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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 � .d C IA/ L- L. 4 4 +1, I C/1CC Q ....1 i.,• .. �'11e.�.Hi. 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