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SOUTH TAHOE PUBLIC UTILITY DISTRICT
REGULAR BOARD MEETING AGENDA
Thursday, December 4, 2014 - 2:00 P.nn.
District Board Room
1275 Meadow Crest Drive, South Lake Tahoe, California
Richard Solbrig, General Manager
Eric W.Schafer, President BOARD MEMBERS Randy Vogelgesang, Vice President
Chris Cefalu, Director James R. Jones, Director Kell Sheehan, Director
1. CALL TO ORDER REGULAR MEETING— PLEDGE OF ALLEGIANCE(At this time, please silence phones and
other electronic devices so as not to disrupt the business of the meeting.)
2. ADMINISTER OATHS OF OFFICE
Director Chris Cefalu , Seat 1
Director Duane WQllace, Seat 5
�.,. COMMENTS FROM THE AUDIENCE (This is an opportunity for members of the public to address the Board on
any shorf non-agenda items that are within the subject matter jurisdiction of the District. No discussion or action can
be taken on matters not listed on the agenda,per the Brown Act. Each member of the public who wishes to
comment shall be allotted five minutes, and no more than three individuals shall address the same subject.)
4. CORRECTIONS TO THE AGENDA OR CONSENT CALENDAR (For purposes of the Brown Act, all Action and
Consent items listed give a brief description of each item of business to be transacted or discussed.
I� Recommendations of the staff,as shown,do not prevent the Board from taking other action.)
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5. 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.)
I 6. CONSENT ITEMS BROUGHT FORWARD FOR SEPARATE DISCUSSION / ACTION
7. PRESENTATION
Board President Appreciation 2014 ,
8. ITEMS FOR BOARD ACTION
� a. Groundwater Management Plan Update �ivo Bergsonn, Hydrogeologist) Pg 19
At 2:15 p.m. hold a Public Hearing to receive public comments regarding (1) Adoption
of Resolution No. 2969-14, the Tahoe Valley South (6-5.01) 2014 Groundwater
Management Plan; and, (2) Enacting Ordinance No. 558-14 amending Division 7 of the
Administrative Code.
REGULAR BOARD MEETING AGENDA- December 4, 2014 PAGE-2
b. Groundwater Management Pian (i�o Bergsonn, Hydrogeologist) Pg 21
Adopt Resolution No. 2969-14 Adopting the Tahoe Valley South (6-5.01) 2014
Groundwater Management Plan (GWMP); and (2) Enacting Ordinance No. 558-14
amending Division 7 of the Aclministrative Code
C. Resolution No. 2968-14 (Richard Solbrig,General Manager) Pg 45
. Adopt Resolution No. 2968-14 in Appreciation of Director Schafer.
d. AppfOVe PC1ym2nt Of CIQIt71S (Debbie Henderson,Accounting Manager) Pg 49
Approve Payment of Claims in the amount of$1,O1 l,bb5.78
9. STANDING AMD AD-HOC COMMITTEE REPORTS (Discussions may take place;however, no action will be
taken.)
10. BOARD MEMBER REPORTS (Discussions may take place;however, no action will be taken.)
11. EL DORADO COUNTY WATER AGENCY PURVEYOR REPORT
12. GENERAL MANAGER REPORT (Discussion may take place;however,no action will be taken.)
13. STAFF/ATTORNEY REPORTS (Discussions may take place; however, no action will be taken.)
14. NOTICE OF PAST AND FUTURE MEETINGS/EVENTS
Past Meetinas/Events
11/27/14 and 11/28/14-Thanksgiving Holiday-District Office Closed
12/04/14-2:00 p.m. Regular Board Meeting at District
Future Meetinas/Events
12/10/14- 10:00 a.m. EI Dorado County Water Agency Meeting
12/15/14-3:30 p.m. Water and Wastewater Operations Committee Meeting
15. CLOSED SESSION (The Board will adjourn to Closed Session to discuss items identified below.Closed Session is not
open to the public;however,an opportunity will be provided at this time if inembers 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 Existing Litigation re: EI Dorado County Superior Court Case
SC20120227 GRCLT Condominium vs. South Tahoe Public Utility District
(Filed 10/22/12). Pg 61
b. Pursuant to Section 54957.9(a) of the California Government Code, Closed Session may
be held for conference with legal counsel regarding existing litigation: STPUD vs.
_ Lakeside Park Association, et al., County of EI Dorado, Superior Court Case No.
SC20010165. Pg 63
ACTION REPORT ON ITEMS DISCUSSED DURING CLOSED SESSION
ADJOURNMENT (The next Regular Board Meeting is Thursday, December 18, 2014 at 2:00 p.m.)
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REGULAR BOARD MEETING AGENDA- December 4, 2014 PAGE -3
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The South Tahoe Public Utility District Board of Directors regularly meets the firsi and third Thursday of each month.A complete Agenda
packet is available for review at the meeting and at the District office during the hours of 8:00 a.m.and 5:00 p.m.,Monday through Friday.
A recording of the meeting is retained for 30 days affer Minutes of the meefing have been approved.Items on the Agenda are numbered
for identification purposes only and will not necessarily be considered in the order in which they appear.Designated times are for particuiar
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 same time the Agenda items
are heard;comments should be brief and directed to the specifics of the item being considered.Please provide the Clerk of the Board with
a copy of all written materials presented at the meeting.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.
Backup materials relating to an open session item on this Agenda,which are not included with the Board packet,will be made available
for public inspection at the same time they are distributed or made available to the Board,and can be viewed at the District office,at the
Board meeting and upon request to the Clerk of ihe Board.
The meeting location is accessible to people with disabilities.Every reasonable efforf will be made to accommodate participation of the
disabled in all of the DistricYs public meetings.If particular accommodations are needed,please contact the Clerk of the Board at(530)
544-6474,extension 6203.All inquiries must be made at least 48 hours in advance of the meeting.
REGULAR BOARD MEETING AGENDA-December 4, 2014 PAGE -4
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SOUTH TAHOE PUBLIC UTILITY DISTRICT
CONSENT CALENDAR
December 4, 2014
ITEMS
a. 2014 Asohait Patching Services
�Randy Curtis,Manager of Feld Operations) Pg 1
(1) Approve the Project Closeout Agreement and Release of Claims for Thomas Haen
Company, Inc.; and (2) Authorize staff to file a Notice of Completion with the EI Dorado
County Clerk.
b. Seff-Insured Dental Plan Renewal
(Nancy Hussmann, Human Resources Director) Pg 1 1
(1) Approve renewal of the Self-Insured Dental Plan with a funding level of $130.69 per
employee per month; and (2) Approve 2015 Dental COBRA rates at$49.29 Single, $98.57
Employee +l, and$167.57 Family.
c. Self-Insured Dental Plan Document Update
�Nancy Hussmann, Human Resources Director) Pg 13
Approve updated Plan Document for the Self-tnsured Dental Plan.
d. R�EGULAR BOARD MEETING MINUTES: November 20. 2014
�Melonie Guttry, Executive Services Manager/Clerk of the Board) Pg 15
Approve November 20, 2014 Minutes Y
6eneral Manager
Richard H.Solbrig
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�'N� `"' �@1y�. O ! ,� � O� Directors
� � Chris Cefalu
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JameS R.Jones
�� ;�yj.= � � RandyVogelgesang
�ubLic Utility D15tri�t KellySheehan
Eric 5chafer
1275 Meadow G-est Drive•South Eake Tahoe•CA 96150-740t
Phone 530 54�F-6474•Fax 530 54-1-06i4•www.s�tpud.us
BOARD AGENDA ITEM 5a
TO: Board of Directors
FROM: Randy Curfis, Manager of Field Operations
MEETING DATE: December 4, 2014
ITEM- PROJECT NAME: 2014 Asphalt Patching Services
REQUESTED BOARD ACTION: (1) Approve the Project Closeout Agreement and Release
of Claims for Thomas Haen Company, Inc.; and (2) Authorize staff to file a Notice of
Completion with the EI Dorado County Clerk.
DISCUSSION: Staff has completed inspections of the project sites to date, and found
that Thomas Haen Company, Inc. has met all the requirements of the contract. Staff
recommends approval of the project Closeout Agreement and Release of Claims, and
the filing of a Notice of Completion with the EI Dorado County Clerk.
SCHEDULE: As soon as possible
COSTS: N/A '
ACCOUNT NO: 2001-6052
BUDGETED AMOUNT REMAINING: <$37,498>
ATTACHMENTS: Closeout Agreement and Release of Claims, Notice of Completion
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: Water
GENERAL MANAGER: YES NO
CHIEF FINANCIAL OFFICER: YES NO
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CLOSEOUT AGREEMENT AND RELEASE OF CLAIMS
THIS AGREEMENT AND RELEASE OF CLAIMS is made in South Lake Tahoe,
California, this 4�' day of December, 2014, by and between South Tahoe Public Utility
DISTRICT, hereinafter refeRed to as "DISTRICT", and Thomas Haen Company, Inc.,
hereinafter referred to as "CONTRACTOR".
KNOW ALL PERSONS BY THESE PRESENTS:
1. That the undersigned, as the authorized representative of CONTRACTOR, for
and in consideration of One hundred finrenty one thousand eight hundred twenty
six dollars and 74 cents ($ 121,826.74), total contract amount, which includes
contract changes, has submitted waivers from all subcontractors and suppliers in
the form required by Civil Code §3262, and does hereby and for each of its
successors, assigns and partners, release acquit and forever discharge the
SOUTH TAHOE PUBLIC UTILITY DISTRICT OF EL DORADO COUNTY,
CALIFORNIA, and each of its successors, assigns, officers, agents, servants,
and employees, from any and all rights, claims, demands, debts, obligations,
liabilities, actions, damages, costs, expenses and other claims whatsoever,
which might have been asserted against DISTRICT by reason of any matter or
thing which was the subject matter of or basis for:
The performance of all terms and conditions of the bid agreement for
Purchase Order No. P27649 DISTRICT project described as 2014
Asphalt Patching Services.
2. That the undersigned, as the authorized representative of DISTRICT, for and in
consideration of the CONTRACTOR's completion of the contract does hereby
and for each of its successors, and assigns, releases, acquits and forever
discharge Thomas Haen Company, Inc. and each of its successors, assigns,
officers, agents, servants, and employees, and sureties from any and all rights,
claims, demands, debts, obligations, liability, actions, costs, expenses
whatsoever which might have been asserted against CONTRACTOR, except for
the rights accruing to the DISTRICT in California Code of Civil Procedure Section
337.15, Entitled 'Ten Years - Action to Recover Damage from Latent
Deficiencies in Planning or Construction of Improvements to Real Property,"
which rights are spec�cally not released, and except for warranties and sureties
provided by reason of any matter or thing which was the subject matter of or
basis for:
The performance of all terms and conditions of the bid agreement for
Purchase Order No. P27649 DISTRICT project described as 2014
Asphalt Patching Services.
3. Nothing contained herein shall waive or alter the rights, privileges, and powers of
the DISTRICT or the duties, liabilities and obligations of the CONTRACTOR and
its surety in respect to any portions of the Specifications for Purchase Order No.
P27649.
4. The DISTRICT has received no claims from the CONTRACTOR.
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5. Upon execution of this agreement, the DISTRICT agrees to immediately file and �
record a NOTICE OF COMPLETION with the County Recorder in order to begin
the running of the statutory lien period.
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6.
The presently retained amount is $ 6,023.84
Original Contract amount $ 116,135.00 �
# Total Change Order Amount $ 5,691.74
; �� Less: Amount Previously Paid $ 115,802.90
� (Request Nos. 1 through 3)
Retainage $ 6,023.84
BALANCE: $ 6,023.84
The retainage will be released to the CONTRACTOR at the expiration of the lien period
35 (thirty-five) calendar days after date of recording a NOTICE OF COMPLETION by EI
Dorado County Recorder or when all liens have been released, whichever last occurs.
4 Release pursuant to this agreement shall not apply to CONTRACTOR's rights to the
� presently retained amount until such time as such amounts are received in full by
'� CONTRACTOR.
7. CONTRACTOR and DISTRICT agree that the total adjusted contract price and
time of performance fo�Purchase Order No. after the execution of change orders
shall be as follows:
Original Contract Price $ 116,135.00 ?
Original Completion Time Fall 2014 g
Total Adjusted Price $ 121,826.74 �
Actual Completion Time Fall 2014
,
_ 8. It is understood and agreed by the undersigneds that the facts with respect to �
which the foregoing Release is given may hereafter tum out to be other than or
different from the facts in that connection now known to be or believed by said
� undersigneds to be true, and the undersigneds hereto expressly assume the risk
of the facts turning out to be different than they now so appear, and agree that �
the foregoing Release shall be, in all respects, effective and not subject to i
termination or recession by any such difference in facts and undersigneds hereby �
expressly waive any and all rights the undersigneds have or may have under ;
California Civil Code Section 1542, which provides as follows: i
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' "A general release does not extend to claims which the creditor does not i
' know or suspect to exist in his favor at the time of executing the Release ';
` which if known by him must have materially affected his settlement with �
the debtor." i
9. The releases made by the CONTRACTOR and the DISTRICT herein are not to �
� be construed as an admission or admissions of liability on the part of either party ';
and that the parties deny liability hereof. The undersigneds agree that they will I
forever refrain and forebear from commencing, instituting or prosecuting any '
lawsuit, action or other proceeding against the other party based on, arising out ;
_ of, or in any way connected with the subject matter of this Release. �
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10. The CONTRACTOR hereby releases the DISTRICT from all claims, including
those of its Subcontractors for all delay and impact costs, if any.
11. The CONTRACTOR represents and warrants to the DISTRICT that the
CONTRACTOR has not heretofore 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,
damages, costs, expenses and other claims whatsoever and the CONTRACTOR
agrees to indemn'rfy and hold harmless the DISTRiCT against, without iimitation,
any and all rights, claims, warranties, demands, debts, obligations, {iabilities,
actions, damages, costs, expenses and other claims, including attorney's fees,
arising out of or connected with any such assignment or transfer or purported
assignment or transfer.
12. The undersigned acknowledge that they have been represented by counsel of
their own choice in connection with the preparation and execution of this
Closeout Agreement and Release of Claims. The undersigned acknowledge and
represent that they understand and voluntarily consent and agree to each and
every provision contained herein.
13. The undersigned further declare and represent that no promise, inducement or
agreement, not herein expressed, have been made to the undersigned and that
this Release contains the entire agreement among the parties hereto and that the
terms of the Release are contractual and not a mere recital.
14. The persons executing this Closeout Agreement and Release of Claims
represent and warrant to the other party that the execution and perFormance of
the terms of this Release have been duly authorized by all requisite corporate,
partnership, individual, or other entity requirements and that said persons have
the right, power, legal capacity and authority to execute and enter in the Closeout
Agreement and Release of Claims.
RICHARD SOLBRIG, GENERAL MANAGER DATED
ATTEST: MELON(E GUTTRY, CLERK OF BOARD DATED
F:
CONTRACTOR -THOMAS HAEN COMPANY, INC DATED
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RECORDING REQUESTED BY: �
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�� SOUTH TAHOE PUBLIC UTILITY DISTRICT �
''. ATTN: LINDA BROWN �
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WHEN RECORDED MAII TO: �
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SOUTH TAHOE PUBLIC UTILITY DISTRICT �
1275 Meadow Crest Drive �
South Lake Tahoe,CA 96150 �
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SPACE ABOVE THIS L1NE FOR RECORDER'S USE �
APN: Numerous in Pubiic Right of i
way NOTICE OF COMPLETION �
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NOTICE IS HEREBY GIVEN THAT: �
1. The undersigned is OWNER or agent of the OWNER of the interest or estate stated below in the properfy i
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.
' 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:
N/A
6. The FULL NAMES of FULL ADDRESSES OF THE PREDECESSORS in INTEREST of the undersigned if the property
' was transfeRed subsequent to the commencement of the work of improvement herein referred to:
` N/A
7. A work of improvement on the property hereinafter described was COMPLETED on 11/30/14.
< 8. The work of improvement completed is described as follows: Asphalt Patching Services.
9. The NAME OF THE ORIGINAL CONTRACTOR,if any, for such work of improvement is Thomas Haen
Company Inc.
10. The street address of said property is various in City of South Lake Tahoe, or unincorporated sections of EI
Dorado County.
11. The property on which said work of improvement was completed is in the City of South Lake Tahoe
and/or the County of EI Dorado,State of California, and is described as follows:
As shown in Exhibit "A" attached hereto and made a parf hereof, and commonly known as 2014
Asphalt Patches.
DATE:
SIGNATURE OF OWNER OR AGENT OF OWNER
ERIC SCHAFER,Board President
VERIFICATION FOR INDIVIDUAL OWNER:
I,the undersigned,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 properfy described in the above notice;that I have read said notice,that I know and understand the contents
thereof,and the facts stated therein ore true and correct.
DATE AND PLACE SIGNATURE OF OWNER NAMED IN PARAGRAPH 2
VERIFICATION FOR NON-INDIVIDUAL OWNER: SOUTH TAHOE PUBLIC UTILITY DISTRICT
I,the undersigned,declare under penalty of perjury under the laws of the State of California that I am the Board President
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 ihereof,and that the facts stated therein are true and correct.
Dec 4, 2014 at South Lake Tahoe, California
DATE AND PLACE SIGNATURE OF PERSON SIGNING ON BEHALF OF OWNER
ERIC SCHAFER
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A B C D E F G H I
1 Exhibit A 2014 Asphalt Patches '
2 CITY PATCH UST 2014
3 Date Street Address Patch S.F. Cost Per S.F. Patch Price Sawcut Price Total Cost Misc
4 10-Jul Top of Elva 65.81 $ 9.50 $ 625.22 $ 35.97 $ 661.19
5 10-Jul Price Rd.&Pioneer Trail 92.63 $ 8.80 $ 815.10 $ 41.97 $ 857.07
6 10.Ju1 1440 Frontier Ct. 36.40 $ 14.40 $ 524.12 $ 2633 $ 550.46
7 14Ju1 1453 Frontier Ct 26.65 $ 14.40 5 383.76 5 22.52 $ 406.28
8 22-Jul Shop Street 75.00 $ 9.50 $ 712.50 5 37.79 $ 750.29
9 22-1u1 1678 Shop Street 88.75 $ 8•80 $ 781.00 $ 42.15 $ 823.15
10 22-Jul 1678 Shop Street 105.11 $ 7.10 $ 746•29 $ 47.60 $ 793.89
11 8-Rug 1014 Echo Road 36.72 $ 14.40 $ 528.77 $ 26.81 $ 555.58
12 &Aug 3649 Rocky Point Road 45.58 $ 9.50 $ 433.01 $ 32.48 $ 465.49
13 8-Aug 3739 Saddie Road 49.82 $ 9.50 $ 473.29 $ 32.05 S 505.34
14 8-Aug 3692 Terrace Drive 141.00 $ 7.10 $ 1,001.09 $ 73.10 $ 1,074.18
15 SAug 3773 Regina Road 38.69 $ 14.40 5 557.14 $ 27.47 $ 584.60
16 8-Aug larch Ave&Figuerou Ln. 104.65 $ 7.10 $ 743.02 $ 4917 $ 792Z8
17 8-Aug 3688 Paredise 77.76 $ 9.50 $ 738•72 $ 39.24 $ 777.96
18 15-Aug 3967 Azure 7.38 S 14.40 5 106.27 $ 12.86 $ 119.13
19 1SAug 3967 Azure 1112 $ 14.40 $ 161.57 $ 14.61 $ 176.17
20 15-Aug 3827 Azure 20.88 $ 14.40 $ 300.67 $ 20.49 $ 321.16
21 15-Aug 3840 Pine 10.56 $ 14.40 $ 152.06 $ 14.17 $ 166.23
22 15-Aug 3903 Cedar 16.65 $ 14.40 $ 239.76 $ 17.88 $ 257.64
23 15-Aug 3894 Pine 36.92 $ 14.40 $ 531.65 $ 26.81 $ 558.46
24 15-Aug 3801 Alder 53.58 $ 9.50 $ 509.01 $ 32.92 $ 541.93
25 15-Aug 3745 Forest 49.47 $ 9.50 $ 469.97 $ 3216 $ 502.23 i
26 15-Aug 3732Tamarack 37.92 $ 14.40 $ 546.05 5 27.69 $ 573.73
27 1SAug 3665 Tamareck 46.98 $ 9.50 $ 446.31 $ 30.30 $ 476.61
28 15-Aug 3839 Larch 35.04 $ 14.40 $ 504-58 $ 2638 $ 530.95
29 15-Aug 3684 Paradise 2736 $ 14.40 $ 393.98 $ 23.98 $ 417.%
30 15-Aug 8728 Merced 32.56 $ 14.40 $ 468.86 $ 25J2 $ 494.59
31 4Sep 2569 Knox 34.68 $ 14.40 $ 499.39 $ 25.94 $ 525.33
32 45ep 2564 Elwood 85.00 $ 8.80 $ 748.00 $ 40.33 $ 788.33
33 45ep 2585 Elwood 64.80 $ 9.50 $ 615.60 $ 37.93 $ 653.53
34 45ep 2648 Artnstrong 32.76 $ 14.40 $ 471.74 $ 26.81 $ 498.56
35 45ep Sussex and Mackina 57.24 $ 9.50 $ 543.78 $ 35.10 $ 578.88
36 45ep 1060 Margorie 34.31 $ 14.40 $ 494.06 $ 26.16 $ 520.22
37 G-Sep 1368 Matheson 53.94 $ 9.50 $ 512.43 5 32.92 $ 54535
38 45ep 1562 Glenwood 48.59 $ 9.50 $ 461.61 $ 34_Ol $ 495.61
39 45ep 3364 Bruce 31.24 S 14.40 S 449•86 $ 25.07 S 474.93
40 45ep 3337 Bedca 10.36 $ 14.40 $ 149.18 $ 19.18 $ 16837
41 45ep 3337 Bedca 18.62 $ 14.40 $ 268.13 5 15.97 $ 287.09
42 4Sep 3382 Becka 57.24 $ 9.50 $ 543.78 5 35.10 $ 578.88 Raise Box
43 4Sep 1509 Walkup 22.75 $ 14.40 S 327.60 $ 21.80 $ 349.40
44 45ep 3386 Wam 48.75 $ 9.50 $ 463.13 $ 30•63 5 493.75
45 23-0ct 1294 Margaret 74.10 $ 9.50 $ 703.95 $ 50.79 $ 754.74
46 23-0ct 1246 Dedi 4437 $ 9.50 S 421.52 $ 30.08 5 451.60
47 23-Od D St 76.65 $ 9.50 $ 728.18 $ 38.80 $ 766•98
as za-o�c�sc si.so 5 s.ao 5 �is.os S ao.9s 5 �se.os
49 23-Oct 1362 Kyburz 31.50 $ 14.40 $ 453.60 $ 24.63 $ 478.23
SO 23-0d 687 Gard�er 55.00 $ 9.50 $ 522.50 $ 34.88 5 55738
51 23-0d 13th&Tylor 51.52 $ 9.50 $ 489.44 $ 34•44 $ 523.88
52 23-Od 838 Clement 49.30 $ 9.50 $ 46835 $ 31.17 5 499.52
53 23-0d 705 Tata 29.70 $ 14.40 $ 427.68 $ 23.76 $ 451.44
54 23-Oct 193313th 21.50 $ 14.40 $ 309•60 $ 2017 5 329.87
55 23-0ct 879 Cement 60.00 $ 9•SO $ 570.00 $ 34.88 $ 604.88
56 23-0d Elm&Winumucca 40.67 $ 9.50 S 38637 $ 28.78 $ 415.14
57 23-0ct 2253 Elm 74.10 $ 9.50 $ 703.95 $ 39.02 $ 742.97
58 23-0d 22635iIverTip 68.00 $ 9.50 $ 646.00 $ 35.97 $ 681.97
59 23-Od 1123 Winumucca 31.90 $ 14.40 $ 459.36 $ 24.63 $ 483.99
60 24-Oct 1092 Glen 56.84 $ 9.50 $ 539.98 $ 34.01 $ 573.99
61 240d 1077 Sheppherds 29.19 $ 14.40 $ 42030 $ 23.81 $ 444.11
62 240ct 1323 Keller 23.01 $ 14.40 $ 331.34 $ 2136 $ 352.71
63 24-0d 1660 Ski Run 52.77 $ 9.50 $ 50119 $ 33.20 $ 534.49
64 24-Od Top of Charlsworth 78Z1 $ 9.50 $ 743.00 $ 38.80 $ 781.80
65 24-Od Charlsworth 46•00 $ 9.50 $ 437.00 $ 31.83 $ 468.83
66 24-0ct 3378 Warr 26.40 $ 14.40 $ 380.16 5 23.11 $ 403.27
67 24-Oct 1473 Matheson 4.00 5 14.40 $ 57.60 5 8•72 $ 66-32
68 240d 3fl32 Oakla�d 35.44 $ 14.40 $ 51030 5 26.16 $ 536.46
69 240d Herbert&Woodlaad 66.00 $ 9.50 $ 627.00 $ 38.15 $ 665.15
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11/25/2014 STPUD Asphalt Patching 2014 Page 1 of 4
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� 3 Date Street Address Patch S.F. Cost Per S.F. Patch Price Sawcut Price Total Cost Misc
70 240ct Needle Peak&Log Road 375.00 $ 7.30 $ 2,662.50 $ 95.32 $ 2,757.82
� 71 27-0c[Tata&Les Schwab 114.48 $ 7.10 $ 812.81 $ 5036 $ 863.17 ',
� 72 27-Oct 2183 James 7937 $ 9.50 $ 754•04 $ 40.48 5 794.53
� 73 27-Oct 2193 Eloise 62.50 $ 9.50 $ 593.75 $ 35.43 $ 629.18
� 74 27-Od 2301 Eloise 99.00 $ 8•SO $ 871.20 $ 43.60 $ 914.80
':� 75 27-0d 4th&Helen 67.80 $ 9.50 $ 644.12 $ 36.14 $ 680.27
� 76 2&Od 41365addle 156J8 $ 7.10 $ 1,113.14 S 65.62 $ 1.118J6
'� 77 28-Oct Kelier 44.80 $ 9.50 S 425.60 $ 29.65 $ 455.25
78 2&Oct Keller 49.60 $ 9.50 $ 471.20 $ 30.96 $ 502.16
79 2&Oct Keller 55.90 $ 9.50 5 531.05 5 32.92 $ 563.97
80 28-Od 3752 Werlook 76.56 $ 9.50 5 727•32 $ 38.15 $ 765.47
81 28-0d 3752 Overiook 129.00 $ 7.10 $ 915.90 $ 74.77 $ 990.67
82 28-Od 2540 Bertha 121.50 $ 7.30 $ 862.65 $ 50.36 $ 913.01
4 83 28-Od Marjorie&O'Malley 42.30 $ 9.50 $ 401.85 $ 29•87 $ 431J2
� 84 28-Oct Mary'orie&O'Maliey 54J2 $ 9.50 $ 519.84 $ 3335 $ 553.19
.� 85 28-Oct 1129 Long Valley 89.90 $ 8•80 $ 791.12 $ 46.43 $ 837.55
86 28-Oct 1046 Fairway 26.50 $ 14.40 5 381.60 $ 22.45 5 404.05
� 87 28-Od Woods 59.16 $ 9.50 $ 562.02 $ 33J9 $ 595.81
; 88 28-Oct Sherman 53J2 5 9•50 $ 51034 $ 32.05 $ 54239
89 28-0d End of Matheson 48.00 $ 9.50 $ 456.00 $ - $ 456.00
� 90 29-Od Elva 49.00 $ 9.50 $ 465.50 $ 30.SZ $ 496.02
`� 91 30-Oct 908 Clement 44.00 $ 9.50 $ 418.00 $ 31.39 $ 449.39
� 92 30-Oct 908 Clement 31.50 $ 14.40 $ 453.60 $ 25.07 $ 478.67
93 30-Oct 1NWfP 44.10 $ 9.50 $ 418.95 $ 28.99 $ 447.94
� ea aaoa wwrv za.os 5 ia.ao 5 aoa.as S za.ii S az�.as
� 95 30-Oct WWTP 90.00 $ 8.80 $ 792-00 $ 41.42 $ 833.42
96 30-Od WWTP 48.16 $ 9.50 $ 457.52 $ 30.96 S 488.48
� 97 340ct WWTP 26.00 $ 14.40 $ 374.40 $ 11.24 $ 385.64
� 98 31-0ct 1040 William 33.15 $ 14.40 $ 47736 $ 27.03 $ 50439
,� 99 31-0d 1040 William 9735 $ 8.80 $ 856.68 $ 48.83 $ 905.51
� 100 Total 5477.06 $ 53,124.99 S 3,143.28 $ 56,26817
�
-$-
11/25/2014 STPUD Asphalt Patching 2014 Page 2 of 4
A B C D E f G H I
3 Date Street Address Catch S.F. Cost Per S.F. Patch Price Sawcut Price Total Cost Misc
101 COUNTY PATCH LIST 2014
102
103 Date Street Address Patch S.F. Cost Per S.F. Patch Price Sawcut Price Totai Cost Misc
104 10-Jul Pioneer&High Meadow 83.05 $ 830 $ 68931 $ 40.68 $ �29-98
105 1a1u1 1152 Prospector Trail 114.98 $ 6.50 $ 74734 $ 49.77 $ 797.11
106 laJul 1208 Prospector Trail 24.00 $ 14.00 $ 336.00 $ 23.98 $ 359.98
107 10-Jul 1220 ProspectorTrail 25.35 $ 14.00 $ 354.90 $ 22.67 5 377.57
108 10-lul Prospector&Golden Bear 43.70 $ 9.00 $ 39330 $ 29.10 $ 422.40
109 10-lul Marshal 41.56 $ 9.00 $ 374.06 $ 29.43 $ 403.49
iio 141u1 Marshal za.�s S ia.00 5 3a6.so 5 zi.so S 36830
iii 10-Jul Marshal as.00 5 9.00 5 a3z.00 S 3osz 5 aezsz
iiz laJul 2307 Marshal �.o0 5 ia.00 5 soa.00 $ n.zs S s3i.zs
113 22-Jul 812 Elk Point 31.15 $ 14.00 $ 436.04 $ 2434 $ 46039
114 22-Jul 1039 Eagle 14.88 $ 14.00 $ 208.25 $ 16.90 $ 225.15
115 22-Jui 1080 ClearView Drive 107.62 $ 6.50 $ 699.50 $ 45.96 $ 745.46
116 22dui 1086 Clear�ew Drive 81.50 $ 830 5 676.48 5 39.60 $ 716.08 GS
117 22-Jul 1075 Lamor Court 33.45 $ 14.00 $ 468.26 $ 25.80 $ 494.06
118 22-Jul 1376 Mt Diablo 25.00 $ 14.00 $ 350.00 $ 22.35 5 372.35
119 22-Jul 1366 Mt Diablo 28.50 5 14.00 $ 399.00 5 23•44 $ 422.44
12 22-1u1 510 Little Mountain 27.13 $ 14.00 $ 379.75 $ 24.53 $ 404.28
121 22-Jul 733 Cayuga 70.46 $ 9.00 $ 634.15 $ 36.88 $ 671.03
122 22-Jul 742 Cayuga 51.77 $ 9.00 $ 465.94 $ 31.97 $ 497.91
123 7-Aug Crystal&Meadowvale 75.00 $ 9.00 $ 675.00 $ 38.15 $ 713.15
124 7-Aug 1875 Mohican 6336 $ 9•00 $ 570.24 $ 35.32 $ 605.56
125 7-Aug 1875 Mohiwn 14.00 $ 14.00 $ 196.00 $ 1635 $ 21235
126 7-Aug 1220 San Diego 7134 $ 9.00 $ 642.06 $ 36.84 $ 678.90
127 7-Aug 1835 Bakersfield 46.75 $ 9.00 $ 420.75 $ 30.52 $ 451.27
128 7-Aug 1003 Portai 6832 $ 9.00 $ 614.88 $ 37.71 $ 652_59
129 7-Aug 1204 Ottawa 36.96 $ 14.00 $ 517.44 $ 2834 $ 545.78
130 7-Aug 1204 Ottawa 150.15 $ 6.50 $ 975.98 $ 5930 $ 1,035.27
132 16-Oct 2546 Bernice 48.00 $ 9.00 $ 432.00 $ 30.52 $ 462.52
133 16-Oc[2284 Cold Creek 51.15 $ 9.00 $ 46035 $ 32.26 $ 492.61
1 lfrOd 2435 Lupine 54.60 $ 9.00 $ 491.40 $ 34.23 $ 525.63
135 16-Oct 2197 Toiyabe 44.64 $ 9.00 $ 401.76 $ 30.74 $ 432.50
13 160ct 2453 Cattlemans 14.72 $ 14.00 $ 206.08 $ 17.00 $ 223.08
137 16-Oct 2453 Cattlemans 36.80 $ 14.OQ $ 515.20 $ 28-78 $ 543.98
138 16-Od 1165 Golden Bear 28.50 $ 14.00 $ 399.00 5 2333 $ 422.33
139 16-Oct 992 Sundown Trail 24.82 $ 14.00 $ 347.48 5 23.33 $ 370.81
1 16-Oct 1955 Jicarilla 70.20 $ 9.00 $ 631.80 $ 40.11 $ 671.91
141 16-Oct 1747 Nadowa 47.00 $ 9•00 $ 423.00 $ 32.05 5 455.05
142 16-Oct 1916 Koyukon 59.40 5 9•00 $ 534•60 $ 38.59 $ 573.19
143 16-Oct 888 Onnotioga 35.10 $ 14.00 5 491.40 $ 25.94 $ 51734
144 16-Oct 1090 Nottoway 75.46 $ 9•00 $ 679.14 $ 38.15 $ 717.29
145 16-Oct 1145 Acoma 5335 $ 9.00 $ 480.15 5 33.14 5 513.29
146 16-Oct Apple Valley 35.75 $ 14.00 $ 500.50 5 26.16 5 526.66
147 16-Oct Apple Valiey 43.74 5 9.00 5 393.66 $ 29.43 $ 423.09
148 16-Oct Apple Valley 25.20 $ 14.00 $ 352.80 $ 23.11 $ 375.91
149 16-Oct Arrowhead 23.50 $ 14.00 $ 329.00 5 Z1.15 5 350.15
150 16-Oct Arapahoe 50.40 $ 9-00 $ 453.60 $ 31.17 $ 484.77
151 16-Od Arepahce 6.00 $ 14.00 $ 84.00 $ 10.90 $ 94.90
152 16-Oct Divot Ct 49.60 $ 9.00 $ 446.40 $ 30.96 $ 477.36
153 16-Oct Wasabe 63.75 $ 9.00 $ 573.75 $ 34.88 $ 608.63
16-Oct Blitzen 66.00 $ 9.00 $ 594.00 $ 37.06 $ 631.06
155 16-Oc[Blitzen 196.02 $ 6.50 $ 1,274.13 $ 8430 $ 1,358.43
156 21-0d Snow Flake 23.00 5 14.00 $ 322.00 $ 20.93 $ 342.93
157 21-0ct Snow Flake 80.00 $ 9.00 $ 720.00 $ 45.78 $ 765.78
158 21-0ct Snow Flake 86.95 $ 830 5 721.69 $ 50.58 $ 772.26
159 21-Oct Snow Flake 46.80 $ 9.00 $ 421.20 S 32.48 $ 453.68
160 21-Oct Snow Flake 108.00 $ 6.50 $ 702.00 $ 45.78 $ 747.78
161 21-0ct Snow Flake 23.10 $ 14.00 $ 323.40 $ 22.45 $ 345.85
162 21-Oct Snow Flake 25.00 $ 14.00 $ 350.00 $ 21.80 $ 371.80
163 21-Oc[Snow Flake 108.00 $ 6.50 $ 702.00 $ 62.13 $ 764.13
164 21-0d Snow Flake 17.50 $ 14.00 $ 245.00 $ 18.53 $ 263.53
165 21-0ct Snow Flake 19.44 $ 14.00 $ 272.16 $ 19.62 $ 291.78
1 21-0ct Snow Flake 112.00 $ 6.50 $ 728•00 5 50.14 $ 778.14
167 21-0c[Snow Flake 90.10 $ 830 $ 747.83 $ 48.61 $ 7%.44
168 22-0ct 1546 Cree 49.40 $ 9.00 $ 444_60 $ 30J4 $ 47534
169 22-Oct 1546 Cree 6336 $ 9.00 $ 570Z4 $ 35.32 $ 605.56
-9-
11/25/2014 STPUD Asphalt Patching 2014 Page 3 of 4
:�
�
p B C D E F G H I
' 3 Date Street Address Patch S.F. Cost Per S.F. Patch Price Sawcut Price Total Cost Mix
" 170 22-0d 1581 Cree 53.76 $ 9.00 $ 483.84 $ 34•88 5 518.72
� 171 22-Oct Mandan 33.75 $ 14.00 $ 472.50 $ 26.16 $ 498.66
� 172 22-Od 1517 Plumas 45.65 $ 9.00 $ 410.85 $ 30.08 $ 440•93
� 173 22-Od 1777 Apche 46.11 $ 9.00 $ 414.99 $ 30.52 $ 445.51
� 174 22-0ct 1467 Sem 72.52 $ 9.00 $ 652.68 $ 42.95 $ 695.63
� 175 22-Oct 1422 Apche 52.08 $ 9.00 $ 46$.72 $ 32.48 $ 501.20
;; 176 22-0d Ulmeca 80.92 5 830 $ 671.64 $ 40.77 $ 712•40 �
` 177 22-Od 2040 Nez Pierce 59.40 $ 9.00 S 534.60 $ 35.53 $ 570.13
's 178 2Z-Od Toppenetam&Mewuk 84.00 $ 830 $ 697.20 $ 43J3 $ 740.93
� 179 22-Oct 1918 Poppewetah 61.00 S 9.00 $ 549.00 $ 37.50 $ 586.50 i
180 22-0d 539 Wintoon 39.06 5 14.00 $ 546.84 $ 29.43 $ 576.27 j
� 181 22-Od 539 Wintoon 39.20 $ 14.00 $ 548•80 5 2812 $ 576.92 i
;� 182 22-Od 533 Wintoon 52.80 $ 9•00 $ 47510 $ 31.83 $ 507•03 (
:� 183 22-0d 1857 Nez Pierce 35.20 $ 14.00 $ 492.80 $ 27.90 $ 520.70
I
'? 1 22-Oct 1835 Nez Pierce 23.32 $ 14.00 $ 326.48 $ 21.15 $ 347.63 i
� 185 22-0ct 716 Kiowa 57.60 $ 9.00 $ 518.40 $ 34.01 $ 552.41 '
%
;� 18G 22-Od Mt.Meadow&N Upper 57.27 $ 9.00 $ 515.43 $ 33.14 $ 548.57 i
.� 187 22-Od 1284 Mt Meadow 30.00 $ 14.00 $ 420.00 $ 23.98 $ 443.98 i
�'� 188 22-0ct 1284 Mt Meadow FH 153.40 $ 6.50 $ 997.10 $ 54.06 $ 1,051.16 W/GS !I
� 189 22-0ct qear View 15.00 5 14.00 $ 210.00 $ 25.55 $ 235.55 ,
'� 19 22-0ct Gear View 69.60 $ 9.00 $ 626.40 $ 38.80 $ 66510 ,
!� 191 22-Oct 764 Elk Point 45.57 $ 9.00 $ 410.13 $ 30.96 $ 441.09 ',
>� 192 22-Oct 753 Elk Point 40.81 $ 9•00 S 367.29 $ 28.34 $ 395.63 '
� 193 22-0d%5 Forest Mt 175.00 $ 6.50 $ 1,137.50 $ 69.81 $ 1,20731
:� 194 22-Od 2217 Tahoe Mt 46.20 $ 9.a0 $ 415.80 $ 30.30 5 446.10
' 195 22-0d Haidas 92.80 $ 8.30 $ 770.24 $ 42.73 $ 812.97
� 196 27-0d Mgore Creek 69.75 $ 9.00 $ 627J5 $ 38.04 $ 665J9
:� 197 27-0ct 564 Lake Tahce Bivd 24.00 $ 14.00 $ 336.00 5 21.80 $ 357.80
'� 198 27-Oct 879 Mountai�Trout 30.00 $ 14.00 $ 420.00 $ 23.98 $ 443.98
'� 199 29-0d 1948 Normuk 41.40 $ 9•00 $ 372.60 $ 29•87 $ 402.47
.� 200 29-Od 1928 Normuk 47.25 $ 9•00 $ 425.25 $ 31.07 $ 45632
� 201 29-Oct 1863 Normuk 117.93 $ 6.50 $ 766.51 $ 48.29 $ 814.80
;� 202 29-Od 2144 Shawnee 54.83 $ 9.00 $ 493.46 $ 33.44 $ 526.90
,q 203 29-Oct Ojibwa 41.32 $ 9.00 $ 371.88 $ 31.24 $ 40312
'� 2 23-Aug 1275 Meadow Crest Drive $ 1,350.00 Striping
E 205 Total 5544.75 $ 50,771.12 3311.35 $ 55,432.47
`� 206 _
.� 207 Raise Valve Box � CURB ANO GUTTER
208 Date Location TotalCost Address Feet CostPerFoot TotaiCost
� 209 22-1u1 1086 Clear View Drive $ 65.00 3739 Saddle 7.5 $ 60.00 $ 450.00
210 4Sep 3382 Becka $ 65.00 3773 Regina 7.5 $ 60•00 $ 450.00
� 211 22-0d 1284 Mt Meadow $ 65.00 3020 Prospedor 12 $ 60•00 5 72�.00
9 212 $ 130.00 _ _ � _ 1020 Prospedor 6 $ 60.00 $ 360.00
- 213 i � I Frontier 6 $ 60.00 5 360•00
214 FLAGGER 2453 Cattlemens 6.9 $ 60•00 $ 414.00
215 Date Hours Cost Per Hour Total Cost 2447,2 Cattlemens 10.1 $ 60.00 $ 606•00
216 30-Jul 16 $ 80.00 $ 1,280.00 3040 William 15.4 $ 60.00 $ 924•00
� 217 7-Aug 3 $ 80.00 $ 240.00 1041 William 8 $ 60.00 $ 480.00
A 218 22-Od 3 5 80•00 5 240.00 Saddle 6 $ 60.00 $ 360•DO
�
� 219 24-Oct 6 5 80.00 5 480.00 Saddle 10.1 $ 60.00 $ 606.00
� 220 27-Od 8 $ 80.00 $ 640.00 Keiler 7 $ 60.00 $ 420.00
� 221 36 $ 2,880.00 Overlook 3.5 5 60•00 S 210.00
� 222 Goldea Bear 6.1 $ 60.00 $ 366•00
223 Clement 6.5 $ 60.00 $ 390.00
224 ' - -- 118.6 $ 7,116.00
225 � ---- ,
226 - , - ,
� 227 I - Totai I $ 121,826J4
� - -- i i
228 Ij I
X
��O
11/25/2014 STPUD Asphalt Patching 2014 Page 4 of 4
General Manager
Richard H.5olbrig
� + 1950 s w
8j� � �� � � A Directors
�r—"� ChriS Cefalu
`� James R.Jonee
�� �u b l�c U ti l i ty D i stri c-� Randy Vogelge5ang
Kelly 5heehan
Eric 5chafer
1275 Meadow Crest Drive•South Lake Tahoe•CA 96150-7401
t'hone 530 54•4-6474•Fax 530 541-0614•www.stpud.us
BOARD AGENDA ITEM 5b
TO: Board of Directors
FROM: Nancy Hussmann, Human Resources Director
MEETING DATE: December 4, 2014
ITEM- PROJECT NAME: Self-Insured Dental Plan Renewal
REQUESTED BOARD ACTION: (1) Approve renewal of the Self-insured Dental Plan with a
funding level of $130.69 per employee per month; and (2) Approve 2015 Dental COBRA
rates at $49.29 Single, $98.57 Employee +1, and $167.57 Family.
DISCUSSION: BBB�H Benefit Designs, Inc., compiled claims data from 2014 and reviewed
District and industry trends. The 4.74% increase in funding level is due to several factors,
as follows: (1) Slight increase in claims exposure due to plan design changes- namely
coverage for dental implants and for a rollover feature that was added in 2014 (impact
1-1.5%); (2) Increase in industry dental trends is estimated to be 3.4%for 2014 and 4.7%
in 2015; and (3) Increase in actual dental claim experience in 2014. The 2014 actual
dental claims cost increased 4.72� compared to year end 2013.
SCHEDULE: 12/5/14 Notify CDS Group Health of new rates
COSTS: $183,489/year
ACCOUNT NO:
BUDGETED AMOUNT AVAILABLE: N/A
ATTACHMENTS: None
CONCURRENCE WITH REQUESTED ACTION: CATEGORY:
GENERAL MANAGER: YES �1�, NO
CHIEF FINANCIAL OFFICER: YES NO
— 1—
General Manager
Richard H.5olbrig
• 1850 •
� w� � v� a o e Director5
Chris Cefalu
JameS R.Jones
'�' :�ye•= e , Randy Vogelgesang
f ubiic Utility DiStrict KellySheehan
Eric 5chafer
1275 Meadow Crest Drive•South Lake Tahoe•CA 96150-7401
t'hone 530 54�4-6474•Fax 530 54-1-0614•www stpud.us
BOARD AGENDA ITEM 5c
TO: Board of Directors
FROM: Nancy Hussmann, Human Resources Director
MEETING DATE: December 4, 2014
ITEM-PROJECT NAME: Self-Insured Dental Plan Document Update
REQUESTED BOARD ACTION: Approve updated Plan Document for the Self-Insured
Dental Plan
DISCUSSION: In 2014, some plan design changes were made, namely, the addition of
dental impiants as a covered benefit, and a Rollover Provision, whereby low utilization
parficipants may roll over up to $750 per calendar year to the following calendar year,
up to a maximum accrued rollover amount of $2,000. This necessitates an update to
the Plan Document.
SCHEDULE: Prior to 1/1/15-publish and distributed updated Plan Document
COSTS: N/A
ACCOUNT NO: N/A
BUDGETED AMOUNT AVAILABLE: N/A
ATTACHMENTS: Redline Version of Dental Plan Document
CONCURRENCE WITH REQUESTED ACTION: CATEGORY:
GENERAL MANAGER: YES � iA NO
CHIEF FINANCIAL OFFICER: YES NO
- 3-
� �
���t'"1 CIOCUr"r"1�1'1�
And
�ummary Plan De�cription ,
For
��►uth Tahoe Public IJ#ility District
Dental Insurance Plan �
�
;
�� �
,
� J
�
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1
1
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1
Implemented: January 1, 2p13
��������� �������� �� ����
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Ta�rle af Cont�nts
i
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( Section �', ��e ��,
�
� Ir�tr�ductian � ���
,
� �OBf�A Notificatian Proc�dure � 1 �������������
� ��
;
Defined Terms �
�
Eligibility, Funding, Ef�ecfiive Date &T�rmin�ti�n Pravis�icrns 6
�
; Schedule c�f Benefifis 13
,
Dental �ch�dul� c�f B�nefits 1�
� �I�ims Prc��edures 19
� Coc�rdinatic�n of B�rrefits 23
5ubrogation and Fteimburs�ment M�rc�vi�icrns �7
�OBRA Ccrntinuatic►n Optic�n 31
' HIPAA Privacy Compli�nce 38
;
�
Respansibiliti�s far Plan /�dministration 41
;
Gen�ral Plan Infarmation 43
;
;
;
<
,
;
;
;
;
;
;
;
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;
;
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� IN'y�l"qC1'�C��O�1
I
� This d�cument is a descriptic�n �f the �c��th "fahc�� Public Utility District Dent�l ����
� Insuranc� Plan (the Plan). Th� Plan d�scribed is desigr��d t� prc�vid� fc�r dental �
� ber�efits.
;
This Plan is intended tcr pr�vide the Emplc�yee and eligible dependents� dental insuranc�
� coverage for prev�ntive �ar�, routine service� and t� �as� financial burdens by
� providing reimbursem�nt f�r cavered exp�nses.
�
�
; This de�cumerrt sumrr�ari��s th� Plan right� and berrefits fc�r cc►v�r�d Employ�es and �
� their Dep�nderrts.
The Pl�n is not intended to be, and may not be construed as corrstituting a contract or
� � czther arr��g�m�;nt b�:finr�:�ro a�y irrdividual and th� Di�trict tc� th� �ff�ect th�t the �
;
� individual will b� employ�d for any sp�cific p��riad c►f time.
�
�
� CC�BRA NCIT1�14ATIO�J PRC►CEDUR,E�
� Natic� Re�or��ib�litie�
� It is a �'lan participant's r�spr�nsibility to p�rovid� th� Fcrllowing I�crtic�s� relatirrr.� tc� CQBF2A �
� Cantirruatior� Cc�verage: ��
�
IVatice of Divorce ar Se�aa�ration — Nc�tice of th� occurr�nce afi a Qualifying Event that
is a dNvcrrc� or legal sep�ration caf a caver�d Emplcryee fr�m his or her�pou�e.
Notice af Child°s Lass crf Dependent Status — IVcrtic� �f a Qualifying Event that is a
� child's I�ss �f Dependen� �tatus under th� Plan (e.g., a Dependerrt child reaching th�
�
maximum age limit).
� Notic� of a �ecorrd Glu�►I�fying Event-- PJotic� of th� crccu�rrence of a seccrr�d
� C�ualifying Event after a Q!ualified Ben�ficiary has beccrme entitled to COBRA coverage
� with a maximum dur�tior� c�f 18 (or 29) mc�nths.
Notice Regarding Disability— Notice that.
1, A Qualified Beneficiary entitled to receive CC7�RA �c�ntinuation Coverage with a
; m�xirrrum duratian c�f 1� months has b�en determin�;d by the Social Security
Administration (SSA) ta be disabled at ar�y time durirrg the first 60 days of
; continuatic�n caverage; c�r
; 2. �, G2��lifi�d E��n�fi�i�ry �s d��crib�d in `°1„ has ��b��q��ntly b���n d�termir��d by
the SSA to no I�nger be disabled.
;
;
;
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S A
Noti�cation Procedures
Natificatian must be made in accordance with #he fallc�wing procedures. Any individual
who is either the covered Employee, a Ctualified Beneficiary with respect ta the i
Q!ualifying Event, or any representative actirrg on behalf af the covered Emplayee or ;
Qualified Beneficiary may provide the �Jotice. Natice by ane individual shall satisfy any ;
resp�nsibility to pra�vide Nc�tice on b�half af all rel�ted Qualified B�neficiaries with j
resp�ct ta the Qu�lifying Event. � j
Farm or Means of Natification — Notificatior� of the Qualifying Event must be provided
�
tr� the District's Human Resaurces D�p�r�m�nt. 1
Carntent— Natification must include any official documentation showing evidenc� that a �
Qual'rfying Event has occurred, such as a capy �f a divorce decree, a child's birth
certificate, a copy of the Social 5ecurity Administratian's disability determination, etc.
%
Delivery of Notifica�tion -- Notification must be received by th� District's Muman i
Resources Department. �
Time Requirements� far Notifica#ion — Should an event occur(as described in Natice �
Ftesponsibilities above), the Emplay�e, c�ther G2ualified Beneficiary, ar a representative
acting an behalf af any such persan must pro�ide �Ic�tice to the desigr�ated recipient �,
within a certairr time frame. � ���
r
In the case af divorce, I�gal separati�n crr a cP�ild losirrg dep�ndent status, Notice must �
be delivered within 60 days from the later of: II
1. Th� d�t� o�f the Qualifying Ev�nt; �
2. The date dental plan cav�r�ge is lost due to the �verrt; or ��
3. Th� date the Qualified Beneficiary is nc�tified ofi th� c,bligatian to pravide IVatice ��
thraugh the 5ummary Plan Descriptiar� or the Plan Spansor's General CtJBF�A �
Notice. If Notice is not r�ceived within fhe 60-d�y period, COBF2A Continuatian �
�average will not be available, e�cept in the case crf a loss of coverage due to �
foreign competi#ion where a second C(�BRA electian periad may be available —
see "Effect of the Trade Act" in the COBRA Continuati4n Ccrverage section af this
Plan Document.
If an Employee or C,C`�ualified Beneficiary is determined to be disabled under the Sc►cial
Security Act, �lotice must be delivered within 60 days frorn the later of:
1. The date of the determinaticrn;
2. Th� date �f th� Qualifying Ev�nt; �
3. The date cc,verage is Icrst as a result af the Qualifying Event; c�r �
4. The date the cavered Ernplayee or Qualified Bene�ciary is advis�d af the Nptice 1
of C7bligation thraugh the Plan Dacument or the Plan Sponsar's General Ct�BRA (
�
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�
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�
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� �lotice. Alse�, I�otic� must b� provid�d within the 18-m�nth COBRA cov�r�ge
� peric�d,
�
�
;
�
� DE�INED TERN��
�
� ?h� follav�ing t�rms have sp�cial meanings ar�d when used in this Plarr will be
capitalized,
,
� A�tive Errt�ploye� is an �mploy�e who perFc�rms all r�f the dutie� c►f his ar h�r jc►b with�
1 the Employ�r on � full-tim� basis.
; Baseline �hall me�n th� initial Test I��sults tcr which the results in future years will be
cc�mpar�d ir� c�rd�r tc� d�t�ct �be�c�rmalitie�.
;
;
;
; �alendar Yea�r m�ans ,Jar�uary 1��thrvugh D�c�ember 31�ti of th� �am� y�ar.
;
� G6"J►BRA m�ans th� C�nsolidat�d CJmnibus Budget Rec.�r�ciliati�n Act of 1985, as
J
� amended. �
;
� Cl�im� A�dministra�ta►r/�or�tract admini�tratc►r -- A c�mpany that perF�rms all
; functic�ns r�asonably rel�at�d t� th� admini�tratic�n of a�ne ar �mc�r� ber��fits of the Plan
�
(�.g., pr�c�ssir�g c�f claims for paymerr� in accorda�nce with th� t�rm� ar►d cc�nditi�ns of
;
� the Eienefit Document and an adminis�tration ��r��ment �etw�er� th� (��rrtract
;
� Administrator and th� Plan Spansc►r. �
�
,
Casmet�c Surgery m�ans� medically unnecessary surgical prac�dures, usually, but ncrt
� lirnited to plastic sur��ry directed toward preserving b�:aufiy crr carre�ting scars, burns c�r
; disfigurem�nts. �
;
;
Cavered Person is an �mplcrye�, D�pendent, c�r Activ� �+�ard M�mber who is cc�ver�d
�
; under this F'lan.
;
;
; D�ntist is � per�crn who i� properly train�d and lic�nsed tc► pr�ctice dentisfiry and whcr is
� practic�ng vwithin fihe s�ape r�f such licens�.
;
;
; D�pendent— See Eligibility S�cticrn
1
;
� Em�loyee means a person wh� is an Active, r�gula�r Employee of fihe Employ�r,
; r�gularly scheduled to work far the Emplayer in an Emplcrye�:/Employer r�lati�anship.
� ��p►�erim�r�t�l a�r�dl�►r Ir��r��tig�fi��raa�l m�ans ��rvice�, �upplies, care �nd treatment
which do nc�t constitute accepted medical c�r dental practice prc�perly within th� range of
% apPrc�priate medical r�r dental practice und�r the standards aF th� case and by th�
standards of a reasonably substantial, qualified, respansible, relevant segment of the
;
� �
� ��
dental community or governm�nt oversight agencies at the time services �rere
rendered.
r
The Plan Adrr�inistratar, or his/her designee, must make an independent evaluation of
the experimental/non-e�perimer�#al standings of specific technologies. The Plan
Administrat�r, �ar his/her design�e shall be guided by reasc�nable interpre�ation af Plan
provisions. The decisions shall �e made in goc�d faith and rendered following a detailed
factual backgrc�und inv�stigation of the claim and the proposed treatment. The F'lan
Administratc�r, crr his/her designe� will be guided by the fallowing principles: �
1, If th� drug �r device can�7a� be lawfully marketed without approv�l of the �J.S. ��'
Faod and Drug �dministratic�n and approval for marketing has not been giv�n at
the time the drug crr device is furnished; or
2. If the drug, device, medwcal treatment �r pracedure, ar the pat�ent infarmed
cansent docum�nt utilized with the drug, device, treatment c�r pracedure, was
reviewed and approved by the treating facility's Institutianal F2ev�ew Baard c�r
c�ther body serving a similar functian, ar if the federal law requires such review c�r
approval; c�r
3. If Reliable Evidence shaw� that the drug, device, medical treatment or proced�are
is the subject a�� c�n-gc�in� phase I or phase II clinical trials, is �he rese�rch,
experimental, study c�r inv�stigatianal arrrr af crngc�ing phase III clinical trials, ar is
atherwise tar�der study ta determin� its ma�cimum tc�lerated dase, its toxicity, its
safety, its effic�cy or it� efficacy as cc�mpared with a standard mean� af
treatment ar diagnosis; or
4. If F2eGable Evidence shaws that the pr�vailing opinion a�mong experks regarding
the drug, device, medical tr�atment c�r procedure is that further studies or cdinical
trials are neces�ary to determine its maximum tolerated d4se, its tc�xicity+, its �
safety, its efficacy or it� efficacy as c+�mpared with a standard means of
treatment ar diagnasis.
Reliable Evidence shall mean only published repc�rts and articles in the authoritative
medical and scientific literat�re; fihe written protcrcol or protocols used by the treating (
facility or the protocol(s) of another facility studyir�g substa�ntially the sam� drug, devic�, �
m�dical treatment or prcrcedure; ar the written informed consent used by the treating ;
facility or by another facility studyirrg substantially the same drug, devic�, medical ;
treatment or prac�dure. �
�
;
Fa�mily Unit is the ccrvered Emplayee and th� family members who are cavered as ;
Dependents under the Plan.
Illness is, far all persons: Sickness, disease ar Pregnancy.
�
s
4
I
l
%
%
; Injury m�arrs an accidental physic�l irrj��ry t� t�r� b�dy caused by un�xpected ext�rnal
means.
;
Medical Emergency means a sudden onsefi c�f a condition with acute symptoms
;
requiring immediat� medi�al car�,
;
' M�dica�lly N�cessary car� and tr�atm�nt is recc�mm�nd�d or approv�d by a Physician;
� is cansistent with the p�ti�nt's canditic�n �r acc�pted standards r�f gcrod medical
� pr�ctice; is medically pr�v�n t� be effective treatm�nt of the condition; is ncrt���perf�rm�d
�
� mainly for t�r� conv�ni�rrc� c�f the pat�ent crr prc�vider crf ined�cal c�r d�;ntal servic�s; is nr�t
; cor�duct�d for res�arch p�urposes; and i� the mo�t appr�priate level of s�rvic�s which
� can safely be provided t� the pati�nt.
;
;
;
� All of these criteria rr�ust be met; m�rely because a Physician/Dentist recomm�nds or
; �pprov�� c�rt�in ��r� de�es n�t m�a� th�t it i� I�tl�d�c�lly I�e��s��ry.
�
� Medicare is th� H�alth Insurar�c� f�r th� Ag�d arrd [�isa�led program under Titl� XVIII
,
; c�f th� �cacial ����rity A�t, �� �m�r�d�d.
;
� No-Fault Auto Irrsuranc� is the basic r�paratic�r�s prc►vision crf a I�w praviding for
� payments with�ut d�t�rmir�ing fault ir� cc�rrn�cti�n with autam�bile accid�nts.
;
�
� P'hy�siciar� means a C�octc�r c�f Dental �urc�ery (D.D.S,) and any r�ther practiticrn�r of th�
he�ling art� wha is licensed and r�gulat�d by � stat� c�r federal agency and is acting
;
�
; wifl�ir� �h� scap� c�fi hi� or her lic�n��.
�
;
,
� P'lan r�r Plan P'rr�gram m�;ans the �c�utt� Tahc�e Public Utility District C►ental Insuranc�
; Plan, which is a benefit� plan for� cerkair� emplcryees af �outh Tah�e Public Utility
; C�istrict, arrd is described irr this dc�cumerrt.
;
; Pla�n P'articip�a�nt is arry Employe� or Depend�:nt who �s cc�ver�d ur�der this Plan.
f
; Plan Year is the 12-mc�nth peric,d beginnir�g crn th� �ffectiv�: date crf th� Plan.
;
Temparomandibular Joint (TMJ) syndrome is the treatment of jaw joint disarders
` ir�cludir�g �c�ndifiic�ns c�f �t�uc��ar�� lir�kir�g fihe j��nr bcrne �nd skull and the cc�mplex crf
' muscles, nerves ar�d other tissues r�lated ta the temporc�mandipbul�r joint.
;
� Usual, Customa�ry and aeasona�bl� Charge (UCR) i� a charge which is nat higher
than the usual charge made by the provider c►f the care crr supply and does not exceed
� the usu�l charge made by mc�st providers of like service in the same area. This test will
consider the nature and severity af the conditicrn being treated. It will alsc� cansider
; medi��l �r�m�li��tic�r�� �r un�as�a�l �dreur�n�tanc�� fiha�� r�q�ire mc►r� tirr�e, skil� c�r
experNence. Fc�r services, supplies or fees wh�re publicatians of Usual, Customary, and
� F��ason�bl� Charges �re not av�ilable, th� Claims Admir�istrator shall survey local or
; �
� �
nearest geographic providers of the same service ta det�rmine th� allawable Usual, '
Custc�mary, and F��asonable Charges utilizing applicable lacal resources.
ELIC#BILITY FUNDING EFFECTIVE DATE & TERMIfVAT14N P"ROV1510AIS '
�
Eli�ibili#v li
Eliqible Classes af Em�lc�yees
The following �las�es af Emplc�yees are considered eligible classes of Emplayees:
1. All Active F�II-Time Emplayees �f the Emplayer. An Employee is c4nsidered to �
be�„F'ull-Time if he or sh� normally works at least 20 hc�urs per weel� and is on th� �
regular payroll crf the Employer for that wcrrk. t
i
2. Active members af the Board of Directc�rs.
Eli ibilit F2� uirements for Em lo ee Covera e
A person �� eligibl� fc�r Emplc►ye� cc►v�rage on the first day of:the Cal�ndar month s
f�llowing date of hir�. �
Efi�ible Cl�asses �f�D�penderrts �� �
�
,
�
Clependerrt is any c�ne of the following persans:
1. A ca�vered Emplayee's 5pouse, as defined; you ar yaur Spc�use's child who is
under age 26 and whc� is not eligible to enroll in an eligible emplayer-spansored
health plan (as defined by law), including a natural child, stepchild, a legally
adopted chiid, a child placed for adaptian c►r a child far wham you or aur Spouse
are the legal guardian. Individuals whose caverage ended or who were denied
coverage (or were ncrt �ligible fcrr coverage), becaus� th� av�il�bility of �
dependent coverage af children ended before attainment of age 26 are eiigible ta J
errrall in th� District'� F'larr. Individuals may request enrollmen� af such childr�rr ��
for 3C► days from the dat� c�f notice of Open Enrollmer�t. Op�en Enrollm�nt period ?
for the district is IVa�vember 1 ta Novemb�r 30. Enrollm�nt will then be effective �
J�nuary 1 of the fcrllowirrg year, Fc�r more information, cantact the Plan �
Administrator at 530-543-6222. �
1
The term "Spouse" shall mean the person recognized as the covered Employee's
husband or wife under the laws af the state where the ccrvered Employee lives. `
The Plan Administratar may require documentation proving a legal marital J
relatiar�ship. �
I
��
6
�
�
i '
i
;
� a � i
�
�
� I
� 2. A cov�red�D�perrd�rrt child who is inc�pable c�f s�ifi-sustaining �mploym�r�t �y
reas��n �f r�ental r�tard�tian c�r physi�cal handicap, primarily d�pendent upon the '
� cc�ver�d �m�l�y�� fa�r suppor� �nd maint�nance, ar�d cov�r�d und�r t�re Plan ,
� when reaching the limiting age. Th� Plan Admirristratr�r may r�quire, at
� reason�ble int�rvals during the twa years follc�wing the C1�pend�nt's r�aching the ���'
limiting age, subsequ�nt proaf of th� child's disability and dependency.
� ���������
After such two-year peric�d, the Plan Administrator may require subsequer�t proafi
� nc�t more than c�nce each year. Th� Plarr Administratar reserv�s th� right�tc� hav� '�
such Dependent ��camir►ed by a �'hy�ician of th� �'lan �dministratc�r�s chc�ice, at
� th� Plan's �exp�nse, tca determin� the �xist�ence af such inc�pacity.
;
These persons are ex�lud�d as D�p�nd�nts:
� 'i. t�th�r ir�di�rid�a�l� living ir� the ccrv�r�:d Empd�zy��'� ht�m�, b�t whcr ar� ncs� �ligible
;
as defined;
;
;
2. Th� I�g�lly �ep�rat�d �r divorced fc�rrrs�r�p��ase �f th� Empl�ye�;
;
�
; �. Arry d�p�r�derrt wha is c�n ac�ive duty irr arry mili�ary service in any country/.
�
;
;
If a persan covered under this Plan chang�s s�tatus frc�m Emplcry�e t� Dependent or
; d�pendent tc� Emp�lc�yee, �►nd the persan is cov�r�d cc�ntinuc�usly und�;r this� Plan befor�,
� during, and after th� change in statu�, cr�dit will be given fcrr all amc►�ants applied to
% maximums.
�
;
If both husband and wife are Emplc�yees, their children will be couered as Dependents
;
� of both.
�
;
�
;
� Eli ibilit Re uir�m�r�fi���rr Cl�: �ndenfi Ccrv�ra �
�
;
;
;
A family m�mber af an Emplc�yee will becc�me �ligible fc�r Dependent coverage an the
� first day that th�f�mily m�mber satisfies th� requirem�nts fcrr Clependent ccrver�ge.
;
,
;
% At any time, th� Plan may require pr�crf that a �p�s�s� or a �hild qu�►lifiies or contirrues to
;
� qualify as a Depend�r�� �� defined by�hi� Plan.
;
� Fundin
;
;
;
�ast c�f the Plan
;
�
�
�outh "Tahcre F'ublic Utility L7isfrict pays �h� �ntire cc��t ofi Empl�y�� and Dependent
�
� ���r�r�ge ur�d�r thi� Pl�r�.
,
�
;
;
,
;
;
;
;
,
;
; �
;
f
,
�
;
,
;
� �
E1"11'Cf��r11�PI� �
Enraliment f�equirements
,
An eligible Employee or eligible Board Member must enroll for coverage by filling out
and �igning an enrollment applicatian. The cov�red Employee ar Board Member is
r�quired ta errrall f�r Dependent coverage also, irrcluding ccrverage far rrewborn �
children. � 1
�
,
�
�
Enr�llrnent Requirements fc�r Newborn Childrer� j
,
;
� A rr�wborn child of a Plan Participant is cc�vered under the parent's ccrverag�. The j
newborn chifd must be enr�lled as a Dependent under this Plan within 31 days of the i
child"s birth in order fic�r non-routin� caverage to tak� �ffect from birth. � i
� l
If the child is not enralled within 31 days af birth, the enrollment will be cansidered a
Late Enrollment.
I,
Tim�lY ar�d Late Enrollmerrts �
An enrallment is either"timely„ ar"late'°:
r
1. Timely Enrollment—The enrollment will be "tim�ly°' if the complet�d form is �'
received by the Plan Administratar na lat�r than 31 days after the person '
F
becomes �lig�bl� for the c�verage. �
2�. Late Errr�llment— Late enrollment is acc�pt�d at the n��ck Annua�l ap�rr : �
Enrollment Perio�d. �
Effective Date
Effective Date af Employ,,.ee Cc�veraae
An Employee ar Board Member will be cavered under thi� Plan as af the first day ofi the
calendar mc�nth fc�llowing the date that the Emplc�yee or Baard Member satisfies all af
the follawing:
1. Eligibility Requirement
2. The Enrollment Requirements of the Plan.
Effective Date af De,�endent Coveraqe �
A Dependent will be cavered under this Plan on the first date that the Dependent j
satisfies all of the following: l,
I
{
s
;
�
�
�
i �
i
� � p
�
� ;
' �. Eligibility f��quirem�nt �
�
�
' 2. Enrollment R�quir�m�nts �f th� Plan
� ,.
� ���
� Coverage fi�r a �ubsequ�nt d�p�ndent is �fFective, upc�n enrc�llm�r�t, as fi�llo�ws: ������������
a �������
I
� 1. For� spaus�, the da�e �f marriage; ���
�
� 2�. Fr�r a n�wborn child, the d�te crf birth; ������������
�
3. For arr �dcrpted child, th� date r�f adc�ption c�r placement far adoption;
4. Fcrr any �ther child, the dat� the child becom�s a Dependent.
; Er�rr�llment P'eriod�
;
� "The �nitial Eligibility Perioc� is th� �1-d�y peric�d which begirrs c►n th� date the Employee
�
� or �c��rd M�rr�ber is fir�� ��ligibl� �ar�d�r this Pl�r�. Th� Ctd�tric�t rrN�a�t r�ff�r�r�rr�llrr��r�t
�
durir�g that time and advis� the emplayee of th� d�;adlirr�.
;
; �rinp�ir�y�es anr�/crr D�p�nd�nt� w�rc� �►re nr�t enroll�d during tl�� Initi�� �ligibility Pericrd,
� �r a �p�cial Enr�llrr��nt I��riod, thrcrugh the Employee's �I�ctian or�missi�n, must wait
;
; until the ne7ct�nr�ual �7p�n Enr�llm�nt P�eria�d tc� enr�ll f�r c�verage.
;
Th� Annual t�pen Enrollrr�ent P'eric�d is d�esignat�d by th� Emplcry�;r as I�c�vember 1 to
� Nov�mber 3(� c�f each y�ar. It is hetd befor� the start r�f�:ach Plaru Year. During this
;
p�ric�d, �II eligible Employ�es arrd D�pendents carr �nrcall far cc�vc��-age.
;
;
�
� Spe�ial Enr�llr��nt Peri�d� ar� availak�le �o cerfi�in persc�n� whc, have last crtf�er
; coverag� and to cer�ain d�p�nd�nts.
;
;
,
,
� A Special Ertr�llment Period is availabl� t� a cc�v�:red Emplc�y�e's spouse crr minor child
� if a court c�rders that c�verage must be pr�vided under this F'larr arrd th� requ�st fcrr
� enr�llment is r�ad� wit�rirr 3C1 days aft�r tF�e issuance crf the order.
,
� A 5p�cia�l �nr�llrrren� F'�ri�d is available t�r � per�on wvl�o rr�e��� each cr�fihe fiollc��nrir�g
�
; conditians:
�
� 1. The Emplayee or Dep�nder►fi was c�vered under a group der�tal plan or had
; dental insuranc� coverag� or was cr�vered under no-share-r�f-ccrst Medi-Cal
� coverage at the time coverage und�r thi� F'lan was pr�viously affer�d fio the
� �mploy�� or Depend�nt.
�
;
2. The Emplc�ye� stated in writing, at the tim� coverage was previously affered, that
the other coverage was the re�san for declinin� enrollrrrent under this Plan. The
Employer must ha�e requested th� statement and provided the Employee with
;
9
;
1
�
� � �
i
a
�
�� natic� of this requirem�nt (and its c�ns�quences) at that time. If the Emplaye�r (
cannot produce the sign�d waiver farm at the time the persan wants ta enrall, �he }
provisian daes not apply. �
� 3. The Erryployee's �r Deperrdent's pric�r coverage was one of the follawing: �
�
a, COBRA continuatian which was exhausted.
b, �lon-CCJ�I�A caverage which was terminated �ither a�s a result of lass a�f �
eligibility f4r the coverage (including a�s a result of legal s�paration, �
divc�rc�, death, terminatic�r� of�mplr�yment, ar reduction in the number of �
hc�urs af employment) �r emplayer contributions toward such caverage
were terrrrinated.
c. The Employee requ�sts enrollment under this Plan not later than 31 days
after the date af the end of COBF2A cantinuation, terminatic�n af coverage,
t�r termination of Emplc►yer contributir�n.
1
A Special Enrollment Peric�d is available tc� Subsequent Dependents. The Dependent
Special Enrollment Peric�d is the 31-day period which begins with the date the person �
becomes a depend�nt. �
If a Subsequent Dependent is errr�lled, th� Employee must enrc�ll at the same time if not J
r
already cavered. In addition, any of the Emplayee's other Dependents may be enroll�d
at the same time, if n�t already covered, siabject to the same enrollment requiremer�t�.
"Subsequent Dependent" irrclud�� a spause �r child af an eligible Emplayee whose ���
caverage is ordered by the court. :The request far enrallment must be made within 3�► �
days after issuance �f the c►rder.
t�u�lified Medical Child Support t�rders
In th� everrt a court order provid�s that ccrv�rag� under th� Plan or some portion �
therecrf, must b� prc►vided for your minor child, the following rules will apply: ;
;
�
1. Ycru must submit the order in a tim�ly manner to th� Plan Administr�tor. The ;
Plan Administrator will notify you and yaur child that th� order has been received �
and what procedur�s will b� used to determin�; if the arder is a qualified medical �
child suppart order within the m�aning of Sectian 609 of EF21SA. The Plan 1
Administrafor will decide whether the 4rder is qualified �nd natify the Participant �
and the Participa�nt's child of th�t decisic�n. t
�
2. If the Plan Administratc�r determines that the arder is qualified, the Plan
Administrator shall permit an alt�rnate recipient (as defined in ERI�A Section ;
609(a)(2)(C)) to designate a r�presentative fr�r recipient of copies af notic�s that j
are sent tc� the alternate recipient with respect to the medical child support arder. a
�
�
I
�.0
i �����
f
r
i " °
r
3. If the Plan Adminisfiratc�r determin�s that the circumsfiances surraur►ding the caurk
� c►rder ca�nstitu�tes and/or s�tisfies th� ch�nge in f�mily status r�quirem�nts under
the Plan, then you vvill be permitted ta chang� yc�ur electic�n of benefits under the
Plan Prc�gram(s).
;
;
� T�rmina�ion of Ccrverag� �
When Em lo ee Covera � Terminates
�
,
;
Employ�e �r Board Mem��r's couerage w�ll terminate c�n the e�rliest af these dates
�
� (�xcept in c�rtain circur�nsfanc�s, a ca�ver�d �mplc�y�e m�y b� eligibl� fc�r CCf�RA �
� Continuatior� Coverage. Fc�r a c+crmplet� e�planati�n �f wh�n COE�RA Cc�ntinua�i�n �
Cc�verag� i� availabl�, what cor�ditions apply, and hc�w t� s�lect it, see the secfiian
� �ntitled C JBRA Cc►ntinu�tior� Op�tion):
;
; 1. The dafie �he Plar� i� �erminated.
,
� �e Th� l���d�y of th� ca�end�r mc�r�tl� ir� which th�e �z�v�red �mplc�yee ceases t� be
in c►ne c�f the �ligible Classes. This includ�s death ar termination crf employment
% af the covered Emplc�ye�. (See the� Ct�BRA (:r�nfiinuati�n C►pti�n)
;
,
� �� G�ntinuatian Clurir� F'eri�ds c�f Em lo er-f��r�ifi�d C�i�abilNt L.�ave of Absenc� or �
� �
; L.avoff
;
�
' A� p�rson may remain eligible fcrr a limi#ed �time if activ�;, full-tim� wc�rk ceases du�; to �
;
;
; disability, I�av� �f abserrce ar layoff. Limited eligibility sh�ll b� d�termined by the
� ruegc�tiated IVlemorarrdum c,f Und�rst�ndin�� b�tw�en�the applicabl� employe� gro�up and
;
the District.
;
� While continued, ccrverage will b� that whi�h w�s in forc� c►n th� last day wc►rk�d as an
�
Active Employee. Hawev�r, if benefits r�duce for crthers in th� class, they will also
' r�duc� for ft�e con�inued person.
;
' Continuatie�n Ctur�n Famil and �I�dical L�ave
;
� ��gardless of ff�� es�ak�li�h�ed I�av� pc�lici�;� m�ntiran�d ak��v�, �F►is Plan sl�ali a� a�ll
' times camply with th� Family ar�d Medical Leave Act c►f 1993 as prorr�ulgated in
regulations �ssued by the C7epartment of Labor.
During any ieave taken under the Family �r�d Med�cal Leave Act, the Emplayer will
mairrtain caverage under this Plan or� the same c�nditions as coverage would have
� b�en pr�vided if th� cov�red Em�loye� had b�en con�inucrusly employed during thre
;
�ntir� I��v� peri�d.
If Plan cc�verage terminates during the FMLA leave, cc�verage will be reinstated fcrr the
Employee and his c�r her�ligible Depend�nts if the Errrplc�ye� returns to work in
11
�
i
� � �
�
�
accardance with th� terms af the FMLA leave. Caverage will be reinstated only if the
person(s) had coverage under this Pian when the FMLA leave started, and will b�
reinstated ta the sarne extent that it was in farce when that cc►verage terminated.
f�ehirinq a Terminated Emplcryee �
;
A terminated Emplayee who is rehired will be treated as a new hire and will be required C
ta satisfy all Eligibility and Enrcallment requirements, with the exception of an Emplc�yee
returning to wark directly from COBRA cc�verag�e. An Employee returning to work
directly fram CC7BRA coverage does not have to satisfiy the emplaym�r�t waiting period.
Emplo,yees on Militar�Leave
Ernplc�yees going into or returnirrg from military service will hav� Plan righ#s mandated
by the Uniformed S�rvices Employment and Fie-emplayment Ftights Act. These rights
include up tc� 24 months of e�ct�nded health car� cov�rage upc►n paymen# af the entire
cost af coverage plus a reasonable administration fee and immediate caverage with no
pre-existing conditians exciusions applied in the Plan upon retum from service, These 1
rights apply only tc� Emplc►yees and their Dependents cc�vered under the Plan befcrre
leaving far military service.
Plan exclusions and waiting p�riods may be imposed for any 5ickness or Injury ,
determined by the Secretary �fi Veterans Affairs t� have been incurred in, or aggravated �
during, military servi�e. � �
When Dependent �crveraqe T�rminates
A Dependent's cov�rage will t�rminate c�n th� e�rliest of th�se dates (except in certain �
circumstances, a covered Dependent may be eligible for CCIBRA continuatian f,
coverage. For a complete explanatian of when COBF2A cantinuatian coverage is u,
available, what cc,nditic�ns apply, and how ta select it, see the section entitled GOBRA J
Ccrntinuati�r� Optian�. �
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1. The date the Plan is terminated.
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2. The date that the Employee's ar Board Member's coverage under the Plan �',
terminates fc►r any rea�son including death (Se� th� Ct�l�FtA Cantinuation Option). �
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3, The date Dependent c4verage is terminated under the Plan. �
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4. On the last day af the manth that follows the first date that he or she ceases to be �
a Dependent as defined by the Plan (Se� eligibility far dependents). �
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SCHECIU�E O�' BENE�ITS
V�rification of Eli ibilit
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C�il Sp0-455-4236 crr?7'S-352-6939
� To verify eligibility fe�r Plan benefit� befor� the charg� i� incurred.
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` Allowable C4vered Exp��nses
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�. All dental benefits ar� �ubject tc� allowable cov�ered ����ns� guid�lines. M�mb�rs are �
� responsible fcrr any applicabl� co-pays, deductibles, and cc►insur�►nce. Th� allvwable
��� cov�r�d exp��nse is d�t�rr»iroed by usual and cu��crmary charge guidelines. Th� usual �
��, �nd c��t�r��ry �t��rge f�r��ch s�rvr��: c�r s�apply r�:c�i��d will b�e th� I����r af the fe� �
�� usually ch�rr�ed by a prc►vider and fihe fe� us�ally eh�rg�d by c�th�r praviders in th� �
�� sam� g�c�graphical ar�a (Taha�e�, ��rr�, and/�r S�cr�merrto) for th�se ��rvices and
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� �uppli�s. �
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' �E�dTAI. S1�HEt�UL.E OF �EN��IT�
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�i Calendar Year Deductibl� far Cla� � �a��c �nd Cla�;� C M�"or Services�� �
,�
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�l Per Person $ 50,00
; P�r Family Unit $100000
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� D►ental P'ercentag� Pavabl� ��
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; Class A Services — F'r�v�r�t��oe 100% (IV� D�ductibl�)'
; Class B S�rvices — Basic 80% aft�r deductible
�� Class C �ervices — Majc►r 70% �ft�r deductible �
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� 1. F�reventive 5�rvic�s are ncrt subj�c� tc� th� Annual C�I�ndar Year Maximum.
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; 2. Se� Prev�ntive Dental F'rogram below.
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; Participants and their families are encauraged tcr obtain their rautine dental exams and
� clea�nirrgs twice p�r y��r, with the g�al erf reducing th� number�f Basic and Major
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; dental services ne�d�d �nd utilizing the Plan in a cost eff�ctiv� manrrer. The District's
� s�lf-ir�sur�d plan therefore irr�plerrti�n�s thi� Prev�retim� C��nt�l F'rogranre to praerid�
� inc�ntives tc► �mplc�yees tcr obtain preventive dental care.
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Preventive D�ntal Pro ra�n ��
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Dental Benefits �'ayable Preventive Dental Pragrarr� Preventive [7ental Program
Guidelines Fallowed Guidelines
Not Foliowed
Preventative (Exam 8� Preventive — 3 or 4 Oral Minimum of 3 oral exams �
Cleaning) Exa�ms and Cl�anirrgs � and cleanings nat rec.eived ��
F"aid at 1p0% with rrcr ev�ry 6-8 months during during th�e previous two �
deductibl� the previous two-year year per�od. Each �
period. exam/cl�aning paid at n
100°/a with no deductible 100% with ncr deductible
Basic Dental Services (�s Basic Dental Services as Basic Dental Services as
defined below) defined below defined belc,w continued ta
Paid at 80% Continued tc► be paid at be paid at 80%
$0%
Major Dental Service as If follow abave preventive, If preventive not fallawed,
defined below— paid at Major dent�l services will Major services will be p�id
�04�4 ��' �c��� c�� 7�Q�0, r�t ��p�0
Participants with full
dentures need only obtain
c�ne oral exam per year to
qualify for the ?0% benefit
for Ma'or Services
Exam� and cleanings will be an on-gc�ing requirement in c�rder to maintain the TO°/4 rate
for Major dental wc�rk,
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N�v�r Hires c�nly: PJa b�ne�ts are p�yable for Class C (Majcrr) Services in the first 12 �
manths af the Covered Person's coverage under the Plar�.
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Maximum Benef�t Amount �
Per Person Per Calendar Year $2,000 �
This benefit applies when covered dental charges are incurred by a p�rsan while
covered under this Plan. Preventive Services (Class A) are not subject to this Maximum
Benefit Amaunt.
Deduc#ible
s
This is an amaunt af dental charges for which na benefits will be paid. Before benefits
can be paid in a Calendar Year, a Covered Persc�n must meet the deductible shown in li
th� Sch�dule ofi �en�fits. �
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a A deductible is� an am�un� c�f man�y that is paid c+rrc� a Calendar Y�ar p�r Cc►v�red
� P�rsan. Typic�lly, ther� is c�r�e deductible am�ur�t per Plan and it must be paid b�fare
; any rinaney is paid �y�h� Plan fi�r any c�ver�d �ervic�. This is an am�unt of cov�r�d
; charges f�r which no b�n�fits rnrill be p�id. Before b�nefits can be paid in a Calendar
� Y�ar, a C�v�red Perse�n must m�et the deductible showrr k��low. �ach Janu�ry 1�ti, a
new deductible amc�unt is required.
� Famil Unit �imit
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; Wher► fihe dc�llar amount �hown in th� Schedul�e crf �enefits h�s been incurred by
� members of a Family Unit tc�ward their Cal�rrdar Ye�r d�ducfiibl�s, the dedu�tibl�s c�f all
� members of that �amily ll�it will be cansider�d satisfi�d for that y�ar. �
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; Benefit Pavment
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� Each �alend�r`�ear b�n��fits will b� paid �cr � Cc►v�r�;d Persc�n for�I�� den�al charg�s in
' exc�ss of the deductible, P"aym�nt will be mad� at th� rat� shc�wn under D�ntal
� F'�rcerrtag� P'�yabl� 6r� th� S�hed�al� c��F B�ne�it�. �Jca kaer�efits wi�l be p�id in ��sc�s� �f
� the Maximum �enefit Amc►unt.
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� Dental Charqe�
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� D�ntal charge��are the U�ual, Customary and I��eas�rrabl� �h�►rg�s made by a Derrtist
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� or athrer Ph�ys�lciarr f�r n��e�sary care, appli�nc�s ar c��h�r d�rrtal r�nafi�rial lis��d as a
� covered dental service.
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; A dental charg� is incurr�d e�n the date th� servic� c�r s�apply f�r w��ich it is made is
� performed crr furnished, Hc�w�ver, t�r�re are tim�s wh�rr one aver�ll charge is mad� far
� all or par� �f a c�urse afi tr�atmenfi. In fihis c�se, the Claims Admir�istrator will apporkic�n
� that ov�r�ll ch�rge tc� ea�ch c�f th�; separate visits c�r tre�tment�, The prc► rata charge will
� be cansid�:red �� b� incurr�d as each visit crr treatm�nt is ccrmpleted.
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Covered Dent�l Service�
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� �lass A ;��rvice� P"revent�ve and Diagnostic Ct��tal F�rocedures
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' The limits orr Class A Services are for routine s�rvices. If d�ntal n�ed is preserrt, this
� Plar� will corrsider for reimk�urs�ment servic�s perfcrrmed more fr�qu�ntly than the limits
shown.
1. Routine �r�l exam�. This includes the cleaning and scaling c�f teeth. Limit of two
� �x�rn� per ��ver�d P�r�c�n e�ch ��l�:nd�r�(ear.
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2. On� bitewing �-ray series every Cal�ndar Year,
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3. One full mc�uth x-ray every five Caler�dar Years.
4. One fluoride treatment for cc�ver�d Dependent children under age 19 each
Calendar 1(ear.
5. Dental s�alants for covered Depend�nt children �ander age 19.
6. 5pace maintainers for cavered Dependent children under age 19 ta replace
primary teeth.
7. Emergency palliative treatment fc�r pain.
Cla�s B 5ervices Basic Der�tal Procedures
1. �Dental x-rays nat includ�d in Class A. �
2. CJral surgery. Oral surgery is limited to removal of teeth, preparation of the j
moufih for derrtures and rema�val af taoth-ger��rat�d cysts crf less than '/ inch. �
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3. Periadcrn�ics (gum treatments) � �
4. Endoda�ntics (roat canals).
5. Extractions. This service includes lo�al anesthes�a and r�utine past-aperative
care.
6. Ftecementing bridges, crawns, �r inl�ys.
7. Fillings, other than gold.
�, GeneraC an�sthetics, upon demonstr�tian of Medical I�ecessity.
9, Antibiotic drugs.
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Class C S�rvices Majar Den#al Pracedures
1. Gald restoratians, including inlays, crn-lays, and fail fillings. The cost of gold
restorations in excess of the cost far amalgam, synthetic porcelain ar plastic �
materials will be included only when the teeth must be restored with gold. �
2. Inst�llaticrn of crc►wns. �
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3. Installing precision attachments far remavable dentures. '
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4. Installing parkial, full or removabl� dentures tc� replace or�e c�r mc�re natural teeth
� that w�r� �xtract�d whil� tt�� persc�n was cav�red for this� b�nefit. This s�rvic�
also includ�s all adjustments m�de during a six-mc�nth p�riod fc�llawing the
; inst�llat�c�n.
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� �. �������������u� ����������� ������������,�
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% 6. Addition of clasp or r�st tcr existing �rartial remervable dentur�s,
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� � 7. Irritia! installati�n r�f fixed bridgewcrrk t� replac� c►ne ar m�r� natural teeth which
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� � were �xtr�ic��d while th� per�o�n w�� cover�d f�r th�se b�nefits. Initial
� � installatic�n �f fixed bridgew�rk will b� cov�r�d�� fc�r�r�� �r more r�afiural teefih if the
� adult perm�rr�nt t��th ar� missing due fi� cong�nital birth d�f�ct.
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� � �. F��p�ir o��reawr��, bridgew�rk, �r�d r�r�r�c��r��l�;���d�r�tur�s.
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9. Rebasirrg or r�lining c�f remc�vable d�ntur�s.
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f1 a.Replacing an �xisting remc►vabl� partial c►r full denture or fixed bridgework;
� addirrg teeth t� an �xisting remc�vable partial d�r�ture; or addirrg teeth to �xisting
�
� k�ridg�work t� r�place newly extra�ctec� na�ural t�ett�. �icrv�r�ver, tY�is it�nr� will
� apply orrly if on� r�f th�s� t�sts is m�t:
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� a. The r�placem�nt c�r additic�n of teeth is��required b�caus� crf on� ar more
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� natural t�eth being exfira�ted after the persarr is c�v�;r�d und�r these
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� benefits.
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� � b. Th� existing denture r�r bridgewcrrk wa� installed af least fiv� y�ars prir�r tcr
� its replacemer�t ar�d c�nnot curr�ntly b� mad� servi�eabl�:. Replac�m�nt
� d�rrtures wil� b� allc�wed �arli�r th�r� 5 ye�rs if d�em�d medically
� necessary due tr� dental c►ral health b�ing cc►mprr�mised and the �xisting
% d�nt�res car�nat be made �ervic�able.
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� c. The existing denture is of arr immediat� t�mp�c�rary rrature. Further,
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� r�placem�n� by permar�enfi derrtures is requir�d and must tak� plac�
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within 12 mc�nths frcrm the date the terr�porary der�ture was ir�stalled.
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� 91.Night guards are c�►v�red for night grinding anly. Th�y ar� nat cavered fcrr
; arthc►dc�nticse
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; ���m�������.��I�I�����°:..I�������wq����w���;�����r�����w�� ��.;��.���;�.��
, , .�
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; � �a������� ������c��u ���� �r���� �µ����u����: ��a�° �� ��Il����r��m s��`� ��.��u���:o���� c��' I��� �u�° ��� �.,��°����� ��������iil�.��
% ����� q,����u���u�� �pir��'���"��� �'��������,���� ������d& ���� 9'�����° ��i�°������. '��`�� 6������,��rc��M a,�� �������
; "���� I�wa������� �� �����c� �:�� ������b �����y�������� ��� c���ir��b ����� �� ��%��� ���'� ������,�u�u„
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�°'� � ��� ���� �a��°���� �6����a�� ��a� ��r��� ��� ���� ������a�r� t�� �����1 �����
������� � ����������� � ����� �� � ��"� ������� ����� �� �� ����
��������� ��� �������, ��� ���� ��������� �u� ���w� r����r������ ������"� ����,, ��'� �������r� ��r���� �
���������� ��� ��� 6���° ��w���"u�� ����� ���i����� �A��m�u�� ��� ���� ����� ������������ ¢d�� �� �.��� �������:
����°�� u� tN�� �a������ ���r����M�� ���k. ��� ������� �� ��v������ ��a��°�� a� ��� ���� u�a�� i'�
����� �� ������������� ����� ������ �����u����o��� ����C���"��a �,
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� r�;������w�� ��u°��i��°��� ���I� ��°��� ��� �m���r���������� ��� ��� �����.��� F'������� 8���:e q� tl��� ��� ���
��� � ����� �� �������°����� c���� ���� ������°� �������� ��� ��� �������w
�"��� �u���ua����� a�������� �d��"�� ���u��;a����""����^������ ���������, �u�c� ��;��� ���ir����� ���a 1
������� �`������ ��� � ��� � w� 1i
� �w°� ���°��a������ ��°��� 1��� a������� ���p����� �� �I
��������u����� � 7� n� �
���� ������ ��� �a��
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������r���'�u��� '���������� ��� ��� �t"������u�a���� �� ���� ���� �����i�� ������re�d ��� �������� �� �
�`�u�������. �em���r�� ��� c��� �� ����h��� �� � cw������� �,���°����"'� V����� a�i����� ���a� �..����� �'����
������� �������°�� �un� ��«��°������ ��� ���� ���� r������a��� ��r�������r� �`����� �m��V��� ����� y������� ���
�����ni��� ��a������� ����u�����r���b ��� ��� ����°������r��� ���uw� ��� ���w ����������� ���°'���°��
�������� A�°� �����d ������t�e
�� ��a�����° ������������ ��� �� ����� �� �������� ��������� ��� ������i���� �����r�:�„ �����t.k��
�u���'���� ��°� ��� ���� ��������,�� ��������:>���� ��°���.������:���° ����� ����, ����m��� t�� �h����
������w������ m������ ��a�� ��tm�����°� ���� � � ������� ��������°������ �o��� ���� �������i����� ����k���
�����6�� �� ���� ������ ��C��� ���� ��������°����� �������°���� ����� (������ ������ ����� ���� �
�� �&����a�� �����h����� ���� ������ ���� �������� ���� ������ ¢�� al� ��� �������� �,���°�� ����� ��� `
��� ���� �a��� ������ �a�o���'n� �� ����� �������G��� �a��� y��� ��������� �����,
,���"��u��ma�m� r��'�"�����w����������m��.�������M��no��
��m��� - ����� ���� ������u�� ��� ����ii�..�a� �����ao-�'� ����°���� ��r����;�. �
���� �������ui�� �,... ���� �V�� u�������.�w��� �����iE��fi �� ��������� ���t � �������� ������ir� ��c� �
� �,,,� ,�. �
�����,,,n�u�� M��� ���° IU���� ��u�G�w
�� ��°� - Vl����er�� �,��^ ������ ���r�a���� ������ ���� �� ����� t� �� ������� ����°����a� I����� �
����iu�a ��� ���° �V�� ��������� ��������� 'u�� �� ��m�m��u� ������;������ �� ��� ����� ��� �������r���,� �
�����������. `
�
��������r�°o����������,.,�,. ����� ���� ������u��¢ �����u�i��� �� ����������� �:q���� � �����,r��� �������a ;
���u� �°�a����� ���fu�� �� ������u� ��������� �t��� �� �������� �� ������� � �����m�� ������7�� �
;
Voluntarv Pre�det�rrrrinatian of Benefits I
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�efore starking a dental treatment for which the charge is expeeted ta be $300 ar more, �
a predetermirration of benefits form should be submitted.
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� A regular dent�l claim fic�rm is us�d for the pred�terminati�n of benefits. The ca�vered
� Employee fills �ut th� Empl�ye� sectian of the form and then gives the form ta th�
;
Dentist. The Der�tist rr�ust itemize all r�corr�m�r�ded services and casts and attach all
; suppc,rtirrg x-rays tc� the fc�rm.
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The Dentist should s�nd th� fc�rm tr� th� Claims Ad��rrinistr�tc�r at this �rddr�ss:
�
<,
; CD� Group He�lth
;
P.CI. Bc�x 501�0
; Spark�, NV 89435�p190
;
� (8p0) 455-4236 �
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� �The Claims Admirristra�c�r will nc►tiiwy th� Dentist c►f the b�nefits payable under the Plan, �
� The ���r�r�d Per��r� �rrd �h� Ci�ntist ��r� fih�r� d��i��: rar� th� �c�ur�� �f tr���ment, �
� knowing in advanc� an ��tima�� af how much the Plan will p�y,
;
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� Alternat Trea�tment �
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�
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Many derrtal cc�nditir�ns c�n b� treafied in mar� tharr or��e vrr�y. This Plan has arr
cc
� °`�It�rna�e treatm�rrt°' claus� wh�ich g�v�rns tt�� am�►unfi of b�n�fits th� Pl�n will pay far
; tr�atm�r�ts covered urrder the Plan. If� pati�nt ch�a�s�s a more expen�iv�; tr�atm�nt �
;
� � than is n��d�d t� ccrrrect � d�ntal prc,bl�:m accc�rding tcr acc�pted starrdards of dental �
� � practi��, the benefit paymerrt will be b�sed r�n th�; �os� c�f the treatment which prr�vides
� �professiorrally sati�fact�r�r results a�t th� mc�st c�st-�ff�ctiv� lev�l.
;
' Far example, if a regular�malgam filling is suffici�nt ta restore a tooth ta health,
� and the patient and th�e Denti�t decide ta use a gr�ld fill�ng ar� any tcroth, or a
� �ompa�ite �illing an posterior�eetl�, the� Pl�n will k�as� �t� reirm�Wrsemen� on tli�
�
� Usual, Cu�tomary and F2easonable �harge for �n ama�lgam filling. Th� pati�nt will �
;
� pay the difference in co�t. �
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; Exclusians
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� � charge fc�r the fc�llowing is nat cov�red:
;
; 1. 5ervices thafi ar� �xcluded under M�dical F'larr Exclusians.
;
� 2, Ser�rices that, t� any �xtent, are payable under ar�y medical exp�nse benefits of
; �
% the Plan.
;
,
� 3. Servic�s which a�re n�fi includ�d in the list crf cr�v�red dental s�rvices.
,
;
;
�
��
� �
4. Crawns �or teeth that �re restorable by other means ar for the purpc�se of i
F��ric�dontal Splir�ting. �
1
�
5. Crowns, fillings, c�r appliances that are used to cannect (splint) teeth, ar change �
or alter the way the teeth meet, including altering the verkical dimension, r�staring �
the bite (c�cclusicrn) c►r are Cosmetic. �� �
;
i
�.. ...��� ��.�-������� .�� ��,� ��w���-���°���������°����� �-�� �����"�� _.������- �.
� � �a_. �° .�- � �
-�, ��������-������....,� � � � � �
������������ � ���-����--����°���-��������;���m
��
� � r
1
7. Replac�ment of lost or stolen appli�nc�s. �
8. C7rthc�dorttic treatmer�t and orthognatic surgery. �
�
�
9. Persanal�zatian c�f dentures.
�
10.t7ral hygien�, plaqu� contral programs �r dietary instructi�ns. �
�
C�AIM$ PRtJCEDURE$
(How to 5ubmit a Cl�im) �
�
It is the intent c�f the Plan Adrrainistrator that the following claims prr�cedures comply with '
c� �
th� lJnit�d Stat�s D�partment af Labar("Clt��") regula�ion �9 �Fa � 2560.5p3-1. �
Where any provision �s in conflict with the DO�'s claims procedure ��gulations, or any �
other applicable law, such law shall contraL
Administrative Processes and Saf��uards
The Plan requires that claims determinations be made in accordance with governing
docum�nts af the Plan and that they be applied consist�ntly with respect to similarly �
situated Claimants. The claims procedures will nc►t be adminis#ered in a way that ��
unduly inhibits c�r hampers th� irritiation ar processing of claims or claims appe�ls. �;
I
�
Authariaed Reqresenta�tive Mav Act far Claimant �
1
;
Any af the fallowing actipns which can be done by the Claimant can also be dane by an ;'
autharized representative acting on the Claimant's behalf. The Claimant may be
required ta provide reascrnable proof af such authorizatian. Far an urgent claim, a �
health care professianal, with knowledge ofi a Claimant's medical condition, will be �
permitted ta act as the authorized representative af the Claimant. "Health care �
f,
za
;
i
�
y rv
ri
� � professia�nal" m�ans a physician c,r�crther health care prc►f�s�i�nal lic�ns�d, accredited,
or cerkified t� perForm sp�cific health services consisterrt with state law.
�
,
,
� B�nefit De+��rmina�icrn�
;
;
,
;
� Upern t�r� �laim� Admirristrator's receipt c►f a writt�n claim f�r ben�fit� and p�r�uant t� �
� th� prac�dur�s describ�d h�r�in, the Claim�Admini�traficrr will r�view�h� �laim
�� submissior�, prc►pf ofi claim, and all as�csciat�d �nd/crr applicable infcrrrnation �prcrvid�d by
; th� Claimant and gafihered ind�pendently by the Claims Administratcrr in light of the
fi Plan D�cument thrc�ugh which benefit� af th� Plan are� paid. Further, the Cl�ims �
� �� Admir�istrator will assur� t�at all ben�:fit d�t�rminatians are �pplied ccrnsistently to �
�
�
similarly-situat�d Plan participants by maintaining apprc�priate cl�im and ben�;fit recc�rds
; which shall b� review�d p�riodically and on a c�s�-by-ca�� basis�a� det�rmine past
� pracfic�s i�r simila�r�i�im �ituaticrr�s. Shr�uld �h�: Claim� Admini�tr�tc�r at �ny�itime d�r6r�g
� its r�view p�ricrd d�t�rmin� th�t �dditi�nal informa�i�n i� r�quired frc�m th� Ernplc►y�e crr
� Claimant, the Claims Adrr�inistrator will request such n�c�ssary informatiorr from th�:
;
� Eo�pl�y��. 1"h� Cl�im� �dministratc�r enril! m�ke �v�ry ��Fcrrt tc� m�k� its b�r��fit
;
� d�terminatic�n in �s r�asc�rrabl� a tim� fram�; a� pc�ssible.
;
;
,,
,
,
; �uk�mittin� a Claim
�
;
;
� p claim is � requ�st fc�r a b�n�fit d�t�rmin�ti�n which is m�de, in acc�ordanc� with th�
;
Plan's pracedures, by a C:laimant or has authoriz�;d repre�entative. A claim must be
± � received by the pers�n o�°organizatior�al unit cust�rmarily respons�ibl� fc�r handling
;
� ben�fit m�tt�rs an behalf of th�� Plan so th�t th� clainn r�view arrd benefit de�ermination
�
� �� proc�ss can begin. A �I�im mus� narr�e the Plan, � specific �laimant, a sp��ific I��al�h
� c�nditian or symptorrr c�r diagnostic cad�, and a specific tr�atm�:r�fi, service or s�pp�Y (or
� procedure/rever�u� cc�de��)fo�r which a benefit �r b�nefit determination is req�ested, the
' date c�f service, the amc►�ar�t of charges, th� addr�ss (locatian) where s�rvic�s are
�
� r�ceived, and prc�vider n�rn�, address, pt�c�ne r�umk��r ar�d �ax ���ntifica�ion number.
� For purpo��s c�f fhe Pla�rr; the P'lar� Adrr�inistratc�r, at its discr�tic�n, may corrtr�ct with
' �ther entiti�s to handle cl�ims communicatiorrs and ben�Fit d�;terminatic�ns for the Plan.
�
�uch c�ther entities may i�clude a third p�►rky claims administrator. C�rrtact irrfcrrmaticrn
� far such entiti�s is pravided bel�w.
;
,
;
;
� Ther� are twc� types of claims: (1) Pre-��rvice Claims, and (2) Post-Service Claims:
<
�
' 1. A P'r�-5ervice Claim i� a wri�t�rr ar crral requ��t fc►r berr�fits wh�;r� th� �erms of
�
� the Plan condition ben�fits, in whole or in park, r�n prior�pproval �f th� �rc�pos�:d
; car�.
;
;
; A P're-Service �laim should be swbmitted tcr:
�
�
�
;
21
jli
� �
� CDS Group H�alth �
P'.O. Bax 501�9p �
5parks, NV 89435-019p �
IJ,
Impartant: A Pre-�ervice Claim is anly far the purposes� of assessing the ��
Medic�l Nece�sity and apprrop�riaten�ss of�are and d�livery setting. A �
� determina�tion crn a Pre-Service Claim is not a guara�nte� of beng�ts from �
the Plan. Plan benefit payments are subject to review upan submissio� of J
a claim to the Plan after medical services h�ve been received, and are �
subject�a ali related Plan provisions, includirrg exclusians and limita�#ions. �
�
PJc►te: Requests far benefit determinatian and reque�ts fcrr Plan approvai where prior �
approval is desired but ncrt required, should b� directed tc► CDS Graup Health, the �
Cl�ims Administratcrr as identified in the '°Post-Service �laim" information below, or call �I
(800) 455-42360
, . . . 1
2. A Post-5ervice Claim is a written request far �en�f�t determinati�n after a �
service has be�n r�rrdered �nd expense has b+�en in�urr�d. Praaf r�f loss f�r a �
�� Post S�rvic� Claim must be submitted ta the c�aims �ffice within twelv� (12) �
months after the date a service is rend�red. F�ilure to furnish such proof within �
the tim� r�quir�d will not invalidat� nor reduc� any claim if it can b� shovvn that it �
was not reasanably possible tc� give prc�4f within such time, provided such proof f
is furnished as so�n as reasanably possible. I� is the Claimant's responsibility f�r ��
timely submissic�rr af all claims. ;
A Post Servic� Claim should be submitted ta: �
�
� CaS Graup Heal#h �
P.t�. Box 50190
�.
Sparks, NV 8�4�5-q'190 �
�
IVc�te: Proaf af lass for a claim has nc�t beerr "furnished" unless and until the Claims f
Administratc�r h�s receiv�ed all information they reasonably deem necessary ta allow
processing af the claim. This includ�s responding tcr reasanable requests fqr �
c+�mpletian c�f forms, providing additional infarmation about the claim, ar providing of �
documents in suppart af the claim. If satisfactory proc►f of loss is nc,t furnished within the '
12-month periad after charges are incurred, benefits will not be available.
Nat�: In accordance with federal law, the C�nters for Medicare and Medicaid Services
(CMS) have three (3) years tc� submit claims when CMS ha�s paid as the primary plan
and the Plan shauld have been primary.
Assi�nmen#s to Praviders
��
22 �
I
1
;
J
J
�
All Eligible��xpenses r�irr�bursable under th� Plan will be parc� tc� the cavered Empiayee
� except that.
;
;
; 1. Assignments �f ben�fits t� Der�tists c�r�th�r pr�viders of s�rvice will be hc�nc�r�d,
;
;
� �. Th� Plarr may pay �enefi�s dir�ctly to praviders c�f servi�e urrless the Cover�d
;
, F'�r�c►rr r�quests a�therwis�, irr writinc�, withir� th�: tim� limits fc�r filing proof c�f Irass,
;
and
�
;
� �. T'he P'lan may mak� benefit paym�rrts f�r a chiPd cov�r�d by a G2u�li�'i�d ��di��i
� Chil� Support Ord�r(a QM�SCJ) dir�ctly to th� custadi�l parer�t c,r leg�l guardian
� of such child,
<
� �Iate: Bert�efit p�ym�nts �n behalf�f a C�v�r�d P�rsc�n wh� i� also c�vered by a
;
� st�t�'s Mer�ocapd prr�gr�r� �nrill b� sa�bject ta th� state'� right tr� r�imb�rs�ment f�r
;
� berr�fiitis it �as paid �rr k��half�f�f�e ��vered P�rs�n, as cr�ated by an assigrrm�r�t �f
<
� rights made by the Cover�ed Person crr his b�neficiary as may be required by fihe stat�
' M�di��id �rAan, Fur�h�rmerr�, th�: Plan will honc�r any subrcrgat�c�n rights that � state may
y
;
; have gain�d frcrm a Medicaid-�ligible ben�fici�ry du�t� th� st�te°s havirrg paid Medicaid
° benefits th�t were p�yabl� under the Plan.
�
;
;
�
;
` Claim� C1�r�ials
;
,
� �
� Th� �laim� Adrin�ni�firatc►r s�rall pravid�; ad�:qua►�e ncrtic� ir� writ�ng �c� any Claimarrt
;
wt�crse cl�irns fc�r benefits under thris Plan hav�: b�en d�ni�d, v�ritt�en in a rnann�r
�
� intended tc� be understood by th� Cl�imant, including:
;
;
; 1. The specific r�as�r�(s) fc,r th� d�nial;
;
�
;
� 2. Sp��ific refer�nce �o th� Plarr prc�vi�icrn(s) ar� which th� denial is based;
f
;
� 3. A d�scription �f any additional infr�rrinati�n n��ded far furkher review of th� claim;
; and;
;
�
fi 4. An ��planatiarr of�h� Plan's revi�w pr�cedure.
,
;
;
,
� Furth�r, �he �laims Adr�ninistra��r shall affc►rd a r�a�r�nable oppr�rkunity tcr any Claimar�t
� whase claim for benefits has b��n deni�d for a full and fair revi�w �f the decisian
� der�ying the claim by the person designated by th� Plan Administratar for that purpc�s�.
;
�
;
' A,pp�a�l P'r�c��d�r��
,
;
;
;
� If a claim h�s beerr d�ni�d in whr�le c�r in part �y�f�� �lairn� Admir�istratcrr, th� Claimarrt
may appeal the determinatian of that claim under the lowest review level indicated
;
,
23
� �����������,
i
e �,
�
I
be{c�w. If the denial is upheld, Glaimant may appeal ta the ne� highest level of review, �
unt�l the entire appeals pracess has be�n exhausted. +I
�
�Level I: Fteview af the Claim by the Claims Ad�inis#rator �
1
The Claimant may submit an appeal letter referencing the claim to the Claims �
Administratar. The Claimant shall have this oppartunity ta present additianal �
information and/or d�cum�ntati4r� supp�rting this appeal. The Claims Administrator will �
r�v6�w th� claim far apprapriateness ba��d on the F'la�rr Dacument, and if rre�d�d far �
me�ical interpretatir�n ar clarificaticrn, request a Physician (dentist) review. Appeal letter �
and additianal informatic,n and/c�r dacumentaticrn must be submitted within si�rty (60)
days of the claim denial tc�:
CDS Mec�ical Managemen#
P.C�. Box 50190
Sparks, NV 89435-0190
Th� �laims Administratc�r will render a c�ecision within sixty (6p) days of receipt of the
appeal letter and will notify the Claiman� in writing of the findings.
Level II. Plan Administra#or Revi�w
If, after completing Level I, the Claimant is dis�atisfied with the Claim Administratc�r
decisic�n, the Claimant may submit a written appeal ta the Plan Administrator for review
and/or Reques#far Plan E�ceptic�n. Th� appeal shall contain all infarmaticrn and/or
dc�cumentatian the Claimant wauld like �eviewed by the Plan Administrator and shall
inc�ude a signed Authori�ation far F�eleas� c�f Medical Informafiian for Claim � �
App�al/Request for Plan E�cceptian farm. The written appeal must be submitted within l
si�cty(60) days of the Level I decision to: �
5auth Tat�o�� Public U#ility District � �
General Mana�er/Plan Administratar
Attn. Fluman Resour�ces Directar/Plan Caardinator
The Claimant will be notified in writing af the Plan Administratar's decision within sixty
(60) days of the date the decisian was made.
GOOFtDINATIOW t3F BENEFIT$ �'I
1
Coordirration crf the Benefit Pl�ns ��
Coordinatian of benefits sets out rules for the order af payment of covered Charges
when two or more plans — including Medicare — are paying. When a Cc�vered Person is �
I
�
z4 �
,
�
t
� , n
;
� covered by this P"lan ar�d �nath�r plan, or the Cav�red Pers�n'� �paus� is cov�red by
� this F'lan ar�d by another pian, or the cc�uple'� C�v�red childr�r� are covered under two �
;
or mare plans, the plans will coc�rdinate benefits when a claim is received.
;
,
� The plarr th�t pays first acca�rdirrg t� the rules will pay as if th�r� w�re no �th�r plan
;
� invalv�d. The secandary�nd s�bsequ�rrt plans will �ay the balanc�e �f th� claim after
;
� th� primary plan has paid. Deducfiibl�(s) and c�-paY(s�) �hall nat be taken when this
� plan is the secandary pl�n.
;
;
�
`'' ���t��� F�I�r�
;
;
�
;
� This pravisic�n will c��rdir►�te th� medic�l �nd d�ntal ben�fits of a b�nefit plan. Th�
� � term benefit plan means this Plarr c�r any one �f��e f�llowing plan�:
;
,
;
;
� � 1. t�r��p s�r grc�up-tYp� pl�r��, includin� fran�his� ar blar�k�� b�n�fdt plar��. �
�
� 2. Blue Cross ar�d �lue �hield grr,u�p pl�r�s.
� �. Group practice and �th�r group prepaym�nt plans.
;
%
%
;
� 4, �'�d�ral governmen� plans crr program�, �his incl�des Medicare.
%
,
�
� 5. Oth�r plar�s r�quir�d or provided by law. This dc�es ncrt include M�dicaid c�r arry
ben�fit plan lik� it that, by its terms, dr��s �ot allaw cc�ordinatic�n.
;
; � 6. I�Ic, Fault Au�� Insurance, by whatev�r n�rrr� it is c�lled, wi�en nr�t prahibited k�y �
; � law.
;
�
;
;
; Allowable �hars�e
;
;
;
Far a charge to be allc�wable it must b�; a lJsual, Custcrma�ry, and Reasonabl�; �harge
� and at least p�rt of it must be cavered under this Pl�r�. �
;
� In fihe case of servic� type plans wher� services are prvvided �rs benefits, the
� re��anabl�e cash valu� �f�ach �ervic� �ill b� th� �Ilc�wable charg�. �
,
,
;
;
,
;
� Bene�t Plan Pavment Order
,
;
,
,
` Wh�n two or mor� plans prr�vide ben�fits for th�; same allc►wabl� charge, benefit
' �aym�;nt will follr�w these rules.
,
�
,
� 1 e Plan� tf�a��t�o ncrt f�ave � ccrc�rdinaticrr� prov���on, or on�: like it, will pay fir�t. P'lans
�
with such a pr�vision will be ccrnsidered aft�r those without one.
;
25
�
�
" ° 1
�
� 2. Plans with a cocrrdirratic►n provisior� will p�y�heir benefiits by these rules up ta the � �
allowable charg�. � `
�
a. The benefits af the plan which covers the person as an employee, member,
c,r subscriber(that is, other than as a depend�nt) are determined befc►re those
c�f the plan which covers the persan as a dependent; except that: if the
persan is alsc� a Medicare beneficiary, and as a result af the rule estab{ished
by Titl� �VII I of#he Social Security act and implementing regulations,
Medicare is:
a. Secondary ta the plan cc�vering the persc�n as a dependent, and � l
b. Primary to the plan cover7ng the person as c�ther than a dependent �
(e.g., a retired employee�,
�'�
Th�n the bene�t� of the plan c�vering the persc,n as a dependent are
� d�termined befc�re thase 4f the plan ccrvering that p�rson as other th�n a �
dependent.
b. If both husband and wife are Employees, benefits cavering the person as an
Emplayee are determined befar� benefits cavering the person as a
Dependent. After determining �►enefits fc�r the persc�n as an Emplc�yee,
, Interrtial Coardinatic►n ofi Benefit:� will apply, and benefits will be determined far
the persan as a Dependenfi.
Benefits fc�r children cavered a� Dependents af bc�th Emplc�yee Spauses will
be determined in accordance with the Dependent rules below and �
coc�rdinated internally.
t
c. The benefits r�f a ber�efit plan vw�ich c�vers a person as an Emplayee who is .
�
neither laid off nor retired are determined before thc�se of a benefit plan which i
cavers that persan as a laid-off or R,etired Emp{c,yee. ?he benefits of a I
benefit plan which covers a per�an as a Dependent af an Employee who is
neither laid aff nor r�tired are determined befare those af a benefit plan which i
cavers a person as a D�pender�t af a laid-off or R�;tired Emplc�yee. If the
other benefit plarr daes nc�t hav� this rule, and if, as a result, the plans do not
agree on the crrder of benefits, this rule does nat apply. �
;
d. The benefits of a benefit plan which covers a person as an Employee whc� is
neither laid off nor retired c�r a Dependent crf an Employee who is neither laid
off nar retired are determined before those of a plan which cavers the persc�n
as a CO�RA beneficiary. �
�
e. When a child is covered �s Dependent and the parents a�re not sepa�rated ar �
divcrrced, fihes�: rules will apply. �
r
a. The benefits of the benefit plan of the parent whase birthd2�y falls �
earlier in a year are determined before thase af the benefit plan of the �
par�nt whose birthday falls lat�r in that y�ar. �
�
z6
�
f
�
� u �
r
;
;
; b. If bvth p�r�nts hav� th� s�me birthday, thr� benefits r�f th� b�nefit plarn
' which has c�v�red the patient fc�r the I�nger time are d�termined ���
;
� before thos� af th� b�nefit pla�n which cov�rs the other parent.
%
� f. Wt�err a child"s �arents �re �ivc�rc�d or I�gally separa�ed, t�tes� rul�s will
,
appiy.
,
;
<
;
a. This rule applies when th� par�r�t wifih custody of the child has nat
�
� remarried. �"h� b�n�fit plan a�f th� parent with cu�tody will be �
,
� cc�nsidered befor� th� b�n�fit plarr �f the parent witha�ut custady.
�
;
;
� b. This rule app�lies wh�n th� par�n�with custc►dy crf th� child has
� remarrier�. Th� ben�fit plan of th� p�ar�nt with custady will be �
;
� cc�r�sid�r�d first. �'h� b�n��it plan af th� �t�ppar��rt tha� coar�r� th�
;
� child as � C�eperrderrt will b� c�ns��idered next. Th� berrefit plan af th� �
,
;
parent without cu�tody will be cc�nsid�red last.
;
,
;
;
� c. This rule will b� ir� place o�f items (a) and (b) abe�ve when it appli��. A
;
; cr�urt d�cre� may sfiate which parent is financially resperrrsibl� for �
� derr�al �enefi�� of�h� ch�ld. Irr �his c�s�, �h� k�enefi� plan of t�at par�r7t
� will b� cc�r�sider�� befi�re �th�r plarr� thafi cav�r the child as a
;
� C►�p�ndent.
;
;
;
� � d. If the sp�cific terrr�s of the court �ecr�� stat� that fih� par�nts sha�ll
share jc�int custody, without statirrg that one crf the parents is
�
a �
� respc�n�ibl� fit�r�h� healfih car� e���ns�s af the cl�ild, th�: plans �
� � cc�vering the child�sh�ll fc►Ilcrw th� c�rd�r crf ben�i�ifi de�erminatic�n rule� �
;
� c►utlined �bove when a child is cavered as a Dependent and th� �
� par�nts �r� n�t separat�d ar divrarced.
;
;
� g. If th�re is still a cc�nflict aft�r th�s� rul�s have b��rr appli�d, the benefit plan
� which has cc�v�:red fihe p�fii�n�f�r the Ir�nger�ime will be cc�nsider�d firs�t. �
;
� 3, M�dicare will pay prlma�ry, secondary, or last, tcr �h� ext�rrt stated in federal law.
;
�
Wher� M�dicar� is� tcr be th� prim�ry payer, thi� Pla� will b�se its p�ym�;nt uporr
� benefiits that wc►uld have be�n paid by Medicare under Parts A and �, regardless
� of whether�r not the perse�n was enrc►Il�d under bafih of these parts.
;
;
% Claims Determination P�ric�d
�
;
;
�
� @�enef6t� e�ill b� c�acrrdin����! c�r� � G�I�r�d�r�'��r ba�i�. Thi� i� ��Il�d �h� �lairrr�
% determination periad.
,
;
;
;
;
;
�
' z�
�
;
,
;
;
�
;
�
,
1
�
�
Ri�ht ta R�ceive ar �elease Necessary Informa#ian ,
I
Ta make this prcrvisian�wark, this P'lan may giv� crr abtain n��ded information from �
an�th�r insurer or a�ny �ther organizatic�n or person. This infic�rmation may be�given or g��
abtained withaut fihe ccans�nt of or nbtic� to any other p�rson. A Covered P�r'scrn will t
give this Plan the information it asks for abaut other plans and their payment of ?�
,
allowable charges.
Facilitv af Pa�vment �� � �
�
This Plan may repay a�h�r plans for ber��fits paid that th� Plan Administrator � �
d�t�rmines it shauld have paid. That r�payment will caunt as a valid payment under �
this Plan. �
f
Ri�ht af Recoverv
This Plan may pay benefit� that should be paid by anather benefit plan. Ir� this case,
the Plan may recc�ver the amount paid from th� other benefit plan r�r the Covered �
P'erson. That repayment vvill count as a valid payment under the c�ther benefi� plan.
� � I
Further, this Plan may pay benefits that are later f�und to be greater than �he all�wable
charge. In this case, the P'lan may recover the amount c�f the c�verpayment frc�m the
sc�urce to which it was �aid. �
� �� f
� �
SUBF20GATION AND REIMBUFtSEMENT PROVISIONS
,
Right afi Subras�atian and I�efurrd �
9
When this P'rc►v"rsion ap�pii�s: �
The Cavered Persan may incur dental charges due tc► injuries, sickness, disease ar
�
disability which may b� ca�ased, in whole or in part, by ar resulting frc�m the acts ar
omissians of a third party, c�r from the acts or camissions af Plan Parkicipant where any
insurance coverage, nc�-fault, uninsured motorist, underinsured motorist, medical
payment provisiar� or ather insurance policies or funds ("Caverage") exist. In such
circumstances, the Cavered Persan may have a claim against that third party, or i
insurer, for paym�nt of the dental ch�rges and the Plan will conditionally adv�nce �
payment ar e�rtend credit of dental benefits as a courtesy in such situations. fl
�
28 �
�
�
�
;
,
Payment Condition�
;
1. Plan F�articiparrt, his ar h�r afitorney, and/c�r legal gu�rdi�an �f a minc�r c�r
' in�apacitated mndividual(s) agre�s, by ac�c�ptin� benefits under this I�lan fc�r thos�
�
� inc�rr�d den�al �x��rrs�s, to �aint�irr in trust arrd witk�c�ut d�ssipa�icrn �ne
;
hundred perc�nt (10p°'/o) of th�e a�mc�ur�t paid for benefits by the Plarr, ar the full
�
� exterrt af p�yment rec�iv�d, less re�►sc�nable attcrrney's fees, when recc�v�r�d
; from any one �r combirratian of firsfi and third p�rty sc�urces. �
,
;
;
' 2, �y acc�epting b�;ne�its under the P'lan, the �'lan F"articipant r�cr�gn�izes this
;
;
� pra�p�erty righ� �r equitabl� ir�t�r�st crfi th� Plan in �ny caus� r�f action th� Plan
% P�r�icipant m�y have a�r th� proc�eds th�r�c►f and allows th� Plan�tcr pursu� arry
�
� claim which the (�c�vered P�rson has against any third party, c�r in�urer, whether
� or n��the �ov�red F'�rsc�n cho�ses �� pursue that cl�im. ,
y
;
;
�
; 3. The Plar� may m�ke a claim directly against th� �hird par�y �r �ns�arer. Irr th�
� event a F'lan Parkicipan� settles, r�cr�vers, �r is reimbursed by any third party crr
� Cc�v�r�g�, th� Pl�r� h�� th�fir�t pri�arity rir�ht �►f r���v�ry �nd a first li�n orr �ny
�
� amaunt r��ov�r�d by the �c�v�red F'ers�n wheth�r c�r not design�ted as paym�r�t
;
� for dental �xp�rrses, and shall be paid b�f�r� any�ther claNms far th� Plan
� Participanfi as�h�e re�ult c�f the illnes� c�r injury. Thi� li�n �hall r�:nnain in �ff�:ct
;
; until th� Plan is repaid in full. S�id right and/c►r li�n may be fil�d witl� any p�rsorr
;
� or a�rgani�atian r�sperrrsible, ar p�terr�ially responsible, to the Pl�r� Parkici��nt for
<
� ind�mnification, th� P'lan Parkicipant's attc�rr►ey, c►r th� �c�urt.
� 4. If th� P"lan Participant fail� �o reimburse th� Plan for all benefifis p�id c�r to b�
� paid, I�ss rea�onable at�orney's fee�, as a result crf said irrjury crr�ondition, out caf
� rec�very crr re�mbursement r�c�ived, th� Plan Participant will be liabl� for any
; and all �xp�ns�s (vrrh�ther fees �r costs) as�sc�ciat�d with the P'lan's attempt to
;
� recov�r such mon�y from th� Pl�n P�rticipant. �
�
;
; 5. ?he Plarr r�quir�s �vrifi��rr c�nsen�fc�r any f�;es or costs ��scrciated with a Plan
� I�ar�icipan� �u�s�in� a claim �gains� any �overag�. T�r� P'lar� ParCicipan� �gre�s
�
� to hold the Pl�n harmle�s agairr�t any unr�asr�r�a�le claims mad� agair�st the
� Plan by th� at�orneys r�tair�ed by the Plan Participarrt, t�r�wev�r these rights of
;
� subr�g�tic�n �r�d r�imb�r��mer�t �hall apply withcrut r�:g�rd t� wh�th�r any
� separate writt�n acknc►wl�dgement crf thes� righfis is issued by the Plan and
;
signed by the Plan Participant.
;
;
;
h
6. This prcrvision sh�61 nc�t limit any e�ther r�medies c�f th�: Plar� prc�vided by I�w.
' Th�s� rights of subrogati�n and reimb�urs�ment s�hall apply withaut reg�rd fo thre
;
� locatic►n af the event that led �a or caus�d the applicable sickn�ss, injury,
% di�e��e, or di�a�bility.
;
,
;
,
,
;
;
;
,
;
29
;
;
,
;
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�
The Cov�red Person:
1. As a conditian ta p�rticipatirrg in and rec�iving benefit� und�r the Plan, �
automatically agrees ta assign to the Plan any and all claims, causes of action ar k
rights that they hav� or that may aris� against any p�rson, cor�oratian �nd/or ��
entity, third party c�r insurer when this prc�vision applie� arrd tc� any Coverage fr�r '
which the Covered Person claims an entitlement ta b�nefits under this Plan,
regardless of how classified ar characterized.
(
2. Tc� prc�mptly reimburse the Plan far any benefits paid r�n his or her behalf out of pi
th� rec;..c�very made frc�m the third party ar in�urer, wh�rr such recovery through il
se�tlement, judgment, award c�r c�th�r payment is received; 1i
3. Ta co�perate with the Plar� ar its ag�nt� in defining, verifying and protecting its �
ric�hts �f subragatian and reimbursement and tc� dc► ncathir�g ta prejudice the
Plan's rights of subrc�gatian and reimbursement. ,
�
4, Ta provide the Plar� with pertirrent informatic�n regarding th� injury c�r sickness, �
in�luding various f�rms c�f documenta�tion, accid�nt repc�rts, settlem�rrt reparks �
an� any other requested additional information; �
�
5. Ta tak� such actian, furnish such irrfiorrrration �nd ass�stance, and �x�cute such �
dacurr�ents as the Plan may r�quire to facilitate enfor�em�nt c�f its subragation �
an� reimbursement rights. . �
1
�
Amount '�ubiect ta 5ubro�ation or Refund �
�
1. The Covered Persc�n agrees tc► recc►gnize the Plan's r"sght tc► subragatian and �
reimbursement, These rights provide the Plan with a priority over any funds to �!
recover 10p% of the benefits paid by a third party to a Covered Person relative ta II
th� Injury ar Sickness, with reasonable deduction for nan-dental charges, (
attorney f�es, or other costs and expenses, withc,ut regard ta whether the Plan �
P'�rticipant is fully campensat�d by his/her net reccrvery from all scrurces. This �
obligatic�n exists whether or nert the judgment or settlement specifically Q,
designates the recovery ar a portion af it as including dental, disability, ar other Vj,
expenses, and exists regardless af haw classified or characterized. If the Plan �
P�rticipant's net recc�v�:ry is less than the benefits paid, then the Plan is entitled
tc� be paid all of the net recavery achieved, less reasonable a#tc�rney's fees.
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 candition, 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 dc�ing
whatever else is n�eded tc� secure the Plan's right af subrogation as � conditic�n �'
to having the Plan make payments. In addition, the Covered Persan will do 1
f
30 1
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� nothing to preju�ice th� right �f the F'lan t� subrogate. If the Caver�d Person
;
; fails to irrclude the Pl�n's subrogation claim ir� that action, the Plan vvill b� I�gally
� presumed t� b� pnclud�d in such action �r recover�r.
�
�
<
3. In th� �vent th� Plan P'articip�nt fails tc► make a cl�irr� �gainst crr pursu� damages
� against:
;
;
;
� a. The respr�nsible party, its insur�r, or any �th�r s�urce on b�half af tha►t
% party;
�
b. Any first part insurance thrc�ugh dental payment cover�ge or personal
,
;
; injury prcrt�cticrn;
� c. Th� P'I�n P�r�icipanfi's �r�in�ur�d or �and�rir�s�ur�d r�n�atari�t �crv�rag�;;
� d. prry policy or ccrntract of insurarrce fram any insurance cermpany crr
;
� guarantar�fi a third party;
� e. 1/Vark�r�' �c�rr�per��a�i�r� ar��h�r li�bil�ty in�c�r�r�ce c�mpan�r; or
� f. Any c�ther scrurce, includir�g but r�c�t limified tc�, crim� victim r�;�tituticrn
funds, any d�ntal, disability c�r�ther b�nefit p�yments, �nd ncr-fault ar
;
;
� �chocal ir��aar�r�c�; �cov�r�ag�:s,
;
� Then the Plan P��rticipanfi�uthori��s the Plan tcr pursue, sue, cc�mp�omis� or
� settl� �ny such cl�ims in tf�eir nam�, t� �x�cut� any ar�d all dacum�nts
,
� n�cessary tcr pur•su� said claims in th�ir name, and �gre�s tc► fully ccrr�perate with
;
; th� Plan in th� prcrsecuti�n c►f any such claims, and assigns all right� t� the P'lar�
� �r its assignee tc� pursu� a claim and the r�c�v�ry �f all e�penses frc�m any
<
� sources listed akacrve. �
,
;
;
� 4. If at�he tir7r�� �f i�j�ry, sickness, disea�e, or di�ability ther� is availa�le, or
; pa�tentially avail��bl� based on information known �r pra�vided to the�Plan �r to the
;
Plan Participant� any c,th�r Coverage, including but nat limified ta judgment at law
�
� c�r settler�n�nts, th� �en�fit� under thi� P'lan sf�all apply c�nly as �xcess ins�uranc�
� over such c�ther�crurc�:s of ind�mnificati�ans. Th� P"I�n's b�rr�fiits shall be excess
;
� t� fihe parti�s list�d abc►v�.
,
% 5. The Plarr may, ir� its �wr� rram�, ar in the n�m� of th� Plan Par�icipa�nt ar their
� personal r�pres�ntafiiv�, commence a proc�eding crr pur�ue a claim �gainst such
� oth�r third p�ers�rt fc�r th� r�covery o�f all d�mag�s in the full extent af the value of
;
� any such benefits c�r s�rvices furnished r�r ��ymenfi advanc�d �r cr�dit �x��;rrded
,
' by the Plan.
;
; 6, In the �verrt the F'lan Particip�nt is � min�r as that t�rrr� is defined b�Y applicable
� law, the minor's par�nts crr caurt-appr�inted guardian, as the case may be, sha�ll
� tal�e and cc�operate in any ar�d all action requ�sfi�d by the F'lan to s��k arrd
�
abtairr any r�quisite court appraval in c�rder tc► bind the minor and his or her
; e�t��e onsr�f�r�� th� �aak�rcrg�kir�r� �r�d r�imk�ur��;r�n�nt prc��ri�iar�� �r� �r�n��rr��ed.
� If the mirror's par�nts crr courk-appoir�ted guar�ian fail err r�:fuse tc� take such
� actian, any cc�urt costs c�r I�gal f��s ir�curr�d by the Plan associ�►t�d with
�
;
;
;
% 31
;
li
�
�
!
obtaining such approval, shall be paid by th� minor's parents ar court-appointed �
guardian. �
�
I`
l.ans�ua�e In#erqr+�ta#Mon and $everabilitY '
�
1. The Plan Administrator retair�s sale, full and �Final discretionary authority to
construe and interpret the language of this prc►visiorr, #e► determine all questir�ns
af fact and law arising under this provision, �nd tc� administer the Plan's
subrogatic�n/reimbursem�nt rights. �
,
2. In the event that any sectic�n of this provisir�n is considered invalid or illegal far
any reasan, said invalidity ar illegality shall not affect the remaining sectians of
this provisian and Plan The s�ctian shall be fully severable. The Plan shal( be
canstrued and enforced as if such invalid ar illegal sections had never been
irrserted in the Plan.
�
[�efined Terms �
1. Fiecovery means moni�s paid ta the Ccmvered Persan by way of judgment, �
s�ttl�ment�,�ar atherwise t� comp�n�ate f4�r��11 los��s �aus�d��by�th� Injurie� or �; �
Sickness whether ar nat said losses refl�ct dental charges cavered by the Plan.
2. Subraga�tion means the Plan's right to �ursue the Cc�vered Person's claims far
dental charges against the other person. � �
�� � �
3. Refund means repayment tsa the Plan fc�r dental benefits that it has paid taward �
care and treatment of the Injury c�r Sickness. �
�
;
� I
CUBRA CONTINU,�4TIO�1 OPTICJ►N �� �
1
To provide c�ptions for individuals whc� lose he�lth caverage from an emplr�yer-
sponsored insurance plan, the Federal Gavernment enacted the Cansolidated Omnibus
Budget Rec�nciliation Act of 1985 (Public Law 99-272, Title 7�), comrrronly known as
C(JBFtA. The follawing will explain your rights under the law and what should be dc�ne if
you (or a cov�r�d d�pendent) exp�ri�nc� a COBF�A "qualifying ev�nt". A qua�lifying �
event is an event that occurs whereby an employee 4r covered dependent wc�uld no �
longer be eligible to continue under a graup health plan. We request that yau and yaur J
cavered dependents take the time t� read this important notificatian. �
;
I
�
1
1�
32
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�
� ��IX M A
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i �k.4 ... Y��� :�1Y � � rt� i� .r. 1Y �.w t .M � � � ! M . � �III P I I� rY �.
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I
�
de endents will be res onsibl� for na#i in the Plan Administrator or his/her. I
desi nee of a divorce le al se ara�tian Medicare en#itlement or when a
de enden# loses his/her `°de ender�#s#atus'°. Yau or our de endent s have
sixt 6p da s tcr noti the Pl�n Ac�ministrator ar his desi nee of t�ese uali in
events. If the Plan Administratar or hi� desi nee is nat notified within this tim�e
frame COBRA continuation cannot be affered. in c�rder to take advantage of the
disability e�rkension described belaw, yau must also natify us within si�cty days of a
determination by Sacial Security that yc�u or a dependent are "disabled".
Ct�►BRA Qu�lifyin�a �vents
Listed below are qualifying events fc�r which yc�u and/or your cr�vered dependents are
able tc� continue coverage under�CJBF�A. As shc�wn, the maximum cantinuation
coverage time frame depends up�n the qualifying event �xperienced. Tc� be consid�red �
a qu�lified berr�ficiary, You or-yo�r d�p�ndent must hav� b�en enroll�d �n the group I
plan c�n the day prior ta the qualifying event. C7ne exceptic►n tc� this rule is when a child f
is bc�rn ta (or placed fc�r adoptian with) an emplc�yee during the CC7BRA continuatic�n
perrod. These childr�n will recei�ae all the rights of a qualified beneficiary thraughout the
CC7BRA continuation period. � � 1����
Qualifying Ev�nts #hat Yield a I�Aa�xi�»um Qualifying Events tha�t Yi�ld a Maxirr�um �(
af 18 Months Coverag� af 36 Man#hs Caverage
(Exp�rienced by the Emplerye�� (Experienced by a Covered Depend�nt) „
�
Termination of employm�nt (for r�as4n Death of the employee �
other than " rass misconduct„ �
Reduction �f em Ic� e�'s wark h�zurs Divorce or le al se aration �
Employee is entitled to Medicare but
de endents are not
Dependent child wha no longer meets �he
lan's definition af a "de endent'
Disabilitv Exten�sian
If the qualifying event is an employee's terminatian or reductian in wark hours and yc�u �
or a covered dependent are determined to be "disabled" by Sacial Security (under Title
7GI or Titl� XVI) eith�r befiore that qualifying event or within sixty days of such event, yau �
and your covered dependents are eligible for an additianal �eleven months af coverage �
yielding a total of 29 manths). Far this extension to apply, evidence of disability under
the Social Security Act must be pravid�d ta the Plan Administratar within the initial },
eighteen month continuatian coverage time frame and within si7cty days from the date of
5acial �ecurity's determir�ation.
�
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' Multi le uali in Ever�ts
;
;,
;
;
;
If you experi�nce a qualifying ev�nt that er�titl�es you and yc�ur cc�vered dependents to
� � less than thirty-six m�arrth� c►f cc�ntinua�icrn ccrverage (including the disability ��tensicrn
;
� described ab�ve) and during yc�ur peric�d c�f confiinu�tie�n c�verage your cov�red �
� � deperrdents �xperienc� a s�c�nd (c�r"mu6tiple") qualifyir�g event, th� p�ri�d of �
� cor�tinuation coverag� far y�ur cavered d�p�nd�nts ma►y b� ext�nd�d under COBRA
� � frc�m �ight�er� m�nths (�r twerrty-nine mc,r�ths if disabled) ta thirty-six months. The
� maximum continuation period is thir�y-six �nc,nths r�gardl�ss c�f haw many qualifying
;
� events your c�vered d�p�nd�nt� experier�ce. I� i� ycrur r�sponsik�ility, ar the
%
' respc�nsibility of yaur ccrver�d depend�nt� tc� notify the Plan Admini�trator wi#hin
;
; � sixty days of the� mu�ltiple qu�l�fying �v�nt. �mplc�y��s whc► experier�c�; a reductic�n �
,
; in w�rk hours follc�w�d k�y a terminafiiorr crf�mple�ym�nt �hall only be �ligi�l� fr�r eighteer�
� � mc�r�th� �f�e�ntir��afiic�n �c�v��ac�� �nd�r�t�E�FiA.
;
�
;
�
;
; F��il �nd Medic�l L.���r� eA�t
,
�
;
� Under th� Family and Medical Leave Act �af 19�3 (FMLA), �ligible employee have the . �
� ri�ht to tak� up to �rnrelve weeks c,f un�aid I�av� to care fc�r fihems�lv�s err a sp�cified �
r
� � relative. If y�u �lect to take thi� I��v� and lat�r nc�tify tl�e cr�rinpany that you will rrof be
,
� � r�turning, Yc►u hav� �h� abili�y�a cc�nfiirru�y�ur�c�v�;ra�� f�ar�:ig��een nncrnfihs firam �h� �
� � date benefits �re t�rmirrafied c�rr account c►f yr�ur�ailure �a r�turn tcr wc�rk. Pl�ase r�f�r to
� � th� District'� �amily Gar� and M�dical Le�v� F'�licy far c�mplete d�tail� regardir�g � �
,
,
% b�n�fits status durinr� this type of leav�.
�
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� Fte-EnroMlment afte�r a �'MLp. Le�av�
;
;
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� If any or all c�f an �mploy�;e's �crv�rag�s �nd while the Emplcryee is c�n a FMLA leave,
' the Employe� can re-enrcrll f�r cover�g�e v�rhen he or she returns to work fram the FMLA �
�
;
' � leavee
>
;
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� The Emplc�ye� and any D�p�rrdents will b� carr�id�r�d timely �nrc►Ilees if the Emplcryee
� re-�nrolls wifii�in th�irky r�n� (31) d�ys frc�m �th� d��e he crr she r�tu�rr�s to wc►rk. Any
; waiting p�riod will �� applied as if ther� I�ad beerr r�cr bre�k in cov�rage.
�
J
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� COF�RA Termination
;
,
; Although �C7BF�A contirr�a�ti�r� co�v�rage has a ma�imum tirnc� fram�;, you may
� vcalunt�rily��rrru76r���� ��a�er�g� �� �ny time� by r��atifyir�g th� F'I�n /�drrdir�istr�tc�r ir�
advance. In addition, COE3F�A stat�s that cc�rrtinuation cov�rage will end for one ar
� more of the fc►Il�wing rea�c�ns:
f
;
,
;
;
; 35
;
f
1. Th� District t�rm�r�ate� all ofi its h�alth plans fc�r similarly situated active �
employees. �
2. COBRA premiums are not paid in a timely manner. �
3, You and/or �our�avered Dependents become covered under anott�er group
plan after el�cting c�antinuatian caverage and that plan does not exclude a pre-
existing mec�ical ar dental condition affecting you or ycrur dependents.
4. 1'ou bec�m� entitled ta Medicare (meaning errrolled in Parts A and/or B) after �
you have el�cted cc�ntinuatian coverage under COBI�A. However, your �
dependent's cc�ntinuation c�verage may be extended ta thirty-six m�nths upc�n
natifying th� Plan Admirristrator of your Medicare entitlement �.
�
5. You or a Co�ered Dependent are enrolled in a plan that require� yor� to live in the �
plan's `°Servi�� Ar�a" or visit cantracted praviders ar�d y�u move out of that �
servic� area. Hcrwever, if ana�th�r plan is availabl� to �imilarly situated active �
employe�s v�rho rnc�ve from the s�rvic�: area, coverage under that pl�arr will b� �
a�ff�red t� yau. � ,�
6. You file fraudulent claims c�r engage in other actiwities far which a similarly
situated actiwe errrployee wc�uld be terminated `°for cause'.
7. A "disabled„ participant is determined by 5ocial Security ta be nc� langer disabled
during th� �I�veri month extensic�n. In that case, the entire fam�ly unit will be
t�rminated f�rm �C1BRA. � `
�
Premium Cas#� J
The cost of continuation cc�verage will be determined at the time of the qualifying event.
Yc►ur cast will be thp amaunt determined by the District for similarly situated active
emplayees under the Plan, plus a 2% administratic►rr fee. An employee wha is deemed
to be disabled and v�rho elects the disability e�rtension may be charged a 50%
administratian fee during the eleven manth e�ctension. (If the disabled employee daes �
not elect the disability extension or terminates ccrverage before the e�tension wauld �
ardinarily end, his/her cavered dependent's administratinn fee will be reduced ta 2%). If �
the District's "premium" funding increases or decrea�ses, th� CO�F�A participants �
premiums wiil be adjusted accardingly. Premiurn rates for the plan are set far#welve ��
month periods based upan the Plan Y�ar, �
_ �
If yau elect tc� continue coverage under CC7�F�A, yc�u will be granted an initial forky five
day grace periad tc► make your payment. Your�rst payment must include the premiums
for caverage retroactive to the date yau or your cc�vered dependents wc�uld have Ic�st
cc�verage if yc�u hadn't elected to cantinue coverage. Subsequent premium payments �
will have a thirty-day grace period. If premiums are nc►t received within the allotted I
r�
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� grace peric�d,�CC7BRA c4ve�age will b� fierminat�d back ta� th� date for which th�
;
; premiums were applied.
�
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� Coveraae under COBRA
,
;
� Since Ct�BF�A is a contin�ation r�� ben�fits, yc�ur benefit� will remain the same �s pricrr
�
ta th� qualifying ever�t. If th� Disfirict el�cts fio chang� plan� and/c�r benefits, ya� will be
� eligible ta� enr�ll in the chan�ed plan ar�d will th�refore rec�ive fih� same benefits as
�
� similarly situated active employ��s. �If your �'lan has d�ductibles and co-insurar�ce
;
� maximums, th�s� arrNo�unts enrill b� based upc�rr ��p�ns�s in�urr�d prior tc� the qualifying
;
� event by anly the�s� family rr�emb�rs el�ctirrg t� cc►nfiinu� under th� plan.
,
;
� COBRA p�rtici�ants who m�rv� fr�m the plan's service ar�a may Icrs� c�ver�ge urrd�r
;
a that gr�up heal�h pl�r� �a� w��ld � �imil�rly �it�a�t�d �ctiv� �mpl�y��). If th� I�i�trict
,
crffers a plan that wcruld provide cav�rage in the new area, the CC1BR�1 particip�n#will
� b� affered th� right ta �nrr�ll in th�t plan.
�
;
�
� Open EnrcrlM�nnent
� �
,
;
� GC7BFtA participa�nts are ofF�r�d th� sam� rights a� �imilarly situated active em�alc�yees
� during apen enrollm�nt. Th�y m�y ch�ng� plan� and add/del�te eligible d�p�r�dents.
� AItY�crugh pa�k c�f the f�rnily uni�, d�pen�en�� (c►�f��:r tt��n n�wk�orrr cf��ldren and �dc�pt�;d
� children of the �m�lc�y��) �dd�d �urir�c� �p�n �nrcrllm�n�will ncr� h�v� tt�e samc �O�RA
�
;
� rights �s the irritial qualifi�d ben��iciaries. The District's open �nrallment may v�ry frcrm
' year to year, so f�el free tcr c;c�nt��t th�: Pl�n Administr�tc�r f�r further informatic►r� orr
�
�
% oper► enrc�llment.
�
�
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% Trade Act af�Op2
;
;
fi C7n August 6, 2(�0�, th� Trade Act af�002 was sign�d inta law expandir�g the b�rr�fits
,
avaifabl� tcr workers displac�d by imperrt ccrmpetitic►n c�r shifts af prcrduction to a�h�r
� countries. The Trad�;Act of 197'4 irritially �ffer�d benefits (knr�wn as "trad� adjustment
� assistance") whicl� �xpired �ept�mber 30, 20�1. The 1"rad� Act c�f�Op� extended this
� period to .��pterrrber 30, �007 and crff�rs qualified wcrrkers a t�� cr�di� of up �0 65% of
� CC7BRA h�alth insuranc� premiums fc�r br�th them and th�ir family. �
;
;
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% To be eligible for the tax credit, yc�u must be curr�ntly receiving trad� adjustmenfi
� assis�anc� or considered arr "�ligible P'�GC pensic�r� recipient", paying premiums far
� qualified h�alth insurance, not receivir�g c�th�r cc�v�rag�; and not in prison. The law also
� cr��t�� � ��c�rrd "�I�ctic�rr p�rir�d" �F�ar ir�ddvid�a�l� r�c�t ����tir�g �t��(� cc�v�r�ge �pc�r�
� their Icrss �f�;mplaymenfi if they are within the six mc�nths immediately aft�r their grpup
� health plan cov�rage �nded, Fc�r further infi�rmatic�n r�n the Trade Act of 2002, please
� visit the website at vv�nrmr.�eabr�law.cr�m/trad�-a�t.
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� 37'
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� ����������
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He�ith In�urance Portak�ilit and Accauntabilit Act r�f 1996 HIPAA �
. �
The scop� of HIPAA is to eliminate barriers fcrr individuals (mainly people wifih pre- �
existing medical or dental conditians that wauld have difficulty c�btaining immediate
cc�verage) who lose coverage and want ta find a replacement pMan. The law limits a
plan'� "Pr�-existing condition limitat"ran time frame" tc� tw�lve months far newly enrolling
individual� and prc►vides credit for prior medical/d�ntal cc�ver�ge, including C(7�FtA
continuati�n ca�verage. When you terminate fram a group medical/dental plan, you will �I
receive a Certificate of Cc�verage that illustrates yc�ur pri�r coverage. This cerkificate
shauld be shawn ta a new employer to receive c�ne mr�nth credit far every manth af prior
coverage. Ifi#here is a break in coverage greater than siaety-three (63) d�ys, the new
empl�yer does nc�t have tc� provide any prior coverage �r�dit. (Individuals receiving
trade adjustment assistance, and who enroll in CC7BRA during the `°second election �
period" shall rec�ive cr�ditabl� coverage �ven with a br��k in c�verage larger than �
sixty-thre� days.) I
In addifi�n, if you elect CC)BRA and k�ep your cover2�ge f�r the maximum cantinuation �
period av�ilable t� you, yc�u may be eligible for caverage under an individual plan �;
(thro�agh �n insur�r of yc►ur choice) an a guararrteed issu� b�sis withaut any pr�-existirrg �
c+�ndi�ion limitations. � � �
I
Questionws R��ardin� GOBRA
C(76R,A is complex, placing certain requirements on bath the employer and the qualified
beneficiary. It is designed ta pravide temporary health insurance with a defined
termination date, If you have any question� regarding #his natificatian of your �
COBRA rights, please feel free ta contac#the Plan Ccrordin�►tor at 530-543-f222. f
� I
�
Cc►nt�nuation of Cov�ras�e under USERRA �
; �
If your Service ends due to a qualified military I�av� af absence you may be eligible ta
contirrue coverage under this provision, subject tc� payment c►f cantributions.
The Unifarmed 5ervices Emplayment and Fieemployment Rights Act of 1994
(USEFiR,A) established requiremen#s that Emplayers must meet far certain Employees
wha are invalved in the Uniformed Services. In addition to the rights under COBRA
cc►ntinuatian of coverage, yc�u are entitled under USERFtA tcr continu� the coverage you
had under the group for Dental coverage.
��
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� "Servir,� in th� llnif�rm�d Servic�s" means tl�� p�rformanc� a�F a�tiv� d�ty in tl��
Uniformed Services under competent auth�rity which include� tra�ning, fiull-time PJational
Guard duty and the time �ecessary for a person ta be absent frc�rr� employment for an
examinati�n to dete�mine the fitn�ss of the person to perfc�rm �ny of th� assign�d
' duties.
�
' Wh�n � c�u�r�d Emplayee tak�s a I�av� fc�r S�rvice in the Urrifc�rmed �ervic�s,
,
� IJS�RRA cov�rag� f�r th� cc�v�r�d Employee and cov�r�d Dep�ndents for whc�m
� c�v�rage is el�cted, begins the day aft�r th� Emplaye� arrd cc�v��ed Dependents lose
;
� caver�g� und�r th� �'lan and it continues fr�r a maximum p�ric�d crf up tc� �4 months.
�
� If you �re entitled tcr t�C76�iA c�ntinu�tion coverar��, b�th COBRA� and U�EF�AA
�
x caverag� ar� �c�ncurrenfi. This m�arrs bath �CJBRA cc�verage and (J�EI�F�A. ca�vera�g�
� will k��gin u�on cvmmerrc�ment af th� �empl�yee's I�ave. The admini�trative pc►licies
,
a�r►d pr�ac�d�ar�s d��cr�b�d fcs� CO�RA ccsntir�uatic�n c�v�rag� vrrill �Isc� �pply t� USERAA
� c�verag�. In �c�me ir��tan���, COB(�,A coverag� m�y contir�u� la�ger. Additic�n�l
� inf�rm�tian on CC7BFtA c�ntinuatir�n c�verage i� describ�d in thi� Plar� �7ocum�nt.
�
;
� If cr�verag� under USERRA is el�cted, th� �r�ver�d �mplaye� anr� ccrv�red D�pend�rrts
� will b� requir�d tc► p�y up tc� 10�% c�f'the �pp�licabl� grcrup r�►te, F�c,w�v�r, if your
;
� Unifarm�d 5�r°vic� I�av� �f abs�nc� is I�ss tharr 31 days, yr�u ar� nc�t r�quir�d tcr p�y
�
� more than the amount that yr�u pay as an �ctive Empl�y�e f�r that cc�verag�,
�
;
�
HIPAA PRIVACY CCIMPLIAhICE
;
;
% Introduction
;
,,
� Th� ��u�h Tat�a� Public Utility District (Plan S�p�ns�r) �ponsvrs th� 5outh Taho� Public
� Utility District [��ntal Insurance Plan, Menrrb�rs c►f the District'� wr�rkfc�rce m�y h�►v�
� acc��s t� th� individually identifiabl� health in�Fc�rm�ti�n �f Plan p�rticipants f�r
� administrative�functic�ns r�f th� Plar�. Wh�n this health irrf�armati�r� is prcrvided fc�rm th�
�
� F'lan ta� the F'I�n Sp�rrsor, it is Prot�ct�d N�alth Infarmati�r� (PHI)4
,
;
� The Nealth In�urarr�� Por�ability ar�d Ac�c►ur�tabili�y act c�f 1�9�6 (MIF"AA) �nd its
' implemerrting r�gulati�ns restrict the P'lan �pc►nsor's �bility to use arrd discic�se P�HI.
The fcrllc�wing HIPAA d�fir�ition of PHI appli�s tcr this Plan.
�
;
� Prot�cfed Healtl� lnfarmatian: Protected health infic�rmaticrn mearrs infcrrmaticrrr
,
� that is creat�d �r r�c�ived by th� Plan and relates fia the �rast, preser�t, or future
;
physical or mental health c«r cc�nditian c,f a participant; the pravision af health care
; �ca � ��rticap�r��; c�r th� p��t, pr���r�t, �r fu��re p�ynr��r�t far fihe pra�vi�ic�r� c�f h��lth
� care tcr a participant; arrd that identifies th� p�articipant or for which there is a
� reascrnable basis t� believ� the inf�rmaticrn can b� �as�d trr ider�tify th�
;
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; 3s
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� parkicipant. Protected h�alth informatic�n includes information af persons living or � �
deceas�d. � �
i
�
The Plan Spansor shall have access t� PHI fram the Plan only as permitted under this
Plan, or as atherwise required or permitted by HIPAA.
f
Provision crf Pratected Hea�lth Informatican to Plan 5pon�or � �
�� 1
Permitted Disclasure af Enrollment/Dis-Enrallr�rent lnform�tic�n
The Plan (�r a health insurance issuer or HMCI with respect tc� #he Plan) may disclose to
the Plan Sponsc�r information on whether the individual is participating in the Plan, ar is '
enrolled in or has dis-enrc,lled fram a health insurance issuer c�r HMO ��`ered by the
Plan.
Permitted Uses and Disclosur� of Summa Health Informatian
The Plan (or a health insurance issuer or HMO with respect#o the Plan) may disclase
Summary Health Infarmatian (defined below) tc► the Plan Sponsor, provided the Plan
Spansor requests the Summary Health Inf�rmation for the purpase of: �
r
i
1. Clbtaining premium bids firom health pl�ns fc�r prc�viding health insurance �
cpverage under the plan; or � ' " �
2. Mc�difying, amending, r�r terminating th� Plan. � �
Summary Health Infr�rmatian.� Sumr�rary health infc�rmatian means infarmation
that (a) summarizes the claims history, claims expenses or type of cla�ims
experienced by individuals fc�r wharr� a plan sp4nsor had provid�d health berrefits �
under a Health Plan; and (b) from which the informatia�n described at 42 CFR t
�i164.514(b)(2)(i)(�) need c�nly be aggregated to the level of a fiv�;-digit zip code.
Permitted and Re uired Uses and Disclasure of Protect�d Health Infarmation for
Plan Administratian Purpases
Unless otherwise permitted by law, and subject ta the canditions af disclosure described
under"Conditic,ns of Disclosure far Plan Administration Purp4ses" , and obtaining
written certification pursuant ta "Certificatiar� af Plan Spanscrr", the Plan (or a health
insurance issuer of HMC1 an behalf af the Plan) may discic�se PHI ta the Plan Spc►nsc►r,
provided the Plan Spansor uses ar discloses such PHI anly for Plan administration �
purpc�ses.
Plan Administratian Purposes: Plan administration purpases means �
administration functians p�:rformed by the Plan Sponsor on behalf of the Plan, ,
such as quality assurance, claims processir�g, utilizatian trends, auditing, and �
�
40
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; �monita�ring. Plar� �dministrati�n furrctions dc� r�at inc�lud� functic�ns perform�d by
� �� �he Pian Spc�nsc�r in cor�necfion with any c�th�r k��n�fit or benefit plan of#he plan
� �f th� F'lan Spons�r, �nd they da� n�fi includ� any empl�ymerrt relat�d fun�tions.
;
;
;
�latwithstanding th� prc�visians c�f this Plan tc� th�e cantrary, ir� na event shall the Plan
� �pr�nsc�r be permi�ted tr� u�� or di�cic�s� PHI in � rrr�nrr�r that is incor�sistent with 4�
�FR �3164.5p4(f).
` ��nditic�ns ofi Discl�sur� fvr Plan Adminisfirati�n P'ur �s�s
;
;
; Plan 5�onsc�r agre�s tha�witf� resp�ct tc� any F'HI (c�th�r than enrallnnent�dis-enrollm�r�t
� i�rf�rm�ti�n and �ummary Nealth Infc�rmation, which are n�t subj�ct to th�s�
,
� r�strict��ns) discl�s�d t� ifi by th� Plar� (or a h��lth ir���ran��e issuer ar HMO on k��half�f
;
� the F'larr) Plar� Sp�ansc�r sh�IL
� �� 1. �lat u�� crr�urther di�cl�s� the PF-li c►t�rer�h�r� �� p�rrrritt�d e►r requir�d by the
;
� �`lan crr as req�ir�d by law.
;
,
;
� 2. �r���ar� th�t �r�ge ag�nt, includirr� � ��ab�r�r�tract�r, tc� vvhe�rr� i� �r��rid�s F'HI
� � ��;c�ived frorr� th� Pl�n, agrees tc► th�; same� r�;stricti�rrs and c�r�difiions that a�p�Y
� ta the Pl�n �pc�r►�c�r with resp�ct tc� PHI.
�
;
� 3. I��t use crr discl��� the PNI for�mplayment-r�l�►t�d �cti�ns �nd decisions or in
� ��nrrection vyith �ny c�ther b�n�fit c�r�mploye�� b�n�fit plarr crf the P'lan aponsc►r,
;
;
,
;
>
� °� 4. I�epc�rf fia tYre F'lar� any u�� or di�cl�sWre c�f�h� infc�rrr��tic�rr th�at is irrcc�nsistent
;
� �vith fih� us�s or di�clr�sur�s prc�vid�d fc,r, crfi which it be�ornes aware.
;
;
� 5. Make available PHI tcr �c�mply wi�h NIPAA's right ta �cc�ss in acccrrdance with 45
` CF� �3164.�24.
�
;
6. Mak� available PHI f�r�mendment and incr�rporate any am�ndments to PHI in
J
; acc�rdance with 45 CFR �164.5526.
�
;
� 7. Mak� available th� infarmatic�rr r�quired fia prcrvide �r� acccrurrting �f discl�asures
� in acccrrd�nc�; with �5 CFI� �3164.5��3. �
�
;
, 8. Ma�e its internal practices, boaks, arrd re�ords r�latir�g tr� the use arrd disclosure
' � af P�#I received from the Plarr av�ilabl� xo th� S�rcr�tary o�` H�alth and I�umarr
� Serwic�s f�r purpr�ses of det�rrr�ining cc�mpliance by th� Plan with HIPAA's
; privacy r�quirements.
;
� �. Ifi fieasible, returrr crr desxrcry �II �'HM r�c�iv�d fro�rr7 tl�� Plan �hat�h� Plan Spc,nsor
� �till rrti�irot�irr� ir� �nyr fmrrre �nd r���6re rrocs copi�� caf�a�ch ir�forrrti��ic�r� when r�ca
� lar�ger need�d fc�r th� purpos�s far which discicrsure was made, �xcept that, if
;
� such return crr d�struction is not f�asible, limit further u�es and disclosur� to
� thase purperses fihat make the refiurn �r destructicrn of the informatiarr inf�asible.
;
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A & f
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10,Ensure that the adeq�ate separation between Plan and Plan Sponsor(i.e., the �
"firewall"), required in �5 CFF� �i504(f)(2)(iii), is satisfied. �
Adequate Separation Betwe�n I�lan and Plan Sponsar
I
The Plan Spansar shall allcrwr the General Manager(as Plan Administrator), Human
Resources Directcrr (as Plan �or�rdinator) and Chief Financial Officer and/or Accaunting t�
Manager (ta canduct internal audit of the Plan's expenses and payment c►f claims), �
access to the PHI, No other persc�ns shall have access to and use PHI ta the extent
necessary to perfarm the Plarr administration functians that the Plan Sponsor perForms
far the Plan. In th� event that arry of these specified emplaye�s do not c4mply with the
prc�visions af this Sectic�n, th�t employee shall be �ubject to disciplinary actian by the
P'lan 5pansor fcrr non-compli�nce, pursuant t� th� Pl�n Sponsor's employe� discipline �
and termination procedures.
Cerkificatian of Plan�onsor
The Plan (c►r a health insurance issuer or HMO with respect to the Plan) shall di�c{ose �
PHI ta the Plan �ponsor anly upe�n the receipt 4f a certificatia�n by the Plan Sponsor that i
the Plan has been amended �o ir�corporate the provisions c�f 45 CFR (3164.504(f�(2)(ii),
and that the Plan Sponsc�r agrees tc� the conditions of discl4sure set forth in the
preceding pa�ragraphs of th�s Section. � � �
�
�
i
RESPC)NSIBILITIES Ft�R PLAN ADMINI$►?RATIClN �
Pla►n Administrator
South Tahoe Public Utility Di�trict Dental Insurance Plan is the benefit plan for
Employe�s of South Taha� Public Utility L7istric�. The Plarr Administrator, also called `
the Plan S onsc�r is an individual a ainted b the South Tahae Public Utility District to ��I
P PP Y
be Plan Administratar and s�rve at the ce�nveni�nce af the Emplc�yer. If th� Plar� �
Administratcrr r�sigrrs, di�s, ar is atherwise remav�d from the pasition, South Tahc�e �
Public Utility District shall ap�oint a new Plan Administratcrr as soan as reasanably �
perssible. 1
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The Plan Administrator shall administer this Plan in accordanc�; with its terms and
establish its policies, interpretatic,ns, practices, and procedur�;s. It is the express in�ent
of this Plan that the Plan Adrninistratcrr shall have maximum legal discretionary authority (
tc� cvnstru�; and int�rpret the terms and provisions c►f fihe Plar�, ta rr��ke determirrations ;
regarding issues which relate to eligibility for benefits, ta decide disputes which may
arise relative ta a Plan F'articipant's rights, and tc► d�;cid� questians of Plan int�rpretaticrn �
and those of fact relating to the Plan. The decisicrns af the Plan Administrator will be 1
�nal �n all interested parti�s. �
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; Duties of the Plan A,dministrator
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; 1. Ta administer th� �"I�n in accordance with its terms.
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� �. To interpr�t the Plan, including the right to remedy possible ambiguities,
,
� inconsis�tenci�s ar c�missions.
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� �. To decide dispr�t�s which may �ris� relativ� tc� a Plan Parti�ipant's rights.
,
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fi � 4, To prescribe prc�c�dures far filir�g a cl�im f�r b�nefits arrd tc� review claim denials. �
%
;
� 5. ?o keep and maintain th� �'lan d�cumer�ts �nd �II oth�r r�cords p�rtaining ficr the
� Plan,
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� 6. Ta app�i�rt a Claim� Administr�tc�r to p�y cl�ims. �
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� 7. To d�l�g�t� t� �r�y per�s�r� �r���ity ���h �aaw�r�, d�a�ie� and r�spcar�sibiliti�� as it �
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deems apprc�priate.
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Plan Administratar Com en�ation
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; The Plan Administratar s�erves withor�t c�m�ensatic►n; hc�wever, all exp�nses fc�r Plan � �
� adminisfiratic�n, including ccrmpensatir��n for hired s�ervic�:s, will be paid by the Plan. �
1
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� Claims Admini�tratarr is not a� Fidu�ia�
;
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� A Claims pdminisfiratc�r is not a fiduci�ry under�I�e Plan k�y virku� c�f�aying cla�ms in
�
� accordance with th� Plan"s rules a� ��t�k�li��red k�y the� Pl�r� Administratar.
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` Fundin th� �'lan and Pa ment af �enefits
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� The c��t c�f th� Plar� is f�nded as fc�il�w�: �
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� 1. For Emplayees and Dep�ndent Coverage:
� a. Funding is d�rived salely frc,m the funds c►f the Emplc�yer.
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� 2, Benefits are paid directly from th� Plarr thrc�ugh the Claims Administrator.
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� Plan is no�an EmpMc►vment �an�ra�t
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The Plan is nc,t to be con�trued as a contract far or crf emplcrymerrt.
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Clerical Errar
Any clerical err�r by the Plan Administrator or an agent af the Plan Administrator in
k�eping perkinent records ar a delay in making any change� will nat irrvalidate coverage '
atherwise validly in fr�rce ar continue coverage validly terminated. An equitable
adjustment af contributi�ns will be made when the error crr delay is discovered.
V
If, due fia a clerlca� error, an averpayment c�ccurs in a Plan reimburs�rr�ent amour�t, the �
Plan retains a cantractuaC right to the overpayment. The person or in�titutian receiving �
the ov�rpaymerrt will be required t� return the incorrec# amc�unt af m�ney. In the case �
c�f a F�lan Participant, if it is requested, the amount of overpayment wiil be deducted from �
future benefits payable. �
D
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Self-Fund�d Ben�fits '
Dental Benefits
The Plan Admir�istratc�r has cc�mplete authority to cantrol and manage the Plan. The f
Plan Administratc►r has full discretion to deterrr�ine eligibility, to int�rpret the Plan, and ta I
determine whe�her a claim shcruld be p�id or d�ni�d, accc�rding to th� pravisions+�f the
Plan as set forth in this booklet. The Employer is fully respansibl� for the self-funded �
b�nefits. The �lai�ms Administratc�r proc�sse� claims and pravid�� o�her services #a� the
Emplc�y�:r r�lated ta the self-furrded ben�fits. The Claims Administrator does not irrsure �
or guarant�e th� ��If-fiunded benefiits. �
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GENERAL PLAIV INFORMATICIN
With respect to c�►mpanertt benefit plans, the Plan will comply, ta the extent applicable,
with the requirem�nts of all applicable laws, such as USEFiF�A, CC7BRA, HIPAA, �
NMHPA, CHIP�A, WHCRA, FMLA, MHPA, MHPA,EA, HITECH, Michelle's Law and
Title 1 af GII�A.
In accc►rdance with Title I of the Genetic Information Nandiscriminatia�n Act af 2008, in
na event shall the Plan or any af its insurers discrirrrinate against any Participant on the
basis af gerretic information with r�sp�ct to eligibility, premiums, or cantributians. �
The Plan will alsa ravide benefits as re uired b an ualified medical child su ort �
p q Y Y q PP �
order, as defined in ERISA �3609(a), and pravide benefits to dependent children piaced
with participants or beneficiaries for adc►ptian under the same terms and conditions as
apply in the case of dependent children who are natural children or participants of
beneficiaries, in accardance with ERISA �i6p9(c). �
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� Yaur right t� benefits ur�d�r tYris P'lan will be determined �r�der each F'r�gram in w,rhich
;
� You p�articip���, Y�ur righ�s to ben�fiits irr this Plan or any Program �r� subj�c��c�
� �m�ndment, m�difiic�fiio�r or termination ir� accordanc� with fih� P'lan Eligibility and
� Participant Sectiorr �f th�s Plan, and th� ap�plic�ble provisia�r�s af�ach Pragram. /�ny
;
� amendment, modii�icati�rr �r t�rminatic�n c�f a F'r�gram will �Is�a b� an am�ndm�r►t,
mc�difNcatic�n c�r fierminati�n of�hi� Plan.
a
� Amendrrnent crr Termin�tian c�f�hi� Pla�n �
�
�
� Th� �mploy�r�ully int�n�d� to m�intain this �'lan ind�fir�it�ly. �ow�ver it r�s�rve�s �h�
;
� righfi to t�rmin�te, susp�nd, discc�ntinu� crr am�nd the F'lan �t ar�y time upon advanc�
;
natice tc� all Participants, subj�ct to th� terms� c�f th� applicable MOU.
� �hanges in the Plan rrN�y �ccur in any ar all part� o�`the Pl�n including beneFit
� �t��✓�r�g�, ded�a�tibles�, r��axirr��m�, ccr�p�yr�a�nt�, ��e�l�sic�n�, lirnita�ic�n�, d��'ir�itpc�rrs,
; eligibility and the like.
�
;
x ��th� Pd�r� is t�rrr�drr�ted, �h� righ�� s�f t�c�v�red F��rssar�s �r� limit��d ta cav�r�� charge�
�
� incurred bef�re t�rmin�►t��n. �
�
�
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� Fundin,g
% All benefits paid under t��e Pl�n are paid in cash frr�m the general assets of the District,
;
� PVc� Emplc�y��s have �ny righrt, titl�, ar infieres�what�v�r in ar tc� any inv�strr��n�
� reserves, �accounts, �r funds t�at th� [7istrict may purchas�, es�tablish, c�r a�cum�alate #�
;
; aid in pr�vidirrg B�n�fits ur�der the Plan. Nofihing cc�ntained in th� Plan, arrd rro �ctic�n
; taken under its provisi�r��, cr�ates a trust c►r fiduciary relatic►nship of any kir�d betw�er�
� the District and an Empl�ye� crr any c►th�r pers�n. Neither an Employ�e nc►r a
; beneficiary of an Empl��ee acquires any int�:rest greater than that of an urr��cured
; creditor.
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� Tvp� of Pl�n
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� The F'lan provid�s der�t�l benefits.
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� Tvpe crf Administratiar�
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The Plarr is a self-fund�d w�lfare plan �nd the adminis�tratic�n is prcrvid�:d �f�rough a �hird
� p�rty Claims Adminis�ratar.
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���C'i ��r1'1�
South Tahr�e Public Utility District aental Benefits Plan Plan Number 901 �
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Plan Effect�v� D,�te � Plan Y�ar j
January 1, 2013 January 1 through Decerrrber 1 I
Em�rfaver Ir�fa►rmatian P'lan Administrator
S�o�uth Tahoe P'ublic Utility District � �eneral Manag�r �
12T5 Meadow Crest Driv� �outh Tahoe P'ublic Utility District �
5auth Lak� Tahae, CA ��i150 1275 Mead4w Crest Drive �
(53�) 544-6474 South Lake Tahoe, �A 96150
� � � (530) 543-6201
Claims Administrator TrusteejsZ
CD� Graup H�alth Baard of Directc�rs
16�5 East Prater Way, Bldg C, Suit� 101 ,�outh Tahoe Public Utility Gistr�ict ?
P.Ct. Box 5019� , 1275 Meadow Crest Drive
Rena, NV 9435-0190 �outh Lake Tahoe, CA 96150
($00) 455-4236
Plan Coordinators� �► ent of Le al Process
P�ar�cy Hussmann; Paul Hughes Gener�l Manager/Plan Administratc�r
South Tahae Public Utility District Sauth �'ahae Public Utility District ��
1275 M�adow Crest Drive 1275 IVleadc�w Crest Drive �
5c►uth Laka Ta�hc►�, CA 9�i150 South Lak� Tahoe, CA 96150 �
(530) 543-6222 or 543-6211 (530� 543-6201
The Plan Trustees reserve the right to change Claims Administrator and/or Plan
Administrator at their discreticrn.
The Plan and its attachrnents constitu#e the wrritten F�lan Document required by ERISA
(34p2.
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yDUTH TqhOF
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- _ _ _��
,p� s
Vsewe� ' 1950 . �s�`
e���171L�TY D���
SOUTH TAHOE PUBLIC UTILITY DISTRICT
�� _ _ _ _. __ __ __ __�__ - _ . _ _�_
Richard Solbrig, General Manager
Eric W.Schafer, President BOARD MEMBERS Randy Vogelgesang, Vice President
Chris Cefalu, Director James R. Jones, Director Kelly Sheehan, Director
REGULAR MEETING OF THE BOARD OF DIRECTORS
SOUTH TAHOE PUBLIC UTILITY DISTRICT
November 20, 2014
MINUTES
The South Tahoe Public Utility District Board of Directors met in a reg�lar session, 2:00 p.m., at the
District Office, located at 1275 Meadow Crest Drive, South Lake Tahoe, California.
ROLL CALL:
Board of Directors: President Schafer, Directors Cefalu, Jones, Vogelgesang
Staff: Ivo Bergsohn, Tim Bledsoe, Dennis Cocking, Shannon Cotulla, Melonie Guttry, Lynn Nolan, Julie
Ryan, Chris Skelly, Richard Solbrig, John Thiel, Paul Hughes, Gary Kvistad
Guests: Jim Hilton, Mike Maley, Kennedy Jenks, Eric Saperstein, Michelle Sweeney, Tim Williams,
Kennedy Jenks
CONSENT CALENDAR:
Moved Vo4elgesang/Second Cefalu /Schafer Yes / Cefalu Yes /Jones Yes / Vogel eq sana Yes /
Sheehan Absent to approve the Consent Calendar as presented.
a. Truckee Marsh Sewer Facilities Protection Project- (1) Approved Change Order No. 2 to
V8�C Construction, Inc. in the amount of $<7,663.75>; (2) Approved the Partial Closeout
Agreement and Release of Claims for VS�C Construction, Inc.; and (3) Authorized staff to
tile a Notice of Partial Completion with the EI Dorado County Clerk for Year 1 improvement.
b. Luther Pass Power and Control Project- Approved proposal from the consultants, GHD, for
engineering services in the amount of $40,277.
c. Resolution for the Department of Water Resources Water-Energy Grant Program 2014-
Adopted Resolution No. 2966-14 approving grant funding for the Commercial/Industrial
Water Efficiency Program.
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� REGULAR BOARD MEETING MINUTES- November 20, 2014 PAGE-2 �
t
¢ d. Resolution for the Bureau of Reclamation WaterSMART: Water and Energy Efficiency Grant,
2014-Adopted Resolution No. 2967-14 approving grant funding for the Bureau of �
Reclamation WaterSMART Water and Energy Efficiency Grant, 2014. �
}
�
e. Regular Board Meeting Minutes: November 6, 2014- Approved November 6, 2014 Minutes. �
�
Director Sheehan arrived at 2:04 p.m. after approval of the Consent Calendar. �
ITEMS FOR BOARD ACTION: �
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a. Truckee Marsh Sewer Facilities Protection Project-Staff gave an overview of the project and �
further recommended accepting the proposal from Lumos 8� Associates in the amount of �
$6,200. �
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' Moved Cefalu / Second Vogelgesang / Schafer Yes / Cefalu Yes /Jones Yes / Voyelgesanq �
' Yes /Sheehan Yes to accept the cost proposal from Lumos 8� Associates to provide ;
professional land survey services for the Upper Truckee Marsh Sewer Facilities Protection �
Project. �
�
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Groundwater Management Plan Update- President Schafer opened the public hearing at �
2:31 to receive public comments on the Groundwater Management Plan Update. Staff
reported on the 11 months of work that has been complete on the plan. Staff introduced Mike ',
Maley of Kennedy Jenks, who provided a PowerPoint Presentation. '
No public comments were received and the public hearing was closed at 3:08 p.m.
� b. Management Memorandum of Understanding - Richard Solbrig gave a summary of the MOU
Redline version.
Moved Schafer / Second Jones / Schafer Yes / Cefalu Yes / Jones Yes / Vogelgesang Yes /
; Sheehan Yes to approve the Management Memorandum of Understanding extending the
contract to June 28, 2017.
c. Payment of Claims
Moved Vogelgesgang / Second Cefalu /Schafer Yes / Cefalu Yes /Jones Yes /
Vogelgesang Yes /Sheehan Yes to approve Payment of Claims in the amount of $817,960.18.
STANDING AND AD-HOC COMMIITEE REPORTS:
Nothing to report.
BOARD MEMBER REPORTS:
Director Vogelgesang reported on the November 14, 2014, City of South Lake Tahoe Oversight
Committee meeting.
� President Schafer suggested staff may want to review the list of property owned by STPUD for
continued necessity. He further mentioned the audit report is now available from Grant-Thornton and
he recognized Paul Hughes and the finance staff for another successful audit with zero adjustments.
-16-
REGULAR BOARD MEETING MINUTES- November 20, 2014 PAGE-3
EL DORADO COUNTY WATER AGENCY PURVEYOR REPORT•
Director Jones provided a reporf regarding the November 12, 2014, EI Dorado County Water Agency
meeting.
GENERAL MANAGER REPORT:
Richard Solbri4 reported there has been four straight days of interviews, tests are currently being
reviewed and candidates will be notified the first week of December at the latest.
STAFF/ATTORNEY REPORTS:
Staff introduced Eric Saperstein from ENS Resources, the District's legislative advocate. Eric Saperstein
recognized President Schafer for his involvement in CASA, where he provided a voice of knowledge,
representing the perspective of small districts on a whole, while doing an excellent job of
representing STPUD throughout.
Saperstein further provided the following legislative update:
1) Fire prevention efforfs for regional suppression needs are continuing. The District is included in
the Forest Service's budget for FY 2015.
2) Corps of Engineers-The District has been able to resolve lack of progress with permitting by
working with McClintock's office to push the Corps of Engineers along and move approval of
the permitting process. This is a credit to the District to convey its needs through appropriate
offices.
3) Tahoe Restoration Act may be reintroduced next year-The District will continue to push the
availability of facility relocation costs under the Tahoe Restoration Act to support 66% cost
share for local agencies costs associated with any Tahoe Restoration activities.
4) WaterSMART-The US Bureau of Reclamation funding assistance for technologies and activities
for efficient usage of water will be funded at a higher level than in the past so there is an
opporfunity for the District to secure funding in this area.
5) Bureau of Land Management-Saperstein is working with the District on the issue of increased
potential for rental fees on BLM properties in Alpine County. Everyone has encountered this
issue with BLM, who has imposed new rate structures and he is working to reduce these for the
District.
Outlook: Tomorrow the President is planning to provide some kind of limited protection to over
five million illegal aliens to stay in this Country and receive work permits. This may create a
backlash with the incoming Republican majority to fight the President on whether or not he is
abusing his executive authority. That could theoretically jeopardize the finalization of an
omnibus spending bill for FY 2015 and put us in a scenario of a continued resolution until
February or March. We may see some kind of omnibus bill for non-controversial pieces of
legislation like energy and water development appropriations bills, which funds a number of
the programs of interest to the District including WaterSMART. Congress has until December
� �rn to do something on the budget or face the prospect of shutting down the government.
Drought Relief Bill -Sen. Feinstein announced this morning that she is pulling the drought relief
bill and will not pursue it. She will come back in January to seek putting through regular order
on a water bill. -1�_
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� REGULAR BOARD MEETING MINUTES- November 20, 2014 PAGE-4
�
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� Staff reporfed the District has received confirmation that PERS rates will drop on salaries from 17.3% to
� 14.2%.This establishes a new benchmark. �
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{ Director Jones expressed appreciation for Director Schafer serving on the Board, bringing great �
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= experience as a CPA and auditor, with involvement on the budget and his involvement with CASA. �
� �
"� BREAK AND ADJOURNMENT TO CLOSED SESSION: 3:30 p.m. �
i �,
9 RECONVENED TO OPEN SESSION: 4:18 p.m. �
a. Pursuant to Government Code Section 54956.9(a)/Conference with Legal Counsel Existing Litigation �
� re: EI Dorado County Superior Court Case SC20120227 GRCLT Condominium vs. South Tahoe Public �
Utility District (Filed 10/22/12). �
;
; No reportable Board action. �
;
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� b. Pursuant to Section 54957.9(a) of the California Government Code, Closed Session may be held for i
� conference with legal counsel regarding existing litigation: STPUD vs. Lakeside Park Association, et al., �
County of EI Dorado, Superior Court Case No. SC20010165. 1
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� No reportable Board action. �
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c. Pursuant to Govemment code Section 54957(a)/Conference with Labor Negotiators re: ',
Memorandum of Understanding with the Management Unit. Present at this Closed Session will be ,
Agency Negotiators: Richard Solbrig/General Manager, Nancy Hussmann/Human Resources '
f Director, and Paul Hughes/Chief Financial Officer.
,�
No reportable Board action.
,
� ADJOURNMENT: 4:18 p.m.
,
Eric Schafer, Board President
South Tahoe Public Utility District
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Melonie Guttry, Clerk of the Board
South Tahoe Public Utility District
�
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General Manager
Richard H.5olbrig
� • 1950 •
w� O �� � O w Directors
�J GhriS Cefalu
VJameS R.Jones
�� =�`" f u b 1 i c U ti l ity D i 5tri ct �ndy Vogelge5ang
KcIIy 9heehan
Eric Schafer
1275 Meadow Crest Drive•South Lake Tahoe•CA 96150-740t
Phone 530 544-6474•Fax 530 541-0614•www.5tpud.u5
BOARD AGENDA ITEM ga
TO: Board of Directors
FROM: Ivo Bergsohn, Hydrogeologist
MEETING DATE: December 4, 2014
ITEM-PROJECT NAME: Groundwater Management Plan Update
REQUESTED BOARD ACTION: 2:15_p.m. PUBLIC HEARING
DISCUSSION: At 2:15 p.m. hold a Public Hearing to receive public comments regording
(1) Adoption of Resolution No. 2969-14, the Tahoe Valley South (6-5.01) 2014
Groundwater Management Plan; and, (2) Enacting Ordinance No. 558-14 amending
Division 7 of the Administrative Code.
SCHEDULE:
COSTS: N/A
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATTACHMENTS: Groundwater Management Plan Update is available on the District's
website (http://www.stpud.us/plan_documents.html) and can be viewed at the Board
Clerk's of�ce upon request.
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: Water
GENERAL MANAGER: YES � NO
CHIEF FINANCIAL OFFICER: YES NO
-19-
General Manager
Richard H.5olbrig
� s 1950 • ��
O �� � O Directors
�j ChriS Cefal u
V� JameS R.Jones
- i � � � � Randy Vogelgesang
�~ ��V ��V U tl I�ty D�5tr�ct Kelly 5heehan
Eric 5chafer
1275 Meadow Crest Drive•South Lake Tahoe•CA 96150-7401
f'hone 530 54�4-64-74•Fax 530 541-0614•www.stpud.us
BOARD AGENDA ITEM gb
TO: Board of Directors
FROM: ivo Bergsohn, Hydrogeologist
MEETING DATE: December 4, 2014
ITEM- PROJECT NAME: Groundwater Management Plan
REQUESTED BOARD ACTION: Adopt Resolution No. 2969-14 Adopting the Tahoe Valley
South (6-5.01) 2014 Groundwater Management Plan (GWMP); and (2) Enacting
Ordinance No. 558-14 amending Division 7 of the Administrative Code.
DISCUSSION: The District has updated its GWMP to ensure compliance with current
requirements in accordance with California Water Code (CWC) Section 10750 et. seq.
Review and amendment of Ordinance No. 477-00 has also been completed
concurrent with this update.
The previous version of the GWMP was developed in 2000 by the District in the form of a
groundwater Ordinance. In December, 2000, the District enacted Ordinance No. 477-
00 adding Division 7 to the Administrative Code, authorizing the Administration of a
GWMP as sanctioned under CWC Section 10750, et seq. The GWMP was developed for
the purposes of regulating, managing, conserving and protecting local groundwater
resources. The 2000 Plan focused attention on the impacts of man-made
contamination on the District and its customers and included an Ordinance for
implementing rules, regulations and procedures to identify potential contamination
before it impacted the District's wells. j
The GWMP is considered a "living document"— a document that the District intends to
update periodically to report on the progress made in managing groundwater
resources. Imporfantly, this Plan will need to be replaced with a Groundwater
Sustainability Plan by 2020 or 2022 (depending on the TVS Basin's DWR prioritization) in
order to comply with the recently passed Sustainable Groundwater Management Act
(SGMA). Tracking the SGMA's requirements, this GWMP update was prepared to ensure
compliance with current req�irements and to plan for expansion of the District's role in
the management of the local groundwater resources and water quality. The GWMP
update was prepared by the District and its consultants in collaboration with a
Stakeholders Advisory Group (SAG) consisting of twelve members who reside within the
boundaries of the District or who represent collaborating businesses or government
agencies who have demonstrated a commitment to protecting groundwater
resources.
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Ivo Bergsohn,Hydrogeologist �
December 4,2014 �
Page 2 �
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Concurrent with this GWMP update, Ordinance No. 477-00 has been reviewed and �
revised. Since 2000, considerable progress has been made with the remediation of �
petroleum sites (the primary focus of the 2000 Ordinance). A key element of the �
; updated Ordinance is to revise the Ordinance to address broader groundwater �
protection concerns, especially the requirements of Section 7.9.2 Basin Monitoring `
Program. The goal for this Ordinance revision is to provide the District with a mechanism �
� for enforcing groundwater protection—protection created in collaboration with other �
' local agencies that minimizes duplicative regulatory oversight or monitoring �
} requirements. �
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SCHEDULE:
COSTS: N/A
ACCOUNT NO: 1029- /GWMPUP
BUDGETED AMOUNT REMAINING:
ATTACHMENTS: Resolution No. 2969-14 and Ordinance No. 558-14: A copy of the
updated GWMP and Groundwater Management Ordinance are available under the
2014 Groundwater Management Plan Update portion of the Plan Documents page of
the District's website (http://www.stpud.us/plan_documents.html) and is also available
upon request to the Clerk of the Board.
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: Water
GENERAL MANAGER: YES � NO
CHIEF FINANCIAL OFFICER: YES NO
-22-
RESOLUTION 2969-14
RESOLUTION OF THE BOARD OF DIRECTORS
OF THE SOUTH TAHOE PUBLIC UTILITY DISTRICT
ADOPTING A GROUNDWATER MANAGEMENT PLAN
PURSUANT TO WATER CODE SECTION 10750, ET SEQ.
WHEREAS, California Water Code Section 10750 contains a legislative finding and
declaration that groundwater is a valuable natural resource that should be managed to insure its
safe production and quality, and that local agencies should work cooperatively to manage
groundwater resources within their jurisdiction; and
WHEREAS, California Water Code Section 10753 authorizes a local agency to adopt a
groundwater management plan pursuant to California Water Code Sections 10750 et seq., for
basins or portions of basins within the jurisdiction of the agency that are not already subject to a
Groundwater Management Plan; and
WHEREAS, the Tahoe South Subbasin of the Tahoe Valley Groundwater Basin(6-5.01)
is located within the South Tahoe Public Utility District's ("District")boundaries; and
WHEREAS, in December 2000, the District enacted Ordinance No. 477-00 adding
Division 7 to the Administrative Code authorizing the administration of the Tahoe Valley South
(6-5.01) Groundwater Management Plan("2000 TVS Basin GWMP")pursuant to California
Water Code section 10750, et seq.; and
WHEREAS, the District desired to update the 2000 TVS Basin GWMP in order to ensure
compliance with current requirements in California Water Code section 10750 et. seq., AB 3030
and SB 1938; and
WHEREAS, a twelve-member Stakeholder Advisory Group(SAG)was convened and
met four times in 2014 (April 16, May 14, June 4 and September 24)to provide input from the
public, local agencies and business owners as to updating the 2000 TVS Basin GWMP ("2014
TVS Basin GWMP"); and
WHEREAS, the District provided a draft of the 2014 TVS Basin GWMP for public
review from October 30 to December 1, 2014 and held a public hearing on November 20, 2014
to present the draft to the public and to solicit comments; and
WHEREAS, the District has made copies of the 2014 TVS Basin GWMP to the public
and notice of the public hearing on whether to adopt the 2014 TVS Basin GWMP was given in
the manner prescribed by law; and
WHEREAS, the District desires to formally adopt the 2014 TVS Basin GWMP; and
Resolution No.2969-14 —23
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WHEREAS, the District held an additional public hearing on December 4, 2014 to
determine whether to adopt the 2014 TVS Basin GWMP; and
WHEREAS, the District's Board of Directors has also adopted revisions to its
Groundwater Management Ordinance, added as Division 7, Sections 7.1 through 7.10 of the
Administrative Code.
NOW,THEREFORE, BE IT RESOLVED,AS FOLLOWS:
1. The foregoing recitals are true and are incorporated by reference.
2. The 2014 TVS Basin GWMP is hereby adopted to be effective as of December 4,
2014.
3. That the adoption of the 2014 TVS Basin GWMP is statutorily exempt from the
California Environmental Quality Act ("CEQA").
4. This Resolution shall take effect immediately.
WE,THE UNDERSIGNED, do hereby certify that the above and foregoing Resolution
was duly adopted and passed by the Board of Directors of the South Tahoe Public Utility District
as a regularly scheduled meeting held on the 4th day of December,2014,by the following vote:
AYES:
NOES:
ABSENT:
Eric Schafer, Board President
South Tahoe Public Utility District
ATTEST:
Melonie Guttry, Clerk of the Board
Resolution No.2969-14
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SOUTH TAHOE PUBLIC UTILITY DISTRICT
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GROUNDWATER MANAGEMENT ORDINANCE
ADDED AS
DIVISION 7, SECTIONS 7.1 THROUGH 7.10
TO THE ADMINISTRATIVE CODE PURSUANT
TO ORDINANCE NO. 558-14
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ORDINANCE NO. 558-14
AN ORDINANCE OF THE SOUTH TAHOE PUBLIC UTILITY DISTRICT
AMENDING DIVISION 7 OF THE ADMINISTRATIVE CODE,AMENDING
THE DISTRICT'S GROUNDWATER MANAGEMENT ORDINANCE,AND
SUPERSEDING ORDINANCE NUMBER 477-00 IN ITS ENTIRETY
BE IT ENACTED, by the Board of Directors of the South Tahoe Public Utility District,
County of El Dorado, California, as follows:
SECTION I-PURPOSE,POLICY AND CITATION
The purpose of this Ordinance is to amend the groundwater management
ordinance of the South Tahoe Public Utility District, El Dorado County, State of
California(District), coincident with the District's update to its groundwater management
plan,pursuant to the Groundwater Management Act(California Water Code sections
10750,et. seq.).
SECTION II-FINDINGS
The District's Board of Directors makes the following findings:
l. The Tahoe South Subbasin of the Tahoe Valley Groundwater Basin(6-
5.01) is located within the District's boundaries;
2. In December 2000,the District enacted Ordinance No. 477-00 adding
Division 7 to the Administrative Code authorizing the administration of the Tahoe Valley
South(6-5.01) Groundwater Management Plan("2000 TVS Basin GWMP")pursuant to
California Water Code section 10750, et seq.;
3. T`he District desires to update the 2000 TVS Basin GWMP in order to
ensure compliance with current requirements in California Water Code section 10750 et.
seq.,AB 3030 and SB 1938;
4. A twelve-member Stakeholder Advisory Group (SAG)was convened and
met four times in 2014 (April 16, May 14, June 4 and September 24)to provide input
from the public, local agencies and business owners as to updating the 2000 TVS Basin
GWNIP ("2014 TVS Basin GWMP");
5. The 2014 TVS Basin GWMP is in accordance with Assembly Bi113030
("AB 3030"),also called the Groundwater Management Act(Section 10750 et. seq. of
the California Water Code)and Senate Bill 1938 ("SB 1938"). The purpose of the 2014
T'VS Basin GWMP is to implement Basin Management Objectives("BMO")to manage
Ordinance No.558-14
Cttoundwater Management Ordinance
Page i
03762'710072\117294842 -2�
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groundwater supplies,protect groundwater quality,and foster stakeholder involvement. '`
T'he Plan is a separate report that provides the technical and planning information �
' supporting this Ordinance; �
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� 6. The Boazd of Directors, pursuant to Resolution 29b9-14,has adopted its `
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� 2014 TVS Basin GWNIP; �
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; 7. The Groundwater Management Ordinance provides the District with a
' mechanism to re late and rotect District's oundwater resources so that oundwater �
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' will remain a viable potable water resource and be available to be put to the most �
� efficient and beneficial use by the District and its customers; �
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` 8. T'he District is an authorized groundwater management agency within the
i meaning of California Water Code Section 10753(a) and assumes responsibility for
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, managing the quantity and quality of the Groundwater resources within the 2014 TVS
; Basin GWMP Plan Area pursuant to this Ordinance. Pursuant to California Water Code �
section 10754, the District may exercise the authority of a water replenishment district �
� pursuant to Part 4 (commencing with section 60220)of Division 18 for the protection and �
preservation of the District's Groundwater resources; �
' �9. Public notice of this Ordinance was duly given,authorized,posted and
� published, as required by law;and �
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10. Because groundwater is the predominant source of the District's drinking
water supply within,the Board of Directors finds it advisable and in the best interests of
the District to implement the Ordinance for comprehensive groundwater management. ;
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� SECTION III-AMENDMENT OF DIVISION 7 OF i
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ADMINISTRATIVE CODE ,
The provisions of this Ordinance amending Division 7, Sections 7.1 through 7.10,
inclusive, of the District's Administrative Code, are incorporated by this reference. This '
Ordinance supersedes Ordinance Number 477-00 in its entirety.
SECTION IV-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 Ordina.nce or the Administrative Code. The Boazd 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
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Ordinance No.558-14
Crroundwater Management Ordinance
Page 2
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03762'T0072\l 1729484.2 —28
sections, subsections, subdivisions,pazagraphs, sentences, clauses or phrases may be
determined to be unconstitutional or invalid.
SECTION V-EFFECTIVE DATE
This Ordinance amending Division 7 to the Administrative Code shall take effect
thirly(30)days after its passa.ge.
PASSED AND ADOPTED by the Board of Directors of the South Tahoe Public
Utility District at its Special Board Meeting on the 4th day of December, 2014, by the
following vote:
AYES:
NOES:
ABSENT:
DATED: December 4, 2014
Eris Schafer, President of the Boaxd
Melonie Guttry, Executive Services Manager
Ordinance No.558-14
Groundwater Management Ordinance
Page 3
03762T0072\117294842 —29
DIVISION 7
OF THE
ADMINISTRATIVE CODE
Section 7.1 Plan Authorization.
7.1.1 Groundwater Management Plan. The District has developed and adopted a
Groundwater Management Plan(Plan) for the Tahoe South Subbasin of the Tahoe Valley
Groundwater Basin listed as DWR Groundwater Basin 6-5.01, or more conveniently referred to
as the Tahoe Valley South Basin(TVS Basin). The Plan is in accordance with Assembly Bill
3030 (AB 3030), also called the Groundwater Management Act (Section 10750 et. seq. of the
California Water Code) and Senate Bill 1938 (SB 1938). The purpose of the Plan is to
implement Basin Management Objectives (BMOs) to manage Groundwater supplies, protect
Groundwater quality, and foster Stakeholder involvement.
7.1.2 Plan Area. For the purposes of carrying out the goals and objectives
established in this Plan, the boundaries of the Plan Area will include portions of El Dorado
County, the City of South Lake Tahoe, the Community of Meyers and Chrishnas Valley situated
within the TVS Basin to the extent that they lie within the El Dorado County portion of the
District's service area.
7.1.3 Groundwater Management Authorization. The District is an authorized
groundwater management agency within the meaning of California Water Code Section
10753(a) and assumes responsibility for managing the quantity and quality of the Groundwater
resources within the Plan Area pursuant to this Ordinance.
7.1.4 Water Quality Authority. Pursuant to California Water Code section 10754,
the District may exercise the authority of a water replenishment district pursuant to Part 4
(commencing with section 60220) of Division 18 for the protection and preservation of the
District's Groundwater resources.
7.1.5 Administration. The District, acting by and through its Board of Directors,
shall have jurisdiction over Groundwater within the Plan Area and shall have the powers
provided by this Division or any other provision of law. The District shall adopt rules,
regulations and procedures to implement and enforce this Plan pursuant to California Water
Code Section 10753.9.
Section 7.2 Purpose and Intent.
7.2.1 Purpose. The purpose of this Ordinance is to provide the District a mechanism
to regulate and protect the Groundwater resources available to the District so that Groundwater
will remain a viable potable water resource and be available to be put to the most efficient and
beneficial use by the District and its customers. The Plan is a separate report that provides the
technical and planning information supporting this Ordinance.
7.2.2 Emphasis on Groundwater QuaGty Protection. The District has been
significantly and adversely affected by past releases of man-made contaminants that have
impaired water supplies. The District has expended significant resources to address the loss of
production capacity and/or added treatment requirements resulting from groundwater
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contamination in order to provide its customers with continued high quality drinking water of �:
sufficient quantity to meet their needs. Groundwater quality in the TVS Basin is highly �
vulnerable to degradation from man-made contaminants and therefore additional protective �
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measures are necessary. �
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7.2.3 Intent. Because groundwater is the predominant source of drinking water �
supply within the Plan Area, the District finds it advisable and in the best interests of all water �
users to develop and implement this Ordinance for comprehensive groundwater management �
with an emphasis on protecting Groundwater quality within the TVS Basin. �
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= 7.2.4 Coordination with Other Authorities. The District will rely on and �
coordinate with the existing governmental agencies and authorities, including the El Dorado
County Environmental Management Department, the Tahoe Regional Planning Agency and the
California Regional Water Quality Control Board, Lahontan Region, in order to manage
Groundwater ualit within the TVS Basin without unnecessary duplication of effort and �
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utilizing consistent standards, to the extent reasonably possible. The District understands and �
f acknowledges that the El Dorado County Environmental Management Department and the �
� California Region Water Quality Control Board, Lahontan Region have other regulatory �
authority to address groundwater contamination and clean up. The District may, in its discretion, �
request that other governmental agencies take actions complementary to the actions taken by the �
District pursuant to this Ordinance, although such governmental agencies exercise their �
independent discretion with respect to taking action within their jurisdiction. &
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Section 7.3 Defmitions. �
a e lo 'c formation or ou of formations �
7.3.1 Aquifer(s). Aquifer(s) shall mean g o gi gr p
that transmits or stores water in sufficient quantities to supply the Extraction of water by Wells �
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or springs.
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7.3.2 Basin. Basin shall mean the TVS Basin(Basin No. 6-5.01) as originally
- established in California Division of Water Resources(DWR) Bulletins 118 and 118-80. ,
7.3.3 Contaminants. Contaminants are any physical, chemical,biological, or '
radiological substance or matter present in any media at concentrations that may pose a threat to
human health or the environment.
7.3.4 Contamination. Contamination shall mean the presence of naturally occurring
or man-made substances in surface water, Groundwater, soil, sediment or upon the land in
quantities that may result in an impairment of Groundwater quality within the Plan Area.
7.3.5 District. District shall mean the South Tahoe Public Utility District, acting by
and through the District's Board of Directors or its duly authorized representatives.
7.3.6 Domestic Use. Domestic Use shall have the same meaning ascribed to it by
California Code of Regulations, Title 23, Section 660.
7.3.7 Drinking Water Source Protection Area. Drinking water source protection
area is comprised of the Aquifer and Recharge area and is delineated using the modified
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calculated fixed radius method or other methods approved by State Water Resources Control
Board—Division of Drinking Water(formerly California Department of Public Health or
CDPH), in accordance with the CDPH Drinking Water Source Assessment Protection(DWSAP)
Program. The protection areas and zones shall be shown on the DWSAP map.
7.3.8 Extraction. Extraction shall mean the act of obtaining Groundwater by
pumping or other controlled means.
7.3.9 Extraction Facility. Extraction Facility shall mean any device or method for
the Extraction of Groundwater, including a Well.
7.3.10 fasl. Feet above mean sea level.
7.3.11 Groundwater. Groundwater shall mean the water beneath the surface of the
earth within the zone below the water table in which the soil is completely saturated with water,
whether or not flowing through known and defined channels.
7.3.12 Groundwater Basin. Groundwater Basin shall mean an Aquifer or system of
Aquifers that has reasonably well defined boundaries and more or less definite areas of Recharge
and discharge.
7.3.13 Man-Made Contaminants. Man-made Contaminants shall mean regulated
industrial and commercial chemicals which degrade Groundwater quality. Man-made
Contaminants which occur most frequently in the TVS Basin include petroleum hydrocarbon and
chlorinated hydrocarbon compounds.
7.3.14 Monitoring Well(s). Monitoring Well(s) shall mean a Well conshucted with a
surface seal and a sand filter pack in accordance with accepted design practices in order to
provide for the collection of representative Groundwater samples for laboratory analysis. Such
Wells may also be used to detect the presence of Contamination, to investigate the extent and
monitor the movement of Groundwater Contamination, to monitor water quality or to collect
water-level elevation data to aid in determining the direction and rate of Groundwater flow.
7.3.15 Natural Contaminants. Natural Contaminants shall mean undesirable
naturally-occurring substances found in water or soil which may result in a degradation of
Groundwater quality for those substances. Natural Contaminants which occur in the Basin
include radiological substances (uranium, gross alpha activity and radon), arsenic, soluble iron
and manganese.
7.3.16 Overdraft. Overdraft shall mean the condition of a groundwater basin where
the average annual amount of water extracted for a long-term period, generally 10 years or more,
exceeds the long-term average annual supply of water to the basin plus any temporary surplus.
7.3.17 Person. Person shall mean any individual, firm, partnership, limited liability
company,partnership, corporation, association or governmental agency. Governmental agency,
as used in this Division, shall not include any local agency exempt from the application of this
Division pursuant to state law.
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7.3.18 Plan. Plan shall mean the District's Groundwater Management Plan and its
modifications, and/or supplements.
7.3.19 Real Property. Real Property shall mean the land and everything permanently
fixed as a part of it.
f 7.3.20 Real Property Owner. Real Property Owner shall mean the Person that is
vested with ownership, dominion or legal or rightful title to the Real Property.
7.3.21 Recharge. Recharge shall mean the natural or artificial Replenishment of
Groundwater storage by percolation or injection of one or more sources of water.
7.3.22 Remediation. Remediation shall mean the clean-up or removal of
Contamination from the soil or Groundwater, and any action taken to prevent or minimize the
release and/or migration of Contamination into or within the Groundwater Basin.
7.3.23 Replenishment. Replenishment shall mean the spreading or injection of water
for the purpose of enhancing Recharge to the Basin, or otherwise adding to the storage of
:; Groundwater within the Basin.
7.3.24 Responsible Party. Responsible Party shall mean the Real Property Owner, the
Operator and/or the discharger of man-made contaminants.
7.3.25 Stakeholder Advisory Group (SAG). Stakeholder Advisory Group shall mean
3 the ad hoc groundwater management advisory committee appointed pursuant to Section 7.6 of
this Ordinance.
7.3.26 Well(s) or Water Well(s). Well(s) or Water Well(s) shall mean any artificial
excavation constructed by any method for the purpose of extracting Groundwater. Well or
- Water Well shall not include:
(1) Oil and gas wells, or geothermal wells constructed under the jurisdiction
of the California State Department of Conservation, except those wells converted to use as Water
Wells; or
(2) Wells used for the purpose o£
(a) Dewatering excavation during construction, or
(b) Stabilizing hillsides or earth embankments.
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Section 7.4 Findin�s of the Plan
7.4.1 Groundwater Basin. The Basin is a sedimentary geologic basin within the
southern portion of the Lake Tahoe Hydrographic Area that occupies approximately 14,800 acres
within a structural valley or graben located between the main range of the Sierra Nevada on the
west and the Carson Range on the east. Land surface elevations across the Basin range from
approximately 6,230 feet above sea level (fasl), along the south shore of Lake Tahoe to more
than 7,000 fasl, where glacial moraine deposits contact bedrock on the mid-slopes of the Sierra
Nevada, along the west mazgins of the Basin. Principle surface water drainages overlying the
Basin include the Upper Truckee River and Trout Creek.
7.4.2 Business/Economic Dependence on Groundwater Basin. The District and its
customers, including the business community and economic vitality of South Lake Tahoe, are
almost entirely dependent on Groundwater. Only a small section of the community, Lakeside
Park, is supplied water from a surface water source. Visitors to the south shore of Lake Tahoe
often compliment on the drinking water of the south shore of Lake Tahoe for its quality and
taste. Drinking water, coupled with the pristine quality and image of Lake Tahoe, is a major
asset of the community.
7.4.3 Groundwater Recharge. Groundwater recharge is derived from two main
sources, which include infiltration of precipitation that falls directly on the land surface overlying
the TVS Basin and groundwater that flows into the groundwater basin from the surrounding
bedrock. Using the long-term average annual precipitation in the Lake Tahoe Basin and
assuming that about 25 percent of this precipitation infiltrated as groundwater recharge, it is
estimated that the total groundwater recharge to the Basin is about 9,875 acre-feet per year
(AFY).
7.4.4 Groundwater Flow. In general, the movement of Groundwater through the
Basin is south to north, toward Lake Tahoe. Areas of Groundwater discharge within the Basin
occur along the upper reaches of the Upper Truckee River and Trout Creek, in wetland areas
situated near the south shore of Lake Tahoe and directly into Lake Tahoe, where basin-fill
deposits intersect the shoreline. Additional sources of Groundwater discharge include
Groundwater pumping, evapotranspiration and seepage to springs.
7.4.5 Groundwater Levels. The basin-fill deposits consist of sequences of sand and
gravels which are inter-layered with silts and clays. The sand and gravel deposits form the
principal water-bearing reservoirs (Aquifers), while the silt and clay deposits form confining
layers (aquitards)which retard the movement of Groundwater. Where these confining layers
separate adjoining Aquifers, the water level elevations measured in these Aquifers may differ. As
a result, Groundwater levels within the Basin may vary with respect to location and construction
of the Wells in which the water level is measured. Local fluctuations in Groundwater levels
occur within the Basin in response to seasonal changes in groundwater recharge,
evapotranspiration and the hydraulic influences of pumping Wells.
7.4.6 Overdraft Potential. The overall trend of the groundwater elevation data
indicates that extractions are not causing any chronic lowering of groundwater levels. As
groundwater levels have been relatively stable over a long-term period, changes in groundwater
storage are not apparent. Existing regulatory policies limiting growth within the Plan Area
further minimize the potential for the development of overdraft conditions within the Basin.
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7.4.7 Potential for Land Subsidence. Inelastic (i.e. irreversible) land surface �
subsidence can occur in a groundwater basin that contains compressible sediments if �
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groundwater levels decline substantially below the historically lowest groundwater level. This �
process can only occur once; therefore, if sediments have been previously compacted due to high �
lithostatic loads or previous low groundwater levels, then no further subsidence can occur. The �
sediments in the Basin have experienced loading due to its glacial history. Therefore, any �
` potentially compressible layers have already been compacted so that no further compaction can �
occur. Because of the geologic history and minimal overdraft potential, land subsidence is not �
� considered an issue of concern.
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; 7.4.8 General Water Quality. Groundwater within the Basin has excellent chemical �
; quality and is suitable for pomestic Use and public water supply. For most constituents, �
:; Groundwater within the Basin meets all drinking water quality standards, including California �
¢ Drinking Water Primary and Secondary Maximum Contaminant Levels (MCLs). However, �
's there have been few instances where, either because of the presence of natural or man-made �
`� Contaminants, MCLs have been exceeded. �
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`� 7.4.9 Natural Contaminants.The presence of these natural contaminants may limit �
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_ areas of the Basin from providing water supply or require expensive treatment and thereby
� reduce the volume of groundwater available for water supply to the community.
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7.4.10 Vulnerability to Man-Made Contaminants. Groundwater has been adversely
affected by releases of man-made contaminants and resultant degradation of groundwater
� quality. Areas of degraded groundwater quality persist and continue to impair water supplies
located near or within commercial areas of the Basin. j
' Section 7.5 Basin Manaeement Obiectives
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7.5.1 Overview of Basin Management Objectives. Basin Management Objectives �
(BMOs) are required in the Plan under the California Water Code(CWC) § 10753.7 (a) (1). �
BMOs are described in Section 8 of the Plan. Actions to be undertaken when there is failure to �
j meet BMOs goals for Groundwater Quality are presented in Section 7.7 of this Ordinance. '
7.5.1 BMO Goals for Groundwater Quality in the Basin. The Plan shall establish
; quantitative Basin Management Objectives that Maintain and Protect Groundwater Quality
consistent with AB 3030, SB 1938 and other regulations and policy.
(1) All groundwater supply wells in the Basin will meet drinking water
standards as defined by the State Water Resources Control Board Division of Drinking Water
(DDW) [formerly the California Department of Public Health (CDPH)].
(2) Groundwater quality in the Basin will not be impaired so as to affect its
beneficial use of current or potential future use of groundwater for municipal water supply as
defined by the LRWQCB Basin Plan.
(3) Detection of contaminants from regulated industrial and commercial
chemicals in any well in the Plan Area will be evaluated as to its potential as an emerging
groundwater quality threat to the water supply.
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(4) Information on areas of degraded water quality will be collected and
maintained in order to consider its effect on available water supply under the District's Methyl
Tertiary Butyl Ether(MtBE)policy and the development of future groundwater supplies.
7.5.3 Basin Monitoring Program. The purpose of the Basin Monitoring Program is
to protect and/or enhance the quality and quantity of water within the Basin. The Basin
Monitoring Program shall consist of the specific measures identified in the Plan and can include
data from both existing monitoring wells and new monitoring wells. The Basin Monitoring
Program may be modified by adding/removing wells over time based on the ongoing assessment
of groundwater conditions and modifications will be addressed in the Annual Reports and Plan
updates.
(1) Groundwater Level Monitoring. Groundwater level measurements will be
collected by the District at designated groundwater supply and monitoring wells as designated by
the Plan. Data will be collected consistent with protocols provided in the Plan and other
supporting documents. Additional groundwater level data will be compiled from other agencies
that collect data in the Basin.
(2) Groundwater Qualiry Monitoring. Samples for groundwater quality will
be collected by the District at all public water system supply wells in accordance with the
requirements of DDW. Groundwater quality samples will be collected at monitoring wells as
designated by the Plan, and collected consistent with protocols provided in the Plan and other
supporting documents. Additional groundwater quality data will be compiled from other
agencies that collect data in the Basin. Groundwater samples shall be sent to an accredited
analytical laboratory for chemical analysis within the appropriate holding times for specific
analytes.
7.5.4 Data Review. Data shall be reviewed with respect to historical data for each
sampling location to assess changes in trends. Groundwater quality data will be compared to
drinking water quality standards as defined by the DDW, and the water quality objectives
provided in the LRWQCB Basin Plan. All data from the Basin Monitoring Program shall be
reviewed by, or under the supervision of, licensed engineers, geologist, or hydrogeologists or
other Persons qualified in hydrology or hydrogeology.
7.5.5 Potential Actions. If Basin BMO Goals are not being achieved, the District
shall present its findings to the Stakeholder Advisory Group to gather additional input for
developing a course of action and determining whether making recommendations of actions to
the Board or regulatory agencies is necessary.
Section 7.6 Groundwater Management ProEram
7.6.1 Establishment of Stakeholder Advisory Group. The District shall appoint a
Stakeholder Advisory Group consisting of individual Persons who reside within the boundaries
of the District or who represent a governmental agency, and who have demonstrated their
commitment to protecting Groundwater resources. The Stakeholder Advisory Group shall: 1)
provide information and insight on key groundwater issues affecting groundwater management
of the Basin; 2) provide a framework to expand and improve interagency collaboration
particularly in the areas of regulatory oversight, coordinated land use planning, data collection
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and public education; and 3)provide review and input during updates to the Plan. The purpose �
of the group is also to enable citizens in the District and representatives of governmental �
agencies to provide a forum for the presentation of findings from groundwater quality �
monitoring and the evaluation of potential threats to groundwater supplies. The group will �
operate on principles of collaboration and consensus. Representation shall be balanced among �;.
the general interest categories as follows: California Regional Water Quality Control Board, �
Lahontan Region, EI Dorado County, Tahoe Regional Planning Agency, City of South Lake
Tahoe,National Forest Service, a Real Property Owner, an Operator, a water purveyor, a �
business community rate payer, a non-business community rate payer and such other persons as �`
� the District deems desirable or advisable. The Stakeholder Advisory Group may advise the �
3 District on all matters included within the purposes and provisions of this Division and may �
� comment on rules, regulations and procedures which may be considered for adoption by the �
� Board pursuant to this Division. �
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� 7.6.2 Public Education and Community Relations. It is essential to involve the �
# public and the commercial and industrial communities in the development and implementation of �'
� the Plan. Public education, public participation and community relations are an integral element �
� to Groundwater management. The District shall continue to provide Groundwater protection �
� educational services to the public through public presentations,public informational items and �
� references to Groundwater protection data available through other governmental agencies. �
� �7.6.3 Technical Investigations. The District may collect data and carry on technical
° and other investigations necessary to carry out this Division. All hydrogeological investigations �
; and studies carried out by, or on behalf of, the District shall be conducted by, or under the
� supervision of, licensed engineers,hydrogeologists or other Persons qualified in hydrology or �
� hydrogeology. The District and its authorized agents shall have the nght to enter upon any �
- property at any reasonable time within the District to the extent permitted by law. �
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� 7.6.4 Establishment of Wellhead Protection Areas. The District shall establish �
, wellhead protection areas in a manner which conforms to the methods contained in the DWSAP
� Program. The District shall delineate zones for the protection areas using the modified
'; calculated fixed radius method or other methods approved in accordance with the DWSAP
'� Program. The District shall also identify potentially contaminating activities in accardance with ;
the DWSAP Program. New monitoring wells may be located in areas to provide adequate
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warning time of potential contaminant plumes reaching water supply wells based on the DWSAP ,
BS and B10 source areas zones delineations. These maps will be provided to land use planning '
and regulatory agencies to help in their planning and oversight activities.
7.6.5 Vulnerability Analysis. The District shall develop a vulnerability analysis of
different areas of the Basin in accordance with the DWSAP Program. Based on the priorities
; identified in the vulnerability analysis, the District shall develop and implement a management
plan to prevent or minimize the potential impact of Contamination from the high priority areas
containing potentially contaminating activities.
7.6.6 Annual Report on Groundwater Conditions. The District shall annually
prepare a report on Groundwater supplies and conditions in the Plan Area, including progress on
implementation of Groundwater management goals and objectives. The report shall identify and
prioritize Groundwater quality problems in the Plan Area, propose specific actions and inter-
governmental agency coordination. The report may include such other information as the
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District determines applicable to Groundwater supplies, the Basin and the Plan Area. The report
shall be presented to the Board as part of a public hearing regarding the Groundwater supplies
and conditions within the Basin.
Section 7.7 District Actions in Response to Contamination
7.7.1 Aquifer Vulnerability. The District considers that releases of man-made
contaminants present a material risk of Contamination. The hydrogeology shows the Basin to be
highly vulnerable to the release of man-made contaminants as evidenced by the impairment of
groundwater supplies. The District finds it advisable and in the best interest of the District in
protecting the quality and quantity of Groundwater in the Plan Area,to establish and implement
a Basin monitoring program.
7.7.2 Potential Effects of Contamination on Water Supply. If contamination is not
remediated, this may result in the loss of portions of the Basin or increase costs to the District for
providing suitable water supply to the community. Areas of contaminated groundwater may
result in the long-term loss of usable Groundwater in storage in the Basin from beneficial use,
which is the same net effect as chronic overdraft.
7.7.3 Potential Actions. If new or increasing water quality issues are detected, the
District shall present its findings to the Stakeholder Advisory Group to gather additional input
for developing a course of action and determining whether making recommendations of actions
to the Board or regulatory agencies is necessary. If the water quality issue poses a clear and
immediate threat to the District's water supply and infrastructure, the District may provide
recommendations for immediate actions by the Board and inform the Stakeholder Advisory
Group. The District will take appropriate actions based on the recommendations of the Board,
District Staff and Stakeholder Advisory Group. Actions may include, but are not limited to, the 4;
following: y;
(1) No further action needed
(2) Continue to monitor the situation
(3) Conduct additional monitoring and/or install new monitoring wells to
better define the extent and concentrations of the potential contamination.
(4) Make a request to El Dorado County Environmental Management
Department and the California Region Water Quality Control Board, Lahontan Region to take
action to enforce groundwater cleanup.
(5) Implement immediate remediation and/or repair actions deemed necessary
to protect the public water supply and infrastructure and recover the costs from Responsible
Parties for the remediation and/or repair.
7.7.4 Documentation for Potential Cost Recovery. To document costs to address a
contamination issue, an implementation schedule along with an estimated budget including
engineering, consultant and legal fees and expenses, and District overhead, and a summary of
District enforcement actions, if any, shall be prepared.
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3
Section 7.8 Enforcement.
7.8.1 Violation. Violation shall mean any act or omission, or an attempt that
contravenes any of the provisions of this Division or other provisions of law.
7.8.2 Cease and Desist Order. The District may issue an administrative order
requiring any Responsible Party to cease and desist from the activity which is causing or
contributing to Groundwater contamination.
7.8.3 Court Ordered Restraining Order. The District may apply for a restraining
order against any Person who violates any section of this Division. The application for
restraining order shall comply with Code of Civil Procedure sections 513.010 and 525, et seq.,
California Rules of Court Rule 359 and other laws, as applicable.
7.8.4 Administrative Hearing.
7.8.4.1 Administrative Hearing Request. Any Person who receives a
_ cease and desist order or a notice that administrative fines and penalties are due may contest that
there was a violation or that he or she is the Responsible Party,by completing a request for
administrative hearing form and returning it to the District within twenty(20) days after the
District gives notice of the cease and desist order or of the administrative fines and penalties. In
the case of a request for an administrative hearing to review administrative fines and penalties,
the requesting party shall make an advance deposit of the fine or penalty at the time of
submitting the request for administrative hearing form.
7.8.4.2 Administrative Hearing Procedures. Upon receipt of a request
for administrative hearing form and deposit, if applicable, the District shall hold an
administrative hearing at the next regularly scheduled board meeting to determine whether the
recipient of the notice of violation is responsible for a violation of this Division. The hearing
shall be conducted pursuant to the United States Constitution and California Government Code
section 11400, et seq.
7.8.5 Administrative Fines and Penalties. Any Person who violates any section of
this Division shall be subject to administrative fines and penalties pursuant to Government Code
section 53069.4. Each day's continuance of a violation of an ordinance shall constitute a separate
and additional violation.
(1) Amount. The District may impose a fine or penalty not to exceed$100 for
a first violation, $200 for a second violation of the same section of this Division within one year,
and$500 for each additional violation of the same section of this Division within one year.
(2) Notice. The District shall notify the Responsible Party responsible for a
violation of this Division that administrative fines and penalties are due. Such notice shall be in
writing, and shall be delivered by first-class mail addressed to the Responsible Party at the
Responsible Party's last known address, and posted on the property where the violation occurred.
Notice of an administrative fine or penalty shall contain the following information:
(a) The date of the violation;
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� (b) The address or a definite description of the location where the
violation occurred;
(c) The section of this Division violated and a description of the
violation;
(d) The amount of the fine for the violation;
(e) A description of the fine or penalty payment process, including a
description of the time within which and the place to which the
fine or penalty shall be paid;
(fl An order prohibiting the continuation or repeated occurrence of the
ordinance violation described in the notice; and
(g) A description of the administrative review process, including the
time within which the administrative fine or penalty may be contested and the place from which
a request for hearing form to contest the administrative fine or penalty may be obtained.
(3) Payment. T'he fine or penalty shall be paid to the District within thirty
(30) days after posting of the notice of violation. Any fine or penalty paid shall be refunded if it
is detennined, after a hearing,that the Person charged was not responsible for the violation or
� that there was no violation as charged.
(4) Collection. Remedies for collecting and enforcing fines and penalties for
violation of this Division are cumulative and any and all may be used alternatively, and none of
the remedies are exclusive. At its discretion, the District may employ the following mechanisms
for the collection of fines and penalties:
(a) Fines and penalties imposed for violation of this Division may be
added to and become part of the charges fixed by the District for commodities and services
furnished to the Real Property where the violation occurred if the Real Property is owned,
controlled, or in the possession of the same Person who owned, controlled, or was in possession
of it during the time the violation occurred,pursuant to California Water Code § 10754.
(b) Fines and penalties imposed for violation of this Division may be
added to and become part of the annual assessment levied upon the land where the violation
occurred if the Real Property is owned, controlled, or in the possession of the same Person who
owned, controlled, or was in possession of it during the time the violation occurred, pursuant to
California Water Code § 10754, and in accordance with Public Utilities Code § 16469. Fines
and penalties added to an assessment are a lien on the land, in accordance with Public Utilities
Code § 16470.
(c) Fines and penalties imposed for violation of this Division may
become a lien on the land where the violation occurred if the District records a certificate of the
amount of fines and penalties due, pursuant to California Water Code § 10754 and Public
Utilities Code § 16472.1.
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�
s
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�
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(d) Fines and penalties may be collected in the same manner,by the
same Persons, and at the same time together with the general taxes levied for the District, „
pursuant to California Water Code § 10754 and Public Utilities Code §§ 16641 et seq.. �
�.
(e) Fines and penalties may be collected by an action in any court of ;
competent jurisdiction against a Person or Persons who owned the Real Property where the �
violation occurred for the collection of all fines and penalties, pursuant to the provisions of the �
Public Utilities Code § 16647. ''
[
r
7.8.6 Judicial Review. Any Person aggrieved by the District's final administrative �
decision to impose fines and penalties for violation of this Division may obtain review of the �
administrative decision by filing an appeal to be heard by the appropriate court in El Dorado �
County in accordance with the timelines and provisions stated in California Government Code �
section 53069.4. Any Person aggrieved by the District's final administrative decision to issue �
fines and penalties may obtain review of the administrative decision by filing a petition for writ �
of mandate in the court in accordance with Government Code section 11523 and Code of Civil �
Procedure section 1094.5, et seq. �
�
7.8.7 Liability. The Real Property Owner and the Operator shall be jointly and �
severally liable for compliance with the provisions of this Division. The Real Property Owner
and Operator may allocate liability between themselves by contract or otherwise but any such
allocation shall not effect compliance with this Division nor be binding upon the District. The
District in pursuing its remedies may proceed against Real Property Owner, the Operator, or �
= both, as determined by the District in its sole discretion. �
i
�
7.8.8 Rules and Regulations. The District shall have the authority to promulgate j
3 rules, regulations and procedures to implement and carry out the intent and purpose of this Plan, '
provided such rules, regulations and procedures are consistent with this Plan and reasonably
.�
related to the intent and purpose of this Plan. �
Section 7.9 Costs of ImplementinS Plan. ',
7.9.1 Findings. The District finds and declares that the Plan is necessary for the
protection of Groundwater resources within the District, and that it is in the public interest and
will benefit all Persons residing within the Plan Area. The District further finds and declares that
specific categories of activities pose greater threats to Groundwater quality than others, and that
Persons engaged in those activities should be responsible for a proportionate share of the costs of
implementing this Plan based on the proportionate risk posed by their activities.
7.9.2 Charges. The District may include the costs associated with the Plan in the
District's charges for commodities and services in accordance with Public Utilities Code section
16467 and the ordinances, rules and regulations of the District. The District may include the
costs of the Plan in(1) general charges for commodities and services, and charge the costs
uniformly to all District customers; (2) special charges for commodities and services, and charge
the costs to a special class of customers engaged in activities which increase the potential for
Groundwater Contamination; or(3) a combination of general and special charges.
7.9.3 Special Taxes. The District may assess special taxes to raise funds for carrying
on its operations and paying its obligations, in accordance with Public Utilities Code section
—42—
16641, et seq. All special taxes assessed by the District must be applied uniformly to all
taxpayers.
7.9.4 Replenishment Assessments. The District may impose Replenishment
assessments for the collection of costs associated with the removal of Contaminants from the
Groundwater supplies of the District, in accordance with California Water Code section 60300,
et seq.
7.9.5 Groundwater Management Account. All monies collected by the District
pursuant to this Division shall be placed in the District's Water Enterprise Fund.
Section 7.10 Amendment/Termination.
7.10.1 Amendment/Termination. This Ordinance may be amended by the District
from time to time after its adoption, or may be terminated at any time by the District.
Amendments or termination will be considered and approved, or disapproved, only at a noticed
public hearing by the District.
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6eneral Manager
Richard H.5olbrig
� . �sso . �
O ` '� a o e Directors
U Chris Cefalu
JameS R.Jonee
'M'�" • � Randy Vogelge5ang
I'u b I i c U ti I ity D 15tri ct Kelly 5heehan
Eric 5chafer
1275 Meadow Crest Drive•South Lake Tahoe•CA 96150-7401
Phone 530 54�4-64-74•Fax 530 541-06'i4•www.stpud.uy
BOARD AGENDA ITEM
TO: Board of Directors
FROM: Richard Solbrig, General Manager
MEETING DATE: December 4, 2014
ITEM- PROJECT NAME: Resolution No. 2968-14
REQUESTED BOARD ACTION: Adopt Resolution No. 2968-14 in Appreciation of Director
Schafer
DISCUSSION: Resolution No. 2968-14 is in appreciation of Director Schafer for his 14
years of service and dedication to the South Tahoe Public Utility Board of Directors.
SCHEDULE:
COSTS:
ACCOUNT NO:
BUDGETED AMOUNT AVAIIABLE:
ATTACHMENTS:
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: Water/Sewer
GENERAL MANAGER: YES NO
CHIEF FINANCIAL OFFICER: YES NO
-45-
i
1 RESOLUTION NO. 2968-14
2 A RESOLUTION OF THE BOARD OF DIRECTORS OF THE
SOUTH TAHOE PUBLIC UTILITY DISTRICT HONORING
3 DIRECTOR ERIC SCHAFER FOR 14 YEARS OF SERVICE
4
WHEREAS, ERIC SCHAFER assumed office in 2001 and has served 14 years on the
5 South Tahoe Pubfic Utility District Board of Directors; and during his term of office he
6 served as Board President for 6 years and 2 years as Vice-President of the Board of the
7 South Tahoe Public Utility District; and
8
WHEREAS, during his tenure, DIRECTOR SCHAFER served on the Finance
9
Committee for 14 years, g�iding the preparation of the District's budget during each
10
one of his years on the Board;
11 �yHEREAS, DIRECTOR SCHAFER, dedicafied many hours to understand the District's
�2 Ordinances, issues facing the District, reviewed in-depth financials and thoughffully
13 prepared for his role as Board Member;
14 WHEREAS, DIRECTOR SCHAFER, demonstrated superior leadership skills in guiding
15 many Board discussions regarding District business with integrity and strong moral
16 character to accomplish one common goal for the greater good of the community;
17 WHEREAS, DIRECTOR SCHAFER lead by example by listening to the public, asked
�$ questions and could be counted upon to attend required meetings fully prepared;
WHEREASE, DIRECTOR SCHAFER helped strike a balance between rate increases
19
to fund District CIP projects and affordability of District services for its customers;
20 WHEREAS, DIRECTOR SCHAFER served as the District's representative for the
2� California Association of Sanitary Districts;
22 NOW, THEREFORE BE IT RESOLVED, that the South Tahoe Public Utility District does
23 hereby express deep appreciation to DIRECTOR SCHAFER for his many hours of public
24 service to the people of South Lake Tahoe, California.
25
WE, THE UNDERSIGNED, do hereby certify that the above and foregoing
26 Resolution No. 296&14 was duly adopted and passed by the Board of Directors of the
27
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29
30 -4�-
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F �
s � South Tahoe Public Utility District at a regularly scheduled meeting held on the 4'n �
�
2 day of December, 2014, by the following vote: �
�;
4 AYES: a
3 F
' NOES: �
�
� 4 `
ABSENT: �
5 �
Eric Schafer, Board President �
3 6 South Tahoe Public Utility District
�
7
� ATTEST:
8
g Melonie Guttry, Clerk of the Board
>
10 �
� 11
� 12 g
x �
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e Resolution No.296&14
30 Page 2
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PAYMENT OF CLAIMS
FOR APPROVAL
December 4, 2014
Payroli 11/25/2014 383,185.48
Totai Payroll 383,185.48
ADP & Insight eTools 0.00
AFLAC/WageWorks claims and fees 498.35
BBVA Compass Bank 0.00
BHFS legal services 36,157.23
CDS health care payments 4,922.67
Total Vendor EFT 41 ,578.25
Accounts Payable Checks-Sewer Fund 353,857.70
Accounts Payabie Checks-Water Fund 233,044.35
Accounts Payable Checks-Grants Fund 0.00
Total Accounts Payabie 586,902.05
Grand Total 1,011,665.78
Pavroll EFTs � Checks 11/25/2014
EFT CA Employment Taxes & W/H 17,060.15
EFT Federal Employment Taxes & W/H 88,912.07
EFT CaIPERS Contributions 28,424.62
EFT Great West Deferred Comp 22,000.45
EFT Stationary Engineers Union Dues 2,478.52
EFT Retirement Health Savings 0.00
EFT United Way Contributions 170.00
EFT Employee Direct Deposits 219,283.33
CHK Employee Garnishments 1 ,273.83
CHK Employee Paychecks 3,582.51
Total 383,185.48
-49-
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-60-
General Manager
Richard H.5olbrig
� ♦ �oW f
�/gr � Directors
��� a u a oe
ChriS Cefalu
JameS R.JoneS
�_ �~� �u b I i c U ti f ity p i�-�ri ct Randy Vogelgesang
Kelly 5heehan
Eric Schafer
1275 Meadaw CreSt Drive•South Lake Tahoe•CA 96150-7401
f'hone 530 5�4�4-6474•Fax 530 541-06i4•W4VW.5t�t.ld.U5
BOARD AGENDA ITEM 1 5a
TO: Board of Directors
FROM: Tim Bledsoe, Customer Service Manager
Debbie Henderson, Accounting Manager
MEETING DATE: December 4, 2014
ITEM- PROJECT NAME: Conference with Legal Counsel - Existing Litigation
REQUESTED BOARD ACTION: Direct Legal Counsel
DISCUSSION: Pursuant to Section 54956.9(a) of the California Government code,
Closed Session may be held for conference with legal counsel regarding existing
litigation: EI Dorado County Superior Court Case SC20120227 GRCLT Condominium vs.
South Tahoe Public Utility District.
SCHEDULE:
COSTS:
ACCOUNT NO:
BUDGETED AMOUNT AVAILABLE:
ATTACHMENTS:
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: Sewer
GENERAL MANAGER: YES _ NO
CHIEF FINANCIAL OFFICER: YES NO
-61-
General Manager
Richard H.Solbrig
��� • � Directors
� � �� a �� ChriS Cefalu
V U James R.JoneS
�" I'u b l i c U�i l i ty D i stri�� Randy Vogelgesang
Kelly 5heehan
Eric 5chafer
1275 Meadow CreSt Drive•South lake Tahoe•CA 96150-7401
f'hone 530 54�4-6474•Fax 530 54-1-06i4•www.�tpud.us
BOARD AGENDA ITEM 1 5b
TO: Board of Directors
FROM: Richard H. Soibrig, General Manager
MEETING DATE: December 4, 2014
ITEM- PROJECT: Conference with Legal Counsel - Existing Litigation
REQUESTED BOARD ACTION: Direct staff.
DISCUSSION: Pursuant to Section 54956.9(a) of the California Government Code,
Closed Session may be held for conference with legal counsel regarding existing
litigation: STPUD vs. Lakeside Park Association, et al., County of EI Dorado, Superior Court
Case No. SC20010165.
SCHEDULE:
COSTS:
ACCOUNT NO:
BUDGETED AMOUNT REMAINING:
ATTACHMENTS:
CONCURRENCE WITH REQUESTED ACTION: CATEGORY: GENERAL
MANAGER: YES �/� NO
CHIEF FINANCIAL OFFICER: YES NO
-63-