Common use of Comprehensive Major Medical Clause in Contracts

Comprehensive Major Medical. The City shall maintain preferred provider organization(s) (PPO) for both medical and prescription drug services. (1) A two hundred dollar ($200.00) annual deductible with an eighty/twenty percent (80/20%) coinsurance of the next fifteen hundred dollars ($1,500.00) in reasonable charges or three hundred dollars ($300.00), for a total out-of-pocket maximum of five hundred dollars ($500.00) per single contract per year. (2) A four hundred dollars ($400.00) annual family deductible with an eighty/twenty percent (80/20%) coinsurance of the next two thousand dollars ($2,000.00) of reasonable charges or four hundred dollars ($400.00), for a total out-of-pocket maximum of eight hundred dollars ($800.00) per family contract per year. (3) If an employee and/or an eligible dependent receive services from a preferred provider (PPO), reimbursements will be paid at the current coinsurance rate of 80/20 percent of reasonable charges. If the participating providers are not used, coinsurance will reduce to 60/40 percent of reasonable charges. The additional twenty-percent (20%) coinsurance will be the employee's responsibility and is not counted toward the deductible or out-of-pocket maximum. (4) The employee's annual out-of-pocket maximum for individual coverage shall be five hundred dollars ($500), and the employee's annual out-of-pocket maximum for family coverage shall be eight hundred dollars ($800). (5) The plan will cover routine physicals, exams and immunizations up to a maximum of $150.00 per individual for covered persons age nine and over; a $300.00 family maximum, subject to deductibles, coinsurance, and out-of-pocket maximums will apply. (6) A mental health/substance abuse case management benefit whereby an eligible participant may elect to exchange unused mental health or substance abuse inpatient days for other needed mental health or substance abuse benefits as determined medically necessary by the plan administrator. The medical necessity and exchange rate shall be determined by the plan administrator. (7) Outpatient alcohol or drug treatment (substance abuse) payments will be limited to 50% of 25 visits per calendar year per individual when provided by a non-network provider. Outpatient alcohol or drug treatment (substance abuse) payments will continue to be limited to a total of twenty-five (25) visits per calendar year per individual when provided by a network provider. An office co- payment of twenty-five dollars ($25.00) per in-network visit will apply [effective January 1, 2006, the co-payment reduces fifteen dollars ($15.00)]. The co-pay does not apply to the annual deductible and coinsurance. (8) Outpatient psychiatric payments will be limited to 60% of 25 visits per calendar year when provided by a non-network provider. Outpatient psychiatric payments will continue to be limited to a total of twenty-five (25) visits per calendar year per individual when provided by a network provider. An office co-payment of twenty-five dollars ($25.00) per in-network visit will apply [effective January 1, 2006, the co-payment reduces to fifteen dollars ($15.00)]. The co- pay does not apply to the annual deductible and coinsurance. (9) Physical therapy, occupational therapy and/or chiropractic visits will be covered up to a combined annual maximum of thirty (30) visits per person, based upon medical necessity. (10) Outpatient psychiatric, alcohol, and drug treatment require prior authorization by the plan administrator. In the event the employee does not obtain authorization for psychiatric, drug or alcohol treatment, the employee will be responsible for 10% of total charges, in addition to the deductible, coinsurance, and out-of- pocket maximum. In the event the care the employee receives is determined to be medically unnecessary, the employee will be responsible for the cost of all medically unnecessary care. (11) In compliance with XX 0000 (HIPAA), for new hires and eligible dependents, a pre-existing condition clause will apply. In the event medical care or consultation is sought or received within six (6) months prior to the employee's date of hire, the medical condition will not be payable for twelve (12) months from the date of hire with the City. The employee can reduce their twelve (12) months of pre- existing condition requirements by submitting a Certificate of Creditable Coverage from a prior health insurer. (12) SB 199 Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA) provided the following minimum coverage for maternity benefits: At least forty-eight (48) hours inpatient hospital care following a normal vaginal delivery; at least ninety-six (96) hours inpatient hospital care following a cesarean section; and physician directed follow-up care. Effective November 8, 1998, language amended the original xxxx so that the minimum stay requirements are not applicable if the mother and attending provider mutually consent that the mother and child can be discharged early. (13) Effective January 1, 2006, physician office visits will be subject to a fifteen dollar ($15.00) co-payment per in-network primary care physician visit (includes Family, General, Internal, Pediatrician, and OB/GYN physicians); the fifteen dollar ($15.00) co-payment will apply to out-patient psychiatric and substance abuse doctors office visits subject to the limits specified in Section 18.1(A)(7) and (8). Eligible services, which shall include diagnostic, surgical and/or specialty services, routine mammograms and routine prostate/colon rectal cancer tests subject to the limits provided in the network physician’s office and billed by that office shall be covered at one hundred percent (100%) after office visit co-payment. A specialty care physician office visit will be subject to a twenty-five dollar ($25.00) co-payment per in-network specialist visit. Eligible services, which shall include diagnostic, surgical and/or specialty services, routine mammograms and routine prostate/colon rectal cancer tests subject to the limits specified in Section 18.1(A)(13), provided in the network physician’s office and billed by that office shall be covered at one hundred percent (100%) after office visit co-payment. The co-payment does not apply to the annual deductible and coinsurance; however, office co-payments will apply to the annual out-of-pocket maximum. The annual medical plan deductible will not apply to office visit charges for which the office co-payment applies. Care rendered by non-network providers shall be subject to the annual deductible, co-insurance, out-of-pocket maximum, and twenty percent (20%) penalty. (14) Effective January 1, 2006, coverage for routine mammograms will increase to $125, according to the following frequency: ▪ One (1) baseline exam for women 35-39 years of age; ▪ One (1) exam every two years for women age 40-49; ▪ One (1) exam every year for women age 50 and older. (15) Effective January 1, 2006, the City will provide coverage for routine prostate/colon rectal test for men age 40-49 up to a maximum of $65. Men from age 50 and over, one sigmoidoscopy exam and/or PSA blood test will be covered up to a maximum of $85. The City reserves the right to change or offer alternative insurance carriers or to self- insure as it deems appropriate.

Comprehensive Major Medical. The City shall maintain preferred provider organization(s) (PPO) for both medical and prescription drug services. (1) A two hundred dollar ($200.00) annual deductible with an eighty/twenty percent (80/20%) coinsurance of the next fifteen hundred dollars ($1,500.00) in reasonable charges or three hundred dollars ($300.00), for a total out-of-pocket maximum of five hundred dollars ($500.00) per single contract per year. (2) A four hundred dollars ($400.00) annual family deductible with an eighty/twenty percent (80/20%) coinsurance of the next two thousand dollars ($2,000.00) of reasonable charges or four hundred dollars ($400.00), for a total out-of-pocket maximum of eight hundred dollars ($800.00) per family contract per year. (3) If an employee and/or an eligible dependent receive services from a preferred provider (PPO), reimbursements will be paid at the current coinsurance rate of 80/20 percent of reasonable charges. If the participating providers are not used, coinsurance will reduce to 60/40 percent of reasonable charges. The additional twenty-percent (20%) coinsurance will be the employee's responsibility and is not counted toward the deductible or out-of-pocket maximum. (4) The employee's annual out-of-pocket maximum for individual coverage shall be five hundred dollars ($500), and the employee's annual out-of-pocket maximum for family coverage shall be eight hundred dollars ($800). (5) The plan will cover routine physicals, exams and immunizations up to a maximum of $150.00 per individual for covered persons age nine and over; a $300.00 family maximum, subject to deductibles, coinsurance, and out-of-pocket maximums will apply. (6) A mental health/substance abuse case management benefit whereby an eligible participant may elect to exchange unused mental health or substance abuse inpatient days for other needed mental health or substance abuse benefits as determined medically necessary by the plan administrator. The medical necessity and exchange rate shall be determined by the plan administrator. (7) Outpatient alcohol or drug treatment (substance abuse) payments will be limited to 50% of 25 visits per calendar year per individual when provided by a non-network provider. Outpatient alcohol or drug treatment (substance abuse) payments will continue to be limited to a total of twenty-five (25) visits per calendar year per individual when provided by a network provider. An office co- payment of twenty-five dollars ($25.00) per in-network visit will apply [effective January 1, 2006, the co-payment reduces fifteen dollars ($15.00)]. The co-pay does not apply to the annual deductible and coinsurance. (8) Outpatient psychiatric payments will be limited to 60% of 25 visits per calendar year when provided by a non-network provider. Outpatient psychiatric payments will continue to be limited to a total of twenty-five (25) visits per calendar year per individual when provided by a network provider. An office co-payment of twenty-five dollars ($25.00) per in-network visit will apply [effective January 1, 2006, the co-payment reduces to fifteen dollars ($15.00)]. The co- pay does not apply to the annual deductible and coinsurance. (9) Physical therapy, occupational therapy and/or chiropractic visits will be covered up to a combined annual maximum of thirty (30) visits per person, based upon medical necessity. (106) Outpatient psychiatricPursuant to the Mental Health Parity Act of 2008, alcoholall inpatient and outpatient treatment for psychiatric and/or alcohol or drug treatment (substance abuse) services will not be subject to treatment limits and will be covered as standard medical treatment. Coverage is subject to deductible, co-insurance, and drug treatment require prior authorization by the plan administrator. In the event the employee does not obtain authorization for psychiatric, drug or alcohol treatment, the employee will be responsible for 10% out of total charges, in addition to the deductible, coinsurance, and out-of- pocket maximum. In the event the care the employee receives is determined to be medically unnecessary, the employee will be responsible for the cost of all medically unnecessary caremaximums. (117) In compliance with XX 0000 HR 3103 (HIPAA), for new hires and eligible dependentsdependents over nineteen (19) years of age, a pre-existing condition clause will apply. In the event medical care or consultation is sought or received within six (6) months prior to the employee's date of hire, the medical condition will not be payable for twelve (12) months from the date of hire with the City. The employee can reduce their twelve (12) months of pre- pre-existing condition requirements by submitting a Certificate of Creditable Coverage from a prior health insurer. (12) 8) SB 199 Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA) provided the following minimum coverage for maternity benefits: At least forty-eight (48) hours inpatient hospital care following a normal vaginal delivery; at least ninety-six (96) hours inpatient hospital care following a cesarean section; and physician directed follow-up care. Effective November 8, 1998, language amended the original xxxx so that the minimum stay requirements are not applicable if the mother and attending provider mutually consent that the mother and child can be discharged early. (139) Effective January 1, 2006, physician Physician office visits will be subject to a fifteen dollar ($15.00) co-co- payment per in-network primary care physician visit (includes Family, General, Internal, Pediatrician, and OB/GYN physicians); in accordance with the Mental Health Parity Act (MHPA), mental health office visits will be subject to a fifteen dollar ($15.00) co-payment will apply to out-patient psychiatric pay and substance abuse doctors office visits not subject to the limits specified in Section 18.1(A)(7) and (8)frequency limits. Eligible services, which shall include diagnostic, surgical and/or specialty services, routine mammograms and routine prostate/colon rectal cancer tests subject to the limits provided in the network physician’s office and billed by that office shall be covered at one hundred percent (100%) after office visit co-co- payment. A specialty care physician office visit will be subject to a twenty-five dollar ($25.00) co-payment per in-network specialist visit. Eligible services, which shall include diagnostic, surgical and/or specialty services, routine mammograms and routine prostate/colon rectal cancer tests subject to the limits specified in Section 18.1(A)(1318.1(A)(12-13), provided in the network physician’s office and billed by that office shall be covered at one hundred percent (100%) after office visit co-co- payment. The co-payment does not apply to the annual deductible and coinsurance; however, office co-payments will apply to the annual out-out- of-pocket maximum. The annual medical plan deductible will not apply to office visit charges for which the office co-payment applies. Care rendered by non-network providers shall be subject to the annual deductible, co-insurance, out-of-pocket maximum, and twenty percent (20%) penalty. (1410) Effective January 1, 20062012, the plan will cover routine physicals, exams, immunizations and diagnostic tests subject to an annual maximum of seven hundred and fifty ($750) per individual for covered persons age one (1) (starting the day following the birthday) to age eighteen (18) birthday; age eighteen (18) and over with a three hundred ($300) maximum; subject to the deductible, coinsurance and reasonable charge provisions. An office visit co-pay shall apply as specified in Paragraph (9) herein. Stress tests are payable only if determined that they are medically necessary. (11) Effective January 1, 2012, well baby care from birth to age one (1) birthday including immunizations, exams, and routine diagnostic services are payable under the program up to a one thousand five hundred ($1500) maximum payment for each eligible dependent, subject to the deductible, coinsurance and reasonable charge provisions. (12) Provide coverage for routine mammograms will increase to $125, according to the following frequency: ▪ One (1) - one baseline exam for women 35-39 years of age; ▪ One (1) - one exam every two years for women age 40-49; ▪ One (1) exam every calendar year for women age 50 40 and olderover. (1513) Effective January 1, 2006, the City will provide Provide coverage for an annual (one (1) per calendar year) routine prostate/colon rectal cancer test for men age forty (40-49 ) and over up to a maximum of eighty-five dollars ($65. Men from 85.00). (14) For men and women age 50 forty (40) and over, one sigmoidoscopy exam and/or per three calendar year period, will be covered up to one hundred dollars ($100.00). For men age forty (40) and over, an annual (one per calendar year) PSA blood test will be covered up to a maximum of one hundred dollars ($85100.00). (15) Up to a two hundred dollar ($200.00) life-time maximum will continue to be paid for temporomandibular joint pain dysfunction, syndrome or disease or any related conditions collectively referred to as TMJ or TMD on the basis of medical necessity. The City reserves the right to change or offer alternative insurance carriers or to self- self-insure as it deems appropriate.

Comprehensive Major Medical. The City shall maintain preferred provider organization(s) (PPO) for both medical and prescription drug services. (1) A two hundred dollar ($200.00) annual deductible with an eighty/twenty percent (80/20%) coinsurance of the next fifteen hundred dollars ($1,500.00) in reasonable charges or three hundred dollars ($300.00), for a total out-of-pocket maximum of five hundred dollars ($500.00) per single contract per year. (2) A four hundred dollars ($400.00) annual family deductible with an eighty/twenty percent (80/20%) coinsurance of the next two thousand dollars ($2,000.00) of reasonable charges or four hundred dollars ($400.00), for a total out-of-pocket maximum of eight hundred dollars ($800.00) per family contract per year. (3) If an employee and/or an eligible dependent receive services from a preferred provider (PPO), reimbursements will be paid at the current coinsurance rate of 80/20 percent of reasonable charges. If the participating providers are not used, coinsurance will reduce to 60/40 percent of reasonable charges. The additional twenty-percent (20%) coinsurance will be the employee's responsibility and is not counted toward the deductible or out-of-pocket maximum. (4) The employee's annual out-of-pocket maximum for individual coverage shall be five hundred dollars ($500), and the employee's annual out-of-pocket maximum for family coverage shall be eight hundred dollars ($800). (5) The plan will cover routine physicals, exams and immunizations up to a maximum of $150.00 per individual for covered persons age nine and over; a $300.00 family maximum, subject to deductibles, coinsurance, and out-of-pocket maximums will apply. (6) A mental health/substance abuse case management benefit whereby an eligible participant may elect to exchange unused mental health or substance abuse inpatient days for other needed mental health or substance abuse benefits as determined medically necessary by the plan administrator. The medical necessity and exchange rate shall be determined by the plan administrator. (7) Outpatient alcohol or drug treatment (substance abuse) payments will be limited to 50% of 25 visits per calendar year per individual when provided by a non-network provider. Outpatient alcohol or drug treatment (substance abuse) payments will continue to be limited to a total of twenty-five (25) visits per calendar year per individual when provided by a network provider. An office co- payment of twenty-five dollars ($25.00) per in-network visit will apply [effective January 1, 2006, the co-payment reduces to fifteen dollars ($15.00)]. The co-pay does not apply to the annual deductible and coinsurance. (8) Outpatient psychiatric payments will be limited to 60% of 25 visits per calendar year when provided by a non-network provider. Outpatient psychiatric payments will continue to be limited to a total of twenty-five (25) visits per calendar year per individual when provided by a network provider. An office co-payment of twenty-five dollars ($25.00) per in-network visit will apply [effective January 1, 2006, the co-payment reduces to fifteen dollars ($15.00)]. The co- co-pay does not apply to the annual deductible and coinsurance. (9) Physical therapy, occupational therapy and/or chiropractic visits will be covered up to a combined annual maximum of thirty (30) visits per person, based upon medical necessity. (10) Outpatient psychiatric, alcohol, and drug treatment require prior authorization by the plan administrator. In the event the employee does not obtain authorization for psychiatric, drug or alcohol treatment, the employee will be responsible for 10% of total charges, in addition to the deductible, coinsurance, and out-of- of-pocket maximum. In the event the care the employee receives is determined to be medically unnecessary, the employee will be responsible for the cost of all medically unnecessary care. (11) In compliance with XX 0000 (HIPAA), for new hires and eligible dependents, a pre-existing condition clause will apply. In the event medical care or consultation is sought or received within six (6) months prior to the employee's date of hire, the medical condition will not be payable for twelve (12) months from the date of hire with the City. The employee can reduce their twelve (12) months of pre- existing condition requirements by submitting a Certificate of Creditable Coverage from a prior health insurer. (12) SB 199 Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA) provided the following minimum coverage for maternity benefits: At least forty-eight (48) hours inpatient hospital care following a normal vaginal delivery; at least ninety-six (96) hours inpatient hospital care following a cesarean section; and physician directed follow-up care. Effective November 8, 1998, language amended the original xxxx so that the minimum stay requirements are not applicable if the mother and attending provider mutually consent that the mother and child can be discharged early. (13) Effective January 1, 2006, physician office visits will be subject to a fifteen dollar ($15.00) co-payment per in-network primary care physician visit (includes Family, General, Internal, Pediatrician, and OB/GYN physicians); the fifteen dollar ($15.00) co-payment will apply to out-patient psychiatric and substance abuse doctors office visits subject to the limits specified in Section 18.1(A)(7) and (8). Eligible services, which shall include diagnostic, surgical and/or specialty services, routine mammograms and routine prostate/colon rectal cancer tests subject to the limits provided in the network physician’s office and billed by that office shall be covered at one hundred percent (100%) after office visit co-payment. A specialty care physician office visit will be subject to a twenty-five dollar ($25.00) co-payment per in-network specialist visit. Eligible services, which shall include diagnostic, surgical and/or specialty services, routine mammograms and routine prostate/colon rectal cancer tests subject to the limits specified in Section 18.1(A)(13), provided in the network physician’s office and billed by that office shall be covered at one hundred percent (100%) after office visit co-co- payment. The co-payment does not apply to the annual deductible and coinsurance; however, office co-payments will apply to the annual out-out- of-pocket maximum. The annual medical plan deductible will not apply to office visit charges for which the office co-payment applies. Care rendered by non-network providers shall be subject to the annual deductible, co-insurance, out-of-pocket maximum, and twenty percent (20%) penalty. (14) Effective January 1, 2006, coverage for routine mammograms will increase to $125, according to the following frequency: ▪ One (1) baseline exam for women 35-39 years of age; ▪ One (1) exam every two years for women age 40-49; ▪ One (1) exam every year for women age 50 and older. (15) Effective January 1, 2006, the City will provide coverage for routine prostate/colon rectal test for men age 40-49 up to a maximum of $65. Men from age 50 and over, one sigmoidoscopy exam and/or PSA blood test will be covered up to a maximum of $85. The City reserves the right to change or offer alternative insurance carriers or to self- self-insure as it deems appropriate.

Comprehensive Major Medical. The City shall maintain preferred provider organization(s) (PPO) for both medical and prescription drug services. (1) A two hundred dollar ($200.00) annual single deductible with an eighty/twenty percent (80/20%) coinsurance of the next fifteen hundred dollars ($1,500.00) in reasonable charges or three hundred dollars ($300.00), for a total out-of-pocket maximum of five hundred dollars ($500.00) per single contract per year. (2) A four hundred dollars ($400.00) annual family deductible with an eighty/twenty percent (80/20%) coinsurance of the next two thousand dollars ($2,000.00) of reasonable charges or four hundred dollars ($400.00), for a total out-of-pocket maximum of eight hundred dollars ($800.00) per family contract per year. (3) If an employee and/or an eligible dependent receive services from a preferred provider (PPO), reimbursements will be paid at the current coinsurance rate of 80/20 percent of reasonable charges. If the participating providers are not used, coinsurance will reduce to 60/40 percent of reasonable charges. The additional twenty-percent (20%) coinsurance will be the employee's responsibility and is not counted toward the deductible or out-of-pocket maximum. (4) The employee's annual out-of-pocket maximum for individual coverage shall be five hundred dollars ($500), and the employee's annual out-of-pocket maximum for family coverage shall be eight hundred dollars ($800). (5) The plan will cover routine physicals, exams and immunizations up to a maximum of $150.00 per individual for covered persons age nine and over; a $300.00 family maximum, subject to deductibles, coinsurance, and out-of-pocket maximums will apply. (6) A mental health/substance abuse case management benefit whereby an eligible participant may elect to exchange unused mental health or substance abuse inpatient days for other needed mental health or substance abuse benefits as determined medically necessary by the plan administrator. The medical necessity and exchange rate shall be determined by the plan administrator. (7) Outpatient alcohol or drug treatment (substance abuse) payments will be limited to 50% of 25 visits per calendar year per individual when provided by a non-network provider. Outpatient alcohol or drug treatment (substance abuse) payments will continue to be limited to a total of twenty-five (25) visits per calendar year per individual when provided by a network provider. An office co- payment of twenty-five dollars ($25.00) per in-network visit will apply [effective January 1, 2006, the co-payment reduces fifteen dollars ($15.00)]. The co-pay does not apply to the annual deductible and coinsurance. (8) Outpatient psychiatric payments will be limited to 60% of 25 visits per calendar year when provided by a non-network provider. Outpatient psychiatric payments will continue to be limited to a total of twenty-five (25) visits per calendar year per individual when provided by a network provider. An office co-payment of twenty-five dollars ($25.00) per in-network visit will apply [effective January 1, 2006, the co-payment reduces to fifteen dollars ($15.00)]. The co- pay does not apply to the annual deductible and coinsurance. (9) Physical therapy, occupational therapy and/or chiropractic visits will be covered up to a combined annual maximum of thirty (30) visits per person, based upon medical necessity. (10) Outpatient psychiatric, alcohol, and drug treatment require prior authorization by the plan administrator. In the event the employee does not obtain authorization for psychiatric, drug or alcohol treatment, the employee will be responsible for 10% of total charges, in addition to the deductible, coinsurance, and out-of- pocket maximum. In the event the care the employee receives is determined to be medically unnecessary, the employee will be responsible for the cost of all medically unnecessary care. (11) In compliance with XX 0000 (HIPAA), for new hires and eligible dependents, a pre-existing condition clause will apply. In the event medical care or consultation is sought or received within six (6) months prior to the employee's date of hire, the medical condition will not be payable for twelve (12) months from the date of hire with the City. The employee can reduce their twelve (12) months of pre- existing condition requirements by submitting a Certificate of Creditable Coverage from a prior health insurer. (12) SB 199 Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA) provided the following minimum coverage for maternity benefits: At least forty-eight (48) hours inpatient hospital care following a normal vaginal delivery; at least ninety-six (96) hours inpatient hospital care following a cesarean section; and physician directed follow-up care. Effective November 8, 1998, language amended the original xxxx so that the minimum stay requirements are not applicable if the mother and attending provider mutually consent that the mother and child can be discharged early. (13) Effective January 1, 2006, physician Physician office visits will be subject to a fifteen dollar ($15.00) co-co- payment per in-network primary care physician visit (includes Family, General, Internal, Pediatrician, mental health and OB/GYN physicians); the fifteen dollar ($15.00) co-payment will apply to out-patient psychiatric and substance abuse doctors office visits subject to the limits specified in Section 18.1(A)(7) and (8). Eligible services, which shall include diagnostic, surgical and/or specialty services, routine mammograms and routine prostate/colon rectal cancer tests subject to the limits provided in the network physician’s office and billed by that office shall be covered at one hundred percent (100%) after office visit co-payment. A specialty care physician office visit will be subject to a twenty-five dollar ($25.00) co-payment per in-network specialist visit. Eligible services, which shall include diagnostic, surgical and/or specialty services, routine mammograms and routine prostate/colon rectal cancer tests subject to the limits specified in Section 18.1(A)(13), 18.1(A)(6)(a) provided in the network physician’s office and billed by that office shall be covered at one hundred percent (100%) after office visit co-payment. The co-payment does not apply to the annual deductible and coinsurance; however, office co-payments will apply to the annual out-out- of-pocket maximum. The annual medical plan deductible will not apply to office visit charges for which the office co-payment applies. Care rendered by non-network providers shall be subject to the annual deductible, co-insurance, out-of-pocket maximum, and twenty percent (20%) penalty.. Preventive care services, as defined and updated under the Affordable Care Act (“ACA”), will be provided by doctors and health care professionals within the City’s plan provider network without cost- sharing (copayments, coinsurance and deductibles). Preventive services that are not originally defined or eventually included in the ACA shall be subject to the annual deductible, co- insurance, and out-of-pocket maximum as specified in Section 18.1 (A)(1), (2), (3) and (4). Preventive services rendered by non-network providers shall be subject to the annual deductible, co-insurance, and out-of-pocket maximum as specified in Section 18.1 (A)(1), (2), (3) and (4), and twenty percent (20%) penalty. Insured members should contact the City’s health plan administrator prior to obtaining preventive services for determination of preventive services coverage. In addition to the preventive services provided for under the ACA, the City shall maintain preventive coverage and limits for the following services: (14a) Effective January 1, 2006, provide coverage for routine mammograms will increase to $125, according to the following frequency: ▪ One an annual (one (1) baseline exam for women 35-39 years of age; ▪ One (1per calendar year) exam every two years for women age 40-49; ▪ One (1) exam every year for women age 50 and older. (15) Effective January 1, 2006, the City will provide coverage for routine prostate/colon rectal test cancer tests for men age 40-49 40 and over up to a maximum of eighty-five dollars ($65. Men from 85.00). (b) for men age 50 40 and over, an annual (one sigmoidoscopy exam and/or per calendar year) PSA blood test will be covered up to a maximum of one hundred dollars ($85100.00). (c) provide coverage for one (1) baseline mammogram for women 35-39 years old. (7) Up to a two hundred dollar ($200.00) life-time maximum will continue to be paid for temporomandibular joint pain dysfunction, syndrome or disease or any related conditions collectively referred to as TMJ or TMD on the basis of medical necessity. The City reserves the right to change or offer alternative insurance carriers or to self- self-insure as it deems appropriate.

Comprehensive Major Medical. The City shall maintain preferred provider organization(s) (PPO) for both medical and prescription drug services. (1) A two hundred dollar ($200.00) annual deductible with an eighty/twenty percent (80/20%) coinsurance of the next fifteen hundred dollars ($1,500.00) in reasonable charges or three hundred dollars ($300.00), for a total out-of-pocket maximum of five hundred dollars ($500.00) per single contract per year. (2) A four hundred dollars ($400.00) annual family deductible with an eighty/twenty percent (80/20%) coinsurance of the next two thousand dollars ($2,000.00) of reasonable charges or four hundred dollars ($400.00), for a total out-of-pocket maximum of eight hundred dollars ($800.00) per family contract per year. (3) If an employee and/or an eligible dependent receive services from a preferred provider (PPO), reimbursements will be paid at the current coinsurance rate of 80/20 percent of reasonable charges. If the participating providers are not used, coinsurance will reduce to 60/40 percent of reasonable charges. The additional twenty-percent (20%) coinsurance will be the employee's responsibility and is not counted toward the deductible or out-of-pocket maximum. (4) The employee's annual out-of-pocket maximum for individual coverage shall be five hundred dollars ($500), and the employee's annual out-of-pocket maximum for family coverage shall be eight hundred dollars ($800). (5) The plan will cover routine physicals, exams and immunizations up to a maximum of $150.00 per individual for covered persons age nine and over; a $300.00 family maximum, subject to deductibles, coinsurance, and out-of-pocket maximums will apply. (6) A mental health/substance abuse case management benefit whereby an eligible participant may elect to exchange unused mental health or substance abuse inpatient days for other needed mental health or substance abuse benefits as determined medically necessary by the plan administrator. The medical necessity and exchange rate shall be determined by the plan administrator. (76) Outpatient alcohol or drug treatment (substance abuse) payments will be limited to 50% of 25 visits per calendar year per individual when provided by a non-network provider. Outpatient alcohol or drug treatment (substance abuse) payments will continue to be limited to a total of twenty-five (25) visits per calendar year per individual when provided by a network provider. An office co- co-payment of twenty-five fifteen dollars ($25.0015.00) per in-network visit will apply [effective January 1, 2006, the co-payment reduces fifteen dollars ($15.00)]apply. The co-pay does not apply to the annual deductible and coinsurance. (8) 7) Outpatient psychiatric payments will be limited to 60% of 25 visits per calendar year when provided by a non-network provider. Outpatient psychiatric payments will continue to be limited to a total of twenty-five (25) visits per calendar year per individual when provided by a network provider. An office co-payment of twenty-five fifteen dollars ($25.0015.00) per in-network visit will apply [effective January 1, 2006, the apply. The co-payment reduces to fifteen dollars ($15.00)]. The co- pay does not apply to the annual deductible and coinsurance. (9) 8) Physical therapy, occupational therapy and/or chiropractic visits will be covered up to a combined annual maximum of thirty (30) visits per person, based upon medical necessity. (109) Outpatient psychiatric, alcohol, and drug treatment require prior authorization by the plan administrator. In the event the employee does not obtain authorization for psychiatric, drug or alcohol treatment, the employee will be responsible for 10% of total charges, in addition to the deductible, coinsurance, and out-of- pocket maximum. In the event the care the employee receives is determined to be medically unnecessary, the employee will be responsible for the cost of all medically unnecessary care. (1110) In compliance with XX 0000 (HIPAA), for new hires and eligible dependents, a pre-existing condition clause will apply. In the event medical care or consultation is sought or received within six (6) months prior to the employee's date of hire, the medical condition will not be payable for twelve (12) months from the date of hire with the City. The employee can reduce their twelve (12) months of pre- existing condition requirements by submitting a Certificate of Creditable Coverage from a prior health insurer. (1211) SB 199 Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA) provided the following minimum coverage for maternity benefits: At least forty-eight (48) hours inpatient hospital care following a normal vaginal delivery; at least ninety-six (96) hours inpatient hospital care following a cesarean section; and physician directed follow-up care. Effective November 8, 1998, language amended the original xxxx so that the minimum stay requirements are not applicable if the mother and attending provider mutually consent that the mother and child can be discharged early. (1312) Effective January 1, 2006, physician Physician office visits will be subject to a fifteen dollar ($15.00) co-co- payment per in-network primary care physician visit (includes Family, General, Internal, Pediatrician, and OB/GYN physicians); the fifteen dollar ($15.00) co-payment will apply to out-patient psychiatric and substance abuse doctors office visits subject to the limits specified in Section 18.1(A)(718.1(A)(6) and (8)7). Eligible services, which shall include diagnostic, surgical and/or specialty services, routine mammograms and routine prostate/colon rectal cancer tests subject to the limits provided in the network physician’s office and billed by that office shall be covered at one hundred percent (100%) after office visit co-payment. A specialty care physician office visit will be subject to a twenty-five dollar ($25.00) co-payment per in-network specialist visit. Eligible services, which shall include diagnostic, surgical and/or specialty services, routine mammograms and routine prostate/colon rectal cancer tests subject to the limits specified in Section 18.1(A)(1318.1(A)(15), provided in the network physician’s office and billed by that office shall be covered at one hundred percent (100%) after office visit co-payment. The co-payment does not apply to the annual deductible and coinsurance; however, office co-payments will apply to the annual out-of-pocket maximum. The annual medical plan deductible will not apply to office visit charges for which the office co-payment applies. Care rendered by non-network providers shall be subject to the annual deductible, co-insurance, out-of-pocket maximum, and twenty percent (20%) penalty. (13) Effective January 1, 2010, the plan will cover routine physicals, exams, immunizations and diagnostic tests subject to an annual maximum of five hundred dollars ($500) per individual for covered persons age one (1) (starting the day following the birthday) to age eighteen (18) birthday; age eighteen (18) and over with a two hundred dollar ($200) maximum; with a twelve hundred dollar ($1200) family maximum, subject to the deductible, coinsurance and reasonable charge provisions. An office visit co-pay shall apply as specified in Paragraph (12) herein. Stress tests are payable only if determined that they are medically necessary. (14) Effective January 1, 20062010, well baby care from birth to age one (1) birthday including immunizations, exams, and routine diagnostic services are payable under the program up to a seven hundred fifty dollar ($750) maximum payment for each eligible dependent, subject to the deductible, coinsurance and reasonable charge provisions. (15) Provide coverage for routine mammograms will increase up to a maximum of one hundred twenty-five ($125, 125.00) dollars according to the following frequency: ▪ One (1) - one baseline exam for women 35-39 years of age; ▪ One (1) - one exam every two years for women age 40-49; ▪ One (1) exam every calendar year for women age 50 40 and olderover. Effective forty-five (45) days after City Council’s acceptance of this Contract, the maximum coverage for routine mammograms will increase to one hundred fifty dollars ($150.00). (1516) Effective January 1forty-five (45) days after City Council’s acceptance of this Contract, 2006, the City will provide coverage for an annual (one (1) per calendar year) routine prostate/colon rectal cancer test for men age forty (40-49 ) and over up to a maximum of eighty-five dollars ($65. Men from 85.00). (17) For men and women age 50 forty (40) and over, one sigmoidoscopy exam and/or per three calendar year period, will be covered up to one hundred dollars ($100.00). For men age forty (40) and over, an annual (one per calendar year) PSA blood test will be covered up to a maximum of one hundred dollars ($85100.00). (18) Up to a two hundred dollar ($200.00) life-time maximum will continue to be paid for temporomandibular joint pain dysfunction, syndrome or disease or any related conditions collectively referred to as TMJ or TMD on the basis of medical necessity. The City reserves the right to change or offer alternative insurance carriers or to self- insure as it deems appropriate.