Summary of material modifications no

SUMMARY OF MATERIAL MODIFICATIONS No. 15
This modification is made as of January 1, 2010, by the City of Marshalltown to the City of Marshalltown Employee and Retiree Medical and Dental Benefit Plan. All other terms and provisions of the Plan remain unaltered and in effect. Distribution of the attached amendment will be handled in the following manner: The Plan Administrator will be responsible for distribution.
First Administrators, Inc. will provide a formal copy of the amendment to the Plan Administrator for distribution. First Administrators, Inc. will provide the Plan Administrator with ________ copies of the ______ Other:__________________________________________________ The following text replaces the “Medical Calendar Year Deductible”, “Biologically Based Mental Illness”,
“Diabetic Self-Management Education Programs/Outpatient”, “Mental Health/Chemical Dependency”
“Prescription Drugs”, and “Preventive Care” benefits and adds the “Prosthetics” and “Smoking
Cessation Medications” benefits found in the Benefit Summary.
MEDICAL BENEFITS
PATIENT’S LIABILITY
GENERAL PLAN LIMITS
Medical Calendar Year Deductible:
The PPO, Non-PPO, and Out-of-Area deductibles are mutually satisfying. PPO Prosthetics (Limbs)
Deductible:
amount applies only to PPO services. The PPO Prosthetic (Limbs) Deductible accumulates to the Medical Deductible. Non-PPO and Out of Area prosthetic charges are subject to the medical deductible amount. MEDICAL BENEFITS
PLAN’S LIABILITY
GENERAL PLAN LIMITS
Note: Mental illnesses not defined as
Biologically Based will be paid under the Includes treatment at a Psychiatric Medical
Institution for Children (PMIC) for dependent **See PPO Office Services Copay for copay and cost-sharing percentages. Page 1 of 8
SUMMARY OF MATERIAL MODIFICATIONS No. 15
MEDICAL BENEFITS
PLAN’S LIABILITY
GENERAL PLAN LIMITS
Limited to 90-day supply per prescription or refill. Includes only those allowable
drugs and medications that are not
payable under the prescription drug
Includes:
 Growth hormones (with prior approval) Excludes:
 Biological sera, blood, or blood plasma  Contraceptive injections, implants, and  Lancets, lancet devices, and glucose Limited to 90-day supply per prescription The copay does not apply to the calendar year deductible or out-of-pocket maximums. Mail order benefits are limited to maintenance medications. The pre-existing conditions exclusion period and coordination of benefits Page 2 of 8
SUMMARY OF MATERIAL MODIFICATIONS No. 15
provisions in the benefit booklet do not apply to the mail order Prescription Drug benefits. MEDICAL BENEFITS
PATIENT’S LIABILITY
GENERAL PLAN LIMITS
Copay are waived.
Limited to $250/CAL YR.
Includes, but is not limited to, the
following routine services:
 routine physical examinations
 immunizations
 mammograms*
 pap smears*
 diagnostic x-ray and labs
 vision exams (including routine
 hearing exams  services for screening of “family history *Charges for mammograms and pap
smears are in excess of the age
scheduled Cancer Screening benefits.
**Excludes surgical procedures, including
colonoscopies and sigmoidoscopies.
*Subject to Prosthetic (Limbs) Deductible. Medical deductible applies to all other prosthetic services. The following text replaces the “Medical Calendar Year Deductible, Biologically Based Mental
Illness, Diabetic Self- Management Education Programs/Outpatient, Mental Health/Chemical
Dependency, Prescription Drugs and Preventive Care” and adds the “Prosthetics” and
“Smoking Cessation Medications” benefits in the Benefit Summary in the current Benefit Book for
the Fire Union Employees only.
MEDICAL BENEFITS
PATIENT’S LIABILITY
GENERAL PLAN LIMITS
Medical Calendar Year Deductible:
The PPO, Non-PPO, and Out-of-Area deductibles are mutually satisfying. PPO Prosthetics (Limbs)
Deductible:
The PPO Prosthetics (Limbs) Deductible amount applies only to PPO services. The PPO Prosthetic (Limbs) Deductible accumulates to the Medical Deductible. Non-PPO and Out of Area prosthetic Page 3 of 8
SUMMARY OF MATERIAL MODIFICATIONS No. 15
charges are subject to the medical deductible amount. Page 4 of 8
SUMMARY OF MATERIAL MODIFICATIONS No. 15
MEDICAL BENEFITS
PLAN’S LIABILITY
GENERAL PLAN LIMITS
Biologically Based will be paid under the Includes treatment at a Psychiatric
**See PPO Office Services Copay for copay and cost-sharing percentages. Limited to 90-day supply per prescription or refill. Includes only those allowable
drugs and medications that are not
payable under the prescription drug
Includes:
 Insulin, syringes, test strips, and insulin  Growth hormones (with prior approval) Excludes:
 Biological sera, blood, or blood plasma  Contraceptive injections, implants, and  Lancets, lancet devices, and glucose Page 5 of 8
SUMMARY OF MATERIAL MODIFICATIONS No. 15
Limited to 90-day supply per prescription calendar year deductible or out-of-pocket maximums. Mail order benefits are limited to maintenance medications. The pre-existing conditions exclusion period and coordination of benefits provisions in the benefit booklet do not apply to the mail order Prescription Drug benefits. Copay are waived.
Limited to $250/CAL YR.
Includes, but is not limited to, the
following routine services:
 routine physical examinations
 immunizations
 mammograms*
 pap smears*
 diagnostic x-ray and labs
 vision exams (including routine
 hearing exams  services for screening of “family history *Charges for mammograms and pap smears are in excess of the age-scheduled Cancer Screening benefits. *Subject to Prosthetic (Limbs) Deductible. Medical deductible applies to all other prosthetic services. The following text replaces the second paragraph in the “Dependent
Eligibility” section found in the current
A covered employee’s or retiree’s unmarried dependent children may be covered until they reach the age of 19. They may continue coverage beyond age 19 if they are unmarried, full-time students in an accredited school. If dependent is not a full-time student they may continue to age 25 if they are residents of Iowa and remain unmarried. A previously ineligible dependent child may become eligible for reenrollment through the plan under certain circumstances. Contact your Human Resources department for details. Page 6 of 8
SUMMARY OF MATERIAL MODIFICATIONS No. 15
The following “Michelle’s Law” is added as the last paragraph to the “Dependent Eligibility” section
Michelle’s Law: Coverage of Dependent Students on Medically Necessary Leave of Absence
In the case of an eligible dependent child, this Plan shall not terminate coverage due to a medically necessary leave of absence from, or any other change in enrollment at, a post-secondary education institution that commences while such dependent child is suffering from a serious illness or injury that causes such dependent child to lose student status for purposes of coverage under this Plan, before the earlier of: up to one year after the beginning of the leave of absence; or the date coverage would otherwise terminate under the Plan. For the student to qualify for this extension, the plan must receive written certification from his/her treating physician stating that the student is suffering from a serious illness or injury and that the leave of absence is medically necessary. A student will qualify for a medically necessary leave of absence from a post-secondary educational institution if the leave of absence: 1. begins while the child is suffering from a serious illness or injury; 2. is certified by a physician as being medically necessary; and 3. causes the child to lose student status for purposes of coverage under the plan. If the dependent child’s treating physician does not provide written documentation that the child is suffering from a serious illness or injury and that the leave of absence is medically necessary, this Plan will not provide continued coverage. The following text is added to the “Mental Health/Chemical Dependency” benefit found in the “What Are
Covered Expenses?” section
in the current Summary Plan Description. Residential Facility Benefits
A residential facility provides treatment for mental health and/or chemical dependency disorders. This benefit will pay for the daily room and board charges subject to the limits of this Plan. Unless otherwise excluded, this Plan will provide benefits for miscellaneous charges such as therapy and supplies incurred during the time room and board benefits are payable. Confinement in a residential facility must be recommended by and under the supervision of a physician. Psychiatric Medical Institution for Children (PMIC) Residential Facility Benefits
This Plan will provide benefits for miscellaneous charges such as therapy and supplies incurred during the time room and board benefits are payable. Confinement in a PMIC residential treatment facility must be recommended by and under the supervision of a physician. The following text replaces the (17) “prosthetic” and the (28) “biologically based mental illness” benefits
found in the “Other Covered Medical Care” section
in the current Summary Plan Description. prosthetic appliances used to aid in the function of or to replace an arm or leg (in whole or in part); or an eye if the appliance is the original appliance or a replacement required by pathological Page 7 of 8
SUMMARY OF MATERIAL MODIFICATIONS No. 15
(28) biologically based mental illness as defined in your Plan booklet including Psychiatric Medical Institution for Children (PMIC) residential facilities for children under the age of 19; and The following text replaces the “Residential Treatment Facility” definition found in the “Definitions” section
in the current Summary Plan Description. “RESIDENTIAL TREATMENT FACILITY” means a 24-hour live-in facility generally used for treatment of
mental health or chemical dependency disorders.
CITY OF MARSHALLTOWN
____________________________ __________________________________
(Authorized
____________________________ __________________________________ (Printed Authorized Signature) Page 8 of 8

Source: http://www.ci.marshalltown.ia.us/static/intranet/ins_smm15.pdf