HomeMy WebLinkAbout2014-0603 Council Agenda PACKET
CITY OF
ASHLAND
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AGENDA FOR THE REGULAR MEETING
ASHLAND CITY COUNCIL
June 3, 2014
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
III. ROLL CALL
IV. MAYOR'S ANNOUNCEMENTS
V. APPROVAL OF MINUTES
1. Study Session of May 19, 2014
3. Executive Session of May 19, 2014
4. Business Meeting of May 20, 2014
VI. SPECIAL PRESENTATIONS & AWARDS
1. Annual Presentation by the Band Board
2. Proclamation of June 14, 2014 as Flag Day in Ashland
VII. CONSENT AGENDA
1. Approval of commission, committee, and board minutes
2. Liquor License Application for Kevin Broadie dba Saltworks, LLC
3. Ambulance operator's license renewal
4. Award of contract to apparent low bidder for the Lori Lane Alley Connection
project
5. A resolution establishing rates for the Ashland Municipal Airport and repealing
Resolution 2013 - 16
6. Ratification of five-year labor contract with the Laborers' International Union of
North America Local No. 121
7. A resolution exercising the Power of Eminent Domain for the Walker Avenue
Safe Routes to School project
COUNCIL MEETINGS ARE BROADCAST LNE ON CHANNEL 9. STARTING APRIL 15, 2014,
CHARTER CABLE WILL BROADCAST LNE ON CHANNEL 180.
VISIT THE CITY OF ASHLAND'S WEB SITE AT WWW.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})
1. Public Hearing and approval of a resolution titled, "A resolution adopting a
Miscellaneous Fees and Charges document and repealing prior fee resolution
2013-17"
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
None
XI. NEW AND MISCELLANEOUS BUSINESS
1. Adoption of the City's self-insurance health plan for the plan year July 1, 2014
through June 30, 2015
2. Update from the Housing and Human Services Commission regarding the
development of the Strategic Social Services Grant review
XII. ORDINANCES. RESOLUTIONS AND CONTRACTS
1. Second reading by title only of an ordinance titled, "An ordinance amending AMC
Chapter 2.26, Firewise Commission to Ashland Wildfire Mitigation Commission"
2. First reading by title only of an ordinance titled, "An ordinance amending the City
of Ashland Comprehensive Plan to add a Normal Neighborhood Plan designation
to Chapter II [Introduction and Definitions], change the Comprehensive Plan map
designation for approximately 94 acres of land within the City of Ashland Urban
Growth Boundary from Single Family Residential and Suburban Residential to
the Normal Neighborhood Plan designations, and adopt the Normal
Neighborhood Plan framework as a support document to the City of Ashland
Comprehensive Plan"
and
First reading by title only of an ordinance titled, "An ordinance amending the
Street Dedication Map, Planned Intersection and Roadway Improvement Map,
and Planned Bikeway Network Map of the Ahsland Transportation System Plan
for the Normal Neighborhood Plan area, and amending Street Design Standards
within the Street Standards Handbook to add a new Shared Street classification"
XIII. OTHER BUSINESS FROM COUNCIL MEMBERSIREPORTS FROM COUNCIL
LIAISONS
XIV. ADJOURNMENT OF BUSINESS MEETING
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. STARTING APRIL 15, 2014,
CHARTER CABLE WILL BROADCAST LIVE ON CHANNEL 180.
VISIT THE CITY OF ASHLAND'S WEB SITE AT WWW.ASHLAND.OR.US
Minutes for the City Council Study Session
May 19, 2014
Page I of 1
MINUTES FOR THE STUDY SESSION
ASHLAND CITY COUNCIL
Monday, May 19, 2014
Siskiyou Room, 51 Winburn Way
Mayor Stromberg called the meeting to order at 5:31 p.m. in the Siskiyou Room.
Councilor Morris, Marsh, Lemhouse, Slattery, and Rosenthal were present. Councilor Voisin arrived at
5:34 p.m.
1. Look Ahead review
City Administrator Dave Kanner reviewed items on the Look Ahead. City Attorney Dave Lohman
addressed the medical marijuana ordinance coining before Council June 17, 2014 and distributed a
document of possible marijuana facility requirements for Council to consider.
2. Recommendation of the Downtown Beautification Committee to remove the kiosk from the
Plaza
City Administrator Dave Kanner explained there were three options for the kiosk at the Plaza. One would
leave it where it was currently, the second was remove the structure and not replace it, and the third was
having staff suggest alternative locations to Council. Replacing the kiosk roof was scheduled for 2018-
2019 and currently replacing the roof now or removing the structure would cost approximately $4,000.
Council directed staff to develop alternatives for the kiosk, post the topic on the website for discussion,
and bring the results to a future meeting for further discussion.
3. Discussion of options for local taxation of marijuana
City Administrator Dave Kanner explained Council needed to provide direction on whether to draft an
ordinance taxing marijuana. If Council was interested in the ordinance, he recommended a gross receipts
tax for easier administration. Ballot measure language contained a local preemption that the legislative
delegation would have to grandfather Ashland in if the measure passed recreational marijuana use. Staff
also recommended the ordinance indicate marijuana in general and not distinguish it from medical
marijuana.
City Attorney Dave Lohman explained the ordinance could have a two-tiered system regarding medical
and recreational marijuana or set the rates by resolution. Council wanted options that taxed medical
marijuana at 0% or a nominal amount and up to 25% for recreational marijuana and information on taxing
growers, producers, and distributors. Council also wanted legal analysis and the economic impact of
certain type of taxes in addition to tax options. Staff noted the City could have a value added tax on the
dispensary and the provider. Council could also allow the entity to retain 5% of the 5% tax collected for
administering their records. Council directed staff to proceed on drafting an ordinance.
Meeting adjourned at 6:25 p.m.
Respectfully submitted,
Dana Smith
Assistant to the City Recorder
Regular City Council Meeting
May 20, 2014
Page I of 7
MINUTES FOR THE REGULAR MEETING
ASHLAND CITY COUNCIL
May 20, 2014
Council Chambers
1175 E. Main Street
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, Lemhouse, Rosenthal, and Marsh were present.
MAYOR'S ANNOUNCEMENTS
Mayor Stromberg announced vacancies on the Airport, Conservation, Firewise, Forest Lands, Historic,
Public Arts, and Tree Commissions. There was also one vacancy on the Citizen Budget Committee.
Mayor Stromberg removed the Planning Commission's report regarding short-term rentals from the agenda
for a future meeting and moved Public Forum after the Consent Agenda with Council consent.
APPROVAL OF MINUTES
The minutes of the Special Meeting of April 22, 2014, Study Session of May 5, 2014, Executive Session of
May 6, 2014, and Business Meeting of May 6, 2014 were approved as presented.
SPECIAL PRESENTATIONS & AWARDS
Firewise Commission member Eric Olson provided the annual presentation on the Commission and shared
accomplishments.
CONSENT AGENDA
1. Approval of commission, committee, and board minutes
2. Award of a professional services contract in excess of $75,000 for consultant engineering of the A
Street Sewer Project
3. TGM Grant application approval for Siskiyou Blvd. Pedestrian Study
4. Award of contract to apparent low bidder for the 2014 Slurry Seal Project
5. Approval of an intergovernmental agreement between Jackson County and the City of Ashland for
Sobering Unit Services
6. Award of professional services contract for the Water Rate Cost of Services Study
7. Third Quarter Financial Report for year one of the 2013-2015 Biennium
8. Declare the barn located at Ashland Creek Park, 27 E. Hersey Street, as surplus property
Council pulled Consent agenda items #3, #5, and 46 for further discussion.
Engineering Services Manager Scott Fleury addressed the Traffic Growth Management (TGM) grant
application and explained they could extend the pedestrian study parameters to Walker Street and Fire
Station # 1. It would require amending the cost for the study possibly $5,000-$10,000. The grant had a 12%
match the City could meet through staff time. The Downtown Multi Modal Committee was looking into
pedestrian traffic issues in the downtown area. Staff also involved consultant Traffic Engineer Kim Parducci
to look at pedestrian safety in the downtown corridor. Ms. Parducci conducted an analysis on the pedestrian
fatality that occurred on Water Street and North Main that resulted in eliminating parking along the north
side of Water Street to increase sight distance.
Councilor Marsh/Lemhouse m/s to approve Consent Agenda item #3 the TGM grant application for
the Siskiyou Boulevard Pedestrian Study with the area to be studied defined as that portion of the
Regular City Council Meeting
May 20, 2014
Page 2 of 7
road between Fire Station #1 and Walker Street. Voice Vote: all AYES. Motion passed.
Councilor Marsh clarified Consent Agenda item #5 noting Jackson County contracted to the non-profit
Addictions Recovery Center who provided sobering services.
Public Works Director Mike Faught addressed Consent Agenda Item #6 Water Rate Cost of Services (COS)
Study and explained the four additional meetings would analyze different conservation levels and tiers.
Councilor Rosenthal/Voisin m/s to approve the Consent Agenda with the exception of the previously
approved Consent Agenda Item #3. Voice Vote: all AYES. Motion passed.
PUBLIC FORUM
Jonny Boulton/165 East Main Street/Provided an update on a group that consisted of Mayor Stromberg,
Councilor Marsh and citizens for and against the gun ordinance. He asked Council to add the gun ordinance
to a future agenda for a final decision.
Jackson Bangs/632 Chestnut/Jackson County Fuel Committee/Explained the Committee's mission to
provide heat to low income households. He opposed the utility rate increases and described the affect it had
on low income household.
Robin Haptonstall/341 Beach Street/Stated that his liberty was very important to him and wanted the gun
ordinance to come before Council as soon as possible.
PUBLIC HEARINGS
1. Public Hearing and approval of five resolutions proposing utility rate increases and repealing
prior resolutions
City Administrator Dave Kanner explained there were five resolutions to increase utility rates for the
transportation utility fee, the storm drain utility fee, water rates, wastewater rates, and electric rates. The rate
increases totaled a 6.5% increase to the average residential customer. The Electric rate was 3.6% and would
build up the Electric Department's working capital that had decreased over the past three years. The City
would use the funds for system wide improvements and capital projects. The water and wastewater increase
would fund capital projects identified as necessary in the Water and Wastewater Master Plans. The
community was dealing with antiquated infrastructure that needed updating. He acknowledged the increase
was painful and noted programs that provided assistance.
Electric Director Mark Holden addressed the electric service increase and explained the 3.6% would apply
across all rate classes. The rate increase involved four components, personal services, materials, Bonneville
Power Association (BPA) costs specifically the new Oversupply Management Protocol (OMP) charge, and
increased transmission costs. The contribution to the Ending Fund Balance (EFB) would stabilize the
decline experienced over the past years.
Mr. Holden clarified the Electric User Tax (EUT) was not in the Electric Department, collected separately by
the City for the General Fund and subsequently not included in the 3.6% rate increase. The rate increase
would build the EFB up to $1,800,000 over the next 2-3 years.
Mr. Kanner explained the electric utility did not include the EUT or the franchise fee in the rate calculations.
The EUT was 25% of the electric bill whether Council raised electric rates or not. That 25% did not change
and the franchise fee was a percentage of gross revenue. If gross revenue decreased, the franchise fee
revenue to the General Fund went down as well and Council would have to cut a project to offset the loss of
revenue. Mr. Kanner would review and bring options to modify the franchise fees and EUT to Council at a
future Study Session.
Regular City Council Meeting
May 20, 2014
Page 3 of 7
Utility Billing Supervisor Bryn Morrison addressed requirements for electric utility assistance and explained
the program was income based at 60% of the state median income.
Public Works Director Mike Faught and Financial Analyst Ray Bartlett from Economic & Financial Analysis
explained the rate increases for water, sewer, the transportation fee, and the storm water fee. Increases
included 10.8% for water, 10% for wastewater, and 2.57% each for transportation and storm drain. The rate
increase for water snatched the Water Master Plan. The TAP project came in higher than the $2,000,000
allocated in the Water Master Plan due to construction and an unexpected $3,000,000 System Development
Charge (SDC) to the Medford Water Commission to use the water. Mr. Bartlett revised the master plan to
accommodate the cost overrun in the TAP project by moving $2,700,000 in projects further out. Another
change was $26,000,000 of capital improvement projects over the next 10 years originally financed at 5%
over a 20-year period. Staff was working with the State to change that to 1% over a 30-year period along
with a grant. These revisions enabled the rate increase to remain at what the Water Master Plan initially
recommended.
The Wastewater Master Plan was on track. The Transportation and Storm Drain rate increases matched the
increase in capital costs. The Transportation Master Plan was complete and the financing was still pending.
The Storm Drain Master Plan was underway. The City was spending 99% of the revenues in the
transportation system on operations leaving very little for capital improvements. The increase in the fee
would add another $33,500 for capital improvements for the future. The Storm Drain fund ran at a deficit.
Mr. Faught clarified the Transportation Utility Fee Study was in the current budget but due to the TAP
project would not move forward until the fall. He confirmed annual 10% rate increases for wastewater
through 2017 with annual 10% increases for water through 2016 where it would drop to 7.9% in 2017 then
3.7% in 2018.
Public Hearing Open: 8:24 p.m.
Sue Crader/2957 Barbara Street/Explained she was the Executive Director of Ashland Supportive Housing
and Community Outreach, and spoke on behalf of the non-typical utility user. She shared utility rates
incurred since 2008 that totaled an increase of $3,475 or 24% and noted salaries had not increased. Her
agency and other businesses were getting squeezed tighter and tighter. She urged Council to examine what
they could do to alleviate the impact of the increases for non typical users, low-income or fixed income.
Pamala Joy/472 Walker Avenue/Ran the Ashland Food Angels and noted that the people she worked with
struggled to make ends meet. Recently Food Angels became part of Partners for a Hunger Free Oregon. She
read statistics that stated the cost of living in Oregon was higher than the national average, 500,000
Oregonians had struggled to get enough food to eat. Hunger was a symptom of lack of sufficient income to
pay basic expenses and an indicator of systemic issues in the economy. She went on to read a poem she
wrote.
Ron Roth/6950 Old 99 South/Understood the need to raise the water rates. The TAP project cost a lot of
money. One of his concerns was the idea of going to curtailment rates before it was necessary. Curtailment
rates should not go into effect until mid September. As far as the overall rate increase, he speculated that
more than 1% of Ashland residents were part of the "1%." There was also a large population of low-income
people and that is where the City should be concerned. He liked the assistance programs and thought the
City should expand them. He also thought Ashland had more water than people thought.
Emma Barry/659 Fordyce Street/Spoke on behalf of Jackson County Fuel Committee (JCFC) who
encouraged Council to reject any utility rate increase until the City had exhausted all alternatives. Of the 178
families the JCFC helped 40 faced shut offs from the City. Statistic showed low-income families reduced
their food budget $9 a month when there was a 10 degree drop in temperature while wealthier families
increased their food budget $11 per month. The increase would harm the poor. The JCFC understood the
Regular City Council Meeting
May 20, 2014
Page 4 of 7
reasons for the increase in rates, shared ways the City assisted JCFC, and listed questions they wanted
answered for the community. She went on to ask Council to enact a moratorium for shut offs for low income
residents from November 1 through March 31 and establish a year round 30% discount for low-income
households as well.
Public Hearing Closed: 8:39 p.m.
Councilor Rosenthal/Marsh m/s to approve Resolution #2014-02 for Water Service. DISCUSSION:
Councilor Rosenthal thought it was responsible to increase the fee based on the amount of research and
calculations done on water infrastructure needs going forward. The state revolving loan fund would require
this adjustment in order to be eligible for loan forgiveness. Councilor Marsh added this was the most
responsible path to develop a sustainable water system. The 1% loan from the state would help pay for a
portion and required a contribution from the community. Councilor Lemhouse noted the aging infrastructure
and now everyone was facing rising costs because action not previously taken and he was not willing to do
that to the future residents of the town. Not taking these steps would create more difficulty for the future.
Councilor Voisin commented water use paid for infrastructure and the General Fund and alternately Council
had a goal to make Ashland affordable. She knew that conservation was the best and most reliable way of
securing water supply and wanted the City to do more.
Roll Call Vote: Councilor Marsh, Rosenthal, Morris, Slattery, and Lemhouse, YES; Councilor Voisin,
NO. Motion passed 5-1.
Councilor Voisin/Slattery m/s to reopen the Public Hearing on utility rates. Voice Vote: all AYES.
Motion passed.
Public Hearing Opened: 8:47 p.m.
Kristin Dilling-Conand/65 Woolen Way #2/Explained that at this point with utility rates it was a choice of
food and utilities for herself and her tenants. She was disabled and during the winter could not buy food
because of her electric bill. The rates just went up in December and the City explained they had used more
power and she claimed they did not. She had three tenants already struggling to pay rent and their electric
rates were going to ACCESS. It was a lot of money for people who did not have good jobs and struggled to
remain in Ashland. Fees were running her out of Ashland. The December rate increase was supposedly to be
6% and with taxes, it was closer to 7%. She assumed the new increase was similar and noted that was 15%
in five and a half months. Council raised the rates already to pay for TAP. She did not think it was fair.
Public Hearing Closed: 8:50 p.m.
Councilor Rosenthal/Marsh m/s to approve Resolution #2014-03 for Wastewater (Sewer) Service.
DISCUSSION: Councilor Rosenthal commented it was difficult approving fees. In 2012, the Waste Water
Master Plan outlined $10,800,000 of high priority capital projects to ensure compliance with all regulatory
requirements and to meet future needs. It was irresponsible to delay or decline adjusting this particular fee
increase. Roll Call Vote: Councilor Rosenthal, Marsh, Slattery, Morris, and Lemhouse, YES;
Councilor Voisin, NO. Motion passed 5-1.
Councilor Marsh/Slattery m/s to approve Resolution #2014-04 for a Transportation Utility Fee.
DISCUSSION: Councilor Marsh explained the streets were degrading at a rate that would cost the
community more in the future. It was important to move forward with the Transportation Utility Fee study
so the City would manage street maintenance issues on a macro level than adding cost of living increases to
the transportation fee. Councilor Slattery agreed. Councilor Voisin did not see any alternative for street
maintenance and would support the increase. Councilor Rosenthal added the metric communities used to
determine quality of street conditions had declined 20 percentage points over the past few years, used East
Main Street as an example, and noted other streets would look similar if the City did not take action.
Regular City Council Meeting
May 20, 2014
Page 5 of 7
Roll Call Vote: Councilor Lemhouse, Morris, Voisin, Marsh, Rosenthal, and Slattery, YES. Motion
passed.
Councilor Morris/Lemhouse m/s to approve Resolution #2014-05 for a Storm Drain Utility Fee.
DISCUSSION: Councilor Morris explained the City was falling behind on maintenance. Councilor
Lemhouse agreed on the infrastructure and explained it was not easy to raise rates, the public elected Council
to make these decisions, and Council needed to make them. Councilor Voisin would support the motion
since there were no other alternatives. Roll Call Vote: Councilor Voisin, Marsh, Rosenthal, Morris,
Slattery, and Lemhouse, YES. Motion passed.
Councilor Voisin/Slattery m/s the electric utility increase and place a moratorium on the Electric User
Tax and the Franchise Fees for those increases directing staff to develop progressive rates with
conservation incentives and a progressive tax structure for the Electric User Tax repealing Resolution
2013-34. DISCUSSION: Councilor Voisin thought it was time to think creatively, admit part of the
conundrum was paying bills, and find other ways. The City did not need a "Cadillac" solution for all cases.
She wanted to know and have the public understand how rate increases affected the General Fund and how
the City would use the increase. Councilor Slattery explained he had not been comfortable increasing the
Electric User Tax (EUT) for a while and thought Council needed to look at in a more comprehensive fashion
and would support the motion.
Councilor Voisin clarified the motion retained the EUT and stopped increases until further study.
Accounting Manager Cindy Hanks confirmed the EUT was an ordinance and the City could handle the
franchise fees internally. Mr. Kanner added revising the rate structure to reward electric conservation was a
larger endeavor and probably required hiring a consultant. Mayor Stromberg commented the motion was not
explicit enough or checked for feasibility. Councilor Lemhouse called for a point order and explained
Councilor Voisin had the opportunity to speak to the motion. He did not think there was another opportunity
to ask questions of staff or seek further clarification. That needed to happen in the motion itself. Roll Call
Vote: Councilor Voisin, YES; Councilor Marsh, Rosenthal, Morris, Slattery, and Lemhouse, NO.
Motion failed 5-1.
Councilor Marsh/Morris m/s to approve Resolution #2014-06 for Electric Service.
DISCUSSION: Councilor Marsh explained Council would address the EUT in a Study Session already
scheduled and that was the time to make adjustments if needed. Ashland owned its own electric utility and
bills were less than other cities and there were subsidy programs that accepted anyone who qualified.
Councilor Morris added this was the only option at this time and wanted the rate structure, franchise fees,
and EUT studied further.
Councilor Voisin noted all the utility increases had a 49% percent tax or fee that needed to be curtailed or
decreased. She wanted progressive taxes and rates so those who used more paid more and conservation
efforts were rewarded through rates. Councilor Slattery would not support the motion and wanted the
process of raising rates reviewed and revised.
Councilor Lemhouse would support the increase, agreed the rate process needed work and that work would
happen. It was frustrating to hear arguments about taking care of people by voting against this when Council
did not lower rates or taxes in other ways and added fees on things that people did in their daily lives. He
would support the motion because it needed to happen. Councilor Slattery asked Council to consider that
one way of making a new plan was voting against the rate increase. Councilor Voisin agreed with Councilor
Slattery. Roll Call Vote: Councilor Marsh, Morris, and Lemhouse, YES; Councilor Voisin, Slattery,
and Rosenthal, NO. Mayor Stromberg broke the tie with a YES vote. Motion passed 4-3.
Mayor Stromberg was confident Council could resolve the issue of the Electric User Tax and did not want to
shut down financial processes as a way of achieving it.
Regular City Council Meeting
May 20, 2014
Page 6 of 7
2. Public Hearing and approval of a resolution titled, "A resolution adopting a Miscellaneous Fees
and Charges document and repealing prior fee resolution 2013-17"
Item delayed.
3. Continuation of the Public Hearing and first reading of two separate ordinances amending the
City of Ashland Comprehensive Plan, Comprehensive Plan Maps, Transportation System Plan, and
Street Standards to adopt the Normal Neighborhood Plan
ABSTENTIONS, CONFLICTS. EXPARTE CONTACT
None reported.
THOSE WISHING TO PROVIDE TESTIMONY
Public Hearing-continued: 9:18 p.m.
Sue DeMarinis/145 Normal Avenue/Read from a document submitted into the record.
Sherry Smilo/2305 C Ashland Street #281/Did not support consultants from out of the area and thought
they should at least live in Jackson County to see how their plans affected the public. She shared her
experience blocking an action to build a road in her back yard. New roads would bring issues and impact.
Wesley Bishop/280 Normal Avenue/Understood that when he moved to Normal 26 years ago his property
was part of the Urban Growth Boundary (UGB) and new change would occur. He supported neighborhood
growth but wanted wise and prudent planning.
Gil Livni/240 Normal Avenue/Read from a document submitted into the record.
Anya Neher/237 Clay Street/Noted the area around Clay Street already supported a lot of high-density
housing that caused increased traffic. She thought it was a lot asking one section of town to keep taking
more high-density housing. She asked Council look into the density and height allowance in the plan:
Councilor Slattery/Voisin m/s to continue the Public Hearing to the next Council Meeting.
DISCUSSION: Councilor Lemhouse would not be present at the next meeting and did not think they should
postpone due to his schedule. Councilor Rosenthal suggested scheduling a special meeting instead.
Councilor Voisin wanted to be sure there was enough time for staff to complete their report and hear from
the Planning Commission. Councilor Lemhouse would vote against the motion and supported having a
special meeting. Roll Call Vote: Councilor Voisin, YES; Councilor Rosenthal, Slattery, Marsh,
Lemhouse, and Morris, NO. Motion failed 5-1.
Councilor Lemhouse/Slattery m/s to schedule Special Meeting on the Normal Avenue project for the
evening of May 29, 2014. DISCUSSION: Councilor Marsh would not support the motion and thought it
should continue to the regular Council meeting June 3, 2014. Council discussed starting the meeting at 7:30
p.m. Roll Call Vote: Councilor Rosenthal, Slattery, Voisin, Lemhouse, and Morris, YES; Councilor
Marsh, NO. Motion passed 5-1.
Mayor Stromberg clarified they would take public testimony from those who filled out speaker request forms
for the May 6 or May 20 meeting and did not speak, and those who wished to speak and had not but would
not hear testimony from people who had already spoken on the manner.
UNFINISHED BUSINESS - None
NEW AND MISCELLANEOUS BUSINESS
1. Planning Commission's report on considering a limited type of short-term traveler
Regular City Council Meeting
May 20, 2014
Page 7 of 7
accommodation in residential zones
Removed from agenda.
ORDINANCES. RESOLUTIONS AND CONTRACTS
1. First reading by title only of an ordinance titled, "An ordinance amending AMC Chapter 2.26,
Firewise Commission to Ashland Wildfire Mitigation Commission"
Division Chief-Forest Resource Chris Chambers explained the proposed ordinance changed the charter of the
commission only. It would give them a broader purview of issues to consider under the Fire Adapted
Communities program but would not create an impetus in any way for landowners to have to remove
vegetation. The Commission might consider that in the future and that would require sending it to the
Planning Commission then to Council.
Councilor m/s to approve First Reading of the ordinance and place it on the agenda for Second
Reading. Roll Call Vote: Councilor Slattery, Rosenthal, Voisin, Morris, Lemhouse, and Marsh, YES.
Motion passed.
OTHER BUSINESS FROM COUNCIL MEMBERS/REPORTS FROM COUNCIL LIAISONS
Councilor Rosenthal explained that each summer the Conservation Commission collaborated with Recology
to offer free composting classes in Ashland. Basic Composting class dates were June 7; 2014, and July 5,
2014. Advance Composting class dates were August 2, 2014 and the Vermicomposting class was September
6, 2014. All classes would happen at the Ashland Recycle Center on Water Street, 2:30-4:30 p.m.
Councilor Lemhouse provided a liaison report on the Downtown Beautification Committee that met May 8,
2014 and made recommendations for projects that staff would provide price summaries and the Committee
will refine their list further.
Councilor Voisin announced the portable shower trailer service was at the food bank and the United
Methodist Church. She expressed gratitude to Jon Warren, the owner of the Holiday Inn Express who
volunteered to launder used towels.
Councilor Marsh invited everyone to attend the ongoing community discussion on guns. The next meeting
was May 29, 2014 at 6:00 p.m. at the Library in the large meeting room.
City Administrator Dave Kanner noted the City was not putting out the hanging baskets in the Plaza this
summer, the Downtown Beautification Committee asked to hang colorful pennants from the pedestrian
lamps. He would also send Council alternative locations for the Plaza information kiosk. Staff was also
launching a water wise campaign that would start in June.
Councilor Morris announced the Historic Preservation awards would occur the next night at 1:00 p.m. in the
Community Center at Winburn Way.
ADJOURNMENT
Meeting was adjourned at 10:04 p.m.
Barbara Christensen, City Recorder John Stromberg, Mayor
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PROCLAMATION 00
° • By act of Congress of the United States dated June 14, 1777, the first
official flag of the United States was adopted.
• By act of Congress dated August 3, 1949, "National Flag Day" was
Q designated each year as June 14.
• The Congress has requested the President to issue annually a
proclamation designating the week in which June 14 occurs as
National Flag Week.
• Flag Day celebrates our nations symbol of unity, a democracy in a
republic, and stands for our country's devotion to freedom, to the rule
of all, and to equal rights for all.
• We pay our respect to all of the many veterans who have served the 00
armed forces of their country.
NOW, THEREFORE, I, John Stromberg, Mayor of Ashland, do hereby
proclaim June 14, 2014 as
7
FLAG DAY in the City of Ashland
e and urge all citizens of Ashland to join in with the Ashland Elks Lodge
#944 to Pledge of Allegiance to our Flag and Nation, at noon on
Thursday, June 14 at the Ashland downtown Plaza.
Dated this 3rd day of June, 2014
John Stromberg, Mayor
6 ~
Barbara Christensen, City Recorder
00
• ~ifi~
`Kjr~~ o o e 0
ZZU
CITY OF
ASHLAND
Ashland Housing and Human Services Commission
Minutes April 24, 2014
CALL TO ORDER
Chair Joshua Boettiger called the meeting to order at 4:35 in the Siskiyou Room at the Community Development and
Engineering Offices located at 51 Winburn Way, Ashland OR 97520.
Commissioners Present: Council Liaison
Joshua Boettiger Pam Marsh, absent
Heidi Parker, left a 5:10
Connie Saldana SOU Liaison
Michael Gutman Andrew Ennslin
Regina Ayars, absent
Rich Rohde, absent Staff Present:
Coriann Matthews Linda Reid, Housing Specialist
Sue Crader Carolyn Schwendener, Admin
Clerk
Gina DuQuenne
Approval of Minutes
Saldana/Parker m/s to approve the minutes of the March 27, 2014 Housing and Human Services Commission.
Voice Vote: All Ayes; minutes were approved as presented.
PUBLIC FORUM
Kathy Kennedy, Landlord and citizen of Ashland was present to listen and participate in the Student Fair Housing
Discussion.
Holly Smith introduced herself stating that she is in Pat Acklin's Planning Issues class at SOU. She will be
participating in a presentation to the Housing and Human Services Commission at a future meeting.
Christy Wright, Fair Housing campaign manager for ASSOU was present.
STUDENT FAIR HOUSING DISCUSSION
Reid acknowledged that the Council voted to direct the Housing and Human Services Commission to study and
develop a recommendation on whether students should be added as a protected class in the City's Fair Housing
ordinance. The Council also directed the Commission to discuss other ways aside from the designation as a
protected class that would provide better protection for students.
Ennslin and Wright expressed their appreciation that the Council considered the request of making students a
protective class and directed it to this Commission for discussion.
The Commissioners discussed their different experiences with living next door or renting to SOU students. Their
experiences were everything from respectful and wonderful to rowdy and drunkenness. The consensus was that it
has not always been pleasant to live next door to students. The commissioners suggested looking at innovative
ways to diminish some of the problems. They were interested in learning how other college communities have
addressed similar issues. Is there a certification process to assure landlords of responsible renters?
Christy Wright recently had a discussion with Janay Haas, author of the book entitled "Landlord Tenant rights in
Oregon." She is a criminal justice professor at SOU and has been an attorney for landlord tenant disputes for about
twenty years. "Ms. Haas is very enthusiastic about helping us with this project", stated Wright.
The Commission encouraged the idea of educating students who may never have been tenants before. They
would support a class that would raise the awareness of what it is to be a good tenant. Currently ACCESS offers
a six week "Ready to Rent" class. After completing the class the participants get a certificate that can be showed to
landlords confirming their intent to be a good tenant. Another idea is to have a fund designated as a security
deposit for landlords that would give some guarantee they would get their money.
The question was proposed "Why do property owners reject students?"
Kathy Kennedy clarified that being a landlord is a business model; it's an investment on someone's part. Ms.
Kennedy said a landlord wants a good tenant. To find those tenants a landlord will use criteria such as
references, qualified income and good credit history. Ms Kennedy explained she has had both good experiences
and bad experiences with students as well as with working people. She questions whether a protected class is
necessary and suggested doing a survey with Ashland landlords. To her knowledge she has not noticed landlords
practicing discrimination against students and would like to see input from landlords to confirm their truly is a
discrimination problem. Wright acknowledged that creating a protected class is not going to stop landlords from
screening their applicants and finding good tenants. What is important is that fair standards apply to everyone and
that landlords don't unfairly single out students.
The next step is to talk with ACCESS regarding their Ready to Rent program and class availability. Wright would
like to work with Ms Kennedy on organizing a focus group with students and landlords. They will put information
together and set a date and time.
BRIEF OVERVIEW OF AFFORDABLE HOUSING PROGRAM
Reid gave an overview of the City of Ashland Housing program explaining affordable housing is one component of it.
In general terms affordable housing refers to a household's ability to find housing within their financial means. The
standard measure of affordability as defined by the U.S. Department of Housing and Urban Development (HUD) is
when the cost of rent and utilities (gross rent) is less than 30% of household income. When gross rent levels exceed
30% of income it places a significant burden on household finances.
Here are three main types of Affordable Housing
1. Workforce Housing
2. Low-Income Housing
3. Subsidized Housing
Federal financing is offered through Rural Development, HUD and the National Housing Trust Fund. State
financing can be through Oregon Housing Tax Credits, Low-income Housing tax credits, Vertical Housing Program
and Pass through Revenue Bond financing.
The City of Ashland has a Housing Trust Fund which currently has between $140,000 and $170,000 in it. These
funds can be used in a variety of ways.
SOCIAL SERVICE GRANT RECOMMENDATION TO COUNCIL REVIEW AND APPROVAL
Reid explained that it is the responsibility of this Commission to come up with a Social Service Grant process
recommendation to the Council at their June 3, 2014 meeting. The Commission would like to develop a strategic
plan for the Social Service Grant money. The following is the grant proposal to the Council including what the
Housing and Human Services Commission will do.
• Work with staff to develop program specific Strategic Plan with measurable goals and objectives to inform the
decision making process in awarding social service grant funds.
• Work with Council to define broad priorities for the use of the funds and measurable goals.
• Review the previously drafter strategic plan for the use of Social Service Funds to see if there are priorities
identified which are still relevant.
• Engage current and former grantees, social service organizations and the public in reviewing the current
process, elicit suggestions on potential changes to the process and to gain feedback on potential goals
• Utilize the social service inventory and gaps analysis and other pertinent demographic reports to inform goals
and objectives
• Draft a short strategic plan to be reviewed periodically and revised as needed.
• Provide a recommendation regarding the exiting process of granting Social Service Grant funds.
The Social Service Grant money comes from the General Fund. The Commission discussed what the most
efficient use of funds would be and if the past use of funds address the unmet needs. Reid will type up a bullet point
addressing this concern. At the next meeting Commissioner's can vote on approval of the proposal.
COMMISSION GOAL SETTING DISCUSSION
The Commission works under the direction of the Council but would also like the Council to further the goals they are
interested in working on. They agreed that the end of August would be a good time for the goal setting meeting.
Put on next month's agenda to finalize the date and time.
CDBG ANNUAL ACTION PLAN REVIEW AND APPROVAL
Reid developed a Final Action Plan for the use of CDBG funds for the Program year 2014. The Action Plan
describes what the City is doing with the grant money and if it meets the goals in the Five Year plan. Once it's
approved Reid will send it to HUD for their approval and then the City receives the grant agreement and funding.
The public hearing was open for comment. No one was present to speak.
Saldana/Gutman m/s to approve the Final Action Plan for the one year use of the CDBG funds. Voice Vote; All
Ayes, motion passed.
LIAISON REPORTS DISCUSSION
Staff - Reid reported that the public hearing on the Normal Avenue plan is scheduled to go to the Council for first
reading on May 6'h and the second reading is scheduled for May 20'h.
APRIL 23RD AGENDA ITEMS
Quorum Check - Reid will be at a HUD training in Portland and will not be able to attend. Brandon Goldman will be
the staff liaison for the meeting.
Agenda items - Presentation by city recorder and city attorney - rules that govern commissions and committees
Brandon will talk about the normal plan in relations to zone change, annexation and how it works with the city's
affordable housing.
UPCOMING EVENTS AND MEETINGS
Housing and Human Services Commission regular meeting - May 22, 2014, 4:30 pm in the Siskiyou Room of the
Community Development Building located at 51 Winburn Way
ADJOURNMENT - The meeting was adjourned at 6:02 p.m.
respectfully submitted by Carolyn Schwendener
ASHLAND TRANSPORTATION COMMISSION
MINUTES
MARCH 20, 2014
CALL TO ORDER: Chair David Young called the meeting to order at 6:00 p.m, in the Civic Center Council
Chambers, 1175 E. Main Street.
Commissioners Present: Joe Graf, Shawn Kampmann, Craig Anderson, David Chapman, Corinne Vieville, and
David Young.
Commissioners Absent: Alan Bender
Staff Present: Scott Fleury, and Mary McClary
Council Liaison Absent: Carol Voisin
ANNOUNCEMENTS
CONSENTAGENDA
Approval of Minutes - None (February/March minutes to be approved at the April meeting)
PUBLIC FORUM
None
NEW BUSINESS
Fleury explained the new agenda format to the commission. He stated that he does the new business/old business
format with the Airport Commission and it works out well. He asked the commission to share their feedback and if
they wanted to go back to action/non-action items that would be ok. Overall the commission likes the new format. He
stated the change was being made to lessen any confusion such as citizens attending a meeting to speak on an
action item when it was the initial discussion of the topic.
Anderson voiced concern with the fact that Mike Faught makes the final decision regarding recommendations that
are made by the commission. He isn't aware of other committees or commissions acting in that same fashion,
according to Ashland's Municipal Code. Fleury stated that he believes the power was granted by way of resolution,
not the Municipal code.
Kampmann likes the idea of being able to hear about an item and if it is something that moves along then it would be
feasible for citizens to be present. He stated that there are times that he feels like they are presented with items to
discuss & the public is present but the commission hasn't had a chance to fully research the item.
Graf isn't sure of how the citizens would understand that "old business" would be items that they could be taking
action on. Fleury staled that if the item involved affected properties they would be informed of the meeting in which
action was being taken. Graff stated that would be fine for the affected properties but there could be other people
that may want to speak on a topic even if they aren't an affected property. He thinks it is important to have it more
clearly labeled on the agenda, such as "consideration of or some language like that.
Vieville would like to have the issue at a meeting and then if it is a big topic, have it deferred to the next meeting to
allow for time to research.
Kampmann agrees with Vieville. He also thinks that there could be items that the general public would want to speak
on but need more notice on.
Fleury recommended possibly posting the normal agenda and rather than attaching the entire meeting packet, there
could be a summary for each agenda item or he could add a brief description for each item on the agenda.
Transportation Com scion
March 20, 2014
Page l or5
Chairperson Young thinks that maybe the commission should ponder this for a while to decide how the agenda is
working out. Fleury stated he will add a summary to the items starting on the next agenda and the Commission can
see how they like it.
Anderson asked that Kim Parducci, Southern Oregon Transportation Engineering, be present at future meetings
when there is a traffic engineers recommendation.
Kampmann added that the Parks Commission, the Conservation and a few other commissions/committees besides
the Council have their meetings printed in the newspaper. Staff stated that it was not required anymore and is no
longer free.
Young thinks it is a good idea to send it to the Mail Tribune/Ashland Daily Tidings and maybe they can include it in
their "things to do today" section.
Chapman feels that Fleury will have a good idea of the complexity of the issues that come up and can plan
accordingly.
Young summarized that the commission would like the meetings noticed in the paper on the Tuesday prior to the
meetings.
Transportation System Capital Improvement Prioritization (CIP)
Fleury pointed out that per the discussion at the February meeting staff provided the commission with the current
Transportation System Plan (TSP) project list along with the currently adopted CIP list. Currently the CIP projects are
ranked as High, Medium and Low. They are broken up into pedestrian, bike and roadway sections Roadway also
includes recommended studies to be performed. The idea is for the commission to develop a strategy on how they
would like to prioritize these projects.
He also stated that Mike Faught wanted him to inform the commission that a letter of intent for a Transportation
Growth Management (TGM) grant for the Siskiyou Blvd. safety study (from Southern Oregon University to the high
school) has been sent in. The full application will be due in June. He wanted to be sure that the commission is ok
with staff pursuing the grant. The commission would like Mike to know that they would all agree that the area should
include Walker around the bend to Siskiyou and Ashland Street up and down to the Siskiyou corridor.
Fleury stated the CIP list was included in the meeting packet and he also showed it on the projector. He went
through the spreadsheet and each of the projects on the list and the commission provided input.
Chapman pointed out that he would still like staff to consider the possibility of extending the bike path to Oak Street
as part of the Oak Street Railroad crossing project.
Fleury pointed out that all of the bike projects currently on the list are in the unfunded category.
Fleury asked how the commission would like to prioritize the projects on the list. His thought is to have the
commission look at one section each meeting and have discussion on prioritizing, funding etc. He would advise
looking primarily at the projects that are not developer driven. The commission feels it would be important to know
which projects staff can feasibly get grant funding for and which ones cannot. Fleury was thinking that would be part
of the discussion for each of these projects.
Anderson stated that he thought the Washington Street Extension project was developer driven. Fleury remarked
that it is both. The iamp (interchange access management plan) is going to limit left turn access out of that location.
Mike Faughl is working to try to create the connection through there. The development will build the project, but we
are trying to refine it so that it meets our codes. We are trying to do some ground work now so that we understand
the process. Anderson also asked about the System Development Charge column (SDC). Fleury stated some of the
projects don't have anything in the SDC column. He pointed out there is currently a SDC committee working on the
Transportation Commission
March 20, 2014
Page 2 of 5
SDC's and once we have that information, the spreadsheet would be updated to reflect that. Anderson asked if there
is anyone on the SDC committee that would represent Transportation interests. There is a representative appointed
that represents the homebuilders association which would likely advocate for lower SDC's so he wonders if there is
anyone on the opposite side to counteract that? Fleury explained that the SDC committee was established in
February (read the list of appointees to the commission) and they have met a few times already. Anderson stated
that the SDC's are a big issue for him. He is concerned that the SDC committee may not have someone appointed to
represent the Transportation interests. He also voiced the Transportation Commission wasn't involved in the process
of applying for the recent Congestion Mitigation and Air Quality (CMAQ) and Surface Transportation Program (STP)
grants that were recently applied for. Chair person Young stated the intent of this agenda item is to address this &
move forward and the points made by Anderson have been well taken and understood.
Chapman requested staff bring the information to the commission each time a grant is being pursued so that the
commission can contribute to the decision making process. Fleury responded that he is asking the commission for
what information the commission would like staff to bring forward to them to help them make recommendations
regarding prioritizing the CIP.
Anderson questions his role as part of the Transportation Commission. He said the Transportation Commission is the
only commission within the City that he could find that makes recommendations directly to the Public Works Director
and not the City Council. Voisin stated according to the Commission webpage "The Transportation Commission
advises the City Council on transportation related issues specifically as they relate to safety, planning, funding and
advocacy for bicycles, transit, parking, pedestrian and all other modes of transportation." Anderson replied that if you
look at the powers that the commission has under municipal code 2.13.0301040 it lists what they are empowered to
do and they are not empowered to make recommendations to council. Voisin stated that if one says advises and the
other one doesn't then maybe it is something that needs to be clarified and/or reviewed. Young feels that by
definition the commission advises council. Municipal code 2.13.040 states "The Transportation Commission will
review and forward all traffic implementation regulations to the Public Works Director for final approval and
implementation of official traffic safety and functional activities." Fleury pointed out that traffic implementation
regulations are different than making recommendations towards capital improvement projects. Traffic regulations are
signed by the Public Works Director and forwarded directly to the Streets department, anything else is brought to the
Transportation Commission for discussion. Fleury has only been involved in this commission for about a year and a
half, he isn't sure how Jim or anyone else handled the CIP previously but since we are going into the next budget
cycle along with a newly adopted Transportation System Plan that outlines the projects Fleury is trying to follow this
and build a paradigm to go forward. Kampmann commented he has always been under the impression that the
commission is an advisory committee to the City and Public Works. He sees it as the commission making
recommendations and ultimately it is up to the City to make the decisions.
Anderson questioned Fleury as to whether or not in hindsight he would have handled the recommendation he made
to Council on December 3rd for the Congestion Mitigation and Air Quality and Surface Transportation Program (STP)
projects, would he have brought it before the Transportation Commission first after having had this discussion. Fleury
remarked staff had previously received Councils approval under a different funding mechanism and also to apply for
the STP funds which Jim Olson had worked on several years ago, so it has been brought to Council numerous times
over the years. He emphasized that as this process unfolds the projects will be brought before the commission. Graf
mentioned that he hopes Anderson will stay on the Commission. He also staled it looks like the commission will be
making recommendation on the transportation section of CIP and if that hasn't been done previously before taking it
to Council then it shouldn't have been handled that way. He mentioned that the East Nevada Street bridge project
which was previously taken to Council at a substantial lesser amount probably should have been brought before the
commission to make the recommendation in favor or against it. Fleury added, by following this process it will solve
the issue. Overall, the commission agrees that going forward taking a look at these projects will help solve these
issues.
Graf added that he agrees with Anderson's concern regarding Transportation representation on the System
Development Charge (SDC) committee. He doesn't think there is anyone on the committee specifically interested in
transportation issues. He feels there is more representation for the home builders. Chapman expressed there are a
Transportation Commission
March 20, 2014
Page 3 of 5
few people on that committee that understand the budget process and how everything interrelates and would also be
interested in the transportation piece. Kampmann questioned whether it should be a concern of the Transportation
Commission. He stated the committee was appointed by the Mayor. A few of the Commissioners think it is a good
idea if the commission feels there needs to be more representation that a motion be made and forwarded to the
Mayor.
Vieville/Chapman m/s to recommend the Mayor appoints a member of the Transportation Commission to the SDC
committee. All in favor. Motion passed.
Anderson/Young m/s to recommend Joseph Graf as the Transportation Commission representative. All in favor.
Motion passed.
Fleury stated the commission will prioritize one of each of the network categories (roadway, bicycle, pedestrian) and
have everything wrapped up by the end of this calendar year. There will be a set total amount for all 3 networks and
the commission will prioritize utilizing the total available funding amount.
OLD BUSINESS
Lithia Way and 3rd St.
Fleury emailed and met with Dan Dorrell & Mike Birch (ODOT) at Lithia and 31d and they talked about relocating the
signs. They told him to submit a speed zone study request and then they would look into it. He submitted the speed
zone study. The speed zone study for the initial speed zone extends past the Fire Station; that sign disappeared. He
speculated that it was probably taken down during the construction of the fire station and the sign was never put
back up. The sign can be placed within 100 feet of its original designation. In order to do so staff would just need to
write a Memo to the State Traffic Engineer for approval. Fleury recommends the sign be placed within the park row
on each side.
Orange Ave Bicycle Boulevard
The Streets department has been out there burning in the sharrows. Signs have also recently been put up.
N. Main Restriping
Kim Parducci conducted an analysis of the lane shift back to Oak Street from Heiman (doing a lane merge over the
bridge) and she determined that it will work fine if ODOT changes the signal liming at the Heiman light to allow more
through traffic on Main Street and less cross traffic from Heiman. There will be a dedicated left hand turn around the
totem. The design, analysis and tech memo are done and we are now waiting on ODOT's review and then it would
be presented to council for approval.
Nevada St. Bridge/Chip Seal Applications
The TAC had their prioritization ranking meeting where the top 5 projects were funded, including the Nevada Street
Bridge. The chip seal wasn't recommended by the TAC. The PAC held a meeting afterwards and followed the TAC
recommendations. The next step is the policy review committee's review and recommendation which should happen
in April.
Bollard Removal
The bollards have been removed at the crossings of East Main, Tolman Creek & Mountain. Per Kim's
recommendation there are full stop bars and signs at those crossings for bicycles.
Downtown Parking Study
Young informed the group that the March meeting included discussion on developing guiding principles & the
upcoming April meeting will include distributing the downtown concept street maps.
INFORMATIONAL ITEMS
Action Summary
Transportabon Commssion
March 20, 2014
Page 4 or5
Oregon Impact February Newsletter
Traffic Crash Summary
COMMISSION OPEN DISCUSSION
FUTURE AGENDA TOPICS
Transportation Safety Public Outreach
SOU Multi-Modal Future
Siskiyou Blvd. Signal Timing
Vieville would like to have a future discussion on the audible pedestrian signals
Anderson would like to have a future discussion regarding the "powers and duties specifically" of the commission
(have Legal come to a future meeting).
ADJOURNMENT
Meeting adjourned at 8:03 pm
Respectfully submitted,
Tami De Mille-Campos, Administrative Assistant
(Minutes completed via audio tape due to being absent at meeting)
Transportafion Commssion
March 20, 2014
Page W5
ASHLAND TRANSPORTATION COMMISSION
MINUTES
APRIL 24, 2014
CALL TO ORDER: Chair David Young called the meeting to order at 6:00 p.m. in the Civic Center Council
Chambers, 1175 E. Main Street.
Commissioners Present: Joe Graf, Craig Anderson, Corinne Vieville, Alan Bender, and David Young
Commissioners Absent: Shawn Kampmann, and David Chapman
Staff Present: Scott Fleury, Mike Faughl and Tami De Mille-Campos
Council Liaison Present: Carol Voisin
ANNOUNCEMENTS
CONSENT AGENDA
Approval of Minutes - February
Page 5 correction: "Chairperson Young stated formal communication from members to other people and/or
organizations and any other form of communication, should clearly state when they are expressing opinions from
themselves. He was asked by Staff whether he thought the City Recorder and City Attorney should refresh the
Commission with the rules and regulations'
Approved as corrected.
PUBLIC FORUM
Honore Depew, 63 California Street
On behalf of Ashland Parks and Recreation he updated the Commission on the Annual Bike Swap happening on
April 26, 2014. He also asked for volunteers, as they are always needed. He offered to set up a table for any of the
Commissioners that might want to be present at the event. Commissioner Young agreed to have a table with some
Transportation System Plan maps, in place of volunteering at the event.
Colin Swales, 95 Coolidge
Now that he is living close to the road diet area he wanted to provide some input on it. He feels it is working well. He
pointed out that there aren't many breaks in the traffic now which has been brought up since the beginning of the
Road Diet. He also stated he used to be able to make a left turn onto Nursery Street heading north out of town rather
than Coolidge Street like he used to. He pointed out the turn markings on the street are past Nursery, almost
encouraging left turns onto Coolidge which isn't allowed. The main thing that hasn't been implemented yet is more
pedestrian crosswalks/medians along North Main. He expressed interest in seeing the City further explore the idea
(Dan Burden's) of roundabouts at Wimer/Hersey and Maple. If the road diet does become permanent, he would like
to see changes made such as street tree plantings, permanent turn lanes etc.
NEW BUSINESS
Transportation System Capital Improvement Prioritization
Fleury stated this would be the first look at prioritizing the roadway network/studies capital improvement projects that
came out of the Transportation System Plan (TSP). Once the commission completes the prioritization of the road
networks they will move on to the bicycle and pedestrian networks in preparation for looking at the revenue/funding
sources by the end of the calendar year for the next budget cycle.
The Committee looked at the studies first, the Siskiyou Boulevard pedestrian crossing evaluation and feasibility
study. Staff is interested in applying for a Transportation Growth Management (TGM) grant to complete the study,
which would fund the study in full. This study is ranked as the only high priority in the TSP. Faught pointed out the
study is timely as SOU looks at additional growth. Chairperson Young is the only remaining Commissioner that
Transportation Comrrcssion
April 24, 2014
Page 10/4
worked on the TSP. He stated during the TSP process he pushed pretty hard to consider the feasibility of a viaduct
at that intersection (Hwy 66/Siskiyou). He is very impressed with how well the diagonal crosswalk redesign is doing
but he thinks it is important to study the whole corridor. He mentioned he thinks it would be a good idea to maybe
invite someone from SOU to the discussion, given the enrollment numbers. Graf feels it is a good idea to have this
study done now rather than waiting. Staff pointed out if the Commission doesn't feel it is a good time to pursue this
grant we can hold off on applying. For more information on this study see attached table 10-2.
Out of respect for the TSP process the Commission decided to go through the high priority projects (those that aren't
already in motion) and prioritized them. The high priority projects that are not already in motion are: Lithia Way
(OR99 NB)/E Main Street Intersection Improvements (R05), Siskiyou Boulevard (OR99)/Tolman Creek Road
Intersection Improvements (ROB), Ashland Street (OR 66)/Oak Knoll Drive-E Main Street Intersection Improvements
(ROB), Walker Avenue Festival Street (Siskiyou Boulevard to Ashland Street) (R40). For more information on each
project see attached table 10-3. Fleury/Officer MacLennan pointed out that the City receives a lot of complaints
regarding this area on a weekly basis.
Vieville/Bender mis to approve the prioritization as follows (excludes R17 & R25 which are already in motion):
1 - Siskiyou Boulevard (OR99)/Tolman Creek Road Intersection Improvements (ROB)
2 - Lithia Way (OR99 NB)/E Main Street Intersection Improvements (R05)
3 - Ashland Street (OR 66)/Oak Knoll Drive-E Main Street Intersection Improvements (ROB)
4 - Walker Avenue Festival Street, (Siskiyou Boulevard to Ashland Street) (R40)
All in favor. Motion passes.
Agenda Layout
As per the discussion at the March Transportation Commission meeting the layout of the agenda has been changed.
Staff also researched advertisement and public notice options with respect to the TC meeting agenda and critical
discussion items. The Commission requested that staff publish a summarized agenda (26 display ad) at a cost of
approximately $45.50 in the Ashland Daily Tidings the Monday before each months meeting.
Transportation and Growth Management Grant
Staff has submitted a letter of intent (LO1) to the Oregon Department of Transportation (ODOT) for a Transportation
Growth and Management grant (TGM) for the Siskiyou Blvd. pedestrian crossing evaluation. TGM Grants help local
communities plan for streets and land use in a way that leads to more livable, economically vital, and sustainable
communities and that increases opportunities for transit, walking and bicycling.
Anderson/Vieville mis to support staff drafting a letter of support on behalf of the Transportation Commission (Chair
person Young will sign) and request that Council drafts a letter of support as well.
All in favor. Motion passes.
OLD BUSINESS
Lithia Way and 311 St.
Fleury spoke to Mike Birch from ODOT again and he is not going to submit to the state because the existing speed
zone warrant is Within a couple hundred feet of where we want to put the 20mph signs so we do not need
permission. He has already spoken to the Streets department and they have already chosen the spot & are going to
install the 20mph signs.
Orange Ave Bicycle Boulevard
The Street department is almost done with sign and striping installation. They are looking to put up four more 20mph
signs in between Willow and Drager directionally on both sides and in between Drager and Laurel. The sharrows
have been installed. The feedback from the residents (Ellen Faulkner) has been positive so far. Fleury stated he had
informed resident Ellen Faulkner, once the signs have been put up staff will ask the Police department to do some
occasional patrolling of the area.
Transportation Commission
April 24, 2014
Page 2 014
N. Main Restriping
Fleury stated they are still trying to finalize the project so the striping can be refreshed. Kim Parducci (Southern
Oregon Transportation Engineering) is going to talk to ODOT (awaiting approval) about the changes so that the
restriping can be finalized.
*Changing the merge location heading northbound just past Oak Street
*Realignment of the Maple Street driveway (Stone Medical) - staff is waiting to hear back from Asante
*Glenn St - moving the dedicated left hand turn onto Glenn & making that the safety lane
*Bush Street left hand turn lane
Chair person Young brought up the concern regarding the need for further pedestrian crossings along North Main.
Staff is having Kim explore that issue.
Faught pointed out that they are looking to put down some more permanent striping rather than just paint. ODOT is
recommending the City use thermoplastic because it wears a lot better. Fleury said he is trying to have ODOT bid the
project out for us because they have contractors who specifically do this kind of work.
Nevada St. Bridge/Chip Seal Applications
Faught stated that the Chip seal was turned down. They thought it was a great idea but it was up against a few large
projects (Table Rock, Foothills). He thinks it will have a good shot at funding next time.
The East Nevada Street project was funded, at 1.5 million. Staff is requesting the infrastructure bank finance the
difference at 1.8% interest. So far they are saying it is eligible and to check with ODOT. COOT is also saying they
are in support of the project because it is a viable project so staff will finish the application for the low interest
funding.
Downtown Parking Study
Young stated the May meeting was cancelled in order to allow for more time for the University of Oregon to work on
getting the second citizen survey out. The survey was "advertised" in the May City Source to help get the word out.
Young mentioned that at the last meeting the downtown committee reviewed maps of some possible lane
configurations. Faught pointed out he thinks it is important to provide the Transportation Commission with those
same maps to get an idea of what those possible lane configurations look like. Staff will provide the maps to the
Commission at the May meeting.
INFORMATIONAL ITEMS
Action Summary
Oregon Impact April Newsletter
Traffic Crash Summary
COMMISSION OPEN DISCUSSION
*Anderson mentioned he would still like the Legal department to provide clarification on the Transportation
Commissions' powers (recommendations made to Council vs. to the Public Works Director)
*Anderson reminded staff that the TC would like to be represented on System Development Committee which would
require a change to the ordinance. Faught said he hasn't had a chance to talk to the Mayor about it but he will. He
did point out in the meantime Graff can still attend the meetings even if he isn't appointed.
*Chair Young recommended staff request Egon to report to the Commission regarding bicycle safety since we will
likely be applying for that grant again soon.
*Anderson expressed some concern regarding the chip sealing and he pointed out he would like to see the TC be a
part of the Congestion Mitigation and Air Quality (CMAQ)/Surface Transportation Program (STP) grant applications
before they are submitted.
FUTURE AGENDA TOPICS
Transportation Comm'ssion
Apr# 24, 2014
Page 3 of 4
Transportation Safety Public Outreach
SOU Multi-Modal Future
Siskiyou Blvd. Signal Timing
ADJOURNMENT
Meeting adjourned at 8:07 pm
Respectfully submitted,
Tami De Mille-Campos, Administrative Assistant
Transportation Comrassion
April 24, 2014
Page 4 014
Ashland Transportation System Plan October 2012
Intersection and Roadway Plan
Policy #26 (l26) Eagle Mill Road
The City of Ashland supports the following route as an alternative route around the downtown area to
areas south and east of downtown from the I-5/Valley View Road interchange: Eagle Mill Road from
Valley View Road to Oak Street, Oak Street from Valley View Road to Nevada Street, E Nevada Street
from Oak Street to N Mountain Avenue, and North Mountain Avenue from E Nevada Street to E Main
Street. The City of Ashland encourages Jackson County to make improvements to Eagle Mill Road on a
similar timeframe to the City's Nevada Street Extension project.
Intersection and Roadway Plan Studies
Table 10-2 summarizes the preferred plan intersection and roadway related studies. Additional
explanation regarding why the Study #7 (S7) was identified follows Table 10-2.
Table 10-2 Refinement Plan Studies
Priority
Do trip !a
(53) N Main Street (OR 99) Conduct access management spacing study and provide near-and Medium
from Heiman street to long-term recommendations for improvement. (5-15 years) $75'000
Sheridan Street _
i
(SS) Siskiyou Boulevard from Conduct access management spacing study and provide near-and Medium
Ashland Street to Tolman long-term recommendations for improvement. (5-15 years) $75,000
Creek Road
(56) Ashland Street (OR 66) Conduct access management spacing study and provide near-and Medium
from Slskiyou Boulevard to $75,000
Tolman Creek Road long-term recommendations for improvement. (5-15 years)
(S7) E Main Street from Conduct access management spacing study and provide near- and Low
Slskiyou Boulevard to long-term recommendations for improvement. (15-25years) $75'000
Wightman5treet
Conduct a transportation safety assessment In five years along
(S9) Ashland Street (OR 66) Ashland Street (OR 66) between Clay Street and Washington Street to Medium $20000
Safety Study identify crash trends and/or patterns (if they exist) as well as (5-15 years)
mitigations to reduce crashes.
Evaluate pedestrian flows, crossing demand, and safety along Siskiyou
Boulevard from Highway 66 to Beach Street. The study should
evaluate the adequacy of the planned pedestrian Improvements
(510) sisldyou Boulevard along Slskiyou Boulevard (the rectangular rapid-Bash beacons at
Pedestrian Crossl ng crosswa lks a nd diagonal crossing at the lndlan3-Wightman High $35,000
Evaluation and Feasibility Intersection) once the new dormitory and dining hall are operational (0-5 years)
Study for existing and future forecast pedestrian demand. The need, ideal
location, feasibility and cost of a grade-separated crossing should be
evaluated. This project Is a joint project with the city and SOU; not
subject to development.
High (0-5 years) $35,000
Medium (5-15 years) $245,000
Low (I5-25 years) $75,000
Development Driven 0
Total $355,000
134 Kittelson & Associates, Inc.
~I\~I
Ashland Transportation System Plan Octaber2012
Intersectlon and Roadway Plan
Table 10.3 Preferred Plan Intersection and Roadway Projects
Reasons for the Mority
(Project#) Name Description
Project ~17imeline) cost
(R2) N Main Street (OR
Install atrafOcsignal at the Intersection
99)/Wlmer5tree6Hersey once MUTCD traffic volume or MUTOD Improve Safety, LOW $300000
Street Intersection crash warrants are met ° Improve Operations (15-25 Years)
Improvements
(RS) Uthla Way (OR 99 NB)/E improve visibility of signal heads. identify High
Main Street intersection and install treatments to slow vehicles on Improve Safety (0-5 Years) $50,000
Improvements northbound approach
(R6) Siskiyou Boulevard (OR Conduct a speed study. Identify and install High
99)/Tolman Creek Road speed reduction treatments on Improve Safety (0-5 Years) $61,000
Intersection Improvements northbound approach
(R8) Ashland Street (OR Realign E Main Street approach to
66Knollon Main eliminate offset and install speed Improve Safety High
Street eet $706,000
Improvements Intersection ctition reduction treatments ' (0-5 Years)
(R9) Ashland Street (OR
66)/Oak Knoll Drive-E Main s Improve5afety, Low
Street Intersection Install. roundabout Gateway to Urban $3,150,000
Area (1525 Years)
Improvements
(R11) Lithla Way (OR 99
NB)/Oak Street Intersection Install a traffic signal Improve Operations Low $200,OW
Improvements (15-25 Years)
(1132) Siskiyou Boulevard (OR
99)/Sherman Street Realign Sherman Street approach to Improve Street Development $391,000
Intersection Improvements eliminate offset Continuity Driven
(1113) Siskiyou Boulevard (OR Reduce Conflicts,
99)/Park Street Intersection Realign Park Street approach to eliminate Improve Street Development $296,000
Improvements offset Continuity Driven
(1114) Siskiyou Boulevard (OR Reduce Conflicts,
99)/Terra Avenue-Faith Avenue Realign Term Avenue approach to Improve Street Development $216,000
Intersectlon improvements eliminate offset ConBnuity Driven
(R37) East Nevada Street Extend Nevada Street from Bear Creek to Balance Mobility High
Extension Kestrel Parkway and Access 10-5 Years) $2,261,000
Extend Normal Avenue to E Main Street
(R19) Normal Avenue Extension consistent with the LAMP Exit 14 Access Balance Mobility Medium $2705,000
Management on Ashland Street (OR 66); and Access (5-15 Years)
Coordinate with Project K3.
Extend Creek Drive from Meadow Drive to Development
(R20) Creek Drive Extension Normal Avenue consistent with the IAMP Balance Mobility & Access Developer
Exit 14 Access Management on Ashland and Access Management Responsibility
Street (OR 66) Driven
Construct a New Roadway from Clay
Street to Tolman Creek Road consistent
with the LAMP Exit 14 Access Development
Management on Ashland Street (OR 66) if Facilitate Economic.
(R22) New ROadway(8) and when Tolman Creek Manufactured Growth Balance &Access Developer
Parkis redeveloped. The location ofthe Mobility and Access Management Responsibility
connection shall be determined atthe Driven
' time of redevelopment of the
manufactured home park.
Facilitate Economic Development
(1123) New Roadway (C) Construct a New ROadwayfrom McCall &Access Developer @
Drive to Engle Street Growth Balance Management Responsibility
Mobility and Access ,
Driven
GNy@
Construct a New Roadway to connect the Development
(R24) Clear Creek Drive two existing segments of clear Creek Facilitate Economic &Access
Extension - Drive providing a continuous east-west Growth Balance Management $2,505,000
Mobility and Access
roadway between Oak Street and N Driven
qq6
I,A
I 137 ptte/son &Associate; Inc.
F I i
Ashland Transportation System Plan October 2012
intersection and Roadway Plan
Reasons art e rianty
(Project 0) Name Description Project T R. C
imell a)
Mountain Avenue
Extend Washington Street to Tolman
(R25) Washington Street Creek Road consistent with the TAMP Exit Facilitate Economic High
Extension to Tolman Creek 14 Access Management on Ashland Street Growth Balance $1,055,000
Road (OR 66). This is a City funded project; not Mobility and Access ' (0-5 Years)
developer driven.
Construct a new roadway from E Main Development
Facilitate Economic
(R26) New Roadway (D) Street to Ashland Street ( 66) Growth Balance & Access $2,422,000
consistent with the IAMP Exit 14 Access management
Management on Ashland Street (OR 66). Mobility and Access Driven
(1127) Grizzly Drive Extension Extend Grizzly Drive from Jacquelyn Street Balance Mobility Development Developer
to Clay Street and Access Driven Responsibility
(R28) Mountain View Drive Extend Mountain View Dr-we from Balance Mobility Development Developer
Extension Parkside Drive to Heiman Street and Access Driven Responsibility.
Facilitate Economic Development
(R29) Washington Street Extend Washington Street to Benson Way Growth Balance $1,301,000
Mobility and Access Driven
(R30) Kirk Lane Extension Extend Kirk Lane to N Mountain Avenue Balance Mobility Development Developer
and Access Driven Responsibility
Extend Winner Street to Ashland Mine Balance Mobility Development
(R31) Wimer Street Extension Road. The exact location of the street will $3,125,000
he refined at the time of annexation. and Access Driven
(R32) Kestrel Parkway Extend Kestrel Parkway to N Mountain Balance Mobility' Development Developer
Extension Avenue at Nepenthe Road and Access Driven Responsibility
Extend Existing Adjacent Streets to Facilitate Economic
D
(R34) Railroad Development Property Provide Connectivity within, to and from Growth Balance Development Developer
Development Driven Responsibility
the property Mobility and Access
Implement a temporary mad diet on N
(R35) N Main Street Tempora Maln Street. Temporary road diet Includes Improve Safety, High
Road Diet ry converting N Main Street to a two-lane Balance Mobility (0.5 Years) $160'000
roadway with a two-way center turn lane and Access
and bicycle lanes In both directions
Convert temporary road diet to
(1336) N Main Street Implement permanent installation, which includes, at Improve. Safely, Medium
Permanent Road Diet aminimum, signal modifications to the N Balance Mobility (5-15 Years) $200,000
Main Street/Maple Street and the N Main and Access
Street/laurel Street Intersections
Widen and reconstruct sidewalks with
(R38) Ashland Street street trees, stormwaler planters and bus Improve Safety,
5treetscepe Enhancements shelters. Ashland Street/Walker Avenue Balance Mobility Medium $1,100,ODD
(Siskiyou Boulevard to Walker Intersection enhancements to Include and Access (SAS Years)
Avenue) concrete crosswalks, paving, and
ornamental lights.
[R39) Ashland Street Widen and reconstruct sidewalks with Improve Safety,
Streetscape Enhancements Development
(Walker Avenue to Normal street trees, stormwater planters and bus Balance Mobility Driven $1,300,000
shelters. and Access
Avenue)
Street reconstruction with flush curbs and
(R40) Walker Avenue Festival soared concrete roadway surface.
Street(Stskiyou Boulevard to Sidewalk treatments to include decorauve Support Pedestrian High $780,000
Ashland Street) bollards to delineated pedestrian space, Places Planning (0-5 Years)
street trees, LID stormwaler facilities and
ornamental lights.
Widen and reconstruct sidewalks with
street trees, stormwater planters and bus
(Reek Ashland/Tolman shelters. Ashland Stree
Creek Road Streetscetscape t/Tolman Creek Support Pedestrian Development $1,500,000
Road Intersection enhancements to Places Planning Driven
Enhancements
include concrete crosswalks, paving, and
ornamental lights.
jr- 138 8ittelson & Associates, Inc.
Ashland Transportation System Plan ocfober2012
Intersection and Roadway Pion
Widen and reconstruct sidesalks with
(R42)E Maln Street/N street trees, stormwater planters and bus
Mountain Avenue Streetsape shelters.EMain Street/N Mountain Support Pedestrian Development $1,500,000
Enhancements 'Avenue intersection enhancement with Places Planning Driven
concrete crosswalks and paving and
ornamental lights.
Construct a new roadway from Mistletoe Facilitate Economic
(R43) New Roadway (E) Road to Siskiyou Boulevard (OR 99) Growth Balance Development $4,322,000
consistent with the Croman Mill District MGrowta nd Balance Driven
Plan
Widen and reconstruct sidewalks with
Road Tolman Creek-Mistletoe Facilitate Economic
street trees, stormwater planters and bus Development
Road etscape shelters consistent with the Croman Mill Growth Balance Driven $3,478,000
Enhance cements District standards. Mobility and Access
Construct a new roadway from Facilitate Economic
Washington Street to New Roadway (E) Development
(R45J New Roadway (F) consistent with the Croman Mill District Growth Balance Driven $1,199,000
Plan; coordinate with Project X2. Mobility and Access
(R46) Ivy Lane Extension Extend Ivy Lane west to Waterline Road Balance Mobility Development Developer
and Access Driven Responsibility
(R47) MaryJane Avenue Extend Mary Jane Avenue south to the Balance Mobility Development Developer
Extension UGB then east to Clay Street and Access Driven Responsibility
(148) Forest Street Extension Construct a new roadway that connects Balance Mobility Development Developer
the two existing segments of Forest Street and Access Driven Responsibility
(R49) Croman Mill District Construct new streets to provide Facilitate Economic Development Developer
Streets connectivity within, to and from the Growth Balance Driven Responsibility
Croman Mill District Mobility and Access
High Priority(0-5 Years) $5,073,000
Medium Priority (5-15 Years) $4,005,000
Low Priority (15-25 Years) $3,650,OOD
Development Driven $23,555,000
Total $38,047,000
Notes:
'Initial roundabout operations analysis and high-level feasibility assessment were performed to confirm a roundabout appears physically and
operationally feasible. A more detailed preliminary roundabout design and study should be conducted before activities such as right-of-way
acquisition and/or developing detailed design plans.
It should also be noted that in November 2008, the State Traffic Engineer Issued a directive to ODOT staff to consider a roundabout as an alternative
whenever a traffic signal was being consid Bred on the slate highway system. However, in March 2011, ODOT Issued updated guidance to staff that
no roundabouts should be approved or designed by staff on the slate highway system due to concerns raised by the trucking industry. Subsequently,
the requirement previously issued to evaluate roundabouts as an alternative to Iraffic signals was temporarily lifted. Currently, COOT is awaiting the
results of a study being led by the Kansas Department of Transportation evaluating the effects of roundabouts on oversized loads. Upon completion
of that study, the agency has Indicated that the current prohibition of roundabouts on the state system will be reconsidered.
'Cost estimates are for engineering and construction costs. They do not Include right-of-way. They are rounded to the nearest thousand dollars.
The projects in Table 10-3 and Figure 10-3 were identified based on input received from the PMT, TAC,
PC, and The intersection projects were also developed based on the 2034 future conditions analysis
results, safety analysis results, rind planning-level feasibility assessments (e.g., is a roundabout
physically possible, could the street actually be realigned given adjacent historic structures). The new
roadway and roadway extension projects were identified from previous and/or related plans such as the
1998 TSP, the unadopted 2007 TSP update, and the Interchange Area Management Plan (LAMP) for Exit
14. The projects identified to support pedestrian places were documented as part of the Pedestrian
Places planning activities. The Pedestrian Places planning is discussed further in the following section.
„7
_y 139 Kittelson & Assoclotes, Inc.
Ashland Transportation System Plan october2012
Intersection and Roadway Plan
Railroad Crossing Projects
Table 10-4 summarizes the preferred plan railroad crossing projects. They include one existing crossing
upgrade and two new railroad crossing locations. Figure 10-3 illustrates the location of these railroad
crossings. Appendix A contains the prospectus sheets for all preferred plan projects,' the prospectus
sheets provide more detail regarding the project location, description, and images illustrating the vision
for the completed project.
Currently under Federal and ODOT rail policy, the City would need to close an existing at-grade crossing
or go through a potentially timely and costly rail order process to obtain an additional new public
crossing within Ashland. The City will pursue all possible alternatives to closing existing at-grade
crossings including exceptions to the policies based on the low projected train volumes (currently none)
and will consider grade separation of future crossings.
Table 10-4 Railroad Crossing Projects
nority,
roject h) Name. ption Reasons for the P act Timeline Cost
m Pursuea New At-Grade Ped/Blke Improve North-South
(X1)4 StreetGrade Railroad Crossing at 4!" Street. Connectivity, Balance Development $275,000
Railroad Crossing
Coordinate with Project TR4., Mobility and Access Driven
Pursue a New At-Grade Railroad
(X2) Washington Street At- Crossing at Washington street as part Facilitate Economic Growth, Development
Grade Railroad Crossing ofthe Croman Mill Site Development. Balance Mobility and Access Driven $1,000,000
Coordinate with project 8451
Upgrade the existing at-grade Railroad
(X3) Normal Avenue At- Improve North-South
Grade Railroad Crossing crossing at Normal Avenue to public Connectivity, Balance Development $750,000
Upgrade crossing standards. Coordinate with Mobility and Axcm Driven
Project R19.
High Priority (0-5 Years) -
Medium Priority (5-15 Years) -
Low Priority (15- 25 Years) -
Development Driven or Driven by Need based on Rail Order Outcomes $2,025,000
Total $2,025,000
Notes:
'Currently under Federal and ODOT rail policy, the City would need to close an existing at-grade crossing or go through a potentially timely and costly
rail order process to obtain an additional new public crossing within Ashland. The City will pursue all possible alternatives to closing existing at-grade
crossings Including exceptions to the policies based on the low projected train volumes (currently none) and will consider grade separation of future
crossings.
'Planning level cost estimates are for construction and engineering of at-grade crossings and do not include right-of-way costs.
140 Kittelson & Assadates, Inc.
l~.t~
CITY OF
ASHLAND
Council Communication
June 3, 2014, Business Meeting
Liquor License Application for Kevin Broadie dba Saltworks, LLC
FROM:
Barbara Christensen, City Recorder, christeb@ashland.or.us
SUMMARY
Approval of a Liquor License Application from Kevin Broadie dba Saltworks, LLC at 11 N 151 Street.
BACKGROUND AND POLICY IMPLICATIONS:
Application is for new license.
The City has determined that the license application review by the city is set forth in AMC Chapter
6.32 which requires that a determination be made to determine if the applicant complies with the city's
land use, business license and restaurant registration requirements (AMC Chapter 6.32).
In May 1999, the council decided it would make the above recommendations on all liquor license
applications.
FISCAL IMPLICATIONS:
N/A
STAFF RECOMMENDATION AND REQUESTED ACTION:
Endorse the application with the following:
The city has determined that the location of this business complies with the city's land use
requirements and that the applicant has a business license and has registered as a restaurant, if
applicable. The city council recommends that the OLCC proceed with the processing of this
application.
SUGGESTED MOTION:
Under Consent agenda item, a motion to approve liquor license for Kevin Broadie dba. Saltworks,
LLC.
ATTACHMENTS:
None
Page I of I
PE`,
CITY OF
ASHLAND
Council Communication
June 3, 2014, Business Meeting
Ambulance Operator's License Renewal
FROM:
John Karns, Fire Chief, Ashland Fire & Rescue kamsi@ashland.or.us
SUMMARY
The Ashland Municipal Code requires that all ambulance service providers in the City obtain an
ambulance operator's license. This is the Fire Department's request for renewal of its ambulance
operator's license.
BACKGROUND AND POLICY IMPLICATIONS:
Ashland Municipal Code Chapter 6.40.110 requires ambulance service providers operating within the
City of Ashland to apply annually for an ambulance operator's license. The Fire Department has
provided emergency services in Ashland since 1885. From 1926 to 1936, the Fire Department operated
the ambulance service in Ashland, and in 1936 the ambulance service was sold to Litwiller Funeral
Home. The Fire Department obtained its first medical response vehicle (Rescue 9) through community
donations in 1973, and began providing first response emergency medical services to the community.
In January 1996, the City of Ashland purchased the Ashland Life Support Ambulance Company and
Ashland Fire & Rescue began providing ambulance services within a 650 sq mile ambulance service
area in south Jackson County, known as ASA III. Ambulance services in Oregon are regulated by
county governments, and within the City of Ashland they are required to obtain an ambulance
operator's license. This license is renewed on an annual basis.
FISCAL IMPLICATIONS:
The license fee is $300 plus $100 per ambulance, for a total of $800. Funds are budgeted in emergency
medical services.
STAFF RECOMMENDATION AND REQUESTED ACTION:
Staff recommends renewal of the Ambulance Operator's License for Ashland Fire & Rescue.
SUGGESTED MOTION:
I move to approve the annual Ambulance Operator's License renewal for Ashland Fire & Rescue.
ATTACHMENTS:
Renewal application
Page I of 1
Ir,
CITY OF ASHLAND
APPLICATION FOR AMBULANCE OPERATOR LICENSE
AMC Ch. 6. 6.40
2014
Applicant's Name: CITY OF ASHLAND
Trade Name, if any: ASHLAND FIRE & RESCUE
Address: 455 Siskiyou Boulevard
Ashland OR 97520
Telephone number: 541 482-2770
Ambulance descriptions Manufacturer Vin # License #
1. 1999 FORD LIFELINE 1FDXE40F2XHAO0469 EXEMPT
2. 2003 FORD LIFELINE 1FDXF47F63EA10341 EXEMPT
3. 2006 FORD LIFELINE 1FDXF47P06ED06467 EXEMPT
4. 2008 FORD LIFELINE 1 FDXF47R48ED90832 EXEMPT
5.2011 FORD LIFELINE 1 FDUF4HTOBEC53861 EXEMPT
❑ Attach information showing that every proposed driver, attendant and driver-
attendant is qualified as required in Ashland Municipal Code Chapter 6.40 and as
required by the laws of the State of Oregon.
❑ Enclose with the application, the initial license fee of $300 plus $100 per ambulance.
❑ Enclose a performance bond in the amount of $500,000.
❑ Enclose an insurance policy meeting the requirements of AMC §6.40.110.7. Attach
additional pages as necessary. Explain any box not checked.
Submit your application and required enclosures to Barbara Christensen, City Recorder,
City Hall, 20 East Main Street, Ashland, Oregon 97520. ,
1 certify that each ambulance listed above is adequate and safe for the purposes for
which it is to be used and that it is equipped as required by Ashland Municipal Code
Chapter 6.40 and the laws of the State of Oregon.
Signature:
Print name: Greg I. Case
Title: Division Chief
Date: 05-23-2013
C:\Users\shipletd\AppData\Local\Microsoft\Windows\Temporary Internet
Files\Content.Outlook\HIW4ND5C\2014 Lic renewal.doc
April 10, 2009
CITY OF
ASHLAND
Council Communication
June 3, 2014, Business Meeting
Award of Contract to Apparent Low Bidder for the Lori Lane Alley Connection
Project
FROM:
Scott A. Fleury, Engineering Services Manager, Public Works/Engineering, fleur s n ashland.or.us
SUMMARY
The Council is asked to approve a construction contract for the N. Main to Lori Lane alley connection
project. Bids were received from five contractors with Pilot Rock Excavation providing the low bid.
BACKGROUND AND POLICY IMPLICATIONS:
Proiect Description:
The project will create a 16 foot wide alley connection between N. Main St. and Lori In. adjacent to the
City owned property at 430 N. Main. The City negotiated an access easement across the property to the
north of the City lot during the Hersey/Wimer intersection realignment process in order to create this
connection. The project includes removal and replacement of an asphalt surface, curb and gutter and
installation of a new concrete sidewalk. The connection was not originally designed during the
intersection realignment process as the access easement was being negotiated at that time. Once the
access easement was finalized engineering hired CEC Engineers to perform necessary surveying and
design work for the alley connection.
Bidding. Procedure:
The Lori Lane alley extension was publicly bid on April 10, 2014. The project was publicly bid in the
Mail Tribune and the Daily Journal of Commerce. In addition, project plans and specifications were
sent to several plan centers and were also posted on the City's website. Bids were opened on May 8,
2014 at 2:00 p.m. with five contractors responding. All five bids were valid and contained the required
bonds, documentation, and acknowledgements. Bidding information is shown on the attached proposal
summary form.
FISCAL IMPLICATIONS:
The alley extension project will be funded through the Street Department capital improvement fund.
STAFF RECOMMENDATION AND REQUESTED ACTION:
Staff recommends the Council accept the bid and authorize the award of contract with Pilot Rock
Excavation in the amount of $35,023.50 for the alley extension project.
SUGGESTED MOTION:
Move to approve the bid and award of contract to Pilot Rock Excavation in the amount of $35,023.50
for the Alley connection project.
Page 1 of 2
r,
CITY OF
ASHLAND
ATTACHMENTS:
1. Bid Summary
2. Alley Extension Engineering Plans
Page 2 of 2
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'v
CITY OF
ASHLAND
Council Communication
June 3, 2014, Business Meeting
A Resolution Establishing Rates for the Ashland Municipal Airport and Repealing
Resolution 2013-16
FROM:
Scott A. Fleury, Engineering Services Manager, Public Works Department, fleurys@ashland.or.us
SUMMARY
One of the Airport Commission's goals is to generate sufficient revenues through Airport fees and
rates to operate the Airport with minimal or no general fund subsidies. To that end, the Airport
Commission is recommending the adoption of a Resolution that increases various hangar, ground
lease, tie-down, freight and fuel flowage rates.
BACKGROUND AND POLICY IMPLICATIONS:
The Ashland Municipal Airport, established in 1965, is a City-owned facility consisting of 56 hangars
and 120 airplane tie-down spaces. The Airport currently supports approximately 86 aircraft. In
addition, the Airport provides fueling, aircraft maintenance and repair facilities operated by Skinner
Aviation, the sole fixed base operator (FBO).
Airport revenue is generated from hangar rentals, ground leases, fuel flowage fees, tariffs from freight
operations, nightly and monthly tie-downs and Specialized Aviation Service Operator (SASO)
agreements. Currently SASO agreements are in place for three companies that perform different
commercial operations at the Airport. The FBO is responsible for collecting and monitoring these fees
and has been performing this duty since 1993 (on contract with the City). The City rents 32 hangars on
a month-month basis and has ground lease agreements with an additional 14 individuals. Revenue
from the hangar rentals and leases provide a monthly stream of income, while the income from tie-
downs and fuel flowage is cyclical and fluctuates during the tourist season.
Each spring, the Airport Commission evaluates the existing rates and makes a recommendation to the
City Council to adjust fees as needed. The current rate policy structure includes rates for the following:
• aircraft tie-downs
• City owned T-hangars without doors
• City owned T-hangars with doors
• City owned Box hangars with doors and amenities
• privately built and owned hangars with a ground lease
• privately built hangars that are deeded to the City with a ground lease
The City offers two options for hangar construction and ground leasing at the Ashland Airport. One is
to build a hangar and keep ownership of the hangar while leasing the ground from the City. The second
Page 1 of 2
11FAI,
CITY OF
ASHLAND
option is to construct a hangar and deed it to the City and lease the ground for a specified term,
typically 20-25 years. The ground lease rates for these options differ by over 50%.
In order to develop the 2014 (FYI 5) pricing policy, City staff presented the January 2014 CPI-U to the
Commission and asked for an open discussion regarding any rate changes. The January CPI-U adjusts
ground leases automatically and gives the Commission a baseline number to look at with regards to
rental rate increases. The Commission motioned to recommend adjusting all rental except the shade
hangar rate by the CPI-U rounded down to the nearest dollar. Motion to recommend rates increase
passed unanimously.
FISCAL IMPLICATIONS:
By approving the recommended airport rate resolution the Airport will generate revenue to maintain
self-sufficiency within its appropriated yearly budget.
STAFF RECOMMENDATION AND REQUESTED ACTION:
Staff recommends that the City Council approve the resolution titled, "Resolution Establishing Rates
for the Ashland Municipal Airport, and repealing Resolution 2013-16. "
SUGGESTED MOTION:
Move to approve the Resolution "Resolution Establishing Rates for the Ashland Municipal Airport,
and Repealing Resolution 2013-16."
ATTACHMENTS:
Draft Resolution
Rate Sheet FY 2014 (attachment to the resolution)
May 6, 2014 Airport Commission Meeting Minutes
Page 2 of 2
RESOLUTION NO. 2014-
A RESOLUTION ESTABLISHING RATES FOR THE ASHLAND
MUNICIPAL AIRPORT, AND REPEALING RESOLUTION 2013-16
RECITALS:
A. The Airport Commission reviewed established airport rates and recommended increasing
current airport rates.
B. The City has determined it is necessary to increase user rates for aircraft hangar rentals,
hangar ground leases, freight charges and aircraft tie downs.
THE CITY OF ASHLAND RESOLVES AS FOLLOWS:
SECTION 1. Effective July 1, 2014, unless otherwise provided by an agreement or lease, the
rates shown on "Exhibit A" are established for facilities at the Ashland Municipal Airport.
SECTION 2. Classification of the fees specified in Section 1 of this resolution are classified as
not subject to the limits of Section I IB of Article XI of the Oregon Constitution (Ballot Measure
5).
SECTION 3. Resolution No. 13-16 is repealed on the effective date of this Resolution.
SECTION 4. This resolution was duly PASSED and ADOPTED this day of
, 2014, and takes effect upon signing by the Mayor.
This resolution was duly PASSED and ADOPTED this day of
2014, and takes effect upon signing by the Mayor.
Barbara Christensen, City Recorder
SIGNED and APPROVED this day of 2014.
John Stromberg, Mayor
Reviewed as to form:
David H. Lohman, City Attorney
Resolution No. 2013- Page 1 of 1
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ASHLAND AIRPORT COMMISSION
May 6, 2014
MINUTES
Members Present: Bob Skinner, David Wolske, Richard Hendrickson, Susan Moen, Alan DeBoer,
Mike Morris and Elizabeth Tripp
Staff: Scott Fleury,
Members Absent: Nicole Doran, Lincoln Zeve, Bill Skillman
Visitors: David Ridsdale
CALL TO ORDER: 9:31 AM
1. APPROVAL OF MINUTES: March 4, 2014 motion by Hendrickson for approval, second by Moen,
minutes approved as written.
2. Agenda Item Addition: None
3. Public Forum: No public discussion.
4. OLD BUSINESS:
A. FBO Lease: Staff has received Skinners comments in writing and plans to create a master
copy of edits to review again with Legal and Skinner before the lease is finalized. Staff
expects to edit lease in May and return to Skinner to verify all issues are appropriately
addressed. Staff needs to meet with Legal to discuss the living wage requirement and
which employees of Skinners it applies to if any. Also, staff needs to discuss the pollution
insurance requirement and if Skinners fuel supplier's underwriter of $50,000,000 covers
the onsite spill requirement.
B. AIP/Hangar Door: Staff informs Commission 90% plans and specifications have been
developed by the consultant. Staff to have onsite meeting and go over plans/specs and
review comments with Precision Approach Engineering shortly. Once FAA and staff
approve of specs and plans the project will be advertised for bid. FAA would like to see
the project bid opening in June in order to award a construction grant. Staff shows
Commission grading plan sheet that shows taxilane layout.
C. Airport Zoning: Staff is still trying to setup a meeting with Severson to start project of
updating code. Commission reiterates to Councilor Morris the importance of getting this
done as if effects potential development onsite due to variances that must be obtained to
build a hangar, in order to comply with the land use code.
D. Airport Policies: Staff asks for any additions or clarifications to policy document. Staff
added pet and camping policy as requested previously. No other changes or modifications
request.
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Commission May 6 2014 Minutes Atch2.doc
5. NEW BUSINESS:
A. Commercial Hangar Tie Down Parking: David Ridsdale of JLC Avionics in attendance to
discuss use of airport tie downs for business parking. Current operations occasionally
require more parking than is available in or directly outside of the hangar. Ridsdale in the
past has used tie down spaces on the ramp adjacent to Sky's hangar. Ridsdale is looking
for parking options when multiple customers are onsite for more than one day. Skinner
stated he has previously spoken with JLC about this issue and mentions one option is to
rent a tie down space on a monthly basis to use as needed. Another option is to amend the
SASO lease and add a tie down without additional charges similar to Skinner's
agreement. Ridsdale believes that Sky's (Sierra Romeo) has something similar in their
lease that allows for tie down space on the ramp. JLC believes they bring in positive
traffic to the airport through their business operations and do not believe a fee is
warranted for the one tie down space on an as needed basis.
Motion be DeBoer: Amend SASO for Commercial Operators to include the equivalent of
one free tie down per month (31 days) for customer airplanes only with parking location
to be determined by FBO. 2nd by Moen, all approved.
Staff asks if this should also be included in the policy document will SASO amendments
occur? Commission agrees language regarding tie down parking should be included in
policy document.
B. Airport Good Neighbor Items: Staff informs Commission of noise complaint from lower
Clay St. regarding jet noise. Their main concern was this becoming more of a daily event
and increasing in the years to come. Staff informed this individual that one operator owns
a jet, but the airport runway length does not allow for larger jet aircraft landing and thus
this operation should be limited in the future. Commission believes the jet noise would be
reduced if they pilot maintains runway heading until the 3000 foot elevation is achieved.
Skinner will mention this to operator. Skinner states a couple of complaints were received
regarding helicopter operations during the past month. One was in respect to the early
morning search and rescue operation in the watershed that recently occurred and the other
was regarding training and check ride operations. Skinner states that many of the issues
were developed from offsite operators working at the Airport.
C. Rate Policy Recommendation: Staff goes over rate sheet and points out the fees that can
be recommended to Council for adjustment. The monthly rental fees and tie downs are up
for discussion with respect to adjustment. The ground lease and SASO fees are
automatically adjusted through the lease agreements. Staff states the CPI-U for January
was 1.58%.
Motion by Moen: Accept CPI-U increase rounded down to the nearest dollar for monthly
rental fees. 2nd by Hendrickson.
Commission discusses shade hangars and how 1-2 are vacant currently and the hardest
to rent. Moen amends motion to keep shade hangars at 5180, Hendrickson accepts
amendment.
DeBoer declares a potential conflict of interest as he rents hangars at the airport.
All approved
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Commission May 6 2014 Minutes Atch2.doc
6. AIRPORT MANAGER REPORT/FBO REPORT/AIRPORT ASSOCIATION:
A. Status of Airport, Financial Report, Review of Safety Reports: Skinner states the weeds
are really taking over and they need to be sprayed. Staff states he will contact Street
Department to develop an appropriate time to spray now that spring is in full force.
Proper notice will be passed on to Commission and users of times and dates for spraying
onsite. Once the weeds are sprayed all the cracks must be sealed by the Street crew as
well. In addition staff will discuss onsite mowing with Streets as a precursor to fire
season.
B. Maintenance Updates: Commission inquires into status of Fire Department training
container. Staff states now that the most recent training has been completed they will
work on relocating the container to Nevada St. within an electric storage yard. The owner
of a truck parked in the public lot has been identified and Skinner has asked them to
move it into long term parking.
C. Brown Bag: No update
D. Transportation Commission: No update.
E. Medford Airport: No update.
F. Action Item List: Hangar door project and avigation easement removed.
G. Airport Day/Marketing: Hendrickson discusses Airport Day preparation with
Commission. A pancake breakfast and BBQ lunch is scheduled. ODFW will have a truck
onsite. Staff is working to see if the Ashland Fire Department can have a truck onsite as
well. Brim will provide helicopter rides and the antique biplane will also provide rides.
There will be an announcer onsite and the Civil Air Patrol will provide marshalling
services during the day. Staff has is getting the banner updated, has porta potty's reserved
and is working on obtaining tables and chairs for the event in addition to obtaining cones
the CAP can use for traffic and pedestrian control. Commission would like to see area
mowed as well and maybe the sweeper to make a pass through to tidy the site up. Staff
will also try and arrange these items.
Hendrickson also states the Chamber will hold their board meeting onsite this coming
Friday in his hangar in order to talk about airport day and airport marketing in general.
Hendrickson will need additional volunteers to help with the event as he has previously
asked for through email and direct contact. Staff and Hendrickson are scheduled to give a
brief presentation before the City Council tonight on airport day festivities.
H. Airport Users Group: No update.
OTHER:
The meeting of the JC airport commission is the third Monday of the month at 12:00 PM.
NEXT MEETING DATE: June 3, beginning at 9:30 AM
ADJOURN: Meeting adjourned at I l :I3AM
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Commission May 6 2014 Minutes Atch2.doc
CITY OF
ASHLAND
Council Communication
June 3, 2014, Business Meeting
Ratification of five-year labor contract with the Laborers' International Union of
North America Local No. 121
FROM
Tina Gray, Human Resources Manager, tina.gray@ashland.or.us
SUMMARY
The existing three-year contract with the Laborers Union expires on June 30, 2014. The bargaining
teams were able to reach tentative agreement and both parties were interested in extending the contract
two additional years for a five-year contract. The contract is a continuation of the existing agreement,
with modifications as described below.
BACKGROUND AND POLICY IMPLICATIONS:
The current labor contract with the Laborers' union expires on June 30, 2014. The City reached
tentative agreement with this bargaining group outlined below.
Previous Contract Proposed in New Contract
~ Ill
3-Year Contract 5-fear Contract
Boot Allowance: Reimbursement of up to Boot Allowance: Reimbursement of up to
$100 every other year with a maximum of $+7>50/contract period, purchases of over $•200 in a
$200 for the contract period. FY must be pre-approved. Purchase can include
orthotics, insoles, weather-related footwear/ *ear.
Duty Pay: 6% of employee's normal monthly Duty Pay: 7% of employyee's normal monthly pay,
pay, with an additional 3% if holiday falls with an additional 3% if holiday falls during on-
durin on-call period call eriodi
2% COLA per year with a re-opener if CPI COLA effective 7,/1/14; outlying years
went over 3.5%. X3.5% based on C•PI-W Average Jan-Jan
Employees in the bargaining unit agreed to Clean-up health insurance article and add language
support the move to self insurance for regarding sebf-insured health plan and insurance
healthcare by MOU. The contract was signed committee.
effective 7/1/2011 which was prior to the
change to self-insurance.
N/A Long ity Pay: @ 20 years of service with the
City one-titae cash payment of $1,000. Employee
may pt to cpt the Longevity pay into his/her
rdeferred com ensation account for retirement.
.
Page 1 of 2
~r,
CITY OF
ASHLAND
FISCAL IMPLICATIONS:
• The current budget anticipated a 2% COLA for this bargaining group effective 7/l/2014.
• Ten employees will qualify for longevity pay on July 1, 2014. This represents a new one-time
expenditure of $10,000.
• The boot allowance is an increase of $50/year over what is currently offered to employees in
the bargaining unit. It is difficult to anticipate how many employees will take advantage of the
reimbursement as current utilization is not 100%. Employees working under this contract work
in all weather conditions and often require multiple boots to accomplish the work safely.
• The duty pay increase from 6% to 7% equates to an increase of approximately $40/week for the
employees who are on-call. The additional compensation is recognition of the impact on family
& personal life and the restrictions that come with being on-call.
Employees working under this contract are funded in multiple funds in the Public Works Department,
and staff is confident the increases called for in the new contract for the current year can be
accomplished within the current budget. A five-year agreement allows the City to anticipate future
expenses and budget appropriately for the remaining years of the labor agreement.
STAFF RECOMMENDATION AND REQUESTED ACTION:
Staff recommends that the Council authorize the City Administrator and Mayor to sign the five-year
labor contract, ratifying the tentative agreements reached in negotiations.
SUGGESTED MOTION:
Move approval of the labor agreement between the City of Ashland and the Laborers' Union and
authorize the City Administrator and Mayor to sign the labor contract, ratifying the tentative agreement
reached in negotiations.
ATTACHMENTS:
Proposed contract for Laborers' Union
Page 2 of 2
Mr,
AGREEMENT
BETWEEN
THE CITY OF ASHLAND, OREGON
and
DISTRICT COUNCIL OF LABORERS
and
LABORERS UNION LOCAL 121
July 1, 2014 - June 30, 2019
TABLE OF CONTENTS
PREAMBLE ..........................................................................................................................................5
SCOPE OF AGREEMENT ...................................................................................................................5
ARTICLE I - RECOGNITION ...............................................................................................................5
ARTICLE II- UNION SECURITY AND CHECK-OFF ...........................................................................6
Section 1. Union Security ....................................................................................................6
Section 2. Check-off for Union Members ..........................................................................6
Section 3. Check-off for Non-Members .............................................................................6
Section 4. Indemnification ...................................................................................................6
ARTICLE III - MANAGEMENT RIGHTS ..............................................................................................7
ARTICLE IV - STRIKE AND LOCKOUT PROHIBITION ....................................................................8
ARTICLE V - HOLIDAYS .....................................................................................................................8
Section 1. Recognized Holidays .........................................................................................8
Section 2. Holiday Pay .........................................................................................................9
Section 3. Holiday Work ......................................................................................................9
ARTICLE VI -VACATIONS ..................................................................................................................9
Section 1. Eligibility ..............................................................................................................9
Section 2. Continuous Service ..........................................................................................9
Section 3. Use of accrued vacation time ..........................................................................9
Section 4. Accrual Notification .........................................................................................10
Section 5. Scheduling ........................................................................................................10
Section 6. Payment on Termination ...................................................................................11
ARTICLE VII - HOURS OF WORK ....................................................................................................11
Section 1. Workweek ..........................................................................................................11
Section 2. Hours ...................................................................................................................11
Section 3. Work Schedules ...............................................................................................11
Section 4. Rest Periods .....................................................................................................11
Section 5. Meal Periods .....................................................................................................12
ARTICLE Vlll - SICK LEAVE .............................................................................................................12
Section 1. Accumulation ....................................................................................................12
Section 2. Utilization for Illness or Injury ........................................................................12
Section 3. Integration with Worker's Compensation .....................................................12
Section 4. Sick Leave Without Pay ...................................................................................12
2014-2019 Laborer's Contract Page 2
Section 5. Termination .......................................................................................................13
Section 6. Compensation for Not Using Sick Leave ......................................................13
Section 7. Use for Family Illness ........................................................................................13
ARTICLE IX - FUNERAL LEAVE ......................................................................................................13
Section 1. Funeral Leave ...................................................................................................13
ARTICLE X - OTHER LEAVES OF ABSENCE .................................................................................13
Section 1. Leaves of Absence Without Pay .....................................................................13
Section 2. Jury Duty ...........................................................................................................14
Section 3. Appearances .....................................................................................................14
Section 4. Required Court Appearances ........................................................................14
Section 5. Election Day ......................................................................................................14
Section 6. Union Business ................................................................................................14
Section 7. Educational Leave ............................................................................................14
Section 8. Military Leave ....................................................................................................15
Section 9. Failure to Return From Leave .........................................................................15
ARTICLE XI - COMPENSATION .......................................................................................................15
Section 1. Pay Schedule ....................................................................................................15
Section 2. Pay Periods .......................................................................................................15
Section 3. Call-Back Time . 15
Section 4. Overtime ............................................................................................................16
Section 5. Over-time Compensation ................................................................................16
Section 6. Standby Pay ......................................................................................................16
Section 7. Certification-Pay .................................................................................................17
Section 8. Mileage ..............................................................................................................17
Section 9. Working Out of Class .......................................................................................17
Section 10. Longevity Pay ...................................................................................................17
ARTICLE XII - DISCIPLINE AND DISCHARGE ................................................................................18
Section 1. Discipline ..........................................................................................................18
Section 2. Discharge ..........................................................................................................18
ARTICLE XIII - SETTLEMENT OF DISPUTES .................................................................................19
Section 1. Grievance and Arbitration Procedure ............................................................19
Section 2. Stewards ...........................................................................................................20
ARTICLE XIV - SENIORITY ...............................................................................................................21
ARTICLE XV - GENERAL PROVISIONS ..........................................................................................23
Section 1. No Discrimination ............................................................................................23
20142019 Laborer's Contract Page 3
J
Section 2. Bulletin Boards .................................................................................................23
Section 3. Visits by Union Representatives ....................................................................23
Section 4. Solicitation ..........................................................................................................24
Section 5. Existing Conditions .........................................................................................24
Section 6. Rules .....................................................................................................24
Section 7. Other Employment ...........................................................................................24
Section 8. Supervisory Employees ..................................................................................24
Section 9. Uniforms, Protective Clothing and Devices ..................................................24
Section 10. Response Time Requirement .......................................................................25
Section 11. Safety Committee ...........................................................................................25
Section 12. Training Opportunities ..................................................................................25
Section 13. Temporary Employees ...................................................................................25
ARTICLE XVI - HEALTH, WELFARE AND RETIREMENT ..............................................................25
Section 1. Health and Welfare ...........................................................................................25
ARTICLE XVIII - WORKER'S COMPENSATION ..............................................................................26
Section 1. Worker's Compensation ..................................................................................26
Section 2. Supplementary Payment .................................................................................26
ARTICLE XIX - LIABILITY INSURANCE ..........................................................................................27
Section 1. Liability Insurance ............................................................................................27
Section 2. Property Insurance ..........................................................................................27
ARTICLE XX - SAVINGS CLAUSE AND FUNDING ........................................................................27
Section 1. Savings Clause ..................................................................................................27
Section 2. Funding .............................................................................................................27
ARTICLE XXI - TERMINATION AND REOPENING .........................................................................28
2014-2019 Laborer's Contract Page 4
AGREEMENT
BETWEEN
THE CITY OF ASHLAND, OREGON
and
DISTRICT COUNCIL OF LABORERS and LABORERS UNION LOCAL 121
PREAMBLE
This Agreement is entered into by the City of Ashland, Oregon, hereinafter referred to
as the "City", and Oregon, Southern Idaho District Council of Laborers International
Union of North America-, AFL-CIO, hereinafter collectively referred to as the "Union".
Unless indicated otherwise, references to the "City" herein shall include the Mayor and
City Council or their designee(s) as the officials directly responsible for the operation of
the department(s) covered by this Agreement. The purpose of this Agreement is to set
forth the fall and complete Agreement between the parties on the matters pertaining to
rates of pay, hours of work and other conditions of employment.
SCOPE OF AGREEMENT
This Agreement shall include employees of the Public Works and Cemetery
Departments, Ashland, Oregon, as set forth in Appendix "A" but excluding supervisory
employees, confidential employees, clerical employees, guards, part-time employees,
or temporary employees.
Where the term "employee" is used, it shall mean regular employees or probationary
employees within the bargaining unit, as the same are defined in Article XIV hereof.
The parties agree as follows:
ARTICLE I - RECOGNITION
The City recognizes the Union as the sole and exclusive bargaining agent for the
purpose of establishing rates of pay, hours of work and other conditions of employment
for all employees within the bargaining unit described immediately above.
2014-2019 Laborer's Contract Page 5
ARTICLE II- UNION SECURITY AND CHECK-OFF
Section 1. Union Security. The terms of this Agreement have been made for all
employees in the bargaining unit and not only for the members of the Union.
Accordingly, it is fair that each employee in the bargaining unit pays his/her own way
and assume his/her obligation along with the grant of equal benefits. Any employee in
the bargaining unit who has not joined the Union within thirty (30) days of this
Agreement, or within thirty (30) days of becoming an employee, shall as a condition of
employment, pay to the Union an amount equal to the uniform dues and initiation fees
required of members of the Union.
Any individual employee objection based on bona fide religious tenets or teachings of a
church or religious body of which such employee is a member, will require such an
employee to inform the City and Union of his/her objection. The employee will meet with
representatives of the Union and establish a satisfactory arrangement for distribution of
a contribution of an amount of money equivalent to regular Union membership dues to
a non-religious charity.
Section 2. Check-off for Union Members. Upon receipt of a lawfully executed
authorization from an employee, the City agrees to deduct the regular monthly dues
uniformly required of members of the Union, and remit such deductions by the fifteenth
(15th) of the succeeding month to the official designated by the Union in writing to
receive such deductions. The Union will notify the City in writing of the exact amount of
such regular membership dues to be deducted. Authorization by the employee shall be
on forms furnished by the City and may be revoked by the employee upon request.
Employees terminating with less than ten (10) working days in any calendar month will
not be subject to a dues deduction.
Section 3. Check-off for Non-Members. A like amount in lieu of Union dues will be
automatically deducted from all employees in the bargaining unit as set forth in
Appendix "A" who have not signed an authorization form requesting the deduction of
Union initiation fees and monthly dues. Such deduction will be remitted along with
amounts deducted from Union members as set forth in Section 2. It is understood that
the like amount in lieu of dues shall only be used as directed by the Constitution and
By-laws of the Union and by the majority vote of the Union membership. Employees
terminating with less than ten (10) working days in any calendar month will not be
subject to an in lieu dues deduction.
Section 4. Indemnification. The Union agrees to indemnify and hold the City
harmless against any and all claims, orders, or judgments brought or issued against the
City as a result of any action taken or not taken by the City under the provisions of this
article. Upon written notification by the Union of a check-off error, the City will make
adjustments within sixty (60) days of receipt of such notification.
2014-2019 Laborer's Contract Page 6
ARTICLE III - MANAGEMENT RIGHTS
Union recognizes the prerogative of City to operate and manage its affairs in all
respects in accordance with its responsibilities, and the powers or authority which City
has not expressly abridged, delegated or modified by this Agreement are retained by
City. It is understood and agreed that City possesses the sole and exclusive right to
operate the City through its City Administrator and department heads and that all
management rights repose in it, but such rights must be exercised consistent with the
other provisions of this contract. These rights include but are not limited to the following:
1. To determine the mission of its constituent departments,
commissions and boards.
2. To set standards of services.
3. To direct its employees.
4. To discipline or discharge for just cause.
5. To relieve its employees from duty because of lack of work,
finances or other legitimate reasons.
6. To maintain the efficiency of governmental operations.
7. To determine the methods, means and personnel by which
government operations are to be conducted; except that the City
will not contract any work which is ordinarily done by its regular
employees for the specific purpose of laying off or demoting such
employees, and will furnish the Union with a copy of any contract
entered into involving work covered by this contract.
8. To determine the content of job classifications.
9. To take all necessary action to carry out its mission in
emergencies, and
10. To exercise complete control and discretion over its organization
and the technology of performing its work.
2014-2019 Laborer's Contract Page 7
ARTICLE IV - STRIKE AND LOCKOUT PROHIBITION
Section 1. The Union and its members, as individuals or as a group, will not initiate,
cause, permit or participate or join in any strike, work stoppage, or slowdown, picketing,
or any other restriction of work at any location in the City. Employees in the bargaining
unit, while acting in the course of their employment, shall not honor any picket line
established in the City by the Union or by any other labor organization when called
upon to cross the picket line in the line of duty. Disciplinary action, including discharge
may be taken by the City against any employee or employees engaged in a violation of
this Article. Such disciplinary action may be undertaken selectively at the option of the
City and shall not preclude or restrict recourse to any other remedies, including an
action for damages, which may be available to the City.
Section 2. In the event of a strike, work stoppage, slowdown, picketing, observance of
a picket line, or other restriction of work in any form, either on the basis of individual
choice or collective employee conduct, the Union will immediately upon notification,
attempt to secure an immediate and orderly return to work. This obligation and the
obligations set forth in Section 1 above shall not be affected or limited by the subject
matter involved in the dispute giving rise to the stoppage or by whether such subject
matter is or is not subject to the grievance and arbitration provision of this Agreement.
Section 3. There will be no lockout of employees in the unit by the City as a
consequence of any dispute with the Union arising during the period of this Agreement.
ARTICLE V - HOLIDAYS
Section 1. Recognized Holidays. The following shall be recognized as Holidays:
New Year's Day (January 1)
Martin Luther King, Jr.'s Birthday (3rd Monday in January)
Washington's Birthday (3rd Monday in February)
Memorial Day (last Monday in May)
Independence Day (July 4)
Labor Day (1 st Monday in September)
Veterans' Day (November 11)
Thanksgiving Day (4th Thursday in November)
Day after Thanksgiving Day (in-lieu of Lincoln's Birthday)
Christmas Day (December 25)
Whenever a Holiday shall fall on Sunday, the succeeding Monday shall be observed as
a Holiday. Whenever a Holiday shall fall on Saturday, the preceding Friday shall be
observed as the Holiday. If an employee is on authorized vacation, sick leave or other
leave with pay when a Holiday occurs, such Holiday shall not be charged against such
leave.
2014-2019 Laborer's Contract Page 8
Section 2. Holiday Pay. Regular employees shall receive eight (8) hours pay for each
of the Holidays listed above on which they perform no work. In order to be eligible for
Holiday pay when no work is performed, an employee must work on his/her last
scheduled work day prior to the Holiday and on his/her first scheduled work day
immediately following the Holiday, unless the employee provides a justifiable excuse to
the City.
Section 3. Holiday Work. If a regular employee is required to work on any of the
Holidays listed above as part of his/her regularly scheduled work week, he/she shall
receive, in addition to his/her regular pay, compensation for all hours worked at his/her
regular straight time rate of pay. Compensation accrued by reason of authorized work
on a Holiday as provided herein shall be paid for at the straight time rate being received
at the time the work was performed or given another compensatory day off at the option
of the department head. If any other regular employee is required to work on a Holiday,
he/she shall receive, in addition to his/her regular pay, compensation for all hours
worked in accordance with call-back pay provisions set forth in Article X, Section 3.
ARTICLE VI - VACATIONS
Section 1. Eligibility. An employee shall be eligible to take accrued vacation leave
with pay after one (1) full year of continuous service. Vacation leave shall accrue on a
monthly basis. During an employee's first year of employment, the employee will
accrue vacation at the rate of 80 hours of vacation per year, accrued through equal
monthly accruals. Following the completion of the first full year of employment the
annual vacation accrual will increase by 6 hours per every full year of continuous
service completed by the employee with the City of Ashland up to a maximum annual
vacation accrual cap of 184 hours.
Section 2. Continuous Service. Continuous service, for the purpose of accumulating
vacation leave, shall be based on the regular hours paid to the employee. Vacation
leave shall not accrue during a leave of absence without pay. Authorized leave without
pay and lay-offs shall not be counted as service, however, employees returning from
such leave and employees on layoff status shall be entitled to credit for service prior to
the leave or layoff.
Section 3. Use of accrued vacation time. Each year, an employee may use accrued
vacation time to take time off or to carry forward to the next year. The following rules
apply:
Section 3.1. After the first year of employment, an employee can use vacation for time
off as soon as the vacation time has been earned.
Section 3.2. The employee must use at least 75% of his/her annual vacation accrual
for time off. Example: an employee who earns 16 vacation days per year (10.67 hours
per month) must take at least twelve (12) days of vacation time off during the year.
2014-2019 Laborer's Contract Page 9
Section 3.3. Vacation time that is not used for time off will carry forward to the next
year.
Section 3.4. An employee cannot accumulate at any time more vacation time than two
times his/her annual vacation accrual. Example: an employee who earns 16 vacation
days per year (10.67 hours per month) may accumulate up to thirty-two (32) days of
vacation.
Section 3.5. If an employee has the maximum amount of vacation accumulated, no
more vacation time is earned until the employee has used some of the accumulated
vacation time.
Section 4. Accrual Notification. The City shall notify an employee thirty (30) days in
advance of impending loss of accrued vacation time. The employee and supervisor will
immediately discuss when the employee can take time off so as to avoid any loss of
vacation time. If the City is unable to release the employee within that thirty day period
to take vacation time off, the vacation time which exceeds the accrual maximum will, by
mutual agreement between the supervisor and the employee, either be cashed out or
the employee will be allowed to carry it forward until the employee can take the time off.
Section 4.1 Accrual Limitations. Vacation leave must be taken by the employee
within twelve (12) months following the date of eligibility, or such vacation shall be
deemed forfeited. An employee who is about to lose vacation leave because of accrual
limitations may, by notifying his/her supervisor fifteen (15) days in advance, absent
himself/herself to prevent loss of vacation leave. Such action taken by the employee
shall not constitute a basis for disciplinary action or loss of pay. The City shall notify an
employee thirty (30) days in advance of impending loss of accrued vacation time. No
payment shall be made for vacation leave lost by an employee because of accrual
limitations, unless the failure to take vacation is caused by the City's insistence that the
employee be at work during a scheduled vacation period.
Section 5. Scheduling. Employees shall be permitted to request vacation on either an
entire basis, or split into increments of not less than one-working day. Vacation times
shall be scheduled based on the head of the department's judgment as to the needs of
efficient operations and the availability of vacation relief. Accordingly, the City will not
guarantee that vacation times selected by the Street Division crew during the last two
weeks of June, and the last two weeks of August or September will be granted. Subject
to the foregoing, employees shall have the right to determine vacation times. Vacation
times shall be selected on the basis of seniority; provided, however, that each
employee will be permitted to exercise his/her right of seniority only once annually. The
vacation schedule for the period of May 1 to April 30, shall be posted annually as of
April 1 and employees shall exercise their choice by bidding in seniority. The list shall
be closed as of April 30 and subsequent changes shall be made only by mutual
consent between the employee and the City. Scheduling of vacation periods to the
2014-2019 Laborer's Contract Page 10
extent consistent with operating requirements of the City and vacation credits of the
employee, shall be in daily units. If an employee's choice for a vacation period is
restricted by the City because of the necessity to complete work in a given time period,
or with the supervisor's approval,- then that employee may accumulate and carry over
five (5) working days of vacation time into a subsequent year.
Section 6. Payment on Termination. In the event of the death or termination of an
employee during the initial twelve (12) months of his/her employment, no payment in
lieu of vacation shall be made. In the event of death or termination of employment after
an employee has served for twelve (12) months, and is otherwise eligible for vacation
credits, the employee shall be entitled to payment for accrued vacation leave at the rate
of the date of eligibility. In the event of death, earned but unused vacation leave shall
be paid in the same manner as salary due the deceased employee is paid.
ARTICLE VII - HOURS OF WORK
Section 1. Workweek. The workweek, to the extent consistent with operating
requirements of the departments covered by this Agreement, and recognizing the
necessity for continuous service by such departments throughout the week, shall
consist of five (5) consecutive days as scheduled by the Department Heads or other
responsible authority.
Section 2. Hours.
a. Treatment plant operators shall be scheduled for eight (8) consecutive hours
(including 1/2 hour for a meal period) which shall be paid. Treatment Plant
operators may be scheduled for ten (10) hour shifts. The regular hours of all
other employees shall be 8 1/2 consecutive hours, including 1/2 hour for a meal
period which shall not be paid. In addition, any other regular employee who is
scheduled to work a shift which begins prior to 6:00 Am., or a shift which ends
after 10:00 p.m., shall be scheduled for 8 consecutive hours, including 1/2 hour
for a meal period which shall be paid.
Section 3. Work Schedules. All employees, to the extent consistent with operating
requirements, shall be scheduled to work on a regular work shift, and each shift shall
have regular starting and quitting times. Work schedules showing the employee's shifts,
workdays and hours shall be posted on department bulletin boards. Except for
emergency situations and for the duration of the emergency, changes in work
schedules shall be posted seven (7) days prior to the effective date of the change.
Section 4. Rest Periods. A rest period of fifteen (15) minutes shall be permitted for all
employees during each half shift, which shall be scheduled by the City in accordance
with its determination as to the operating requirements and each employee's duties.
2014-2019 Laborer's Contract Page 11
Rest periods may be taken at a place of the employee's choosing provided no more
than the allotted time is used and no City vehicles are used for transportation to or from
such place.
Section 5. Meal Periods. To the extent consistent with operating requirements of the
respective departments, meal periods shall be scheduled in the middle of the work shift.
Meal periods may be taken at a place of the employee's choosing provided no more
than the allotted time is used and no City vehicles are used for transportation to or from
such place.
ARTICLE VIII - SICK LEAVE
Section 1. Accumulation. Sick leave shall be earned for the purposes stated herein
by each eligible employee at the rate of eight (8) hours for each full calendar month of
service. No new sick leave credit may be accrued after the first thirty (30) calendar days
on sick leave resulting from an injury incurred in the course of employment. Sick leave
may be accumulated to a total of nine hundred sixty (960) hours and must be taken for
the purposes specified in Section 2 hereof as a condition precedent to any sick leave
payment.
Section 2. Utilization for Illness or Iniurv. Employees may utilize their allowance for
sick leave when unable to perform their work duties by reason of illness or injury. In
such event, the employee shall notify the department head or other supervisor of
absence due to illness or injury, the nature and expected length thereof, as soon as
possible prior to the beginning of his/her scheduled regular work shift, unless unable to
do so because of the serious nature of injury or illness. A physician's statement of the
nature and identity of the illness, the need for the employee's absence and the
estimated duration of the absence may be required at the option of the City for
absences of over two days prior to payment of any sick leave benefits or prior to
allowing the employee to return to work. A physician's s statement may be required as
a prerequisite to payment of sick leave for less than three (3) days if the employee has
been advised in advance of such requirement.
Section 3. Integration with Workers' Compensation. When an injury occurs in the
course of employment, the City's obligation to pay under this sick leave article is limited
to the difference between any payment received under Worker's Compensation laws
and the employee's regular pay. In such instances, pro-rated charges will be made
against accrued sick leave for the first thirty (30) calendar days in proportion to the
City's contribution to the employee's daffy wage. Thereafter, full charges will be made
against accrued sick leave until such sick leave is exhausted, after which time the only
compensation will be Workmen's Compensation benefits, if any.
Section 4. Sick Leave Without Pay. Upon application by the employee, sick leave
without pay may be granted by the City for the remaining period of disability after
accrued sick leave has been exhausted. The City may require that the employee submit
2014-2019 Laborer's Contract Page 12
a certificate from a physician periodically during the period of such disability, and before
returning to work.
Section 5. Termination. Sick leave is provided by the City in the nature of insurance
against loss of income due to illness or injury. No compensation for accrued sick leave
shall be provided for any employee upon his/her death or termination of employment,
except that upon retirement, accumulated sick leave will be applied to retirement as
provided in ORS238.153. Sick leave shall not accrue during any period of leave without
pay.
Section 6. Compensation for Not Using Sick Leave. Employees may elect to
receive 1/3 of their unused annual sick leave accrual (maximum of 32 hours) as cash
on their first paycheck in December. If cash payment is not elected, the unused portion
of sick leave will be added to employee's cumulative sick leave balance or converted to
accrued vacation at the option of the employee.
Section 7. Use for Family Illness.
An employee may be granted leave to care for an ill or injured family member in
accordance with applicable federal and state Family & Medical Leave Laws.
For the purpose of this Section, family member shall include any family member
recognized under the Oregon and/or Federal Family and Medical Leave Acts.
ARTICLE IX - FUNERAL LEAVE
Section 1. Funeral Leave. An employee may be granted three (3) days funeral leave
with regular pay in the event of death in the immediate family of the employee. An
employee's immediate family shall include spouse, parent, children, brother, sister,
brother-in-law, sister-in-law, mother-in-law, father-in-law, grandparents and
grandparents-in-law. The employee will be paid his/her regular hourly rate for any such
days of excused absence which occur only during his/her assigned workweek. An
additional two (2) days may be granted if the funeral is over 750 miles from Ashland,
one way.
ARTICLE X - OTHER LEAVES OF ABSENCE
Section 1. Leaves of Absence Without Pay. Leaves of absence without pay not to
exceed one (1) year may be granted upon establishment of reasonable justification and
where it is determined that the operation of the department and/or division win not be
negatively impacted by the temporary absence of the employee. Requests for such
leaves must be in writing and submitted to the Department Head 30 days prior to the
requested leave date.
2014-2019 Laborer's Contract Page 13
Section 2. Jury Dutv. Employees shall be granted leave with pay for service upon a
jury; provided, however, that the regular pay of such an employee for the period of
absence shall be reduced by the amount of money received by him/her for such jury
service, and upon being excused from jury service for any day an employee shall
immediately contact his/her supervisor for assignment for the remainder of his/her
regular workday.
Section 3. Appearances. Leave with pay shall be granted for an appearance before a
court, legislative committee, judicial or quasi-judicial body as a witness in response to a
subpoena or other direction by proper authority; provided, however, that the regular pay
of such employee shall be reduced by an amount equal to any compensation he/she
may receive as witness fees.
Section 4. Required Court Appearances. Leaves of absence with pay shall be
granted for attendance in court in connection with an employee's officially assigned
duties, including the time required for travel to the court and return to the employee's
headquarters.
Section 5. Election Day. Employees shall be granted two (2) hours to vote on any
election day only if, due to scheduling of work, they would not otherwise be able to vote.
Section 6. Union Business. Employees elected to any legitimate full-time paid Union
office which takes them from their employment with the City, shall upon written request
of the Union and the employee, be granted a leave of absence of up to one (1) year
without pay, renewable upon application. Employees selected by the Union to attend
conventions and related Union activities, shall upon written request of the Union and the
employee, be granted a leave of absence of up to thirty (30) days without pay.
Section 7. Educational Leave. After completing one (1) year of continuous service, an
employee, upon written request may be granted a leave of absence without pay by the
City for the purpose of upgrading his/her professional ability through the enrollment in
educational courses directly related to employment at an accredited school or course of
study. The period of such leave of absence shall not exceed one (1) year, but may be
renewed or extended upon request of the employee and approval by the department
head. One year leaves of absence, with requested extensions, for educational
purposes may not be provided more than once in any three (3) year period. His/her
replacement shall be considered a temporary employee.
Employees may also be granted time off with pay for educational purposes for
reasonable lengths of time, to attend conferences, seminars, briefing sessions, training
program , and other programs of a similar nature that are intended to improve or
upgrade the employee's skill and professional ability, when ordered by the employee's
department head.
2014-2019 Laborer's Contract Page 14
Section 8. Military Leave. Military leave shall be granted in accordance with Oregon
Revised Statutes.
Section 9. Failure to Return From Leave. Any employee who is granted a leave of
absence and who, for any reason, fails to return to work at the expiration of said leave
of absence, shall be considered as having resigned his/her position with the City, and
his/her position shall be declared vacated; except and unless the employee, prior to the
expiration of his/her leave of absence, has furnished evidence that he/she is unable to
work by reason of sickness, physical disability or other legitimate reason beyond his/her
control.
ARTICLE XI - COMPENSATION
Section 1. Pay Schedule. Employees shall be compensated in accordance with the
pay schedule attached to this Agreement and marked Appendix "B" which is hereby
incorporated into and made a part of this Agreement. When any position not listed on
the pay schedule is established, the City shall designate a job classification and pay
rate for the position. The Union shall be notified and the pay rate established by the City
shall be considered tentative until the Union has been afforded the opportunity to meet
and discuss the matter. If the Union does not agree that the classification or pay rate is
proper, the Union may submit the issue as a grievance according to the grievance
procedure.
The Following Wage Rate Increases shall be applied:
Effective 7/1/2014, the City and union agree to apply 2% to the salary schedule for all
positions in the bargaining unit.
During the remaining years of the contract, the City and the union agree to apply a
COLA each July 1 sr based on the CPI-W average, January-January, between 1.5% and
3.5% using the LGPI Newsletter CPI Index. (htto://www.Igpi.orq/current-coi-click-image-
larger-view). If the actual CPI is higher than 3.5% or lower than 1.5% by more than .5%,
both parties agree to re-open contract negotiations to discuss wages and benefits only.
In the event that the City grants or negotiates a VEBA contribution of more than 2% to
any other employee group at the City during the life of this contract, the City agrees to
apply the same HRA-VEBA contribution, at the same time, to members of the Laborer's
Union.
Section 2. Pay Periods. Paydays shall be on the Friday following the close of each
pay period.
Section 3. Call-Back Time. Employees called back to work shall receive overtime pay
with a guaranteed minimum of one (1) hour at double time for the work for which they
2014-2019 Laborer's Contract Page 15
are called back. This section applies only when call-back results in hours worked which
are not annexed consecutively to one end or the other of the working day or working
shift. This section does not apply to scheduled overtime, call-in times annexed to the
beginning of the work shift, or hold-over times annexed to the end of the work shift or
work day.
Section 4. Overtime. The City has the right to assign overtime work as required in a
manner most advantageous to the City, and consistent with the requirements of
municipal service and the public interest. Employees shall be compensated at the rate
of two (2) times the regular rate for overtime work under the following conditions, but in
no event shall such compensation be received twice for the same hours:
(a) All assigned work in excess of eight (8) hours on any scheduled workday.
(b) All assigned work in excess of -forty (40) hours in any workweek.
Section 5. Over-time Compensation. Overtime may be paid in the form of
compensatory time off at the applicable rate, subject to the approval of the Department
Head or designated supervisor. All overtime shall be recorded by the employee and
must be approved by the Department Head or designated supervisor in advance. The
employee must designate whether he/she desires pay or compensatory time off on the
time sheet reporting the overtime worked. Compensatory time shall be accrued on an
annual basis from December 1 to November 30 with any amount unused at November
30 to be compensated as pay on the first pay check of December. Accrued
compensatory time shall not exceed twenty (20) hours which represents forty (40) hours
of straight time. However, at the option of the employee, up to twenty (20) hours (40
hours of straight time) may be carried forward for use in the next year, rather than being
cashed out in December.
Section 5.1. Overtime Meal Allowance. Employees who are required to work
more than (12) hours in one work day or are required to report to work without
adequate time to prepare a meal shall be entitled to a meal allowance. An
overtime meal allowance of $15.00 will be paid on the first paycheck that
includes the overtime work. Overtime meal allowance should be approved by
the employee's supervisor and requested on the timesheet when the overtime
work occurred.
If overtime work continues after a meal has been provided, employees shall be
entitled to additional meals at (4) hour intervals thereafter.
Section 6. Standby Pay. Standby pay shall be 7% of an employee's regular monthly
rate. If a holiday occurs during such period, an additional 3% of the employee's regular
monthly rate shall be paid to such employee.
2014-2019 Laborers Contract Page 16
Section 7. Certification -Pa .
Certification pay will be added as follows:
(1) Mechanic - more than 2 certification, but less than 6 = $0.25 per hr.
(a) Master Mechanic Certification - $0.50 per hr.
(2) Water / Waste Water -
(a) # II Certification = $0.25 per hr.
(b) # III Certification = $0.35 per hr.
(c) # IV Certification = $0.50 per hr.
(3) Back-Flow Certification Required by the City (Inspector Certification or
Testing Certification -
(a) Any one of these certification = $0.35 per hr.
(b) Both certifications = $0.50 per hr.
(4) Building Maintenance Certification = $0.25 per hr.
(5) Pesticide Certification Required by the City = $0.35 per hr.
(6) Erosion Control Certification = $0.25 per hr.
(7) Pre-Need Sales Certification = $0.25 per hr. (Limited to two employees
actively working in the Cemetery Division.)
Employees currently receiving certification pay through grandfathered provisions
will receive the above certification pay in lieu of and not in addition to the
certification pay they are currently receiving.
Employees may receive pay for more than one certification, but pay for
combined certifcations may not exceed $0.50/hr. To be eligible for certification
pay, an employee must obtain prior approval from his or her supervisor.
Section 8. Mileage. An employee required to report for special duty or assignment at
any location other than his/her permanent reporting location and who is required to use
his/her personal automobile for transportation to such location shall be compensated at
the mileage reimbursement rate established annually by the IRS.
Section 9. Working Out of Class. Whenever an employee is required to work in a
higher job classification he/she shall receive an additional 5% for the next higher
classification, 10% for a two classification upgrade and 15% for a three classification
upgrade for the actual hours worked in the higher classification.
Section 10. Longevity Pa v. Once a member of the bargaining acheives a total of 20
years of service, he/she shall receive a one-time cash payment of $1,000. At the
2014-2019 Laborers Contract Page 17
employee's option, he or she may accept the longevity payment as cash, or the
member may elect to defer (all or part of) the longevity pay through one of the City's
available deferred compensation programs.
ARTICLE XII - DISCIPLINE AND DISCHARGE
Section 1. Discipline. Disciplinary action may include the following:
(a) Oral reprimand.
(b) Written reprimand.
(c) Demotion.
(d) Suspension.
(e) Discharge.
Disciplinary action may be imposed upon any employee for failing to fulfill his/her
responsibilities as an employee. Conduct reflecting discredit upon the City or
department, or which is a direct hindrance to the effective performance of City
functions, shall be considered good cause for disciplinary action. Such cause may also
include misconduct abuse of sick leave, inefficiency, incompetence, insubordination,
misfeasance, malfeasance, the willful giving of false or confidential information, the
withholding of information with intent to deceive when making application for
employment willful violation of departmental rules or for political activities forbidden by
State law. Any disciplinary action imposed upon an employee shall be protested only as
a grievance through the regular grievance procedure. Written reprimands shall not be
kept in an employee's file longer than 12 months unless there is a similar disciplinary
problem during this time. Oral reprimands shall not be protested through the grievance
procedure.
If the Department Head or other supervisor has reason to discipline an employee,
he/she shall make reasonable efforts to impose such discipline in a manner that will not
embarrass or humiliate the employee before other employees or the public.
Section 2. Discharge. An employee having less than twelve (12) months continuous
service shall serve at the pleasure of the City. An employee having continuous service
in excess of twelve (12) months shall be discharged only for cause. If the department
head or other supervisor determines that there is cause for discharge, he/she shall
suspend the employee without pay for five (5) calendar days and shall deliver to the
employee and the Union a written notice of such suspension and pending dismissal.
Such notice shall specify the principal grounds for such action. Unless otherwise
resolved, the dismissal shall become effective at the end of the five-day suspension.
Protest of the discharge of any regular employee shall be made only through the
grievance procedure set forth in Article XIII. The Union may process a grievance
concerning suspension or discharge, or both, at Step 11 of the grievance procedure.
2014-2019 Laborer's Contract Page 18
ARTICLE XIII - SETTLEMENT OF DISPUTES
Section 1. Grievance and Arbitration Procedure. Any grievance or dispute which
may arise between the parties concerning the application, meaning or interpretation of
this Agreement shall be settled in the following manner:
Step I. The affected employee shall take up the grievance or dispute with the
employee's division head or supervisor within seventy-two (72) hours of its occurrence,
excluding Saturday and Sunday. Such employee may be accompanied by the Steward,
if he/she so desires. The division head or supervisor shall then attempt to adjust the
matter within three (3) working days.
Step II. If the grievance has not been settled between the affected employee and the
division head or supervisor, it may be presented in writing by the Union Business
Manager or his/her designee to the Director of Public Works within seventy-two (72)
hours, excluding Saturday and Sunday, after the response specified in Step I is due.
The written notice shall include details of the grievance, the section of this Agreement
allegedly violated and the specific remedy requested. The Director of Public Works
shall respond to the Union representative in writing within five (5) working days after
receipt thereof.
Step III. Board of Adjustment
If the grievance is not resolved at Step 11, it shall be referred to a Board of Adjustment
by written notice which is served on the City within five (5) working days after the failure
to resolve the grievance at Step 11 or within five (5) working days after expiration of the
time limit applicable to that step. Failure to serve timely notice of referral to the Board of
Adjustment shall constitute a waiver of the grievance. The Board of Adjustment shall
consist of two (2) representatives appointed by the City and two (2) representatives by
the Union. None of these four (4) shall be a City employee. The Board shall hear the
matter at a mutually convenient time and place within ten (10) working days following
written referral to the Board of Adjustment. Upon hearing the matter, the Board shall
issue a written decision signed by the members within twenty-four (24) hours. The
majority of the Board of Adjustment shall determine the matter, and such decisions
shall be final and binding on all parties - the City, the Union and the grievant or
grievants. Each member of the Board of Adjustment shall be entitled to one (1) vote. In
the event the Board of Adjustment is deadlocked, such result will be noted in writing.
The parties may, by mutual agreement, waive submission of a grievance to the Board
of Adjustment.
Step IV. If the grievance still remains unadjusted, it may be presented by the Union to
the City Administrator or his/her designee, within five (5) working days after the Board
of Adjustment's action. The City Administrator or his/her designee shall respond in
writing to the Union within five (5) working days.
2014-2019 Laborer's Contract Page 19
Step V. If the grievance is still unsettled, either party may, within ten (10) days after the
reply of the City Administrator is due, by written notice to the other, request arbitration
of the dispute under Step IV hereof.
Step VI. If the grievance is still unsettled, either party may within ten (10) days of the
decision of the City Administrator or his/her designee(s) under Step V have the right to
have the matter arbitrated by a third party jointly agreed upon by the City and the Union.
If the parties are unable to agree upon an arbitrator, the Oregon State Conciliation
Service shall be requested to submit a list of five names. Both the City and the Union
shall have the right to strike two names from the list. The party requesting arbitration on
shall strike the first name and the other party shall then strike one name. The process
shall be repeated and the remaining person shall be the arbitrator. The City and the
Union shall meet in a prehearing conference and shall prepare a submission agreement
regarding the specific issues in dispute. The designated arbitrator shall hear both
parties as soon as possible on the disputed matter and shall render a decision within
thirty (30) days which shall be final and binding on the parties and the employee. The
arbitrator shall have no right to amend, modify, nullify, ignore or add provisions to the
agreement, but shall be limited to consideration of the particular issue(s) presented to
him/her. His/her decision shall be based solely upon his/her interpretation of the
meaning and application of the express language of the agreement. Expenses for the
arbitrator shall be borne equally by the City and the Union; however, each party shall be
responsible for compensating his/her own representatives and witnesses. If either party
desires a verbatim recording of the proceedings, it may cause such a record to be
made, provided it pays for the record. If the other party desires a copy, both parties
shall jointly share the cost of the transcript of all copies.
If any grievance is not presented or forwarded by the employee or Union within the time
limits specified above, such grievance shall be deemed waived. If any grievance is not
answered by the City within the time limits specified above, such grievance and the
remedy requested shall be deemed granted.
Section 2. Stewards. Employees selected by the Union to act as Union
representatives shall be known as "Stewards" and shall not exceed three (3) in number.
The names of the employees selected as Stewards, and the names of local Union
representatives, state council or international representatives who may represent
employees, shall be certified in writing to the City by the Union. Duties required by the
Union of Stewards, excepting attendance at meetings with supervisory personnel and
aggrieved employees arising out of a grievance already initiated by an employee under
Section hereof, shall not interfere with their or other employees' regular work
assignments as employees of the City. Contacts between Stewards and employees or
the Union shall be made outside working hours so as not to disrupt regular City
operations. Business agent or designee may place phone calls to Steward during work
hours, the Steward will return such calls while on break or lunch and this practice will
not be abused.
20142019 laborer's contract Page 20
ARTICLE XIV - SENIORITY (Language taken from MOU dated 3-12-09)
Section 1. Seniority. Seniority shall be an employee's length of continuous service with
the bargaining unit, dating from his/her last date of hire, and shall apply by job
classification within his/her division in the matter of layoff, recall and vacation.
In the event of a layoff, such employee may exercise his/her seniority in a lower job
classification within any division he/she has previously worked. If the employer
determines that a layoff requires seniority to be bypassed in order to retain an
employee with a skill not possessed by others in the division, the employer shall notify
the union at least 10 working days prior to implementation. The matter shall be subject
to the grievance procedure.
Seniority shall accrue separately for each division he/she works in. "Division" shall be
defined as:
Water Distribution
Water Treatment
Wastewater Collections
Wastewater Treatment Plant
Storm water Collections
Street Operations/Maintenance
Facilities
Cemetery
Equipment Maintenance
The employment relationship shall be broken or terminated if an employee (1) quits; (2)
is discharged for just cause; (3) is absent from work for two consecutive working days
without notification to the employee's supervisor by the employee; (4) is laid off and fails
to report to work within three days after being recalled; (5) is laid off from work for any
reason for 24 months, or for a period of time equal to his/her seniority, whichever is
shorter; (6) fails to report for work at the termination of a leave of absence; (7) if while
on a leave of absence for personal health reasons, accepts other employment without
permission; or (8) if he/she is retired.
Section 1.1 Suspension of Seniority. Seniority shall be retained but shall not
continue to accrue during (1) authorized sick leave or disability leave in excess of thirty
(30) calendar days; (2) educational leave requested by the employee; (3) military leave
for disciplinary reasons; (4) election to a full-time paid Union office up to one (1) year,
renewable upon application; (5) other authorized leaves of absence up to thirty (30)
calendar days; and (6) promotion to a supervisory position outside of the bargaining unit
for six (6) months.
Section 1.2 Accrual of Seniority. Seniority shall continue to accrue during (1)
authorized sick leave or disability leave up to thirty (30) calendar days; (2) vacation
2014-2019 Laborer's Contract Page 21
leave; (3) educational leave required by the City; (4) military leave as specified in Article
X; (5) funeral leave; (6) holiday leave; (7) jury duty; and (8) compensatory time off.
Section 2. Probationary Period. The probationary period is an integral part of the
employee selection process and provides the City with the opportunity to upgrade and
improve the department by observing a new employee's work, training, aiding new
employees in adjustment to their positions, and by providing an opportunity to reject any
employee whose work performance fails to meet required work standards. Every new
employee hired into the bargaining unit shall serve a probationary period of twelve (12)
full months after which he/she shall be considered a regular employee and granted
seniority to the last date of hire. The Union recognizes the right of the City to terminate
probationary employees for any reason and to exercise all rights not specifically
modified by this Agreement with respect to such employees including, but not limited to,
the shifting of work schedules and job classifications, the assignment of on-the-job
training, cross-training in other classifications, the assignment of educational courses
and training programs and the request that such employees attend training programs
on their off-duty time. Termination of a probationary employee shall not be subject to
the grievance procedure under Article XIII.
Section 3. Promotional Probationary Period. Regular employees promoted into a
higher classification shall serve a promotional probationary period of six (6) months.
The City may extend probation for six (6) months. Any extension beyond twelve (12)
months would require mutual consent by the Union and the City. The Union also
recognizes the right of the employer to demote an employee on promotional
probationary status to his/her previous position. Demotion of an employee on
promotional probationary status shall be subject to the grievance procedure under
Article XIII.
Section 4. Promotional Opportunities. The City and the Union recognize that
promotions from within the divisions increase productivity and morale. The City and the
Union also recognize the affirmative action policy of the City that all job opportunities
shall be advertised both within and without the City service pursuant to the Federal
Equal Opportunity Act of 1972 and Presidential Executive Order 11246. To this end,
training will be provided as specified in Article XV, Section 13, and all job opportunities
shall be posted. At the option of the City, promotional job opportunities may be
advertised only within the City. Any decision made by the City regarding this option is
not grievable. If two or more present employees who apply for the vacancy are equally
qualified, seniority shall govern. If a present employee and an outside applicant are
equally qualified, the present employee shall receive the appointment. Employees who
are promoted shall not suffer a reduction in wages. The City shall be the judge of an
employee or applicant's qualifications.
Section 5. Recall From Layoff. Recall from layoff exceeding five (5) workdays shall
be by certified letter sent to the employee at his/her last known address furnished to the
City by the employee. The City may use any other means to return an employee
sooner.
2014-20191aborels Contract Page 22
Section 6. Temporary Employees. If any regular bargaining unit employees are on a
layoff status, temporary employees shall not be used to supplant the duties previously
performed by such regular employees, provided such regular employees are qualified.
ARTICLE XV - GENERAL PROVISIONS
Section 1. No Discrimination. The provisions of this Agreement shall be applied
equally to all employees in the bargaining unit without discrimination as to race, creed,
color, sex, age or national origin. The Union shall share equally with the City the
responsibility for applying the provisions of this Section. All references to employees in
this Agreement designate both sexes and, wherever the male gender is used, it shall be
construed to include male and female employees.
Employees shall have the right to form, join and participate in the activities of the Union
or any other labor organization, or to refrain from any or all such activities, and there
shall be no discrimination by either the City or Union by reason of the exercise of such
right except as specifically provided herein. Nothing in this Agreement shall be
construed as precluding or limiting the right of an individual employee to represent
himself/herself in individual personal matters.
Section 2. Bulletin Boards. The City agrees to furnish and maintain a suitable bulletin
board in a convenient place in the work or assembly area to be used by the Union. The
Union shall limit its postings of Union notices and bulletins to such bulletin board, which
shall be used only for the following Union notices and bulletins:
a. Recreational and social affairs of the Union.
b. Union meetings.
C. Union elections.
d. Reports of Union committees.
e. Rulings or policies of the International Union.
Section 3. Visits by Union Representatives. The City agrees that accredited
representatives of the District Council of Laborers and Laborers Union, Local #121,
upon reasonable and proper introduction, may have reasonable access to the premises
of the City at any time during working hours for the purpose of assisting in the
administration of this agreement.
The City agrees to allow (1) hour of paid time per year for the entire bargaining unit to
meet. The union agrees to provide adequate advanced notice to City management so
that workschedules can be adjusted for employee attendance at the annual union
meeting. It is understood and agreed by both parties that no overtime will be incurred
or paid for the purpose of employee participation in the annual meeting.
2014-2019 Laborer's Contract Page 23
Section 4. Solicitation. The Union agrees that its members will not solicit membership
in the Union or otherwise carry on Union activities during working hours, except as
specifically provided in this Agreement.
Section 5. Existing Conditions. Only such existing and future work rules and benefits
as are specifically covered by the terms of this Agreement shall be affected by
recognition of the Union and the execution of this Agreement. It is further agreed that if
modification of work rules or benefits covered by a specific provision of this Agreement
is proposed, any such modification shall be posted prominently on all bulletin boards for
a period of seven (7) consecutive days prior to implementation.
Section 6. Rules. It is jointly recognized that the City must retain broad authority to
fulfill and implement their responsibilities and may do so by work rule, oral or written,
existing or future. It is agreed, however, that no work rule will be promulgated or
implemented which is inconsistent with a specific provision of this Agreement, or is
contrary to the provisions of Oregon State Law. All work rules which have been, or shall
be reduced to writing, will be furnished to the Union and to affected employees.
Section 7. Other Employment. Outside employment shall be permitted only with the
express prior written approval of the City.
Section 8. Supervisory Employees. It is understood that supervisory employees not
covered under this Agreement shall not perform work within the jurisdiction of the Union
except in the case of an unforeseen emergency, or for purposes of instruction or
training, or where the complement of regular employees is temporarily reduced by
reason of absence of any employee due to illness or other legitimate reasons, or where
the work load is temporarily increased.
Section 9. Uniforms. Protective Clothing and Devices. If an employee is required to
wear a uniform, protective clothing, or use any type of protective device, such article
shall be provided, maintained and cleaned by the City, if exposed to chemical or
biohazard that require special cleaning. Employees may be provided with routine
clothing items such as shirts, jackets or hats imprinted with the City's logo for easy
identification in the field; however, cleaning and maintenance of routine clothing items
shall be the responsibility of the employee unless special cleaning is required as
described above. The City will continue to honor any agreements made with
employees prior to 7/1/2011 regarding the cleaning of non-protective clothing items.
Lost articles or damage to articles due to negligence shall be reimbursed to the City by
the employee. The City shall provide a safe place for the storage of such articles.
Failure of an employee to wear such required uniform, protective clothing, or use such
protective devices as prescribed by the City shall be cause for disciplinary action as set
forth in Article XII hereof.
Section 9.1. Boot Allowance. Employees may receive reimbursement of up to
a maximum of $750 per contract period' toward the cost of the purchase or
2014-2019 Laborer's Contract Page 24
repair of shoes, boots or protective footwear (including orthotics, insoles, or
weather-related footwear/gear). Purchases of more than $200 in a fiscal year
must be pre-approved by the employee's supervisor.
Section 10. Response Time Requirement. All regular employees regularly assigned
to standby status shall establish their residence to enable them to report for emergency
duty within forty (40) minutes of notification, including get ready time and travel time.
New employees shall establish their residency within a forty (40) minute response time
within six (6) months of date of hire.
Section 11. Safety Committee. The City and Union will comply with all state and
federal laws on this subject.
Section 12. Training Opportunities. On-the-job training may be provided by the City
as time and the work load permit.
Section 13. Temporary Employees. Temporary employees shall not be used in such
a way as to negate the purpose and intent of ARTICLE XV - GENERAL PROVISIONS
Section 12. Training Opportunities relating to the operation of heavy equipment.
ARTICLE XVI - HEALTH, WELFARE AND RETIREMENT
Section 1. The Employee Health Benefits Advisory Committee including one (1)
representative of Laborers Union shall meet at least eight (8) times per year for the
purpose of reviewing program performance and advising the City Council on desired
changes in health insurance benefits. The committee shall meet and review any
proposed changes to the insurance benefits plan before a change is made.
Health benefits and other insurance will be provided to Laborers Union represented
employees under the same conditions and restrictions as provided to all other City
employees. Coverage may be adjusted or modified by the City after soliciting a
recommendation from the City Employee Health Benefits Advisory Committee
(EHBAC). Nothing in this agreement shall be deemed a limitation on the annual plan
benefit adjustments.
Section 2. A health benefits plan document shall be adopted annually by the City
Council following a review by the Employee Health Benefits Advisory Committee. The
per-FTE cost of providing the single-person, employee-plus-spouse and full-family
health benefits called for in this plan (the "premium") shall be determined by an
actuarial valuation or by a review conducted by either: the City's excess insurance
carrier; the City's third party administrator; or the City's employee benefits consultant.
The City shall annually, as part of the plan adoption process, establish an employee
premium contribution. The employee premium contribution shall not exceed 5% of the
premium cost and shall be deducted from the employee's check through regular payroll
deductions.
2014-2019 Laborer's Contract Page 25
Section 3. HRA-VEBA. The City agrees to contribute an amount equivalent to 2% of
salary for each member of the bargaining unit into an HRA-VEBA program for the
duration of the contract.
Section 4. Life Insurance. The City agrees to provide each member with life insurance
coverage: Employee ($10,000) with a matching Accidental Death and Dismemberment
(AD&D) policy; Dependent ($1,000) coverage. Members may purchase additional
voluntary coverage to supplement city-provided policies.
Section 5. Long Term Disability Insurance. The City agrees to provide long term
disability insurance for the employee only.
Section 6. Deferred Compensation. The City agrees to contribute $15.00 per month
in matching funds per member enrolled in a City deferred compensation program
(currently ICMA or AETNA). This program is at the option of the member and
contingent upon a minimum $15.00 per month contribution paid by the member.
A contribution of $30.00 per month shall be contributed by the City to the
Deferred Compensation plan of employee's choice whether the employee elects
to contribute his or her personal funds to the plan or not. This contribution
recognizes benefit concessions made in prior negotiations that were intended to
go toward annual insurance deductible cost.
Section 7. Flexible Spending Account. Pre-tax flexible spending account options for
eligible health and dependent care expenses
Section 8. Retirement. The City agrees to maintain the existing retirement plan and to
pay the employee's contribution of 6% for all employees governed by the agreement.
ARTICLE XVIII - WORKER'S COMPENSATION
Section 1. Worker's Compensation. All employees will be insured under the
provisions of the Oregon State Worker's Compensation Act for injuries received while at
work for the City.
Section 2. Supplementary Payment. Compensation paid by the City for a period of
sick leave also covered by worker's compensation shall be equal to the difference
between worker's compensation pay for lost time and the employee's regular pay rate.
2014-2019 Laborer's Contract Page 26
ARTICLE XIX - LIABILITY INSURANCE
Section 1. Liability Insurance. The City shall purchase liability insurance to the limits
set forth in ORS 30.270 for the protection of all employees covered by this Agreement
against claims against them incurred in or arising out of the performance of their official
duties. The premiums for such insurance shall be paid by the City.
Section 2. Property Insurance. The City carries catastrophic coverage for property
losses, including to employee property, resulting from fire and other catastrophes. In
addition, the City will reimburse replacement costs (to the extent those costs are not
covered by other insurance) if all or most of a mechanic's personal work tools are stolen
from City property. To obtain reimbursement under this section, the mechanic must
maintain an accurate inventory of the tools which has been provided to the City in
advance of the theft, a crime report must be filed with the local police, and the
mechanic must not be in any way involved in the theft.
ARTICLE XX - SAVINGS CLAUSE AND FUNDING
Section 1. Savings Clause Should any provision of this Agreement be subsequently
declared by the proper legislation or judicial authority to be unlawful, unenforceable, or
not in accordance with applicable statutes or ordinances, all other provisions of this
Agreement shall remain in full force and effect for the duration of this Agreement.
Section 2. Funding. The parties recognize that revenue needed to fund the wages
and benefits provided by this Agreement must be approved annually by established
budget procedures and in certain circumstances by vote of the citizens of the City. All
such wages and benefits are therefore contingent upon sources of revenue and, where
applicable, annual voter budget approval. The City has no intention of cutting the wages
and benefits specified in this Agreement because of budgetary limitations, but cannot
and does not guarantee any level of employment in the bargaining unit covered by this
Agreement. The City agrees to include in its annual budget request amounts sufficient
to fund the wages and benefits provided by this Agreement, but makes no guarantee as
to passage of such budget requests or voter approval thereof.
2014-2019 Laborer's Contract Page 27
ARTICLE XXI - TERMINATION AND REOPENING
This Agreement shall be effective July 1, 2014, and shall remain in full force and effect
until the 30th day of June 2019, and shall terminate all prior agreements and practices,
and concludes all collective bargaining during the term of this Agreement. It shall be
automatically renewed from year to year thereafter unless either party shall notify the
other in writing not later than 180 days prior to the expiration or subsequent anniversary
date that it wishes to modify the Agreement for any reason. Such notification shall
include the substance of the modification and the language with which such desired
modifications are to be expressed.
APPROVED:
CITY OF ASHLAND ASHLAND CITY COUNCIL
By By
Dave Kanner, City Administrator John Stromberg, Mayor
Date
Date
L.I.U.N.A. Local No. 121
By Date
Kyle Estes
By Date
Greg Whittenburg
By Date
Tony Friesen
By Date
Jeff Gritz
Oregon Southern Idaho District Council of Laborers
By Date
2014-2019 Laborers Contract Page 28
Appendix "A"
Job Classifications in the Bargaining Unit
Cemetery Sexton
Mechanic
Senior Mechanic
Meter Reader/Repair
Wastewater Treatment Plant Operator
Senior Wastewater Treatment Plant Operator
Utility Worker I
Utility Worker II
Senior Utility Worker
Utility Technician
Water Quality Technician
Water Treatment Plant Operator I, II
Senior Water Treatment Plant Operator
Indicates Flexible Staffing Option - The City can hire a I or a 11 base on operational
needs, and promote I to II without a competitive process.
2014-2019 Laborer's Contract Page 29
Appendix "B" Salary Schedule
2% COLA per contract. 25 COLA per contract.
HOUR MONTH ANNUAL HOUR MONTH ANNUAL
SALARY
RANGE
SIGNMENT_ NEW JOB CLASSIFICATION
Unfilled Job Class
First 6 Months $16.4125 $2,845 $34,137 $16.7408 $2,901.67 7~44134
Next 12 Months $17.2331 $2,987 $35,844 $17.5777 $3,046.75 Next 12 Months $18.2671 $3,166 $37,995 $18.6324 $3,229.56 Next 12 Months $19.3631
$3,356 $40,275 $19.7504 $3,423.33 Rate Thereafter $20.3313 $3,524 $42,288 $20.7379 $3,594.50 CPS RANGE 2
Utility Worker I
First 6 Months $17.2331 $2,987 $35,844 $17.5777 $3,046.75 $36,561
Next 12 Months $18.0948 $3,136 $37,636 $18.4567 $3,199.09 $38,389
Next 12 Months $19.1805 $3,325 $39,895 $19.5641 $3,391.04 $40,693
Next 12 Months $20.3313 $3,524 $42,288 $20.7379 $3,594.50 $43,134
Rate Thereafter $21.3478 $3,700 $44,403 $21.7748 $3,774.23 $45,291
7First ob Class
Months $18.09 48 $3,136 $37,636 $18.4567 $3,199.09 $38,389
2 Months $18.9995 $3,293 $39,518 $19.3795 $3,359.05 $40,309
2 Months $20.1395 $3,491 $41,889 $20.5423 $3,560.59 $42,727
2 Months $21.3478 $3,700 $44,403 $21.7748 $3,774.23 $45,291
hereafter $22.4152 $3,885 $46,623 $22.8635 $3,962.94 $47,555
Months $18.999 5 $3,293 $39,518 $19.3795 $3,359.05 $40,309
2 Months $19.9495 $3,458 $41,494 $20.3485 $3,527.00 $42,324
7Rate orker II
2 Months $21.1465 $3,665 $43,984 $21.5694 $3,738.62 $44,863
2 Months $22.4152 $3,885 $46,623 $22.8635 $3,962.94 $47,555
hereafter $23.5360 $4,079 $48,954 $24.0067 $4,161.08 $49,933
Meter Reader/Repairer, Water
Treatment Plant Op 1' (1)
First 6 Months $19.9495 $3,458 $41,494 $20.3485 $3,527.00 $42,324
Next 12 Months $20.9470 $3,631 $43,569 $21.3659 $3,703.35 $44,440
Next 12 Months $22.2038 $3,849 $46,183 $22.6479 $3,925.55 $47,107
Next 12 Months $23.5360 $4,079 $48,954 $24.0067 $4,161.08 $49,933
Rate Thereafter $24.7128 $4,283 $51,402 $25.2071 $4,369.14 $52,430
2014-2019 Laborer's Contract Page 30
Senior Utility Worker
(Previously Utility Worker lllJ
(4)
Mechanic (5)
First 6 Months 1$20.9470 $3,631 $43,569 $21.3659 W$3,703.35$44,440
Next 12 Months $21.9943 $3,812 $45,747 $22.4342 $3,888.52 $46,662
Next 12 Months $23.3140 $4,041 $48,492 $23.7802 $4,121.83 $49,462
Next 12 Months $24.7128 $4,283 $51,402 $25.2071 $4,369.14 $52,430
Rate Thereafter $25.9484 $4,498 $53,972 $26.4674 $4,587.60 $55,051
Senior Mechanic, Water
CPSRANGE7 Treatment Plant Op ll* (1 J,
Wastewater Treatment Plant
Operator (2,3,7)
First 6 Months $21.9943 $3,812 $45,747 $22.4342 $3,888.52 $46,662
Next 12 Months $23.0940 $4,003 $48,035 $23.5559 $4,082.94 $48,995
Next 12 Months $24.4797 $4,243 $50,917 $24.9693 $4,327.92 $51,935
Next 12 Months $25.9484 $4,498 $53,972 $26.4674 $4,587.60 $55,051
Rate Thereafter $27.2458 $4,723 $56,670 $27.7908 $4,816.97 $57,804
Cemetery Sexton
Utility Technician
First 6 Months $23.0940 $4,003 $48,035 R$23.5559 $4,082.94 $48,995
Next 12 Months $24.2487 $4,203 $50,436 $24.7337 $4,287.09 $51,445
Next 12 Months $25.7036 $4,455 $53,462 $26.2177 $4,544.31 $54,532
Next 12 Months $27.2458 $4,723 $56,670 $27.7908 $4,816.97 $57,804
Rate Thereafter $28.6081 $4,959 $59,504 $29.1803 $5,057.82 $60,694
Senior Water Treatment Plant
OF, Water Quality Technician,
Senior Wastewater Treatment
Plant Operator
First6 Months $24.2487 $4,203 L$62,479 $24.7337 $4,287.09 $51,445
Next 12 Months $25.4611 $4,413 $25.9703 $4,501.44 $54,017
Next 12 Months $26.9888 $4,678 $27.5286 $4,771.53 $57,258
Next 12 Months $28.6081 $4,959 $29.1803 $5,057.82 $60,694
Rate Thereafter $30.0385 $5,207 $30.6393 $5,310.71 $63,729
*PLEASE NOTE: Hourly rates are accurate to 4 decimal places. A Monthly wage is provided as an approximate salary, but actual
monthly earnings may differ from those quoted above.
(1) All rates include 25 cents per hour for state required Level II Certification.
(2) All rates include 35 cents per hour for state required Level III Certification.
(3) Add 15 cents per hour for employees currently receiving certification pay for state Level IV
Waste Water Treatment Certification.
(4) Plus $1.00 per hour when assigned Lead Worker responsibilities.
(5) Includes 20 cents per hour for required I&M Certification.
(7) Plus $1.00 per hour or the rate the employee received as of June 30, 2001, whichever is greater, when performing Lead
Operator responsibilities.
2014-2019 Laborer's Contract Page 31
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2014-2019 Laborer's Contract Page 32
CITY OF
ASHLAND
Council Communication
June 3, 2014, Business Meeting
A Resolution Exercising the Power of Eminent Domain for the Walker Avenue
Safe Routes to School Project
FROM:
Scott Fleury, Engineering Services Manager, Public Works, fleurys@ashland.or.us
SUMMARY
Staff is requesting approval of a Resolution exercising the power of eminent domain with respect to
right of way acquisition from the railroad for the Walker Avenue safe route to school project. The
resolution is required as part of an intergovernmental agreement (IGA) between the City of Ashland
and the Oregon Department of Transportation (ODOT).
BACKGROUND AND POLICY IMPLICATIONS:
The City of Ashland received a Congestion Mitigation and Air Quality (CMAQ) improvement grant to
fund engineering and construction of a sidewalk connection between Ashland St. and E. Main along
Walker Ave. As part of the process the City entered into an IGA with ODOT for both the project
engineering and construction along with a separate IGA for right of way services.
ham://ashland.or.us/Agendas.asp?Display=Minutes&AMID=4649
The engineering design was awarded to OBEC Engineering consultants of Medford, Oregon, through a
qualification based selection process. OBEC is also tasked with acquiring the necessary easements
from the railroad in order to engineer and construct an at grade pedestrian crossing over the railroad
tracks on Walker Ave.
The right of way services IGA allows ODOT to conduct right of way documentation review and ensure
all applicable laws are being met. The resolution to exercise eminent domain is required as part of the
right of way services IGA (reference Exhibit A, B. Lc of attachment two). With this resolution in place,
OBEC will have the ability to make a formal offer to the railroad for the pedestrian easement. The
option to exercise eminent domain only comes into play if the consultant cannot successfully obtain
the necessary pedestrian easement voluntarily from the railroad. This resolution is required as part of
the project and shows the City is willing to take the necessary steps in order to construct the grant
funded project. OBEC is currently in negotiations with the railroad and an appraisal is being produced
as required. OBEC has had good preliminary discussion with the railroad and believes the easement
will be obtained voluntarily.
FISCAL IMPLICATIONS:
The maximum cost is $5,000 for ODOT to perform any right of way review services. The cost to
purchase an easement from the railroad is still to be determined but can be covered under the grant if
the total project cost does not exceed the grant amount. The CMAQ grant carries a maximum amount
of $666,694; anything over this amount must be covered by the City of Ashland along with the 10.27%
Page 1 of 2
~r,
CITY OF
ASHLAND
match. The complete project budget of $750,000 is in the approved FYI 3 Capital Improvement Plan
and FYI 3 budget and funds were carried over to FYI 4/15.
STAFF RECOMMENDATION AND REQUESTED ACTION:
Staff recommends approving the Resolution exercising the power of eminent domain.
SUGGESTED MOTION:
Move to approve the resolution titled, "A resolution exercising the power of eminent domain."
ATTACHMENTS:
1. Draft resolution
2. IGA no. 28455 for right of way services
3. Local Agency Agreement no. 27871, Congestion Mitigation and Air Quality
Page 2 of 2
RESOLUTION NO. 2014-
A RESOLUTION EXERCISING THE POWER OF EMINENT
DOMAIN
RECITALS:
A. The City of Ashland may exercise the power of eminent domain pursuant to its charter and
the law of the State of Oregon generally, when the exercise of such power is deemed
necessary by the City's governing body to accomplish public purposes for which the City has
a responsibility.
B. The City has the responsibility of providing safe transportation routes for commerce,
convenience and to adequately serve the traveling public.
C. The project or projects known as Walker Avenue have been planned in accordance with
appropriate engineering standards for construction, maintenance or improvement of said
transportation infrastructure such that property damage is minimized, transportation
promoted, travel safeguarded; and
D. To accomplish the project or projects set forth above it is necessary to acquire the interests in
property described in "Exhibit A," attached to this resolution and, by this reference
incorporated herein; now, therefore.
THE CITY OF ASHLAND RESOLVES AS FOLLOWS:
SECTION 1. The foregoing statements of authority and need are, in fact, the case. The project
or projects for which the property is required and is being acquired are necessary in the public
interest, and the same have been planned, designed, located, and will be constructed in a manner
which will be most compatible with the greatest public good and the lease private injury.
SECTION 2. The power of eminent domain is hereby exercised with respect to each of the
interests in the property described in Exhibit A. Each is acquired subject to payment of just
compensation and subject to procedural requirements of Oregon Law;
SECTION 3. City's staff and Counsel are authorized and requested to attempt to agree with the
owner and other persons in interest as to the compensation to be paid for each acquisition, and, in
the event that no satisfactory agreement can be reached, to commence and prosecute such
condemnation proceedings as may be necessary to finally determine just compensation or any
other issue appropriate to be determined by a court in connection with the acquisition. This
authorization is not intended to expand the jurisdiction of any court to decide matters determined
above or determinable by the Commission.
SECTION 4. City expressly reserves its jurisdiction to determine the necessity or propriety of
any acquisition, its quantity, quality, or locality, and to change or abandon any acquisition.
SECTION 5. This resolution was duly PASSED and ADOPTED this day of
2014, and takes effect upon signing by the Mayor.
Resolution No. 2013- Page 1 of 2
This resolution was duly PASSED and ADOPTED this day of
2014, and takes effect upon signing by the Mayor.
Barbara Christensen, City Recorder
SIGNED and APPROVED this day of 2014.
John Stromberg, Mayor
Reviewed as to form:
David H. Lohman, City Attorney
Resolution No. Page 2 of 2
f
Misc. Contracts and Agreements
No. 271371
LOCAL AGENCY AGREEMENT
CONGESTION MITIGATION AND AIR QUALITY PROGRAM
Walker Avenue: Ashland Street to East Main Street
THIS AGREEMENT is made and entered into by and between the STATE OF
OREGON, acting by and through its Department of Transportation, hereinafter referred
to as "State," and the City of Ashland, acting by and'through its elected officials,
hereinafter referred to as "Agency," both herein referred to individually or collectively as
"Party" or "Parties."
RECITALS
1. Walker Avenue, Ashland Street and East Main Street are parts of the Agency street
system under the jurisdiction and control of Agency.
2. By the authority granted in Oregon Revised Statutes (ORS) 190.110, 366.572 and
366.576, State may enter into cooperative agreements with counties, cities, and units
of local governments for the performance of work on certain types of improvement
projects with the allocation of costs on terms and conditions mutually agreeable to the
contracting parties.
NOW THEREFORE, the premises being in general as stated in the foregoing Recitals,
it is agreed by and between the Parties hereto. as follows:
TERMS OF AGREEMENT
1. Under such authority, State and Agency agree, to fund, design and construct
sidewalks, bicycle lanes and improvements to the rail crossing on Walker Avenue,
hereinafter referred to as "Project." The location of the Project is approximately as
shown on the sketch map attached hereto, marked* "Exhibit A," and by this reference
made a part hereof.
2. This Project shall be conducted as a part of the Congestion Mitigation and Air
Quality (CMAQ) Program under Title 23, United States Code. The total Project cost
`is estimated at.$666,694, which is subject to change. The CMAQ'funds are limited
to $666,694. Eligible costs for the Project will be reimbursed at the full federal share
or until the $666,694 limit is reached. 'Agency shall be responsible for any portion of
the' Project which is not covered by federal funding. Agency shall be responsible for
determining the amount of federal funds to be applied to each phase of the Project.
Agency is not guaranteed the use of unspent funds for a particular phase of work. It
is Agencys responsibility to notify State in advance of State obligating the funds for
Key No. 17249
024741
Agency/State
Agreement No. 27871
a subsequent phase if Agency wants to release funds on the current authorized
phase(s) of work.
3. The federal funding for this Project is contingent upon approval by the Federal
Highway Administration (FHWA). Any work performed prior to acceptance by
FHWA or outside the scope of work will be considered nonparticipating and paid for
at Agency expense.
4. State considers Agency a subrecipient of the federal funds it receives as
reimbursement under this Agreement. The Catalog of Federal Domestic Assistance
(CFDA) number for this Project is 20.205, title Highway Planning and Construction.
5. Agency shall require its contractor(s) and subcontractor(s) that are not units of local
government as defined in ORS 190.003, if any, to indemnify, defend, save and hold
harmless the State of Oregon, Oregon Transportation Commission and its
members, Department of Transportation and its officers, employees and agents
from and against any and all claims, actions, liabilities, damages, losses, or
expenses, including attorneys' fees, arising from a tort, as now or hereafter defined
in ORS 30.260, caused, or alleged to be caused, in whole or in part, by the negligent
or willful acts or omissions of Agency's contractor or any of the officers, agents,
employees or subcontractors of the contractor ("Claims"). It is the specific intention
of the Parties that State shall, in all instances, except for Claims arising solely from
the negligent or willful acts or omissions of State, be indemnified by the contractor
and subcontractor from and against any and all Claims.
6. Any such indemnification shall also provide that neither Agency's contractor and
subcontractor nor any attorney engaged by Agency's contractor and subcontractor
shall defend any claim in the name of the State of Oregon or any agency of the
State of Oregon, nor purport to act as legal representative of the State of Oregon or
any of its agencies, without the prior written consent of the Oregon Attorney
General. The State of Oregon may, at anytime at its election assume its own
defense and settlement in the event that it determines that Agency's contractor is
prohibited from defending the State of Oregon, or that Agency's contractor is not
adequately defending the State of Oregon's interests, or that an important
governmental principle is at issue or that it is in the best interests of the State of
Oregon to do so. The State of Oregon reserves all rights to pursue claims it may
have against Agency's contractor if the State of Oregon elects to assume its own
defense.
7. The term of this Agreement shall begin on the date all required signatures are
obtained and shall terminate upon completion of the Project and final payment or
2
Agency/State
Agreement No. 27871
ten (10) calendar years following the date all required signatures are obtained,
whichever is sooner.
8. This Agreement may be terminated by mutual written consent of the Parties.
9. State may terminate this Agreement effective upon delivery of written notice to
Agency, or at such later date as may be established by State, under any of the
following conditions:
a. If Agency fails to provide services called for by this Agreement within the
time specified herein or any extension thereof.
b. If Agency fails to perform any of the other provisions of this Agreement,
or so fails to pursue the work as to endanger performance of this
Agreement in accordance with its terms, and after receipt of written
notice from State fails to correct such failures within ten (10) days or
such longer period as State may authorize.
c. If Agency fails to provide payment of its share of the cost of the Project.
d. If State fails to receive funding, appropriations, limitations or other
expenditure authority sufficient to allow State, in the exercise of its
reasonable administrative discretion, to continue to make payments for
performance of this Agreement.
e. 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 if State is prohibited from paying for such work from the
planned funding source.
10.Any termination of this Agreement shall not prejudice any rights or obligations
accrued to the Parties prior to termination.
11. The Special and Standard Provisions attached hereto, marked Attachments 1 and 2,
respectively, are by this reference made a part hereof. The Standard Provisions
apply to all federal-aid projects and may be modified only by the Special Provisions.
The Parties hereto mutually agree to the terms and conditions set forth in
Attachments 1 and 2. In the event of a conflict, this Agreement shall control over
the attachments, and Attachment 1 shall control over Attachment 2.
3
Agency/State
Agreement No. 27871
12.Agency, as a recipient of federal funds, pursuant to this Agreement with the State,
shall assume sole liability for Agency's breach of any federal statutes, rules,
program requirements and grant provisions applicable to the federal funds, and
shall, upon Agency's breach of any such conditions that requires the State to return
funds to the Federal Highway Administration, hold harmless and indemnify the State
for an amount equal to the funds received under this Agreement, or if legal
limitations apply to the indemnification ability of Agency, the indemnification amount
shall be the maximum amount of funds available for expenditure, including any
available contingency funds or other available non-appropriated funds, up to the
amount received under this Agreement.
13.Agency certifies and represents that the individual(s) signing this Agreement has
been authorized to enter into and execute this Agreement on behalf of Agency,
under the direction or approval of its governing body, commission, board, officers,
members or representatives, and to legally bind Agency.
14.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.
15.This Agreement and attached exhibits 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
waiver, consent, modification or change of terms of this Agreement shall bind either
Party unless in writing and signed by both Parties and all necessary approvals have
been obtained. 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 State to enforce any provision of this Agreement shall not constitute a waiver by
State of that or any other provision.
16. State's Project Manager for this Project is Kelli Sparkman, ODOT Region 3 Local
Agency Liaison, 100 Antelope Road, White City, Oregon 97503; (541) 774-6383, or
assigned designee upon individual's absence. Agency's Project Manager shall be
notified in writing of any contact information changes during the term of this
Agreement.
17. Agency's Project Manager for this Agreement is Morgan Wayman, Project Manager,
20 East Main Street, Ashland, OR 97520; waymanm@ashland.or.us; (541) 552-
2414; or assigned designee upon individual's absence. Agency shall notify State in
writing of any contact information changes during the term of this Agreement.
4
Agency/State
Agreement No. 27871
THE PARTIES, by execution of this Agreement, hereby acknowledge that its signing
representatives have read this Agreement, understand it, and agree to be bound by its
terms and conditions.
This Project is in the 2010-2013 Statewide Transportation Improvement Program, (Key
#17249) that was approved by the Oregon Transportation Commission on December
16, 2010 (or subsequently approved by amendment to the STIP).
City of Ashland, by and through its STATE OF OREGON, by and through
elected officials its a ent of Transportation
By
High ay Division Administrator
Title
Date 7 Date (b',Z~
~
By APPROVAL RECOMMENDED
Title W~ By
Date CMAQ Program Coordinator Date OCT 18 2011
APPROVED AS TO LEGAL
N, (n~''
SUFFIC CY By m./,L.Y-
By Technical Services Manager/Chief
City Attorney Engineer
Date - q~l I Date
Agency Contact By
Jim Olson R ion Manager
Ashland City Engineer
20 East Main Street Date
Ashland, OR 97520
(541) 488-5587 APPROVED AS TO LEGAL
jimo@ashland.or.us SUFFI NNCCY
State Contact: By ^ fki'e-...----
Kelli Sparkman Assistant Attorney General (If over
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Agency/State
Agreement No. 27871
ODOT Region 3 Local Agency Liaiso $150,000)
100 Antelope Road /
White City, OR 97503 Date
(541) 774-6383
Kelli.sparkman@odot.state.or.us
I
I
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Agency/State
Agreement No. 27871
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Agency/State
Agreement No. 27871
ATTACHMENT NO. 1 to Agreement No. 27871
SPECIAL PROVISIONS
1. Agency or its consultant shall, as a federal-aid participating preliminary engineering
function, conduct the necessary field surveys, environmental studies, traffic
investigations, foundation explorations, and hydraulic studies, identify and obtain all
required permits, assist State with acquisition of necessary right of way and/or
easements, and perform all preliminary engineering and design work required to produce
final plans, preliminary/final specifications and cost estimates.
2. Upon State's award of the construction contract, Agency, or its consultant, shall be
responsible to perform all construction engineering, field testing of materials, technical
inspection and project manager services for administration of the contract.
1 State may make available Region 3's On-Call Preliminary Engineering (PE), Design and
Construction Engineering Services consultant for Local Agency Projects upon written
request. If Agency chooses to use said services, Agency agrees to manage the work
performed by the consultant and make funds available to the State for payment of those
services. All eligible work shall be a federally participating cost and included as part of
the total cost of the Project.
4. Indemnification language in the Standards Provisions, Paragraphs 46 and 47, shall be
replaced with the following language:
a. 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 Party Claim") against State or
Agency with respect to which the other Party may have liability, the notified Party must
promptly notify the other Parry 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
a Party of the notice and copies required in this paragraph and meaningful opportunity
for the Party to participate in the investigation, defense and settlement of the Third
Party Claim with counsel of its own choosing are conditions precedent to that Party's
liability with respect to the Third Party Claim.
b. With respect to a Third Party Claim for which State is jointly liable with Agency (or
would be if joined in the Third Party.Claim), State 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 Agency in such proportion as
is appropriate to reflect the relative fault of State on the one hand and of Agency 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 State on the one hand and of Agency on the other
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Agreement No. 27871
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.
State's contribution amount in any instance is capped to the same extent it would have
been capped under Oregon law, including the Oregon Tort Claims Act, ORS 30.260 to
30.300, if State had sole liability in the proceeding.
c. With respect to a Third Party Claim for which Agency is jointly liable with State (or
would be if joined in the Third Party Claim), Agency 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 State in such proportion as is
appropriate to reflect the relative fault of Agency on the one hand and of State 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 Agency on the one hand and of State 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.
Agency's contribution amount in any instance is capped to the same extent it would
have been capped under Oregon law, including the Oregon Tort Claims Act, ORS
30.260 to 30.300, if it had sole liability in the proceeding.
d. The Parties shall attempt in good faith to resolve any dispute arising out of this
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.
7. Agency shall, at its own expense, maintain and operate the Project upon completion at a
minimum level that is consistent with normal depreciation and/or service demand.
8. Maintenance responsibilities shall survive any termination of this Agreement.
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ATTACHMENT NO. 2
FEDERAL STANDARD PROVISIONS
JOINT OBLIGATIONS
PROJECT ADMINISTRATION
1. State (ODOT) is acting to fulfill its responsibility to the Federal Highway Administration (FHWA) by
the administration of this Project, and Agency (i.e. county, city, unit of local government, or other
state agency) hereby agrees that State shall have full authority to carry out this administration. If
requested by Agency or if deemed necessary by State in order to meet its obligations to FHWA,
State will further act for Agency in other matters pertaining to the Project. Agency shall, if
necessary, appoint and direct the activities of a Citizen's Advisory Committee and/or Technical
Advisory Committee, conduct a hearing and recommend the preferred alternative. State and
Agency shall each assign a liaison person to coordinate activities and assure that the interests of
both parties are considered during all phases of the Project.
2. Any project that uses federal funds in project development is subject to plans, specifications and
estimates (PS&E) review and approval by FHWA or State acting on behalf of FHWA prior to
advertisement for bid proposals, regardless of the source of funding for construction.
PRELIMINARY & CONSTRUCTION ENGINEERING
3. State, Agency, or others may perform preliminary and construction engineering. If Agency or
others perform the engineering, State will monitor the work for conformance with FHWA rules and
regulations. In the event that Agency elects to engage the services of a personal services
consultant to perform any work covered by this Agreement, Agency and Consultant shall enter
into a State reviewed and approved personal services contract process and resulting contract
document. State must concur in the contract prior to beginning any work. State's personal
services contracting process and resulting contract document will follow Title 23 Code of Federal
Regulations (CFR) 172, Title 49 CFR 18, ORS 279A.055, the current Stale Administrative Rules
and State Personal Services Contracting Procedures as approved by the FHWA. Such personal
services contract(s) shall contain a description of the work to be performed, a project schedule,
and the method of payment. Subcontracts shall contain all required provisions of Agency as
outlined in the Agreement. No reimbursement shall be made using federal-aid funds for any costs
incurred by Agency or its consultant prior to receiving authorization from State to proceed. Any
amendments to such contract(s) also require State's approval.
4. On all construction projects where State is the signatory party to the contract, and where Agency
is doing the construction engineering and project management, Agency, subject to any limitations
imposed by state law and the Oregon Constitution, agrees to accept all responsibility, defend
lawsuits, indemnify and hold State harmless, for all tort claims, contract claims, or any other
lawsuit arising out of the contractor's work or Agency's supervision of the project.
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REQUIRED STATEMENT FOR UNITED STATES DEPARTMENT OF TRANSPORTATION
(USDOT) FINANCIAL ASSISTANCE AGREEMENT
5. If as a condition of assistance, Agency has submitted and the United States Department of
Transportation (USDOT) has approved a Disadvantaged Business Enterprise Affirmative Action
Program which Agency agrees to carry out, this affirmative action program is incorporated into the
financial assistance agreement by reference. That program shall be treated as a legal obligation
and failure to carry out its terms shall be treated as a violation of the financial assistance
agreement. Upon notification from USDOT to Agency of its failure to carry out the approved
program, USDOT shall impose such sanctions as noted in Title 49. CFR. Part 26, which sanctions
may include termination of the agreement or other measures that may affect the ability of Agency
to obtain future USDOT financial assistance.
6. Disadvantaged Business Enterprises (DBE) Obligations. State and its contractor agree to
ensure that DBE as defined in Title 49. CFR Part 26, have the opportunity to participate in the
performance of contracts and subcontracts financed in whole or in part with federal funds. In this
regard, Agency shall take all necessary and reasonable steps in accordance with Title 49. CFR.
Part 26, to ensure that DBE have the opportunity to compete for and perform contracts. Neither
State nor Agency and its contractors shall discriminate on the basis of race, color, national origin
or sex in the award and performance of federally-assisted contracts. Agency shall carry out
applicable requirements of Title 49. CFR. Part 26, in the award and administration of such
contracts. Failure by Agency to carry out these requirements is a material breach of this
Agreement, which may result in the termination of this contract or such other remedy as State
deems appropriate.
7. The DBE Policy Statement and Obligations shall be included in all subcontracts entered into
under this Agreement.
8. Agency agrees to comply with all applicable civil rights laws, rules and regulations, including Title
V and Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990
(ADA), and Titles VI and VII of the Civil Rights Act of 1964.
9. The parties hereto agree and understand that they will comply with all applicable federal, state,
and local laws, regulations, executive orders and ordinances applicable to the work including, but
not limited to, the provisions of ORS 2790.505. 279C.515. 2790 520 279C.530 and 2796 270
incorporated herein by reference and made a part hereof, Title 23 CFR Parts 1 11, 140, 710 and
771; Title 49 CFR Parts 18, 24 and 26; 2 CFR 225, and OMB CIRCULAR NO A-133 Title 23,
USG. Federal-Aid Highway Act: Title 41, Chapter 1 USC 51-58 Anti-Kickback Act Title 42 USC,
Uniform Relocation Assistance and Real Property Acquisition Policy Act of 1970, as amended and
provisions of Federal-Aid Policy Guide (FAPG).
STATE OBLIGATIONS
PROJECT FUNDING REQUEST
10. State shall submit a Project funding request to FHWA with a request for approval of federal-aid
participation in all engineering, right-of-way acquisition, eligible utility relocations and/or
construction work for the Project. No work shall proceed on any activity in which federal-aid
participation is desired until such approval has been obtained. The program shall include
services to be provided by State, Agency, or others. State shall notify Agency in writing when
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authorization to proceed has been received from FHWA. Major responsibility for the various
phases of the Project will be as outlined in the Special Provisions. All work and records of such
work shall be in conformance with FHWA rules and regulations.
FINANCE
11. State shall, in the first instance, pay all reimbursable costs of the Project, submit all claims for
federal-aid participation to FHWA in the normal manner and compile accurate cost accounting
records. Agency may request a statement of costs to date at any time by submitting a written
request. When the actual total cost of the Project has been computed, State shall furnish Agency
with an itemized statement of final costs. Agency shall pay an amount which, when added to said
advance deposit and federal reimbursement payment, will equal 100 percent of the final total
actual cost. Any portion of deposits made in excess of the final total costs of Project, minus
federal reimbursement, shall be released to Agency. The actual cost of services provided by State
will be charged to the Project expenditure account(s) and will be included in the total cost of the
Project.
12. If federal funds are used, State will specify the Catalog of Federal Domestic Assistance (CFDA)
number in the Agreement. State will also determine and clearly state in the Agreement if recipient
is a subrecipient or vendor, using criteria in Circular A-133.
PROJECT AC72VIUES
13. State shall, if the preliminary engineering work is performed by Agency or others, review and
process or approve all environmental statements, preliminary and final plans, specifications and
cost estimates. State shall, if they prepare these documents, offer Agency the opportunity to
review and approve the documents prior to advertising for bids.
14. The party responsible for performing preliminary engineering for the Project shall, as part of its
preliminary engineering costs, obtain all Project related permits necessary for the construction of
said Project. Said permits shall include, but are not limited to, access, utility, environmental,
construction, and approach permits: All pre-construction permits will be obtained prior to
advertisement for construction.
15. State shall prepare contract and bidding documents, advertise for bid proposals, and award all
contracts.
16. Upon State's award of a construction contract, State shall perform independent assurance testing
in accordance with State and FHWA Standards, process and pay all contractor progress
estimates, check final quantities and costs, and oversee and provide intermittent inspection
services during the construction phase of the Project.
17. State shall, as a Project expense, assign a liaison person to provide Project monitoring as needed
throughout all phases of Project activities (preliminary engineering, right-of-way acquisition, and
construction). The liaison shall process reimbursement for federal participation costs.
RIGHT OF WAY
18. State is responsible for proper acquisition of the necessary right of way and easements for
construction and maintenance of the Project. Agency may perform acquisition of the necessary
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right of way and easements for construction and maintenance of the Project, provided Agency (or
Agency's consultant) are qualified to do such work as required by the Slate's Right of Way
Manual and have obtained prior approval from State's Region Right of Way office to do such
work.
19. Regardless of who acquires or performs any of the right of way activities, a right of way services
agreement shall be created by State's Region Right of Way office setting forth the responsibilities
and activities to be accomplished by each party. State shall always be responsible for requesting
project funding, coordinating certification of the right of way, and providing oversight and
monitoring. Funding authorization requests for federal right of way funds must be sent through the
State's Region Right of Way offices on all projects. All projects must have right of way certification
coordinated through State's Region Right of Way offices (even for projects where no federal
funds were used for right of way, but federal funds were used elsewhere on the Project). Agency
should contact the State's Region Right of Way office for additional information or clarification.
20. State shall review all right of way activities engaged in by Agency to assure compliance with
applicable laws and regulations. Agency agrees that right of way activities shall be in accord with
the Uniform Relocation Assistance & Real Property Acquisition Policies Act of 1970, as amended,
ORS Chapter 35, FHWA Federal-Aid Policy Guide, State's Right of Way Manual and the Code of
Federal Regulations, Title 23, Part 710 and Title 49, Part 24.
21. If any real property purchased with federal-aid participation is no longer needed for the originally
authorized purpose, the disposition of such property shall be subject to applicable rules and
regulations, which are in effect at the time of disposition. Reimbursement to State and FHWA of
the required proportionate shares of the fair market value may be required.
22. Agency insures that all Project right of way monumentation will be conducted in conformance with
ORS 209.155.
23. State and Agency grants each other authority to enter onto the other's right of way for the
performance of the Project.
AGENCY OBLIGATIONS
FINANCE
24. Federal funds shall be applied toward Project costs at the current federal-aid matching ratio,
unless otherwise agreed and allowable by law. Agency shall be responsible for the entire match
amount, unless otherwise agreed to and specified in the intergovernmental agreement.
25. Agency's estimated share and advance deposit.
a) Agency shall, prior to commencement of the preliminary engineering and/or right of
way acquisition phases, deposit with State its estimated share of each phase.
Exception may be made in the case of projects where Agency has written approval
from State to use in-kind contributions rather than cash to satisfy all or part of the
matching funds requirement.
b) Agency's construction phase deposit shall be 110 percent of Agency's share of the
engineer's estimate and shall be received prior to award of the construction
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contract. Any additional balance of the deposit, based on the actual bid must be
received within forty-five (45) days of receipt of written notification by State of the
final amount due, unless the contract is canceled. Any unnecessary balance of a
cash deposit, based on the actual bid, will be refunded within forty-five (45) days of
receipt by State of the Project sponsor's written request.
c) Pursuant to ORS 366.425, the advance deposit may be in the form of 1) money
deposited in the State Treasury (an option where a deposit is made in the Local
Government Investment Pool, and an Irrevocable Limited Power of Attorney is sent
to the Highway Finance Office), or 2) an Irrevocable Letter of Credit issued by a
local bank in the name of Stale, or 3) cash.
d) Agency may satisfy all or part of any matching funds requirements by use of in-
kind contributions rather than cash when prior written approval has been given by
State.
26. If the estimated cost exceeds the total matched federal funds available, Agency shall deposit its
share of the required matching funds, plus 100 percent of all costs in excess of the total matched
federal funds. Agency shall also pay 100 percent of the cost of any item in which FHWA will not
participate. If Agency has not repaid any non-participating cost, future allocations of federal funds,
or allocations of State Highway Trust Funds, to that Agency may be withheld to pay the
non-participating costs. If. State approves processes, procedures, or contract administration
outside the Local Agency Guidelines that result in items being declared non-participating, those
items will not result in the withholding of Agency's future allocations of federal funds or the future
allocations of State Highway Trust Funds.
27. Costs incurred by State and Agency for services performed in connection with any phase of the
Project shall be charged to the Project, unless otherwise mutually agreed upon.
28. If Agency makes a written request for the cancellation of a federal-aid project; Agency shall bear
100 percent of all costs as of the date of cancellation. If State was the sole cause of the
cancellation, State shall bear 100 percent of all costs incurred. If it is determined that the
cancellation was caused by third parties or circumstances beyond the control of State or Agency,
Agency shall bear all development costs, whether incurred by State or Agency, either directly or
through contract services, and State shall bear any State administrative costs incurred. After
settlement of payments. State shall deliver surveys, maps, field notes, and all other data to
Agency.
29. Agency shall follow requirements of the Single Audit Act. The requirements stated in the Single
Audit Act must be followed by those local governments and non-profit organizations receiving
$500,000 or more in federal funds. The Single Audit Act of 1984, PL 98-502 as amended by PL
104-156, described in "OMB CIRCULAR NO. A-133", requires local governments and non-profit
organizations to obtain an audit that includes internal controls and compliance with federal laws
and regulations of all federally-funded programs in which the local agency participates. The cost
of this audit can be partially prorated to the federal program.
30. Agency shall make additional deposits, as needed, upon request from State. Requests for
additional deposits shall be accompanied by an itemized statement of expenditures and an
estimated cost to complete the Project.
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31. Agency shall present invoices for 100 percent of actual costs incurred by Agency on behalf of the
Project directly to State's Liaison Person for review and approval. Such invoices shall identify the
Project and Agreement number, and shall itemize and explain all expenses for which
reimbursement is claimed. Billings shall be presented for periods of not less than one-month
duration, based on actual expenses to date. All billings received from Agency must be approved
by State's Liaison Person prior to payment. Agency's actual costs eligible for federal-aid or State
participation shall be those allowable under the provisions of Title 23 CFR Parts 1. 11, 140 and
710, Final billings shall be submitted to State for processing within three (3) months from the end
of each funding phase as follows: 1) award date of a construction contract for preliminary
engineering (PE) 2) last payment for right of way. acquisition and 3) third notification for
construction. Partial billing (progress payment) shall be submitted to State within three (3) months
from date that costs are incurred. Final billings submitted after the three months shall not be
eligible for reimbursement.
32. The cost records and accounts pertaining to work covered by this Agreement are to be kept
available for inspection by representatives of State and FHWA for a period of six (6) years
following the date of final voucher to FHWA. Copies of such records and accounts shall be made
available upon request. For real property and equipment, the retention period starts from the date
of disposition (Title 49 CFR 18.42).
33. State shall request reimbursement, and Agency agrees to reimburse State, for federal-aid funds
distributed to Agency if any of the following events occur:
a) Right of way acquisition or actual construction of the facility for which preliminary
engineering is undertaken is not started by the close of the tenth fiscal year
following the fiscal year in which the federal-aid funds were authorized;
b) Right of way acquisition is undertaken utilizing federal-aid funds and actual
construction is not started by the close of the twentieth fiscal year following the
fiscal year in which the federal-aid funds were authorized for right of way
acquisition.
c) Construction proceeds after the Project is determined to be ineligible for federal-aid
funding (e.g., no environmental approval, lacking permits, or other reasons).
34. Agency shall maintain all Project documentation in keeping with State and FHWA standards and
specifications. This shall include, but is not limited to, daily work records, quantity documentation,
material invoices and quality documentation, certificates of origin, process control records, test
results, and inspection records to ensure that projects are completed in conformance with
approved plans and specifications.
RAILROADS
35. Agency shall follow State established policy and procedures when impacts occur on railroad
property. The policy and procedures are available through State's appropriate Region contact or
State's Railroad Liaison. Only those costs allowable under Title 23 CFR Part 646, subpart B and
Title 23 CFR Part 140, subpart I, shall be included in the total Project costs; all other costs
associated with railroad work will be at the sole expense of Agency, or others. Agency may
request State, in writing, to provide railroad coordination and negotiations. However, State is
under no obligation to agree to perform said duties.
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UTIL17TES
36. Agency shall follow State established Statutes, Policies and Procedures when impacts occur to
privately or publicly-owned utilities. Only those utility relocations, which are eligible for federal-aid
participation under, the FAPG, Title 23 CFR 645A, Subpart A and B, shall be included in the total
Project costs; all other utility relocations shall be at the sole expense of Agency, or others. State
will arrange for utility relocations/adjustments in areas lying within jurisdiction of State, if State is
performing the preliminary engineering. Agency may request State in writing to arrange for utility
relocations/adjustments lying within Agency jurisdiction, acting on behalf of Agency. This request
must be submitted no later than twenty-one (21) weeks prior to bid let date. However, State is
under no obligation to agree to perform said duties.
37. The State utility relocation policy, procedures and forms are available through the appropriate
State's Region Utility Specialist OF State Utility Liaison. Agency shall provide copies of all signed
utility notifications, agreements and Utility Certification to the State Utility Liaison.
STANDARDS
38. Agency agrees that design standards for all projects on the National Highway System (NHS) and
the Oregon State Highway System shall be in compliance to standards specified in the current
"State Highway Design Manual" and related references. Construction plans shall be in
conformance with standard practices of State for plans prepared by its own staff. All specifications
for the Project shall be in substantial compliance with the most current "Oregon Standard
Specifications for HighwaV Construction".
39. Agency agrees that minimum design standards for non-NHS projects shall be recommended
AASHTO Standards and in accordance with the current "Oregon Bicycle and Pedestrian Plan
unless otherwise requested by Agency and approved by State.
40. Agency agrees and will verify that the installation of traffic control devices shall meet the warrants
prescribed in the "Manual on Uniform Traffic Control Devices and Oregon Supplements".
41. All plans and specifications shall be developed in general conformance with the current "Contract
Plans Development Guide" and the current "Oregon Standard Specifications for HighwaV
Construction" and/or guidelines provided.
42. The standard unit of measurement for all aspects of the Project shall be English Units. All Project
documents and products shall be in English. This includes, but is not limited to, right of way,
environmental documents, plans and specifications, and utilities.
GRADE CHANGE LL4BILI2-Y
43. Agency, if a County, acknowledges the effect and scope of ORS 105.755 and agrees that all acts
necessary to complete construction of the Project which may alter or change the grade of existing
county roads are being accomplished at the direct request of the County.
44. Agency, if a City, hereby accepts responsibility for all claims for damages from grade changes.
Approval of plans by State shall not subject State to liability under ORS 105.760 for change of
grade.
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45. Agency, if a City, by execution of Agreement, gives its consent as required by ORS 373.030(2) to
any and all changes of grade within the City limits, and gives its consent as required by ORS
373.050(1) to any and all closure of streets intersecting the highway, if any there be in connection
with or arising out of the project covered by the Agreement.
CONTRACTOR CLAIMS
46. Agency shall, to the extent permitted by state law, indemnify, hold harmless and provide legal
defense for State against all claims brought by the contractor, or others resulting from Agency's
failure to comply with the terms of this Agreement.
47. Notwithstanding the foregoing defense obligations under Paragraph 46, neither Agency nor any
attorney engaged by Agency shall defend any claim in the name of the State of Oregon or any
agency of the State of Oregon, nor purport to act as legal representative of the State of Oregon or
any of its agencies, without the prior written consent of the Oregon Attorney General. The State of
Oregon may, at anytime at its election assume its own defense and settlement in the event that it
determines that Agency is prohibited from defending the State of Oregon, or that Agency is not
adequately defending the State of Oregon's interests, or that an important governmental principle
is at issue or that it is in the best interests of the State of Oregon to do so. The State of Oregon
reserves all rights to pursue any claims it may have against Agency if the State of Oregon elects
to assume its own defense.
MAINTENANCE RESPONSIBILITIES
48. Agency shall, upon completion of construction, thereafter maintain and operate the Project at its
own cost and expense, and in a manner satisfactory to State and FHWA.
WORKERS' COMPENSATION COVERAGE
49. All employers, including Agency, that employ subject workers who work under this Agreement in
the State of Oregon shall comply with ORS 656.017 and 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. Agency shall
ensure that each of its contractors complies with these requirements.
LOBBYING RESTRICTIONS
50. Agency certifies by signing the Agreement that:
a) No federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or
employee of any federal agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in connection with the
awarding of any federal contract, the making of any federal grant, the making of
any federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment, or modification of any federal
contract, grant, loan, or cooperative agreement.
b) If any funds other than federal appropriated funds have been paid or will be paid to
any person for influencing or attempting to influence an officer or employee of any
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federal agency, a Member of Congress, an officer or employee of Congress, or an
employee of a Member of Congress in connection with this federal contract, grant,
loan, or cooperative agreement, the undersigned shall complete and submit
Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its
instructions.
c) The undersigned shall require that the language of this certification be included in
the award documents for all subawards at all tiers (including subgrants, and
contracts and subcontracts under grants, subgrants, loans, and cooperative
agreements) which exceed $100,000, and that all such subrecipients shall certify
and disclose accordingly.
d) This certification is a material representation of fact upon which reliance was
placed when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction imposed by
Title 31, USC Section 1352:
e) Any person who fails to file the required certification shall be subject to a civil
penalty of not less than $10,000 and not more than $100,000 for each such failure.
Paragraphs 36, 37, and 48 are not applicable to any local agency on state highway projects.
STDPRO-2011.doc 19
Rev. 01-18-2011
Misc. Contracts and Agreements
No.28455
INTERGOVERNMENTAL AGREEMENT
FOR RIGHT OF WAY SERVICES
Walker Avenue: Ashland Street to East Main Street
THIS AGREEMENT is made and entered into by and between the STATE OF
OREGON, acting by and through its Department of Transportation, hereinafter referred
to as "State"; and the City of Ashland, acting by and through its elected officials,
hereinafter referred to as "Agency," both herein referred to individually or collectively as
"Party" or "Parties."
RECITALS
1. By the authority granted in Oregon Revised Statute (ORS) 190.110, 283.110,
366.572 and 366.576, state agencies may enter into agreements with units of local
government or other state agencies for the performance of any or all functions and
activities that a Party to the agreement, its officers, or agents have the authority to
perform.
2. By the authority granted in ORS 366.425, State may accept deposits of money or an
irrevocable letter of credit from any county, city, road district, person, firm, or
corporation for the performance of work on any public highway within the State. When
said money or a letter of credit is deposited, State shall proceed with the Project.
Money so deposited shall be disbursed for the purpose for which it was deposited.
3. That certain Walker Avenue is under the jurisdiction and control of Agency and
Agency may enter into an agreement for the acquisition of real property.
4. N/A, is a part of the state highway system under the jurisdiction and control of the
Oregon Transportation Commission (OTC).
5. This Agreement shall define roles and responsibilities of the Parties regarding the real
property to be used as part of right of way for road, street or construction of public
improvement. The scope and funding may be further described in CONGESTION
MITIGATION AND AIR QUALITY (CMAQ) PROGRAM Agreement number 27871.
Hereinafter, all acts necessary to accomplish services in this Agreement shall be
referred to as "Project."
NOW THEREFORE, the premises being in general as stated in the foregoing Recitals, it
is agreed by and between the Parties hereto as follows:
TERMS OF AGREEMENT
1. Under such authority, State and Agency agree to perform certain right of way activities
shown in Special Provisions - Exhibit A, attached hereto and by this reference made a
part hereof. If the State performs right of way services on behalf of the Agency, under
R/W Services IGA (Revised June 2011) - 1
no conditions shall Agency's obligations for said services exceed a maximum of
$5,000, including all expenses, unless agreed upon by both Parties.
2. The work shall begin on the date all required signatures are obtained and shall be
completed no later than July 31, 2022, on which date this Agreement automatically
terminates unless extended by a fully executed amendment.
3. The process to be followed by the Parties in carrying out this Agreement is set out in
Exhibit A.
4. It is further agreed both Parties will strictly follow the rules, policies and procedures of
the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970,
as amended, ORS Chapter 35 and the "State Right of Way Manual".
STATE OBLIGATIONS
1. State shall perform the work described in Special Provisions - Exhibit A.
2. With the exception of work related to appraisals, State shall not enter into any
subcontracts for any of the work scheduled under this Agreement without obtaining
prior written approval from Agency.
3. If the State performs right of way services on behalf of the Agency, State shall perform
the service under this Agreement as an independent contractor and shall be
exclusively responsible for all costs and expenses related to its employment of
individuals to perform the work under this Agreement including, but not limited to,
retirement contributions, workers compensation, unemployment taxes, and state and
federal income tax withholdings.
4. State's right of way contact person for this Project is Craig Pearsall, ODOT Sr. Right of
Way Agent, 3500 NW Stewart Pkwy, Roseburg, OR 97470-1687, 541-957-3552,
craig.a.pearsall@odot.state.or.us, or assigned designee upon individual's absence.
State shall notify the other Party in writing of any contact changes during the term of
this Agreement.
AGENCY OBLIGATIONS
1. Agency shall perform the work described in Special Provisions - Exhibit A.
2. Agency certifies, at the time this Agreement is executed, that sufficient funds are
available and authorized for expenditure to finance costs of this Agreement within
Agency's current appropriation or limitation of current budget. Agency is willing and
able to finance all, or its pro-rata share of all, costs and expenses incurred in the
Project up to its maximum.
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3. Agency may utilize its own staff or subcontract any of the work scheduled under this
Agreement provided Agency receives prior written approval of any staff, consultant or
contractor by the State's Region Right of Way office.
4. Agency represents that this Agreement is signed by personnel authorized to do so on
behalf of Agency.
5. Agency's right of way contact person for this Project is Morgan Wayman, Project
Manager, 20 East Main Street, Ashland, OR 97520; waymanm@ashland.or.us; (541)
552-2414, or assigned designee upon individual's absence. Agency shall notify the
other Party in writing of any contact information changes during the term of this
Agreement.
PAYMENT FOR SERVICES AND EXPENDITURES:
1. In consideration for the services performed by State (as identified in the attached
Exhibit A), Agency agrees to pay or reimburse State a maximum amount of $5,000.
Said maximum amount shall include reimbursement for all expenses, including
travel expenses. Travel expenses shall be reimbursed to State in accordance with
the current Oregon Department of Administrative Services' rates. Any expenditure
beyond federal participation will be from, or reimbursed from, Agency funds.
Payment in Agency and/or federal funds in any combination shall not exceed said
maximum, unless agreed upon by both Parties.
2. Agency agrees to reimburse salaries and payroll reserves of State employees working
on Project, direct costs, costs of rental equipment used, and per-diem expenditures.
GENERAL PROVISIONS:
1. This Agreement may be terminated by either Party upon thirty (30) days' notice, in
writing and delivered by certified mail or in person, under any of the following
conditions:
a. If either Party fails to provide services called for by this Agreement within the
time specified herein or any extension thereof.
b. If either Party fails to perform any of the other provisions of this Agreement or so
fails to pursue the work as to endanger performance of this Agreement in
accordance with its terms, and after receipt of written notice fails to correct such
failures within ten (10) days or such longer period as may be authorized.
c. If Agency fails to provide payment of its share of the cost of the Project.
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d. If State fails to receive funding, appropriations, limitations or other expenditure
authority sufficient to allow State, in the exercise of its reasonable administrative
discretion, to continue to make payments for performance of this Agreement.
e. 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 State is
prohibited from paying for such work from the planned funding source.
2. Any termination of this Agreement shall not prejudice any rights or obligations
accrued to the Parties prior to termination.
3. Agency acknowledges and agrees that State, the Oregon Secretary of State's
Office, the federal government, and their duly authorized representatives shall have
access to the books, documents, papers, and records of Agency which are directly
pertinent to this Agreement for the purpose of making audit, examination, excerpts,
and transcripts for a period of six (6) years after final payment. Copies of applicable
records shall be made available upon request. Payment for costs of copies is
reimbursable by State.
4. Agency shall comply with all federal, state, and local laws, regulations, executive
orders and ordinances applicable to the work under this Agreement, including,
without limitation, the provisions of ORS 279B.220, 279B.225, 2798.230, 27913.235
and 27913.270 incorporated herein by reference and made a part hereof. Without
limiting the generality of the foregoing, Agency expressly agrees to comply with (i)
Title VI of Civil Rights Act of 1964; (ii) Title V and Section 504 of the Rehabilitation
Act of 1973; (iii) the Americans with Disabilities Act of 1990 and ORS 659A.142; (iv)
all regulations and administrative rules established pursuant to the foregoing laws;
and (v) all other applicable requirements of federal and state civil rights and
rehabilitation statutes, rules and regulations.
5. All employers that employ subject workers who work under this Agreement in the
State of Oregon shall comply with ORS 656.017 and 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. Both Parties shall ensure that each of its subcontractors complies with
these requirements.
6. 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 Party Claim") against State
or Agency with respect to which the 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 a Party of the notice and copies required in this paragraph and
meaningful opportunity for the Party to participate in the investigation, defense and
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settlement of the Third Party Claim with counsel of its own choosing are conditions
precedent to that Party's liability with respect to the Third Party Claim.
7. With respect to a Third Party Claim for which State is jointly liable with Agency (or
would be if joined in the Third Party Claim), State 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 Agency in such
proportion as is appropriate to reflect the relative fault of State on the one hand and
of Agency 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 State on the one hand and of Agency
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. State's contribution amount in any instance is capped to the
same extent it would have been capped under Oregon law, including the Oregon
Tort Claims Act, ORS 30.260 to 30.300, if State had sole liability in the proceeding.
8. With respect to a Third Party Claim for which Agency is jointly liable with State (or
would be if joined in the Third Party Claim), Agency 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 State in such
proportion as is appropriate to reflect the relative fault of Agency on the one hand
and of State 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 Agency on the one hand and of State
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. Agency's contribution amount in any instance is capped to the
same extent it would have been capped under Oregon law, including the Oregon
Tort Claims Act, ORS 30.260 to 30.300, if it had sole liability in the proceeding.
9. The Parties shall attempt in good faith to resolve any dispute arising out of this
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.
10. If federal funds are involved in this Agreement, Exhibits B and C are attached hereto
and by this reference made a part of this Agreement, and are hereby certified to by
Agency.
11. If federal funds are involved in this Agreement, Agency, as a recipient of federal
funds, pursuant to this Agreement with the State, shall assume sole liability for
Agency's breach of any federal statutes, rules, program requirements and grant
provisions applicable to the federal funds, and shall, upon Agency's breach of any
such conditions that requires the State to return funds to the Federal Highway
Administration, hold harmless and indemnify the State for an amount equal to the
-5-
28455
funds received under this Agreement; or if legal limitations apply to the
indemnification ability of Agency, the indemnification amount shall be the maximum
amount of funds available for expenditure, including any available contingency funds
or other available non-appropriated funds, up to the amount received under this
Agreement.
12. The Parties hereto agree that if any term or provision of this Agreement is declared
by a court of competent jurisdiction to be invalid, unenforceable, illegal or in conflict
with any law, the validity of the remaining terms and provisions shall not be affected,
and the rights and obligations of the Parties shall be construed and enforced as if
the Agreement did not contain the particular term or provision held to be invalid.
13. 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.
14.This Agreement and attached exhibits 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
waiver, consent, modification or change of terms of this Agreement shall bind either
Party unless in writing and signed by both Parties and all necessary approvals have
been obtained. 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 State to enforce any provision of this Agreement shall not constitute a waiver by
State of that or any other provision.
THE PARTIES, by execution of this Agreement, hereby acknowledge that their signing
representatives have read this Agreement, understand it, and agree to be bound by its
terms and conditions.
Signature Page to Follow
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28455
CITY OF ASHLAND, by and through STATE OF OREGON, by and through
its elected officials its Departs nt of Tr n/sportation
By /gy
~rr~,tat
Date e Right f Way anager
Date (o Z, -?Q b z..
By APPROVAL COMMENDED
By
Date Region Righ of W y Manager
APPROVED AS TO LEGAL Date Z
SUFFICIENCY
By ~1~ i BY
Date Date
A 2-
APPROVED AS TO LEGAL SUFFICIENCY
gencv Contact:
Jim Olson By N/A
Ashland City Engineer Assistant Attorney General
20 East Main Street
Ashland, OR 97520 Date
(541) 488-5587
jimo@ashland.or.us APPROVED
(If Litigation Work Related to Condemnation
is to be done by State)
By N/A
State Contact: Chief Trial Counsel
Craig Pearsall, Sr. Agent
ODOT Region 3 Right of Way Date
3500 NW Stewart Pkwy
Roseburg, OR 97470-1687
541-957-3552
craig.a.pearsall@odot.state.or.us
28455 7
SPECIAL PROVISIONS EXHIBIT A
Right of Way Services
THINGS TO BE DONE BY STATE OR AGENCY
1. Pursuant to this Agreement, the work performed on behalf of the Agency can be
performed by the Agency, the Agency's consultant, or a State Flex Services
consultant. The work may be performed by Agency staff or any of these
representatives on behalf of Agency individually or collectively provided they are
qualified to perform such functions and after receipt of approval from the State's
Region 3 Right of Way Manager. Said approval must be obtained, in writing, prior to
the performance of said activities.
2. With the exception of work related to appraisals, State shall not enter into any
subcontracts for any of the work scheduled under this Agreement without obtaining
prior written approval from Agency.
3. Both Parties will strictly follow the rules, policies and procedures of the Uniform
Relocation Assistance and Real Property Acquisition Policies Act of 1970, as
amended, ORS Chapter 35 and the "State Right of Way Manual".
Instructions: Insert either: State, Agency, or N/A on each line.
A. Preliminary Phase
1. Agency shall provide preliminary cost estimates.
2. Agency shall make preliminary contacts with property owners.
3. Agency shall gather and provide data for environmental documents.
4. Agency shall develop access and approach road list.
5. Agency shall help provide field location and Project data.
B. Acquisition Phase
1. General:
a. When doing the Acquisition work, Agency shall provide State with a status
report of the Project monthly.
b. Title to properties acquired shall be in the name of the Agency.
c. Prior to the initiation of acquisitions, if title to the properties is to be acquired in
the name of the Agency, the Agency shall adopt a resolution of intention and
determination of necessity in accord with ORS 35.235 and ORS 35.610,
authorizing acquisition and condemnation. If the Oregon Department of Justice
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28455
is to handle condemnation work, prior approval evidenced by Chief Trial
Counsel, Department of Justice, signature on this Agreement is required; and
authorization for such representation shall be included in the resolution
adopted by the Agency. Prior approval by Oregon Department of Justice is
required.
2. Legal Descriptions:
a. Agency shall provide sufficient horizontal control, recovery and retracement
surveys, vesting deeds, maps and other data so that legal descriptions can be
written.
b. Agency shall provide construction plans and cross-section information for the
Project.
c. Agency shall write legal descriptions and prepare right of way maps. If the
Agency acquires any right of way on a State highway, the property descriptions
and right of way maps shall be based upon centerline stationing and shall be
prepared in accordance with the current "State Right of Way & Rail/Utility
Coordination Manual", "Contractor Services Guide" and the "Right of Way
Engineering Manual". The preliminary and final versions of the property
descriptions and right of way maps must be reviewed and approved by the
State.
d. Agency shall specify the degree of title to be acquired (e.g., fee, easement).
3. Real Property and Title Insurance:
a. Agency shall provide preliminary title reports, if State determines they are
needed, before negotiations for acquisition commence.
b. Agency shall determine sufficiency of title (taking subject to). If the Agency
acquires any right of way on a State highway, sufficiency of title (taking subject
to) shall be determined in accordance with the current "State Right of Way
Manual" and the "Contractor Services Guide". Agency shall clear any
encumbrances necessary to conform to these requirements, obtain Title
Insurance policies as required and provide the State copies of any title policies
for the properties acquired.
c. State shall conduct a Level 1 Hazardous Materials Study within project limits
to detect presence of hazardous materials on any property purchase,
excavation or disturbance of structures, as early in the project design as
possible, but at a minimum prior to property acquisition or approved design.
d. Agency shall conduct a Level 2 Site Investigation of sufficient scope to
confirm the presence of contamination, determine impacts to properties and
develop special provisions and cost estimates, if the Level 1 Corridor study
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indicates the potential presence of contamination that could impact the
properties.
• If contamination is found, a recommendation for remediation will be
presented to Agency.
e. Agency shall be responsible for arrangement of any necessary remediation.
f. Agency shall conduct asbestos, lead paint and other hazardous materials
surveys for all structures that will be demolished, renovated or otherwise
disturbed. Asbestos surveys must be conducted by an AHERA (asbestos
hazard emergency response act) certified inspector.
4. Appraisal:
a. Agency shall conduct the valuation process of properties to be acquired.
b. Agency shall perform the Appraisal Reviews.
c. Agency shall recommend Just Compensation, based upon a review of the
valuation by qualified personnel.
5. Negotiations:
a. Agency shall tender all monetary offers to land-owners in writing at the
compensation shown in the appraisal review. Conveyances taken for more or
less than the approved Just Compensation will require a statement justifying
the settlement. Said statement will include the consideration of any property
trades, construction obligations and zoning or permit concessions. If State
performs this function, it will provide the Agency with all pertinent letters,
negotiation records and obligations incurred during the acquisition process.
b. State and Agency shall determine a date for certification of right of way and
agree to cosign the State's Right of Way Certification form. State and Agency
agree possession of all right of way shall occur prior to advertising of any
construction contract, unless appropriate exceptions have been agreed to by
Agency and State.
c. Agency agrees to file all Recommendations for Condemnation at least seventy
(70) days prior to the right of way certification date if negotiations have not
been successful on those properties.
6. Relocation:
a. Agency shall perform any relocation assistance, make replacement housing
computations, and do all things necessary to relocate any displaced parties on
the Project.
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28455
b. Agency shall make all relocation and moving payments for the Project.
c. Agency shall perform the relocation appeal process.
C. Closing Phase
1. Agency shall close all transactions. This includes drawing of deeds, releases and
satisfactions necessary to clear title, obtaining signatures on release documents,
and making all payments. If Agency is handling the closing, State shall submit all
signed Final Report packets, information required by the Uniform Act, and
agreements to the Agency.
2. Agency shall record conveyance documents, only upon acceptance by appropriate
agency.
D. Property Management
1. Agency shall take possession of all the acquired properties. There shall be no
encroachments of buildings or other private improvements allowed upon the State
highway right of way.
2. Agency shall dispose of all improvements and excess land.
E. Condemnation
1. Agency may offer mediation if the parties have reached an impasse.
2. Agency shall perform all administrative functions in preparation of the
condemnation process, such as preparing final offer and complaint letters.
3. Agency shall perform all legal and litigation work related to the condemnation
process. (If State agrees to handle legal and litigation work, prior approval
evidenced by Chief Trial Counsel, Department of Justice, signature on this
Agreement is required. Where it is contemplated that property will be obtained for
Agency for the Project, such approval will be conditioned on passage of a
resolution by Agency substantially in the form attached hereto as Exhibit D, and by
this reference made a part. hereof, specifically identifying the property being
acquired.)
4. Where State shall perform legal or litigation work related to the condemnation
process, Agency acknowledges, agrees and undertakes to assure that no member
of Agency's board or council, nor Agency's mayor, when such member or mayor is
a practicing attorney, nor Agency's attorney nor any member of the law firm of
Agency's attorney, board or council member, or mayor, will represent any party,
except Agency, against the State of Oregon, its employees or contractors, in any
matter arising from or related to the Project which is the subject of this Agreement.
F. Transfer of Right of Way to State
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If applicable, Agency agrees to transfer to the State all right of way acquired on the
State highway which was acquired in the Agency's name. The specific method of
conveyance will be determined by the Agency and the State at the time of transfer and
shall be coordinated by the State's Region Right of Way Manager. Agency agrees to
provide the State all information and file documentation the State deems necessary to
integrate the right of way into the State's highway system. At a minimum, this includes:
copies of all recorded conveyance documents used to vest title in the name of the
Agency during the right of way acquisition process, and the Agency's Final Report or
Summary Report for each acquisition file that reflects the terms of the acquisition and
all agreements with the property owner(s).
G. Transfer of Right of Way to Agency
If applicable, State agrees to transfer and Agency agrees to accept all right of way
acquired on the Agency's facility which was acquired in the State's name. The
specific method of conveyance will be determined by the State and the Agency at
the time of transfer and shall be coordinated by the State's Region Right of Way
Manager. If requested, State agrees to provide Agency information and file
documentation associated with the transfer.
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28455
RESOLUTION EXERCISING THE POWER OF EMINENT DOMAIN EXHIBIT D
Right of Way Services
WHEREAS the City of Ashland may exercise the power of eminent domain pursuant to its charter
and the Law of the State of Oregon generally, when the exercise of such power is deemed necessary
by the City's governing body to accomplish public purposes for which the City has responsibility;
WHEREAS the City has the responsibility of providing safe transportation routes for commerce,
convenience and to adequately serve the traveling public;
WHEREAS the project or projects known as Walker Avenue have been planned in accordance with
appropriate engineering standards for the construction, maintenance or improvement of said
transportation infrastructure such that property damage is minimized, transportation promoted, travel
safeguarded; and
WHEREAS to accomplish the project or projects set forth above it is necessary to acquire the
interests in the property described in 'Exhibit A," attached to this resolution and, by this reference
incorporated herein; now, therefore
BE IT HEREBY RESOLVED by Council:
1. The foregoing statements of authority and need are, in fact, the case. The project or
projects for which the property is required and is being acquired are necessary in the
public interest, and the same have been planned, designed, located, and will be
constructed in a manner which will be most compatible with the greatest public good and
the least private injury;
2. The power of eminent domain is hereby exercised with respect to each of the interests in
property described in Exhibit A. Each is acquired subject to payment of just compensation
and subject to procedural requirements of Oregon law;
3. City's staff and Counsel are authorized and requested to attempt to agree with the owner
and other persons in interest as to the compensation to be paid for each acquisition, and,
in the event that no satisfactory agreement can be reached, to commence and prosecute
such condemnation proceedings as may be necessary to finally determine just
compensation or any other issue appropriate to be determined by a court in connection
with the acquisition. This authorization is not intended to expand the jurisdiction of any
court to decide matters determined above or determinable by the Commission.
4. City expressly reserves its jurisdiction to determine the necessity or propriety of any
acquisition, its quantity, quality, or locality, and to change or abandon any acquisition.
DATED this day of 20-
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28455
CITY OF
ASHLAND
Council Communication
June 3, 2014, Business Meeting
Public Hearing and adoption of Miscellaneous Fees & Charges for FY 2015
FROM:
Lee Tuneberg, Administrative Services Director, tuneberl@ashland.or.us
SUMMARY
This public hearing is to consider changes to some of the various fees and charges used by the city.
Many are remaining the same but some are recommended to increase by an inflationary factor. Others
are to be adjusted to cover cost of service as recommended by staff. There are also a few new charges
recommended.
BACKGROUND AND POLICY IMPLICATIONS:
In the past the City of Ashland adopted many separate resolutions and ordinances that set specific rates
and fees for the multitude of services rendered to the public. That was greatly simplified during FY
2010-2011 when the current process of adopting a single fee resolution was approved. A staff goal had
been to create an annual process that deals with most, if not all, miscellaneous fees and charges, and a
booklet that is comprehensive yet easy to use. This is the third annual renewal of that process.
Attached are the draft booklet and a resolution to establish or update the included fees effective July 1,
2014, unless another effective date is set by separate Council action. New fees and changes to old ones
are identified in a "proposed" column and are bolded in red. If an entry is not bolded in red or
identified as a new or changed fee it is the existing amount or methodology for calculation. Also
attached are memos from departments explaining significant changes beyond inflationary adjustments.
Please note that:
1. Items not approved may come back to Council separately or in this process next year.
2. Not all fees and charges are changing.
3. City and Park fees are included.
4. Utility rates and system development charges are examples of charges that are not incorporated
within this process and resolution.
5. Some of the larger increases relate to "cost of providing the service," as substantiated by the
departmental memo, and are intended to have the requester bear the cost.
We should expect that there may be some "errors and omissions" so staff is requesting through the
resolution that the new fee schedule take priority over any disconnects or conflicts with prior
resolutions that were not repealed. When such incidents occur, staff will correct them as soon as
possible and incorporate the revisions in updates to this new, annual process.
Page I of 2
Ir,
CITY OF
ASHLAND
Those departments requesting changes are listed below. To assist you in your review, the following
proposed changes are attached:
• Finance
• Community Development
• Electric
• Fire
• Information Technology
• Municipal Courts
• Police
• Public Works
• Parks & Recreation
FISCAL IMPLICATIONS:
These adjustments will fund or help to fund operations, most representing payments for requested
services.
STAFF RECOMMENDATION AND REQUESTED ACTION:
Staff recommends Council approve these charges.
SUGGESTED MOTION:
I move approval of the resolution titled, "A Resolution Adopting a Miscellaneous Fees & Charges
Document and Repealing Prior Fee Resolution 2013-17."
ATTACHMENTS:
All attachments for this item can be found in the May 6, 2014 packet:
http://www.ashland.or.us/Page.asl2?NavlD=16241
Page 2 of 2
RESOLUTION NO. 2014-
A RESOLUTION ADOPTING A MISCELLANEOUS FEES AND
CHARGES DOCUMENT AND REPEALING PRIOR FEE
RESOLUTION 2013-17
Recitals:
A. The City currently has many resolutions and ordinances that establish fees for
different departments and activities.
B. The City desires to provide all of its miscellaneous fees and charges in one document
so citizens can easily determine the costs of city services.
C. The City desires to repeal all prior resolutions that establish fees and charges and
adopt all fees and charges with one resolution for convenience of its citizenry.
THE CITY OF ASHLAND RESOLVES AS FOLLOWS:
SECTION 1. The Miscellaneous Fees and Charges Document, which is attached hereto and
incorporated herein by this reference, is hereby approved and establishes the fees and charges for
City services. New fees, those not charged before, are not affective until 30 days following date
of approval unless otherwise established by Council action.
SECTION 2. The following resolutions are specifically repealed: Resolutions 2013-17 and all
other fees and charges inconsistent with the fees and charges set forth herein are repealed.
SECTION 3. This resolution was duly PASSED and ADOPTED this day of
2014, and takes effect upon signing by the Mayor.
Barbara Christensen, City Recorder
SIGNED and APPROVED this day of April, 2014.
John Stromberg, Mayor
Reviewed as to form:
David Lohman, City Attorney
Page I of 1
CITY OF
^ASH LAN D
MISCELLANEOUS FEES AND CHARGES DOCUMENT
ADOPTED: June 4, 2013
EFFECTIVE: July 1, 2013
2014 PROPOSED CHANGES
ASHLAND
PARKS
RECREATION
PARKS AND RECREATION MISCELLANEOUS FEES AND CHARGES
ADOPTED: June 4, 2013
EFFECTIVE: July 1, 2013
2014 PROPOSED CHANGES
Miscellaneous Fees and Charges
page 2 miscellaneous fees 8 charges
Table of Contents
CITY OF
ASHLAND
MISCELLANEOUS FEES AND CHARGES
ALPHABETICALLY BY DEPARTMENT
SECTION1 -Administrative Services/Finance
Administrative Billing Charge ..............................................................................................................................Page 8
Initial Business License Application Fee ..............................................................................................................Page 8
Temporary Business License Application Fee ......................................................................................................Page 8
Renewal Application Fee ......................................................................................................................................Page 8
Rental Property Fees .............................................................................................................................................Page 8
Late Application Fee .............................................................................................................................................Page 8
Late Renewal Fee (paid 30 days after the due date) ..............................................................................................Page 8
Utility Billing Administrative Fees .......................................................................................................................Page 9
Reconnection Charge ............................................................................................................................................Page 9
Service Connection ...............................................................................................................................................Page 9
Parking Structure Fees ..........................................................................................................................................Page 9
Downtown Parking Area Fees ...............................................................................................................................Page 9
SECTION 2 - City Recorder
Copy Fees ............................................................................................................................................................Page 10
Audio Tapes ..........................................:.............................................................................................................Page 10
Liquor Licenses ...................................................................................................................................................Page 10
Taxicab Licenses .................................................................................................................................................Page 10
Lien Searches ......................................................................................................................................................Page 10
Elections ..............................................................................................................................................................Page 10
Street/Alley Vacations ........................................................................................................................................Page 10
Ambulance ..........................................................................................................................................................Page 10
Annexation ..........................................................................................................................................................Page 10
Research Fee .......................................................................................................................................................Page 10
SECTION 3 - Community Development
Pre-Application Conference ................................................................................................................................Page 11
Administration Actions .......................................................................................................................................Page 11
Type 1,11 and III Reviews ...................................................................................................................................Page 11
Legislative Amendments .....................................................................................................................................Page 12
Appeals ................................................................................................................................................................Page 12
Solar Access ........................................................................................................................................................Page 12
Community Development Fee ............................................................................................................................Page 12
Copy Fees ............................................................................................................................................................Page 12
Prepared Documents ...........................................................................................................................................Page 12
Research Fee .......................................................................................................................................................Page 12
Building Permit Fees ...........................................................................................................................................Page 13
Plan Review Fee for Commercial and Residential ..............................................................................................Page 13
Miscellaneous Fees for Commercial ...................................................................................................................Page 13
Inspection Fees for Commercial and Residential ................................................................................................Page 14
Change of Occupancy Fees .................................................................................................................................Page 14
Residential Plumbing Permit Fees ......................................................................................................................Page 14
Commercial Plumbing Permit Fees .....................................................................................................................Page 15
Residential Mechanical Permit Fees ...................................................................................................................Page 15
Commercial Mechanical Permit Fees ..................................................................................................................Page 16
Electrical Permit Fees .........................................................................................................................................Page 16
Residential Restricted Energy Electrical Permit Fees .........................................................................................Page 17
Renewable Energy Systems ................................................................................................................................Page 17
State of Oregon Surcharge ................................................................................................:.................................Page 17
Building Permit Refund Policy ..........................................................................................................................Page 18
Excavation/Grading Fees ....................................................................................................................................Page 18
miscellaneous fees 8 charges page 3
Table of Contents
SECTION 4 - Electric
Temporary Service Drop .....................................................................................................................................Page 19
Meter Charges .....................................................................................................................................................Page 19 _
Non Radio Frequency Meter Charges .................................................................................................................Page 19
Non Sufficient Funds Check Fee ........................................................................................................................Page 19
Reconnection Charge ..........................................................................................................................................Page 19
Service Calls .......................................................................................................................................................Page 19
Service Connection .............................................................................................................................................Page 19
Scheduled Work After Hours ..............................................................................................................................Page 19
Unauthorized Connection ...................................................................................................................................Page 19
Line Extension Charges ......................................................................................................................................Page 20
ENR Calculations .........................................:......................................................................................................Page 20
SECTION 5 - Fire
Copy Fees ............................................................................................................................................................Page 21
Report Fees .........................................................................................................................................................Page 21
Research Fee .......................................................................................................................................................Page 21
Fire Fees ..............................................................................................................................................................Page 21
Emergency Medical Services ..............................................................................................................................Page 21
Plan Checks .........................................................................................................................................................Page 22
Other ...................................................................................................................................................................Page 22
First Aid/CPR Classes .........................................................................................................................................Page 22
Inspection Fees ....................................................................................................................................................Page 22
Weed Abatement .................................................................................................................................................Page 22
SECTION 6 - Information Technology
Installation Fees ..................................................................................................................................................Page 23
Disconnect Fees ..................................................................................................................................................Page 23
Truck Roll ...........................................................................................................................................................Page 23
Field Technician Hourly Rate .............................................................................................................................Page 23
Consulting and Technical Support Hourly Rate ..................................................................................................Page 23
Non-City Employee Staff Screening ...................................................................................................................Page 23
Fiber Service Installation ....................................................................................................................................Page 23
Transit Fees .........................................................................................................................................................Page 23
Static IP Address .................................................................................................................................................Page 24
Quality of Service Fee .........................................................................................................................................Page 24
Business Augmented Upload Package ................................................................................................................Page 24
Non-Return of Customer Premise Equipment (CPE) Devices ............................................................................Page 24
CATV Seasonal Reconnects & Disconnects .......................................................................................................Page 24
CATV House Amp Fee ................................................................................................................:......................Page 24
Utility Billing Lobby Signage Fee ......................................................................................................................Page 24
page 4 miscellaneous fees 8 charges
Table of Contents
SECTION 7 - Municipal Court
Appeal Transcript Fee .........................................................................................................................................Page 25
City Attorney Deferred Sentence/Diversion .......................................................................................................Page 25
Civil Compromise Costs .....................................................................................................................................Page 25
Compliance Inspection Fee .................................................................................................................................Page 25
Court Appointed Counsel Fees and Charges .......................................................................................................Page 25
Default Judgment ................................................................................................................................................Page 25
Discovery Fees ....................................................................................................................................................Page 25
Diversion by Municipal Court .............................................................................................................................Page 25
Extend/Amend City Attorney Deferred Sentence/Diversion ..............................................................................Page 25
Failure to Appear for Bench Trial/Show Cause Hearing ....................................................................................Page 25
Failure to Appear for Jury Trial ..........................................................................................................................Page 25
Forfeiture of Security ............................................................:.............................................................................Page 25
Mediation of Violation (Municipal Court Mediation) ........................................................................................Page 25
Non Sufficient Funds Check Fee ........................................................................................................................Page 25
Court Costs .........................................................................................................................................................Page 25
Expunction ..........................................................................................................................................................Page 25
Show Cause Admission of Allegation .................................................................................................................Page 25
Bench Probation Fee ...........................................................................................................................................Page 25
Warrant ................................................................................................................................................................Page 25
Withholding on County Assessment ...................................................................................................................Page 25
Domestic Partnership Registration .....................................................................................................................Page 25
SECTION 8 - Police
Police Reports Page 26
Research Fee .......................................................................................................................................................Page 26
Visa Letters .........................................................................................................................................................Page 26
Finger Print Cards ...............................................................................................................................................Page 26
Photographs (CD) ................................................................................................................................................Page 26
Audio Tapes/ICOP Videos ..................................................................................................................................Page 26
Non Sufficient Funds Check Fee .........................................................................................................................Page 26
Impoun&Tow Fee ...............................................................................................................................................Page 26
Taxi Operator License .........................................................................................................................................Page 26
Bicycle License ...................................................................................................................................................Page 26
SECTION 9 - Public Works - Miscellaneous Fees & Charges
Copy Fees, Black, White and Color ....................................................................................................................Page 27
Plat & Plan Checks ..............................................................................................................................................Page 27
Public Works/Engineering Inspections, Permit Etc ............................................................................................Page 28
GIS Data & Mapping Services ............................................................................................................................Page 29
Sanitary Sewer Connection Fees .........................................................................................................................Page 30
Water Connection Fees .......................................................................................................................................Page 30
Cemetery Fees .....................................................................................................................................................Page 31
Sexton Fees .........................................................................................................................................................Page 32
Miscellaneous Fees .............................................................................................................................................Page 32
Vases ..........................................................................:........................................................................................Page 32
CPI & ENR Calculations .....................................................................................................................................Page 32
miscellaneous fees 6 charges page 5
Table of Contents
SECTION 10 - Parks and Recreation Miscellaneous Fees and Charges
Wedding Packages ..............................................................................................................................................Page 34
Group Picnic Rentals ..........................................................................................................................................Page 34
Deposits ...............................................................................................................................................................Page 34
Special Event Fees ..............................................................................................................................................Page 34
Alcohol Fee .........................................................................................................................................................Page 34
General Building Reservations ...........................................................................................................................Page 34
Field Usage .........................................................................................................................................................Page 34
Calle Seating .......................................................................................................................................................Page 35
Daniel Meyer Pool ..............................................................................................................................................Page 35
Youth & Adult Recreation Programs Ashland Rotary Centennial Ice Rink .......................................................Page 35
Oak Knoll Golf Course Fees ...............................................................................................................................Page 35
Community Garden Fees ....................................................................................................................................Page 36
Nature Center School Programs ..........................................................................................................................Page 36
Nature Center Community Programs ..................................................................................................................Page 36
Oak Knoll Golf Course Wedding Fees ...............................................................................................................Page 36
Maps ....................................................................................................................................................................Page 36
SECTION 11 - List of Rates and Charges Set by Separate Resolutions
System Development Charges (SDCs) List of Resolutions
Parks and Recreation Resolution 2000-29 ..........................................................................................................Page 37
Transportation Resolution 1999-42 .....................................................................................................................Page 37
Sewer Resolution 2006-27 ..................................................................................................................................Page 37
Storm Resolution 2002-15 ..................................................................................................................................Page 37
Water Resolution 2006-27 ..................................................................................................................................Page 37
Utilities Rates and Fees List of Resolutions
AFN Resolution 2010-28 ....................................................................................................................................Page 37
Electric Resolution 2012-34 ................................................................................................................................Page 37
Sewer Resolution 2013-09 ..................................................................................................................................Page 37
Storm Drain Resolution 2013-28 ........................................................................................................................Page 37
Transportation Resolution 2013-27 .....................................................................................................................Page 37
Water Resolution 2013-08 ..................................................................................................................................Page 37
SECTION 12 - Research Fee
Research Fee .......................................................................................................................................................Page 37
SECTION 13 - Building Valuation Data
i Building Safety Division-Building Valuation Data-February 2013 ...............................................................Page 38
SECTION 14 - Attachments
Community Development - Excavation Grading Fees - Exhibit A - Resolution 2006-19 ..................................Page 39
page 6 miscellaneous fees 8 charges
Miscellaneous Fees and Charges
rim
Miscellaneous fees 8 charges page 7
Section 1-Administration
Administration Services/Finance Miscellaneous Fees and Charges
Administrative Billing Charge (up to 10%) Per Billing
Business License Fees
Initial Business License Application Fee
Licensee shall pay a prorated fee of $10 for each month, $120.00 for first 2 employees*
or portion of a month, remaining in the fiscal year from +$5.00 for each additional
the date of the application with a minimum fee of $25.00 employee
Temporary Business License Application Fee $25.00
Renewal Application Fee $75.00 for first 2 employees*
+$10.00 for each additional
employee
Rental Property Fees Same as above for activity
including six or more properties.
Late Application Fee $25.00
Late Renewal Fee (paid 30 days after the due date) 10% with a minimum of $25.00
*Pursuant to AMC 6.04.020.E an employee is an individual who performs service for another individual or
organization. The number of employees reported shall be the number of employees as of the date the new ap-
plication or renewal will become effective if approved. It does not matter whether an individual is a full, part-
time, or temporary employee for business license purposes.
page 8 miscellaneous tees and charges
Section 1-Administration
Utility Billing Miscellaneous Fees and Charges
Administrative Fees: Current Proposed
Notification of Pending Collection $10.00
Returned Check Charge $35.00
Reconnection Charge:
During Business Hours $25.00
After Hours or Holidays $100.00
Service Connection:
Normal working hours $10.00
Other Hours or Holidays $100.00
Parking Fees
Parking Structure Fees:
6:00 a.m. - 6:00 p.m. (or segment) $1.00
6:00 p.m. - 2:00 a.m. (per hour) $1.00
6:00 a.m. - 2:00 a.m. (maximum) $3.00
Parking pen-nit (where applicable in City structure or lot)
6:00 a.m. - 6:00 p.m. Monday - Saturday (unless otherwise posted) $20.00
Parking Ticket Surcharge (citywide) $4.00
Downtown Parking Area Fees:
Short Term (<30 minutes) unloading from "marked" No charge
business vehicle with flashers
Daily parking permit (Orange)- 1 st day or fraction of day $5.00/day $10.00/day
Additional days (limited to 5 days; no charge on Sunday or $1.00/day $2.00/day
federal holidays)
• Limit of two per business address at a time
• Applicable permits/licenses must be current
• Each permit is good for one parking space
• Not applicable to handicapped or short term spaces
equal to or less than 15 minutes, green loading zones,
fire or other restricted areas.
miscellaneous fees and charges page 9
Section 2-City Recorder
City Recorder Miscellaneous Fees & Charges
Copy Fees:
Black and White Copies Letter/Legal Single-Sided $ .20 each
Black and White Copies Letter/Legal Double-Sided $ .40 each
Black and White Copies Tabloid Single-Sided $ .40 each
Black and White Copies Tabloid Double-Sided $ .80 each
Color Copies Letter Legal Single-Sided $1.50 each
Color Copies Tabloid Single-Sided $3.00 each
Audio Tapes:
CD/DVD/Cassette $5.00 each
Liquor Licenses:
Temporary Liquor License (processing fee) $10.00
Liquor License (new processing fee) $100.00
Liquor License (change of ownership processing fee) $75.00
Annual Renewal Liquor License $35.00
Taxicab Licenses:
New Certification application (one-time processing fee) $250.00
Annual Renewal of Certificate $200.00 (per vehicle)
Lien Searches: (fees set by Ordinance 2385 in 1986)
Routine requests $20.00
Rush/Fax Requests $30.00
Elections: (amount set by Resolution #2009-05)
Required deposit for Citizens Initiative $500.00
Street/Alley Vacations: (filing fee set by Resolution 1994-24)
Required deposit of filing fee $500.00
Ambulance:
Annual renewal fee $300.00
Annual ambulance fee (each vehicle) $100.00
Annexation:
Processing fee for County Department of Assessment $300.00
Research Fee: Refer to Section 12
on page 37
page 10 miscellaneous fees and charges
Section 3-Community Development
Planning/Community Development Miscellaneous Fees and Charges
Current Proposed
Pre-Application Conference: $130.00 $131.00
Administration Actions:
Final Plat Review:
Partitions* $130.00+$10/lot $131.00+SIO/lot
Subdivisions* $330.00+$28/lot $335.00+$28/lot
New Sign Permit $130.00+$2.50/sq ft $131.00+$2.50/sq ft
Replacement Sign Permit $28.00+$2.50/sq ft
Home Occupation Permits $28.00
Zoning permit (fence, accessory structure, etc.) $28.00
Land Use Approval Extension Request $330.00 $335.00
Lot Line Adjustments $330.00 $335.00
Any other Administrative Action $330.00 $335.00
Type I Reviews:
Tree Removal Permit (not associated with another action) $28.00
Solar Setback Variance $998.00 $1,012.00
Amendments to Conditions $998.00 S1,012.00
Physical & Environmental Constraints Permit $998.00 $1,012.00
Conditional Use Permit - Accessory Residential Unit $649.00 $658.00
Conditional Use Permit (Type I only) $998.00 51,012.00
Variance (Type I only) $998.00 $1,012.00
Residential Site Review $998.00+$66/unit 51,012.00+S67/unit
Final Plan Performance Standards $998.00+$66/unit 51,012.00+S67/unit
Land Partitions $998.00+$66/unit $1,012.00+S67/unit
Commercial Site Review $998.00+.5% of $1,012.00+,5% of
project value** project value**
Any other Type I Review $998.00 $1,012.00
Independent Review of Wireless Communication Facilities***$5000.00
Type II Reviews:
Conditional Use Permit (Type II only) $2,002.00 $2,032.00
Variance (Type II only) $2,002.00 52,032.00
Outline Plan or Preliminary Plat for Subdivisions $2,002.00+$134/lot $2,032.00+$136/lot
Final Plan with Outline $2,666.00+$134/lot $2,705.00+5136/lot
Commercial Site Review $2,002.00+.5% (.005) 52,032.00+.5%(.005)
of project value** of project value**
Any other Type 11 Review $2,002.00 $2,032.00
Independent Review of Wireless Communication Facilities*** $5000.00
*(Does not include Public 111orks review fee, See pg 27)
**Project value includes the estimated valuation of all structures (per State of Oregon Building Code), as well as all related
project site improvements, such as grading, paving, landscaping, bioswales, etc.
***The initial deposit required with an application for a new wireless communication facility that is not collocated is
$5,000, and shall be used by the City for the costs of expert review of the application. If any time during the planning ap-
plication process the account balance is less than $1,000, the Applicant shall upon notification by the City replenish the
account so the balance is at least $5,000. The maximum total consultant fees to be charged to the Applicant shall be
$10,000, and any unused portion of fee will be refunded.
miscellaneous fees and charges page 11
Section 3-Community Development
Type III Reviews: Current Proposed
Zone/Comprehensive Plan Map Change $2,666.00 $2,705.00
Comprehensive Plan Change $2,666.00 $2,705.00
Annexation $4,010.00 $4,070.00
Urban Growth Boundary Amendment $4,010.00 $4,070.00
Any other Type III Review $3,339.00 $3,389.00
Legislative Amendments:
Comprehensive Plan Map/Large Zoning Map Amendment $4,680.00 54,750.00
Land Use Ordinance Amendment $4,680.00 $4,750.00
Comprehensive Plan Amendment $4,680.00 $4,750.00
City Sponsored Legislation (City Council Directive) $0.00
Appeals:
Appeal for initial Public Hearing $150.00
(Building Appeals BoardlDemolition Review Board/Planning Commission)
Appeal for Final Decision of City $325.00
(Planning Commission or City Council)
Solar Access:
Solar Access Permit (not a Solar Variance) $50.00+$10.00
per lot affected
Community Development Fee:
This fee is charged concurrently with Building Permit . 1.1% (.011) of
Fees at the time of building permit application for all new construction
building permits requiring a plan review. per building code
definition of valuation
Community Development Copy Fees
Copy Fees:
Black and White Copies Letter/Legal Single-Sided $ .20 each
Black and White Copies Letter/Legal Double-Sided $ .40 each
Black and White Copies Tabloid Single-Sided $ .40 each
Black and White Copies Tabloid Double-Sided $ .80 each
Color Copies Letter/Legal Single-Sided $1.50 each
Color Copies Tabloid Single-Sided $3.00 each
Prepared Documents:
Site Design & Use Standards $5.00
Street Tree Guide $5.00
Transportation Element $5.00
Downtown Plans (2001, 1998) $5.00
Street Standards Guide $5.00
Comprehensive Plan/Land Use Code $40.00
Research Fee: Refer to Section 12 on page 37
page 12 miscellaneous fees and charges
Section 3-Community Development
Building Division Permit Fees for Commercial and Residential
In accordance with OAR 918-050-0030, the applicant for a building permit shall provide an estimate of con-
struction costs at the time of application. Permit valuations shall include value of all work, including mate-
rials and labor, for which the permit is issued. This estimate shall also include the cost of electrical, gas, me-
chanical, plumbing, and permanent equipment and systems. The City will also prepare an estimate of the
building valuation based on the current ICC Valuation table that is published and updated annually. The
building permit will.be based on the highest of these two estimates.
Building Permit Fees:
Total Value of Work Performed:
$1.00 to $500.00 $10.00
$501.00 to $2,000.00 $10.00 for the first $500.00 plus $1.50 for each
additional $100.00 or fraction thereof, to and
including $2,000.00
$2,001.00 to $25,000.00 $32.50 for the first $2000.00 plus $6.00 for each
additional $1000.00 or fraction thereof, to and
including $25,000.00
J
$25,001.00 to $50,000.00 $170.50 for the first $25,000.00 plus $4.50 for each
additional $1,000.00 or fraction thereof, to and
including $50,000.00
$50,001.00 to $100,000.00 $283.00 for the first $50,000.00 plus $3.00 for each
additional $1,000.00 or fraction thereof, to and
including $100,000.00
$100,001.00 and up $433.00 for the first $100,000.00 plus $2.50 for
each additional $1,000.00 or fraction thereof
Plan Review Fee for Commercial and Residential:
Plan Review Fee A plan review fee equal to 65% of the structural
permit fee shall be due at application
Additional Plan Review Fee $65.00 per hour
Deferred Submittal Fee 65% of structural permit fee of deferred submittal
valuation with a $50.00 minimum fee
Miscellaneous Fees for Commercial:
Commercial Fire Sprinkler/Fire Suppression/ Total value of work performed (structural permit
Fire Alarm fee)
Commercial Fire Sprinkler/Fire Suppression/ 65% of structural permit fee
Fire Alarm Plan Review
Note: See appendix for methodology for calculation of valuation for all permit fees utilizing valuation/
value of work
miscellaneous fees and charges page 13
Section 3-Community Development
Inspection Fees for Commercial and Residential:
Inspections for which no building permit applies $65.00 per hour;
(minimum 1 hour) per inspector
Re-inspection Fee $50.00
Inspections outside normal business hours (minimum 1 hr) $130.00 per hour;
perinspector
Chanee of Occupancv Fees:
Special Inspection:
Single Building $65.00 per hour; 1 hour
minimum
Multiple Buildings or Tenant Spaces in a building or on a
single lot $65.00 per building, per
inspector, per hour; 1 hour
Minimum
Special Inspection Report 565.00 per hour
Re-issued Certificate of Occupancy No Charge
Residential Plumbing Permit Fees
New Residential: Cost Each
1 bathroom/kitchen (includes: first 100 feet of water/sewer lines; hose bibs;
ice maker; under floor low-point drains; and rain-drain packages) $285.00
2 bathrooms/1 kitchen $345.00
3 bathrooms/1 kitchen- $405.00
Each additional bathroom (over 3) $45.00
Each additional kitchen (over 1) $45.00
Remodel / Alterations:
Remodel / Alterations (minimum fee) $40.00
Each fixture, appurtenance, and first 100 ft of piping $15.00
Miscellaneous Residential:
Minimum Fee $40.00
Piping or private storm drainage systems exceeding the first 100 feet $22.00
Backflow Assembly $15.00
Residential Fire Sprinkler (include plan review):
$2.44 x total square footage of structure = Sprinkler Valuation
(use Building Permit Fees Valuation Table on page 13 for fee calculation)
Manufactured Dwelling or Pre-Fab:
Connections to building sewer and water supply $50.00
RV and Manufactured Dwelling Parks:
Base fee (including the first 10 or fewer spaces) $150.00
Each additional 10 spaces $100.00
page 14 miscellaneous fees and charges
Section 3-Community Development
Commercial Plumbing Permit Fees
Commercial, Industrial, and Dwellings other than one - or two-family:
Minimum fee $40.00
Each fixture $15.00
Piping (based on number of feet) $0.75/11
Miscellaneous:
Minimum fee $40.00
Specialty fixtures $15.00
Re-inspection (no. of hrs. x fee per hour) $65.00
Special requested inspections (no. of hrs x fee per hour) $65.00
Medical gas piping:
Minimum fee $50.00
Valuation $500 to $2,000 $50.00 + $5 per $100 of valuation
Valuation $2,001 to $25,000 $125.00 + $18 per $100 of valuation
Valuation $25,001 to $50,000 $540.00 + $14 per $100 of valuation
Valuation $50,001 to $100,000 $890.00 + $9 per $100 of valuation
Valuation greater than $100,000 $1,340.00 + $8 per $100 of valuation
Residential Mechanical Permit Fees
Mechanical Permit Minimum Fee: $50.00
Furnace/Burner including ducts & vents:
Up to I00k BTU/hr. $12.00
Over 100k BTU/hr. $15.00
Heaters/StovesNents:
Unit Heater $15.00
Wood/pellet/gas stove/flue $15.00
Repair/alter/add to heating appliance or refrigeration $12.00
unit or cooling system/absorption system
Evaporated cooler $15.00
Vent fan with one duct/appliance vent $7.50
Hood with exhaust and duct $10.00
Floor furnace including vent $15.00
Gas Piping:
One to four outlets $6.00
Additional outlets (each) $0.75
Air-handling Units, including Ducts:
Up to 10,000 CFM $10.00
Over 10,000 CFM $15.00
miscellaneous fees and charges page 15
Section 3-Community Development
Compressor/Absorption System/Heat Pump:
Up to 3 hp/100K BTU $15.00
Up to 15 hp/500K BTU $25.00
Up to 30 hp/1,000 BTU $50.00
Up to 50 hp/1,750 BTU $60.00
Over 50 hp/1,750 BTU $75.00
Incinerator:
Domestic incinerator $25.00
Commercial Mechanical Permit Fees
Minimum Fee $50.00
Total valuation of mechanical system and installation costs 0.5% of valuation
Miscellaneous Fees:
Re-inspection $50.00
Specially requested inspection (per hour) $65.00
Regulated equipment (un-classed) $50.00
Electrical Permit Fees
Residential per unit, service included: Cost Each
1,000 sq. ft. or less $106.00
Each additional 500 sq. ft. or portion thereof $19.00
Limited energy $25.00
Each manufactured home or modular dwelling service or feeder $50.00
Multi-family residential $45.00
Residential and Commercial-Services or Feeders: installation, alteration, relocation:
200 amps or less $63.00
201 to 400 amps $75.00
401 to 600 amps $125.00
601 to 1,000 amps $163.00
Over 1,000 amps or volts $375.00
Reconnect Only $50.00
Temporary Services or Feeders:
200 amps or less $50.00
201 to 400 amps $69.00
401 to 600 $100.00
Over 600 amps or 1,000 volts, see services or feeders section above
Branch Circuits: new, alteration, extension per panel:
Branch circuits with purchase of a service or feeder $3.00
Branch circuits without purchase of a service or feeder:
First branch circuit $43.00
Each additional branch circuit $3.00
page 16 miscellaneous fees and charges
Section 3-Community Development
Miscellaneous Fees: service or feeder not included:
Each pump or irrigation circle $50.00
Each sign or outline lighting $50.00
Signal circuit or a limited energy panel, alteration or extension $50.00
Specially requested inspection (per hour) $65.00
Each additional inspection over the allowable $50.00
Residential Restricted Energy Electrical Permit Fees
Fee for all systems*: $25.00
Audio and stereo systems
Burglar alarm system
Doorbell
Garage-door opener
Heating, ventilation, & air-conditioning systems
Landscape lighting & Sprinkler controls
Landscape irrigation controls
Outdoor landscape lighting
Vacuum Systems
Each additional inspection $25.00
*For new construction, this permit fee covers all systems
listed or can be sold separately.
Renewable Energy Systems:
5 KVA or less $79.00
5.01 KVA to 15 KVA $94.00
15.01 KVA to 25 KVA $156.00
Wind generation systems in excess of 25 KVA:
25.01 KVA to 50 KVA $204.00
50.10 KVA to 100 KVA $469.00
For wind generations systems that exceed 100 KVA the permit fee shall be calculated in accordance with
OAR 918-309-0040
Solar generation systems in excess of 25 KVA: $6.25/KVA
The permit charge will not increase beyond the calculation for 100 KVA. Permits issued under this sub-
section include three inspections. Additional inspections will be billed at an hourly rate.
Building Permit Reinstatement Fee
A building permit expires after a period of 180 days from the date of issue with no inspection activity.
To reactivate an expired permit, a fee.of $50.00 per construction discipline is required (Building, Plumb-
ing, Mechanical, Electrical).
State of Oregon Surcharge - ORS 455.210(4)
State of Oregon permit surcharge is 12% of structural, plumbing, mechanical and electrical components
of the overall building permit.
miscellaneous fees and charges page 17
Section 3-Community Development
Excavation/Grading Fees
See attachment 1. Exhibit A, Resolution 2006-19 (page 40)
Building Permit Refund Policy
The City Ashland Community Development Department offers partial refunds for building permits that
,have been issued, have had no inspections performed and have not yet expired (six months from issue
date). Refunds for permits that have expired are limited to any Systems Development Charges (SDC's)
that were part of the permit fees.
The following fees are not refundable:
• Building Plan Check Fee
• Fire Protection Review Fee
• 50% of Community Development Fee (maximum equal to Building Plan Check Fee)
• 50% of Engineering Development Fee (maximum equal to Building Plan Check Fee)
The remainder of the permit fees are refundable. A $50 administrative fee will be subtracted from the
eligible refund amount for costs associated with the refund process. Refund amounts can be placed on
account for future use and no administrative fees are charged.
How to request a refund
Submit the following documents to the Community Development Department at 51 Winburn Way:
• Approved set of plans (stamped)
• Job Inspection card
• Letter of refund request signed by applicant/owner with mailing address for refund check
The refund will be processed within 30 days of the date of the request letter.
page 18 miscellaneous fees and charges
Section 4-Electric
Electric Miscellaneous Fees and Charges
Temporary Service Drop:
Current Proposed
Single Phase Underground temp 300 amps or less $245.00 5247.00
Single Phase Overhead temp 300 amps or less $291.00 5295.00
Three Phase Actual Cost
Meter Charges:
Meter Tests for accuracy:
Once in twelve months No Charge
Two or more times in twelve months $172.00 S176.00,
Meter repairs/replacement (Damaged by Customer) Actual Cost
Non Radio Frequency Meter Charges:
Conversion from Radio Frequency (RF) to Non RF meter No Charge
Monthly Fee to manually read Non RF meter No Charge
Non Sufficient Funds Check Fee: $35.00
Reconnection Charge:
Normal working hours $25.00
Other hours or Holidays $100.00
Service Calls:
Once in twelve months No Charge
Two or more times in twelve months $199.00 S203.00
Other hours or Holidays $297.00 5303.00
Service Connection for Applicant:
Normal working hours $10.00
Other hours or Holidays $100.00
Deenergize Service NA 5254.00
Scheduled work after hours: Actual Cost
Unauthorized Connection: $215.00
miscellaneous fees and charges page 19
Section 4- Electric
Line Extension Charges
New Single-Family Residential Service: Current Proposed
Overhead service in existing developed areas
from distribution line to and including meter $568.00
Overhead service upgrade or increased
service for 300 amps or less $568.00
Replacement of service from overhead to underground,
300 amps or less. Customer provides all trenching,
conduit, backfilling and.compaction
as directed by the City. $1,161.00
Underground residential service of 300 amps or less.
Customer provides conduit, trenching, back fill,
compaction as directed by the City. $695.00
*Underground Distribution Installation Charges: Per Lot
less house service and engineering fees. $1,158.00 51,186.00
*Subdivisions of 0 to 20 engineering fee per lot $167.00 5171.00
* Subdivisions of 21+ engineering fee per lot $253.00 $259.00
*Three Phase subdivision as required by city per lot $253.00 5259.00
Any overhead/underground service over 300 amps Actual Cost
Commercial, Institutional and Industrial Service Actual Cost
**Blower Door Leak Test (gas heat customers only) $75.00
**Duct Leak Test (gas heat customers only) $125.00
* Methodology: Current ENR Rate - Old ENR Rate/Old ENR Rate = % Rate of Adjustment
(9515.86-9289.65)/9289.65 = 2.44%
Source: Engineering News Record Construction Cost Index (ENR)
**Electric heat customers = no fee
miscellaneous fees and charges page 20
Section 5-Fire
Fire Miscellaneous Fees and Charges
Copy Fees: Current Proposed
Black and White Copy Letter/Legal Single Sided $ .20 each
Black and White Copies Letter/Legal Double Sided $ .40 each
Black and White Copies Tabloid Single Sided $ .40 each
Black and White Copies Tabloid Double-Sided $ .80 each
Color Copy Letter/Legal Single Sided $ 1.50 each
Color Copy Tabloid $ 3.00 each
Report Fees:
Non patient
Pre-hospital Care Reports $12.00 for 10 pages or less
$15.00 over 10 pages
Fire Incident Reports $12.00 for 10 pages or less
$15.00 over 10 pages
Photographs $12.00 per case request
CD/DVD $19.00 per case request
1
Mailing Cost Actual Cost
Research Fee: Refer to Section 12
on page 37
Fire Fees:
Cost Recovery Equipment *Per Current Oregon State
Fire Marshal Standardized
Cost Schedule
Personnel *$50.00 per person per hour - 2
Hour minimum per person
Hazardous Materials Cleanup Actual Cost
Emergency Medical Services:
FireMed Annual Household Fee-Annual Renewal $55.00 per year
FireMed Plus Annual Household Fee-Annual Renewal $95.00 per year
Emergency Medical Service Fee -Aid Call $302.40 per patient 5305.42
Ambulance Base Rate (per current rate schedule) $1,029.54 per patient SI,039.84
Ambulance Mileage Rate (per current rate schedule) $14.00 per mile
Ambulance Base rate for sit-up patients $514.77 per patient 5519.92
Ambulance Waiting Time $25.00 per 1/2 hour
Ambulance Stand By (2 hour minimum) $100.00 per hour
On scene Coordinator $50.00 per hour
Extra attendant $45.00 each
Ambulance Service Area 1112013 rate schedule
Base rates hill be adjusted each calendar year by the most current rate schedule posted by the Center for Medicare/
Medicaid Semites (CMS) that sets the "Ambulance Inflation Factor" . Other rates and mileage charges hill be updated as
approved by the County Commissioners.
miscellaneous fees and charges page 21
Section 5-Fire
Fire and Life Safety:
Plan Checks:
Any Building Permit - 24% of the Building Division Structural Permit Fee and Plan Check Fee
New Subdivision or Land Partition - 24% of the Engineering Subdivision Plat Check Fee
Other:
Fire Hydrant Flow Tests required for new installations will be assessed at $100 per flow test.
Any review required by the Oregon Fire Code, and which does not involve a building permit, will be
charged at the rate of $50.00 per hour. A minimum charge of $25.00 will be assessed to these reviews.
When the Building Division assesses additional fees for plan reviews and/or field inspections, any fire
department staff time associated with that activity will be included in their fees at their specified rate.
First Aid/CPR Classes: Current Proposed
Basic Life Support (BLS) for Healthcare Providers CPR Class $55.00/person
Heart Saver CPR & First Aid Class $55.00/person
Heart Saver CPR Class $35.00/person
Family and Friends CPR Class $5.00/person
Inspection Fees: Initial Inspection (Re-inspection Included)
Occupancy Type
"B" 0-1,000 sf. $34.00 535.00
1,001-3000 sf. $51.00 552.00
Occupancy Type
"A, E, F, H,1, M, S" 0-3,000 sf. + B 1,001-3,000 $51.00 $52.00
Occupancy Type
"A,B, E, F, H,1, M, S" 3,001-10,000 sf. $100.00 $102.00
10,001-20,000 sf. $150.00 5152.00
Over 20,000 sf. $200.00 $203.00
Occupancy Type "R, SR" 3 to 10 Units $51.00 $52.00
11 to 40 Units $100.00 5102.00
41 to 70 Units $150.00 5153.00
Over 70 Units $200.00 5203.00
Non-Compliance after 2nd Inspection
Inspection Fee + $53.00 554.00
Non-Compliance after 3rd Inspection
Inspection Fee + $105.00 $107.00
Non-Compliance after 4 s Inspection /
Subsequent Inspections Inspection Fee + $156.00 5158.00
Weed Abatement:
Staff time Refer to Section 12
on page 37
Mailing Cost Actual Cost
Weed Abatement by Contractor Actual Cost
page 22 miscellaneous fees and charges
Section 6-Information Technology
Information Technology Miscellaneous Fees and Charges*
Installation Fees:
Basic installation-Pre-wired CATV outlets only $ 20.00
(Additional charges for parts and supplies apply)
Add Trap ("filter") $10.00
New customer cable modem activation $10.00
Cable Modem $50.00
Refurbished 90 -day replacement warranty
Additional materials $10.00
Over-and-beyond regular installation' including
multi outlets, outlet plates, additional wiring,
replacement of customer damaged outlets.
Wi Max standard installation S200.00
Disconnect Fees:
Disconnect $50.00
Remove Trap ("Filter") $10.00
Truck Roll: $35.00
Field Technician Hourly Rate:
Non-standard work such as advancing troubleshooting, $55.00
non-standard outlets, fishing wire inside walls, etc.
Consulting and Technical Support Hourly Rate:
For support issues not related to AFN infrastructure, performance, $85.00
and reliability. Minimum charge on hour.
Non-City Employee Staff Screening:
Charge for each vendor employee submitted for authorization to
Access AFN and City Service Center facilities. $150.00
Fiber Service Installation:
Minimum one-time fee fe; overhead served eenneetion . indfli ideal n.._:____
1000* feet of existing use, hend AFN fibut rictnui k ~i *11 be chniged by quole.
Overhead served connections. Individual Business Case
(IBC) & quote
Underground served connections IBC & quote
Ethernefffa„ansit-Fees-
Transit @ 100 Mbps IBC & quote
miscellaneous fees and charges page 23
Section 6-Information Technology
Static IP Address: $5.00/mo each
Maximum of 5 Static Internet Protocol (IP) addresses*
• Minimum level of service for static IP and Quality of Service (QoS) is
"CHOICE" or higher service tier.
QoS Fee: $3.50/mo
VOIP (phone) enhancement available with AFN
Choice or higher service level through AFN certified
Modems.
Business Augmented Upload Package (additional 5 Mbps): $15.00/mo
Available exclusively on AFN Directwith the following requirements-
CUFFeRtCotyof,ksh'nndBusonessEceise
=-Business Augmented Uplend Peeliage available eulY ithi
Small OfficelHonre Office (SOHO) or Small Business
Must have current City of Ashland Business License
*Additional fee added to base AFN Direct retail rates on specific packages.
Maximum SOHO upload speed with augmented upload service at up to 9 Mbps
Small Office/Home Office Business Augmented Upload Package @$80/month
Maximum Small Business upload speed with augmented upload service at up to 10 Mbps
Small Business Augmented Upload Package @ $100.00/month
Non-return of customer premise equipment (CPE) devices: $300.00
CPE's must be returned on disconnect date of AFN Any n hm and/or
services.
Cable TV (CATV) Seasonal Reconnects & Disconnects: $10.00/visit
Non-pay disconnects & reconnects
Service change
Install HBO filter
CAN House Amp Fee: $35.00/each
Utility Billing Lobby Signage Fee: $100.00/mo.
Cable Modem Rental $5.00/mo.
Non Return of Rented Modem at Closing of Account $50.00each
Cable Modem Purchase $50.00/each
* Resolution 2010-28 (Section 2, page 38) grants Information Technology management ability to set promotional rates.
page 24 miscellaneous fees and charges
Section 7-Municipal Court
Transit @ 1000 Mbps Municipal Court Miscellaneous Fees and Chifdds quote
Court Administration Fees: Crime Violation
Appeal Transcript Fee $35.00 $10.00
City Attorney Deferred Sentence/Diversion $60.00 540:90 N/A
Civil Compromise Costs $75.00 N/A
Compliance Inspection Fee N/A $25.00
Court Appointed Counsel Fees and Charges Billed ranging from $250 - $600
Default Judgment N/A $15.00..
Discovery Fees Imposed in Accordance with
Miscellaneous Fee & police Department Resolutions See Police and City Recorder Fees
Diversion by Municipal Court: Classes I-IV, A-D
Unclassified and Specific Fine Violations N/A Presumptive Fine
Extend/Amend City Attorney Deferred Sentence/Diversion $45.00 S45.00 N/A
Failure to appear for Bench Trial/Show Cause hearing $90.00 $70.00
Failure to Appear for Jury Trial $150.00 N/A
Forfeiture of Security $25.00 $25.00
Mediation of Violation (Municipal Court Mediation) N/A $65.00
Non Sufficient Funds Check $25.00 $25.00
Court Costs $35.00 $45.00
Expunction $240.00 $240.00
Show cause Admission of Allegation $25.00 SiO.0 N/A
Bench Probation Fee $100.00 N/A
Bank Costs
Warrant $25.00
10% at monthly
Withholding
Other
Domestic Partnership Registration $25.00
All other fees and charges inconsistent with the fees and charges set forth herein are repealed. Nothing in
the Resolution is intended to detract from the inherent power of the Court pursuant to general law to im-
pose fees and charges established in state law of city ordinance in addition to the fees and charges speci-
fied herein.
master miscellaneous fees and charges page 25
Section 8-Police
Police Miscellaneous Fees and Charges
Current Proposed
Police Reports: $12.00 for reports 10 pages or less
$15.00 for reports over 10 pages
Research Fee: Refer to Section 12
on page 37
Visa Letters: $19.00
Fingerprints Cards: $20.00 first card 535.00 first card
$10.00 each additional card
Photographs (CD): $19.00
Audio Tapes/
ICOP Videos: $19.00
Non Sufficient Funds Check Fee: $35.00
Impoundrrow Fee: $105.00 Cash only
Taxi Operator License: $20.00 renewal
$42.00 new
page 26 miscellaneous fees and charges
Section 9-Public Works
Public Works Miscellaneous Fees and Charges
Copy Fees: Current Proposed
Black and White Copies Letter/Legal Single-Sided $0.20 each
Black and White Copies Letter/Legal Double-Sided $0.40 each
Black and White Copies Tabloid Single-Sided $0.40 each
Black and White Copies Tabloid Double-Sided $0.80 each
Color Copies Letter/Legal Single-Sided $1.50 each
Color Copies Tabloid Single-Sided $3.00 each
Existing maps printed in color on HPI055CM plotter (24Ib bond Paper)
Arch C 18 x 24 3.00 sq. ft. $18.00
Arch D 24 x 36 6.00 sq. ft. $36.00
Arch E 36 x 48 12.00 sq. ft. $72.00.
Existing maps or copies of existing maps copied in B&W on Xerox 3030 large format copier
(201b bond paper)
Arch C 18 x 24 $8.00 S2.00
Arch D 24 x 36 $12.00 S3.00
Arch E 36x48 $16.00 $4.00
Note: Maps printed on materials other than the specified bond are double the standard print fee
Plat & Plan Checks: Current Proposed
Subdivision Plats
(does not include planning review fee See page 11)
$730.00 plus $741.00 plus
$110.00 per lot '$112.00 per lot
Condominium Plats $730.00 plus $741.00 plus
$110.00 per lot 5112.00 per lot
Partition Plats
(does not include 24% Fire Department Review Fee) $391.00 5397.00
Subdivision Improvement Plat Check 5% Engineer Fee (5% of
the public improvement
cost)
Engineering Development Fee
(this fee is charged concurrently with Building Permit
Fees at the time of building permit applications. Applies
To all new residential dwelling units and commercial 0.75% of valuation
Developments. Remodels, additions and accessory
Buildings are not assessed this fee.)
miscellaneous fees and charges page 27
Section 9-Public Works
Public Works/Engineering Inspections, Permits, etc:
Current Proposed
Subdivision Construction Inspection/ 5% Engineer Fee (5% of
Public Works Improvement Inspection the public improvement cost)
Street or Alley Excavation Permit $197.00 + per ft. cost S200.00+
based on pavement age
Encroachment Permit $197.00 5200.00 .
Miscellaneous Construction Permit $64.00 565.00
(Construction of curb, sidewalk, driveway
Apron, etc.)
Dust Suppression Permit $64.00 S65.00
Driveway Painting Permit $16.00
(includes a can of paint)
Right-of Way Closure-Street $197.00 5200.00
Right-of Way Closure-Sidewalk(>72 hrs) $64.00 565.00
Right-of Way Closure-Sidewalk(<72 hrs) $16.00
Right-of Way Closure-Parking Space(>72 hrs) $64.00 $65.00
Right-of Way Closure-Parking Space(<72 hrs) $16.00
Block Party $16.00
Sidewalk Dining-Annual Renewal $4.00/sq. ft. 54.50/sq. ft.
(minimum 50 sq. ft) 1st increase in 4 yrs
Functional Item-Annual Renewal $64.00 565.00
Special Event Permits (per Resolution 2012-08):
Base Special Event Permit Fee (plus applicable $130.00 5132.00
Fees below) Events that require city staff overtime 60% of city staff O/T 60% of city staff
Rush Fee (less than 90 days advance notice) $250.00
page 28 miscellaneous fees and charges
Section 9-Public Works
Public Works/Engineering Inspections. Permits, etc. (cont)
Current Proposed
Loaned Functional Item, Pennant Application Fee $133.00 5135.00
Publication Box Per Publication-Annual Renewal $27.00
Special vehicle Permit-Initial Fee $272.00 $276.00
Special vehicle Permit-Annual Renewal $109.00 $111.00
Penalty for No Permit 150% of permit cost
Street or Alley Vacation $659.00 5669.00
An administrative fee of 25% will be assessed on all permit refunds. Refunds will not be issued
if requested later than one-year following the application date.
GIS Data & Mapping Services:
GIS Hourly Rate $80.00 S81.00
Information on Disk $40.00/utility per 541.00/utility per
Quarter section Quarter section
Planning Pre-Application Maps $22.00
Plotting Fee $6.00/square foot
New Address Assignment $37.00/address # 538.00/address #
Street Name Approval Fee $105.00 5107.00
miscellaneous fees and charges page 29
Section 9-Public Works
Sanitary Sewer Connection Fees: Current Proposed
Sanitary sewer mainline video inspection $317.00 minimum $325.00 minimum
(cost based on time and materials)
Water Connection Fees:
The installation of all new water services and large taps regardless of size will be charged on a time and
materials basis.
First Utility Locate at an address No Charge
Additional Locates at same address $69.00 $71.00
Water meter re-lead
Once in 12 months No Charge
Each additional re-read in 12 months $31.00 $32.00
Water Meter Field Test $49.00 $56.00
Water Meter Bench Test
3/4" or 1" Water Meter $107.00 $110.00
1 1/2" or 2" Water Meter $201.00 $206.00
Larger Meters Actual Cost
page 30 miscellaneous fees and charges
Section 9-Public Works
Water Connection Fees Continued Current Proposed
Water pressure check once in 12 month No Charge
Each additional pressure check in 12 months $39.00 $40.00
Water Chlorination Test -Subdivision retest
upon failure (cost based on time and materials) $636.00 5653.00
Water Pressure Test -Subdivision retest up
failure (cost based on time and materials) $381.00 S391.00
Cemetery Fees:
Sales of grave spaces or burial plots:
(fees split, 40% to the cemetery fund & 60% to the cemetery trust fund)
Grave Space -Lawn and Monument Sections $506.00 5514.00
Grave Space -Baby Land $160:00 $162.00
Grave Space -Niches (bronze) $428.00 $434.00
Grave Space -Urn garden $160.00 5162.00
Grave space -Crypt $1,071.00 51,087.00
Sales of liners and markers:
(fees split, 40% to the cemetery fund & 60% to the cemetery trust fund)
Concrete cemetery box, including setting $428.00 5434.00
Concrete liners Cost plus 10%
Final inscriptions $125.00 min charge 5158.00 min charge
Niche Vases* $160.00 5162.00
Grave markers Wholesale cost X 2.5
not to exceed $700.00
Grave marker setting, concrete base $160.00 $162.00
Monticello burial vault (sealed concrete) $1,178.00 51,196.00
*Previously not in book.
miscellaneous fees and charges page 31
Section 9-Public Works
Sexton Fees:
Current Proposed
Opening and closing graves, ground $428.00 $434.00
Opening and closing graves, double-deep $481.00 $488.00
Opening and closing graves, infant $160.00 5162.00
Opening and closing crypts $428.00 5434.00
Opening closed crypts $428.00 5434.00
Opening and closing niches $108.00 5110.00
Opening closed niche NA 5110.00
Inter cremains in grave spaces $160.00 S162.00
Scattering of cremains $108.00 5110.00
Disinterment $1,050.00/in advance 51,081.00/in advance
Saturday, Sunday or Holiday burial $428.00 $434.00
Miscellaneous Fees:
Grave Setup Rental $106.00/occurrence 5108.00/occurrence
Tent Rental $53.00/day 554.00
Perpetual care lots, sold before 1927 $108.00 S110.00
Vases:
Galvanized $43.00 544.00
*cemetery fees will be subject to a 1.5% finance charge per month if not paid within 60 days of use. All above
services will be sold pre-need in installments, interest free, with a minimum payment of one-twelfth of the total
sale.
2013 CPI and ENR Calculations:
Methodology: Current CPI Rate - Old CPI Rate/Old CPI Rate = % Rate of Adjustment
(232.773-229.292)/229.292= 1.5% (236.293-232.773)/232.773=1.5%
Methodology: Current ENR Rate - Old ENR Rate/Old ENR Rate = % Rate of Adjustment
(9455.98-9267.57)/9267.57= 2.00/6 (9701.96-9455.98)/9455.98=2.6%
CPI used for: ENR used for:
Plat & Plan Checks Sanitary Sewer Connection Fees
Public Works/engineering Inspections, Permits, etc. Water Connection Fees
GIS Data & Mapping Services
Cemetery Fees
page 32 miscellaneous fees and charges
Section 10 - Parks and Recreation
Jar&
ASHLAN[D.
PARKS-
RlEC::RlEAYIC3N
Section 10
Parks and Recreation
Miscellaneous Fees and Charges
miscellaneous fees and charges page 33
Section 10-Parks and Recreation
Parks Miscellaneous Fees and Charges
Current Proposed
Wedding Packages:
Lithia Park Sites $800.00/8 hrs.
$400.00/4 hrs.
Community Center $1,150.00 park site included
Pioneer Hall $1,150.00 park site included
Group Picnic Rentals:
Cotton Memorial Area $75.00/4 hrs.
Madrone Area $60.00/4 hrs.
Top Southern Lawn $55.00/4 hrs.
Hillside Picnic Area $55.00/4 hrs.
Sycamore Grove $75.00/4 hrs.
Brinkworth Area $60.00/4 hrs.
Lawn below Upper Duck Pond $60.00/4 hrs.
Butler Bandshell $220.00/8 hrs.
Deposits:
Picnic Areas $75.00
Lithia Park Weddings $75.00
Butler Bandshell $190.00
Buildings Security $300.00 for events (refundable)
$150.00 for meetings (refundable)
Special Event Fees:
Special Event Application Fee (preriousryr ondrted) N/A 525.00
Street Closure Fee $75.00
Park Booth fee $25.00/per booth (max. 10)
Alcohol Fee: $150.00 (non-refundable)
General Building Reservations:
The Grove Full Facility $41.50/hr. on weekdays
$50.00/hr. on weekends
The Grove Otte/Petterson $22.50/hr. on weekdays
$25.00/hr. on weekends
Hunter Park Senior Center $21.00/hr. on weekdays
$33.00/hr. on weekends
Long Term User Fee $18.001hr. (at least 6 days/yr)
Oak Knoll Golf Course $21.00/hr. on weekdays
$33.00/hr. on weekends
Pioneer Hall/Community Center $21.00/hr. on weekdays
$33.00/hr. on weekends
Miscellaneous Equipment Fee $100.00
Field Usage:
Tournaments $36.50/day each team
Ball field Lights $31.00/hr S34.00/hr
page 34 miscellaneous fees and charges
Section 10-Parks and Recreation
Calle Seating: Current Proposed
Artisans $5.00/sq.foot S7.00/sq.foot
Restaurant Seating $6.00/sq. foot
Daniel Meyer Pool:
Admission $2.00
Lap Swim $2.50
Water Aerobics $3.25
Swim Lessons S40542548 (adjusted in 2012)
(age of child/length of lesson)
Private Lessons $18.00
Open Swim punch card $30.00
Lap Swim punch card $40.00
Water Aerobics punch card $55.00
Season Pass $140.00
Youth Recreation Programs: 60/40 split with instructor and Parks Department
Adult Recreation Programs: 60/40 split with instructor and Parks Department
Ashland Rotary Centennial
Ice Rink:
Youth Admission $3.50
Adult Admission $4.00
Skate Rental $2.50
ffacke3 Admission S5.50
Adult Hockey Admission (preriouslr ontitted) NA 55.50
Youth Hockey Admission (preriouslP ondned) NA $5.00
Adult Hockey Punch Card (preriouslr omitted) NA 550.00
Youth Hockey Punch Card (preriouslr omitted) NA $45.00
Open Skate/Kids Only Punch Card (prerionstromitted) NA 530.00
Ice Skating Private Lesson (prerious!r on,itled) NA 510.00 per 30mins
Helmets (preriouslr omitted) NA 58.00
Group Rental $5.00
Oak Knoll Golf Course
Annual Passes:
Annual Pass-Single $1,100.00
Annual Pass-Family $1,540.00
Daily Adult Fees (ages 18 to 54)
9 Holes: November-February $14.00
March-October $16.00
18 Holes: November-February $20.00
March-October $24.00
Daily Coupon Rate $10.00
miscellaneous fees and charges page 35
Section 10-Parks and Recreation
Daily Senior Fees (ages 55 & up)
Monday-Friday Only
9 Holes: November-February $12.00
March-October $14.00
18 Holes: November-February $18.00
March-October $22.00
Daily Junior Fees (ages 8 to 17)
9 Holes: Year-Round $5.00
18 Holes: Year-Round $10.00
Driving Range One token (35) balls $3.00
Cart Fees (per person)
9 _Holes: Year Round $10.00
Year Round Senior rate $8.00
18 Holes: Year Round $13.00
Community Garden Fees: IOx10 $29.00-$34.50 depending on location
10x20 $49.00-$57.50 depending on location
20x20 $75.00-$86.50 depending on location
4x12 $29.00
Refundable Deposit $20.00
Nature Center School Programs: $200.00/Class
Nature Center Community Programs: 70/30 split with instructor
and Parks Department
Oak Knoll Golf Course
Wedding Fees: November-February $1,500.00 - full day
November-February $800.00 - half day
March-October $750.00 - full day
March-October $400.00 - half day
Maps: City of Ashland Map $3.00 (or 2 maps for $5.00)
Watershed Map $3.00 (or 2 maps for $5.00)
page 36 miscellaneous fees and charges
Section 11-Rates and Charges Set by Separate Resolutions
Rates and Charges Set by Separate Resolutions Listed Below* .
System Development Charges (SDCs)
Parks and Recreation SDCs -Resolution 2000-29
Transportation SDCs -Resolution 1999-42
Sewer SDCs -Resolution 2006-27
Storm SDCs -Resolution 2002-15
Water SDCs -Resolution 2006-27
Utility Rates and Fees
AFN Utility Fees -Resolution 2010-28
Electric Rates - Resolution 2013-34
Sewer Rates -Resolution 2013-12
Storm Drain Fees -Resolution 2013-13
Transportation Fees -Resolution 2013-14
Water Rates -Resolution 2013-11
SECTION 12 - Research Fee
A. The City shall charge a research fee based on the hourly wage of the staff person doing the re
search, and the fee shall be billed in fifteen minute increments. The hourly wage used to calcu-
late the research fee shall not include the cost of benefits. The City will establish a fee in its an-
nual fee resolution that is reasonably calculated to reimburse the City for the actual cost of mak-
ing public records available, including locating the requested records, reviewing the records to
delete exempt material, supervising a person's inspection of original documents to protect the
integrity of the records, summarizing, compiling, or tailoring a record, either in organization of
media, to meet the person's request.
The City may charge for search time even if it fails to locate any records responsive to the
requester even if the records located are subsequently determined to be exempt from disclosure.
Copies of documents provided by a routine file search of 15-30 minutes or less will be charged at
a copy rate established in the annual fee resolution.
B. The City may include a fee established to reimburse for the costs of time spent by the city
attorney in reviewing the public records, redacting materials from the public records into exempt
and nonexempt records. The City fee may also include the cost of time spent by an attorney for
the City in determining the application of the provisions of ORS 192.505.
C. The City may not establish a fee greater than $25 unless the requester is provided with written
notification of the estimated amount of the fee and the requester confirms in writing that he/she
wants the City to proceed with making the records available.
D. Prepayment shall be required if the amount of the request is greater than $25. If the actual
charges are less than the prepayment, and overpayment shall be refunded.
*All of the above resolutions can be found in full text on the City of Ashland's Website:
http://0shlandor.us
miscellaneous fees and charges page 37
Section 13 - Building Valuation Data
Community Development Department -Building Safety Division
Methodology for calculation of permit valuation
Icc INTERNATIONAL
11 COUNCIL Building Valuation Data - February 2014
The International Code Council is pleased to provide the does not take into account any regional cost differences. As
following Building Valuation Data (BVD) for its members. The such, the use of Regional Cost Modifiers is subject to the
BVD will be. updated at six-month intervals, with the next authority having jurisdiction.
update in August 2014. ICC strongly recommends that all Permit Fee Multiplier
jurisdictions and other Interested parties actively evaluate and
assess the impact of this BVD table before utilizing it in their Determine the Permit Fee Multiplier;
curent code enforcement related activities. 1. Based on historical records, determine the total annual
The BVD table provides the 'average' construction costs per construction value which has occurred within the
square, foot, which can be used in determining permit fees for jurisdiction for the past year.
a jurisdiction. Permit fee schedules are addressed in Section . 2 Determine the percentage of the building
109,2 of the 2012 International Building Code (IBC) whereas - department budget expected to be provided by building
Section 109.3 addresses building permit valuations. The
permit fees can be established by using the BVD table and a permit revenue.
Permit Fee Multiplier, which is based on the total construction Bldg. Dept. Budget z
value within the jurisdiction for the past year. The Square Fool Permit Fee Multiplier =
Construction Cost table presents factors that reflect relative Total Annual Construction Value
value of one construction class cation/occupancy group to Example
another so that more expansive construction is assessed The building department operates on a $300,000 budget, and
greater permit fees than less expensive construction.
it expects to cover 75 percent of that from building permit fees.
ICC has developed this data. to aid.jurisdictions in determining The total annual construction value which occurred within the
permit fees. It is important to note that while this BVD table jurisdiction in the previous year is $30,000,000.
does determine an estimated value of a building (i.e., Gross S300,000 x 75%
Area z Square Foot Constriction Cost), this data is only Permit Fee Multiplier = - = 0.0075
intended to assist jurisdictions in determining their permit fees. $30,000,00.0
This data table is not intended to be used as an estimating
guide because the data only reflects average costs and is not Permit Fee
representative of specific construction. The permit fee is determined using the building gross area, the
This degree of precision is sufficient for the intended purpose, Square Foot Construction Cost and the PermitFee Multiplier.
which is to help establish permit fees so as to fund code PermitFee = Gross Area x Square Foot Construction Cost
compliance activities, This BVD table provides jurisdictions x Permit Fee Multiplier
with a simplified way to determine the estimated value of a Example
building that does not rely on the permit applicant to determine
the cost of construction. Therefore, the bidding process for a Type of Construction: IIB
particular job and other associated factors do not affect the Area: 1st story= 8,000 sq. ft.
value of a building for determining the permit fee. Whether a 2nd story = 8,000 sq. ft.
specific project is bid at a cost above or below the computed Height 2 stories
value of construction does not affect the permit fee because Permit Fee Multiplier = 0.0075
the cost of related code enforcement activities is not directly Use Group: B
affected by the bid process and results. -
- 1. Gross area:
Building Valuation Business = 2 stories x 8,000 sq. ft..= 16,000 sq. ft.
The following building valuation data represents average 2. Square Foot Construction Cost:
valuations for most buildings. In conjunction with IBC Section B/IIB = $158.70/sq. ft.
109.3, this data is offered as an aid for the building official to
determine If the permit valuation is underestimated. Again it 3. Permit Fee:
should be noted that, when using this data, these ere Business = 16,000 sq. ft. x $158.70/sq. ft x 0.0075
'average' costs based on typical construction methods for -$19,044
each occupancy group and type of construction. The average
costs include foundation work, structural and nonstructural
building components, electrical, plumbing, mechanical and
interior finish material. The data is a national average and
page38 miscellaneous fees and charge
Section 13 - Building Valuation Data
Important Points For purposes of establishing the Permit Fee Multiplier, the
The BVD is not intended to apply to alterations or repairs estimated total annual construction value for a given time
to existing buildings. Because the scope of alterations or period (1 year) is the sum of each building's value (Gross
repairs to an existing building varies so greatly, the Square Area x Square Foot Construction Cost) for that time period
foot Construction Costs table does not reflect accurate (e.g., 1 year).
values for that purpose. However, the Square Foot The Square Foot Construction Cost does not include the
Construction Costs table can be used to determine the price of the land on which the building is built.. The Square
cost of an addition that is basically a stand-alone building
which happens to be attached to an existing building. In Foot Construction Cost takes into account everything from
the case of such additions, the only alterations to the foundation work to the roof structure and coverings but
existing building would involve the attachment of the does not include the price of the land. The cost of the land
addition to the existing building and the openings between does not affect the cost of related code enforcement
the addition and the existing building. activities and is not included in the Square Foot
Construction Cost.
Square Foot Construction Costs a 4
Group 2012 International Building Code IA IB IIA IIB IIIA Ills IV VA VB
A-1 Assembly, theaters. with sla a 224.49 217.12 211.82 202.96 '190.83 185.33 196.14 174.43 167.83
A-1 Assembly, theaters. wilhoulstage 205.71 188.34 193.04 184.18 172.15 166.65 177.36 155.75 149.15
A-2 Assembly, ni htdubs 177.15 172.12 167.31 160.58 150.83 146.74 154.65 136.68 132.81
A-2 Assembly, reslaumnts, bars, banquet halls 176.15 171.12 .165.31 159.58 148.83 145.74 153.65 134.68 131.81
A-3 Assembly, churches 207.73 200.36 195.06 186.20 174.41 168.91 179.38 158.02 151.41
A-3 Assembly, general, wrri mni halls libraries museums 173.36 165.99 159.69 151.83 138.90 134.40 145.01 122.50 116.69
A4 Assembly, - arenas 204.71 197.34 191.04 183.18 170.15 165.65 176.36 153.75 148.15
B Business 179.29 172.71 166.96 158.70 144.63 13910 152.43 126.93 121.32
E Educational 192.11 185.49 180.05 171.90 160.09 151.62 165.97 139.90 135.35
F-1 Factory and industrial, moderate hazard 108.42 103.32 97.18 93.38 8324 79.62 8922 68.69 64.39
F-2 Factory and industrial, low hazard 107.42 102.32 97.18 92.38 8324 78.62 88.22 68.69 63.39
H-1 Hi Hazard, explosives 101.53 96.44 91.29 86.49 77.57 7295 82.34 63.02 N.P.
H234 High Hazard 101.53 96.44 91.29 88.49 77.57 72.95 82.34 63.02 57.71
H5 HPM 17929 172.71 166.96 158.70 144.63 139.20 152.43 126.93 121.32
1-1 Institutional, w kwised environment 177.76 171.50 168.52 159.45 146.31 142.45 15913 131.29 126.72
1-2 lnstibdional. hospitals 30144 295.85 290.11 281.84 266.80 N.P. 275.58 249.09 N.P.
1-21ns6tAwal, nursing hams 209.38 20179 197.05 188.78 175.72 N.P. 182.52 Mot N.P.
1.3 Institutional. restrained 204.27 197.68 191.94 18187 171.10 164.68 177.41 153.40 145.80
14 Institutional, day care facilities 177.76 171.50 166.52 159.45 146.31 14245 159.13 131.29 126.72
M Merwntile 132.04 127.01 121.20 115.47. 105.47 102.39 109.54 91.33. 88.45
R-1 Residential, hotels 179.14 172.89 167.90 160.83 147.95 144.10 160.52 132.93 128.38
R-2 Residenfial multiple family 150.25 143.99 139.01 131.94 119.77 115.91 131.62 104.74 100.18
R-3 Residental, one. and twu-famil 141.80 137.90 134.46 131.00 125.88 122.71 128.29 117.71 110.29
R4 Residential, wrelassisted hying facilities 177.76 171.50 166.52 159.45 146.31 142.45 159.13 13129 126.72
S-1 Storage, moderate t=am 100.53 95.44 69.29 85.49 75.57 71.95 81.34 61.02 56.71
5-2 Stor4 e, bw hazard 99.53 94.44 8929 84.49 75.57 70.95 80.34 61.02 55.71
U lAili ,miscellaneous 75.59 71.22 66.76 83.37 56.99 5322 60.41 44.60 42.48
a. Private Garages use Utility, miscellaneous
b. Unfinished basements (aa use group) = 515.00 per sq. R
C. For shell only buildings deduct 20 percent -
d. N.P. = M pemutted
miscellaneous fees and charges page 39
Miscellaneous Fees and Charges
Attachment 1.
CITY OF Exhibit A
ASHLAND
GRADING FEES
General. Fees shall be assessed In accordance with the provisions of this section.
Plan Review Fees. When a plan or other data are required to be submitted, a plan review fee shall be
paid at the time of submitting plans and specifications for review. Said plan review fee shall be as
set forth In Table A. Separate plan review fees shall apply to retaining walls or major drainage
. structures as required. For excavation and fill on the same site, the fee shall be based on the
volume of excavation or fill, whichever is greater.
Grading Permit. Fees. A fee for each grading permit shall be paid to the City of Ashland, Building
DepL as set forth In Table B. Separate permits and, fees shall apply to retaining walls or major
drainage structures as required. There shall be no separate charge for standard terrace drains and
similar facilities.
TABLE A-GRADING PLAN REVIEW FEES
56 cubic yards or less No Fee
51 to 100 cubic yards $100.00
101 to 1,000 cubic yards $125.00
1A01 to 10,000 cubic yards $150.00
10,001 to 100,000 cubic yards $100.00 for the Omt 100,000 cubic years, plus $25.00 for each additional
10,000 yards or fraction thereof.
Other Fees:
Additional plan review mqulred by changes, additions or revislons to approved plane $65.25 par .
hour minimum -onshalf hour)
*Or the total hourly cost to the city, whidmver Is the greatesL This cost shall Include supervision,
overhead, equipment, hourly wages and fringe benefits of the employees Involved.
TABLE B-GRADING PERMFir FEES'
50 cubic yards or less No Fee
51 to 100 cubic yards $75.00
101 to 1,000 cubic yards $75.00 for the first 100 cubic yards plus $25.00 for each additional too cubic
yards or fraction thereof.
Other Inspections and Fees:
• Inspections outside of normal business houre (minimum charge -two houre)$6525 per hour
• Re-Inspection fees $6525 per hour
• Inspections for which rho fee Is specifically Indicated (minimum chargeone half hour)
$6525 perhour'
The fee for a grading permit authorizing additional work to that under a valid permit shall be the
difference between the fee paid for the original permit and the fee shown for the entire pmjecL
s0r the total hourly cost to the City, whichever Is the greatest This cost shall include supervision,
overhead equipment, hourly wages and fringe benefits of the employees involved.
page 40 miscellaneous fees 8 charge
Miscellaneous Fees and Charges
-Miscellaneous fees 8 charges page 41
CITY OF
ASHLAND
Memo
DATE: April 29, 2014
TO: Dave Kanner, City Administrator
CC:
FROM: Lee Tuneberg, Finance Director
DEPT: Administrative Services
SUBJECT: Parking Fees
I am recommending that the daily charge for the orange placard to park for an extended period in a
regular space in the Plaza be raised from $5 the first day and $1 per day thereafter with a weekly total of
$10 to $10 the first day and $2 per day thereafter with a weekly total of $20.
The current fee was established one year ago attempting to recover some of the cost of managing the
permitting and to reduce the prior demand for free parking for construction projects (or other activities
that can't be done in a 2 hour timeframe) that were not necessary or abused. Recent experience has
shown that charging for the permits is beneficial in that it eliminated most of the frivolous requests but
also that bona fide requests require management, especially during periods of high demand where
contractors are trying to complete projects before a specific deadline or during the high season of
tourism. Like our current parking ticket of $11, many visitors consider the low amounts we charge as a
cost of doing business. Especially since other large cities or tourist destinations charge so much for
regular parking. Been to downtown Portland lately?
This indicates we are priced to low for both permitted parking and ticketing for time violations. Staff is
researching the basis for changing parking ticket fees but feels the increase for parking all day or all
week should be adjusted to better recognize the economic value of the space.
Current estimates indicate a parking space's economic value is many.times that of $10 per day and
charging appropriately will still provide a benefit to the requesting party white minimizing the over-use
of permits in the plaza.
Staff plans to submit a request for changes in ticketing when research has been completed.
ADMINISTRATIVE SERVICES DEPARTMENT
D. L. Tuneterg, Director Tel: 541A88-5300
20 East Mara Street Fax: 541-552-2059
Ashland, Oregon 97520 TTY: 800-735-2900
wmashlend.onus
CITY OF
-ASH LAN D
Memo
DATE: April 28, 2014
TO: Lee Tuneberg, Director of Administrative Services
FROM: Bill Molnar, Director of Community Development
RE: Miscellaneous Fees and Charges Update
The Community Development Department is requesting the following updates to the Miscellaneous
Fees and Charges document:
1) Update the Planning Fees in accordance with the March 2014 CPI.
2) Add reference to Public Works plat review fees.
A notation has been added that cross references Public Work's Plat and Plan Check fees
identified later in the document. It is intended to inform the customer that a plat review fee is
charged by both the Community Development and Public Works Departments. These are existing
fees.
3) Add Building Appeals Board to the Appeals Fee structure.
This is a new fee targeted at covering a percentage of the costs associated with conducting an
appeal hearing before the Building Appeals Board. AMC 15.04.200 outlines the-appeal process
and notes that "an appeal shall include the applicable.appeal fee or deposit, as applicable. " This,
fee will assist in recovering a percentage of the administrative costs associated with preparing
public notice for the appeal hearing, convening the six member Building Appeals Board,
compiling a packet of relevant information regarding the nature of the appeal, including the
Building Official's staff report, and preparation of the Appeals Board final decision.
4) Add Change of Occupancy Fees. -
Often times a new tenant will move into an existing commercial building and open a new
business without knowing that the building they occupy has been constructed and intended for a
different use. The Oregon Structural Specialty Code has specific requirements that apply to
specific occupancy types. If a building is constructed to a less restrictive construction method
and a ,more hazardous or intensive occupancy type moves into the building, alterations are
required to make the building safe for the new occupancy type. This change in use triggers the
need for a special inspection and the reissuance of the Certificate of Occupancy.
COMMUNITY DEVELOPMENT DEPARTMENT Tel: 54146&5305
51 Winbum Way Fax:541481 E=
Ashland, Ohellon 91520 TTY: 60&135-2900
www.ashland.or.us
5) Insert Excavation/Grading Fees Chart (Exhibit-A).
The Excavation/Grading Fees chart was originally adopted by Resolution 2006-19 and was
accidentally omitted from the 2013-14 Miscellaneous Fees & Charges Book.
COMMUNITY DEVELOPMENT DEPARTMENT Tek 5414885305
51 Winhum Way Fax: 5414885006
Ashland, Oregon 97520 TTY: 800-735-2900
www.ashlondnrm
CITY OF
ASHLAND
Memo
DATE: April 18, 2014
TO: Lee Tuneberg, Administrative Services Director
FROM: Warren DiNapoli, Electric Distribution Systems Manager)
RE: 2014 Miscellaneous Fees and Charges
Attached'are the Electric Department's proposed miscellaneous fees and charges for 2014.
Payroll, with the exception of minor increases in materials, is the driver for the fee increases. The 2013
schedule incorporates a bargaining union's 2.5% pay increase.
The remaining fees on the table were increased using the April 2014 Engineering News Record
Construction Cost Index (ENR) of 9749.51 in relation to the previous ENR of 9515.86.
An additional fee "denergize service" was developed for .2014. This is to reimburse the City for costs
associated with a customer request to denergize their electric service for modification associated with
their customer owned panel.
Also included in the packet for your review are the itemized costs for each of the fees. The detail
consists of material, vehicle and labor as estimated for each line item.
All fees have been rounded to the nearest dollar.
If you have any questions or need additional details, please let me know.
90 N. Electric Department Tex: 541
AO N. Mountain Ave. Fax: 541.652-2436
Ashland, Oregon 97520 TTY: 800-735-2900
www.ashxand.orms
City of Ashland
2014 Electric Department Misc Fees and Charges
Proposed Current % Change
Fees Fees
Tempora Service Dro :
Single Phase Underground temp
300 amps or less .$247.00 $ 245.00 0.8%
Single Phase Overhead temp
300 amps or less $295.00 $ 291.00 1.4%
Three Phase Actual Cast Actual Cost
Meter Charges: Test r accuracy
Once in twelve months No charge No charge
Two or more times in 12 months-test for accuracy $176.00 $ 172.00 2.3%
Meter repairs/replacement (Damaged b y Customer) I Actual Cost Actual Cost
Service Calls
Once in twelve months No charge No charge
Two or more times in 12 months $203.00 S 199.00 2.00
Other hours or on Holidays 5303.00 $ 297.00
Deener ize service $254.00 NA
Scheduled Work after hours Actual Cost Actual Cost
Line Extension Charges:
NEW Single-family Residential Service:
Overhead service in existing developed area from
distribution line to and including meter $580.00 $ 568.00 2.1%
Overhead SERVICE UPGRADE or increased service
fo00 am s or less $580.00 $ 568.00 2.1%
Uacement U service m ove ea to underground,
300 amps or less. Customer provides all trenching,
conduit, back filling and compaction as directed by the
city. $1,217.00 $ 1,161.00 4.8%
Underground resr enta service o 300 amps or less
Customer provides conduit, trenching, back 511,
compaction as directed by the City $697:00 $ 695.00 0.3%
UG Distribution Installation Charges: Per Lot less house
service and engineering fees S 1,186.00 S 1,158.00 2.420/.
Subdivisions of 0-20 en innerin fee per lot $ 171.00 S 167.00 2.40%
Three Phase as required b city per lot $ 259.00 S 253.00 2.37%
Subdivisions of 2l+engineering fee per lot $ 259.00 S 253.00 2.370/a
City of Ashland
2014 Electric Department Misc Fees and Charges
Proposed Current % Change
Fees Fees
Tempora Service Dro :
Single Phase Underground temp
300 amps or less $247.00 $ 245.00 0.80/0
Single Phase Overhead temp
300 amps or less $295.00 $ 291.00 1.4%
Three Phase Actual Cost Actual Cost
Meter Char es: Test for accuracy
Once in twelve months No char a No charge
Two or more times in 12 months--test for accuracy $176.00 $ 172.00 23%
Meter re airstre lacement (Damaged b Customer Actual Cost Actual Cost
Service Calls
Once in twelve months No charge No charge
Two or more times in 12 months $203.00 $ 199.00 2.0%
Other hours or on Holidays - $303.00 $ 297.00 2.0%
Deener 'u service $254.00 NA
Scheduled Work after hours Actual Cost Actual Cost
Line Extension Charges:
NEW Single-family Residential Service:
Overhead service in existing developed area from
distribution line to and including meter $580.00 $ 568.00 2.1%
Overhead SERVICE UPGRADE or increased service
for 300 am s or less $580.00 $ 568.00 2.1%
ep acement o service from overhead to underground ,
300 amps or less. Customer provides all trenching,
conduit, back filling and compaction as directed by the
city. $1,217.00 $ 1,161.00 4.8%
Underground resr enta service o 300 amps or less
Customer provides conduit, trenching, back fill,
compaction as directed by the City $697.00 $ 695.00 0.3%
UG Distribution Installation Charges: Per Lot less house
service and engineering fees $ 1,186.00 $ 1,158.00 2.42%
Subdivisions of 0-20 en innerin fee per lot $ 171.00 $ 167.00 2.40%
Three Phaseasre uiredby city per lot $ 259.00 $ 253.00 2.37%
Subdivisions of2l+engineering fee per lot $ 259.00 $ 253.00 237%
2of11
CITY OF
ASHLAND
Electric Department Project Invoice
Name' Temporary Service Drop 4/16/2014
c/o
Address Phone
City, State Zip
Project#
Account#
Description Single Phase Underground temp 300 amps or
less
Total Material $23.62
• o Description Extended. 3 2-0801-00 CONNECTOR, PED 3-250 $5.29 $15.87
3 2-0783-01 CONNECTOR, COVER 4-HOLE $2.55 $7.65
Total
Equl ment $43.13
Qty Description Unit cost ExtendecNm
1.5 E-6 - Service Vehicle $28.75 $43.13
Total Labor $180A7
Qty-HRs _qfy-Stiff Description Unit Cost Extended
1.5 1 Groundsperson $49.43 $74.15
1.5 1 Line Installer/Serviceperson $70.88 $106.32
Total Project $247.11
Prepared By:
Signature:
CITY OF
ASHLAND
Electric Department Project Estimate
Name, _TempRFpry Seryice prop 411512014
c/o
Address Phone
City, State Zip
Project#
Account#
Description r Single Phase Overhead temp 300 amps or less
Total Material $69.20
• ST6CKff Description Price EA Extended
2 2-0950-00 DEADEND WEDGE CLAMP 2 - 6, SM $1.00 $2.00
65 2-2905-00 WIRE #40H TRIPLEX ACC OYSTER $0.84 $54.60
6 2-0705-01 CONNECTOR ALUM PARALLEL #8-210 STIR $1.42 $8.52
2 2-2667-00 WIREHOLDER, NYLON ALLOY $2.04 $4.08
Total
Equipment $43.13
1.5 E-6 - Service Vehicle. $28.75 $43.13
Total Labor $183.12
p p
Description Unit Cost Extended
1.6 1 Groundsperson, Meter Reader $49.43 $74.15
1.5 1 Line Installer/Serviceperson $72.65 $108.98
Total Project, $295.45 1
Prepared By:
Signature:
CITY OF
ASHLAND
Electric Department Project Estimate
Name', Meter Test for Accuracy 4/1512014
c/o
Address Phone
City, State Zip
Project#
Account#
Description . Two ormore times in twelve months
Total Material
Description Price EA
• •
Total
Equipment $23.00
My Description Unit Cost Extended
2 E-3 - Meter Relay Van $11.60 $23.00
Total Labor $162.66
Qty-HRs ty-staff Description Unit Cost Extended
2 1 Meter Relay Technician $76.28 $152.56
Total Project: $175.56
Prepared By:
Signature:
CITY OF
ASHLAND
Electric Department Project Estimate
Name Service Calls 4/1512014
.
c/o
Address Phone
City, State Zip
Project#
Account#
Description two or more times in twelve months -normal
business hours _
Total
Equipment $57.50
MWQ_ty_~ Description Unit Cost Extended
2 E-6 - Service Vehicle $28.75 $57.50
Total Labor $145.30
• a -'Description Unit,Cost Extended
2 1 Line Installer/Senriceperson $72.65 , $145.30
Total Project $202.80
Prepared By:
Signature:
CITY OF
ASHLAND
Electric Department Project Estimate
Name 'Service calls 411512014 .
c/o
Address Phone
City, State Zip
Project#
Account#
Description Two or more times in twelvemonths - after
hours or holidays
Total E ul ment $57.60
QtyDescription Unit Cost Extended
2 E-6 - Service Vehicle $28.76 $57.50
Total Labor $245.04
w • ff Description Unit Cost. Extended
2 1 Line Installer/Serviceperson (OT) $122.62 $245.04
Total Project! $302.54
Prepared By:
Signature:
CITY OF
ASHLAND
Electric Department Project Estimate
Name, Denergize Service 4115/2014
CIO
Address Phone
city, State Zip
Project#
Account#
Description Request to denergize existing electric service
for any modifications to customer owned
F electric. panel,..
Total E ui ment $71.88
ME-FIT77 Description Extended
2.5 E-6 - Service Vehicle $26.75 $71.88
Total Labor $181.63
w a Description Unit Cost Extended
2.5 1 Line Installer/Serviceperson (OT) $72.65 $181.63
Total Project' $25-3.50-
Prepared By:
Signature:
CITY OF
ASHLAND
Electric Department Project Estimate
Name Line Extension Charge 411512014
c/o
Address Phone
City, State Zip
Project#
Account#
Description, Overhead service in existing developed areas
from distribution line to and Including meter
Total Material $202.48
2 2-0945-00 DEADEND WEDGE CLAMP 1/0-4, LG $3.37 $6.74
1 0-ooo0-0 METER IPH RES RADIO READ $65.84 $65.84
100 2-2915-00 WIRE-110 OH TRIPLEX MUREX $1.16 $116.00
6 2-0705-00 CONNECTOR ALUM PARALLEL #8 - 210 STR $1.42 $8.52
~1 2-2667-00 WIREHOLDER, NYLON ALLOY $2.04 $2.04
1 2-2670-00 WIREHOLDER, SERVICE PIPE CLAMP $3.34 $3.34
Total
Equipment $71.88
• Description
2.5 E-6 - Service Vehicle $28.75 $71.88
Total Labor $305.20
•
2.5 1 Groundsperson, Meter Reader $49.43 $123.58
2.5 1 Line Installer/Serviceperson $72.65 $181.63
Total Project $579.56
Prepared By:
Signature:
CITY OF
ASHLAND
Electric Department Project Estimate
Name Line Extension Charge 4115/2014
c/o
Address Phone
city, state zip'
Project#
Account#
Description' Overhead service upgrade or Increased service
for 300-amps-or less
Total Material $202.48
2 2-0945-00 DEADEND WEDGE CLAMP 1/0-4, LG $3.37 $6.74
1 0-0000-0 METER 1PH RES RADIO READ $65.84 $65.84
100 2-2915-00 WIRE 1/0 OH TRIPLEX MUREX $1.16 $116.00
6 2-0705-00 CONNECTOR ALUM PARALLEL #8 - 2/0 STR $1.42 $8.52
1 2-2667-00 WIREHOLDER, NYLON ALLOY $2.04 $2.04
1 2-2670-00 WIREHOLDER, SERVICE PIPE CLAMP $3.34 $3.34
Total
Equipment $71.88
• Description: 2.5 E-6 - Service Vehicle $28.75 $71.88
Total Labor $305.20
• • Descriptioh Unit Cost Extended
2.5 1 Groundsperson, Meter Reader $49.43 $123.58
2.5 1 Line Installer/Serviceperson $72.65 $181.63
Total Project $579.56
Prepared By:
Signature:
CITY OF
-ASHLAND
Electric Department Project Estimate
Name Line Extension, Charges __f 4/15/2014
c/o
Address Phone
City, State Zip
Project#
Account# _
Description Replacement of service from overhead to
underground, 300 amps or less. Customer
provides all trenching, conduit, backfilling and
compaction as directed by the-City
Total Material $349.00
Description Price EA tExt6nd&d
3 2-0197-00 BRACKET 3" KENDORF STRAP $2.42 $7.26
3 2.0194-00 BRACKET, STANDOFF, 12" $13.46 $40.38
10 2-0447-00 CONDUIT 3" PVC SCH 80 10' $2.57 $25.70
40 2-0446-00 CONDUIT, 3" PVC, SCH 40 $1.75 $70100
125 2-3030-00 WIRE, UG, #4/0 TRIPLEX, URD ALUM 600V $1.55 $193.75
3 2.0801-00 CONNECTOR ALUM PARALLEL #8-2/0 STIR $1.42 $4.26
3 2-9998-00 CONNECTOR, COVER 4-HOLE $2.55 $7.65
Total
Equipment $241.50
B Description
3 E-10 - Bucket Truck $34.50 $103.60
3 E-12 - Line Truck $46.00 $138.00
Total Labor $626.07
P D'
3 - 1 Lead Working Line Installer $78.58 $235.74
3 1 Line Installer $72.65 $217.95
3 1 Line Truck Driver $57.46 $172.38
Total Project $1,296.57
Prepared By:
Signature:
CITY OF
ASHLAND
Electric Department Project Estimate
Name ~ Line Extension charges I 411512014
c/o
Address Phone
City, State Zip
Project#
AccounW
Description Underground residential service of 300 amps or~
less. Customer provides conduit, trenching,
backfili, and compaction as directed by the City
Total Material $234.01
rip ~
• s o• . .
3 2-0784-00 CONNECTOR, PED 4-350 $4.39 $13.17
1 0-0000-0 METER 1PH RES RADIO READ $65.84 $65.84
100 2-3030-00 WIRE, UG, #4/0 TRIPLEX, URD ALUM 600V $1.55 $155.00
Total
Equipment $158.13.
w Description Cost Extc~nded
2.5 E-6 - Service Vehicle $28.75 $71.88
2.5 E-9 - Bucket truck $34.50 $86.25
Total Labor $305.20
r a r
2.5 1 Groundsperson, Meter Reader $49.43 $123.58
2.5 1 Line Installer/Serviceperson $72.65 $181.63
Total Project' $697.34
Prepared By:
Signature:
LINE EXTENSION CHARGES
Previous Proposed
Underground Distribution Installation Charges: Per Lot less house
service and engineering fees. $ 1,158.00 $ 1,186.00
Subdivisions of 0 to 20 engineering fee per lot $ 167.00 $ 171.00
Subdivisions of 21+ engineering fee per lot $ 253.00 $ 259.00
Three phase subdivision as required by city per lot $ 253.00 $ 259.00
Previous ENR (Engineering News Record Construction Cost 9515.86
April 2014 ENR Construction Cost 9749.51
% Rate of Adjustment 2.46%
CITY OF
ASHLAND
Memo
DATE: April 21, 2014
TO: Kristy Blackman
FROM: Margueritte Hickman, Division Chief / Fire Marshal
RE: Inspection Fee Increase
Please adjust the fire inspection fees in accordance with the CPI of 1.5% effective March 1,
2014.
with 1.7%
increase
2014 rounded up.
10,001-
Occupancy 0-1,000 1,001-3,000 0-3,000. 3,001-10,000 20,000 >20,000
B $35.00 $52.00 $102.00 $152.00 $203.00
A, E, F, H, I, M, S _ $52.00 $102.00 $152.00 $203.00
Number of Units 3-10 11-40 41-70 >70
R, SR $52.00 $102.00 $153.00 $203.00
Reinspection Fees
3rd $54.00
4th $107.00
5th or greater $158.00
ASHLAND FIRE & RESCUE
455 Slsklyou Boulevard Ashland, OR 97520 /r,
(541) 482-2770 • Fax (541) 488.5318
TTY: 800-735-2900
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CITY OF
ASHLAND
Memo
DATE: April 29, 2014
TO: Lee Tuneberg, Administrative Services Director
FROM: Michael Ainsworth, Telecommunications Manager
CC: Kristy Blackman, Administrative Services/Finance Administrative Assistant
RE: Telecom's Proposed Changes/Revisions to Miscellaneous Fees and Charges
The AFN Telecommunications Division is proposing changes solely to the text descriptions listed in the
Information Technology section pages 23 and 24 and no changes to the actual fees or fees structure.
Changes to the document (pages 23 and 24) are primarily revisions of the description of services and
text formatting to improve the reading flow.
Significant changes include:
Page 23, under the category of Installation Fees: The line "Wi Max standard installation $200" has
been moved to the bottom of the category listings.
Page 23, formatting only changes, replacement of standard font with bold font for improved clarity.
Page 24, under the category of Non-return of customer premise equipment (CPE) devices: $300
"Anywhere and/or AFN Max" are deleted so that the CPE's will not be associated solely to wireless
services.
Page 23 the header Transit Fee is being changed to Ethernet to better describe the connection circuit.
Page 23 under the category of Fiber Service Installation:
"Mandatory two-year agreement" is deleted and future service terms will be defined by
Individual Business Case (IBC)
Product descriptions have been trimmed down to "overhead served" and "underground served" to
simplify the two primary service descriptions.
Page 24 under the category of Business Augmented Upload Package (additional 5Mbps)
The wording for the product descriptions have been tightened up. Dated descriptions have been revised
and/or deleted.
No changes proposed for actual fees or to the fee structures for Telecommunication services listed
on pages 23 and 24.
DEPARTMENT HERE Tel: 541488-8002
Street Address Fac 541488-5311
Ashland, Oregon 97520 TTY: 800-7352900
w Ashland.orus
1
Section 6-Information Technology
Information Technology Miscellaneous Fees and Charges*
Installation Fees:
Basic installation-Pre-wired CATV outlets only $ 20.00
(Additional charges for parts and supplies apply)
Add Trap ("filter") $10.00
New customer cable modem activation $10.00
Cable Modem $50.00
Refurbished 90 -day replacement warranty
Additional materials $10.00
Over-and-beyond regular installation including
multi outlets, outlet plates, additional wiring,
replacement of customer damaged outlets.
Wi Max standard nstailation ;$200'cQ0
Disconnect Fees:
Disconnect $50.00
Remove Trap ("Filter") $10.00
Truck Roll: $35.00
Field Technician Hourly Rate:
Non-standard work such as advancing troubleshooting, $55.00
non-standard outlets, fishing wire inside walls, etc.
Consultina and Technical Support Hourly Rate:
For support issues not related to AFN infrastructure, performance, $85.00
and reliability. Minimum charge on hour.
Non-City Employee Staff Screening:
Charge for each vendor employee submitted for authorization to
Access AFN and City Service Center facilities. $150.00
Fiber Service Installation:
f;4iaintum one Ine Jkt fer 6r ei6ead sei o ed eenseefiens '`a "---i
1008, ftt
Overhead served connections. Individual Business Case
(IBC) & quote
Underground served connections IBC & quote
Ethe"rne'T''m~.i cca-
Transit @ 100 Mbps IBC & quote
miscellaneous fees and charges page 23
Section 6-Information Technology
Static IP Address: $5.00/mo each
Maximum of 5 Static Internet Protocol (IP) addresses*
• Minimum level of service for static IP and Quality of Service (QoS)'is
"CHOICE" or higher service tier.
oS Fee: $3.50/mo
VOIP (phone) enhancement available with AFN
Choice or higher service level through AFN certified
Modems.
Business Augmented Upload Package (additional 5 Mbps): $15.00/mo
Available' exclusively on.AFNDirect
x
iplend I'aeknge:ava~lehle enl~ ~yFfh _
Small Uffcel fome Office- (SO)iO) or Snail Business.
1lusi have'currerit.60 of Ashland Business License
*Additional fee added to base AFN Direct retail rates on specific packages.
Maximum SOHO upload speed with augmented upload service at up to 9 Mbps
Small Office/Home Office Business Augmented Upload Package @$80/month
Maximum Small Business upload speed with augmented upload service at up to 10 Mbps
Small Business Augmented Upload Package @ $100.00/month
Non-return of customer premise equipment (CPE) devices: $300.00
CPE's must be returned on disconnect date of AFM*nq."rM_a dfor
AFNNiax services.
Cable N (CAN) Seasonal Reconnects & Disconnects: $10.00/visit
Non-pay disconnects & reconnects
Service change
Install HBO filter
CAN House Amp Fee: $35.00/each
Utility Billing Lobby Sianape Fee: $100.00/mo.
Cable Modem Rental $5.00/mo.
Non Return of Rented Modem at Closina of Account $50.00each
Cable Modem Purchase $50.00/each
* Resolution 2010-28 (Section 2, page 38) grants tnformation Technology management ability to set promotional rates.
page 24 miscellaneous fees and charges
C I T Y OF
ASHLAND
Memo
DATE: April 30, 2014
TO: City of Ashland, Finance Department
FROM: Ashland Municipal Court
RE: Miscellaneous Fees and Charges (Updated)
f
The Court has 4 changes to our Fees and Charges:
City Attorney Deferred Sentence/Diversion for
Violations: Not charged on Violations -0-.
Extend/Amend City Attorney Deferred Sentence or
Diversion: Not charged on Violations -0-.
Show Cause Admission of Allegation: Not charged
on Violations -0-.
Withholding on County Assessment: N/A/New County
Assessment all collected goes to the County.
MUNICIPAL COURT 541A82-5214
1175 East Main Street Fax: 541-0885586
AsNand, Oregon 97520 TTY: 800-735-2900
w .asNarvJ.or.w
CITY OF
Memo, ASHLAND
DATE: April 22, 2014
TO: Lee Tuncberg, Administrative Services Director
FROM: Kelly Haptonstall, Lead Police Clerk
RE: Fingerprint Pee Increase
Attached is the Ashland Police Department's proposed fingerprint fee increase.
General cost increase is the main driver for the fee increase.
Also included in the packet for your review are the itemized costs for fingerprinting. The detail
consists of the clerk's time, maintenance fees, use of machine, toner, and gloves.
The proposed fee increase is $35.00 per initial card and $10.00 for additional cards.
If you have any questions or need additional details, please let me know
ASHLAND POLICE DEPT, Tel: 541482.5211
1155E. Main St Fax: 541488-5351
AsNand, OR 97520 TTY: 000-735.2000
www asNand.or.os APD Fonn 82, Rev 9/12
City of Ashland
Police Department
Cost of Services for Finger printing . .
Number of cards per year 540
Number of years use of machine 6
Number of toner cartridges per year 2
Cost per unit (finger print card):
Time
Clerk hr rate $ 22.76
Gross up for benefits $ 35.28
Half hour per unit 50%
Cost of time $ 17.64 $ 17.64
Maintenance Fee
Cost per year $ 2,400
Number of cards per year 540
Cost of fee $ 4.44 $ 4.44
Use of Machine
Cost of Machine $16,538
Useful life 6 yrs
Replacement cost Q 3% inflation $20,507
Replacement cost per year $ 3,418
Number of cards per year 540
Cost of machine $ 6.33 $ 6.33
Toner
Toner cost per year (2 * $1,015) $ 2,030
Number of cards per year 540
Cost of machine $ 3.76 $ 3.76
Gloves
Cost per box of 500 gloves $ 150
Cost per glove. $ 0.30 $ 0.30
Total Cost Per Unit $ 32;47
Memo CITY OF
ASHLAND
Date: 4/25/2014
From: Betsy Harshman
To: Lee Tuneberg
Re: Miscellaneous Fees and Charges
Please make the adjustments in the FY 2014/2015 Miscellaneous Fees and Charges Document as
shown in the attached documents.
To cover some of our refund processing costs, we'd also like to add a clause that states: An
administrative fee of 25% will be assessed on all permit refunds. Refunds will not be issued if
requested later than one-year following the application date.
On page 27 of this year's book, following Subdivision plats and partition plats, please add: (does
not include planning review fee, see page 11). Planning requested we add these statements so
customers know there are will be additional fees upfront; they have added similar verbiage to
their update.
Engineering Tel: 541/499-5347
20 E. Main Street Far 541-/490
As ,
Ashland, Oregon 97520 TN: 800!7355--2902900
w .ashtand.orms .
Section 9-Public Works
Public Works Miscellaneous Fees and Charges
Copy Fees:
Black and White Copies Letter/Legal Single-Sided $0.20 each
Black and White Copies Letter/Legal Double-Sided $0.40 each
Black and White Copies Tabloid. Single-Sided $0.40 each
Black and White Copies Tabloid Double-Sided $0.80 each
Color Copies Letter/Legal Single-Sided $1.50 each
Color Copies Tabloid Single-Sided $3.00 each
Existing maps printed in color on HP1055CM plotter (241b bond Paper)
Arch C 18 x 24 3.00 sq. ft. $18.00
Arch D 24 x 36 6.00 sq. ft. $36.00
Arch E 36 x 48 12.00 sq. ft. $72.00
Existing maps or copies of existing maps copied in B&W on Xerox 3030 large format copier
(201b bond paper)
Arch C 18 x 24 $8.00
Arch D 24 x 36 $12.00
Arch E 36 x 48 $16.00
Note: Maps printed on materials other than the specified bond are double the standard print fee
Plat & Plan Checks:.
Ldpe_C190` %AO-Ade~11dhAf/uf
Subdivision Plats $730.00 plus t~~
$110.00 per lot rt/ O& O Ae b'w
P"t
Condominium Plats $730.00 plus
$110.00 per lot
Partition Plats 4\
(does not include 24% Fire Department Review Fee) $391.00 J
Subdivision Improvement Plat Check 5% Engineer Fee (5% of
the public improvement cost)
Engineering Development Fee
(this fee is charged concurrently with Building Permit
Fees at the time of building permit applications. Applies
To all new residential dwelling units and commercial 0.75% of valuation
Developments. Remodels, additions and accessory
Buildings are not assessed this fee.)
miscellaneous fees and charges page 27
Section 9-Public Works
Public Works Miscellaneous Fees and Charges
Copy Fees:
Black and White Copies Letter/Legal Single-Sided $0.20 each
Black and White. Copies Letter/Legal Double-Sided $0.40 each
Black and White Copies Tabloid Single-Sided $0.40 each
Black and White Copies Tabloid Double-Sided $0.80 each
Color Copies Letter/Legal Single-Sided $1.50 each
Color Copies Tabloid Single-Sided $3.00 each
Existing maps printed in color on AP1055CM plotter (241b bond Paper)
Arch C 18 x 24 3.00 sq. ft. $18.00
Arch D 24 x 36 6.00 sq. ft. $36.00
Arch E 36 x 48 12.00 sq. ft. $72.00
i
Existing snaps or copies of existing snaps copied in B&W on Xerox 3030 large format copier
(201b bond paper)
Arch C 18 x 24 800
Arch D 24 x 36 AM &O
Arch E 36 x 48 6t0~-
Note: Maps printed on materials other than the specified bond are double the standard print fee
Plat & Plan Checks:
r liis 1
Subdivision Plats E$I QT 9
10!00 pei of ~q +
Condominium Plats 730t00Tilus - '
$110! 'j" lot
Partition Plats
(does not include 24% Fire Department Review Fee) 0_icajai(ui
Subdivision Improvement Plat Check 5%o Engineer Fee (5% of
the public improvement cost)
Engineering Development Fee
(this fee is charged concurrently with Building Permit
Fees at the time of building permit applications. Applies
To all new residential dwelling units and commercial 0.75% of valuation
Developments. Remodels, additions and accessory
Buildings are not assessed this fee)
miscellaneous fees and charges page 27
Section 9-Public Works
Public Works/Engineering Inspections. Permits, etc:
Subdivision Construction Inspection/ 5% Engineer Fee(5% of
Public Works Improvement Inspection the public improvement cost)
Street or Alley Excavation Permit $~1 6 + per ft. cost
based on pavement age
Encroachment Permit $19 c00' i` +
Miscellaneous Construction Permit $64c00~ - '
(Construction of curb, sidewalk, driveway
Apron, etc.)
Dust Suppression Permit
Driveway Painting Permit $16.00
(includes a can of paint)
Right-of Way Closure-Street $19,,60/
Right-of Way Closure-Sidewalk(>72 his)
Right-of Way Closure-Sidewalk(<72 hrs) $16.00
Right-of Way Closure-Parking Space(>72 hrs) $_640
'
Right-of Way Closure-Parking Space(<72 hrs) $16.00 °
Block Parry $16.00
Sidewalk Dining-Annual Renewal
(minimum 50 sq. ft)
Functional Item-Annual Renewal $nt 64101ti a
Special Event Permits (per Resolution 2012-08):
Base Special Event Permit Fee (plus applicable fees M 3,_ !d00 y~{ ' f 1
below) Events that require city staff overtime Y~160%Toftcityjstaffi0'hI b ildli} 1r
Rush Fee (less than 90 days advance notice) $250.00
page 28 miscellaneous tees and charges
Section 9-Public Works
Public Works/Engineering Inspections, Permits, etc. (cont)
i - - -Loaned Functional Item, Pennant Applica-
on Eee $133 00 _
Publication Box Per Publication-Annual Renewal $27.00
Special vehicle Permit-Initial Fee + 9A yyy
Special vehicle Permit-Annual Renewal 8$11;0 : 0 t'1
Penalty for No Permit .150% of permit cost
Street or Alley Vacation $tR 65910
GIS Data & Mapping Services:
00
GIS Hourly Rate
Information on Disk $40.0-6/utiIity;(per I
Quarter section l
Planning Pre-Application Maps $22.00
Plotting Fee $6.00/square foot
New Address Assignment ~$`~7 ad Tess a:
Street Name Approval Fee SON' 0'F=
miscellaneous fees and charges page 29
Section 9-Public Works
Sanitary Sewer Connection Fees:
Sanitary sewer mainline video inspection $3 700, minimum ,
(cost based on time and materials)
Water Connection Fees:
The installation of all new water services and large taps regardless of size will be charged on a time and
materials basis.
First Utility Locate at an address No Charge
Additional Locates at same address t$0 !
Water. meter re-read
Once in 12 months No Charge
Each additional re-read in 12 months $ 1 UO iYI
l
Water Meter Field Test
Water Meter Bench Test
3/4" or I" Water Meter $JU70
1 1/2" or 2" Water Meter $r009W11a1
Larger Meters Actual Cost
page 30 miscellaneous fees and charges
Section 9-Public Works
Water Connection Fees Continued
Water pressure check once in 12 month No Charge
Each additional pressure check in 12 months $!3;>t0d ( '
j..
Water Chlorination Test -Subdivision retest
upon failure (cost based on time and materials) $ 01MI . w
Water Pressure Test -Subdivision retest up
failure (cost based on time and materials) $o., -0 _
Cemetery Fees:
Sales of grave spaces or burial plots:
(fees split, 40% to the cemetery fund & 60% to the cemetery trust fund)
Grave Space -Lawn and Monument Sections6 "G'•
Grave Space -Baby Land b0:00
Grave Space-Niches (bronze)
Grave Space -Um garden $ ly~oo
Grave space ;Crypt $1;071 Q0
Sales of liners and markers:
(fees split, 40% to the cemetery fund & 60% to the cemetery trust fund)
Concrete cemetery box, including setting x$_428(00 '
Concrete liners Cost plus 10%
Final inscriptions $125t0~min oGarge itta$IjirNtyt
Grave markers ` - " Z Wholesale cost X 2.5 t~ t . 4 "E
not to exceed $700.00
Grave marker setting, concrete base 06,0. 0
f
Monticello burial vault (sealed concrete) mj)~i]<78.0000
MUM
FY-
miscellaneous fees and charges page 31
Section 9-Public Works
Sexton Fees:
Opening and closing graves, ground $42$ 0U .!1't
Opening and closing graves, double-deep
Opening and closing graves, infant/Oi~O l' }
Opening and closing crypts' $428A0
Opening closed crypts $42g:0
Opening and closing niches $1108:00
Q~+[~~;: O~ c.h11T~!'~i Lei'.. i t .+.Ate:•1'-i.t;,, I •I--...,,
Inter cremains in grave spaces $ I ou.Vu
Scattering of cremains $108!00
41~.
Disinterment $W010/in advance
s'
Saturday, Sunday or Holiday burial $4,28.00 _ WI~f
Miscellaneous Fees:
Grave Setup Rental $ I O 46/,0ccurrcnce N It l
Tent Rental $53007day
lP..~
Perpetual care lots, sold before 1927 $10
Vases: t;.
Galvanized $4 0 '
*cemetery fees will be subject to a 1..5% finance charge per mo ifnotpaid within 60 days of use. All above
services will be sold pre-need in installments, interest free, with a minimum payment of one-twelfth of the total
sale.
2013 CPI and ENR Calculations:
Methodology: Current CPI Rate - Old CPI Rate/Old CPI Rate = % Rate of` djustment
($32.773-229:292)/229:292'=1:5%
Methodology: Current ENR Rate - Old ENR Rate/Old ENR Rate = % Rate of Adjustment
`(1A55"I8b92$7F57)/92'G7 57 2 0% ,;T °7 , t if 114 }Z2E.( 1 t; s f-
CPI used for: ENR used for:
Plat & Plan Checks Sanitary Sewer Connection Fees
Public Works/engineering Inspections, Permits, etc. Water Connection Fees
GIS Data & Mapping Services
Cemetery Fees
page 32 miscellaneous fees and charg
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ASHLAND PARKS AND RECREATION COMMISSION
340 SO. PIONEER STREET ASHLAND. OREGON 97520
COMMISSIONERS: Don Robertson
Mike Gardner _ Director
Rick Lath r`
Jim Lewls TEL: (541) 498-5340
Stelam Sefingor FAX' (541) 4995314
Venston Shaw jf
MEMORANDUM
TO Lee Tuneberg, Finance Director
FROM Rachel Dials, Recreation Superintendent
DATE 4-18-14
SUBJECT Fees and Charges-Ashland Parks and Recreation
In 2006 the Parks and Recreation Commission set a goal of reviewing fees and charges for the
Ashland Parks and Recreation Department each year in November. The annual review includes
fees and charges associated with the Calle Guanajuato, North Mountain Park Nature Center, .
Ashland Senior Center, adult and youth recreation programs, indoor and outdoor reserved
facilities, the Oak Knoll Golf Course; the Daniel Meyer Pool, and the Ashland Rotary Centennial
Ice Rink.
As of this date, the Parks Commission has not reviewed fees'and charges and moving
forward will sync up the process with the biennium budgets.
Staff did find a few corrections and omissions from previous reviews that are highlighted below
and reflected in the proposed document. They are:
Special Event Application Fee $25.00 (omitted from document)
Ballfield Lights $34.00/hr (scheduled for increase in 2014)
Calle Guanajuato-Restaurant Seating $7.00/sq. foot(scheduled for increase in 2014)
Swim Lessons $40/$42/$48 (adjusted in 2012)
Adult Hockey Admission $5.50 (omitted from document)
Youth Hockey Admission $5.00 (omitted from document)
Ice Skating Private Lesson $10.00 for 30 min (omitted from document)
Youth Hockey Punch Card $45.00 (omitted from document)
Adult Hockey Punch Card $50.00 (omitted from document)
Open Skate/Kids Only Punch Card $30.00 (omitted from document)
Helmets $8.00 (omitted from document)
Home of Famous Llthia Park
CITY OF
ASHLAND
Council Communication
June 3, 2014, Business Meeting
Adoption of the City's self-insured health plan for the plan year July 1, 2014
through June 30, 2015.
FROM
Dave Kanner, City Administrator, dave.kannergashland.or.us
Tina Gray, Human Resources Manager, tina. ray(a ashland.or.us
SUMMARY
As a self-insured entity for health benefits, the City must adopt a plan document annually. The
Employee Health Benefit Advisory Committee reviewed the plan at its meetings this spring and
recommends that the City Council adopt the City's existing self-insured health plan with only two
modifications:
1) Revised language regarding the appeal process which serves to streamline the process for the
covered individual filing an appeal and giving the City a more clearly defined role in the
process; and
2) Incorporate administrative changes that are required by the Affordable Care Act for the purpose
of standardizing coverage.
BACKGROUND AND POLICY IMPLICATIONS:
July 1, 2013, the City transitioned from a fully-insured health plan with PacificSource, to a self-
insured health plan (medical, dental and vision). We retained PacificSource as our third party claims
administrator so the change in claims administration would be seamless for employees.
The City established an Employee Health Benefits Advisory Committee (EHBAC), composed of
representatives from each bargaining group as well as non-represented City and Parks employees. The
charge of the EHBAC is to meet regularly and review claims experience and make recommendations
for the upcoming plan year.
The EHBAC reviewed a number of suggested changes, but in the interest of cost savings and getting
more experience as a self-insured entity, the only recommendation for change is to update the appeal
language in order to streamline the process for appealing an adverse benefit decision and to provide a
more clearly defined role for the City in the process. This revised language replaces the existing
language that begins on page 61 of the current plan document under the heading "Your Right to
Appeal," up to the language on page 64 under the heading, "Independent External Review." A short
list of additional changes must be incorporated into our health plan to ensure compliance with the
Affordable Care Act.
Page I of 2
Pr,
CITY OF
ASHLAND
FISCAL IMPLICATIONS:
The modification to the appeal process language will have no fiscal impact. The language will allow
the City to enter the appeal process as the "Plan Administrator" earlier in the appeal process which
serves to provide the covered employee with a less cumbersome process.
STAFF RECOMMENDATION AND REQUESTED ACTION:
Staff is recommends approval of the 2014-2015 City of Ashland Self-insured Health Benefits Plan
with revised appeal language and administrative changes required by the Affordable Care Act.
SUGGESTED MOTION:
I move approval of the 2014-2015 City of Ashland self-insured health benefit plan with the
modifications recommended by the Employee Health Benefits Advisory Committee.
ATTACHMENTS:
Prior year health plan summary City
Prior year health plan summary Parks
Proposed revision to language regarding the Appeal Process
Modifications required under the Affordable Care Act.
Page 2 of 2
~r,
CITY'OF
-ASHLAND
City of Ashland
Group No.: G0032482
Preferred 90+200 VAR GF 0812
Effective: July 1, 2013
Third Party Administrative Services Provided By:
6
PacificSource
HEALTH PLANS
SPD 0713_City of Ashland SinyleSouroe Self-Insured
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SingleSource Self-Insured 2
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.
SingleSource Self-Insured 3
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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
SingleSource Self-Insured 5
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 33
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
SingleSource Self-Insured 6
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 Sponsor's 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 Sponsorwithout 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
SingleSource Self-Insured 7
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SingleSource Self-Insured 8
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
PacificSource at:
PacificSource Health Plans
PO Box 7068
Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
email: cs@pacificsource.com
SingleSource Self-Insured
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SingleSource Self-Insured 2
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: 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.
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-insuranoe
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
SingleSource Self-Insured 3
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 A 10% co-insurance A
Ambulance, Ground 10% co-insuranre 10% co-insurance
Ambulance, Air 10% co-insurance 10% co-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 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 change is incurred.
SingleSource Self-Insured 4
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.
PRESCRIPTION DRUG OUT-OF-POCKET LIMIT $2,500
The co-payment and/or co-insurance for prescription drugs obtained from a participating pharmacy is
waived at participating pharmacies during the remainder of a calendar year in which you have satisfied
a Prescription Drug Out of Pocket Limit of $2,500. The limit applies to each member. Claims must be
submitted by the participating pharmacy electronically. Differential between brand name and generic
drugs, and drugs obtained at a non-participating pharmacy do not apply toward the limit.
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 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.
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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
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 PacifcSource'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
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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.
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
SERVICEISUPPLY 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
PacifcSource 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 co-payments 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 II Restorative Services- Plan pays 70% toward covered Class 11 Restorative Services -
Restorative Treatment.
Class II Complicated Services- Plan pays 70% toward covered Class 11 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, 11 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.
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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, co-payment, and/or co-insurance 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.
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 participating providers and/or a list of participating health care professionals
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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, co-
payment, and/or co-insurance 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
PPG'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 co-payments 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.
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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 Sponsorwill 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.
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 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 aftera 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 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 Sponsor-just 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 FMtA 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 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 COVERAGE
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 60 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 Sponsorfor 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 f les for Cha ter 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 26
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 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 Sponsor's
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 Sponsor's 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 4
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 PERS (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 60 days of the date of marriage, registration of domestic
partnership, birth, or adoption.
SingleSource Self-Insured 27
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 Coverage 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 andlor 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.
Co-payments - Co-payments 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 co-payments do not apply to your annual deductible or out-of-pocket maximum,
unless otherwise specified on the Medical Benefit Summary. The co-payment 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 30
\I
Least Costly Setting For Services - Benefits of the plan provide for reimbursement of covered
. , services performed in the least costly setting where services can,besafely 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 SeneNt
In the event of an injury caused by an accident the plan benefit will be as follows:
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 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 to mammograms that are
considered 'routine' according to the guidelines of the U.S. Preventive Services Task
Force.
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.
SingleSource Self-Insured 31
Breast exams annually for women 18 years of age or older or at anytime 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:
- 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 to colonoscopies that
are considered 'routine' according to the guidelines of the U.S. Preventive Services
Task Force.
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
SingleSource Self-Insured 32
• 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:
• 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.
SingleSource Self-Insured 33
• 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
• 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
SingleSource Self-Insured 34
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.
• 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. 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
SingleSource Self-Insured 35
• Difficulty breathing
• Sudden fevers
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
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
SingleSource Self-Insured 36
• 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
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:
SingleSource Self-Insured 37
- 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
- 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
SingleSource Self-Insured 38
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.
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 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
SingleSource Self-Insured 39
• Pancreas whole organ transplantation (under certain criteria)
• Heart
• Heart - Lung
• 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 up to $8,000, 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, up to $8,000 (as outlined above).
• 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 PacifcSource'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.
SingleSource Self-Insured 40
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
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 co-
insurance. 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 Iymphedema
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, Norplant 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
SingleSource Self-Insured 41
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`aft& the injury, surgery, scar,
or defect first occurred. Preauthorization by PacificSource is required for all cosmetic and
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.
SingleSource Self-Insured 42
• 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
• 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 Bene/its
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 far 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 andlor 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,
SingleSource Self-Insured 43
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.
• 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 hyperplasla 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)
SingleSource Self-Insured 44
• 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
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
SingleSource Self-Insured 45
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,
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 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.
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
• 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
SingleSource Self-Insured 46
• Educational or correctional services or sheltered living provided by a school or halfway house
• Equine/animal therapy
• 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
• 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 applianceslike 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.
• 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
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;
SingleSource Self-Insured 47
• 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 coverage 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
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
SingleSource Self-Insured 48
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.
• Benefits not stated - Services and supplies not specifically described as benefits under the group
health policy and/or any endorsement attached hereto
SingleSource Self-Insured 49
EXCLUSION PERIODS
Exclusion Period for Transplant BeneTts
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 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.
The medical professionals who conduct the program focus their review on the appropriateness for
reimbursement of hospital stays and proposed surgical procedures.
SingleSource Self-Insured 50
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
Espanol (800) 624-6052, extension 1009
cs@pacificsource.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:
• Terminal illnesses (Cancer, AIDS, Multiple Sclerosis, Renal Failure, Obstructive Pulmonary
Disease, Cardiac conditions, etc.)
SingleSource Self-Insured 51
• 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 PacifcSource 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 PacifcSource 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 / 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 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 corona) 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 coverage 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
How to Fiie/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 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, extensi6n 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 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@ pacificsou rce. 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.
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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.
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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 Pte-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
SingleSource Self-Insured 64
• Information about PacificSource's drug formulary
• A copy of PacifcSource'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
hftp://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.
SingleSource Self-Insured 65
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,
co-payments and co-insurance. 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, co-payments and co-insurance 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, co-payments and co-insurance. 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. This does not apply to City of
Ashland.
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;
SingleSource Self-Insured 66
o The natural parent without custody's coverage pays third, and
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 Sponsor from 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
SingleSource Self-Insured 67
for the specific claim involved at the time, and will not be a continuing waiver of the term or condition in
the future.
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.
SingleSource Self-Insured 68
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 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.
SingleSource Self-Insured 69
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 Sponsorwill 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.P/an 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 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 70
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 Sponsor without Certification by Plan
Sponsor
Except as provided below in 'Disclosures of Summary Health Information and Enroll ment/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 Sponsor with 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.
SingleSource Self-Insured 71
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 Sponsor 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', 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 Sponsor will
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 Sponsor will 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, 11, 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.
SingleSource Self-Insured 73
Co-payment or co-insurance 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
PacifcSource 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,
PacifcSource 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 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 PacificSource.
Generic drugs are drugs that, under federal law, require a prescription by a licensed physician (M.D. or
D.C.) 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 60 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 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. 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 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 member or 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.
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;
• 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;
SingleSource Self-Insured 79
• 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 Sponsor to 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
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.
SingleSource Self-Insured 80
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://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:
hftp:/thealth.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.azaheccs.gov/applicants Website: https://www.flmedicaidtplrecovery.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.cov/
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://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
LOUISIANA - Medicaid NEW JERSEY - Medicaid and CHIP
Website: http:/Avwv.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/of/public- Medicaid Phone: 1-800-356-1561
assistance/index.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://v w .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://www.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.aov/upv
Phone: 1-888-365-3742 Phone: 1-866-435-7414
OREGON - Medicaid and CHIP VERMONT- Medicaid
Website: http://www.oregonhealthykids.gov Website: http://www.greenmountaincare.org/
http://www.hijossaludablesoregon.gov Phone: 1-800-250-8427
Phone: 1-877-314-5678
SingleSource Self-Insured 82
PENNSYLVANIA - Medicaid VIRGINIA - Medicaid and CHIP
Website: http://www.dpw.state.pa.us/hipp Medicaid Website: http://www.dmas.virginia.gov/rcp-
Phone:1-800-692-7462 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://www.sodhhs.gov Website: www.dhhr.wv.gov/bms/
Phone: 1-888-549-0820 Phone: 1-877-598-5820, HMS Third Paqy_ LiaNlit
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/equalityGare
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
PacificSource Health Plans
PO Box 7068
Springfield, OR 97475-0068
(888) 977-9299
Fax: (541) 684-5264
cs@ pacificsou rce. com
Internal Revenue Service and Plan Identification Number
The corporate tax identification number assigned by the Internal Revenue Service is
936002117.
Benefit Year
The benefit 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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CITY OJIF
-ASH LA.N D
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 SingleSource Self-Insured
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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-i nsured,' 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, extension 1009
cs@pacificsou rce. 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 COVERAGE 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 35
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 If 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
SingleSource Self-Insured 7
RIGHTS OF PLAN MEMBERS 83
SingleSource Self-Insured 8
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
PacificSource at:
PacificSource Health Plans
PO Box 7068
Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
email: cs@pacificsource.com
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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: 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.
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 BabyMell 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% ro-insurance 30% co-insurance
RoutineColonoscopy 10% co-insurance 30% co-insuranne
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%oo-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-insuranre 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 PacificSource has not contracted with providers in the geographical area of the members 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.
PRESCRIPTION DRUG OUT-OF-POCKET LIMIT $2,500
The co-payment and/or co-insurance for prescription drugs obtained from a participating pharmacy is
waived at participating pharmacies during the remainder of a calendar year in which you have satisfied
a Prescription Drug Out of Pocket Limit of $2,500. The limit applies to each member. Claims must be
submitted by the participating pharmacy electronically. Differential between brand name and generic
drugs, and drugs obtained at a non-participating pharmacy do not apply toward the limit.
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
PacitcSource 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.
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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
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
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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.
- 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 co-payments 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: 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.
DENTAL BENEFIT SUMMARY
Subject to all the terms of this Group Dental Policy, the Plan Sponsor will 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 II 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 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, 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 Sponsorwill pay 50% of the usual, customary and reasonable for orthodontics for all covered
individuals.
Lifetime Maximum
The maximum amount payable by the Plan Sponsorfor 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 Sponsor's monthly or periodic payments for orthodontics shall cease if your eligibility
is terminated.
• The Plan Sponsor's 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, co-payment, and/or co-insurance 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.
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 participating providers and/or a list of participating health care professionals
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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, co-
payment, and/or co-insurance 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
PPG'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 20
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 21
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 co-payments 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 22
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 Sponsorwill 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 23
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.
QualiRed 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 Sponsors 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 Sponsors 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 (FIALA). 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 24
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 Sponsors 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 FMLA leave.
Member lD 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
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 COVERAGE
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 60 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
Sponsor will 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 QualiRed 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 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.
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 Sponsorwithin 30 days of your Plan Sponsor's 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 PERS (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 60 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 Coverage 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.
Co-payments - Co-payments 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 co-payments do not apply to your annual deductible or out-of-pocket maximum,
unless otherwise specified on the Medical Benefit Summary. The co-payment 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 Benefit
In the event of an injury caused by an accident the plan benefit will be as follows:
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 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 to mammograms that are
considered 'routine' according to the guidelines of the U.S. Preventive Services Task
Force.
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.
SingleSource Self-Insured 33
Breast exams annually for women 18 years of age or older or at anytime 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:
- 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 to colonoscopies that
are considered 'routine' according to the guidelines of the U.S. Preventive Services
Task Force.
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
SingleSource Self-Insured 34
• 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:
• 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.
SingleSource Self-Insured 35
• 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
• 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
SingleSource Self-Insured 36
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.
• 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. 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
SingleSource Self-Insured 37
• Difficulty breathing
• Sudden fevers
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
fora 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
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
SingleSource Self-Insured 38
• 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
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:
SingleSource Self-Insured 39
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
- 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
SingleSource Self-Insured 40
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.
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 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
SingleSource Self-Insured 41
• Pancreas whole organ transplantation (under certain criteria)
• Heart
• Heart - Lung
• 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 PacifcSource member, only those complications of the donation that occur
during the initial hospitalization are covered up to $8,000, 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, up to $8,000 (as outlined above).
• 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 LICR 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.
SingleSource Self-Insured 42
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
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 co-
insurance. 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, Norplant 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
SingleSource Self-Insured 43
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 16 months after the injury, surgery, scar,
or defect first occurred. Preauthorization by PacificSource is required for all cosmetic and
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.
SingleSource Self-Insured 44
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.
• 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 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, than 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,
SingleSource Self-Insured 45
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.
• 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)
SingleSource Self-Insured 46
• 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
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
SingleSource Self-Insured 47
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,
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 fallowing 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 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.
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
• 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
SingleSource Self-Insured 48
• Educational or correctional services or sheltered living provided by a school or halfway house
• Equine/animal therapy
• 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
• 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.
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
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;
SingleSource Self-Insured 49
• 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 coverage 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
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
SingleSource Self-Insured 50
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.
• Benefits not stated - Services and supplies not specifically described as benefits under the group
health policy and/or any endorsement attached hereto
SingleSource Self-Insured 51
EXCLUSION PERIODS
Exclusion Period for Transplant BeneTts
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 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 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.
The medical professionals who conduct the program focus their review on the appropriateness for
reimbursement of hospital stays and proposed surgical procedures.
SingleSource Self-Insured 52
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
Espanol (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:
• Terminal illnesses (Cancer, AIDS, Multiple Sclerosis, Renal Failure, Obstructive Pulmonary
Disease, Cardiac conditions, etc.)
SingleSource Self-Insured 53
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 Sponsor's 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 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 ll 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 ll 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 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.
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).
• 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.
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 coverage 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@pacificsou rce. 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
12190 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, extensi6n 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
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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
Espahol (800) 624-6052, extensi6n 1009
cs@ pacificsou rce. 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.
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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 Parry 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.
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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 64
• 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 65
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 PacifcSource 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 PacifcSource 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 PacifcSource
PacifcSource 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 66
• 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
http://insurance.oregon.gov/consumer/consumer.html, or by email at cp.ins@state.or.us.
Plan Sponsoes 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.
SingleSource Self-Insured 67
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,
co-payments and co-insurance. 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, co-payments and co-insurance 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, co-payments and co-insurance. 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. This does not apply to City of
Ashland.
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;
SingleSource Self-Insured 68
o The natural parent without custody's coverage pays third; and
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 PacifcSource 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
SingleSource Self-Insured 69
for the specific claim involved at the time, and will not be a continuing waiver of the term or condition in
the future.
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 PacifcSource may be provided in any form or document
that the Plan Sponsor and PacifcSource 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 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 Sponsorwill 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 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 Sponsoror
PacifcSource 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
enrol lment/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 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.
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 Sponsor will
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, 11, 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 ft 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.
SingleSource Self-Insured 75
Co-payment or co-insurance 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 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 60 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 Sponsors 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 member or 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.
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;
• 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;
SingleSource Self-Insured 81
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 PacifcSource. 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 administratoris 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
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.
SingleSource Self-Insured 82
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 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 83
ALABAMA - Medicaid COLORADO - Medicaid
Website: http://www.medicaid.alabama.gov Medicaid Website: http://w".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.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.flmedicaidtplrecovery.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:/Avww.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:/twww.state.nj.us/humanservices/
MAINE - Medicaid dmahs/clients/medicaid/
Website: http://www.maine.gov/dhhs/ofi/public- Medicaid Phone: 1-800-356-1561
assistancelndex.html CHIP Website:
Phone: 1-800-977-6740 http://www.njfamilycare.org/index.html
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:/Avww.dss.mo.gov/mhd/participants/pages/hipp.ht http://www.nd.gov/dhs/services/medicalserv/medirai
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/uoD
Phone: 1-888-365-3742 Phone: 1-866-435-7414
OREGON - Medicaid and CHIP VERMONT- Medicaid
Website: http:/hvww.oregonhealthykids.gov Website: http://www.greenmountaincare.org/
http://www.hijossaludablesoregon.gov Phone: 1-800-250-8427
Phone: 1-877-314-5678
SingleSource Self-Insured 84
PENNSYLVANIA - Medicaid VIRGINIA - Medicaid and CHIP
Website: http://ewiw.dpw.state.pa.us/hipp Medicaid Website: http://www.dmas.virginia.gov/rcp-
Phone: 1-800-692-7462 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 PartLiabilit
SOUTH DAKOTA - Medicaid WISCONSIN - Medicaid
Website: http://dss.sd.gov Website: http://www.badgercareplus.org/pubs/p-
Phone: 1-888-828-0059 10095.h
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 09/30/2013)
SingleSource Self-Insured 85
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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
PacificSource Health Plans
PO Box 7068
Springfield, OR 97475-0068
(888) 977-9299
Fax: (541) 684-5264
cs@pacificsource.com
Internal Revenue Service and Plan Identification Number
The corporate tax identification number assigned by the Internal Revenue Service is
936002117.
Benefit Year
The benefit 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
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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
B
Title
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SingleSource Self-Insured 90
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 riles 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.
When you appeal an adverse benefit determination at levels 1 or II, 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
these 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
1
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 vocation 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 provides for three levels of appeal, as follows.
LEVEL I:
The Third Party Administrator will evaluate all the information and make a decision. The Third Party
Administrator will advise you in writing of its decision and the reasons for it. Some appeals may take
longer if there are delays beyond the Plan's control. In those cases, an additional 15 days may be needed
to resolve your appeal. The Claims Administrator will give you or the authorized representative a notice
of delay that includes a specific reason for the delay.
Written or electronic notice of the Claims Administrator's decision will be provided to you within:
• 30 days of receipt of a appeal for a Post-Service Claim;
• . 15 days of receipt of a appeal for a Pre-Service Claim or a Concurrent Care Claim; or
• 72 hours of receipt of an appeal for an Urgent Care Claim.
Except for appeals concerning Urgent Care Claims, if the Plan Participant is not satisfied with the
outcome at Level I, the Plan Participant may request a review at Level II:
• If regarding a Post-Service Claim, 60 days of the date you are notified of the outcome of the
Level I review;
• If regarding a Pre-Service Claim, 30 days of the date you are notified of the outcome of the Level
1 review; or
• If regarding a Concurrent Care Claim, 15 days of the date you are notified of the outcome of the
Level I review.
If regarding an Urgent Care Claim, 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 no 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 a level III
independent external review take place at the same time as you pursue the plan's internal appeal process.
LEVEL II:
2
The Appeal will be reviewed by the Plan Administrator. The Plan Administrator may elect to delegate
this review to the Third Party Administrator or an independent external review organization chosen by the
Plan Administrator. You should provide the Plan Administrator with any additional information not
previously reviewed to support the Appeal. Such additional information should be provided with the
Appeal or as soon after the Appeal is submitted as possible, but in no event later than 20 days after
submission of the Appeal.
You may also provide a written statement to the Plan Administrator explaining why the Appeal should be
resolved as you have requested. The written statement must be provided no later than 20 days after
submission of the Appeal at Level II. Any written statement you provide will be reviewed and considered
by the Plan Administrator in deciding the Appeal.
If the Plan Administrator has elected to delegate review of the Appeal to an independent review
organization, the written statement will be provided to the independent review organization for review
and consideration. In the event you fail to timely provide additional information or a written statement in
support of the Appeal, the additional information or written statement will not be considered. The Plan
Administrator's decision regarding the Appeal shall be based on (1) the findings and conclusions of a
delegated external review, if any, and (2) the express terms and conditions of the Plan Document. Written
or electronic notice of the Plan Administrator's decision will be provided,to the Plan Participant within:
• 30 days of receipt of a Appeal for a Post Service Claim;
• 15 days of receipt of a Appeal for a Pre-Service Claim or a Concurrent Care Claim; or
If you are not satisfied with the outcome of the Level III review, you may request a third and final
external review through Level III.
LEVEL III:
This Plan has an external review program that meets the requirements of ORS 743.857(1)(a)(b) or (c),
ORS 743.859(1)(2) or (3), and ORS 743.861(1). External reviews will be provided through an
independent review organization that is under contract with the Oregon Director of the Department of
Consumer and Business Services. You may include additional written information which will be
included with the documents provided to the independent review organization.
You may, by written application to the Plan, obtain review by an independent review organization for a
Level III Appeal on one or more of the following:
• Whether a course or plan of treatment is medically necessary and/or appropriate.
• Whether a course or plan of treatment is experimental or, investigational as defined by the Plan
document.
• Whether the health care setting or level of care is appropriate.
• Whether medical standards of care demonstrate the effectiveness of the proposed course of
treatment.
3
• Whether a course or plan of treatment that you are undergoing is an active course of treatment for
purposes of continuity of care under ORS 743.854.
You must apply in writing for external review of an adverse decision by the Plan not later than
180 days after receipt of the Plan's final written decision following Step 1 and 11 of this Appeal
procedure. You are eligible for external review only if the following requirements have been met:
• You must have signed a waiver granting the independent review organization access to your
medical records.
• You must have exhausted all review rights through Level I and Level 11 of the Plan's Appeal
procedure before submitting a request for a Level III external review. The Plan may waive the
requirement of compliance with the internal Appeal procedure and have a dispute referred
directly to external review upon your written consent.
• You must provide accurate and complete information to the independent review organization in a
timely manner.
The Plan agrees to be bound by the results of the Level III external review. 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.
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;
• A statement disclosing an internal rule, guideline, 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.
4
2014 City of Ashland Self-Insured Plan
Renewal Benefit Changes for ACA compliance
EligibilitV Changes:
Foster Children who are placed with a member by an authorized placement agency or by
judgment, decree, or other order of any court of competent jurisdiction are eligible under their
foster parent's health plan under the ACA.
Same gender non-registered Domestic Partners should be updated in the Plan Document to
include same gender marriage if they are married a in a State that recognizes same sex marriages,
even if residence is in a State that does not recognize same sex marriage.
Vision Plan:
Pediatric Vision Coverage is an essential health benefit (EHB). While large employers are not
required to cover pediatric vision, the benefit must comply with the related ACA provisions for
members under age 19 years old.
(Pediatric) Eve Exams
• No dollar maximum
• One eye exam per calendar year
(Pediatric) Vision Hardware
• No dollar maximum (replaced with a prior authorization requirement for frames over
$175).
• No charge for one pair of non-collection glasses (frames and/or lenses) per calendar year.
• Collection glasses (lenses and frames) are not covered. Collection lenses or frames refer
to brand name hardware when comparable non-brand/non-collection glasses are
available.
• Elective contact lenses are in lieu of frames/lenses, up to the following limits per calendar
year:
➢ Standard (one pair) 1-contact lens per eye (total 2 lenses); or
➢ Monthly (six-month supply) - 6 lenses per eye (total 12 lenses); or
➢ Bi-weekly (three-month supply) - 6 lenses per eye (total 12 lenses); or
➢ Dailies (one-month supply) - 30 lenses per eye (total 60 lenses).
c
CITY OF
ASHLAND
Council Communication
June 3, 2014, Business Meeting
Update from Housing and Human Services Commission regarding the
Development of the Strategic Social Services Grant review
FROM:
Linda Reid, Housing Program Specialist, Community Development Department, reidl@ashland.or.us
SUMMARY
The Housing and Human Services Commission is requesting that the Council allow the commission to
undertake the drafting of a strategic plan for the use of social service grant funds. The strategic plan
will address several criteria formerly identified by the Council for analysis as well as recommend goals
and outcomes for future grant funded projects based on priorities identified by the Council and the
Budget Committee. A draft of the plan is scheduled to be completed and brought to the Council and
Budget Committee for consideration in August/September of 2014.
BACKGROUND AND POLICY IMPLICATIONS:
At their regular meeting on December 17, 2013, the City Council approved a motion to "request the
new Housing and Human Services Commission to conduct an analysis of the current social service
grant program, focusing on whether grants are targeted to the right areas and with the appropriate
allocations, then have them bring those findings to a discussion with the Budget Committee." To
address the Council's request, the Housing and Human Services Commission evaluated the following
questions:
• What is the history and background of Ashland's social service grant program?
o What are the goals of the social service grant program?
o Are the program goals being met?
• What is the application process?
o Is the process of soliciting and screening grant applications efficient and effective?
o Is the process of awarding grants efficient and effective?
o Could the award and reporting processes be improved?
o Should the Housing and Human Services Committee have a role in the process?
o What are the follow-up reporting requirements on outcomes?
o What is the assessment of the processes by prior grantees?
• How is the Ashland community benefitting from the grant awards?
o Is this the most efficient and effective use of the funding?
o Is the funding leveraging additional investments in the community?
o Are there efficiencies to be gained by awarding fewer organizations larger grants?
Page 1 of 2
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CITY OF
-AS H LAN D
• Should the criteria for award target particular community needs?
o How would any funding criteria or priority needs be determined overtime?
o Should there be funding restrictions?
The Housing and Human Services Commission reviewed and discussed the charge at their regular
meeting on January 23, 2014. At that time, the Commission decided that the most efficient way to
analyze the existing social service grant program and address the specific questions identified above
was to develop a strategic plan for the use of the social service grant funds. The plan would evaluate
the questions/specific areas of interest identified above and use those answers to inform the analysis
and propose a plan which would set forth objective criteria for making grants and identify measurable
outcomes for funded activities.
FISCAL IMPLICATIONS:
N/A
STAFF RECOMMENDATION AND REQUESTED ACTION:
The Housing and Human Services Commission recommends that the Council direct the Commission to
develop a strategic plan for the use of social service grant funds to bring back to the council for
consideration
SUGGESTED MOTION:
I move to direct the Housing and Human Services Commission to undertake the development of a
strategic plan for the use of social service grant funds to bring back to the council for consideration.
ATTACHMENTS:
Strategic Plan Proposal
Strategic Plan Timeline
Page 2 of 2
SOCIAL SERVICES GRANT PROPOSAL TO THE COUNCIL
The Housing and Human Services Commission will;
• Work with staff to develop program specific Strategic Plan with measurable goals and objectives
to inform the decision making process in awarding social service grant funds.
• Work with Council to define broad priorities for the use of the funds and measurable goals.
goal/outcome identification
• Review the previously drafted strategic plan for the use of Social Service Funds to see if there are
priorities identified which are still relevant. Review ofhistory and purpose ofprogram
• Engage current and former grantees, social service organizations, and the public in reviewing the
current process, elicit suggestions on potential changes to the process and to gain feedback on
potential goals. Application process evaluation/recommendation
• Examine the makeup of past grants; evaluate the range of services previously funded, with regard
to met and unmet needs, include an analysis of the ratio of funding to local agencies to regional
agencies._Application process evaluation
• Utilize the social service inventory and gaps analysis and other pertinent demographic reports to
inform goals and objectives. Identify priority needs/quantify goals/outcomes
• Draft a short (4-5 page) strategic plan to be reviewed periodically and revised as needed. The
strategic plan will include:
i. A brief history/background of the Social Service Grant program, an evaluation of the
current application process including feedback from past, current, and potential
applicants.
ii. An outline of the goals of the social service grant program including identified
"priority needs/uses"
iii. Quantified target goal outcomes over an identified period of time
iv. A methodology for quantifying and measuring goal outcomes
• Provide a recommendation regarding the existing process of granting Social Service Grant funds.
a cog c. 'v wm» z - .waq maon ..m vise r.
c > , „ ?Rropgser! Time/nreaElements Rer! 04/Ip/I ,
Steps TasA Date Deliverable
Gather data and compile a Gaps
] Analysis Febmary/April 2014 Matrix of services vs. needs
Data presentation-brainstorm any other
Brainstorming Agenda item at informational needs/gaps among commission
2 the H&I IS meeting Febmary-14 members
Draft a Recommendation for Staff to prepare a recommendation based on
Council (and budget discussion from commission members of what
3 committee?) April-14 proposal will be presented to council.
Brief review and approval of draft
Bring to H&HS for review and recommendation to council at the March
4 approval April-14 Meeting if there is time.
Present a recommnndation to the
council to work with the H&HS
Commission to draft a strategic
$ plan June 2 or 16, 2014 Recommendation/Timeline
'Strategte an Timeline
Generate a list of invitees, draft an email-flyer,
send it out to invitees. Feedback from
H&HS agenda or subcommittee community outreach meeting participants on;
item: plan community outreach social service process, grant fund amounts,
meeting, what will it look like, reporting requirements, grant fund uses, and
1 what do we want to learn? June-14 priority needs for the community
Hold a meeting to gain feedback July 24, 2014 or an
from SS Grant recipients and earlier date in July (I
Community Members at regular maybe out of the omce
2 H&HS meeting time/date 7/19-08/02)
Draft an outline/preliminary
document/Review at regular
3 meeting July/August 2014 Draft document
Study Session with Find out if the priorities proposed by the SS
council/budget committee? to go grant recipients and community memboers are
over findings, review draft amenable to them and if they have anything that
4 document and discuss priorities? August-14 they would like to add.
Revise document with
suggestions from Council/budget
committee, incorporate priorities
$ suggested by Council August/September 14 Final version of the strategic plan
H&HS comm review and
recommendations of draft
6 document August/September 14
Dra0 an ordinance to adopt the
strategic plan for the use of
7 Social Service Grant Funds September-14
Bring draft document and
ordinance with recommendations
from advisory commission to September/October
$ council for review and adoption 2014
Complete revisions and bring
forward for first reading/second October/November
9 reading? 2014
Document is adopted-30 days November/December
10 later is enacted 2014 Completed adopted Strategic Plan
CITY OF
ASHLAND
Council Communication
June 3, 2014, Business Meeting
Second Reading of an Ordinance Amending AMC Chapter 2.26, Firewise
Commission to Ashland Wildfire Mitigation Commission
FROM:
Chris Chambers, Forest Division Chief, Ashland Fire & Rescue, chamberc@ashland.or.us
SUMMARY
This is an ordinance to create a Wildfire Mitigation Commission in place of the Firewise Commission.
The initial vision for the Firewise Commission's role has not been as central as originally conceived;
while at the same time a new federal program called Fire Adapted Communities has provided Ashland
with an opportunity to engage in a comprehensive and long-term program of work to address a wider
range of wildfire preparedness issues. By changing the charge and name of the Firewise Commission,
the City will address a larger suite of issues related to wildfire protection in Ashland.
BACKGROUND AND POLICY IMPLICATIONS:
The proposed ordinance expands the scope of the current Firewise Commission and retains the current
seated commissioners. The Firewise Commission was created in 2010 to assist in implementation of
the Firewise Communities program. Work on the ground has been largely driven by staff, with 12
neighborhoods and nearly 900 individual homes now with a heightened state of wildfire safety. The
Firewise Commission's role thus became less urgent over time, while the need for the Firewise
Communities approach strengthened. The Fire Adapted Communities program requires significant
investments of time for planning and engaging citizens and stakeholders during policy development.
Where Firewise is a recognition based program that we will retain and expand, Fire Adapted
Communities is a program of work over time that successively lowers a community's risk to wildfire
on many fronts. The ordinance, while mentioning the Fire Adapted Communities program, does not
limit the commission's purview to a particular federal program, realizing that programs come and go
over time while the wildfire problem is relatively constant at the local level. The new commission will
be guiding community input on issues related to wildfire protection and prevention, and making
recommendations to Council as issues mature to the policy level.
FISCAL IMPLICATIONS:
There is no fiscal impact to the City.
STAFF RECOMMENDATION AND REQUEST~E ACTION:
Staff recommends Council approve first rea ' g of this ordinance and move to second reading.
SUGGESTED MOTION:
I move approval of second reading by title only of an ordinance titled "An Ordinance Amending AMC
Chapter 2.26, Firewise Commission to Ashland Wildfire Mitigation Commission"
Page I of 2
Pl,
CITY OF
ASHLAND
ATTACHMENTS:
Wildfire Mitigation Commission ordinance.
Page 2 of 2
~r,
ORDINANCE NO.
AN ORDINANCE AMENDING AMC CHAPTER 2.26 FIREWISE
COMMISSION TO ASHLAND WILDFIRE MITIGATION COMMISSION
Annotated to show deletions and additions to the code sections being modified. Deletions are
bold lined through and additions are bold underlined.
WHEREAS, Article 2. Section 1 of the Ashland City Charter provides:
Powers of the City. The City shall have all powers which the constitutions, statutes, and
common law of the United States and of this State expressly or impliedly grant or allow
municipalities, as fully as though this Charter specifically enumerated each of those
powers, as well as all powers not inconsistent with the foregoing; and, in addition thereto,
shall possess all powers hereinafter specifically granted. All the authority thereof shall
have perpetual succession.
WHEREAS, Ashland Fire & Rescue desires to create a commission to develop, implement, and
maintain a community wildfire mitigation strategy.
THE PEOPLE OF THE CITY OF ASHLAND DO ORDAIN AS FOLLOWS:
SECTION 1. Chapter 2.26 of the Ashland Municipal Code is hereby amended to read as
follows:
FIREWISE ASHLAND WILDFIRE MITIGATION COMMISSION
Section 2.26.010 Purpose
The re rise Ashland Wildfire Mitigation Commission shall provide advice and guidanee
support to the Council and eCity departments and education to the community on wildfire
issues and plans for mitigation actionwithin the community. Specifically, the Commission will
function as the entity to foster the efforts of the City of Ashland to adopt and achieve the
goals set forth in the Fire Adapted Communities program City' support and maintain the certification through Firm,ise Communities, USA.
Section 2.26.020 Established Membership
The wise Ashland Wildfire Mitigation Commission is established and shall consist of no
less than seven (7) voting members, and certain non-voting ex officio members consisting of a
member of the City Council, a representative of Ashland Fire and Rescue, and additional staff as
needed. The Fire Department st& f designee shall serve as the primary staff liaison and as
Secretary of the Commission. Voting members will be community members at large, and shall
be designated by the Mayor and confirmed by the Council. Community members will be
encouraged, but not limited to, neighbor-hood r-epy-esentatives based on FireWiSe
Communities neighbor-hoods.
Section 2.26.030 Powers and Duties Generally
Ordinance No. _ Page 1 of 2
The powers, duties and responsibilities of the ; ire Ashland Wildfire Mitigation
Commission shall be as follows:
A. To develop, coordinate and promote wildfire mitigation aetivities based on Firewise
a comprehensive community wildfire strategy;
B. To initiate, and enhance and promote full eitizew community participation and
responsibility in reducing wildfire risk;
C. To submit recommendations to City Council and eCity departments regarding the
community's wildfire safety mitigation strategy; and
D. To implement and renew Firewise Communities USA eer-tifiention on an annual basis;
and
1, To promote and support a relationship with surrounding areas and jurisdictions that
pertain to or benefit wildfire safety in Ashland. public knowledge and neeeptanee of th
Firewise Communities program and homeowner- par-fleipatien in assit-i-
SECTION 2. Savings. Notwithstanding this amendment/repeal, the City ordinances in existence
at the time any criminal or civil enforcement actions were commenced, shall remain valid and in
full force and effect for purposes of all cases filed or commenced during the times said
ordinances(s) or portions thereof were operative. This section simply clarifies the existing
situation that nothing in this Ordinance affects the validity of prosecutions commenced and
continued under the laws in effect at the time the matters were originally filed.
SECTION 3. Severability. The sections, subsections, paragraphs and clauses of this ordinance
are severable. The invalidity of one section, subsection, paragraph, or clause shall not affect the
validity of the remaining sections, subsections, paragraphs and clauses.
SECTION 4. Codification. Provisions of this Ordinance shall be incorporated in the City Code,
and the word "ordinance" may be changed to "code", "article", "section", or another word, and
the sections of this Ordinance may be renumbered or re-lettered, provided however, that any
Whereas clauses and boilerplate provisions (i.e., Sections [No 3-4] need not be codified, and the
City Recorder is authorized to correct any cross-references and any typographical errors.
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 2014,
and duly PASSED and ADOPTED this day of 2014.
Barbara M. Christensen, City Recorder
SIGNED and APPROVED this day of , 2014.
John Stromberg, Mayor
Reviewed as to form:
David H. Lohman, City Attorney
Ordinance No. _ Page 2 of 2
CITY OF
ASHLAND
Council Communication
June 3, 2014, Business Meeting
First Reading of two separate ordinances amending the City of Ashland
Comprehensive Plan, Comprehensive Plan Maps, Transportation System Plan,
and Street Standards to adopt the Normal Neighborhood Plan
FROM:
Brandon Goldman, Senior Planner, Community Development Department,
Brandon. Goldman@ashland.or. us
SUMMARY
These two ordinances amend the Comprehensive Plan and Transportation System Plan to implement
the Normal Neighborhood Plan. A Normal Neighborhood District Land Use code amendment is
presented for discussion only. It will be reviewed as part of a separate legislative action in the
upcoming months and is intended to be included in the Unified Land Use Ordinance. Given the
interrelated nature of the Normal Neighborhood Plan elements this Draft Land Use Ordinance, this
language is presented for Council consideration, discussion, and direction at the May 6`h hearing.
The Normal Neighborhood Plan will guide future development associated with approximately 94 acres
of unincorporated lands within Ashland's Urban Growth Boundary. It attempts to implement existing
City land use policies that promote the construction of diverse housing types and a neighborhood
network of connected streets, walkways and cycling facilities, while requiring integration of, and
protection for, the neighborhood's natural areas, consisting of wetlands, creeks and associated
floodplains and riparian areas.
BACKGROUND
In March of 2011 the City Council directed the Community Development Department to apply for a
Transportation and Growth Management (TGM) grant to prepare a neighborhood master plan for the
94 acre Normal Neighborhood area. Having received the grant award in May 2012, an extensive
public involvement process was undertaken to develop the plan. Public engagement included 32 public
meetings where the viewpoints of a variety of participants including the general public, property
owners and neighboring residents affected the plan's evolution.
On December 2, 2013, the City Council received an update on draft plan which had been discussed by
the Transportation Commission and Planning Commission at their September, October, and November
meetings. The final Normal Neighborhood Plan and draft implementing ordinances were initially
presented to the Planning Commission at a study session on February 25, 2014. The Planning
Commission held a public hearing on the final plan on March 11 th, and completed its deliberations on
April 8, 2014.
The Normal Neighborhood Plan is comprised of Normal Neighborhood Plan Framework document,
official Normal Neighborhood Plan maps, and the proposed Normal Neighborhood District land use
Page 1 of3
1r,
CITY OF
ASHLAND
ordinance amendments (Ch. 18-3.13). Collectively these documents create the underlying physical
form and regulatory structure for the area's future development. Development of this area is expected
to occur in an incremental way, as individual parcels propose annexation for specific housing
developments. The adoption of a Neighborhood Plan for the area will ultimately provide a general
framework for evaluating future annexation requests to ensure that in addition to housing the
coordination of streets, pedestrian connections, utilities, storm water management and open space is
considered as part of development proposals.
A detailed description of the proposed Normal Neighborhood plan's land use, transportation, and open
space, frameworks is provided in the attached Planning Action Staff Report (PL-2013-01858).
Council held a public hearing on this item on May 6, May 20, and May 29, 2014.
NEXT STEPS
Upon approval of first reading of the Normal Neighborhood Plan's implementing ordinances, the final
plan and ordinances, as amended, will be presented to the City Council for second reading.
The Normal Neighborhood District Land Use Ordinance will be presented for legislative approval as
part of the Unified Land Use Ordinance hearing process and will be forwarded to the City Council
following the Planning Commission's public hearing and deliberation.
FISCAL IMPLICATIONS:
N/A
STAFF RECOMMENDATION AND REOUESTED ACTION:
Staff believes the revisions that have been made over the last 15 months have refined and improved the
neighborhood plan, and are largely consistent with the original goals and objectives for the planning
project.
Staff recommends Council approve first reading of the ordinance amending the Comprehensive Plan,
Comprehensive Plan Map, and adopting of the Normal Neighborhood Plan Framework as a technical
supporting document of the Comprehensive Plan.
Staff recommends Council approve first reading of the ordinance amending the Transportation System
Plan maps and Street Standards handbook to incorporate the Normal Neighborhood Street Network as
proposed. The Future Traffic Analysis conducted as part of this planning effort found that all existing
intersections in vicinity of the project are expected to continue to function within operational standards
at full build out of the plan area. Further the report confirms that each of the planned street
intersections with East Main Street are expected to function within applicable mobility standards upon
the improvement of East Main Street to meet City standards to include sidewalks and bike lanes.
The proposed Normal Neighborhood District Land Use ordinance will be reviewed as part of the
broader Unified Land Use Ordinance amendment process. However, given the interrelated nature of
the Normal Neighborhood Plan elements, the City Council is asked to provide recommendations on
this ordinance as part of tonight's hearing.
Page 2 of 3
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CITY OF
ASHLAND
SUGGESTED MOTION(S):
Individual motions are required to address each of the proposed ordinances separately:
I move to approve the first reading by title only of an ordinance titled "An Ordinance amending the
City of Ashland Comprehensive Plan to add a Normal Neighborhood Plan designation to Chapter II
[Introduction and Definitions], Change the Comprehensive Plan Map designation for approximately 94
acres of land within the City of Ashland Urban Growth Boundary from Single Family Residential and
Suburban Residential to the Normal Neighborhood Plan Designation, and adopt the Normal
Neighborhood Plan Framework as a support document to the City of Ashland Comprehensive Plan,"
and move the ordinance on to second reading.
I move to approve the first reading by title only of an ordinance titled "An Ordinance amending the
Street Dedication Map, Planned Intersection and Roadway Improvement Map, and Planned Bikeway
Network Map of the Ashland Transportation System Plan for the Normal Neighborhood Plan area, and
amending Street Design Standards within the Street Standards Handbook to add a new Shared Street
classification," and move the ordinance on to second reading.
I move to recommend the Draft Land Use Ordinance for the Normal Neighborhood District be
incorporated into the Draft Unified Land Use Ordinance (as amended) to be reviewed under a separate
legislative action.
ATTACHMENTS:
Ordinance amending comprehensive plan
Exhibit A to ordinance amending comprehensive plan
Ordinance amending street dedication map
Exhibit A to ordinance amending street dedication map
Page 3 of 3
kepTrW,
ORDINANCE NO.
AN ORDINANCE AMENDING THE CITY OF ASHLAND
COMPREHENSIVE PLAN TO ADD A NORMAL NEIGHBORHOOD
PLAN DESIGNATION TO CHAPTER II [INTRODUCTION AND
DEFINITIONS], CHANGE THE COMPREHENSIVE PLAN MAP
DESIGNATION FOR APPROXIMATELY 94 ACRES OF LAND WITHIN
THE CITY OF ASHLAND URBAN GROWTH BOUNDARY FROM
SINGLE FAMILY RESIDENTIAL AND SUBURBAN RESIDENTIAL TO
THE NORMAL NEIGHBORHOOD PLAN DESIGNATION, AND ADOPT
THE NORMAL NEIGHBORHOOD PLAN FRAMEWORK AS A SUPPORT
DOCUMENT TO THE CITY OF ASHLAND COMPREHENSIVE PLAN
Annotated to show deletions and additions to the code sections being modified. Deletions are
bold and additions are in bold underline.
WHEREAS, Article 2. Section 1 of the Ashland City Charter provides:
Powers of the City The City shall have all powers which the constitutions, statutes, and
common law of the United States and of this State expressly or impliedly grant or allow
municipalities, as fully as though this Charter specifically enumerated each of those
powers, as well as all powers not inconsistent with the foregoing; and, in addition thereto,
shall possess all powers hereinafter specifically granted. All the authority thereof shall
have perpetual succession.
WHEREAS, the above referenced grant of power has been interpreted as affording all
legislative powers home rule constitutional provisions reserved to Oregon Cities. City of
Beaverton v. International Ass'n of Firefighters, Local 1660, Beaverton Shop 20 Or. App. 293;
531 P 2d 730, 734 (1975); and
WHEREAS, the City of Ashland Planning Commission considered the above-referenced
recommended amendments to the Ashland Comprehensive Plan at a duly advertised public
hearing on March It, 2014 and subsequent public hearing continuance dates, and on April 8,
2014, following deliberations, recommended approval of the amendments by a vote of 6-0; and
WHEREAS, the City Council of the City of Ashland conducted a duly advertised public hearing
on the above-referenced amendments on May 6, May 20, and May 29, 2014; and
WHEREAS, the City Council of the City of Ashland, following the close of the public hearing
and record, deliberated and conducted first and second readings approving adoption of the
Ordinance in accordance with Article 10 of the Ashland City Charter; and
Page I of 3
WHEREAS, the City Council of the City of Ashland has determined that in order to protect and
benefit the health, safety and welfare of existing and future residents of the City, it is necessary
to amend the Ashland Comprehensive Plan in manner proposed, that an adequate factual base
exists for the amendments, the amendments are consistent with the comprehensive plan and that
such amendments are fully supported by the record of this proceeding.
THE PEOPLE OF THE CITY OF ASHLAND DO ORDAIN AS FOLLOWS:
SECTION 1. The above recitations are true and correct and are incorporated herein by this
reference.
SECTION 2. The City of Ashland Comprehensive Plan, Chapter II, [INTRODUCTION AND
DEFINITIONS] is hereby amended to add the following new Section [NORMAL
NEIGHBORHOOD PLAN 2.04.171 and to adopt the Normal Neighborhood Plan Framework; as
amended, as a supporting document to the City's Comprehensive Plan; former Section 2.04.17 is
renumbered [PLAN REVIEW 2.04.181, to read as follows:
PLAN REVIEW (2.04.17)
NORMAL NEIGHBORHOOD PLAN (2.04.17)
This is a residential area that promotes a variety of housing types including single
family, attached, and multi family residential, with densities ranging from 5 to 15
units per acre. This area implements the Normal Neighborhood Plan Framework
(2014) to accommodate future housing, neighborhood scaled business, create a
system of greenwavs, protect and integrate existing stream corridors and natural
wetlands, and enhance overall mobility by planning for a safe and connected
network of streets and walking and bicycle routes.
PLAN REVIEW (2.04.18)
SECTION 3. The City of Ashland Comprehensive Plan Appendix entitled "Technical Reports
and Supporting Documents" is attached hereto and made a part hereof as Exhibit A.
SECTION 4. The document entitled "The City of Ashland Normal Neighborhood Plan
Framework (2014)," attached hereto as Exhibit B, and made a part hereof by this reference is
hereby added to the above-referenced Appendix to support Chapter II, [INTRODUCTION AND
DEFINITIONS] of the Comprehensive Plan.
SECTION 5. The officially adopted City of Ashland Comprehensive Plan Map, adopted and
referenced in Ashland Comprehensive Plan Chapter II [PLAN MAP 2.03.04] is hereby amended
to change the Comprehensive Plan map designation of approximately 94 acres of land inside the
urban growth boundary from Single Family Residential and Suburban Residential, to the Normal
Neighborhood Plan designation including designated Conservation Areas as reflected on the
revised adopted Comprehensive Plan Map, attached hereto as Exhibit C, and made a part hereof
by this reference.
Page 2 of 3
SECTION 6. Severability. The sections, subsections, paragraphs and clauses of this ordinance
are severable. The invalidity of one section, subsection, paragraph, or clause shall not affect the
validity of the remaining sections, subsections, paragraphs and clauses.
SECTION 7. Codification. Provisions of this Ordinance shall be incorporated in the City
Comprehensive Plan and the word "ordinance" may be changed to "code", "article", "section",
or another word, and the sections of this Ordinance may be renumbered, or re-lettered, provided
however that any Whereas clauses and boilerplate provisions (i.e. Sections 1, 3-6 need not be
codified and the City Recorder is authorized to correct any cross-references and any
typographical errors.
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 2014,
and duly PASSED and ADOPTED this day of 2014.
Barbara M. Christensen, City Recorder
SIGNED and APPROVED this day of , 2014.
John Stromberg, Mayor
Reviewed as to form:
David Lohman, City Attorney
Page 3 of 3
Exhibit A
Appendix A: Technical Reports and Supporting Documents
City of Ashland, Oregon Comprehensive Plan
Periodically, the City may choose to conduct studies and prepare technical reports to adopt by reference within
the Comprehensive Plan to make available for review by the general public. These studies and reports shall not
serve the purpose of creating new city policy, but rather the information, data and findings contained within the
documents may constitute part of the basis on which new policies may be formulated or existing policy
amended. In addition, adopted studies and reports provide a source of information that may be used to assist
the community in the evaluation of local land use decisions.
Chapter II, Introduction and Definitions
The following reports are adopted by reference as a supporting document to the Ashland Comprehensive Plan,
Chapter Il, Introduction and Definitions.
1. Croman Mill Site Redevelopment Plan (2008) by Ordinance 3030 on August 17, 2010
2. Normal Neighborhood Plan Framework (2014) by Ordinance on .20141
Chapter IV, Environmental Resources
The following reports are adopted by reference as a support document to the Ashland Comprehensive Plan,
Chapter IV, Environmental Resources.
1. City of Ashland Local Wetland Inventory and Assessment and Riparian Corridor Inventory (2005/2007) by
Ordinance 2999 on December 15, 2009.
Chapter VII, Economy
The following reports are adopted by reference as a support document to the Ashland Comprehensive Plan,
Chapter VII, The Economy.
1. City of Ashland: Economic Opportunities Analysis (April 2007) by Ordinance 3030 on August 17, 2010
Chapter XII, Urbanization
The following reports are adopted by reference as a support document to the Ashland Comprehensive Plan,
Chapter XII, Urbanization.
1. City of Ashland: Buildable Lands Inventory (2011) by Ordinance 3055 on November 15, 2011.
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CITY OF Exhibit C
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ORDINANCE NO.
AN ORDINANCE AMENDING THE STREET DEDICATION MAP,
PLANNED INTERSECTION AND ROADWAY IMPROVEMENT MAP,
AND PLANNED BIKEWAY NETWORK MAP OF THE ASHLAND
TRANSPORTATION SYSTEM PLAN FOR THE NORMAL
NEIGHBORHOOD PLAN AREA, AND AMENDING STREET DESIGN
STANDARDS WITHIN THE STREET STANDARDS HANDBOOK TO
ADD A NEW SHARED STREET CLASSIFICATION.
Annotated to show deletions and additions to the code sections being modified. Deletions are
bold hned4hFotFgh and additions are in bold underline.
WHEREAS, Article 2. Section 1 of the Ashland City Charter provides:
Powers of the Citv The City shall have all powers which the constitutions, statutes, and
common law of the United States and of this State expressly or impliedly grant or allow
municipalities, as fully as though this Charter specifically enumerated each of those
powers, as well as all powers not inconsistent with the foregoing; and, in addition thereto,
shall possess all powers hereinafter specifically granted. All the authority thereof shall
have perpetual succession.
WHEREAS, the above referenced grant of power has been interpreted as affording all
legislative powers home rule constitutional provisions reserved to Oregon Cities. City of
Beaverton v. International Ass'n of Firefighters, Local 1660, Beaverton Shop 20 Or. App. 293;
531 P 2d 730, 734 (1975); and
WHEREAS, the City of Ashland Planning Commission considered the above-referenced
amendments to the Transportation System Plan at a duly advertised public hearing on March 11,
2014 and subsequent public hearing continuance dates, and on April 8, 2014, following
deliberations, recommended approval of the amendments by a vote of 6-0; and
WHEREAS, the City Council of the City of Ashland conducted a duly advertised public hearing
on the above-referenced amendments on May 6, 20, and 29, 2014; and
WHEREAS, the City Council of the City of Ashland, following the close of the public hearing
and record, deliberated and conducted first and second readings approving adoption of the
Ordinance in accordance with Article 10 of the Ashland City Charter; and
WHEREAS, the Ashland Comprehensive Plan includes goals and policies intended to work
towards creating an integrated land use and transportation system to address the Transportation
Planning Rule (TPR) Oregon Administrative Rule 660-012-0000 directive for coordinated
land use and transportation plans should ensure that the planned transportation system supports a
pattern of travel and land use in urban areas that will avoid the air pollution, traffic and livability
Page I of 3
problems faced by other large urban areas of the country through measures designed to increase
transportation choices and make more efficient use of the existing transportation system."; and
WHEREAS, the Street Dedication Map, Planned Intersection and Roadway Improvement Map
and Planned Bikeway Network Map are adopted official maps for long range planning purposes,
and are periodically amended to identify streets and pedestrian and bicycle pats that will be
needed in the future to connect the street network and provide access to undeveloped areas
within the Urban Growth Boundary (UGB); and
WHEREAS, the Ashland Comprehensive Plan includes the following policies addressing street
dedications: 1) Development of a modified grid street pattern shall be encouraged for connecting
new and existing neighborhoods during subdivisions, partitions, and through the use of the Street
Dedication map. (10.09.02.32); and 2) Street dedications shall be required as a condition of land
development. A future street dedication map shall be adopted and implemented as part of the
Land Use Ordinance. (10.09.02.34).; and
WHEREAS, the City Council of the City of Ashland has determined that in order protect and
benefit the health, safety and welfare of existing and future residents, and to address changes in
existing conditions and projected needs related to land use and transportation patterns, it is
necessary to amend the Ashland Comprehensive Plan in the manner proposed, that an adequate
factual base exists for the amendments, the amendments are consistent with the comprehensive
plan and that such amendments are fully supported by the record of this proceeding.
THE PEOPLE OF THE CITY OF ASHLAND DO ORDAIN AS FOLLOWS:
SECTION 1. The above recitations are true and correct and are incorporated herein by this
reference.
SECTION 2. The officially adopted City of Ashland Street Dedication Map, referenced in
Ashland as Figure 10-1 in the Ashland Transportation System Plan is hereby amended to include
the Normal Neighborhood Plan Street Network attached hereto as Exhibit A.
SECTION 4. The City of Ashland Planned Bikeway Network Map, referenced in the Ashland
Transportation System Plan as Figure 8-1. is hereby amended to include the Normal
Neighborhood Plan Pedestrian and Bicycle Network attached hereto as Exhibit B.
SECTION 5. The City of Ashland Planned Intersection and Roadway Improvement Map,
referenced in the Ashland Transportation System Plan as Figure 10-3. is hereby amended to
include East Main Street as a Planned Avenue from Walker Avenue to Ashland St.
SECTION 6. The Ashland Street Standards Handbook, Street Design Standards
is hereby amended to include a new classification of "Shared Street" as attached hereto as
Exhibit C.
Page 2 of 3
SECTION 7. Severability. The sections, subsections, paragraphs and clauses of this ordinance
are severable. The invalidity of one section, subsection, paragraph, or clause shall not affect the
validity of the remaining sections, subsections, paragraphs and clauses.
SECTION 8. Codification. Provisions of this Ordinance shall be incorporated in the City
Comprehensive Plan and the word "ordinance" may be changed to "code", "article", "section",
or another word, and the sections of this Ordinance may be renumbered, or re-lettered, provided
however that any Whereas clauses and boilerplate provisions (i.e. Sections 1, 3-6 need not be
codified and the City Recorder is authorized to correct any cross-references and any
typographical errors.
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 2014,
and duly PASSED and ADOPTED this day of 12014.
Barbara M. Christensen, City Recorder
SIGNED and APPROVED this _ day of , 2014.
John Stromberg, Mayor
Reviewed as to form:
David Lohman, City Attorney
Page 3 of 3
CITY OF ExhibitA
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C I T Y OF Exhibit B
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Exhibit C
Shared Street
Provides access to residential in an area in which right-of-way is constrained by natural
features, topography or historically significant structures. The constrained right-of-way
prevents typical bicycle and pedestrian facilities such as sidewalks and bicycle lanes.
Therefore, the entire width of the street is collectively shared by pedestrians, bicycles,
and autos. The design of the street should emphasize a slower speed environment and
provide clear physical and visual indications the space is shared across modes.
Street Function: Provide vehicular, pedestrian, and bicycle neighborhood
circulation and access to individual residential and
commercial properties designed to encourage socializing
with neighbors, outdoor play for children, and creating
comfortable spaces for walking and biking.
Connectivity: Connects to all types of streets.
Average Daily Traffic: 1,500 or less motor vehicle trips per day
Managed Speed: Motor vehicle travel speeds should be below 15 mph
Right-of-Way Width: 25'
Pavement width: 18' minimum, maintaining full fire truck access and minimum
turning paths at all changes in alignment and intersections.
Motor Vehicle Travel Lanes: Minimum 12' clear width.
Bike Lanes: Not applicable, bicyclists can share the travel lane and easily
negotiate these low use areas
Parking: Parking and loading areas may be provided within the right
of way with careful consideration to ensure parked vehicles
do not obstruct pedestrian, bicycles, or emergency vehicle
access.
Parkrow: Not applicable
Sidewalks: Not applicable, pedestrians can share the travel lane and
easily negotiate these low use areas. Refuge areas are to be
provided within the right of way to allow pedestrians to step
out of the travel lane when necessary.
Shared Street Cross Section
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