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Resolution No. 6725 ~, " " 1 R~SOLUlKULNO.6725 2 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF VERNON APPROVING AND AUTHORIZING THE EXECUTION OF UNIVERSAL CARE GROUP SUBSCRIBER AGREEMENT (90-100) BY AND BETWEEN THE CITY OF VERNON AND UNIVERSAL CARE 3 4 5 WHEREAS, the City Council of the City of Vernon has 6 three agreements with United of Omaha Life Insurance Company ("Omaha") for administering the City's employee health care plan, 7 8 two Administrative Service Agreements (GUSI-2R04 AND GUSI-2R05) and an Exclusive Provider Option Payor Agreement (EPSI-4H15); and WHEREAS, Mutual of Omaha has formed a partnership with Universal Care HMO to replace the Exclusive Provider Option Payor 9 10 11 12 13 Agreement; and WHEREAS, the City of Vernon employees having an Exclusive Provider Option will be requested to sign statements accepting Universal Care HMO as their medical program of choice; 14 15 16 and 17 WHEREAS, the effective date of replacement is January 1, 18 1996; and 19 WHEREAS, the Administrative Service Agreements will 20 21 continue in full force and effect. NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF 22 THE CITY OF VERNON AS FOLLOWS: 23 SECTION 1: The City Council of the City of Vernon 24 hereby finds and determines that the recitals contained 25 hereinabove are true and correct. 26 SECTION 2: The City Council of the City of Vernon 27 hereby approves the replacement of the Exclusive Provider Option 28 ... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 .. Payor program with the universal Care HMO program, effective January 1, 1996, subject to the review and approval by the City Attorney. SECTION 3: Upon approval as to form by the City Attorney, said Agreement shall be received and filed by the City Clerk. SECTION 4: The City Council of the City of Vernon hereby authorizes the Mayor and the City Clerk, upon approval as to form by the City Attorney, to execute said Universal Care Group Subscriber Agreement (90-100) for, and on behalf of, the City of Vernon. SECTION 5: The City Clerk of the City of Vernon shall certify to the passage of this resolution, and thereupon and thereafter the same shall be in full force and effect. APPROVED AND ADOPTED this 5th day of December, 1995. A~/~ BRUCE V. MAtKENHORST, City Clerk -2- . , ~ ~ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 . J j. ." STATE OF CALIFORNIA ) ) ss COUNTY OF LOS ANGELES ) I, BRUCE V. MALKENHORST, City Clerk of the City of Vernon, do hereby certify that the foregoing Resolution, being Resolution No. 6725 was duly adopted by the City Council of the City of Vernon at a regular meeting of the City Council duly held on Tuesday, December 5, 1995, and thereafter was duly signed by the Mayor of the City of Vernon. (SEAL) -3- MEMORANDUM TO: Bruce V. Malkenhorst, City Administrator FROM: Joan Francone, Risk Manager DATE: March 19, 1997 SUBJECT: U1~TIVERSAL CARE HMO Please find attached for execution. the Universal Care HMO Group Subscriber Agreement. This program became effective commencing January 1, 1996 and will continue until the renewal date of January 1, 1998. Please contact me if there are any questions. JF/ca Enclosure c: City Attorney _ _ MEMORANDUM TO; Bruce V. Malkenhorst, City Administrator FROM: Joan Francone, Risk Manager DATE: March 19, 1997 ~ ~ ~J ~ ~J/" SUBJECT: UNIVERSAL CARE HMO ~ G~ Please find attached for execution the Universal Care HMO Group Subscriber Agreement. - This program became effective commencing January 1, 1996 and will continue until the renewal date of January i, 1998. Please contact me if there are any questions. JF/ca Enclosure c: City Attorney c . ~ t INTER-OFFICE- MEMORANDUM DATE: April 1, 1997 TO: Joan Francone, 'sk Manager/Personnel Assistant FROM: Gloria J. Oro c Chief Deputy City Clerk SUBJECT: UNIVERSAL CARE OUP SUBSCRIBER AGREEMENT 90-100 Attached hereto is a fully executed duplicate original of the above referenced agreement for you to forward to the appropriate official at Universal Care. I have retained a duplicate original for our files. GJO/hr Attachment UNIVERSAL CARE _ GROUP SUBSCRIBER AGREEIVIENT 90-100 THIS GROUP SUBSCRIBER.' AGREEMENT (the "Agreement") is entered - into between City of Vernon (the "Subscriber Group") and Universal Care, a California corporation (the "Plan" or "Universal Care") which operates a health care service plan licensed and regulated by the Commissioner of .Corporations of the State of California. under the Knox- Keene Health Care Service Plan Act of 1975, as amended. This .Agreement shall be effective commencing January 1, 1996;. and shall - continue. until its termination or non-renewal as hereinafter provided. This Agreement consists of this signature page, the terms: and conditions that follow, Schedules A, B and C and any duly executed addenda or amendments. The Renewal Date shall be :January 1,1998 Group's minimum enrollment is 51 Group Number is 1OOIOA The prepayment-fees the Group mustpay in exchange for the Plan's basic benefits are set forth in Schedule C. The prepayment fees for the Plan's supplemental'benefits, if any, are set forth. in the supplemental benefit rider(s) for those. benefits. IN WITNESS..WHEREOF, the parties have caused this. Agreement to be executed at Los Angeles. County,.California on this fifteenth day of August, 1996: AL CARE SUBSCRIBER GROUP:. J By: ~ BY: Jay B. is Executive Vice President. Date: August 15,1996 Date:. ~ / ' 9 ~ ^y~,~~yow cr [Address] ONLY THE PRESIDENT OR A VICE PRESIDENT OF UNNERSAL CARE M[AY SIGN THIS AGREEMENT ON ITS BEHALF. ATTEST: By. BRUCE V. MALKENHORST, City Clerk LARGE GROUP SUBSCRIBER AGREEMENT - 3/6/96 Y ppPROVED AS TO FORM: By : ~ ~ DAVID B: BREARLEY Cit Attorney AMENDMENT TO UNIVERSAL CARE GROUP SUBSCRIBER AGREEMENT 90-100 The Universal Care Group Subscriber Agreement is hereby amended in the following particulars: Section 1. Definitions, (w) "Service Area" is revised to read: - (w) "Service Area" is the geographic area in which Universal Care is licensed to arrange for Medical and Hospital Services in the State of California by the California Department of Corporations. Service Area includes, but is not limited to, the counties shown on Schedule B. All other provisions of the Universal Care Group Subscriber Agreement 90-100 remain unchanged. servicearea amend 4/8/96-ctyvernon 1. DEFINITIONS For the purpose of this Agreement, the terms set. forth in this section shall have _ the meanings described below, except where the context indicates that such meanings aze not intended. In the event of any dispute withxegazd to the definition of any of the within terms, the parties agree to use the definitions for such terms as set forth in the Knox-Keene Health Care - Service Plan Act of 1975, as amended. (a) "Benefits" and "Covered Services" aze those hospital, medical, surgical and other health care services, procedures, tests, and medicines,. devices and appliances listed in Schedule A of this Agreement under the heading "Benefits", except as limited and qualified by the limitations and exclusions in that Schedule and the other provisions of this Agreement. (b) "Child" includes a natural or legally adopted child of Subscriber. It also includes a stepchild of the Subscriber who depends on the .Subscriber for support and maintenance and resides with the Subscriber in a regular pazent-child relationship. _ (c) "Copavment" means an additional fee charged to a Subscriber or Enrollee which is approved by the Commissioner, provided. for in the Plan contract, and disclosed in the Evidence of Coverage. Percentage of charges copayments indicate a percentage of the charges the Plan has negotiated with the Provider. (d) "Custodial Care" means non-Medically Necessary personal health care. - primarily to assist a member in the activities of daily living, but not care that requires skilled nursing services on a continuing basis. Such care includes, but is not limited to, .assistance in walking, getting in or out of bed, dressing, feeding, bathing, or using the lavatory, prepazation of - special diets and supervision of medication schedules. Custodial care does not require the continuing attention of trained medical or paramedical personnel. .Whether care is custodial shall be determined by the Universal Care Medical Director. (e) "Dependent" means a spouse or child of Subscriber who is eligible and enrolled in accord with this Agreement. (f) "Enrollee" or "Member" means a person who is eligible and enrolled under _ this Agreement as a Subscriber or a Dependent and is entitled to the benefits available under this Group Subscriber Agreement in return for the payment required to be made. to the Plan in accordance with'the provision of said Agreement. (g) "Exclusion" is any provision of this Agreement whereby coverage for a specified hazard or condition or method of diagnosis or treatment is entirely eliminated. - UC-90100.gsa 06/26/96-ctyvemon 2 (h) "Experimental" means the medical treatment, procedure, drug or product: (1) is classified by the U.S. Food and Drug Administration as experimental or restricted to investigational use, or (2) is not widely recognized as proven and effective for the illness, injury or medical condition in question. (i) "Fee-for-service rates" means the fees or charges the participating provider _ reasonably and customarily charges persons who are not members of Plan or other prepaid managed health plans. (j) "Health statement" means a report of certain information about an individual's health history or conditions that must be submitted for each person applying for enrollment. (k) "Hospital" means a health ,facility licensed by the state in which it is located to provide general acute care hospital services to registered. bed patients on a 24-hour-a- day, 7-day-a-week basis. For purposes of surgery benefits, it includes free-standing ambulatory surgery centers that meet state licensing requirements. (1) "Inpatient" refers to services a member receives on a physician's orders while. admitted. to a hospital, a psychiatric or substance abuse treatment facility or a skilled _ nursing facility as a registered bed patient. (m) "Late Enrollee" means an eligible employee or dependent who has declined enrollment in the Plan. at the time of the initial enrollment period and who subsequently :requests enrollment in the Plan. An eligible employee or dependent shall not be considered a Late Enrollee if (1) the individual has certified that he or she was covered under another employer health benefit plan during the initial. enrollment period, 'has lost that coverage and requests enrollment within 30 days after termination of coverage; (2) the employee elected a different plan offered through the employer during the initial enrollment period; (3) a court has ordered - coverage fora spouse or minor child and request for enrollment is made within 30 days of the court order. (n) "Limitation" means any provision other than an exclusion which restricts coverage under this Agreement for an otherwise Covered Service. (o) "Medically Necessary" means that a covered service is needed by the enrollee and is necessary to maintain the health of an enrollee consistent with professionally _ recognized standards. of care: (1) in the judgment of the Universal Care participating physician in charge of the Member's care or (2) in the judgment of the Universal Care Medical Duector if a Non-Participating physician is in charge of the Member's care. UC-90100.gsa 06/26/96-ctyvemon 3 (p) "Non-participating Provider" means a physician or other Provider of - covered services who does not. have a contract with Universal Care or with a Universal Care Medical Group to provide such services to the Plan's members. "Open Enrollment" refers to the period of time, not less often than thirty (30) days a year, agreed. to by the Plan and Subscriber Group, during which any person eligible to be a Subscriber under this Agreement may apply to enroll him/herself and eligible dependents or may renew or terminate such enrollment. (r) "Outpatient" means an individual. receiving Hospital or other medical. services under the direction of a physician or other health care Provider, but novas an inpatient. (s) "Participating. Physician", "Particinatin Hospital"~ "Participating Pharmacy" and/or "Participating Providers" refer to .health care providers who are employed. by or are under contract with Universal Care or a Universal Care Medical Group to provide Covered Services to members. _ (t) "Plan" shall refer to Universal Care,. a California Corporation. which operates a health care service plan licensed by the State of California under the Knox-Keene Health Care Service Plan Act of 1975, as amended. (u) "Proper Referral" means a procedure in which a Member is given authorization to see anon-participating or non-contracting. Provider by a Participating Physician, Participating Hospital and/or Participating Provider and such authorization is approved by Universal Care's Medical Director or designee. - (v) "Provider" means any professional person, organization,. health facility, or other person or institution licensed to .provide certain health care services by the State of California to deliver or furnish health care services. (w) "Service Area" is the geographic .area in-which Universal Care is licensed to _ arrange for Medical and Hospital Services in the State of California by the California Department of Corporations. Service Area includes, but is not limited to, the counties shown on Schedule B. (x) "Skilled Nursing Facility". refers to a skilled nursing facility or skilled nursing unit of a legally operated hospital, licensed by the State of .California as a 'skilled nursing facility' or any similar institution certified under Titles XVIII and XIX of the Social Security Act, and which is under contract with Universal Care. UC-90100.gsa 06/26/96-ctyvernon 4 (y) "Subscriber" means the Member who is responsible for payment to the Plan or whose employment or other status, except for family dependency, is .the basis .for eligibility for membership in the Plan. (z) "Subscriber Group" is the organization or company which has entered in .this Group Subscriber Agreement with the Plan. under which benefits are made available to eligible group members and their dependents. (aa) "Totally Disabled" means (i) with respect to a Subscriber, one who, because of illness or injury, is prevented from engaging in any occupation for wages or profit. for which. he is qualified based on education or training:. (ii) with respect to a Dependent, one who, because of illness or injury, is prevented from engaging in substantially all of his or her normal activities. (ab) "Universal Care Medical Group" means: (1) medical offices owned and operated by Universal Care and (2) independent medical groups which contract with the Plan to provide primary care or "first contact" medical services to Universal Care members at their _ offices. Each Subscriber is to select a Universal Care Medical Group and the Subscriber .and his or her Dependents should each. select an individual. physician within that Medical Group as his or her primary physician. 2. ELIGIBLE ENROLLMENT AND EFFECTIVE DATE OF COVERAGE (a) Eli ibili To be eligible to enroll and to remain. enrolled, a Subscriber and Dependents must satisfy the following requirements: (i) A Subscriber must be an active, full time employee of the. Subscriber Group as defined in the Subscriber Group's Accepted Application. The "Accepted Application" is incorporated in this Agreement by reference .and consists of the Universal Care Group Application and. Participation Request submitted by the Subscriber Group to Universal- Care in the form and on the terms in which it is accepted by Universal Care, including; for instance, the _ Plan's "exceptions" or acceptance letter. Directors, part-time employees and employees on leaves of absence are eligible only if Universal Care specifically agrees in the Accepted Application or in an amendment to this Agreement that they are eligible. Substitute or temporary _ _ UC-90100.gsa 06/26/96-ctyvemon 5 employees are ineligible. An employee's eligibility may also require the expiration of a waiting period as specified in the Accepted Application. (ii) Eligible Dependents are the Subscriber's spouse and each Child of Subscriber. A stepchild of the Subscriber shall be deemed to be eligible. as a Child of the .Subscriber if the Child resides with the Subscriber in a regular parent-child relationship and _ depends on Subscriber for support and maintenance. A Child is eligible until his or her 19th birthday, except the age limit is the 24th birthday if the Child is a full-time student in an accredited secondary school or college or university. All Children must be unmarried and legal dependents of Subscriber. Children of Subscriber's Children are not eligible or covered, except as stipulated in Section 2.(c)ii. Mentally retarded or physically handicapped Dependent children will be offered continued coverage beyond the above stated age restrictions, if as a results of such retardation or handicap the Dependent child is incapable of self-sustaining employment and is chiefly dependent upon the Subscriber for support and maintenance. Subscriber must provide proof of such incapacity to Plan within thirty-one (31) days. of the Dependent Children age limitation and upon the request of such information by the Plan afterwards. Plan may make frequent requests for information but no more frequently than annually after the two-year period following child's attainment of limiting age. All coverage for such dependent children will end when such children are capable of self-sustaining employment and are no longer -dependent on the Subscriber. (iii) To be and remain eligible, a Subscriber and each Dependent must reside continuously within the service area, except a Child attending school outside the service area may remain enrolled, if otherwise eligible. A Child attending school, like members who are temporarily outside the service area, will be covered for out-of--area emergencies. See Section 7(iii} on Emergency Care. All other services must be obtained within the service area, and be - provided or arranged or authorized, except in an emergency, by a Universal Care Medical Group. (iv) No one is eligible to enroll hereunder while covered under any of the. Subscriber Group's alternative medical and hospital. benefit programs or while covered, as a retiree or enrolled in a Subscriber Group of less than twenty (20) employees, under any ..other health benefits Plan to which an effective assignment of federal Medicare benefits has been made or who is eligible for federal Medicare benefits and fails to enroll under Medicare Parts A and B and/or fails to effectively assign his or her Medicare benefits to the attending Medical Group. UC-90100.gsa - 06/26/96-ctyvemon 6 (b) Enrollment. (i) How to apply for enrollment. Each person who is eligible to enroll as a Subscriber may apply for coverage by submitting a completed enrollment form and a completed .health statement to the Subscriber .Group no later than thirty (30) days after he or she first becomes eligible or during an open enrollment period. The enrollment list must identify a1T _ _ dependents the subscriber wishes to enroll. Plan will provide Subscriber Group with enrollment forms. A subscriber may apply to add an eligible dependent by submitting a completed enrollment form within thirty-one (31) days of the Dependent's first becoming eligible or during - an open enrollment period. (ii) Health statements. If the Subscriber Group and the Plan agree (on the - signature page or an amendment to this Agreement) that health statements are required, a health statement must be submitted along with the enrollment form as part of the application for each person who is to be enrolled under this .Agreement except for a newly born or newly adopted Child_for whom an enrollment form is submitted to Plan withinthirty-one (31) days. after birth or placement with the Subscriber for adoption. Plan will provide Subscriber Group with health statement forms. Plan reserves the right to reject an enrollment of an otherwise eligible person based on the late submission (as determined under (b)(i) above) or incompleteness of a health ..statement. (c) Effective Date of Coverage. - (i) Persons enrolled at the beginning of the Agreement. The effective date of coverage (or the date of enrollment) is the effectivedate specified on the signature page of this Agreement for each person whose name appears on the initial enrollment list the Subscriber - Group delivers to the Plan. pursuant to Section 2(b)(i) above, if the following conditions are met: (1) that person is eligible on that date; (2) his or her completed enrollment form has been submitted; (3) his or her health statement (if required) is timely submitted. and is accepted by the Plan; and (4) the Subscriber Group timely remits the prepayment fees. (ii) Newly eligible Subscribers and Dependents. If a person becomes eligible as a subscriber (or dependent) within the time limits specified in paragraph 2(b) above, the effective date of coverage is the first day of the month for which the person's name appears in the _ _ monthly enrollment list the Subscriber Group delivers to Plan pursuant to section 2(b)(i) above, provided that the other four (4) conditions set forth in paragraph 2 (c)(i) are fulfilled for each person. However, a newly born or newly adopted Child of a Member is automatically enrolled as a dependent upon birth or placement. in the custody of the Member for adoption up to thirty- one (31) days.. A completed enrollment form. and health statement must be submitted within the aforementioned thirty-one (31) days after birth or adoption for coverage to continue for newly - born or newly adopted child beyond thirty-one (31) days. UC-90100.gsa 06/26/96-ctyvernon 7 (iii) .Open enrollment. The effective date of coverage of persons enrolling during an open enrollment period will be as decided by the Plan and Subscriber Group. The four conditions listed in paragraph 2(c)(i) above will apply. (iv) Late enrollees. The enrollment of a person who does not submit a complete application. within the time limits set forth above will be subject to a twelve (12) month waiting period from the date of the. Late Enrollee's application for coverage. The Employer agrees to inform it's employees of the availability of coverage and. the provision that those. not electing coverage must wait one year from the. date of application to obtain coverage through the group if the employee later decides he or she would like to have coverage. An eligible employee or Dependent shall not be considered a Late Enrollee if any of the following is applicable: (1) The individual meets all of the following requirements: (a) The individual was covered under another employer health benefit plan at the time the individual. was eligible to enroll (b) The individual certified, at the time of the initial enrollment that coverage under another employer health benefit plan was the reason for declining enrollment provided .that, if the individual was covered under another employer health plan, the individual was given the opportunity to make the certification required, and was notified that failure to do so could result in later treatment as a Late Enrollee. (c) The individual has lost or will lose coverage under another employer health benefit plan as a result of termination of employment of the individual. or of a person through whom the individual was covered as a dependent,: change in employment status of the .individual or of a person through whom the individual was covered as a dependent, termination of the other plan's coverage, .cessation of an employer's contribution toward an employee or dependent's coverage, death of a person through whom the individual was covered as a dependent, or divorce. (d) The individual requests enrollment within 30 days after .termination of coverage, or cessation of employer contribution toward coverage provided under another employer health benefit plan. (2) The individual is employed by an employer that offers multiple health benefit plans and the individual elects a different plan during an open enrollment period. (3) A court has ordered that coverage be provided .for a spouse or UC-90100.gsa 06126/96-cryvernon g minor child under a covered employee's health benefit plan and request for enrollment is made within 30 days after issuance of the court order. (4) Acceptance of the individual by the Plan after screening the individual by Plan Health Statement. If the Plan accepts the individual under this. provision and it is later determined that the Health Statement did not disclose alI medical conditions, the Plan may terminate the individual retroactively to the effective date of coverage. The individual will. be considered a Late Enrollee and will not be eligible to reenroll until the expiration of the 12 month waiting period. (v) Delayed effective date for hospital inpatients. A person. who is a hospital - inpatient on an otherwise effective date of coverage will not be covered until discharged from the hospital. 3. PRINCIPAL BENEFITS .AND COVERAGES. INCLUDING EXCLUSIONS. LIMITATIONS. AND COPAYMENTS APPLICABLE TO SPECIFIC .PRINCIPAL BENEFITS AND COVERAGES Enrollees shall be entitled to the medical and hospital services as set forth in Schedule A which is attached hereto and incorporated by reference herein: This schedule establishes the medical and hospital services which are available without. charge (designated as "No charge" in the schedule), those services for which enrollees are obligated to pay a copayment to the Provider, and those services which are excluded hereunder: The amount of the copayment which the Provider is permitted to charge for specific services is set forth under the heading "copayment Required". SCHEDULE A IS AN ESSENTIAL PART OF THIS CONTRACT. PLEASE REVIEW IT CAREFULLY. 4. RELATIONSHIP BETWEEN PARTIES The relationship between Plan and the physicians, hospitals and other .health care Providers who are its Participating Physicians, Participating Providers, Participating Hospitals. is that of an independent contractor relationship (except for the employees of Universal Care who _ _ provide services. at the medical offices owned and operated by Universal Care); they are not agents or employees of Universal Care, and this Plan and its employees are not employees or .agents of those Participating Providers. UC-90100.gsa 06/26/96-ctyvernon 9 Each physician, Hospital or other Provider of health caze services is to maintain. a direct. physician-patient,. hospital-patient or other such relationship with Universal Caze members to whom it provides services, and. is solely responsible for its decisions as to what health caze diagnostic, treatment or other services aze required. 5. PLAN MEMBER IDENTIFICATION The Plan shall make available the Benefits outlined in the benefit. schedule to all persons who are enrolled as Members in the Plan. The Plan shall furnish each Member with an identification cazd evidencing enrollment in the Plan. 6. PREPAYMENT FEES AND COPAYMENTS (a) The prepayment fees are the monthly fees the Subscriber Group must pay to maintain coverage under this Agreement for Subscribers and Dependents. The prepayment fees under this Agreement are set forth in .Schedule C. Schedule C is an essential part of this Agreement; please review it carefully. (b) The prepayment fee for all members. enrolled on the first day of each payment month must be paid to the Plan by check by the 25th day of the preceding month. There will be no grace period for the payment of the prepayment fee beyond the first day of the month for _ which said fee is due. There shall be no proration of prepayment fees with respect to enrollees enrolled after the first day of the month, (c) Only the Subscriber Group may pay the monthly prepayment fee for any or all Enrollees. (d) In addition to the prepayment fee, Enrollees are required to pay certain copayments for specific benefits. Such copayments aze payable by the enrollee to the Universal Caze Medical Group or other Provider of the Covered Services at the time they aze rendered or furnished. These copayments are identified, with the benefits to which they apply, in Schedule A of this Agreement. (e) When an enrollee receives any durable appliance (including. wheelchairs, prosthetic devices, crutches, etc.) for use pursuant to this Agreement,. a deposit may be required from the Enrollee, which will be refunded upon return of said appliance in good condition, reasonable wear and tear excepted. UC-901 OO.gsa 06/26/96-ctyvernon 10 7. CHOICE OF PHYSICIANS AND PROVIDERS: (a) Selection of Primary Care Ph, sician. Each Subscriber shall select or be assigned to a Universal Care Medical Group whose physicians shall serve as the primary care or "first contact" physicians for the Subscriber and his or her Dependents. Each member is encouraged to select one physician within the Medical Group to be his or her Primary Physician. Schedule B lists the current Universal Care Medical Groups. The -Plan shall notify the Subscriber Group of any change in Schedule B that materially affects the member's choice of physicians. (b) Facilities. Information regarding the services available, and. the location and hours of Plan Providers. and Plan facilities, may be obtained by calling the Plan offices at (800) 635- 6668 or (310) 424-6200. In case of an emergency the member should contact. his Universal Care - Medical Group 24 hour emergency number as follows: in Orange County, at (714) 636-7330, and in Los Angeles County, at (310) 595-5667. (c) Receipt of Benefits. Universal Care members may receive benefits under this Agreement in the following three ways: (i) `Universal Care Medical Groups - At the Universal Care member's Medical Group or of another Universal Care Medical Group to which the member is referred. (ii) Referrals or Admissions by Universal Care Participating Physicians -From other outpatient providers or from hospitals, ambulatory .surgical centers, or other inpatient facilities .specifically identified on the prior written authorization by the Member's Medical Group or the Universal Care Medical Director, and for the treatment specifically set forth therein; and (iii) Emergency Care -Emergency care is a covered benefit under the Plan without the referral, order or directive of a Participating Provider, but only in situations where, at the time of treatment, the member was experiencing a sudden, serious and unexpected illness, injury or condition requiring immediate medical attention, under circumstances where it was impractical for the. member to call the member's Universal Care Medical. Group or receive treatment there or from a participating provider. to which the Medical Group refers the member. The Member must notify the Plan within twenty-four (24) hours of the commencement of all _ emergencies or as soon as reasonably possible, so it can arrange for post-emergency care. Emergency care coverage ends when the Member's medical condition first permits release from the care of emergency providers or transfer of the Member's care to a Participating Provider. Continuing or follow up care must be obtained through the Member's Universal Care Medical Group or be approved in advance by the Plan Medical Director. The Plan Medical Director shall determine. for purposes of this Agreement when and how long. an emergency exists based on the - findings of the Enrollee's. treating physician and consistent with. professionally recognized UC-90100.gsa 06/26/96-ctyvemon 11 standards of care and when release or transfer to a participating provider is possible. If the Member's late notification to the Plan prevents transfer of the Enrollee to a contracting. facility when first medically appropriate, costs incurred from that point forward will be considered non- emergency and will be charged to Member on afee-for-service basis. (d) Liability of Subscriber or Enrollee for Payment. An Enrollee will be financially liable to the provider of health care services for: {i) all copayments he or she incurs for Covered Services under this _ Agreement, except as limited herein; (ii) all services and products not included as Covered Services under this Agreement; and (iii) all services and products not received from a physician or other provider pursuant to Section 7(a) above. In the event the Plan fails to pay a participating provider, the Member shall not be liable to the provider for any sums owed the provider by the Plan. In the event the Plan fails to pay a non-participating provider for Covered Services, the Member may be responsible for initial payment to that provider. The Plan shall inform members how to submit such bills for payment by the Plan. The Employer's Membership kit will explain to Subscribing Group and/or Members how to submit such bills for payment to the Plan and the Subscribing Group and/or Member can also obtain such information by .calling Universal Care's Membership Services at either (800) 635-6668 or (310) 424-6200. - The Plan will pay or reimburse an enrollee for all emergency care services, less any applicable copayments, .and products received in accordance with Section 7(c)iii above, on presentation of the provider's bill, therefore, copies of the Enrollee's medical records in connection therewith, and other relevant information may be requested by the Plan. 8. TERM, RENEWAL AND AMENDMENT (a) Term and Renewal. The Term and Renewal Date of this Agreement are set forth _ on the first page. This Agreement may be renewed on each Renewal Date by resolution of the City Council of the City of Vernon. _ UC-90100.gsa 06/26/96-cryvemon 12 (b) Amendment on Renewal Date. If the Plan proposes any amendment to this - Agreement, including a change in the prepayment fees or benefits or copayments, and gives the Subscriber Group written notice of the amendment at least thirty (30) days in advance, the amendment shall become effective on the Renewal Date. 9. TERMINATION OF GROUP SUBSCRIBER AGREEMENT. (a) Non-renewal or rejection of amendment. Plan or Subscriber Group may terminate this Agreement as provided. in the preceding section by nonrenewal. (b) Non-payment of prepayment fees. The Plan may terminate this Agreement if the Subscriber Group fails to pay the monthly prepayment fees within fifteen (15) days after - receiving notice of delinquency. The termination shall be effective retroactively to the last day of the last month for which full payment has been made by the Subscriber Group. (i) Reinstatement. If, after giving .notice of termination of this Agreement for non-payment of the prepayment fees, the Plan receives those fees from the Subscriber Group before the due date of the next month's prepayment fees, this Agreement shall be reinstated, unless; (1) the Plan's notice of termination states that if payment is not received within fifteen (15) days after issuance of the notice or such longer period as it may allow, the Plan-will require anew application and impose conditions on a new Agreement or reinstatement of this Agreement, or (2) the payment is received more than fifteen (15) days after .issuance of this notice and the Plan refunds the payment within twenty (20) business days after receipt, or (3) the payment is received more than fifteen (15) days after issuance and within twenty (20) business days of receipt the Plan issues anew Agreement and a statement of the ways the new Agreement differs from this Agreement. Individual Subscribers or other members have no right. to renew or - reinstate this Agreement. (c) Minimum enrollment. The Plan may terminate this Agreement on sixty (60) days written notice if the number of Enrollees for two consecutive months is less than the minimum enrollment specif ed on the signature page. (d) Misrepresentation. The Plan may terminate this Agreement effective immediately upon notice if the Plan finds that the Subscriber Group has engaged in fraud or deception in enrolling members or otherwise using the Plan's services or other benefits or has knowingly permitted such fraud or deception by any. other person, including a Subscriber or purported .Enrollee. The Subscriber Group shall be liable to Plan at fee-for-service rates for hospital and medical care. the Plan or the health care provider assumed, as a result of such fraud or deception, to be Covered Services for person who were in fact not eligible or enrolled. _ UC-90100.gsa 06/26/96-ctyvemon 13 (e) Notice to Members: Refunds. In the event the Plan terminates or refuses to renew this Agreement, the Subscriber Group shall promptly mail a copy of such notice to each _ Subscriber and will provide proof of the mailing to the. Plan. In the event of termination other than for fraud by the Subscriber Group, the Plan shall within thirty (30) days return sums paid by Subscriber Group for coverage after the termination effective date, less any amounts due the Plan, Universal Care Medical Groups or other Participating Physicians, Participating Hospital' and/or Participating Providers. (f) Extension of Benefits for Members Who Become Totally Disabled. If a person becomes totally disabled while a Plan. Member and is totally disabled when this Agreement terminates, then the Plan will extend the benefits of this Agreement which directly relate to the disabling condition, subject to the requirements, limitations and exclusions of this Agreement, to .the earlier of the following dates: (1) twelve (12) months after dues payment (premium) cease being paid .for Member, (2) the member ceases to be totally disabled or (3) the member is eligible for group coverage without a limitation specific to the disabling condition. (g) Effect of Termination on Members under Treatment. Except as provided in the immediately preceding subsection, a member is not entitled to benefits under this Agreement for services required or rendered after the effective date of termination of this Agreement, even if the Member is hospitalized or has not completed a course of treatment as of that date. Members shall be liable at fee-for-service rates for services rendered after-the effective date of termination. 10. TERMINATION OF MEMBERS (a) Termination for Cause:. If a Participating Physician, Participating Hospital and/or Participating Provider, after reasonable efforts. to establish and maintain a satisfactory Provider/patient relationship with any member, is unable to do so, the Plan may notify the - subscriber in writing that it proposes to terminate the rights of the member in the Plan and that the member has thirty (30) days in which to appeal this decision to the Plan's Grievance Committee through the. Plan's grievance system. If the member does not file an appeal within thirty (30) days, or if an appeal is filed and the Grievance Committee determines that a satisfactory Provider/patient relationship for the member cannot be .established .and maintained, _ then the rights of the member may be terminated effective after thirty (30) days' written notice to the member. (b) Nonpayment: If a member fails to pay any amount due the Plan or Plan providers -after written notice to the Subscriber of: (1) the amount due and (2) that failure to pay such amount due within fifteen (15) days will result in termination of the rights of the Subscriber and the Subscriber's Dependents in this Plan, then the Plan may terminate the rights of the Subscriber _ UC-90100.gsa 06/2.6/96-ctyvemon 14 and the Subscriber's Dependents, effective fifteen (15) days after the date of such. notification, and their rights may be reinstated only by payment of the amounts due and by renewed application and re-enrollment. (c) Furnishing_Incorrect or Incomplete Information: Subscribers warrant that all material. information contained in applications, questionnaires or statements submitted to the. Plan incidental to enrollment under this Agreement, or the administration hereof, is true, correct and complete. If a Subscriber knowingly furnishes incorrect or incomplete information and Plan relies on such information in enrolling Subscriber and/or Dependent, then the Plan has the right. to terminate Subscriber and/or Dependent immediately retroactive to the effective date of the enrollment based on the inaccurate or incomplete information upon written notice to the Subscriber and/or Dependent. If the. inaccurate and incomplete information did not affect - enrollment but did materially adversely affect the Plan's administration of this Agreement, the Plan may terminate the enrollment of the Subscriber and the .Subscriber's Dependents effective after five (5) days written notice. (d) .Misuse of Identification Card: If any Member permits the use of his or her Plan identification card by any other person, or uses another person's card, the card so misused may be - retained by the Plan, and all rights of the member who wrongfully permitted use of such card or who wrongfully used such card may, upon written notice to the Subscriber, be terminated immediately. (e) Return of Pro Rata Portion of Monthly Payment in Certain Cases. If the Member`s right and privileges under this Agreement are terminated for just cause under the provisions of this Agreement, the Plan will remit any premium to Subscriber Group that - covers Member during any period after Member's termination date, less any expenditures for medical bills incurred within thirty (30) days of said termination. - (f) Liability for services received after the effective date. of termination. The Plan will not be responsible for payment for any services received by a Member after the effective date of that Member's termination, and the providers of such services (or Plan, if it has paid for the services) may bill the member for all services rendered after said date. _ (g) Onnortunity for Review of Certain Terminations. by the Commissioner of Corporations. A Member who alleges that his or her rights under this Agreement were terminated or not renewed because of the .Member's health status or requirements for health care _ services may request a review of the termination by the Commissioner of Corporations as permitted by Section 1365(b) of the Health and Safety Code. UC-90100.gsa - 06/26/96-ctyvernon 15 (h) Plan Acceptance of Payment. Acceptance by the Plan of the proper prepayment - fees after termination of the Member and without requiring a new application shall reinstate the Member as though there were never a termination unless the Plan shall, within five (5) business _ days of the receipt of such payment either (1) refund the payment,. or (ii) issue to the Member a new Agreement accompanied by written notice stating clearly those respects in which the new Agreement differs from the terminated Agreement in Benefits, coverage or otherwise. 11. RIGHT TO CONVERT TO INDIVIDUAL. COVERAGE In the event a Subscriber's coverage under this Group Subscriber Agreement- ends due to loss of employment, the Subscriber may apply to enroll in a Universal Care Conversion Subscriber Agreement with the prepayment fees,. benefits and other terms then offered to persons eligible for such an agreement in the service area. No Health Statement will be required. The Plan must receive the application for conversion coverage and the initial prepayment fees no later than thirty-one (31} days after coverage ends under .this Agreement. The application and fees must be submitted for the Subscriber. and for any Dependents who were enrolled under this _ Agreement and who wish to continue coverage. The same right to apply for a Conversion Subscriber Agreement is granted to enrolled Dependents who lose eligibility because of age or the death or divorce of Subscriber. A Member may not convert to such coverage if: (1} the Member has been a Plan member less than ninety (90) days .when the Member ceases to be covered under this Agreement, (2} the Group Subscriber Agreement terminates on or before the Member's coverage under it would terminate, or (3) the Plan is entitled to terminate the Member - pursuant to Subsections 9(a), (b), (c) or (d) of this Agreement. 12. BINDING ARBITRATION (a) Except as provided in Subsection 12(c) below, any controversy or dispute between any of the following interested parties the Subscriber Group; an agent, trustee, affiliate or assignee of the Subscriber Group;. a Subscriber; a Dependent; or an heir at law or _ personal representative of a Subscriber or Dependent on the one hand, and .any of the following parties the Plan, its employees or agents, or .its Participating Providers or their agents or employees, on the other, whether involving a claim in tort, contract or otherwise, including _ disputes pertaining to this Agreement or the care or other benefits rendered pursuant hereto or :refused as not covered hereunder, and including disputes which are not adequately resolved by the Plan's grievance procedures, shall be submitted to binding arbitration. (b) Arbitration may be initiated. by any interested party, but if the matter in dispute is one which' is subject to review under the Plan's grievance procedures, arbitration may not be - initiated until the completion of such procedures. The arbitration shall follow the applicable UC-90100.asa 06/26/96-cryvernon 16 rules of the American Arbitration Association. The arbitration process may be initiated by calling the American Arbitration Association and requesting a demand for arbitration. The demand for .arbitration must be served personally or by recognized messenger service or by certified mail, return receipt requested, on or before the last date. it would have to be filed. in a court of law under the applicable statute of limitations. (c) Participating Physician, Participating Hospital and/or Participating Providers .may bring legal actions to collect copayments for covered. services or fee-for-service rates for non- covered services. The Plan or Subscriber .Group may seek declaratory relief regarding the interpretation of this Agreement or seek judicial remedies to collect prepayment fees. (d) The costs of the arbitration shall be borne equally by both parties; however, for - purposes of this Agreement, the costs of arbitration are limited to fees and expenses of the arbitrators and charges for arbitrators' transcripts- of the proceedings, and the room. where the arbitration is conducted. The arbitrator may require the submission of pleadings, briefs and other - memoranda and documents and may compel discovery from the parties,. shall hold a hearing within a reasonable time and shall set forth the decision in writing, with his reasons and authority _ therefor. Any judgment or award rendered by the arbitrator may be entered into any court having jurisdiction thereof.. The arbitration procedure established by this Agreement is the sole and exclusive means for the settlement of any such. controversy or dispute. 13. ADMINISTRATION (a) The Subscriber Group will cooperate with the .Plan with respect to soliciting and enrolling .persons eligible. to enroll hereunder and in obtaining authorized payroll withholding - from such persons to the extent the applicable prepayment fees exceed the Subscriber's Group contribution on their behalf. - (b) Within ten (10) days after the commencement of the term of this Agreement, and on the first day of each month thereafter, the Subscriber Group will deliver to the Plan an alphabetized list of names and social security numbers of all persons who enroll .hereunder and whose enrollment has not terminated pursuant to the provisions hereof. A completed and delivered enrollment form is effective as to the eligible persons and Dependents listed thereon _ until termination of enrollment as provided herein. (c) The Subscriber Group will promptly send the Plan copies of all signed enrollment _ forms and enrollment change forms and Health Statements. Plan may inspect the Subscriber Group's records pertinent to eligibility, enrollment and payment of prepayment fees hereunder,. and make copies thereof, at all reasonable times upon reasonable prior notice to the Subscriber - Group. _ UC-90100.gsa 06/26/96-ctyvemon 17 (d) The Plan may adopt reasonable policies, procedures, rules and interpretations to promote the orderly and efficient administration of this Agreement. Such policies, procedures, rules, and interpretations shall be consistent with the terms and. conditions of this Agreement. 14. UNDERTAKING TO PROVIDE OR PROCURE BENEFITS (a) The Plan undertakes to provide or procure the benefits. to each Subscriber and Dependent whose enrollment is effective hereunder. Except as otherwise provided in this Agreement, Covered Services and Benefits will be provided for Subscribers and Dependents regardless of whether the condition requiring such services existed prior to such person's - enrollment hereunder. The Plan has no duty, however, to provide or procure any care, services, appliances, tests, medicines or devices pursuant to this Agreement to any person whose name. is not on the current enrollment list provided for herein or whose ,enrollment has terminated hereunder. (b) The Plan will provide written notice within a reasonable time to the Subscriber Group of any termination or breach of contract by, or inability to perform by any participating Physician, Participating Hospital and/or Participating Providers if the Plan determines that enrollees may. be materially and adversely affected thereby. The Plan shall remain liable for covered services rendered by Participating Physician, Participating Hospital and/or Participating Providers (other than for copayments) upon termination of a provider contract, to Enrollees who _ _ retain eligibility under this Agreement or by operation of law, and who are under the care of such provider at the time of termination or the Plan will make reasonable and medically appropriate provision for the assumption of such services by another Plan approved Provider. 15. VETERANS In the event an Enrollee has a condition which has been determined by the military to be a military services connected condition for which the .Enrollee is legally entitled to care, and if military facilities are reasonably available, the Plan shall refer the Enrollee to the Veteran's Administration Hospital. 16. THIRD PARTY RESPONSIBILITY: COORDINATION OF BENEFITS (a) In the event an Enrollee suffers an injury or illness, for which expenses he or she is entitled to reimbursement, indemnification, damages or other redress (e.g., from a negligent third party, insurance company or other prepayment plan, workers compensation, employers _ UC-90100.gsa 06/26/96-ctyvemon 18 liability, unemployment compensation, disability or other sources -except. Medi-Cal) the Enrollee is still entitled. to Covered Services. Whenever the enrollee receives Covered Services, the Enrollee automatically assigns and grants a lien and charge against his or her claim for _ reimbursement,. indemnification, damages or other redress for medical benefits, to the Plan, and- subrogates the Plan to that claim. The Plan's lien, change and right of subrogation shall be at the fee-for-service rates for the Covered Services. (b) In the event the Member receives Covered Services for which the member has coverage under any group health plan, the Plan will .coordinate benefits in accord with the rules promulgated by the Department of Corporations that govern Plan as a health care service plan. (c) In no event will a Member be denied the provision of Covered Services by Participating Providers due to the existence of third party liability or other coverage. _ (d) The Enrollee must cooperate reasonably in the Plan's efforts to coordinate benefits or collect from liable third parties, and shall provide the Plan with information regarding potentially liable third parties or other hospital or medical benefit plans and sign,. when reasonably requested, acknowledgments of Plan's rights. 17. INDEMNIFICATION OF GROUP BY THE PLAN The Plan agrees to save, hold harmless, defend and indemnify the Subscriber Group from - and against all claims, demands, liabilities, actions or causes of action of any kind or nature which may. arise .out of, in connection with, or related' to .any act, omission, negligence, malpractice or lack of due care caused or alleged to have been caused by the Plan, any subcontractor of the Plan, or any. of their employees, Participating Physicians, Participating Hospitals, Participating Providers, consulting doctors, agents or partners in the performance of the services, duties and obligations of the Plan under this Agreement, except as may result from a breach of the Subscriber Group's obligations hereunder. 18. ASSIGNMENT The Plan may assign this Agreement and its rights hereunder, and delegate its duties hereunder, to any entity which is a licensed health care service plan into which it is merged or which. acquires substantially all of its assets upon the approval of the Department of Corporations. The .Subscriber Group may not assign this contract without the prior written consent of the Plan. Neither party may otherwise assign this Agreement unless such assignment is required by law. Any purported assignment in violation hereof shall be void and unenforceable. UC-90TOO.gsa 06/26/96-ctyvemon 19 19. APPLICABLE LAW AND INTERPRETATION This Agreement shall be construed and interpreted in accordance with the laws of the State of California and, so as to effectuate its purpose in accordance with the Medical Practice . Act, the ethics of the medical profession; the Knox-Keene Health Care Service Plan Act of 1975, as amended ("Knox-Keene Act") and any other applicable laws and regulations. Any provision required to be in this Agreement by the Knox-Keene Act (Health & Safety Code Section 1340 et seg. or regulations promulgated thereunder - i.e., Subchapter 5.5 of Chapter 3 of Title 10 of the California Administrative Code) shall bind the parties whether or not contained in this Agreement. 20. MISCELLANEOUS PROVISIONS (a) .Acceptance of Contract. The Subscriber Group may accept this Agreement either - by execution of the acceptance provided below, or by making payment to the Plan pursuant to Section 6 hereof, and such acceptance shall render all terms and provisions hereof binding on the Plan and Subscriber Group. (b) Contract Binding on Members. By this. Agreement the Subscriber Group makes the Plan coverage available to .persons who are eligible under Section 2; however, this - Agreement shall be subject to amendment or modification in accordance with the provisions hereof or by mutual agreement between the Plan. and the Subscriber Group without the consent - or concurrence of the Members. (c) Application, Statements, etc. Members or those persons applying for membership shall complete and submit to the Plan such applications, forms or statements as the Plan may reasonably request. Members warrant that all material information contained in such applications, questionnaires; forms or health statements submitted to the administration hereof _ are true, correct and complete, and all rights to benefits hereunder are subject to the condition. - that all. such information is true, correct and complete. All such information. shall -remain _ confidential except for arbitration or legal proceedings. (d) Identification Cards. Cards issued by the Plan to members pursuant to this Agreement are for identification only. Possession of a Plan identification card confers no rights to services or other benefits under this Agreement.. To be entitled to suchservices or benefits, the holder of the card .must, in fact, be a Member. on whose behalf all applicable charges under this Agreement have actually been paid. Any persons receiving services or other benefits to UC-90100.gsa 06/26/96-cryvemon 20 which he is not then entitled pursuant to the provisions of this Agreement shall be charged therefor at prevailing rates. 21. GRIEVANCE PROCEDURES Members are encouraged to contact the Plan regarding any problems that are encountered while obtaining services. The Plan maintains a grievance system to deal with member problems. and complaints. Member complaints or grievances can be made. in person at the Plan office or can be made in writing. Complaint forms may be obtained at each Plan office and should be returned to the Plan office located at 1600 East Hill Street, Signal Hill, California 90806; (800) 635-6668 or (310) 424-6200. All complaints which are unresolved within four (4) working days will be reviewed by the Grievance Committee within thirty (30) days. Members will receive a written response within ten (10) days after the hearing as to the disposition of complaints referred to the Grievance Committee. In the event a member is dissatisfied. with the disposition of his complaint by the _ Grievance Committee, the member may avail himself of the arbitration procedures set forth in Section 12 of this Agreement. 22. NOTICES - Any notice under this Agreement may be given personally, by a recognized messenger service such as Federal Express or by United States mail, postage prepaid, addressed as follows: To the Plan: Universal Care 1600 E. Hill Street Signal Hill, CA 90806 ATTN: President _ To the Member: To the latest address provided for the member on the enrollment or change of address forms actually delivered to the Plan. To the Subscriber Group: To the address set forth under the signature of the Subscriber Group on the signature page of this Agreement. .Notice of material matter sent to the Subscriber Group by the Plan shall be disseminated to Plan members by the Subscriber Group in its regular communication to Plan members, but in no case - later than thirty (30) days after receipt of such notice. UC-90100.gsa 06/26/96-ctyvernon 21 I 23. DISCRIMINATION PROHIBITED The Plan shall not cancel .this Agreement, nor decline to renew or reinstate. this Agreement, nor shall the terms of this .Agreement be modified and the benefits or coverage be _ subject to any limitations, exceptions, exclusions, reductions, copayments, .coinsurance, deductibles,. reservations, premiums, price change differentials or other. modifications because of the race, color, national origin, ancestry, religion, sex, marital status, sexual orientation or, age of any Enrollee or applicant .for enrollment .except that premium, price or charge differentials because of the sex or, age of any such individual and based on objective, valid and up-to-date statistical, underwriting or actuarial data shall not be prohibited. i The Plan will not. deny or limit coverage or charge higher prepayment fees for an enrollee solely because of a physical or mental impairment, except when the refusal, limitation or rate differential is based on sound actuarial or underwriting principles or practices.. However, if Plan has requested an enrollee to disclose a physical or mental impairment on a Health Statement or in other- enrollment application materials (see Section 2.b.(ii) above) and that person fails to disclose or misrepresents such an impairment, the Plan may terminate that person's enrollment, as provided in Section 9(d) and Section 10(c) of this Agreement. 24. SCHEDULES AND EXHIBITS Schedules A, B, and C are attached to this Agreement and are incorporated in it wherever referenced or pertinent. UC-90100.gsa 06/26/96-ctyvemon 22 OPTIMA PLAN SCHEDULE A UNIVERSAL CARE BENEFIT SCHEDULE (90-100) THE SERVICES OF THIS PLAN ARE PROVIDED WHEN PERFORMED, PRESCRIBED, DIRECTED OR AUTHORIZED AS MEDICALLY NECESSARY BY A PHYSICIAN OR MEDICAL DIRECTOR IN THE UNIVERSAL CARE MEDICAL GROUP THE MEMBER HAS SELECTED. 1. PRINCIPAL BENEFITS AND COVERAGES A. Physician Services COPAYMENT REOUIREMENTS* The Plan provides services by family practitioners, pediatricians, obstetricians, other health care physicians at the member's - Universal Care Medical Group, and also. services by specialists upon Proper Referral by said Medical Group, as follows: 1. Unlimited Office Visits No charge 2. Unlimited Hospital Visits No charge _ 3. X-ray and laboratory tests for No charge diagnostic purposes, and other diagnostic, radiological services, electrocardiography and electroencephalography - 4. Injectable medication, including No charge allergy antigen 5. Allergy testing series No charge 6. Radiation, cobalt, radioisotope No charge therapy and chemotherapy (outpatient) * No Copayment will be imposed on any Member in any contract year, when Copayment made by such Member in such contract year will total more than $2,000.00. Plan will provide each Member with receipts of all Copayments in order for the Member to calculate Copayment limits. Note: Coverage for benefits and/or services related to any pre-existing condition may require the expiration of a six-month period. Consult the Group Subscriber Agreement for details. Universal Care" 6/26/96 OPTIMA Plan-ctyvernon 1 ~,~,erh~.r~.~~~,s~<~,.x _ 7. Physical therapy, speech therapy and No charge occupational therapy, both inpatient and outpatient, on a short term basis for conditions determined by a Universal Care physician to be subject to significant improvement within thirty - (30) days of start of such therapy B. Preventive Health Services Elective annual physical examinations No charge (including x-rays and laboratory tests), well baby care, pediatric and adult immunizations, periodic papanicolaou (pap) tests and venereal disease testing. C. Hospital Benefits (except Mental Health Care - The Plan pays the charges of designated hospitals, ambulatory surgical centers or similax facilities when authorized in advance by a Universal Care physician as follows: 1. Room and board in asemi-private room No charge (where available), including intensive and cardiac care unit, general nursing _ care, special duty nursing, meals and special diets... _ 2. Diagnostic laboratory and x-ray No charge services. - 3. Use of operating room and related No charge facilities. - 4. Drugs, medications, biologicals, No charge anesthesia and oxygen services. _ 5. Physical therapy, respiratory therapy, No charge administration of blood and blood _ products, other diagnostic, therapeutic and rehabilitative services as appropriate, radiation therapy, cathode Note: Coverage for benefits and/or services related to any pre-existing condition may require the expiration of a six-month period. Consult the Group Subscriber Agreement for details. p 'C Universal Care" 6/26/96 OPTIMA Plan-ctyvernon 2 klnnlthcrrre yon an fe fywdnbnxt _ ray scanning and dialysis. 6. Miscellaneous hospital charges for No charge necessary care and treatment. 7. Coordinated discharge planning. No charge 8. Chemotherapy (inpatient) No charge D. Ambulance Service When authorized in advance by a Universal: No charge Care physician or in emergency situations E. Surgical Benefits Universal Care surgeon, assistant surgeon No charge and anesthesiologist; including - reconstructive surgery when Medically Necessary (reconstructive surgery incident to a mastectomy which is not medically contraindicated is deemed to be Medically Necessary). F. Skilled Nursing Care Benefits Room and board and general nursing care in Plan covers in full. up to a Plan approved Skilled Nursing.Facility. sixty (60) days for each illness or injury - G. Family Planning Benefits 1. Vasectomy (male sterilization) - $100 copayment 2. Information and instruction on methods No charge of birth control; IUD (infra-uterine device); diaphragm - 3. Tubal ligation (female sterilization). - $100 copayment 4. Induced interruption of pregnancy. $150 copayment Note: Coverage for benefits and/or services related to any pre-existing condition may require the expiration of a six-month period. Consult the Group Subscriber Agreement for details. u 'c Universal Care" 6/26/96 OPTIMA Plan-ctyvernon 3 H~„rh~ ,w„~i~r,.,~~~,,.L 5. Infertility studies including sperm count; $25 copayment for entire study hysterosalpingography; endometrial biopsy; - clomid therapy; estrogen level; prolactin serum level; blood studies to rule out systemic diseases such as anemia, diabetes, - hyperthyroidism or hypothyroidism 6. Infertility treatment, including surgery, 50% of charges artificial insemination, embryo transplants and in vitro fertilization, if determined to be medically necessary by the Universal - Care Medical Director. H. Hearing Care Benefits Examination to determine the need for hearing No charge correction for members under age eighteen (18). I. Vision Care Benefits Examination to determine the need for vision No charge correction for members under age eighteen (18). J. Medical Social Services Includes. hospital discharge planning,. counseling:.:......... No charge: (Counseling for Alcohol and Drug use is _ included under item N., "Alcohol and Drug Use") K. Health Education Services Health education services for specific conditions such as: 1. Diabetes counseling, post coronary No charge counseling, nutritional counseling, etc. 2. General health education services not No charge _ addressed to specific conditions such as weight control, anti-smoking, etc. Note: Coverage for benefits and/or services related to any pre-existing condition may require the expiration of a six-month period. Consult the Group Subscriber Agreement for details. T. Universal Care"" 6/26/96 OPTIMA Plan-ctyvernon 4 HeaUbmrs wr. amf fgrwda6oar. _ 3. Education and appropriate use of Plan No charge services and instructions on achieving and maintaining good health. L. Home Health Services When authorized as Medically Necessary by the No charge Member's Universal Care Medical Group. M. Mental Health Care Benefits Mental health care is provided when referred by a Universal Care physician. 1. Outpatient Services - A maximum of twenty $10.00 per visit (20) visits in any twelve (12) month period, up to fifty (50) minutes per visit, with psychiatrist (M.D.), psychologist (Ph.D.) or therapist with a Master's degree - office visit or by telephone. 2. Inpatient Services -thirty (30) days in No charge any twelve (12) month period, with psychiatrist (M.D.) or psychologist (Ph.D.). Inpatient Services does not include coverage - for Alchol and Drug use. N. Alcohol and Drug Use:. 1. Counseling No charge 2. Treatment for outpatient detoxification No charge 3. Treatment for in-patient detoxification No charge For the purpose of this Agreement, detoxification shall mean acute medically supervised withdrawal by Member from outside harmful toxic substances (specifically alcohol and drugs) until Member is medically cleared. Section N does not include benefits for Rehabilitative Services. For the purposes of this Agreement, Rehabilitative Services are substance abuse services which are psychological in nature, non-acute and designed to prevent further use or abuse of harmful substances. Note: Coverage for benefits and/or services related to any pre-existing condition may require the expiration of a six-month period. Consult the Crroup Subscriber Agreement for details. Universal Care° 6/26/96 OPTIMA Plan-ctyvernon 5 Fleu,racnrc r~u um( ts,w,taFk,.n O. Maternity Care Benefits _ Medical Group physician, Participating Physician, No charge Participating Hospital care and Participating Providers, including pregnancy complications, - and physician's normal care of mother at designated facilities before, during and six (6) weeks after delivery. Coverage shall include. prenatal diagnosis of the. fetus as Medically. necessary and consistent with professionally recognized tandards Newborn Child is covered from the date of birth to thirty-one. (31) days afterward. Newborn Child must be enrolled within the aforementioned thirty-one (31) days after birth to continue coverage. P. Prescription Drug Benefit Up to a one-month supply per prescription $3.00 per prescription prescribed by a Universal Care physician is provided on a formulary prescription basis, including birth control pills, at Participating Pharmacies. Medication sold "over the counter" are not covered. Prescriptions from dentists.. and for excluded benefits are not covered. Q. Durable Medical Appliances - Crutches, wheelchairs, prosthetic devices, No charge canes, braces, cardiac devices and pacemakers. R. Emergency Services - An emergency is defined as a sudden, serious and unexpected illness, injury or condition requiring immediate medical attention. It is of the utmost importance that the Member's Universal Care Medical Group be contacted prior to seeking emergency services. The only permissible exception is if the Member is unable to contact .his Universal Care Medical Group because of unconsciousness or the catastrophic nature of the illness or accident and immediate emergency treatment is essential. Note: Coverage for benefits and/or services related to any pre-existing condition may require the expiration of a six-month period. Consult the Group Subscriber Agreement for details. u Universal Care" 6/26/96 OPTIMA Plan-ctyvernon 6 ~:w A°dfhuirzyoumn(ce1S'wA°F IN THE EVENT THAT, DUE TO IMMEDIATE MEDICAL NECESSITY, EMERGENCY MEDICAL CARE MUST BE PROVIDED BY PHYSICIANS OR HOSPITALS WHO DO NOT CONTRACT WITH UNIVERSAL CARE, THE MEMBER'S UNIVERSAL CARE GROUP MUST BE NOTIFIED WITHIN TWENTY-FOUR(24) HOURS AFTER CARE IS SOUGHT OR AT THE EARLIEST POSSIBLE TIME. A UNIVERSAL CARE MEDICAL GROUP PHYSICIAN, OR A NON- PARTICIPATING PROVIDER UPON PROPER REFERRAL,WILL BE AVAILABLE TO TAKE OVER CARE. FOLLOW-UP CARE PROVIDED OUTSIDE THE UNIVERSAL CARE PROGRAM IS NOT COVERED. Therefore, in any situation where the Member's Universal Care Medical Group is not notified, or where the Member does not request all follow-up care through Universal Care, such services are -not provided through the Universal Care program and are not Universal: Care Benefits. Payment for continuing or- follow-up emergency care will be made ONLY if provided by a Universal Caxe Medical Group or if authorized by the Universal Care Medical Director. If a Member's Universal Care Medical Group is notified within twenty-four (24) hours after care is sought or at the earliest possible time and the emergency care is authorized, copayments will be as follows: IN AREA EMERGENCY CARE Emergency services for necessary medical services requiring immediate treatment within the Universal Care service area. 1. When provided at an emergency facility designated by the member's Universal Caxe Medical Group and Universal Care Medical Director. $25.00 COPAYMENT PER VISIT 2. When medical services are obtained at a facility not selected by Member's Universal Care Medical Group and Universal Care Medical Director. $50.00 COPAYMENT PER VISIT. UNIVERSAL CARE MUST BE NOTIFIED WITHIN TWENTY-FOUR (24) HOURS TO DETERMINE VALIDITY AND EXTENT OF COVERAGE OR AS SOON AS REASONABLY POSSIBLE. IN THE EVENT THE MEMBER IS HOSPITALIZED, COVERED BENEFITS AND REQUIRED COPAYMENTS - WILL BE AS SET FORTH ABOVE UNDER "HOSPITAL BENEFITS". CONTINUING TREATMENT SHALL BE COVERED FOR ONLY SO LONG AS THE MEDICAL DIRECTOR OF THE PLAN, AFTER REVIEWING ANY MEDICAL RECORDS OR OTHER RELEVANT INFORMATION AND CONFERRING WITH THE PHYSICIAN IN CHARGE OF THE PATIENT'S CARE, DETERMINES THAT THE MEMBER CANNOT BE TRANSFERRED TO THE CARE OF A UNIVERSAL CARE MEDICAL GROUP OR CONTRACTING PROVIDER. Note: Coverage for benefits and/or services related to any pre-existing condition may require the expiration of a six-month period. Consult the Group Subscriber Agreement for details. Universal Care" 6/26/96 OPTIMA Plan-ctyvernon Flrutrkmrcvouamfuls~waaf w~ OUT OF AREA EMERGENCY CARE Emergency services for necessary medical services requiring immediate treatment out of the Universal Care Service Area. 1. When medical services are obtained outside the Universal Care Service Area. MEMBER PAYS 50% OF CHARGES UP TO A MAXIMUM COPAYMENT OF $100.00 PER VISIT. CONTINUING TREATMENT. SHALL. BE COVERED FOR ONLY SO LONG AS THE MEDICAL DIRECTORS OF THE PLAN, AFTER REVIEWING ANY MEDICAL. RECORDS OR OTHER RELEVANT INFORMATION AND CONFERRING' WITH THE PHYSICIAN IN CI-IARGE OF THE PATIENT'S CARE, DETERMINES THAT THE MEMBER CANNOT BE TRANSFERRED TO THE CARE OF A UNIVERSAL CARE MEDICAL GROUP OR CONTRACTING PROVIDER. Note: Coverage for benefits and/or services related to any pre-existing condition may require the expiration of a six-month period. Consult the Group Subscriber Agreement for details. p ~C Universal Care° 6/26/96 OPTIMA Plan-ctyvernon 8 rrratr,,~,.r;~oN~r~,t~wdnb~>wz 2. PRINCIPAL EXCLUSIONS AND LIMITATIONS ON BENEFITS A. All non-emergency services by physicians, Hospitals and other health care Providers that are not _ rendered or authorized by the Member's Universal Care Medical Group or the Universal Care Medical Director. - B. Dental care not considered Medically Necessary, including X-Rays. Oral surgery will be covered if Medically Necessary. - C. Cosmetic surgery, unless determined to be Medically Necessary by the Plan's Medical Director. Medically Necessary cosmetic surgery. shall include, but is not limited to, reconstructive surgery after a mastectomy. D. Rehabilitation programs, including treatment for chronic alcoholism and drug addiction and special educational programs for development disabilities. E. Custodial care, extended care, homemaker services or convalescent care not requiring skilled nursing care. F. Experimental medical, surgical or other health care procedures and products unless approved as _ Medically Necessary in the judgment of the physician responsible for that patient's care. G. Personal or comfort items. H. Private hospital rooms unless: (1) semi-private rooms are not available or (2) determined by the Plan's medical director to be Medically Necessary. I. Whole blood, plasma and any specially processed derivative. J. Blood bank fee. - K. Hearing aids. L. Personal or home-based artificial kidney equipment. M. Shoe, shoes, or orthotics to be used for corrective purposes. - N. House calls by a physician unless authorized by the Member's Universal Care Medical Group. O. Podiatry care not prescribed by a Universal Care physician. P. Chiropractic services unless covered in a special supplemental benefit rider to this Agreement. Q. Intersex surgery (trans-sexual operations). Note: Coverage for benefits. and/or services related to any pre-existing condition may require the expiration of a six-month period. Consult the Group Subscriber Agreement for details. 'C Unuversal Caze" 6126/96 OPTIMA Plan-ctyvernon 9 Y r~.,~,,,~~~~~s„~~, R. Services and .products which the Plan's Medical Director determines are not Medically Necessary for prevention of illness or treatment of illness or injury. _ S. All services and products received after termination of this Agreement or the termination of a Member's eligibility or enrollment under it except as specified in Section 9 (f) of the Agreement. T. Eye examinations by an optometrist or any eyeglass appointment. U. Preventive dental services. V. Care for military service connected disabilities for which the Member is legally entitled to services and for which the service is reasonably available. _ 3. PRINCIPAL LIMITATIONS AND REDUCTIONS IN SERVICES A. Universal Care is not responsible for delay or failure to render services due to matters beyond the control of the Plan. B. Universal Care is not responsible for unusual circumstances, such as complete or partial destruction of - facilities, war, riot, labor disputes, disability of a significant number of personnel, or similar events which result in delay in providing services in or ability to provide services. C. When a Participating Physician recommends specific treatment for a particular condition for which the Participating Physician believes no professionally acceptable alternative treatment exists, and the member refuses the recommended treatment due to personal beliefs, Universal Care is not responsible for the treatment of said condition or for the consequences which may result from such refusal to accept the recommended treatment. D. Physical therapy, occupational therapy, .speech: herapy: and other rehabilitative treatments are limited to a maximum. of thirty (30) days for any injury, illness or congenital abnormality and only for°significant improvements in that period time. Unless, in the opinion of the Participating Physician and the Medical Director, significant improvement may result in expanding the aforementioned time limit by additional thirty (30) day increments. E. Extended care or convalescent hospital care is limited to a maximum of sixty (60) days for any injury or illness. F. Mental health services are limited to outpatient short term or crisis intervention services, to a maximum of twenty (20) visits in a twelve-month period. G. Inpatient mental health services for mental or emotional disorders are limited to thirty (30) days in any twelve (12) month period. Note: Coverage for benefits and/or services related to any pre-existing condition may require the expiration of a six-month period. Consult the Group Subscriber Agreement for details. p___ 1 3.--C Universal Care° 6/26/96 OPTIMA Plan-ctyvernon lO Fluutrharre vm. crm leelgxl Wnrut - Schedule B PARTICIPATING iVIEDICAL GROUPS AND INDEPENDENT PRACTICE ASSOCIATIONS Los Angeles County Alliance of Private Practice Physicians Medical Group Keystone Health -South Valley American Health Medical Group -Downey Lakeside .Medical Group, Inc. - Burbank/ American. Health Medical Group -Gardena North Hollywood Asian Community Medical Group Lakeside Medical Group,. Inc. - Tarzana/Encino Associated Physicians of St, John's Memorial IPA Medical Group, Inc. Bright Medical Associates Omnicare Medical Group _ Caremore Medical Group, Inc. Prairie Medical Group, Inc. Centinela IPA Primary Care Medical Group of Little Company Gallatin Medical Foundation of Mary Hospital. _ Gateway Medical Group I Prospect Medical Group, Inc. Good Samaritan Medical Practice Association St. Francis Care Medical Group Harbor -UCLA Medical Foundation, Inc. St. Jude Medical Group IPA - -Universal Care Medical Group Universal Care Medical Group Healthcare Partners Medical Group, Inc. U. S. FamilyCare -Pomona Intercounry Medical Group, Inca U. S. FamilyCare -San Dimas - Keystone Health -Central Valley Valley Independent Physicians. Inc. Keystone Health -North Valley Valley Physicians Network Keystone Health -Santa Clarita Orange County American Health Medical Group -Downey Memorial IPA Medical Group, Inc. AMVI Medical Group,. Inc. Monarch Healthcare _ Caremore Medical Group, Inc. Premier Medical Group Edinger Medical Group, Inc. Prospect Medical Group, Inc. Gateway Medical Group I St. Jude Medical Group IPA Gateway Medical Group III Universal Care Medical Group Greater Newport Physicians at Hoag Hospital Yorba Park Medical Group, Inc. Intercounty Medical Group, Inc. Riverside County - Circle City Medical Group, Inc. Riverside Medical Clinic Inland. Healthcare Group U. S. FanulyCare - Temecula~ldomar/Menifee Riverside CommunityHealthplan Medical Group, Inc. San Bernardino County Chino Medical Group U. S. FamilvCare -Ontario Circle City Medical Group, Inc. U. S. FamilyCare -Rancho Cucamonga Independent Physicians of San Antonio U. S. FamilvCare -Rialto Inland Healthcare Group U. S. FamilyCare -San Bernardino '~loiave Medical Group, Inc. U. S. FamilyCare -Upland U. S_ FamilyCare -Fontana U. S. FamilyCare - ~'ictorriilerHesperia U. S. FamilyCare - ivlontclair Valley Independent Physicians. Inc. PARTICIPATING HOSPITALS - Los Angeles County Bay Harbor Hospital Little Company of Mary Hospital California Medical Center -Los Angeles Long Beach Community Hospital Centinela Hospital Medical Center Long Beach Memorial Medical Center Century City Hospital Medical Center of North Hollywood - Children's Hospital Los Angeles Pomona Valley Hospital Medical Center Daniel Freeman Memorial Hospital Presbyterian Intercommunity Hospital _ Downey Community Hospital St. Francis Medical Center Encino -Tarzana Regional Medical Center St. John's Hospital and Health Center Foothill Presbyterian Hospital St. Joseph Medical Center -Burbank Gazden Grove Hospital and Medical Center, AMI St. Luke Medical Center Glendale Memorial Hospital and Health Center St: Mary Medical Center Henry Mayo Newhall Memorial Hospital San Dimas Community Hospital - Holy Cross Medical Center San Gabriel Valley Medical Center Huntington Memorial Hospital Santa Monica Hospital Medical Center Inter-Community Medical Center Torrance Memorial Medical Center - La Palma Intercommunity Hospital Valley Presbyterian Hospital LAC - Hazbor -UCLA Medical Center Whittier Hospital Medical Center Orange County - Anaheim Memorial Hospital Saddleback Memorial Medical Center Chapman General Hospital St. Joseph Hospital, Orange Children's Hospital of Orange County St. Jude Medical Center Fountain Valley Regional Hospital South Coast Medical Center Hoag 1Vlemorial Hospital Presbyterian The Hospital of the Good Samaritan _ Irvine Medical Center Western Medical Center -Anaheim Martin Luther Hospital Western Medical Center -Santa Ana Mission Hospital Regional Medical Center Riverside County Corona Regional Medical Center Pazkview Community Hospital Medical Center Inland Valley Regional Medical Center Riverside Community Hospital San Bernardino County Chino Valley Medical Center St. Mary Desert Valley Hospital Loma Linda.Community Hospital San Antonio Community Hospital - Loma Linda University Medical Center San Bernardino Community Hospital St. Bernazdine Medical Center Victor Valley Community. Hospital - Universal Care® Corporate Offices: z 60o East Hill Street CITY OF VERNON Signal Hill, CA go8o6-3682 3ro 424-6zoo 3zo 427-3842 (Fax) - Schedule C 800 635-6668 _ Group Number: 10010A Optima Plan - Family Mix One Year Rate EE Only 98.58 EE + 1 226.70 EE + 2 or more 394.59 Group 10010A Effective Date: 01/01/96 Date: 10/29/96 • ~ ~ ~ ~ Universal. Care' I~mployer Healthcare you can feelggod about. . 1.600 E. Hill Street •-Signal Hill, CA.90806 The Employer Certifies the Following Information:. (800) 635=6668 exc. 4848 _ . City of Vernon _ 9 ' 5 6 ' _ D , 0' 8 0 $ - ll :_.4305 Santa Fe Avenue ;~"Joan Francone_ _ ~213.,IF 583-8811 ;322 ~ CarporaUon ? Sole PropdetorshiP ' ` ~ Vernon CA 9005$ Q Partnership Other (please specify): titt1I21C1 _ Pais-tY N ji"lUIl1G1~d1 Sel'V1CE'_S . 4 ubsidiaries and Affiliates to be covered . - _ . _ , ..u ~ - . _ . ',^~mployer Eligibility . . , -Eligible employees shall. be active, full time employees who work at least 4 ~ hours per week.. Are alt. eligible employees subject to withholdings as appears on a W-2 foam? rxYes ~ No ~ - - ! ' j r ,,.:..NOTE: _ - Retirees wily also par-l=icipate and are not subject.. to W-2 witholdings_, ' urgent Carrier Is this plan intended to replace any existing coverage? Yes G No If Yes, complete the information below and attach_a copy of the present carrier's last month's billing statement' • • _ - Month , .,Day.- Year I Exclusi~are (Mutual of ~nai~a) 1:2" 31 95 ~j orkers' Compensation - u. Be sure to sfgn and : ~ date appficatlon Self insured ' on back page.: lease lisf the name and job title of any person to be included as a subscriber under the Universal Care coverage who is not an employee for the - purpose of Worker's.. Compensation law or similar legislation. Please note that under California'Labor Code Section 3381 ,partners and-corporate officers, or members of boards of directors are employees for Worker's Compensation .purposes except under limited. circumstances. -In order for ihdividuais holding the above mentioned positions to fall outside the Worker's Compensation laws, they must be a shareholder of the corporation: Alf stock of the corporation .must be held by persons who are either officers or members of the board of directors of the corporation. - Exempt according to above ~ requirements? , . _ _ - _ " Yes cNo Yes ~ No waiting. period for enrolment of future employees..-(Eligibility date • is always the first day of the month.. following th-Q:waiting period.) Employer Contribuli~~ - r~30 days L?90 days _ - ; 0 0 Lso days: Other (please specify} First day,~of ~al~awing_ lOQ ~p 100 ~0 _ Requested Effective Date . : t: . ,Effective Date Monet Day Year 'Actual effective date will be assigned by the Moen oar YFar ;This date will be assigned by the OL Ol 9b Underwriting Department of Universal Care CI OI . ; 9i1 Underwriting Department of Universal Care . upon acceptance. . _ _ _ . .upon acceptance...:. O enefitS Requested (check all that apply and indicate. plans) . 6 PTA r.1 ,d - ; - - --z._..::~.=.r__ .~_t moo. _.~...~a.w.~:~ ~.;...~~=_..c y signing this application, applicant agrees to be oourtd by all. provisions of the Universal. Care Subscriber Agreement, upon acceptance by Universal Care. - mom....-_. _ , , ~ ~ ~ ~-~r., r-.~, - - Dated at .__Vernon,._Califorraia-_.::,..~:.~ on the _ ~~Ez---_. day of s.~~D~~. r ~ t~;-.95 _~~!t'r~~_. _~L~y _ _Cit=y ~c~11,n~tra.,~or:--~-_ ~ ~ z hereby certify that: 1 am not aware of any information not disclosed in this application or employee application and enrollment forms by my client. which. may have: a bearing on this risk. hereby certify that: Ihave-advised my client not to terminate any existing coverage until receiving notice that the coverage being applied for by the application is accepted. hereby certify that:. I have advised my client of his rights tinder AB1672 and have provided himlher with all benefit options offered by Universal Care to small. group employers. - .gent's Certification O . _ _ ~ ~~,~t f- UDC: S a_ -CG~;~-n,~:_ erg- ,~~t<-:=__ _ _ , . ~donth Day Year _ , (~~ov,P !-~ArS oPrc ,wry- s~ ~ L-~- 9r-~ ~o lDf2 ® For company use .only ~ _ _ . Month Day• Yea ~ ~ ~ ~ Medical S ~5 lam, ltd F1 ~ _ `Dental S Mogth U'y ~'e~ ` Vision S iJ - ~ -t-- _ ~ _ _ _ ~ _ Chiro..:. S , , ~ Month Day 'Year `tither S - _ _ _ _ i20