HomeMy Public PortalAboutAgreement_ 2017-07-18 to 2018-07-17_Empathia Pacific, Inc._Employee Assistance Program_17-019EMPATHIA
LifeMatters® Employee Assistance Program
(EAP)
Specialized Health Care Service
Plan Contract
Empathia Pacific, Inc.
5234 Chesebro Road, Suite 201
Agoura Hills, California 91301
(818) 707-0544
Web site: www.emi)athia.com
EMP•THIA
SPECIALIZED HEALTH CARE SERVICE PLAN CONTRACT
This Specialized Health Care Service Plan Contract ("Subscriber Contract') is made July 12,
2017, between Empathia Pacific, Inc., a California Corporation (The Plan), and The City of
Temple City (Subscriber), in support of the LifeMatters EAP Proposal dated June 27, 2017. The
terms of the Subscriber Contract between The Plan and Subscriber are as follows:
1.0 The Plan has a Knox -Keene License from the State of California, Department of
Managed Health Care.
2.0 The Plan is retained by Subscriber to develop, implement, and provide ongoing
Employee Assistance Program (EAP) services. The Plan warrants its work will conform
to the highest professional standards in its field.
SECTION I - DEFINITIONS
3.0 The following definitions apply to this Specialized Health Care Service Plan Contract:
3.1 BENEFITS means those Covered Services an Enrollee is entitled to receive under
the applicable Empathia Pacific, Inc. Specialized Health Care Service Plan
Contract.
3.2 BENEFIT PERIOD means a period identified by the Specialized Health Care
Service Plan Contract (usually twelve months), which serves to limit your
Covered Services for that period of time.
3.3 COBRA means Consolidated Omnibus Budget Reconciliation Act of 1985 for
continued access to health insurance coverage to be provided to Enrollees, and
their dependents, of Subscribers with 20 or more eligible Enrollees.
3.4 COMBINED EVIDENCE OF COVERAGE/DISCLOSURE FORM (EOC/DF)
means the certificate, agreement, contract, brochure, or letter of entitlement issued
to a Subscriber or Enrollee setting forth the coverage to which the Subscriber or
Enrollee is entitled. The document is attached to this Subscriber Contract as
Exhibit A.
3.5 COMMUNITY SERVICES are defined as qualified long-term behavioral health
and/or chemical dependency treatment resources. Community Services are not
included under this specialized health care service plan contract.
3.6 CO -PAYMENT means the amount, if any specified herein, which represents the
Enrollees portion of the cost of Covered Services. There are no Co -Payments
required of any Enrollee.
3.7 COVERED SERVICES means the LifeMatters EAP services that are covered by
the Plan.
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3.8 CRISIS is the perception or experiencing of an event or situation as an intolerable
difficulty that exceeds the person's current resources and coping mechanisms and
that has the potential to cause behavioral and cognitive malfunction.
3.9 CRISIS INTERVENTION means the process of responding to a request for
immediate services in order to determine whether or not a medical -psychiatric
emergency or urgent situation exists and to otherwise assess the needs for short-
term counseling, referrals to community resources and/or referrals to medical
psychiatric services.
3.10 EFFECTIVE DATE means the actual calendar date when your Specialized Health
Care Service Plan Contract becomes effective. This date is found on page 1, line
1 of the Subscriber Contract.
3.11 EMERGENCY MEDICAL CONDITION means a medical condition manifesting
itself by acute symptoms of sufficient severity including severe pain such that the
absence of immediate medical attention could reasonably be expected to result in
placing the patient's health in serious jeopardy, serious impairment to bodily
functions or serious dysfunction of any bodily organ or part.
3.12 EMERGENCY SERVICES includes medical screening, examination and
evaluation by a physician, or other appropriate Providers under the supervision of
a physician to determine if an Emergency Medical Condition exists, and if it does,
the care, treatments, and surgery by a physician necessary to relieve or eliminate
the Emergency Medical Condition. Emergency Services also include screening
examination and evaluation by an MD psychiatrist, physician or other applicable
Providers within the scope of their licenses to determine if a psychiatric medical
condition exists and the care and treatment necessary to relieve or eliminate the
psychiatric Emergency Medical Condition.
3.13 ENROLLEE means an employee/family member of the employer organization
and who is a recipient of services from the Plan.
3.14 EXCLUSIONS means services that are not covered under this Subscriber
Contract.
3.15 FRAUD means the deliberate submission of false information by a Provider,
Subscriber, Enrollee, plan employee or other individual or entity, to gain an
undeserved payment on a claim or false information relating to the number of
Enrollees covered under the Subscriber Contract with the Plan or false
information relating to making formal management referrals or deceptive
practices that violate the confidentiality of the Enrollee and demands for
confidential Enrollee information that would violate federal and state law
governing confidentiality and professional codes of ethics for employee
assistance program services Providers, and mental health professionals.
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3.16 GRIEVANCE means a written or oral expression of dissatisfaction regarding the
Plan and/or Provider, including quality of care concerns, and shall include a
complaint, dispute, or request for reconsideration or appeal made by an Enrollee
or the Enrollee's representative. Where the Plan is unable to distinguish between
a Grievance and an inquiry, it shall be considered a Grievance.
3.17 LIMITATION means the maximum number of EAP counseling sessions an Enrollee
is eligible to receive under the Subscriber Contract per problem.
3.18 PREMIUM means the sum of money paid monthly to the Plan that entitles the
Enrollee to receive the Covered Services provided by the Plan (Empathia Pacific,
Inc. Employee Assistance Program).
3.19 PROVIDER means a clinical psychologist (PhD), licensed clinical social worker
(LCSW), marriage family and child therapist (MFT), or certified addictions
counselor (CAC) who provides EAP assessment, referral and short-term
counseling services to Enrollees under the Plan.
3.20 SESSION means an outpatient visit with the Provider conducted on an individual
basis during which counseling services are delivered.
3.21 SPECIALIZED HEALTH CARE SERVICE PLAN CONTRACT means a
contract for health care services in a single specialized area of health care, for
Subscribers or Enrollees, or which pays for or which reimburses any part of the
cost for those services, in return for a prepaid or periodic charge paid by or on
behalf of the Subscribers or Enrollees.
3.22 SUBSCRIBER means the person who is responsible for payment to a plan. The
employer organization contracting with the Plan for EAP services is responsible
for payment to the Plan.
SECTION H - SUBSCRIBER SERVICES
COVERED SERVICES
4.0 The Subscriber has contracted for a six (6) Session model LifeMatters Employee
Assistance Program (EAP).
5.0 The Plan will provide EAP services to Subscriber's employees, hereafter referred to as
Enrollees, at times and locations(s) agreed to and arranged by The Plan and the Enrollees.
5.1 Services will be provided through a contracted Provider on an off-site basis,
within 30 minutes or a 15 -mile radius of the eligible Enrollee's home or office
location. The Plan has also established reasonable patterns of practice for more
urban and rural areas; 15 minutes or 7 -mile radius in more urban areas; with rural
areas not to exceed 60 minutes or 50 -mile radius of a contracting Provider.
5.2 All persons who reside with an Enrollee on a non-commercial basis are eligible
for services under this Subscriber Contract.
Page 4
Any minor child or spouse/former spouse, who does not permanently reside with
the Enrollee and is ordered by the court that coverage be provided, is also eligible.
6.0 The Plan will provide EAP assessment and referral to community resources, and/or
psychiatric Emergency Services, and/or short-term counseling services that are
appropriate to help Enrollees resolve their personal problems. The Plan offers counseling
services for a wide range of personal problems and immediate response for Crisis
situations.
7.0 These services are a blend of clinical and worksite services that are based in EAP core
technology as defined by the U. S. Department of Health and Human Services and the
International Employee Assistance Professionals Association, regardless of the
educational background and licensure level of the Provider. Listed services are provided
through Providers who have agreed to enter into a written contract with Empathia Pacific,
Inc.
7.1 All contracting Providers are appropriately licensed and/or certified qualified
clinical professionals who function as EAP counselors within the scope of
employee assistance services and shall comply with professionally recognized
standards of practice and all applicable state and federal laws.
7.2 EAP Providers may be licensed as Marriage Family and Child Therapists (MFT),
Licensed Clinical Social Workers (LCSW), Clinical Psychologists (PhD), and
Certified Addictions Counselor (CAC). All perform EAP counseling within the
defined scope of EAP services.
8.0 The Plan provides clinical counseling for the following issues:
o Marital or Relationship Difficulties
o Family and Child Problems
o Stress/Anxiety
o Depression
o Grief and Loss
o Substance Abuse
o Domestic Violence
o Job Performance Issues
o Crisis Intervention
o Communication and/or Conflict Issues
o Weight and eating disorders
9.0 The Plan provides individual and or family outpatient counseling focused on problem
resolution, helping the individual and/or family develop early stage prevention skills that
improve their quality of life and family relationships, and that encourages early self -
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detecti.:..:..&, ,: lation of personal and/or family problems before they become
unmanageable requiring professional assistance.
10.0 Emergency Health Condition
10.1 Emergency Services. In the event of a medical emergency, the Enrollee should
call 911 or go to the nearest hospital emergency room. Medil;dl einergeucles and
services for medical or other medical care are not Covered Services
and will not be paid by the EAP.
Enrollees are encouraged to use appropriately the "911" emergency
response system, in areas where the system is established and operating,
when they have, or believe they have, an emergency psychiatric or
medical condition that requires an emergency response.
10.2 The Plan provides 24-hour telephone Crisis Intervention. The EAP will determine
whether or not a clinical emergency exists and provide appropriate intervention,
as well as assess the need for short-term counseling, referrals to community
resources or referrals for medical emergency care and treatment.
10.3 Where there is no clinical emergency, but the Enrollee or dependent has an urgent
need to see a Provider within 48 hours to address a serious problem or condition,
the EAP will schedule the Enrollee with a Provider who will offer an appointment
within this time frame.
11.0 The Plan will maintain a 24-hour EAP HelpLine for calls from eligible Enrollees.
Enrollees call the EAP HelpLine for confidential assistance and access to assessment
referral and short-term counsdilag from the Plan's network of Providers.
12.0 The Plan will conform to all applicable state and federal regulations concerning
confidentiality.
13.0 The Plan will maintain confidential records on EAP Enrollees for a period of seven (7)
years. All records which the Plan prepares and maintains are the sole property of the
Plan and will be confidentially retained by the Plan in the event this Subscriber Contract
is terminated.
14.0 The Plan will provide a notice to Enrollees in the evidence of coverage, plan newsletter,
or any direct plan communication to Enrollees, informatio...organ donation
options. This notice shall inform Enrollees of the societal Benefits of organ donations
and the method whereby they may elect to be an organ or tissue donor and goes as
follows:
"There is a need for organ donors across the Country. You can agree to have your
organs donated in the event of your death. If you wish to become an organ donor or
tiaauc du.tw, the California Department of Motor Vehicles (DMV) can give you a
donor card that you carry with your driver's license or I.D. card, and a donor sticker
to place on the front of your driver's license or I. D. card."
Page 6
CO -PAYMENTS, DEDUCTIBLES AND OTHER FEES
15.0 There are no Co -Payments or deductibles required from an Enrollee. The Subscriber whc
has contracted with The Plan to provide EAP services under the Subscriber Contract pays
all fees for EAP services provided under the Plan. Upon each case opening, the Plan
shall inform the Enrollee of the number of visits he/she may be entitled to receive under
the Plan.
EXCLUSIONS
16.0 The following services are specifically excluded from Covered Services provided under
this Subscriber Contract:
(a) Aversion Therapy;
(b) Biofeedback and hypnotherapy;
(c) Court-ordered services required as a condition of parole or probation;
(d) Services for remedial education including evaluation or treatment of learning
disabilities or minimal brain dysfunction, developmental and learning disorders,
behavioral training, or cognitive rehabilitation;
(e) Treatment or diagnostic testing related to learning disabilities, developmental
delays, or educational testing or training;
(f) Services received from a non -contracting Provider, unless the Plan provides prior
approval;
(g) Psychological testing;
(h) Examinations and diagnostic services in connection with the following: obtaining
or continuing employment, obtaining or maintaining any license issued by a
municipality, state or federal government, securing insurance coverage, foreign
travel or school admissions,
(i) Services of a psychiatrist (M.D.), including medication management or
medication consultation;
0) Prescription drugs;
(k) Inpatient, Outpatient, or Residential services for behavioral health or substance
abuse treatment;
(1) Services for which the Subscriber promotes use through monetary or other
material incentives or rewards offered or provided to Enrollees who use or are
encouraged to use such services;
(m) Services that are provided to an individual who is not an Enrollee based upon any
misrepresentations of that individual's family relationship to an Enrollee.
17.0 A Plan Provider will, when clinically appropriate, refer an Enrollee to appropriate
community resources for counseling whenever the assessment clearly indicates that the
problem cannot be resolved by short-term counseling. Enrollees shall be advised that
they are responsible for any costs or fees for services provided by the community
resource.
Page 7
LIMITATION
18.0 When short-term counseling is clinically appropriate, Enrollees may receive up to the
maximum number of Sessions of EAP counseling for each problem, based on the plan
design the Subscriber has contracted for under the Specialized Health Care Service Plan
Contract.
19.0 Complaint/Grievance
19.1 An Enrollee may request voluntary mediation with the Plan prior to submitting a
formal Grievance. This does not preclude the right of the Enrollee to submit a
written Grievance.
19.2 The Plan has established a Grievance process for receiving and resolving Enrollee
complaints or Grievances with Empathia Pacific, Inc., LifeMatters Employee
Assistance Program, and its contracted EAP Providers. If Enrollees have any
problem with services delivered through Empathia Pacific, Inc., our Member
Services Department should be able to assist them and resolve those problems.
19.3 A Member Services Officer reviews any complaint involving care that has been
received or denied. In the case of a denial, the reviewer will not have been
involved in the initial denial of services.
19.4 Enrollee may file a complaint by writing to: Empathia Pacific, Inc., Attention:
Member Services Officer, 5234 Chesebro Road, Suite 201, Agoura Hills, CA
91301, or via toll-free number 1-800-367-7474, or online at
www.mylifematters.com.
19.5 The Member Services Officer will advise the Enrollee that the Plan will
acknowledge in writing receipt of the Grievance within five (5) calendar days and
will provide written resolution of the Grievance within (30) calendar days of
receipt.
19.6 If a Grievance requires an urgent attention, it will be resolved within 48 business
hours.
20.0 Review by the 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 the health plan, you should first
telephone the Plan at 1-800-367-7474 and use the Plan's Grievance process before
contacting the Department for assistance. The Member Services Department is available
to assist you with any complaints and Grievances. 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 the health plan, or a Grievance that has remained unresolved for
more than 30 days, you may call the department for assistance. You may also be eligible
for an Independent Medical Review (IMR).
Page 8
If you are eligible for IMR, the IMR process will provide an impartial review of medical
decisions made by a health plan related to the medical necessity of a proposed service or
treatment, coverage decisions for treatments thu. 4. "F. '... ".. Al or investigational in
nature and payment disputes for emergency or urgent medical services. The Department
also has a toll-free telephone number (1-888466-2219) and a TDD line
(1-877-688-9891) for the hearing and speech impaired. The Department's Internet Web
site hitp.11www.hmohelp.ca gov has complaint forms, IMR application forms and
hila .�Au..6 online.
21.0 Additional Disclosures.
Please refer to the Combined Evidence of Coverage/Disclosure Forms (EOC/DF),
attached as Exhibit A of this Subscriber Contract, for additional disclosures that pertain to
the Plan.
Organ Donation Notice: There is a need for organ donors across the Country. You
can agree to have your organs donated in the event of your death. If you wish to
become an organ donor or tissue donor, the California Department of Motor Vehicles
(DMV) can give you a donor card that you carry with your driver's license or I.D.
card, and a donor sticker to place on the front of your driver's license or I.D. card
22.0 Premium. The Plan will provide services to Subscriber on a per -capita basis of $1.70
per ft),Jlkw y,,....u...h, fora ..F.titll, ... of 100 Enrollees, or $170.00 per month, for the
period of July 18, 2017 through July 17, 2018 as set forth in the attached Business
Proposal dated June 27, 2017, payable in monthly installments on or before the first day
of each calendar month. The fee includes those services as specified in the Business
Proposal. Terms for services paid pursuant to the fee schedule; Net 30 days, date of
invoice. The P)...the right CU ..,..r,6ULcL to service fees and other contract
provisions on an annual basis at the time of Subscriber Contract renewal unless otherwise
specified and agreed to between Subscriber and the Plan. An addendum to the
Specialized Health Care Service Plan Contract will be mailed if an increase is approved.
23.0 The Plan agrees to assume the risk of and liability for and shall indemnify, defend,
protect, and hold harmless Subscriber and its officers, agents and employees from and
against any and all claims, damages, suits, judgments, liabilities, losses, court costs and
expenses, arising out of or in the course of performance of services under its Subscriber
Contract by the Plan. Subscriber agrees to assume the risk of and liability for and shall
indemnify, defend, protect, and hold harmless the Plan and its officers, agents and
employees from and against any and all claims, damages, suits, judgments, liabilities,
losses, court costs and expenses arising out of the negligence of Subscriber or its
employeesireprescmadves.
24.0 The Plan will maintain, during life of this Subscriber Contract, general liability
professional malpractice insurance in the minimum amount of One Million Dollars
($1,000,000) per each occurrence limit and Three Million Dollars ($3,000,000) aggregate
limit. Providers under contract to the Plan maintain professional liability insurance of not
less than $1,000,000 per claim or $3,000,000 annual aggregate. The Plan shall provide
and maintain insurance as stated in Subscriber's Insurance Requirements, attached and
incorporated herein as Exhibit B.
Page 9
25.0 The Plan agrees its relationship to the Subscriber during the terms of this Subscriber
Contract is that of an independent contractor; and, as such, the Plan has no right or
authority to commit or otherwise obligate Subscriber or any of its affiliates to any third
parry in any manner.
26.0 The Plan agrees that as an independent contractor no Social Security, Federal, or State
income tax will be deducted by Subscriber and no retirement and unemployment
Benefits, disability, old age, survivors, workmen's compensation, and hospital insurance,
or other Benefits available to Subscriber's Enrollees will accrue.
27.0 The Plan will enter into no sub -contracts, employment contracts, or agency relationships
that do not specifically require the subcontractor, employee, or agent to abide by the
terms of this Subscriber Contract.
28.0 The Plan will not refuse to enter into any contract or will not cancel or decline to renew
or reinstate any contract, and will not discriminate against any employee, Provider,
Subscriber, or applicant, because of race, religion, color, sex, age, marital status,
handicap status, veteran status, sexual orientation, ancestry or national origin and agrees
that to the extent this contract is applicable, the Plan will comply with all applicable
provisions and requirements of Executive Order 11246 as amended by Executive Order
11375 setting forth the rules, regulations and relevant orders of the Secretary of Labor as
well as California Statutes 12940 (Non -Discrimination in Employment), 12945
(Pregnancy Leave Non -Discrimination), and Section 504 of the Federal Rehabilitation
Act of 1973 (Non -Discrimination of Handicap).
29.0 Subscriber and the Plan agree this Subscriber Contract may be expanded upon mutual
agreement to include additional Enrollees, locations, times, or geographical areas.
30.0 This Subscriber Contract shall have a term of 12 months (the "Initial Term") and shall
automatically renew on the same terms and conditions for annual periods of 12 months
(each, a "Renewal Term") at the end of the Initial Term and each Renewal Term unless
either the Plan or Subscriber give the other notice of termination not less than ninety (90)
days before the end thereof.
31.0 Termination
31.1 Subscriber Termination. Subscriber shall have the option to terminate this
Subscriber Contract upon sixty (60) days notice to the Plan which notice shall
specify concerns and/or complaints expressed by employees or Enrollees
regarding use of services, and which concerns and/or complaints shall not be
resolved by the Plan to Subscriber's satisfaction during such sixty day notice
period.
31.1.1 Subscriber agrees to provide its Enrollees (employees and family
members) notice of the termination.
31.2 Plan Cancellation. The Plan shall have the right to cancel this Subscriber
Contract upon written notice to Subscriber in the following circumstances:
31.2.1 Termination of Contract with Subscriber for Non-Davment of Premium.
The Plan may cancel or decline to renew this contract for cause if
Subscriber fails to pay all premiums owing to the Plan in accordance with
Page 10
the following terms and conditions:
31.2.1.1 Notice of Conseauences of Nonnavment of Premium. The Plan
shall send the Subscriber a written "Notice of Consequences for
Nonpayment of Premium" that shall at a minimum: (i) state the
date(s) that the premiums are due and the consequences of the
failure to pay premiums by the due date; and (ii) inform the
Subscriber that the Plan shall continue to provide coverage
during the 30 -day Grace Period described below. The Plan shall
send the "Notice of Consequences for Nonpayment of Premium"
to the Subscriber concurrent with the billing information and
prior to the commencement of any Grace Period described in this
Section 31.2.
31.2.1.2 Notice of Cancellation for Nonnavment of Premium and Grace
Period. If the Plan does not receive any payment of premium
from Subscriber when due, the Plan may initiate the termination
of this contract by sending the Subscriber a written "Notice of
Cancellation for Nonpayment of Premium and Grace Period"
that shall be dated and at a minimum state the following
information: (i) the reason for the cancellation; (ii) the effective
date of the cancellation; (iii) the dollar amount due to the Plan;
(iv) the date of the last day of paid coverage; (v) the dates the 30
day Grace Period described in Section 31.2.1.3 below begins and
expires; (vi) the 30 day Grace Period notice requirements
described in Section 31.2.1.3 below; (vii) the obligations of the
Subscriber during the 30 day Grace Period described in Section
31.2.1.3 below, if any; and (viii) a clear and concise explanation
of the Subscriber's right to submit a Request for Review by the
Plan and/or the Director of the Department of Managed Health
Care. The "Notice of Cancellation for Nonpayment of Premiums
and Grace Period" shall in form and content comply with all
requirements of applicable laws and regulations. The Plan shall
send the "Notice of Cancellation for Nonpayment of Premiums
and Grace Period" to the Subscriber no later than five (5)
business days following the last day of paid coverage. The
Subscriber shall promptly send a copy of the "Notice of
Cancellation for Nonpayment of Premiums and Grace Period" to
each Enrollee.
31.2.1.3 Grace Period. The Plan shall provide the Subscriber a grace
period ("Grace Period") during which the Plan shall continue to
provide coverage notwithstanding the Subscriber's failure to pay
premiums when due. The Grace Period shall begin on the date
described in the "Notice of Cancellation for Nonpayment of
Premiums and Grace Period," which shall be no earlier than the
first day after the last day of paid coverage. The Grace Period
shall end on the date specified in the "Notice of Cancellation for
Nonpayment of Premiums and Grace Period," which shall be no
Page 11
less than thirty (30) days following the date on which the Grace
Period begins. If the Subscriber, or another party acting on its
behalf, makes the necessary premium payment to the Plan and
the Plan receives that payment on or before the last day of the
Grace Period, the Plan shall ensure that coverage is not cancelled
or not renewed on account of nonpayment of such premiums. In
the event the Plan fails to receive the past due premium payment
on or before the last day of the Grace Period, coverage will be
cancelled effective the day after the last day of the Grace Period.
31.2.1.3.1 Notwithstanding any such cancellation of this
contract, the Subscriber shall remain financially
responsible for any payment of any and all unpaid
premiums, including without limitations premiums
incurred during the Grace Period.
31.2.2 Cancellation of Contract for Intentional Misrevresentative of Materials
Fact by Subscriber. The Plan may cancel or decline to renew this contract
if the Plan demonstrates an intentional misrepresentation of a material fact
by the Subscriber in obtaining this contract. The Plan may cancel or
decline to renew this contract if the Subscriber violates a material
provision of this contract relating to employer contributions or group
participation rates.
31.2.3 Notice of Cancellation or Nonrenewal. Prior to cancelling or declining to
renew this contract for any reason other than for nonpayment of
premiums, the Plan shall send the Subscriber a written "Notice of
Cancellation, Rescission or Nonrenewal" that shall be dated and describe
at a minimum: (i) the reason for the cancellation, rescission or
nonrenewal; (ii) the effective date of the cancellation, rescission or
nonrenewal; and (iii) a clear and concise explanation of the right to submit
a Request for Review to the Plan and/or the Director of the Department of
Managed Health Care. The "Notice of Cancellation, Rescission or
Nonrenewal" shall comply in form and content with all requirements of
applicable laws and regulations. The Plan shall send the "Notice of
Cancellation, Rescission or Nonrenewal" to the Subscriber at least thirty
(30) days prior to the cancellation, rescission or nonrenewal unless
applicable laws require a longer period of advance notice. The Subscriber
shall promptly send a copy of the "Notice of Cancellation, Rescission or
Nonrenewal" to each Enrollee.
31.2.4 Subscriber's Right to Submit Reauest for Review of Cancellation.
Rescission or Nonrenewal of Contract. If the Subscriber alleges that the
contract has been, or will be, improperly cancelled, rescinded, or not
renewed, the Subscriber may file a Request for Review within 180 days
from the date of the "Notice of Cancellation for Nonpayment of Premiums
and Grace Period" or "Notice of Cancellation, Rescission or Nonrenewal"
to the Plan and/or the California Director of the Department of Managed
Health Care.
Page 12
The Subscriber may submit a Request for Review directly to the
Department of Managed Health Care by mail to the attention of the Help
Center, Department of Managed Health Care, 980 Ninth Street, Suite 500,
Sacramento, CA 95814-2725; by phone at 1-888-466-2219/TDD 1-877-
688-9891; by fax at 1-916-255-5241; or online at www.healthheln.ca.gov.
The Subscriber may submit a Request for Review by contacting the Plan
by mail at 5234 Chesebro Road, Suite 201, Agoura Hills, CA 91301; by
phone at 1-818-707-0544; or online at www.empathia.com. The Plan
shall provide the Subscriber and the Director of the Department of
Managed Health Care with a disposition or pending status of the Request
for Review within three (3) calendar days of the Plan's receipt of the
request. If the Plan upholds the cancellation or nonrenewal, the Plan will
immediately transmit the Subscriber's Request for Review to the Director
of the Department of Managed Health Care. The Subscriber will be
notified of the Plan's decision and the Subscriber's right to request further
review of the Plan's decision by the Director. Upon receipt of a request
for review, the Director shall determine whether the request is timely and
shall notify the Plan and the Subscriber that the request for review has
been accepted. The Plan shall provide the Director with a copy of all
information the Plan used to make its determination and all other relevant
information needed for the Director's review within five (5) calendar days
of the Director's notice of acceptance of Request for Review.
If the Subscriber submits a Request for Review prior to the cancellation,
rescission or nonrenewal of the contract, the Plan shall continue to provide
coverage as specified in Section 31.2.5 below. The Director shall send
written notice of the final determination and reasons therefore to the
Subscriber and to the Plan within thirty (30) days, or longer if the Director
determines that additional time is needed to review the cancellation or
nonrenewal. If the Director determines that the cancellation or
nonrenewal is contrary to existing law, the Director shall order
reinstatement or direct the Plan not to cancel the contract. The Plan may
request a hearing within 15 days of the Director's determination.
31.2.5 Continuation of Coverage. If the Subscriber files a Request for Review
with the Plan and/or the California Director of the Department of
Managed Health Care prior to the effective date of cancellation, rescission,
or nonrenewal of this contract for any reason other than nonpayment of
premiums, the Plan shall continue to provide coverage pursuant to this
contract while the Request for Review remains pending with the Plan
and/or the Department of Managed Health Care. During the period of
continued coverage, the Subscriber shall remain responsible for paying
premiums as required by the contract.
31.3 Reinstatement of Coverage. If the Director determines that the cancellation,
rescission or nonrenewal, including a cancellation for nonpayment of premium,
does not comply with existing law, and the Subscriber submitted the Request for
Review after the contract was cancelled or not renewed, the Plan shall reinstate
the contract, retroactive to the date specified in the Director's order and as
Page 13
required by applicable laws and regulations. If the Director so orders
reinstatement, the Plan shall in accordance with applicable laws and regulations
reimburse the Subscriber for covered expenses incurred by the Subscriber, and
reimburse Enrollees for expenses, if any, incurred after the termination or
nonrenewal for services that would otherwise have been Covered Services under
the terms of this contract.
31.4 In the event of cancellation by either the Plan (except in the case of fraud or
deception in the use of services or facilities of the Plan or knowingly permitting
such fraud or deception by another), or the Subscriber, the Plan shall within 30
days return to the Subscriber any pro rata portion of fees paid to the Plan by the
Subscriber which corresponds to any unexpired period for which payment has
been received, together with amounts due on claims, if any, less any amounts due
the Plan.
31.5 No additional eligible Enrollees will be referred or accepted for EAP service after
the date of termination of this contract.
31.6 The Plan does not engage in retroactive termination, and Enrollees covered under
this Subscriber Contract will not be held retroactively responsible for any services
provided to them by the Plan. The Plan holds full accountability for payment of
services rendered to Enrollees under this contract.
32.0 Upon termination of a Provider contract, the Plan will pay the Provider to complete all
Sessions remaining for Sessions in progress, unless the Plan makes other arrangements
for Provider services. In either case no costs will be incurred by Subscriber or any
Enrollee due to this event. The Plan will provide sixty (60) days written notice to
Enrollee/Subscriber of any termination or breach of contract by, or inability to perform
of, any contracting Provider if Enrollee/Subscriber may be materially and adversely
affected thereby.
33.0 No increase in cost or change in Benefits will be proposed by the Plan without providing
30 days advanced written notice to Subscriber.
34.0 The "800" telephone number for use by Enrollees for filing complaints and Grievances is
1-800-367-7474.
35.0 No Enrollee shall be liable for any payments due from The Plan to Providers if the Plan
fails to pay said Providers.
36.0 Subscriber has the responsibility to notify the Plan if EAP services are to be included in
Subscriber's benefit plans subject to COBRA.
37.0 All notices by either party shall be to the addresses indicated below (or such other
addresses as the parties may designate).
38.0 No waiver, modification, or amendment of this Subscriber Contract is valid unless in
writing and duly executed by both parties.
Page 14
39.0 This Subscriber Contract is to be interpreted under the laws of the State of California, and
is intended to be consistent with the requirements of the Knox -Keene Health Care
Service Plan Act of 1975 (as amended on January 1, 2000). The provisions of said Act
will bind the parties regardless of any contrary wording in this Subscriber Contract.
40.0 Notices:
To Subscriber:
To Plan: EMPATHIA PACIFIC, INC.
5234 Chesebro Road, Suite 201
Agoura Hills, California 91301
41.0 Binding Arbitration
All disputes under this Subscriber Contract that cannot be resolved informally must be
submitted to binding arbitration under the commercial rules of the American Arbitration
Association ("AAA"). By signing this contract you are agreeing that all disputes arising
under this Subscriber Contract, including cases of alleged medical malpractice, will be
resolved through neutral arbitration and that neither the Subscriber nor Enrollees will
retain any right to a trial by jury or a court trial in the case. For those disputes for which
the total amount of damages claimed is $200,000 or less, the parties to the dispute shall
select a single arbitrator who shall have no jurisdiction to award more than $200,000.
The arbitration shall take place in California and judgment upon any award rendered by
the arbitrator may be duly entered in any court in the State of California, having
jurisdiction thereof. The prevailing, party shall be entitled to court costs and reasonable
attorney's fees.
In case of financial hardship, the AAA may determine that the Subscriber or the Enrollee
may not be required to pay for the administrative costs of arbitration. The Plan will
provide the Subscriber and Enrollees, upon request, with an application for relief under
this requirement. If the AAA does not grant such a request, the Plan shall, in cases of
extreme hardship, assume all or a part of the Subscriber's or Enrollee's share of those
administrative costs.
Signature Page Follows
Page 15
Signature Page
Executed on the 12th day of July, 2017 in Agoura Hills, California
EMPATHIA PACIFIC, INC.
By: Barbara Weir
Title: Chief Executive Officer
"1041111m/m
Executed on the ?1 s day of in
By: 1yc.. Cc�C
Title:
Page 16
EMPATHIA
LifeMatters® Employee Assistance Program
(EAP)
Combined Evidence of Coverage
and
Disclosure Form
(EXHIBIT A OF SPECIALIZED HEALTH CARE SERVICE PLAN CONTRACT
PLEASE READ THE FOLLOWING INFORMATION
SO YOU WILL KNOW FROM WHOM
YOUR EAP SERVICES MAY BE OBTAINED
Your employer has chosen Empathia Pacific, Inc. (Empathia) to provide
LifeMatters Employee Assistance Program (EAP) services. All LifeMatters EAP
services covered under this Plan will be provided by Empathia EAP Providers.
Empathia Pacific, Inc. is a private national firm specializing in employee
assistance programs. Empathia is not an insurance company.
This Evidence of Coverage and Disclosure Form constitute only a
summary of your plan Benefits. The Empathia LifeMatters Employee
Assistance Program Subscriber Contract (the contract between your
Employer and Empathia) must be consulted to determine the exact terms
and conditions of coverage.
Any questions? Call our Member Services Department at 800-367-7474
Table of Contents
Welcome to Empathia Pacific, Inc. (Empathia)..........................................................................1
Introduction to LifeMatters EAP by Empathia..........................................................................2
ImportantTerms........................................................................................................................ 3-4
ObtainingYour LifeMatters EAP Benefits................................................................................5
Principal Benefits and Coverage.............................................................................................. 5-8
Limitation........................................................................................................................6
Choiceof Providers..................................................................................................... 6-7
Continuityof Care.............................................................................................................7
Facilities..........................................................................................................................7
Obtaining Emergency Services.........................................................................................8
CrisisIntervention.............................................................................................................8
Exclusions..................................................................................................................................8-9
Eligibility, Enrollment, Effective Date and Renewal Provisions ......................................... 9-10
Eligibility.................................................................................................................... 9-10
Enrollment...................................................................................................................... 10
Effective Date of Coverage............................................................................................ 10
RenewalProvisions.........................................................................................................10
Confidentiality and Release of Information........................................................................10-11
Anti -Discrimination Notice.........................................................................................................11
Anti -Fraud Plan...........................................................................................................................11
OrganDonation Notice................................................................................................................11
Terminationof Benefits........................................................................................................12-13
IndividualContinuation of Benefits.......................................................................................... 13
ElectingCOBRA Coverage...............................................................................................13
Liability of Subscriber or Enrollee for Payment...............................................................13-14
Co-Payment.....................................................................................................................13
Prepaymentof Fees.........................................................................................................13
Reimbursement Provisions.......................................................................................13-14
Liability for Sums Owed By Empathia Pacific, Inc. EAP..............................................14
How Empathia Pacific, Inc. compensates EAP Providers..............................................14
Complaint, Grievance and Appeals Procedures
15-16
Complaint/Grievance Process.........................................................................................15
BindingArbitration...................................................................................................15-16
Review by the Department of Managed Health Care.....................................................16
PublicPolicy Committee................................................................................................16
COMBINED EVIDENCE OF COVERAGE
AND DISCLOSURE FORM
WELCOME TO EMPATHIA PACIFIC, INC.
LIFEMATTERS EAP
Your employer has chosen Empathia Pacific, Inc. (Empathia) to provide LifeMatters Employee
Assistance Program (EAP) services for you, your dependents and other members living in your
home. Empathia Pacific, Inc. (the "Plan") is a specialized health care service plan licensed in
California under the Knox Keene Act. This brochure is your COMBINED EVIDENCE OF
COVERAGE AND DISCLOSURE FORM. Your employer has entered into a contract with the
Plan.
This Combined Evidence of Coverage and Disclosure Form provides you with important
information on how to obtain Covered Services and the circumstances under which Benefits will
be provided to you. PLEASE READ IT CAREFULLY.
Keep this publication in a safe place where you can easily refer to it when you are in need of
Covered Services.
Empathia Pacific, Inc.
LifeMatters Employee Assistance Program
5234 Chesebro Road, Suite 201
Agoura Hills, CA 91301
(800) 367-7474
Web site: www.mvlifematters.com
INTRODUCTION TO
LIFEMATTERS EAP BY EMPATHIA
LifeMatters Employee Assistance Program is provided by Empathia Pacific, Inc., a Specialized
California Health Care Service Plan headquartered in Agoura Hills, California.
When you receive Covered Services from an EAP Provider, you will not be responsible for
paying any Co -Payment. You will not make Premium payments; your employer makes Premium
payments on your behalf.
If you wish to know more information about any of the issues covered in this Combined
Evidence of Coverage/Disclosure Form, you may request additional information from the Plan.
Also if you have any questions or concerns about LifeMatters by Empathia, Employee
Assistance Program, call our Member Services Department at the telephone number provided
below. Our Member Services Officer will be happy to assist you.
The Plan, operating as a specialized health care service plan, will provide you an appropriately
qualified and licensed behavioral health care Provider, acting within the scope of EAP practice,
and who possesses a clinical background, including training and expertise related to the delivery
of employee assistance program services.
Empathia Pacific, Inc.
LifeMatters Employee Assistance Program
Member Services Department
5234 Chesebro Road, Suite 201
Agoura Hills, CA 91301
Telephone: (800) 367-7474
IMPORTANT TERMS
The following definitions apply to this Combined Evidence of Coverage and Disclosure Form:
BENEFITS means those Covered Services an Enrollee is entitled to receive under the applicable
Empathia Pacific, Inc. Specialized Health Care Service Plan Contract.
BENEFIT PERIOD means a period identified by the Specialized Health Care Service Plan
Contract (usually twelve months), which serves to limit your Covered Services for that period of
time.
COBRA means Consolidated Omnibus Budget Reconciliation Act of 1985 for continued access
to health insurance coverage to be provided to Enrollees, and their dependents, of Subscribers
with 20 or more eligible Enrollees.
COMBINED EVIDENCE OF COVERAGE/DISCLOSURE FORM (EOC/DF) means the
certificate, agreement, contract, brochure, or letter of entitlement issued to a Subscriber/Enrollee
setting forth the coverage to which the Subscriber or Enrollee is entitled.
COMMUNITY SERVICES are defined as qualified long-term behavioral health and/or chemical
dependency treatment resources. Community Services are not included under this specialized
health care plan.
CO -PAYMENT means the amount, if any specified herein, which represents the Enrollee's
portion of the cost of Covered Services. There are no Co -Payments required of any Enrollee.
COVERED SERVICES means those services an Enrollee is entitled to receive under the Plan.
CRISIS INTERVENTION means the process of responding to a request for immediate services
in order to determine whether or not a medical -psychiatric emergency or urgent situation exists
and to otherwise assess the needs for short term counseling, referrals to community resources
and/or referrals to medical psychiatric services.
EFFECTIVE DATE means the actual calendar date when your Specialized Health Care Service
Plan Contract becomes effective. This date is found on Page 1, line 1 of the Subscriber Contract.
EMERGENCY MEDICAL CONDITION means a medical condition manifesting itself by acute
symptoms of sufficient severity including severe pain such that the absence of immediate
medical attention could reasonably be expected to result in placing the patient's health in serious
jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or
part.
EMERGENCY SERVICES includes medical screening, examination and evaluation by a
physician, or other appropriate Providers under the supervision of a physician to determine if an
Emergency Medical Condition exists, and if it does, the care, treatments, and surgery by a
physician necessary to relieve or eliminate the Emergency Medical Condition. Emergency
Services also include screening examination and evaluation by an MD psychiatrist, physician or
other applicable Providers within the scope of their licenses to determine if a psychiatric medical
condition exists and the care and treatment necessary to relieve or eliminate the psychiatric
Emergency Medical Condition.
ENROLLEE means an employee of the Subscriber organization, their eligible dependents and
significant others who are permanent residents of the Enrollee's household are eligible for
services under the Plan. Any minor child or spouse/former spouse who does not permanently
reside with the Enrollee and is ordered by the court that coverage be provided, is also eligible
under the Plan.
EMPLOYER means an organization that has contracted with the Plan to provide employee
assistance services to its eligible employees and who is responsible for payment to the Plan.
EXCLUSIONS mean services that are not covered under the Plan.
FRAUD means the deliberate submission of false information by a Provider, Subscriber, Plan
Enrollee, Plan employee or other individual or entity, to gain an undeserved payment on a claim
or false information relating to the number of Enrollees covered under the Subscriber Contract
with the Plan or false information relating to making formal management referrals or deceptive
practices that violate the confidentiality of the Enrollee and demands for confidential Enrollee
information that would violate federal and state law governing confidentiality and professional
codes of ethics for employee assistance program services Providers, and mental health
professionals.
GRIEVANCE means a written or oral expression of dissatisfaction regarding the Plan and/or a
Provider, including quality of care concerns, and shall include a complaint, dispute, request for
reconsideration or appeal made by an Enrollee or the Enrollee's representative. Where the Plan
is unable to distinguish between a Grievance and an inquiry, it shall be considered a Grievance.
LIMITATION means the maximum number of EAP counseling sessions an Enrollee is eligible to
receive under the Subscriber Contract for each problem.
PREMIUM means the sum of money paid monthly to the Plan that entitles the Enrollee to
receive the Covered Services provided by the Plan (Empathia Employee Assistance Program) as
outlined in this Evidence of Coverage and Disclosure Form.
PROVIDER means a clinical psychologist (PhD), licensed clinical social worker (LCSW),
marriage family and child therapist (MFT), or certified addictions counselor (CAC) who
provides EAP assessment, referral and short-term counseling services to Enrollees under the
Plan.
SESSION means an outpatient visit with a Provider conducted on an individual basis during
which counseling services are delivered.
SPECIALIZED HEALTH CARE SERVICE PLAN CONTRACT means a contract for health
care services in a single specialized area of health care, for Subscribers or Enrollees, or which
pays for or which reimburses any part of the cost for those services, in return for a prepaid or
periodic charge paid by or on behalf of the Subscribers or Enrollees.
SUBSCRIBER means the entity that is responsible for payment to the Plan. The employer
organization contracting with the Plan for EAP services is responsible for payment to the Plan.
OBTAINING YOUR LIFEMATTERS EAP BENEFITS
Please read the remainder of this Combined Evidence of Coverage and Disclosure Form to fully
understand how to use your LifeMatters by Empathia, Employee Assistance Program Benefits.
Here are the basics:
For confidential assistance, call the toll free EAP Help Line number 24 hours a day.
An EAP Help Line professional will take your information, assess your situation, and use
that information to find the appropriate Provider in the area close to your home or work,
as you prefer it.
The EAP Help Line professional will then provide you with the contact information for
the Provider for you to call the Provider to schedule an in-person appointment at the
Provider's office.
LifeMatters by Empathia will authorize the number of short-term counseling Sessions
allowed under your EAP. The actual number of short-term counseling Sessions provided
is a decision made between you and the Provider based on the Provider's assessment of
your situation and goals for short-term counseling.
At the initial in-person appointment, an assessment is made by the Provider to determine
if short-term counseling is appropriate, or if a referral to Community Services is needed
to resolve your situation/problem.
If the Provider determines that short-term counseling is appropriate, the Provider will
help you evaluate and work toward resolving your problem. In many cases, problems can
be resolved within the number of Sessions available through LifeMatters by Empathia.
PRINCIPAL BENEFITS AND COVERAGE
This section summarizes the Covered Services provided to Enrollees, their dependents and
household members.
The services offered by LifeMatters by Empathia EAP include problem assessment, short-term
counseling, referral, and follow-up. Formal medical diagnoses or on-going treatment services
are not provided. The EAP services provided to you may include referring you to independent
resources for on-going assistance. If a referral is made, the EAP will usually provide two or
three resource options; the final choice will be your responsibility. These referrals are made in
consideration of our assessment of your needs. The EAP receives no reimbursement from any
referral source.
If a referral for on-going treatment services is required, your EAP Provider will consider your
insurance benefits and ability to pay, and will discuss these matters with you.
However, you are responsible for final verification of insurance coverage and any Co -Payments
or charges not covered by your insurance. The Plan provides clinical assessment, short-term
counseling and referral for a variety of problems including, but not limited to:
o Marital or Relationship Difficulties
o Family and Child Problems
o Stress/Anxiety
o Depression
o Grief and Loss
o Substance Abuse
o Domestic Violence
o Job Performance Issues
o Crisis Intervention
o Communication and/or Conflict Issues
o Weight and eating disorders
Referrals are provided to Enrollee to community resources for any ongoing assistance in these
areas. Services by a community resource are not Covered Services.
When the Plan refers an Enrollee to community resources for assistance for non -Covered
Services, the Enrollee is responsible for payment of costs and fees for services provided by
community resources that are not contracted Providers.
Limitation
Enrollees may receive up to six (6) EAP counseling sessions for each problem specified in the
Subscriber Contract.
Choice of Providers
These services to Enrollees are based in EAP core technology as defined by the U. S.
Department of Health and Human Services and the International Employee Assistance
Professionals Association, regardless of the educational background and licensure level of the
Provider. Listed services are provided through Providers who have agreed to enter into a written
contract with Empathia Pacific, Inc.
(a) All contracting Providers are appropriately licensed and/or certified qualified clinical
professionals who function as EAP counselors within the scope of employee assistance
services and shall comply with professionally recognized standards of practice and all
applicable state and federal laws.
(b) EAP Providers may be licensed as Marriage Family and Child Therapists (MFT),
Licensed Clinical Social Workers (LCSW), Clinical Psychologists (PhD), and Certified
Addictions Counselors (CAC). All perform EAP counseling within the defined scope of
EAP services.
A list of contracting providers within the Enrollee's general geographic area is available upon
request.
The Plan will provide EAP services to Subscriber's employees, hereafter referred to as eligible
Enrollees, at times and locations(s) agreed to and arranged by the Plan and Enrollee.
You may request a different EAP Provider for assessment and referral and/or short-
term counseling for second opinion at no cost to you, by contacting the Member
Services Officer at 800/367-7474. Requests for a second opinion by an Enrollee will
be authorized or denied in a timely manner, appropriate to the nature of the
Enrollee's condition, and will be provided in a time period not to exceed 72 hours
after the Plan's receipt of the request. The second opinion will be given by a licensed
health care Provider who is acting within his/her scope of practice, and who possess
a clinical background related to the condition associated with the Enrollees request.
This second opinion will be given, without cost to the Enrollee.
Continuity of Care
• Terminated Providers
Should the Subscriber, Provider, or the Plan terminate its contract, the Plan will provide
Enrollees continuity of care fb. and referral, or short-:)�..i. �u_.y ,:ing services. The
Plan will complete all assessment and referral services and/or remaining short .�.... ,,,, .d/L..g
which have been started prior to the date of termination and that are clinically appropriate. The
Plan will p,u i%[ , y ,, dl [.y (60) days written notice of termination of any contracting EAP
Provider if you may, or would, be materially and adversely affected by such termination.
• New Employee
The Plan will allow any new Enrollee involved in a current episode of short-term counseling
with a prior employee assistance program (EAP) service Provider, at the time their employer
terminated the prior EAP contract, to continue in short-term counseling with that Provider under
the former plan, up to the limits of the number of short-term counseling Sessions to be provided
by the Plan under the new Subscriber Contract. The Plan will not attempt to offer continuity of
care beyond the scope of employee assistance services and its licensed capabilities.
Facilities
Enrollees may obtain a list of EAP Providers in their geographic area by calling the Plan at
1-800-367-7474, or by submitting a request to the Plan. All a�. V lees must be
CU016i,iaLe11 by cuk,l"dLy, 1k Plan through the 24 hours/day, 7 days/week toll-free EAP Help
Line at 1-800-367-7474.
Obtaining Emergency Services
In the event that an Enrollee is having or believes that he/she is having a medical or
psychological emergency, the Enrollee or dependent should call 911, or go to the nearest hospital
e...u.gu..�y .uw... Medical/psychlaa.L dad services for medical ..nu.gc..uy or other
medical/psychiatric care are not Covered Services and will not be paid by the EAP.
Enrollees are encouraged to use appropriately the "911" emergency response system, in
areas where the system is established and operating, when they have, or believe they
have, an emergency psychiatric or medical condition that requires an emergency
response.
Crisis Intervention
Your EAP provides 24-hour telephone Crisis Intervention. The EAP will determine whether or
not to providb vc,..tion, as well as assess the need for short-term counseling,
referrals to community ."u."6 v. referrals for emergency behavioral care and treatment.
Where there is no Crisis, but the Enrollee or dependent has an urgent need to see a Provider
within 48 hours to address a serious problem or condition, the EAP will schedule the Enrollee
with a Provider who will offer an alilidlita.Yent within this time frame.
EXCLUSIONS
The following services are specifically excluded:
• All services other than the Employee Assistance Plan services covered on page 6.
The following services are specifically excluded from Covered Services:
(a) Aversion Therapy;
(b) Biofeedback and hypnotherapy;
(c) Court-ordered ��. o."; .�464i d as a condition of parole or probation;
(d) Services for remedial education including evaluation or treatment of learning
disabilities or minimal brain dysfunction, developmental and learning disorders,
behavioral training, u. rehabilitation;
(e) Treatment or diagnostic testing related to learning disabilities, developmental
delays, or educational testing or training;
(f) Services received from a non -contracting Provider, unless the Plan provides prior
approval;
(g) Psychological testing;
(h) Examinations and diagnostic services in connection with the following: obtaining
or continuing employment, obtaining or maintaining any license issued by a
municipality, state or federal government, securing insurance coverage, foreign
travel or school admissions;
(i) Services of a psychiatrist (M.D.), including medication management or
medication consultation;
0) Prescription drugs;
(k) Inpatient, Outpatient, or Residential services for behavioral health or substance
abuse treatment;
(1) Services for which the Subscriber promotes use through monetary or other
material incentives or rewards offered or provided to Enrollees who use or are
encouraged to use such services;
(m) Services that are provided to an individual who is not an Enrollee based upon any
misrepresentation of that individual's family relationship to an Enrollee.
ELIGIBILITY, ENROLLMENT,
EFFECTIVE DATE AND RENEWAL PROVISIONS
Eligibility
To be eligible for services under the Plan, your employer must have executed a Specialized
Health Care Service Plan Contract ("Subscriber Contract") with Empathic Employee Assistance
Program.
Your employer makes the determination of who is eligible to participate and who actually
participates in the Plan. Disputes or inquiries regarding eligibility, including rights regarding
renewal, reinstatement and the like may be referred by Empathia Employee Assistance Program
to your employer for determination.
If an Enrollee is terminated from employment and he or she returns to active employment with
Subscriber, such Enrollee and his or her eligible dependents may again become eligible.
Dependent coverage is included in the Plan. Dependent is defined as follows:
The lawful spouse of the Enrollee. All newborn infants whose eligibility begins from and
after the moment of birth. Adopted children, stepchildren, and foster children are eligible
from and after the date of placement. Except as stated above, dependents are eligible for
coverage on the date the Enrollee is eligible for coverage or on the day the Enrollee
acquires such dependent.
2. An Enrollee's dependent, up to age twenty-six (26), irrespective of the dependent's place
of residence, marital, financial, or student status.
3. Coverage will not terminate while a dependent child is and continues to be (1) incapable
of self-sustaining employment by reason of mental retardation or physical handicap; and
(2) chiefly dependent upon the Enrollee for support and maintenance provided the
Enrollee famishes proof of such incapacity and dependency to Empathia Pacific, Inc.,
Employee Assistance Program within thirty (30) days of the child attaining the limiting
age set forth in paragraph 2 above, and every two (2) years thereafter, if requested by the
Plan.
4. In addition to the above, all permanent residents of the Enrollee's household are eligible
for Covered Services under the Plan. Any spouse/former spouse who does not
permanently reside with the Enrollee and is ordered by the court that coverage be
provided is also eligible.
Enrollment
As an employee of your company, you and all persons who reside with you on a non-commercial
basis are automatically eligible for coverage in the Empathia Employee Assistance Program.
Any minor child or spouse/former spouse who does not permanently reside with you and is
ordered by the court that coverage be provided is also eligible for services.
Effective Date of Coverage
The beginning of eligibility coverage is determined by the effective date of the Specialized
Health Care Service Plan Contract. From that date forward, you must receive all EAP services
through the Empathia Employee Assistance Program in order to maximize your Benefits.
Renewal Provisions
The Plan shall have a term of 12 months and shall automatically renew on the same terms and
conditions for annual periods of 12 months at the end of the initial term and each renewal term
unless either the Plan or Subscriber gives the other notice of termination not less than ninety (90)
days before the end thereof. An addendum to the Subscriber Contract will be mailed to the
employer if a change is approved.
CONFIDENTIALITY AND RELEASE OF INFORMATION
The Plan will maintain the confidentiality of all Enrollee EAP records except to the extent that
disclosure is authorized by the Enrollee in writing, or is otherwise mandated by federal and state
law. All EAP case records are maintained in compliance with all federal and state laws
protecting the confidentiality and security of EAP records. The Plan maintains a comprehensive
standard procedure on the confidentiality of case records that prescribes how Enrollee case
records are to be maintained.
The Plan's procedures are also fully compliant with the Federal Health Insurance Portability &
Accountability Act [HIPAA] that became effective April 14, 2003.
10
The Plan's Notice of Privacy Practices, which describes the Plan's policies and procedures for
preserving the confidentiality of medical records, will be offered to each enrollee during the EAP
intake call or counseling appointment. Members may request a paper copy of this Notice at any
time by contacting the Plan at 1-800-367-7474. The Plan's Notice of Privacy Practices is also
available on the Plan's ... v. J.te at mylifematters.com
ANTI -DISCRIMINATION NOTICE
The Plan will never refuse to (i) enter into any Subscriber Contract, cancel or decline to renew or
reinstate any Subscriber Contract, or (ii) enroll any person or accept any person as a Enrollee or
renew any person as a Enrollee on the basis of race, color, national origin, ancestry, religion, sex,
marital status, sexual orientation, age, or disability of any contracting party, prospective
contracting party, or person reasonably expected to benefit from that contract as a Subscriber,
Enrollee, member, or otherwise.
ANTI—FRAUD PLAN
The Plan has established an Anti -Fraud Plan to identify and reduce the risk and potential costs to
the Plan, and to protect its EAP Providers, Subscribers, and their Enrollees, in the delivery of
emp!L) j , c sijw .w services through the timely detection, investigation and prosecution of
suspected fraudulent activities
Subscribers and their Enrollees should file a report of suspected or alleged fraudulent activities to
the Plan. This filing of any report will be treated confidentially and should be filed with the
Plan's Chief Executive Officer, who can be contacted by mail at 5234 Chesebro Road, Suite 201,
Agoura Hills, California 91301 or by telephone at 1-818-707-0544 or by fax at 1-818-707-0496.
Any report of suspected or alleged fraudulent activities will be immediately investigated
according to the Plan's published Anti -Fraud Plan S-00-08. Copies of the Anti -Fraud Plan are
available .,,y,.,,dt through the address and contact numbers listed above.
ORGAN DONATION
Organ Donation Notice: There is a need for organ donors across the country. You can
agree to have your organs donated in the event of your death. If you wish to become an
organ donor or tissue donor, tell your family members that you have decided to become
an organ and tissue donor so they will understand your wishes and support them. Have a
frank discussion about the steps they will need to take at the time of your death to ensure
your donations take place in the proper time frame. If you wish to become an organ and
tissue donor, the California Department of Motor Vehicles (DMV) can give you a donor
card that you carry with your driver's license or I.D. card, and a donor sticker to place on
the front of your driver's license or I.D. card and carry it in your wallet or purse at all
times. Have two people witness your signature, preferably family members.
For more information you can contact the National Transplant Society/National Donor
Registry on-line at www.organdonor.org, or by contacting U. S. Department of Health
and Human Services website at www.organdonor.gov.
TERMINATION OF BENEFITS
In most cases, your coverage will end when the Plan's Subscriber Contract with your employer
(Subscriber) terminates. There are also some circumstances when your coverage may end even
though the Plan's contract with your employer remains in effect, for example, when you are no
longer eligible to receive EAP Benefits as an Enrollee (employee or family member).
Your coverage cannot be cancelled because of your health status or your use of EAP services. If
you believe this has happened you may send us a written complaint to the attention of the
Member Services Officer as described in the "Compliant, Grievance and Appeals Procedure"
section of this Evidence of Coverage / Disclosure Form, or on-line at www.mvlifematters.com,
or by calling 1-800-367-7474, asking to speak with the Member Services Officer. You may also
request a review by the Director of the California Department of Managed Health Care.
❑ Termination by your employer — Your employer (the Subscriber) may terminate the
Plan's contract at any time upon sixty (60) days written notice to the Plan, if the Plan is
unable to resolve your employer's satisfaction concerns and/or complaints expressed by
employees or Enrollees regarding use of the services.
❑ Termination by the Plan for non-payment — If your employer (the Subscriber) fails to
pay our fees, the Plan may terminate the Subscriber Contract for nonpayment. The Plan
must first give your employer a "Notice of Consequences for Nonpayment of Premiums"
and a "Notice of Cancellation for Nonpayment of Premiums and Grace Period" before
termination may take effect. Your employer is responsible to promptly provide enrollees
with a copy of the Notice of Cancellation. Before any termination for nonpayment may
occur, the Plan must provide a Grace Period of not less than thirty (30) days during which
time your coverage will continue. If your employer fails to pay a past due premium
before the end of the Grace Period, the contract and your coverage will end after the end
of the Grace Period.
❑ Termination of coverage based on other grounds — The Subscriber Contract permits the
Plan to terminate the contract and your coverage on certain other grounds, such as an
intentional misrepresentation of a material fact by your employer (the Subscriber) in
obtaining the Subscriber Contract. The Plan must first give your employer a "Notice of
Cancellation, Rescission or Nonrenewal" before termination may take effect. Your
employer is responsible to provide a copy of this Notice of Cancellation to you promptly.
❑ Review by Department of Managed Health Care — In certain circumstances, your
employer will have the right to submit a Request of Review of any cancellation,
rescissions or nonrenewal of the Subscriber Contract to the California Director of the
Department of Managed Health Care. Depending on the outcome of such a review, the
termination of the Subscriber Contract and your coverage may be delayed or may not
take effect. In any event, your employer is responsible to inform you of any termination
of your coverage under the Subscriber Contract.
12
The Plan does not engage in retroactive termination, and as an Enrollee (employee or eligible
family member) under your employer's Subscriber Contract, you will not be held retroactively
responsible for any services provided to you by the Plan.
INDIVIDUAL CONTINUATION OF BENEFITS
Electing COBRA Coverage
Your employer is responsible for providing you notice of your right to receive continuing coverage
under COBRA. Your employer is responsible for notifying the Plan of the duration of your
eligibility.
If you terminate your employment with the Subscriber, you may elect to continue your EAP
benefit through your employer under COBRA. If you elect to continue this benefit, you are
eligible for all EAP services covered under the Subscriber Contract up to the limits of the Plan.
You must notify your employer that you elect to continue the EAP benefit. Your employer will
include your name on a list of employees who have selected the EAP benefit under COBRA, and
will provide the Plan this updated list on a regular basis. You will not be responsible for filing a
claim for EAP services under COBRA, as these services will continue to be paid by your former
employer.
LIABILITY OF SUBSCRIBER OR ENROLLEE FOR PAYMENT
Co -Payment
There are no Co -Payments. All Covered Services are paid for by the Plan.
Prepayment of Fees
Your employer is paying the monthly Premium for your EAP services. Neither you nor your
dependents and other members of your household have any responsibility for payment of any
Premiums or Co -Payments for EAP services provided to you under the Plan.
There are no restrictions on assignment of Benefits payable to the Enrollee by the Plan.
Reimbursement Provisions
All EAP services are 100% paid for by your employer under the Subscriber Contract it maintains
with the Plan. Under the terms of the Subscriber Contract, Enrollees are required to access all
EAP services through the Plan's nationwide toll free EAP HelpLine, 1-800-367-7474, available
to Enrollees 24 hours/day, 7 days/week.
In the rare case that an Enrollee might have to access EAP services though a Provider who is not
contracted with the Plan due to the Plan's inability to offer the Enrollee access to a contracted
Provider within the accessibility and time limits specified in the Plan's standards of accessibility,
the Enrollee can request reimbursement from the Plan for any out-of-pocket payment for services
13
incurred. Any such claim for reimbursement should be submitted to the Plan, Attention:
Member Services Officer, at 5234 Chesebro Road, Suite 201, Agoura Hills, California 91301.
Claims can also be submitted via fax at (818) 707-0496, Attention: Member Services Officer.
The Plan will evaluate the claim for reimbursement and notify the Enrollee within 15 days of the
receipt of the claim of the approval or denial of the claim. If the claim is denied, the Plan will,
during the same 15 -day period, provide the Enrollee with information about the basis for denial
and how to appeal the decision. If the claim for reimbursement is approved, payment will be
made within 30 days from the date of receipt of the request for reimbursement.
This provision does not alter the Enrollee's requirement to access EAP services through the
Plan's nationwide toll free EAP Help Line, 1-800-367-7474, available to Enrollees 24
hours/day, 7 days/week.
Liability for Sums Owed by Empathia Pacitic, Inc.
Employee Assistance Program
California law requires that every contract between a Plan and a Provider must contain a
provision that prohibits the Plan from holding you financially responsible for sums owed to a
Provider by the Plan. Therefore, in the event the Plan fails to pay a Provider for Covered
Services, you will not be liable to that Provider for the amount owed by the Plan.
How Empathia Pacific, Inc. Compensates EAP Providers
The Plan will pay each of the contracting EAP Providers directly for Covered Services on a
negotiated fee-for-service basis.
Empathia Employee Assistance Program does not pay financial bonuses or other incentives to
Plan Providers. Should you wish to know more about these issues, please contact our Member
Services Department at 1-800-367-7474.
Providers are allowed to self -refer for continuing services beyond the scope of EAP services in
specific situations in which the clinical need is best served by the Member remaining with the
Provider for ongoing treatment services. In such cases, the Member will be asked to sign a
Freedom of Choice Affidavit, which clarifies that the Member has been offered at least two
alternative treatment resources and chooses to enter into a direct payment agreement with the
Provider and that these treatment services are not covered under the Plan's EAP.
14
COMPLAINT, GRIEVANCE AND APPEALS PROCEDURES
Complaint/Grievance Process
Empathia Employee Assistance Program has established a Grievance process for receiving and
resolving Enrollee complaints or Grievances with Empathia Employee Assistance Program and
its contracted EAP Providers. If you should have any problem with services delivered through
Empathia, the Empathia Member Services Department should be able to assist you and resolve
those problems.
A Member Services Officer reviews any complaint involving care that has been received or
denied. In the case of a denial, the reviewer will not have been involved in the initial denial of
services.
The Member Services Officer will advise the Enrollee that the Plan will acknowledge in writing
receipt of the Grievance within five (5) calendar days and will provide written resolution of the
Grievance within (30) calendar days of receipt.
If a Grievance requires urgent attention, the Plan shall expedite its review of the Grievance to be
resolved no less than three calendar days of receipt of Grievance.
You may file a complaint by phone, in writing, or online @ www.mvlifematters.com. Our toll-
free number is 1-800-367-7474. Please ask to speak to the Member Services Officer, or address
your correspondence to:
Empathia Pacific, Inc.
LifeMatters Employee Assistance Program
Attention: Member Services Officer
5234 Chesebro Road, Suite 201
Agoura Hills, CA 91301
Neither the Plan nor any of its participating providers will discriminate against an Enrollee based
on the filing of a Grievance. If you believe that you have been discriminated against due to your
filing a Grievance, please call 1-800-367-7474 and ask to speak to the Member Services Officer.
Binding Arbitration
All disputes that may arise between an Enrollee and the Plan, if they cannot be resolved informally
shall be resolved by arbitration under the commercial rules of the American Arbitration Association
(`AAA"). Therefore, any dispute, including any dispute as to medical malpractice, that is as to
whether any medical or other services rendered under this contract were unnecessary or unauthorized
or were improperly, negligently or incompletely rendered, will be determined by submission to
arbitration, and not by a lawsuit or resort to court process except as California law provides for
15
judicial review of arbitration proceedings. Enrollees, by accepting Covered Services, give up their
constitutional right to have any such dispute decided n a court of law before a jury, and instead
accept the use of arbitration.
For those disputes for which the total amount of damages claimed is $200,000 or less, the parties
shall select a single arbitrator who shall have no jurisdiction to award more than $200,000. The
arbitration shall take place in California and judgment upon any award rendered by the arbitrator
maybe duly entered in any court in the State of Califomia, having jurisdiction thereof. The
prevailing, party shall be entitled to court costs and reasonable attorney's fees.
In case of financial hardship, the AAA may determine that you are not required to pay for the
administrative costs of arbitration. The Plan will, upon request, provide you an application for relief
from this requirement. If the AAA does not grant your request, the Plan shall, in cases of extreme
hardship, assume all or part of your share of these administrative costs.
Review by the 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 your health plan, you should first telephone your
Plan at 1-800-367-7474 and use The Plan's Grievance process before contacting the Health Plan
Division for assistance. The Member Services Department is available to assist Enrollees with
any complaints and Grievances. 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 your
health plan, or a Grievance that has remained unresolved for more than 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 a health plan 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 (1-888-466-2219) and a TDD line
(1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site
http://Www.kmohelp.ca.gov has complaint forms, IMR application forms and instructions online.
Public Policy Committee
The Plan has established a Public Policy Committee, with the majority of the committee
members being from Subscriber groups who contract for the Plan's EAP services.
This committee meets at least quarterly and assists the Plan in establishing its public policy
relating to services provided by the Plan, its Enrollees and contract Providers, to assure the
comfort, dignity, and convenience of Enrollees seeking EAP services for themselves, their
families and the public. If you are interested in more information, please call us at 818/707-
0544.
16
0:i:i10.1w.
INSURANCE
A. Insurance Reouirements. Service Provider shall provide and maintain
insurance, acceptable to the City, in full force and effect throughout the term of this
Agreement, against claims for injuries to persons or damages to property which may
arise from or in connection with the performance of the Services by Service Provider, its
agents, representatives or employees. Insurance is to be placed with insurers with a
current A.M. Best's rating is an assigned policyholders' Rating of A (or higher) and
Financial Size Category Class VII (or larger).
Only the following "marked" requirements are applicable and Service Provider shall
provide the following scope and limits of insurance:
1. Minimum Scope of Insurance. Coverage shall be at least as broad
as:
x Commercial General Liabilitv. Insurance Services Office Form PF -
12827C(03/15) Healthcare Facilities General Liability Coverage Part
(Occurrence)
x Automobile Liabilitv. Service provider shall maintain automobile insurance at
least as board as Insurance Services Office form CA 00 01 covering bodily injury
and property damage for all activities of the Service Provider arising out of or in
connection with work to be performed under this Agreement, including coverage
for any owned, hired, non -owned or rented vehicles.
x Workers' Compensation. Workers' Compensation Insurance (Statutory Limits)
and Employer's Liability Insurance as required by the Labor Code of State of
California covering all persons providing Services on behalf of the Service
Provider and all risks to such persons under this Agreement.
x Professional (Errors and Omissions) Liabilitv. Professional liability insurance
appropriate to the Service Provider's profession. This coverage may be written
on a "claims made" basis, and must include coverage for contractual liability.
The insurance must be maintained for at least three (3) consecutive years
following the completion of Service Provider's services or the termination of this
Agreement. During this additional three (3) year period, Service Provider shall
annually and upon request of the City submit written evidence of this continuous
coverage.
Service Provider shall maintain professional liability insurance that covers the
Services to be performed in connection with this Agreement. Any policy
inception date, continuity date, or retroactive date must be before the effective
RIV 44838-6958-3880 0
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EXHIBIT B
date of this agreement and Service Provider agrees to maintain continuous
coverage through a period of no less than three years after completion of the
services required by this agreement.
1. Minimum Limits of Insurance. Service Provider shall maintain limits
of insurance no less than:
(1) Commercial General Liabilitv. $1,000,000 per occurrence,
$2,000,000 general aggregate for bodily injury, personal injury and property damage.
(2) Automobile Liabilitv., No less than $1,000,000 combined
single limit for each accident.
(3) Workers' Compensation. Workers' Compensation as
required by the Labor Code of the State of California of not less than $1,000,000 per
occurrence and Employer's Liability Insurance with limits of at least $1,000,000.
(4) Professional Liabilitv. $1,000,000 per claim and in the
aggregate.
B. Other Provisions. Insurance policies required by this Agreement shall
contain the following provisions:
1. All Policies. Each insurance policy required by this Agreement
shall state the coverage shall not be suspended, voided, cancelled by the insurer or
either Party to this Agreement, reduced in coverage or in limits except after 30 days'
prior written notice by certified mail, return receipt requested, has been given to City by
the insurer's producer or broker.
2. Commercial General Liabilitv and Automobile Liabilitv Coveraaes.
(1) City, and its respective elected and appointed officers,
officials, and employees and volunteers are to be covered as additional insureds as
respects: liability arising out of activities Service Provider performs; products and
completed operations of Service Provider; premises owned, occupied or used by
Service Provider; or automobiles owned, leased, hired or borrowed by Service Provider.
(2) Service Provider's insurance shall apply to each insured
against whom claim is made or suit is brought, except with respect to the limits of the
insurer's liability.
RIV #4838-6958-3880 A
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C-2
EXHIBIT B
(3) Requirements of specific coverage features or limits
contained in this Section are not intended as a limitation on coverage, limits or other
requirements, or a waiver of any coverage normally provided by any insurance. Specific
reference to a given coverage feature is for purposes of clarification only as it pertains
to a given issue and is not intended by any party or insured to be all inclusive, or to the
exclusion of other coverage, or a waiver of any type.
(4) Coverage provided by the CONTRACTOR shall be primary
and any insurance or self-insurance or maintained by Agency shall not be required to
contribute to it. The limits of insurance required herein may be satisfied by a
combination of primary and umbrella or excess insurance. Any umbrella or excess
insurance shall contain or be endorsed to contain a provision that such coverage shall
also apply on a primary and non-contributory basis for the benefit of Agency before the
Agency's own insurance or self-insurance shall be called upon to protect is as a named
insured.
(5) Any failure to comply with the reporting or other provisions of
the insurance policies, including breaches of warranties, shall not affect coverage
provided to City, and its respective elected and appointed officers, officials, employees
or volunteers.
3. General Liabilitv Coveraqe. The City Manager has not agreed that
the insurer can waive all rights of subrogation against City, and its respective elected
and appointed officers, officials, employees and agents for losses arising from work
performed by Service Provider and therefore a waiver is required.
4. Workers' Compensation Coveraoe. The City Manager has agreed
in writing (attached), that the insurer does not need to agree to waive all rights of
subrogation against City, and its respective elected and appointed officers, officials,
employees and agents for losses arising from work performed by Service Provider.
C. Other Reauirements. Service Provider agrees to deposit with City, at or
before the effective date of this Agreement, certificates of insurance necessary to
satisfy City that the insurance provisions of this contract have been complied with. The
City may require that Service Provider furnish City with copies of original endorsements
effecting coverage required by this Exhibit "B". The certificates and endorsements are
to be signed by a person authorized by that insurer to bind coverage on its behalf. City
reserves the right to inspect complete, certified copies of all required insurance policies,
at any time.
1. Service Provider shall furnish certificates and endorsements from
each subcontractor identical to those Service Provider provides.
RIV #4838-6958-3880 v3
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EXHIBIT B
2. Any deductibles or self-insured retentions must be declared to and
approved by City. At the option of City, either the insurer shall reduce or eliminate such
deductibles or self-insured retentions as respects City or its respective elected or
appointed officers, officials, employees and volunteers or the Service Provider shall
procure a bond guaranteeing payment of losses and related investigations, claim
administration, defense expenses and claims.
3. The procuring of such required policy or policies of insurance shall
not be construed to limit Service Provider's liability hereunder nor to fulfill the
indemnification provisions and requirements of this Agreement.
RIV #4838-6958-38800
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��I
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r.r,s
. 1960 /_
9701 LAS TUNAS DRIVE • TEMPLE CITY • CALIFORNIA 91780-2249 • (626) 285-2171
July 31, 2017
I have agreed that Empathia does not need to agree to waive all rights of subrogation
against City for Workers' Compensation, and its respective elected and appointed
officers, officials, employees and agents for losses arising from work performed by
Service Provider.
Bryan Cook, City Manager