HomeMy WebLinkAboutPR 19946: BLUE CROSS MEDICARE ADVANTAGE RENEWAL 1/01/18 ` \ :/
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INTEROFFICE MEMORANDUM
Human Resources Department
Date: October 11, 2017
To: Brian McDougal, City Manager
From: Monique LeFlore, Human Resource Director
Lisa Colten, Assistant Human Resource Director
Elizabeth Diaz, Compensation & Benefits Manager
RE: Blue Cross Medicare Advantage Renewal Effective 1/01/18
P. R. No. 19946 - A Resolution Authorizing The City Manager To Execute Contracts
Between Its Third Party Administrator (Administrative Services Only) For The City of
Port Arthur Blue Cross Medicare Advantage PPO and Prescription Drug Plan for its
Existing Medicare Eligible Retirees and/or Their Medicare Eligible Dependent(s)
Nature of the request:
The City of Port Arthur provides access to their Medicare eligible retirees and/or their Medicare
eligible dependent(s) to the Blue Cross Medicare Advantage PPO and Prescription Drug Plan for
major medical health insurance coverage, including prescription drug coverage. Medicare eligible
retirees and their Medicare eligible dependent(s) transitioned to the Blue Cross Medicare Advantage
PPO and Prescription Drug Plan last year.
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. In addition, the overall savings to the City's health insurance fund
resulted in a substantial savings of over one million dollars($1,000,000)last year(Attachment"A").
City staff and Mr. Mickey Moshier, the City's Insurance Consultant, met with representatives of
Blue Cross and Blue Shield of Texas to gain a better understanding of the proposal as presented with
regard to offering a Blue Cross Medicare Advantage PPO and prescription Drug Plan to its Medicare
eligible retires and/or their Medicare eligible dependent(s) effective 1/01/2018.
Brian McDougal, City Manager
Page 2 of 2
P.R. #19946
Key points are as follows:
1. 133 Medicare eligible retirees and/or their Medicare eligible dependents impacted generating
savings of over one million dollars ($1,000,000) last year to the City's overall health
insurance fund.
2. Benefits equal to or better than most other marketplace Medicare Advantage plans
• $0 Annual Deductible
• Maximum Out-of-Pocket$1,500
• Level Copays
• SilverSneakers Program(i.e. YMCA, Curves,World Gym, etc.)
• Hearing Aid Benefits
• Incentives totaling$100/per year for Wellness Benefits
3. Premium Cost Increase to Impacted Medicare eligible retirees and/or their Medicare eligible
dependents of six percent(6%)over the 2017 rate.
4. Reduction to the City's GASB 45 Funding Liability
Staff views the health insurance benefit as an earned as well as deserved benefit for its City retirees,
and will continue to strive to provide the best health plan available at the best price to all of its plan
participants. However, the proposal offered by Blue Cross Blue Shield to offer its existing Medicare
eligible retirees and/or their Medicare eligible dependent(s)the Blue Cross Medicare Advantage PPO
and Prescription Drug Plan effective on 1/01/18 will allow the City to accomplish these goals for the
reasons stated herein.
Note: Inasmuch as all impacted Medicare eligible retirees and/or their Medicare eligible
dependent(s)will be required to pay 100%of their premium cost, staff further recommends that Blue
Cross Blue Shield will direct-bill the participants.
Recommendation: It is recommended that the City Council adopt P. R. No. 19946 authorizing
the renewal of the Blue Cross Medicare Advantage PPO and Prescription Drug Plan for its
Medicare eligible retirees and/or their Medicare eligible dependent(s), and authorizing the City
Manager to execute all documents necessary for its 1/01/18-12/31/18 plan year.
Budget Considerations: Approval of P. R.No. 19946 will have no budgetary impact. Premium
costs will be entirely covered by those participating members.
"Remember we are here to serve the Citizens of Port Arthur
P.R. No. 19946
10/11/2017 ml/lc/ed
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
BLUE CROSS MEDICARE ADVANTAGE PPO AND PRESCRIPTION
DRUG PLAN FOR ITS MEDICARE ELIGIBLE RETIREES AND/OR
THEIR MEDICARE ELIGIBLE DEPENDENT(S), AND AUTHORIZING
THE CITY MANAGER TO EXECUTE ALL DOCUMENTS NECESSARY
FOR ITS 1/01/18 — 12/31/18 PLAN YEAR
WHEREAS, the City Council of the City of Port Arthur deems it necessary and
appropriate to continue to offer major medical health care benefits along with a
prescription drug benefit to its Medicare eligible retirees and/or their Medicare
eligible dependent(s) effective on 1/01/2018; and,
WHEREAS, the City Council deems it to be a significant cost savings to the
overall health insurance plan (approximately one million dollars' savings annually) to
accept the proposal as offered by Blue Cross and Blue Shield of Texas to renew the
Blue Cross Medicare Advantage PPO and Prescription Drug Plan for its Medicare
eligible retirees and/or their Medicare eligible dependent(s) for the 1/01/18 —
E
12/31/18 plan year as delineated in Exhibit "A"; and,
WHEREAS, Blue Cross and Blue Shield of Texas will take the necessary
actions to comply with the Centers for Medicare and Medicaid Services' (CMS)
requirements to continue the provisions enacted annually, and do hereby affirm to
continue to make changes to its existing health plan policies or products as required
to comply with the law;
P.R. No. 19946
10/11/2017 ml/lc/ed
Page 2 of 3
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 accepts
the contact proposal from Blue Cross and Blue Shield of Texas, Inc. to renew the
Blue Cross Medicare Advantage PPO and Prescription Drug Plan for its Medicare
eligible retirees and/or their Medicare eligible dependent(s) for the 1/01/18 —
12/31/18 plan year which includes renewal rate of 6% over 2017 and direct-bill to
participants as delineated in Exhibit "A"; and,
Section 2. That, the City Manager is hereby 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, to bind coverage subject to the terms
and conditions of the contract proposal to effectuate said services; and,
Section 3. 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, 2018, 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. 19946
9/14/2017 ml/lc/ed
Page 3 of 3
Derrick Ford Freeman, Mayor
ATTEST:
Sherri Bellard, City Secretary
APPROVED 0 FORM:
(Ya
Valecia Tize o, City Attorney
APPROVED FOR ADMINISTRATION:
Monique LeFiore, Human Resource Director
Brian McDougal, City Manager
I
ATTACHMENT "A"
Secure Message: RE: PHI - COPA Enrollment 9/1/17 Page 1 of 4
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Secured Message Reply ReplyAll Forward
From: Malana Hearn <Melana_Hearn@bcbstx.com>
To: Mickey Moshier <Mickey@edwardsandsherlock.com>
CC: Terry Villiva <terry_villiva@bcbstx.com>, Angie Bfacksher <Angie_Blacksher@bcbstx.com>
Date: 09/11/2017 09:44:30 PM GMT RE: PHI - COPA Enrollment 9/1/17
Attachments: image001.emz 2018 City of Port Arthur BPA.DOCX City of Port Arthur 201.8 Reneval.xlsx
Mickey-
Here are the updated renewal rates after the concessions and approval provided by upper management at
BCBS.
The revised 2018 renewal rate for the City of Port Arthur plan would be$172.00,with $0.10-$0.20 less for the
alternate coverage with cost sharing on non-preferred diabetic supplies.The 2017 rate was$162.30;therefore,
the revised renewal rate represents a 6%increase over the 2017 rate.
Attached is the revised BPA and renewal document which contains the GFS, rates are updated in these
documents. Both need signature for acceptance of the revised rates. We also need the signed documents
returned before we can order enrollment materials. Hopefully we can get this completed this week at or after
the meeting.
Look forward to meeting later this week!
Thanks!
Malaria Hearn -Account Executive III-Southeast Region- Mid Market
Blue Cross Blue Shield of Texas
Beaumont Office Address: 2615 Calder,Suite 7CO3 Beaumont,Teras
401?:35-013.>
Cell:409-781-97571 mafana hearn@bcbstx.com
A Better Track Record of Customer Performance
A Bolder Strategy for the Future of Healthcare
Visit our Website:www.bcbstx.com
See Video Clips @ video2go.tv
Custome Service—Claims or Benefit Questions:1.80o-521-2227
Membership/Eligibility:1.80o-445-2227
BCBSTX Help Desk/Technical Support or Password Resets:1-800-706-0583
Blue Line for Producers:1-800-471-8212
This communication is intended for informational purposes only. it is not intended to provide,does not
constitute,and cannot be relied upon as legal, tax or compliance advice. Furthermore, this communication is
not intended to provide tax advice,and any tax-related statements that may be contained herein is not
intended or written to be used,and cannot be used,for the purposes of(i)avoiding penalties under the
internal Revenue Code or(ii)promoting,marketing,or recommending to another party any transaction or
matters herein. Please consult with your legal,compliance and tax professionals to understand your legal,
compliance and tax obligations under the law.
https://res.cisco.com/envelopeopener/postxeo/oo/fDFfXzRiNzJiYWNkMD... 9/12/2017
Secure Message: RE: PHI - COPA Enrollment 9/1/17 Page 2 of 4
From: Malana Hearn
Sent: Monday,September 11, 2017 9:35 AM
To: 'Mickey Moshier'<Mickey@edwardsandsherlock.com>;Terry VIIliva <terry_villiva@bcbstx.com>;Angie
Blacksher<Angie_Blacksher@bcbstx.com>
Subject:RE: PHI -COPA Enrollment 9/1/17
Hi Mickey—I am going through emails this morning and will call you as soon as I retrieve it and we will discuss
delivery plans.
i.Cpoomtwg PTO
August is-August 25
Thanksl
Malana Hearn -Account Executive III-Southeast Region- Mid Market
Blue Cross Blue Shield of Texas
Beaumont Office Address: 2615 Calder,Suite 700,Beaumont,Texas
8':409-896-0135
Cell:409-781-97571®malaise hears@bcbstr.com
A Better Track Record of Customer Performance
A Bolder Strategy for the Future of Healthcare
Visit our Website:www.bcbstx.com
See Video Clips @ video2go.tv
Custome Service—Claims or Benefit Questions:1-80o-521-2227
Membership/Eligibility:1-8 0 0.445-2227
BCBSTX Help Desk/Technical Support or Password Resets:1-80o-706.0583
Blue Line for Producers:1.800.971-8212
This communication is intended for informational purposes only. it is not intended to provide,does not
constitute,and cannot be retied upon as legal,tax or compliance advice.Furthermore,this communication is
not intended to provide tax advice,and any tax-related statements that may be contained herein is not
intended or written to be used,and cannot be used,for the purposes of(i)avoiding penalties under the
internal Revenue Code or(ii)promoting,marketing,or recommending to another party any transaction or
matters herein.Please consult with your legal,compliance and tax professionals to understand your legal,
compliance and tax obligations under the law.
From: Mickey Moshier[mailto:Mickey@edwardsandsherlock.com)
Sent: Monday,September 11, 2017 8:23 AM
To: Malana Hearn<Malana Hearn@bcbstx.com>;Terry Villiva <terry villiva@bcbstx.com>;Angie Blacksher
<Angie Blacksher@bcbstx.com>
Subject: FW: PHI-COPA Enrollment 9/1/17
Per Brian, Malana has the City's Medicare Advantage renewal info. Please let me know
how we need to handle it being delivered to me/the City ASAP.
Thank you, Ladies. Thoughts and prayers with you all.
Mickey
https://res.cisco.com/envelopeopener/postxeo/oo/fDFfXzRiNzJiYWNkMD... 9/12/2017
0 Blue Cross Medicare Advantage'
Blue Cross MedicareRX (PDP)
BENEFIT PROGRAM APPLICATION ("BPA")
For GROUP MAPD/PDP PLANS
ACCOUNT INFORMATION
(TO BE COMPLETED BY THE PLAN)
Account Status: ❑ New ® Renewal Current Non-Medicare Group Customer: ❑ Yes ® No
Off-Cycle Change: ❑ Yes ® No
Account Number(6-digits): 031118 Group Number(s): 031118\0311120
Sub-Group Number(if applicable):
Policy Effective Date: 1/1/2018 Policy Anniversary Date: 1/1/2019
Legal Account Name: City of Port Arthur
CMS Contract#: H1666 Region:
Plan Benefit Package (PBP) Code#: 801
Plan/Product Description: ❑ Standard ® Custom
GROUP INFORMATION
Legal Name of Applicant/Employer and d/b/a if any: City of Port Arthur
Check One: ® Employer ❑ Union ❑ Trustee of a Fund
(Specify the employer, labor organization, or trust applying for coverage. An employee benefit plan may not
be named.)
Employer Identification
Number ("EIN"): 74- SIC: 9199 Public Entity: ® Yes ❑ No
6001885
Employer Organization Type (check one):
Blue Cross MedicareRx(PDP)is a prescription drug plan provided by HCSC Insurance Services Company(HISC), an Independent Licensee of
the Blue Cross and Blue Shield Association.A Medicare-approved Part D sponsor. Enrollment in HISC's plan depends on contract renewal.
Blue Cross Medicare Advantage HMO plan in Montana,HMO and HMO-POS plans in Illinois and New Mexico,and PPO plans in Illinois,
Montana,New Mexico, and Oklahoma are provided by Health Care Service Corporation,a Mutual Legal Reserve Company(HCSC).Blue Cross
Medicare Advantage PPO plans in Texas are provided by HCSC Insurance Services Company(HISC). Blue Cross Medicare Advantage HMO
plans in Texas are provided by GHS Insurance Company(GHS). Blue Cross Medicare Advantage HMO and HMO-POS plans in Oklahoma are
provided by GHS Health Maintenance Organization, Inc.d/b/a BlueLincs HMO(BlueLincs)and by GHS Managed Health Care Plans, Inc.(GHS-
MHC). HCSC, HISC, GHS, GHS-MHC, and BlueLincs are Independent Licensees of the Blue Cross and Blue Shield Association.HCSC, HISC,
GHS, GHS-MHC,and BlueLincs are Medicare Advantage organizations with a Medicare contract. Enrollment in Blue Cross Medicare
Advantage plans depends on contract renewal.
❑ State Government
® Local Government
❑ Publicly Traded Organization
❑ Privately Held Organization
❑ Non-Profit
❑ Church Group
❑ Other:
Nature of Business: City Government
Primary(Mailing)Address (location where Employer is domiciled): 444 4th Street
City: Port Arthur State: TX Zip: 77641-6450
Administrative Contact: Lisa Colton Title: Acting Assistant Director Human Resources
Phone: 409-983-8215 Email:
Fax: 409-983-8282 lisa.colten a(�portarthurtx
.gov
BAE Contact (if applicable): If Medicare Plan has approved Employer to use Blue Access for Employers
(BAE) under this agreement, please list the Employer's BAE Contact Name:
The BAE Contact is the employee of the account authorized by the employer to access and maintain its
account via BAE.
Title: Phone: Fax: Email:
Physical Address (if different from Primary- required):
City: State: Zip: Contact:
Billing Address (if different from Primary):
City: State: Zip: Billing Contact:
Title: Phone: Fax: Email:
SubsidiaryCompanies: SubsidiaryA dress:
City: State: Zip: Contact:
Title: Phone: Fax: Email:
Affiliated Companies: Location(s):
ERISA Plan: ❑Yes ❑ No If yes, specify ERISA plan year: (mm/dd/yyyy)
ERISA Plan Administrator: Plan Administrator's Address:
PRODUCER OF RECORD INFORMATION
Please provide the information requested below on all Producers/Agencies to whom commissions are to be paid.
Producers/Agencies must be appointed to do business with HCSC and Medicare Certified for sale of MA-PD Plans.
The Producer's or Agency's name(s) must exactly match the name(s)on record with HCSC.
Page 2
Benefit Program Application(BPA)for Medicare Group Plans 7/2015
Only one (1)Producer/Agency can receive commission from Medicare Plan for this Medicare group plan. If a Producer
is affiliated with a General Agent, the General Agent for the Producer listed below may receive override compensation
from Medicare Plan.
Producer/Agency name to whom commissions are to be paid (if Medicare Certified and Eligible for Payment): n/a
Producer Number of ❑ Producer or El Agency: n/a
Street Address: City: Zip:
Phone: Fax: Email:
Is Producer/Agency Medicare Certified with HCSC? ❑Yes ❑ No
General Agent's Signature Date:
Producer Agency Representative Signature of Employer/Authorized Purchaser
Signature of Producer Agency Representative Title
Producer Agency Name Date
Witness
Producer Address
Producer Phone No.
Amount Submitted (for initial enrollment only)
Contracted Producer Tax ID No.
Other Information
HCSC Sales Representative District/Cluster
UNDERWRITING AUTHORIZATION
INTERNAL Date BPA approved by Underwriting: Underwriter:
USE ONLY Benefit program and premium notification letter included: ElYes ❑No Date of Letter:
SCHEDULE OF ELIGIBILITY
1. Standard Eligibility Provisions:
Page 3
Benefit Program Application(BPA)for Medicare Group Plans 7/2015
Z Retirees. If checked, Employer has determined that Eligible Person means a retiree who was
enrolled in the Employer's health plan while an active employee, and meets CMS eligibility criteria to
enroll in the Medicare Plan (e.g., entitled to Part A and enrolled in Part B).
❑ Active Employees (for groups less than 20). If checked, Employer represents that it has less
than 20 employees and has determined that Eligible Person includes an active employee who is
Medicare Eligible and meets CMS eligibility criteria to enroll in the Medicare Plan, and who works on
a full-time basis, who usually works at least 30 hours a week, and who otherwise meets the
Participation Criteria established by an employer. The term includes a sole proprietor, a partner, and
an independent contractor, if the individual is included as an employee under a Health Benefit Plan of
a large employer regardless of the number of hours the sole proprietor, partner, or independent
contractor works weekly, but only if the plan includes at least two other eligible employees who work
on a full-time basis and who usually work at least 30 hours a week. Participation Criteria means any
criteria or rules established by a large employer to determine the employees who are eligible for
enrollment or continued enrollment under the terms of a Health Benefit Plan. The Participation Criteria
may not be based on Health Status Related Factors.
The term "employee" has the meaning set forth under ERISA and applicable law.The Medicare
Plan reserves the right to audit Employer's initial and ongoing eligibility determinations.
❑ If checked, Employer has determined that"full-time basis" means an active employee that,
based on advice from Employee's own counsel with expertise in these matters (including but
not limited to expertise in non-discrimination laws), is required to be covered under the Policy
in order to avoid liability and penalties under the Employer Shared Responsibility Requirements
(26 USC § 4980H) and related rules and regulations, as amended or replaced.
NOTE: Medicare Plan reserves the right to deny coverage for any group in which less than 51% of
the Eligible Persons live in the geographical service area of Medicare Plan's provider network.
2. Employer has determined the following are also eligible (check all that apply):
® Dependents of Retirees. Eligible retirees' spouses, children, and Civil Union Partners (as
defined in Employer's Policy) who are Medicare Eligible, meet CMS eligibility criteria to enroll in the
Medicare Plan (e.g., entitled to Part A and enrolled in Part B), and for those of retired employees,were
formerly covered by the group health plan.
❑ Domestic Partners. Domestic Partners, as defined in the Policy, who are Medicare Eligible,
meet CMS eligibility criteria to enroll in the Medicare Plan (e.g., entitled to Part A and enrolled in Part
B), and for those of retired employees, were formerly covered by the group health plan. The Employer
is responsible for providing notice of possible tax implications to those retirees with Domestic Partner
Coverage.
❑ Active Employee Dependents (if active employees are covered). Eligible Active Employees'
spouses, children, and Civil Union Partners/Domestic Partners (as defined in Employer's Policy) who
are Medicare Eligible, and meet CMS eligibility criteria to enroll in the Medicare Plan (e.g., entitled to
Part A and enrolled in Part B). Employer is responsible for providing notice of possible tax implications
to those covered employees with Domestic Partners.
❑ Part-time. Part-time active employees of the employer (if active employees are covered) who
meet the above criteria for active employees except for full-time status and hours of work.
❑ Other:
Page 4
Benefit Program Application(BPA)for Medicare Group Plans 7/2015
Are any classes of employees or retirees to be excluded from coverage? 0 Yes 0 No
If yes, please identify the classes and describe the exclusion:
NOTE: The Medicare Plan reserves the right to disapprove a class exclusion if prohibited under
applicable law.
3. Effective Date for Active Employee Coverage (if applicable): If Employer has less than 20
employees and has determined that active employees who are Medicare Eligible are eligible for
enrollment in the Medicare Plan, Employer has determined that new Active Employees who are
Medicare eligible may be subject to a waiting period before the employee and any dependents may
have coverage effective under the group Medicare Plan. Such coverage effective date is indicated
below.
❑ The 1st day of the month following the date of employment.
0 The 1st day of the month following month(s) (standard is 1 to 3 months)of employment.
5. The Limiting Age for covered children (if applicable): Covered child means a natural child, a
stepchild, an eligible foster child, an adopted child (including a child involved in a suit for adoption,) a
child for whom the Insured is the legal guardian, under twenty-six (26) years of age, regardless of
presence or absence of a child's financial dependency, residency, student status, employment status
(if applicable under the Policy), marital status, or any combination of those factors. If the covered child
is eligible military personnel, the Limiting Age is thirty(30)years as described in the Certificate Booklet.
To cover children age twenty-six(26) or over, Employer may select option (a)or(b) below:
❑ (a) Limiting Age for covered children age twenty-six (26) or over, who are married who are unmarried
regardless of marital status, is years (twenty-seven (27)—thirty(30) are the available options).
If the covered child is eligible military personnel, the Limiting Age is thirty(30)years as described in the
Certificate Booklet.
❑ (b) Limiting Age for covered children who are full-time students and age twenty-six (26 or over, who
are married who unmarried regardless of marital status, is years (twenty-seven (27)—thirty(30)
are the available options). If the covered child is eligible military personnel, the Limiting Age is thirty
(30)years as described in the Certificate Booklet.
6. Coverage will terminate at the end of the period for which premium has been accepted. However,
coverage shall be extended due to a leave of absence in accordance with any applicable federal or
state law.
CURRENT ELIGIBLE POPULATION
INFORMATION
1. Total Number of Employees (not including Dependents) on payroll
2. Total Number declining coverage (not covered elsewhere):
3. Total Number of Retirees (not including Dependents):
4. Total Number of Employees Eligible for Medicare (not including Dependents):
5. Total Number of Retirees Eligible for Medicare (not including Dependents):
6. Total Number(or estimate) of Dependents Eligible for Medicare (if applicable):
7. Total Number of expected enrollees in the Medicare Plan: 175
Employer's Open Enrollment Period: N/A
Page 5
Benefit Program Application(BPA)for Medicare Group Plans 7/2015
l
BENEFIT PLAN OPTIONS
If non-calendar year plan, provide renewal date:
Late Enrollment Penalty(LEP) attestation for enrollees*: ® Global ❑ Partial
*Employer please note whether you certify (either globally as to all enrollees or partially as to a subset of enrollees)
that Eligible Persons had prior creditable Part D prescription drug coverage, and therefore should not be subject to
any CMS Late Enrollment Penalty.
Person/entity responsible for paying LEP: ® Employer/Group ❑ Member
Medicare Benefit Plan Options (check all that
apply): Additional coverage options (check all that
❑ Medicare Prescription Drug Plan (PDP) apply):
❑ Medicare Advantage Prescription Drug (MAPD) Vision
Plan (HMO) ®Hearing
® Medicare Advantage Prescription Drug (MAPD) ®Fitness Program
Plan (PPO) Dental Coverage
❑ Medicare Advantage ONLY* ❑Over-the-Counter Benefits (OTC medicines
and supplies)
* If you select Medicare Advantage ONLY, enrollees ®Wellness Incentives & Rewards
will not have coverage for Part D prescription drugs at
the pharmacy(retail or mail order), but Part B drugs will
be covered under the medical benefit (in the doctor's Comments:
office, hospital, clinic, etc., but not in a pharmacy).
RATES
For the current year's premium and rate information, and benefit package selected, refer to the accepted
finalized new group rates letter("Letter")or the renewal exhibit ("Exhibit") for complete details. The Letter,
or Exhibit, shall be incorporated by reference and made part of the BPA and Group Administration
Document.
1. FUNDING ARRANGEMENT:
® Premium — Prospective
❑ Other(if approved in advance): Please specify:
2.. PAYMENT METHOD: Employer chooses one of the following three methods of paying premiums as
described in the Rate Letter:
❑ Employer Pays full amount directly to Medicare Plan (Employer may in its discretion collect some
or a portion from Participants, according to its policies, but need not indicate that amount herein)
® Eligible Person/Participant Pays full amount directly to Medicare Plan
❑ Split: Employer has determined the flat amount or percentage of contribution as outlined in the
table below. Employer pays its portion directly to Medicare Plan; Eligible Person/Participant pays its
portion directly to Medicare Plan.
Page o
Benefit Program Application(BPA)for Medicare Group Plans 7/2015
PRODUCT DESCRIPTION TOTAL MONTHLY MONTHLY EMPLOYER
PREMIUM CONTRIBUTION IF SPLIT METHOD
IS CHECKED ABOVE
MA/PD
Plan 1 $ 172.00 PMPM % or$
Plan 2 $ % or$
Plan 3 $ % or$
PDP
Plan 1 $ % or$
Plan2 $ % or$
Plan 3 $ % or$
MA ONLY
Plan 1 $ % or $
Plan 2 $ % or $
Plan 3 $ % or$
3. Premium must be paid in accordance with the timeframes set out in Section III of the Group
Administration Document for Medicare Group Plans. If not paid within the stated time, Medicare Plan can
cancel coverage for non-payment in accordance with Sections III and IV of the Group Administration
Document.
4. Medicare Plan will give sixty(60)days prior written notification to Employer for change of premium rates,
in accordance with the terms of Section III (F) of the Group Administration Document.
5. HCSC reserves the right to change premium rates when a substantial change occurs in the number or
composition of subscribers covered. A substantial change will be deemed to have occurred when the
number of subscribers covered changes by ten percent(10%) or more over a thirty(30) day period or
twenty five percent (25%) or more over a ninety(90) day period.
BILLING SPECIFICATIONS
Employees Listed: ® alphabetically ❑ by location
If by location, list locations including location numbers if applicable:
Billing Method for Employer Payments (check one): Billing Contact:
® Paper Bill Billing Contact Phone Number:
® Electronic pdf
❑ Excel version Billing Address if different:
(Billing Method for Participant Payments will be selected by Billing email address:
each Participant upon enrollment.)
ID CARD DELIVERY
Page 7
Benefit Program Application(BPA)for Medicare Group Plans 7/2015
Medicare Plan will mail ID Cards to each Participant's address on file with Medicare Plan.
OTHER PROVISIONS
1. This BPA is incorporated into and made a part of the Contract entered into and agreed upon by the
Medicare Plan and the account.
2. Changes in state or federal law or regulations or interpretations thereof may change the terms and
conditions of coverage.
3. Employer represents and warrants that this'BPA includes retiree-only plans and excepted benefits that
are not subject to some or all of the provisions of Part A(Individual and Group Market Reforms)of Title
XXVII of the Public Health Service Act (and/or related provisions in the Internal Revenue Code and
Employee Retirement Income Security Act) (an "exempt plan status"). In no event shall the Medicare
Plan be responsible for any legal, tax or other ramifications related to Employer's representation of
exempt plan status. Employer shall indemnify and hold harmless the Medicare Plan and its directors,
officers and employees against any and all loss, liability, damages, fines. penalties, taxes, expenses
(including attorneys' fees and costs) or other costs or obligations resulting from or arising out of any
claims, lawsuits, demands, governmental inquiries or actions, settlements or judgments brought or
asserted against the Medicare Plan in connection with exempt plan status or any provision of inaccurate
information. Changes in state or federal law or regulations or interpretations thereof may change the
terms and conditions of coverage.
4. All terms of any existing BPA as amended from time to time shall remain in force and effect. For the
purposes of this Contract, the term "existing BPA" includes any other BPA for commercial group
coverage, Schedule of Specifications and/or Group Agreement signed by the Employer, and any
subsequent Schedules of Specifications and/or Group Agreements and amendments thereto.)
I UNDERSTAND AND AGREE THAT:
1. A minimum participation of two (2) Participants must be maintained under the MA-PD Plan(s)
elected. With regard to MA-PD Plan(s), a substantial change in enrollment will be deemed to have
occurred when the number of covered Participants changes by 10% or more over a 30-day period
or 25% or more over a 90-day period.
2. Producer Statement (if applicable): I certify that I have reviewed all enrollment materials. I have
also advised the employer that I have no authority to bind these coverages, to alter the terms of
the Contract(s), this BPA or enrollment material in any manner or to adjust any claims for benefits
under the Contract(s).
3. The Medicare Plan will report the value of all remuneration by the Medicare Plan to ERISA plans
with 100 or more participants for use in preparation of ERISA Form 5500 schedules. Reporting will
also be provided upon request to non-ERISA plans or plans with fewer than 100 participants.
Reporting will include base commissions, bonuses, incentives, or other forms of remuneration for
which your agent/consultant is eligible for the sale or renewal of self-funded and/or insured
products.
4. The undersigned person represents that he/she is authorized and responsible for purchasing
coverage on behalf of the employer. It is understood that the actual terms and conditions of
coverage are those contained in the Contract into which this BPA shall be incorporated at the time
of acceptance by the Medicare Plan. Upon acceptance, the Medicare Plan shall issue a Contract
to the employer and the employer shall be referred to as the"Employer"or"Group" in the Contract.
Page 8
Benefit Program Application(BPA)for Medicare Group Plans 7/2015
5. The Employer's Benefit Program Application must pre-date the requested Policy Effective Date and
be received by the Medicare Plan at its home office, 300 East Randolph Street, Chicago, Illinois
60601, no less than ninety(90) days prior to the requested Policy Effective Date.
Authorized Medicare Plan Representative Signature of Authorized Purchaser
Title Title
Address
Date Date
Agent Representative (if applicable)
Page 9
Benefit Program Application(BPA)for Medicare Group Plans 7/2015
PROXY
If Employer selects a Medicare plan offered by Health Care Service Corporation, a Mutual Legal Reserve Company, or any
successor thereof("HCSC"), the undersigned hereby appoints the Board of Directors of Health Care Service Corporation,
a Mutual Legal Reserve Company, or any successor thereof("HCSC"), with full power of substitution, and such persons as
the Board of Directors may designate by resolution, as the undersigned's proxy to act on behalf of the undersigned at all
meetings of members of HCSC(and at all meetings of members of any successor of HCSC)and any adjournments thereof,
with full power to vote on behalf of the undersigned on all matters that may come before any such meeting and any
adjournment thereof. The annual meeting of members shall be held each year in the corporate headquarters on the last
Tuesday of October at 12:30 p.m. Special meetings of members may be called pursuant to notice mailed to the member
not less than 30 nor more than 60 days prior to such meetings. This proxy shall remain in effect until revoked in writing by
the undersigned at least 20 days prior to any meeting of members or by attending and voting in person at any annual or
special meeting of members. This proxy is not applicable to a Medicare plan offered by a subsidiary or affiliate of HCSC.
Group No.: By:
Print Signer's Name Here
Signature and Title
Group Name:
Address:
City: State: Zip Code:
Dated this day of
Month Year
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•
Elizabeth Villarreal
From: Mickey Moshier <Mickey@edwardsandsherlock.com>
Sent: Wednesday, October 18, 2017 11:53 AM
To: Monique Leflore; Lisa Colten; Elizabeth Villarreal
Subject: FW: Medicare Advantage
See response below from Brian regarding the direct billing change. As indicated, there is no
additional charge for that.
Let me know if you have any additional questions.
Mickey
Mickey Moshier, MHP
J. S. Edwards & Sherlock Insurance Agency, LLP
409-832-7736 ext 126
409-833-1721 Fax
409-951-3926 Direct Number
www.edwardsandsherlock.com www.facebook.com/edwardsandsherlock
Please Note:Coverage can not be bound,altered or canceled via electronic communication including but not limited to email,text,fax or any other
transmission or communication device without verification from a licensed representative.The information contained in this E-mail message,and any
files transmitted with it,is confidential and may be legally privileged.It is intended only for the use of the individuals or entity named above.If you are the
intended recipient, be aware that your use of any confidential or personal information may be restricted by state and federal privacy laws. If you,the
reader of this message,are not the intended recipient,you are hereby notified that you should not further disseminate,distribute,or forward this E-mail
message. If you have received this E-mail in error,please notify the sender and delete the material from any computer.Thank you.
*We at J.S.Edwards&Sherlock Insurance Agency are neither tax professionals nor legal experts.In all things Healthcare Reform,please consult
your tax professionals and your legal team to ensure that you are in compliance with the new regulations.*
Please consider the environment before printing this e-mail
From: Brian Boe [mailto:Brian ]_Boe@bcbstx.com]
Sent: Wednesday, October 18, 2017 9:40 AM
To: Mickey Moshier; Malana Hearn
Subject: FW: Medicare Advantage
We are working on the billing change as we speak. Our goal is to have it set up in time for the 1/1/18 billing, which goes
out prior to 12/15/17. There are no additional fees, charges, or credits, to go to this billing method. Mickey, please pass
this on as you wish.
Brian J. Boe
Group Medicare Sales/Account Executive
Blue Cross Blue Shield of Texas
(office) 713.354.7284
(cell) 830.343.7775
Brian J Boe@bcbstx.com
Blue Cross Blue Shield of Texas
1800 West Loop South, Ste. 600
Houston,TX 77027
1