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HomeMy WebLinkAboutPR 20408: ADMINISTRATIVE SERVICES ONLY FOR CITY OF PORT ARTHUR WITH BLUE CROSS AND BLUE SHIELD OF TEXAS, INC. City of I)rt rthur ,ux INTEROFFICE MEMORANDUM Human Resources Department Date: August 17, 2018 To: Harvey Robinson, Interim City Manager From: Elizabeth Diaz,Acting Director of Human Resources / Re: BC/BS Renewal Effective 11/1/2018 P.R. No. 20408 - 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 is self-insured and contracts with a third party administrator to administer its Health Insurance Plan for major medical health and dental insurance, basic life insurance; basic accidental death and dismemberment insurance are also provided for employees and City Council appointees. Additionally,the City 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) transitioned to the Blue Cross Medicare Advantage PPO and Prescription Drug Plan 11/1/2016. 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.). Also, this year's renewal reflects no increase in recommended premium funding. 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. Harvey Robinson, Interim City Manager Page 2 of 2 P.R. #20408 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%-I1%. Further, the Blue Cross and Blue Shield network discounts and national availability provide not only significant plan cost savings, but also access for employees, City Council appointees,retirees under the age of 65, and dependents across the nation. As we reviewed the upcoming renewal with Blue Cross and Blue Shield of Texas, staff feels the move to a Medicare Advantage plan for its Medicare retirees and/or Medicare dependents in November, 2016 has attributed to substantial savings to the City's health insurance fund over the past few years. 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.). Also, this year's renewal reflects no 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. 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 2018-2019 Open Enrollment period will be from October 1 to October 31,2018. Recommendation: It is recommended that the City Council adopt P. R. No. 20408 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 11/1/2018- 10/31/2019 plan year. Budget Considerations: Approval of P. R. No. 20408 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 $6,817,524 Administration/Stop Loss $1,439,340 Dental $328,540 Basic Life/AD8cD $ 30,000 Total $8,615,404 "Remember we are here to serve the Citizens of Port Arthur" Attachment "A" City o k.. 1 ort rthur Texas CITY OF PORT ARTHUR Employee Benefits Information Effective 11/1/2018 J.S. Edwards & Sherlock Insurance Agency Mickey Moshier, MHP J.S. Edwards Sherlock June 26, 2018 Employee Benefit Renewals Dear Monique: It is with pleasure I am bringing you the health, dental, and life insurance renewal offers from Blue Cross Blue Shield and from Dearborn National. While both the dental and life numbers came to me originally with NC to rates, we worked together with the local BCBS office and their underwriting staff to review and obtain the best possible consideration on the health plan. Originally at an 8.1% adjustment to current suggested funding, a review of all aspects of the plan allowed us to get to our goal, NC to the health suggested funding for the upcoming contract year as well! I have also included the option to move from your current $100K specific stop loss level to $125K. Looking forward to discussing this with you at your convenience. Cordially, Mickey Moshier, MHP 4155 Phelan Boulevard • Beaumont,TX 77707 • P.O. Box 22237, 77720-2237 Beaumont(409)832-7736 • Fax(409)833-1721 • Houston(713) 224-8723 Dearborn * National' • June 14, 2018 City of Port Arthur Attention: Elizabeth Villarreal P.O. Box 1089 Port Arthur, Tx 77641-1089 • Re: Group Policy G31118 Anniversary Date: November 1, 2018 Dear Policyholder: Dearborn National would like to thank you for allowing us the opportunity to provide you and your employees with Group insurance products. You are currently under a rate guarantee until November 1, 2019. If you have any questions pertaining to your policy, please let us know. We value our relationship with you and look forward to providing quality service to you in the future. Sincerely, K.cure,i./ L. f o-u sei Karen L. House National Strategic Account Executive cc: Mickey Moshier • 1001 East Lookout Drive, Richardson, Texas 75082 A Toll Free: 800.778.2281 A Fax: 312.540.4706 Products and services marketed under the Dearborn Nationain brand and the star logo are underwritten and/or provided by Dearborn NationaP%Life Insurance Company (Downers Grove.IL)in all states(excluding New York),the District of Columbia.the United States Virgin Islands,the British Virgin Islands,Guam and Puerto Rico. co a . N c F O CDT LLc C O E c O N 0 76 a) g 0 N— HQ N M 113EC a It o L 3To To '�a o CD m c70 4••• U g c _ R L. a) O c� N N 0 0 O Ems ' }r O COIn U O L . 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N yEc .O m 7c pUC 15 co O N 0N R m dLLa U CmNmE” N 2 2 N C-E cc .- 5 130 _cm ' O O .5 m U m z m •_ R d N r 0 Va .. Es ` nN oU > E Em t m =Ero S' ‘-.13 R C 0Nn N C T , N U -5 . ` Om Cy Is 'caa m � r O o cN E U c 'fa" -0- c m o 3 v v > a ` am o Yc� T 0 v O OOv E m oc .> NCa oQ a- v3 C "G E ' ii c CE D C Rb./ vl m N C L C ` ` d N m y 'ORW O m rUT• 4l .O R N Y m ° c U .) CN O >- U m CO Z m i` O c ci m 5 o O No 5 a a a -. No Onm CJ m aU a O U O O OE4 0 mU 0 - U m <n m - co 0 OD - 03 c .c . R o cc -F, 0 ma_ 0 EU .VU E L L o R R e U `' D oi- IR w 2n Sm I- a. )- c OF 4 - - - O_ > MO - P. R. No. 20408 8.14.18--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 GROUP MEDICAL, DENTAL INSURANCE, BASIC LIFE, 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 effective on 11/01/2018; 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$111,552 per year (administrative charge based on the present number of employees) as well as at a cost of $1,439,340 per year for stop loss premium (excess indemnity) per 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 affirm to continue to make changes to its existing health plan policies or products as required to comply with the law; and, current language ties the City of Port Arthur to specific disaster declaration by the President in which the City wishes to modify to a more standard term; 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 reflects the costs for administration by P. R. No. 20408 8.14.18--ed 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 10/01/2017 Collective Bargaining Agreement between the City $.22/per thousand dollar unit, and all other eligible employees' coverage will remain a$6,000 death 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 Employee (for a $5,000 accidental death and dismemberment policy for all eligible Employees) per month as attached Exhibit"B"; and, WHEREAS, the current year's renewal provides no increase in premium to the City or to employees, City Council appointees, or to retirees under the age 65. NOW, THEREFORE, IT BE 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, 2018 City of Port Arthur's Group Medical and Stop Loss Dental Blue Cross and Blue Shield November 1, 2018 Basic Life &AD&D Dearborn National Life November 1, 2018 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 Services Only) and the Contracts for Insurance attached hereto as required effectuate said services; and, P. R. No. 20408 8.14.18--ed 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 A.D. 2018 at a Regular Meeting of the City Council of the City of Port Arthur, Texas by the following votes: AYES: Mayor Councilmembers Noes Derrick Ford Freeman, Mayor ATTEST: Sherri Bellard,TRMC, City Secretary APPROVED AS TO FORM: Val Tizeno, C. Attorney APPROVED FOR ADMINISTRATION: Harvey Robinson, Interim City Manger Attachment "A" am City of " ',1 % `''' ort rth itr Texas CITY OF PORT ARTHUR Employee Benefits Information Effective 11/1/2018 J.S. Edwards & Sherlock Insurance Agency Mickey Moshier, MHP J.S. Edwards Sherlock INSURANCE AGENCY June 26, 2018 Employee Benefit Renewals Dear Monique: It its with pleasure I am bringing you the health, dental, and life insurance renewal offers from Blue Cross Blue Shield and from Dearborn National. While both the dental and life numbers came to me originally with NC to rates, we worked together with the local BCBS office and their underwriting staff to review and obtain the best possible consideration on the health plan. Originally at an 8.1% adjustment to current suggested funding, a review of all aspects of the plan allowed us to get to our goal, NC to the health suggested funding for the upcoming contract year as well! I have also included the option to move from your current $100K specific stop loss level to $125K. Looking forward to discussing this with you at your convenience. Cordially, Mickey Moshier, MHP 4155 Phelan Boulevard • Beaumont,TX 77707 • P.O. Box 22237, 77720-2237 Beaumont(409) 832-7736 • Fax(409)833-1721 • Houston(713) 224-8723 Exhibit "A" PPO ASO Standard with Network (g2BlueCross Blue-Shield Deductible and Split Copay of Texas BENEFIT HIGHLIGHTS Prepared For City of Port Arthur BlueChoice Network Effective Date: 11 /01 /2018 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 Deductible applies to Out-of-Pocket Yes—no option Yes** Copayment applies to Out-of-Pocket Yes—no option Yes** Network Deductible&Out-of- Out-of-Network Deductible&Out-of °'Copayment amounts and per admission deductibles are applied but will continue to Pocket will only apply toward Network Out-of-Pocket will only be required after the benefit percentage increases to 100%. Network Deductible&Out-of- apply toward Out-of-Network Pocket Maximum Deductible&Out-of-Network Out-of- Pocket Maximum 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 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 Ded,Split Copay Rev 72017 for effective dates 01/01/18&after(8/2017 Release) Page 1 of 5 PPO ASO Standard with Network BlueCross BlueShield Deductible and Split Copay of Texas ical Expenses In-Network Out-of-Network Medical/Sur 9 p 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 Virtual Visit MUNE(Standard) NOT COVERED N/A N/A -Telemedicine Vendor(Specific procedures and providers) Not Covered Does not apply In Vitro Fertilization Services Not Covered 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 Mental Health (Serious Mental Illness (SMI)included) and Chemical Dependency(Substance Use Disorder) 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 per-admission Deductible None Penalty for failure to preauthorize services $250 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 Ded,Split Copay Rev 7/2017 for effective dates 01/01/18&after(8/2017 Release) Page 2 of 5 PPO ASO Standard with Network BlueCrossBtueShield Deductible and Split Copay D.D ofThxas Special Provisions Expenses, cont. In-Network Out-of- rk Benefits Benneefifitsts 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 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 Ded,Split Copay Rev 7/2017 for effective dates 01/01/18&after(8/2017 Release) Page 3 of 5 PPO ASO Standard with Network BlueCrossBiueShieid Deductible and Split Copay Q;9 of Texas Pharmacy Benefits Participating Pharmacy* Non-Participating Pharmacy (member files claim) Drug List** Basic Compound Drugs Not Covered(2015 Standard) Non-sedating antihistamine(NSA)drugs and combination Cover prescription strength NSAs only medications containing a non-sedating antihistamine and decongestant Proton Pump Inhibitors Generics and Brands coverage NOTE:For Performance and Performance Select drug lists,coverage will be based on the drug list.Customization is not allowed. Cover prescribed over-the-counter(OTC)medications Cover only prescribed ACA OTCs NOTE: ACA OTCs(aspirin,vitamin D,folic acid,iron,prenatal and fluoride)are standardly covered for Non-Grandfathered plans due to ACA with no cost share with a prescription from a provider. Cover prescription medications with OTC equivalents(same No strength,same active ingredients) If no,cover Omeprazole 20 mg ® Yes ❑No Prescription Drug Deductible*** None Prescription Drug Out-of-Pocket Maximum Separate Prescription Drug Out-of-Pocket Maximum applies to Retail&Mail Service Pharmacy:Individual: $ 1,500/Famil : $3,000 Vaccinations obtained through Pharmacies**** All ACA vaccines,including flu 80%of Allowable Amount minus (standard) Copayment Amount and deductible Covered at pharmacies participating in Prime's Vaccination Network only: Zero Copayment Deductible does not apply 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 Out-of-Pocket Maximum.) Preferred/Non-Preferred 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 $60 Copayment Amount 80%of Allowable Amount minus Non-Preferred Brand Name Copayment Amount Specialty Copay$150 Not Covered Specialty Drugs are not covered unless obtained through a participating Specialty Pharmacy Provider. Specialty Drugst Specialty Lock-Out through Prime Specialty Pharmacy applies: No coverage available for specialty drugs when purchased through any other provider. 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 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 Ded,Split Copay Rev 7/2017 for effective dates 01/01/18&after(8/2017 Release) Page 4 of 5 PPO ASO Standard with Network BlueCross BlueShield Deductible and Split Copay of Texas MAC 3-Generic incentive(Standard)-Members who purchase Brand Name Drugs when a Generic equivalent exists,will be required to pay the difference between the cost of the Generic and Brand Name Drug,plus the applicable Copayment Amount. *To locate a preferred/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 drug lists are available at. bcbstx.com/member/rx_drugs.html ***Three-month Deductible carryover does not apply to prescription drug deductible. ****Select Participating Pharmacies have been contracted to provide vaccination services. Each pharmacy may have age,scheduling,or other requirements that will apply. Members are encouraged to contact the store in advance. Benefit does not include childhood immunizations,subject to state regulations. tFor more information on the specialty drug program,call Prime Specialty Pharmacy at(877)627-6337. 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. Standard UM Programs(prior authorization and step therapy)and exclusions apply,including auto updates and FastPath. Note:To confirm standard benefits,refer to the Pharmacy page on Product Central on FYIBlue. Malana Hearn 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 Ded,Split Copay Rev 7/2017 for effective dates 01/01/18&after(8/2017 Release) Page 5 of 5 BlueEdge ASO HSA with Embedded BlueCrossBlueShield Deductible Clig of Texas BENEFIT HIGHLIGHTS Prepared for City of Port Arthur HSA Plan BlueChoice Network Effective Date : 11 /01 /2018 **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. Out-of-Pocket Maximum $5,000 Individual/ $10,000 individual/ $10,000 Family $20,000 Family Deductible 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 CDHP Prefix I EIC code: Order of Payment(CDHP Stacking) Stack#1:HSA 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 preautho6ze services None $250 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 01/01/2016(Rev. 2/2016 for 4/2016 Released Page 1 of 5 BlueEdge ASO HSA with Embedded (9) BlueCrossBlueShield Deductible u of Texas • BENEFIT HIGHLIGHTS Prepared for City of Port Arthur HSA Plan BlueChoice Network Effective Date : 11 /01 /2018 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 Not Covered In Vitro Fertilization Services 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) 80%of Allowable Amount after 60%of Allowable Amount after -Hospital services(facility) 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 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 01/01/2016,Re t.2u 1 i.or 4 zo to,4c east; Page 2 of 5 BlueEdge ASO HSA with Embedded aB1ueCrossBlueShield Deductible �'�� of Texas BENEFIT HIGHLIGHTS Prepared for City of Port Arthur HSA Plan BlueChoice Network Effective Date : 11 /01 /2018 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 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 6"i 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 01/01/2016 i Rev.2/2016 for 4/2(116 Release) Page 3 of 5 BlueEdge ASO HSA with Embedded Q►ueCross B►ueShie►d Deductible C o of Texas • Pharmacy Benefits Participating Non-Participating Pharmacy* Pharmacy (member files claim) Prime Therapeutics Drug List** Drug List 1-Basic (Standard) Compound Drugs Not Covered Nonsedating antihistamine(NSA)drugs and combination medications Cover prescription strength NSA's only containing a non-sedating antihistamine and decongestant Proton Pump Inhibitors Generics and Brands coverage Cover prescribed over-the-counter(OTC)medications Cover only prescribed ACA OTCs NOTE: ACA OTCs(aspirin, vitamin D,folic acid,iron,prenatal and fluoride)are standardly covered for Non-Grandfathered plans due to ACA with no cost share with a prescription from a provider. Cover prescription medications with OTC equivalents(same strength, No same active ingredients) If no,cover Omeprazole 20 mg ® Yes ❑No 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 Covered under medical policy,if All ACA vaccines,including flu applicable (standard) Covered at pharmacies participating in Prime's Vaccination Network only: Zero Copayment Deductible does not apply 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.) Specialty Drugst Specialty Lock-Out through Prime Specialty Pharmacy applies.Members are required to obtain specialty medications through Prime Therapeutics Specialty Pharmacy LLC(Prime Specialty Pharmacy). No coverage available for specialty drugs when purchased through any other provider. 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.) MAC 1-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 preferred/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 standard and generics plus drug list is available at:bcbstx.com/member/rx_drugs.html ***Select Participating Pharmacies have been contracted to provide vaccination services. Each pharmacy may have age,scheduling,or other requirements that will apply. Members are encouraged to contact the store in advance. Benefit does not include childhood immunizations,subject to state regulations. 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,added Specialty Lock-Out through Prime Specialty Pharmacy applies. No coverage available for specialty drugs when purchased through any other provider. One grace fill allowed. **Effective 11/1/2015,Prior Authorization is required for the drug class PCSK-9 Inhibitors(Specialty injectable drugs)for Homozygous Familial Hypercholesterolemia Agents. 1For more information on the specialty drug program,call Prime Specialty Pharmacy at(877)627-6337. 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 01/01/2016 . 2i2016 for 4/2016 Release) Page 4 of 5 BlueEdge ASO HSA with Embedded BlueCrossBlueShield Deductible c? of Texas Non-Standard Covered Benefits Effective 11-1-2011: • Radial Keratotomy covered • Lasik surgery covered • Medicare Assumption/Estimation • 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 01/01/2016(Rev.2/2016 for 4/2016 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 11/01/2018 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. o 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. 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 Group Executive Name and Title Signature Date Agent of Record Name Signature Date BCBSTX Representative Name Signature Date 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 Exhibit "B" Dearborn National® June 14, 2018 City of Port Arthur Attention: Elizabeth Villarreal P.O. Box 1089 Port Arthur, Tx 77641-1089 Re: Group Policy G31118 Anniversary Date: November 1, 2018 Dear Policyholder: Dearborn National would like to thank you for allowing us the opportunity to provide you and your employees with Group insurance products. You are currently under a rate guarantee until November 1, 2019. If you have any questions pertaining to your policy, please let us know. We value our relationship with you and look forward to providing quality service to you in the future. Sincerely, K.ac renv L. 1-4of e� Karen L. House National Strategic Account Executive cc: Mickey Moshier 1001 East Lookout Drive, Richardson,Texas 75082 A Toll Free:800.778.2281 A Fax: 312.540.4706 Products and services marketed under the Dearborn Nationale brand and the star logo are underwritten and/or provided by Dearborn National°Life Insurance Company (Downers Grove.IL)in all states(excluding New York).the District of Columbia,the United States Virgin Islands,the British Virgin Islands,Guam and Puerto Rico. CO 0 N 0 O CD T Las C o p N o .s U +P Z O U r m . M i� 0 L 3 � 0 a ;� -a p 3 m p +� 2 � c U r E �N O 0 0 o em VL co U 0 L Wm j � N ,s— 0c c O � N • �o ° U L (2) Q) e- Ta F timaN m 0_ 0 o 0 o L.L.. .i m p o Z I 1 r F. V` O) } . 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