Item C19C ounty of M onroe
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BOARD OF COUNTY COMMISSIONERS
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Mayor David Rice, District 4
The FlOnda Key
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Mayor Pro Tem Sylvia J. Murphy, District 5
Danny L. Kolhage, District 1
George Neugent, District 2
Heather Carruthers, District 3
County Commission Meeting
September 19, 2018
Agenda Item Number: C.19
Agenda Item Summary #4639
BULK ITEM: Yes DEPARTMENT: Employee Services
TIME APPROXIMATE: STAFF CONTACT: Maria Fernandez- Gonzalez (305)
292 -4448
n/a
AGENDA ITEM WORDING: Approval to renew with Vision Service Plan Insurance Company
(VSP), with staff completing the necessary forms, for fully insured voluntary vision benefits for a
term of one (1) year effective January 1, 2019 through December 31, 2019.
ITEM BACKGROUND: A one -year renewal with Vision Service Plan Insurance Company (VSP),
with no rate increase in either the low or high option vision plans. Current policy ends 12/31/2018.
Staff plan to evaluate the vision provider network and insurance options through a Request for
Proposals in 2019.
PREVIOUS RELEVANT BOCC ACTION:
April 2003 — BOCC approved recommendation to have the dental and vision benefits fully
insured and voluntary.
October 2003 — Approval of American General (carrier 1/1/04 - 12/31/07)
November 2007 — Approval of EyeMed (carrier 1/1/08 - 12/31/11)
October 2011 — Approval of VSP (carrier 1/1/12- current)
September 2013 — Approval of renewal with VSP (1/1/14- 12/3/16)
May 2016 — Fully Insured Vision Benefit RFP approved by BOCC
September 2016 — Selection Committee recommended renewing with VSP. BOCC approved a
term of two (2) years to become effective 1/1/17 through 12/31/18.
CONTRACT /AGREEMENT CHANGES:
One year renewal. No increase in rates.
STAFF RECOMMENDATION: Approval of one year renewal with VSP (1 /l /19- 12/31/19).
Staff to issue RFP in 2019 for both vision and dental fully insured plans.
DOCUMENTATION:
VSP ONE YEAR RENEWAL 2019.ORIGINAL
VSP 2019 RATE SHEET
VSP LOW OPTION PLAN SUMMARY 2019
VSP HIGH OPTION PLAN SUMMARY 2019
VSP VISION CARE POLICY 2012.1st policy
VSP RENEWAL 2014
VSP VISION CARE POLICY 2014
VSP RENEWAL 2017
VSP VISION CARE POLICY 2017
FINANCIAL IMPACT:
Effective Date: 1/1/19
Expiration Date: 12/31/19
Total Dollar Value of Contract: N/A
Total Cost to County: NONE — Fully Insured Benefit
Current Year Portion:
Budgeted:
Source of Funds: Premiums paid by participants
CPI:
Indirect Costs:
Estimated Ongoing Costs Not Included in above dollar amounts:
Revenue Producing:
Grant:
County Match:
Insurance Required:
Additional Details:
If yes, amount:
REVIEWED BY:
Bryan Cook
Completed
Cynthia Hall
Completed
Assistant County Administrator Christine
Hurley
08/31/2018 4:55 PM
Budget and Finance
Completed
Maria Slavik
Completed
Kathy Peters
Completed
Board of County Commissioners
Pending
08/28/2018 12:29 PM
08/29/2018 5:47 PM
Completed
09/04/2018 3:02 PM
09/04/2018 3:11 PM
09/04/2018 3:47 PM
09/19/2018 9:00 AM
Ell
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Mark Tafuri
Mwket air�
I am providing this letter as confirmation between VSP and Monroe County Board of County Commissioners keeping current rates and plan in place,
effective January 1, 2019 for another 12 months. 1,244 employees total are currently covered under VSP's Choice Plan B- Low Plan (exam & lenses
every 12 months and frame every 24 months) and Choice C — High Plan (Exam, lenses and frame every 12 months) with a $10!$20 split copay. The
current rates for this coverage are $4.441$8.809.501$15.18 Low Plan & $9.271$18.521$19.81!$31.67 High Plan.
Current Plant Renewing
Group Name:
Monroe County Board of County Commissioners
Group Number:
30029497
Plans:
Choice Plan B - Low Plan & Choice C — High Plan
Plan Frequency:
Exam & lenses every 12 months and frame every 24 months Low Plan
Exam, lenses and frame every 12 months High Plan
Frame Allowance:
$140 Low Plan 1$180 High Plan
Elective Contact Lenses:
$115 Low Plan 1$130 High Plan
Co- payments:
$10 Exam and $20 Materials Copay (Low & High Plans)
$10 Polycarbonate, $55 Progressive, $30 Photochromic, $40 Anti - Reflective- High Plan
UV Covered in full — High Plan
CurrentlRenewing Rates:
$4.441$8.88/$9.501$15.18 Low Plan
$9.27/$18.521$19.81!$31.67 High Plan
Renewal Period:
January 1, 2019— December 31, 2019 (12 months)
Please have the appropriate group representative sign the renewal below and fax or email a copy of this renewal to Fabian Whipple @ (404) 816 -1914
or Fabian.Whipple @vsp.com.
We appreciate your business and value our relationship with your organization.
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Authorized Group Representative Signature
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W&ONEIIIIIIIIIII
2019 RATES
LOW OPTION Y'
Prescription Glasses '
$20 See frame and lenses
• $140 allowance for a wide selection of frames
Included in
• $160 allowance for featured frame brands
Frame
Prescription Every other calendar year
• 20% savings on the amount over your allowance
Glasses
• $75 Costcoe frame allowance
• Single vision, lined bifocal, and lined trifocal lenses
Lenses
Included in
Prescription Every calendar year
• Polycarbonate lenses for dependent children
Glasses
• Standard progressive lenses $0
• Premium progressive lenses $95-$105
Lens Enhancements Every calendar year
• Custom progressive lenses $150-$175
• Average savings of 20 -25% on other lens enhancements
Contacts (Instead of • $115 allowance for contacts; copay does not apply Up to $60 Every calendar year
glasses) • Contact lens exam (fitting and evaluation)
• Services related to diabetic eye disease, glaucoma and age - related
Diabetic'Eyscare Plus macular degeneration (AMD). Retinal screening for eligible members $20 As needed
Program with diabetes. Limitations and coordination with medical coverage
may apply. Ask your VSP doctor for details.
1. Brands/Promotion subject to change.
2. Savings based on network doctors retail price and vary by plan and purchase selection; average savings determined after benefits are applied. Available only through VSP network doctors to VSP
members with applicable plan benefits. Ask your VSP network doctor for details.
02018 Vision Service Plan. All rights reserved.
VSP, VSP Vision care for life, eyeconic.com, and Wel[Vision Exam are registered trademarks, and 'Life is better in focus.' is a trademark of Vision Service Plan. Flexon Is a registered trademark of Marchon
Eyewear, Inc. All other company names and brands are trademarks or registered trademarks of their respective owners.
(D
Your VSP Vision Benefits Summary 0
VSP.
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS - Low Option and VSP vision care for life
provide you with an affordable eyecare plan.
Your VSP Vision Benefits Summary
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS - High Option and VSP
provide you with an affordable eyecare plan.
VSP Coverage Effective Date: 01/0112019
C.19.d
VSP.
Vision care for life
VSP Provider Network: VSP Choice
WeIlVision Exam
- Focuses on your eyes and overall wellness
$10 Every calendar year
Prescription Glasses
$20 See frame and lenses
- $180 allowance for a wide selection of frames
Included in
Frame
- $200 allowance for featured frame brands
- 20% savings on the amount over your allowance
Prescription Every calendar year
- $110 Cosmos frame allowance
Glasses
Included in
Lenses
- Single vision, lined bifocal, and lined trifocal lenses
Prescription Every calendar year
Glasses
- Standard progressive lenses
$0
- UV protection
$0
- Premium progressive lenses
$55
Lens Enhancements
- Custom progressive lenses
- Anti - reflective coating
$55 Every calendar year
$40
- Photochromic adaptive lenses
$30
- Polycarbonate lenses
$10
- Average savings of 20 -25% on other lens enhancements
Contacts (instead of
- $130 allowance for contacts; copay does not apply
glasses)
- Contact lens exam (fitting and evaluation)
Up to $60 Every calendar year
- Services related to diabetic eye disease, glaucoma and age - related
Diabetic Eyecare Plus
macular degeneration (AMD). Retinal screening for eligible members
Program
with diabetes. Limitations and coordination with medical coverage
$20 As needed
may apply. Ask your VSP doctor for details.
Glasses and Sunglasses
- Extra $20 to spend on featured frame brands. Go to vsp.comispecialoffers for details.
- 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12
months of your last WeIlVision Exam.
Extra Savings
Retinal Screening
- No more than a $39 copay on routine retinal screening as an enhancement to a WeIlVision Exam
Laser Vision Correction
- Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities
Your Goveragewith t}ut- af- Natvuarlc Providers
Get the most out of your benefits and greater savings with a VSP network doctor. Call Member Services for out -of- network plan details.
1.8randslPromotion subject to change.
2. Savings based on network doctor's retail price and vary by plan and purchase selection; average savings determined after benefits are applied. Available only through VSP network doctors to VSP
members with applicable plan benefits. Ask your VSP network doctor for details.
02018 Vision Service Plan. All rights reserved.
VSP, VSP Vision care for life, eyeconic com, and WeIlVision Exam are registered trademarks, and "Life is better in focus." is a trademark of Vision Service Plan. Flexon is a registered trademark of Marchon
Eyewear, Ina All other company names and brands are trademarks or registered trademarks of their respective owners.
•
vsp Vis €oo Care for Life
VISION SERVICE PLAN INSURANCE COMPANY
3333 QUALITY DRIVE
RANCHO CORDOVA, CALIFORNIA 95670
GROUP VISION CARE POLICY
Group Name MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
Policy Number
30029497
State of Delivery
FLORIDA
Effective Date
JANUARY 1, 2012
Policy Term TWENTY -FOUR (24) MONTHS
In consideration of the statements and agreements contained in the Group Application and in consideration of
payment by the Group of the premiums as herein provided, VISION SERVICE PLAN INSURANCE COMPANY ( "VSP ")
agrees to insure certain individuals under this Group Vision Care Policy ( "Policy ") for the benefits provided herein,
subject to the exceptions, limitations and exclusions hereinafter set forth. This Policy is delivered in and governed by
the laws of the state of delivery and is subject to the terms and conditions recited on the subsequent pages hereof,
including any Exhibits or state - specific Addenda, which are a part of this Policy..
4-4 _ t��4
Gary N. Brooks, Secretary
VSP GVCP FL. 9004. DDM 11/28/11 Kxf
VISION SERVICE PLAN INSURANCE COMPANY
GROUP VISION CARE POLICY
TABLE OF CONTENTS
I . DEFINITIONS ........................................................................... ...............................
IL TERM, TE,RMINAT1ON, AND RENEW AL .t ....... ......... ......... ......... . +............. ..,,,.
III. OBLIGATIONS OF' VSP..,,„ .. ,,,.., : ............................. .... ....t,,.......,... ,,...,....
IV. OBLIGATIONS OF THE GROUP ............................................... ............................... 7
V. OBLIGATIONS OF COVERED PERSONS UNDER THE POLICY,. . . ........ .:..... t..., . 9
V. ELIGIBILITY FOR CO VERAGE .........................
VIll. CONTINUATION OF COVERAGE...,...,---...- ....,, ;; ;,,,, ,,,,,,;,,,;,.,....;...,....,... 3
VII ARBITRATION 'Of DISPUTES.. ..... .... . ...................................... .............. 1
I . NOTICES. - . ................
X . MISCELLANEOUS . -....... ......, .. ... .... . ........ ................ ,,,, - 17
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..* �J
EXHIBIT C
ADDITIONAL BENEFIT m DIABETIC EYECARE . ..................... 27
ADDENDUM
PERFORMANCE STANDAR ...... --- ... ... ......... ..... ............... ;..,.,.., 29
VISION SERVICE PLAN INSURANCE COMPANY
GROUP VISION CARE POLICY
DEFINITIONS
The key terms in this Policy are defined:
1.01. ADDITIONAL BENEFIT RIDER The document, attached as Exhibit C to this Policy (if purchased by
Group), which lists selected vision care services and vision care materials which a Covered Person is entitled to receive
under this Policy. Additional Benefits are only available when purchased by Group in conjunction with a Plan Benefit offered
under Exhibit A.
1.02. ADMINISTRATIVE SERVICES PROGRAM A group vision care plan whereby Group pays VSP for the
Plan Benefits in addition to a monthly administrative fee.
1.03. BENEFIT AUTHORIZATION Authorization from VSP identifying the individual named as a Covered
Person of VSP, and identifying those Plan Benefits to which Covered Person is entitled.
1.04. CONFIDENTIAL MATTER All confidential information concerning the medical, personal, financial or
business affairs of Covered Persons acquired in the course of providing Plan Benefits hereunder.
1.05. COORDINATION OF BENEFITS Procedure which allows more than one insurance plan to consider
Covered Person's vision care claims for payment or reimbursement.
1.06. COPAYMENTS Those amounts required to be paid by or on behalf of a Covered Person for Plan Benefits
which are not fully covered, and which are payable at the time services are rendered or materials provided.
1.07. COVERED PERSON An Enrollee or Eligible Dependent who meets Group's eligibility criteria and on
whose behalf premiums have been paid to VSP, and who is covered under this Policy.
1.08. ELIGIBLE DEPENDENT Any dependent of an Enrollee of Group who meets the criteria for eligibility
established by Group
1.09. EMERGENCY CONDITION A condition, with sudden onset and acute symptoms, that requires the
Covered Person to obtain immediate medical care, or an unforeseen occurrence calling for immediate, non - medical action.
1.10. ENROLLEE An employee or member of Group who meets the criteria for eligibility specified under VI.
ELIGIBILITY FOR COVERAGE.
1.11. EXPERIMENTAL NATURE Procedure or lens that is not used universally or accepted by the vision care
1
profession, as determined by VSP.
1.12. EVIDENCE OF COVERAGE: A summary of the Policy provisions, prepared by VSP and provided to
Group for distribution to Enrollee.
1.13. GROUP An employer or other entity which contracts with VSP for coverage under this Policy in order to
provide vision care coverage to its Enrollees and their Eligible Dependents.
1.14. GROUP APPLICATION The form signed by an authorized representative of the Group to signify the
Group's intention to have its Enrollees and their Eligible Dependents become Covered Persons of VSP.
1.15. GROUP VISION CARE Poli also "The Poli " : The Policy issued by VSP to a Group, under which
its Enrollees or members, and their Eligible Dependents are entitled to become Covered Persons of VSP and receive Plan
Benefits in accordance with the terms of such Policy.
1.16. VSP NETWORK DOCTOR An optometrist or ophthalmologist licensed and otherwise qualified to practice
vision care and/or provide vision care materials who has contracted with VSP to provide vision care services and/or vision
care materials on behalf of Covered Persons of VSP.
1.17. NON -VSP PROVIDER Any optometrist, optician, ophthalmologist, or other licensed and qualified vision
care provider who has not contracted with VSP to provide vision care services and/or vision care materials to Covered
Persons of VSP.
1.18. PLAN or PLAN BENEFITS The vision care services and vision care materials which a Covered Person is
entitled to receive by virtue of coverage under this Policy, as defined in the Schedule of Benefits (Exhibit A) and, if
purchased by Group, the Additional Benefit Rider (Exhibit C), attached hereto.
1.19. RENEWAL DATE The date when the Policy shall renew, or terminate if proper notice is given.
1.20. SCHEDULE OF BENEFITS: The document, attached as Exhibit A to this Policy, which lists the vision care
services and vision care materials which a Covered Person is entitled to receive under this Policy.
1.21. SCHEDULE OF PREMIUMS: The document, attached hereto as Exhibit B, which states the payments to
be made to VSP by or on behalf of a Covered Person to entitle him/her to Plan Benefits.
9
TERM. TERMINATION, AND RENEWAL
2.01. This Policy is effective on the Effective Date and shall remain in effect for the Policy Term. At the end of the
Policy Term, the Policy shall renew on a month to month basis unless either party notifies the other in writing, at least sixty
(60) days before the end of the Policy Term, that such party is unwilling to renew the Policy If such notice is given, the
Policy shall terminate at 11:59 p.m, in the state of delivery on the last day of the Policy Term unless the parties agree on its
renewal of the Policy. If the Policy continues on a month to month basis after the Policy Term, either party may terminate
the Policy upon forty -five (45) days advance written notice to the other party.
If VSP issues written renewal materials to Group at least sixty (60) days before the end of the Policy Term and
Group fails to accept the new terms and/or rates in writing prior to the end of the Policy Term, this Policy shall terminate at
11:59 p.m. on the last day of the Policy Term.
2.02. Early Termination Provision The premium rate payable by Group under this Policy is based on an
assumption that VSP will receive these amounts over the full Policy Term in order to cover costs associated with greater
vision utilization that tends to occur during the first portion of a Policy Term. If Group terminates this Policy before the end of
the Policy Term or before the end of any subsequent renewal terms, for any reason other than material breach by VSP, then
Group shall be liable for the lesser of any deficit incurred by VSP or the remaining payments which Group would have paid
for the full term of this agreement. A deficit incurred by VSP will be calculated by subtracting the cost of incurred and
outstanding claims, as calculated on an incurred date basis with a claim run -out not to exceed six months from the date of
termination, from the net premiums received by VSP from Group. Net premiums shall mean premiums paid by Group minus
any applicable retention amounts and/or broker commissions. Group agrees to pay VSP within thirty -one (31) days of
notification of the amount due. VSP shall return any unearned premiums to Group upon termination.
M
Ill.
OBLIGATIONS OF VSP
3.01. Coverage of Insureds: VSP will enroll for coverage each eligible Enrollee and his/her Eligible
Dependents, if dependent coverage is provided, all of whom shall be referred to upon enrollment as "Covered Persons." To
institute coverage, VSP may require Group to complete, sign and forward to VSP a Group Application along with information
regarding Enrollees and Eligible Dependents, and all applicable premiums. (Refer to VI. ELIGIBILITY FOR COVERAGE for
further details.)
Following the enrollment of the Covered Persons, VSP will provide Group with Member Benefit Summaries and a
copy of the Evidence of Coverage, with Exhibits, for distribution to Covered Persons. Such Member Benefit Summaries and
Evidence of Coverage will summarize the terms and conditions set forth in this Policy.
3.02. Provision of Plan Benefits Through its VSP Network Doctors (or through other licensed vision care
providers where a Covered Person is eligible for, and chooses to receive Plan Benefits from a Non -VSP Provider), VSP
shall provide Covered Persons such Plan Benefits listed in the Schedule of Benefits (Exhibit A) or, when purchased by
Group, Additional Benefit Rider (Schedule C) attached hereto, subject to any limitations, exclusions, or Copayments therein
stated. Benefit Authorization must be obtained prior to a Covered Person obtaining Plan Benefits from a VSP Network
Doctor. When a Covered Person seeks Plan Benefits from a VSP Network Doctor, the Covered Person must schedule an
appointment and identify himself as a VSP Covered Person, so the VSP Network Doctor can obtain Benefit Authorization
from VSP. VSP shall provide Benefit Authorization to the VSP Network Doctor to authorize the provision of Plan Benefits to
the Covered Person. Each Benefit Authorization will contain an expiration date, stating a specific time period for the
Covered Person to obtain Plan Benefits.
VSP shall issue Benefit Authorizations in accordance with the latest eligibility information furnished by Group and the
Covered Person's past service utilization, if any. Any Benefit Authorization so issued by VSP shall constitute a certification
to the VSP Network Doctor that payment will be made, irrespective of a later loss of eligibility of the Covered Person,
provided Plan Benefits are received prior to the Benefit Authorization expiration date.
VSP shall pay or deny claims for Plan Benefits provided to Covered Persons, less any applicable Copayment, but not more
than thirty (30) calendar days after VSP has received a completed claim, unless special circumstances require additional
time. If VSP requires additional information in order to pay or deny all or any portion of a claim, VSP will notify the person
submitting the claim within forty -five (45) days after the receipt of the claim. Upon receipt of the requested information, VSP
will pay or deny the claim within sixty (60) days. All claims shall be paid or denied by VSP within one hundred twenty (120)
days after receipt of claim.
WARNING, LIMITED BENEFITS WILL BE PAID WHEN NON -VSP PROVIDERS ARE USED.
When Covered Persons elect to utilize the services of a Non -VSP Provider for a covered service in non - emergency
situations, benefit payments for services from such Non -VSP Provider are not based upon the amount billed. The basis of
the benefit payment will be determined according to the Policy's Non -VSP Provider fee schedule. COVERED PERSONS
CAN EXPECT TO BE LIABLE FOR MORE THAN THE COPAYMENT AMOUNT DEFINED IN THE ATTACHED
SCHEDULE OF BENEFITS OR ADDITIONAL BENEFITS RIDER (when purchased by Group) AFTER THE PLAN HAS
PAID ITS REQUIRED PORTION.
When payment is made to the Non -VSP Provider, the provider may bill Covered Persons for any amount up to the
billed charges after the Plan has paid its portion of the bill. VSP Network Doctors have agreed to accept discounted
payments for services with no additional billing to the Covered Person other than Copayments, co- insurance and any
amounts for non - covered services and/or materials. Covered Persons may obtain further information about the participating
status of providers and information on out-of-pocket expenses through www.vsp.com, or by calling VSP's Customer Service
Department at 1- 800 - 877 -7195.
3.03. Provision of Information to Covered Persons Upon request, VSP shall make available to Covered
Persons necessary information describing Plan Benefits and how to use them. A copy of this Policy shall be placed with
Group and also will be made available at the offices of VSP for any Covered Persons. VSP shall provide Group with an
updated list of VSP Network Doctors' names, addresses, and telephone numbers for distribution to Covered Persons twice
a year. Covered Persons may also obtain a copy of the VSP Network Doctor directory through VSP's website at
www.vsp.com, VSP's Customer Service Departments toll -free telephone line, or by written request.
M
3.04. Preservation of Confident "fl : VSP shall hold in strict confidence all Confidential Matters and exercise
its best efforts to prevent any of its employees, VSP Network Doctors, or agents, from disclosing any Confidential Matter,
except to the extent that such disclosure is necessary to enable any of the above to perform their obligations under this
Policy, or to comply with applicable law. Covered Persons and/or Groups that want more information on VSP's
Confidentiality Policy may obtain a copy of the policy from VSP's website at www.vsp.com or by contacting VSP's Customer
Service Department.
3.05. Emergency Vision Care When vision care is necessary for Emergency Conditions, Covered Persons
may obtain Plan Benefits by contacting a VSP Network Doctor or Non -VSP Provider. No prior approval from VSP is required
for Covered Person to obtain vision care for Emergency Conditions of a medical nature. However, services for medical
conditions, including emergencies, are covered by VSP only under the Acute EyeCare and Supplemental Primary EyeCare
Plans. If Group has not purchased one of these plans, Covered Persons are not covered by VSP for medical services and
should contact a physician under Covered Persons' medical insurance plan for care. For emergency conditions of a
non- medical nature, such as lost, broken or stolen glasses, the Covered Person should contact VSP's Customer Service
Department for assistance. Reimbursement and eligibility are subject to the terms of this Policy.
3.05 Coordination of Benefits When VSP is primary, it will pay benefits according to the terms of the
Policy, subject to any applicable state or federal codes, statutes or regulations. When VSP is secondary, it will coordinate
those vision care services and materials that were considered by the primary plan ("Allowable Expenses "). VSP will pay the
lesser of
a) The normal Plan Benefit, in the absence of other coverage, or
b) The remaining balance up to Covered Person's Plan Benefits, not to exceed the billed amount.
A
IV.
OBLIGATIONS OF THE GROUP
4.01. Identification of Eligible Enrollees An Enrollee is eligible for coverage under this Policy if he/she
satisfies the enrollment criteria specified in Paragraph 6.01(a) and as established by Group. By the Effective Date of this
Policy, Group shall provide VSP with eligibility information, in a mutually agreed upon format and medium, to identify all
Enrollees who are eligible for coverage under this Policy as of that date. Thereafter, Group shall supply to VSP by the 16th
day of each month, eligibility information sufficient to identify all Enrollees to be added to or deleted from VSP's coverage
rosters. All additions and deletions shall become effective on the first day of the month specified by Group. The eligibility
information shall include designation of each Enrollee's family status if dependent coverage is provided. Upon VSP's
request, Group shall make available for inspection records regarding the coverage of Covered Persons under this Policy.
4.02. Payment of Premiums By the first day of each month, Group shall remit to VSP the premiums payable
for the next month on behalf of each Enrollee and Eligible Dependents, if any, to be covered under this Policy. The
Schedule of Premiums incorporated in this Policy as Exhibit B provides the premium amount for each Covered Person. Only
Covered Persons for whom premiums are actually received by VSP shall be entitled to Plan Benefits under this Policy and
only for the period for which such payment is received, subject to the grace period provision below.
VSP may change the premiums set forth in Exhibit B (Schedule of Premiums) by giving Group at least sixty (60)
days advance written notice. No change will be made during the Policy Term unless there is a change in the Schedule of
Benefits and /or Additonal Benefits Rider (if purchased by Group), or there is a material change in Policy terms or conditions,
provided any such change is mutually agreed upon in writing by VSP and Group.
Notwithstanding the above, VSP may increase premiums during a Policy Term by the amount of any tax or assessment not
now in effect but subsequently levied by any taxing authority, which is attributable to premiums VSP received from Group.
4.03. Grace Period Group shall be allowed a grace period of thirty -one (31) days following the premium
payment due date to pay premiums due under this Policy. During said grace period, this Policy shall remain in full force and
effect for all Covered Persons of Group. VSP will consider late payments at the time of Policy renewal. Such payment may
impact Group's premium rates in future Policy Terms.
N
If Group fails to make any premiums payment due by the end of any grace period, VSP may notify Group that the
premiums payment has not been made, that coverage is canceled and that Group is responsible for payment for all Plan
Benefits provided to Covered Persons after the last period for which premiums were paid in full, including the grace period
through the effective date of termination. Group shall also be responsible for any legal and/or collection fees incurred by
VSP to collect amounts due under this Policy.
4.04. Distribution of Required Documents: Group shall distribute to Enrollees any disclosure forms, Policy
summaries or other material required to be given to Policy subscribers by any regulatory authority. Such materials shall be
distributed by Group no later than thirty (30) days after the receipt thereof, or as required under applicable law.
4.05. Converting to an Administrative Services Program Due to the cyclical nature of vision care, in the
event Group wishes to convert its method of funding from a risk program to an Administrative Services Program, an
appropriate level of reserve will need to have been established.
Upon conversion to an Administrative Services Program, for vision care begun on and after the effective date of
conversion, all claims will be paid through the Administrative Services Program.
U
V.
OBLIGATIONS OF COVERED PERSONS UNDER THE POLICY
5.01. General By this Policy, Group makes coverage available to its Enrollees and their Eligible Dependents, if
dependent coverage is provided. However, this Policy may be amended or terminated by agreement between VSP and
Group as indicated herein, without the consent or concurrence of Covered Persons. This Policy, and all Exhibits, Riders and
attachments hereto, constitute VSP's sole and entire undertaking to Covered Persons under this Policy.
As conditions of coverage, all Covered Persons under this Policy have the following obligations:
5.02. Comments ments for Services Received: Where, as indicated in Exhibit A (Schedule of Benefits) and Exhibit
C (Additional Benefit Rider) when purchased by Group, Copayments are required for certain Plan Benefits. Copayments
shall be the personal responsibility of the Covered Person receiving the care and must be paid at the time services are
rendered. Amounts that exceed Plan allowances, annual maximum benefits, options reimbursements, or any other stated
Plan limitations are not considered Copayments but are also the responsibility of the Covered Person.
5.03. Obtaining Services from VSP Network Doctors Benefit Authorization must be obtained prior to
receiving Plan Benefits from a VSP Network Doctor. When a Covered Person seeks Plan Benefits, the Covered Person
must select a VSP Network Doctor, schedule an appointment, and identify himself as a Covered Person so the VSP
Network Doctor can obtain Benefit Authorization from VSP. Should the Covered Person receive Plan Benefits from a VSP
Network Doctor without such Benefit Authorization, then for the purposes of those Plan Benefits provided to the Covered
Person, the VSP Network Doctor will be considered a Non -VSP Provider, and the benefits available will be limited to those
for a Non -VSP Provider, if any.
5.04. Submission of Non -VSP Provider Claims If Non -VSP Provider coverage is indicated in Exhibit A
(Schedule of Benefits) or Exhibit C (Additional Benefit Rider), when purchased by Group, written proof (receipt and the
Covered Person's identification information) of all claims for services received from Non -VSP Providers shall be submitted
by Covered Persons to VSP within three hundred sixty five (365) days of the date of service. VSP may reject such claims
filed more than three hundred sixty five (365) days after the date of service.
Failure to submit a claim within this time period, however, shall not invalidate or reduce the claim if it was not
reasonably possible to submit the claim within such time period, provided the claim was submitted as soon as reasonably
possible and in no event, except in absence of legal capacity, later than one year from the required date of three hundred
sixty five (365) days after the date of service.
5.05. Complaints and Grievances Covered Persons shall report any complaints and/or grievances to VSP at
the address given herein. Complaints and grievances are disagreements regarding access to care, quality of care,
E
treatment or service. Complaints and grievances may be submitted to VSP verbally or in writing. A Covered Person may
submit written comments or supporting documentation concerning his/her complaint or grievance to assist in VSP's review.
VSP will resolve the complaint or grievance within thirty (30) days after receipt, unless special circumstances require an
extension of time. In that case, resolution shall be achieved as soon as possible, but not later than one hundred twenty
(120) days after VSP's receipt of the complaint or grievance. If VSP determines that resolution cannot be achieved within
thirty (30) days, VSP will notify the Covered Person of the expected resolution date. Upon final resolution, VSP will notify the
Covered Person of the outcome in writing.
5.06. Claim Denial Appeals If, under the terms of this Policy, a claim is denied in whole or in part, a request
may be submitted to VSP by Covered Person, or Covered Person's authorized representative, for a full review of the denial.
Covered Person may designate any person, including their provider, as their authorized representative. References in this
section to "Covered Person" include Covered Person's authorized representative, where applicable.
a) Initial Appeal: The request must be made within one hundred eighty (180) days following denial of a
claim and should contain sufficient information to identify the Covered Person for whom the claim was denied, including the
VSP Enrollee's name, the VSP Enrollee's Member Identification Number, the Covered Person's name and date of birth, the
provider of services and the claim number. The Covered Person may review, during normal working hours, any documents
held by VSP pertinent to the denial. The Covered Person may also submit written comments or supporting documentation
concerning the claim to assist in VSP's review. VSP's response to the initial appeal, including specific reasons for the
decision, shall be provided and communicated to the Covered Person as follows:
Denied Claims for Services Rendered: within thirty (30) calendar days after receipt of a request for an
appeal from the Covered Person.
b) Second Level Appeal: If the Covered Person disagrees with the response to the initial appeal of the
claim, the Covered Person has the right to a second level appeal. Within sixty (60) calendar days after receipt of VSP's
response to the initial appeal, the Covered Person may submit a second appeal to VSP along with any pertinent
documentation. VSP shall communicate its final determination to the Covered Person in compliance with all applicable
state and federal laws and regulations and shall include the specific reasons for the determination.
c) Other Remedies: When Covered Person has completed the appeals stated herein, additional
voluntary alternative dispute resolution options may be available, including mediation or arbitration. Group should advise
Covered Person to contact the U.S. Department of Labor or the state insurance regulatory agency for details. Additionally,
under the provisions of ERISA (Section 502(a)(1)(B)) [29 U.S.C. 11 32(a)(1)(13)], Covered Person has the right to bring a civil
10
action when all available levels of review of denied claims, including the appeals process, have been completed, the claims
were not approved in whole or in part, and Covered Person disagrees with the outcome.
5.07. Time of Action No action in law or in equity shall be brought to recover on the Policy prior to the
expiration of sixty (60) days after the claim and any applicable invoices have been filed with VSP. No such action shall be
brought after the expiration of any applicable statute of limitations from the time such claim and invoices are required to be
given, in accordance with the terms of this Policy.
5.08. Insurance Fraud Any Group and/or person who intends to defraud, knowingly facilitates a fraud, or
submits an application, or files a claim with a false or deceptive statement, is guilty of insurance fraud. Such an act is
grounds for immediate termination of the Policy for the Group or individual that committed the fraud. In the absence of fraud,
all statements made by Group or Enrollees shall be deemed representations and not warranties and no statement made for
the purpose of effecting insurance shall avoid such insurance or reduce benefits unless contained in a written instrument
signed by Group or Enrollee, a copy of which has been furnished to Group or Enrollee or Enrollee's beneficiary.
it
VI.
ELIGIBILITY FOR COVERAGE
6.01. Eligibility Criteria Individuals will be accepted for coverage hereunder only upon meeting all
requirements set forth below.
a) Enrollees To be eligible, a person must:
1. currently be an employee or member of Group, and
2. meet the coverage criteria mutually agreed upon by Group and VSP.
b.1 Eligible Dependents If dependent coverage is provided, the persons eligible for dependent coverage
are specified on the attached Schedule of Benefits and Additional Benefit Riders (if applicable).
If a dependent child prior to attainment of the prescribed age for termination of eligibility becomes, and continues to be,
incapable of self - sustaining employment because of mental or physical disability, that Eligible Dependents coverage shall
not terminate so long as he remains chiefly dependent on the Enrollee for support and the Enrollee's coverage remains in
force; PROVIDED that satisfactory proof of the dependent's incapacity can be furnished to VSP within thirty-one (31) days
of the date the Eligible Dependent's coverage would have otherwise terminated and at such other times as VSP may
request proof, but not more frequently than annually.
6.02. Documentation of Eligibility Persons satisfying the coverage requirements under either of the above
criteria shall be eligible if:
a) for an Enrollee, the individual's name and Member ID Number have been reported by Group to
VSP in the manner provided hereunder, and
b) for changes to an Eligible Dependent's status, the change has been reported by the Group to VSP
in the manner provided herein. As stated in paragraph 4.01 above, VSP may elect to audit Group's records to verify
eligibility of Enrollees and dependents and any errors. Subject to the terms of paragraph 4.03 above, only persons on
whose behalf premiums have been paid for the current period shall be entitled to Plan Benefits hereunder. If a clerical error
is made, it will not affect the coverage a Covered Person is entitled to under this Policy.
im
6.03. Retroactive Eligibility Changes Retroactive eligibility changes are limited to sixty (60) days prior to the
date notice of any such requested change is received by VSP. VSP may refuse retroactive termination of a Covered
Person if Plan Benefits have been obtained by, or authorized for, the Covered Person after the effective date of the
requested termination. As stated in Section 4.01 herein, Group agrees to provide timely eligibility changes to VSP.
6.04. Change of Participation Reguirements. Contribution of Fees. and Eligibility Rules Composition of
the Group, percentage of Enrollees covered under the Policy, and Group's contribution and eligibility requirements, are all
material to VSP's obligations under this Policy. During the term of this Policy, Group must provide VSP with written notice of
changes to its composition, percentage of Enrollees covered, contribution and eligibility requirements. Any change which
materially affects VSP's obligations under this Policy must be agreed upon in writing between VSP and Group and may
constitute a material change to the terms and conditions of this Policy for purposes of paragraph 4.02. Nothing in this
section shall limit Group's ability to add Enrollees or Eligible Dependents under the terms of this Policy.
6.05. Change in Family or Employment Status In the event Group is notified of any change in a Covered
Person's family status [by marriage, the addition (e.g., newborn or adopted child) or deletion of Dependent , etc.] or
employment status, Group shall provide notice of such change to VSP via the next eligibility listing required under
Paragraph 4.09. If notice is given, the change in the Covered Person's status will be effective on the first day of the month
following the change request, or at such later date as may be requested by or on behalf of the Covered Person.
Notwithstanding any other provision in this section, a newborn child will be covered for a period of at least sixty (60) days
after birth, and an adopted child will be covered for a period of at least sixty (60) days after the date the Enrollee or the
Enrollee's spouse acquires the right to control that child's health care. If Enrollee provides notice to the Group within said
sixty (60) day period, VSP shall not deny coverage for said newborn or adopted child. Coverage for an adopted newborn will
begin from the moment of birth if an agreement to adopt is entered into by Enrollee or Enrollee's spouse, and the child is
ultimately placed in the Enrollee's home. To continue coverage for a newborn or adopted child beyond the initial sixty (60)
day period, the Group must be properly notified of the Enrollee's change in family status and applicable premiums must be
paid to VSP.
3
IT41
CONTINUATION OF COVERAGE
7.01. COBRA The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that, under
certain circumstances, health plan benefits available to an Enrollee and his or her Eligible Dependents be made available to
said persons upon the occurrence of a COBRA qualifying event. If, and only to the extent, COBRA applies to the parties to
this Policy, VSP shall make the required COBRA continuation coverage available for purchase in accordance with COBRA
14
VIII.
ARBITRATION OF DISPUTES
8.01. Dispute Resolution Any dispute or question arising between VSP and Group involving the application,
interpretation, or performance under this Policy shall be settled, if possible, by amicable and informal negotiations, allowing
such opportunity as may be appropriate under the circumstances for fact- finding and mediation. If any issue cannot be
resolved in this fashion, it shall be submitted to arbitration where permitted by state law.
8.02. Procedure Arbitration hereunder shall be conducted pursuant to the Rules of the American Arbitration
Association subject to the provisions of Section 10.06 of this Policy. Such Rules, the enforcement thereof, and enforcement
of the arbitrator's decision shall be governed by applicable laws.
8.03. Choice of Law. If any matter arises in connection with this Policy which becomes the subject of arbitration
or legal process, the law of the State of delivery of the Policy shall be the applicable law.
15
NOTICES
9.01. Notice Any notices required under this Policy to either Group or VSP shall be in written format. Notices
sent to the Group will be sent to the address or email address shown on the Group's Application unless otherwise directed
by Group. Notices to VSP shall be sent to the address shown on the front page of this Policy. Notwithstanding the above,
any notices may be hand - delivered by either party to an appropriate representative of the other party. The party effecting
hand- delivery bears the burden to prove delivery was made, if questioned.
MI
X.
MISCELLANEOUS
10.01. Entire Policy This Policy, the Group Application, the Evidence of Coverage, and all Exhibits, Riders and
attachments hereto, constitute the entire agreement of the parties and supersedes any prior understandings and
agreements between them, either written or oral. Any change or amendment to the Policy must be approved by an officer of
VSP and attached hereto to be valid. No agent has the authority to change this Policy or waive any of its provisions.
Communication materials prepared by Group for distribution to Enrollees do not constitute a part of this Policy.
10.02. Indemnitr VSP agrees to indemnify, defend and hold harmless Group, its shareholders, directors,
officers, agents, employees, successors and assigns from and against any and all liability, claim, loss, injury, cause of
action and expense (including defense costs and legal fees) of any nature whatsoever arising from the failure of VSP, its
officers, agents or employees, to perform any of the activities, duties or responsibilities specified herein. Group agrees to
indemnify, defend and hold harmless VSP, its members, shareholders, directors, officers, agents, employees, successors
and assigns from and against any and all liability, claim, loss, injury, cause of action and expense (including defense costs
and legal fees) of any nature whatsoever arising or resulting from the failure of Group, its officers, agents or employees to
perform any of the duties or responsibilities specified herein.
10.03. Liabilily VSP arranges for the provision of vision care services and materials through agreements with
VSP Network Doctors. VSP Network Doctors are independent contractors and are responsible for exercising independent
judgement. VSP does not itself directly furnish vision care services or supply materials. Under no circumstances shall VSP
or Group be liable for the negligence, wrongful acts or omissions of any doctor, laboratory, or any other person or
organization performing services or supplying materials in connection with this Policy.
10.04. Assignment Neither this Policy nor any of the rights or obligations of either of the parties hereto may be
assigned or transferred without the prior written consent of both parties hereto except as expressly authorized herein.
10.05. Seyerability Should any provision of this Policy be declared invalid, the remaining provisions shall remain
in full force and effect.
1
10.06. Governing Law This Policy shall be governed by and construed in accordance with applicable federal
and state law. Any provision that is in conflict with, or not in conformance with, applicable federal or state statutes or
regulations is hereby amended to conform with the requirements of such statutes or regulation, now or hereafter existing.
10.07. Gender All pronouns used herein are deemed to refer to the masculine, feminine, neuter, singular, or
plural, as the identity(ies) of the person(s) may require.
10.08. Equal OpRort� VSP is an Equal Opportunity and Affirmative Action employer.
10.09. Communication Materials Communication materials created by Group which relate to this vision care
Policy must adhere to VSP's Member Communication Guidelines distributed to Group by VSP. Such communication
materials may be sent to VSP for review and approval prior to use. VSP's review of such materials shall be limited to
approving the accuracy of Plan Benefits and shall not encompass or constitute certification that Group's materials meet any
applicable legal or regulatory requirements, including but not limited to, ERISA requirements. In the event of any dispute
between the communication materials and this Policy, the provisions of this Policy shall prevail.
iv
EXHIBIT A
SCHEDULE OF BENEFITS
VSP Choice Plan
GENERAL,
This Schedule lists the vision care benefits to which Covered Persons of VISION SERVICE PLAN INSURANCE COMPANY( "VSP ") are entitled,
subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein. If Plan Benefits are available for Non -VSP
Provider services, as indicated by the reimbursement provisions below, vision care benefits may be received from any licensed eye care provider
whether VSP Network Doctors or Non -VSP Providers. This Schedule forms a part of the Policy or Evidence of Coverage to which it is attached.
VSP Network Doctors are those doctors who have agreed to participate in VSP's Choice Network.
When Plan Benefits are received from VSP Network Doctors, benefits appearing in the VSP Network Doctor Benefit column below are applicable
subject to any applicable Copayments and other conditions, limitations and /or exclusions as stated below. When Plan Benefits are available and
received from Non -VSP Providers, the Covered Person is reimbursed for such benefits according to the schedule in the Non -VSP Provider Benefit
column below, less any applicable Copayment. The Covered Person pays the provider the full fee at the time of service and submits an itemized bill
to VSP for reimbursement. Discounts do not apply for vision care benefits obtained from Non -VSP Providers.
BENEFIT PERIOD
A twelve -month period beginning on January 1st and ending on December 31st.
ELIGIBILITY
The following are Covered Persons under this Policy:
" Enrollee.
The legal spouse of Enrollee.
Any child of Enrollee, including any natural child from the date of birth, legally adopted child from the date of placement for adoption with the
Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible.
The domestic partner of the same or opposite gender as Enrollee, pursuant to Group's eligibility rules.
• Any children of the domestic partner provided they depend upon the Enrollee for support and maintenance.
Dependent children are covered up to the end of the year in which they turn age 26.
A dependent child over the limiting age may continue to be eligible as a dependent if the child is incapable of self - sustaining employment because of
mental or physical disability, and chiefly dependent upon Enrollee for support and maintenance.
See schedule below for Plan Benefits, payments and /or reimbursement subject to any Copayment(s) as stated:
COMMENT
The benefits herein are available to each Covered Person subject only to payment of the applicable Copayment by the Covered Person. Plan
Benefits received from VSP Network Doctors and Non -VSP Providers require Copayments. Covered Persons must also follow Benefit Authorization
Procedures.
There shall be a Copayment of $10.00 for the examination payable by the Covered Person at the time services are rendered. If materials (lenses,
frames or Necessary Contact Lenses) are provided, there shall be an additional $20.00 Copayment payable at the time the materials are ordered.
The Copayment shall not apply to Elective Contact Lenses.
9
PLAN BENEFITS
SERVICE OR MATERIAL
VSP NETWORK DOCTOR
HON -VSP PROVIDER BENEFIT
FREQUENCY
BENEFIT
Eye Examination
Covered in full*
Up to $ 45.00*
Available once each 12 months*"
Complete initial vision analysis: includes appropriate examination of visual functions and prescription of corrective eyewear where
indicated.
*Less any applicable Copayment.
**Beginning with the first day of the Benefit Period.
SERVICE OR MATERIAL
VSP NETWORK DOCTOR
NON -VSP PROVIDER BENEFIT
FREQUENCY
BENEFIT
Lenses
Available once each 12 months **
Single Vision
Covered in full *
Up to $ 30.00*
Bifocal
Covered in full *
Up to $ 50.00* "-
Trifocal
Covered in full *
Up to $ 65.00*
Lenticular
Covered in full *
Up to $100.00*
Plan Benefits for lenses are per complete set, not per lens.
*Less any applicable Copayment.
**Beginning with the first day of the Benefit Period.
SERVICE OR MATERIAL
VSP NETWORK DOCTOR
NON -VSP PROVIDER BENEFIT
FREQUENCY
BENEFIT
FRAMES
Covered up to Plan Allowance*
Up to $ 70.00*
Available once each 24 months **
Benefits for lenses and frames include
reimbursement for the followin necessa professional services!
1. Prescribing and ordering proper lenses;
2. Assisting in frame selection;
3. Verifying accuracy of finished lenses;
4. Proper fitting and adjustments of frames;
5. Subsequent adjustments to frames to maintain comfort and efficiency;
6. Progress or follow -up work as necessary.
*Less any applicable Copayment.
*"Beginning with the first day of the Benefit Period.
......:..:
......:..:
SERVICE OR MATERIAL
VSP NETWORK DOCTOR NON -VSP PROVIDER BENEFIT
FREQUENCY
FREQUENCY
BENEFIT I
BENEFIT
CONTACT LENSES
NECESSARY CONTACT
Elective
Elective Contact Lens fitting and
LENSES
Available once each 12 months **
evaluation *** services are covered
Covered in full "
Up to $ 210.00*
in full once every 12 months",
after a $60.00 Copayment.
**Beginning with the first day of the Benefit Period.
** *15% Discount applies to VSP Network Doctor's usual and customary professional fees for contact lens evaluation and fitting.
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's VSP Network
Materials
Professional FeeslMaterials
Utilization of contact lens benefits exhausts all of the Covered Person's lens and frame benefits for the current Benefit Period, and future
eligibility for lenses and frames will be determined as if spectacle lenses only were obtained in the current Benefit Period.
Up to $ 105.00
Up to $ 105.00
*Less any applicable Copayment.
**Beginning with the first day of the Benefit Period.
** *15% Discount applies to VSP Network Doctor's usual and customary professional fees for contact lens evaluation and fitting.
Contact Leases are provided in lieu of all other lens and frame benefits available herein.
Utilization of contact lens benefits exhausts all of the Covered Person's lens and frame benefits for the current Benefit Period, and future
eligibility for lenses and frames will be determined as if spectacle lenses only were obtained in the current Benefit Period.
SERVICE OR MATERIAL
VSP NETWORK DOCTOR
NON -VSP PROVIDER BENEFIT
FREQUENCY
BENEFIT
NECESSARY CONTACT
Available once each 12 months**
LENSES
Professional Fees and
Covered in full "
Up to $ 210.00*
Materials
*Less any applicable Copayment
**Beginning with the first day of the Benefit Period.
** *15% Discount applies to VSP Network Doctor's usual and customary professional fees for contact lens evaluation and fitting.
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's VSP Network
Doctor or Non -VSP Provider:: Prior review and approval by VSP are not required for Covered Person to be eligible for Necessary Contact Lenses.
Necessary Contact Lenses are provided in lieu of all other lens and frame benefits available herein.
Utilization of contact lens benefits exhausts all of the Covered Person's lens and frame benefits for the current Benefit Period, and future
eligibility for lenses and frames will be determined as if spectacle lenses only were obtained in the current Benefit Period.
......:..:
N
SERVICE OR MATERIAL l VSP NEETWORK DOCTOR I NON -VSP PROVIDER BENEFIT I FREQUENCY
Low Vision
Professional services for severe visual problems not correctable with regular lenses, including:
Supplemental Testing Covered in full Up to $125.00*
(Includes evaluation, diagnosis and prescription of vision aids where indicated.)
Supplemental Aids 75% of amount 75% of amount
up to $1000.00* LID to $1000.00*
*Maximum benefit for all Low Vision services and materials is $1000.00 every two (2) Benefit Periods.
Low Vision benefits secured from Non -VSP Providers (if covered) are subject to the same time and Copayment provisions described above for
VSP Network Doctors. The Covered Person should pay the Non -VSP Provider's full fee at the time of service. Covered Person will be reimbursed
an amount not to exceed what VSP would pay a VSP Network Doctor for the same services and/or materials.
THERE IS NO ASSURANCE THAT THE AMOUNT REIMBURSED WILL COVER 75% OF THE PROVIDER'S FULL FEE.
W
EXCEPTIONS
Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional limitations. Covered Persons
may obtain details regarding frame brand availability from their VSP Network Doctor or by calling VSP's Customer Care Division at (800) 877 -7195.
PATIENT OPTIONS
This Plan is designed to cover visual needs rather than cosmetic materials. When a Covered Person selects any of the following extras, the Plan will
pay the basic cost of the allowed lenses or frames, and the Covered Person will pay the additional costs for the options.
• Optional cosmetic processes.
• Anti - reflective coating.
• Color coating.
• Mirror coating.
• Scratch coating.
• Blended lenses.
• Cosmetic lenses.
• Laminated lenses.
• Oversize lenses.
• Polycarbonate lenses.
• Photochromic lenses, tinted lenses except Pink #1 and Pink #2.
• Progressive multifocal lenses.
• UV (ultraviolet) protected lenses.
• Certain limitations on low vision care.
NOT COVERED
There are no benefits for professional services or materials connected with:
• Orthoptics or vision training and any associated supplemental testing.
• Comeal Refractive Therapy (CRT)
• Orthokeratology (a procedure using contact lenses to change the shape of the comea in order to reduce myopia).
• Refitting of contact lenses after the initial (90 -day) fitting period.
• Plano lenses (lenses with refractive correction of less than f .50 diopter).
• Two pair of glasses in lieu of bifocals.
• Replacement of lenses and frames fumished under this Policy that are lost or broken, except at the normal intervals when services are
otherwise available.
• Medical or surgical treatment of the eyes.
• Corrective vision treatment of an Experimental Nature.
• Plano contact lenses to change eye color cosmetically.
• Artistically - painted contact lenses.
• Contact lens insurance policies or service contracts.
• Additional office visits associated with contact lens pathology.
• Contact lens modification, polishing, or cleaning.
• Costs for services and/or materials exceeding Plan Benefit allowances.
• Services or materials of a cosmetic nature.
• Services and /or materials not indicated on this Schedule as covered Plan Benefits.
PLAN BENEFITS
AFFILIATE PROVIDERS
GENERAL
Affiliate Providers are providers of Covered Services and Materials who are not contracted as VSP Network Doctors but who have agreed to bill VSP
directly for Plan Benefits provided pursuant to this Schedule. However, some Affiliate Providers may be unable to provide all Plan Benefits included
in this Schedule. Covered Persons should discuss requested services with their provider or contact VSP Customer Care for details.
COPAYMENT
There shall be a Copayment of $10.00 for the examination payable by the Covered Person at the time services are rendered. If materials (lenses,
frames or Necessary Contact lenses) are provided, there shall be an additional! $ 20.00 Copayment payable at the time materials are ordered. The
Copayment shall not apply to Elective Contact Lenses.
COVERED SERVICES AND MATERIALS
Eye Examination Covered in full * Available once each 12 months**
Comprehensive examination of visual functions and prescription of corrective a ewear.
Spectacle Lenses
Single Vision, Lined Covered in Full* Available once each 12 months*"
Bifocal or Lined Trifocal,
Polycarbonate lenses are covered in full for dependent children up to age
Frames Covered up to the Plan allowance* Available once each 24 months'*
M
CONTACT LENSES
Elective Contact Lenses Up to $105.00 Available once each 12 months**
The Elective Contact Lens allowance applies to materials only.
Necessary Contact Lenses Up to $130.00* Available once each 12 months**
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor.
Contact Lenses are provided in place of spectacle lens and frame benefits available herein.
*Less any applicable Copayment.
"beginning with the first day of the Benefit Period.
LOW VISION
Professional services for severe visual problems not correctable with regular lenses, including:
Supplemental Testing: Up to $125.00t
- Includes evaluation, diagnosis and prescription of vision aids where indicated.
Supplemental Aids: 75% of Affiliate Provider's fee up to $1000.001
tMaximum benefit for all Low Vision services and materials is $1000.00 every two (2) years and a
maximum of two supplemental tests within a two -year period
Low Vision Services are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor.
EXCLUSIONS AND LIMITATIONS OF BENEFITS
1. Exclusions and limitations of benefits described above for VSP Network Doctors shall also apply to services rendered by Affiliate Providers.
2. Services from an Affiliate Provider are in lieu of services from a VSP Network Doctor or a Non -VSP Provider.
3. VSP is unable to require Affiliate Providers to adhere to VSP's quality standards.
4. Where Affiliate Providers are located in membership retail environments, Covered Persons may be required to purchase a membership in such
entities as a condition of obtaining Plan Benefits.
92
Exhibit B
VISION SERVICE PLAN INSURANCE COMPANY (VSP)
SCHEDULE OF PREMIUMS
VSP Choice Plan
VISION SERVICE PLAN INSURANCE COMPANY ( "VSP ") shall be entitled to receive premiums for each month on behalf of each Enrollee and
his/her Eligible Dependents, if any, in the amounts specified below.
$ 4.44 per month for each eligible Enrollee without dependents.
$ 8.88 per month for each eligible Enrollee with an eligible spouse.
$ 9.50 per month for each eligible Enrollee with eligible child(ren).
$ 15.18 per month for each eligible Enrollee with eligible spouse and child(ren).
NOTICE: The premium under th'"s Policy is subject to change upon renewal (after the end of the initial Policy Term or any subsequent Policy Term),
or upon change of the Schedule of Benefits or a material change in any other terms or conditions of the Policy.
W
ADDENDUM
ADDITIONAL BENEFIT RIDER
DIABETIC EYECARE PROGRAM
GENERAL
This Rider lists additional vision care benefits to which Covered Persons of VISION SERVICE PLAN INSURANCE COMPANY ( "VSP ") are entit<ed,
subject to any applicable Copayment and other conditions, limitations and/or exclusions stated herein. Plan Benefits under the Diabetic Eyecare
Program ( "DEP ") are available to Covered Persons who have been diagnosed with Type 1 diabetes and specific ophthalmological conditions. The
Diabetic Eyecare Program does not cover medical treatment for Covered Persons with diabetic or any other medical conditions.
PROCEDURES FOR OBTAINING DIABETIC EYECARE PROGRAM SERVICES
Covered Person's VSP Network Doctor will provide services under the DEP as needed following Covered Person's routine VSP Plan eye
examination. No referrals or authorizations are required for services provided under the DEP.
ELIGIBILITY
Covered Persons under this Program are the same as stated on the VSP Signature Plan Schedule of Benefits associated with this Rider.
COPAYMENT
A Copayment of $20.00 is required for each Ophthalmological Service and Office Visit under the DEP, and is paid to the VSP Network Doctor at the
time of service. Other Copayments may apply to services under Covered Person's VSP Plan. Refer to the VSP Plan Schedule of Benefits
associated with this Rider.
PLAN BENEFITS
SERVICE'
VSP NETWORK DOCTOR
BENEFIT
BENEFIT FREQUENCYt
Ophthalmological services and
Office Visits
Covered in full, less $20.00
Co pa ment
Once every 12 months
Gonioscopy
Covered in full
Once every 12 months
Extended Ophthalmoscopy
Covered in full
Once every 6 months*
Fundus Photography
Covered in full
Once every 6 months
COVERED SERVICES
Description
(The following list is current as of [711108] and is subject to change without notice.)
Procedure Code
0 hthalmol ical services
92002, 92004, 92012, 92014
Office Visits
99201- 99205, 99211- 99215
92020
Fundus Phot rah 92250
*Service and/or diagnosis limitations apply, or certain procedures require special handling. VSP Network Doctors must consult the VS
ProviderReference Manua/ for details before rendering services.
tBenefit frequency periods begin on the date of the first Ophthalmological Service or Office Visit.
Fri
EXCLUSIONS AND LIMITATIONS OF BENEFITS
The DEP covers diabetic eyecare evaluation services only. There is no coverage provided under the Plan for the following:
• Costs associated with securing frames, lenses or any other materials.
• Orlhoptics or vision training and any associated supplemental testing.
• Surgical procedures, including Laser or any other form of refractive surgery, and any pre- or post- operative services.
• Pathological treatment of any type for any condition.
• Any eye examination required by an employer as a condition of employment.
• Insulin or any medications or supplies of any type.
• Services and/or materials not included in this Rider as covered Plan Benefits.
DIABETIC EYECARE PROGRAM DEFINITIONS
Diabetes A disease where the pancreas has a problem either making, or making and using, insulin.
Type 1 Diabetes A disease in which the pancreas stops making insulin.
Type 2 Diabetes A disease in which the pancreas makes insufficient insulin or can't efficiently use it.
Fundus Photography Taking photos of the inside of the eye that show the optic nerve and retinal vessels.
Extended Ophthalmosoopy A method of examining the posterior of the eye, including a true drawing of the retina accompanied by an
interpretation and plan.
Gonioscopy Use of a special contact lens to look at the eye's aqueous drainage area.
ADDENDUM
VISION SERVICE PLAN INSURANCE COMPANY
PERFORMANCE STANDARDS
VSP guarantees the performance standards outlined herein by offering to pay a financial penalty of 11% of quarterly administrative revenue per unmet
standard, up to a total annual maximum of $100,000 and a minimum annual threshold of $250. VSP's company -wide quarterly performance results
shall be used in determining whether any or all of the performance standards have been met. Any penalties owed shall be accrued quarterly and
paid on an annual basis, as long as the cumulative total for the four quarters exceeds $250. Cumulative annual penalties less than $250 will not be
carried over into the following calendar year for purposes of determining financial penalties. Payment of penalties shall be conditioned on VSP's
receipt of all premiums due to VSP within established due dates.
VSP's performance hereunder is subject to interruption and delay due to causes beyond VSP's reasonable control such as acts of God, act of any
government, war or other hostility, the elements, fire, explosion, power failure, equipment failure, industrial or labor dispute. In the event of any such
interruption or delay, any period of performance shall be extended for a period of time equal to the interruption or delay.
CLAIMS PROCESSING
Claims financial accuracy
Performance Standard = 99% processed without financial error
Performance Penalty =1 %
Claims financial accuracy is calculated much like that of claims processing accuracy. The same random sampling of claims audited for processing
accuracy is also audited for financial accuracy. Any error found that results in a financial impact is recorded as a financial error. At the end of the
month, financial errors are totaled and taken as a percentage of the total dollar paid for all claims audited during the given month.
Claims processing accuracy
Performance Standard = 99% processed without error
Performance Penalty =1 %
Claims processing accuracy is calculated on a monthly basis based upon daily audit results. The term "processing error" encompasses all errors
found in the audit regardless of whether the error caused a financial impact. At month's end, all processing errors for the month are totaled and
taken as a percentage of the total number of claims audited for the month.
Claims timeliness
Performance Standard:
VSP preferred provider claims = 95% processed within 5 business days
Performance Penalty =1 %
• All other provider claims = 95% processed within 5 business days
Performance Penalty =1 %
• All other provider claims = 99% processed within 15 business days
Performance Penalty =1 %
Claims timeliness, or turnaround time, is measured on a monthly basis. Each claim audited in the daily audit is audited for timeliness. Timeliness is
measured by calculating the number of business days elapsing between the received date and the pricing date. When additional information is
needed to process a claim, the timeliness date is calculated from the date the information needed to process the claim was received to the pricing
date.
RE
CALL CENTER MANAGEMENT
Abandoned call rate
Performance Standard = Less than or equal to 3%
Performance Penalty =1 %
The Call Center telephone abandon rate is calculated monthly by taking the total number of abandoned calls before and after sixty (60) seconds,
divided by the total number of calls accepted by the Call Center, which includes calls answered via the Interactive Voice Response and Automated
Call Distribution systems.
Average speed of answer
Performance Standard = Less than or equal to 25 Seconds
Performance Penalty =1 %
The average speed of answer (the amount of time a caller is waiting while on hold) is calculated by dividing the total time all calls are on hold (in
seconds) by the total number of calls received.
Average call blockage rate
Performance Standard = Less than or equal to 2%
Performance Penalty =1 %
VSP call blockage is defined as any call blocked by VSP. A blocked call results in the caller receiving a "busy" signal, and is considered
unsuccessful. VSP call blockage does not include calls blocked by the long distance carrier due to circumstances beyond VSP's control. VSP call
blockage standard is 2% or less of total calls attempted to VSP. The formula for this standard is: number of blocked calls divided by (blocked calls
plus accepted calls) as reported by the long distance carrier.
Calf resolution (same day response)
Performance Standard = 98%
Performance Penalty =1 %
Measurement based on internal VSP system -driven statistics. The percentage of telephone inquiries handled within the same day is obtained by
taking the number of research inquiries entered into our system and dividing by the number of calls answered in the Call Center, and subtracting the
result from 1.00.
Complaint acknowledgement within 5 business days
Performance Standard = 96%
Performance Penalty =1 %
"Telephone complaints" not resolved by the end of the following business day must be acknowledged in writing within 5 by business days. "Written
complaints" not resolved within 5 business days will be acknowledged in writing on the 5th business day from receipt. Complaint acknowledgement
compliancy is calculated monthly. The method for calculating the percentage is: total number of complaints meeting the 5 business day goal divided
by total number of complaints.
Complaint resolution within 30 calendar days
Performance Standard = 99%
Performance Penalty =1 %
When a complaint is received, in writing or via phone, the person receiving it documents it in our online Research Inquiry system. The Complaint and
Grievance unit monitors this workflow to assure all complaints have been resolved by the 30 calendar day.
Average response to e-mail inquiries within 2 business days
Performance Standard =100%
Performance Penalty =1 %
The average time required to send the first manual reply to an email, in the specified time period.
W
SATISFACTION
Patient satisfaction (satisfied with level of coverage)
Performance Standard = 96% overall satisfaction with VSP
Performance Penalty =1 %
Performance Standard = 96% overall experience with VSP preferred provider
Performance Penalty =1 %
VSP conducts patient satisfaction surveys on a quarterly basis. A random sample of claims from the prior three months is chosen that is statistically
representative of all claims.
While VSP makes recommendations to all prospective Groups on which plan we feel best suits the group's employees, the ultimate decision for
selection of a plan rests with the Group. As such, our performance standard is based on patients who are satisfied with the level of coverage
provided by their plan. Satisfied patients includes patients who rated their overall level of coverage as "Excellent," 'Very Good" and °Good ".
Dissatisfied patients include patients who rated their overall level of coverage as "Fair" or "Poor".
VSP preferred provider retention rate (based on voluntary turnover)
Performance Standard = 98%
Performance Penalty =1 %
VSP preferred provider satisfaction is based on changes in the VSP preferred provider network. On a quarterly basis, the voluntary retention rate of
providers (those choosing to stay on the VSP panel) is measured as a percentage of the total number of providers in the network. The annual
preferred provider retention rate is equal to the total number of providers on the panel on December 31 divided by the total number of providers on
the panel January 1 of that same year.
ACCOUNT ADMINISTRATION
Electronic eligibility online within 24 hours
Performance Standard = 98%
Performance Penalty =1 %
Percentage reported based on a measurement against all maintenance files* loaded within that quarter. VSP records both the received and loaded
dates for all membership files. The data is compiled into a monthly report, which is used to calculate the quarterly statistical average.
*All files measured for this standard must meet the following criteria:
+ Identifiable Media: Eligibility file must be labeled properly.
• Proper Format: No change in format from the previously loaded eligibility file.
• Clean File:
1) Physical Media must be undamaged.
2) Electronic Media must have clean and complete data transmission. We must be able to successfully unzip /decrypt the incoming
data.
3) All media must contain proper /complete records for members and dependents.
Exclusions to this performance standard are as follows:
1) Membership files for open enrollment loaded prior to effective date.
2) Group /division restructures for existing groups (1st eligibility load based on the restructure will be excluded from the
performance standard measurement).
3) Incorrect/Incomplete individual records for members and dependents.
4) If instructed to wait for group approval to load the file.
Online reports available by the 25th of the month
Performance Standard =100%
Performance Penalty =1%
All eligible online reports will be available on VSP's Resource Center by the 25th of each month..
Web portal availability
Performance Standard = 99%
Performance Penalty =1 %
Based on a 7 x 24 schedule.
New group implementation
Performance Standard = Satisfaction guaranteed
We guarantee MONROE COUNTY BOARD OF COUNTY COMMISSIONERS's satisfaction with the implementation of its VSP benefit. In support of
this, we are placing a one -time penalty of $100,000 at risk. We will collaborate with MONROE COUNTY BOARD OF COUNTY COMMISSIONERS to
create a customized Implementation Action Plan that includes detailed roles, responsibilities and timeframes to ensure a successful implementation.
Our comprehensive Implementation Action Plan includes the following sections:
Communications
System Accuracy
Plan Accuracy
Membership Management
Preferred Provider Access
Each of the above sections is assigned a maximum penalty amount of $100,000 to be paid in the event VSP was not able to meet MONROE
COUNTY BOARD OF COUNTY COMMISSIONERS's satisfaction in that category. If MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
does not fulfill its obligations as documented in the Implementation Action Plan„ no penalty will apply to VSP.
IN
VS P cure foi We
August 29, 2013
Ms. Maria Fernandez - Gonzalez
Sr. Benefits Administrator
1100 Simonton Street, Suite 2 -268
Key West, FL 33040
RE: Monroe County Board of County Commissioners — January 1, 2014 Vision Plan Renewal
Dear Maria
Mark Tafuri
Senior Account Executivz;
Pursuant to your request, I am providing renewal information for Monroe County Board of County Commissioners, effective January 1, 2014. 1,144
employees are currently covered under VSP's Choice Plan B (exam & lenses every 12 months and frames every 24 months) with a $10 exam and $20
materials copay. The current rates for this coverage are $4.4448.8849.501$15.18.
VSP has reviewed the current plan and developed rates based on the experience of the program over the recent contract term. VSP considers many
factors when determining rates including, claim cost, utilization, claim frequency and trend. As a result of this analysis, our underwriters have calculated
the renewal options described below. Please note the rates include the new federal Affordable Care Act (ACA) tax.
Current Plan
Group Name: Monroe County Board of County Commissioners
Group Number: 30029497
Current Plans: Choice Plan B L
Plan Frequency: Exam & lenses every 12 months and frames every 24 months
Frame Allowance: $130
Elective Contact Lenses: $105
Co- payments: $10 Exam 1$20 Materials 0
Current Rates: $4.441$8.881$9.50!$15.18
Renewal >
Renewal Period: January 1, 2014 —December 31, 2016 (36 months) �° ` 2
Renewal Plans: Choice Plan B
Plan Frequency: Exam & lenses every 12 months and frames every 24 months
Frame Allowance: $140
Elective Contact Lenses: $115 CD
Co- payments: $10 Exam I $20 Materials
Renewal Rates: $4.44158.881$9.501$15.18
Please have the appropriate group representative sign the renewal below and fax or email a copy of this renewal to Fabian Whipple @ (770) 263 -6008
or Fabian.Whipple @vsp.com.
We appreciate your business and value our relationship with your organization. X110 OE COUNTY ATTO R N F cL
ROVED A� TQ NI: ..
Thank you,
CYNTHIA L. ALL
ASSIS AN� CQUNTY ATTORP 0
:. /... ' Date
Mark Tafuri
Authorized Group Representative Signature
cc: Mary Kay Lantz, Sr. Client Manager — Gallagher Benefits Services, Inc. l�F1 ��
C tng Onn I V minls Or
!fw
4521 PGA Blvd., #161, Palm Beach Gardens, FL 33418 ' 561.744.6556: 561.744.6557 : vsp.com
•
Y `i+ iai Care 'arl.iPe
VISION SERVICE PLAN INSURANCE COMPANY
3333 QUALITY DRIVE
RANCHO CORDOVA, CALIFORNIA 95670
GROUP VISION CARE POLICY
Group Dame MONROE COUNTY BOARD OF COUN'T'Y COMMISSIONERS
Policy Number 30029497
State of Delivery FLORIDA
Effective Date JANUARY 1, 2014
Policy Term THIRTY -SIX (36) MONTHS
In consideration of the statements and agreements contained in the Group Application and in consideration of
payment by the Group of the premiums as herein provided, VISION SERVICE PLAN INSURANCE COMPANY ( "VSP ")
agrees to insure certain individuals under this Group Vision Care Policy ( "Policy ") for the benefits provided herein,
subject to the exceptions, limitations and exclusions hereinafter set forth. This Policy is delivered in and governed by
the laws of the state of delivery and is subject to the terms and conditions recited on the subsequent pages hereof,
including any Exhibits or state - specific Addenda, which are a part of this Policy..
James M. McGrann, Secretary
VSP GVCP FL 1004. DDM 10/31/13 Kav
VISION SERVICE PLAN INSURANCE COMPANY
GROUP VISION CARE POLICY
TABLE OF CONTENTS
I .
DEFINITIONS .... ................. ........................... . ................... . ......... . ....................... I.......
1
II.
TERM, TERMINATION, AND RENEWAL .................................... ...............................
3
III.
OBLIGATIONS OF VSP ............................................................... ...............................
4
IV.
OBLIGATIONS OF THE GROUP ................................................. ...............................
7
V.
OBLIGATIONS OF COVERED PERSONS UNDER THE POLICY .............................
9
VI.
ELIGIBILITY FOR COVERAGE .................................................... ...............................
12
VII.
CONTINUATION OF COVERAGE.... ..........................................................................
14
VIII,
ARBITRATION OF DISPUTES ..................................................... ...............................
15
IX .
NOTICES ........................................................................................ .............................16
X .
MISCELLANEOUS ....................................................................... ...............................
17
EXHIBIT A
SCHEDULE OF BENEFITS ............................................ ...............................
19
EXHIBIT B
SCHEDULE OF PREMIUMS .......................................... ...............................
26
EXHIBIT C
ADDITIONAL BENEFIT - DIABETIC EYECARE ............ ...............................
27
ADDENDUM
PERFORMANCE STANDARDS .......................... ...............................
31
VISION SERVICE PLAN INSURANCE COMPANY
GROUP VISION CARE POLICY
DEFINITIONS
The key terms in this Policy are defined:
1.01. ADDITIONAL BENEFIT RIDER The document, attached as Exhibit C to this Policy (if purchased by
Group), which lists selected vision care services and vision care materials which a Covered Person is entitled to receive
under this Policy. Additional Benefits are only available when purchased by Group in conjunction with a Plan Benefit offered
under Exhibit A.
1.02. ADMINISTRATIVE SERVICES PROGRAM A group vision care plan whereby Group pays VSP for the
Plan Benefits in addition to a monthly administrative fee.
1.03. BENEFIT AUTHORIZATION Authorization from VSP identifying the individual named as a Covered
Person of VSP, and identifying those Plan Benefits to which Covered Person is entitled.
1.04. CONFIDENTIAL MATTER All confidential information concerning the medical, personal, financial or
business affairs of Covered Persons acquired in the course of providing Plan Benefits hereunder.
1.05. COORDINATION OF BENEFITS Procedure which allows more than one insurance plan to consider
Covered Person's vision care claims for payment or reimbursement.
1.06. COPAYMENTS Those amounts required to be paid by or on behalf of a Covered Person for Plan
Benefits which are not fully covered, and which are payable at the time services are rendered or materials provided.
1.07. COVERED PERSON An Enrollee or Eligible Dependent who meets Group's eligibility criteria and on
whose behalf premiums have been paid to VSP, and who is covered under this Policy.
1.08. ELIGIBLE DEPENDENT Any dependent of an Enrollee of Group who meets the criteria for eligibility
established by Group
1.09. EMERGENCY CONDITION A condition, with sudden onset and acute symptoms, that requires the
Covered Person to obtain immediate medical care, or an unforeseen occurrence calling for immediate, non - medical action
1.10. ENROLLEE An employee or member of Group who meets the criteria for eligibility specified under VI.
ELIGIBILITY FOR COVERAGE.
1.11. EXPERIMENTAL NATURE Procedure or lens that is not used universally or accepted by the vision care
profession, as determined by VSP.
1.12. EVIDENCE OF COVERAGE: A summary of the Policy provisions, prepared by VSP and provided to
Group for distribution to Enrollee.
1.13. GROUP An employer or other entity which contracts with VSP for coverage under this Policy in order to
provide vision care coverage to its Enrollees and their Eligible Dependents.
1.14. GROUP APPLICATION The form signed by an authorized representative of the Group to signify the
Group's intention to have its Enrollees and their Eligible Dependents become Covered Persons of VSP.
1.15. GROUP VISION CARE Policy (also, "The Policy ") : The Policy issued by VSP to a Group, under which
its Enrollees or members, and their Eligible Dependents are entitled to become Covered Persons of VSP and receive Plan
Benefits in accordance with the terms of such Policy.
1.16. VSP NETWORK DOCTOR: An optometrist or ophthalmologist licensed and otherwise qualified to practice
vision care and/or provide vision care materials who has contracted with VSP to provide vision care services and/or vision
care materials on behalf of Covered Persons of VSP.
1.17. NON-VSP PROVIDER: Any optometrist, optician, ophthalmologist, or other licensed and qualified vision
care provider who has not contracted with VSP to provide vision care services and /or vision care materials to Covered
Persons of VSP.
1.18. PLAN or PLAN BENEFITS The vision care services and vision care materials which a Covered Person
is entitled to receive by virtue of coverage under this Policy, as defined in the Schedule of Benefits (Exhibit A) and, if
purchased by Group, the Additional Benefit Rider (Exhibit C), attached hereto.
1.19. RENEWAL DATE The date when the Policy shall renew, or terminate if proper notice is given.
1.20. SCHEDULE OF BENEFITS: The document, attached as Exhibit A to this Policy, which lists the vision
care services and vision care materials which a Covered Person is entitled to receive under this Policy.
1.21. SCHEDULE OF PREMIUMS: The document, attached hereto as Exhibit B, which states the payments to
be made to VSP by or on behalf of a Covered Person to entitle him /her to Plan Benefits.
2
TERM TERMINATION AND RENEWAL
2.01. This Policy is effective on the Effective Date and shall remain in effect for the Policy Term. At the end of the
Policy Term, the Policy shall renew on a month to month basis unless either parry notifies the other in writing, at least ninety
(90) days before the end of the Policy Term, that such party is unwilling to renew the Policy If such notice is given, the
Policy shall terminate at 11:59 p.m. in the state of delivery on the last day of the Policy Term unless the parties agree on its
renewal of the Policy. If the Policy continues on a month to month basis after the Policy Term, either party may terminate
the Policy upon thirty (30) days advance written notice to the other party.
If VSP issues written renewal materials to Group at least sixty (60) days before the end of the Policy Term and
Group fails to accept the new terms and/or rates in writing prior to the end of the Policy Term, this Policy shall terminate at
11:59 p.m. on the last day of the Policy Term.
2.02. Early Termination Provision The premium rate payable by Group under this Policy is based on an
assumption that VSP will receive these amounts over the full Policy Term in order to cover costs associated with greater
vision utilization that tends to occur during the first portion of a Policy Term. If Group terminates this Policy before the end of
the Policy Term or before the end of any subsequent renewal terms, for any reason other than material breach by VSP, then
Group will remain liable to VSP for the lesser amount of any deficit incurred by VSP or the payments which Group would
have paid for the remaining term of this Policy, not to exceed one year. A deficit incurred by VSP will be calculated by
subtracting the cost of incurred and outstanding claims, as calculated on an incurred date basis with a claim run -out not to
exceed six months from the date of termination, from the net premiums received by VSP from Group. Net premiums shall
mean premiums paid by Group minus any applicable retention amounts and/or broker commissions. Group agrees to pay
VSP within thirty -one (31) days of notification of the amount due. VSP shall return any unearned premiums to Group upon
termination.
III.
OBLIGATIONS OF VSP
3.01. Coverage of _Insureds VSP will enroll for coverage each eligible Enrollee and his/her Eligible
Dependents, if dependent coverage is provided, all of whom shall be referred to upon enrollment as "Covered Persons." To
institute coverage, VSP may require Group to complete, sign and forward to VSP a Group Application along with information
regarding Enrollees and Eligible Dependents, and all applicable premiums. (Refer to VI. ELIGIBILITY FOR COVERAGE for
further details.)
Following the enrollment of the Covered Persons, VSP will provide Group with Member Benefit Summaries and a
copy of the Evidence of Coverage, with Exhibits, for distribution to Covered Persons. Such Member Benefit Summaries and
Evidence of Coverage will summarize the terms and conditions set forth in this Policy.
3.02. Provision of Plan Benefits Through its VSP Network Doctors (or through other licensed vision care
providers where a Covered Person is eligible for, and chooses to receive Plan Benefits from a Non -VSP Provider), VSP
shall provide Covered Persons such Plan Benefits listed in the Schedule of Benefits (Exhibit A) or, when purchased by
Group, Additional Benefit Rider (Schedule C) attached hereto, subject to any limitations, exclusions, or Copayments therein
stated. Benefit Authorization must be obtained prior to a Covered Person obtaining Plan Benefits from a VSP Network
Doctor. When a Covered Person seeks Plan Benefits from a VSP Network Doctor, the Covered Person must schedule an
appointment and identify himself as a VSP Covered Person, so the VSP Network Doctor can obtain Benefit Authorization
from VSP. VSP shall provide Benefit Authorization to the VSP Network Doctor to authorize the provision of Plan Benefits to
the Covered Person, Each Benefit Authorization will contain an expiration date, stating a specific time period for the
Covered Person to obtain Plan Benefits.
VSP shall issue Benefit Authorizations in accordance with the latest eligibility information furnished by Group and the
Covered Person's past service utilization, if any. Any Benefit Authorization so issued by VSP shall constitute a certification
to the VSP Network Doctor that payment will be made, irrespective of a later loss of eligibility of the Covered Person,
provided Plan Benefits are received prior to the Benefit Authorization expiration date.
4
VSP shall pay or deny claims for Plan Benefits provided to Covered Persons, less any applicable Copayment, but not more
than thirty (30) calendar days after VSP has received a completed claim, unless special circumstances require additional
time. If VSP requires additional information in order to pay or deny all or any portion of a claim, VSP will notify the person
submitting the claim within forty -five (45) days after the receipt of the claim. Upon receipt of the requested information, VSP
will pay or deny the claim within sixty (60) days. All claims shall be paid or denied by VSP within one hundred twenty (120)
days after receipt of claim.
WARNING, LIMITED BENEFITS WILL BE PAID WHEN NON -VSP PROVIDERS ARE USED.
When Covered Persons elect to utilize the services of a Non -VSP Provider for a covered service in non - emergency
situations, benefit payments for services from such Non -VSP Provider are not based upon the amount billed. The basis of
the benefit payment will be determined according to the Policy's Non -VSP Provider fee schedule. COVERED PERSONS
CAN EXPECT TO BE LIABLE FOR MORE THAN THE COPAYMENT AMOUNT DEFINED IN THE ATTACHED
SCHEDULE OF BENEFITS OR ADDITIONAL BENEFITS RIDER (when purchased by Group) AFTER THE PLAN HAS
PAID ITS REQUIRED PORTION.
When payment is made to the Non -VSP Provider, the provider may bill Covered Persons for any amount up to the
billed charges after the Plan has paid its portion of the bill. VSP Network Doctors have agreed to accept discounted
payments for services with no additional billing to the Covered Person other than Copayments, co- insurance and any
amounts for non - covered services and/or materials. Covered Persons may obtain further information about the participating
status of providers and information on out -of- pocket expenses through www.vsp.com, or by calling VSP's Customer Service
Department at 1- 800 -877 -7195.
3.03. Provision of Information to Covered Persons Upon request, VSP shall make available to Covered
Persons necessary information describing Plan Benefits and how to use them. A copy of this Policy shall be placed with
Group and also will be made available at the offices of VSP for any Covered Persons. VSP shall provide Group with an
updated list of VSP Network Doctors' names, addresses, and telephone numbers for distribution to Covered Persons twice
a year. Covered Persons may also obtain a copy of the VSP Network Doctor directory through VSP's website at
www.vsp.com, VSP's Customer Service Department's toll -free telephone line, or by written request.
3.04. Preservation of Confidentiality VSP shall hold in strict confidence all Confidential Matters and exercise
its best efforts to prevent any of its employees, VSP Network Doctors, or agents, from disclosing any Confidential Matter,
except to the extent that such disclosure is necessary to enable any of the above to perform their obligations under this
Policy, or to comply with applicable law. Covered Persons and/or Groups that want more information on VSP's
Confidentiality Policy may obtain a copy of the policy from VSP's website at www.vsp.com or by contacting VSP's Customer
Service Department.
3.05. Emergency Vision Care When vision care is necessary for Emergency Conditions, Covered Persons
may obtain Plan Benefits by contacting a VSP Network Doctor or Non -VSP Provider. No prior approval from VSP is required
for Covered Person to obtain vision care for Emergency Conditions of a medical nature. However, services for medical
conditions, including emergencies, are covered by VSP only under the Acute EyeCare and Supplemental Primary EyeCare
Plans. if Group has not purchased one of these plans, Covered Persons are not covered by VSP for medical services and
should contact a physician under Covered Persons' medical insurance plan for care. For emergency conditions of a
non - medical nature, such as lost, broken or stolen glasses, the Covered Person should contact VSP's Customer Service
Department for assistance. Reimbursement and eligibility are subject to the terms of this Policy.
3.06 Coordination of Benefits When VSP is primary, it will pay benefits according to the terms of the
Policy, subject to any applicable state or federal codes, statutes or regulations. When VSP is secondary, it will coordinate
those vision care services and materials that were considered by the primary plan ( "Allowable Expenses "). VSP will pay the
lesser of:
a) The normal Plan Benefit, in the absence of other coverage, or
b) The remaining balance up to Covered Person's Plan Benefits, not to exceed the billed amount.
6
IV.
OBLIGATIONS OF THE GROUP
4.01. Identification of Eligible Enrollees An Enrollee is eligible for coverage under this Policy if he/she
satisfies the enrollment criteria specified in Paragraph 6.01(a) and as established by Group. By the Effective Date of this
Policy, Group shall provide VSP with eligibility information, in a mutually agreed upon format and medium, to identify all
Enrollees who are eligible for coverage under this Policy as of that date. Thereafter, Group shall supply to VSP by the 15th
day of each month, eligibility information sufficient to identify all Enrollees to be added to or deleted from VSP's coverage
rosters. All additions and deletions shall become effective on the first day of the month specified by Group. The eligibility
information shall include designation of each Enrollee's family status if dependent coverage is provided. Upon VSP's
request, Group shall make available for inspection records regarding the coverage of Covered Persons under this Policy.
4.02. Payment of Premiums By the first day of each month, Group shall remit to VSP the premiums payable
for the next month on behalf of each Enrollee and Eligible Dependents, if any, to be covered under this Policy. The
Schedule of Premiums incorporated in this Policy as Exhibit B provides the premium amount for each Covered Person. Only
Covered Persons for whom premiums are actually received by VSP shall be entitled to Plan Benefits under this Policy and
only for the period for which such payment is received, subject to the grace period provision below.
VSP may change the premiums set forth in Exhibit B (Schedule of Premiums) by giving Group at least hundred
twenty (120) days advance written notice. No change will be made during the Policy Term unless there is a change in the
Schedule of Benefits and /or Additional Benefits Rider (if purchased by Group), or there is a material change in Policy terms
or conditions, provided any such change is mutually agreed upon in writing by VSP and Group.
Notwithstanding the above, VSP may increase premiums during a Policy Term by the amount of any tax or assessment not
now in effect but subsequently levied by any taxing authority, which is attributable to premiums VSP received from Group.
4.03. Grace Period Group shall be allowed a grace period of thirty -one (31) days following the premium
payment due date to pay premiums due under this Policy. During said grace period, this Policy shall remain in full force and
effect for all Covered Persons of Group. VSP will consider late payments at the time of Policy renewal. Such payment may
impact Group's premium rates in future Policy Terms.
7
If Group fails to make any premiums payment due by the end of any grace period, VSP may notify Group that the
premiums payment has not been made, that coverage is canceled and that Group is responsible for payment for all Plan
Benefits provided to Covered Persons after the last period for which premiums were paid in full, including the grace period
through the effective date of termination. Group shall also be responsible for any legal and/or collection fees incurred by
VS to collect amounts due under this Policy.
4.04. Distribution of Required Documents: Group shall distribute to Enrollees any disclosure forms, Policy
summaries or other material required to be given to Policy subscribers by any regulatory authority. Such materials shall be
distributed by Group no later than thirty (30) days after the receipt thereof, or as required under applicable law.
4.05. Converting to an Administrative Services Program: Clue to the cyclical nature of vision care, in the
event Group wishes to convert its method of funding from a risk program to an Administrative Services Program, an
appropriate level of reserve will need to have been established.
Upon conversion to an Administrative Services Program, for vision care begun on and after the effective date of
conversion, all claims will be paid through the Administrative Services Program.
V.
OBLIGATIONS OF COVERED PERSONS UNDER THE POLICY
5.09. General By this Policy, Group makes coverage available to its Enrollees and their Eligible Dependents, if
dependent coverage is provided. However, this Policy may be amended or terminated by agreement between VSP and
Group as indicated herein, without the consent or concurrence of Covered Persons. This Policy, and all Exhibits, Riders and
attachments hereto, constitute VSP's sole and entire undertaking to Covered Persons under this Policy.
As conditions of coverage, all Covered Persons under this Policy have the following obligations:
5.02. Comments for Services Received Where, as indicated in Exhibit A (Schedule of Benefits) and Exhibit
C (Additional Benefit Rider) when purchased by Group, Copayments are required for certain Plan Benefits. Copayments
shall be the personal responsibility of the Covered Person receiving the care and must be paid at the time services are
rendered. Amounts that exceed Plan allowances, annual maximum benefits, options reimbursements, or any other stated
Plan limitations are not considered Copayments but are also the responsibility of the Covered Person.
5.03. Obtainina Services from VSP Network Doctors: Benefit Authorization must be obtained prior to
receiving Plan Benefits from a VSP Network Doctor. When a Covered Person seeks Plan Benefits, the Covered Person
must select a VSP Network Doctor, schedule an appointment, and identify himself as a Covered Person so the VSP
Network Doctor can obtain Benefit Authorization from VSP. Should the Covered Person receive Plan Benefits from a VSP
Network Doctor without such Benefit Authorization, then for the purposes of those Plan Benefits provided to the Covered
Person, the VSP Network Doctor will be considered a Nan -VSP Provider, and the benefits available will be limited to those
for a Non -VSP Provider, if any.
5.04. Submission of Nan -VSP Provider Claims If Non -VSP Provider coverage is indicated in Exhibit A
(Schedule of Benefits) or Exhibit C (Additional Benefit Rider), when purchased by Group, written proof (receipt and the
Covered Person's identification information) of all claims for services received from Non -VSP Providers shall be submitted
by Covered Persons to VSP within three hundred sixty -five (365) days of the date of service. VSP may reject such claims
filed more than three hundred sixty -five (365) days after the date of service.
Failure to submit a claim within this time period, however, shall not invalidate or reduce the claim if it was not
reasonably possible to submit the claim within such time period, provided the claim was submitted as soon as reasonably
possible and in no event, except in absence of legal capacity, later than one year from the required date of three hundred
sixty-five (365) days after the date of service.
5.05. Complaints and Grievances: Covered Persons shall report any complaints and/or grievances to VSP at
the address given herein. Complaints and grievances are disagreements regarding access to care, quality of care,
1
treatment or service. Complaints and grievances may be submitted to VSP verbally or in writing. A Covered Person may
submit written comments or supporting documentation concerning hislher complaint or grievance to assist in VSP's review.
VSP will resolve the complaint or grievance within thirty (30) days after receipt, unless special circumstances require an
extension of time. In that case, resolution shall be achieved as soon as possible, but not later than one hundred twenty
(120) days after VSP's receipt of the complaint or grievance. If VSP determines that resolution cannot be achieved within
thirty (30) days, VSP will notify the Covered Person of the expected resolution date. Upon final resolution, VSP will notify the
Covered Person of the outcome in writing.
5.06. Claim Denial Appeals If, under the terms of this Policy, a claim is denied in whole or in part, a request
may be submitted to VSP by Covered Person, or Covered Person's authorized representative, for a full review of the denial.
Covered Person may designate any person, including their provider, as their authorized representative. References in this
section to "Covered Person" include Covered Person's authorized representative, where applicable.
a) Initial Appeal: The request must be made within one hundred eighty (180) days following denial of a
claim and should contain sufficient information to identify the Covered Person for whom the claim was denied, including the
VSP Enrollee's name, the VSP Enrollee's Member Identification Dumber, the Covered Person's name and date of birth, the
provider of services and the claim number. The Covered Person may review, during normal working hours, any documents
held by VSP pertinent to the denial. The Covered Person may also submit written comments or supporting documentation
concerning the claim to assist in VSP's review. VSP's response to the initial appeal, including specific reasons for the
decision, shall be provided and communicated to the Covered Person as follows:
Denied Claims for Services Rendered: within thirty (30) calendar days after receipt of a request for an
appeal from the Covered Person.
b) Second Level Appeal: If the Covered Person disagrees with the response to the initial appeal of the
claim, the Covered Person has the right to a second level appeal. Within sixty (60) calendar days after receipt of VSP's
response to the initial appeal, the Covered Person may submit a second appeal to VSP along with any pertinent
documentation. VSP shall communicate its final determination to the Covered Person in compliance with all applicable
state and federal laws and regulations and shall include the specific reasons for the determination.
c) Other Remedies: When Covered Person has completed the appeals stated herein, additional
voluntary alternative dispute resolution options may be available, including mediation or arbitration. Group should advise
Covered Person to contact the U.S. Department of labor or the state insurance regulatory agency for details. Additionally,
under the provisions of ERISA (Section 502(a)(1)(B)) [29 U.S.C. 1132(a)(1)(B)], Covered Person has the right to bring a civil
10
action when all available levels of review of denied claims, including the appeals process, have been completed, the claims
were not approved in whole or in part, and Covered Person disagrees with the outcome.
5.07. Time of Action No action in law or in equity shall be brought to recover on the Policy prior to the
expiration of sixty (60) days after the claim and any applicable invoices have been filed with VSP. No such action shall be
brought after the expiration of any applicable statute of limitations from the time such claim and invoices are required to be
given, in accordance with the terms of this Policy.
5.08. Insurance Fraud Any Group and/or person who intends to defraud, Knowingly facilitates a fraud, or
submits an application, or files a claim with a false or deceptive statement, is guilty of insurance fraud. Such an act is
grounds for immediate termination of the Policy for the Group or individual that committed the fraud. In the absence of fraud,
all statements made by Group or Enrollees shall be deemed representations and not warranties and no statement made for
the purpose of effecting insurance shall avoid such insurance or reduce benefits unless contained in a written instrument
signed by Group or Enrollee, a copy of which has been fumished to Group or Enrollee or Enrollee's beneficiary.
11
VI.
ELIGIBILITY FOR COVERAGE
6.01. Eligibility Criteria Individuals will be accepted for coverage hereunder only upon meeting all
requirements set forth below.
a) Enrollees To be eligible, a person must:
1. currently be an employee or member of Group, and
2. meet the coverage criteria mutually agreed upon by Group and VSP.
b.} Eligible Dependents If dependent coverage is provided, the persons eligible for dependent
coverage are specified on the attached Schedule of Benefits and Additional Benefit Riders (if applicable).
If a dependent child prior to attainment of the prescribed age for termination of eligibility becomes, and continues to be,
incapable of self - sustaining employment because of mental or physical disability, that Eligible Dependent's coverage shall
not terminate so long as he remains chiefly dependent on the Enrollee for support and the Enrollee's coverage remains in
force; PROVIDED that satisfactory proof of the dependent's incapacity can be furnished to VSP within thirty -one (31) days
of the date the Eligible Dependent's coverage would have otherwise terminated and at such other times as VSP may
request proof, but not more frequently than annually.
6.02. Documentation of Eligibility Persons satisfying the coverage requirements under either of the above
criteria shall be eligible if:
a) for an Enrollee, the individual's name and Member ID Number have been reported by Group to
VSP in the manner provided hereunder; and
b) for changes to an Eligible Dependent's status, the change has been reported by the Group to VSP
in the manner provided herein. As stated in paragraph 4.01 above, VSP may elect to audit Group's records to verify
eligibility of Enrollees and dependents and any errors. Subject to the terms of paragraph 4.03 above, only persons on
whose behalf premiums have been paid for the current period shall be entitled to Plan Benefits hereunder. If a clerical error
is made, it will not affect the coverage a Covered Person is entitled to under this Policy.
12
6.03. Retroactive Eligibility Changes Retroactive eligibility changes are limited to sixty (60) days prior to the
date notice of any such requested change is received by VSP. VSP may refuse retroactive termination of a Covered
Person if Plan Benefits have been obtained by, or authorized for, the Covered Person after the effective date of the
requested termination. As stated in Section 4.01 herein, Group agrees to provide timely eligibility changes to VSP.
6.04. Chancie of Pardo ation Requirements, Contribution of Fees and Eli ibili Rules: Composition of
the Group, percentage of Enrollees covered under the Policy, and Group's contribution and eligibility requirements, are all
material to VSP's obligations under this Policy. During the term of this Policy, Group must provide VSP with written notice of
changes to its composition, percentage of Enrollees covered, contribution and eligibility requirements. Any change which
materially affects VSP's obligations under this Policy must be agreed upon in writing between VSP and Group and may
constitute a material change to the terms and conditions of this Policy for purposes of paragraph 4.02. Nothing in this
section shall limit Group's ability to add Enrollees or Eligible Dependents under the terms of this Policy.
6.45. Change in Family or Employment Status In the event Group is notified of any change in a Covered
Person's family status [by marriage, the addition (e.g., newborn or adopted child) or deletion of Dependent , etc.] or
employment status, Group shall provide notice of such change to VSP via the next eligibility listing required under
Paragraph 4.01. If notice is given, the change in the Covered Person's status will be effective on the first day of the month
following the change request, or at such later date as may be requested by or on behalf of the Covered Person.
Notwithstanding any other provision in this section, a newborn child will be covered for a period of at least sixty (60) days
after birth, and an adopted child will be covered for a period of at least sixty (60) days after the date the Enrollee or the
Enrollee's spouse acquires the right to control that child's health care. If Enrollee provides notice to the Group within said
sixty (60) day period, VSP shall not deny coverage for said newborn or adopted child. Coverage for an adopted newborn will
begin from the moment of birth if an agreement to adopt is entered into by Enrollee or Enrollee's spouse, and the child is
ultimately placed in the Enrollee's home. To continue coverage for a newborn or adopted child beyond the initial sixty (60)
day period, the Group must be properly notified of the Enrollee's change in family status and applicable premiums must be
paid to VSP.
13
1911
CONTINUATION OF COVERAGE
7.01. COBRA The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that, under
certain circumstances, health plan benefits available to an Enrollee and his or her Eligible Dependents be made available to
said persons upon the occurrence of a COBRA - qualifying event. If, and only to the extent, COBRA applies to the parties to
this Policy, VSP shall make the required COBRA continuation coverage available for purchase in accordance with COBRA.
14
VIII.
ARBITRATION OF DISPUTES
8.01. Dispute Resolution Any dispute or question arising between VSP and Group involving the application,
interpretation, or performance under this Policy shall be settled, if possible, by amicable and informal negotiations, allowing
such opportunity as may be appropriate under the circumstances for fact - finding and mediation. If any issue cannot be
resolved in this fashion, it shall be submitted to arbitration where permitted by state law.
8.02. Procedure Arbitration hereunder shall be conducted pursuant to the Rules of the American Arbitration
Association subject to the provisions of Section 10.06 of this Policy. Such Rules, the enforcement thereof, and enforcement
of the arbitrator's decision shall be governed by applicable laws.
8.03. Choice of Law If any matter arises in connection with this Policy which becomes the subject of
arbitration or legal process, the law of the State of delivery of the Policy shall be the applicable law.
15
IX.
NOTICES
9. 01. Notice Any notices required under this Policy to either Group or VSP shall be in written format. Notices
sent to the Group will be sent to the address or email address shown on the Group's Application unless otherwise directed
by Group. Notices to VSP shall be sent to the address shown on the front page of this Policy. Notwithstanding the above,
any notices may be hand - delivered by either party to an appropriate representative of the other parry. The party effecting
hand - delivery bears the burden to prove delivery was made, if questioned.
111.1
X.
MISCELLANEOUS
10.01. Entire Policy This Policy, the Group Application, the Evidence of Coverage, and all Exhibits, Riders and
attachments hereto, constitute the entire agreement of the parties and supersedes any prior understandings and
agreements between them, either written or oral. Any change or amendment to the Policy must be approved by an officer of
VSP and attached hereto to be valid. No agent has the authority to change this Policy or waive any of its provisions.
Communication materials prepared by Group for distribution to Enrollees do not constitute a part of this Policy.
10.02. Indemnity: VSP agrees to indemnify, defend and hold harmless Group, its shareholders, directors,
officers, agents, employees, successors and assigns from and against any and all liability, claim, loss, injury, cause of
action and expense (including defense costs and legal fees) of any nature whatsoever arising from the failure of VSP, its
officers, agents or employees, to perform any of the activities, duties or responsibilities specified herein. Group agrees to
indemnify, defend and hold harmless VSP, its members, shareholders, directors, officers, agents, employees, successors
and assigns from and against any and all liability, claim, loss, injury, cause of action and expense (including defense costs
and legal fees) of any nature whatsoever arising or resulting from the failure of Group, its officers, agents or employees to
perform any of the duties or responsibilities specified herein.
10.03. Liability: VSP arranges for the provision of vision care services and materials through agreements with
VSP Network Doctors. VSP Network Doctors are independent contractors and are responsible for exercising independent
judgement. VSP does not itself directly furnish vision care services or supply materials. tinder no circumstances shall VSP
or Group be liable for the negligence, wrongful acts or omissions of any doctor, laboratory, or any other person or
organization performing services or supplying materials in connection with this Policy.
10.04. Assignment Neither this Policy nor any of the rights or obligations of either of the parties hereto maybe
assigned or transferred without the prior written consent of both parties hereto except as expressly authorized herein.
10.05. Severability Should any provision of this Policy be declared invalid, the remaining provisions shall
remain in full force and effect.
17
10.06. Governing -Law This Policy shall be governed by and construed in accordance with applicable federal
and state law. Any provision that is in conflict with, or not in conformance with, applicable federal or state statutes or
regulations is hereby amended to conform with the requirements of such statutes or regulation, now or hereafter existing.
10.07. Gender All pronouns used herein are deemed to refer to the masculine, feminine, neuter, singular, or
plural, as the identity(ies) of the person(s) may require.
10.08. Equal Opportunity VSP is an Equal Opportunity and Affirmative Action employer.
10.09. Communication Materials Communication materials created by Group which relate to this vision care
Policy must adhere to VSP's Member Communication Guidelines distributed to Group by VSP. Such communication
materials may be sent to VSP for review and approval prior to use. VSP's review of such materials shall be limited to
approving the accuracy of Plan Benefits and shall not encompass or constitute certification that Group's materials meet any
applicable legal or regulatory requirements, including but not limited to, ERISA requirements. In the event of any dispute
between the communication materials and this Policy, the provisions of this Policy shall prevail.
im
EXHIBIT A
SCHEDULE OF BENEFITS
VSP Choice Plan
GENERAL
This Schedule lists the vision care benefits to which Covered Persons of VISION SERVICE PLAN INSURANCE COMPANY( "VSP ") are entitled,
subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein. If Plan Benefits are available for Nan -VSP
Provider services, as indicated by the reimbursement provisions below, vision care benefits may be received from any licensed eye care provider
whether VSP Network Doctors or Non -VSP Providers. This Schedule forms apart of the Policy or Evidence of Coverage to which it is attached.
VSP Network Doctors are those doctors who have agreed to participate in VSP's Choice Network.
When Plan Benefits are received from VSP Network Doctors, benefits appearing in the VSP Network Doctor Benefit column below are applicable
subject to any applicable Copayments and other conditions, limitations and/or exclusions as stated below. When Plan Benefits are available and
received from Non -VSP Providers, the Covered Person is reimbursed for such benefits according to the schedule in the Non -VSP Provider Benefit
column below, less any applicable Copayment. The Covered Person pays the provider the full fee at the time of service and submits an itemized bill
to VSP for reimbursement. Discounts do not apply for vision care benefits obtained from Non -VSP Providers.
BENEFIT PERIOD
A twelve -month period beginning on January 1st and ending on December 31st.
ELIGIBILITY
The following are Covered Persons under this Policy:
• Enrollee.
• The legal spouse of Enrollee.
• Any child of Enrollee, including any natural child from the date of birth, legally adopted child from the date of placement for adoption with the
Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible.
• The domestic partner of the same or opposite gender as Enrollee, pursuant to Group's eligibility rules.
• Any children of the domestic partner provided they depend upon the Enrollee for support and maintenance
Dependent children are covered up to the end of the year in which they turn age 26.
A dependent, child over the limiting age may continue to be eligible as a dependent if the child is incapable of self- sustaining employment because of
mental or physical disability, and chiefly dependent upon Enrollee for support and maintenance.
See schedule below for Plan Benefits, payments and /or reimbursement subject to any Copayment(s) as stated:
COMMENT
The benefits herein are available to each Covered Person subject only to payment of the applicable Copayment by the Covered Person. Plan
Benefits received from VSP Network Doctors and Non -VSP Providers require Copayments. Covered Persons must also follow Benefit Authorization
Procedures.
There shall be a Copayment of $10.40 for the examination payable by the Covered Person at the time services are rendered. If materials (lenses,
frames or Necessary Contact Lenses) are provided, there shall be an additional $20.00 Copayment payable at the time the materials are ordered.
The Copayment shall not apply to Elective Contact Lenses.
19
PLAN BENEFITS
SERVICE OR MATERIAL VSP NETWORK DOCTOR NON -VSP PROVIDER BENEFIT I FREQUENCY
BENEFIT I .... - A
Eye Examination I Covered in full` I Up to $ 45.00' 1 Available once each 12 months **
Complete initial vision analysis: includes appropriate examination of visual functions and prescription of corrective eyewear where
indicated.
*Less any applicable Copayment.
* *Beginning with the first day of the Benefit Period.
SERVICE OR MATERIAL
VSP NETWORK DOCTOR
BENEFIT
NON -VSP PROVIDER BENEFIT
FREQUENCY
Lenses
BENEFIT
Available once each 12 months **
Single Vision
Covered in full *
Up to $ 30.00*
Up to $ 70.00*
Bifocal
Covered in full
Up to $ 50.00*
1. Prescribing and ordering proper lenses;
Trifocal
Covered in full'
Up to $ 65.00*
5. Subsequent adjustments to frames to maintain comfort and efficiency;
Lenticular
Covered in full *
Up to $100.40*
Plan Benefits for lenses are per complete set, not per lens.
*Less any applicable Copayment.
* *Beginning with the first day of the Benefit Period.
SERVICE OR MATERIAL
VSP NETWORK DOCTOR
NON -VSP PROVIDER BENEFIT
FREQUENCY
BENEFIT
FRAMES
Covered up to Plan Allowance*
Up to $ 70.00*
Available once each 24 months **
Benefits for lenses and frames include
reimbursement for the following necessary professional services:
1. Prescribing and ordering proper lenses;
2. Assisting in frame selection;
3. Verifying accuracy of finished lenses;
4. Proper fitting and adjustments of frames;
5. Subsequent adjustments to frames to maintain comfort and efficiency;
6. Progress or follow -up work as necessary.
*Less any applicable Copayment.
* *Beginning with the first day of the Benefit Period.
20
SERVICE OR MATERIAL
VSP NETWORK DOCTOR
NON -VSP PROVIDER
FREQUENCY
BENEFIT
BENEFIT
CONTACT LENSES
Available once each 12 months **
Elective
Elective Contact Lens fitting
Available once each 12
Covered in full *
and evaluation'** services
months**
are covered In full once
*Less any applicable Copayment
* *Beginning with the first day of the Benefit Period.
every 12 months * *, after a
Doctor or Non -VSP Provider. Prior review and approval by VSP are not required for Covered Person to be eligible for Necessary Contact Lenses.
Necessary Contact Lenses are provided in lieu of all other lens and frame benefits available herein.
Utilization of contact lens benefits exhausts all of the Covered Person's lens and frame benefits for the current Benefit Period, and future
maximum $60.00
Go a meat.
Mat dais
Professional Fees /Materials
Up to $ 115.00
Up to $ 105.00
* *Beginning with the first day of the Benefit Period,
* * *15% Discount applies to VSP Network Doctor's usual and customary professional fees for contact lens evaluation and
fitting.
Contact Lenses are provided in lieu of all other lens and frame benefits available herein.
Utilization of contact lens benefits exhausts all of the Covered Person's lens and frame benefits for the current
Benefit Period, and future eligibility for lenses and frames will be determined as if spectacle lenses only were
obtained in the current Benefit Period.
SERVICE OR MATERIAL
VSP NETWORK DOCTOR
NON -VSP PROVIDER BENEFIT
FREQUENCY
BENEFIT
NECESSARY CONTACT
Available once each 12 months **
LENSES
Professional Fees and
Covered in full *
Up to $ 210.00'
Materials
*Less any applicable Copayment
* *Beginning with the first day of the Benefit Period.
Necessary Contact tenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's VSP Network
Doctor or Non -VSP Provider. Prior review and approval by VSP are not required for Covered Person to be eligible for Necessary Contact Lenses.
Necessary Contact Lenses are provided in lieu of all other lens and frame benefits available herein.
Utilization of contact lens benefits exhausts all of the Covered Person's lens and frame benefits for the current Benefit Period, and future
eligibility for lenses and frames will be determined as if spectacle lenses only were obtained in the current Benefit Period.
......:..:
R..
21
SERVICE OR MATERIAL VSP NETWORK DOCTOR NON -VSP PROVIDER BENEFIT FREQUENCY
BENEFIT
Professional services for severe visual problems not correctable with regular lenses, including:
Supplemental Testing Covered in full Up to $125.00*
(Includes evaluation, diagnosis and prescription of vision aids where indicated.)
Supplemental Aids 75% of amount 75% of amount
up to $1000.00* up to $1000.00*
*Maximum benefit for all Low Vision services and materials is $1000.00 every two (2) Benefit Periods.
Low Vision benefits secured from Non -VSP Providers (if covered) are subject to the same time and Copayment provisions described above for
VSP Network Doctors. The Covered Person should pay the Non -VSP Provider's full fee at the time of service. Covered Person will be reimbursed
an amount not to exceed what VSP would pay a VSP Network Doctor for the same services and/or materials.
THERE IS NO ASSURANCE THAT THE AMOUNT REIMBURSED WILL COVER 75% OF THE PROVIDER'S FULL. FEE.
22
EXCEPTIONS
Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional limitations. Covered Persons
may obtain details regarding frame brand availability from their VSP Network Doctor or by calling VSP's Customer Care Division at (800) 877 -7195.
PATIENT OPTIONS
This Plan is designed to cover visual needs rather than cosmetic materials. When a Covered Person selects any of the following extras, the Plan will
pay the basic cost of the allowed lenses or frames, and the Covered Person will pay the additional costs for the options.
• Optional cosmetic processes.
• Anti - reflective coating.
• Color coating.
• Mirror coating.
• Scratch coating.
• Blended lenses.
• Cosmetic lenses.
• Laminated lenses.
• Oversize lenses.
• Polycarbonate lenses.
• Photochromic lenses, tinted lenses except Pink #1 and Pink #2.
• Progressive multifocal lenses.
• UV (ultraviolet) protected lenses.
• Certain limitations on low vision care.
NOT COVERED
There are no benefits for professional services or materials connected with;
• Orthoptics or vision training and any associated supplemental testing.
• Corneal Refractive Therapy (CRT)
• Orthokeratology (a procedure using contact lenses to change the shape of the cornea in order to reduce myopia).
• Refitting of contact lenses after the initial (90 -day) fitting period.
• Plano lenses (lenses with refractive correction of less than ± .50 diopter).
• Two pair of glasses in lieu of bifocals.
• Replacement of lenses and frames furnished under this Policy that are lost or broken, except at the normal intervals when services are
otherwise available.
• Medical or surgical treatment of the eyes.
• Corrective vision treatment of an Experimental Nature.
• Plano contact lenses to change eye color cosmetically.
• Artistically- painted contact lenses.
• Contact lens insurance policies or service contracts.
• Additional office visits associated with contact lens pathology.
• Contact lens modification, polishing, or cleaning.
• Costs for services and/or materials exceeding Plan Benefit allowances.
• Services or materials of a cosmetic nature.
• Services and /or materials not indicated on this Schedule as covered Plan Benefits.
23
PLAN BENEFITS
AFFILIATE PROVIDERS
GENERAL
Affiliate Providers are providers of Covered Services and Materials who are not contracted as VSP Network Doctors but who have agreed to bill VSP
directly for Plan Benefits provided pursuant to this Schedule. However, some Affiliate Providers may be unable to provide all Plan Benefits included
in this Schedule. Covered Persons should discuss requested services with their provider or contact VSP Customer Care for details.
COPAYMENT
There shall be a Copayment of $10.00 for the examination payable by the Covered Person at the time services are rendered. If materials (lenses,
frames or Necessary Contact Lenses) are provided, there shall be an additional $20.00 Copayment payable at the time the materials are ordered.
The Copayment shall not apply to Elective Contact Lenses,
COVERED SERVICES AND MATERIALS
Eye Examination Covered in full *
Available once each 12 months **
Comprehensive examination of visual functions and prescription of corrective eyewear.
Spectacle Lenses
Single Vision, Lined BifocalCovered in Full*
or Lined Trifocal,
Frames
Covered up to the Plan allowance*
CONTACT LENSES
Elective Contact Lenses
(Materials Only)
Up to $115.00
Available once each 12 months **
Available once each 24 months **
Available once each 12 months **
The Elective Contact Lens fitting and evaluation services are covered in full once every 12 months, after a maximum $60.00 Copayment.
Necessary Contact Lenses Up to $210.00* Available once each 12 months **
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor.
Contact Lenses are provided in place of spectacle lens and frame benefits available herein f=uture eligibility for lenses and frames will be determined
as if spectacle lenses only were obtained in the current Benefit Period.
*Less any applicable Copayment.
* *Beginning with the first day of the Benefit Period.
24
Law VISION
Professional services for severe visual problems not correctable with regular lenses, including;
Supplemental Testing: Up to $125.00t
- Includes evaluation, diagnosis and prescription of vision aids where indicated.
Supplemental Aids: 75% of Affiliate Provider's fee up to $1000.001
tMaximum benefit for all Low Vision services and materials is $1000.00 every two (2) years and a
maximum of two supplemental tests within a two -year period
Low Vision Services are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor.
EXCLUSIONS AND LIMITATIONS OF BENEFITS
1. E=xclusions and limitations of benefits described above for VSP Network Doctors shall also apply to services rendered by Affiliate Providers.
2. Services from an Affiliate Provider are in lieu of services from a VSP Network Doctor or a Non -VSP Provider.
3. VSP is unable to require Affiliate Providers to adhere to VSP's quality standards,
4. Where Affiliate Providers are located in membership retail environments, Covered Persons may be required to purchase a membership in such
entities as a condition of obtaining Plan Benefits.
25
Exhibit B
VISION SERVICE PLAN INSURANCE COMPANY (VSP)
SCHEDULE OF PREMIUMS
VSP Choice Plan
VISION SERVICE PLAN INSURANCE COMPANY ( "VSP ") shall be entitled to receive premiums for each month on behalf of each Enrollee and
his/her Eligible Dependents, if any, in the amounts specified below.
4.44 per month for each eligible Enrollee without dependents.
8.88 per month for each eligible Enrollee with an eligible spouse.
9.50 per month for each eligible Enrollee with eligible child(ren),
15.18 per month for each eligible Enrollee with eligible spouse and child(ren).
NOTICE: The premium under this Policy is subject to change upon renewal (after the end of the initial Policy Term or any subsequent Policy Term),
or upon change of the Schedule of Benefits or a material change in any other terms or conditions of the Policy.
C .
� � �►.I. +ll�l�'J
VISION SERVICE PLAN INSURANCE COMPANY
ADDITIONAL_ BENEFIT RIDER
DIABETIC EYECARE PLUS PROGRAM
GENERAL.
This Rider lists additional vision care benefits to which Covered Persons of VISION SERVICE PLAN INSURANCE COMPANY ( "VSP ") are entitled,
subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein or in the Schedule of Benefits with which it is
associated. Plan Benefits under the Diabetic Eyecare Plus Program are available to Covered Persons who have been diagnosed with type 1 or type
2 diabetes and specific ophthalmological conditions. This Rider forms a part of the Policy or Evidence of Coverage to which it is attached.
ELIGIBILITY
The following are Covered Persons under this Policy, pursuant to eligibility criteria established by Client:
• Enrollee.
• The legal spouse of Enrollee.
• Any child of Enrollee, including any natural child from the date of birth, legally adopted child from the date of placement for adoption with the
Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible.
• The domestic partner of the same or opposite gender as Enrollee, pursuant to Group's eligibility rules.
• Any children of the domestic partner provided they depend upon the Enrollee for support and maintenance.
Dependent children are covered up to the end of the year in which they turn age 26.
A dependent, unmarried child over the limiting age may continue to be eligible as a dependent if the child is incapable of self- sustaining employment
because of mental or physical disability, and chiefly dependent upon Enrollee for support and maintenance.
......:..:
R..
k
■;
f
*y
k
27
PROGRAM DESCRIPTION
The Diabetic Eyecare Plus Program ( 'DEP Plus') is intended to be a supplement to Covered Person's group medical plan. Providers will first
submit a claim to Covered Person's group medical insurance plan, and then to VSP. Any amounts not paid by the medical plan will be considered
for payment by VSP. (This is referred to as "Coordination of Benefits" or "COB." Please refer to the Coordination of Benefits section of Covered
Person's Evidence of Coverage for additional information regarding COB.) If Covered Person does not have a group medical plan, providers will
submit claims directly to VSP.
Examples of symptoms which may result in a Covered Person seeking services under DEP Plus may include, but are not limited to:
• blurry vision trouble focusing
• transient loss of vision "floating" spats
Examples of conditions which may require management under DEP Plus may include, but are not limited to:
• diabetic retinopathy rubeosis
• diabetic macular edema
REFERRALS
If Covered Person's Member Doctor cannot provide Covered Services, the doctor will refer the Covered Person to another Member Doctor or to a
physician whose offices provide the necessary services.
If the Covered Person requires services beyond the scope of DEP Plus, the Member Doctor will refer the Insured to a physician.
Referrals are intended to insure that Covered Persons receive the appropriate level of care for their presenting condition. Covered Person do not
require a referral from a Member Doctor in order to obtain Plan Benefits.
28
PLAN BENEFITS
VSP NETWORK DOCTORS
COVERED SERVICES
Eye Examination: Covered in full after a Copayment of $20,40.
Special Ophthalmological Services: Covered in Full,
EXCLUSIONS AND LIMITATIONS OF BENEFITS
The Diabetic Eyecare Plus Program provides coverage for limited, vision - related medical services. A current list of these procedures will be made
available to Covered Person upon request. The frequency at which these services may be provided is dependent upon the specific service and the
diagnosis associated with such service.
NOT COVERED
1. Services and/or materials not specifically included in this Rider as Plan Benefits.
2. Frames, lenses, contact lenses or any other ophthalmic materials.
3. Orthoptics or vision training and any associated supplemental testing.
4. Surgery of any type, and any pre- or post- operative services.
5. Treatment for any pathological conditions.
6. An eye exam required as a condition of employment,
7. Insulin or any medications or supplies of any type.
8. Local, state and /or federal taxes, except where VSP is required by law to pay.
29
Packet'Pg. 645
DIABETIC EYECARE PROGRAM DEFINITIONS
Diabetes A disease where the pancreas has a problem either making, or making and using, insulin.
Type 1 Diabetes A disease in which the pancreas stops making insulin.
Type 2 Diabetes A disease in which the pancreas either makes too little insulin or cannot properly use the insulin it makes to
convert blood glucose to energy.
Diabetic Retinopathy A weakening in the small blood vessels at the back of the eye.
Rubeosis Abnormal blood vessel growth on the iris and the structures in the front of the eye.
Diabetic Macular Edema Swelling of the retina in diabetes mellitus due to leaking of fluid from blood vessels within the macula.
30
ADDENDUM
VISION SERVICE PLAN INSURANCE COMPANY
PERFORMANCE STANDARDS
VSP guarantees the performance standards outlined herein by offering to pay a financial penalty of 1 % of quarterly administrative revenue per unmet
standard, up to a total annual maximum of $100,000 and a minimum annual threshold of $250. VSP's company -wide quarterly performance results
shall be used in determining whether any or all of the performance standards have been met. Any penalties owed shall be accrued quarterly and
paid on an annual basis, as long as the cumulative total for the four quarters exceeds $250. Cumulative annual penalties less than $250 will not be
carried over into the following calendar year for purposes of determining financial penalties. Payment of penalties shall be conditioned on VSP's
receipt of all premiums due to VSP within established due dates.
VSP's performance hereunder is subject to interruption and delay due to causes beyond VSP's reasonable control such as acts of God, act of any
government, war or other hostility, the elements, fire, explosion, power failure, equipment failure, industrial or labor dispute. In the event of any such
interruption or delay, any period of performance shall be extended for a period of time equal to the interruption or delay.
CLAIMS PROCESSING
Claims financial accuracy
Performance Standard = 99% processed without financial error
Performance Penalty =1 %
Claims financial accuracy is calculated much like that of claims processing accuracy. The same random sampling of claims audited for processing
accuracy is also audited for financial accuracy. Any error found that results in a financial impact is recorded as a financial error. At the end of the
month, financial errors are totaled and taken as a percentage of the total dollar paid for all claims audited during the given month.
Claims processing accuracy
Performance Standard = 99% processed without error
Performance Penalty =1%
Claims processing accuracy is calculated on a monthly basis based upon daily audit results. The term "processing error" encompasses all errors
found in the audit regardless of whether the error caused a financial impact. At month's end, all processing errors for the month are totaled and
taken as a percentage of the total number of claims audited for the month.
Claims timeliness
Performance Standard:
VSP preferred provider claims = 96% processed within 5 business days
Performance Penalty= 11%
All other provider claims = 95% processed within 5 business days
Performance Penalty =1 %
All other provider claims = 99% processed within 15 business days
Performance Penalty =1%
Claims timeliness, or turnaround time, is measured on a monthly basis. Each claim audited in the daily audit is audited for timeliness. Timeliness is
measured by calculating the number of business days elapsing between the received date and the pricing date. When additional information is
needed to process a claim, the timeliness date is calculated from the date the information needed to process the claim was received to the pricing
date.
31
CALL CENTER MANAGEMENT
Abandoned call rate
Performance Standard = Less than or equal to 3%
Performance Penalty= 1%
The Call Center telephone abandon rate is calculated monthly by taking the total number of abandoned calls before and after sixty (60) seconds,
divided by the total number of calls accepted by the Call Center, which includes calls answered via the Interactive Voice Response and Automated
Call Distribution systems.
Average speed of answer
Performance Standard = Less than or equal to 25 Seconds
Performance Penalty =1 %
The average speed of answer (the amount of time a caller is waiting while on hold) is calculated by dividing the total time all calls are on hold (in
seconds) by the total number of calls received.
Average call blockage rate
Performance Standard = Less than or equal to 2%
Performance Penalty =1 %
VSP call blockage is defined as any call blocked by VSP. A blocked call results in the caller receiving a "busy" signal, and is considered
unsuccessful. VSP call blockage does not include calls blocked by the long distance carrier due to circumstances beyond VSP's control. VSP call
blockage standard is 2% or less of total calls attempted to VSP, The formula for this standard is: number of blocked calls divided by (blocked calls
plus accepted calls) as reported by the long distance carrier.
Call resolution (same day response)
Performance Standard = 98%
Performance Penalty= 1 %
Measurement based on internal VSP system - driven statistics. The percentage of telephone inquiries handled within the same day is obtained by
taking the number of research inquiries entered into our system and dividing by the number of calls answered in the Call Center, and subtracting the
result from 1.00.
Complaint acknowledgement within 5 business days
Performance Standard = 96%
Performance Penalty =1 %
"Telephone complaints" not resolved by the end of the following business day must be acknowledged in writing within 5 by business days. "Written
complaints" not resolved within 5 business days will be acknowledged in writing on the 5th business day from receipt. Complaint acknowledgement
compliancy is calculated monthly. The method for calculating the percentage is: total number of complaints meeting the 5 business day goal divided
by total number of complaints.
Complaint resolution within 30 calendar days
Performance Standard = 99%
Performance Penalty= 1%
When a complaint is received, in writing or via phone, the person receiving it documents it in our online Research Inquiry system. The Complaint and
Grievance unit monitors this workflow to assure all complaints have been resolved by the 30m calendar day.
Average response to e-mail inquiries within 2 business days
Performance Standard =100%
Performance Penalty= 1 %
The average time required to send the first manual reply to an email, in the specified time period.
32
SATISFACTION
Patient satisfaction (satisfied with level of coverage)
Performance Standard = 96% overall satisfaction with VSP
Performance Penalty =1 %
Performance Standard = 9$% overall experience with VSP preferred provider
Performance Penalty =1 %
VSP conducts patient satisfaction surveys on a quarterly basis. A random sample of claims from the prior three months is chosen that is statistically
representative of all claims.
While VSP makes recommendations to all prospective Groups on which plan we feel best suits the group's employees, the ultimate decision for
selection of a plan rests with the Group. As such, our performance standard is based on patients who are satisfied with the level of coverage
provided by their plan. Satisfied patients includes patients who rated their overall level of coverage as "Excellent," "Very Good" and "Good ".
Dissatisfied patients include patients who rated their overall level of coverage as "Fair" or "Poor ".
VSP preferred provider retention rate (based on voluntary turnover)
Performance Standard = 98%
Performance Penalty = 1%
VSP preferred provider satisfaction is based on changes in the VSP preferred provider network. On a quarterly basis, the voluntary retention rate of
providers (those choosing to stay on the VSP panel) is measured as a percentage of the total number of providers in the network. The annual
preferred provider retention rate is equal to the total number of providers on the panel on December 31 divided by the total number of providers on
the panel January 1 of that same year.
ACCOUNT ADMINISTRATION
Electronic eligibility online within 24 hours
Performance Standard = 98%
Performance Penalty= 1 %
Percentage reported based on a measurement against all maintenance files* loaded within that quarter. VSP records both the received and loaded
dates for all membership files. The data is compiled into a monthly report, which is used to calculate the quarterly statistical average.
*All files measured for this standard must meet the following criteria:
• Identifiable Media: Eligibility file must be labeled properly.
• Proper Format: No change in format from the previously loaded eligibility file.
• Clean File:
1) Physical Media must be undamaged.
2) Electronic Media must have clean and complete data transmission. We must be able to successfully unzipidecrypt the incoming
data.
3) All media must contain proper /complete records for members and dependents.
Exclusions to this performance standard are as follows:
1) Membership files for open enrollment loaded prior to effective date.
2) Groupidivision restructures for existing groups (1 st eligibility load based on the restructure will be excluded from the
performance standard measurement).
3) Incorrect/Incomplete individual records for members and dependents.
4) If instructed to wait for group approval to load the file.
33
Online reports available by the 25th of the month
Performance Standard =100%
Performance Penalty =1%
All eligible online reports will be available on VSP's Resource Center by the 25th of each month.
Web portal availability
Performance Standard = 99%
Performance Penalty = 1 %
Based on a 7 x 24 schedule.
New group implementation
Performance Standard = Satisfaction guaranteed
We guarantee MONROE COUNTY BOARD OF COUNTY COMMISSIONERS's satisfaction with the implementation of its VSP benefit. In support of
this, we are placing a one -time penalty of $100,000 at risk. We will collaborate with MONROE COUNTY BOARD OF COUNTY COMMISSIONERS to
create a customized Implementation Action Plan that includes detailed roles, responsibilities and fimeframes to ensure a successful implementation.
Our comprehensive Implementation Action Plan includes the following sections:
Communications
System Accuracy
Plan Accuracy
Membership Management
Preferred Provider Access
Each of the above sections is assigned a maximum penalty amount of $100,000 to be paid in the event VSP was not able to meet MONROE
COUNTY BOARD OF COUNTY COMMISSIONERS's satisfaction in that category. If MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
does not fulfill its obligations as documented in the Implementation Action Plan, no penalty will apply to VSP.
34
VS Vision care for life
October 25, 2016
Mary Kay Lantz
Arthur Gallagher & Co.
Via email
RE; MONROE COUNTY BOARD OF COUNTY COMMISSIONERS– January 1,.2017 Vision Plan Renewal
Dear Mary Kay,
Mark Tafuri
Market D rector
I am providing renewal information for Monroe County Board of County Commissioners, effective January 1, 2017. 1,263 employees are currently
covered under VSP's Choice Plan B (exam & lenses every 12 months and frame every 24 months) with a $101$20 split copay. The current rates for this
coverage are $4.441$8.881$9.501$15,18.
VSP has reviewed the current plan and developed rates based on the experience of the program over the recent contract term. VSP considers many
factors when determining rates including, claim cost, utilization, claim frequency and trend.
Monroe County Board of County Commissioners has elected to add a High Option vision plan to its benefit offering effective 01101/17. Rates are
guaranteed for a term of 24 months, The Benefits and rates for both plans are included with this letter as Exhibit A & Exhibit C.
Please have the appropriate group representative sign the renewal below and fax or email a copy of this renewal to Fabian Whipple @ (404) 816 -1914
or Fabian.Whipple @vsp.com.
We appreciate your business and value our relationship with your organization.
Thank you,
Mark Tafuri
Itw
Au ho 'zed G up Represen tine Signature — MA" 6� i _j
4521 PGA Blvd., #161, Palm Beach Gardens, FL 33418 i. 561.410.0394 € F 404.816.1914 vsp.com
EXHIBIT A - VSP LOW AND HIGH OPTION RATES
VSP RATE
LOW OPTION PLAN
T� final alesW*j !on plan.
*NOTE: VSP did not increase the current Low Option Plan premiums.
VSP RATE
HIGH OPTION
+ce
Ga ERA
rene ;;
OUVERAGE.
RA' , "
* 4t5
to,
TYpE
AR NTEE
'RATE -
K4
EE
$4.44
$4.44
EE SPOUSE
$8.88
$8.88
No se
EE CHILDREN)
$9.50
$9.50
No a
EE +FAMILY
$15.18
$15.18
No h
T� final alesW*j !on plan.
*NOTE: VSP did not increase the current Low Option Plan premiums.
VSP RATE
HIGH OPTION
+ce
Ga ERA
test l yVl J �r
*NOTE: This is the first year offering a High Option Vision Plan. No rates to compare.
EXHIBIT A
RA' , "
* 4t5
to,
TYPE,
1 1
ImT�s
Rolt s
$9.27
EE SPOUSE
$18.52
A ,
1 EE
EE CHIL REN
$19.81,
EE+FAMILY
$31.67
test l yVl J �r
*NOTE: This is the first year offering a High Option Vision Plan. No rates to compare.
EXHIBIT A
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
FULLY INSURED VISION RFP
EXHIBIT C - BENEFIT OFFERING*
• True cost based on Monroe County mom,"
punduae.
t
i
e'
V5P
VSP
CATEGORY
Current
Ptan
Renewal
Low Option Zahn
Renewal
High Option Plan
f�rtl#fieleiw#rs�ftee
ular Exam with Dilation as Needed
Caread Lena exam (" end WN *ion)
1Q% Cif Raw
WA
15% off RBI lip
WA
10% off Kwo up to
WA
LIP to SW copayovei
to till snpayrMM
ii0 copaynaarM
MnterWlCopaay appe" on* *"7fi
bed
¢70
AhmencePrwAded
mcolsap
Fames tt any avertable provider k*W*n
Covered up to
$70
Covered in AW W
$7n
rbvered in fw up to
$70
1- ,
W nag arnaranc*
rep" aeowenae $160
$110Mowana
$14020%awcoset
2O%dly w off my
210% okcorant on
off any amount
areow" above r"
bataow over $110
above room
Wkwance
art& Vw"
COM ra Fur doer
$30
$20
$w
$m
$30
Bifocal
Covered In Fur after
$50
See
$30
$2fl
$50
rtfcco
Covered le Fsrr after
$0
$70
$66
$20
$6
LPIS oRflofa
uV coetwe
Addnhxel Cost
N/A
312.6>f•
N/A
$0
N/A
Sta nda , rd Scratch- reslsbnce
Additional Cost
N/A
590.99`
N/A
$17 Copy then [wend
N/A
in full
Sta ndafd
Indwodfor
N/A
50 fwddid(ron)
N/A
510Cooaythen
N/A
Dependant Ch"dnn
535A9 Aduh'
cowed in fur
Addalonal Cost Adults
AMLnflecthre ootting
Addaforel Cost
N/A
$7534'
N/A
$40 Copay then
N/A
in fun
Standard PrgmOve
$55
lip to $50
$LMAS.
Sw
$SS Copay then
$50
cworodi
Premkim Pro{rout a
S95 - $105
lip to $50
$124A5'
$30
$55 Copay then
$70
covered In full
Custom Prormstwo
$150 -$175
UPto $50
$124,45'
$50
$55Ceptythen
$50
fun
Phctocrornk Lee
AddPtkmml Cost
N/A
$79.69
NIA
$30 Copey then
N/A
covered In full
Otfw Addbris and servk"
Average 20% off Retan
N/A
20%off addbb l
N/A
20% off aciclb al pair
N/A
pelr of RX gturas
of FIX slassas or norm RX
and /or rwn
surclasw
Corm* ndDna4
$115 AlVowanw
$105
$115 allowance fn
$106
$L30 allowance in lieu
$=
In lieu of Lerues and
neu c( frame and
of frame and lens"
Fnm"
D40mble
$115 Arowanw
$1055
In neu of Lora" acrd
Framn
-weary
Pam In fun afl: r
$210 Mmaar" less
Paid b fu0 after
$110
Paid in fur after w"y
$210
Neraasary Cof"d lm as are a Plan Bona* when
Appllobla oWays
Copylawt
com
specific benefit crharla am sat6fWd and when
Prescribed by Covered Person's VSP Network
Doaor or Non -VSP Provider. Prior revkw and
approval by VSP an not required for Covered
Person to to e"rbk for Necessary Contact Lero t.
Fregrsency Llrttlla
Exam every 12 rnooft
Exam every 12 murths
Exam every 12 marths
Lenses every L2 nronUn
Lenm every 12 momhs
Lora" every 12 rnmondss
Frames every 24 maths
Frames every 24 nmOu
Frames every 12 momM
• True cost based on Monroe County mom,"
punduae.
t
i
e'
i
VSP.
V'Sion Care for Lrf
VISION SERVICE PLAN INSURANCE COMPANY
3333 QUALITY DRIVE
RANCHO CORDOVA, CALIFORNIA 95670
GROUP VISION CARE POLICY
Group Name MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
Policy Number 30029497
State of Delivery FLORIDA
Effective Date JANUARY 1, 2017
Policy Term TWENTY -FOUR (24) MONTHS
In consideration of the statements and agreements contained in the Group Application and in consideration of
payment by the Group of the premiums as herein provided, VISION SERVICE PLAN INSURANCE COMPANY ( "VSP ")
agrees to insure certain individuals under this Group Vision Care Policy ( "Policy ") for the benefits provided herein,
subject to the exceptions, limitations and exclusions hereinafter set forth. This Policy is delivered in and governed by the
laws of the state of delivery and is subject to the terms and conditions recited on the subsequent pages hereof, including
any Exhibits or state - specific Addenda, which are a part of this Policy..
Kate Renwick - Espinosa, President
VSP GVCP FL 1004. DDM 11/30118 Cnb
VISION SERVICE PLAN INSURANCE COMPANY
GROUP VISION CARE POLICY
TABLE OF CONTENTS
I .
DEFINITIONS ............................................................................... ...............................
1
II.
TERM, TERMINATION, AND RENEWAL .................................... ...............................
3
III.
OBLIGATIONS OF VSP ............................................................... ...............................
4
IV.
OBLIGATIONS OF THE GROUP ................................................. ...............................
7
V.
OBLIGATIONS OF COVERED PERSONS UNDER THE POLICY .............................
9
VI.
ELIGIBILITY FOR COVERAGE .................................................... ...............................
12
VII.
CONTINUATION OF COVERAGE ............................................... ...............................
14
VIII.
ARBITRATION OF DISPUTES ..................................................... ...............................
15
IX .
NOTICES ........................................................................................ .............................16
X .
MISCELLANEOUS ......................................................................... .............................17
EXHIBIT A
SCHEDULEOF BENEFITS ............................................ ...............................
19
SCHEDULE OF BENEFITS ............................................ ...............................
26
EXHIBIT B
SCHEDULEOF PREMIUMS .......................................... ...............................
34
SCHEDULE OF PREMIUMS .......................................... ...............................
35
EXHIBIT C
ADDITIONAL BENEFIT - DIABETIC EYECARE ............ ...............................
36
ADDENDUM
PERFORMANCE STANDARDS ................................. ...............................
40
VISION SERVICE PLAN INSURANCE COMPANY
GROUP VISION CARE POLICY
DEFINITIONS
The key terms in this Policy are defined:
1.01. ADDITIONAL BENEFIT RIDER The document, attached as Exhibit C to this Policy (if purchased by Group),
which lists selected vision care services and vision care materials which a Covered Person is entitled to receive under this
Policy. Additional Benefits are only available when purchased by Group in conjunction with a Plan Benefit offered under
Exhibit A.
1.02. ADMINISTRATIVE SERVICES PROGRAM A group vision care plan whereby Group pays VSP for the Plan
Benefits in addition to a monthly administrative fee.
1.03. BENEFIT AUTHORIZATION Authorization from VSP identifying the individual named as a Covered Person
of VSP, and identifying those Plan Benefits to which Covered Person is entitled.
1.04. CONFIDENTIAL MATTER All confidential information concerning the medical, personal, financial or
business affairs of Covered Persons acquired in the course of providing Plan Benefits hereunder.
1.05. COORDINATION OF BENEFITS Procedure which allows more than one insurance plan to consider Covered
Person's vision care claims for payment or reimbursement.
1.06. COPAYMENTS Those amounts required to be paid by or on behalf of a Covered Person for Plan Benefits
which are not fully covered, and which are payable at the time services are rendered or materials provided.
1.07. COVERED PERSON An Enrollee or Eligible Dependent who meets Group's eligibility criteria and on whose
behalf premiums have been paid to VSP, and who is covered under this Policy.
1.08. ELIGIBLE DEPENDENT Any dependent of an Enrollee of Group who meets the criteria for eligibility
established by Group
1.09. EMERGENCY CONDITION A condition, with sudden onset and acute symptoms, that requires the Covered
Person to obtain immediate medical care, or an unforeseen occurrence calling for immediate, non - medical action.
1.10. ENROLLEE An employee or member of Group who meets the criteria for eligibility specified under VI.
_LIGIBILITY FOR COVERAGE.
1.11. EXPERIMENTAL NATURE Procedure or lens that is not used universally or accepted by the vision care
profession, as determined by VSP.
1.12. EVIDENCE OF COVERAGE: A summary of the Policy provisions, prepared by VSP and provided to Group
Tor distribution to Enrollee.
1.13. GROUP An employer or other entity which contracts with VSP for coverage under this Policy in order to
provide vision care coverage to its Enrollees and their Eligible Dependents.
1.14. GROUP APPLICATION The form signed by an authorized representative of the Group to signify the
Group's intention to have its Enrollees and their Eligible Dependents become Covered Persons of VSP.
1.15. GROUP VISION CARE Policy also "The Polic " : The Policy issued by VSP to a Group, under which its
Enrollees or members, and their Eligible Dependents are entitled to become Covered Persons of VSP and receive Plan
Benefits in accordance with the terms of such Policy.
1.16. VSP NETWORK DOCTOR: An optometrist or ophthalmologist licensed and otherwise qualified to practice
vision care and/or provide vision care materials who has contracted with VSP to provide vision care services and/or vision
care materials on behalf of Covered Persons of VSP.
1.17. NON-VSP PROVIDER: Any optometrist, optician, ophthalmologist, or other licensed and qualified vision
, -- -ire provider who has not contracted with VSP to provide vision care services and /or vision care materials to Covered
Persons of VSP.
1.18. PLAN or PLAN BENEFITS The vision care services and vision care materials which a Covered Person is
entitled to receive by virtue of coverage under this Policy, as defined in the Schedule of Benefits (Exhibit A) and, if purchased
by Group, the Additional Benefit Rider (Exhibit C), attached hereto.
1.19. RENEWAL DATE The date when the Policy shall renew, or terminate if proper notice is given.
1.20. SCHEDULE OF BENEFITS: The document, attached as Exhibit A to this Policy, which lists the vision care
services and vision care materials which a Covered Person is entitled to receive under this Policy.
1.21. SCHEDULE OF PREMIUMS: The document, attached hereto as Exhibit B, which states the payments to be
made to VSP by or on behalf of a Covered Person to entitle him/her to Plan Benefits.
F
TERM. TERMINATION, AND RENEWAL
2.01. This Policy is effective on the Effective Date and shall remain in effect for the Policy Term. At the end of the
Policy Term, the Policy shall renew on a month to month basis unless either party notifies the other in writing, at least ninety
(90) days before the end of the Policy Term, that such party is unwilling to renew the Policy If such notice is given, the Policy
shall terminate at 11:59 p.m. in the state of delivery on the last day of the Policy Term unless the parties agree on its renewal
of the Policy. If the Policy continues on a month to month basis after the Policy Term, either party may terminate the Policy
upon thirty (30) days advance written notice to the other party.
If VSP issues written renewal materials to Group at least sixty (60) days before the end of the Policy Term and Group
fails to accept the new terms and/or rates in writing prior to the end of the Policy Term, this Policy shall terminate at 11:59 p.m.
on the last day of the Policy Term.
2.02. Early Termination Provision The premium rate payable by Group under this Policy is based on an
assumption that VSP will receive these amounts over the full Policy Term in order to cover costs associated with greater vision
utilization that tends to occur during the first portion of a Policy Term. If Group terminates this Policy before the end of the
Policy Term or before the end of any subsequent renewal terms, for any reason other than material breach by VSP, then
Group will remain liable to VSP for the lesser amount of any deficit incurred by VSP or the payments which Group would have
paid for the remaining term of this Policy, not to exceed one year. A deficit incurred by VSP will be calculated by subtracting
the cost of incurred and outstanding claims, as calculated on an incurred date basis with a claim tun -out not to exceed six
months from the date of termination, from the net premiums received by VSP from Group. Net premiums shall mean premiums
paid by Group minus any applicable retention amounts and /or broker commissions. Group agrees to pay VSP within
thirty-one (31) days of notification of the amount due. VSP shall return any unearned premiums to Group upon termination.
0
Ill.
OBLIGATIONS OF VSP
3.01. Coverage of Insureds VSP will enroll for coverage each eligible Enrollee and his/her Eligible Dependents,
if dependent coverage is provided, all of whom shall be referred to upon enrollment as "Covered Persons." To institute
coverage, VSP may require Group to complete, sign and forward to VSP a Group Application along with information regarding
Enrollees and Eligible Dependents, and all applicable premiums. (Refer to VI. ELIGIBILITY FOR COVERAGE for further
details.)
Following the enrollment of the Covered Persons, VSP will provide Group with Member Benefit Summaries and a
copy of the Evidence of Coverage, with Exhibits, for distribution to Covered Persons. Such Member Benefit Summaries and
Evidence of Coverage will summarize the terms and conditions set forth in this Policy.
3.02. Provision of Plan Benefits Through its VSP Network Doctors (or through other licensed vision care
providers where a Covered Person is eligible for, and chooses to receive Plan Benefits from a Non -VSP Provider), VSP shall
provide Covered Persons such Plan Benefits listed in the Schedule of Benefits (Exhibit A) or, when purchased by Group,
Additional Benefit Rider (Schedule C) attached hereto, subject to any limitations, exclusions, or Copayments therein stated.
Benefit Authorization must be obtained prior to a Covered Person obtaining Plan Benefits from a VSP Network Doctor. When
d Covered Person seeks Plan Benefits from a VSP Network Doctor, the Covered Person must schedule an appointment and
identify himself as a VSP Covered Person, so the VSP Network Doctor can obtain Benefit Authorization from VSP. VSP shall
provide Benefit Authorization to the VSP Network Doctor to authorize the provision of Plan Benefits to the Covered Person.
Each Benefit Authorization will contain an expiration date, stating a specific time period for the Covered Person to obtain Plan
Benefits.
VSP shall issue Benefit Authorizations in accordance with the latest eligibility information furnished by Group and the Covered
Person's past service utilization, if any. Any Benefit Authorization so issued by VSP shall constitute a certification to the VSP
Network Doctor that payment will be made, irrespective of a later loss of eligibility of the Covered Person, provided Plan
Benefits are received prior to the Benefit Authorization expiration date.
'n
VSP shall pay or deny claims for Plan Benefits provided to Covered Persons, less any applicable Copayment, but not more
,,.,,- an thirty (30) calendar days after VSP has received a completed claim, unless special circumstances require additional time.
if VSP requires additional information in order to pay or deny all or any portion of a claim, VSP will notify the person submitting
the claim within forty -five (45) days after the receipt of the claim. Upon receipt of the requested information, VSP will pay or
deny the claim within sixty (60) days. All claims shall be paid or denied by VSP within one hundred twenty (120) days after
receipt of claim.
WARNING, LIMITED BENEFITS WILL BE PAID WHEN NON -VSP PROVIDERS ARE USED.
When Covered Persons elect to utilize the services of a Non -VSP Provider for a covered service in non - emergency
situations, benefit payments for services from such Non -VSP Provider are not based upon the amount billed. The basis of the
benefit payment will be determined according to the Policy's Non -VSP Provider fee schedule. COVERED PERSONS CAN
EXPECT TO BE LIABLE FOR MORE THAN THE COPAYMENT AMOUNT DEFINED IN THE ATTACHED SCHEDULE OF
BENEFITS OR ADDITIONAL BENEFITS RIDER (when purchased by Group) AFTER THE PLAN HAS PAID ITS REQUIRED
PORTION.
When payment is made to the Non -VSP Provider, the provider may bill Covered Persons for any amount up to the
'*illed charges after the Plan has paid its portion of the bill. VSP Network Doctors have agreed to accept discounted payments
for services with no additional billing to the Covered Person other than Copayments, co- insurance and any amounts for
non - covered services and/or materials. Covered Persons may obtain further information about the participating status of
providers and information on out -of- pocket expenses through www.vsp.com, or by calling VSP's Customer Service
Department at 1- 800 - 877 -7195.
3.03. Provision of Information to Covered Persons Upon request, VSP shall make available to Covered
Persons necessary information describing Plan Benefits and how to use them. A copy of this Policy shall be placed with Group
and also will be made available at the offices of VSP for any Covered Persons. VSP shall provide Group with an updated list of
VSP Network Doctors' names, addresses, and telephone numbers for distribution to Covered Persons twice a year. Covered
Persons may also obtain a copy of the VSP Network Doctor directory through VSP's website at www.vsp.com, VSP's
Customer Service Department's toll -free telephone line, or by written request.
9
3.04. Preservation of Confidentiality VSP shall hold in strict confidence all Confidential Matters and exercise its
,,, , st efforts to prevent any of its employees, VSP Network Doctors, or agents, from disclosing any Confidential Matter, except
to the extent that such disclosure is necessary to enable any of the above to perform their obligations under this Policy, or to
comply with applicable law. Covered Persons and/or Groups that want more information on VSP's Confidentiality Policy may
obtain a copy of the policy from VSP's website at www.vsp.com or by contacting VSP's Customer Service Department.
3.05. Emergency Vision Care When vision care is necessary for Emergency Conditions, Covered Persons may
obtain Plan Benefits by contacting a VSP Network Doctor or Non -VSP Provider. No prior approval from VSP is required for
Covered Person to obtain vision care for Emergency Conditions of a medical nature. However, services for medical
conditions, including emergencies, are covered by VSP only under the Acute EyeCare and Supplemental Primary EyeCare
Plans. If Group has not purchased one of these plans, Covered Persons are not covered by VSP for medical services and
should contact a physician under Covered Persons' medical insurance plan for care. For emergency conditions of a
non - medical nature, such as lost, broken or stolen glasses, the Covered Person should contact VSP's Customer Service
Department for assistance. Reimbursement and eligibility are subject to the terms of this Policy.
3.06 Coordination of Benefits When VSP is primary, it will pay benefits according to the terms of the
'olicy, subject to any applicable state or federal codes, statutes or regulations. When VSP is secondary, it will coordinate
those vision care services and materials that were considered by the primary plan ( "Allowable Expenses "). VSP will pay the
lesser of:
a) The normal Plan Benefit, in the absence of other coverage, or
b) The remaining balance up to Covered Person's Plan Benefits, not to exceed the billed amount.
N
IV.
OBLIGATIONS OF THE GROUP
4.01. Identification of Eligible Enrollees An Enrollee is eligible for coverage under this Policy if he/she satisfies
the enrollment criteria specified in Paragraph 6.01(a) and as established by Group. By the Effective Date of this Policy, Group
shall provide VSP with eligibility information, in a mutually agreed upon format and medium, to identify all Enrollees who are
eligible for coverage under this Policy as of that date. Thereafter, Group shall supply to VSP by the 15th day of each month,
eligibility information sufficient to identify all Enrollees to be added to or deleted from VSP's coverage rosters. All additions and
deletions shall become effective on the first day of the month specified by Group. The eligibility information shall include
designation of each Enrollee's family status if dependent coverage is provided. Upon VSP's request, Group shall make
available for inspection records regarding the coverage of Covered Persons under this Policy.
4.02. Payment of Premiums By the first day of each month, Group shall remit to VSP the premiums payable for
the next month on behalf of each Enrollee and Eligible Dependents, if any, to be covered under this Policy. The Schedule of
Premiums incorporated in this Policy as Exhibit B provides the premium amount for each Covered Person. Only Covered
Persons for whom premiums are actually received by VSP shall be entitled to Plan Benefits under this Policy and only for the
period for which such payment is received, subject to the grace period provision below.
VSP may change the premiums set forth in Exhibit B (Schedule of Premiums) by giving Group at least hundred twenty
(120) days advance written notice. No change will be made during the Policy Term unless there is a change in the Schedule of
Benefits and /or Additional Benefits Rider (if purchased by Group), or there is a material change in Policy terms or conditions,
provided any such change is mutually agreed upon in writing by VSP and Group.
Notwithstanding the above, VSP may increase premiums during a Policy Term by the amount of any tax or assessment not
now in effect but subsequently levied by any taxing authority, which is attributable to premiums VSP received from Group.
4.03. Grace Period Group shall be allowed a grace period of thirty-one (31) days following the premium payment
due date to pay premiums due under this Policy. During said grace period, this Policy shall remain in full force and effect for all
Covered Persons of Group. VSP will consider late payments at the time of Policy renewal. Such payment may impact Group's
premium rates in future Policy Terms.
0
If Group fails to make any premiums payment due by the end of any grace period, VSP may notify Group that the
,,,,,_ -premiums payment has not been made, that coverage is canceled and that Group is responsible for payment for all Plan
Benefits provided to Covered Persons after the last period for which premiums were paid in full, including the grace period
through the effective date of termination. Group shall also be responsible for any legal and/or collection fees incurred by VSP
to collect amounts due under this Policy.
4.04. Distribution of Required Documents: Group shall distribute to Enrollees any disclosure forms, Policy
summaries or other material required to be given to Policy subscribers by any regulatory authority. Such materials shall be
distributed by Group no later than thirty (30) days after the receipt thereof, or as required under applicable law.
4.05. Converting to an Administrative Services Pro ram: Due to the cyclical nature of vision care, in the event
Group wishes to convert its method of funding from a risk program to an Administrative Services Program, an appropriate level
of reserve will need to have been established.
Upon conversion to an Administrative Services Program, for vision care begun on and after the effective date of
conversion, all claims will be paid through the Administrative Services Program.
A
V.
OBLIGATIONS OF COVERED PERSONS UNDER THE POLICY
5.01. General By this Policy, Group makes coverage available to its Enrollees and their Eligible Dependents, if
dependent coverage is provided. However, this Policy may be amended or terminated by agreement between VSP and Group
as indicated herein, without the consent or concurrence of Covered Persons. This Policy, and all Exhibits, Riders and
attachments hereto, constitute VSP's sole and entire undertaking to Covered Persons under this Policy.
As conditions of coverage, all Covered Persons under this Policy have the following obligations:
5.02. Copayments for Services Received Where, as indicated in Exhibit A (Schedule of Benefits) and Exhibit C
(Additional Benefit Rider) when purchased by Group, Copayments are required for certain Plan Benefits. Copayments shall be
the personal responsibility of the Covered Person receiving the care and must be paid at the time services are rendered.
Amounts that exceed Plan allowances, annual maximum benefits, options reimbursements, or any other stated Plan
limitations are not considered Copayments but are also the responsibility of the Covered Person.
5.03. Obtaining Services from VSP Network Doctors: Benefit Authorization must be obtained prior to receiving
Plan Benefits from a VSP Network Doctor. When a Covered Person seeks Plan Benefits, the Covered Person must select a
VSP Network Doctor, schedule an appointment, and identify himself as a Covered Person so the VSP Network Doctor can
jbtain Benefit Authorization from VSP. Should the Covered Person receive Plan Benefits from a VSP Network Doctor without
such Benefit Authorization, then for the purposes of those Plan Benefits provided to the Covered Person, the VSP Network
Doctor will be considered a Non -VSP Provider, and the benefits available will be limited to those for a Non -VSP Provider, if
any.
5.04. Submission of Non-VSP Provider Claims If Non -VSP Provider coverage is indicated in Exhibit A
(Schedule of Benefits) or Exhibit C (Additional Benefit Rider), when purchased by Group, written proof (receipt and the
Covered Person's identification information) of all claims for services received from Nan -VSP Providers shall be submitted by
Covered Persons to VSP within three hundred sixty-five (365) days of the date of service. VSP may reject such claims filed
more than three hundred sixty -five (365) days after the date of service.
Failure to submit a claim within this time period, however, shall not invalidate or reduce the claim if it was not
reasonably possible to submit the claim within such time period, provided the claim was submitted as soon as reasonably
possible and in no event, except in absence of legal capacity, later than one year from the required date of three hundred
.: (365) days after the date of service.
5.05. Complaints and Grievances Covered Persons shall report any complaints and/or grievances to VSP at the
address given herein. Complaints and grievances are disagreements regarding access to care, quality of care,
�7
treatment or service. Complaints and grievances may be submitted to VSP verbally or in writing. A Covered Person may
,submit written comments or supporting documentation concerning his/her complaint or grievance to assist in VSP's review.
VSP will resolve the complaint or grievance within thirty (30) days after receipt, unless special circumstances require an
extension of time. In that case, resolution shall be achieved as soon as possible, but not later than one hundred twenty (120)
days after VSP's receipt of the complaint or grievance. If VSP determines that resolution cannot be achieved within thirty (30)
days, VSP will notify the Covered Person of the expected resolution date. Upon final resolution, VSP will notify the Covered
Person of the outcome in writing.
5.06. Claim Denial Appeals If, under the terms of this Policy, a claim is denied in whole or in part, a request may
be submitted to VSP by Covered Person, or Covered Person's authorized representative, for a full review of the denial.
Covered Person may designate any person, including their provider, as their authorized representative. References in this
section to "Covered Person' include Covered Person's authorized representative, where applicable.
a) Initial Appeal: The request must be made within one hundred eighty (180) days following denial of a
claim and should contain sufficient information to identify the Covered Person for whom the claim was denied, including the
VSP Enrollee's name, the VSP Enrollee's Member Identification Number, the Covered Person's name and date of birth, the
-- rovider of services and the claim number. The Covered Person may review, during normal working hours, any documents
held by VSP pertinent to the denial. The Covered Person may also submit written comments or supporting documentation
concerning the claim to assist in VSP's review. VSP's response to the initial appeal, including specific reasons for the
decision, shall be provided and communicated to the Covered Person as follows:
Denied Claims for Services Rendered: within thirty (30) calendar days after receipt of a request for an appeal
from the Covered Person.
b) Second Level Appeal: If the Covered Person disagrees with the response to the initial appeal of the
claim, the Covered Person has the right to a second level appeal. Within sixty (60) calendar days after receipt of VSP's
response to the initial appeal, the Covered Person may submit a second appeal to VSP along with any pertinent
documentation. VSP shall communicate its final determination to the Covered Person in compliance with all applicable state
and federal laws and regulations and shall include the specific reasons for the determination.
c) Other Remedies: When Covered Person has completed the appeals stated herein, additional voluntary
alternative dispute resolution options may be available, including mediation or arbitration. Group should advise Covered
person to contact the U.S. Department of Labor or the state insurance regulatory agency for details. Additionally, under the
provisions of ERISA (Section 502(a)(1)(13)) [29 U.S.C. 1132(a)(1)(13)], Covered Person has the right to bring a civil
10
action when afi available levels of review of denied claims, including the appeals process, have been completed, the claims
were not approved in whole or in part, and Covered Person disagrees with the outcome.
5.07. Time of Action No action in law or in equity shall be brought to recover on the Policy prior to the expiration
of sixty (60) days after the claim and any applicable invoices have been filed with VSP. No such action shall be brought after
the expiration of any applicable statute of limitations from the time such claim and invoices are required to be given, in
accordance with the terms of this Policy.
5.08. Insurance Fraud Any Group and/or person who intends to defraud, knowingly facilitates a fraud, or submits
an application, or files a claim with a false or deceptive statement, is guilty of insurance fraud. Such an act is grounds for
immediate termination of the Policy for the Group or individual that committed the fraud. In the absence of fraud, all statements
made by Group or Enrollees shall be deemed representations and not warranties and no statement made for the purpose of
effecting insurance shall avoid such insurance or reduce benefits unless contained in a written instrument signed by Group or
Enrollee, a copy of which has been furnished to Group or Enrollee or Enrollee's beneficiary.
11
VI.
ELIGIBILITY FOR COVERAGE
6.01. Eli ibili Criteria: Individuals will be accepted for coverage hereunder only upon meeting all requirements
set forth below.
a) Enrollees To be eligible, a person must:
1. currently be an employee or member of Group, and
2. meet the coverage criteria mutually agreed upon by Group and VSP.
b.) Eligible Dependents If dependent coverage is provided, the persons eligible for dependent coverage
are specified on the attached Schedule of Benefits and Additional Benefit Riders (if applicable).
If a dependent child prior to attainment of the prescribed age for termination of eligibility becomes, and continues to be,
incapable of self-sustaining employment because of mental or physical disability, that Eligible Dependent's coverage shall not
terminate so long as he remains chiefly dependent on the Enrollee for support and the Enrollee's coverage remains in force;
PROVIDED that satisfactory proof of the dependent's incapacity can be furnished to VSP within thirty -one (31) days of the
date the Eligible Dependent's coverage would have otherwise terminated and at such other times as VSP may request proof,
but not more frequently than annually.
6.02. Documentation of Eligibil : Persons satisfying the coverage requirements under either of the above
criteria shall be eligible if:
a) for an Enrollee, the individual's name and Member ID Number have been reported by Group to VSP
in the manner provided hereunder; and
b) for changes to an Eligible Dependent's status, the change has been reported by the Group to VSP in
the manner provided herein. As stated in paragraph 4.01 above, VSP may elect to audit Group's records to verify eligibility of
Enrollees and dependents and any errors. Subject to the terms of paragraph 4.03 above, only persons on whose behalf
premiums have been paid for the current period shall be entitled to Plan Benefits hereunder. If a clerical error is made, it will
not affect the coverage a Covered Person is entitled to under this Policy.
ib
6.03. Retroactive Eligibift Changes Retroactive eligibility changes are limited to sixty (60) days prior to the
", notice of any such requested change is received by VSP. VSP may refuse retroactive termination of a Covered Person
if Plan Benefits have been obtained by, or authorized for, the Covered Person after the effective date of the requested
termination. As stated in Section 4.01 herein, Group agrees to provide timely eligibility changes to VSP.
6.04. Change of Participation Requirements, Contribution of Fees, and Eligibility Rules Composition of the
Group, percentage of Enrollees covered under the Policy, and Group's contribution and eligibility requirements, are all
material to VSP's obligations under this Policy. During the term of this Policy, Group must provide VSP with written notice of
changes to its composition, percentage of Enrollees covered, contribution and eligibility requirements. Any change which
materially affects VSP's obligations under this Policy must be agreed upon in writing between VSP and Group and may
constitute a material change to the terms and conditions of this Policy for purposes of paragraph 4.02. Nothing in this section
shall limit Group's ability to add Enrollees or Eligible Dependents under the terms of this Policy.
6.05. Change in Family or Employment Status In the event Group is notified of any change in a Covered
Person's family status [by marriage, the addition (e.g., newborn or adopted child) or deletion of Dependent , etc.] or
employment status, Group shall provide notice of such change to VSP via the next eligibility listing required under Paragraph
A1. If notice is given, the change in the Covered Person's status will be effective on the first day of the month following the
change request, or at such later date as may be requested by or on behalf of the Covered Person. Notwithstanding any other
provision in this section, a newbom child will be covered for a period of at least sixty (60) days after birth, and an adopted child
will be covered for a period of at least sixty (60) days after the date the Enrollee or the Enrollee's spouse acquires the right to
control that child's health care. If Enrollee provides notice to the Group within said sixty (60) day period, VSP shall not deny
coverage for said newborn or adopted child. Coverage for an adopted newborn will begin from the moment of birth if an
agreement to adopt is entered into by Enrollee or Enrollee's spouse, and the child is ultimately placed in the Enrollee's home.
To continue coverage for a newborn or adopted child beyond the initial sixty (60) day period, the Group must be properly
notified of the Enrollee's change in family status and applicable premiums must be paid to VSP.
13
VII.
CONTINUATION OF COVERAGE
7.01. COBRA The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that, under
certain circumstances, health plan benefits available to an Enrollee and his or her Eligible Dependents be made available to
said persons upon the occurrence of a COBRA - qualifying event. If, and only to the extent, COBRA applies to the parties to
this Policy, VSP shall make the required COBRA continuation coverage available for purchase in accordance with COBRA.
14
VIII.
ARBITRATION OF DISPUTES
8.01. Dispute Resolution Any dispute or question arising between VSP and Group involving the application,
interpretation, or performance under this Policy shall be settled, if possible, by amicable and informal negotiations, allowing
such opportunity as may be appropriate under the circumstances for fact - finding and mediation. If any issue cannot be
resolved in this fashion, it shall be submitted to arbitration where permitted by state law.
8.02. Procedure Arbitration hereunder shall be conducted pursuant to the Rules of the American Arbitration
Association subject to the provisions of Section 10.06 of this Policy. Such Rules, the enforcement thereof, and enforcement of
the arbitrator's decision shall be governed by applicable laws.
8.03. Choice of Law If any matter arises in connection with this Policy which becomes the subject of arbitration or
legal process, the law of the State of delivery of the Policy shall be the applicable law.
i
KII
NOTICES
9.91. Notice Any notices required under this Policy to either Group or VSP shall be in written format. Notices sent
to the Group will be sent to the address or email address shown on the Group's Application unless otherwise directed by
Group. Notices to VSP shall be sent to the address shown on the front page of this Policy. Notwithstanding the above, any
notices may be hand - delivered by either party to an appropriate representative of the other party. The party effecting
hand - delivery bears the burden to prove delivery was made, if questioned.
IN.
X.
MISCELLANEOUS
10.01. Entire Po
_ This Policy, the Group Application, the Evidence of Coverage, and all Exhibits, Riders and
attachments hereto, constitute the entire agreement of the parties and supersedes any prior understandings and agreements
between them, either written or oral. Any change or amendment to the Policy must be approved by an officer of VSP and
attached hereto to be valid. No agent has the authority to change this Policy or waive any of its provisions. Communication
materials prepared by Group for distribution to Enrollees do not constitute a part of this Policy.
10.02. lndemni : VSP agrees to indemnify, defend and hold harmless Group, its shareholders, directors, officers,
agents, employees, successors and assigns from and against any and all liability, claim, loss, injury, cause of action and
expense (including defense costs and legal fees) of any nature whatsoever arising from the failure of VSP, its officers, agents
or employees, to perform any of the activities, duties or responsibilities specified herein. Group agrees to indemnify, defend
and hold harmless VSP, its members, shareholders, directors, officers, agents, employees, successors and assigns from and
against any and all liability, claim, loss, injury, cause of action and expense (including defense costs and legal fees) of any
nature whatsoever arising or resulting from the failure of Group, its officers, agents or employees to perform any of the duties
"r responsibilities specified herein.
10.03. Liability; VSP arranges for the provision of vision care services and materials through agreements with VSP
Network Doctors. VSP Network Doctors are independent contractors and are responsible for exercising independent
judgement. VSP does not itself directly fumish vision care services or supply materials. Under no circumstances shall VSP or
Group be liable for the negligence, wrongful acts or omissions of any doctor, laboratory, or any other person or organization
performing services or supplying materials in connection with this Policy.
10.04. Assignment Neither this Policy nor any of the rights or obligations of either of the parties hereto may be
assigned or transferred without the prior written consent of both parties hereto except as expressly authorized herein.
10.05. Severabili : Should any provision of this Policy be declared invalid, the remaining provisions shall remain in
full force and effect.
M
10.06. Governing Law This Policy shall be governed by and construed in accordance with applicable federal and
,,,, $ate law. Any provision that is in conflict with, or not in conformance with, applicable federal or state statutes or regulations is
hereby amended to conform with the requirements of such statutes or regulation, now or hereafter existing.
10.07. Gender All pronouns used herein are deemed to refer to the masculine, feminine, neuter, singular, or plural,
as the identity(ies) of the person(s) may require.
10.08. Equal Opportunity VSP is an Equal Opportunity and Affirmative Action employer.
10.09. Communication Materials Communication materials created by Group which relate to this vision care
Policy must adhere to VSP's Member Communication Guidelines distributed to Group by VSP. Such communication materials
may be sent to VSP for review and approval prior to use. VSP's review of such materials shall be limited to approving the
accuracy of Plan Benefits and shall not encompass or constitute certification that Group's materials meet any applicable legal
or regulatory requirements, including but not limited to, ERISA requirements. In the event of any dispute between the
communication materials and this Policy, the provisions of this Policy shall prevail.
EXHIBIT A
SCHEDULE OF BENEFITS
VSP Choice Plan
Low Plan
GENERAL
This Schedule lists the vision care benefits to which Covered Persons of VISION SERVICE PLAN INSURANCE COMPANY( "VSP ") are entitled,
subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein. If Plan Benefits are available for Non -VSP
Provider services, as indicated by the reimbursement provisions below, vision care benefits may be received from any licensed eye care provider
whether VSP Network Doctors or Non -VSP Providers. This Schedule forms a part of the Policy or Evidence of Coverage to which it is attached.
VSP Network Doctors are those doctors who have agreed to participate in VSP's Choice Network.
When Plan Benefits are received from VSP Network Doctors, benefits appearing in the VSP Network Doctor Benefit column below are applicable
subject to any applicable Copayments and other conditions, limitations and/or exclusions as stated below. When Plan Benefits are available and
received from Non -VSP Providers, the Covered Person is reimbursed for such benefits according to the schedule in the Non -VSP Provider Benefit
column below, less any applicable Copayment. The Covered Person pays the provider the full fee at the time of service and submits an itemized bill to
VSP for reimbursement. Discounts do not apply for vision care benefits obtained from Non -VSP Providers.
BENEFIT PERIOD
A twelve -month period beginning on January 1st and ending on December 31st.
LIGIBILITY
The following are Covered Persons under this Policy:
• Enrollee.
• The legal spouse of Enrollee.
• Any child of Enrollee, including any natural child from the date of birth, legally adopted child from the date of placement for adoption with the
Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible.
• The domestic partner of the same or opposite gender as Enrollee, pursuant to Group's eligibility rules.
Dependent children are covered up to the end of the year in which they turn age 26.
A dependent, unmarried child over the limiting age may continue to be eligible as a dependent if the child is incapable of self- sustaining employment
because of mental or physical disability, and chiefly dependent upon Enrollee for support and maintenance.
See schedule below for Plan Benefits, payments and/or reimbursement subject to any Copayment(s) as stated:
COMMENT
The benefits herein are available to each Covered Person subject only to payment of the applicable Copayment by the Covered Person. Plan Benefits
received from VSP Network Doctors and Non -VSP Providers require Copayments. Covered Persons must also follow Benefit Authorization
Procedures.
There shall be a Copayment of $10.00 for the examination payable by the Covered Person at the time services are rendered. If materials (lenses,
frames or Necessary Contact Lenses) are provided, there shall be an additional $20.00 Copayment payable at the time the materials are ordered. The
opayment shall not apply to Elective Contact Lenses.
W
PLAN BENEFIT S
SERVICE OR MATERIAL I VSP NETWORK DOCTOR I NON -VSP PROVIDER BENEFIT
BENEFIT
Eye Examination I Covered in full* I Up to $ 45.00' C Available once each 12 months'"
indicated.
Initial vision analysis: includes appropriate examination of visual functions and prescription of corrective eyewear where
*Less any applicable Copayment.
** Beginninq with the first day of the Benefit Period.
SERVICE OR MATERIAL
SERVICE OR MATERIAL
VSP NETWORK DO!
BENEFIT
NON -VSP PROVIDER BENEFIT
FREQUENCY
BENEFIT
Lenses
Available once each 12 months"
Covered up to Plan Allowance*
Single Vision
Covered in full "
Up to $ 30.00*
-
1. Prescribing and ordering proper lenses;
Bifocal
Covered in full
Up to $ 50.00"
5. Subsequent adjustments to frames to maintain comfort and efficiency;
6. Progress or follow -up work as necessary.
Trifocal
Covered in full *
Up to $ 65.00*
Lenticular
Covered in full *
Up to $100.00*
Plan Benefits for lenses are per complete set, net per lens.
'Less any applicable Copayment.
**Beginning with the first day of the Benefit Period.
SERVICE OR MATERIAL
VSP NETWORK DOCTOR
NON -VSP PROVIDER BENEFIT
FREQUENCY
BENEFIT
FRAMES
Covered up to Plan Allowance*
Up to $ 70.00*
Available once each 24 months**
Benefits for lenses and frames include
reimbursement for the following necessary professional services:
1. Prescribing and ordering proper lenses;
2. Assisting in frame selection;
3. Verifying accuracy of finished lenses;
4. Proper fitting and adjustments of frames;
5. Subsequent adjustments to frames to maintain comfort and efficiency;
6. Progress or follow -up work as necessary.
*Less any applicable Copayment.
**Beginning with the first day of the Benefit Period.
01
SERVICE OR MATERIAL
VSP NETWORK DOCTOR
NON -VSP PROVIDER IFREQUENCY
BENEFIT
BENEFIT
'ONTACT LENSES
Elective
Elective Contact Lens fitting
Available once each 12
and evaluation"* services
months**
are covered in full once
every 12 months**, after a
maximum $60.00
Co t.
Materials
Professional FeeslMaterials
Up to $ 115.00
Up to $ 105.00
**Beginning with the first day of the Benefit Period.
***15% Discount applies to VSP Network Doctor's usual and customary professional fees for contact lens evaluation and
fitting.
Contact Lenses are provided in lieu of all other lens and frame benefits available herein.
Utilization of contact lens benefits exhausts all of the Covered Person's lens and frame benefits for the current
Benefit Period, and future eligibility for lenses and frames will be determined as if spectacle lenses only were
obtained in the current Benefit Period.
SERVICE OR
BENEFIT
PROVIDER
NECESSARY CONTACT
LENSES
Professional Fees and I) Covered in
Materials
*Less any applicable Copayment
"*Beginning with the first day of the Benefit Period.
Available once each 12 months*"
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's VSP Network
or Non -VSP Provider. Prior review and approval by VSP are not required for Covered Pers to be eligible for Necessary Contact Lenses.
Necessary Contact Lenses are provided in lieu of all other lens and frame benefits available herein.
Utilization of contact lens benefits exhausts all of the Covered Person's lens and frame benefits for the current Benefit Period, and future
eligibility for lenses and frames will be determined as if spectacle lenses only were obtained in the current Benef it Period.
a
SERVICE OR MATERIAL VSP NETWORK DOCTOR NON -VSP PROVIDER BENEFIT FREQUENCY
BENEFIT
Low Vision
i
Professional services for severe visual problems not correctable with regular lenses, including:
Supplemental Testing Covered in full Up to $125.00'
(includes evaluation, diagnosis and prescription of vision aids where indicated.)
Supplemental Aids 75% of amount 75% of amount
uo to $1000.00; uo to $1000.00'
*Maximum benefit for all Low Vision services and materials is $1000.00 every two (2) Benefit Periods.
Low Vision benefits secured from Non -VSP Providers (if covered) are subject to the same time and Copayment provisions described above for VSP
Network Doctors. The Covered Person should pay the Non -VSP Providers full fee at the time of service. Covered Person will be reimbursed an
amount not to exceed what VSP would pay a VSP Network Doctor for the same services andlor materials.
THERE IS NO ASSURANCE THAT THE AMOUNT REIMBURSED WILL COVER 75% OF THE PROVIDER'S FULL FEE.
PM
EXCEPTIONS
Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional limitations. Covered Persons may
obtain details regarding frame brand availability from their VSP Network Doctor or by calling VSP's Customer Care Division at (800) 877 -7195.
ATIENT OPTIONS
This Plan is designed to cover visual needs rather than cosmetic materials. When a Covered Person selects any of the following extras, the Plan will
pay the basic cost of the allowed lenses or frames, and the Covered Person will pay the additional costs for the options.
• Optional cosmetic processes.
• Anti- reflective coating.
• Color coating.
• Mirror coating.
• Scratch coating.
• Blended lenses.
• Cosmetic lenses.
• Laminated lenses.
• Oversize lenses.
• Polycarbonate lenses.
• Photochromic lenses, tinted lenses except Pink #1 and Pink #2.
• Progressive multifocal lenses.
• UV (ultraviolet) protected lenses.
• Certain limitations on low vision care.
NOT COVERED
There are no benefits for professional services or materials connected with:
• Orthoptics or vision training and any associated supplemental testing.
• Corneal Refractive Therapy (CRT)
Orthokeratology (a procedure using contact lenses to change the shape of the cornea in order to reduce myopia).
Refitting of contact lenses after the initial (90 -day) fitting period.
• Plano lenses (lenses with refractive correction of less than t .50 diopter).
• Two pair of glasses in lieu of bifocals.
• Replacement of lenses and frames furnished under this Policy that are lost or broken, except at the normal intervals when services are otherwise
available.
• Medical or surgical treatment of the eyes.
• Corrective vision treatment of an Experimental Nature.
• Plano contact lenses to change eye color cosmetically.
• Artistically- painted contact lenses.
• Contact lens insurance policies or service contracts.
• Additional office visits associated with contact lens pathology.
• Contact lens modification, polishing, or cleaning.
• Costs for services and/or materials exceeding Plan Benefit allowances.
• Services or materials of a cosmetic nature.
• Services and/or materials not indicated on this Schedule as covered Plan Benefits.
W
PLAN BENEFITS
AFFILIATE PROVIDERS
GENERAL
,4iate Providers are providers of Covered Services and Materials who are not contracted as VSP Network Doctors but who have agreed to bill VSP
directly for Plan Benefits provided pursuant to this Schedule. However, some Affiliate Providers may be unable to provide all Plan Benefits included in
this Schedule. Covered Persons should discuss requested services with their provider or contact VSP Customer Care for details.
COPAYMENT
There shall be a Copayment of $10.00 for the examination payable by the Covered Person at the time services are rendered. If materials (lenses,
frames or Necessary Contact Lenses) are provided, there shall be an additional $20.00 Copayment payable at the time the materials are ordered. The
Copayment shall not apply to Elective Contact Lenses.
COVERED SERVICES AND MATERIALS
Eye Examination Covered in full * Available once each 12 months**
Comprehensive examination of visual functions and prescription of corrective eyewear.
Spectacle Lenses
Single Vision, Lined BifocalCovered in Full*
or Lined Trifocal,
Frames
Covered up to the Plan allowance*
CONTACT LENSES
Elective Contact Lenses
(Materials Only)
Up to $115.00
Available once each 12 months**
Available once each 24 months**
Available once each 12 months"
The Elective Contact Lens fitting and evaluation services are covered in full once every 12 months, after a maximum $60.00 Copayment.
Necessary Contact Lenses Up to $210.00* Available once each 12 months**
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor.
Contact Lenses are provided in place of spectacle lens and frame benefits available herein.
*Less any applicable Copayment.
"Beginning with the first day of the Benefit Period.
When contact lenses are obtained, the Covered Person shall not be eligible for lenses and frames again for one plan year.
Low VISION
Professional services for severe visual problems not correctable with regular lenses, including:
upplemental Testing: Up to $125.00#
- Includes evaluation, diagnosis and prescription of vision aids where indicated.
Supplemental Aids: 75% of Affiliate Provider's fee up to $1000.00t
tMaximum benefit for all Low Vision services and materials is $1000.00 every two (2) years and a
maximum of two supplemental tests within a two -year period
Low Vision Services are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor.
EXCLUSIONS AND LIMITATIONS OF BENEFITS
1. Exclusions and limitations of benefits described above for VSP Network Doctors shall also apply to services rendered by Affiliate Providers.
2. Services from an Affiliate Provider are in lieu of services from a VSP Network Doctor or a Non -VSP Provider.
3. VSP is unable to require Affiliate Providers to adhere to VSP's quality standards.
4. Where Affiliate Providers are located in membership retail environments, Covered Persons may be required to purchase a membership in such
entities as a condition of obtaining Plan Benefits_
PR
EXHIBIT A
SCHEDULE OF BENEFITS
VSP Choice Plan
High Plan
GENERAL
This Schedule lists the vision care benefits to which Covered Persons of VISION SERVICE PLAN INSURANCE COMPANY('VSP') are entitled,
subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein. If Plan Benefits are available for Non -VSP
Provider services, as indicated by the reimbursement provisions below, vision care benefits may be received from any licensed eye care provider
whether VSP Network Doctors or Non -VSP Providers. This Schedule forms a part of the Policy or Evidence of Coverage to which it is attached.
VSP Network Doctors are those doctors who have agreed to participate in VSP's Choice Network.
When Plan Benefits are received from VSP Network Doctors, benefits appearing in the VSP Network Doctor Benefit column below are applicable
subject to any applicable Copayments and other conditions, limitations and/or exclusions as stated below. When Plan Benefits are available and
received from Non -VSP Providers, the Covered Person is reimbursed for such benefits according to the schedule in the Non -VSP Provider Benefit
column below, less any applicable Copayment. The Covered Person pays the provider the full fee at the time of service and submits an itemized bill to
VSP for reimbursement. Discounts do not apply for vision care benefits obtained from Non -VSP Providers.
BENEFIT PERIOD
A twelve -month period beginning on January t st and ending on December 31 st.
LIGIBILITY
The following are Covered Persons under this Policy:
• Enrollee.
• The legal spouse of Enrollee.
• Any child of Enrollee, including any natural child from the date of birth, legally adopted child from the date of placement for adoption with the
Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible.
• The domestic partner of the same or opposite gender as Enrollee, pursuant to Group's eligibility rules.
Dependent children are covered up to the end of the year in which they turn age 26.
A dependent, unmarried child over the limiting age may continue to be eligible as a dependent if the child is incapable of self - sustaining employment
because of mental or physical disability, and chiefly dependent upon Enrollee for support and maintenance.
See schedule below for Plan Benefits, payments and/or reimbursement subject to any Copayment(s) as stated:
COMMENT
The benefits herein are available to each Covered Person subject only to payment of the applicable Copayment by the Covered Person. Plan Benefits
received from VSP Network Doctors and Non -VSP Providers require Copayments. Covered Persons must also follow Benefit Authorization
Procedures.
There shall be a Copayment of $10.00 for the examination payable by the Covered Person at the time services are rendered. if materials (lenses,
frames or Necessary Contact Lenses) are provided, there shall be an additional $20.00 Copayment payable at the time the materials are ordered. The
:opayment shall not apply to Elective Contact Lenses.
M
PLAN BENEFITS
SERVICE OR MATERIAL VSP NETWORK DOCTOR NON -VSP PROVIDER BENEFIT FREQUENCY
BENEFIT
Eye Examination Covered in full* Up to $ 45.00* Available once each 12 months**
Complete Initial vision analysis: Includes appropriate examination of visual functions and prescription of corrective eyewear where
indicated.
*Less any applicable Copayment.
**@ginning with the first day of the Benefit Period.
SERVICE OR MATERIAL
SERVICE OR MATERIAL
VSP NETWORK DOCTOR
BENEFIT
NON -VSP PROVIDER BENEFIT
FREQUENCY
BENEFIT
Lenses
Available once each 12 months**
Covered up to Plan Allowance*
Single Vision
Covered in full *
Up to $ 30.00*
reimbursement for the following necessary professional services:
1. Prescribing and ordering proper lenses;
Bifocal
Covered in full *
Up to $ 50.00'
i
6. Progress or follow -up work as necessary.
Trifocal
Covered in full *
Up to $ 65.00*
Lenticular
Covered in full *
Up to $100.00*
Plan Benefds. for lenses are per complete set, not per lens.
"mess any applicable Copayment.
**Beginning with the first day of the Benefit Period.
SERVICE OR MATERIAL
VSP NETWORK DOCTOR
NON -VSP PROVIDER BENEFIT
FREQUENCY
BENEFIT
FRAMES
Covered up to Plan Allowance*
Up to $ 70.00*
Available once each 12 months**
Benefits for lenses and frames include
reimbursement for the following necessary professional services:
1. Prescribing and ordering proper lenses;
2. Assisting in frame selection;
3. Verifying accuracy of finished lenses;
4. Proper fitting and adjustments of frames;
5. Subsequent adjustments to frames to maintain comfort and efficiency;
6. Progress or follow -up work as necessary.
*Less any applicable Copayment.
**Beginning with the first day of the Benefit Period.
w
OR MATERIAL 1 VSP NETWORK DOCTOR
LENS OPTIONS
nti- reflective coating Covered in
Photochromic lenses Covered in
NON -VSP PROVIDER BENEFIT
Not covered
Not covered
Available once each 12 months"
Polycarbonate lenses
Covered in tull
Not covered
Progressive lenses
Covered in ful1
lip to $ 50.00
W (ultraviolet) protected
Covered in full
Not covered
1. Less $ 40.00 Copayment.
2. Less $ 30.00 Copayment.
3. Less $10.00 Copayment.
4. Less $ 55.00 Copayment.
'Beginning with the first day of the Benefit Period.
l
SERVICE OR MATERIAL
VSP NETWORK DOCTOR
P NON-VSP PROVIDER
FREQUENCY
BENEFIT
BENEFIT
�ONTACT LENSES
Available once each 12 months**
Elective
Elective Contact tens fitting
Available once each 12
Covered in full *
and evaluation*"' services
months"
are covered in full once
*Less any applicable Copayment
*"Beginning with the first day of the Benefit Period.
every 12 months**, after a
or Non -VSP Provider. Prior review and approval by VSP are not required for Covered Person to be eligible for Necessary Contact Lenses.
Necessary Contact tenses are provided in lieu of all other lens and frame benefits available herein.
This means that utilization of contact lens benefits exhausts all of the Covered Person's lens and frame benefits for the current Benefit Period, and future
maximum $60.00
Co a ment
Materials
Professional Fees/Materials
Up to $ 130.00
Up to $ 105.00
*"Beginning with the first day of the Benefit Period.
***15% Discount applies to VSP Network Doctor's usual and customary professional fees for contact lens evaluation and
fitting.
i
Contact Lenses are provided in lieu of all other lens and frame benefits available herein.
This means that utilization of contact lens benefits exhausts all of the Covered Person's lens and frame benefits for the
current Benefit Period, and future eligibility for lenses and frames will be determined as if spectacle lenses and frames
were obtained in the current Benefit Period.
SERVICE OR MATERIAL
VSP NETWORK DOCTOR
NON -VSP PROVIDER BENEFIT
FREQUENCY
BENEFIT
NECESSARY CONTACT
Available once each 12 months**
LENSES
Professional Fees and
Covered in full *
Up to $ 210.00*
Materials
*Less any applicable Copayment
*"Beginning with the first day of the Benefit Period.
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's VSP network Docta
or Non -VSP Provider. Prior review and approval by VSP are not required for Covered Person to be eligible for Necessary Contact Lenses.
Necessary Contact tenses are provided in lieu of all other lens and frame benefits available herein.
This means that utilization of contact lens benefits exhausts all of the Covered Person's lens and frame benefits for the current Benefit Period, and future
eligibility for lenses and frames will be determined as if spectacle lenses and frames were obtained in the current Benefit Period.
R..
C O
OR MATERIAL I VSP NETWORK DOCTOR I NON -VSP PROVIDER BENEFIT I FREQUENCY
Vision
BENEFIT
Professional services for severe visual problems not correctable with regular lenses, including:
Supplemental Testing Covered in full Up to $125.00"
(Includes evaluation, diagnosis and prescription of vision aids where indicated.)
Supplemental Aids 75% of amount 75% of amount
un to $1000.00* uo to $1000.00
*Maximum benefit for all Low Vision services and materials is $1000.00 every two (2) Benefit Periods.
Low Vision benefits secured from Non -VSP Providers (if covered) are subject to the same time and Copayment provisions described above for VSP
Network Doctors. The Covered Person should pay the Non -VSP Provider's full fee at the time of service. Covered Person will be reimbursed an
amount not to exceed what VSP would pay a VSP Network Doctor for the same services and/or materials.
THERE IS NO ASSURANCE THAT THE AMOUNT REIMBURSED WILL COVER 75% OF THE PROVIDER'S FULL_ FEE.
KE
EXCEPTIONS
Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional limitations. Covered Persons may
obtain details regarding frame brand availability from their VSP Network Doctor or by calling VSP's Customer Care Division at (800) 577 -7195.
ATIENT OPTIONS
This Plan is designed to cover visual needs rather than cosmetic materials. When a Covered Person selects any of the following extras, the Plan will
pay the basic cost of the allowed lenses or frames, and the Covered Person will pay the additional costs for the options.
• Optional cosmetic processes.
• Color coating.
• Mirror ooating.
• Scratch coating.
• Blended lenses.
• Cosmetic lenses.
• laminated lenses.
• Oversize lenses.
• Certain limitations on low vision care.
NOT COVERED
There are no benefits for professional services or materials connected with:
• Orthoptics or vision training and any associated supplemental testing.
• Corneal Refractive Therapy (CRT)
• Orthokeratology (a procedure using contact lenses to change the shape of the comea in order to reduce myopia).
• Refitting of contact lenses after the initial (90 -day) fitting period.
• Plano lenses (lenses with refractive correction of less than t .50 diopter).
• Two pair of glasses in lieu of bifocals.
Replacement of lenses and frames furnished under this Policy that are lost or broken, except at the normal intervals when services are otherwise
available.
• Medical or surgical treatment of the eyes.
• Corrective vision treatment of an Experimental Nature.
• Plano contact lenses to change eye color cosmetically.
• Artistically- painted contact lenses.
• Contact lens insurance policies or service contracts.
• Additional office visits associated with contact lens pathology.
• Contact lens modification, polishing, or cleaning.
• Costs for services and/or materials exceeding Plan Benefit allowances.
• Services or materials of a cosmetic nature.
• Services and /or materials not indicated on this Schedule as covered Plan Benefits.
KE
PLAN BENEFITS
AFFILIATE PROVIDERS
GENERAL
,affiliate Providers are providers of Covered Services and Materials who are not contracted as VSP Network Doctors but who have agreed to bill VSP
directly for Plan Benefits provided pursuant to this Schedule. However, some Affiliate Providers may be unable to provide all Plan Benefits included in
this Schedule. Covered Persons should discuss requested services with their provider or contact VSP Customer Care for details.
COPAYMENT
There shall be a Copayment of $10.00 for the examination payable by the Covered Pennon at the time services are rendered. If materials (lenses,
frames or Necessary Contact Lenses) are provided, there shall be an additional $20.00 Copayment payable at the time the materials are ordered. The
Copayment shall not apply to Elective Contact Lenses.
COVERED SERVICES AND MATERIALS
Eye Examination Covered in full Available once each 12 months**
Comprehensive examination of visual functions and prescription of corrective eyewear.
Spectacle Lenses
Single Vision, Lined BifocalCovered in Full'
or Lined Trifocal,
LENS OPTIONS
Anti - reflective Coating - Covered in full' once every 12 months*
Photochromic Lenses- Covered in fu11 once every 12 months'*
Polycarbonate Lenses - Covered in fu11 once every 12 months"
-ProqressIve Lenses - Covered in full once every 12 months'
V (uRraviolet) protected - Covered in full once every 12 months'
1. Less $ 40.00 Copayment.
2. Less $ 30.00 Copayment.
3. Less $10.00 Copayment.
4. Less $ 55.00 Copayment
Frames
Covered up to the Plan allowance'
Available once each 12 months*'
Available once each 12 months**
CONTACT LENSES
Elective Contact Lenses
(Materials Only)
Up to $130.00
Available once each 12 months'*
The Elective Contact Lens fitting and evaluation services are covered in full once every 12 months, after a maximum $60.00 Copayment.
Necessary Contact Lenses Up to $210.00* Available once each 12 months**
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor
Contact tenses are provided in place of spectacle lens and frame benefits available herein.
*Less any applicable Copayment.
!'Beginning with the first day of the Benefit Period.
KK
LOW VISION
Professional services for severe visual problems not correctable with regular lenses, including:
'upplemental Testing: Up to $125.00 f
- Includes evaluation, diagnosis and prescription of vision aids where indicated.
Supplemental Aids: 75% of Affiliate Provider's fee up to $1 000.00t
tMaximum benefit for all Low Vision services and materials is $1000.00 every two (2) years and a
maximum of two supplemental tests within a two -year period
Low Vision Services are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor.
EXCLUSIONS AND LIMITATIONS OF BENEFITS
1. Exclusions and limitations of benefits described above for VSP Network Doctors shall also apply to services rendered by Affiliate Providers.
2. Services from an Affiliate Provider are in lieu of services from a VSP Network Doctor or a Non -VSP Provider.
3. VSP is unable to require Affiliate Providers to adhere to VSP's quality standards.
4. Where Affiliate Providers are located in membership retail environments, Covered Persons may be required to purchase a membership in such
entities as a condition of obtaining Plan Benefits.
W
VISION SERVICE PLAN INSURANCE COMPANY (VSP)
SCHEDULE OF PREMIUMS
VSP Choice Plan
Low Plan
VISION SERVICE PLAN INSURANCE COMPANY ('VSP") shall be entitled to receive premiums for each month on behalf of each Enrollee and hiher
Eligible Dependents, if any, in the amounts specified below.
4.44 per month for each eligible Enrollee without dependents.
8.88 per month for each eligible Enrollee with an eligible spouse.
9.50 per month for each eligible Enrollee with eligible child(ren).
15.18 per month for each eligible Enrollee with eligible spouse and child(ren).
NOTICE: The premium under this Policy is subject to change upon renewal (after the end of the initial Policy Term or any subsequent Policy Term), or
upon change of the Schedule of Benefits or a material change in any other terms or conditions of the Policy.
92
EXHIBIT B
VISION SERVICE PLAN INSURANCE COMPANY (VSP)
SCHEDULE OF PREMIUMS
VSP Choice Plan
High Plan
VISION SERVICE PLAN INSURANCE COMPANY ( "VSP ") shall be entitled to receive premiums for each month on behalf of each Enrollee and his/her
Eligible Dependents, if any, in the amounts specified below.
$ 9.27 per month for each eligible Enrollee without dependents.
$ 18.52 per month for each eligible Enrollee with an eligible spouse.
$ 19.81 per month for each eligible Enrollee with eligible child(ren).
$ 31.67 per month for each eligible Enrollee with eligible spouse and child(ren).
NOTICE: The premium under this Policy is subject to change upon renewal (after the end of the initial Policy Term or any subsequent Policy Term), or
upon change of the Schedule of Benefits or a material change in any other terms or conditions of the Policy.
RR
ADDENDUM
VISION SERVICE PLAN INSURANCE COMPANY
ADDITIONAL BENEFIT RIDER
DIABETIC EYECARE PLUS PROGRAM
GENERAL
This Rider lists additional vision care benefits to which Covered Persons of VISION SERVICE PLAN INSURANCE COMPANY ('VSF) are entitled,
subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein or in the Schedule of Benefits with which it is
associated. Plan Benefits under the Diabetic Eyecare Plus Program are available to Covered Persons who have been diagnosed with type 1 or type 2
diabetes and specific ophthalmological conditions. This Rider forms a part of the Policy or Evidence of Coverage to which it is attached.
ELIGIBILITY
The following are Covered Persons under this Policy, pursuant to eligibility criteria established by Client:
• Enrollee.
• The legal spouse of Enrollee.
• Any child of Enrollee, including any natural child from the date of birth, legally adopted child from the date of placement for adoption with the
Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible.
• The domestic partner of the same or opposite gender as Enrollee, pursuant to Group's eligibility rules.
Dependent children are covered up to the end of the year in which they turn age 26.
A dependent, unmarried child over the limiting age may continue to be eligible as a dependent if the child is incapable of self- sustaining employment
because of mental or physical disability, and chiefly dependent upon Enrollee for support and maintenance.
PROGRAM DESCRIPTION
The Diabetic Eyecare Plus Program ( "DEP Plusl is intended to be a supplement to Covered Person's group medical plan. Providers will first submit a
claim to Covered Person's group medical insurance plan, and then to VSP. Any amounts not paid by the medical plan will be considered for payment
.. "'y VSP. (This is referred to as "Coordination of Benefits" or "COB." Please refer to the Coordination of Benefits section of Covered Person's Evidence
of Coverage for additional information regarding COB.) If Covered Person does not have a group medical plan, providers will submit claims directly to
VSP.
Examples of symptoms which may result in a Covered Person seeking services under DEP Plus may include, but are not limited to:
• blurry vision • trouble focusing
• transient loss of vision • 'floating' spots
Examples of conditions which may require management under DEP Plus may include, but are not limited to:
• diabetic retinopathy rubeosis
• diabetic macular edema
REFERRALS
If Covered Person's Member Doctor cannot provide Covered Services, the doctor will refer the Covered Person to another Member Doctor or to a
physician whose offices provide the necessary services.
If the Covered Person requires services beyond the scope of DEP Plus, the Member Doctor will refer the Insured to a physician.
Referrals are intended to insure that Covered Persons receive the appropriate level of care for their presenting condition, Covered Person do not
require a referral from a Member Doctor in order to obtain Plan Benefits.
f
PLAN BENEFITS
VSP NETWORK DOCTORS
COVERED SERVICES
c'ye Examination: Covered in full after a Copayment of $20.00.
Special Ophthalmological Services: Covered in Full.
EXCLUSIONS AND LIMITATIONS OF BENEFITS
The Diabetic Eyecare Plus Program provides coverage for limited, vision - related medical services. A current list of these procedures will be made
available to Covered Person upon request. The frequency at which these services may be provided is dependent upon the specific service and the
diagnosis associated with such service.
NOT COVERED
1. Services and/or materials not specifically included in this Rider as Plan Benefits.
2. Frames, lenses, contact lenses or any other ophthalmic materials.
3. Orthoptics or vision training and any associated supplemental testing.
4. Surgery of any type, and any pre- or post - operative services.
5. Treatment for any pathological conditions.
6. An eye exam required as a condition of employment.
7. Insulin or any medications or supplies of any type.
8. Local, state and/or federal taxes„ except where VSP is required by law to pay.
0
DIABETIC EYECARE PROGRAM DEFINITIONS
Diabetes A disease where the pancreas has a problem either making, or making and using, insulin.
ype 1 Diabetes A disease in which the pancreas stops making insulin.
Type 2 Diabetes A disease in which the pancreas either makes too little insulin or cannot properly use the insulin it makes to
convert blood glucose to energy.
Diabetic Retinopathy A weakening in the small blood vessels at the back of the eye.
Rubeosis Abnormal blood vessel growth on the iris and the structures in the front of the eye.
Diabetic Macular Edema Swelling of the retina in diabetes mellitus due to leaking of fluid from blood vessels within the macula.
C
ADDENDUM
VISION SERVICE PLAN INSURANCE COMPANY
PERFORMANCE STANDARDS
VSP guarantees the performance standards outlined herein by offering to pay a financial penalty of I% of quarterly administrative revenue per unmet
standard, up to a total annual maximum of $100,000 and a minimum annual threshold of $250. VSP's company -wide quarterly performance results
shall be used in determining whether any or all of the performance standards have been met. Any penalties owed shall be accrued quarterly and paid
on an annual basis, as long as the cumulative total for the four quarters exceeds $250. Cumulative annual penalties less than $250 will not be carried
over into the following calendar year for purposes of determining financial penalties. Payment of penalties shall be conditioned on VSP's receipt of all
premiums due to VSP within established due dates.
VSP's performance hereunder is subject to interruption and delay due to causes beyond VSP's reasonable control such as acts of God, act of any
government, war or other hostility, the elements, fire, explosion, power failure, equipment failure, industrial or labor dispute. In the event of any such
interruption or delay, any period of performance shall be extended for a period of time equal to the interruption or delay.
CLAIMS PROCESSING
Claims financial accuracy
Performance Standard = 99% processed without financial error
Performance Penalty =1 %
Claims financial accuracy is calculated much like that of claims processing accuracy. The same random sampling of daims audited for processing
accuracy is also audited for financial accuracy. Any error found that results in a financial impact is recorded as a financial error. At the end of the month,
financial errors are totaled and taken as a percentage of the total dollar paid for all claims audited during the given month.
Claims processing accuracy
Performance Standard = 99% processed without error
,—Performance Penalty =1 %
Claims processing accuracy is calculated on a monthly basis based upon daily audit results. The term 'processing error" encompasses all errors found >
in the audit regardless of whether the error caused a financial impact. At month's end, all processing errors for the month are totaled and taken as a
CL
percentage of the total number of claims audited for the month. CL
Claims timeliness
Performance Standard:
VSP preferred provider claims = 95% processed within 5 business days
Performance Penalty =1 %
All other provider claims = 95% processed within 5 business days
Performance Penalty =1 %
All other provider claims = 99% processed within 15 business days
Performance Penalty =1 %
Claims timeliness, or turnaround time, is measured on a monthly basis. Each claim audited in the daily audit is audited for timeliness. Timeliness is
measured by calculating the number of business days elapsing between the received date and the pricing date. When additional information is needed
to process a claim, the timeliness date is calculated from the date the information needed to process the claim was received to the pricing date.
R..
J
5
CALL CENTER MANAGEMENT
Abandoned call rate
Performance Standard = Less than or equal to 3%
"`'Ierformance Penalty =1 %
The Call Center telephone abandon rate is calculated monthly by taking the total number of abandoned calls before and after sixty (60) seconds,
divided by the total number of calls accepted by the Call Center, which includes calls answered via the Interactive Voice Response and Automated Call
Distribution systems.
Average speed of answer
Performance Standard = Less than or equal to 25 Seconds
Performance Penalty =1 %
The average speed of answer (the amount of time a caller is waiting while on hold) is calculated by dividing the total time all calls are on hold (in
seconds) by the total number of calls received.
Average call blockage rate
Performance Standard = Less than or equal to 2%
Performance Penalty =1 %
VSP call blockage is defined as any call blocked by VSP. A blocked call results in the caller receiving a "busy" signal, and is considered unsuccessful.
VSP calf blockage does not include calls blocked by the long distance carrier due to circumstances beyond VSP's control. VSP call blockage standard
is 2% or less of total calls attempted to VSP. The formula for this standard is: number of blocked calls divided by (blocked calls plus accepted calls) as
reported by the long distance carrier.
Call resolution (same day response)
Performance Standard = 98%
Performance Penalty =1 %
Neasurement based on internal VSP system -driven statistics. The percentage of telephone inquiries handled within the same day is obtained by taking
e number of research inquiries entered into our system and dividing by the number of calls answered in the Call Center, and subtracting the result
from 1.00.
Complaint acknowledgement within 5 business days
Performance Standard = 96%
Performance Penalty =1 %
"Telephone complaints" not resolved by the end of the following business day must be acknowledged in writing within 5 by business days. "Written
complaints" not resolved within 5 business days will be acknowledged in writing on the 5th business day from receipt. Complaint acknowledgement
compliancy is calculated monthly. The method for calculating the percentage is: total number of complaints meeting the 5 business day goal divided by
total number of complaints.
Complaint resolution within 30 calendar days
Performance Standard = 99%
Performance Penalty =1 %
When a complaint is received, in writing or via phone, the person receiving it documents it in our online Research Inquiry system. The Complaint and
Grievance unit monitors this workflow to assure all complaints have been resolved by the 30 calendar day.
Average response to e-mail inquiries within 2 business days
Performance Standard =100%
Performance Penalty =1 %
The average time required to send the first manual reply to an email, in the specified time period.
M
SATISFACTION
Patient satisfaction (satisfied with level of coverage)
Performance Standard = 96% overall satisfaction with VSP
irformance Penalty =1 %
Performance Standard = 96% overall experience with VSP preferred provider
Performance Penalty =1 %
VSP conducts patient satisfacction surveys on a quarterly basis. A random sample of claims from the prior three months is chosen that is statistically
representative of all claims.
While VSP makes recommendations to all prospective Groups on which plan we feel best suits the group's employees, the ultimate decision for
selection of a plan rests with the Group. As such, our performance standard is based on patients who are satisfied with the level of coverage provided
by their plan. Satisfied patients includes patients who rated their overall level of coverage as "Excellent," °Very Good" and "Good ". Dissatisfied patients
include patients who rated their overall level of coverage as "Fair' or °Poor".
VSP preferred provider retention rate (based on voluntary turnover)
Performance Standard = 98%
Performance Penalty =1%
VSP preferred provider satisfaction is based on changes in the VSP preferred provider network. On a quarterly basis, the voluntary retention rate of
providers (those choosing to stay on the VSP panel) is measured as a percentage of the total number of providers in the network. The annual preferred
provider retention rate is equal to the total number of providers on the panel on December 31 divided by the total number of providers on the panel
January 1 of that same year.
ACCOUNT ADMINISTRATION
Electronic eligibility online within 24 hours
Performance Standard = 98%
rmance Penalty =1 %
Percentage reported based on a measurement against all maintenance files" loaded within that quarter. VSP records both the received and loaded
dates for all membership fifes. The data is compiled into a monthly report, which is used to calculate the quarterly statistical average.
"AII files measured for this standard must meet the following criteria:
• Identifiable Media: Eligibility file must be labeled properly.
• Proper Format: No change in format from the previously loaded eligibility file.
• Clean File:
1) Physical Media must be undamaged.
2) Electronic Media must have clean and complete data transmission. We must be able to successfully unzip /decrypt the incoming
data.
3) All media must contain proper /complete records for members and dependents.
Exclusions to this performance standard are as follows:
1) Membership files for open enrollment loaded prior to effective date.
2) Group /division restructures for existing groups (1 st eligibility load based on the restructure will be excluded from the performance
standard measurement).
3) Incorrect/Incomplete individual records for members and dependents.
4) If instructed to wait for group approval to load the file.
4
Online reports available by the 2P of the month
Performance Standard =100%
Performance Penalty =1%
ql eligible online reports will be available on VSP's Resource Center by the 25th of each month.
Web portal availability
Performance Standard = 99%
Performance Penalty = I %
Based on a 7 x 24 schedule.
New group implementation
Performance Standard = Satisfaction guaranteed
We guarantee MONROE COUNTY BOARD OF COUNTY COMMISSIONERS's satisfaction with the implementation of its VSP benefit. In support of
this, we are placing a one -time penalty of $100,000 at risk. We will collaborate with MONROE COUNTY BOARD OF COUNTY COMMISSIONERS to
create a customized Implementation Action Plan that includes detailed roles, responsibilities and timeframes to ensure a successful implementation.
Our comprehensive Implementation Action Plan includes the following sections:
Communications
System Accuracy
Plan Accuracy
Membership Management
Preferred Provider Access
Each of the above sections is assigned a maximum penalty amount of $100,000 to be paid in the event VSP was not able to meet MONROE COUNTY
BOARD OF COUNTY COMMISSIONERS's satisfaction in that category. If MONROE COUNTY BOARD OF COUNTY COMMISSIONERS does not
fulfill its obligations as documented in the Implementation Action Plan, no penalty will apply to VSP.
EN