HomeMy WebLinkAbout87-0301 Maxicare Illinois Fe}'o3a1
IL HOLD AGR PAGE 1
MAXICARE ILLINOIS, INC.
(Hereinafter called 'MAX' )
Registered Offices:
CHICAGO, ILLINOIS G0G85
APPLICATION is hereby made to MAX by the Applicant, named below,
for the purpose of making available to eligible individuals under
subscription certificates issued by MAX certain medical , hospital
and surgical services and benefits. The arran9ement of the
provision of such services and benefits shall be the subject of a
Contract between MAX and the Applicant and shall be based on the
statements and representations contained in this Application , a
copy of which shall be attached to and made• a part of the
Contract .
1 . Applicant : CITY OF ELGIN
Address: 150 DEXTER COURT
City : ELGIN, IL G0120
2 . The contract shall be effective 12: 01 A.M . on
MARCH 1 , 1987
3. Classes of Persons to be covered under Subscription
Certificates : ALL EMPLOYEES WORKING 30 HRS. OR MORE PER
WEEK.
4 . Coverage for Family Dependent is /X/ is not / / to be
provided .
IL HG 485
.
IL HOLD AGR PAGE 2
5. Rules of Eligibility:AFTER 30 DAYS OF EMPLOYMENT .
6 . Dependents who are fulltime students shall be eligible
until a9e 23.
7 . Copayments or Limitations Applicable :
Outpatient Mental Health: No. of Visits 20.
Copayment 20.00
Inpatient Mental Health: No. of Days 14.
Other NONE
In-Area Emergency Copayment $ 10_.00
Outpatient Prescription Drugs $ 2_.9Q .
Other
INJURY TO SOUND g NATURAL TEETH - NO CHARGE
IL HG 485
' IL HOLD AGR PAGE 3
8. Monthly Premium:
Holder Group MEDICAL DENTAL
Subscriber SN/A $N/A.
Subscriber + 1 Dependent $N/A $N/A
( Spouse if 4 tier )
Subscriber + 2 or more $N/A $N/A
Dependents
Subscriber + Child(ren)
Super Composite $1GG .G7 $N/A
MEDICARE RATES:
1 Party over 65 = $ 52.05.
2 Parties over 65 = $ 104. 10
1 Party over G5 + 1 Party under G5 = $ 131.81_
2 Parties over 65 + 1 or more under G5 = $ 200 .85
1 Party over 65 + 2 or more under G5 = $ 236.56
HOLDER GROUP
CITY OF ELGIN
DATE: 3/15/f7 BY: r1-4.0 (;*
PLACE: TITLE : / e c.oe-riJ
Attn: JAMES AYDT
977 lb
KAREN ANDERSON
IL HG 485
IL HOLD AGR PAGE 4
HOLDER GROUP CONTRACT
(MEDICAL AND HOSPITAL SERVICE CONTRACT )
This HOLDER GROUP CONTRACT, Number 977: (hereinafter called the
'Contract' , has been entered into by and between MAXICARE
ILLINOIS, INC . (hereinafter called 'MAX' ) , an ILLINOIS
Corporation and CITY OF ELGIN hereinafter called 'Holder group' )
and sets forth the basis on which eligible persons and their
family dependents , if any, are provided with coverage , under a
Subscription Certificate, issued by MAX to each such Subscriber ,
for certain medical , surgical , hospital and related health
services and benefits, to the extent described herein.
MAX will arrange to provide such services and benefits through
contractual arrangements with Participating Independent Practice
Associations , hospitals , and other health care providers during
the term of this Contract, subject, however , to all of the
provisions and conditions set forth in the Subscription
Certificate and in this Contract .
This Contract is made in consideration of the application of the
Holder , a copy of which is attached hereto and made a part
hereof, and of the payment by the Holder of the required
prepayment amounts (hereinafter called ' Premium' ) .
IL HG 485
IL HOLD AGR PAGE 5
This contract shall become effective on MARCH 1 , 1967 and may be
renewed at the end of each Contract Year unless terminated by MAX
or the Holder as provided herein. The first Contract Year shall
commence as of the effective date and shall terminate on FEBRUARY
29, 1988 . This contract shall continue in force only for the
period for which Premiums are paid with respect to Subscription
Certificates issued in accordance with the provisions of this
Contract, subject to the grace period provided for payment of
Premiums under this Contract .
All periods of time to which reference is made in this Contract
shall begin and end at 12:01 A.M. , Standard Time , at the address
of the Holder .
IN WITNESS WHEREOF , Maxicare Illinois , Inc. and Holder execute
this Contract this day of , 19___
CITY OF ELGIN
. 4La —y '.
.c (j)e;21/'11
Title: President le:
(76C 1)1 n
, (kfliwark..
By By
Title: Secretary Title:
IL HG 485
A
Il Fold igr page 6
I>I'!'EODOCTION
Xaxicars Illinois, Inc. (referred to as 'lO.x') is a for-profit
corporation, certified ander the Stats of Illinois IDSA Act of 1974, .
and qualified ander the Federal HMO Act of 1973 as amended. In
consideration of the payment of monthly premiums by or on behalf of
the Subscriber, lO X agrees to arrange to provide medical and hospital
services and other health ears services to the Subscriber in
accordance vitt ' the Solder Group' Contract and the subscription
Certificate.
INMPRZTATION
In order to provide the advantages of organised and planned health
cars delivery systsa, XXX arranges cars.-on a direct service basis
rather than an indemnity basis. To this end, WAX undertakes to arrange
to provide the health cars services described in this Contract. The
interpretation of this Contract and Subscription Certificates issued
hereunder shall be gaided by the direct service arrangements of l X
with the objective of promoting comprehensive health cars.
SECTION 1. DETIUITZOX3
IL NG 4SS.
I1 Meld Agr Page 7
The following definitions apply to all provisions of this Contract.
1.1 =UMW:: as used herein shall mean charges which say be
collected directly by the Participating Medical Group or Hospital
• from a 1( as additional payseats for services covered under
this Molder Group Contract and the Subscription Certificate.
1.2 CCVMMtn SZA`4ICMS (PSZSIC= 7) : as used herein shall mean those
physician and related health care services which the Participating
Medical Groupe rill provide to =MMUS pursuant to Section 6 of
this Contract.
1.2 PCZ MZDICiL_ SEAVI S: shall mean those services required for
alleviation of severs pain or immediate diagnosis and.trsataent of
unforeseen medical conditions which4 if not treated, would
jeopardise.= impair the health of the MMIMMR.
1.4 TAMill CCVMMAGZ: shall sewn- the coverage provided for a
Subscribing =MR and his/her family dependents by or on whose
behalf the applicable family premium has bean paid.
1.5 TAX= DZ T: shall seen a member of the family of a
Subscriber as defined in Section 2.2.
IL. MG 4is
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21 Sold A4r Page 9
■
of the Joint Commission on accreditation of Eospitals, or any
(Altar institution which is operated, pursuant to lav, under the
supervision of a staff of Physicians and vith tventy-tour (24)
boor a day mussing s.rrice, and which is primarily engaged in
providing general inpatient medical ears and trsatment of sick
and injured parsons through medical, diagnostic and major surgical
facilities, all of 'Mich facilities must be provided on its
premises or ander its control. In no event shall the tars
hospital, include a convalescent nursing home or include an
institution or part thereof vhieh is used principally as a
eonvalescant facility, rest facility or facility for the aged, or
furnished primarily domiciliary or custodial cars, including
training in. the routines of daily living, or is operated primarily
as 'a school. _ •
1.10 Maxicare Illinois, Inc. Marian referred to as *l0.20) : shall saga
xaxicars Illinois, Inc. , an Zlliaois Por-Profit Corporation,
vhich is certified ander the State of Illinois IMO Act of 1974.
1.11 =ICA= SZC=S11AZ: shall mean medical or surgical trsataant
which a =MUM ragcirss, as datarained by one or more
Participating Medical Group Physicians.
1.12 JW4))R: shall lean a Subscriber or covered family dependent.
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IL MO 485
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Page 11
21 Sold J1gr
l.l$ PRI]O►RT GPa PROPSSSICK L: as used herein ball mean the
Participating Professional selected by a XZXSZR to reader first
contact medical care and includes Family (General) Practitioners,
and Pediatricians.
•
1.19 Smtn= APU: shall mean an. area within a thirty (20) air ails
radius from the geographical location of the selected facility or
Primary car. Physician.
1.20 Ma= NURSING PAC=Z.T?T: as used herein shall mean an
institution or part thereof which is accredited as a skilled
nursing facility by the Joint Casoaissicn on accreditation of
• Hospitals or is recognised as a skilled nursing facility by the
• Secretary of Health and Num= Services of the United States
pursuant to Title XV=s= of the Social Security Act, as amended.
1.21 SUBSCSLI : as used rain shall mean a person meeting the
rega,rasents of Section 2.1 who has enrolled in )1242 and for vhca
the current prsaium payments have been received.
1.22 SCISCRS3i2 CSI?: herein used interchangeably with ' (S) g,
shall scan the Subscriber and the enrolled dependants of the
Subscriber.
IL Asa sus
Z1 Sold Lqr Page 13
2.1 SUBSC322= To become a MAX Subscriber, an individual mast bean
employe . of the Solder Group or be entitled by agreement,
contract or ' other established standard to participate in
employee beaetits arranged by the Solder Group.
2.2 7AX= 02;P'SdTVlT: To be eligible to enroll in MAi as a family
dependent, an individual must be either:
a. The legal spouse of a Subscriber, or
b. D dependant, unmarried child under the age of nineteen (19) :
this retais to natural and legally adopted Children as veil as to
children for viae the ".3ubseriber is the legal guardian. Per the
purpose of this section, a child vbo is in the custody of the •
insured, pursuant to an interim court order of adoption vesting
temporary cars of the child, regardless of whether a final order
granting. option is ultimately issued, is a dependent.
c. Zt a dependant is a full-tine student, eligibility for such
dependant is determined by the !older Group and such definition is
attached to the Contract.
d. A dependant vho attains the age of nineteen (19) and is both a)
incapable of salt-sustaining- employment by reason of cental
retardation or physical handicap and b) chiefly dependent upon the .
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Z1 Hold Aqr
3.3 It the Holder or the Subscriber, if applicable, tails to pay the
premium within thirty-one (31) days attar it becomes due, this
Contract and the Subscription Cartiticatas issued thersunder are
automatically cancelled and covered ?IDBS ars not entitled to
further benefits. The Contract will be reinstated only upon the
subsequent acceptance of payaant by 2012. Such reinstatement,
however, will apply only to sickness first manifested more than
tan (10) days attar the acceptance of the premium and injuries
occurring attar the data of reinstatamant. Zf a Subscriber
• tarainatas amp1oysant with the Holder Group, coverage under the
Subscription Csrtiticata shall tarainata attar the last day of the
period for which the premium has bean paid. A Subscriber who is no
longer eligible for )UX membership through a Holder Group has the
option of converting to an individual coverage plan (see Section
9.3) . Holder shall provide MAX with additions and deletions within
fifteen (13) days of the effective data and shall not
retroactively add or delete a ?gaily Unit Meaber due to clerical
error for sore than two (2) months of eligibility.
SECTION 4. TERXIMATION OF AGREEMENT
4.1 Termination by either the Holder Group or by MAX may be
aoeaapliehed by giving written notice to-the other party at least
sixty (60) days prior to the expiration data of the Holder Group
Contract or any subsequent anniversary data.
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XL EG 463
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Il Hold Agr Page 19
a. Willfully providing a MAX membership identification card to any
person ineligible for MAX services:
b. Failure to maks payment to MAX or its contracting providers
within thirty-one (31) days of charges for noncaversd services or
of copayments required for covered services:
c. Situations vbers the hospital or health professionals are
unable to establish and maintain satisfactory patient hospital or
patient health professional relationship.
MAX, upon accepting the committee's recommendation, may tarainata
the Subscriber effective on the first day of the month subsequent
to the month in which the committee makes its recommendation. .
4.5 A subscribing la'; spouse rill cease to be eligible for
coverage hereunder on the first day of the month following the
month in which a final decree of dissolution of-aarriage is
recorded.
6.6 A lam, other than the Subscriber or spouse of Subscriber,
coverage shall terminate upon the attainment of age nineteen (19) ,
unless coverage is extended as provided for under Section 2.2.
SECTION s. PSYSICIAN/PAMENT RELATIONSHIP
IL HG 463
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IL km Page 25
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1LiSI2M1 �
Z1 Hold Agr page 27
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MAX must be notified of Emergency Medical Services within
forty-sight (46) hours, condition permitting at (312) 786-
s
1630. t
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(b) Shock or unconsciousness caused by the accident or illness
occasioned the use of such services, in the absence of another
adult MEMBER of the 'S family vho is able to assist the '
!amount.
OUT OT ARZA Eminency Medical Services.
A. A MEMBER vitt be entitled to benefits for emergency physician
and hospital services (including ambulance services) received
fifty (SO) miles or more tram the MEMBER'S regular
Participating Medical Group from a physician in a hospital,
but only -in the case vhere Emergency Medical Services are
• needed.
3. MAX must be notified of Emergency Medical Services within
forty-eight (46) hours, condition permitting at (312) 766-
l630.
C. MAX vitt reimburse Subscriber for non-Plan providers for such
services rendered at prevailing rates .less any -copayments, if
applicable.
ZL MG 46S
11 Bold Lqr Page 29
Necessary definitions include the following:
OMER GROUP CONTRACT means: any group arrangement other than this
Contract which provides a NEMER with hospital, medical, surgical
or dental benefits and which consists of employer sponsored group
insurance coverage, . association-sponsored group prepayment
coverage, coverage under labormanagement trusteed plans,
employer organisation plans or employee benefit organization
plans, or coverage under governmental programs or coverage
required or provided by statute, but not student accident
policies or group franchise plans.
ALL412313 W ZZITS means: the stn of each necessary, reasonable
and custaaary itsa of expense incurred by a beneficiary, at least
a portion of which is covered by this Contract or some other
group contract covering the lR. Where a service provided is
not otherwise valued in teras of money, then the reasonable cash
- - value shall be deemed to be the benefit.
. OXI YEAR PERIOD means: the period of ' twelve (12) consecutive
months commencing on the first day on which a ICER incurs an
item of allowable benefit.
Benefits may be reduced as follows: If the total benefits to which a
?SLR would be entitled under this Contract and all other group
IL NG 445 •
Zl Sold Aqr Page 31
N. When the parents are divorced and the bZXZER with the custody of
the dependent child has married, the benefits ander a group contract
covering the dependent child of the =BEN with custody shall be
detarsined before the benefits ander any group contract covering that
dependent child of the step-parent, - and the benefits of a group
contract covering the dependent child as a dependant of the step-
parent vill be determined before the benefits ander any group contract
covering that dependant child of the =MEI without custody.
*Notwithstanding A and D above, if there is a court decree which would
otherwise establish financial responsibility for the medical, dental
or other hialth care expanses with respect to the dependant child, the
benefits ander a group contract covering the dependant child as a
.dependent of the XICKNER with such financial responsibility shall be
determined before the benefits of any other group contract covering
the dependent child.
When the two preceding rules do not apply, the benefits under any
group contract which has covered the MUM for a longer period of
time shall be determined before the benefits ander any group contract
ander which such =CM has been covered the shorter period of time;
provided that:
(i) the benefits of a Plan covering the parson on whose expense
claia is based as a laid-off or retired employee or as the
IL NO 4$S
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Page 33
Il- Bold Agr
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Right of Recovery. If the total payments made by MAX as to allowable
expense at any time exceed the maxima payment then necessary to
satisfy the intent of this part, MAX shall have the right to recover
such payment to the extant of such excess, from one or more of the
following, as MAX shall detarsins: any person to or for, or with
respect to whom such payments vera made, any other insurance-
cospanies, and any other organisations.
No benefit shall be paid (whether reduced or not) , under the
provisions of this Section 7, to the extent that it would be
. inconsistent with any definition, limitation, condition, exception or
- other Contract provision applying to this plan.
7.3 IT HOSPITALIZED ON EllECTIVE DATE: A MEMBER who is hospitalized
prior to the effective data of eligibility is covered by MAX as of
the data of eligibility. However, expenses incurred prior to the
effective data of eligibility for MAX are not covered. MEMBER at
the discretion of the IPA may be transferred to a MAX facility on
the effective data of eligibility.
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7.4 THIRD PARTY CLQ: If MEMBER is injured through the act or
'omission of another person, the benefits provided under the group
policy, except Comprehensive Dental Expanse Benefits, vill be paid
only on the condition that the subscriber or family dependent (or
his legally authorised representative if the family member is
legally incapable) agrees in writing:
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Zi Bold Agr Page 39
9.2 Acceptance of Agreement. Bolder Group may accept this Agrsasent
either by execution of the acceptance provision on the last page
of this Service Agreement or by making payment to MAX pursuant to
Section 3 hereof, and such acceptance renders all tarns and
-provisions hereof binding on )GX and Holder Group.
9.2 The health services benefits provided for in this Contract and
Subscription Certificate are not transferable to another party by
any =.
9.4 MAX or its providers are permitted to charge a reasonable fee to
cover its costs for completing medical abstracts or insurance
claim forms.
9.3 )ZDICARE: A =BEI who attains the age of sixty-five (63) (except
an actively employed lmsBZR or, the spouse of an actively employed
UMBER between the ages of sixty-five (63) through sixty-nine
(69) ) or who is otherwise eligible for Medicare (e4q. , a recipient
of social security disability for a mini of two (2) years) may
quality for continued eligibility if they obtain Part A and B
Medicare Coverage. After Medicare benefits become effective, a MAX
UMBER nay continue to receive care through the MAX facilities and
arrangements, however, the MBX3M4 must assign to the persons or
organisations actually providing services or supplies the right to
collect the applicable Medicare benefits.
* XL BG 443
Zl Hold Ag?'
Page 41
representative or agent of 1LAX, other than by a written amendment
rider or endorsement by two (2) officers of 1012.
9.9 =GAL ACTIONS: No action at law or. in equity shall be brought to
recover ander this Contract prior to the expiration of sixty (60)
days attar written claim- for benefits has been ' furnished in
accordance with the requirements hereof. No such action shall be
brought after the expiration of three (3) years from the time
written claim for benefits is regaired to be furnished.
9.10 RESTRICTION ON LIA!ILITT: ]012 shall not be liable for injuries
resulting from negligence, misfeasance, nonfeasance or silpractice
on the part of any officer or employee of MAX, or on the part of
any person, organisation, agency or corporation rendering health
services to a 102'!P.
9.11 SIMICS ARZA: 1012 reserves the right to refuse enrollsant to an
applicant or terminate enrollment of a 'Subscriber if the residence
of such applicant or Subscriber is outside of the service area.
9.11 XXXISMS ars not permitted to assign benefits or payments for
services covered under this coverage.
SECTION 10. SZLECTIOX 07 PARTICIPATING MEDICAL
•
IL NG 499
♦ a y
Page 43
21. Hold Agr
(31) days, depending upon the circumstances. If the Somber is not
satisfied as to the resolution of the natter, the Somber may
request that a grievance committee be convened as provided below.
(2) In the event of any controversy, disputa, or claim with
respect to the administration of this Agreement between a Somber,
an IPA Health Professional, and MAX, such controversy, disputa or
claim shall be submitted to a Grievance Committee composed of one
person each to represent the Somber, the IPA Health Professional,
and SAX. Notice requesting a committee rereview shall include a
description of the grievance and &ball be sent to the Executive
Director of )X at:
P.O. Doo: 2942
•
Chicago, Illinois 60690
The Executive Director shall -Convene a committee within thirty-one
(31) days of such notice. said Grievance Committee shall be alloyed a
period of (31) subsequent days in which to reach an
agreeable settlement of the controversy, dispute, or claim.
If a compromise satisfactory to the Member cannot be reached by the
Grievance Committee, the Member, has the option of requesting the
utter be reviewed by the Patient Satisfaction Committee. Half of the
u HG 4$s
.
page 45
Il Hold AV
12.1 I? ANY DISPUTE OR CONTROVERSY SHALL ARISE AMONG TEE PARTIES
ZERETO LATE RESPECT TO TEE RAZING OF, CONSTRUCTION OF, TEE TERMS
07, OR INTEURETATION OF TETE AGREEMENT OR TEE RIGHTS OF ANY PARTY
HERETO OR WITH RESPECT TO ANT TRANSACTION INVOLVED, TEE DISPUTE OR
CONTROVERSY SHALL BE SETTLED BY ARBITRATION BEFORE TER=
ARSITR&TORS, SELECTED FRO* THE PANES OF ARBITRATORS 07 TEE
AMERICAN ARBITRATION ASSOCIATION, IN ACCORDANCE MITI TEE
COMOIRCIn ON RGI OF THE ANEMIC AN ARBITRATION
ASSOCIATION, PURSUANT TO TEE UNIPORX ARBITRATION ACT AS ADOPTED IN
ZIS.IN028, AND A JUDGMENT UPON TRE AWARD ENTERED IN ANT COURT
RAPING JURISDICTION T'RZO?. TEE PARTIES BERM SUBMIT TO THE
PERSONAX JURISDICTION or THE CIRa IT COURT 0? TEE COUNTY 07 COOK
OP THE STATE OF ILLINOIS, ?O1 THE PURPOSE OF CONFIRMING ANY SUCH
- AWARD AND ENTERING JUDGMENT Tom.
12.2 IN THE EVENT SUIT IS BRGUGET TO ENFORCE OR INTERPRET AAT PART OP
TETE AGREE1T, TEE -PASTY *HALL BE ENTITLED TO RECOVER,
AS AN ZI. NT -O? ITS COSTS OP SUIT (INCLUDING PAYMENT OWED TO THE
ARBITRATOR INCURRED IN THE ACTION OR PROCEEDING) AND NOT AS
DAXAGES, A REASONABLE ATTORNEYS' PEs TO BE DETERMINED BY TEE
ARBITRATOR OR OTEER JUDICIAL BODY. TEE 'PREVAILING PARTY' SHALL BE
TEE PARTY WHO IS ENTITLED TO RSR ITS COSTS OF SUIT, MT= OR
NOT TEE SUIT PROCEEDS TO FINAL JUDGMENT. A PARTY NOT ENTITLED TO
RECOVER ITS COSTS BE1LL NOT RECOVER ATTORNEY'S FEES. NO SUM FOR
ATTORNEY'S FEES SHALL BE COUNTED IU CALCULATING THE AMOUNT 07 A
IL MG 4$S
August 9 , 1988
MEMORANDUM
TO: Mayor and Members of the City Council
FROM: City Manager
SUBJECT: Maxi Care Amendment
PURPOSE: The purpose of this memorandum is to forward to the
Mayor and City Council an amendment to the Maxi Care Group
Service Agreement.
BACKGROUND: Maxi Care has been the City' s Federally Qualified
Health Maintenance Organization (HMO) provider since 1982 .
There are currently 59 employees enrolled in the HMO program.
The attached amendment increases certain monthly premiums
required for Maxi Care coverage. For example, the super compos-
ite rate which the City pays on behalf of the above employees
has been increased to $191 . 67 a month from $166 .67 . Even with
the aforementioned increase, the Maxi Care rate is lower than
the premiums of the City' s traditional major medical policies .
FINANCIAL IMPACT: The new Maxi Care rate will result in an
additional annualized cost of $17 ,700 . There are sufficient
resources in the Risk Management Fund to pay for the rate
increase.
RECOMMENDATION: It is recommended that the Mayor and City
Council authorize the execution of the Maxi Care amendment.
e
ames J. •ok, City Manager
JJC:am•
A HEALTH MAINTENANCE ORGANIZATION
An Illinois Corporation (hereinafter called ',MAXI')
AMENDMENT TO 1987
HOLDER GROUP CONTRACT
FEDERALLY QUALIFIED PROGRAM
The Bolder Group Contract between Maxicare Illinois, Inc. and the Holder Group named below is amended as
set forth below:
I. BENEFIT AND CONTRACTUAL LANGUAGE AMENDMENT
II. RATE AMENDMENT is effective on APRIL 1, 1988.
THE MONTHLY PAYMENTS PER FAMILY UNIT REQUIRED UNDER THIS AGREEMENT ARE:
MONTHLY MEDICAL MONTHLY DENTAL
PREMIUMS: PREMIUMS:
SUBSCRIBER: • $ $
SUBSCRIBER + 1 DEPENDENT (Spouse if 4 tier): $ $
SUBSCRIBER + 2 OR MORE DEPENDENTS: $ $
SUBSCRIBER + CHILD(REN): $ $
SUPER COMPOSITE: $191.67 $19.47
MEDICARE SUPPLEMENT RATES FOR RETIREES:
1 PARTY ON MEDICARE $ 55.72
2 PARTIES ON MEDICARE $111.44
1 PARTY ON MEDICARE + 1 PARTY NON-MEDICARE $148.45
2 PARTIES ON MEDICARE + 1 OR MORE NON-MEDICARE $213.44
1 PARTY ON MEDICARE + 2 OR MORE NON-MEDICARE $250.45
Group #977, Unit
II. COORDINATION OF BENEFITS SECTION is amended as follows:
BENEFIT COORDINATION WITH OTHER COVERAGE:
This health plan has been designed to help the Member meet the cost of receiving health care services. MAX will
provide benefits as specified herein, but shall be entitled to coordinate the cost of providing these benefits with
any other Plan(s) whether group, governmental or otherwise, under which the Member has health care coverages. MAX
is not relieved of providing covered services as a result of this Coordination of Benefits. Specifically, if a
Member is eligible to receive benefits under another Plan(s) for services provided at MAX's expense, MAX reserves
the right to obtain reimbursement from any such Plan(s) for the cost of the services provided which are payable
under the other Plan(s), but not in excess of one hundred percent (100%) of the value of services provided in the
aggregate. Members claiming benefits under this contract must notify MAX of the existence of any and all other
coverages as well as the benefits payable under such contracts. The Member agrees to assist MAX in the
implementation of its right to coordinate benefits, including the execution of any assignment or other documents
necessary to authorize or facilitate such payment to MAX or to any of its contracting providers. MAX shall have the
right to release to any Physician or other medical professional, insurance company or any other person or
organization, any claim information, including copies of records relating hereto, necessary for the administration
of this Article.
DEFINITION OF THE TERM "PLAN(s)":
The term "Plan(s)" as used herein shall mean any of the following which provide benefits or services for, or because
of, medical or dental care or treatment:
(1) Group insurance or group-type coverage, whether insured or uninsured. This includes prepayment, group
practice or individual practice coverage;
(2) Coverage under governmental plan or required or provided by law. This does not include a state plan under
Medicaid (Title XIX, Grants to states for Medical Assistance Programs, of the United States Social
Security Act as amended from time to time);
It also does not include any plan when, by law, benefits are excess to those of any private insurance
program or other non-governmental program.
Each contract or other arrangement for coverage under (1) or (2) is a separate Plan. Also, if an
arrangement has two parts and Coordination of Benefit rules apply only to one of the two, each of the
parts is a separate Plan.
CLAIM DETERMINATION PERIOD:
Shall mean a calendar year. However, it does not include any part of a year during which a person has no coverage
under MAX's Plan, or any part of a year before the date this Coordination of Benefit provision or a similar
provision takes effect.
ORDER OF BENEFITS PAYMENT:
When a Member is covered by more than one insurance or medical coverage Plan, benefits under the other Plan shall be
coordinated with benefits provided under MAX's Plan to avoid duplicate coverage. One Plan will have primary
obligation and the other Plan will have secondary obligation. Duplication in the payment or provision of services
will not occur. When there is a basis for a claim under MAX's Plan and another plan, the benefits under MAX's Plan
are secondary unless:
(1) The other Plan has rules coordinating its benefits with the benefits of MAX's Plan; and
(2) Both the other Plan's rules and the rules of MAX's Plan, inclusive below, require that the benefits of
MAX's Plan be determined before the benefits of the other Plan.
MAX's Plan determines benefits by using the first of the following rules which apply:
(A) The Plan covering the Member as an employee (subscriber) has primary obligation. The Plan covering the
Member as a dependent has secondary obligation;
(B) When MAX's Plan and another Plan cover the same child as a dependent of different person, called
"parents", except as stated in subparagraph (C) below:
(1) The benefits of the Plan of the parent whose birthday falls earlier in a year is determined before
the Plan of the parent whose birthday falls later in that year; but
(2) If both parents have the same birthday, the benefits of the Plan which covered the parent longer is
determined before the Plan which covered the other parent for a shorter period of time.
(3) However, if the other Plan does not have the rule described in (1) immediately above, but instead has
a rule based upon the gender of the parent, and if, as a result, the Plans do not agree on the order
of benefits, the rule in the other Plan will determine the order of benefits.
•
(4) If two or more Plans cover a person as a dependent child of divorced or separated parents, benefits for
the child are determined in this order:
(A) First, the Plan of the parent with custody of the child;
(B) Then, the Plan of the spouse of the parent with the custody of the child; and
(C) Finally, the Plan of the parent not having custody of the child.
However, if the specific terms of a court decree state that one of the parent is responsible for the
health care expenses of the child, and the entity obligated to pay or provide the benefits of the Plan of
that parent has actual knowledge of those terms, the benefits of that Plan are determined first. This
paragraph does not apply with respect to any Claim Determination Period or Plan year during which any
benefits are actually paid or provided before MAX has that actual knowledge.
(5) The benefits of a Plan which cover a person as an employee who is neither laid off nor a retired employee
(nor that employee's dependent) are determined before a Plan which covers that person as a laid off or
retired employee (or that employee's dependent). If the other Plan does not have this rule, and if, as a
result, the Plans do not agree on the order of benefits, this rule (4) is ignored.
(6) If none of the above rules determine the order of benefits, the benefits of the Plan which covered an
employee, the Member, or Subscriber longer is determined before the Plan which covered that person for a
shorter time.
MAX may, at its option, pay to other health insurance Plans any amount which MAX determines will satisfy the intent
of the Coordination of Benefits provision. The amount paid will be considered Covered Medical Services and MAX will
not have further liability.
III. ELIGIBILITY SECTION OF THE HOLDER GROUP CONTRACT is amended as follows, effective July 1, 1986.
CONTINUATION OF COVERAGE FOR CERTAIN SUBSCRIBERS AND FAMILY DEPENDENTS:
The subscriber and/or their family dependents are eligible to retain coverage under this Service Agreement during
any continuation of Coverage period necessary for the Subscriber Group's compliance with the requirements of the
Consolidated OMNIBUS Budget Reconciliation Act of 1985 (COBRA) (Title X) and any regulations adopted thereunder, or
any similar state law requiring the Continuation of Benefits for MEMBERS, provided the premiums for such MEMBERS
continue to be paid by the Subscriber Group pursuant to the terms of the contract.
IV. ELIGIBILITY SECTION OF THE HOLDER GROUP CONTRACT is amended as follows, effective May 1, 1986.
MAXICARE will administer all provisions of the agreement in accordance with the requirements of COBRA as it amended
ADEA and the SOCIAL SECURITY ACT. All references herein to MEDICARE and MEDICARE ELIGIBILITY shall be interpreted
in compliance with COBRA. •
This Amendment does not alter or affect the terms of the Holder Group Contract except as described above.
IN WITNESS WHEREOF, the parties hereto have caused this Amendment to be executed by duly authorized representatives
this day of , 19 , at Chicago, Illinois.
CITY OF ELGIN MAXICARE ILLINOIS, INC.
= mss
BY: BY:
Title: Tit„ler!Th 'man of the"Board
r 1).
BY: BY:
Title: Title: Secretary
150 DEXTER CT.
ELGIN, IL 60120-5555
Attn: VITU SOMI
Group #977, Unit
MARY CURRAN/sh