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HomeMy WebLinkAboutPR 19499: ADMINISTRATOR SERVICES, BLUE CROSS AND BLUE SHIELD OF TEXAS, INC. City of r1 rthur Texas INTEROFFICE MEMORANDUM Human Resources Department Date: August 26, 2016 To: Brian McDougal, City Manager From: Lisa Colten, Assistant Director of Human Resources Patricia Davis, Human Resources Training Manager 6j)ityr RE: BC/BS Renewal Effective 11/1/2016 P. R. No. 19499 - A Resolution Authorizing The City Manager To Execute Contracts Between Its Third Party Administrator(Administrative Services Only) For The City of Port Arthur Group Medical, Dental Insurance; For Basic Life, For Basic Accidental Death And Dismemberment, And Excess Loss Indemnity With Blue Cross and Blue Shield of Texas,Inc. Nature of the request: The City of Port Arthur considers its employees to be its most valuable asset and resource. In keeping with this premise, major medical health insurance and dental insurance, basic life insurance, and basic accidental death and dismemberment insurance are provided for its employees and City Council appointees. Additionally, the City also provides access to its major medical health insurance coverage, including prescription drug coverage, for its retirees under age 65. Medicare retirees as well as their Medicare dependent(s) will transition to the Blue Cross Medicare Advantage PPO and Prescription Drug Plan effective on 11/1/2016. Staff Analysis, Considerations: The City of Port Arthur has a Preferred Provider Organization (PPO) insurance format which provides participants great latitude in selection of health care providers. This format has been deemed most beneficial for plan participants and most compatible with our organizational culture. The City also offers a lower cost Health Savings Account (HSA) option. The City is self-insured for major medical health insurance coverage. As we reviewed the upcoming renewal with Blue Cross and Blue Shield of Texas along with the adoption of a Blue Cross Medicare Advantage PPO and Prescription Drug Plan for our Medicare retirees and their Medicare dependent(s) affecting approximately 175 plan participants, staff feels it Brian McDougal, City Manager Page 2 of 2 P.R. #19499 is in the overall best interest of the City to accept this renewal which has resulted in a substantial savings of over one million dollars($1,000,000). Each renewal year comes with additional elements of the Affordable Care Act impacting the City's health insurance that must be taken into account. In the upcoming renewal year there are no changes to the current level of benefits (i.e. no change in annual deductible, no change in maximum out-of-pocket deductible, no change in co-pays, etc.). The City of Port Arthur has enjoyed surprising price stability with Blue Cross and Blue Shield of Texas, Inc. with average rate increases of 2.3% where industry averages are significantly greater at 7%-11%. Further, the Blue Cross and Blue Shield network discounts and national availability provide not only significant plan cost savings, but also access for employees,retirees, and dependents across the nation. This current year's renewal reflects a 5% increase in recommended premium funding. Also included as Attachment "A" is an analysis of this year's renewal proposal as presented by the City's insurance consultant, Mr. Mickey Moshier. The renewal as presented does not pass on any increase to employees. It provides for the City to absorb the proposed 5% increase. Dental, AD&D, and Life insurance rates remained constant with no increase. Additional efforts with regard to wellness and education regarding plan usage and alternatives will be a significant initiative in the upcoming renewal year. The 2016-2017 Open Enrollment period will be from October 1 to October 31,2016. Recommendation: It is recommended that the City Council adopt P. R. No. 19499 which authorizes the City Manager to execute contracts between its third party administrator (administrative services only) for the City of Port Arthur group medical, dental insurance; for basic life, for basic accidental death and dismemberment, and excess loss indemnity with Blue Cross and Blue Shield of Texas, Inc., and Dearborn National Life Insurance Company for its 11/1/2016- 10/31/2017 plan year. Budget Considerations: Approval of P.R.No. 19499 which authorizes the City Manager to execute contracts with the following budgetary impact for which funds are available: Fund No. 614-1701-583.54.00 (Health Insurance Fund) Expected claims $7,249,874 Administration/Stop Loss $1,522,620 Dental $ 318,004 Basic Life/AD&D $ 30,000 Total $9,120,498 "Remember we are here to serve the Citizens of Port Arthur" P.R. No. 19499 8/26/2016—LC/pd RESOLUTION NO. A RESOLUTION AUTHORIZING THE CITY MANAGER TO EXECUTE CONTRACTS BETWEEN ITS THIRD PARTY ADMINISTRATOR (ADMINISTRATIVE SERVICES ONLY) FOR THE CITY OF PORT ARTHUR GROUP MEDICAL, DENTAL INSURANCE; FOR BASIC LIFE; FOR BASIC ACCIDENTAL DEATH AND DISMEMBERMENT; AND EXCESS LOSS INDEMNITY WITH BLUE CROSS AND BLUE SHIELD OF TEXAS, INC. FUND NO. (S): 614-1701-583.54-00 (HEALTH INSURANCE FUND) WHEREAS, the City Council of the City of Port Arthur deems it necessary and appropriate to provide major medical health care benefits for the City's employees, City Council appointees, and its retirees under the age of 65. Additionally, Medicare retirees as well a their Medicare dependent(s) will be covered through the Blue Cross Medicare Advantage PPO and Prescription Drug Plan effective on 11/1/2016; and, WHEREAS, the City Council deems it in the best interest of the citizens of Port Arthur to be self-funded and to accept the renewal from Blue Cross and Blue Shield of Texas, Inc. as a third party administrator at an estimated cost of $466,694 per year (administrative charge based on the present number of employees) as well as at a cost of $1,251,194 per year for stop loss premium (excess indemnity) per the recommendation of the City's insurance consultant, Mickey Moshier, listed hereto as Attachment"A"; and, WHEREAS, the City's group health plan coverage encompasses the enactment of the Patient Protection and Affordable Care Act (PPACA) effectuated on March 23, 2010, with continuing provisions enacted annually, and do hereby P.R. No. 19499 8/26/2016 LC/pd Page 2 of 5 affirm to continue to make changes to its existing health plan policies or products as required to comply with the law; and, WHEREAS, such contracting with Blue Cross and Blue Shield of Texas, Inc. complies with Sections 252.021(b), Competitive Requirements for Certain Purchases, 252.024, Section of Insurance Broker, and 252.048, Change Orders, respectively, of the Local Government Code; and, WHEREAS, the nature of the premiums to be charged by the City and the summary of benefits are as delineated in Exhibit "A", which reflect the costs for administration by Blue Cross and Blue Shield of Texas, Inc., the stop loss premium and the expected reserve; and, WHEREAS, the Basic Life Insurance will also be continued per Dearborn National Life which includes provisions to provide basic life insurance coverage to Fire Civil Service personnel at a rate of one times his/her base annual salary in accordance with the 10/01/2011 Collective Bargaining Agreement between the City of Port Arthur, Texas and Local 397 International Association of Fire Fighters, which will cost the City $.22/per thousand dollar unit, and all other eligible employees' coverage will remain a $6,000 death benefit policy, which will cost the City $.19/per thousand dollar unit/per employee/per month and attached as Exhibit "B"; and, WHEREAS, as part of the Dearborn National Life proposal, the City is also obtaining Accidental Death and Dismemberment insurance on behalf of its employees which will remain at a cost of $.04/per thousand dollar unit/per P.R. No. 19499 8/26/2016 LC/pd Page 3 of 5 Employee (for a $5,000 accidental death and dismemberment policy for all eligible Employees) per month as attached as Exhibit "B"; and, WHEREAS, the current year's renewal reflects a 5% increase in recommended premium funding, the renewal as presented does not pass on any increases to employees and retirees. Further, it provides for the City to absorb the proposed 5% increase. NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PORT ARTHUR, TEXAS: Section 1. That, the City Council of the City of Port Arthur hereby accept the following contracts to Blue Cross and Blue Shield of Texas, Inc., attached hereto and made a part hereof, as is fully delineated herein: INSURANCE COVERAGE ADMINISTRATIVE SERVICES EFFECTIVE DATE Administrative Services Blue Cross and Blue Shield November 1, 2016 City of Port Arthur's Group Medical and Stop Loss Dental Blue Cross and Blue Shield November 1, 2016 Basic Life & AD&D Dearborn National Life November 1, 2016 Section 2. That, the City Manager is hereby further authorized to execute the necessary contracts and other documents on behalf of the City of Port Arthur subject to the approval of the City Attorney, and to make payment of necessary premium and administrative charges to bind coverage subject to the terms and conditions of the contract for Third Party Administrator (Administrative P.R. No. 19499 8/26/2016 LC/pd Page 4 of 5 Services Only) and the Contracts for Insurance attached hereto as required to effectuate said services; and, Section 3. That, The City Manager is hereby directed to take all actions necessary to ensure proper funding of the City of Port Arthur's Employee Health Insurance Fund; and, Section 4. That, a copy of the caption of this Resolution be spread upon the minutes of the City Council. READ, ADOPTED, AND APPROVED this day of , AD, 2016, at a Regular Meeting of the City Council of the City of Port Arthur, by the following vote: AYES: Mayor , Councilmembers: NOES: P.R. No. 19499 8/26/2016 LC/pd Page 5 of 5 Derrick Freeman, Mayor ATTEST: Sherri Bellard, City Secretary APPROV AS TO FORM: // / V ecia zen's City Attorney APPROVED FOR ADMINISTRATION: Lisa Colten, Assistant Director of Human Resources Brian McDougal, City Manager APPROVED AS TO AVAILABILITY OF FUNDS: ra-x A 1 4•i -a( ate,.. -d Jerry Dale, Director of Finance g# d►lIi ATTACHMENT "A" J.S. Edwards Sherlock INSURANCE AGENCY City of Port Arthur Employee Benefits Renewal November 2016 As a reminder, the City solicited proposals for employee benefits in November 2013. The specifications requested and we received a 3 year offer with options for years 4 and 5 included. We are now in the 4th year of this process. Fee guarantees were included in the Blue Cross Blue Shield of Texas (BCBSTX) proposal and remain part of the November 2016 renewal offer from BCBSTX. The original November 2016 renewal proposal suggested a 13.5% funding level adjustment. This suggestion was as a result of overall utilization, medical trends, and large ongoing claims. Overall claims experience for the renewal period reflect a 10% increase in total claims vs the renewal period last year. There have been 12 claims over $100,000 each during the experience period. Remember that the City's plan is partially self-funded and we maintain a stop loss policy to help fund extremely large claims. That stop loss coverage has a $100,000 deductible per covered participant; therefore, claims over 4155 Phelan Boulevard • Beaumont,TX 77707 • P.O.Box 22237,77720-2237 Beaumont(409)832-7736 • Fax(409)833-1721 • Houston(713)224-8723 $100,000 become the responsibility of the stop loss carrier while claims below $100,000 are funded by the City's health claim fund. Review and discussion of the overall claims info with BCBSTX yielded relief from the suggested funding level to a 5% suggested adjustment to current. That reduction is a result of updated data and a reduction in the trend/medical inflation factor originally used. This reduced level also reflects that Medicare eligible participants will be moving to the previously approved Medicare Advantage program effective 11/1/16 as well. No benefit changes other than those required by the ACA are suggested at this time. In my opinion, the revised renewal offering is extremely fair given the City's claim history during the renewal calculation period. We were also able to negotiate no change to current dental rates and benefits and life insurance rates and coverage levels. I am available for additional review and/or discussion that city officials might have on this recommendation. Respectfully submitted, )24(,:pzt,(i Mickey Moshier, MHP J.S. Edwards and Sherlock Insurance Exhibit "A" BlueEdge ASO HSA with Embedded Rig,e ,o $ ke; p, ,� Deductibles �; of Texas • • BENEFIT HIGHLIGHTS Prepared gar City of Port ArthurBlueChoice Network Effective Date : 11 /01 /2015 'This is a general summary of your benefits. Please refer to your Summary of Benefits and Coverage(SBC), or you may request a copy of the policy or plan document for additional details and a description of the plan requirements and benefit design. This plan does not cover all health care expenses. Please carefully review the plan's limitations and exclusions. Overall Payment Provisions In-Network Out-of-Network Benefits Benefits Embedded Deductible Calendar Year Deductible $2,600 Individual/ $5,200 Individual/ Applies to all Eligible Expenses(unless otherwise indicated) $5,200 Family $10,400 Family Applies to Out-of-Pocket Maximum Family coverage:When one family member meets the individual Deductible, benefits become available under the plan for that individual. NOTE:The individual Deductible amount must be equal to or greater than the minimum family Deductible amount. This qualification is established by the U. S. Treasury for a plan to be considered a qualified HSA plan. Deductible credit from prior carrier(Applied on initial group enrollment only) Yes Yes Out-of-Pocket Maximum $5,000 Individual/ $10,000 Individual/ $10,000 Family $20,000 Family Deductibles applies to Out-of-Pocket Yes—no option Yes** Copayment applies to Out-of-Pocket Yes—no option Yes** Network Deductible&Out-of-Pocket Out-of-Network Deductible&Out- will only apply toward Network of Network Out-of-Pocket will also Deductible&Out-of-Pocket Maximum apply toward Network Deductible& Out-of-Pocket Maximum Maximum Lifetime Benefits Per Participant I Unlimited BlueEdge CDHP Health Savings Account Order of Payment(CDHP Stacking) Stack#1: t9SA Inpatient Hospital Expenses Inpatient Hospital Expenses All services must be preauthorized Inpatient Hospital Expenses 80%of Allowable Amount after 60%of Allowable Amount after Each admission must be preauthorized Deductible Deductible All usual Hospital services and supplies,including semiprivate room, intensive care,and coronary care units. Penalty for failure to preauthorize services None 5250 A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business BlueEdge ASO H S A Embedded Deductible Effective 01/01/2015(Revised 11/2014 for 02/2015 Release) Pana 9 of BlueEdge ASO HSA with Embedded nitiecrosN niDgvst e4,7A Deductible czo of Texas BENEFIT HIGHLIGHTS Prepared for City of Port Arthur BlueChoice Network Effective Date : 11 /01 /2015 Medical/Surgical Expenses Medical/Surgical Expenses -Services performed during the Physician's office visit/consultation,including 80%of Allowable Amount after 60%of Allowable Amount after lab& x-ray Deductible Deductible -Lab&x-ray in other outpatient facilities 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -Physician surgical services performed in any setting 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -Physician inpatient hospital visits 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -Certain Diagnostic Procedures;such as Bone Scan,Cardiac Stress Test,CT 80%of Allowable Amount after 60%of Allowable Amount after Scan(with or without contrast), MRI, Myelogram,PET Scan. Deductible Deductible -Home Infusion Therapy(Services must be preauthorized) 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -All other outpatient services and supplies 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible In Vitro Fertilization Services Not Covered Extended Care Expenses In-Network Out-of-Network Benefits Benefits Extended Care Expenses(must be preauthorized) 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Skilled Nursing Facility Limited to 25 day maximum each Year* Home Health Care Limited to 60 visit maximum each Year" Hospice Care Unlimited Special Provisions Expenses Serious Mental Illness/Mental Health Care/ Treatment of Chemical Dependency Inpatient Services Inpatient Chemical Dependency treatment must be provided in a Chemical Dependency/Residential Treatment Center(RTC) -Hospital services(facility) 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -Physician services 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Penalty for failure to preauthorize services None $250 Preauthorization required for inpatient,residential treatment centers(RTC), partial hospital program admissions, and certain outpatient professional services Outpatient Services -Services performed during Physician office visit/consultation (does not include psychological testing) 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -All outpatient services and psychological testing 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Emergency Room/Emergency Treatment Room Accidental Injury&Emergency Care -Facility charges 80%of Allowable Amount after Deductible -Physician charges 80%of Allowable Amount after Deductible Non-Emergency Care -Facility charges 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -Physician charges 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business BlueEdge ASO H S A Embedded Deductible Effective 01/01/2015(Revised 11/2014 for 02/2015 Release) Page 2 of 5 BlueEdge ASO HSA with Embedded t31uecross MueShield Deductible 1 ofTexas BENEFIT HIGHLIGHTS Prepared for City of Port Arthur BlueChoice Network Effective Date: 11 /01 /2015 Urgent Care Services Urgent Care center visit,including lab&x-ray services 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Certain Diagnostic Procedures;such as Bone Scan,Cardiac Stress Test,CT Scan(with or without contrast),MRI,Myelogram,PET Scan,surgical 80%of Allowable Amount after 60%of Allowable Amount after procedures and all other services and supplies. Deductible Deductible Ground and Air Ambulance Services 80%of Allowable Amount after Deductible Preventive Care Routine annual physical examinations,well-baby care exams,immunizations 6 100%of Allowable Amount 60%of Allowable Amount years of age&over,and any other preventive health services as determined by USPSTF Immunizations for Dependent children through the date of the child's 6th 100%of Allowable Amount 100%of Allowable Amount birthday *Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated. Speech and Hearing Services Services to restore loss of or correct an impaired speech or hearing Covered same as any other sickness Covered same as any other sickness function Hearing Aids 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Hearing Aid Maximum Hearing aids are subject to 1 per ear per 36 month period Physical Medicine Services Chiropractic Care-Office Services 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Maximum Limited to 35 visit maximum each Year* All other Physical Medicine Services rendered by any other Provider will be allowed on the same basis as any other sickness. *Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated. A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business BlueEdge ASO H S A Embedded Deductible Effective 01/01/2015(Revised 11/2014 for 02/2015 Release) Page 3 of 5 BlueEdge ASO HSA with Embedded t;'uc rossl;turshteht Deductible r�,;�� of Texas Pharmacy Benefits Participating Non-Participating Pharmacy* Pharmacy (member files claim) Drug List** I Preferred Drug List 1 Deductible and Out of Pocket Accums-Integrated is the Standard option for HSA. Integrated RX Accum The drug deductible and Out-of-Pocket is the same as the medical Deductible and!Out-of-Pocket.All benefits,including prescription drug benefits(retail and mail order)must apply to the plan's overall Deductible and Out-of-Pocket Maximum. Vaccinations obtained through Pharmacies*** Yes - If yes, flu vaccinations covered as follows: Select pharmacies participating in Flu Network —100% All other pharmacies—apply appropriate tier copay Retail Pharmacy (Benefit payments are based on a 30-day supply. With appropriate $50 Copayment Amount after the Deductible**** prescription order,up to a 90-day supply is available.) Mail Order Program (Benefit payments are based on a 30-day supply. With appropriate $50 Copayment Amount after the Deductible**** prescription order,up to a 90-day supply is available.) Specialty Drugst Members will be required to obtain specialty pecfaKy medications through Prime Therapeutics Specialty Pharmacy LLC(Prime Specialty Pharmacy). No Penalty—Member pays no more than the applicable Generic,Preferred Drug,or Non-Preferred Drug Copayment. Product selection is permitted,even when generic equivalents are available. *To locate a participating pharmacy in your area,go to mvprime.com or contact customer service at the phone number on the back of your identification card. **The preferred drug list is available at: bcbstx.com/member/rx_drugs.html ***Select pharmacies participating in the Flu Network are contracted to provide vaccination services. Flu vaccinations at all other in-network and out-of-network pharmacies are payable at the applicable tier copay. Each pharmacy may have age,scheduling,or other requirements that will apply. You are encouraged to contact the store in advance. Childhood immunizations subject to state regulations are not available under this pharmacy benefit. Refer to your BCBSTX medical coverage for benefits available for childhood immunizations. Diabetes Supplies are available under the Prescription Drug benefits of your plan.Diabetic Supplies include insulin and insulin analog preparations,insulin syringes necessary for self-administration,prescriptive and non-prescriptive oral agents,all required test strips and tablets which test for glucose,ketones,and protein,lancets and lancet devices,biohazard disposable containers,glucagon emergency kits,and other injection aids.All provisions of this portion of the plan will apply including Copayment Amounts and any pricing differences that may apply to the items dispensed. All medications with over-the-counter(OTC)equivalents are excluded from coverage except for Omeprazole 20 mg. **Effective 111112015,Specialty Lock Out through Prime Specialty Pharmacy applies. No coverage available for specialty drugs when purchased through any other provider. One grace fill allowed. 1 For more Information on the specialty drug program,call Prime Specialty Pharmacy at(877)627-6337. "Effective 111112015,Prior Authorization is required for the drug class PCSK-9 Inhibitors(Specialty injectable drugs)for Homozygous Familial Hypercholesterolemla Agents. A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business BlueEdge ASO H S A Embedded Deductible Effective 01/01/2015(Revised 11/2014 for 022015 Release) Page 4 of 5 BlueEdge ASO HSA with Embedded ruaz ,,o3‘tirSatDetrLieal ri Deductible ; ¢�f:F`sex.:a;, Non-Standard Covered Benefits Effective 11-1-2011: a Radial Keratotomy covered o Lasilc surgery covered A Medicare Assumption/Estimation 0 Services, supplies and prescription drugs for the reduction of morbid obesity, including surgical procedures, when medically necessary, covered same as any other illness(note: prescription drugs for morbid obesity are not subject to medical necessity) Age limit increased to age 26 for the following benefit: Reconstructive surgery performed on a covered dependent child under the age of 26 due to craniofacial abnormalities to improve the function of, or attempt to create a normal appearance of an abnormal structure caused by congenital defects, developmental deformities,trauma,tumors, infections or disease. Non-Standard Covered Benefits Effective 11-1-2014: Effective 11-1-14—Services, supplies and Prescription Drugs for Sexual Dysfunction are covered. Prescription Drugs for Sexual Dysfunction are limited to 8 pills per month. ± Please be reminded that Health Savings Accounts(HSA's)have tax and legal ramifications. Blue Cross and Blue Shield of Texas does not provide legal or tax advice,and nothing herein should be construed as legal or tax advice. These materials,and any tax-related statements in them,are not intended or written to be used,and cannot be used or relied on,for the purpose of avoiding tax penalties. Tax-related statements,if any,may have been written in connection with the promotion or marketing of the transaction(s)or matter(s)addressed by these materials. You should seek advice based on your particular circumstances from an independent tax advisor regarding the tax consequences of specific health insurance plans or products. Group Executive Name and Title Signature Date (Please type or print) Agent of Record Name Signature Date (Please print or type) BCBSTX Representative Name Signature Date (Please print or type) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business BlueEdge ASO H S A Embedded Deductible Effective 01/01/2015(Revised 11/2014 for 02/2015 Release) Page 5 of 5 PPO ASO Standard with Network UlueCrog BlueShield Deductible and Split Copay ? 11- ofTexas BENEFIT HIGHLIGHTS Prepared for City of Port Arthur BlueChoice Network Effective Date : 11 /01 /2015 Benefit Agreement #: 0002 & 001 This is a general summary of your benefits. Please refer to your Summary of Benefits and Coverage(SBC), or you may request a copy of the policy or plan document for additional details and a description of the plan requirements and benefit design. This plan does not cover all health care expenses. Please carefully review the plan's limitations and exclusions, Overall Payment Provisions In-Network Out-of-Network Benefits Benefits Deductibles Per-admission Deductible None $200 Calendar Year Deductible $1,500 Individual/ $2,000 Individual/ Applies to all Eligible Expenses except Inpatient Hospital Expenses(unless $3,500 Family $6,000 Family otherwise indicated) Three-month Deductible carryover applies Yes Yes Out-of-Pocket Maximum $5,000 Individual/ $6,500 Individual/ $10,200 Family $15,000 Family Deductibles applies to Out-of-Pocket Yes es Copayment applies to Out-of-Pocket Yes Network Deductible&Out-of- Out-of-Network Deductible&Out-of Pocket -til on, apply toward Network Out-of-Pocket will also Network Deductible&Out-of- apply toward Network Deductible& Pocket Maximum Out-of-Pocket Maximum Copayment amounts and per admission deductibles are applied but will continue to be required after the benefit percentage increases to 100% Copayment Amounts Required Physician office visit/consultation: Primary Care Copayment Amount for office visit/consultation when $35 Primary Care Copayment services rendered by a Family Practitioner,OB/GYN,Pediatrician, Behavioral Health Practitioner,or Internist and Physician Assistant or Advanced Practice Nurse who works under the supervision of one of these listed physicians Specialty Care Copayment Amount for office visit/consultation when services $50 Specialty Care Copayment rendered by a Specialty Care Provider Refer to Medical/Surgical Expenses section for more information Urgent Care center visit $75 Copayment Amount Refer to Urgent Care Services section for more information Outpatient Hospital Emergency Room/Treatment Room visit $150 Copayment Amount $150 Copayment Amount Refer to Emergency Room/Treatment Room section for more information Maximum Lifetime Benefits Per Partici•ant Unlimited Inpatient Hospital Expenses Inpatient Hospital Expenses All services must be preauthorized All usual Hospital services and supplies, including semiprivate room,intensive 80%of Allowable Amount 60%of Allowable Amount after per- care,and coronary care units admission Deductible Penalty for failure to preauthorize services None $250 A Division of Health Care Senvice Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association ANGF 151+Business PPO ASO Standard with Network Deductible,Split Copay Effective 01/01/15(Rev 11/2014 for 02/2015 Release) Pace 1 of 5 PPO ASO Standard with Network isitAccross eSkieid Deductible and Split Copay of ofTexas Medical/Surgical Expenses In-Network Out-of-Network Benefits Benefits Medical/Surgical Expenses Services performed during the office visit/consultation when rendered by a Primary 100%of Allowable Amount after 70%of Allowable Amount after Care Provider,including lab and x-ray(does not include Certain Diagnostic Procedures $35 Primary Care Copayment** Deductible and surgical services) Services performed during the office visit/consultation when services rendered by a 100%of Allowable Amount after 70%of Allowable Amount after Specialty Care Provider,including lab&x-ray(does not include Certain Diagnostic $50 Specialty Care Copayment Deductible Procedures and surgical services) Lab&x-ray in other outpatient facilities(excluding Certain Diagnostic Procedures) 100%of Allowable Amount 70%of Allowable Amount after Deductible -Physician surgical services performed in any setting 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -Physician inpatient hospital visits 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -Certain Diagnostic Procedures;such as Bone Scan,Cardiac Stress Test,CT-Scan 80%of Allowable Amount after 60%of Allowable Amount after (with or without contrast), MRI,Myelogram, PET Scan. Deductible Deductible -Home Infusion Therapy(Services must be preauthorized) 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -All other outpatient services and supplies 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible In Vitro Fertilization Services Decline Extended Care Expenses Extended Care Expenses All services must be preauthorized 100%of Allowable Amount 70%of Allowable Amount after Deductible Skilled Nursing Facility Limited to 25 day maximum each Year* Home Health Care Limited to 60 visit maximum each Year' Hos•ice Care Unlimited Special Provisions Expenses Serious Mental Illness/Mental Health Care/ Treatment of Chemical Dependency Inpatient Services Inpatient Chemical Dependency treatment must be provided in a Chemical Dependency/Residential Treatment Center(RTC) -Hospital services(facility) 80%of Allowable Amount 60%of Allowable Amount after None Per Admission Deductible Penalty for failure to preauthorize services $Y50 Preauthorization required for inpatient,residential treatment centers(RTC),partial hospital program admissions, and certain outpatient professional services -Physician services 80%of Allowable Amount after 60%of Allowable Amount after Calendar Year Deductible Deductible Outpatient Services -Services performed during office visit/consultation when rendered by a Primary 100%of Allowable Amount after 70%of Allowable Amount after Care Provider(does not include psychological testing) $35 Primary Care Copayment Deductible Amount -All outpatient services and psychological testing 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated **Primary Care/Specialty Care copayments are defined in the Overall Payment Provisions section in this document. A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business PPO ASO Standard with Network Deductible,Split Copay Effective 01/01/15(Rev 11/2014 for 02/2015 Release) Page 2 of 5 PPO ASO Standard with Network ;_ BllueCross R lueMudd Deductible and Split Copay of Texas Special Provisions Expenses, cont. In-Network Out-of-network Benefits Benefits Emergency Room/Treatment Room Accidental Injury&Emergency Care -Facility charges 80%of Allowable Amount after$150 Copayment Amount (Copayment Amount waived if admitted,Inpatient Hospital Expenses will apply) -Physician charges 80%of Allowable Amount after Deductible Non-Emergency Care -Facility charges 80%of Allowable Amount after$150 60%of Allowable Amount after$150 Copayment Amount(Copayment Copayment Amount&Deductible Amount waived if admitted,Inpatient (Copayment Amount waived if Hospital Expenses will apply) admitted,Inpatient Hospital Expenses will apply) -Physician charges 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Urgent Care Services Urgent Care center visit,including lab&x-ray services(does not include 100%of Allowable Amount after$75 70%of Allowable Amount after Certain Diagnostic Procedures and surgical services) Copayment Amount Deductible Certain Diagnostic Procedures;such as Bone Scan,Cardiac Stress Test, CT-Scan(with or without contrast),MRI,Myelogram,PET Scan,surgical 80%of Allowable Amount after 60%of Allowable Amount after procedures and all other services and supplies. Deductible Deductible Ground and Air Ambulance Services 80%of Allowable Amount after Deductible Preventive Care Routine annual physical examinations,well-baby care exams, 100%of Allowable Amount 70%of Allowable Amount after immunizations 6 years of age&over,and any other preventive health Deductible services as determined by USPSTF Immunizations for Dependent children through the date of the child's 6th 100%of Allowable Amount 100%of Allowable Amount birthday Speech and Hearing Services Services to restore loss of or correct an impaired speech or hearing function Covered same as any other sickness Covered same as any other sickness Hearing Aid Maximum Hearing aids are subject to 1 per ear per 36 month period *Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated Physical Medicine Services Chiropractic Care-Office Services 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Maximum Limited to 35 visits each Year" All other Physical Medicine Services rendered by any other eligible Provider will be allowed on the same basis as any other sickness. *Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business PPO ASO Standard with Network Deductible,Split Copay Effective 01/01/15(Rev 11/2014 for 02/2015 Release) Page 3 of 5 PPO ASO Standard with Network - tilu,PCrotrrr liieee'si®�rllcif Deductible and Split Copay `\-/ orTeias Pharmacy Benefits Participating Pharmacy* Non-Participating Pharmacy (member files claim) Drug List** Preferred Drug List 1 Prescription Drug Out-of-Pocket Maximum Separate Prescription Drug Out-of-Pocket Maximum applies to Retail&Mail Service Pharmacy:Individual: $1,500/Family.• $3,000 Vaccinations obtained through Pharmacies""*" Yes - If yes, flu vaccinations covered as follows: Select pharmacies participating in Flu 80%of Allowable Amount minus Network—100% Copayment Amount All other in-network pharmacies— appropriate tier copay applies Retail Pharmacy (Copayment amounts are based on a 30-day supply. With appropriate prescription order,up to a 90-day supply is available. Copayment amounts apply to the Out-of-Pocket Maximum.) Generic Drug $15 Copayment Amount 80%of Allowable Amount minus Copayment Amount Preferred Brand Name Drug $35 Copayment Amount 80%of Allowable Amount minus Copayment Amount Non Preferred Brand Name Drug $60 Copayment Amount 80%of Allowable Amount minus Copayment Amount All Specialty Drugs $150 Copayment Amount 80%of Allowable Amount minus Copayment Amount Specialty Drugst Members will be required to obtain specialty medications through Prime Therapeutics Specialty Pharmacy LLC(Prime Specialty Pharmacy). Mail Order Program Yes (Copayment amounts are based on a 30-day supply. With appropriate prescription order,up to a 90-day supply is available. Copayment amounts apply to the Out-of-Pocket Maximum.) Generic Drug $15 Copayment Amount Preferred Brand Name Drug $35 Copayment Amount Non-Preferred Brand Name Drug $60 Copayment Amount Generic Incentive-Members who purchase Preferred/Non-Preferred Brand Name Drugs when a Generic equivalent exists will be required to pay the difference between the cost of the Generic and Preferred/Non-Preferred Brand Name Drug,plus the Preferred Brand Name Copayment Amount. All medications with over-the-counter(OTC)equivalents are excluded from coverage except for Omeprazole 20 mg. *To locate a participating pharmacy in your area go to myprime.com or contact customer service at the phone number on the back of your identification card. **The preferred drug list is available at: bcbstx.com/member/rx_drugs.html ****Select pharmacies participating in the Flu Network are contracted to provide vaccination services. Flu vaccinations at all other in-network and out-of- network pharmacies are payable at the non-participating Flu Network pharmacy benefit level. Each pharmacy may have age,scheduling, or other requirements that will apply. You are encouraged to contact the store in advance. Childhood immunizations subject to state regulations are not available under this pharmacy benefit. Refer to your BCBSTX medical coverage for benefits available for childhood immunizations. Diabetes Supplies are available under the Prescription Drug benefits of your plan. Diabetic Supplies include insulin and insulin analog preparations, insulin syringes necessary for self-administration,prescriptive and non-prescriptive oral agents,all required test strips and tablets which test for glucose,ketones,and protein, lancets and lancet devices,biohazard disposable containers, glucagon emergency kits,and other injection aids.All provisions of this portion of the plan will apply including Copayment Amounts and any pricing differences that may apply to the items dispensed. **Effective 11/1/2015,Specialty Lock-Out through Prime Specialty Pharmacy applies. No coverage available for specialty drugs when purchased through any other provider. One grace fill allowed. t For more information on the specialty drug program,call Prime Specialty Pharmacy at(877)627-6337. "Effective 11/1/2015,Prior Authorization is required for the drug class PCSK-9 Inhibitors(Specialty injectable drugs)for Homozygous Familial Hypercholesterolemia Agents. A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business PPO ASO Standard with Network Deductible,Split Copay Effective 01/01/15(Rev 11/2014 for 02/2015 Release) Page 4 of 5 PPO ASO Standard with Network I- llueCro. ilta,��t,t�t,t Deductible and Split Copay rad >' or Texas Non-Standard Covered Benefits • Radial Keratotomy covered • Lasik surgery covered • Effective 7/1/04 -Medicare Assumption/Estimation • Effective 11-1-08-Services, supplies and prescription drugs for the reduction of morbid obesity, including surgical procedures,when medically necessary, covered same as any other illness(note: prescription drugs for morbid obesity are not subject to medical necessity) • Effective 11-1-11 -Age limit increased to age 26 for the following benefit: Reconstructive surgery performed on a covered dependent child under the age of 26 due to craniofacial abnormalities to improve the function of, or attempt to create a normal appearance of an abnormal structure caused by congenital defects, developmental deformities,trauma,tumors, infections or disease. • Effective 11-1-14—Services, supplies and Prescription Drugs for Sexual Dysfunction are covered. Prescription Drugs for Sexual Dysfunction are limited to 8 pills per month. EMPLOYEE INFORMATION This is a general Summary of your benefit design. Please refer to your benefit booklet for other details and for limitations and exclusions. The following benefits apply to dependent coverage: • Dependent children are covered to age 26. • Automatic coverage for newborns for the first 31 days following birth. Infants not enrolled for coverage within the first 31 days after birth will not be eligible for coverage until the following open enrollment period or special enrollment event. Group Executive Name and Title Signature Date (Please type or print) Agent of Record Name Signature Date (Please print or type) BCBSTX Representative Name Signature Date (Please print or type) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business PPO ASO Standard with Network Deductible,Split Copay Effective 01/01/15(Rev 11/2014 for 02/2015 Release) Page 5 of 5 Blue Cross and Blue Shield of Texas Dental Summary of Benefits Prepared for CITY OF PORT ARTHUR—Account#31118 Group#031120 Effective 11/1/2015 TYPE OF SERVICE BENEFIT GENERAL PROVISIONS FOR PREVENTIVE,BASIC AND MAJOR CARE BENEFITS Calendar Year Deductible(4th quarter carryover applies) $50 Individual/$150 Family Deductible Credit from Prior Carrier N/A Calendar Year Maximum per Participant $1,000 PREVENTIVE CARE BENEFITS(deductible waived) 100% • Oral Examinations,X-Rays,Cleanings BASIC CARE BENEFITS 80% • Fillings, Extractions,Endodontics,Oral Surgery,Root Canal Therapy MAJOR CARE BENEFITS 50% • Prosthetics(dentures,bridgework),Crowns,Inlays and Onlays ORTHODONTIC BENEFITS(no deductible) No • Orthodontic Diagnostic Procedures and Treatment Available Only to Participants Under 19 Years of Age N/A Lifetime Maximum per Participant N/A TEMPOROMANDIBULAR JOINT(TMJ)BENEFITS(no deductible) No Lifetime Maximum per Participant N/A • This is a general Summary of your benefit design. Please refer to your benefit booklet for other details and for limitations and exclusions. • The following eligibility provisions apply: Dependent children are covered until age 26. Disabled dependent children can be covered beyond age 26. Retirees are not eligible for coverage. Employees may enroll dependent children up to age 5 on the first of the month following application with no late enrollment penalty. • A pre-existing condition exclusion will apply to expenses involving the replacement of teeth that were missing prior to the effective date of the dental contract. This exclusion will not apply to: Any participant who becomes effective on the dental contract date who was covered under a previous group dental care contract by the Employer. Any participant who has been continuously covered for 24 months under a group dental care contract with BCBSTX which included prosthetic benefits. • When the course of treatment will be in excess of$300, a predetermination request should be submitted to BCBSTX in advance of treatment. g Please note that our dental is a `freestanding"product and can be purchased separately from the Health Care Services Corporation product, i.e., an employee can have only himself covered for health, but have dental for the family and vice versa. DENT-FRSTG-Summary of Benefits Blue Cross and Blue Shield of Texas,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association I c c 0 Y t N- r c C O n c N 0 cv _ ca d ErC C) CO c4 x m CU me Ii ! 0 0To 5 J W r (25 g U 4 o m O c9 N CU p N 7— Cr) z m C 1. _ 0 T. 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O- C -0= 0= ,5 L a c e- ", m - a m E o 3; d m m v N o.0` ° c c m a c m31 a 3 w°- 'Ti o, mw ° om az --'1 Vc 'Umv SN _ c m N NJryU cae 22 _y m mm m? a `- m u O m0 2 au = 2Q 52,1' U " qU m cm 5' Em o m >` ,_m mm df m , mm% =im0o z ,, om= ;o oa a - 9 C., ;";,-g 'T v 2 m g0 m m ' 23 = J m _dFE'�- p,Nz-E mcd9N- mm 0 ¢ m -51 --mn v °" m No uouu _ o m ? m a 5- a= m - _>+ v Do3 m c5 . 'a' ;. m .32m- = V= cs p ` om� ao = mu o u5 m c vE,m = 0 m maE UoOmo -m m _ m ° u I - m al 2G 27,-0▪"0, 4� v G' c 0a3 mm mmv a c o a m 'o . oamm U m ° 3 ` m v y m u c °- a m 2U U pnOm ° 8—‘,3 529m 11• c.Y , O m.0 UC N O mm C 5- 3m O . Q OdLm5mE 1O U7 N5 o amm m um u = ¢ wmoamo m m 0 ` `,u - _ _ 5 c c m U .2 -y▪o LL3 a um , 2o • O m _m mmm ? �. • U. mao - ca =wv9v mE - aa .- v = m w Ea 08u O __ J I. a N m� m EN Cod ` OOO cOQa 22 X -O._ p= m . C m L 1--) U m C O 0 O m _ Oa R L L m • O E m 0 aa m p U L m CN 6N C O U a O a' O a ° a_ c m. o_ m = 0 .0 L m w a p C cc a N N C o a a 2 OC LE O E m CO O L O U oami cU N E a d m T C N h. Naz- - ma � c p ' E m m&- o m m >. n .N � N -o CO = a NvQ N -p a) d )n T., mILI _ C T' - m E O U c3 ° mn L m y Q 5 a E T -a < n m . m f pC 6 S U LN .5 O N : - N EU E n -Y oU =o. m 0 p Z 7, . m m oc 0 - O ' - Q a TwN Q u c 0 oTs 2 N V O2 3 tLa ONZ COO n, co U O 'er c E a� 3 k" a• 1a T .CO 0N -m U a m mwm N 3 um =ULm m c N J meZ • u UO P a U . w 0 >O m c X 'G o m U Q ° ° imm m oC_ .. Z Um cc cg. cmN ) = r c S• 1 _ a m Ea _ co -5Q � m2 Em Nr _ a E 01mm 5 _ • _ ra d 2 m N •s= Omcm L . ca N N .3 N Li m L N E 3Q N. U m OI CO 75 E. C C mm E .0LUL N Nr 0= u iii > O L T a Q m , 3 m o m 0• 00 mac u m - T 3 _0 -p c c '- E L _ - a OE x " a o Cm ^ - N _.- a x N C N a T a C m Q9m E Q7 O = F m 0 co C m iJ m C m y m co o m m 3a d • o 0 o ° '=i- aL Nm N aO 2 ` 4 E ` a o 2 m c = mLmE , . 2mam • m >,N m O m C .o C 'yA 8 Cl) Oa O N 3 N 27 C ma sm L m C U E c O & .. h a X UC L X - > O O N . = O a) F-2 2 a C C iN TC O C N m a m y6 TU • NN N Cl) `N E m N - E ., N a E 0 8 a a L m ° o a a E a m mo - 3 a) -0 mao a m m m o m _ Cl) o mm _ .m U m mmaa L - m 3NE -Z N m m � m a E OF- - -0 m 0• Um E > a 2m O m Ll O m TO 2 ° V m mc ° N . m2 m c N . CN w , a a• O a 0 C C w 5 O > mm 1 O c3 ow C 32 Tc -m 2 m c m-5 .2Q -8 8 8 o o 2 am im c m -) fat -5 cN mo 6 m i (75 c a mm o E ` N m .1)) a m C2E O mN c ` o Uym ,4i 2, m y mNE o a1 ' mm m 2 > C o c C c L . g y . _m y2 � Eaoo,pmmc' �k C m . U oC -F.'. i c 1 OU ` Il E E E m CCDe o Cl)y E L m 2a Er ° conm 1.5O mCl)m • - ) m EU a mc a co ac" L ._ >m 0 3 m > a -p m _ VC ocm U L c m o c E 6N N C .3 O- O a a3 N a - U CUU9 I I m E a m TT " m y m mm Nm . mO mU >' m Z m N o a) m = m Q EUN ° a a N a N L ammQ a m xoa g c a a r TN m 1 = aa I) 0) w0 E= C amt j - L m U c- U m t O F I- C 0 I- I.= - - o_ > m m S = Q I- d11 -1 I , i 11 I City Cf Fort Arthur November 1,2016 - October 31,2017 Network Discount Guarantee Medical Claims Only Claims Paid 11/01/16 Through 10/31/17 Guaranteed Discount Percentage 67.0% • Actual Discounts Admin Fee Penalty 65.00% or Higher 0.00% 64.20% to 64.99% 5.00% 63.40% to 64.19% 10.00% 62.59% or Lower 15.00% 1 1 1.The formula for the Overall Network Discount Percentage calculation is as follows: (Eligible/Covered Claims less Allowed Claims equals the Provider Savings.The Provider Savings divided by the Eligible/Covered Claims equals the Overall Network Discount %). 2.Both In-Network and Out-of-Network claims are included in the Overall Network Discount Percentage calculation. 3.Network Discount Guarantee applies only to eligible employees and retirees who enroll in the proposed BCBS benefit plans. 4.BCBS will exclude all claims in excess of$100,000,claims the Employer authorizes to be paid on an exception basis,Medicare claims,claims with COB,Prescription Drug claims,Specialty Rx,claims not covered/processed by BCBS,and claims for non-contracted providers paid at the in-network level of benefits. 5.BCBS reserves the right to re-evaluate and re-establish the Guaranteed Discount Percentage if participation changes by+/-10.0%,and/or the distribution of enrolled employees between geographic areas,the single/family mix,or age/gender composition of the group changes significantly. 6.BCBS reserves the right to void this Network Discount Guarantee if there are less than 607 employees enrolled in the plan. 7.BCBS reserves the right to re-evaluate and re-establish the Guaranteed Discount Percentage if Medicare changes its payment systems during the term of this Network Discount Guarantee. 8.BCBS reserves the right to re-evaluate and re-establish the Guaranteed Discount Percentage if there is a change in the benefit plan design. 9.BCBS reserves the right to re-evaluate and re-establish the Guaranteed Discount Percentage if a narrow or high performance network is elected. 10.Discount Guarantee is based on In-Network Utilization of 97.7%. If In-Network Utilization is not met,Discount Guarantee does not apply. 11.Administrative Fee at Risk will be finalized upon sale of the Network Discount Guarantee. 12.Administrative Fee at Risk is the Medical Administration fee only. It does not include any additional elected services such as Fiduciary,BCC,etc. 13.Any penalty paid will be dollar for dollar up to the maximum amount at risk for each tier. 14.Guaranteed Discount Percentage is only valid for the quoted policy period. 'Amount at Risk is based on current enrollment of 674 HCSC Primary employees.Actual amount at risk is subject to change based on final enrollment of employees who select BCBS coverage. A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association City Of Port Arthur November 1,2016 - October 31,2017 In Network Utilization Guarantee Medical Claims Only Claims Paid 11/01/16 Through 10/31/17 • Guaranteed In Network Utilization 97.7% Actual In Network Utilization Admin Fee Penalty 95.70% or Higher 0.00% 94.80% to 95.69% 5.00% 93.90% to 94.79% 10.00% 92.99% or Lower 15.00% 1.The formula for the Overall In Network Utilization Percentage calculation is as follows: (The In Network Paid Claims divided by the Total Paid Claims equals the Overall In Network Utilization%). 2.In Network Utilization Guarantee applies only to eligible employees and retirees who enroll in the proposed BCBS benefit plans. 3.BCBS will exclude all claims in excess of 5100,000,claims the Employer authorizes to be paid on an exception basis.Medicare claims. claims with COB,Prescription Drug claims,Specialty Rx,claims not covered/processed by BCBS,and claims for non-contracted providers paid at the in-network level of benefits. 4.BCBS reserves the right to re-evaluate and re-establish the Guaranteed In Network Utilization Percentage if participation changes by+/- 11` 10.0%,and/or the distribution of enrolled employees between geographic areas,the single/family mix,or age/gender composition of the group changes significantly. 5.BCBS reserves:he right to void this In Network Utilization Guarantee if there are less than 607 employees enrolled in the plan. 6.BCBS reserves the right to re-evaluate and re-establish the Guaranteed In Network Utilization Percentage if Medicare changes its payment systems during the term of this In Network Utilization Guarantee. 7.BCBS reserves the right to re-evaluate and re-establish the Guaranteed In Network Utilization Percentage if there is a change in the benefit plan design. 8.BOBS reserves the right to re-evaluate and re-establish the Guaranteed In Network Utilization Percentage if a narrow or high performance network is elected. t i b 9.Administrative Fee at Risk will be finalized upon sale of the In Network Utilization Guarantee. 10.Administrative Fee at Risk is the Medical Administration fee only.It does not include any additional elected services such as Fiduciary, I!� BCC,etc. 11.Any penalty paid will be dollar for dollar up to the maximum amount at risk for each tier. 12.In Network Utilization Percentage Guarantee is only valid for the quoted policy period. *Amount at Risk is based on current enrollment of 674 HCSC Primary employees.Actual amount at risk is subject to change based on final enrollment of employees who select BOBS coverage. A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association • C1 N N N V O C) (O N N- N O u) m O V CO N- V V V 0 V O C m.. n n n n r N- co N co 0 a,-, N- I I r N- I, N. r (NO N- (NO (rD co u '.E.. 2 m E Di • — -"E, — a G o m Om — Ui Ui C C: N(C) O O CO LO CO O C) r 0 V N C) V0 C N )O el C) (7 CO C) W Ni C) O CO V co r coco co V m (O -,-COCOCOco V ( 4 C _ .- C) V T a7 (O 01O (O (O O V r O r C) C) O N6 N (O N (C (O Q C) O O C) N (O (O N N (O N N C) N- (O ( V C) C) (O (O N CO V N- r N N N- CO CO _ N- C) N O N CO C) N e- CO r O O CO N O C) N N CO r (O C) (O N CO N co r CO E a CO (� (O V r C) O C) C) O O O ' N E9 r Co C) IO (O O '- (O V C) V (O N V `C C) O C) r CO r O) V CO V r N (O O C) (O (O CO O r C) N- C) (V (O C u O CO (O 0 Ca V) CO (O CO (n N- 0 O C F V) (O u) co co V N V el (O (O (O _ C) r ~ 64 64 69 69 E9 E9 E9 64 64 E9 E9 E9 f` .S E9 69 69 E9 E9 E9 E9 E9 E9 69 64 E9 r V n L• N a 64 .- -- .3 ce p (")_ C co N N W CO V O V N r CO O T CO O) lO V co O co r O CO N- N-. O 2 L Q) Q C (t) N O U CO CO V N r (C V O O cl N O O N N (O O e-- (O (O r CO. er CO i x < al V N- C) N C) N C) (O O r r (O O) (O r V) W 6 (O V N r V ' C) _ E.Q 0 Z n N r 0 N m (') r N- o N V N co N O C) co N V r O N N O m V V y O C) (O .- W O (O O N N V co N m O O CO O O C) (i) r V OO (O r O) N n +, C U O C - C) O O N- V r Cc (D O N E9 E - C) U) O r (n CO - C) oC Oj (O O Ef3 0 L m O A Z 0 '� tC (C N N O CO N N N C CO LO Q) (C -- C co r O co N V CO CO O CO O N N o U 0 d N W O - E9 69 69 E9 E9 E9 E9 69 E9 E9 E9 E9 Ni a 69 69 69 69 E9 E9 69 fPr 69 69 E9 E9 N 69 69 9- u Z W Et E u m O O a-O X 76 m O (O N O N- (D e- CO C) O r (O m CO C) N N O u) O N- CO u) N- N CO CO > y CO Ill () (O r CO N O O O N (D CO M (O c0 W O O N V V O CO (� y m I'Q N O N ' (O V O O (O (O (O N r N N N N 4 C) O O C) V C) V C) O m }� E r C r N r r O (O r N O C) O O r co V O N V. C) N N V CO t7i co Cl C_ Q (p. O (O r oC N N r N (O l() (O (O V V) C C) N CO N CO r (O N N CO ,- V co (O V 76, O COV Q Q 'C CO) (VO m r C V V m V (`n (o N r) "C N N CC m N O N C = (Oo O ? E9 ' Z J O a) n C) C) (n (fl C) V C) V C) V CO ,- a) (n C) C) (O 'n M N C) N co V V C S c 0 Q 69 64 69 69 EA ER E9 EA 69 E9 fA fR m 64 E9 69 E9 E9 E9 E9 E9 E9 E9 E9 E9 V E9 69 L O N CO IOf CC d m 0) (n O Y Y m ;3O d d CL v 1 d CI L to co co ,O co (n O co O O O d Z V V V V V V V (O (n (n Lo (n a Z m ^ r e- I 51 0 N j j) a) U O N N ate) N O. (�O O L CI OC 0 ? 7 ?) m 5 'o m N a) N a m Q 00 L O� ;2 , a (n O Z O , a 2 < 2 F- O O d, 2 2 , -, a O O Z O , tl 2 < 2 H O O J 1 Exhibit "B" 4 g, DC01 Of NOiiIO Q,1 July 13, 2016 CITY OF PORT ARTHUR ATTENTION: ELIZABETH VILLARREAL PO BOX 1089 . PORT ARTHUR TX 77641-1089 Subject: Renewal Analysis Group Policy Number: G31118 Anniversary Date: November 1,2015 - Dear Policyholder: Dearborn National would like to thank you for allowing us the opportunity to provide you and your employees with Group insurance products. We have reviewed the current demographics of your group insurance programs. We are pleased to inform you that there will be no change in the existing rates for the upcoming renewal period. Rates will be guaranteed until November 1, 2017. Products Current Rates Renewal Rates Life-Firefighters $0.22 per $1.000 $0.22 per $1.000 Life—All Others $0.19 per $1,000 $0.19 per $1,000 AD&D $0.04 per$1,000 $0.04 per$1,000 If you have any questions pertaining to your renewal, or would like more information including the availability of other products as well as a quote for additional benefit programs, please contact your local Dearborn National sales office or insurance broker. We value our relationship with you and look forward to providing quality service to you in the future. Sincerely, Underwriting Department- lb Force Team . _J , --2.-:1 __.-. -- _. _.:__. :.c. ;L A F_. . _ ._._ 47C13 ___.._.inc:ei J1css 9''a:'3c_ :I _ear:Cr.? ',_-_.; I':.^.i`.arc;le:ar CCC are:nG:r.Wtt arcic::wcv:c'ac _ n earcc .ai;Cl al°_:f3 � . .L..an.a L'GrIC ar.Y ,, .:dune. .;ivve,'L;r.all,,4(.:. _.•c:uclr j -+tO :n _(;. e_I£t1 Cl a.'CIUmCla.te'.nite dales llrCir.slangs.theurian Jirgin .arcs.Guam and?5eric Fico.