HomeMy WebLinkAbout2016-1 City of Auburn LEOFF Board
RESOLUTION 2016-1
A RESOLUTION OF THE LEOFF BOARD OF THE
CITY OF AUBURN, WASHINGTON� AMENDING
SECTIONS 1,01, 9:01, 9.02, 9.09, AND APPENDIX B
OF THE BOARD'S POLICY AND PROCEDURE
MANUAL
THE LEOFF BOARD OF THE CITY OF AUBURN, WASHINGTON,
HEREBY RESOLVES as follows:
Section 1. That Policy section 1.01, Membership, be amended to read
asfollows:
7.01 Membership
The Board shall consist of five (5) members, as follows:
A. Two (2) members of the City legislative body to be appointed
by the Mayor.
B. One (1) LEOFF 1 or LEOFF 2 firefighter elected by those
members subject to the jurisdiction of the Board, LEOFF 1, active or
retired. Elections for firefighter representative shall be in even numbered
years.
C. One (1) LEOFF 1 or LEOFF 2 police officer to be elected by
those members subject to the jurisdiction of the Board, LEOFF 1, active or
retired. Elections for police officer representative will be in odd numbered
years.
D. One (1) member from 4he public at large who [esides within
the City to be appointed by the other four (4) appointed members.
E If there are either no firefiahters or no law enforcement
o�cers under the iurisdiction of the board eliqible to vote. the elipible
officers or firefiahters shall elect a second eliqibie emalovee
representative.
Section 2. That Policy section 9.02, Med.ical Claims for Cor�ectiVe
Lenses and Frames, be amended to read as follows:
Resolution No 2016-1
April 5, 2016
Page 1 of 8
9.02 Medical Claims for Corrective Lenses and Frames
A. Active LEOFF 1 Members
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The LEOFF Board will reimburse up to the amounts described below.
The reimbursement rates apply after all insurance coverages have
been applied. Any balance due after the LEOFF Board reimbursement
is the responsibility of the LEOFF I member. To receive
reimbursement the member shall forward a copv of anv insurance
Explanation of Benefits statement tocaether with a completed Corrective
Lenses and Frames Worksheet to the LEOFF Board for consideration.
B. Retired-LEOFF 1 Members
Eye examinations for retired LEOFF I members are to be charged to
� the citv-contracted alan�y�^�� Q' �c"�'`'• The retired LEOFF I
member may purchase from the optician or ophthalmologist of his or
her choice.
� The member s#�e�shall forward a completed Corrective lenses and
Frames Worksheet to the LEOFF Board for consideration for any
lenses and frames expense. The LEOFF Board will reimburse up to
the amounts described below. The reimbursement rates apply after
all, if any, insurance coverages have been applied. Any balance due
after the LEOFF Board reimbursement is the responsibility of the
LEOFF I member.
C. Vision Benefits
Payments for eyeglasses and contact lenses, plus the reasonable
costs of necessary eye examination services of a lice.nsed
ophthalmologist or optometrist, will be approved pursuant to the
authority granted to the Board under RCW 41.26.150, if eyeglasses
are prescribed by an ophthalmologist or optometrist.
I Unless it is medicallv necessarv for a member to have both contacts
and eve4lasses, �the Board will approve payment for either one pair of
eyeglasses or for contacf lenses, at the member's option or as
prescribed, to correct vision when required for a new prescrip4ion in
accordance with the fo.11owing schedule:
1. Evealass Lenses and Frames: $270.00 maximum per
single set of frames and pair of lenses not more than once every
Resolution No. 2016-1
April 5, 2016
Page 2 of 8
twelve (12) consecutive months. Lenses covered include single vision,
bifocal, trifocal and progressive lenses.
2. Second Pair: A second pair of monofocal (i.e. computer)
glasse.s shall be approved only if prescribed by a ophthalmologist or
licensed optometrist. The maximum cost of the second pair shall not
exceed $270.00 per single set of frames and pair of lenses not more
than once in a twen4y-four (24) consecutive months.
3. Contact Lenses: Not to exceed $250 maximum during
any twelve (12) month period including disposable contact lenses.
4. Realacement: Claims for replacement pair of eyeglass
frames and/or lenses or contacts will be allowed 'rf proof of damage is
provided and showh to have been incurred in the performance of a
member's fire or law enforcement duties. Only one replacement pair
per year, due to accidental damage, will be allowed, not to exceed the
amount allowable above.
5. Additional/S�are Pair: No reimbursement will be made
for a spare pair of glasses or contact lenses. (Rev. 5/2008)
D. Corrective Vision Suraerv
The Board will reimliurse the member the amount of$1,000 per eye fot
corrective vision surgery. If a member is reimbursed the $1,000 per
eye for the surgery, he or she will not be reimbursed for eyeglasses or
contact lenses during the subsequent two calendar years, unless
eyeglasses or contact lenses are medically necessary. (Rev. 7/2012)
Section 3. That Policy section 9.01, Medical Claim Procedure, is
amended to read as follows:
9.01 Medical Claim Procedure
A. Obtain prior LEOFF Board approval for any necessa_ry medical
expense not covered by insuran.ce, Medicare or other sim'ilar
sources. All medical expenses incurred and claimed for
reimbursement by the member will be submitted through the
member's health insurance provider(s) BEFORE the claim is
sent to the Board for approval. The medical expenses claim
submitted for reimbursement is to be that portion NOT covered
by the existing health insurance provider(s).
Resolution No. 2016-1
April 5, 2016
Page 3 of 8
1. Each individual who has attained the age sixty-five (65)
shall either apply for Medicare within the initial eligibility
period or will provitle a statement to the Board that they
are eligible for, and are taking advantage of, a special
enroliment period. Medicare premiums supplementing
other medical insurance coverage are authorized for
reimbursement upon receipt of Form SSA-1099, Social
Security Benefit Stateriient, showing annual Medicare
premiums paid for individual members. In circumstances
where the member, and not Social Security, pay some or
all of the prem.ium, proof of such payment shall also be
submitted.
The Board will noY authorize payment for necessary
medical serqices where such expenses are, or would be,
met by Medicare; pursuant to RCW 41.26.150(2). Where
the expense of necessary medical services exceeds that
which is paid by Me.dicare, the Board may authorize the
payment of the excess.
The Board will authorize payment for Medicare
premiums. Hoinrever, if, because an individual delays
signing up for Medicare, #h.e premiums are higher than
they would be if the individual signed up during the
� appropriate enrollment period, the Board �way-will not pay
for the difference between the regular premium and the
more expensive premium.
2. Members are advised to consult their employer or
personnel office regarding eligibility for Medicare health
insurance coverage, Parts A and B. Where the expense
of necessary medical serVices ezceeds 4hat which is paid
6y Medicare, 4he Board will authorize the payment of any
balance which may exist after coordination of benefts
with the provided medical insurance carrier.
B. Process all medical expenses through the appropriate
insurance carriers. Members are advised to consult first with
their health insurance providers or their employer/personnel
o�cer to learn what is or is not covered in existing health
insurance BEFORE incurring treatment seryices. Electiye
medical procedures, surgery and/or appliances/supplies may
not be covered by the health insurance provided by the
employer or authorized by the Board.
Resolu4ion No. 2016-1
April 5, 2016
Page 4 of 8
C. If the medical expense is not covered by insurance, a claim
can be submitted to the LEOFF Board for payment. The
burden is upon fhe claimant to establish necessity of a
provided medical service and that the reasonableness of the
service charge in order for the Board to consider the claim for
payment.
D. Complete a Claim for Payment form and attach all explanation
of benefits insurance documentation forms showing the
amount they paid and/or rejected and any physician
documentation necessary to support a claim.
E. Submit the ciaim with the above information to your LEOFF
Representative by 4he last Tuesday of the month. LEOFF
Board agendas are prepared the last Wednesday of the month
and mailed to each Board member at their last address of
record, Any claims submitted after that date will be held until
the next regularly scheduled LEOFF Board meeting, the frst
Tuesday of each month.
F. If the LEOFF Board approves the claim for payment, the claim
will be processed according to established Finance
Department policies and procedures.
G. Claims which do not have complete documentation may be
tabled until the next LEOFF Board meeting or until the
required documenfation is provided so it is crucial to have the
required paperwork. Only those medical services which are
deemed necessa_ry shall be approved, unless the Board finds
the condition which has caused the need for such medical
service was caused or brought on by dissipa.tion or abuse.
Determinations of dissipation or abuse and the necessity of
such medical services shall be determined tiy the Board after
considering the medical evaluation of 4he Board's medical
advisor together wi4h any other relevant evidence.
H. Ali ciaims for hearing aids must have prior authorization by the
LEOFF Board. Failu�e to obtain advance authorization may
result in only partial reimbursement or rejection of the claim at
the Boards discretion.
� I. All claims, except prescription claims, co-qay claims, and
Social Security Medicare Part B claims, shall be submitted to
the Board within ninety (90) days of date processed/paid by
the insurance documentation. The Board will review the
submitted claim at the next full Board meeting. If all
Resolution No 2016-1
April 5, 2016
Page 5 of 8
documentation is submitted properly the Board will consider
reimbursement of expenses. However, if for any reason, the
claim for payment/reimbursement is insuffcient, at the
d.iscretion of the Board, it may table the claim until the next
meeting or until receipt of the requested documentafion. The
claim may be tabled for three consecutive Board meetings. If,
after three (3) Board meetings the Claimant has not provided
the Board with the requested documentation, the claim for
paymenbreimbursement may be rejected. (Rev. 5/2008)
� J. Prescription claims and co-pav .claims shail be submitted to
the Board within twelve (12) months from date of purchase.
(Rev. 5/2008)
K. All medical expenses are the member's responsibility to pay.
Claims for ne.cessary medical services submitted to the Board
shall be reimbursed to the member in the amount approved by
the Board.
L. Upon making payment for authorized medical services, the
employer shail be subrogated to ail rights of the member
against any third party who may be held liable for the
member's injuries or for fhe payment of #he costs of inedical
services in connecfion with a member's sickness or disability.
Such subrogation shall be to the extent necessary to recover
payments made by the employer.
M. The Board may approve a max.imum one-time only $500
weight loss program fee if the member submits a description
of a physician monitored and prescr'ibed weight loss program
documenting a medical necessity of losing at least 60 pounds.
The Board will not consider payment or costs of food
supplements/replacements..
N. All claims for durable medical equipment must have prior
authorization of fhe Board. The Boa.rd may approve self-help
or comfort items if, in the Board's sole discretion, failure to
approve these items will result in the claimant going into a
nursing home, and 4he cost of the items is less cost of nursing
home care.
Section 4. That Policy section 9.09, Medical Claims for Services Where
Treatment is Not Covered by Insurance, is amended to read as follows:
Resolution No 2016-1
April 5, 2016
Page 6 of 8
9.09 Medical Claims for Services Where Treatment is Not
Cove.red by Insurance
Unless otherwise stated in this manual, 1in instances where
insurance does not cover treatment, +� ,..�...��� m' F _eeL �.,,,.
. failu�e to de
seobtain authorization bv the Board prior fo receivinq services may cause
denial or only partial approval of the medical claim. The Board shall
consider the routine nature of the services (e.q. phvsicals, eve and
hearinq exams) when determininq whether to authorize pavment for
medical services received without prior authorization.
Section 5. That the first p.aragraph of the "Eye Exam, Corrective Lenses
and Frames" Worksheet for Active Members, Appendix B of the Policy &
Procedures Manual, shall be amended to read as follows and the same form for
Re4ired Members shall be deleted in its entirety from the manual. :
. Please complete the information below and
attach receipts and explanation of benefits statements. The LEOFF Board
will reimburse up to $270.00 per yeaF12-month period for lenses and
frames, OR up to $250 00 per 12-month period for contact lenses, or both
if inedicallv necessarv (�see Secfion 9.02 of the Policy and Procedure
Manual for additional information:), The reimbursement rate applies after
Resolutian No. 2016-1
Aprii 5, 2016
Page 7 of 8
all insurance coverages have been applied. Any balance due after the
LEOFF Board reimbursementis the responsibility of the LEOFF I member.
Dated and Signed this 5 '� day of�-�-�> , 2016.
CITY OF AUBURN LEOFF BOARD
�' �`�J�
JIM KE LY, Police repr entati4e
�3�/IX �
BILL PETERSEN, Fire Representative
�
KURT VOGEL, Mem r at-large
C�
LAND TROUT, Councilmember
CLAUDE DaCORSI, Councilmember
Resolution No. 2016-1
April 5, 2016
Page 8 of S