HomeMy WebLinkAboutContracts & Agreements_258-2016HEALTH AND HUMAN RESOURCE CENTER, INC.
(dba AETNA RESOURCES FOR LIVING)
EMPLOYEE ASSISTANCE PROGRAM (EAP)
SERVICES AGREEMENT
Cover Sheet
Initial Term of Agreement: ......................................................... January 1, 2017 through December 31, 2018
Date of Submission of Initial Periodic Fees: ............................................................................ January 1, 2017
Effective Date of Coverage for Initial Members:..................................................................... January 1, 2017
Initial Periodic Fee: ........................................................................................ $1.52 Per Employee Per Month*
Other Pertinent Information:
* Provided that enrollment for City of Redlands does not exceed 550 covered employees, EAP fees are not to
exceed $10,000.00 per year.
Exhibits. A and B
Group
City of Red ands
By. `
Its:
Date:
35 Cajon Street, Suite 10
Redlands, CA 92373
Telephone: (909) 798-7514
Attest:
City Clerk
Plan
Health and Human Resource Center, Inc.,
dba Aetna Resources For Living
By:
(Peggy Wagner)
Its: President
Date:
10260 Meanley Drive
San Diego, CA 92131
Telephone: (800) 890-1921
HEALTH AND HUMAN RESOURCE CENTER, INC.
(dba AETNA RESOURCES FOR LIVING)
EMPLOYEE ASSISTANCE PROGRAM (EAP)
SERVICES AGREEMENT
Cover Sheet
Initial Term of Agreement:......................................................... January 1, 2017 through December 31, 2018
Date of Submission of Initial Periodic Fees:.... .......................... ............................................. January 1, 2017
Effective Date of Coverage for Initial Members: ... ............................................................ January 1, 2017
InitialPeriodic Fee:........................................................................................ $1.52 Per Employee Per Month*
Other Pertinent Information:
* Provided that enrollment for City of Redlands does not exceed 550 covered employees, fees are not to
exceed $10,000.00 per year.
Exhibits: A and B
G
Ci/ofReands
Bs
Its:
Date:
35 Cajon Street, Suite 10
Redlands, CA 92373
Telephone: (909) 798-7514
Attest:
City Clerk
Plan
Health and Human Resource Center, Inc.,
dba Aetna Resoure For Living
By:
Wagner]
Its: q Pr 'dent
Date: ��l
10250 Meanley Drive
San Diego, CA 92131
Telephone: (800) 890-1921
HEALTH AND HUMAN RESOURCE CENTER, INC.
(dba AETNA RESOURCES FOR LIVING)
EMPLOYEE ASSISTANCE PROGRAM (EAP)
SERVICES AGREEMENT
This Employee Assistance Program (EAP) Services Agreement ("Agreement") is made and entered into by
and between Health and Human Resource Center, Inc., doing business as Aetna Resources For Living
("Plan"), and the organization identified as Group on the Cover Sheet of this Agreement ("Group").
RECITALS
A. Plan operates a specialized health care service plan licensed under the Knox -Keene Health Care Service
Plan Act of 1975, as amended (the "Act"), and the regulations promulgated thereunder (the "Regulations").
B. Plan will provide and arrange for the provision of Benefits to Group employees and certain persons
associated with Group employees, as Members, in accordance with the terms, conditions, Limitations and
Exclusions of this Agreement, as such terms are defined below.
C. Group will pay Periodic Fees to Plan for the provision of Benefits by Plan to Group employees and certain
persons associated with Group employees, as Members.
AGREEMENT
NOW, THEREFORE, in consideration of the above recitals and the promises and covenants contained herein,
Plan and Group agree as follows:
I. DEFINITIONS
The following terms shall have the following meanings:
A. "Act" The Knox -Keene Health Care Service Plan Act of 1975, as amended (California Health and
Safety Code Sections 1340 et seq.).
B. 'Benefits" The coverages to which Members are entitled under this Agreement, and the services to
be provided to Group hereunder, which are set forth in Exhibit A to this Agreement.
C. "Director" Director of the California Department of Managed Health Care.
D. "EAP Provider" A licensed assessment and short-term counseling professional employed by, or under
contract with Plan to provide Benefits to Members.
E. "Exclusion" Any provision of this Agreement whereby coverage for Benefits is entirely eliminated.
F. "Evidence of Coverage" or "Combined Evidence of Coverage and Disclosure Form" The document
issued to an employee of Group which summarizes the essential terms of this Agreement.
G. "Group" The organization identified as such on the Cover Sheet of this Agreement.
EAP Services Agreement I
H. "Limitation" Any provision of this Agreement which restricts Benefits, other than an Exclusion.
I. "Member" An eligible employee of Group, the eligible employee's children under the age of 26,
persons covered under the eligible employee's health benefit plan, persons residing with the eligible
employee, including domestic partners.
J. "Periodic Fees" The monthly amounts due and payable to Plan from Group for providing Benefits to
Members.
K. "Plan" Health and Human Resource Center, Inc., doing business as Aetna Resources For Living.
L. "Regulations" Those regulations promulgated and officially adopted under the Act.
M. "Service Area" Those areas in which Plan is licensed to operate.
II. CHOICE OF PROVIDERS
Benefits must be obtained from an EAP Provider through Plan. A Member may obtain Benefits by
contacting Plan at 1-800-342-8111. Upon contact, Plan will determine the Member's eligibility for
Benefits and arrange for Benefits.
III. BENEFITS
Subject to all of the terms, conditions, Limitations and Exclusions of this Agreement, Members are entitled
to receive Benefits as follows:
A. Obtaining Benefits. Unless otherwise specifically stated to the contrary, the services described herein
are Benefits only if, and to the extent, that they are authorized and directed by Plan and performed by
an EAP Provider,
B Non -EAP Providers. In the event Plan fails to pay a non -EAP Provider, the Member will be liable to
such non -EAP Provider for the cost of services provided to the Member.
C. Benefits. Benefits may be changed in accordance with Section XII.A hereof.
IV. LINIITATIONS AND EXCLUSIONS
The rights of Members and the obligations of Plan hereunder are subject to the following Limitations and
Exclusions:
A. Limitation. In the event of any major disaster or epidemic, Plan shall provide Benefits to Members to
the extent practical, according to its best judgment, within the limitations of such facilities and
personnel as are then available. Plan shall have no liability to Members for any delay in providing or
failure to provide Benefits under such conditions.
B. Exclusion. Court ordered treatment or therapy, or any treatment or therapy ordered as a condition of
parole, probation or custody or visitation evaluations, is entirely excluded from. Benefits.
EAP Services Agreement2
V. PERIODIC FEES AND MEMBER CHARGES
A. Periodic Fees. Group shall remit to Plan, by the date specified on the Cover Sheet of this Agreement,
the number of employees entitled to receive Benefits as of the effective date of coverage for initial
Members also set forth on the Cover Sheet, together with the applicable Periodic Fees set forth on
Exhibit B of this Agreement for each such employee. Thereafter, on or before the first day of each
month of the term of this Agreement, Group shall provide Plan with the number of employees entitled
to receive Benefits during such month, and Plan shall invoice Group for Periodic Fees for such
employees. Group shall remit such Periodic Fees to Plan within thirty (30) days of receipt of Plan's
invoice therefore for Members entitled to receive Benefits during the month to which the invoice
applies. In the event Group fails to timely provide Plan with the number of employees entitled to
Benefits during a particular month, Plan may bill Group for Periodic Fees based on the most recent
employee count provided by Group and adjust subsequent invoices to reflect any discrepancies
accordingly. The Periodic Fees set forth on Exhibit B shall remain in effect for the term of this
Agreement, unless changed in accordance with Section XII.A hereof.
B. Other Charges. Plan shall invoice Group for additional services or benefits provided under this
Agreement. Group shall remit payment to Plan within thirty (30) days of receipt of each such invoice.
C. Member Charges. Members will not be required to make co -payments to EAP Providers for Benefits.
However, a Member is responsible for paying for the services of EAP Providers and others to whom
the Member is referred, when the services do not constitute Benefits.
VI. EFFECTIVE DATE OF BENEFITS
A. Initial Members. All employees of Group as of the effective date of this Agreement provided for on
the Cover Sheet hereof, and all persons entitled to be Members through such employees shall be
entitled to receive Benefits as of 12.01 a.m. on such effective date.
B. Subsequent Members. Any employee who becomes eligible after the effective date of this Agreement
and all persons entitled to be Members through the employee, shall be entitled to Benefits, effective
immediately. Group shall notify Plan of newly eligible employees.
VII. TERM AND TERMINATION
A. Term. The Initial Term of this Agreement for the provision of Benefits to Members hereunder is set
forth on the Cover Sheet of this Agreement.
B. Termination of Individual Member.
1. Loss of Eligibility. If an employee ceases to meet the eligibility requirements of Group, as
determined by Group's personnel and benefit policies, then coverage for Benefits under this
Agreement for such employee, and all other Members covered for Benefits through the employee,
terminates automatically at midnight on the last day of the month in which the employee ceases to
meet the eligibility requirements of Group. Group shall notify Plan monthly of the employees
ceasing to meet Group's eligibility requirements. Plan shall not charge an employee who ceases
to meet Group's eligibility requirements, or Members covered for Benefits through such employee,
for Benefits rendered prior to Group's notice to Plan of the employee's loss of eligibility.
EAP Services Agreement3
2. Ri ht to Review. A Member who alleges that his or her rights hereunder were terminated or not
renewed because of the Member's health status or requirements for Benefits, may request a review
of the termination by the Director pursuant to Section 1365(b) of the California Health and Safety
Code,
C. Termination of Groin.
1. Termination of this Agreement. This Agreement may be terminated by Group, with or without
cause, by giving Plan at least ninety (90) days advance written notice stating when, after the date
of such notice, termination shall become effective. This Agreement may also be terminated by
Plan for nonpayment, as provided in Section VII.C.2 and VII.C.3.
2. Nonpayment. If Group fails to pay any amount due Plan within thirty (30) days after Plan's notice
to Group of, and bill for the amount due, then Plan may terminate the rights of the Members
involved, effective upon Plan's issuance of notification of cancellation to Group. Such rights may
be reinstated only by payment of the amounts due and in accordance with Section VII.C.3. Plan
shall continue to provide Benefits to Members until expiration of the applicable reinstatement
period and shall not charge Members for services rendered during such period. Thereafter, Plan
shall not be liable for Benefits to Members.
3. Reinstatement. Receipt by Plan of the proper Periodic Fees within fifteen (15) days of Plan's
issuance of the notice of cancellation to Group for non-payment of Periodic Fees shall reinstate
the Members as though there never was a cancellation. If such payment is received after said
fifteen (15) day period, Plan, at its option, may either refund to Group the amounts paid and
consider this Agreement terminated, or issue to Group, within twenty (20) days of the receipt of
such payment, a new agreement accompanied by written notice stating clearly those respects in
which the new agreement differs from this Agreement in Benefits or other terms.
D. Extension of Benefits upon Termination
1. Termination of Provider Contract. Upon termination of a contract with an EAP Provider, Plan shall
be liable for Benefits rendered by such EAP Provider to Members who retain eligibility under this
Agreement, or by operation of law, under the care of such EAP Provider at the time of such
termination, until the Benefits being rendered to such Members are completed, or until Plan makes
reasonable provision for the assumption of such Benefits by another EAP Provider.
2. Group Continuation Benefits. Federal or state law requires Group to continue to make health care
benefits available to certain Members who lose eligibility for Benefits under this Agreement. To
assist Group in complying with such laws, Plan, in its sole discretion, may agree to continue to
make Benefits available to such persons. Under such circumstances, Group shall be solely
responsible for complying with all applicable laws governing such continuation coverage, and for
notifying eligible persons of the availability, terms, conditions and duration of, and of all changes
in, such coverage. Group agrees to indemnify, save and hold harmless Plan from any and all
liability in any way arising out of Group's health care benefit continuation obligations under federal
or state law, and Group's notification obligations provided for above.
EAP Services Agreement4
VIII. COMPLAINT AND GRIEVANCE PROCEDURE
Members are entitled to present complaints and grievances involving Benefits, Plan and EAP Providers
to Plan, and Plan is obliged to seek to resolve such complaints and grievances. Plan has established a
procedure for processing and resolving Member complaints and grievances. A copy of this procedure,
and the form to be used to file a complaint or grievance, are available from Plan and from all EAP
Providers and EAP Provider locations.
A grievance is a written or oral expression of dissatisfaction regarding Plan and/or an EAP Provider,
including quality of care concerns, and includes a complaint, dispute, request for reconsideration or appeal
made by a Member or the Member's representative. A complaint is the same as a grievance. There is no
discrimination by Plan against a Member for filing a grievance.
Members are entitled to present complaints and grievances. Plan is obliged to seek to resolve such
complaints and grievances in a timely fashion. Members may file a grievance up to 365 calendar days
following an incident or action that is the subject of the member's dissatisfaction. Plan has established a
procedure for processing and resolving Member complaints and grievances.
Should a Member desire to register a complaint or grievance with Plan concerning Benefits, he/she can
either call Plan at the toll-free telephone number 1-800-342-8111 to report the complaint or grievance, or
to request a copy of Plan's Complaint Form, or write directly to Plan at 10260 Meanley Drive, San Diego,
CA 92131. The telephone call or letter should be addressed to the Director, Clinical Quality Improvement.
Plan will acknowledge each complaint and grievance within five (5) days of receipt. The Director, Clinical
Quality Improvement, will receive and investigate all Member complaints and grievances. The Director,
Clinical Quality Improvement, will respond to the Member stating the disposition and the rationale within
thirty (30) days of receipt of the grievance. If the grievance is not resolved to the Member's satisfaction,
a second level of review may be requested within ten (10) days of notification of such disposition. Any
such request will be reviewed by the Medical Director and responded to within seventy-two (72) hours of
receipt.
If the complaint or grievance involves a delay, modification, or denial of service related to a clinically
emergent or urgent situation, the review will be expedited and a response provided in writing to the
Member within three (3) days from receipt of the complaint or grievance. There is no requirement that
the Member participate in Plan's grievance process before requesting a review by the California
Department of Managed Care ("Department") in any case determined by the Department to be a case
involving an imminent and serious threat to the health of the patient, including but not limited to severe
pain, the potential loss of life, limb, or major bodily function, or in any other case where the Department
determines that an earlier review is warranted. The criteria for determining emergent situations are
whether the Member is assessed to be at imminent risk to seriously harm himself or another person, or is
so impaired in judgment as to destroy property or be unable to care for his own basic needs. The criteria
for determining urgent situations are whether the Member is assessed to be significantly distressed, and is
experiencing a reduced level of functioning due to more than a moderate impairment resulting in an
inability to function in key family/work roles.
A Member, or the agent acting on behalf of the Member, may also request voluntary mediation with Plan
prior to exercising the right to submit a grievance to the Department. The use of mediation services will
not preclude the Member's right to submit a grievance to the Department upon completion of the
mediation. In order to initiate mediation, the Member, or the agent acting on behalf of the Member, and
EAP Services Agreements
Plan will voluntarily agree to mediation. Expenses for the mediation will be borne equally by the parties.
The Department will have no administrative or enforcement responsibilities in connection with the
voluntary mediation process. Mediations will take place in San Diego, California unless otherwise
determined by the parties.
Pursuant to Section 1365(b) of the Act, any Member who alleges his enrollment has been canceled or not
renewed because of his health status or requirement for services may request review by the Department.
The California Department of Managed Health Care is responsible for regulating health care service plans.
If a member has a grievance against Plan, the member should first telephone Plan at (1-800-342-8111)
and use Plan's grievance process (or locate Plan's grievance form on their website at
www.resourcesforliving.com) before contacting the Department. Utilizing this grievance procedure does
not prohibit any potential legal rights or remedies that may be available to the member. If a member needs
help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by
Plan, or a grievance that has remained unresolved for more than thirty (30) days, the member may call the
Department for assistance. The member may also be eligible for an Independent Medical Review (IMR).
If the member is eligible for IMR, the IMR process will provide an impartial review of medical decisions
made by a health plan related to the medical necessity of a proposed service or treatment, coverage
decisions for treatments that are experimental or investigational in nature, and payment disputes for
emergency or urgent medical services. The Department also has a toll-free telephone number (1 -888 -
HMO -2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The Department's
internet website http://www.hmohelp.ca.gov has complaint forms, IMR application forms and
instructions online. Plan's grievance process and the Department's complaint review process are in
addition to any other dispute resolution procedures that may be available to the member, and the member's
failure to use these processes does not preclude the member's use of any other remedy provided by law.
IX. RECORDS
Plan agrees to maintain, in the State of California, such records and to provide such information to the
Director as may be necessary for compliance by Plan with the provisions of the Act and the Regulations.
Plan further agrees that such obligations are not terminated upon termination of this Agreement, whether
by rescission or otherwise, and that such records shall be retained by Plan for at least seven (7) years. Plan
agrees to permit the Director access, at all reasonable times upon demand, to such records and information.
X. ARBITRATION
If any dispute or controversy shall arise between the parties with respect to the making, construction,
terms, application or interpretation of this Agreement, or the rights of either party, or with respect to any
transaction contemplated by this Agreement, either party may refer the dispute or controversy to the
American Arbitration Association for resolution.
The arbitration shall be an adversary hearing and each party shall be entitled to call and cross-examine
witnesses under oath and to introduce oral and documentary evidence. The arbitration shall be held within
thirty (30) days of the appointment of the arbitrator. The decision of the arbitrator shall be final and
binding. Judgment on the award may be entered in any court having jurisdiction and shall be fully binding
on the parties.
EAP Services Agreenient6
The arbitration shall take place in San Diego, California, unless some other location is mutually agreed
upon by the parties, and shall be governed by the rules of the American Arbitration Association, except
as may otherwise be expressly provided herein. The expenses of the arbitrator shall be shared equally by
the parties. The prevailing party in the arbitration or in any legal action concerning the arbitration or the
judgment on the arbitration award, shall be entitled to recover its costs and reasonable attorney's fees from
the other party.
XI. HIPAA COMPLIANCE
Each party acknowledges that the use and disclosure of individually identifiable health information is
limited by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and any current and
future regulations promulgated thereunder including without limitation the federal privacy regulations
contained in 45 CFR Parts 160 and 164, the federal security standards contained in 45 CFR Part 160, 162
and 164 and the federal standards for electronic transactions contained in 45 CFR Parts 160 and 162, all
collectively referred to herein as the HIPAA Requirements. Each party agrees to comply with the HIPAA
Requirements to the extent applicable to such party and further agrees that it shall not use or further
disclose Protected Health Information (as defined under the HIPAA Requirements) other than as permitted
by the HIPAA Requirements. The parties further agree to execute such other agreements and
understandings as may be necessary or required to satisfy all HIPAA Requirements applicable to this
Agreement and the transactions contemplated hereby.
XII. MISCELLANEOUS
A. Change of Periodic Fees and/or Benefits. Plan may change Periodic Fees and/or Benefits hereunder,
effective thirty (30) days after receipt by Group of written notice from Plan setting forth any such
change, but in no event during the term of the Agreement then in effect.
B. Member Consent. By this Agreement, Group makes Benefits available to Members. However, this
Agreement shall be subject to amendment, modification or termination, in accordance with the
provisions hereof, or by mutual agreement between Plan and Group, without the consent or
concurrence of Members. By electing Benefits pursuant to this Agreement, or accepting Benefits
hereunder, all Members legally capable of contracting, and the legal representatives of all Members
incapable of contracting, agree to all terms, conditions and provisions hereof.
C. Entitlement to Benefits. To be entitled to receive Benefits under this Agreement, a person must be a
Member on whose behalf Periodic Fees have been paid. Any person receiving Benefits to which he
or she is not then entitled pursuant to the provisions of this Agreement shall be responsible for payment
therefore.
D. Notice of Certain Events. Plan shall give Group written notice within a reasonable time of any
termination or breach of contract by, or inability to perform of an EAP Provider, or any person with
whom Plan has a contract to provide Benefits hereunder, if Group can be materially and adversely
affected thereby.
E. Liability of Plan. In the event Plan fails to pay EAP Providers for Benefits provided to Members,
Members shall not be liable to EAP Providers for any sums owed by Plan.
EAP Services Agreernenr7
F. Member's Liability to Non -Plan Providers. Except with respect to Benefits rendered in an emergency,
in the event Plan fails to pay non -EAP Providers, Members may be liable to such non -EAP Providers
for the cost of services rendered.
G. Plan Referrals to Members. When EAP Providers refer Members for further treatment, EAP
Providers, to the best of their ability, will inform Members of the insurance deductibles and
co -payments that Members will be liable for as a result of the referral. Members will be informed they
are fully liable for all costs of treatment subsequent to the. Benefits provided herein.
H. Plan's Policies. Plan may adopt reasonable policies, procedures, rules and interpretations to promote
orderly and efficient administration of this Agreement.
1. Entire Agreement. This Agreement, including its Exhibits, constitutes the entire understanding
between the parties with respect to the subject matter hereof and, as of the effective date hereof,
supersedes all other agreements between the parties with respect to such subject matter. if any part of
this Agreement is deemed unenforceable, the remaining parts shall remain in full force and effect.
Amendments. No agent or other person, except an authorized representative of Plan, has authority to
waive any condition or restriction of this Agreement, to extend the time for making a payment, or to
bind Plan by making any promise or representation or by giving or receiving any information. No
change in this Agreement shall be valid unless evidenced by an endorsement to it signed by the
aforesaid representative, or by an amendment to it signed by Group and such representative of Plan.
The above notwithstanding, this Agreement shall be deemed automatically amended to comply with
the provisions of the Act and the Regulations.
K. Notices. Any notice under this Agreement may be given, addressed to the applicable party at the
address provided on the Cover Sheet, or to such other address as may be provided by giving notice
pursuant to this Section. Notices given by United States mail, postage prepaid, return receipt requested
shall be deemed given three (3) days after deposit in the mail. Notices given by next day or overnight
delivery or in person shall be deemed given upon delivery.
L. Notices to Members. Group agrees to disseminate all notices regarding material matters with respect
to this Agreement and Plan to Members within ten (10) days after the receipt of notice of such matters
from Plan. In the event that any such notice from Plan involves the cancellation or termination of, or
decision not to renew this Agreement, Group shall provide notice of such to Members promptly and
shall provide Plan with written evidence of such notification.
M. Discrimination. Plan may not refuse to enter into any contract, or cancel or decline to renew or
reinstate any contract, nor may Plan modify the terms of a contract because of the race, color, national
origin, ancestry, religion, sex, marital status, sexual orientation, handicap or age of any contracting
party, or person reasonably expected to benefit from such contract.
N. Headings. The headings of the Articles and Sections of this Agreement are for information purposes
only and shall not limit or otherwise restrict the meaning of any provision of this Agreement.
EAP Services Agreement$
O. Interpretations and Governing Law.
1. Plan is subject to the requirements of the Act and the Regulations, and any provision required to
be in this Agreement by either of the above shall bind Plan whether or not set forth herein.
2. This Agreement shall be governed by and construed in accordance with the laws of the State of
California.
P. Limitation on Liability. Group acknowledges that the information and advice provided to Members
by legal and financial persons to whom Members are referred under this Agreement ("Referees") are
not, expressly or impliedly, endorsed, recommended or approved by Plan. The relationship between
Plan and a Referee is that of independent third party entities. Plan, its agents and affiliates are not
agents or affiliates of any Referee. Referees maintain a Referee -client relationship with Members,
and Referees are solely responsible to Members for any and all services that they may provide to
Members. Plan makes no warranties, expressed or implied, of any kind with respect to the services
provided by a Referee. Plan shall not be liable for the negligence or wrongful acts or omissions of
Referees.
EAP Services Agreerietag
EXHIBIT A
DESCRIPTION OF SERVICES
EMPLOYEE ASSISTANCE PROGRAM SERVICES
Subject to the terms and conditions of this Services Agreement, the EAP Services selected by Group and
provided by Plan are reflected in this EXHIBIT A: DESCRIPTION OF SERVICES and SERVICE AND
FEE SCHEDULE. Additional EAP Services may be provided at Group's request under the terms of this
Services Agreement. All Services described in this Services Agreement are available within the United States
only. International EAP Services are only available if specifically described and priced separately.
1. UNLIMITED TELEPHONIC ASSESSMENT AND REFERRAL: Unlimited telephonic access to the
EAP call center staff, available 24 hours per day, 7 days per week, 365 days per year for purposes of
assessing member needs and referring to appropriate EAP Services.
2. COUNSELING SESSIONS WITH EAP NETWORK PROVIDERS AND CONTRACTED
TELEVIDEO PROVIDERS: Counseling sessions can be provided face-to-face, telephonically, or via
televideo (when appropriate). Face-to-face or telephonic sessions are provided by an EAP Network
Provider. Televideo sessions are provided by one of our specialty telepsychiatry vendors. Each
member is entitled, on a contract year, up to the allowed number of counseling sessions authorized as
set forth herein under Exhibit B. All counseling sessions require prior authorization. The member
must contact Plan to receive referrals and authorizations for all counseling sessions whether face-to-
face, telephonic, or televideo. Marital and/or family sessions are considered one incident for the
couple or family, and sessions are not authorized individually for each attendee. Face-to-face,
telephonic, and televideo counseling sessions count toward the number of counseling sessions
authorized.
3. EAP PROVIDER NETWORK: A nationwide network of licensed behavioral health professionals,
who meet all Plan credentialing standards, and who are contracted by Plan, as independent contractors,
to provide counseling to Members. EAP Network Providers include, but are not limited to: social
workers, licensed professional counselors, marriage and family therapists, master's level psychiatric
nurses and psychologists.
4. TRAINING AND EDUCATION: The term "Training and Education" refers to training, provided by
Plan, or a Plan Contracted educator to the Group, concerning general behavioral health and work/life
issues. This includes Employee Orientation Meetings and Supervisor Orientation Trainings. This
training may be provided in different ways, i.e. in-person, telephonically, or web -based (webinars).
Additional fees apply to webinars with over 25 participants (participants are defined as unique phone
lines calling into the webinar). Department of Transportation (DOT) services are excluded from
standard Training and Education services. For specialized DOT training, see separate definition under
Drug Free Workplace Services. Mental Health First Aid trainings are excluded from standard Training
and Education services. For specialized Mental Health First Aid training, see separate definition under
Mental Health First Aid.
5. MANAGEMENT SERVICES:
MANAGEMENT CONSULTATION: A telephonic resource for managers, supervisors, and
human resources professionals to assist in identifying and resolving workplace issues and
EAP Services Agreement] 0
promoting a productive workforce. Issues may include but are not limited to employee
personal and family issues, behavioral health concerns, workplace conflict, workplace crisis
and other disruptions, substance abuse, threats of violence and employee performance
concerns. This includes the provisions of guidance to the Group in making voluntary referrals
for employees to the EAP. EAP will coordinate with specialty providers as needed (SAP,
DOT, FFD).
• MANDATORY REFERRALS: Case management to assist Group and employees in
addressing significant workplace performance issues. Mandatory referrals are used to monitor
compliance with the EAP Behavioral Health Professional's recommendations, wherein the
EAP, with appropriate executed release of information forms, confirms the employee's
participation in and compliance with the Program.
• DRUG FREE WORKPLACE SERVICES. Suite of services to assist Group in managing
workplace related employee substance misuse and/or disclosure of substance abuse in the
workplace. Services for general employer industries include Plan EAP case management of
mandatory referrals related to workplace impacted substance abuse, as well as management
consultation services as described above. Services for transportation related industries, such
as employers who are regulated by DOT, FMCSA, FAA, FRA, FTA, PHMSA, etc., include
substance abuse case management by a Substance Abuse Professional (SAP) for Department
of Transportation regulation compliance. Additional service for transportation regulated
employees includes DOT training to meet Drug -Free Workplace regulations regarding drug
and alcohol awareness available through American Substance Abuse Professionals (ASAP) or
comparable SAP provider. A variety of training formats are available, including on-site, on-
line or video.
• FITNESS FOR DUTY (FFD) CONSULTATION AND COORDINATION: A Fitness for
Duty Evaluation is a forensic evaluation completed by a specially trained psychologist,
psychiatrist, outside the EAP, for the purpose of evaluating an employee's ability to safely
perform the functions of their job, assess organizational and behavioral risk, and provide a
report recommending steps needed to be taken to minimize Group risk in returning the
employee to work. Fitness for Duty Evaluations are outside the scope of EAP, and as such the
EAP does not conduct Fitness for Duty Evaluations. Upon specific request, the EAP may
assist Group with locating companies or providers external to the EAP who are capable of
performing FFD Evaluations. At all times the Group is responsible for working directly with
the identified FFD provider as well as directly making payment arrangements with that
provider for the FFD Evaluation. All decisions, regarding returning to work, retaining or
dismissing employees remain with the Group.
• SUBSTANCE ABUSE PROFESSIONAL (SAP) CONSULTATION AND CONTACT
INFORMATION: Upon request of Group, for drug and alcohol cases that fall under the
Department of Transportation (DOT) guidelines, Plan shall provide initial and ongoing
management consultation on DOT issues. Plan will further provide contact information of local
providers in our specialized network of qualified Substance Abuse Professionals. Group is
responsible for choosing and working directly with the SAP, as well as performing Follow-up,
Compliance and Aftercare attendance monitoring. Group is responsible for payment of the
SAP and determines whether the employee or employer pays SAP fees as well as
recommended treatment costs.
EAP Services Ag reenient 11
• MENTAL HEALTH FIRST AID: An educational program offered to Customers to help
managers and employees recognize and respond to mental health issues in the workplace. The
curriculum includes an overview of mental health and provides education about Anxiety,
Depression, Suicide, Trauma, Psychosis, and Substance Use Disorders, along with videos,
interactive exercises and practice scenarios. Courses must be taught onsite. The eight hour
course provides all participants with Mental Health First Aid Certification for three years. A
four-hour option is available for a general overview of the topic. The four-hour class does NOT
provide participants with a Mental Health First Aid Certification. Courses are limited to 30
participants per course.
6. CRITICAL INCIDENT SUPPORT (Crisis Support/Management Services/Critical Incident Stress De -
Briefing (CISD) Services): An array of services offered by the EAP that helps an organization to
prepare for, prevent, or respond to traumatic events. Acts of war are excluded from on-site CISD
Services.
• ON-SITE STANDARD CRITICAL INCIDENT SUPPORT: On-site attendance response time
in greater than two hours for hourly onsite crisis support and Critical Incident Stress De -
Briefing (CISD) Services at Group sites to help an organization prepare for, prevent, or respond
to traumatic events.
• ON-SITE IMMEDIATE CRITICAL INCIDENT SUPPORT: On-site attendance response
time in less than two hours for hourly onsite crisis support and Critical Incident Stress De -
Briefing (CISD) Services at Group sites to help an organization prepare for, prevent, or respond
to traumatic events.
7. REDUCTION IN FORCE: The process by which a work organization reduces its work force by
eliminating jobs, such as closing subsidiaries or departments.
S. COMMUNICATION AND PROMOTIONAL MATERIALS: Information provided to Employees
and management about EAP Services, including, in part, how EAP Services can be accessed for
consultation and assistance. The communications and promotional resources may include template e-
mails, letters, flyers, wallet cards, and posters for Employees and management. Plan will provide
reasonable quantities of printed materials in support of implementation and/or on an annual basis at
Group's request at no cost. Reasonable quantities are defined as up to 120% of the number of eligible
Employees for items such as flyers or brochures; a quantity up to 5% of the number of eligible
Employees for items such as posters; and a quantity of up to 20% of anticipated attendees at health
fairs for other promotional items. Requests exceeding these quantities may incur an additional fee.
9. MANAGEMENT REPORTS: A specific collection of data and narrative information designed to
inform Group about the overall utilization of the program. Group may receive reports on an electronic
basis. If for any two consecutive reporting periods there is less than 1% utilization, reporting
frequency will default to annual reporting.
10. INTAKE MODEL:
STANDARD MODEL: Initial intake calls answered by a care service associate /customer service
representative.
11. EAP EXCLUSIONS: The following services are outside the scope of the EAP:
EAP Services Agreement 12
• Counseling services beyond the allowed number of sessions covered by the EAP benefit.
• Court ordered treatment or therapy, or any treatment or therapy ordered as a condition of
parole, probation, custody, or visitation evaluations, or paid for by Workers' Compensation.
• Formal psychological evaluations which normally involve psychological testing and result in
a written report.
• Diagnostic testing and/or treatment.
• Visits with psychiatrist, including medication management.
• Prescription medications.
• Services for remedial education.
• Inpatient treatment of any kind, residential treatment, partial hospitalizations, intensive
outpatient treatment.
• Ongoing counseling for a chronic diagnosis that requires long term care.
• Biofeedback.
• Hypnotherapy.
• Aversion therapy.
• Examination and diagnostic services required to meet employment, licensing, insurance
coverage, travel needs.
• Services with a non -contracted EAP Provider.
• Fitness for duty evaluations.
• Legal representation in court, preparation of legal documents, or advice in the areas of taxes,
patents, or immigration, except as otherwise described in this document.
• Investment advice (nor does Plan loan money or pay bills).
EAP Services Agreementl3
WORIULIFE PROGRAM SERVICES
UNLIMITED TELEPHONIC ACCESS: Unlimited telephonic access to the call center staff, available
24 hours per day, 7 days per week, 365 days per year.
2. CAREGIVING SERVICES: Services that include consultation, information, education and referral
services in connection with, in part, adoption, child care, parenting, temporary back-up care, summer
care, special needs, high-risk adolescents, academic services, education loans, grandparents as parent,
adult care, elder care, and disaster resources.
3. PERSONAL SERVICES: Free educational materials, personalized referrals, and interactive web tools
to assist with:
• Health & Wellness --Children's health; women's health; men's health; seniors' health; weight
loss and nutrition; fitness and exercise programs; general health; safety; stress management;
information on diseases and conditions; and more.
Daily Life --Home improvement; pet care; consumer information; automotive services;
relocation; travel; time management; cleaning services; and more.
4. LEGAL, FINANCIAL, and IDENTITY THEFT SERVICES: Services provided through the EAP that
include:
LEGAL SERVICES:
1/2 hour Initial Consultation with selected participating attorney on an unlimited number of
new Legal Topics (each plan year). Certain topic areas are excluded, including
employment law. Also excluded are matters that, in the attorney's opinion, lack merit.
Court costs, filing fees and fines are the responsibility of the member. If members choose
to continue with the participating attorney and hire that attorney on their own, they will
receive 25% off of the fees for services beyond the initial consultation (excluding flat legal
fees, contingency fees, and plan mediator services).
Mediation Services — Each member is entitled to one (1) initial thirty minute office or
telephone consultation per separate legal matter at no cost with a participating mediator.
In the event that the member wishes to retain a participating mediator after the initial
consultation, they will be provided with a preferred rate reduction of 25% from the
mediator's normal hourly rate. Typical matters may include divorce and child custody,
contractual and consumer disputes, real estate and landlord tenant, car accidents and
insurance disputes.
• Document Preparation: Members have access to telephonic document preparers and an
on-line assisted process to complete their own legal document preparation. Member's will
receive a preferred discount of 10% off and the types of forms include, divorce, wills, living
wills, powers of attorney, immigrations and others.
• Simple Will Preparation: Members receive resources to complete one Simple Will.
EAP Services Agreement 14
• All initial consultation (and discounted consultations) must be for legal matters related to
the Employee and eligible household members.
FINANCIAL SERVICES:
® 1/z hour Initial Consultation with the selected participating financial counselor on an
unlimited number of new Financial Counseling Topics each plan year.
• Financial counseling topics include Budgeting, Credit, Debt, Retirement, College
Planning, Buying vs. Leasing, Mortgages/Refinancing, Financial Planning, Tax Questions,
Tax Preparation, IRS Matters, Tax Levies and Garnishments, Consumer Credit
Counseling, and Community Services.
• A discount of 25% off the tax preparation services.
• Individual Employees may have the option to purchase additional services for a monthly
nominal fee.
IDENTITY THEFT SERVICES:
• 1 -hour telephonic fraud resolution consultation for Identity Theft.
• Coaching and direction on prevention and restoring credit for victims of Identity Theft.
• Free Identity Theft Emergency Response Kit for victims of Identity Theft.
• Individual Employees may have the option to purchase additional services for a monthly
nominal fee.
5. MEMBER WEBSITE:
CORE MEMBER WEBSITE: Access to customizable member website for free webinars, online
work/life searches, concierge database, discount program, thousands of articles, videos, and tools
on work/life and behavioral health topics.
EAP Services Agreeme t15
DOMESTIC EAP GROUP SERVICE AND FEE SCHEDULE
Group hereby elects to receive the Services designated below. The below Service Fees shall be in effect
for the Initial Term of Agreement as specified on the Cover Sheet of this Agreement, and, thereafter, if
this Services Agreement is renewed for any additional successive Term(s), such Service Fees may be
revised for each such successive Term.
CRITICAL INCIDENT SUPPORT/CRITICAL INCIDENT STRESS DE -BRIEFING (CISD) SERVICES:
STANDARD CISD SERVICES (On-site attendance response time in greater than two (2) hours.)
Unlimited Standard CISD Services: Unlimited Standard CISD sessions are included, limited to
10 hours per incident.
Issues concerning downsizing, mergers, acquisition activities (i.e., Reductions in Force, or RIFs),
catastrophic natural disasters, and terrorism, or services beyond the 10 hours per incident
limitation, are subject to the hourly rate of $250.00 per hour plus travel and preparation expenses
reimbursed at a flat rate of $150.00 per location. Immediate CISD Services are subject to the fees
described below.
Cancellation: Whenever possible, Group agrees to provide Plan with 24 hours advance notice
of cancellation of any requested Workplace Crisis Response Services. Failure to provide Plan
with 24 hours advance notice of cancellation of services which are excluded from the provision
of Unlimited Standard CISD Service as described above, i.e., beyond the 10 hours per incident
limitation, Immediate CISD Services, downsizing, mergers, acquisition activities (i.e.,
Reductions in Force, or RIF's), catastrophic natural disasters, and terrorism which are subject
to the hourly fee-for-service rate will result in a charge of $375.00 per incident.
IMMEDIATE CISD SERVICES (On-site attendance response time in two (2) hours or less.)
Fee -For -Service: $350.00 per hour plus travel and preparation expenses reimbursed at a flat rate
of $150.00 per location.
Cancellation: Services which are provided on a fee-for-service basis and which are subject to
the hourly rate will result in a charge of $375.00 per incident.
CISD hours used, whether fee-for-service and/or within a bank of Standard CISD hours included, are
calculated based upon the combined total number of hours all clinicians are on-site.
If Group requests a specific crisis counselor, or a counselor with specific qualities, including but not
limited to specialized certifications, experience, or language, Group will be billed the applicable
hourly rate "door-to-door" which will include the specialist's travel time. This is in lieu of the flat
preparation time and travel fee.
If Group requests on-site crisis response services in a location which is further than 50 miles from a
town with a population of at least 25,000 people, Group will be billed the applicable hourly rate "door-
to-door" which will include the specialist's travel time. This is in lieu of the flat preparation time and
travel fee.
EAP Services Agreenteti 16
If Group requests on-site support services in response to a large scale disaster area affecting the
transportation infrastructure of that area, and/or the availability of local providers, necessitating the
assistance of providers from outside the affected areas, Group will be billed the current hourly rate
plus $50 per hour for each on-site hour. In addition, Group will be billed $200 per travel hour from
the command center to the intervention site. This is in lieu of the flat preparation time and travel fee.
Any other Group requested services wherein the crisis counselor incurs non-standard travel (e.g.
having to fly to accompany employees affected by a crisis) will be billed at the exact travel costs in
addition to the hourly fees.
REDUCTION IN FORCE (RIF) SERVICES:
Fee -For -Service: $250.00 per hour plus travel and preparation expenses reimbursed at a flat rate of
$150.00 per location.
Cancellation: Group agrees to provide Plan with 24 hours advance notice of cancellation of any
requested RIF service. Failure to provide Plan with 24 hours advance notice of cancellation will
result in a charge of $375.00 per incident.
TRAINING AND EDUCATION SERVICES:
Fee -For -Service — On -Site Training: $250.00 per hour for the total amount of time that the educator
is on-site, plus travel and preparation expenses reimbursed at a flat rate of $150.00 per location. If
training is not scheduled consecutively, or multiple topics are scheduled, additional travel and
preparation costs may apply.
Fee for Service — Webinar Training: $250.00 per hour plus $150.00 for preparation for each web -
based training for up to 25 participants. For webinars with more than 25 participants, an additional
charge of $50.00 applies for each additional 25 participants up to a maximum of 200 participants.
Sessions less than one (1) hour in duration will count as one (1) hour of Training and Education.
If Group requests a specific educator, or an educator with specific qualities, including but not limited
to specialized certifications, experiences or language, Group will be billed any additional incurred fees
beyond the hourly fee above, or have hours deducted from bank.
In addition, if Group cannot accommodate the schedule/availability of a local Plan contracted
educator, requiring that the services of an educator 50 miles away or greater from the Group location
is necessary, then Group will be billed any additional incurred fees beyond the hourly fee above, or
have hours deducted from bank.
Cancellation: Group agrees to provide Plan with at least three (3) business days advance notice
of cancellation of a previously scheduled Training and Education Service. Failure to provide Plan
at least three (3) business days advance notice of cancellation may result in a charge of $375.00
per cancelled hour of service.
DRUG-FREE WORKPLACE SERVICES:
DEPARTMENT . OF _TRANSPORTATION (DOT) TRAINING TO MEET DRUG-FREE
WORKPLACE REGULATIONS REGARDING DRUG AND ALCOHOL AWARENESS:
EAP Services Agreement 17
SUPERVISOR TRAINING: Alcohol and Drug -Free Workplace Training to meet Drug -Free
Workplace regulations regarding drug and alcohol use.
Fee -For -Service: $800.00 per two-hour DOT Supervisor Training.
Additional fees may be added on to the base rate for DOT training. These fees will be assessed
on a case-by-case basis and are dependent upon travel expenses and for classes that exceed 50
participants.
EMPLOYEE TRAINING: Alcohol and Drug -Free Workplace Awareness (Note: this training does
not meet Drug -Free Workplace regulations regarding drug and alcohol use.)
Fee -For -Service: $400.00 per one-hour DOT Employee Training.
Additional fees may be added on to the base rate for DOT training. These fees will be assessed
on a case-by-case basis and are dependent upon travel expenses and for classes that exceed 50
participants.
SUBSTANCE ABUSE CASE MANAGEMENT:
Case Management of Substance Abuse Professional (SAP)/DOT cases.
Fee -For -Service: $750.00 per case.
MENTAL HEALTH FIRST AID:
Fee -For -Service: $7,200.00 per eight-hour course.
$5,700.00 per four-hour course.
Above fees include instructor fees, travel, and customization.
Cancellation: Group agrees to provide Plan with at least thirty (30) days advance notice of
cancellation of a scheduled Mental Health First Aid course. If Group cancels for any reason within
30 days from the scheduled training date, Group will be responsible for cancellation fees
as follows:
• 50% of the total fee if cancelled within 15-30 days prior to the scheduled date of training.
• 100% of the total fee if cancelled within 0-14 days prior to the scheduled date of training.
EAP Services Agreentent18
EXHIBIT B
Periodic Fees
$1.52 Per Employee Per Month.
This rate includes the following services, more fully documented in Exhibit A and the Agreement:
Service Rate
Three -session Employee Assistance Program
and Telephonic WorkLife services $ 1.52 per employee per month
Additional services not specifically covered by this contract will be billed at then current rates.
EAP Services Agree,neatl g
EMPLOYEE ASSISTANCE PROGRAM
COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM
TABLE OF CONTENTS
I.
DEFINITIONS........................................................................................................................................... 32
II.
HOW TO OBTAIN BENEFITS................................................................................................................
43
III.
EMERGENCY SERVICES.......................................................................................................................
43
IV.
CRISIS INTERVENTION.........................................................................................................................
54
V.
PERIODIC FEES.......................................................................................................................................
54
VI.
OTHER CHARGES...................................................................................................................................
54
VII.
PREPAYMENT OF FEES.........................................................................................................................
54
VHL
CHOICE OF EAP PROVIDERS..............................................................................................................
65
IX.
FACILITIES...............................................................................................................................................
65
X.
LIABILITY OF PLAN 1 MEMBERS......................................................................................................
65
A. LIABILITY OF PLAN................................................................................................................................. 63
B. LIABILITY OF MEMBERS......................................................................................................................... GS
C. MEMBER LIABILITY TO NON -EAP PROVIDERS....................................................................................... 65
XI. PROVIDER COMPENSATION............................................................................................................... 65
XII. SECOND OPINION POLICY................................................................................................................... 76
XHI. ELIGIBILITY/ENROLLMENT/EFFECTIVE DATE OF COVERAGE ............................................. 76
XIV. TERMINATION OF BENEFITS.............................................................................................................. 86
A. CANCELLATION OF GROUP CONTRACT FOR NONPAYMENT OF PREMIUMS ............................................. 8-7
B. REINSTATEMENT OF THE CONTRACT AFTER CANCELLATION................................................................. 97
C. MEMBER TERMINATION FOR NON-ELIGIBILITY...................................................................................... 87
D. TERMINATION FOR GOOD CAUSE........................................................................................................... 99
XV. CONTINUITY OF CARE................................................................. .. 98
A. NEW MEMBERS...................................................................................................................................... 98
1) Eligibility ........................................................................................................................................98
i Evidence of Coverage
2) Access....................................................................... ................ 108
B. TERMINATED EAP PROVIDERS............................................................................................................. log
XVI. CONTINUATION OF GROUP COVERAGE...................................................................................... 11-13
A. COBRA CONTINUATION OF COVERAGE.............................................................................................. 1 1 l
B. CAL -COBRA CONTINUATION OF COVERAGE.................................................................................... 114-0
1) Eligibility for Cal -COBRA Continuation Coverage................................................................... 119
2) Notification of Qualifying Events............................................................................................... 1214
3) Cal -COBRA Enrollment and Premium Information................................................................... 12�4
4) Termination of Cal -COBRA Continuation Coverage.................................................................1344
XVII. COMPLAINT AND GRIEVANCE PROCEDURE............................................................................. 1442
XVIII. MISCELLANEOUS............................................................................................................................... 16-14
A. CONFIDENTIALITY POLICY................................................................................................................. 1644
B. MEMBER CONSENT............................................................................................................................. 1644
C. PLAN'S POLICIES................................................................................................................................ 16-14
D. PLAN'S PUBLIC POLICY COMMITTEE.................................................................................................. 164-5
E. TERM AND RENEWAL PROVISIONS..................................................................................................... 16-1-5
F. IMPORTANT INFORMATION ABOUT ORGAN AND TISSUE DONATIONS ................................................. 174-5
SCHEDULE OF BENEFITS, LIMITATIONS, AND EXCLUSIONS............................................................. 18-16
A. BENEFITS............................................................................................................................................18-16
B. LIMITATIONS...................................................................................................................................... 184-6
C. EXCLUSIONS ....................... ....................................................................................... ......................... 194-7
COMPARISON OF BENEFITS.......................................................................................................................... 2118
ii Evidence of Coverage
HEALTH AND HUMAN RESOURCE CENTER
(dba AETNA RESOURCES FOR LIVING)
10260 Meanley Drive
San Diego, CA 92131
1-800-342-8111
EMPLOYEE ASSISTANCE PROGRAM
COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM
The Employee Assistance Program (EAP) is being offered by your employer to provide you with
confidential assistance from licensed mental health professionals. These professionals can help
with problems affecting your life at work as well as at home. Such problems include marital issues,
family relationships, depression and anxiety, alcohol and drug issues, and/or problems within the
workplace.
The EAP counselors will conduct a thorough assessment of your problem and together with you
will decide on an action plan that will either resolve the issue within the EAP sessions or will refer
you to appropriate providers and/or community resources that have been reviewed by the EAP.
Your involvement with the EAP counselor will be at no cost to you.
This Combined Evidence of Coverage and Disclosure Form constitutes only a summary of
the health plan. The EAP Services Agreement must be consulted to determine the exact terms
and conditions of coverage. A copy of the agreement will be furnished on request and is
available from your employer.
This Combined Evidence of Coverage and Disclosure Form discloses the terms and conditions of
coverage. It also provides you with important information on how to obtain Benefits and the
circumstances under which Benefits will be provided to you. PLEASE READ IT CAREFULLY.
Individuals with special health care needs should read carefully those sections that apply to them.
Keep this publication in a safe place where you can easily refer to it when you are in need of
Benefits.
Contact Plan at 1-800-342-8111 to receive additional information about Benefits.
Enclosed as Exhibit B is Plan's matrix of covered services.
EAP plans - IMPORTANT: Can you read this document? If not, we can have somebody help you
read it. You may also be able to get this document written in your language. For free help, please
call right away at 1-877-287-0117.
Evidence of Coverage
Planes EAP - IWORTANTE: Puede leer esta documento? En caso de no poder leerla, le
brindamos nuestra ayuda. Tambien puede obtener esta documento escrita en su idioma. Para
obtener ayuda gratuita, por favor Ilame de inmediato al 1-877-287-0117.
Evidence of Coverage
1. DEFINITIONS
The following terms have the following meanings for purposes of this Combined Evidence of
Coverage and Disclosure Form.
A. "Act" means the Knox -Keene Health Care Service Plan Act of 1975, as amended
(California Health and Safety Code, Sections 1340 et seq.).
B. "Benefits" means the services to which Members are entitled under an EAP Services
Agreement, and which are described in Exhibit A to this Combined Evidence of Coverage
and Disclosure Form.
C. "EAP Provider" means the licensed assessment and short-term counseling mental health
professionals employed by, or under contract with, Plan to provide Benefits to Members.
D. "EAP Services Agreement" means the Employee Assistance Program (EAP) Services
Agreement between Plan and Group, which establishes the terms and conditions governing
the provision of Benefits to Members by Plan.
E. "Exclusion" means any provision of an EAP Services Agreement whereby coverage for
Benefits is entirely eliminated, and which is set forth in Exhibit A to this Combined
Evidence of Coverage and Disclosure Form.
F. "Pian" means Health and Human Resource Center, Inc., doing business as Aetna Resources
For Living,
G. "Group" means the company that has entered into an EAP Services Agreement with Plan
for Plan to provide Benefits to Members.
H. "Limitation" means any provision of an EAP Services Agreement, other than an Exclusion,
which restricts Benefits, and which is set forth in Exhibit A to this Combined Evidence of
Coverage and Disclosure Form.
I. "Enrollee" means any eligible employee of Group who (1) resides in California and (2)
may be covered under the Act.
I. "Member" means an Enrollee covered by Group, as defined above, the Enrollee's children
under the age of 26, persons covered under the Enrollee's health benefit plan, and persons
residing with the Enrollee, including domestic partners of the same or opposite sex.
K. "Periodic Fees" means the monthly amounts due and payable to Plan by Group for
providing Benefits to Members.
Evidence of Coverage
L. "Emergency Services" means medically necessary transport using the 911 system or
medical screening, examination and evaluation by a physician to determine if an
emergency medical condition or psychiatric emergency medical condition exists.
M. "Crisis Intervention" means assessment and problem solving in situations which you feel
require immediate attention. Crisis intervention is available 24 hours per day, 7 days a
week by telephone, and face to face by appointment. To access, call 1-800-342-8111.
N. "Emergency Medical Condition" means a medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) such that the absence of immediate
medical attention could reasonably be expected by the Member to result in any of the
following:
■ Placing the Member's health in serious jeopardy;
Serious impairment to bodily functions; or
Serious dysfunction of any bodily organ or part.
H. HOW TO OBTAIN BENEFITS
Unless otherwise provided herein, you are entitled to Benefits from an EAP Provider. You
must obtain Benefits by calling 1-800-342-8111. Upon contact, Plan will determine your
eligibility for Benefits and arrange for Benefits.
All Benefits must be provided by Plan or by an EAP Provider referred to by Plan. Local and
toll-free telephone numbers are available to access Benefits. Appointments with EAP
Providers are readily available and, depending on your desire for a particular time and location,
most appointments are offered within forty-eight (48) hours of contact.
Plan does not directly provide specialty services beyond assessment, brief counseling and/or
referral. Plan's role in the referral process is to function as an advocate for you to obtain
necessary and appropriate levels of care; usually under your group health plan. Your EAP
Provider will assist you in securing potential referral resources.
During or after business hours, any Member may access a licensed mental health professional
for a telephone assessment. The telephone assessor may provide crisis intervention over the
telephone, arrange a same-day appointment with an EAP Provider in your area, or assist you
in obtaining more intensive, acute care services.
111. EMERGENCY SERVICES
Emergency services are medically necessary ambulance and ambulance transport services
provided through the 911 emergency response system and medical screening, examination,
and evaluation by a physician, or other personnel, to the extent provided by Iaw, to determine
4 Evidence of Coverage
if an Emergency Medical Condition or psychiatric emergency medical condition exists; and, if
it does, the care, treatment, and/or surgery by a physician necessary to relieve or eliminate the
Emergency Medical Condition or psychiatric emergency medical condition within the
capabilities of the facility.
What To Do When You Require Emergency Services
If you believe that you need Emergency Services, you should call 911 or go to the nearest
emergency medical facility for treatment. Plan does not cover emergency medical services.
It is appropriate for you to use the 911 emergency response system, or alternative emergency
system in your area, for assistance in an emergency situation described above when ambulance
transport services are required and you reasonably believe that your condition is immediate
and serious and requires emergency ambulance transport services to transport you to an
appropriate facility
IV. CRISIS INTERVENTION
If you need crisis intervention or problem solving, call Plan at 1-800-342-8111. Plan provides
crisis intervention both during and after business hours at this number. A member who is
currently outside Plan's service area and requires this service can call 1-800-342-8111.
Members can obtain care if they are temporarily outside of Plan's service area. Members can
also be scheduled for an appointment on an urgent basis following assessment by a licensed
clinician over the telephone
V. PERIODIC FEES
Plan bills Group for Periodic Fees and Group remits such fees to Plan each month during the
term of the EAP Services Agreement for Members entitled to receive Benefits during such
month. Plan may change the Periodic Fees and/or Benefits under the EAP Services
Agreement, effective thirty (30) days after receipt by Group of written notice from Plan setting
forth any such change, but in no event during the then -existing twenty-four (24) month term
of the EAP Services Agreement. There are no co -payments, deductibles, or charges to you for
Benefits.
VI. OTHER CHARGES
Plan will bill Group for additional services or benefits provided under the Agreement. Group
will remit payment to Plan within thirty (30) days of receipt of invoice.
VII. PREPAYMENT OF FEES
The Member does not pay co -payments, deductibles, or fees for Plan. All fees are paid by
Group.
5 Evidence of Coverage
VIII. CHOICE OF EAP PROVIDERS
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM
WHOM OR WHAT GROUP OF PROVIDERS BENEFITS MAY BE OBTAINED: You
will be referred to an EAP Provider in accordance with your clinical, appointment time, and
location needs. You should call Plan at 1-800-342-8111 to determine the names and locations
of EAP Providers.
EAP contracted providers include licensed psychologists, licensed clinical social workers, and
licensed marriage and family therapists. Psychiatrists are not provided through the EAR
Members are given names of contracted providers in their area with knowledge in the problem
area that is indicated. You may also request a list of providers, and this will be provided for
the geographic area, customized by specialty, if you prefer.
IX. FACILITIES
The location of Providers is obtained by calling Plan at 1-800-342-8111. If you prefer, a
customized list of providers will be provided upon request. This is arranged by zip code in the
area specialty that you request.
X. LIABILITY OF PLAN / MEMBERS
A. Liability of Plan
In the event Plan fails to pay EAP Providers for Benefits provided to you, you shall not be
liable to EAP Providers for any sums owed by Plan.
B. Liability of Members
It is not contemplated that Members would make payment to Plan providers for benefits.
If this has occurred, the Member may contact Plan at 1-800-342-8111 to be reimbursed.
There is no restriction on assignment of sums payable to the Member by the health plan.
C. Member Liability to Non -EAP Providers
You may be liable to non -EAP Providers for the cost of services rendered when such
services are not authorized or referred by Plan.
XI. PROVIDER COMPENSATION
Plan compensates EAP Providers through an agreement by which they are paid a fixed amount
of money based on hours worked, number of Members seen, or number of sessions provided.
Providers are compensated within thirty (30) days after claim is received.
Evidence of Coverage
Plan does not distribute financial bonuses or use any other incentive program to compensate
its EAP Providers other than the methods of compensation defined above.
Members may request further information about Plan's EAP Provider reimbursement policies
and procedures by contacting Plan's Manager, Provider Relations, at 1-800-342-8111 or the
Member's EAP Provider.
XII. SECOND OPINION POLICY
You may request a second opinion regarding both treatment recommended by the treating EAP
Provider and treatment desired by you. Plan will authorize second opinions where the second
opinion is consistent with professionally recognized standards of practice. The second opinion
request will not result in a change in what is and is not a Benefit as described in the EAP
Services Agreement and this Combined Evidence of Coverage and Disclosure Form. Plan may
deny coverage for second opinion requests for services not listed as Benefits in the EAP
Services Agreement and this Combined Evidence of Coverage and Disclosure Form. If Plan
denies such a request, you will bear the financial responsibility for any self-directed second
opinion. There will be no cost to you if the second opinion is received from an EAP Provider
under contract with Plan. If you request a second opinion from a provider not under contract
with Plan, you must provide an explanation as to why an EAP Provider cannot render such an
opinion. Plan's Medical Director shall review the request to determine whether there is an
EAP Provider qualified to render a second opinion.
Requests for second opinions may be made by contacting the Director, Clinical Quality
Improvement at (1-800-342-8111) or in writing to 10260 Meanley Drive, San Diego, CA
92131. All requests for second opinions shall be processed and approved or denied by Plan
within five (5) business days of receipt. Requests related to urgent care or crisis intervention
shall be processed and approved or denied within forty-eight (48) hours of receipt.
XIII. ELIGIBILITY/ENROLLMENT/EFFECTIVE DATE OF COVERAGE
All Enrollees identified by Group prior to the effective date of the EAP Services Agreement
and all persons covered under the identified Enrollee's health benefit plan or residing with the
identified Enrollee shall be entitled to Benefits as of such effective date. Group shall be
responsible for notifying Plan of any Enrollee who becomes newly eligible after the effective
date of the EAP Services Agreement. Plan shall rely upon the determination by Group as to
which Enrollees are eligible for Benefits under the EAP Services Agreement. Any disputes or
inquiries regarding eligibility, including rights regarding renewal, reinstatement and the like,
shall be referred by Plan to Group, which shall then advise Plan of its determination with
respect to the matter.
7 Evidence of Coverage
XIV. TERMINATION OF BENEFITS
Usually, your enrollment in the plan terminates when Group or Enrollee is no longer eligible
for coverage under the employer's EAP plan. In most instances, Group determines the date in
which coverage will terminate. Coverage can be terminated, however, because of other
circumstances as well, which are described below.
A. Cancellation of Group Contract for Nonpayment of Premiums
Continuing coverage under this EAP Plan is subject to the terms and conditions of Group's
EAP Services Agreement with Plan. If the EAP Services Agreement is cancelled because
Group failed to pay the required premiums when due, then coverage for you and all your
dependents will end 15 days after Group mails you the Notice Confirming Termination of
Coverage.
Plan will mail your Group a notice at least 30 days before any cancellation of coverage.
This Prospective Notice of Cancellation will provide information to your Group regarding
the consequences of your Group's failure to pay the premiums due within 15 days of the
date the notice was mailed.
If payment is not received from Group within 15 days of the date the Prospective Notice
of Cancellation is mailed, Plan will mail Group a Notice Confirming Termination of
Coverage, which Group will then forward to you. This notice will provide you with the
following information:
1) That Group's EAP Services Agreement has been cancelled for non-payment of
premiums;
2) The specific date and time when Group coverage ends, which will be no sooner than
15 days after the Notice Confirming Termination of Coverage is mailed to you.
B. Reinstatement of the Contract after Cancellation
If Group's EAP Services Agreement is cancelled for Group's nonpayment of premiums,
then Plan will permit reinstatement of Group's Agreement if Group pays the amounts owed
within 15 days of the date of the Notice Confirming Termination is mailed to Group.
C. Member Termination for Non -Eligibility
In addition to terminating the EAP Services Agreement, Plan may terminate a Member's
coverage for any of the following reasons:
■ Member no longer meets eligibility requirements established by Group and/or Plan;
■ Member lives or works outside Plan's Service Area and does not work inside Plan's
Service Area (except for a child who is covered as a dependent).
Evidence of Coverage
Ending Coverage — Special Circumstances for Enrolled, Family Members.
Enrolled Family Members terminate on the same date of termination as Group. If there is
a divorce, the Spouse loses eligibility at the end of the month in which a final judgment or
decree of dissolution of marriage is entered. Dependent children lose their eligibility when
they reach the Limiting Age of 26 and do not qualify for extended coverage as a disabled
dependent.
D. Termination for Good Cause
Plan has the right to terminate your coverage under this EAP Plan in the following
situation:
Fraud or Misrepresentation. Your coverage may be terminated if you knowingly
provide false information (or misrepresent a meaningful fact) on your enrollment form
or fraudulently or deceptively use services or facilities of Plan and/or Plan's
participating Providers (or knowingly allow another person to do the same).
Termination is effective immediately on the date Plan mails the Notice of Termination,
unless Plan has specified a later date in that notice.
If coverage is terminated for the above reason, you forfeit all rights to enroll in the COBRA
Plan.
Under no circumstances will a Member be terminated due to health status or the need for
EAP Services. Any Member who believes his or her enrollment has been terminated due
to the Member's health status or requirements for EAP Services may request a review of
the termination by the California Department of Managed Health Care. For more
information, contact our Customer Service Department.
NOTE: If the EAP Services Agreement is terminated by Plan, reinstatement with Plan is
subject to all terms and conditions of the EAP Services Agreement between Plan and the
employer.
XV. CONTINUITY OF CARE
A. New Members
1) Eligibility
Any newly covered Member with an acute, serious, chronic, or other mental health
condition who has been receiving services from a licensed mental health provider who
is not on Plan's panel is eligible for continuation of care. This does not include the
services of psychiatrists, as the EAP benefit does not include psychiatric care. If you
are newly covered under the EAP, you will be offered the option of continued care with
your non -plan provider through the EAP. The Manager of Provider Relations or the
Evidence of Coverage
Director of Clinical Services will review all requests for continued care with a non -plan
provider. Consideration will be given to the potential clinical effect that a change of
provider would have on your treatment for the condition. Notification of the referral
acceptance is by telephone and a referral confirmation to the provider. If the provider
declines to provide services, you will be notified in writing.
2) Access
You may access the services of the provider by calling Plan and indicating to the intake
person that you have an ongoing client -patient relationship with the Provider. You then
should ask the Provider to call and provide information to Provider Relations to be
added to the panel for you. The non -plan provider must agree to continue until one of
the following occurs:
a. The episode of care is completed.
b. Your benefit is exhausted, in which case you will be transitioned to other ongoing
care.
c. A reasonable transition period is determined on a case-by-case basis, during which
time you would continue to see the non -plan provider. The decision as to how long
this time will be takes into consideration the severity of your condition and the
amount of time reasonably necessary to effect a safe transfer. This will be
determined on a case-by-case basis with input from you and the therapist as to when
it is safe to transition you to another provider, or into the full service health plan.
The Medical Director will be consulted on these decisions.
The following conditions must be met to receive continuing care services from a
licensed mental health provider who is not on Plan's panel:
a. Plan must authorize the continuing cage.
b. Requested treatment must be a covered benefit under Group's EAP Services
Agreement with Plan.
c. The non -plan provider must agree in writing to the same contractual terms as a plan
provider, which includes payment rates.
d. Member must be new to Plan.
B. Terminated EAP Providers
Should Plan terminate an EAP Provider for reasons other than a disciplinary cause, fraud,
or other criminal activity, you may be able to continue receiving Benefits from the
terminated provider following the termination, if the provider agrees in writing to continue
to provide Benefits under the terms and conditions of his/her agreement with Plan. To
inquire about continued care, you should contact the Member Services Department.
10 Evidence of Coverage
XVI. CONTINUATION OF GROUP COVERAGE
A. COBRA Continuation of Coverage
If Group is subject to the Consolidated Omnibus Budget Reconciliation Act (COBRA) of
1985, as amended, you may be entitled to continuation of Group coverage under that act
(COBRA Coverage). You may qualify for COBRA Coverage if you lose Group coverage
due to the occurrence of certain qualifying events. Such events include, but are not limited
to:
■ Termination or separation from employment for reasons other than gross misconduct.
■ Reduction of work hours.
■ Death of the Participant.
■ Termination of eligibility of a spouse due to divorce or legal separation.
■ Termination of eligibility of a dependent child.
■ Covered dependent if Member becomes eligible for Medicare
COBRA Coverage extends up to thirty-six (36) months, depending upon your qualifying
event. COBRA Coverage may be terminated on the occurrence of certain events, including
you becoming eligible for coverage under Medicare. In addition, COBRA Coverage is not
available to certain Members, including those Members who have certain other coverage
at the time of the qualifying event. You may obtain complete information on COBRA
qualifying events, COBRA Coverage termination circumstances, and ineligibility for
COBRA Coverage from Group.
Group is responsible for providing you with notice of your right to receive COBRA
Coverage. You must provide Group, or Group's COBRA administrator, with a written
request for COBRA Coverage within sixty (60) days of eligibility for such coverage or
receipt of notice of the qualifying event. Qualified Members must make payment of
Periodic Fees within forty-five (45) days of such written request. Members whose
continuation of coverage under COBRA will expire may be eligible for continuation of
coverage under Cal -COBRA.
B. Cal -COBRA Continuation of Coverage
1) Eligibility for Cal -COBRA Continuation Coverage
If Group is subject to the California Continuing Benefits Replacement Act (Cal -
COBRA), Members may be entitled to continuation of Group coverage under that act
(Cal -COBRA Coverage). Group is subject to Cal -COBRA continuation coverage if it:
a) employs 2 — 19 employees on at least 50% of its working days during the preceding
calendar year; or if the employer was not in business during any part of the previous
year and employed 2 — 19 eligible employees on at least 50% of its working days during
I I Evidence of Coverage
the previous calendar quarter; b) is not subject to the federal Consolidated Omnibus
Budget Reconciliation Act of 1985, as amended (COBRA). If your employer is subject
to Cal -COBRA, you and your dependents may qualify for Cal -COBRA if you would
lose coverage due to one of the following Qualifying Events:
■ Termination of employment or reduction in work hours for reasons other than gross
misconduct.
■ Death of Enrollee.
■ Termination of eligibility of a spouse due to divorce or legal separation.
■ Termination of eligibility of a dependent child.
■ Covered dependent if Member is entitled to Medicare.
■ Member whose COBRA coverage will expire.
Cal -COBRA Coverage extends for up to thirty-six (36) months from the Qualifying
Event unless earlier terminated by the occurrence of certain events.
Group is responsible for providing you with notice of your right to receive Cal -COBRA
Coverage. You must provide Group, or Group's COBRA administrator, with a written
request for Cal -COBRA Coverage within sixty (60) days of eligibility for such
coverage or receipt of notice of the Qualifying Event. Qualified Members must make
payment of Periodic Fees within forty-five (45) days of such written request.
2) Notification of Qualifying Events
It is the responsibility of the Member to notify Group of the occurrence of any of the
Qualifying Events noted below within sixty (60) days:
■ Subscriber's death.
■ Spouse ceases to be eligible due to divorce or legal separation.
■ Loss of dependent status by a Dependent enrolled in the group benefit plan.
■ With respect to a covered Dependent only, the Subscriber's entitlement to
Medicare.
Group must notify Plan within thirty (30) days of a termination of employment or
reduction in work hours, which would result in ending coverage under the Member's
group benefit plan. Failure to notify Plan within sixty (60) days of the occurrence of a
Qualifying Event will disqualify the Member from receiving continuation coverage.
Notifications of a Qualifying Event are generally made to Group, or Group's COBRA
administrator.
3) Cal -COBRA Enrollment and Premium Information
Within fourteen (14) days of receiving notification of a Qualifying Event, Group, or
Group's COBRA administrator, will send enrollment and premium information,
12 Evidence of Coverage
including a Cal -COBRA Election Form. You must return the completed Cal -COBRA
Election Form within the required time period. The Cal -COBRA Election Form must
be received within sixty (60) days of the latest of these occurrences:
■ The date coverage under the plan was terminated or will terminate due to a
Qualifying Event; or
■ The date you were sent the Cal -COBRA enrollment and premium information.
Your Cal -COBRA premium payment must be received within forty-five 45 days of the
date that your Cal -COBRA Election Form was received. Failure to send the correct
premium amount within forty-five (45) days will disqualify you from continuation
coverage under Cal -COBRA. The first premium payment equals the amount of all
premiums due from the first month following the Qualifying Event through the current
month. After the initial payment, Cal -COBRA premiums are due on the first day of
each month. The Cal -COBRA premium is generally 110% of the premium charged to
Group for employees. Your enrollment in Cal -COBRA will not occur until both your
Cal -COBRA Election Form and your first Cal COBRA premium payment have been
received.
4) Termination of Cal -COBRA Continuation Coverage
Usually, a Member's Cal -COBRA continuation coverage will last up to thirty-six (36)
months. The continuation coverage shall end automatically if the individual becomes
eligible for Medicare or becomes covered under any group health plan not maintained
by the employer or any other health plan, regardless of whether that coverage is less
valuable. Member's Cal -COBRA continuation coverage may terminate early if:
Member moves out of Plan's service area; Member does not pay the required premium
within fifteen (15) days of it being due; Member commits fraud or deception in using
Plan's services; Member obtains other group coverage.
If the group benefit plan is terminated prior to the date that a Member's Cal -COBRA
continuation coverage would expire, Member's coverage with Plan will expire.
Member has the opportunity to continue coverage under any group benefit plan
purchased by Group. If Group purchases a new plan, that plan will send Member
premium information and enrollment forms. Member may continue coverage for the
remainder of the Cal -COBRA continuation period. It is important for Member to keep
Plan and Group updated if there are any changes of address. Cal -COBRA continuation
coverage will terminate if Member fails to enroll and pay premiums to the new group
benefit plan within thirty (30) days after receiving notification of the termination of
Plan's group benefit plan.
If Group changes its EAP benefit to another plan, Member's coverage with Plan will
expire, and Member will be given the opportunity to continue coverage with the new
13 Evidence of Coverage
plan. The new plan is required to provide coverage for the balance of the Cal -COBRA
continuation coverage period.
XVII. COMPLAINT AND GRIEVANCE PROCEDURE
A grievance is a written or oral expression of dissatisfaction regarding Plan and/or an EAP
Provider, including quality of care concerns, and includes a complaint, dispute, request for
reconsideration, or appeal made by you or your representative. A complaint is the same as a
grievance.
You are entitled to present complaints and grievances within one year of the occurrence. Plan
is obliged to seek to resolve such complaints and grievances in a timely fashion. Plan has
established a procedure for processing and resolving your complaints and grievances.
Should you desire to register a complaint or grievance with Plan concerning Benefits, you can
either call Plan at the toll-free telephone number 1-500-342-8111, or access Plan's website at
www.resourcesforliving.com to either download the complaint form or to fill it out online.
To request a copy of Plan's complaint form, write directly to Plan at 10260 Meanley Drive,
San Diego, CA 92131. The telephone call or letter should be addressed to the Director, Clinical
Quality Improvement. Plan will acknowledge each complaint and grievance within five (5)
days of receipt. The Director, Clinical Quality Improvement will receive and investigate all
Member complaints and grievances. The Director, Clinical Quality Improvement will respond
to you stating the disposition and the rationale within thirty (30) days of receipt of the
grievance. If the grievance is not resolved to your satisfaction, a second level of review may
be requested within ten (10) days of notification of such disposition. Any such request will be
reviewed by the Medical Director and responded to within seventy-two (72) hours of receipt.
Linguistic and cultural needs will be addressed by translation of grievance forms and
procedures into languages other than English. Using TTY lines and varying the means by
which an Enrollee may submit a grievance, including verbally to Plan's staff (bi-lingual
capability), on website (Spanish and English), verbally by provider (multi -language
capability), or interpreter. This allows Enrollees to submit grievances in a linguistically
appropriate manner. When an Enrollee is seen with the aid of an interpreter, the interpreter or
counselor reading this statement will explain the information that is normally provided in a
written format.
If you have a complaint or grievance about the services you have received, or will receive in
the future, you may notify your counselor (or interpreter), who will supply them with a
grievance form and a description of the process. If you wish to submit the grievance through
your counselor or interpreter, you may do so.
Visually impaired clients may phone the Director of Quality Improvement directly at 1-800-
342-8111. The Director, Quality Improvement, will describe the grievance procedure and take
14 Evidence of Coverage
the grievance information. In this case, the appropriate letters would be sent, and the client
contacted by telephone so that the letter can be read. Hearing impaired clients may file a
grievance using the telephone number 858-712-1080 to contact Plan.
If the complaint or grievance involves a delay, modification, or denial of service related to a
clinically emergent or urgent situation, the review will be expedited and a response provided
in writing to you within three (3) days from receipt of the complaint or grievance. There is no
requirement that you participate in Plan's grievance process before requesting a review by the
California Department of Managed Care (Department) in the case of an urgent or emergent
grievance. The criteria for determining emergent situations are whether you are assessed to be
at imminent risk to seriously harm yourself or another person, or are so impaired in judgment
as to destroy property or be unable to care for your own basic needs. The criteria for
determining urgent situations are whether you are assessed to be significantly distressed, and
are in any medical danger due to the level of the problem, or are experiencing a reduced level
of functioning due to more than a moderate impairment resulting in an inability to function in
key family/work roles.
You, or the agent acting on your behalf, may also request voluntary mediation with Plan prior
to exercising the right to submit a grievance to the Department. The use of mediation services
will not preclude your right to submit a grievance to the Department upon completion of the
mediation. In order to initiate mediation, you, or the agent acting on your behalf, and Plan will
voluntarily agree to mediation. Expenses for the mediation will be borne equally by the parties.
The Department will have no administrative or enforcement responsibilities in connection with
the voluntary mediation process. Mediations will take place in San Diego, California unless
otherwise determined by the parties.
Pursuant to Section 1365(b) of the Act, any Member who alleges his enrollment has been
canceled or not renewed because of his health status or requirement for services may request
review by the Department.
The California Department of Managed Health Care is responsible for regulating health care
service plans. If you have a grievance against your health plan, you should first telephone Plan
at (1800-3425111) and use Plan's grievance process (or locate Plan's grievance form on their
website at www.resourcesforliving.com) before contacting the Department. Utilizing this
grievance procedure does not prohibit any potential legal rights or remedies that may be
available to you. If you need help with a grievance involving an emergency, a grievance that
has not been satisfactorily resolved by your plan, or a grievance that has remained unresolved
for more than thirty (30) days, you may call the Department for assistance. You may also be
eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR
process will provide an impartial review of medical decisions made by a health plan related to
the medical necessity of a proposed service or treatment, coverage decisions for treatments that
are experimental or investigational in nature and payment disputes for emergency or urgent
medical services. The Department also has a toll-free telephone number (1 -888 -HMO -2219)
15 Evidence of Coverage
and a TDD line (1-877-688-9891) for the hearing and speech impaired. The Department's
internet web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms
and instructions online. Plan's grievance process and the Department's complaint review
process are in addition to any other dispute resolution procedures that may be available to you,
and your failure to use these processes does not preclude your use of any other remedy provided
by law.
XVIII. MISCELLANEOUS
A. Confidentiality Policy
A STATEMENT DESCRIBING PLAN'S POLICIES AND PROCEDURES FOR
PRESERVING THE CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE
AND WILL BE FURNISHED TO A MEMBER UPON REQUEST.
B. Member Consent
Under the EAP Services Agreement, Group makes Benefits which are consistent with
professionally recognized standards of practice, available to Members. The EAP Services
Agreement is subject to amendment, modification or termination, in accordance with the
provisions thereof, or by mutual agreement between Plan and Group, without the consent
or concurrence of Members. By accepting Benefits hereunder, all Members legally capable
of contracting, and the legal representatives of all Members incapable of contracting, agree
to all terms, conditions and provisions of the EAP Services Agreement.
C. Plan's Policies
Plan may adopt reasonable policies, procedures, rules and interpretations to promote
orderly and efficient administration of the EAP Services Agreement.
D. Plan's Public Policy Committee
Plan has established a Public Policy Committee that includes, among others, Members of
Groups that have contracted with Plan for Benefits. This committee meets quarterly and
Plan's Board of Directors reviews the reports and recommendations of the committee: Any
Member desiring more information about this committee should contact Plan at 1-800-342-
8111.
E. Term and Renewal Provisions
The initial term of the EAP Services Agreement is twenty-four (24) months. Thereafter
the agreement is automatically renewed for successive twelve (12) month periods, subject
to the termination provisions contained therein.
16 Evidence of Coverage
F. Important Information about Organ and Tissue Donations
Organ and tissue transplants have helped thousands of people with a variety of problems.
The need for donated organs, corneas, skin, bone and tissue continues to grow beyond the
supply. Organ and tissue donation provides you with an opportunity to help others. Almost
anyone can become a donor. There is no age limit. If you have questions or concerns you
may wish to discuss them with your doctor, your family, or your clergy.
Resources for Information:
■ For information and donor card call 1 -SOD -355 -SHARE.
■ Request donor information from the Department of Motor Vehicles.
■ On the Internet, contact All About Transplantation and Donation (www.transweb.org).
■ Department of Health and Human Services, contact http://www.organdonor.gov.
Share ygur decision with family.
If you decide to become a donor:
■ Sign the donor card in the presence of family members.
■ Have your family sign as witnesses and pledge to carry out your wishes.
17 Evidence of Coverage
EXHIBIT A
SCHEDULE OF BENEFITS, LIMITATIONS, AND EXCLUSIONS
Employee Assistance Program Services which include the following components:
I Employee Assistance Program
A. Benefits.
1) Individual, couple, or family assessment and brief counseling for personal, marital,
family, relationship, work-related, and alcohol or substance abuse problems. Brief
counseling is provided when, in the judgment of the EAP provider, the issues meet
community standards of practice for brief counseling within three (3) private
counseling sessions per separate incident. A "session" is defined as either an in --person
or telephone consultation with the Member, of approximately one hour in duration.
Sessions are used to identify or work on resolving the issues or conditions that the
Member is experiencing. A new incident for the same Member would involve different
issues or conditions. Benefits will be consistent with professionally recognized
standards of practice. A separate incident involves a single underlying issue or
condition, regardless of the number of same or different events involving the issue or
condition. Plan shall make the clinical determination as to what constitutes a separate
incident.
2) Referrals are offered to Members whose problem cannot be resolved within the scope
of the three (3) sessions per separate incident. The EAP Provider works with the
Member to identify resources of an appropriate type and level of care beyond the
benefit.
3) Referrals to other resources are offered to Members if the type of care is outside of the
scope of practice of this benefit.
4) 24-hour crisis hotline, 7 days/week.
5) Referrals for legal consultation.
6) Referrals for financial counseling.
7) Identity theft consultation.
B. Limitations
1) The Benefits provided to Members by Plan are limited in nature as described in sections
1-7 above.
2) Plan will make a good faith effort to provide or arrange for the provision of Benefits to
Members, in the event of certain circumstances, such as major disaster, epidemic, riot
or civil insurrection.
18 Evidence of Coverage
C. Exclusions.
1) Inpatient treatment of any kind, or outpatient treatment for any medically treated
illness.
2) Psychiatrist services.
3) Prescription drugs.
4) Counseling services beyond the number of sessions covered by the benefit.
S) Services by counselors who are not Participating Providers.
G) Court ordered treatment or therapy, or any treatment or therapy ordered as a condition
of parole, probation, custody, or visitation evaluations, or paid for by Workers'
Compensation.
7) Formal psychological evaluations which normally involve psychological testing and
result in a written report.
8) Fitness for duty evaluations which are used to evaluate whether an employee is safely
able to perform his or her duties. This typically includes psychological testing and a
written report.
9) Investment advice (nor does Plan loan money or pay bills).
10) Legal representation in court, preparation of legal documents, or advice in the areas of
taxes, patents, or immigration.
II. Telephonic WorkLife Program Services
A. Benefits
Our exclusive, phone -based program designed to assist members with a full range of
WorkLife issues. Members are connected with WorkLife specialists who can assist them
with child and elder care issues, temporary care, special needs, disaster relief, personal and
convenience services, and many other needs.
B. Limited Liability
Plan makes no warranties, expressed or implied, with respect to any information, service
or product provided by a WorkLife referral or on-line assessment provided to Members
("Referees") and all such warranties are expressly disclaimed by Plan and waived by
Group. Referrals to "Referees" do not imply an endorsement, recommendation, or
approval by Plan of the particular information, service, or product provided to the Referee.
While Plan makes every effort to make appropriate referrals for Members, Plan does not
guarantee the accuracy of the information, or the quality or appropriateness of the services
19 Evidence of Coverage
or products provided to the Referee. The decision about any information, products, or
services to a Referee must be made by the Members themselves or Group, as applicable.
20 Evidence of Coverage
EXHIBIT B
COMPARISON OF BENEFITS
The Employee Assistance Program (EAP) is being offered by your employer to provide you with
confidential assistance from licensed mental health professionals. These professionals can help with
problems affecting your life at work as well as at home. Such problems include marital issues, family
relationships, depression and anxiety, alcohol and drug issues, and/or problems within the workplace.
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS
AND IS A SUMMARY ONLY. THE COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE
FORM AND THE EAP SERVICES AGREEMENT SHOULD BE CONSULTED FOR A DETAILED
DESCRIPTION OF BENEFITS, LIMITATIONS AND EXCLUSIONS.
A.
Deductible
Not applicable
B.
Lifetime Maximum
Not applicable
C.
Professional Services
The EAP provides:
Psychosocial Assessment
Treatment Referrals and Resources for Psychosocial Problems
24-hour Crisis Telephone Access
Three (3) Counseling Sessions Per Incident
Legal Referrals
Financial Counseling Referrals
Identity Theft Consultation
D.
Outpatient Services
Please see Item C: Professional Services
E.
Hospitalization Services
None
F.
Emergency Health Coverage
Please see Item C: Professional Services
G.
Ambulance Services
None
H.
Prescription Drug Coverage
None
L
Durable Medical Services
None
J.
Mental Health Services
Please see Item C: Professional Services
K
Chemical Dependency Services
Please see Item C: Professional Services
L.
Home Health Services
None
M.
Other
None
Members pay no co -payment. Coverage is limited to: a) eligible employees; b) the eligible
employee's children under the age of 26; c) persons covered under the eligible employee's health
benefit plan; d) persons residing with the eligible employee, including domestic partners of the same
or opposite sex.
21 Evidence of Coverage