ORD 1995-21 - Amend Employee Medical Benefits Plan 06-06-1995ORDINANCE 95 -21
AN ORDINANCE OF THE CITY COUNCIL OF THE CITY OF
HUNTSVILLE, TEXAS, AMENDING THE EMPLOYEE MEDICAL
BENEFIT PLAN REGARDING THE COORDINATION OF BENEFITS;
AND MAKING OTHER FINDINGS AND PROVISIONS RELATED
THERETO.
WHEREAS by Ordinance 93 -40 adopted December 14, 1993, the City Council adopted "THE
CITY OF HUNTSVILLE EMPLOYEE HEALTH PLAN" as the plan document
for the City of Huntsville Employee Health Plan and Trust; and
WHEREAS the City Council wants to amend the Plan to provide coordination of benefits
consistent with the model regulations of the National Association of Insurance
Commissioners;
NOW, THEREFORE, BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF
HUNTSVILLE, TEXAS, that:
SECTION 1: "THE CITY OF HUNTSVILLE EMPLOYEE HEALTH PLAN" is amended by
the substitution of the following for that part of Article V. Coordination of
Benefits that explains when the Plan is "primary" or "secondary ": paragraph c. of
section 11.15, the definition of "Dependent ":
a. If the other plan contains no provision for coordination of benefits, that plan shall be
primary and this Plan shall be secondary.
b. For Covered Expenses incurred by an Employee who is covered under another plan as a
dependant, this Plan shall be primary and the other plan secondary; except that: if the
person is also a Medicare beneficiary, and as a result of the rule established by Title
XVIII of the Social Security Act and implementing regulations, Medicare is (i) secondary
to the plan covering the person as a dependent and (ii) primary to the plan covering the
person other than a dependent (e.g. a retired employee), then the plan covering the person
as a dependent shall be primary and the plan covering that person as other than a
dependent shall be secondary.
C. For Covered Expenses incurred by an Employee or for the Dependent of an Employee
when either such person is covered by another plan as a laid off or retired employee or
as the dependent of such employee, this plan shall be primary and the other plan shall
be secondary. If the other plan does not have this rule; and if, as a result, the plans do
not agree on the order of benefits, this rule is ignored.
d. When this Plan provides COBRA continuation coverage for a qualified beneficiary who
is covered under another plan, this Plan shall be secondary and the other plan, if it
covers that same person as an active employee or the dependent of an active employee,
shall be primary. In such a case, however, this Plan shall be primary for a preexisting
condition to the extent such condition is excluded under the other plan. If the other plan
does not have this rule; and if, as a result, the plans do not agree on the order of
benefits, this rule is ignored.
e. For Covered Expenses incurred by a Dependent who is covered under another plan as an
employee or member, this Plan shall be secondary and the other plan primary.
f. If a child is covered under plans of both parents, of which the Plan is one, then the plan
covering the parent whose birthday, excluding year of birth, falls earlier in the Calendar
Year shall be primary and the plan of the other parent secondary. If the other plan has
a rule based on the gender of the parent; and if, as a result, the plans do not agree on
the order of benefits, the rule based on the gender of the parent shall determine the order
of benefits. However, when parents are separated or divorced, the primary plan for the
dependent child shall be the plan of the parent who has custody of the child. Secondary
liability for the dependent child rests with the plan of the stepparent who has custody of
the dependent child and will be determined before the plan of the parent who does not
have custody of the child.
g. If the specific terms of a divorce decree state which parent has responsibility for the
medical expenses of a dependent child, then the plan of that parent shall be primary and
the plan of the other parent shall be secondary.
h. If the specific terms of a divorce decree state that the parents shall share joint custody,
without stating that one of the parents is responsible for the health care expenses of the
child, the plans covering the child shall follow the rule outlined in f. above.
Medicare shall be primary, secondary or last to the extent stated in federal law. When
Medicare is to be the primary payer, this Plan shall base its payment upon benefits that
would have been paid by Medicare under Parts A and B, regardless of whether or not the
person was enrolled under both of these parts.
j. When none of the rules stated above are determinative for a person, the plan which has
covered that person continuously for the longer period of time shall be primary.
SECTION 2: "THE CITY OF HUNTSVILLE EMPLOYEE HEALTH PLAN" is amended by
the substitution of the following for item a. in the definition o f the term plan, as
used in this section:
a. group insurance or any other arrangement of coverage for persons in a group, including
HMOs, whether on an insured or uninsured basis.
SECTION 3: The Plan Document is amended effective May 1, 1995.
PASSED AND APPROVED this the 6th day of June, 1995.
THE CITY OF HUNT VILLE
W
by William B. Green, Its Mayor
AT T:
N&k4u
Danna Welter, City Secretary
4OVAPL unds, City Attorney