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HomeMy WebLinkAboutPR 24602: CONTRACTS BETWEEN ITS THIRD PARTY ADMIN. (BLUE CROSS AND BLUE SHIELD) CITY OF PORT ARTHUR, BLUE CROSS MEDICARE ADVANTAGE PPO AND PRESCRIPTION DRUG PLAN, RETIREES AND DEPENDENTS INTEROFFICE MEMORANDUM Human Resources Department Date: October 16,2025 To: Ronald Burton, CPM, City Manager From: Trameka Williams, Assistant Director of Human Resou RE: Blue Cross Medicare Advantage Renewal Effective 1/01/2026 P. R. No. 24602 - A Resolution Authorizing The City Manager To Execute Contracts Between Its Third Party Administrator(Blue Cross and Blue Shield of Texas, Inc.)For The City of Port Arthur Blue Cross Medicare Advantage PPO and Prescription Drug Plan for its Existing Medicare Eligible Retirees and/or Their Medicare Eligible Dependent(s) Nature of the request: The City of Port Arthur provides access to their Medicare eligible retirees and/or their Medicare eligible dependent(s) to the Blue Cross Medicare Advantage PPO and Prescription Drug Plan for major medical health insurance coverage, including prescription drug coverage. Medicare eligible retirees and their Medicare eligible dependent(s) transitioned to the Blue Cross Medicare Advantage PPO and Prescription Drug Plan effective on 01/1/2026. Staff Analysis, Considerations: The City of Port Arthur has a Preferred Provider Organization (PPO) insurance format which provides participants in the selection of health care providers. This format has been deemed most beneficial for plan participants and most compatible with our organizational culture. The upcoming 1/1/2026 renewal has presented an increase of 10%over last year's renewal. Per the attached, it has been determined that this year's 10%increase was principally due to high utilization of claims experience incurred during the current plan year to date. There are approximately 77 Medicare eligible retirees and/or Medicare dependents on the plan. "Remember,we are here to serve the Citizens of Port Arthur." Staff views the health insurance benefit as an earned as well as deserved benefit for its City retirees, and will continue to strive to provide the best health plan available at the best price to all of its plan participants. The City will continue to pay 50%. There are a number of updates to the medical grid for next year, and items that are in the inclusions are Virtual Visits by MDLive for certain categories of treatment. In addition, Opioid treatment and Acupuncture treatments have been added by CMS for next year. There are minor changes that are required of the plan to maintain CMS compliance, all highlighted changes are CMS mandated,which are beneficial changes for the retiree. No change in the current benefit levels as follows: • $0 Annual Deductible • Maximum Out-of-Pocket$1,500 • Level Copays • SilverSneakers Program(i.e.YMCA,Curves,World Gym, etc.) • Hearing Aid Benefits • Incentives totaling$100/per year for Wellness Benefits It is recommended that the City continue to share the premium cost with the medicare eligible retiree. Medicare eligible retirees are required to pay 50% of the proposed monthly premium cost and/or their Medicare eligible dependent(s)are required to pay 100%of their premium cost. Recommendation: It is recommended that the City Council adopt P. R. No. 24602 authorizing the renewal of the Blue Cross Medicare Advantage PPO and Prescription Drug Plan for its Medicare eligible retirees and/or their Medicare eligible dependent(s), and authorizing the City Manager to execute all documents necessary for its 1/01/2026-12/31/2026 plan year. Budget Considerations: Approval of P.R.No.24602 will have a projected budgetary impact of $90,000 which is available in the FY 2025-2026 Health Insurance Fund(614-11-025-5127-00-00- 000). "Remember,we are here to serve the Citizens of Port Arthur." P.R. No. 24602 10/16/25—taw RESOLUTION NO. A RESOLUTION AUTHORIZING THE CITY MANAGER TO EXECUTE CONTRACTS BETWEEN ITS THIRD-PARTY ADMINISTRATOR (BLUE CROSS AND BLUE SHIELD OF TEXAS, INC.) FOR THE CITY OF PORT ARTHUR'S BLUE CROSS MEDICARE ADVANTAGE PPO AND PRESCRIPTION DRUG PLAN FOR ITS MEDICARE ELIGIBLE RETIREES AND/OR MEDICARE ELIGIBLE DEPENDENT(S),AND AUTHORIZING THE CITY MANAGER TO EXECUTE ALL DOCUMENTS,WITH A PROJECTED BUDGETARY IMPACT OF$90,000.00 FUND NO: 614-11-025-5127-00-00-000 (HEALTH INSURANCE FUND) WHEREAS, the City Council of the City of Port Arthur deems it necessary and appropriate to provide major medical health care benefits along with a prescription drug benefit to its Medicare eligible retirees and/or Medicare eligible dependent(s) effective 01/01/2026; and, WHEREAS, inasmuch as the upcoming year's renewal reflects a 10%increase over last year's renewal, the City recommends acceptance of the BC/BS Medicare Advantage PPO Prescription and Drug Plan renewal as presented with minor positive changes in its current benefits levels, as fully delineated in Exhibit"A"; and, WHEREAS, Blue Cross and Blue Shield of Texas will take the necessary actions to comply with the Centers for Medicare and Medicaid Services' (CMS) requirements to continue the provisions enacted annually,and do hereby affirm to continue to make changes to its existing health plan policies or products required to comply with the law; and, NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY PORT ARTHUR, TEXAS: Section 1. That, the City Council of the City of Port Arthur hereby accepts the contract proposal from Blue Cross and Blue Shield of Texas, Inc., to renew the Blue Cross Medicare Advantage PPO and Prescription Drug Plan for its Medicare eligible retirees and/ or their Medicare eligible dependent(s) for the 01/01/2026 plan year which includes a P.R. No. 24602 10/16/2025 taw renewal rate of 10% over last year's renewal, with a projected budgetary impact of $90,000, funding available in Health Insurance Fund - Account No. 614-11-025-5127- 00-00-000. Section 2. That, the City will be billed 50% of the proposed premium cost of $23/month for all impacted Medicare eligible retirees (approximately 77 Medicare retiree participants). The City's monthly premium cost which equates to $126.25/per member/month, for all impacted Medicare eligible retirees for the 01/01/2026 — 12/31/2026 plan year as is fully delineated in Exhibit"B". Section 3. That, the City Manager is hereby further authorized to execute the necessary contracts and other documents on behalf of the City of Port Arthur subject to the approval of the City Attorney, and to make payment of necessary premium and administrative charges to bind coverage subject to the terms and conditions of the contract for Third Party Administrator(Blue Cross and Blue Shield of Texas,Inc.)and the Contracts for Insurance attached hereto as required to effectuate said services. Section 4. That, a copy of the caption of this Resolution be spread upon the minutes of the City Council. READ, ADOPTED, AND APPROVED this day of AD, 2025, at a Regular Meeting of the City Council of the City of Port Arthur, by the following vote: AYES: Mayor Councilmembers: NOES: Charlotte M. Moses, Mayor P.R. 24602 10/16/25 taw ATTEST: Sherri Bellard, City Secretary APPROVED A_ S—T • Roxann Pais Cotroneo, City Attorney APPROVED FOR ADMINISTRATION: C Trameka Wi hams, CPM, Assistant Director of Human Resources Ron Burton, PM, City Man APPRO ED AS TO AVAILABILITY OF FUNDS: Jt.d.(4 Lyn a Boswell, Director of Finance EXHIBIT "A" c a 0 2 g .0 t C 2 e » & \ © 2 CL ~ kq [ / /2 / 7 2 2 Ce 0 2 © / r E ( So0 ` ) 2# I a & w: , t ) k = oc ® 2 / e@ &2 ( k - ® i 0 & 2 o \ £ /f/ ) # Io > I . \ j &° 72 § 0 § N- 2 ) m2 § \ \ 7 � \ 7 ) CI (R 2 /\ \ \ 0 o \ o. 2 4 , @ � _ § , § £ < \ 2Q7 ® - o E 0 { a) t � �o. § � 0 (C ) \ / / � § Ct o § � f� 2 a \ co_ _ { = 4.1 re00 W o \ u) \\ k _. > Ce 2 \ /} $ ® { : o m E E # ¢ �_ c ir ] E \ \ k � c / - \ « -) 2 7E § \ a : O m E % o � © dw ® \ 5 . � � CIS 4, \ �0 / , C \ f § / § f§ / / Li » G2 � 0 \ { ) § - \ cooed c > © - S ° ° 2 7 2 $ - E 2 < o \ \) ot 2 E ■ = ° o E- ^ a. 03 CD \ \ /) 0 £ m dp \ j % f j \ \ 2 Table of Contents eV Blue Cross Group Medicare Options" Blue Cross Group Medicare Advantage Account Information Account Name _ City of Port Arthur Account Stale TX Plan T e MAPD Traditional PPO CMS Contract-PBP H1666 801 %•.Benefit Effective Date 1/12028 Plan Name n/a Premium _-- - TBD Benefit Design In-Network Out-of-Network 'Annual Medical Deductible' $0 $250 Annual Combined Medical Deductible' n/a Annual Out-of-Pocket Maximum $1,500 M.250__ Annual Combined Out-of-Pocket Maximum $2,250 ,Referral Requirement None Inpatient Hospital Inpatient Hospital-Acute $100/day(days 1-6) 40% $0/day(days 7+) Inpatient Mental Health Care $100/day(days 1-6) 40% Limited to 190 lifetime days $0/day(days 7+) Skilled Nursin•Facilit Benefit Period 1-20 days $0 copay/per day 40% No poor hospitalization required Benefit Period 21-100 days' $100 copay/per day 40% Limited to 100 days per Medicare Benefit Pedal. Home Health/Hospice Home Health $0 copay 40% Hospice(Medicare-covered)' Covered by Original Medicare at a Medicare certified hospice Emergent 8 Urgent Care Emergency Care(Worldwide) $50 copay $50 copay Cost sham waived if admitted within 3 days for the same condition. Urgently Needed Services(Worldwide) $40 copay $40 copay Cost share waived if admitted within 3 days for the same condition. Virtual Urgent Care-Vise through MDLive $25 copay(through MDLive only) Not Applicable Ambulance Services(Ground) 20% 20% Ambulance Services(Air) 20% 20% Health Care Professional Services Primary Care Physician Services $30 copay 40% Physician Specialist Services $50 copay 40% Excluding Psychiatric and Radiology Services Other Health Care Professional Services E30 copay/PCP 40% $50 copay/SPC Medicare-Covered Specialist Visits Chiropractic Services(Medicare-covered) Coverage is limited to manual manipulation of the spine to correct for $10 copay 40% Podiatry Services(Medicare-covered) Coverage is limited to foot exams or treatment for diabetes-related naive $5 copay 40% damage or medically necessary treatment for foot injuries or diseases. Acupuncture(Medicare-covered) Coverage far chronic low back pain up to 12 visits in 90 days.No more than 20 $0 copay $0 copay acupuncture treatments may be administered annually. Dental Services(Medicare-covered) Coverage for inpatient hospital care for emergency or complicated dental 20% 40% Procedures. Eye beam(Medicare-covered) SO copay 40% Coverage for eye exams limited to specific condition. Eyeweer(Medicare-covered) Coverage for corrective lenses if you have cataract surgery to implant an $0 copay 40% intraocular lens-one pair of eyeglasses with standard frames or one set of contact lenses. Hearing Exam(Medicare-covered) Coverage for diagnostic hearing and balance evaluations to determine if you 25% 40% need medical treatment. Outpatient Rehabilitation Services Cardiac Rehabilitation Services Maximum of 2 one-hour sessions per day up to 36 sessions in 36 weeks. Limit to 36 per year. $20 copay 40% Intensive Cardiac Rehabilitation Servl•= Medic -coveredlateeSive Cardiac.Ref-i $20 copay 40% Pulmonary Rehabilitation Services $20 copay 40% Limit to 36 sessions per year Supervised Exercise Therapy for PAD $20 copay 40% Up to 36 sessions in 12 weeks Occupational Therapy Services $20 copay 40% Physical Therapy end Speech Language Pathology Services $20 copay 40% Outpatient Mental Health Services Mental Health Specialty Services-Individual Visit $20 copay 40% Mental Health Specialty Services-Group Visit $20 copay 40% Virtual Mental Health Specialty Services-Visit through MDLive $20 copay(through MDLive only) Not Applicable , Psychiatric Services-Individual Visit $20 copay 40% Psychiatric Services-Group Visit $20 copay 40% Virtual Psychiatric Services-Vise $20 copay(through MDLive only) Not Applicable Partial Hospitalization/Intensive Outpatient Program Services Partial Hospitalizat,on $30 copay 40% Intensive Outpatient Services Outpatient Substance Abuse Services Outpatient Substance Abuse_ IL:._33...,.. $40 copay 40% Outpatient Substance Abuse:Group Visit I $40 copay 40% Opioid Services $0 copay $0 copay Outpatient Dia•nosticfTherapeutic Radiation Services Lab Services • $20 copay 40% Diagnostic Procedures $10 copay ' 40% Therapeutic Radiology $60 copay 40% Diagnostic Radiology Services/X-Ray $30 copay 40% • 'Advanced Imaging(MRI,MRA,CT Scan,PET) $60 copay 40% Other Outpatient Services Outpatient Observation $0 copay $0 copay I Outpatient Hospital Services $100 copay 40% ;'Ambulatory Surgical Center(ASC)Services $100 copay 40% 'JOP Blood Services-Coverage begins with the first pint of blood $0 copay $0 copay End-Stage Renal Disease/Dialysis Services 10% 40% 'Kidney Disease Education Services $0 Copay $0 Copay DME,Prosthetics.Diabetic Supplies 1Durable Medical Equipment(DME) 10% 40% Prosthetics/Orthotics 10% 40% Wig(s)w/Cancer Diagnosis Not Covered Medical Supplies 10% 40% Diabetes Supplies and Services-Preferred Testing Supplies' 0% 40% Diabetes Supplies and Services-Non Preferred Testing Supplies 20% 40% 'Diabetes Supplies and Services-All other supplies' 20% 40% Therapeutic Shoes and Inserts Lim to 1 pair of diabetic shoes per year;Limit to 2 pairs of inserts per year for 40% Lin* custom tried shoes bond to 3 pans of inserts per year for off the Shelf shoes Medicare Preventive Services ;Medicare-covered Preventive Services $0 Copay $0 Copay Medicare Part B Rx Drugs Medicare Part B Rx Drugs Chemotherapy/Radiation 20% 40% Medicare Part B Rx Drugs Other 20% 40% Home Infusion Therapy Administration $0 copay $0 copay Supplemental Benefits Preventive&Diagnostic Not Covered Not Covered 2x exams,2x cleaning,1 x-ray each year Basic Restorative Example;cavities,non-surgical extractions,dental pain relief Not Covered Not Covered Major Restorative Example,Surgical tooth extractions,root canals,includes Not Covered Not Covered was and dentures ' Dental Deductible/Waiting Periods n/a implants rile Dental Annual Calendar Maximum Combined in-network and out-of-network allowance on Na supplemental comprehensive dental services each year Routine Eve Exam Not Covered Not Covered 1 routine eye exam each year Eyewear Allowance Not Covered Not Covered _ Eyewear Allowance Benefit Period n/a Routine Heal'61g: Routine Hearing Exam $10 copay 40% -:'Mine hearing exam each year Hearing Aids Allowance $1,000 Allowance _ Benefit Per Ear or Both Ears Both Ears Hearing Aid Allowance Benefit Period 36 months Annual Physical Exam $0 copay $0 Copay Routine Podiatry Services Not Covered Not Covered Routine Chiropractic Services Not Covered Not Covered Routine Acupuncture Not Covered Not Covered Private Duty Nursing Not Covered Not Covered Over-the-Counter Rx Allowance Not Covered Not Applicable ';Provided by Convey Health Solutions) Post-Discharge Meal Benefit Not Covered Not Applicable (Provided by Morn's Meals) Non-Emergency Transportation Services Not Covered Not Applicable ;Provided by Modivcare Solutions LLC) Wellness!Clinical Programs Fitness Program Included Not Applicable (Provided by SilverSneakers'I Member Rewards Program Up to$100 per year Not Applicable (Provided byHealthmine) I NurseLine Included Not Applicable Blue3660 Included Not Applicable • Discount Pladonn Intensive Case Management Included Not Applicable • Complex Care Management Programs° Included Not Applicable _ _ Transplants Management Program Included Not Applicable Preferred Diabetic Supply Program Included Not Applicable Tru Hearing Aid Discount Program Included Not Applicable In-home assessments(Signify Health) Included ; Not Applicable Footnotes 'Deductible. Only applicable to coinsurance,not copay.Deductible counts toward out of pocket maximum.Deductible does not apply to Medicare Preventive Service,Ambulance Services,ER,and Urgent Care Services. a'Skilled Nursing Facility-The member cost sharing applies to covered benefits incurred during a members inpatient stay.A benefit period begins 'the day you go into a hospital or skilled nursing facility.The benefit period ends when you haven't received any inpatient hospital care(or skilled care in a SNF)for 60 days Ina row.If you go into a hospital or a skilled nursing facility after one benefit period has ended,a new benefit period begins.There is no limit to the number of benefit periods. a Hospice-When you enroll in a Medicare-certified hospice program,your hospice services and your Part A and Part B services related to your 'terminal condition are paid for by Original Medicare,not Blue Cross Group Medicare Advantage.Your plan will pay fora consultative visit before you select hospice. a Diabetes'. 0%cost sharing is Limited to diabetic testing supplies(meters and strips)obtained through the pharmacy to Ascensra and Abbott branded products (OneTouch Verb Flex,OneTouch Verb Reflect.OneTouch Verio IQ,OneTouch Verb,OneTouch Ultra Mini and OneTouch Ultra 2).All other diabetic testing supplies(meters and strips)and will be subject to 20%cost sharing. a Continuous Glucose Monitoring(CGM)products obtained through the pharmacy are subject to Prior Authorization,Quantity Limit and 20%cost sharing.Continuous Glucose Monitoring(CGM)preferred products are Dexcom G6,Dexcom G7 when used with a Dexcom Receiver,and Abbott Freestyle Libre and Freestyle Libre 2 products,and Freestyle Libre 3 when used with a Freestyle Libre receiver.Prior approval and trial and failure of a preferred CGM product will be requited for a0 other continuous glydose monitoring products CGM recaiesrs era subject tea • lima of °Complex Care Management Programs include:Alcohol end substance abuse disorders,Anxiety and panic disorders,Asthma/chronic obstructive pulmonary disease,Cancer,Congestive heart failure,Coronary artery disease,Depression,Diabetes,Hypertension,Schizophrenia,other psychotic disorders and ESRD(End Stage Renal Disease) HMO plan in New Mexico,HMO and HMO-POS plans in Illinois,and PPO plans in Illinois,Montana,and New Mexico are provided by Health Care Service Corporation,a Mutual Legal Reserve Company(HCSC).HMO plan in Illinois provided by Illinois Blue Cross Blue Shield Insurance Company(ILBCBSIC).HMO Special Needs Plan and PPO Special Needs Plan in New Mexico provided by HCSC.HMO,PPO,and Dual Care HMO Special Needs plans in Texas provided by HCSC Insurance Services Company(HISC).HMO and PPO plans in Texas provided by GHS Insurance Company(GHSIC).All HMO and PPO employer/union group plans provided by HCSC.HMO plan in Oklahoma provided by GHS Health Maintenance Organization,Inc.d/b/a BlueLincs HMO(BlueLincs).PPO plan in Oklahoma provided by GHS Insurance Company(GHSIC).HCSC, ILBCBSIC,HISC,GHSIC,and BlueLincs are Independent Licensees of the Blue Cross and Blue Shield Association.ILBCBSIC,GHSIC and BlueLincs are Medicare Advantage organizations with a Medicare contract.HCSC is a Medicare Advantage organization with a Medicare contract and a contract with the New Mexico Medicaid program.HISC is a Medicare Advantage organization with a Medicare contract and a contract with .the Texas Medicaid program.Enrollment in these plans depends on contract renewal. •®Blue Cross Group Medicare Options` Blue Cross Group Medicare Advantage Account Name CSy of Pon Arthur Deauc1:Lie Stage Account State TX - Plan Name Traditional PPO 50 Benefit Effective Date 2020-01-01 CMS Contract H1666 I,final Coverage Stage PBP SO1 Formulary 5 Ter Standard THE FOLLOWING COST SHARES WILL APPLY UP TO THE OUT-OF-POCKET CAP Supplemental Drug Uat Ha Supplemental Coverage'Der 5i5 Premium' TBD Retail Pharmacy Mail der Pharmacy se-day supplywary so-day supply day supply 30day supply soday supply 30day supply Preferred Standard Preferred Standard Preferred Standard Preferred Standard Pretend Standard Preferred Standard Tler 1:Preered Generic SO S5 SO 210 50 515 50 55 SA 310 50 315 • Tier2:Genere S6 $et $12 522 SIt 333 S6 $11 512 $22 $18 S. Ter 3:Preferred Brand 330 See 528 588 5117 $132 539 6.11 578 US E112 3132 Tur e:Non-Preferred Drug S85 $05 5170 3100 E2S5 $285 S85 393 5130 5190 5255 3385 Tier 6:Specialty 33% 33% 33% 33% 33% 33% 33% 33% 33% 33% 33% 33% Matinu Jo•-ot•Poctet When member reaches Me maximum out-Of-pocket limit. $1,500 cost shares will no longer apply. Catastrophic.Stag Member Cost Share SO Notes 'Rolm me Paf ewster per maple for persons who have Medicare as primary coverage. •Anm Inr a law are is required by the federal gouemmem to all 2026 Medirare Pan D pogrom spat w rret tub'. ierre"M.. •AX c0Y-eharhg prem..Ngdee prescnp000 filled at a riebrork pharmacy of our mail-order aerator •The formulary 0 renewed and approved annually by the Centers for Medicare 6 Medicaid Services ICMSI.but 5 subpcl to charge as maintenance updates are ma.I0rdrgrwl me year . Aaeocietion.A Medicare-apprded Poi O%pornor.EnreSnenl in RCSCe pore depends on maim remora. The 5eneyelary will leare the initial coverage prase and anterMe etafYeelwn phone eleeeey Xbureee.M TrOOP-akytle cools to meet the wow) OOP threshold.IMbn a 32.100 in CV 2023 TbOCP LLywWeg on mired Pert D OMp(VIM bpMvlarrar one.bet.ty...in thee parties TI0OP MN AnUMa previously excluded HrWlevrarrw benefits and ege%ge Disco.P.O.n.Oeptreuu 2026 CMS SlarxWdMOOP in$2.100. 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