HomeMy WebLinkAbout2013-0618 Council Agenda PACKET
CITY OF
ASHLAND
Important: Any citizen may orally address the Council on non-agenda items during the Public Foram, Any citizen may submit written
comments to the Council on any item on the Agenda, unless it is the subject of a public hearing and the record is closed. Time permitting, the
Presiding Officer may allow oral testimony. If you wish to speak, please fill out the Speaker Request form located near the entrance to the Council
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some extent on the nature of the item under discussion, the number of people who wish to speak, and the length of the agenda.
AGENDA FOR THE REGULAR MEETING
ASHLAND CITY COUNCIL
June 18, 2013
Council Chambers
1175 E. Main Street
Note: Items on the Agenda not considered due to time constraints are automatically continued to the next
regularly scheduled Council meeting [AMC 2.04.030.E.]
7:00 p.m. Regular Meeting
1. CALL TO ORDER
II. PLEDGE OF ALLEGIANCE
Ill. ROLL CALL
IV. MAYOR'S ANNOUNCEMENTS
V. APPROVAL OF MINUTES
1. Study Session of June 3, 2013
2. Business Meeting of June 4, 2013
VI. SPECIAL PRESENTATIONS & AWARDS
None
VII. CONSENT AGENDA
1. Approval of minutes from committees, and commissions
2. Amendment to the IGA between the City of Ashland and the Transportation
Growth Management Program for the Normal Avenue neighborhood plan
3. Appointment of Alyssa Clark to the Public Arts Commission
4. Extension of City Waiver of Rights to Terminate Lease Agreement with
Ashland Community Hospital for failure to maintain working capital and debt
service coverage ratios
5. Approval of parking and marking options for the Plaza
6. Approval of a resolution titled, "A resolution to close the Youth Activity Levy
Fund in the Parks and Recreation Fund effective June 30, 2013"
COUNCIL MEETINGS ARE BROADCAST LIVE ON CHANNEL 9
VISIT THE CITY OF ASHLAND'S WEB SITE AT W WW.ASHLAND.OR.US
VIII. PUBLIC HEARINGS (Persons wishing to speak are to submit a "speaker request
form" prior to the commencement of the public hearing. All hearings must
conclude by 9:00 p.m., be continued to a subsequent meeting, or be extended to
9:30 p.m. by a two-thirds vote of council {AMC §2.04.050})
None
IX. PUBLIC FORUM Business from the audience not included on the agenda.
(Total time allowed for Public Forum is 15 minutes. The,Mayor will set time limits
to enable all people wishing to speak to complete their testimony.) [15 minutes
maximum]
X. UNFINISHED BUSINESS
1. Annual budget approval of:
A resolution titled, "Resolution adopting the biennial budget and making
appropriations"
and
A resolution titled, "Resolution certifying City provides sufficient municipal
services to qualify for State Subventions"
and
A resolution titled, "A Resolution declaring the City's election to receive State
Revenues"
and
Second reading of an ordinance titled, "An ordinance levying taxes for the
period of July 1, 2013 to and including June 30, 2014, such taxes in the sum
of $10,519,347 upon all the real and personal property subject to assessment
and levy within the corporate limits of the City of Ashland, Jackson County,
Oregon"
XI. NEW AND MISCELLANEOUS BUSINESS
1. Report from the Homelessness Steering Committee on the Thursday night
winter shelter and discussion of plans for future winter shelter
2. Grant award for Help Center services in Ashland
3. Clarification of Mt. Ashland Association Agreement
XII. ORDINANCES. RESOLUTIONS AND CONTRACTS
1. Approval of a resolution titled, "A resolution authorizing the establishment and
governance of a self-insured health benefit program"
Xlll. OTHER BUSINESS FROM COUNCIL MEMBERSIREPORTS FROM COUNCIL
LIAISONS
XIV. ADJOURNMENT
In compliance with the Americans with Disabilities Act, if you need special assistance to participate in this meeting,
please contact the City Administrator's office at (541) 488-6002 (TTY phone number 1-800-735-2900). Notification 72
hours prior to the meeting will enable the City to make reasonable arrangements to ensure accessibility to the
meeting (28 CFR 35.102-35.104 ADA Title 1).
COUNCIL MEETINGS ARE BROADCAST LIVE ON CHANNEL 9
VISIT THE CITY OF ASHLAND'S WEB SITE AT WWW.ASHLAND.OR.US
City Council Special Study Session
June 3, 2013
Page 1 of 2
MINUTES FOR THE SPECIAL STUDY SESSION
ASHLAND CITY COUNCIL
Monday, June 3, 2013
Siskiyou Room, 51 Winburn Way
Mayor Stromberg called the meeting to order at 5:27 p.m. in the Siskiyou Room.
Councilor Lemhouse, Rosenthal, Voisin, Morris, Slattery, and Marsh were present.
1. Review of Look Ahead
City Administrator Dave Kanner reviewed items on the Look Ahead.
2. Presentation by Commissioner Don Skundrick on Jackson County's budget and its possible impacts
to the City of Ashland (request of Mayor Stromberg)
Jackson County Commissioner Don Skundrick explained how the County had previously funded library services
through a deficit in the General Fund and decided not to use reserve funds and make cuts instead. Another factor
effecting funding was the County paying $3,600,000, $1,800,000 from the General Fund, and $1,800,000 from
dedicated funds for PERS (Public Employees Retirement System).
The Budget Committee would fund the libraries one more year who in turn would try to form a library district.
At the end of 2013-14 if the libraries failed to create a district, the County would close 14 of 15 libraries and
leave Medford open. If funds were insufficient for the 2014-15 budget cycle, the Medford library would close.
To counter these cuts, Commissioner Skundrick proposed a motion the Budget Committee passed that would
add a County Jail Fee on the November Ballot. The monthly $7 fee per household/unit would exclude
hotels/motels, and office buildings, produce close to $7,000,000 for the General Fund, and partially cover funds
for the County jail, the gap in the General Fund and subsequently the libraries. The County was waiting on
survey results to gauge voter support prior to adding it to the ballot. The ordinance would collect the $7 fee
without an increase except for CPI (Consumer Price Index) for five years. At the end of five years, it could
increase to $10 with no further raises except for CPI. All increases required voter approval. The ordinance
would also dedicate money to fund libraries that did not use the Jail Fee.
Commissioner Skundrick clarified if the County had to make cuts to RVCOG (Rogue Valley Council of
Governments) they would cut the dues and continue to contract with RVCOG.
3. Discussion of possible Plaza improvements (request of Councilors Marsh and Voisin and Mayor
Stromberg)
Councilor Marsh was interested in adding tables and chairs to the Plaza and using flowerpots to define space.
Council expressed concern over the color of the pavers used in the Plaza noting the color renditions provided by
Covey and Pardee depicted buff colored concrete. In addition, the consultants discussed adding six benches to
the Plaza and added only four. City Administrator Dave Kanner explained the colors in the renderings were
limitations to the software used and the gray pavers complimented the artwork. Professional designers
consulted with the Public Arts Commission and the Plaza artist to select the paver color. The pallet of materials
presented to Council and the public during a Council meeting were gray pavers.
Council majority was interested in directing staff to research tables and chairs, cost and maintenance. Opposing
comments expressed concern the Plaza was a pedestrian travel area and table and chairs reduced that capacity.
Greg Covey and Alan Pardee of Covey Pardee Landscape Architects supported adding tables and chairs. They
clarified initially Council wanted the Plaza to be a flexible space for variety of activities. They went on to
explain construction standards, handicapped access, and grade changes on the Plaza limited the number of
benches to four instead of six. Covey Pardee created graphics of the proposed design that showed buff colored
City Council Special Study Session
June 3, 2013
Page 2 of 2
concrete. When Council decided to use permeable pavers instead, the consultants worked with the Public Arts
Commission on a neutral color to set off the mosaic artwork on the benches that resulted in dark gray. The
Public Arts Commission then presented the color pallet to the public. Council reviewed the final materials
during a Council meeting.
Engineering Services Manager Scott Fleury researched suggested paver options and explained acid staining
would make the pavers darker. Painting the pavers was an involved process that could affect the permeability
and it was unknown how long the paint would last. The third option to install new pavers would cost
approximately $35,000. Covey Pardee explained the pavers untouched would lighten over time.
Council majority did not think the pavers should change with one comment wanting to replace the pavers. They
discussed painting the visitor's information booth and directed staff to bring back a recommendation. Council
consensus went on to agree not to allow dogs on the Plaza other than passing through the area.
Covey Pardee addressed the tree grates and explained cast iron initially exposed to air created rust and oxidized
over time before achieving its natural color. Council suggested the possibility of painting the flier structure.
Council did not think the Plaza needed skateboard deterrents on the benches and seat wall caps as long as police
enforcement remained consistent.
Council discussed painting the curb around the Plaza. Suggestions included not painting, restriping part of the
area as loading zone only, partially painting the curb or painting the entire curb yellow. Discussion ranged from
having extra parking places to potential safety and traffic hazards. The Transportation Commission and Police
Department recommended painting the entire curb yellow.
4. Discussion of creation of a Jobs Commission
Management Analyst Adam Hanks presented two options for a Jobs Commission. The first would establish a
small advisory board to meet quarterly and the second was a larger body that would handle economic
development as well. The commission would work with regional efforts to avoid duplicating services.
Executive Director Jim Fong of the Rogue Workforce Partnership (RWP) added John Lee from Folium Partners
was a new Ashland representative for RWP and thought RWP would accept a second representative appointed
by the Mayor.
Aurora King, the career navigator and lead for The Job Council One-Stop Centers suggested establishing a
satellite office in Ashland with Southern Oregon University (SOU) that offered resume building, career
coaching and job clubs.
Council discussed the benefits of option two with opposing comments wanting the commission to focus on job
creation locally and not economic development at this time. Alternately, Council expressed interest in having a
Mayor appointed representative join RWP and wanted cost information for The Job Council to meet in Ashland
once a week. Council directed staff to research a proposal for The Job Council and provide further information
on a Mayor appointed representative to the RWP while considering the two options proposed by staff.
Meeting adjourned at 7:44 p.m.
Respectfully submitted,
Dana Smith
Assistant to the City Recorder
ASHLAND CITY COUNCIL MEETING
June a, 2013
Page I of 6
MINUTES FOR THE REGULAR MEETING
ASHLAND CITY COUNCIL
June 4, 2013
Council Chambers
1175 E. Main Street
l
CALL TO ORDER
Mayor Stromberg called the meeting to order at 7:00 p.m. in the Civic Center Council Chambers.
ROLL CALL
Councilor Voisin, Morris, Slattery, Rosenthal, and Marsh were present. Councilor Lemhouse arrived at
7:55 p.m.
MAYOR'S ANNOUNCEMENTS
Mayor Stromberg announced vacancies on the Firewise, Housing, Transportation, and Tree Commissions
and one vacancy on the Band Board.
He went on move the agenda item for the second reading of the ordinance to extend the Verde Village
timetable following the Consent Agenda. He also explained the resolution and affiliation agreement
between City of Ashland, Asante, Ashland Community Hospital, and the Ashland Community Hospital
Foundation would occur when the representatives arrived.
APPROVAL OF MINUTES
The minutes of the Business Meeting of May 21, 2013 were approved as presented.
SPECIAL PRESENTATIONS & AWARDS
Mayor Stromberg introduced Ashland High School Princesses Katie Shammel and Vicki Lawton-Diez
who gave a brief presentation of what they would perform during their stay in the City Sister of
Guanajuato, Mexico.
CONSENT AGENDA
1. Approval of minutes from committees and commissions
2. Renewal of ambulance operator's license
3. Amendment to IGA with Jackson County for Emergency Notification System
4. Appointment of Dave Chapman to the Transportation Commission
5. Approval of Local Agency Agreement No. 29101 for a Congestion Mitigation and Air Quality
improvement grant for construction of Hersey Street sidewalk
6. Appointment of Carol Davis to the Planning Commission
7. Special procurement for the purchase of Type 1 fire pumpers
8. Award of contract to apparent low bidder for the miscellaneous concrete project
9. Approval of a contract with Pathway Enterprises for janitorial services
10. Declaration and authorization to dispose of surplus property in a sealed bid auction
11. Liquor license application for James Mills, dba Caldera Brewing Co.
12. Liquor license application for Robert Lindauer, dba Paddy Brannan's Irish Pub
13. An amendment to the IGA for a code assistance grant for the Unified Development Code
Councilor Marsh pulled Consent Agenda items #3 and #8 for further discussion. She noted the IGA
(Intergovernmental Agreement) with Jackson County for Emergency Notification System went through
March 14, 2016 instead of 2015.
ASHLAND CITY COUNCIL MEETING
June 4, 2013
Page 2 of 6
Engineering Services Manager Scott Fleury clarified funds left over from the contract for the
miscellaneous concrete project could go towards engineered projects associated with the miscellaneous
concrete or to engineering on TSP (Transportation System Plan) projects budgeted for 2016-2019. The
bid process awarded new projects to contractors as separate contracts. The standard amount of bonds for
bids was 10%.
Councilor RosenthaWoisin m/s to approved Consent Agenda items. Voice Vote: all AYES. Motion
passed.
ORDINANCES, RESOLUTIONS AND CONTRACTS
1. Second reading of an ordinance titled, "An ordinance granting a timetable extension to the
Verde Village Subdivision development agreement"
EXPARTE CONTACT
Mayor Stromberg noted a conversation with the applicants regarding outdated energy items they had
agreed on with the initial development. City Attorney Dave Lohman confirmed the conversation did not
constitute Exparte contact, as it had ho bearing on the decision currently before Council.
Councilor Marsh/Slattery m/s to approve Ordinance #3082. DISCUSSION: Staff confirmed nine
items recommended by the Planning Commission were included in the development agreement.
Roll Call Vote: Councilor Voisin, Marsh, Morris, Slattery, and Rosenthal, YES. Motion passed.
PUBLIC HEARINGS
1. Public hearing and approval of a resolution establishing rates for the Ashland Municipal
Airport and repealing Resolution 2012-18
Engineering Services Manager Scott Fleury explained the Airport Commission proposed rate increases
for hangar rentals and tie down fees. Ground lease agreements adjusted automatically on the CPIU
(Consumer Price Index for All Urban Consumers) annually. The Airport Commission recommended
raising rental rates $5 per month for hangar leases and increasing the monthly tie down fee by $l. The
Airport maintained a contingency fund and an End Fund Balance.
Public Hearing Open: 7:32 p.m.
Public Hearing Closed: 7:32 p.m.
Councilor Slattery/Marsh m/s to approve Resolution #2013-1.6. Roll Call Vote: Councilor Slattery,
Morris, Voisin, Rosenthal, and Marsh, YES. Motion passed.
2. Public Hearing to consider adopting the annual budget and approval of:
Council delayed discussion and approval of the resolutions associated with the Annual Budget to the next
Council meeting.
Administrative Services Director Lee Tuneberg noted a change to the budget in the Water Fund for the
Fire Resiliency Program. Instead of $175,000, it should have shown $350,000 for the biennium. The
amount would come from the Ending Fund Balance but the total amount would remain the same for
appropriations in the Forest Lands Management. The other items were Public Works projects not
complete as originally projected.
PUBLIC HEARING OPEN: 7:42 p.m.
Stefani Seffinger/Chair of the Park Commission/448 Taylor Street/Explained that normally she would
address the importance of the Parks and Recreation Commission retaining control of the Parks and
Recreation budget and operations. Instead, she thanked the Council for the work they did and the citizens
ASHLAND CITY COUNCIL MEETING
June 4, 2013
Page 3 of 6
who supported the parks with their time and dedication. It was more important now to look to the future
where the Parks and Recreation Commission and the Council worked effectively together.
Mary Wooding/727 Park Street/Opposed taking money from the Parks and Recreation Department and
hoped the next budget would reinstate the 50%.
Abi Maghamfar/Ashland Lodging Association/451 N Main Street/Represented the Ashland Lodging
Association and thanked the Council and Budget Committee for funding the position of Code
Enforcement Officer. The position would help bring over 100 illegal vacation rental operations into
compliance and the Ashland Lodging Association volunteered to assist in that process. The Association
asked Council to have a quarterly report on the status of illegal vacation homes.
Rick Landt/468 Heiman Street/Thought the budget was contrary to the City Charter and Council policy.
It was a radical departure from the development of previous budgets for the Parks and Recreation
Department and not in the best interest of the citizenry. It was unclear to him why the change was
necessary other than a 1997 state law made it possible. The Parks Commission's sole responsibilities
were the preservation and enhancement of the parks and recreation system. He would work with the
public and the City Council/Parks and Recreation Commission ad hoc Committee to continue to shed
light on this issue and work for a permanent solution to find dependable sufficient funding for city parks.
PUBLIC HEARING CLOSED: 7:50 p.m.
Councilor Voisin/Slattery m/s to approve First Reading of the Ordinance, "An ordinance levying
taxes for the period of July 1, 2013 to and including June 30, 2014, such taxes in the sum of
$10,519,347 upon all the real and personal property subject to assessment and levy within the
corporate limits of the City of Ashland, Jackson County, Oregon" and place on agenda for second
reading. DISCUSSION: Councilor Voisin explained the ordinance needed approval of First Reading to
remain in compliance. Councilor Rosenthal supported the budget except for the change and methodology
pertaining to the allocation for the Parks and Recreation Department and would not'support the motion.
The mission and vision outlined in the City Charter for the parks systems was still pertinent and
significant. He was concerned in 5-10 years there might not be adequate funding for the parks system.
Councilor Marsh noted the process over the last year regarding the Parks and Recreation budget
concerned several people. There was an opportunity through the City Council/Parks and Recreation
Commission ad hoc Committee to start fresh and discuss how to fund parks in the future. Councilor
Slattery commented there would be serious funding issues and challenges over the next 10-20 years and
thought every department needed review. The City Council/Parks and Recreation Commission ad hoc
Committee and the work the Council and the Parks and Recreation were doing collaboratively would
result in a better plan that worked.
Councilor Lemhouse arrived at 7:55 p.m.
Roll Call Vote: Councilor Slattery, Morris, Voisin, Marsh, and Lemhouse, YES; Councilor
Rosenthal NO. Motion passed 5-1.
NEW AND MISCELLANEOUS BUSINESS
1. Approval of a resolution titled, "A resolution authorizing Mayor and City Administrator
signature of an affiliation agreement Asante, Ashland Community Hospital, the Ashland
Community Hospital Foundation and the City of Ashland and authorizing the City
Administrator to sign documents necessary to close the affiliation transaction."
City Administrator Dave Kanner provided background on the affiliation agreement and noted some slight
ASHLAND CITY COUNCIL MEETING
June 4, 2013
Page 4 of 6
changes to the Letter of Intent. One was a provision that if Asante failed to operate Ashland Community
Hospital (ACH) as a general hospital under Oregon Administrative Rule, the City had the right to request
the hospital revert to the City's sole ownership with a payment of $8,000,000. What was new was Asante
could reduce the $8,000,000 to amounts equal to contributions in excess of on average $900,000 per year
paid into the ACH benefit pension plan. The reduction would not exceed $2,000,000 and no payment at
all if Asante satisfied the outstanding balance of the Umqua bank note the hospital took out in 2004. Also
in the first three years, Asante would not cause any distributions of real property from ACH to Asante or
any other entity.
Councilor Slattery/Lemhouse m/s to approve Resolution 42013-15. DISCUSSION: Councilor
Lemhouse appreciated the effort Councilor Slattery and everyone involved put into the affiliation
agreement process. Councilor Morris also expressed appreciation for the effort. Mr. Kanner explained
clarifications to the affiliation agreement better defined capital improvements and tied it to Section 5.2.1
of the GAAP (Generally Accepted Accounting Principles).
Asante President and CEO Roy Vinyard noted the negotiation process was complex and involved four
parties, and commented that everyone kept the best interest of the community in the forefront. He was
looking forward to rebuilding some of the services.
Councilor Marsh commented on good faith and Asante's commitment to provide the community with
high quality services that reflected community values. Councilor Voisin would support the motion
-because the City was giving the buildings and land to Asante in exchange for 15 years of maintaining
ACH as a general hospital. Councilor Slattery clarified the City was not giving anything away and
Asante was paying $8,000,000 loan, picking up a $16,000,000 pension fund and $10,000,000 of capital
improvements. Councilor Voisin reiterated the importance of the community getting a general hospital
for the next 15 years. Roll Call Vote: Councilor Morris, Lemhouse, Slattery, Marsh, Voisin, and
Rosenthal, YES. Motion passed.
PUBLIC HEARINGS -continued
3. Public hearing and approval of a resolution titled, "A resolution adopting a miscellaneous fees
and charges document and repealing prior fee resolution 2012-21"
Administrative Services Director Lee Tuneberg explained changes to miscellaneous fees and charges
would go into effect July 1, 2013. Often departments did not charge enough for the services provided and
fee increases were inflationary. Community Development Director Bill Molnar added the Planning
Commission did not review fee amounts and staff based community development increases on changes in
the CPI (Consumer Price Index). Community Development did not have an official policy regarding fees
or waiving them. A study in 2000 indicated community development fees should cover approximately
75% of the department's resources that went to current development. The Ashland Municipal Code
codified waiving fees on projects that met affordability criteria.
Mr. Tuneberg noted due to infrequent use, it was hard to calculate revenue from fees. He went on to
clarify substantive changes to the fees would come back the following year or staff would go to Council
directly. Staff would add fire and rescue recovery costs to the document.
Public Hearing Open: 8:36 p.m.
Public Hearing Closed: 8:36 p.m.
Councilor Voisin/Morris m/s to approve Resolution #2013-17. Voice Vote: all AYES. Motion
passed.
PUBLIC FORUM - None
ASHLAND CITY COUNCIL MEETING
June a, 2013
Page 5 of 6
UNFINISHED BUSINESS - None
NEW AND MISCELLANEOUS BUSINESS - continued
2. Economic Development Strategy, phase two implementation plan
Management Analyst Adam Hanks addressed 33 Create coordinated economic development
information and marketing plan to maximize public communication tools and explained how it
combined a variety of actions to one area for the business community. The concept was having a
resource that fit different stages of development. Sub-actions would include a snapshot of the local
economy using business license registration, total employees, residential, commercial construction
permits, home occupation permits, and Transient Occupancy Tax (TOT) collections.
Council wanted to include an AFN (Ashland Fiber Network) strategy or priority action in the plan and
have the specific action for the current year be completion of the 5-year plan. City Administrator Dave
Kanner thought they could add wording to 6.4 to read, "Pursue the expansion of a State E-commerce
Zone for Ashland, and complete the 5-year AFN Business Plan." He also suggested setting aside
funds to help AFN market its service to potential E-commerce Zone developers.
Council was interested in revisiting 6.1 Evaluate the use of urban renewal districts to spur private
reinvestment in targets commercial and employment areas of Ashland and directed staff to change
the status to ongoing and schedule a Study Session to discuss the matter further.
Mr. Kanner explained there was approximately $150,000 budgeted for the economic development
program from the TOT. Of the $150,000, $45,000 was set aside to cover a portion of Mr. Hanks' salary.
The remaining $105,000 would fund economic development projects:
• . $30,000 was set aside of short videos to promote innovation and recruit businesses to Ashland
• $20,000 for a business portal program online
• $20,000 for commercial property inventory
• $10,000 to revive the Green Business program
• $10,000 for the Jobs Commission
• $15,000 for the City's contribution to the Festival of Lights instead of having the money come
from the Electric Department
Mayor Stromberg noted it might cost more than $10,000 to establish a Job Commission and suggested the
Electric Department fund the Festival of Lights one more year. Mr. Kanner explained the budget
included the $105,000 for economic development projects, but did not specify individual projects.
Council could adopt the updated Economic Development Strategy and discuss how to spend the $105,000
at a separate meeting.
Council wanted to quantify the Economic Development Strategy to show how the City benefited from the
$150,000 spent annually. Some of Council was not convinced it was worthwhile investing in a portal and
thought a better intermediary goal for the next year was establishing a "Doing Business in Ashland" page
on the city website with connections to community partners, license and permit information and business
associations.
Mayor Stromberg clarified his memo of proposed additions to the Economic Development Strategy. He
wanted to recognize the significance and importance of having good schools in the economic
development strategy. He also wanted to include how parks fit into the economic development strategy
as well. Finally, he wanted to create interaction between innovative and creative people to form
something the entire community could access.
ASHLAND CITY COUNCIL MEETING
June 4, 2013
Page 6 of 6
Councilor Lemhouse/Rosenthal m/s to accept the Economic Development Strategy Phase Two
Implementation Plan Update as amended by Council as an appendix to the original Economic
Development Strategy adopted by City Council in July 2011. Voice Vote: all AYES. Motion passed.
Staff would set up two meetings, a future Study Session on urban renewal and either a Study Session or
Council meeting for economic strategy budget items and possibly have Sandra Slattery from the Ashland
Chamber of Commerce attend to discuss the portal.
3. Update to financial management policies and account methods in consideration of a biennial
budget.
Administrative Services Director Lee Tuneberg noted there were nine changes several critical. The first
change was the review of required ending fund balance/carry forward minimums and calculations needed
with a biennium budget. This revision proposes lowering the General Fund Ending Fund Balance to
10%, to reflect two year's worth of property taxes receipted in as operating income.
"Council moved the agenda item to a Study Session for further discussion and clarification.
City Administrator Dave Kanner commented that one of the applicants submitting a proposal for the Help
Center that Council would review during the June 17, 2013 Study Session wanted to provide a multi-
media presentation regarding their proposal.
Councilor Voisin/Rosenthal m/s that the two applicants for the RFP for the Help Center have ten
minutes to present their applications to the Council. DISCUSSION: Councilor Rosenthal thought ten
minutes each was reasonable and the topic was important. Councilor Morris would not support the
motion. It was too late in the process for presentations and the meeting should be a question and answer
session. Councilor Slattery was not opposed to 5-minute presentations. Roll Call Vote: Councilor
Voisin, Rosenthal, and Marsh, YES; Councilor Morris, Lemhouse, and Slattery, NO. Mayor
Strom berg broke the tie with a NO vote. Motion failed 3-4.
Councilor Slattery/Marsh m/s give the applicants 5-minutes. Roll Call Vote: Councilor Voisin,
Lemhouse, Slattery, Rosenthal, and Marsh, YES; Councilor Morris, NO. Motion passed 5-1.
OTHER BUSINESS FROM COUNCIL MEMBERS/REPORTS FROM COUNCIL LIAISONS
ADJOURNMENT
Meeting adjourned at 9:40 p.m.
Barbara Christensen, City Recorder John Stromberg, Mayor
CITY OF
ASHLAND
ASHLAND HISTORIC COMMISSION
Meeting Minutes
May 8, 2013
Community Development/Engineering Services Building - 51 Winburn Way - Siskiyou Room
CALL TO ORDER - REGULAR MEETING, 6:15 Pm
Historic Commissioners Present: Allison Renwick, Dale Shostrom, Keith Swink, Sam Whitford, Kerry Kencairn
(late-6:15)
Commission Members Absent: Terry Skibby (e), Ally Phelps (e), Tom Giordano (e), Victoria Law (e)
Council Liaison: Greg Lemhouse, absent
High School Liaison: None Appointed
SOU Liaison: None Appointed
Staff Present: Staff Liaison: Amy Gunter; Clerk: Billie Boswell
APPROVAL OF MINUTES: The minutes of the April 3, 2013 Historic Commission meeting were reviewed. Mr.
Whitford made a motion to approve the minutes as presented. Mr. Swink seconded the motion. Ms. Renwick pointed
out an error on the Public Hearing section that the address shown was incorrect. Mr. Whitford made a new motion to
approve with noted correction. It was seconded by Mr. Swink and passed unanimously.
PUBLIC FORUM: There was no one in the audience wishing to speak. Public Forum was closed.
COUNCIL LIAISON REPORT: None
PUBLIC HEARING:
PLANNING ACTION: 2013-00532
SUBJECT PROPERTY: 15 North First
APPLICANT: Eric Brown/ Robert Saladoff
DESCRIPTION: A request for a Site Review approval to install a walk-in cooler and enclose half of the existing patio
at the rear of 15 North First Street. COMPREHENSIVE PLAN DESIGNATION: Commercial; ZONING: C-1-D;
ASSESSOR'S MAP: 391 E 09BA TAX LOT: 10300
Ms. Gunter presented the application as a 2-phase project. Initially the 10'x10' walk-in cooler and the trash enclosure
would be done as phase 1 and then enclosing the patio to create a new space and upgrading the First Street fagade
for the second phase.
Architect Rob Saladoff and Amuse owner Eric Brown reviewed the project with the Commissioners. Mr. Saladoff
confirmed that the entry will remain as recessed. The new area will have a roof and the old canvass would be
removed. The fence shielding the trash enclosure would be walnut stained. Chairman Shostrom and Ms. Kencaim
both felt the cooler building should be painted to match the existing building or the fence.
There being no one in the audience wishind'to speak, the public hearing was closed. r`
Ms. Kencaim made a motion to recommend approval if the cooler building is painted to match existing building or the
fence. Mr. Swink seconded the motion. There was no discussion and the motion passed unanimously.
Ms. Kencaim left the meeting and there was no longer a quorum.
Ashland Historic Commission Minutes
6/6/2013
CITY Of
ASHLAND
OLD BUSINESS:
Historic Markers Subcommittee report - A power-point presentation to be done at the June 4th Council meeting by
Ms. Renwick. (Later changed to May 2111).
Historic Brochures Subcommittee report - No report. They are still waiting for a draft.
Historic Preservation Week - Mr. Swink requested that we expand the awards for Churchill Hall to include the
Ausland Group, the contractors. Ms. Boswell stated the brochure of events would be posted on the website and
were being handed out to the Chamber of Commerce and City Hall.
NEW BUSINESS:
A. Review Board Schedule
May 91^ Terry, Keith, Sam
May 161h Terry, Allison, Dale
May 231d Terry, Kerry, Sam
May 301' Terry, Victoria, Tom
June 61h Terry, Keith, All
B. Project Assi nments for Planning Actions
BD-2011-01029 400 Allison Robin Biermann New SFR under construction Whitford/Renwick
BD-2011-01079 134 Terrace Allman New SFR under construction Whitford
BD-2011-00621 89 Oak St Amorotico New fagade on building under construction Shostrom
BD-2012-01330 117 Eighth St (McKinney) New ARU (under construction Renwick
BD-2013-00256 175 Lithia W First Place Partners 3-story mixed use building in review Giordano
PA-2012-01737 111 Coolidge Wallace 4 Accessory Units Shostrom
BD-2013-00093 108 Second Dudley Rood CUP and Solar Waiver for 2nd sto unit in review Shostrom
PA-2013-00081 245 Van Ness Nate Witembur & Brint Bor ilt Addition Kencalm
PA-2013-00003 207 Enders Alley Dresher conversion to motel unit Swink
PA-2013-00366 57 N Main St. North Mix Sweet Shop entry door Phelps
PA-2013-00308 5 B Street (Spartan Properties) New Comm Bldg Phelps
PA-2013-00532 15 N First Amuse Walk in Cooler
DISCUSSION ITEMS: None
ANNOUNCEMENTS & INFORMATIONAL ITEMS
Next meeting is scheduled for June 5, 2013.
There being no other items to discuss, the meeting adjourned at 7:10 pm.
Ashland Historic Commission Minutes
&/62013
CITY OF
ASHLAND
Council Communication
June 18, 2013, Business Meeting
An amendment to the Intergovernmental Agreement
Between the City of Ashland and the Transportation Growth Management
Program for the Normal Avenue Neighborhood Plan
FROM:
Brandon Goldman, Senior Planner, brandon.goldman@ashland.or.us
SUMMARY
The City Council's authorization is requested to amend the Intergovernmental Agreement (IGA) with
the Oregon Department of Transportation (ODOT) for a grant from the Transportation and Growth
Management (TGM) program for the Normal Avenue Neighborhood Plan project. The amendments to
the IGA are to increase the grant amount, and revise the statement of work. The City's contribution to
the grant is the staff time necessary to complete the amended statement of work, and does not include
any additional cash matching amount.
BACKGROUND AND POLICY IMPLICATIONS:
The City Council approved the IGA for the grant from the TGM program at their May 1, 2012,
business meeting. The TGM is a joint program of ODOT and the Oregon Department of Land
Conservation and Development. The TGM program objective is to better integrate transportation and
land use planning, and develop new ways to manage growth in order to achieve compact pedestrian,
bicycle and transit friendly development. Upon approval of the amendment as proposed the grant
amount from TGM would be increased from $82,450 to $95,417. The additional $12,967 in grant
would be provided by the TGM program in support of this project.
The Normal Avenue Neighborhood plan has already been developed through the previously seeped
steps indentified in the original Statement of Work, including the original concept plan, a the three-day
public charrette, a public open-house, and neighborhood meetings, and the draft ordinance. However,
input and involvement from area residents, property owners, and the Planning Commission through the
process have identified a number of further revisions that should be addressed in a final concept plan.
Areas to be further evaluated in a revised concept plan include redistribution of the concentration of
housing within the plan area, identification of transitional standards to relate future housing
development to existing neighborhoods, the potential use of open space corridors to provide pedestrian
connectivity, and development standards that address retention of storm water to preserve the area's
hydrology.
This additional plan iteration, which would be funded by the increased grant funding, will require an
additional project management, public involvement, and further revisions to the draft plan and
proposed code changes. The increased grant funding also provides for additional communication time
with the consultant during the development of the final draft of the Normal Avenue Neighborhood
Pagel of 2
1PEAR
CITY OF
ASHLAND
Plan, including an additional public open house and Planning Commission presentation by the
Consultant team scheduled for June 25, 2013.
The amendment document, as well as the original IGA establishes a completion date of the TGM
funded tasks of June 30, 2013. The City recognizes that the Consultants will be unable to complete
their work on the Final Plan per the outlined tasks in that time period given the Planning Commission
meeting will take place on June 25, 2013. In discussions with the ODOT it was explained that due to
State fiscal year budgeting implications the amendment to the IGA needs to maintain the original June
30, 2013 completion date. However as part of this review of the IGA Amendment the City Council
can authorize the City Administrator to approve of future changes to the term of agreement to extend
the timeline beyond July 1, 2013. It is anticipated that all consultant tasks covered under the TGM
scope of work will be completed by August 30, 2013 and the formal adoption process for the Final
Plan will be completed in December 2013.
FISCAL IMPLICATIONS:
The TGM program funds the consultant time, and the full amount of the grant is used for this purpose.
The City is not required to provide a direct cash matching amount. The contribution of Staff time
dedicated to completing the tasks identified in the statement of work is necessary.
STAFF RECOMMENDATION AND REQUESTED ACTION:
Staff recommends that Council approve the amendment to the IGA with ODOT for additional grant
funding from the TGM program for the Normal Avenue Neighborhood Plan
SUGGESTED MOTION:
Move approval of amending the IGA between the City of Ashland and ODOT for the Normal Avenue
Neighborhood Plan, and to authorize the City Administrator to approve of modifications to the Term of
the Agreement as necessary.
ATTACHMENTS:
Amendment No. 1 to the Intergovernmental Agreement
Intergovernmental Agreement dated June 4, 2012 - TGM Grant No. 28461
Page 2 of 2
~r,
Amendment No. 1
TGM Grant Agreement No. 28461
TGM File Code 3A-11
EA# TG12LA55
AMENDMENT NO. 1
The State of Oregon, acting by and through its Department of Transportation,
hereinafter referred to as "ODOT" or "Agency", and City of Ashland, hereinafter
referred to as "City", entered into an intergovernmental agreement on June 4, 2012
("Agreement"). Said Agreement covers a Transportation and Growth Management
grant for City of Ashland, Normal Avenue Neighborhood Plan.
It has now been determined by ODOT and City that the Agreement referenced above,
although remaining in full force and effect, shall be amended to include an addendum to
the Statement of Work, and increase the dollar amount. Except as expressly amended
below, all other terms and conditions of the Agreement, as previously amended, are
still in full force and effect.
Exhibit A, the Statement of Work, shall be amended to include an addendum to
the Statement of Work.
Paragraph B of Section 2 (Terms of Agreement); which currently reads:
"Grant Amount. The Grant Amount which includes City's Matching
Amount of $12,450 shall not exceed $82,450."
Shall be amended to read:
"Grant Amount. The Grant Amount which includes City's Matching
Amount of $12,450 shall not exceed $ 95,417."
Paragraph D of Section 2 of (Terms of Agreement); which currently reads:
"Consultant's Amount. The Consultant's Amount shall not exceed
$82,450."
Shall be amended to read:
"Consultant's Amount. The Consultant's Amount shall not exceed
$95,417."
1
Amendment No. 1
TGM Grant Agreement No. 28461
TGM File Code 3A-11
EA# TG12LA55
This Amendment may be executed in several counterparts (facsimile or otherwise) all
of which when together shall constitute one agreement binding on all Parties,
notwithstanding that all Parties are not signatories to the same counterpart. Each copy
of this Amendment so executed shall constitute an original.
IN WITNESS WHEREOF, the parties hereto have set their hands as of the day and
year hereinafter written.
On December 1, 2010 the Director of the Oregon Department of Transportation
approved DIR-06, in which authority is delegated from the Director of the Oregon
Department of Transportation to the Operations Deputy Director and Transportation
Development Division Administrator, to approve agreements with local governments,
other state agencies, federal governments, state governments, other countries, and
tribes as described in ORS 190 developed in consultation with the Chief Procurement
Officer.
STATE OF OREGON, by and through
its Department of Transportation Contact Names:
Maria Harris
By City of Ashland
Division Administrator, Transportation City Hall, 20 East Main Street
Development Division Ashland, OR 97520-1849
Phone: 5415522045
Date Fax: 541-488-5311
E-Mail: harrism@ashland.or.us
City of Ashland John McDonald, Contract Administrator
y Transportation and Growth Management
Program
By 3500 NW Stewart Parkway
Official's Signature Roseburg, OR 97470
Phone: 541-957-3688
Date Fax: 541-957-3547
E-Mail: John.McDonald@odot.state.or.us
2
Amendment No. 1
TGM Grant Agreement No. 28461
TGM File Code 3A-11
EA# TG12LA55
EXHIBIT A
STATEMENT OF WORK
CITY OF ASHLAND
NORMAL AVENUE NEIGHBORHOOD PLAN
Project Workscope Amendment
The purpose of this scope amendment is to document the additional effort and deliverables
needed for successful completion of the planning project.
The City of Ashland has energetically engaged this planning project. The plan has already been
developed through the previously scoped steps including the original concept plan, the
charrene, and the draft plan. Additional input and involvement from major stakeholders, City
staff, and the planning commission now require additional project management, public
involvement and revisions the plan and proposed code changes.
Task 7 shall be deleted in its entirety and replaced with the following:
Task 7: Final Draft Plan and Imulementine Ordinances
Objective: To prepare an adoption-ready plan and related ordinances.
7.1 Revised Draft Normal Avenue Neighborhood Plan
Consultant shall prepare and submit to City and WOCPM Revised Draft Normal Avenue
Neighborhood Plan, incorporating feedback from subtask 6.5 and subsequent discussions with
City.
7.2 Revised Draft Area Site Design and Use Standards and Chapter 18 Code
Amendments
Consultant shall prepare and submit to City and WOCPM Revised Draft of the Site Design and
Use Standards and Chapter 18 Code Amendments, incorporating feedback from subtask 6.5 and
City.
7.3 Public Open House and PC Study Session #2 (Revised Plan and Standards)
Consultant shall conduct a Public Open House directly before a PC Study Session #2, in
coordination with City, providing an opportunity at for citizens to review the Revised Draft
Normal Avenue Neighborhood Plan and the associated Design and Use Standards and Chapter
18 Code Amendments. Consultant shall prepare and submit to City and WOCPM a meeting
summary within one week of Public Open House/PC Study Session.
7.4 Final Draft Normal Avenue Neighborhood Plan
Consultant shall prepare and submit to City and WOCPM Final Draft Normal Avenue
Neighborhood Plan, incorporating feedback from subtask 7.3 into draft. Consultant shall
provide two hard copies and two electronic copies - both pdf and editable format - on compact
3
Amendment No. 1
TGM Grant Agreement No. 28461
TGM File Code 3A-11
EA# TG 12LA55
disc to both City and WOCPM at conclusion of Project. City shall make any necessary final
changes to make the Plan adoption ready.
7.5 Final Draft Area Site Design and Use Standards and Chapter 18 Code
Amendments
Consultant shall prepare and submit to City and WOCPM Final Area Site Design and Use
Standards and Chapter 18 Code Amendments, incorporating feedback from subtask 7.3 into
draft.
7.6 Final Area Site Design and Use Standards and Chapter 18 Code Amendments
Following review of Deliverable 7.2, Consultant shall prepare and submit to City and WOCPM
Final Area Site Design and Use Standards and Chapter 18 Code Amendments.. Consultant shall
provide two hard copies and two electronic copies - both pdf and editable format - on compact
disc to WOCPM at conclusion of Project.
7.7 Final Buildable Lands Inventory and Housing Needs Analysis
City shall prepare and submit to Consultant and WOCPM Final Buildable Lands Inventory and
Housing Needs Analysis.
7.8 Comprehensive Plan Change Planning Application
City shall prepare and submit to WOCPM Comprehensive Plan Change Planning Application.
7.9 Transportation Planning Rule Findings
City shall prepare and submit to WOCPM Transportation Planning Rule Findings.
7.10 Final Presentations
City shall present the Final Normal Avenue Neighborhood Plan, Comprehensive Plan Changes,
and associated Ordinance Amendments to the Planning Commission at a Public Hearing for
final approval and recommendation to the Council.
City shall present the Final Normal Avenue Neighborhood Plan, Comprehensive Plan Changes,
and associated Ordinance Amendments to the Council at a Public Hearings for adoption.
City shall provide the PMT a Public Hearings Summary, identifying issues, feedback received
and guidance given by decision-makers, and a copy of adopted Findings relating to the final
decision of the City.
7.11 Title VI Report
City shall prepare and 'submit to WOCPM a report delineating Title VI activities, documenting
project process and outreach for all low income, race, gender, and age groups.
7.12 Project Management Coordination Meetings
Consultant shall facilitate Project Management Coordination meetings via video- or
teleconference with City. During Project Management Coordination meetings City shall
4
Amendment No. 1
TGM Grant Agreement No. 28461
TGM File Code 3A-11
EA# TG12LA55
provide Consultant direction on preparing for Task 7.3; and shall provide direction to
Consultant on Tasks 7.4, 7.5, and 7.6 based on comments from the public and Planning
Commission. Consultant shall prepare and submit a summary of coordination meetings to
WOCPM upon completion of the code revisions and plan drafts.
City Deliverables
7.7 Final Buildable Lands Inventory and Housing Needs Analysis
7.8 Comprehensive Plan Change Planning Application
7.9 Transportation Planning Rule Findings
7.10 Final Presentations
7.11 Title VI Report
Consultant Deliverables
7.1 Revised Draft Normal Avenue Neighborhood Plan
7.2 Revised Site Design and Use Standards and Chapter 18 Code Amendments
7.3 Public Open House/PC Study Session #2 (and summary)
7.4 Final Draft Normal Avenue Neighborhood Plan
7.5 Final Draft Area Site Design and Use Standards and Chapter 18 Code Amendments
7.6 Final Area Site Design and Use Standards and Chapter 18 Code Amendments
7.12 Five Project Management Coordination meetings and Summaries
Consultant Amounts per Deliverable and Schedule
Task Description Total Fixed Amount Schedule
Payable to Consultant
Per Deliverable
1.1 Pro.ect Management Meeting #1 $650 June 1, 2012
1.2 Project Schedule $900 June 1, 2012
Task 1 Total $1550
Task 2 - No Consultant Deliverables
3.1 Housing and Land Use Framework $6,250 August 2012
3.2 Greenwa and O ens ace Framework $2,050 August 2012
3.3 Mobility Framework $2,000 August 2012
3.4 Infrastructure Framework $1,300 August 2012
3.5 Sustainable Neighborhood Framework $1,550 August 2012
3.6 One conceptual Plan $11,500 October 2012
Task 3 Total $24,650
4.1 Project Management Meeting #2 $500 November 2012
4.2 Charette and Final Charette Materials $26,500 December 2012
Task 4 Total $27,000
5.3 Existing Traffic Analysis $7,900 August 2012
Task 5 Total $7,900
6.1 Project Management Meeting #3 $650 February 2013
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Amendment No. 1
TGM Grant Agreement No. 28461
TGM File Code 3A-11
EA# TG12LA55
Task Description Total Fixed Amount Schedule
Payable to Consultant
Per Deliverable
6.2 Draft Normal Avenue Neighborhood Plan $8,500 March 2013
6.3 Draft Area Site Design and Use $2,500 March 2013
Standards
6.4 Draft Chapter 18 Code Amendments $2,500 April 2013
6.5 Public Open House and PC Study $3,800 May 2013
Session
Task 6 Total $17,950
7.1 Revised Draft Plan $5,598 June 2013
7.2 Revised Draft Standards and Code $363 June 2013
7.3 Open House & Planning Commission $3,931 June 2013
Meeting 92
7.4 Final Draft Normal Avenue $3,400 June 2013
Neighborhood Plan
7.5 Final Draft Standards and Code $1,155 June 2013
7.6 Final Draft Design Standards and Code $958 June 2013
7.12 Project Management Coordination $962 June 2013
Meetings and Summaries
Task 7 Total $16,367
Project Total $95,417
6
TGM Grant Agreement No. 28461
TGM File Code 3A-1 I
EA # TG 12LA55
INTERGOVERNMENTAL AGREEMENT
City of Ashland, Normal Avenue Neighborhood Plan
i
THIS INTERGOVERNMENTAL AGREEMENT ("Agreement') is made and
entered into by and between the STATE OF OREGON, acting by and through its
Department of Transportation ("ODOT" or "Agency"), and City of Ashland ("City" or
"Grantee").
RECITALS
1. The Transportation and Growth Management ("TGM") Program is a joint
program of ODOT and the Oregon Department of Land Conservation and Development.
2. The TGM Program.includes a program of grants for local governments for
planning projects. The objective of these projects is to better integrate transportation and
land use planning and develop new ways to manage growth in order to achieve compact
pedestrian, bicycle, and transit friendly urban development.
3. This TGM Grant (as defined below) is financed with federal Safe,
Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users
("SAFETEA-LU") funds. Local funds are used as match for SAFETEA-LU funds.
4. By authority granted in ORS 190.110, state agencies may enter into
agreements with units of local government or other state agencies to perform any
functions and activities that the parties to the agreement or their officers or agents have
the duty or authority to perform.
5. City has been awarded a TGM Grant which is conditional upon the
execution of this Agreement.
6. The parties desire to enter into this Agreement for their mutual benefit.
NOW, THEREFORE, for good and valuable consideration, the receipt and
sufficiency of which is hereby acknowledged, the parties agree as follows:
SECTION 1. DEFINITIONS
Unless the context requires otherwise, the following terms, when used in this
Agreement, shall have the meanings assigned to them below:
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TGM Grant Agreement No. 28461
TGM File Code 3A-1 I
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A. "City's Amount" means the portion of the Grant Amount payable by ODOT
to City for performing the tasks indicated in Exhibit A as being the responsibility of
city.
B. "City's Matching Amount" means the amount of thatching funds which
City is required to expend to fund the Project.
C. "City's Project Manager" means the individual designated by City as its
project manager for the Project.
D. "Consultant" means the personal services contractor(s) (if any) hired by
ODOT to do the tasks indicated in Exhibit A as being the responsibility of such
contractor(s).
E. "Consultant's Amount" means the portion of the Grant Amount payable by
ODOT to the Consultant for the deliverables described in Exhibit A for which the
Consultant is responsible.
F. "Direct Project Costs" means those costs which are directly associated with
the Project. These may include the salaries and benefits of personnel assigned to the
Project and the cost of supplies, postage, travel, and printing. General administrative
costs, capital costs, and overhead are not Direct Project Costs. Any jurisdiction or
metropolitan planning organization that has federally approved indirect cost plans may
treat such indirect costs as Direct Project Costs.
G. "Federally Eligible Costs" means those costs which are Direct Project Costs
of the type listed in Exhibit D incurred by City and Consultant during the term of this
Agreement.
H. "Grant Amount" or "Grant" means the total amount of financial assistance
(including City's Matching Amount) disbursed under this Agreement, which
disbursements consist of the City's Amount and the Consultant's Amount.
1. "ODOT's Contract Administrator" means the individual designated by
ODOT to be its contract administrator for this Agreement.
I "PSK" means the personal services contract(s) executed between ODOT
and the Consultant related to the portion of the Project that is the responsibility of the
Consultant.
K. "Project" means the project described in Exhibit A.
L. "Termination Date" has the meaning set forth in Section 2.A below.
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TGM Grant Agreement No. 28461
TGM Pile Code 3A-1 I
EA # TG 12LA55
M. "Total Project Costs" means the total amount of money required to
complete the Project.
N. "Work Product" has the meaning set forth in Section 5.1 below.
SECTION 2. TERMS OF AGREEMENT
A. Term. This Agreement becomes effective on the date on which all parties
have signed this Agreement and all approvals (if any) required to be obtained by ODOT
have been received. Further, ODOT's obligation to make any disbursements under this
Agreement is subject to payment of the City's Matching Amount by City to ODOT. This
Agreement terminates on July 31, 2013 ("Termination Date"). The Agency's payments
of amounts under this Agreement attributed to work performed after June 30, 2013, is
limited to a maximum amount of $3,400.
B. Grant Amount. The Grant Amount which includes City's Matching
Amount of $12,450 shall not exceed $82,450.
C. City's Amount. The City's Amount shall not exceed $0.
D. Consultant's Amount. The Consultant's Amount shall not exceed $82,450.
E. City's Matching Amount. The City's Matching Amount is $12,450. City
shall pay ODOT the City's Matching Amount at time of the signing of this Agreement
SECTION 3. DISBURSEMENTS
A. Subject to submission by City of such documentation of costs and progress
on the Project (including deliverables) as are satisfactory to ODOT, the City may be
reimbursed by ODOT for, or may use as part of the City's Matching Amount, as the case
may be only Direct Project Costs that are Federally Eligible Costs that City incurs after
the execution of this Agreement up to the City's Amount. Generally accepted accounting
principles and definitions of ORS 294.311 shall be applied to clearly document verifiable
costs that are incurred.
B. City shall present cost reports, progress reports, and deliverables to
ODOT's Contract Administrator no less than every other month. City shall submit cost
reports for 100% of City's Federally Eligible Costs.
C. Reserved
D. Reserved
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TGM File Code 3A-11
EA # TG12LA55
E. Reserved
F. ODOT shall limit reimbursement of, or use as part of the City's Matching
Amount, travel expenses in accordance with current State of Oregon Accounting Manual,
General Travel Rules, effective on the date the expenses are incurred.
SECTION 4. CITY'S REPRESENTATIONS, WARRANTIES, AND
CERTIFICATION
A. City represents and warrants to ODOT as follows:
1. It is a municipality duly organized and existing under the laws of the
State of Oregon.
2. It has full legal right and authority to execute and deliver this
Agreement and to observe and perform its duties, obligations, covenants and
agreements hereunder and to undertake and complete the Project.
3. All official action required to be taken to authorize this Agreement
has been taken, adopted and authorized in accordance with applicable state law
and the organizational documents of City.
4. This Agreement has been executed and delivered by an authorized
officer(s) of City and constitutes the legal, valid and binding obligation of City
enforceable against it in accordance with its terms.
5. The authorization, execution and delivery of this Agreement by City,
the observation and performance of its duties, obligations, covenants and
agreements hereunder, and the undertaking and completion of the Project do not
and will not contravene any existing law, rule or regulation or any existing order,
injunction, judgment, or decree of any court or governmental or administrative
agency, authority or person having jurisdiction over it or its property or violate or
breach any provision of any agreement, instrument or indenture by which City or
its property is bound.
6. The statement of work attached to this Agreement as Exhibit A has
been reviewed and approved by the necessary official(s) of City.
B. As federal funds are involved in this Grant, City, by execution of this
Agreement, makes the certifications set forth in Exhibits B and C.
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TGM File Code 3A-11
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SECTION 5. GENERAL COVENANTS OF CITY
A. City shall be responsible for the portion of the Total Project Costs in excess
of the Grant Amount. City shall complete the Project; provided, however, that City shall
not be liable for the quality or completion of that part of the Project which Exhibit A
describes as the responsibility of the Consultant.
B. City shall, in a good and workmanlike manner, perform the work on the
Project, and provide the deliverables for which City is identified in Exhibit A as being
responsible.
C. City shall perform such work identified in Exhibit A as City's responsibility
as an independent contractor and shall be exclusively responsible for all costs and
expenses related to its employment of individuals to perform such work. City shall also
be responsible for providing for employment-related benefits and deductions that are
required by law, including, but not limited to, federal and state income tax withholdings,
unemployment taxes, workers' compensation coverage, and contributions to any
retirement system.
D. All employers, including City, that employ subject workers who work
under this Agreement in the State of Oregon shall comply with ORS 656.017 provide the
required Workers' Compensation coverage unless such employers are exempt under ORS
656.126. Employers Liability insurance with coverage limits of not less than $500,000
must be included. City shall ensure that each of its contractors complies with these
requirements.
E. City shall not enter into any subcontracts to accomplish any of the work
described in Exhibit A, unless it first obtains written approval from ODOT.
F. City agrees to cooperate with ODOT's Contract Administrator. At the
request of ODOT's Contract Administrator, City agrees to:
(1) Meet with the ODOT's Contract Administrator; and
(2) Form a project steering committee (which shall include ODOT's
Contract Administrator) to oversee the Project.
G. City shall comply with all federal, state and local laws, regulations,
executive orders and ordinances applicable to the work under this Agreement, including,
without limitation, applicable provisions of the Oregon Public Contracting Code.
Without limiting the generality of the foregoing, City expressly agrees to comply with:
(1) Title VI of Civil Rights Act of 1964; (2) Title V and Section 504 of the Rehabilitation
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Act of 1973; (3) the Americans with Disabilities Act of 1990 and ORS 659A.142; (4) all
regulations and administrative rules established pursuant to the foregoing laws; and (5)
all other applicable requirements of federal and state civil rights and rehabilitation
statutes, rules and regulations.
H. City shall maintain all fiscal records relating to this Agreement in
accordance with generally accepted accounting principles. In addition, City shall
maintain any other records pertinent to this Agreement in such a manner as to clearly
document City's performance. City acknowledges and agrees that ODOT, the Oregon
Secretary of State's Office and the federal government and their duly authorized
representatives shall have access to such fiscal records and other books, documents,
papers, plans, and writings of City that are pertinent to this Agreement to perform
examinations and audits and make copies, excerpts and transcripts.
City shall retain and keep accessible all such fiscal records, books, documents,
papers, plans, and writings for a minimum of six (6) years, or such longer period as may
be required by applicable law, following final payment and termination of this
Agreement, or until the conclusion of any audit, controversy or litigation arising out of or
related to this Agreement, whichever date is later.
1. (1) All of City's work product related to the Project that results from
this Agreement ("Work Product") is the exclusive property of ODOT. ODOT and City
intend that such Work Product be deemed "work made for hire" of which ODOT shall be
deemed the author. If, for any reason, such Work Product is not deemed "work made for
hire", City hereby irrevocably assigns to ODOT all of its rights, title, and interest in and
to any and all of the Work Product, whether arising from copyright, patent, trademark,
trade secret, or any other state or federal intellectual property law or doctrine. City shall
execute such further documents and instruments as ODOT may reasonably request in
order to fully vest such rights in ODOT. City forever waives any and all rights relating to
the Work Product, including without limitation, any and all rights arising under 17 USC
§ 106A or any other rights of identification of authorship or rights of approval, restriction
or limitation on use or subsequent modifications.
(2) ODOT hereby grants to City a royalty free, non-exclusive license to
reproduce any Work Product for distribution upon request to members of the public.
(3) City shall ensure that any work products produced pursuant to this
Agreement include the following statement:
"This project is partially funded bya grant from the Transportation
and Growth Management (TGM) Program, a joint program of the Oregon
Department of Transportation and the Oregon Department of Land
-6-
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TGM Grant Agreement No. 28461
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Conservation and Development. This TGM grant is financed, in part, by
federal Safe, Accountable, Flexible, Efficient Transportation Equity Act: A
Legacy for Users (SAFETEA-LU), local government, and State of Oregon
funds.
The contents of this document do not necessarily reflect views or
policies of the State of Oregon."
(4) The Oregon Department of Land Conservation and Development and
ODOT may each display appropriate products on its "home page".
J. Unless otherwise specified in Exhibit A, City shall submit all final products
produced in accordance with this Agreement to ODOT's Contract Administrator in the
following form:
(1) two hard copies; and
(2) in electronic form using generally available word processing or graphics
programs for personal computers via e-mail or on compact diskettes.
K. Within 30 days after the Termination Date, City shall
(1) pay to ODOT City's Matching Amount less Federally Eligible Costs
previously reported as City's Matching Amount. ODOT may use any
funds paid to it ]coder this Section 5.K (1) to substitute for an equal amount
of federal SAFETEA-LU funds used for the Project or use such funds as
matching funds; and
(2) provide to ODOT's Contract Administrator, in a format provided by
ODOT, a completion report. This completion report shall contain:
(a) The permanent location of Project records (which may be subject to audit);
(b) A summary of the Total Project Costs, including a breakdown of those
Project costs that are reimbursable hereunder and those costs which are
being treated by City as City's Matching Amount;
(c) A list of final deliverables; and
(d) City's final disbursement request.
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SECTION 6. CONSULTANT
If the Grant provided pursuant to this Agreement includes a Consultant's Amount,
ODOT shall enter into a PSK with the Consultant to accomplish the work described in
Exhibit A as being the responsibility of the Consultant. In such a case, even though
ODOT, rather than City is the party to the PSK with the Consultant, ODOT and City
agree that as between themselves:
A. Selection of the Consultant will be conducted by ODOT in accordance with
ODOT procedures with the participation and input of City;
B. ODOT will review and approve Consultant's work, billings and progress
reports after having obtained input from City;
C. City shall be responsible for prompt communication to ODOT's Contract
Administrator of its comments regarding (A) and (B) above; and
D. City will appoint a Project Manager to:
(1) be City's principal contact person for ODOT's Contract Administrator and
the Consultant on all matters dealing with the Project;
(2) monitor the work of the Consultant and coordinate the work of the
Consultant with ODOT's Contract Administrator and City personnel, as necessary;
(3) review any deliverables produced by the Consultant and communicate any
concerns it may have to ODOT's Contract Administrator; and
(4) review disbursement requests and advise ODOT's Contract Administrator
regarding payments to Consultant.
SECTION 7. ODOT'S REPRESENTATIONS AND COVENANTS
A. ODOT certifies that, at the time this Agreement is executed, sufficient
funds are authorized and available for expenditure to finance ODOT's portion of this
Agreement within the appropriation or limitation of its current biennial budget.
B. ODOT represents that the statement of work attached to this Agreement as
Exhibit A has been reviewed and approved by the necessary official(s) of ODOT.
C. ODOT will assign a Contract Administrator for this Agreement who will be
ODOT's principal contact person regarding administration of this Agreement and will
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participate in the selection of the Consultant, the monitoring of the Consultant's work,
and the review and approval of the Consultant's work, billings and progress reports.
D. If the Grant provided pursuant to this Agreement includes a Consultant's
Amount, ODOT shall enter into a PSK with the Consultant to perform the work described
in Exhibit A designated as being the responsibility of the Consultant, and in such a case
ODOT agrees to pay the Consultant in accordance with the terms of the PSK up to the
Consultant's Amount.
SECTION 8. TERMINATION
This Agreement may be terminated by mutual written consent of all parties.
ODOT may terminate this Agreement effective upon delivery of written notice to City, or
at such later date as may be established by ODOT under, but not limited to, any of the
following conditions:
A. City fails to complete work specified in Exhibit A within the time
specified in this Agreement, including any extensions thereof, or fails to perform
any of the provisions of this Agreement and does not correct any such failure
within 10 days of receipt of written notice or the date specified by ODOT in such
written notice.
B. Consultant fails to complete work specified in Exhibit A within the
time specified in this Agreement, including any extensions thereof, and does not
correct any such failure within 10 days of receipt of written notice or the date
specified by ODOT in such written notice.
C. If federal or state laws, regulations or guidelines are modified or
interpreted in such a way that either the work under this Agreement is prohibited
or ODOT is prohibited from paying for such work from the planned funding
source.
D. If ODOT fails to receive funding, appropriations, limitations or other
expenditure authority sufficient to allow ODOT, in the exercise of its reasonable
administrative discretion, to continue to make payments for performance of this
Agreement.
In the case of termination pursuant to A, B, C or D above, ODOT shall have any
remedy at law or in equity, including but not limited to termination of any further
disbursements hereunder. Any termination of this Agreement shall not prejudice any
right or obligations accrued to the parties prior to termination.
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SECTION 9. GENERAL PROVISIONS
A. Time is of the essence of this Agreement.
B. Except as otherwise expressly provided in this Agreement, any notices to
be given hereunder shall be given in writing by personal delivery, facsimile, or mailing
the same, postage prepaid, to ODOT or City at the address or number set forth on the
signature page of this Agreement, or to such other addresses or numbers as either party
may hereafter indicate pursuant to this Section. Any communication or notice so
addressed and mailed is in effect five (5) days after the date postmarked. Any
communication or notice delivered by facsimile shall be deemed to be given when receipt
of the transmission is generated by the transmitting machine. To be effective against
ODOT, such facsimile transmission must be confirmed by telephone notice to ODOT's
Contract Administrator. Any communication or notice by personal delivery shall be
deemed to be given when actually delivered.
C. ODOT and City are the only parties to this Agreement and are the only
parties entitled to enforce the terms of this Agreement. Nothing in this Agreement gives, is
intended to give, or shall be construed to give or provide any benefit or right not held by or
made generally available to the public, whether directly, indirectly or otherwise, to third
persons (including but not limited to any Consultant) unless such third persons are
individually identified by name herein and expressly described as intended beneficiaries of
the terms of this Agreement.
D. Sections 5(H), 5(1), and 9 of this Agreement and any other provision which
by its terms is intended to survive termination of this Agreement shall survive.
E. The parties agree as follows:
(a) Contribution.
If any third party makes any claim or brings any action, suit or proceeding alleging a tort
as now or hereafter defined in ORS 30.260 ("Third Patty Claim") against ODOT or Grantee
("Notified Party") with respect to which the other party ("Other Party") may have liability, the
Notified Party must promptly notify the Other Party in writing of the Third Party Claim and
deliver to the Other Party a copy of the claim, process, and all legal pleadings with respect to the
Third Party Claim. Each party is entitled to participate in the defense of a Third Party Claim, and
to defend a Third Party Claim with counsel of its own choosing. Receipt by the Other Party of
the notice and copies required in this paragraph and meaningful opportunity for the Other Party
to participate in the investigation, defense and settlement of the Third Party Claim with counsel
of its own choosing are conditions precedent to the Other Party's liability with respect to the
Third Party Claim.
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I
With respect to a Third Party Claim for which ODOT is jointly liable with the Grantee
(or would be if joined in the. Third Party Claim ODOT shall contribute to the amount of
expenses (including attorneys' fees), judgments, fines and amounts paid in settlement actually j
and reasonably incurred and paid or payable by the Grantee in such proportion as is appropriate
to reflect the relative fault of ODOT on the one hand and of the Grantee on the other hand in
connection with the events which resulted in such expenses, judgments, fines or settlement
amounts, as well as any other relevant equitable considerations. The relative fault of ODOT on
the one hand and of the Grantee on the other hand shall be determined by reference to, among
other things, the parties' relative intent, knowledge, access to information and opportunity to I
correct or prevent the circumstances resulting in such expenses, judgments, fines or settlement
amounts. The ODOT's contribution amount in any instance is capped to the same extent it would
have been capped under Oregon law, including but not limited to the Oregon Tort Claims Act,
ORS 30.260 to 30.300, if ODOT had sole liability in the proceeding.
With respect to a Third Party Claim for which the Grantee is jointly liable with ODOT
(or would be if joined in the Third Party Claim), the Grantee shall contribute to the amount of
expenses (including attorneys' fees), judgments, fines and amounts paid in settlement actually
and reasonably incurred and paid or payable by ODOT in such proportion as is appropriate to
reflect the relative fault of the Grantee on the one hand and of ODOT on the other hand in
connection with the events which resulted in such expenses, judgments, fines or settlement
amounts, as well as any other relevant equitable considerations. The relative fault of the Grantee
on the one hand and of ODOT on the other hand shall be determined by reference to, among
other things, the parties' relative intent, knowledge, access to information and opportunity to
correct or prevent the circumstances resulting in such expenses, judgments, fines or settlement
amounts. The Grantee's contribution amount in any instance is capped to the same extent it
would have been capped under Oregon law, including but not limited to the Oregon Tort Claims
Act, ORS 30.260 to 30.300, if it had sole liability in the proceeding.
(b) Choice of Law• Designation of Forum; Federal Forum.
(1) The laws of the State of Oregon (without giving effect to its conflicts of law principles)
govern all matters arising out of or relating to this Agreement, including, without limitation, its
validity, interpretation, construction, performance, and enforcement.
(2) Any party bringing a legal action or proceeding against any other party arising out of
or relating to this Agreement shall bring the legal action or proceeding in the Circuit Court of the
State of Oregon for Marion County (unless Oregon law requires that it be brought and conducted
in another county). Each party hereby consents to the exclusive jurisdiction of such court, waives
any objection to venue, and waives any claim that such forum is an inconvenient forum.
(3) Notwithstanding Section 9.E (b)(2), if a claim must be brought in a federal
forum, then it must be brought and adjudicated solely and exclusively within the United
States District Court for the District of Oregon. This Section 9.E(b)(3) applies to a claim
brought against the State of Oregon only to the extent Congress has appropriately
abrogated the State of Oregon's sovereign immunity and is not consent by the State of
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Oregon to be sued in federal court. This Section 9.E(b)(3) is also not a waiver by the
State of Oregon of any form of defense or immunity, including but not limited to
sovereign immunity and immunity based on the Eleventh Amendment to the Constitution
of the United States.
(c) Alternative Dispute Resolution.
The parties shall attempt in good faith to resolve any dispute arising out of this
Agreement. This may be done at any management level, including at a level higher than persons
directly responsible for administration of the Agreement. In addition, the parties may agree to
utilize a jointly selected mediator or arbitrator (for non-binding arbitration) to resolve the dispute
short of litigation.
F. This Agreement and attached Exhibits (which are by this reference
incorporated herein) constitute the entire agreement between the parties on the subject
matter hereof. There are no understandings, agreements, or representations, oral or
written, not specified herein regarding this Agreement. No modification or change of
terms of this Agreement shall bind either party unless in writing and signed by all parties
and all necessary approvals have been obtained. Budget modifications and adjustments
from the work described in Exhibit A must be processed as an aniendment(s) to this
Agreement and the PSK. No waiver or consent shall be effective unless in writing and
signed by the party against whom such waiver or consent is asserted. Such waiver,
consent, modification or change, if made, shall be effective only in the specific instance
and for the specific purpose given. The failure of ODOT to enforce any provision of this
Agreement shall not constitute a waiver by ODOT of that or any other provision.
G. This Agreement may be executed in several counterparts (facsimile or
otherwise) all of which when taken together shall constitute one agreement binding on all
parties, notwithstanding that all parties are not signatories to the same counterpart. Each
copy of this Agreement so executed shall constitute an original.
On December 1, 2010 the Director of the Oregon Department of Transportation approved
DIR-06, in which authority is delegated from the Director of the Oregon Department of
Transportation to the Operations Deputy Director and Transportation Development
Division Administrator, to approve agreements with local governments, other state
agencies, federal governments, state governments, other countries, and tribes as described
in ORS 190 developed in consultation with the Chief Procurement Officer.
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City Jerri Bohard, Division Administrator
Transportation Development Division
City ofAshland
Date:_ t -y-iz
By: - ffl _VLI
ge h
Ocial'sSignatnre) Contact Names;
Maria Hams ( ) L
City of Ashland
(Printed N We and Title o Official) City Hall, 20 East Main Street
Ashland, OR 97520-1849
Date: 2 Phone: 5415522045
Fax: 541488-5311
E-Mail: harrism@ashlandor.us
John McDonald, Contract Administrator
ODOT Transportation and Growth Management Program
3500 NW Stewart Parkway
STATE OF OREGON, by and through Roseburg, OR 97470
its Department ofTrap rtation Phone: 541-957-3688
Fax: 541-957-3547
B !L E-Mail: John.McDonald@odot.state.or.us
y:
r' .
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EXHIBIT A
CITY OF ASHLAND
NORMAL AVENUE NEIGHBORHOOD PLAN
I
Acronyms/Definitions
Agency/ODOT Oregon Department of Transportation
City City of Ashland
Council Ashland City Council
County Jackson County in Oregon
GIS Geographic Information Systems
PC City of Ashland Planning Commission
Plan City of Ashland Normal Avenue Neighborhood Plan
PMT Project Management Team
RVMPO Rogue Valley Metropolitan Planning Organization
TPAU Transportation Planning Analysis Unit
TSP Transportation System Plan
UGB Urban Growth Boundary
WOC Work Order Contract
WOCPM Work Order Contract Project Manager
PROJECT MANAGEMENT TEAM ("PMT")
Consultant - Parametrix
Jason Franklin, Project Manager jfranklin(iuparametrix.com
Parametrix 503-416-6167
700 NE Multnomah Suite 1000
Portland, OR 97232
City of Ashland
Brandon Goldman, Senior Planner brandon.goldman@ashland.or.us
Department of Community Development 541-552-2045
20 E Main Street
Ashland, OR 97520
ODOT/TGM
Work Order Contract Project Manager john.mcdonald@odot.state,or.us
John McDonald 541-957-3688
Oregon Department of Transportation
3500 NW Stewart Parkway
Roseburg, OR 97470
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This statement of work describes the responsibilities of all entities involved in this cooperative project.
The work order contract (for the purposes of the quoted language below the "WOC") with the work
order consultant ("Consultant") shall contain the following provisions in substantially the form set forth
below:
"PROJECT COOPERATION
This statement of work describes the responsibilities of the entities involved in this cooperative
Project. In this Work Order Contract (WOC), the Consultant shall only be responsible for those
deliverables assigned to the Consultant. All work assigned to other entities are not Consultant's
obligations under this WOC, but shall be obtained by Agency through separate intergovernmental
agreements which contain a statement of work that is the same as or similar to this statement of work.
The obligations of entities in this statement of work other than the Consultant are merely stated for
informational purposes and are in no way binding, nor are the named entities parties to this WOC.
Any tasks or deliverables assigned to a subcontractor shall be construed as being the responsibility of
the Consultant.
Any Consultant tasks or deliverables which are contingent upon receiving information, resources,
assistance, or cooperation in any way from another entity as described in this statement of work shall
be subject to the following guidelines:
1. At the first sign of non-cooperation, the Consultant shall provide written notice (email
acceptable) to Oregon Department of Transportation (Agency) Work Order Contract Project
Manager (WOCPM) of any deliverables that may be delayed due to lack of cooperation by other
entities referenced in this statement of work.
2. WOCPM shall contact the non-cooperative entity or entities to discuss the matter and attempt to
correct the problem and expedite items determined to be delaying the Consultant.
If Consultant has followed the notification process described in item 1, and Agency finds that
delinquency of any deliverable is a result of the failure of other referenced entities to provide
information, resources, assistance, or cooperation, as described in this statement of work, the
Consultant will not be found in breach of contract; nor shall Consultant be assessed or liable for any
damages arising as a result of such delinquencies. Neither shall ODOT be responsible or liable for
any damages to Consultant as the result of such non-cooperation by other entities. WOCPM will
negotiate with Consultant in the best interest of the State, and may amend the delivery schedule to
allow for delinquencies beyond the control of the Consultant."
PROJECT BACKGROUND AND OBJECTIVES
Project Purpose/Transportation Relationship and Benefit
The Normal Avenue Neighborhood Plan (Plan) will guide future development to provide for a compact
urban form which better accommodates needed housing types, creates a system of greenways, protects
and integrates natural features, enhances overall mobility while reducing reliance on the automobile, and
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supports green infrastructure within the Project Area. Given the project area's central location, it
presents an opportunity for a concentration of housing and neighborhood services in a manner that
supports efficient land use and transit-oriented development.
Project Area
Normal Avenue neighborhood, situated between East Main Street in the north and railroad tracks in the
south, Clay Street in the east and the Ashland Middle School in the west. Currently, the 94 acre area has
a mix of Comprehensive Plan designations including single family residential and suburban residential,
and is presently outside the City of Ashland (City) city limits but within the City Urban Growth
Boundary (UGB).
See attached Map.
Background
Residential development in the Project Area has historically been low density - rural residential large lot
single family homes - consistent with Jackson County (County) zoning standards. Unfortunately, this
pattern of large lot development did not fully consider opportunities for further intensification of land
use nor achieve the densities provided for in City's Comprehensive Plan.
Project Area constitutes the largest remaining area of residentially designated land that is suitable for
medium- to high-density development which remains largely vacant or redevelopable. However, City's
current Comprehensive Plan anticipates this area will primarily develop as low density and suburban
residential upon annexation into the City. City is concerned that these planned densities may be
insufficient to accommodate projected population growth and support a high level of transit service. In
2010, City received a pre-application to annex an individual parcel within the Project Area with a
proposed density over twice that of the future zoning anticipated in the underlying Comprehensive Plan.
Such high density housing would be supportive of transit and help City maintain a tight urban form. It is
City's intention to update the current Comprehensive Plan to provide for a coordinated approach to
planning the entire area.
This Normal Avenue Neighborhood Plan project (Project) will implement policies of the
Comprehensive Plan's Transportation Element and City Transportation System Plan (TSP), currently
being updated and likely adopted spring 2012, which aim to reduce automobile dependency by
providing enhanced pedestrian, bicycle, and transit connections between the Normal Avenue
Neighborhood to the rest of the City. The integrated land use and transportation plan will provide a
circulation plan identifying new local streets, bike and pedestrian paths, transit route opportunities, and
consolidated access points to the adjacent major arterial street (East Main Street). The Project will seek
to implement policies of the Ashland Comprehensive Plan including the provision openspace and
greenways within an area of compact transit oriented development.
Given its centralized location, equidistant between the downtown and commercial center surrounding I-
5 interchange 14, the property is well-positioned to accommodate a concentration of a variety of housing
in an area where multi-modal transportation options are likely to be convenient and utilized. City's
Central Bike Path borders the south side of the Project Area and provides ready access to pedestrians
and bicyclists to the City's commercial centers, schools, and recreation opportunities. Along the
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northern boundary of the Project Area is East Main Street which is a main arterial which previously was
served by the Rogue Valley Transportation District's Route 15 bus line. The Draft TSP projects the
Project Area will have transit supporting densities upon build-out under the current comprehensive plan
designations. The success of transit is largely a factor of the residential or job densities served by the
line, and as such the efficient development of these lands will support and enhance the existing
transportation system.
The Project Area includes the largest locally significant wetland within City's UGB, totaling about five
acres in size. The area includes'sections of Clay Creek and Cemetery Creek. Preservation and
enhancement of these existing wetlands and streams will provide amenities that benefit the area and City
as a whole. A coordinated planning effort to accommodate needed housing types in an efficient manner
in consideration of these natural resources supports the long-term vision of City.
Timeliness
As City continues to promote a compact urban form through efficient land use, the development
pressure on lands currently outside the city limits yet within the UGB has increased. City recently
identified no new growth areas through the Regional Problem Solving process between County and local
municipalities. This position is reliant on the expectation that City continues to accommodate future
population growth within the existing UGB throughout the Regional Problem Solving planning period.
As such, it is imperative that City examines opportunities to most efficiently urbanize remaining lands,
secure multi-modal transportation options, build upon the City's system of greenways as identified in
the Parks and Openspace Plan, and remain sensitive to environmental constraints in relation to future
development potential. This Project is not contingent upon the ultimate approval of the Regional
Problem Solving plan, but rather supports the position that future urbanization should occur within
City's existing UGB to accommodate future growth.
City recently adopted new ordinances regulating the protection of wetlands and riparian area (chapter
18.63 of the Ashland Land Use Ordinance), which went into effect in January, 2010. Project Area
contains both significant wetlands and locally designated streams which would be impacted by future
development within County or upon annexation. Plan will serve as a demonstration of how future
development can occur in a manner that is sensitive to these vital natural resources.
City is currently conducting an update of City's TSP funded in large part through the Transportation and
Growth Management program. Anticipating higher residential densities where appropriate will assist in
the development of the Updated TSP in factoring such densities to support a high level of transit service.
Future updates of the pedestrian and bicycle circulation elements will also benefit from identified
linkages both internally and to nearby transit stops. The Plan will follow up the momentum established
with review and adoption of the Updated TSP with specific neighborhood planning to implement
portions of the Updated TSP.
Project Objectives
• Increase efficiency in the use of land through concentration of housing in a centrally located area
within the City UGB planned for future urban development;
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• Achieve a development pattern that results in a balanced, multi-modal transportation system and
that enhances opportunities for walking, bicycling or using transit in areas planned for transit
service;
• Delineate housing, neighborhood serving commercial, open space, public space, and green
infrastructure improvements, in a manner that provides for preservation and enhancement of
creeks and wetlands;
• Develop new illustrative conceptual architectural and site plans for Project Area consistent with
Transportation and Growth Management objectives. Concepts will meet City's and the property
owners' development goals and standards.
• Design a local street grid for the Project Area including connections to existing and planned
street, pedestrian, and bicycle facilities outside Project Area, to more fully integrate the Project
Area into the City transportation system;
• Provide for pedestrian and bicycle routes and facility improvements within the Project Area that
will provide safe access to local schools;
• Provide alternatives to, or delay the need for, expansion of the City UGB;
• Reduce emissions that contribute to climate change through changes to transportation or land use
plans that reduce expected automobile vehicle miles traveled;
• Provide an implementation strategy that includes supporting Comprehensive Plan and updated
TSP amendments, form based codes, and design standards; and
• Present the Plan and documentation necessary to support adoption to City's Planning
Commission (PC) and City Council (Council).
GENERAL PROVISIONS
Expectations about Written and Graphic Deliverables
Plan must be written concisely and use a simple and direct style, both to minimize the length of the final
document and to make the document understandable to as large an audience as is reasonable. Where
possible, information must be presented in tabular or graphic format, with a simple and concise
accompanying narrative (e.g. system inventories, traffic conditions). Electronic documents must be in a
format easily translated by a screen reader or text-to-voice software.
Consultant shall provide copies of written deliverables to the Project Management Team (PMT),
including the City and WOCPM, in electronic formats.
The following apply to all deliverables unless otherwise specified in this SOW or by Agency:
1. Draft Materials
It is expected that draft deliverables shall be substantially complete and that any changes or revisions
needed to address comments will be minor. Consultant is not required to make major or extensive
revisions without an approved contract amendment. This provision does not limit the right of Agency to
require correction of deliverables that do not meet the requirements of this SOW.
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Consultant shall provide draft deliverables to the PMT at least ten working days prior to the scheduled
meeting/public release.
City shall submit one set of consolidated, non-conflicting comments on draft deliverables to Consultant
within five working days after receipt, unless otherwise directed by PMT. WOCPM shall submit one set
of comments on draft deliverables to Consultant within three working days after receipt of draft
materials, unless otherwise directed by PMT.
Consultant shall make minor revisions and corrections to draft deliverables based on comments received
and provide new draft to City and WOCPM at least two working days prior to meeting/public release.
2. Text memorandums and reports
All memorandums and reports are to be delivered to local government and TGM program digitally in
Microsoft Word format, or an editable format agreed upon by PMT. Final versions of deliverables must
also be provided in an open universally readable format. Memorandums and reports are to be formatted
for 8%-inch by I 1-inch or I 1-inch by 17-inch paper.
The following text must appear in Project's final products:
"This project is partially funded by a grant from the Transportation and Growth Management
(TGM) Program, ajoint program of the Oregon Department of Transportation and the Oregon
Department of Land Conservation and Development. This TGM grant is financed, in part, by
federal Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users
(SAFETEA-LU), local government, and the State of Oregon funds. The contents of this
document do not necessarily reflect views or policies of the State of Oregon."
Consultant name or logos may not appear on Final Plan documents with the exception of the
acknowledgement page
3. Maps and graphic deliverables,
Maps and site plans must be provided as electronic deliverables which can be read and used directly
with ArcGIS 9.0, geo-referenced to the City's Geographic Information System (GIS) base data, or in a
format as agreed between Consultant, City, and Agency.
Maps and graphics must include details necessary to ensure usability. Maps must include, at a minimum:
a scale; a direction indicator indicating north; a color scheme that ensures readability in black and white;
a legend; source; and date for the underlying information.
All graphics, including but not limited to vector based graphics including perspectives, axonometric
drawings and elevations created digitally, are to be delivered to the PMT digitally in both the native
format in which they are created (such as Adobe Indesign, Photoshop, Sketch up, AutoCad etc.) and in
an open universally readable format (such as PDFs and or JPGs), as agreed between Consultant, City
and Agency.
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4. Web Access to All Materials
Consultant shall provide the PMT continued web access to all completed project files throughout the
duration of the Project. Consultant may satisfy this requirement for an online repository of electronic
project files by providing a dedicated webpage for PMT use which includes links to each file, providing
access to a File Transfer Protocol site enabling direct downloading of Project files, or an alternative
distribution method as agreed between Consultant, City and WOCPM.
Expectations About Meetings and Public Involvement
The Public Involvement program must comply with Statewide Planning Goal 1 (Citizen Involvement),
which calls for "the opportunity for citizens to be involved in all phases of the planning process."
City shall consider environmental justice issues, which is the fair treatment and meaningful involvement
of all people regardless of race, color, national origin, or income with respect to the development,
implementation, and enforcement of environmental laws, regulations, and policies. Fair treatment
means that no group of people, including a racial, ethnic, or a socioeconomic group, should bear a
disproportionate share of the negative environmental consequences resulting from industrial, municipal,
and commercial operations or the execution of federal, state, local, and tribal programs and policies.
Meaningful involvement means that:
(1) potentially affected community residents have an appropriate opportunity to participate in
decisions about a proposed activity that will affect their environment and health;
(2) the public's contribution can influence the regulatory agency's decision;
(3) the concerns of all participants involved will be considered in the decision making process;
and
(4) the decision makers seek out and facilitate the involvement of those potentially affected.
City shall consider Title VI regarding outreach to minorities, women, and low-income populations.
Special efforts shall be directed to ensuring outreach to and representation of minorities, women, and
low income populations.
The primary aspect of public involvement is through the City's PC. City shall ensure that commission
meetings include outreach to and opportunity for representatives of the following interests to be heard:
property owners, property development, business, residents-at-large, freight, and environmental justice.
Specific information regarding the deliverables and responsibility of public involvement tasks are listed
under the appropriate task. In general the following applies to all public involvement:
Meetings
a. City shall schedule and arrange all PC/Council meetings
b. City shall provide support for all meetings including published and mailed notices as
appropriate, meeting space and collecting feedback after the meeting.
c. City shall maintain a project webpage on the City web site containing all materials and
information relevant to development of the plan.
d. City shall facilitate PC/Council Study Sessions.
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e. Consultant shall present materials and answer questions at PC/Council Study Sessions, as
agreed between Consultant and Agency.
f. Consultant shall provide hard copies of large scale maps and concept plans for use at public
meeting that are a minimum 2-foot by 3-foot in size.
g. Meeting notes must confirm that Consultant conducted or attended the meeting as required.
Meeting notes are a brief summary of the attendees, topics discussed, and decisions reached.
Clear, handwritten notes taken during the meeting are acceptable. Minutes from public
meetings before City Commissions or Council shall be completed by the City and shall
satisfy this provision.
Expectations About Traffic Analysis
An Oregon-registered professional engineer (civil or traffic) shall perform or oversee all traffic analysis
work. Traffic analysis software must follow Highway Capacity Manual 2010 procedures. Traffic
analysis must comply with ODOT Analysis Procedures Manual. Consultant shall coordinate all analysis
with ODOT's Transportation Planning Analysis Unit (TPAU). Consultant shall get approval of
methodology from TPAU prior to beginning analysis.
The planning horizon year for future scenarios is 2034 to provide consistency with other local and
regional planning efforts. The expectations for the evaluation of the existing and future traffic
conditions are more fully described in the related tasks.
Project Workscope
Task 1: Information Assembly and Existing Conditions Analysis
1.1 Project Management Meeting #1
Consultant shall facilitate Project Management Meeting #1 via video- or teleconference with PMT to
initiate the Project and discuss the planning process, schedule, and issues. Consultant shall submit
Meeting Summary of Project Management Meeting #1 to City and WOCPM within one week following
Project Management Meeting #1.
1.2 Project Schedule
Consultant shall prepare and submit to City and WOCPM at Project Management Meeting #1 a Project
Schedule using MS Project compatible software. Consultant shall update Project Schedule as needed, as
WOCPM requests, and distribute updated schedule to City and WOCPM.
Consultant shall provide Project Schedule and updates to City for placement on Project Webpage (see
Task 2).
1.3 Background Information Summary
City shall prepare and submit Background Information Summary to Consultant and WOCPM within two
weeks following Project Management Meeting #1. The Background Information Summary must
include a simple and concise narrative of the background information as it pertains to Plan.
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Background information must include, but is not limited to:
• City Comprehensive Plans, maps and text;
• Development regulations, coning maps and text;
City Street Standards (City Handbook for Planning and Designing Streets);
• City most recent Buildable Lands Inventory;
• Section 18.63 of the Ashland Land Use Ordinance;
• City Local Wetlands Inventory;
• National Flood Insurance Program Study for County;
• TSP;
• Draft TSP including all technical memoranda;
• Multi-modal LOS methodology used in City TSP update;
• Site surveys or detailed maps of the Project Area and immediate surroundings;
• Aerial photography;
• Topographic maps;
GIS shapefiles including taxlots, wetlands, floodplains, roads, buildings, soils, and other relevant
data;
• Site plans or pending applications within the Project Area, including existing conceptual plans;
• Traffic studies prepared for previous applications within the Project Area;
• Rogue Valley Transit District routes and schedules;
• Rogue Valley Transit District Strategic Business and Operations Plan;
• City Capital Improvement Program; and
• Any other pertinent data specific to the Project Area.
1.4 Base Maps
City shall prepare and submit to Consultant and WOCPM Base Maps depicting relevant existing
conditions for use in later tasks. Base Maps must include a digital copy of the map, and geospatial data
files developed to create Base Maps. Base Maps must include:
• Streets;
• Railroad;
pedestrian and bike paths;
• property boundaries;
• tax lots;
• buildings;
• designated wetlands;
• wetland buffer areas;
• creeks;
• floodplains; and
other significant natural features.
1.5 Stakeholder Meetings and Summary
City shall arrange and conduct Stakeholder Meetings interviewing up to twenty stakeholders or
stakeholder groups. City shall provide a location in Ashland for Stakeholder Meeting's. Potential
participants include:
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• Property owners of parcels in and next to Project Area;
• Representatives from religious institutions in and next to Project Area;
• Representatives of the Ashland business and civic community;
• Representatives of the City's Community Development, and various City Departments;
• Rogue Valley Transportation District;
• County Planning Department; and
• Other Stakeholders as identified.
City may use Base Maps for illustrative purposes at Stakeholder Meetings.
City shall prepare and submit Summary to Consultant and WOCPM within two weeks following
Stakeholder Meetings outlining the topics of discussion and comments of each Stakeholder
Meeting/interview.
1.6 Annotated Map
City shall prepare Annotated Map of the key opportunity areas, constraints and issues for Project Area
based upon information obtained from subtasks 1.1 through 1.4. Annotated Map must include a digital
copy of the map, and geospatial data files developed to create the map.
1.7 Existing Site Conditions Executive Summary
City shall prepare Existing Site Conditions Executive Summary and submit to Consultant and WOCPM.
Existing Site Conditions Executive Summery must include:
• An evaluation of the Project Area in relation to schools, commercial business districts,
commercial and civic attractors, and adjacent residential development; An inventory and
delineation of existing natural areas including wetlands, riparian areas, floodplains, significant
trees, and other significant natural features;
• An evaluation of the existing road classifications and transit availability as they relate to the
Project Area;
• Photos of the Project Area; and
• Stakeholder Meetings Summary
City Deliverables
1.1 Project Management Meeting #1
1.3 Background Information Summary
1.4 Base Maps
1.5 Stakeholder Meetings and Summary
1.6 Annotated Map
1.7 Existing Site Conditions Executive Summary
Consultant Deliverables
1.1 Project Management Meeting #1
1.2 Project Schedule
Task 2: Public Involvement
Objective: Ensure early involvement of property owners, residents, local and state government, and
other interested parties in developing an identity and vision for the Project Area.
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2.1 Project Webpage
City shall develop and maintain a public Project Webpage on the City's website containing all materials
and information relevant to development of the Plan. Webpage with all project related information and
materials developed, all GIS products and graphics, and meeting information (times, locations, agendas,
summaries, and materials). Project Webpage will be "live" within eight weeks of Notice to Proceed.
2.2 Project Area Mailing and Summary
City shall prepare Project Area mailing and submit to WOCPM. City shall mail the Project Area
Mailing to all property owners within the Project Area (up to 25 mailers). Project Area Mailing must
include: i
• A summary sheet that outlines Project Objectives and processes;
• A general outline of the public involvement process and timeline;
• Project Webpage information (from City);
• A Key Participant Survey;
• A stamped return envelope for survey responses;
• A framework to examine residents' expectations about the future development of the Project
Area and their property;
• A means of eliciting comments regarding potential development constraints and opportunities in
the Project Area; and
• A request for contact information including email to receive future information regarding the
Normal Avenue Neighborhood Plan development
City shall prepare Summary which must include a summary of responses received.
2.3 PC/Council Update and Summary
City shall update the Council and PC on the Plan's initial phase. City shall provide PC and Council an
analysis of input received from Key Participant Survey, Stakeholder Meetings Summary, and Project
Webpage. City shall solicit from Council/PC any specific and general goals and guiding principles for
the Project. City shall prepare and submit to Consultant and WOCPM a Council/PC update Summary.
Summary must include materials presented, feedback received, questions asked, and meeting minutes.
2.4 City-wide Mailing
City shall prepare a Project Summary for inclusion in the CitySource publication to be included in city
utilitybill. City-wide Mailing must include a general description of the Project and Project Area to be
evaluated, clear direction regarding how residents can participate in the planning process and obtain
more detailed information, and Project Webpage information.
City Deliverables
2.1 Project Webpage
2.2 Project Area Mailing and Summary
2.3 PC/Council Update and Summary
2.4 City-wide Mailing
Consultant Deliverables
none
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Task 3: Alternatives Development and Analysis
Objective: To develop a series of neighborhood framework overlays which identify and illustrate
alternatives for the concentration, density, and types of land uses in relation to neighborhood
transportation networks, significant natural area, open spaces and community facilities.
3.1 Housing and Land Use Framework
Consultant shall prepare and submit to City and WOCPM Housing and Land Use Framework which
must include:
• A summary of the City Buildable Lands Inventory (provided by City) land supply within the
Project Area;
• A summary of the City Housing Needs Analysis (provided by City);
• Market Feasibility Report, including: market profile, market demand scenarios, and describing
the potential ranges of numbers and types of dwelling units;
• A summary of Housing Equity opportunities providing for a broad range of housing types of
varying costs commensurate with area income ranges;
• A summary and illustrative plan outlining housing development potential under two alternative
land use development scenarios:
1. Development consistent with existing Comprehensive Plan designations;
2. Development consistent with a high density residential Comprehensive Plan designation.
Scenario 2 above may additionally consider the inclusion of neighborhood-serving commercial
uses where appropriate.
(In recognition of Ashland's position in the Regional Problem Solving Plan, to maintain the
existing Urban Growth Boundary in its present location, each scenario above must include an
evaluation of whether the objective of accommodating future population growth within the
existing UGB is supported by the scenario.)
• An evaluation of opportunities for neighborhood serving commercial uses and mixed use
development within the Project Area.
3.2 Greenway and Openspace Framework
Consultant shall prepare and submit to City and WOCPM Greenway and Openspace Framework,
consistent with subtask 3. 1, which must include:
• Identification of natural areas including wetlands, riparian area, and other environmentally-
sensitive areas;
• Identification of opportunities for public spaces and parks; and
• Identification of opportunities for private openspace.
3.3 Mobility Framework
Consultant shall prepare and submit to City and WOCPM Mobility Framework, consistent with subtask
3. 1, which must include:
• A circulation system for bicyclists and pedestrians that includes connectivity with the Ashland
Central Area Multi-Use Path, open space and natural areas, and safe routes to schools;
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• A circulation system for automobile connectivity within the existing street system in keeping
with the Transportation Element policies of the Comprehensive Plan;
• Identification of street alignment opportunities to maximize building solar orientation
opportunities;
• Identification of specific access points along East Main Street and Clay Street;
• Analysis of current and potential opportunities for transit service; and identification of future
transit stop locations and amenities.
• Preliminary identification of safety focus locations requiring further study in Task 5. Safety
focus locations are defined as those intersections or roadway segments where the existing five-
year crash rate exceeds published Crash Rate Tables for similar facilities.
3.4 Infrastructure Framework
Consultant shall prepare and submit to City and WOCPM Infrastructure Framework, consistent with
subtask 3. 1, which must include
• Identification of location and extension of key public facilities including sewer, water, electric
and the Ashland Fiber Network; and
• Identification of storm water management strategies and regulations to be implemented through
the development of public facilities and site design, including:
o Green streets;
o Pervious parking and hardscape requirements;
o Study Area water retention location opportunities; and
o Landscaping and water conservation requirements.
3.5 Sustainable Neighborhood Framework
Consultant shall prepare and submit to City and WOCPM Sustainable Neighborhood Framework which
must include:
• A summary of the relationships between frameworks (subtasks 3.1 to 3.4) in creating and
fostering a sustainable neighborhood;
• Examination of LEED-ND requirements and application opportunities in the Project Area;
• Identification of opportunities to increase energy efficiency and sustainability in site planning,
and building design; and
• Identification of incentives (e.g density bonuses, height bonus, expedited permitting and
planning application process) for achieving efficiency in energy use, water conservation, waste
reduction and in providing support of a multimodal transportation system.
3.6 Conceptual Plan
Consultant shall use assembled data, comments from PMT, Stakeholder Interviews, Annotated Map, and
frameworks developed iri tasks 3.1 through 3.5 to generate one Conceptual Plan. The Conceptual Plan
is intended to show ideas for development of the Project Area based on the requirements and desires of
participants in Stakeholder Meetings and City. The Plan must illustrate an alternative development
scenario that could presently be achievable under the existing Comprehensive Plan designations and
development standards. The Conceptual Plan must include area plan showing proposed zoning;
openspace areas; street circulation and design; pedestrian and bike facilities; housing density; building
massing, photos of existing examples to demonstrate the general character and scale of proposed
structures; and other graphic materials necessary to show the overall design of the Conceptual Plan. The
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Conceptual Plan does not require a high level of architectural design detail, but must be suitable to the
local context (i.e. the "small-town character" of Ashland).
Conceptual Plan must
• include development types identified in Housing and Land Use Framework
• identify best locations for concentrations of housing, and any proposed neighborhood serving
mixed-use commercial components.
• show any designated greenways or public open space.
• identify locations for consolidated storm water management water retention facilities if
proposed.
• each include adequate methods of accommodating pedestrian, bicycle, and motor vehicle traffic
through Project Area.
• show any connections to existing or planned transportation facilities within, or neighboring, the
Project Area.
Consultant shall coordinate with PMT to ensure the Concept Plan is adequate to meet City and ODOT
requirements for issues such as access management and local street standards
The Conceptual Plan must include:
o Plan views showing zoning and lot layouts in consideration of natural features and transportation
network;
o Vehicular, pedestrian, and bicycle circulation plans, including their connections to the City
transportation system;
o A short narrative with the highlights including a summary of
• Housing and Land Use Framework
• Greenway and Openspace Framework;
• Mobility Framework
• Infrastructure Framework and
• Sustainability Framework
City Deliverables
3.1 Summary of Buildable Lands Inventory and City Housing Needs Analysis
Consultant Deliverables
3.1 Housing and Land Use Framework
3.2 Greenway and Openspace Framework
3.3 Mobility Framework
3.4 Infrastructure Framework
3.5 Sustainable Neighborhood Framework
3.6 One Conceptual Plan
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Task 4: Concept Plan Alternatives Review
4.1 Project Management Meeting #2
Consultant shall facilitate Project Management Meeting #2 via video- or teleconference with PMT to
review the Three Conceptual Plan Alternatives and provide guidance to Consultant prior to the charrette.
Consultant shall prepare summary and submit to City and WOCPM within one week.
4.2 Charrette
Consultant shall conduct the charrette in Ashland to exhibit the Conceptual Plans and Frameworks,
obtain input from key stakeholders and the public and create a preferred alternative. City will arrange
the charrette space and logistics, including ensuring proper amount of studio space with adequate
facilities and provide at least one staff person full time to provide ongoing logistical support. The
charrette will occur over four consecutive days and three nights with the following general schedule.
Da 1 Da 2 Da 3 Da 4
Staff & Technical Studio Studio to package
Meetings deliverables
One-on-one Lunch
stakeholder meetings
Site Tour and Lunch Break Lunch Break
Stakeholder meetings
Public Meeting to Studio Public meeting to
resent Frameworks resent work
Consultant shall prepare summary and submit to City and W OCPM within one week of charrette;
summary must include a brief outline of the charrette (time, location, duration, summary of materials
presented), participants list, comment and feedback, and comment and feedback trends.
Consultant shall prepare and submit to City and WOCPM Final Charrette Materials, including up to two
(2) illustrations of key opportunity sites, and a plan that addresses each framework component (housing,
land use, mobility, openspace, infrastructure, and sustainability).
The charrette will result in the development of a preferred alternative for inclusion in the draft Plan as
well as draft language for code and design changes to be included in the draft plan. The public meetings
must include diagrams, maps and drawings necessary to convey the ideas and issues present in the
Project Area.
City Deliverables
4.1 Project Management Meeting #2
4.2 Charrette
Consultant Deliverables
4.1 Project Management Meeting #2
4.2 Charrette and Final Charrette Materials
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Task 5: Transportation Analysis
5.1 Traffic Counts
ODOT will conduct 4-hour PM peak period (2-6 PM) counts of the following intersections:
• OR66/Normal Ave (only needed if a plan alternative will include formalization of the Normal
Avenue railroad crossing)
• East Main/Clay
• East Main/Tolman Creek Road
Counts must include vehicular traffic by type, pedestrian movements, bicycle, wheeled pedestrians
(wheelchairs, skateboards, etc.), and whether bicyclists are wearing helmets. Counts must use 15-
minutes intervals over the entire period. Counts should be taken when school is in session and avoid any
holiday weeks (September-May).
ODOT will submit traffic counts, recordings, and related data to WOCPM, City, and the Rogue Valley
Metropolitan Planning Organization (RVMPO).
5.2 Existing Traffic Analysis
Consultant shall prepare and submit to City and WOCPM Existing Traffic Analysis for all traffic count
intersections identified in subtask 5.1 and shall include the Draft TSP analysis of the intersections of
East Main/Walker, OR66/Walker, and OR66/Tolman Creek Road in order to judge impacts on the
surrounding system.
Analysis must include deficiencies (e.g. failure to meet application state or local policies or laws).
Operational analysis for all facilities, regardless of jurisdiction, must include:
• Volume-to-capacity ratio
• Level of Service
• Multi-Modal Level of Service, utilizing the methodology in the current City TSP Update
• 95`s Percentile queuing
• Turning movements
Non-automobile transportation analysis must include:
• Volume
• Type
• Direction
• For non-automobile devices that typically require safety equipment (e.g. bicycle, skateboard), the
percentage of users wearing safety equipment (at least helmets).
Consultant shall obtain approval of methodology and assumptions for the existing conditions, (and for
future conditions and alternatives) from TPAU and Region 3 Traffic Office prior to beginning analysis
of existing conditions. Consultant shall prepare a Methodology and Assumptions Memorandum: for
review by TPAU and Region 3 traffic. Methodology and Assumptions Memorandum must cover
analysis methodologies and assumptions for developing 30`a highest hour volumes, 2034 future baseline
volumes (to be developed from forecasts in the City's Draft TSP Update), and 2034 volumes for any
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alternatives, travel demand model scenario descriptions, and any other relevant analysis
methodologies/assumptions/major parameters used throughout the analysis tasks.
Consultant shall obtain three to five years of crash data from Agency's Crash Data & Reporting Unit for
Project Area intersections and adjacent roadway segments. Consultant shall calculate segment and
intersection crash rates in the Project Area. Intersection crash rate calculations must use the Highway
Safety Manual Critical Rate method. Segment crash rates must be compared with Table II in the
Agency's published Crash Rate Tables for similar facilities. For any identified locations that exceed the
published segment or calculated critical intersection rate, Consultant shall identify and present crash
patterns and potential countermeasures/safety improvements in the Existing Traffic Analysis. Consultant
shall document summary crash data results including crash rates in Existing Traffic Analysis.
All traffic volumes must use the 30`h Highest Hour. All traffic analysis, including electronic files, must
be submitted to ODOT Region 3 Traffic for approval. Consultant shall submit all traffic count analysis
to WOCPM, City, and the RVMPO.
Consultant shall collect (either from the Draft TSP work or from site-visits) all necessary inventory data
to support the base and future analysis.
City Deliverables
None
ODOT Deliverables
5.1 Traffic Counts
5.2 Crash Data
Consultant Deliverables
5.3 Existing Traffic Analysis
Task 6• Final Plan and Implementing Code Amendments
Objective: To prepare the final adopted plan and related code amendments.
6.1 Project Management Meeting #3
Consultant shall schedule and facilitate Project Management Meeting #3 via teleconference with PMT to
review the results of the public involvement efforts, and to determine which Concepts or elements from
Task 3 to include in the Draft Normal Avenue Neighborhood Plan. Consultant shall prepare and submit
a meeting summary to City and WOCPM within one week of Project Management Meeting 43.
6.2 Draft Normal Avenue Neighborhood Plan
Consultant shall refine Concepts and prepare a Draft Normal Avenue Neighborhood Plan based upon the
input received from the charrette and direction of the PMT.
The Draft Normal Avenue Neighborhood Plan must include, at a minimum:
• Maps, plans, and drawings as refined from the previous tasks.
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• At least one perspective or axonometric drawing of Project Area to convey the essence of the
Plan's implementation.
• Internal and external street designs for Project Area consistent with City's Street Standards, or
clearly identify any recommended deviations, that accommodates pedestrian, bicycle, and motor
vehicle traffic.
The Draft Normal Avenue Neighborhood Plan must be consistent with City's development requirements
or clearly identify any recommended deviations. Consultant shall coordinate with PMT to ensure Draft
Normal Avenue Neighborhood Plan is adequate to meet City and ODOT requirements for issues such as
driveway spacing, access management, and capacity impacts to major and minor intersections as
identified in Task 5.
6.3 Draft Area Site Design and Use Standards
Consultant shall prepare and submit to City and WOCPM Draft Area Site Design and Use Standards.
Draft Area Site Design and Use Standards must address any deviations from the City's existing Site
Design Standards which are necessary to regulate development of the Project Area consistent with the
Draft Normal Avenue Neighborhood Plan. Consultant shall draft code language to incorporate site
design and use Standards. Code language will not be adoption ready but have enough detail to allow
staff to put into adoption format.
6.4 Draft Chapter 18 Code Amendments
Consultant shall prepare and submit to City and WOCPM Draft Chapter 18 Code Amendments. Draft
Chapter 18 Code Amendments must address any deviations from the City's existing Chapter 18
necessary to allow the development of the area consistent with the Draft Normal Avenue Neighborhood.
Code language will not be adoption ready but have enough detail to allow staff to put into adoption
format.
6.5 Public Open House and PC Study Session
Consultant shall conduct a Public Open House directly before a PC Study Session, in coordination with
City staff, providing an opportunity for citizens to review the Draft Normal Avenue Neighborhood Plan.
Consultant shall prepare and submit to City and WOCPM a meeting summary one week after Public
Open House and PC Study Session.
City Deliverables
6.1 Project Management Meeting 43
6.5 Public Open House and PC Study Session
Consultant Deliverables
6.1 Project Management Meeting 43
6.2 Draft Normal Avenue Neighborhood Plan
6.3 Draft Area Site Design and Use Standards
6.4 Draft Chapter 18 Code Amendments
6.5 Public Open House and PC Study Session
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Task 7• Final Draft Plan and Implementing Ordinances
Objective: To prepare an adoption-ready plan and related ordinances.
7.1 Final Draft Normal Avenue Neighborhood Plan
Consultant shall prepare and submit to City and WOCPM Final Draft Normal Avenue Neighborhood
Plan, incorporating feedback from subtask 6.5 into draft. Consultant shall provide two hard copies and
two electronic copies -both pdf and editable format - on compact disc to both City and WOCPM at
conclusion of Project. City shall make any necessary final changes to make the Plan adoption ready.
7.2 Final Draft Area Site Design and Use Standards
City shall prepare and submit to Consultant and WOCPM Final Area Site Design and Use Standards,
incorporating feedback from subtask 6.5 into draft. City shall provide two hard copies and two
electronic copies - both pdf and editable format - on compact disc to WOCPM at conclusion of Project.
7.3 Final Chapter 18 Code Amendments
City shall prepare and submit to Consultant and WOCPM Final Chapter 18 Code Amendments,
incorporating feedback from subtask 6.5 into draft. City shall provide two hard copies and two
electronic copies - both pdf and editable format - on compact disc to WOCPM at conclusion of Project.
7.4 Final Buildable Lands Inventory and Housing Needs Analysis
City shall prepare and submit to Consultant and WOCPM Final Buildable Lands Inventory and Housing
Needs Analysis.
7.5 Comprehensive Plan Change Planning Application
City shall prepare and submit to WOCPM Comprehensive Plan Change Planning Application.
7.6 Transportation Planning Rule Findings
City shall prepare and submit to WOCPM Transportation Planning Rule Findings.
7.7 Final Presentations
City shall present the Final Normal Avenue Neighborhood Plan, Comprehensive Plan Changes, and
associated Ordinance Amendments to the Planning Commission at a Public Hearing for final approval
and recommendation to the Council.
City shall present the Final Normal Avenue Neighborhood Plan, Comprehensive Plan Changes, and
associated Ordinance Amendments to the Council at a Public Hearings for adoption.
City shall provide the PMT a Public Hearings Summary, identifying issues, feedback received and
guidance given by decision-makers, and a copy of adopted Findings relating to the final decision of the
City.
7.8 Title V1 Report
City shall prepare and submit to WOCPM a report delineating Title VI activities, documenting project
process and outreach for all low income, race, gender, and age groups.
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City Deliverables
7.2 Final Area Site Design and Use Standards
7.3 Final Chapter 18 Code Amendments
7.4 Final Buildable Lands Inventory and Housing Needs Analysis
7.5 Comprehensive Plan Change Planning Application
7.6 Transportation Planning Rule Findings
7.7 Final Presentations
7.8 Title VI Report
Consultant Deliverables
7.1 Final Draft Normal Avenue Neighborhood Plan
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Consultant Amounts per Deliverable and Schedule
Task Description Total Fixed Amount Schedule
Payable to Consultant
Per Deliverable
1.1 Project Management Meeting #1 $650 June 1, 2012
1.2 Project Schedule $900 June 1, 2012
Task 1 Total $1550
Task 2 - No Consultant Deliverables
3.1 Housing and Land Use Framework $6,250 August 2012
3.2 Greenwa and Opens ace Framework $2,050 August 2012
3.3 Mobility Framework $2,000 August 2012
3.4 Infrastructure Framework $1,300 August 2012
3.5 Sustainable Neighborhood Framework $1,550 August 2012
3.6 One Conceptual Plan $11,500 October 2012
Task 3 Total $24,650
4.1 Project Management Meeting #2 $500 November
2012
4.2 Charrette and Final Charrette Materials $26,500 December 2012
Task 4 Total $27,000
5.3 Existing Traffic Analysis $7,900 August 2012
Task 5 Total $7,900
6.1 Project Management Meeting #3 $650 February 2013
6.2 Draft Normal Avenue Neighborhood $8,500
Plan
6.3 Draft Area Site Design and Use $2,500 March 2013
Standards
6.4 Draft Chapter 18 Code Amendments $2,500 Aril 2013
6.5 Public Open House and PC Study $3,800 May 2013
Session
Task 6 Total $17,950
7.1 Final Draft Normal Avenue $3,400 July 2013
Neighborhood Plan
Task 7 Total $3,400
Project Total $82,450
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EXHIBIT B (Local Agency or State Agency)
CONTRACTOR CERTIFICATION
Contractor certifies by signing this contract that Contractor has not:
(a) Employed or retained for a commission, percentage, brokerage, contingency fee or other consideration, any firm
or person (other than a bona fide employee working solely for me or the above consultant) to solicit or secure this
contract,
(b) agreed, as an express or implied condition for obtaining this contract, to employ or retain the services of any firm
or person in connection with carrying out the contract, or
(c) paid or agreed to pay, to any firm, organization or person (other than a bona fide employee working solely for me
or the above consultant), any fee, contribution, donation or consideration of any kind for or in connection with,
procuring or carrying out the contract, except as here expressly stated (if any):
Contractor further acknowledges that this certificate is to be furnished to the Federal Highway Administration, and is subject
to applicable State and Federal laws, both criminal and civil.
AGENCY OFFICIAL CERTIFICATION (ODOT)
Department official likewise certifies by signing this contract that Contractor or his/her representative has not been required
directly or indirectly as an expression of implied condition in connection with obtaining or carrying out this contract to:
(a) Employ, retain or agree to employ or retain, any firm of person or
(b) pay or agree to pay, to any firm, person or organization, any fee, contribution, donation or consideration of any
kind except as here expressly stated (if any):
Department official further acknowledges this certificate is to be furnished to the Federal Highway Administration, and is
subject to applicable State and Federal laws, both criminal and civil.
EXHIBIT C
Federal Provisions
Oregon Department of Transportation
1. CERTIFICATION OF NONINVOLVEMENT IN ANY DEBARMENT AND SUSPENSION
Contractor certifies by signing this contract that to the best of its knowledge and belief, it and its principals:
1. Are Inot presently debarred, suspended, proposed for criminal offense in connection with obtaining,
debarment, declared ineligible or voluntarily attempting to obtain or performing a public (federal,
excluded from covered transactions by any Federal state or local) transaction or contract under a public
department or agency; transaction; violation of federal or state antitrust
statutes or commission of embezzlement, theft,
2. Have not within a three-year period preceding this forgery, bribery falsification or destruction of
proposal been convicted of or had a civil judgment records, making false statements or receiving stolen
rendered against them for commission of fraud or a property;
Rev. 511MOOa AGR.FEDCERT
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3. Are not presently indicted for or otherwise criminally certification, in addition to other remedies available
or civilly charged by a governmental entity to the Federal Government or the Department may
(federal, state or local) with commission of any of terminate this transaction for cause of default.
the offenses enumerated in paragraph (1)(b) of this
certification; and 4. The Contractor shall provide immediate written
notice to the Department to whom this proposal is
4. Have not within a three-year period preceding this submitted if at any time the Contractor learns that
application/proposal had one or more public its certification was erroneous when submitted or
transactions (federal, state or local) terminated for has become erroneous by reason of changed
cause or default. circumstances.
Where the Contractor is unable to certify to any of the 5. The terms "covered transaction", "debarred",
statements in this certification, such prospective participant "suspended", "ineligible", "lower tier covered
shall attach an explanation to this proposal. transaction", "participant", "person", "primary
covered transaction", "principal", and "voluntarily
List exceptions. For each exception noted, indicate to whom excluded", as used in this clause, have the meanings
the exception applies, initiating agency, and dates of action. set out in the Definitions and Coverage sections of
If additional space is required, attach another page with the the rules implementing Executive Order 12549.
following heading: Certification Exceptions continued, You may contact the Department's Program Section
Contract Insert. (Tel. (503) 986-3400) to which this proposal is
being submitted for assistance in obtaining a copy
EXCEPTIONS: of those regulations.
Exceptions will not necessarily result in denial of award, but 6. The Contractor agrees by submitting this proposal
will be considered in determining Contractor responsibility. that, should the proposed covered transaction be
Providing false information may result in criminal entered into, it shall not knowingly enter into any
prosecution or administrative sanctions. lower tier covered transactions with a person who is
debarred, suspended, declared ineligible or
The Contractor is advised that by signing this contract, the voluntarily excluded from participation in this
Contractor is deemed to have signed this certification. covered transaction, unless authorized by the
II. INSTRUCTIONS FOR CERTIFICATION REGARDING Department or agency entering into this transaction.
DEBARMENT, SUSPENSION, AND OTHER 7. The Contractor further agrees by submitting this
RESPONSIBILITY MATTERS-PRIMARY COVERED proposal that it will include the Addendum to Form
TRANSACTIONS FHWA-1273 titled, "Appendix B--Certification
Regarding Debarment, Suspension, Ineligibility and
1. By signing this contract, the Contractor is providing Voluntary Exclusion--Lower Tier Covered
the certification set out below. Transactions", provided by the Department entering
into this covered transaction without modification,
2. The inability to provide the certification required in all lower tier covered transactions and in all
below will not necessarily result in denial of solicitations for lower tier covered transactions.
participation in this covered transaction. The
Contractor shall explain why he or she cannot 8. A participant in a covered transaction may rely
provide the certification set out below. This upon a certification of a prospective participant in a
explanation will be considered in connection with lower tier covered transaction that it is not
the Oregon Department of Transportation debarred, suspended, ineligible or voluntarily
determination to enter into this transaction. Failure excluded from the covered transaction, unless it
to furnish an explanation shall disqualify such knows that the certification is erroneous. A
person from participation in this transaction. participant may decide the method and frequency
by which it determines the eligibility of its
3. The certification in this clause is a material principals. Each participant may, but is not
representation of fact upon which reliance was required to, check the Nonprocurement List
placed when the Department determined to enter published by the U. S. General Services
into this transaction. If it is later determined that Administration.
the Contractor knowingly rendered an erroneous
Rev. 5/10/2000 AGRYWCERT
-37-
TGM Grant Agreement No. 28461
TGM File Code 3A-I I
EA N TG12LA55
9. Nothing contained in the foregoing shall be 4. The terms "covered transaction", "debarred",
construed to require establishment of a system of "suspended", "ineligible", "lower tier covered
records to render in good faith the certification transaction", "participant", "person", "primary
required by this clause. The knowledge and covered transaction", "principal", "proposal", and
information of a participant is not required to "voluntarily excluded", as used in this clause, have
exceed that which is normally possessed by a the meanings set out in the Definitions and
prudent person in the ordinary course of business Coverage sections of rules implementing Executive
dealings. Order 12549. You may contact the person to which
this proposal is submitted for assistance in
10. Except for transactions authorized under paragraph obtaining a copy of those regulations.
6 of these instructions, if a participant in a covered
transaction knowingly enters into a lower tier 5. The prospective lower tier participant agrees by
covered transaction with a person who is submitting this contract that, should the proposed
suspended, debarred, ineligible or voluntarily covered transaction be entered into, it shall not
excluded from participation in this transaction, in knowingly enter into any lower tier covered
addition to other remedies available to the Federal transaction with a person who is debarred,
Government or the Department, the Department suspended, declared ineligible or voluntarily
may terminate this transaction for cause or default. excluded from participation in this covered
transaction, unless authorized by the department or
III. ADDENDUM TO FORM FHWA-1273, REQUIRED agency with which this transaction originated.
CONTRACT PROVISIONS
6. The prospective lower tier participant further agrees
This certification applies to subcontractors, material by submitting this contract that it will include this
suppliers, vendors, and other lower tier participants. clause titled, "Certification Regarding Debarment,
Suspension, Ineligibility and Voluntary
• Appendix B of 49 CFR Part 29 - Exclusion--Lower Tier Covered Transaction",
without modification, in all lower tier covered
Appendix B-Certification Regarding Debarment, transactions and in all solicitations for lower tier
Suspension, Ineligibility, and Voluntary covered transactions.
Exclusion-Lower Tier Covered Transactions
7. A participant in a covered transaction may rely
Instructions for Certification upon a certification of a prospective participant in a
lower tier covered transaction that it is not
1. By signing and submitting this contract, the debarred, suspended, ineligible or voluntarily
prospective lower tier participant is providing the excluded from the covered transaction, unless it
certification set out below. knows that the certification is erroneous. A
participant may decide the method and frequency
2, The certification in this clause is a material by which it determines the eligibility of its
representation of fact upon which reliance was principals. Each participant may, but is not
placed when this transaction was entered into. If it required to, check the nonprocurement list.
is later determined that the prospective lower tier
participant knowingly rendered an erroneous 8. Nothing contained in the foregoing shall be
certification, in addition to other remedies available construed to require establishment of a system of
to the Federal Government, the department or records to render in good faith the certification
agency with which this transaction originated may required by this clause. The knowledge and
pursue available remedies, including suspension information of a participant is not required to
and/or debarment. exceed that which is normally possessed by a -
prudent person in the ordinary course of business
3. The prospective lower tier participant shall provide dealings.
immediate written notice to the person to which this
contract is submitted if at any time the prospective 9. Except for transactions authorized under paragraph
lower tier participant learns that its certification was 5 of these instructions, if a participant in a covered
erroneous when submitted or has become erroneous transaction knowingly enters into a lower tier
by reason of changed circumstances. covered transaction with a person who is
Rm 5/102000 AOR.FEDCERT
-38-
TGM Grant Agreement No. 28461
TGM File Code 3A-11
EA # TG12LA55
suspended, debarred, ineligible or voluntarily entitled to rely on the accuracy, competence, and
excluded from participation in this transaction, in completeness of Contractor's services.
addition to other remedies available to the Federal
Government, the department or agency with which V. NONDISCRIMINATION
this transaction originated may pursue available
remedies, including suspension and/or debarment. During the performance of this contract, Contractor, for
himself, his assignees and successors in interest, -
Certification Regarding Debarment, Suspension, hereinafter referred to as Contractor, agrees as follows:
Ineligibility, and Voluntary Exclusion-Lower Tier
Covered Transactions I. Compliance with Regulations. Contractor agrees to
comply with Title VI of the Civil Rights Act of
a. The prospective lower tier participant certifies, 1964, and Section 162(a) of the Federal-Aid
by submission of this proposal, that neither it Highway Act of 1973 and the Civil Rights
nor its principals is presently debarred, Restoration Act of 1987. Contractor shall comply
suspended, proposed for debarment, declared with the regulations of the Department of
ineligible or voluntarily excluded from Transportation relative to nondiscrimination in
participation in this transaction by any Federal Federally assisted programs of the Department of
department or agency. Transportation, Title 49, Code of Federal
Regulations, Part 21, as they may be amended from
b. Where the prospective lower tier participant is time to time (hereinafter referred to as the
unable to certify to any of the statements in this Regulations), which are incorporated by reference
certification, such prospective participant shall and made a part of this contract. Contractor, with
attach an explanation to this proposal, regard to the work performed after award and prior
to completion of the contract work, shall not
IV. EMPLOYMENT discriminate on grounds of race, creed, color, sex or
national origin in the selection and retention of
I. Contractor warrants that he has not employed or subcontractors, including procurement of materials
retained any company or person, other than a bona and leases of equipment. Contractor shall not
fide employee working solely for Contractor, to participate either directly or indirectly in the
solicit or secure this contract and that he has not discrimination prohibited by Section 21.5 of the
paid or agreed to pay any company or person, other Regulations, including employment practices, when
than a bona fide employee working solely for the contract covers a program set forth in
Contractors, any fee, commission, percentage, Appendix B of the Regulations.
brokerage fee, gifts or any other consideration
contingent upon or resulting from the award or 2. Solicitation for Subcontractors, including
making of this contract. For breach or violation of Procurement of Materials and Equipment. In all
this warranting, Department shall have the right to solicitations, either by competitive bidding or
annul this contract without liability or in its negotiations made by Contractor for work to be
discretion to deduct from the contract price or performed under a subcontract, including
consideration or otherwise recover, the full amount procurement of materials and equipment, each
of such fee, commission, percentage, brokerage fee, potential subcontractor or supplier shall be notified
gift or contingent fee. by Contractor of Contractor's obligations under this
contract and regulations relative to
2. Contractor shall not engage, on a full or part-time nondiscrimination on the grounds of race, creed,
basis or other basis, during the period of the color, sex or national origin,
contract, anv professional or technical personnel
who are or have been at any time during the period 3. Nondiscrimination in Employment (Title VII of the '
of this contract, in the employ of Department, 1964 Civil Rights Act). During the performance of
except regularly retired employees, without written this contract, Contractor agrees as follows:
consent of the public employer of such person.
a. Contractor will not discriminate against any
3. Contractor agrees to perform consulting services employee or applicant for employment because
with that standard of care, skill and diligence of race, creed, color, sex or national origin.
normally provided by a professional in the Contractor will take affirmative action to
performance of such consulting services on work ensure that applicants are employed, and that
similar to that hereunder. Department shall be employees are treated during employment,
Rev. 5/102000 AGR.FEDCERT
-39-
TGM Grant Agreement No. 28461
TGM File Cade 3A-I 1
EA # TG 12LA55
without regard to their race, creed, color, sex or direction, Department may, at its option, enter into such
national origin. Such action shall include, but litigation to protect the interests of Department, and, in
not be limited to the following: employment, addition, Contractor may request Department to enter
upgrading, demotion or transfer; recruitment or into such litigation to protect the interests of the State of
recruitment advertising; layoff or termination; Oregon.
rates of pay or other forms of compensation;
and selection for training, including VI. DISADVANTAGED BUSINESS
apprenticeship. Contractor agrees to post in ENTERPRISE (DBE) POLICY
conspicuous places, available to employees and
applicants for employment, notice setting forth In accordance with Title 49, Code of Federal
the provisions of this nondiscrimination clause. Regulations, Part 26, Contractor shall agree to abide by
and take all necessary and reasonable steps to comply
b. Contractor will, in all solicitations or with the following statement:
advertisements for employees placed by or on
behalf of Contractor, state that all qualified DBE POLICY STATEMENT
applicants will receive consideration for
employment without regard to race, creed, DBE Policy. It is the policy of the United States
color, sex or national origin. Department of Transportation (USDOT) to practice
nondiscrimination on the basis of race, color, sex
4. Information and Reports. Contractor will provide and/or national origin in the award and administration
all information and reports required by the of USDOT assist contracts. Consequently, the DBE
Regulations or orders and instructions issued requirements of 49 CFR 26 apply to this contract,
pursuant thereto, and will permit access to his
books, records, accounts, other sources of Required Statement For USDOT Financial
information, and his facilities as may be determined Assistance Agreement. If as a condition of assistance
by Department or FHWA as appropriate, and shall the Agency has submitted and the US Department of
set forth what efforts he has made to obtain the Transportation has approved a Disadvantaged Business
information. Enterprise Affirmative Action Program which the
Agency agrees to carry out, this affirmative action
S. Sanctions for Noncompliance. In the event of program is incorporated into the financial assistance
Contractor's noncompliance with the agreement by reference.
nondiscrimination provisions of the contract,
Department shall impose such agreement sanctions DBE Obligations. The Oregon Department of
as it or the FHWA may determine to be Transportation (ODOT) and its contractor agree to
appropriate, including, but not limited lo: ensure that Disadvantaged Business Enterprises as
defined in 49 CFR 26 have the opportunity to
a. Withholding of payments to Contractor under participate in the performance of contracts and
the agreement until Contractor complies; and/or subcontracts financed in whole or in part with Federal
funds. In this regard, Contractor shall take all
b. Cancellation, termination or suspension of the necessary and reasonable steps, in accordance with
agreement in whole or in part. 49 CFR 26 to ensure that Disadvantaged Business
Enterprises have the opportunity to compete for and
6. Incorporation ot'Provisions, Contractor will perform contracts. Neither ODOT nor its contractors
include the provisions of paragraphs I through 6 of shall discriminate on the basis of race, color, national
this section in every subcontract, including origin or sex in the award and performance of
procurement of materials and leases of equipment, federally-assisted contracts. The contractor shall carry
unless exempt from Regulations, orders *or out applicable requirements of 49 CFR Part 26 in the
instructions issued pursuant thereto. Contractor award and administration of such contracts. Failure by
shall take such action with respect to any the contractor to carry out these requirements is a
subcontractor or procurement as Department or material breach of this contract, which may result in
FHWA may direct as a means of enforcing such the termination of this contract or such other remedy as
provisions, including sanctions for noncompliance; ODOT deems appropriate.
provided, however, that in the event Contractor
becomes involved in or is threatened with litigation The DBE Policy Statement and Obligations shall be
with a subcontractor or supplier as a result of such included in all subcontracts entered into under this
contract.
Tim S/IMON AGRFEDCEKr
-40-
TGM Grant Agreement No. 28461
TGM File Code 3A-11
EA 4 TG 12LA55
influence an officer or employee of any Federal
Records and Reports. Contractor shall provide agency, a Member of Congress, an officer or
monthly documentation to Department that it is employee of Congress or an employee of a Member
subcontracting with or purchasing materials from the of Congress in connection with the awarding of any
DBEs identified to meet contract goals. Contractor Federal contract, the making of any Federal grant,
shall notify Department and obtain its written approval the making of any Federal loan, the entering into of
before replacing a DBE or making any change in the any cooperative agreement, and the extension,
DBE participation listed. If a DBE is unable to fulfill continuation, renewal, amendment or modification
the original obligation to the contract, Contractor must of any Federal contract, grant, loan or cooperative
demonstrate to Department the Affirmative Action agreement.
steps taken to replace the DBE with another DBE.
Failure to do so will result in withholding payment on 2. If any funds other than Federal appropriated funds
those items. The monthly documentation will not be have been paid or will be paid to any person for
required after the DBE goal commitment is satisfactory influencing or attempting to influence an officer or
to Department. employee of any Federal agency, a Member of
Congress, an officer or employee of Congress or an
Any DBE participation attained after the DBE goal has employee of a Member of Congress in connection
been satisfied should be reported to the Departments. with this agreement, the undersigned shall complete
and submit Standard Form-LLL, "Disclosure Form
DBE Definition. Only firms DBE certified to Report Lobbying", in accordance with its
by the State of Oregon, Department of Consumer & instructions.
Business Services, Office of Minority, Women &
Emerging Small Business, may be utilized to satisfy This certification is a material representation of fact
this obligation. upon which reliance was placed when this transaction
was made or entered into. Submission of this
CONTRACTOR'S DBE CONTRACT GOAL certification is a prerequisite for making or entering
into this transaction imposed by Section 1352, Title 31,
DBE GOAL 0 % U. S. Code. Any person who fails to file the required
certification shall be subject to a civil penalty of not
By signing this contract, Contractor assures that good less than $10,000 and not more than $100,000 for each
faith efforts have been made to meet the goal for the such failure.
DBE participation specified in the Request for
Proposal/Qualification for this project as required by The Contractor also agrees by signing this agreement
ORS 200.045, and 49 CFR 26.53 and 49 CFR, Part 26, that he or she shall require that the language of this
Appendix A. certification be included in all lower tier
subagreements, which exceed $100,000 and that all
VII. LOBBYING such subrecipients shall certify and disclose
accordingly.
The Contractor certifies, by signing this agreement to
the best of his or her knowledge and belief, that: FOR INQUIRY CONCERNING ODOT' S
1. No Federal appropriated funds have been paid or DBE PROGRAM REQUIREMENT
will be paid, by or on behalf of the undersigned, to CONTACT OFFICE OF CIVIL RIGHTS
any person for influencing or attempting to AT (503)986-4354.
Rcv, 5/10/2000 AGR.FEDCERT
-41-
TGM Grant Agreement No. 28461
TGM File Code 3A-1 I
EA # TG12LA55
EXHIBIT D
ELIGIBLE PARTICIPATING COST
DESCRIPTION
PERSONNEL SERVICES
Salaries - Straight time pay for regular working hours in a monthly period. Includes standard labor distributions like
Social Security Taxes, Workers' Compensation Assessments and Medical. Dental, Life Insurance- Excludes mass
;transit tax, vacation leave, sick leave and compensatory time taken.
Overtime - Payments to employees for work performed in excess of their regular work shift. _
Shift Differential - Payments_to employees, in addition to regular pay, for shift differential work as descibed in labor '
:contracts or Personnel Rules.
Travel Differential - Payments to employees, in addition to regular pay. far travel time to and from work on projects in
excess and beyond ,an,3 hour day as described in labor contracts or Personnal Rules:
SERVICES AND SUPPLIES
In-State Travel - Per Rates.ldentdied in State Travel Handbook
wn the State of Oregon
theals & Misc Payment for meals incurred while traveling dhi
- - - - -
Lodging 8_ Room-Tax- Payment for lodging; including room taxes.. incurred while. traveling within the State of Oregon-
Fares. Taxi, Bus, Air, Etc_
Per Diem - Payment for per diem, incurred while traveling within the State of Oregon.
Other Payment for other miscellaneous expense, incurred while traveling within the State of Oregon.
Private Car k1deage - Payment for private car mileage while traveling within the State of Oregon.
i0ffice Expense _
Direct Prnrect Expenses Including:
;Photo, Video & Microfilm Supplies Payment for photography video and microfilm supplies such as film for cameras,
blank video tapes. storage folders, etc _
Pnnting, Reproduction & Duplication Expenditures for services to copy, print, reproduce andlor duplicate documents_
;Postage _Payment for direct project postage.
;Freight & Exptass tvlail Payment for direct project freight services on outgoing shipments.
Telecom mumcations_ .
Phone Toll Charges-(long distance) Payment for telphone long distance charges
.Publicity & Publication
'Publish &Print Photos - Payment for printing and publishing photographs to development of publicity and publications.
Conferences (costs to put on conference or seminars)
Equipment $250 - $4,999
NOT ELIGIBLE
;Employee Training, Excluding Travel
INOT ELIGIBLE......
;Training In-State Travel
NOT ELIGIBLE
i
CAPITOL OUTLAY
NOT ELIGIBLE
-42-
CITY OF
ASHLAND
Council Communication
June 18, 2013, Business Meeting
Appointment to Public Arts Commission
FROM:
Barbara Christensen, City Recorder, christeb@ashland.or.us
SUMMARY
Confirm Mayor's appointment of Alyssa Clark to the Public Arts Commission with a term to expire
April 30, 2016.
BACKGROUND AND POLICY IMPLICATIONS:
This is confirmation by the City Council on the Mayor's appointment to the Public Arts Commission.
Ashland Municipal Code (AMC) Chapter 2.17.020
FISCAL IMPLICATIONS:
N/A
STAFF RECOMMENDATION AND REQUESTED ACTION:
None
SUGGESTED MOTION:
Motion to approve appointment of Alyssa Clark to the Public Arts Commission with a term to expire
April 30, 2016.
ATTACHMENTS:
None
Page 1 of I
~r,
CITY OF
ASHLAND
APPLICATION FOR APPOINTMENT TO
CITY COMMISSION/COMMITTEE
Please type or print answers to the following questions and submit to the City Recorder at
City Hall, 20 E Main Street, or email christeb(ibashland.or.us. If you have any questions,
please feel free to contact the City Recorder at 488-5307. Attach additional sheets if
necessary. I n II//
Name SS ` I Q r I~
Requesting to serve on: P()-b hC- Rr-4 eo )1M ISSt(Mommission/Committee)
Address 99. iimevicK
Occupations 10 rnGU10.~f(/fit Phone: Home 5(J3 g5~ SZ22
Work
Email 0, i 5- GLY K(e))ko4✓vtLi.t 4, ft
Fax
1. Education Background
What schools have you attended? N olr~ y~eVil n Y 12(Jbll~ W1 IV. -UPI V, CT
What degrees do you hold?
What additional training or education have you had that would apply to this position?
l Ax worked as I~asl~, 0V%' '5evtod boards
2. Related Experience
What prior work experience have you had that would help you if you were appointed to
this position? '
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Do you feel it would be advantageous for you to ryha'v^e further tr fining n this fesuch
as attending conferences or seminars? Why? O JA LA I~ U~e~ GL (n such
IS else u(IdlAq he&orKS 1S vi+60
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3. Interests 1
Why are you applying for this position? ~j l (~11 Ct tUVP 4o be Iii( if~
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4. Availability
Are you available to attend special meetings, in addition to the regularly scheduled
meetings? Do you prefer-day or evening meetings?
ytYS no yy ier to[VuL.
5. Additional Information
How long have you lived in this community? (Q (~Qla V~
Please use the space below to summarize any additional qualifications you have for this
position
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Alissa Clary
503.957.5122 Ashland, Oregon
Education:
2002: Master of Fine Arts, University of Arizona, Tucson
1997: Bachelor of Fine Arts, Northem Arizona University, Flagstaff
Selected Professional Experience:
2010-present: Ashland Art Center, Ceramic Studio Manager. Responsible for all aspects of a
16 member ceramic facility.
2010-present: Ashland Art Center, Instructor. Beginning through intermediate handbuilding
and wheel-throwing.
2004-present: Full-time Studio Potter (national wholesale, gallery, and fine art exhibitions)
2011: Lithia Artisan's Market. Board Member
2006-2011: Oregon Potters Association, Sponsorship Chair. Responsible for all fund-raising,
coordination of business/productlartist/public interface for Ceramic Showcase.
20052007: Portland Saturday Market, Board Member at large.
2009: Trillium Charter School (K-12) mosaic project, Resident Artist. Responsible for design and
team execution of huge tree-of-life mural for center hallway.
20052009: Portland Community College. Rock Creek campus, Ceramics Instructor. Ceramics I
and 11, Beginning and intermediate level students, hand-building and wheel.
2004: Ashland Artworks, GaUery Director. Coordinated artists and gallery areas for upcoming
exhibitions, installation and breakdown of all exhibitions, organized/ran monthly meetings and
committee work. Organized fast Friday art walks and workshops.
2003-2004: Kid's House.- Board Member at large.
2003-2004: Thrown Stone Studios, Ceramic Instructor. Co-taught all methods of beginning
clay classes to adult community members. Co-conducted all firings. Responsible for all glaze-
making, supply stock and ordering.
2003: King Academy Hi School Public Art Tile Mosaic Project, Resident Artist Responsible
for material ordering, coordination of student conceptual design, implementation, and execution
of mosaic projects, interface with community public art council.
2002-2003: Tucson Community Public Art Foram, Facilitator. Liasion/organizer between
University, city of Tucson and individual public artists.
2002: University of Arizona, Appreciating the Visual Arts, Team Instructor. Responsible for
studio still-life drawing, design principle, art history instruction, and grading of descriptive
critical art essays. Coordinated and ran group performance art projects.
2002: Northern Arizona University, Adjunct Professor. Taught beginning ceramics, intermediate
hand-building ceramics, and wheel-throwing. Job included all cone 10 firings, glaze-making,
clay-making and studio maintenance.
2000-2002: University of Arizona. Adjunct Instructor. Beginning, intermediate, and wheel-
throwing courses. Taught low-fire, sculptural ceramics, wheel techniques, glaze-making and
kiln- firing. Responsible for studio maintenance/improvement.
~ZECFIV F~
vtB0151
2000-2001: SEEK extended program, University of Arizona, Art Instructor. Taught figure/still-
life drawing, watercolor painting, two and three-dimensional design to gifted jr-high and high
school students. Responsible for course design, material ordering, studio instruction, exhibition
planning and installation.
2000: University of Arizona Ceramics Lab Technician. Responsible for all aspects of studio
maintenance and improvement, raw materials, glaze-making, and kiln repair.
1996-1997: Northern Arizona University. Cheerful Kiln yard Slave. Co-responsible for all kiln
yard maintenance, anagama/naborigama repair, building door bricks, re-designing flue, chimney
and stoke-holes of kiln chambers, ordering wood by the cord, delivery, splitting. Ran bobcat and
forklift.
Current Galleries/work locations:
Anenome, Spokane, WA
Pinch Gallery, Northhampton, MA
Ashland Art Center, Ashland, OR
Mud and Metal, Ann Arbor, MI
Ansel Adams Gallery, Yosemite, CA
Real Mother Goose, Portland, OR
Touchstone Gallery, Yachats, OR
Arizona Handmade, Flagstaff, AZ
Blondie's Gallery, Santa Fe, NM
W inddrift Gallery, Newport, OR
Skamania Lodge, Upper Gorge, WA
Selected Fine Art Shows 2012:
Mill Valley Fine Art Festival, Mill Valley, CA
Ceramic Showcase, Oregon Potters Association, Portland, OR
Scottsdale Fine Art Festival, Scottsdale, AZ
Bellevue Fine Art Festival, Bellevue, WA
Sun Valley Fine Arts Festival, Sun Valley, ID
Park City Art Festival, Park City, UT
Professional References
Kris Paul, Ceramic Showcase Executive Chair, OPA 503.344.6213
Richey Bellinger, Portland Community College Ceramics Chair 503.614.7090
Cheryl Kempner, Ashland Artworks 541.552.0100
CITY OF
ASHLAND
Council Communication
June 18, 2013, Business Meeting
Extension of City Waiver of Right to Terminate Lease Agreement with Ashland
Community Hospital for failure to maintain working capital and debt service
coverage ratios
FROM:
Dave Kanner, City Administrator, kannerd@ashland.or.us
SUMMARY
The facilities lease agreement between the City of Ashland and Ashland Community Hospital (ACH)
allows the City to declare the Hospital in default if it fails to maintain certain working capital and debt
service coverage ratios. According to the Hospital's FY 2012 audit, ACH failed to maintain those
ratios. Rather than declaring ACH to be in default, the City granted a waiver of that particular
provision of the lease. That waiver expires on June 30, 2013. Staff proposes extending the waiver for
one more month, after which Asante will become the sole corporate member of the ACH corporation.
BACKGROUND AND POLICY IMPLICATIONS:
The City of Ashland entered into a facilities lease agreement with Ashland Community Hospital in
1996. Paragraph 16.1.4 of this agreement states that Ashland Community Healthcare Services must
have a working capital ratio of 2 to 1. Paragraph 16.1.5 of this agreement states that Ashland
Community Healthcare Services must also maintain a debt service coverage ratio of at least 1.25 to 1.
The Hospital's FY `12 annual audit determined that ACH's working capital ratio as of June 30, 2012,
was 1.73:1 and their debt service coverage was -.48:1.
Section 16.2 of the lease agreement allows the City to declare the Hospital in default, terminate the
lease and exercise full authority over the operation of the Hospital. Rather than doing so, the City last
year granted the hospital a waiver of this lease provision. That waiver expires on June 30, 2013.
However, the City, on June 5, entered into an affiliation agreement with Asante under which Asante
will become the sole corporate member of the ACH corporation on August 1, 2013, thus making this
lease provision moot. What's more, the ACH FY '13 audited financial statement will not be available
until after this transaction closes. In order to prevent any misunderstanding, the current ACH
management has requested that the waiver be extended.
FISCAL IMPLICATIONS:
N/A
STAFF RECOMMENDATION AND REQUESTED ACTION:
Staff recommends approval of the requested extension of the waiver.
Page 1 of 2
~r,
CITY OF
ASHLAND
SUGGESTED MOTIONS:
I move approval of the City Administrator's signature of a letter to Ashland Community Hospital
extending the waiver of the City's right to terminate the lease agreement with Ashland Community
Hospital for failure to maintain working capital and debt service coverage ratios.
ATTACHMENTS:
Draft letter to Ashland Community Hospital
Page 2 of 2
CITY OF
ASHLAND
June 19, 2013
Marvin Haas, Interim Chief Executive Officer
Ashland Community Hospital
280 Maple Street
Ashland, Oregon 97520
SUBJECT: City Waiver of Right to Terminate Lease Agreement for FY 2012 Audit of Ashland
Community Hospital
Dear Mr. Haas:
In 1996, the City of Ashland and Ashland Community Healthcare Services signed an agreement for the
Lease of the Ashland Community Hospital. The agreement includes several provisions related to default
and termination of the agreement. Paragraph 16.1.4 of this agreement states that Ashland Community
Healthcare Services must have a working capital ratio oft to 1, and 16.1.5 of this agreement states that
Ashland Community Healthcare Services must also maintain a debt service coverage ratio of at least
1.25 to 1.
Section 16.2 of the lease allows the City to terminate the agreement if the debt service and working
capital ratios described above are not maintained. On September 4, 2012, the City Council agreed to
waive its rights as outlined in section 16.2 of the lease agreement through June 30, 2013. Given the
hospital's pending affiliation with Asante, the City Council has agreed to extend the waiver of its rights
under Section 16.2 until June 30, 2014 or the closing date of the affiliation agreement between the City
of Ashland, Asante, Ashland Community Hospital and the Ashland Community Hospital Foundation,
dated June 5, 2013, whichever comes soonest.
Please let me know if you have questions.
Sincerely,
Dave Kanner
City Administrator
C. David Lohman, City Attorney
Lee Tuneberg, Administrative Services/ Finance Director
ADMINISTRATION DEPT. Tel: 541488-6002
20 East Main Street Fax: 541488-5311
Ashland, Oregon 97520 TTY: 800.735-2900
w .ashland.or.us -
CITY OF
ASHLAND
Council Communication
June 18, 2013, Business Meeting
Parking and Marking Options for the Plaza
FROM:
Scott A. Fleury, Engineering Services Manager, Public Works/Engineering, fleurys(pashland.or.us
SUMMARY
Due to the Plaza Beautification project, the previous Plaza curb was removed and replaced. The curb
was previously painted yellow, designating a "no parking" zone and was enforced as a temporary
loading zone adjacent to the business frontage. Since completion of the Plaza work, parking
prohibitions have not been re-installed around the Plaza loop. Staff presented alternate parking
prohibition solutions for discussion at the Transportation Commission meeting on May 25`h. The
Transportation Commission considered the alternate traffic control solutions for the newly installed
curb around the Plaza. Those alternate solutions included ground stenciling a loading zone or allowing
parking on the commercial side of the Plaza combined with "no parking" stenciling around the
remainder of the loop. The Commission recommended repainting the entire new curb yellow and
continue enforcement as a temporary loading zone adjacent to the businesses.
BACKGROUND AND POLICY IMPLICATIONS:
During the design and implementation of the Plaza Beautification project alternate, methods of parking
prohibitions were discussed in order to eliminate vertical signs and or yellow curb striping. The
alternate methods included stenciling the ground around the Plaza with an approved parking
prohibition, with either a no parking or loading zone designation. There is adequate room between the
two crosswalks on the west side of the Plaza for a loading or a timed parking zone (reference attached
drawings). This section of the Plaza has been used and enforced previously as a temporary loading
zone. There is no room for additional parking at any other section surrounding the Plaza.
The alternate striping methods were presented to the Transportation Commission at the May 25`h
meeting for discussion and recommendation to the Council. Staff presented two general options to the
Commission as possible striping plans. The plans included ground stenciling of a loading zone and no
parking, and stenciling of timed parking along with no parking around the rest of the Plaza.
The Commission discussed the options and concluded that, for safety concerns and circulation, the
Plaza curb should be striped yellow around the perimeter.
The key points of the discussion included:
1. Yellow is universal for no parking and everyone driving a vehicle downtown would understand
the prohibition.
2. Parking on the island would create poor visibility of pedestrians crossing.
3. Parallel parking along the Plaza island could create traffic back-up issues down and onto E.
Main.
Page 1 of 2
CITY OF
ASHLAND
4. Potential for drivers/passengers leaving their vehicles and crossing in an unpredictable manner.
(e.g. passenger side exit into traffic creating a conflict with vehicles backing out of the diagonal
spaces.)
5. If an emergency occurred on the Plaza, Police and/or Fire would potentially need to double
park within that section effectively shutting down the Plaza for traffic trying to enter this area.
6. Parking on the island would create a visual barrier to the current open space.
FISCAL IMPLICATIONS:
There are no fiscal implications. The Street Department will repaint the curb yellow if approved by the
City Council.
STAFF RECOMMENDATION AND REQUESTED ACTION:
Staff recommends following the Transportation Commission recommendation of painting the entire
Plaza curb yellow designating no parking and continuing enforcement as it has been done in the past.
SUGGESTED MOTION:
Move to approve the Transportation Commission's recommendation to paint the entire Plaza curb
yellow.
ATTACHMENTS:
Plaza curb striping plans
Draft Transportation Commission minutes
Mike Gardiner Memo
Barbara Christensen email
Page 2 of 2
ASHLAND PLAZA STRIPING PLAN "A"
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ASHLAND PLAZA STRIPING PLAN "B"
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ASHLAND PLAZA STRIPING PLAN "C"
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ASHLAND TRANSPORTATION COMMISSION
MINUTES
MAY 23, 2013
These,minutes are pending approval by the Transportation Commission.
A. Plaza Parking
Staff Report
Commissioners were given additional handouts at the meeting which included an aerial photo of the Plaza (prior to
redesign); a second Plaza striping plan drawing; and a memo from former Transportation Commissioner, Mike
Gardiner.
Scott Fleury gave a brief overview of the Plaza parking, both prior and post Plaza redesign. He reminded the
Commission the previous Plaza configuration included a yellow painted curb that was used as a temporary loading
zone for truck deliveries. He noted vehicles are currently parking along the curb adjacent to the Plaza as it is no
longer painted yellow.
Mr. Fleury pointed out the Plaza redesign committee was in favor of painting the loading zone on the pavement as
illustrated in the Ashland Plaza Striping Plan #1 (provided in the Transportation Commission packet). He stated
several business owners were in favor of adding extra parking spaces along the Plaza as illustrated in the Ashland
Plaza Striping Plan #2 (handout provided at the meeting). He encouraged Commissioners to discuss options keeping
in mind the future Downtown Multi-Modal Parking and Circulation Study.
Commission Discussion
A question was asked regarding the lawfulness of the prior yellow painted curb configuration along the Plaza island
indicating a no parking zone, yet being used as a temporary loading zone. Officer MacLennan replied that Diamond
Parking and Ashland Police allow the temporary truck parking. It was noted the way the Plaza parking functioned in
the past (i.e. truck deliveries in the morning, temporary parking throughout the day for rafters, mountain bike clients,
Plaza events, Ashland Police enforcement in the evenings) seemed to work well.
Staff informed the Commission that streets surrounding the Plaza will be chip sealed and reslriped in the fall, creating
two additional parking spaces.
Commissioners discussed posting signage which led to a discussion on the amount of signs throughout the city
adding to the clutter.
Comments
A comment was made that the Plaza is also a public space used as a community gathering for music, artistic events,
etc. causing this area to be a critical loading zone (not just used for business deliveries).
It was implied that both visitors and residents recognize yellow painted curbs as a no parking zone and
Commissioners felt it would make sense to keep it standardized.
It was noted that allowing parking along the curb detracts from the Plaza improvements by closing off the open
space.
It was expressed that the decision seemed to be a trade-off between convenient parking and safety.
Concerns
Areas of concern surrounding the current configuration (without yellow painted curb) and use of the Plaza included:
• traffic backing up while drivers parallel pads,
• vehicles double parked while waiting for another vehicle to leave,
• poor visibility of pedestrians crossing due to cars parked too closely to the crosswalks,
• potential for drivers/passengers leaving their vehicles and crossing in an unpredictable manner (e.g.
passenger side exit into traffic; not using the crosswalks), and
• lack of emergency access for Police and Fire if vehicles are allowed to park along the curb.
Suoaestions (durino discussion)
A suggestion was made to enforce a no parking zone on N. Main St. prior to turning into the Plaza. Staff noted that
52 foot trucks rarely park in the Plaza because of the turn radius making this zone preferable for longer trucks.
Officer MacLennan concluded from a safety standpoint that he would recommend making this area a no parking
zone. He felt the next best thing would be to post signs. He added that temporary loading zone curb colors (white or
green) do not prevent cars from parking in those areas.
Commissioners Vieville /Anderson m/s to recommend painting the curb yellow around the entire Plaza, with
no signage, and with the understanding that enforcement occur as it has historically. Voice vote: all AYES.
Motion passed.
Mr. Fleury summarized the Commission concerns were safety related, specifically police and fire emergency access;
the potential for double parking; passengers opening doors into traffic; vehicle backing conflicts; pedestrians walking
in between cars; and drivers attempting to parallel pads which creates a narrow passing lane. In addition to safety,
the Commission recommendations were also based on circulation concerns.
Memo
5/23/13
To: Ashland Transportation Commission
From: Mike Gardiner
Re: Plaza Island Parking Analysis -Action Item A on your May 23, 2013 Agenda
I received a call from Mike Faught last week regarding truck parking in
Ashland. As some of you know I work for a local trucking company that makes
daily deliveries to most cities in Southern Oregon. There are several different
requirements for making in-town, ground deliveries: Time of day, size of delivery
vehicle, business hours of the consignee, etc. But above all the delivery company
needs reasonable access to the delivery addresses. The more difficult the delivery
the more it costs the delivery company and, generally speaking, the business
owner. Restrictive time of day deliveries or loading zones that are not
conveniently located may lead to increased labor costs and/or special equipment
needs which add to the costs of transportation.
I would encourage the commission to preserve the loading zone as
proposed in this item for the downtown Plaza Island. I would also encourage you
to look for additional options for truck parking around the downtown zone. The
faster a delivery driver can complete his delivery the quicker he will be on his way
to his next stop and downtown congestion will be minimized. As we say in the
business, "if you bought it, a truck brought it". Please do not overlook the
importance and necessity of truck deliveries to our downtown businesses.
If I can be of any help to the Transportation Commission or the Ashland
Public Works Department regarding future truck transportation concerns please
do not hesitate to contact me.
Best Regards,
Mike Gardiner
Scott Fleury
To: Mike Faught .
Subject: RE: Share of parking issues around Plaza
From: Barbara Christensen [mailto:christeb@ashland.or.usj
Sent: Thursday, June 06, 2013 3:26 PM
To., 'Mike Faught'
Subject: Share of parking issues around Plaza
Mike, sharing with again the problem we had this week with our Armored Car service, truck. This service picks up our
daily deposits everyday around the same time (11ish). When cars parked in the horizontal parking spots and along the
plaza it makes it impossible for this truck to maneuver through. This happened and they had do sit and wait (in the truck
because of security reasons) for someone to come and finally move their vehicle. In the meantime, there were
numerous vehicles backed up behind the truck who also could not move forward. Not a very safe situation for anyone.
Also, if you would allow my own comment about parking around the plaza ...I would much rather see a yellow painted
curb than all the cars that park all around the plaza. Even though I do understand that painting a yellow curb may take
away the "beauty" of the plaza, I do believe that the cars that block the view of the plaza is more disturbing as you can't
even see the plaza when the cars are parked all around it.
I am also concerned with safety issues as I ride a scooter to work and frequently have to make my way around the
plaza. With so many cars parked around the plaza it keeps me more on my toes (attention) to make sure that I am seen.
Thank youHH
Barbara Christensen
City Recorder/Treasurer
City of Ashland
Ashland OR 97520
(541) 488-5307
PUBLIC RECORDS LAW DISCLOSURE
This is a public document and is subject to the Oregon Public Records Law.
Messages to and from this email may be available to the public.
1
CITY OF
ASHLAND
Council Communication
June 18, 2013, Business Meeting
Resolution Closing the Youth Activity Levy Fund into the Parks and Recreation
Fund effective June 30, 2013
FROM:
Lee Tuneberg, Finance Director, Administrative Services Department tuneberl@ashland.or.us
SUMMARY
Oregon budget law (ORS 294.343) requires the City Council to pass a resolution when a fund is no
longer needed, detailing what will happen to any residual amounts held in the fund to be closed. This
resolution conforms to negotiations between Parks and the school district on disposition of any
remaining amounts.
BACKGROUND AND POLICY IMPLICATIONS:
The last renewal of the Youth Activity Levy was in 2003 with final property tax authority in 2008.
Since 2008 small amounts of uncollected taxes have been received and paid to the Ashland School
District. Based upon an agreement, Ashland Parks and Recreation paid a sum to the school district
representing the value of the fund balance and future receipts. The fund can now be closed into the
Parks general fund.
The biennial budget reflects the closure and the estimated ending balance of the Youth Activity Levy
Fund for June 30, 2013, is added to the working capital carryover for the Parks and Recreation Fund.
FISCAL IMPLICATIONS:
The residual amount transferred to the Ashland Parks and Recreation Fund is available for use.
STAFF RECOMMENDATION AND REQUESTED ACTION:
Staff recommends approval of the accompanying Resolution closing the Youth Activity Levy Fund.
SUGGESTED MOTIONS:
I move to approve a resolution titled, "Resolution Closing the Youth Activity Levy Fund into the
Ashland Parks and Recreation Fund Effective June 30, 2013."
ATTACHMENTS:
Resolution
Page 1 of I
~r,
RESOLUTION NO.
A RESOLUTION TO CLOSE THE YOUTH ACTIVITY LEVY FUND INTO
THE PARKS AND RECREATION FUND EFFECTIVE JUNE 30, 2013
THE CITY OF ASHLAND RESOLVES AS FOLLOWS:
The City of Ashland follows the Oregon Local Budget Laws ORS 294 in preparing its budget.
ORS 294.353 requires the governing body when closing a fund no longer necessary to determine
the disposition of any remaining funds.
SECTION 1. The Youth Activity levy Fund was established when the voters approved to tax
themselves to provide added support to the Ashland School District for extracurricular activities.
The fund provided for receipt of monies and coordination of programs by the Parks Commission
for which an agreed upon amount was kept to reimburse costs.
SECTION 2. The levy was renewed on a regular basis and the fund was continued as needed
through the budget process. The last renewal of the levy was in 2003, ending 2008. Since 2008
the fund has been used to collect prior year, unpaid taxes and to appropriate payment to the
school district. The Parks Commission and the school district have settled on payment of
$45,000 to close the fund representing the current balance and the value of future delinquent tax
receipts.
SECTION 3. With the ending of the levy in 2008 and the annual proceeds of delinquent taxes
being considered diminimis and the settlement of dissolution of all obligations, the fund is
deemed unnecessary and eligible for closure.
SECTION 4. With this resolution, Council closes the Youth Activity levy Fund and approves
transfer of existing residual amounts and future receipts to the Ashland Parks and Recreation
Fund for general use.
SECTION 5. This resolution takes effect upon signing by the Mayor.
This resolution was duly PASSED and ADOPTED this day of
2013, and takes effect June 30, 2013.
Barbara Christensen, City Recorder
SIGNED and APPROVED this day of 2013.
John Stromberg, Mayor
Reviewed as to form:
David Lohman, City Attorney
Page 1 of 1
CITY OF
ASHLAND
Council Communication
June 18, 2013, Business Meeting
Adoption of the 2013-15 Biennial Budget, including Second Reading of an
Ordinance Levying Taxes for the Period of July 1, 2013, to and including June 30,
2014
FROM:
Lee Tuneberg, Finance Director, Administrative Services Department, tuneberl@ashland.or.us
SUMMARY
Oregon budget law requires the City Council to hold a public hearing prior to adopting the budget for
the City of Ashland (including the Ashland Parks & Recreation Commission) for Biennium 2013-
2015. After the public hearing, Council will take action to adopt the budget, make appropriations,
certify it qualifies for and elects to receive state revenue sharing; and levy property taxes by ordinance.
BACKGROUND AND POLICY IMPLICATIONS:
Oregon law identifies the process by which public agencies develop, approve and adopt a budget. The
process uses a Citizen Budget Committee and open meetings to review the Proposed Budget and to
gain approval. The Budget Committee met four times and two grant subcommittees met two nights
this spring to review the Proposed Budget and allocations for the biennial budget covering 2013-2015.
On May 22, 2013, the Budget Committee approved the budget. The Council must take the actions
listed under "Suggested Motions" to adopt the biennium 2013-2015 budget.
This is the first biennial budget ever produced by the City. It provides appropriations and expenditure
authority for a two-year period. However, the Council must elect to levy taxes annually, although it
cannot levy an amount great than what has been approved by the Budget Committee in either year of
the biennium without going through a prescribed public process. This is also the first budget in
memory that does not record Parks and Recreation Fund revenue as "property tax." Instead, this
budget records all general property tax collections in the General Fund and shows the Parks Fund's
primary revenue source as a payment from the General Fund.
Also noteworthy in this approved budget are the following:
I . The budget includes $175,000 in each year of the biennium for the Ashland Forest Resiliency
project. This is shown in the Water Fund. A revenue stream has not been identified to offset
the expense so a reduction in fund balance is reflected.
2. The General Fund transfers to the Debt Service Fund are reduced by $956,176. Instead,
revenue from voter-approved tax levies are directly deposited in the Debt Service fund as
revised by staff.
3. Certain Public Works program and project work funded in FY 2012-2013 will not be
completed as projected due to extenuating circumstances, such as poor weather which has
delayed construction. Such delays, in effect, reduce expenditures this year, increasing the
Pagel of 3
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CITY OF
ASHLAND
corresponding carry forward into next year. As such, the budget proposed for adoption
recognizes a larger beginning fund balance for the biennium and an increase in 2013-2015
appropriations (re-budgeting for the incomplete work). This has no net impact between the two
budget periods. The attached memo supports:
a. $716,573 (net) in Street programs for improvements
b. $20,000 in Storm Drain programs for improvements
c. $411,500 in Water Fund programs for improvements
d. $584,605 in Wastewater Fund programs for improvements
Other changes may come forward from public input during the hearing and changes accepted by
Council should be addressed in the final budget adoption. The resolution to establish appropriations has
been constructed to reflect the action taken by the Budget Committee on May 22, 2013. Staff will be prepared
to address changes at the hearing.
Oregon budget law allows the elected body to increase expenditures by $5,000 ($10,000 for a
biennium) or 10% (whichever is greater) of any fund without further review and approval by the
Committee. Council cannot increase the tax rate without republishing the amended budget and a
second hearing before July 1.
Total changes to a fund beyond 10% also would require re-publishing the amended budget and holding
another public hearing prior to July 1. A summary memo is provided that identifies changes made to
the proposed budget to create the approved budget.
Council certifies that the City qualifies for subventions (revenues shared by the state) by resolution
each year. Additionally, Council annually adopts a resolution electing to receive an apportionment of
the Oregon Department of Administrative Services General Fund revenues derived from taxes imposed
as part of state revenue sharing. These are both necessary steps in the 2013-2015 budget process.
The operating property tax rate is calculated to remain unchanged at $4.1972 for a total of $10,519,347
from the permanent rate for the General Fund. The local option levy that is included for the Library
has Committee approval of $0.1921. This levy will generate $432,000 before discounts. Included as
well is voter-approved, tax supported debt of $299,970 to pay for 2005 bonded debt and $216,527 for
the 2011 bonded debt for Fire Station 42 levy.
The ordinance authorizing the tax levy rate is consistent with the Budget Committee's approved tax rates and
amounts for the first year (2013-2014) of the biennium. Taxes for the second year (2014-2015) of the biennium
will be considered by Council in the spring of 2014.
FISCAL IMPLICATIONS:
The Biennium 2013-15 is the City's fiscal plan for the coming two-year period. The total budget is
$202,124,365 and is up 1.8% over the prior two-year period. Without an adopted budget, the City has
no expenditure authority
STAFF RECOMMENDATION AND REQUESTED ACTION:
Staff recommends approval of the accompanying four Resolutions and the reading by title only of the
Ordinance.
Page 2 of 3
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CITY OF
ASHLAND
SUGGESTED MOTIONS:
I move to approve a resolution titled, "Resolution Adopting the 2013-2015 Biennial Budget and
Making Appropriations,"
And
I move to approve a resolution titled, "Resolution Certifying City Provides Sufficient Municipal
Services to Qualify for State Subventions,"
And
I move to approve a resolution titled, "A Resolution Declaring the City's Election to Receive State
Revenues,"
And
I move to approve second reading by title only of an ordinance titled, "An Ordinance Levying Taxes
for the Period of July 1, 2013 to and including June 30, 2014, Such Taxes in the Sum of $10,519,347
Upon All the Real and Personal Property Subject to Assessment and Levy Within the Corporate Limits
of the City of Ashland, Jackson County, Oregon" and move the ordinance on to second reading.
ATTACHMENTS:
1) Resolution adopting budget and making appropriations
2) Summary tables incorporated in Notice of Public Hearing to adopt the budget
3) Resolution certifying City qualifies for State Subventions
4) Resolution declaring City elects to receive State revenue
5) Certification of election to receive State Revenue
6) Ordinance to levy property taxes
7) Memo to Mayor and Council from Budget Officer
8) Biennium 2013-2015 Summary of Changes - Resources & Requirements
9) Public Works memo on capital projects adjustments
Page 3 of 3
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RESOLUTION 2013-
RESOLUTION ADOPTING THE BIENNIAL BUDGET AND MAKING
APPROPRIATIONS
The City of Ashland resolves that the 2013-2015 Biennial Budget, now on file in the office of the
City Recorder, is adopted. Summary tables from the notice of the public hearing are attached.
The amounts for the biennial budget year beginning July 1, 2013, and for the purposes shown
below are hereby appropriated as follows:
SECTION 1:
GENERALFUND
Administration Department $ 553,465
Administration Department - Library 812,000
Administration Department- Municipal Court 994,970
Administrative Services - Social Services Grants 257,688
Administrative Services - Economic & Cultural Grants 1,433,226
Administrative Services - Miscellaneous 610,208
Administrative Services - Band 120,390
Administrative Services - Parks Services 8,856,000
Police Department 12,391,656
Fire and Rescue Department 13,053,484
Public Works - Cemetery Division 704,551
Community Development - Planning Division 2,730,822
Community Development - Building Division 1,390,632
Transfers 192,824
Contingency 1,041,000
TOTAL GENERAL FUND 45,142,916
COMMUNITY DEVELOPMENT BLOCK GRANT FUND
Personal Services 61,100
Materials and Services 406,735
TOTAL CDBG FUND 467,835
RESERVE FUND
Inlerfund Loan 900,000
Transfers 190,000
TOTAL RESERVE FUND 1,090,000
STREET FUND
Public Works - Street Operations 7,628,710
Public Works - Street Operations Debt 341,750
Public Works - Storm Water Operations 1,247,230
Public Works - Storm Water Operations Debt 26,317
Public Works - Transportation SDC's 446,613
Public Works - Storm Water SDC's 80,600
Contingency 215,000
TOTAL STREET FUND 9,986,220
Page 1 of 4
AIRPORT FUND
Materials and Services 143,310
Capital Outlay 65,000
Debt Service 77,072
Interfund Loan 19,000
Contingency 10,000
TOTAL AIRPORT FUND 314,382
CAPITAL IMPROVEMENTS FUND
Public Works - Facilities 2,406,460
Administrative Services - Parks Open Space 3,929,000
Transfers 466,900
Contingency 200,000
TOTAL CAPITAL IMPROVEMENTS 7,002,360
DEBT SERVICE FUND
Debt Service 4,548,084
Interfund Loan 370,000
TOTAL DEBT SERVICE FUND 4,918,084
WATER FUND
Administration - Conservation Division 449,010
Fire - Forest Lands Management Division 887,265
Public Works - Water Supply 2,951,820
Public Works - Water Supply Debt 44,985
Public Works - Water Treatment 2,570,700
Public Works - Water Treatment Debt 467,427
Public Works - Water Distrbulion 8,570,680
Public Works - Water Distribution Debt 662,995
Public Works - Reimbursement SDC's -
Public Works - Improvement SDC's 282,750
Public Works - Debt SDC's 241,845
Debt Services -
Interfund loan 150,000
Contingency 403,000
TOTAL WATER FUND 17,682,477
WASTEWATER FUND
Public Works - Wastewater Collection 5,298,621
Public Works - Wastewater Collection Debt 151,075
Public Works - Wastewater Treatment 6,527,385
Public Works - Wastewater Treatment Debt 3,253,250
Public Works - Reimbursement SDC's 117,500
Public Works - Improvement SDC's 1,383,491
Debt Services 30,000
Contingency 440,000
TOTAL WASTEWATER FUND 17,201,322
Page 2 of 4
ELECTRIC FUND
Administration - Conservation Division 1,494,890
Electric - Supply 13,628,373
Electric - Distribution 13,398,521
Electric - Transmission 2,177,635
Debt Services 47,774
Contingency 923,000
TOTAL ELECTRIC FUND 31,670,193
TELECOMMUNICATIONS FUND
Personal Services 1,288,560
Materials and Services 2,667,283
Capital Outlay 308,000
Contingency 150,000
TOTAL TELECOMMUNICATIONS FUND 4,413,843
CENTRAL SERVICES FUND
Administration Department 3,015,362
IT - Computer Services Division 2,537,128
Administrative Services Department 4,084,194
City Recorder Division 708,330
Public Works - Administration and Engineering 3,362,420
Interfund Loan -
Contingency 104,000
TOTAL CENTRAL SERVICES FUND 13,811,434
INSURANCE SERVICES FUND
Personal Services 178,080
Materials and Services 1,446,500
Contingency 300,000
TOTAL INSURANCE SERVICES FUND 1,924,580
HEALTH BENEFITS FUND
Personal Services -
Maledals and Services 7,816,992
Interfund Loan 510,000
Contingency 500,000
TOTAL INSURANCE SERVICES FUND 8,826,992
EQUIPMENT FUND
Public Works - Maintenance 2,054,460
Public Works - Purchasing and Acquisition 3,113,000
Interfund Loan -
Contingency 156,000
TOTAL EQUIPMENT FUND 5,323,460
CEMETERY TRUST FUND
Transfers 10,600
TOTAL CEMETERY TRUST FUND 10,600
Page 3 of 4
PARKS AND RECREATION FUND
Parks Division 7,469,390
Recreation Division 2,547,830
Golf Division 1,012,880
Transfer 922,000
Contingency 100,000
TOTAL PARKS AND RECREATION FUND 12,052,100
YOUTH ACTIVITIES LEVY FUND - Closed 613012013
Materials and Services -
TOTAL YOUTH ACTIVITIES LEVY FUND -
PARKS CAPITAL IMPROVEMENTS FUND
Capital Outlay 4,851,000
TOTAL PARKS CAPITAL IMP. FUND 4,851,000
TOTAL APPROPRITATIONS, ALL FUNDS $ 186,689,798
TOTAL UNAPPROPRIATED AND RESERVE $ 15,434,567
AMOUNTS, ALL FUNDS
TOTAL ADOPTED BUDGET $ 202,124,365
SECTION 2. This resolution takes effect upon signing by the Mayor.
This resolution was duly PASSED and ADOPTED this day of June, 2013.
Barbara Christensen, City Recorder
SIGNED AND APPROVED this day of June, 2013.
John Stromberg, Mayor
Reviewed as to form:
David Lohman, City Attorney
Page 4 of 4
Last Year This Year Next Year
TOTAL OF ALL FUNDS Actual 2011-2012 Adopted 2012-2013 Biennial Approved 2013-2015
FINANCIAL SUMMARY - RESOURCES
Beginning Fund Balancei Working Capital $ 23,622,354 $ 24,873,472 $ 28,265,776
Fees, Licenses, Permits, Fines, Assessments & Other Service Charges 31,076,016 32,513,972 64,451,609
Federal, State & all Other Grants, Gifts, Allocations & Donations 3,450,632 8,433,178 10,108,357
Revenue from Bonds &Other Debt 3,060,434 8,336,930 9,495,500
Intedund Transfersllntemal Service Reimbursements 10,693,800 8,488,917 45,967,344
All Other Resources Except Property Taxes 11,028,281 10,488,577 21,672,967
Property Taxes Estimated to be Received 9,758,876 10,083,098 21,386,310
Total Resources $ 92,690,393 $ 103,218,144 $ 201,347,863
FINANCIAL SUMMARY - REQUIREMENTS BY OBJECT CLASSIFICATION
Personal Services $ 23,697,543 $ 26,158,408 $ 55,473,254
Materials and Services 29,036,630 34,236,111 82,082,898
Capital Outlay 5,359,064 18,350,085 28,885,070
Debt Service 4,576,034 4,513,787 9,892,574
Transfers 203,105 406,635 2,738,500
Other Financing Uses (Intedund Loan) 408,000 408,000 1,949,000
Contingencies - 2,060,000 4,542,000
Unappropriated Ending Fund Balance 29,410,017 17,085,118 15,784,567
Total Requirements $ 92,690,393 $ 103,218,144 $ 201,347,863
FINANCIAL SUMMARY-REQUIREMENTS AND FULL-TIME EQUIVALENT EMPLOYEES (FTE) BY ORGANIZATIONAL UNIT
NAME: Administration Department $ 2,102,339 $ 2,577,362 $ 7,367,471
FTE: 12.15 13.15 15.15
NAME: Information Technology Department $ 2,952,668 $ 3,184,835 $ 6,800,971
FTE: 15.50 14.50 14.50
NAME: Adminsitrative Services Department $ 3,767,642 $ 5,767,149 $ 29,312,119
FTE: 16.25 16.25 16.25
NAME: City Recorder $ 319,864 $ 324,681 $ 708,330
FTE: 2.00 2.00 2.00
NAME: Police Department $ 5,645,100 $ 5,794,103 $ 12,391,656
FTE: 36.30 36.30 36.75
NAME: Fire & Rescue Department $ 5,929,825 $ 9,680,564 $ 13,590,749
FTE: 34.75 34.75 34.00
NAME: Public Works Department $ 19,092,546 $ 29,645,743 $ 52,135,777
FTE: 58.50 60.05 5930
NAME: Community Development Department $ 1,91 $ 2,128,214 $ 4,589,289
FTE: 12.60 13.00 14.00
NAME: Electric Department $ 13,403,471 $ 15,877,397 $ 29,204,529
FTE: 20.25 20.75 17.25
NAME: Parks & Recreation $ 5,352,747 $ 6,013,810 $ 15,881,100
FTE: 43.80 43.80 43.80
NAME: Non-departmental $ 32,138,269 $ 22,224,286 $ 29,365,872
FTE: 0 0 0
Total Requirements $ 92,690.393 E 103,218,144 $ 201,347,863
Total Full-Time Equivalents 252.10 254.55 253.00
PROPERTY TAX LEVIES
Permanent Rate Limit $ 4,2865 $ 4.2865 $ 4.2865
Rate Levied $ 4.1973 $ 4.1972 $ 4.1972
Ashland Local Option Library Levy $ 0.1921 $ 0.1921 $ 0.1921
Levy for Bonded Debt Obligations $ 625,750 $ 518,876 $ 1,032,670
Estimated Debt Estimated Debt
Outstanding Authorized, Not trimmed
STATEMENT OF INDEBTEDNESS at July 1, 2013 at July 1, 2013
General Obligation Bonds $ 34,250,000
Revenue Bonds 3,210,824
Other 233,617
Total Indebtedness $ 37,694,441 $
G:\ftnanm\Administration\Budget\Notices12013-15\2013-2015 Official Big Notice Worksheet 5/28/2013
RESOLUTION 2013-
RESOLUTION CERTIFYING CITY PROVIDES SUFFICIENT
MUNICIPAL SERVICES TO QUALIFY FOR STATE SUBVENTIONS
RECITALS:
A. ORS 221.760 provides as follows:
Section 1. The officer responsible for disbursing fund to cities under ORS 323.455, 366.785 to
366.820 and 471.805 shall, in the case of a city located within a county having more than 100,000
inhabitants according to the most recent federal decennial census, disburse such funds only if the city
provides four or more of the following services:
1. Police Protection
2. Fire Protection
3. Street construction, maintenance, lighting
4. Sanitary Sewer
5. Storm Sewer
6. Planning, zoning and subdivision control
7. One or more utility services
B. City officials recognize the desirability of assisting the state officer responsible for determining
the eligibility of cities to receive such funds in accordance with 221.760.
Be it resolved, the City of Ashland hereby certifies that it provides the following municipal services
enumerated in ORS 221.760(1):
1. Police Protection
2. Fire Protection
3. Planning
4. Street construction, maintenance, lighting
5. Storm Sewer
6. Water
7. Sanitary Sewer
8. Electric Distribution
This resolution takes effect upon signing by the Mayor.
This resolution was duly PASSED and ADOPTED this day of June, 2013.
Barbara Christensen, City Recorder
SIGNED AND APPROVED this day of June, 2013.
John Stromberg, Mayor
Reviewed as to form:
David Lohman, City Attorney
Page 1 of 1
RESOLUTION 2013-
A RESOLUTION DECLARING THE CITY'S ELECTION
TO RECEIVE STATE REVENUES
RECITALS:
The City must annually adopt a resolution electing to receive an apportionment of the Oregon
Department of Administrative Services General Fund revenues derived from tax imposed on the
sale of liquor as part of State Revenue Sharing.
THE CITY OF ASHLAND RESOLVES AS FOLLOWS:
Pursuant to ORS 221.770, the City hereby elects to receive state revenues for fiscal year 2013-
2014
This resolution takes effect upon signing by the Mayor.
This resolution was duly PASSED and ADOPTED this day of June, 2013.
Barbara Christensen, City Recorder
SIGNED AND APPROVED this day of June, 2013.
John Stromberg, Mayor
Reviewed as to form:
David Lohman, City Attorney
Page 1 of 1
A RESOLUTION DECLARING THE CITY'S ELECTION
TO RECEIVE STATE REVENUES
I certify that a public hearing before the Budget Committee was held on May 22, 2013
and a public hearing before the City Council was held on June 4, 2013, giving citizens an
opportunity to comment on use of State Revenue Sharing.
Barbara Christensen, City Recorder
Page 1 of 1
ORDINANCE NO.
AN ORDINANCE LEVYING TAXES FOR THE PERIOD OF JULY 1, 2013
TO AND INCLUDING JUNE 30, 2014, SUCH TAXES IN THE SUM OF
$10,5199347 UPON ALL THE REAL AND PERSONAL PROPERTY
SUBJECT TO ASSESSMENT AND LEVY WITHIN THE CORPORATE
LIMITS OF THE CITY OF ASHLAND, JACKSON COUNTY, OREGON
THE PEOPLE OF THE CITY OF ASHLAND ORDAIN AS FOLLOWS:
Section 1. That the City Council of the City of Ashland hereby levies the taxes provided for in
the adopted budget in the permanent rate of $4.1972 per thousand an amount estimated to be
$9,570,850, voter authorized Local Option in the rate of $.1921 per thousand an amount
estimated to be $432,000 as well as $516,497 authorized for the repayment of General
Obligation Debt and that these taxes are hereby levied upon the assessed value for the fiscal year
starting July 1, 2013, on all taxable property within the City.
Section 2. That the City Council hereby declares that the taxes so levied are applicable to the
following funds:
Permanent Rate Local Option Bonded Debt Per $ 1,000
General Fund - Operations $ 9,570,850 4.1972
Ashland Library Levy $ 432,000 0.1921
2005 GO Bonds $ 299,970
2011 GO Bonds - Fire Station #2 216,527
__L_9,670,860 $ 432,000 $ 616,497
The foregoing ordinance was first read by title only in accordance with Article X,
Section 2(C) of the City Charter on the day of 2013,
and duly PASSED and ADOPTED this day of 12013.
Barbara M. Christensen, City Recorder
SIGNED and APPROVED this _ day of , 2013.
John Stromberg, Mayor
Reviewed as to form:
David H. Lohman, City Attorney
Page 1 of 1
CITY OF
ASHLAND
Memo
DATE: June 4, 2013
TO: Mayor and Council
FROM: Dave Kanner, Budget Officer
RE: FY 2013-2015 Budget Process - Summary of Changes
Below is a summary of proposed adjustments for this stage of the process:
1. Preliminary revisions to the Proposed Budget from staff:
a. The long-term portion of the budget anticipates the potential for renewal of some
portion of the inter-fund loan for self-insuring health care costs in the Health Benefits
Fund. The initial loan of $500,000 is budgeted for repayment within the biennium
and renewal of the loan is reflected in the next biennium. It is more appropriate to
budget the second, smaller loan, if needed, at the end of the 2013-2015 biennium.
The estimate, after repayment of the initial amount is $400,000 and has been reflected
in both the Reserve Fund and the Health Benefits Fund.
b. Repayment of a $150,000 inter-fund loan by the Water Fund to the Equipment Fund
was not input into the detail of the budget. The omission is corrected by decreasing
the Water Fund ending balance and appropriating the repayment. The Equipment
Fund is revised to show the added resource and a larger ending balance.
2. Committee accepted changes from staff and approved the following revisions to the budget:
a. Appropriate $100,000 as a transfer from the Reserve Fund to the General Fund to pay
for the Help Center. An appropriation of $100,000 is reflected in the General Fund,
Administration Services - Miscellaneous division to reflect the potential expenditure.
b. Appropriate $90,000 as a transfer from the Reserve Fund to the Central Service Fund
to pay for the computer operating system upgrade. An appropriation of $90,000 is
reflected in Central Services Fund, Information Technology Department to reflect the
potential expenditure.
c. Reduce appropriations for consultant work on the Downtown Plan by $35,000 in the
General Fund, Community Development - Planning Division.
ADMINISTRATION DEPARTMENT
Dave Kanner, City Administrator Tel: 541488-5300
20 East Main Street Fax: 541-552-2059
Ashland, Oregon 97520 TTY: 800-735.2900
v .ashland.orms
CITY OF
ASHLAND
Memo
3. Based upon discussion with the Committee, staff recommends the following adjustments in
the adoption of the budget by Council:
a. Reduce General Fund Transfers by $956,176 to reflect the direct deposit into the Debt
Service Fund of property taxes for voter-approved debt service relating to the 2005
and 2011 general obligation bonds. Doing so removes the need to transfer the like
amount. A similar change is reflected in the revenue reconciliation.
b. Appropriate $350,000 in the Water Fund, Fire Department - Forest Lands
Management Division for the Ashland Forest Resiliency program. Since no revenue
stream has been identified adding this appropriation decreases the Water Fund Ending
Fund Balance by a like amount.
4. Staff recommends further adjustments to the Approved Budget based upon a request from
the Public Works Department recognizing capital project costs that will not be incurred in FY
2012-2013 as estimated when preparing the proposed budget. The recommended changes
will increase the carry forward from 2012-2013 by $1,732,678 and increase appropriations in
the Street, Water and Wastewater funds in BN 2013-2015 by the same amount, not affecting
the ending fund balances projected for June 30, 2015.
Incorporating all the changes listed above results in an Adopted Budget that totals $202,124,365.
ADMINISTRATION DEPARTMENT
Dave Kanner, City Administrator Tel: 541-088-5300
20 East Main Street Fax: 541-552-2059
Ashland, Oregon 97520 TTY: 800-7352900
~ .ashlan l or.us
City of Ashland
Biennium 2013-2015 Summary of Changes
20132015 Stan 2013 2015 Cammblee W13 NIS Council 2013.2015
Proposed Revisions Revised Revisions Approved Revisions Adopted
GENERALFUND
AdndnistratiOn Deparrort 553,465 553,465 553,465 553,465
AdmiruGrabon Depabrent - Ubary 812,000 812,000 812,000 812,000
Adminstratm DepatrnenF Municipal Court 994,970 994,970 994,9]0 994,970
Administrative Services Social Services Grams 257,688 257,688 257,688 257,688
Admnionative Services- Ecomunc B Cultural Grants 1,433,226 1,V3,226 1,433,226 1,433,226
Administrative Services - Miscellaneous 222,483 287725 510,208 100,000 610,278 610,208
Administrative Services - Band 120,390 120,390 120,390 120,390
Administrative Services - Parks Sr ices 8,056,000 8,856,000 8,856,000 8,856000
Police DepaNrent 12,391,656 12,391,656 12,391,656 12,391,656
Fee and Rescue Depardent 13,053,484 13,053,484 13,053,484 1],053,484
Public Works -Cemetery Ei ison 704,551 704,551 704,551 704,551
Coninunity Development - Planning Dimon 2,765,822 2,765,822 135,000) 2,730,822 2,730,822
Community Development - Building Dimson 1,390,632 1,390,632 1,390,632 1,390,632
Transfers 1,149000 1,149,000 1,149,000 (956,176) 192824
Cone agency 1,041,000 1,041,000 1,041,000 1,D41,000
Ending Fund Balance 1,030,159 (287,725) 742,434 35,00D 777,434 777,434
TOTALGENERALFUND 46,776,526 - 46,A6,526 100,000 46,876,526 (956,176) 45,920,350
COMMUNITY DEVELOPMENT BLOCK GRANT FUND
Personal Services 61,100 61,100 61,100 81,100
Materials and Services 406,735 406,735 406735 406,735
Ending Fund Balance TOTAL COBG FUND 467,835 - 467,835 - 467,835 - 467,835
RESERVE FUND
Intedund Loan 500,000 400,000 900,000 900,000 900,000
Transfers - - 190,000 190,000 190,000
Ending Fund Balance 1,044,910 (400,000) 644,910 (190,000) 49,910 454,910
TOTAL RESERVE FUND 1,544,910 - 1,544,910 - 1,544,910 - 1,544,910
STREET FUND
Public Works - Street Operations 6,985,460 6,985,460 6,985,460 643,250 7,628,710
Public Works- Street Operators Debt 341,750 341,750 341,750 341,750
Public Works- Starm Wafer Operators 1,247,230 1,247,230 1,247,230 1,247,230
Public Works- Slprm Water Operatons Debt 26,317 26,317 26,317 26,317
Public Works- Transportation SDCs 373,290 373,290 373,290 73,323 446,613
Pudic Works - Storm Water SDCs 60.600 60,600 60,600 20000 80,600
Contingency 215,000 215,000 215,000 215,000
Ending Fund Balance 1,059,860 1,059,860 1,059,860 1,059,860
TOTAL STREET FUND 10,309,50 - 10,309507 - 10,309,507 736,573 11,046,080
AIRPORT FUND
Materials and Sersices 143,310 143,310 143,310 143,310
Capital Outlay 65,000 65,000 65,000 65,000
Debt Serke n,072 77,072 77,072 77,072
Irani Loan 19,000 19wo 19.000 19,000
Contngency 10,000 10,000 10,000 10,000
Ending Fund Balance 64,468 64,468 64,468 64,468
TOTAL AIRPORT FUND 378,850 - 378,850 - 378,850 - 378,850
CAPITAL NPROVEMEN7S FUND
Pudic Works - Factrtes 2,406,460 2,406,460 2,406,460 2,406,460
Adninislratve Barron; - Pads Open Space 3,929,000 3,929,000 3,929,000 3,929,000
Transfers 466,900 466,900 466,900 466,900
Contingency 200,000 200,11110 200,000 200,000
Ending Fund Bak. 1,890,308 1,890,308 1,890308 1,890,308
TOTAL CAPITAL IMPROVEMENTS 8,89$668 - 8,892,660 - 8,892.668 - 8,892,668
DEBT SERVICE FUND
Debt service 4,548,084 4,548,084 4,548,084 4,548,064
Intedund Loan 370,000 370,000 370,000 370,000
Ending Food Balance 606,593 606,593 606,593 606,593
TOTAL DEBT SERVICE FUND 5,524,677 - 5,524,677 - 5,524,6A - 5,524,677
GVinanceVkdministration\Council CommunicabonsUune 1Wune 18, 2013\[)mft'Appmprialions\Biennium 2013-2015 Summary of Changes-
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City of Ashland
Biennium 2013-2015 Summary of Changes
20138015 Suff 2013-2015 Untrained, 2013-MlS Council 20132015
Proposed Revisions Revised Revisions Approved Revisions Adapted
WATER FUND
Administration- Canservabon Division 449,010 449,010 449,010 449,010
Fire - Forest Lands Management Division 537,265 537,265 537,265 350,000 887,265
Pubic Woks - Water Supply 2,884,90 2,884,570 2,884,570 67,250 2,951,020
Public Works- Water Supply Debt 44,985 44,985 44,985 44,985
Public Works - Water Treabnem 2,494,200 2,494,200 2,494,200 76,500 2,570,700
Pualc Works-Water Treatment Debt 467,427 467,427 467,427 467,427
Public Works-Neva Disbibutlm 8,305,600 8,385,690 8,385,680 185,000 8,570,680
Public Works- Water DisbibNm Debt 662,995 662,995 662,995 662,995
Public Woks- Reimbursement SOCs - - - -
PublcWorks - Improvement SDCs 200,000 200,00 200,000 82,750 281,750
Publi Works Debt SDCs 241,845 241,845 241,845 241,845
Debt Services - - - -
Interfundloan - 150,000 150,000 150,000 150,000
Contingency 403,000 403,000 403,000 403,000
Ending Fund Balance 4,059,316 (150,000) 3,909,316 3,909,316 1350,0001 3,559,316
TOTAL WATER FUND 20,030,293 - 20,830,293 - 20,030,293 411,500 21,241,793
WASTEWATER FUND
Public Works- Wastewater Cokcdon 5,062,377 5,062,377 5,062,377 236,244 5,298,621
Public Works- Wastewater Collation Debt 151,075 151,075 151,075 151,075
Public Works- Wastewater Treabnent 6,201,385 6,201,385 6,201,385 326,000 6,527,385
Public Works- Wastewaly Treffineal Deal 3,253,250 3,253,250 3,253,250 3,253,250
Public Works- ReimbursareN SDCs 117,500 117,500 117,500 117,500
Pubic Works - Improvement SOCS 1,361,130 1,361,130 1,361,130 22,361 1,383,491
Debt Servies 30,000 30,000 30,000 30,000
Contingemy 440,000 440,000 440,000 440,000
Ending Fund Balance 2,305.611 2,305,611 2,305,611 2,305,611
TOTAL WASTEWATER FUND 18,922,328 - 18,922,328 - 18,922,328 584,605 19,506,933
ELECTRIC FUND
Administration -Conservation Division 1,494,890 1,494,890 1,494,090 1,494,890
Electric -Supply 13,628,373 13,628,373 13,628,373 11628,373
Electric - DisNWUan 13,398,521 13,398,521 13,398,521 13,398,521
Electric - Transmsson 2,177,635 2,177,635 2,177,635 2,177,635
Debt Services 47,P4 47,774 47,774 47,774
Contrngeay, 923,000 923,000 923,000 923,000
Ending Fund Balance 590.117 590,117 590,117 590,117
TOTAL ELECTRIC FUND 32250,310 - 32,260,310 32,260,310 - 32,260,310
TELECOMMUNICATIONS FUND
Persona Services 1,280,560 1,288,560 1,289,560 1,288,560
Materials and Services 2,667,203 2,667,283 2,667,283 2,667,283
Capital ouvid, 308,000 30000 308,000 300,000
Contingeny 150,000 150,000 150,000 150,000
Ending Fund Balance 30.968 30.960 30.960 30,968
TOTAL TELECOMMUNICATIONS FUND 4,444,811 - 4,444,811 - 4,444,811 - 4,444,811
CENTRAL SERVICES FUND
Administration Depatrrent 3,015,362 3,015,362 3,015,362 3,015,362
n- Co"uler Services Orison 2,447,128 2,97,128 90.000 2,537,128 2,537,128
Addrustratrie SerAces Oeparvaenl 4,084,194 4,084,194 4,004,194 4,064,194
City Recorder DIMsbn 700,330 708,330 708,330 708,330
Pubic Works- Administraion and Engineering 3,361,420 3,362420 3,362,420 3,362,420
Intafund Loan
Contingency 104,000 iD4,000 104,000 104,000
Ending Fund Balance 392031 392,031 392,031 392,031
TOTAL CENTRAL SERVICES FUND 14,113,465 - 14,113,465 90,000 14,203,465 - 14,203,465
INSURANCE SERVICES FUND
Personal Services 170,080 178,000 178,080 178,080
Materials and Servces 1,446,500 1,446,500 1,446,500 1,446,500
Contingency 300.000 300,00 300,000 300,000
Ending Fund Balance 429,287 429,287 429,287 429,287
TOTAL INSURANCE SERVICES FUND 2,353,867 2,353,857 - 2,353,867 - 2353,867
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City of Ashland
Biennium 2013-2015 Summary of Changes
2013 2015 SUN 2013-2015 Committee M13-415 Coach 20132015
Proposed Remords Revised Revisions Approved Revisions Adopted
HEALTH BENEFITS FUND
Persona Services - - -
Maledalsand Services 7,816,992 7,816,992 7,816,992 7,816,992
In@dund Loan 510,000 510,000 510,000 510,000
Contingency 500,000 500,000 500,000 500,000
Ending Fund Balance (313182) 401 86,718 86,718 86,718
TOTAL INSURANCE SERVICES FUND 0,513,710 400,000 0,913,710 - 8,913,710 - 8,913,710
EQUIPMENT FUND
Public Works - Maintenance 2.054.460 2.054,460 2.054,460 2,054,460
Public Wales- Purchasing and ArquLd6on 3,131,000 (18,000) 3,113,000 3,113,000 3,113,000
Intedund Loan
Contingency 156,000 156,000 156,000 156,000
Ending Fund Balance 1,112,781 168,000 1,280,781 1,280,781 1,280,781
TOTAL EQUIPMENT FUND 6,454,241 150,000 6,604,241 - 6,604,241 - 6604,241
CEMETERY TRUST FUND
Transfers 10,600 10.600 10,600 10,600
Ending Fund Baance 937,744 937.744 937.7M 937,744
TOTAL CEMETERY TRUST FUND 948,344 - 90,344 - 948,344 - 948,344
PARKS AND RECREATION FUND
Parks Divisim 7,469,390 7,469,390 7,469,390 7,469,390
Recreation Division 2,547,830 2,547,830 2,547,830 2,547,830
Golf Division 1,012,880 1,012,880 1,012,880 1,012,880
Transfer 922,000 922,000 922,000 922,000
Contingency 100.000 100.000 100.000 100.000
Ending Fund Balance 656,289 666,289 666,289 666189
TOTAL PARKS AND RECREATION FUND 12,718,389 - 12,718,389 - 12,718,389 - 12.718.389
YOUTH ACTIVITIES LEVY FUND
Materials and Services - - -
Ending Fund Doi
TOTAL YOUTH ACTIVITIES LEVY FUND - - - - - -
PARKS CAPITAL IMPROVEMENTS FUND
Combat Outlay 4,851,000 4,851,000 4,851,000 4,851,000
Ending Fund Baance 302,132 302,132 302.132 302,132
TOTAL PARKS CAPITAL MP. FUND 5.153.132 - 5,153,132 - 5,153,132 - 5,153,132
TOTAL BUDGET 40,007,863 550,000 201,157,863 190,000 41,347,863 776,502 201
Less Ending Fund Balance 16,209,292 (269,725) 15,939,567 (155,000) 15,784,567 (350,000) 15,434,567
Total Appropriations 184,398,571 819,725 185,218,296 345,000 185,563,296 1,126,502 186,689,798
Appropriate funds committed to parking improvements. $287725
Remove appropriations for the Conservation Vehicle. o18,000)
Recognize Self - Insurance Interfund Loan renewal d needed. $4001
(Only amount needed will be borrowed effective 613012015)
Recognize Interrund Loan repayment from Water to Equipment Fund. 31501000
$ 819,725
Appropriate Transfer from Reserve Fund to General and Central Service funds. $190.000
Appropriate expenditure in General Fund for Help Center. $100.000
Appropriate expenditure in Cenbal Services Fund, Inforlnsumn Technology for Operating system. $90.000
Remove Downtown Plan Study ($35.000)
$ 345,000
Appropriate Ashland Forest Resiliency project in Water Fund, reducing Ending Fund Balance. $3501000
To reflect reduced Property Tax revenue, offset by reduction of Transfers DUE in the General Fund caused by the
direct deposit of tax proceeds in the Debt Service Fund. Transfer no longer needed. (5956.176)
Delayed Public Works projects creating larger than projected carry over and requiring re-budgeting in the biennium. $1,734678
$ 1,126,502
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City of Ashland
Biennium 2013-2015 Summary of Changes
RESOURCE SUMMARY 2013.2015 Staff 2013-2015 Committee 2013-2015 Council 2013.2015
Proposed Revisions Revised Revisions Approved Revisions Adopted
Revenues:
Taxes $ 41,694,083 $ 41,694,083 $ 41,694,083 $ 41,694,083
Licenses and Permits 1,545,692 1,545,692 1,545,692 1,545,692
Intergovernmental Revenues 10,108,357 10,108,357 10,108,357 10,108,357
Charges for Services 102,694,761 102,694,761 102,694,761 102,694,761
Systems Development Charges 610,000 610,000 610,000 610,000
Fines and Forfeitures 339,000 339,000 339,000 339,000
Assessment Payments 272,000 272,000 272,000 272,000
Interest on Investments 339,700 339,700 339,700 339,700
Miscellaneous Revenues 1,295,494 1,295,494 1,295,494 1,295,494
Total Revenues 158,899,087 - 158,899,087 - 158,899,087 - 158,899,087
Budgetary Resources: -
Working Capital Carryover 28,265,776 28,265,776 28,265,776 1,732,678 29,998,454
Other Financing Sources 9,495,500 9,495,500 9,495,500 9,495,500
Interfund Loan 1,399,000 550,000 1,949,000 1,949,000 1,949,000
Operating Transfers In 2,548,500 2,548,500 190,000 2,738,500 (956,176) 1,782,324
Total Budgetary Resources 41,708,776 550,000 42,258,776 190,000 42,448,776 776,502 43,225,278
Total Resources S 200,607,863 S 550,000 $ 201,157,863 $ 190,000 $ 201,347,863 S 776,502 $ 202,124,365
Recognize Self - Insurance Interfund Loan renewal if needed. $460,000
(Only re-borrow what is needed at 613012015)
Recognize lnterfund Loan repayment. $150,000
(From Water Fund to Equipment Fund)
S 550,000
Recognize Transfer from Reserve Fund to General Fund for Help Center. $100,000
Recognize Transfer from Reserve Fund to Central Services for IT Operating system. $90,000
$ 190,000
To reflect reduced Transfers In for the Debt Service Fund from the General Fund caused by the
direct deposit of tax proceeds in the Debt Service Fund. Transfer no longer needed. ($956,176)
Delayed Public Works projects creating larger than projected carry over and requiring re-budgeting in the biennium. $1,732,678
$ 776,502
G:\finance\Administration\Council CommunicationsWune 13Wune 18, 2013\Draft\Appropriations\3iennium 2013-2015 Summary of
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OF
Memo CITY
ASHHL LAN D
Date: May 29, 2013
From: Scott A. Fleury, Engineering Services Manager
To: Lee Tuneberg, Finance Director
Re: May FY13 Capital Project Adjustments
As requested, the Public Works Department has reevaluated the end-of-year capital project cost
estimates and subsequent adjustments to the FY13 capital budget.
The format used for this exercise provides a side by side comparison of the capital budget costs
outlined in the current proposed FYI 3 budget and the proposed adjustments by fund.
In summary, there are six (6) capital project adjustments to the street fund budget. To that end,
please add the following FY2013Street Operation, Street SDC and Storm Drain SDC projects to the
FY2014 capital project list. In addition, please increase the FY2014 Street Operations cash
carryover by $736,573 (ODOT grant for the Hersey Street Railroad crossing $405,400, remaining
Street Operations projects $237,850, Street SDCs $73,323 and Strom Drain SDCs $20,000).
Details of the proposed adjustments are as follows:
FY13 February FY13 May Difference
Street Operations Projection Adjustment carryover
260.08.12.00.704200 Contracted Projects
Railroad Crossing Improvement; Hersey
St. * $ 575,000 $ 169,600 $ 405,400
Slur Seal per PMS $ 100,000 $ 0.00 $ 100,000
High School Beacon $ 50,000 $ 0.00 $ 50,000
Miscellaneous Concrete Repairs $ 6,000 $ 45,000 $ 41,000
New Sidewalk Improvements TSP $ 116 250 $ 0.00 $ 116,250
Audible Pedestrian Signals $ 23,000 $ 10,400 $ 12,600
TOTAL $ 845,250 $ 225,000 $ 643,250
*Total project budget was $430,000 of which $365,500 is grant and $64,500 is SDC. Have spent
$199,513.29 to date, $169,586.30 from Street and $29,926.99 from SDC (project accounting
worksheet including for reference).
ENGINEERING DIVISION Tel: 5411488-5347
20 Main Street Fax'. 5411488-8006
Ashland OR 97520 TTY: 80035-2900
w ashland.or.us
FY13 February FY13 May Difference
Street SDC Projection Adjustment car over
260.08.35.00.704200 Contracted Projects
Railroad Crossing Improvement; Hersey
St. see above $ 34,573 $ 0.00 $ 34,573
New Sidewalk Improvements TSP $ 38,750 $ 0.00 $ 38,750
TOTAL $ 73,323 $ 0.00 $ 73,323
There is one (1) capital project adjustments to the Storm Drain SDC Fund.
FY13 February FY13 May Difference
Storm Drain SDC Projection Adjustment (carryover)
260.08.34.00.704200 Contracted Projects
Storm Drain Master Plan $ 29,000 $ 9,000 $ 20,000
In summary, there are eleven (11) capital project adjustments to the Water Fund. To that end,
please add the following FY2013 Water Supply, Water Treatment and Storage, Water Distribution,
and Water SDC projects to the FY 2014 capital project list. In addition, please increase the FY2014
Water Fund cash carryover by $411,500 (Water Supply $67,250, Water Treatment and Storage
$76,500, Water Distribution $185,000 and Water SDC $82,750). Details of the proposed
adjustments are as follows:
FY13 February FY13 May Difference
Water Supply Projection Adjustment carr over
670.08.15.00.704200 Contracted Projects
FERC Security and Telemetry
Improvements $ 26,250 $ 15,000 $ 11,250
High Ca aci Well Testing $ 50,000 $ 10,000 $ 40,000
Ashland Creek W. Fork Bride $ 3,000 $ 2,000 $ 1,000
Sediment TMDL in Reeder Reservoir $ 15,000 $ 0.00 $ 15,000
TOTAL $ 94,250 $ 27,000 $ 67,250
ENGINEERING DIVISION Tel: 541148&5347
20 Main Street Fax: 5411488-2008
Ashland OR 97520 TTY: 800/135-2900
w ashland.or.us
FY13 February FY13 May Difference
Water Treatment and Storage Projection Adjustment (ca over
670.08.19.00.704200 Contracted Projects
Raw Water Bypass Measurement $ 25,000 $ 0.00 $ 25,000
Scada Radio Frequency Compliance $ 45,000 $ 10,000 $ 35,000
Final CT Disinfection Improvements $ 85,000 S 68,500 $ 16,500
TOTAL $ 155,000 $ 78,5800 $ 76,500
FY13 February FY13 May Difference
Water Distribution Projection Adjustment Carr over
670.08.18.00.704200 Contracted Projects
Park Estates Pump Station Alternatives $ 140,000 $ 0.00 $ 140,000
Ivy Lane-Morton to West end of Ivy
Lane $ 35,000 $ 0.00 $ 35,000
I Lane-S. Mountain $ 10,000 $ 0.00 $ 10,000
TOTAL $ 185,000 $ 0.00 $ 185,000
FY13 February FY13 May Difference
Water SDC Projection Adjustment carr over
670.08.38.00.704200 Contracted Projects
FERC Security and Telemetry
Improvements $ 8,750 $ 0.00 $ 8,750
Reeder Reservoir Stud Implementation $ 22,500 $ 2,500 $ 20,000
Ashland Creek W. Fork Bride $ 91000 $ 0.00 $ 9,000
Sediment TMDL in Reeder Reservoir $ 45,000 $ 0.00 $ 45,000
TOTAL $ 85,250 $ 2,500 $ 82,750
ENGINEERING DIVISION Tel: 5411488-5347
20 E. Main Street Fax: 5411488-6006 ~~A
Ashland OR 97520 TTY: 8001735-2900
w .ashland.or.us
In summary, there are nine (9) capital project adjustments in the Wastewater fund. To that end,
please add the following FY2013 Wastewater Treatment Plant, Collections and SDC projects to the
FY 2014 capital project list. In addition, please increase the FY2014 Wastewater cash carryover by
$584,605 (Wastewater Treatment Plant $326,000, Collections $236,244, and SDC $22,361).
Details of the proposed adjustments are as follows:
FY13 February FY13 May Difference
Wastewater Treatment Plant Projection Adjustment carr over
675.08.19.00.704200 Contracted
Projects
Outfall Relocation $ 20,000 $ 0.00 $ 20,000
Shading $ 246,000 $ 0.00 $ 246,000
Backup Portable Pump $ 60,000 $ 0.00 $ 60,000
TOTAL $ 326,000 $ 0.00 $ 326,000
FY13 February FY13 May Difference
Wastewater Collections Projcction Adjustment (carryover)
675.08.17.00.704200 Contracted
Projects
Ashland Creek Trunkline
Rehabilitation $ 426,400 $ 211,855 $ 214,545
Bear Creek Parallel Trunkline $ 7,488 $ 0.00 $ 7,488
15" Mountain Ave. Mainline $ 1,770 $ 0.00 $ 1,770
24" Oak St. Trunkline $ 680 $ 0.00 $ 680
15" A St. Mainline $ 9,396 $ 0.00 $ 9,396
12" Railroad Mainline $ 2,365 $ 0.00 $ 2,365
TOTAL $ 448,099 $ 211,855 $ 236,244
ENGINEERING DIVISION Tel: 5411488-5347
20 Main Street Fax: 5411488-8008
Ashland OR 97520 TTY: 800/735-2900
~ ashland.or.us
FY13 February FY13 May Difference
Wastewater SDC Projection Adjustment carryover
675.08.38.00.704200 Contracted
Projects
Bear Creek Parallel Trunkline $ 17,472 $ 0.00 $ 17,472
15" Mountain Ave. Mainline $ 590 $ 0.00 $ 590
24" Oak St. Trunkline $ 120 $ 0.00 $ 120
15" A St. Mainline $ 1,044 $ 0.00 $ 1,044
12" Railroad Mainline $ 3,135 $ 0.00 $ 3,135
TOTAL $ 22,361 $ 0.00 $ 22,361
All other projects previously entered in with carryover amounts are tracking correctly at this time.
ENGINEERING DIVISION Tel: 5411488-5347
20 Main Street r3C: 5411488-8008
Ashland OR 97520 TTY: 8001735-2900
w ashland.orus
CITY OF
ASHLAND
Council Communication
June 18, 2013, Business Meeting
Report from the Homelessness Steering Committee on the Thursday Night Winter
Shelter and Discussion of Plans for Future Winter Shelter
FROM:
Linda Reid, Housing Program Specialist, Planning, reidl@ashland.or.us
Dave Kanner, city administrator, dave.kanner@ashland.or.us
SUMMARY
A report from the ad hoc Homelessness Steering Committee (HSC) providing an overview of the
Thursday night winter shelter use at Pioneer Hall was requested by council at the January 2, 2013,
regular meeting. A follow up meeting with the faith community, shelter organizers and volunteers was
facilitated by the HSC on April 29°i to gather data on shelter use, to determine what worked, what did
not, and whether to continue providing temporary winter shelter for next winter.
BACKGROUND AND POLICY IMPLICATIONS:
At a regular council meeting held on December 18, 2012 representatives from Temple Emek Shalom
and the Unitarian Universalist Fellowship approached the council about providing space to serve as a
temporary weekly homeless shelter. The two faith groups were partnering to provide volunteers for
the shelter but did not have a space to host another shelter night and wanted to collaborate with the
City to add a third regular shelter night a week within Ashland. At a special meeting held on January
2, 2013, the Council directed staff to draft a resolution (Resolution 2013-01) authorizing the City to
provide a city owned building to be used as a temporary winter shelter one night a week through April
2013. Details on the number of shelter users are contained in the HSC minutes dated April 29, 2013
(attached).
In addition, Councilor Voisin requested a study session discussion of the possibility of offering City
support for a winter shelter for the homeless next winter. Because a report on this past winter's shelter
program had been scheduled for your June 18 business meeting, this discussion has been added to this
agenda item. Council can provide direction to staff or defer the discussion to a later date.
FISCAL IMPLICATIONS:
N/A
STAFF RECOMMENDATION AND REQUESTED ACTION:
This item has been placed on the agenda for information and discussion only. Council may, at its
discretion, provide direction to staff regarding city support for a winter shelter this coming winter.
SUGGESTED MOTION:
N/A
Page I of 2
Ir,
CITY OF
ASHLAND
ATTACHMENTS:
Resolution 2013-01
Resolution 2013-04
Minutes from the Regular Homelessness Steering Committee meeting-April 29, 2013
Page 2 of 2
~r,
RESOLUTION NO.2013-0 1*
A RESOLUTION AUTHORIZING THE CITY OF ASHLAND TO
PROVIDE A CITY BUILDING FOR A WINTER SHELTER ONE NIGHT
PER WEEK THROUGH APRIL, 2013
RECITALS:
A. Ashland provides for emergency shelter housing in extreme weather through Resolution No.
2007-11. The resolution provides terms and conditions and policies for doing so when
temperatures drop to 20 degrees or below.
B. Rogue Valley Unitarian Universalist Fellowship (RVUUF) and Temple Emek Shalom
(Temple) have proposed to partner with the City of Ashland to provide shelter for community
members at a City building one night per week from January through April, 2013, regardless
of the temperature.
C. The proposal includes RVUUF and the Temple providing trained volunteers to staff, manage
and clean the shelter.
D. The City is willing to provide a building one night a week on a temporary basis to
accommodate the proposal in accordance with the provisions below.
THE CITY OF ASHLAND RESOLVES AS FOLLOWS:
SECTION 1. Provision of a Shelter.
Ashland will provide shelter one night per week. under the terms and conditions set forth herein.
SECTION 2. Terms and Conditions.
a. This is a temporary solution for the period January through April, 2013.
b. Prior to staffing a City-owned facility, volunteers must sign a waiver releasing the City
from liability for any personal injuries to them.
c. The shelter will be staffed by volunteers from RVUUF and Temple who are certified to
staff an overnight shelter. RVUUF and Temple must provide to the Parks and Recreation
Department written assurance that every volunteer who will staff the shelter is certified to
have completed appropriate training on the emergency plan, mental health plan and
emergency communications for the shelter and has passed criminal background checks.
d. Each night of operation of the shelter, at least one male volunteer and one female
volunteer will staff the shelter from 8:00 p.m. to 8:00 a.m. An additional male volunteer
will be required when more than 10 male guests are present. More volunteers may be
required by the City depending on the building to be used. If the minimum number or
qualified volunteers are not available for the entire time, the shelter will not be opened
that night.
e. Shelter occupancy will be limited to 25 guests on a first come, first serve basis.
f. Shelter will open at approximately 7:30 p.m. and close the following morning at 8:00
a.m. Doors will be locked at 10:00 p.m. with no re-entry for any that leave.
g. City insurance requires separate sleeping space be designated for single men, women and
families. Appropriate signage must be displayed that warns against children being left
alone. Buildings must have separate restrooms for men and women.
h. Ashland Parks & Recreation will identify the building to be used and provide access.
The priority from an operational and safety perspective is Pioneer Hall, the Community
I
Center and the Grove, in that order.
i. No showers or food service will be made available during the hours of operation.
.SECTION 3. Shelter Policies.
Operation of the shelter shall, to the greatest extent feasible, comply with the following
guidelines:
a. Shelter services must be provided with dignity, care, and concern for the individuals
involved.
b. The buildings used as a shelter will comply with City, County and State Building, Fire
and Health Codes, unless exemptions have been obtained from the appropriate agencies,
and must be maintained in a safe and sanitary condition at all times.
c. Upon entering the shelter facility each night, each guest must sign in, and sign an
agreement committing to comply with shelter rules, absolving the City and volunteers of
any responsibility for the security of the guest's personal property, releasing the City and
volunteers from all claims of liability for property damage or personal injury arising from
operation of the shelter or use of the City's building and certifying that he or she is
eighteen years of age, or older.
d. No cooking. Kitchen facilities are to be secured and access, is prohibited.
e. No drugs, alcohol, weapons or pets will be allowed in the shelter property at any time,
f No disorderly conduct will be tolerated.
g. No threatening or abusive language will be tolerated.
h. No excessive noise will be tolerated, e.g. loud radios, telephone conversations, etc.
L Smoking will be restricted to the outdoors in designated areas.
j. All guests should maintain their own areas and belongings in an orderly condition.
k. If a volunteer/staff member accepts any item from a guest for safe keeping at least one
other volunteer/staff member will witness the transaction.
1. Failure to comply with shelter policies may disqualify a guest(s) from future stays.
m. The check-in/check-out process shall be maintained by the volunteers sufficient to ensure
a control of the premises and exiting by guests at 7:30 a.m. to allow cleaning before
closure at 8:00 a.m.
SECTION 4. This resolution takes effect upon signing by the Mayor.
This olution was duly PASSED and ADOPTED this day of January, 2013, and takes
eff upon signing by $ iMayor.
Barbara Christensen, City Recorder
SIGNED and APPROVED this 0 day of January, 2013.
qs> 47
Jo Stromberg, Mayor
Re ' wed as to form:
vid H. Lohm ity Attorney
RESOLUTION NO.2013-D
A RESOLUTION SETTING FORTH POLICIES AND CONDITIONS
UNDER WHICH ASHLAND WILL PROVIDE EXTREME WEATHER
RELATED EMERGENCY SHELTER HOUSING AND REPEALING
RESOLUTION NO. 2007-11
RECITALS:
A. Ashland is located in an area that has four distinct seasons, and the winter season can have
weather extremes that can be hazardous to persons without adequate shelter.
B. The City of Ashland desires to set forth the conditions under which it will provide emergency
shelter housing and the policies related to those staffing or utilizing such emergency shelter.
THE CITY OF ASHLAND RESOLVES AS FOLLOWS:
SECTION 1. Provision of Emergency Shelter.
Ashland will provide emergency shelter under the terms and conditions set forth herein during
times of extreme weather conditions. For purposes herein, weather conditions shall be considered
extreme when outside temperatures are 20° F or below or a combination of weather conditions,
in the discretion of the City Administrator, make conditions hazardous to human life without
adequate shelter.
SECTION 2. Terms and Conditions.
1) In the event of the need for an emergency shelter during extreme weather, an available city-
owned building such as the Grove or Pioneer Hall may be used. Previously booked groups in
those locations may be subject to cancellation.
2) The shelter will be staffed by volunteers from nonprofit organizations or other organizations
in the business of providing for the needs of persons. The city's insurance company requires
organizations providing volunteers to provide a letter to the City of Ashland stating that all
shelter volunteers have received appropriate training to staff a shelter and have passed criminal
background checks.
3) Shelter(s) will open at 8:00 p.m. Doors will be locked at 9:00 p.m. Guests may leave the
shelter but not re-enter after 9:00 p.m. Guests arriving at the shelter after 9:00 p.m. will not be
admitted unless brought to the shelter by a police officer. Guests must vacate the shelter no later
than 8:00 a.m. the following morning.
4) Shelters must have separate restrooms for men and women and separate sleeping spaces for
single men, for single women and for families. Children must not be left alone in the shelter, and
signage must be conspicuously displayed to remind guests and volunteers of this requirement.
Resolution No. 2013- Page I of 3
5) The shelter must contain an emergency box with a first aid kit. Shelter volunteers should bring
their own cell phones in case of emergency.
SECTION 3. Emergency Shelter Activation.
Provisions for emergency shelter will be activated as follows:
1) When the City Administrator or designee determines that weather conditions are or are likely
to become "extreme," he/she will contact the City's CERT Coordinator.
2) The CERT Coordinator will contact the Parks and Recreation to determine which facility or
facilities will be used as an emergency shelter.
3) The CERT Coordinator will contact designated representatives from volunteer organizations
to arrange for staff volunteers at the shelter.
4) Volunteers and guests are responsible for following the same cleaning requirements as other
groups.
SECTION 4. Emergency Shelter Policies.
Operation of the emergency shelters shall, to the greatest extent feasible, comply with the
following policy guidelines:
1) Shelter services must be provided with dignity, care, and concern for the individuals involved.
2) The buildings used as shelter must be maintained in a safe and sanitary condition at all times
and must comply with City, County and State Building, Fire and Health Codes, unless
exemptions have been obtained from the appropriate agencies..
3) In all Shelters, there should be adequate separation of families and singles, and adequate
separation of single women.
4) No drugs, alcohol, or weapons will be allowed in shelter property at any time.
5) No disorderly conduct will be tolerated.
6) No threatening or abusive language will be tolerated.
7) No excessive noise will be tolerated, e.g. loud radios etc.
8) Smoking will be restricted to the outdoors in designated areas.
9) Guests should maintain their own areas in an orderly condition and may be assigned other
responsibilities or tasks at the shelter.
Resolution No. 2013- Page 2 of 3
SECTION 5. Dogs
Dogs may be permitted in an emergency shelter under the following circumstances:
1) Shelter volunteers must designate a specific area in the shelter for dogs. The floor of such
area must be covered with thick plastic.
2) Dogs must remain in crates while in the shelter. Crates will not be provided, stored, repaired
or cleaned by the City of Ashland and must be removed from the shelter when it is vacated.
3) If taken outside for biological needs, dogs must be leashed.
4) Shelter volunteers are to devise and follow procedures to keep dogs away from each other and
other guests as they are being housed for the night and as they exit in the morning.
5) Shelter volunteers must be responsible for cleaning and sanitizing any areas soiled by a dog or
dogs. Such cleaning is to be done to the satisfaction of City facilities maintenance staff.
6) Dogs that become threatening to others or are otherwise unmanageable will be required to
leave the shelter.
7) Shelter volunteers must notify Jackson County Animal Control in the event a dog bite breaks
the skin of an emergency shelter guest or volunteer.
SECTION 6. Resolution No. 2007-11 is hereby repealed.
SECTION 7. This resolution takes effect upon signing by the Mayor.
This resolution was duly PASSED and ADOPTED this day of
2013, takes effect upon signing by the Mayor.
Barbara Christensen, City Recorder
SIGNED. and APPROVED this day of 2012.
o Stromberg, Mayor
Red we as to form:
J
David I-1. man, City Attorney
Resolution No. 2013- Page 3 of 3
Approved Minutes
April 29, 2013
Ad-Hoc Homelessness Steering Committee
Ashland Library
4:00 - 6:00 p.m.
Attendance
Ayars, Parker, Saldana, O'Bryon, Sohl, Hopkins-Powell, Lewis, Rohde, Reid (Staff), Marsh
(Council)
Absent
None
Guests
Winter shelter program coordinators and volunteers
Agenda Item 41: Call to Order
Hopkins-Powell called the meeting to order at 4:10 p.m.
Agenda Item #2: Approval of Minutes
Saldana/Parker m/s to approve the minutes as presented, Voice Vote-Motion passed one
abstentions due to absence.
Agenda Item #3: Welcome and Introductions:
The Winter Shelter Coordinators and Volunteers introduced themselves.
Agenda Item #4: Winter Shelter:
a. Debrief from this year's shelter efforts-Reports/numbers:
Ruth Coulthard reported on the Presbyterian Church Winter shelter program (Monday
night shelter): This year the Presbyterian Shelter volunteers hosted 26 nights of shelter
(there was one more shelter night before the end of April; the night of the meeting so it
would be 27 in total). Twenty-two regular shelter nights and five emergency shelter
nights (one of which was held at the Grove). The shelter hosted 362 guests, which was
approximately 50 people less than last year. Coulthard was concerned that opening the
other two shelters would deplete the pool of available volunteers but that was not the
case.
Russ Otte reported on the Trinity Episcopal shelter program (Wednesday night shelter):
Trinity offered 22 nights of shelter, hosting 283 guests (235 Men, 48 women and 37
dogs.) Trinity had 19 different volunteer hosts. Otte reported that the volunteer list filled
up quickly; noting that 14 of the volunteers were Trinity members and 5 were community
members. Otte stated that the biggest surprise for him was the amount of donated food
that appeared at the shelter; from volunteers, community businesses and from the guests
themselves. He learned that some guests just come to socialize and do not stay the night.
Trinity has board games and the guests enjoy playing the games, it seemed to calm some
guests who may have been agitated by being indoors or around so many other people.
Many volunteers commented that the lighting at Trinity helped to set a calm and peaceful
environment and also allowed those who wanted to go right to sleep a place for that while
still allowing others enough light to play games and socialize. Otte reported that this
initial winter shelter program at Trinity has been a wonderful experience and that he will
Page 1 of 5
be presenting these numbers to the leadership group to gain approval to operate the
seasonal shelter again next year.
John Wieczorek reported on the Pioneer Hall (Thursday night) Shelter Program which is
a partnership between the Universal Unitarian Church, Temple Emek Shalom and the
City: Pioneer hall started a little later than the others so there were only 16 shelter nights
that hosted 208 guests. On average the shelter hosted approximately 13 guests a night.
No dogs were allowed in the shelter. The Unitarian Universalist Church partnered with
Temple Emek Shalom who provided breakfast burritos and fruit to help get people up and
moving in the morning. Wieczorek also learned that the guests come for a sense of
community, whether it is derived from a sense of safety or to get warm. Wieczorek
expressed appreciation for the partnership with the City for a space to hold the shelter;
Wieczorek felt that Pioneer hall was a good space for that purpose. Wieczorek stated that
he hoped that the Pioneer Hall shelter program can continue next year, he felt that the
Universal Unitarian church would be willing to continue and hopes that Emek and the
City will want to as well. Wieczorek also thanked the Committee members for all of the
work they did to get the shelter programs together for the winter.
Councilor Voisin asked if there were any issues at Trinity and Presbyterian with pets.
Trinity reported that they had zero issues with dogs; dogs entered on leashes and would
be taken off leash once inside then would either go to their usual spot and lie down or
stay with their owners. They had two potty accidents. Presbyterian reported that they
have always allowed dogs in the shelters since they started offering a no frills shelter in
2007 and have never had an incident. Most of the dogs owned by homeless people are
better behaved than housed people's dogs because they are always in public.
Hopkins-Powell stated that she felt the biggest issue to be the lack of shower and laundry
facilities. By the end of the season, the lack of shower and laundry facilities was
becoming all too apparent in a confined space for a long period of time. One volunteer
commented that he thought some people were taking advantage of the access to hot
running water at the shelter facilities by sponge bathing in the bathrooms.
b. Good Stories
One volunteer commented on how he was impressed by the community of volunteers and
the support from the community. He liked the trust and simplicity of the process and
how well the shelter worked. It seemed to him that before people volunteer they think of
all of the problems and issues that could come up, but when you volunteer you see how
simply and easily the shelter comes together, how relaxed the atmosphere is and that
problems just don't arise. When he volunteered he felt compelled to bring food and
approached some of the local restaurants about getting some food donations and was
amazed at how eager and supportive the businesses were of the shelter program. He was
overwhelmed by the food donations.
Another volunteer commented that the guests have pride to, just thinner skin and
sometimes the less experienced volunteers are not aware of that.
All of the shelter coordinators commented on how there were no police calls from any of
the shelters.
Page 2 of 5
Parker asked about the need for food. All of the coordinators agreed that there is always
plenty of food and that the food is really appreciated after the 20`h of the month when
guests' food stamp accounts start running low. One of the coordinators stated that the
guests really appreciate the higher nutrition foods and when the weather is really cold
having something warm to eat is really valuable.
One audience member asked "was it hard to staff the shelters with the one male, one
female volunteer a night rule?" Otte stated that Trinity only had one night were there
were two women signed up to volunteer, one of them felt a little uncomfortable and
commented about it to him loudly enough that the guests could hear. He said that
immediately several male guests approached the volunteers and stated that they would
make sure nothing happened to them. The volunteers were reassured and everything was
fine.
Another audience member asked whether coordinators and volunteers have seen an
increase in the population. Coulthard stated that over the course of this season the
population did not seem to grow, that you see the same core group of guests with the
occasional new face, maybe someone who is traveling through. Coulthard stated that in
prior years there was a smaller core group of guests, that this winter was milder than in
previous winters so that may have been a factor as well. Another coordinator stated that
there is better information now out in the community about the shelters rather than having
to put out flyers about the shelter the day of, especially with the regularity of the shelter
nights. One audience member commented that he wondered about whether the shelters
would be a draw for homeless outside of the Ashland area, but reported that he too saw a
core group of guests at Pioneer and did not see an influx of guests from other areas.
Wieczorek stated that his numbers did not show an increase in guests from other
communities. Similarly, a volunteer at the Presbyterian shelter who also works with
homeless populations in Medford stated that he tried to persuade some of the Medford
homeless to come to the shelters in Ashland and they were not receptive of the idea.
Otte reported that over the course of this season Trinity saw two guests, a male and a
female, get into permanent housing. The male approached him one night and asked him
if they might have an iron that he could use to press the wrinkles out of his clothes
because he had ajob interview in the morning. They did come up with an iron and made
sure that the man was able to have enough time to use it the next morning before it was
time to close the shelter. The next week the man reported that he got the job and a couple
weeks later he came back to let the volunteers know that with the help of St. Vincent De
Paul he was able to get into permanent housing. Similarly a female guest was eventually
about to get into housing though not in Ashland because she couldn't find something
local that she could afford.
One volunteer who has been volunteering at Presbyterian for several years but was not
able to volunteer as much this year shared how she has run into shelter guests on the
street who asked her if she was okay since they have not been seeing her at the shelter
lately.
One volunteer commented that she volunteered for one shelter night this season and
found the experience to be very rewarding. She felt very welcomed by the guests, and
enjoyed the conversations. She really felt that people were honoring each other's space.
Page 3 of 5
c. Concerns:
• Otte stated that the volunteer list needed to get out into the community more.
Wider communication was needed to solicit volunteers either through the City's
utility mailer or through the offering volunteer trainings again next year.
• The back ground checks were an issue for the Pioneer Hall volunteers. The APD
background checks were very expensive in comparison to other organizations
background checks and there was a lack of communication between APD and the
State. Some volunteers received other people's background checks in the mail
which were incorrectly addressed, and the number of background checks that
APD could do at no cost to the volunteers was very limited. Two questions that
were asked were; how long is a background check good for, and can the process
be streamlined and made less expensive. Reid will look into it. Hopkins-Powell
commented that the Parks department does free background checks for the
listening post volunteers. Parker stated that at the Ashland School District she
would get background checks for a reduced rate for non-profits, but the results
come back to the sender (the non-profit).
• Dorita from the Methodist Church stated that this year the Church has seen a rise
in the incidents of people sleeping on their property overnight whereas in prior
years they have had no instances where people were spending the night on church
property. Trinity reported that they too have had guests sleeping on church
property on non-shelter nights. Wieczorek had a theory about these incidents
stating that Ashland Christian Fellowship (ACF) has recently completed some
landscape work which included removing some bushes along the Creek and he
was told that in past years ACF has had several incidents of homeless individuals
sleeping in the bushes and on the ACF property, however this year they didn't
have one incident of homeless individuals sleeping on their property.
• One Coordinator stated that there are a few people who are sleeping legally in
their cars in the church parking lot on shelter nights stating that some people
prefer their own space. The coordinator reiterated the need for a legal place for
these individuals to park on non-shelter nights with access to bathroom and
garbage facilities; stating that the proposal to offer an overnight parking program
at the police station would be perfect for this population. One shelter coordinator
stated that there are some negative impacts to every church that offers services to
this population; that the neighborhoods around the churches may not be open to
the impacts of an overnight parking program.
• One coordinator commented that one of the problems with the higher numbers of
regular shelter guests and the food is that there is less time to visit with the guests
and get to know them. Others commented that having three volunteers, one to
help with the food at least at the beginning, was really helpful.
d. Best Practices-What could be done differently next
It was suggested that a column for a third volunteer, a food prep volunteer get added to
the volunteer signup sheet.
Schedule trainings for next year, the trainings were helpful, but they should start earlier
and at mid-season
Earlier background checks.
Earlier sign-up, broader promotion
Utility mailer, post on City website with a link to Google does
Page 4 of 5
Agenda item # 5:Next Steps:
• Committee members added a goal of establishing one more regular shelter night for next
season.
• Outreach to elected and appointed officials- Councilor Marsh invited volunteers to
compile and share any stories that they had of their experiences and send them to the staff
liaison, Linda Reid.
• All three coordinators and their sites are hoping to continue their respective programs
next winter.
• See if the City will grant some space for an additional shelter night next year.
Item Not on the Agenda: Agenda for the Joint Housing Commission Homelessness Steering
Committee Meeting
• Update on vet court.
• Councilor Marsh would like to look at the merger
• It was suggested that at the joint meeting the two groups discuss:
o Willingness to work together
o Individual Commission/Committee Goals
o Shared Goals
o Education about one another's Committee/Commissions
o Set a schedule with targeted goals for merging the two entities
Adjourn-6:00
Next meeting: May 8, 2013 4:00-6:00 P.M.
Ashland Library
Respectfully Submitted by Linda Reid, Housing Program Specialist
Page 5 of 5
CITY OF
ASHLAND
Council Communication
June 18, 2013, Business Meeting
Grant award for Help Center services in Ashland
FROM:
Dave Kanner, City Administrator, kannerd@ashland.or.us
SUMMARY
The Council has received two applications for grant funding from non-profit organizations to provide
"Help Center" services in Ashland. A Help Center would provide services to citizens in need, either
directly or via information and referral. Applications have been received from ACCESS, a Medford-
based non-profit and the federally designated community action agency that has been providing
services to low-income individuals in the Rogue Valley since 1976, and from Options for Homeless
Residents of Ashland (OHRA), an Ashland-based organization that incorporated as a non-profit in
2012. The Council will review and discuss the applications at its study session on June 17. Grant
award to one of the applicants, if the Council so chooses, can be done via Council motion at this
business meeting.
BACKGROUND AND POLICY IMPLICATIONS:
At its study session on April 1, 2013, the Council directed staff to prepare a grant application for the
purpose of soliciting interest from a social service provider who would establish a Help Center for
those in need, including the homeless and those at risk of becoming homeless in Ashland. The
application proposed by staff offers $50,000 a year for two years to a qualified non-profit to cover
operational costs associated with such a program. The applications would be judged on the following
four criteria, each equally weighted: 1. Organizational stability and solvency; 2. Demonstrated history
of providing similar services; 3.Extent to which the proposal meets grant objectives; and 4. Ability to
work cooperatively with other area non-profits in area of interest.
The funding offered in the grant application is $50,000 a year for two years, with the successful
grantee expected to make the center self-sustaining after that initial two-year period. Applicants were
asked to provide financial information about their organizations and to respond to six questions
intended to elicit detailed information about the organization's history, experience in providing similar
services, plans for sustaining the resource center beyond the grant period and performance
measurement. The application proposes a list of "desired services" that could be provided in a Help
Center but does not require any particular menu of services.. Instead,'Applicants were asked to provide
a description of services they would provide.
FISCAL IMPLICATIONS:
Approx. $50,000/yr. for two years. Funds were appropriated for this purpose by the Budget
Committee in the recently completed budget approval process.
Page 1 of 2
Ir,
CITY OF
ASHLAND
STAFF RECOMMENDATION AND REQUESTED ACTION:
N/A
SUGGESTED MOTIONS:
I move to award grant funding in the amount of $ to to provide
Help Center services as described in their application to the City of Ashland dated May 24, 2013, and I
further move to direct staff to draft and execute a grant agreement with
ATTACHMENTS:
None
Page 2 of 2
Mr,
CITY OF
ASHLAND
Council Communication
June 18, 2013, Business Meeting
Clarification of Mt. Ashland Association Agreement
FROM:
David H. Lohman, City Attorney, Iohmand@ashland.or.us
SUMMARY
Council is asked to approve an addendum to the City's agreement with Mt. Ashland Association to
clarify certain obligations set forth in that agreement.
BACKGROUND AND POLICY IMPLICATIONS:
At the March 19, 2013 regular business meeting of the Ashland City Council, members questioned
whether the agreement between Mt. Ashland Association ("MAA") and the City entered into
October 25, 2011 ("Agreement") obligated MAA to (1) present to the City in advance detailed plans
for any future phases of the Mt. Ashland ski area expansion and (2) demonstrate in advance its ability
to fully pay for the subject expansion. At the March 19, 2013 meeting, General Manager Kim Clark
expressed the view that the Agreement already included those requirements and agreed to ask the
MAA board to consider a written clarification of the Agreement to remove any possible doubt about
the applicability of these requirements to subsequent phases of the Mt. Ashland Ski Area expansion
efforts.
Council directed staff to work with Mr. Clark toward such a written clarification ("Addendum"). The
resulting proposed Addendum is attached. It is acceptable to MAA.
FISCAL IMPLICATIONS:
Not applicable.
STAFF RECOMMENDATION AND REQUESTED ACTION:
Approve the Addendum as presented.
SUGGESTED MOTIONS:
• I move that Council approve the proposed Addendum to the agreement between the Mt. Ashland
Association and the City of Ashland.
• I move that Council direct staff to seek MAA agreement to the following'inodifications to the
proposed Addendum....
ATTACHMENTS:
Agreement dated October 25, 2011
Proposed Addendum
Page 1 of I
r,
AGREEMENT
WHEREAS, the City of Ashland, as lessor ("the City"), and the Mt. Ashland Association, as
lessee ("the MAX'), on or about July 9, 1992, entered into the Mt. Ashland Ski Area Lease ("the
Lease") a copy of which is attached hereto and marked as Exhibit "I
WHEREAS, the City desires to surrender to the United States Department of Agriculture Forest
Service Special Use Permit ("the Permit") as described in the Lease if a comparable permit is issued to
MAA, and the MAA desires to have the Permit or a comparable permit issued to it;
WHEREAS, the City is the owner of certain improvements in and on that certain real property
located on Mt. Ashland in Jackson County, Oregon, which is described in and is subject to the Permit
("the Permit Property");
WHEREAS, the City is the owner of certain personal property, fixtures, furnishings, inventory
and items of equipment used in connection with the operation of the Mt. Ashland Ski Area and/or
located on the Permit Property including but not limited those items described in the Lease and
identified in Exhibit "B" to the Lease (the "Equipment"); and
WHEREAS, the City has determined that it would improve MAA's ability to provide winter
recreation to the Rogue Valley, which is beneficial to the economy of the region if MAA became the
holder of the Permit and the owner of the property; and
WHEREAS, the City has further determined that it would reduce the potential legal and financial
liability of the City to convey the Permit and property to MAA; and
WHEREAS, the City has determined that conveying the Permit Property and Equipment to the
MAA would further the public interest and the MAA desires to receive the Permit Property and the
Equipment to use in the operation of the Mt. Ashland Ski Area;
Based on the foregoing and the mutual promises and covenants contained herein, the City and
the MAA shall as soon thereafter as practicable accomplish the following:
1. The City will surrender the Permit to the Forest Service, and the MAA will apply for
issuance of the Permit. The City agrees to assist reasonably the MAA in the process of issuing the
Permit or a comparable permit to the MAA.
2, The City shall convey whatever interest it has, or by rights should have, in and to the
Permit Property and the Equipment to the MAA by execution of a bill of sale for personal property and a
statutory quitclaim deed for real property.
3. Upon issuance of the Permit or a comparable permit to the MAA, the provisions of the
Lease shall have no further force or effect whatsoever, except that MAA will remain responsible for any
amounts the City is required to pay pursuant to the Permit as a result of the City's surrender of the
Permit.
Page I of 4
4. The parties further agree that:
a) The City shall have the right annually to appoint one person to serve as a non-
voting liaison to the Board of Directors of the MAA. The City's liaison will be provided with all
information provided to directors, except that the City's liaison will not participate in personnel or legal
matters.
b) MAA will provide the City with copies of all architectural, engineering,
construction and logging plans, including without limitation any related environmental impact studies,
relating to any improvements contemplated by MAA within the Permit Property, now or in the future.
MAA will deliver such plans to the City no less than thirty (30) days prior to the commencement of any
construction, earth movement or logging. Within 30 days of receiving the plans from the MAA, the City
may but is not required to conduct a technical review of MAA's plans with respect to its impact on
water quality, including without limitation erosion, sedimentation, stormwater, revegetation, watershed
restoration, wetlands, and spill control. MAA agrees to confer with the City in good faith on any
matters raised in a technical review relating to water quality. The City of Ashland may appoint a
representative to provide daily on-site monitoring and inspection during any earth movement, logging or
construction, and MAA agrees to provide access to the City's representative. MAA and the City will
confer with the USDA Forest Service and any affected regulatory agencies if issues are identified during
construction as ones that will affect water quality, erosion, sedimentation, and spill control.
C) MAA agrees to comply with any obligations imposed with respect to
sedimentation in Reeder Reservoir in the July 2007 Total Daily Maximum Load (TMDL) document
prepared by the Oregon Department of Environmental Quality to meet the requirements of Section
303(d) of the 1972 Federal Clean Water Act.
d) The Permit or a comparable permit will require MAA to maintain a "Restoration
Amount," which shall mean and refer to the maintenance of available funds or assets by the MAA to
cover area restoration in the unlikely event of the ski area closure. MAA agrees to increase the amount
it maintains as the Restoration Amount on July 15 of every year by a percentage equal to the percentage
increase of the US Department of Labor: Consumer Price Index, All Urban Consumers (CPI-U), U.S.
City Average, CPI - All Items ("standard reference base period" 1982-84 = 100) in the previous twelve
(12) calendar months. MAA further agrees that it shall at all times maintain the Restoration Amount (as
increased pursuant to this paragraph) in unencumbered funds or assets, i.e., readily transferable assets
subject to no lien. MAA shall ensure that any security interest in its assets that it has granted or may in
the future grant excludes the funds maintained for the Restoration Amount.
e) The MAA agrees that it will not proceed with any logging, earth movement, or
construction activities related to the portion of the expansion identified as Phase 1 until MAA has
received a combination of cash contributions, binding financial commitments, and performance bonding
necessary to cover the entire cost of the Phase 1 improvements. The final details of the projects included
in Phase I will be defined by permits issued by the USDA Forest Service, but Phase I can generally be
described as the Ski Run Settlement Sale, a chairlift with new lower intermediate and novice runs, a
warming ditional parking spaces, the widening of several existing runs, and 23 watershed
restoration projects.
Net-r - u
I0-a4 -It
Page 2 of 4
f) The MAA agrees not to amend its articles of incorporation, without the express
written consent of the City, in any way that would impair its current provision that, in the event the
MAA dissolves, all of its assets which remain after MAA's creditor claims and other obligations are
satisfied shall be distributed to the City.
g) The MAA agrees that in the event it dissolves, that none of its assets shall be
distributed to a director, officer or other private person or private entity.
h) MAA agrees that it will not, without the express written consent of the City,
which consent shall not be unreasonably withheld: (1) transfer or convey to another person or entity the
Permit or the comparable permit issued to MAA as contemplated in this Agreement; or (2) enter into an
agreement with any other person or entity whereby the rights and obligations under the Permit or the
comparable permit issued to MAA as contemplated in this Agreement would be assumed by any other
person or entity.
i) MAA will reimburse the City for the City's reasonable attorney fees and any
other out-of-pocket expenses up to $7,500 incurred in connection with the negotiation and performance
of this Agreement through the date the Forest Service issues the Permit or a comparable permit to MAA
as contemplated in this Agreement or declines to issue such a permit. The City will provide MAA with
a complete accounting of its attorney fees and out-of-pocket expenses within thirty (30) days after the
Forest Service issues the Permit or a comparable permit to MAA as contemplated in this Agreement or
declines to issue such a permit. MAA will pay the amount owed under this paragraph within ten (10)
business days after the City delivers its accounting of those fees and expenses.
5. This Agreement is conditioned on the Forest Service issuing to MAA the Permit or a
comparable permit and, with the exception of Paragraphs 3 and 4(i), shall be of no force or effect if that
condition is not met on or before December 31, 2012.
6. Miscellaneous:
a) There are no oral agreements or representations between the parties hereto which
affect this Agreement, and this Agreement supersedes and cancels any and all previous negotiations,
arrangements, warranties, representations and understandings, if any, between the parties.
b) The paragraph headings set forth in this Agreement are set forth for convenience
purposes only, and do not in any way define, limit or construe the contents of this Agreement.
C) If any provision of this Agreement shall be determined to be void by any court of
competent jurisdiction, then that determination shall not affect any other provisions of this Agreement,
and all such other provisions shall remain in full force and effect.
d) It is the intention of the parties that if any provision of this Agreement is capable
of two constructions, only one of which would render the provision valid, then the provision shall have
the meaning which renders it valid.
Page 3 of 4
e) If suit or action is instituted in connection with any controversy arising out of this
Agreement, the prevailing party in that suit or action or any appeal there from shall be entitled to
recover, in addition to any other relief, the sum which the court may judge to be reasonable attorney
fees.
f) Any notice required or permitted under this Agreement shall be deemed to have
been given and delivered when personally delivered or when deposited in the United States mail, as
certified mail, postage prepaid, and addressed to the last-known address of the party being provided with
the notice.
g) The MAA may not assign its interest in this Agreement to any third party without
the express written consent of the City. This agreement shall inure to the benefit of and shall be binding
upon the City and any permitted successors and assigns of MAA.
h) This Agreement is being executed in two counterparts, each of which shall be an
original, and both of which shall constitute a single instrument, when signed by both of the parties.
i) Waiver by either party of strict performance of any of the provisions of this
Agreement shall not be a waiver of, and shall not prejudice the party's right to subsequently require
strict performance of, the same provision or any other provision.
j) The consent or approval of either party to any act by the other party of a nature
requiring consent or approval shall not be deemed to waive or render unnecessary the consent to or
approval of any subsequent similar act.
k) This Agreement shall be governed and performed in accordance with the laws of
the state of Oregon.
1) In the event of a dispute pertaining to this Agreement, the parties agree to attempt
to negotiate in good faith an acceptable resolution prior to commencing litigation. If a resolution cannot
be negotiated, then the parties agree to submit the dispute to voluntary non-binding mediation before
commencing litigation. Each of the parties hereby irrevocably submits to the jurisdiction of the courts
of Jackson County, Oregon, and agrees that any legal proceedings with respect to this Agreement shall
be filed and hc4 in the appropriate court in Jackson County, Oregon.~J~
Date: O Date: Oct ` as / go//
MT. ASHLAND ASSOcIATION - LESSEE CITY OF ASHLAND, OREGON - LESSOR
By:
n v
Title: / /JIWI/ itle:
Page 4 of 4
ADDENDUM TO AGREEMENT
BETWEEN MT. ASHLAND ASSOCIATION AND CITY OF ASHLAND
Date: June 2013
Parties: Mt. Ashland Association ("MAA")
and
City of Ashland ("City")
Recitals
A. MAA and City are parties to an October 25, 2011 agreement ("Agreement") pursuant to which City
surrendered' its United States Department of Agriculture Forest Set-vice Special Use Permit to the Forest
Service and conveyed its interest in the Permit Property and Equipment to MAA.
B. MAA and City desire to clarify the Agreement.
Aereements
Now, therefore, in consideration of the rmutual.covenants contained herein, the parties agree as follows:
1. Paragraph 4 of the Agreement is clarified by addition of the following commitments at the end of
subparagraph (e) following the words "watershed restoration projects":
"Before undertaking any logging, earth movement, or construction activities related to
expansion of the Mt. Ashland Ski Area subsequent to Phase 1, for each such phase, MAA
will
(1) Provide to the Forest Service and the City detailed plans for the activities
comprising the subject phase;
(2) Obtain all required permits for the activities comprising the subject phase; and
(3) Substantiate by means of a Forest Service financial ability determination, or other
means acceptable to the Forest Service, that sufficient financial resources are available to
pay for completion of the activities comprising the subject phase."
2. Except as clarified by this Addendum, the Agreement is ratified and affirmed by the parties.
The parties have executed this Addendum as of the date set forth above.
Mt. Ashland Association City of Ashland
By: By:
John Stromberg, Mayor
Title:
CITY OF
ASHLAND
Council Communication
June 18, 2013, Business Meeting
Resolution Authorizing the Establishment and Governance of a Self-Insured
Health Benefit Program
FROM:
Dave Kanner, City Administrator, dave.kanner@ashland.or.us
Tina Gray, Human Resource Manager, grayt@ashland.or.us
SUMMARY
The City of Ashland, like most large employers, purchases health insurance for its employees, and
employees help cover the cost of health insurance through premium contributions, deductibles and co-
pays. The City Council first began discussing the idea of switching to a self-funded health benefit
plan about two years ago. Based on our claims experience and projected increases in premiums for
purchased health insurance, we have determined that the potential exists for substantial savings by
converting to a self-funded benefits plan at this time. Although the benefits do not change in a self-
insurance plan, the City saves money by virtue of lower overhead costs and the absence of a profit. A
dedicated health benefits fund, as required by law, has been created in the 2013-15 budget and is
funded at current expenditure levels. Had the City remained fully insured with its current provider,
premiums would have increased by 10% on July 1, costing the City about $400,000. In order to create
a self-insurance plan, the City Council must adopt a resolution authorizing its establishment and
governance, and adopt a plan document.
BACKGROUND AND POLICY IMPLICATIONS:
For more than 25 years, Ashland was part of the City County Insurance Benefit Trust (CIS), as are
many cities and counties in Oregon. When CIS premiums began increasing at rates the City
considered unsustainable, the City left the trust and bid out its insurance needs, ultimately purchasing
insurance through PacificSource. At the same time, the Council asked staff to explore the feasibility of
converting to a self-funded benefits plan. Having had the opportunity to monitor claims experience for
two years, staff is confident that moving to self-insurance is an appropriate course for the City. In a
self-insurance plan, the self-insured entity establishes a separate account from which it directly pays
medical, dental and vision claims, rather than paying a premium to a health insurance company that
pays those claims. Claims management and payment is handled by a contracted third party
administrator (TPA) and the self nsured entity purchases stop-loss insurance to protect the City from
catastrophic individual claims as well as aggregate stop-loss to insulate the city from the risk of
multiple large claims in one year. Stop-loss insurance is not required in order to be self-insured but it
is considered a prudent practice. Locally, Ashland Community Hospital, the Ashland School District
and Jackson County managers are also self-insured.
The City meets all the legal requirements in the state of Oregon to self-fund our health benefits
program. Staff has worked with our health benefits consultant, J.L. Jones & Associates, to bid the
Page I of 2
11FAI,
CITY OF
ASHLAND
City's TPA and reinsurance contracts and as a result of that process will contract with PacificSource to
be our TPA and reinsurer. Contracting with PacificSource also offers the advantage of a seamless
transition in terms of claims management.
All insurance, whether purchased or self-funded, is governed by a plan document. In the City's case,
our existing plan document with PacificSource will become the City of Ashland Employee Health
Benefits Plan Document.
The City has established an Employee Health Benefit Advisory Committee (EHBAC) which will act as
a self-directed employee team with representatives from each employee group and bargaining unit. The
EHBAC will make recommendations to management regarding any changes to the employee health
plan. Due to union contracts, the City has little flexibility in terms of changes to our plan for the next
two years. However, becoming self-insured for health benefits will give the city more ownership and
control over our plan. We will be able to make changes based on utilization, rather than passively
accepting changes dictated by health insurance companies for profit motives. Recommendations of the
EHBAC will be included annually in a recommendation to the City Council when the Council adopts
the plan document.
FISCAL IMPLICATIONS:
Becoming self-insured requires that the City establish a dedicated Health Insurance Fund that will be
used to pay claims as they are incurred. The fund is budgeted at slightly more than $3.9 million in
each year of the coming biennium. This includes anticipated claims costs, third-party administration
fees and appropriate stop loss coverage. Claims experience is extremely unpredictable and the costs of
reinsurance can also fluctuate from year to year. The amount budgeted represents our, J.L. Jones' and
PacificSource's best judgment as to expected costs. Had the City stayed fully insured with
PacificSource, our FY ' 14 health insurance premium would have been about $4.38 million.
The City's loss ratio has hovered around 80% over the past two years. If this trend continues, the City
of Ashland will be able to retain the remaining 20% in our health insurance fund and bring some
stability to the funding of health benefits. Any surplus in the health benefits fund must remain in the
fund and could be used to help reduce the charges to City departments for personnel costs.
STAFF RECOMMENDATION AND REQUESTED ACTION:
Staff recommends that approval of a self-funded health benefits plan for the City of Ashland.
SUGGESTED MOTIONS:
I move approval of a Resolution Authorizing the Establishment and Governance of a Self-Insured
Health Benefit Program.
ATTACHMENTS:
Resolution
Resolution Exhibit A: City of Ashland Group Plan
Resolution Exhibit B: Parks Group Plan
Resolution Exhibit C: Duties and Responsibilities of EBAC
Page 2 of 2
RESOLUTION NO. 2013-
A RESOLUTION AUTHORIZING THE ESTABLISHMENT AND
GOVERNANCE OF A SELF-INSURED HEALTH BENEFIT PROGRAM
RECITALS:
A. The City of Ashland has a vested interest in providing health benefits to its employees,
retirees and eligible dependents.
B. The City meets all the legal requirements of the state of Oregon to self-fund its health
benefit program.
C. The City has retained a third-party administrator to process health benefits claims
D. The City has secured the appropriate reinsurance to protect the City from catastrophic
individual claims as well as aggregate stop loss insurance to insulate the city from the
risk of multiple large claims in one year.
E. The City has established a restricted Health Benefits Fund and will pre-fund the account
at appropriate levels to pay claims beginning July 1, 2013.
THE CITY OF ASHLAND RESOLVES AS FOLLOWS:
SECTION 1.
The City Council authorizes a change from a fully-insured health benefits plan, to a self-funded
health benefits plan beginning July 1, 2013.
SECTION 2.
The benefits offered by the City of Ashland Benefits Plan and the City of Ashland - Parks
Benefit Plan shall be those described in the plan documents, which are attached as exhibits A and
B, and which is hereby approved by the City Council.
SECTION 3.
The City Council hereby establishes an Employee Health Benefits Advisory Committee
(EHBAC) which will act as a self-directed employee team with representatives from each
employee group and bargaining unit. An administrative policy delineating the duties of the
EHBAC is attached as Exhibit C and is hereby approved by the City Council. The EHBAC will
make recommendations for modification of the employee health plan. Recommendations of the
EHBAC will be forwarded annually to the City Council for inclusion in the plan document.
SECTION 4.
The City Administrator is designated as the Plan Administrator for all City of Ashland Employee
Benefits Plan.
SECTION 5.
This resolution takes effect upon signing by the Mayor.
Page I of 2
This resolution was duly PASSED and ADOPTED this day of , 2013, and
takes effect upon signing by the Mayor.
Barbara Christensen, City Recorder
SIGNED and APPROVED this day of , 2013.
John Stromberg, Mayor
Reviewed as to form:
David H. Lohman, City Attorney
Page 2 of 2
Exhibit'A'
I~
C I T Y OF
-ASHLAND
City of Ashland
Group No.: G0032482
Preferred 90+200 VAR GF 0812
Effective: July 1, 2013 '
Third Party Administrative Services Provided By:
Aiw~
PaciticSource
HEALTH PLANS
SPD 07130ty of Ashland SingleSource Self-Insured
Exhibit 'A'
SingleSource Self-Insured 2
INTRODUCTION
Welcome to your City of Ashland (also referred to as 'the employer' or 'employee) group health plan. Your
employer offers this coverage to help you and your family members stay well, and to protect you in case
of illness or injury. Your plan includes a wide range of benefits and services, and PacificSource hopes
you will take the time to become familiar with them.
Your employer, who is also the Plan Sponsor, has prepared this document to help you understand how
your plan works and how to use it. This document summarizes the benefits provided under the Preferred
90+200 VAR GF 0812 Plan (referred to as 'the plan' or 'this plan' throughout this document). Please read
it carefully and thoroughly. Your benefits are affected by certain limitations and conditions, which require
you to be a wise consumer of health services and to use only those services you need. Also, benefits are
not provided for certain kinds of treatments or services, even if your health care provider recommends
them.
The plan is a self-insured medical plan intended to meet the requirements of Sections 105(b), 105(h), and
106 of the Internal Revenue Code so that the portion of the cost of coverage paid by your Plan Sponsor,
and any benefits received by you through this plan, are not taxable income to you. Your specific tax
treatment will depend on your personal circumstances; the plan does not guarantee any particular tax
treatment. You are solely responsible for any and all federal, state, and local taxes attributable to your
participation in this plan, and the plan expressly disclaims any liability for such taxes.
The plan is 'self-insured,' which means benefits are paid from your employer's general assets and or trust
funds and are not guaranteed by an insurance company. The Plan Sponsor has contracted with a Third
Party Administrator to perform certain administrative services related to this plan.
PacificSource Health Plans is the Third Party Administrator and provides administrative services for this
plan on behalf of the Plan Sponsor. If anything is unclear to you, PacificSource's staff is available to
answer your questions. Please give them a call or visit them on the Internet at PacificSource.com.
PacificSource looks forward to serving you and your family.
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espahol (800) 624-6052, extension 1009
cs@pacificsource.com
This document serves as the written Plan document and Summary Plan Description (SPD). It is very
important that you review the entire document carefully to confirm a complete understanding of the
benefits available, as well as your responsibility, under the plan.
This document is written in simple, easy-to-understand language. Technical terms are printed in italics
and defined in the Plan Terms and Definitions section. This document explains the services covered by
the plan; the benefit summaries tell you how much this plan pays toward expenses and amounts for
which you are responsible.
As used in this document, the word 'year' refers to the benefit year, which is the 12-month period
beginning January 1 and ending December 31. The word lifetime as used in this document refers to the
period of time you or your eligible dependents participate in this plan or any other Plan Sponsored by the
Plan Sponsor.
Any amount you or your eligible dependents have accumulated toward the benefit maximum amounts,
deductible, or out-of-pocket maximum of any immediately prior Plan Sponsored by the Plan Sponsor will
be counted toward the benefit maximum amounts of this plan.
The Plan Sponsor reserves the right to amend, modify, or terminate this plan in any manner, at any time,
which may result in termination or modification of your coverage. If this plan is terminated, any plan
assets will be used to pay for eligible expenses incurred prior to the plan's termination, and such
expenses will be paid as provided under the terms of this plan prior to termination. If there is any conflict
between this document and the underlying plan document(s), the plan document(s) control.
SingleSource Self-Insured 3
SingleSource Self-Insured 4
CONTENTS
MEDICAL BENEFIT SUMMARY 3
PRESCRIPTION BENEFIT SUMMARY 5
CHIROPRACTIC CARE BENEFIT SUMMARY ..............................................................9
ADDITIONAL ACCIDENT BENEFIT SUMMARY .........................................................11
VISION BENEFIT SUMMARY ......................................................................................13
DENTAL BENEFIT SUMMARY ....................................................................................15
USING THE PROVIDER NETWORK ............................................................................17
Preferred Provider Organization (PPO) .................................................................................................17
What is a PPO .......................................................................................................................................17
Who is Your PPO ...................................................................................................................................17
About Your PPO ....................................................................................................................................17
Non-PPO Providers ...............................................................................................................................18
Example of Provider Payment ...............................................................................................................18
Allowable Amount ..................................................................................................................................18
NETWORK NOT AVAILABLE BENEFITS ...................................................................18
COVERAGE WHILE TRAVELING ................................................................................18
Nonemergency Care While Traveling ....................................................................................................19
Emergency Services While Traveling ....................................................................................................19
FINDING PARTICIPATING PROVIDER INFORMATION .............................................19
TERMINATION OF PROVIDER CONTRACTS ............................................................19
BECOMING ELIBIGLE .................................................................................................20
Who Pays for Your Benefits ...................................................................................................................20
Who is Eligible .......................................................................................................................................20
ENROLLING DURING THE INITIAL ENROLLMENT PERIOD 21
Newborns 21
Adopted Children 21
Family Members Acquired by Marriage .................................................................................................21
Family Members Acquired by Domestic Partnership .............................................................................21
Family Members Placed in Your Guardianship 22
Qualified Medical Child Support Orders ................................................................................................22
ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD 22
Returning to Work after a Layoff ............................................................................................................22
Returning to Work after a Leave of Absence .........................................................................................22
Returning to Work after Family Medical Leave ......................................................................................22
Special Enrollment Periods ....................................................................................................................23
Dental Enrollment ..................................................................................................................................23
Late Enrollment ......................................................................................................................................23
Member ID Card ....................................................................................................................................24
PLAN SELECTION PERIOD 24
TERMINATING COVERAGE 24
Divorced Spouses ..................................................................................................................................24
Dependent Children ...............................................................................................................................24
Dissolution of Domestic Partnership.. 24
Certificates of Creditable Coverage .......................................................................................................25
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CONTINUATION OF INSURANCE 25
USERRA CONTINUATION 25
Surviving or Divorced Spouses and Qualified Domestic Partners .........................................................26
COBRA CONTINUATION 26
COBRA Eligibility 26
When Continuation Coverage Ends ......................................................................................................26
Type of Coverage .......................................................:..........................................................................27
Your Responsibilities and Deadlines .....................................................................................................27
Continuation Premium ...........................................................................................................................27
Keep Your Plan Informed of Address Changes .....................................................................................27
CONTINUATION WHEN YOU RETIRE 27
WORK STOPPAGE 28
Labor Unions ..........................................................................................................................................28
COVERED EXPENSES 28
Medical Necessity ..................................................................................................................................28
Healthcare Providers .............................................................................................................................29
Your Annual Out-of-Pocket Limit ...........................................................................................................29
MEDICAL BENEFITS ...................................................................................................29
About Your Medical Benefits .................................................................................................................29
PLAN BENEFITS 31
PREVENTIVE CARE SERVICES 31
PROFESSIONAL SERVICES 32
HOSPITAL AND SKILLED NURSING FACILITY SERVICES 34
OUTPATIENT SERVICES 34
EMERGENCY SERVICES 35
MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES 36
Mental Health and Chemical Dependency Services .............................................................................36
Medical Necessity and Appropriateness of Treatment ..........................................................................37
HOME HEALTH AND HOSPICE SERVICES 37
DURABLE MEDICAL EQUIPMENT 38
TRANSPLANT SERVICES 39
Payment of Transplant Benefits .............................................................................................................40
OTHER COVERED SERVICES, SUPPLIES, AND TREATMENTS .............................40
BENEFIT LIMITATIONS AND EXCLUSIONS ..............................................................43
Least Costly Setting for Services ...........................................................................................................43
EXCLUDED SERVICES 43
A Note About Optional Benefits .............................................................................................................43
Experimental or Investigational Treatment ............................................................................................47
EXCLUSION PERIODS ................................................................................................50
Exclusion Period for Transplant Benefits ...............................................................................................50
CREDIT FOR PRIOR COVERAGE 50
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Evidence of Prior Creditable Coverage 50
HEALTH CARE MANAGEMENT AND PREAUTHORIZATION 50
What is Health Care Management .........................................................................................................50
Case Management ...............................................................:.................................................................51
Individual Benefits Management ............................................................................................................52
HOW TO USE YOUR DENTAL PLAN 52
DENTAL PLAN BENEFITS 52
COVERED DENTAL SERVICES 53
Class I Services - Diagnostic and Preventive Treatment ......................................................................53
Class II Restorative Services - Basic and Restorative Treatment ........................................................53
Class II Complicated Services - Complicated Treatment .....................................................................53
Class III Services - Major Treatment 54
EXCLUDED DENTAL SERVICES 54
CLAIMS Procedures 57
Questions about Your Claims ................................................................................................................57
Types of Claims 58
How to File a Claim ................................................................................................................................58
Incomplete Claims .................................................................................................................................60
Notification of Benefit Determination .....................................................................................................60
Adverse Benefit Determination ..............................................................................................................61
Your Right to Appeal ..............................................................................................................................61
Resources For Information And Assistance ..........................................................................................64
Plan Sponsors Discretionary Authority; Standard of Review ................................................................65
Coordination of Benefits .........................................................................................................................65
Order of Payment When Coordinating with Other Group Health Plans ................................................66
OTHER IMPORTANT PLAN PROVISIONS 67
Assignment of Benefits ..........................................................................................................................67
Proof of Loss ..........................................................................................................................................67
No Verbal Modifications of Plan Provisions ...........................................................................................67
Reimbursement to the Plan ...................................................................................................................68
Subrogation 68
Recovery of Excess Payments ..............................................................................................................69
Right To Receive and Release Necessary Information .........................................................................69
Reliance on Documents and Information ...............................................................................................69
No Waiver ..............................................................................................................................................69
Physician/Patient Relationship ..............................................................................................................70
Plan not responsible for Quality of Health Care ....................................................................................70
Plan is not a Contract of Employment 70
Right to Amend or Terminate Plan ........................................................................................................70
Applicable Law .......................................................................................................................................70
PRIVACY AND CONFIDENTIALITY 70
Permitted Disclosures of Protected Health Information to the Plan Sponsor ........................................71
No Disclosure of Protected Health Information to the Plan Sponsor without Certification by Plan
Sponsor 71
Conditions of Disclosure of Protected Health Information to the Plan Sponsor ....................................71
Disclosures of Summary Health Information and Enrollment/Disenrollment Information to the Plan
Sponsor 72
Required Separation between the Plan and the Plan Sponsor .............................................................72
DEFINITIONS 72
RIGHTS OF PLAN MEMBERS 81
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Grandfathered Health Plan
The Plan Sponsor believes this plan is a 'grandfathered health plan' under the Patient
Protection and Affordable Care Act (the Affordable Care Act). As permitted by the
Affordable Care Act, a grandfathered health plan can preserve certain basic health
coverage that was already in effect when that law was enacted. Being a grandfathered
health plan means that your plan may not include certain consumer protections of the
Affordable Care Act that apply to other plans, for example, the requirement for the
provision of preventive health services without any cost sharing. However,
grandfathered health plans must comply with certain other consumer protections in the
Affordable Care Act, for example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a
grandfathered health plan and what might cause a plan to change from grandfathered
health plan status can be directed to the Plan Sponsor, or you may contact
PacifcSource at:
PacificSource Health Plans
PO Box 7068
Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
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MEDICAL BENEFIT SUMMARY
POLICY INFORMATION
Group Name: City of Ashland
Group Number: G0032482
Plan Name: Preferred 90+200 VAR GF 0812
Provider Network: Preferred PSN
EMPLOYEE ELIGIBILITY REQUIREMENTS
Minimum Hour Requirement: Full Time: 40 hours, Part Time: 20-39 hours
Waiting Period for New Employees: 1st day of the month following one (1) day. A person hired on the
first day of the month is eligible on the first day of the following
month.
ANNUAL DEDUCTIBLE $200 per person / $600 per family
The deductible is an amount of covered medical expenses the member pays each benefit year before the plan's
benefits begin. The deductible applies to all services and supplies except those marked with an asterisk Once a
member has paid a total amount toward covered expenses during the benefit year equal to the per person amount
listed above, the deductible will be satisfied for that person for the rest of that benefit year. Once any covered
family members have paid a combined total toward covered expenses during the benefit year equal to the per
family amount listed above, the deductible will be satisfied for all covered family members for the rest of that benefit
year. Deductible expense is not applied to the out-of-pocket limit.
ANNUAL OUT-OF-POCKET LIMIT
Participating Providers .................................................$700 per person / $1,400 per family
Non-participating Providers. _ $1,700 per person / $3,400 per family
Only participating provider expense applies to the participating provider out-of-pocket limit and only non-
participating provider expense applies to the non-participating out-of-pocket limit. Once the participating provider
out-of-pocket limit has been met, this plan will pay 100% of covered charges (after the co-payment is deducted) for
participating and network not available providers for the rest of that benefit year. Once the non-participating
provider out-of-pocket limit has been met, this plan will pay 100% of covered charges (after the co-payment is
deducted) for non-participating providers for the rest of that benefit year. Deductibles, co-payments, benefits paid in
full and non-participating provider charges in excess of the allowable fee do not accumulate toward the out-of-
pocket limit. Co-payments and non-participating provider charges in excess of the allowable fee will continue to be
the members responsibility even after the out-of-pocket limit is met.
ADDITIONAL ACCIDENT BENEFIT
The first $1,000 of covered expenses within 90 days of an accident is covered at no charge and is not subject to
the deductible. The balance is covered as shown below.
The member is responsible for the above deductible and the following co-payments and co-insurance.
PARTICIPATING PROVIDERS/ NON-PARTICIPATING
SERVICE: NETWORK NOT AVAILABLE: PROVIDERS:
PREVENTIVE CARE
Well Baby/Well Child Care 10% co-insurance 30% co-insurance
Routine Physicals No charge' No charge'
Well Woman Visits No charge' No charge'
Immunizations - 0-18 yrs No charge' No charge'
Immunizations - age 19 and over 10% co-insurance 30% co-insurance
Routine Colonoscopy 10% co-insurance 30% co-insurance
PROFESSIONAL SERVICES
Office and Home Visits 10% co-insurance 30% co-insurance
Office Procedures and Supplies 10% co-insurance 30% co-insurance
Surgery 10% co-insurance 30% co-insurance
Outpatient Rehabilitation Services 10% co-insurance 10% co-insurance
HOSPITAL SERVICES
Inpatient Room and Board 10% co-insurance 30% co-insurance
Inpatient Rehabilitation Services 10% co-insurance 30% co-insurance
Skilled Nursing Facility Care 10% co-insurance 30% co-insurance
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OUTPATIENT SERVICES
Outpatient Surgery/Services 10% co-insurance 30% co-insurance
Advanced Diagnostic Imaging 10% co-insurance 30% co-insurance
Diagnostic and Therapeutic Radiology 10% co-insurance 30% co-insurance
and Lab
URGENT AND EMERGENCY SERVICES
Urgent Care Center Visits 10% co-insurance 30% co-insurance
Emergency Room Visits $100 co-pay/visit plus $100 co-pay/visit plus
10% co-insurance" 10% co-insurance A
Ambulance, Ground 10% co-insurance 10% co-insurance
Ambulance, Air 10% co-insurance 10% co-insurance
MENTAL HEALTHICHEMICAL DEPENDENCY SERVICES
Office Visits 10% co-insurance 30% co-insurance
Inpatient Care 10% co-insurance 30% co-insuranre
Residential Programs 10% co-insurance 30% co-insurance
OTHER COVERED SERVICES
Allergy Injections 10% co-insurance 30% co-insurance
Durable Medical Equipment 10% co-insurance 30% co-insurance
Home Health Care 10% co-insurance 10% co-insurance
Chiropractic Plus (12 visits/benefit 10% co-insurance 10% co-insurance
year)
" For emergency medical conditions, non-participating providers are paid at the participating
provider level.
Not subject to annual deductible.
Payment to providers is based on the prevailing or contracted Pacific Source fee allowance for covered services. Although
participating providers accept the fee allowance as payment in full, non-participating providers may not. Services of non-
participating providers could result in out-of-pocket expense in addition to the cost share above. Network Not Available (NNA)
payment is allowed when PacificSource has not contracted with providers in the geographical area of the member's residence
or work for a specific service or supply. Payment to providers for NNA is based on the usual, customary, and reasonable
charge for the geographical area in which the charge is incurred.
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PRESCRIPTION BENEFIT SUMMARY
Your Plan Sponsor's health plan includes coverage for prescription drugs and certain other
pharmaceuticals, subject to the information below. Your prescription drug plan qualifies as
creditable coverage for Medicare Part D.
MEMBER COST SHARE (other than for Specialty Drugs)
Each time a covered pharmaceutical is dispensed, you are responsible for the co-payment and/or co-
insurance below:
Tier 1: Tier 1: Tier 1:
Generic Preferred Nonmreferred
From a participating retail pharmacy using the
PacificSource Pharmacy Program (see below):
Up to a 34-day supply: $5 $25 $50
From a participating mail order service (see below):
Up to a 34-day supply: $5 $25 $50
35 to 90-day supply: $10 $50 $100
From a participating retail pharmacy without using Not covered,
the PacificSource Pharmacy Program, or from a except 5-day emergency supply
non-participating pharmacy (see below):
MEMBER COST SHARE FOR SPECIALTY DRUG
Each time a covered specialty drug is dispensed, you are responsible for the co-payment and/or co-
insurance below:
From the participating specialty pharmacy:
Up to a 30-day supply: Same as retail pharmacy co-payment above
From a participating retail pharmacy, from a
participating mail order service, or from a non- Not covered,
participating pharmacy or pharmaceutical service except 5-day emergency supply
provider:
WHAT HAPPENS WHEN A BRAND NAME DRUG IS SELECTED
Regardless of the reason or medical necessity, if you receive a brand name drug or if your physician
prescribes a brand name drug when a generic is available, you will be responsible for the brand name
drug's co-payment and/or co-insurance.
USING THE PACIFICSOURCE PHARMACY PROGRAM
Retail Pharmacy Network
To use the PacificSource pharmacy program, you must show the pharmacy plan number on the
PacificSource ID card at the participating pharmacy to receive your plan's highest benefit level.
When obtaining prescription drugs at a participating retail pharmacy, the PacificSource pharmacy
program can only be accessed through the pharmacy plan number printed on your PacificSource ID
card. That plan number allows the pharmacy to collect the appropriate co-payment and/or co-insurance
from you and bill PacificSource electronically for the balance.
Mail Order Service
This plan includes a participating mail order service for prescription drugs. Most, but not all, covered
prescription drugs are available through this service. Questions about availability of specific drugs may
be directed to the PacificSource Customer Service Department or to the plan's participating mail order
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service vendor. Forms and instructions for using the mail order service are available from PacificSource
and on PacifcSource's website, PacificSource.com.
Specialty Drug Program
PacificSource contracts with a specialty pharmacy services provider for high-cost injectable
medications and biotech drugs. A pharmacist-led CareTeam provides individual follow-up care and
support to covered members with prescriptions for specialty medications by providing them strong
clinical support, as well as the best drug pricing for these specific medications and biotech drugs.
The CareTeam also provides comprehensive disease education and counseling, assesses patient
health status, and offers a supportive environment for patient inquiries.
Participating provider benefits for specialty drugs are available when you use PacificSource's
specialty pharmacy services provider. Specialty drugs are not available through the participating
retail pharmacy network or mail order service. More information regarding PacificSource's
exclusive specialty pharmacy services provider and health conditions and a list of drugs requiring
preauthorization and/or are subject to pharmaceutical service restrictions is on PacificSource's
website, PacificSource.com.
OTHER COVERED PHARMACEUTICALS
Supplies covered under the pharmacy plan are in place of, not in addition to, those same covered
supplies under the medical plan. Member cost share for items in this section are applied on the
same basis as for other prescription drugs, unless otherwise noted.
Diabetic Supplies
• Insulin, diabetic syringes, lancets, and test strips are available.
• Glucagon recovery kits are available for the plan's preferred brand name co-payment.
• Glucostix and glucose monitoring devices are not covered under this pharmacy benefit, but are
covered under the medical plan's durable medical equipment benefit.
Contraceptives
• Oral contraceptives
• Implantable contraceptives, contraceptive injections, contraceptive patches, and contraceptive rings
are available.
• Diaphragm or cervical caps are available.
Tobacco Cessation
Program specific tobacco cessation medications are covered with active participation in a plan
approved tobacco cessation program (see Preventive Care in the policy's Covered Expenses section).
Orally Administered Anticancer Medications
Orally administered anticancer medications used to kill or slow the growth of cancerous cells are
available. Co-payments for orally administered anticancer medication are applied on the same basis as
for other drugs. Orally administered anticancer medications covered under the pharmacy plan are in
place of, not in addition to, those same covered drugs under the medical plan.
LIMITATIONS AND EXCLUSIONS
• This plan only covers drugs prescribed by a licensed physician (or other licensed practitioner
eligible for reimbursement under your plan) prescribing within the scope of his or her professional
license, except for:
- Over-the-counter drugs or other drugs that federal law does not prohibit dispensing without a
prescription (even if a prescription is required under state law).
- Drugs for any condition excluded under the health plan. That includes drugs intended to
promote fertility, treatments for obesity or weight loss, tobacco cessation drugs (except as
specifically provided for under Other Covered Pharmaceuticals), experimental drugs, and drugs
available without a prescription (even if a prescription is provided).
- Some specialty drugs that are not self-administered are not covered by this pharmacy benefit,
but are covered under the medical plan's office supply benefit.
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- Immunizations (although not covered by this pharmacy benefit, immunizations may be covered
under the medical plan's preventive care benefit).
- Drugs and devices to treat erectile dysfunction.
- Drugs used as a preventive measure against hazards of travel.
- Vitamins, minerals, and dietary supplements, except for prescription prenatal vitamins and
fluoride products, and for services that have a rating of 'A' or'B' from the U.S Preventive
Services Task Force (USPSTF).
• Certain drugs require preauthorization by PacificSource in order to be covered. An up-to-date list of
drugs requiring preauthorization is available on PacificSource's website, PacificSource.com.
• PacificSource may limit the dispensing quantity through the consideration of medical necessity,
generally accepted standards of medical practice, and review of medical literature and
governmental approval status.
• Quantities for any drug filled or refilled are limited to no more than a 34-day supply when purchased
at retail pharmacy or a 90-day supply when purchased through mail order pharmacy service or a
30-day supply when purchased through a specialty pharmacy.
• For drugs purchased at non-participating pharmacies or at participating pharmacies without using
the PacificSource pharmacy program, reimbursement is limited to an allowable fee.
• Non-participating pharmacy charges are not eligible for reimbursement unless you have a true
medical emergency that prevents you from using a participating pharmacy. Drugs obtained at a
non-participating pharmacy due to a true medical emergency are limited to a 5 day supply.
• The member cost share for prescription drugs (co-payments, co-insurance, and service charges)
does not apply to the medical deductible or out-of-pocket limit of the policy. You continue to be
responsible for the prescription drug co-payments and service charges regardless of whether the
policy's out-of-pocket limit is satisfied.
• Prescription drug benefits are subject to your plan's coordination of benefits provision. (For more
information see Claims Payment - Coordination of Benefits in your Summary Plan Description.)
GENERAL INFORMATION ABOUT PRESCRIPTION DRUGS
A drug formulary is a list of preferred medications used to treat various medical conditions. The
formulary for this plan is known as the Preferred Drug List (PDL). The drug formulary is used to help
control rising healthcare costs while ensuring that you receive medications of the highest quality. It is a
guide for your physician and pharmacist in selecting drug products that are safe, effective, and cost
efficient. The drug formulary is made up of name brand products. A complete list of medications
covered under the drug formulary is available on the For Members area on PacificSource's website,
PacificSource.com. The drug formulary is developed by Caremark@ in cooperation with PacificSource.
Non-preferred drugs are covered brand name medications not on the drug formulary.
Generic drugs are equivalent to name brand medications. By law, they must have the same active
ingredients as the brand name medication and are subject to the same standards of their brand name
counterpart. Name brand medications lose their patent protection after a number of years. Any drug
company can then produce the drug, and the manufacturer must pass the same strict FDA standards of
quality and product safety as the original manufacturer. Generic drugs are less expensive than brand
name drugs because there is more competition and there is no need to repeat costly research and
development. Your pharmacist and physician are encouraged to use generic drugs whenever they are
available.
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CHIROPRACTIC CARE BENEFIT SUMMARY
Your plan's chiropractic care benefit allows you to receive treatment from licensed chiropractors for
medically necessary diagnosis and treatment of illness or injury. Refer to the Medical Benefit Summary
for your co-payment and/or co-insurance information.
PacificSource contracts with a network of chiropractors, so you can reduce your out-of-pocket expense
by using one of the participating providers. For a listing of participating chiropractors in your area,
please refer to your plan's participating provider directory, visit our website, Pacificsource.com, or call
our Customer Service Department.
Covered Services
• Chiropractic manipulation, massage therapy, and any laboratory services, x-rays, radiology, and
durable medical equipment provided by or ordered by a chiropractor.
The combined benefit for all treatments, services, and supplies provided or ordered by a chiropractor is
limited to 12 visits per person in any benefit year.
Excluded Services
• Any service or supply excluded or not otherwise covered by the medical plan.
• Drugs, homeopathic medicines, or homeopathic supplies furnished by a chiropractor.
• Services of an alternative care provider for pregnancy or childbirth.
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ADDITIONAL ACCIDENT BENEFIT SUMMARY
In the event of an injury caused by an accident, first dollar benefits are provided for covered expenses
according to the following:
Related Definitions
'Accident' means an unforeseen or unexpected event causing injury that requires medical attention.
'Injury' means bodily trauma or damage which is independent of disease or infirmity. The damage must
be caused solely through external and accidental means. Injury, for the purpose of this benefit, does not
include musculoskeletal sprains or strains obtained in the performance of physical activity.
Covered Expenses
Benefits for the following covered expenses are provided, subject to the limitations stated below:
• Services or supplies provided by a physician (except orthopedic braces)
• Services of a hospital
• Services of a registered nurse who is unrelated to the injured person by blood or marriage
• Services of a registered physical therapist
• Services of a physician or a dentist for the repair of a fractured jaw or natural teeth
• Diagnostic radiology and laboratory services
• Transportation by local ground ambulance
Limitations
• The treatment must be medically necessary for the injury.
• The treatment or service must be provided within 90 days after the injury occurs.
• The first $1,000 of covered expense is paid at 100% and is not subject to the deductible.
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VISION BENEFIT SUMMARY
Your Plan Sponsor covers vision exams, eyeglasses, and contact lenses. The following shows the
vision benefits available.
Benefit Period
Eye Exam: Once every 12 months for covered children. Once every 24 months for
covered adults.
Lenses: Once every 12 months for covered children. Once every 24 months for
covered adults.
Frames: Once every 24 months for all covered individuals OR
Contact lenses: Once every 12 months for covered children. Once every 24 months for
covered adults.
Member Responsibility
PARTICIPATING NON-PARTICIPATING
SERVICE/SUPPLY PROVIDERS: PROVIDERS:
Eye Exam No charge No charge up to a
$71 maximum
Hardware
Lenses (maximum per pair)
Single Vision No charge No charge up to a
$51 maximum
Bifocal No charge No charge up to a
$77 maximum
Trifocal No charge No charge up to a
$100 maximum
Lenticular No charge Not covered
Progressive No charge Not covered
Frames No charge up to a No charge up to a
$120 maximum $66 maximum
Contacts (in place of No charge up to a No charge up to a
glasses) $166 maximum $166 maximum
The amounts listed above are the maximum benefits available for all vision exams, lenses, and
frames furnished during any benefit period when prescribed by a licensed ophthalmologist or
licensed optometrist. Participating providers discount hardware services.
Limitations and Exclusions
The out-of-pocket expense for vision services (co-payments and service charges) does not apply
to the medical plan's deductible or out-of-pocket limit. Also, the member continues to be
responsible for the vision co-payments and service charges regardless of whether the medical
plan's out-of-pocket limit is satisfied.
Covered expenses do not include, and no benefits are payable for:
• Special procedures such as orthoptics or vision training
• Special supplies such as sunglasses (plain or prescription) and subnormal vision aids
• Tint
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• Plano contact lenses
• Anti-reflective coatings and scratch resistant coatings
• Separate charges for contact lens fitting
• Replacement of lost, stolen, or broken lenses or frames
• Duplication of spare eyeglasses or any lenses or frames
• Nonprescription lenses
• Visual analysis that does not include refraction
• Services or supplies not listed as covered expenses
• Eye exams required as a condition of employment, or required by a labor agreement or government
body
• Expenses covered under any worker's compensation law
• Services or supplies received before this plan's coverage begins or after it ends
• Charges for services or supplies covered in whole or in part under any other medical or vision
benefits provided by the Plan Sponsor
• Medical or surgical treatment of the eye
Important information about your vision benefits
Your Plan Sponsor's health plan includes coverage for vision services, including prescription
eyeglasses and contact lenses. To make the most of those benefits, it's important to keep in mind
the following:
• Participating Providers
PacificSource is able to add value to your vision benefits by contracting with a network of vision
providers. Those providers offer vision services at discounted rates, which are passed on to you in
your benefits.
• Paying for Services
Please remember to show your current PacificSource ID card whenever you use your plan's
benefits. PacificSource's provider contracts require participating providers to bill us directly
whenever you receive covered services and supplies. Providers normally call PacificSource to
verify your vision benefits. Participating providers should not ask you to pay the full cost in
advance. They may only collect your share of the expense up front, such as copayments and
amounts over your plan's allowances. If you are asked to pay the entire amount in advance,
tell the provider you understand they have a contract with PacificSource and should bill
PacificSource directly.
• Sales and Special Promotions
Vision retailers often use coupons and promotions to bring in new business, such as free eye
exams, two-for-one glasses, or free lenses with purchase of frames. Because participating
providers already discount their services through their contract with PacificSource, your plan's
participating provider benefits cannot be combined with any other discounts or coupons. You can
use your plan's participating provider benefits, or you can use your plan's non-participating provider
benefits to take advantage of a sale or coupon offer. If you do take advantage of a special offer, the
participating provider may treat you as an uninsured customer and require full payment in advance.
You can then send the claim to PacificSource yourself, and PacificSource will reimburse you
according to your plan's non-participating provider benefits.
PacificSource hopes this information helps clarify your vision benefits. If you or your provider have any
questions about your benefits, please call PacificSource Customer Service at (541) 686-1242 from
Eugene-Springfield or (888) 977-9299 from other areas.
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DENTAL BENEFIT SUMMARY
POLICY INFORMATION
Group Name: City of Ashland
Group Number: G0032482
Plan Name: Preferred Incentive Dental $1500 VAR 0711
EMPLOYEE ELIGIBILITY REQUIREMENTS
Minimum Hour Requirement: Full Time: 40 hours, Part Time: 20-39 hours
Waiting Period for New Employees: 1 st day of the month following one (1) day. A person hired on the
first day of the month is eligible on the first day of the following
month.
DENTAL BENEFIT SUMMARY
Subject to all the terms of this Group Dental Policy, the Plan Sponsorwill pay a dental benefit for
covered dental expenses incurred by a covered person. The dental benefit is a percentage of the usual,
customary, and reasonable charge for covered dental expenses incurred, subject to an annual
maximum benefit, and an annual deductible, as follows:
Maximum Payment
The amount payable by this plan for covered services received under Class I are unlimited. The
maximum amount payable by this plan for covered Class 11 and Class III services received each benefit
year, or portion thereof, for each eligible patient is limited to $1,500.
PLAN PAYMENT SCHEDULE
Class I Services- Plan pays 70% toward covered Class I Services - Diagnostic and
Preventive Treatment.
Class 11 Restorative Services- Plan pays 70% toward covered Class 11 Restorative Services -
Restorative Treatment.
Class II Complicated Services- Plan pays 70% toward covered Class II Complicated Services -
Complicated Treatment.
Class III Services- Plan pays 70% toward covered Class III Services - Major Treatment.
This plan pays the percentage indicated above toward Class I, II and III Services during the first year an
individual is eligible. Payment increases 10 percent (to a maximum benefit of 100 percent) each
successive benefit year for Class I, 11 and III Services if the member visits a dentist at least once during
the benefit year. Payment decreases 10 percent (to a minimum benefit of the percentage stated above)
each successive benefit year if the member does not visit a dentist at least once during the previous
benefit year.
SingleSource Self-Insured 15
SingleSource Self-Insured 16
USING THE PROVIDER NETWORK
This section explains how your plan's benefits differ when you use participating and non-participating
providers. This information is not meant to prevent you from seeking treatment from any provider if you
are willing to take increased financial responsibility for the charges incurred.
All healthcare providers are independent contractors. Neither your Plan Sponsor nor PacificSource can
be held liable for any claim or damages for injuries you experience while receiving medical care.
Preferred Provider Organization (PPO)
What is a PPO
A preferred provider organization (PPO) has made agreements with hospitals, physicians, practitioners,
and other health care providers to discount the cost of services they provide.
Who is Your PPO
The Plan Sponsor has chosen PacificSource to provide PPO services for employees and eligible
dependents in Oregon, Idaho, and Montana service areas and in bordering communities in southwest
Washington. They also have an agreement with a nationwide provider network, The First Health@
Network. The First Health providers outside PacificSource's service area are also considered
participating providers under your plan.
A list of participating providers can be accessed through the PacificSource website: PacificSource.com
or by calling PacificSource at (888) 977-9299. This list of participating providers is updated regularly.
About Your PIRO
PacificSource has selected the participating physicians, practitioners, and hospitals after carefully
reviewing their qualifications. Each health care provider has agreed to a contracted amount in payment
for their services. Additionally, you cannot be 'balanced billed' for the difference between the PPO
contracted amount and the provider's normal billed charge for a particular service. You are only
responsible for the deductible, copayment, and/or coinsurance payment shown on the Medical Benefit
Summary.
Enrolling in this plan does not guarantee that a particular participating providerwill remain a
participating provider or that a particular participating providerwill provide members under this plan only
with covered services. Members should verify a health care provider's status as a participating provider
each time services are received from the health care provider.
It is not safe to assume that when you are treated at a participating medical facility, all services are
performed by participating providers. A list of participating providers can be accessed through the
PacificSource website: PacificSource.com or by calling PacificSource at (888) 977-9299. Whenever
possible, you should arrange for professional services such as surgery and anesthesiology to be
provided by a participating provider. Doing so will help you maximize your benefits and limit your out-of-
pocket expenses. The PPO benefits are outlined on the Medical Benefit Summary.
You have a free choice of any health care provider, and the physician-patient relationship shall be
maintained. Members, together with their health care provider, are ultimately responsible for
determining the appropriate course of medical treatment, regardless of whether the plan will pay for all
or a portion of the cost of such care. The participating providers are merely independent contractors;
neither the plan, the Plan Sponsor, nor PacificSource makes any warranty as to the quality of care that
may be rendered by any participating provider.
This plan generally allows the designation of a primary care provider. You have the right to designate
any primary care provider who participates in the network and who is available to accept you or your
family members. For children, you may designate a pediatrician as the primary care provider. You do
not need prior authorization from this plan or from any other person (including a primary care provider)
in order to obtain access to obstetrical or gynecological care from a health care professional in the
network who specializes in obstetrics or gynecology. The health care professional, however, may be
required to comply with certain procedures, including obtaining prior authorization for certain services,
following a pre-approved treatment plan, or procedures for making referrals. For a list of the
SingleSource Self-Insured 17
participating providers and/or a list of participating health care professionals who specialize in obstetrics
or gynecology, contact PacificSource at (888) 977-9299 or PO Box 7068, Springfield, OR 97475-0068.
Non-PPO Providers
When you receive services or supplies from a nonparticipating provider, your out-of-pocket expense is
likely to be higher than if you had used a participating provider. Besides the non-PPO deductible,
copayment, and/or coinsurance amounts shown on the Medical Benefit Summary, you may become
responsible for the provider's billed amount that exceeds the plan's allowable amount.
Example of Provider Payment
The following illustrates how payment could be made for a covered service billed at $120. In this
example, the Medical Benefit Summary shows a participating providers co-insurance of 20 percent and
a non-participating providers co-insurance of 30 percent. This is only an example; your plan's benefits
may be different.
Participating Non-participating
Provider Provider
Provider's usual billed charge $120 $120
PPO's negotiated provider discount $20 $0
Plan's allowable amount $100 $100
Percent of payment 20% 30%
Plan's payment $80 $70
Patient's amount of allowable amount $20 $30
Charges above the allowable amount $0 $20
Patient's total payment to provider $20 $50
Percent of charge paid by plan 80% 58%
Percent of charge paid by patient 20% 42%
Allowable Amount
The plan bases payment to nonparticipating providers on an allowable amount for the same services or
supplies. Several sources are used to determine the allowable amount, depending on the service or
supply and the geographical area where it is provided. The allowable amount may be based on data
collected from the Centers for Medicare and Medicaid Services (CMS), Viant Health Payment
Solutions, other nationally recognized databases, or PacificSource.
NETWORK NOT AVAILABLE BENEFITS
The term 'network not available' is used when a member does not have reasonable geographic access
to a participating provider for a covered medical service or supply.
If you live in an area without access to a participating provider for a specific service or supply, your
plan's Network Not Available benefits apply. Here's how that works,
• You seek treatment from a nearby non-participating provider of that service or supply.
• PacificSource determines the allowable fee for that service or supply (the term 'allowable fee' is
explained above under the Non-participating Providers section).
• PacificSource applies the Network Not Available benefit level stated in your Medical Benefit
Summary to the allowable fee to calculate covered expenses.
• You are responsible for any co-payments, co-insurance, deductibles, and amounts over the
allowable fee.
COVERAGE WHILE TRAVELING
Your plan is powered by the PacificSource Network (PSN). The PSN Network covers Oregon, Idaho,
Montana, southwest Washington, and eastern Washington. When you need medical services outside of
the PSN Network, you can save out-of-pocket expense by using the participating providers available
through The First Health@ Network.
SingleSource Self-Insured 18
Nonemergency Care While Traveling
To find a participating provider outside the regions covered by the PacificSoume Network, call The First
Health® Network at (800) 226-5116. (The phone number is also printed on your PacificSoume ID card
for convenience.) Representatives are available at any time to help you find a participating physician,
hospital, or other outpatient provider. Nonemergency care outside of the United States is not covered.
• If a participating provider is available in your area, your plan's participating provider benefits will
apply if you use a participating provider.
• If a participating provider is not available in your area, your plan's Network Not Available benefits
will apply.
• If a participating provider is available but you choose to use a non-participating provider, your plan's
non-participating provider benefits will apply.
Emergency Services While Traveling
In medical emergencies (see the Covered Expenses - Emergency Services section of this Summary
Plan Description), your plan pays benefits at the participating provider level regardless of your location.
Your covered expenses are based on PacificSource's allowable fee. If you are admitted to a hospital as
an inpatient following the stabilization of your emergency condition, your physician or hospital should
contact the PacificSource Health Services Department at (888) 691-8209 as soon as possible to make
a benefit determination on your admission. If you are admitted to a non-participating hospital,
PacificSource may require you to transfer to a participating facility once your condition is stabilized in
order to continue receiving benefits at the participating provider level.
FINDING PARTICIPATING PROVIDER INFORMATION
You can find up-to-date participating provider information:
• By asking your healthcare provider if he or she is a participating provider for your Plan Sponsor's
plan.
• On the PacificSource website, PacificSource.com. Simply click on 'Find a Provider' and you can
easily look up participating providers or print your own customized directory.
• By contacting the PacificSource Customer Service Department. PacificSource can answer your
questions about specific providers. If you'd like a complete provider directory for your plan, just ask
- PacificSource will be glad to mail you a directory free of charge.
• By calling The First Health® Network at (800) 226-5116 if you live outside the area covered by the
PacificSource Network.
TERMINATION OF PROVIDER CONTRACTS
PacificSource will notify you within ten days of learning of the termination of a provider contractual
relationship if you have received services in the previous three months from such a provider when:
• A provider terminates a contractual relationship with PacificSource in accordance with the terms
and conditions of the agreement;
• A provider terminates a contractual relationship with an organization under contract with
PacificSource; or
• PacificSource terminates a contractual relationship with an individual provider or the organization
with which the provider is contracted in accordance with the terms and conditions of the agreement.
For the purposes of continuity of care, PacificSource may require the provider to adhere to the medical
services contract and accept the contractual reimbursement rate applicable at the time of contract
termination.
SingleSource Self-Insured 19
BECOMING ELIBIGLE
Who Pays for Your Benefits
The Plan Sponsor shares the cost of providing benefits for you and your enrolled dependents. From
time to time, the Plan Sponsor may adjust the amount of contributions required for coverage. In
addition, the deductibles and copayments may also change periodically. You will be notified by your
Plan Sponsor of any changes in the cost of plan coverage before they take effect.
Who is Eligible
Employees - You are eligible to participate in this plan if you are a regular, full-time employee of the
Plan Sponsor upon the completion of the minimum number of hours and probationary waiting period set
by your Plan Sponsor. Your Plan Sponsor's eligibility requirements are stated in your Medical Benefit
Summary. All employees who meet those requirements are eligible for coverage.
Eligibility for Medicaid or the receipt of Medicaid benefits will not be taken into account in determining
eligibility. Status as an employee is determined under the employment records of the Plan Sponsor.
Workers classified by the Plan Sponsor as independent contractors are not eligible for this plan under
any circumstances.
Retirees - You are eligible to participate in this plan if you are a retired employee of the Plan Sponsor,
or a spouse of a retired employee. Eligibility for Medicaid or the receipt of Medicaid benefits will not be
taken into account in determining eligibility.
Dependents - While you are enrolled under this plan, the following family members, and only the
following family members, are also eligible to participate in the plan:
• Your legal spouse or qualified domestic partner. The Plan Sponsor may require documentation
proving a legal marital relationship, an Affidavit of Domestic Partnership or a Certificate of Qualified
domestic partnership.
• Your, your spouse's, or your qualified domestic partner's dependent children under age 26
regardless of the child's place of residence, marital status, or financial dependence on you.
• Your, your spouse's, or your qualified domestic partner's unmarried dependent children age 26 or
over who are mentally or physically disabled. To qualify as dependents, they must have been
continuously unable to support themselves since turning age 26 because of a mental or physical
disability. PacificSource requires documentation of the disability from the child's physician, and will
review the case before determining eligibility for coverage.
• Your grandchildren. A child of an eligible dependent enrolled on your plan under age 19 who is
unmarried, not in a domestic partnership, registered or otherwise, who is related to you by blood,
marriage, or domestic partnership AND for whom you are the court appointed legal custodian or
guardian with the expectation that the family member will live in your household for at least a year.
• A child placed for adoption with you, your spouse, or qualified domestic partner. Placed for
adoption means the assumption and retention by you, your spouse, or qualified domestic partner of
a legal obligation for total or partial support of a child in anticipation of adoption or placement for
adoption. Upon any termination of such legal obligations the placement for adoption shall be
deemed to have terminated.
• 'Dependent children' means any natural, step, or adopted children as well as any child placed for
adoption with you or your domestic partner are legally obligated to support or contribute support for.
It may also include grandchildren under age 19 who are unmarried and expected to live in your
household for at least a year, if you are the court appointed legal custodian or guardian.
No family or household members other than those listed above are eligible to enroll under your
coverage.
Special Rules for Eligibility - At any time, the Plan Administrator may require proof that a person
qualifies or continues to qualify as a dependent as defined by this plan.
SingleSource Self-Insured 20
ENROLLING DURING THE INITIAL ENROLLMENT PERIOD
The 'initial enrollment period' is the 60-day period beginning on the date a person is first eligible for
enrollment in this plan. Everyone who becomes eligible for coverage has an initial enrollment period.
When you satisfy your Plan Sponsor's probationary waiting period at the hours required for eligibility
and become eligible to enroll in this plan, you and your eligible family members must enroll within the
initial enrollment period. If you miss your initial enrollment period, you may be subject to a waiting
period. (For more information, see 'Special Enrollment Periods' and 'Late Enrollment' under the
Enrolling After the Initial Enrollment Period section.) To enroll, you must complete and sign an
enrollment application, which is available from your Plan Sponsor. The application must include
complete information on yourself and your enrolling family members. Return the application to your
Plan Sponsor, and your Plan Sponsor will send it to PacificSource.
Coverage for you and your enrolling family members begins on the first day of the month after you
satisfy your Plan Sponsor's probationary waiting period. The probationary waiting period is stated in
your Medical Benefit Summary. Coverage will only begin if Your Plan Sponsor receives your enrollment
application and premium.
Newborns
Your, your spouse's, or your qualified domestic partner's natural born baby is eligible for
enrollment under this plan during the 60-day initial enrollment period after birth. PacificSource
cannot enroll the child and pay benefits until your Plan Sponsor receives an enrollment application
listing the child as your dependent. A claim for maternity care is not considered notification for the
purpose of enrolling a newborn child. Anytime there is a delay in providing enrollment information,
your Plan Sponsor may ask for legal documentation to confirm validity.
Adopted Children
When a child is placed in your home for adoption, the child is eligible for enrollment under this plan
during the 60-day initial enrollment period after placement for adoption. 'Placement for adoption' means
the assumption and retention by you, your spouse's, or your domestic partner's of a legal obligation for
full or partial support and care of the child in anticipation of adoption of the child. To add the child to
your coverage, you must complete and submit an enrollment application listing the child as your
dependent. You may be required to submit a copy of the certificate of adoption or other legal
documentation from a court or a child placement agency to complete enrollment.
If additional premium is required, then the natural born or adopted child's eligibility for enrollment will
end 60 days after placement if Plan Sponsor has not received an enrollment application and premium.
Premium is charged from the date of placement and prorated for the first month.
If no additional premium is required, then the natural born or adopted child's eligibility continues as long
as you are covered. However, PacificSource cannot enroll the child and pay benefits until your Plan
Sponsor receives an enrollment application listing the child as your dependent.
Family Members Acquired by Marriage
If you marry, you may add your new spouse and any newly eligible dependent children to your
coverage during the 60-day initial enrollment period after the marriage. Your Plan Sponsor must receive
your enrollment application and additional premium during the initial enrollment period. Coverage for
your new family members will then begin on the first day of the month after the marriage. You may be
required to submit a copy of your marriage certificate to complete enrollment.
Family Members Acquired by Domestic Partnership
If you and your same-gender domestic partner have been issued a Certificate of Qualified domestic
partnership, your domestic partner and your partner's dependent children are eligible for coverage
during the 60-day initial enrollment period after the registration of the domestic partnership. Your Plan
Sponsor must receive your enrollment application and additional premium during the initial enrollment
period. Coverage for your new family members will then begin on the first day of the month after the
registration of the domestic partnership. You may be required to submit a copy of your Certificate of
Qualified domestic partnership to complete enrollment.
SingleSource Self-Insured 21
Unregistered same-gender domestic partners and their children may also become eligible for
enrollment. If you and your unqualified domestic partner meet the criteria on the Affidavit of Domestic
Partnership supplied by your Plan Sponsor, your domestic partner and your partner's dependent
children are eligible for coverage during the 60-day initial enrollment period after the requirements of
the Affidavit of Domestic Partnership are satisfied. Your Plan Sponsor must receive your enrollment
application, a notarized copy of your Affidavit of Domestic Partnership, and additional premium during
the initial enrollment period. Coverage for your new family members will then begin on the first day of
the month after the Affidavit of Domestic Partnership is notarized.
Family Members Placed in Your Guardianship
If a court appoints you custodian or guardian of an eligible grandchild, you may add that family member
to your coverage. To be eligible for coverage, the family member must be:
• Unmarried;
• Not in a domestic partnership, registered or otherwise;
• Related to you by blood, marriage, or domestic partnership,
• Under age 19; and
• Expected to live in your household for at least a year.
Your Plan Sponsor must receive your enrollment application and additional premium during the 60-day
initial enrollment period beginning on the date of the court appointment. Coverage will then begin on the
first day of the month following the date of the court order. You may be required to submit a copy of the
court order to complete enrollment.
Qualified Medical Child Support Orders
This health plan complies with qualified medical child support orders (QMCSO) issued by a state court
or state child support agency. A QMCSO is a judgment, decree, or order, including approval of a
settlement agreement that provides for health benefit coverage for the child of a plan member.
If a court or state agency orders coverage for your spouse or child, they may enroll in this plan within
the 60-day initial enrollment period beginning on the date of the order. Coverage will become effective
on the first day of the month after Plan Sponsor receives the enrollment application. You may be
required to submit a copy of the QMCSO to complete enrollment.
ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD
Returning to Work alter a Layoff
If you are laid off and then rehired by your Plan Sponsor within six months, you will not have to satisfy
another probationary waiting period or new exclusion period.
Your health coverage will resume the first of the month following the date you return to work and again
meet your Plan Sponsor's minimum hour requirement. If your family members were covered before
your layoff, they can resume coverage at that time as well. You must re-enroll your family members by
submitting an enrollment application within the 60-day initial enrollment period following your return to
work.
Returning to Work after a Leave of Absence
If you return to work after a Plan Sponsor-approved leave of absence of six months or less, you will not
have to satisfy another probationary waiting period. Your health coverage will resume the day you
return to work and again meet your Plan Sponsor's minimum hour requirement. If your family members
were covered before your leave of absence, they can resume coverage at that time as well. You must
re-enroll your family members by submitting an enrollment application within the 60-day initial
enrollment period following your return to work.
Returning to Work after Family Medical Leave
Your Plan Sponsor is probably subject to the Family Medical Leave Act (FMLA). To find out if you have
rights under FMLA, ask your health plan administrator. Under FMLA, if you return to work after a
SingleSource Self-Insured 22
qualifying FMIA medical leave, you will not have to satisfy another probationary waiting period or any
previously satisfied exclusion period under this plan. Your health coverage will resume the day you
return to work and meet your Plan Sponsor's minimum hour requirement. If your family members were
covered before your leave, they can also resume coverage at that time if you re-enroll them within the
60-day initial enrollment period following your return.
Special Enrollment Periods
If you are eligible to decline coverage and you wish to do so, you must submit a written waiver of
coverage to your Plan Sponsor. You and your family members may enroll in this plan later if you qualify
under Rule #1, Rule #2, or Rule #3 below.
• Special Enrollment Rule #1 - If you declined enrollment for yourself or your family members
because of other health insurance coverage, you or your family members may enroll in the plan
later if the other coverage ends involuntarily. 'Involuntarily' means coverage ended because
continuation coverage was exhausted, employment terminated, work hours were reduced below
the Plan Sponsor's minimum requirement, the other insurance plan was discontinued or the
maximum lifetime benefit of the other plan was exhausted, the Plan Sponsor's premium
contributions toward the other insurance plan ended, or because of death of a spouse, divorce, or
legal separation. To do so, you must request enrollment within 60 days after the other health
insurance coverage ends (or within 60 days after the other health insurance coverage ends if the
other coverage is through Medicaid or a State Children's Health Insurance Program). Coverage will
begin on the first day of the month after the other coverage ends.
• Special Enrollment Rule #2 - If you acquire new dependents because of marriage, qualification of
domestic partnership, birth, or placement for adoption, you may be able to enroll yourself and/or
your newly acquired eligible dependents at that time. To do so, you must request enrollment within
60 days after the marriage, registration of the domestic partnership, birth, or placement for
adoption. In the case of marriage or domestic partnership, coverage begins on the first day of the
month after the marriage or registration of the domestic partnership. In the case of birth or
placement for adoption, coverage begins on the date of birth or placement.
• Special Enrollment Rule #3 - If you or your dependents become eligible for a premium assistance
subsidy under Medicare or CHIP, you may be able to enroll yourself and/or your dependents at that
time. To do so, you must request enrollment within 60 days of the date you and/or your dependents
become eligible for such assistance. Coverage will begin on the first day of the month after
becoming eligible for such assistance.
Dental Enrollment
Employees or their dependents who did not enroll with dental benefits when initially eligible may later
enroll on the policy's anniversary date. Employees and/or dependents who enrolled with dental benefits
under this policy but later terminated coverage may enroll on an anniversary date of the policy following
a 24-month waiting period from the date coverage was last terminated.
Late Enrollment
If you did not enroll during your initial enrollment period and you do not qualify for a special
enrollment period, your enrollment will be delayed until the plan's anniversary date.
A'late enrollee' is an otherwise eligible employee or dependent who does not qualify for a special
enrollment period explained above, and who:
• Did not enroll during the 60-day initial enrollment period; or
• Enrolled during the initial, enrollment period but discontinued coverage later.
A late enrollee may enroll by submitting an enrollment application to your Plan Sponsor during an open
enrollment period designated by your Plan Sponsorjust prior to the plan's anniversary date. When you
or your dependents enroll during the open enrollment period, plan coverage begins on the date Plan
Sponsor receives the enrollment application or on the plan's anniversary date.
You may enroll in coverage prior to an open enrollment period if one of the following exceptions are
met:
SingleSource Self-Insured 23
• You and/or your dependent may enroll in coverage if you involuntary lose other Group Coverage or
lose coverage under the Oregon Health Plan.
• You and/or your dependent may enroll in coverage if your hours per week are increased or your
employer's contribution is increased. You and/or your dependent may also enroll if you return from
a qualified FMLA leave.
Member ID Card
The membership card issued to you by PacificSource is for identification purposes only. Possession of
a membership card confers no right to services or benefits under this plan and misuse of your
membership card may be grounds for termination of your coverage under this plan. To be eligible for
services or benefits under this plan, you must be eligible and enrolled in the plan and you must present
the membership card to your health care provider. If you receive services or benefits for which you are
not entitled to receive under the terms of this plan, you may be charged for such services or benefits at
the prevailing rate. If you permit the use of your membership card by any other person, your card may
be retained by this plan, and all your rights under this plan may be terminated.
PLAN SELECTION PERIOD
If your Plan Sponsor offers more than one benefit plan option, you may choose another plan option only
upon your plan's anniversary date. You may select a different plan option by completing a selection
form or application form. Coverage under the new plan option becomes effective on your plan's
anniversary date.
TERMINATING COVERAGE
If you leave your job for any reason or your work hours are reduced below your Plan Sponsor's
minimum requirement, coverage for you and your enrolled family members will end. Coverage ends on
the last day of the last month in which you worked full time. You may, however, be eligible to continue
coverage for a limited time; please see the Continuation section of this Summary Plan Description for
more information.
You can voluntarily discontinue coverage for your enrolled family members at any time by completing a
Termination of Dependent Coverage form and submitting it to your Plan Sponsor. Keep in mind that
once coverage is discontinued, your family members may be subject to the late enrollment waiting
period if they wish to re-enroll later.
Divorced Spouses
If you divorce, coverage for your spouse will end on the last day of the month in which the divorce
decree or legal separation is final. You must notify your Plan Sponsor of the divorce or separation, and
continuation coverage may be available for your spouse. If there are special child custody
circumstances, please contact your Plan Sponsor. Please see the Continuation section for more
information.
Dependent Children
When your enrolled child no longer qualifies as a dependent, coverage will end on the last day
of that month. Please see the Eligibility section of this Summary Plan Description for information
on when your dependent child is eligible beyond age 25. The Continuation section includes
information on other coverage options for those who no longer qualify for coverage.
Dissolution of Domestic Partnership
r'
If you dissolve your domestic partnership, coverage for your domestic partner and their children not
related to you by birth or adoption will end on the last day of the month in which the dissolution of the
domestic partnership is final. You must notify your Plan Sponsor of the dissolution of the domestic
partnership. Under Oregon state continuation laws, a qualified domestic partner and their covered
children may continue this policy's coverage under the same circumstances and to the same extent
afforded an enrolled spouse and their enrolled children (see Oregon Continuation in the Continuation of
Insurance section). Domestic partners and their covered children are not recognized as qualified
beneficiaries under federal COBRA continuation laws. Domestic partners and their covered children
SingleSource Self-Insured 24
may not continue this policy's coverage under COBRA independent of the employee (see COBRA
Continuation in the Continuation of Insurance section).
Certificates of Creditable Coverage
A certificate of creditable coverage is used to verify the dates of your prior health plan coverage
when you apply for coverage under a new policy. These certificates are issued by health
insurers whenever a plan participant's coverage ends. After your or your dependent's coverage
under this plan ends, you will receive a certificate of creditable coverage by mail. PacificSource
has an automated process that generates and mails these certificates whenever coverage ends.
PacificSource will send a separate certificate for any dependents with an effective or termination
date that differs from yours. For questions or requests regarding certificates of creditable
coverage, you are welcome to contact Membership Services Department at (541) 684-5583 or
(866) 999-5583.
CONTINUATION OF INSURANCE
Under federal and state laws, you and your family members may have the right to continue this
plan's coverage for a specified time. You and your dependents may be eligible if:
• Your employment ends or you have a reduction in hours
• You take a leave of absence for military service
• You divorce
• You die
• You become eligible for Medicare benefits if it causes a loss of coverage for your dependents
• Your children no longer qualify as dependents
The following sections describe your rights to continuation under state and federal laws, and
the requirements you must meet to enroll in continuation coverage.
USERRA CONTINUATION
If you take a leave of absence from your job due to military service, you have continuation rights under
the Uniformed Services Employment and Re-employment Rights Act (USERRA).
You and your enrolled family members may continue this plan's coverage if you, the employee, no
longer qualify for coverage under the plan because of military service. Continuation coverage under
USERRA is available for up to 24 months while you are on military leave. If your military service ends
and you do not return to work, your eligibility for USERRA continuation coverage will end. Premium for
continuation coverage is your responsibility.
The following requirements apply to USERRA continuation:
• Family members who were not enrolled in the group plan cannot take continuation. The only
exceptions are newborn babies and newly acquired dependents not covered by another group
health plan.
• To apply for continuation, you must submit a completed Continuation Election Form to your Plan
Sponsorwithin 31 days after the last day of coverage under the group plan.
• You must pay continuation premium to your Plan Sponsor by the first of each month. Your Plan
Sponsorwill include your continuation premium in the group's regular monthly payment.
PacificSource cannot accept the premium directly from you.
• Your Plan Sponsor must still be self-insured through PacificSource. If your Plan Sponsor
discontinues this plan, you will no longer qualify for continuation.
SingleSource Self-Insured 25
Surviving or Divorced Spouses and Qualified Domestic Partners
If you die, divorce, or dissolve your qualified domestic partnership, and your spouse or qualified
domestic partner is 55 years or older, your spouse or qualified domestic partner may be able to
continue coverage until eligible for Medicare or other coverage. Dependent children are subject to the
health plan's age and other eligibility requirements. Some restrictions and guidelines apply; please see
your Plan Sponsor for specific details.
COBRA CONTINUATION
Your Plan Sponsor is subject to the continuation of coverage provisions of the Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA) as amended. To find out if you have continuation rights
under COBRA, ask your health plan administrator.
COBRA Eligibility
To be eligible, a member must experience a 'qualifying event' which is an event that causes your
regular group coverage to end and makes you eligible for continuation coverage. When the following
qualifying events happen, you may continue coverage for the lengths of time shown:
Qualifying Event Continuation Period
Employee's termination of employment or reduction in Employee, spouse, and children may continue for up to
hours 18 months'
Employee's divorce or legal separation Souse and children may continue for u to 36 months
Employee's eligibility for Medicare benefits if it causes a Spouse and children may continue for up to 36 months
loss of coverage
Employee's death Souse and children may continue for u to 36 months
Child no longer qualifies as a dependent Child may continue for u to 36 months
Em to er files for Chapter 11 bankruptcy Only applies to retirees and their covered dependents
If the employee or covered dependent is determined disabled by the Social Security Administration within the first
60 days of continuation coverage, all qualified beneficiaries may continue coverage for up to an additional 11
months, for a total of up to 29 months.
2 The total maximum continuation period is 36 months, even if there is a second qualifying event. A second
qualifying event might be a divorce, legal separation, death, or child no longer qualifying as a dependent after the
employee's termination or reduction in hours.
If your dependents were not covered prior to your qualifying event, they may enroll in the continuation
coverage while you are on continuation. They will be subject to the same rules that apply to active
employees, including the late enrollment waiting period.
If your employment is terminated for gross misconduct, you and your dependents are not eligible for
COBRA continuation.
Domestic partners and their covered children may not continue this policy's coverage under COBRA
independent of the employee.
When Continuation Coverage Ends
Your continuation coverage will end before the end of the continuation period above if any of the
following occur:
• Your continuation premium is not paid on time.
• You become covered under another group health plan that does not exclude or limit treatment for
your pre-existing conditions.
• You become entitled to Medicare benefits.
• Your Plan Sponsor discontinues its health plan and no longer offers a group health plan to any of
its employees.
• Your continuation period was extended from 18 to 29 months due to disability, and you are no
longer considered disabled.
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Type of Coverage
Under COBRA, you may continue any coverage you had before the qualifying event. If your Plan
Sponsor provides both medical and dental coverage and you were enrolled in both, you may continue
both medical and dental. If your Plan Sponsor provides only one type of coverage, or if you were
enrolled in only one type of coverage, you may continue only that coverage.
COBRA continuation benefits are always the same as your Plan Sponsors current benefits. Your Plan
Sponsor has the right to change the benefits of its health plan or eliminate the plan entirely. If that
happens, any changes to the group health plan will also apply to everyone enrolled in continuation
coverage.
Your Responsibilities and Deadlines
You must notify your Plan Sponsor within 60 days if you divorce, or if your child no longer qualifies as
a dependent. That will allow your Plan Sponsor to notify you or your dependents of your continuation
rights.
When your Plan Sponsor learns of your eligibility for continuation, your Plan Sponsor will notify you of
your continuation rights and provide a Continuation Election Form. You then have 60 days from that
date or 60 days from the date coverage would otherwise end, whichever is later, to enroll in
continuation coverage by submitting a completed Election Form to your Plan Sponsor. If continuation
coverage is not elected during that 60-day period, coverage will end on the last day of the last month
you were an active employee.
If you do not provide these notifications within the time frames required by COBRA, Plan Sponsors
responsibility to provide coverage under the health plan will end.
Continuation Premium
You or your family members are responsible for the full cost of continuation coverage. The monthly
premium must be paid to your Plan Sponsor. PacificSource cannot accept continuation premium
directly from you. You may make your first premium payment any time within 45 days after you return
your Continuation Election Form to your Plan Sponsor. After the first premium payment, each monthly
payment must reach your Plan Sponsorwithin 30 days of your Plan Sponsors premium due date. If
your Plan Sponsor does not receive your continuation premium on time, continuation coverage will end.
If your coverage is canceled due to a missed payment, it will not be reinstated for any reason. Premium
rates are established annually and may be adjusted if the plan's benefits or costs change.
Keep Your Plan Informed of Address Changes
In order to protect your and your family's rights, you should keep the Plan Sponsor informed of any
changes in your address and the addresses of family members. You should also keep a copy, for your
records, of any notices you send to the Plan Sponsor.
CONTINUATION WHEN YOU RETIRE
If you retire, you and your insured dependents are eligible to continue coverage subject to the following:
• You must apply for continued coverage within 60 days after retirement.
• You must be receiving benefits from PIERS (Public Employee Retirement System) or from a similar
retirement plan offered by your Plan Sponsor.
• You will have the same opportunity to switch to another plan during the open enrollment period as
do active employees. If the plan's benefits are changed by the policyholder, your benefits will
change accordingly.
• Except for newly acquired dependents due to marriage, registration of domestic partnership, birth,
or adoption, only your dependents who were covered at the time of retirement may continue
coverage under this provision. You may add a new spouse, domestic partner, or other newly
acquired dependent after retirement if family coverage is available. A completed enrollment
application must be submitted within 31 days of the date of marriage, registration of domestic
partnership, birth, or adoption.
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Your continuation coverage will end when any one of the following occurs:
• When full premium is not paid or when your coverage is voluntarily terminated, your coverage will
end on the last day of the month for which premium was paid.
• When you become eligible for Medicare coverage, your coverage will end on the last day of the
month preceding Medicare eligibility.
• When the regular group policy is terminated, your coverage will end on the date of termination.
Your dependent's continuation coverage will end when any one of the following occurs:
• When full premium for the dependent is not paid or when the dependent's coverage is voluntarily
terminated by you or your dependent, coverage will end on the last day of the month for which
premium was paid.
• When your dependent becomes eligible for Medicare coverage, your dependent's coverage will end
on the last day of the month preceding Medicare eligibility.
• When you die, divorce, or dissolve your domestic partnership, your dependent's coverage will end
on the last day of the month following the death, divorce, or dissolution of the domestic partnership.
• When your dependent is otherwise no longer considered a dependent under the group plan, his or
her coverage will end on the last day of the month of their eligibility. Continuation of coverage may
be available under COBRA continuation (see Continuation of Coverage provisions).
• When the regular group policy is terminated, your dependent's coverage will end on the date of
termination.
WORK STOPPAGE
Labor Unions
If you are a union member, you have certain continuation rights in the event of a labor strike. Your
union is responsible for collecting your premium and can answer questions about coverage during the
strike.
EXTENSION OF BENEFITS
If you are on a Plan Sponsor-approved non-FMLA leave of absence, you may continue coverage under
active status for up to three months by self pay to the Plan Sponsor. Absences extending beyond three
months will be subject to the Continuation of Insurance provisions of this plan.
COVERED EXPENSES
This plan provides comprehensive medical coverage when care is medically necessary to treat an
illness or injury. Be careful -just because a treatment is prescribed by a healthcare professional does
not mean it is medically necessary under the terms of the plan. Also remember that just because a
service or supply is a covered benefit under this plan does not necessarily mean all billed charges will
be paid.
Some medically necessary services and supplies may be excluded from coverage under this plan. Be
sure you read and understand the Benefit Limitations and Exclusions section of this book, including the
section on Preauthorization. If you ever have a question about your plan benefits, contact the
PacificSource Customer Service Department.
Medical Necessity
Except for specified Preventive Care services, the benefits of this health plan are paid only toward the
covered expense of medically necessary diagnosis or treatment of illness or injury. This is true even
though the service or supply is not specifically excluded. All treatment is subject to review for medical
necessity. Review of treatment may involve prior approval, concurrent review of the continuation of
treatment, post-treatment review or any combination of these. For additional information, see 'medically
necessary' in the Definitions section of this Summary Plan Description.
SingleSource Self-Insured 28
Be careful. Your healthcare provider could prescribe services or supplies that are not covered under
this plan. Also, just because a service or supply is a covered benefit does not mean all related charges
will be paid.
Healthcare Providers
This plan provides benefits only for covered expenses and supplies rendered a physician (M.D. or
O.D.), practitioner, nurse, hospital or specialized treatment facility, durable medical equipment supplier,
or other licensed medical provider as specifically stated in this Summary Plan Description. The services
or supplies provided by individuals or companies that are not specified as eligible practitioners are not
eligible for reimbursement under the benefits of this plan. For additional information, see 'practitioner',
'specialized treatment facility', and 'durable medical equipment supplier' in the Definitions section of this
Summary Plan Description.
Your Annual Deductible
Deductible Carryover. The deductible must be satisfied only once in any benefit year, even though
there may be several conditions treated. Covered expenses incurred during the last three (3) months of
the previous benefit year will be applied to the subsequent year's benefit year deductible subject to the
following:
• The covered expenses were applied to the deductible;
• The covered expenses were incurred during the last three (3) months of the year; and
• The prior year's deductible was not satisfied.
Final determination of which expenses apply to the deductible will be based on the order in which
charges are incurred, even if bills for charges are not received in that order.
Your Annual Out-of-Pocket Limit
This plan has an out-of-pocket limit provision to protect you from excessive medical expenses. The
Medical Benefit Summary shows your plan's annual out-of-pocket limits for participating and/or
nonparticipating providers. If you incur covered expenses over those amounts, this plan will pay 100
percent of eligible charges, subject to the allowable fee.
Your expenses for the following do not count toward the annual out-of-pocket limit:
• Charges applied to deductible, if applicable to your plan
• Co-payments, if applicable to your plan
• Prescription drugs
• Charges over the allowable fee for services of non-participating providers
• Incurred charges that exceed amounts allowed under this plan
Charges over the allowable fee for services of non-participating providers, and incurred charges that
exceed amounts allowed under this plan, and co-payments will continue to be your responsibility even
after the out-of-pocket or stop-loss limit is reached.
Prescription drug benefits are not affected by the out-of-pocket or stop-loss limit. You will still be
responsible for that co-payment or co-insurance payment even after the out-of-pocket or stop-loss limit
is reached.
MEDICAL BENEFITS
About Your Medical Benefits
All benefits provided under this plan must satisfy some basic conditions. The following conditions are
commonly included in health benefit plans but are often overlooked or misunderstood.
SingleSource Self-Insured 29
Medical Necessity - The plan provides benefits only for covered services and supplies that are
medically necessary for the treatment of a covered illness or injury. Be careful-just because a
treatment is prescribed by a healthcare professional does not necessarily mean it is medically
necessary as defined by the plan. And, some medically necessary services and supplies may be
excluded from coverage. Also, the treatment must not be experimental and/or investigational.
Allowable Fees -The plan provides benefits only for covered expenses that are equal to or less than
the allowable amount, as defined by the plan, in the geographic area where services or supplies are
provided. Any amounts that exceed the allowable amount are not recognized by the plan for any
purpose.
Health Care Provider- The plan provides benefits only for covered expenses and supplies rendered
by a physician, practitioner, nurse, hospital or specialized treatment facility, durable medical equipment
supplier, or other licensed medical provider as specifically stated in this plan summary. The services or
supplies provided by individuals or companies that are not specified as eligible practitioners are not
eligible for reimbursement under the benefits of this plan. For additional information, see practitioner,
specialized treatment facility, and durable medical equipment in the Definitions section of this
document.
Custodial Care Providers - The plan does not provide benefits for services and supplies that are
furnished primarily to assist an individual in the activities of daily living. Activities of daily living include
such things as bathing, feeding, administration of oral medications, academic, social, or behavior skills
training, and other services that can be provided by persons without the training of a health care
practitioner.
Benefit Year - The word year, as used in this document, refers to the benefit year, which is the 12-
month period beginning January 1 and ending December 31. Unless otherwise specified, all annual
benefit maximums and deductibles accumulate during the benefit year.
Deductibles - A deductible is the amount of covered expenses you must pay during each year before
the plan will consider expenses for reimbursement. The individual deductible applies separately to each
covered person. The family deductible applies collectively to all covered persons in the same family.
When the family deductible is satisfied, no further deductible will be applied for any covered family
member during the remainder of the year. The annual individual and family deductible amounts are
shown on the Medical Benefit Summary.
Benefit Percentage Payable - Benefit percentage payable represents the portion of covered
expenses paid by the plan after you have satisfied any applicable deductible. These percentages apply
only to covered expenses which do not exceed the allowable amount. You are responsible for all
remaining covered and non-covered expenses, including any amount that exceeds the allowable
amount for covered services. The benefit percentages payable are shown on the Medical Benefit
Summary.
Copayments - Copayments are the first-dollar amounts you must pay for certain covered services,
which are usually paid at the time the service is performed (i.e. physician office visits or emergency
room visits). These copayments do not apply to your annual deductible or out-of-pocket maximum,
unless otherwise specified on the Medical Benefit Summary. The copayment amounts are shown on
the Medical Benefit Summary.
Out-Of-Pocket Maximum(s) - An out-of-pocket maximum is the maximum amount of covered
expenses you must pay during a year, before the plan's benefit percentage payable increases. The
individual out-of-pocket maximum applies separately to each covered person. When a covered person
reaches the annual out-of-pocket maximum, the plan will pay 100% of additional covered expenses for
that individual during the remainder of that year, subject to the lifetime maximum amount, if applicable.
However, expenses for services which do not apply to the out-of-pocket maximum will never be paid at
100%. The annual individual and family out-of-pocket maximum amounts are shown on the Medical
Benefit Summary.
Benefit Maximums - Total plan payments for each covered person are limited to certain maximum
benefit amounts. A benefit maximum can apply to specific benefit categories or to all benefits. A benefit
maximum amount may also apply to a specific time period, such as annual.
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Least Costly Setting For Services - Benefits of the plan provide for reimbursement of covered
services performed in the least costly setting where services can be safely provided. If a procedure can
be done safely in an outpatient setting but is performed in a hospital inpatient setting, this plan will only
pay what it would have paid for the procedure on an outpatient basis. If services are performed in an
inappropriate setting, your benefits may be reduced.
PLAN BENEFITS
This plan provides benefits for the following services and supplies as outlined on your Medical Benefit
Summary. These services and supplies may require you to satisfy a deductible, make a co-payment, or
both, and they may be subject to additional limitations or maximum dollar amounts. For a medical
expense to be eligible for payment, you must be covered under this plan on the date the expense is
incurred. Please refer to your Medical Benefit Summary and the Benefit Limitations and Exclusions
section of this Summary Plan Description for more information.
Accident Benefit
In the event of an injury caused by an accident the plan benefit will be as follows:
The balance is covered as stated in your Medical Benefit Summary for covered expense.
'Accident' means an unforeseen or unexpected event causing injury which requires medical attention.
'Injury' means bodily trauma or damages which is independent of disease or infirmity. The damage
must be caused solely through external and accidental means. For the purpose of this benefit, injury
does not include musculoskeletal sprains or strains obtained in the performance of physical activity.
PREVENTIVE CARE SERVICES
This plan covers the following preventive care services when provided by a physician, physician
assistant, or nurse practitioner:
• Routine physicals for members age 22 and older according to the following schedule:
- Ages 22 and over One exam every benefit year
Only laboratory work tests and other diagnostic testing procedures related to the routine physical
exam are covered by this benefit. Any laboratory tests and other diagnostic testing procedures
ordered during, but not related to, a routine physical examination are not covered by this
preventative care benefit. Please see Outpatient Services in this section.
• Well woman visits, including the following:
- One routine gynecological exam each benefit year for women 18 and over. Exams may
include Pap smear, pelvic exam, breast exam, blood pressure check, and weight check. Exams
may also include an annual mammogram for women over the age of 40, once between the
ages of 35-40 unless medically necessary, for the purpose of early detection. Covered lab
services are limited to occult blood, urinalysis, and complete blood count.
- Routine preventive mammograms for women as recommended.
o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit
Summary for'Preventive Care - Well Woman Visits' applies.
o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit
Summary for'Outpatient Services - Diagnostic and Therapeutic Radiology and Lab'
applies to diagnostic mammograms related to the ongoing evaluation or treatment of a
medical condition.
- Pelvic exams and Pap smear exams at any time upon referral of a women's healthcare
provider; and pelvic exams and Pap smear exams annually for women 18 to 64 years of age
with or without a referral from a women's healthcare provider.
- Breast exams annually for women 18 years of age or older or at any time when recommended
by a women's healthcare provider for the purpose of checking for lumps and other changes for
early detection and prevention of breast cancer.
• Colorectal cancer screening exams and lab work including the following:
SingleSource Self-Insured 31
A fecal occult blood test once per benefit year
A flexible sigmoidoscopy every five benefit years
A colonoscopy for age 50+ every ten benefit years
o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit
Summary for'Preventive Care - Routine Colonoscopy' applies.
o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit
Summary for 'Professional Services - Surgery' and for 'Outpatient Services -
Outpatient Surgery/Services' apply to colonoscopies related to ongoing evaluation or
treatment of a medical condition.
A double contrast barium enema every five benefit years
• Prostate cancer screening, every two benefit years. Exams may include a digital rectal
examination and a prostate-specific antigen test. Screenings apply to outpatient surgery/services
benefit regardless of whether they are preventive or diagnostic.
• Well baby/well child care exams for members age 21 and younger according to the following
schedule:
- At birth: One standard in-hospital exam
- Ages 0 - 2: 12 additional exams during first 36 months of life
- Ages 3 - 21: One exam per benefit year
Newborn circumcision is a covered benefit even if performed several days after birth. Only
laboratory tests and other diagnostic testing procedures related to a well baby/child care exam are
covered by this plan. Any laboratory tests and other diagnostic testing procedures ordered during,
but not related to, a well baby/child care exam are not covered by this preventative care benefit.
Please see Outpatient Services in this section.
• Standard age-appropriated childhood and adult immunizations for primary prevention of infectious
diseases as recommended by and adopted the Centers for Disease Control and Prevention,
American Academy of Pediatrics, American Academy of Family Physicians, or similar standard-
setting body. Benefits do not include immunizations for more elective, investigative, unproven, or
discretionary reasons (e.g. travel). Covered immunizations include, but may not be limited to the
following:
- Diphtheria, pertussis, and tetanus (DPT) vaccines, given separately or together
- Hemophilus influenza B vaccine
- Hepatitis A vaccine
- Hepatitis B vaccine
- Human papillomavirus (HPV) vaccine
- Influenza vaccine
- Measles, mumps, and rubella (MMR) vaccines, given separately or together
- Meningococcal (meningitis) vaccine
- Pneumococcal vaccine
- Polio vaccine
- Varicella (chicken pox) vaccine
• Tobacco use cessation program services are covered only when provided by a PacificSource
,approved program. Approved programs are covered at 100% of the cost up to a maximum lifetime
benefit of two quit attempts. Approved programs are limited to members age 15 or older. Specific
nicotine replacement therapy will only be covered according to the program's description. If this
policy includes benefits for prescription drugs, tobacco use cessation related medication prescribed
in conjunction with an approved tobacco use cessation program will be covered to the same extent
this policy covers other prescription medications.
PROFESSIONAL SERVICES
This plan covers the following professional services when medically necessary:
SingleSource Self-Insured 32
• Services of a physician (M.D. or D.O.) for diagnosis or treatment of illness or injury
• Services of a licensed physician assistant under the supervision of a physician
• Services of a certified surgical assistant, surgical technician, or registered nurse (R.N.) when
providing medically necessary services as a surgical first assistant during a covered surgery
• Services of a nurse practitioner, including certified registered nurse anesthetist (C.R.N.A.) and
certified nurse midwife (C.N.M.), for medically necessary diagnosis or treatment of illness or injury
• Urgent care services provided by a physician. Urgent care is unscheduled medical care for an
illness, injury, or disease that a prudent lay person would consider not life-threatening and treatable
at urgent care. Examples of urgent care situations include sprains, cuts, and illnesses that do not
require immediate medical attention in order to prevent seriously damaging the health of the
person.
• Outpatient rehabilitative services provided by a licensed physical therapist, occupational
therapist, speech language pathologist, physician, or other practitioner licensed to provide physical,
occupational, or speech therapy. Services must be prescribed in writing by a licensed physician,
dentist, podiatrist, nurse practitioner, or physician assistant. The prescription must include site,
modality, duration, and frequency of treatment. Total covered expenses for outpatient rehabilitative
services is limited to a combined maximum of 30 visits per benefit year subject to preauthorization
and concurrent review by PacificSource for medical necessity. Only treatment of neurologic
conditions (e.g. stroke, spinal cord injury, head injury, pediatric neurodevelopmental problems, and
other problems associated with pervasive developmental disorders for which rehabilitative services
would be appropriate for children under 18 years of age) may be considered for additional benefits,
not to exceed 30 visits per condition, when criteria for supplemental services are met.
• Services for speech therapy will only be allowed when needed to correct stuttering, hearing loss,
peripheral speech mechanism problems, and deficits due to neurological disease or injury. Speech
and/or cognitive therapy for acute illnesses and injuries are covered up to one year post injury
when the services do not duplicate those provided by other eligible providers, including
occupational therapists or neuropsychologists.
• Outpatient pulmonary rehabilitation programs are covered when prescribed by a physician for
patients with severe chronic lung disease that interferes with normal daily activities despite optimal
medication management.
• For related provisions, see 'motion analysis', 'vocational rehabilitation', and 'speech therapy' under
'Excluded Services - Types of Treatments' in the Benefit Limitations and Exclusions section of this
Summary Plan Description.
• Services of a physician or a licensed certified nurse midwife for pregnancy. Services are subject to
the same payment amounts, conditions, and limitations that apply to similar expenses for illness,
except that pregnancy is not considered a pre-existing condition.
Please contact the PacificSource Customer Service Department as soon as you learn of your
pregnancy. Pacific Source's staff will explain your plan's maternity benefits and help you enroll in
PacificSource's free prenatal care program.
• Routine nursery care of a newborn while the mother is hospitalized and eligible for pregnancy-
related benefits under this plan if the newborn is also eligible and enrolled in this plan.
• Services of a licensed audiologist for medically necessary audiological (hearing) tests.
• Services of a dentist or physician to treat injury of the jaw or natural teeth. Services must be
provided within 18 months of the injury. Except for the initial examination, services for treatment of
an injury to the jaw or natural teeth require preauthorization to be covered.
• Services of a dentist or physician for orthognathic (jaw) surgery as follows:
- When medically necessary to repair an accidental injury. Services must be provided within
one year after the accident.
- For removal of a malignancy, including reconstruction of the jaw within one year after that
surgery
• Services of a board-certified or board-eligible genetic counselor when referred by a physician or
nurse practitioner for evaluation of genetic disease
SingleSource Self-Insured 33
• Medically necessary telemedical health services for health services covered by this plan when
provided in person by a healthcare professional when the telemedical health service does not
duplicate or supplant a health service that is available to the patient in person. The location of the
patient receiving telemedical health services may include, but is not limited to: hospital; rural health
clinic; federally qualified health center; physician's office; community mental health center; skilled
nursing facility; renal dialysis center; or site where public health services are provided. Coverage of
telemedical health services are subject to the same deductible, co-payment, or co-insurance
requirements that apply to comparable health services provided in person.
HOSPITAL AND SKILLED NURSING FACILITY SERVICES
This plan covers medically necessary hospital inpatient services. Charges for a hospital room are
covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer
semi-private rooms). Charges for a private room are covered if the attending physician orders
hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary
isolation. Coverage includes eligible services provided by a hospital owned or operated by the state of
Oregon, or any state approved mental health and developmental disabilities program.
In addition to the hospital room, covered inpatient hospital services may include (but are not limited to):
• Cardiac care unit
• Operating room
• Anesthesia and post-anesthesia recovery
• Respiratory care
• Inpatient medications
• Lab and radiology services
• Dressings, equipment, and other necessary supplies
The plan does not cover charges for rental of telephones, radios, or televisions, or for guest meals or
other personal items.
Services of a skilled nursing facility and convalescent homes are covered for up to 120 days per
benefit year when preauthorized by PacificSource. Services must be medically necessary. Confinement
for custodial care is not covered.
Inpatient rehabilitative services are covered up to a maximum of 50 days of rehabilitative care per
benefit year, except that treatment for head or spinal cord injuries is covered for up to 60 days per
benefit year. Recreation therapy is only covered as part of an inpatient rehabilitation admission.
Services must be preauthorized by PacificSource
OUTPATIENT SERVICES
This plan covers the following outpatient care services:
• Advanced diagnostic imaging procedures that are medically necessary for the diagnosis of
illness or injury. For purposes of this benefit, advanced diagnostic imaging procedures include CT
scans, MRIs, PET scans, CATH labs and nuclear cardiology studies. When services are provided
as part of a covered emergency room visit, your plan's emergency room benefit applies. In all other
situations and settings, benefits are subject to the deductibles, co-payments, and/or co-insurance
stated in your Medical Benefit Summary for Outpatient Services - Advanced Diagnostic Imaging.
• Diagnostic radiology and laboratory procedures provided or ordered by a physician, nurse
practitioner, or physician assistant. These services may be performed or provided by laboratories,
radiology facilities, hospitals, and physicians, including services in conjunction with office visits.
SingleSource Self-Insured 34
• Benefits for members who are receiving services for end-stage renal disease (ESRD) who are
eligible for Medicare, are limited to 125% of the current Medicare allowable amount for participating
and nonparticipating ESRD service providers. Benefits will continue to be paid at the cost share
level applied to other benefits in the same category for members who are not eligible for Medicare.
PacificSource will contact members when the first ESRD preauthorization request is received to
assist the member in understanding their out-of-pocket expenses and care plan.
• Emergency room services. The emergency room co-payment stated in your Medical Benefit
Summary covers medical screening and any diagnostic tests needed for emergency care, such as
radiology, laboratory work, CT scans, and MRIs. The co-payment does not cover further treatment
provided on referral from the emergency room.
In true medical emergencies, non-participating providers are paid at the participating provider level.
Emergency room charges for services, supplies, or conditions excluded from coverage under this
plan are not eligible for payment. That includes conditions subject to the plan's exclusion periods
for pre-existing and other conditions. Please see the Benefit Limitations and Exclusions section of
this Summary Plan Description.
• Surgery and other outpatient services. Benefits are based on the setting where services are
performed.
- For surgeries or outpatient services performed in a physician's office, the benefit stated in
your Medical Benefit Summary for Professional Services - Office Procedures and Supplies
applies.
- For surgeries or outpatient services performed in an ambulatory surgical center or
outpatient hospital setting, both the benefits stated in your Medical Benefit Summary for
Professional Services - Surgery and the Outpatient Services -Outpatient Surgery/Services
apply.
• Therapeutic radiology services, chemotherapy, and renal dialysis provided or ordered by a
physician. Covered services include a prescribed, orally administered anticancer medication used
to kill or slow the growth of cancerous cells.
• Other medically necessary diagnostic services provided in a hospital or outpatient setting,
including testing or observation to diagnose the extent of a medical condition.
EMERGENCY SERVICES
In a true medical emergency, this plan covers services and supplies necessary to determine the nature
and extent of the emergency condition and to stabilize the patient.
An emergency medical condition is an injury or sudden illness, including severe pain, so severe that a
prudent layperson with an average knowledge of health and medicine would expect that failure to
receive immediate medical attention would risk seriously damaging the health of a person or fetus in the
case of a pregnant woman. Examples of emergency medical conditions include (but are not limited to):
• Unusual or heavy bleeding
• Sudden abdominal or chest pains
• Suspected heart attacks
• Major traumatic injuries
• Serious burns
• Poisoning
• Unconsciousness
• Convulsions or seizures
• Difficulty breathing
• Sudden fevers
SingleSource Self-Insured 35
If you need immediate assistance for a medical emergency, call 911. If you have an emergency
medical condition, you should go directly to the nearest emergency room or appropriate facility. Care
for a medical emergency is covered at the participating provider percentage stated in your Medical
Benefit Summary even if you are treated at a non-participating hospital.
If you are admitted to a non-participating hospital after your emergency condition is stabilized, your Plan
Sponsor may require you to transfer to a participating facility in order to continue receiving benefits at
the participating provider level.
Maternity Services
Maternity means, in any one pregnancy, all prenatal services including complications and miscarriage,
delivery, postnatal services provided within six months of delivery, and routine nursery care of a
newborn child. Maternity services are covered subject to the deductible, co-payments, and/or co-
insurance stated in your Medical Benefit Summary regardless of marital status.
• Services of a physician or a licensed certified nurse midwife for pregnancy. Services are subject to
the same payment amounts, conditions, and limitations that apply to similar expenses for illness.
• Please contact the PacificSoume Customer Service Department as soon as you learn of your
pregnancy. PacificSource's staff will explain your plan's maternity benefits and help you enroll in
PacificSource's free prenatal care program.
• This plan provides routine nursery care of a newborn while the mother is hospitalized and eligible
for pregnancy-related benefits under this plan if the newborn is also eligible and enrolled in this
plan, regardless of marital status.
Special Information about Childbirth - This plan covers hospital inpatient services for childbirth
according to the Newborns' and Mothers' Health Protection Act of 1996. This plan does not restrict the
length of stay for the mother or newborn child to less than 48 hours after vaginal delivery, or to less
than 96 hours after Cesarean section delivery. Your provider is allowed to discharge you or your
newborn sooner than that, but only if you both agree. For childbirth, your provider does not need to
preauthorize your hospital stay with PacificSource.
MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES
This plan covers medically necessary crisis intervention, diagnosis, and treatment of mental health
conditions and chemical dependency. Refer to the Benefit Limitations and Exclusions section of this
Summary Plan Description for more information on services not covered by your plan.
Mental Health and Chemical Dependency Services
It is the intent of this plan to comply with all existing regulations of Mental Health Parity and Addiction
Equity Act of 2008 (MHPAEA). If for some reason the information presented in the plan differs from the
actual regulations of the MHPAEA, the plan reserves the right to administer the plan in accordance with
such actual regulations.
Providers Eligible for Reimbursement
A mental and/or chemical healthcare provider (see Definitions section of this Summary Plan
Description) is eligible for reimbursement if:
• The mental and/or chemical healthcare provider is approved by the Oregon Department of Human
Services;
• The mental and/or chemical healthcare provider is accredited for the particular level of care for
which reimbursement is being requested by the Oregon Joint Commission on Accreditation of
Hospitals or the Commission on Accreditation of Rehabilitation Facilities; or
• The patient is staying overnight at the mental and/or chemical healthcare facility (see Definitions
section of this Summary Plan Description) and is involved in a structured program at least eight
hours per day, five days per week; or
• The mental and/or chemical healthcare provider is providing a covered benefit under this policy;
and
SingleSource Self-Insured 36
Eligible mental and/or chemical healthcare providers are:
• A program licensed, approved, established, maintained, contracted with, or operated by the
Addictions and Mental Health Division of the Oregon Health Authority,
• A medical or osteopathic physician licensed by the State Board of Medical Examiners;
• A psychologist (Ph.D.) licensed by the State Board of Psychologists' Examiners;
• A nurse practitioner registered by the State Board of Nursing;
• A clinical social worker (L.C.S.W.) licensed by the State Board of Clinical Social Workers;
• A Licensed Professional Counselor (L.P.C) licensed by the State Board of Licensed Professional
Counselors and Therapists;
• A Licensed Marriage and Family Therapist (L.M.F.T) licensed by the State Board of Licensed
Professional Counselors and Therapists; and
• A hospital or other healthcare facility licensed by the Joint Commission on Accreditation of
Hospitals or the Commission on Accreditation of Rehabilitation Facilities for inpatient or residential
care and treatment of mental health conditions and/or chemical dependency.
Medical Necessity and Appropriateness of Treatment
• As with all medical treatment, mental health and chemical dependency treatment is subject to
review for medical necessity and/or appropriateness. Review of treatment may involve pre-service
review, concurrent review of the continuation of treatment, post-treatment review, or a combination
of these. PacificSource will notify the patient and patient's provider when a treatment review is
necessary to make a determination of medical necessity.
• A second opinion may be required for a medical necessity determination. PacificSource will notify
the patient when this requirement is applicable.
• PacificSource must be notified of an emergency admission within two business days.
• Medication management by an M.D. (such as a psychiatrist) does not require review.
• Treatment of substance abuse and related disorders is subject to placement criteria established by
the American Society of Addiction Medicine.
Mental Health Parity and Addiction Equity Act of 2008
This group health plan complies with all federal laws and regulations related to the Mental Health Parity
and Addiction Equity Act of 2008.
HOME HEALTH AND HOSPICE SERVICES
• This plan covers home health services up to 180 visits per benefit year when preauthorized by
PacificSource. Covered services include skilled nursing by a R.N. or L.P.N.; physical, occupational,
and speech therapy; and medical social work services provided by a licensed home health agency.
Private duty nursing is not covered.
• Home infusion services are covered when preauthorized by PacificSource. This benefit covers
parenteral nutrition, medications, and biologicals (other than immunizations) that cannot be self-
administered. Benefits are paid at the percentage stated in your Medical Benefit Summary for home
health care.
• This plan covers hospice services when preauthorized by PacificSource. Hospice services are
intended to meet the physical, emotional, and spiritual needs of the patient and family during the
final stages of illness and dying, while maintaining the patient in the home setting. Services are
intended to supplement the efforts of an unpaid caregiver. Hospice benefits do not cover services
of a primary caregiver such as a relative or friend, or private duty nursing. PacificSource uses the
following criteria to determine eligibility for hospice benefits:
- The member's physician must certify that the member is terminally ill with a life expectancy of
less than six months;
- The member must be living at home;
- A non-salaried primary caregiver must be available and willing to provide custodial care to the
member on a daily basis; and
SingleSource Self-Insured 37
- The member must not be undergoing treatment of the terminal illness other than for direct
control of adverse symptoms.
Only the following hospice services are covered:
- Home nursing visits.
- Home health aides when necessary to assist in personal care.
- Home visits by a medical social worker.
- Home visits by the hospice physician.
- Prescription medications for the relief of symptoms manifested by the terminal illness.
- Medically necessary physical, occupational, and speech therapy provided in the home.
- Home infusion therapy.
- Durable medical equipment, oxygen, and medical supplies.
- Respite care provided in a nursing facility to provide relief for the primary caregiver, subject to a
maximum of five consecutive days and to a lifetime maximum benefit of 30 days. A member
must be enrolled in a hospice program to be eligible for respite care benefits.
- Inpatient hospice care when provided by a Medicare-certified or state-certified program when
admission to an acute care hospital would otherwise be medically necessary.
- Pastoral care and bereavement services.
The member retains the right to all other services provided under this contract, including active
treatment of non-terminal illnesses, except for services of another provider that duplicate the services of
the hospice team.
DURABLE MEDICAL EQUIPMENT
• This plan covers prosthetic and orthotic devices that are medically necessary to restore or
maintain the ability to complete activities of daily living or essential job-related activities and that are
not solely for comfort or convenience. Benefits include coverage of all services and supplies
medically necessary for the effective use of a prosthetic or orthotic device, including formulating its
design, fabrication, material and component selection, measurements, fittings, static and dynamic
alignments, and instructing the patient in the use of the device. Benefits also include coverage for
any repair or replacement of a prosthetic or orthotic device that is determined medically necessary
to restore or maintain the ability to complete activities of daily living or essential job-related activities
and that is not solely for comfort or convenience.
• This plan covers durable medical equipment prescribed exclusively to treat medical conditions.
Covered equipment includes crutches, wheelchairs, orthopedic braces, home glucose meters,
equipment for administering oxygen, and non-power assisted prosthetic limbs and eyes. Durable
medical equipment must be prescribed by a licensed M.D., D.O., N.P., P.A., D.D.S., D.M.D., or
D.P.M. to be covered. This plan does not cover equipment commonly used for nonmedical
purposes, for physical or occupational therapy, or prescribed primarily for comfort. Please see
'Excluded Services - Equipment and Devices' in the Benefit Limitations and Exclusions section for
information on items not covered. The following limitations apply to durable medical equipment:
- This benefit covers the cost of either purchase or rental of the equipment for the period
needed, whichever is less. Repair or replacement of equipment is also covered when
necessary, subject to all conditions and limitations of the plan. If the cost of the purchase,
rental, repair, or replacement is over $800, preauthorization by PacificSource is required.
- Only expenses for durable medical equipment, or prosthetic and orthotic devices that are
provided by a PacificSource contracted provider or a provider that satisfies the criteria of
the Medicare fee schedule for Suppliers of Durable Medical Equipment, Prosthetics,
Orthotics, Supplies (DMEPOS) and Other Items and Services Summary Plan Description
are eligible for reimbursement. Mail order or Internet/Web based providers are not eligible
providers.
- Purchase, rental, repair, lease, or replacement of a power-assisted wheelchair (including
batteries and other accessories) requires preauthorization by PacificSource and is payable
only in lieu of benefits for a manual wheelchair.
SingleSource Self-Insured 38
The durable medical equipment benefit also covers lenses to correct a specific vision
defect resulting from a severe medical or surgical problem, such as stroke, neurological
disease, trauma, or eye surgery other than refraction procedures. Coverage is subject to
the following limitations:
o The medical or surgical problem must cause visual impairment or disability due to loss
of binocular vision or visual field defects (not merely a refractive error or astigmatism)
that requires lenses to restore some normalcy to vision.
o The maximum allowance for glasses (lenses and frames), or contact lenses in lieu of
glasses, is limited to $200 per initial case. 'Initial case' is defined as the first time
surgery or treatment is performed on either eye. Other policy limitations, such as
exclusions for extra lenses, other hardware, tinting of lenses, eye exercises, or vision
therapy, also apply.
o Benefits for subsequent medically necessary vision corrections to either eye (including
an eye not previously treated) are limited to the cost of lenses only.
Reimbursement is subject to the deductible, co-payment, and/or co-insurance stated in
your Medical Benefit Summary for durable medical equipment and is in lieu of, and not in
addition to benefits payable under any vision endorsement that may be added to this plan.
The durable medical equipment benefit also covers hearing aids for members under 18
years of age and younger, or 25 years of age and younger if the member is enrolled in a
secondary school or an accredited educational institution. Coverage is limited to a
maximum benefit of $4,000 every 48 months. The benefit amount may be adjusted on
January 1 of each year to reflect the U.S City Average Consumer Price Index.
Medically necessary treatment for sleep apnea and other sleeping disorders is covered
when preauthorized by PacificSource. Coverage of oral devices includes charges for
consultation, fitting, adjustment, follow-up care, and the appliances , is limited to a lifetime
maximum benefit of $500, including charges for consultation, fitting, adjustment, follow-up
care, and the appliance.. The appliance must be prescribed by a physician specializing in
evaluation and treatment of obstructive sleep apnea, and the condition must meet criteria
for obstructive sleep apnea.
Wigs following chemotherapy or radiation therapy are covered up to a maximum benefit of
$150 per benefit year.
Breastfeeding pumps, manual and electric, are covered at no cost per pregnancy when
purchased or rented from a licensed provider, or purchased from a retail outlet. Hospital-
grade breast pumps are excluded under preventive care and regular benefits.
TRANSPLANT SERVICES
This plan covers certain medically necessary organ and tissue transplants. It also covers the cost of
acquiring organs or tissues needed for covered transplants and limited travel expenses for the patient,
subject to certain limitations.
All pretransplant evaluations, services, treatments, and supplies for transplant procedures require
preauthorization by PacificSource.
You must have been covered under this plan for at least 24 consecutive months or since birth to be
eligible for transplant benefits, including benefits for transplantation evaluation. See Exclusion Periods -
Transplants in the Benefit Limitations and Exclusions section of this Summary Plan Description for
details.
This plan covers the following medically necessary organ and tissue transplants:
• Kidney
• Kidney - Pancreas
• Pancreas whole organ transplantation (under certain criteria)
• Heart
• Heart - Lung
SingleSource Self-Insured 39
• Lung
• Liver (under certain criteria)
• Bone marrow and peripheral blood stem cell
• Pediatric bowel
This plan only covers transplants of human body organs and tissues. Transplants of artificial, animal, or
other non-human organs and tissues are not covered.
Expenses for the acquisition of organs or tissues for transplantation are covered only when the
transplantation itself is covered under this contract, and is subject to the following limitations:
• Testing of related or unrelated donors for a potential living related organ donation is payable at the
same percentage that would apply to the same testing of an insured recipient.
• Expense for acquisition of cadaver organs is covered, payable at the same percentage and subject
to the same maximum dollar limitation, if any, as the transplant itself.
• Medical services required for the removal and transportation of organs or tissues from living donors
are covered. Coverage of the organ or tissue donation is at the same percentage payable for the
transplant itself up to $5,000 if the donor is a member of this plan, and applies to the maximum
dollar limitation for the transplant, if any.
- If the donor is not a PacificSource member, only those complications of the donation that occur
during the initial hospitalization are covered, and such complications are covered only to the
extent that they are not covered by another health plan or government program. Coverage is at
the same percentage payable for the transplant itself, and also applies to the maximum dollar
limitation, if any, for the transplant.
- If the donor is a PacificSource member, complications of the donation are covered as any other
illness would be covered.
• Transplant related services, including HLA typing, sibling tissue typing, and evaluation costs, are
considered transplant expenses and accumulate toward any transplant benefit limitations and are
subject to PacificSource's provider contractual agreements (see Payment of Transplant Benefits,
below).
Travel and housing expenses for the recipient are limited to $5,000 per transplant. Travel and living
expenses are not covered for the donor.
Payment of Transplant Benefits
If a transplant is performed at a participating Center of Excellence transplantation facility, covered
charges of the facility are subject to plan deductibles (co-insurance and co-payment amounts after
deductible are waived). If PacificSource's contract with the facility includes the services of the medical
professionals performing the transplant (such as physicians, nurses, and anesthesiologists), those
charges are also subject to plan deductibles (co-insurance and co-payment amounts after deductible
are waived). If the professional fees are not included in PacificSource's contract with the facility, then
those benefits are provided according to your Medical Benefit Summary.
If transplant services are available through a contracted transplantation facility but are not performed at
a contracted facility, you are responsible for satisfying any deductibles or co-payments stated in your
Medical Benefit Summary. This plan then pays at of 60% of the UCR after deductible and co-payments.
Services of non-participating medical professionals are paid at the non-participating provider benefit
level percentages and do not apply to the out-of-pocket maximum.
OTHER COVERED SERVICES, SUPPLIES, AND
TREATMENTS
• This plan covers services of a state certified ground or air ambulance when private transportation
is medically inappropriate because the acute medical condition requires paramedic support.
Benefits are provided for emergency ambulance service and/or transport to the nearest facility
capable of treating the condition. Air ambulance service is covered only when ground transportation
is medically or physically inappropriate. Reimbursement to nonparticipating air ambulance services
are based on 125% of the Medicare allowance. In some cases Medicare allowance may be
SingleSource Self-Insured 40
significantly lower than the provider's billed amount. The provider may hold you responsible for the
amount they bill in excess of the Medicare allowance, as well as applicable deductibles and
coinsurance. Medically necessary travel, other than transportation by a licensed ambulance
service, to the nearest facility qualified to treat the patient's medical condition is covered when
approved in advance by PacificSource.
• This plan covers biofeedback to treat migraine headaches or urinary incontinence when provided
by an otherwise eligible practitioner.
• This plan covers blood transfusions, including the cost of blood or blood plasma.
• This plan covers removal, repair, or replacement of an internal breast prosthesis due to a
contracture or rupture, but only when the original prosthesis was for a medically necessary
mastectomy. Preauthorization by PacificSource is required, and eligibility for benefits is subject to
the following criteria:
- The contracture or rupture must be clinically evident by a physician's physical examination,
imaging studies, or findings at surgery.
- This plan covers removal, repair, and/or replacement of the prosthesis; a new reconstruction is
not covered.
- Removal, repair, and/or replacement of the prosthesis is not covered when recommended due
to an autoimmune disease, connective tissue disease, arthritis, allergenic syndrome,
psychiatric syndrome, fatigue, or other systemic signs or symptoms.
- PacificSource may require a signed loan receipt/subrogation agreement before providing
coverage for this benefit.
• This plan covers breast reconstruction in connection with a medically necessary mastectomy.
Coverage is provided in a manner determined in consultation with the attending physician and
patient for:
- All stages of reconstruction of the breast on which the mastectomy was performed;
- Surgery and reconstruction of the other breast to produce a symmetrical appearance;
- Prostheses; and
- Treatment of physical complications of the mastectomy, including lymphedema
Benefits for breast reconstruction are subject to all terms and provisions of the plan, including
deductibles, co-payments and/or co-insurance stated in your Medical Benefit Summary.
• This plan covers cardiac rehabilitation as follows:
- Phase I (inpatient) services are covered under inpatient hospital benefits.
- Phase II (short-term outpatient) services are covered subject to the deductible, co-payment,
and/or co-insurance stated in your Medical Benefit Summary for outpatient hospital
benefits. Benefits are limited to services provided in connection with a cardiac rehabilitation
exercise program that does not exceed 36 sessions and that are considered reasonable
- and necessary.
- Phase III (long-term outpatient) services are not covered.
• This plan covers IUD, diaphragm, and cervical cap contraceptive devices along with their
insertion or removal. Contraceptive devices that can be obtained over the counter or without a
prescription, such as condoms are not covered.
• This plan covers corneal transplants. Preauthorization is not required.
• In the following situations, this plan covers one attempt at cosmetic or reconstructive surgery:
- When necessary to correct a functional disorder; or
- When necessary because of an accidental injury, or to correct a scar or defect that resulted
from treatment of an accidental injury; or
- When necessary to correct a scar or defect on the head or neck that resulted from a
covered surgery.
Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar,
or defect first occurred. Preauthorization by PacificSource is required for all cosmetic and
SingleSource Self-Insured 41
reconstructive surgeries covered by this plan. For information on breast reconstruction, see 'breast
prosthesis' and 'breast reconstruction' in this section.
• This plan covers dental and orthodontic services for the treatment of craniofacial anomalies when
medically necessary to restore function. Coverage includes but is not limited to physical disorders
identifiable at birth that affect the bony structures of the face or head, such as cleft palate, cleft lip,
craniosynostosis, craniofacial microsomia and Treacher Collins syndrome. Coverage is limited to
the least costly clinically appropriate treatment. Cosmetic procedures and procedures to improve on
the normal range of functions are not covered. See the exclusions for cosmetic/reconstructive
services, dental examinations and treatment, jaw surgery, and orthognathic surgery under the
'Excluded Services' section
• This plan provides coverage for certain diabetic supplies and training as follows:
Diabetic supplies other than insulin and syringes (such as lancets, test strips, and glucostix)
are covered subject to the deductible, co-payment, and/or co-insurance stated in your
Medical Benefit Summary for durable medical equipment. You may purchase those
supplies from any retail outlet and send your receipts to PacificSource, along with your
name, group number, and member ID number. PacificSource will process the claim and
mail you a reimbursement check.
- Diabetic insulin and syringes are covered under your prescription drug benefit, if your plan
includes prescription coverage. Lancets and test strips are also available under that
prescription benefit in lieu of those covered supplies under the medical plan.
- This plan covers one diabetes self-management education program at the time of
diagnosis, and up to three hours of education per year if there is a significant change in
your condition or its treatment. To be covered, the training must be provided by an
accredited diabetes education program, or by a physician, registered nurse, nurse
practitioner, certified diabetes educator, or licensed dietitian with expertise in diabetes.
- This plan covers medically necessary telemedical health services provided in connection
with the treatment of diabetes (see Professional Services in this section).
• This plan covers dietary or nutritional counseling provided by a registered dietitian under certain
circumstances. It is covered under the diabetic education benefit, or for management of inborn
errors of metabolism (excluding obesity), or for management of anorexia nervosa or bulimia
nervosa (to a lifetime maximum of five visits).
• This plan covers nonprescription elemental enteral formula ordered by a physician for home use.
Formula is covered when medically necessary to treat severe intestinal malabsorption and the
formula comprises a predominant or essential source of nutrition. Coverage is subject to the
deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for durable
medical equipment.
• This plan covers routine foot care for patients with diabetes mellitus.
• Hospitalization for dental procedures is covered when the patient has another serious medical
condition that may complicate the dental procedure, such as serious blood disease, unstable
diabetes, or severe cardiovascular disease, or the patient is physically or developmentally disabled
with a dental condition that cannot be safely and effectively treated in a dental office. Coverage
requires preauthorization by PacificSource, and only charges for the facility, anesthesiologist, and
assistant physician are covered. Hospitalization because of the patient's apprehension or
convenience is not covered.
• This plan covers treatment for inborn errors of metabolism involving amino acid, carbohydrate,
and fat metabolism for which widely accepted standards of care exist for diagnosis, treatment, and
monitoring exist, including quantification of metabolites in blood, urine or spinal fluid or enzyme or
DNA confirmation in tissues. Coverage includes expenses for diagnosing, monitoring and
controlling the disorders by nutritional and medical assessment, including but not limited to clinical
visits, biochemical analysis and medical foods used in the treatment of such disorders. Nutritional
supplies are covered subject to the deductible, co-payment, and/or co-insurance stated in your
Medical Benefit Summary for durable medical equipment.
• Injectable drugs and biologicals administered by a physician are covered when medically
necessary for diagnosis or treatment of illness or injury. This benefit does not include
immunizations (see Preventive Care Services in this section) or drugs or biologicals that can be
self-administered or are dispensed to a patient.
SingleSource Self-Insured 42
• This plan covers maxillofacial prosthetic services when prescribed by a physician as necessary
to restore and manage head and facial structures. Coverage is provided only when head and facial
structures cannot be replaced with living tissue, and are defective because of disease, trauma, or
birth and developmental deformities. To be covered, treatment must be necessary to control or
eliminate pain or infection or to restore functions such as speech, swallowing, or chewing.
Coverage is limited to the least costly clinically appropriate treatment, as determined by the
physician. Cosmetic procedures and procedures to improve on the normal range of functions are
not covered. Dentures, prosthetic devices for treatment of TMJ conditions, and artificial larynx are
also not covered.
• Pediatric dental care is not covered.
• The routine costs of care associated with approved clinical trials are covered. Benefits are
only provided for routine costs of care associated with approved clinical trials. Expenses for
services or supplies that are not considered routine costs of care are not covered. For more
information, see 'routine costs of care' in the Definitions section of this Summary Plan Description.
A'qualified individual' is someone who is eligible to participate in a qualifying clinical trial. If a
participating provider is participating in an approved clinical trial, the qualified individual may be
required to participate in the trial through that participating provider if the provider will accept the
individual as a participant in the trial.
• Sleep studies are covered when ordered by a pulmonologist, neurologist, otolaryngologist, or
certified sleep medicine specialist, and when performed at a certified sleep laboratory.
• This plan covers medically necessary therapy and services for the treatment of traumatic brain
injury.
• This plan covers tuba) ligation and vasectomy procedures with no waiting period.
BENEFIT LIMITATIONS AND EXCLUSIONS
Least Costly Setting for Services
Covered services must be performed in the least costly setting where they can be provided safely. If a
procedure can be done safely in an outpatient setting but is performed in a hospital inpatient setting,
this plan will only pay what it would have paid for the procedure on an outpatient basis. If services are
performed in an inappropriate setting, your benefits can be reduced by up to 30 percent or $2,500,
whichever is less.
EXCLUDED SERVICES
A Note About Optional Benefits
If your Plan Sponsor provides coverage for optional benefits such as prescription drugs, vision services,
chiropractic care, or alternative care, you'll find those Member Benefit Summaries in this Summary Plan
Description. If your Plan Sponsor provides optional benefits for an exclusion listed below, then the
exclusion does not apply to the extent that coverage exists under the optional benefit. For example, if
your Plan Sponsor provides optional chiropractic coverage, then the exclusion for chiropractic care
listed below under 'Types of Treatment' does not apply to you.
Types of Treatment- This plan does not cover the following:
• Acupuncture
• Chelation therapy including associated infusions of vitamins and/or minerals, except as medically
necessary for the treatment of selected medical conditions and medically significant heavy metal
toxicities
• Day care or custodial care - Care and related services designed essentially to assist a person in
maintaining activities of daily living, e.g. services to assist with walking, getting in/out of bed,
bathing, dressing, feeding, preparation of meals, homemaker services, special diets, rest cures,
day care, and diapers. Custodial care is only covered in conjunction with respite care allowed under
this plan's hospice benefit. For related provisions, see'Hospital and Skilled Nursing Facility
Services' and 'Home Health and Hospice Services' in the Covered Expenses section of this
Summary Plan Description.
SingleSource Self-Insured 43
• Dental examinations and treatment, which means any services or supplies to prevent, diagnose, or
treat diseases of the teeth and supporting tissues or structures, except as specified in Covered
Expenses - Preventive Care Services except as specifically provided with a separate PacificSource
Dental Plan (See the Dental Benefit Plan section of this Summary Plan Description).
• Eye exercises, therapy, and procedures - Orthoptics, vision therapy, and procedures intended to
correct refractive errors
• Fitness or exercise programs and health or fitness club memberships
• Foot care (routine) - Services and supplies for corns and calluses of the feet, conditions of the
toenails other than infection, hypertrophy or hyperplasia of the skin of the feet, and other routine
foot care, except in the case of patients being treated for diabetes mellitus
• Genetic (DNA) testing, except for tests identified as medically necessary for the diagnosis and
standard treatment of specific diseases
• Homeopathic treatment
• Infertility - Services and supplies, surgery, treatment, or prescriptions to prevent, or cure infertility
or to induce fertility (including Gamete and/or Zygote Interfallopian Transfer; i.e. GIFT or ZIFT),
except for medically necessary medication to preserve fertility during treatment with cytotoxic
chemotherapy. For related provisions, see the exclusion for'family planning' in this section. For
purposes of this plan, infertility is defined as:
o Male: Low sperm counts or the inability to fertilize an egg
o Female: The inability to conceive or carry a pregnancy to 12 weeks
• Instructional or educational programs, except diabetes self-management programs
• Jaw - Services or supplies for developmental or degenerative abnormalities of the jaw,
malocclusion, dental implants, or improving placement of dentures.
• Massage, massage therapy, or neuromuscular re-education, even as part of a physical therapy
program
• Motion analysis, including videotaping and 3-D kinematics, dynamic surface and fine wire
electromyography, and physician review
• Myeloablative high dose chemotherapy, except when the related transplant is specifically covered
under the transplantation provisions of this plan. For related provisions, see 'Transplant Services' in
the Covered Expenses section of this Summary Plan Description.
• Naturopathic treatment
• Obesity or weight control - Surgery or other related services or supplies provided for weight control
or obesity (including all categories of obesity) except as listed under 'Preventive Care Services',
whether or not there are other medical conditions related to or caused by obesity. This also
includes services or supplies used for weight loss, such as food supplementation programs and
behavior modification programs, regardless of the medical conditions that may be caused or
exacerbated by excess weight, and self-help or training programs for weight control. Obesity
screening and counseling are covered for children and adults; see the 'dietary or nutritional
counseling' section under'Other Covered Services'.
• Oral/facial motor therapy for strengthening and coordination of speech-producing musculature and
structures
• Osteopathic manipulation, except for treatment of disorders of the musculoskeletal system
• Physical or eye examinations required for administrative purposes such as participation in athletics,
admission to school, or by a Plan Sponsor
• Private nursing service
• Programs that teach a person to use medical equipment, care for family members, or self
administer drugs or nutrition (except for diabetic education benefit)
• Rehabilitation - Functional capacity evaluations, work hardening programs, vocational
rehabilitation, community reintegration services, and driving evaluations and training programs
• Routine services and supplies - Services, supplies, and equipment not involved in diagnosis or
treatment but provided primarily for the comfort, convenience, cosmetic purpose, environmental
SingleSource Self-Insured 44
control, or education of a patient or for the processing of records or claims. These include but are
not limited to:
o Missed appointments, completion of claim forms, or reports requested by PacificSource in
order to process claims
o Appliances, such as air conditioners, humidifiers, air filters, whirlpools, hot tubs, heat
lamps, or tanning lights
o Private nursing services or personal items such as telephones, televisions, and guest
meals in a hospital or skilled nursing facility
o Maintenance supplies and equipment not unique to medical care
• Screening tests - Services and supplies, including imaging and screening exams performed for the
sole purpose of screening and not associated with specific diagnoses and/or signs and symptoms
of disease or of abnormalities on prior testing (including but not limited to total body CT imaging, CT
colonography and bone density testing).This does not include preventive care screenings listed
under 'Preventive Care Services' in the Covered Expenses section of this Summary Plan
Description.
• Self-help or training programs
• Sexual disorders - Services or supplies for the treatment of sexual dysfunction or inadequacy
unless medically necessary to treat a mental health issue and diagnosis. For related provisions,
see the exclusions for'family planning', 'infertility', and 'mental illness' in this section.
• Snoring - Services or supplies for the diagnosis or treatment of snoring or upper airway resistance
disorders, including somnoplasty
• Speech therapy - Oral/facial motor therapy for strengthening and coordination of speech-producing
muscles and structures, except as medically necessary in the restoration or improvement of speech
following a traumatic brain injury or for a child 17 years of age or younger diagnosed with a
pervasive developmental disorder.
• Temporomandibular joint (TMJ)-related services, or treatment for associated myofascial pain,
including physical or oromyofacial therapy
Surgeries and Procedures - This plan does not cover the following:
• Abdominoplasty for any indication
• Artificial insemination, in vitro fertilization, or GIFT procedures
• Cosmetic/reconstructive services and supplies - Except as specified in the Covered Expenses -
Other Covered Services, Supplies, and Treatments section of this Summary Plan Description,
services and supplies, including drugs, rendered primarily for cosmetic/reconstructive purposes and
any complications as a result of non-covered cosmetic/reconstructive surgery.
Cosmetic/reconstructive services and supplies are those performed primarily to improve the body's
appearance and not primarily to restore impaired function of the body, regardless of whether the
area to be treated is normal or abnormal.
• Electronic Beam Tomography (EBT)
• Eye refraction procedures, orthoptics, vision therapy, or other services to correct refractive error
except as indicated in the Covered Services section of this Summary Plan Description
• Jaw surgery - Treatment for abnormalities of the jaw, malocclusion, or improving the placement of
dentures and dental implants
• Orthognathic surgery - Services and supplies to augment or reduce the, upper or lower jaw, except
as specified under 'Professional Services' in the Covered Expenses section of this Summary Plan
Description.
• Panniculectomy for any indication
• Sex reassignment - Procedures, services or supplies related to a sex reassignment unless
medically necessary. For related provisions, see exclusions for'mental illness' in this section.
o Excluded procedures include, but are not limited to: staged gender reassignment surgery,
including breast augmentation; penile implantation; liposuction, thyroid chondroplasty,
SingleSource Self-Insured 45
laryngoplasty, or shortening of the vocal cords, and/or hair removal specifically to assist the
appearance of other characteristics of gender reassignment.
• Surgery to reverse voluntary sterilization
• Transplants - Any services, treatments, or supplies for the transplantation of bone marrow or
peripheral blood stem cells or any human body organ or tissue, except as expressly provided under
the provisions of this plan for covered transplantation expenses. For related provisions see
'Transplant Services' in the Covered Expenses section of this Summary Plan Description.
Mental Health Services - This plan does not cover the following services, whether provided by a
mental health or chemical dependency specialist or by any other provider:
Treatment for the following diagnosis:
• Diagnostic codes V 15.81 through V71.09 (DSM-IV-TR, Forth Edition) except V61.20, V61.21, and
V62.82 when used with children five years of age or younger
• Food dependencies
• Gender Identity Disorders in Adults (GID)
• Learning disorders
• Mental illness does not include - Treatment of intellectual disabilities; learning disorders,
paraphilias; and relationship problems (e.g. parent-child, partner, sibling, or other relationship
issues), except the treatment of children five years of age or younger for parent-child relational
problems, physical abuse of a child, sexual abuse of a child, neglect of a child, or bereavement.
This plan does not cover educational or correctional services or sheltered living provided by a
school or halfway house, except outpatient services received while temporarily living in a shelter,
psychoanalysis or psychotherapy received as part of an educational or training program, regardless
of diagnosis or symptoms that may be present; a court-ordered sex offender treatment program; a
court-ordered screening interview or drug or alcohol treatment program; or nicotine related
disorders.
The following treatment types are also excluded, regardless of diagnosis: marital/partner
counseling; support groups; sensory integration training; biofeedback except to treat migraine
headaches or urinary incontinence; hypnotherapy; academic skills training; narcosynthesis;
aversion therapy; and social skill training. Recreation therapy is only covered as part of an inpatient
or residential admission.
The following are also excluded: court-mandated diversion and/or chemical dependency education
classes; court-mandated psychological evaluations for child custody determinations; voluntary
mutual support groups such as Alcoholics Anonymous; adolescent wilderness treatment programs;
mental examinations for the purpose of adjudication of legal rights; psychological testing and
evaluations not provided as an adjunct to treatment or diagnosis of a stress management,
parenting skills, or family education; assertiveness training; image therapy; sensory movement
group therapy; marathon group therapy, sensitivity training; and psychological evaluation for sexual
dysfunction or inadequacy.
• Mental retardation for individuals 18 years of age or older
• Nicotine related disorders
• Paraphilias
Treatment programs, training, or therapy as follows:
• Academic skills training
• Aversion therapy
• Biofeedback (other than as specifically noted under the Covered Expenses - Other covered
Services, Supplies, and Treatment section)
• Court-ordered sex offender treatment programs
• Court-ordered screening interviews or drug or alcohol treatment programs
• Educational or correctional services or sheltered living provided by a school or halfway house
• Equine/animal therapy
SingleSource Self-Insured 46
• Hypnotherapy
• Narcosynthesis
• Psychoanalysis or psychotherapy received as part of an educational or training program,
regardless of diagnosis or symptoms that may be present
• Marital/partner counseling
• Recreation therapy outside a inpatient or residential treatment setting
• Sensory integration training
• Social skill training
• Support groups
Drugs and Medications- This plan does not cover the following:
• Drugs and biologicals that can be self administered (including injectibles), other than those
provided in a hospital emergency room, or other institutional setting, or as outpatient chemotherapy
and dialysis, which are covered
• Drugs or medications not prescribed for inborn errors of metabolism, diabetic insulin, or autism
spectrum disorder that can be self-administered (including prescription drugs, injectable drugs, and
biologicals), unless given during a visit for outpatient chemotherapy or dialysis or during a medically
necessary hospital, emergency room or other institutional stay.
• Growth hormone injections or treatments, except to treat documented growth hormone deficiencies
• Immunizations when recommended for or in anticipation of exposure through travel or work
• Over-the-counter medications or non-prescription drugs
Equipment and Devices - This plan does not cover the following:
• Computer or electronic equipment for monitoring asthmatic, diabetic, or similar medical conditions
or related data
• Equipment commonly used for nonmedical purposes - This plan does not cover the following:
o Equipment commonly used for nonmedical purposes, or marketed to the general public, or
intended to alter the physical environment. This includes appliances like adjustable power
beds sold as furniture, air conditioners, air purifiers, room humidifiers, heating and cooling
pads, home blood pressure monitoring equipment, light boxes, conveyances other than
conventional wheelchairs, whirlpool baths, spas, saunas, heat lamps, tanning lights, and
pillows. It also includes orthopedic shoes and shoe modifications. Mattresses and mattress
pads are only covered when medically necessary to heal pressure sores.
o Modifications to vehicles or structures to prevent, treat, or accommodate a medical
condition
o Replacement costs for worn or damaged durable medical equipment that would otherwise
be replaceable without charge under warranty or other agreement
o Personal items such as telephones, televisions, and guest meals during a stay at a hospital
or other inpatient facility
• Equipment used primarily in athletic or recreational activities. This includes exercise equipment for
stretching, conditioning, strengthening, or relief of musculoskeletal problems
• Modifications to vehicles or structures to prevent, treat, or accommodate a medical condition
• Personal items such as telephones, televisions, and guest meals during a stay at a hospital or other
inpatient facility
• Replacement costs for worn or damaged durable medical equipment that would otherwise be
replaceable without charges under warranty or other agreement
Experimental or investigational Treatment
Your Plan Sponsors plan does not cover experimental or investigational treatment. By that,
PacificSource means services, supplies, protocols, procedures, devices, chemotherapy, drugs or
SingleSource Self-Insured 47
medicines or the use thereof that are experimental or investigational for the diagnosis and treatment of
the patient. It includes treatment that, when and for the purpose rendered:
• Has not yet received full U.S. government agency approval (e.g. FDA) for other than experimental,
investigational, or clinical testing;
• Is not of generally accepted medical practice in Oregon or as determined by PacificSource in
consultation with medical advisors, medical associations, and/or technology resources;
• Is not approved for reimbursement by the Centers for Medicare and Medicaid Services;
• Is furnished in connection with medical or other research; or
• Is considered by any governmental agency or subdivision to be experimental or investigational, not
reasonable and necessary, or any similar finding.
An experimental or investigational service is not made eligible for benefits by the fact that other
treatment is considered by your healthcare provider to be ineffective or not as effective as the service or
that the service is prescribed as the most likely to prolong life.
When making benefit determinations about whether treatments are investigational or experimental,
PacificSource relies on the above resources as well as:
• Expert opinions of specialists and other medical authorities;
• Published articles in peer-reviewed medical literature;
• External agencies whose role is the evaluation of new technologies and drugs; and
• External review by an independent review organization.
The following will be considered in making the determination whether the service is in an experimental
and/or investigational status:
• Whether there is sufficient evidence to permit conclusions concerning the effect of the services on
health outcomes;
• Whether the scientific evidence demonstrates that the services improve health outcomes as much
or more than established alternatives;
• Whether the scientific evidence demonstrates that the services' beneficial effects outweigh any
harmful effects; and
• Whether any improved health outcomes from the services are attainable outside an investigational
setting.
If you or your provider have any concerns about whether a course of treatment will be covered,
PacificSource encourages you to contact PacificSource's Customer Service Department. PacificSource
will arrange for medical review of your case against PacifcSource's criteria, and notify you of whether
the proposed treatment will be covered.
Other Items - This plan does not cover the following:
• Treatment not medically necessary - Services or supplies that are not medically necessary for the
diagnosis or treatment of an illness, injury, or disease. For related provisions, see 'medically
necessary' in the Definitions section and 'Understanding Medical Necessity' in the Covered
Expenses section of this Summary Plan Description.
• Treatment prior to enrollment - Services or supplies a member received prior to enrolling in
coverage provided by this plan; charges for inpatient stays that begin before you were covered by
this plan; services or supplies received before this plan's coverage began; admission prior to
coverage; services and supplies for an admission to a hospital, skilled nursing facility or specialized
facility that began before the patient's coverage under this plan
• Treatment after insurance ends - Services or supplies received after enrollment in this policy ends.
(The only exception is if this policy is replaced by another group health policy while you are
hospitalized. The plan will continue paying covered hospital expenses until you are released or your
benefits are exhausted, whichever occurs first.)
• Care and related services designed essentially to assist a person in maintaining activities of daily
living, e.g. services to assist with walking, getting in/out of bed, bathing, dressing, feeding, and
SingleSource Self-Insured 48
preparation of meals, homemaker services, special diets, rest crew, day care, and diapers.
Custodial care is only covered in conjunction with respite care allowed under this policy's hospice
benefit (see Covered Expenses - Hospital, Skilled Nursing Facility, Home Health, and Hospice
Services).
• Services or supplies available to you from another source, including those available through a
government agency
• Services or supplies for which no charge is made, for which the member is not legally required to
pay, or for which a provider or facility is not licensed to provide even though the service or supply
may otherwise be eligible. This exclusion includes services provided by the member, or by an
immediate family member.
• Services or supplies for which you are not willing to release the medical or eligibility information
PacificSource needs to determine the benefits paid under this plan
• Charges that are the responsibility of a third party who may have caused the illness, injury, or
disease or other insurers covering the incident (such as workers' compensation insurers,
automobile insurers, and general liability insurers)
• Charges over the usual, customary, and reasonable fee (UCR) -Any amount in excess of the UCR
for a given service or supply, except alternative care.
• Treatment of any illness, injury, or disease resulting from an illegal occupation or attempted felony,
or treatment received while in the custody of any law enforcement authority
• Treatment of any condition caused by a war, armed invasion, or act of aggression, or while serving
in the armed forces
• Treatment of any work-related illness or injury, unless you are the owner, partner, or principal of the
Plan Sponsor, injured in the course of employment of the Plan Sponsor, and are otherwise exempt
from, and not covered by, state or federal workers' compensation insurance. This includes illness or
injury caused by any for-profit activity, whether through employment or self-employment.
• Treatment while incarcerated - Services or supplies a member receives while in the custody of any
state or federal law enforcement authorities or while in jail or prison
• Charges for phone consultations, missed appointments, get acquainted visits, completion of claim
forms, or reports PacificSource needs to process claims
• Any amounts in excess of the allowable fee for a given service or supply Training or self-help
programs - General fitness exercise programs, and programs that teach a person how to use
durable medical equipment or care for a family member. Also excluded are health or fitness club
services or memberships and instruction programs, including but not limited to those to learn to
self-administer drugs or nutrition, except as specifically provided for in this plan.
• Services of providers who are not eligible for reimbursement under this plan. An individual
organization, facility, or program is not eligible for reimbursement for services or supplies,
regardless of whether this plan includes benefits for such services or supplies, unless the
individual, organization, facility, or program is licensed by the state in which services are provided
as an independent practitioner, hospital, ambulatory surgical center, skilled nursing facility, durable
medical equipment supplier, or mental and/or chemical healthcare facility. And to the extent
PacificSource maintains credentialing requirements the practitioner or facility must satisfy those
requirements in order to be considered an eligible provider.
• Scheduled and/or non-emergent medical care outside of the United States.
• Services otherwise available - These include but are not limited to:
o Services or supplies for which payment could be obtained in whole or in part if the member
applied for payment under any city, county, state (except Medicaid), or federal law; and
o Services or supplies the member could have received in a hospital or program operated by
a federal government agency or authority, except otherwise covered expenses for services
or supplies furnished to a member by the Veterans' Administration of the United States that
are not military service-related.
This exclusion does not apply to covered services provided through Medicaid or by any hospital
owned or operated by the State of Oregon or any state-approved community mental health and
developmental disability program.
SingleSource Self-Insured 49
• Benefits not stated - Services and supplies not specifically described as benefits under the group
health policy and/or any endorsement attached hereto
EXCLUSION PERIODS
Exclusion Period for Transplant Benefits
Except for corneal transplants, organ and tissue transplants are not covered until you have been
enrolled in this plan for 24 months or since birth. If you were covered under another health insurance
plan before enrolling in this plan, you can receive credit for your prior coverage. See the Credit for Prior
Coverage section, below.
CREDIT FOR PRIOR COVERAGE
You can receive credit toward this plan's exclusion periods if you had qualifying healthcare coverage
before enrolling in this plan. To qualify for this credit, there may not have been more than a 63-day
gap between yourlast day of coverage under the previous health plan and your first day of coverage
(or the first day of your Plan Sponsor's probationary waiting period) under this plan.
Your prior coverage must have been a group health plan, COBRA or state continuation coverage,
individual health policy (including student plans), Medicare, Medicaid, TRICARE, State Children's
Health Insurance Program, and coverage through high risk pools and the Peace Corps. If you were
covered as a dependent under a plan that meets these qualifications, you will qualify for credit. Many
people elect the COBRA or state continuation coverage available under a prior plan to make sure they
won't have more than a 63-day gap in coverage.
It is your responsibility to show you had creditable coverage. If you qualify for credit, PacificSource
will count every day of coverage under your prior plan toward this plan's exclusion periods for pre-
existing conditions, other specified conditions, and transplants (explained above).
Evidence of Prior Creditable Coverage
You can show evidence of creditable coverage by sending PacificSource a Certificate of Creditable
Coverage from your previous health plan. All health plans, insurance companies, and HMOs are
required by law to provide these certificates on request. Most insurers issue these certificates
automatically whenever someone's coverage ends. The certificate shows how long you were covered
under your previous plan and when your coverage ended.
If you do not have a certificate of prior coverage, contact your previous insurance company or Plan
Sponsor (such as your former employer, if you had a group health plan). You have the right to request a
certificate from any prior plan, insurer, HMO, or other entity through which you had creditable coverage.
If you are unable to obtain a certificate, contact PacificSource's Membership Services Department for
assistance.
HEALTH CARE MANAGEMENT AND PREAUTHORIZATION
What is Health Care Management
Your Plan Sponsor desires to provide you and your family with a heath care benefit plan that financially
protects you from significant health care expenses and assures you quality care. While part of
increasing health care costs results from new technology and important medical advances, another
significant cause is the way health care services are used.
Some studies indicate that a high percentage of the cost for health care services may be unnecessary.
For example, hospital stays may be longer than necessary. Some hospitalizations may be entirely
avoidable, such as when surgery could be performed at an outpatient facility with equal quality and
safety. Also, surgery is sometimes performed when other treatment could be more effective. All of these
instances increase costs for you and the plan.
Your Plan Sponsor has contracted with PacificSource to assist you in determining whether or not
proposed services are appropriate for reimbursement under this plan. The program is not intended to
diagnose or treat medical conditions, dictate a treatment plan, guarantee benefits, or validate eligibility.
SingleSource Self-Insured 50
The medical professionals who conduct the program focus their review on the appropriateness for
reimbursement of hospital stays and proposed surgical procedures.
Required Admission Review - You are required to call PacificSource's toll-free number, (888) 977-
9299, prior to any elective inpatient stay or any scheduled surgical procedure. In most cases, your
medical provider will make the call for you. You must also call within 48 hours of any emergency
admission. When you or your provider call, it will be necessary to provide the program with your name,
the patient's name, the name of the physician or practitioner and hospital, the reason for the
hospitalization and any other information needed to complete the review. In some cases, you may be
asked for more information or a second opinion may be required to complete the review.
Preauthorization - Preauthorization is necessary to determine if certain services and supplies are
covered under this plan and if you meet the plan's eligibility requirements. PacificSource reviews new
technologies and standards of medical practice on an ongoing basis and therefore the list of
preauthorization requirements is subject to changes and updates. The current list of procedures and
services that require preauthorization under the plan can be found the PacificSource' website:
PacificSource.com.
The list of services that require preauthorization is not intended to suggest that all the items
included are necessarily covered by the benefits of this plan.
A request for preauthorization must be made to PacificSource as soon as the patient knows that he or
she will be receiving services for which preauthorization is required. Your medical provider can request
preauthorization from PacificSource by phone - (888) 977-9299, fax - (541) 684-5264, or mail:
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espaliol (800) 624-6052, extensi6n 1009
cs@pacificsou rce. com
If your provider will not request preauthorization for you, you may contact PacificSource yourself. In
some cases, you may be asked for more information or be required to obtain a second opinion before a
benefit determination can be made.
If you are preauthorized for one facility, but are then transferred to another facility you will need to
obtain preauthorization for the new facility before transferring, except in the case of emergencies in
which case notification must be made as soon as possible after transferring facilities.
If your provider's preauthorization request is denied as not medically necessary or as experimental,
your provider may appeal the adverse benefit determination. You retain the right to appeal the adverse
benefit determination independent from your provider.
Note: A preauthorization determination is valid for 90 days. However, if your coverage under the plan
ends before the services are rendered or supplies received, the preauthorization determination will
become invalid.
Case Management
The primary objective of large case management is to identify and coordinate cost-effective medical
care alternatives and to help manage the care of patients who have special or extended care illnesses
or injuries. Large case management also monitors the care of the patient, offers emotional support to
the family, and coordinates communications among health care providers, patients and others.
Benefits may be modified by the Plan Sponsor to permit a method of treatment not expressly provided
for, but not prohibited by law, rules or public policy, if the Plan Sponsor determines that such
modification is medically necessary and is more cost-effective than continuing a benefit to which you or
your eligible dependents may otherwise be entitled. The Plan Sponsor also reserves the right to limit
payment for services to those amounts which would have been charged had the service been provided
in the most cost-effective setting in which the service could safely have been provided.
Examples of illnesses or injuries that may be appropriate for large case management include, but are not
limited to:
SingleSource Self-Insured 51
• Terminal illnesses (Cancer, AIDS, Multiple Sclerosis, Renal Failure, Obstructive Pulmonary
Disease, Cardiac conditions, etc.)
• Accident victims requiring long-term rehabilitative care
• Newborns with high-risk complications or multiple birth defects
• Diagnoses involving long-term IV therapy
• Illnesses not responding to medical care
• Child and adolescent mental/nervous disorders
• Organ transplants
Individual Benefits Management
Individual benefits management addresses, as an alternative to providing covered services,
PacificSource's consideration of economically justified alternative benefits. The decision to allow
alternative benefits will be made by on a case-by-case basis. The determination to cover and pay for
alternative benefits for an individual shall not be deemed to waive, alter or affect the Plan Sponsors or
PacificSource's right to reject any other or subsequent request or recommendation. The Plan Sponsor
may provide alternative benefits if PacificSource and the individual's attending provider concur in the
request for and in the advisability of alternative benefits in lieu of specified covered services, and, in
addition, PacificSource concludes that substantial future expenditures for covered services for the
individual could be significantly diminished by providing such alternative benefits under the individual
benefit management program (See Case Management above).
HOW TO USE YOUR DENTAL PLAN
When you need dental care, you may visit any dentist. Most dental offices will bill PacificSource directly.
If your dentist has any questions regarding billing procedures, he or she can call PacificSource at (541)
225-1981, or (866) 373-7053 from outside the Eugene-Springfield area.
When you first visit your dentist after becoming covered under this plan, let the office staff know you
have dental benefits through PacificSource. You will need to show your PacificSource ID card, which
contains your group number and benefit information. Your dentist may submit claims and treatment
programs on a standard American Dental Association form.
For extensive dental work, PacificSource recommends that your dentist submit a pre-treatment
estimate to PacificSource. PacificSource then determines how much your plan will pay toward the
proposed treatment and review the estimate with your dentist prior to treatment. If your covered family
members require extensive dental work, be sure your member ID number and group number are
included on their pre-treatment form for identification purposes.
DENTAL PLAN BENEFITS
When this plan pays for dental services, it actually pays the stated percentage of charges based on
reasonable and customary charges. A charge is reasonable and customary when it falls within a
general range of charges being made by most dental providers in your service area for similar
treatment of similar dental conditions. If the charge for a treatment or service is more than the
reasonable and customary charge in your service area, you may be required to pay the difference. The
reasonable and customary charge for dental expense is the 'covered charge' referred to in this booklet.
If you or your covered family member selects a more expensive treatment than is customarily provided,
this plan will pay the applicable percentage of the lesser fee. You will be responsible for the balance of
the provider's charges.
With the Advantage Network, participating dentists agree to write off any charges over and above the
negotiated, contracted fees for most services. When you use a participating dentist in the Advantage
Network, you will not be responsible for any excess charges and will pay only your plan's deductible
and/or co-insurance amount. If you choose not to use a participating Advantage Network dentist, or
don't have access to them, reimbursement will continue to be based on usual, customary, and
reasonable (UCR) charges. If that non-participating dentist's fees exceed the UCR charges, the excess
charges are also your responsibility
SingleSource Self-Insured 52
COVERED DENTAL SERVICES
This dental plan covers the following services when performed by an eligible provider and when
determined to be necessary by the standards of generally accepted dental practice for the prevention or
treatment of oral disease or for accidental injury, including masticatory function. Covered services may
also be provided by a dental hygienist or denturist to the extent that he or she is operating within the
scope of his or her license as required under law in the State of Oregon.
Covered dental services are organized into three classes, starting with preventive care and advancing
into specialized dental procedures.
Class I Services - Diagnostic and Preventive Treatment
• Examinations (routine or other diagnostic exams) are covered. Separate charges for review of a
proposed treatment plan or for diagnostic aids such as study models and certain lab tests are not
covered.
• Full mouth x-rays and/or panorex are covered up to one complete mouth series and/or panorex
in any three-year period and limited to four bite-wing films in a six-month period. When an
accumulative charge for additional periapical x-rays in a one-year period matches that of a
complete mouth series, no further benefits for periapical x-rays or panorex are available for the
remainder of the year.
• Dental cleanings (prophylaxis and periodontal maintenance) are covered to a combined total
of three procedures per person per benefit year. The limitation for dental cleaning applies to any
combination of prophylaxis and/or periodontal maintenance in the benefit year. A separate charge
for periodontal charting is not a covered benefit. Periodontal maintenance is not covered when
performed within three months of periodontal scaling and root planing and/or curettage.
• Topical applications of fluoride are covered to two applications per benefit year through age 22.
• Fluoride varnish applications are covered to 12 applications per benefit year for children age 12
and under if the child is deemed at risk for dental infection.
• The application of sealants is covered to one application in a five-year period to permanent
molars and bicuspids and only for individuals through age 17.
• Vizilite is a covered up to two screenings per benefit year.
• Benefits for athletic mouth guards are limited to one per lifetime through age 17 if the member is
still in secondary school.
• Benefits for brush biopsies used to aid in the diagnosis of oral cancer are covered.
Class R Restorative Services - Basic and Restorative Treatment
• Composite, resin, or similar restoration in a posterior (back) tooth is covered to the amount that
would be paid for a corresponding amalgam restoration. A separate charge for anesthesia when
used during restorative procedures is not a covered benefit. Only one filling is allowed per tooth
surface. The Plan Sponsorwill pay for a filling on a tooth surface only once per benefit year. Three
or more surface fillings are limited to one per surface per benefit year.
• Simple and surgical extractions of teeth and other minor oral surgery procedures are covered.
General anesthesia used in conjunction with these extractions administered by a dentist in a dental
office is also covered. A separate charge for alveolectomy performed in conjunction with removal of
teeth is not a covered benefit.
• Periodontal scaling and root planing and/or curettage is covered but limited to only one
procedure per quadrant in any 24-month period. For the purpose of this limitation, eight or fewer
teeth existing in one arch will be considered one quadrant.
• Benefits for full mouth debridement are limited to once every 24 months. This procedure is only
covered if the teeth have not received a prophylaxis in the prior 24 months and if an evaluation
cannot be performed due to the obstruction by plaque and calculus on the teeth. This procedure is
not covered if performed on the same date as the prophylaxis.
Class R Complicated Services - Complicated Treatment
Complicated oral surgical procedures such as removal of impacted teeth are covered when
SingleSource Self-Insured 53
preauthorized by PacificSource. Benefits for complicated oral surgical procedures include general
anesthesia administered by a dentist in a dental office. A separate charge for alveolectomy
performed in conjunction with removal of teeth is not a covered benefit.
• Pulp capping is covered only when there is an exposure to the pulp. These are direct pulp caps.
Indirect pulp caps are not covered.
• Pulpotomy is covered only for deciduous teeth.
• Root canal therapy is covered on the same tooth only for one charge in a three-year period.
• Periodontal surgery is covered when the procedure is preauthorized by PacificSource and
accompanied by a periodontal diagnosis and history of conservative (non-surgical) periodontal
treatment.
• Tooth desensitization is covered as a separate procedure from other dental treatment.
• Space maintainers are a covered benefit for individuals through the age of 13.
Class Services - Major Treatment
• Crowns and other cast or laboratory-processed restorations are covered but limited to the
restoration of any one tooth in a five-year period. If a tooth can be restored with a material such as
amalgam or composite resin, covered charges are limited to the cost of amalgam or non-laboratory
composite resin restoration even if another type of restoration is selected by the patient and/or
dentist.
• Replacement of an existing prosthetic device is covered only when the device being replaced is
unserviceable, cannot be made serviceable, and has been in place for at least five years.
• Cast partial denture, full, immediate, or overdenture are covered only to the cost of a standard
full or cast partial denture. A separate charge for denture adjustments and relines performed within
six months of the initial placement is not a covered benefit. Benefits for subsequent relines are
provided only once in a 12-month period. Cast restorations for partial denture abutment teeth or for
splinting purposes are not covered unless the tooth in and of itself requires a cast restoration.
• Fixed bridges or removable cast partials are covered. Benefits for temporary full or partial
dentures must be preauthorized. Benefits for the initial placement of full or partial dentures or fixed
bridges (including acid-etch metal bridges) are provided only if the denture or bridgework includes
replacement of a natural tooth which is extracted or lost while the member's coverage is in effect.
However, this limitation does not apply after the member has been covered under the policyholder's
group dental plan for a period of at least 36 consecutive months.
• Benefits for the surgical placement and removal of implants are limited to once per lifetime per
tooth space for each service. Services must be preauthorized by PacificSource to be covered.
Benefits include final crown and implant abutment over a single implant and final implant-supported
bridge abutment and implant abutment or pontic. An alternative benefit per arch of a conventional
full or partial denture for the final implant-supported full or partial denture prosthetic device is
available.
• Bruxism splint and nightguard (appliances to reduce or prevent pain or damage from grinding of
teeth) are covered.
EXCLUDED DENTAL SERVICES
This plan does not provide benefits in any of the following circumstances or for any of the following
conditions:
• Aesthetic dental procedures - Services and supplies provided in connection with dental
procedures that are primarily aesthetic, including bleaching of teeth and labial veneers.
• Antimicrobial agents - Localized delivery of antimicrobial agents into diseased crevicular tissue
via a controlled release vehicle.
• Benefits not stated - Any services and supplies not specifically described as covered benefits
under this plan
• Biopsies or histopathologic exams - A separate charge for a biopsy of oral tissue or
histopathologic exam.
SingleSource Self-Insured 54
• Bone replacement grafts to prepare sockets for implants after tooth extraction.
• Charges for broken appointments
• Collection of cultures and specimens.
• Connector bar or stress breaker.
• Core build-ups are not covered unless used to restore a tooth that has been treated
endodontically (root canal).
• Cosmetic/reconstructive services and supplies - Procedures, appliances, restorations, or other
services that are primarily for cosmetic purposes. This includes services or supplies rendered
primarily to correct congenital or developmental malformations, including but not limited to, peg
laterals, cleft palate, maxillary and mandibular (upper and lower jaw) malformation, enamel
hypoplasia, and fluorosis (discoloration of teeth). However, the replacement of congenitally missing
teeth is covered.
• Denture replacement made by necessary by loss, theft, or breakage.
• Diagnostic casts - Diagnostic casts (study models), gnathological recordings, occlusal
appliances, occlusal equilibration procedures, or similar procedures.
• Drugs and medications that are prescribed drugs, premedication drugs, analgesics (e.g., nitrous
oxide or non-intravenous sedation), any other euphoric drugs, or any take-home medicine or
supplies distributed by a provider.
• Educational programs - Instructions and/or training in plaque control and oral hygiene.
• Experimental or investigational procedures - Services, supplies, protocols, procedures,
devices, drugs or medicines, or the use thereof that are experimental or investigational for the
diagnosis and treatment of the patient. An experimental or investigational service is not made
eligible for benefits by the fact that other treatment is considered by the member's dental care
provider to be ineffective or not as effective as the service or that the service is prescribed as the
most likely to prolong life.
• Fractures of the mandible - Services and supplies provided in connection with the treatment of
simple or compound fractures of the mandible.
• General anesthesia except when administered by a dentist in connection with oral surgery in
his/her office
• Gingivetomcy, gingivoplasty or crown lengthening in conjunction with crown preparation or
fixed bridge services done on the same date of service.
• Hospital charges or additional fees charged by the dentist for hospital treatment
• Hypnosis
• Infection control -A separate charge for infection control or sterilization
• Intra and extra coronal splinting - Devices and procedures for intra and extra coronal splinting to
stabilize mobile teeth.
• Oral Surgery treating any fractured jaw
• Orthodontic services - Treatment of malalignment of teeth and/or jaws, or any ancillary services
expressly performed because of orthodontic treatment, unless your Dental Benefit Summary shows
orthodontic services as a covered benefit.
• Orthognathic surgery - Surgery to manipulate facial bones, including the jaw, in patients with
facial bone abnormalities performed to restore the proper anatomic and functional relationship to
the facial bones
• Periodontal probing, charting, and re-evaluations
• Photographic images.
• Pin retention in addition to restoration.
• Precision attachments
• Pulpotomies on permanent teeth
SingleSource Self-Insured 55
• Removal of clinically serviceable amalgam restorations to be replaced by other materials free
of mercury, except with proof of allergy to mercury.
• Services covered by the member's medical plan.
• Services for rebuilding or maintaining chewing surfaces due to teeth out of alignment or
occlusion, or for stabilizing the teeth.
• Services otherwise available - These include but are not limited to:
- Services or supplies for which payment could be obtained in whole or in part if the member
applied for payment under any city, county, state, or federal law (except Medicaid); and
- Services or supplies the member could have received in a hospital or program operated by a
federal government agency or authority. Covered expenses for services or supplies furnished
to a member by the Veterans' Administration of the United States that are not service-related
are eligible for payment according to the terms of this policy.
- Services or supplies for which payment would be made by Medicare.
• Services or supplies for which no charge is made which you are not legally required to pay or
which a provider or facility is not licensed to provide even though the service or supply may
otherwise be eligible. This includes services provided by you or an immediate family member.
• Sinus lift grafts to prepare sinus site for implants.
• Temporomandibular joint (TMJ) -Any services or supplies for treatment of any disturbance of
the Temporomandibular joint.
• Third party liability, motor vehicle liability, motor vehicle insurance coverage, workers'
compensation -Any services or supplies for illness or injury for which a third party is responsible
or which are payable by such third party or which are payable pursuant to applicable workers'
compensation laws, motor vehicle liability, uninsured motorist, underinsured motorist, and personal
injury protection insurance and any other liability and voluntary medical or dental payment
insurance to the extent of any recovery received from or on behalf of such sources.
• Tooth transplantation - Services and supplies provided in connection with tooth transplantation,
including re-implantation from one site to another and splinting and/or stabilization. This exclusion
does not relate to the re-implantation of a tooth into its original socket after it has been avulsed.
• Treatment after insurance ends - Services or supplies provided after enrollment in this plan
ends. The only exception is for Class III Services ordered and fitted before enrollment ends and
placed within 31 days after enrollment ends.
• Treatment not dentally necessary according to acceptable dental practice or treatment not likely
to have a reasonably favorable prognosis.
• Treatment prior to enrollment - Dental services begun before you or your family member
became eligible for those services under this plan.
• Treatment while incarcerated - Services or supplies received while in the custody of any state or
federal law enforcement authorities or while in jail or prison.
• Unwilling to release information - Charges for services or supplies for which you are unwilling to
release medical or dental information necessary to determine eligibility for payment under this
policy
• War-related conditions - The treatment of any condition caused by or arising out of an act of war,
armed invasion, or aggression, or while in the service of the armed forces.
• Work-related conditions - Services or supplies for treatment of illness or injury arising out of or in
the course of employment or self-employment for wages or profit, whether or not the expense for
the service or supply is paid under workers' compensation.
SingleSource Self-Insured 56
CLAIMS PROCEDURES
Now to File/Now to Appeal a Claim
These claim procedures describe how benefit claims and appeals are made and decided under this
plan.
Only members or a designated authorized representative may submit claims for benefits (for
themselves and on behalf of their covered dependents), and benefits will only be paid to the member or
the actual provider of services. Under the following claims procedures section, the words 'you' and
'your' will mean a member of the group health plan of the Plan Sponsor. You become a claimant when
you make a request for a plan benefit or benefits in accordance with these claims procedures.
You and your covered dependents have the right to elect group health care benefits as offered by the
Plan Sponsor, and your and their rights will be determined under the plan's provisions and in
conjunction with the claims and appeals procedures outlined later in this section. Claims will also be
considered filed by you if communications and requests for benefits come from an individual that you
have designated as your authorized representative to act on your behalf with respect to a claim. In the
event that you designate an authorized representative to act on your behalf, the plan will send all
notifications, requests for further information, appeal decisions, and all other communications to your
authorized representative and provide you with a copy of all communications, unless you request
otherwise in writing.
An authorized representative may act on behalf of a claimant with respect to benefit claim or appeal
under these procedures. However, no person (including a treating health care professional) will be
recognized as an authorized representative until the plan receives an Designation of Authorized
Representative form signed by the claimant, except that for urgent care claims the plan shall, even in
the absence of a signed Designation of Authorized Representative form, recognize a health care
professional with knowledge of the claimant's medical condition (e.g., the treating physician or
practitioner) as the claimant's authorized representative unless the claimant provides specific written
direction otherwise.
A Designation of Authorized Representative form may be obtained from and completed forms must be
returned to:
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espafiol (800) 624-6052, extensi5n 1009
cs@pacifi csource. com
An assignment for purposes of payment (e.g., to a health professional) does not constitute appointment
of an authorized representative under these claims procedures. However, unless you have directed the
plan otherwise, claims submitted on your behalf by a health care professional will be considered a valid
claim if submitted pursuant to the guidelines outlined in these claim procedures.
Any reference in these claims procedures to the claimant is intended to include the authorized
representative of such claimant appointed in compliance with the above procedures.
For the purposes of the claims procedures section, any reference to 'days' will refer to calendar days,
not business days.
Questions about Your Claims
PacificSource is available to listen and help with any concerns or problems you may have with resolving
a claim. Because PacificSource wants you to be completely satisfied with the member services
assistance you receive, a process has been established for addressing your concerns and solving your
problems. If you have a concern regarding a person, a service, the quality of care, or you want to
inquire about what benefits are covered under the plan, please call PacificSource at (888) 977-9299
and explain your concern to one of their Customer Service Representatives. You may also express that
concern in writing. PacificSource will do their best to resolve the matter on your initial contact. If
PacificSource needs more time to review or investigate your concern, they will get back to you as soon
SingleSource Self-Insured 57
as possible, but in any case within 30 days. They will not consider any of these communications to be a
'claim' for benefits. A formal claim for benefits must meet certain other standards which are described in
greater detail in these procedures.
Types of Claims
Pre-Service Claims - The plan subjects the receipt of benefits for some services or supplies to a
preauthorization review. Although a preauthorization review is generally done on a pre-service basis, it
may in some cases be conducted on a post-service basis. Unless a response is needed sooner due to
the urgency of the situation, a pre-service preauthorization review will be completed and notification
made to you and your medical provider as soon as possible, generally within two working days, but no
later than 15 days within receipt of the request.
Urgent Care Claims - If the time period for making a non-urgent care determination could seriously
jeopardize your life, health or ability to regain maximum function, or would subject you to severe pain
that cannot be adequately managed without the care or treatment that is proposed, a preauthorization
review will be completed as soon as possible, generally within 24 hours, but no later than 72 hours
within receipt of the request.
Concurrent Care Review - A concurrent care decision occurs when a previously approved course of
treatment is reconsidered and reduced or denied, or where an extension is requested beyond the
initially approved period of time or number of treatments. Inpatient hospital or rehabilitative facilities,
skilled nursing facilities, intensive outpatient, and residential behavioral health care require concurrent
review for a benefit determination with regard to an appropriate length of stay or duration of service.
Benefit determinations will be made as soon as possible within receipt of all the information necessary
to make such a determination.
Post-Service Claims -A claim determination that involves only the potential payment of
reimbursement of the cost of medical care that has already been provided will be made as soon as
reasonably possible but no later than 30 days from the day after receiving the claim.
How to File a Claim
Most health care providers will file claims on your behalf. Electronically submitted claims are processed
most efficiently. If unable to file electronically, you, your health care provider, or an authorized
representative must file your claim using HCFA-1500 (revision 12/90 and later), UB92, or ADA (revision
12/90 and later) forms, or an itemized statement. These forms are available from your health care
provider or PacificSource.
A claim will be considered filed when it is received by PacificSource at the address listed below:
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espanol (800) 624-6052, extension 1009
cs@pacifi csou rce. com
The following information is required in order quality your request for benefits as a properly submitted
claim:
• Plan member's name, member ID and current address;
• Patient's name, member ID and address if different from the member's;
• Provider's name, tax identification number, address, degree and signature;
• Date(s) of service(s);
• Place of service(s);
• Diagnostic Code;
• Procedure Codes (describes the treatment or services rendered);
• Assignment of Benefits, signed (if payment is to be made to the provider);
• Release of Information Statement, signed; and
SingleSource Self-Insured 58
Explanation of Benefits (EOB) information if another plan is the primary payer.
This plan also recognizes the following actions and submission of forms as claims:
• A request by you for benefits through preauthorization in cases where use of preauthorization is
required in order to obtain a particular benefit.
• Requests by your formally-designated authorized representative for preauthorization in cases
where use of preauthorization is required in order to obtain a particular benefit. The plan will take
reasonable steps to determine whether an individual claiming to be acting on your behalf is, in fact,
validly empowered to do so under the circumstances, and the plan will require that you complete
and file a form identifying any person you authorize to act on your behalf with respect to a claim.
However, when inquiries by a health care provider relate to payments due to the provider-rather
than due to you-under participating provider contracts (where the health care provider has no
recourse against you for the amounts) such inquiries by a health care provider will not be
considered 'claims' by the plan.
• Requests for benefits (in the case of a claim involving urgent care) by a health care provider with
knowledge of your medical condition. For urgent care claims, you are not required to complete a
form and formally designate a health care provider as your representative with respect to a claim.
Claims must be submitted individually for each claimant. Please do not staple claims together. Send
completed information to:
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espanol (800) 624-6052, extension 1009
cs@pacificsource.com
If you have any questions regarding your eligibility, benefits or claims information, please call
PacificSource at: (888) 977-9299.
All claims for benefits must be submitted to the plan within 90 days of the date of service. If it is not
possible to submit a claim within 90 days, you should submit the claim as soon as possible. In some
cases the plan will accept the late claim. The plan, however, will not pay a claim that was submitted
more than one year after the date of service.
All submitted claims and appeals will fall into one of the categories described previously. The handling
of your initial claim or later appeal will be governed, in all respects, by the appropriate category of claim
or appeal, and each time your claim or appeal is examined, a new determination will be made regarding
the category into which the claim or appeal falls at that particular time.
Pre-service claims - Your plan subjects the receipt of benefits for some services or supplies to a
preauthorization review. Although a preauthorization review is generally done on a pre-service basis, it
may in some case be conducted on a post-service basis. Unless a response is needed sooner due to
the urgency of the situation, a pre-service preauthorization review will be completed and notification
made to you and your medical provider as soon as possible, generally within two working days, but no
later than 15 days within receipt of the request.
Urgent care claims - If the time period for making a non-urgent care determination could seriously
jeopardize your life, health or ability to regain maximum function, or would subject you to severe pain
that cannot be adequately managed without the care or treatment that is proposed, a preauthorization
review will be completed as soon as possible, generally within 24 hours, but no later than 72 hours of
receipt of the request.
Concurrent care review - Inpatient hospital or rehabilitation facilities, skilled nursing facilities,
intensive outpatient, and residential behavioral healthcare require concurrent review for a benefit
determination with regard to an appropriate length of stay or duration of service. Benefit determinations
will be made as soon as possible but no later than one working day after receipt of all the information
necessary to make such a determination.
Post-service claims - A claim determination that involves only the payment of reimbursement of the
cost of medical care that has already been provided will be made as soon as reasonably possible but
no later than 30 days from the day after receiving the claim.
SingleSource Self-Insured 59
Retrospective review - A claim for benefits for which the service or supply requires a preauthorization
review but was not submitted for review on a pre-service basis will be reviewed on a retrospective basis
within 30 working days after receipt of the information necessary to make a claim determination.
Extension of time - Despite the specified timeframes, nothing prevents the member from voluntarily
agreeing to extend the above timeframes. Unless additional information is needed to process your
claim, PacificSource will make every effort to meet the timeframes stated above. If a claim cannot be
paid within the stated timeframes because additional information is needed, PacificSource will
acknowledge receipt of the claim and explain why payment is delayed. If PacificSource does not
receive the necessary information within 15 days of the delay notice, PacificSource will either deny the
claim or notify you every 45 days while the claim remains under investigation. No extension is permitted
for urgent care claims.
Extension of time - Unless additional information is needed to process your claim, the plan will make
every effort to meet the timeframes stated above. If a claim cannot be paid within the stated timeframes
because additional information is needed, PacificSource will acknowledge receipt of the claim and
explain why payment is delayed. If they do not receive the necessary information within 15 days of the
delay notice, they will either deny the claim or notify you every 45 days while the claim remains under
investigation.
Adverse benefit determinations - Any denial, reduction or termination of, or failure to provide or
make a payment for a benefit based on:
• A determination that the member is not eligible to participate in the plan.
• A determination that the benefit is not covered by the plan.
• The imposing of limits, such as preexisting condition or source-of-injury exclusions.
• A determination that the benefit is experimental, investigational or not medically necessary or
medically appropriate.
An adverse benefit determination made to reduce or deny benefits applied for a pre-service, post-
service, or concurrent care basis may be appealed in accordance with the plan's appeals procedures
described later in this section.
Incomplete Claims
If any information needed to process a claim is missing, the claim shall be treated as an incomplete
claim.
Other Incomplete Claims - If a pre-service or post-service claim is incomplete, the plan may deny the
claim or may take an extension of time, as described above. If the plan takes an extension of time, the
extension notice shall include a description of the missing information and shall specify a timeframe, no
less than 45 days, in which the necessary information must be provided. The timeframe for deciding the
claim shall be suspended from the date the extension notice is received by the claimant until the date
the missing necessary information is provided to the plan. If the requested information is provided, the
plan shall decide the claim within the extension period specified in the extension notice. If the requested
information is not provided within the time specified, the claim may be decided without that information.
If you fail to follow the plan's filing procedures because your request for benefits does not: 1) identify
the patient; 2) note a specific medical condition or symptom; 3) describe a specific treatment, service,
or product for which approval is requested; or 4) is not sent to the correct address, you will not have
submitted a claim. You will be notified orally, and/or by written notification if requested by the claimant,
within 24 hours, that you have failed to follow the filing procedures, and you will be reminded of the
proper filing procedures.
Notification of Benefit Determination
The plan will pay the benefit according to plan provisions. This may mean that less than 100% of your
claim is payable by the plan. In each case where the plan pays benefits or determines that it is not
responsible for your medical claim, you will receive an Explanation of Benefits which will outline the
basis for the plan's payment. If your claim is denied or payable at a level less than outlined in this
Summary Plan Description, you are entitled to appeal the decision under the rules governing adverse
benefit determination.
SingleSource Self-Insured 60
Adverse Benefit Determination
• Written notification will be provided to you of the plan's adverse benefit determination (as defined in
the How To File A Claim section above) and will include the following:
Information sufficient to identify the claim involved, including the date of service, the health care
provider, and the claim amount (if applicable), as well as how to obtain the diagnosis code, the
treatment code, and the corresponding meanings of these codes.
• A statement of the specific reason(s) for the decision;
• Reference(s) to the specific plan provision(s) on which the determination is based;
• A description of any additional material or information necessary to perfect the claim and why such
information is necessary;
• A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making
the adverse determination or a statement that such information will be provided free of charge upon
request;
• If the determination involves scientific or clinical judgment, disclose either (a) an explanation of the
scientific or clinical judgment applying the terms of the plan to the claimant's medical
circumstances, or (b) a statement that such explanation will be provided at no charge upon request;
• In the case of an urgent care claim, an explanation of the expedited review methods available for
such claims; and
• A statement regarding the availability of, and contact information for, any applicable office of health
insurance consumer assistance or ombudsman.
Notification of the plan's adverse benefit determination on an urgent care claim may be provided orally,
but written notification shall be furnished not later than three days after the oral notice.
You may call the Third Party Administrator at (888) 977-9299 to discuss the adverse benefit
determination if you have concerns. You may also express those concerns in writing and if needed,
may submit additional information that you believe would clarify any of the circumstances that lead to
the adverse benefit determination. Third Party Administrator will not consider any of these questions or
clarifications to be a formal appeal unless you specifically state it as such. The process for filing a
formal appeal is listed below.
Your Right to Appeal
You have the right to appeal an adverse benefit determination under these claims procedures. If you
choose to appeal the plan's adverse benefit determination, your appeal will be governed by rules that
assure you a full and fair review.
If you are denied benefits based upon the plan's finding that you are/were ineligible for benefits, the
denial of benefits gives you the opportunity to appeal the plan's decision.
If the plan decides to reduce or terminate benefits for your previously-approved course of treatment, the
plan's decision will be treated as an adverse benefit determination, and the plan will provide you
reasonable advance notice of the reduction or termination to allow you to appeal the plan's decision
before the benefit reduction or termination takes place. If you decide to appeal the plan's decision, you
must follow the rules for appealing a plan's decision.
No lawsuit can be instituted until the claimant has exhausted the plan's internal and external claims
review and appeals procedures. No lawsuit can be instituted more than one year after the date of the
notice to the claimant that a claim appeal has been denied.
Appealing an Initial Claim Determination - You must submit a written request to the plan within 180
days of receipt of an adverse benefit determination in order to initiate an appeal. An oral request for
review is acceptable for urgent care claims and may be made by calling the Third Party Administrator at
(888) 977-9299 and asking the plan to register your oral appeal.
SingleSource Self-Insured 61
When you appeal an adverse benefit determination, the plan will provide a full and fair review which will
include the following features:
• You will have the opportunity to submit written comments, documents, records, and other
information related to the claim.
• At your request (and free of charge), you will be provided with reasonable access to (and copies of)
all documents, records, and other information relevant to your claim for benefits. Included in this
category are any documents, records or other information in your claim file, whether or not those
materials were relied upon by the plan in making its adverse benefit determination. You also have
the right to review documentation showing that the plan followed its own internal processes for
ensuring appropriate decision making.
• The review of your claim will take into account all comments, documents and other information
without regard to whether such information was submitted or considered in the initial benefit
determination.
• Any appeal of an adverse benefit determination will not give deference to the initial decision on your
claim, and the review will be conducted by a designated plan representative who did not make the
original determination and does not report to the plan representative who made the original
determination.
• In deciding an appeal of any adverse benefit determination that is based on a medical judgment
(including determinations with regard to whether a particular treatment, drug, or other item is
experimental, investigational, or not medically necessary or medically appropriate), the designated
plan representative will consult with a health care professional who has appropriate training and
experience in the particular field of medicine involved in the medical judgment. This health care
professional will not be the same professional who was originally consulted in connection with the
adverse determination; neither will this health care professional report to the health care
professional who was consulted in connection with the adverse determination. The plan will uphold
the findings of the independent review in responding to the appeal.
• The plan will identify medical or vocational experts whose advice was obtained on behalf of the
plan in connection with an adverse benefit determination of your claim, whether or not that advice
was relied upon in making the benefit determination.
You must first follow this appeal process before taking any outside legal action. After you submit the
claim for appeal, the plan will make a decision on your appeal as follows:
Appeal of Urgent Care Claims - The plan's expedited appeal process for urgent care claims will allow
you to request (orally or in writing) an expedited appeal, after which, all necessary information, including
the plan's benefit determination on review, will be transmitted between the plan and you by telephone,
fax, or other expeditious method. You will be notified (in writing or electronically) of the benefit
determination as soon as possible, but not later than 72 hours after the plan receives the request for
review of the prior benefit determination. For urgent care claims you may also be able to request an
independent external review take place at the same time as you pursue the plan's internal appeal
process.
Appeal of Non-Urgent Pre-Service Claims - For non-urgent pre-service claims, you will be notified (in
writing or electronically) of the benefit determination within a reasonable period of time appropriate to
the medical circumstances, but not later than 30 days.
Appeal of Concurrent Care Claims - For concurrent care claims, you will be notified (in writing or
electronically) of the benefit determination with reasonable advance notice before the benefit reduction
or termination takes place.
Appeal of Post-Service Claims - For post-service claims, you will be notified (in writing or
electronically) of the benefit determination within a reasonable period of time, but not later than 60 days.
Denial of Claim on Appeal - If your appealed claim is denied, the plan will send you written or
electronic notification that explains why your appealed claim was denied and shall include the following:
• A statement of the specific reason(s) for the decision;
• Reference(s) to the specific plan provision(s) on which the determination is based;
SingleSource Self-Insured 62
• A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making
the adverse determination or a statement that such information will be provided free of charge upon
request;
• If the determination involves scientific or clinical judgment, the plan will disclose either (a) an
explanation of the scientific or clinical judgment applying the terms of the plan to the claimant's
medical circumstances, or (b) a statement that such explanation will be provided at no charge upon
request; and
• A statement indicating your right to receive, upon request (and free of charge), reasonable access
to (and copies of) all documents, records, and other information relevant to the determination.
Included in this category are any documents, records or other information in your claim file, whether
or not those materials were relied upon by the plan in making its adverse determination.
Additional Level of Review - If you are dissatisfied with the outcome of your appeal, you may request
an additional review. To initiate this review you should follow the same process required for an appeal.
You must submit a written request for additional review within 60 days following the receipt of the
appeal decision.
When you submit a request for additional review of an adverse benefit determination, the plan will
provide a full and fair review which will include the following features:
• You will have the opportunity to submit written comments, documents, records, and other
information related to the claim.
• At your request (and free of charge), you will be provided with reasonable access to (and copies of)
all documents, records, and other information relevant to your claim for benefits. Included in this
category are any documents, records or other information in your claim file, whether or not those
materials were relied upon by the plan in making its adverse benefit determination. You also have
the right to review documentation showing that the plan followed its own internal processes for
ensuring appropriate decision making.
• The review of your claim will take into account all comments, documents and other information
without regard to whether such information was submitted or considered in the initial adverse
benefit determination.
• Additional review will not afford deference to the appeal determination, and the review will be
conducted by a designated plan representative who did not make the original determination and
does not report to the plan representative who made the original determination.
• In deciding an appeal of any adverse benefit determination that is based on a medical judgment
(including determinations with regard to whether a particular treatment, drug, or other item is
experimental, investigational, or not medically necessary or medically appropriate), the designated
plan representative will consult with a health care professional who has appropriate training and
experience in the particular field of medicine involved in the medical judgment. This health care
professional will not be the same professional who was originally consulted in connection with the
adverse determination; neither will this health care professional report to the health care
professional who was consulted in connection with the adverse determination. The plan will uphold
the findings of the independent review in responding to the appeal.
• The plan will identify medical or vocational experts whose advice was obtained on behalf of the
plan in connection with an adverse benefit determination of your claim, whether or not that advice
was relied upon in making the benefit determination.
After you submit the claim for additional review, the plan will make a decision on your appeal as follows:
Additional Review of Urgent Care Claims - The plan's expedited additional review process for urgent
care claims will allow.you to request (orally or in writing) an expedited review, after which, all necessary
information, including the plan's benefit determination on review, will be transmitted between the plan
and you by telephone, fax, or other expeditious method. You will be notified (in writing or electronically)
of the benefit determination as soon as possible, but not later than 72 hours after the plan receives the
request for the review.
Additional Review of Non-Urgent Pre-Service Claims - For non-urgent pre-service claims, you will
be notified (in writing or electronically) of the review outcome within a reasonable period of time
appropriate to the medical circumstances, but not later than 30 days.
SingleSource Self-Insured 63
Additional Review of Concurrent Care Claims - For concurrent care claims, you will be notified (in
writing or electronically) of the review outcome with reasonable advance notice before the benefit
reduction or termination takes place.
Additional Review of Post-Service Claims - For post-service claims, you will be notified (in writing or
electronically) of the review outcome within a reasonable period of time, but not later than 60 days.
Denial of Claim after Additional Review - If after your request for additional review the claim is
denied, the plan will send you written or electronic notification that explains why the additional review
upheld the denial and shall include the following:
• A statement of the specific reason(s) for the decision;
• Reference(s) to the specific plan provision(s) on which the determination is based;
• A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making
the adverse determination or a statement that such information will be provided free of charge upon
request;
• If the determination involves scientific or clinical judgment, the plan will disclose either (a) an
explanation of the scientific or clinical judgment applying the terms of the plan to the claimant's
medical circumstances, or (b) a statement that such explanation will be provided at no charge upon
request; and
• A statement indicating your right to receive, upon request (and free of charge), reasonable access
to (and copies of) all documents, records, and other information relevant to the determination.
Included in this category are any documents, records or other information in your claim file, whether
or not those materials were relied upon by the plan in making its adverse determination.
Independent External Review - You may have the right to have your case reviewed by an external
independent review organization. Only decisions that are based on issues related to medical necessity,
medical appropriateness, health care setting, level of care, or effectiveness of a covered benefit may be
appealed to an external independent review organization. The plan must contract with at least three
different independent external review organizations and must rotate between them on a random or
circulating basis.
Your request for an independent review must be made in writing to PacificSource within 180 days of the
date of the final internal adverse benefit determination. You may include additional written information,
which will be included with the documents PacificSource provides to the independent review
organization.
A final decision made by an independent review organization is binding on the Plan Sponsor. This
decision is also binding on you, except to the extent other remedies are available under state or federal
law.
In certain instances you may be able to request an expedited review process, such as when the
timeframe for completion of the internal appeals process would seriously jeopardize the life or health of
the claimant or their ability to regain maximum function, or if the final adverse benefit determination
concerns an admission, availability of care, continued stay or health care service for which the claimant
received emergency services, but has not been discharged from a facility.
Resources For Information And Assistance
Assistance in Other Languages
Members who do not speak English may contact PacificSource's Customer Service Department for
assistance. They can usually arrange for a multilingual staff member or interpreter to speak with them in
their native language.
Information Available from PacificSource
PacificSource makes the following written information available to you free of charge. You may contact
their Customer Service Department by phone, mail, or email to request any of the following:
• A directory of participating healthcare providers under your plan
SingleSource Self-Insured 64
• Information about PacificSource's drug formulary
• A copy of PacificSource's annual report on complaints and appeals
• A description (consistent with risk-sharing information required by the Centers for Medicare and
Medicaid Services, formerly known as Health Care Financing Administration) of any risk-sharing
arrangements PacificSource has with providers
• A description of PacificSource's efforts to monitor and improve the quality of health services
• Information about how PacificSource checks the credentials of PacificSource's network providers
and how you can obtain the names and qualifications of your healthcare providers
• Information about PacificSource's preauthorization procedures
• Information about any healthcare plan offered by the Plan Sponsor
Information Available from the Oregon Insurance Division
The following consumer information is available from the Oregon Insurance Division:
• The results of all publicly available accreditation surveys
• A summary of PacificSource's health promotion and disease prevention activities
• Samples of the written summaries delivered to PacificSource policyholders
• An annual summary of grievances and appeals against PacificSource
• An annual summary of PacificSource's quality assessment activities
• An annual summary of the scope of PacificSource's provider network and accessibility of
healthcare services
You can request this information by contacting the Oregon Insurance Division by writing to the Oregon
Insurance Division, Consumer Advocacy Unit, PO Box 14489, Salem, OR 97309-0405 or by phone at
(503) 947-7984, or the toll-free message line at (888) 877-4894, on the Internet at
hfp://insurance.oregon.gov/consumer/consumer.html, or by email at cp.ins@state.or.us.
Plan Sponsor's Discretionary Authority; Standard of Review
The Plan Sponsor is the sole fiduciary of the plan, and exercises all discretionary authority and control
over the administration of the plan and the management and disposition of plan assets. Benefits under
the plan will be paid only if the Plan Sponsor decides, in its discretion, that the member or beneficiary is
entitled to such benefits. Any construction of the terms of any plan document and any determination of
fact adopted by the Plan Sponsor shall be final and legally binding on the parties. A court of law or
arbitrator reviewing any fiduciary's decision, including one relating the plan interpretation or a benefit
claim, must consider only the documents, testimony and other evidence that were presented to the
fiduciary at the time the fiduciary made the decision. In addition, the court or arbitrator must use the
'arbitrary and capricious' standard of review. That is, the fiduciary's determination can be reversed only
if it was made in bad faith, is not supported by substantial evidence or is erroneous as to a question of
law.
The Plan Sponsor may hire someone to perform claims processing and other specified services in
relation to the plan. Any such contractor will not be a fiduciary of the plan and will not exercise any of
the discretionary authority and responsibility granted to the Plan Sponsor, as described above.
Coordination of Benefits
Coordinating with Other Group Health Plans - When benefits are coordinated, one plan pays
benefits first (the 'primary coverage') and the other plan pays benefits second (the 'secondary
coverage').
When you and/or your dependents are covered under more than one group health plan, the combined
benefits payable by this plan and all other group plans will not exceed 100% of the eligible expense
incurred by the individual. The plan assuming primary payer status will determine benefits first without
regard to benefits provided under any other group health plan.
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Note: If your primary and secondary coverage both include a deductible, you will be required to satisfy
each of those deductibles before benefits will be paid.
There are two types of Coordination of Benefits -'True' Coordination of Benefits and Non-Duplicating
Coordination of Benefits (also called Integration of Benefits.) See the Medical Benefit Summary to
determine if your plan offers True Coordination of Benefits or Non-Duplicating/Integration of Benefits.
For True Coordination of Benefits, the primary plan will pay benefits first, subject to any deductibles,
copayments and coinsurance. The remaining balance will be passed on to the secondary payer. When
this plan is the secondary payer, the balance of eligible expenses will be applied as if it was a new
claim under this plan. Deductibles, copayments and coinsurance relevant to this plan will be subtracted
from the amount before paying the remainder.
For Non-Duplicating Coordination of Benefits/Integration of Benefits, the primary plan will pay
benefits first, subject to any deductibles, copayments and coinsurance. The remaining balance will be
passed on to the secondary payer. When this plan is the secondary payer, it will reimburse the balance
of remaining eligible expenses, not to exceed normal plan liability if this plan had been primary. This
means that if the primary payer has already paid as much as or more than this plan would have paid
had this plan been primary, there will be no additional payment made.
Government Programs and Other Group Health Plans -The term group health plan, as it relates to
coordination of benefits, includes the government programs Medicare, Medicaid and TriCare. The
regulations governing these programs take precedence over the determination of benefits under this
plan. For example, in determining the benefits payable under the plan, the plan will not take into
account the fact that you or any eligible dependent(s) are eligible for or receive benefits under a
Medicaid plan.
The term group health plan also includes all group insurance and group subscriber contracts, such as
union welfare plans.
Order of Payment When Coordinating with Other Group Health Plans
• If the other plan does not include 'coordination of benefits,'that plan is primary and this plan is
secondary.
• If you are covered as an employee on one plan and a dependent on another, your Plan Sponsors
plan is primary.
• When a child is covered under both parents' policies and the parents are either married or are living
together (regardless of whether or not they have ever been married):
- The parent whose birthday falls first in a benefit year has the primary plan; or
- If both parents have the same birthday, the parent who has been covered the longest has the
primary plan.
• When a child is covered under both parents' plans and the parents are divorced, separated, or not
living together (regardless of whether or not they have ever been married):
- If a court order specifies that one parent is responsible for the child's healthcare expenses,
the mandated parent's coverage is primary regardless of custody.
- If a court order specifies that both parents are responsible for the child's healthcare
expenses, the parent whose birthday falls first in a benefit year has the primary plan. If both
parents have the same birthday, the parent who has been covered the longest has the
primary plan.
- If a court order specifies that both parents have joint custody without specifying that one
parent has responsibility for the child's healthcare expenses, the parent whose birthday falls
first in a benefit year has the primary plan. If both parents have the same birthday, the parent
who has been covered the longest has the primary plan.
- If there is no court order, the order of benefits for the child are as follows:
o The custodial parent's coverage is primary;
o The spouse of the custodial parent's coverage pays second;
o The natural parent without custody's coverage pays third; and
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o The spouse of the natural parent without custody's coverage pays fourth.
• If a plan covers you as an active employee or a dependent of an active employee, that plan is
primary. Another plan covering you as inactive, laid off, or retired is secondary.
• When this plan covers you or your dependent pursuant to COBRA or under a right of continuation
pursuant to other federal law, the plan covering you or your dependent as an employee, member,
subscriber, or retiree or covering you or your dependent as a dependent of an employee, member,
subscriber or retiree is the primary plan and this plan's coverage is the secondary plan.
• If none of these rules apply, the coverage that has been in place longest is primary.
Most insurers or administrators send you an explanation of benefits, or EOB, when they pay a claim. If
your other plan's coverage is primary, send PacificSource the other plan's EOB with your original bill
and they will process your claim. If you receive more than you should when your benefits are
coordinated, you will be expected to repay any over-payment to the plan.
Right to Make Payments to Other Organizations - Whenever payments, which should have been
made by this plan, have been made by any other plan(s), this plan has the right to pay the other plan(s)
any amount necessary to satisfy the terms of this coordination of benefits provision. Amounts paid will
be considered benefits paid under this plan and, to the extent of such payments, the plan will be fully
released from any liability regarding the person for whom payment was made.
Automobile Insurance - This plan provides benefits relating to medical expenses incurred as a result
of an automobile accident on a secondary basis only. Benefits payable under this plan will be
coordinated with and secondary to benefits provided or required by any no-fault automobile insurance
statute, whether or not a no-fault policy is in effect, and/or any other automobile insurance.
Any benefits provided by this plan will be subject to the plan's reimbursement and/or subrogation
provisions.
OTHER IMPORTANT PLAN PROVISIONS
Assignment of Benefits
All benefits payable by the plan are automatically assigned to the provider of services or supplies,
unless evidence of previous payment is submitted with the claim form. However, the plan reserves the
right to reimburse the member, the provider, or both jointly. Payments made in accordance with an
assignment are made in good faith and release the plan's obligation to the extent of the payment.
Payments will also be made in accordance with any assignment of rights required by a state Medicaid
plan.
Members are expressly prohibited from assigning any right to payment of benefits under a Benefit
Program, including this plan. No attempts at assignment of any such expenses under a Benefit
Program will be recognized. Except as may be expressly prescribed in an agreement to which the Plan
Sponsor is a party, nothing contained in any written designation of coverage under a Benefit Program
will make the Benefit Program, or the Plan Sponsor or any other employer, liable to any third-party to
whom a member may be liable for medical care, treatment or services.
Proof of Loss
The Plan Sponsor has the right to require a claimant to undergo physical or psychological examinations
relating to the claimant's illness, injury or condition as often as the Plan Sponsor deems reasonably
necessary while the claim for benefits is pending. The Plan Sponsor also has the right to require an
autopsy in case of death (where not prohibited by law).
No Verbal Modifications of Plan Provisions
No verbal statement made by anyone involved in administering this plan can waive any of the terms or
conditions of this plan or prevent the Plan Sponsorfrom enforcing any provision of this plan. Waivers
are valid only if they are contained in a written instrument signed by an authorized individual on behalf
of the Plan Sponsor. Any such written waiver will be valid only as to the specific plan, term or condition
set forth in the written instrument. Unless specifically stated otherwise, a written waiver will be valid only
for the specific claim involved at the time, and will not be a continuing waiver of the term or condition in
the future.
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Reimbursement to the Plan
This section applies whenever another party (including your own insurer under an automobile or other
policy) is legally responsible or agrees to compensate you or your dependent, by settlement, verdict or
otherwise, for an illness or injury. In that case, you or your dependent (or the legal representatives,
estate or heirs of either you or your dependent), must promptly reimburse the plan for any benefits it
paid relating to that illness or injury, up to the full amount of the compensation received from the other
party (regardless of how that compensation may be characterized and regardless of whether you or
your dependent have been made whole). If the plan has not yet paid benefits relating to that illness or
injury, the plan may reduce or deny future benefits on the basis of the compensation received by you or
your dependent.
Benefits relating to such illness or injury will not be payable by the plan until you sign and return a
statement, provided by the plan, acknowledging your obligation to reimburse the plan under this
provision. That obligation will arise upon the payment of any plan benefits relating to the illness or
injury, whether or not you sign such a statement.
You or your dependent must cooperate with the plan and its authorized representatives, and must sign
and deliver such documents as the plan or its agents reasonably request to protect the plan's right of
reimbursement. You or your dependent must also provide any relevant information and take such
actions as the plan or its agents reasonably request to assist the plan in making a full recovery of the
reasonable value of the benefits provided. You or your dependent must not take any action that
prejudices the plan's right of reimbursement.
In order to secure the rights of the plan under this section, you or your dependent hereby: (1) grant to
the plan a first priority lien against the proceeds of any such settlement, verdict or other amounts
received by you or your dependent; and (2) assign to the plan any benefits you or your dependent may
have under any automobile policy or other coverage, to the extent of the plan's claim for
reimbursement.
The reimbursement required under this provision will not be reduced to reflect any costs or attorneys'
fees incurred in obtaining compensation unless separately agreed to, in writing, by the Plan Sponsor, in
the exercise of its sole discretion.
This plan expressly disavows and repudiates the make whole doctrine, which, if applicable, would
prevent the plan from receiving a recovery unless a member has been 'made whole' with regard to
illness or injury that is the responsibility of a third party. This plan also expressly disavows and
repudiates the common fund doctrine, which, if applicable, would require the plan to pay a portion of the
attorney fees and costs expended in obtaining a recovery. These doctrines have no application to this
plan, since the plan's recovery rights apply to the first dollars payable by a third party.
Subrogation
This section applies whenever another party (including your own insurer under an automobile or other
policy) is legally responsible or agrees to compensate you or your dependent for you or your
dependent's illness or injury and the plan has paid benefits related to that illness or injury.
The plan is subrogated to all of the rights of you or your dependent against any party liable for you or
your dependent's illness or injury to the extent of the reasonable value of the benefits provided to you or
your dependent under the plan. The plan may assert this right independently of you or your dependent.
You and your dependent are obligated to cooperate with the plan and its authorized representatives in
order to protect the plan's subrogation rights. Cooperation means providing the plan or its agents with
any relevant information requested by them, signing and delivering such documents as the plan or its
agents reasonably request to secure the plan's subrogation claim, and obtaining the consent of the plan
or its agents before releasing any party from liability for payment of medical expenses.
If you or your dependent enters into litigation or settlement negotiations regarding the obligations of
other parties, you or your dependent must not prejudice, in any way, the subrogation rights of the plan
under this section.
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The costs of legal representation of the plan in matters related to subrogation will be borne solely by the
plan. The costs of legal representation of you or your dependent must be borne solely by you or your
dependent.
Recovery of Excess Payments
Whenever payments have been made in excess of the amount necessary to satisfy the provisions of
this plan, or were made in error by the plan, the plan has the right to recover these payments from any
individual (including yourself), insurance company or other organization to whom the payments were
made or to withhold payment, if necessary, on future benefits until the overpayment is recovered. If
excess or erroneous payments were made for services rendered to your dependent(s), the plan has the
right to withhold payment on your future benefits until the overpayment is recovered.
Further, whenever payments have been made based on fraudulent information provided by you, the
plan will exercise all available legal rights, including its right to withhold payment on future benefits, until
the overpayment is recovered.
In the same manner, if the plan applies medical expenses to the plan deductible that would not
otherwise be reimbursable under the terms of this policy; the plan may deduct a like amount from the
accumulated deductible amounts and/or recover payment of medical expenses that would have
otherwise been applied to the deductible. The fact that a medical expense was applied to the plan's
deductible, or that a drug was provided under the plan's prescription drug program, does not in itself
create an eligible expense or infer that benefits will continue to be provided for an otherwise excluded
condition.
Right To Receive and Release Necessary Information
The plan may, without the consent of or notice to any person, release to or obtain from any organization
or person, information needed to implement plan provisions, including medical information. When you
request benefits, you must either furnish or authorize the release of all the information required to
implement plan provisions. Your failure to fully cooperate will result in a denial of the requested benefits
and the plan will have no further liability for such benefits.
Under normal conditions, benefits are payable to the provider of services or supplies, unless evidence
of previous payment is submitted with the claim form. If conditions exist under which a valid release or
assignment cannot be obtained, the plan may make payment to any individual or organization that has
assumed the care or principal support for you and is equitably entitled to payment. The plan must make
payments to your separated/divorced spouse, state child support agencies or Medicaid agencies if
required by a qualified medical child support order (QMCSO) or state Medicaid law.
The plan may also honor benefit assignments made prior to your death in relation to remaining benefits
payable by the plan.
Any payment made by the plan in accordance with this provision will fully release the plan of its liability
to you.
Reliance on Documents and Information
Information required by the Plan Sponsor or PacificSource may be provided in any form or document
that the Plan Sponsor and PacificSource considers acceptable and reliable. The Plan Sponsor and
PacificSource relies on the information provided by you and others when evaluating coverage and
benefits under the plan. All such information, therefore, must be accurate, truthful and complete. The
Plan Sponsor and PacificSource is entitled to conclusively rely upon, and will be protected for any
action taken in good faith in relying upon, any information provided to the Plan Sponsor or
PacificSource. In addition, any fraudulent statement, omission or concealment of fads,
misrepresentation, or incorrect information may result in the denial of the claim, cancellation or
rescission of coverage, or any other legal remedy available to the plan.
No Waiver
The failure of the Plan Sponsorto enforce strictly any term or provision of this plan will not be construed
as a waiver of such term or provision. The Plan Sponsor reserves the right to enforce strictly any term
or provision of this plan at any time.
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Physician/Patient Relationship
This plan is not intended to disturb the physician/patient relationship. Physicians, practitioners and other
health care providers are not agents or delegates of the Plan Sponsor, or the Third Party Administrator.
Nothing contained in this plan will require you or your dependent to commence or continue medical
treatment by a particular provider. Further, nothing in this plan will limit or otherwise restrict a physician
or practitioner's judgment with respect to the physician or practitioner's ultimate responsibility for patient
care in the provision of medical services to you or your dependent.
Plan not responsible for Quality of Health Care
You and your enrolled dependents have the right to select your health care provider. Neither the plan,
your Plan Sponsor, nor Third Party Administrator is responsible for the quality of care received and
cannot be held liable for any claim or damages connected with injuries suffered while receiving health
services or supplies.
Plan is not a Contract of Employment
Nothing contained in this plan will be construed as a contract or condition of employment between the
Plan Sponsor and any employee. All employees are subject to discharge to the same extent as if this
plan had never been adopted.
Right to Amend or Terminate Plan
Plan Sponsor reserves the right to amend, modify or terminate the plan in any manner, for any reason,
at any time.
If changes occur, your Plan Sponsor will notify you of changes to your plan.
If your health plan terminates and your Plan Sponsor does not replace the coverage with another group
policy, your Plan Sponsor is required by law to advise you in writing of the termination. When this plan
terminates, your Plan Sponsorwill notify you about any available options for you to continue your
coverage.
The Plan Sponsor may pay your medical claims if a workers' compensation claim has been denied on
the basis that the illness or injury is not work related, and the denial is under appeal. But before
PacificSource does that, you must sign a written agreement to reimburse the Plan Sponsor any money
you recover from the workers' compensation coverage.
Rescissions
The Plan Sponsor or PacificSource may not rescind the coverage of a member unless the member, or
person seeking coverage on behalf of the member, performs an act, practice or omission that
constitutes fraud or makes an intentional misrepresentation of a material fad as prohibited by the terms
of this plan and the Plan Sponsor or PacificSource gives the member a 30-day prior written notice.
PacificSource may not rescind the policyholder's group health benefit plan unless the policyholder, or
representative of the policyholder, performs an act, practice or omission that constitutes fraud or makes
an intentional misrepresentation of a material fact as prohibited by the terms of this plan and
PacificSource gives a 30-day prior written notice to all member covered under the plan. Rescissions do
not include a cancellation or discontinuance of coverage that is prospective or to the extent it is
attributable to a failure to timely pay required contributions towards the cost of coverage.
Applicable Law
This is a self-insured benefit plan. As such, Federal law preempts State law and jurisdiction. To the
extent not preempted by federal law, the laws of the state of Oregon shall apply.
PRIVACY AND CONFIDENTIALITY
This notice is intended to bring the City of Ashland Employee Benefit Plan into compliance with the
requirements of Section 164.504(f) of the Health Insurance Portability and Accountability Act of 1996
and its implementing regulations, 45 C.F.R. parts 160 through 164 (the'HIPAA Privacy Rule') by
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establishing the conditions under which the Plan Sponsor will receive, use and/or disclose protected
health information.
Permitted Disclosures of Protected Health Information to the Plan Sponsor
Subject to the conditions of the 'No Disclosure of Protected Health Information to the Employer Without
Certification by Employer' and 'Conditions of Disclosure of Protected Health Information to the
Employer', the plan (and any third party administrator or business associate acting on behalf of the
plan) may disclose individuals' protected health information to the Plan Sponsorfor the Plan Sponsor or
PacificSource to carry out plan administration functions. The plan (and any third party administrator or
business associate acting on behalf of the plan) may not disclose individuals' protected health
information to the Plan Sponsor for employment-related actions and decisions or in connection with any
other benefit or employee benefit plan of the Plan Sponsor.
No Disclosure of Protected Health Information to the Plan Sponsorwithout Certification by Plan
Sponsor
Except as provided below in 'Disclosures of Summary Health Information and Enrollment/Disenrollment
• Information to the Employer,' with respect to the plan's disclosure of summary health information and
enrollment/disenrollment information, the plan will not disclose protected health information to any
employee of the Plan Sponsor.
Conditions of Disclosure of Protected Health Information to the Plan Sponsor
The Plan Sponsor certifies that the plan has been amended to incorporate this section and agrees to
the following restrictions and conditions of receiving protected health information (other than summary
health information or enrol lment/disenrollment information as explained in 'Disclosures of Summary
Health Information and Enrollment/Disenrollment Information to the Plan Sponsor below). The Plan
Sponsor shall
• Not use or further disclose the protected health information other than as permitted or required
herein or as required by law.
• Ensure that any agent(s), including a subcontractor, to whom it provides protected health
information received from the plan agrees to the same restrictions and conditions that apply to the
Plan Sponsorwith respect to such protected health information.
• Not use or disclose protected health information for employment-related actions and decisions or in
connection with any other benefit or employee benefit plan of the Plan Sponsor.
• Report to the plan any use or disclosure of protected health information that is inconsistent with the
uses or disclosures provided for of which the Plan Sponsor becomes aware.
• Make available protected health information to comply with an individual's right to access protected
health information in accordance with 45 C.F.R. Section 164.524.
• Make available protected health information for amendment and incorporate any amendments to
protected health information in accordance with 45 C.F.R. Section 164.526.
• Make available the information required to provide an accounting of disclosures in accordance with
45 C.F.R. §164.528.
• Make its internal practices, books and records relating to the use and disclosure of protected health
information received from the plan available to the Secretary of the Department of Health and
Human Services for purposes of determining compliance by the plan with the HIPAA Privacy Rule.
• If feasible, return or destroy all protected health information received from the plan that the Plan
Sponsor still'maintains in any form and retain no copies of such information when no longer needed
for the purpose for which disclosure was made, except that, if such return or destruction is not
feasible, the Plan Sponsor will limit further uses and disclosures to those purposes that make the
return or destruction of the information infeasible.
• Ensure that the required adequate separation, described in 'Required Separation Between the Plan
and the Plan Sponsor below, is established and maintained.
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Disclosures of Summary Health Information and Enrollment/Disenrollment Information to the
Plan Sponsor
• The plan (or a third party administrator of the plan) may disclose summary health information to the
Plan Sponsorwithout the need to comply with the conditions and restrictions of 'No Disclosure of
Protected Health Information to the Plan Sponsor Without Certification by Plan Sponsor' and
'Conditions of Disclosure of Protected Health Information to the Plan Sponsor, if the Plan Sponsor
requests the summary health information for the purpose of:
- Obtaining premium bids from health plans (including health insurance issuers) for providing
health insurance coverage under the plan; or
- Modifying, amending, or terminating the plan
• The plan (or a third party administrator of the plan) may disclose information on whether the
individual is participating in the group health plan, or is enrolled in or has disenrolled from the plan
without the need to comply with the conditions and restrictions of 'No Disclosure of Protected
Health Information to the Plan Sponsor Without Certification by Plan Sponsor and 'Conditions of
Disclosure of Protected Health Information to the Plan Sponsor'
Required Separation between the Plan and the Plan Sponsor
• The following classes of employees or other persons under the control of the Plan Sponsorwill
have access to protected health information received from the plan (or from a health insurance
issuer with respect to the plan):
- Human Resources
• No other persons shall have access to protected health information. The listed classes of
employees or other persons under the control of the Plan Sponsorwill have access to protected
health information solely to perform the plan administration functions that the Plan Sponsor
performs for the plan. They will be subject to disciplinary action and/or sanctions (including
termination of employment or affiliation with the Plan Sponsor) for any use or disclosure of
protected health information in violation of the provisions of this plan.
DEFINITIONS
Wherever used in this plan, the following definitions apply to the terms listed below, and the masculine
includes the feminine and the singular includes the plural. For the purpose of this plan, 'employee'
includes the Plan Sponsor when covered by this plan. Other terms are defined where they are first used
in the text.
Abutment is a tooth used to support a prosthetic device (bridges, partials or overdentures). With an
implant, an abutment is a device placed on the implant that supports the implant crown.
Accident means an unforeseen or unexpected event causing injury that requires medical attention.
Actively at work or active employment means that an employee is performing in the customary
manner all of the regular duties of his/her occupation with the Plan Sponsor, either at one of the Plan
Sponsor's regular places of business or at some location to which the Plan Sponsor's business requires
the employee to travel to perform his/her regular duties assigned by the Plan Sponsor. An employee is
also considered to be actively at work on each day of a regular paid vacation or non-work day, but only
if the employee is performing in the customary manner all of the regular duties of the employee's
occupation with the Plan Sponsor on the immediately preceding regularly scheduled workday.
Advanced diagnostic imaging means diagnostic examinations using CT scans, MRIs, PET scans,
CATH labs, and nuclear cardiology studies.
Adverse benefit determination means a denial, reduction, or termination of a healthcare item or
service, or a failure or refusal to provide or to make a payment in whole or in part for a healthcare item
or service, that is based on the Plan Sponsor's or PacificSource's:
• Denial of eligibility for or termination of enrollment in a health benefit plan;
• Rescission or cancellation of a policy or coverage;
• Imposition of a source-of-injury exclusion, network exclusion, annual benefit limit or other limitation
on otherwise covered items or services;
SingleSource Self-Insured 72
• Determination that a healthcare item or service is experimental, investigational, or not medically
necessary, effective, or appropriate; or
• Determination that a course or plan of treatment that a member is undergoing it an active course of
treatment for purposes of continuity of care under ORS 743.854.
Advantage Essential Network is the exclusive provider network that provides dental care to members
under this plan.
Allowable fee is the dollar amount established by the plan for reimbursement of charges for specific
services or supplies provided by nonparticipating providers. The plan uses several sources to
determine the allowable amount. Depending on the service or supply and the geographical area in
which it is provided, the allowable amount may be based on data collected from the Centers for
Medicare and Medicaid Services (CMS), Viant Health Payment Solutions, other nationally recognized
databases, or PacificSource.
Where the provider network is deemed adequate, the allowable fee for professional services is based
on PacificSource's standard participating provider reimbursement rate or a contracted reimbursement
rate. Outside the PacificSource service area and in areas where the participating provider network is
not deemed adequate, the allowable fee is based on the usual, customary, and reasonable charge
(UCR) at the 85th percentile. UCR is based on data collected for a geographic area. Provider charges
for each type of service are collected and ranked from lowest to highest. Charges at the 85th position in
the ranking are considered to be the 85th percentile.
Alveolectomy is the removal of bone from the socket of a tooth.
Amalgam is a silver-colored material used in restoring teeth.
Ambulatory surgical center means a facility licensed by the appropriate state or federal agency to
perform surgical procedures on an outpatient basis.
Ancillary Services means service rendered in connection with Inpatient or Outpatient care in a
Hospital or in connection with a medical emergency, such as assistant surgeon, anesthesiology,
ambulance, pathology and radiology.
Approved clinical trials are Phase I, II, III, or IV clinical trials for the prevention, detection, or treatment
of cancer or another life-threatening condition or disease.
Authorized representative is an individual who by law or by the contest of a person may act on behalf
of the person.
Benefit year means the 12-month period beginning on each January 1 and ending on the next
December 31.
Cardiac rehabilitation refers to a comprehensive program that generally involves medical evaluation,
prescribed exercise, and cardiac risk factor modification. Education, counseling, and behavioral
interventions are sometimes used as well. Phase I refers to inpatient services that typically occur during
hospitalization for heart attack or heart surgery. Phase 11 refers to a short-term outpatient program,
usually involving ECG-monitored exercise. Phase III refers to a long-term program, usually at home or
in a community-based facility, with little or no ECG monitoring.
Cast restoration includes crowns, inlays, onlays, and other restorations made to fit a patient's tooth
that are made at a laboratory and cemented onto the tooth.
Certificate of Creditable Coverage means a certificate or other documentation that shows previous
health insurance coverage for a member and can be used to reduce the length of any pre-existing
condition exclusions under a plan. See Creditable coverage.
Chemical dependency means the addictive relationship with any drug or alcohol characterized by
either a physical or psychological relationship, or both, that interferes with the individual's social,
psychological, or physical adjustment to common problems on a recurring basis. Chemical dependency
does not include addiction to, or dependency on, tobacco products or foods.
Claims Administrator means the organization selected by the City of Ashland to provide claims
processing and adjudication under their plans. The Claims Administrator for their medical, vision and
pharmacy coverage is PacificSource.
Composite resin is a tooth-colored material used in restoring teeth.
Contracted amount means the amount that participating providers have contracted to accept as
payment in full for covered expenses under the plan.
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Copayment or coinsurance is the out-of-pocket amount a member is required to pay to a provider.
Creditable coverage means a member's prior health coverage that meets the following criteria:
• There was no more than a 63-day break between the last day of coverage under the previous
policy and the first day of coverage under this policy. The 63-day limit excludes the Plan Sponsor's
eligibility waiting period.
• The prior coverage was one of the following types of insurance: group coverage (including Federal
Employee Health Benefit Plans and Peace Corps), individual coverage (including student health
plans), Medicaid, Medicare, TRICARE, Indian Health Service or tribal organization coverage, state
high-risk pool coverage, and public health plans.
Curettage is the scraping and cleaning of the walls of a real or potential space, such as a gingival
pocket or bone, to remove pathological material.
Custodial Care means non-medical care that is primarily to assist with activities of daily living, whether
or not the care is administered by a licensed provider.
Deductible means the portion of the healthcare expense that must be paid by the member before the
benefits of this plan are applied.
Dental emergency means the sudden and unexpected onset of a condition, or exacerbation of an
existing condition, requiring necessary care to control pain, swelling or bleeding in or around the teeth
and gums. Such emergency care must be provided within 48 hours following the onset of the
emergency and includes treatment for acute infection, pain, swelling, bleeding, or injury to natural teeth
and oral structures. The emergency care does not include follow-up care such as, but not limited to,
crowns, root canal therapy, or prosthetic benefits.
Dentist means a person acting within the scope of their license, holding the degree of Doctor of
Medicine (M.D.), Doctor of Dental Surgery (D.D.S.), or Doctor of Dental Medicine (D.M.D.), and who is
legally entitled to practice dentistry in all its branches under the laws of the state or jurisdiction where
the services are rendered.
Durable medical equipment means equipment that can withstand repeated use; is primarily and
customarily used to serve a medical purpose rather than convenience or comfort; is generally not useful
to a person in the absence of an illness or injury; is appropriate for use in the home; and is prescribed
by a physician. Examples of durable medical equipment include but are not limited to hospital beds,
wheelchairs, crutches, canes, walkers, nebulizers, commodes, suction machines, traction equipment,
respirators, TENS units, and hearing aids.
Durable medical equipment supplier means a PacificSource contracted provider or a provider that
satisfies the criteria in the Medicare Qualify Standards for Suppliers of Durable Medical Equipment,
Prosthetics, Orthotics, Supplies (DMEPOS) and Other Items and Services Summary Plan Description.
Elective surgery or procedure refers to a surgery or procedure for a condition that does not require
immediate attention and for which a delay would not have a substantial likelihood of adversely affecting
the health of the patient.
Eligible dental provider means a physician, dentist, oral surgeon, endodontist, orthodontist,
periodontist, or pedodontist. Eligible provider may also include a denturist or dental hygienist to the
extent that he/she operates within the scope of their license.
Emergency medical condition means a medical condition:
• That manifests itself by acute symptoms of sufficient severity, including severe pain that a prudent
layperson possessing an average knowledge of health and medicine would reasonably expect that
failure to receive immediate medical attention would:
- Place the health of a person, or an unborn child in the case of a pregnant woman, in serious
jeopardy;
- Result in serious impairment to bodily functions; or
- Result in serious dysfunction of any bodily organ or part; or
• With respect to a pregnant woman who is having contractions, for which there is inadequate time to
affect a safe transfer to another hospital before delivery or for which a transfer may pose a threat to
the health or safety of the woman or the unborn child.
Emergency medical screening exam means the medical history, examination, ancillary tests, and
medical determinations required to ascertain the nature and extent of an emergency medical condition.
SingleSource Self-Insured 74
Emergency services means, with respect to an emergency medical condition:
• An emergency medical screening exam that is within the capability of the emergency department of
a hospital, including ancillary services routinely available to the emergency department to evaluate
such emergency medical condition; and
• Such further medical examination and treatment as are required under 42 U.S.C. 1395dd to
stabilize the patient to the extent the examination and treatment are within the capability of the staff
and facilities available at a hospital.
Employee means any individual employed by a Plan Sponsor.
Endorsement is a written attachment that alters and supersedes any of the terms or conditions set
forth in this contract.
Enrollee means an employee, dependent of the employee, or individual otherwise eligible and enrolled
for coverage under this plan. In this policy, enrollee is referred to as subscriber or member.
Essential health benefits are services defined as such by the Secretary of the U.S. Department of
Health and Human Services. Essential health benefits fall into the following categories:
• Ambulatory patient services;
• Emergency services;
• Hospitalization,
• Maternity and newborn care;
• Mental health and substance use disorder services, including behavioral health treatment;
• Prescription drugs;
• Rehabilitative and habilitative services and devices;
• Laboratory services;
• Preventive and wellness services and chronic disease management; and
• Pediatric services, including oral and vision care.
Exclusion period means a period during which specified conditions, treatments or services are
excluded from coverage.
Experimental or investigational procedures means services, supplies, protocols, procedures,
devices, chemotherapy, drugs or medicines, or the use thereof, that are experimental or investigational
for the diagnosis and treatment of illness or injury.
• Experimental or investigational services and supplies include, but are not limited to, services,
supplies, procedures, devices, chemotherapy, drugs or medicines, or the use thereof, which at the
time they are rendered and for the purpose and in the manner they are being used:
- Have not yet received full U.S. government agency required approval (e.g., FDA) for other
than experimental, investigational, or clinical testing,
- Are not of generally accepted medical practice in the state of Oregon or as determined by
PacificSource in consultation with medical advisors, medical associations, and/or technology
resources;
- Are not approved for reimbursement by the Centers for Medicare and Medicaid Services;
- Are furnished in connection with medical or other research, or
- Are considered by any governmental agency or subdivision to be experimental or
investigational, not considered reasonable and necessary, or any similar finding.
• When making decisions about whether treatments are investigational or experimental,
PacificSource relies on the abovd resources as well as:
- Expert opinions of specialists and other medical authorities;
- Published articles in peer-reviewed medical literature,
- External agencies whose role is the evaluation of new technologies and drugs; and
- External review by an independent review organization.
SingleSource Self-Insured 75
• The following will be considered in making the determination whether the service is in an
experimental and/or investigational status:
- Whether there is sufficient evidence to permit conclusions concerning the effect of the
services on health outcomes;
- Whether the scientific evidence demonstrates that the services improve health outcomes as
much or more than established alternatives;
- Whether the scientific evidence demonstrates that the services' beneficial effects outweigh
any harmful effects; and
- Whether any improved health outcomes from the services are attainable outside an
investigational setting.
Formulary is a list of approved brand name medications used to treat various medical conditions. The
formulary list is developed by the pharmacy benefits management company and PacifcSource.
Generic drugs are drugs that, under federal law, require a prescription by a licensed physician (M.D. or
D.O.) or other licensed medical provider and are not a brand name medication. By law, generic drugs
must have the same active ingredients as the brand name medication and are subject to the same
standards of their brand name counterpart.
Grievance means:
• A request submitted by a member or an authorized representative of a member;
- In writing, for an internal appeal or an external review; or
- In writing or orally, for an expedited internal review or an expedited external review; or
• A written complaint submitted by a member or an authorized representative of a member regarding:
- The availability, delivery, or quality of a healthcare service;
- Claims payment, handling, or reimbursement for healthcare services and, unless the member
has not submitted a request for an internal appeal, the complaint is not disputing an adverse
benefit determination; or
- Matters pertaining to the contractual relationship between a member and PacificSource.
Health care provider means a physician, practitioner, nurse, hospital or specialized treatment facility
as defined in this document.
Health benefit plan means any hospital expense, medical expense, or hospital or medical expense
policy or certificate, healthcare contractor or health maintenance organization subscriber contract, or
any plan provided by a multiple employer welfare arrangement or by another benefit arrangement
defined in the federal Employee Retirement Income Security Act of 1974, as amended, to the extent
that plan is subject to state regulation.
Hearing aids mean any nondisposable, wearable instrument or device designed to aid or compensate
for impaired human hearing and any necessary ear mold, part, attachments or accessory for the
instrument or device, except batteries and cords. Hearing aids include any amplifying device that does
not produce as its output an electrical signal that directly stimulates the auditory nerve. For the purpose
of this definition, such amplifying devices include air conduction and bone conduction devices, as well
as those that provide vibratory input to the middle ear.
Homebound means the ability to leave home only with great difficulty with absences infrequently and
of short duration. Infants and toddlers will not be considered homebound without medical
documentation that clearly establishes the need for home skilled care. Lack of transportation is not
considered sufficient medical criterion for establishing that a person is homebound.
Hospital means an institution licensed as a'general hospital' or 'intermediate general hospital' by the
appropriate state agency in the state in which it is located.
Illness includes a physical or mental condition that results in a covered expense. Physical illness is a
disease or bodily disorder. Mental illness is a psychological disorder that results in pain or distress and
substantial impairment of basic or normal functioning.
Incurred expense means charges of a healthcare provider for services or supplies for which a member
becomes obligated to pay. The expense of a service is incurred on the day the service is rendered, and
the expense of a supply is incurred on the day the supply is delivered.
SingleSource Self-Insured 76
Initial enrollment period means a period of 31 days following the date an individual is first eligible to
enroll.
Injury means bodily trauma or damage that is independent of disease or infirmity. The damage must be
caused solely by external and accidental means and does not include muscular strain sustained while
performing a physical activity.
Inquiry means a written request for information or clarification about any subject matter related to the
member's health benefit plan.
Internal appeal means a review by PacificSource or your Plan Sponsorof an adverse benefit
determination made by PacificSource.
Leave of absence is a period of time off work granted to an employee by the Plan Sponsor at the
employee's request and during which the employee is still considered to be employed and is carried on
the employment records of the Plan Sponsor. A leave can be granted for any reason acceptable to the
Plan Sponsor, including disability and pregnancy.
Lifetime means the period of time a member is enrolled in this plan or any other Plan Sponsored by the
Plan Sponsor.
Mastectomy is the surgical removal of all or part of a breast or a breast tumor suspected to be
malignant.
Medically necessary means those services and supplies that are required for diagnosis or treatment of
illness or injury and that are:
• Consistent with the symptoms or diagnosis and treatment of the condition;
• Consistent with generally accepted standards of good medical practice in the state of Oregon, or
expert consensus physician opinion published in peer-reviewed medical literature, or the results of
clinical outcome trials published in peer-reviewed medical literature;
• As likely to produce a significant positive outcome as, and no more likely to produce a negative
outcome than, any other service or supply, both as to the disease or injury involved and the
patient's overall health condition,
• Not for the convenience of the member or a provider of services or supplies,
• The least costly of the alternative services or supplies that can be safely provided. When
specifically applied to a hospital inpatient, it further means that the services or supplies cannot be
safely provided in other than a hospital inpatient setting without adversely affecting the patient's
condition or the quality of medical care rendered.
Services and supplies intended to diagnose or screen for a medical condition in the absence of signs or
symptoms, or of abnormalities on prior testing, including exposure to infectious or toxic materials or
family history of genetic disease, are not considered medically necessary under this definition (see
General Exclusions - Screening tests).
Medical supplies means items of a disposable nature that may be essential to effectively carry out the
care a physician has ordered for the treatment or diagnosis of an illness or injury. Examples of medical
supplies include but are not limited to syringes and needles, splints and slings, ostomy supplies, sterile
dressings, elastic stockings, enteral foods, drugs or biologicals that must be put directly into the
equipment in order to achieve the therapeutic benefit of the durable medical equipment or to assure the
proper functioning of this equipment (e.g. Albuterol for use in a nebulizer).
Member means an individual insured through the Plan Sponsor.
Mental and/or chemical healthcare facility means a corporate or governmental entity or other
provider of services for the care and treatment of chemical dependency and/or mental or nervous
conditions which is licensed or accredited by the Joint Commission on Accreditation of Hospitals or the
Commission on Accreditation of Rehabilitation Facilities for the level of care which the facility provides.
Mental and/or chemical healthcare program means a particular type or level of service that is
organizationally distinct within a mental and/or chemical healthcare facility.
Mental and/or chemical healthcare provider means a person that has met the credentialing
requirements of PacificSource, is otherwise eligible to receive reimbursement under the policy and is:
• A healthcare facility where appropriately licensed or accredited by the Commission on Accreditation
of Hospitals or the Commission on Accreditation of Rehabilitation Facilities;
• A residential program or facility;
SingleSource Self-Insured 77
• A day or partial hospitalization program;
• An outpatient service; or
• An individual behavioral health or medical professional authorized for reimbursement under Oregon
law.
Mental or nervous conditions means all disorders listed in the'Diagnostic and Statistical Manual of
Mental Disorders, DSM-IV-TR, Fourth Edition' except for:
• Mental Retardation (diagnostic codes 317, 318.0, 318.1, 318.2, 319);
• Learning Disorders (diagnostic codes 315.00, 315.1, 315.2, 315.9);
• Paraphilias (diagnostic codes 302.4, 302.81, 302.89, 302.2, 302.83, 302.84, 302.82, 302.9); and
• Gender Identity Disorders in Adults (diagnostic codes 302.85, 302.6, 302.9 - this exception does
not extend to children and adolescents 18 years of age or younger); and
• 'V' codes (diagnostic codes V15.81 through V71.09 - this exception does not extend to children five
years of age or younger for diagnostic codes V61.20, V61.21, and V62.82).
Network not available means a member does not have reasonable geographic access to a
PacificSource participating provider for a medical service or supply.
Non-participating provider is a provider of covered medical services or supplies that does not directly
or indirectly hold a provider contract or agreement with PacificSource.
Non-preferred drugs are covered brand name medications not on the Preferred Drug List.
Orthotic devices means rigid or semirigid devices supporting a weak or deformed leg, foot, arm, hand,
back or neck or restricting or eliminating motion in a diseased or injured leg, foot, arm, hand, back or
neck. Benefits for orthotic devices include orthopedic appliances or apparatus used to support, align,
prevent, or correct deformities or to improve the function of movable parts of the body. An orthotic
device differs from a prosthetic in that, rather than replacing a body part, it supports and/or rehabilitates
existing body parts. Orthotic devices are usually customized for an individual's use and are not
appropriate for anyone else. Examples of orthotic devices include but are not limited to Ankle Foot
Orthosis (AFO), Knee Ankle Foot Orthosis (KAFO), Lumbosacral Orthosis (LSO), and foot orthotics.
PacificSource refers to PacificSource Health Plans. PacificSource is the claims administrator of the
Plan Sponsor's medical, vision and pharmacy coverage. References to PacificSource as paying claims
or issuing benefits means that PacificSource processes a claim in accordance with the provisions of the
Plan Sponsor's plans.
Participating provider means a physician, healthcare professional, hospital, medical facility, or
supplier of medical supplies that directly or indirectly holds a provider contract or agreement with the
plan.
Periapical x-ray is an x-ray of the area encompassing or surrounding the tip of the root of a tooth.
Periodontal maintenance is a periodontal procedure for patients who have previously been treated for
periodontal disease. In addition to cleaning the visible surfaces of the teeth (as in prophylaxis) surfaces
below the gum-line are also cleaned. This is a more comprehensive service than a regular cleaning
(prophylaxis).
Periodontal scaling and root planing means the removal of plaque and calculus deposits from the
root surface under the gum line.
Physical/occupational therapy is comprised of the services provided by (or under the direction and
supervision of) a licensed physical or occupational therapist. Physicalloccupational therapy includes
emphasis on examination, evaluation, and intervention to alleviate impairment and functional limitation
and to prevent further impairment or disability.
Physician means a state-licensed Doctor of Medicine (M.D.) or a Doctor of Osteopathy (D.O.).
Physician assistant is a person who is licensed by an appropriate state agency as a physician
assistant.
Plan means the City of Ashland Employee Benefits Plan, and all documents, including any insurance
contracts, administrative service agreements, Summary Plan Descriptions and any related terms and
conditions associated with the Plan.
SingleSource Self-Insured 78
Plan Administrator means the Risk Services Division of the City of Ashland, which has responsibility
for the management of the plan.
Plan Sponsor('the Plan Sponsor or'your Plan Sponsor), means the City of Ashland. The City of
Ashland is the fiduciary of the plan, and exercises all discretionary authority and control over the
administration of the plan and the management and disposition of plan assets. The Plan Sponsor shall
have the sole discretionary authority to determine eligibility for plan benefits or to construe the terms of
the plan, and benefits under the plan'will be paid only if the Plan Sponsor decides, in its discretion, that
the memberor beneficiary is entitled to such benefits. The Plan Sponsor has the right to amend,
modify, or terminate the plan in any manner, at any time, regardless of the health status of any plan
member or beneficiary.
Plan Year means the twelve-month period of time for the City of Ashland beginning January 1, and
ending December 31.
Practitioner means Doctor or Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery
(D.D.S.), Doctor of Dental Medicine (D.M.D.), Doctor of Podiatry Medicine (D.P.M.), Doctor of
Chiropractic (D.C.), Doctor of Optometry (O.D.), Licensed Nurse Practitioner (including Certified Nurse
Midwife (C.N.M.) and Certified Registered Nurse Anesthetist (C.R.N.A.)), Registered Physical Therapist
(R.P.T.), Speech Therapist, Occupational Therapist, Psychologist (Ph.D.), Licensed Clinical Social
Worker (L.C.S.W.), Licensed Professional Counselor (L.P.C.), Licensed Marriage and Family Therapist
(LMFT), Licensed Psychologist Associate (LPA), Physician Assistant (PA), Audiologist, Acupuncturist,
Naturopathic Physician, and Licensed Massage Therapist.
Pre-existing condition means a condition (physical or mental) for which medical advice, diagnosis,
care, or treatment was recommended by or received from a licensed provider within the six-month
period ending on the enrollment date. For the purpose of this definition, the enrollment date of a
member is the earlier of the effective date of coverage or the first day of any required group eligibility
waiting period, and the enrollment date of a late enrollee is the effective date of coverage. Pregnancy
does not constitute a pre-existing condition, nor does genetic information without a diagnosis of a
condition related to such information.
Preferred is a list of approved brand name medications used to treat various medical conditions. The
Preferred Drug List is developed by the pharmacy benefits management company and PacificSource.
Prescription drugs are drugs that, under federal law, require a prescription by a licensed physician
(M.D. or D.O.) or other licensed medical provider.
Prophylaxis is a cleaning and polishing of all teeth.
Prosthetic devices (excluding dental) means artificial limb devices or appliances designed to replace
in whole or in part an arm or a leg. Benefits for prosthetic devices include coverage of devices that
replace all or part of an internal or external body organ, or replace all or part of the function of a
permanently inoperative or malfunctioning internal or external organ, and are furnished on a physician's
order. Examples of prosthetic devices include but are not limited to artificial limbs, cardiac pacemakers,
prosthetic lenses, breast prosthesis (including mastectomy bras), and maxillofacial devices.
Pulpotomy is the removal of a portion of the pulp, including the diseased aspect, with the intent of
maintaining the vitality of the remaining pulpal tissue by means of a therapeutic dressing.
Qualified domestic partner means a registered domestic partner or unregistered same gender
domestic partner with an Affidavit of Domestic Partnership, supplied by the Plan Sponsor.
Restoration is the treatment that repairs a broken or decayed tooth. Restorations include, but are not
limited to, fillings and crowns.
Routine costs of care means medically necessary conventional care, items, or services covered by
the health benefit plan if typically provided absent a clinical trial. Routine costs of care do not include:
• The drug, device, or service being tested in the clinical trial unless the drug, device, or service
would be covered for that indication by the policy if provided outside of a clinical trial;
• Items or services required solely for the provisions of the drug, device, or service being tested in
the clinical trial;
• Items or services required solely for the clinically appropriate monitoring of the drug, device, or
service being tested in the clinical trial;
• Items of services required solely for the prevention, diagnosis, or treatment of complications arising
from the provision of the drug, device, or service being tested in the clinical trial;
SingleSource Self-Insured 79
• Items or services that are provided solely to satisfy data collection and analysis needs and that are
not used in the direct clinical management of the patient;
• Items or services customarily provided by a clinical trial sponsor free of charge to any participant in
the clinical trial; or
• Items or services that are not covered by the policy if provided outside of the clinical trial.
seasonal employee is an employee who is hired with the agreement that their employment will end
after a predetermined period of time.
Skilled nursing facility convalescent home means an institution that provides skilled nursing care
under the supervision of a physician, provides 24-hour nursing service by or under the supervision of a
registered nurse (R.N.), and maintains a daily record of each patient. Skilled nursing facilities must be
licensed by an appropriate state agency and approved for payment of Medicare benefits to be eligible
for reimbursement.
Specialized treatment facility means a facility that provides specialized short-term or long-term care.
The term specialized treatment facility includes ambulatory surgical centers, birthing centers, chemical
dependency/substance abuse day treatment facilities, hospice facilities, inpatient rehabilitation facilities,
mental and/or chemical healthcare facilities, organ transplant facilities, psychiatric day treatment
facilities, residential treatment facilities, skilled nursing facilities, substance abuse treatment facilities,
and urgent care treatment facilities.
Specialty drugs are high dollar oral, injectable, infused or inhaled biotech medications prescribed for
the treatment of chronic and/or genetic disorders with complex care issues that have to be managed.
The major conditions these drugs treat include but are not limited to: cancer, HIV/AIDS, hemophilia,
hepatitis C, multiple sclerosis, Crohn's disease, rheumatoid arthritis, and growth hormone deficiency.
Specialty pharmacies specialize in the distribution of specialty drugs and providing pharmacy care
management services designed to assist patients in effectively managing their condition.
Stabilize means to provide medical treatment as necessary to ensure that, within reasonable medical
probability, no material deterioration of an emergency medical condition is likely to occur during or to
result from the transfer of the patient from a facility; and with respect to a pregnant woman who is in
active labor, to perform the delivery, including the delivery of the placenta.
Subscriber means an employee or former employee insured under the Plan Sponsor's health policy
through PacificSource. When a family unit that does not include an employee or former employee is
insured under a policy, the oldest family member is referred to as the subscriber.
Surgical procedure means any of the following operative procedures:
• Procedures accomplished by cutting or incision
• Suturing of wounds ,
• Treatment of fractures, dislocations, and burns
• Manipulations under general anesthesia
• Visual examination of the hollow organs of the body including biopsy, or removal of tumors or
foreign body
• Procedures accomplished by the use of cannulas, needling, or endoscopic instruments
• Destruction of tissue by thermal, chemical, electrical, laser, or ultrasound
Telemedical means medical services delivered through a two-way video communication that allows a
provider to interact with a patient who is at a different physical location than the provider.
Temporomandibular Joint Disorder (TMJ) means any dysfunction or disorder of the jawjoint
resulting in pain and impairment of the jaw.
Third Party Administrator is an administrator hired by the Plan Sponsorto perform claims processing
and other specified administrative services in relation to the plan. The third party administrator is not an
insurer of health benefits under this plan, is not a fiduciary of the plan, and does not exercise any of the
discretionary authority and responsibility granted to the Plan Sponsor. The third party administratoris
not responsible for plan financing and does not guarantee the availability of benefits under this plan.
The third party administrator is PacificSource Health Plans
SingleSource Self-Insured 80
Tobacco use cessation program means a program recommended by a physician that follows the
United States Public Health Services guidelines for tobacco use cessation. Tobacco use cessation
program includes education and medical treatment components designed to assist a person in ceasing
the use of tobacco products.
Unregistered domestic partner means an individual of the same-gender who is joined in a domestic
partnership with the subscriber and meets the following criteria:
• Is at least 18 years of age;
• Not related to the policyholder by blood closer than would bar marriage in Oregon or the state
where they have permanent residence and are domiciled;
• Shares jointly the same permanent residence with the policyholder for at least six months
immediately preceding the date of application to enroll and intent to continue to do so indefinitely;
• Has joint financial accounts with the policyholder and has agreed to be jointly responsible with the
policyholder for each others' common welfare, including basic living expenses;
• Has an exclusive domestic partnership with the policyholder and has no other domestic partner;
• Does not have a legally binding marriage nor has had another domestic partner within the previous
six months;
• Was mentally competent to consent to contract when the domestic partnership began and remains
mentally competent.
Urgent care treatment facility means a healthcare facility whose primary purpose is the provision of
immediate, short-term medical care for minor, but urgent, medical conditions.
Waiting period means the period of time before coverage becomes effective for a memberwho is
otherwise eligible to enroll in the plan.
Women's healthcare provider means an obstetrician, gynecologist, physician assistant or nurse
practitioner specializing in women's health, or certified nurse midwife practicing within the applicable
scope of practice.
RIGHTS OF PLAN MEMBERS
MEDICAID AND CHIP STATE CONTACT INFORMATION
If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from
your Plan Sponsor, your State may have a premium assistance program that can help pay for
coverage. These States use funds from their Medicaid or CHIP programs to help people who are
eligible for these programs, but also have access to health insurance through their Plan Sponsor. If you
or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium
assistance programs.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below,
you can contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of
your dependents might be eligible for either of these programs, you can contact your State Medicaid or
CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you
qualify, you can ask the State if it has a program that might help you pay the premiums for a Plan
Sponsor-sponsored plan.
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid
-or CHIP, as well as eligible under your Plan Sponsor plan, your Plan Sponsor must permit you to enroll
in your Plan Sponsor plan if you are not already enrolled. This is called a 'special enrollment'
opportunity, and you must request coverage within 60 days of being determined eligible for
premium assistance. If you have questions about enrolling in your Plan Sponsor plan, you can contact
the Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free 1-866-444-EBSA
(3272).
If you live in one of the following States, you may be eligible for assistance paying your Plan Sponsor
health plan premiums. The following list of States is current as of July 31, 2012. You should contact
your State for further information on eligibility -
SingleSource Self-Insured 81
ALABAMA - Medicaid COLORADO - Medicaid
Website: http://wvv.mediGaid.alabama.gov Medicaid Website: http://www.colorado.gov/
Phone: 1-855-692-5447 Medicaid Phone (In state): 1-800-866-3513
ALASKA - Medicaid Medicaid Phone (Out of state): 1-800-221-3943
Website:
http:/Ihealth.hss.state.ak.us/dpa/programs/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
ARIZONA-CHIP FLORIDA - Medicaid
Website: http://www.azahcccs.gov/applicants Website: https://www.flmediraidtplrecovery.com/
Phone (Outside of Maricopa County): 1-877-764-5437 Phone: 1-877-357-3268
Phone (Maricopa County): 602-417-5437 GEORGIA - Medicaid
Website: http://dch.georgia.gov/
Click on Programs, then Medicaid, then Health
Insurance Premium Payment (HIPP)
Phone: 1-800-869-1150
IDAHO - Medicaid and CHIP MONTANA - Medicaid
Medicaid Website: Website:
www.accesstohealthinsurance.idaho.gov http://medicaidprovider.hhs.mt.gov/clientpages/
Medicaid Phone: 1-800-926-2588 clientindex.shtml
CHIP Website: www.mediGaid.idaho.gov Phone: 1-800-694-3084
CHIP Phone: 1-800-926-2588
INDIANA - Medicaid NEBRASKA - Medicaid
Website: http://www.in.gov/fssa Website: www.ACCESSNebraska.ne.gov
Phone: 1-800-889-9949 Phone: 1-800-383-4278
IOWA - Medicaid NEVADA - Medicaid
Website: www.dhs.state.ia.us/hipp/ Medicaid Website: http://dwss.nv.gov/
Phone: 1-888-346-9562 Medicaid Phone: 1-800-992-0900
KANSAS - Medicaid
Website: http://www.kdheks.gov/hef/
Phone: 1-800-792-4884
KENTUCKY - Medicaid NEW HAMPSHIRE - Medicaid
Website: http://chfs.ky.gov/dms/default.htm Website:
Phone: 1-800-635-2570 http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
LOUISIANA- Medicaid NEW JERSEY - Medicaid and CHIP
Website: http://www.lahipp.dhh.louisiana.gov Medicaid Website:
Phone: 1-888-695-2447 http://www.state.nj.us/humanservices/
MAINE - Medicaid dmahs/clients/medicaid/
Website: http://www.maine.gov/dhhs/ofi/public- Medicaid Phone: 1-800-356-1561
assistancelindex.html CHIP Website:
Phone: 1-800-977-6740 http://www.njfamilycare.org/index.htmi
TTY 1-800-977-6741 CHIP Phone: 1-800-701-0710
MASSACHUSETTS - Medicaid and CHIP NEW YORK - Medicaid
Website: http://www.mass.gov/MassHealth Website:
Phone: 1-800-462-1120 http://www.nyhealth.gov/health-care/medicaid/
Phone: 1-800-541-2831
MINNESOTA- Medicaid NORTH CAROLINA - Medicaid
Website: http://www.dhs.state.mn.us/ Website: http://www.ncdhhs.gov/dma
Click on Health Care, then Medical Assistance Phone: 919-855-4100
Phone: 1-800-657-3629
MISSOURI - Medicaid NORTH DAKOTA-Medicaid
Website: Website:
http:/twww.dss.mo.gov/mhd/participants/pages/hipp.ht http://www.nd.gov/dhs/services/medicalserv/medicai
m d/
Phone: 573-751-2005 Phone: 1-800-755-2604
OKLAHOMA - Medicaid and CHIP UTAH - Medicaid and CHIP
Website: http://www.insureoklahoma.org Website: http://health.utah.gov/upp
Phone: 1-888-365-3742 Phone: 1-866-435-7414
SingleSource Self-Insured 82
OREGON - Medicaid and CHIP VERMONT- Medicaid
Website: http://www.oregonhealthykids.gov Website: http:/hvww.greenmountainrare.org/
http://www.hijossaludablesoregon.gov Phone: 1-800-250-8427
Phone: 1-877-314-5678
PENNSYLVANIA - Medicaid VIRGINIA - Medicaid and CHIP
Website: http://www.dpw.state.pa.us/hipp Medicaid Website:
Phone: 1-800-692-7462 http://www.dmas.virginia.gov/rcp-HIPP.htm
Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.famis.org/
CHIP Phone: 1-866-873-2647
RHODE ISLAND - Medicaid WASHINGTON - Medicaid
Website: www.ohhs.ri.gov Website:
Phone: 401-462-5300 http:/Ihrsa.dshs.wa.gov/premiumpymt/Apply.shtm
Phone: 1-800-562-3022 ext. 15473
SOUTH CAROLINA - Medicaid WEST VIRGINIA - Medicaid
Website: http://www.scdhhs.gov Website: www.dhhr.wv.gov/bms/
Phone: 1-888-549-0820 Phone: 1-877-598-5820, HMS Third Party Liability
SOUTH DAKOTA - Medicaid WISCONSIN - Medicaid
Website: http://dss.sd.gov Website: http://www.badgereareplus.org/pubs/p-
Phone:1-888-828-0059 10095.htm
Phone: 1-800-362-3002
TEXAS - Medicaid WYOMING - Medicaid
Website: https://www.gethipptexas.com/ Website:
Phone: 1-800-440-0493 http://health.wyo.gov/healthoarefin/equalitycare
Phone: 307-777-7531
To see if any more States have added a premium assistance program since July 31, 2012, or for more
information on special enrollment rights, you can contact either:
U.S. Department of Labor U.S. Department of Health & Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/ebsa www.cros.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565
OMB Control Number 1210-0137 (expires 09/30/2013)
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PLAN INFORMATION
Name and Address of the Plan Sponsor
City of Ashland
20 East Main
Ashland, OR 97520
(541) 488-6002
Name and Address of the Designated Agent for Service of Legal Process
Dave Kanner, City Administrator
20 East Main
Ashland, OR 97520
541-488-6002
Name and Address of the Third Party Administrator
PacifcSource Health Plans
PO Box 7068
Springfield, OR 97475-0068
(888) 977-9299
Fax: (541) 684-5264
Internal Revenue Service and Plan Identification Number
The corporate tax identification number assigned by the Internal Revenue Service is
936002117.
Plan Year
The plan year is the 12-month period of time beginning January 1 and ending December 31.
Method of Funding Benefits
Health benefits are self-insured from the general assets and or trust funds of the Plan Sponsor
and are not guaranteed under an insurance policy or contract. The Plan Sponsor may purchase
excess risk insurance coverage which is intended to reimburse the Plan Sponsorfor certain
losses incurred and paid under the plan by the Plan Sponsor. Such excess risk coverage, if
any, is not part of the plan. The cost of the plan is paid with contributions by the Plan Sponsor
and participating employees. The Plan Sponsor determines the amount of contributions to the
plan, based on estimates of claims and administration costs.
Payments out of the plan to health care providers on behalf of the covered person will be based
on the provisions of the plan.
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SIGNATURE PAGE
The effective date of the Preferred 90+200 VAR GF 0812 is July 1, 2013.
It is agreed by the City of Ashland that the provisions of this document are correct and will be the
basis for the administration of the Preferred 90+200 VAR GF 0812.
Dated this day of
By
Title
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Exhibit'B'
CITY OF
ASHLAND
City of Ashland - Parks
Group No.: G0032482
Preferred 90+200 VAR GF 0812
Effective: July 1, 2013
Third Party Administrative Services Provided By:
PaciticSource
HEALTH PLANS
SPD 0713_City of Ashland-Parks SingleSouroe Self-Insured
Exhibit'B'
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INTRODUCTION
Welcome to your City of Ashland (also referred to as'the employer' or'employee) group health plan. Your
employeroffers this coverage to help you and your family members stay well, and to protect you in case
of illness or injury. Your plan includes a wide range of benefits and services, and PacificSource hopes
you will take the time to become familiar with them.
Your employer, who is also the Plan Sponsor, has prepared this document to help you understand how
your plan works and how to use it. This document summarizes the benefits provided under the Preferred
90+200 VAR GF 0812 Plan (referred to as 'the plan' or'this plan' throughout this document). Please read
it carefully and thoroughly. Your benefits are affected by certain limitations and conditions, which require
you to be a wise consumer of health services and to use only those services you need. Also, benefits are
not provided for certain kinds of treatments or services, even if your health care provider recommends
them.
The plan is a self-insured medical plan intended to meet the requirements of Sections 105(b), 105(h), and
106 of the Internal Revenue Code so that the portion of the cost of coverage paid by your Plan Sponsor,
and any benefits received by you through this plan, are not taxable income to you. Your specific tax
treatment will depend on your personal circumstances; the plan does not guarantee any particular tax
treatment. You are solely responsible for any and all federal, state, and local taxes attributable to your
participation in this plan, and the plan expressly disclaims any liability for such taxes.
The plan is 'self-insured,' which means benefits are paid from your employer's general assets and or trust
funds and are not guaranteed by an insurance company. The Plan Sponsor has contracted with a Third
Party Administratorto perform certain administrative services related to this plan.
PacificSource Health Plans is the Third Party Administrator and provides administrative services for this
plan on behalf of the Plan Sponsor. If anything is unclear to you, PacificSource's staff is available to
answer your questions. Please give them a call or visit them on the Internet at PacificSource.com.
PacificSource looks forward to serving you and your family.
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espanol (800) 624-6052, extensi6n 1009
cs@pacificsource.com
This document serves as the written Plan document and Summary Plan Description (SPD). It is very
important that you review the entire document carefully to confirm a complete understanding of the
benefits available, as well as your responsibility, under the plan.
This document is written in simple, easy-to-understand language. Technical terms are printed in italics
and defined in the Plan Terms and Definitions section. This document explains the services covered by
the plan; the benefit summaries tell you how much this plan pays toward expenses and amounts for
which you are responsible.
As used in this document, the word 'year' refers to the benefit year, which is the 12-month period
beginning January 1 and ending December 31. The word lifetime as used in this document refers to the
period of time you or your eligible dependents participate in this plan or any other Plan Sponsored by the
Plan Sponsor.
Any amount you or your eligible dependents have accumulated toward the benefit maximum amounts,
deductible, or out-of-pocket maximum of any immediately prior Plan Sponsored by the Plan Sponsorwill
be counted toward the benefit maximum amounts of this plan.
The Plan Sponsor reserves the right to amend, modify, or terminate this plan in any manner, at any time,
which may result in termination or modification of your coverage. If this plan is terminated, any plan
assets will be used to pay for eligible expenses incurred prior to the plan's termination, and such
expenses will be paid as provided under the terms of this plan prior to termination. If there is any conflict
between this document and the underlying plan document(s), the plan document(s) control.
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CONTENTS
MEDICAL BENEFIT SUMMARY 3
PRESCRIPTION BENEFIT SUMMARY 5
CHIROPRACTIC CARE BENEFIT SUMMARY 9
ADDITIONAL ACCIDENT BENEFIT SUMMARY .........................................................11
VISION BENEFIT SUMMARY ......................................................................................13
DENTAL BENEFIT SUMMARY ....................................................................................15
ORTHODONTIA BENEFITS .........................................................................................17
USING THE PROVIDER NETWORK ............................................................................19
Preferred Provider Organization (PPO) .................................................................................................19
What is a PPO .......................................................................................................................................19
Who is Your PPO ...................................................................................................................................19
About Your PPO ....................................................................................................................................19
Non-PPO Providers ...............................................................................................................................20
Example of Provider Payment ...............................................................................................................20
Allowable Amount 20
NETWORK NOT AVAILABLE BENEFITS 20
COVERAGE WHILE TRAVELING 20
Nonemergency Care While Traveling ....................................................................................................21
Emergency Services While Traveling ....................................................................................................21
FINDING PARTICIPATING PROVIDER INFORMATION .............................................21
TERMINATION OF PROVIDER CONTRACTS 21
BECOMING ELIBIGLE .................................................................................................22
Who Pays for Your Benefits ...................................................................................................................22
Who is Eligible .......................................................................................................................................22
ENROLLING DURING THE INITIAL ENROLLMENT PERIOD 23
Newborns 23
Adopted Children ...................................................................................................................................23
Family Members Acquired by Marriage .................................................................................................23
Family Members Acquired by Domestic Partnership .............................................................................23
Family Members Placed in Your Guardianship .....................................................................................24
Qualified Medical Child Support Orders ................................................................................................24
ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD 24
Returning to Work after a Layoff ............................................................................................................24
Returning to Work after a Leave of Absence 24
Returning to Work after Family Medical Leave ......................................................................................24
Special Enrollment Periods ....................................................................................................................25
Dental Enrollment ..................................................................................................................................25
Late Enrollment ......................................................................................................................................25
Member ID Card ....................................................................................................................................26
PLAN SELECTION PERIOD 26
TERMINATING COVERAGE 26
Divorced Spouses ..................................................................................................................................26
Dependent Children ...............................................................................................................................26
Dissolution of Domestic Partnership ......................................................................................................26
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Certificates of Creditable Coverage .......................................................................................................27
CONTINUATION OF INSURANCE 27
USERRA CONTINUATION 27
Surviving or Divorced Spouses and Qualified Domestic Partners .........................................................28
COBRA CONTINUATION 28
COBRA Eligibility ...................................................................................................................................28
When Continuation Coverage Ends ......................................................................................................28
Type of Coverage ..................................................................................................................................29
Your Responsibilities and Deadlines .....................................................................................................29
Continuation Premium ...........................................................................................................................29
Keep Your Plan Informed of Address Changes .....................................................................................29
CONTINUATION WHEN YOU RETIRE 29
WORK STOPPAGE 30
Labor Unions ..........................................................................................................................................30
COVERED EXPENSES 30
Medical Necessity ..................................................................................................................................30
Healthcare Providers 31
Your Annual Out-of-Pocket Limit ...........................................................................................................31
MEDICAL BENEFITS ....................................................................................................31
About Your Medical Benefits .................................................................................................................31
PLAN BENEFITS ..........................................................................................................33
PREVENTIVE CARE SERVICES 33
PROFESSIONAL SERVICES 34
HOSPITAL AND SKILLED NURSING FACILITY SERVICES 36
OUTPATIENT SERVICES 36
EMERGENCY SERVICES 37
MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES 38
Mental Health and Chemical Dependency Services .............................................................................38
Medical Necessity and Appropriateness of Treatment ..........................................................................39
HOME HEALTH AND HOSPICE SERVICES ...............................................................39
DURABLE MEDICAL EQUIPMENT .............................................................................40
TRANSPLANT SERVICES 41
Payment of Transplant Benefits .............................................................................................................42
OTHER COVERED SERVICES, SUPPLIES, AND TREATMENTS .............................42
BENEFIT LIMITATIONS AND EXCLUSIONS ..............................................................45
Least Costly Setting for Services ...........................................................................................................45
EXCLUDED SERVICES 45
A Note About Optional Benefits .............................................................................................................45
Experimental or Investigational Treatment ............................................................................................49
EXCLUSION PERIODS ................................................................................................52
Exclusion Period for Transplant Benefits ...............................................................................................52
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CREDIT FOR PRIOR COVERAGE 52
Evidence of Prior Creditable Coverage .................................................................................................52
HEALTH CARE MANAGEMENT AND PREAUTHORIZATION ...................................52
What is Health Care Management .........................................................................................................52
Case Management .................................................................................................................................53
Individual Benefits Management ............................................................................................................54
HOW TO USE YOUR DENTAL PLAN 54
DENTAL PLAN BENEFITS 54
COVERED DENTAL SERVICES 55
Class I Services - Diagnostic and Preventive Treatment 55
Class II Restorative Services- Basic and Restorative Treatment ........................................................55
Class II Complicated Services - Complicated Treatment .....................................................................55
Class III Services - Major Treatment .....................................................................................................56
ORTHODONTIA BENEFITS 56
EXCLUDED DENTAL SERVICES 56
CLAIMS Procedures 59
Questions about Your Claims ................................................................................................................59
Types of Claims .....................................................................................................................................60
How to File a Claim ................................................................................................................................60
Incomplete Claims .................................................................................................................................62
Notification of Benefit Determination .....................................................................................................62
Adverse Benefit Determination ..............................................................................................................63
Your Right to Appeal ..............................................................................................................................63
Resources For Information And Assistance ..........................................................................................66
Plan Sponsors Discretionary Authority; Standard of Review ................................................................67
Coordination of Benefits .........................................................................................................................67
Order of Payment When Coordinating with Other Group Health Plans ................................................68
OTHER IMPORTANT PLAN PROVISIONS 69
Assignment of Benefits ..........................................................................................................................69
Proof of Loss ..........................................................................................................................................69
No Verbal Modifications of Plan Provisions ...........................................................................................69
Reimbursement to the Plan 70
Subrogation 70
Recovery of Excess Payments ..............................................................................................................71
Right To Receive and Release Necessary Information .........................................................................71
Reliance on Documents and Information. 71
No Waiver ..............................................................................................................................................71
Physician/Patient Relationship ..............................................................................................................72
Plan not responsible for Quality of Health Care ....................................................................................72
Plan is not a Contract of Employment ...................................................................................................72
Right to Amend or Terminate Plan ........................................................................................................72
Applicable Law .......................................................................................................................................72
PRIVACY AND CONFIDENTIALITY 72
Permitted Disclosures of Protected Health Information to the Plan Sponsor ........................................73
No Disclosure of Protected Health Information to the Plan Sponsor without Certification by Plan
Sponsor 73
Conditions of Disclosure of Protected Health Information to the Plan Sponsor ....................................73
Disclosures of Summary Health Information and Enrollment/Disenrollment Information to the Plan
Sponsor 74
Required Separation between the Plan and the Plan Sponsor .............................................................74
DEFINITIONS 74
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RIGHTS OF PLAN MEMBERS 83
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Grandfathered Health Plan
The Plan Sponsor believes this plan is a 'grandfathered health plan' under the Patient
Protection and Affordable Care Act (the Affordable Care Act). As permitted by the
Affordable Care Act, a grandfathered health plan can preserve certain basic health
coverage that was already in effect when that law was enacted. Being a grandfathered
health plan means that your plan may not include certain consumer protections of the
Affordable Care Act that apply to other plans, for example, the requirement for the
provision of preventive health services without any cost sharing. However,
grandfathered health plans must comply with certain other consumer protections in the
Affordable Care Act, for example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a
grandfathered health plan and what might cause a plan to change from grandfathered
health plan status can be directed to the Plan Sponsor, or you may contact
PacifcSource at:
PacificSource Health Plans
PO Box 7068
Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
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MEDICAL BENEFIT SUMMARY
POLICY INFORMATION
Group Name: City of Ashland
Group Number: G0032482
Plan Name: Preferred 90+200 VAR GF 0812
Provider Network: Preferred PSN
EMPLOYEE ELIGIBILITY REQUIREMENTS
Minimum Hour Requirement: Full Time: 40 hours, Part Time: 20-39 hours
Waiting Period for New Employees: 1st day of the month following one (1) day. A person hired on the
first day of the month is eligible on the first day of the following
month.
ANNUAL DEDUCTIBLE $200 per person / $600 per family
The deductible is an amount of covered medical expenses the member pays each benefit year before the plan's
benefits begin. The deductible applies to all services and supplies except those marked with an asterisk Once a
member has paid a total amount toward covered expenses during the benefit year equal to the per person amount
listed above, the deductible will be satisfied for that person for the rest of that benefit year. Once any covered
family members have paid a combined total toward covered expenses during the benefit year equal to the per
family amount listed above, the deductible will be satisfied for all covered family members for the rest of that benefit
year. Deductible expense is not applied to the out-of-pocket limit.
ANNUAL OUT-OF-POCKET LIMIT
Participating Providers .................................................$700 per person / $1,400 per family
Non-participating Providers ..........................................$1,700 per person / $3,400 per family
Only participating provider expense applies to the participating provider out-of-pocket limit and only non-
participating provider expense applies to the non-participating out-of-pocket limit. Once the participating provider
out-of-pocket limit has been met, this plan will pay 100% of covered charges (after the co-payment is deducted) for
participating and network not available providers for the rest of that benefit year. Once the non-participating
provider out-of-pocket limit has been met, this plan will pay 100% of covered charges (after the co-payment is
deducted) for non-participating providers for the rest of that benefit year. Deductibles, co-payments, benefits paid in
full and non-participating provider charges in excess of the allowable fee do not accumulate toward the out-of-
pocket limit. Co-payments and non-participating provider charges in excess of the allowable fee will continue to be
the member's responsibility even after the out-of-pocket limit is met.
ADDITIONAL ACCIDENT BENEFIT
The first $1,000 of covered expenses within 90 days of an accident is covered at no charge and is not subject to
the deductible. The balance is covered as shown below.
The member is responsible for the above deductible and the following co-payments and co-insurance.
PARTICIPATING PROVIDERS/ NON-PARTICIPATING
SERVICE: NETWORK NOT AVAILABLE: PROVIDERS:
PREVENTIVE CARE
Well Baby/Well Child Care 10% co-insurance 30% co-insurance
Routine Physicals No charge` No charge`
Well Woman Visits No charge' No charge'
Immunizations - 0-18 yrs No charge' No charge'
Immunizations - age 19 and over 10% co-insurance 30% co-insurance
RoutineColonoscopy 10% co-insurance 30% co-insuranoe
PROFESSIONAL SERVICES
Office and Home Visits 10% co-insurance 30% co-insurance
Office Procedures and Supplies 10% co-insurance 30% co-insurance
Surgery 10% co-insuranoe 30% co-insurance
Outpatient Rehabilitation Services 10% co-insuranoe 10% co-insurance
HOSPITAL SERVICES
Inpatient Room and Board 10% co-insurance 30% co-insurance
Inpatient Rehabilitation Services 10% co-insurance 30% co-insurance
Skilled Nursing Facility Care 10% co-insurance 30% co-insurance
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OUTPATIENT SERVICES
Outpatient Surgery/Services 10% co-insuranre 30% co-insurance
Advanced Diagnostic Imaging 10% co-insurance 30% co-insurance
Diagnostic and Therapeutic Radiology 10% oo-insuranre 30% co-insurance
and Lab
URGENT AND EMERGENCY SERVICES
Urgent Care Center Visits 10% oo-insurance 30% co-insurance
Emergency Room Visits $100 co-pay/visit plus $100 co-pay/visit plus
10% co-insurance A 10% co-insurance A
Ambulance, Ground 10% co-insurance 10% co-insurance
Ambulance, Air 10% co-insurance 10% oo-insurance
MENTAL HEALTH/CHEMICAL DEPENDENCY SERVICES
Office Visits 10% co-insurance 30% co-insurance
Inpatient Care 10% co-insurance 30% co-insurance
Residential Programs 10% co-insurance 30% co-insurance
OTHER COVERED SERVICES
Allergy Injections 10% co-insurance 30% co-insurance
Durable Medical Equipment 10% co-insurance 30% co-insurance
Home Health Care 10% co-insurance 10% co-insurance
Chiropractic Plus (12 visits/benefit 10% co-insurance 10% co-insurance
year)
A For emergency medical conditions, non-participating providers are paid at the participating
provider level.
Not subject to annual deductible.
Payment to providers is based on the prevailing or contracted PacificSource fee allowance for covered services. Although
participating providers accept the fee allowance as payment in full, non-participating providers may not. Services of non-
participating providers could result in out-of-pocket expense in addition to the cost share above. Network Not Available (NNA)
payment is allowed when Pacific Source has not contracted with providers in the geographical area of the member's residence
or work for a specific service or supply. Payment to providers for NINA is based on the usual, customary, and reasonable
charge for the geographical area in which the charge is incurred.
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PRESCRIPTION BENEFIT SUMMARY
Your Plan Sponsors health plan includes coverage for prescription drugs and certain other
pharmaceuticals, subject to the information below. Your prescription drug plan qualifies as
creditable coverage for Medicare Part D.
MEMBER COST SHARE (other than for Specialty Drugs)
Each time a covered pharmaceutical is dispensed, you are responsible for the co-payment and/or co-
insurance below:
Tier 1: Tier 1: Tier 1:
Generic Preferred Nonoreferred
From a participating retail pharmacy using the
PacificSource Pharmacy Program (see below):
Up to a 34-day supply: $5 $25 $50
From a participating mail order service (see below):
Up to a 34-day supply: $5 $25 $50
35 to 90-day supply: $10 $50 $100
From a participating retail pharmacy without using Not covered,
the PacificSource Pharmacy Program, or from a
non-participating pharmacy (see below): except 5-day emergency supply
MEMBER COST SHARE FOR SPECIALTY DRUG
Each time a covered specialty drug is dispensed, you are responsible for the co-payment and/or co-
insurance below:
From the participating specialty pharmacy:
Up to a 30-day supply: Same as retail pharmacy co-payment above
From a participating retail pharmacy, from a
participating mail order service, or from a non- Not covered,
participating pharmacy or pharmaceutical service except 5-day emergency supply
provider.
WHAT HAPPENS WHEN A BRAND NAME DRUG IS SELECTED
Regardless of the reason or medical necessity, if you receive a brand name drug or if your physician
prescribes a brand name drug when a generic is available, you will be responsible for the brand name
drug's co-payment and/or co-insurance.
USING THE PACIFICSOURCE PHARMACY PROGRAM
Retail Pharmacy Network
To use the PacificSource pharmacy program, you must show the pharmacy plan number on the
PacificSource ID card at the participating pharmacy to receive your plan's highest benefit level.
When obtaining prescription drugs at a participating retail pharmacy, the PacificSource pharmacy
program can only be accessed through the pharmacy plan number printed on your PacificSource ID
card. That plan number allows the pharmacy to collect the appropriate co-payment and/or co-insurance
from you and bill PacificSource electronically for the balance.
Mail Order Service
This plan includes a participating mail order service for prescription drugs. Most, but not all, covered
prescription drugs are available through this service. Questions about availability of specific drugs may
be directed to the PacificSource Customer Service Department or to the plan's participating mail order
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service vendor. Forms and instructions for using the mail order service are available from PacificSource
and on PacificSource's website, PacificSource.com.
Specialty Drug Program
PacificSource contracts with a specialty pharmacy services provider for high-cost injectable
medications and biotech drugs. A pharmacist-led CareTeam provides individual follow-up care and
support to covered members with prescriptions for specialty medications by providing them strong
clinical support, as well as the best drug pricing for these specific medications and biotech drugs.
The CareTeam also provides comprehensive disease education and counseling, assesses patient
health status, and offers a supportive environment for patient inquiries.
Participating provider benefits for specialty drugs are available when you use PacificSource's
specialty pharmacy services provider. Specialty drugs are not available through the participating
retail pharmacy network or mail order service. More information regarding PacificSource's
exclusive specialty pharmacy services provider and health conditions and a list of drugs requiring
preauthorization and/or are subject to pharmaceutical service restrictions is on PacificSource's
website, PacificSource.com.
OTHER COVERED PHARMACEUTICALS
Supplies covered under the pharmacy plan are in place of, not in addition to, those same covered
supplies under the medical plan. Member cost share for items in this section are applied on the
same basis as for other prescription drugs, unless otherwise noted.
Diabetic Supplies
• Insulin, diabetic syringes, lancets, and test strips are available.
• Glucagon recovery kits are available for the plan's preferred brand name co-payment.
• Glucostix and glucose monitoring devices are not covered under this pharmacy benefit, but are
covered under the medical plan's durable medical equipment benefit.
Contraceptives
• Oral contraceptives
• Implantable contraceptives, contraceptive injections, contraceptive patches, and contraceptive rings
are available.
• Diaphragm or cervical caps are available.
Tobacco Cessation
Program specific tobacco cessation medications are covered with active participation in a plan
approved tobacco cessation program (see Preventive Care in the policy's Covered Expenses section).
Orally Administered Anticancer Medications
Orally administered anticancer medications used to kill or slow the growth of cancerous cells are
available. Co-payments for orally administered anticancer medication are applied on the same basis as
for other drugs. Orally administered anticancer medications covered under the pharmacy plan are in
place of, not in addition to, those same covered drugs under the medical plan.
LIMITATIONS AND EXCLUSIONS
• This plan only covers drugs prescribed by a licensed physician (or other licensed practitioner
eligible for reimbursement under your plan) prescribing within the scope of his or her professional
license, except for:
- Over-the-counter drugs or other drugs that federal law does not prohibit dispensing without a
prescription (even if a prescription is required under state law).
- Drugs for any condition excluded under the health plan. That includes drugs intended to
promote fertility, treatments for obesity or weight loss, tobacco cessation drugs (except as
specifically provided for under Other Covered Pharmaceuticals), experimental drugs, and drugs
available without a prescription (even if a prescription is provided).
- Some specialty drugs that are not self-administered are not covered by this pharmacy benefit,
but are covered under the medical plan's office supply benefit.
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- Immunizations (although not covered by this pharmacy benefit, immunizations may be covered
under the medical plan's preventive care benefit).
- Drugs and devices to treat erectile dysfunction.
- Drugs used as a preventive measure against hazards of travel.
- Vitamins, minerals, and dietary supplements, except for prescription prenatal vitamins and
fluoride products, and for services that have a rating of 'A' or 'B' from the U.S Preventive
Services Task Force (USPSTF).
• Certain drugs require preauthorization by PacificSource in order to be covered. An up-to-date list of
drugs requiring preauthorization is available on PacificSource's website, PacifcSource.com.
• PacificSource may limit the dispensing quantity through the consideration of medical necessity,
generally accepted standards of medical practice, and review of medical literature and
governmental approval status.
• Quantities for any drug filled or refilled are limited to no more than a 34-day supply when purchased
at retail pharmacy or a 90-day supply when purchased through mail order pharmacy service or a
30-day supply when purchased through a specialty pharmacy.
• For drugs purchased at non-participating pharmacies or at participating pharmacies without using
the PacificSource pharmacy program, reimbursement is limited to an allowable fee.
• Non-participating pharmacy charges are not eligible for reimbursement unless you have a true
medical emergency that prevents you from using a participating pharmacy. Drugs obtained at a
non-participating pharmacy due to a true medical emergency are limited to a 5 day supply.
• The member cost share for prescription drugs (co-payments, co-insurance, and service charges)
does not apply to the medical deductible or out-of-pocket limit of the policy. You continue to be
responsible for the prescription drug co-payments and service charges regardless of whether the
policy's out-of-pocket limit is satisfied.
• Prescription drug benefits are subject to your plan's coordination of benefits provision. (For more
information see Claims Payment - Coordination of Benefits in your Summary Plan Description.)
GENERAL INFORMATION ABOUT PRESCRIPTION DRUGS
A drug formulary is a list of preferred medications used to treat various medical conditions. The
formulary for this plan is known as the Preferred Drug List (PDL). The drug formulary is used to help
control rising healthcare costs while ensuring that you receive medications of the highest quality. It is a
guide for your physician and pharmacist in selecting drug products that are safe, effective, and cost
efficient. The drug formulary is made up of name brand products. A complete list of medications
covered under the drug formulary is available on the For Members area on PacificSource's website,
PacificSource.com. The drug formulary is developed by Caremark@ in cooperation with PacificSource.
Non-preferred drugs are covered brand name medications not on the drug formulary.
Generic drugs are equivalent to name brand medications. By law, they must have the same active
ingredients as the brand name medication and are subject to the same standards of their brand name
counterpart. Name brand medications lose their patent protection after a number of years. Any drug
company can then produce the drug, and the manufacturer must pass the same strict FDA standards of
quality and product safety as the original manufacturer. Generic drugs are less expensive than brand
name drugs because there is more competition and there is no need to repeat costly research and
development. Your pharmacist and physician are encouraged to use generic drugs whenever they are
available.
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CHIROPRACTIC CARE BENEFIT SUMMARY
Your plan's chiropractic care benefit allows you to receive treatment from licensed chiropractors for
medically necessary diagnosis and treatment of illness or injury. Refer to the Medical Benefit Summary
for your co-payment and/or co-insurance information.
PacificSource contracts with a network of chiropractors, so you can reduce your out-of-pocket expense
by using one of the participating providers. For a listing of participating chiropractors in your area,
please refer to your plan's participating provider directory, visit our website, Pacificsource.com, or call
our Customer Service Department.
Covered Services
• Chiropractic manipulation, massage therapy, and any laboratory services, x-rays, radiology, and
durable medical equipment provided by or ordered by a chiropractor.
The combined benefit for all treatments, services, and supplies provided or ordered by a chiropractor is
limited to 12 visits per person in any benefit year.
Excluded Services
• Any service or supply excluded or not otherwise covered by the medical plan.
• Drugs, homeopathic medicines, or homeopathic supplies furnished by a chiropractor.
• Services of an alternative care provider for pregnancy or childbirth.
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ADDITIONAL ACCIDENT BENEFIT SUMMARY
In the event of an injury caused by an accident, first dollar benefits are provided for covered expenses
according to the following:
Related Definitions
'Accident' means an unforeseen or unexpected event causing injury that requires medical attention.
'Injury' means bodily trauma or damage which is independent of disease or infirmity. The damage must
be caused solely through external and accidental means. Injury, for the purpose of this benefit, does not
include musculoskeletal sprains or strains obtained in the performance of physical activity.
Covered Expenses
Benefits for the following covered expenses are provided, subject to the limitations stated below:
• Services or supplies provided by a physician (except orthopedic braces)
• Services of a hospital
• Services of a registered nurse who is unrelated to the injured person by blood or marriage
• Services of a registered physical therapist
• Services of a physician or a dentist for the repair of a fractured jaw or natural teeth
• Diagnostic radiology and laboratory services
• Transportation by local ground ambulance
Limitations
• The treatment must be medically necessary for the injury.
• The treatment or service must be provided within 90 days after the injury occurs.
• The first $1,000 of covered expense is paid at 100% and is not subject to the deductible.
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VISION BENEFIT SUMMARY
Your Plan Sponsor covers vision exams, eyeglasses, and contact lenses. The following shows the
vision benefits available.
Benefit Period
Eye Exam: Once every 12 months for covered children. Once every 24 months for
covered adults.
Lenses: Once every 12 months for covered children. Once every 24 months for
covered adults.
Frames: Once every 24 months for all covered individuals OR
Contact lenses: Once every 12 months for covered children. Once every 24 months for
covered adults.
Member Responsibility
PARTICIPATING NON-PARTICIPATING
SERVICE/SUPPLY PROVIDERS: PROVIDERS:
Eye Exam No charge No charge up to a
$71 maximum
Hardware
Lenses (maximum per pair)
Single Vision No charge No charge up to a
$51 maximum
Bifocal No charge No charge up to a
$77 maximum
Trifocal No charge No charge up to a
$100 maximum
Lenticular No charge Not covered
Progressive No charge Not covered
Frames No charge up to a No charge up to a
$120 maximum $66 maximum
Contacts (in place of No charge up to a No charge up to a
glasses) $166 maximum $166 maximum
The amounts listed above are the maximum benefits available for all vision exams, lenses, and
frames furnished during any benefit period when prescribed by a licensed ophthalmologist or
licensed optometrist. Participating providers discount hardware services.
Limitations and Exclusions
The out-of-pocket expense for vision services (co-payments and service charges) does not apply
to the medical plan's deductible or out-of-pocket limit. Also, the member continues to be
responsible for the vision co-payments and service charges regardless of whether the medical
plan's out-of-pocket limit is satisfied.
Covered expenses do not include, and no benefits are payable for:
• Special procedures such as orthoptics or vision training
• Special supplies such as sunglasses (plain or prescription) and subnormal vision aids
• Tint
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• Plano contact lenses
• Anti-reflective coatings and scratch resistant coatings
• Separate charges for contact lens fitting
• Replacement of lost, stolen, or broken lenses or frames
• Duplication of spare eyeglasses or any lenses or frames
• Nonprescription lenses
• Visual analysis that does not include refraction
• Services or supplies not listed as covered expenses
• Eye exams required as a condition of employment, or required by a labor agreement or government
body
• Expenses covered under any worker's compensation law
• Services or supplies received before this plan's coverage begins or after it ends
• Charges for services or supplies covered in whole or in part under any other medical or vision
benefits provided by the Plan Sponsor
• Medical or surgical treatment of the eye
Important information about your vision benefits
Your Plan Sponsor's health plan includes coverage for vision services, including prescription
eyeglasses and contact lenses. To make the most of those benefits, it's important to keep in mind
the following:
• Participating Providers
PacificSource is able to add value to your vision benefits by contracting with a network of vision
providers. Those providers offer vision services at discounted rates, which are passed on to you in
your benefits.
• Paying for Services
Please remember to show your current PacificSource ID card whenever you use your plan's
benefits. PacificSource's provider contracts require participating providers to bill us directly
whenever you receive covered services and supplies. Providers normally call PacificSource to
verify your vision benefits. Participating providers should not ask you to pay the full cost in
advance. They may only collect your share of the expense up front, such as copayments and
amounts over your plan's allowances. If you are asked to pay the entire amount in advance,
tell the provider you understand they have a contract with PacificSource and should bill
PacificSource directly.
• Sales and Special Promotions
Vision retailers often use coupons and promotions to bring in new business, such as free eye
exams, two-for-one glasses, or free lenses with purchase of frames. Because participating
providers already discount their services through their contract with PacificSource, your plan's
participating provider benefits cannot be combined with any other discounts or coupons. You can
use your plan's participating provider benefits, or you can use your plan's non-participating provider
benefits to take advantage of a sale or coupon offer. If you do take advantage of a special offer, the
participating provider may treat you as an uninsured customer and require full payment in advance.
You can then send the claim to PacificSource yourself, and PacificSource will reimburse you
according to your plan's non-participating provider benefits.
PacificSource hopes this information helps clarify your vision benefits. If you or your provider have any
questions about your benefits, please call PacificSource Customer Service at (541) 686-1242 from
Eugene-Springfield or (888) 977-9299 from other areas.
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DENTAL BENEFIT SUMMARY
POLICY INFORMATION
Group Name: City of Ashland
Group Number: G0032482
Plan Name: Preferred Incentive Dental $1500 VAR 0711
EMPLOYEE ELIGIBILITY REQUIREMENTS
Minimum Hour Requirement: Full Time: 40 hours, Part Time: 20-39 hours
Waiting Period for New Employees: 1 st day of the month following one (1) day. A person hired on the
first day of the month is eligible on the first day of the fallowing
month.
DENTAL BENEFIT SUMMARY
Subject to all the terms of this Group Dental Policy, the Plan Sponsorwill pay a dental benefit for
covered dental expenses incurred by a covered person. The dental benefit is a percentage of the usual,
customary, and reasonable charge for covered dental expenses incurred, subject to an annual
maximum benefit, and an annual deductible, as follows:
Maximum Payment
The amount payable by this plan for covered services received under Class I are unlimited. The
maximum amount payable by this plan for covered Class II and Class III services received each benefit
year, or portion thereof, for each eligible patient is limited to $1,500.
PLAN PAYMENT SCHEDULE
Class I Services- Plan pays 70% toward covered Class I Services - Diagnostic and
Preventive Treatment.
Class If Restorative Services- Plan pays 70% toward covered Class II Restorative Services -
Restorative Treatment.
Class II Complicated Services- Plan pays 70% toward covered Class II Complicated Services -
Complicated Treatment.
Class 111 Services- Plan pays 70% toward covered Class III Services - Major Treatment.
This plan pays the percentage indicated above toward Class I, II and III Services during the first year an
individual is eligible. Payment increases 10 percent (to a maximum benefit of 100 percent) each
successive benefit year for Class I, II and III Services if the member visits a dentist at least once during
the benefit year. Payment decreases 10 percent (to a minimum benefit of the percentage stated above)
each successive benefit year if the member does not visit a dentist at least once during the previous
benefit year.
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ORTHODONTIA BENEFITS
Covered Charges
The Plan Sponsor will pay 50% of the usual, customary and reasonable for orthodontics for all covered
individuals.
Lifetime Maximum
The maximum amount payable by the Plan Sponsor for orthodontic benefits to an eligible patient is
$1,000 per lifetime.
Exclusions and Limitations
• The Plan Sponsorwill cease making payment for orthodontic treatment if the treatment ends for
any reason prior to the completion of your case.
• The Plan Sponsorwill not make any payments for the repair or replacement of an orthodontic
appliance that was furnished under this coverage.
• The Plan Sponsors monthly or periodic payments for orthodontics shall cease if your eligibility
is terminated.
• The Plan Sponsors obligation to make payments for orthodontic treatment that began prior to
your eligibility date is calculated based on remaining balance at your initial eligibility date. The
calculation will take into account the dentist's or orthodontist's normal payment pattern. The
above-mentioned maximum will apply to this amount.
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USING THE PROVIDER NETWORK
This section explains how your plan's benefits differ when you use participating and non-participating
providers. This information is not meant to prevent you from seeking treatment from any provider if you
are willing to take increased financial responsibility for the charges incurred.
All healthcare providers are independent contractors. Neither your Plan Sponsor nor PacificSource can
be held liable for any claim or damages for injuries you experience while receiving medical care.
Preferred Provider Organization (PPO)
What is a PPO
A preferred provider organization (PPO) has made agreements with hospitals, physicians, practitioners,
and other health care providers to discount the cost of services they provide.
Who is Your PPO
The Plan Sponsor has chosen PacificSource to provide PPO services for employees and eligible
dependents in Oregon, Idaho, and Montana service areas and in bordering communities in southwest
Washington. They also have an agreement with a nationwide provider network, The First Health®
Network. The First Health providers outside PacificSource's service area are also considered
participating providers under your plan.
A list of participating providers can be accessed through the PacificSource website: PacificSource.com
or by calling PacificSource at (888) 977-9299. This list of participating providers is updated regularly.
About Your PPO
PacificSource has selected the participating physicians, practitioners, and hospitals after carefully
reviewing their qualifications. Each health care provider has agreed to a contracted amount in payment
for their services. Additionally, you cannot be 'balanced billed' for the difference between the PPO
contracted amount and the provider's normal billed charge for a particular service. You are only
responsible for the deductible, copayment, and/or coinsurance payment shown on the Medical Benefit
Summary.
Enrolling in this plan does not guarantee that a particular participating providerwill remain a
participating provideror that a particular participating providerwill provide members under this plan only
with covered services. Members should verify a health care provider's status as a participating provider
each time services are received from the health care provider.
It is not safe to assume that when you are treated at a participating medical facility, all services are
performed by participating providers. A list of participating providers can be accessed through the
PacificSource website: PacificSource.com or by calling PacificSource at (888) 977-9299. Whenever
possible, you should arrange for professional services such as surgery and anesthesiology to be
provided by a participating provider. Doing so will help you maximize your benefits and limit your out-of-
pocket expenses. The PPO benefits are outlined on the Medical Benefit Summary.
You have a free choice of any health care provider, and the physician-patient relationship shall be
maintained. Members, together with their health care provider, are ultimately responsible for
determining the appropriate course of medical treatment, regardless of whether the plan will pay for all
or a portion of the cost of such care. The participating providers are merely independent contractors;
neither the plan, the Plan Sponsor, nor PacificSource makes any warranty as to the quality of care that
may be rendered by any participating provider.
This plan generally allows the designation of a primary care provider. You have the right to designate
any primary care provider who participates in the network and who is available to accept you or your
family members. For children, you may designate a pediatrician as the primary care provider. You do
not need prior authorization from this plan or from any other person (including a primary care provider)
in order to obtain access to obstetrical or gynecological care from a health care professional in the
network who specializes in obstetrics or gynecology. The health care professional, however, may be
required to comply with certain procedures, including obtaining prior authorization for certain services,
following a pre-approved treatment plan, or procedures for making referrals. For a list of the
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participating providers and/or a list of participating health care professionals who specialize in obstetrics
or gynecology, contact PacificSource at (888) 977-9299 or PO Box 7068, Springfield, OR 97475-0068.
Non-PPO Providers
When you receive services or supplies from a nonparticipating provider, your out-of-pocket expense is
likely to be higher than if you had used a participating provider. Besides the non-PPO deductible,
copayment, and/or coinsurance amounts shown on the Medical Benefit Summary, you may become
responsible for the provider's billed amount that exceeds the plan's allowable amount.
Example of Provider Payment
The following illustrates how payment could be made for a covered service billed at $120. In this
example, the Medical Benefit Summary shows a participating providers co-insurance of 20 percent and
a non-participating providers co-insurance of 30 percent. This is only an example, your plan's benefits
may be different.
Participating Non-participating
Provider Provider
Provider's usual billed charge $120 $120
PPO's negotiated provider discount $20 $0
Plan's allowable amount $100 $100
Percent of payment 20% 30%
Plan's payment $80 $70
Patient's amount of allowable amount $20 $30
Charges above the allowable amount $0 $20
Patient's total payment to provider $20 $50
Percent of charge paid by plan 80% 58%
Percent of charge paid by patient 20% 42%
Allowable Amount
The plan bases payment to nonparticipating providers on an allowable amount for the same services or
supplies. Several sources are used to determine the allowable amount, depending on the service or
supply and the geographical area where it is provided. The allowable amount may be based on data
collected from the Centers for Medicare and Medicaid Services (CMS), Viant Health Payment
Solutions, other nationally recognized databases, or PacificSource.
NETWORK NOT AVAILABLE BENEFITS
The term 'network not available' is used when a member does not have reasonable geographic access
to a participating provider for a covered medical service or supply.
If you live in an area without access to a participating provider for a specific service or supply, your
plan's Network Not Available benefits apply. Here's how that works:
• You seek treatment from a nearby non-participating provider of that service or supply.
• PacificSource determines the allowable fee for that service or supply (the term 'allowable fee' is
explained above under the Non-participating Providers section).
• PacificSource applies the Network Not Available benefit level stated in your Medical Benefit
Summary to the allowable fee to calculate covered expenses.
• You are responsible for any co-payments, co-insurance, deductibles, and amounts over the
allowable fee.
COVERAGE WHILE TRAVELING
Your plan is powered by the PacificSource Network (PSN). The PSN Network covers Oregon, Idaho,
Montana, southwest Washington, and eastern Washington. When you need medical services outside of
the PSN Network, you can save out-of-pocket expense by using the participating providers available
through The First Health® Network.
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Nonemergency Care While Traveling
To find a participating provider outside the regions covered by the PacificSource Network, call The First
Health® Network at (800) 226-5116. (The phone number is also printed on your PacificSource ID card
for convenience.) Representatives are available at any time to help you find a participating physician,
hospital, or other outpatient provider. Nonemergency care outside of the United States is not covered.
• If a participating provider is available in your area, your plan's participating provider benefits will
apply if you use a participating provider.
• If a participating provider is not available in your area, your plan's Network Not Available benefits
will apply.
• If a participating provider is available but you choose to use a non-participating provider, your plan's
non-participating provider benefits will apply.
Emergency Services While Traveling
In medical emergencies (see the Covered Expenses - Emergency Services section of this Summary
Plan Description), your plan pays benefits at the participating provider level regardless of your location.
Your covered expenses are based on PacificSource's allowable fee. If you are admitted to a hospital as
an inpatient following the stabilization of your emergency condition, your physician or hospital should
contact the PacificSource Health Services Department at (888) 691-8209 as soon as possible to make
a benefit determination on your admission. If you are admitted to a non-participating hospital,
PacificSource may require you to transfer to a participating facility once your condition is stabilized in
order to continue receiving benefits at the participating provider level.
FINDING PARTICIPATING PROVIDER INFORMATION
You can find up-to-date participating provider information:
• By asking your healthcare provider if he or she is a participating provider for your Plan Sponsor's
plan.
• On the PacificSource website, PacificSource.com. Simply click on'Find a Provider' and you can
easily look up participating providers or print your own customized directory.
• By contacting the PacificSource Customer Service Department. PacificSource can answer your
questions about specific providers. If you'd like a complete provider directory for your plan, just ask
- PacificSource will be glad to mail you a directory free of charge.
• By calling The First Health® Network at (800) 226-5116 if you live outside the area covered by the
PacificSource Network.
TERMINATION OF PROVIDER CONTRACTS
PacificSource will notify you within ten days of learning of the termination of a provider contractual
relationship if you have received services in the previous three months from such a provider when:
• A provider terminates a contractual relationship with PacificSource in accordance with the terms
and conditions of the agreement,
• A provider terminates a contractual relationship with an organization under contract with
PacificSource; or
• PacificSource terminates a contractual relationship with an individual provider or the organization
with which the provider is contracted in accordance with the terms and conditions of the agreement.
For the purposes of continuity of care, PacificSource may require the provider to adhere to the medical
services contract and accept the contractual reimbursement rate applicable at the time of contract
termination.
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BECOMING ELIBIGLE
Who Pays for Your Benefits
The Plan Sponsor shares the cost of providing benefits for you and your enrolled dependents. From
time to time, the Plan Sponsor may adjust the amount of contributions required for coverage. In
addition, the deductibles and copayments may also change periodically. You will be notified by your
Plan Sponsor of any changes in the cost of plan coverage before they take effect.
Who is Eligible
Employees - You are eligible to participate in this plan if you are a regular, full-time employee of the
Plan Sponsor upon the completion of the minimum number of hours and probationary waiting period set
by your Plan Sponsor. Your Plan Sponsors eligibility requirements are stated in your Medical Benefit
Summary. All employees who meet those requirements are eligible for coverage.
Eligibility for Medicaid or the receipt of Medicaid benefits will not be taken into account in determining
eligibility. Status as an employee is determined under the employment records of the Plan Sponsor.
Workers classified by the Plan Sponsor as independent contractors are not eligible for this plan under
any circumstances.
Retirees - You are eligible to participate in this plan if you are a retired employee of the Plan Sponsor,
or a spouse of a retired employee. Eligibility for Medicaid or the receipt of Medicaid benefits will not be
taken into account in determining eligibility.
Dependents - While you are enrolled under this plan, the following family members, and only the
following family members, are also eligible to participate in the plan:
• Your legal spouse or qualified domestic partner. The Plan Sponsor may require documentation
proving a legal marital relationship, an Affidavit of Domestic Partnership or a Certificate of Qualified
domestic partnership.
• Your, your spouse's, or your qualified domestic partner's dependent children under age 26
regardless of the child's place of residence, marital status, or financial dependence on you.
• Your, your spouse's, or your qualified domestic partner's unmarried dependent children age 26 or
over who are mentally or physically disabled. To qualify as dependents, they must have been
continuously unable to support themselves since turning age 26 because of a mental or physical
disability. PacificSource requires documentation of the disability from the child's physician, and will
review the case before determining eligibility for coverage.
• Your grandchildren. A child of an eligible dependent enrolled on your plan under age 19 who is
unmarried, not in a domestic partnership, registered or otherwise, who is related to you by blood,
marriage, or domestic partnership AND for whom you are the court appointed legal custodian or
guardian with the expectation that the family member will live in your household for at least a year.
• A child placed for adoption with you, your spouse, or qualified domestic partner. Placed for
adoption means the assumption and retention by you, your spouse, or qualified domestic partner of
a legal obligation for total or partial support of a child in anticipation of adoption or placement for
adoption. Upon any termination of such legal obligations the placement for adoption shall be
deemed to have terminated.
• 'Dependent children' means any natural, step, or adopted children as well as any child placed for
adoption with you or your domestic partner are legally obligated to support or contribute support for.
It may also include grandchildren under age 19 who are unmarried and expected to live in your
household for at least a year, if you are the court appointed legal custodian or guardian.
No family or household members other than those listed above are eligible to enroll under your.
coverage.
Special Rules for Eligibility -At any time, the Plan Administrator may require proof that a person
qualifies or continues to qualify as a dependent as defined by this plan.
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ENROLLING DURING THE INITIAL ENROLLMENT PERIOD
The 'initial enrollment period' is the 60-day period beginning on the date a person is first eligible for
enrollment in this plan. Everyone who becomes eligible for coverage has an initial enrollment period.
When you satisfy your Plan Sponsor's probationary waiting period at the hours required for eligibility
and become eligible to enroll in this plan, you and your eligible family members must enroll within the
initial enrollment period. If you miss your initial enrollment period, you may be subject to a waiting
period. (For more information, see 'Special Enrollment Periods' and 'Late Enrollment' under the
Enrolling After the Initial Enrollment Period section.) To enroll, you must complete and sign an
enrollment application, which is available from your Plan Sponsor. The application must include
complete information on yourself and your enrolling family members. Return the application to your
Plan Sponsor, and your Plan Sponsor will send it to PacificSource.
Coverage for you and your enrolling family members begins on the first day of the month after you
satisfy your Plan Sponsor's probationary waiting period. The probationary waiting period is stated in
your Medical Benefit Summary. Coverage will only begin if Your Plan Sponsor receives your enrollment
application and premium.
Newborns
Your, your spouse's, or your qualified domestic partner's natural born baby is eligible for
enrollment under this plan during the 60-day initial enrollment period after birth. PacificSource
cannot enroll the child and pay benefits until your Plan Sponsor receives an enrollment application
listing the child as your dependent. A claim for maternity care is not considered notification for the
purpose of enrolling a newborn child. Anytime there is a delay in providing enrollment information,
your Plan Sponsor may ask for legal documentation to confirm validity.
Adopted Chi/then
When a child is placed in your home for adoption, the child is eligible for enrollment under this plan
during the 60-day initial enrollment period after placement for adoption. 'Placement for adoption' means
the assumption and retention by you, your spouse's, or your domestic partner's of a legal obligation for
full or partial support and care of the child in anticipation of adoption of the child. To add the child to
your coverage, you must complete and submit an enrollment application listing the child as your
dependent. You may be required to submit a copy of the certificate of adoption or other legal
documentation from a court or a child placement agency to complete enrollment.
If additional premium is required, then the natural born or adopted child's eligibility for enrollment will
end 60 days after placement if Plan Sponsor has not received an enrollment application and premium.
Premium is charged from the date of placement and prorated for the first month.
If no additional premium is required, then the natural born or adopted child's eligibility continues as long
as you are covered. However, PacificSource cannot enroll the child and pay benefits until your Plan
Sponsor receives an enrollment application listing the child as your dependent.
Family Members Acquired by Marriage
If you marry, you may add your new spouse and any newly eligible dependent children to your
coverage during the 60-day initial enrollment period after the marriage. Your Plan Sponsor must receive
your enrollment application and additional premium during the initial enrollment period. Coverage for
your new family members will then begin on the first day of the month after the marriage. You may be
required to submit a copy of your marriage certificate to complete enrollment.
Family Members Acquired by Domestic Partnership
If you and your same-gender domestic partner have been issued a Certificate of Qualified domestic
partnership, your domestic partner and your partner's dependent children are eligible for coverage
during the 60-day initial enrollment period after the registration of the domestic partnership. Your Plan
Sponsor must receive your enrollment application and additional premium during the initial enrollment
period. Coverage for your new family members will then begin on the first day of the month after the
registration of the domestic partnership. You may be required to submit a copy of your Certificate of
Qualified domestic partnership to complete enrollment.
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Unregistered same-gender domestic partners and their children may also become eligible for
enrollment. If you and your unqualified domestic partner meet the criteria on the Affidavit of Domestic
Partnership supplied by your Plan Sponsor, your domestic partner and your partner's dependent
children are eligible for coverage during the 60-day initial enrollment period after the requirements of
the Affidavit of Domestic Partnership are satisfied. Your Plan Sponsor must receive your enrollment
application, a notarized copy of your Affidavit of Domestic Partnership, and additional premium during
the initial enrollment period. Coverage for your new family members will then begin on the first day of
the month after the Affidavit of Domestic Partnership is notarized.
Family Members Placed in Your Guardianship
If a court appoints you custodian or guardian of an eligible grandchild, you may add that family member
to your coverage. To be eligible for coverage, the family member must be:
• Unmarried;
• Not in a domestic partnership, registered or otherwise;
• Related to you by blood, marriage, or domestic partnership,
• Under age 19; and
• Expected to live in your household for at least a year.
Your Plan Sponsor must receive your enrollment application and additional premium during the 60-day
initial enrollment period beginning on the date of the court appointment. Coverage will then begin on the
first day of the month following the date of the court order. You may be required to submit a copy of the
court order to complete enrollment.
Qualified Medical Child Support Orders
This health plan complies with qualified medical child support orders (QMCSO) issued by a state court
or state child support agency. A QMCSO is a judgment, decree, or order, including approval of a
settlement agreement that provides for health benefit coverage for the child of a plan member.
If a court or state agency orders coverage for your spouse or child, they may enroll in this plan within
the 60-day initial enrollment period beginning on the date of the order. Coverage will become effective
on the first day of the month after Plan Sponsor receives the enrollment application. You may be
required to submit a copy of the QMCSO to complete enrollment.
ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD
Returning to Work after a Layoff
If you are laid off and then rehired by your Plan Sponsor within six months, you will not have to satisfy
another probationary waiting period or new exclusion period.
Your health coverage will resume the first of the month following the date you return to work and again
meet your Plan Sponsor's minimum hour requirement. If your family members were covered before
your layoff, they can resume coverage at that time as well. You must re-enroll your family members by
submitting an enrollment application within the 60-day initial enrollment period following your return to
work.
Returning to Work after a Leave of Absence
If you return to work after a Plan Sponsor-approved leave of absence of six months or less, you will not
have to satisfy another probationary waiting period. Your health coverage will resume the day you
return to work and again meet your Plan Sponsor's minimum hour requirement. If your family members
were covered before your leave of absence, they can resume coverage at that time as well. You must
re-enroll your family members by submitting an enrollment application within the 60-day initial
enrollment period following your return to work.
Returning to Work after Family Medical Leave
Your Plan Sponsor is probably subject to the Family Medical Leave Act (FMLA). To find out if you have
rights under FMLA, ask your health plan administrator. Under FMLA, if you return to work after a
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qualifying FMLA medical leave, you will not have to satisfy another probationary waiting period or any
previously satisfied exclusion period under this plan. Your health coverage will resume the day you
return to work and meet your Plan Sponsor's minimum hour requirement. If your family members were
covered before your leave, they can also resume coverage at that time if you re-enroll them within the
60-day initial enrollment period following your return.
Special Enrollment Periods
If you are eligible to decline coverage and you wish to do so, you must submit a written waiver of
coverage to your Plan Sponsor. You and your family members may enroll in this plan later if you qualify
under Rule #1, Rule #2, or Rule #3 below.
• Special Enrollment Rule #1 - If you declined enrollment for yourself or your family members
because of other health insurance coverage, you or your family members may enroll in the plan
later if the other coverage ends involuntarily. 'Involuntarily' means coverage ended because
continuation coverage was exhausted, employment terminated, work hours were reduced below
the Plan Sponsor's minimum requirement, the other insurance plan was discontinued or the
maximum lifetime benefit of the other plan was exhausted, the Plan Sponsor's premium
contributions toward the other insurance plan ended, or because of death of a spouse, divorce, or
legal separation. To do so, you must request enrollment within 60 days after the other health
insurance coverage ends (or within 60 days after the other health insurance coverage ends if the
other coverage is through Medicaid or a State Children's Health Insurance Program). Coverage will
begin on the first day of the month after the other coverage ends.
• Special Enrollment Rule #2 - If you acquire new dependents because of marriage, qualification of
domestic partnership, birth, or placement for adoption, you may be able to enroll yourself and/or
your newly acquired eligible dependents at that time. To do so, you must request enrollment within
60 days after the marriage, registration of the domestic partnership, birth, or placement for
adoption. In the case of marriage or domestic partnership, coverage begins on the first day of the
month after the marriage or registration of the domestic partnership. In the case of birth or
placement for adoption, coverage begins on the date of birth or placement.
• Special Enrollment Rule #3 - If you or your dependents become eligible for a premium assistance
subsidy under Medicare or CHIP, you may be able to enroll yourself and/or your dependents at that
time. To do so, you must request enrollment within 60 days of the date you and/or your dependents
become eligible for such assistance. Coverage will begin on the first day of the month after
becoming eligible for such assistance.
Dental Enrollment
Employees or their dependents who did not enroll with dental benefits when initially eligible may later
enroll on the policy's anniversary date. Employees and/or dependents who enrolled with dental benefits
under this policy but later terminated coverage may enroll on an anniversary date of the policy following
a 24-month waiting period from the date coverage was last terminated.
Late Enrollment
If you did not enroll during your initial enrollment period and you do not qualify for a special
enrollment period, your enrollment will be delayed until the plan's anniversary date.
A'late enrollee' is an otherwise eligible employee or dependent who does not qualify for a special
enrollment period explained above, and who:
• Did not enroll during the 60-day initial enrollment period; or
• Enrolled during the initial enrollment period but discontinued coverage later.
A late enrollee may enroll by submitting an enrollment application to your Plan Sponsor during an open
enrollment period designated by your Plan Sponsorjust prior to the plan's anniversary date. When you
or your dependents enroll during the open enrollment period, plan coverage begins on the date Plan
Sponsor receives the enrollment application or on the plan's anniversary date.
You may enroll in coverage prior to an open enrollment period if one of the following exceptions are
met:
SingleSource Self-Insured 25
• You and/or your dependent may enroll in coverage if you involuntary lose other Group Coverage or
lose coverage under the Oregon Health Plan.
• You and/or your dependent may enroll in coverage if your hours per week are increased or your
employer's contribution is increased. You and/or your dependent may also enroll if you return from
a qualified FMIA leave.
Member ID Card
The membership card issued to you by PacificSource is for identification purposes only. Possession of
a membership card confers no right to services or benefits under this plan and misuse of your
membership card may be grounds for termination of your coverage under this plan. To be eligible for
services or benefits under this plan, you must be eligible and enrolled in the plan and you must present
the membership card to your health care provider. If you receive services or benefits for which you are
not entitled to receive under the terms of this plan, you may be charged for such services or benefits at
the prevailing rate. If you permit the use of your membership card by any other person, your card may
be retained by this plan, and all your rights under this plan may be terminated.
PLAN SELECTION PERIOD
If your Plan Sponsor offers more than one benefit plan option, you may choose another plan option only
upon your plan's anniversary date. You may select a different plan option by completing a selection
form or application form. Coverage under the new plan option becomes effective on your plan's
anniversary date.
TERMINATING COVERAGE
If you leave your job for any reason or your work hours are reduced below your Plan Sponsors
minimum requirement, coverage for you and your enrolled family members will end. Coverage ends on
the last day of the last month in which you worked full time. You may, however, be eligible to continue
coverage for a limited time; please see the Continuation section of this Summary Plan Description for
more information.
You can voluntarily discontinue coverage for your enrolled family members at any time by completing a
Termination of Dependent Coverage form and submitting it to your Plan Sponsor. Keep in mind that
once coverage is discontinued, your family members may be subject to the late enrollment waiting
period if they wish to re-enroll later.
Divorced Spouses
If you divorce, coverage for your spouse will end on the last day of the month in which the divorce
decree or legal separation is final. You must notify your Plan Sponsor of the divorce or separation, and
continuation coverage may be available for your spouse. If there are special child custody
circumstances, please contact your Plan Sponsor. Please see the Continuation section for more
information.
Dependent Children
When your enrolled child no longer qualifies as a dependent, coverage will end on the last day
of that month. Please see the Eligibility section of this Summary Plan Description for information
on when your dependent child is eligible beyond age 25. The Continuation section includes
information on other coverage options for those who no longer qualify for coverage.
Dissolution of Domestic Partnership
If you dissolve your domestic partnership, coverage for your domestic partner and their children not
related to you by birth or adoption will end on the last day of the month in which the dissolution of the
domestic partnership is final. You must notify your Plan Sponsor of the dissolution of the domestic
partnership. Under Oregon state continuation laws, a qualified domestic partner and their covered
children may continue this policy's coverage under the same circumstances and to the same extent
afforded an enrolled spouse and their enrolled children (see Oregon Continuation in the Continuation of
Insurance section). Domestic partners and their covered children are not recognized as qualified
beneficiaries under federal COBRA continuation laws. Domestic partners and their covered children
SingleSource Self-Insured 26
may not continue this policy's coverage under COBRA independent of the employee (see COBRA
Continuation in the Continuation of Insurance section).
Certificates of Creditable Coverage
A certificate of creditable coverage is used to verify the dates of your prior health plan coverage
when you apply for coverage under a new policy. These certificates are issued by health
insurers whenever a plan participant's coverage ends. After your or your dependent's coverage
under this plan ends, you will receive a certificate of creditable coverage by mail. PacificSource
has an automated process that generates and mails these certificates whenever coverage ends.
PacificSource will send a separate certificate for any dependents with an effective or termination
date that differs from yours. For questions or requests regarding certificates of creditable
coverage, you are welcome to contact Membership Services Department at (541) 684-5583 or
(866) 999-5583.
CONTINUATION OF INSURANCE
Under federal and state laws, you and your family members may have the right to continue this
plan's coverage for a specified time. You and your dependents may be eligible if:
• Your employment ends or you have a reduction in hours
• You take a leave of absence for military service
• You divorce
• You die
• You become eligible for Medicare benefits if it causes a loss of coverage for your dependents
• Your children no longer qualify as dependents
The following sections describe your rights to continuation under state and federal laws, and
the requirements you must meet to enroll in continuation coverage.
USERRA CONTINUATION
If you take a leave of absence from your job due to military service, you have continuation rights under
the Uniformed Services Employment and Re-employment Rights Act (USERRA).
You and your enrolled family members may continue this plan's coverage if you, the employee, no
longer qualify for coverage under the plan because of military service. Continuation coverage under
USERRA is available for up to 24 months while you are on military leave. If your military service ends
and you do not return to work, your eligibility for USERRA continuation coverage will end. Premium for
continuation coverage is your responsibility.
The following requirements apply to USERRA continuation:
• Family members who were not enrolled in the group plan cannot take continuation. The only
exceptions are newborn babies and newly acquired dependents not covered by another group
health plan.
• To apply for continuation, you must submit a completed Continuation Election Form to your Plan
Sponsor within 31 days after the last day of coverage under the group plan.
• You must pay continuation premium to your Plan Sponsor by the first of each month. Your Plan
Sponsorwill include your continuation premium in the group's regular monthly payment.
PacificSource cannot accept the premium directly from you.
• Your Plan Sponsor must still be self-insured through PacificSource. If your Plan Sponsor
discontinues this plan, you will no longer qualify for continuation.
SingleSource Self-Insured 27
Surviving or Divorced Spouses and Qualified Domestic Partners
If you die, divorce, or dissolve your qualified domestic partnership, and your spouse or qualified
domestic partner is 55 years or older, your spouse or qualified domestic partner may be able to
continue coverage until eligible for Medicare or other coverage. Dependent children are subject to the
health plan's age and other eligibility requirements. Some restrictions and guidelines apply; please see
your Plan Sponsor for specific details.
COBRA CONTINUATION
Your Plan Sponsor is subject to the continuation of coverage provisions of the Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA) as amended. To find out if you have continuation rights
under COBRA, ask your health plan administrator.
COBRA Eligibility
To be eligible, a membermust experience a'qualifying event' which is an event that causes your
regular group coverage to end and makes you eligible for continuation coverage. When the following
qualifying events happen, you may continue coverage for the lengths of time shown:
Qualifying Event Continuation Period
Employee's termination of employment or reduction in Employee, spouse, and children may continue for up to
hours 18 months'
Employee's divorce or legal separation Souse and children may continue for u to 36 months
Employee's eligibility for Medicare benefits if it causes a Spouse and children may continue for up to 36 months
loss of coverage
Employee's death Souse and children may continue for u to 36 months
Child no longer qualifies as a dependent Child may continue for u to 36 months
Em to er fles for Chapter 11 bankruptcy Only applies to retirees and their covered dependents
If the employee or covered dependent is determined disabled by the Social Security Administration within the first
60 days of continuation coverage, all qualified beneficiaries may continue coverage for up to an additional 11
months, for a total of up to 29 months.
2 The total maximum continuation period is 36 months, even if there is a second qualifying event. A second
qualifying event might be a divorce, legal separation, death, or child no longer qualifying as a dependent after the
employee's termination or reduction in hours.
If your dependents were not covered prior to your qualifying event, they may enroll in the continuation
coverage while you are on continuation. They will be subject to the same rules that apply to active
employees, including the late enrollment waiting period.
If your employment is terminated for gross misconduct, you and your dependents are not eligible for
COBRA continuation.
Domestic partners and their covered children may not continue this policy's coverage under COBRA
independent of the employee.
When Continuation Coverage Ends
Your continuation coverage will end before the end of the continuation period above if any of the
following occur:
• Your continuation premium is not paid on time.
• You become covered under another group health plan that does not exclude or limit treatment for
your pre-existing conditions.
• You become entitled to Medicare benefits.
• Your Plan Sponsor discontinues its health plan and no longer offers a group health plan to any of
its employees.
• Your continuation period was extended from 18 to 29 months due to disability, and you are no
longer considered disabled.
SingleSource Self-Insured 28
Type of Coverage
Under COBRA, you may continue any coverage you had before the qualifying event. If your Plan
Sponsor provides both medical and dental coverage and you were enrolled in both, you may continue
both medical and dental. If your Plan Sponsor provides only one type of coverage, or if you were
enrolled in only one type of coverage, you may continue only that coverage.
COBRA continuation benefits are always the same as your Plan Sponsor's current benefits. Your Plan
Sponsor has the right to change the benefits of its health plan or eliminate the plan entirely. If that
happens, any changes to the group health plan will also apply to everyone enrolled in continuation
coverage.
Your Responsibilities and Deadlines
You must notify your Plan Sponsor within 60 days if you divorce, or if your child no longer qualifies as
a dependent. That will allow your Plan Sponsor to notify you or your dependents of your continuation
rights.
When your Plan Sponsor learns of your eligibility for continuation, your Plan Sponsorwill notify you of
your continuation rights and provide a Continuation Election Form. You then have 60 days from that
date or 60 days from the date coverage would otherwise end, whichever is later, to enroll in
continuation coverage by submitting a completed Election Form to your Plan Sponsor. If continuation
coverage is not elected during that 60-day period, coverage will end on the last day of the last month
you were an active employee.
If you do not provide these notifications within the time frames required by COBRA, Plan Sponsors
responsibility to provide coverage under the health plan will end.
Continuation Premium
You or your family members are responsible for the full cost of continuation coverage. The monthly
premium must be paid to your Plan Sponsor. PacificSource cannot accept continuation premium
directly from you. You may make your first premium payment any time within 45 days after you return
your Continuation Election Form to your Plan Sponsor. After the first premium payment, each monthly
payment must reach your Plan Sponsor within 30 days of your Plan Sponsors premium due date. If
your Plan Sponsor does not receive your continuation premium on time, continuation coverage will end.
If your coverage is canceled due to a missed payment, it will not be reinstated for any reason. Premium
rates are established annually and may be adjusted if the plan's benefits or costs change.
Keep Your Plan Informed of Address Changes
In order to protect your and your family's rights, you should keep the Plan Sponsor informed of any
changes in your address and the addresses of family members. You should also keep a copy, for your
records, of any notices you send to the Plan Sponsor.
CONTINUATION WHEN YOU RETIRE
If you retire, you and your insured dependents are eligible to continue coverage subject to the following:
• You must apply for continued coverage within 60 days after retirement.
• You must be receiving benefits from PIERS (Public Employee Retirement System) or from a similar
retirement plan offered by your Plan Sponsor.
• You will have the same opportunity to switch to another plan during the open enrollment period as
do active employees. If the plan's benefits are changed by the policyholder, your benefits will
change accordingly.
• Except for newly acquired dependents due to marriage, registration of domestic partnership, birth,
or adoption, only your dependents who were covered at the time of retirement may continue
coverage under this provision. You may add a new spouse, domestic partner, or other newly
acquired dependent after retirement if family coverage is available. A completed enrollment
application must be submitted within 31 days of the date of marriage, registration of domestic
partnership, birth, or adoption.
SingleSource Self-Insured 29
Your continuation coverage will end when any one of the following occurs:
• When full premium is not paid or when your coverage is voluntarily terminated, your coverage will
end on the last day of the month for which premium was paid.
When you become eligible for Medicare coverage, your coverage will end on the last day of the
month preceding Medicare eligibility.
When the regular group policy is terminated, your coverage will end on the date of termination.
Your dependent's continuation coverage will end when any one of the following occurs:
• When full premium for the dependent is not paid or when the dependent's coverage is voluntarily
terminated by you or your dependent, coverage will end on the last day of the month for which
premium was paid.
• When your dependent becomes eligible for Medicare coverage, your dependent's coverage will end
on the last day of the month preceding Medicare eligibility.
• When you die, divorce, or dissolve your domestic partnership, your dependent's coverage will end
on the last day of the month following the death, divorce, or dissolution of the domestic partnership.
• When your dependent is otherwise no longer considered a dependent under the group plan, his or
her coverage will end on the last day of the month of their eligibility. Continuation of coverage may
be available under COBRA continuation (see Continuation of Coverage provisions).
• When the regular group policy is terminated, your dependent's coverage will end on the date of
termination.
WORK STOPPAGE
Labor Unions
If you are a union member, you have certain continuation rights in the event of a labor strike. Your
union is responsible for collecting your premium and can answer questions about coverage during the
strike.
EXTENSION OF BENEFITS
If you are on a Plan Sponsor-approved non-FMLA leave of absence, you may continue coverage under
active status for up to three months by self pay to the Plan Sponsor. Absences extending beyond three
months will be subject to the Continuation of Insurance provisions of this plan.
COVERED EXPENSES
This plan provides comprehensive medical coverage when care is medically necessary to treat an
illness or injury. Be careful -just because a treatment is prescribed by a healthcare professional does
not mean it is medically necessary under the terms of the plan. Also remember that just because a
service or supply is a covered benefit under this plan does not necessarily mean all billed charges will
be paid.
Some medically necessary services and supplies may be excluded from coverage under this plan. Be
sure you read and understand the Benefit Limitations and Exclusions section of this book, including the
section on Preauthorization. If you ever have a question about your plan benefits, contact the
PacificSource Customer Service Department.
Medical Necessity
Except for specified Preventive Care services, the benefits of this health plan are paid only toward the
covered expense of medically necessary diagnosis or treatment of illness or injury. This is true even
though the service or supply is not specifically excluded. All treatment is subject to review for medical
necessity. Review of treatment may involve prior approval, concurrent review of the continuation of
treatment, post-treatment review or any combination of these. For additional information, see 'medically
necessary' in the Definitions section of this Summary Plan Description.
SingleSource Self-Insured 30
Be careful. Your healthcare provider could prescribe services or supplies that are not covered under
this plan. Also, just because a service or supply is a covered benefit does not mean all related charges
will be paid.
Healthcare Providers
This plan provides benefits only for covered expenses and supplies rendered a physician (M.D. or
O.D.), practitioner, nurse, hospital or specialized treatment facility, durable medical equipment supplier,
or other licensed medical provider as specifically stated in this Summary Plan Description. The services
or supplies provided by individuals or companies that are not specified as eligible practitioners are not
eligible for reimbursement under the benefits of this plan. For additional information, see 'practitioner',
'specialized treatment facility', and 'durable medical equipment supplier' in the Definitions section of this
Summary Plan Description.
Your Annual Deductible
Deductible Carryover. The deductible must be satisfied only once in any benefit year, even though
there may be several conditions treated. Covered expenses incurred during the last three (3) months of
the previous benefit year will be applied to the subsequent year's benefit year deductible subject to the
following:
• The covered expenses were applied to the deductible;
• The covered expenses were incurred during the last three (3) months of the year; and
• The prior year's deductible was not satisfied.
Final determination of which expenses apply to the deductible will be based on the order in which
charges are incurred, even if bills for charges are not received in that order.
Your Annual Out-of-Pocket Limit
This plan has an out-of-pocket limit provision to protect you from excessive medical expenses. The
Medical Benefit Summary shows your plan's annual out-of-pocket limits for participating and/or
nonparticipating providers. If you incur covered expenses over those amounts, this plan will pay 100
percent of eligible charges, subject to the allowable fee.
Your expenses for the following do not count toward the annual out-of-pocket limit:
• Charges applied to deductible, if applicable to your plan
• Co-payments, if applicable to your plan
• Prescription drugs
• Charges over the allowable fee for services of non-participating providers
• Incurred charges that exceed amounts allowed under this plan
Charges over the allowable fee for services of non-participating providers, and incurred charges that
exceed amounts allowed under this plan, and co-payments will continue to be your responsibility even
after the out-of-pocket or stop-loss limit is reached.
Prescription drug benefits are not affected by the out-of-pocket or stop-loss limit. You will still be
responsible for that co-payment or co-insurance payment even after the out-of-pocket or stop-loss limit
is reached.
MEDICAL BENEFITS
About Your Medical Benefits
All benefits provided under this plan must satisfy some basic conditions. The following conditions are
commonly included in health benefit plans but are often overlooked or misunderstood.
SingleSource Self-Insured 31
Medical Necessity - The plan provides benefits only for covered services and supplies that are
medically necessary for the treatment of a covered illness or injury. Be careful-just because a
treatment is prescribed by a healthcare professional does not necessarily mean it is medically
necessary as defined by the plan. And, some medically necessary services and supplies may be
excluded from coverage. Also, the treatment must not be experimental and/or investigational.
Allowable Fees - The plan provides benefits only for covered expenses that are equal to or less than
the allowable amount, as defined by the plan, in the geographic area where services or supplies are
provided. Any amounts that exceed the allowable amount are not recognized by the plan for any
purpose.
Health Care Provider - The plan provides benefits only for covered expenses and supplies rendered
by a physician, practitioner, nurse, hospital or specialized treatment facility, durable medical equipment
supplier, or other licensed medical provider as specifically stated in this plan summary. The services or
supplies provided by individuals or companies that are not specified as eligible practitioners are not
eligible for reimbursement under the benefits of this plan. For additional information, see practitioner,
specialized treatment facility, and durable medical equipment in the Definitions section of this
document.
Custodial Care Providers - The plan does not provide benefits for services and supplies that are
furnished primarily to assist an individual in the activities of daily living. Activities of daily living include
such things as bathing, feeding, administration of oral medications, academic, social, or behavior skills
training, and other services that can be provided by persons without the training of a health care
practitioner.
Benefit Year- The word year, as used in this document, refers to the benefit year, which is the 12-
month period beginning January 1 and ending December 31. Unless otherwise specified, all annual
benefit maximums and deductibles accumulate during the benefit year.
Deductibles -A deductible is the amount of covered expenses you must pay during each year before
the plan will consider expenses for reimbursement. The individual deductible applies separately to each
covered person. The family deductible applies collectively to all covered persons in the same family.
When the family deductible is satisfied, no further deductible will be applied for any covered family
member during the remainder of the year. The annual individual and family deductible amounts are
shown on the Medical Benefit Summary.
Benefit Percentage Payable - Benefit percentage payable represents the portion of covered
expenses paid by the plan after you have satisfied any applicable deductible. These percentages apply
only to covered expenses which do not exceed the allowable amount. You are responsible for all -
remaining covered and non-covered expenses, including any amount that exceeds the allowable
amount for covered services. The benefit percentages payable are shown on the Medical Benefit
Summary.
Copayments - Copayments are the first-dollar amounts you must pay for certain covered services,
which are usually paid at the time the service is performed (i.e. physician office visits or emergency
room visits). These copayments do not apply to your annual deductible or out-of-pocket maximum,
unless otherwise specified on the Medical Benefit Summary. The copayment amounts are shown on
the Medical Benefit Summary.
Out-Of-Pocket Maximum(s) - An out-of-pocket maximum is the maximum amount of covered
expenses you must pay during a year, before the plan's benefit percentage payable increases. The
individual out-of-pocket maximum applies separately to each covered person. When a covered person
reaches the annual out-of-pocket maximum, the plan will pay 100% of additional covered expenses for
that individual during the remainder of that year;'subject to the lifetime maximum amount, if applicable.
However, expenses for services which do not apply to the out-of-pocket maximum will never be paid at
100%. The annual individual and family out-of-pocket maximum amounts are shown on the Medical
Benefit Summary.
Benefit Maximums - Total plan payments for each covered person are limited to certain maximum
benefit amounts. A benefit maximum can apply to specific benefit categories or to all benefits. A benefit
maximum amount may also apply to a specific time period, such as annual.
SingleSource Self-Insured 32
Least Costly Setting For Services - Benefits of the plan provide for reimbursement of covered
services performed in the least costly setting where services can be safely provided. If a procedure can
be done safely in an outpatient setting but is performed in a hospital inpatient setting, this plan will only
pay what it would have paid for the procedure on an outpatient basis. If services are performed in an
inappropriate setting, your benefits may be reduced.
PLAN BENEFITS
This plan provides benefits for the following services and supplies as outlined on your Medical Benefit
Summary. These services and supplies may require you to satisfy a deductible, make a co-payment, or
both, and they may be subject to additional limitations or maximum dollar amounts. For a medical
expense to be eligible for payment, you must be covered under this plan on the date the expense is
incurred. Please refer to your Medical Benefit Summary and the Benefit Limitations and Exclusions
section of this Summary Plan Description for more information.
Accident Benef<t
In the event of an injury caused by an accident the plan benefit will be as follows:
The balance is covered as stated in your Medical Benefit Summary for covered expense.
'Accident' means an unforeseen or unexpected event causing injury which requires medical attention.
'Injury' means bodily trauma or damages which is independent of disease or infirmity. The damage
must be caused solely through external and accidental means. For the purpose of this benefit, injury
does not include musculoskeletal sprains or strains obtained in the performance of physical activity.
PREVENTIVE CARE SERVICES
This plan covers the following preventive care services when provided by a physician, physician
assistant, or nurse practitioner:
• Routine physicals for members age 22 and older according to the following schedule:
- Ages 22 and over One exam every benefit year
Only laboratory work tests and other diagnostic testing procedures related to the routine physical
exam are covered by this benefit. Any laboratory tests and other diagnostic testing procedures
ordered during, but not related to, a routine physical examination are not covered by this
preventative care benefit. Please see Outpatient Services in this section.
• Well woman visits, including the following:
- One routine gynecological exam each benefit year for women 18 and over. Exams may
include Pap smear, pelvic exam, breast exam, blood pressure check, and weight check. Exams
may also include an annual mammogram for women over the age of 40, once between the
ages of 35-40 unless medically necessary, for the purpose of early detection. Covered lab
services are limited to occult blood, urinalysis, and complete blood count.
- Routine preventive mammograms for women as recommended.
o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit
Summary for'Preventive Care - Well Woman Visits' applies.
o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit
Summary for'Outpatient Services - Diagnostic and Therapeutic Radiology and Lab'
applies to diagnostic mammograms related to the ongoing evaluation or treatment of a
medical condition.
- Pelvic exams and Pap smear exams at any time upon referral of a women's healthcare
provider; and pelvic exams and Pap smear exams annually for women 18 to 64 years of age
with or without a referral from a women's healthcare provider.
- Breast exams annually for women 18 years of age or older or at any time when recommended
by a women's healthcare provider for the purpose of checking for lumps and other changes for
early detection and prevention of breast cancer.
• Colorectal cancer screening exams and lab work including the following:
SingleSource Self-Insured 33
A fecal occult blood test once per benefit year
A flexible sigmoidoscopy every five benefit years
A colonoscopy for age 50+ every ten benefit years
o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit
Summary for'Preventive Care- Routine Colonoscopy' applies.
o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit
Summary for 'Professional Services - Surgery' and for 'Outpatient Services -
Outpatient Surgery/Services' apply to colonoscopies related to ongoing evaluation or
treatment of a medical condition.
A double contrast barium enema every five benefit years
• Prostate cancer screening, every two benefit years. Exams may include a digital rectal
examination and a prostate-specific antigen test. Screenings apply to outpatient surgery/services
benefit regardless of whether they are preventive or diagnostic.
• Well baby/well child care exams for members age 21 and younger according to the following
schedule:
At birth: One standard in-hospital exam
Ages 0 - 2: 12 additional exams during first 36 months of life- Ages 3 - 21:
One exam per benefit year
Newborn circumcision is a covered benefit even if performed several days after birth. Only
laboratory tests and other diagnostic testing procedures related to a well baby/child care exam are
covered by this plan. Any laboratory tests and other diagnostic testing procedures ordered during,
but not related to, a well baby/child care exam are not covered by this preventative care benefit.
Please see Outpatient Services in this section.
• Standard age-appropriated childhood and adult immunizations for primary prevention of infectious
diseases as recommended by and adopted the Centers for Disease Control and Prevention,
American Academy of Pediatrics, American Academy of Family Physicians, or similar standard-
setting body. Benefits do not include immunizations for more elective, investigative, unproven, or
discretionary reasons (e.g. travel). Covered immunizations include, but may not be limited to the
following:
- Diphtheria, pertussis, and tetanus (DPT) vaccines, given separately or together
- Hemophilus influenza B vaccine
- Hepatitis A vaccine
- Hepatitis B vaccine
- Human papillomavirus (HPV) vaccine
- Influenza vaccine
- Measles, mumps, and rubella (MMR) vaccines, given separately or together
- Meningococcal (meningitis) vaccine
- Pneumococcal vaccine
- Polio vaccine
- Varicella (chicken pox) vaccine
• Tobacco use cessation program services are covered only when provided by a PacificSource
approved program. Approved programs are covered at 100% of the cost up to a maximum lifetime
benefit of two quit attempts. Approved programs are limited to members age 15 or older. Specific
nicotine replacement therapy will only be covered according to the program's description. If this
policy includes benefits for prescription drugs, tobacco use cessation related medication prescribed
in conjunction with an approved tobacco use cessation program will be covered to the same extent
this policy covers other prescription medications.
PROFESSIONAL SERVICES
This plan covers the following professional services when medically necessary:
SingleSource Self-Insured 34
• Services of a physician (M.D. or D.O.) for diagnosis or treatment of illness or injury
• Services of a licensed physician assistant under the supervision of a physician
• Services of a certified surgical assistant, surgical technician, or registered nurse (R.N.) when
providing medically necessary services as a surgical first assistant during a covered surgery
• Services of a nurse practitioner, including certified registered nurse anesthetist (C.R.N.A.) and
certified nurse midwife (C.N.M.), for medically necessary diagnosis or treatment of illness or injury
• Urgent care services provided by a physician. Urgent care is unscheduled medical care for an
illness, injury, or disease that a prudent lay person would consider not life-threatening and treatable
at urgent care. Examples of urgent care situations include sprains, cuts, and illnesses that do not
require immediate medical attention in order to prevent seriously damaging the health of the
person.
• Outpatient rehabilitative services provided by a licensed physical therapist, occupational
therapist, speech language pathologist, physician, or other practitioner licensed to provide physical,
occupational, or speech therapy. Services must be prescribed in writing by a licensed physician,
dentist, podiatrist, nurse practitioner, or physician assistant. The prescription must include site,
modality, duration, and frequency of treatment. Total covered expenses for outpatient rehabilitative
services is limited to a combined maximum of 30 visits per benefit year subject to preauthorization
and concurrent review by PacificSource for medical necessity. Only treatment of neurologic
conditions (e.g. stroke, spinal cord injury, head injury, pediatric neurodevelopmental problems, and
other problems associated with pervasive developmental disorders for which rehabilitative services
would be appropriate for children under 18 years of age) may be considered for additional benefits,
not to exceed 30 visits per condition, when criteria for supplemental services are met.
• Services for speech therapy will only be allowed when needed to correct stuttering, hearing loss,
peripheral speech mechanism problems, and deficits due to neurological disease or injury. Speech
and/or cognitive therapy for acute illnesses and injuries are covered up to one year post injury
when the services do not duplicate those provided by other eligible providers, including
occupational therapists or neuropsychologists.
• Outpatient pulmonary rehabilitation programs are covered when prescribed by a physician for
patients with severe chronic lung disease that interferes with normal daily activities despite optimal
medication management.
• For related provisions, see 'motion analysis', 'vocational rehabilitation', and 'speech therapy' under
'Excluded Services - Types of Treatments' in the Benefit Limitations and Exclusions section of this
Summary Plan Description.
• Services of a physician or a licensed certified nurse midwife for pregnancy. Services are subject to
the same payment amounts, conditions, and limitations that apply to similar expenses for illness,
except that pregnancy is not considered a pre-existing condition.
Please contact the PacificSource Customer Service Department as soon as you learn of your
pregnancy. PacificSource's staff will explain your plan's maternity benefits and help you enroll in
PacificSource's free prenatal care program.
• Routine nursery care of a newborn while the mother is hospitalized and eligible for pregnancy-
related benefits under this plan if the newborn is also eligible and enrolled in this plan.
• Services of a licensed audiologist for medically necessary audiological (hearing) tests.
• Services of a dentist or physician to treat injury of the jaw or natural teeth. Services must be
provided within 18 months of the injury. Except for the initial examination, services for treatment of
an injury to the jaw or natural teeth require preauthorization to be covered.
• Services of a dentist or physician for orthognathic (jaw) surgery as follows:
- When medically necessary to repair an accidental injury. Services must be provided within
one year after the accident.
- For removal of a malignancy, including reconstruction of the jaw within one year after that
surgery
• Services of a board-certified or board-eligible genetic counselor when referred by a physician or
nurse practitioner for evaluation of genetic disease
SingleSource Self-Insured 35
• Medically necessary telemedical health services for health services covered by this plan when
provided in person by a healthcare professional when the telemedical health service does not
duplicate or supplant a health service that is available to the patient in person. The location of the
patient receiving telemedical health services may include, but is not limited to: hospital; rural health
clinic; federally qualified health center; physician's office; community mental health center; skilled
nursing facility; renal dialysis center; or site where public health services are provided. Coverage of
telemedical health services are subject to the same deductible, co-payment, or co-insurance
requirements that apply to comparable health services provided in person.
HOSPITAL AND SKILLED NURSING FACILITY SERVICES
This plan covers medically necessary hospital inpatient services. Charges for a hospital room are
covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer
semi-private rooms). Charges for a private room are covered if the attending physician orders
hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary
isolation. Coverage includes eligible services provided by a hospital owned or operated by the state of
Oregon, or any state approved mental health and developmental disabilities program.
In addition to the hospital room, covered inpatient hospital services may include (but are not limited to):
• Cardiac care unit
• Operating room
• Anesthesia and post-anesthesia recovery
• Respiratory care
• Inpatient medications
• Lab and radiology services
• Dressings, equipment, and other necessary supplies
The plan does not cover charges for rental of telephones, radios, or televisions, or for guest meals or
other personal items.
Services of a skilled nursing facility and convalescent homes are covered for up to 120 days per
benefit year when preauthorized by PacificSource. Services must be medically necessary. Confinement
for custodial care is not covered.
Inpatient rehabilitative services are covered up to a maximum of 50 days of rehabilitative care per
benefit year, except that treatment for head or spinal cord injuries is covered for up to 60 days per
benefit year. Recreation therapy is only covered as part of an inpatient rehabilitation admission.
Services must be preauthorized by PacificSource
OUTPATIENT SERVICES
This plan covers the following outpatient care services:
Advanced diagnostic imaging procedures that are medically necessary for the diagnosis of
illness or injury. For purposes of this benefit, advanced diagnostic imaging procedures include CT
scans, MRIs, PET scans, CATH labs and nuclear cardiology studies. When services are provided
as part of a covered emergency room visit, your plan's emergency room benefit applies. In all other
situations and settings, benefits are subject to the deductibles, co-payments, and/or co-insurance
stated in your Medical Benefit Summary for Outpatient Services - Advanced Diagnostic Imaging.
• Diagnostic radiology and laboratory procedures provided or ordered by a physician, nurse
practitioner, or physician assistant. These services may be performed or provided by laboratories,
radiology facilities, hospitals, and physicians, including services in conjunction with office visits.
SingleSource Self-Insured 36
• Benefits for members who are receiving services for end-stage renal disease (ESRD) who are
eligible for Medicare, are limited to 125% of the current Medicare allowable amount for participating
and nonparticipating ESRD service providers. Benefits will continue to be paid at the cost share
level applied to other benefits in the same category for members who are not eligible for Medicare.
PacificSource will contact members when the first ESRD preauthorization request is received to
assist the member in understanding their out-of-pocket expenses and care plan.
• Emergency room services. The emergency room co-payment stated in your Medical Benefit
Summary covers medical screening and any diagnostic tests needed for emergency care, such as
radiology, laboratory work, CT scans, and MRIs. The co-payment does not cover further treatment
provided on referral from the emergency room.
In true medical emergencies, non-participating providers are paid at the participating provider level.
Emergency room charges for services, supplies, or conditions excluded from coverage under this
plan are not eligible for payment. That includes conditions subject to the plan's exclusion periods
for pre-existing and other conditions. Please see the Benefit Limitations and Exclusions section of
this Summary Plan Description.
• Surgery and other outpatient services. Benefits are based on the setting where services are
performed.
- For surgeries or outpatient services performed in a physician's office, the benefit stated in
your Medical Benefit Summary for Professional Services - Office Procedures and Supplies
applies.
- For surgeries or outpatient services performed in an ambulatory surgical center or
outpatient hospital setting, both the benefits stated in your Medical Benefit Summary for
Professional Services - Surgery and the Outpatient Services -Outpatient Surgery/Services
apply.
• Therapeutic radiology services, chemotherapy, and renal dialysis provided or ordered by a
physician. Covered services include a prescribed, orally administered anticancer medication used
to kill or slow the growth of cancerous cells.
• Other medically necessary diagnostic services provided in a hospital or outpatient setting,
including testing or observation to diagnose the extent of a medical condition.
EMERGENCY SERVICES
In a true medical emergency, this plan covers services and supplies necessary to determine the nature
and extent of the emergency condition and to stabilize the patient.
An emergency medical condition is an injury or sudden illness, including severe pain, so severe that a
prudent layperson with an average knowledge of health and medicine would expect that failure to
receive immediate medical attention would risk seriously damaging the health of a person or fetus in the
case of a pregnant woman. Examples of emergency medical conditions include (but are not limited to):
• Unusual or heavy bleeding
• Sudden abdominal or chest pains
• Suspected heart attacks
• Major traumatic injuries
• Serious burns
• Poisoning
• Unconsciousness
• Convulsions or seizures
• Difficulty breathing
• Sudden fevers
SingleSource Self-Insured 37
If you need immediate assistance for a medical emergency, call 911. If you have an emergency
medical condition, you should go directly to the nearest emergency room or appropriate facility. Care
for a medical emergency is covered at the participating provider percentage stated in your Medical
Benefit Summary even if you are treated at a non-participating hospital.
If you are admitted to a non-participating hospital after your emergency condition is stabilized, your Plan
Sponsor may require you to transfer to a participating facility in order to continue receiving benefits at
the participating provider level.
Maternity Services
Maternity means, in any one pregnancy, all prenatal services including complications and miscarriage,
delivery, postnatal services provided within six months of delivery, and routine nursery care of a
newborn child. Maternity services are covered subject to the deductible, co-payments, and/or co-
insurance stated in your Medical Benefit Summary regardless of marital status.
• Services of a physician or a licensed certified nurse midwife for pregnancy. Services are subject to
the same payment amounts, conditions, and limitations that apply to similar expenses for illness.
• Please contact the PacificSource Customer Service Department as soon as you learn of your
pregnancy. PacificSource's staff will explain your plan's maternity benefits and help you enroll in
PacificSoume's free prenatal care program.
• This plan provides routine nursery care of a newborn while the mother is hospitalized and eligible
for pregnancy-related benefits under this plan if the newborn is also eligible and enrolled in this
plan, regardless of marital status.
Special Information about Childbirth - This plan covers hospital inpatient services for childbirth
according to the Newborns' and Mothers' Health Protection Act of 1996. This plan does not restrict the
length of stay for the mother or newborn child to less than 48 hours after vaginal delivery, or to less
than 96 hours after Cesarean section delivery. Your provider is allowed to discharge you or your
newborn sooner than that, but only if you both agree. For childbirth, your provider does not need to
preauthorize your hospital stay with PacificSource.
MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES
This plan covers medically necessary crisis intervention, diagnosis, and treatment of mental health
conditions and chemical dependency. Refer to the Benefit Limitations and Exclusions section of this
Summary Plan Description for more information on services not covered by your plan.
Mental Health and Chemical Dependency Services
It is the intent of this plan to comply with all existing regulations of Mental Health Parity and Addiction
Equity Act of 2008 (MHPAEA). If for some reason the information presented in the plan differs from the
actual regulations of the MHPAEA, the plan reserves the right to administer the plan in accordance with
such actual regulations.
Providers Eligible for Reimbursement
A mental and/or chemical healthcare provider (see Definitions section of this Summary Plan
Description) is eligible for reimbursement if:
• The mental and/or chemical healthcare provider is approved by the Oregon Department of Human
Services;
• The mental and/or chemical healthcare provider is accredited for the particular level of care for
which reimbursement is being requested by the Oregon Joint Commission on Accreditation of
Hospitals or the Commission on Accreditation of Rehabilitation Facilities; or
• The patient is staying overnight at the mental and/or chemical healthcare facility (see Definitions
section of this Summary Plan Description) and is involved in a structured program at least eight
hours per day, five days per week; or
• The mental and/or chemical healthcare provider is providing a covered benefit under this policy;
and
SingleSource Self-Insured 38
Eligible mental and/or chemical healthcare providers are:
• A program licensed, approved, established, maintained, contracted with, or operated by the
Addictions and Mental Health Division of the Oregon Health Authority;
• A medical or osteopathic physician licensed by the State Board of Medical Examiners,
• A psychologist (Ph.D.) licensed by the State Board of Psychologists' Examiners;
• A nurse practitioner registered by the State Board of Nursing;
• A clinical social worker (L.C.S.W.) licensed by the State Board of Clinical Social Workers;
• A Licensed Professional Counselor (L.P.C) licensed by the State Board of Licensed Professional
Counselors and Therapists;
• A Licensed Marriage and Family Therapist (L.M.F.T) licensed by the State Board of Licensed
Professional Counselors and Therapists; and
• A hospital or other healthcare facility licensed by the Joint Commission on Accreditation of
Hospitals or the Commission on Accreditation of Rehabilitation Facilities for inpatient or residential
care and treatment of mental health conditions and/or chemical dependency.
Medical Necessity and Appropriateness of Treatment
• As with all medical treatment, mental health and chemical dependency treatment is subject to
review for medical necessity and/or appropriateness. Review of treatment may involve pre-service
review, concurrent review of the continuation of treatment, post-treatment review, or a combination
of these. PacificSource will notify the patient and patient's provider when a treatment review is
necessary to make a determination of medical necessity.
• A second opinion may be required for a medical necessity determination. PacificSource will notify
the patient when this requirement is applicable.
• PacificSource must be notified of an emergency admission within two business days.
• Medication management by an M.D. (such as a psychiatrist) does not require review.
• Treatment of substance abuse and related disorders is subject to placement criteria established by
the American Society of Addiction Medicine.
Mental Health Parity and Addiction Equity Act of 2008
This group health plan complies with all federal laws and regulations related to the Mental Health Parity
and Addiction Equity Act of 2008.
HOME HEALTH AND HOSPICE SERVICES
• This plan covers home health services up to 180 visits per benefit year when preauthorized by
PacificSource. Covered services include skilled nursing by a R.N. or L.P.N.; physical, occupational,
and speech therapy, and medical social work services provided by a licensed home health agency.
Private duty nursing is not covered.
• Home infusion services are covered when preauthorized by PacificSource. This benefit covers
parenteral nutrition, medications, and biologicals (other than immunizations) that cannot be self-
administered. Benefits are paid at the percentage stated in your Medical Benefit Summary for home
health care.
• This plan covers hospice services when preauthorized by PacificSource. Hospice services are
intended to meet the physical, emotional, and spiritual needs of the patient and family during the
final stages of illness and dying, while maintaining the patient in the home setting. Services are
intended to supplement the efforts of an unpaid caregiver. Hospice benefits do not cover services
of a primary caregiver such as a relative or friend, or private duty nursing. PacificSource uses the
following criteria to determine eligibility for hospice benefits:
- The member's physician must certify that the member is terminally ill with a life expectancy of
less than six months;
- The member must be living at home;
- A non-salaried primary caregiver must be available and willing to provide custodial care to the
member on a daily basis; and
SingleSource Self-Insured 39
- The member must not be undergoing treatment of the terminal illness other than for direct
control of adverse symptoms.
Only the following hospice services are covered:
- Home nursing visits.
- Home health aides when necessary to assist in personal care.
- Home visits by a medical social worker.
- Home visits by the hospice physician.
- Prescription medications for the relief of symptoms manifested by the terminal illness.
- Medically necessary physical, occupational, and speech therapy provided in the home.
- Home infusion therapy.
- Durable medical equipment, oxygen, and medical supplies.
- Respite care provided in a nursing facility to provide relief for the primary caregiver, subject to a
maximum of five consecutive days and to a lifetime maximum benefit of 30 days. A member
must be enrolled in a hospice program to be eligible for respite care benefits.
- Inpatient hospice care when provided by a Medicare-certified or state-certified program when
admission to an acute care hospital would otherwise be medically necessary.
- Pastoral care and bereavement services.
The member retains the right to all other services provided under this contract, including active
treatment of non-terminal illnesses, except for services of another provider that duplicate the services of
the hospice team.
DURABLE MEDICAL EQUIPMENT
• This plan covers prosthetic and orthotic devices that are medically necessary to restore or
maintain the ability to complete activities of daily living or essential job-related activities and that are
not solely for comfort or convenience. Benefits include coverage of all services and supplies
medically necessary for the effective use of a prosthetic or orthotic device, including formulating its
design, fabrication, material and component selection, measurements, fittings, static and dynamic
alignments, and instructing the patient in the use of the device. Benefits also include coverage for
any repair or replacement of a prosthetic or orthotic device that is determined medically necessary
to restore or maintain the ability to complete activities of daily living or essential job-related activities
and that is not solely for comfort or convenience.
• This plan covers durable medical equipment prescribed exclusively to treat medical conditions.
Covered equipment includes crutches, wheelchairs, orthopedic braces, home glucose meters,
equipment for administering oxygen, and non-power assisted prosthetic limbs and eyes. Durable
medical equipment must be prescribed by a licensed M.D., D.C., N.P., P.A., D.D.S., D.M.D., or
D. P.M. to be covered. This plan does not cover equipment commonly used for nonmedical
purposes, for physical or occupational therapy, or prescribed primarily for comfort. Please see
'Excluded Services - Equipment and Devices' in the Benefit Limitations and Exclusions section for
information on items not covered. The following limitations apply to durable medical equipment:
- This benefit covers the cost of either purchase or rental of the equipment for the period
needed, whichever is less. Repair or replacement of equipment is also covered when
necessary, subject to all conditions and limitations of the plan. If the cost of the purchase,
rental, repair, or replacement is over $500, preauthorization by PacificSource is required.
- Only expenses for durable medical equipment, or prosthetic and orthotic devices that are
provided by a PacificSource contracted provider or a provider that satisfies the criteria of
the Medicare fee schedule for Suppliers of Durable Medical Equipment, Prosthetics,
Orthotics, Supplies (DMEPOS) and Other Items and Services Summary Plan Description
are eligible for reimbursement. Mail order or Internet/Web based providers are not eligible
providers.
- Purchase, rental, repair, lease, or replacement of a power-assisted wheelchair (including
batteries and other accessories) requires preauthorization by PacificSource and is payable
only in lieu of benefits for a manual wheelchair.
SingleSource Self-Insured 40
The durable medical equipment benefit also covers lenses to correct a specific vision
defect resulting from a severe medical or surgical problem, such as stroke, neurological
disease, trauma, or eye surgery other than refraction procedures. Coverage is subject to
the following limitations:
o The medical or surgical problem must cause visual impairment or disability due to loss
of binocular vision or visual field defects (not merely a refractive error or astigmatism)
that requires lenses to restore some normalcy to vision.
o The maximum allowance for glasses (lenses and frames), or contact lenses in lieu of
glasses, is limited to $200 per initial case. 'Initial case' is defined as the first time
surgery or treatment is performed on either eye. Other policy limitations, such as
exclusions for extra lenses, other hardware, tinting of lenses, eye exercises, or vision
therapy, also apply.
o Benefits for subsequent medically necessary vision corrections to either eye (including
an eye not previously treated) are limited to the cost of lenses only.
Reimbursement is subject to the deductible, co-payment, and/or co-insurance stated in
your Medical Benefit Summary for durable medical equipment and is in lieu of, and not in
addition to benefits payable under any vision endorsement that may be added to this plan.
The durable medical equipment benefit also covers hearing aids for members under 18
years of age and younger, or 25 years of age and younger if the member is enrolled in a
secondary school or an accredited educational institution. Coverage is limited to a
maximum benefit of $4,000 every 48 months. The benefit amount may be adjusted on
January 1 of each year to reflect the U.S City Average Consumer Price Index.
Medically necessary treatment for sleep apnea and other sleeping disorders is covered
when preauthorized by PacificSource. Coverage of oral devices includes charges for
consultation, fitting, adjustment, follow-up care, and the appliances, is limited to a lifetime
maximum benefit of $500, including charges for consultation, fitting, adjustment, follow-up
care, and the appliance.. The appliance must be prescribed by a physician specializing in
evaluation and treatment of obstructive sleep apnea, and the condition must meet criteria
for obstructive sleep apnea.
Wigs following chemotherapy or radiation therapy are covered up to a maximum benefit of
$150 per benefit year.
Breastfeeding pumps, manual and electric, are covered at no cost per pregnancy when
purchased or rented from a licensed provider, or purchased from a retail outlet. Hospital-
grade breast pumps are excluded under preventive care and regular benefits.
TRANSPLANT SERVICES
This plan covers certain medically necessary organ and tissue transplants. It also covers the cost of
acquiring organs or tissues needed for covered transplants and limited travel expenses for the patient,
subject to certain limitations.
All pretransplant evaluations, services, treatments, and supplies for transplant procedures require
preauthorization by PacificSource.
You must have been covered under this plan for at least 24 consecutive months or since birth to be
eligible for transplant benefits, including benefits for transplantation evaluation. See Exclusion Periods -
Transplants in the Benefit Limitations and Exclusions section of this Summary Plan Description for
details.
This plan covers the following medically necessary organ and tissue transplants:
• Kidney
• Kidney - Pancreas
• Pancreas whole organ transplantation (under certain criteria)
• Heart
• Heart - Lung
SingleSource Self-Insured 41
• Lung
• Liver (under certain criteria)
• Bone marrow and peripheral blood stem cell
• Pediatric bowel
This plan only covers transplants of human body organs and tissues. Transplants of artificial, animal, or
other non-human organs and tissues are not covered.
Expenses for the acquisition of organs or tissues for transplantation are covered only when the
transplantation itself is covered under this contract, and is subject to the following limitations:
• Testing of related or unrelated donors for a potential living related organ donation is payable at the
same percentage that would apply to the same testing of an insured recipient.
• Expense for acquisition of cadaver organs is covered, payable at the same percentage and subject
to the same maximum dollar limitation, if any, as the transplant itself.
• Medical services required for the removal and transportation of organs or tissues from living donors
are covered. Coverage of the organ or tissue donation is at the same percentage payable for the
transplant itself up to $8,000 if the donor is a member of this plan, and applies to the maximum
dollar limitation for the transplant, if any.
- If the donor is not a PacificSource member, only those complications of the donation that occur
during the initial hospitalization are covered, and such complications are covered only to the
extent that they are not covered by another health plan or government program. Coverage is at
the same percentage payable for the transplant itself, and also applies to the maximum dollar
limitation, if any, for the transplant.
- If the donor is a PacificSource member, complications of the donation are covered as any other
illness would be covered.
• Transplant related services, including HLA typing, sibling tissue typing, and evaluation costs, are
considered transplant expenses and accumulate toward any transplant benefit limitations and are
subject to PacificSource's provider contractual agreements (see Payment of Transplant Benefits,
below).
Travel and housing expenses for the recipient are limited to $5,000 per transplant. Travel and living
expenses are not covered for the donor.
Payment of Transplant Benerits
If a transplant is performed at a participating Center of Excellence transplantation facility, covered
charges of the facility are subject to plan deductibles (co-insurance and co-payment amounts after
deductible are waived). If PacificSource's contract with the facility includes the services of the medical
professionals performing the transplant (such as physicians, nurses, and anesthesiologists), those
charges are also subject to plan deductibles (co-insurance and co-payment amounts after deductible
are waived). If the professional fees are not included in PacificSource's contract with the facility, then
those benefits are provided according to your Medical Benefit Summary.
If transplant services are available through a contracted transplantation facility but are not performed at
a contracted facility, you are responsible for satisfying any deductibles or co-payments stated in your
Medical Benefit Summary. This plan then pays at of 60% of the UCR after deductible and co-payments.
Services of non-participating medical professionals are paid at the non-participating provider benefit
level percentages and do not apply to the out-of-pocket maximum.
OTHER COVERED SERVICES, SUPPLIES, AND
TREATMENTS
• This plan covers services of a state certified ground or air ambulance when private transportation
is medically inappropriate because the acute medical condition requires paramedic support.
Benefits are provided for emergency ambulance service and/or transport to the nearest facility
capable of treating the condition. Air ambulance service is covered only when ground transportation
is medically or physically inappropriate. Reimbursement to nonparticipating air ambulance services
are based on 125% of the Medicare allowance. In some cases Medicare allowance may be
SingleSource Self-Insured 42
significantly lower than the provider's billed amount. The provider may hold you responsible for the
amount they bill in excess of the Medicare allowance, as well as applicable deductibles and
coinsurance. Medically necessary travel, other than transportation by a licensed ambulance
service, to the nearest facility qualified to treat the patient's medical condition is covered when
approved in advance by PacificSource.
• This plan covers biofeedback to treat migraine headaches or urinary incontinence when provided
by an otherwise eligible practitioner.
• This plan covers blood transfusions, including the cost of blood or blood plasma.
• This plan covers removal, repair, or replacement of an internal breast prosthesis due to a
contracture or rupture, but only when the original prosthesis was for a medically necessary
mastectomy. Preauthorization by PacificSource is required, and eligibility for benefits is subject to
the following criteria:
- The contracture or rupture must be clinically evident by a physician's physical examination,
imaging studies, or findings at surgery.
- This plan covers removal, repair, and/or replacement of the prosthesis; a new reconstruction is
not covered.
Removal, repair, and/or replacement of the prosthesis is not covered when recommended due
to an autoimmune disease, connective tissue disease, arthritis, allergenic syndrome,
psychiatric syndrome, fatigue, or other systemic signs or symptoms.
- PacificSource may require a signed loan receipt/subrogation agreement before providing
coverage for this benefit.
• This plan covers breast reconstruction in connection with a medically necessary mastectomy.
Coverage is provided in a manner determined in consultation with the attending physician and
patient for:
- All stages of reconstruction of the breast on which the mastectomy was performed;
- Surgery and reconstruction of the other breast to produce a symmetrical appearance;
- Prostheses, and
- Treatment of physical complications of the mastectomy, including lymphedema
Benefits for breast reconstruction are subject to all terms and provisions of the plan, including
deductibles, co-payments and/or co-insurance stated in your Medical Benefit Summary.
• This plan covers cardiac rehabilitation as follows:
- Phase I (inpatient) services are covered under inpatient hospital benefits.
- Phase II (short-term outpatient) services are covered subject to the deductible, co-payment,
and/or co-insurance stated in your Medical Benefit Summary for outpatient hospital
benefits. Benefits are limited to services provided in connection with a cardiac rehabilitation
exercise program that does not exceed 36 sessions and that are considered reasonable
and necessary.
- Phase III (long-term outpatient) services are not covered.
• This plan covers IUD, diaphragm, and cervical cap contraceptive devices along with their
insertion or removal. Contraceptive devices that can be obtained over the counter or without a
prescription, such as condoms are not covered.
• This plan covers corneal transplants. Preauthorization is not required.
• In the following situations, this plan covers one attempt at cosmetic or reconstructive surgery:
- When necessary to correct a functional disorder; or
- When necessary because of an accidental injury, or to correct a scar or defect that resulted
from treatment of an accidental injury; or
- When necessary to correct a scar or defect on the head or neck that resulted from a
covered surgery.
Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar,
or defect first occurred. Preauthorization by PacificSource is required for all cosmetic and
SingleSource Self-Insured 43
reconstructive surgeries covered by this plan. For information on breast reconstruction, see 'breast
prosthesis' and 'breast reconstruction' in this section.
• This plan covers dental and orthodontic services for the treatment of craniofacial anomalies when
medically necessary to restore function. Coverage includes but is not limited to physical disorders
identifiable at birth that affect the bony structures of the face or head, such as cleft palate, cleft lip,
craniosynostosis, craniofacial microsomia and Treacher Collins syndrome. Coverage is limited to
the least costly clinically appropriate treatment. Cosmetic procedures and procedures to improve on
the normal range of functions are not covered. See the exclusions for cosmetic/reconstructive
services, dental examinations and treatment, jaw surgery, and orthognathic surgery under the
'Excluded Services' section
• This plan provides coverage for certain diabetic supplies and training as follows:
- Diabetic supplies other than insulin and syringes (such as lancets, test strips, and glucostix)
are covered subject to the deductible, co-payment, and/or co-insurance stated in your
Medical Benefit Summary for durable medical equipment. You may purchase those
supplies from any retail outlet and send your receipts to PacificSource, along with your
name, group number, and member ID number. PacificSource will process the claim and
mail you a reimbursement check.
- Diabetic insulin and syringes are covered under your prescription drug benefit, if your plan
includes prescription coverage. Lancets and test strips are also available under that
prescription benefit in lieu of those covered supplies under the medical plan.
- This plan covers one diabetes self-management education program at the time of
diagnosis, and up to three hours of education per year if there is a significant change in
your condition or its treatment. To be covered, the training must be provided by an
accredited diabetes education program, or by a physician, registered nurse, nurse
practitioner, certified diabetes educator, or licensed dietitian with expertise in diabetes.
- This plan covers medically necessary telemedical health services provided in connection
with the treatment of diabetes (see Professional Services in this section).
• This plan covers dietary or nutritional counseling provided by a registered dietitian under certain
circumstances. It is covered under the diabetic education benefit, or for management of inborn
errors of metabolism (excluding obesity), or for management of anorexia nervosa or bulimia
nervosa (to a lifetime maximum of five visits).
• This plan covers nonprescription elemental enteral formula ordered by a physician for home use.
Formula is covered when medically necessary to treat severe intestinal malabsorption and the
formula comprises a predominant or essential source of nutrition. Coverage is subject to the
deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for durable
medical equipment.
• This plan covers routine foot care for patients with diabetes mellitus.
• Hospitalization for dental procedures is covered when the patient has another serious medical
condition that may complicate the dental procedure, such as serious blood disease, unstable
diabetes, or severe cardiovascular disease, or the patient is physically or developmentally disabled
with a dental condition that cannot be safely and effectively treated in a dental office. Coverage
requires preauthorization by PacificSource, and only charges for the facility, anesthesiologist, and
assistant physician are covered. Hospitalization because of the patient's apprehension or
convenience is not covered.
• This plan covers treatment for inborn errors of metabolism involving amino acid, carbohydrate,
and fat metabolism for which widely accepted standards of care exist for diagnosis, treatment, and
monitoring exist, including quantification of metabolites in blood, urine or spinal fluid or enzyme or
DNA confirmation in tissues. Coverage includes expenses for diagnosing; monitoring and
controlling the disorders by nutritional and medical assessment, including but not limited to clinical
visits, biochemical analysis and medical foods used in the treatment of such disorders. Nutritional
supplies are covered subject to the deductible, co-payment, and/or co-insurance stated in your
Medical Benefit Summary for durable medical equipment.
• Injectable drugs and biologicals administered by a physician are covered when medically
necessary for diagnosis or treatment of illness or injury. This benefit does not include
immunizations (see Preventive Care Services in this section) or drugs or biologicals that can be
self-administered or are dispensed to a patient.
SingleSource Self-Insured 44
• This plan covers maxillofacial prosthetic services when prescribed by a physician as necessary
to restore and manage head and facial structures. Coverage is provided only when head and facial
structures cannot be replaced with living tissue, and are defective because of disease, trauma, or
birth and developmental deformities. To be covered, treatment must be necessary to control or
eliminate pain or infection or to restore functions such as speech, swallowing, or chewing.
Coverage is limited to the least costly clinically appropriate treatment, as determined by the
physician. Cosmetic procedures and procedures to improve on the normal range of functions are
not covered. Dentures, prosthetic devices for treatment of TMJ conditions, and artificial larynx are
also not covered.
• Pediatric dental care is not covered.
• The routine costs of care associated with approved clinical trials are covered. Benefits are
only provided for routine costs of care associated with approved clinical trials. Expenses for
services or supplies that are not considered routine costs of care are not covered. For more
information, see 'routine costs of care' in the Definitions section of this Summary Plan Description.
A'qualified individual' is someone who is eligible to participate in a qualifying clinical trial. If a
participating provider is participating in an approved clinical trial, the qualified individual may be
required to participate in the trial through that participating provider if the provider will accept the
individual as a participant in the trial.
• Sleep studies are covered when ordered by a pulmonologist, neurologist, otolaryngologist, or
certified sleep medicine specialist, and when performed at a certified sleep laboratory.
• This plan covers medically necessary therapy and services for the treatment of traumatic brain
injury.
• This plan covers tubal ligation and vasectomy procedures with no waiting period.
BENEFIT LIMITATIONS AND EXCLUSIONS
Least Costly Setting for Services
Covered services must be performed in the least costly setting where they can be provided safely. If a
procedure can be done safely in an outpatient setting but is performed in a hospital inpatient setting,
this plan will only pay what it would have paid for the procedure on an outpatient basis. If services are
performed in an inappropriate setting, your benefits can be reduced by up to 30 percent or $2,500,
whichever is less.
EXCLUDED SERVICES
A Note About Optional BeneFts
If your Plan Sponsor provides coverage for optional benefits such as prescription drugs, vision services,
chiropractic care, or alternative care, you'll find those Member Benefit Summaries in this Summary Plan
Description. If your Plan Sponsor provides optional benefits for an exclusion listed below, then the
exclusion does not apply to the extent that coverage exists under the optional benefit. For example, if
your Plan Sponsor provides optional chiropractic coverage, then the exclusion for chiropractic care
listed below under 'Types of Treatment' does not apply to you.
Types of Treatment - This plan does not cover the following:
• Acupuncture
• Chelation therapy including associated infusions of vitamins and/or minerals, except as medically
necessary for the treatment of selected medical conditions and medically significant heavy metal
toxicities
• Day care or custodial care - Care and related services designed essentially to assist a person in
maintaining activities of daily living, e.g. services to assist with walking, getting in/out of bed,
bathing, dressing, feeding, preparation of meals, homemaker services, special diets, rest cures,
day care, and diapers. Custodial care is only covered in conjunction with respite care allowed under
this plan's hospice benefit. For related provisions, see 'Hospital and Skilled Nursing Facility
Services' and 'Home Health and Hospice Services' in the Covered Expenses section of this
Summary Plan Description.
SingleSource Self-Insured 45
• Dental examinations and treatment, which means any services or supplies to prevent, diagnose, or
treat diseases of the teeth and supporting tissues or structures, except as specified in Covered
Expenses - Preventive Care Services except as specifically provided with a separate PacificSource
Dental Plan (See the Dental Benefit Plan section of this Summary Plan Description).
• Eye exercises, therapy, and procedures - Orthoptics, vision therapy, and procedures intended to
correct refractive errors
• Fitness or exercise programs and health or fitness club memberships
• Foot care (routine) - Services and supplies for corns and calluses of the feet, conditions of the
toenails other than infection, hypertrophy or hyperplasia of the skin of the feet, and other routine
foot care, except in the case of patients being treated for diabetes mellitus
• Genetic (DNA) testing, except for tests identified as medically necessary for the diagnosis and
standard treatment of specific diseases
• Homeopathic treatment
• Infertility - Services and supplies, surgery, treatment, or prescriptions to prevent, or cure infertility
or to induce fertility (including Gamete and/or Zygote Interfallopian Transfer; i.e. GIFT or ZIFT),
except for medically necessary medication to preserve fertility during treatment with cytotoxic
chemotherapy. For related provisions, see the exclusion for'family planning' in this section. For
purposes of this plan, infertility is defined as:
o Male: Low sperm counts or the inability to fertilize an egg
o Female: The inability to conceive or carry a pregnancy to 12 weeks
• Instructional or educational programs, except diabetes self-management programs
• Jaw- Services or supplies for developmental or degenerative abnormalities of the jaw,
malocclusion, dental implants, or improving placement of dentures.
• Massage, massage therapy, or neuromuscular re-education, even as part of a physical therapy
program
• Motion analysis, including videotaping and 3-D kinematics, dynamic surface and fine wire
electromyography, and physician review
• Myeloablative high dose chemotherapy, except when the related transplant is specifically covered
under the transplantation provisions of this plan. For related provisions, see 'Transplant Services' in
the Covered Expenses section of this Summary Plan Description.
Naturopathic treatment
• Obesity or weight control - Surgery or other related services or supplies provided for weight control
or obesity (including all categories of obesity) except as listed under 'Preventive Care Services',
whether or not there are other medical conditions related to or caused by obesity. This also
includes services or supplies used for weight loss, such as food supplementation programs and
behavior modification programs, regardless of the medical conditions that may be caused or
exacerbated by excess weight, and self-help or training programs for weight control. Obesity
screening and counseling are covered for children and adults; see the 'dietary or nutritional
counseling' section under 'Other Covered Services'.
• Oral/facial motor therapy for strengthening and coordination of speech-producing musculature and
structures
• Osteopathic manipulation, except for treatment of disorders of the musculoskeletal system
• Physical or eye examinations required for administrative purposes such as participation in athletics,
admission to school, or by a Plan Sponsor
• Private nursing service
• Programs that teach a person to use medical equipment, care for family members, or self
administer drugs or nutrition (except for diabetic education benefit)
• Rehabilitation - Functional capacity evaluations, work hardening programs, vocational
rehabilitation, community reintegration services, and driving evaluations and training programs
• Routine services and supplies - Services, supplies, and equipment not involved in diagnosis or
treatment but provided primarily for the comfort, convenience, cosmetic purpose, environmental
SingleSource Self-Insured 46
control, or education of a patient or for the processing of records or claims. These include but are
not limited to:
o Missed appointments, completion of claim forms, or reports requested by PacificSource in
order to process claims
o Appliances, such as air conditioners, humidifiers, air filters, whirlpools, hot tubs, heat
lamps, or tanning lights
o Private nursing services or personal items such as telephones, televisions, and guest
meals in a hospital or skilled nursing facility
o Maintenance supplies and equipment not unique to medical care
• Screening tests - Services and supplies, including imaging and screening exams performed for the
sole purpose of screening and not associated with specific diagnoses and/or signs and symptoms
of disease or of abnormalities on prior testing (including but not limited to total body CT imaging, CT
colonography and bone density testing).This does not include preventive care screenings listed
under'Preventive Care Services' in the Covered Expenses section of this Summary Plan .
Description.
• Self-help or training programs
• Sexual disorders - Services or supplies for the treatment of sexual dysfunction or inadequacy
unless medically necessary to treat a mental health issue and diagnosis. For related provisions,
see the exclusions for 'family planning', 'infertility', and 'mental illness' in this section.
• Snoring - Services or supplies for the diagnosis or treatment of snoring or upper airway resistance
disorders, including somnoplasty
• Speech therapy - Oral/facial motor therapy for strengthening and coordination of speech-producing
muscles and structures, except as medically necessary in the restoration or improvement of speech
following a traumatic brain injury or for a child 17 years of age or younger diagnosed with a
pervasive developmental disorder.
• Temporomandibular joint (TMJ)-related services, or treatment for associated myofascial pain,
including physical or oromyofacial therapy
Surgeries and Procedures - This plan does not cover the following:
• Abdominoplasty for any indication
• Artificial insemination, in vitro fertilization, or GIFT procedures
• Cosmetic/reconstructive services and supplies - Except as specified in the Covered Expenses -
Other Covered Services, Supplies, and Treatments section of this Summary Plan Description,
services and supplies, including drugs, rendered primarily for cosmetictreconstructive purposes and
any complications as a result of non-covered cosmetic/reconstructive surgery.
Cosmetic/reconstructive services and supplies are those performed primarily to improve the body's
appearance and not primarily to restore impaired function of the body, regardless of whether the
area to be treated is normal or abnormal.
• Electronic Beam Tomography (EBT)
• Eye refraction procedures, orthoptics, vision therapy, or other services to correct refractive error
except as indicated in the Covered Services section of this Summary Plan Description
• Jaw surgery - Treatment for abnormalities of the jaw, malocclusion, or improving the placement of
dentures and dental implants
• Orthognathic surgery - Services and supplies to augment or reduce the upper or lowerjaw, except
as specified under 'Professional Services' in the Covered Expenses section of this Summary Plan
Description.
• Panniculectomy for any indication
• Sex reassignment - Procedures, services or supplies related to a sex reassignment unless
medically necessary. For related provisions, see exclusions for'mental illness' in this section.
o Excluded procedures include, but are not limited to: staged gender reassignment surgery,
including breast augmentation; penile implantation; liposuction, thyroid chondroplasty,
SingleSource Self-Insured 47
laryngoplasty, or shortening of the vocal cords, and/or hair removal specifically to assist the
appearance of other characteristics of gender reassignment.
• Surgery to reverse voluntary sterilization
• Transplants -Any services, treatments, or supplies for the transplantation of bone marrow or
peripheral blood stem cells or any human body organ or tissue, except as expressly provided under
the provisions of this plan for covered transplantation expenses. For related provisions see
'Transplant Services' in the Covered Expenses section of this Summary Plan Description.
Mental Health Services - This plan does not cover the following services, whether provided by a
mental health or chemical dependency specialist or by any other provider:
Treatment for the following diagnosis:
• Diagnostic codes V 15.81 through V71.09 (DSM-IV-TR, Forth Edition) except V61.20, V61.21, and
V62.82 when used with children five years of age or younger
• Food dependencies
• Gender Identity Disorders in Adults (GID)
• Learning disorders
• Mental illness does not include - Treatment of intellectual disabilities; learning disorders;
paraphilias; and relationship problems (e.g. parent-child, partner, sibling, or other relationship
issues), except the treatment of children five years of age or younger for parent-child relational
problems, physical abuse of a child, sexual abuse of a child, neglect of a child, or bereavement.
This plan does not cover educational or correctional services or sheltered living provided by a
school or halfway house, except outpatient services received while temporarily living in a shelter;
psychoanalysis or psychotherapy received as part of an educational or training program, regardless
of diagnosis or symptoms that may be present; a court-ordered sex offender treatment program; a
court-ordered screening interview or drug or alcohol treatment program; or nicotine related
disorders.
The following treatment types are also excluded, regardless of diagnosis: marital/partner
counseling; support groups; sensory integration training; biofeedback except to treat migraine
headaches or urinary incontinence; hypnotherapy; academic skills training; narcosynthesis;
aversion therapy; and social skill training. Recreation therapy is only covered as part of an inpatient
or residential admission.
The following are also excluded: court-mandated diversion and/or chemical dependency education
classes; court-mandated psychological evaluations for child custody determinations; voluntary
mutual support groups such as Alcoholics Anonymous, adolescent wilderness treatment programs;
mental examinations for the purpose of adjudication of legal rights; psychological testing and
evaluations not provided as an adjunct to treatment or diagnosis of a stress management,
parenting skills, or family education; assertiveness training; image therapy; sensory movement
group therapy; marathon group therapy; sensitivity training; and psychological evaluation for sexual
dysfunction or inadequacy.
• Mental retardation for individuals 18 years of age or older
• Nicotine related disorders
• Paraphilias
Treatment programs, training, or therapy as follows:
• Academic skills training
• Aversion therapy
• Biofeedback (other than as specifically noted under the Covered Expenses - Other covered
Services, Supplies, and Treatment section)
• Court-ordered sex offender treatment programs
• Court-ordered screening interviews or drug or alcohol treatment programs
• Educational or correctional services or sheltered living provided by a school or halfway house
• Equine/animal therapy
SingleSource Self-Insured 48
• Hypnotherapy
• Narcosynthesis
• Psychoanalysis or psychotherapy received as part of an educational or training program,
regardless of diagnosis or symptoms that may be present
• Marital/partner counseling
• Recreation therapy outside a inpatient or residential treatment setting
• Sensory integration training
• Social skill training
• Support groups
Drugs and Medications- This plan does not cover the following:
• Drugs and biologicals that can be self administered (including injectibles), other than those
provided in a hospital emergency room, or other institutional setting, or as outpatient chemotherapy
and dialysis, which are covered
• Drugs or medications not prescribed for inborn errors of metabolism, diabetic insulin, or autism
spectrum disorder that can be self-administered (including prescription drugs, injectable drugs, and
biologicals), unless given during a visit for outpatient chemotherapy or dialysis or during a medically
necessary hospital, emergency room or other institutional stay.
• Growth hormone injections or treatments, except to treat documented growth hormone deficiencies
• Immunizations when recommended for or in anticipation of exposure through travel or work
• Over-the-counter medications or non-prescription drugs
Equipment and Devices - This plan does not cover the following:
• Computer or electronic equipment for monitoring asthmatic, diabetic, or similar medical conditions
or related data
• Equipment commonly used for nonmedical purposes - This plan does not cover the following:
o Equipment commonly used for nonmedical purposes, or marketed to the general public, or
intended to alter the physical environment. This includes appliances like adjustable power
beds sold as furniture, air conditioners, air purifiers, room humidifiers, heating and cooling
pads, home blood pressure monitoring equipment, light boxes, conveyances other than
conventional wheelchairs, whirlpool baths, spas, saunas, heat lamps, tanning lights, and
pillows. It also includes orthopedic shoes and shoe modifications. Mattresses and mattress
pads are only covered when medically necessary to heal pressure sores.
o Modifications to vehicles or structures to prevent, treat, or accommodate a medical
condition
o Replacement costs for worn or damaged durable medical equipment that would otherwise
be replaceable without charge under warranty or other agreement
o Personal items such as telephones, televisions, and guest meals during a stay at a hospital
or other inpatient facility
• Equipment used primarily in athletic or recreational activities. This includes exercise equipment for
stretching, conditioning, strengthening, or relief of musculoskeletal problems
• Modifications to vehicles or structures to prevent, treat, or accommodate a medical condition
• Personal items such as telephones, televisions, and guest meals during a stay at a hospital or other
inpatient facility
• Replacement costs for worn or damaged durable medical equipment that would otherwise be
replaceable without charges under warranty or other agreement
Experimental or Investigational Treatment
Your Plan Sponsor's plan does not cover experimental or investigational treatment. By that,
PacificSource means services, supplies, protocols, procedures, devices, chemotherapy, drugs or
SingleSource Self-Insured 49
medicines or the use thereof that are experimental or investigational for the diagnosis and treatment of
the patient. It includes treatment that, when and for the purpose rendered:
• Has not yet received full U.S. government agency approval (e.g. FDA) for other than experimental,
investigational, or clinical testing;
• Is not of generally accepted medical practice in Oregon or as determined by PacificSource in
consultation with medical advisors, medical associations, and/or technology resources;
• Is not approved for reimbursement by the Centers for Medicare and Medicaid Services;
• Is furnished in connection with medical or other research; or
• Is considered by any governmental agency or subdivision to be experimental or investigational, not
reasonable and necessary, or any similar finding.
An experimental or investigational service is not made eligible for benefits by the fact that other
treatment is considered by your healthcare provider to be ineffective or not as effective as the service or
that the service is prescribed as the most likely to prolong life.
When making benefit determinations about whether treatments are investigational or experimental,
PacificSource relies on the above resources as well as:
• Expert opinions of specialists and other medical authorities;
• Published articles in peer-reviewed medical literature;
• External agencies whose role is the evaluation of new technologies and drugs; and
• External review by an independent review organization.
The following will be considered in making the determination whether the service is in an experimental
and/or investigational status:
• Whether there is sufficient evidence to permit conclusions concerning the effect of the services on
health outcomes;
• Whether the scientific evidence demonstrates that the services improve health outcomes as much
or more than established alternatives;
• Whether the scientific evidence demonstrates that the services' beneficial effects outweigh any
harmful effects; and
• Whether any improved health outcomes from the services are attainable outside an investigational
setting.
If you or your provider have any concerns about whether a course of treatment will be covered,
PacificSource encourages you to contact PacificSource's Customer Service Department. PacificSource
will arrange for medical review of your case against PacificSource's criteria, and notify you of whether
the proposed treatment will be covered.
Other Items - This plan does not cover the following:
• Treatment not medically necessary - Services or supplies that are not medically necessary for the
diagnosis or treatment of an illness, injury, or disease. For related provisions, see 'medically
necessary' in the Definitions section and 'Understanding Medical Necessity' in the Covered
Expenses section of this Summary Plan Description.
• Treatment prior to enrollment - Services or supplies a member received prior to enrolling in
coverage provided by this plan; charges for inpatient stays that begin before you were covered by
this plan; services or supplies received before this plan's coverage began; admission prior to
coverage; services and supplies for an admission to a hospital, skilled nursing facility or specialized
facility that began before the patient's coverage under this plan
• Treatment after insurance ends - Services or supplies received after enrollment in this policy ends.
(The only exception is if this policy is replaced by another group health policy while you are
hospitalized. The plan will continue paying covered hospital expenses until you are released or your
benefits are exhausted, whichever occurs first.)
• Care and related services designed essentially to assist a person in maintaining activities of daily
living, e.g. services to assist with walking, getting in/out of bed, bathing, dressing, feeding, and
SingleSource Self-Insured 50
preparation of meals, homemaker services, special diets, rest crew, day care, and diapers.
Custodial care is only covered in conjunction with respite care allowed under this policy's hospice
benefit (see Covered Expenses - Hospital, Skilled Nursing Facility, Home Health, and Hospice
Services).
• Services or supplies available to you from another source, including those available through a
government agency
• Services or supplies for which no charge is made, for which the member is not legally required to
pay, or for which a provider or facility is not licensed to provide even though the service or supply
may otherwise be eligible. This exclusion includes services provided by the member, or by an
immediate family member.
• Services or supplies for which you are not willing to release the medical or eligibility information
PacificSource needs to determine the benefits paid under this plan
• Charges that are the responsibility of a third party who may have caused the illness, injury, or
disease or other insurers covering the incident (such as workers' compensation insurers,
automobile insurers, and general liability insurers)
• Charges over the usual, customary, and reasonable fee (UCR) - Any amount in excess of the UCR
for a given service or supply, except alternative care.
• Treatment of any illness, injury, or disease resulting from an illegal occupation or attempted felony,
or treatment received while in the custody of any law enforcement authority
• Treatment of any condition caused by a war, armed invasion, or act of aggression, or while serving
in the armed forces
• Treatment of any work-related illness or injury, unless you are the owner, partner, or principal of the
Plan Sponsor, injured in the course of employment of the Plan Sponsor, and are otherwise exempt
from, and not covered by, state or federal workers' compensation insurance. This includes illness or
injury caused by any for-profit activity, whether through employment or self-employment.
• Treatment while incarcerated - Services or supplies a member receives while in the custody of any
state or federal law enforcement authorities or while in jail or prison
• Charges for phone consultations, missed appointments, get acquainted visits, completion of claim
forms, or reports PacificSource needs to process claims
• Any amounts in excess of the allowable fee for a given service or supply Training or self-help
programs - General fitness exercise programs, and programs that teach a person how to use
durable medical equipment or care for a family member. Also excluded are health or fitness club
services or memberships and instruction programs, including but not limited to those to learn to
self-administer drugs or nutrition, except as specifically provided for in this plan.
• Services of providers who are not eligible for reimbursement under this plan. An individual
organization, facility, or program is not eligible for reimbursement for services or supplies,
regardless of whether this plan includes benefits for such services or supplies, unless the
individual, organization, facility, or program is licensed by the state in which services are provided
as an independent practitioner, hospital, ambulatory surgical center, skilled nursing facility, durable
medical equipment supplier, or mental and/or chemical healthcare facility. And to the extent
PacificSource maintains credentialing requirements the practitioner or facility must satisfy those
requirements in order to be considered an eligible provider.
• Scheduled and/or non-emergent medical care outside of the United States.
• Services otherwise available - These include but are not limited to,
o Services or supplies forwhich payment could be obtained in whole or in part if the member
applied for payment under any city, county, state (except Medicaid), or federal law, and
o Services or supplies the member could have received in a hospital or program operated by
a federal government agency or authority, except otherwise covered expenses for services
or supplies furnished to a member by the Veterans' Administration of the United States that
are not military service-related.
This exclusion does not apply to covered services provided through Medicaid or by any hospital
owned or operated by the State of Oregon or any state-approved community mental health and
developmental disability program.
SingleSource Self-Insured 51
• Benefits not stated - Services and supplies not specifically described as benefits under the group
health policy and/or any endorsement attached hereto
EXCLUSION PERIODS
Exclusion Period for Transplant Benefits
Except for corneal transplants, organ and tissue transplants are not covered until you have been
enrolled in this plan for 24 months or since birth. If you were covered under another health insurance
plan before enrolling in this plan, you can receive credit for your prior coverage. See the Credit for Prior
Coverage section, below.
CREDIT FOR PRIOR COVERAGE
You can receive credit toward this plan's exclusion periods if you had qualifying healthcare coverage
before enrolling in this plan. To qualify for this credit, there may not have been more than a 63-day
gap between your last day of coverage under the previous health plan and your first day of coverage
(or the first day of your Plan Sponsor's probationary waiting period) under this plan.
Your prior coverage must have been a group health plan, COBRA or state continuation coverage,
individual health policy (including student plans), Medicare, Medicaid, TRICARE, State Children's
Health Insurance Program, and coverage through high risk pools and the Peace Corps. If you were
covered as a dependent under a plan that meets these qualifications, you will qualify for credit. Many
people elect the COBRA or state continuation coverage available under a prior plan to make sure they
won't have more than a 63-day gap in coverage.
It is your responsibility to show you had creditable coverage. If you qualify for credit, PacificSource
will count every day of coverage under your prior plan toward this plan's exclusion periods for pro-
existing conditions, other specified conditions, and transplants (explained above).
Evidence of Prior Creditable Coverage
You can show evidence of creditable coverage by sending PacificSource a Certificate of Creditable
Coverage from your previous health plan. All health plans, insurance companies, and HMOs are
required by law to provide these certificates on request. Most insurers issue these certificates
automatically whenever someone's coverage ends. The certificate shows how long you were covered
under your previous plan and when your coverage ended.
If you do not have a certificate of prior coverage, contact your previous insurance company or Plan
Sponsor (such as your former employer, if you had a group health plan). You have the right to request a
certificate from any prior plan, insurer, HMO, or other entity through which you had creditable coverage.
If you are unable to obtain a certificate, contact PacificSource's Membership Services Department for
assistance.
HEALTH CARE MANAGEMENT AND PREAUTHORIZATION
What is Health Care Management
Your Plan Sponsordesires to provide you and your family with a heath care benefit plan that financially
protects you from significant health care expenses and assures you quality care. While part of
increasing health care costs results from new technology and important medical advances, another
significant cause is the way health care services are used.
Some studies indicate that a high percentage of the cost for health care services may be unnecessary.
For example, hospital stays may be longer than necessary. Some hospitalizations may be entirely
avoidable, such as when surgery could be performed at an outpatient facility with equal quality and
safety. Also, surgery is sometimes performed when other treatment could be more effective. All of these
instances increase costs for you and the plan.
Your Plan Sponsor has contracted with PacificSource to assist you in determining whether or not
proposed services are appropriate for reimbursement under this plan. The program is not intended to
diagnose or treat medical conditions, dictate a treatment plan, guarantee benefits, or validate eligibility.
SingleSource Self-Insured 52
The medical professionals who conduct the program focus their review on the appropriateness for
reimbursement of hospital stays and proposed surgical procedures.
Required Admission Review - You are required to call PacificSource's toll-free number, (888) 977-
9299, prior to any elective inpatient stay or any scheduled surgical procedure. In most cases, your
medical provider will make the call for you. You must also call within 48 hours of any emergency
admission. When you or your provider call, it will be necessary to provide the program with your name,
the patient's name, the name of the physician or practitionerand hospital, the reason for the
hospitalization and any other information needed to complete the review. In some cases, you may be
asked for more information or a second opinion may be required to complete the review.
Preauthorization - Preauthorization is necessary to determine if certain services and supplies are
covered under this plan and if you meet the plan's eligibility requirements. PacificSource reviews new
technologies and standards of medical practice on an ongoing basis and therefore the list of
preauthorization requirements is subject to changes and updates. The current list of procedures and
services that require preauthorization under the plan can be found the PacificSource' website:
PacificSource.com.
The list of services that require preauthorization is not intended to suggest that all the items
included are necessarily covered by the benefits of this plan.
A request for preauthorization must be made to PacificSource as soon as the patient knows that he or
she will be receiving services for which preauthorization is required. Your medical provider can request
preauthorization from PacificSource by phone - (888) 977-9299, fax - (541) 684-5264, or mail:
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espahol (800) 624-6052, extension 1009
cs@ pacificsou rce. com
If your provider will not request preauthorization for you, you may contact PacificSource yourself. In
some cases, you may be asked for more information or be required to obtain a second opinion before a
benefit determination can be made.
If you are preauthorized for one facility, but are then transferred to another facility you will need to
obtain preauthorization for the new facility before transferring, except in the case of emergencies in
which case notification must be made as soon as possible after transferring facilities.
If your provider's preauthorization request is denied as not medically necessary or as experimental,
your provider may appeal the adverse benefit determination. You retain the right to appeal the adverse
benefit determination independent from your provider.
Note: A preauthorization determination is valid for 90 days. However, if your coverage under the plan
ends before the services are rendered or supplies received, the preauthorization determination will
become invalid.
Case Management
The primary objective of large case management is to identify and coordinate cost-effective medical
care alternatives and to help manage the care of patients who have special or extended care illnesses
or injuries. Large case management also monitors the care of the patient, offers emotional support to
the family, and coordinates communications among health care providers, patients and others.
Benefits may be modified by the Plan Sponsor to permit a method of treatment not expressly provided
for, but not prohibited by law, rules or public policy, if the Plan Sponsor determines that such
modification is medically necessary and is more cost-effective than continuing a benefit to which you or
your eligible dependents may otherwise be entitled. The Plan Sponsor also reserves the right to limit
payment for services to those amounts which would have been charged had the service been provided
in the most cost-effective setting in which the service could safely have been provided.
Examples of illnesses or injuries that may be appropriate for large case management include, but are not
limited to:
SingleSource Self-Insured 53
• Terminal illnesses (Cancer, AIDS, Multiple Sclerosis, Renal Failure, Obstructive Pulmonary
Disease, Cardiac conditions, etc.)
• Accident victims requiring long-term rehabilitative care
• Newborns with high-risk complications or multiple birth defects
• Diagnoses involving long-term IV therapy
• Illnesses not responding to medical care
• Child and adolescent mental/nervous disorders
• Organ transplants
individual BeneFts management
Individual benefits management addresses, as an alternative to providing covered services,
PacificSource's consideration of economically justified alternative benefits. The decision to allow
alternative benefits will be made by on a case-by-case basis. The determination to cover and pay for
alternative benefits for an individual shall not be deemed to waive, alter or affect the Plan Sponsors or
PacificSource's right to reject any other or subsequent request or recommendation. The Plan Sponsor
may provide alternative benefits if PacificSource and the individual's attending provider concur in the
request for and in the advisability of alternative benefits in lieu of specified covered services, and, in
addition, PacificSource concludes that substantial future expenditures for covered services for the
individual could be significantly diminished by providing such alternative benefits under the individual
benefit management program (See Case Management above).
HOW TO USE YOUR DENTAL PLAN
When you need dental care, you may visit any dentist. Most dental offices will bill PacificSource directly.
If your dentist has any questions regarding billing procedures, he or she can call PacificSource at (541)
225-1981, or (866) 373-7053 from outside the Eugene-Springfield area.
When you first visit your dentist after becoming covered under this plan, let the office staff know you
have dental benefits through PacificSource. You will need to show your PacificSource ID card, which
contains your group number and benefit information. Your dentist may submit claims and treatment
programs on a standard American Dental Association form.
For extensive dental work, PacificSource recommends that your dentist submit a pre-treatment
estimate to PacificSource. PacificSource then determines how much your plan will pay toward the
proposed treatment and review the estimate with your dentist prior to treatment. If your covered family
members require extensive dental work, be sure your member ID number and group number are
included on their pre-treatment form for identification purposes.
DENTAL PLAN BENEFITS
When this plan pays for dental services, it actually pays the stated percentage of charges based on
reasonable and customary charges. A charge is reasonable and customary when it falls within a
general range of charges being made by most dental providers in your service area for similar
treatment of similar dental conditions. If the charge for a treatment or service is more than the
reasonable and customary charge in your service area, you may be required to pay the difference. The
reasonable and customary charge for dental expense is the 'covered charge' referred to in this booklet.
If you or your covered family member selects a more expensive treatment than is customarily provided,
this plan will pay the applicable percentage of the lesser fee. You will be responsible for the balance of
the provider's charges.
With the Advantage Network, participating dentists agree to write off any charges over and above the
negotiated, contracted fees for most services. When you use a participating dentist in the Advantage
Network, you will not be responsible for any excess charges and will pay only your plan's deductible
and/or co-insurance amount. If you choose not to use a participating Advantage Network dentist, or
don't have access to them, reimbursement will continue to be based on usual, customary, and
reasonable (UCR) charges. If that non-participating dentist's fees exceed the UCR charges, the excess
charges are also your responsibility
SingleSource Self-Insured 54
COVERED DENTAL SERVICES
This dental plan covers the following services when performed by an eligible provider and when
determined to be necessary by the standards of generally accepted dental practice for the prevention or
treatment of oral disease or for accidental injury, including masticatory function. Covered services may
also be provided by a dental hygienist or denturist to the extent that he or she is operating within the
scope of his or her license as required under law in the State of Oregon.
Covered dental services are organized into three classes, starting with preventive care and advancing
into specialized dental procedures.
Class / Services - Diagnostic and Preventive Treatment
• Examinations (routine or other diagnostic exams) are covered. Separate charges for review of a
proposed treatment plan or for diagnostic aids such as study models and certain lab tests are not
covered.
• Full mouth x-rays and/or panorex are covered up to one complete mouth series and/or panorex
in any three-year period and limited to four bite-wing films in a six-month period. When an
accumulative charge for additional periapical x-rays in a one-year period matches that of a
complete mouth series, no further benefits for periapical x-rays or panorex are available for the
remainder of the year.
• Dental cleanings (prophylaxis and periodontal maintenance) are covered to a combined total
of three procedures per person per benefit year. The limitation for dental cleaning applies to any
combination of prophylaxis and/or periodontal maintenance in the benefit year. A separate charge
for periodontal charting is not a covered benefit. Periodontal maintenance is not covered when
performed within three months of periodontal scaling and root planing and/or curettage.
• Topical applications of fluoride are covered to two applications per benefit year through age 22.
• Fluoride varnish applications are covered to 12 applications per benefit year for children age 12
and under if the child is deemed at risk for dental infection.
• The application of sealants is covered to one application in a five-year period to permanent
molars and bicuspids and only for individuals through age 17.
• Vizilite is a covered up to two screenings per benefit year.
• Benefits for athletic mouth guards are limited to one per lifetime through age 17 if the member is
still in secondary school.
• Benefits for brush biopsies used to aid in the diagnosis of oral cancer are covered.
Class Restorative Services - Basic and Restorative Treatment
• Composite, resin, or similar restoration in a posterior (back) tooth is covered to the amount that
would be paid for a corresponding amalgam restoration. A separate charge for anesthesia when
used during restorative procedures is not a covered benefit. Only one filling is allowed per tooth
surface. The Plan Sponsorwill pay for a filling on a tooth surface only once per benefit year. Three
or more surface fillings are limited to one per surface per benefit year.
• Simple and surgical extractions of teeth and other minor oral surgery procedures are covered.
General anesthesia used in conjunction with these extractions administered by a dentist in a dental
office is also covered. A separate charge for alveolectomy performed in conjunction with removal of
teeth is not a covered benefit.
• Periodontal scaling and root planing and/or curettage is covered but limited to only one
procedure per quadrant in any 24-month period. For the purpose of this limitation, eight or fewer
teeth existing in one arch will be considered one quadrant.
• Benefits for full mouth debridement are limited to once every 24 months. This procedure is only
covered if the teeth have not received a prophylaxis in the prior 24 months and if an evaluation
cannot be performed due to the obstruction by plaque and calculus on the teeth. This procedure is
not covered if performed on the same date as the prophylaxis.
Class Complicated Services - Complicated Treatment
• Complicated oral surgical procedures such as removal of impacted teeth are covered when
SingleSource Self-Insured 55
preauthorized by PacificSource. Benefits for complicated oral surgical procedures include general
anesthesia administered by a dentist in a dental office. A separate charge for alveolectomy
performed in conjunction with removal of teeth is not a covered benefit.
• Pulp capping is covered only when there is an exposure to the pulp. These are direct pulp caps.
Indirect pulp caps are not covered.
• Pulpotomy is covered only for deciduous teeth.
• Root canal therapy is covered on the same tooth only for one charge in a three-year period.
• Periodontal surgery is covered when the procedure is preauthorized by PacificSource and
accompanied by a periodontal diagnosis and history of conservative (non-surgical) periodontal
treatment.
• Tooth desensitization is covered as a separate procedure from other dental treatment.
• Space maintainers area covered benefit for individuals through the age of 13.
Class Services - Major Treatment
• Crowns and other cast or laboratory-processed restorations are covered but limited to the
restoration of any one tooth in a five-year period. If a tooth can be restored with a material such as
amalgam or composite resin, covered charges are limited to the cost of amalgam or non-laboratory
composite resin restoration even if another type of restoration is selected by the patient and/or
dentist.
• Replacement of an existing prosthetic device is covered only when the device being replaced is
unserviceable, cannot be made serviceable, and has been in place for at least five years.
• Cast partial denture, full, immediate, or overdenture are covered only to the cost of a standard
full or cast partial denture. A separate charge for denture adjustments and relines performed within
six months of the initial placement is not a covered benefit. Benefits for subsequent relines are
provided only once in a 12-month period. Cast restorations for partial denture abutment teeth or for
splinting purposes are not covered unless the tooth in and of itself requires a cast restoration.
• Fixed bridges or removable cast partials are covered. Benefits for temporary full or partial
dentures must be preauthorized. Benefits for the initial placement of full or partial dentures or fixed
bridges (including acid-etch metal bridges) are provided only if the denture or bridgework includes
replacement of a natural tooth which is extracted or lost while the member's coverage is in effect.
However, this limitation does not apply after the member has been covered under the policyholder's
group dental plan for a period of at least 36 consecutive months.
• Benefits for the surgical placement and removal of implants are limited to once per lifetime per
tooth space for each service. Services must be preauthorized by PacificSource to be covered.
Benefits include final crown and implant abutment over a single implant and final implant-supported
bridge abutment and implant abutment or pontic. An alternative benefit per arch of a conventional
full or partial denture for the final implant-supported full or partial denture prosthetic device is
available.
• Bruxism splint and nightguard (appliances to reduce or prevent pain or damage from grinding of
teeth) are covered.
ORTHODONTIA BENEFITS
This plan pays 50% of the usual, customary, and reasonable for orthodontics for all covered individuals.
The lifetime maximum amount payable for orthodontic benefits is $1,000 per person.
EXCLUDED DENTAL SERVICES
This plan does not provide benefits in any of the following circumstances or for any of the following
conditions:
• Aesthetic dental procedures - Services and supplies provided in connection with dental
procedures that are primarily aesthetic, including bleaching of teeth and labial veneers.
• Antimicrobial agents - Localized delivery of antimicrobial agents into diseased crevicular tissue
via a controlled release vehicle.
SingleSource Self-Insured 56
• Benefits not stated - Any services and supplies not specifically described as covered benefits
under this plan
• Biopsies or histopathologic exams -A separate charge for a biopsy of oral tissue or
histopathologic exam.
• Bone replacement grafts to prepare sockets for implants after tooth extraction.
• Charges for broken appointments
• Collection of cultures and specimens.
• Connector bar or stress breaker.
• Core build-ups are not covered unless used to restore a tooth that has been treated
endodontically (root canal).
• Cosmeticireconstructive services and supplies - Procedures, appliances, restorations, or other
services that are primarily for cosmetic purposes. This includes services or supplies rendered
primarily to correct congenital or developmental malformations, including but not limited to, peg
laterals, cleft palate, maxillary and mandibular (upper and lower jaw) malformation, enamel
hypoplasia, and fluorosis (discoloration of teeth). However, the replacement of congenitally missing
teeth is covered.
• Denture replacement made by necessary by loss, theft, or breakage.
• Diagnostic casts - Diagnostic casts (study models), gnathological recordings, occlusal
appliances, occlusal equilibration procedures, or similar procedures.
• Drugs and medications that are prescribed drugs, premedication drugs, analgesics (e.g., nitrous
oxide or non-intravenous sedation), any other euphoric drugs, or any take-home medicine or
supplies distributed by a provider.
• Educational programs - Instructions and/or training in plaque control and oral hygiene.
• Experimental or investigational procedures - Services, supplies, protocols, procedures,
devices, drugs or medicines, or the use thereof that are experimental or investigational for the
diagnosis and treatment of the patient. An experimental or investigational service is not made
eligible for benefits by the fact that other treatment is considered by the member's dental care
provider to be ineffective or not as effective as the service or that the service is prescribed as the
most likely to prolong life.
• Fractures of the mandible - Services and supplies provided in connection with the treatment of
simple or compound fractures of the mandible.
• General anesthesia except when administered by a dentist in connection with oral surgery in
his/her office
• Gingivetomcy, gingivoplasty or crown lengthening in conjunction with crown preparation or
fixed bridge services done on the same date of service.
• Hospital charges or additional fees charged by the dentist for hospital treatment
• Hypnosis
• Infection control -A separate charge for infection control or sterilization
• Intra and extra coronal splinting - Devices and procedures for intra and extra coronal splinting to
stabilize mobile teeth.
• Oral Surgery treating any fractured jaw
• Orthodontic services - Treatment of malalignment of teeth and/or jaws, or any ancillary services
expressly performed because of orthodontic treatment, unless your Dental Benefit Summary shows
orthodontic services as a covered benefit.
• Orthognathic surgery - Surgery to manipulate facial bones, including the jaw, in patients with
facial bone abnormalities performed to restore the proper anatomic and functional relationship to
the facial bones
• Periodontal probing, charting, and re-evaluations
• Photographic images.
SingleSource Self-Insured 57
• Pin retention in addition to restoration.
• Precision attachments
• Pulpotomies on permanent teeth
• Removal of clinically serviceable amalgam restorations to be replaced by other materials free
of mercury, except with proof of allergy to mercury.
• Services covered by the member's medical plan.
• Services for rebuilding or maintaining chewing surfaces due to teeth out of alignment or
occlusion, or for stabilizing the teeth.
• Services otherwise available - These include but are not limited to:
- Services or supplies for which payment could be obtained in whole or in part if the member
applied for payment under any city, county, state, or federal law (except Medicaid), and
- Services or supplies the member could have received in a hospital or program operated by a
federal government agency or authority. Covered expenses for services or supplies furnished
to a member by the Veterans' Administration of the United States that are not service-related
are eligible for payment according to the terms of this policy.
- Services or supplies for which payment would be made by Medicare.
• Services or supplies for which no charge is made which you are not legally required to pay or
which a provider or facility is not licensed to provide even though the service or supply may
otherwise be eligible. This includes services provided by you or an immediate family member.
• Sinus lift grafts to prepare sinus site for implants.
• Temporomandibular joint (TMJ) - Any services or supplies for treatment of any disturbance of
the Temporomandibular joint.
• Third party liability, motor vehicle liability, motor vehicle insurance coverage, workers'
compensation - Any services or supplies for illness or injury for which a third party is responsible
or which are payable by such third party or which are payable pursuant to applicable workers'
compensation laws, motor vehicle liability, uninsured motorist, underinsured motorist, and personal
injury protection insurance and any other liability and voluntary medical or dental payment
insurance to the extent of any recovery received from or on behalf of such sources.
• Tooth transplantation - Services and supplies provided in connection with tooth transplantation,
including re-implantation from one site to another and splinting and/or stabilization. This exclusion
does not relate to the re-implantation of a tooth into its original socket after it has been avulsed.
• Treatment after insurance ends - Services or supplies provided after enrollment in this plan
ends. The only exception is for Class III Services ordered and fitted before enrollment ends and
placed within 31 days after enrollment ends.
• Treatment not dentally necessary according to acceptable dental practice or treatment not likely
to have a reasonably favorable prognosis.
• Treatment prior to enrollment - Dental services begun before you or your family member
became eligible for those services under this plan.
• Treatment while incarcerated - Services or supplies received while in the custody of any state or
federal law enforcement authorities or while in jail or prison.
• Unwilling to release information - Charges for services or supplies for which you are unwilling to
release medical or dental information necessary to determine eligibility for payment under this
policy
• War-related conditions - The treatment of any condition caused by or arising out of an act of war,
armed invasion, or aggression, or while in the service of the armed forces.
• Work-related conditions - Services or supplies for treatment of illness or injury arising out of or in
the course of employment or self-employment for wages or profit, whether or not the expense for
the service or supply is paid under workers' compensation.
SingleSource Self-Insured 58
CLAIMS PROCEDURES
Now to File/How to Appeal a Claim
These claim procedures describe how benefit claims and appeals are made and decided under this
plan.
Only members or a designated authorized representative may submit claims for benefits (for
themselves and on behalf of their covered dependents), and benefits will only be paid to the member or
the actual provider of services. Under the following claims procedures section, the words 'you' and
'your' will mean a member of the group health plan of the Plan Sponsor. You become a claimant when
you make a request for a plan benefit or benefits in accordance with these claims procedures.
You and your covered dependents have the right to elect group health care benefits as offered by the
Plan Sponsor, and your and their rights will be determined under the plan's provisions and in
conjunction with the claims and appeals procedures outlined later in this section. Claims will also be
considered filed by you if communications and requests for benefits come from an individual that you
have designated as your authorized representative to act on your behalf with respect to a claim. In the
event that you designate an authorized representative to act on your behalf, the plan will send all
notifications, requests for further information, appeal decisions, and all other communications to your
authorized representative and provide you with a copy of all communications, unless you request
otherwise in writing.
An authorized representative may act on behalf of a claimant with respect to benefit claim or appeal
under these procedures. However, no person (including a treating health care professional) will be
recognized as an authorized representative until the plan receives an Designation of Authorized
Representative form signed by the claimant, except that for urgent care claims the plan shall, even in
the absence of a signed Designation of Authorized Representative form, recognize a health care
professional with knowledge of the claimant's medical condition (e.g., the treating physician or
practitioner) as the claimant's authorized representative unless the claimant provides specific written
direction otherwise.
A Designation of Authorized Representative form may be obtained from and completed forms must be
returned to:
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espanol (800) 624-6052, extension 1009
cs@pacificsource.com
An assignment for purposes of payment (e.g., to a health professional) does not constitute appointment
of an authorized representative under these claims procedures. However, unless you have directed the
plan otherwise, claims submitted on your behalf by a health care professional will be considered a valid
claim if submitted pursuant to the guidelines outlined in these claim procedures.
Any reference in these claims procedures to the claimant is intended to include the authorized
representative of such claimant appointed in compliance with the above procedures.
For the purposes of the claims procedures section, any reference to 'days' will refer to calendar days,
not business days.
Questions about Your Claims
PacificSource is available to listen and help with any concerns or problems you may have with resolving
a claim. Because PacificSource wants you to be completely satisfied with the member services
assistance you receive, a process has been established for addressing your concerns and solving your
problems. If you have a concern regarding a person, a service, the quality of care, or you want to
inquire about what benefits are covered under the plan, please call PacificSource at (888) 977-9299
and explain your concern to one of their Customer Service Representatives. You may also express that
concern in writing. PacificSource will do their best to resolve the matter on your initial contact. If
PacificSource needs more time to review or investigate your concern, they will get back to you as soon
SingleSource Self-Insured 59
as possible, but in any case within 30 days. They will not consider any of these communications to be a
'claim' for benefits. A formal claim for benefits must meet certain other standards which are described in
greater detail in these procedures.
Types of Claims
Pre-Service Claims - The plan subjects the receipt of benefits for some services or supplies to a
preauthorization review. Although a preauthorization review is generally done on a pre-service basis, it
may in some cases be conducted on a post-service basis. Unless a response is needed sooner due to
the urgency of the situation, a pre-service preauthorization review will be completed and notification
made to you and your medical provider as soon as possible, generally within two working days, but no
later than 15 days within receipt of the request.
Urgent Care Claims - If the time period for making a non-urgent care determination could seriously
jeopardize your life, health or ability to regain maximum function, or would subject you to severe pain
that cannot be adequately managed without the care or treatment that is proposed, a preauthorization
review will be completed as soon as possible, generally within 24 hours, but no later than 72 hours
within receipt of the request.
Concurrent Care Review - A concurrent care decision occurs when a previously approved course of
treatment is reconsidered and reduced or denied, or where an extension is requested beyond the
initially approved period of time or number of treatments. Inpatient hospital or rehabilitative facilities,
skilled nursing facilities, intensive outpatient, and residential behavioral health care require concurrent
review for a benefit determination with regard to an appropriate length of stay or duration of service.
Benefit determinations will be made as soon as possible within receipt of all the information necessary
to make such a determination.
Post-Service Claims -A claim determination that involves only the potential payment of
reimbursement of the cost of medical care that has already been provided will be made as soon as
reasonably possible but no later than 30 days from the day after receiving the claim.
How to File a Claim
Most health care providers will file claims on your behalf. Electronically submitted claims are processed
most efficiently. If unable to file electronically, you, your health care provider, or an authorized
representative must file your claim using HCFA-1500 (revision 12/90 and later), UB92, or ADA (revision
12/90 and later) forms, or an itemized statement. These forms are available from your health care
provider or PacificSource.
A claim will be considered filed when it is received by PacificSource at the address listed below:
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espanol (800) 624-6052, extension 1009
cs@pacificsource.com
The following information is required in order qualify your request for benefits as a properly submitted
claim:
• Plan member's name, member ID and current address;
• Patient's name, member ID and address if different from the member's;
• Provider's name, tax identification number, address, degree and signature;
Date(s) of service(s);
• Place of service(s);
• Diagnostic Code;
• Procedure Codes (describes the treatment or services rendered);
• Assignment of Benefits, signed (if payment is to be made to the provider);
• Release of Information Statement, signed; and
SingleSource Self-Insured 60
Explanation of Benefits (EOB) information if another plan is the primary payer.
This plan also recognizes the following actions and submission of forms as claims:
• A request by you for benefits through preauthorization in cases where use of preauthorization is
required in order to obtain a particular benefit.
• Requests by your formally-designated authorized representative for preauthorization in cases
where use of preauthorization is required in order to obtain a particular benefit. The plan will take
reasonable steps to determine whether an individual claiming to be acting on your behalf is, in fact,
validly empowered to do so under the circumstances, and the plan will require that you complete
and file a form identifying any person you authorize to act on your behalf with respect to a claim.
However, when inquiries by a health care provider relate to payments due to the provider-rather
than due to you-under participating provider contracts (where the health care provider has no
recourse against you for the amounts) such inquiries by a health care provider will not be
considered 'claims' by the plan.
• Requests for benefits (in the case of a claim involving urgent care) by a health care provider with
knowledge of your medical condition. For urgent care claims, you are not required to complete a
form and formally designate a health care provider as your representative with respect to a claim.
Claims must be submitted individually for each claimant. Please do not staple claims together. Send
completed information to:
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espanol (800) 624-6052, extension 1009
cs@ pacificSource. com
If you have any questions regarding your eligibility, benefits or claims information, please call
PacificSource at: (888) 977-9299.
All claims for benefits must be submitted to the plan within 90 days of the date of service. If it is not
possible to submit a claim within 90 days, you should submit the claim as soon as possible. In some
cases the plan will accept the late claim. The plan, however, will not pay a claim that was submitted
more than one year after the date of service.
All submitted claims and appeals will fall into one of the categories described previously. The handling
of your initial claim or later appeal will be governed, in all respects, by the appropriate category of claim
or appeal, and each time your claim or appeal is examined, a new determination will be made regarding
the category into which the claim or appeal falls at that particular time.
Pre-service claims - Your plan subjects the receipt of benefits for some services or supplies to a
preauthorization review. Although a preauthorization review is generally done on a pre-service basis, it
may in some case be conducted on a post-service basis. Unless a response is needed sooner due to
the urgency of the situation, a pre-service preauthorization review will be completed and notification
made to you and your medical provider as soon as possible, generally within two working days, but no
later than 15 days within receipt of the request.
Urgent care claims - If the time period for making a non-urgent care determination could seriously
jeopardize your life, health or ability to regain maximum function, or would subject you to severe pain
that cannot be adequately managed without the care or treatment that is proposed, a preauthorization
review will be completed as soon as possible, generally within 24 hours, but no later than 72 hours of
receipt of the request.
Concurrent care review - Inpatient hospital or rehabilitation facilities, skilled nursing facilities,
intensive outpatient, and residential behavioral healthcare require concurrent review for a benefit
determination with regard to an appropriate length of stay or duration of service. Benefit determinations
will be made as soon as possible but no later than one working day after receipt of all the information
necessary to make such a determination.
Post-service claims -A claim determination that involves only the payment of reimbursement of the
cost of medical care that has already been provided will be made as soon as reasonably possible but
no later than 30 days from the day after receiving the claim.
SingleSource Self-Insured 61
Retrospective review - A claim for benefits for which the service or supply requires a preauthorization
review but was not submitted for review on a pre-service basis will be reviewed on a retrospective basis
within 30 working days after receipt of the information necessary to make a claim determination.
Extension of time - Despite the specified timeframes, nothing prevents the member from voluntarily
agreeing to extend the above timeframes. Unless additional information is needed to process your
claim, PacificSource will make every effort to meet the timeframes stated above. If a claim cannot be
paid within the stated timeframes because additional information is needed, PacificSource will
acknowledge receipt of the claim and explain why payment is delayed. If PacificSource does not
receive the necessary information within 15 days of the delay notice, PacificSource will either deny the
claim or notify you every 45 days while the claim remains under investigation. No extension is permitted
for urgent care claims.
Extension of time - Unless additional information is needed to process your claim, the plan will make
every effort to meet the timeframes stated above. If a claim cannot be paid within the stated timeframes
because additional information is needed, PacificSource will acknowledge receipt of the claim and
explain why payment is delayed. If they do not receive the necessary information within 15 days of the
delay notice, they will either deny the claim or notify you every 45 days while the claim remains under
investigation.
Adverse benefit determinations -Any denial, reduction or termination of, or failure to provide or
make a payment for a benefit based on:
• A determination that the member is not eligible to participate in the plan.
• A determination that the benefit is not covered by the plan.
• The imposing of limits, such as preexisting condition or source-of-injury exclusions.
• A determination that the benefit is experimental, investigational or not medically necessary or
medically appropriate.
An adverse benefit determination made to reduce or deny benefits applied for a pre-service, post-
service, or concurrent care basis may be appealed in accordance with the plan's appeals procedures
described later in this section.
Incomplete Claims
If any information needed to process a claim is missing, the claim shall be treated as an incomplete
claim.
Other Incomplete Claims - If a pre-service or post-service claim is incomplete, the plan may deny the
claim or may take an extension of time, as described above. If the plan takes an extension of time, the
extension notice shall include a description of the missing information and shall specify a timeframe, no
less than 45 days, in which the necessary information must be provided. The timeframe for deciding the
claim shall be suspended from the date the extension notice is received by the claimant until the date
the missing necessary information is provided to the plan. If the requested information is provided, the
plan shall decide the claim within the extension period specified in the extension notice. If the requested
information is not provided within the time specified, the claim may be decided without that information.
If you fail to follow the plan's filing procedures because your request for benefits does not: 1) identify
the patient; 2) note a specific medical condition or symptom; 3) describe a specific treatment, service,
or product for which approval is requested; or 4) is not sent to the correct address, you will not have
submitted a claim. You will be notified orally, and/or by written notification if requested by the claimant,
within 24 hours, that you have failed to follow the filing procedures, and you will be reminded of the
proper filing procedures.
Notification of Benefit Determination
The plan will pay the benefit according to plan provisions. This may mean that less than 100% of your
claim is payable by the plan. In each case where the plan pays benefits or determines that it is not
responsible for your medical claim, you will receive an Explanation of Benefits which will outline the
basis for the plan's payment. If your claim is denied or payable at a level less than outlined in this
Summary Plan Description, you are entitled to appeal the decision under the rules governing adverse
benefit determination.
SingleSource Self-Insured 62
Adverse Benefit Determination
• Written notification will be provided to you of the plan's adverse benefit determination (as defined in
the How To File A Claim section above) and will include the following:
• Information sufficient to identify the claim involved, including the date of service, the health care
provider, and the claim amount (if applicable), as well as how to obtain the diagnosis code, the
treatment code, and the corresponding meanings of these codes.
• A statement of the specific reason(s) for the decision;
• Reference(s) to the specific plan provision(s) on which the determination is based;
• A description of any additional material or information necessary to perfect the claim and why such
information is necessary;
• A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making
the adverse determination or a statement that such information will be provided free of charge upon
request;
• If the determination involves scientific or clinical judgment, disclose either (a) an explanation of the
scientific or clinical judgment applying the terms of the plan to the claimant's medical
circumstances, or (b) a statement that such explanation will be provided at no charge upon request;
• In the case of an urgent care claim, an explanation of the expedited review methods available for
such claims; and
• A statement regarding the availability of, and contact information for, any applicable office of health
insurance consumer assistance or ombudsman.
Notification of the plan's adverse benefit determination on an urgent care claim may be provided orally,
but written notification shall be furnished not later than three days after the oral notice.
You may call the Third Party Administrator at (888) 977-9299 to discuss the adverse benefit
determination if you have concerns. You may also express those concerns in writing and if needed,
may submit additional information that you believe would clarify any of the circumstances that lead to
the adverse benefit determination. Third Party Administrator will not consider any of these questions or
clarifications to be a formal appeal unless you specifically state it as such. The process for filing a
formal appeal is listed below.
Your Right to Appeal
You have the right to appeal an adverse benefit determination under these claims procedures. If you
choose to appeal the plan's adverse benefit determination, your appeal will be governed by rules that
assure you a full and fair review.
If you are denied benefits based upon the plan's finding that you are/were ineligible for benefits, the
denial of benefits gives you the opportunity to appeal the plan's decision.
If the plan decides to reduce or terminate benefits for your previously-approved course of treatment, the
plan's decision will be treated as an adverse benefit determination, and the plan will provide you
reasonable advance notice of the reduction or termination to allow you to appeal the plan's decision
before the benefit reduction or termination takes place. If you decide to appeal the plan's decision, you
must follow the rules for appealing a plan's decision.
No lawsuit can be instituted until the claimant has exhausted the plan's internal and external claims
review and appeals procedures. No lawsuit can be instituted more than one year after the date of the
notice to the claimant that a claim appeal has been denied.
Appealing an Initial Claim Determination - You must submit a written request to the plan within 180
days of receipt of an adverse benefit determination in order to initiate an appeal. An oral request for
review is acceptable for urgent care claims and may be made by calling the Third Party Administrator at
(888) 977-9299 and asking the plan to register your oral appeal.
SingleSource Self-Insured 63
When you appeal an adverse benefit determination, the plan will provide a full and fair review which will
include the following features:
• You will have the opportunity to submit written comments, documents, records, and other
information related to the claim.
• At your request (and free of charge), you will be provided with reasonable access to (and copies of)
all documents, records, and other information relevant to your claim for benefits. Included in this
category are any documents, records or other information in your claim file, whether or not those
materials were relied upon by the plan in making its adverse benefit determination. You also have
the right to review documentation showing that the plan followed its own internal processes for
ensuring appropriate decision making.
• The review of your claim will take into account all comments, documents and other information
without regard to whether such information was submitted or considered in the initial benefit
determination.
• Any appeal of an adverse benefit determination will not give deference to the initial decision on your
claim, and the review will be conducted by a designated plan representative who did not make the
original determination and does not report to the plan representative who made the original
determination.
• In deciding an appeal of any adverse benefit determination that is based on a medical judgment
(including determinations with regard to whether a particular treatment, drug, or other item is
experimental, investigational, or not medically necessary or medically appropriate), the designated
plan representative will consult with a health care professional who has appropriate training and
experience in the particular field of medicine involved in the medical judgment. This health care
professional will not be the same professional who was originally consulted in connection with the
adverse determination; neither will this health care professional report to the health care
professional who was consulted in connection with the adverse determination. The plan will uphold
the findings of the independent review in responding to the appeal.
• The plan will identify medical or vocational experts whose advice was obtained on behalf of the
plan in connection with an adverse benefit determination of your claim, whether or not that advice
was relied upon in making the benefit determination.
You must first follow this appeal process before taking any outside legal action. After you submit the
claim for appeal, the plan will make a decision on your appeal as follows:
Appeal of Urgent Care Claims - The plan's expedited appeal process for urgent care claims will allow
you to request (orally or in writing) an expedited appeal, after which, all necessary information, including
the plan's benefit determination on review, will be transmitted between the plan and you by telephone,
fax, or other expeditious method. You will be notified (in writing or electronically) of the benefit
determination as soon as possible, but not later than 72 hours after the plan receives the request for
review of the prior benefit determination. For urgent care claims you may also be able to request an
independent external review take place at the same time as you pursue the plan's internal appeal
process.
Appeal of Non-Urgent Pre-Service Claims - For non-urgent pre-service claims, you will be notified (in
writing or electronically) of the benefit determination within a reasonable period of time appropriate to
the medical circumstances, but not later than 30 days.
Appeal of Concurrent Care Claims - For concurrent care claims, you will be notified (in writing or
electronically) of the benefit determination with reasonable advance notice before the benefit reduction
or termination takes place.
Appeal of Post-Service Claims - For post-service claims, you will be notified (in writing or
electronically) of the benefit determination within a reasonable period of time, but not later than 60 days.
Denial of Claim on Appeal - If your appealed claim is denied, the plan will send you written or
electronic notification that explains why your appealed claim was denied and shall include the following:
• A statement of the specific reason(s) for the decision;
• Reference(s) to the specific plan provision(s) on which the determination is based;
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• A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making
the adverse determination or a statement that such information will be provided free of charge upon
request;
• If the determination involves scientific or clinical judgment, the plan will disclose either (a) an
explanation of the scientific or clinical judgment applying the terms of the plan to the claimant's
medical circumstances, or (b) a statement that such explanation will be provided at no charge upon
request; and
• A statement indicating your right to receive, upon request (and free of charge), reasonable access
to (and copies of) all documents, records, and other information relevant to the determination.
Included in this category are any documents, records or other information in your claim file, whether
or not those materials were relied upon by the plan in making its adverse determination.
Additional Level of Review - If you are dissatisfied with the outcome of your appeal, you may request
an additional review. To initiate this review you should follow the same process required for an appeal.
You must submit a written request for additional review within 60 days following the receipt of the
appeal decision.
When you submit a request for additional review of an adverse benefit determination, the plan will
provide a full and fair review which will include the following features:
• You will have the opportunity to submit written comments, documents, records, and other
information related to the claim.
• At your request (and free of charge), you will be provided with reasonable access to (and copies of)
all documents, records, and other information relevant to your claim for benefits. Included in this
category are any documents, records or other information in your claim file, whether or not those
materials were relied upon by the plan in making its adverse benefit determination. You also have
the right to review documentation showing that the plan followed its own internal processes for
ensuring appropriate decision making.
• The review of your claim will take into account all comments, documents and other information
without regard to whether such information was submitted or considered in the initial adverse
benefit determination.
• Additional review will not afford deference to the appeal determination, and the review will be
conducted by a designated plan representative who did not make the original determination and
does not report to the plan representative who made the original determination.
• In deciding an appeal of any adverse benefit determination that is based on a medical judgment
(including determinations with regard to whether a particular treatment, drug, or other item is
experimental, investigational, or not medically necessary or medically appropriate), the designated
plan representative will consult with a health care professional who has appropriate training and
experience in the particular field of medicine involved in the medical judgment. This health care
professional will not be the same professional who was originally consulted in connection with the
adverse determination; neither will this health care professional report to the health care
professional who was consulted in connection with the adverse determination. The plan will uphold
the findings of the independent review in responding to the appeal.
• The plan will identify medical or vocational experts whose advice was obtained on behalf of the
plan in connection with an adverse benefit determination of your claim, whether or not that advice
was relied upon in making the benefit determination.
After you submit the claim for additional review, the plan will make a decision on your appeal as follows:
Additional Review of Urgent Care Claims - The plan's expedited additional review process for urgent
care claims will allow you to request (orally or in writing) an expedited review, after which, all necessary
information, including the plan's benefit determination on review, will be transmitted between the plan
and you by telephone, fax, or other expeditious method. You will be notified (in writing or electronically)
of the benefit determination as soon as possible, but not later than 72 hours after the plan receives the
request for the review.
Additional Review of Non-Urgent Pre-Service Claims - For non-urgent pre-service claims, you will
be notified (in writing or electronically) of the review outcome within a reasonable period of time
appropriate to the medical circumstances, but not later than 30 days.
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Additional Review of Concurrent Care Claims - For concurrent care claims, you will be notified (in
writing or electronically) of the review outcome with reasonable advance notice before the benefit
reduction or termination takes place.
Additional Review of Post-Service Claims - For post-service claims, you will be notified (in writing or
electronically) of the review outcome within a reasonable period of time, but not later than 60 days.
Denial of Claim after Additional Review - If after your request for additional review the claim is
denied, the plan will send you written or electronic notification that explains why the additional review
upheld the denial and shall include the following:
• A statement of the specific reason(s) for the decision;
• Reference(s) to the specific plan provision(s) on which the determination is based;
• A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making
the adverse determination or a statement that such information will be provided free of charge upon
request;
• If the determination involves scientific or clinical judgment, the plan will disclose either (a) an
explanation of the scientific or clinical judgment applying the terms of the plan to the claimant's
medical circumstances, or (b) a statement that such explanation will be provided at no charge upon
request; and
• A statement indicating your right to receive, upon request (and free of charge), reasonable access
to (and copies of) all documents, records, and other information relevant to the determination.
Included in this category are any documents, records or other information in your claim file, whether
or not those materials were relied upon by the plan in making its adverse determination.
Independent External Review - You may have the right to have your case reviewed by an external
independent review organization. Only decisions that are based on issues related to medical necessity,
medical appropriateness, health care setting, level of care, or effectiveness of a covered benefit may be
appealed to an external independent review organization. The plan must contract with at least three
different independent external review organizations and must rotate between them on a random or
circulating basis.
Your request for an independent review must be made in writing to PacificSource within 180 days of the
date of the final internal adverse benefit determination. You may include additional written information,
which will be included with the documents PacificSource provides to the independent review
organization.
A final decision made by an independent review organization is binding on the Plan Sponsor. This
decision is also binding on you, except to the extent other remedies are available under state or federal
law.
In certain instances you may be able to request an expedited review process, such as when the
timeframe for completion of the internal appeals process would seriously jeopardize the life or health of
the claimant or their ability to regain maximum function, or if the final adverse benefit determination
concerns an admission, availability of care, continued stay or health care service for which the claimant
received emergency services, but has not been discharged from a facility.
Resources For Information And Assistance
Assistance in Other Languages
Members who do not speak English may contact PacificSource's Customer Service Department for
assistance. They can usually arrange for a multilingual staff member or interpreter to speak with them in
their native language.
Information Available from PacificSource
PacificSource makes the following written information available to you free of charge. You may contact
their Customer Service Department by phone, mail, or email to request any of the following:
• A directory of participating healthcare providers under your plan
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• Information about PacificSource's drug formulary
• A copy of PacificSource's annual report on complaints and appeals
• A description (consistent with risk-sharing information required by the Centers for Medicare and
Medicaid Services, formerly known as Health Care Financing Administration) of any risk-sharing
arrangements PacificSource has with providers
• A description of PacificSource's efforts to monitor and improve the quality of health services
• Information about how PacificSource checks the credentials of PacificSource's network providers
and how you can obtain the names and qualifications of your healthcare providers
• Information about PacificSource's preauthorization procedures
• Information about any healthcare plan offered by the Plan Sponsor
Information Available from the Oregon Insurance Division
The following consumer information is available from the Oregon Insurance Division:
• The results of all publicly available accreditation surveys
• A summary of PacificSource's health promotion and disease prevention activities
• Samples of the written summaries delivered to PacificSource policyholders
• An annual summary of grievances and appeals against PacificSource
• An annual summary of PacificSource's quality assessment activities
• An annual summary of the scope of PacificSource's provider network and accessibility of
healthcare services
You can request this information by contacting the Oregon Insurance Division by writing to the Oregon
Insurance Division, Consumer Advocacy Unit, PO Box 14489, Salem, OR 97309-0405 or by phone at
(503) 947-7984, or the toll-free message line at (888) 877-4894, on the Internet at
hfp://insurance.oregon.gov/consumer/consumer.htmi, or by email at cp.ins@state.or.us.
Plan Sponsor's Discretionary Authority; Standard of Review
The Plan Sponsor is the sole fiduciary of the plan, and exercises all discretionary authority and control
over the administration of the plan and the management and disposition of plan assets. Benefits under
the plan will be paid only if the Plan Sponsor decides, in its discretion, that the member or beneficiary is
entitled to such benefits. Any construction of the terms of any plan document and any determination of
fact adopted by the Plan Sponsor shall be final and legally binding on the parties. A court of law or
arbitrator reviewing any fiduciary's decision, including one relating the plan interpretation or a benefit
claim, must consider only the documents, testimony and other evidence that were presented to the
fiduciary at the time the fiduciary made the decision. In addition, the court or arbitrator must use the
'arbitrary and capricious' standard of review. That is, the fiduciary's determination can be reversed only
if it was made in bad faith, is not supported by substantial evidence or is erroneous as to a question of
law.
The Plan Sponsor may hire someone to perform claims processing and other specified services in
relation to the plan. Any such contractor will not be a fiduciary of the plan and will not exercise any of
the discretionary authority and responsibility granted to the Plan Sponsor, as described above.
Coordination of Benefits
Coordinating with Other Group Health Plans - When benefits are coordinated, one plan pays,
benefits first (the 'primary coverage') and the other, plan pays benefits second (the 'secondary
coverage').
When you and/or your dependents are covered under more than one group health plan, the combined
benefits payable by this plan and all other group plans will not exceed 100% of the eligible expense
incurred by the individual. The plan assuming primary payer status will determine benefits first without
regard to benefits provided under any other group health plan.
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Note: If your primary and secondary coverage both include a deductible, you will be required to satisfy
each of those deductibles before benefits will be paid.
There are two types of Coordination of Benefits -'True' Coordination of Benefits and Non-Duplicating
Coordination of Benefits (also called Integration of Benefits.) See the Medical Benefit Summary to
determine if your plan offers True Coordination of Benefits or Non-Duplicating/Integration of Benefits.
For True Coordination of Benefits, the primary plan will pay benefits first, subject to any deductibles,
copayments and coinsurance. The remaining balance will be passed on to the secondary payer. When
this plan is the secondary payer, the balance of eligible expenses will be applied as if it was a new
claim under this plan. Deductibles, copayments and coinsurance relevant to this plan will be subtracted
from the amount before paying the remainder.
For Non-Duplicating Coordination of Benefits/Integration of Benefits, the primary plan will pay
benefits first, subject to any deductibles, copayments and coinsurance. The remaining balance will be
passed on to the secondary payer. When this plan is the secondary payer, it will reimburse the balance
of remaining eligible expenses, not to exceed normal plan liability if this plan had been primary. This
means that if the primary payer has already paid as much as or more than this plan would have paid
had this plan been primary, there will be no additional payment made.
Government Programs and Other Group Health Plans -The term group health plan, as it relates to
coordination of benefits, includes the government programs Medicare, Medicaid and TriCare. The
regulations governing these programs take precedence over the determination of benefits under this
plan. For example, in determining the benefits payable under the plan, the plan will not take into
account the fact that you or any eligible dependent(s) are eligible for or receive benefits under a
Medicaid plan.
The term group health plan also includes all group insurance and group subscriber contracts, such as
union welfare plans.
Order of Payment When Coordinating with Other Group Health Plans
• If the other plan does not include 'coordination of benefits,' that plan is primary and this plan is
secondary.
If you are covered as an employee on one plan and a dependent on another, your Plan Sponsor's
plan is primary.
When a child is covered under both parents' policies and the parents are either married or are living
together (regardless of whether or not they have ever been married):
- The parent whose birthday falls first in a benefit year has the primary plan; or
- If both parents have the same birthday, the parent who has been covered the longest has the
primary plan.
When a child is covered under both parents' plans and the parents are divorced, separated, or not
living together (regardless of whether or not they have ever been married):
- If a court order specifies that one parent is responsible for the child's healthcare expenses,
the mandated parent's coverage is primary regardless of custody.
- If a court order specifies that both parents are responsible for the child's healthcare
expenses, the parent whose birthday falls first in a benefit year has the primary plan. If both
parents have the same birthday, the parent who has been covered the longest has the
primary plan.
- i' If a court order specifies that both parents have joint custody without specifying that one
parent has responsibility for the child's healthcare expenses, the parent whose birthday falls
first in a benefit year has the primary plan. If both parents have the same birthday, the parent
who has been covered the longest has the primary plan.
- If there is no court order, the order of benefits for the child are as follows:
o The custodial parent's coverage is primary;
o The spouse of the custodial parent's coverage pays second;
o The natural parent without custody's coverage pays third; and
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o The spouse of the natural parent without custody's coverage pays fourth.
• If a plan covers you as an active employee or a dependent of an active employee, that plan is
primary. Another plan covering you as inactive, laid off, or retired is secondary.
• When this plan covers you or your dependent pursuant to COBRA or under a right of continuation
pursuant to other federal law, the plan covering you or your dependent as an employee, member,
subscriber, or retiree or covering you or your dependent as a dependent of an employee, member,
subscriber or retiree is the primary plan and this plan's coverage is the secondary plan.
• If none of these rules apply, the coverage that has been in place longest is primary.
Most insurers or administrators send you an explanation of benefits, or EOB, when they pay a claim. If
your other plan's coverage is primary, send PacificSource the other plan's EOB with your original bill
and they will process your claim. If you receive more than you should when your benefits are
coordinated, you will be expected to repay any over-payment to the plan.
Right to Make Payments to Other Organizations - Whenever payments, which should have been
made by this plan, have been made by any other plan(s), this plan has the right to pay the other plan(s)
any amount necessary to satisfy the terms of this coordination of benefits provision. Amounts paid will
be considered benefits paid under this plan and, to the extent of such payments, the plan will be fully
released from any liability regarding the person for whom payment was made.
Automobile Insurance - This plan provides benefits relating to medical expenses incurred as a result
of an automobile accident on a secondary basis only. Benefits payable under this plan will be
coordinated with and secondary to benefits provided or required by any no-fault automobile insurance
statute, whether or not a no-fault policy is in effect, and/or any other automobile insurance.
Any benefits provided by this plan will be subject to the plan's reimbursement and/or subrogation
provisions.
OTHER IMPORTANT PLAN PROVISIONS
Assignment of Benefits
All benefits payable by the plan are automatically assigned to the provider of services or supplies,
unless evidence of previous payment is submitted with the claim form. However, the plan reserves the
right to reimburse the member, the provider, or both jointly. Payments made in accordance with an
assignment are made in good faith and release the plan's obligation to the extent of the payment.
Payments will also be made in accordance with any assignment of rights required by a state Medicaid
plan.
Members are expressly prohibited from assigning any right to payment of benefits under a Benefit
Program, including this plan. No attempts at assignment of any such expenses under a Benefit
Program will be recognized. Except as may be expressly prescribed in an agreement to which the Plan
Sponsor is a party, nothing contained in any written designation of coverage under a Benefit Program
will make the Benefit Program, or the Plan Sponsor or any other employer, liable to any third-party to
whom a member may be liable for medical care, treatment or services.
Proof of Loss
The Plan Sponsor has the right to require a claimant to undergo physical or psychological examinations
relating to the claimant's illness, injury or condition as often as the Plan Sponsor deems reasonably
necessary while the claim for benefits is pending. The Plan Sponsor also has the right to require an
autopsy in case of death (where not prohibited by law).
No Verbal Modifications of Plan Provisions
No verbal statement made by anyone involved in administering this plan can waive any of the terms or
conditions of this plan or prevent the Plan Sponsorfrom enforcing any provision of this plan. Waivers
are valid only if they are contained in a written instrument signed by an authorized individual on behalf
of the Plan Sponsor. Any such written waiver will be valid only as to the specific plan, term or condition
set forth in the written instrument. Unless specifically stated otherwise, a written waiver will be valid only
for the specific claim involved at the time, and will not be a continuing waiver of the term or condition in
the future.
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Reimbursement to the Plan
This section applies whenever another party (including your own insurer under an automobile or other
policy) is legally responsible or agrees to compensate you or your dependent, by settlement, verdict or
otherwise, for an illness or injury. In that case, you or your dependent (or the legal representatives,
estate or heirs of either you or your dependent), must promptly reimburse the plan for any benefits it
paid relating to that illness or injury, up to the full amount of the compensation received from the other
party (regardless of how that compensation may be characterized and regardless of whether you or
your dependent have been made whole). If the plan has not yet paid benefits relating to that illness or
injury, the plan may reduce or deny future benefits on the basis of the compensation received by you or
your dependent.
Benefits relating to such illness or injury will not be payable by the plan until you sign and return a
statement, provided by the plan, acknowledging your obligation to reimburse the plan under this
provision. That obligation will arise upon the payment of any plan benefits relating to the illness or
injury, whether or not you sign such a statement.
You or your dependent must cooperate with the plan and its authorized representatives, and must sign
and deliver such documents as the plan or its agents reasonably request to protect the plan's right of
reimbursement. You or your dependent must also provide any relevant information and take such
actions as the plan or its agents reasonably request to assist the plan in making a full recovery of the
reasonable value of the benefits provided. You or your dependent must not take any action that
prejudices the plan's right of reimbursement.
In order to secure the rights of the plan under this section, you or your dependent hereby: (1) grant to
the plan a first priority lien against the proceeds of any such settlement, verdict or other amounts
received by you or your dependent, and (2) assign to the plan any benefits you or your dependent may
have under any automobile policy or other coverage, to the extent of the plan's claim for
reimbursement.
The reimbursement required under this provision will not be reduced to reflect any costs or attorneys'
fees incurred in obtaining compensation unless separately agreed to, in writing, by the Plan Sponsor, in
the exercise of its sole discretion.
This plan expressly disavows and repudiates the make whole doctrine, which, if applicable, would
prevent the plan from receiving a recovery unless a member has been 'made whole' with regard to
illness or injury that is the responsibility of a third party. This plan also expressly disavows and
repudiates the common fund doctrine, which, if applicable, would require the plan to pay a portion of the
attorney fees and costs expended in obtaining a recovery. These doctrines have no application to this
plan, since the plan's recovery rights apply to the first dollars payable by a third party.
Subrogation
This section applies whenever another party (including your own insurer under an automobile or other
policy) is legally responsible or agrees to compensate you or your dependent for you or your
dependent's illness or injury and the plan has paid benefits related to that illness or injury.
The plan is subrogated to all of the rights of you or your dependent against any party liable for you or
your dependent's illness or injury to the extent of the reasonable value of the benefits provided to you or
your dependent under the plan. The plan may assert this right independently of you or your dependent.
You and your dependent are obligated to cooperate with the plan and its authorized representatives in
order to protect the plan's subrogation rights. Cooperation means providing the plan or its agents with
any relevant information requested by them, signing and,delivering such documents as the plan or its
agents reasonably request to secure the plan's subrogation claim, and obtaining the consent of the plan
or its agents before releasing any party from liability for payment of medical expenses.
If you or your dependent enters into litigation or settlement negotiations regarding the obligations of
other parties, you or your dependent must not prejudice, in any way, the subrogation rights of the plan
under this section.
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The costs of legal representation of the plan in matters related to subrogation will be borne solely by the
plan. The costs of legal representation of you or your dependent must be borne solely by you or your
dependent.
Recovery of Excess Payments
Whenever payments have been made in excess of the amount necessary to satisfy the provisions of
this plan, or were made in error by the plan, the plan has the right to recover these payments from any
individual (including yourself), insurance company or other organization to whom the payments were
made or to withhold payment, if necessary, on future benefits until the overpayment is recovered. If
excess or erroneous payments were made for services rendered to your dependent(s), the plan has the
right to withhold payment on your future benefits until the overpayment is recovered.
Further, whenever payments have been made based on fraudulent information provided by you, the
plan will exercise all available legal rights, including its right to withhold payment on future benefits, until
the overpayment is recovered.
In the same manner, if the plan applies medical expenses to the plan deductible that would not
otherwise be reimbursable under the terms of this policy; the plan may deduct a like amount from the
accumulated deductible amounts and/or recover payment of medical expenses that would have
otherwise been applied to the deductible. The fact that a medical expense was applied to the plan's
deductible, or that a drug was provided under the plan's prescription drug program, does not in itself
create an eligible expense or infer that benefits will continue to be provided for an otherwise excluded
condition.
Right To Receive and Release Necessary Information
The plan may, without the consent of or notice to any person, release to or obtain from any organization
or person, information needed to implement plan provisions, including medical information. When you
request benefits, you must either furnish or authorize the release of all the information required to
implement plan provisions. Your failure to fully cooperate will result in a denial of the requested benefits
and the plan will have no further liability for such benefits.
Under normal conditions, benefits are payable to the provider of services or supplies, unless evidence
of previous payment is submitted with the claim form. If conditions exist under which a valid release or
assignment cannot be obtained, the plan may make payment to any individual or organization that has
assumed the care or principal support for you and is equitably entitled to payment. The plan must make
payments to your separated/divorced spouse, state child support agencies or Medicaid agencies if
required by a qualified medical child support order (QMCSO) or state Medicaid law.
The plan may also honor benefit assignments made prior to your death in relation to remaining benefits
payable by the plan.
Any payment made by the plan in accordance with this provision will fully release the plan of its liability
to you.
Reliance on Documents and Information
Information required by the Plan Sponsor or PacificSource may be provided in any form or document
that the Plan Sponsor and PacificSource considers acceptable and reliable. The Plan Sponsor and
PacificSource relies on the information provided by you and others when evaluating coverage and
benefits under the plan. All such information, therefore, must be accurate, truthful and complete. The
Plan Sponsor and PacificSource is entitled to conclusively rely upon, and will be protected for any
action taken in good faith in relying upon, any information provided to the Plan Sponsor or
PacificSource. In addition, any fraudulent statement, omission or concealment of facts,
misrepresentation, or incorrect information may result in the denial of the claim, cancellation or
rescission of coverage, or any other legal remedy available to the plan.
No Waiver
The failure of the Plan Sponsor to enforce strictly any term or provision of this plan will not be construed
as a waiver of such term or provision. The Plan Sponsorreserves the right to enforce strictly any term
or provision of this plan at any time.
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Physician/Patient Relationship
This plan is not intended to disturb the physician/patient relationship. Physicians, practitioners and other
health care providers are not agents or delegates of the Plan Sponsor, or the Third Party Administrator.
Nothing contained in this plan will require you or your dependent to commence or continue medical
treatment by a particular provider. Further, nothing in this plan will limit or otherwise restrict a physician
or practitioner's judgment with respect to the physician or practitioner's ultimate responsibility for patient
care in the provision of medical services to you or your dependent.
Plan not responsible for Quality of Health Care
You and your enrolled dependents have the right to select your health care provider. Neither the plan,
your Plan Sponsor, nor Third Party Administrator is responsible for the quality of care received and
cannot be held liable for any claim or damages connected with injuries suffered while receiving health
services or supplies.
Plan is not a Contract of Employment
Nothing contained in this plan will be construed as a contract or condition of employment between the
Plan Sponsor and any employee. All employees are subject to discharge to the same extent as if this
plan had never been adopted.
Right to Amend or Terminate Plan
Plan Sponsor reserves the right to amend, modify or terminate the plan in any manner, for any reason,
at any time.
If changes occur, your Plan Sponsor will notify you of changes to your plan.
If your health plan terminates and your Plan Sponsor does not replace the coverage with another group
policy, your Plan Sponsor is required by law to advise you in writing of the termination. When this plan
terminates, your Plan Sponsor will notify you about any available options for you to continue your
coverage.
The Plan Sponsor may pay your medical claims if a workers' compensation claim has been denied on
the basis that the illness or injury is not work related, and the denial is under appeal. But before
PacificSource does that, you must sign a written agreement to reimburse the Plan Sponsor any money
you recover from the workers' compensation coverage.
Rescissions
The Plan Sponsor or PacificSource may not rescind the coverage of a member unless the member, or
person seeking coverage on behalf of the member, performs an act, practice or omission that
constitutes fraud or makes an intentional misrepresentation of a material fact as prohibited by the terms
of this plan and the Plan Sponsor or PacificSource gives the member a 30-day prior written notice.
PacificSource may not rescind the policyholder's group health benefit plan unless the policyholder, or
representative of the policyholder, performs an act, practice or omission that constitutes fraud or makes
an intentional misrepresentation of a material fact as prohibited by the terms of this plan and
PacificSource gives a 30-day prior written notice to all member covered under the plan. Rescissions do
not include a cancellation or discontinuance of coverage that is prospective or to the extent it is
attributable to a failure to timely pay required contributions towards the cost of coverage.
Applicable Law
This is a self-insured benefit plan. As such, Federal law preempts State law and jurisdiction. To the
extent not preempted by federal law, the laws of the state of Oregon shall apply.
PRIVACY AND CONFIDENTIALITY
This notice is intended to bring the City of Ashland Employee Benefit Plan into compliance with the
requirements of Section 164.504(f) of the Health Insurance Portability and Accountability Act of 1996
and its implementing regulations, 45 C.F.R. parts 160 through 164 (the'HIPAA Privacy Rule') by
SingleSource Self-Insured 72
establishing the conditions under which the Plan Sponsorwill receive, use and/or disclose protected
health information.
Permitted Disclosures of Protected Health Information to the Plan Sponsor
Subject to the conditions of the 'No Disclosure of Protected Health Information to the Employer Without
Certification by Employer' and 'Conditions of Disclosure of Protected Health Information to the
Employer', the plan (and any third party administrator or business associate acting on behalf of the
plan) may disclose individuals' protected health information to the Plan Sponsorfor the Plan Sponsoror
PacificSource to carry out plan administration functions. The plan (and any third party administrator or
business associate acting on behalf of the plan) may not disclose individuals' protected health
information to the Plan Sponsor for employment-related actions and decisions or in connection with any
other benefit or employee benefit plan of the Plan Sponsor.
No Disclosure of Protected Health Information to the Plan Sponsorwithout Certification by Plan
Sponsor
Except as provided below in 'Disclosures of Summary Health Information and Enrollment/Disenrollment
Information to the Employer,' with respect to the plan's disclosure of summary health information and
enrollment/disenrollment information, the plan will not disclose protected health information to any
employee of the Plan Sponsor.
Conditions of Disclosure of Protected Health Information to the Plan Sponsor
The Plan Sponsor certifies that the plan has been amended to incorporate this section and agrees to
the following restrictions and conditions of receiving protected health information (other than summary
health information or enrollment/disenrollment information as explained in 'Disclosures of Summary
Health Information and Enrollment/Disenrollment Information to the Plan Sponsor below). The Plan
Sponsor shall:
• Not use or further disclose the protected health information other than as permitted or required
herein or as required by law.
• Ensure that any agent(s), including a subcontractor, to whom it provides protected health
information received from the plan agrees to the same restrictions and conditions that apply to the
Plan Sponsorwith respect to such protected health information.
• Not use or disclose protected health information for employment-related actions and decisions or in
connection with any other benefit or employee benefit plan of the Plan Sponsor.
• Report to the plan any use or disclosure of protected health information that is inconsistent with the
uses or disclosures provided for of which the Plan Sponsor becomes aware.
• Make available protected health information to comply with an individual's right to access protected
health information in accordance with 45 C.F.R. Section 164.524.
• Make available protected health information for amendment and incorporate any amendments to
protected health information in accordance with 45 C.F.R. Section 164.526.
• Make available the information required to provide an accounting of disclosures in accordance with
45 C.F.R. §164.528.
• Make its internal practices, books and records relating to the use and disclosure of protected health
information received from the plan available to the Secretary of the Department of Health and
Human Services for purposes of determining compliance by the plan with the HIPAA Privacy Rule.
• If feasible, return or destroy all protected health information received from the plan that the Plan
Sponsor still maintains in any form and retain no copies of such information when no longer needed
for the purpose for which disclosure was made, except that, if such return or destruction is not
feasible, the Plan Sponsorwill limit further uses and disclosures to those purposes that make the
return or destruction of the information infeasible.
• Ensure that the required adequate separation, described in 'Required Separation Between the Plan
and the Plan Sponsor below, is established and maintained.
SingleSource Self-Insured 73
Disclosures of Summary Health Information and Enrollment/Disenrollment Information to the
Plan Sponsor
• The plan (or a third party administrator of the plan) may disclose summary health information to the
Plan Sponsorwithout the need to comply with the conditions and restrictions of 'No Disclosure of
Protected Health Information to the Plan Sponsor Without Certification by Plan Sponsor and
'Conditions of Disclosure of Protected Health Information to the Plan Sponsor, if the Plan Sponsor
requests the summary health information for the purpose of:
- Obtaining premium bids from health plans (including health insurance issuers) for providing
health insurance coverage under the plan; or
- Modifying, amending, or terminating the plan
• The plan (or a third party administrator of the plan) may disclose information on whether the
individual is participating in the group health plan, or is enrolled in or has disenrolled from the plan
without the need to comply with the conditions and restrictions of 'No Disclosure of Protected
Health Information to the Plan Sponsor Without Certification by Plan Sponsor and 'Conditions of
Disclosure of Protected Health Information to the Plan Sponsor
Required Separation between the Plan and the Plan Sponsor
• The following classes of employees or other persons under the control of the Plan Sponsorwill
have access to protected health information received from the plan (or from a health insurance
issuer with respect to the plan):
- Human Resources
• No other persons shall have access to protected health information. The listed classes of
employees or other persons under the control of the Plan Sponsorwill have access to protected
health information solely to perform the plan administration functions that the Plan Sponsor
performs for the plan. They will be subject to disciplinary action and/or sanctions (including
termination of employment or affiliation with the Plan Sponsor) for any use or disclosure of
protected health information in violation of the provisions of this plan.
DEFINITIONS
Wherever used in this plan, the following definitions apply to the terms listed below, and the masculine
includes the feminine and the singular includes the plural. For the purpose of this plan, 'employee'
includes the Plan Sponsorwhen covered by this plan. Other terms are defined where they are first used
in the text.
Abutment is a tooth used to support a prosthetic device (bridges, partials or overdentures). With an
implant, an abutment is a device placed on the implant that supports the implant crown.
Accident means an unforeseen or unexpected event causing injury that requires medical attention.
Actively at work or active employment means that an employee is performing in the customary
manner all of the regular duties of his/her occupation with the Plan Sponsor, either at one of the Plan
Sponsors regular places of business or at some location to which the Plan Sponsors business requires
the employee to travel to perform his/her regular duties assigned by the Plan Sponsor. An employee is
also considered to be actively at work on each day of a regular paid vacation or non-work day, but only
if the employee is performing in the customary manner all of the regular duties of the employee's
occupation with the Plan Sponsor on the immediately preceding regularly scheduled workday.
Advanced diagnostic imaging means diagnostic examinations using CT scans, MRIs, PET scans,
CATH labs, and nuclear, cardiology studies.
Adverse benefit determination means a denial, reduction, or termination of a healthcare item or
service, or a failure or refusal to provide or to make a payment in whole or in part for a healthcare item
or service, that is based on the Plan Sponsors or PacificSource's:
• Denial of eligibility for or termination of enrollment in a health benefit plan;
• Rescission or cancellation of a policy or coverage;
• Imposition of a source-of-injury exclusion, network exclusion, annual benefit limit or other limitation
on otherwise covered items or services;
SingleSource Self-Insured 74
• Determination that a healthcare item or service is experimental, investigational, or not medically
necessary, effective, or appropriate; or
• Determination that a course or plan of treatment that a member is undergoing it an active course of
treatment for purposes of continuity of care under ORS 743.854.
Advantage Essential Network is the exclusive provider network that provides dental care to members
under this plan.
Allowable fee is the dollar amount established by the plan for reimbursement of charges for specific
services or supplies provided by nonparticipating providers. The plan uses several sources to
determine the allowable amount. Depending on the service or supply and the geographical area in
which it is provided, the allowable amount may be based on data collected from the Centers for
Medicare and Medicaid Services (CMS), Viant Health Payment Solutions, other nationally recognized
databases, or PacificSource.
Where the provider network is deemed adequate, the allowable fee for professional services is based
on PacificSource's standard participating provider reimbursement rate or a contracted reimbursement
rate. Outside the PacificSource service area and in areas where the participating provider network is
not deemed adequate, the allowable fee is based on the usual, customary, and reasonable charge
(UCR) at the 85th percentile. UCR is based on data collected for a geographic area. Provider charges
for each type of service are collected and ranked from lowest to highest. Charges at the 85th position in
the ranking are considered to be the 85th percentile.
Alveolectomy is the removal of bone from the socket of a tooth.
Amalgam is a silver-colored material used in restoring teeth.
Ambulatory surgical center means a facility licensed by the appropriate state or federal agency to
perform surgical procedures on an outpatient basis.
Ancillary Services means service rendered in connection with Inpatient or Outpatient care in a
Hospital or in connection with a medical emergency, such as assistant surgeon, anesthesiology,
ambulance, pathology and radiology.
Approved clinical trials are Phase I, ll, III, or IV clinical trials for the prevention, detection, or treatment
of cancer or another life-threatening condition or disease.
Authorized representative is an individual who by law or by the contest of a person may act on behalf
of the person.
Benefit year means the 12-month period beginning on each January 1 and ending on the next
December 31.
Cardiac rehabilitation refers to a comprehensive program that generally involves medical evaluation,
prescribed exercise, and cardiac risk factor modification. Education, counseling, and behavioral
interventions are sometimes used as well. Phase I refers to inpatient services that typically occur during
hospitalization for heart attack or heart surgery. Phase II refers to a short-term outpatient program,
usually involving ECG-monitored exercise. Phase III refers to a long-term program, usually at home or
in a community-based facility, with little or no ECG monitoring.
Cast restoration includes crowns, inlays, onlays, and other restorations made to fit a patient's tooth
that are made at a laboratory and cemented onto the tooth.
Certificate of Creditable Coverage means a certificate or other documentation that shows previous
health insurance coverage for a member and can be used to reduce the length of any pre-existing
condition exclusions under a plan. See Creditable coverage.
Chemical dependency means the addictive relationship with any drug or alcohol characterized by
either a physical or psychological relationship, or both, that interferes with the individual's social,
psychological, or physical adjustment to common problems on a recurring basis. Chemical dependency
does not include addiction to, or dependency on, tobacco products or foods.
Claims Administrator means the organization selected by the City of Ashland to provide claims
processing and adjudication under their plans. The Claims Administrator for their medical, vision and
pharmacy coverage is PacificSource.
Composite resin is a tooth-colored material used in restoring teeth.
Contracted amount means the amount that participating providers have contracted to accept as
payment in full for covered expenses under the plan.
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Copayment or coinsurance is the out-of-pocket amount a member is required to pay to a provider.
Creditable coverage means a member's prior health coverage that meets the following criteria:
• There was no more than a 63-day break between the last day of coverage under the previous
policy and the first day of coverage under this policy. The 63-day limit excludes the Plan Sponsors
eligibility waiting period.
• The prior coverage was one of the following types of insurance: group coverage (including Federal
Employee Health Benefit Plans and Peace Corps), individual coverage (including student health
plans), Medicaid, Medicare, TRICARE, Indian Health Service or tribal organization coverage, state
high-risk pool coverage, and public health plans.
Curettage is the scraping and cleaning of the walls of a real or potential space, such as a gingival
pocket or bone, to remove pathological material.
Custodial Care means non-medical care that is primarily to assist with activities of daily living, whether
or not the care is administered by a licensed provider.
Deductible means the portion of the healthcare expense that must be paid by the member before the
benefits of this plan are applied.
Dental emergency means the sudden and unexpected onset of a condition, or exacerbation of an
existing condition, requiring necessary care to control pain, swelling or bleeding in or around the teeth
and gums. Such emergency care must be provided within 48 hours following the onset of the
emergency and includes treatment for acute infection, pain, swelling, bleeding, or injury to natural teeth
and oral structures. The emergency care does not include follow-up care such as, but not limited to,
crowns, root canal therapy, or prosthetic benefits.
Dentist means a person acting within the scope of their license, holding the degree of Doctor of
Medicine (M.D.), Doctor of Dental Surgery (D.D.S.), or Doctor of Dental Medicine (D.M.D.), and who is
legally entitled to practice dentistry in all its branches under the laws of the state or jurisdiction where
the services are rendered.
Durable medical equipment means equipment that can withstand repeated use; is primarily and
customarily used to serve a medical purpose rather than convenience or comfort; is generally not useful
to a person in the absence of an illness or injury; is appropriate for use in the home; and is prescribed
by a physician. Examples of durable medical equipment include but are not limited to hospital beds,
wheelchairs, crutches, canes, walkers, nebulizers, commodes, suction machines, traction equipment,
respirators, TENS units, and hearing aids.
Durable medical equipment supplier means a PacifcSource contracted provider or a provider that
satisfies the criteria in the Medicare Qualify Standards for Suppliers of Durable Medical Equipment,
Prosthetics, Orthotics, Supplies (DMEPOS) and Other Items and Services Summary Plan Description.
Elective surgery or procedure refers to a surgery or procedure for a condition that does not require
immediate attention and for which a delay would not have a substantial likelihood of adversely affecting
the health of the patient.
Eligible dental provider means a physician, dentist, oral surgeon, endodontist, orthodontist,
periodontist, or pedodontist. Eligible provider may also include a denturist or dental hygienist to the
extent that he/she operates within the scope of their license.
Emergency medical condition means a medical condition:
• That manifests itself by acute symptoms of sufficient severity, including severe pain that a prudent
layperson possessing an average knowledge of health and medicine would reasonably expect that
failure to receive immediate medical attention would:
- Place the health of a person, or an unborn child in the case of a pregnant woman, in serious
jeopardy;
- Result in serious impairment to bodily functions; or
- Result in serious dysfunction of any bodily organ or part, or
• With respect to a pregnant woman who is having contractions, for which there is inadequate time to
affect a safe transfer to another hospital before delivery or for which a transfer may pose a threat to
the health or safety of the woman or the unborn child.
Emergency medical screening exam means the medical history, examination, ancillary tests, and
medical determinations required to ascertain the nature and extent of an emergency medical condition.
SingleSource Self-Insured 76
Emergency services means, with respect to an emergency medical condition:
• An emergency medical screening exam that is within the capability of the emergency department of
a hospital, including ancillary services routinely available to the emergency department to evaluate
such emergency medical condition; and
• Such further medical examination and treatment as are required under 42 U.S.C. 1395dd to
stabilize the patient to the extent the examination and treatment are within the capability of the staff
and facilities available at a hospital.
Employee means any individual employed by a Plan Sponsor.
Endorsement is a written attachment that alters and supersedes any of the terms or conditions set
forth in this contract.
Enrollee means an employee, dependent of the employee, or individual otherwise eligible and enrolled
for coverage under this plan. In this policy, enrollee is referred to as subscriber or member.
Essential health benefits are services defined as such by the Secretary of the U.S. Department of
Health and Human Services. Essential health benefits fall into the following categories:
• Ambulatory patient services;
• Emergency services;
• Hospitalization;
• Maternity and newborn care,
• Mental health and substance use disorder services, including behavioral health treatment;
• Prescription drugs;
• Rehabilitative and habilitative services and devices;
• Laboratory services;
• Preventive and wellness services and chronic disease management; and
• Pediatric services, including oral and vision care.
Exclusion period means a period during which specified conditions, treatments or services are
excluded from coverage.
Experimental or investigational procedures means services, supplies, protocols, procedures,
devices, chemotherapy, drugs or medicines, or the use thereof, that are experimental or investigational
for the diagnosis and treatment of illness or injury.
• Experimental or investigational services and supplies include, but are not limited to, services,
supplies, procedures, devices, chemotherapy, drugs or medicines, or the use thereof, which at the
time they are rendered and for the purpose and in the manner they are being used:
- Have not yet received full U.S. government agency required approval (e.g., FDA) for other
than experimental, investigational, or clinical testing;
- Are not of generally accepted medical practice in the state of Oregon or as determined by
PacificSource in consultation with medical advisors, medical associations, and/or technology
resources;
- Are not approved for reimbursement by the Centers for Medicare and Medicaid Services;
- Are furnished in connection with medical or other research, or
- Are considered by any governmental agency or subdivision to be experimental or
investigational, not considered reasonable and necessary, or any similar finding.
• When making decisions about whether treatments are investigational or experimental,
PacificSource relies on the above resources as well as:
- Expert opinions of specialists and other medical authorities;
- Published articles in peer-reviewed medical literature;
- External agencies whose role is the evaluation of new technologies and drugs; and
- External review by an independent review organization.
SingleSource Self-Insured 77
• The following will be considered in making the determination whether the service is in an
experimental and/or investigational status:
- Whether there is sufficient evidence to permit conclusions concerning the effect of the
services on health outcomes;
- Whether the scientific evidence demonstrates that the services improve health outcomes as
much or more than established alternatives;
- Whether the scientific evidence demonstrates that the services' beneficial effects outweigh
any harmful effects; and
- Whether any improved health outcomes from the services are attainable outside an
investigational setting.
Formulary is a list of approved brand name medications used to treat various medical conditions. The
formulary list is developed by the pharmacy benefits management company and PacificSource.
Generic drugs are drugs that, under federal law, require a prescription by a licensed physician (M.D. or
D.O.) or other licensed medical provider and are not a brand name medication. By law, generic drugs
must have the same active ingredients as the brand name medication and are subject to the same
standards of their brand name counterpart.
Grievance means:
• A request submitted by a member or an authorized representative of a member;
- In writing, for an internal appeal or an external review; or
- In writing or orally, for an expedited internal review or an expedited external review; or
A written complaint submitted by a member or an authorized representative of a member regarding:
- The availability, delivery, or quality of a healthcare service;
- Claims payment, handling, or reimbursement for healthcare services and, unless the member
has not submitted a request for an internal appeal, the complaint is not disputing an adverse
benefit determination; or
- Matters pertaining to the contractual relationship between a member and PacificSource.
Health care provider means a physician, practitioner, nurse, hospital or specialized treatment facility
as defined in this document.
Health benefit plan means any hospital expense, medical expense, or hospital or medical expense
policy or certificate, healthcare contractor or health maintenance organization subscriber contract, or
any plan provided by a multiple employer welfare arrangement or by another benefit arrangement
defined in the federal Employee Retirement Income Security Act of 1974, as amended, to the extent
that plan is subject to state regulation.
Hearing aids mean any nondisposable, wearable instrument or device designed to aid or compensate
for impaired human hearing and any necessary ear mold, part, attachments or accessory for the
instrument or device, except batteries and cords. Hearing aids include any amplifying device that does
not produce as its output an electrical signal that directly stimulates the auditory nerve. For the purpose
of this definition, such amplifying devices include air conduction and bone conduction devices, as well
as those that provide vibratory input to the middle ear.
Homebound means the ability to leave home only with great difficulty with absences infrequently and
of short duration. Infants and toddlers will not be considered homebound without medical
documentation that clearly establishes the need for home skilled care. Lack of transportation is not
considered sufficient medical criterion for establishing that a person is homebound.
Hospital means an institution licensed as a'general hospital' or 'intermediate general hospital' by the
appropriate state agency in the state in which it is located.
Illness includes a physical or mental condition that results in a covered expense. Physical illness is a
disease or bodily disorder. Mental illness is a psychological disorder that results in pain or distress and
substantial impairment of basic or normal functioning.
Incurred expense means charges of a healthcare provider for services or supplies for which a member
becomes obligated to pay. The expense of a service is incurred on the day the service is rendered, and
the expense of a supply is incurred on the day the supply is delivered.
SingleSource Self-Insured 78
Initial enrollment period means a period of 31 days following the date an individual is first eligible to
enroll.
Injury means bodily trauma or damage that is independent of disease or infirmity. The damage must be
caused solely by external and accidental means and does not include muscular strain sustained while
performing a physical activity.
Inquiry means a written request for information or clarification about any subject matter related to the
member's health benefit plan.
Internal appeal means a review by PacificSource or your Plan Sponsor of an adverse benefit
determination made by PacificSource.
Leave of absence is a period of time off work granted to an employee by the Plan Sponsor at the
employee's request and during which the employee is still considered to be employed and is carried on
the employment records of the Plan Sponsor. A leave can be granted for any reason acceptable to the
Plan Sponsor, including disability and pregnancy.
Lifetime means the period of time a member is enrolled in this plan or any other Plan Sponsored by the
Plan Sponsor.
Mastectomy is the surgical removal of all or part of a breast or a breast tumor suspected to be
malignant.
Medically necessary means those services and supplies that are required for diagnosis or treatment of
illness or injury and that are:
• Consistent with the symptoms or diagnosis and treatment of the condition;
• Consistent with generally accepted standards of good medical practice in the state of Oregon, or
expert consensus physician opinion published in peer-reviewed medical literature, or the results of
clinical outcome trials published in peer-reviewed medical literature;
• As likely to produce a significant positive outcome as, and no more likely to produce a negative
outcome than, any other service or supply, both as to the disease or injury involved and the
patient's overall health condition;
• Not for the convenience of the member or a provider of services or supplies;
• The least costly of the alternative services or supplies that can be safely provided. When
specifically applied to a hospital inpatient, it further means that the services or supplies cannot be
safely provided in other than a hospital inpatient setting without adversely affecting the patient's
condition or the quality of medical care rendered.
Services and supplies intended to diagnose or screen for a medical condition in the absence of signs or
symptoms, or of abnormalities on prior testing, including exposure to infectious or toxic materials or
family history of genetic disease, are not considered medically necessary under this definition (see
General Exclusions - Screening tests).
Medical supplies means items of a disposable nature that may be essential to effectively carry out the
care a physician has ordered for the treatment or diagnosis of an illness or injury. Examples of medical
supplies include but are not limited to syringes and needles, splints and slings, ostomy supplies, sterile
dressings, elastic stockings, enteral foods, drugs or biologicals that must be put directly into the
equipment in order to achieve the therapeutic benefit of the durable medical equipment or to assure the
proper functioning of this equipment (e.g. Albuterol for use in a nebulizer).
Member means an individual insured through the Plan Sponsor.
Mental and/or chemical healthcare facility means a corporate or governmental entity or other
provider of services for the care and treatment of chemical dependency and/or mental or nervous
conditions which is licensed or accredited by the Joint Commission on Accreditation of Hospitals or the
Commission on Accreditation of Rehabilitation Facilities for the level of care which the facility provides.
Mental and/or chemical healthcare program means a particular type or level of service that is
organizationally distinct within a mental and/or chemical healthcare facility.
Mental and/or chemical healthcare provider means a person that has met the credentialing
requirements of PacificSource, is otherwise eligible to receive reimbursement under the policy and is:
• A healthcare facility where appropriately licensed or accredited by the Commission on Accreditation
of Hospitals or the Commission on Accreditation of Rehabilitation Facilities;
• A residential program or facility,
SingleSource Self-Insured 79
• A day or partial hospitalization program,
• An outpatient service; or
• An individual behavioral health or medical professional authorized for reimbursement under Oregon
law.
Mental or nervous conditions means all disorders listed in the 'Diagnostic and Statistical Manual of
Mental Disorders, DSM-IV-TR, Fourth Edition' except for:
• Mental Retardation (diagnostic codes 317, 318.0, 318.1, 318.2, 319);
• Learning Disorders (diagnostic codes 315.00, 315.1, 315.2, 315.9);
• Paraphilias (diagnostic codes 302.4, 302.81, 302.89, 302.2, 302.83, 302.84, 302.82, 302.9); and
• Gender Identity Disorders in Adults (diagnostic codes 302.85, 302.6, 302.9 - this exception does
not extend to children and adolescents 18 years of age or younger); and
• 'V codes (diagnostic codes V15.81 through V71.09 - this exception does not extend to children five
years of age or younger for diagnostic codes V61.20, V61.21, and V62.82).
Network not available means a member does not have reasonable geographic access to a
PacificSource participating provider for a medical service or supply.
Non-participating provider is a provider of covered medical services or supplies that does not directly
or indirectly hold a provider contract or agreement with PacificSource.
Non-preferred drugs are covered brand name medications not on the Preferred Drug List.
Orthotic devices means rigid or semirigid devices supporting a weak or deformed leg, foot, arm, hand,
back or neck or restricting or eliminating motion in a diseased or injured leg, foot, arm, hand, back or
neck. Benefits for orthotic devices include orthopedic appliances or apparatus used to support, align,
prevent, or correct deformities or to improve the function of movable parts of the body. An orthotic
device differs from a prosthetic in that, rather than replacing a body part, it supports and/or rehabilitates
existing body parts. Orthotic devices are usually customized for an individual's use and are not
appropriate for anyone else. Examples of orthotic devices include but are not limited to Ankle Foot
Orthosis (AFO), Knee Ankle Foot Orthosis (KAFO), Lumbosacral Orthosis (LSO), and foot orthotics.
PacificSource refers to PacificSource Health Plans. PacificSource is the claims administrator of the
Plan Sponsor's medical, vision and pharmacy coverage. References to PacificSource as paying claims
or issuing benefits means that PacificSource processes a claim in accordance with the provisions of the
Plan Sponsor's plans.
Participating provider means a physician, healthcare professional, hospital, medical facility, or
supplier of medical supplies that directly or indirectly holds a provider contract or agreement with the
plan.
Periapical x-ray is an x-ray of the area encompassing or surrounding the tip of the root of a tooth.
Periodontal maintenance is a periodontal procedure for patients who have previously been treated for
periodontal disease. In addition to cleaning the visible surfaces of the teeth (as in prophylaxis) surfaces
below the gum-line are also cleaned. This is a more comprehensive service than a regular cleaning
(prophylaxis).
Periodontal scaling and root planing means the removal of plaque and calculus deposits from the
root surface under the gum line.
Physical/occupational therapy is comprised of the services provided by (or under the direction and
supervision of) a licensed physical or occupational therapist. Physical/occupational therapy includes
emphasis on examination, evaluation, and intervention to alleviate impairment and functional limitation
and to prevent further impairment or disability.
Physician means a state-licensed Doctor of Medicine (M.D.) or a Doctor of Osteopathy (D.O.).
Physician assistant is a person who is licensed by an appropriate state agency as a physician
assistant.
Plan means the City of Ashland Employee Benefits Plan, and all documents, including any insurance
contracts, administrative service agreements, Summary Plan Descriptions and any related terms and
conditions associated with the Plan.
SingleSource Self-Insured 80
Plan Administrator means the Risk Services Division of the City of Ashland, which has responsibility
for the management of the plan.
Plan Sponsor ('the Plan Sponsor' or'your Plan Sponsor), means the City of Ashland. The City of
Ashland is the fiduciary of the plan, and exercises all discretionary authority and control over the
administration of the plan and the management and disposition of plan assets. The Plan Sponsor shall
have the sole discretionary authority to determine eligibility for plan benefits or to construe the terms of
the plan, and benefits under the plan will be paid only if the Plan Sponsor decides, in its discretion, that
the memberor beneficiary is entitled to such benefits. The Plan Sponsor has the right to amend,
modify, or terminate the plan in any manner, at any time, regardless of the health status of any plan
member or beneficiary.
Plan Year means the twelve-month period of time for the City of Ashland beginning January 1, and
ending December 31.
Practitioner means Doctor or Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery
(D.D.S.), Doctor of Dental Medicine (D.M.D.), Doctor of Podiatry Medicine (D.P.M.), Doctor of
Chiropractic (D.C.), Doctor of Optometry (O.D.), Licensed Nurse Practitioner (including Certified Nurse
Midwife (C.N.M.) and Certified Registered Nurse Anesthetist (C.R.N.A.)), Registered Physical Therapist
(R.P.T.), Speech Therapist, Occupational Therapist, Psychologist (Ph.D.), Licensed Clinical Social
Worker (L.C.S.W.), Licensed Professional Counselor (L.P.C.), Licensed Marriage and Family Therapist
(LMFT), Licensed Psychologist Associate (LPA), Physician Assistant (PA), Audiologist, Acupuncturist,
Naturopathic Physician, and Licensed Massage Therapist.
Pre-existing condition means a condition (physical or mental) for which medical advice, diagnosis,
care, or treatment was recommended by or received from a licensed provider within the six-month
period ending on the enrollment date. For the purpose of this definition, the enrollment date of a
member is the earlier of the effective date of coverage or the first day of any required group eligibility
waiting period, and the enrollment date of a late enrollee is the effective date of coverage. Pregnancy
does not constitute a pre-existing condition, nor does genetic information without a diagnosis of a
condition related to such information.
Preferred is a list of approved brand name medications used to treat various medical conditions. The
Preferred Drug List is developed by the pharmacy benefits management company and PacificSource.
Prescription drugs are drugs that, under federal law, require a prescription by a licensed physician
(M.D. or D.O.) or other licensed medical provider.
Prophylaxis is a cleaning and polishing of all teeth.
Prosthetic devices (excluding dental) means artificial limb devices or appliances designed to replace
in whole or in part an arm or a leg. Benefits for prosthetic devices include coverage of devices that
replace all or part of an internal or external body organ, or replace all or part of the function of a
permanently inoperative or malfunctioning internal or external organ, and are furnished on a physician's
order. Examples of prosthetic devices include but are not limited to artificial limbs, cardiac pacemakers,
prosthetic lenses, breast prosthesis (including mastectomy bras), and maxillofacial devices.
Pulpotomy is the removal of a portion of the pulp, including the diseased aspect, with the intent of
maintaining the vitality of the remaining pulpal tissue by means of a therapeutic dressing.
Qualified domestic partner means a registered domestic partner or unregistered same gender
domestic partner with an Affidavit of Domestic Partnership, supplied by the Plan Sponsor.
Restoration is the treatment that repairs a broken or decayed tooth. Restorations include, but are not
limited to, fillings and crowns.
Routine costs of care means medically necessary conventional care, items, or services covered by
the health benefit plan if typically provided absent a clinical trial. Routine costs of care do not include:
• The drug, device, or service being tested in the clinical trial unless the drug, device, or service
would be covered for that indication by the policy if provided outside of a clinical trial;
Items or services required solely for the provisions of the drug, device, or service being tested in
the clinical trial;
• Items or services required solely for the clinically appropriate monitoring of the drug, device, or
service being tested in the clinical trial;
• Items of services required solely for the prevention, diagnosis, or treatment of complications arising
from the provision of the drug, device, or service being tested in the clinical trial;
SingleSource Self-Insured 81
• Items or services that are provided solely to satisfy data collection and analysis needs and that are
not used in the direct clinical management of the patient;
• Items or services customarily provided by a clinical trial sponsor free of charge to any participant in
the clinical trial; or
Items or services that are not covered by the policy if provided outside of the clinical trial.
Seasonal employee is an employee who is hired with the agreement that their employment will end
after a predetermined period of time.
Skilled nursing facility convalescent home means an institution that provides skilled nursing care
under the supervision of a physician, provides 24-hour nursing service by or under the supervision of a
registered nurse (R.N.), and maintains a daily record of each patient. Skilled nursing facilities must be
licensed by an appropriate state agency and approved for payment of Medicare benefits to be eligible
for reimbursement.
Specialized treatment facility means a facility that provides specialized short-term or long-term care.
The term specialized treatment facility includes ambulatory surgical centers, birthing centers, chemical
dependency/substance abuse day treatment facilities, hospice facilities, inpatient rehabilitation facilities,
mental and/or chemical healthcare facilities, organ transplant facilities, psychiatric day treatment
facilities, residential treatment facilities, skilled nursing facilities, substance abuse treatment facilities,
and urgent care treatment facilities.
Specialty drugs are high dollar oral, injectable, infused or inhaled biotech medications prescribed for
the treatment of chronic and/or genetic disorders with complex care issues that have to be managed.
The major conditions these drugs treat include but are not limited to: cancer, HIV/AIDS, hemophilia,
hepatitis C, multiple sclerosis, Crohn's disease, rheumatoid arthritis, and growth hormone deficiency.
Specialty pharmacies specialize in the distribution of specialty drugs and providing pharmacy care
management services designed to assist patients in effectively managing their condition.
Stabilize means to provide medical treatment as necessary to ensure that, within reasonable medical
probability, no material deterioration of an emergency medical condition is likely to occur during or to
result from the transfer of the patient from a facility; and with respect to a pregnant woman who is in
active labor, to perform the delivery, including the delivery of the placenta.
Subscriber means an employee or former employee insured under the Plan Sponsor's health policy
through PacificSource. When a family unit that does not include an employee or former employee is
insured under a policy, the oldest family member is referred to as the subscriber.
Surgical procedure means any of the following operative procedures:
• Procedures accomplished by cutting or incision
• Suturing of wounds
• Treatment of fractures, dislocations, and burns
• Manipulations under general anesthesia
• Visual examination of the hollow organs of the body including biopsy, or removal of tumors or
foreign body
• Procedures accomplished by the use of cannulas, needling, or endoscopic instruments
• Destruction of tissue by thermal, chemical, electrical, laser, or ultrasound
Telemedical means medical services delivered through a two-way video communication that allows a
provider to interact with a patient who is at a different physical location than the provider.
Temporomandibular Joint Disorder (TMJ) means any dysfunction or disorder of the jaw joint
resulting in pain and impairment of the jaw.
Third Party Administrator is an administrator hired by the Plan Sponsorto perform claims processing
and other specified administrative services in relation to the plan. The third party administrator is not an
insurer of health benefits under this plan, is not a fiduciary of the plan, and does not exercise any of the
discretionary authority and responsibility granted to the Plan Sponsor. The third party administrator is
not responsible for plan financing and does not guarantee the availability of benefits under this plan.
The third party administrator is PacificSource Health Plans
SingleSource Self-Insured 82
Tobacco use cessation program means a program recommended by a physician that follows the
United States Public Health Services guidelines for tobacco use cessation. Tobacco use cessation
program includes education and medical treatment components designed to assist a person in ceasing
the use of tobacco products.
Unregistered domestic partner means an individual of the same-gender who is joined in a domestic
partnership with the subscriber and meets the following criteria:
• Is at least 18 years of age;
• Not related to the policyholder by blood closer than would bar marriage in Oregon or the state
where they have permanent residence and are domiciled;
• Shares jointly the same permanent residence with the policyholder for at least six months
immediately preceding the date of application to enroll and intent to continue to do so indefinitely;
• Has joint financial accounts with the policyholder and has agreed to be jointly responsible with the
policyholder for each others' common welfare, including basic living expenses;
• Has an exclusive domestic partnership with the policyholder and has no other domestic partner;
• Does not have a legally binding marriage nor has had another domestic partner within the previous
six months;
• Was mentally competent to consent to contract when the domestic partnership began and remains
mentally competent.
Urgent care treatment facility means a healthcare facility whose primary purpose is the provision of
immediate, short-term medical care for minor, but urgent, medical conditions.
Waiting period means the period of time before coverage becomes effective for a member who is
otherwise eligible to enroll in the plan.
Women's healthcare provider means an obstetrician, gynecologist, physician assistant or nurse
practitioner specializing in women's health, or certified nurse midwife practicing within the applicable
scope of practice.
RIGHTS OF PLAN MEMBERS
MEDICAID AND CHIP STATE CONTACT INFORMATION
If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from
your Plan Sponsor, your State may have a premium assistance program that can help pay for
coverage. These States use funds from their Medicaid or CHIP programs to help people who are
eligible for these programs, but also have access to health insurance through their Plan Sponsor. If you
or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium
assistance programs.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below,
you can contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of
your dependents might be eligible for either of these programs, you can contact your State Medicaid or
CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you
qualify, you can ask the State if it has a program that might help you pay the premiums for a Plan
Sponsor-sponsored plan.
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid
or CHIP, as well as eligible under your Plan Sponsor plan, your Plan Sponsormust permit you,to enroll
in your Plan Sponsor plan if you are not already enrolled. This is called a'special enrollment'
opportunity, and you must request coverage within 60 days of being determined eligible for
premium assistance. If you have questions about enrolling in your Plan Sponsor plan, you can contact
the Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free 1-866-444-EBSA
(3272).
If you live in one of the following States, you may be eligible for assistance paying your Plan Sponsor
health plan premiums. The following list of States is current as of July 31, 2012. You should contact
your State for further information on eligibility -
SingleSource Self-Insured 83
ALABAMA - Medicaid COLORADO - Medicaid
Website: http://www.medicaid.alabama.gov Medicaid Website: http://www.colorado.gov/
Phone: 1-855-692-5447 Medicaid Phone (In state): 1-800-866-3513
ALASKA - Medicaid Medicaid Phone (Out of state): 1-800-221-3943
Website:
http://health. hss. state.ak. usldpa/programs/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
ARIZONA - CHIP FLORIDA - Medicaid
Website: http://www.azahcecs.gov/applicants Website: https://www.flmediGaidtpirecovery.com/
Phone (Outside of Maricopa County): 1-877-764-5437 Phone: 1-877-357-3268
Phone (Maricopa County): 602-417-5437 GEORGIA - Medicaid
Website: http://dch.georgia.gov/
Click on Programs, then Medicaid, then Health
Insurance Premium Payment (HIPP)
Phone: 1-800-869-1150
IDAHO - Medicaid and CHIP MONTANA - Medicaid
Medicaid Website: Website:
www.accesstohealthinsurance.idaho.gov http://medicaidprovider.hhs.mt.gov/clientpages/
Medicaid Phone: 1-800-926-2588 clientindex.shtml
CHIP Website: www.medicaid.idaho.gov Phone: 1-800-694-3084
CHIP Phone: 1-800-926-2588
INDIANA - Medicaid NEBRASKA - Medicaid
Website: http://www.in.gov/fssa Website: www.ACCESSNebraska.ne.gov
Phone: 1-800-889-9949 Phone: 1-800-383-4278
IOWA - Medicaid NEVADA - Medicaid
Website: www.dhs.state.ia.us/hipp/ Medicaid Website: http://dwss.nv.gov/
Phone: 1-888-346-9562 Medicaid Phone: 1-800-992-0900
KANSAS - Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-800-792-4884
KENTUCKY - Medicaid NEW HAMPSHIRE - Medicaid
Website: http://chfs.ky.gov/dms/default.htm Website:
Phone: 1-800-635-2570 http:/twww.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
LOUISIANA - Medicaid NEW JERSEY - Medicaid and CHIP
Website: http://www.lahipp.dhh.louisiana.gov Medicaid Website:
Phone: 1-888-695-2447 http://ewwv.state.nj.us/humanservices/
MAINE - Medicaid dmahs/clients/medicaid/
Website: http://www.maine.gov/dhhs/ofi/public- Medicaid Phone: 1-800-356-1561
assistancefindex.html CHIP Website:
Phone: 1-800-977-6740 http://www.nifamilycare.org/index.html
TTY 1-800-977-6741 CHIP Phone: 1-800-701-0710
MASSACHUSETTS - Medicaid and CHIP NEW YORK - Medicaid
Website: http:/Avww.mass.gov/MassHealth Website:
Phone: 1-800-462-1120 http:/Avww.nyhealth.govthealth-care/medicaid/
Phone: 1-80G-541-2831
MINNESOTA - Medicaid NORTH CAROLINA - Medicaid
Website: http://www.dhs.state.mn.us/ Website: http://www.ncdhhs.gov/dma
Click on Health Care, then Medical Assistance Phone: 919-855-4100
Phone: 1-800-657-3629
MISSOURI - Medicaid NORTH DAKOTA- Medicaid
Website: Website:
http://www.dss.mo.gov/mhd/participants/pages/hipp.ht http:/Avww.nd.gov/dhs/services/medicalserv/medicai
m I d/
Phone: 573-751-2005 Phone: 1-800-755-2604
OKLAHOMA - Medicaid and CHIP UTAH - Medicaid and CHIP
Website: http://www.insureoklahoma.org Website: htto://health.utah.gov/uoo
Phone: 1-888-365-3742 Phone: 1-866-435-7414
SingleSource Self-Insured 84
OREGON - Medicaid and CHIP VERMONT- Medicaid
Website: http://www.oregonhealthykids.gov Website: http:/hvww.greenmountaincare.org/
http://www.hijossaludablesoregon.gov Phone: 1-800-250-8427
Phone: 1-877-314-5678
PENNSYLVANIA - Medicaid VIRGINIA - Medicaid and CHIP
Website: http://www.dpw.state.pa.us/hipp Medicaid Website:
Phone: 1-800-692-7462 http://www.dmas.virginia.gov/rcp-HIPP.htm
Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.famis.org/
CHIP Phone: 1-866-873-2647
RHODE ISLAND - Medicaid WASHINGTON - Medicaid
Website: www.ohhs.ri.gov Website:
Phone: 401-462-5300 http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm
Phone: 1-800-562-3022 ext. 15473
SOUTH CAROLINA - Medicaid WEST VIRGINIA - Medicaid
Website: http:/Avww.scdhhs.gov Website: www.dhhr.wv.gov/bms/
Phone: 1-888-549-0820 Phone: 1-877-598-5820, HMS Third Party Liability
SOUTH DAKOTA - Medicaid WISCONSIN - Medicaid
Website: http://dss.sd.gov Website: http://www.badgercareplus.org/pubs/p-
Phone: 1-888-828-0059 10095.htm
Phone: 1-800-362-3002
TEXAS - Medicaid WYOMING - Medicaid
Website: https://www.gethipptexas.com/ Website:
Phone: 1-800-440-0493 http://health.wyo.gov/healthcarefin/equalitycare
Phone: 307-777-7531
To see if any more States have added a premium assistance program since July 31, 2012, or for more
information on special enrollment rights, you can contact either:
U.S. Department of Labor U.S. Department of Health & Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/ebsa www.cros.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565
OMB Control Number 1210-0137 (expires 09130/2013)
SingleSource Self-Insured 85
SingleSource Self-Insured 86
PLAN INFORMATION
Name and Address of the Plan Sponsor
City of Ashland
20 East Main
Ashland, OR 97520
(541) 488-6002
Name and Address of the Designated Agent for Service of Legal Process
Dave Kanner, City Administrator
20 East Main
Ashland, OR 97520
541-488-6002
Name and Address of the Third Party Administrator
PacifcSource Health Plans
PO Box 7068
Springfield, OR 97475-0068
(888) 977-9299
Fax: (541) 684-5264
Internal Revenue Service and Plan Identification Number
The corporate tax identification number assigned by the Internal Revenue Service is
936002117.
Plan Year
The plan year is the 12-month period of time beginning January 1 and ending December 31.
Method of Funding Benefits
Health benefits are self-insured from the general assets and or trust funds of the Plan Sponsor
and are not guaranteed under an insurance policy or contract. The Plan Sponsor may purchase
excess risk insurance coverage which is intended to reimburse the Plan Sponsor for certain
losses incurred and paid under the plan by the Plan Sponsor. Such excess risk coverage, if
any, is not part of the plan. The cost of the plan is paid with contributions by the Plan Sponsor
and participating employees. The Plan Sponsor determines the amount of contributions to the
plan, based on estimates of claims and administration costs.
Payments out of the plan to health care providers on behalf of the covered person will be based
on the provisions of the plan.
SingleSource Self-Insured 87
SingleSource Self-Insured 88
SIGNATURE PAGE
The effective date of the Preferred 90+200 VAR GF 0812 is July 1, 2013.
It is agreed by the City of Ashland that the provisions of this document are correct and will be the
basis for the administration of the Preferred 90+200 VAR GF 0812.
Dated this day of
By
Title
SingleSource Self-Insured 89
SingleSource Self-Insured 90
Exhibit'C'
DUTIES AND RESPONSIBILITIES OF THE EMPLOYEE HEALTH
BENEFITS ADVISORY COMMITTEE
In the interest of providing a quality health insurance benefit program on a consistent basis to
all regular City employees, the City Council will create an Employee Health Benefits Advisory
Committee (EHBAC). The primary responsibility of the EHBAC will be to meet with
Personnel staff, the agent of record, and insurance representatives, in order to review/evaluate
all possible options with regard to employee benefits. The EHBAC will make
recommendations to the City Council regarding insurance benefits.
Specific responsibilities of the EHBAC include:
• Review monthly loss run and claims reports to identify trends and issues that could pose
a threat to the fiscal integrity of the health insurance plan;
• Monitor the performance of the third party administrator and other benefit
administrators;
• Review and recommend deletions or additions to the health benefits plan, as well as
changes in deductibles, co-pays, out-of-pocket maximums and other direct employee
costs;
• Annually recommend to the City Council a plan document that establishes benefit levels
within budgetary constraints;
• Provide a forum for employees to raise concerns about specific elements of the health
benefits plan;
• Serve as a conduit for information and questions from employees to the committee and
the plan administrator.
Members of the EHBAC shall at all times protect confidential information from disclosure and
shall honor requests for confidentiality from individual employees who have concerns or who
want to offer suggestions and input to the committee anonymously. EHBAC members are not
expected to resolve problems and concerns with individual claims or to contact the third party
administrator or other benefits administrators. Such contacts should be made only by the
Human Resources Office or the plan administrator.
EHBAC MEMBERSHIP
The EHBAC will be comprised of the following voting membership:
One representative from IBEW Local 659 (Clerical/Technical)
One representative from IBEW Local 659 (Electrical Workers)
One representative from the Ashland Firefighter's Association
One representative from the Ashland Police Association
One representative from Laborers Union Local 121
One representative from the Parks and Recreation Department
Four management and/or non-represented employees
The City Administrator or designee will be a non-voting member of the committee. Additional
non-voting members may be appointed at the discretion of the committee. Committee
Exhibit'C'
membership may be modified from time to time in order to ensure an equal balance of
represented and non-represented employees.
A Chair and Vice Chair will be selected annually by the committee, with one position to be
filled by a manager and the other will be a non-management representative.
The Human Resources Office will provide staff support to the committee.
MINIMUM MEETING REQUIREMENTS
At a minimum, the EHBAC will strive to meet monthly and in no case less than eight (8) times
per year. Additional meetings may be scheduled at the discretion of the committee.
Subcommittees may also be established at the discretion of the committee.
The EHBAC may request the removal or replacement of a voting member who is not able to
attend two (2) or more consecutive EHBAC meetings, or four (4) or more meetings in any
twelve-month period.
No vote shall be taken on any recommendation to the City Council in an EHBAC meeting
without a quorum present. A quorum is defined as a majority of the voting members, not
including vacant positions.
The meetings will be open to all interested employees. Minutes of each meeting will be kept
and in turn distributed to each committee member, the City Council and Department Heads, and
will be posted on department bulletin boards. All employees with an e-mail address will
receive notice of planned meetings and an electronic copy of the minutes of each meeting.