Common use of Cost Containment Procedures Clause in Contracts

Cost Containment Procedures. The following health care cost containment procedures shall be effective for all employees: (a) Mandatory second surgical opinions, pre-admission notification or certification, emergency care limitations, post-admission concurrent review, outpatient surgery, continued treatment and technological review, medical case management, planned discharge, and other procedures as may be established under the medical review programs established by the City shall be followed. Failure to follow the procedures shall result in only eighty percent (80%) coverage for necessary care. (b) Full-time employees covered by another health care program due to marriage or other reasons may waive their City of Toledo coverage and receive twenty- five thousand dollars ($25,000.00) in life insurance coverage. This shall also be extended to those employees whose spouses are also employed by the Clerk or the City. (c) Coverage for nervous and mental treatment is limited as follows: Inpatient care shall be maintained at a maximum of thirty-one (31) days per calendar year. Outpatient coverage shall be expanded to a maximum of twenty-two (22) visits per year at fifty percent (50%) co-insurance. Coverage for drug and alcoholism treatment is limited as follows: Inpatient care shall be maintained at a maximum of thirty-one (31) days per calendar year. Coverage is limited to a maximum of twenty-five thousand dollars ($25,000.00) lifetime benefits for all inpatient and outpatient care. Inpatient coverage shall be at one hundred percent (100%) for an individual’s first admission, seventy-five percent (75%) for a second admission, and fifty percent (50%) for a third admission for drug and alcohol treatment. No coverage shall be provided beyond three (3) admissions per lifetime or thirty-one (31) days per calendar year. Outpatient coverage shall be expanded to a maximum of two thousand five hundred dollars ($2,500.00) per calendar year at fifty percent (50%) co-insurance. Employees using drug and alcoholism treatment benefits must use the City’s employee assistance program. The agency selected by the City for managing health care must be used by employees to certify coverage for drug and alcoholism treatment for themselves or their dependents.

Cost Containment Procedures. The following health care cost containment procedures shall be effective for all employees: (a) A. Mandatory second surgical opinions, pre-admission notification or certification, emergency care limitations, post-admission concurrent review, outpatient surgery, continued treatment and technological review, medical case management, planned discharge, and other procedures as may be established under the medical review programs established by the City shall be followed. Failure to follow the procedures shall result in only eighty percent (80%) coverage for necessary care. (b) B. Full-time employees covered by another health care program due to marriage or other reasons may waive their City of Toledo coverage and receive twenty- twenty-five thousand dollars ($25,000.00) in life insurance coverage. This shall also be extended to those employees whose spouses are also employed by the Clerk or the City. (c) C. Coverage for nervous and mental treatment is limited as follows: Inpatient care shall be maintained at a maximum of thirty-one (31) days per calendar year. Outpatient coverage shall be expanded to a maximum of twenty-two (22) visits per year at fifty percent (50%) co-insurance. Coverage for drug and alcoholism treatment is limited as follows: Inpatient care shall be maintained at a maximum of thirty-one (31) days per calendar year. Coverage is limited to a maximum of twenty-five thousand dollars ($25,000.0025,000) lifetime benefits for all inpatient and outpatient care. Inpatient coverage shall be at one hundred percent (100%) for an individual’s first admission, seventy-five percent (75%) for a second admission, and fifty percent (50%) for a third admission for drug and alcohol treatment. No coverage shall be provided beyond three (3) admissions per lifetime or thirty-one (31) days per calendar year. Outpatient coverage shall be expanded to a maximum of two thousand five hundred dollars ($2,500.00) per calendar year at fifty percent (50%) co-insurance. Employees using drug and alcoholism treatment benefits must use the City’s employee assistance program. The agency selected by the City for managing health care must be used by employees to certify coverage for drug and alcoholism treatment for themselves or their dependents.