CARVE-OUT MENTAL HEALTH AND SUBSTANCE ABUSE AGREEMENT (2)
CARVE-OUT MENTAL HEALTH AND SUBSTANCE ABUSE AGREEMENT
This Agreement, entered into this 1st day of January, 2007 between CITY OF
CLEARWATER (herein referred to as CLEARWATER) and UNIPSYCH BENEFITS
Inc., a Florida corporation which contracts with duly licensed providers of
psychological and psychiatric services, other mental health professionals and inpatient
facilities, for the provision of mental health and substance abuse treatment (hereinafter
referred to as "UPB"):
WITNESSETH:
WHEREAS, CLEARWATER desires to provide for the examination and
treatment of mental health and substance abuse conditions to its employees and their
authorized, lawful dependents (hereinafter referred to as "Eligible Employees and
Dependents"); and
WHEREAS, UPB is a Florida corporation which contracts with duly registered
providers of psychological and psychiatric services, other mental health professionals
and inpatient facilities; and
WHEREAS, UPB is willing and able to arrange for examination and treatment
for mental health and substance abuse conditions to those Eligible Employees and
Dependents for whom CLEARWATER desires to provide such services; and
WHEREAS, CLEARWATER and UPB wish to enter into an Agreement
relating to the provision of such mental health and substance abuse examination and
treatment to said Eligible Employees and Dependents by UPB;
NOW, THEREFORE, in consideration of the promises and mutual covenants
herein contained, the parties hereto covenant and agree as follows.
1. SERVICES TO BE PROVIDED
UPB agrees to provide those benefits necessary for the treatment of mental
health and substance abuse conditions as they are set forth in the "Summary Plan
Description" attached hereto as "EXHIBIT A" . CLEARWATER acknowledges that
the benefits being provided hereunder are limited in nature and that there might be
treatment necessary for mental health and substance abuse conditions for Eligible
Employees and Dependents covered hereby which will not be provided pursuant to this
Agreement and the Exhibit hereto. In the event that CLEARW A TER wishes to have
UPB cover any additional services for Eligible Employees and Dependents, which are
not covered under the terms of this Agreement, then CLEARW A TER agrees to pay
UPB additionally for those services at the rate of 80% of UPB's usual and customary
charges.
2. PAYMENT FOR SERVICES
CLEARWATER shall compensate UPB according to the fee schedule attached
hereto. UPB agrees to look solely to CLEARWATER for payment for such services
rendered during the term of this Agreement and shall not seek to collect any sums from
Eligible Employees and Dependents, notwithstanding CLEARWATER's failure to pay
sums due under this Agreement for any reason provided, however, that UPB may
charge and collect copayments (a fixed dollar amount to be paid by Eligible Employees
and Dependents receiving treatment in addition to any payments received from
CLEARWATER from Eligible Employees and Dependents as set forth in "EXHIBIT
A" hereto.
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3. INDEMNIFICATION
a) Indemnification of CLEARWATER: UPB agrees to indemnify and hold
harmless CLEARWATER, its agents, employees and other authorized representatives
against any and all claims, causes of action, suits or demands including but not limited
to legal fees and costs incurred in defending any such action which might arise out of
the furnishing of or the failure to furnish the services contemplated hereunder.
b) Indemnification of UPB: CLEARWATER agrees to indemnify and hold
harmless UPB, its agents, employees and other authorized representatives against any
and all claims, causes of action, suits or demands including but not limited to legal fees
and costs incurred in defending any such action which might arise out of the sole
negligence of CLEARWATER.
c) Any language in this Agreement to the contrary notwithstanding, the
maximum sum that CLEARWATER shall be liable to reimburse UPB under any
theory of liability shall not exceed $100,000 per person and $200,000 per incident as
expressed in Section 768.28, Florida Statutes.
4. NON-INTERFERENCE OF CLEARWATER
CLEARWATER and UPB agree that UPB is an independent contractor
hereunder and that CLEARW A TER has no right or obligation of control over the
activities of UPB.
CLEARWATER agrees that it shall not interfere nor attempt to interfere with
UPB's professional judgment as to the benefits to be afforded to any Eligible Employees
and Dependents receiving services hereunder.
5. REFERRALS
CLEARW A TER acknowledges that UPB might be required to refer Eligible
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Employees and Dependents for medical treatment not provided hereunder and agrees
that UPB shall not be liable for paying for such services unless such services are listed
on the "Summary Plan Description", "EXHIBIT A" hereto.
6. TERM OF AGREEMENT
The initial term of this Agreement shall be for three (3) years and this
Agreement shall run from the commencement date as set forth in Paragraph Eleven
(11) herein. Said Agreement shall automatically renew for another period of three (3)
years. However, either party hereto may cancel this Agreement by written notice to the
other, delivered at least ninety (90) days prior to the expiration of the term, providing
that, in the event of a termination of this Agreement, UPB shall continue to treat those
Eligible Employees and Dependents who are undergoing treatment, at the time of
termination, until satisfactory arrangements are made between CLEARW A TER and
Eligible Employees and Dependents undergoing treatment, for the continuation of care
by a similar provider and UPB has been notified by such similar provider, in writing,
that it has undertaken the responsibility to render such services to Eligible Employees
and Dependents undergoing treatment in question.
7. DEFINITIONS
a) An Elie:ible Emplovee or Dependent: Is any person who has been
authorized by CLEARWATER to receive services hereunder and whose
authorization to receive services has been communicated to UPB by
CLEARW A TER in the manner required by this Agreement and all Exhibit
hereto, together with such person's name, address and such other identifying
factors as are required by UPB for proper records keeping.
b) Mental Health and Substance Abuse Condition: Means an illness,
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disorder or condition listed in the American Psychiatric Association's Diagnostic
and Statistical Manual (DSM), as it might be revised from time to time, not
including V-Codes.
c) Services Necessary for Treatment of Mental Health and Substance Abuse
Condition: Means those services which are appropriate for the treatment of a
mental health or substance abuse condition and within the standards of practice
recognized by the local psychiatric and/or psychological communities.
d) Similar Provider: Means a person, professional association or other
entity, licensed to render mental health, substance abuse, psychological and/or
psychiatric services under applicable State laws and duly registered and
authorized to provide those services set forth in the "Summary Plan
Description"
e) Undere:oine: Treatment: Means that Eligible Employees and Dependents
have been covered for a mental health and/or substance abuse condition by UPB
and have not yet been released from such treatment by UPB authorized
providers.
8. ENROLLMENT
a) Determination and Notice of Elie:ibilitv: During the term of this
Agreement, CLEARWATER shall be solely responsible for determining
whether an individual is eligible to receive services hereunder, to communicate
such eligibility to UPB, along with such identifying factors as are required by
UPB for proper records keeping and CLEARWATER shall be solely
responsible to communicate, to all Eligible Employees and Dependents, the
services provided hereunder as well as all restrictions and limitations applicable
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thereto.
b) Roll of Elie:ible Employees and Dependents: CLEARWATER agrees to
provide UPB with a list of those employees and eligible dependents entitled to
receive care hereunder, to update said list monthly and to continuously
supplement said list of Eligible Employees and Dependents as is necessary due
to the termination or inception of memberships or otherwise. CLEARWATER
further agrees to reimburse UPB, at 80% ofUPB's usual and customary rate for
such services, for any and all services provided under this Agreement to a
person who is not an Eligible Employee or Dependent, when such services are
provided due to erroneous, incomplete or delayed communication of the roll of
Eligible Employees and Dependents by CLEARW A TER to UPB.
9. MISCELLANEOUS PROVISIONS
a) Amendment: This Agreement may be amended only by written
instrument signed by both CLEARWATER and UPB.
b) Entire Ae:reement: This Agreement, attached Exhibit and any documents
incorporated by reference herein constitute the entire Agreement between the
parties and supersedes any prior Agreement, representations, warranties or
promises between the parties that are not set forth herein or otherwise
incorporated into this Agreement by express reference.
c) Applicable Law: This Agreement and the covenants set forth herein, as
well as any Exhibit hereto, are to be construed in accordance with the Statutory,
Regulatory and Common Laws of the State of Florida as well as any applicable
Federal Laws and Regulations.
d) Self Fundine:: CLEARW A TER represents to UPB that Mental
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Health/Substance Abuse benefits it is providing to its Eligible Employees and
Dependents pursuant to this Agreement are being provided on a self-funded
basis.
e) Non-Assie:nabilitv: Neither party may assign either the obligations or the
benefits hereof without the written consent of the other party hereto.
t) Captions: Captions appearing in this Agreement are inserted only as a
matter of convenience and, in no way, derme or describe the provisions of this
Agreement nor do they affect the construction hereof.
g) Partial Invaliditv: In the event any provision of this Agreement shall be
found to be invalid or unenforceable by any Court of competent jurisdiction,
such invalid or unenforceable provision shall be severed from this Agreement
and shall not affect the remaining provisions of this Agreement.
h) Pronouns: All pronouns shall be deemed to refer to the masculine,
feminine or neuter, singular or plural, as the identity or the number of the
person or persons, entity or entities might require.
i) Venue: Any and all actions arising out of this Agreement or the
transactions contemplated hereby shall lie in the Courts of the State of Florida
situated in Broward County, Florida.
j) Successor Parties: This Agreement shall inure to the benefit of and be
binding upon the parties hereto and their successors and permitted assigns.
k) Representations: No representations, negotiations, understandings or
communications be1;Ween the parties shall be binding thereon, unless
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10. NOTICES
a) Notices to UPB: All notices to UPB hereunder shall be hand delivered or
sent by certified mail, return receipt requested, to:
Denise M. Scott
Vice President, Administration
UniPsych Benefits, Inc.
7777 Davie Road Extension, Suite 100
Hollywood, FL 33024
b) Notices to: All notices to City of Clearwater hereunder shall be hand
delivered or sent by certified mail, return receipt requested, to the
following address:
Human Resources Department
City of Clearwater
P.O. Box 4748
Clearwater, FL 33758-4748
11. COMMENCEMENT DATE
The commencement date of this Agreement shall be the 1st day of January,
2007.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the
day and year first above written.
UNIPSYCH BENEFITS, INC.
~ SLOXl
BY:
TITLE:
Vice President, Administration
EXHIBIT A
SUMMARY PLAN DESCRIPTION
This is the Summary Plan Description which outlines those mental health and substance
abuse benefits which are being rendered pursuant to an Agreement entered into between
CITY OF CLEARWATER (hereinafter referred to as "CLEARWATER") and UNIPSYCH
BENEFITS, INC. (hereinafter referred to as "UPB").
A. MENTAL HEALTH AND/OR SUBSTANCE ABUSE BENEFITS:
This Agreement provides for both office visits and inpatient care for mental health
and/or substance abuse disorders. Covered services must be authorized by UPB. UPB shall
have sole discretion as to determining coverage and authorized providers.
Outpatient therapy is covered at Network Rates up to a maximum of 30 visits per
contract year with a copayment to be made by Eligible Employees and Dependents, at the time
of each service, in the amount of $10.00
Inpatient care and the associated services of physicians and other health
Professionals are covered at Network rates up to a limit of 30 days per contract year with a
$100.00 copayment made by Eligible Employees and Dependents, at the time of each
admission.
The maximum limitations of available services are included in the Health Plan
lifetime dollar maximum for Mental Disorders and the maximum limitation of available
services for Substance Abuse Disorders is a lifetime maximum of $25,000.00.
B. MIXED SERVICES
UPB is responsible only for those services and supplies associated with the treatment of
mental health or substance abuse conditions. UPB shall not be responsible for the cost of any
medical or surgical services that are provided concurrently or in conjunction with the
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treatment of mental health or substance abuse conditions pursuant to this Agreement, whether
or not UPB makes referrals or recommendations for such medical or surgical services. These
include but are not limited to all services and supplies relating to neurological conditions and
all ancillary services and supplies relating to medical conditions.
All determinations as to whether services rendered are primarily for mental health or
substance abuse conditions or, in the alternative, for medical conditions, shall be determined as
set forth under Section J herein.
C) SERVICE AREA
The Service Area covered under this Agreement is the continental United States of
America and the services covered under this Agreement are available to Eligible Employees
and Dependents only in this Service Area. In order to obtain mental health and/or substance
abuse services outside of the Service Area, Eligible Employees and Dependents shall be
required to obtain such services with prior authorization of UPB. UPB is available 24 hours
per day through its national toll-free number, 1-800-BRADMAN or 1-800-272-3626. UPB shall
not be responsible for any cost of transportation related to the transfer of Eligible Employees
and Dependents to facilities authorized by UPB.
D. EMERGENCY ADMISSIONS
In the event Eligible Employees and Dependents require emergency mental health
and/or substance abuse treatment and/or admissions, UPB shall be responsible for the cost
thereof only in the event that:
1. UPB is notified within 24 hours of the inception thereof;
2. UPB specifically authorizes the admission/treatment;
3. the admission/treatment is for the purposes of acute crisis intervention and
stabilization only. The maximum coverage allowable for non- authorized
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emergency, out-of-network services will be up to $500.00 for services within the
Service Area and up to $1,500.00 for services outside the Service Area.
E. MEDICAL NECESSITY
A determination of the medical or clinical necessity for the provision of mental health
and/or substance abuse services to Eligible Employees and Dependents under this Agreement
shall be in the sole discretion of UPB authorized therapists, psychiatrists and facilities.
F. INFORMATION AND REPORTS
UPB agrees to make available to CLEARWATER statistical information compiled and
retained by UPB, which CLEARWATER reasonably requests for reporting purposes. Detailed
utilization reports shall be provided to CLEARWATER on a regular basis.
G. LIMITATION ON BILLING ELIGIBLE EMPLOYEES & DEPENDENTS
UPB agrees that, in no event, including but not limited to non-payment by
CLEARWATER for any reason including but not limited to insolvency of CLEARWATER or
breach of this Agreement by CLEARW A TER, shall UPB bill, charge, collect a deposit from,
seek compensation, remuneration or reimbursement from or have any recourse against
Eligible Employees and Dependents or person other than CLEARWATER acting on Eligible
Employees and Dependents' behalf for covered services provided pursuant to this Agreement.
This provision shall not prohibit collection of copayments made in accordance with the terms
of the Agreement. This provision shall not prohibit collection for non-covered services or from
third parties when such parties are primarily responsible for paying for covered services.
UPB shall aggressively and fully pursue and process any coordination of benefit or
subrogation claims which relate to services provided by UPB. UPB shall be entitled to any
amounts collected by UPB, through coordination of benefits or subrogation, related to mental
health and substance abuse services.
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UPB further agrees that (1) this provision shall survive the termination of this
Agreement regardless of the cause giving rise to termination and shall be construed to be for
the benefit of Eligible Employees and Dependents and that
(2) this provision supersedes any oral or written agreement to the contrary now existing or
hereafter entered into between UPB and Eligible Employees and Dependents or persons acting
on Eligible Employees and Dependents' behalf.
H. GRIEVANCE SYSTEMILITIGATION UPB shall cooperate with CLEARWATER in
resolving any grievances by Eligible Employees and Dependents and shall comply with the
grievance system established. UPB shall comply with the decision reached through the
grievance system established as to coverage and responsibility for payment of covered services
rendered to Eligible Employees and Dependents. A representative ofUPB shall be present and
participate in all proceedings involving grievances regarding the provision of services covered
by this Agreement.
I. EXCLUSIONS OR LIMITATIONS
All medically or clinically necessary Mental Health and Substance Abuse Services and
conditions shall be covered only for the period of evaluation, initial stabilization, case
management and referral. The following specific conditions or treatments are excluded, or
limited, and may require coordination of benefits.
1. Treatments rendered or conditions covered under the auspices or funding of any other
governmental program.
2. Post-acute care for a formal psychiatric disability which is covered under another
Medical Disability benefit.
3. Maintenance, custodial, assisted living, residential or institutional care.
4. A neurological condition or treatment or a permanent organic brain syndrome.
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5. Relationship, family, marriage, or divorce counseling when such services extend
beyond the period necessary for crisis intervention and short-term evaluation.
6. Psychiatric or psychological examinations, testing or treatments for any of the
following:
a. Pre-and post-operative procedures and evaluations.
b. Services sought for the purposes of obtaining or maintaining employment or
insurance coverage.
c. Services sought in connection with, or in regard to, Judicial or Administrative
proceedings.
d. Services sought pursuant to a Court Order or as a condition of parole or
probation.
e. Treatment of a sex offender.
7. Sex therapy will only be covered when it is an adjunct to therapy for other mental
health conditions, for which benefits are afforded under the Group Health Plan.
8. Inpatient services for detoxification more than two times in anyone calendar year for
the removal of toxic substances from the system.
9. Educational, vocational or telephone counseling, testing, remedial education, learning
disabilities, speech therapy, behavioral therapy, hearing therapy.
10. Attention Deficit Hyperactivity Disorder and therapy when services are provided by a
non-psychiatric physician or non-mental health provider.
11. Diet counseling, weight control therapy or nutritional counseling. Treatment for
smoking cessation.
12. Psychotherapy or other mental health intervention for pain or other medical
conditions.
Services shall be rendered only by UPB authorized providers. The treatment
provided shall include reasonable follow-up consistent with the total benefit.
J. MEDICAL vs. MENTAL HEALTH DETERMINATIONS
I. HOSPITALIZATION
The intent of this Section is to establish guidelines to help avoid payment disputes. UPB
shall only be financially responsible for the hospital room and board charges in the event that
the primary treatment for which the patient has been hospitalized is mental health and/or
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substance abuse and the primary treatment is being provided by a psychiatrist. Individual
physician charges and charges for tests that the physician orders or causes to be ordered shall
only be the responsibility of UPB when the physician is a UPB-approved psychiatrist.
The following guidelines shall be used in utilization review and in processing
claims when the services rendered include a combination of mental health and medical care:
1) When a patient is admitted with a primary medical diagnosis and a mental
health consultation is requested, UPB shall be fmancially responsible only for
the consultation;
2) When a patient is admitted for the treatment of a medical problem and there is
a concomitant psychiatric problem, UPB shall not be responsible for the medical
care rendered. In the event the patient is medically cleared subsequent to
admission and then transferred to a Psychiatric Unit, UPB shall be financially
responsible for only that part of the admission occurring after the transfer to
the Psychiatric Unit. For example, if a patient ingests a toxic substance in a
suicide attempt and requires medical care in an ICU, UPB shall not be
responsible for the patient's care until the patient is medically cleared and
transferred to a Psychiatric Unit. In the event medical care continues following
transfer to a Psychiatric Unit, UPB shall not be financially responsible for such
medical treatment including but not limited to tests ordered by a non-
psychiatrist physician;
3) UPB shall be fmancially responsible only for that portion of the claim incurred
due to the mental health diagnosis. For example, if a patient
is being treated for alcoholism with a secondary diagnosis of hepatitis, the care
rendered for the hepatitis by a medical consultant, including ancillary charges,
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shall not be the responsibility of UPB; the care rendered by a mental health
professional, including ancillary charges, shall be the responsibility of UPB.
Financial responsibility for the hospital room and board will be determined by
where the patient is housed and who the primary care giver is (i.e. if the patient
is admitted to a Psychiatric Unit under the care of a psychiatrist, UPB shall be
responsible; if the patient is admitted to a medical unit under the care of a non-
psychiatrist physician, UPB shall not be responsible); When inpatient
detoxification requires treatment on a medical unit by a non-psychiatrist
physician, it shall be considered a medical expense and shall not be the clinical
or financial responsibility of UPB;
5) If a patient is admitted for a medical complaint but the medical evaluation does
not lead to a medical diagnosis and a psychiatric diagnosis is then assigned to the case,
the care rendered, other than for psychiatric consultations, shall not be the
responsibility of UPB. When the patient is transferred to a Psychiatric Unit and the
primary care giver is a psychiatrist, UPB shall be fmancially responsible. For example,
if a patient is admitted for evaluation of pain of unknown etiology but no organic
etiology is identified and the patient is then given a diagnosis of psychogenic pain, the
care rendered, other than for the psychiatric consultation, shall not be the
responsibility of UPB. If and when the patient has been transferred to a Psychiatric
Unit, the care shall become the responsibility of UPB;
6) When a patient is admitted for a medical or a neurological problem but is placed
on a Psychiatric Unit because the patient has a concomitant psychiatric diagnosis and is
a management problem, UPB shall not be fmancially responsible. The operative
criterion for determining claims-paying responsibility shall be which diagnosis is the
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condition which required the inpatient treatment which could only be provided in a
hospital setting. For example, in the case where a patient with Alzheimer's Disease or
mental retardation is housed on a Psychiatric Unit for management purposes but the
primary care giver is a neurologist, UPB shall not be financially responsible. Another
example would be a patient with diabetes mellitus who is also a stable chronic
schizophrenic, If a patient is admitted because his diabetes is out of control but is
placed on a Psychiatric Unit, UPB shall not be f'mancially responsible since the chronic
schizophrenia would not have required hospitalization;
7) When the above guidelines are insufficient, the following additional general
principles shall be used to determine claims-paying responsibility:
a) What is the primary cause for hospitalization?
Which condition could only be treated in a hospital setting?
b) What does the cover sheet on the medical record list as the primary diagnosis
for the admission?
c) Is the attending physician of record a psychiatrist or a medical consultant?
d) Has the patient been admitted to a Psychiatric Unit or a Med/Surg Unit?
e) Who is the primary care giver?
f) What condition is causing the patient to remain in the hospital and who is
treating this problem?
II. EMERGENCY ROOM
If Eligible Employees and Dependents are referred to or self-refer to an Emergency
Room, the cost of the emergency room evaluation shall not be the responsibility of UPB. If a
psychiatric consultation is requested, UPB shall pay for the cost of the psychiatric assessment
and/or treatment. UPB shall not be responsible for the cost of ambulance transfers.
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III. BIOFEEDBACK
UPB shall not be responsible for the cost of Biofeedback unless same is utilized by a
UPB therapist as an adj unctive modality in the course of treatment when specifically treating a
DSM diagnosis (for example, in the treatment of selected patients with anxiety, panic or phobic
disorders).
K. PREEXISTING CONDITIONS: Benefits are not provided for symptomatology related
to any mental health or substance abuse condition (DSM diagnosis) for which Eligible
Employees and Dependents have received treatment within three months prior to the inception
of Eligible Employees and Dependent's coverage under this Agreement. Coverage for such
conditions shall be provided under this Agreement only after:
a) Eligible Employees and Dependents have had three consecutive months without
any treatment for said condition after such inception; or
b) Eligible Employees and Dependents have been covered under this Agreement
for twelve consecutive months. This exclusion of pre-existing conditions shall be
waived for all Eligible Employees and Dependents who are on
CLEARWATER's rolls as of the first effective date of this Agreement.
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EXHIBIT B - FEE SCHEDULE
CLEARWATER agrees to pay toUniPsych Benefits, Inc. as follows:
MentalHealth/Substance Abuse Benefits Per Employee Per Month.....................$6.41
Up to 5 Employee Assistance Program Visits ......... ..............................................$1.48
Such per employee per month fee is to be paid to UPB by the 15th day of each month
commencing January 1,2007 and shall be paid on a monthly basis thereafter based upon the
number of employees of CLEARW A TER and their respective dependents which are on
CLEARWATER's membership rolls each month.
Adjustments shall be made for additional Eligible Employees and Dependents and
discontinued Eligible Employees and Dependents during each month. If Eligible Employees
and Dependents are either added or dropped from the membership rolls between the 1st and
15th of the month, there shall be an appropriate adjustment on the payment provided by in the
following month. If the adjustment on the membership rolls takes place on the 16th of the
month or thereafter, there shall be no adjustment for that particular month.
The above-noted Per Employee Per Month cost shall be construed as a per employee fee
for both inpatient and outpatient services provided in accordance with the Plan Description
attached hereto as EXHIBIT A and documents incorporated therein by reference. Such fee
shall include coverage for all dependents participating in the Group Medical Plan in
accordance with this Agreement. In addition to the above-noted fee, UPB shall collect from
each Eligible Employee and Dependent, the agreed upon co-payments as outlined in such Plan
Description attached hereto. Also, the above-noted fee includes up to 25 hours of training and
other on-site activities per contract year to be provided upon request of CLEARW A TER.
REVISED 2006
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