 -6474 • Fax 530 541 -0614 • www stpud.us
BOARD AGENDA ITEM 14d
TO: Board of Directors
FROM: Executive Committee (Rise / Mosbacher)
MEETING DATE: November 18, 2010
ITEM - PROJECT NAME: Conference with Labor Negotiators
REQUESTED BOARD ACTION: Direct negotiators
DISCUSSION: Pursuant to Section 54957.6(a) of the California Government Code,
Closed Session may be held regarding contract negotiations for unrepresented
employee position.
Unrepresented Employee Position: General Manager .
Agency Negotiators: Executive Committee, Board of Directors
SCHEDULE:
COSTS:
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATTACHMENTS:
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: General
GENERAL MANAGER: YES NO
CHIEF FINANCIAL OFFICER: YES NO
-133-
General Manager
Rkh"Kft"
out
Tahoe
a�
°`
Jsm" R Jones
public Utility District -
'"
1275 Meadow Crest Drive • 5outh Lake Tahoe • CA 96150 -7401
Phone 530 544 -6474 • Fax 530 541 -0614 • www stpud.us
BOARD AGENDA ITEM 14d
TO: Board of Directors
FROM: Executive Committee (Rise / Mosbacher)
MEETING DATE: November 18, 2010
ITEM - PROJECT NAME: Conference with Labor Negotiators
REQUESTED BOARD ACTION: Direct negotiators
DISCUSSION: Pursuant to Section 54957.6(a) of the California Government Code,
Closed Session may be held regarding contract negotiations for unrepresented
employee position.
Unrepresented Employee Position: General Manager .
Agency Negotiators: Executive Committee, Board of Directors
SCHEDULE:
COSTS:
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATTACHMENTS:
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: General
GENERAL MANAGER: YES NO
CHIEF FINANCIAL OFFICER: YES NO
-133-