HomeMy WebLinkAboutAgenda Report - February 16, 2022 C-16AGENDA ITEM ~
CITY OF LODI
4
y 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: February 16, 2022
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 and
COBRA participants. 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, 2022 and continue in effect until January 31, 2023.
This contract shall automatically renew for successive one-year terms on each anniversary of the
commencement date of this Agreement. The city may terminate this Agreement by providing Landmark
Healthplan with 30 calendar days' prior written notice.
FISCAL IMPACT: Annual cost of approximately $50,000.
FUNDING AVAILABLE: Included in Benefits Fund appropriations (65522000).
Adele Post, Human Resources Manager
FuHrw � ir•iT
Andrew Keys, Deputy City Manager/Internal Services Director
APPROVED: Steve Schwabauer
Stephen Schwabauer, City Manager
Signature: IFeb, r,2.vaais1sPST)
Email: sschwabauer@lodi.gov
GROUP AGREEMENT BY AND BETWEEN
LANDMARK HEALTHPLAN OF CALIFORNIA, INC.
AND
City of Lodi
CHIROPRACTIC BENEFIT
COVERSHEET
In consideration of the prepayment of applicable fees by Group and receipt by Landmark of the Group Application
(which is made a part of this Group Agreement by reference), Group hereby agrees to offer to its Members: Covered
Chiropractic Services.
llcriodmc UmWci. The monthly subscription fees ("premiums") For Plan membership are as follows:
Employee Only $5.71
Employee & One $11.47
Employee & Family $15.00
2. Group, or its designated agent, shall remit applicable periodic subscription fees in full on or before February 1,
2022 (the "Effective Date") for Members enrolled 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 subsetiption fee schedule set forth above shall remain in effect for the
initial term of this Agreement as described below. 'hereafter, 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, 2022 through January 31, 2023. Thereafter, this
Agreement shall be automatically renewed annually, subject to the termination provisions herein.
4. -Ilii llai irjCriteria. 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 thus Agreement are material to the execution of this Agreement by Plan.
During the term of this Agreement, no change in Group's eligibility or participation 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) - 1v ILM.PlovycWailing Perin 1. All new employees become eligible on the first of the month following
the date of hire.
b)MedicA r • n P' r I Only enrollees of the employer-sponsored medical plan
are eligible to enroll. Plan requires that all enrollees of the employer-sponsored medical plan enroll. Employees who
have waived an employer sponsored medical plan are eligible if they maintain medical plan coverage through a spouse's
group medical plan or a government medical plan program.
i,acqan Sate of (:rnur. c
a) Intl_ tett l rll.t121i13#inr Periaxl_ The initial Open Enrollment Period will commence prior to the Effective
Date and continue up to thirty (30) calendar days thereafter for Subscribers and their eligible Dependents enrolled
during this initial Open Enrollment Period. Dependents must be eligible at the time of their Enrollment. Subsequent
Open Enrollment Periods shall occur on the anniversary date of the Group's Effective Date or upon a mutually
22GROUP AGREEMENT City of Lodi Page 1 of 17
agreeable date designated by both parties.
b) Fn mil me,nl I `� ffcctive l)a t c o f Coverai c ata Time (_) tltcr Than 1)uritig ilie .( )pQp I. n yjlment ileriod. Any
person who becomes newly eligible at a time other than during the Open Enrollment Period (e.g., newborn, adopted
child, new spouse or registered domestic partner, newly lured 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.
22GROUP AGREEMENT City of Lodi Page 2 of 17
GROUP AGREEMENT BY AND BETWEEN
LANDMARK HEALTHPLAN OF CALIFORNIA, INC.
AND
City of Lodi
CHIROPRACTIC BENEFIT
LANDMARK HEA1.THPLAN 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 associations of 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.
W.ft i
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
Agreement provided to the Member during Open Enrollment that sets forth the Coverage to which the Member is
entitled. It includes the Schedule(s) of Benefits and is attached as Exhibit 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 try all
programs to eliminate over -insurance 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 set -vices within the scope of chiropractic care that
are supportive or necessary to help Members achieve the physical state enjoyed before an injury or illness, and that are
generally furnished for the diagnosis and/or treatment of a neuromusculoskeletal condition associated with an injury or
illness, including 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 he contacted 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
22GROUP AGREEMENT City of Lodi Page 3 of 17
Westlake Village, CA 91320
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
Est of all eligible Members for the applicable month. This Eligibility Roster may be in electronic data format such as
diskette or tape, or electronically transferred.
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(s) of Benefits,
attached as part of Exhibit A. for which the Plan will not provide Coverage or remit payment for services.
1.15 "Grievance Procedure" means the procedure for reviewing Member complaints unrelated to the
quality or appropriateness of chiropractic services.
1.16 "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.
1.17 "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.
1.18 "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.
1.19 "Limitation" means any provision other than an Exclusion that restricts Coverage under this Group
Agreement.
1.20 [Intentionally Left Blank]
1.21 "Medicare" means Title XVIII of the Social Security Act (Paragraphs 1801 et seq., 2142 U.S.C. §§
1395 et seq.), and all amendments thereto.
1.22 "Member" means any Subscriber or Dependent as defined in this Agreement.
1.23 "Neuromusculoskeletal" means conditions that display symptoms of and/or signs related to the
nervous, muscular and/or skeletal body systems.
1.24 "Non -Participating Chiropractor" means a chiropractor who is not under contract with Plan to
pro-
vide Covered Chiropractic Services to Members.
1.25 "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.
22GROUP AGREEMENT City of Lodi Page 4 of 17
1.26 "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.
1.27 "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.
1.28 "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.
1.29 "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.
1.30 "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.
1.31 "Prevailing Rates" means the rates generally prevailing in the Service Area for chiropractic and
related services, as determined by Plan.
1.32 "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.
1.33 "Schedule(s) of Benefits" means the schedule of Covered Chiropractic Services that. are provided to
Members. The Schedule(s) of Benefits are included in the Combined Evidence of Coverage and Disclosure Form,
attached as Exhibit A and incorporated herein.
1.34 "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.
1.35 [Intentionally Left Blank]
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.
1.37 [Intentionally Left Blank]
1.38 "Utilization Management Program" means a coordinated program to promote the efficient use of
resources and maintain the quality of health care and includes, but is not limited to, the prospective, concurrent, and
retrospective review of Covered Chiropractic Services provided to Members pursuant to this Agreement.
2. fil.lrvi1B1111'l'1'.1N1) 1'I tl� t I) .ja111lti�i'1.
2.01 EWMInent Pngcdmyr Plan provides Covered Chiropractic Services to Members who meet the
eligibility requirements stated in this Agreement, who arc 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.
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.
22GROUP AGREEMENT City of Lodi Page 5 of 17
2.02 SWwril.trr ]i.lil„ibilitt,. 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 Set -vice Area.
b) Subscriber must meet any eligibility requirements of Group for membership in this Plan.
2.03 Dq=dent C ' ' slily. A 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 (hat 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 Cormnenrem}ent.of Cu verag,_�., Coverage shall commence on the date Plan accepts Member's Plan
Enrollment Form and verifies Member's eligibility through the Eligibility Roster from Group. Plan's acceptance of
Member's Plan Enrollment Form is contingent upon receipt of the applicable Plan premium payment.
2.05 1 I •'a l 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 ( )BU 1,1.1'lQj% 5. Nr. rl it l,s_ ,tN[� 111,;IN P11L."MIU,NIS
3.01`i�tLl�iScrimiu:ylie�n, 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
offered by Group.
3.02 Notieyi to Plus. 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 Members. Group acknowledges that
22GROUP AGREEMENT City of Lodi Page 6 of 17
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 an Eligibility Roster.
3.03 Nott to 1 7 lxr_
a. Termination. If Plan sends Group a Notice of Start of Grace Period or a Notice of Cancellation, Rescission
or. Nonrenewal pursuant to Paragraph 9.02 hereof, Group shall promptly send a copy of such Notice to each Subscriber.
Any such Notice shall be sent by Plan to Group in accordance with Paragraph 15.09 hereof. 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 End of Coverage that Plan shall send to Group in accordance with Paragraph 9.02
and 15.09 hereof. Group shall promptly provide Plan with proof of that mailing and the date thereof.
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
premum 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.
3.04 Rtes. Plan shall provide benefits for each validly enrolled Member for which Plan Premiums are
received by Plan. The rales for Plan membership are set forth in the Periodic Charges section of the Cover Sheet.
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) day of the month of Coverage for which Covered Chiropractic Services are provided.
3.06 iM fifrcation of,Rates-and Bsznefits. The Plan Premium rates set forth in the Periodic Charges section
of the Cover Sheet, and benefits set forth in Exhibit R 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 the number of
Members or any portions of either, then upon thirrp (30) calendar days' written notice to Group, Group shall remit 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 P: •nhen &gdc In lirrar, 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 Member's 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 Uffrut tif> 'ITScm. Except as otherwise provided in this Agreement, Covered Chiropractic Services
shall only be provided to 14embers during the period in which Nfetnber's Plan Premiums are paid. Member will be billed
for Coverage for the first month of Coverage for newborn or adopted children eligible as provided in Subparagraph
2.03(a).
22GROUP AGREEMENT City of Lodi Page 7 of 17
3.09 Noticu of I}YxCtitinr7cr'1'ernun9tiun. Tf 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 Chiropractor's 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.
4. BEN MATS AND CON 011-1ONS FOlkCOV 1iR.1Gf
4.01 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 conditions, 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 Belmfim 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(s) of Benefits,
all of which are attached hereto as Exhibit A and incorporated herein by this reference.
4.03 Memhcr Migalivils, Subscriber shall subinil: 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 91320
4.04 Uaims. 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. 'Ihe Participating
Chiropractor is responsible for subinitting all other claims to Plan. ,'additionally, Members should be aware that
Participating Chiropractors cannot balance -bill Members for Covered Chiropractic Services.
4.05 [Intentionally Left Blank]
4.06 [Intentionally Left Blank]
4.07 L;p-paXi17gnts• 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(s) of Benefits,
attached hereto as part of Exhibit A.
4.08 24,nicltt ,Seaices• 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.
22GROUP AGREEMENT City of Lodi Page 8 of 17
4.09 Emcrgency &mic;es. Plan shall only cover Emergency Services as defined in Section 1.12 of this
Agreement. Emergency Services may be provided without pre -authorization horn Plan. If Plan decides that the
professional services rendered to Member by a Non -Participating Chiropractor fail to meet Emergency Services
guidelines, Plan shall have no responsibility to cover such services. Continuing follow-up treatment after Emergency
Services have been rendered must be pre -authorized and coordinated by Plan. Plan may elect to transfer Member to a
Participating Chiropractor if such transfer would not create an unreasonable risk to Member's health.
4.10 i ilk), to NQn-Pax6cipating ChiroplaytoLl, 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 in an Emergency situation.
5. 1.LIIITAT( )N_[ ]N_ III :N I:f9'i'S
5.01 Acts Beluad 111n 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 filabillLy to Pwykk_Lhim�.aclicSurAces. 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 Scconchn [;nvcmgc. 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.
i'.11L'1'It S:1FFF.,[ TE) BY,'l116,AQRF?P r ONS111Pti l'?Jy'1tiYl1?LN I':11i'L'II"sti
6.01 Mumber Non-ltyz In the event Plan fails to pay a Participating Chiropractor for a Covered
Chiro-
practic Service as set forth in Exhibii A, a Member shall not be liable to the Participating Chiropractor for any sums
owed by Plan.
6.02 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 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.
i1':LN s Pi ] , T' tZPT "1T
7.01 Lkn?ber Grievaucc-ResctlutionJ tent. 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
22GROUP AGREEMENT City of Lodi Page 9 of 17
_Ishii it 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 -Ni
mmilly-1. chums .A,gainsl Participating 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 Clvropractors as such. Member claims for damages as a result of an injury caused or alleged to have been
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 DispustsJ3etween Nall and C;roun_ 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.
rIiil ()l -r i]'r. r I .r ALJ'r(2NL,%TJCli
8.01 J'rrm:. wminatig &,ncWiL 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 dale of this Agreement, or as indicated on the
Cover Sheet, unless terminated as provided herein.
9.01 _LesmiaaiiLm by (JeQL 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 1krnriaakoll lay plaa
a) In the event Group or its designee fails to remit
Plan Premiums to Plan by the date required, Plan may terminate this Agreement subject to its compliance with the
provisions of this paragraph and paragraph 3.03. Prior to any such termination, Plan shall send Group a Notice of Start
of Grace Period in the form required by the California Department of Managed Care (the "DhIFfC"). This Notice will
inform Group that it has until the end of the grace period, which lasts 30 consecutive days, in which to pay the Plan
Premiums due before any cancellation of the Group Agreement takes effect. In addition, the Notice of Start of Grace
Period will provide information to Group regarding the reason for cancellation, the telephone number of the Plan's
Customer Service Department, the effective date of cancellation, the dollar amount(s) due to Plan by applicable month,
the dale of the last day of paid coverage, the date the grace period begins and expires, any obligations of Group during
the grace period, consequences of Group's failure to pay Plan Premiums by the end of the grace period, as well as the
right of Group to submit a grievance to the Plan and/or the DMHC if Group believes coverage has been or will be
improperly cancelled. Such grace period shall begin on the date of such Notice but no earlier than the day after the last
date of paid coverage. If Group does not pay all unpaid Plan Premiums by the end of the grace period, Coverage for all
Members enrolled in this Plan shall terminate effective the day after the last day of the grace period provided that Plan
sends Group a Notice of End of Coverage in the form required by the DMHC within five calendar days of the date
coverage terminated in accordance with paragraph 3.03. The Notice of End of Coverage will provide Croup with the
following information: (1) that the Group Agreement has been cancelled for non-payment of Plan Premiums; (2) the
specific date and time when the coverage ended; (3) the responsibility of Group to pay all Plan Premiums due, including
for coverage during the grace period provided; (4) the right of Group to submit a grievance to Plan and/or the DMHC
22GROUP AGREEMENT City of Lodi Page 10 of 17
if Group believes coverage has been improperly cancelled, and the right to reinstatement of the Group Agreement if the
DMIIC rules in favor of Group in any such review; and (5) Plan's telephone number to call to obtain additional
information, including learning about obtaining new coverage or whether coverage can be reinstated. 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.
b) Cancellations, Rescissions or Non -renewals for Reasons Other Than Non -Payment of Plan
Premiums. Plan may cancel, rescind or non -renew tNs Agreement in the event of fraud or intentional misrepresentation
by Group or if Group fails to adhere to the employer contribution or group participation rules of this Agreement subject
to Plan's compliance with this paragraph and paragraph 3.03. Plan shall give Group at least 30 days advance notice of
any cancellation, rescission or nonrenewal by sending Group a Notice of Cancellation, Rescission or Nonrenewal in the
form required by the DMHC. Such Notice shall specify the reason(s) for the cancellation, rescission or nonrenewal, the
effective date of any such cancellation, rescission or nonrenewal and the grievance rights available to Group.
9.03 ltttrr rim of 11Hn I'runiums. 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. i .: I�] l'1"li)N OF \1[i,IBJI,R81 [IIS
10.01 I'ermitutticm. The rights of Members under this Agreement shall terminate upon occurrence of any of
the following:
a) Termination of Group by Plan. In the event of termination of Group by
Plan pursuant to Paragraph 9.02, Members' membership in the Plan shall terminate upon the
effective date of any such termination of Group by Plan.
b) 'I'ertnin �n s�E: p, lnct7l b, GtrQW- 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 Member's behalf.
c) Zykniber Permanently Mom _Out of Service .ln:tt_ Member's enrollment in this Plan shall
terminate in the event that either: (i) Member is absent from the Service Area for ninety ()0) 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 Member's last known address shall be deemed
effective notice for purposes hereunder.
d) NL[embers Luss of I?l4ibiliM Member's 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.
e) i) Dist:oluIion of subxc 61 it: r's i'yhl r Vi �Igjz Qr Douxs ' c P t sendtnt CF'gibihLy, 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
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.
f) I ohinuiy 1]hwrolimcm 4, Mcmbe . 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 Upon termination of this Agreement for any reason, Plan shall have
22GROUP AGREEMENT City of Lodi Page 11 of 17
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. (LONTINUATION UP 1 r 1;4
11.01 S;«r�tictuaf.iaalt of 13enefltf radar C[]lll[:1. 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 "�ilt.l." The California CONTIN UA'11ON 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 SIB, a copy of which is attached and
made a part of this Agreement.
12. MNIVEIj,;'IION
12.01 S1•tilsclijltgr C onversicm 1'rivilcM Ira the event the Subscriber ceases Coverage under this Agreement
solely as a result of leaving Group, then Subscriber may witi-in thirty (3 0) calendar days frtllowirq; termination of
Crnierage, convert his/her snerribmiship to non -Group membership. for himseLr/herself and his rat her enrolled
Dependents regardless of health status or requirements for Covered Chiropractic Services.
12.02 U-c-pertclent 4 g r t 'lirtilt:r. Q2giversionPr9vilgMIn the event the Dependent spn use or
dornestic partner of tht- Subacribet ceases to be covered under- this Agrrement it a result. of rhv termination of the
marriage or domestic partnership or Subscriher)s death, Uependent spouse or domestic partner shall have the privilege
of converting to a non -Group membership agreement ifapplication for such Coverage is trade within thirty (30)
calendar days of ternvnatina of the marriage or domestic partnership or the Subscriber':; drnth, whichever is applicable.
12.03 12e4H •a t 'r vii • Tn the event Suliscribet's Dependent child masc:i to he
covered under this Agreement solely due to child's attainment of the .Urniring. age for eligible DepcndrnI children as
specified in this Agreement, such child shall have the privilege of converting 10 a non -Group memlactship agreement
under the same conditions as would :apply to the Subscribur were he or she leaving tic Group, if such application rs
made within thu•ty (30) calendar days of the Deprttdent child's atNinme.n.t of the knitting age.
12.04 11t11t3stf Co=tyciriu, 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. S�1R.I_]•!'.IR'l�' LLll3ILI'1 Y"
13.01 ! 1j dJz _'A q• I..la AU) 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.
22GROUP AGREEMENT City of Lodi Page 12 of 17
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 alien 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 Members 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
14. 4
14.01 Workers' (:tatnnansetion. 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
sery-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
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 claim or
action made or filed on Member's behalf and the signing of any documents evidencing such lien. Members failure to
cooperate reasonably with Plan as provided herein may result in such Member's termination from this Plan.
14.02 Nle l�,t'yare BencGts. Upon Plan's request, Member shall furnish information to Plan concerning
Member's eligibility for Medicare (Part A and/or Part Ii Coverage). If a Member is eligible to enroll in Medicare, Plan
shall furnish benefits under this agreement on Members 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.
22GROUP AGREEMENT City of Lodi Page 13 of 17
14.03 COIL§MPUS Bencfits. 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 Autoniubile.Aceiefent_nr_l.iabili Ciovetagy. 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 f rdination of Benefits. All benefits provided under this Plan are subject to Coordination of
Benefits. Coordination of Benefit miles 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.
�t� l i<.Yilf �l14►s11i�Iif�E�ii9�Ci]`�rl
15.01 Ugvgrning Law. 'Phis 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 Usu of N;il_II4 iii 1'1'Ninterials. Plan reserves the right to control all use of its
name, symbols, trademarks, or service marks currently existing or later established. IIowever, either party may use the
other party's name, symbols, trademarks or set -vice 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 Assignmenr.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 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 Yandij,y, 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 f' jjif1 i '•dim 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 Member's 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.
22GROUP AGREEMENT City of Lodi Page 14 of 17
15.06 Amendments Except as otherwise provided herein, this ikgreement 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 Waiver of 1'h:fauh. 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 either
delivered personally or 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: CEO
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 he 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. IXEC,UTIDill
16.01 .hatecudort uk Agrestneitt. 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. :ll,=IRATION.
17.01 Ditwutes llglwuti Qrouliind 1.4tndtnark. All disputes between Group and Landmark shall be
resolved by binding arbitration before JAMS, RD on -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 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
arbittator(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. §4 1-16, will also apply to the arbitration.
17.02 l')i�ytfrz 13c.nvctl_tIti:nsher iql+j {,a:ethnttrk.
17.02.01 �ICmbc�_�1t;cal :uid C;ricyances. The Landmark Combined Evidence of Coverage and
Disclosure Form attached hereto as E 1 it A includes a complete description of the Landmark appeals and grievance
procedures and dispute resolution processes for Members.
22GROUP AGREEMENT City of Lodi Page 15 of 17
17.02.02 Mini n}I Axbit.ration. 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 patty 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. 45 1-16, shall also apply to the arbitration.
17.03 Mandatnt3! Arbitratl6n. 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.
22GROUP AGREEMENT City of Lodi Page 16 of 17
IN WITNESS WHEREOF, the Parties have executed this Agreement on the date set forth below.
LANDMARK HEALTHPLAN City of Lodi
OF CALIFORNIA, INC. 221 West Pine P.O. Box 3006
2629 Townsgate Road, Suite 235 Lodi, CA 95241-1910
Westlake Village, CA 91320
(800) 298-4875
Tax Identification Number: 68-0352158
By:
By:
George W. Vieth, Jr.
11r' i N:� rxc:
Chief Executive Officer
Title- _
Date: January 12, 2022
Date:
Approved as to Form:
JANICE D. MAGIDICH
City Attorney
22GROUP AGREEMENT City of Lodi Page 17 of 17
EXHIBIT A&B
SCHEDULE of BENEFITS
Chiropractic 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, option 2,
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, option
2, between 8:30 AM and 5:00 PM, Monday through Friday, for free help. We can also help you in lan-
guages 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:/iwww.LHPI-CA.cotii/SLirvey.asp 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 Road, Suite 235
Westlake Village, CA 91361
Benefits and Co-
a ments
Office Visit
$10 co -payment
Maximum Annual Visits
40 visits
X-ray Services*
$75 annual maximum benefit
Emergency Care"*
Same co -payment 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 support-
ive to help Members achieve the physical state
enjoyed before an injury or illness and that are
furnished for the diagnosis and/or treatment of a
neuromusculoskeletal condition associated with
an injury or illness including the following sevic-
es:
■ Examinations
■ Manipulation
N 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
Landmark Healthplan of California, Inc. • 2629 Townsgale Road, Suite 235 . Westlake Village, CA 91361 •1-800-298-4875 Page 1
that the Member would reasonably have consid-
ered that Emergency Services were required.
Emergency Services rendered by a
Non -Participating Chiropractor are covered only
when the chiropractor rendering services can
show that the services were for a neuromuscu-
loskeletal condition and were provided to reduce
the severity of the condition including pain until a
Participating 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 consulta-
tion only, from another chiropractor. Landmark
does not require an authorization for any second
opinion. Second opinions initiated by your Par-
ticipating 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, or long-term rehabilitation
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
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. 9 2629 Townsgate Road, Suite 235 • Westlake Village, CA 91361 ■ 1-800-298-4875 Page 2
EXHIBIT C
NOTE: The City of Lodi is now using the online Insurance program PINS Advantage. Once you have been awarded a
contract you will receive an email from the City's online insurance program requesting you W forward the email to your
insurance provider(s) to submit the required Insurance documentation electronically
Insurance Reaulrements for Professional Services
Contractor shall procure and maintain for the duration of the contract Insurance against claims for Injuries to persons or damages
to property which may arise from or In connection with the performance of the work hereunder and the results of that work by the
Contractor, his agents, representatives, employees or subcontractors.
MINIMUM SCOPE AND LIMIT OF INSURANCE
Coverage shall be at least as broad as:
1. Commercial General Liability (CGL): Insurance Services Office Form CG 00 01 covering CGL on an "occurrence" basis, Including
products and completed operations, property damage, bodily injury and personal & advertising Injury with limits no less than
$1,000,000 per occurrence. If a general aggregate limit applies, either the general aggregate limit shall apply separately to this
project/location (ISO CG 25 03 or 25 04) or the general aggregate limit shall be twice the required occurrence limit.
2. Automobile Liability: ISO Form Number CA 00 01 covering any auto or If Contractor has no owned autos, then hired, and non -
owned autos with Ilmit no less than $1,000,000 per accident for bodily Injury and property damage.
3. Workers' Compensation: as required by the State of California, with Statutory Limits, and Employer's Liability Insurance with limit
of no less than $1,000,000 per accident for bodily injury or disease,
4. Professional Liability (Errors and Omissions) Insurance approprlate to the Consultant`s profession, with limits not less than
$1,000,000 per occurrence or claim, $2,000,000 aggregate. May be waived by Risk Manager depending on the scope of services.
Other lnsurance Provisions:
(a) Additional Named Insured Status
The City of,Lodl, Its elected and appointed boards, commissions, officers, agents, employees, and volunteers are to be covered
as additional insureds on the CGL and auto policy with respect to liability arlsing out of work or operations performed by or on
behalf of the Contractor Including materials, parts, or equipment furnished In connection with such work or operatlons. General
liability coverage can be provided in the form of an endorsement to the Contractor's insurance (at least as broad as ISO Form
CG 20 10 11 85 or If not available, through the addition of both CG 20 10, CG 20 26, CG 20 33, or CG 20 38; and CG 20 37 if a
later edition Is used
(b) Primary and Non -Contributory Insurance Fndorsement
The limits of insurance coverage required may be satisfied by a combination of primary and umbrella or excess Insurance. For
any claims related to this contract, the Contractor's insurance coverage shall be primary coverage at least as broad as ISO CG
20 01 04 13 as respects the Entity, its officers, officials, employees, and volunteers. Any Insurance or self -Insurance maintained
by the Entity, its officers, officials, employees, or volunteers shall be excess of the Contractor's Insurance and shall not contribute
with It.
(c) Waiver of Subrogation Contractor hereby grants to City of Lodi a waiver of any right to subrogation which any Insurer of said
Contractor may acquire against the City of Lodi by virtue of the payment of any loss under such insurance. Contractor agrees to
obtain any endorsement that may be necessary to affect this waiver of subrogation, but this provision applies regardless of whether
or not the City of Lodl has received a waiver of subrogation endorsement from the Insurer
NOTE: (1) The street address of the CITY OF LODI must be shown along with (a) and (b) and (c) above: 221 West Pine Street,
Lodi, California, 95240; (2) The Insurance certificate must state, on its face or as an endorsement, a description of thero ect
that It Is Insuring.
(d) Severability of Interest Close
The term "Insured" is used severally and not collectively, but the Inclusion herein of more than one Insured shall not operate to
Increase the Ilmlt of the company's liability under the Contractors commercial general liability and automobile liability policies.
(e) Mica a o ancella Ion or Change In over$ a Endorsemen
This policy may not be canceled nor the coverage reduced by the company without 30 days' prior written notice of such
cancellation or reduction In coverage to the Risk Manager, City of Lodi, 221 West Pine St., Lodi, CA 95240.
Page 1 I of 2 pages Risk: rev. 3/1/2018
(f) Continully of Coverage
All policies shall be in effect on or before the first day of the Term of this Agreement. At least thirty (30) days prior to the expiration
of each insurance policy, Contractor shall furnish a certificate(s) showing that a new or extended policy has been obtained which
meets the minimum requirements of this Agreement. Contractor shall provide proof of continuing insurance on at least an annual
basis during the Term, If Contractor's insurance lapses or is discontinued for any reason, Contractor shall immediately notify the
City and immediately obtain replacement Insurance. Contractor agrees and stipulates that any insurance coverage provided to the
City of Lodi shall provide for a claims period following termination of coverage which is at least consistent with the claims period or
statutes of limitations found in the California Tort Claims Act (California Government Code Section 810 et seq.).
(g) Failure to Cornoiv
If Contractor fails or refuses to obtain and maintain the required insurance, or fails to provide proof of coverage, the City may obtain
the insurance. Contractor shall reimburse the City for premiums paid, with Interest on the premium paid by the City at the maximum
allowable legal rate then in effect In California. The City shall notify Contractor of such payment of premiums within thirty (30) days
of payment stating the amount paid, the name(s) of the insurer(s), and rate of interest. Contractor shall pay such reimbursement
and interest on the first (1st) day of the month following the City's notice. Notwithstanding any other provision of this Agreement,
if Contractor falls or refuses to obtain or maintain Insurance as required by this agreement, or fails to provide proof of Insurance,
the City may terminate this Agreement upon such breach. Upon such termination, Contractor shall immediately cease use of the
Site or facilities and commence and diligently pursue the removal of any and all of its personal property from the site or facilities.
(h) Verification of Coverage
Consultant shall furnish the City with a copy of the policy declaration and endorsement page(s), original certificates and
amendatory endorsements or copies of the applicable policy language effecting coverage required by this clause. All certificates
and endorsements are to be received and approved by the City before work commences. However, failure to obtain the required
documents prior to the work beginning shall not waive the Consultant's obligation to provide them. The City reserves the right to
require complete, certified copies of all required Insurance policies, including endorsements required by these specifications, at
any time. Failure to exercise this right shall not constitute a waiver of the City's right to exercise after the effective
date.
(1) Se# -Insured Retentions
Self-insured retentions must be declared to and approved by the City. The City may require the Consultant to provide proof of ability
to pay losses and related investigations, claim administration, and defense expenses within the retention. The policy language shall
provide, or be endorsed to provide, that the self-insured retention may be satisfied by either the named insured or City.
(j) Insurance Limits
The limits of insurance described herein shall not limit the liability of the Contractor and Contractor's officers, employees, agents,
representatives or subcontractors. Contractor's obligation to defend, indemnify and hold the City and Its officers, officials,
employees, agents and volunteers harmless under the provisions of this paragraph Is not limited to or restricted by any requirement
in the Agreement for Contractor to procure and maintain a policy of insurance.
(k) Subco-ntrap,
tars
Consultant shall require and verify that all subcontractors maintain insurance meeting all the requirements stated herein, and
Consultant shall ensure that City is an additional insured on Insurance required from subcontractors
(1) Claims Made Policies
If any of the required policies provide coverage on a claims -made basis:
1. The Retroactive Date must be shown and must be before the date of the contract or the beginning of contract work.
2. Insurance must be maintained and evidence of insurance must be provided for at least five (5) years after completion of the
contract of work.
3. If coverage Is canceled or non -renewed, and not replaced with another claims -made policy form with a Retroactive Date prior
to the contract effective date, the Consultant must purchase "extended reporting" coverage for a minimum of five (5) years after
completion of contract work.
(m) Clualified_Insurertsl
All insurance required by the terms of this Agreement must be provided by Insurers licensed to do business In the State of
California which are rated at least "A-, VI" by the AM Best Ratings Guide, and which are acceptable to the City. Non -admitted
surplus lines carriers may be accepted provided they are included on the most recent list of California eligible surplus lines
insurers (LESLI list) and otherwise meet City requirements,
Page 2 1 of 2 pages
Risk: rev. 3/1/2018
RESOLUTION NO. 2022-36
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 employees.
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, 2022 through January 31, 2023, and in the event no termination notice has been
given by either party, and a new agreement has not been negotiated, the contract shall
automatically renew for successive one-year terms on each anniversary of the commencement
date of this agreement.
Dated: February 16, 2022
I hereby certify that Resolution No. 2022-36 was passed and adopted by the City
Council of the City of Lodi in a regular meeting held February 16, 2022 by the following vote:
AYES: COUNCIL MEMBERS — Hothi, Khan, Kuehne, Nakanishi, and
Mayor Chandler
NOES: COUNCIL MEMBERS — None
ABSENT: COUNCIL MEMBERS — None
ABSTAIN: COUNCIL MEMBERS — None
PAMELA M. FARRIS
Assistant City Clerk
2022-36