HomeMy WebLinkAboutAgenda Report - January 15, 2020 C-17AGENDA ITEM Co, -17
&IM CITY OF LODI
COUNCIL COMMUNICATION
• TM
AGENDA TITLE: Adopt Resolution Approving Renewal of Chiropractic Benefit Administration
Agreement with Landmark Healthplan of California; and Further Authorizing the City
Manager to Execute Agreement
MEETING DATE: January 15, 2020
SUBMITTED BY: Human Resources Manager
RECOMMENDED ACTION: Adopt resolution approving renewal of Chiropractic Benefit
Administration Agreement with Landmark Healthplan of California;
and further authorizing the City Manager to execute agreement.
BACKGROUND INFORMATION: The City of Lodi is contracted with Landmark Healthplan of California
to provide chiropractic services to the City's full-time employees. This
chiropractic plan is a stand alone policy separate from the City's
medical plans offered through CalPERS.
The term of this agreement shall begin on February 1, 2020 and continue in effect until January 31, 2021.
This contract shall automatically renew for successive one-year terms on each anniversary of the
commencement date of this Agreement. City may terminate this Agreement by providing Landmark
Healthplan with 30 calendar days' prior written notice.
FISCAL IMPACT: Annual cost of approximately $39,500.
FUNDING AVAILABLE: Included in Benefits Fund appropriations (65522000).
Ade a Post, Human Resources Manager
cww-,J?��
Andrew Keys, teputy City Manager/Internal Services Director
APPROVED:
Stephen Schwaba , City Manager
GROUP AGREEMENT BY AND BETWEEN
LANDMARK HEALTHPLAN OF CALIFORNIA, INC.
AND
City of Lodi
CHIROPRACTIC EXPANDED BENEFIT
COVER SHEET
In consideration of the prepayment of applicable fees by Group and receipt by Landmark of the Group Application
(which is mane a part of this Group Agreement by reference), Group hereby agrees to offer to its Members: Covered
Chiropractic Services.
Per'Qdic Charges. The monthly subscription fees ("premiums") for Plan membership are as follows:
Employee Only $4.44
Employee & One $8.91
Employee & Family $11.65
2. Group, or its designated agent, shall remit applicable periodic subscription fees in full on or before February 1,
2020 (the ")affective Date") for Nfembers cnrolled during the initial Open Enrollment Period. Thereafter, a Full monthly
subscription fee for each. Member, made in accordance with the provisions herein, shall be remitted before the first
business day of each month for which membership is effective. Subject to fee increases that may result pursuant to
Paragraph 3.06 of this Agreement, the monthly subscription fee schedule set forth above shall remain in effect for the
initial term of this Agreement as described below. Thereafi:er, the monthly subscription schedule shall be subject to
change from year to year. The parties hereby agree to Amendments for the standard payment provisions as follows:
3. The initial term of this Group Agreement is from February 1, 2020 through January 31, 2021. Thereafter, this
Agreement shall be automatically renewed annually, subject to the termination provisions herein.
4• E1W Group shall provide Plan with a description of its eligibility requirements prior to the
execution of this Agreement. The composition of Group and requirements determining eligibility for membership in
Group that exist at the Effective Date of this Agreement are material to the execution of this Agreement by flan. During
the term of this Agreement; no change in Group's eligibility or particiFyAtion requirements shall be permitted to affect
eligibility or Enrollment unless such change is agreed to by Plan pursuant to Amendments for this Agreement as specified
in Paragraph 6 of this Cover Sheet.
a) jar Employee Waiting Period. All new employees become eligible on the fust of the month following the
date of hire.
b) Employe-812onsored Medical Plan I nrollges. Only enrollees of the employer-sponsored medical plan are
eligible to enroll. Plan requires that all enrollees of the employer-sponsored medical plan enroll.
Effective Date of Cgyg; ,ane
a) Initial Onen Enrollment Period. The initial Open Enrollment Period will continence prior to the Effective
Date and continue up to thirty (30) calendar days thereafter for Subscribers and their eligible Dependents to enroll during
this initial Open Enrollment Period. Dependents must be eligible at the time of their Enroilmertt. Subsequent Open
Enrollment Periods shall occur on the anniversary date of the Group's Effective Date or upon a mutually agreeable date
designated by both parties.
b) nr n Ef£ Dat f ❑v eat T'im h an urin h en m n ri Any
person who becomes newly eligible at a time other than during the Open Enrollment Period (e.g., newborn, adopted child,
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new spouse or registered domestic partner, newly hired or newly transferred employee) shall have Coverage effective on
the date eligibility was obtained if the person enrolls within thirty (30) calendar days of becoming eligible and if payment of
the applicable prepayment fees and other provisions of this Agreement have been met.
c) Anyone failing to enroll during an Open Enrollment Period or within thirty (30) calendar days of becoming
newly eligible must wait to enroll during Group's subsequent periodic Open Enrollment Period, unless such individual
qualifies as a late enrollee pursuant to §§1376.50 of the California Health & Safety Code.
s. M I TI
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GROUP AGREEMENT BY AND BETWEEN
LANDMARK HEALTHPLAN OF CALIFORNIA, INC.
AND City of Lodi
CHIROPRACTIC EXPANDED BENEFIT
LANDMARK HEALTHPLAN OF CALIFORNIA, INC., a California Corporation, (hereinafter referred to as "Plan"),
and City of Lodi, the employer, association, labor union, trust, or other entity specified on the Cover Sheet (hereinafter
referred to as "Group"), agree as follows:
DECLARATIONS
Plan is a specialized health care service plan that arranges for the provision of Covered Chiropractic Services to persons
enrolled as Members on a prepaid and direct service basis through contracts with licensed Chiropractors. Group is an
employer, organization or association that desires to provide Covered Chiropractic Services for its eligible Subscribers and
their eligible Dependents (hereinafter referred to as "Members"). In consideration of the Group's application for the
benefits provided under this Agreement (a copy of which Application has been executed by Group and submitted to Plan
along with the applicable payments, and which is incorporated herein by reference) and the periodic payment of premiums
by Group to Plan on behalf of the Members, Plan agrees to arrange or provide for Covered Chiropractic Services subject
to all the terms and conditions of this Group Agreement.
DEFINITIONS:
1.01 "Chiropractor" means an individual who is licensed pursuant to the Chiropractic Act approved by the
electors on November 7, 1922, as amended, and who is qualified to render chiropractic services.
1.02 "COBRA" means the Federal "Consolidated Omnibus Budget Reconciliation Act" of 1985, P.L.
99-272, as amended.
1.03 "Combined Evidence of Coverage and Disclosure Form" means the summary of this Group Agree-
ment provided to the Member during Open Enrollment that sets forth the Coverage to which the Member is entitled. It
includes the Schedule of Benefits, and is attached as Exhibit A and incorporated herein.
1.04 "Coordination of Benefits" means a contractual provision that applies when a Member is covered
under more than one health insurance program. Such provision requires that payment of benefits be coordinated by all
programs to eliminate overinsurance or duplication of benefits.
1.05 "Co -payments" means fees payable pursuant to this Agreement by the Member to a Participating
Chiropractor at the time of the provision of Covered Chiropractic Services, which are in addition to the Plan Premiums
paid by Group. No Co -payment may exceed fifty percent (50°/") of the total cost of the service to the Plan..
1.06 "Coverage" means coverage under this Agreement pertaining to a Subscriber or Dependent.
1.07 "Covered Chiropractic Services" means those services within the scope of chiropractic care that are
supportive or necessary to help Members achieve the physical state enjoyed before an injury or illness. In addition, services
for preventive, maintenance, and wellness care for any mechanical neuromusculoskeletal condition are also covered.
Services need not be pre -authorized, will not be reviewed for Medical Necessity, and include the following: examinations,
manipulation, conjunctive physiotherapy, X-rays, and Emergency Services.
1.08 "Cover Sheet" means the Group Agreement Cover Sheet, which is incorporated into this Agreement.
1.09 "Customer Service Department" means the person or persons designated by Plan to whom oral and
written Member complaints may be addressed. The Customer Service Department may be contacted by telephone at
1-800-298-4875, or in writing at:
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Landmark Healthplan of California, Inc.
ATTN: Customer Service Department
2629 Townsgate Road, Suite 235
Westlake Village, CA 91361
1.10 "Dependent" means any spouse, registered domestic partner, or child (including a stepchild or legally
adopted child) of a Subscriber who is enrolled hereunder, who meets all the eligibility requirements set forth in Paragraph
2.03 and for whom applicable Plan Premiums are received by Plan.
1.11 "Eligibility Roster" means a database provided to Plan by Group on a monthly basis that contains a
list of all eligible Members for the applicable month.
1.12 "Emergency Services" means those services rendered for the sudden and unexpected onset of an
acute illness, extreme neuromusculoskeletal pain or accidental injury to the nervous, musculoskeletal and/or skeletal body
systems, that, in the reasonable judgment of the Member, requires immediate care, the delay of which could decrease the
likelihood of maximum recovery, and for which the Member seeks to secure chiropractic services immediately after the
onset, or as soon thereafter as practicable.
1.13 "Enrollment" means the execution of the Plan Enrollment Form by the Subscriber on behalf of the
Subscriber and his or her Dependents and acceptance thereof by Plan, conditional upon the execution of this Agreement
by Group and Plan and the timely payment of applicable Plan Premiums by Group.
1.14 "Exclusion" means specific conditions or circumstances set forth in the Schedule of Benefits, attached
as part of Exhibit for which the Plan will not provide Coverage or remit payment for services.
1.15 "Expanded Benefit" means coverage for chiropractic services that are supportive or necessary to help
Members achieve the physical state enjoyed before an injury or illness. In addition, services for preventive, maintenance,
and wellness care for any mechanical neuromusculoskeletal condition are also covered. Services need not be pre -authorized
and will not be reviewed for Medical Necessity.
1.16 "Grievance Procedure" means the procedure for reviewing Member complaints unrelated to the
quality or appropriateness of chiropractic services.
1.17 "Group" means the employer, association, labor union, trust, or other entity named on the Cover Sheet
that has elected Coverage for that group of Subscribers and their Dependents and is the contract holder.
1.18 "Group Agreement" means this Agreement between the employer group, association, labor union,
trust, or other entity specified and the Plan, including, but not limited to, the Cover Sheet, referenced attachments, and any
amendments hereto.
1.19 "Late Enrollee" means an eligible employee or dependent who has declined health coverage under a
health benefit plan offered through employment or sponsored by an employer at the time of the initial enrollment period
provided under the terms of the health benefit plan, and who subsequently requests enrollment in a health benefit plan of
that employer; provided that the initial enrollment period shall be a period of at least thirty (30) days.
1.20 "Limitation" means any provision other than an Exclusion that restricts Coverage under this Group
Agreement.
1.21 "Medically Necessary" means Chiropractic Services that are:
a) necessary for the treatment or diagnosis of neuromusculoskeletal disorders;
b) established as safe and effective and furnished in accordance with generally accepted chiropractic
standards to treat neuromusculoskeletal disorders in the most economically efficient manner that may be provided safely
and effectively to the Member, and not furnished primarily for the convenience of the Member, the Participating
Chiropractor, or other provider of service; and
c) appropriate for the symptoms, consistent with the diagnosis, and otherwise in accordance with
generally accepted chiropractic practice and professionally recognized standards.
1.22 "Medicare" means Title XVIII of the Social Security Act (Paragraphs 1801 et seq., 2142 U.S.C. C§ 1395
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et seq.), and all amendments thereto.
1.23 "Member" means any Subscriber or Dependent as defined in this Agreement.
1.24 "Neuromusculoskeletal' means conditions that display symptoms of and/or signs related to the
nervous, muscular and/or skeletal body systems.
1.25 "Non-Participating Chiropractor" means a chiropractor who is not under contract with Plan to pro-
vide Covered Chiropractic Services to Members.
1.26 "Open Enrollment Period" means the period agreed upon by Plan and Group during which all
eligible Group employees and their eligible Dependents may enroll in this Plan.
1.27 "Outside Service Area" means all geographic areas beyond the identified Service Area of Plan as
approved by the Director of the California Department of Managed Health Care.
1.28 "Participating Chiropractor" means a Chiropractor who has contracted with Plan to provide Covered
Chiropractic Services to Members at an agreed-upon compensation plus any applicable Co-payments as the total charge.
1.29 "Plan' means Landmark Healthplan of California, Inc., a California corporation licensed under the
Knox-Keene Health Care Service Plan Act of 1975, as amended, organized to provide chiropractic health care services.
1.30 "Plan Enrollment Packet" means the packet of information supplied by Plan to prospective
Subscribers that includes the Combined Evidence of Coverage and Disclosure Form summarizing this Agreement and
contains the Plan Enrollment Form.
1.31 "Plan Premiums" means amounts set forth in the Cover Sheet to be paid to Plan by Group on behalf
of Members in consideration of the benefits provided under this Plan.
1.32 "Prevailing Rates" means the rates generally prevailing in the Service Area for chiropractic and related
services, as determined by Plan.
1.33 "Quality Assurance Program" means the procedures and standards established and administered by
Plan to ensure that Covered Chiropractic Services rendered by a Participating Chiropractor comply with the professionally
recognized standards of chiropractic care.
1.34 "Schedule of Benefits" means the schedule of Covered Chiropractic Services that are provided to
Members. The Schedule of Benefits is included in the Combined Evidence of Coverage and Disclosure Form, attached as
i it and incorporated herein.
1.35 "Service Area" means the geographic area designated by Plan and approved by the Director of the
California Department of Managed Health Care within which Plan shall provide Covered Chiropractic Services.
1.36 "Subscriber" means the person who is responsible for payment to Plan or whose employment or other
status, except for family dependency, is the basis for eligibility in Plan. A Subscriber must meet all the applicable eligibility
requirements of this Agreement, and applicable Plan Premiums must have been received by Plan on behalf of the
Subscriber.
2.ENROLLMEN
2.01 Enrollment Procedure. Plan provides Covered Chiropractic Services to Members who meet the
eligibility requirements stated in this Agreement, who are properly enrolled in the Plan pursuant to this Agreement and
who are listed on the Eligibility Roster provided by Group. No services or benefits under this Agreement shall be
available to any person not specifically enrolled.
a) Plan Enrollment Form. A properly completed Plan Enrollment Form must be submitted to Plan
by Group for each Subscriber on behalf of the Subscriber and any Dependents.
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b) Time of Enrollment. All Plan Enrollment Forms shall be submitted by the applicant to Group
during Open Enrollment Periods, except as noted on the Cover Sheet of this !Agreement.
2.02 Subscriber Efigibili[y, Only Subscribers meeting the eligibility requirements may be enrolled in the Plan.
Loss of eligibility shall terminate Subscriber's membership in this Plan. Subscriber must meet each of the following
eligibility requirements:
a) Subscriber must permanently reside within the Service Area.
b) Subscriber must meet any eligibility requirements of Group for membership in this Plan.
2.03 Dependent ElioA Dependent's eligibility for Enrollment is contingent upon Subscriber's
eligibility for Enrollment in this Plan, i.e., a Dependent child of an eligible Subscriber who meets the eligibility
requirements set forth in Paragraph 2.02 may be enrolled as a Dependent of Subscriber.
a) Coverage for newborn children of Subscribers begins at birth. Coverage for adopted children of
Subscribers begins from the date physical custody of the child is obtained by Subscriber. Plan may require Subscriber to
present evidence that physical custody has been obtained, including, without limitation, adoption agency documentation.
In order for Coverage to continue beyond thirty-one (31) calendar days after the date of birth or, in the case of adoption,
thirty-one (31) calendar days past the date physical custody is obtained, a Plan Enrollment Form for the Dependent must
be submitted to Group within thirty-one (31) calendar days of the date of birth or in the case of adoption, the date physical
custody is obtained. Eligibility for an adopted child ends if the placement is interrupted before legal adoption and the child
is removed from the Subscriber's custody. Newborn care is not a covered benefit at any time if the Mother of the
newborn is a Dependent child of the Subscriber.
b) Dependent children are eligible up to the age of twenty-six (26) years.
c) Dependent unmarried children over the age of twenty-six (26) years who are incapable of self-
sustaining employment by reason of mental retardation or physical handicap and who are dependent upon Subscriber for
support and maintenance are eligible for continuing membership in this Plan, provided proof of such incapacity and
dependency is provided to Plan within thirty (30) calendar days of the child's attainment of the limiting age specified in
section b) above or on the Cover Sheet. Plan may periodically require proof of Dependent's incapacity and dependency,
but not more frequently than annually. Such proof shall consist of a written statement by a licensed psychologist,
psychiatrist, or other physician to the effect that such Dependent is incapable of self-sustaining employment by reason of
mental retardation or physical handicap.
d) An application to enroll Dependents who become Dependents as a result of marriage to a
Subscriber must be made within thirty (30) calendar days of the date of marriage. An application to enroll Dependents
who become Dependents as a result of registration of domestic partnership with a Subscriber must be made within thirty
(30) calendar days of the date a valid Declaration of Domestic Partnership is filed with the California Secretary of State, or
an equivalent document is issued by a local agency of California, another state, or a local agency of another state under
which the partnership was created.
2.04 Commencement of Coverage. Coverage shall commence on the date Plan accepts Subscriber's Plan
Enrollment Form and verifies the s eligibility of Subscriber and his/her Dependents through the Eligibility Roster from
Group. Plan's acceptance of Subscriber's Plan Enrollment Form is contingent upon receipt of the applicable Plan
premium payment.
2.05 Member's Eligibility Not Affected 4 €Icalth Status. A Member otherwise eligible and duly enrolled
hereunder shall not be terminated from this Plan due to the Member's health status or need for chiropractic services.
3. GROUP OBLIGATIONS. NOTICES, AND PLAN PREMIUMS
3.01 Non -Discrimination. Group shall allow Plan to market its chiropractic benefit to Group's employees
and shall offer Group's employees an opportunity to enroll in this Plan under no less favorable terms or conditions than
Group offers enrollment in other Health Care Service Plans or Employee Health Benefit Plans. Group shall provide a
payroll deduction plan comparable to that made available to any alternative health benefits plan or insurance coverage
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offered by Group.
3.02 Notices to Plan. Group shall forward all completed or amended Plan Enrollment Forms to Plan for
processing within thirty (30) calendar days after Group receives the Forms from Subscribers . Group acknowledges that
any Plan Enrollment Forms not forwarded to Plan within thirty (30) calendar days may be rejected by Plan. Group shall
forward all notices of termination to Plan within thirty (30) calendar days after Member loses eligibility or elects to
terminate membership under this Agreement. Group shall be responsible for any Member Plan Premiums through the last
day of the month in which notice of termination is received by Plan. Group shall also submit to Plan on or before the first
(1st) Friday of each month a listing of additions and deletions to the Eligibility Roster..
3.03 Notices to Member.
a. Termination. In the event of termination of this Agreement pursuant to Paragraph 9.02 herein, Group shall
promptly notify all Members enrolled through Group of the termination of their membership in this Plan. Group shall
provide such notice by delivering to each Member a true, legible copy of the Notice of Cancellation sent from Plan to
Group at the Members last known address. Group shall promptly provide Plan with proof of that mailing and the date
thereof. The notice of cancellation shall include information regarding the conversion rights of persons covered under the
Plan contract upon termination of such contract.
b. Other Notices. In the event an increase in Co -payments or premiums or a reduction in the benefits provided
under this Agreement occurs for any reason, Group shall provide its notice to its Members of such Co -payment or
premium increase or benefit reduction within thirty (30) calendar days of Group's receipt of such notice from Plan. In the
event of any regulatory changes, Group shall provide notice to its Members, as applicable, within thirty (30) calendar days
of receipt of such regulatory changes that may affect how Group operates. Group acknowledges that the Plan may send
notices to Group of the impact that state-wide emergencies may have on Plan operations. Group agrees to promptly notify
its Members of such operational changes. Plan shall have no responsibility to Members in the event Group fails to provide
the notices required by this Paragraph 3.03.
3.04 Rates. Plan shall provide benefits for each validly enrolled Member for which Plan Premiums are
received by Plan. The rates for Plan membership are set forth in the Periodic Charges section of the Cover Sheet. Subject
to Plan minimums, Group shall determine the applicability of any employee contribution toward Plan Premiums for
membership in this Plan.
3.05 Due Date. Plan Premiums are due on a monthly basis and shall be paid directly by Group to Plan on or
before the first (1st) business day of the month of Coverage for which Covered Chiropractic Services are provided.
3.06 Modification of Rgtes and Bgncfits. The Plan Premium rates set forth in the Periodic Charges section
of the Cover Sheet, and benefits set forth in Exhibit A and in the Plan Enrollment Packet may be modified by Plan in its
sole discretion upon thirty (30) calendar days' written notice mailed postage prepaid to Group. Any such modification
shall take effect commencing the first full month following the expiration of the thirty- (30) calendar -day notice period.
Notwithstanding the above, if the State of California or any other taxing authority imposes upon Plan a tax or license fee
that is levied upon or measured by the monthly amount of Plan Premiums or by Plan's gross receipts or any portions of
either, then upon thirty (30) calendar days' written notice to Group, Group shallremit to Plan with the appropriate
payment, a pro rata amount sufficient to cover all such taxes and license fees rounded to the nearest cent.
The terms and benefits set forth in this Plan may be amended or modified without the consent of a
Member if such amendments or modifications are required by law. Written notice of such amendments or modifications
must be given to Member by Plan at least thirty (30) calendar days prior to the effective date of such amendment or
modification.
3.07 INymcnm Made in lirrQg, Should Plan pay any fees for services that were not authorized by Plan under
this Agreement or that were not provided as Emergency Services, Member shall reimburse Plan for such payment. Failure
to reimburse Plan or reach reasonable accommodations with Plan concerning repayment within fifteen (15) calendar days
after Plan's request for reimbursement shall be grounds for termination of Members membership pursuant to
Subparagraph 10.01(a) of this Agreement. The exercise of Plan's right to terminate this Agreement shall not affect Plan's
right to reimbursement from Member.
3.08 Ef[e_aLof_Pavment. Except as otherwise provided in this Agreement, Covered Chiropractic Services
shall only be provided to Members during the period in which Member's Plan Premiums are paid. Member will be billed
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for Coverage for the first month of Coverage for newborn or adopted children eligible as provided in Subparagraph
2.03(a).
3.09 Notice Prattitioner Termination. If Plan determines a Group may be adversely or materially affected
by the termination of, or material breach by, a Participating Chiropractor, or a Participating Chiropractor is unable to
perform under this Agreement, Plan shall provide written notice to Group within thirty (30) calendar days. In the event
any of Plan's Agreements with its Participating Chiropractors terminates, Plan shall remain liable for payment of Covered
Chiropractic Services rendered to Members under such Chiropractors care at the time of termination, until such services
are completed or until Plan makes reasonable and medically appropriate provisions for the assumption of Covered
Chiropractic Services by another Participating Chiropractor.
:�;jDf►! CIdf.`R�►aHIKi7>•h7iit[i7�Pr?
4.01 Conditions for Coverage. Unless stated otherwise, the benefits and services described herein are
covered benefits only if and to the extent they are provided, prescribed, referred to or approved by, and obtained from
Participating Chiropractors. For other than Emergency Services , Plan will not pay charges incurred by a Member for
services by Non -Participating Chiropractors unless authorized by the Plan. Whenever the determination of a Member's
entitlement to a benefit is based on the need for Emergency Services, Plan shall have final authority governing such
determination. Plan shall govern all other benefits determinations provided that such determinations are consistent with
professional standards of practice and all terms and conditions of Coverage set forth in the Combined Evidence of
Coverage and Disclosure Form.
4.02 I-enefits. Subject to the terms, conditions, exclusions, and limitations set forth herein, upon receipt by
Plan of all applicable monthly Plan Premium payments, all eligible Members shall be entitled to Covered Chiropractic
Services described in the Combined Evidence of Coverage and Disclosure Form, including the Schedule of Benefits, both
of which are attached hereto as ExhibitA and incorporated herein by this reference.
4.03 Member Obligations. Subscriber shall submit to Plan a complete Plan Enrollment Form and/or other
forms or statements as Plan may reasonably request. Subscriber agrees to promptly notify Plan or Group of any changes
in the information submitted in the Plan Enrollment Packet. Subscriber warrants to the best of his or her knowledge that
all information contained in such application, forms and statements is true and complete, and agrees that all rights to
benefits under this Agreement are subject to the condition that all such information is true and complete.
The Member or Chiropractor may decide to refuse the relationship at any time when allowed by
chiropractic ethics and contract. If a Member wishes to change Participating Chiropractors, he or she can consult the Plan
Practitioner Directory available through his/her Group, Plan Administrator, or Plan's Customer Service Department by
telephone at 1-800-298-4875, or in writing at:
Landmark Healthplan of California, Inc.
ATTN: Customer Service Department
2629 Townsgate Road, Suite 235
Westlake Village, CA 91361
4.04 Claims. The Member is not responsible for submitting claims to Plan for Covered Chiropractic
Services, except for claims for Emergency Services rendered by a Non -Participating Chiropractor. The Participating
Chiropractor is responsible for submitting all other claims to Plan. Additionally, Members should be aware that
Participating Chiropractors cannot balance -bill Members for Covered Chiropractic Services.
4.05 Co-pgymcnts. When applicable, Co -payments must be paid by Member at the time Covered
Chiropractic Services are rendered. Failure to pay a Co -payment may result in termination of Member's Coverage under
this Plan. Applicable Co -payments for services rendered to Member are set forth in the Schedule of Benefits, attached
hereto as part of FAhibit A.
4.06 Payment for Non-Cyyered Scrvires_ Plan or the Participating Chiropractor may collect directly from
the Member for non -covered services or for services rendered due to fraud or deception by Member.
4.07 Finagcacy S�crvlces. Plan shall only cover Emergency Services as defined in Section 1.12 of this
Agreement. Emergency Services may be provided without pre -authorization from Plan. If Plan decides that the
professional services rendered to Member by a Non -Participating Chiropractor fail to meet Emergency Services guidelines,
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Plan shall have no responsibility to cover such services. Plan may elect to transfer Member to a Participating Chiropractor
if such transfer would not create an unreasonable risk to Member's health.
4.08 DAembees Liability_to_Non-Pgrtigipating-Chiropractors. In the event Member obtains services from a
Non -Participating Chiropractor and Plan fails to pay such practitioner, the Member may be liable to the Non -Participating
Chiropractor for the costs of services rendered unless such visit had the prior approval of the Plan or services were
rendered as Emergency Services.
LIMITATION ON BENEFITS
5.01 Acts Beyond Plan's Control. In the event of circumstances not reasonably within Plan's control, such as
any major disaster, epidemic, earthquakes, complete or partial destruction of Plan, war, riot, or civil insurrection that results
in the unavailability of Plan's personnel or the Participating Chiropractors, Plan and Participating Chiropractors shall
provide or attempt to arrange for Covered Chiropractic Services insofar as practical, according to their best judgment and
within the personnel limitation of Plan and Participating Chiropractors. Neither Plan nor any Participating Chiropractor
shall have any liability or obligation for the delay or failure to provide or arrange for Covered Chiropractic Services if such
delay or failure is the result of any of the circumstances described above.
5.02 Inabili to Provide Chiropractic Serrviees. In the event that Plan is unable, for any reason beyond its
control, to provide Covered Chiropractic Services, then Plan shall be liable for reimbursement of the expenses necessarily
incurred by any Member in procuring the services through Non -Participating Chiropractors, to the extent required by the
Director of the California Department of Managed Health Care.
5.03 SecondaryCoverage. If any benefits to which a Member is entitled under this Agreement are also
covered under another Health Benefits Plan or group insurance policy, the payable benefits hereunder shall be reduced to
the extent that benefits are available to Member under such other group plan or policy, whether or not a claim is made for
the same.
6. PARTIES AFFECTED BY THIS AGREEMENT: RELATIONSHIPS BETWEEN PARTIES
6.01 11 gml&r Nan -Liability. In the event Plan fails to pay a Participating Chiropractor for a Covered Chiro-
practic Service as set forth in Exhibit A, a Member shall not be liable to the Participating Chiropractor for any sums owed
by Plan.
6.02 ParticipatingChiWacLors_Are Indrp&ndent Contractors. Plan and its Participating Chiropractors are
independent contractors. None of the Participating Chiropractors or their employees or agents are employees or agents of
Plan, and none of Plan's employees or agents are employees or agents of any Participating Chiropractor.
6.03 Relationship of Parties to this Agreement. Group is not the agent or representative of Plan.
Accordingly, Group shall not be liable for any acts or omissions of Plan, its agents or employees, or independent
contractors, or any other person or organization with which Plan has made, or hereafter shall make, arrangements for the
performance of services under this Plan. Member is not the agent or representative of Plan and shall not be liable for any
acts or omissions of Plan, its agents or employees.
GRIEVANCE PROCEDURI AND DISPUTE RESOI_U'I'ION
7.01-Nlember Grievance Resolution System. A Member Grievance Resolution System has been established
by Plan for the receipt, processing, review and resolution of Member complaints, grievances and appeals. The Member
Grievance Resolution Procedure is described in the Combined Evidence of Coverage and Disclosure form, attached as
Exhibit A and incorporated herein. Member is bound to comply with the Member Grievance Resolution System
procedures. Subject to the Member right of appeal therein, Member shall be bound by any decisions reached under the
Member Grievance Resolution System. The Member Grievance Resolution System shall not be amended except upon
thirty (30) calendar days' advance written notification to the Member. All complaints, grievances and appeals will be
appropriately logged, retained in a confidential manner, and routinely monitored by authorized Plan staff.
7.02 Member Claims Againg-Earticipating Chiropractors. Member acknowledges that Plan's Participating
Chiropractors are independent contractors and that Plan does not assume responsibility for the acts of its contracting
Participating Chiropractors as such. Member claims for damages as a result of an injury caused or alleged to have been
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June 2019 gv
caused by an act or failure to act by a Participating Chiropractor are not governed by this Agreement. Upon mutual
agreement between the Member and Participating Chiropractor, Plan agrees to make available the Member Grievance
Resolution Procedure for resolution of disputes not governed by this Agreement.
In such instance, the decisions of Plan's Director of Chiropractic Services, Plan's President and the
Board of Directors shall not be binding upon the parties except upon agreement between the parties. Such grievance shall
not be subject to binding arbitration, except upon agreement between the parties. Member may also seek appropriate legal
action against such Participating Chiropractor.
7.03 Disputes Between Plan and Group. All disputes between Plan and Group shall be resolved by binding
arbitration before the American Arbitration Association. Upon submission of a dispute to the American Arbitration
Association, Plan and Group agree to be bound by the Commercial Rules of Procedure and decision of the American
Arbitration Association. The California Code of Civil Procedures Paragraph 1283.05, permitting the use of depositions
and other discovery methods, shall be incorporated into and made applicable to this Agreement.
8. TERM OF AGREEMENT: AUTOMX11C RENEWAL.
8.01 Term: Automatic Renewal. The term of this Agreement shall be one (1) year commencing on the date
of execution, unless otherwise indicated on the Cover Sheet. This Agreement shall automatically renew for successive one -
(1) year terms on each anniversary of the commencement date of this Agreement, or as indicated on the Cover Sheet,
unless terminated as provided herein.
TERMINATION E—GROUP COVERAQ
9.01 Vermination by Group. Group may terminate this Agreement by providing Plan with thirty (30)
calendar days' prior written notice. Until this Agreement terminates, Group shall continue to be liable for Plan Premiums
for all of its enrolled Members.
9.02 7krminadon by Plan
a) Nonpayment of Plan Premiums. In the event Group or its designee fails to remit Plan Premiums
to Plan by the date required, Plan may terminate this Agreement. A written notice of such termination shall be provided to
Group and will specify that payment of all unpaid Plan Premiums must be received by Plan within fifteen (15) calendar
days of the date of receipt of the notice and that if payment is not received within the fifteen- (15) calendar -day period, no
further notice shall be given and Coverage for all Members enrolled in this Plan shall terminate effective at the end of the
month for which premiums were actually received by Plan. Reinstatement of this Agreement may occur only through
execution of a new Group Agreement and submission of a new Plan Enrollment Form for each Subscriber in accordance
with current eligibility and Enrollment requirements. Group shallremain liable for any unpaid Plan Premiums due prior to
the effective date of Group termination.
b) Breach of HateciaLTerm Plan may terminate this Agreement if Group breaches any material term,
covenant or condition of this Agreement and fails to cure such breach within thirty (30) calendar days of receiving written
notice of such breach from Plan. Plan's written notice of breach shall specify Group's action causing such breach. Should
Group fail to cure its breach to Plan's satisfaction within thirty (30) calendar days of receiving Plan's notice of the breach,
Plan may terminate this Agreement at that time.
c) Providing Misigaffigg or FraudulenLlafoicmafiomPlan may terminate this Agreement upon thirty
(30) calendar days' written notice to Group in the event Group provides misleading or fraudulent information to Plan.
Provision of misleading or fraudulent information includes information in any Group questionnaires or Plan Enrollment
Forms.
d) iness. If Group materially alters the nature of its business, Plan
may terminate Group upon thirty (30) calendar days' written notice. "Materially Alters" means a significant change in the
business conduct by Group after commencement of this Agreement.
e) Without Cause. Plan may terminate this Agreement on ninety (90) days written notice to Group as
permitted under California law.
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9.03 Proration of Plan Premiums. Any portion of the Plan Premium received by Plan or payable to Plan
corresponding to any unexpired full month for which payment is received or is payable, shall be prorated and returned by
the owing party together with any other amounts due, less any offsets.
10. TERMINATION OF 1vIEM13I:•:RSI HP
10.01 Termination. The rights of Members under this Agreement shall terminate upon occurrence of any of
the following:
a) Nonpayment of Plan Premiums/Co-payments or Fees for Nan -Covered Services. Upon fifteen
(15) calendar days' written notice, Plan may disenroll any Member from Plan if applicable Plan premiums, prepaid
payments or Co -payments are not paid. Such notice shall state that the receipt by Plan of the applicable Plan Premium or
Co -payments within fifteen (15) calendar days shall cause Plan to revoke the notice. The notice of termination shall be
revoked and membership in this Plan shall continue without interruption upon the receipt of the applicable Plan premium.
The failure of any Member to reimburse Plan for payments made in error by Plan within fifteen
(15) days after the mailing of written notice of termination for nonpayment by Plan, or to reach reasonable
accommodations with Plan regarding repayment shall result in the termination of Member's Enrollment in this Plan. To
reinstate Coverage, Member must submit a new Plan Enrollment Form and comply with all applicable eligibility
requirements.
b) 'Termination of Agreement by Gm*. In the event Group voluntarily terminates this Agreement
pursuant to Paragraph 9.01 of this Agreement, Member's membership in this Plan shall terminate at the end of the month
for which the last Plan Premium is received by Plan from Group on Members behalf.
c) Member Permanendy Moves Out of Servigg Area. Members Enrollment in this Plan shall
terminate in the event that either: (i) Member is absent from the Service Area for ninety (90) consecutive days, or (ii)
Member moves from the Service Area without the intent to return. Member shall notify Plan of his or her permanent
move from the Service Area within thirty (30) calendar days. Termination shall be effective the last day of the month in
which Member receives notice of termination from Plan. Notice sent to Members last known address shall be deemed
effective notice for purposes hereunder.
d) Nlembq?s Lass of Eligibility, Members Enrollment in this Plan shall terminate on the last day of
the month in which Member's eligibility ceases. Continuation of benefits is available to Member as set forth in Paragraph
11.
i) Dluplution of Subscriber's Magriage or Registyred Domestic Partnership,D
U4gibiliLy. A Dependent spouse's membership as a Dependent of Subscriber shall terminate on the first day of the month
following the month in which a final judgment or decree of dissolution of marriage is entered by the court. A Dependent
registered domestic partner's membership as a Dependent of Subscriber shall terminate on the first day of the month
following the month in which a final judgment or decree of dissolution of the partnership is entered by the court.
ii) A Dependent child's membership in this Plan shall continue notwithstanding dissolution of
Subscriber's marriage for as long as Dependent's child remains eligible pursuant to Paragraph 2.03 of this Agreement and
Plan receives Plan Premiums.
e) Member Fraud or Decentinn. A Member's membership in this Plan shall immediately terminate if
such Member knowingly provides Plan with fraudulent information upon which Plan relies and that materially affects
Member's eligibility for Enrollment or benefits under this Plan. In the event of Member fraud or deception, Plan shall
mail a written notice of termination to Member.
f) Member Assists_Another to Improperl}' Obtain Benefits, A Member's Enrollment in this Plan shall
terminate immediately if such Member assists a person who is not a Member to obtain benefits under this Plan. In such
instance, Plan shall mail a written notice of termination to the Member.
g) Disenrolment for Cause. Disenrollment of a Member may occur if a Member's conduct is unduly
disruptive or injurious to the Participating Chiropractor/patient relationship, so that Members treatment suffers as a
result. Disenrollment for cause shall be effective on the first (1st) day of the calendar month following the month in which
notice of disenrollment is given to the Member.
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h) Yoluatarn Disenrollment by ;4lember. A Member may voluntarily disenroll by submitting a written
request for disenrollment to Group, as determined by Group. Group shall forward all disenrollment requests to Plan for
processing. Group shall be responsible for any Member premiums through the last day of the month in which notice of
disenrollment is received by Plan.
10.02 Written Notice of Termination. When a written notice of termination is sent to the Member pursuant
to this Agreement, it shall be dated and state:
a) The cause of termination with specific reference to the Paragraph of this Agreement giving rise to
the right of termination;
ices;
b) The cause for termination was not the Member's health status or requirements for health care serv-
c) The effective date of termination; and
d) Notwithstanding the Member Grievance Resolution Procedure set forth in Paragraph 7.01 of this
Agreement, Member may request a review before the Director of the Department of Managed Health Care for the State of
California, if Member believes that his or her Plan membership was terminated as a result of Member's health status or
requirements for health care services.
10.03 Non -Liability After Termination, Upon termination of this Agreement for any reason, Plan shall have
no further liability to provide benefits to any Member, including, without limitation, those Members undergoing treatment
for an ongoing condition. Member's right to receive benefits hereunder shall cease upon the effective date of termination.
11
11.01 Condnuation of Benefits Under COBRA. Plan shall make available continuation Coverage under this
Plan to Members entitled to continuation; provided that Group notifies Plan that such Coverage is desired and the
Coverage is required under federal or state law, including "COBRA". The continuation Coverage under this Paragraph
shall be equal to, and subject to the same limitations as, the benefits provided to other Members enrolled by Group in this
Plan. Group agrees to forward to Plan in a timely manner copies of any notice regarding continuation of group Coverage
provided to eligible employees and/or their Dependents.
11.02 "Cal -COBRA." The California CONTINUATION BENEFITS REPLACEMENT ACT, or "Cal -
COBRA," requires that a Group with fewer than twenty (20) eligible Employees on at least 50% of its working days during
the preceding calendar year, or, if the Group was not in business during any part of the preceding calendar year, employed
2 to 19 eligible employees on at least 50% of its working days during the preceding calendar quarter, offer eligible
Employees and their families the opportunity for a temporary extension of Coverage (called "continuation of Coverage")
in certain instances where Coverage under the plan would otherwise end. Therefore, if Group meets the above conditions,
then the Parties agree to implement the provisions of Exhibit B, a copy of which is attached and made a part of this
Agreement.
12. CONVERSION
12.01 Subscriber Conversion EiEs*gc. In the event the Subscriber ceases Coverage under this Agreement
solely as a result of leaving Group, then Subscriber may within thirty (30) calendar days following termination of Coverage,
convert his/her membership to non -Group membership for himself/herself and his or her enrolled Dependents regardless
of health status or requirements for Covered Chiropractic Services.
12.02 Depgndent Spouse zLE gjsteted, Dgmutic Partner Conversion Privilege. In the event the Dependent
spouse or registered domestic partner of the Subscriber ceases
to be covered under this Agreement as a result of the termination of the marriage or domestic partnership or Subscriber's
death, Dependent spouse or registered domestic partner shall have the privilege of converting to a non -Group
membership agreement if application for such Coverage is made within thirty (30) calendar days of termination of the
marriage or domestic partnership or the Subscriber's death, whichever is applicable.
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12.03 Dep.Qndcnt Chfld Conversion Privilege. In the event Subscriber's Dependent child ceases to be covered
under this Agreement solely due to child's attainment of the limiting age for eligible Dependent children as specified in this
Agreement, such child shall have the privilege of converting to a non -Group membership agreement under the same
conditions as would apply to the Subscriber were he or she leaving the Group, if such application is made within thirty (30)
calendar days of the Dependent child's attainment of the limiting age.
12.04 Terms of Conversion. Member shall convert his or her membership in accordance with such rules and
regulations governing conversions under a non -Group membership agreement, as Plan may have in effect prior to the time
of the application for conversion.
13. THIRD -PARTY LIABILITY
13.01 'Third -Party Liability. In the case of injuries caused by a third party's act or omission and any incidental
complications, Plan shall furnish the benefits of this Agreement to Member. Immediately upon obtaining a monetary
recovery, Member agrees to reimburse Plan, or its nominee, for the cost of such services and benefits rendered on account
of such injury. Member shall hold any such sum in trust for Plan, but said sum shall not exceed the costs incurred in
perfecting the lien and the lesser of (1) (a) one-half of the total judgment or settlement, if the Member did not engage an
attorney or (b) one-third of the total judgment or settlement, if the Member engaged an attorney; or (2) the amount
actually paid by Plan to the Provider. Plan does not delegate to providers Plan's lien rights.
a) Member agrees that Plan's reimbursement under this Paragraph 13.01 is the first -priority claim
against any third party. Thus, Plan shall be reimbursed from any recovery from a third party before payment of any other
existing claims are made, including any claim by the Member for general damages. Plan may collect from the proceeds of
any settlement of judgment recovered by Member or his or her legal representative regardless of whether the Member has
been fully compensated.
b) Member agrees to cooperate in protecting Plan's interests under this provision. Member shall
execute and deliver to Plan or its nominee any and all liens, assignments or other documents that may be necessary or
proper to protect Plan's rights, or its nominee, including, but not limited to the granting of a lien right in any claim or
action made or filed on Member's behalf and the signing of documents evidencing the same.
c) Member shall not settle any claim or release any person from liability without Plan's prior written
consent if such release or settlement will extinguish or bar Plan's rights of reimbursement.
d) In the event Plan employs an attorney for the purpose of enforcing any part of this section against a
Member based upon Member's failure to cooperate with Plan, the prevailing party in any legal action or proceeding shall be
entitled to reasonable attorney's fees.
e) In lieu of payment as indicated above, Plan, at its option, may choose to be subrogated to the
Member's rights to the extent of the benefits received under this Plan. Plan's subrogation right shall include the right to
bring suit in the Member's name. Member shall fully cooperate with Plan when Plan exercises its subrogation right and
Member shall not take any action or refuse to take any action that would prejudice the rights of Plan under this Paragraph
13.01.
14. NON -DUPLICATION OF ENE?I''ITSICOORDINATION -0�rN I I I'S,.
14.01 Workers' Compensation. Plan shall not furnish benefits under this Agreement to any Member that
duplicate the benefits to which any Member is entitled under any applicable Workers' Compensation law. Member is
responsible for taking whatever action is necessary to obtain payment under Workers' Compensation laws where payment
under that system can be reasonably expected. Member's failure to take proper and timely action under such
circumstances will preclude Plan from responsibility for furnishing such benefits to such Member to the extent that
payment of such benefits could have been reasonably expected under Workers' Compensation laws had action been taken.
a) In the event Plan, for any reason, provides benefits that duplicate the benefits to which Member is
entitled under Workers' Compensation law, Member agrees to reimburse Plan or its nominee for the cost of all such serv-
ices and benefits provided by Plan. Reimbursement shall be made at Prevailing Rates immediately upon obtaining a
monetary recovery, whether due to settlement or judgment. Member shall hold any sum collected as the result of a
Workers' Compensation action in trust for Plan. Such sum shall not exceed the lesser of the amount of the recovery
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obtained by the Member or the reasonable value of all services and benefits furnished to Member or on Member's behalf
by Plan on account of each incident.
b) Member agrees to cooperate in protecting Plan's interests under this provision. Member must
execute and deliver to Plan or its nominee any and all liens, assignments, or other documents that may be necessary or
proper to protect Plan's rights, or its nominee, including, but not limited to, the granting of a lien right in any claire or
action made or filed on Member's behalf and the signing of any documents evidencing such lien. Member's failure to
cooperate reasonably with Plan as provided herein may result in such Member's termination from this Plan.
14.02 Medicare Benefits. Upon Plan's request, Member shall furnish information to Plan concerning
Member's eligibility for Medicare (Part A and/or Part B Coverage). If a Member is eligible to enroll in Medicare, Plan shall
furnish benefits under this Agreement on Member's behalf in accordance with federal law and regulation, regardless of
whether or not Member has actually enrolled in Medicare. Should the cost of Chiropractic Services exceed the coverage of
any applicable Medicare coverage, Plan benefits shall be provided over and above such coverage.
a) If Plan's payment duplicates the Medicare benefits available to Member, Plan may seek
reimbursement from the insurance carrier, practitioner or Member up to the amount Plan has paid for benefits that
duplicate Medicare coverage.
14.03 CHAMPUS Benefits. Members shall furnish Plan with information concerning any applicable benefits
from the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) to which Members may be
entitled, upon request by Plan. Plan shall not furnish benefits under this Agreement that duplicate CHAMPUS benefits to
which Member is entitled.
a) If Plan's payment duplicates CHAMPUS benefits available to Member, Plan may seek
reimbursement up to the amount Plan has paid for benefits that duplicate such CHAMPUS coverage.
14.04 Automobile. Accident or Liahiiity Coverage. Plan shall not furnish benefits under this Agreement that
duplicate the benefits to which a Member is entitled under any other automobile, accident or liability coverage. Member is
responsible for taking the necessary action to obtain benefits of such coverage and shall notify Plan of such coverage. If
payment or services are provided by Plan in duplication of the benefits available to Member under other automobile,
accident or liability coverage, Plan may seek reimbursement to the extent of the reasonable value of the benefits provided
by Plan from the insurance carrier, practitioner and Member.
a) Should the cost of Covered Chiropractic Services exceed any other applicable coverage pursuant to
this Paragraph 14.04, Plan benefits shall be provided over and above such coverage.
14.05 CooidinaLi2n of Benefits, All benefits provided under this Plan are subject to Coordination of Benefits.
Coordination of Benefit rules shall be applied by Plan in accordance with the Coordination of Benefits regulations and
interpretive instructions promulgated by the California Department of Managed Health Care, as amended from time to
time, which are incorporated into this Agreement.
15. 'I�t. ISCT." L.WEOUS 29—OVISIONS
15.01 Qoverning Lay. This Agreement is subject to the laws of the State of California, specifically, the
Knox -Keene Health Care Service Plan Act of 1975, as amended, and the regulations promulgated thereunder by the
California Department of Managed Health Care. Any provisions required to be in this Agreement by any of the above
shall bind Plan, Group, Participating Chiropractors and Member whether or not expressly provided in this Agreement.
15.02 Use of Name in Promotional/MarketingMaterial& Plan reserves the right to control all use of its name,
symbols, trademarks, or service marks currently existing or later established. However, either party may use the other
party's name, symbols, trademarks or service marks with the prior written or verbal approval of the other party in
advertising or other promotional materials or information relating to this Agreement.
15.03 Assignment. This Agreement and the rights, interests, and benefits hereunder shall not be assigned,
transferred, pledged, or hypothecated in any way by either party and shall not be subject to execution, attachment or
similar process, nor shall the duties imposed herein be subcontracted or delegated without the approval of the other party.
Notwithstanding the above, if Plan assigns, sells, or otherwise transfers substantially all of its assets and business to
another corporation, firm, or person, with or without recourse, this Agreement will continue in full force and effect as if
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such corporation, firm, or person were a party to this Agreement, provided such corporation, firm, or person continues to
provide Covered Chiropractic Services.
15.04 Validity. The unenforceability or invalidity of any paragraph of this Agreement shall not affect the
enforceability and validity of the balance of this Agreement.
15.05 Confldentialii�z. Plan agrees to maintain and preserve the confidentiality of Member's medical records in
accordance with state and federal laws. However, a Member authorizes the release of information and access to Member's
medical records to Plan, its agents and employees, Member's Participating Chiropractor, and appropriate governmental
agencies for purposes of utilization review, quality assurance, processing of any claim, financial audit, Coordination of
Benefits, or for any other purpose reasonably related to the provision of benefits under this Agreement. When required by
law, Plan shall obtain Member's specific written authorization for the release of Members medical records. Plan shall not
release any information to Group that would directly or indirectly indicate to Group that a Member is receiving or has
received services under this Agreement, unless authorized to do so by the Member.
15.06 ,amendments. Except as otherwise provided herein, this Agreement may be modified or amended upon
the mutual written consent of the parties.
15.07 Attachments. Attachments referenced throughout this Agreement including the Cover Sheet are
incorporated herein and made an integral part of this Agreement.
15.08 -W iyer of Default. The waiver by Plan of any one or more defaults by Group or Member shall not be
construed as a waiver of any other defaults, or defaults that may occur in the future, under the same or different terms,
conditions or covenants contained in this Agreement.
15.09 Notice. Any notice required to be given to Group or Plan hereunder shall be in writing and sent by
registered or certified mail, return receipt requested, to either Group or Plan at the addresses listed below, or at such other
addresses as either Group or Plan may hereafter designate to the other:
To Plan: Landmark Healthplan of California, Inc.
ATTN: Chief Executive Officer
2629 Townsgate Road, Suite 235
Westlake Village, CA 91361
To Group: City of Lodi
ATTN: Adele Post
221 West Pine P.O. Box 3006
Lodi, CA 95241-1910
All notices shall be deemed given on the date of delivery if delivered personally or three (3) business
days after such notice is deposited in the United States mail, addressed and sent as provided above.
16. EXECUTION
16.01 Execution of agreement. Execution of this Agreement by the parties indicates their acceptance of the
terms, conditions and provisions stated herein. Member accepts the terms, conditions and provisions of this Agreement
upon completion and execution of the Plan Enrollment Form.
17
17.01 Disputes Between Group and. J.andmark. All disputes between Group and Landmark shall be resolved
by binding arbitration before JAMS, a non -judicial arbitration and mediation service. If the amount at issue is less than
$200,000, then the arbitrator will have no jurisdiction to award more than $200,000. The JAMS Comprehensive
Arbitration Rules and Procedures ("Rules") in effect at the time a demand for arbitration is made will be applied to the
arbitration. The parties will seek to mutually agree on the appointment of an arbitrator; however, if an agreement cannot
be reached within thirty (30) days following the date demanding arbitration, the parties will use the arbitrator appointment
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procedures in the Rules. Arbitration hearings will be held at the neutral administrator's offices in Sacramento County,
California or at another location agreed upon in writing by the parties. Civil discovery may be taken in such arbitration as
provided by California law and civil procedure. The arbitrator(s) selected will have the power to control the timing, scope,
and manner of the taking of discovery and will have the same powers to enforce the parties' respective duties concerning
discovery as would a Superior Court of California. This includes, but is not limited to, the imposition of sanctions. The
arbitrator(s) will have the power to grant all remedies provided by California law. The arbitrator(s) will prepare in writing
an award that includes the legal and factual reasons for the decision. The parties will divide equally the fees and expenses
of the arbitrator(s) and the neutral administrator. The arbitrator(s) will not have the power to commit errors of law or legal
reasoning, and the award may be vacated or corrected pursuant to California law. The Federal Arbitration Act, 9 U.S.C.
1-16, will also apply to the arbitration.
17.02 115pMtes Between Member and Landmark.
17.02.01 and Gricvances. The Landmark Combined Evidence of Coverage and
Disclosure Form attached hereto as Ex includes a complete description of the Landmark appeals and grievance
procedures and dispute resolution processes for Members.
17.02.02 Binjing Arbitration. Any and all disputes of any kind whatsoever, including claims relating to
the delivery of services under the Plan and claims of medical malpractice (that is as to whether any medical services
rendered under the health plan were unnecessary or unauthorized or were improperly, negligently, or incompetently
rendered), except for claims subject to ERISA, between Member (including any heirs, successors, or assigns of Member)
and Landmark shall be submitted to binding arbitration. Any such dispute will not be resolved by a lawsuit or resort to
court process, except as the Federal Arbitration Act provides for judicial review of arbitration proceedings. Member and
Landmark are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and are
instead accepting the use of binding arbitration by a single arbitrator in accordance with the Comprehensive Rules of
JAMS, and administration of the arbitration shall be performed by JAMS or such other arbitration service as the parties
may agree to in writing. The parties will endeavor to mutually agree to the appointment of the arbitrator, but if such
agreement cannot be reached within thirty (30) days following the date demand for arbitration is made, the arbitrator
appointment procedures in the Comprehensive Rules will be utilized.
Arbitration hearings shall be held in Sacramento County, California or at such other location as the
parties may agree to in writing. Civil discovery may be taken in such arbitration as provided by California law and the Code
of Civil Procedure. The arbitrator selected shall have the power to control the timing, scope, and manner of the taking of
discovery and shall further have the same powers to enforce the parties' respective duties concerning discovery as would a
Superior Court of California including, but not limited to, the imposition of sanctions. The arbitrator shall have the power
to grant all remedies provided by federal and California law. The parties shall divide equally the expenses of JAMS and the
arbitrator. In cases of extreme hardship, Landmark may assume all or part of the Member's share of the fees and expenses
of JAMS and the arbitrator, provided the Member submits a hardship application to JAMS. The approval or denial of the
hardship application will be determined solely by JAMS.
The arbitrator shall prepare in writing an award that includes the legal and factual reasons for the
decision. The requirement of binding arbitration shall not preclude a party from seeking a temporary restraining order or
preliminary injunction or other provisional remedies from a court with jurisdiction; however, any and all other claims or
causes of action including, but not limited to, those seeking damages, shall be subject to binding arbitration as provided
herein. The Federal Arbitration Act, 9 U.S.C. §§ 1-16, shall also apply to the arbitration.
17.03 Mandato Arl)itrtation. Group, Member, and Landmark agree and understand
that any and all disputes, including claims relating to the delivery of services under the Plan
and claims of medical malpractice (that is as to whether any medical services rendered under
the health plan were unnecessary or unauthorized or were improperly, negligently, or
incompetently rendered), except for claims subject to ERISA, shall be determined by
submission to binding arbitration in accordance with the terms of this Agreement. Any such
dispute will not be resolved by a lawsuit or resort to court process, except as the Federal
Arbitration Act provides for judicial review of arbitration proceedings. All parties to this
Agreement are giving up the constitutional right to have any such dispute decided in a court
of law before a jury, and instead are accepting the use of binding arbitration.
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June 2019 gv
IN WITNESS WHEREOF, the Parties have executed this !Agreement on the date set forth below.
LANDMARK HEALTHPLAN
OF CALIFORNIA, INC
2629 Townsgate Road, Suite 235
Westlake Village, CSA 91361
(800) 298-4875
Tax Identification Number: 68-0352158
George W. Vieth Jr.
Chief Executive Officer
Date: May 28, 2019
City of Lodi
221 West Pine P.O. Sox 3006
Lodi, CSA 95241-1910
By:
Print Name: SCJAWIl6,LLU-
Title:
CSG Lo-4.ka !�, e C
Date:
Approved as to Form:
1AWCE D. MAGD CH
City Attorney
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June 2019 gv
AMENDMENT to the GROUP AGREEMENT
between
City of Lodi
and
LANDMARK HEALTHPLAN OF CALIFORNIA, INC.
This Amendment dated December 17, 2019 is entered into by and between City of Lodi and Landmark
Healthplan of California, Inc. ("Plan"), collectively referred to herein as "Parties", in order to modify the
Group Agreement ("Agreement"), dated January 1, 2020 as amended.
In consideration of the recitals, covenants, conditions, and promises contained in the Agreement, the
Parties agree to modify the Agreement as follows:
1. Cover Sheet, Provision 3, is deleted in its entirety and replaced with the following:
"This agreement shall renew on February 1, 2020 and shall be automatically renewed annually, subject to
the termination provisions herein."
All other provisions of the Agreement, its Addenda or Amendments not inconsistent herein shall remain
in full force and effect.
This Amendment is hereby agreed to by the parties and effective on the date and year set forth above.
Please sign digitally and return via email or sign and fax to (916) 307-5250.
Signature
S h & aura ,e,�'
Print Name and Title
Approved as to Form:
JANICE D. MAGDICH
City Attorney
EXHIBIT A
SCHEDULE OF BENEFITS
Chiropractic Expanded Benefit
Your Employer Group has contracted with Landmark Healthplan of California, Inc. (Landmark) to provide
you with a chiropractic benefit that requires the use of Participating Chiropractors. You can obtain a direc-
tory of Participating Chiropractors through your employer, plan administrator, or Landmark, or you can
access a continuously updated directory on Landmark's Web site at www.LHP-CA.com under the "Mem-
ber" option. You may also call Landmark's Customer Service Department at 1-800-298-4875 for referrals
to Participating Practitioners in your area.
FREE LANGUAGE ASSISTANCE IS AVAILABLE
If you need help in understanding your Landmark chiropractic benefits or need help to handle an issue
about your benefits, please contact Landmark's Customer Service Department at 1-800-298-4875 be-
tween 5:30 AM and 5 Pm, Monday through Friday, for free help. We can also help you in languages other
than English.
If you or your dependents would like Landmark and your doctor to use a specific language when speaking
or writing to you, please go to https://www.LHP-CA.com/Survey.aspx on the Internet and complete Land-
mark's brief language preference survey. The survey only takes about 3 minutes to complete and your
answers will be strictly confidential. If you prefer to complete a paper copy of this survey, you may re-
quest one by writing to us at:
Landmark Healthplan of California, Inc.
Attn: QM Dept. -SURVEY
2629 Townsgate Rd Suite 235
Westlake Village, CA 91361
Benefits and Co -payments
Office Visit
$15 co -Payment
Maximum Annual Visits
12 visits
X-ray Services"
$75 annual maximum benefit
Emergency Care"
Same co- a ment as office visit
Durable Medical Equipment Purchase or Rental"""
$50 annual maximum benefit
"X --ray Services must be prescribed by a Participating Chiropractor.
*"Services provided by Non -Participating Chiropractors are covered for Emergency Services only.
'Durable Medical Equipment must be prescribed by a Participating Chiropractor.
A. Covered Services
1. Chiropractic Treatment
Covered Chiropractic Services are those within
the scope of chiropractic care that are suppor-
tive or necessary to help Members achieve the
physical state enjoyed before an injury or illness.
In addition, services for preventive, mainte-
nance, and wellness care for any mechanical
neuromusculoskeletal condition are also cov-
ered. Services need not be pre -authorized, will
not be reviewed for Medical Necessity, and in-
clude the following:
■ Examinations
■ Manipulation
Landmark Healthplan of California, Inc.. 1-800-298-4875
• Conjunctive Physiotherapy
■ X-rays
■ Emergency Services
2. Emergency Services
Emergency Services are covered for the sudden
and unexpected onset of an acute illness, ex-
treme neuromusculoskeletal pain or accidental
injury to the nervous, musculoskeletal and/or
skeletal body systems, that, in the reasonable
judgment of the Member, requires immediate
care, the delay of which could decrease the like-
lihood of maximum recovery, and for which the
Member seeks to secure chiropractic services
immediately after the onset, or as soon thereaf-
ter as practicable. Emergency Services do not
require pre -authorization; however, Emergency
Services rendered by a Non -Participating Chiro-
practor are subject to Landmark's determination
that the Member would reasonably have consid-
ered that Emergency Services were required.
Emergency Services rendered by a Non -Parti-
cipating Chiropractor are covered only when the
chiropractor rendering services can show that
the services were for a neuromusculoskeletal
condition and were provided to reduce the se-
verity of the condition including pain until a Par-
ticipating Chiropractor could safely assume
treatment. Similarly, Emergency Services re-
ceived outside of Landmark's Service Area will
be covered only when the Non -Participating Chi-
ropractor rendering services can show that the
services were for a neuromusculoskeletal condi-
tion and were provided to reduce the severity of
the condition including pain until a Participating
Chiropractor could safely assume treatment. Un-
der the Landmark Plan, emergency care must
be transferred to a Participating Chiropractor as
soon as such transfer would not create an un-
reasonable risk to the Member's health.
B. Second Opinions and Referrals
1. Second opinions
On occasion, a Participating Chiropractor may
require a second opinion, which is for consul-
tation only, from another chiropractor. Land-
mark does not require an authorization for any
second opinion. Second opinions initiated by
your Participating Chiropractor will not count
against your maximum annual visits and will
not require a Member office visit co -payment.
Second opinions initiated by Members do not
require prior authorization, but will count against
the maximum annual visits and will require a
Member office visit co -payment.
2. Referrals to non -chiropractic practitioners
For referrals to non -chiropractic practitioners,
Members or enrollees of full-service plans or
HMOs will be referred to the plan or HMO practi-
tioner network for non -neuromusculoskeletal
conditions, conditions not improving with chiro-
practic care, and other such services that cannot
be provided by another Participating Chiroprac-
tor.
C. Limitations and Exclusions
Circumstances Causing Services to be
Excluded or Limited
1. Services provided by a Non -Participating
Chiropractor, except for emergencies
2. Services provided outside of Landmark's
Service Area, except for emergencies
3. Services incurred prior to the beginning or
after the end of coverage
4. Services that exceed the maximum covered
visits for the benefit year
5. X-ray services that exceed the annual max-
imum benefit
6. Charges incurred for missed appointments
7. Educational programs
8. Pre-employment, school entrance, or athlet-
ic physical exams
9. Services for conditions arising out of em-
ployment, including self-employment or cov-
ered under any workers' compensation act
or law
10. Services for any bodily injury arising from or
sustained in an automobile accident that is
covered under an automobile insurance pol-
icy
11. Charges for which the Member is not legally
required to pay
12. Services rendered by a person who ordinari-
ly resides in the Member's home or who is
related to the Member by marriage or blood.
Specific Services that are Excluded or
Limited
1. Drugs, vitamins, nutritional supplements, or
herbs
2. Experimental or investigational services
3. Vocational, stroke, or long-term rehabilita-
tion
4. Hypnotherapy, behavior training, sleep ther-
apy, or biofeedback
5. Rental or purchase of Durable Medical
Equipment (DME)
6. Treatment primarily for purposes of weight
control
7. Lab services
8. Thermography, hair analysis, heavy metal
screening, or mineral studies
9. Transportation costs, including ambulance
charges
10. Inpatient services
11. Massage or soft-tissue techniques
12. Manipulation under anesthesia
13. Services related to diagnosis and treatment
of jaw joint or TMJ disorders
14. Treatment of non -neuromusculoskeletal dis-
orders
15. Advanced diagnostic services, such as MRI,
CT, EMG, SEMG, and NCV
Landmark Healthplan of California, Inc. ■ 1-800-298-4875 2
RESOLUTION NO. 2020-12
A RESOLUTION OF THE LODI CITY COUNCIL APPROVING
RENEWAL OF CHIROPRACTIC BENEFIT ADMINISTRATION
AGREEMENT WITH LANDMARK HEALTHPLAN OF
CALIFORNIA; AND FURTHER AUTHORIZING THE
CITY MANAGER TO EXECUTE THE AGREEMENT
WHEREAS, the City of Lodi utilizes Landmark Healthplan of California for the
administration of the chiropractic benefits offered to City of Lodi full-time employees; and
WHEREAS, staff recommends that the City Council approve the renewal of the
Chiropractic Benefit Administration Agreement with Landmark Healthplan of California; and
WHEREAS, staff further recommends that the City Council authorize the City Manager
to execute the Agreement on behalf of the City of Lodi.
NOW, THEREFORE, BE IT RESOLVED that the Lodi City Council does hereby approve
the renewal of the Chiropractic Benefit Administration Agreement with Landmark Healthplan of
California; and
BE IT FURTHER RESOLVED that the City Council does hereby authorize the
City Manager to execute the Agreement with Landmark Healthplan of California on behalf of the
City of Lodi; and
BE IT FURTHER RESOLVED that the term of the Agreement shall be effective
February 1, 2020 through January 31, 2021, and in the event no termination notice has been
given by either party or no new agreement has been negotiated, the Agreement shall
automatically renew for successive one-year terms on each anniversary of the commencement
date of this Agreement; and
BE IT FURTHER RESOLVED, pursuant to Section 6.3q of the City Council Protocol
Manual (adopted 11/6/19, Resolution No. 2019-223), the City Attorney is hereby authorized to
make minor revisions to the above -referenced document(s) that do not alter the compensation
or term, and to make clerical corrections as necessary.
Dated: January 15, 2020
I hereby certify that Resolution No. 2020-12 was passed and adopted by the City
Council of the City of Lodi in a regular meeting held January 15, 2020 by the following vote:
AYES: COUNCIL MEMBERS — Chandler, Johnson, Nakanishi, and Mayor Kuehne
NOES: COUNCIL MEMBERS — None
ABSENT: COUNCIL MEMBERS — Mounce
ABSTAIN: COUNCIL MEMBERS — None
(AV
PAMELA M. FARRIS
Assistant City Clerk
2020-12