HomeMy WebLinkAboutC-9370-1 - Group Contract - EAP PlanAMENDMENT NO. ONE TO
HOLMAN PROFESSIONAL COUNSELING CENTERS
GROUP CONTRACT
EAP PLAN
THIS AMENDMENT NO. ONE TO AGREEMENT ("Amendment No. One") is made
and entered into as of this 1st day of July, 2025 ("Effective Date"), by and between
HOLMAN PROFESSIONAL COUNSELING CENTERS, (hereinafter "HPCC"), a
California corporation, having its principal place of business at PO BOX 8011, Canoga
Park, CA 91309, and the CITY OF NEWPORT BEACH, (hereinafter "Employer") a
California municipal corporation and charter city, and is made with reference to the
following:
RECITALS
A. On July 1, 2023, City and Consultant entered into a Professional Services
Agreement (Contract No. C-9370-1) ("Agreement") for Employee Assistance
Program Services.
B. The parties desire to enter into this Amendment No. One to extend the term of the
Agreement to June 30, 2028.
NOW, THEREFORE, it is mutually agreed by and between the undersigned parties
as follows:
1. TERM
Section 1 of the Agreement is amended in its entirety and replaced with the
following: "The term of this Agreement shall commence on the Effective Date, and shall
terminate on June 30, 2028, unless terminated earlier as set forth herein."
2. INTEGRATED CONTRACT
Except as expressly modified herein, all other provisions, terms, and covenants
set forth in the Agreement shall remain unchanged and shall be in full force and effect.
[SIGNATURES ON NEXT PAGE]
IN WITNESS WHEREOF, the parties have caused this Amendment No. One to be
executed on the dates written below.
APPROVED AS TO FORM:
CITY ATTORNEY'S OFFICE
Date: q / / z S
By.
A on C. Harp
0\
City Attorney
ATTEST:
Date: 9 /z S
By:
4 Mo ly Perry
Interim City Clerk
CITY OF NEWPORT BEACH,
a California municipal corporation
Date:
B
Barbara Salvini
Human Resources Director
Holman Professional Counseling Centers,
a California corporation
Date:
Signed in Counterpart
By:
Elizabeth
President
[END OF SIGNATURES]
Holman, M.B.A
Holman Professional Counseling Centers, Inc. Page 2
IN WITNESS WHEREOF, the parties have caused this Amendment No. One to t),�
executed on the dates written below.
APPROVED AS TO FORM: CITY OF NEWPORT BEACH,
CITY ATTORNEY'S OFFICE a California municipal corporation
Date: 91,3�7----- Date: --
By: —444� _ By:
AVon C. Harp ., , �,Barbara Salvini
City Attorney �' Human Resources Director
ATTEST: Holman Professional Counseling Centers.
Date: a California corporation
Date:_
y:_
Moll Pe
Y try Elizabeth Holman, M.B.A
Interim City Clerk President
[END OF SIGNATURES]
Holman Professional Counseling Centers, Inc. Page 2
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Holman Professional Counseling
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FV00001031
P.O. Box 8011, Canoga Park, CA,
91309
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Insured: Holman
Professional
Counseling
Centers
Address 1: P.O. Box
8011
Address 2:
City: Canoga
Park
Address Updated:
Physical Address
Zip: 91309
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Contract Information
Contract Number
Contract Start Date: 07/01/2023 Contract End Date:
Contract Effective Date: Contract Expiration Date:
Description of Services: EAP Plan Safety Form II:
Contact Information
Contact Name: Jill Misc:
Schlesinger
Phone Number: 8003212228 Alt Phone Number:
Fax Number:
E-Mail Address:
jills@holmangroup.com; robert@ieibrokers.
Approval Date:
Rush:
No
Contract on File:
Yes
Certificate Received:
No
Indemnification Agreement:
No
Tax Id:
This Account created by 936 on 06/29/2023.
HOLMAN PROFESSIONAL COUNSELING CENTERS
GROUP CONTRACT
EAP PLAN
This Agreement is made by and between, HOLMAN PROFESSIONAL COUNSELING
CENTERS (hereinafter "HPCC") a California corporation having its principal place of business
at P.O. Box 8011, Canoga Park, CA 91309, telephone number (800) 321-2843, and CITY OF
NEWPORT BEACH, a California municipal corporation and charter city (hereinafter
"Employer") hereby enter into this Group Plan Contract as of this July 1, 2023 ("Effective Date").
RF.f iTAI .0
A. HPCC provides Employee Assistance Program Services and a full range of inpatient,
outpatient, and day care Behavioral Health Services to employer groups, eligible
individuals employed by such groups, and eligible dependents, while at the same time
maintaining the requisites of an independent and responsible profession; and
B. Employer desires to provide its eligible employees and dependents with the benefits and
services of HPCC's programs. Employer covenants that their employee population is now,
and shall continue to have minimum ten or more employees working within the State of
California.
C. HPCC desires to enter into this Agreement to render covered services to Employer's
Enrollees pursuant to this Agreement.
D. Employer desires to enter into this Agreement to have HPCC render covered services to its
Enrollees pursuant to this Agreement.
E. This Agreement incorporates by reference all exhibits mentioned and attached, including
but not limited to, the Benefit Schedule/Description ("Exhibit A") as well as the Evidence
of Coverage/Disclosure Form ("Exhibit B").
AGREEMENT
1.0 DEFINITIONS
1.1 Acute Condition. A medical condition of limited duration that involves a sudden onset of
symptoms due to an illness, injury, or other medical problem that requires prompt medical
attention.
1.2 Acute Psychiatric Hospital. Health facility with a medical staff that provides 24-hour
care
care patients.
00238534.1
1.3 Annual Benefit Maximum. Total amount of money HPCC will pay for authorized
Behavioral Health Services provided to Enrollees by Providers per year. Enrollee will be
responsible for any Behavioral Health Services beyond this amount.
1.4 Behavioral Health Services. Behavioral health services include all procedures utilizing
psychological principles and methods for the understanding, diagnostic, referral,
prevention, and treatment of psychological or personal problems in adults, children,
couples, and families. Procedures utilized may include, but are not limited to, individual
counseling, marital counseling, psychotherapy, behavior modification, chemical and
alcohol abuse counseling, and hypnosis, used in a professional relationship to assist a
person or persons to acquire greater human effectiveness, or to modify feelings, work
situations, conditions, attitudes, and behavior which are emotionally, intellectually, or
socially ineffectual or maladjustive.
1.5 Benefits Schedule. (Attached as Exhibit A.) Describes the available levels of treatments
provided through a Group Plan Contract, along with required deductibles and copayments
if any.
1.6 COBRA. Is a special law that gives members a chance to keep their health plan if they lose
their job, have a reduction in hours, or a change in dependents status. Members will usually
have to pay the monthly charges to keep the plan under COBRA.
1.7 Contracted Provider. A person licensed as a psychologist, clinical social worker, marriage,
family and child counselor, licensed professional counselor, registered associate counselor
or other licensed health care professional with appropriate training and experience in
behavioral health services, and who has contracted with HPCC to deliver specified services
to HPCC Enrollees.
1.7.1 A marriage and family therapist means a licensed marriage and family therapist
who has received specific instruction in assessment, diagnosis, prognosis and
counseling, and psychotherapeutic treatment of premarital, marriage, family, and
child relations dysfunctions, which is equivalent to the instruction required for
licensure on January 1, 1981.
1.7.2 Professional clinical counselor means a licensed professional clinical counselor
who has received specific instruction in assessment, diagnosis, prognosis,
counseling and psychotherapeutic treatment of mental and emotional disorders,
which is equivalent to the instruction required for licensure on January 1, 2012.
1.8 Coordination of Benefits. The allocation of financial responsibility between two or more
insuranee eo . :Ries or health eare providers, eaeh with a legal duty to pay for eovered
services provided to an Enrollee at the same time.
1.9 Co -payment. Fixed fee paid to a Provider by Enrollee at time of provision of Behavioral
Health Services, which are in addition to the Premiums paid by the Employer. Such fees
00238534.1 Rev.2017 2
may be a specific dollar amount or a percentage of total fees, depending on the type of
services provided.
1.10 Coverage Decision. The approval or denial of health care services by a plan, or by one of
its contracting providers, substantially based on a finding that the provision of a particular
service is included or excluded as a covered benefit under the terms and conditions of the
health care service plan contract. The criteria used to determine whether to authorize,
modify, or deny health care services are developed with the involvement from actively
practicing health care providers, consistent with sound clinical principles and processes and
are evaluated and updated, if necessary, at least annually. This criteria is available to the
public upon request. The materials provided to enrollees are guidelines used by HPCC to
authorize, modify, or deny care for persons with similar illnesses or conditions. Specific
care and treatment may vary depending on individual need and the benefits covered under
this contract. Upon enrollee request, HPCC will disclose its processes, including criteria
and guidelines, for authorizing, modifying or denying services.
1.11 Covered Services. EAP services provided by Providers that are determined to fall within
the scope of EAP services and covered under the Group Plan Contract.
1.12 Disputed Health Care Service. Any health care service eligible for coverage and payment
under a health care service plan contract that has been denied, modified, or delayed by a
decision of the plan, or by one of its contracting providers, in whole or in part due to a
finding that the service is not medically necessary.
1.13 Eligible Dependents. Includes Eligible Employee's lawful spouse, domestic partner (as
defined in Section 297 of the Family Code), and children to age 26. Children include
stepchildren, adopted children, and foster children, provided such children are dependent
upon the employee for support and maintenance. Coverage for each minor child placed for
adoption immediately begins from and after the date on which the adoptive child's birth
parent or other appropriate legal authority signs a written document, including, but not
limited to, a health facility minor release report, a medical authorization form, or a
relinquishment form, granting the subscriber or spouse the right to control health care for
the adoptive child. Attainment of the limiting age of 26 by children, shall not operate to
terminate the coverage of a child while the child is and continues to be incapable of
selfsustaining employment by reason of physical or mental condition (certified by a doctor
in writing), the child is chiefly dependent upon an Eligible Employee for support and
maintenance.
1.14 Eligible Employee. Employee of Employer who is eligible for benefits by Employer
pursuant to Employer's obligations under this Group Plan Contract. Regular, full-time
employees are eligible for EAP Benefits upon date of hire, and upon termination of
employment, are covered through the last day of the month. Continuation of EAP Coverage
will be allowed as specified by COBRA provisions.
00238534.1 Rev. 2017 3
1.15 Emergency. The sudden onset of severe behavioral health symptoms and impairment of
functioning due to a mental disorder or chemical dependency such that the absence of
immediate attention could reasonably be expected to result in any of the following:
1.15.1 Enrollee's health is placed in serious jeopardy;
1.15.2 Serious impairment to bodily functions;
1.15.3 Serious dysfunction to any bodily organ or part.
1.16 Emergency Behavioral Health Services and Care. Includes the screening, examination, and
evaluation to the extent permitted by applicable law and within the scope of their licensure
and clinical privileges, to determine if a clinical emergency medical condition exists, and
to determine the care and treatment necessary to relieve or eliminate that emergency
medical condition, within their capability.
1.17 Emergency Services: are services given because of a medical or psychiatric emergency.
1.18 Employee Assistance Program Services ("EAP") A program of comprehensive assessment,
short term treatment and referral services designed to identify and make appropriate
referrals for treatment of physical, mental or emotional conditions which may result in
impaired employee performance.
1.19 Employee/Member: Individual who works for an employer or is a member of a trust, who
has contracted with HPCC for behavioral health services.
1.20 Employer. An Employer is a company that has contracted with HPCC to provide
Behavioral Health Services to its Eligible Employees.
1.21 Enrollee. An Eligible Employee (and/or such Eligible Employee's eligible dependents) of
an Employer who has contracted with HPCC to provide Behavioral Health Services to its
Employees. Employee must meet HPCC's eligibility requirements, enroll in the
Employer's Group Plan, and accept the financial responsibility for any co -payments that
may be incurred in treatment through the Group Plan.
1.22 Evidence of Coverage and Disclosure Form. Brochure issued to an Enrollee setting forth
the coverage to which the Enrollee is entitled and describing the procedure through which
HPCC furnishes care; see Exhibit B.
1.23 Family/Household Unit. Comprised of Enrollee plus Enrollee's eligible dependents.
1.24 Fraud. Fraudis the deliberate submission o a se in orma ion by a provider, enrollee,
HPCC employee, or other individual or entity, to gain an undeserved payment on a claim.
00238534.1 Rev. 2017 4
1.25 Grievance. Any expression of dissatisfaction, whether written or oral. Members have 180
days to file a grievance with HPCC.
1.26 Group Plan Contract. Agreement between an Employer and HPCC providing that HPCC
will provide Behavioral Health Services for the Employer's eligible employees/members
in exchange for Premiums paid by the Employer to HPCC.
1.27 Group Therapy Session. Goal -oriented Behavioral Health Services provided in a small
group setting by a HPCC Provider. Group Therapy Sessions can be made available to the
Enrollee in lieu of individual EAP sessions when appropriate.
1.28 Language Assistance Program: HPCC shall establish and maintain an ongoing language
assistance program to ensure Limited English Proficient ("LEP). Enrollees have
appropriate access to language assistance while accessing health care services as required
by the Language Assistance Program Regulations. Provider shall cooperate and comply, as
applicable, with HPCC's language assistance program; however, HPCC shall maintain
ongoing administrative and financial responsibility for implementing and operating on an
ongoing basis the language assistance program for Enrollees.
1.29 Life Threatening Illness. Includes 1) diseases or conditions where the likelihood of death
is high unless the course of the disease is interrupted; or 2) diseases or conditions with
potentially fatal outcomes, where the end point of clinical intervention is survival.
1.30 Medical Detoxification. Medical detoxification is the medically based supervised treatment
for an unstable or acute medical condition resulting from withdrawal from chemical
substances including drugs or alcohol.
1.31 Medically Necessary. Except were state law or regulation requires a different definition,
"Medically Necessary" or "Medical Necessity" shall mean mental health or substance
related disorder services that a Licensed Mental Health Professional exercising prudent
clinical judgment would provide to an enrollee for the purpose of evaluating, diagnosing,
or treating a mental or substance related disorders that are:
Appropriate and necessary for the diagnosis or treatment of the condition within standards
of good clinical practice within the substance related treatment community, clinically
appropriate in terms of type, frequency, extent, site and duration, and considered effective
for the enrollee's condition.
1.32 Mental Disorder. A mental disorder is a behavioral or psychological syndrome that causes
significant distress or disability, or a significantly increased risk of suffering death, pain,
or an important loss of freedom. The syndrome is considered to be a manifestation of som-e
behavioral, psychological, or biological dysfunction in the person.
1.33 Mental Health Services. Behavioral Health Services for the treatment of Mental Disorders
including substance abuse.
00238534.1 Rev. 2017
1.34 Non -Contracted Provider. Any Provider not contracted with HPCC to deliver services to
Enrollees. Every effort will be made to assure Enrollees are not subject to balance billing
practices for services paid under the HPCC Agreement. Enrollees are liable for the cost of
non -emergency services provided by Non -Contracted Providers.
1.35 Outpatient Behavioral Health Services. Outpatient Behavioral Health Services are those
Behavioral Health Services that are provided by a Provider in his or her office or
appropriate outpatient setting, covered under the employer's medical plan.
1.36 Premium. Predetermined monthly membership fee paid by an Employer for EAP coverage
under Group Plan Contract.
1.37 Prior Authorization. Approval of coverage from HPCC prior to the Enrollee obtaining
covered services. Requests for prior authorization will be denied if not Medically
Necessary, if in conflict with HPCC's policies or otherwise are not covered services.
1.38 EAP Session. A private session consists of one Enrollee with a Provider and includes:
1.38.1 A 45-50 minute consultation as treatment needs dictate.
1.38.2 A 45-50 minute psychological assessment and referral.
1.38.3 A 1 hour — 2 hour group therapy session.
1.39 Provider. A person licensed as a psychologist, psychiatrist, clinical social worker, marriage
and family therapist, nurse or other licensed health care professional, except Psychiatrists,
with appropriate training and experience in Behavioral Health Services, working
individually or within a corporation, clinic, or group practice, who is employed or under
contract with HPCC to deliver Behavioral Health Services to Enrollees.
1.40 Serious Chronic Condition. A medical condition due to a disease, illness, or other medical
problem or medical disorder that is serious in nature and that does either of the following:
1.40.1 Persists without full cure or worsens over an extended period of time;
1.40.2 Requires ongoing treatment to maintain remission or prevent deterioration.
1.41 Serious DebilitatingIllness. lness. Diseases or conditions that cause major irreversible morbidity.
1.42 Treatment Plan. A written clinical presentation of the Provider's diagnostic impressions
and therapeutic intervention plans. The behavioral health Treatment Plan is submitted
routinely to HPCC for review as part of die concurTent review monitoring process.
1.43 Urgently Needed Behavioral Health Care Services. Medically Necessary Behavioral
Health Services required outside of the service area to prevent serious deterioration of an
Enrollee's behavioral health resulting from a sudden onset of illness or injury manifesting
00238534.1 Rev. 2017 6
itself by acute behavioral health symptoms of sufficient severity, such that treatment cannot
be delayed until the Enrollee returns to the service area.
1.44 Utilization Management Committee (UMC). A committee operating within HPCC whose
function is to ensure both quality and cost-effectiveness of treatment.
1.45 EAP Visit: Outpatient. An outpatient session with a Provider conducted on an individual
or group basis during which EAP and Behavioral Health Services are delivered.
2.0 COVENANTS OF EMPLOYER
2.1 Premium. Employer agrees to pay HPCC a monthly -prepaid Premium, commencing with
the effective date of this Group Plan Contract, and thereafter on or before the first (1 st) day
of the month prior to the month of coverage, the sum (See "Exhibit A") for each Enrollee,
per month, to be covered pursuant to this Group Plan Contract. Such rates may from time
to time be adjusted in accordance with the provisions of this Group Plan Contract. These
payments will be facilitated through an electronic fund transfer mechanism. Calculation of
the premiums will be determined by using the previous month's eligibility list; as a result,
premium reconciliation will trail by one month.
2.1.1 The Premium payable to HPCC over the term of this Group Plan Contract shall not
exceed Seventy -Five Thousand Dollars ($75,000) ("Not to Exceed Amount");
provided, however, that it HPCC reaches the Not to Exceed Amount under this
Group Plan Contract, HPCC shall not be required to provide additional EAP Services
unless and until the Parties agree to increase the Not to Exceed Amount.
2.2 Enrollee Count. Employer agrees to furnish to HPCC, on or prior to the first day the
effective date of this Group Plan Contract, an enrollee count on the monthly invoice of all
persons who shall be Eligible Enrollees under this Group Plan Contract.
2.3 Late Enrollment Provisions: Late Enrollment Provisions shall not apply to this Agreement.
2.4 Required Distribution. Employer agrees to distribute to all Enrollees copies of the Evidence
of Coverage and Disclosure Form as provided by HPCC (See "Exhibit B") and
Identification Cards for EAP. Additionally, Employer agrees to disseminate any materials
supplied by HPCC, in accordance with legal or contractual requirements, to its Enrollees
by its next regular communication to Eligible Employees, but in no event later than thirty
(30) days after receipt by Employer. Additionally, if an enrollee requests a copy of the
Group Contract from the Employer, the Employer will provide such copy.
9-5 Required FmDlover Notice to_Fnrollees Employer shall direct Enrollees who wish to
receive EAP Services to telephone HPCC at (800) 321-2843.
2.5.1 Written notice of cancellation of enrollment according to Section 2.7.
00238534.1 Rev.2017 7
2.6 Required Employer Notifications to HPCC. Employer shall notify HPCC in writing within
thirty (30) days of any enrollee who has had one of the following qualifying events:
2.6.1 Death of an Eligible Employee;
2.6.2 Termination of employment, (except that termination for gross misconduct does
not constitute a qualifying event);
2.6.3 Divorce or legal separation of the Eligible Employee from the covered Employee's
spouse;
2.6.4 Loss of dependent status by a dependent enrolled in the group benefit plan;
2.6.5 With respect to a covered dependent only, the Eligible Employee's entitlement to
benefits under Title XVIII of the United States Social Security Act (Medicare).
Employer shall notify HPCC in writing within thirty (30) days of the date when Employer
becomes subject to Section 4980B of the United States Internal Revenue Code or Chapter
18 of the Employment Retirement Income Security Act, 29 U.S.C. Sec. 1161 et seq.
2.7 Plan Cancellation Notification. In the event of the cancellation of the Group Plan Contract,
HPCC shall notify the Employer in writing 90 days prior to the effective date of the
cancellation. The group contract holder shall then promptly mail to each Enrollee a legible,
true copy of the notice of cancellation of the contract received from the Plan. It is the
responsibility of the Employer to notify the enrollee of the termination of this agreement.
2.8 Notice of Cancellation for Non -Payment of Premiums and Grace Period. In the event
HPCC provides notice of cancellation for non-payment of premium to the Employer,
Employer agrees to promptly mail a legible, true copy of the notice of cancellation to all
subscriber/enrollee at their current address. The notice of cancellation to Employer will
include:
• Effective date of the cancellation and grace period; the date of the last day of paid
coverage
• The reason for cancellation, including reference to the applicable clause in this
Agreement
• The dollar amount due to HPCC
• The date the grace period begins and expires. Grace period means a period of at
least 30 days beginning no earlier than the first day after the last date of paid
coverage to allow the Employer to pay an unpaid premium amount without losing
healthcare coverage. At a minimum this grace period shall extend through the
thirtieth (30tb) day after the last date of paid coverage.
00238534.1 Rev. 2017
• The obligations of the enrollee or group contract holder during the grace period (if
any)
• A statement that the cause for cancellation was not due to the enrollees health status
or requirements for health services
• A clear and concise explanation of the right to submit a Request for Review to the
Director including the language provided in subdivision 1300.65(c)(6) of the
California Code of Regulations, Title 28.
• That a enrollee who alleges that cancellation was due to the enrollees health status
may request a review of cancellation by the Department of Managed Health Care
• Information regarding the enrollees COBRA, Cal -COBRA, conversation coverage
and HIPAA individual coverage.
The notice of cancellation for nonpayment of premiums and grace period shall be sent no
later than 5 business days after the last day of paid coverage. The notice of cancellation for
nonpayment of premiums and grace period shall include the language in California Title
28, Section 1300.65(c)(3)(B)(ii) in be in at least 12 point font:
"You are receiving this Notice of Cancellation because your HPCC coverage is being
cancelled or not renewed because you have not paid your premium. Even though you have
not paid your premiums, you are being provided a "grace period " to allow you time to
make your past due premiums payment(s) without losing your health care coverage.
"Grace period " means a period of at least 30 days beginning no sooner than the first day
after the last day of paid coverage and lasts at least 30 days. Your grace period ends on
(insert month, day, year). You may avoid losing your coverage if you pay the premium(s)
owed to HPCC before the end of the grace period. If you do not pay the required premium
amount by the end of the grace period, your coverage will be terminated effective the day
after the last day of the grace period. Your grace period ends on (insert month, day, year).
Coverage will continue during the grace period; however, you are still responsible to pay
unpaid premiums and any copayments, coinsurance or deductible amounts required under
the plan contract. For information about individual health care coverage and health care
subsidies that may be available to you, contact Covered California at (800) 300-1506 or
TTYat (888) 889-4500 or online at www. CoveredCa. com. If you wish to end your coverage
immediately, please contact HPCC as soon as possible. "
The Employer shall also provide proof of the mailing and the date thereof to HPCC by way
of a signed attestation within 3 days of such mailing. In the event the Employer fails to
complywith this condition, coverage will he extended until such time14PCC can comply
with the mandated notice requirements. In the event that HPCC cancels the Group Plan
Contract, other than for non-performance by the Employer, HPCC will comply with the
mandated notice requirements and cover the costs for such mailing described in this
section.
00238534.1 Rev.2017 9
After 24 months following the issuance of this group contract, HPCC shall not rescind this
group contract for any reason, and shall not cancel the group contract, limit any of the
provisions of the group contract, or raise premiums on the group contract due to any
omissions, misrepresentations, or inaccuracies in the application form, whether willful or
not.
In the event that HPCC withdraws from the market, HPCC will notify the Employer, all
enrollees and the Director at least 90 days prior to the discontinuation. If HPCC withdraws
a health benefit plan from the market, HPCC will notify the Employer, enrollees and the
director at least 90 days prior to the discontinuation of the group contract. Notice of the
decision to cease new or existing health benefit plans in the state is provided to the director,
the Employer and the enrollees covered under this group plan contract at least 180 days
prior to the discontinuation of this contract. HPCC will notify the employer to promptly
send the notice listed in 2.8 to the enrollees.
2.9 Notification of Continuation Coverage to Qualified Beneficiaries. Employer shall notify
qualified beneficiaries currently receiving continuation coverage, whose continuation
coverage will terminate under one group benefit plan prior to the end of the period the
qualified beneficiary would have remained covered as specified in Section 1366.27 of the
California Health and Safety Code, of the qualified beneficiary's ability to continue
coverage under a new group benefit plan for the balance of the period the qualified
beneficiary would have remained covered under the prior group benefit plan. This notice
shall be provided either thirty (30) days prior to the termination or when all enrolled
Employees are notified, whichever is later.
2.10 Notice of Consequences for Nonpayment of Premiums means notice sent by HPCC to the
Employer that this group contract will be cancelled, rescinded or not renewed unless the
premium amount due is received by HPCC no later than the last day of the Grace Period.
Should there be a nonpayment of premiums by the Employer to HPCC, HPCC will send
the Employer a notice of consequences for nonpayment of premiums.
2.11 Notice of Cancellation, Rescission or Nonrenewal means the notice sent by HPCC to the
Employer that this group contract will be cancelled, rescinded or not renewed for any
reason other than non-payment of premiums as permitted under Health and Safety Code
1365 or Section 1300.65. The Notice will be sent by HPCC to the Employer to promptly
send the Notice to the enrollees. The language of the notice must be in at least 12 point
font with the language listed in California Title 28, Section 1300.65(c)(6):
"Right to Submit Requestfor Review of Gancellation, Rescission, or Nvnienewal of
Your Plan Contract, Enrollment, or Subscription. "
If you believe your plan coverage has been, or will be, improperly cancelled,
rescinded, or not renewed, you have the right to file a Request for Review. You
00238534.1 Rev. 2017 10
have the options of going to the plan and/or the Department if you do not agree
with the plan decision to cancel, rescind or not renew your plan coverage.
Option (1) - You may submit a Request for Review to your plan.
* You may submit a Request for Review to HPCC by calling 1-800-321-2843
or submitting a request at www.HolmanGroup.com, or by mailing your written
Request for Review to HPCC, P.O. Box 8011, Canoga Park, CA 91309.
* You may want to submit your Request for Review to HPCC first if you believe
your cancellation, rescission or nonrenewal is the result of a mistake. Requests for
Review should be submitted as soon as possible after you receive the Notice of
Cancellation, Rescission, or Nonrenewal.
* HPCC will resolve your Request for Review or provide a pending status
within three (3) days. If the plan upholds your cancellation, rescission or
nonrenewal, it will immediately transmit your Request for Review to the Department
of Managed Health Care and you will be notified of the plan's decision and your
right to also seek a further review of the plan's decision by the Department as
detailed under
Option 2, below.
Option (2) - You may submit a Request for Review to the Department of Managed
Health Care.
* You may submit a Request for Review directly to the Department of Managed
Health Care without first submitting it to the plan or after you have received the
plan's decision on your Request for Review.
* Requests for Review by the Department of Managed Health Care may be
submitted:
By mail:
HELP CENTER
DEPARTMENT OF MANAGED HEALTH CARE
980 NINTH STREET, SUITE 500
SACRAMENTO, CALIFORNIA 95814-2725
BY PHONE:
1-888-466-2219
TDD: 1-877-688-9891
FAX.- 1-916-255-5241 OR
ONLINE:
2.12 Notification of Continuation Coverage to Successor Group Benefit Plan. Employer shall
notify the successor group benefit plan in writing of the qualified beneficiaries currently
00238534.1 Rev. 2017 11
receiving continuation coverage so that the successor plan, or contracting employer or
administrator, may provide those qualified beneficiaries with the necessary Premium
information, enrollment forms, and instructions consistent with the required disclosure in
order to allow the qualified beneficiary to continue coverage.
3.0 COVENANTS OF HPCC
3.1 Provision of Services. HPCC shall provide EAP Services through Providers pursuant to the
Schedule of Benefits. If an Enrollee wishes to use a Contracted Provider, such Enrollee
shall telephone HPCC at (800) 321-2843. HPCC will then assign the Enrollee to an
appropriate Contracted Provider based upon intake information that HPCC will
request in its telephone conversation with the Enrollee. If the Enrollee wishes to use a Non -
Contracted Provider, Enrollee would do so at his or her own expense, and it shall be the
responsibility of the Enrollee to arrange for services to be rendered with the NonContracted
Provider.
3.2 Additional Services. In addition to Behavioral EAP, HPCC will also provide legal and
financial counseling referrals to its Enrollees.
3.3 Policies and Procedure Assistance. HPCC shall be available to assist Employer in
developing internal policies and procedures for referring Enrollees to HPCC for EAP
Services.
3.4 Provision of EAP Brochure. HPCC shall provide a generic Employee Assistance Program
brochure to Employer and shall consult with Employer and Employer's representatives
about it.
3.5 Access to HPCC. HPCC shall make available to Enrollees the telephone number of HPCC
for making appointments and obtaining information with respect to services provided by
HPCC pursuant to this Group Plan Contract.
3.6 Quality Control. HPCC shall establish and maintain a quality control procedure, under the
oversight of the Quality Management and Utilization Management Committees. This
process will govern all private and group sessions provided by Contracted Providers, in
order to assure delivery of effective health care services to Enrollee.
3.7 Provider Ethics Requirement. HPCC shall require all Contracted Providers and their
authorized professional employees to abide by all ethical principles and standards of their
respective professions.
3.8 Premiums and Benefits Increase/Decrease. HPCC shall not increase the amount of the
Premium to be paid by Employer, or otherwise increase the compensation to be paid to
HPCC by Employer for services provided pursuant to this Group Plan Contract, except
after a period of at least thirty (30) days from either 1) the postage paid mailing to the
00238534.1 Rev. 2017 12
Employer's business address, or 2) by hand delivery of the written notice of such increase
to the Employer by HPCC. If the increase is at time of renewal, then the time frame for
notice of increase is thirty (30) days. HPCC shall not decrease the amount of benefits to
be provided pursuant to this Group Plan Contract except after a period of at least thirty (30)
days from either the postage paid mailing to the Employer, or by hand delivery to Employer
of a written notice of such decrease.
3.9 Provider Insurance. HPCC shall require that all Providers have malpractice liability
insurance coverage for one million dollars ($1,000,000.00) per each occurrence and one
million dollars ($1,000,000.00) in the aggregate.
3.10 HPCC Insurance. HPCC will carry:
3.10.1 Comprehensive general liability insurance, $2,000,000 each occurrence (bodily
injury and property damage) and business personal property insurance on all HPCC
facilities in the amount of $1,557, 961.
3.10.2 Statutory Worker's Compensation insurance coverage for all HPCC employees up
to California Statutory limit of $1,000,000.
3.10.3 Fidelity Bond in the amount in compliance with applicable Department of Managed
Health Care regulations.
4.0 GENERAL PROVISIONS
4.1 Period of Coverage. Coverage of Enrollees shall become effective on the date set forth on
the signature page provided Employer has paid the required Premium, and coverage shall
end on the last day of month for which Premium was paid or when this Group Plan Contract
is terminated.
4.2 Annual Benefit Maximum. Payments for HPCC authorized services are limited to those
benefits outlined in Exhibit A.
4.3 Co -payments. Enrollee and Enrollee's eligible dependent(s) are not responsible for paying
co -payment amounts unless outlined in "Exhibit A".
4.4 Service Specifics. EAP services shall be provided by HPCC in either HPCC's offices,
Providers' offices, or in an office provided by Employer at a work location. Normally
services shall be delivered within five business days of a request by an Enrollee.
Emergency services will be available on a - our -per- ay, 7-day-per-week basis, w is
may result in a face to face EAP session or a referral to a hospital or psychiatrist.
4.5 Confidentiality. HPCC will maintain the confidentiality of all Enrollee records in
accordance with the Health Information Portability and Accountability Act (HIPAA) and
00238534.1 Rev. 2017 13
other applicable federal and state laws. Except to the extent that disclosure is authorized by
the Enrollee in writing or is otherwise mandated or permitted by law.
A STATEMENT DESCRIBING HPCC'S POLICIES AND PROCEDURES FOR
PRESERVING THE CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE
AND WILL BE FURNISHED TO THE EMPLOYER AND/OR ENROLLEE UPON
REQUEST.
Providers are required to maintain records and provide such information HPCC or to the
Director as may be necessary for compliance by the HPCC with provisions of the
Act and the rules thereunder; that such records will be retained by the provider for at least
five years, and that such obligation is not terminated upon a termination of the agreement,
whether by rescission or otherwise.
4.6 Choice of Providers. A HPCC clinician or Care Access Specialist will refer Enrollees to a
Contracted Providers in their community. If the Enrollee uses a Non -Contracted Provider,
the Enrollee may choose which Non -Contracted Provider to use and is responsible for
arranging for services to be rendered and for any charges incurred. HPCC shall not
reimburse Enrollees who secure services from licensed Non -Contracted Providers except
in emergency cases or as outlined in this Group Plan Contract. Section 1.7 defines
contracted providers.
4.7 Concurrent Reviews. In order to determine continuing Medical Necessity for an Enrollee's
treatment, concurrent reviews of Enrollee's treatment will occur on a regular basis. During
each review, a HPCC clinician monitors the Enrollee's course of treatment to determine its
effectiveness, the appropriate level of care, and continued Medical Necessity. The HPCC
clinician must authorize all extended lengths of stay and transfers to different levels of care
as well as any related additional services. HPCC's Process and Criteria for determining
Medical Necessity will be furnished to the Enrollee upon request.
4.8 Enrollee Reimbursement Provisions. HPCC has made arrangements with its Contracted
Providers to ensure that all bills are submitted directly to HPCC for payment. However, if
an Enrollee receives emergency behavioral health treatment from a Non -Contracted
Provider, the Enrollee may receive a bill for such services. The Enrollee must provide
HPCC with a copy of the bill or claim as soon as possible. Enrollees should mail claims to:
HPCC Professional Counseling Centers, P.O. Box 8011, Canoga Park, CA 91309.
4.9 HPCC Provider Compensation Procedure. HPCC Providers are paid on a discounted
feefor-service or fixed charge per day. HPCC does not use or permit any type of financial
onuses or incentives in its contracts With rovi ers.
4.10 Liability of HPCC upon Provider Termination. Upon termination of a Provider Agreement
by any Contracted Provider, HPCC shall be liable for covered services rendered by such
Provider, to an Enrollee who retains eligibility under the Group Plan Contract and who is
00238534.1 Rev. 2017 14
under the care of such Provider, at the time of such termination until the services being
rendered by such Provider, are completed. HPCC may make appropriate provisions for the
assumption of such services by another Provider.
4.10.1 HPCC shall provide 30 day written notice to any Enrollee whose provider
terminates, breaches the contract, or is unable to perform within the limits of the
law. HPCC will also provide this notice if the provider's actions may materially or
adversely affect the enrollee.
4.11 Coordination of Benefits. Pursuant to the provisions below, HPCC will not be responsible
for making payments for services when another plan is primarily responsible for making
payment for such services:
4.11.1 A "plan" is considered to be any group insurance coverage or other arrangement of
coverage for individuals in a group that provides benefits or services on an insured
or uninsured basis, and any governmental program providing benefits or services
of a similar nature.
4.11.2 An "allowable expense" is any necessary, reasonable and customary mental health
expense covered by HPCC and covered in full or in part under any one of the plans
involved.
4.11.3 With respect to coordinating benefits with other carriers, the "primary" plan pays its
benefits without regard to any other plans. The "secondary" plans adjust their
benefits so that the total benefits available will not exceed the allowable expenses.
No plan will pay more than it does without the coordinating provision.
4.11.4 A plan without a coordinating provision is always the primary plan. If all plans have
such a provision (1) the plan covering the Enrollee directly, rather than an
Enrollee's dependent, is primary and the others are secondary; (2) if a child is
covered under both parents' plans, when two members are under the same plan in
a family, the member whose birthday falls first in a calendar year is the one who
will be utilized; (3) if neither (1) nor (2) applies, the plan which has covered the
Enrollee the longest period of time is primary.
4.11.5 Employer shall provide HPCC with any information it may have regarding other
plans of its employee that may cover services provided by HPCC. HPCC may
exchange benefit information with insurance companies, organizations and
individuals, and has the right to recover any overpayment made from Employer if
there is neglect by Employer in reporting coverage under another plan.
4.11.6 An Enrollee may not be covered as an Employee and Dependent on a plan, and an
Enrollee's dependents may not be covered by more than one Employee. If an
Enrollee is an Employee who is also a dependent of an Enrollee, the Enrollee will
be insured solely as an Employee and all co -payments will be waived. In this case,
00238534.1 Rev. 2017 15
the combined maximum contractual benefits to which an enrollee is entitled under
the terms of the master contract is not to exceed in the aggregate 100 percent of the
charge for the covered expense or service. If an Enrollee and spouse belong to
different HPCC plans, each of the children, stepchildren, and legally adopted
children may be insured under one HPCC plan only and all copayments will be
waived.
4.12 Charges for Missed Appointments. An Enrollee will forfeit one (1) EAP session for any
appointment made with a Contracted Provider and not kept, except in those cases where
the Contracted Provider is notified at least twenty-four (24) hours in advance of the
appointment that it will not be kept or the failure to keep the appointment was due to
circumstances beyond the Enrollee's reasonable control. HPCC will pay for no more than
two (2) late/cancel no show sessions in any one benefit year at the late cancellation/no show
rate after which enrollee will be responsible for payment to the provider at HPCC's
contracted rate.
4.13 Liability of Enrollee for Payment for Pre -Authorized Services. Every contract between
HPCC and its Contracting Providers will contain a provision stating that Enrollees shall
not be responsible for payment to any Contracted Provider in the event that HPCC should
fail to pay the Provider for services rendered, unless such services are determined to not be
covered under this Agreement. Authorized treatment by a provider shall not be rescinded
or modified after the provider renders the service in good faith pursuant to the
authorization.
4.14 Second Medical Opinions. An Enrollee or participating provider, who is treating an
Enrollee, may request a second opinion by an appropriately qualified health care
professional. Reasons for a second opinion to be provided or authorized shall include, but
are not limited to, the following:
• Reasonableness or necessity of recommended treatment is questioned;
• Diagnosis or treatment plan is questioned;
• Clinical indications are not clear or are complex and confusing;
• Treatment plan in progress is not improving the condition of the Enrollee within an
appropriate period of time given the diagnosis and plan of care.
HPCC's decision to grant or deny the request for a second medical opinion will be
delivered to the individual who requested the second medical opinion. If the Enrollee faces
2n imminent and serious threat to his or her mental health, be
rendered within (72) hours after the receipt of the request. If the request for a second
opinion is approved, the Enrollee will be responsible for all applicable co -payments. If the
request for a second opinion is denied, the Enrollee will be notified in writing of the reasons
for the denial and shall be informed of the right to file a grievance with the Plan. The
00238534.1 Rev. 2017 16
request for a second medical opinion can be made by calling HPCC at 1-800-3212843, or
by writing to: Holman Professional Counseling Centers, Care Management Department,
P.O. Box 8011, Canoga Park, CA 91309.
4.15 Renewal Provisions. This Group Plan Contract is for a term of two years unless otherwise
indicated. The Group Plan Contract will be automatically renewed annually at the same
rate, unless HPCC and Employer agree on different terms at the time of renewal or unless
terminated pursuant to Section 4.16. Employer will notify Enrollees of any change to the
Group Plan thirty (30) days prior to the effective date of coverage. At renewal, any
change in the benefits included in this EAP contract will constitute the termination of this
contract. Should Employer wish to continue with HPCC providing some additional benefits
or fewer benefits, a new contract outlining the new terms and new premium, will be
provided.
4.16 Independent Medical Review Process:
4.16.1 The California Department of Managed Health Care provides an Independent
Medical Review process for coverage decisions that have been denied, modified,
or delayed by a decision of HPCC due to a finding that the service is not Medically
Necessary.
4.16.2 HPCC shall provide enrollees whose coverage request has been denied, modified,
or delayed due to a finding that such treatment is not Medically Necessary with the
opportunity to seek an independent review. An enrollee may apply to the
Department within six months of HPCC's denial, modification, or delay of a
coverage decision, for an Independent Medical Review when all of the following
conditions are met:
a. Enrollee's provider has recommended a health care service as Medically
Necessary, or enrollee has received urgent care or emergency services that
a provider determined was medically necessary; or enrollee, in the absence
of a provider recommendation or the receipt of urgent or emergency care
services by a provider, has been seen by contracted provider for the
diagnosis or treatment of the medical condition for which the enrollee seeks
Independent Medical Review.
b. The disputed health care service has been denied, modified, or delayed by
HPCC based in whole or in part on a decision that the health care service is
not Medically Necessary.
c. The enrollee has filed a grievance with HPCC and the disputed decision is
upheld or the grievance remains unresolved after thirty (30) days, or three
(3) days in the case of an expedited review case.
00238534.1 Rev. 2017 17
4.16.3 The enrollee has the right to file information in support of the request for review.
The Independent Medical Review panel shall provide the Department of Managed
Health (Department) Care Director, HPCC, the enrollee, and the enrollee's provider
with an analyses and determination of the case. The Department Director shall
immediately adopt the determination of the independent medical review
organization, and shall promptly issue a written decision to the parties that shall be
binding on HPCC.
4.16.4 Upon receiving the decision of the Department Director that a disputed health care
services is medically necessary, HPCC shall immediately contact the enrollee and
offer to promptly implement the decision.
4.16.5 An enrollee's decision not to participate in the Independent Medical Review
Process may cause the enrollee to forfeit any statutory right to pursue legal action
against HPCC regarding the disputed health care service.
4.16.6 Additional information on the Independent Medical Review Process may be
obtained by contacting HPCC by phone at 1-800-321-2843 or in writing at Holman
Professional Counseling Centers, P.O. Box 8011, Canoga Park, CA 91309.
4.17 Experimental/Investigational Therapies- External, Independent Review Process: HPCC
will provide an external, independent review process for treatment decisions regarding
experimental or investigational therapies for individual enrollees who meet all of the
following criteria:
4.17.1 Enrollee has a life -threatening or Substance Related condition;
4.17.2 Enrollee's physician certifies that the enrollee has a life -threatening Substance
Related or seriously debilitating Substance Related condition for which standard
therapies would not be medically appropriate for the enrollee or for which there is
no more beneficial standard therapy covered by the plan than the therapy proposed
in the next section 4.19.3;
4.17.3 Either 1) the enrollee's contracted provider has recommended a drug, device,
procedure, or other therapy that the provider certifies in writing is likely to be more
beneficial to the enrollee than any available standard therapies, or 2) the enrollee,
or the enrollee's contracted provider, has requested a therapy that, based on two
documents from the medical and scientific evidence, is likely to be more beneficial
for the enrollee than any available standard therapy. The provider certification
pursuant to this section shall include a statement of the evidence relied upon by the
provider in certifying his or tier recommendation,
4.17.4 Enrollee has been denied coverage by HPCC for a drug, device, procedure, or other
therapy recommended or requested pursuant to paragraph 4.19.3 above;
00238534.1 Rev. 2017 18
4.17.5 The specific drug, device, procedure, or other therapy recommended pursuant to
paragraph 4.19.3 above would be a covered service, except for HPCC's
determination that the therapy is experimental or investigational.
For those enrollees who meet the above listed criteria, HPCC will offer the
opportunity to have the requested therapy reviewed under the external, independent
review process. HPCC will notify the enrollee in writing of this opportunity to
request such review within five (5) business days of the decision to deny coverage.
The enrollee has the right to file information in support of the request for
independent review.
The external, independent review panel, consisting of at least two experts, shall
render a decision within thirty (30) days of receipt of the review request, unless a
shorter time period is warranted by the enrollee's condition. If a majority of the
expert panel recommends the experimental or investigational treatment, the
decision shall be binding on HPCC. If the panel is evenly divided, the treatment
shall be provided by HPCC. If less than half of the panel recommends against the
experimental or investigational treatment, then HPCC is not required to provide the
treatment.
4.18 Cancellations, Terminations, and Non -renewal. Cancellation, termination or non -renewal
of this Group Plan Contract may only be effected in accordance with the following
provisions:
4.18.1 This Group Plan Contract may be canceled, terminated or non -renewed by HPCC
for the following reasons:
a. Failure to pay. For nonpayment of the required premiums owed to HPCC if
the employer has been duly notified and billed for the charge and at least a
30-day grace period has elapsed since the date of the receipt of the last
premium payment. Coverage will continue during the grace period;
however, the Employer will be still responsible to pay unpaid premiums and
the Enrollee will be responsible for any copayments, coinsurance or
deductible amounts required under the group plan contract.
b. Fraud. For fraud or misrepresentation by Employer with respect to coverage
of individuals, the individuals, or their representatives.
C. Noncompliance. Failure to comply with the Plan's participation or
employer contribution requirements at time of renewal.
d. Either party may cancel this contract with or without cause with 30 days
written notice to the other party.
00238534.1 Rev. 2017 19
e. In all instances of cancellation in (a-d) aforementioned, written notice will
be given thirty (30) days prior to date of cancellation and cancellation will
not be retroactive. Enrollment will be cancelled as of the last day for which
payment has been received, subject to compliance with stated notice
requirements.
4.18.2 HPCC may terminate, cancel or decline to renew this Agreement when required to
effectuate the purposes of the Knox -Keene Health Care Service Plan Act, with the
consent of the Director of the Department of Managed Health Care.
4.18.3 All benefits under this Contract shall cease as of the date of cancellation,
termination, or non -renewal with HPCC and Employer being released from all
further obligations.
4.18.4 In the event of cancellation by HPCC (except in the case of fraud or deception in
the use of services or facilities of HPCC or knowingly permitting such fraud or
deception by another) or by Employer, HPCC shall, within thirty (30) days, return
to Employer the prorated portion, if any, of the money paid to HPCC which
corresponds to any unexpired period of which payment has been received, less any
amounts due HPCC.
4.18.5 Acceptance by HPCC of the proper prepaid or periodic payment, after termination
of this Group Plan Contract and without requiring new application, shall reinstate
the Contract as though it had never terminated or been canceled unless HPCC shall,
within five (5) business days of receipt of such payment, either refund the payment
so made or issue to the other party a new contract accompanied by written notice
stating clearly those respects in which the new contract differs from the terminated
contract in benefits, coverage, or otherwise.
4.18.6 Section 1374.72 of the Health and Safety Code requires health care plans to provide
coverage for the diagnosis and medically necessary treatment and management of
mental health services (as defined) in a manner that matches the Employer's
medical plan benefits. In order to ensure that this matching is current and accurate,
Employers must notify HPCC of any benefit changes in their full service health
plan within 90 days of the effective date of such changes.
4.18.7 In the case of this group plan contract, violation of a material contract provision
relating to employer contribution or group participation rates by the contract holder
or employer.
4.19 Individual on inua ion of Services: Federal COBRA Provisions.
4.19.1 The Federal Consolidated Omnibus Reconciliation Act of 1985 provides for the
continuation of health insurance coverage for eligible enrollees and their
dependents, of employers/trusts with 20 and over eligible employees, for a defined
00238534.1 Rev. 2017 20
period of time after certain qualifying events occur. Ordinarily, an Enrollee's
benefits will cease when employer/trust's group Coverage terminates or under any
other circumstance listed in "Termination of Benefits". However, in the case of
certain qualifying events, a qualified Enrollee and Enrollee's Eligible Dependents
may be able to continue group plan coverage under federal COBRA (Consolidated
Omnibus Budget Reconciliation Act of 1985) provisions for a limited time, if
Enrollee agrees to pay the Premium for such coverage. A qualified enrollee is an
enrollee, who on the day before a qualifying event, is an enrollee in a group benefit
plan offered by a health care service plan, and who has a qualifying event. A
qualifying event is limited to the following: death of covered Enrollee; termination
of employment or reduction in hours of the covered Enrollee's employment for
reasons other than gross misconduct; divorce or legal separation of the covered
Enrollee from the covered Enrollee's spouse; or loss of dependent status by a
dependent enrolled in the Group Plan.
4.19.2 The qualified Enrollee shall, upon election, be able to continue his or her coverage
under the Group Plan Contract, subject to the Group Plan's terms and conditions,
for a limited amount of time. The Enrollee must elect COBRA coverage by
notifying the Enrollee's Employer/trust in writing within sixty (60) days of the date
of the qualifying event. The written request must be delivered by first-class mail,
or other reliable means of delivery, including personal delivery, express mail, or
private courier company, to the Employer/trust within the sixty (60) day period
following the later of 1) the date that the Enrollee's coverage under the group plan
contract terminated or will terminate by reason of a qualifying event, or 2) the date
the Enrollee was sent notice of the ability to continue coverage under the Group
Plan Contract.
4.19.3 The failure to notify the Employer/trust within the required sixty (60) days will
disqualify the qualified beneficiary from receiving continuation coverage under
COBRA provisions. An Enrollee electing continuation shall pay to the
Employer/trust in accordance with the terms and conditions of the group plan
contract, the amount of the required Premium payment. The Enrollee's first
Premium payment required to establish Premium payment shall be delivered by
first-class mail, certified mail, or other reliable means of delivery, including
personal delivery, express mail, or private courier company, to the Employer/trust
within forty-five (45) days of the date the qualified beneficiary provided written
notice to Employer/trust, of the election to continue coverage, in order for coverage
to be continued under COBRA provisions.
4194 The first Premium payment must equal an amount sufficient to pay any required
Premiums and all Premiums due, and failure to submit the correct Premium amount
within the forty-five (45) day period will disqualify the Enrollee from receiving
continuation coverage pursuant to COBRA provisions. Enrollees whose
continuation coverage terminates under a prior Group Plan may continue their
00238534.1 Rev. 2017 21
coverage for the balance of the period that the Enrollee would have remained
covered under the prior Group Plan. Enrollees electing to continue coverage must
notify Employer/trust in writing and pay to the Employer/trust the required
Premium payments. The continuations coverage will terminate if the Enrollee fails
to comply with the requirements pertaining to enrollment in, and payment of
Premiums to, the new Group Plan Contract within thirty (30) days of receiving
notice of the termination of the prior group plan contract.
4.19.5 A qualified enrollee can request Cal -Cobra at the conclusion of their Federal Cobra
benefits explained below.
Cal -Cobra Provisions (applicable only to California enrollees)
The California Continuation Benefits Replacement Act (Cal -COBRA) provides
that continued access to health insurance coverage is provided to employees, and
their dependents, of employers/trusts with 2 to 19 eligible employees who are not
currently offered continuation coverage under the federal COBRA, and those
eligible enrollees who have exhausted their Federal COBRA benefits. For a
California qualified enrollee whose Cal -COBRA coverage begins on or after
January 1, 2003, and who has exhausted continuation coverage under COBRA, the
enrollee may extend their Cal -COBRA coverage for up to 36 months after the date
the qualified enrollee's benefits under a group plan health contract would otherwise
have ended because of a qualifying event if the enrollee agrees to pay the Premium
for such coverage. A qualified enrollee is an enrollee, who on the day before a
qualifying event is an enrollee in a group benefit plan offered by a health care
service plan, and who has a qualifying event. A Cal -COBRA qualifying event is
limited to the following: death of covered enrollee, termination of employment or
reduction in hours of the covered enrollee's employment for reasons other than
gross misconduct; divorce or legal separation of the covered enrollee from the
covered enrollee's spouse, or loss of dependent status by a dependent enrolled in
the group plan.
The qualified enrollee must notify their employer/trust within 60 days of the date
of the qualifying event. Failure to make such notification within the required 60
days will disqualify the enrollee from receiving continuation coverage. A qualified
enrollee who wishes to continue coverage under the group benefit plan must request
the continuation in writing and deliver the written request, by firstclass mail, or
other reliable means of delivery, including personal delivery, express mail, or
private courier company, to the employer/trust -within the 60-day period following
the later of (1) the date that the enrollee's coverage under the group benefit plan
terminated or will terminate by reason of a qualifying event, or (2) the date the
enrollee was sent notice of the ability to continue coverage under the group benefit
plan.
00238534.1 Rev. 2017 22
A qualified beneficiary electing continuation shall pay to their employer/trust the
required Premium on or before the due date of each payment but not more
frequently than on a monthly basis. The Premium will not be more than 110 percent
of the applicable rate charged for a covered employee or, in the case of dependent
coverage, not more than 110 percent of the applicable rate charged to a similarly
situated individual under the group benefit plan being continued under the group
contract. In the case of a qualified beneficiary who is determined to be disabled
pursuant to Title II or Title XVI of the United States Social Security Act, the
qualified beneficiary shall be required to pay to their employer/trust an amount no
greater than 150 percent of the group rate after the first 18 months of continuation
coverage provided pursuant to this section.
The qualified enrollee's first Premium payment required to establish Premium
payment shall be delivered by first-class mail, certified mail, or other reliable means
of delivery, including personal delivery, express mail, or private courier company,
to the employer/trust within 45 days of the date the qualified enrollee provided
written notice to the employer/trust of the election to continue coverage.
The first Premium payment must equal an amount sufficient to pay any required
Premiums and all Premiums due, and failure to submit the correct Premium amount
within the 45-day period will disqualify the qualified beneficiary from receiving
continuation coverage. —In the event the qualified enrollee does not receive
information from his or her employer/trust, i.e. Premium amount and due date, the
qualified enrollee should contact HPCC using the contact information provided
below.
Individuals not eligible for Cal -COBRA are those who: are entitled to Medicare
benefits; have other hospital, medical, or surgical coverage; are eligible for federal
COBRA; are eligible for coverage under Chapter 6A of the Public Health Service
Act; fail to meet the specified time limits for electing coverage; and, fail to submit
the correct premium amount required.
Enrollees whose continuation coverage terminates under a prior group plan may
continue their coverage for the balance of the period that the enrollee would have
remained covered under the prior group plan. Enrollees electing to continue
coverage must notify employer/trust in writing and pay to the employer/trust the
required Premium payments. The continuations coverage will terminate if the
enrollee fails to comply with the requirements pertaining to enrollment in, and
payment of Premiums to, the new group plan contract within thirty (30) days of
receiving notice of the termination of the prior group plan contract.
For more information on how to extend their Cal -COBRA coverage, the enrollee
should contact Lisa Solomon by phone at 1-800-321-2843, or in writing at HPCC
Professional Counseling Centers, P.O. Box 8011, Canoga Park, CA 91309.
00238534.1 Rev. 2017 23
4.19.6 Language Interpretation: HPCC retains sole, full and final discretionary authority
to construe and interpret the language of all provisions in this contract, in order to
clarify its initial intention when and if there are questions of fact and law arising
regarding any HPCC provisions.
5.0 EXCLUSIONS:
5.1 Services provided by Non -Contracted Providers.
5.2 Treatments which do not meet national standards for behavioral health professional
practice.
5.3 Court ordered outpatient treatment is covered only when Medically Necessary. Reporting
to the court and interacting with the court are not covered services under this Agreement,
and if requested, the requesting party will be responsible for all costs associated.
5.4 Academic or educational testing. Services to remedy an academic or educational problem
are not an EAP covered benefit.
5.5 EAP Psychotherapy used as professional training and not for the treatment of a medical or
mental condition, is not an EAP covered benefit.
5.6 Use of sexual surrogate, sexual treatment of sexual offenders or perpetrators of sexual
violence are not an EAP covered benefit. Reporting to the court and interacting with the
court are not covered services under this Agreement.
5.7 Pastoral or spiritual counseling, if delivered by a licensed therapist, will be covered under
EAP benefits.
5.8 Experimental or investigational therapies which are not recognized in accordance with
professionally recognized standards of practice as being safe and effective for use are not
an EAP covered benefit.
5.9 All non-prescription and prescription drugs prescribed in connection with an enrollee's
treatment, are not an EAP covered benefit.
5.10 Surgery, acupuncture, physical therapy, or occupational therapy, are not an EAP covered
benefit.
5-1-1- Neurological services and tests, hhiding but not limited to- EEGs, Pet scans, beam ccan,
MRIs, skull X-rays, and lumbar punctures, are not an EAP covered benefit.
5.12 Acute care hospital, residential outpatient, day treatment, and partial hospital services are
not an EAP covered benefit.
00238534.1 Rev. 2017 24
5.13 Bio-feedback is not an EAP covered benefit.
5.14 Any service that is not specifically listed as a covered benefit is not an EAP covered benefit.
5.15 HPCC is the decider of Medical Necessity subject to only Department review process.
6.0 ENROLLEE GRIEVANCE PROCESS
6.1 Enrollee Grievance Process
Grievances will be directed to the Compliance Specialist. Enrollee's shall have up to 180
calendar days following any incident or action that is the subject of the enrollee's
dissatisfaction to file a grievance with HPCC. The Compliance Specialist will work
together with the Enrollee to resolve the issue if possible. If no solution is reached, the
Compliance Specialist will refer the matter to the Grievance Committee. The HPCC
Grievance Committee will review the grievance and within thirty (30) days from HPCC's
receipt of the grievance, HPCC will send a written notice of the resolution. If the grievance
is denied, the notice will explain how the Enrollee may appeal the decision of the Grievance
Committee. HPCC shall assure that there is no discrimination against an enrollee or
subscriber (including cancellation of the contract) on the grounds that the
complainant filed a grievance.
6.2 Arbitration. If the Enrollee remains dissatisfied with the decision, the Enrollee may submit
a request to HPCC to submit the grievance to binding Arbitration before the American
Arbitration Association. Pursuant to California law a single neutral arbitrator who shall be
chosen by the parties and who shall have no jurisdiction to award more than $200,000 must
decide any claim of up to $200,000. However, after a request for arbitration has been
submitted, HPCC and the Enrollee may agree in writing to waive the requirement to use a
single arbitrator and instead use a tripartite arbitration panel that includes the two party -
appointed arbitrators or a panel of three neutral arbitrators or another multiple arbitrator
system mutually agreeable to the parties. The Enrollee shall have three (3) business days
to rescind the waiver agreement unless the agreement has also been signed by the Enrollee's
attorney, in which case the waiver cannot be rescinded. In cases of extreme hardship, HPCC
may assume all or part of the Enrollee's share of the fees and expenses of the neutral
arbitrator provided the Enrollee has submitted a hardship application with the American
Arbitration Association. The American Arbitration Association shall determine the
approval or denial of a hardship application. A hardship application may be obtained by
contacting the American Arbitration Association in Los Angeles at 213-383-6516, in
Orange County at 714-474-5090, in San Diego at 619-2393051 and in San Francisco at
415-981-3901.
6.2.1 If the Enrollee does not request arbitration within six months from the date of the
Grievance Resolution Notice, the decision of the Committee shall be final and
binding. However, if the Enrollee has legitimate health or other reasons which
00238534.1 Rev. 2017 25
would prevent them from electing binding arbitration in a timely manner, the
Enrollee will have as long as necessary to accommodate his or her special needs in
order to elect binding arbitration. Further, if the Enrollee seeks review by the
Department of Managed Health Care, the Enrollee will have an additional ninety
(90) days from the date of the final resolution of the matter by the Department of
Managed Health Care to elect binding arbitration. Upon submission of a dispute to
the American Arbitration Association, both the Enrollee and HPCC agree to be
bound by the rules of procedure and decision of the American Arbitration
Association. Full discovery shall be permitted in preparation for arbitration
pursuant to California Code of Civil Procedure, Section 1285.05.
6.3 Expedited Grievance Review/Appeal Review. For cases involving an imminent and serious
threat to the health of the enrollee, including, but not limited to, severe pain, potential loss
of life, limb, or major bodily function, HPCC provides expedited review. When HPCC has
notice of a case requiring expedited review, HPCC shall immediately inform the enrollee
in writing of their right to notify the Department of Managed Health Care of the request.
For these cases, HPCC will provide the Enrollee and the Department with a written
statement on the disposition or pending status of the request no later than three (3) days
from receipt.
6.4 Treatment Denials. If a Provider or Enrollee notifies HPCC of a dissatisfaction regarding
a treatment authorization denial, it will be directed to the assigned staff. HPCC will work
together with the Provider and/or Enrollee to resolve the complaint. Within thirty (30) days
from HPCC's receipt of the complaint, HPCC will send the Provider and/or Enrollee a
written notice of the resolution. If the Provider or Enrollee's complaint is denied, the notice
will explain how the Provider or Enrollee may appeal the decision.
6.5 Treatment Denial Appeals. If the Provider/Enrollee is dissatisfied with HPCC's resolution
of the treatment denial, the Provider/Enrollee may file an appeal through either the
American Arbitration Association or the Department of Managed Health Care.
6.5.1 Expedited reviews of treatment denials are available to Providers and/or Enrollees.
In these cases, HPCC will provide verbal resolution within eight (8) business hours
of HPCC's receipt of necessary information to make an informed decision and in
writing within two (2) days of receipt.
6.6 California Department of Managed Health Care. The California Department of Managed
Health Care is responsible for regulating health care service plans. If you have a grievance
against HPCC Professional Counseling Centers, you should first telephone HPCC
Professional Counseling Centers, at (1-800-321-2843) and use Holman Professional
Counseling Centers, grievance process before contacting the Department. Utilizing this
grievance procedure does not prohibit any potential legal rights or remedies that may be
available to you. If you need help with a grievance involving an emergency, a grievance
00238534.1 Rev. 2017 26
that has not been satisfactorily resolved by HPCC Professional Counseling Centers, or a
grievance that has remained unresolved for more than thirty (30) days, you may call the
Department for assistance. You may also be eligible for an Independent Medical Review
(IMR). If you are eligible for IMR, the IMR process will provide an impartial review of
medical decisions made by HPCC Professional Counseling Centers, related to the medical
necessity of a proposed service or treatment, coverage decisions for treatments that are
experimental or investigational in nature and payment disputes for emergency or urgent
medical services. The Department also has a toll -free telephone number (1-888-HMO-
2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The
Department's Internet website http://www.hmohelp.ca.gov has complaint forms, IMR
application forms and instructions online. HPCC also has these forms available and will
furnish them as appropriate and required.
6.7 Claims Disclosure Notice Required by ERISA. If a plan is subject to ERISA, ERISA
applies some additional claim procedure rules. These additional rules set forth by ERISA
will be provided in accordance with the applicable section in the Agreement between
"Company Name" and their medical plan.
7.0 GENERAL
7.1 HPCC's Medical Necessity Philosophy. HPCC's Medical Necessity Philosophy includes
authorizing the most intensive treatment in the least restrictive setting because life's
problems MUST be solved while engaged in life; living at home, on the job and with family
and friends. At the same time, as the Enrollee starts to put into practice the coping
mechanisms and life skill tools that are learned or re -awakened in therapy, we want the
Enrollee to start to stand on their own without developing a dependency on a therapist. This
standing on your own can result in scheduling sessions every other week to every three/four
weeks. Once ending a course of treatment and implementing the NEW coping tools for
some time and as your medical needs dictate, you are always encouraged to call again,
within the EAP benefit.
7.2 Language Assistance Program ("LAP") The Department of Managed Health Care
("Department") of California has added Section 1300.67.04 (Language Assistance
Programs) to Title 28 California Code of Regulations. This new regulation requires health
care service Plans to implement new policies, procedures and quality improvement efforts
in regards to assisting those who are Limited English Proficient ("LEP"). The Department
regulations require California health Plans to set up a system where services, materials, and
information are provided to members in a language that they speak and understand.
HPCC has established a free Language Assistance Program LAP") and made the
following resources available for LEP individuals: Translations (of both vital and nonvital
documents), Interpreters, and Bilingual staff/Providers. These resources are available for
all persons speaking any language other than English, who request these services at any of
our points of contact.
00238534.1 Rev. 2017 27
In accordance with the Department regulations, HPCC has identified its threshold
language(s) which comprise five (5) percent of its Enrollee Population. All vital documents
as identified by the Department will be translated into the threshold language. All non -
vital documents will contain a notice at the bottom of said document (in the threshold
language) informing the member how to request a translation of the document.
7.3 HPCC's Public Policy Committee. HPCC operates a Public Policy Committee that is
mandated to maintain professional standards. It functions as an open forum to provide
Enrollees with an opportunity to discuss prevailing societal issues, difficulties with current
policies, and additional available services. The purpose of the Public Policy Committee is
to ensure the comfort, dignity, and convenience of persons relying upon HPCC for
Behavioral Health Services. In order to assure Enrollee participation in HPCC policy, the
Public Policy Committee shall consist of the following members: HPCC Executive Vice
President, Director of Corporate Account Management, Account Management staff and a
minimum of three current Enrollees. The Executive Vice President selects the Enrollee
members of the Public Policy Committee. Any Enrollee interested in the Public Policy
Committee may direct his or her request in writing to:
HPCC Professional Counseling Centers, P.O. Box 8011, Canoga Park, CA 91309.
7.4 Antifraud Policy and Procedures. HPCC makes every effort to detect, investigate, and
prosecute any incidents of fraud at any level within its Behavioral Health Service. HPCC
contracts with a special investigator trained in fraud investigation to assist us in
investigating fraud. In the event that HPCC detects any fraudulent activity on the part of a
Provider, the Provider's contract with HPCC will be terminated. If HPCC detects any
fraudulent activity on the part of an Enrollee or Employer, HPCC will deny Enrollee any
additional benefits under Enrollee's Group Plan and may terminate Employer or the
Enrollee. Additionally, HPCC will prosecute fraud to the fullest extent of the law. We also
cooperate with all government agencies in a combined effort to prevent and prosecute fraud
on the part of both Providers and Enrollees.
7.5 Enrollees Held Harmless. As required by California law, every contract between HPCC
and a Provider shall provide that the Provider accepts the payment rate under the HPCC
Agreement as payment in full. The Provider may not, under any circumstances bill, charge,
collect a deposit, seek compensation, remuneration, or reimbursement from, or have any
recourse against the Enrollee for services provided. The Enrollee is held harmless and may
not be balance billed. Collection from the Enrollee of any co -payments or deductibles in
accordance with the terms of the benefit plan, or charges for services determined to not be
covered under the plan, may be excluded from the hold harmless clause.
7.6 Approval of Materials. All materials published or distributed by Employer concerning this
Group Plan Contract shall be approved by HPCC prior to use.
00238534.1 Rev. 2017 28
7.7 Professionalism. Both parties to this Group Plan Contract agree to permit and encourage
the professional relationship between Providers and Enrollees to be maintained without
interference and in a manner that would enhance the confidentiality of services.
7.8 Notices. All notices provided hereunder, and by Employer's insurance broker, shall be
deemed as having been properly made upon depositing the same in the United States mail,
postage prepaid, and addressing such notices to HPCC at its administrative office, or to
Employer at the address appearing last on the books of HPCC.
7.9 Entire Contract. This Group Plan Contract contains all of the provisions of the agreement
between the parties hereto, and no promise or agreement not contained herein shall be
binding on the parties unless the same is mutually agreed upon in writing, signed by the
parties hereto and attached to this Group Plan Contract. Only an officer or director of HPCC
has the power to change, modify, or waive the provisions of this Group Plan Contract, and
then only in writing. Consent of Enrollees is not required to effect any such change.
7.10 Assignment. Neither this Group Plan Contract nor any rights, obligations or duties under
this Group Plan Contract may be assigned without the consent of contracting parties,
provided however, that HPCC may assign its rights, obligations or duties under this
Contract to any corporate affiliate or other entity which may purchase substantially all
assets of HPCC or is the surviving entity in a merger with HPCC.
7.11 Severability. If any provision of this Group Plan Contract is declared invalid or
unenforceable by any arbitrator, court or other competent authority, the remaining
provisions hereof shall remain in full force and effect.
7.12 Waiver. A failure of either party to exercise any right provided for herein shall not be
deemed a waiver of any right hereunder. No party will be deemed to have waived any rights
hereunder unless the waiver is made in writing and is signed by the waiving party's duly
authorized representative. No waiver of a party's right under this Agreement shall be
deemed to have been effective if and to the extent waiver of such right is prohibited under
applicable law.
7.13 Applicable Law. This Group Plan Contract shall be governed by and construed under the
laws of the State of California. Subject to Section 7.16, any action brought relating to this
Group Plan Contract shall be adjudicated in a court of competent jurisction in the County
of Orange, State of California.
7.14 Amendment. Except as otherwise specifically provided in this Agreement, this Agreement
may be amended only by mutual written consent of the parties.
7.15 No Attorney's Fees. In the event of any dispute or legal action arising under this Group
Plan Contract, the prevailing party shall not be entited to attorneys' fees.
7.16 Dispute Resolution.
00238534.1 Rev. 2017 29
7.16.1 Arbitration. Subject to the California Government Claims Act (Cal. Gov. Code §900
et seq.) governing claims against public entities, either party may submit a dispute
arising under or relating to this Group Plan Contract for resolution exclusively
through confidential, binding arbitration, instead of through trial by court or jury, in
Orange County, California. The arbitration will be conducted by American
Arbitration Association ("AAA") in accordance with the commercial dispute rules
then in effect for AAA; provided, however, that this Group Plan Contract shall
control in instances where it conflicts with AAA's rules. The arbitration shall be
conducted on an expedited basis by a single arbitrator. Unless otherwise approved
by the parties, any arbitrator appointed under this Group Plan Contract shall have at
least ten (10) years demonstrable experience in health care and managed care issues.
In making decisions about discovery and case management, it is the parties' express
agreement and intent that the arbitrator at all times promote efficiency without
denying either party the ability to present relevant evidence. In reaching and issuing
decisions, the arbitrator shall have no jurisdiction to make errors of law and/or legal
reasoning. The parties shall share the costs of arbitration equally, and each party shall
bear its own attorneys' fees and costs. Any dispute under this Section 7.16.1 must be
submitted for arbitration within one (1) year after the alleged controversrty or claim
occurred. Failure to inintiate arbitration within that one (I) -year period constitutes
an absolute bar to instituting any arbitration procedure, provided that if applicable
law mandates a longer period for instituting an arbitration proceeding, that longer
timer period shall control.
7.16.2 Exclusive Remedy. With the exception of any dispute that under applicable laws may
not be settled through arbitration, arbitration under Section 7.16.1 is the exclusive
method to resolve a dispute between the parties arising out of or relating to this Group
Plan Contract.
7.16.3 Waiver. By agreeing to binding arbitration as set forth in Section 7.16.1, the parties
acknowledge that they are waiving certain substantial rights and protections which
otherwise may be available if a dispute between them was determined by litigation
in a court, including the right to a jury trial, attorneys' fees, and certain rights of
appeal.
[SIGNATURES ON NEXT PAGE]
00238534.1 Rev. 2017 30
IN WITNESS WHEREOF, the parties have caused this Group Plan Contract to be
executed as of the Effective Date set forth above.
CITY OF NEWPORT BEACH,
a California municipal corporation
("Employer")
By:g?L�[
Barbara Salvini
Human Resources Director
APPROVED AS TO FORM:
CITY ATTORNEY'S OFFICE
By:
A on . Ha fj •Za •23 WC..
City Attorney
HOLMAN PROFESSIONAL
COUNSELING CENTERS,
a California Corporation ("HPCC")
By: 4
Elizabeth Holman, M.B.A
President
ATTEST:
By: -
Leilani I. Brown
City Clerk wpOA
[END OF SIGNATURES]
00238534.1 Rev.2017 31
Exhibit A
EAP Benefit Schedule/Description
Employee Assistance Program Benefit: 4 EAP sessions with network provider per
individual, per issue, per year; Legal and Financial referrals included.
EAP Rate: $1.64 pepm
LifeSolutions: Included
E1derSolutions: Included CISD/Training Hours: 12 Hours Included
1. Contract and Benefit Renewal Provisions: This Group Plan Contract is for a term of
two years unless otherwise indicated, commencing on July 1, 2023, or unless
terminated by the parties or pursuant to Section 4.16 of this Agreement. At renewal,
any change in the benefits included in this EAP contract will constitute the termination
of this contract. Should Employer wish to continue with HPCC providing some
additional benefits or fewer benefits, a new contract outlining the new terms, conditions
and premiums will be provided. Employer will notify Enrollees of any changes to the
Group Plan thirty (30) days prior to the effective date of coverage.
2. Assessment: Each one of Employers employees/family shall be eligible to receive an
assessment of needs as part of an initial counseling session. Such assessments consist
of clinical interviews and do not include psychological testing. Additionally, HPCC
shall provide the following types of special assessment:
a. Substance Abuse: HPCC will assess the type and severity of substance abuse
and appropriate level of treatment. These assessments may include face to face
assessment, the use of questionnaires and/or brief screening instruments.
b. Crisis or Emergency: HPCC will assess a patient who presents in crisis to
determine an appropriate level of intervention or treatment. Such assessments
will be conducted whether or not the Member has used all of his/her EAP
benefits for the Contract Year.
c. Fitness for Duty: Upon request by employer, HPCC will assess an Employee's
fitness for duty. Such assessments are based upon information provided by the
employer and on the Employee's condition at the time, with an understanding
that the Employee's condition can change at any time. Employer will remain
responsible for monitoring Employee's condition and for notifying HPCC of
any change, in which case HPCC will reassess Employee's fitness for duty.
Fitness for Duty EAP evaluations require an additional fee from employer.
00238534.1 Rev. November 2017 32
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79843_
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HPCC will provide to employer upon request a Fitness for Duty evaluations at
HPCC's contracted provider cost; usually between $2,500 - $5,000.
d. Threat of Violence Potential: Upon request by employer, HPCC will assess the
situation for potential violence. Employer agrees to complete all necessary
forms and supply any supporting information and documentation as requested
by HPCC. HPCC will refer the patient to a recognized threat of violence expert
as indicated by the assessment. The charges for the specialist's services are not
included in the compensation paid hereunder and the employer shall be
responsible for all such charges. HPCC will provide to employer upon request
a Threat of Violence Potential evaluation at HPCC's contracted provider cost;
usually between $2,500 - $5,000.
e. Employer agrees to hold HPCC, it affiliates, officers, directors, agents and
employees harmless from and indemnify HPCC, its affiliates, officers,
directors, agents and employees against actions or complaints relating to any
injury or damage sustained as a result of the assessment of the situation for
evaluation for `fitness for duty' and/or evaluation for `potential violence'.
f. Assessments for the purpose of disability determination are not provided for
under this Agreement and can be added if employer wishes.
3. Short-term Counseling: HPCC will provide counseling to the Members for minor
problems on a short-term basis. These services will be provided throughout the United
States. Locations may be changed at the sole discretion of HPCC. Counseling services
shall consist of outpatient psychological counseling provided by a master's or doctoral
level counseling professionals. HPCC will not be responsible through the EAP, for the
following treatments: serious or chronic psychological disorders, psychiatric disorders,
substance abuse treatment, or conditions requiring medication.
4. Referral: HPCC will provide appropriate referrals for services not covered under this
Agreement (the "Excluded Services"). The Excluded Services include, and are not
limited to, psychiatric/medical services, psychological testing, substance abuse
treatment, long-term psychotherapy, treatment for serious & severe mental disorders
(AB88) or chronic conditions, impatient or residential treatment, or other
nonpsychological counseling. Referrals for Excluded Services will be made to
providers under Member's insurance, or to appropriate community resources. HPCC_
will not be responsible for any charges or fees the Member may incur from such
referrals for Excluded Services.
5. Case Management: HPCC will provide limited case management for emergency
situations or for management -referred Employees whom HPCC provided a referral for
00238534.1 Rev. November 2017 33
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79843_
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continued assessment and/or treatment and progress, and communication with the
treating provider.
6. Crisis Management: HPCC shall provide a 24-hour crisis line for emergencies; (800)
321-2843 in the United States for access by employer and employer's
employees/family.
7. HPCC shall conduct Employee orientations to explain HPCC'S EAP services. Sites of
the information programs and the expenses for those sites will be the responsibility of
the employer. HPCC will provide at HPCC's expense, generic promotional brochures,
that employer can distribute to its employees, to encourage use of EAP services. On
site employee orientations can be purchased at $150/hr and $75/hr for travel.
8. HPCC shall provide supervisory training, to assist the Employer's managers that
educates in utilizing, outlining and motivating employees in the use of EAP services.
CD Training for supervisors will include explanations of the EAP program, impact of
behavioral problems on Employee performance, and substance abuse information. If
employer wished on sites training, site of the training programs and the expenses for
those sites will be the responsibility of the Employer. The Employer can purchase on
site training at $150/hour and $75/hour for travel.
9. HPCC shall provide supervisory consultation regarding specific Employee issues, via
telephone and HPCC shall provide supervisory training. This confidential consultation
& training is intended to facilitate appropriate referrals to the EAP program.
10. HPCC shall periodically provide generic promotional materials to facilitate utilization
of EAP services by Employer Members, at HPCC's expense.
11. HPCC shall provide quarterly and annual statistical reports of EAP utilization and other
HPCC services furnished to Employer Members on the HPCC website. These reports
shall be in HPCC's generic format and no patient/names shall be identified. If employer
required specialized non -confidential reports, HPCC may be willing to provide such
reports for an additional fee.
12. HPCC shall provide periodic program consultation with Employer management
regarding utilization of HPCC's services.
00238534.1 Rev. November 2017 34
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79843_
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13. HPCC is available, for a fee, to provide crisis intervention at the work -site for traumatic
events which affect the performance and attitude of the staff (e.g. robbery, death or
suicide of a co-worker, industrial accidents or mass casualty incidents). Each incident
will be assessed on its own merits, but in general, a minimum of four (4) hours advance
notice is required. This service is available at all locations, upon request by Employer,
for the same fee. Crisis intervention for business -based decisions (e.g. downsizing,
reductions in force, etc.) may also be purchased for the same fee of $150/hour &
$75/hour for travel.
14. HPCC LifeSolutions is a work/life product designed to give referrals for a wider range
of daily living needs. Examples include adoption resources, special education needs,
summer camps, financial aid, college prep, car repair, home improvement, pet care,
relocation assistance.
15. HPCC E1derSolutions is a work/life product designed to provide referrals and education
materials for a wider range of eldercare needs. Examples include assisted living
facilities, skilled nursing facilities, residential care facilities, senior health newsletter,
eldercare tips, age -in -place guides, elder abuse signs.
00238534.1 Rev. November 2017 35
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79843_
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Holmin Profession:
' Counseling Centers
Exhibit B
Employee Assistance Program (EAP) Evidence of Coverage (Disclosure Statement)
Benefit Schedule:
4 face-to-face counseling sessions with Network Providers per individual, per issue, per year
To utilize benefits simply call 1-800-321-2843 for an appointment.
Notice to Plan Participants:
Federal law requires all employer benefit plan administrators to furnish each plan participant and each
beneficiary receiving benefits under the plan, a copy of a summary plan description. This summary plan
description constitutes only a brief overview of the provisions of the Group Plan Contract that has been
entered into between your Company and Holman Professional Counseling Centers, ("HPCC") « The
Group Plan Contract must be consulted to determine the exact provisions of the Group Plan Contract. Your
Company or HPCC will present a copy of the Group Plan Contract to you upon request.
Plan Name and Type of Administration: Employee Assistance Program (EAP)
Plan Administrator:
City of Newport Beach
100 Civic Center Drive
Newport Beach, CA 92660
Agent for Service of Legal Process: Same
as plan administrator
Behavioral Health Benefit Provider Company:
Holman Professional Counseling Centers, is a California corporation, which provides Employee Assistance
Program health services to the plan participants of your Company's Flexible Compensation Plan. HPCC may
be contacted at the following address and telephone number:
Holman Professional Counseling Centers
P.O. Box 8011, Canoga Park, CA 91309 (800)321-2843
Period of Coverage:
The Plan year is July 1" through June 291n
Charges for Missed Appointments (Contracted Providers Only):
Employee Assistance Program Sessions- An enrollee will forfeit one session for failure to attend any session
except in the, ca.-W-- Wh-Wfe-- t-h-e-- cen#acted prowAdder is ne-tiffi-e-d- At- le-ast twenty- four (24) hours i-n Afthe
appointment or the failure to keep the appointment was due to circumstances beyond the enrollee's reasonable
control.
Eligibility Requirements: Includes Eligible Employee's lawful spouse, domestic partner (as defined in Section
297 of the Family Code), and dependent children to age 26. Children include stepchildren, adopted children,
and foster children, provided such children are dependent upon the employee for support and maintenance.
00238534.1 Rev. November2017 36 Printed 11/8/2017
79843_
1
Coverage for each minor child placed for adoption immediately begins from and after the date on which the
adoptive child's birth parent or other appropriate legal authority signs a written document, including, but not
limited to, a health facility minor release report, a medical authorization form, or a relinquishment form,
granting the subscriber or spouse the right to control health care for the adoptive child. Attainment of the
limiting age of 26 by dependent children, shall not operate to terminate the coverage of a child while the child
is and continues to be incapable of self-sustaining employment by reason of physical or mental condition
(certified by a doctor in writing) and the child is chiefly dependent upon an Eligible Employee for support and
maintenance.
Renewal Provisions. The Group Plan Contract between your Employer and HPCC is for a term of two years
unless otherwise indicated. Unless terminated in one of the methods included in "Termination of Benefits," the
Group Plan Contract will be renewed annually at such rates and upon such terms as may be agreed upon by the
HPCC and your employer at the time of renewal. The Employer will notify enrollees of any change to the Group
Health Plan thirty (30) days prior to the effective date of change.
Termination of Benefits. If your Employer fails to pay HPCC the appropriate premiums for you and/or your
dependents, HPCC may terminate the benefits for you and/or your dependents if the Employer has been duly
notified with the Notice of Cancellation for Nonpayment of Premiums and Grace Period and billed for the
charge and at least a 30-day grace period has elapsed since the date of the receipt of the last premium payment.
The notice of cancellation for nonpayment of premiums and grace period shall include the language in California
Title 28, Section 1300.65(c)(3)(B)(ii) in be in at least 12 point font:
"You are receiving this Notice of Cancellation because your HPCC coverage is being cancelled or not
renewed because you have not paid your premium. Even though you have not paid your premiums, you
are being provided a "grace period " to allow you time to make your past due premiums payment(s)
without losing your healthcare coverage. "Grace period" means a period of at least 30 days beginning
no sooner than the first day after the last day of paid coverage and lasts at least 30 days. Your grace
period ends on (insert month, day, year). You may avoid losing your coverage if you pay the premium(s)
owed to HPCC before the end of the grace period. If you do not pay the required premium amount by
the end of the grace period, your coverage will be terminated effective the day after the last day of the
grace period. Your grace period ends on (insert month, day, year). Coverage will continue during the
grace period; however, you are still responsible to pay unpaid premiums and any copayments,
coinsurance or deductible amounts required under the plan contract. For information about individual
health care coverage and health care subsidies that may be available to you, contact Covered California
at (800) 300-1506 or TTY at (888) 889-4500 or online at www. CoveredCa. com. If you wish to end your
coverage immediately, please contact HPCC as soon as possible. "
Coverage will continue during the grace period; however, the Employer will be still responsible to pay unpaid
premiums and the Enrollee will be responsible for any copayments, coinsurance or deductible amounts required
under the group plan contract. Grace period means a period of at least 30 days beginning no earlier than the
first day after the last date of paid coverage to allow the Employer to pay an unpaid premium amount without
losiniz healthcare covera2e At a minimum this graceperiod shall extend through the thirtieth th
) day after
the last date of paid coverage.
If HPCC withdraws a health benefit plan from the market, HPCC will notify the Employer, enrollees and the
director at least 90 days prior to the discontinuation of the group contract. Notice of the decision to cease new
00238534.1 Rev. November 2017 37 Printed 11/8/2017
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1
or existing health benefit plans in the state is provided to the director, the Employer and the enrollees covered
under this group plan contract at least 180 days prior to the discontinuation of this contract.
HPCC has the right to terminate your coverage under this Plan in the following situations:
• Failure to Pay. Your coverage may be terminated for employer's nonpayment of required premiums
owed to HPCC if your employer has been duly notified and billed for the charge and at least a 30-day
grace period has elapsed since the date of the receipt of the last premium payment. Coverage will
continue during the grace period; however, the Employer will be still responsible to pay unpaid
premiums and the Enrollee will be responsible for any copayments, coinsurance or deductible amounts
required under the group plan contract.
• Fraud or Misrepresentation. Your coverage may be terminated if you knowingly provide false
information (or misrepresent a meaningful fact) in the enrollment process or fraudulently or deceptively
use services or facilities of HPCC and/or its contracted providers (or knowingly allow another person
to do the same). If coverage is terminated for the above reasons, you forfeit all rights to enroll in the
COBRA Plan and lose the right to re -enroll with HPCC in the future.
Responsibilities of Employer- Cancellation of Contract. Continuing coverage under this Plan is subject to
the terms and conditions of the Employer's Group Contract with HPCC. If the Group Contract is cancelled,
coverage for you and all your Eligible Dependents will end after a written notice of termination of coverage is
given and a 30-day grace period has elapsed since the date of the receipt of the last premium payment. Coverage
will continue during the grace period
If an enrollee's eligibility has ended for any of the above reasons, the enrollee will be notified in writing and
informed of the effective termination date and information regarding the grace period. Coverage of the
enrollee's dependents will end when enrollee's coverage ends. Any enrollee who is undergoing treatment in a
hospital for acute care at the time of cancellation will continue to be covered under the terms of the Group
Contract until discharge.
It is the responsibility of Employer to notify the enrollee of the termination of this group contract. In the event
we provide notice of cancellation, within five business days, for non-payment of premium to the Employer,
Employer agrees to promptly mail a legible, true copy of the notice of cancellation to all enrollee at their current
address. The notice of cancellation will include:
• Effective date of the cancellation and grace period; the date of the last day of paid coverage
• The reason for cancellation, including reference to the applicable clause in this Agreement;
• The dollar amount due to HPCC
• The date the grace period begins and expires. Grace period means a period of at least 30 days beginning
no earlier than the rst day after the last date of paid coverage to allow the Employer to pay an unpaid
premium amount without losing healthcare coverage. At a minimum this grace period shall extend
through the thirtieth (30tb) day after the last date of paid coverage.
• The obligations of the enrollee or group contract holder during the grace period (if any)
00238534.1 Rev. November2017 38 Printed 11/8/2017
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1
A statement that the cause for cancellation was not due to the enrollees health status or requirements
for health services;
• That a enrollee who alleges that cancellation was due to the enrollees health status'may request a review
of cancellation by the Department of Managed Health Care;
Under no circumstances will an enrollee be terminated due to health status or the need for services. Any
enrollee who believes his or her enrollment has been terminated due to health status or required services
may request a review of the termination by the California Department of Managed Health Care.
Right to Submit Request for Review of Cancellation, Rescission, or Nonrenewal of Your Plan Contract,
Enrollment, or Subscription.
If you believe your plan coverage has been, or will be, improperly cancelled, rescinded, or not renewed, you
have the right to file a Request for Review. You have the options of going to the plan and/or the Department
if you do not agree with the plan decision to cancel, rescind or not renew your plan coverage.
Option (1) - You may submit a Request for Review to your plan.
* You may submit a Request for Review to HPCC by calling 1-800-321-2843 or submitting a request at
www.HolmanGroo.com, or by mailing your written Request for Review to HPCC, P.O. Box 8011, Canoga
Park, CA 91309.
* You may want to submit your Request for Review to HPCC first if you believe your cancellation,
rescission or nonrenewal is the result of a mistake. Requests for Review should be submitted as soon as
possible after you receive the Notice of Cancellation, Rescission, or Nonrenewal.
* HPCC will resolve your Request for Review or provide a pending status within three (3) days. If the
plan upholds your cancellation, rescission or nonrenewal, it will immediately transmit your Request for
Review to the Department of Managed Health Care and you will be notified of the plan's decision and your
right to also seek a further review of the plan's decision by the Department as detailed under
Option 2, below.
Option (2) - You may submit a Request for Review to the Department of Managed Health Care.
* You may submit a Request for Review directly to the Department of Managed Health Care without
first submitting it to the plan or after you have received the plan's decision on your Request for Review.
Requests for Review by the Department of Managed Health Care may be submitted:
By mail:
HELP CENTER
DEPARTMENT OF MANAGED HEALTH CARE
980 NINTH STREET, SUITE 500
SACRAMENTO, CALIFORNIA 95814-2725
BY PHONE:
1-888-466-2219
00238534.1 Rev. November 2017 39 Printed 11/8/2017
79843_
1
TDD: 1-877-688-9891
FAX: 1-916-255-5241 OR
ONLINE:
W W W . HEALTHHE LP . CA. GO V
There is no charge to call. Help is available in many languages.
For a California enrollee whose Cal -COBRA coverage begins on or after December 1st, and who has exhausted
continuation coverage under COBRA, the enrollee shall have the opportunity to extend their Cal -COBRA
coverage to 36 months after the date the qualified beneficiary's benefits under a group plan contract would
otherwise have terminated by reason of a qualifying event.
Benefit Claims Procedures:
Plan participants may access their behavioral health benefit services for emergency and urgent assistance by
calling HPCC's toll -free number 24 hours a day, seven days a week: (800) 321-2843. To schedule an
appointment, plan participants should call the toll -free number during the plan's office hours, Monday through
Friday 7:30 a.m. - 5:00 p.m. Pacific Standard Time (PST) and a trained Care Access Specialist will have a
qualified network provider who is located in the participant's local area call him/her back directly, usually within
48 business hours of receiving the call, to schedule an appointment. To receive a community referral or for
inquiries regarding HPCC's behavioral health services or benefits, the plan participant should call HPCC
Monday through Friday 7:30 a.m. — 5:00 p.m. PST. If a plan participant has questions about his/her company's
employer benefit plan, he/she should contact City of Newport Beach directly at (949) 644-3310. If a plan
participant has questions regarding their rights under their company's benefit plan or the Health Insurance
Portability and Accountability Act of 1996, plan participants may contact the Department of Labor at (415)
945-4600 in Northern California or (626) 583-7862 in Southern California.
Appeals of Denied Claims and Denied Treatment Authorization:
If a plan participant disagrees with the decision to deny treatment authorization or they deny a claim, they are
encouraged to contact HPCC directly at 1-800-321-2843. HPCC will direct the participant's disagreement to
the assigned Care Manager. The Care Manager will work together with the participant and a Care Supervisor
to resolve the matter. Within thirty (30) days from HPCC's receipt of the grievance, HPCC will send the plan
participant a written notice of the resolution. If the request is denied, the plan participant may appeal the Care
Manager's decision as follows:
Grievance Process:
HPCC wants you to be satisfied with your behavioral health care services. If a problem arises, we want to help
solve it. If a question arises, we want to help you answer it. All enrollees will have reasonable access to the
filing of a complaint. Enrollee's shall have up to 180 calendar days following any incident or action that is
the subject of the enrollee's dissatisfaction to file a grievance with HPCC. Complaints may be reported to any
HPCC staff member in person, or by telephone by calling (800) 321-2843. Also, complaints may be submitted
in writing to Holman, P.O. Box 8011, Canoga Park, CA 91309, or via the Plan's secure website at
http://www.Holmangroup.com. A HPCC staff member will then immediately direct the complaint to the
Compliance Specialist. The Plan's address, telephone number and procedures for initiating complaints are
00238534.1 Rev. November 2017 40 Printed 11/8/2017
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1
communicated in the enrollee benefit book. Grievance Complaint forms are also available from all Plan
providers (Grievance Complaint Forms are included in the initial packet of documents provided to contracted
providers). In addition, grievance forms are placed on HPCC's website. Additionally, providers are sent a
mailing notification informing them that the grievance forms in their packets should be copied and made
available to enrollees upon request or when indicated (via concerns voiced) by the enrollee. Grievance Forms
and a description of the grievance procedure shall be readily available at each facility of the plan, on the plan's
website, and from each contracting provider's office or facility. Grievance forms shall be provided promptly
upon request. Enrollees will be updated of any revisions to the grievance process -whether it be by sending the
updated grievance policy and/or Combined Evidence of Coverage and Disclosure Form detailing the changes
in the grievance policy. HPCC shall assure that there is no discrimination against an enrollee or subscriber
(including cancellation of the contract) on the grounds that the complainant filed a grievance.
Expedited Grievance Review. For cases involving an imminent and serious threat to the health of the enrollee,
including, but not limited to, severe pain, potential loss of life, limb, or major bodily function, HPCC provides
expedited review. When HPCC has notice of a case requiring expedited review, HPCC shall immediately
inform the enrollee in writing of their right to notify the Department of Managed Health Care (the
"Department") of the request. For these cases, HPCC will provide the enrollee and the Department with a
written statement on the disposition or pending status of the request no later than three (3) days from receipt.
California Department of Managed Health Care:
The California Department of Managed Health Care is responsible for regulating health care service plans. If
you have a grievance against Holman Professional Counseling Centers, Inc., you should first telephone Holman
Professional Counseling Centers. at (1-800-321-2843) and use Holman Professional Counseling Centers,
grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any
potential legal rights or remedies that may be available to you. If you need help with a grievance involving an
emergency, a grievance that has not been satisfactorily resolved by Holman Professional Counseling Centers,
or a grievance that has remained unresolved for more than thirty (30) days, you may call the Department for
assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR,
the IMR process will provide an impartial review of medical decisions made by Holman Professional
Counseling Centers related to the medical necessity of a proposed service or treatment, coverage decisions for
treatments that are experimental or investigational in nature and payment disputes for emergency or urgent
medical services. The Department also has a toll -free telephone number (1-888-HMO-2219) and a TDD line
(1-877-688-9891) for the hearing and speech impaired. The Department's Internet website
htttp://www.hmohelo.ca.gov has complaint forms, IMR application forms and instructions online.
A rhitrn ti nn
If the Enrollee remains dissatisfied with the decision, the Enrollee may submit a request to HPCC to submit the
grievance to binding Arbitration before the American Arbitration Association. Pursuant to California law a
single neutre arbitrator who stiall be chosen by die parties and who shall have no jurisdiction to award more
than $200,000 must decide any claim of up to $200,000. However, after a request for arbitration has been
submitted, HPCC and the Enrollee may agree in writing to waive the requirement to use a single arbitrator and
instead use a tripartite arbitration panel that includes the two party -appointed arbitrators or a panel of three
neutral arbitrators or another multiple arbitrator system mutually agreeable to the parties. The Enrollee shall
have three (3) business days to rescind the waiver agreement unless the agreement has also been signed by the
00238534.1 Rev. November 2017 41 Printed 11 /8/2017
79843_
1
Enrollee's attorney, in which case the waiver cannot be rescinded. In cases of extreme hardship, HPCC may
assume all or part of the Enrollee's share of the fees and expenses of the neutral arbitrator provided the Enrollee
has submitted a hardship application with the American Arbitration Association. The American Arbitration
Association shall determine the approval or denial of a hardship application. A hardship application may be
obtained by contacting the American Arbitration Association in Los Angeles at 213-383-6516, in Orange
County at 714-4745090, in San Diego at 619-239-3051 and in San Francisco at 415-981-3901.
If the Enrollee does not request arbitration within six months from the date of the Grievance Resolution Notice,
the decision of the Committee shall be final and binding. However, if the Enrollee has legitimate health or other
reasons which would prevent them from electing binding arbitration in a timely manner, the Enrollee will have
as long as necessary to accommodate his or her special needs in order to elect binding arbitration. Further, if the
Enrollee seeks review by the Department of Managed Health Care, the Enrollee will have an additional ninety
(90) days from the date of the final resolution of the matter by the Department of Managed Health Care to elect
binding arbitration. Upon submission of a dispute to the American Arbitration Association, both the Enrollee
and HPCC agree to be bound by the rules of procedure and decision of the American Arbitration Association.
Full discovery shall be permitted in preparation for arbitration pursuant to California Code of Civil Procedure,
Section 1285.05.
HIPAA Compliance. HPCC is compliant with all HIPAA privacy requirements. Our HIPAA compliance
statement is posted on our website.
HPCC's Public Policy Committee. HPCC operates a Public Policy Committee that is mandated to maintain
professional standards. It functions as an open forum to provide enrollees with an opportunity to discuss
prevailing societal issues, difficulties with current policies, and additional available services. The purpose of
the Public Policy Committee is to ensure the comfort, dignity, and convenience of persons relying upon HPCC
for behavioral health care services. In order to assure enrollee participation in Plan policy, the Public Policy
Committee shall consist of the following enrollees: Holman Executive Vice President, Director of Corporate
Account Management, Account Management staff and a minimum of three current enrollees. The Executive
Vice President selects the enrollee enrollees of the Public Policy Committee. Any enrollee interested in the
Public Policy Committee may direct their request in writing to: Holman, P.O. Box 8011, Canoga Park, CA
91309.
Language Assistance Program ("LAP"). The Department of Managed Health Care ("Department") of
California has added Section 1300.67.04 (Language Assistance Programs) to Title 28 California Code of
Regulations. This regulation requires health care service Plans to implement new policies, procedures and
quality improvement efforts in regards to assisting those who are Limited English Proficient ("LEP"). The
Department regulations require California health Plans to set up a system where services, materials, and
information are provided to enrollees in a language that they speak and understand.
In accordance with the Department regulations, HPCC has identified its threshold language(s) which comprise
five (5) percent of its enrollee Population. All vital documents as identified by the Department will be translated
into the threshold language. All non -vital documents will contain a notice at the bottom of said document (in
the threshold language) informing the enrollee how to request a translation of the document.
00238534.1 Rev. November2017 42 Printed 11/8/2017
79843_
1
HPCC has established a free Language Assistance Program ("LAP") and made the following resources
available for LEP individuals: Translations (in the threshold languages), Interpreters, and Bilingual
staff/providers. These resources are available for all persons who request these services at any of our points of
contact.
Antifraud Policy and Procedures. HPCC makes every effort to detect, investigate, and prosecute any incidents
of fraud at any level within its behavioral health care service. Fraud hurts everyone through higher taxes to fund
government health care plans and higher premiums for private health coverage. In order to insure that our
enrollees do not have to pay for the high cost of fraud, we encourage you to report fake claim schemes. We are
here to help you recognize and report any incidents or suspected incidents of fraud you discover. If you notice
that a claim submitted to HPCC by your provider's office includes a charge for a therapy session you did not
receive, you may have detected health care fraud. The first step is to notify your provider of the incorrect charge.
The second step is to notify HPCC at 1-800-321-2843. HPCC wants your help to identify potentially fraudulent
or abusive claim activities. If you know or suspect illegal or wrongful billing practices by a provider or an
enrollee, please tell us. We will treat any information you provide with strict confidentiality. We promise not to
disclose your identity unless you are willing to voluntarily give us your written permission. Furthermore, state
and federal laws protect the confidentiality of your medical records. We will not release any medical information
without lawful authorization.
HPCC contracts with a special investigator trained in fraud investigation to assist us in investigating fraud. In
the event that HPCC detects any fraudulent activity on the part of a provider, the provider's contract with HPCC
will be terminated. If HPCC detects any fraudulent activity on the part of an enrollee, HPCC will deny enrollee
any additional benefits under enrollee's Group Health Plan. Additionally, HPCC will prosecute fraud to the
fullest extent of the law. We also cooperate with all government agencies in a combined effort to prevent and
prosecute fraud on the part of both providers and enrollees.
Organ and Tissue Donation. Approximately 77,000 people in the U.S. are on the national waiting list for an
organ. An average of 15 people die every day because not enough organs are available. Organ and tissue
transplantation saves lives. For example, about 60 people receive life -enhancing organ transplants each day and
about 82% of patients who receive a donated kidney are still alive 5 years later.
For more information on how to become an organ and tissue donor, visit the U.S. Department of Health and
Human Services web site at www.organdonor.gov or call: 1-888-ASK-HRSA (1-888-275-4772).
DEFINITIONS
1. Benefits Schedule. Incorporated by reference. Describes the available levels of treatments provided
through a Group Plan Contract, along with required deductibles and co -payments.
2. Contracted Provider. A person licensed as a psychologist, clinical social worker, marriage, family and
child counselor, licensed professional counselor, registered associate counselor or other licensed health
00238534.1 Rev. November 2017 43 Printed 11 /8/2017
79843_
1
care professional with appropriate training and experience in behavioral health services, and who has
contracted with HPCC to deliver specified services to HPCC Enrollees.
3. Co -payment. Fixed fee paid pursuant to this Agreement to a Provider by Enrollee at time of provision of
behavioral health services, which are in addition to the premiums paid by the Employer/Trust. Such fees
may be a specific dollar amount or a percentage of total fees, depending on the type of services provided.
The EAP has $0.00 copay.
4. Covered Services. EAP services provided by Providers that are determined to fall within the scope of EAP
services and covered under the Group Plan Contract.
5. Employee/Member. Individual who works for an employer or is a member of a trust, who has contracted
with HPCC for behavioral health care services.
6. Employee Assistance Program (EAP). The EAP is a confidential service designed to provide employees
and their families with experienced counseling professionals for help with personal problems and issues.
Additionally, the program offers limited free legal and financial advice and referral, CD training, and access
to helpful online articles. The program is available to employees and their eligible dependents at no cost.
7. Employer. An organization that has contracted with HPCC to provide behavioral health care services to
its eligible employees.
Enrollee. An eligible employee or trust member (and/or such employee's/member's eligible dependents)
of an employer/trust who has contracted with HPCC to provide behavioral health services to its
employees/members. Employee/member must meet HPCC's eligibility requirements, enroll in the
employer/trust's Group Plan, and accept the financial responsibility for any co -payments that may be
incurred in treatment through the Group Plan.
9. Family Unit. Comprised of Enrollee plus Enrollee's eligible dependents.
10. Group Plan Contract. Agreement between an Employer/Trust and HPCC providing that HPCC will
provide behavioral health care services for the Employer/Trust's eligible employees/members in exchange
for Premium paid by the Employer/Trust.
11. Premium. Predetermined monthly membership fee paid by an employer/trust for coverage under the Group
Plan Contract.
12. Provider. A person licensed as a psychiatrist, psychologist, clinical social worker, marriage, family and
child counselor, nurse or other licensed health care professional with appropriate training and experience
in behavioral health services, working individually or within a corporation, clinic, or group practice, who
is employed or under contract with HPCC to deliver EAP behavioral health services to Enrollees.
00238534.1 Rev. November 2017 44 Printed 11/8/2017
79843_
1
Q 2 191 D+ 30 ® C
Q Search slt Insured
Insured Name
Name: Holman Professional Counseling
Holman Professional Counseling Centers Centers
Q
Account Number: FV00001031
Holman Professional Counseling Address: P.O. Box 8011, Canoga Park, CA,
91309
Active Records Only
Status: Compliant with Waived
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Risk Type:
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Insured:
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Address 1:
P.O. Box
8011
Address 2:
City: Canoga
Park
State: CA
Country:
Contract Information
Contract Number:
Contract Start Date:
Contract Effective Date:
Description of Services:
Contact Information
Contact Name:
Phone Number:
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07/01/2023 Contract End Date:
Contract Expiration Date:
EAP Plan Safety Form IL
Jill Misc:
Schlesinger
8003212228 Alt Phone Number:
E-Mail Address: jills@holmangroup.com; robert@ieibrokers.co
Approval Date:
Rush: No
Contract on File: Yes
Certificate Received: No
Indemnification Agreement: No
Tax Id:
This Account created by e55 on 06/29/2023.