HomeMy WebLinkAboutPR 15505: BLUE CROSS/BLUE SHIELD OF TEXAS - RENEWAL CONTRACTSMEMO
To: Mr. Stephen Fitzgibbons, City Manager
From: Patricia Davis, Senior Human Resource Anatyst t~F~
Date: September 14, 2009 ~f(/fif/
Re: Adoption of Proposed Resolution No. 15505 Authorizing the City Manager to Execute the
Necessary Renewal Contrail Documerits for a Third Party Administrator (Administrative
Services Onty) Contrail for the City of Port Arthur Group Medical, Derrtal Insurance; For
Basic Lffe, Basic Accidental Death and Dismemberment, and Excess Loss Indemnity with
Blue Cross and Blue Shield of Texas, Inc. (BCBS)
Recommendation:
I recommend that the City Council adopt proposed Resolution No. 15505, which authorizes the
City Manager to execute the necessary renewal contrail documents for a third party administrator
(administrative services only contract) for the City of Port Arthur Group Medical, Dental
Insurance; for Basic Life, Basic Accidental Death and Dismemberment, and Excess loss
Indemnity with Blue Cross and Blue Shield of Texas, Inc. (BSBS).
The City of Port Arthur on last year issued a RFP (Request for Proposal) for its major medical,
dental and life insurance plan, and with thirteen (13) responses received, Blue Cross and Blue
Shield of Texas, Inc. (BCBS) was awarded the successful proposal with athree-year option to
renew. Staff recommend that we accept the second year offer due to no change in rates for
administrative services costs, stop loss costs, derital costs and basic life and accidental death
and dismemberneM costs forthe 11/1/09 -10/31/10 plan year.
Backaround•
A breakdown of the cost and benefit levels forthe 11/1/09 plan year is delineated as follows
- The cost of the administrative services only (ASO) coverage will be $358,290-no
change over last year's rates.
- The cost of aggregate and specific stop loss coverage will remain the same as last
year's rate of $438,044.
- Dental rates will also remain the same as last year's total cost of $270,000 with no
change to existing benefits. (Note: The Dermal Plan is Fully Insured).
- Basic Life and Accidental Death and Dismembertnerit (AD&D) rates will remain
unchanged at $12,398ryr.
"Retnernber, we ore here to serve the citizens of Port Arfihur.°
Stephen Fitzgibbons/Memo
September 14, 2009
Page 2 of 3
Key plan amendmerKs effective November 1, 2008 are as follows:
1). Update Mental Health, SMI & Chemical Dependency to meet new
legislative guidelines.
2). Setting a $10 flu shot copay for elioible employees, retirees, and/or dependents
at parfiapating pharmacy locafions.
3). Change in diabetic supplies covered via preferred RX copay.
4). No sum increase for dental coverage for all impacted plan partiapams.
5). As City Councl has been made aware, the City has a significant liability due to
GASB 45 which particularly focuses on the funding of the liability for retiree
insurance. Addftionally, the City faces the on-going costs associated with rising
medical costs.
In onierto address these issues, we are recommending the implementafion of
several plan changes. The first recommendation is to move from the current
'blended" [all categories combined and rated as one] rate to three (3) distinct
categories: Active employees, Retirees under 6b, and Retirees over 65
(Medicare). Following meetings with Mickey Moshier, the City's insurance
consultant, and Chris Solimine, of ICMA, each confirmed the national
tends, and administrative wisdom, of moving to an 'un-blended' or
unique rates for the key listed groups.
The City's Health Insurance plan states that the City will pay one-half (1/2) the
dependent cost for employees and retirees. However, during times when the
City Council either was unable, only able to provide minimal, cost-of-living
adjustments (COLAs), the City absorbed various cost increases. This has led
to the City paying more than fifty percent (50%) of dependent insurance
premium costs. It is recommended that we begin to move back toward the
ffty percent (50%) payment as stated in the plan.
The City requested, and received, ratings for the C(ty's three (3) plan groups [q.v.
Attachment No. 1] based on their actual cost to the insurance plan. These
ratings indicate a five percent (5%) decrease in the rate for 'Actives' with a
substantial increase for both 'Retirees Under 85° and 'Retirees Over 65
(Medicare)' groups. After careful and critical review, this increase was deemed
too signficant to pass on at one time. Further, as we continue to review the City's
insurance plan, and the need to divide costs closer to fifty percent (50%)
as stated in the plan, lt seemed prudent that these increases be phased-in
over a three (3) year period. Therefore, the flrst one-thins (113), the d'rfference
between the currently subsidized premium rate and the °actuaP fifty
percent (50%) is recommended to be phased-in beginning this year.
This will allow the City to continue to use the month of October for 'Open
Enrollment' purposes (i.e. sign-ups, benefd and dependent changes, etc.).
It will also allow time to notify plan partiaparrts of the antiapated rate changes.
"Remember, we are here to serve the citizens of Port Arthur."
Stephen Fitzgibbons/Memo
September 14, 2009
Page 3 of 3
Additionally, k will afford City staff the opportunity to continue to critically
analyze the insurance and benefit offerings--balancing fiscal and
administrative responsibility wtth responsiveness and consideration of
particpants needs.
The Cty's actuarial consukent is evaluating the impact these plan
changes will have on ks GASB 45 liability; however, we are certain
that these recommendations will (1) resuk in a reduction of that
liability and (2) will place the City in a poskion to more accuretely
see and apportion, insurance costs based on plan utilization.
Premium increases for all impacted active employees and retirees and/
or dependent overages at one-third (1/3) the difference of the estimated
ASO conventional rates and the employees and retirees current monthly
rates.
NOTE: All other existing copays and deducffbies will remain the same.
Budaetarv/Fiscal Effect:
Approval of proposed Resolution No. 15505 will require the following amounts: {Note: Accounts
are estimated. Actual costs will depend on the City's experience and the number of plan
participants.}
Funding will be from Fund No. 614 -Health Insurance Fund
Major Medical Health Insurance ......................................................
Denta I Insurance .........................................................................
Basic L'rfe Insurance .....................................................................
Basic Accidental Death & Dismemberment (AD&D) ............................
TOTAL RECOMMENDED FUND FROM
FUND NO. 614 HOSPITAL INSURANCE FUND ..................................
NOTE• LAST YEAR'S RECOMMENDED FUNDING LEVEL..57.157.849
StatTina/Emolovee Effect:
Adoption of the proposed resolution would have no impact on staffing levels.
Summarv•
$8,875,451
$ 270,000
$ 10,886
$ 1,512
57.157.849
We recommend that the City Council approve proposed Resolution No. 15505, which authorizes
the Cky Manager to execute necessary renewal c:ontrac:t documents fora Thins Party
Administrator (Administrative Services Only) Contract for the City of Port ARhur Group Medical,
Dental Insurance; For Basic Life and Basic Accidertal Death and Dismemberment, and Excess
Loss Indemnity Coverage with Blue Cross and Blue Shield of Texas, Inc. (BC/BS).
"Remember, we are here to scr're the eitizerrs of Port Arthur."
ATTACHMENT N0. 1
City Of Port Arthur
ASO Projection
for the period
November 1, 2009 -October 31, 2010
1110112009 Medical ASO Renewal
CONVENTIONAL EQUIVALENT RATE DEVELOPMENT
Medical
HCSC Primary
Single $393.10 $589.65 $216.70
Single+1 $984.45 $1,476.68 $977.75
Family $1,153.88 $1,730.82 $1,177.67
Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
P.R. No. 15505
09/14/09 - ATT/pd
RESOLUTION N0.
A RESOLUTION AUTHORIZING THE CITY MANAGER TO IXECUTE RENEWAL
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 IXCESS LOSS INDEMNITY
WITH BLUE CROSS AND BLUE SHIELD OF TEXAS, INC.
FUND N0. (S) : 614 -HEALTH INSURANCE FUND
WHEREAS, the City Counal of the City of Port Arthur deems it necessary
and appropriate to wntinue major medical health care benefits for the City's
employees and its retirees, and;
WHEREAS, the City Counal deems it in the best interest of the cit9zens of
Port Arthur to be self-funded and to accept the renewal proposal from Blue Cross
and Blue Shield of Texas, Inc. as a tfiird party administrator at an estimated cost
of $358,290 per year (administrative charge based on the present number of
employees and retirees) as well as at a cost of $436,044 per year for stop loss
premium (excess indemnity), and;
WHEREAS, such contracting with Blue Cross and Blue Shield of Texas,
Inc. complies with Sections 252.021(b), Comp~tive Reouirements for Certain
Purchases 252.024, lion 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 Exhibits "A-i", and "A 2"which
EXHIBIT "A-1"
~ City Of Port Arthur
ASO Projection
for the period
November 1, 2009 -October 31, 2010
11/01/2009 Medical ASO Renewal
Presented by:
Blue Cross Blue Shield of Texas
Division of HeaNh Cere Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee o/the Blue Cross and Blue Shiald Association
City Of Port Arthur
ASO Projection
November 1, 2009 -October 31, 2010
1110112 0 0 9 Medical ASO Renewal
CLAIM PROJECTION
Net Paitl Claims $4,448,093 $4,197,534 $1,271,I3u >1.~sy,oa~ a~.r ia,oeo .o~.o.,.,,~.~
Remove Large Claims $703,356 $515,274 8703,356 $515,274
Number of Large Claims 5
737
744
$3 4
682,260
$3
81,271,730
$1,337,592 5
$5,016,467 4
$5,019,852
Adjusted Nel Paid Claims ,
,
9
395 ,
9,668 9,395 9,668 9,395 9,668
Exposures
Average Claim Value (ACV) Per Contract Per Month (PCPM) ,
$398.59 $380.87 $135.36 $138.35 $533.95 $519.22
Annual Trend Rate 9.9 % 10.3% 8.2% 7.0
Trend Months (mitlpoinl method) 29.0 17.0 29.0 17.0
Trend Factor 25.7% 14.9% 21.0 % 10.1 %
Trended ACV PCPM $501.03 $437.62 $163.79 $152.32 $664.82 $589.94
Historical Plan Change Adjustment 0.00% 0.00% 0.00% 0.00%
Dependent Ratio Adjustment 0.22 % 0.65 % 0.25 % 0.61
Adjusted ACV PCPM $502.13 $440.46 $164.20 $153.25 $666.33 $593.71
7
Non-Pooled Large Claims PCPM $53.22 $41.37 $0.00 $0.00 $53.22 $41.3
Projected ACV PCPM by Period $555.35 $481.83 $164.20 $153.25 $719.55 $635.08
c....e~e,.~o oodnd Wainhtino i6% g4% i6% 84% 16% 84%
Blended Experience ACV PCPM $493.59 $155.00 $848.59
Manual ACV PCPM $476.07 $130.33 $606.40
100%
Cretlibility 100%
$493
59 100%
$155.00 $646.59
Total Projected ACV PCPM .
00%
0 0.00 %
Projecetl Plan Change Adjustment .
$493
59 $155.00 $648.59
Total Projected ACV PCPM with Projected Plan Changes .
Projected Enrollment 814 814
12 814
12
Number o(Months in Policy Period 12
387
$4
821 514,040
$1 $6,335,427
Prniacted Net Paid Claims _ ,
, ,
niviaian of Heellh Care Servim Corpore4on, a MuWel Lepel Reserve Lompany,
en InEepontlenl Liwnaaa o11M1e Blue Crop and Blue SMelO PseorleYOn
City Of Port Arthur
ASO Projection
for the period
November 1, 2009 -October 31, 2010
11/01/2009 Medical ASO Renewal
TOTAL PROJECTED COST
All Employees ~ ~ ~~ ~ ' F.~
Individual Stop Loss ($100,000 Level)
Aggregate Stop Loss 125% Attachment Point
Administration Fee
Prescription Drug Rebate Credit
Net Administration Fee
Total Projected Cost
Run-Off Administration
Run-Off Claim Liability
$44.64 $436,044
$4.04 $39,463
$50.05 $488,888
($13.37) ($130,598)
$36.68 $358,290
$7,169,224
$28.48 $69,548
$297.69 $726,960
Division of HeaIN Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shieltl Association 3
City Of Port Arthur
ASO Projection
November 1, 2009 -October 31, 2010
11/01/2009 Medical ASO Renewal
Mature
Projected Enrollment
Projected Average Claim Value
Aggregate Stop Loss Attachment Point
Aggregate Stop Loss Limit
Aggregate Stop Loss Premium
Individual Stop Loss Attachment Point
Individual Stop Loss Premium
STOP LOSS
.Actives ; .F,~ «Medicare Retirees
SINGL'E'; FAMILY ~SINGCE: ':FAMILY
395 305 76 36
$368.95 $1,032.70 $161.23 $732.36
l25% 125% 125% 125%
$461.19 $1,290.88 $201.54 $915.45
$2.30 $6.44 $2.30 $6.44
$100,000 $100,000 $100,000 $100,000
$25.39 $71.07 $25.39 $71.07
Minimum Aggregate Attachment Point
Run Off Administration
Run Off Liability
$16.20 $45.35 $16.20 $45.35
$178.53 $499.69 $78.02 $354.37
Subject to and contingent upon conditions and caveats outlined in attached addendum.
Custortier Total ,
'` 'PCRMI :TOTAL
814 9,768
$648.64 $6,335,427
125% 125%
$810.74 $7,919,284
$4.04 $39,463
$100,000 $100,000
$44.64 $436,044
$7,127, 356
$28.48 $69,548
$297.69 $726,960
Division of Health Care Service Corporation, a Mutual Lagal Reserve Company, 4
an Independent Licensee of the Blue Cross and Blue Shield Assoclatlon
City Of Port Arthur
ASO Projection
for the period
November 1, 2009 -October 31, 2010
1110112009 Medical ASO Renewal
FEE COMPARISON
Mature
;>'A
Projected Enrollment
Administration Fee
Prescription Drug Rebate Credit
Net Administration Fee PCPM
All Employees
Current ; , Rem
iule. -~cFamily .•Sir' 1
ulv `~ ..
Individual Stop Loss $100,000 Level
Aggregate Stop Loss 125% Att. Pt.
Total Fixed Costs PCPM
$27.31 $76.46 $28.46 $79.69
($6.45) ($18.06) ($7.60) ($21.29)
$20.86 $58.40 $20.86 $58.40
$25.39 $71.07 $25.39 $71.07
$2.30 $6.44 $2.30 $6.44
$48.55 $135.91 $48.55 $135.91
Projected Average Claim Value PCPM $368.95 $1,032.70 $368.95 $1,032.70
Projected Aggregate Limit PCPM $461.19 $1,290.88 $461.19 $1,290.86
Total Projected Costs PCPM $417.50 $1,168.61 $417.50 $1,168.61
~E
8
$48.02 $50.05 4.2%
($11.34) ($13.37) 17.9%
$36.68 $36.66 0.0%
$44.64 $44.64 0.0%
$4.04 $4.04 0.0%
$85.36 $85.36 0.0%
$648.64 $648.64 0.0%
$810.80 $810.80 0.0%
$734.00 $734.00 0.0%
Divislan of Healih care service Corporation, a Mutual Legal Reserve Company, 5
an Independent Liwnsee or the Blue Cross and Blue shieltl Association
City Of Port Arthur
ASO Projection
for the period
November 1, 2009 -October 31, 2010
11/01/2009 Medical ASO Renewal
CONVENTIONAL EQUIVALENT RATE DEVELOPMENT
Medical
:. 'G->± ~> tLlves~~'~Gurrentf>=Renewal''-
HCSC Primary
Single 395 $413.79 $413.79
Single+l 106 $1,036.26 $1,03626
Family 199 $1,214.61 $1,214.61
Medicare Primary
Single 76 $180.58 $180.58
Single + 1 18 $814.79 $814.79
Family 20 $981.39 $981.39
HCSC 8 Medicare Total 814
Division of Healih Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross antl Blue Shieltl Association 6
City Of Port Arthur
AEO Pro(sctlon
November 1, 3009 -October E1, 3010
11/O1I200B Metllcel ASO Renewal
CONDITIONS AND CAVEATS
Ralas are proledetl to De attedive for Ne 13-monN Oanod beginning on Ilse ettectlva date Intlirated.
Final rates may very based on edual enrollment reaulle.
This renewal attar asaumea BCBSTX will remain the axduaive wMCr.
Tne Idol annual premiums are based upon the total wrrent enmllmenl end wn1reG disldbution az intliwtetl.
Renewal ottere esaumo ozlsling adminisbalion preGlwe end wntroG provisbn¢ will remain in place.
II IM1e enrollment ar wntrad disVibugon vadee by mare Nan 10%in total ar in each wvemga indBpendenfly, we reserve tM1e dgM1t b re-rate.
Tno minimum parlidpagon requirement le ]b%wimoul waivers end 65%wllh valltl welvere in order tar wvempea tp be issued.
Tne employer maintaining the wnent wntnbution sUledule.
Annual open enrollment.
No atltlNOnal bzes will be imposed antl no increase in ezisgn0 taxes until the next Anniversary Oate.
Roles tlo not i0GU0e any Nlure mandated benefit cheogee.
Upon inquiry from employer groups, BCBSTX will provide Inlonnagon b me employer Bmup re9artling Commissions antl other wmpensagon paid
to the empbyers agent Dy BCBSTX in wnrleUion wim ma ampbyefs poliq or wnlreU with BCBSTX.
The ewwal ie bein0 offered on a pale basis.
HeeIN Paid Llalms subjeG to Bbp Lose are Gaima peb OutlnB me poky period iMiceled above.
Heelm Paid Claims ¢ogeU to In0lvbual Slap Loas are paid Gaima hom me fdlowlnB lino(y of wverega: Medical antl Drop
Health Paitl Claims 6u0jeG to Aggregate Stop Lass are paid G811na from me Igllowirp line(s) IN wvere9e: MBdiwl and Omg
The total annual heahM1 Stop Lode premiums end ACV ladora ore Dosed upon Ne brat wrtenl onrollmenl end wntraG di¢VibWOn ea Indicated on Nb exM1lDll.
SiOnifiwnl changes in the above stated enrollment and wnhaU tliztdbugon unit require a review end etllusMent of melees antl fedora.
BCBSTX reserves the nphl b adjust me Average Claim Value if one or more of the lollowln9 occurs Mmin me wvOre90 penotl.
The minimum Aggregate Attachment Point was nalwlatetl as 90%d me ASL limit par wnlreU per monm
mul9plle0 by me projected wmulaliva wnVeGS roc me pedotl.
Individual Health Slop Loss antl Apgrepele Heeltn Stop Loas premiums ere payable on me prat day of eaUl monm.
Any amount in exwae of me Individual HeeIN Stop Loea limit will rid be IndudM In ma Ag9regale Mealm Slop Leea Betllemenl.
Tha Agge9ate Slop Losa benefit payments shell not exceed a maximum of E1,000,000 per policy petlotl.
Premium Equivalent Rates reflaU expeGed Denefil wet ody antl tlo not induda en etljuslmenl for a change in needed reserves.
Premium Equlvelenl Rates should luntl expodetl poitl Gaima (EPC), atlminlsfraDOn, Uoploee cher9an end eelimaled reserves',
it Gelme exceetl EPC, me Empoyer wig De mquiretl to make eddgonal NMS oveilable up to the Maximum Clelm Liability
Upon Tennlnelian, the mnatt ladors above will ba multlplle0limes me total of all wNOCe1Be edualty expowtl tlunn0 earA
al me three monms immediately prowtlin9 wnVeG lerminogon a~b me result wilt be me obliBetion W ma Employer.
Tha Runatt Adminishatiw amount is tlua erb payable wMther a not BCBSTX prowasas ma mn-oB Geims.
Tne AdminiUragve charge inGudes a naMroB ecceas Ire tar Texas emDloyeea. 0ul-d-able employees will be accessed a dlarpe al 1096 al me discount per Uaim,
not Ip exceed E3.000 par Uaim. Tnia Gelm chergo w01 ba inGUded in your monthly BARS alatemanl.
Costs asaodetetl wim apedal ¢ervicee or wetom maledalz pravidetl by BLESTX will De billetl separate and aDad Oom me Adminisaa4ve CM1aryes outlined on mis exhibit.
TM1e employer is responsible for any edminie0a9ve services razes tlue for Denegle peb under this agreement.
pl.aMntl WYx W Srnu LVpaNn, •aWUY lyn Ruw~pmawry.
m lMgxWMLk~rs~NMBFe Crw W alu 6MN4wan
06/75/2009
City Of Port Arthur
Prospective Premium Projection
for the period
November 1, 2009 -October 31, 2010
11/01/2009 Dental Fully Insured Renewal
Presented by:
Blue Cross Blue Shield of Texas
Division of Health Care Service Corporation, a Mutual Legel Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association $
City Of Port Arthur
Prospective Premium Projection
November 1, 2009 -October 31, 2010
11/01/2009 Dental Fully Insured Renewal
CLAIM PROJECTION
All
Net Paid Claims
Exposures
Average Claim Value (ACV) Per Contract Per Month (PCPM)
Annual Trend Rate
Trend Months (midpoint method)
Trend Factor
Trended ACV PCPM
Historical Plan Change Adjustment
Dependent Ratio Adjustment
Projected ACV PCPM by Period
Experience Period Weighting
7,194
$28.93
5.5%
29.0
13.8%
$32.92
0.00%
0.42%
$33.06
12%
7, 346
$28.21
5.0%
17.0
7.2%
$30.24
0.00%
0.78%
$30.48
88%
Blended Experience ACV PCPM
Manual ACV PCPM
Credibility
Total Projected ACV PCPM
Projected Plan Change Adjustment
Total Projected ACV PCPM with Projected Plan Changes
Projected Enrollment
Number of Months in Policy Period
Projected Net Paid Claims
$30.79
$27.05
100%
$30.79
0.00%
$30.79
624
12
30.556
Division or Health Care Service Corporation, a Mutual legal Reserve Company,
an Independent Licensee or the 81ue Cross and Blue Shield Association 9
City Of Port Arthur
Prospective Premium Projection
for the period
November 1, 2009 -October 31, 2010
11/0112009 Dental Fully Insured Renewal
TOTAL PROJECTED COST
All Employees - : ~ ~ Trad
Projected Enrollment 624
Total Projected Net Claims $230,556
Risk $10,606
Total Benefit Charges $241,162
Desired Loss Ratio (DLR) 88.65%
Preliminary Premium $272,027
Required Premium $272,027
Premium at Current Rates $272,011
Required Premium/Premium at Current Rates 0.00%
Division of Heallh Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross antl Blue Shield Association ], t)
City Of Port Arthur
Prospective Premium Projection
for the period
November 1, 2009 -October 31, 2010
11/01/2009 Dental Fully Insured Renewal
RATE DEVELOPMENT
Dental
Rate Action 0.00
- .. ;: Lives~Current : Renewal
Single 342 $20.28 $20.28
Single + 1 91 $48.37 $48.37
Family 191 $59.32 $59.32
Dental Total 624
Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
))
l
City Of Port Arthur
Prospective Premium Projection
November 1, 2009 -October 31, 2010
11/01/2009 Dental Fully Insured Renewal
CONDITIONS AND CAVEATS
Rates are projected to be effective for the 12-month period beginning on the effective date indicated.
Final rates may vary based on actual enrollment results.
This renewal offer assumes BCBSTX will remain the exclusive carrier.
The total annual premiums are based upon the total current enrollment and contract distribution as indicated.
Renewal offers assume existing administration practices and contract provisions will remain in place.
If the enrollment or contract distribution varies by more than 10% in total or in each coverage independently, we reserve the right to re-rate.
The minimum participation requirement is 75% without waivers and 65% with valid waivers in order for coverages to be issued.
The employer maintaining the current contribution schedule.
Annual open enrollment.
No additional taxes will be imposed and no increase in existing taxes until the next Anniversary Date.
Rates do not include any future mandated benefit changes.
Upon inquiry from employer groups, BCBSTX will provide information to the employer group regarding commissions and other compensation paid
to the employer's agent by BCBSTX in connection with the employer's policy or contract with BCBSTX.
Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association 1 z
EXHIBIT "A-2"
Blue Cross and Blue Shield of Texas
Summary of Benefits Prepared for CITY OF PORT ARTHUR #31118
PPO
TYI'EOFSERVICE NETWORK OUT-OF-NETWORK.
GENERAL PROVISIONS
Calendar Year Deductible (Applies to Non-Inpatient Hospital Services) $500 Indiv/$1,500 Family $1,000Indiv/$3,000 Family
4'h Quarter Carryover Applies Yes Yes
Deductible Credit from Prior Carrier N/A N/A
Coshare Stoploss Maximum $2,500 Indiv/$5,000 Family per cal. yr. $3,000 Indiv/$9,000 Family per cal. yr.
Nehvork deductible and cosha~e Our-of-Nenvm~k deductible and coshm~e
will only apply towm~rl Network will also npply toward Network
deductible aad coshnre deductible and Coshare
Coshare Stoploss Credit fTOm Prior Carrier N/A ~ N/A
Lifetime Maximum per Partici ant $1.00 0.000
INPATIENT HOSPITAL SFRVICES (nmst be precenitied) 80% GO%alier per adm. deductible
Per Admission Deductible None $200
Penalty for Failure to Precertif ~ None $250
EMERGENCY ROOM/TREATMENI' ROOM
Accident & Medical Emergency Situation within 48 Hours
Facility Charges 80%after $100 copay, waived i I' admitted
Physician Charges 80%after cal. yr. deductible
Non-Emergency Situations
Facility Charges 80%after $100 copay, waived if adm itted 60°/ after $100 copay & cal. yr. deductible,
waived if admitted
Ph sician Char es 80%after cal. a'. deductible GO%after cal. yr. deductible
MEDICAL, SURGICAL SERVICES
Services Performed in Physician Ottlce (non-surgical); Including Lab & X-ray 100% after $25 copay per visit 70%after cal. yr. deductible
Immunizations (birth to the day of the 6'~ birlhdate) 100% l00%
Physician Surgical Services in any Setting 80%after cal. yr. deductible GO%aRer cal. yr. deductible
Lab & X-Ray in Other Outpatient Facilities (excluding Certain Diagnostic Procedw~es): 100% 70%after cal. yr. deductible
• Certain Diagnostic Procedures: Bone Scan, Cardiac Stress Test. CT Scan (with or 80%after cal. yr. deductible 60%after cal. yr. deductible
without contrast), UIO'asound, MRI, Myelogrtm, PBT Scan
Home Infusion Therapy (must be przcertified) 80%after cal. yr. deductible 60%after cal. yr. deductible
In-Vitro Fertilization lleclincd
Chiropractic Care -Office Services 80% after cal. yr. deductible 60%after cal. yr. deductible
$1,500 cal. yr. max.
All Other Ph~~sicnl Medicine Services rendered by nny other eligible Provider
mill be allowed on the same basis as any other sickness.
Speech and Hearing Services with Hearing Aids Covered as any other sickness Covered as any other sickness
$1.000 Maximum be nztlt tzr 3G-month eriod for Hearing Aids'
All Other Outpatient Services and Su dies 80%after cal. ~r. deductible 60%after cal. vr. deducible
PI'O-ASO-STRD. W I"1'Ii.NBT.DFD-C-5013 R fi V. 8120/03
131uc Cross and 131uz Shield of'I'cxas, a Division of licahh Care Service Corporation, a Mutual Legal Reserve Company,
C11'Y OF PORT ARTHUR #31118
PPO
TXPE OF SERVICE
NETWORK
OUT-OF-NETWORK
PREVENTIVE CARE
Routine Physicals, Well Baby Care, Onmunizations (after 6'h birthdale),
100% after $25 copay per v+sit
70% after cal. yr. deductible
Vision & I-tearing Exams
100%
70% after cal. yr. deductible
EXTENDED CARE SERVICES (must be precertiLed)
Home I-lealth Carc
$10,000 per cal. yr.
$7,000 per cal. yr.
Calendar Year Maximum $10,000 per cal. yr. $7,000 per cal. yr.
Skilled Nw~sing Facility $20,0001ifetime max. $14,000 lifetime max.
Hospice Care Benefits used in Nehvork or Out-o -Networ k ap ~(' towards saris in bode maximums.
MENTAL HEALTH/CHEMICAL DEPENDENCY (must be precertified)
Inpatient Services
gp%
60%after per adm. deductible
Hospital Services (Facility)
80%after cal. }'r. deductible
60%after cal. yr. deductible
Physician Services 30 inpatient days/30 physician visits 15 inpatient days/IS physician visas'
Calendar Ycar Limitations
i Days mrd visits used in Nehvork nr Our-of-Ne hvork apply towards snlisjyin ~ both maximums.
ces
Outpatient Serv
Services Performed in Plrysician OtTice (non-surgical) 100%after $25 copay 70%after cal. yr. deductible
ency Rootnlfreatmenl RoondFacility Charges
Emer 80%after $100 cops}', waived if admitted 60%after $100 copay & cal. yr. deductible
g waived if admitted
80%after cal. yr. deductible 60% after cal. yr. deductible
Prolessional Provider 30 outpatient visas per cal. yc 15 outpatient visits per cal. yr.
Visits Allowed
Chemical De cadency Maximum far each Covered Individual $1Q000 lifetime maximum
SERIOUS MENTAL ILLNESS (must be precertified) Covered as an other sickness
REV. 820/03
pl'O-ASO-STRU. W ITH.NI?T.DEU-G-506 .
131ue Cross and 131ue Shield of l'esas, a Divismn of lieahh Carc Service Corporation, a Mutual Legal Reserve Company',
CITY OF PORT ARTIiUli #31118
PPO
NON-PAR'I'ICIPA'f1NG PHARMACY
TYPE OF SERVICE PARTICIPATING PHARMACY member files claim
PRESCRIPTION DRUC PROGRAM "
Retail Prescription
(all copays nre per 30-day supply and will not apply to coshare stoploss maximum)
Non-Preferred Brand Name $50 copay 80%of Allowable Amount minus copay
Preferred Brand Name $30 copay 80%of Allowable Amount minus copay
Generic $ ] 0 copay 80 % of Al towable Amount minus copay
Mail Service Prescription Yes
(all copays are per 30-day supply and will not apply to coshare stoploss maximum)
Non-Preferred Brand Name $50 copay
Preferred Brand Name $30 copay
Generic $]Oco ay
'/jd+ere is no Generic Drug for fhe Preferred Brand Nnnre Drug presn~iprion, the Pnr(icipan( will pny uo mmr than Ure applicnhle Preferred Brnnd Nnnie Drag copay. /jrhe Parlicipan( receives n
Preferred brand Name Drug for which a Generic Drug is availnhle. dre copay arnoun(+rill be the sour aj(a) (he difference behveerr the Allowable Amourt( ojthe Preferred Brnnd Name Drug m+d the
Allowable Amount oj(Ire Generic D+'ug. plus (b) the Preferred Brnnd Name Drug copay.
PPO-ASO-SIRD.wITH.NhT.DGD-G-SOI3 RHV. 81?0/03
131ue Cross and 131uc Shield of Texas. a Divisiar of Health Care Sewice Corporation, a Mutual Legal lieserve Company,
CITY OF PORT ARTHUR #31118
PPO
F,MPLOYEE INFORMATION
• This is a general Swtnnary of your benefit design. Please refer to your beneG[ booklet for other details and for limitations and exclusions.
• The following benefits apply to dependent coverage:
• Dependent children are covered to age 25.
• Unmartied grandchild of the insured are covered if the grandchild is under 25 years of age and is claimed as a dependent by the subscriber for federal income tax
purposes.
• 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 emolhnent period or special enrollment event.
• Provider charges are paid according to BCBSTX determined Allowable Amount and negotiated prices.
• Preexisting conditions afe defined in the benefit booklet and are excluded for 12 months. Appropriate credit will be given for time served under another health benefit plan
as defined under [he law.
• Radial Keratotomy -covered
• Lasik -covered
Eff 11/1/OS Services, supplies and/or prescription drugs for reduction of morbid obesity, including surgical procedures, when medically necessary, covered same as any other
sickttes9. (Note: PresoriptiomDrugs for morbid obesity are not subject to medical necessity)
• Replacement of Medical Coverage: In compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), [he following provisions apply to each
eligible participant who has health coverage under the employer's plan immediately prior to [he effective date of the health contract between the employer and BCBSTX (the
contract date):
• Benefits for eligible expenses incun'ed for any service or supplies prior to the contract date; are not covered under the conu-act.
Eligible expenses for services or supplies incwTed on or after the effective date will be considered for benefits subject to all applicable contract provisions.
I'RO-ASO-STRU.WII'H.NE"I'.DhD-G-SOH RGV. R/20/03
l3lue Cross mtJ 131ue Shield of Texas. ~ Division ul lieahh Cnre Service Cogrotatiat, n Muntal Legal Reserve Compact)',
EXHIBIT "B- i"
CITY OF PORT ARTHUR HEALTH INSURANCE RATES
(BLUE CRO55 BLUS SHIELD OF TEXAS/THIRD PARTY ADMINISTRATOR)
.:--~
EFFECTIVE NOVEMBER 1, 2009
EXHIBIT "B-2"
City of Port Arthur Health Insurance Rates
(Blue Cross Blue Shield of Texas/Third Party Administrator)
Effective November 1 2009
tetirte Under 65
tetiree<65 6 1 Dependent
Zetiree<65 6 2 Dependents
2etiree<65 6 Medicare Depen~
Medicare Retiree
Medicare Retiree 6 1 Depends
Medicare Retiree d 2 Depend
u~.ei~~ere Retiree & Medicare
Clty's turcent Retlrss's Cwt t
Monthly Coat Monthly Cost
$ 230.24 $ 183.55 $
$ 390.12 $ 646.14 $
$ 490.28 $ 724.33 $
26130 $ 333.07 9
$ 31.08 $
$ 393.43 $
$ 481.85 $
g 62.15 $
421.36 $
499.54 $
299.01 $
Clty's Monthly
Total Current Lest Effective
Monthly Cost 11/1/09
413.79 $ 369.01
~ naa ~a S 701.53
Retinds
Cost Ef.
~`2
,214.61 $ 861.16 $ 869.66.
594.37 $ 413.79 $; 392.56
180.58 $ 44.80 $ IZI.90
814.79 $ 497.77 $ 479.98
981.39 $ 612.25 $ 565.42
361.16 $ 89.59 $ 343.81
.•
EXHIBIT "C"
~~'F
B1ueCross BlueSlueld
of Texas
June 25, 2009
Mr. Albert Thigpen
City of Port Arthur
P. O- Box 1089
Port Arthur, Texas 77641-1089
Re: Anniversary Date: November t, 2009
Group #: 31118/G31118
Dear Mr. Thigpen:
Thank you for allowing Blue Cross and Blue Shield of Texas (BCBSTX) the opportunity to provide group be~efit coaerage
to you and your employees this past year. We are proud of the partnership we have developed with you an continue
to strive to meet your needs for quality health care coverage while managing health care costs.
New Federal Requirements for Mental Health Care and Treatment of Chemical Dependency Coverage
On October 3, 2008, President Bush signed the Emergency Economic Stabilization Act of 2008. This legislation included
the Mental Health Parity and Addiction Equity Act (MHPAEA) which amends the Employee Retirement Income Security
Act (FRIBA), the internal Revenue Code (Code) and the Public Health Service Act (PHSA). The MHPAEA generally
requires that group health plans and group health insurers apply the same Veatment and financial limits to medical and
surgical benefits and to mental health and substance use disorder benefits.
For renewing groups, the provisions of the law will go into effect on each group's anniversary date beginning on and after
October 3, 2009.
Corporate Revisions to ASO Benefits and Provisions
BCBSTX must periodically adjust its standard benefd plans and provisions. We have implemented several standard plan
and provision enhancements which will become effective on your anniversary date. The enhancements will have minimal
impact to your group health coverage and your benefit booklet will be updated, as described below, to reflect these slight
revisions:
Exclusion for video fluoroscopy and manipulations under anesthesia (except for that of the spine) will be removed
from the medical limitations and exclusions. These services are no longer considered
experimentaUnvestigationalond are now supported by medical policy guidelines for certain diagnoses.
Anew provision, entitled Notice of Creditable Coverage, will be added to the General Provisions section of your
benefd booklet. The new provision is compliant wdh Department of Labor (DOL) requests, but does not affect
existing policies and/or procedures.
Text clarifications have been made in the section entitled, Preauthorizafion for Inpatient Hospifal Admissions. The
text clarification is compliant with Department of Labor (DOL) requests, but does not affect existing policies and/or
procedures
WHY BLUE CROSS
Access: Unparalleled Provider Networks
BCBSTX offers managed care and tradftional provider networks that are among the largest in the health care industry,
with superior savings.
The Texas PPO network, BiueChoice®, is one of the largest PPO networks in the stafe. it includes more than 56,000
physicians, nearly 500 hospitals, and is available in all 254 Texas counties. Our network is buik on strong relationships
with local providers and is fostered by our Office of Physiaan Advocacy.
>ar•, culal•c Sunl• .on. nl•.ulll,llnl,-rr•\,IS rr7na • t+o))) sari-nla) • r•1.. (rIR)) ti91i-01 I 1
1 Ilivw•nl rd' Ilmlllr I~,n~ 5rnu+• 1sgmmlNnl i \htlual Ir~l Ilevr,r Guymp. nu Lnlge~nlrw I m+w•v arlle• Ilinr I i,e. anA INne ]LnNA tv.,-ii1Ln1
N,yl i.! 1 i.ll NII:
When consulting a Physician or Professional Other Provider who does not parfidpate in the Network, your employees
may also benefit from discounts'rf the provider participates in ParPlan - a simple, direct~ayment cost protection feature
That is not available with other carriers. If the Physidan or Professional Other Provider participates in ParPlan, he agrees
to:
File member Gaims directly with BCBSTX,
• Accept the allowable amount determination as payment for Medically Necessary services, and
• Not bill for services over the Allowable Amount determination
Service: Unparalleled Customer Service, Online Capabilities
BCBSTX traces its origin to the non-profit Baylor Plan founded in ~ 929. We have continued to serve Texans and Texas-
based employers ever since, and have become one of the most widely recognized and widely respelled health care
wmpanies in the state.
As your carrier, BCBSTX has demonstrated a commitment to outstanding account management and customer service.
The account management team will continue to interect with you to ensure the ongoing maintenance of your benefits
program. Your employees have benefited from the one-stop shopping of the Full Service Unit Online resources
empower members to take control of their health care and afford them the necessary information to make wise decisions.
Stateof-the-AR Technology: BCBSTX.com
- Blue Acesss®tor Employers (BAE)
To help reduce the time spent on paperwork and help you more quirky and easly administer your company's health
care benefits plan, we ofrer a range of online employer and employee online capabilities through BlueAccess®for
Employers (BAE).
With BAE, you can conduct a variety of membership, enrollment, reporting, administrative and billing transactions
online quickly and accurately. You can verity and edit information. Changes that impact your bill are recorded
immediately. And because BAE is secure, you can be confident that your transactions are safe and protected.
To see an onfine demonstration of how the many features of SAE can work for you, simply go to
www.bcbs6r.comlemnfovers and take a tour.
BlueOuUook and Bluelnsight Reporting
Based on group size and funding arrangement, available data reporting services may include standard monthly,
quarterty, and annual reports that provide in-depth utilaation analysis, enrollment reports, and related savings, such
as coordination of benefits and subrogation. Ad hoc reports may be available for an addifional charge. Employer
groups may access their reports onfine.
- Blue Aec~s for Members
Secured access to view claims and Explanations of Benefits, request replacement ID cards, print temporary ID cards,
and e-mail questions to Customer Service.
Provider FirMermand Pharmacy Finder - downbadable network provider directories that can tre formatted by
product/network type, region, and city area- A link to the Blue Cross and Blue Shield Association Web site provides a
listing of national and international providers. A link to the Prime Therapeutcs LLC sfte is available for national
pharmacy listings.
Pharmacy-related services -including online mail order capabilities for members currently enrolled in Prime
Therapeutics' mail order prescription program; an alphabetical listing of the most commonly prescribed medications
available in the preferred brand name category with noted generic equivalents; and information about the BCBSTX
three-tier copayment structure.
Downloadable fomrs -for claims submissicn, student dependent certification, prescription drug claim
reimbursement, and prescription mail orders.
Customer service -for replacement ID card requests and other a-mail inquiries.
Health Care Decision Tools -- In addition to offering eligihility and claim status information online, BCBSTX provides
members with access to exclusive online health and wellness content and derision-making tools.
Health Risk Assessment -Members will benefit from the Health Risk Assessment and other self-management Web-
based tools relating to Gammon health care problems such as asthma, law back pain, and headaches. These
2
programs will be integrated with BCBSTX care management programs, as applicable. Members may also access
information about specfic diseases and treatments, including aRemative medicine and interactive health lifestyle
decision-making tools.
Hospital CompaHson Tooi -BCBSTX also offers members access to a hospital comparison tool that allows
members to make informed hospital selections using interactive software. Members can generate a list of hospitals
meeting criteria they've specified, such as patient volume, location, mortality rates, and unfavorable outcomes.
Members wn pertortn their own side-by-side comparisons of network hospitals, to ensure their comfort and
satisfaction with their hospital experience.
Value: Competitive Administrative Costs, Innovative Medical ManagemerM, Health Care Cost Solutions
Keeping health care affordable is important to us because it's important to you. BCBSTX takes a proactive approach to
lowering the cost of health care for employers and empbyees.
Blue Resource
in conjunction with the Blue Cross and Biue Shield Association, BCBSTX has launched the Blue Resource
communication campaign to increase awareness of how health rare choices impact the rising cost of health care.
BCBSTX provides applicable messages and artwork online at www.bcbsbc.com, at no cost to employers. Campaign
materials are grouped by health care topic such as Health and Wellness, Weight Lass and Fithess for Work (maxim¢ing
productivity through ergonomics, stress management and more}.
BlueExtrasga Discount Program
Blue Cross and Blue Shield of Texas (BCBSTX} is committed to supporting our members' wellness objectives and is
pleased to offer BlueExtras, value-added discount programs designed to encourage healthy Irfestyles. BCBSTX currently
offers our members the following discount programs including vision, hearing, weight management, and wmplementary
aftemative medicine.
Davis Vision
The value-added vision program offered by Davis vision for BCBSTX members provides your employees with discounts
for routine exams, lenses, frames, and contact lenses. It also includes a mail order contact Tens replacement program
(LENS 123), and a network of participating providers offering discounts on laser vision correction.
TruHearing
The TruHearimg program allows your empbyees (as well as their children, parents and grandparents regardless of
whether they are members) to receive discounts of 30% to 60% off manufacturer suggested retail price for the latest
technology in digital hearing instruments. The program also includes a free hearing screening, hearing instrument felting
and related services through the TruHearing network of participating providers. To access the program, call 1-877-882-
2020, between 8 a.m. and 8 p.m., Menday through Friday to locate a provider, schedule an appointment and obtain a
referral to the provider. It's that easy!
Jenny Craig'
Jenny Craig offers BCBSTX members and their covered dependents joining fee discounts, and up to 35 percent off food
purchases under certain terms and conditions. Regular monthly fees apply. With 653 Jenny Craig Centres throughout the
Unified States members have wnvenient access to Jenny Crai~ Centres, or can join Jenny Direct, the at-home program.
Members can register for discounts online through BlueAccess for Members or present their BCBSTX ID cards at
participating Centres. To locate the nearest Centre, members can visit the Jenny Craig Web site at www.jennycraig.com
or call (800) 597Jenny. Franchise participation and discounts may vary, so members are encouraged to verify their
discounts before joining.
Curves®"'
Curves is the largest fitness franchise in the world with over 10,000 locations worldwide. It is the first fitness and weight
loss facility to target women and provide them affordable, one-stop exercise and nutritional information. BCBSTX
members and their covered dependents can join Curves for a special $49.00 joining fee. Regular monthly fees appy. To
join, members will simply present their BCBSTX ID cards at Curves fdness centers. To locate the nearest fitness center,
members can visit www.curves.com or call (800) CURVES-30. Franchise paticpation and discounts may vary, so
members are encouraged to verify their discounts before joining.
Complementary AltemaWe Medicine
The Complementary Alternative Medicine program through Healthways VyholeHeaith Networks, Inc. provides BCBSTX
members access to the Healthways network of more than 35,000 practitioners, spa, wellness and fitness centers.
BCBSTX members receive discounts of up to 30% off services such as yoga, Pilates, massage therapy, acupuncture,
Thai Chi, and nutritional counseling. The program also includes discounts to spas, and wellness and fitness centers such
as Gold's Gym, Lifetime Fitness, and Anytime FRness.
Additionalry, BCBSTX members have access to up to 25 percent off the regular price for purchase of vitamins and herbal
supplements; and discounts of 50 to 80% on health and wellness-related magazines. For additional information, or to find
locations nearest them, members can log on to wholehealthmd.com or to order vitamins and magazines, log into BAM at
www bcbstx corn/member and visit the BlueExtras Discount Program under the My Coverage tab.
Rates
- The rates provided in this renewal are effective for the 12-month period beginning November 1, 2009.
- These rates are subject to the terms and conditions of the applicable group agreement, contract, schedule of
coverage, schedule of specifications, or schedule of benefits.
Please advise your agent and/or BCBSTX of your renewal decision at least 15 days prior to your anniversary
date.
Additional Information and Reminders
Texas legislation mandates an annual open enrollment period. This means your annual open enrollment for all eligible
employees and their dependents must be at least 31 days long and prior to your anniversary date. It Ls imperative that
you submit all enrollmeni applications and change forms during this open enrollment period. Enrollment updates received
after your anniversary date will be considered late. The next eligibility window will occur at your group's open enrollment
the next year.
The Health Insurance PoKabilHy and Accountability Act of t986 (HIPAA) became effective 07/01197 and was
modified 07/01/05. HIPAA continues to affect all individuals eligible to enroll for coverage under your plan. A requirement
of this bill is to provide a General Notice of Enrollment Rights and Pre-existing Condition Exclusions. This notice is
directly related to Empbyer Groups and is required by HIPAA and does not necessariry reflect the rules mandated by
House Bill 1212 (Texas Legislation). A copy of the HIPAA Notice has been included with your renewal for use in
distribution.
Please copy and disbibute this General Notice of Enrollment Rights directly to aff of your emobvees as soon as
possible. This new notice must also be given to each new employee prior to enrollment in or declination of health
coverage.
The Employee Retirement Inwme Security Act of 1974 (FRIBA) is a federal law that sets minimum standards for
employee benefit plans in the private industry. ERISA status is important in determining whether state laws appty to a
benefd plan, and is also important for tax and reporting purposes. BCBSTX requires written documentation including
signature of your group n:presentative concerning your ERISA exemption status. Please contact your broker or BCBSTX
account executive to report changes in your ERISA status or to confine you have previously reported your ERISA status.
- Please seethe attached ASO Exhibit for the Medical renewal retes.
If you have any questions regarding the information provided In this letter, any of the enclosed documents, or woukf like
alternate plans quoted, please do not hesitate to contact your agent. We appreciate the opportunity to provide your
benefits program and we value the partnership we have built with the City of Port Arthur and look forward to continuing
our relationship.
Sincerely,
Blue Cross Blue Shield of Texas
Teny Villiva, MHP
Account Executive
Phone: 409-896-0104
Fax: 409-896-0111
Email: Te~VillivaCrDbcbstx.com
TV:mj
Endosures
cc_ Mickey Moshier
r
EXHIBIT "D"
ASO
Benefit Program Application ("ASO BPA")
Application to Administrative Services Only (ASO) Group Accounts
Administered by Blue Cross and Blue Shield of Texas, a division of Health Care Services Corporation,
A Mutual Legal Reserve Company, hereinafter referred to as the "Claim Administrator' or "HCSC"
Group Status: Renewing ASO Account Off Cycle Change: ^Yes ®No
Employer Account Number (6-digits): 031118 Group Number(s): Section Number(s):
031118,031120 0007,0002,0009,9900
Legal Employer Name: City of Port Arthur
(Specify the employer or the employee trust applying for coverage. AN EMPLOYEE BENEFIT PLAN MAY NOT BE NAMED)
Employer Identification Number: 74-6001885 SIC: 9199 Public Entity? ®Yes ^ No
Primary Address: P. O. Box 1089
City: Port Arthur State: Texas Zip: 77641 Administrative Contact: Patricia Davis
Title: Sr. HR Analyst Phone Number: 409- Fax Number: 409-983- Email Address:
983-8214 8282 padavis@portarthur.net
Physical Address (if different from Primary -required): 444 4th Street
City: Port Arthur State: Texas Zip: 77640
Billing Address: P. O. Box 1089
City: Port Arthur State: Texas Zip: 77641 Billing Contact: Patricia Davis
Title: Sr. HR Analyst Phone Number: 409- Fax Number: 409-983- Email Address:
983-8214 8282 padavis@portarthur.net
Subsidiary Companies: N/A Subsidiary Address: NIA
City: N/A State: NIA Zip: N/A
Administrative Contact: N/A Title: N/A
Phone Number: N/A Fax Number: N/A Email Address: NIA
Blue Access for Employers (BAE) Contact: Patricia Davis
(The BAE Contact is the Employee of the account authorized by the Employer to access and maintain its account via
BAE. )
Title: Sr. HR Analyst Phone Number: 409- Fax Number: 409- Email Address: padavis@portarthur.net
983-8214 983-8282
Affiliated Companies: N/A Location(s): N/A
ERISA Plan: ^Yes ®No If yes, specify ERISA Plan Year: N/A (mmldd/yy)
ERISA Plan Administrator: NIA Plan Administrator's Address: N/A
Effective Date of Coverage: 11-01-2009 Anniversary Date (AD): 11/01 Nature of Business: City Government
Effective: 11/01/2008
If applicable, the below-named agent(s)or agency(ies) is/are recognized as Employer's Agent of Record (AOR) to act
as representative in negotiations with and to receive commissions from Blue Cross and Blue Shield of Texas, a
division of Health Care Service Corporation (HCSC), a Mutual Legal Reserve Company, and HCSC subsidiaries for
Employer's employee benefit programs. This statement rescinds any and all previous AOR appointments for
Employer. The AOR is authorized to perform membership transactions on behalf of Employer. This appointment will
remain in effect until withdrawn or superseded in writing by Employer.
1. `Agent(s) or Agency(ies) to whom commissions are to be paid: Note: Agent of Record Only - No commissions
are paid on this Account - Sherlock Insurance Agency, Inc.
Tax ID Number (TIN) of ^ Agent or ® Agency: 760236574 Producer #:
Agency Address: Street:4155 Phelan City: Beaumont, Texas Zip: 77707
hcsc tx gen aso bpa 060309 (on-line version) 1
Phone: 409-832-7736 Fax: 409-833-1721 Email: mickey@edwardsandsherlock.com
Is AgenUAgency appointed with BCBSTX? ® Yes ^ No General Agent? ^Yes ®No
Affiliated with General Agent? ^Yes ®No
2. 'Agent(s) or Agency(ies)" to whom commissions are to be paid:
Tax ID Number (TIN) of ^ Agent or ^ Agency: Producer #:
Agency Address: Street: City: Zip:
Phone: Fax: Email:
Is AgenUAgency appointed with BCBSTX? ^ Yes ^ No General Agent? ^Yes ^ No
Affiliated with General Agent? ^Yes ^ No
If commission split, designate percentage for each age oU AgenUAgency 1: % AgenUAgency 2:
agency. Note: total commissions paid must equal 100 /o
3. Multiple Location Agency(ies): If servicing agency is not listed above as Item 1 or 2, specify location below:
' The agent or agency name(s) above to whom commissions are to be paid must exactly match the name(s) on the appointment
application(s).
"* If commissions are split, please provide the information requested above on both agents/agencies. BOTH must be appointed to do
business with BCBSTX.
1. Eligible Person means:
® A full-time employee of the Employer.
^ A full-time employee who is a member of:
(name of union)
^ Apart-time employee of the Employer.
® A retiree of the Employer.
^ Other:
Are any classes of employees to be excluded from coverage? ®Yes ^ No
If yes, please identify the classes and describe the exclusion: Part-time, temporary and seasonal
2. Full-Time Employee means:
® A person who is regularly scheduled to work a minimum of 30 hours per week and who is on the permanent
payroll of the Employer.
^ Other:
3. Domestic Partners covered: ^Yes ®No
!f yes: A Domestic Partner, as defined in the Plan, shall be considered eligible /or coverage. The Employer is responsible for
providing notice of possible tax implications to those Covered Employees with Domestic Partners.
If yes, are Domestic Partners eligible to continue coverage under COBRA? ^Yes ^ No
If yes, are dependents of Domestic Partners eligible far coverage? ^Yes ^ No
4. Are unmarried children of any age who are medicall~certified as disabled and dependent on the employee for support
and maintenance eligible for coverage? ®Yes No
Are unmarried children over the limiting age who are medically certified as disabled and dependent on the employee
for support and maintenance eligible for coverage under the plan if they were not covered under the plan prior to
reaching the limiting age? ^Yes ®No
5. Are unmarried step-children under the limiting age eligible for coverage? ®Yes ^ No
If yes, is residency with the employee required? ^Yes ®No
6. Are unmarried grandchildren eligible for coverage? ®Yes ^ No
If yes, must the grandchild be dependent on the employee for federal income tax purposes at the time application is
made? ®Yes ^ No
7. The effective date for a newly eligible person who becomes effective after the employer's initial enrollment date:
^ The date of employment.
hcsc tx gen aso bpa 060309 (on-line version) 2
^ The day of employment
^ The day of the month following _ month(s) or days of employment.
^ The day of the month following the date of employment.
® Other: Civil Service employees - effective 1st of the month following the date of employment;
All other employees -effective 1st of the month following 180 days of employment.
Is the waiting period requirement to be waived on initial group enrollment? ^Yes ®No
Are there multiple new hire waiting periods? ®Yes ^ No
If yes, please attach eligibility and contribution details for each section.
8. The Effective Date of termination for a person who ceases to meet the definition of Eligible Person:
^ The date such person ceases to meet the definition of Eligible Person.
® The last day of the calendar month in which such person ceases to meet the definition of an Eligible Person.
^ Other:
9. Limiting Age for covered unmarried children:
® The limiting age for covered unmarried children is 25.
^ The limiting age for covered unmarried children is ;age if a full-time student.
^ Other:
Student certification: ^ Account or ^ BCBSTX or ®None
Frequency of Certification Letters: Annually (AN) ^ Quarterly (QU) ^ Semi-Annually (SA) ^
Certification Schedule: Month 1: Month 2: Month 3 Month 4:
` For Annual Notifcation, indicate one month (Jan-Dec) for notification, for Semi-annual, select 2 months, for
quarterly, select 4 months
Automatically cancel dependents who reach the maximum limiting age? ®Yes ^ No
10. Termination of coverage upon reaching the Limiting Age:
^ Coverage is terminated on the birthday.
^ Coverage is terminated on the last day of the month in which the limiting age is reached.
® Coverage is terminated on the last day of the billing month.
^ Coverage is terminated on the last day of the year (12!31) in which the limiting age is reached.
^ Coverage is terminated on the group's Anniversary Date.
Will coverage for a child who is medically certified as disabled and dependent on the parent terminate upon reaching
the limiting age even if the child continues to be both disabled and dependent on the parent? ^Yes ®No
11. Enrollment:
Special Enrollment: An Eligible Person may apply for coverage, Family coverage or add dependents within thirty-one
(31) days of a qualifying event if he/she did not apply prior to his/her Eligibility Date or when eligible to do so. Such
person's Coverage Date, Family Coverage Date, and/or dependent's Coverage Date will be the effective date of the
qualifying event or, in the event of Special Enrollment due to termination of previous coverage, the first day of the Plan
Month following receipt of the application.
Late Enrollment: An Eligible Person may apply for coverage, Family coverage or add dependents if he/she did not
apply prior to his/her Eligibility Date or did not apply when eligible to do so. Such person's Coverage Date, Family
Coverage Date, and/or dependent's Coverage Date will be a date mutually agreed to by the Claim Administrator and
the Employer.
An Eligible Person may apply for coverage, Family coverage or add dependents if he/she did not apply prior to his/her
Eligibility Date or did not apply when eligible to do so, during the Employer's Open Enrollment Period. Such person's
Coverage Date, Family Coverage Date, and/or dependent's Coverage Date will be a date mutually agreed to by the
Claim Administrator and the Employer. Such date shall be subsequent to the Open Enrollment Period.
Late applicant enrollment options:
® Annual open enrollment -late applicant may apply during open enrollment and be subject to a 12-month pre-
existing waiting period (credit will always be applied).
^ No Annual Open Enrollment -late applicants are never eligible for coverage (dental only).
^ Annual open enrollment - no preexisting waiting period.
^ Late applicants may apply at any time -coverage is effective first of the month following receipt of the application.
An 18-month pre-existing waiting period applies.
Specify Open Enrollment Period: 10/01 - 10/31
12. Pre-existing waiting period (applies to the account's initial enrollment):
hcsc tx gen aso bpa 060309 (on-line version)
^ No pre-existing waiting period.
® Pre-existing applies to all participants.
^ Pre-existing is waived on the account's initial enrollment. All others must serve pre-existing waiting period.
Benefits for treatment incurred during the 6 months prior to the effective date of membership will not be covered
for 12 months after the effective date.
13. Extension of benefits due to Temporary Layoff, Disability or Leave of Absence:
Temporary Layoff: N1A days Disability: N/A days Leave of Absence: N/A days
However, benefits shall be extended for the duration of an Eligible Person's leave in accordance with any applicable
federal or state law.
14. COBRA Auto Cancel? ®Yes ^ No
Member's COBRA/Continuation of Coverage will be automatically cancelled at the end of the member's eligibility
period.
15. Eligibility reporting method (applies to initial enrollment):
® Account will self-enroll online through BlueAccess for Employers.
^ Members will self~nroll online through BlueAccess for Members.
^ BCBSTX will enter enrollment online through BlueAccess for Employers.
^ BCBSTX will enter enrollment via paper applications.
^ BCBSTX will enter enrollment from membership spreadsheet.
^ BCBSTX will process enrollment via Automated Eligibility Process (AEP).
2. Total number of employees serving new hire eligibility period: NIA -RENEWING ACCOUNT
3. Total number of employees with other coverage (i.e., other group coverage, Medicare, Medicaid,
TRICAREIChampus): N/A -RENEWING ACCOUNT
4. Total number of individuals currently covered under COBRA:
• Copy of client's application to CMS for exemption
• Copy of client's notice of such exemption to plan participants
Indicate Opting out of:
^ Limitations on pre-existing condition exclusion period, excluding maternity NOTE: ISDs may not opt out
^ Limitations on pre-existing condition exclusion period, including maternity NOTE: ISDs may not opt out
^ Special enrollment periods for individuals losing other coverage
^ Prohibits discriminating against individual participants and beneficiaries based on health status
^ Maternity hospital stay standards relating to mothers and their newborns
^ Parity in the application of certain limits to mental health benefits
^ Mandated reconstructive surgery benefits following mastectomy
hcsc tx gen aso 6pa 060309 (on-line version)
1. Total number of employees presently eligible for coverage: N/A -RENEWING ACCOUNT
Certain non-federal governmental ASO plans may elect to be exempted from some or a!! of the group market provisions
in the HIPAA regulations. Such clients must apply for exemption, in writing with the Centers for Medicaid & Medicare
Services (CMS). If exempt, please provide the following: (Documents attached? ^Yes ^ No)
^ Underwrite for an AD effective date
^ Underwrite for an effective date the next service date following approval
^ No underwriting; effective on AD
^ Annual open enrollment; late applicants may apply and be subject to 18 months
® Managed Health Care Coverage
® PPO
^ Dual Option
High Plan Name:
Low Plan Name:_
^ Annual Max
^ Consumer Driven Health Plan
(BlueEdge)
^ Traditional coverage
® Prescription Drug Coverage:
® Comprehensive Dental Coverage
^ Comprehensive Vision Coverage
^ In-Hospital Indemnity (IHI)
^ HCA
^ HSA
^ Out-of-Area (Indemnity)
^ Benefit Offering
® Prescription Drug Program
^ Stand-Alone Prescription Drug Program
exclusion
^ EPO
^ POS
^ HMO
^ with Drug coverage
^ without Drug coverage
® PPO Provider Network: ®BlueChoice (PTXOA)
^ BlueChoice Solutions (PSNOA)
^ Dual Network Option (both BlueChoice and BlueChoice Solutions)
^ Healthcare Management Services: For BCBSTX Members: For Non-BCBSTX Members only:
^ Wellness Incentives
^ Blue Care Connection ^ Personal Health Manager (Stand-alone)
^ Special Beginnings only ^ Health Risk Assessment (Stand-alone)
^ BlueEdge HCA (Stand-alone)
COMMENTS: Dental is Fully Insured under Group Number 031120
PPO (ASO) Sections:
0007 -Active Employees
0008 -Retirees without Medicare
0009 -Retirees with Medicare
9900 Cobra Admin
hcsc tx gen aso bpa 060309 (on-line version)
Note: no creditable coverage applies if opting out. Pre-existing applies, including maternity
FINANCIAL DOCUMENT ADMINISTRATION
FEE SCHEDULE
To begin on Effective Date of Coverage and continue fr
®12 Months ^ Other: Months
1. Type:
® Medical
^ Medical 1 Dental
^ Other:
2. Administrative Charge Chart for Single Year Contract:
11/1/09 11/1/09 11/1/10 11/1/10
Product I Service Employe Employe Employe Employe
e Onl a Famil a Onl a Famil
Base Administrative Charge<'> (Medical) $28.46 $79.69 $30.11 $84.29
Prescription Drug Administrative Charge $ $ $ $
Prescription Drug Rebate Credit per Covered Employee per month
is the guaranteed Prescription Drug Rebate savings reflected as a
Prescription Drug Rebate credit. Expected rebate amounts to be
received by the Claim Administrator are passed back to the
Employer with one hundred percent (100%) of the expected amount
applied as a credit on the monthly billing statement on a per $To be $To be
Covered Employee per month basis. Rebate credits are paid $(7.60) $(21.29) determin determin
prospectively to the Employer and shall not continue after ed ed
termination of the Prescription Drug Program. (Further information
concerning this credit is included in the governing Administrative
Services Agreement to which this ASO BPA is attached under the
section titled "CLAIM ADMINISTRATOR'S SEPARATE FINANCIAL
ARRANGEMENTS WITH PHARMACY BENEFIT MANAGERS.°)
Blue Care Connection ("BCC") Program: Select from Pull Down
$ $ $ $
Special Beginnings $ $ $ $
Other: $ $ $ $
Other: $ $ $ $
Other: $ $ $ $
$To be $To be
Total $20.86 $58.40 determin determin
ed ed
Additional Comments: None
Dental: $ $ $ S
3. Termination Administrative Charge for Single Year Contract:
The Termination Administrative Charge applicable to [he Run-Off Period shall be equal to [he sum of the amounts obtained
by multiplying the total number of Covered Employees by category (per Covered Employee per individual or family
hcsc be gen aso bpa 060309 (on-line version) 6
composite)during the three (3) months immediately preceding the date of termination by the appropriate factors shown
below.
Service 11/1/0 11/1/10 11/1/1
9 11/1/09 Em l0
p y 0
Emplo Employ ee Only Emplo
yee ee
Family yee
onl Famil
Medical Run-off Administration Charge $16.20 $45.35 $17.86 $50.00
Other: $ $ $ $
Dental Run-off Administration Charge $ $ $ $
Additional Comments: None
Dental: $ $ $ $ $ $
4. BlueCard Program/Network access fee: $ (Available upon request)
1. Benefit booklets - Is BCBSTX providing benefit booklets? ®Yes ^ No
®Standard benefit booklet (no additional charge)
^ Customized benefit booklets ^ No additional charge
^ Supplemental Billing**
^ Customized booklet covers* ^ No additional charge
^ Supplemental Billing**
^ ERISA plan information ^ No additional charge
^ Supplemental Billing**
2. SubscriberlD cards
® Standard subscriber ID cards (no additional charge)
^ Customized ID card services ^ No additional charge
^ Supplemental Billing*`
3. Network provider directories ®No additional charge
^ Supplemental Billing**
4. Subscriber claim forms, enrollment forms, enrollment materials ®No additional charge
^ Supplemental Billing**
5. Special mailings
Provider directories to be mailed to home addresses: ^Yes ®No ^ Cost included in admin charge
^ Supplemental Billing**
6. Other: N/A Additional charge: $N/A
* Custom booklet covers are not available on electronic documents.
**As indicated in fee table on previous page.
hcsc tz gen aso bpa 060309 (on-line version)
5. Reimbursement Provision: ®Yes ^ No
If yes: It is understood and agreed that in the event the Claim Administrator makes a recovery on a third-party liability
hcsc be gen aso bpa 060309 (on-line version)
Run-Off Period: Transfer Payments are to be made for twelve (12) months following the end of the Fee Schedule Period.
Final Settlement: Final Settlement to be made within (60) days after end of Run-Off Period.
BROKERICONSULTANT COMPENSATION
The Employer acknowledges that if any broker/consultant acts on its behalf for purposes of purchasing services in
connection with the Employer's Plan under the Administrative Services Agreement to which this ASO BPA is attached, the
Claim Administrator may pay the Employer's broker/consultant a commission and/or other compensation in connection
with such services under the Agreement. If the Employer desires additional information regarding commissions and/or
other compensation paid the broker/consultant by the Claim Administrator in connection with services under the
Agreement, the Employer should contact its broker/consultant.
nw~. ~.varcH AumIrvIJ l KA I IVt SERVICES
HCSC COBRA Administrative Services Purchased: ®Yes ^ No
If yes, please complete the COBRA sections below. If no, the COBRA sections below do not apply.
•:
/1 • ~ ~~• • •• •
COBRA Administrative Billing Services Only: ^Yes ®No
COBRA Administrative Full Services: ®Yes ^ No
Notification Services included: (Full Services) ®Yes ^ No
Conversion Rights included: (Full Services) ®Yes ^ No
Monthly Reports` included: ®Yes ^ No if Yes: Email Address: PADAVIS@PORTARTHUR.NET
`Paper reports provided by mail/electronic reports via email
Effective date(s) of services if different from ASO Effective Date of Coverage: 1/1/1987
•: ..
Billing Services Fee per Participant per month: $GRANDFATHERED PRICING
If Not cation Services included(Fuli Services)
Notification Fee [per Participant, per notifcation]: $GRANDFATHERED PRICING
Monthly Administrative Fee: $GRANDFATHERED PRICING
The Employer will pay HCSC a sum of One Hundred Dollars ($100.00) per hour far any system programming costs associated with non-standard
administration services.
hcsc tx gen aso bpa 060309 (on-line version)
.-
Number of Active Members':833
Number of current COBRA participants/members':1
Number of current COBRA retiree participants/members':0
`Ful! Service Unit (FSU) set-up of paRicipantsimem6ers in BlueStarmquired
FSU Location: San Angelo
FSU Contact: Email Address:
Is all COBRA participant census information attached?^ Yes ®No
Is all COBRA participant coverages) and level elected information attached?^ Yes ®No
Is all dependent census information attached?^ Yes ®No
•
Are rates (SINGLE/FAMILY or TIERED) for all coverages attached? ^Yes ®No
Is 2% included in attached rates? ^Yes ^ No
Does Employer have any non-HCSC coverage? ^Yes ®No
If Yes, Other Carrier(s):
Name:
Address: Email Address:
City: State: Zip:
Administrative Contact: Phone Number: Fax Number:
Name:
Address: Email Address:
City: State: Zip:
Administrative Contact: Phone Number: Fax Number:
COBRA coverage begins: ®On date of Qualifying Event ^ First of month following date of Qualifying Event
Should 150% of the COBRA premium be charged to participants eligible for disability extension for the remaining 11
months of COBRA? ®Yes ^ NO (Eztension is from Z8 months to 29 months when deemed disabled by Socia! Secuhty)
Is contract provided and signed? ^Yes ®No
Prior COBRA administrator info:
Name:
Address: Email Address:
City: State: Zip:
Administrative Contact: Phone Number: Fax Number:
hcsc tx gen aso bpa 060309 (on-line version) 10
1. Certificate of Creditable Coverage: ®Yes ^ No
!f yes: The Employer directs the Claim Administrator fo issue to individuals, whose coverage under the Plan terminates
during the term of the Administrative Services Agreement to which this ASO BPA is attached, a Certificate of
Creditable Coverage. The Certificate of Creditable Coverage shall be based upon information required for issuance
of a Certificate of Creditable Coverage to be provided to the Claim Administrator by the Employer and coverage
under the Plan during the term of the Administrative Services Agreement.
2. Stop Loss Coverage purchased: ®Yes ^ No (If yes, complete separate Stop Loss exhibit)
3. Fort Dearborn Life Insurance purchased: ®Yes ^ No (If yes, complete separate application)
4. Health Care Account (HCA) Administrative Services purchased: ^Yes ®No
5. Employer contribution. The percentage of premium to be paid by the employer is:
Emp: 100% g Dep: % S ~ Emp: 100%
Dep:
6. This ASO Benefit Program Application (ASO BPA) is incorporated into and made a part of the Administrative
Services Agreement with both such documents to be referred to collectively as the "Agreement" unless specified
otherwise.
ADDITIONAL PROVISIONS:
hcsc tx gen aso bpa 060309 (on-line version) 11
I UNDERSTAND AND AGREE THAT:
1. The proposed fees are effective for 12 months, subject to contract provisions, and are based on the information and
conditions stated. Final fees are subject to review based on actual enrollment results. If there is a 10% or greater
variance in the enrollment and/or less than the minimum enrollment requirement of N/A -RENEWING ACCOUNT,
BCBSTX reserves the right to review the final fees. The information provided in this application is complete and
accurate to the best of my knowledge. If this information is incomplete or inaccurate, BCBSTX may rerate the plan,
withdraw the proposal or cancel the contract.
2. No material changes have been made to the claims experience previously provided. ^Yes ®No If changes
have been made, please complete and attach the account experience addendum.
3. No material changes have been made to the previously provided location(s) of eligible employees? ^Yes ®No If
changes have been made, please attach new census.
4. Receipt by BCBSTX of the advance administrative fee (where applicable), in the amount of $N/A -RENEWING
ACCOUNT, and completed enrollment forms does not constitute approval and acceptance by the BCBSTX Home
Office.
5. If applicable, effective 11/01/08, the above-named agent(s)or agency(ies) is/are recognized as Employer's Agent of
Record (AOR), to act as representative in negotiations with and to receive commissions from Blue Cross and Blue
Shield of Texas, a division of Health Care Service Corporation (HCSC), a Mutual Legal Reserve Company, and
HCSC subsidiaries for our employee benefit programs. This statement rescinds any and all previous Agent of Record
appointments for this company. The above named agent(s) or agency(ies) is authorized to pertorm membership
transactions on behalf of the Employer. This appointment will remain in effect until withdrawn or superseded in writing
by our company.
6. AgenUBroker 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)/Policy(ies), this Beneft
Program Application or enrollment material in any manner or to adjust any claims for benefits under the
Contract(s)IPolicy(ies).
7. BCBSTX will report the value of all remuneration by BCBSTX 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.
Terry Villiva
Authorized BCBSTX Representative
Account Executive 7/g/Og
Title Date
409-896-0104-Phone 409-896-0111-Fax
BCBSTX Telelphone and Fax numbers
Agent Representative (if applicable)
Telephone and FAX numbers
Signature of Authorized Purchaser
hcsc tx gen aso bpa 060309 (on-line version) tp
PROXY
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.
Group No.: 031118 BY
~-
Print Signer's Name Here
Signature and Title
Group Name: City of Port Arthur
Address: P. O. Box 1089
City: Port Arthur
State: Texas Zip Code: 77641
Dated this day of 2009
Month Year
hcsc tx gen aso bpa 060309 (on-line version) 13
BlueCross BlueShield
~~~ \ ,~/ of Texas
APPLICATION FOR STOP LOSS COVERAGE
(ASO Accounts Only)
Employer Group Name: City of Port Arthur
Employer Group Address: P. O. Box t 089
City: Port Arthur State of Situs :Texas Zip Code: 77641
Account Number: 031118
Employer Group Number(s): 031 t 18
Effective Date of Policy 11/01/2009
Policy Period: These specifications are far the Policy Period commencing on 1 ]/01/2009 and ending on 10/31/2010
The specifications below shall become effective on the first day of the Policy Period specified above and shall continue in
full force and effect until the earliest of the following dates: (1) The last day of the Policy Period; (2) The date the Policy
terminates; or (3) The date this Application for Stop Loss Coverage (herein called the "Application") is superseded in
whole or in part by a later executed Application.
A. Aggregate Stop Loss Insurance: ®Yes ^ No
If yes, complete items 1 through 9 below.
1. ^ New Coverage ®Renewal of Existing Coverage
2. Stop Loss Coverage Period:
^ New Coverage (Select one from below):
^ Standard: Claims incurred and paid during the Policy Period.
^ "Run-in" included: Claims incurred on or after and paid during the Policy Period.
"Run-in" includes claims paid by Policyholder's prior claim administrator: Yes ^ No ^
If yes, such claims must be reported by the Policyholder to the Company (Blue Cross and Blue Shield of
Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company) within 12
months of the Policy Effective Date and paid by the Policyholder's prior claim administrator within 6
months after the Policy Effective Date.
® Renewal of Existing Coverage:
Claims incurred on or after the original Effective Date of Policy and paid during the Policy Period.
3. Aggregate Stop Loss Insurance shall apply to:
® Medical Claims
® Outpatient Prescription Drug Claims
^ Dental Claims
^ Other (please specify):
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company
an Independent Licensee of the Blue Cross and Blue Shield Association
StopLOSSApp-0808 50554.0808
4. Average Claim Value: $648.64 (per employee)
Attachment Factor: 125% of the Average Claim Value
5. Aggregate Claim Liability and Run-Off Claim Liability Factors
a. Employer's Claim Liability for each Policy Period shall be the sum of the Monthly amounts obtained by
multiplying the number of Coverage Units for each Month by the following factors:
$461.19 -Active Employees; $201.54 -Medicare Retirees for each Employee Coverage Unit
$1,290.88 -Active Employees; $915.45 -Medicare Retirees for each Employee/Family Coverage Unit
Please use the continuous text field directly below for any other structure (leaving the fields above blank).
Note: you can use the "return"key to create additional rows, if needed.'
b. Employer's Run-Off Claim Liability shall be calculated by multiplying the sum average of the total of all
Coverage Units during each of the three calendar Months immediately preceding termination by the factors
shown below. Settlement for the final accounting period will be described in the section of the Policy entitled
SETTLEMENTS, Run-Off Period subsection of the Policy.
$178.53 -Active Employees; $78.02 -Medicare Retirees for each Employee Coverage Unit
$499.69 -Active Employees; $354.37 -Medicare Retirees for each Employee/Family Coverage Unit
Please use the continuous text field directly below for any other structure (leaving the fields above blank).
Note: you can use the "return"key to create additional rows, if needed:
6. CAP Arrangement ®Yes ^ No
7. Aggregate Stop Loss Coverage
The amount of Paid Claims during the current Policy Period (less Individual (Specific) Stop Loss Claims, if any)
that exceed the Point of Attachment. The Point of Attachment shall equal the sum of the Employer's Claim
Liability amounts calculated Monthly as described in Item 5.a. above for the indicated Policy Period.
In the event of termination at the end of a Policy Period, the Final Settlement Point of Attachment shall equal the
sum of the Employer's Claim Liability amount for the Final Policy Period and the Employer's Run-Off Claim
Liability calculated as described in item S.b. above. However, for the indicated Policy Period the minimum Point
of Attachment shall be $7,127,356. Aggregate Stop Loss coverage shall not exceed a maximum of $1,000,000
for the indicated Policy Period.
8. Premium (Select one):
^ Annual Premium (Due on the first day of the Policy Period): $
®Monthly Premium shall be equal to the amounts obtained by multiplying the number of Coverage Units for a
particular Month by
$2.30 for each Employee Coverage Unit
$6.44 for each Employee/Family Coverage Unit
Please use the continuous text field directly below for any other structure (leaving the fields above blank). Note:
you can use the "return" key to create additional rows, if needed:
StopLossApp-0808 2 50554.0808
9. The premium is based upon a current membership of 471 Individual Coverage Units and;4; Family Coverage
Units.
B. Individual (Specific) Stop Loss Insurance: ®Yes ^ No
If yes, complete items 1 through 6 below.
1. ^ New Coverage ®Renewal of Existing Coverage
2. Stop Loss Coverage Period:
^ New Coverage (Select one from below):
^ Standard: Claims incurred and paid during the Policy Period.
^ "Run-in" included: Claims incurred on or after and paid during the Policy Period
"Run-in' includes claims paid by Policyholder's prior claim administrator: Yes ^ No ^
If yes, such claims must be reported by the Policyholder to the Company (Blue Cross and Blue Shield of
Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company) within 12
months of the Policy Effective Date and paid by the Policyholder's prior claim administrator within 6
months after the Policy Effective Date.
® Renewal of Existing Coverage:
Claims incurred on or after the original Effective Date of Policy and paid during the Policy Period.
3. Individual (Specific) Stop Loss Insurance shall apply to:
® Medical Claims
® Outpatient Prescription Drug Claims
^ Dental Claims
^ Vision Claims
^ Other (please specify):
4. Individual (Specific) Stop Loss Coverage
For NIA who is identified by the health identification (ID) number N/A, the amount of Paid Claims during the
current Policy Period in excess of the Point of Attachment of $N/A. Such amount shall apply for the Policy
Period.
For each other Covered Person:
The amount of Paid Claims during the current Policy Period in excess of the Point of Attachment of $100,000
per Covered Person but not to exceed a maximum Point of Attachment of $900,000 per Policy Period. Such
amount shall apply for the Policy Period.
5. Premium (select one):
^ Annual Premium (Due on the first day of the Policy Period): $
®Monthly Premium shall be equal to the amounts obtained by multiplying the number of Coverage Units for a
particular Month by
X25.39 for each Emolovee Coveraqe Unit
X71.07 for each Emolovee/Family Coveraqe Unit
StopLossApp-0808 3 50554.0808
Please use the continuous text field directly below for anv other structure !leaving the fields above blank). Note:
you can use the "return"kev to create additional rows. if needed:
6. The premium is based upon a current membership of 471 Individual Coverage Units and 34; Family
Coverage Units.
Additional Provisions:
The undersigned person represents that he/she is authorized and responsible for purchasing stop loss coverage on behalf
of the Employer Group. It is understood that the actual terms and conditions of coverage are those contained in the Stop
Loss Coverage Policy into which this Application shall be incorporated at the time of acceptance by Blue Cross and Blue
Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company ("HCSC"). Upon
acceptance, HCSC shall issue a Stop Loss Coverage Policy and/or a new Application to the Employer Group. Upon
acceptance of this Application and issuance of the Stop Loss Coverage Policy, the Employer Group shall be referred to as
the "Policyholder."
Terry Villiva
Sales Representative
Authorized Purchaser
James Juroch
Name of Underwriter
Title of Authorized Purchaser
Date
INTERNAL USE ONLY Date A lication a roved b Underwritin
StopLossApp-0808 4 50554.0808
PPO-ASO-Standard-with Network Deductible BlueCroesBlueS6ield
of 7~xas
BENEFIT HIGHLIGHTS Prepared
for City of Port Arthur- Effective ®BlueChoice Network
11-1-09 ^SlueChoice Solutions Network
This is a general summary of your benefits. Please refer fo your bene(rt booklet /or addRional details and a description of the plan requirements and benefit design. This plan does not
cover all health care expenses. Upon receipt o/irour bene(rf booklet carekrly review the plan's limitations and exclusions.
Deductibles
Per-admission Deductible None $200
Calendar Year Deductible $5001ndividual/ $1,000lndividua!/
Applies to all Eligible Expenses except Inpatient Hospital Expenses (unless $1,500 Family $3000 Family
otherwise indicated)
Three-month Deductiblecanyoverapplies ®Yesr~No ®Yesr~No
Deductible credit from orior canier (Aoolied on initial arouo enrollment onlvl N/A N/A
Coshare Stoploss Maximum
Deductibles are not applied to the Coshare Stoploss Maximum. Copayment
Amounts are applied bu[ will continue to be required after the benefit
percentages increase to 100%. Your beneft booklet will provide more details.
$2, 500lndividual /
$5,000 Family
Network Deductible &Coshare
Stoploss will only apply toward
Network Deductible 6 Coshare
Stoploss Maximum
Credit for Coshare Stoploss Maximum from prior carrier (Applied on initial
group enrollment only)
N/A
$8,000 l ndividual l
$9,000 Family
Out-0f-Network Deductible 8 Coshare
Stoploss will also apply toward
Network Deductible 8 Coshare
Stoploss Maximum
Copayment Amounts Required
Physician office visitlconsultation $25 Copayment Amount
Re/er to Medical/Surgical Expenses section for more information
Outpatient Hospital Emergency Room/Treatment Room visit $100 Copayment Amount $100 Copayment Amount
Refer to Emergency Room/rreatmenf Room section /or more information
Maximum Lifetime Benefits
Per Partidpanf $1,000,000'
.. . . .-
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 aRer per-
care, and coronary care units admission Deductible
Penalty forfailure to preauthorize services None $250
' BenefAS used In-Network and Out-0f-Network vnll apply toward satisfying any Calentlar Year, Plan Year, Annual Maximum, or Maximum Lifetime tx;nefits indicated
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
151+ business-PPO-A50-Standard-with Nehvnrk Deductible (Rev. ti/t4/09) Page f o/ 6
PPO-ASO-Standard-with Network Deductible
Medical /Surgical Expenses
BlueLy'oesBlueShield
of'I~xas
Services performed during the Physician's office visit/consultation, 100% ofAllowable Amount affer $25 70%of Allowable Amount after
including lab & x-ray Copayment Amount Calendar Vear Deductible
(does not include Certain Diagnostic Procedures and surgical services)
Lab 8 x-ray in other outpatient facilities (excluding Certain Diagnostic 100%ofAllowable Amount 70% ofAllowable Amount affer
Procedures) Calendar Year Deductible
-Physician surgical services pedormed in any setting 80%ofAllowable Amount affer 60%ofAllowable Amount after
Calendar Year Deductible Calendar Year Deductible
-Physician inpatient hospital visits 80%ofAllowable Amount affer 60% ofAllowable Amount affer
Calendar Year Deductible Calendar YearDeducfible
-Certain Diagnostic Procedures; such as Bone Scan, Cardiac Stress Test, 80%ofAllowable Amount affer 60%ofAllowable Amount after
CT -Scan (with or without contrast), Ultrasound, MRI, Myelogram, PET Calendar Year Deductible Calendar Year Deductible
Scan.
-Home Infusion Therapy (Services must be preaufhorized) 80%ofAllowable Amount after 60%ofAllowable Amount affer
Calendar Year Deductible Calendar Year Deductible
-All other outpatient services and supplies 80% of Allowable Amount after 60% oI Allowable Amount after
Calendar VearDeducfible Calendar Year Deductible
In Vitro Fertilization Services ®De cline
All services must be preaufhorized 100% ofAllowable Amount 70%ofAllowable Amount after
Calendar Year Deductible
Skilled Nursing Facility $f0,000CalendarYearmaximum' $7,000CalendarYearmaximum'
Home Health Care S10,000CalendarYearmaximum' $7,000CalendarYearmaximum"
Hospice Care $20,0001ifetimemaxtmum' $14,000 lifetime maximum'
Serious Mental Illness
Mental Health Care
Treatment of Chemical Dependency
Inpatient Services (All services must be preaufhorized)
-Hospital services (facility)
(Inpatient Chemical Dependency treatment must be provided in a 80% of Allowable Amount 60% ofAllowable Amount after per-
Chemical Dependency Treatment Center) admission Deductible
80%ofAllowable Amount after Calendar 60%ofAllowable Amount affer
-Ph sicianservices Year Deductible Calendar Year Deductible
Outpatient Services (All services must be preaufhorized)
-Services pedormed dudng Physician office visit/consultalion 100% of Allowable Amount affer $25 70% o/Allowable Amount affer
(does not include psychological testing) Copayment Amount Calendar Year Deductible
-All outpatient services and psychological testing 80%ofAllowable Amount after Calendar 60% ofAllowable Amount affer
Year Deductible Calendar Year Deductible
' Benefits used IMJetwork antl Oul-0f-Network will apply toward satisfying any Calendar Year, Plan Year, Annual Maximum, or Maximum Lifetime benefAs indicated
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Crass and Blue Shield Association
151+ business-PPO-ASOStandard-with Netuwrk Deductible (Rev. 6R4/09J Page 1 or 6
PPO-ASO-Standard-with Network Deductible BluecroesBluesmcad
of'I~xas
.- .-
Emergency Room?reatment Room
Accidental Injury & Emergency Care (within 48 hours)
-Facility charges 80% of Allowable Amount offer $100 Copayment Amount
(Copaymenf Amount waived if admitted, Inpatient Hospital Expenses will apply)
Non•Emergency Care (after 48 hours)
-Fadlity charges
-Physician
Ground and AirAmbulance Services
80% of Allowable Amount offer Calendar Year
80% of Allowable Amounf offer $100
Copayment Amount (Copayment
Amount waived rf admitted, Inpatient
Hospdal Expenses will apply)
60% of Allowable Amounf offer $100
Copaymenf Amount & Calendar Year
Deductible (CopaymentAmounf
waived if admitted, Inpatient Hospital
Expenses will apply)
80% of Allowable Amount after Calendar
60% of Allowable Amount after
Calendar Year Deductible
80% o(Allowable Amount offer Calendar Year Deductible
BenefAS used In-Network and Out-0l-Network wll apply toward satisfying any Calendar Year, Plan Year, Annual Maximum, or Mazimum Ldetime benefis indicated
A Division of Healih Care Service Corporation, a Mutual Legal Reserve Company, an Indepentlent Licensee of the Blue Cross and Blue Shield Association
751+ business-PPO-ASO-Standard-wdh Network Deductible (Rev. CJ24/09J Page 3 of 6
PPO-ASO-Standard-with Network Deductible BlueCroesBiueShield
of Tie~cae
.- .-
Preventive Care
Routine annual physical examinations,well-baby care exams, 100%ofAllowableAmountafter ,625 70%ofAllowable Amountaffer
immunizations for Participants 6 years of age & over, vision exams and Copaymenf Amount CalendarYear Deductible
hearing exams
Immunizations for Dependent children through the date of the child's 6" ~ 100% ofAllowable Amount ~ 100% ofAllowable Amount
Speech and Hearing Services
Services to restore loss of or correct an impaired speech or hearing
function
Hearing Aid Maximum
Physicai Medicine Services
Chiropractic Care-Offce Services
Calendar Year Maximum
Covered same as any othersickness Covered same as any othersickness
Hearing aids are subject fo a £1,000 maximum amount each 3frmonth period'
80%ofAllowable Amount afterCalendar I 50%ofAllowable Amount after
Year Deductible Calendar Year Deductible
All other Physical Medicine Services rendered by any other eligible Provider will
be allowed on the same basis as anv other sickness.
' Benefhs used In-NeNrork and Ou[-0f-Network will apply toward salsfying any Calendar Year, Plan Year, Annual Maximum, or Maximum Lrfetime 6eneftls indicated
A Division of Health Care Service Corporation, a Mutual legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Assodation
151+busir~ss-PPO-ASO-Standard-with Network Deductible (Rev. fv74Ng) Page 4 orb
PPO-ASO-Standard-with Network Deductible
BlueCroesBlueS6ield
of'I~xas
$10 Copeymerd Amount
Dadrrdibles do not a 1
Retail Pharmacies
(All Copayment Amounts are per 3(}day supply and will not apply to
Coshare Stoploss Maximum)
Generic Drug S10 Copayment Amount 80% of Allowable Amount minus
Copayment Amount
Preferred Brand Name Drug $30 Copayment Amount 80% of Allowable Amount minus
Copayment Amount
Non-Preferred Brand Name Drug $50 Copayment Amount 80% of Allowable Amount minus
Cooavment Amount
(All Copayment Amounts are per 30-0ay supply and will not apply to
Coshare Stoploss Maximum)
Generic Drug
Preferred Brand Name
S10 Copayment Amount
S30 Copayment Amount
Generic Incentive•Members electing to pumhase Preferred/Non-Preferred Brand Name Drugs when a Genedc equivalent is available, will be required fo pay
the difference between fhe cost of fhe Generic and Pre%rred/Non-Preferred Brend Name Dmg, plus the Prefered Brand Name CopaymentAmount.
" Three-month Deductible carryover does not apply to prescription drug deductible.
"' Each Participating Pharmacy that has contracted to provide vaccination services 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 (or benefits available for childhood immunizations.
YJie6etes Supplies are available underthe
sydnges necessary for seN-adminisfration,
protein; lancets arld lancet devices; biohai
Diebetlc Supplies irlrJude insulin end insu!m analog praparatlars, insulin
germs; all raquhad test stops and tablets which test forgfucose, ketones, arrd
felgency id1s; and oilier lnjectloil aids. All provisans of this porflar of the plan
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shieltl Association
151 * business-PPO-ASO-Standard-wdh Network Dedudi6le (Rev. 624/09) Page S of 6
VaeranetionsobtalnedtllroughPhannadea"' ~ ®Yesr~No
PPO-ASO-Standard-with Network Deductible BlueCroesBlueshield
of'I~xae
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 25.
• Unmanied grandchildren of the insured are covered if the grandchild is under 25 years of age and is daimed as a dependent by the insured for Federal
Income Tax purposes.
• Automatic coverage for newborns far 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 follovdng open enrollment pedod or special enrollment event.
Payments: Network providers agree to accept amounts negotiated with BCBSTX and are paid according to this BCBSTX-determined Allowable Amount. Covered
individuals are responsible for any required Deductibles, Coinsurance or Out-of-Pocket Amounts, and Copayments. Plan benefits paid to Outof-Network providers are
based on the BCBSTX-determined Allowable Amount. These providers may balance bill covered individuals for charges in excess of the BCBSTX Allowable Amount.
The covered individual will be responsible for charges in excess of the Allowable Amount in addition to any applicable Deductibles, Coinsurance or Out-0f-Pocket
Amounts, and Copayments. For cost savings information, refer to the section on ParPlan Providers and the definition of Allowable Amount in the benefit booklet.
Preexisting conditions are defned in the benefit booklet and are excluded for 12 months. Appropdate credit will be given for time served under Creditable Coverage
as defined under the law and shown in your benefit booklet.
Replacement of Medical Coverage: In compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the following provisions apply to
each eligible participant who has health coverage under the employer's plan immediately pdor to fhe effective date of the health contract between the employer and
BCBSTX (the contract date):
• Benefits for eligible ezpenses incuned for any service or supplies prior to the contract date, are not covered under the contract.
• Eligible expenses for services or supplies incuned on or after the effective date will be considered for benefits subject to all applicable contract provisions.
Members residing in other states may use that state's network through the BlueCard program. To locate a participating provider in your state, please contact
1-800-810-BLUE or visit our web site at ~nvw.bcbstx.com to use our Provider Finder° tool.
• RADIAL KERATOTOMY -COVERED
• LASIK -COVERED
• EFFECTNE 1111108, SERVICES, SUPPLIES ANDIOR PRESCRIPTION DRUGS FOR 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 NECESSRY. )
Group Executive Name and Title
(Please type or print)
Signature
Date
Agent of Record Name
(Please print or type)
BCBSTX Representative Name
(Please print or type)
Signature
Signature
Date
Uate
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Intlependent Licensee of the Blue Cross and 81ue Shield Association
161 business-PPO-ASO-Standard-with Network Deductible (Rev. 6'24/09) Page 6 of 6
PPO-ASO-Standard-with Network Deductible BlueCroesBluesweld
of'I~xas
BENEFIT HIGHLIGHTS Prepared
for City of Port Arthur- Effective ®BlueChoice Network
11-1-09 ^BlueChoice Solutions Network
This is a general summary of your benefits. Please refer fo your bene(A booklet for adddional details and a description of the plan requirements and benefd design. This plan does not
cover all health care expenses. Upon receipt of vour benefit booklet carerully review the plan's limitan'ons and exclusions.
Deductibles
Per-admission Deductible
Calendar Year Deductible
Applies to all Eligible Expenses except Inpatient Hospital Expenses (unless
otherwise indicated)
Three-month Deductible carryover applies
Deductible credit from prior carrier (Applied on initial arouo enrollment
Coshare Stoploss Maximum
Deductibles are not applied to the Coshare Stoploss Maximum. Copayment
Amounts are applied but will continue to be required after the benefit
percentages increase to 100%. Your benett booklet will provide more details.
Credit for Coshare Stoploss Maximum from prior carrier (Applied on initial
group enrollment only)
None
$5001ndividual /
$1,500 Family
®Yesrt]No
$2,500 Individual/
$5, 000 Family
Network Deductible 8 Coshare
Stoploss will onlyapply toward
Network Deductible 8 Coshare
Stoploss Maximum
N/A
$200
$1,000 Individual /
$3,000 Family
®Yes~No
$3,000 Individual /
$9,000 Family
Out-0f-Network Deductible 6 Coshare
Stoploss will also apply toward
Network Deductible 8 Coshare
Stoploss Maximum
Copayment Amounts Required
Physidan office visiUconsultation $25 Copayment Amount
Refer to Medical/Surgical Expenses section formore information
Outpatient Hospital Emergency Room/Treatment Room visit $100 Copayment Amount $100 Copayment Amount
Refer fo Emergency RooMrreatmenf Room section for more information
Maximum Lifetime Benefits
Per Padicipant $1,000,000'
~ ~ . .-
inpatient Hospital Expenses
A11 services must be preauthodzed
AA usual Hosprfal services and supplies, including semiprivate room, intensive 80%of Allowable Amount 60% of Allowable Amount aRer per-
care, and coronary care units admission Deductible
Penalty for failure to preauthorize services None $250
' 8enefts used In-Netwodc and Out-of-Network will apply toward satistying any Calendar Year, Plan Year, Annual Maximum, or Maximum L'detime benefits indicated
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Intlepentlent Licensee of the Blue Cross antl Blue Shield Association
151+business-PPO-ASO-Standard-with Network Deductible (Rev 624/09) Page 1 of 6
PPO-ASO-Standard-with Network Deductible
Medical /Surgical Expenses
SlueCroes B1ueShield
af'Iiexas
Services performed during the Physician's office visiUconsultation, 100%ofAllowable Amount affer $25 70% o/Allowable Amount after
including lab & x-ray Copayment Amount CalendarYear Deductible
(does not include Cedain Diagnostic Procedures and surgical services)
Lab & x-ray in other outpatient facilities (excluding Certain Diagnostic 100%ofAllowable Amount 70%ofAllowable Amount after
Procedures) Calendar Year Deductible
-Physician surgical services performed in any setting 80% ofAllowable Amount after 60%ofAllowable Amount after
Calendar Year Deductible Calendar Year Deductible
-Physician inpatient hospital visits 80%ofAllowable Amount aBer 60%ofAllowable Amount affer
Calendar Year Deductible Calendar Year Deductible
-Certain Diagnostic Procedures; such as Bone Scan, Cardiac Stress Test, 80%ofAllowable Amount aBer 60% ofAllowable Amount affer
CT -Scan (with or without contrast), Ultrasound, MRI, Myelogram, PET CalendarYear Deductible Calendar Year Deductible
Scan.
-Home Infusion Therapy (Services must be preauthorized) 80%ofAllowable Amount affer 60% ofAllowable Amounf after
Calendar Year Deductible Calendar Year Deductible
-All other outpatient services and supplies 80%ofAllowable Amount aBer 60%ofAllowable Amount after
Calendar Year Deductible Calendar YearDeducfible
In Vitro Fertilization Services ®De cline
Extended Care Expenses
All services must be preauthorized ~ 100% ofAllowable Amount ~ 70% of Allowable Amount aBer
Skilled Nursing Facility I $10,000 Calendar Year maximum' I $7,000 Calendar Year maximum'
Home Health Care $10,000 Calendar Year maximum" $7,000 Calendar Year maximum'
Serious Mental Illness
Mental Heal[h Care
Treatment of Chemical Dependency
Inpatient Services (All services must be preauthorized)
-Hospital services (facility)
(Inpatient Chemical Dependency treatment must be provided in a 80%ofAllowable Amounf 60% ofAllowable Amount affer per-
Chemical Dependency Treatment Center) admission Deductible
80%ofAllowable Amount after Calendar 60%ofAllowable Amount affer
-Ph sicianservices Year Deductible Calendar Year Deductible
Outpatient Services (All services must be preauthorized)
-Services performed during Physician office visiUconsultation 100% ofAllowable Amount affer $25 70%ofAllowable Amount affer
(does not include psychological testing) Copayment Amount CalendarYear Deductible
-All outpatient services and psychological testing 80% of Allowable Amount after Calendar 60%ofAllowable Amount aBer
Year Deductible Calendar Year Deductible
' Benefits used In~Jetwork and Out-of-Nehvork will apply toward satafying any Calendar Year, Plan Year, Annual Maximum, or Maximum Ltletime benefits indirated
A Division of Heanh Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
151+business-PP0.AS0-Standard-wish Network Deductible (Rev. 624/09) Page 1 or 6
PPO-ASO-Standard-with Nefwork Deductible B~ueCroesBlues6ieta
of'Iiexae
.• .-
Emergency Room/Treatment Room
Accidental Injury & Emergency Care (within 48 hours)
-Facility charges 80% of Allowable Amount after $100 Copayment Amount
(Copayment Amovnt waived if admitted, Inpatient Hospital Expenses will apply)
Non-Emergency Care (after 48 hours)
-Facility charges 80%ofAllowableAmounfaffer$100 60%ofAllowable Amountafter$i00
Copayment Amounf (Copayment Copayment Amount & Calendar Year
Amount waivedi(admitted,lnpatienf Deductible (CopaymentAmount
Hospdal Expenses will apply) waived it admitted, Inpatient Hospital
Expenses will apply)
80% of Allowable Amount after Calendar 60% of Allowable Amount after
-Physician charges Year Deductible Calendar Year Deductible
Ground and Air Ambulance Services
80% of Allowable Amount after Calendar Year Deductible
' Benefits used In~Jetwork and Out-of-Network will apply toward satisying any Calendar Year, Plan Year, Annual Maximum, or Maximum LBetime benefAS indipted
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
i5fi business-PPO-ASO-StandaN-wAh Network Deductible (Rev. fi24/09) Page 3 0/6
PPO-ASO-Standard-with Network Deductible s~ueCrosaslueShieta
of'I~xas
.- .-
Preventive Care
Routine annual physical examinations, well-baby care exams, 100% of Allowable Amount aRer 525 70'~ o/Allowable Amount aRer
immunizations for PartirJpants 6 years of age & over, vision exams and Copayment Amount Calendar Year Deductible
hearing exams
Immunizations for Dependent children through the date of the child's 6'"
Speech and Hearing Services
Services to restore loss of or coned an impaired speech or hearing
function
Hearing Aid Maximum
Physics! Medicine Services
Chiropractic Care-0ffice Services
Calendar Year Maximum
100%ofAllowable Amount 100%ofAllowable Amount
Covered same as any othersickness Covered same as any other sickness
Hearing aids are subject to a $1,000 maximum amount each 36-month period'
80% o(AllowableAmountaNerCalendar I 60%o(AllowableAmountatter
Year Deductible Calendar Year Deductible
51.500 maximum benefit each Calendar Year'
All other Physical Medicine Services rendered by any other eligible Provider will
Benefds used InNeAvork and Out-of-Network will apply toward satisfying any Calendar Year, Plan Year, Annual Maximum, or Maximum L'detime beneffs indicated
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Indepentlent Licensee of the Blue Cross and Blue Shield Association
151+ business-PPO-ASOStandard-with Nehvrork Deductible (Rev. fi24/091 Page 4 0( 6
PPO-ASO-Standard-with Network Deductible
Prescription Drug Benefits*
Vaainationc obtained through Pharmaces*"'
BlueCroes BlueShield
of'II'xas
®Yes~No
$10 Copayriierit Amount
'Deductibles do not a
Retail Pharmacies
(All Copayment Amounts are per 30.day supply and will riot apply to
Coshare Stoploss Maximum)
Generic Drug $10 Copayment Amount 80% of Allowable Amount minus
Copayment Amount
Preferred Brand Name Drug $30 Copayment Amount 80% o)Aflowable Amount minus
Copayment Amount
Non-Preferred Brand Name Drug $50 Copayment Amount 80%, olAllowable Amount minus
Copayment Amount
Mail Service Pharmacy ®Yesr~No
(All Copayment Amounts are per 30-0ay supply and will not apply to
Coshare Stoploss Maximum)
Generic Drug $10 Copayment Amount
Prefened Brand Name Drug $30 CopaymentAmount
Generic Incentive-Members electing to purchase Prefened/Non-Prefened Brand Name Drugs when a Generic equivalent is available, will be requir
the di(/erence between the cost of the Generic and Preferred/Non-Prefened Brand Name Drug, plus the Preferred Brand Name Copayment Amount.
"Three-month Deductible carryover does riot apply fo prescdpfion dmg deductible.
"' Each Participating Pharmacy that has contracted to provide vaccination services may have age, scheduling, or other requirements that will apply. You are
encouraged fo contact the store in advance. Childhood immunizations subject fo state regulations are not available under this pharmacy benefit. Re(erto your
BCBSTX medical coverage forbenefds available Ior childhood immunizations.
Diabetes Supplies are available under the Prescription
'syringes necessaryforseH-adminishafion, prascdptive
protein, lancets and lance! devices, biohazard dispose
tic supplies include insulin and insufm analog prepamdons, insulin
aft required test ships end tablets whirit test forglutwse, ketones, and
cY kits; and otharfifeo6on aids: A!f provisions ofthis portion ofthe plan
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Intlependent Licensee of the Blue Cmss and Blue Shield Association
151+business-PPO-ASO-Standard-wRh Network Deductrble (Rev. 624/09) Page 5 0( 6
PPO-ASO-Standard-with Network Deductible s~ueClrossBtueSlilela
af'I~xas
EMPLOYEE INFORMATION
This is a general Summary of your benefit design. Please refer to your benefit booklet far other details and for limitations and exclusions.
The following benefits apply to dependent coverage:
• Dependent children are covered to age 25.
• Unmarried grandchildren of the insured are covered if the grandchild is under 25 years of age and is claimed as a dependent by the insured far Federal
Income Tax purposes.
• Automatic coverage for newborns for the f rst 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 spedal enrollment event.
Payments: Network providers agree to accept amounts negotiated with BCBSTX and are paid according to this BCBSTX-determined Allowable Amount. Covered
individuals are responsible for any required Deductibles, Coinsurance or Out-0f-Pocket Amounts, and Copayments. Plan benefits paid to Out-0f-Network providers are
based on the BCBSTX-determined Allowable Amount. These providers may balance bill covered individuals for charges in excess of the BCBSTX Allowable Amount.
The covered individual will be responsible for charges in excess of the Allowable Amount in addition to any applicable Deductibles, Coinsurance or Outof-Pocket
Amounts, and Copayments. For cost savings information, refer to the section on ParPlan Providers and the defnition of Allowable Amount in the beneft booklet.
Preexisting conditions are defined in the benefit booklet and are excluded for 12 months. Appropriate credit will be given for time served under Credhable Coverage
as defined under the law and shown in your benefit booklet.
Replacement of Medical Coverage: In compliance with the Health Insurance Portability and Accountability Ad of 1996 (HIPAA), the following provisions apply to
each eligible participant who has health coverage under the employer's plan immediately prior to the efteilive date of the health contract between the employer and
BCBSTX (the contract date):
• Benefits for eligible expenses incuned for any service or supplies prior to the contrail date, are not covered under the contract.
• Eligible expenses for services or supplies incurred on or after the effective date will be considered for benefits subject to all applicable contract provisions.
Members residing in other states may use that state's network through the BlueCard program. To locate a participating provider in your state, please contact
1-800-810-BLUE or visit our web site at www.bcbsa.com to use our Provider Findere tool.
• RADIAL KERATOTOMY-COVERED
• LASIK • COVERED
• EFFECTIVE 11!1108, SERVICES, SUPPLIES ANDIOR PRESCRIPTION DRUGS FOR 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. )
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 AssodaLOn
751+business-PPO-ASO-Standard-with Network Deductible (Rev. 624/09) Page 6 of 6
Flu Vaccinations
at Walgreens
Age limitations, cidvance
registration, ar oll[er
-'~9 ~f' cpply.
For your convetdeAae,
You are encouraged to
preregister by adl!n9 .
olr in pe~;~ any;:
participating W~greens
up b I it daps in
advance of clinic. ;
CaY ~00f1,Al-9950
(~Od-35s~-9950]
ar vise
1AI~r~ns,.oom/~
Every year thousands of people are
affected by colds and flu. Get your flu
shot and stay protected!
Blue Cross and Blue Shield of Texas'(BCBSTX), Walgreens, and your
employer care about your health and wellness. That's why we are
joining together to offer you and your family members protection for
the flu season with vaccinations available each fall at select Walgreens
locations throughout the country.
To learn when and where you can receive the vaccinations, visit
the online flu center at Walgreens.com/flu or call 800-FLU-9950
(800-358-9950).
At the time you receive services, present your BCBSTX identification
card to the pharmacist. This will identify you as a participant in the
BCBSTX health care plan provided by your employer. The pharmacist
will submit the claim and collect the appropriate copayment amount,
if any.
BCBSTX, Walgreens, and your employer encourage you to participate
in this offer -your health is important to us!
~~
B1ueCross BlueShield
of Texas
Experience. Wellness. Everywhere."
Z+QIa~greestrat
,~~.~ Ame~r~.sH~r~,.
'A Division of Heahh Core Service Corpomnon, a Munwl Legol Reserve Compairy,
on independem Gcernee o1 dte Blve Cross aid Blve ShieM Auociofion
,~'
,;
496B1.0POp /v
• ~ 1
Mickey Moshier
From: Terry_Villiva@bcbstx.com
Sent: Friday, July 10, 2009 9:49 AM
To: Mickey Moshier
Cc: maureenJones@bcbstx.com
Subject: City of Port Arthur - Mental Health Parity and Addiction Equity Act - PPO & HMO
W
~~
MHPAEA Election
Form (Non-HMO)...
RE: City of Port Arthur
The City of Port Arthur will need to complete the election form attached.
We've gone ahead and revised the SOB to reflect removing the day/dollar limits from Mental
Health, SMI & Chemical Dependency. If they elect a different offering we will revise as
indicated. I'll send you the revised SOB in a seperate email.
Texas MHPAEP. Implementation Outline
On Oct. 3, 2008, President Bush signed the Emergency Economic Stabilization Act of 2008.
This legislation included the Mental Health Parity and Addiction Equity Act (MHPAEA) which
amends the Employee Retiremer.•t Income Security Act (ERISP.), the internal Revenue Code
(Code) and the Public Health Service Act (PHSA). The MHPAEA generally requires that group
health plans and oroup health insurers apply the same treatment and financial limits to
medical and surgical benefits and to mental health and substance use disorder benefits.
As a reminder, the Mental Health Parity and Addiction Equity Act provides that small group
health plans are exempt from the new recuirements.
For renewing groups, the provisions of the law will go into effect on each group's renewal
date beginning on and after Oct. 3, 2009.
SELF-FUNDED PPO ACCOUNTS
The law is not a mandate to provide mental health or substance abuse disorder benefits and
does not mandate coverage of all mental health conditions. As applies to self-funded
accounts, if a self-funded client elects to cover mental health care, serious mental
illness, and/or treatment of chemical dependency, coverage must be in accordance with the
Mental Health Parity and Addiction Equity Act.
Self-funded clients have several options available and must complete the attached election
form. If your self-funded client elects any variation from the benefits indicated in the
Benefit Highlights attached, please let me know asap.
(See attached £ile: MHPAEA Election Form (Non-HMO).doc)
Thank you,
Terry Villiva, MHP 1 Account Executive
Blue Cross Blue Shield of Texas 1 2615 Calder, Suite 700 1 Beaumont, Texas
77702
Phone: 409-896-0104 1 Fax: 909-896-Olli 1 Mobile: 909-656-9463 1 Email:
terry_villiva@bcbstx.com
Visit our Website: www.bcbstx.com.
The information contained in this communication is confidential, private, proprietary, or
otherwise privileged and is intended only for the use of the addressee. Unauthorized use,
disclosure, distribution or copying is strictly prohibited and may be unlawful. If you
have received this coR~unication in error, please notify the sender immediately at
(312)653-6000 in Illinois; (800)835-8699 in New N,exico; (918)560-3500 in Oklahoma; o-
(972)766-6900 in Yexas.
BlueCroes BlueSlileld
af'I~xas
MENTAL HEALTH PARITY and ADDICTION EQUITY ACT ELECTIONS (NON-HMO)
Group Name:
Group Number: Renewal Date:
Completed By: Extension:
New Federal Requirements for Mental Health Care, Serious Mental Illness, and Treatment of Chemical
Dependency Coverage
On October 3, 2008, President Bush signed the Emergency Economic Stabilization Act of 2008. This legislation included the Mental
Health Parity and Addiction Equity Act (MHPAEA) which amends the Employee Retirement Income Security Act (ERISA), the Internal
Revenue Code (Code) and the Public Health Service Act (PHSA). The MHPAEA generally requires that group health plans and group
health insurers apply the same treatment and financial limits to medical and surgical benefts and to mental health and substance use
disorder benefits.
The MHPAEA does not mandate cove2ge of mental health, serious mental illness, or chemical dependency (substance abuse). It does,
however, require group health plans that cover mental health care, serious mental illness, and/or treatment of chemical dependency
not apply more restrictive beatment/imitations(number of visits, days of coverage or other similar limits on the scope or duration of
treatment) or frnancia/requirements(deductibles, copayments, coinsurance, and out-of-pocket expenses) than those applied to
substantially all medical and surgical benefits. As applies to PPO plans, parity requirements also apply to the out-of-network coverage
for medical and surgical benefits and mental health and chemical dependency benefits. For renewing groups, the provisions of the law
will go into effect on your renewal date beginning on and after October 3, 2009.
It is important that you review your plan design in light of this new law and provide notice of your elections to Blue Cross and Blue
Shield of Texas (BCBSTX) as your claims administrator.
Ranefite fnr Grinuc Mental Tllnecc (rhark tha hnx that annlies -must SeIPd nrlel
^ We are a public entity, therefore, benefits for serious mental illness are paid same as any other physical illness. No
changes are necessary.
We are not a public entity and have elected to provide benefits for serious mental illness same as any other physical
^ illness with no inpatient day or outpatient visit limitations. All benefits paid are to be applied to the maximum
lifetime benefits amount of the plan.
^ We are not a public entity and have elected to no longer provide benefits for serious mental illness.
Benefts for serious mental illness are carved out of the group health plan administered by BCBSTX and are
^ administered by another vendor. It is our desirethat medical and serious mental illness claims paid be accumulated
to apply to any deductibles, co-share amounts, and maximum lifetime benefits of the plan.*
Benefits for serious mental illness are carved out of the group health plan administered by BCBSTX and are
^ administered by another vendor. It is not our desirethat medical and serious mental illness claims paid be
accumulated to apply to any deductibles, co-share amounts, and maximum lifetime benefits of the plan.
Benefits fnr Treatment of Chemical Dependency (check the box that coolies -must select onel
^ We have elected to provide benefts for treatment of chemical dependency same as any other illness with no
limitations on series of treatments. All benefds paid are to be applied to the maximum lifetime benefits of the plan.
We have elected to no longer provide benefds far treatment of chemical dependency. We understand, however,
^ that benefits for medical management of acute life-threatening intoxication (toxicity) in a Hospital will be available
on the same basis as for sickness generally as described under Benefits for Inpatient Hospital Expenses.
Benefits for treatment of chemical dependency are carved out of the group health plan administered by BCBSTX
^ and are administered by another vendor. It is our desire that medical and treatment of chemical dependency
claims paid be accumulated to apply to any deductibles, co-share amounts, and maximum lifetime benefits of the
plan.*
Benefits for treatment of chemical dependency are carved out of the group health plan administered by BCBSTX
^ and are administered by another vendor. It is notour desirethat medical and treatment of chemical dependency
claims paid be accumulated to apply to any deductibles, co-share amounts, and maximum lifetime benefits of the
plan.
A Division of Health Care Service Corporatlon, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Assodation
Non-HMO Renewal-MHPAEA Page 1 of 2
BlueCiroes B1ueShield
af'I~xas
Benefits for Mental Health Care (check the box that coolies -must select onel
^ We have elected to provide benefts for mental health care same as any other illness with no limitations inpatient
days or outpatient visits. All benefits paid are to be applied to the maximum lifetime benefits amount of the plan.
^ We have elected to no longer provide benefits for mental health care.
Benefits for mental health care are carved out of the group health plan administered by BCBSTX and are
^ administered by another vendor. It is ourdesirethat medical and mental health claims paid be accumulated to
apply to any deductibles, co-share amounts, and maximum lifetime benefts of the plan.*
BenefRS for mental health care are carved out of the group health plan administered by BCBSTX and are
^ administered by another vendor. It is not our desire that medical and mental health claims paid be accumulated to
apply to any deductibles, co-share amounts, and maximum lifetime benefts of the plan.
*If benefits for Mental Health Care, Serious Mental Illness, and / or treatment of Chemical Dependency are to be carved out to another
vendor and the Plan Sponsor desires accumulated amounts to be applied to any deductibles and calendar year maximums of the plan,
please provide the following:
Vendor name:
Phone
City State
Contact, if available:
BCBSTX, as your claims administrator, is ready to assist you with any questions you may have regarding the elections above. Contact
your Marketing Account Representative.
The information and elections provided in this addendum should not be construed as legal advice for implementation of the Mental
Health Parity and Addiction Equity Act of 2008. The Department of Labor is responsible far enforcing the provisions of the Mental
Health Parity and Addiction Equity Act with respect to ERISA group health plans. Penalties may be assessed for non-compliance. The
Plan Sponsor retains the final authority and responsibility to establish the terms and conditions of the group health plan and is
encouraged to seek legal counsel with any questions concerning compliance with this federal law.
Signature:
Title:
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Dcensee of the Blue Cross and Blue Shield Associatlon
Non-HMO Renewal-MHPAEA Page 2 of 2