Meetings/2013/December... · 2019-12-11 · December 3, 2013 Board Agenda Page 1 * Board Action Requested McLEOD COUNTY BOARD OF COMMISSIONERS . PROPOSED MEETING AGENDA . DECEMBER

December 3, 2013 Board Agenda

Page 1 * Board Action Requested

McLEOD COUNTY BOARD OF COMMISSIONERS

PROPOSED MEETING AGENDA DECEMBER 3, 2013

1 4:30 CALL TO ORDER PLEDGE OF ALLEGIANCE 2 4:33 CONSIDERATION OF AGENDA ITEMS* 3 4:38 CONSENT AGENDA*

A. November 19, 2013 Meeting Minutes and Synopsis. B. November 15, 2013 Auditor's Warrants. C. November 22, 2013 Auditor's Warrants. D. Approve gambling permit for Brownton Rod & Gun Club in Brownton to conduct a

raffle on February 1, 2014. The application is acknowledged with no waiting period.

E. Approve gambling permit for Brownton Rod & Gun Club in Brownton to conduct a Paddlewheel on March 8, 2014. The application is acknowledged with no waiting period.

F. Approve renewal of Liquor, Wine, Club or 3.2% Licenses for Crow River Winery in Hutchinson from January 1, 2014 through December 31, 2014.

G. Approve renewal of Liquor, Wine, Club or 3.2% Licenses for Lake Marion Supper Club in Brownton from January 1, 2014 through December 31, 2014.

H. Approve renewal of Non-Intoxicating 3.2% Liquor License for Gopher Campfire Club in Hutchinson from January 1, 2014 through December 31, 2014.

I. Approve renewal of Non-Intoxicating 3.2% Liquor Licenses for Major Ave Hunt Club, Inc. in Glencoe from January 1, 2014 through December 31, 2014.

J. Approve 3.2% Non-Intoxicating Liquor License for Brownton Rod & Gun Club in Brownton from January 1, 2014 through December 31, 2014.

4 PAYMENT OF BILLS - COMMISSIONER WARRANT LIST* 5 PAYMENT OF BILLS - ADDITIONAL MISCELLANEOUS BILLS TO BE PAID BY

AUDITORS WARRANTS* 6 4:45 PARKS – Director Al Koglin

A. Consider acceptance of bid from L & P Supply Co. (Hutchinson, MN) to purchase a new Z950R Ferris Zero Trun 72” Mower for $10,350 plus sales tax. This purchase price will be reduced by $5,350 due to the trade in value of an IS3100Z.* Additional bid received: Midwest Machinery Co. (Glencoe, MN) for $6,091.88 including trade in.

7 4:50 SOLID WASTE – Director Ed Homan and Coordinator Sarah Young



A. Consider approval to purchase a new paint can crusher for the Household Hazardous Waste Facility from Teemark (Aitkin, MN) for $31,065.*

Additional bid received Compactors Inc. (Hilton Head, SC) quoted $32,190.00.

This will replace the current 14 year-old crusher which needs frequent adjustments to operate efficiently. The old crusher is not capable of crushing and filtering aerosols, which the new one is able to do.

B. Mattress Recycling Program update.

8 5:10 AUDITOR-TREASURER – Auditor-Treasurer Cindy Schultz

A. Consider approval of Application for Repurchase of Forfeited Property pursuant to Minnesota Statutes, Section 282.241, Resolution 13-CB-44, Property ID Number: 18.050.0200, Property Address: 112 Main St, Plato, Minnesota, Legal Description: Plat of Plato, Block 2, Lots 14-15-16, Legal Owner at the time of Forfeiture Brad Janssen, 7688 174th St, Carver, Minnesota 55315.*

9 5:20 ROAD AND BRIDGE – Highway Engineer John Brunkhorst

A. Consider approval of a culvert replacement on County Road 57.*

During recent patching the poor condition of this culvert was discovered. We would like to expedite the replacement of the pipe. Quotes for labor and materials are being solicited and will be presented at Board meeting.

B. Consider agreement with the state Office of MN.IT Services (MN.IT) Geospatial Information Office (MnGeo) to cooperatively acquire 2014 digital aerial photography for a portion of central and northwest Minnesota on behalf of a multi-agency/county collaborative effort. County share of agreement is not to exceed $50,400 with funding coming from the GIS Aerial Photos Special Revenue Fund and the Technology Fund.* By partnering with MnGeo the county will be saving approximately $20,000 compared to a standalone project. The Cities of Hutchinson and Glencoe have provided letters of commitment to also cost share, which should lower the overall county contribution.

C. Consider hiring Houston Engineering (Maple Grove, MN) for GeoMoose application upgrade and 2014 web hosting. Costs based on hourly rates with an estimated total fee of $10,700 with funding coming from Technology Fund.* The GeoMoose is the interactive web map available on the county website. It has been several years since this has been upgraded. This upgrade is for a new software version and file conversion to better serve our users. The parcel data will also be enhanced with additional attributes.

D. Consider adoption of Resolution 13-RB14-45 Support for the Move MN Campaign.*



The Move MN campaign was created to support the passage of a transportation funding package during the 2014 Legislative Session. The Move MN campaign is committed to addressing Minnesota’s urgent transportation needs – roads, bridges, transit, bike and pedestrian connections. The campaign consists of a growing, diverse coalition dedicated to starting to erase Minnesota’s transportation deficit and creating new funding that will enable the state to properly maintain and improve transportation assets that expand access and opportunity for all, and create living wage jobs.

10 5:35 PROPOSED NORTH COMPLEX SECURITY – John McNamara

A. Presentation from Wold Architects on north complex security.

11 COUNTY ADMINISTRATION

Review of Commissioners Calendar Commissioner reports of committee meetings attended since November 19 2013.

A. Consider approval of 2014 Board Meeting dates.* B. Consider approval of full-time Deputy (grade 19) in Sheriff’s Office due to

reassignment to Communications Officer.* C. Consider approval of full-time Office Support Aide (grade 9) in Public Health due

to resignation.* D. Consider changing the Plan Year for the 2014 Flexible Spending Accounts. The

IRS allows for a grace period of not more than 75 days for expenses to be incurred after the end of the Plan Year. So for 2014, the employee could submit for expenses incurred through March 15, 2015.*

E. Consider approval of Medica Plan documents.* F. Announcement of 2013 Minnesota Counties Intergovernmental Trust (MCIT)

2013 dividend notice. A total dividend to all counties within Minnesota was $19 million. McLeod County 2013 dividend is $237,356 allocated as follows: Workers’ Compensation $86,985 and Property/Casualty $150,371.

G. Meeting to learn more about the County’s proposed plans to retrofit the Materials Recovery Facility (MRF) to accommodate single sort, Thursday, December 5 at 6:00 pm at the Solid Waste facility in Hutchinson.

12 6:00 PUBLIC HEARING – Truth in Taxation

OTHER Open Forum Press Relations RECESS Next board meeting December 17, 2013 at 9:00 a.m. in the County Boardroom.

November 19, 2013 County Board Meeting Page 1


PROPOSED MEETING MINUTES – November 19, 2013 CALL TO ORDER The regular meeting of the McLeod County Board of Commissioners was called to order at 9:00 a.m. by Chair Paul Wright in the County Board Room. Commissioners Nies Shimanski, Terlinden and Christensen were present. County Administrator Patrick Melvin, Administrative Assistant Donna Rickeman, County Auditor-Treasurer Cindy Schultz and County Attorney Michael Junge were also present. PLEDGE OF ALLEGIANCE At the request of the Board Chair, all present recited the Pledge of Allegiance. CONSIDERATION OF AGENDA ITEMS Nies/Shimanski carried unanimously to approve the agenda. CONSENT AGENDA

A) November 5, 2013 Meeting Minutes and Synopsis. B) November 1, 2013 Auditor's Warrants. C) November 8, 2013 Auditor's Warrants. D) Approve Confession of Judgment for Troy Schulze on Property ID 20.050.1600 in

the City of Stewart. E) Approve the following construction changes:

1. SAP 43-602-030 (CSAH 2 concrete overlay south of Silver Lake) a. Work Order 1 – Changes to curb and gutter – Net cost increase =

$17,440 b. Work Order 2 – Additional shouldering material – Net cost increase

= $3,976 c. Change Order 1 – Reduced concrete paving area - Net cost

decrease = $246.84 d. Change Order 2 – Ride disincentive – Net cost decrease =

$2,167.32 2. County Project 5500 (Vehicle Storage Facility)

Terlinden/Shimanski motion carried unanimously to approve the consent agenda. PAYMENT OF BILLS – COMMISSIONER WARRANT LIST

General Revenue $217,243.97 Road & Bridge $21,352.61 Solid Waste $22,647.34


County Ditch Fund $4,684.55 Nies/Terlinden motion carried unanimously to approve payment of bills totaling $265,928.47 from the aforementioned funds. ROAD AND BRIDGE –Engineer John Brunkhorst

A) John Brunkhorst requested approval for final payment of $8,729.90 to Midwest Contracting, LLC (Marshall, MN) for SAP 43-599-034, SAP 43-599-035, and SAP 43-598-013, box culvert construction projects in Bergen Township and on County Road 74. This project is completed satisfactorily and final acceptance and payment is recommended.

Christensen/Nies motion carried unanimously to approve final payment of $8,729.90 to Midwest Contracting, LLC (Marshall, MN) for SAP 43-599-034, SAP 43-599-035, and SAP 43-598-013, box culvert construction projects in Bergen Township and on County Road 74.

B) John Brunkhorst requested adoption of Resolution 13-RB13-43 for 2014-2018 Bridge Programs. This is required by MnDOT State Aid. It is used by their office to prioritize bridges on a statewide level. It also helps them get a handle on the amount of bridge replacements statewide and the amount of funding needed when they approach the legislature.

Nies/Shimanski motion carried unanimously to adopt Resolution 13-RB13-43 for 2014-2018 Bridge Programs.

C) John Brunkhorst requested approval to purchase a Handi Hitch motor grader packer/roller from RDO Equipment (Burnsville, MN) for a total of $26,800 with funding coming from the 2013 Capital Budget. Additional quote received: Ziegler Cat (Minneapolis, MN) $28,700 for similar unit. The Highway Department has two similar units on other motor graders and this has enhanced the quality of the gravel road maintenance by reducing the frequency of blading and gravel loss.

Nies/Terlinden motion carried unanimously to approve the purchase of a Handi Hitch motor grader packer/roller from RDO Equipment (Burnsville, MN) for a total of $26,800 with funding coming from the 2013 Capital Budget.


D) John Brunkhorst requested approval of an agreement with Winsted Township for the replacement of bridge L9913. This is the standard agreement for Townships wanting to proceed with a bridge replacement project. The project is typically funded with Town Bridge, State Bridge Bonds, and Local Township funding.

Christensen/Shimanski motion carried unanimously to approve an agreement with Winsted Township for the replacement of bridge L9913. HUMAN RESOURCES – Director Mary Jo Wieseler

A) Consider November 12, 2013 Staffing Request Recommendations.

1. Discuss filling Communications Officer vacancy due to resignation. Recommendation: Hire full-time Communications Officer (grade15) due to vacancy.

Nies/Shimanski motion carried unanimously to hire full-time Communications Officer (grade15) due to vacancy.

2. Discuss filling vacancy in Tri-Star ACT Team for Mental Health Professional (grade 28). McLeod County is the hiring authority for the ACT Team. Recommendation: Act as hiring authority to hire full-time Mental Health Professional (grade 28) for Tri-Star ACT Team. Position will continue only as long as McLeod County is reimbursed at least 105%.

Terlinden/Shimanski motion carried unanimously to act as hiring authority to hire full-time Mental Health Professional (grade 28) for Tri-Star ACT Team. Position will continue only as long as McLeod County is reimbursed at least 105%.

3. Discuss temporary increase in hours for Social Worker from end of Jan 2014 to approximately end of April 2014 from 28 hours per week to 33 per week to help cover for leave of another Social Worker. Recommendation: Due to the Affordable Care Act (ACA) requiring everyone who is at 30 hours per week or more to be enrolled in Health Insurance and not knowing what other changes might be required under ACA, recommendation is not to increase hours of part-time employees to over 30 hours per week.

Terlinden/Nies motion carried unanimously to not increase hours of part-time employees to over 30 hours per week.


4. Discuss Technical Specialist II position in Recorder’s Office. Recommendation: Hire part-time (28 hours per week) Technical Specialist II in Recorder’s Office.

Nies/Terlinden motion carried unanimously to hire part-time (28 hours per week) Technical Specialist II in Recorder’s Office.

5. Discuss staffing needs in Public Health for MN Choices. Recommendation:

Hire part-time (28 hours per week) Public Health Nurse II (grade 26)

Hire full-time Licensed Social Worker (grade 22) Hire full-time Public Health Nurse (grade 24) or Registered Nurse

(grade 22) if no PHNs apply or are selected Hire full-time Technical Clerk (grade 12)

Shimanski/Christensen motion carried unanimously to hire part-time (28 hours per week) Public Health Nurse II (grade 26), hire full-time Licensed Social Worker (grade 22), hire full-time Public Health Nurse (grade 24) or Registered Nurse (grade 22) if no PHNs apply or are selected and hire full-time Technical Clerk (grade 12).

B) Mary Jo Wieseler requested approval to send out a Request for Proposal for Classification and Compensation Study. This is one of the goals that were determined from the long range/strategic planning sessions that were held earlier in 2013.

The last compensation study was done over 13 years ago with many job duties and responsibilities having changed during that period of time along with the job market. The high cost of turnover including additional staff time for reviewing applicants and interviewing, advertising, training new employees, loss of proficiency, cost of required certificates/training for certain employees constitutes a need to complete a market study to focus on retaining current employees and attract knowledgeable candidates for future openings.

Nies/Shimanski motion carried unanimously to approve submission of Request for Proposal for Classification and Compensation Study. JAIL – Administrator Kate Jones

A) Kate Jones presented Will Feltmann with the Correctional Officer of the Year Award that was announced at the Minnesota Sheriffs Association Conference. Will is one of the jail’s seasoned go-to officers for most anything. He is willing to do any job and take on any task that is asked of him no matter how menial. Will


works very well with difficult inmates, not everyone can keep their cool and deescalate situations. Will has worked on making this a seamless priority so that the inmate feels that they have a vested interest in their care and behavior while he affects a win-win for everyone.

ZONING DEPARTMENT –Zoning Administrator Larry Gasow

A) Larry Gasow brought forward a request from Joel Zellmann for approval of Conditional Use Permit 13-10 tabled from the November 5th County Board Meeting with the following conditions defined by the County Attorney, Zoning Administrator and Applicant:

1. The home occupation of the auto repair and sales shall have the umbrella of one use and considered as compatible since they are similar in nature and are located at the same site.

2. Applicant shall keep and maintain a valid Dealer’s License from the Minnesota Department of Motor Vehicle and abide by the regulations set forth. An invalid Dealer’s License shall constitute this Conditional Use Permit for auto sale null and void. Proof of a valid Dealer’s License shall be made available to the zoning office upon request.

3. Hours of operation for both the auto repair and sales shall not exceed 8:00 AM – 8:00 PM., Monday – Saturday or as authorized by statute regarding auto sales. Any repair work done beyond these normal hours of operation shall be done within the shop area, with the exception of emergency towing services.

4. The applicant shall construct a designated visible outdoor display area not to exceed 50 feet in width and 30 feet in depth, of which display area shall not exceed five (5) units being for sale.

5. The designated outdoor display area shall maintain a minimum of 10 feet from CR #15 (Falcon Ave) road right of way areas. Future road re-construction plans call for a new road right of way width of 60 feet, to conform to with future plans the display area shall be moved to 70 feet from the centerline of CR #15. The display area shall also be a minimum of 20 feet and maximum of 40 feet to the south of the applicant’s driveway to create a proper site clearance area for on-coming traffic on CR #15.

6. This designated area shall be constructed prior to the use of auto sales on an outdoor display lot within the front yard area.

7. The concern of traffic safety will be monitored by the McLeod County Highway Department. If a safety situation arises that is solely attributable to the applicant, the problem will be addressed and corrective measures will be put into place by McLeod County with costs being incurred by the current conditional use permit owner. These measures could include, but not limited to: proper signage, the construction of a right turn lane for north bound traffic and a left turn and/or bypass lane for the south bound traffic.

8. The site shall not exceed a total 40 vehicles, this will include but not limited to all vehicles for sale, personal vehicles, customer vehicles, employee vehicles and any unlicensed or inoperable vehicles. This will not include


vehicles that are enclosed in a building with 4 sides and a roof or vehicles of non-business related visitors for a period not to exceed 24 hours on holidays or family events shall not be included in said count.

9. The exterior storage of all vehicles not for sale, campers, boats and recreational vehicles shall not be kept within the front yard area.

10. The outdoor display area will not have any lights, flags, balloons or any other type of mechanisms to draw attention to the vehicle sales lot.

11. All solid and potential hazardous wastes generated by the businesses shall be collected by a licensed hauler for proper disposal.

12. The applicant shall communicate with the customers that upon test drives of all vehicles that neighboring private driveways should not be used as a turn around.

13. There shall be a review of the site by the McLeod County Planning Commission, with copies of the dealer’s license and receipts of waste disposal that will be submitted to the zoning office for documentation on an annual basis.

Terlinden/Nies motion carried unanimously to approve Conditional Use Permit 13-10 for Joel Zellmann with the conditions listed.

COUNTY ADMINISTRATION

A) Pat Melvin requested approval to set Public Hearing for fee schedule on December 17, 2013 for 10:00 AM.

Shimanski/Christensen motion carried unanimously to set Public Hearing for fee schedule on December 17, 2013 for 10:00 AM.

B) Donna Rickeman requested approval to set date for the Board to meet with Elected Department Heads on December 3, 2013 beginning at 3:30 PM.

Terlinden/Shimanski motion carried unanimously to set date for the Board to meet with Elected Department Heads on December 3, 2013 beginning at 3:30 PM.

C) Pat Melvin requested approval to set closed meeting for his performance evaluation on December 31, 2013 following the Board Meeting.

Terlinden/Shimanski motion carried unanimously to set date for Pat Melvin’s performance evaluation on December 31, 2013 following the Board Meeting.

D) Discussion was held on county commissioner vacancies on the Soil and Water Resources Board. Son Shimanski and Kermit Terlinden will consider this and if interested apply prior to the November 26th deadline.

E) Pat Melvin reminded the board of the recognition party, December 6th at 5:30 pm in Commercial Building at the Fairgrounds.

F) Pat Melvin reminded the board to turn in all expense reports by December 2nd.


Nies/Shimanski motion carried unanimously to adjourn at 11:08 a.m. until 4:30 p.m. December 3, 2013 in the County Boardroom. ATTEST: _____________________________ ___________________________________ Paul Wright, Board Chair Patrick Melvin, County Administrator


SYNOPSIS – November 19, 2013

1. Commissioners Wright, Nies, Shimanski, Terlinden and Christensen were present.

2. Nies/Shimanski carried unanimously to approve the agenda. 3. Terlinden/Shimanski motion approved the consent agenda including November

5, 2013 Meeting Minutes and Synopsis; November 1, 2013 Auditor's Warrants; November 8, 2013 Auditor's Warrants; Approve Confession of Judgment for Troy Schulze on Property ID 20.050.1600 in the City of Stewart; Approve the following construction changes: SAP 43-602-030 (CSAH 2 concrete overlay south of Silver Lake), County Project 5500 (Vehicle Storage Facility).

4. Nies/Terlinden motion carried unanimously to approve payment of bills totaling $265,928.47 from the aforementioned funds.

5. Christensen/Nies motion carried unanimously to approve final payment of $8,729.90 to Midwest Contracting, LLC (Marshall, MN) for SAP 43-599-034, SAP 43-599-035, and SAP 43-598-013, box culvert construction projects in Bergen Township and on County Road 74.

6. Nies/Shimanski motion carried unanimously to adopt Resolution 13-RB13-43 for 2014-2018 Bridge Programs.

7. Nies/Terlinden motion carried unanimously to approve the purchase of a Handi Hitch motor grader packer/roller from RDO Equipment (Burnsville, MN) for a total of $26,800 with funding coming from the 2013 Capital Budget.

8. Christensen/Shimanski motion carried unanimously to approve an agreement with Winsted Township for the replacement of bridge L9913.

9. Nies/Shimanski motion carried unanimously to hire full-time Communications Officer (grade15) due to vacancy.

10. Terlinden/Shimanski motion carried unanimously to act as hiring authority to hire full-time Mental Health Professional (grade 28) for Tri-Star ACT Team. Position will continue only as long as McLeod County is reimbursed at least 105%.

11. Terlinden/Nies motion carried unanimously to not increase hours of part-time employees to over 30 hours per week.

12. Nies/Terlinden motion carried unanimously to hire part-time (28 hours per week) Technical Specialist II in Recorder’s Office.

13. Shimanski/Christensen motion carried unanimously to hire part-time (28 hours per week) Public Health Nurse II (grade 26), hire full-time Licensed Social Worker (grade 22), hire full-time Public Health Nurse (grade 24) or Registered Nurse (grade 22) if no PHNs apply or are selected and hire full-time Technical Clerk (grade 12).

14. Nies/Shimanski motion carried unanimously to approve submission of Request for Proposal for Classification and Compensation Study.

15. Terlinden/Nies motion carried unanimously to approve Conditional Use Permit 13-10 for Joel Zellmann with the conditions listed.

16. Shimanski/Christensen motion carried unanimously to set Public Hearing for fee schedule on December 17, 2013 for 10:00 AM.

17. Terlinden/Shimanski motion carried unanimously to set date for the Board to meet with Elected Department Heads on December 3, 2013 beginning at 3:30 PM.

18. Terlinden/Shimanski motion carried unanimously to set date for Pat Melvin’s performance evaluation on December 31, 2013 following the Board Meeting.

Complete minutes are on file in the County Administrator’s Office. The meeting adjourned at 11:08 a.m. until December 3, 2013. Attest: Paul Wright, Board Chair Patrick Melvin, County Administrator

ROBECK

Explode Dist. Formulas?:

Paid on Behalf Of Name

1:32PM11/15/13Audit List for Board Page 1

Print List in Order By:

Y

on Audit List?: N

Type of Audit List: D

Save Report Options?:

AUDITOR'S VOUCHERS ENTRIES

D - Detailed Audit ListS - Condensed Audit List

2 1 - Fund (Page Break by Fund)2 - Department (Totals by Dept)3 - Vendor Number4 - Vendor Name

N

1Page Break By: 1 - Page Break by Fund2 - Page Break by Dept

********* McLeod County IFS *********

ROBECK

General Revenue Fund1

Account/Formula

Copyright 2010 Integrated Financial Systems

1:32PM11/15/13

35.01 1

121.78 3

156.79

1,369.78 12

35.0167

64.98121

17.68122

39.12123

105.0087

123.7588

11.2577

18.7578

120.0079

127.5080

7.5081

168.7582

166.0383

255.0084

120.0085

146.2586

780.0090

618.7591

356.2592

303.7593

577.5094

611.2595

690.0096

1,083.7597

AUDITOR'S VOUCHERS ENTRIESPage 2

Audit List for Board

Account/Formula Description Rpt Invoice #Warrant DescriptionVendor NamePaid On Bhf #Accr Amount On Behalf of NameNo. Service Dates

5 Board of County CommissionersDEPT

VERIZON WIRELESS6412

01-005-000-0000-6203 I PAD USE 9714268184 Communications

VERIZON WIRELESS Transactions6412

VISA1440

01-005-000-0000-6336 GERT & ERMAS-SECURITY LUNCH Meals, Lodging, Parking & Miscellaneous

01-005-000-0000-6336 COBORNS-NEG CLOSED MTG Meals, Lodging, Parking & Miscellaneous

01-005-000-0000-6336 SUBWAY-NEG CLOSED MTG Meals, Lodging, Parking & Miscellaneous

VISA Transactions1440

5 Board of County Commissioners 2 Vendors 4 TransactionsDEPT Total:

13 Court Administrator's OfficeDEPT

CONKEL/JEANNE M V9555

01-013-000-0000-6272 COURT APPOINT NO/BB JV-13-103 Court Appt Atty-Dep/Neg/Ter

01-013-000-0000-6272 COURT APPOINT AG/ER JV-13-134 Court Appt Atty-Dep/Neg/Ter

01-013-000-0000-6273 COURT APPOINT CJ F2-03-50440 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT DH FA-13-552 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT LM PR-13-1572 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT GE P8-99-71 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT KW PR-13-1010 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT DD PR-13-327 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT CV PR-06-563 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT B KLIMA Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT JD PR-13-1474 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT MF P9-96-64 Court Appt Atty-Other

CONKEL/JEANNE M V Transactions9555

ELSE/JENNIFER R5915

01-013-000-0000-6273 COURT APPOINT JB PR-13-782 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT GV PR-13-1154 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT PD PR-13-915 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT SF PR-13-875 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT TP PR-13-623 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT HP PR-13-533 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT PJ FA-13-1497 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT AM JV-13-104 Court Appt Atty-Other


ROBECK


Account/Formula

GAVIN OLSON WINTERS TWISS THIEMANN LONG

GAVIN OLSON WINTERS TWISS THIEMANN LONG


1:32PM11/15/13

5,021.25 8

776.25 3

2,107.50 7

9,274.78

195.57 1

195.57

3,749.26 2

15.0099

502.50100

258.7598

1,252.50107

405.00108

180.00109

15.00110

225.00111

15.00112

15.00113

195.575810/03/2013 11/02/2013

31.50310/18/2013 11/17/2013

3,717.76410/18/2013 11/17/2013

1,290.796




ELSE/JENNIFER R Transactions5915

812

01-013-000-0000-6273 COURT APPOINT AD FA-07-2483 20090595-000M Court Appt Atty-Other

01-013-000-0000-6273 COURT APPOINT AR PR-13-1541 20110506-001M Court Appt Atty-Other

01-013-000-0000-6272 COURT APPOINT MB/EB JV-13-155 20130331-000M Court Appt Atty-Dep/Neg/Ter

Transactions812

THE LAW OFFICE OF TROY A SCOTTING377

01-013-000-0000-6272 COURT APPT RD/JC/EC JV-13-42 Court Appt Atty-Dep/Neg/Ter

01-013-000-0000-6272 COURT APPT AS/TS JV-13-207 Court Appt Atty-Dep/Neg/Ter

01-013-000-0000-6272 COURT APPT JB/JL JV-13-180 Court Appt Atty-Dep/Neg/Ter

01-013-000-0000-6272 COURT APPT AG/AR JV-12-253 Court Appt Atty-Dep/Neg/Ter

01-013-000-0000-6273 COURT APPT DS FA-13-1370 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPT JU FA-13-1105 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPT KF FA-13-588 Court Appt Atty-Other

THE LAW OFFICE OF TROY A SCOTTING Transactions377

13 Court Administrator's Office 4 Vendors 30 TransactionsDEPT Total:

65 Information Systems OfficeDEPT


01-065-000-0000-6203 CELL PHONE USAGE 9714268184 Communications


65 Information Systems Office 1 Vendors 1 TransactionsDEPT Total:

76 Central Services - County WideDEPT

CENTURYLINK5906

01-076-000-0000-6203 LOCAL SVC 313623769 Communications

01-076-000-0000-6203 LOCAL SVC 314019358 Communications

CENTURYLINK Transactions5906

CENTURYLINK11580

01-076-000-0000-6203 LONG DISTANCE 320439462 Communications


ROBECK


Account/Formula


1:32PM11/15/13

1,290.79 1

19.00 1

2,220.14 1

7,279.19

32.06 1

75.82 1

107.88

165.00 1

165.00

64.15 1

19.0025

2,220.1447

32.0624

75.82103

165.00120

64.155910/03/2013 11/02/2013





DEX ONE5433

01-076-000-0000-6203 OCTOBER ADVERTISING CHARGE 300142598 Communications

DEX ONE Transactions5433

NU-TELECOM5771

01-076-000-0000-6203 T1, EXT, PRI, SW B1 81038173 Communications

NU-TELECOM Transactions5771

76 Central Services - County Wide 4 Vendors 5 TransactionsDEPT Total:

85 ElectionsDEPT

DS SOLUTIONS INC6141

01-085-000-0000-6350 GENERAL TEST DECK &SPREADSHEET 10713 Other Services & Charges

DS SOLUTIONS INC Transactions6141

MINNESOTA HUMAN SERVICES46486

01-085-000-0000-6407 VOTER REG CARDS 281 A300IC4317I State Voter Registration Cards

MINNESOTA HUMAN SERVICES Transactions46486

85 Elections 2 Vendors 2 TransactionsDEPT Total:

103 County Assessor's OfficeDEPT

VISA1440

01-103-000-0000-6245 USPAP-MN ASSOC OF ASSESSORS-JS Dues And Registration Fees


103 County Assessor's Office 1 Vendors 1 TransactionsDEPT Total:

111 Courthouse BuildingDEPT





ROBECK


Account/Formula


1:32PM11/15/13

64.15

99.00 1

4,269.38 13

99.00175

319.013209/30/2013 10/30/2013

40.873509/30/2013 10/30/2013

727.872909/30/2013 10/30/2013

786.163009/30/2013 10/30/2013

385.433109/30/2013 10/30/2013

532.093809/30/2013 10/30/2013

32.113309/30/2013 10/30/2013

36.573909/30/2013 10/30/2013

927.744009/30/2013 10/30/2013

268.003609/30/2013 10/30/2013

67.634109/30/2013 10/30/2013

40.773409/30/2013 10/30/2013

105.133709/30/2013 10/30/2013

136.14170




111 Courthouse Building 1 Vendors 1 TransactionsDEPT Total:

117 FairgroundsDEPT

COMMISSIONER OF REVENUE651

01-117-000-0000-6612 OCTOBER 2013 USE TAX Capital - $100-$5,000 (Inventory)

COMMISSIONER OF REVENUE Transactions651

HUTCHINSON UTILITIES COMMISSION540

01-117-000-0000-6253 ELECTRIC FAIRGROUNDS 436962-045052 Electricity

01-117-000-0000-6253 ELECTRIC 898 CENTURY AVE SW 436962-045052 Electricity

01-117-000-0000-6253 ELECTRIC GRANDSTAND 436972-045045 Electricity

01-117-000-0000-6253 ELECTRIC ADMIN BLDG 436973-045045 Electricity

01-117-000-0000-6253 ELECTRIC AGRIBITION 436974-045045 Electricity

01-117-000-0000-6255 GAS AGRIBITION 436974-045045 Natural Gas

01-117-000-0000-6253 ELECTRIC MAINT BLDG 436976-045045 Electricity

01-117-000-0000-6255 GAS MAINT BLDG 436976-045045 Natural Gas

01-117-000-0000-6255 GAS FAIRGROUNDS 436978-045045 Natural Gas

01-117-000-0000-6253 ELECTREC 820 CENTURY AVE SW 436979-045045 Electricity

01-117-000-0000-6255 GAS 820 CENTURY AVE SW HOUSE 436979-045045 Natural Gas

01-117-000-0000-6253 ELECTRIC SIGN 436981-045045 Electricity

01-117-000-0000-6253 ELECTRIC 816 CENTURY AVE SW 437020-045045 Electricity

HUTCHINSON UTILITIES COMMISSION Transactions540

NU-TELECOM5771

01-117-000-0000-6203 PHONE 81038426 Communications


ROBECK


Account/Formula


1:32PM11/15/13

136.14 1

422.66 1

4,927.18

20.35 1

20.35

31.62 1

297.11 1

7.00 1

22,903.25 1

6,540.50 1

422.66171

20.356010/03/2013 11/02/2013

31.62710/04/2013 11/05/2013

297.115

7.00176

22,903.2589

6,540.50135





WASTE MANAGEMENT OF WI MN2038

01-117-000-0000-6257 REFUSE 6587302-1593 Sewer, Water And Garbage Removal

WASTE MANAGEMENT OF WI MN Transactions2038

117 Fairgrounds 4 Vendors 16 TransactionsDEPT Total:

121 Veteran Services OfficeDEPT




121 Veteran Services Office 1 Vendors 1 TransactionsDEPT Total:

201 County Sheriff's OfficeDEPT

CENTER POINT ENERGY539

01-201-000-0000-6253 GAS-STORAGE 5987117-8 Electricity

CENTER POINT ENERGY Transactions539

CENTURYLINK5906

01-201-000-0000-6203 LEC ARMER T1 TO NYA 313623769 Communications



01-201-000-0000-6350 OCTOBER 2013 USE TAX Other Services & Charges


COUNTY OF ANOKA4724

01-201-000-0000-6369 4TH QTR 2013 SERVICES MEDICAL EXAMINER

COUNTY OF ANOKA Transactions4724

GLENCOE AUTO BODY INC2836

01-201-000-0000-6327 130 REPAIR SQUAD 13729 General Auto Maintenance

GLENCOE AUTO BODY INC Transactions2836


ROBECK


Account/Formula


1:32PM11/15/13

142.97 1

842.33 5

30,764.78

17.69 1

35.44 1

53.13

35.92 1

142.97136

165.245111/03/2013 12/02/2013

44.855311/03/2013 12/02/2013

257.035511/03/2013 12/02/2013

349.195611/03/2013 12/02/2013

26.025411/03/2013 12/02/2013

17.695211/03/2013 12/02/2013

35.446110/03/2013 11/02/2013

35.926210/03/2013 11/02/2013




LIGHT & POWER COMMISSION253

01-201-000-0000-6253 ELECTRIC BAXTER AVE 01-802120-03 Electricity

LIGHT & POWER COMMISSION Transactions253

VERIZON WIRELESS150

01-201-000-0000-6203 SO CELL PHONE USAGE 9714275857 Communications

01-201-000-0000-6203 CO ATTY-CELL PHONE USAGE 9714275877 Communications

01-201-000-0000-6203 MCSO CELL PHONE USAGE 9714275877 Communications

01-201-000-0000-6203 MCSO AIR SOURCE CARDS 9714275877 Communications

01-201-000-9001-6350 BROWNTON PD AIR SOURCE CARDS 9714275877 Other Services & Charges-Brownton Cl


201 County Sheriff's Office 7 Vendors 11 TransactionsDEPT Total:

251 County JailDEPT

VERIZON WIRELESS150

01-251-000-0000-6203 JAIL CELL PHONE USAGE 9714275857 Communications





251 County Jail 2 Vendors 2 TransactionsDEPT Total:

255 County Court ServicesDEPT





ROBECK


Account/Formula


1:32PM11/15/13

35.92

12.00 1

89.65 4

101.65

40.25 1

40.25

18.95 1

224.43 1

243.38

53,430.00

12.00177

12.84114

6.42115

35.01116

35.386310/03/2013 11/02/2013

40.2546

18.956410/03/2013 11/02/2013

224.43119




255 County Court Services 1 Vendors 1 TransactionsDEPT Total:

485 County Public Health NursingDEPT


01-485-000-0000-6402 OCTOBER 2013 USE TAX Office Supplies



01-485-000-0000-6203 WIRELESS CHARGES (CC 15) 9714268164 Communications

01-485-000-0000-6203 WIRELESS CHARGES (CC 53) 9714268164 Communications

01-485-474-0000-6203 IPAD CHARGES 9714268164 Communications



485 County Public Health Nursing 2 Vendors 5 TransactionsDEPT Total:

520 County Park'sDEPT

NU-TELECOM5771

01-520-000-0000-6203 PIEPENBURG 587-2082 81038173 Communications


520 County Park's 1 Vendors 1 TransactionsDEPT Total:

609 Environmental Services OfficeDEPT




VISA1440

01-609-000-0000-6336 BWSR ACADEMY CONF-CRAGUNS-RB Meals, Lodging, Parking & Miscellaneous


609 Environmental Services Office 2 Vendors 2 TransactionsDEPT Total:

1 General Revenue FundFund Total: 83 Transactions


ROBECK

Road & Bridge Fund3

Account/Formula


1:32PM11/15/13

60.00 1

60.00

94,269.70 2

249,681.09 3

18,179.20 1

362,129.99

1,449.16 1

181.17 1

1,630.33

60.00178

5,380.26138

88,889.44139

4,483.199

184,524.1510

60,673.7511

18,179.2026

1,449.16109/30/2013 10/22/2013

181.175709/03/2013 10/02/2013




310 Highway MaintenanceDEPT


03-310-000-0000-6532 OCTOBER 2013 USE TAX Traffic Marking


310 Highway Maintenance 1 Vendors 1 TransactionsDEPT Total:

320 Highway ConstructionDEPT

CITY OF SILVER LAKE315

03-320-000-0000-6641 #6 602-029 JOB 21 SL 602-029-6 State Aid-Regular Construction

03-320-000-0000-6641 #6 602-029 JOB 21 SL 602-029-6 State Aid-Regular Construction

CITY OF SILVER LAKE Transactions315

CITY OF STEWART324

03-320-000-0000-6643 #9 711-005 CSAH 111 STEWART 711-005-10 County Road Construction

03-320-000-0000-6643 #9 711-005 CSAH 111 STEWART 711-005-10 County Road Construction

03-320-000-0000-6680 #9 711-005 CSAH 111 STEWART 711-005-10 Saftey Grant

CITY OF STEWART Transactions324

HOFFMAN CONCRETE INC1500

03-320-000-0000-6643 #3 SAP 43-602-30 602-30-3 County Road Construction

HOFFMAN CONCRETE INC Transactions1500

320 Highway Construction 3 Vendors 6 TransactionsDEPT Total:

330 Highway AdministrationDEPT

ARAMARK UNIFORM SERVICES5658

03-330-000-0000-6145 UNIFORM SERVICES 800409000 Uniform Allowance

ARAMARK UNIFORM SERVICES Transactions5658


03-330-000-0000-6203 CELL PHONE USE 9873744852 Communications


330 Highway Administration 2 Vendors 2 TransactionsDEPT Total:


ROBECK

Road & Bridge Fund3

Account/Formula


1:32PM11/15/13

34.16 1

242.46 2

153,844.90 1

114.90 3

154,236.42

518,056.74

34.168

139.8927

102.5728

153,844.9049

19.4270

36.3169

59.1768




340 Highway Equipment MaintenanceDEPT

CITY OF SILVER LAKE315

03-340-000-0000-6257 WATER/SEWER 20000148009 Sewer, Water And Garbage Removal

CITY OF SILVER LAKE Transactions315


03-340-000-0000-6253 ELECTRIC TEMP STORAGE 31021-045101 Electricity

03-340-000-0000-6255 GAS TEMP STORAGE 31021-045101 Natural Gas


RAM GENERAL CONTRACTING INC1600

03-340-000-0000-6610 #4 CP 13-5500 NEW SHOP 5500-4-3319 Capital - Over $5,000 (Fixed Assets)

RAM GENERAL CONTRACTING INC Transactions1600


03-340-000-0000-6257 GARBAGE REMOVAL-SL 6587350-1593-0 Sewer, Water And Garbage Removal

03-340-000-0000-6257 GARBAGE REMOVAL-GLENCOE 6587351-1593-8 Sewer, Water And Garbage Removal

03-340-000-0000-6257 GARBAGE REMOVAL-LP 6587353-1593-4 Sewer, Water And Garbage Removal


340 Highway Equipment Maintenance 4 Vendors 7 TransactionsDEPT Total:

3 Road & Bridge FundFund Total: 16 Transactions


ROBECK

Solid Waste Fund5

Account/Formula


1:32PM11/15/13

843.99 2

12,488.42 7

13,332.41

3,469.82 2

133.27 1

606.7214109/27/2013 10/30/2013

237.2714409/27/2013 10/30/2013

917.8414610/01/2013 10/31/2013

2,638.7914710/01/2013 10/31/2013

917.8414810/01/2013 10/31/2013

229.4614910/01/2013 10/31/2013

334.1915010/01/2013 10/31/2013

5,094.3015210/01/2013 10/31/2013

2,356.0016210/01/2013 10/31/2013

2,494.3414009/27/2013 10/30/2013

975.4814309/27/2013 10/30/2013

133.27172




391 Solid Waste Tip FeeDEPT


05-391-000-0000-6253 ELECTRIC 410076-027482 Electricity

05-391-000-0000-6255 GAS 410076-027482 Natural Gas


WEST CENTRAL SANITATION INC4147

05-391-000-0000-6259 STEWART DROP BOX RECYCLING Recycling

05-391-000-0000-6259 GLENCOE DROP BOX RECYCLING Recycling

05-391-000-0000-6259 BROWNTON DROP BOX RECYCLING Recycling

05-391-000-0000-6259 SL DROP BOX RECYCLING Recycling

05-391-000-0000-6259 LP DROP BOX RECYCLING Recycling

05-391-000-0000-6259 TOWNSHIP SHED Recycling

05-391-000-0000-6258 COUNTY & SCHOOL COLLECTION 9876941 School Recycling

WEST CENTRAL SANITATION INC Transactions4147

391 Solid Waste Tip Fee 2 Vendors 9 TransactionsDEPT Total:

393 Materials Recovery FacilityDEPT



05-393-000-0000-6255 GAS 410076-027482 Natural Gas



05-393-000-0000-6257 RECYCLING RESIDUE GARBAGE 10657-1702-5 Sewer, Water And Garbage Removal



ROBECK

Solid Waste Fund5

Account/Formula


1:32PM11/15/13

32,620.65 17

36,223.74

145.0615110/01/2013 10/31/2013

120.6015310/01/2013 10/31/2013

5,995.1615410/01/2013 10/31/2013

15,943.3215510/01/2013 10/31/2013

846.8815610/01/2013 10/31/2013

1,795.6015710/01/2013 10/31/2013

380.5615810/01/2013 10/31/2013

954.0815910/01/2013 10/31/2013

621.7616010/01/2013 10/31/2013

2,511.1616110/01/2013 10/31/2013

26.7216310/01/2013 10/31/2013

26.8016410/01/2013 10/31/2013

234.3516510/01/2013 10/31/2013

2,820.8016610/01/2013 10/31/2013

86.0016710/01/2013 10/31/2013

51.6016810/01/2013 10/31/2013

60.2016910/01/2013 10/31/2013





05-393-000-0000-6257 GARBAGE HAULING CHARCES Sewer, Water And Garbage Removal

05-393-000-0000-6259 BISCAY COLLECTION 9876941 Recycling

05-393-000-0000-6259 GLENCOE COLLECTION 9876941 Recycling

05-393-000-0000-6259 HUTCHINSON COLLECTION 9876941 Recycling

05-393-000-0000-6259 BROWNTON COLLECTION 9876941 Recycling

05-393-000-0000-6259 LESTER PRAIRIE COLLECTION 9876941 Recycling

05-393-000-0000-6259 PLATO COLLECTION 9876941 Recycling

05-393-000-0000-6259 SILVER LAKE COLLECTION 9876941 Recycling

05-393-000-0000-6259 STEWART COLLECTION 9876941 Recycling

05-393-000-0000-6259 WINSTED COLLECTION 9876941 Recycling

05-393-000-0000-6259 VALET SERVICE 9876941 Recycling

05-393-000-0000-6259 RURAL RDU COLLECTION 9876941 Recycling

05-393-000-0000-6259 GLENCOE MUD COLLECTION 9876941 Recycling

05-393-000-0000-6259 HUTCHINSON MUD COLLECTION 9876941 Recycling

05-393-000-0000-6259 WINSTED MUD COLLECTION 9876941 Recycling

05-393-000-0000-6259 SILVER LAKE MUD COLLECTION 9876941 Recycling

05-393-000-0000-6259 BROWNTON MUD COLLECTION 9876941 Recycling


393 Materials Recovery Facility 3 Vendors 20 TransactionsDEPT Total:


ROBECK

Solid Waste Fund5

Account/Formula


1:32PM11/15/13

375.10 2

375.10

49,931.25

269.6514209/27/2013 10/30/2013

105.4514509/27/2013 10/30/2013




397 Household Hazardous WasteDEPT



05-397-000-0000-6255 GAS 410076-027482 Natural Gas


397 Household Hazardous Waste 1 Vendors 2 TransactionsDEPT Total:

5 Solid Waste FundFund Total: 31 Transactions


ROBECK

Human Service Fund11

Account/Formula


1:32PM11/15/13

131.80 1

131.80

197.72 1

197.72

329.52

131.806510/03/2013 11/02/2013

197.726610/03/2013 11/02/2013




420 Income MaintenanceDEPT


11-420-600-0010-6203 CELL PHONE USAGE 9714268184 Communications/Postage


420 Income Maintenance 1 Vendors 1 TransactionsDEPT Total:

430 Individual and Family Social ServicesDEPT


11-430-700-0010-6203 CELL PHONE USAGE 9714268184 Communications/Postage


430 Individual and Family Social Services 1 Vendors 1 TransactionsDEPT Total:

11 Human Service FundFund Total: 2 Transactions


ROBECK

Special Revenue Fund25

Account/Formula


1:32PM11/15/13

123.53 1

2,209.68 2

2,333.21

274.81 1

145.91 1

420.72

187.63 1

187.63

85.00 1

123.5371

125.0012510/01/2013 10/31/2013

2,084.6812410/01/2013 10/31/2013

274.812

145.9143

187.63137

85.00102




15 Law LibraryDEPT

MATTHEW BENDER & CO INC6

25-015-000-0000-6451 LAW BOOKS DUNNELL MN DIGEST 52062279 Books

MATTHEW BENDER & CO INC Transactions6

WEST PAYMENT CENTER358

25-015-000-0000-6451 WEST INFORMATION CHARGES 828321675 Books

25-015-000-0000-6451 WEST INFORMATION CHARGES 8283271761 Books

WEST PAYMENT CENTER Transactions358

15 Law Library 2 Vendors 3 TransactionsDEPT Total:

32 McLeod For TomorrowDEPT

CARLSONS ORCHARD & BAKERY5902

25-032-000-0000-6350 MFT WINSTED 10/2013 Leadership Program Expenses

CARLSONS ORCHARD & BAKERY Transactions5902

HENRICH/MICHAEL1854

25-032-000-0000-6350 MFT WINSTED 10/2013 Leadership Program Expenses

HENRICH/MICHAEL Transactions1854

32 McLeod For Tomorrow 2 Vendors 2 TransactionsDEPT Total:

252 Jail Canteen AccountDEPT

BOB BARKER COMPANY INC3510

25-252-000-0000-6460 DEODERANT WEB000291385 Jail Supplies

BOB BARKER COMPANY INC Transactions3510

252 Jail Canteen Account 1 Vendors 1 TransactionsDEPT Total:

614 Wetlands Administration - GrantDEPT

MAWD1833

25-614-000-0000-6245 CONF REG-R BERGGREN Dues And Registration Fees

MAWD Transactions1833


ROBECK


Account/Formula


1:32PM11/15/13

85.00

153,844.90 1

7,588.05 1

161,432.95

164,459.51

153,844.9048

7,588.0550




614 Wetlands Administration - Grant 1 Vendors 1 TransactionsDEPT Total:

807 Designated for Capital AssetsDEPT

RAM GENERAL CONTRACTING INC1600

25-807-000-0000-6610 #4 CP 13-5500 NEW SHOP 5500-4-3319 Capital - Over $5,000 (Fixed Assets)

RAM GENERAL CONTRACTING INC Transactions1600

RTVISION INC5

25-807-000-0000-6610 E-TIMECARD TRAINING-SPPT CON 11585 Capital - Over $5,000 (Fixed Assets)

RTVISION INC Transactions5

807 Designated for Capital Assets 2 Vendors 2 TransactionsDEPT Total:

25 Special Revenue FundFund Total: 9 Transactions


ROBECK

Community Health Service Fund82

Account/Formula

Community Health Service Fund


1:32PM11/15/13

1,800.00 1

1,800.00

212.00 2

212.00

2,023.38 3

2,023.38

4,035.38

1,800.0042

200.0075

12.0076

1,960.0072

46.7374

16.6573




849 Immunization GrantDEPT

MEEKER COUNTY TREASURER222

82-849-000-0000-6850 IMMUN-IPI SEP Collections For Other Agencies

MEEKER COUNTY TREASURER Transactions222

849 Immunization Grant 1 Vendors 1 TransactionsDEPT Total:

853 Local Public Health GrantDEPT

BUERKLE/RHONDA718

82-853-000-0000-6121 GENERAL CHS TIME(SIBLEY) Personnel Wages

82-853-000-0000-6336 CHS MEALS/LODGING Meals, Lodging, Parking & Miscellaneous

BUERKLE/RHONDA Transactions718

853 Local Public Health Grant 1 Vendors 2 TransactionsDEPT Total:

862 SHIPDEPT

BUERKLE/RHONDA718

82-862-000-0000-6121 SHIP GRANT TIME Personnel Wages

82-862-000-0000-6203 SHIP COMMUNICATIONS Communications

82-862-000-0000-6335 SHIP GRANT MILAGE Mileage Expense

BUERKLE/RHONDA Transactions718

862 SHIP 1 Vendors 3 TransactionsDEPT Total:

82 Fund Total: 6 Transactions


ROBECK

Supporting Hands N F P Fund84

Account/Formula

Supporting Hands Nurse Family Partnershi



1:32PM11/15/13

104.20 1

437.27 1

541.47

906.96 1

117.36 1

1,024.32

1,565.79

104.20106

437.27117

906.96101

117.36118




490 DEPT

MORRIS ELECTRONICS INC5069

84-490-000-0000-6265 10/30 OUTLOOK REINSTALLED 20124264 Professional Services

MORRIS ELECTRONICS INC Transactions5069


84-490-000-0000-6203 CALL CHARGES 9713905542 Communications


490 2 Vendors 2 TransactionsDEPT Total:

493 MIECHVDEPT

LUTHERAN SOCIAL SERVICE-FBS41380

84-493-000-0000-6269 OCTOBER CONSULTATIONS Contracts

LUTHERAN SOCIAL SERVICE-FBS Transactions41380


84-493-000-0000-6203 CALL CHARGES MIECHV 9713905542 Communications


493 MIECHV 2 Vendors 2 TransactionsDEPT Total:

84 Supporting Hands N F P FundFund Total: 4 Transactions


ROBECK

Trust and Agency Fund86

Account/Formula

Real Estate Assurance - Registered Land

Real Estate Assurance - Registered Land


1:32PM11/15/13

39,911.78 1

39,911.78

46,207.62 1

46,207.62

178.50 1

178.50

6,415.50 1

6,415.50

3,280.00 1

39,911.78104

46,207.62105

178.501210/01/2013 10/31/2013

6,415.501310/01/2013 10/31/2013

3,280.001410/01/2013 10/31/2013




833 Mortgage Registry TaxDEPT

MINNESOTA DEPARTMENT OF REVENUE1004

86-833-000-0000-6850 OCTOBER MTG REG Collections For Other Agencies

MINNESOTA DEPARTMENT OF REVENUE Transactions1004

833 Mortgage Registry Tax 1 Vendors 1 TransactionsDEPT Total:

834 Deed TaxDEPT

MINNESOTA DEPARTMENT OF REVENUE1004

86-834-000-0000-6850 OCTOBER DEED TAX Collections For Other Agencies

MINNESOTA DEPARTMENT OF REVENUE Transactions1004

834 Deed Tax 1 Vendors 1 TransactionsDEPT Total:

935 DEPT

COMMISSIONER OF FINANCE3411

86-935-000-0000-6850 OCTOBER REGISTERED LAND Collections For Other Agencies

COMMISSIONER OF FINANCE Transactions3411


939 State Surcharge 3%DEPT


86-939-000-0000-6850 OCTOBER REGISTRARS FEES Collections For Other Agencies


939 State Surcharge 3% 1 Vendors 1 TransactionsDEPT Total:

940 Vital Records Surcharge - Birth & DeathDEPT


86-940-000-0000-6850 OCTOBER BIRTH/DEATH SURCHARGE Collections For Other Agencies



ROBECK


Account/FormulaVital Records Surcharge - Birth & Death

Children's Trust Fund Surcharge - Birth


1:32PM11/15/13

3,280.00

680.00 1

680.00

294.00 1

294.00

900.00 6

900.00

680.001510/01/2013 10/31/2013

294.001610/01/2013 10/31/2013

495.001710/01/2013 10/31/2013

45.001810/01/2013 10/31/2013

30.001910/01/2013 10/31/2013

225.002010/01/2013 10/31/2013

60.002110/01/2013 10/31/2013

45.002210/01/2013 10/31/2013





950 Birth Record SurchargeDEPT


86-950-000-0000-6850 OCTOBER BIRTH RECORD SURCHARGE Collections For Other Agencies


950 Birth Record Surcharge 1 Vendors 1 TransactionsDEPT Total:

952 Children's Trust Fund Surcharge - BirthDEPT


86-952-000-0000-6850 OCTOBER CHILDREN SRCHG Collections For Other Agencies



954 Marriage LicenseDEPT


86-954-000-0000-6850 OCTOBER MARR LIC SRCHG Collections For Other Agencies

86-954-000-0000-6850 OCTOBER MARR LIC SUPRVD VISIT Collections For Other Agencies

86-954-000-0000-6850 OCTOBER MARR LIC/MN ENABLE Collections For Other Agencies

86-954-000-0000-6850 OCT MARR LIC/DISPL HOME REG Collections For Other Agencies

86-954-000-0000-6850 OCTOBER MARR LIC/HEALTHY MARR Collections For Other Agencies

86-954-000-0000-6850 OCT MARR LIC/COUPLES ON BRINK Collections For Other Agencies


954 Marriage License 1 Vendors 6 TransactionsDEPT Total:

956 Sales TaxDEPT



ROBECK


Account/Formula


1:32PM11/15/13

466.00 1

466.00

1,279.07 1

1,279.07

27.00 1

27.00

297.50 1

297.50

335.00 1

335.00

100,271.97

466.00174

1,279.072310/01/2013 10/31/2013

27.00173

297.504511/05/2013 11/12/2013

335.004411/05/2013 11/12/2013




86-956-000-0000-6850 OCTOBER 2013 SALES TAX (6,778) Collections For Other Agencies


956 Sales Tax 1 Vendors 1 TransactionsDEPT Total:

958 TIF Administration FeesDEPT


86-958-000-0000-6850 OCTOBER TIF ADMINISTRATIVE FEE Collections For Other Agencies


958 TIF Administration Fees 1 Vendors 1 TransactionsDEPT Total:

966 HUTCHINSON CITY SALES TAXDEPT


86-966-000-0000-6850 OCTOBER HUTCHINSON TAX (5,400) Collections For Other Agencies


966 HUTCHINSON CITY SALES TAX 1 Vendors 1 TransactionsDEPT Total:

975 DNR Clearing AccountDEPT

MINNESOTA DNR509

86-975-000-0000-6850 DNR Collections For Other Agencies

MINNESOTA DNR Transactions509

975 DNR Clearing Account 1 Vendors 1 TransactionsDEPT Total:

976 Game & Fish Clearing AccountDEPT

MINNESOTA DNR509

86-976-000-0000-6850 G & F Collections For Other Agencies


976 Game & Fish Clearing Account 1 Vendors 1 TransactionsDEPT Total:

86 Trust and Agency FundFund Total: 18 Transactions


ROBECK

Tax and Penalty Fund87

Account/Formula

SCHOOL DISTRICT OF HUTCHINSON 0423

SCHOOL DISTRICT OF HUTCHINSON 0423


1:32PM11/15/13

1,208.79 1

527.14 1

112.76 1

346.61 1

88.83 1

245.34 1

267.81 1

62.27 1

161.89 1

3,021.44

1,208.79134

527.14133

112.76126

346.61127

88.83128

245.34129

267.81130

62.27131

161.89132




982 Miscellaneous Tax CollectionsDEPT

SCHOOL DISTRICT OF GSL 28591576

87-982-000-0000-6850 2013 US IN LIEU OF TAX Collections For Other Agencies

SCHOOL DISTRICT OF GSL 2859 Transactions1576

488


Transactions488

TOWN OF COLLINS476


TOWN OF COLLINS Transactions476

TOWN OF HASSAN VALLEY497


TOWN OF HASSAN VALLEY Transactions497

TOWN OF HUTCHINSON479


TOWN OF HUTCHINSON Transactions479

TOWN OF LYNN480


TOWN OF LYNN Transactions480

TOWN OF PENN481


TOWN OF PENN Transactions481

TOWN OF RICH VALLEY482


TOWN OF RICH VALLEY Transactions482

TOWN OF SUMTER484


TOWN OF SUMTER Transactions484

982 Miscellaneous Tax Collections 9 Vendors 9 TransactionsDEPT Total:


ROBECK


Account/Formula


1:32PM11/15/13

3,021.44

895,101.60




87 Tax and Penalty FundFund Total: 9 Transactions

Final Total: 90 Vendors 178 Transactions


ROBECK


1:32PM11/15/13 AUDITOR'S VOUCHERS ENTRIESPage 24



AMOUNT


53,430.001

518,056.743

49,931.255

329.5211

164,459.5125

4,035.3882

1,565.7984

100,271.9786

3,021.4487

895,101.60

NameFundRecap by Fund

General Revenue Fund

Road & Bridge Fund

Solid Waste Fund

Human Service Fund

Special Revenue Fund

Supporting Hands N F P Fund

Trust and Agency Fund

Tax and Penalty Fund

All Funds Total Approved by, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

POOL

Explode Dist. Formulas?:

Paid on Behalf Of Name

2:01PM11/22/13Audit List for Board Page 1

Print List in Order By:

Y

on Audit List?: N

Type of Audit List: D

Save Report Options?:

AUDITOR'S VOUCHERS ENTRIES

D - Detailed Audit ListS - Condensed Audit List

2 1 - Fund (Page Break by Fund)2 - Department (Totals by Dept)3 - Vendor Number4 - Vendor Name

N

1Page Break By: 1 - Page Break by Fund2 - Page Break by Dept


POOL


Account/Formula


2:01PM11/22/13

19.68 1

19.68

10,031.12 9

10,031.12

104.74 1

104.74

1,601.45 1

19.681509/23/2013 10/28/2013

1,927.5021

1,912.5022

472.5023

1,766.4424

682.7525

629.4326

870.0027

836.2528

933.7529

104.747711/01/2013 11/30/2013

1,601.45309/30/2013 10/31/2013




3 County WideDEPT

CITY OF HUTCHINSON134

01-003-000-0000-6350 440 GROVE W ST SW 145544006 Other Services & Charges

CITY OF HUTCHINSON Transactions134

3 County Wide 1 Vendors 1 TransactionsDEPT Total:

13 Court Administrator's OfficeDEPT

ELSE/JENNIFER R5915

01-013-000-0000-6272 COURT APPOINT CP/PC JV-12-255 Court Appt Atty-Dep/Neg/Ter

01-013-000-0000-6272 COURT APPOINT MP/CA JV-13-29 Court Appt Atty-Dep/Neg/Ter

01-013-000-0000-6272 COURT APPT BH/JH J3-03-50057 Court Appt Atty-Dep/Neg/Ter

01-013-000-0000-6273 COURT APPOINT M BOYD PR-13-851 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPT J DOSEN PR-10-1934 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPT G ANNETT PR-13-155 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPT S HEERMA PR-13-451 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPT K OLSEN PR-13-1574 Court Appt Atty-Other

01-013-000-0000-6273 COURT APPT R J PR-13-1193 Court Appt Atty-Other

ELSE/JENNIFER R Transactions5915

13 Court Administrator's Office 1 Vendors 9 TransactionsDEPT Total:

76 Central Services - County WideDEPT

CENTURYLINK293

01-076-000-0000-6203 HUTCHINSON T1 612E921781 Communications


76 Central Services - County Wide 1 Vendors 1 TransactionsDEPT Total:

111 Courthouse BuildingDEPT


01-111-000-0000-6255 GAS 1969231-9 Natural Gas




POOL


Account/Formula


2:01PM11/22/13

10,209.70 3

11,811.15

512.00 1

1,852.78 2

2,364.78

605.83 2

11.843210/01/2013 11/01/2013

9,149.133110/01/2013 11/01/2013

1,048.733710/01/2013 11/01/2013

512.00409/30/2013 10/31/2013

1,753.353310/01/2013 11/01/2013

99.433810/01/2013 11/01/2013

565.92609/30/2013 10/31/2013

39.91509/30/2013 10/31/2013

1,964.793510/01/2013 11/01/2013

209.934010/01/2013 11/01/2013




01-111-000-0000-6253 ELECTRIC 07-814100-00 Electricity


01-111-000-0000-6257 WATER SEWER 13-857000-00 Sewer, Water And Garbage


111 Courthouse Building 2 Vendors 4 TransactionsDEPT Total:

112 North Complex BuildingDEPT


01-112-000-0000-6255 GAS 5987110-3 Natural Gas




01-112-000-0000-6257 WATER SEWER 15-800100-00 Sewer, Water And Garbage


112 North Complex Building 2 Vendors 3 TransactionsDEPT Total:

116 Health And Human Services BuildingDEPT


01-116-000-0000-6255 GAS 6008184-1 Natural Gas

01-116-000-0000-6255 GAS 7484082-8 Natural Gas




01-116-000-0000-6257 WATER SEWER 02-803800-00 Sewer, Water And Garbage Removal


POOL


Account/Formula

MCLEOD COUNTY AUDITOR TREASURER

MCLEOD COUNTY AUDITOR TREASURER


2:01PM11/22/13

2,983.93 4

3,589.76

757.74 4

757.74

19.51 1

12.00 1

31.51

738.763410/01/2013 11/01/2013

70.453910/01/2013 11/01/2013

134.85909/23/2013 10/22/2013

452.331009/23/2013 10/22/2013

110.911109/23/2013 10/22/2013

59.651209/23/2013 10/31/2013

19.513610/01/2013 11/01/2013

12.00111

25.0078





01-116-000-0000-6257 WATER SEWER 14-899800-00 Sewer, Water And Garbage Removal


116 Health And Human Services Building 2 Vendors 6 TransactionsDEPT Total:

117 FairgroundsDEPT


01-117-000-0000-6257 WATER SEWER GARBAGE 0130082003 Sewer, Water And Garbage Removal





117 Fairgrounds 1 Vendors 4 TransactionsDEPT Total:

201 County Sheriff's OfficeDEPT




1160

01-201-000-0000-6327 #132 LICENSE PLATES FEE 793AMT General Auto Maintenance

Transactions1160

201 County Sheriff's Office 2 Vendors 2 TransactionsDEPT Total:

485 County Public Health NursingDEPT

MASS CARE CONFERENCE1005

01-485-000-0000-6245 PARTNERING IN EMERGENCIES-EH Dues And Registration Fees


POOL


Account/Formula

MINNESOTA STATE COLLEGES & UNIVERSITIES

MINNESOTA STATE COLLEGES & UNIVERSITIES


2:01PM11/22/13

25.00 1

25.00 1

50.00

836.39 7

836.39

29,596.87

25.0067

250.4945

40.2841

302.4546

50.2444

39.7543

57.5242

95.6647




MASS CARE CONFERENCE Transactions1005

591

01-485-000-0000-6245 MRTC MEMBERSHIP DUES (CC 93) 147845006 Dues And Registration Fees

Transactions591

485 County Public Health Nursing 2 Vendors 2 TransactionsDEPT Total:

520 County Park'sDEPT

MCLEOD COOP POWER ASSN213

01-520-000-0000-6253 525 POWER 140900 Electricity


01-520-000-0000-6253 526 POWER HOUSE 416900 Electricity





MCLEOD COOP POWER ASSN Transactions213

520 County Park's 1 Vendors 7 TransactionsDEPT Total:

1 General Revenue FundFund Total: 39 Transactions


POOL

Road & Bridge Fund3

Account/Formula


2:01PM11/22/13

44.03 2

930.22 20

18.4489

25.5990

47.2491

59.3892

56.8393

45.9094

44.2095

43.7296

43.8397

44.8198

41.1799

43.10100

45.06101

42.75102

44.20103

43.83104

42.87105

43.10106

42.75107

49.68108

48.08109

57.72110

14.38120

14.38121

14.63122

10.24123

10.07124

42.39117

67.49118

52.71119




310 Highway MaintenanceDEPT


03-310-000-0000-6350 ELECTRIC 12557 MAJOR AVE 14-459100-00 Other Services & Charges

03-310-000-0000-6350 ELECTRIC 6988 120TH ST 14-606200-00 Other Services & Charges


MCLEOD COOP POWER ASSN213

03-310-000-0000-6350 TRAFFIC LIGHT HWY 212 & CR 1 861100 Other Services & Charges

03-310-000-0000-6350 TRAFFIC LIGHT ST HWY 7 &CR 115 903000 Other Services & Charges

03-310-000-0000-6350 TRAFFIC LIGHT HWY 15 & CR 18 903100 Other Services & Charges

03-310-000-0000-6350 TRAFFIC LIGHT 16007 30TH ST 906900 Other Services & Charges



03-310-000-0000-6350 TRAFFIC LIGHT 20008 YORK RD 907300 Other Services & Charges

03-310-000-0000-6350 TRAFFIC LIGHT 14999 CR 7 907400 Other Services & Charges


03-310-000-0000-6350 TRAFFIC LIGHT 1598 JEFFERSON R 907600 Other Services & Charges

03-310-000-0000-6350 TRAFFIC LIGHT 1598 ADAMS ST 907700 Other Services & Charges

03-310-000-0000-6350 TRAFFIC LIGHT 15188 PAGE AVE 907800 Other Services & Charges


03-310-000-0000-6350 TRAFFIC LIGHT 21989 TAGUS AVE 908000 Other Services & Charges

03-310-000-0000-6350 TRAFFIC LIGHT 19008 VALE AVE 908100 Other Services & Charges


03-310-000-0000-6350 TRAFFIC LIGHT 23498 FALCON AVE 908300 Other Services & Charges



03-310-000-0000-6350 TRAFFIC LIGHT ST HWY 22 &CR 11 908701 Other Services & Charges

MCLEOD COOP POWER ASSN Transactions213

XCEL ENERGY465

03-310-000-0000-6350 ELECTRTIC 11989 CR 9 51-0276939-7 Other Services & Charges

03-310-000-0000-6350 ELECTRIC 988 6TH ST N 51-0276939-7 Other Services & Charges




03-310-000-0000-6350 ELECTRIC 2205 TH 7 51-9068278-5 Other Services & Charges

03-310-000-0000-6350 ELECTRIC 19991 CSAH 9 51-9068278-5 Other Services & Charges

03-310-000-0000-6350 ELECTRIC 20010 CSAH 2 51-9068278-5 Other Services & Charges


POOL

Road & Bridge Fund3

Account/Formula


2:01PM11/22/13

226.29 8

1,200.54

1,342.00 1

142,237.78 7

8,729.89 6

152,309.67

297.50 1

297.50

1,342.0081

1,132.30136

10,190.68132

10,190.68133

4,006.90135

1,132.30134

23,116.98138

92,467.94137

1,221.4052

974.6955

947.7653

1,158.3656

3,061.3454

1,366.3457

297.50128




XCEL ENERGY Transactions465

310 Highway Maintenance 3 Vendors 30 TransactionsDEPT Total:

320 Highway ConstructionDEPT

BRAUN INTERTEC CORPORATION1174

03-320-000-0000-6265 MATERIAL TESTING NEW SHOP 377786 Professional Services

BRAUN INTERTEC CORPORATION Transactions1174

DUININCK INC4365

03-320-000-0000-6641 #3 ROUNDABOUT JOB 1152 SP070-006-1 State Aid-Regular Construction

03-320-000-0000-6648 #3 ROUNDABOUT JOB 1152 SP070-006-3 Federal Aid Road Construction Projects

03-320-000-0000-6647 #3 ROUNDABOUT JOB 1152 SP070-006-6 Joint Road Projects

03-320-000-0000-6647 #3 ROUNDABOUT CONST (CITY) SP070-006-7 Joint Road Projects

03-320-000-0000-6647 #3 ROUNDABOUT (MNDOT) SP070-006-8 Joint Road Projects

03-320-000-0000-6647 #3 TH15 MILL&OVERLAY JOB 1152 SP4304-90-8 Joint Road Projects

03-320-000-0000-6647 #3 TH15 MILL&OVERLAY JOB 1152 SP4304-90-9 Joint Road Projects

DUININCK INC Transactions4365

MIDWEST CONTRACTING LLC1107

03-320-000-0000-6643 #3 CR 74 BRIDGE JOB 9813 598-013-3 County Road Construction

03-320-000-0000-6646 #3 CR 74 BRIDGE JOB 9813 598-013-3 Bridge Bonding

03-320-000-0000-6643 #3 165 ST BRIDGE JOB 9934 599-034-3 County Road Construction

03-320-000-0000-6644 #3 165 ST BRIDGE JOB 9934 599-034-3 Town Bridge

03-320-000-0000-6643 #3 BABCOCK BRIDGE JOB 9935 599-035-3 County Road Construction

03-320-000-0000-6644 #3 BABCOCK BRIDGE JOB 9935 599-035-3 Town Bridge

MIDWEST CONTRACTING LLC Transactions1107

320 Highway Construction 3 Vendors 14 TransactionsDEPT Total:

330 Highway AdministrationDEPT

HAGEN CHRISTENSEN & MCILWAIN1358

03-330-000-0000-6610 SL/LP SHOP 1314-9 Capital - Over $5,000 (Fixed Assets)

HAGEN CHRISTENSEN & MCILWAIN Transactions1358

330 Highway Administration 1 Vendors 1 TransactionsDEPT Total:

340 Highway Equipment MaintenanceDEPT


POOL

Road & Bridge Fund3

Account/Formula


2:01PM11/22/13

599.42 4

97.80 2

17.08 1

206.18 4

920.48

154,728.19

223.648510/01/2013 10/31/2013

132.178310/01/2013 10/31/2013

44.058410/01/2013 10/31/2013

199.568210/01/2013 10/31/2013

51.4486

46.3687

17.08112

104.34116

69.54113

24.23114

8.07115





03-340-000-0000-6255 GLENCOE SHOP 5987115-2 Natural Gas

03-340-000-0000-6255 L P SHOP FUEL 6029864-3 Natural Gas

03-340-000-0000-6255 BERGEN PORTION 6029864-3 Natural Gas

03-340-000-0000-6255 S L SHOP FUEL 6048963-0 Natural Gas


CITY OF BROWNTON32

03-340-000-0000-6253 ELECTRIC 1AVS000208 Electricity

03-340-000-0000-6257 WATER SEWER 1AVS000208 Sewer, Water And Garbage Removal

CITY OF BROWNTON Transactions32


03-340-000-0000-6257 GARBAGE REMOVAL-BROWNTON 9868422 Sewer, Water And Garbage Removal


XCEL ENERGY465

03-340-000-0000-6253 ELECTRIC S L 19555 FALCON AVE 51-10122591-5 Electricity

03-340-000-0000-6253 ELECTRIC SL 305 MAIN ST E 51-4752670-7 Electricity

03-340-000-0000-6253 ELECTRIC L P 18454 CO RD 9 51-4752670-7 Electricity

03-340-000-0000-6253 OCT BERGEN TWP SHOP 51-4752670-7 Electricity

XCEL ENERGY Transactions465

340 Highway Equipment Maintenance 4 Vendors 11 TransactionsDEPT Total:

3 Road & Bridge FundFund Total: 56 Transactions


POOL


Account/Formula

MINNESOTA CONTINUING LEGAL EDUCATION

MINNESOTA CONTINUING LEGAL EDUCATION


2:01PM11/22/13

66.26 1

855.55 1

921.81

45.87 1

45.87

1,251.81 1

1,251.81

9,880.00 1

7,300.00 1

9,875.00 1

66.2658

855.5565

45.8788

1,251.8130

9,880.00129

7,300.00130

9,875.00131




15 Law LibraryDEPT

1393

25-015-000-0000-6451 PROBATE&TRUST LAW STATUTORY 603860 Books

Transactions1393

WEST PAYMENT CENTER358

25-015-000-0000-6451 LAW BOOKS #1000381462 828402800 Books

WEST PAYMENT CENTER Transactions358

15 Law Library 2 Vendors 2 TransactionsDEPT Total:

285 E-911 System Maintenance - GrantDEPT

INDEPENDENT EMERGENCY SERVICES161

25-285-000-0000-6203 E-911 ADDRESS INFO 400-0037 Communications - Telephone Equipment

INDEPENDENT EMERGENCY SERVICES Transactions161

285 E-911 System Maintenance - Grant 1 Vendors 1 TransactionsDEPT Total:

602 SSTS BISCAYDEPT

KENNEDY & GRAVEN, CHARTED1850

25-602-000-0000-6350 SEWER PROJECT-BISCAY J KUNKEL 116675 Other Services & Charges

KENNEDY & GRAVEN, CHARTED Transactions1850

602 SSTS BISCAY 1 Vendors 1 TransactionsDEPT Total:

619 Crow River Septic System LoansDEPT

HJERPE CONTRACTING INC2042

25-619-000-0000-6350 SEPTIC SYSTEM- H KARG 4378 Other Services & Charges

HJERPE CONTRACTING INC Transactions2042

JUUL CONTRACTING COMPANY INC3609

25-619-000-0000-6350 SEPTIC SYSTEM - J PLATH 13-907 Other Services & Charges

JUUL CONTRACTING COMPANY INC Transactions3609

MID MN SEPTIC SERVICES1119

25-619-000-0000-6350 SEPTIC SYSTEM-J SCHIROO 1934 Other Services & Charges

MID MN SEPTIC SERVICES Transactions1119


POOL


Account/Formula


2:01PM11/22/13

27,055.00

29,274.49




619 Crow River Septic System Loans 3 Vendors 3 TransactionsDEPT Total:

25 Special Revenue FundFund Total: 7 Transactions


POOL

Forfeited Tax Fund74

Account/Formula


2:01PM11/22/13

15.76 3

15.76

15.76

2.351310/16/2013 11/15/2013

10.241410/16/2013 11/15/2013

3.1712710/16/2013 11/15/2013




987 Forfeited Tax SaleDEPT


74-987-000-0000-6350 STORM DRAINAGE 23.142.0020 0321057200 Other Services & Charges

74-987-000-0000-6350 1178 BLACKHAWK DR SW 124510730 Other Services & Charges

74-987-000-0000-6350 141 5TH AVE NE HUTCHINSON 307514104 Other Services & Charges


987 Forfeited Tax Sale 1 Vendors 3 TransactionsDEPT Total:

74 Forfeited Tax FundFund Total: 3 Transactions


POOL


Account/Formula

NATIONAL RURAL HEALTH ASSOCIATION

NATIONAL RURAL HEALTH ASSOCIATION


2:01PM11/22/13

250.00 1

250.00

161.74 1

196.48 1

53.26 1

70.60 1

434.91 3

240.00 1

1,156.99

250.0079

161.741

196.4819

53.2620

70.6048

44.9749

49.9750

339.9751

240.002




853 Local Public Health GrantDEPT

816

82-853-000-0000-6245 2013-2014 DUES 41754 Dues And Registration Fees

Transactions816

853 Local Public Health Grant 1 Vendors 1 TransactionsDEPT Total:

856 FPSPDEPT

ACMC LITCHFIELD8125

82-856-000-0000-6261 MMS CHS EXAMS #49-10782 Physical Examinations

ACMC LITCHFIELD Transactions8125

HUTCHINSON HEALTH1269

82-856-000-0000-6261 EXAMS MMS CHS Physical Examinations

HUTCHINSON HEALTH Transactions1269

HUTCHINSON LEADER137

82-856-000-0000-6241 PUBLISHING-NABC #300916 Printing And Publishing

HUTCHINSON LEADER Transactions137

MCLEOD PUBLISHING INC658

82-856-000-0000-6241 PUBLISHING-NABC Printing And Publishing

MCLEOD PUBLISHING INC Transactions658

MEDICINE SHOPPE1251

82-856-000-0000-6439 MMS CHS PRESCRIPTION ONE STEP Prescriptions

82-856-000-0000-6439 MMS CHS PRESCRIPT CONTRACEPT Prescriptions

82-856-000-0000-6439 MMS CHS PRESCRIPT CONTRACEPT Prescriptions

MEDICINE SHOPPE Transactions1251

MEEKER MEMORIAL HOSPITAL6206

82-856-000-0000-6260 MMS CHS-STD #232223 Std Testing

MEEKER MEMORIAL HOSPITAL Transactions6206

856 FPSP 6 Vendors 8 TransactionsDEPT Total:

862 SHIPDEPT

GEISLINGER/DARLA1478


POOL


Account/Formula



2:01PM11/22/13

1,384.30 2

249.00 1

1,633.30

3,040.29

1,240.0017

144.3018

249.0080




82-862-000-0000-6121 SHIP GRANT TIME Personnel Wages

82-862-000-0000-6335 MILEAGE FOR SHIP GRANT Mileage Expense

GEISLINGER/DARLA Transactions1478

VIVID IMAGE INC2747

82-862-000-0000-6265 WORDPRESS UPGRADE&MAINT 5140 Professional Services

VIVID IMAGE INC Transactions2747

862 SHIP 2 Vendors 3 TransactionsDEPT Total:

82 Fund Total: 12 Transactions


POOL

Supporting Hands N F P Fund84

Account/Formula




2:01PM11/22/13

1,438.02 5

1,102.22 1

2,540.24

1,048.89 2

66.52 1

1,115.41

3,655.65

1,332.6468

10.0070

43.5071

4.2873

47.6074

1,102.2275

888.4369

160.4672

66.5276




490 DEPT

POPE COUNTY PUBLIC HEALTH6075

84-490-000-0000-6105 SALARY/FRINGE OCT 2013 Salaries And Wages - Full Time

84-490-000-0000-6245 REGISTRATION Dues And Registration Fees

84-490-000-0000-6335 77 MLG OCT Mileage Expense

84-490-000-0000-6336 MEETING EXPENSE Meals, Lodging, Parking & Miscellaneous

84-490-000-0000-6403 PRINTED SUPPLIES Printed Paper Supplies

POPE COUNTY PUBLIC HEALTH Transactions6075

RENVILLE CO PUBLIC HEALTH932

84-490-000-0000-6269 STAFF OCT 2013 Contracts

RENVILLE CO PUBLIC HEALTH Transactions932


493 MIECHVDEPT

POPE COUNTY PUBLIC HEALTH6075

84-493-000-0000-6105 SALARY/FRINGE OCT 2013 Salaries And Wages - Full Time

84-493-000-0000-6335 284 MLG OCT Mileage Expense

POPE COUNTY PUBLIC HEALTH Transactions6075

RENVILLE CO PUBLIC HEALTH932

84-493-000-0000-6265 MIECHV STAFF OCT 2013 Professional Services

RENVILLE CO PUBLIC HEALTH Transactions932

493 MIECHV 2 Vendors 3 TransactionsDEPT Total:

84 Supporting Hands N F P FundFund Total: 9 Transactions


POOL


Account/Formula


2:01PM11/22/13

16,986.43 1

84.40 1

6,362.73 1

191.73 1

616.67 1

606.82 1

24,848.78

100.00 1

50.00 1

16,986.437

84.408

6,362.7316

191.73126

616.6759

606.8262

100.0060

50.0061

100.0063




961 Municipal AssessmentsDEPT

CITY OF BROWNTON32

86-961-000-0000-6850 SPECIAL ASSESSMENTS Collections For Other Agencies

CITY OF BROWNTON Transactions32

CITY OF GLENCOE4917


CITY OF GLENCOE Transactions4917

CITY OF WINSTED362


CITY OF WINSTED Transactions362

MICHAEL BRAUN1883

86-961-000-0000-6810 REFUND-SPECIAL ASSESSMENT Refunds And Reimbursements

MICHAEL BRAUN Transactions1883

TOWN OF ACOMA172

86-961-000-0000-6850 SPECIAL ASSESSMENT Collections For Other Agencies

TOWN OF ACOMA Transactions172




961 Municipal Assessments 6 Vendors 6 TransactionsDEPT Total:

963 Township Non-Intoxicating LicensesDEPT

TOWN OF COLLINS476

86-963-000-0000-6850 BROWNTON ROD & GUN LIC 2013 Collections For Other Agencies

TOWN OF COLLINS Transactions476


86-963-000-0000-6850 GOPHER CAMPFIRE LIC 2013 Collections For Other Agencies


TOWN OF SUMTER484

86-963-000-0000-6850 MAJOR AVE HUNT CLUB LIC 2013 Collections For Other Agencies


POOL


Account/Formula


2:01PM11/22/13

100.00 1

90.00 1

340.00

343.00 1

343.00

25,531.78

90.0064

343.006611/13/2013 11/18/2013




TOWN OF SUMTER Transactions484

TOWN OF WINSTED485

86-963-000-0000-6850 SHADOWBROOKE LIC 2013 Collections For Other Agencies

TOWN OF WINSTED Transactions485

963 Township Non-Intoxicating Licenses 4 Vendors 4 TransactionsDEPT Total:

975 DNR Clearing AccountDEPT

MINNESOTA DNR509

86-975-000-0000-6850 DNR Collections For Other Agencies


975 DNR Clearing Account 1 Vendors 1 TransactionsDEPT Total:

86 Trust and Agency FundFund Total: 11 Transactions


POOL


Account/Formula


2:01PM11/22/13

12.24 1

12.24

12.24

245,855.27

12.24125




980 Tax CollectionsDEPT

MICHAEL BRAUN1883

87-980-000-0000-6810 REFUND-PENALTY CORRECTION Refunds And Reimbursements

MICHAEL BRAUN Transactions1883

980 Tax Collections 1 Vendors 1 TransactionsDEPT Total:

87 Tax and Penalty FundFund Total: 1 Transactions

Final Total: 59 Vendors 138 Transactions


POOL


2:01PM11/22/13 AUDITOR'S VOUCHERS ENTRIESPage 18



AMOUNT


29,596.871

154,728.193

29,274.4925

15.7674

3,040.2982

3,655.6584

25,531.7886

12.2487

245,855.27

NameFundRecap by Fund

General Revenue Fund

Road & Bridge Fund

Special Revenue Fund

Forfeited Tax Fund

Supporting Hands N F P Fund

Trust and Agency Fund

Tax and Penalty Fund

All Funds Total Approved by, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

J O H N O E S R E ^_PSuggSyCc 1470South GradeRoT Hutchinson, MN 55350 Phone (320)587-2332 Fax (320)537-8159

OUTDOOR POWER EQUIPMENT DEALER

Price Quote

Customer Name filcUaA C S O K V ^ Date U-2S-/3

Address

Citv Zio Code

Telephone

Salesperson 13 j fVg

*

i 21 7<ro K 5 7

f>7/tUtJL.S'

s f o /

— „... _ . , . . . — • —

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Subtotal:

sax;

Total:

AI Keg 11 in

From: Ron Mielke <[email protected]>

Sent: Thursday, November 21, 2013 11:15 A M

To: AI Koglin

Subject: Quote for JD Z960R Zero Turn

Good Morning AI;

Per your request I am quoting a new JD Z960R Zero Turn Mower with a 72" Side Discharge Deck and a fully adjustable

Suspension Seat with Armrests. Without any equipment to trade $10,600, plus Mn. Sale tax ($728.75), for a Total of

$11,328.75. This price includes freight, set up and delivery.

If McLeod County Parks were to trade i>the-Fer-r-is-IS^100j^Zero Turn Mower wjl l i .72^-S4de-&is^argeMower, 37 HP

Engine, 1018 Hours, price would be S5,700 tdJTrade, plus Mn . Sale Tax ($391.88), ^orjlo\^%S^912^P

Midwest Machinery appreciates the opportunity to quoT^T+rts-equipmentr - -

I talked to Keith, our service manager, he told me you should bring in your Z960A zero turn mower next week so we can

rework your ROPS in the coming weeks. If you have any questions about rework, please call Keith at 320-864-5571.

Ron Mielke Sales < ^ j d ^ T ^ ^ ^ ^ ^ ^

Glencoe, M N 55336

Office: 320-864-5571

Cell: 320-510-1662

[email protected]

JOHN D E E R E S M I D W E S T .JWhffM WfckKfc. f , + MACHINERY CO

1

Sarah Young

Subject: Attachments:

FW: Quotation Super 200 cost savings.doc

From: Denny Rach [mailto:[email protected]] Sent: Tuesday, November 12, 2013 12:35 PM To: [email protected]; Sarah Young Cc: Sandra Hensel Subject: RE: Quotation

Sarah: The process is all about economics. One machine to process everything is less expensive and does not require as much maintenance, and there is always the floor space issue. The Super 200 is $12,348.00, The Super 6PJ is $24,524.00, a machine to do both (Super 6PJ-VC) is $29,664.00. That is a cost savings of $8,208.00, and you save on shipping, maintenance, and floor space. These prices do not include any price increase for next year or the following years.

To help off set the cost of the new Super 6PJ-VC I would offer you a trading value of $2500.00 for you Super 6PJ that is a 2000 model, this brings the cost down to $27,164.00 The new Super 6PJ-VC uses the state of the art Pneumatic/Hydraulic Block were as your present machine is using the Auto Cycle Valve.

- Best regards, • -

Denny Rach President, TeeMark Manufacturing TeeMark Crushers, D&E Foundry Ladles Ph. 800-428-9900, Cell 218-851-0094 website: teemarkmfg.com

Donna Rickeman

From: Sent: To: Subject: Attachments:

Chuck Imm <[email protected]> Monday, July 15, 2013 3:42 PM Sarah Young Re: Compactors Inc Model Teemark Super 6 PJ Quote Request Super_6PJVC.pdf

H i Sarah, Below is a quote and info on the Model Super 6PJ-VC. This is our most versatile crusher. The Super 6 Series is available in 4 different configurations. Which machine you select will depend on the type and volume of cans you wish to process.

The Model Super 6PJ-VC Can, Pail and Filter Crusher opens, empties, crushes and ejects 6 gallon and smaller pails and cans. The Super 6PJ-VC is safe and explosion proof and will not operate with the door open. The Super 6PJ-VC employs a rugged two speed hydraulic pump which provides 30,0000 pounds of crushing force. The Super 6PJ-VC will crush 6 gallon and smaller containers in preparation for recycling or disposal. When crushing only one container per cycle the Super 6PJ-VC will process 150 containers per hour. The Super 6PJ-VC allows for convenient liquid collection into 55 gallon drums, totes or custom containers. The Super 6PJ-VC handles aerosol cans and and is available with a stand alone Carbon Filtration Cabinet, complete with two Carbon Filters and a Breakthrough Detector.The Super 6PJ-VC is powered by a 1 1/2hp 115/230 volt single phase motor.

In the quote below, I have also supplied pricing and some notes, on the other configurations of the Model Super 6.

EQUIPMENT PRICE

Super 6PJ-VC $29,564.00

Super 6PJ $24,324.00 (unlike the Super 6PJ-VC this machine will not process aerosol cans)

New Generation Super 6PM $11,425.00 (this machine does not eject the crushed cans, the can must be removed from the crushing chamber manually by the operator. This machine is a new economical solution and requires no air pressure. This machine does not process aerosol cans)

New Generation Super 6M $9,876.00 (Same as the Super 6PM except designed to only process empty containers)

Carbon Filtration Package $2,626.00

Shipping is Additional.

The above crushers carry a one year limited warranty on all materials and workmanship.

Lead time is approximately 10 weeks. I am attaching the spec-sheets for the machines to this email. You can go here http://www.compactorsinc.com/super 6 pjvc.htm to view a

video of the Model Super 6PJ. If you require more information or have any questions on any of our machines do not hesitate to call or email.

Best Regards, Chuck Imm 904-647-9892 Office 800-423-4003 Corporate Office Visit us on the web www.compactorsinc.com

On Jul 15, 2013, at 4:27 P M , [email protected] wrote:

Below is the result of your feedback form. It was submitted by ([email protected]) on /usr/sbin/sendmail -oi -t

company_name: McLeod County Solid Waste

customer name: Sarah Young

address: 1065 5th Avenue SE

city: Hutchinson

state: M N

zip: 55350

phone: 320-484-4319

fax: 320-484-4317

Submit: Submit

2

Topper/Fabric

Foam or Felt

Foam

Foam

Foam or Felt

Cotton

Felt

Felt

Inner Steel Spring

Felt

Felt

Foam

Wood Frame encasing

the inner spring

Mattress Layers (varies depending on age and brand) McLeod County Mattress Recycling Program (update)

Why recycle mattresses?

Expensive to dispose of locally

Takes up a lot of landfill space

Does not compact well

Can create flammable air pockets

Springs can damage equipment

Best end-of-life solution for product

80-90% of mattress components are recyclable

Lack of options in central & southwestern MN

Mattress Layers

Wood Base/frame

Metal Spring (steel)

Felt

Foam

Cotton

Fabric

Other (wool, bamboo, or coconut fibers)

Marketable Commodities

Wood

Steel

Fabric

Cotton

Foam

McLeod County has recycled 1,279 mattress and box spring units since the program

started in July of 2012. These units were transported to Goodwill Industries in

Duluth, MN for recycling.

McLeod County Solid Waste began dismantling mattresses and box springs on

November 18th, 2013. there are currently 170 estimated units ready for on-site

recycling .

Next Steps

Involve more retailers in collecting and promoting mattress recycling

Create partnerships with neighboring counties to establish recycling opportunities

Possibly re-evaluate recycling fee based on program costs and commodity

revenue

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McLeod County Auditor-Treasurer Cindy Schultz

2391 Hennepin Ave. N. Glencoe, MN 55336 (320) 864-1210 office (320) 864-3268 fax

E-mail: [email protected]

NOTICE OF APPLICATION FOR REPURCHASE

November 22, 2013 State of Minnesota County of McLeod To the McLeod County Board of Commissioners: This is to notify you that an application for the repurchase of a parcel of tax-forfeited land, pursuant to Minnesota Statutes, Section 282.241, has been received in my office. The name and address of the applicant, the applicant’s legal interest in the property and the legal description of the parcel are listed below.

Brad Janssen Property ID Number: 18.050.0200 7685 174th St Plat of Plato Carver, MN 55315 Block 2 Lots 14-15-16

Property Address: Legal Owner at the time of Forfeiture 112 Main St Plato, MN 55370 The county board has the authority and responsibility, pursuant to the above statute, to approve or disapprove the application for repurchase only if at least one of the following conditions is determined to be true.

1. The county board is to determine that undue hardship or injustice resulting from the tax forfeiture will be corrected by the repurchase.

2. The county board is to determine that the repurchase will best serve the public interest.

My recommendation is to approve this repurchase using condition number 2; under this option it will best serve the public interest. As part of a repurchase, the county auditor is to reinstate all delinquent taxes and special assessments which were cancelled at the time of the forfeiture starting with tax year 2004 through 2013. In addition, compute additional costs and interest which would

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have accrued on the delinquent real property taxes and special assessments. The repurchase price will be $13,055.06. (See attached for the breakdown of taxes, special assessments, costs and interest calculation.) FOUR (4) YEAR INSTALLMENT PLAN I recommend as well, county board approve Mr. Janssen to enter into a four (4) year Installment Plan, Contract for Repurchase of Tax-Forfeited Property. The four (4) year installment plan requires a minimum down payment of 20%. A cashier’s check was received in the amount of $6,067.85 on November 19, 2013. The amount the Mr. Janssen owes calculated through December 31, 2013 equals $13,055.06. After applying the $6,067.85 the balance remaining equals $6,987.21. The balance must be paid in not more than four (4), equal, annual installments plus ten (10) percent interest annually on the principal remaining. The first installment of principal and interest is due by December 31 of the year following the year when the repurchase agreement is signed. The remaining installments are due on December 31 of each subsequent year until the basic repurchase price and the extra costs are paid in full. The final installment must include payment of any extra costs which have not been paid earlier i.e. State Deed Tax 0.33% of repurchase price, State Deed Fee $25.00, County Service Fee $50.00, County Recording Fee of State Deed $46.00. The repurchaser has the privilege of paying off the deferred installments in full any time without penalty. Additional requirement, the repurchaser shall pay all current taxes upon said property before they become delinquent. If current taxes become delinquent Mr. Janssen would be in default of the contract. If he fails to pay his annual installment by December 31 he will be in default of the contract as well. Until the basic repurchase price and the required extra costs are paid in full, Mr. Janssen is not allowed to remove the structure on the property and he will not have clear title to the property to sell. I have prepared Resolution 13-CB-44 for the county board to consider. If the repurchase is approved and the four (4) year installment plan, I will draw up the Contract of Repurchase of Tax-Forfeited Property agreement for Mr. Janssen to sign. Sincerely,

Cindy Schultz McLeod County Auditor-Treasurer

18.050.0200 Repurchase Brad Janssen Property Tax Breakdown Calculation 2004 Through 2013

Tax Year

Estimated Market Value

Net Tax

CapacityTax

AmountSpecial

AssessmentTotal Tax Penalty Cost

Interest Rate Thru

11/30/2013

Interest Thru

11/30/2013

Total Due Tax

Penalty Cost

Interest

2004 9,500 143 303.05 702.95 1,006.00 140.84 20.00 89.1667% 1,040.43 2,207.272005 9,500 143 291.49 670.51 962.00 134.68 20.00 79.1667% 884.04 2,000.722006 10,000 150 289.94 638.06 928.00 129.92 20.00 69.1667% 745.56 1,823.482007 11,000 165 312.38 605.62 918.00 128.52 20.00 59.1667% 631.02 1,697.542008 14,300 215 380.80 573.20 954.00 133.56 20.00 49.1667% 544.55 1,652.112009 14,300 215 374.00 0.00 374.00 52.36 20.00 39.1667% 174.82 621.182010 14,300 215 376.00 0.00 376.00 52.64 20.00 29.1667% 130.85 579.492011 20,000 300 568.00 0.00 568.00 79.52 20.00 19.1667% 127.94 795.462012 20,000 300 688.00 0.00 688.00 96.32 20.00 9.1667% 73.73 878.052013 20,000 300 684.00 0.00 684.00 95.76 20.00 0.0000% 0.00 799.76

$4,267.66 $3,190.34 $7,458.00 $1,044.12 $200.00 $4,352.94 $13,055.06

Prepared by:Cindy Schultz, McLeod County Auditor-Treasurer Date 11/22/2013

1 | P a g e

County of McLeod 830 11th Street East

Glencoe, Minnesota 55336 FAX (320) 864-3410

COMMISSIONER RON SHIMANSKI COMMISSIONER KERMIT TERLINDEN COMMISSIONER PAUL WRIGHT 1st District 2nd District 3rd District Phone (320) 327-0112 Phone (320) 864-3738 Phone (320) 587-7332 23808 Jet Avenue 1112 14th Street East 15215 County Road 7 Silver Lake, MN 55381 Glencoe, MN 55336 Hutchinson, MN 55350 [email protected] [email protected] [email protected]

COMMISSIONER SHELDON NIES COMMISSIONER JON CHRISTENSEN COUNTY ADMINISTRATOR 4th District 5th District PATRICK MELVIN Phone (320) 587-5117 Phone (320) 587-5663 Phone (320) 864-1363 1118 Jefferson Street South 1245 Highway 7 East 830 11th Street East, Suite 110 Hutchinson, MN 55350 Hutchinson, MN 55350 Glencoe, MN 55336 [email protected] [email protected] [email protected]

RESOLUTION 13-CB-44

REPURCHASE OF FORFEITED PROPERTY

WHEREAS, an application for the repurchase of a parcel of tax-forfeited land, pursuant to Minnesota Statutes, Section 282.241, has been received in the office of McLeod County Auditor-Treasurer on November 19, 2013. WHEREAS, the name and address of the applicant, the applicant’s legal interest in the property and the legal description of the parcel are listed below.

Brad Janssen Property ID Number: 18.050.0200 7685 174th St Plat of Plato Carver, MN 55315 Block 2, Lots 14-15-16

Property Address: Legal Owner at the time of Forfeiture 112 Main St Plato, MN 55370 WHEREAS, that said property forfeited to the State of Minnesota on the 16th day of January 2009. At which time a County Auditor’s Certificate of Forfeiture was recorded in the County Recorder’s office on January 22, 2009 transferring ownership to the State of Minnesota. WHEREAS, the provisions of Minnesota Statute 282.241 to 282.324 apply to the repurchase of tax-forfeited land classified as “nonconservation land” before being sold at the next tax-forfeited auction may be repurchased by the property owner at the time of forfeiture. WHEREAS, the Board of County Commissioners of McLeod County has the authority and responsibility to approve or disapprove any written request for repurchase if at least one of the following conditions is determined to be true;

1. The county board is to determine that undue hardship or injustice resulting from the tax forfeiture will be corrected by the repurchase.

2. The county board is to determine that the repurchase will best serve the public interest.

2 | P a g e

WHEREAS, the repurchase price is $13,055.06 calculated through November 30, 2013 which includes the delinquent taxes, special assessments that were cancelled at the time of the forfeiture starting with tax year 2004 through 2013 including costs and interest computed that would have accrued on the delinquent real property taxes and special assessments. WHEREAS, a Cashier’s Check was received from Brad Janssen by the County Auditor-Treasurer on November 19, 2013 in the amount of $6,067.85. BE IT RESOLVED, the Board of County Commissioners of McLeod County, Minnesota, that the foregoing application is hereby approved for the reasons stated as follows: The County Board determines that the repurchase will best serve the public interest. BE IT FURTHER RESOLVED, the County Auditor-Treasurer will reinstate all delinquent taxes and special assessments which were cancelled at the time of the forfeiture starting with tax year 2004 through 2013 and compute costs and interest which would have accrued on the delinquent real property taxes and special assessments for a repurchase price of $13,055.06. BE IT FURTHER RESOLVED, a Cashier’s Check was received by the County Auditor-Treasurer on November 19, 2013 in the amount of $6,067.85. The amount that Mr. Janssen owes calculated through November 30, 2013 equals $13,055.06. After applying the $6,067.85 the balance remaining equals $6,987.21. BE IT FURTHER RESOLVED, the Board of County Commissioners of McLeod County, Minnesota, approve Brad Janssen to enter into a four (4) year installment plan with the County Auditor-Treasurer. The four (4) year installment plan requires a minimum down payment of 20% ($2,611.01) of the repurchase price. The $6,067.85 Cashier’s Check exceeds this dollar amount. BE IT FURTHER RESOLVED, the balance of $6,987.21 must be paid in not more than four (4), equal, annual installments plus ten (10) percent interest calculated annually on the remaining principal. The first installment of principal and interest is due by December 31 of the year following the year when the repurchase agreement is signed. The remaining installments are due on December 31 of each subsequent year until the basic repurchase price paid in full. BE IT FURTHER RESOLVED, the final installment must include payment of any extra costs which have not been paid earlier i.e. State Deed Tax 0.33% of repurchase price, State Deed Fee $25.00, County Service Fee $50.00, County Recording Fee of State Deed $46.00. BE IT FURTHER RESOLVED, the repurchaser has the privilege of paying off the deferred installments in full any time without penalty. BE IT FURTHER RESOLVED, Brad Janssen shall pay all current taxes upon said property before they become delinquent. If current taxes become delinquent Brad Janssen would be in default of the contract. If he fails to pay his annual installment by December 31 he will be in default of the contract.

3 | P a g e

BE IT FURTHER RESOLVED, until the repurchase price and the required extra costs are paid in full, Brad Janssen is not allowed to remove the structure on the property. BE IT FURTHER RESOLVED, the State of Minnesota, upon performance by Brad Janssen of all conditions and terms set forth, agrees to convey said land to Brad Janssen, his heirs and assigns, by quitclaim deed. THEREFORE, BE IT RESOLVED, the Board of County Commissioners of McLeod County, Minnesota, authorizes the County Auditor-Treasurer to enter in a Contract for Repurchase of Tax-Forfeited Property with Brad Janssen. Adopted this 3rd day of December 2013.

______________________________________ Paul Wright, Chairperson

Attest:

______________________________________ Patrick Melvin, County Administrator

Filed this _____________day of _________________________ 2013 ________________________________________ County Auditor-Treasurer

Joint Powers Agreement (Rev. 07/11) 1

STATE OF MINNESOTA

JOINT POWERS AGREEMENT

This agreement is between McLeod County, hereinafter referred to as COUNTY and the Office of MN.IT Services

(MN.IT) Geospatial Information Office (MnGeo), hereinafter referred to as the STATE.

Recitals

Under Minnesota Statute § 471.59, subdivision 10, the STATE is empowered to engage such assistance as deemed

necessary. This agreement supports a shared effort among Minnesota state agencies and county governments seeking to

benefit from cooperative financing of large data collections to meet their mutual needs. This agreement has been developed

to cooperatively acquire 2013 and 2014 digital aerial photography for a portion of central and northwest Minnesota on

behalf of a multi-agency/county collaborative effort.

Agreement

1 Term of Agreement

1.1 Effective date: November 1, 2013, or the date the STATE obtains all required signatures under Minnesota

Statutes Section 16C.05, subdivision 2, whichever is later.

1.2 Expiration date: April 4, 2015, or until all obligations have been satisfactorily fulfilled, whichever occurs first.

2 Agreement between the Parties

2.1 STATE agrees to:

Serve as coordinator and contract manager for the 2013 and 2014 Central and Northwest Minnesota Aerial

Photography Project on behalf of the state of Minnesota;

2.1.1 Contract for digital aerial photography for COUNTY, meeting the following specifications:

2.1.1.1. 4-band (red, green, blue, near infrared) orthographically rectified, for the entire area of the county.

2.1.1.2 Compressed County Mosaics – A mosaicked data file in compressed delivery format (compression

ratio= 15:1), in a JPG2000 format.

2.1.1.3 Uncompressed Tiles – A complete set of uncompressed images, in a GeoTIFF format; the extent

of each file covering the area agreeable to the County and the State

2.1.1.4 Spatial Resolution: Pixel = 6 inches GSD (ground sample distance);

2.1.2 Provide a copy of the final data products to COUNTY through the most efficient and effective method

of delivery available at such time as the data have been deemed error free and accepted.

2.1.3 Oversee the fiscal management of the 2013 and 2014 Central and Northwest Minnesota Aerial

Photography Project.

2.2 The COUNTY agrees to:

2.2.1 Participate in quality assurance testing as needed;

2.2.2 Evaluate, approve, and accept the deliverables from the Contractor.

3 Payment

COUNTY agrees to pay to the State a total obligation not to exceed $50,400.00 (Fifty Thousand Four Hundred

Dollars) to support its portion of the 2013 and 2014 Central and Northwest Minnesota Aerial Photography Project;

including data collection, processing and delivery.


4 Conditions of Payment

The STATE will bill the COUNTY for the COUNTY’s project cost share and the COUNTY will process payment in a

timely fashion so that payments to all contractors can be made by the STATE. Payment of undisputed invoices shall be

made within 30 (thirty) days of invoicing by the STATE. Invoicing to the COUNTY will adhere to the following

schedule:

One half the total obligation amount as defined in Clause 3 will be due upon successful acquisition of all imagery and

review of sample images by the County.

The final half of the total obligation will be due upon delivery of all data products as described in Clause 2. All

necessary obligations will be met and paid to the Contractor by the State.

5 Authorized Representatives

The STATE's Authorized Representative is Christopher Cialek, MnGeo Geospatial Information Manager, 658 Cedar

Street, 330 Centennial Building, Saint Paul, MN 55155, 651.201.2481, [email protected], or his successor.

The COUNTY's Authorized Representative is Christian Christensen, McLeod County GIS Director, 1400 Adams

Street SE, Hutchinson, MN 55350, 320.484.4375, [email protected], or his successor.

6 Assignment, Amendments, Waiver, and Contract Complete

6.1 Assignment. The COUNTY may neither assign nor transfer any rights or obligations under this agreement without

the prior consent of the STATE and a fully executed Assignment Agreement, executed and approved by the same

parties who executed and approved this agreement, or their successors in office.

6.2 Amendments. Any amendment to this agreement must be in writing and will not be effective until it has been

executed and approved by the same parties who executed and approved the original agreement, or their successors

in office.

6.3 Waiver. If the STATE fails to enforce any provision of this agreement, that failure does not waive the provision or

its right to enforce it.

6.4 Contract Complete. This agreement contains all negotiations and agreements between the STATE and the

COUNTY. No other understanding regarding this agreement, whether written or oral, may be used to bind either

party.

7 Indemnification

Each party will be responsible for its own acts and behavior and the results thereof.

8 State Audits

Under Minnesota Statute § 16C.05, subdivision 5, the COUNTY’s books, records, documents, and accounting

procedures and practices relevant to this agreement are subject to examination by the STATE and/or the State Auditor

or Legislative Auditor, as appropriate, for a minimum of six years from the end of this agreement.

9 Government Data Practices and Intellectual Property

9.1 The STATE must comply with the Minnesota Government Data Practices Act, Minnesota Statute Ch. 13, as it

applies to all data provided by the STATE under this agreement, and as it applies to all data created, collected,

received, stored, used, maintained, or disseminated by the STATE under this agreement. The civil remedies of

Minnesota Statute § 13.08 apply to the release of the data referred to in this clause by either the COUNTY or the

STATE.

9.2 The STATE grants to COUNTY a nonexclusive, perpetual, fully-paid license to use, disseminate, and modify its

copy of the final data products delivered by the State.

10 Venue

Venue for all legal proceedings out of this agreement, or its breach, must be in the appropriate state or federal court

with competent jurisdiction in Ramsey County, Minnesota.


11 Termination

11.1 Termination. The STATE may terminate this agreement at any time, with or without cause, upon 30 days’

written notice to the other party.

11.2 Termination for Insufficient Funding. The STATE may immediately terminate this agreement if it does not

obtain funding from the Minnesota Legislature, or other funding source; or if funding cannot be continued at a level

sufficient to allow for the payment of the services covered here. Termination must be by written or fax notice to the

COUNTY. The STATE is not obligated to pay for any services that are provided after notice and effective date of

termination. However, payment from the COUNTY will be determined on a pro rata basis, for services satisfactorily

performed to the extent that funds are available. The STATE will not be assessed any penalty if the agreement is

terminated because of the decision of the Minnesota Legislature, or other funding source, not to appropriate funds. The

STATE must provide the COUNTY notice of the lack of funding within a reasonable time of the STATE’s receiving

that notice.

1. McLEOD COUNTY

By: ________________________________________________

Title: _______________________________________________

Date: _______________________________________________

By: ________________________________________________

Title: _______________________________________________

Date: _______________________________________________

2. OFFICE OF MN.IT SERVICES

By: _______________________________________________

(with delegated authority)

Title: ______________________________________________

Date: ______________________________________________

3. COMMISSIONER OF ADMINISTRATION As delegated to Materials Management Division

By: ________________________________________________

Date: _______________________________________________

November 1, 2013 Christy Christensen

GIS Director

McLeod County

1400 Adams Street SE

Hutchinson, MN 55350

Subject: GeoMoose Application Upgrade and 2014 Web Hosting Agreement

Dear Mr. Christensen, We would like to thank you for continuing to work with Houston Engineering (HEI) on hosting the County’s GeoMoose application.

This letter includes a scope of service to update the scope of services and costs associated with migrating the County’s map viewer to GeoMoose 2.6.1 or latest and continued hosting for 2014.

The purpose of this letter is to memorialize the agreement (“Agreement”) among Houston Engineering, Inc. (“Engineer”) and McLeod County (“Owner”) for this project. The Scope of Services under this agreement includes the proposed tasks HEI agrees to complete. The compensation for this agreement is listed by task below. I believe this agreement accurately sets forth our understanding. If so, I would ask you, or an authorized representative of McLeod County, to sign the agreement and mail it back to us. Sincerely, HOUSTON ENGINEERING INC.

Brian Fischer, CFM Principal | GIS Project Manager

McLeod County, MN GeoMoose Upgrade and Web Hosting Agreement

CLIENT/OWNER SERVICES AGREEMENT

PROJECT NAME

HOUSTON JOB NO. HOUSTON PROJ. MGR.

CLIENT/OWNER NAME CLIENT/OWNER PHONE NO.

CLIENT/OWNER ADDRESS

This Independent Services Agreement (“Agreement”) is made and entered into effective as of this 1st day

of ___________________________, 20_____, by and between HOUSTON ENGINEERING, INC. (“HOUSTON”) and

____________________________________________________________________________(“CLIENT/OWNER”).

Recitals

A. The Owner has requested Houston Engineering, Inc. to perform certain services in connection with the project (“Project”) as more fully described in the “Scope of Services”.

SCOPE OF SERVICES: Describe here or attached Exhibit “A” The following Attachments are hereby made a part of this AGREEMENT: X GENERAL TERMS AND CONDITIONS X Fee Scheduled Work Authorizations X Other – Scope of Services NOW, THEREFORE, for good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, HOUSTON and SUBCONSULTANT agree as follows: $ Lump Sum fee based upon the SCOPE OF SERVICES above or attached. X $ Estimated Fee. To be performed and invoiced on an hourly basis commensurate with the current Fee Schedule $ Percentage of Estimated Construction Cost Other

IN WITNESS WHEREOF, the parties have caused this Agreement to be executed as of the date first above written: CLIENT/OWNER HOUSTON ENGINEERING, INC. BY: BY: AUTHORIZED REPRESENTATIVE AUTHORIZED REPRESENTATIVE TITLE: TITLE: DATE: DATE:

PLEASE SIGN AND RETURN ONE COPY TO HOUSTON AT THE ADDRESS ABOVE

GeoMoose 2.6 Upgrade and Web Hosting

Brian Fischer

McLeod County, MN

1400 Adams Street SE, Hutchinson, MN 55350

McLeod County, MN

District

November 13

320-484-4375

10,700


Exhibit A – Scope of Services

1 SCOPE OF SERVICES

HEI is currently hosting McLeod County’s GeoMoose applications. The goal of this scope of work is to migrate the map viewers to the latest version of GeoMoose, convert a series of aerial photos to Mr. SID format and setup a process to import and use assessor data files that can be joined to the parcel layer.

TASK 1: MIGRATE AND CONFIGURE GEOMOOSE 2.6 APPLICATION HEI will migrate and configure McLeod County’s existing mapping applications hosted on HEI’s web server. These include 2 public viewers and 4 internal viewers. During the migration HEI will reconfigure the application authentication on the new web server. The internal map viewers will be authenticated by the web server using IP or username/password authentication. GeoMoose currently does not have its own authentication module for application level authentication, so this is configured at the web server level. The mapping viewers will utilize MapServer (http://mapserver.gis.umn.edu/) and GeoMOOSE (http://www.geomoose.org/). MapServer and GeoMOOSE are both Open Source projects whose code can be downloaded for free with no software maintenance costs. The costs to the client are to install and configure the software code to work with your GIS data. HEI will perform these configuration tasks during the setup and migration of the new GeoMoose application in version 2.6.1 or later.

Setup URL for hosting the application on a new web server Configure the web server for a public and internal geomoose application Setup the geomoose applications with the same configuration as previous but running on the latest

version of GeoMoose with HEI’s enhancements Setup a link to open the map viewer from an external tax database link. Configure a hyperlink to go from a parcel result to the tax database web pages Configure the out of the box GeoMoose tools to work with McLeod County GIS data Link Google Analytics tracking for website statistics

Any new tools or customizations to existing tools will be deemed out of scope, but may be added for additional costs.

1.1 TASK 2: CONVERT ECW AERIAL PHOTOS HEI will convert McLeod County’s existing aerial photo collection that are currently stored in an ECW format to a Mr. SID format. The primary reason for this is the ECW format has now become proprietary and cannot be used with GeoMoose without a commercial license for it. HEI will convert the files listed below. The new files will be placed on an FTP site where they can be downloaded.

- 1937 ECW – 110MB - 1950 ECW – 261MB - 1961 ECW – 135MB


- 1968 ECW – 56MB - 1979 ECW – 49MB - 1985 ECW – 126MB - 1996 ECW (tiled into 14 ECW files) – 60MB - 2002 ECW (tiled into 14 ECW files) – 60MB - 2003 ECW – 201MB - 2005 ECW - 59MB - 2007 ECW (tiled into 60 ECW files) – 7.5GB - 2011 Already have a SID format - Hutchinson ECW – 500MB

1.2 TASK 3: TRAINING AND DEPLOYMENT PHASE

HEI developed this proposal to work collaboratively with the GIS Coordinator to provide training and knowledge transfer so the County can maintain the data used by the GeoMoose applications. In order to accomplish this objection, HEI will provide a 2 hour web meeting to go over and explain the procedures.

After the GeoMoose viewers have been configured, HEI will deploy them on the production server, setup authentication and go live with the hosted applications.

1.3 TASK 4: IMPORT ASSESSOR DATABASE FILES The goal of this task is to develop a script that will import the GIS parcel layer and specific assessor data files fields into a PostGreSQL database. The data would be setup on a weekly schedule to automatically import and refresh the data. The fields that need to be imported into the database from the assessor files include Bedrooms, Bathrooms, Prime sq footage, actual sq. footage and lot size. The data stored in the database will then be used in the map viewer as identify results and in a feature report created for a parcel.

1.4 TASK 5: WEB HOSTING AND TECHNICAL SUPPORT After signoff by client and final deployment, the project team will have met their obligations under this project. HEI will provide web hosting, GIS technical support and maintenance services as requested on a time and materials basis by McLeod County from January 1, 2014 thru December 31, 2014. These services typically include general GIS help in the form of answering questions, education, map creation, data creation or GIS analysis. These services may also include bug fixes, feature enhancements, configuration changes and GIS data updates for the interactive mapping application.

HEI will only complete requests as authorized by the McLeod County. Christy Christensen will be designated as the authorized individual to approve technical support requests. McLeod County will supply an email as authorization to complete a technical support or maintenance request. HEI will provide an estimate of the amount of time to complete the request, if requested by McLeod County. These services will be billed as time and materials in ¼ hour increments. The requests will be billed for time beginning at the start of the request. For 2014, technical support will be billed as time and materials using the 2014 HEI Fee schedule below. We assume most of the requests can be handled by a GIS Technician unless it involves a programming change


to the interactive mapping application. The request will generally be handled via web meetings, phone, or email. If onsite meetings are requested, then the travel time and mileage will be billed.

GIS Manager - $126/hr

GIS Developer - $115/hr

GIS Technician - $87/hr

2 ASSUMPTIONS

The Project Team reserves the right to reallocate hours among tasks to suit the needs of the project. Interaction with third-party software and APIs introduces risk that this software may not work as

advertised and are out of the control of the HEI. HEI is not responsible for the performance of third-party software such as PostGIS, MapServer, OpenLayers and GeoMoose. HEI is not responsible for bugs or defects found in these 3rd party API’s. Our approach is to find an alternative path or fix the bug if it is possible in a reasonable amount of effort in a situation if a bug is found.

Interactive map functionality will be limited to that provided out of the box with GeoMoose, with the exception of the custom enhancements already made by HEI for other clients.

All data and map layers will be provided by the County. If additional fields are requested from the Assessor data files outside the specific one’s outlined in

task 4, they can be added for an hourly fee.

3 COST ESTIMATE AND TIMELINE

The estimated cost is based upon the project approach and the assumptions. Invoices will be submitted periodically (customarily on a monthly basis) and are due and payable upon receipt. Invoices will include the amount of work currently performed on the total project costs for that given period.

Task 1: Migrate GeoMoose Apps $5,000

Task 2: Convert ECW files $1,500

Task 3: Training and Deployment $1,000

Task 4: Import Assessor database files $2,000

Task 5: 2014 Hosting $1,200

TOTAL: $10,700

HEI can provide additional technical

support at our 2014 hourly fee schedule. As needed


General Terms and Conditions

These general terms and conditions (“Terms”) together with the attached Client/Owner Services Agreement between Houston Engineering, Inc.

(“ENGINEER”) and OWNER attached hereto (“Agreement”) shall exclusively govern the relationship between ENGINEER and OWNER with respect

to the transaction described in the Agreement. No addition, modification, or amendment to these Terms or the Agreement will be binding on ENGINEER unless agreed to in writing and signed by an authorized representative of ENGINEER. (These Terms and the Agreement are hereinafter

collectively referred to as the “Agreement”).

1. STANDARD OF CARE

ENGINEER will perform its services in accordance with the terms of this Agreement. The standard of care applicable to ENGINEER’S services

will be the degree of care, skill and diligence normally employed by others performing the same or similar services under similar circumstances at the same time and in the same locality. All estimates, recommendations, opinions and decisions of ENGINEER will be made upon the basis of

information provided to or made available to ENGINEER based upon ENGINEER’S experience, technical qualifications and professional

judgment.

2. WARRANTY

Except as specifically set forth in this Agreement, Engineer has not made and does not make any warranties or representations

whatsoever, express or implied, as to services to be performed or materials to be provided including, without limitation, any warranty or

representation as to: (i) the merchantability or fitness or suitability of the services or products for a particular use or purpose whether or

not disclosed to Engineer; and (ii) delivery of the services and products free of the rightful claim of any person by way of infringement

(including, but not limited to, patent or copyright infringement) or the like. Engineer does not warrant and will not be liable for any design, material or construction criteria furnished or specified by owner and incorporated into the services and products provided hereunder.

3. PAYMENT TERMS

Invoices will be submitted periodically (customarily on a monthly basis) and are due and payable upon receipt. OWNER agrees to pay a service charge on all accounts 30 days or most past due at a rate equal to one percent (1%) each month but in no event shall such service charge exceed

the maximum amount allowed by law. Acceptance of any payment from OWNER without accrued service charges shall not be deemed to be a

waiver of such service charges by ENGINEER. In the event OWNER is past due with respect to any invoice ENGINEER may, after giving five (5) days written notice to OWNER, suspend all services without liability until OWNER has paid in full all amounts owing ENGINEER on

account of services rendered and expenses incurred, including service charges on past due invoices. Payment of invoices is not subject to

discount or offset by OWNER.

4. CHANGES OR DELAYS

The fee set forth in this Agreement constitute ENGINEER’S estimate to perform the services required to complete the Project as ENGINEER

understands it to be defined. If the Project requires conceptual or process development services, such services often are not fully definable in the initial planning. If, as the Project progresses, facts develop that in ENGINEER’S judgment dictate a change in the services to be performed,

which may alter the Scope of Services, ENGINEER will inform OWNER so that negotiation of change in scope and adjustment to the time of

performance and compensation can be accomplished. If such change results in an increase or decrease in the cost of or time required for performance of the services an equitable adjustment shall be made and the Agreement modified accordingly.

5. PAYMENT

Where the method of payment under the Agreement is based upon cost reimbursement (e.g., hourly rate, time and materials, direct personnel expense or per diem) the provisions of subparagraph a. shall apply in addition to the provisions of subparagraphs b. through d.

a. The minimum time segment for charging fieldwork is one (1) hour. The minimum time segment for charging work done at any of ENGINEER’S offices is one-quarter hour.

b. Direct costs, excluding travel and subsistence, are payable at actual documented cost plus 10% for administration. These direct costs

include, but are not limited to, shipping, communication, printing and reproduction, computer services, supplies and equipment, and equipment items rented from commercial sources. Travel and subsistence expenses of personnel when on business connected with the

Project are reimbursable at cost.

c. When applicable, rental charges will be applied to cover the cost of pilot-scale facilities or equipment, apparatus, instrumentation, or other technical machinery. When such charges are applicable, OWNER will be advised at the start of an assignment, task, or phase.

d. Invoices based upon cost reimbursement will be submitted showing labor (hours worked) and total expense. If requested by OWNER,

supporting documentation will be supplied at the cost of providing such documentation, including labor and copying costs.

6. TERMINATION

OWNER and ENGINEER shall both have the right to terminate this contract at any time and for any reason by submitting written notice of

termination to the other party at least thirty (30) days prior to the specified effective date of termination. In addition, each shall have the right to terminate this contract on ten (10) days written notice in the event that the other has breached any of the covenants, agreements or stipulations in

this contract. In either event, on the termination of this contract, all finished and unfinished reports, data, materials, information , and other work

products prepared by ENGINEER pursuant to this contract shall, as limited by the other provisions of this agreement, become the property of the


OWNER and ENGINEER will be paid for services performed up to the date of the contract termination. Notwithstanding the above, neither

party shall be relieved of the liability to the other for damages sustained by virtue of any breach of the contract.

7. LIMITATION OF LIABILITY

OWNER agrees to indemnify and hold ENGINEER harmless against all claims, losses, damages, liability judgments, cost and expenses including

attorneys’ fees arising out of or related to OWNER’s products and/or services described herein. However, OWNER does not have any liability

under this Section to the extent that a court of competent jurisdiction shall determine that ENGINEER was guilty of malfeasance or negligence that resulted in such claims, losses, damages, liability judgments, costs and/or expenses. Furthermore, OWNER shall have no liability to

ENGINEER relating to or arising out of his services. ENGINEER agrees to indemnify and hold OWNER harmless against all claims, losses,

damages, liability judgments, cost and expenses including attorneys’ fees arising out of or related to ENGINEER’s malfeasance or negligence.

8. INSURANCE

ENGINEER agrees to purchase, at its own expense, workers’ compensation insurance and comprehensive general liability insurance in amounts

determined by ENGINEER and will, upon request, furnish insurance certificates to OWNER. The existence of any such insurance shall not increase ENGINEER’S liability as limited by paragraph 8 above.

9. INDEMIFICATION

OWNER shall defend, indemnify, and hold harmless the ENGINEER from and against all actions and claims, including attorneys' fees and other

costs of litigation related thereto, involving or in any way relates to establishing the right to indemnification, which may arise out of or in any

way relates to OWNERS failure to perform any of its obligations under the Contract. ENGINEER shall indemnify and hold harmless OWNER from all actions, claims, accounts, demands, losses, injuries, and expenses, including

attorney’s fees and other costs of litigation, which may relate to ENGINEERS negligent acts, negligent errors or willful omissions.

10. HAZARDOUS SUBSTANCE INDEMNIFICATION

OWNER acknowledges that neither ENGINEER nor ENGINEER’s agents or consultants have any professional liability (errors or omissions) or

other insurance for claims or damages arising out of the performance of or failure to perform professional services, including but not limited to

the preparation of reports, designs, drawings, and specifications related to the investigation, detection, abatement, replacement, or removal of parts, materials, or processes containing asbestos or relating to the actual, alleged, or threatened discharge, dispersal, release or escape of

pollutants (defined herein as any solid, liquid, gaseous, or thermal irritant or contaminant, including smoke, vapor, soot, fumes, acids, alkalis,

chemicals, and waste) or hazardous substances of any kind however defined. Accordingly, OWNER hereby agrees to bring no claim for fault, negligence, breach of contract, indemnity, or other action against ENGINEER, its principals, employees, agents, and consultants, if such claim in

any way would relate to asbestos, pollutants or hazardous substances in connection with the Project. This indemnification shall survive

termination of the Agreement.

11. PROJECT SITE

OWNER shall furnish or cause to be furnished to ENGINEER all documents and information known to OWNER that relate to the identity,

location, quantity, nature, or characteristics of any asbestos, pollutant or hazardous substance, however defined, at, on or under the Project site. In addition, OWNER shall furnish such other reports, data, studies, plans, specifications, documents, and other information regarding surface and

subsurface site conditions required by ENGINEER for proper performance of its services. ENGINEER shall be entitled to rely upon OWNER

provided documents and information in performing the services required under this Agreement; however, ENGINEER assumes no responsibility or liability for the accuracy or completeness of any such documents or information. ENGINEER will not direct, supervise, or control the work of

contractors or their subcontractors. ENGINEER’s services will not include a review or evaluation of the contractor’s or subcontractor’s safety

measures. ENGINEER shall be responsible only for its activities and those of its employees on any site. The presence of ENGINEER, its employees, agents or subcontractors on a site shall not imply that ENGINEER controls the operations of others nor shall it be construed to be an

acceptance by ENGINEER of any responsibility for job-site safety.

13. DISPOSAL OF CONTAMINATED MATERIAL

ENGINEER is not, and has no responsibility as a handler, generator, operator, treater, storer, transporter, or disposer of hazardous or toxic

substances found or identified at a site.

14. CONFIDENTIALITY

ENGINEER shall maintain as confidential and not disclose to others without OWNER’s prior consent all information obtained from OWNER

that was not otherwise previously known to ENGINEER or in the public domain and is expressly designated by OWNER in writing to be

“CONFIDENTIAL.” The provisions of this paragraph shall not apply to information in whatever form that (a) is published or comes into the public domain through no fault of ENGINEER, (b) is furnished by or obtained from a third party who is under no obligation to keep the

information confidential, or (c) is required to be disclosed by law on order of a court, administrative agency, or other authority with proper

jurisdiction. OWNER agrees that ENGINEER may use and publish OWNER’s name and a general description of ENGINEER’s services with respect to the Project in describing ENGINEER’s experience and qualifications to other clients or potential clients.


15. RE-USE OF DOCUMENTS

All documents, including drawings and specifications, prepared or furnished by ENGINEER (and ENGINEER’s affiliates, agents, subsidiaries,

independent professional associates, consultants, and subcontractors) pursuant to this Agreement are instruments of service in respect of the Project, and ENGINEER shall retain ownership thereof, whether or not the Project is completed. OWNER may make and retain copies for

information and reference in connection with the Project; however, such documents are not intended or represented to be suitable for re-use by

OWNER or others on extensions of the Project or on any other project. Any re-use without written verification or adaptation by ENGINEER for the specific purpose intended will be at OWNER’s sole risk and without liability to ENGINEER or ENGINEER’s affiliates, agents, subsidiaries,

independent professional associates, consultants, and subcontractors with respect to any and all costs, expenses, fees, losses, claims, demands,

liabilities, suits, actions, and damages whatsoever arising out of or resulting therefrom. Any such verification or adaptation will entitle ENGINEER to further compensation at rates to be agreed upon by OWNER and ENGINEER.

16. CONTROLLING AGREEMENT

This Agreement shall take precedence over any inconsistent or contradictory provisions contained in any proposal, contract, purchase order, requisition, notice-to-proceed, or like document regarding ENGINEER’s services. If any provision of this Agreement is determined to be invalid

or unenforceable in whole or part by a court of competent jurisdiction, the remaining provisions hereof shall remain in full force and effect and be binding upon the parties hereto. The parties agree to reform this Agreement to replace any such invalid or unenforceable provision with a valid

and enforceable provision that as closely as possible expresses the intention of the stricken provision. This Agreement, including but not limited

to the indemnification provisions, shall survive the completion of the services under this Agreement and the termination of this Agreement for any cause. This Agreement gives no rights or benefits to anyone other than ENGINEER and OWNER and has no third party beneficiaries except

as may be specifically set forth in this Agreement. This Agreement constitutes the entire agreement between the parties and shall not in any way

be modified, varied or amended unless in writing signed by the parties. Prior negotiations, writings and understandings relating to the subject matter of this Agreement are merged herein and are superceded and canceled by this Agreement. Headings used in this Agreement are for the

convenience of reference only and shall not affect the construction of this Agreement.

17. PROPRIETARY DATA

The technical and pricing information contained in the Scope of Services is confidential and proprietary and is not to be disclosed or otherwise

made available to third parties by OWNER without the express written consent of ENGINEER.

18. GOVERNING LAW

This Agreement is to be governed by and construed in accordance with the laws of the principal place of business of ENGINEER.

19. DATA PRACTICES ACT REQUESTS

ENGINEER considers certain information developed during the execution of services as “not public” and “protected” from public disclosure

under the various local, state and federal Data Practices Act Requests. OWNER shall reimburse ENGINEER for any and all costs and expenses,

including attorneys’ fees associated with any type of data practices act request.

20. ASSIGNMENTS

This Agreement and the rights and duties hereunder may not be assigned by OWNER, in whole or in part, without ENGINEER’S prior written

approval.

21. FORCE MAJURE

ENGINEER shall not be liable for any loss, damage or delay resulting out of its failure to perform hereunder due to causes beyond its reasonable

control including, without limitation, acts of nature or the OWNER, acts of civil or military authority, terrorists threats or attacks, fires, strikes,

floods, epidemics, quarantine restrictions, war, riots, delays in transportation, transportation embargos, extraordinary weather conditions or other natural catastrophe or any other cause beyond the reasonable control of ENGINEER. In the event of any such delay, ENGINEER’S performance

date(s) will be extended for that length of time as may be reasonably necessary to compensate for the delay.

22. WAIVER

No failure or delay on the part of ENGINEER in exercising the right, power or remedy under this Agreement shall operate as a waiver thereof;

nor shall any single or partial exercise of any rights, power or remedy preclude any other or further exercise thereof or the exercise of any other

right, power or remedy hereunder. The remedies provided in this Agreement are cumulative and not exclusive of any remedies provided by law.

23. WAIVER OF JURY

In the interest of expediting any disputes that might arise between ENGINEER and OWNER, ENGINEER and OWNER hereby waive their

respective rights to a trial by jury of any dispute or claim concerning this Agreement, the services and any other documents or agreements contemplated by or executed in connection with this Agreement.

24. NOTICES

Any and all notices, demands or other communications require or desire to be given under this Agreement shall be in writing and shall be validly given or made if personally served; sent by commercial carrier service; or if deposited in the United States Mail, certified or registered, postage

prepared, return receipt requested. If such notice or demand is served personally, notice shall be deemed constructively made at the time of such

personal service. If such notice, demand or other communication is given by mail or commercial carrier service, such notice shall be conclusively deemed given three (3) days after deposit thereof in the United States Mail or with a commercial carrier service. Notices, demand or

other communications required or desired hereunder shall be addressed to the individuals indicated in this Agreement at the addresses indicated in


this Agreement. Any party may change its address or authorized recipient for purposes of this paragraph by written notice given in the manner

provided above.

25. WARRANTIES AND MAINTENANCE – WEB HOSTING AND PROGRAMMING

ENGINEER MAKES NO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR ANY OTHER

WARRANTIES OR GUARANTIES WHATSOEVER, EXPRESSED OR IMPLIED, WITH RESPECT TO ANY SERVICE PERFORMED OR ANY MATERIALS PROVIDED UNDER THIS AGREEMENT. In addition, and without limitation, Engineer does not guarantee the website

application and source code is free from programming bugs or irregularities or that the service performed or materials provided are free of claims

of any person by way of infringement (including, but not limited to, patent or copyright infringement) or the like. Owner agrees to indemnify and save and hold Engineer and its officers, directors, shareholders, agents, servants, employees and insurers, harmless from any and all liabilities and

expenses, including, without limitation, reasonable attorneys’ fees, expenses, costs, judgments, settlements, contract losses, damages, injuries

(including, but not limited to, liquidated damages) or other costs actually incurred arising directly or indirectly from any alleged or actual defects, nonconformities or breach of warranties with respect to the products and services contemplated by this Agreement.

While the Engineer shall make every reasonable effort to protect and backup data for Owner on a regular basis, Engineer is not responsible for

Client’s files residing on Engineer’s server. Owner is solely responsible for independent backup of data stored on Engineer’s server and network. If the Engineer needs and is able to restore client’s files due to a file lost engineer is not responsible for, provider may charge an additional fee for

this service.

Use of illegal or copyright material on any web page or other distribution mechanism used in conjunction with the Customer's account, will result in termination of this Service Agreement. Illegal material is defined as any material not permitted under United States local, state or federal laws.

If "illegal material" was submitted by a client of the Customer without Customer's knowledge, this Service Agreement will remain in effect if the

Customer removes the "illegal material."

Any use of Houston Engineering’s systems that disrupts the normal use of the system for other Houston Engineering Inc. customers is considered

to be abuse of Houston Engineering Inc. services and is grounds for termination of this Service Agreement. Some examples of abuse include spawning dozens of processes, consuming large amounts of memory or CPU cycles for long periods of time, attempting to access other

Customers' account areas, or conducting provocative activities such as mass emailing which may result in retaliatory actions against Houston

Engineering Inc.' systems.

Move MN Campaign Support Form We Need You! A comprehensive transportation funding bill needs to be passed in 2014. We can’t wait and we need your organization to join the campaign and help build our strength. Campaign Guiding Principles: To be effective, members of the coalition agree that a transportation funding package needs to be passed in 2014 and must be: Comprehensive. Any transportation funding package must include funding for roads and highways, transit, bike and pedestrian systems throughout Minnesota for both the state and local systems. In addition, the state must work to continually improve the efficiency of transportation construction and operations. Balanced. Any transportation funding package must be balanced across transportation modes and between Greater Minnesota and the Twin Cities Metropolitan Area. We support developing a transportation system that serves all Minnesotans equitably. Sustainable/Gimmick-Free. Transportation funding solutions must be long-term and sustainable, and must grow with the economy to meet the state’s growing transportation needs. Bonding or borrowing is not a suitable substitute to sustainable revenue for transportation. Bonding should only supplement additional revenue. Dedicated. New funding must be dedicated to transportation. Join the Campaign: The Move MN campaign is carried out by the many organizations and individuals which have committed resources, time and expertise to advance the mission of the campaign. By joining the campaign and signing on as an official campaign supporter your organization agrees to:

Make the campaign policy agenda a top legislative priority for your organization;

Help in carrying out the tactical elements of the campaign;

Be a public voice for the campaign; and

Engage your constituent groups in the campaign through communications, events, calls to action and other relevant strategies.

Additional activities we may encourage your organization to participate in include:

Agree to publically support the campaign agenda.

Testify at the legislature.

Write a letter to the editor.

Make a statement to the media.

Take part in a presentation to key stakeholder groups. Please indicate your commitment of support by completing and signing this form. Your participation will help ensure our greatest level of success. Organization Name: _________________________________________________ Organization Contact Person: _________________________________ Contact’s Title: ___________________________ Phone: _________________________ Email: _______________________________________________________ Signature: ___________________________________________________ Kris Jensen, Deputy Campaign Manager 952-851-7240 | [email protected]

MCLEOD COUNTY

830 11th Street East Glencoe, Minnesota 55336

FAX (320)864-3410

COMMISSIONER RON SHIMANSKI 1 st District Phone (320) 327-0112 23808 Jet Avenue Silver Lake, MN 55381 Ron.Shimanski(g)co.mcleod.mn.us

COMMISSIONER SHELDON NIES 4th District Phone (320) 587-5117 1118 Jefferson Street South Hutchinson, MN 55350 [email protected]

COMMISSIONER KERMIT TERLINDEN 2nd District Phone (320) 864-3738 1112 14th Street East Glencoe, MN 55336 [email protected]

COMMISSIONER JON CHRISTENSEN 5th District Phone (320) 587-5663 1245 Highway 7 East Hutchinson, MN 55350 Jon.Christensentaico.mcleod.mn.us

COMMISSIONER PAUL WRIGHT 3rd District Phone (320) 587-7332 15215 County Road 7 Hutchinson, MN 55350 Paul.WriqhtOco.mcleod.mn.us

COUNTY ADMINISTRATOR PATRICK MELVIN

Phone (320) 864-1363 830 11th Street East, Suite 110 Glencoe, MN 55336 Pat.Melvin(5?co.mcleod.mn.us

RESOLUTION 13-RB14-45 SUPPORTING MOVE MN AND 2014 TRANSPORTATION FUNDING PACKAGE

WHEREAS, McLeod County supports an increase in transportation funding to allow for improvements to roadways, bridges and transit service;

WHEREAS, MnDOT's future revenue projections show that little or no highway funds will be available for work beyond maintenance and preservation that would expand or further improve highways such as T H 15 and US 212 for the next 20 years;

WHEREAS, McLeod County agrees that increased state funding for transportation will create jobs, improve economic development in the area and improve the quality of life for our residents while also reducing the pressure on the local property tax to pay for needed infrastructure;

WHEREAS, a new statewide transportation funding package must be:

• Comprehensive, including funding for roads, bridges, transit and bicycle and pedestrian facilities throughout Minnesota;

• Balanced across transportation modes and between Greater Minnesota and the Twin Cities Metropolitan Area, serving all Minnesotans equitably;

• Sustainable, including long-term solutions that will grow with the economy to meet the state's growing transportation needs; and

• Dedicated to transportation.

NOW, THEREFORE, BE IT RESOLVED that McLeod County supports the Move M N campaign and its work to support the passage of a transportation funding package during the 2014 Legislative Session.

MCLEOD COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER

Adopted this 3r day of December, 2013

Paul Wright, Board Chair

CERTIFICATION I hereby certify that the foregoing Resolution is a trae and correct copy of the Resolution presented to and adopted by McLeod County at a duly authorized meeting thereof held on the 3 r d day of December, 2013, as shown by the minutes of said meeting in my possession.

Patrick Melvin, County Administrator

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Board Meetings

Holidays

June 17th Board Meet ing 5:00 pm Board of Appeals 6:00 pm

December 2nd Board Meet ing 4:30 pm Truth and Taxation 6:00 pm

Medica Choice Passport

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SIBLEY/MCLEOD EMPLOYEE BENEFIT PLAN MEDICA CHOICE PASSPORT ASO 1000-40-30%

Bronze Group #45957, 45958, 53441

BPL #28660

Effective January 1, 2014

MEDICA CUSTOMER SERVICE

© 2013 Medica. Medica® is a registered service mark of Medica Health Plans. “Medica” refers to the family of health plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica Self-Insured, and Medica Health Management, LLC.

Minneapolis/St. Paul Metro Area: (952) 945-8000

Outside the Metro Area: 1-800-952-3455

Hearing Impaired: National Relay Center 1-800-855-2880, then ask them to dial Medica at 1-800-952-3455

More information about the plan can also be obtained by signing in at www.mymedica.com.

Table Of Contents

14 Sibley McLeod Bronze 45957+ iii

Table Of Contents

A. Introduction ...................................................................................................................... 1

Definitions ......................................................................................................................... 1

To be eligible for benefits .................................................................................................. 1

Language interpretation ..................................................................................................... 2

B. Plan Overview ................................................................................................................... 3

General plan information ................................................................................................... 3

Funding ............................................................................................................................. 5

Benefits ............................................................................................................................. 5

Post-mastectomy coverage ............................................................................................... 5

HIPAA compliance ............................................................................................................ 5

C. Choice Of Provider ........................................................................................................... 8

Network providers ............................................................................................................. 8

Non-network providers ...................................................................................................... 8

Continuity of care .............................................................................................................. 9

Prior authorization ............................................................................................................10

D. Role Of Medica ............................................................................................................... 13

Provider payment disclosure ............................................................................................13

Assignment ......................................................................................................................14

E. Your Out-Of-Pocket Expenses ...................................................................................... 15

Copayments, coinsurance, and deductibles .....................................................................15

Out-of-pocket maximum ...................................................................................................16

Lifetime maximum amount ...............................................................................................17

Out-of-Pocket Expenses ...................................................................................................17

F. Ambulance Services ...................................................................................................... 19

Covered ...........................................................................................................................19

Not covered ......................................................................................................................19

Ambulance services or ambulance transportation ............................................................20

Non-emergency licensed ambulance service ...................................................................20

G. Durable Medical Equipment And Prosthetics .............................................................. 21

Covered ...........................................................................................................................21

Not covered ......................................................................................................................22

Durable medical equipment and certain related supplies ..................................................22

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14 Sibley McLeod Bronze 45957+ iv

Repair, replacement, or revision of durable medical equipment ........................................22

Prosthetics .......................................................................................................................22

Hearing aids .....................................................................................................................23

Breast pumps ...................................................................................................................23

H. Home Health Care .......................................................................................................... 24

Covered ...........................................................................................................................24

Not covered ......................................................................................................................25

Intermittent skilled care.....................................................................................................25

Skilled physical, speech, or occupational therapy .............................................................25

Home infusion therapy......................................................................................................26

Services received in your home from a physician .............................................................26

I. Hospice Services ........................................................................................................... 27

Covered ...........................................................................................................................27

Not covered ......................................................................................................................28

Hospice services ..............................................................................................................28

J. Hospital Services ........................................................................................................... 29

Covered ...........................................................................................................................29

Not covered ......................................................................................................................29

Outpatient services ...........................................................................................................30

Services provided in a hospital observation room .............................................................31

Inpatient services .............................................................................................................31

Services received from a physician during an inpatient stay .............................................31

Anesthesia services received from a provider during an inpatient stay .............................31

Treatment of temporomandibular joint (TMJ) disorder and craniomandibular disorder .....32

K. Infertility Services .......................................................................................................... 33

Covered ...........................................................................................................................33

Not covered ......................................................................................................................33

Office visits, including any services provided during such visits ........................................34

Virtual care .......................................................................................................................34

Outpatient services received at a hospital or ambulatory surgical center ..........................34




L. Maternity Services.......................................................................................................... 35

Newborns’ and Mothers’ Health Protection Act of 1996 ....................................................35

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14 Sibley McLeod Bronze 45957+ v

Covered ...........................................................................................................................35

Additional information about coverage of maternity services ............................................36

Not covered ......................................................................................................................36

Prenatal and postnatal services ........................................................................................36

Inpatient hospital stay for labor and delivery services .......................................................37

Professional services received during an inpatient stay for labor and delivery ..................37

Anesthesia services received during an inpatient stay for labor and delivery ....................37

Labor and delivery services at a free-standing birth center ...............................................37

Home health care visit following delivery ..........................................................................38

M. Medical-Related Dental Services ................................................................................... 39

Covered ...........................................................................................................................39

Not covered ......................................................................................................................39

Charges for medical facilities and general anesthesia services ........................................40

Orthodontia, dental implants, and oral surgery treatment related to cleft lip and palate ....40

Accident-related dental services .......................................................................................41

Oral surgery .....................................................................................................................41

N. Mental Health .................................................................................................................. 42

Covered ...........................................................................................................................43

Not covered ......................................................................................................................44

Office visits .......................................................................................................................45

Intensive outpatient programs ..........................................................................................45

Intensive behavioral and developmental therapy for the treatment of autism spectrum disorders ..........................................................................................................................45

Inpatient services (including residential treatment services) .............................................45

O. Miscellaneous Medical Services And Supplies ............................................................ 46

Covered ...........................................................................................................................46

Not covered ......................................................................................................................46

Blood clotting factors ........................................................................................................47

Dietary medical treatment of phenylketonuria (PKU) ........................................................47

Amino acid-based elemental formulas ..............................................................................47

Total parenteral nutrition ...................................................................................................47

Eligible ostomy supplies ...................................................................................................47

Insulin pumps and other eligible diabetic equipment and supplies ....................................47

P. Organ And Bone Marrow Transplant Services ............................................................. 48

Covered ...........................................................................................................................48

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14 Sibley McLeod Bronze 45957+ vi

Not covered ......................................................................................................................49

Office visits .......................................................................................................................49

Virtual care .......................................................................................................................49





Q. Physical, Speech, And Occupational Therapies .......................................................... 52

Covered ...........................................................................................................................52

Not covered ......................................................................................................................52

Physical therapy services received outside of your home .................................................53

Speech therapy services received outside of your home ..................................................54

Occupational therapy services received outside of your home .........................................54

R. Prescription Drug Program ........................................................................................... 56

Preferred drug list .............................................................................................................56

Exceptions to the preferred drug list .................................................................................56


Step therapy .....................................................................................................................57

Quantity limits ...................................................................................................................57

Covered ...........................................................................................................................57

Prescription unit................................................................................................................58

Not covered ......................................................................................................................58

Outpatient covered drugs .................................................................................................59

Infertility covered drugs ....................................................................................................59

Diabetic equipment and supplies, including blood glucose meters ...................................59

Tobacco cessation products .............................................................................................59

Drugs and other supplies considered preventive health services ......................................60

S. Prescription Specialty Drug Program ........................................................................... 61

Designated specialty pharmacies .....................................................................................61

Specialty preferred drug list ..............................................................................................61

Exceptions to the specialty preferred drug list ..................................................................61


Step therapy .....................................................................................................................62

Quantity limits ...................................................................................................................62

Covered ...........................................................................................................................62

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14 Sibley McLeod Bronze 45957+ vii


Not covered ......................................................................................................................63

Specialty prescription drugs received from a designated specialty pharmacy ...................63

Specialty infertility prescription drugs received from a designated specialty pharmacy .....63

Specialty growth hormone received from a designated specialty pharmacy .....................63

T. Professional Services .................................................................................................... 64

Covered ...........................................................................................................................64

Not covered ......................................................................................................................64

Office visits .......................................................................................................................65

Virtual care .......................................................................................................................65

Convenience care/retail health clinic visits........................................................................65

Urgent care center visits ...................................................................................................66

Preventive health care ......................................................................................................66

Allergy shots .....................................................................................................................67

Hearing exams .................................................................................................................67

Routine annual eye exams ...............................................................................................67

Chiropractic services ........................................................................................................68

Surgical services ..............................................................................................................68

Anesthesia services received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit ....................................................................................68

Services received from a physician during an emergency room visit ................................68



Outpatient lab and pathology ............................................................................................68

Outpatient x-rays and other imaging services ...................................................................68

Other outpatient hospital or ambulatory surgical center services ......................................68

Treatment to lighten or remove the coloration of a port wine stain ....................................69


Diabetes self-management training and education ...........................................................69

Neuropsychological evaluations/cognitive testing .............................................................70

Acupuncture .....................................................................................................................70

Services related to lead testing .........................................................................................70

Vision therapy and orthoptic and/or pleoptic training ........................................................70

Genetic counseling ...........................................................................................................70

Genetic testing .................................................................................................................71

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14 Sibley McLeod Bronze 45957+ viii

Routine patient costs in connection with a qualified individual’s participation in an approved clinical trial ........................................................................................................................71

U. Reconstructive And Restorative Surgery ..................................................................... 72

Covered ...........................................................................................................................72

Not covered ......................................................................................................................72

Office visits .......................................................................................................................73

Virtual care .......................................................................................................................73





V. Skilled Nursing Facility Services .................................................................................. 75

Covered ...........................................................................................................................75

Not covered ......................................................................................................................75

Daily skilled care or daily skilled rehabilitation services ....................................................76


Services received from a physician during an inpatient stay in a skilled nursing facility ....76

W. Substance Abuse ........................................................................................................... 77

Covered ...........................................................................................................................78

Not covered ......................................................................................................................79

Office visits .......................................................................................................................79


Opiate replacement therapy .............................................................................................79


X. Surgery For Weight Loss ............................................................................................... 81

Covered ...........................................................................................................................81

Not covered ......................................................................................................................81

Office visits .......................................................................................................................82

Virtual care .......................................................................................................................82

Outpatient hospital services .............................................................................................82

Outpatient services received from a physician in a hospital ..............................................82



Y. Harmful Use Of Medical Services .................................................................................. 83

When this section applies .................................................................................................83

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14 Sibley McLeod Bronze 45957+ ix

Z. Exclusions ...................................................................................................................... 84

AA. How To Submit A Claim ................................................................................................. 87

Claims for benefits from network providers .......................................................................87

Claims for benefits from non-network providers ................................................................87

Claims for services provided outside the United States ....................................................87

Time limits ........................................................................................................................88

BB. Coordination Of Benefits ............................................................................................... 89

Applicability ......................................................................................................................89

Definitions that apply to this section..................................................................................89

Order of benefit determination rules .................................................................................90

Effect on the benefits of this plan ......................................................................................91

Right to receive and release needed information ..............................................................92

Facility of payment ...........................................................................................................92

Right of recovery ..............................................................................................................92

CC. Right Of Recovery .......................................................................................................... 94

DD. Eligibility And Enrollment .............................................................................................. 95

Who can enroll .................................................................................................................95

How to enroll ....................................................................................................................95

Initial enrollment ...............................................................................................................95

Open enrollment ...............................................................................................................95

Special enrollment ............................................................................................................96

Late enrollment ................................................................................................................98

Medical Support Order .....................................................................................................99

The date your coverage begins ........................................................................................99

Other changes ................................................................................................................ 100

Identification card ........................................................................................................... 100

EE. Ending Coverage .......................................................................................................... 101

When coverage ends ..................................................................................................... 101

FF. Continuation ................................................................................................................. 103

Your right to continue coverage under state law .............................................................. 103

Your right to continue coverage under federal law .......................................................... 106

Other continuation coverage .......................................................................................... 111

Insurability ...................................................................................................................... 111

GG. Complaints ................................................................................................................... 112

First level of review ......................................................................................................... 112

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14 Sibley McLeod Bronze 45957+ x

Second level of review.................................................................................................... 113

External review ............................................................................................................... 114

HH. Miscellaneous General Provisions ............................................................................. 115

II. Definitions .................................................................................................................... 117

JJ. Signatures .................................................................................................................... 127

Introduction

14 Sibley McLeod Bronze 45957+ 1

A. Introduction

Definitions

Many words in this plan have specific meanings. These words are identified in each section and defined in Definitions.

See Definitions. These words have specific meanings: benefits, covered person, dependent, employee, enrollee, plan, plan administrator, sponsor.

Sibley/McLeod County (sponsor) has established the Sibley/McLeod Health Insurance Plan (plan) through which medical benefits are provided to certain employees and their dependents. The plan is administered by Sibley/McLeod County (plan administrator). This plan was originally established January 1, 1993. This restatement of the plan is effective January 1, 2014 unless specifically stated otherwise.

The plan is not an employee welfare benefit plan within the meaning of the Employee Retirement Income Security Act of 1974 (ERISA). The plan is a self-insured medical plan generally intended to meet the requirements of Section 106 and Section 105(h) of the Internal Revenue Code of 1986 (Code) and applicable Minnesota law, including but not limited to Section 471.617 of the Minnesota Statutes.

When changes are made to the plan, the plan administrator will notify enrollees or covered persons as required by law and those individuals will receive a new plan or an amendment to this plan.

In this plan, the words you, your, and yourself refer to the covered person. The word sponsor refers to the organization through which you are eligible for coverage. This plan defines benefits and describes the health services for which you have coverage and the procedures you must follow to obtain in-network coverage. Coverage is subject to all terms and conditions of the plan. As a condition of coverage under the plan, you must consent to the release and re-release of medical information necessary for the administration of this plan. The confidentiality of such information will be maintained in accordance with existing law.

Because many provisions are interrelated, you should read this plan in its entirety. Reviewing just one or two sections may not give you a complete understanding of the coverage described. The most specific and appropriate section will apply for those benefits related to the treatment of a specific condition.

To be eligible for benefits

Each time you receive health services, you must:

1. Confirm with Customer Service that your provider is a network provider with Medica Choice Passport to be eligible for in-network benefits; and

2. Identify yourself as a covered person under the plan; and

3. Present your plan identification card. (If you do not show your identification card, providers have no way of knowing that you are a covered person under the plan and you may receive a bill for health services or be required to pay at the time you receive health services.)

Introduction


However, possession and use of a plan identification card does not necessarily guarantee coverage.

Network providers are required to submit claims within 180 days from when you receive a service. If your provider asks for your health care identification card and you do not identify yourself as a covered person under the plan within 180 days of the date of service, you may be responsible for paying the cost of the service you received.

Language interpretation

Language interpretation services will be provided upon request, as needed in connection with the interpretation of this plan. If you would like to request language interpretation services, please call Customer Service at one of the telephone numbers listed inside the front cover.

If you have an impairment that requires alternative communication formats such as Braille, large print, or audiocassettes, please call Customer Service at one of the telephone numbers listed inside the front cover to request these materials.

If this plan is translated into another language or an alternative communication format is used, this written English version governs all coverage decisions.

Plan Overview


B. Plan Overview

See Definitions. These words have specific meanings: benefits, claim, coinsurance, copayment, deductible, dependent, employee, enrollee, HIPAA privacy standards, medically necessary, plan, plan administration functions, plan administrator, protected health information or PHI, provider, sponsor.

The information contained in this section of the plan provides general information regarding the plan. It is important to remember that this section of the plan is only an overview. You also need to refer to the section that describes a particular plan requirement in detail. Language interpretation services will be provided upon request, as needed in connection with the interpretation of this document. Please contact Customer Service to make such a request. If this plan is translated into another language, this written English version governs all coverage decisions.

General plan information

Plan Name Sibley/McLeod Health Insurance Plan

Sponsoring Employer (Sponsor), Address, and Telephone Number of Sponsor

McLeod County Pat Melvin, County Administrator 830 11th Street E. Glencoe, MN 55336

Sibley County Roseann Nagel, Human Resource Director PO Box 256, 400 Court Avenue Gaylord, MN 55334

Plan Administrator, Business Address, and Business Telephone Number of Plan Administrator



Agent for Service of Legal Process Sibley County Attorney

Plan Overview


Sponsor IRS Employer Identification Number (EIN) McLeod County 41-6005841

Sibley County 41-6005897

Plan Year January 1 through December 31

Plan Number 501

Type of Welfare Plan Medical

Type of Administration Self-insured

The sponsor has entered into a service agreement with Medica Self-Insured (Medica) under which Medica performs a variety of administrative services with respect to the medical benefits provided under the plan. Medica may, from time to time at its sole discretion, contract with other parties, related or unrelated, to arrange for provision of other administrative services including, but not limited to, arrangement of access to a provider network; claims processing services; and complaint resolution assistance. The agreement is for administrative services only. Medica does not insure the provision of benefits under the plan; Medica is not a health insurer. The plan offers Medica Choice Passport.

Name and Address of Claims Administrator Medica Self-Insured 401 Carlson Parkway Minnetonka, MN 55305

United HealthCare Services, Inc. (UHS) 5901 Lincoln Drive Edina, MN 55436

Network Administration Network administration is primarily responsible for negotiating and executing all provider contracts, as well as ensuring that all contracts are implemented correctly.

Medica Self-Insured 401 Carlson Parkway Minnetonka, MN 55305


Plan Overview


Funding

Benefits under the plan are paid from the general assets of sponsor. You may be responsible for a portion of the cost of the coverage provided under this plan. The portion of the cost of coverage for which the enrollee is responsible may be paid on a pre-tax basis through a cafeteria plan of sponsor if such a plan is made available by sponsor.

Benefits

Plan benefits are furnished in accordance with this plan, which is issued by the plan administrator. This plan provides an explanation of the benefits offered by the plan. If there is a conflict between any other document and the plan document, the plan document shall govern.

The benefits described in this plan document detail the medical benefits available under the plan. Your Out-Of-Pocket Expenses describes the copayment, coinsurance, and deductible amounts that impact how much the plan pays and how much you pay. The procedures to be followed in obtaining benefits or presenting claims for benefits under the plan and seeking remedies for redress of claims that are denied in whole or in part are described in this plan.

This plan covers medically necessary health services as described throughout the plan. Please pay particular attention to the benefits that have limitations. Some benefits require that certain things be done first (i.e., prior authorization be obtained). Not following these requirements may impact whether benefits are paid under this plan. Additionally, you consent to the release and re-release of medical information necessary for the administration of this plan as a condition of coverage under this plan. Certain services are specifically excluded from coverage under this plan. The fact that a provider recommends or orders services does not always mean the services are covered or medically necessary. For additional details, see Exclusions. This plan coordinates the benefits it provides with other coverage and/or other sources of payment. For additional details, see Right Of Recovery.

Post-mastectomy coverage

The plan will cover all stages of reconstruction of the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. The plan will also cover prostheses and physical complications, including lymphedemas, at all stages of mastectomy.

HIPAA compliance

This plan will be administered in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and all implementing regulations. The HIPAA privacy standards address disclosure to a plan sponsor of protected health information (or PHI). The sponsor may use or disclose PHI received from the plan or from another party acting on behalf of the plan for certain limited purposes. These include health care operations purposes and health care payment purposes relating to the plan. However, with respect to such PHI, the sponsor agrees as follows:

1. The sponsor will not use or further disclose such PHI other than as permitted or required by this plan or as required by law (as defined in the HIPAA privacy standards).

Plan Overview


2. The sponsor will ensure that any agents, including a subcontractor, to whom the sponsor provides PHI received from the plan or from another party acting on behalf of the plan, agree to the same restrictions and conditions that apply to the sponsor with respect to such PHI.

3. The sponsor will not use or disclose PHI for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the sponsor, except under an authorization which meets the requirements of the HIPAA privacy standards.

4. The sponsor will report to the plan any PHI use or disclosure that is inconsistent with the uses or disclosures provided for of which the sponsor becomes aware.

5. The sponsor will make available PHI in accordance with your right of access under the HIPAA privacy standards.

6. The sponsor will make available PHI for amendment and incorporate any amendments to PHI in accordance with the HIPAA privacy standards.

7. The sponsor will make available the information required to provide an accounting of certain disclosures of PHI in accordance with the HIPAA privacy standards.

8. The sponsor will make its internal practices, books, and records relating to the use and disclosure of PHI received from the plan or another party on behalf of the plan, available to the Secretary of the U.S. Department of Health and Human Services for purposes of determining compliance by the plan with the HIPAA privacy standards.

9. If feasible, the sponsor will return or destroy all PHI received from the plan, or another party acting on behalf of the plan, that the sponsor still maintains in any form and retain no copies of such PHI when no longer needed for the purpose for which disclosure was made. If such return or destruction is not feasible, the sponsor will limit further uses and disclosures to those purposes that make the return or destruction of the PHI infeasible.

10. The sponsor will ensure that adequate separation between the plan and the sponsor is established as follows:

a. Only the following persons under control of the sponsor may be given access to the PHI that is disclosed:

For McLeod County: County Auditor, County Administrator, Technical Specialist III (Auditor)

For Sibley County: Human Resource Coordinator, Payroll Coordinator, Auditor

b. The access to and use of PHI by the persons described above is restricted to the plan administration functions that the sponsor performs for the plan.

c. If any of the persons described above do not comply with the above provisions relating to HIPAA compliance, the sponsor will impose sanctions as necessary, in its discretion, to ensure that no further non-compliance occurs. Such sanctions may be imposed progressively (for example, an oral warning, a written warning, time off without pay, and termination), if appropriate. Sanctions, when imposed, will be commensurate with the severity of the violation.

11. The HIPAA security standards govern the security of electronic protected health information created, received, maintained or transmitted by the plan. The sponsor agrees as follows:

a. The sponsor will implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the

Plan Overview


electronic protected health information that it creates, receives, maintains or transmits on behalf of the plan.

b. The sponsor will ensure that the adequate separation required by the HIPAA privacy standard is supported by reasonable and appropriate security measures.

c. The sponsor will ensure that any agent, including a subcontractor, to whom it provides electronic protected health information, agrees to implement reasonable and appropriate security measures to protect the information.

d. The sponsor will report to the plan any security incident of which it becomes aware.

Choice Of Provider


C. Choice Of Provider

See Definitions. These words have specific meanings: benefits, claim, coinsurance, copayment, covered person, deductible, emergency, enrollee, hospital, medically necessary, network, non-network, non-network provider reimbursement amount, physician, plan, provider, sponsor.

This section describes the benefits that apply based on your choice of provider.

Provider network

In-network benefits are available through the Medica Choice Passport provider network. For a list of the in-network providers, please consult your Medica Choice Passport provider directory by signing in at www.mymedica.com or by contacting Customer Service. Out-of-network benefits will apply when you choose to receive eligible health services from providers that are not contracted with Medica.

Network providers

In-network benefits apply when you receive eligible health services from network providers, unless otherwise indicated in this plan. In-network benefits also apply to coverage for services that meet emergency criteria and are received from non-network providers. To be eligible for in-network benefits, follow-up care or scheduled care after an emergency must be received from a network provider.

Enrolling in the plan does not guarantee that a particular network provider on the list of network providers will remain a network provider or that a particular network provider will provide you with health services. When a provider no longer remains a network provider, you must either choose to receive health services from among the remaining network providers or receive out-of-network benefits. You should verify a network provider’s status as a network provider each time health services are received from the network provider.

Network providers are not agents or employees of Medica or UHS. The relationship between a provider and any covered person is that of health care provider and patient. The provider is solely responsible for health care provided to any covered person.

Non-network providers

Out-of-network benefits apply when you receive health services from non-network providers, except for emergencies and prior authorizations by Medica as indicated in this plan.

Be aware that if you choose to go to a non-network provider and use out-of-network benefits, you will likely have to pay much more than if you use in-network benefits. The charges billed by your non-network provider may exceed the non-network provider reimbursement amount, leaving a balance for you to pay in addition to any applicable copayment, coinsurance, and deductible amount. This additional amount you must pay to the provider will not be applied toward the out-of-pocket maximum amount described in Your Out-Of-Pocket Expenses and you will owe this amount regardless of whether you previously reached your out-of-pocket maximum with amounts paid for other services. Please see the example calculation below.

Choice Of Provider


Because obtaining care from non-network providers may result in significant out-of-pocket expenses, it is important that you do the following before receiving services from a non-network provider:

Discuss the expected billed charges with your non-network provider; and

Contact Customer Service to verify the estimated non-network provider reimbursement amount for those services, so you are better able to calculate your likely out-of-pocket expenses; and

If you wish to request that the plan authorize the non-network provider’s services be covered at the in-network benefit level, follow the procedure described under Prior authorization in Choice Of Provider.

An example of how to calculate your out-of-pocket costs* You choose to receive non-emergency inpatient care at a non-network hospital provider without an authorization from the plan providing for in-network benefits. The out-of-network benefits described in this plan apply to the services you receive. For purposes of this example, you have previously satisfied your deductible. The non-network hospital provider bills $30,000 for your hospital stay. The plan’s non-network provider reimbursement amount for those hospital services is $15,000. You must pay a portion of the non-network provider reimbursement amount, generally as a percentage coinsurance. In addition, the non-network provider will likely bill you for the amount by which the provider’s charge exceeds the non-network provider reimbursement amount. If your coinsurance is 40%, you will be required to pay:

40% coinsurance (40% of $15,000 = $6,000) and

The billed charges that exceed the non-network provider reimbursement amount ($30,000 - $15,000 = $15,000)

The total amount you will owe is $6,000 + $15,000 = $21,000.

The $6,000 you pay as coinsurance will be applied to the out-of-pocket maximum amount described in Your Out-Of-Pocket Expenses. However, the $15,000 amount you pay for billed charges in excess of the non-network provider reimbursement amount will not be applied toward the out-of-pocket maximum amount described in Your Out-Of-Pocket Expenses. You will owe the provider this $15,000 amount regardless of whether you have previously reached your out-of-pocket maximum with amounts paid for other services.

*Note: The numbers in this example are used only for purposes of illustrating how out-of-network benefits are calculated. The actual numbers will depend on the services received.

Continuity of care

To request continuity of care or if you have questions about how this may apply to you, call Customer Service at one of the telephone numbers listed inside the front cover.

In certain situations, you have a right to continuity of care.

1. If your current provider is terminated without cause, you may be eligible to continue care with that provider at the in-network benefit level.

2. If you are new to Medica as a result of the sponsor changing its third party administrator and your current provider is not a network provider, you may be eligible to continue care with that provider at the in-network benefit level.

Choice Of Provider


This applies only if your provider agrees to comply with the prior authorization requirements, provide all necessary medical information related to your care, and accept as payment in full the lesser of the network provider reimbursement or the provider’s customary charge for the service. This does not apply when a provider’s contract is terminated for cause.

a. Upon request, the plan will authorize continuity of care for up to 120 days as described in 1. and 2. above for the following conditions:

i. an acute condition;

ii. a life-threatening mental or physical illness;

iii. pregnancy beyond the first trimester of pregnancy;

iv. a physical or mental disability defined as an inability to engage in one or more major life activities, provided that the disability has lasted or can be expected to last for at least one year, or can be expected to result in death; or

v. a disabling or chronic condition that is in an acute phase.

Authorization to continue to receive services from your current provider may extend to the remainder of your life if a physician certifies that your life expectancy is 180 days or less.

b. Upon request, the plan will authorize continuity of care for up to 120 days as described in 1. and 2. above in the following situations:

i. if you are receiving culturally appropriate services and a network provider who has special expertise in the delivery of those culturally appropriate services is not available; or

ii. if you do not speak English and a network provider who can communicate with you, either directly or through an interpreter, is not available.

The plan may require medical records or other supporting documentation from your provider to review your request, and will consider each request on a case-by-case basis. If the plan authorizes your request to continue care with your current provider, the plan will explain how continuity of care will be provided. After that time, your services or treatment will need to be transitioned to a network provider to continue to be eligible for in-network benefits. If your request is denied, the plan will explain the criteria used to make its decision. You may appeal this decision.

Coverage will not be provided for services or treatments that are not otherwise covered under this plan.

Prior authorization

Note: Prior authorization is a clinical review that services are medically necessary. Receiving prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, your eligibility and the terms and conditions of this plan applicable on the date you receive services. Prior authorization from the plan may be required before you receive certain services or supplies in order to determine whether a particular service or supply is medically necessary and a benefit. Written procedures and criteria are used when reviewing your request for prior authorization. To determine whether a certain service or supply requires prior authorization, please call Customer

Choice Of Provider


Service at one of the telephone numbers listed inside the front cover or sign in at www.mymedica.com. Emergency services do not require prior authorization.

Your attending provider, you, or someone on your behalf may contact Customer Service to request prior authorization. Your network provider will contact Customer Service to request prior authorization for a service or supply. You must contact Customer Service to request prior authorization for services or supplies received from a non-network provider. If a network provider fails to obtain prior authorization after you have consulted with them about services requiring prior authorization, you are not subject to a penalty for failure to obtain prior authorization.

Some of the services that may require prior authorization from the plan include:

Reconstructive or restorative surgery;

Certain drugs;

Home health care;

Medical supplies and durable medical equipment;

Outpatient surgical procedures;

Certain genetic tests; and

Skilled nursing facility services.

Prior authorization is always required for:

Organ and bone marrow transplants; and

In-network benefits for services from non-network providers, with the exception of emergency services.

This is not an all-inclusive list of all services and supplies that may require prior authorization.

When you, someone on your behalf, or your attending provider calls, the following information may be required:

Name and telephone number of the provider who is making the request;

Name, telephone number, address, and type of specialty of the provider to whom you are being referred, if applicable;

Services being requested and the date those services are to be rendered (if scheduled);

Specific information related to your condition (for example, a letter of medical necessity from your provider); and

Other applicable covered person information (i.e., plan identification number).

Medica will review your request and provide a response to you and your attending provider within 10 business days after the date your request was received, provided all information reasonably necessary to make a decision has been made available to Medica.

Both you and your provider will be informed of the decision as soon as the medical condition warrants, not to exceed 72 hours from the time of the initial request if your attending provider believes that an expedited review is warranted, or if it is concluded that a delay could seriously jeopardize your life, health, or ability to regain maximum function, or subject you to severe pain that cannot be adequately managed without the care or treatment you are requesting.

Choice Of Provider


If Medica does not approve your request for prior authorization, you have the right to appeal Medica’s decision as described in Complaints.

Under certain circumstances, Medica may perform concurrent review to determine whether services continue to be medically necessary. If Medica determines that services are no longer medically necessary, Medica will inform both you and your attending provider in writing of its decision. If Medica does not approve continued coverage, you or your attending provider may appeal Medica’s initial decision (see Complaints).

Role Of Medica


D. Role Of Medica

See Definitions. These words have specific meanings: benefits, claim, coinsurance, copayment, covered person, deductible, network, non-network, plan, plan administrator, provider, sponsor.

The plan administrator has entered into a service agreement with Medica Self-Insured (Medica) under which Medica performs a variety of administrative services with respect to the medical benefits provided under the plan. Medica’s responsibilities generally consist of determining the validity of claims pursuant to the terms of the plan and administering benefit payments under this plan and determining the resolution of complaints and appeals pursuant to the terms of Complaints. The service agreement between the plan administrator and Medica is for administrative services only. Medica does not insure the provision of benefits under the plan; Medica is not a health insurer. Medica is a third party retained by the plan administrator. Medica is not a COBRA administrator. The plan offers Medica Choice Passport.

The relationships between Medica or UHS (network administrator), the plan administrator, and network providers are contractual relationships between independent contractors. Network providers are not agents or employees of Medica or UHS. The relationship between a provider and any covered person is that of health care provider and patient. The provider is solely responsible for health care provided to any covered person.

Provider payment disclosure

This section describes how Medica generally pays providers for health services on behalf of sponsor.

Network providers

Network providers are paid using various types of contractual arrangements which are intended to promote the delivery of health care in a cost efficient and effective manner. These arrangements are not intended to affect your access to health care. These payment methods may include:

1. A fee-for-service method, such as per service or percentage of charges; or

2. A risk-sharing arrangement, such as an amount per day, per stay, per episode, per case, per period of illness, per covered person, or per service with targeted outcome.

The methods by which specific network providers are paid may change from time to time. Methods also vary by network provider. The primary method of payment under the plan is fee-for-service.

Fee-for-service payment means that the network provider is paid a fee for each service provided. If the payment is per service, the network provider’s payment is determined according to a set fee schedule. The amount the network provider receives is the lesser of the fee schedule or what the network provider would have otherwise billed. If the payment is percentage of charges, the network provider’s payment is a set percentage of the provider’s charge. The amount paid to the network provider, less any applicable copayment, coinsurance, or deductible, is considered to be payment in full.

Risk-sharing payment means that the network provider is paid a specific amount for a particular unit of service, such as an amount per day, an amount per stay, an amount per episode, an

Role Of Medica


amount per case, an amount per period of illness, an amount per covered person, or an amount per service with targeted outcome. If the amount paid is less than the cost of providing or arranging for a covered person’s health services, the network provider may bear some of the shortfall. If the amount paid to the network provider is more than the cost of providing or arranging a covered person’s health services, the network provider may keep some of the excess.

Some network providers are authorized to arrange for a covered person to receive certain health services from other providers. This decision may result in a network provider keeping more or less of the risk-sharing payment.

Withhold arrangements For some network providers paid on a fee-for-service basis, including most network physicians and clinics, Medica holds back some of the payment. This is sometimes referred to as a physician contingency reserve or holdback. The withhold amount generally will not exceed 15 percent of the fee schedule amount. In general, Medica does not hold back a portion of network hospitals’ fee-for-service payments. However, when it does, the withhold amount will not usually exceed 5 percent of the fee schedule amount.

Network providers may earn the withhold amount based on Medica’s financial performance as determined by Medica’s Board of Directors and/or certain performance standards identified in the network provider’s contract including, but not limited to, quality and utilization. Based on individual measures, the percentage of the withhold amount paid, if any, can vary among network providers.

Assignment

Medica may arrange for various persons or entities to provide administrative services on behalf of Medica, including claims processing and utilization management services. You must cooperate with those persons or entities in the performance of their responsibilities.

Your Out-Of-Pocket Expenses


E. Your Out-Of-Pocket Expenses

This section describes the expenses that are your responsibility to pay. These expenses are commonly called out-of-pocket expenses.

See Definitions. These words have specific meanings: benefits, claim, coinsurance, copayment, covered person, deductible, dependent, enrollee, medically necessary, network, non-network, non-network provider reimbursement amount, plan, prescription drug, provider, sponsor.

You are responsible for paying the cost of a service that is not medically necessary or not a covered benefit even if the following occurs:

1. A provider performs, prescribes, or recommends the service; or

2. The service is the only treatment available; or

3. You request and receive the service even though your provider does not recommend it. (Your network provider is required to inform you or in some instances provide a waiver for you to sign.)

If you miss or cancel an office visit less than 24 hours before your appointment, your provider may bill you for the service.

Please see the applicable benefit section(s) of this plan for specific information about your in-network and out-of-network benefits and coverage levels.

To verify coverage before receiving a particular service or supply, call Customer Service at one of the telephone numbers listed inside the front cover.

Copayments, coinsurance, and deductibles

For in-network benefits, you must pay the following:

1. Any applicable copayment, coinsurance, and per covered person deductible each calendar year as described in this plan (see the Out-of-Pocket Expenses table in this section).

When covered persons in a family unit (an enrollee and his or her dependents) have together paid the applicable per family deductible for benefits received during a calendar year (see the Out-of-Pocket Expenses table in this section), then all covered persons in the family unit are considered to have satisfied the applicable per covered person and per family deductible for that calendar year.

2. Any charge that is not covered under the plan.

For out-of-network benefits, you must pay the following:





2. Any charge that exceeds the non-network provider reimbursement amount. This means you are required to pay the difference between what the plan pays and what the provider bills.

If you use out-of-network benefits, you may incur costs in addition to your copayment, coinsurance, and deductible amounts. If the amount that your non-network provider bills you is more than the non-network provider reimbursement amount, you are responsible for paying the difference. In addition, the difference will not be applied toward satisfaction of the deductible or the out-of-pocket maximum (described in this section).

To inquire about the non-network provider reimbursement amount for a particular procedure, call Customer Service at one of the telephone numbers listed inside the front cover. When you call, you will need to provide the following:

a. The CPT (Current Procedural Terminology) code for the procedure (ask your non-network provider for this); and

b. The name and location of the non-network provider.

Customer Service will provide you with an estimate of the non-network provider reimbursement amount based on the information provided at the time of your inquiry. The actual amount paid will be based on the information received at the time the claim is submitted and subject to all applicable benefit provisions, exclusions, and limitations, including but not limited to copayments, coinsurance, and deductibles, as described in this plan.


Out-of-pocket maximum

The out-of-pocket maximum is an accumulation of copayments, coinsurance, and deductibles paid for benefits received during a calendar year. Except as described below or as otherwise specified, you will not be required to pay more than the applicable per covered person out-of-pocket maximum for benefits received during a calendar year (see the Out-of-Pocket Expenses table in this section). Please note: Charges for services not eligible for coverage and any charge in excess of the non-network provider reimbursement amount are not applicable toward the out-of-pocket maximum. Additionally, you will owe these amounts regardless of whether you previously reached your out-of-pocket maximum with amounts paid for other services. When covered persons in a family unit (the enrollee and his or her dependents) have together met the applicable per family out-of-pocket maximum for benefits received during the calendar year, then all covered persons of the family unit are considered to have met the applicable per covered person and per family out-of-pocket maximum for that calendar year (see the Out-of-Pocket Expenses table in this section).

There are separate in-network and out-of-network out-of-pocket maximums for this plan. Once your out-of-pocket maximum for in-network and out-of-network is met, then other benefits in the same category are covered at 100 percent. For example, if your eligible out-of-pocket maximum for in-network benefits is met, all in-network benefits for the remainder of the calendar year are covered at 100 percent, but your out-of-network benefits will not be covered at 100 percent until that out-of-pocket maximum is met.

The plan refunds any amount you pay over the out-of-pocket maximum during any calendar year when proof of excess copayments, coinsurance, and deductibles is received and verified by the plan.



Lifetime maximum amount

The lifetime maximum amount payable per covered person for out-of-network benefits under the plan and for out-of-network benefits under any and all other benefit plans, programs, or arrangements offered by the sponsor is described in the Out-of-Pocket Expenses table in this section. Any lifetime maximum dollar limit referenced pertains only to those health care services and supplies that are not essential benefits as defined in the Patient Protection and Affordable Care Act, including any amendments, regulations, rules or other guidance issued with respect to the Act. Note, that if you reach a lifetime benefit maximum under one benefit package, option, plan, program, or arrangement offered by sponsor and either change packages, options, plans, programs, or arrangements offered by sponsor at open enrollment or under a special enrollment opportunity, the amounts paid for benefits under the first benefit package, option, plan, program, or arrangement will carry forward and count towards the applicable lifetime maximum benefit under the second benefit package, option, plan, program, or arrangement offered by sponsor. In other words, the lifetime maximum does not start anew.

Out-of-Pocket Expenses

In-network benefits

* Out-of-network benefits

* For out-of-network benefits, in addition to the deductible, copayment, and coinsurance, you are responsible for any charges in excess of the non-network provider reimbursement amount. Additionally, these excess charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum.

Copayment or coinsurance See specific benefit for applicable copayment or coinsurance.

Deductible

Per covered person $1,000 $2,000

Per family $2,000 Per family deductible does not apply. Refer to the per covered person deductible above.

Out-of-pocket maximum This annual maximum does include the annual deductible.

This annual maximum does include the annual deductible.


Per family $7,000 $10,000



In-network benefits



Lifetime maximum amount payable per covered person

Unlimited $1,000,000. Applies to all benefits you receive under this plan or that you have received under another benefit package, option, plan, program, or arrangement offered by sponsor prior to participating in this plan.

Ambulance Services


F. Ambulance Services

This section describes coverage for ambulance transportation and related services received for covered medical and medical-related dental services (as described in this plan).

See Definitions. These words have specific meanings: benefits, coinsurance, copayment, deductible, emergency, hospital, network, non-network, non-network provider reimbursement amount, physician, plan, provider, skilled nursing facility.

Prior authorization. Prior authorization from the plan may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See Choice Of Provider for more information about the prior authorization process.

Covered

For benefits and the amounts you pay, see the table in this section. More than one copayment or coinsurance may be required if you receive more than one service or see more than one provider per visit.

For non-emergency licensed ambulance services described in the table in this section:

In-network benefits apply to ambulance services arranged through a physician and received from a network provider.

Out-of-network benefits apply to non-emergency ambulance services described in this section that are arranged through a physician and received from a non-network provider. In addition to the deductible and coinsurance described for out-of-network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits.

Not covered

These services, supplies, and associated expenses are not covered:

1. Ambulance transportation to another hospital when care for your condition is available at the network hospital where you were first admitted.

2. Non-emergency ambulance transportation services, except as described in this section.

See Exclusions for additional services, supplies, and associated expenses that are not covered.

Ambulance Services


Your Benefits and the Amounts You Pay

Benefits In-network benefits after deductible

* Out-of-network benefits after deductible

* For out-of-network benefits, in addition to the deductible and coinsurance, you are responsible for any charges in excess of the non-network provider reimbursement amount. Additionally, these excess charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum.

1. Ambulance services or ambulance transportation to the nearest hospital for an emergency

30% coinsurance Covered as an in-network benefit.

2. Non-emergency licensed ambulance service that is arranged through an attending physician, as follows:

a. Transportation from hospital to hospital when:

i. Care for your condition is not available at the hospital where you were first admitted; or

ii. Required by the plan

30% coinsurance 50% coinsurance

b. Transportation from hospital to skilled nursing facility


Durable Medical Equipment And Prosthetics


G. Durable Medical Equipment And Prosthetics

This section describes coverage for durable medical equipment, certain related supplies, and prosthetics.

See Definitions. These words have specific meanings: benefits, coinsurance, copayment, covered person, deductible, medically necessary, network, non-network, non-network provider reimbursement amount, physician, plan, provider.


Covered


The plan covers only a limited selection of durable medical equipment, certain related supplies, and hearing aids that meet the criteria established by the plan. The plan determines if durable medical equipment will be purchased or rented. Some items ordered by your physician, even if medically necessary, may not be covered. The list of eligible durable medical equipment and certain related supplies is periodically reviewed and modified. To request a list of eligible durable medical equipment and certain related supplies, call Customer Service at one of the telephone numbers listed inside the front cover.

If the durable medical equipment, prosthetic device, or hearing aid is covered by the plan, but the model you select is not the plan’s standard model, you will be responsible for the cost difference.

In-network benefits apply to durable medical equipment, certain related supplies, and prosthetic services prescribed by a physician and received from a network durable medical equipment provider, and hearing aids as described in 4. in the table in this section when prescribed by a network provider. To request a list of durable medical equipment providers, call Customer Service at one of the telephone numbers listed inside the front cover.

Out-of-network benefits apply to durable medical equipment, certain related supplies, and prosthetic services prescribed by a physician and received from a non-network provider. Out-of-network benefits also apply to hearing aids as described in 4. in the table in this section. In addition to the deductible and coinsurance described for out-of-network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits.



Not covered


1. Durable medical equipment, supplies, prosthetics, appliances, and hearing aids not on the plan eligible list.

2. Charges in excess of the plan standard model of durable medical equipment, prosthetics, or hearing aids.

3. Repair, replacement, or revision of durable medical equipment, prosthetics, and hearing aids, except when made necessary by normal wear and use.

4. Duplicate durable medical equipment, prosthetics, and hearing aids, including repair, replacement, or revision of duplicate items.






1. Durable medical equipment and certain related supplies


2. Repair, replacement, or revision of durable medical equipment made necessary by normal wear and use


3. Prosthetics

a. Initial purchase of external prosthetic devices that replace a limb or an external body part, limited to:


i. Artificial arms, legs, feet, and hands;

ii. Artificial eyes, ears, and noses;

iii. Breast prostheses







b. Scalp hair prostheses due to alopecia areata. Coverage is limited to one hair prosthesis (i.e., wig) per covered person per calendar year.


c. Repair, replacement, or revision of artificial arms, legs, feet, hands, eyes, ears, noses, and breast prostheses made necessary by normal wear and use


4. Hearing aids for covered persons 18 years of age and younger for hearing loss that is not correctable by other covered procedures

30% coinsurance. Coverage is limited to one hearing aid per ear every three years. Related services must be prescribed by a network provider.

50% coinsurance. Coverage is limited to one hearing aid per ear every three years.

5. Breast pumps Nothing. The deductible does not apply.

50% coinsurance

Home Health Care


H. Home Health Care

This section describes coverage for home health care. Home health care must be directed by a physician and received from a home health care agency authorized by the laws of the state in which treatment is received.

See Definitions. These words have specific meanings: benefits, coinsurance, copayment, custodial care, deductible, dependent, hospital, network, non-network, non-network provider reimbursement amount, physician, plan, provider, skilled care, skilled nursing facility.


Covered


As described under 1. and 2. in the table in this section, the plan (in accordance with Medicare guidelines) considers you homebound when it is medically contraindicated for you to leave your home (i.e., when leaving your home would directly and negatively affect your physical health). A dependent child may still be considered "confined to home" when attending school where life support specialized equipment and help are available.

Benefits covered under 1. and 2. in the table in this section are limited to a combined maximum of 120 visits per calendar year for in-network and 60 visits per calendar year for out-of-network benefits. Please note: These visit limits include any visits that you pay for in order to satisfy any part of your deductible. You may be eligible for additional intermittent skilled care if you have Medica coverage and are also enrolled in the Medical Assistance Program.

The plan covers up to 120 hours of services provided by a private duty nurse or personal care assistant who has provided home care services to a ventilator-dependent patient for the purpose of assuring adequate training of the hospital staff to communicate with that patient.

In-network benefits apply to home health care services ordered or prescribed by a physician and received from a network home health care agency.

Out-of-network benefits apply to home health care services that are ordered or prescribed by a physician and received from a non-network home health care agency. In addition to the deductible and coinsurance described for out-of-network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits.

Please note: Your place of residence is where you make your home. This may be your own dwelling, a relative’s home, an apartment complex that provides assisted living services, or some other type of institution. However, an institution will not be considered your home if it is a hospital or skilled nursing facility.

Home Health Care


Not covered


1. Companion, homemaker, and personal care services.

2. Services provided by a member of your family.

3. Custodial care and other non-skilled services.

4. Physical, speech, or occupational therapy provided in your home for convenience.

5. Services provided in your home when you are not homebound.

6. Services primarily educational in nature.

7. Vocational and job rehabilitation.

8. Recreational therapy.

9. Self-care and self-help training (non-medical).

10. Health clubs.

11. Disposable supplies and appliances, except as described in Durable Medical Equipment And Prosthetics, Miscellaneous Medical Services And Supplies, and Prescription Drug Program.

12. Physical, speech, or occupational therapy services when there is no reasonable expectation that the covered person’s condition will improve over a predictable period of time according to generally accepted standards in the medical community.

13. Voice training.

14. Home health aide services, except when rendered in conjunction with intermittent skilled care and related to the medical condition under treatment.






1. Intermittent skilled care when you are homebound, provided by or supervised by a registered nurse


2. Skilled physical, speech, or occupational therapy when you are homebound


Home Health Care






3. Home infusion therapy 30% coinsurance 50% coinsurance

4. Services received in your home from a physician


Hospice Services


I. Hospice Services

This section describes coverage for hospice services including respite care. Care must be ordered, provided, or arranged under the direction of a physician and received from a hospice program.

See Definitions. These words have specific meanings: benefits, coinsurance, copayment, covered person, deductible, network, non-network, non-network provider reimbursement amount, physician, plan, skilled nursing facility.

Covered


Hospice services are comprehensive palliative medical care and supportive social, emotional, and spiritual services. These services are provided to terminally ill persons and their families, primarily in the patients’ homes. A hospice interdisciplinary team, composed of professionals and volunteers, coordinates an individualized plan of care for each patient and family. The goal of hospice care is to make patients as comfortable as possible to enable them to live their final days to the fullest in the comfort of their own homes and with loved ones.

Respite care is a form of hospice services that gives your uncompensated primary caregivers (i.e., family members or friends) rest or relief when necessary to maintain a terminally ill covered person at home. Respite care is limited to not more than five consecutive days at a time.

In-network benefits apply to hospice services arranged through a physician and received from a network hospice program.

Out-of-network benefits apply to hospice services arranged through a physician and received from a non-network hospice program. In addition to the deductible and coinsurance described for out-of-network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits.

A plan of care must be established and communicated by the hospice program staff to Medica. To be eligible for coverage, hospice services must be consistent with the hospice program’s plan of care.

To be eligible for the hospice benefits described in this section, you must:

1. Be a terminally ill patient; and

2. Have chosen a palliative treatment focus (i.e., one that emphasizes comfort and supportive services rather than treatment attempting to cure the disease or condition).

You will be considered terminally ill if there is a written medical prognosis by your physician that your life expectancy is six months or less if the terminal illness runs its normal course. This certification must be made not later than two days after the hospice care is initiated.

Hospice Services


Covered persons who elect to receive hospice services do so in place of curative treatment for their terminal illness for the period they are enrolled in the hospice program.

You may withdraw from the hospice program at any time upon written notice to the hospice program. You must follow the hospice program’s requirements to withdraw from the hospice program.

Not covered


1. Respite care for more than five consecutive days at a time.

2. Home health care and skilled nursing facility services when services are not consistent with the hospice program’s plan of care.

3. Services not included in the hospice program’s plan of care.

4. Services not provided by the hospice program.

5. Hospice daycare, except when recommended and provided by the hospice program.

6. Any services provided by a family member or friend, or individuals who are residents in your home.

7. Financial or legal counseling services, except when recommended and provided by the hospice program.

8. Housekeeping or meal services in your home, except when recommended and provided by the hospice program.

9. Bereavement counseling, except when recommended and provided by the hospice program.






1. Hospice services Nothing. The deductible does not apply.

50% coinsurance

Hospital Services


J. Hospital Services

This section describes coverage for use of hospital and ambulatory surgical center services. A physician must direct care.

See Definitions. These words have specific meanings: approved clinical trial, benefits, coinsurance, copayment, covered person, deductible, emergency, genetic testing, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, provider, qualified individual, routine patient costs.


Covered


In-network benefits apply to hospital services received from a network hospital or ambulatory surgical center.

Out-of-network benefits apply to hospital services received from a non-network hospital or ambulatory surgical center. In addition to the deductible and coinsurance described for out-of-network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits. Emergency services from non-network providers will be covered as in-network benefits. If you are confined in a non-network facility as a result of an emergency you will be eligible for in-network benefits until your attending physician agrees it is safe to transfer you to a network facility.

Not covered


1. Drugs received at a hospital on an outpatient basis, except drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection; or drugs received in an emergency room or a hospital observation room. Coverage for drugs is as described in Prescription Drug Program, Prescription Specialty Drug Program, or otherwise described as a specific benefit in this plan.

2. Transfers and admission to network hospitals solely at the convenience of the covered person.

3. Admission to another hospital is not covered when care for your condition is available at the network hospital where you were first admitted.

Hospital Services







1. Outpatient services

a. Services provided in a hospital or facility-based emergency room

$95/visit. The deductible does not apply.

Covered as an in-network benefit.

b. Outpatient lab and pathology 30% coinsurance 50% coinsurance

c. Outpatient x-rays and other imaging services


d. Genetic testing when test results will directly affect treatment decisions or frequency of screening for a disease, or when results of the test will affect reproductive choices Please note: BRCA testing, if appropriate, is covered as a women’s preventive health service.


e. Other outpatient services $40/visit. The deductible does not apply.

50% coinsurance

f. Other outpatient hospital and ambulatory surgical center services received from a physician


50% coinsurance

g. Anesthesia services received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit

Nothing. The deductible does not apply.

50% coinsurance

Hospital Services






h. Routine patient costs in connection with a qualified individual’s participation in an approved clinical trial

Covered at the corresponding in-network benefit level, depending on type of services provided.

For example, office visits are covered at the office visit in-network benefit level and surgical services are covered at the surgical services in-network benefit level.

Covered at the corresponding out-of-network benefit level, depending on type of services provided.

For example, office visits are covered at the office visit out-of-network benefit level and surgical services are covered at the surgical services out-of-network benefit level.

2. Services provided in a hospital observation room


50% coinsurance

3. Inpatient services 30% coinsurance 50% coinsurance

4. Services received from a physician during an inpatient stay


5. Anesthesia services received from a provider during an inpatient stay


Hospital Services






6. Treatment of temporomandibular joint (TMJ) disorder and craniomandibular disorder


For example, office visits are covered at the office visit in-network benefit level and surgical services are covered at the surgical services in-network benefit level. Please note: Dental coverage is not provided under this benefit.


For example, office visits are covered at the office visit out-of-network benefit level and surgical services are covered at the surgical services out-of-network benefit level. Please note: Dental coverage is not provided under this benefit.

Infertility Services


K. Infertility Services

This section describes coverage for the diagnosis and treatment of infertility in connection with the voluntary planning of conceiving a child. Coverage includes benefits for professional, hospital, and ambulatory surgical center services. Infertility treatment must be received from or under the direction of a physician. See Prescription Drug Program and Prescription Specialty Drug Program for coverage of infertility drugs.

See Definitions. These words have specific meanings: benefits, coinsurance, copayment, covered person, deductible, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, provider, virtual care.


Covered


In-network benefits apply to infertility services received from a network provider.

Out-of-network benefits apply to infertility services received from a non-network provider. In addition to the deductible and coinsurance described for out-of-network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits.

Coverage for infertility services is limited to a maximum of $5,000 per covered person per calendar year for in-network and out-of-network benefits combined.

Not covered


1. Drugs provided or administered by a physician or other provider on an outpatient basis, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program, Prescription Specialty Drug Program, or otherwise described as a specific benefit in this plan.

2. In vitro fertilization (IVF), gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures.

3. Services for a condition that a physician determines cannot be successfully treated.



4. Services related to surrogate pregnancy for a person not covered as a covered person under the plan.

5. Sperm banking.

6. Adoption.

7. Donor sperm.

8. Donor eggs.

9. Embryo and egg storage.






1. Office visits, including any services provided during such visits


2. Virtual care $25/visit. The deductible does not apply.

No coverage

3. Outpatient services received at a hospital or ambulatory surgical center







Maternity Services


L. Maternity Services

This section describes coverage for maternity services. Benefits for maternity services include all medical services for prenatal care, labor and delivery, postpartum care, and related complications.

See Definitions. These words have specific meanings: benefits, coinsurance, copayment, covered person, deductible, dependent, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, prenatal care, provider, skilled care.


Newborns’ and Mothers’ Health Protection Act of 1996

Generally, Medica may not restrict benefits for any hospital stay in connection with childbirth for the mother or newborn child covered person to less than 48 hours following a vaginal delivery (or less than 96 hours following a cesarean section). However, federal law generally does not prohibit the mother or newborn child covered person’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours, as applicable). In any case, Medica may not require a provider to obtain prior authorization from Medica for a length of stay of 48 hours or less (or 96 hours, as applicable).

Covered

For benefits and the amounts you pay, see the table in this section. More than one copayment or coinsurance may be required if you receive more than one service or see more than one provider per visit. Each covered person's admission is separate from the admission of any other covered person. A separate deductible and copayment or coinsurance will be applied to both you and your newborn child for inpatient services related to maternity labor and delivery. Please note: We encourage you to enroll your newborn dependent under the plan within 30 days from the date of birth, date of placement for adoption, or date of adoption. Please refer to Eligibility And Enrollment for additional information.

In-network benefits apply to maternity services received from a network provider.

Out-of-network benefits apply to maternity services received from a non-network provider. In addition to the deductible and coinsurance described for out-of-network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits.

Maternity Services


Additional information about coverage of maternity services

Not all services that are received during your pregnancy are considered prenatal care. Some of the services that are not considered prenatal care include (but are not limited to) treatment of the following:

1. Conditions that existed prior to (and independently of) the pregnancy, such as diabetes or lupus, even if the pregnancy has caused those conditions to require more frequent care or monitoring.

2. Conditions that have arisen concurrently with the pregnancy but are not directly related to care of the pregnancy, such as back and neck pain or skin rash.

3. Miscarriage and ectopic pregnancy.

Services that are not considered prenatal care may be eligible for coverage under the most specific and appropriate section of this plan. Please refer to those sections for coverage information.

Not covered


1. Health care professional services for maternity labor and delivery in the home.

2. Services from a doula.

3. Childbirth and other educational classes.






1. Prenatal and postnatal services

a. Office visits for prenatal care, including professional services, lab, pathology, x-rays, and imaging


50% coinsurance

Maternity Services






b. Hospital and ambulatory surgical center services for prenatal care, including professional services received during an inpatient stay for prenatal care


50% coinsurance

c. Intermittent skilled care or home infusion therapy when you are homebound due to a high risk pregnancy


50% coinsurance

d. Supplies for gestational diabetes


50% coinsurance

e. Postnatal services Nothing. The deductible does not apply.

50% coinsurance

2. Inpatient hospital stay for labor and delivery services Please note: Maternity labor and delivery services are considered inpatient services regardless of the length of hospital stay.


3. Professional services received during an inpatient stay for labor and delivery


50% coinsurance

4. Anesthesia services received during an inpatient stay for labor and delivery


5. Labor and delivery services at a free-standing birth center

a. Facility services for labor and delivery


b. Professional services received for labor and delivery


50% coinsurance

Maternity Services






6. Home health care visit following delivery Please note: One home health care visit is covered if it occurs within 4 days of discharge. If services are received after 4 days, please refer to Home Health Care for benefits.


50% coinsurance

Medical-Related Dental Services


M. Medical-Related Dental Services

This section describes coverage for medical-related dental services. Services must be received from a physician or dentist.

This section does not describe coverage for comprehensive dental procedures. Comprehensive dental procedures are services rendered by a dentist to treat teeth, their supporting soft tissue and bony structure, or the alignment or occlusion of the teeth. These services are not covered under any section of this plan.

See Definitions. These words have specific meanings: benefits, coinsurance, copayment, covered person, deductible, dependent, network, non-network, non-network provider reimbursement amount, physician, plan, provider.


Covered


In-network benefits apply to medical-related dental services received from a network provider.

Out-of-network benefits apply to medical-related dental services received from a non-network provider. In addition to the deductible and coinsurance described for out-of-network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits.

Not covered


1. Dental services to treat an injury from biting or chewing.

2. Osteotomies and other procedures associated with the fitting of dentures or dental implants.

3. Dental implants (tooth replacement), except as described in this section for the treatment of cleft lip and palate.

4. Any other dental procedures or treatment, whether the dental treatment is needed because of a primary dental problem or as a manifestation of a medical treatment or condition.

5. Any orthodontia, except as described in this section for the treatment of cleft lip and palate.

6. Tooth extractions, except as described in this section.



7. Any dental procedures or treatment related to periodontal disease.

8. Endodontic procedures and treatment, including root canal procedures and treatment, unless provided as accident-related dental services as described in this section.

9. Routine diagnostic and preventive dental services.






1. Charges for medical facilities and general anesthesia services that are:

a. Recommended by a physician; and

b. Received during a dental procedure; and


50% coinsurance

c. Provided to a covered person who:

i. Is a child under age five; or

ii. Is severely disabled; or

iii. Has a condition and requires hospitalization or general anesthesia for dental care treatment

2. For a dependent child, orthodontia, dental implants, and oral surgery treatment related to cleft lip and palate








3. Accident-related dental services to treat an injury to sound, natural teeth and to repair (not replace) sound, natural teeth. The following conditions apply:

a. Coverage is limited to services received within 24 months from the later of:

i. The date you are first covered under the plan; or

ii. The date of the injury


b. A sound, natural tooth means a tooth (including supporting structures) that is free from disease that would prevent continual function of the tooth for at least one year.

In the case of primary (baby) teeth, the tooth must have a life expectancy of one year.

4. Oral surgery for:

a. Partially or completely unerupted impacted teeth; or

b. A tooth root without the extraction of the entire tooth (this does not include root canal therapy); or

c. The gums and tissues of the mouth when not performed in connection with the extraction or repair of teeth


Mental Health


N. Mental Health

This section describes coverage for services to diagnose and treat mental disorders listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders. For a description of coverage for the diagnosis and primary treatment of substance abuse disorders, see Substance Abuse.

See Definitions. These words have specific meanings: benefits, claim, coinsurance, copayment, covered person, deductible, emergency, hospital, inpatient, medically necessary, mental disorder, network, non-network, non-network provider reimbursement amount, physician, plan, provider.

Prior authorization. For prior authorization requirements of in-network and out-of-network benefits, call the designated mental health and substance abuse provider at 1-800-848-8327 or for Hearing Impaired covered persons, please contact: National Relay Center 1-800-855-2880, then ask them to dial Medica Behavioral Health at 1-866-567-0550.

For purposes of this section:

1. Outpatient services include:

a. Diagnostic evaluations and psychological testing.

b. Psychotherapy and psychiatric services.

c. Intensive outpatient programs, including day treatment, meaning time limited comprehensive treatment plans, which may include multiple services and modalities, delivered in an outpatient setting (up to 19 hours per week).

d. Treatment for a minor, including family therapy.

e. Treatment of serious or persistent disorders.

f. Diagnostic evaluation for attention deficit hyperactivity disorder (ADHD) or pervasive development disorders (PDD).

g. Services, care, or treatment described as benefits in this plan and ordered by a court on the basis of a behavioral health care evaluation performed by a physician or licensed psychologist and that includes an individual treatment plan.

h. Treatment of pathological gambling.

i. Intensive behavioral and developmental therapy for the treatment of autism spectrum disorders for covered persons 17 years of age and younger when provided in accordance with an individualized treatment plan prescribed by the covered person’s treating physician or mental health professional.

2. Inpatient services include:

a. Room and board.

b. Attending psychiatric services.

c. Hospital or facility-based professional services.

d. Partial program. This may be in a freestanding facility or hospital based. Active treatment is provided through specialized programming with medical/psychological intervention and

Mental Health


supervision during program hours. Partial program means a treatment program of 20 hours or more per week and may include lodging.

e. Services, care, or treatment described as benefits in this plan and ordered by a court on the basis of a behavioral health care evaluation performed by a physician or licensed psychologist and that includes an individual treatment plan.

f. Residential treatment services. These services include either:

i. A residential treatment program serving children and adolescents with severe emotional disturbance, certified under law; or

ii. A licensed or certified mental health treatment program providing intensive therapeutic services. In addition to room and board, at least 30 hours a week per individual of mental health services must be provided, including group and individual counseling, client education, and other services specific to mental health treatment. Also, the program must provide an on-site medical/psychiatric assessment within 48 hours of admission, psychiatric follow-up visits at least once per week, and 24-hour nursing coverage.

Covered


For in-network benefits:

The designated mental health and substance abuse provider arranges in-network mental health benefits. If you require hospitalization, the designated mental health and substance abuse provider will refer you to one of its hospital providers. (The plan and the designated mental health and substance abuse provider hospital networks are different.)

For claims questions regarding in-network benefits, call the designated mental health and substance abuse provider Customer Service at 1-866-214-6829.

For out-of-network benefits:

1. Mental health services from a non-network provider listed below will be eligible for coverage under out-of-network benefits provided that the health care professional or facility is licensed, certified, or otherwise qualified under state law to provide the mental health services and practice independently:

a. Psychiatrist

b. Psychologist

c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric and mental health nursing

d. Mental health clinic

e. Mental health residential treatment center

f. Independent clinical social worker

g. Marriage and family therapist

h. Hospital that provides mental health services

Mental Health


i. Licensed professional clinical counselor

2. Emergency mental health services are eligible for coverage under in-network benefits.

In addition to the deductible and coinsurance described for out-of-network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits.

Not covered


1. Services for mental disorders not listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders.

2. Services, care, or treatment that is not medically necessary, unless ordered by a court as specifically described in this section.

3. Relationship counseling.

4. Family counseling services, except as specifically described in this plan as treatment for a minor.

5. Services for telephone psychotherapy.

6. Services beyond the initial evaluation to diagnose mental retardation or learning disabilities, as those conditions are defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders.

7. Services, including room and board charges, provided by health care professionals or facilities that are not appropriately licensed, certified, or otherwise qualified under state law to provide mental health services. This includes, but is not limited to, services provided by mental health providers who are not authorized under state law to practice independently, and services received from a halfway house, housing with support, therapeutic group home, boarding school, or ranch.

8. Services to assist in activities of daily living that do not seek to cure and are performed regularly as a part of a routine or schedule.

9. Room and board charges associated with mental health residential treatment services providing less than 30 hours a week per individual of mental health services, or lacking an on-site medical/psychiatric assessment within 48 hours of admission, psychiatric follow-up visits at least once per week, and 24-hour nursing coverage.


Mental Health






1. Office visits, including evaluations, diagnostic, and treatment services

$35/visit-group; $40/visit-individual. The deductible does not apply.

50% coinsurance

2. Intensive outpatient programs $40/day. The deductible does not apply.

50% coinsurance

3. Intensive behavioral and developmental therapy for the treatment of autism spectrum disorders for covered persons 17 years of age and younger when provided in accordance with an individualized treatment plan prescribed by the covered person’s treating physician or mental health professional. Examples of such therapy include applied behavioral analysis, intensive early intervention behavior therapy, and intensive behavioral intervention.


4. Inpatient services (including residential treatment services)

a. Room and board 30% coinsurance 50% coinsurance

b. Hospital or facility-based professional services


c. Attending psychiatrist services


d. Partial program 30% coinsurance 50% coinsurance

Miscellaneous Medical Services And Supplies


O. Miscellaneous Medical Services And Supplies

This section describes coverage for miscellaneous medical services and supplies prescribed by a physician. The plan covers only a limited selection of miscellaneous medical services and supplies that meet the criteria established by the plan. Some items ordered by a physician, even if medically necessary, may not be covered.

See Definitions. These words have specific meanings: benefits, coinsurance, copayment, deductible, medically necessary, network, non-network, non-network provider reimbursement amount, physician, plan, provider.


Covered


In-network benefits apply to miscellaneous medical services and supplies received from a network provider.

Out-of-network benefits apply to miscellaneous medical services and supplies received from a non-network provider. In addition to the deductible and coinsurance described for out-of-network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits.

Not covered

Other disposable supplies and appliances, except as described in Durable Medical Equipment And Prosthetics, Home Health Care, and Prescription Drug Program.








1. Blood clotting factors 30% coinsurance 50% coinsurance

2. Dietary medical treatment of phenylketonuria (PKU)


3. Amino acid-based elemental formulas for the following diagnoses:


a. cystic fibrosis;

b. amino acid, organic acid, and fatty acid metabolic and malabsorption disorders;

c. IgE mediated allergies to food proteins;

d. food protein-induced enterocolitis syndrome;

e. eosinophilic esophagitis;

f. eosinophilic gastroenteritis; and

g. eosinophilic colitis

Coverage for the diagnoses in 3.c.-g. above is limited to covered persons five years of age and younger.

4. Total parenteral nutrition 30% coinsurance 50% coinsurance

5. Eligible ostomy supplies 20% coinsurance. The deductible does not apply.

40% coinsurance

6. Insulin pumps and other eligible diabetic equipment and supplies

20% coinsurance. The deductible does not apply.

40% coinsurance

Organ And Bone Marrow Transplant Services


P. Organ And Bone Marrow Transplant Services

This section describes coverage for certain organ and bone marrow transplant services. Services must be provided under the direction of a network physician and received at a designated transplant facility. This section also describes benefits for professional, hospital, and ambulatory surgical center services.

Coverage is provided for certain types of organ transplants and related services (including organ acquisition and procurement) and for certain bone marrow transplant services that are medically necessary, appropriate for the diagnosis, without contraindications, and non-investigative.

See Definitions. These words have specific meanings: benefits, coinsurance, copayment, covered person, deductible, hospital, inpatient, investigative, medically necessary, network, non-network, non-network provider reimbursement amount, physician, plan, plan administrator, provider, virtual care.

Prior authorization. Prior authorization from the plan is required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See Choice Of Provider for more information about the prior authorization process.

Covered


The plan administrator uses specific medical criteria to determine benefits for organ and bone marrow transplant services. Because medical technology is constantly changing, the plan reserves the right to review and update these medical criteria. Benefits for each individual covered person will be determined based on the clinical circumstances of the covered person according to the plan’s administrative medical criteria.

Coverage is provided for the following human organ transplants, if appropriate, under the plan’s medical criteria and not otherwise excluded from coverage (see Not covered below): cornea, kidney, lung, heart, heart/lung, pancreas, liver, allogeneic, autologous, and syngeneic bone marrow. Bone marrow transplants include the transplant of stem cells from bone marrow, peripheral blood, and umbilical cord blood.

The preceding is not a comprehensive list of eligible organ and bone marrow transplant services.

Benefits apply to transplant services provided by a network provider and received at a designated transplant facility. A designated transplant facility means a hospital that has entered into a separate contract with Medica to provide certain transplant-related health services to covered persons receiving transplants. You may be evaluated and listed as a potential recipient at multiple designated facilities for transplant services.

The plan requires that all pre-transplant, transplant, and post-transplant services, from the time of the initial evaluation through no more than one year after the date of the transplant, be received at one designated transplant facility. Based on the type of transplant you



receive, the plan will determine the specific time period medically necessary for these services.

Not covered


1. Organ and bone marrow transplant services, except as described in this section.

2. Supplies and services related to transplants that would not be authorized by the plan under the medical criteria referenced in this section.

3. Chemotherapy, radiation therapy, drugs, or any therapy used to damage the bone marrow and related to transplants that would not be authorized by the plan under the medical criteria referenced in this section.

4. Living donor transplants that would not be authorized by the plan under the medical criteria referenced in this section.

5. Services required to meet the patient selection criteria for the authorized transplant procedure. This includes treatment of nicotine or caffeine addiction, services and related expenses for weight loss programs, nutritional supplements, appetite suppressants, and supplies of a similar nature not otherwise covered under the plan.

6. Mechanical, artificial, or non-human organ implants or transplants and related services that would not be authorized by the plan under the medical criteria referenced in this section.

7. Transplants and related services that are investigative.

8. Private collection and storage of umbilical cord blood for directed use.







1. Office visits $40/visit. The deductible does not apply.

No coverage


No coverage








a. Professional services

i. Surgical services (as defined in the Physicians’ Current Procedural Terminology code book) received from a physician during an office visit or an outpatient hospital or ambulatory surgical center visit


No coverage

ii. Anesthesia services received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit


No coverage

iii. Outpatient lab and pathology

30% coinsurance No coverage

iv. Outpatient x-rays and other imaging services


v. Other outpatient hospital or ambulatory surgical center services received from a physician


No coverage

vi. Services related to human leukocyte antigen testing for bone marrow transplants


No coverage

b. Hospital and ambulatory surgical center services

i. Outpatient lab and pathology


ii. Outpatient x-rays and other imaging services








iii. Other outpatient hospital or ambulatory surgical center services


No coverage

4. Inpatient services 30% coinsurance No coverage





Physical, Speech, And Occupational Therapies


Q. Physical, Speech, And Occupational Therapies

This section describes coverage for physical therapy, speech therapy, and occupational therapy services provided on an outpatient basis. A physician must direct your care in order for it to be eligible for coverage. Coverage for services provided on an inpatient basis is as described elsewhere in this plan.

See Definitions. These words have specific meanings: benefits, coinsurance, copayment, deductible, habilitative, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, rehabilitative.


Covered


Therapy services described in this section include coverage for the treatment of autism spectrum disorders.

In-network benefits apply to outpatient physical therapy, speech therapy, and occupational therapy services arranged through a physician and received from the following types of network providers: physical therapist, speech therapist, occupational therapist, or physician.

Out-of-network benefits apply to outpatient physical therapy, speech therapy, and occupational therapy services arranged through a physician and received from the following types of non-network providers: physical therapist, speech therapist, occupational therapist, or physician. In addition to the deductible and coinsurance described for out-of-network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits.

Not covered






5. Health clubs.

6. Voice training.



7. Group physical, speech, and occupational therapy.

8. Physical, speech, or occupational therapy services (including but not limited to services for the correction of speech impediments or assistance in the development of verbal clarity) when there is no reasonable expectation that the covered person’s condition will improve over a predictable period of time according to generally accepted standards in the medical community.

9. Massage therapy, provided in any setting, even when it is part of a comprehensive treatment plan.






1. Physical therapy services received outside of your home

a. Habilitative services $40/visit. The deductible does not apply.

50% coinsurance. Coverage for physical and occupational therapy is limited to a combined limit of 20 visits per calendar year. Please note: This visit limit includes physical and occupational therapy visits that you pay for in order to satisfy any part of your deductible.

b. Rehabilitative services $40/visit. The deductible does not apply.








2. Speech therapy services received outside of your home


50% coinsurance. Coverage for speech therapy is limited to 20 visits per calendar year. Please note: This visit limit includes speech therapy visits that you pay for in order to satisfy any part of your deductible.



3. Occupational therapy services received outside of your home











Prescription Drug Program


R. Prescription Drug Program

This section describes coverage for prescription drugs and supplies received from a pharmacy or a designated mail order pharmacy. For purposes of this section, the phrase “covered drugs” is meant to include those prescription drugs, over-the-counter (OTC) drugs, and supplies found on the Preferred Drug List (PDL) and prescribed by a provider authorized to prescribe such covered drugs, unless such prescription drugs, OTC drugs, and supplies are identified in this plan as not covered. The phrase “professionally administered drugs” means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection; the phrase “self-administered drugs” means all other drugs. For the definition and coverage of specialty prescription drugs, see Prescription Specialty Drug Program.

See Definitions. These words have specific meanings: benefits, claim, coinsurance, copayment, covered person, deductible, emergency, hospital, network, non-network, non-network provider reimbursement amount, physician, plan, prescription drug, preventive health service, provider.

Preferred drug list

Medica’s PDL identifies whether a drug is classified by Medica as a Tier 1, Tier 2, or Tier 3 covered drug. In general, only drugs on Medica’s PDL are eligible for benefits under this plan. The PDL includes the following tiers:

Tier 1 is your lowest copayment or coinsurance option. For the lowest out-of-pocket expense, you should consider a Tier 1 covered drug if you and your physician decide it is appropriate for your treatment.

Tier 2 is your higher copayment or coinsurance option. You may consider a Tier 2 covered drug to treat your condition if you and your physician decide it is appropriate.

Tier 3 is your highest copayment or coinsurance option. The covered drugs in Tier 3 are usually more costly.

If you have questions about Medica’s PDL or whether a specific drug is covered (and/or the PDL tier in which the drug may be covered), or if you would like to request a copy of the PDL at no charge, call Customer Service at one of the telephone numbers listed inside the front cover. The PDL is also available when you sign in at www.mymedica.com.

Medica selects drugs for the PDL based on recommendations of an independent Pharmacy and Therapeutics (P&T) Committee that includes practicing physicians and pharmacists. Placement of a drug on the PDL, and the tier to which a drug is assigned, are based on the drug’s safety, efficacy, uniqueness, and cost.

Exceptions to the preferred drug list

Exceptions to the PDL can include antipsychotic drugs prescribed to treat emotional disturbance or mental illness, and certain drugs for diagnosed mental illness or emotional disturbance if removed from the PDL or you change health plans. If you would like to request a copy of the plan’s PDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover.



Prior authorization

Certain covered drugs require prior authorization as indicated on the PDL. The provider who prescribes the drug initiates prior authorization. The PDL is made available to providers, including pharmacies and the designated mail order pharmacies. You are responsible for paying the cost of drugs received if you do not meet the plan's authorization criteria.

Step therapy

The plan requires step therapy prior to coverage of specific drugs as indicated on the PDL. Step therapy involves trying an alternative covered drug first (typically a Tier 1 drug) before moving on to a Tier 2 or Tier 3 covered drug for treatment of the same medical condition. Applicable step therapy requirements must be met before the plan will cover Tier 2 or Tier 3 covered drugs.

Quantity limits

Certain covered drugs are assigned quantity limits as indicated on the PDL. These limits indicate the maximum quantity allowed per prescription over a specific time period. Some quantity limits are based on packaging, FDA labeling, or clinical guidelines.

Covered

The following table provides important general information concerning in-network, out-of-network, and mail order benefits. For specific information concerning benefits and the amounts you pay, see the benefit table at the end of this section. Please note that Prescription Drug Program describes your copayment or coinsurance for prescription and OTC drugs themselves. An additional copayment or coinsurance applies for the provider’s services if you require that a provider administer self-administered drugs, as described in other applicable sections of this plan including, but not limited to, Hospital Services, Infertility Services, and Professional Services.

In-network benefits Out-of-network benefits* Mail order benefits**

Covered drugs received at a network pharmacy; and

Covered drugs received at a non-network pharmacy; and

Covered drugs received from a designated mail order pharmacy; and

Diabetic equipment and supplies, including blood glucose meters when received from a network pharmacy; and

Diabetic equipment and supplies, including blood glucose meters when received from a non-network pharmacy; and

Diabetic equipment and supplies (excluding blood glucose meters) received from a designated mail order pharmacy.

Tobacco cessation products when prescribed by a provider authorized to prescribe the product and received at a network pharmacy.

Tobacco cessation products when prescribed by a provider authorized to prescribe the product and received at a non-network pharmacy.

Not available.



* When out-of-network benefits are received from non-network providers, in addition to the deductible and copayment or coinsurance, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits.

** Please note: Some drugs and supplies are not available through the designated mail order pharmacy.

See Miscellaneous Medical Services And Supplies for coverage of insulin pumps.

See Prescription Specialty Drug Program for coverage of growth hormone and other specialty prescription drugs.

Prescription unit

Generally, covered drugs will not be dispensed in excess of one prescription unit except as indicated below. One prescription unit is equal to a 31-consecutive-day supply of a covered drug from your pharmacy (or, in the case of contraceptives, up to a one-cycle supply) or a 93-consecutive-day supply of a covered drug from your designated mail order pharmacy (or, in the case of contraceptives, up to a three-cycle supply), unless limited by drug manufacturer’s packaging, dosing instructions, or Medica’s medication request guidelines, including quantity limits as indicated on the PDL. Copayment or coinsurance amounts will apply to each prescription unit dispensed.

Three prescription units may be dispensed for covered drugs prescribed to treat chronic conditions that are received at a network pharmacy that Medica has specifically designated to dispense multiple prescription units. For the current list of such designated pharmacies, sign in at www.mymedica.com or call Customer Service at one of the telephone numbers listed inside the front cover. When you have used 75 percent of your medication as prescribed, you may refill your prescription.

Not covered

The following are not covered:

1. Any amount above what the plan would have paid when you fail to identify yourself to the pharmacy as a covered person. (The plan will notify you before enforcement of this provision.)

2. Replacement of a drug due to loss, damage, or theft.

3. Appetite suppressants.

4. Tobacco cessation products or services dispensed through a mail order pharmacy.

5. Drugs prescribed by a provider who is not acting within his/her scope of licensure.

6. Homeopathic medicine.

7. Specialty prescription drugs, except as described in Prescription Specialty Drug Program.

See Exclusions for additional drugs, supplies, and associated expenses that are not covered.





In-network benefits


Mail order benefits

1. Outpatient covered drugs other than those described below or in Prescription Specialty Drug Program

Tier 1: $12 per prescription unit; or


Tier 3: $75 per prescription unit

$75 or 40% coinsurance (whichever is greater) per prescription unit




2. Infertility covered drugs. Limited to a maximum benefit of $3,000 per calendar year for all infertility covered drugs described in Prescription Drug Program and Prescription Specialty Drug Program combined.








3. Diabetic equipment and supplies, including blood glucose meters

Tier 1: 20% coinsurance per prescription unit; or


Tier 3: 40% coinsurance per prescription unit

40% coinsurance per prescription unit




4. Tobacco cessation products

Tier 1: Nothing per prescription unit; or


Tier 3: Nothing per prescription unit


Not available through a mail order pharmacy.





In-network benefits


Mail order benefits

5. Drugs and other supplies (including women’s contraceptives) considered preventive health services, as specifically defined in Definitions, when prescribed by a provider authorized to prescribe such drugs. This group of drugs and supplies is specific and limited. For the current list of such drugs and supplies, please refer to the Preventive Drug and Supply List within the PDL or call Customer Service at one of the telephone numbers listed inside the front cover. Note: Tobacco cessation products are covered as described in item 4. in this benefit table.








Prescription Specialty Drug Program


S. Prescription Specialty Drug Program

This section describes coverage for specialty prescription drugs received from a designated specialty pharmacy. Specialty prescription drugs include, but are not limited to, high technology prescription drug products for individuals with diseases that require complex therapies. Such specialty prescription drugs are identified on Medica’s Specialty Preferred Drug List (SPDL), as described below. For purposes of this section, the phrase “professionally administered drugs” means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection; the phrase “self-administered drugs” means all other drugs.

See Definitions. These words have specific meanings: benefits, claim, coinsurance, copayment, covered person, deductible, network, physician, plan, prescription drug, provider.

Designated specialty pharmacies

A designated specialty pharmacy means a specialty pharmacy that has entered into a separate contract with Medica to provide specialty prescription drug services to covered persons. For the current list of designated specialty pharmacies, call Customer Service at one of the telephone numbers listed inside the front cover or sign in at www.mymedica.com.

Specialty preferred drug list

Medica has a tiered SPDL that identifies specialty prescription drugs that are covered, unless otherwise listed as not covered in this plan. The SPDL also identifies whether a drug is classified by Medica as a Tier 1 or Tier 2 specialty prescription drug. In general, only specialty prescription drugs on Medica’s SPDL are eligible for benefits under this plan.

The applicable copayments and coinsurance amounts for coverage of drugs on the SPDL are set forth in the benefit table below.

If you have questions about Medica’s SPDL or whether a specific specialty prescription drug is covered (and/or the SPDL tier in which the drug may be covered), or if you would like to request a copy of the SPDL at no charge, call Customer Service at one of the telephone numbers listed inside the front cover. The SPDL is also available by signing in at www.mymedica.com.

Medica selects specialty drugs for the SPDL based on recommendations of an independent Pharmacy and Therapeutics (P&T) Committee that includes practicing physicians and pharmacists. Placement of a specialty drug on the SPDL, and the tier to which a specialty drug is assigned, are based on the specialty drug’s safety, efficacy, uniqueness, and cost.

Exceptions to the specialty preferred drug list

Exceptions to the SPDL can include antipsychotic drugs prescribed to treat emotional disturbance or mental illness, and certain drugs for diagnosed mental illness or emotional disturbance if removed from the SPDL or you change health plans. If you would like to request a copy of the plan’s SPDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover.



Prior authorization

Certain specialty prescription drugs require prior authorization. The provider who prescribes the specialty drug initiates prior authorization. The SPDL is made available to providers, including designated specialty pharmacies. You are responsible for paying the cost of specialty prescription drugs you receive if you do not meet the plan’s authorization criteria.

Step therapy

The plan requires step therapy prior to coverage of specific specialty prescription drugs as indicated on the SPDL. Step therapy involves trying an alternative covered specialty prescription drug (typically a Tier 1 specialty prescription drug) before moving on to certain other Tier 1 or Tier 2 specialty prescription drugs for treatment of the same medical condition. Applicable step therapy requirements must be met before the plan will cover certain Tier 1 or Tier 2 specialty prescription drugs.

Quantity limits

Certain specialty prescription drugs are assigned quantity limits as indicated on the SPDL. These limits indicate the maximum quantity allowed per prescription over a specific time period. Some quantity limits are based on packaging, FDA labeling, or clinical guidelines.

Covered

For benefits and the amounts you pay, see the table at the end of this section. Benefits apply to specialty prescription drugs prescribed by a provider authorized to prescribe such drugs and received from a designated specialty pharmacy.

Specialty prescription drugs are not subject to the deductible.

This section describes your copayment or coinsurance for specialty prescription drugs. An additional copayment or coinsurance applies for the provider’s services if you require that a provider administer self-administered drugs, as described in other applicable sections of this plan including, but not limited to, Hospital Services, Infertility Services, and Professional Services.

Prescription unit

Generally, specialty prescription drugs will not be dispensed in excess of one prescription unit. When you have used 65 percent of your medication as prescribed, you may refill your prescription. One prescription unit is equal to a 31-consecutive-day supply of a specialty prescription drug, unless limited by the manufacturer’s packaging or Medica’s medication request guidelines, including quantity limits as indicated on the SPDL.



Not covered


1. Any amount above what the plan would have paid when you fail to identify yourself to the designated specialty pharmacy as a covered person. (The plan will notify you before enforcement of this provision.)

2. Replacement of a specialty drug due to loss, damage, or theft.

3. Specialty prescription drugs prescribed by a provider who is not acting within their scope of licensure.

4. Prescription drugs and OTC drugs, except as described in Prescription Drug Program.

5. Specialty prescription drugs received from a pharmacy that is not a designated specialty pharmacy.



Benefits You pay

1. Specialty prescription drugs, other than those described below, received from a designated specialty pharmacy

Tier 1 specialty prescription drugs: 20% coinsurance up to a maximum of $200 per prescription unit; or

Tier 2 specialty prescription drugs: 40% coinsurance per prescription unit

2. Specialty infertility prescription drugs received from a designated specialty pharmacy. Limited to a maximum benefit of $3,000 per calendar year for all infertility drugs described in Prescription Drug Program and Prescription Specialty Drug Program combined.



3. Specialty growth hormone when prescribed by a physician for the treatment of a demonstrated growth hormone deficiency and received from a designated specialty pharmacy



Professional Services


T. Professional Services

This section describes coverage for professional services received from or directed by a physician.

See Definitions. These words have specific meanings: approved clinical trial, benefits, coinsurance, convenience care/retail health clinic, copayment, deductible, emergency, genetic testing, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, preventive health service, provider, qualified individual, routine patient costs, urgent care center, virtual care.


Covered


In-network benefits apply to professional services received from a network provider.

Out-of-network benefits apply to professional services received from a non-network provider. In addition to the deductible and coinsurance, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits. Emergency services from non-network providers will be covered as in-network benefits.

The most specific and appropriate section of this plan will apply for professional services related to the treatment of a specific condition. For example, benefits for transplant services are described in Organ And Bone Marrow Transplant Services.

For some services, there may be a facility charge resulting in copayment or coinsurance (see Hospital Services) in addition to the professional services copayment or coinsurance.

Not covered


1. Drugs provided or administered by a physician or other provider, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program, Prescription Specialty Drug Program, or otherwise described as a specific benefit in this plan.

2. Diagnostic casts, diagnostic study models, and bite adjustments unless related to the treatment of temporomandibular joint (TMJ) disorder and craniomandibular disorder.








1. Office visits Please note: Some services received during an office visit may be covered under another benefit in this plan. The most specific and appropriate benefit in this plan will apply for each service received during an office visit.

For example, certain services received during an office visit may be considered surgical or imaging services; see below for coverage of these surgical or imaging services. In such instances, both an office visit copayment or coinsurance and outpatient surgical or imaging services copayment or coinsurance apply.

Call Customer Service at one of the telephone numbers listed inside the front cover to determine in advance whether a specific procedure is a benefit and the applicable coverage level for each service that you receive.


50% coinsurance


No coverage

3. Convenience care/retail health clinic visits


50% coinsurance







4. Urgent care center visits Please note: Some services received during an urgent care center visit may be covered under another benefit in this plan. The most specific and appropriate benefit in this plan will apply for each service received during an urgent care center visit.

For example, certain services received during an urgent care center visit may be considered surgical or imaging services; see below for coverage of these surgical or imaging services. In such instances, both an urgent care center visit copayment or coinsurance and outpatient surgical or imaging services copayment or coinsurance apply.




5. Preventive health care Please note: If you receive preventive and non-preventive health services during the same visit, the non-preventive health services may be subject to a copayment, coinsurance, or deductible, as described elsewhere in this plan. The most specific and appropriate benefit in this plan will apply for each service received during a visit.

a. Child health supervision services, including well-baby care


50% coinsurance







b. Immunizations Nothing. The deductible does not apply.

50% coinsurance

c. Early disease detection services including physicals


No coverage

d. Routine screening procedures for cancer, including but not limited to ovarian cancer and prostate cancer


50% coinsurance

e. Women’s preventive health services including mammograms, screenings for cervical cancer, human papillomavirus (HPV) testing, counseling for sexually transmitted infections, counseling for immunodeficiency virus (HIV), BRCA genetic testing and related genetic counseling (when appropriate), and sterilization


50% coinsurance

f. Other preventive health services


50% coinsurance

6. Allergy shots Nothing. The deductible does not apply.

50% coinsurance

7. Hearing exams Nothing. The deductible does not apply.

No coverage

8. Routine annual eye exams Nothing. The deductible does not apply.

No coverage







9. Chiropractic services to diagnose and to treat (by manual manipulation or certain therapies) conditions related to the muscles, skeleton, and nerves of the body


50% coinsurance. Coverage is limited to a maximum of 15 visits per calendar year. Please note: This visit limit includes chiropractic visits that you pay for in order to satisfy any part of your deductible.

10. Surgical services (as defined in the Physicians’ Current Procedural Terminology code book) received from a physician during an office visit or an outpatient hospital or ambulatory surgical center visit


50% coinsurance

11. Anesthesia services received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit


50% coinsurance

12. Services received from a physician during an emergency room visit







15. Outpatient lab and pathology 30% coinsurance 50% coinsurance

16. Outpatient x-rays and other imaging services


17. Other outpatient hospital or ambulatory surgical center services received from a physician


50% coinsurance







18. Treatment to lighten or remove the coloration of a port wine stain










20. Diabetes self-management training and education, including medical nutrition therapy, received from a provider in a program consistent with national educational standards (as established by the American Diabetes Association)


50% coinsurance







21. Neuropsychological evaluations/cognitive testing, limited to services necessary for the diagnosis or treatment of a medical illness or injury


50% coinsurance

22. Acupuncture. Limited to 15 visits per calendar year for in-network and out-of-network benefits combined. Please note: This visit limit includes visits that you pay for in order to satisfy any part of your deductible.


50% coinsurance

23. Services related to lead testing $40/visit. The deductible does not apply.

50% coinsurance

24. Vision therapy and orthoptic and/or pleoptic training, to establish a home program, for the treatment of strabismus and other disorders of binocular eye movements. Coverage is limited to a combined in-network and out-of-network total of 5 training visits and 2 follow-up eye exams per calendar year. Please note: These visit and exam limits include visits and exams that you pay for in order to satisfy any part of your deductible.


50% coinsurance

25. Genetic counseling, whether pre- or post-test, and whether occurring in an office, clinic, or telephonically Please note: Genetic counseling for BRCA testing, if appropriate, is covered as a women’s preventive health service.


50% coinsurance







26. Genetic testing when test results will directly affect treatment decisions or frequency of screening for a disease, or when results of the test will affect reproductive choices Please note: BRCA testing, if appropriate, is covered as a women’s preventive health service.


27. Routine patient costs in connection with a qualified individual’s participation in an approved clinical trial.





Reconstructive And Restorative Surgery


U. Reconstructive And Restorative Surgery

This section describes coverage for professional, hospital, and ambulatory surgical center services for reconstructive and restorative surgery. To be eligible, reconstructive and restorative surgery services must be medically necessary and not cosmetic.

See Definitions. These words have specific meanings: benefits, coinsurance, copayment, cosmetic, deductible, hospital, inpatient, medically necessary, network, non-network, non-network provider reimbursement amount, physician, plan, provider, reconstructive, restorative, virtual care.


Covered


In-network benefits apply to reconstructive and restorative surgery services received from a network provider.

Out-of-network benefits apply to reconstructive and restorative surgery services received from a non-network provider. In addition to the deductible and coinsurance described for out-of-network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits.

Not covered


1. Revision of blemishes on skin surfaces and scars (including scar excisions) primarily for cosmetic purposes, unless otherwise covered in Professional Services.

2. Repair of a pierced body part and surgical repair of bald spots or loss of hair.

3. Repairs to teeth, including any other dental procedures or treatment, whether the dental treatment is needed because of a primary dental problem or as a manifestation of a medical treatment or condition.

4. Services and procedures primarily for cosmetic purposes.

5. Surgical correction of male breast enlargement primarily for cosmetic purposes.

6. Hair transplants.

7. Drugs provided or administered by a physician or other provider on an outpatient basis, except those requiring intravenous infusion or injection, intramuscular injection, or



intraocular injection. Coverage for drugs is as described in Prescription Drug Program, Prescription Specialty Drug Program, or otherwise described as a specific benefit in this plan.







50% coinsurance


No coverage

3. Outpatient services a. Professional services






















iii. Other outpatient hospital and ambulatory surgical center services







Skilled Nursing Facility Services


V. Skilled Nursing Facility Services

This section describes coverage for use of skilled nursing facility services. Care must be provided under the direction of a physician. Coverage of the services described in 1. in the table in this section is limited to a combined in-network and out-of-network maximum benefit of 120 days per person per calendar year. Skilled nursing facility services are eligible for coverage only if you are admitted to a skilled nursing facility within 30 days after a hospital admission of at least three consecutive days for the same illness or condition.

See Definitions. These words have specific meanings: benefits, coinsurance, copayment, custodial care, deductible, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, skilled care, skilled nursing facility.


Covered

For benefits and the amounts you pay, see the table in this section. More than one copayment or coinsurance may be required if you receive more than one service or see more than one provider per visit. For purposes of this section, room and board includes coverage of health services and supplies.

In-network benefits apply to skilled nursing facility services arranged through a physician and received from a network skilled nursing facility.

Out-of-network benefits apply to skilled nursing facility services arranged through a physician and received from a non-network skilled nursing facility. In addition to the deductible and coinsurance described for out-of-network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits.

Not covered



2. Self-care or self-help training (non-medical).




6. Health clubs.




8. Voice training.


10. Long-term care.






1. Daily skilled care or daily skilled rehabilitation services, including room and board, up to 120 days per person per calendar year for in-network and out-of-network services combined Please note: Such services are eligible for coverage only if you are admitted to a skilled nursing facility within 30 days after a hospital admission of at least three consecutive days for the same illness or condition. This day limit includes days that you pay for in order to satisfy any part of your deductible.


2. Skilled physical, speech, or occupational therapy when room and board is not eligible to be covered


3. Services received from a physician during an inpatient stay in a skilled nursing facility


Substance Abuse


W. Substance Abuse

This section describes coverage for the diagnosis and primary treatment of substance abuse disorders listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders.





a. Diagnostic evaluations.

b. Outpatient treatment.

c. Intensive outpatient programs, including day treatment and partial programs, which may include multiple services and modalities, delivered in an outpatient setting (up to 19 hours per week).

d. Services, care, or treatment for a covered person that has been placed in any applicable Department of Corrections’ custody following a conviction for a first-degree driving while impaired offense; to be eligible, such services, care, or treatment must be required and provided by any applicable Department of Corrections.


a. Room and board.

b. Attending physician services.



e. Residential treatment services. These are services from a licensed chemical dependency rehabilitation program that provides intensive therapeutic services following detoxification. In addition to room and board, at least 30 hours (15 hours for children and adolescents) per week per individual of chemical dependency services must be provided, including group and individual counseling, client education, and other services specific to chemical dependency rehabilitation.

Substance Abuse


Covered



1. The designated mental health and substance abuse provider arranges in-network substance abuse benefits. If you require hospitalization, the designated mental health and substance abuse provider will refer you to one of its hospital providers (the plan and the designated mental health and substance abuse provider hospital networks are different).

2. In-network benefits will apply to services, care, or treatment for a covered person that has been placed in any applicable Department of Corrections’ custody following a conviction for a first-degree driving while impaired offense. To be eligible, such services, care, or treatment must be required and provided by any applicable Department of Corrections.



1. Substance abuse services from a non-network provider listed below will be eligible for coverage under out-of-network benefits provided that the health care professional or facility is licensed, certified, or otherwise qualified under state law to provide the substance abuse services and practice independently:

a. Psychiatrist

b. Psychologist


d. Chemical dependency clinic

e. Chemical dependency residential treatment center

f. Hospital that provides substance abuse services

g. Independent clinical social worker

h. Marriage and family therapist

2. Emergency substance abuse services are eligible for coverage under in-network benefits.


Substance Abuse


Not covered


1. Services for substance abuse disorders not listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders.

2. Services, care, or treatment that is not medically necessary.

3. Services to hold or confine a person under chemical influence when no medical services are required, regardless of where the services are received.

4. Telephonic substance abuse treatment services.

5. Services, including room and board charges, provided by health care professionals or facilities that are not appropriately licensed, certified, or otherwise qualified under state law to provide substance abuse services. This includes, but is not limited to, services provided by mental health or substance abuse providers who are not authorized under state law to practice independently, and services received from a halfway house, therapeutic group home, boarding school, or ranch.

6. Room and board charges associated with substance abuse treatment services providing less than 30 hours (15 hours for children and adolescents) a week per individual of chemical dependency services, including group and individual counseling, client education, and other services specific to chemical dependency rehabilitation.









50% coinsurance


50% coinsurance

3. Opiate replacement therapy 30% coinsurance 50% coinsurance



Substance Abuse








c. Attending physician services 30% coinsurance 50% coinsurance

Surgery For Weight Loss


X. Surgery For Weight Loss

This section describes coverage for surgery for morbid obesity. Services must be provided under the direction of a designated network physician and received at a designated network facility. This section also describes benefits for professional and hospital and ambulatory surgical center services.

See Definitions. These words have specific meanings: benefits, coinsurance, copayment, cosmetic, deductible, designated facility, designated physician, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, provider, virtual care.


Covered


In-network benefits apply to surgery for morbid obesity provided by a designated network physician and received at a designated network facility. A designated physician or facility is a network physician or hospital that has been designated by the plan to provide surgery for morbid obesity. To request a list of designated physicians and facilities to provide surgery for morbid obesity, call Customer Service at one of the telephone numbers listed inside the front cover.

There is no coverage for out-of-network benefits.

Not covered


1. Surgery for morbid obesity when performed by a network physician that is not a designated physician or received at a network facility that is not a designated facility.

2. Surgery for morbid obesity when performed by a non-network physician or received at a non-network hospital.

3. Surgery for morbid obesity, except as described in this section.


5. Supplies and services for surgery for morbid obesity that would not be authorized by the plan.

6. Services required to meet the patient selection criteria for an authorized surgery for morbid obesity. This includes services and related expenses for weight loss programs, nutritional supplements, appetite suppressants, and supplies of a similar nature not otherwise covered under the plan.










No coverage


No coverage

3. Outpatient hospital services 30% coinsurance No coverage

4. Outpatient services received from a physician in a hospital





Harmful Use Of Medical Services


Y. Harmful Use Of Medical Services

This section describes what Medica will do if it is determined you are receiving health services or prescription drugs in a quantity or manner that may harm your health.

See Definitions. These words have specific meanings: benefits, emergency, hospital, network, physician, prescription drug, provider.

When this section applies

After Medica notifies you that this section applies, you have 30 days to choose one network physician, hospital, and pharmacy to be your coordinating health care providers.

If you do not choose your coordinating health care providers within 30 days, Medica will choose for you. Your in-network benefits are then restricted to services provided by or arranged through your coordinating health care providers.

Failure to receive services from or through your coordinating health care providers will result in a denial of coverage.

You must obtain a referral from your coordinating health care provider if your condition requires care or treatment from a provider other than your coordinating health care provider.

Medica will send you specific information about:

1. How to obtain approval for benefits not available from your coordinating health care providers; and

2. How to obtain emergency care; and

3. When these restrictions end.

Exclusions


Z. Exclusions

See Definitions. These words have specific meanings: claim, cosmetic, covered person, custodial care, emergency, genetic testing, investigative, medically necessary, non-network, physician, plan, provider, reconstructive, routine foot care.

The plan will not provide coverage for any of the services, treatments, supplies, or items described in this section even if it is recommended or prescribed by a physician or it is the only available treatment for your condition.

This section describes additional exclusions to the services, supplies, and associated expenses already listed as Not covered in this plan. These include:

1. Services that are not medically necessary. This includes but is not limited to services inconsistent with the medical standards and accepted practice parameters of the community and services inappropriate—in terms of type, frequency, level, setting, and duration—to the diagnosis or condition.

2. Services or drugs used to treat conditions that are cosmetic in nature, unless otherwise determined to be reconstructive.

3. Refractive eye surgery, including but not limited to LASIK surgery.

4. The purchase, replacement, or repair of eyeglasses, eyeglass frames, or contact lenses when prescribed solely for vision correction, and their related fittings.

5. Services provided by an audiologist when not under the direction of a physician.

6. Hearing aids (including internal, external, or implantable hearing aids or devices) and other devices to improve hearing, and their related fittings, except as described in Durable Medical Equipment And Prosthetics.

7. A drug, device, or medical treatment or procedure that is investigative.

8. Genetic testing when performed in the absence of symptoms or high risk factors for a genetic disease; genetic testing when knowledge of genetic status will not affect treatment decisions, frequency of screening for the disease, or reproductive choices; genetic testing that has been performed in response to direct-to-consumer marketing and not under the direction of your physician.

9. Services or supplies not directly related to care.

10. Autopsies.

11. Enteral feedings, unless they are the sole source of nutrition; however, enteral feedings of standard infant formulas, standard baby food, and regular grocery products used in blenderized formulas are excluded regardless of whether they are the sole source of nutrition.

12. Nutritional and electrolyte substances, except as specifically described in Miscellaneous Medical Services And Supplies.

13. Physical, occupational, or speech therapy or chiropractic services when there is no reasonable expectation that the condition will improve over a predictable period of time.

14. Reversal of voluntary sterilization.

Exclusions


15. Personal comfort or convenience items or services.

16. Custodial care, unskilled nursing, or unskilled rehabilitation services.

17. Respite or rest care, except as otherwise covered in Hospice Services.

18. Travel, transportation, or living expenses.

19. Household equipment, fixtures, home modifications, and vehicle modifications.


21. Routine foot care, except for covered persons with diabetes, blindness, peripheral vascular disease, peripheral neuropathies, and significant neurological conditions such as Parkinson’s disease, Alzheimer’s disease, multiple sclerosis, and amyotrophic lateral sclerosis.

22. Services by persons who are family members or who share your legal residence.

23. Services for which coverage is available under workers' compensation, employer liability, or any similar law.

24. Services received before coverage under the plan becomes effective.

25. Services received after coverage under the plan ends.

26. Unless requested by the plan, charges for duplicating and obtaining medical records from non-network providers and non-network dentists.

27. Photographs, except for the condition of multiple dysplastic syndrome.

28. Occlusal adjustment or occlusal equilibration.

29. Dental implants (tooth replacement), except as described in Medical-Related Dental Services.

30. Dental prostheses.

31. Any orthodontia, except as described in Medical-Related Dental Services for the treatment of cleft lip and palate.

32. Treatment for bruxism.

33. Services prohibited by applicable law or regulation.

34. Services to treat injuries that occur while on military duty, and any services received as a result of war or any act of war (whether declared or undeclared).

35. Exams, other evaluations, or other services received solely for the purpose of employment, insurance, or licensure.

36. Exams, other evaluations, or other services received solely for the purpose of judicial or administrative proceedings or research, except emergency examination of a child ordered by judicial authorities unless otherwise covered under this plan.

37. Non-medical self-care or self-help training.

38. Educational classes, programs, or seminars, including but not limited to childbirth classes, except as described in Professional Services.

39. Coverage for costs associated with translation of medical records and claims to English.

40. Treatment for superficial veins, also referred to as spider veins or telangiectasia.

Exclusions


41. Services not received from or under the direction of a physician, except as described in this plan.

42. Orthognathic surgery for cosmetic purposes.

43. Services for sex transformation operations.

44. Sensory integration, including auditory integration training.

45. Services for or related to vision therapy and orthoptic and/or pleoptic training, except as described in Professional Services.

46. Services for or related to intensive behavior therapy treatment programs for the treatment of autism spectrum disorders for covered persons 18 years of age and older. Examples of such services include, but are not limited to, Intensive Early Intervention Behavior Therapy Services (IEIBTS), Intensive Behavioral Intervention (IBI), and Lovaas therapy.

47. Health care professional services for home labor and delivery.

48. Surgery for weight loss or morbid obesity, including initial procedures, surgical revisions, and subsequent procedures, except as described in Surgery For Weight Loss.

49. Services solely for or related to the treatment of snoring.

50. Interpreter services, except as described in Home Health Care.

51. Services provided to treat injuries or illness that are the result of committing a felony or attempting to commit a felony.

52. Services for private duty nursing, except as described in Home Health Care. Examples of private duty nursing services include, but are not limited to, skilled or unskilled services provided by an independent nurse who is ordered by the covered person or the covered person’s representative, and not under the direction of a physician.

53. Laboratory testing that has been performed in response to direct-to-consumer marketing and not under the direction of a physician.

54. Medical devices that are not approved by the U.S. Food and Drug Administration (FDA), other than those granted a humanitarian device exemption.

55. Health clubs.

56. Long-term care.

57. Expenses associated with participation in weight loss programs, including but not limited to membership fees and the purchase of food, dietary supplements, or publications.

58. Charges for mailing, interest, and delivery.

How To Submit A Claim


AA. How To Submit A Claim

This section describes the process for submitting a claim.

See Definitions. These words have specific meanings: benefits, claim, covered person, network, non-network, non-network provider reimbursement amount, plan, provider.

Claims for benefits from network providers

If you receive a bill for any benefit from a network provider, you may submit the claim following the procedures described below, under Claims for benefits from non-network providers, or call Customer Service at one of the telephone numbers listed inside the front cover. Claim forms may also be obtained by signing in at www.mymedica.com.

Network providers are required to submit claims within 180 days from when you receive a service. If your provider asks for your health care identification card and you do not identify yourself as a covered person within 180 days of the date of service, you may be responsible for paying the cost of the service you received.

Claims for benefits from non-network providers

Claim forms are provided in your enrollment materials. You may request additional claim forms by calling Customer Service at one of the telephone numbers listed inside the front cover. Claim forms may also be obtained by signing in at www.mymedica.com. If the claim forms are not sent to you within 15 days, you may submit an itemized statement without the claim form to Medica. You should retain copies of all claim forms and correspondence for your records.

You must submit the claim in English along with a Medica claim form to Medica no later than 365 days after receiving benefits. Your plan membership number must be on the claim.

Mail to the address identified on the back of your identification card.

Upon receipt of your claim for benefits from non-network providers, the plan will generally pay to you directly the non-network provider reimbursement amount. The plan will only pay the provider of services if:

1. The non-network provider is one that the plan has determined can be paid directly; and

2. The non-network provider notifies the plan of your signature on file authorizing that payment be made directly to the provider.

Call Customer Service at one of the telephone numbers listed inside the front cover for a list of non-network providers that the plan will not pay directly.

Claims for services provided outside the United States

Claims for services rendered in a foreign country will require the following additional documentation:

Claims submitted in English with the currency exchange rate for the date health services were received.



Itemization of the bill or claim.

The related medical records (submitted in English).

Proof of your payment of the claim.

A complete copy of your passport and airline ticket.

Such other documentation as the plan may request.

For services rendered in a foreign country, the plan will pay you directly.

The plan will not reimburse you for costs associated with translation of medical records or claims.

Time limits

If you have a complaint or disagree with a decision by the plan, you may follow the complaint procedure outlined in Complaints.

Coordination Of Benefits


BB. Coordination Of Benefits

This section describes how benefits are coordinated when you are covered under more than one plan.

See Definitions. These words have specific meanings: benefits, claim, covered person, deductible, dependent, emergency, enrollee, hospital, medically necessary, non-network, non-network provider reimbursement amount, plan, provider.

1. Applicability

a. This coordination of benefits (COB) provision applies to this plan when an employee or the employee's covered dependent has health care coverage under more than one plan. Plan and this plan are defined below.

b. If this coordination of benefits provision applies, Order of benefit determination rules should be looked at first. Those rules determine whether the benefits of this plan are determined before or after those of another plan. Under Order of benefit determination rules, the benefits of this plan:

i. Shall not be reduced when this plan determines its benefits before another plan; but

ii. May be reduced when another plan determines its benefits first. The above reduction is described in Effect on the benefits of this plan.

2. Definitions that apply to this section

a. Plan is any of these which provides benefits or services for, or because of, medical or dental care or treatment:

i. Group insurance or group-type coverage, whether insured or uninsured, or individual coverage. This includes prepayment, group practice, or individual practice coverage. It also includes coverage other than school accident-type coverage.

ii. Coverage under a governmental plan, or coverage required or provided by law. This does not include a state plan under Medicaid (Title XIX, Grants to States for Medical Assistance Programs, of the United States Social Security Act, as amended from time to time).

Each contract or other arrangement for coverage under i. or ii. is a separate plan. Also, if an arrangement has two parts and COB rules apply only to one of the two, each of the parts is a separate plan.

b. This plan is the part of the plan that provides benefits for health care expenses.

c. Primary plan/secondary plan. The Order of benefit determination rules state whether this plan is a primary plan or secondary plan as to another plan covering the person.

When this plan is a primary plan, its benefits are determined before those of the other plan and without considering the other plan's benefits.

When this plan is a secondary plan, its benefits are determined after those of the other plan and may be reduced because of the other plan's benefits.



When there are two or more plans covering the person, this plan may be a primary plan as to one or more other plans, and may be a secondary plan as to a different plan or plans.

d. Allowable expense means a necessary, reasonable, and customary item of expense for health care, when the item of expense is covered at least in part by one or more plans covering the person for whom the claim is made. Allowable expense does not include the deductible for covered persons with a primary high deductible plan and who notify Medica of an intention to contribute to a health savings account.

The difference between the cost of a private hospital room and the cost of a semi-private hospital room is not considered an allowable expense under the above definition unless the patient's stay in a private hospital room is medically necessary, either in terms of generally accepted medical practice or as specifically defined in the plan.

The difference between the charges billed by a provider and the non-network provider reimbursement amount is not considered an allowable expense under the above definition.

When a plan provides benefits in the form of services, the reasonable cash value of each service rendered will be considered both an allowable expense and a benefit paid.

When benefits are reduced under a primary plan because a covered person does not comply with the plan provisions, the amount of such reduction will not be considered an allowable expense. Examples of such provisions are those related to second surgical opinions, and preferred provider arrangements.

e. Claim determination period means a calendar year. However, it does not include any part of a year during which a person has no coverage under this plan, or any part of a year before the date this COB provision or a similar provision takes effect.

3. Order of benefit determination rules

a. General. When there is a basis for a claim under this plan and another plan, this plan is a secondary plan which has its benefits determined after those of the other plan, unless:

i. The other plan has rules coordinating its benefits with the rules of this plan; and

ii. Both the other plan's rules and this plan's rules, in 3.b. below, require that this plan's benefits be determined before those of the other plan.

b. Rules. This plan determines its order of benefits using the first of the following rules which applies:

i. Nondependent/dependent. The benefits of the plan that covers the person as an employee, covered person or enrollee (that is, other than as a dependent) are determined before those of the plan, which covers the person as a dependent.

ii. Dependent child/parents not separated or divorced. Except as stated in 3.b.iii. below, when this plan and another plan cover the same child as a dependent of different persons, called parents:

a) The benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year; but



b) If both parents have the same birthday, the benefits of the plan which covered one parent longer are determined before those of the plan which covered the other parent for a shorter period of time.

However, if the other plan does not have the rule described in a) immediately above, but instead 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 in the other plan will determine the order of benefits.

iii. Dependent child/separated or divorced parents. If two or more plans cover a person as a dependent child of divorced or separated parents, benefits for the child are determined in this order:

a) First, the plan of the parent with custody of the child;

b) Then, the plan of the spouse of the parent with the custody of the child; and

c) Finally, the plan of the parent not having custody of the child.

However, if the specific terms of a court decree state that one of the parents is responsible for the health care expense of the child, and the entity obligated to pay or provide the benefits of the plan of that parent has actual knowledge of those terms, the benefits of that plan are determined first. The plan of the other parent shall be the secondary plan. This paragraph does not apply with respect to any claim determination period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge.

iv. Joint custody. If the specific terms of a court 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 follow the Order of benefit determination rules outlined in 3.b.ii.

v. Active/inactive employee. The benefits of a plan which covers a person as an employee who is neither laid off nor retired (or as that employee's dependent) are determined before those of a plan which covers that person as a laid off or retired employee (or as that employee's dependent). 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.

vi. Workers’ compensation. Coverage under any workers’ compensation act or similar law applies first. You should submit claims for expenses incurred as a result of an on-duty injury to the employer, before submitting them to the plan.

vii. No-fault automobile insurance. Coverage under the No-Fault Automobile Insurance Act or similar law applies first.

viii. Longer/shorter length of coverage. If none of the above rules determines the order of benefits, the benefits of the plan which covered an employee, covered person, or enrollee longer are determined before those of the plan which covered that person for the shorter term.

4. Effect on the benefits of this plan

a. When this section applies. This 4. applies when, in accordance with 3. Order of benefit determination rules, this plan is a secondary plan as to one or more other plans. In that



event, the benefits of this plan may be reduced under this section. Such other plan or plans are referred to as the other plans in b. immediately below.

b. Reduction in this plan's benefits. The benefits of this plan will be reduced when the sum of:

i. The benefits that would be payable for the allowable expense under this plan in the absence of this COB provision; and

ii. The benefits that would be payable for the allowable expenses under the other plans, in the absence of provisions with a purpose like that of this COB provision, whether or not a claim is made, exceeds those allowable expenses in a claim determination period. In that case, the benefits of this plan will be reduced so that they and the benefits payable under the other plans do not total more than those allowable expenses.

For non-emergency services received from a non-network provider and determined to be out-of-network benefits, the following reduction of benefits will apply:

When this plan is a secondary plan, this plan will pay the balance of any remaining expenses determined to be eligible under the plan, according to the out-of-network benefits described. Most out-of-network benefits are covered at 50 percent of the non-network provider reimbursement amount, after you pay the applicable deductible amount. In no event will this plan provide duplicate coverage.

When the benefits of this plan are reduced as described above, each benefit is reduced in proportion. It is then charged against any applicable benefit limit of this plan.

5. Right to receive and release needed information

Certain facts are needed to apply these COB rules. The plan has the right to decide which facts it needs. It may get needed facts from or give them to any other organization or person. This plan need not tell, or get the consent of, any person to do this. Unless applicable law prevents disclosure of the information without the consent of the patient or the patient's representative, each person claiming benefits under this plan must give the plan any facts it needs to pay the claim.

6. Facility of payment

A payment made under another plan may include an amount, which should have been paid under this plan. If it does, this plan may pay that amount to the organization which made that payment. That amount will then be treated as though it were a benefit paid under this plan. This plan will not have to pay that amount again. The term payment made includes providing benefits in the form of services, in which case payment made means reasonable cash value of the benefits provided in the form of services.

7. Right of recovery

If the amount of the payments made by this plan is more than it should have paid under this COB provision, it may recover the excess from one or more of the following:

a. The persons it has paid or for whom it has paid; or

b. Insurance companies; or



c. Other organizations.

The amount of the payments made includes the reasonable cash value of any benefits provided in the form of services.

Please note: See Right Of Recovery for additional information.

Right Of Recovery


CC. Right Of Recovery

This section describes this plan’s right of recovery. This plan’s rights may be subject to Minnesota and federal law. For information about the effect of applicable state and federal law on this plan’s subrogation rights, contact an attorney.

See Definitions. These words have specific meanings: benefits, covered person, plan, plan administrator, sponsor.

1. This plan has a right of subrogation against any third party, individual, corporation, insurer, or other entity or person who may be legally responsible for payment of medical expenses related to your illness or injury. This plan’s right of subrogation shall be governed according to this section. This plan’s right to recover its subrogation interest applies only after you have received a full recovery for your illness or injury from another source of compensation for your illness or injury.

2. This plan’s subrogation interest is the reasonable cash value of any benefits received by you.

3. This plan’s right to recover its subrogation interest may be subject to an obligation by the plan to pay a pro rata share of your disbursements, attorney fees, and costs you pay in obtaining your recovery.

4. By accepting coverage under the plan, you agree:

a. To cooperate with the plan administrator, sponsor, or plan designee to help protect the plan’s legal rights under this subrogation provision and to provide all information the plan may reasonably request to determine its rights under this provision.

b. To provide prompt written notice to the plan administrator when you make a claim against a party for injuries.

c. To provide prompt written notice of the plan’s subrogation rights to any party against whom you assert a claim for injuries.

d. To do nothing to decrease the plan’s rights under this provision, either before or after receiving benefits.

e. The plan may take action to preserve its legal rights. This includes bringing suit in your name.

f. The plan may collect its subrogation interest from the proceeds of any settlement or judgment recovered by you, your legal representative, or the legal representative(s) of your estate or next-of-kin.

g. To hold in trust the proceeds of any settlement or judgment for the plan’s benefit under this provision.

Eligibility And Enrollment


DD. Eligibility And Enrollment

This section describes who can enroll and how to enroll.

See Definitions. These words have specific meanings: benefits, certificate of creditable coverage, claim, covered person, creditable coverage, dependent, employee, enrollee, enrollment date, late enrollee, placed as a foster child, placed for adoption, plan, plan administrator, qualified employee, sponsor, waiting period.

Who can enroll

All qualified employees and dependents as defined in Definitions are eligible for coverage under this plan. In order for an eligible dependent to enroll in the plan, the qualified employee must also be enrolled.

How to enroll

What qualified employees must do Submit an application for coverage for the qualified employee and/or any dependents to the plan administrator:

1. During the initial enrollment period as described in this section under Initial enrollment; or

2. During the open enrollment period as described in this section under Open enrollment; or

3. During a special enrollment period as described in this section under Special enrollment; or

4. At any other time as a late enrollee as described in this section under Late enrollment.

Dependents will not be enrolled without the qualified employee also being enrolled. A child who is the subject of a medical support order can be enrolled as described in this section under Medical Support Order and under Special enrollment.

Initial enrollment

Qualified employees must submit an application for the qualified employee and/or any dependents to the plan administrator during the initial enrollment period, which will be communicated to the qualified employee by the plan administrator.

A covered person who is a child entitled to receive coverage through a medical support order is not subject to any initial enrollment period restrictions, except as noted in this section.

Open enrollment

Qualified employees must submit an application for the qualified employee and any dependents to the plan administrator during the open enrollment period, which will be communicated to the qualified employee by the plan administrator. Open enrollment period means the period of time occurring toward the end of the calendar year during which qualified employees and eligible



dependents who are not covered under the plan may elect to begin coverage effective the first day of the upcoming calendar year.

Special enrollment

Special enrollment periods are provided to qualified employees and dependents under certain circumstances. Qualified employees and dependents who are eligible to enroll during a special enrollment period may enroll in any medical benefit package or option available to similarly situated individuals who enroll when first eligible. However, all other provisions of the plan, including but not limited to provisions setting a lifetime maximum on benefits, will apply to special enrollees. 1. Loss of other coverage

a. A special enrollment period will apply to a qualified employee and dependent if the individual was covered under Medicaid or a State Children’s Health Insurance Plan and lost that coverage as a result of loss of eligibility. The qualified employee or dependent must present evidence of the loss of coverage and request enrollment within 60 days after the date such coverage terminates.

In the case of the qualified employee’s loss of coverage, this special enrollment period applies to the qualified employee and all of his or her dependents. In the case of a dependent’s loss of coverage, this special enrollment period applies to both the dependent who has lost coverage and the qualified employee.

b. A special enrollment period will apply to a qualified employee and dependent if the qualified employee or dependent was covered under creditable coverage other than Medicaid or a State Children’s Health Insurance Plan at the time the qualified employee or dependent was eligible to enroll under the plan, whether during initial enrollment, open enrollment, or special enrollment and declined coverage for that reason.

The qualified employee or dependent must present to the plan administrator either evidence of the loss of prior coverage due to loss of eligibility for that coverage or evidence that employer contributions toward the prior coverage have terminated; and request enrollment in writing within 30 days of the date of the loss of coverage or the date the employer’s contribution toward that coverage terminates.

For purposes of 1.b.:

i. Prior coverage does not include federal or state continuation coverage;

ii. Loss of eligibility includes:

Loss of eligibility as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment;

Cessation of dependent status;

Incurring a claim that causes the qualified employee or dependent to meet or exceed the lifetime maximum limit on all benefits;

If the prior coverage was offered through an individual health maintenance organization (HMO), a loss of coverage because the qualified employee or dependent no longer resides or works in the HMO’s service area;



If the prior coverage was offered through a group HMO, a loss of coverage because the qualified employee or dependent no longer resides or works in the HMO’s service area and no other coverage option is available; and

The prior coverage no longer offers any benefits to the class of similarly situated individuals that includes the qualified employee or dependent.

iii. Loss of eligibility occurs regardless of whether the qualified employee or dependent is eligible for or elects applicable federal or state continuation coverage;

iv. Loss of eligibility does not include a loss due to failure of the qualified employee or dependent to pay premiums on a timely basis or termination of coverage for cause;

In the case of the qualified employee’s loss of other coverage, the special enrollment period described above applies to the qualified employee and all of his or her dependents. In the case of a dependent’s loss of other coverage, the special enrollment period described above applies only to the dependent who has lost coverage and the qualified employee; dependents will not be enrolled without the qualified employee also being enrolled.

c. A special enrollment period will apply to a qualified employee and dependent if the qualified employee or dependent was covered under benefits available under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, or any applicable state continuation laws at the time the qualified employee or dependent was eligible to enroll under the plan, whether during initial enrollment, open enrollment, or special enrollment and declined coverage for that reason.

The qualified employee or dependent must present to the plan administrator evidence that the qualified employee or dependent has exhausted such COBRA or state continuation coverage and has not lost such coverage due to failure of the qualified employee or dependent to pay premiums on a timely basis or for cause, and request enrollment in writing within 30 days of the date of the exhaustion of coverage.

For purposes of 1.c.:

i. Exhaustion of COBRA or state continuation coverage includes:

Losing COBRA or state continuation coverage for any reason other than those set forth in ii. below;

Losing coverage as a result of the employer’s failure to remit premiums on a timely basis;

Losing coverage as a result of the qualified employee or dependent incurring a claim that meets or exceeds the lifetime maximum limit on all benefits and no other COBRA or state continuation coverage is available; or

If the prior coverage was offered through a health maintenance organization (HMO), losing coverage because the qualified employee or dependent no longer resides or works in the HMO’s service area and no other COBRA or state continuation coverage is available.

ii. Exhaustion of COBRA or state continuation coverage does not include a loss due to failure of the qualified employee or dependent to pay premiums on a timely basis or termination of coverage for cause.

iii. In the case of the qualified employee’s exhaustion of COBRA or state continuation coverage, the special enrollment period described above applies to the qualified



employee and all of his or her dependents. In the case of a dependent’s exhaustion of COBRA or state continuation coverage, the special enrollment period described above applies only to the dependent who has lost coverage and the qualified employee; dependents will not be enrolled without the qualified employee also being enrolled.

2. The dependent is a new spouse of the enrollee or qualified employee, provided that the marriage is legal and enrollment is requested in writing within 30 days of the date of marriage and provided that the qualified employee also enrolls during this special enrollment period;

3. The dependent is a new dependent child of the enrollee or qualified employee, provided that enrollment is requested in writing within 30 days of the enrollee or qualified employee acquiring the dependent and provided that the qualified employee also enrolls during this special enrollment period;

4. The dependent is the spouse of the enrollee or qualified employee through whom the dependent child described in 3. above claims dependent status and:

a. That spouse is eligible for coverage; and

b. Is not already enrolled under the plan; and

c. Enrollment is requested in writing within 30 days of the dependent child becoming a dependent; and

d. The qualified employee also enrolls during this special enrollment period; and

5. The dependents are eligible dependent children of the enrollee or qualified employee and enrollment is requested in writing within 30 days of a dependent, as described in 2. or 3. above, becoming eligible to enroll under the coverage provided the qualified employee also enrolls during this special enrollment period.

6. When the employer is provided with notice of a medical support order and a copy of the order, as described in this section, the employer will provide the eligible dependent child with a special enrollment period provided the qualified employee also enrolls during this special enrollment period.

7. When the qualified employee or dependent becomes eligible for group health plan premium assistance provided by Medicaid or a State Children’s Health Insurance Plan. The qualified employee must request enrollment within 60 days after the date the employee or dependent is determined to be eligible for premium assistance.

In the case of the qualified employee becoming eligible for premium assistance, this special enrollment period applies to the qualified employee and all of his or her dependents. In the case of a dependent becoming eligible for premium assistance, this special enrollment period applies to both that dependent and the qualified employee.

Late enrollment

The plan allows enrollment as a late enrollee for qualified employees and eligible dependents enrolling outside of the initial enrollment period, the open enrollment period, or any special enrollment period described in this section.



Medical Support Order

The plan is intended to comply with the requirements of applicable Minnesota law regarding medical support orders. This may result in the delay of a termination of coverage as described in Ending Coverage. Notwithstanding any provision of this plan to the contrary, this plan shall recognize support orders that address medical coverage for dependent children and former spouses in accordance with the requirements under Section 518.171 of the Minnesota Statutes as determined by the plan administrator according to its policy relating to the plan established for the purpose of complying with these requirements.

The date your coverage begins

Your coverage begins at 12:01 a.m. on the effective date of your enrollment.

1. For qualified employees and dependents who enroll during the initial enrollment period, coverage begins on the first of the month following 30 days (one month) of employment.

2. For qualified employees and dependents who enroll during the open enrollment period, coverage begins on the first day of the calendar year for which the open enrollment period was held.

3. For qualified employees and/or dependents who enroll during a special enrollment period, coverage begins on the date indicated below for the particular special enrollment. In the case of:

a. Number 1. or 7. under Special enrollment, coverage begins on the first day of the first calendar month following the date the written request for enrollment is received by the plan administrator;

b. Number 2. under Special enrollment, coverage begins on the first day of the first calendar month following the date the written request for enrollment is received by the plan administrator;

c. Number 3. under Special enrollment, in the case of birth, the date of birth; in the case of adoption or placement for adoption or placement as a foster child, date of adoption or placement. In all other cases, the date the enrollee acquires the dependent child;

d. Number 4. under Special enrollment, the date coverage for the dependent child is effective, as set forth in 3.c. above;

e. Number 5. under Special enrollment, the date coverage for the dependent identified in 2. or 3. under Special enrollment becomes effective;

f. Number 6. under Special enrollment, the first day of the first calendar month following the date the written request for enrollment is received by the plan administrator. Any child who is a covered person pursuant to a medical support order will be covered without application of waiting periods.

4. For qualified employees and/or dependents who enroll during late enrollment, coverage begins on the first day of the first calendar month following the date the written application has been received and approved by the plan administrator.

5. An enrollee’s newborn dependent, including a newborn adopted dependent, is covered under the plan from the date of birth. (Eligibility for a child placed for adoption or placed as a foster child with the enrollee ends if the placement is interrupted before legal adoption and the child is removed from placement.) The enrollee must pay any required premium for the



newborn child’s coverage and must enroll the newborn child under the plan. The plan encourages enrollees to enroll newborn children under the plan within 31 days from the date of birth.

Other changes

Qualified employees should notify the plan administrator in writing within 30 days of the effective date of any changes to name or address, changes to status of dependents, or other relevant facts concerning qualified employees or dependents.

Identification card

When you enroll under the plan, you will receive a plan identification card. You should present the plan identification card every time health services are requested. If you do not show the card, providers have no way of knowing that you are a covered person under the plan, which may result in delay of payment for benefits. For example, you may receive a bill for health services or be required to pay at the time health services are received and later submit a claim for reimbursement as described in How To Submit A Claim. Possession and use of a plan identification card does not guarantee coverage.

If you permit the use of your identification card by any unauthorized person, use another person’s card, or submit fraudulent claims, your coverage under the plan may be terminated on the date specified by the plan administrator, as described in Ending Coverage.

Ending Coverage


EE. Ending Coverage

This section describes when coverage ends under the plan. When this happens you may exercise your right to continue coverage as described in Continuation.

See Definitions. These words have specific meanings: benefits, certificate of creditable coverage, claim, covered person, dependent, enrollee, plan, plan administrator, qualified employee, sponsor.

When coverage ends

You have the right to a certification of creditable coverage when coverage ends. You will receive a certification of creditable coverage when coverage ends. You may also request a certification of creditable coverage at any time while you are covered under the plan or within 24 months following the date your coverage ends. To request a certification of creditable coverage, call Customer Service at one of the telephone numbers listed inside the front cover. Upon receipt of your request, the certification of creditable coverage will be issued as soon as reasonably possible.

Unless otherwise specified, coverage ends the earliest of the following:

1. The date on which this plan terminates. If the relationship between the plan administrator and Medica ends, coverage under the plan will not necessarily end. Only the sponsor determines when this plan terminates.

2. The end of the month for which the enrollee or covered person last paid any required contribution to the plan.

3. The end of the month in which the covered person is no longer eligible as determined by the plan administrator. See Eligibility And Enrollment for information on eligibility.

4. The effective date of a plan amendment terminating coverage for the class to which a covered person belongs.

5. The end of the month following the date the plan administrator approves the enrollee’s or covered person’s request to end his or her coverage.

6. The date specified by the plan administrator because a covered person permitted the use of his or her identification card by any unauthorized person or used another person’s card or submitted fraudulent claims.

7. The end of the month in which a covered person enters active military duty for more than 31 days. Upon completion of active military duty, contact the plan administrator to discuss reinstatement of coverage.

8. The date specified by the plan administrator in written notice to a covered person that coverage ended due to the plan administrator’s determination that the covered person committed fraud in applying for this coverage or for any of its benefits. Fraud includes, but is not limited to, intentionally providing the plan administrator with false material information such as:

a. Information related to an enrollee’s eligibility or another person’s eligibility for coverage or status as a dependent; or

Ending Coverage


b. Information related to an enrollee’s health status or that of any dependent; or

c. Intentional misrepresentation of the employer-employee relationship.

Coverage will be retroactively terminated at the plan administrator’s discretion to the original date of coverage or the date on which the fraudulent act took place. No continuation privilege will be extended.

Continuation


FF. Continuation

Required continuation coverage

This section describes continuation coverage provisions. When coverage ends, covered persons may be able to continue coverage under federal law. All aspects of continuation coverage administration are the responsibility of the plan administrator.

See Definitions. These words have specific meanings: covered person, dependent, employee, enrollee, placed for adoption, plan, plan administrator, qualified employee, retirees, sponsor.

1. Your right to continue coverage under state law

Notwithstanding the provisions regarding termination of coverage described in Ending Coverage, you may be entitled to extended or continued coverage as follows:

a. Minnesota state continuation coverage

Continued coverage shall be provided as required under applicable Minnesota law. Minnesota state continuation requirements apply to all group health plans that are subject to state regulation, regardless of the number of employees in the group. The plan administrator shall, within the parameters of Minnesota law, establish uniform policies pursuant to which such continuation coverage will be provided.

b. Notice of rights

Minnesota law requires that covered employees and their dependents (spouse and/or dependent children) be offered the opportunity to pay for a temporary extension of health coverage (called continuation coverage) at group rates in certain instances where health coverage under an employer sponsored group health plan(s) would otherwise end.

This notice is intended to inform you, in summary fashion, of describes your rights and obligations under the continuation coverage provision of Minnesota law. It is intended that no greater rights be provided than those required by Minnesota law. Take time to read this section carefully.

Enrollee’s loss The enrollee has the right to continuation of coverage for him or herself and his or her dependents if there is a loss of coverage under the plan because of the enrollee’s voluntary or involuntary termination of employment (for any reason other than gross misconduct) or layoff from employment. In this section, layoff from employment means a reduction in hours to the point where the enrollee is no longer eligible for coverage under the plan.

Enrollee’s spouse’s loss The enrollee’s covered spouse has the right to continuation coverage if he or she loses coverage under the plan for any of the following reasons:

a. Death of the enrollee;

Continuation


b. A termination of the enrollee’s employment (for any reason other than gross misconduct) or layoff from employment;

c. Dissolution of marriage from the enrollee; or

d. The enrollee’s enrollment for benefits under Medicare.

Enrollee’s child’s loss The enrollee’s dependent child has the right to continuation coverage if coverage under the plan is lost for any of the following reasons:

a. Death of the enrollee if the enrollee is the parent through whom the child receives coverage;

b. Termination of the enrollee’s employment (for any reason other than gross misconduct) or layoff from employment;

c. The enrollee’s dissolution of marriage from the child’s other parent;

d. The enrollee’s enrollment for benefits under Medicare if the enrollee is the parent through whom the child receives coverage; or

e. The enrollee’s child ceases to be a dependent child under the terms of the plan.

Responsibility to inform Under Minnesota law, the enrollee and dependents have the responsibility to inform the plan administrator of a dissolution of marriage or a child losing dependent status under the plan within 60 days of the date of the event or the date on which coverage would be lost because of the event.

Election rights When the plan administrator is notified that one of these events has happened, the enrollee and the enrollee’s dependents will be notified of the right to choose continuation coverage.

Consistent with Minnesota law, the enrollee and dependents have 60 days to elect continuation coverage for reasons of termination of the enrollee’s employment or the enrollee’s enrollment for benefits under Medicare measured from the later of:

a. The date coverage would be lost because of one of the events described above; or

b. The date notice of election rights is received.

If continuation coverage is elected within this period, the coverage will be retroactive to the date coverage would otherwise have been lost.

The enrollee and the enrollee’s covered spouse may elect continuation coverage on behalf of other dependents entitled to continuation coverage. Under certain circumstances, the enrollee’s covered spouse or dependent child may elect continuation coverage even if the enrollee does not elect continuation coverage.

If continuation coverage is not elected, your coverage under the plan will end.

Type of coverage and cost If continuation coverage is elected, the enrollee’s sponsor is required to provide coverage that, as of the time coverage is being provided, is identical to the coverage provided under the plan to similarly situated employees or employees’ dependents.

Continuation


Under Minnesota law, a person continuing coverage may have to make a monthly payment to the sponsor of all or part of the premium for continuation coverage. The amount charged cannot exceed 102 percent of the cost of the coverage.

Surviving dependents of a deceased enrollee have 90 days after notice of the requirement to pay continuation premiums to make the first payment.

Duration Under the circumstances described above and for a certain period of time, Minnesota law requires that the enrollee and his or her dependents be allowed to maintain continuation coverage as follows:

a. For instances when coverage is lost due to the enrollee’s termination of or layoff from employment, coverage may be continued until the earliest of the following:

i. 18 months after the date of the termination of or layoff from employment;

ii. The date the enrollee becomes covered under another group health plan (as an employee or otherwise) that does not contain any exclusion or limitation with respect to any applicable pre-existing condition; or

iii. The date coverage would otherwise terminate under the plan.

b. For instances where the enrollee’s spouse or dependent children lose coverage because of the enrollee’s enrollment under Medicare, coverage may be continued until the earliest of:

i. 36 months after continuation was elected;

ii. The date coverage is obtained under another group health plan; or


c. For instances where dependent children lose coverage as a result of loss of dependent eligibility, coverage may be continued until the earliest of:




d. For instances of dissolution of marriage from the enrollee, coverage of the enrollee’s spouse and dependent children may be continued until the earliest of:

i. The date the former spouse becomes covered under another group health plan; or

ii. The date coverage would otherwise terminate under the plan.

If a dissolution of marriage occurs during the period of time when the enrollee’s spouse is continuing coverage due to the enrollee’s termination of or layoff from employment, coverage of the enrollee’s spouse may be continued until the earliest of:



e. If coverage is lost because of the enrollee’s absence from work due to total disability, coverage of the enrollee and any dependents may be continued until the date coverage would otherwise terminate under the plan.

Continuation


f. Upon the death of the enrollee, the coverage of the enrollee’s spouse or dependent children may be continued until the earlier of:

i. The date the surviving spouse and dependent children become covered under another group health plan; or

ii. The date coverage would have terminated under the plan had the enrollee lived.

Extension of benefits for total disability of the enrollee Coverage may be extended for an enrollee and his or her dependents in instances where the enrollee is absent from work due to total disability, as defined in Definitions. If the enrollee is required to pay all or part of the premium for the extension of coverage, payment shall be made to the sponsor. The amount charged cannot exceed 100 percent of the cost of coverage.

2. Your right to continue coverage under federal law


COBRA continuation coverage Continued coverage shall be provided as required under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended as it applies to state governmental entities through the Public Health Service Act (PHSA), as amended. The plan administrator shall, within the parameters of federal law, establish uniform policies pursuant to which such continuation coverage will be provided. See General COBRA information in this section. In addition, continuation of coverage requirements under Minnesota law shall be followed as described in this section.

USERRA continuation coverage Continued coverage shall be provided as required under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), as amended. The plan administrator shall, within the parameters of federal law, establish uniform policies pursuant to which such continuation coverage will be provided. See General USERRA information in this section.

General COBRA information COBRA, as it applies to state governmental entities through the PHSA, requires employers with 20 or more employees to offer employees and their families (spouse and/or dependent children) the opportunity to pay for a temporary extension of health coverage (called continuation coverage) at group rates in certain instances where health coverage under employer sponsored group health plan(s) would otherwise end. This coverage is a group health plan for purposes of COBRA.

This section is intended to inform you, in summary fashion, of your rights and obligations under the continuation coverage provision of federal law. It is intended that no greater rights be provided than those required by federal law. Take time to read this section carefully.

Continuation


Qualified beneficiary For purposes of this section, a qualified beneficiary is defined as:

a. A covered employee (a current or former employee who is actually covered under a group health plan and not just eligible for coverage);

b. A covered spouse of a covered employee; or

c. A dependent child of a covered employee. (A child placed for adoption with or born to an employee or former employee receiving COBRA continuation coverage is also a qualified beneficiary.)

Enrollee’s loss The enrollee has the right to elect continuation of coverage if there is a loss of coverage under the plan because of termination of the enrollee’s employment (for any reason other than gross misconduct), or the enrollee becomes ineligible to participate under the terms of the plan due to a reduction in his or her hours of employment.



b. A termination of the enrollee’s employment (for any reason other than gross misconduct) or reduction in the enrollee’s hours of employment with the employer;

c. Divorce or legal separation from the enrollee; or

d. The enrollee’s entitlement to (actual coverage under) Medicare.



b. The enrollee’s termination of employment (for any reason other than gross misconduct) or reduction in the enrollee’s hours of employment with the employer;

c. The enrollee’s divorce or legal separation from the child’s other parent;

d. The enrollee’s entitlement to (actual coverage under) Medicare if the enrollee is the parent through whom the child receives coverage; or


Responsibility to inform Under the law, the enrollee and dependent have the responsibility to inform the plan administrator of a divorce, legal separation, or a child losing dependent status under the plan within 60 days of the date of the event, or the date on which coverage would be lost because of the event.

Continuation


Also, an enrollee and dependent who have been determined to be disabled under the Social Security Act as of the time of the enrollee’s termination of employment or reduction of hours or within 60 days of the start of the continuation period must notify the plan administrator of that determination within 60 days of the determination. If determined under the Social Security Act to no longer be disabled, he or she must notify the plan administrator within 30 days of the determination.

Bankruptcy Rights similar to those described above may apply to retirees (and the spouses and dependents of those retirees) if the enrollee’s employer commences a bankruptcy proceeding and these individuals lose coverage.

Election rights When notified that one of these events has happened, the plan administrator will notify the enrollee and dependents of the right to choose continuation coverage.

Consistent with federal law, the enrollee and dependents have 60 days to elect continuation coverage, measured from the later of:




The enrollee and the enrollee’s covered spouse may elect continuation coverage on behalf of other covered dependents entitled to continuation coverage. However, each person entitled to continuation coverage has an independent right to elect continuation coverage. The enrollee’s covered spouse or dependent child may elect continuation coverage even if the enrollee does not elect continuation coverage.


Type of coverage and cost If the enrollee and the enrollee’s dependents elect continuation coverage, the employer is required to provide coverage that, as of the time coverage is being provided, is identical to the coverage provided under the plan to similarly situated employees or employee’s dependents.

Under federal law, a person electing continuation coverage may have to pay all or part of the premium for continuation coverage. The amount charged cannot exceed 102 percent of the cost of the coverage. The amount may be increased to 150 percent of the applicable premium for months after the 18th month of continuation coverage when the additional months are due to a disability under the Social Security Act.

There is a grace period of at least 30 days for the regularly scheduled premium.

Duration of COBRA coverage Federal law requires that you be allowed to maintain continuation coverage for 36 months unless you lost coverage under the plan because of termination of employment or reduction in hours. In that case, the required continuation coverage period is 18 months.

Continuation


The 18 months may be extended if a second event (e.g., divorce, legal separation, or death) occurs during the initial 18-month period. It also may be extended to 29 months in the case of an employee or employee’s covered dependent who is determined to be disabled under the Social Security Act at the time of the employee’s termination of employment or reduction of hours, or within 60 days of the start of the 18-month continuation period.

If an employee or the employee’s covered dependent is entitled to 29 months of continuation coverage due to his or her disability, the other family members’ continuation period is also extended to 29 months. If the enrollee becomes entitled to (actually covered under) Medicare, the continuation period for the enrollee’s dependents is 36 months measured from the date of the enrollee’s Medicare entitlement even if that entitlement does not cause the enrollee to lose coverage.

Under no circumstances is the total continuation period greater than 36 months from the date of the original event that triggered the continuation coverage.

Federal law provides that continuation coverage may end earlier for any of the following reasons:

a. The enrollee’s employer no longer provides group health coverage to any of its employees;

b. The premium for continuation coverage is not paid on time;

c. Coverage is obtained under another group health plan (as an employee or otherwise) that does not contain any exclusion or limitation with respect to any applicable pre-existing condition; or

d. The enrollee becomes entitled to (actually covered under) Medicare.

Continuation coverage may also end earlier for reasons which would allow regular coverage to be terminated, such as fraud.

General USERRA information USERRA requires employers to offer employees and their families (spouse and/or dependent children) the opportunity to pay for a temporary extension of health coverage (called continuation coverage) at group rates in certain instances where health coverage under employer sponsored group health plan(s) would otherwise end. This coverage is a group health plan for the purposes of USERRA.


Employee’s loss The employee has the right to elect continuation of coverage if there is a loss of coverage under the plan because of absence from employment due to service in the uniformed services, and the employee was covered under the plan at the time the absence began, and the employee, or an appropriate officer of the uniformed services, provided the employer with advance notice of the employee’s absence from employment (if it was possible to do so).

Service in the uniformed services means the performance of duty on a voluntary or involuntary basis in the uniformed services under competent authority, including active duty, active duty for training, initial active duty for training, inactive duty training, full-time National

Continuation


Guard duty, and the time necessary for a person to be absent from employment for an examination to determine the fitness of the person to perform any of these duties.

Uniformed services means the U.S. Armed Services, including the Coast Guard, the Army National Guard, and the Air National Guard, when engaged in active duty for training, inactive duty training, or full-time National Guard duty, and the commissioned corps of the Public Health Service.

Election rights The employee or the employee’s authorized representative may elect to continue the employee’s coverage under the plan by making an election on a form provided by the plan administrator. The employee has 60 days to elect continuation coverage measured from the date coverage would be lost because of the event described above. If continuation coverage is elected within this period, the coverage will be retroactive to the date coverage would otherwise have been lost. The employee may elect continuation coverage on behalf of other covered dependents, however there is no independent right of each covered dependent to elect. If the employee does not elect, there is no USERRA continuation available for the spouse or dependent children. In addition, even if the employee does not elect USERRA continuation, the employee has the right to be reinstated under the plan upon reemployment, subject to the terms and conditions of the plan.

Type of coverage and cost If the employee elects continuation coverage, the employer is required to provide coverage that, as of the time coverage is being provided, is identical to the coverage provided under the plan to similarly situated employees. The amount charged cannot exceed 102 percent of the cost of the coverage unless the employee’s leave of absence is less than 31 days, in which case the employee is not required to pay more than the amount that they would have to pay as an active employee for that coverage. There is a grace period of at least 30 days for the regularly scheduled premium.

Duration of USERRA coverage When an employee takes a leave for service in the uniformed services, coverage for the employee and dependents for whom coverage is elected begins the day after the employee would lose coverage under the plan. Coverage continues for up to 24 months.


a. The employer no longer provides group health coverage to any of its employees;


c. The employee loses their rights under USERRA as a result of a dishonorable discharge or other undesirable conduct;

d. The employee fails to return to work following the completion of his or her service in the uniformed services; or

e. The employee returns to work and is reinstated under the plan as an active employee.


Continuation


COBRA and USERRA coverage are concurrent If the employer is subject to COBRA and USERRA, and you elect COBRA continuation coverage in addition to USERRA continuation coverage, these coverages run concurrently.

3. Other continuation coverage


Retiree coverage Retiree coverage shall be provided in accordance with Section 471.61 of the Minnesota Statutes for a retiree and his or her dependents enrolled under the plan immediately preceding the enrollee’s retirement. Sponsor may pay a portion of the premium for such coverage. Eligibility with respect to the availability of continuation coverage beyond the requirements of Minnesota Statutes Section 471.61 shall be determined by sponsor, pursuant to its Policy and Procedure. The retiree coverage may run concurrently with any available COBRA or state continuation coverage or the retiree coverage may be offered in lieu of the COBRA or state continuation coverage.

Surviving spouse The surviving spouse (widow or widower) of a qualified employee or a retiree will remain eligible for coverage under this plan if:

a. Both the spouse and the qualified employee or retiree were covered persons under the plan at the time of the qualified employee’s or retiree’s death; and

b. The surviving spouse remains unmarried.

c. The sponsor may pay a portion of the premium for such coverage. Any available COBRA or state continuation coverage may run concurrently with surviving spouse coverage.

Leaves of absence An enrollee on a leave of absence from employment with the sponsor and that is approved by the sponsor may be entitled to continuation coverage. The sponsor may pay a portion of the premium for such coverage. Eligibility, as it pertains to the availability of continuation coverage during a leave of absence, shall be determined by the sponsor, in accordance with its leave of absence policy. Any available COBRA or state continuation coverage may run concurrently with leave of absence coverage.

4. Insurability

A person does not have to demonstrate insurability to elect continuation coverage. At the end of the 18, 24, 29, or 36-month continuation period, as applicable, there is no opportunity to enroll in an individual conversion health plan.

Complaints


GG. Complaints

This section describes what to do if you have a complaint or would like to appeal a decision made by the plan.

See Definitions. These words have specific meanings: benefits, claim, complaint, covered person, emergency, investigative, medical necessity review, plan, provider.

You may call Customer Service at one of the telephone numbers listed inside the front cover or by writing to the address below in First level of review. You also may contact the Commissioner of Commerce, Minnesota Department of Commerce, at (651) 296-2488 or 1-800-657-3602.

Filing a complaint may require that Medica review your medical records as needed to resolve your complaint.

You may appoint an authorized representative to make a complaint on your behalf. You may be required to sign an authorization which will allow Medica to release confidential information to your authorized representative and allow them to act on your behalf during the complaint process.

Upon request, Medica will assist you with completion and submission of your written complaint. Medica will also complete a complaint form on your behalf and mail it to you for your signature upon request.

At any time during the complaint process, you have a right to submit any information or testimony that you want Medica to consider and to review any information that Medica relied on in making its decision.

In addition to directing complaints to Customer Service as described in this section, you may direct complaints at any time to the Commissioner of Commerce at the telephone number listed at the beginning of this section.

First level of review

You may direct any question or complaint to Customer Service by calling one of the telephone numbers listed inside the front cover or by writing to the address listed below.

1. Complaints that do not involve a medical necessity review by Medica:

a. For an oral complaint, if Medica does not communicate a decision within 10 business days from Medica’s receipt of the complaint, or if you determine that Medica’s decision is partially or wholly adverse to you, Medica will provide you with a complaint form to submit your complaint in writing. Mail the completed form to:

Customer Service Route 0501 PO Box 9310 Minneapolis, MN 55440-9310

Medica will provide written notice of its first level review decision to you within 30 days from the initial receipt of your complaint.

Complaints


b. For a written complaint, Medica will provide written notice of the first level review decision to you within 30 days from initial receipt of your complaint.

c. If Medica’s first level review upholds the initial decision made by Medica, you have a right to request a second level review. The second level of review, as described below, must be exhausted before you have the right to submit a request for external review.

2. Complaints that involve a medical necessity review by Medica:

a. Your complaint must be made within one year following Medica’s initial decision and may be made orally or in writing.

b. Medica will provide written notice of its first level review decision to you and your attending provider, when applicable, within 30 calendar days from receipt of your complaint.

c. When an initial decision by Medica does not grant a prior authorization request made before or during an ongoing service, and your attending provider believes that Medica’s decision warrants an expedited review, you or your attending provider will have the opportunity to request an expedited review by telephone. Alternatively, if Medica concludes that a delay could seriously jeopardize your life, health, or ability to regain maximum function, or could subject you to severe pain that cannot be adequately managed without the care or treatment you are requesting, Medica will process your claim as an expedited review. In such cases, Medica will notify you and your attending provider by telephone of its decision no later than 72 hours after receiving the request.

d. If Medica’s first level review decision upholds the initial decision made by Medica, you have a right to request a second level review or submit a written request for external review as described in this section. The second level of review is optional and you may submit a request for external review without exhausting the second level of review.

e. If your complaint involves Medica’s decision to reduce or terminate an ongoing course of treatment that Medica previously approved, the treatment will be covered pending the outcome of the review process.

Second level of review

If you are not satisfied with Medica’s first level review decision, you may request a second level of review through either a written reconsideration or a hearing.

1. Your request can be oral or in writing. It must be provided to Medica within one year following the date of Medica’s first level review decision. If your request is in writing, it must be sent to the address listed above in First level of review.

2. Regardless of the method chosen for review (hearing or a written reconsideration), testimony, explanation, or other information provided by you, Medica staff, providers, and others is reviewed.

3. Medica will provide written notice of its second level review decision to you within:

a. 30 calendar days from receipt of written notice of your appeal for required second level reviews; or

b. 45 calendar days from receipt of written notice of your appeal for optional second level reviews.

Complaints


For some complaints, the second level of review must be exhausted before you have the right to submit a request for external review. For other complaints, this second level of review is optional before you may submit a request for external review. Generally, a second level review is optional if the complaint requires a medical necessity review. Medica will inform you in writing whether the second level of review is optional or required.

External review

If you consider Medica’s decision to be partially or wholly adverse to you, you may submit a written request for external review of Medica’s decision to the Commissioner of Commerce at:

Minnesota Department of Commerce 85 7th Place East, Suite 500 St. Paul, MN 55101-2198

You must submit your written request for external review within six months from the date of Medica’s decision. You must include a filing fee of $25 with your written request, unless waived by the Commissioner. An independent review organization contracted with the State Commissioner of Administration will review your request. You may submit additional information that you want the review organization to consider. You will be notified of the review organization’s decision within 45 days. The Department of Commerce will refund the filing fee if the review organization completely reverses Medica’s decision. The external review decision will not be binding on you but will be binding on Medica. Medica may seek judicial review on grounds that the decision was arbitrary and capricious or involved an abuse of discretion. Contact the Commissioner of Commerce for more information about the external review process. Under most circumstances, you must complete all required levels of review, described above, before you proceed to external review. You may proceed to external review without completing the required levels of review if Medica agrees that you may do so, or if Medica fails to substantially comply with the complaint and review process described in this section, including meeting any required deadlines. For complaints that involve a medical necessity review, you may request an expedited external review at the same time you request an expedited first level of review. You may also request an expedited external review if Medica’s decision involves a medical condition for which the standard external review time would seriously jeopardize your life, health, or ability to regain maximum function, or if Medica’s decision concerns an admission, availability of care, continued stay, or health care service for which you received emergency services and you have not been discharged from a facility. If an expedited review is requested and approved, a decision will be provided within 72 hours.

If Medica’s decision involves a treatment that Medica considers investigative, the review organization will base its decision on all documents submitted by you and Medica, your provider’s recommendation, consulting reports from health care professionals, your benefits under this plan, federal Food and Drug Administration approval, and medical or scientific evidence or evidence-based standards.

Complaints regarding fraudulent marketing practices or agent misrepresentation cannot be submitted for external review.

Miscellaneous General Provisions


HH. Miscellaneous General Provisions

This section describes the general provisions of the plan.

See Definitions. These words have specific meanings: benefits, covered person, enrollee, plan, plan administrator, sponsor.

Records

The sponsor, the plan administrator, Medica, and others to whom the sponsor has delegated duties and responsibilities under the plan shall keep accurate and detailed records of any matters pertaining to administration of the plan in compliance with applicable law.

Examination of a covered person To settle a dispute concerning provision or payment of benefits under the plan, the plan administrator may require that you be examined or an autopsy of the covered person’s body be performed. The examination or autopsy will be at the plan’s expense.

Clerical error and misstatements Should a clerical error be found or should any misstatement of relevant facts pertaining to coverage under the plan be found, and should such error or misstatement affect the existence or amount of coverage under the plan, the plan administrator reserves the right to investigate the matter and determine the existence or amount of coverage. For example, you will not be eligible for coverage beyond the scheduled termination of coverage because of a failure to record the termination. On the other hand, you will not be deprived of coverage under the plan because of a clerical error.

Plan amendment and termination Any change or amendment to or termination of the plan, its benefits, or its terms and conditions, in whole or in part, whether prospective or retroactive, shall be made solely in a written amendment (in the case of a change or amendment) or in written resolution (in the case of termination) to the plan, approved by the Board of Directors (if a corporation), the general partner(s) (if a partnership), the proprietor (if a sole proprietorship) or similar governing body (in all other cases) of the sponsor or any of their designees to whom such Board of Directors, general partner(s), proprietor, or similar body has delegated in writing the foregoing authority. You will receive notice of any amendment to the plan in accordance with applicable law. No one has the authority to make any oral modification to the plan.

Applicable law This plan is intended to be construed, and all rights and duties hereunder are to be governed, in accordance with the laws of the State of Minnesota, except to the extent such laws are preempted by the laws of the United States of America.

USERRA The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) imposes certain obligations on employers. This plan shall be administered in a manner consistent with USERRA.



Nondiscrimination This plan is intended to be nondiscriminatory and to meet the requirements under applicable sections of the Code. Should a problem arise, the plan administrator shall determine the manner of correction and may do so with or without the consent of enrollees.

Enrollee rights The action of the sponsor in creating this plan shall not be construed to constitute and shall not be evidence of any contractual relationship between the sponsor and any enrollee, or as a right of any enrollee to continue in the employment of the sponsor, or as a limitation of the right of the sponsor to discharge any of its employees, with or without cause.

Family and Medical Leave Act of 1993 (FMLA) The Family and Medical Leave Act of 1993 (FMLA) imposes certain obligations on employers with fifty (50) or more employees. This plan shall be administered in a manner consistent with the FMLA and the applicable employer’s FMLA policy.

Reservation of discretion The plan administrator and its delegate have the full discretionary power to interpret and apply the terms of the plan, and its components (including, without limitation, supplying omissions from, correcting deficiencies in, or resolving inconsistencies or ambiguities in the language of the plan and its underlying documents) as they relate to matters for which the named fiduciary has responsibility. All decisions of the plan administrator and its delegate as to the facts of the case, interpretation of any provisions of the plan, or its application to any case and any other interpretative matter, determination, or question under the plan will be final and binding on all affected parties.

Definitions


II. Definitions

In this plan (and in any amendments), some words have specific meanings. Within each definition, you may note bold words. These words also are defined in this section.

Approved clinical trial. A phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening condition, is not designed exclusively to test toxicity or disease pathophysiology, and is described in any of the following subparagraphs:

1. The study or investigation is conducted under an investigational new drug application reviewed by the U.S. Food and Drug Administration.

2. The study or investigation is a drug trial that is exempt from having such an investigational new drug application.

3. The study or investigation is approved or funded by one of the following: (i) the National Institutes of Health (NIH), the Centers for Disease Control and Prevention, the Agency for Health Care Research and Quality, the Centers for Medicare and Medicaid Services, or cooperating group or center of any of the entities described in this item; (ii) a cooperative group or center of the United States Department of Defense or the United States Department of Veterans Affairs; (iii) a qualified non-governmental research entity identified in the guidelines issued by the NIH for center support grants; or (iv) the United States Departments of Veterans Affairs, Defense, or Energy if the trial has been reviewed or approved through a system of peer review determined by the secretary to: (a) be comparable to the system of peer review of studies and investigations used by the NIH; and (b) provide an unbiased scientific review by qualified individuals who have no interest in the outcome of the review.

Benefits. The health services or supplies (described in this plan and any subsequent amendments) approved by the plan as eligible for coverage.

Certification of creditable coverage. A written certification that group health plans and health insurance issuers must provide to an individual to confirm the creditable coverage provided to the individual under the group health plan or health insurance.

Claim. An invoice, bill, or itemized statement for benefits provided to you.

Coinsurance. The percentage amount you must pay to the provider for benefits received. Full coinsurance payments may apply to scheduled appointments canceled less than 24 hours before the appointment time or to missed appointments.

For in-network benefits, the coinsurance amount is based on the lesser of the:

1. Charge billed by the provider (i.e., retail); or

2. Negotiated amount that the provider has agreed to accept as full payment for the benefit (i.e., wholesale).

When the wholesale amount is not known nor readily calculated at the time the benefit is provided, Medica, on behalf of sponsor, uses an amount to approximate the wholesale amount. For services from some network providers, however, the coinsurance is based on the provider’s retail charge. The provider’s retail charge is the amount that the provider would charge to any patient, whether or not that patient is a covered person of Medica.

Definitions


For out-of-network benefits, the coinsurance will be based on the lesser of the:


2. Non-network provider reimbursement amount. For out-of-network benefits, in addition to any copayment, coinsurance, and deductible amounts, you will be responsible for any charges billed by the provider in excess of the non-network provider reimbursement amount. The coinsurance may not exceed the charge billed by the provider for the benefit. Complaint. Any grievance against Medica, submitted by you or another person on your behalf, that is not the subject of litigation. Complaints may involve, but are not limited to, the scope of coverage for health care services; retrospective denials or limitations of payment for services; eligibility issues; denials, cancellations, or non-renewals of coverage; administrative operations; and the quality, timeliness, and appropriateness of health care services rendered. If the complaint is from an applicant, the complaint must relate to the application. If the complaint is from a former covered person, the complaint must relate to services received during the time the individual was a covered person.

Continuous creditable coverage. The maintenance of continuous and uninterrupted creditable coverage by a qualified employee or dependent. A qualified employee or dependent is considered to have maintained continuous creditable coverage if enrollment is requested under the plan within 63 days of termination of the previous creditable coverage.

Convenience care/retail health clinic. A health care clinic located in a setting such as a retail store, grocery store, or pharmacy, which provides treatment of common illnesses and certain preventive health care services.

Copayment. The fixed dollar amount you must pay to the provider for benefits received. Full copayments may apply to scheduled appointments canceled less than 24 hours before the appointment time or to missed appointments.

When you receive eligible health services from a network provider and a copayment applies, you pay the lesser of the charge billed by the provider for the benefit (i.e., retail) or your copayment. Medica, on behalf of sponsor, pays any remaining amount according to the written agreement with the provider. The copayment may not exceed the retail charge billed by the provider for the benefit. For out-of-network benefits, in addition to any copayment, coinsurance, and deductible amounts, you will be responsible for any charges in excess of the non-network provider reimbursement amount. Cosmetic. Services and procedures that improve physical appearance but do not correct or improve a physiological function, and that are not medically necessary, or as determined by the plan.

Covered person. A person who is enrolled under the plan. Creditable coverage. Health coverage provided under one of the following plans:

1. A group health benefit plan, including a self-insured plan;

2. Health insurance coverage, whether through a group or individual contract;

3. Medicare;

4. Medicaid (other than coverage consisting solely of benefits under the program for distribution of pediatric vaccines);

Definitions


5. A state health benefit risk pool;

6. A military health plan or other coverage provided under United States Code, title 10, chapter 55;

7. A medical care program of the Indian Health Service or of a tribal organization;

8. The Federal Employees Health Benefits Program or other similar coverage provided under federal law applicable to government organizations and employees;

9. A health benefit plan provided under Section 5(e) of the federal Peace Corps Act;

10. State Children’s Health Insurance Program; or

11. A public health plan similar to any of the above plans established or maintained by a state, the U.S. government, a foreign country, or any political subdivision of a state, the U.S. government, or a foreign country.

Coverages of the following types, including any combination of the following types, are not creditable coverage:

1. Coverage only for accident, or disability income insurance, or any combination thereof;

2. Coverage issued as a supplement to liability insurance;

3. Liability insurance;

4. Workers’ compensation insurance;

5. Automobile medical payment insurance;

6. Credit-only insurance;

7. Coverage for on-site medical clinics;

8. Limited scope dental or vision coverage;

9. Coverage for long-term care, nursing home care, home health care, community-based care, or any combination of these;

10. Coverage only for a specified disease or illness;

11. Hospital indemnity or other fixed indemnity insurance; or

12. Medicare supplemental health insurance, benefits supplemental to military health care, and similar supplemental coverage if such benefits are provided under a separate policy or contract of insurance.

Custodial care. Services to assist in activities of daily living that do not seek to cure, are performed regularly as a part of a routine or schedule, and, due to the physical stability of the condition, do not need to be provided or directed by a skilled medical professional. These services include help in walking, getting in or out of bed, bathing, dressing, feeding, using the toilet, preparation of special diets, and supervision of medication that can usually be self-administered.

Deductible. The fixed dollar amount you must pay for eligible services or supplies before claims for health services or supplies received from providers are reimbursable as benefits under this plan.

Dependent. Unless otherwise specified in the plan, the following are considered dependents:

1. The enrollee’s spouse.

Definitions


2. The following dependent children up to the dependent limiting age of 26:

a. The enrollee’s or enrollee’s spouse’s natural or adopted child;

b. A child placed for adoption with the enrollee or enrollee’s spouse;

c. A child for whom the enrollee or the enrollee’s spouse has been appointed legal guardian; however, upon request by the plan, the enrollee must provide satisfactory proof of legal guardianship;

d. The enrollee’s stepchild;

e. A child placed as a foster child with the enrollee or the enrollee’s spouse; and

f. The enrollee’s or enrollee’s spouse’s unmarried grandchild who is dependent upon and resides with the enrollee or enrollee’s spouse continuously from birth.

For residents of a state other than Minnesota, the dependent limiting age may be higher if required by applicable state law.

3. The enrollee’s or enrollee’s spouse’s disabled child who is a dependent incapable of self-sustaining employment by reason of developmental disability, mental illness, mental disorder, or physical disability and is chiefly dependent upon the enrollee for support and maintenance. An illness that does not cause a child to be incapable of self-sustaining employment will not be considered a physical disability. This dependent may remain covered under the plan regardless of age and without application of health screening or waiting periods. To continue coverage for a disabled dependent, you must provide the plan with proof of such disability and dependency within 31 days of the child reaching the dependent limiting age set forth in 2. above. Beginning two years after the child reaches the dependent limiting age, the plan may require annual proof of disability and dependency.

4. The enrollee’s or enrollee’s spouse’s disabled dependent who is incapable of self-sustaining employment by reason of developmental disability, mental illness, mental disorder, or physical disability and is chiefly dependent upon the enrollee or enrollee’s spouse for support and maintenance. For coverage of a disabled dependent, you must provide the plan with proof of such disability and dependency at the time of the dependent’s enrollment.

Designated facility. A network hospital that Medica has authorized to provide certain benefits to covered persons, as described in this plan.

Designated physician. A network physician that Medica has authorized to provide certain benefits to covered persons, as described in this plan.

Emergency. A condition or symptom (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, would believe requires immediate treatment to:

1. Preserve your life; or

2. Prevent serious impairment to your bodily functions, organs, or parts; or

3. Prevent placing your physical or mental health (or, if you are pregnant, the health of your unborn child) in serious jeopardy.

Employee. Any person employed by the sponsor on or after the effective date of this plan, except that it shall not include a self-employed individual as described in Section 401(c) of the Code. All employees who are treated as employed by a single employer under Subsections

Definitions


(b), (c), or (m) of Section 414 of the Code are treated as employed by a single employer for purposes of this plan. Employee does not include any of the following:

1. Any employee included within a unit of employees covered under a collective bargaining unit unless such agreement expressly provides for coverage of the employee under this plan;

2. Any employee who is a nonresident alien and receives no earned income from the sponsor from sources within the United States; and

3. Any employee who is a leased employee as defined in Section 414(n)(2) of the Code.

Enrollee. A qualified employee who the plan administrator determines is enrolled under the plan.

Enrollment date. The date of the qualified employee’s or dependent’s first day of coverage under the plan or, if earlier, the first day of the waiting period for the qualified employee’s or dependent’s enrollment.

Genetic testing. An analysis of human DNA, RNA, chromosomes, proteins, or metabolites, if the analysis detects genotypes, mutations, or chromosomal changes. Genetic testing includes pharmacogenetic testing. Genetic testing does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. For example, an HIV test, complete blood count, or cholesterol test is not a genetic test.

Habilitative. Health care services are considered habilitative when they are provided to improve an impairment in physical function or speech due to congenital or developmental conditions, including autism spectrum disorders, that have impeded normal speech and motor development.

HIPAA privacy standards. Standards for Privacy of Individually Identifiable Health Information issued pursuant to the Health Insurance Portability and Accountability Act of 1996, as amended, and codified at 45 CFR Parts 160 and 164.

Hospital. A licensed facility that provides diagnostic, medical, therapeutic, rehabilitative, and surgical services by, or under the direction of, a physician and with 24-hour R.N. nursing services. The hospital is not mainly a place for rest or custodial care, and is not a nursing home or similar facility.

Inpatient. An uninterrupted stay, following formal admission to a hospital, skilled nursing facility, or licensed acute care facility. Inpatient services in a licensed residential treatment facility for treatment of emotionally disabled children will be covered as any other health condition.

Investigative. As determined by the plan, a drug, device, diagnostic or screening procedure, or medical treatment or procedure is investigative if reliable evidence does not permit conclusions concerning its safety, effectiveness, or effect on health outcomes. The plan will make its determination based upon an examination of the following reliable evidence, none of which shall be determinative in and of itself:

1. Whether there is final approval from the appropriate government regulatory agency, if required, including whether the drug or device has received final approval to be marketed for its proposed use by the United States Food and Drug Administration (FDA), or whether the treatment is the subject of ongoing Phase I, II, or III trials;

2. Whether there are consensus opinions and recommendations reported in relevant scientific and medical literature, peer-reviewed journals, or the reports of clinical trial committees and other technology assessment bodies; and

Definitions


3. Whether there are consensus opinions of national and local health care providers in the applicable specialty or subspecialty that typically manages the condition as determined by a survey or poll of a representative sampling of these providers.

Notwithstanding the above, a drug being used for an indication or at a dosage that is an accepted off-label use for the treatment of cancer will not be considered by the plan to be investigative. The plan will determine if a use is an accepted off-label use based on published reports in authoritative peer-reviewed medical literature, clinical practice guidelines, or parameters approved by national health professional boards or associations, and entries in any authoritative compendia as identified by the Medicare program for use in the determination of a medically accepted indication of drugs and biologicals used off-label.

Late enrollee. A qualified employee or dependent who requests enrollment under the plan other than during:

1. The initial enrollment period set by the sponsor; or

2. The open enrollment period set by the sponsor; or

3. A special enrollment period as described in Eligibility And Enrollment.

In addition, a covered person who is a child entitled to receive coverage through a medical support order is not subject to any initial or open enrollment period restrictions.

Life-threatening condition. Any disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted.

Medical necessity review. Medica’s evaluation of the necessity, appropriateness, and efficacy of the use of health care services, procedures, and facilities, for the purpose of determining the medical necessity of the service or admission.

Medically necessary. Diagnostic testing and medical treatment, consistent with the diagnosis of and prescribed course of treatment for your condition, and preventive services. Medically necessary care must meet the following criteria:

1. Be consistent with the medical standards and accepted practice parameters of the community as determined by health care providers in the same or similar general specialty as typically manages the condition, procedure, or treatment at issue; and

2. Be an appropriate service, in terms of type, frequency, level, setting, and duration, to your diagnosis or condition; and

3. Help to restore or maintain your health; or

4. Prevent deterioration of your condition; or

5. Prevent the reasonably likely onset of a health problem or detect an incipient problem.

Mental disorder. A physical or mental condition having an emotional or psychological origin, as defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Network. A term used to describe a provider (such as a hospital, physician, home health agency, skilled nursing facility, or pharmacy) that has entered into a written agreement to provide benefits to you. The participation status of providers will change from time to time.

The network provider directory will be furnished automatically, without charge.

Non-network. A term used to describe a provider not under contract as a network provider.

Definitions


Non-network provider reimbursement amount. The amount that Medica will pay, on behalf of sponsor, to a non-network provider for each benefit is based on one of the following, as determined by Medica, on behalf of sponsor: 1. A percentage of the amount Medicare would pay for the service in the location where the

service is provided. Medica generally updates its data on the amount Medicare pays within 30-60 days after the Centers for Medicare and Medicaid Services updates its Medicare data; or

2. A percentage of the provider’s billed charge; or

3. A nationwide provider reimbursement database that considers prevailing reimbursement rates and/or marketplace charges for similar services in the geographic area in which the service is provided; or

4. An amount agreed upon between Medica, on behalf of sponsor, and the non-network provider.

Contact Customer Service for more information concerning which method above pertains to your services, including the applicable percentage if a Medicare-based approach is used.

For certain benefits, you must pay a portion of the non-network provider reimbursement amount as a copayment or coinsurance.

In addition, if the amount billed by the non-network provider is greater than the non-network provider reimbursement amount, the non-network provider will likely bill you for the difference. This difference may be substantial, and it is in addition to any copayment, coinsurance, or deductible amount you may be responsible for according to the terms described in this plan. Furthermore, such difference will not be applied toward the out-of-pocket maximum described in Your Out-Of-Pocket Expenses. Additionally, you will owe these amounts regardless of whether you previously reached your out-of-pocket maximum with amounts paid for other services. As a result, the amount you will be required to pay for services received from a non-network provider will likely be much higher than if you had received services from a network provider. Pharmacogenetic testing. A type of genetic testing that attempts to use personal gene-based information to determine the proper drug and dosage for an individual. Pharmacogenetic testing seeks to determine how a drug is absorbed, metabolized, or cleared from the body of an individual based on their genetic makeup. Physician. A Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (O.D.), or Doctor of Chiropractic (D.C.) practicing within the scope of his or her licensure.

Placed as a foster child. The acceptance of the placement in your home of a child who has been placed away from his or her parents or guardians in 24-hour, substitute care and for whom a State agency has placement and care responsibility. Eligibility for a child placed as a foster child with the enrollee or enrollee’s spouse ends when such placement is terminated.

Placed for adoption. The assumption and retention of the legal obligation for total or partial support of the child in anticipation of adopting such child.

(Eligibility for a child placed for adoption with the enrollee ends if the placement is interrupted before legal adoption is finalized and the child is removed from placement.)

Plan. The plan of health care coverage established by sponsor for its covered persons, as this plan currently exists or may be amended in the future.

Definitions


Plan administration functions. Administration functions performed by sponsor on behalf of the plan (such as quality assurance, claims processing, auditing, and other similar functions). Plan administration functions do not include functions performed by sponsor in connection with any other benefit or benefit plan of sponsor. Plan administrator. Sibley/McLeod County.

Prenatal care. The comprehensive package of medical and psychosocial support provided throughout a pregnancy and related directly to the care of the pregnancy, including risk assessment, serial surveillance, prenatal education, and use of specialized skills and technology, when needed, as defined by Standards for Obstetric-Gynecologic Services issued by the American College of Obstetricians and Gynecologists.

Prescription drug. A drug approved by the FDA for the prescribed use and route of administration.

Preventive health service. The following are considered preventive health services:

1. Evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force;

2. Immunizations for routine use that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the covered person involved;

3. With respect to covered persons who are infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration;

4. With respect to covered persons who are women, such additional preventive care and screenings not described in 1. as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

Contact Customer Service for information regarding specific preventive health services, services that are rated A or B, and services that are included in guidelines supported by the Health Resources and Services Administration. For a list of preventive health services, please visit www.medica.com.

Protected health information or PHI. With some exceptions, information that: (i) identifies or could reasonably be used to identify you; and (ii) relates to your physical or mental health or condition, the provision of your health care, or your payment for health care.

Provider. A health care professional or facility licensed, certified, or otherwise qualified under state law to provide health services.

Qualified employee. An employee of sponsor. The plan administrator determines an employee’s status as a qualified employee.

Qualified individual. (1) An individual who is eligible to participate in an approved clinical trial according to the trial protocol with respect to treatment of cancer or other life-threatening condition, and (2) either (a) the referring health care professional is a network provider and has concluded that the individual’s participation in the trial would be appropriate, or (b) the individual provides medical or scientific information establishing that their participation would be appropriate.

Reconstructive. Surgery to rebuild or correct a:

1. Body part when such surgery is incidental to or following surgery resulting from injury, sickness, or disease of the involved body part; or

Definitions


2. Congenital disease or anomaly which has resulted in a functional defect as determined by your physician.

In the case of mastectomy, surgery to reconstruct the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance shall be considered reconstructive.

Rehabilitative. Health care services are considered rehabilitative when they are provided to restore physical function or speech that has been impaired due to illness or injury.

Restorative. Surgery to rebuild or correct a physical defect that has a direct adverse effect on the physical health of a body part, and for which the restoration or correction is medically necessary.

Retiree. A former employee who is an enrollee under the plan immediately preceding retirement and who, upon retirement:

1. Is receiving a disability benefit from a Minnesota public pension plan other than a volunteer firefighter plan or an annuity from a Minnesota public pension plan other than a volunteer firefighter plan; or

2. Has met age and service requirements to receive an annuity from such a plan as described in 1. above.

Routine foot care. Services that are routine foot care may require treatment by a professional and include but are not limited to any of the following:

1. Cutting, paring, or removing corns and calluses; 2. Nail trimming, clipping, or cutting; and 3. Debriding (removing toenails, dead skin, or underlying tissue). Routine foot care may also include hygiene and preventive maintenance such as: 1. Cleaning and soaking the feet; and 2. Applying skin creams in order to maintain skin tone. Routine patient costs. All items and services that would be covered benefits if not provided in connection with a clinical trial. In connection with a clinical trial, routine patient costs do not include an investigative or experimental item, device, or service; items or services provided solely to satisfy data collection and analysis needs and not used in clinical management; or a service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis.

Skilled care. Nursing or rehabilitation services requiring the skills of technical or professional medical personnel to develop, provide, and evaluate your care and assess your changing condition. Long-term dependence on respiratory support equipment and/or the fact that services are received from technical or professional medical personnel do not by themselves define the need for skilled care.

Skilled nursing facility. A licensed bed or facility (including an extended care facility, hospital swing-bed, and transitional care unit) that provides skilled nursing care, skilled transitional care, or other related health services including rehabilitative services.

Sponsor. Sibley/McLeod County.

Total disability. Disability due to injury, sickness, or pregnancy that requires regular care and attendance of a physician, and in the opinion of the physician renders the employee unable to

Definitions


perform the duties of his or her regular business or occupation during the first two years of the disability and, after the first two years of the disability, renders the employee unable to perform the duties of any business or occupation for which he or she is reasonably fitted.

Urgent care center. A health care facility distinguishable from an affiliated clinic or hospital whose primary purpose is to offer and provide immediate, short-term medical care for minor, immediate medical conditions on a regular or routine basis.

Virtual care. Professional evaluation and medical management services provided to patients through e-mail, telephone, or webcam. Virtual care includes interactive audiovisual telehealth services. Virtual care is used to address non-urgent medical symptoms for patients describing new or ongoing symptoms to which providers respond with substantive medical advice. Virtual care does not include telephone calls for reporting normal lab or test results, or solely calling in a prescription to a pharmacy.

Waiting period. In accordance with applicable state and federal laws, the period of time, as determined by the sponsor’s eligibility requirements, that must pass before a qualified employee and/or dependent becomes covered under the plan. However, if a qualified employee and/or dependent enrolls as a late enrollee or through either an open enrollment period or a special enrollment period as set forth herein in Eligibility And Enrollment, any period before such late, open, or special enrollment is not a waiting period. Periods of employment in an employment classification that is not eligible for coverage under the plan do not constitute a waiting period.

Signatures


JJ. Signatures

IN WITNESS WHEREOF, the of the sponsor has executed the foregoing plan on behalf of sponsor on this day of , .

Sibley County

By:

(please print)

(signature)

Its:

McLeod County

By:

(please print)

(signature)

Its:



SIBLEY/MCLEOD EMPLOYEE BENEFIT PLAN MEDICA CHOICE PASSPORT ASO 500-30-20%

Silver Group #45192, 45193, 45799

BPL #28659








Table Of Contents

14 Sibley McLeod Silver 45192+ iii

Table Of Contents

A. Introduction ...................................................................................................................... 1

Definitions ......................................................................................................................... 1



B. Plan Overview ................................................................................................................... 3


Funding ............................................................................................................................. 5

Benefits ............................................................................................................................. 5








D. Role Of Medica ............................................................................................................... 13


Assignment ......................................................................................................................14


Copayments, coinsurance, and deductibles .....................................................................15





Covered ...........................................................................................................................19

Not covered ......................................................................................................................19




Covered ...........................................................................................................................21

Not covered ......................................................................................................................22


Table Of Contents

14 Sibley McLeod Silver 45192+ iv


Prosthetics .......................................................................................................................22

Hearing aids .....................................................................................................................23

Breast pumps ...................................................................................................................23


Covered ...........................................................................................................................24

Not covered ......................................................................................................................25






Covered ...........................................................................................................................27

Not covered ......................................................................................................................28



Covered ...........................................................................................................................29

Not covered ......................................................................................................................29








Covered ...........................................................................................................................33

Not covered ......................................................................................................................33


Virtual care .......................................................................................................................34







Table Of Contents

14 Sibley McLeod Silver 45192+ v

Covered ...........................................................................................................................35


Not covered ......................................................................................................................36








Covered ...........................................................................................................................39

Not covered ......................................................................................................................39




Oral surgery .....................................................................................................................41

N. Mental Health .................................................................................................................. 42

Covered ...........................................................................................................................43

Not covered ......................................................................................................................44

Office visits .......................................................................................................................45





Covered ...........................................................................................................................46

Not covered ......................................................................................................................46








Covered ...........................................................................................................................48

Table Of Contents

14 Sibley McLeod Silver 45192+ vi

Not covered ......................................................................................................................49

Office visits .......................................................................................................................49

Virtual care .......................................................................................................................49






Covered ...........................................................................................................................52

Not covered ......................................................................................................................52








Step therapy .....................................................................................................................57

Quantity limits ...................................................................................................................57

Covered ...........................................................................................................................57


Not covered ......................................................................................................................58











Step therapy .....................................................................................................................62

Quantity limits ...................................................................................................................62

Covered ...........................................................................................................................62

Table Of Contents

14 Sibley McLeod Silver 45192+ vii


Not covered ......................................................................................................................63





Covered ...........................................................................................................................64

Not covered ......................................................................................................................64

Office visits .......................................................................................................................65

Virtual care .......................................................................................................................65




Allergy shots .....................................................................................................................67

Hearing exams .................................................................................................................67















Acupuncture .....................................................................................................................70




Genetic testing .................................................................................................................71

Table Of Contents

14 Sibley McLeod Silver 45192+ viii



Covered ...........................................................................................................................72

Not covered ......................................................................................................................72

Office visits .......................................................................................................................73

Virtual care .......................................................................................................................73






Covered ...........................................................................................................................75

Not covered ......................................................................................................................75





Covered ...........................................................................................................................78

Not covered ......................................................................................................................79

Office visits .......................................................................................................................79





Covered ...........................................................................................................................81

Not covered ......................................................................................................................81

Office visits .......................................................................................................................82

Virtual care .......................................................................................................................82







Table Of Contents

14 Sibley McLeod Silver 45192+ ix

Z. Exclusions ...................................................................................................................... 84





Time limits ........................................................................................................................88


Applicability ......................................................................................................................89









Who can enroll .................................................................................................................95

How to enroll ....................................................................................................................95


Open enrollment ...............................................................................................................95


Late enrollment ................................................................................................................98



Other changes ................................................................................................................ 100




FF. Continuation ................................................................................................................. 103




Insurability ...................................................................................................................... 111

GG. Complaints ................................................................................................................... 112


Table Of Contents

14 Sibley McLeod Silver 45192+ x


External review ............................................................................................................... 114


II. Definitions .................................................................................................................... 117

JJ. Signatures .................................................................................................................... 127

Introduction

14 Sibley McLeod Silver 45192+ 1

A. Introduction

Definitions













Introduction








Plan Overview


B. Plan Overview

See Definitions. These words have specific meanings: benefits, claim, coinsurance, copayment, deductible, dependent, employee, enrollee, HIPAA privacy standards, medically necessary, plan, plan administration functions, plan administrator, protected health information or PHI, provider, sponsor.











Plan Overview





Plan Number 501









Plan Overview


Funding


Benefits


The benefits described in this plan document detail the medical benefits available under the plan. Your Out-Of-Pocket Expenses describes the copayment, coinsurance, and deductible amounts that impact how much the plan pays and how much you pay. The procedures to be followed in obtaining benefits or presenting claims for benefits under the plan and seeking remedies for redress of claims that are denied in whole or in part are described in this plan.




HIPAA compliance



Plan Overview


















Plan Overview






Choice Of Provider



See Definitions. These words have specific meanings: benefits, claim, coinsurance, copayment, covered person, deductible, emergency, enrollee, hospital, medically necessary, network, non-network, non-network provider reimbursement amount, physician, plan, provider, sponsor.


Provider network


Network providers






Be aware that if you choose to go to a non-network provider and use out-of-network benefits, you will likely have to pay much more than if you use in-network benefits. The charges billed by your non-network provider may exceed the non-network provider reimbursement amount, leaving a balance for you to pay in addition to any applicable copayment, coinsurance, and deductible amount. This additional amount you must pay to the provider will not be applied toward the out-of-pocket maximum amount described in Your Out-Of-Pocket Expenses and you will owe this amount regardless of whether you previously reached your out-of-pocket maximum with amounts paid for other services. Please see the example calculation below.

Choice Of Provider












Continuity of care





Choice Of Provider















Prior authorization


Choice Of Provider






Certain drugs;

Home health care;

















Choice Of Provider




Role Of Medica


D. Role Of Medica

See Definitions. These words have specific meanings: benefits, claim, coinsurance, copayment, covered person, deductible, network, non-network, plan, plan administrator, provider, sponsor.





Network providers





Fee-for-service payment means that the network provider is paid a fee for each service provided. If the payment is per service, the network provider’s payment is determined according to a set fee schedule. The amount the network provider receives is the lesser of the fee schedule or what the network provider would have otherwise billed. If the payment is percentage of charges, the network provider’s payment is a set percentage of the provider’s charge. The amount paid to the network provider, less any applicable copayment, coinsurance, or deductible, is considered to be payment in full.

Risk-sharing payment means that the network provider is paid a specific amount for a particular unit of service, such as an amount per day, an amount per stay, an amount per episode, an

Role Of Medica


amount per case, an amount per period of illness, an amount per covered person, or an amount per service with targeted outcome. If the amount paid is less than the cost of providing or arranging for a covered person’s health services, the network provider may bear some of the shortfall. If the amount paid to the network provider is more than the cost of providing or arranging a covered person’s health services, the network provider may keep some of the excess.




Assignment






See Definitions. These words have specific meanings: benefits, claim, coinsurance, copayment, covered person, deductible, dependent, enrollee, medically necessary, network, non-network, non-network provider reimbursement amount, plan, prescription drug, provider, sponsor.








Copayments, coinsurance, and deductibles











If you use out-of-network benefits, you may incur costs in addition to your copayment, coinsurance, and deductible amounts. If the amount that your non-network provider bills you is more than the non-network provider reimbursement amount, you are responsible for paying the difference. In addition, the difference will not be applied toward satisfaction of the deductible or the out-of-pocket maximum (described in this section).




Customer Service will provide you with an estimate of the non-network provider reimbursement amount based on the information provided at the time of your inquiry. The actual amount paid will be based on the information received at the time the claim is submitted and subject to all applicable benefit provisions, exclusions, and limitations, including but not limited to copayments, coinsurance, and deductibles, as described in this plan.



The out-of-pocket maximum is an accumulation of copayments, coinsurance, and deductibles paid for benefits received during a calendar year. Except as described below or as otherwise specified, you will not be required to pay more than the applicable per covered person out-of-pocket maximum for benefits received during a calendar year (see the Out-of-Pocket Expenses table in this section). Please note: Charges for services not eligible for coverage and any charge in excess of the non-network provider reimbursement amount are not applicable toward the out-of-pocket maximum. Additionally, you will owe these amounts regardless of whether you previously reached your out-of-pocket maximum with amounts paid for other services. When covered persons in a family unit (the enrollee and his or her dependents) have together met the applicable per family out-of-pocket maximum for benefits received during the calendar year, then all covered persons of the family unit are considered to have met the applicable per covered person and per family out-of-pocket maximum for that calendar year (see the Out-of-Pocket Expenses table in this section).


The plan refunds any amount you pay over the out-of-pocket maximum during any calendar year when proof of excess copayments, coinsurance, and deductibles is received and verified by the plan.






In-network benefits



Copayment or coinsurance See specific benefit for applicable copayment or coinsurance.

Deductible

Per covered person $500 $1,000

Per family $1,000 Per family deductible does not apply. Refer to the per covered person deductible above.




Per family $4,000 $8,000



In-network benefits





Ambulance Services




See Definitions. These words have specific meanings: benefits, coinsurance, copayment, deductible, emergency, hospital, network, non-network, non-network provider reimbursement amount, physician, plan, provider, skilled nursing facility.


Covered





Not covered





Ambulance Services







20% coinsurance Covered as an in-network benefit.












See Definitions. These words have specific meanings: benefits, coinsurance, copayment, covered person, deductible, medically necessary, network, non-network, non-network provider reimbursement amount, physician, plan, provider.


Covered








Not covered















3. Prosthetics

















20% coinsurance. Coverage is limited to one hearing aid per ear every three years. Related services must be prescribed by a network provider.



30% coinsurance

Home Health Care


H. Home Health Care


See Definitions. These words have specific meanings: benefits, coinsurance, copayment, custodial care, deductible, dependent, hospital, network, non-network, non-network provider reimbursement amount, physician, plan, provider, skilled care, skilled nursing facility.


Covered








Home Health Care


Not covered











10. Health clubs.



13. Voice training.











Home Health Care






3. Home infusion therapy 20% coinsurance 40% coinsurance



Hospice Services


I. Hospice Services


See Definitions. These words have specific meanings: benefits, coinsurance, copayment, covered person, deductible, network, non-network, non-network provider reimbursement amount, physician, plan, skilled nursing facility.

Covered











Hospice Services




Not covered
















1. Hospice services Nothing. The deductible does not apply.

40% coinsurance

Hospital Services




See Definitions. These words have specific meanings: approved clinical trial, benefits, coinsurance, copayment, covered person, deductible, emergency, genetic testing, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, provider, qualified individual, routine patient costs.


Covered




Not covered





Hospital Services











b. Outpatient lab and pathology 20% coinsurance 40% coinsurance





e. Other outpatient services $30/visit. The deductible does not apply.

30% coinsurance



30% coinsurance



30% coinsurance

Hospital Services













30% coinsurance






Hospital Services















See Definitions. These words have specific meanings: benefits, coinsurance, copayment, covered person, deductible, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, provider, virtual care.


Covered





Not covered








5. Sperm banking.

6. Adoption.

7. Donor sperm.

8. Donor eggs.










No coverage








Maternity Services




See Definitions. These words have specific meanings: benefits, coinsurance, copayment, covered person, deductible, dependent, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, prenatal care, provider, skilled care.




Covered

For benefits and the amounts you pay, see the table in this section. More than one copayment or coinsurance may be required if you receive more than one service or see more than one provider per visit. Each covered person's admission is separate from the admission of any other covered person. A separate deductible and coinsurance will be applied to both you and your newborn child for inpatient services related to maternity labor and delivery. Please note: We encourage you to enroll your newborn dependent under the plan within 30 days from the date of birth, date of placement for adoption, or date of adoption. Please refer to Eligibility And Enrollment for additional information.



Maternity Services








Not covered













30% coinsurance

Maternity Services








30% coinsurance



30% coinsurance



30% coinsurance

e. Postnatal services Nothing. The deductible does not apply.

30% coinsurance





30% coinsurance








30% coinsurance

Maternity Services








30% coinsurance






See Definitions. These words have specific meanings: benefits, coinsurance, copayment, covered person, deductible, dependent, network, non-network, non-network provider reimbursement amount, physician, plan, provider.


Covered




Not covered






















30% coinsurance

























Mental Health


N. Mental Health
















a. Room and board.




Mental Health







Covered







a. Psychiatrist

b. Psychologist







Mental Health





Not covered












Mental Health








30% coinsurance


30% coinsurance









d. Partial program 20% coinsurance 40% coinsurance





See Definitions. These words have specific meanings: benefits, coinsurance, copayment, deductible, medically necessary, network, non-network, non-network provider reimbursement amount, physician, plan, provider.


Covered




Not covered









1. Blood clotting factors 20% coinsurance 40% coinsurance





a. cystic fibrosis;








4. Total parenteral nutrition 20% coinsurance 40% coinsurance

5. Eligible ostomy supplies 20% coinsurance. The deductible does not apply.

40% coinsurance


20% coinsurance. The deductible does not apply.

40% coinsurance






See Definitions. These words have specific meanings: benefits, coinsurance, copayment, covered person, deductible, hospital, inpatient, investigative, medically necessary, network, non-network, non-network provider reimbursement amount, physician, plan, plan administrator, provider, virtual care.


Covered










Not covered

















No coverage


No coverage











No coverage



No coverage







No coverage



No coverage














No coverage










See Definitions. These words have specific meanings: benefits, coinsurance, copayment, deductible, habilitative, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, rehabilitative.


Covered





Not covered






5. Health clubs.

6. Voice training.










































See Definitions. These words have specific meanings: benefits, claim, coinsurance, copayment, covered person, deductible, emergency, hospital, network, non-network, non-network provider reimbursement amount, physician, plan, prescription drug, preventive health service, provider.

Preferred drug list


Tier 1 is your lowest copayment or coinsurance option. For the lowest out-of-pocket expense, you should consider a Tier 1 covered drug if you and your physician decide it is appropriate for your treatment.

Tier 2 is your higher copayment or coinsurance option. You may consider a Tier 2 covered drug to treat your condition if you and your physician decide it is appropriate.

Tier 3 is your highest copayment or coinsurance option. The covered drugs in Tier 3 are usually more costly.




Exceptions to the PDL can include antipsychotic drugs prescribed to treat emotional disturbance or mental illness, and certain drugs for diagnosed mental illness or emotional disturbance if removed from the PDL or you change health plans. If you would like to request a copy of the plan’s PDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover.



Prior authorization


Step therapy


Quantity limits


Covered

The following table provides important general information concerning in-network, out-of-network, and mail order benefits. For specific information concerning benefits and the amounts you pay, see the benefit table at the end of this section. Please note that Prescription Drug Program describes your copayment or coinsurance for prescription and OTC drugs themselves. An additional copayment or coinsurance applies for the provider’s services if you require that a provider administer self-administered drugs, as described in other applicable sections of this plan including, but not limited to, Hospital Services, Infertility Services, and Professional Services.










Not available.



* When out-of-network benefits are received from non-network providers, in addition to the deductible and copayment or coinsurance, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits.




Prescription unit

Generally, covered drugs will not be dispensed in excess of one prescription unit except as indicated below. One prescription unit is equal to a 31-consecutive-day supply of a covered drug from your pharmacy (or, in the case of contraceptives, up to a one-cycle supply) or a 93-consecutive-day supply of a covered drug from your designated mail order pharmacy (or, in the case of contraceptives, up to a three-cycle supply), unless limited by drug manufacturer’s packaging, dosing instructions, or Medica’s medication request guidelines, including quantity limits as indicated on the PDL. Copayment or coinsurance amounts will apply to each prescription unit dispensed.


Not covered














In-network benefits


Mail order benefits



































In-network benefits


Mail order benefits













See Definitions. These words have specific meanings: benefits, claim, coinsurance, copayment, covered person, deductible, network, physician, plan, prescription drug, provider.





The applicable copayments and coinsurance amounts for coverage of drugs on the SPDL are set forth in the benefit table below.




Exceptions to the SPDL can include antipsychotic drugs prescribed to treat emotional disturbance or mental illness, and certain drugs for diagnosed mental illness or emotional disturbance if removed from the SPDL or you change health plans. If you would like to request a copy of the plan’s SPDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover.



Prior authorization


Step therapy

The plan requires step therapy prior to coverage of specific specialty prescription drugs as indicated on the SPDL. Step therapy involves trying an alternative covered specialty prescription drug (typically a Tier 1 specialty prescription drug) before moving on to certain other Tier 1 or Tier 2 specialty prescription drugs for treatment of the same medical condition. Applicable step therapy requirements must be met before the plan will cover certain Tier 1 or Tier 2 specialty prescription drugs.

Quantity limits


Covered


Specialty prescription drugs are not subject to the deductible.

This section describes your copayment or coinsurance for specialty prescription drugs. An additional copayment or coinsurance applies for the provider’s services if you require that a provider administer self-administered drugs, as described in other applicable sections of this plan including, but not limited to, Hospital Services, Infertility Services, and Professional Services.

Prescription unit




Not covered









Benefits You pay














See Definitions. These words have specific meanings: approved clinical trial, benefits, coinsurance, convenience care/retail health clinic, copayment, deductible, emergency, genetic testing, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, preventive health service, provider, qualified individual, routine patient costs, urgent care center, virtual care.


Covered





For some services, there may be a facility charge resulting in copayment or coinsurance (see Hospital Services) in addition to the professional services copayment or coinsurance.

Not covered












For example, certain services received during an office visit may be considered surgical or imaging services; see below for coverage of these surgical or imaging services. In such instances, both an office visit copayment or coinsurance and outpatient surgical or imaging services copayment or coinsurance apply.



30% coinsurance


No coverage



30% coinsurance








For example, certain services received during an urgent care center visit may be considered surgical or imaging services; see below for coverage of these surgical or imaging services. In such instances, both an urgent care center visit copayment or coinsurance and outpatient surgical or imaging services copayment or coinsurance apply.




5. Preventive health care Please note: If you receive preventive and non-preventive health services during the same visit, the non-preventive health services may be subject to a copayment, coinsurance, or deductible, as described elsewhere in this plan. The most specific and appropriate benefit in this plan will apply for each service received during a visit.



30% coinsurance








30% coinsurance



No coverage



30% coinsurance



30% coinsurance



30% coinsurance

6. Allergy shots Nothing. The deductible does not apply.

30% coinsurance

7. Hearing exams Nothing. The deductible does not apply.

No coverage


No coverage









30% coinsurance. Coverage is limited to a maximum of 15 visits per calendar year. Please note: This visit limit includes chiropractic visits that you pay for in order to satisfy any part of your deductible.



30% coinsurance



30% coinsurance








15. Outpatient lab and pathology 20% coinsurance 40% coinsurance





30% coinsurance



















30% coinsurance









30% coinsurance



30% coinsurance

23. Services related to lead testing $30/visit. The deductible does not apply.

30% coinsurance



30% coinsurance



30% coinsurance


















See Definitions. These words have specific meanings: benefits, coinsurance, copayment, cosmetic, deductible, hospital, inpatient, medically necessary, network, non-network, non-network provider reimbursement amount, physician, plan, provider, reconstructive, restorative, virtual care.


Covered




Not covered


















40% coinsurance


No coverage


































See Definitions. These words have specific meanings: benefits, coinsurance, copayment, custodial care, deductible, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, skilled care, skilled nursing facility.


Covered

For benefits and the amounts you pay, see the table in this section. More than one copayment or coinsurance may be required if you receive more than one service or see more than one provider per visit. For purposes of this section, room and board includes coverage of health services and supplies.



Not covered







6. Health clubs.




8. Voice training.


10. Long-term care.












Substance Abuse


W. Substance Abuse











a. Room and board.





Substance Abuse


Covered








a. Psychiatrist

b. Psychologist









Substance Abuse


Not covered
















30% coinsurance


30% coinsurance

3. Opiate replacement therapy 20% coinsurance 40% coinsurance



Substance Abuse








c. Attending physician services 20% coinsurance 40% coinsurance





See Definitions. These words have specific meanings: benefits, coinsurance, copayment, cosmetic, deductible, designated facility, designated physician, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, provider, virtual care.


Covered




Not covered

















No coverage


No coverage

3. Outpatient hospital services 20% coinsurance No coverage




















Exclusions


Z. Exclusions













10. Autopsies.





Exclusions




























Exclusions
















55. Health clubs.

56. Long-term care.































Time limits







1. Applicability





































































Right Of Recovery





















Who can enroll


How to enroll







Initial enrollment



Open enrollment





Special enrollment










































7. When the qualified employee or dependent becomes eligible for group health plan premium assistance provided by Medicaid or a State Children’s Health Insurance Plan. The qualified employee must request enrollment within 60 days after the date the employee or dependent is determined to be eligible for premium assistance.

In the case of the qualified employee becoming eligible for premium assistance, this special enrollment period applies to the qualified employee and all of his or her dependents. In the case of a dependent becoming eligible for premium assistance, this special enrollment period applies to both that dependent and the qualified employee.

Late enrollment











a. Number 1. or 7. under Special enrollment, coverage begins on the first day of the first calendar month following the date the written request for enrollment is received by the plan administrator;







5. An enrollee’s newborn dependent, including a newborn adopted dependent, is covered under the plan from the date of birth. (Eligibility for a child placed for adoption or placed as a foster child with the enrollee ends if the placement is interrupted before legal adoption and the child is removed from placement.) The enrollee must pay any required premium for the



newborn child’s coverage and must enroll the newborn child under the plan. The plan encourages enrollees to enroll newborn children under the plan within 31 days from the date of birth.

Other changes


Identification card



Ending Coverage


EE. Ending Coverage



When coverage ends












Ending Coverage





Continuation


FF. Continuation








b. Notice of rights






Continuation




















Continuation
























Continuation












Continuation



















Continuation















Continuation















Continuation














Continuation











4. Insurability


Complaints


GG. Complaints















Complaints

















Complaints



External review











Records













Definitions


II. Definitions














Definitions




2. Non-network provider reimbursement amount. For out-of-network benefits, in addition to any copayment, coinsurance, and deductible amounts, you will be responsible for any charges billed by the provider in excess of the non-network provider reimbursement amount. The coinsurance may not exceed the charge billed by the provider for the benefit. Complaint. Any grievance against Medica, submitted by you or another person on your behalf, that is not the subject of litigation. Complaints may involve, but are not limited to, the scope of coverage for health care services; retrospective denials or limitations of payment for services; eligibility issues; denials, cancellations, or non-renewals of coverage; administrative operations; and the quality, timeliness, and appropriateness of health care services rendered. If the complaint is from an applicant, the complaint must relate to the application. If the complaint is from a former covered person, the complaint must relate to services received during the time the individual was a covered person.



Copayment. The fixed dollar amount you must pay to the provider for benefits received. Full copayments may apply to scheduled appointments canceled less than 24 hours before the appointment time or to missed appointments.

When you receive eligible health services from a network provider and a copayment applies, you pay the lesser of the charge billed by the provider for the benefit (i.e., retail) or your copayment. Medica, on behalf of sponsor, pays any remaining amount according to the written agreement with the provider. The copayment may not exceed the retail charge billed by the provider for the benefit. For out-of-network benefits, in addition to any copayment, coinsurance, and deductible amounts, you will be responsible for any charges in excess of the non-network provider reimbursement amount. Cosmetic. Services and procedures that improve physical appearance but do not correct or improve a physiological function, and that are not medically necessary, or as determined by the plan.




3. Medicare;


Definitions


























Definitions


















Employee. Any person employed by the sponsor on or after the effective date of this plan, except that it shall not include a self-employed individual as described in Section 401(c) of the Code. All employees who are treated as employed by a single employer under Subsections

Definitions


(b), (c), or (m) of Section 414 of the Code are treated as employed by a single employer for purposes of this plan. Employee does not include any of the following:














Definitions




















Non-network. A term used to describe a provider not under contract as a network provider.

Definitions


Non-network provider reimbursement amount. The amount that Medica will pay, on behalf of sponsor, to a non-network provider for each benefit is based on one of the following, as determined by Medica, on behalf of sponsor: 1. A percentage of the amount Medicare would pay for the service in the location where the






For certain benefits, you must pay a portion of the non-network provider reimbursement amount as a copayment or coinsurance.

In addition, if the amount billed by the non-network provider is greater than the non-network provider reimbursement amount, the non-network provider will likely bill you for the difference. This difference may be substantial, and it is in addition to any copayment, coinsurance, or deductible amount you may be responsible for according to the terms described in this plan. Furthermore, such difference will not be applied toward the out-of-pocket maximum described in Your Out-Of-Pocket Expenses. Additionally, you will owe these amounts regardless of whether you previously reached your out-of-pocket maximum with amounts paid for other services. As a result, the amount you will be required to pay for services received from a non-network provider will likely be much higher than if you had received services from a network provider. Pharmacogenetic testing. A type of genetic testing that attempts to use personal gene-based information to determine the proper drug and dosage for an individual. Pharmacogenetic testing seeks to determine how a drug is absorbed, metabolized, or cleared from the body of an individual based on their genetic makeup. Physician. A Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (O.D.), or Doctor of Chiropractic (D.C.) practicing within the scope of his or her licensure.





Definitions

















Definitions














Total disability. Disability due to injury, sickness, or pregnancy that requires regular care and attendance of a physician, and in the opinion of the physician renders the employee unable to

Definitions


perform the duties of his or her regular business or occupation during the first two years of the disability and, after the first two years of the disability, renders the employee unable to perform the duties of any business or occupation for which he or she is reasonably fitted.


Virtual care. Professional evaluation and medical management services provided to patients through e-mail, telephone, or webcam. Virtual care includes interactive audiovisual telehealth services. Virtual care is used to address non-urgent medical symptoms for patients describing new or ongoing symptoms to which providers respond with substantive medical advice. Virtual care does not include telephone calls for reporting normal lab or test results, or solely calling in a prescription to a pharmacy.


Signatures


JJ. Signatures


Sibley County

By:

(please print)

(signature)

Its:

McLeod County

By:

(please print)

(signature)

Its:



SIBLEY/MCLEOD EMPLOYEE BENEFIT PLAN MEDICA CHOICE PASSPORT ASO 3000-0% HSA

Group #53052, 53053 BPL #28661








Table Of Contents

14 Sibley McLeod HSA 53052+ iii

Table Of Contents

A. Introduction ...................................................................................................................... 1

Definitions ......................................................................................................................... 1



Health savings accounts .................................................................................................... 2

B. Plan Overview ................................................................................................................... 3


Funding ............................................................................................................................. 5

Benefits ............................................................................................................................. 5








D. Role Of Medica ............................................................................................................... 13


Assignment ......................................................................................................................14


Coinsurance and deductibles ...........................................................................................15





Covered ...........................................................................................................................19

Not covered ......................................................................................................................19




Covered ...........................................................................................................................21

Not covered ......................................................................................................................21

Table Of Contents

14 Sibley McLeod HSA 53052+ iv



Prosthetics .......................................................................................................................22

Hearing aids .....................................................................................................................23

Breast pumps ...................................................................................................................23


Covered ...........................................................................................................................24

Not covered ......................................................................................................................25






Covered ...........................................................................................................................27

Not covered ......................................................................................................................28



Covered ...........................................................................................................................29

Not covered ......................................................................................................................29








Covered ...........................................................................................................................33

Not covered ......................................................................................................................33


Virtual care .......................................................................................................................34





Table Of Contents

14 Sibley McLeod HSA 53052+ v



Covered ...........................................................................................................................35


Not covered ......................................................................................................................36








Covered ...........................................................................................................................39

Not covered ......................................................................................................................39




Oral surgery .....................................................................................................................41

N. Mental Health .................................................................................................................. 42

Covered ...........................................................................................................................43

Not covered ......................................................................................................................44

Office visits .......................................................................................................................45





Covered ...........................................................................................................................46

Not covered ......................................................................................................................46







Table Of Contents

14 Sibley McLeod HSA 53052+ vi


Covered ...........................................................................................................................48

Not covered ......................................................................................................................49

Office visits .......................................................................................................................49

Virtual care .......................................................................................................................49






Covered ...........................................................................................................................52

Not covered ......................................................................................................................52








Step therapy .....................................................................................................................57

Quantity limits ...................................................................................................................57

Covered ...........................................................................................................................57


Not covered ......................................................................................................................58











Step therapy .....................................................................................................................62

Table Of Contents

14 Sibley McLeod HSA 53052+ vii

Quantity limits ...................................................................................................................62

Covered ...........................................................................................................................62


Not covered ......................................................................................................................63





Covered ...........................................................................................................................64

Not covered ......................................................................................................................64

Office visits .......................................................................................................................65

Virtual care .......................................................................................................................65




Allergy shots .....................................................................................................................67

Hearing exams .................................................................................................................67















Acupuncture .....................................................................................................................70



Table Of Contents

14 Sibley McLeod HSA 53052+ viii


Genetic testing .................................................................................................................71



Covered ...........................................................................................................................72

Not covered ......................................................................................................................72

Office visits .......................................................................................................................73

Virtual care .......................................................................................................................73






Covered ...........................................................................................................................75

Not covered ......................................................................................................................75





Covered ...........................................................................................................................78

Not covered ......................................................................................................................79

Office visits .......................................................................................................................79





Covered ...........................................................................................................................81

Not covered ......................................................................................................................81

Office visits .......................................................................................................................82

Virtual care .......................................................................................................................82





Table Of Contents

14 Sibley McLeod HSA 53052+ ix



Z. Exclusions ...................................................................................................................... 84





Time limits ........................................................................................................................88


Applicability ......................................................................................................................89









Who can enroll .................................................................................................................95

How to enroll ....................................................................................................................95


Open enrollment ...............................................................................................................95


Late enrollment ................................................................................................................98



Other changes ..................................................................................................................99




FF. Continuation ................................................................................................................. 103




Insurability ...................................................................................................................... 111

Table Of Contents

14 Sibley McLeod HSA 53052+ x

GG. Complaints ................................................................................................................... 112



External review ............................................................................................................... 114


II. Definitions .................................................................................................................... 117

JJ. Signatures .................................................................................................................... 127

Introduction

14 Sibley McLeod HSA 53052+ 1

A. Introduction

Definitions













Introduction








Health savings accounts

This coverage is intended to comply with the requirements of the Internal Revenue Code section 223 for a qualified high deductible health plan. This coverage may qualify you to make a pre-tax contribution to a health savings account. You are responsible for the cost of all health services, other than preventive care, up to the deductible amount.

Plan Overview


B. Plan Overview

See Definitions. These words have specific meanings: benefits, claim, coinsurance, deductible, dependent, employee, enrollee, HIPAA privacy standards, medically necessary, plan, plan administration functions, plan administrator, protected health information or PHI, provider, sponsor.











Plan Overview





Plan Number 501









Plan Overview


Funding


Benefits


The benefits described in this plan document detail the medical benefits available under the plan. Your Out-Of-Pocket Expenses describes the coinsurance and deductible amounts that impact how much the plan pays and how much you pay. The procedures to be followed in obtaining benefits or presenting claims for benefits under the plan and seeking remedies for redress of claims that are denied in whole or in part are described in this plan.




HIPAA compliance



Plan Overview


















Plan Overview






Choice Of Provider



See Definitions. These words have specific meanings: benefits, claim, coinsurance, covered person, deductible, emergency, enrollee, hospital, medically necessary, network, non-network, non-network provider reimbursement amount, physician, plan, provider, sponsor.


Provider network


Network providers






Be aware that if you choose to go to a non-network provider and use out-of-network benefits, you will likely have to pay much more than if you use in-network benefits. The charges billed by your non-network provider may exceed the non-network provider reimbursement amount, leaving a balance for you to pay in addition to any applicable coinsurance and deductible amount. This additional amount you must pay to the provider will not be applied toward the out-of-pocket maximum amount described in Your Out-Of-Pocket Expenses and you will owe this amount regardless of whether you previously reached your out-of-pocket maximum with amounts paid for other services. Please see the example calculation below.

Choice Of Provider












Continuity of care





Choice Of Provider















Prior authorization


Choice Of Provider






Certain drugs;

Home health care;

















Choice Of Provider




Role Of Medica


D. Role Of Medica

See Definitions. These words have specific meanings: benefits, claim, coinsurance, covered person, deductible, network, non-network, plan, plan administrator, provider, sponsor.





Network providers





Fee-for-service payment means that the network provider is paid a fee for each service provided. If the payment is per service, the network provider’s payment is determined according to a set fee schedule. The amount the network provider receives is the lesser of the fee schedule or what the network provider would have otherwise billed. If the payment is percentage of charges, the network provider’s payment is a set percentage of the provider’s charge. The amount paid to the network provider, less any applicable coinsurance or deductible, is considered to be payment in full.

Risk-sharing payment means that the network provider is paid a specific amount for a particular unit of service, such as an amount per day, an amount per stay, an amount per episode, an amount per case, an amount per period of illness, an amount per covered person, or an amount

Role Of Medica


per service with targeted outcome. If the amount paid is less than the cost of providing or arranging for a covered person’s health services, the network provider may bear some of the shortfall. If the amount paid to the network provider is more than the cost of providing or arranging a covered person’s health services, the network provider may keep some of the excess.




Assignment






See Definitions. These words have specific meanings: benefits, claim, coinsurance, covered person, deductible, dependent, enrollee, medically necessary, network, non-network, non-network provider reimbursement amount, plan, prescription drug, provider, sponsor.








Coinsurance and deductibles


1. Any applicable coinsurance and per covered person deductible each calendar year as described in this plan (see the Out-of-Pocket Expenses table in this section).




1. Any applicable coinsurance and per covered person deductible each calendar year as described in this plan (see the Out-of-Pocket Expenses table in this section).





If you use out-of-network benefits, you may incur costs in addition to your coinsurance and deductible amounts. If the amount that your non-network provider bills you is more than the non-network provider reimbursement amount, you are responsible for paying the difference. In addition, the difference will not be applied toward satisfaction of the deductible or the out-of-pocket maximum (described in this section).




Customer Service will provide you with an estimate of the non-network provider reimbursement amount based on the information provided at the time of your inquiry. The actual amount paid will be based on the information received at the time the claim is submitted and subject to all applicable benefit provisions, exclusions, and limitations, including but not limited to coinsurance and deductibles, as described in this plan.



The out-of-pocket maximum is an accumulation of coinsurance and deductibles paid for benefits received during a calendar year. Except as described below or as otherwise specified, you will not be required to pay more than the applicable per covered person out-of-pocket maximum for benefits received during a calendar year (see the Out-of-Pocket Expenses table in this section). Please note: Charges for services not eligible for coverage and any charge in excess of the non-network provider reimbursement amount are not applicable toward the out-of-pocket maximum. Additionally, you will owe these amounts regardless of whether you previously reached your out-of-pocket maximum with amounts paid for other services. When covered persons in a family unit (the enrollee and his or her dependents) have together met the applicable per family out-of-pocket maximum for benefits received during the calendar year, then all covered persons of the family unit are considered to have met the applicable per covered person and per family out-of-pocket maximum for that calendar year (see the Out-of-Pocket Expenses table in this section).


The plan refunds any amount you pay over the out-of-pocket maximum during any calendar year when proof of excess coinsurance and deductibles is received and verified by the plan.






In-network benefits



Coinsurance See specific benefit for applicable coinsurance.

Deductible


Per family $6,000 $9,000




Per family $6,000 Per family out-of-pocket maximum does not apply. Refer to the per covered person out-of-pocket maximum above.



In-network benefits





Ambulance Services




See Definitions. These words have specific meanings: benefits, coinsurance, deductible, emergency, hospital, network, non-network, non-network provider reimbursement amount, physician, plan, provider, skilled nursing facility.


Covered

For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit.




Not covered





Ambulance Services







Nothing Covered as an in-network benefit.





Nothing 20% coinsurance







See Definitions. These words have specific meanings: benefits, coinsurance, covered person, deductible, medically necessary, network, non-network, non-network provider reimbursement amount, physician, plan, provider.


Covered






Not covered

















3. Prosthetics

















Nothing. Coverage is limited to one hearing aid per ear every three years. Related services must be prescribed by a network provider.



20% coinsurance

Home Health Care


H. Home Health Care


See Definitions. These words have specific meanings: benefits, coinsurance, custodial care, deductible, dependent, hospital, network, non-network, non-network provider reimbursement amount, physician, plan, provider, skilled care, skilled nursing facility.


Covered








Home Health Care


Not covered











10. Health clubs.



13. Voice training.











Home Health Care






3. Home infusion therapy Nothing 20% coinsurance



Hospice Services


I. Hospice Services


See Definitions. These words have specific meanings: benefits, coinsurance, covered person, deductible, network, non-network, non-network provider reimbursement amount, physician, plan, skilled nursing facility.

Covered











Hospice Services




Not covered
















1. Hospice services Nothing 20% coinsurance

Hospital Services




See Definitions. These words have specific meanings: approved clinical trial, benefits, coinsurance, covered person, deductible, emergency, genetic testing, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, provider, qualified individual, routine patient costs.


Covered




Not covered






Hospital Services









b. Outpatient lab and pathology Nothing 20% coinsurance





e. Other outpatient services Nothing 20% coinsurance





Hospital Services













3. Inpatient services Nothing 20% coinsurance





Hospital Services















See Definitions. These words have specific meanings: benefits, coinsurance, covered person, deductible, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, provider, virtual care.


Covered





Not covered








5. Sperm banking.

6. Adoption.

7. Donor sperm.

8. Donor eggs.









2. Virtual care Nothing No coverage








Maternity Services




See Definitions. These words have specific meanings: benefits, coinsurance, covered person, deductible, dependent, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, prenatal care, provider, skilled care.




Covered

For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Each covered person's admission is separate from the admission of any other covered person. A separate deductible and coinsurance will be applied to both you and your newborn child for inpatient services related to maternity labor and delivery. Please note: We encourage you to enroll your newborn dependent under the plan within 30 days from the date of birth, date of placement for adoption, or date of adoption. Please refer to Eligibility And Enrollment for additional information.



Maternity Services








Not covered













20% coinsurance

Maternity Services








20% coinsurance



20% coinsurance



20% coinsurance

e. Postnatal services Nothing 20% coinsurance












Maternity Services













See Definitions. These words have specific meanings: benefits, coinsurance, covered person, deductible, dependent, network, non-network, non-network provider reimbursement amount, physician, plan, provider.


Covered




Not covered














































Mental Health


N. Mental Health


See Definitions. These words have specific meanings: benefits, claim, coinsurance, covered person, deductible, emergency, hospital, inpatient, medically necessary, mental disorder, network, non-network, non-network provider reimbursement amount, physician, plan, provider.














a. Room and board.




Mental Health







Covered







a. Psychiatrist

b. Psychologist








Mental Health




Not covered












Mental Health








2. Intensive outpatient programs Nothing 20% coinsurance




a. Room and board Nothing 20% coinsurance





d. Partial program Nothing 20% coinsurance





See Definitions. These words have specific meanings: benefits, coinsurance, deductible, medically necessary, network, non-network, non-network provider reimbursement amount, physician, plan, provider.


Covered




Not covered









1. Blood clotting factors Nothing 20% coinsurance





a. cystic fibrosis;








4. Total parenteral nutrition Nothing 20% coinsurance

5. Eligible ostomy supplies Nothing 20% coinsurance








See Definitions. These words have specific meanings: benefits, coinsurance, covered person, deductible, hospital, inpatient, investigative, medically necessary, network, non-network, non-network provider reimbursement amount, physician, plan, plan administrator, provider, virtual care.


Covered










Not covered
















1. Office visits Nothing No coverage











Nothing No coverage


Nothing No coverage


Nothing No coverage


Nothing No coverage


Nothing No coverage


Nothing No coverage



Nothing No coverage


Nothing No coverage








Nothing No coverage

4. Inpatient services Nothing No coverage


Nothing No coverage


Nothing No coverage





See Definitions. These words have specific meanings: benefits, coinsurance, deductible, habilitative, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, rehabilitative.


Covered





Not covered






5. Health clubs.

6. Voice training.












a. Habilitative services Nothing 20% coinsurance. Coverage for physical and occupational therapy is limited to a combined limit of 20 visits per calendar year. Please note: This visit limit includes physical and occupational therapy visits that you pay for in order to satisfy any part of your deductible.

b. Rehabilitative services Nothing 20% coinsurance. Coverage for physical and occupational therapy is limited to a combined limit of 20 visits per calendar year. Please note: This visit limit includes physical and occupational therapy visits that you pay for in order to satisfy any part of your deductible.








a. Habilitative services Nothing 20% coinsurance. Coverage for speech therapy is limited to 20 visits per calendar year. Please note: This visit limit includes speech therapy visits that you pay for in order to satisfy any part of your deductible.

b. Rehabilitative services Nothing 20% coinsurance. Coverage for speech therapy is limited to 20 visits per calendar year. Please note: This visit limit includes speech therapy visits that you pay for in order to satisfy any part of your deductible.


a. Habilitative services Nothing 20% coinsurance. Coverage for physical and occupational therapy is limited to a combined limit of 20 visits per calendar year. Please note: This visit limit includes physical and occupational therapy visits that you pay for in order to satisfy any part of your deductible.







b. Rehabilitative services Nothing 20% coinsurance. Coverage for physical and occupational therapy is limited to a combined limit of 20 visits per calendar year. Please note: This visit limit includes physical and occupational therapy visits that you pay for in order to satisfy any part of your deductible.





See Definitions. These words have specific meanings: benefits, claim, coinsurance, covered person, deductible, emergency, hospital, medically necessary, network, non-network, non-network provider reimbursement amount, physician, plan, prescription drug, preventive health service, provider.

Preferred drug list


Tier 1 is your lowest coinsurance option. For the lowest out-of-pocket expense, you should consider a Tier 1 covered drug if you and your physician decide it is appropriate for your treatment.

Tier 2 is your higher coinsurance option. You may consider a Tier 2 covered drug to treat your condition if you and your physician decide it is appropriate.

Tier 3 drugs are not covered unless they meet the requirements under the PDL exception process described in this plan.




If your physician thinks a non-covered drug is medically necessary, he/she may request an exception. Please note that exceptions will only be allowed when specific clinical criteria are satisfied. In the event the plan grants an exception, coverage will be provided at the Tier 3 benefit level. In certain circumstances, your physician may request that the plan make an exception to the coverage rules described under Preferred drug list above. Please note that



exceptions will only be allowed when specific clinical criteria are satisfied. Any exception the plan grants will improve the coverage by only one tier. Exceptions to the PDL can also include antipsychotic drugs prescribed to treat emotional disturbance or mental illness, and certain drugs for diagnosed mental illness or emotional disturbance if removed from the PDL or you change health plans. If you would like to request a copy of the plan’s PDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover.

Prior authorization


Step therapy


Quantity limits


Covered

The following table provides important general information concerning in-network, out-of-network, and mail order benefits. For specific information concerning benefits and the amounts you pay, see the benefit table at the end of this section. Please note that Prescription Drug Program describes your coinsurance for prescription and OTC drugs themselves. An additional coinsurance applies for the provider’s services if you require that a provider administer self-administered drugs, as described in other applicable sections of this plan including, but not limited to, Hospital Services, Infertility Services, and Professional Services.













Not available.

* When out-of-network benefits are received from non-network providers, in addition to the deductible and coinsurance, you will be responsible for any charges in excess of the non-network provider reimbursement amount. These excess charges will not be applied toward satisfaction of the deductible or out-of-pocket maximum. Please see Non-network providers in Choice Of Provider for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits.




Prescription unit

Generally, covered drugs will not be dispensed in excess of one prescription unit except as indicated below. One prescription unit is equal to a 31-consecutive-day supply of a covered drug from your pharmacy (or, in the case of contraceptives, up to a one-cycle supply) or a 93-consecutive-day supply of a covered drug from your designated mail order pharmacy (or, in the case of contraceptives, up to a three-cycle supply), unless limited by drug manufacturer’s packaging, dosing instructions, or Medica’s medication request guidelines, including quantity limits as indicated on the PDL. Coinsurance amounts will apply to each prescription unit dispensed.


Not covered


1. Tier 3 drugs unless covered through the PDL exception process described in this plan.













In-network benefits after deductible


Mail order benefits after deductible




Tier 3: No coverage




Tier 3: No coverage




Tier 3: No coverage




Tier 3: No coverage





In-network benefits after deductible


Mail order benefits after deductible




Tier 3: No coverage




Tier 3: No coverage




Tier 3: No coverage

The deductible does not apply.






Tier 3: No coverage





Tier 3: No coverage






See Definitions. These words have specific meanings: benefits, claim, coinsurance, covered person, deductible, medically necessary, network, physician, plan, prescription drug, provider.





Tier 2 specialty prescription drugs are not covered unless they meet the requirements under the SPDL exception process described in this plan. The applicable coinsurance amounts for coverage of drugs on the SPDL are set forth in the benefit table below.




If your physician thinks a non-covered specialty drug is medically necessary, he/she may request an exception. Please note that exceptions will only be allowed when specific clinical criteria are satisfied. In the event the plan grants an exception, coverage will be provided at the Tier 2 specialty prescription drug benefit level. In certain circumstances your physician may request that the plan make an exception to the coverage rules described under Specialty preferred drug list above. Please note that exceptions will only be allowed when



specific clinical criteria are satisfied. Any exception the plan grants will improve the coverage by only one tier. Exceptions to the SPDL can also include antipsychotic drugs prescribed to treat emotional disturbance or mental illness, and certain drugs for diagnosed mental illness or emotional disturbance if removed from the SPDL or you change health plans. If you would like to request a copy of the plan’s SPDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover.

Prior authorization


Step therapy

The plan requires step therapy prior to coverage of specific specialty prescription drugs as indicated on the SPDL. Step therapy involves trying an alternative covered specialty prescription drug (typically a Tier 1 specialty prescription drug) before moving on to certain other Tier 1 or Tier 2 specialty prescription drugs for treatment of the same medical condition. Applicable step therapy requirements and SPDL exception process requirements must be met before the plan will cover certain Tier 1 or Tier 2 specialty prescription drugs.

Quantity limits


Covered


This section describes your coinsurance for specialty prescription drugs. An additional coinsurance applies for the provider’s services if you require that a provider administer self-administered drugs, as described in other applicable sections of this plan including, but not limited to, Hospital Services, Infertility Services, and Professional Services.

Prescription unit




Not covered


1. Tier 2 specialty prescription drugs unless covered through the SPDL exception process described in this plan.








Benefits After in-network deductible, you pay


Tier 1 specialty prescription drugs: Nothing per prescription unit; or

Tier 2 specialty prescription drugs: No coverage











See Definitions. These words have specific meanings: approved clinical trial, benefits, coinsurance, convenience care/retail health clinic, deductible, emergency, genetic testing, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, preventive health service, provider, qualified individual, routine patient costs, urgent care center, virtual care.


Covered





For some services, there may be a facility charge resulting in coinsurance (see Hospital Services) in addition to the professional services coinsurance.

Not covered












For example, certain services received during an office visit may be considered surgical or imaging services; see below for coverage of these surgical or imaging services. In such instances, both an office visit coinsurance and outpatient surgical or imaging services coinsurance apply.













For example, certain services received during an urgent care center visit may be considered surgical or imaging services; see below for coverage of these surgical or imaging services. In such instances, both an urgent care center visit coinsurance and outpatient surgical or imaging services coinsurance apply.



5. Preventive health care Please note: If you receive preventive and non-preventive health services during the same visit, the non-preventive health services may be subject to a coinsurance or deductible, as described elsewhere in this plan. The most specific and appropriate benefit in this plan will apply for each service received during a visit.



20% coinsurance








20% coinsurance



No coverage



20% coinsurance



20% coinsurance



20% coinsurance

6. Allergy shots Nothing 20% coinsurance

7. Hearing exams Nothing No coverage


No coverage


Nothing 20% coinsurance. Coverage is limited to a maximum of 15 visits per calendar year. Please note: This visit limit includes chiropractic visits that you pay for in order to satisfy any part of your deductible.

















15. Outpatient lab and pathology Nothing 20% coinsurance

































23. Services related to lead testing Nothing 20% coinsurance






















See Definitions. These words have specific meanings: benefits, coinsurance, cosmetic, deductible, hospital, inpatient, medically necessary, network, non-network, non-network provider reimbursement amount, physician, plan, provider, reconstructive, restorative, virtual care.


Covered




Not covered








7. Drugs provided or administered by a physician or other provider on an outpatient basis, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program,



Prescription Specialty Drug Program, or otherwise described as a specific benefit in this plan.






1. Office visits Nothing 20% coinsurance



































See Definitions. These words have specific meanings: benefits, coinsurance, custodial care, deductible, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, skilled care, skilled nursing facility.


Covered

For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. For purposes of this section, room and board includes coverage of health services and supplies.



Not covered







6. Health clubs.




8. Voice training.


10. Long-term care.












Substance Abuse


W. Substance Abuse


See Definitions. These words have specific meanings: benefits, claim, coinsurance, covered person, deductible, emergency, hospital, inpatient, medically necessary, mental disorder, network, non-network, non-network provider reimbursement amount, physician, plan, provider.









a. Room and board.





Substance Abuse


Covered








a. Psychiatrist

b. Psychologist









Substance Abuse


Not covered
















2. Intensive outpatient programs Nothing 20% coinsurance

3. Opiate replacement therapy Nothing 20% coinsurance


a. Room and board Nothing 20% coinsurance



Substance Abuse






c. Attending physician services Nothing 20% coinsurance





See Definitions. These words have specific meanings: benefits, coinsurance, cosmetic, deductible, designated facility, designated physician, hospital, inpatient, network, non-network, non-network provider reimbursement amount, physician, plan, provider, virtual care.


Covered




Not covered

















1. Office visits Nothing No coverage


3. Outpatient hospital services Nothing No coverage


Nothing No coverage

5. Inpatient services Nothing No coverage


Nothing No coverage















Exclusions


Z. Exclusions













10. Autopsies.





Exclusions




























Exclusions
















55. Health clubs.

56. Long-term care.































Time limits







1. Applicability





































































Right Of Recovery





















Who can enroll


How to enroll







Initial enrollment



Open enrollment





Special enrollment










































Late enrollment











a. Number 1. under Special enrollment, coverage begins on the first day of the first calendar month following the date the written request for enrollment is received by the plan administrator;







5. An enrollee’s newborn dependent, including a newborn adopted dependent, is covered under the plan from the date of birth. (Eligibility for a child placed for adoption or placed as a foster child with the enrollee ends if the placement is interrupted before legal adoption and the child is removed from placement.) The enrollee must pay any required premium for the newborn child’s coverage and must enroll the newborn child under the plan. The plan encourages enrollees to enroll newborn children under the plan within 31 days from the date of birth.

Other changes




Identification card



Ending Coverage


EE. Ending Coverage



When coverage ends












Ending Coverage





Continuation


FF. Continuation








b. Notice of rights






Continuation




















Continuation
























Continuation












Continuation



















Continuation















Continuation















Continuation














Continuation











4. Insurability


Complaints


GG. Complaints















Complaints

















Complaints



External review











Records













Definitions


II. Definitions














Definitions




2. Non-network provider reimbursement amount. For out-of-network benefits, in addition to any coinsurance and deductible amounts, you will be responsible for any charges billed by the provider in excess of the non-network provider reimbursement amount. The coinsurance may not exceed the charge billed by the provider for the benefit. Complaint. Any grievance against Medica, submitted by you or another person on your behalf, that is not the subject of litigation. Complaints may involve, but are not limited to, the scope of coverage for health care services; retrospective denials or limitations of payment for services; eligibility issues; denials, cancellations, or non-renewals of coverage; administrative operations; and the quality, timeliness, and appropriateness of health care services rendered. If the complaint is from an applicant, the complaint must relate to the application. If the complaint is from a former covered person, the complaint must relate to services received during the time the individual was a covered person.



Cosmetic. Services and procedures that improve physical appearance but do not correct or improve a physiological function, and that are not medically necessary, or as determined by the plan.




3. Medicare;








Definitions


























Definitions












Employee. Any person employed by the sponsor on or after the effective date of this plan, except that it shall not include a self-employed individual as described in Section 401(c) of the Code. All employees who are treated as employed by a single employer under Subsections (b), (c), or (m) of Section 414 of the Code are treated as employed by a single employer for purposes of this plan. Employee does not include any of the following:





Definitions













Definitions


















Non-network. A term used to describe a provider not under contract as a network provider. Non-network provider reimbursement amount. The amount that Medica will pay, on behalf of sponsor, to a non-network provider for each benefit is based on one of the following, as determined by Medica, on behalf of sponsor: 1. A percentage of the amount Medicare would pay for the service in the location where the



Definitions





For certain benefits, you must pay a portion of the non-network provider reimbursement amount as a coinsurance.

In addition, if the amount billed by the non-network provider is greater than the non-network provider reimbursement amount, the non-network provider will likely bill you for the difference. This difference may be substantial, and it is in addition to any coinsurance or deductible amount you may be responsible for according to the terms described in this plan. Furthermore, such difference will not be applied toward the out-of-pocket maximum described in Your Out-Of-Pocket Expenses. Additionally, you will owe these amounts regardless of whether you previously reached your out-of-pocket maximum with amounts paid for other services. As a result, the amount you will be required to pay for services received from a non-network provider will likely be much higher than if you had received services from a network provider. Pharmacogenetic testing. A type of genetic testing that attempts to use personal gene-based information to determine the proper drug and dosage for an individual. Pharmacogenetic testing seeks to determine how a drug is absorbed, metabolized, or cleared from the body of an individual based on their genetic makeup. Physician. A Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (O.D.), or Doctor of Chiropractic (D.C.) practicing within the scope of his or her licensure.







Definitions


















Definitions











Total disability. Disability due to injury, sickness, or pregnancy that requires regular care and attendance of a physician, and in the opinion of the physician renders the employee unable to perform the duties of his or her regular business or occupation during the first two years of the disability and, after the first two years of the disability, renders the employee unable to perform the duties of any business or occupation for which he or she is reasonably fitted.


Virtual care. Professional evaluation and medical management services provided to patients through e-mail, telephone, or webcam. Virtual care includes interactive audiovisual telehealth

Definitions


services. Virtual care is used to address non-urgent medical symptoms for patients describing new or ongoing symptoms to which providers respond with substantive medical advice. Virtual care does not include telephone calls for reporting normal lab or test results, or solely calling in a prescription to a pharmacy.


Signatures


JJ. Signatures


Sibley County

By:

(please print)

(signature)

Its:

McLeod County

By:

(please print)

(signature)

Its:

I Minnesota Counties Intergovernmentaljrust 100 Empire Drive, Suite 100 St. Paul, M N 55103-1885 www.mci t .org

Phone: 651-209-6400 Toll Free: 866-547-6516

Fax: 651-209-6496

BOARD OF DIRECTORS

Scott Sanders Trust Chair Watonwan Count)' Commissioner

Felix Schmiesing

Vice Chair Sherburne County Commissioner

Graylen Carlson Secretary/Treasurer Lac qui Parle County Commissioner

Donald Diedrich Polk County Commissioner

Richard Downham Cass County Commissioner

Dan Kuhns

Waseca County Commissioner

Randy Schrcifels Stearns County Auditor/Treasurer

Kevin Corbid Washington County Deputy Admin/Auditor

Charles Enter Brown County Administrator

November 15,2013

Pat Melv in Administrator McLeod County 830 E 11th St Ste 110 Glencoe, M N 55336-2200

Re: 2013 M C I T D I V I D E N D P A Y M E N T

Dear Pat:

The Minnesota Counties Intergovernmental Trust Board of Directors is pleased to provide McLeod County with the enclosed dividend. Your dividend totals $237,356 and consists of $86,985 attributable to your workers' compensation coverage and $150,371 attributable to your property and casualty coverage.

In June of 2013 the M C I T Board of Directors declared a $19 million dividend to members in good standing. This marks the 23 r d consecutive year M C I T has returned dividends to members and brings the total dividends paid to almost $276 million.

The board of directors is pleased to provide this dividend but reminds members that past dividends are no guarantee of future distributions. The dividends are the result of favorable loss experience within the pool, members' commitment to risk management and the positive performance of the M C I T investment portfolio. Without your hard work and support, these distributions would not be possible. Thank you for your ongoing participation in M C I T .

For your convenience in announcing this dividend, enclosed is a copy of a press release template that you can modify with your specific information and distribute to your local press.

Sincerely,

Scott Sanders, Watonwan County Commissioner

Trust Chair

Encl. Cc: County Board Chair

"Ptoviding Minnesota counties and associated membets cost-effective coverage with comprehensive and quality risk management services."

Documents

Meetings/2013/December... · 2019-12-11 · December 3, 2013 Board Agenda Page 1 * Board Action Requested McLEOD COUNTY BOARD OF COMMISSIONERS . PROPOSED MEETING AGENDA . DECEMBER