HomeMy WebLinkAboutContracts & Agreements_258A-2016 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
Initial Periodic Fee $1 52 Per Employee Per Month*
Other Pertinent Information
* Provided that enrollment for City of Redlands does not exceed 550 covered emplovees, EAP fees are not
to exceed $10,000 00 tier year
Exhibits A and B
Group Plan
City of Redlands Health and Human Resource Center, Inc ,
dba Aetna Resourc s For Living
By By
r
gy Wagner}
Its �! Vj Its resident
Date- 2/27 /1 --7 Date•
35 Capon Street, Suite 10 10260 Meanley Drive
Redlands, CA 92373 San Diego, CA 92131
Telephone (909) 798-7514 Telephone (800) 890-1921
Attest
City Clerk
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 Covei 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
1. 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, of
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 Covcrai�e" of "Combined Evidence of Coverage and Disclosure Form" The document
issued to an employee of Group which summarizes the essential terms of this Agreement
1 EAP Services Agreement
G "Group" The organization identified as such on the Cover Sheet of this Agreement
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 fol the cost of services provided to the Member
C Benefits Benefits may be changed in accordance with Section XII A hereof
IV.LIMITATIONS 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 majoi 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
of failure to provide Benefits under such conditions
2 EAP Services Agreement
B Exclusion Court ordered treatment or therapy, or any treatment or therapy ordered as a condition of
parole, probation of custody or visitation evaluations, is entirely excluded from Benefits
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 Pian 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 fol 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 Charles 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 Charles 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 Covei Sheet hereof, and all persons entitled to be Members through such employees shall be
entitled to receive Benefits as of 12 01 a in 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 foi the provision of Benefits to Members hereunder is set
forth on the Covei 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
3 EAP Services Agreement
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
2 Right to Review A Member who alleges that his or hes rights hereunder were terminated or not
renewed because of the Member's health status or requirements fol 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 Group
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 Noni)avinent 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 propel 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 urion 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 Provides to Members who retain eligibility
under this Agreement, of 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 ass-Limption of such Benefits by another EAP Provider
2 Group Continuation Benefits Federal of 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 foi notifying eligible persons of the availability, teruis, conditions and duration of,
4 EAP Services Agreement
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
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 foi 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/oi 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
Membei within,three (3) days from receipt of the complaint or grievance There is no requirement that
the Membei 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, of is
so impaired in judgment as to destroy property of 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
5 EAP Services Agreement
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
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 corn) 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 foi 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, of the rights of either party, or with respect to any
transaction contemplated by this Agreement, either party may refer the dispute on controversy to the
American Arbitration Association foi resolution
6 EAP Services Agreement
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
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 of required to satisfy all HIPAA
Requirements applicable to this Agreement and the transactions contemplated hereby
XII MISCELLANEOUS
A Chante 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 of
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 fol
payment therefore
D Notice of Certain Events Plan shall give Group written nonce within a reasonable time of any
termination or breach of contract by, or inability to perform of an EAP Provider, or any person with
7 EAP Services Agreement
whom Plan has a contract to provide Benefits hereunder, if Group can be materially and adversely
affected thereby
E Liability of PIan 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
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
I 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
J 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 aftei 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 of
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 entei into any contract, or cancel or decline to renew or
reinstate any contract, not may Plan modify the terms of a contract because of the race, color,
national origin, ancestry, religion, sex, marital status, sexual orientation, handicap of age of any
contracting party, or person reasonably expected to benefit from such contract
8 EAP Services Agreement
N Headznu 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
O lntemretations and Governlna 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 of 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
9 EAP Services Agreement
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 terns 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 pei 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 Foi 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 foi managers, supervisors, and
human resources professionals to assist in identifying and resolving workplace issues and
10 EAP Services figreement
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
perforin the functions of their fob, 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 tines 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 furthei provide contact information of
local providers in oui 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
11 EAP Services Agreement
• 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
8 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/oi 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
12 EAP Services Agreement
11 EAP EXCLUSIONS• The following services are outside the scope of the EAP
• 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)
13 EAP Services Agreeinent
WORK/LIFE PROGRAM SERVICES
1 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
• %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 smatter 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
14 EAP Services Agreement
® All initial consultation (and discounted consultations) must be for legal matters related to
the Employee and eligible household members
FINANCIAL SERVICES
• '/2 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
0 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 webmars, online
work/life searches, concierge database, discount program,thousands of articles, videos, and tools
on work/life and behavioral health topics
15 EAP Services Agreement
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
16 EAI'Services Agreement
If Group requests on-sate 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 balled $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—Webmar 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
17 Evil'Senates Agivemeni
DEPARTMENT OF TRANSPORTATION (DOT) TRAINING TO MEET DRUG-FREE
WORKPLACE REGULATIONS REGARDING DRUG AND ALCOHOL AWARENESS
SUPERVISOR TRAINING Alcohol and Drug-Free Workplace Training to meet Drug-Free
Workplace regulations regarding drug and alcohol use
Fee-Far-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 fol 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
18 EAP Services Agreement
EXHIBIT B
Periodic Fees
51.52 Per Employee Per Month.
This rate includes the following services, more filly documented in Exhibit A and the Agreement
Service Rate
Three-session Employee Assistance Program
and Telephonic WorkLife services $ 152 per employee per month
Additional services not specifically covered by this contract will be billed at then current rates
19 EAP Services Agreement
EMPLOYEE ASSISTANCE PROGRAM
COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM
TABLE OF CONTENTS
1. DEFINITIONS 2
II HOW TO OBTAIN BENEFITS 3
III EMERGENCY SERVICES.................. 3
IV CRISIS INTERVENTION 4
V PERIODIC FEES ... . . . ... . . ........................ ................. 4
VI OTHER CHARGES 4
VII PREPAYMENT OF FEES 4
VIII. CHOICE OF EAP PROVIDERS 5
IX FACILITIES 5
X LIABILITY OF PLAN/MEMBERS.... ..... ....... 5
A LIABILITY OF PLAN 5
B LIABILITY OF MEMBERS 5
C MEMBER LIABILITY TONON-EAP PROVIDERS 5
XI. PROVIDER COMPENSATION 5
XII SECOND OPINION POLICY 6
XIII ELIGIBILITY/ENROLLMENT/EFFECTIVE DATE OF COVERAGE 6
XIV. TERMINATION OF BENEFITS 6
A CANCELLATION OF GROUP CONTRACT FOR NONPAYMENT OF PREMIUMS 7
B REINSTATEMENT OF THE CONTRACT AFTER CANCELLATION 7
C MEMBER TERMINATION I'OR NON ELIGIBILITY 7
D TERMINATION FOR GOOD CAUSE 8
XV CONTINUITY OF CARE . . ....... .................. ... .. ... 8
A NEW MEMBERS 8
1) Eligibility 8
2) Access 8
B TERMINATED EAP PROVIDERS 9
i Evidence of Coverage
XVI CONTINUATION OF GROUP COVERAGE 9
A COBRA CONTINUATION OF COVERAGE 9
B CAL COBRA CONTINUATION Or COVERAGE 10
1) Eligibility far Cal-COBRA Continuation Cover age 10
2) Notification of Qualifying Events 11
3) Cal-COBRA Enrollment and Premium In/or matron 11
4) Termination of Cal-COBRA Continuation Coverage 12
XVII COMPLAINT AND GRIEVANCE PROCEDURE 12
XVIII MISCELLANEOUS ... ......... .. ..... . ....... . .....................................................................14
A CONFIDENTIALITY POLICY 14
B MEMBER CONSENT 14
C PLAN S POLICIES 15
D PLAN'S PUBLIC POLICY COMMITTEE 15
E TERM AND RENEWAL PROVISIONS 15
F IMPORTANT INFORMATION ABOUT ORGAN AND TISSUE DONATIONS 15
SCHEDULE OF BENEFITS, LIMITATIONS,AND EXCLUSIONS 16
A BENEFITS 16
B LIMITATIONS 16
C EXCLUSIONS 17
COMPARISON OF BENEFITS . . . ............................18
I 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 Fol free help,
please call right away at 1-877-287-0117
Planes EAP - IMPORTANTE: ,Puede lees esta documento? En caso de no poder leerla, le
brindamos nuestra ayuda Tambien puede obtener esta documento escrita en su idioma Para
obtenei ayuda gratuita, par favor Maine de inmediato al 1-877-287-0117
1 Evidence of Covet age
I 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 Aueement" 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 1s set forth in Exhibit A to this Combined
Evidence of Coverage and Disclosure Form
F "Plan" 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
7 "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 oa
opposite sex
K "Periodic Fees" means the monthly amounts due and payable to Plan by Group foi
providing Benefits to Members
2 Evidence of Cover age
L "Emer2encv Services" means medically necessary transport using the 911 system or
medical screening, examination and evaluation by a physician to determine of 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 "Emer2encv 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
II 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 fol 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 Providei in your area, or assist you
in obtaining more intensive, acute care services
III 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 law, to determine
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
3 Evidence of Coverage
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-foul (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 foi 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, of fees foi Plan All fees are paid by
Group
4 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 Providet 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 EAP
Members are given names of contracted providers to their area with knowledge to 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 to
the area specialty that you request
X. LIABILITY OF PLAN I 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 Nan-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
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
5 Evidence of Coverage
Members may request further information about Plan's EAP Provider reimbursement policies
and procedures by contacting Plan's Managei, 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 Plari 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
elfdirected 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/E NROLLMENT/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
of 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
XIV TERMINATION OF BENEFITS
Usually, youi enrollment in the plan terminates when Group of Enrollee is no longer eligible
for coverage undei the employei'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
6 Evidence of Coverage
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
foi 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 foi 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 of 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)
Ending Coveran--Special Circumstances for Enrolled Familv 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 there eligibility
when they reach the Limiting Age of 26 and do not qualify for extended coverage as a
disabled dependent
7 Evidence of Coverage
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 undei the EAP, you will be offered the option of continued
care with your non-plan provider through the EAP The Manager of Providei
Relations or the Directoi of Clinical Services will review all requests fol continued
care with a non-plan providei Consideration will be given to the potential clinical
effect that a change of provider would have on your treatment foi the condition
Notification of the referral acceptance is by telephone and a referral confirmation to
the provides 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
8 Evidence of Cove,age
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 care
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
XVI CONTINUATION OF GROUP COVERAGE
A. COBRA Continuation of Coverage
If Group is subject to the Consolidated Omnibus Budget Reconciliation Act (COBRA) of
1955, 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 foi reasons other than gross misconduct
9 Evidence of Cover age
= Reduction of work hours
= Death of the Participant
Termination of eligibility of a spouse due to divorce of 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 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 of 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
10 Evidence of Coverage
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
Z) 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,
including a Cal-COBRA Election Form You must return the completed Cal-COBRA
Election Form within the required time period The Cal-COBRA Electron 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 antral payment, Cal-COBRA premiums are due
11 Evidence of Coverage
on the first day of each month The Cal-COBRA premium is generally 110% of the
premium charged to Group fol 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 pian will send Membei
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
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 1-800-342-8111, or access Plan's
website at www resourcesforliving com to either download the complaint form or to fill it
12 Evidence of Coverage
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 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, of are experiencing
a reduced level of fiinctioning due to more than a moderate impairment resulting in an
inability to function in key family/work roles
You, or the agent acting on youl behalf, may also request voluntary mediation with Plan
prior to exercising the right to submit a grievance to the Department The use of mediation
13 Evidence of Coverage
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 (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 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) 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, of by mutual agreement between Plan and Group, without the
consent or concurrence of Members By accepting Benefits hereunder, all Members
14 Evidence of Covet-age
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
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 thein with your doctor, your family, or your clergy
Resources for Information
■ For information and donor card call 1-800-355-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 voui 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
15 Evidenee 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 of 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 majoi disaster, epidemic,
riot or civil insurrection
16 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 youi 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 PIease 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
I 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 Horne Health Services Nona
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 undei the eligible employee's health
benefit plan, d) persons residing with the eligible employee, including domestic partners of the
same or opposite sex
18 Evidence of Coverage