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HomeMy WebLinkAboutP.R. 15505 (PRE APPROVAL BY CITY COUNCIL)MEMO To: Mr. Stephen Fitzgibbons, Ciiy Manager Firom: Patricia Davis, Senior Human Resource Analyst ~G~i(/ Date: September 14, 20pg Re: Adoption of Proposed Resolution No. 15505 Authorizing the City Manager to Execute the Necessary Renewal Contrail Documents for a Third Party Administrator (Administrative Services Only) Contrail for the City of port Arthur Group Medics!, Dental Insurance; For Basic life, Basic Accidents! Death and Dismemberment, and Excess Lass Indemnity with Blue Cross and Blue Shield of Texas, Inc. {BOBS} ~c~endatian• ~~ I recommend that the City Counat adapt proposed Resatutton Na. 15505, which authorizes the City Manager to execute the necessary renewal centred documents for a third party administrator (administrative services only contrail) for the City of Porf Arthur Group Medical, Dental Insurance; for Basic Life, Basic Accidental Death and Dismemberment, and Excess Loss Indemnityr with Blue Cross and Blue Shield of Texas, Inc. (BSBS). The City of port Arthur on test year issued a RF'p (Request far Proposal} for its major medical, dental and life insurance plan, and with thirteen {13} responses received, Biue Cross and Blue Shield of Texas, Inc. {BC/BS} was awarded the successful propose! with a tfires-year option to renew. Staff recommend that we accept the second year offer due to no change in ra~~tes for adrninistrattve services costs, stop loss costs, dental ousts and basic life and accidental death aril! dismemberment costs for the 1111109 -10/31110 plan year. ~.ckaround: A b~~eakdawn of tfie cost and benefit levels for the 11/7/09 plan year is delineated as fellows,: The cost of the administrative services only (ASO) coverage wiN be $35g,291~-no change over fast year's rates. ~ The cost of aggregate and specific stop lass coverage will n3main the same as cast 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 e~asting benefits. (Nets: The Derrtar Plan is Furry rnsured). ~, Basic Life and Accidental Death and Dismemberment (AO&D} rates wilt riemain unchanged at $12,3913tyr. "Renro~er, we arm here to serMe the e~tfztns of Port Arthur.` Stephen FitzgibbonslMemo September 14, 2009 Page 2 of 3 Key plan amendments et1`eclive November 1, 2Q09 are as follows: 1}. Update Mental Health, SMI & Chemical Dependency to meet new legislative guidelines. Z). Setting a $10 flu shot copay for elioible employees, retirees, and/or dependents at partidpating pharmacy locations. 3). Change in diabetic supplies covered via prefen~ed RX eopay. 4). No ium i ase for ~grttal coverage for all impacted plan partiaparrt:;. 5). As City Counal has been made aware, the City has a significant liability due to GASB 45 which par#iculariy focuses on the funding of the liability for retiree insurance. Additionally, the City faces the on-going cysts assodated with rising medical costs. in aRierto address these issues, we are recommending the implementation of several plan changes. The first recommendation is to move from the cumeirtt `blended' [all categories combined and rated as one) rate to three (3) distinct categories: Active employees, Retirees under 65, and Retirees over 65 (Medicartj. Following meetings with Mickey Moshier, the City's insurance consultant, and Chris Solimine, of ICMA, each confirmed the national trends, and administrative wisdom, of moving to an 'un-blended' or unique rates for the key fisted groups. The City's Health Insurance plan states that the City wilt pay one-half (1/Z) t:he dependent cost far employees and retirees. However, during times when the City Counal either was unable, only able to provide minimal, cost-of-living adjustmerrts (COlJ1s), the City absorbed various oast increases. This has led to the City paying more than fifty percent (5096) of dependent insurance premium costs. It is recommended that we begin to move back toward the filly percent (5096} payment as stated in the plan. The City requested, and received, ratings for the City'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 (596) decrease in the rate for'Actives' with a substantial increase for both 'Retirees Under 65' and `Retirees Over t35 (Medicare)' groups. After careful and aitical review, thFs increase was deemed too significant to pass on at one time. Further, as we continue to review the City's insurance plan, and the need to divide costs loser to fifty percent (5096) as stated in the plan, it seemed prudent that these increases be phased-in over a three (3) year period. Therefore, the first one-third (113), the difference between the currently subsidized premium rate and the actual' fifty percent (5096) is recommended to be phased-in beginning this year. This will allow the City to continue to use the mo h of October for `Open Enrollment' purposes (i.e. sign-ups, benefit and dependent changes, etc.). It wiN also allow time to notify plan partiaparrts of the anticipated rate changes. "Remember, we nne hers to servt the citisens of Port Arthur." Stephen Fitzgibbons/Memo September 14, 2009 Page 3 of 3 Additionally, it wiN afford City staff the opportunity to continue to critically analyze the insurance and benefit offerings--balanang fiscal and administrative responsibility with responsiveness and consideration of participants needs. The City's ailuarial consuRant is evaluating the impact these plan changes wilt have on its GASB 45 liabil'Ry; however, we are certain that #hese recommendations will (1} result in a reduction of that liability and (2} will place the City in a position to more accurately see and apportion, insurance costs taased on plan utilization. Premium increases for all impacted active employees and retirees and/ ar dependent overages at one-thins {113) the difference of the estimated ASO conventional rates and the employees and retlnaes current monthly rates. NQTE: All other existing copaYs and ded'uc~f6les will remain the same. By~daetarv/Fiscal Effect: Approval of proposed Resolution No. 15505 will require the following amour><s: {Note: Acx:ounts 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 ......................................... $6,875 Derrtal Insurance .................. ............. ,4:i1 Basic Life Insurance ...................................................................... $ 270,Ott0 Death & D .................... .. $ 10,886 Basic Accidental ismemberment (AD&D} ............................ $ 1,512 TOTAL RECOMMENDED FUND FROM FUND N0.614 HOSPITAL IN8URANCE FUND .................................. 7 7 84R NQTE: LAST YEAR'S REt~MMINDED FUNDING LEVEr _ _ _s~ t~ ~s ~ffina/Emolovee Effect• Adoption of the proposed resolution would have no impad on staffing levels. We recommend that the City Council approve proposed Resolution Ng. 15505, which authorizes the City Manager to execute necessary renewal contrail documents fora Third Pally Adnninistrator (Administrative Services Only} Contrail for the City of Port Arthur Group Medical, Dental Insurance; For Basic Ufe and Basic Acadental Death and Dismemberment, and Excess Loss Indemnity Coverage with Blue Cross and Blue Shield of Texas, Inc. {BC/BS). "Remerpber, wr are here to ser~+ee the citizens of Port Arthur'." - ATTACHMENT 130. 1. 0 City pf Port Arthur DSO projection for the period November '1, 2009 -October 31, 2010 11!01!2009 Medical ASO Renewal CONVENTIONAL EQWiVALENT RATE DEVELOPMEN"f Single ~ $393.10 Single + 1 $589.65 $216.70 Family $984.45 $1,476.68 $977.75 $1,153.88 $1,730.82 $1,177.67 Division of Heatth Care Service Corporation, a Ntutuat Legal Reserve Company, an lndepencfent Liccensee of the Btue Cross and Slue Shield Association MedicaE P.R. No. 15505 09/14/09 - ATT/pd R1=SOLUTION NO., A RESOLUTION AUTHORIZING THE CITY MANAGER TO EXECUTE RENEWAL CONTRACTS BETWEEN ITS THIRD PARTY ADMINISTRATOR {ADMINISTRATIVE SERVICES ONLY) FOR THE CITY OF PORT ARTHUR GROUP MEDICAL, DENTAL INSURANCE; FOR BASIC LIFE, FOR BAStt: ACCIDENTAL DEATH AND DISMEMBERMENT, AND EXCESS LOSS INDEMNITY WITH BLUE CROSS AND BLUE SHIELD OF TEXAS, INC. FUND N0. {5) : 614 -HEALTH INSURANCE FUND WHEREAS, the City Counal of the City of Port Arthur deems it necessary and appropriate to continue major medical health care benefits for the City's ennployees and its retirees, and; WHEREAS, the City Counal deems it in the best interest of the citizens of Port Arthur to be self-funded and to acct the renewal proposal from Blue Cross and Blue Shield of Texas, Inc. as a third party administrator at an estimated cost of $358,290 per year (administrative charge based on the present numlber of ennployees 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}, Cor~oetitive Rffiuireln~n2r,C~ in p,I~ 252.024, Se~kion of insurance Broker. and 252.048, Chanfle ~-rders. respectively of the Local Government Code; and, WHEREAS, the nature of the premiums to be charged by the Ci1.y and the summary of benefits are as delineated in Exhibits "A-1 ;and "A-2" which EXHIBIT "A-1" city of sort artnur 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 Health Cere Service Corporation, a Mutual Legal Reserve Company, an Indepeindent Li~oensee of the Blue Cross and Blue Shield Association City Of Port Arthur ASO Projection November 4, 2009 -October 31, 2040 11101J2009 Medical ASO Renewal A!t CLAIM PROJECTION Net Paid Claims Remove Large Claims Number of Large Gaims Adjusted 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 Adjusted ACV PCPM Non-Pooled Large Claims PCPM Projected ACV PCPM by Period 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 Enroliment Number o[ Months in Policy Period Projected Net Paid Claims $703,356 5 $3,744,737 9,395 5398.59 9.9% 29.0 25.7°~ $501.03 0.00°k 0.22% $502.13 $53.22 $555.35 $515,274 4 $3,682,260 9,668 5380.87 10.3% 17.0 1a.a% $437.62 0.00% 0.65% $440.46 $41.37 $481.83 84% $493.59 $476.07 100% $493.59 0.00% $493.59 814 12 $1,271,730 9, 395 $13:1.36 8.2% 29.0 z1.o% $163.79 0.00°~ 0.:!5% $164.20 $o.oo $1 &t.20 16% $1,337,592 9,868 5138.35 7.0% 17.0 10.1 °~ $152.32 0.00°~ 0.61 $153.25 $o.oo $153.25 84% 5703,356 5 $5, 016,467 9,395 $533.95 $664.82 $666.33 $53.22 $719.55 $155.00 $130.33 100% $155.00 o.oo% $155.00 814 12 Oiviaion of HaNlh Care Service Corporation, a Mutual Lepal Reserve Company, an IndspentlaM Licernee Ot the Blue Cmss and Blue Shield Aasorlalion City Of Port Arthur ASO Projection for the period November 1, 20x9 -October 31, 2010 11/01/2009 Medical ASO Renewal TOTAL PROJECTED COST Ali Employees ~ ,'~~ ~ ~ ~Ft Individual Stop Loss {$100,000 Level) Aggregate S#op Loss 125% Attachment Point Administration Fee Prescription Drug Rebate Credit Net Administration Fee Total Projected Cost Run-Off Administration Run-Off Claim liability . • TotalCost $6,335,427 $44.64 $436, 044 $4.04 $39,463 $50.05 $488,888 ($13.37) ($130,598) $3E>.68 $358,290 $7,169,224 $28.48 $69,548 $297.69 $726,960 Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association City 4f Port Arthur ASO Projection November 1„ 2409 -October 31, 2010 11101!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 lndividuaf Stop Lass Premium STOP'LOSS =Actives • + IYledicare Retirees ':F.,. ' SINGLE . ~ FAMILY `-~~SINGLE_~ :FAMILY 395 305 76 36 $368.95 $1,032.70 $161.23 $732.36 '125% 125% 125% '125% $461.19 $1,290.$8 $201.54 $915.45 $2.30 $6.44 $2.30 $6.44 $101),000 $100,000 $100,000 $101),000 $:?5.39 $71.07 $25.39 $71.07 Minimum Aggregate Attachment Point Run Off Administration $16.20 $45.35 $16.20 $45.35 Run Off Liability $178.53 $499.69 $78.02 $354.37 Subject to and contingent upon conditions and caveats outlined in attached addendum. Division of Health Cane Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the etue Cross and Blue Shield Association Custo ~; $648.6 125° $810.7 $4.0 $1 oa,0o $44.6 $28.4E $297.6f City Of Port Arthur ASO Projection for the period November 1, 2009 -October 31, 2010 11/0112009 Medical ASO Renewal FEE COMPARISON Mature All Em~lovees . ~ ,` ~ ' , Cuurrent ~; ;Renewal S~ngfe ~Famlty. ~~Smgle. ~Farnily ` Proiected Enrollment 471 343 471 343 Administration Fee Prescription Drug Rebate Credit Net Administration Fee PCPM Individual Stop Loss $100,000 Level Aggregate Stop Loss 125% Att. Pt. Total Fixed Costs PCPM Projected Average Claim Value PCPM Projected Aggregate Limit PCPM Total Projected 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 $368.95 $1,032.70 $368.95 $1,032.70 $461.1! $1,290.88 $461.19 $1,290.88 $417.50 $1,168.61 $417.50 $1,168.61 Customer Tc .Current=Renew . `! ~ ~ QCPM ~ ~ ~PCP..N 814 814 $48.02 $50.0; ($11.34) ($13.3' $36.68 $36.6 $44.64 $44.6 $4.04 $4.0~ $85.36 $85.3 $648.64 $64$.+ $810.80 $81 a. $734.00 $734. Division of Neatth Gare Service Corporation, a Mutual Legal Reserve C+3mpany, an Independent Licensee of the Blue Cross and Blue Shield Association City Of Port Arthur ASO Projection for the period November 1, 2009 -October 31, 2010 11/01/2009 Medical ASO Renewal CONVENTIONAL EQUIIVALENT RATE DEVELOPMENT' ,,,,~, Medical ._.~,~~ . - .' ;' •s_~~ ',; ~ r~laves~~~,Gu'rrent~~Renewal^~ ~._ r HCSC Primary te' Single 395 $413.79 $413.79 " Single + 1 106 $1,036.26 $1,036.26 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 8r Medicare Total 814 Division of Health Care Service Corporation, a Mutual Legal Reserve Comiaany, an independent Licensee of the Blue Cross and Blue Shield Association City Of Port Arthur ASO ProJecNon November 1, 200f - Qetobar 31, 2010 71r01120Qf Medleal ASO Renewal CONDITIONS AND CAVEATS Rates are pojeded to DB ettedive for the 12-month period bepinMnp~ on Ore ettet:Hve date indicate0. Finat rates may vary base0 on actual enropmen roeultB. This renewal attar assumes OCBSTX will remain the oxdus~ive r~rrin~. The fatal annual premiums era Oased upon the tatat Current enrollment and wntred tlistnbudon as indicated. RerxTVal often easumo exYstinp atlminiatration preUicea erM wntnCS proviBiona wYl romatn in place, M the enrollmem or wntrad dislrbuson varies 6y more than 10% in kxel or in each ooverope indeperMemly, we reserve the right to re-rate. Ttw minimum participation requlremem Is 75% wittwut wair~era and 65% with va0d waWen in order for wverapea ~ De issued. The employer maintaining the wnant wntriwtion sdledule. Annual open enrollment. No additional taxes will be imposed and no inaease in existing taxes until the next Armivelsary Date. Rotes do net intude any future mandated benefx changes. Upon inquiry from employer groups, BCBSTX will provide Infonnadon b the employer Oroup repardirrp Commissions and other oomgsnsabon paid to the employer's spent try BCBSTX in conneUion with the empbyel'.s policy a wntraet wlOt BCBSTX. The renewal ie being olferetl On a paid basis. Health Paid Claims subject to Sbp lAaa are daima paid duutnp the q~licy period indiicated above. Health Paid Claims subjeU to M0ivf0ual Slap Loas ore paidl daims frtrm the f011wWnp lino(:) of coverage: Medical and prtlp Heath Paid Clamn 6ubjed to Aggregate Slop Loss aro paid daima flnrrt the tdlowinp line(sy d wvenpe: Medical antl Drug Ths total annual health Stop Loas premiums and ACV factors are Dosed upon the Wtat Ouh'ent onrollment and wntreU Wsbibu0on sB NMicaled on thla ezhlbit. Significant Changes in the above stated enrollment and wntrad dtstribvlion wal roquire a review end adjustmert of the leas and fachxa. BCOSTX reservos the right to adjust the Average Glaim Value if one or more of the following arson within the coverage period: TTe minimum Aggregate Attachment Point was r~lrulated as 90% of the ASL Limit par wnfroU per month mulliplietl by the projected cumulative contreds for the period. Individual Health Stop Loas and Apprepate Health Stop Lass promiurne ese payable an the first dsy of each month. Arty amount in excess a} he Individual Health Stop Losa lirnil will not Oe kxltWOtl m ate Apprepate Health Stop Lou Settlement. The Aggregate Stap Loss benefd payments ahas not exceed a maxinwm of 51,000,000 pBr policy period. Premium £quivabrt Rates ratted exped6d beneM wet anti end do not intrude an adjustment for a change in needed roaarves. Pnmium Equivabm Rstea should fund expoUed paid daims fEPC1, admMberation, stopbu charpos and estimated rosavea; if dafrns exceed EPC, dte Emppyer wla be roqulred to make atltltbnal funds available up b the Maximum Claim Lbbitly Upon Tertnlnation, the rtrnatt fedora ai»ve will De muRpHatl times 7e total er atl corlilkata8 actualy exposed during eats O11he three months immetliately preceding wmred tertninatbn and the roeut wilt be the oblipstlon of the Empbyer. The RuneM Admirtiatration amount is due and payada whether of riot BCBS7X prooassea ttto rw-oM daims. Ttxe Administrative charge indudes a network access fee kx Tezaa rmployeea. Out-d-slats employees roll lte accessed a rharpe o4 1d9L of Ule discount per daim, not to exceed 52.000 per daBn, Thia dalm cherpc will be included in your monthly BARS atatdmem. Costs aseoCiatBd with apedal services or CuatOm materials provided by BCBSTX will 1>e 4illed separNe and apart 1rWtt the Administabve Charges outlined On ONa ezhiblt. The employer i5 responsible for any admirtistreWe services taxes due for ber~Ota paid under this agreement. OMrrM ~d Iwaul c.r. s.,.~ taawrr,,,., rwur t.w nr.or CrneaM. rn M,lrprMlM llr N III Blur Cmn W W srwq ~Ynetla City Of Port Arthur Prospective Premium Projection for the period November 1, 2009 -October 31, 2010 '1110112009 Dental Fully Insured Renewal Presented by: Bkie Cross Blue Shield of Texas Division of Health Gare Service Gorporation, a Mutual legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association +Ci#~ Qf Port Arthur Prospective Premium Projection November 1, 2009 -October 31, 2010 11/01/2009 Dental Fully Insured Renewal CLAIM PROJECTION Ail 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 DENTAL .. '-05108 ~~ 08,109 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 Projjected 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 of He:altn Care: Service Corporation, a Mutual Legal Reserve Comipany, an Independent Licensee of the Blue Cross and Blue Shield Assodalion City Of Port Arthur Prospective Premium Projection for the period Tlovember 1, 2009 -October 31, 2010 11!01!2009 Dental Fully Insured Renewal TOTAL PROJECTED COST ~,, All Employees ~. ... `' ~ .. ~ ~ Trail Projetted Enrollment -- 6 42 Total Projected Net Claims $23p,~,~ Risk $10,606 Total Benefit Charges $241,162 Desired Loss Raticl (DLR) gg,gb% Preliminary Premium $272,027 Required Premium $272,027 Premium at Currerlt Rates $272,Oi 1 Required PremiumlPremium at Current Rates 0.00% Division of He+31th Care Service Corporation, a Mutual Legal Resenre Carripany, an Independent Licensee of the Blue Cross and Blue Shield AssociatAm ~Cit~ Of Por# Arthur Prospective Premium Projection for the period November 1, 2009 -October 31, 2010 17!0112009 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 City Of Port Arthur Praspective Premium Projection November 1, 2009 -October 31, 2010 '11101!2009 Dental Fully Insured Renewal CQNDITIQNS 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 <;arrier. 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 I The minimum participation requirement is 75% without waivers and 65% with valid waivers in order for coverages to be issue The employelr maintaining the current contribution schedule, Annual open enrollment. No additional taxes wilt 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 oth~ to the employer's agent by BCBSTX in connection with the emple~yer's policy or contract with BCBSTX. Division of Heallh Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association EXHIBIT "A-Z" Blue Cross and Blue Shield of Texas Summary of Benefits Prepared for CITY OF PORT ARTHUR #31118 PPO __T__ TYPE ON SERVICE NETWORK: GENERA[, PROVISIONS Calendar Year Deductible (Applies to Non-Inpatient Hospital Services) $500 lndiv/$1,500 Family 4'h Quarter Carryover Applies Yes Deductible Credit front Prior Carrier N/A coshare Stoploss Maximum $2,500 Indiv/$5,U00 Family per cal. yr. 9 !\'envork ded~actibJe and coshare C wi!! only apply tvwarc! Network deduc~rble aatd ccshare coshare Stoploss Credit tiom Prior Carrier NIA Lifetime Maximum per Participant $1,00 0,000 INPATIENT HOSPITAL SERVICES (must be preeertitied) 80% Per Admission Deductible None Pcnalt for Failure to Precertitj~ None EMERGENCY ROOPvIfI'REATMENI' ROOM Accident & Medical Emergency Situation within 48 Hours Facility Charges 80%afler $100 copay, waive Physician Charges 80% after cal. yr. ded~ Nort-Emergency Situations Facility Charges 80%afler $100 copay, waived if admitted GO Ph siciart Char es 80% after cal. ~r. deductible MEDICAL-5URGIC~-L SERVICES Services Performed in Physician Office (non-surgical); Including Lab & X-ray 100% after $25 copay per visit Immunizations (birth to the day of the 6`h birthdate} IQO% Physician Surgical Services in any Setting 80% after cal. yr. deductible Lab & X-Ray in Other Outpatient Facilities (excluding Certain Diagnostic Procedures): i00% • Certain Diagnostic Procedures: Bone Scan, Cardiac Stress Pest. CT Scan (.with or 80% after cal. yr. deductible without contrast), Ultrasound; MRI, Myelogram, PE'I' Scan Home infusion Therapy (must be precertitied) 80%afler cal. yr. deductible in-Vitro fertilization Ucc lincd Chiropractic Care - Ott'ice Sen~ices 80% afler cal. yr. deductible $1.500 ca l. yr. m: A!1 prher Ph}~sicaf d~edicrare Services reaiclerec wt!! be allowed oar the same basis a Speech and Hearing Services with i-fearing Aids Covered as any other sickness $1.000 Maximum benefit per 3G-month Ali Other Outpatient Services and Supplies 80% after cal. yr. deductible PI'v-ASO•STRL7.WI"i"fi.NFT.DFD-G-SOi3 ' i31uc Cross and ]31ue Shield of'fcxas, a Division of health Care Service Corf~orauion, a Mutual Legal [icservc Coanpast}•, PPO CITY OF PORT ARTHUR #31118 ~_ TXPE OF SERVICE NETWORK PREVENTIVE CARE Routine Physicals, Well L3aby Care, Immunizations (after 6`h birthdale), 100% after $25 eopay per visit Vision & I•leari~Exams EXTENDED CARE SERVICES (must be preccrtified) 100% Home 1•Iealth Care Calendar Year A+laximatn $10,000 per cal. yr. Skilled Nursing Facility $10,000 per cal. yr. Hospice Care $20,000 Lifetime max. Bene its used in Network or Our-o -rVetwor k ap ~l ~ t MENTAL HEALTNi/CHEMICAL DEPENDENCY (must be precctKified) Inpatient Services Hospital Service's (Facility) 80% Ph}~sician Services 80% after cal. yr. deductible Calendar 'car Limitations 30 inpatient days/30 physician visits Outpatient Services Dn s and visas used irr Network or Uret-o -Netrurk a ~ Services Perfornned in Physician Office (non-surgictil) 100% after $25 eopay Emergency Room/Creatment Roon>/Facility Charges SU% after $ I OU eopay, waived if admitted 60~ Professional Provider 8U% after cal. yr. deductible Visits Allowed 30 outpatient visits per cal. yr. Chemical De endency Maximum for each Covered Individua{ $10,000 lifetime max SERIOUS MENTAL ILLNESS (must be precertified) Cnvrrrrl :.~ :,~,., ,,,h,., ,. 1~1'O-ASO-STRi:). W ITH,NE"-1'.DCll-G-SOA Blue Ccoss and 131ue Shield of'I'exas, a Division of Health Carc Sen~ice Corporation, a Mutual Legal Kescrve Company, CITl~C OF PORT ARTHUR #3ilIS PPO TYPE OF SERVICE PARTICIPATING PkIARMACY N( PRESCRIPTIOiY DRUG PROGRAM Retail Prescriptiort (all copays are per 30-day supply atzd wild not apply to coshare sloploss maximum) ?ion-I'relerred 13rartd Name $SO copay g( Preferred 13ranci Namt' $30 copay g( Generic $10 copay g{ Mail Service Prescription Yes (all copays are pear 30-day supply and wilt not apply to coshare stoploss ma~imutn) Non-Preferred Brand Name $SO copay Preferred. Lirand l~fame $30 copay Generic $lOco ay *If there t:r r:o Generic Drug for the Preferred Brand A'ante Drug prescriptirr,l, the Participant wit! pay no mar than the appiicabte Preferred Brand Name Dt Prejerred Grand h'arne Drug ja- which a Generic Drug is availabtc~, the copay mttoran N~ill be the stun of (aJ the difference behs~een the ,4lJorva6le Rnto:utl of t f1(lowaflle Amount oJrhe Generic Drug. plus (b} the Preferred B,-aitd Nanre Drug copay. PPO-ASO-Sl~l2t:).WiTH NL-T.DGD-G•S013 Blue Goss ,end l3ltre Shield of Texas: a Division of Hea3th Care Se:vice Cbrporalion, a Mutual [.e~al RCSCI'vt: Company, CIT7~' Ok PORT ARTHUR #31118 PPO EiVIPLOYEE INFORMATION • This is a. gent:ral Stltruttary 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. • Unmat•ried grandchild of the insured are covered if the grandchild is under 25 years of age and is claimed as a dependent by thl purposes. • Automa~Iic coverage for newborns for the first 31 days folllowin;g birth. Infants not enrolled for coverage within the first 31 day: coverage until the following open enrollment period or special enrollment event. Provider cha~,rges arc paid according to BCBSTX detet~nined Allowable Amount and negotiated prices. • Preexisting conditions are defined in the benefit booklet and are excluded far l2 months. Appropriate credit will be given for time serve as defined u~itder the law. Radial Keratotomy -covered • Lasik --covered • Eff 11/1/0.8 Services, supplies and/or prescription drugs for reduction of morbid obesity, including surgical procedures, whets medically n sickness. (Note: Prescription Drugs 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 (H1PAA), the eligible pat~ricipant who has health coverage under the employer's plan immediately prior to the effective date: of the health contract helve contract date): • Benefits for eligible expenses incun•ed for any service or supplies prior to the contract date; are not covered under dte contract. • Eligible expenses for services or supplies incurred on or after the efieetivc date will be considered for benefits subject to all applicab t~ho-nso-sTRV.~un'li.tvr r.l~rl~-G-sot3 t31U1 CfOSS 11115 I31Ue SIIIeId of -Texas. ~ Division ufflaellth Care Service Corpu,auon, a Mutual Legal Reserve Compln)'. E~CHIBIT "B-1" CITY OF PORT ARTHUR HEALTH INSURANCE RATES (BLUE CRO55 BLUS SHIELD OF TEXAS/THIRD PARTY ADMINISTRA' EFFECTIVE NOVEMBER Z, 2009 PPO RATE5 1=0R All ACTLYE EMPwrt~~ Medical d pental City's Monthly Cost Employee's Monthly Cost Employee's 8i-Weekly Cost (24} Employee - 145.24 Employee ~ 1 C~ependent $742,34 $290.48 $183.73 Employee de 2+ bependents $845.74 $367.46 $ EDICAL AWD DENTA4 R Medica) d Dental ATES Medical pentat Medical d Dental 38 $413 Employee ;393.10 $20.28 . $2 032 1 $ Employee ~ 1 Dependent $984.43 $48.37 , , 2Q 213 1 $ Fmnlovee 6 2+ Dependents ;1,1'93.88 $59.32 . , ~.-,~7 EXHIBIT "B - 2" City of Port Arthur Health Insurance Rates (Blue Cross Blue Shield of Texas/Third Party Administrator} Effective November 1. 2009 ~ ~ ~ City's Monthly Rstir Clty's Cwt Retlrss's - Total ~t Cost Effsctivs .Cos Monthly Cost Monthly Cost Monthly Cost 1!/1/09 , Rstiress (Medical Only) 24 230 $ 183.55 $ 413.79 $ 369.01 $~. ~~ Retiree Under b5 $ . 12 90 $ 14 646 $ 1,036.26 $ 701,53 ~'$ Retiree<65 & 1 Dependent $ . 3 . 33 4 $ 214.61 1 $ 861.16 $ Retiree<65 ~ 2 Dependents $ 490.28 $ . 72 , 4 37 $ 79 413 $; Retiree~65 6 Medicare Dependent $ 2b1.30 $ 333.07 $ . 59 . 80 44 $ . $ 31.06 $ 149.50 $ 180.58 ~ $ . :. Medicare Retiree ~' 393.43 $ 421.36 $ 814 79 $ 497.77 _$ - Medicare Retiree d~ i Dependent 54 9 $ 98139 $ b12 25 $ Medicare Retiree d~ 2 Dependents $ 481.85 $ 49 . 16 3b1 $ 89.59 $ Medicare Retiree & Medicare Dependent $ 62.15 $ 299.01 $ . .•~a EXHIBIT '"C" •*'F~ B1ueCross BIue,Slueld of Texas ,tune 25, 2009 Mr. Afber# Thigpen City of Port Arthur P. O. Box 4089 Port Arthur, Texas 77641-1089 pear Mr. Thigpen: Re: Anniversary Date: November 1, 2009 Group #: 31118lG31118 Thank you for• allowing Blue Cross and Blue Shield of Texas (BCBSI'X} the opportunity to provide group be~efit co~rerage to you and your employees this past year. We are proud of the pa{tnership 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 Addicfion >rquity Act (MHPAEA} which amends the Employee Re#irement Income Security Act (ER1SA), the internal Revenue Code (Code) and the Public Health Service Act (PHSA}. The MHPAF~+, generally requires that group health plans and group health insurers apply the same treatment and financial limits to medical and surgical benefits and to mental health and subs#ance use disorder benefits. l=or 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 F;evisions to ASO Benefits and Provisions SCBSTX must periodically adjust its s#andard benefit 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 reViSlOnS: Exclusion #or video fluoroscopy and manipulations under anesthesia (except for chat of the spine) wilt be removed from the medical limitations and exclusions. These services are no longer considered experirnentaUnvestigationalond are now supported by medical policy guidelines for certain diagnoses. Anew provision, entitled Not6ce of Credrta6le Coverage, will be added to the General Provisions section of your benefit booklet. The new provision is compliant with Department of Labor (DOL) requests, bui does not affect existing pol'ICies and/or procedures. Te~:t Garifications have been made in the section entitled, ,Preauthorizatian for inpairerrt Hospital Admissions. The text: clarification is compliant with 1epartment of Labor (DCft) requests, but does not affect existing polices and/or procedures WHY BLUE. CROSS Access: Unparalleled Provider Networks BCBSTX offers managed care and traditional 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 state. it includes more than 56,004 physicians, nearly 540 hospita'.s, and is available in all254 Texas counties. Our network is built on strong relationships with local providers and is fastened by our Office of Physician Advocacy. 3ti1~~ t:aldt•r, Sllit+• 7{)0. Nt•al:mnnl, "li~~t+s -7i{)' • (.~Qt)} Si){i-{IiQI) • F:1~ (.){){)) Sii{i-i){ ! 1 t Ili. ,.p.u .d' ilralU, G,n- ti,~r~,ev lw.rta,rn[Mnf, a 11„teal ir~,l llr~-nr Ii+aga,n, all lad,i„~ulru! I.nnwr er1Uv ti{ur t],e+. cad lilur Sbu•h! lv.eialinu Nqk i.! 1 i.111t11: When consulting a Physician or Professional Other Provider who does trot par't-Gpate in the Network, your employees may also benefd from discounts if the provider participates in ParPla» --- a simple, direct~ayment cost protection feature that is not available with other carriers. if the Physician or Professional Other Provider participates in ParPlan, he agrees to: • File member claims direc#ly with 8CBSTX, • Acoept the allowable amount determination au payment for Medically Necessary services, and • Not bill for services over the Allowable Amount determination Sanrice: Untparaltaled Customer Service, Online Capabilities BCBSTX traces its origin to the non-profit Baylor Plan founded In 14129. We have continued to serve Texans and Texas- based employers ever since, and have become one of the most widely recognized and widely respected health care companies in the state. As your carrier, BC85TX has demonstrated a commitrnent to outstanding account management and customer service. The account management team will continue th interact with you to ensure the ongoing maintenance of your benefits program. Your employees have benefited from the one~sLop 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. Sate-of~her-Art Technology: BCBSTXoom D Blua Ac:cerss®for Empbysrs ~BAE} To help reduce the time spent on paperwork and help you more quicdcty and easily administer your company's health care benefits plan, we offer a range of online employer and employee online rzpabillties through BlueAccess® for Employers (BAE). Wtth BAE, you can conduct a variety of membership, enrollment, reporting, administrative and billing transactions online quickly and accurately. You can verify and edit information. Changes that impact your bill are recorded immediartely. Md because 8AE is secure, you can be confident that your transactions are safe and protected. To see a» o»lirre demonstration of horn >3he many features of BAE Ca» work for you, simply go to www.bcbs~CC.com/errralovers a»d take a tour. D BlueOu~tlook and Bluelnsight Reporting Based on group size and funding arrangement, available data repotting services may include standard monthly, quarterly, and annual reports that provide in-depth utilization anaiys~, enrollment reports, and related savings, such as coorcrnatian of benefits and subrogation. Ad hoc reports may be available for an additlonal charge.. Employer groups tray access their reports online. Blue Access 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 Servk~a. Provider Finders and Pharmacy Finder - downbadable network provider directories that can be formatted by produc!/inetwork type, region, and city area_ A link tD the Blue Cross and Btue Shield Association Web site proves a listing of national and international providers. A Link to the Prime Therapeutics LLC site 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 avaiiabla~ in the preferred brand tame category with noted generic equivalents; and information about the BCBSTX three-tier copayment structure. Downlo~adabie forms -for claims submission, Student dependent certification, prescription drug claim reimbursement, and prescription mail orders. Customer service -for replacement iD card requests and other a-mail inquiries. Health tare Qeciaion Tools -- In addition to offering eligibility and Bairn status information online, BCBSTX provides members with access to exclusive online health and wellness content and decision-making tools. Health Frisk Assessment -Members will benefrt ftom the Health Risk Assessment and other self-management Web- based tools relating to common health care problems such as asthma, kner back pain, and headaches. These programs vvi14 be integrated with BCBSTX care management programs, as applicable. Members may also access information about specific diseases and treatments, including alternative medicine and interactive health/Iifestyle decision-making tools. Hospital Comparison Tool -BCBSTX also offers members access to a hospital comparison toot that alksws members 'to make informed hospital selections using interactive software. Members can generate a fist of hospitals meeting criteria they've specified, such as patient volume, location, mortality rates, and unfavorable outcomes. Memlaers can perform their own side-by-side comparisons of network hospitals, to ensure their comfort and satisfaction with their hospital experience. Value: Competitive Administratfire Costs, Innovative Medical Management, Health Care Cost Solutions Keeping healHl care affordable is important to us because it's important to you. BCBSTX takes a proactive approach to Powering the post of health care for employers and empbyees. Blue Resoun:e In conjunction with the Blue Cross and Blue Shield Association, BCBSTX has launched the Blue Resource communication campaign to increase awareness of how health care choices impact the rising cast of heaps care. BCt3STX provides applicable messages and attvvork online at vrww.l~rebsbc.com, at no cost to employers. Campaign materials are !grouped by heaRh race topic such as Health and Wellness, Weight Loss and Fitness for Work {maximizing productivity through ergonomics, stress management and more}. BlueExtrassr'' Discount Program Blue Cross acrd Blue Shield of Texas {BCBSTX} is committed M supporting our members' wellness objectives and is pleased to offer BlueExtras, valueadded discount programs designed to encourage healthy lifestyles. BCBSTX currently offers our merr-bers the folbwing discount programs including vision, hearing, weight management, and complementary aftemative medicine. Davis Vision The value,ad+~ed vision program offered by Davis Ysion for BCBSTX; members provides your employees with discounts for routine exrams, Tenses, frames, and contact lenses. It also incPudes a mail order contact lens repfaoement program {LENS 123), and a network of participating providers offering discounts on laser vision correction. TruHearing The TruHearing program allows your employees {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 screen':ng, hearing instrument fitting and related services through the TruHearing network of participating providers. To access the program, calf 1-877-882- 2020, betweern 8 a.m. and 8 p.m., Monday through Friday m locate a provider, schedule an appointment and obtain a referral to they provider. lYs that easyl Jenny Craigr>9' 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 State:. members have convenient access 1A Jenny Crai~ Centres, or can join Jenny Direct, the at-home program. Members can register for discounts online through BlueAcxess for Members or present their BCBSTX ID cards at participating Centres. To locate the nearest Cersbe, members can visit the Jenny Craig Web site at wvrw.jennycraig.com or call (800)'.597-Jenny. Franchise partiapation and discounts may vary, so members are encouraged m verify their discounts belFore joining. Curves"' Curves is thes Largest fitrsess franchise in the world with over 10,000 locations worldwide. It is the first fitness and weight Foss faality to target women and provide them affordable, one-stop exercise and nutritionaE inforcnation. BCBSTX members and their covered dependents can join Curves for a special $49.00 joining fee. Regular monthly fees apply. 7e join, member3 will simply present their 8Ct3STX lD cards at Curves frtrtess centers. To locate the nearest fitness center, members can visit www.curves.com or call (800} CURVES-30.. Franchise partidpadon and discounts may vary, so members are encouraged to verify their discounts before joining. ComplemeMlary Altemativs Medicine The Comptennantary AlEemative Medicine program through Healthways WhofeHeafth Networks, Inc. provides BCBSTX members aa~ess to the Heaithwarys network of more than 35,000 practitioners, spa, wellness and fitness centers. BCBSTX memmbers receive discounts of up to 3456 off services such as yoga, Pilates, massage therapy, acupuncture, Thai Chi, and nutritional counseling. The pn~gram also includes discounts to spas, and wellness and frtness centers such as Gold's Gym, Lifetime Fitr-ess, and Anytime Fitness. Additionally, (BCBSTX members have access to up to 25 percent off the n3guiar price for purchase of vitamins and herbal supplements; and discounts of 50 to 80°!0 on health and wellness-related magazines. For additional information, or fo find locations nearest them, members can log on to wholehealthmd.oam or to order vitamins and magazines, log into BAM at www.bcbstx.+aomlmember and vis'st 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 andlor BCIBSTX of your renewal decision at toast 15 days prior to your anniversary date, - Please s:ee the attached A3O Exhibit for the Medical ntnewal rates. Dental & One ~ Fam Life Rates {Guaranteed until Present Effective on Renewal 11-1-2010~_~ Basic Lime S.24 $.24 AD 8~ D;) 5.04 $.aa Additional (Monnation and Reminders Texas legislation mandates an annual open enrollment period. Phis means your annual open enrollment for ail eligible employees and their dependents must be at least 31 days tong and prior to your anniversary date. It is imperative that you submit all enrollment applications and change forms during thiw open enrollmen# 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 Portability and Accountability Act of 1886 {HIPAA) became effective 07J01/97 and was modfied 07J'01/05. HIPAA continues to affect all individuals eligible to enro14 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 rested to Empbyer Groups and is required by HIPAA and does not necessarily reflect the rules mandas,ed by House Bill 1212 (Texas Legislation). A copy of the HIPAA Notice has been included with your renewal far use in distribution. Please copy and drsbibute this Genera! Notice of Enrollment ,Rights, dinec~ly to a!1 of your gm gees as soon as possible. 77ais new notice must also be given fo each new employee prior to enratlmenf in or declination of health coverage. The Employee Retirement income Security Act of 1974 (ERISA) is a federal law that seas minimum standards for employee benefit plans in the private industry. ERISA status is important in determining whether state laves apply tv a benefit plan, and is also important for tax and reporting purposes. BCBSTX requires written documentation tnduding signature o1` your group representative connsming your ERISA exemption status. Please contact your broker or BCBSTX account exE~cutive to report changes in your ERISA status or to confirm you have previously reported your ERISA status. 4 If you have any questions regarding the information provided In this Fetter, any of the enclosed documents, or would 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 bunt with the City of Port Arthur and took forward to contsnuing our relationship. Sincerely, Blue Cross Blue Shield of Texas r- ~ V VV Terry Villiva, ~AHP Account Executive Phone: 408.896-4104 Fax: 409-896-0111 Email: Terrv ,Vi1[ivaCaabc~sbc.co~n TV:mj Endosures cc: Mickey Nloshier ASO Exxzsz~ rr~~rr Benefit Program Application ~"ASO BPA") Applications 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): 031118,031 '120 0407,0002,0009,9900 Legal Employer Name: City of Port Arthur (Specify the employer or the employee trust applying for co~~erage. 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: 7'7641 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: NIA Subsidiary Address: N!A Gity: N!A State: NJA Zip: N/A AdministrativE~ Contact: NIA Title: NJA Phone Number: NIA Fax Number: NIA Email Address: NJA Blue Access 1`or 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 Anal st Phone Number: 409- Fax Number: 409- y 983-8214 983-8282 Email Address: padavis@portarthur.net Affiliated Companies: NJA Location{s}: N!A ERISA Plan: ^Yes ®No If yes, specify ERISA Plan Year: N/A (mmldd/yy) ERISA Plan Administrator: N!A Plan Administrator's Address: N/A Effective Date of Coverage: 11-01-2009 Anniversary Date (AD): 11/01 Nature of Business: City Government ttteCUVe: i 1,rU1/1UUti 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 wham commissions are to be paid: Note: Agent of Record Only - No commissions are paid on this Account - Sherlock Insurance Agency, line. Tax ID Number {TIN) of ^ Agent or ® Agency: 760236574 Producer#: Agency Address: Street:4155 Phelan City: Beaumont, Texas Zip: 77707 hest tx gen aso bpa 060309 (on-line version) 1 Phone: 409-832-7736 Fax: 409-833-1721 Email: mickey@edwardsandsherlock.com 1s Agent/A.gency 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: Em;3il: Is AgentlA,gency appointed with BCBSTX? ^ Yes ^ No General Agent? ^Yes ^ No Affiliated with General Agent? ^Yes ^ No If commission split, designate percentage for each agent! agency. Alote: total commissions paid must equal 100% AgentlAgency 1: % Agent/Agency 2: 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 abovea on both agents/agencies. BOTH must be appointed to do business with BCBSTX, (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. Ful!-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 if yes: A i~omestic Partner, as defrned in the Plan, shall be considered eligible for coverage. The Employer is responsible for providing notice ofpossible tax implications to those Covered Employees with Domestic Partners. If yes, are Domestic Partners eligible to continue coverage undE:r COBRA? ^Yes ^ No If yes, are dependents of Domestic Partners eligible for coverage? ^Yes ^ No 4. Are unmarried children of any age who are medically certified as disabled and dependent on the employee for support and maintesnance eligible for coverage? ®Yes ^ No Are unmarried children over the limiting age who are medically certified as disabled and dependent on the employee for supponl 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 ®IVo fi. Are unmarried grandchildren eligible for coverage? ®Yes ^ No If yes, mu:;t 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 Q60309 (on-line version) 2 1. Eligible Person means: ® A full-time employee of the Employer. ^ A full-time employee who is a member of: ^ The . day of employment. ^ 'The , day of the month following months} or days of employment. ^ The . day of the month following the date of employment. ® Other: Civil Service emp#oyees - effective 1st of the month following the date of employment; All ol:her employees -effective 1st of the month follawing 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 ^ IVo If yes, please attach eligibility and contribution details for eachf 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 Eliyible 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; __ M+onth 3 Month 4: For Annual Notification, indicate one month (Jan-Dec} for notification, for Semi-annual, select 2 months, for quar#erly, select 4 months Au#omatically cancel dependents who reach the maximum limiting age? ®Yes ^ No 10. Termination of coverage upon reaching the Limiting Age: ^ Coverage is term#nated on the bir#hday. ^ Coverage is terminated on the last day of the month in whiich 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 (12131) in which the limiting age is reached. ^ Covearage 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. EnroNlmerrt: 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 e;,overage 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 ar did not apply when a#igible 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 mutua0y 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 follawing receipt of the application. An 18••month pre-existing waiting period applies. Specify Open Enrollment Period: 10101 - 10/31 12. Pre-existing waiting period {applies to the accounts initial enrollment): hcsc tx gen aso bpa 060309 {on-line version) ^ No pn:-existing waiting period. ® Pre-e;~isting applies to all participants. ^ Pre-e:isting 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 i.o the effective date of membership will not be covered for 1 ~'. months after the effective date. 13. Extension of benefits due to Temporary Layoff, Disability or Leave of Absence: Temporary Layoff: NIA days Disability: NIA days Leave of Absence: NIA days However, benefits shall be extended for the duration of an Eligible Person's leave in accordance with any applicable federa! or state law. 14. COBRA Auto Cancel? ®Yes ^ No Member's COBRA/Continuation of Coverage will be automaitically 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 far Members. ^ BCBSTX will enter enrollment online through BlueAccess for Employers. ^ BCBSTX wil! enter enrollment via paper applications. ^ BCBSTX will enter enro{Invent 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): NIA -RENEWING ACCOUNT 4. Total number of individuals currently covered under COBRA: 1 LEGISLATIVE ELECTIONS Copy of client's application to CMS for exemption • Copy of client's notice of such exemption to plan participants Indicate Opting out of: ^ Limitation;; 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 cliscriminating against individual participants and beneficiaries based on health status ^ Maternity hospital stay standards relating to mothers and their newborns ^ Parity in the applica#ion of certain limits to mental health benefits ^ Mandated reconstructive surgery benefits following mastectomy hcsc tx gen aso f~~~a 060309 (on-fine version) 1. Total number of employees presently eligible #or coverage: NIA, -RENEWING ACCOUNT Certain non-federa! governmental ASO plans may elect to be exentpfed 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 (CM;S). If exempt, please provide the following: (Documents attached? ^Yes ^ No} _ __... _. __..~.,.,, ,,,,.~,~yG arN,~~~ „ ciN~ri,y vuc. rre-exrstr.ng applres, including maternity ^ Underwrit{e 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 subjiect to 78 months pre-existing exclusion ® Managed Health Care Coverage: ^ Consumer Driven Health Plan (BlueEdge) ^ Traditional coverage: ® Prescription Drug Coverage: ® Comprehensive Dental Coverage ^ Comprehensive Vision Coverage ^ In-Hospital Indemnity (IHI) ® PPO ^ Dual ppiion High Plan Name: __ Low Plan Name: ^ Annual Max ^ HCA ^ HSA ^ Out-of-Area (Indemnity} ^ Benefit Offering ® Prescription Drug Program ^ Stand-Alone Prescription Drug Program ^ 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 A+>anagement Services: For BCBSTX Members: For Non-BCBSTX Members only: ^ Blue Care Connection ^ Personal Health Manager (Stand-alone) ^ Special Beginnings only ^ Health Risk Assessment (Stand-alone) ^ BlueEdge HCA (Stand-alone) ^ Wellness Incentives 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~ Q603~9 (on-line version) 5 FINANCIAL DOCUMENT ADMINISTRATION FEE SCHEDULE 1. Type: ®Medical ^ Medical !Dental ^ Other: _ 2. Administrative Charge Chart for Single Year Contract: 11/1/09 11/1/09 1111/10 11!1110 Product 1 Service Employe Employe Employe Employe e Onl a Famil a Onl a Famil Base Administrative Charges*> (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 int'ormal:'son 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 FINANCIIAL ARRANGEMENTS WITH PHARMACY BENEFIT MANAGERS.") Blue Care C~onnection® ("BCC"~ Program: Select from Pull Dav+m $ $ $ $ Special Beginnings $ $ $ $ Other: _ $ $ $ $ Other: `_~~_ g $ $ $ Other: g $ $ $ $To be $To be Total $20.86 $58.40 determin determin ed ed Additional Comments: None Dental: _ $ $ $ $ 3. Terminatior- Administrative Charge for Single Year Contract: The Termination Administrative Charge applicable to the Run-Off Period shall be equal to the sum of the amounts obtained by mu}tiplying the total number of Covered Employees by category (pea• Covered Emplopee per lrrdividual or family hcsc tx gen aso bpa 060309 (on-line version) 6 To begin on Effective Date of Coverage and continue for: ®12 Months ^ Other: Months composite)during the three (3) months immediately preceding the date of iermination by the appropriate factors shown below. Service 1111 /Q 11/1!09 11/1!10 111111 9 Employ Em l0 p Y 0 Emplo ee Only Emplo yee ee Family yee oral Famil Medical Run-off Administration Charge $16.20 $45.35 $17.86 $sa.oo Outer: _` $ $ $ $ Dental Ftun-off Administration Charge $ $ $ $ Additional Comments: None Dental: _____ $ $ $ $ $ ~ $ ~~ 4. BlueCard IPragramlNetwork 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** ^ Custantized booklet covers" ^ No additional charge ^ Supplemental Billing** ^ ERISA plan information ^ No additional charge ^ Supplemental Billing*' 2. Subscriber ID 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, NIF- Additiona! charge: $N!A Custom booklet covers are not available on electronic dacuments~. **As indicated in fee table on previous page. hcsc tx gen aso bpa 060309 (on-line version) 5. Reimburseament Provision: ®Yes ^ No If yes; It is understood and agreed that in the event the Claim Administra#or makes a recovery on a third-party liability claim. the Claim Administrator will retain 25% of the net recovery after attnmpvc' fees if any havo horn n7irl hcsc be gen aso bpi 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. ~~ BROKER/CONSULTANT 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 infiormation regarding commissions and/or other compensation paid the broker/consultant by the Ci'aim ,Administrator in connection with services under the Agreement, the Employer should contact its broker/consultant. HCSC COBRA ADMIINISTRATlVE SERVICES HCSC COBRAS Administrative Services Purchased: ®Yes [] No If yes, please complete the COBRA sections below. If no, the COBRA sections below do not apply. COBRA Administrative Billing Services Only: ^Yes ®No COBRA Administrative Full Services: ®Yes ^ No Notification Services included: (Full Services} ®Yes ^ No Conversion Rights included: (Fuf! Services) ®Yes [] No Monthly Reports` included: ®Yes ^ No 1f Yes: Email Address: PADAViS@PORTARTHUR.NET "Paper reports iprovided by mail/electronic reports via email Effec#ive date(s) of services if different from ASO Effective Date of Coverage: 1/1/1987 Billing Services Fee per Participant per month: $GRANDFATHERECI PRICING If Notifrcation St=rvices included(Full Services) Notification Fee [per Participant, per not~cationJ: $GRANDFATHERED PRICING Monthly Administrative Fee: $GRANDFATHERED PRICING The Employer will pay HCSC a sum of One Hundred Dollars ($100.00) per hour four any system programming casts associated with non-standard administration services. hesc be gen aso bpa 060309 (on-fine version) Are rates (SINGLE/FAMILY or TIERED) for all coverages attached? ^Yes ~ No Is 2% inclluded in attached rates? ^Yes ^ No Does Employer have any non-MCSC coverage? ^Yes ®No ~f Yes, Other C;arrier(s}: Name: Address: ~__~ Email Address: City'. State: zip: Administrative Contact: Phone Number: Fax Number: Name: T 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 15t7% oaf the COBRA premium be charged to participants eligible for disability extension for the remaining 11 months of COEtRA? ®Yes U NO (Extension is from i8 mcmths to 28 months when deemed disabled by Socra! Security) is contract provided and signed? ^Yes ®No Prior COBRA administrator info: Name: Address: _, Emai! Address: City: __~_ State: Zip: Administrative i~ontact: Phone Number: Fax Number: hcsc tx gen aso bpsi O6o3o9 (on-line version) ~ p Certificate of Creditable Coverage: ®Yes ^ No Jf yes: The Employer directs the Claim Administrator to issue to individuals, whose coverage under the Plan terminates during the Perm of the Administrative Services Agreement to which this ASO BPA is attached, a Certifrcate of Crr:rditable Coverage. The Certificate of Creditable Coverage shall be based upon information required for issuance of ,~ Certifrcate 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 l;,overage purchased: ®Yes ^ No (lf yes, complete separate Stop Loss exhibit} 3. Fort Dearborn Life Insurance purchased: ®Yes ^ No {If ye>, 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: 1(~O% $ I Dep: % $ ~ Emp: 1 QQ°/n $ Dep: % $ 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. ADDITIONAIL PROVISIONS: hcsc tx gen aso bpa 060309 (on-line version} 11 I UIYDERSTA~ND 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 andlor 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 ina~mplete or inaccurate, BCBSTX may rerate the plan, withdraw the proposal or cancel the contract. 2. No maternal 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 maternal changes have been made to the previously providefd 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. I# applicable, effective 11!01/08, the above-named agents}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 Slue 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 a!I previous Agent of Record appointments for this company. The above named agents} or agency(ies) is authorized to perform membership transactions on behalf of the Employer. This appointment will remain in effect until withdrawn or superseded in writing by our company, 6. AgenG'Brok;er Statement (if applicable}: I certify that t 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)lPolicy(ies}, this Benefit 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 1`ewer than 100 participants. Reporting will include base commissions, bonuses, incentives, or other farms of remuneration for which your agent/consultant is eligible for the sale or renewal of self-funded andlor insured products. Te Villiva Authorized BCB~>TX Representative Signature of Authorized Purchaser Account Executive ~/s/as title Date 409-896-0104-Phone 409-896-0111-Fax BCBSTX Telelphone and Fax numbers Agent Representative (/applicable) Telephone and FAX numbers Title Date hcsc tx gen aso bpa 060309 (on-fine version) ty 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 t:he undersigned's proxy to act on behalf of the undersigned at ail meetings of members of HCSC (and at all meetings of members of any successor of HCSC) and any adjoun-iments 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 then 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: Nrint 5igner's Name Here ~- Group Name Address: Signature and Title Cit of Port Arthur P. O. Box 1089 city: Port Arthur Dated this day of State: Texas Zip Code: 77841 2D09 Month Year hcsc tx gen aso bpa 064309 {on-line version) 13 B1ueCross BlueShield ~*~ of Texas APPLICATION FOR STOP ILOSS 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: 031 I i8 Employer Group Number(s): 031118 Effective Date of Palicy 1 110 1 /2009 Policy Period: These specifications are for the Policy Period commencing on 11/01/2009 and ending on 10/3l/2010 The specifications below shall become effective on the first day of thie Policy Period specified above and shall continue in full force and eeect 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. Aggregat4: Stop Loss Insurance: ®Yes ^ No If yes, con'Iplete 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 ciuring 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 ^ llf 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. ^ Retnewa! of Existing Coverage: Claims incurred on or after the original Effective Date of Palicy and paid during the Policy Period. 3. Aggre!~ate 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 StopL.os:;App-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: 6461.19 -Active Employees; $201.54 -Medicare Retirees for each Employee Coverage Unit 911,290.88 -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. E:mployer's Run-Off Claim Liability shat! be calculated by multiplying the sum average of the total of all Coverage Units during each of the three calendar Months immedia#ely 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 EmployeelFamily Coverage Unit Please use the continuous text field directly below for,sny other structure (leaving the fields above blank). !Vote: you can use the "return" key to create additional rows, if needed: C:AP Arrangement ®Yes ^ No 7. Aggregate Stop Loss Coverage The amount of Paid Claims during the current Policy Perioci (less Individual {Specific) Stop Loss Claims, if any) that e;KCeed the Point of Attachment. The Point of Attachment shall equal the sum of the Employer's Claim Liabilil;y amounts calculated Monthly as described in Item 5~.a. above for the indicated Policy Period. Iri 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 far the indicated Policy Period. 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 far any aFher 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 durinig 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. ® F;enewal of Existing Coverage: Claims incurred on or after the original Effective Cate of Policy and paid during the Policy Period. 3. Individual {Specific) Stop Loss Insurance shall apply to: ® Medical Claims ~ Outpatient Prescrip#ion Drug Claims ^ Dental Claims (] Vi:;ion Claims [] Other {please specify}: 4. Individual (Specific) Stop Loss Coverage For N,+A_who is identified by the health identification {ID) number NIA, the amount of Paid Claims during the currer+t Policy Period in excess of the Point of Attachment iaf $N/A. Such amount shaft apply for the Policy Period. For each other Covered Person: The amount of Paid Claims during the current Policy Perioci 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}: $ ® Monthily Premium shall be egual to the amounts obtained by multiplying the number of Coverage Units for a particular Month by X25.3!3 for each Emolovee Coverage Unit ~'71.O;r_for each Emolovee/Family Covera, a Unit StopLossApp-080E1 3 50554.0808 Ple~~se use the continuous text field directly below for anv other structure )leaving the fields above blank) Note ,tau can use the "return" key to create addltiona! rows if needed: fi. The premium is based upon a current membership of 47] Individual Coverage Units and 343 Family Coverage Units. AddiEional Provisions: The undersigined 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 Teuas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company ("HCSC°}. Upon acceptance, i-ICSC 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 Safes Representative Signature of Authorized Purchaser James Juroch Name of Underwriter Title of Authorized Purchaser Date INTERNAL ilSE ONLY Date Application approved by Underwriting: StopLossApp-0808 4 50554.0808 PPO-AS>O-Standard-with Network Deductible BIaeB~e~6ieid at 7~xas BEI~EF~IT HIGHLIGHTS Prepared far City of Port Arthur- Effective ®BlueChoice IVefwork 1 1 -1 -09 ^B/ueChoice Solutions Network this is a gerren3l summary of your benefits. Please refer to your benefit booklet for additional details and a description of the plan requirements and benerrt design. Tfrrs plan does not cover all health care expenses. Upon receipt of your benefit booklet carefu!!y review the plan's limitations and exclusions. Deductible:> Peer-admission Deductible Calendar Year Deductible Applies to all Eligible Expenses except inpatient Hospital Expenses (unless otherwise indicafedJ Three-month Deductible carryover applies Deductible credit from prior carrier (Applied on initial croup enrollment on1yL 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 benefit booklet will provide more details. Credit for Coshare Stoploss Maximum from prior carrier (Applied on initial group enrollment only) Copayment Amounfs Required Physician office visitfconsultation Refer to Nledical/Surgical Expenses section for mare information Outpatient Hospital Emergency Roomfr-eatment Room visit Refer to Emergency RooMTreatment Room section for more information Maximum Lifetime Benefits Per Participant Inpatient Ho~spita! Expenses All services must be preauthorized A!1 usual htospifa! services and supplies, including semiprivate room, intensive care, and coronary care units Penalty forfaiiure to preauthorize services None $500 Individual / $1,500 Family ®Yesi[]No N/A $2, 5001ndividuall $5,000 Family Network Deductible ~ Coshare Stoploss will only apply Toward Network Deductible &Coshare Stoploss Maximum N/A S25 Copayment Amount Sf OO Copayment Amount $100 Copayment Amount sl,ooo,aoo* 80~° of AAowable Amount 60% of Allowable Amount aRerper- admission Deductible None $250 denetrts used In-Network and Out-0! Network will apply toward satisfying any Calendar Year, Plan Year, Annual tvlaximum, or Maximum Lifetime benefits indicated $200 $i, 000 Individual / $3:000 Family ®Yesi[]No N/A $3,000 Individual / $9,000 Family Out-0f-Network Deductible 8 Coshare Sfoptoss wf11 also applyToward Network Deducfible &Coshare Sfoptoss Maximum A [)ivision of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the 81ue Cross and Blue Shield Association t 57+business-PPO•ASO-Standard-wrlh Network thductible (Rev. 6?4/09} Page 1 of 6 PPC)-ASC)-Standard-with 111etwork Deductible Medical f Surgical Expenses B1ueC~'ossBhteShield of'Iiexels Services performed during the Physician's office visiUconsultation, 100% of Allowable Amount after $25 70% otAlJowable Amount after including lab & x-ray Copayment Amount Calendar Year Deductible (does not include Certain Diagnostic Procedures and surgical services) lab 8. x-ray in other outpatient facilities (excluding Certain Diagnostic 100% of Alowable Amount 70% of Allowable Amount after Proce;dures'i Calendar Year C)eductible -Physician surgical services performed in any setting ft0% of Allowable Amount offer 60% of Allowable Amount after Calendar Year Deductible Calendar Year Deductible -Physician inpatient hospital visits fJ0% of ARowable Amount after 60'x6 of Allowable Amount after Calendar Year Deductible Calendar Year Deductible -Certain Diatgnostic Procedures; such as Bone Scan, Cardiac Stress Test, t10% of Atlowabte Amount after 60% of AAowable Amount after CT :icon (with or without contrast), Ultrasound, MRf, Myelogram, PET Calendar Year Deductible Calendar Year Deductible Scan,. -Home Infusion Therapy (Services must be preaufhorized} t30% of Allowable Amount after GO% otAllowabfe Amount after Calendar Year Deductible Calendar Year Deductible -All other outpatient services and supplies t30% of ANowable Amount after 60% ofAflowable Amount after Calendar Yaar Deductible Calendar Year Deductible In Vitro Fertilization Services De cline Extended Care Expenses Al! services must tfe preaufhorized 100% of Allowable Amount 70% of Allowable Amount after Calendar Year Deductible Skilled Nun>ing Facility 511?, 000 Calendar Year maximum' $7,000 Calendar Year maximum' Home Health Care S10,000 Calendar Yearmaxirnum' $7,000 Calendar Year maxrmum' Hospice Care $20,0001ifetime maximum' $14,000 tifetirne_maximum' Serious Mental /llness Mental Heath Care Tieatmeni o1` Chemical Dependency Inpatient Siervices (All services must be preaufhorized} -Hospital services (facility) (inpatient C'hemkal Clependency treatment must be provided in a 80% of AHowabfe Amount 60% of Allowable Amount offer per- Chernical Dependency Treatment Center) admission Deductible 8(?% of Allowable Amount after Calendar 60% of Allowable Amount after -Physician services Year Deductible Calendar Year Deductible Outpatient: Services (All services must be preaufhorized) ;'~ervicis performed during Physician office visiUconsultation 100% of Allowable Amount after $25 70% of Allowable Amounf after (does rot include psychological testing) Copayment Amount Calendar Year Deductible -All outpatient services and psychological testing 80% ofA!lowable Amount after Calendar 60% of Allowable Amount after Year Deductible Calendar Year Deductible * Benefits used In~letwork and out-0f-tVetwork will apply toward satisfying any Calendar Year, Plan Year, Annual Maximum, or Maximum Lifetime benerrts indicated A (Division of Health Care Service Corporation, a Mutual Legal Reserve Company, ain Independent Licensee of the Blue Cross and Blue Shield Association 151+ business-PPO-ASO-Standard-with Network Dedudible (Rev. &/14!09) Page 2 of 6 PPO-ASO-Standard-with Network Deductibl'e~ sluecrossBlu~Shiela of'li~xae • - ~ • • • ~ • . f • • Emergency 14oomlTreatment Roam Accidental Injury & Emergency Care (within 48 hours) -Facility charges 80% of Alowable Amount after $100 Copayment Amount (Co~paymenf Amount waived if admitted, Inpatient Hospital Expenses will apply) -Ph Non•Emergency Care {after 48 hours} -Faality charges 8(1% of Allowable Amount aRer Calendar 'Year Deductible 80'% of Allowable Amount a8`er $i00 (:opayment Amount (Copayment Amount waived if admitted,lnpatient Hospital Expenses wiR apply) -Physician charges Ground and AirAmbulance Services 60% of Allowable Amount after $100 Copayment Amount & Calendar Year Deductible (Copayment Amount waived if admitted, Inpatient Hospital Expenses wilt apply) 80'/° of Allowable Amount after Calendar j 60% of ARowabte Amount aRer Year Deductible I Calendar Year Deductible 80~° of Allowable Amount aRer Calendar '/ear Deductible '~ Benefits used In-Network and Out-of-Network w11 apply toward sa6s1)ring any Calendar Year, Plan Year, Armual Maximum, or Max+mum Lifetime benefits indicated A Ciivision of Health Care Service Corporation, a Mutual Legal Reserve Company, art Independent Licensee of the Blue Cross and 131ue Shield Association t 51+business-PPO-,4S0-Standard-with Network Deducble (Rev. &24/09] Page 3 or 6 PPO-AS~O-Standard-with 1Vefwork Deductible BltueC,~oesBlueS6ield ~~ .- • . .- Preventive (:are Routine annual physical examinations, well-baby care exams, f tCiO%ofAllowable Amount after,~25 ~ 70%ofAiJowabfe Amount after immunizations for Participants 6 years of age ~ over, vision exams and I Copaymenf Amount Calendar Year Deductible hearing exams imrrlunizationstor Dependent children through the date of the child's 6r^ Speech and Nearing Services Services to restore loss of or correct an impaired speech or hearing funcaion Heating Aid Maximum Physics! Medicine Services Chiropractic Care-0ffice Services Calendar Year Maximum f00% of Allowable Amount ~ ?00'0 of Allowable Amount Covered same as any other sickness Covered same as any other sickness Nearing aids are subject fo a .f;9,000 maximum amount each 3b~month period' 80%~ of Allowable Amount after Calendar ~ 60% of Allowable Amount after Year Deductible Calendar Year Deductible $1,500 maximum benefit each Calendar Year' All other Physical Medicine Services rendered by any other a/igible Provider wilt be allowed on the same basis as anv other sickness. BenefAs used In-~letwork and Out-oi-Network will apply toward satisfying any Calendar Year, Plan Year, Annual Maximum, or Mtaximum L'rfetime benefits indicated A IJivision of Health Care Service Corporation, a Mutual Legal Reserve Coaapany, an Independent Licensee of the Blue Cross and Blue Shield Association 15i+buslness-PPO-ASO-Standard-with NeMrork Deductible (Rev. 624/09) Page 4 of 6 ~PP4-ASl~-Standard-with Network Deductible j B1ueCraes BhieS6ieid oF'I~xss Flu traacination- $10 copaynentAmount Deductibles do riot a Retail Pharmacies (All t:;opayrnent Amounts are per 30-day supply and will not apply to Coshare Stoploss Maximum) Generic Dn~g S10 Copaymer>t Amount 80% of,Atlowable Amount minus Preferred Brand Name Dru Copaymeni Amount g S30 Copayment Amount 80% of ANowable Amount minus Non-I°refen~ed Brand Name Drug $50 Copayment Amount 80% of Atowab atAmount minus Copayment Amount Mail Service Pharmacy ®Yes~No (All Copayment Amounts are per 30-day supply and will not apply to Coshare Stoploss Maximum) Generic Dr<Ig $!0 Copayment Amount Preferred Brand Name Drug S30 CopaymentAmounf Non-Preferred Brand Name Dru $50 CopaymentAmounf Generic lncentive•Members electing to purchase PreferredMon-Preferred Brand Name Drugs when a Generic equivalent is available, wilt be required to pay the difference between the cost of the Generic and Preferred/Non-Preferredl Brand (Jame Drug, plus the Preferred Brand Name Copaymenf Amount. " Three-month Deductible carryover does not apply to prescription drug deductible. "' Each Participating Phamracy that has contracted fo provide vaccination services may have age, scheduling, or otherrequirem~nts 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 BCBS TX rrn~dicat coverage for benefrfs avaitabte for childhood immunizatia~s. Diabetes Supplies are available under the Pras<xipbon Drug benelks of your plan: Dtahetlc Suplplia5 include insuln and insulin analog preparatkms, insulin syringes nat~assary for self-administration, presafptrve and non~rescriptrve aalagenfs, aB raqubeol test aMps and tablets which test for glucose, ketones, and protein, fancr9fs and lancet devk~s;'biohaza-d dfsprisabte corrteiners;'glucalon evn~jency l~s; and brlierlnjerxion aids. A!f provisions'of this portion of the plan A Division of Ftealth Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association l51+busines-PPO-ASO-Standard-with Network Uedudible (Rev. G24/09j Page 5 ot6 ~laccfnafioas obtained through PRannades'"' L ®YesrQNo PPO-AS~O-Standard--with Network Deductible alueCroesslueShieEd ~~ of 'Iiexa>9 EMPLOYEE 1NFf?RMATION This is a genertl Summary of your benefit design. Please refer to your benefit baoklef for other details and for limitations and exclusions. The following benefits apply to dependent coverage: • Dependent children are covered to age 25. • Unmarred grandchildren of the insured are covered if the grandchild is under 25 years of age and is claimed as a dependent by the insured for Federal Income Tax purposes. • Autonnatic coverage for newborns far the first 3t days fotlowing birth. Infants not enrolled far coverage within the first 31 days after birth witl not be eligible for coverage unfit the following open enrollment period or special enrollrn~ent event. Payments: Nehaork providers agree to accept amounts negotiated with BCBSTX and are paid according to this BCBSTX-determined Allawabte Amount. Covered individuals. are re~sponsibie for any required Deductibles, Coinsurance or Out-of-Pocket Amounts, and Copayments. Plan benefits paid toOut-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 Allowabte Amount. The covered individual will be responsible for charges in excess of the Allowable Amount in addition to any applicable Deductibles, Coinsurance or Out~f-Pocket Amounts, and Copayments. For cost savings information, refer fo the section on ParPlan Providers and the defnition of Allowable Amount in the benefit booklet. Preexisting conditions are defined in the benefit booklet and are excluded for 12 months. Appropriate credit will be given far time served under Creditable Coverage as defined under the law and shown in your benefit booklet. Replacement of Medical Coverage: In comptiance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA}, the following provisions apply to each eligible pan:icipant who has health coverage under the employer's plan immediately prior to the effective date of the health contract between the employer and BCBSTX {the contract date): • Benefits for eligible expenses incurred for any service or supplies prior to the contract date, are not covered under the contract. • Eligible expenses for services or supplies incurred on or after the effective dalie will be considered for benefits subject to all applicable contract provisions. Members residing in otlher states may use that state's network through the BlueCard program. To locate a pariigpating provider in your state, please contact 1.840-810-BLUE or visit our web site at www.bcbstx.com to use our Provider Finderm Coal. • RADIAL KERATOTOMY -COVERED • IASIh~ - COVEREfl • EFFECTNE 11f11t)8, SERVICES, SUPPLIES ANDfOR PRESCRIPTION DRUGS FOR REDUCTION OF MORBID OBESITY, fNCLUDENG SURGICAL PROCEDURES, WHEN MEDICALLY NECESSARY, COVERED SAME AS ANY OTHER ILLNESS. (NOTE- PRESCRIPTION DRUGS FOR ~iIORBtD OBESITY ARE NOT SUBJECT TO MEDICAL NECESSRY. ) Group Executive Name and Title Signature (PNea:se type or print} ~geni: of Record Name (Please print or type) Signature BCB.~~TX Representative Name (Plea:ae print or type) Signature Date Oate Date A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, art Independent Licensee or the Blue Cross and Blue shield Association iSt~ business•PPO-ASO-Standard-with Netxrork Deductible {Rev. &124/09) Page 6 of 6 PPO-ASOi-Standard-with Network Deductible, stuet~oesBlueShteld of'li~xas BENEFI'T' HIGHLIGHTS Prepared for City c-f Port Arthur- Effective ~~BlueChoice Network 1 1 -1 -G9 ^BlueChoice So/ufions Network this is a general summary of your benefits. Please refer to your benefit booklet for additional details and a desorption of the plan requirements and benefit design. This plan does not cover aR heaAtl care expenses. Upon receipt of your benefit booklet, earetuUy review the plan's limitations and exclusions. Deductibles Per-admission Deductible Calendar Year Deductible Applies to alt Eligible Expenses except lnpaflenf Hospital Expenses (unless otherwise indicated) Three-month Deductible carryover applies Dedurtible credit from prior carrier (Applied on initial group enrollment only} 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 benefit booklet wi[I provide more details. Credit for Coshare Stoploss Maximum from prior carrier {Applied on initial group enrollment only) None $500 lndividua! / $1,500 Family ®Yes~No $2,500 tndividua! / $5,000 Family Network Deductible 8 Coshare Stoploss wiR only apply toward Network Deductible b Coshare Stoploss Maximum N/A Copayment Amounts Required Physician office visitlconsultation Refer to Medico!/Surgical Expenses section formon; information Outpatient hospital Emergency RoomJTreatment Room visit Refer to Enreroency RooMTreafinent Room section for more information Maximum Lifetime Benefits Per Participant Penalty for failure to preauthorize services None $200 $'t,000 Individual / $3,000 Family ®Yesr(]No N/A $3,000 Individual / $9,000 Family Out-0f Network Deductible b Coshare Stoploss will also apply toward Network Deductible 8 Coshare Stoploss Maximum N/A $~00 Copayment Amount I 70,000' $250 ' Benefits used 1n-Network and Out-ot-Network will apply toward satisfying any Calendar Year, Plan Year, Annual Maximum, or Maximum L'rfetime benefits indicated $25 Copayment Amount $100 Copayment Amount A Divis+cm of Health Care Service Corporation, a Mutual Legal Reserve Connpany, an Independent Licensee of the Blue Cross and Blue Shield Association 15i+bustness-PPC1y4S0-Standard-with Nefworic Dedrrclibfe {Rev. trzaiosJ Page } of 6 Inpatient Hospital Expenses All services must be preauthorized All usual Hospdal services and supplies, including semiprivate room, intensive ~ 80% of Allowable Amount fi0% of Allowable Amount after per- care, and coronary care units admission Deductible ~ PP4-ASi0-Standard-with Network Dedulcfiblel BfueCros~ BlueShietd of 'Iiexas Medtcat J Surgical Expenses Services I~erformed during the Physician's office visiUconsultation, 1 Lt0% of Allowable Amount after $25 70'~ of Allowable Amount after including lab & x-ray (does not include Certain Diagnostic Procedures and surgical services) Copayment Amount Calendar Year Deductible Lab & x-ray in other outpatient facilities (excluding Certain Diagnostic 100% of Allowable Amount 70% of Allowable Amount after Prax?dure:>} Calendar Year Deductible -Physician surgical services performed in any setting 80% ofAlfowabte Amount after 60% of Allowable Amount after -Physirian inpatient hospital visits Calendar Year Deductible 80% of Allowable Amount aRer Calendar Year Deductible 60% of Allowable Amount after -Certain Diagnostic Procedures; such as Bone Scan, Cardiac Stress Test, Calendar Year Deductible 80%ofAliowable Amount aRer Galendar Year Deductible 60% of Allowab/e Amount aRer CT -Scan (with or without contrast), Ultrasound, MRI, Myelogram, PET Calendar Year Deductible Calendar Year Deductible Scan. -Home Infusion Therapy (Services must be preauthorrzedJ 80% of Alowable Amount after 60•~ of Allowable Amount aRer -All other outpatient services and supplies Calendar Year Deductible 80% of Allowable Amount aRer Calendar Year Deductible 60•/ of Allowable Amount aRer Calendar Year Deductible Calendar Year Deductible In Vitro Fertilization Services Rlne. .r.,., Extended Care Expenses Alf services must be preauthorized 100% of Allowable Amount 70% of Allowable Amount aRer Calendar Year Deductible Skilled Nursing Facility $f~Q000 Calendar Year maximum' $7,000 Calendar Year maximum' Home 'Health Care $10,000 Calendar Year maxr""mum' $7,000 Calendar Year maximum' Hospice Care _ $20,0001rfefime maximum' $14.000lifeSme marrmum` Serious Mental !l/Hess Mental Health Care Treatment ot" Chemical Dependency Inpatient Services (All services must be preauthorized) -Hospitz~l services (facility) (Inpatient C:hemicaJ Dependency treatment must be provided in a 80% of Afiowable Amount 60% of Allowable Amount after per- Chemical L>ependency Treatment Center) admission Deductible 80'~ Hof Allowable Amount aRer Calendar 60% of Allowable Amount aRer -F'hysig,an services Year Deductible Calendar Year Deductible Outpatient Services (All services must be preauthorized) -Services performed during Physician office visit/cortsultation 10L>% of Altowabfe Amount aRer $23 70% at Allowable Amount aRer (does n~ai include psychological testing) Copayment Amoum Calendar Year Deductible -A,II outpatient services and psychological testing 80% of Allowable Amount after Calendar 60% ofAllowabfe Amount aRer - Year Deductible Ga/endar Year Deductible * Benefits used ifn~letwork and Out-of-Network will apply toward satisfying any Calendar Yea r, Plan `tear, Annual Maximum, a Maximum litetlme benefits indicated A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent licensee or the Blue Cross and Blue Shield Association 15f+ business-PPO-,4S0-Standard-with Network Deductrble (Rev. 6~24/U9) Page 1 a}f 6 PPO-ASt)-Standard-with Network Deductible ~ ~~Uecll'066BIu+P.~~da of'~xsis Emergency Room?reatment Room Accidental Injury 8 Emergency Care (within 48 hours) -Facility charges 80% of Allowable Amount after ~t00 Copayment Amount (Copayment Amount waived if admitted, Inpatient Nospifa! Expenses wilt apply} 80% of Allowable Amount Year Deductible Non-Emergiency Care {aRer 48 hours -Facility charges -Physician charges Ground and i4ir Ambulance Services 80°io of Allowable Amount after $100 Gopaymenf Amount (Copayrrrent Amounf waived if admitded, Inpatient Hosprta! Expenses wit! apply) 80% of Allowable Amount after Calendar Year Deductible fi0% ofA!lowableAmounf after$t00 Copayment Amounf & Calendar Year Deductible (Copayment Amount waived if admitted, Inpatient Hospital Expenses will apply) 60'~ of Allowable Amount after Calendar Year Deductible 80% ofA!lowable Arrrount after Calendar Year Deductible ' Benefits used In~Vetwork and Out-of-Network will appty toward satisfying any Calendar Ye~3r, Plan fear, Annual Maximum, or Maximum Litetfine benefits indipted A Division of hleaRh Care Service Corporation, a Mutual Legal Reserve Company, an lindependent Licensee of the Blue Cross and Biue Shield Association f5f+bustness-PPO-ASO-Standard-with Network Deduct~bte {Rev. 6)24/49) Page 3 of fi PPO-ASC)-Standard-wifh Network Deductible BlueCrosBBlueShieta of .- - . .- Preventive Gare Routine annual physical examinations, well-baby care exams, i00% otAllawable Amount aRer $25 ~ 70'/ of Alowable Amount after immunizations for Participants 6 years of age ~ over, vision exams and Copayment Amount Calendar Year Deductible hearing exams Immunixaticrns #or Dependent children through the date of the child's 6'" 100% ofAllowable Amount ~ 100% aiAllowabte Amount Speech and blearing Services Sen+ices to restore loss of ar correct an impaired speech or hearing function Hearing Aili Maximum Physical Mealicine Services Chiropractic. Care-0ffice Services Calendar Year Maximum Cot+ered same as any other sickness Covered same as any other sickness Nearing aids are subject fo a 51,(100 maximum amount each 38-month period' 80% of Allowable Amount after Calendar I 60% of ,Allowable Amount ader Yeas Deductible l Calendar Year Deductible 51,500 maximum benefit each Calendar Year' AQ o1°her Physical Medicine Services rendered by any other eligible Provider will be allowed on the same basis as anv other sickness. Benefits used In~letwork and Out-0f-Network will apply toward satisfying any Calendar Year, Plan Year, Annual Maximum, or Maximum Lifetime henefi~ indipted A Division of lHealth Case Service Corporation, a Mutual Legal Reserve Company, an Ilndependent Licensee of the Blue Cross and 8iue Shield Association i5?+ business-PPO-ASOSfandard-with Nehvnrk Deducfitsle (Rev. fi24109} Page 4 of 6 PPO-ASO-Standard-with Network Deductible BIu~eCroes B1ueShleld af'I~cBs ?t7 Co~peyrii+3irt Amatmt t7adtrcGibles da rrot a Retail Pharmacies (All Copayment Amounts are per 30-day supply and will not apply to Coshare Stc>ploss Maximum} Generic Drug $10 Copayment Amount 80% of Allowable Amount minus Copaymenf Amount Preferred Brand Name Drug $30 Copayment Amount 80% of Allowable Amount mrnus Copaymenf Amount Nan-Preferred Brand Name Dru g $50 Co payment Amount o 80% of AUawabte Amount mrnus __ Copayment Amount Mail Service Pharmacy Yes~No (All Copaym~ent Amounts are per 30~ay supply and will not apply to Coshare Staploss Maximum} Generic Drug $10 CopaymentAmounf Prefeired Bound Name Drug $30 CopaymentAmount Non-preterr~ed Brand Name Drug $50 CooavmentAmounf Generic Incentive-Members electing to purchase Preferred/Non-Preferred Brand Name Drugs when a Generic equivalent is available, will be required fo pay the difference between the cost of the Generic and Preferred/Non-Preferrea' Brand ,Name Drug, plus the Preferred Brand Name Copayment Amount. " Three-month Deductible carryover does not apply to prescription drug de,fuctible. "' Each Participating Pharmacy that has contracted to provide vaccination services may have age, scheduling, or other requirements lhaf will apply. You are encouraged fo contact the store in advance. Childhood immunizations subject to state regulations are not available under fhis pharmacy benefit. Refer to your BC85T,K medical coverage for benefits available for childhood immunizatia~s. Diabetes Su~pptfes are available under the Prasafption Drug 6ene~frfs.of yoour plan .Uiabetic Saipplies fnckrde insulin and insuJm analog praparaflons, insulin syringes neraessary for salt-admtnfsbatian, prescriptive and non~p~esalptiva oral egeirtss; aU requtreC test skips and tai~Jeis whir3l test for gluoosa, kefones, and protein, lancets and lancet devices, biohazard disposaale centai»ais g/ucagon errrargency tats; end othrir trrjedton aids: Att previsions of ifais portion efihe plan A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 15J+ business-PPO-~4S0•Standard-with Net+aork Deductible (Rev. 6i24/09,i Page 3 of fi va~haf~~ a~me'a ~>ro'~n t~at~~* ~ ®Yesr[}No PPO-ASO-Standard-with Network Deductible stueCtrotssBtueShteta ~~~ ~~~ of'I~xas 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 benefds apply to dependent coverage: • Dependent children are covered to age 25. Unmarred grandchildren of the insured are covered if the grandchild is under 25 years of age and is claimed as a dependent by the insured for Federal I n~rom~e Tax purposes. Automatic coverage for newborns for the first 31 days fallowing birth. ~Infanis not enrolled for coverage within the first 31 days after birth will not be eligible for coverage until the following open enrollment period or speaal 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~f-Pocket Amounts, and Copayments. Plan benefits paid to Out-0f-Network providers are based on ttie BCE3STX-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 Copaymenfs. For cost savings information, refer to the section on 1'arPlan Providers and the definition of Allowable Amount in the benefit booklet, Preexisting condlitions are defined in tt-e benefit booklet and are excluded for 1:! months. Appropriate 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 f'artability and Accountability Act of 1996 (HIPAA), the following provisions apply to each eligible participant who has health coverage under the employer's plan immediately prior to the effective date of the health contract between the employer and BCBSTX (the contract date): • Benefits for eligible expenses incurred for any service or supplies prior to the oontract date, are not covered under the contract. • Eligible expenses for services or supplies incurred on ar after the effective dates will be considered for benefits subect to all applicable contract provisions. Members residin~,g 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.bcbsbc.com to use our Provider Finders tool. RADIAL KERATOTOMY -COVERED LASiK • COVERED EMPLOYEE INFORMATION • EFFECTIVE 11!1108, SERVICES, SUPPLIES AND10R PRESCRIPTION DRUGS FOR REDUCTION OF MORBID OBESITY, INCLUDING SURGICAL PROCEDURES, WHEN MEDICALLY NECESSARY, COVERED SAME AS ANY OTHER ILLNESS. (NOTE -PRESCRIPTION DRUGS F'OR MORBID OBESITY ARE NOT SUBJECT TO MEDICAL NECESSITY. ) Date Group Executive Name and Title (Please type or print) Agent of Record Name (Please print ar type) BCBSTX Representative Name (Please print or type} Signature Signature Signature Date Date A Division .if Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 751+ business-PPO•ASO•Standard-with Network Deductible fRev. ti24/09) Page 6 ot6 Flu Vaccinations at Walgreens ~ limitaticros, vdyanoe tsgistrotion, tx other moY cppi~-. Far yrwr cotwleoa,. ~ are ~~~ Pry E or in par~osr ~~~ ~~ up to I rt dary-s in od~anoe a~ diaic. Dal X00-E~94s0 (~0~-3Ss~~9950'~ Qr vw'ir a~ Every year thousands of people are affected by colds and flu. Get your flu shot and stay protected! Blue Cross and Slue Shield of Texas*{$CBSTX}, 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 Iota#ions throughout they country. To learn when and where you can receive the vaccinations, visit the online flu center at Wa[greens.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 i;; important to us! %i s s B1ueCross B1ueShield of 'I'exay Experience. WelYness.liverywhere." TAe PfivmLLy Mne~iw TnAts • SUa lppt^ A Division of Heollh Care Service Corporofion, o Mutuol Legol Rexrve (=omperry, on independent licensee o! the Blue Cross and Blve Shield Associotion >~ ~ f f 1 49d~4.020p ~ A . fi!! ` Mich Mushier From: Terry_Villiva@bcbstx.com Sent: Friday, July 10, 2409 9:49 AM To: Mickey Moshier Cc: maureenJones@bcbstx.com Subject;, City of Port Arthur - Mental Health Parity and Addiction Equity Act - PPO & HMO ~~ l MHPAEA Election Form (NorrHMC~)... RE: City cf Port Arthur The City of Port Arthur will need to complete the' election ford attached. We've gone ~shead and revised the SOB to reflect removing the day/dollar lim:Lts from Mental Health,. SMI & Chemical Dependency. If they eaect a different offering we wial revise as indicated. I'll send you the revised SOB in a seperate email. Texas MHPAEA Implementation Outline On Oct.. 3, 2008, President Bush signed the Ernerge:ncy Economic Stabilization Act of 2008. This legislation included the Mental Health ]?arit:y and Addiction Equity Act (MHPAEA) which amends the Employee Retirement Income Security Aca (ERISP.}, the internal Revenue Code (Code} a.nd `she Public Health Service Act (PHSA). The MHPAEA generally requires that group health F>lans and group health insurers apply the same treatment: and financial limits to medica:_ and surgical benefits and to mental health and substance use disorder benefits. As a reminder, the Mental Health Parity and ~~ddicaion Equity Aca provides that small group health plans are exempt from the new recuirements. For rer:~ewing groups, the provisions of the law will go into effect on each group's renewal date bE>ginn:ing on and after Oct. 3, 2009. SELF-FUNDEC PPO ACCOUNTS The law is not a mandate to provide mental health or substance abuse disorder benefits and does not ma:ldate coverage of all :rental heait:h conditions. As applies to self-funded accounts, if a self-funded client elects to cover mental healttn 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 inciicated in the Benefit: Highlights attached, please let me ti:now asap. (See attached file: MHPAEA Election Form (Non-HMC~).doc) Thank you, Terry Villiva, MHP 1 Account Executive Blue Cxoss Blue Shield of Texas 1 2615 Calder, Suite 700 1 Beaumont, Texas 77702 Phone: 409-896-0104 1 Fax: 409-8 %-0111 ~ Mobile: 909-656-9463 1 Email: terry_villiva@bcbstx.com Visit crur webs:ite: 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 strict:Ly prohibited and may be unlawful. If you have received this eonsnunication in error, pl~~ase notify the sender immediatE=_ly at (312)65:3-6000 in Illinois; (800}835-8699 in New Mexico; {918}560-3500 in Oklahoma; or (972}766--6900 in Texas. * *#**# it ~M ~~f ]3lue~roes B1ueShleld of Timis MENTAL HEALTH PARITY and nnnirrinN Fnt ttTV arr ct t`rrrn~uc ~w~nw~_uu.,. ____ _-_ _ _ _ _ _ __ _ _ - ~_ - ~t.,.~ rev ~ rrrv ~ av7~V I~Vi~-f77'~V Group Name: Group Numbelr:_ 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 Empi+oyee Retirement Income Security Act (FRIBA), the Internal Revenue (:ode (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 benefits and to mental health and substance use disorder benefits. The MHPAEA does not mandate coverage of mental health, serious mentc!I 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 treatment limitations (number of visits, days of coverage or other similar limits on the scope or duration of treatment) or linancia/requirements(deductibles, copayments, coinsuran+_e, 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 Eaw 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 Btue Shield of Texas (BCBSTX) as your claims administrator. Benefits for Serious Mental IfEness !check the box that coolies - musr seir~t ~nP~ ^ We are a public entity, therefore, benefits for serious tnentai 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 ill ith i ti t d ness w no npa en ay or outpatient visit limitatic!ns. Atl 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. ^ Benefits for serious mental illness are carved out of the group health plan administered by BCBSTX and are d i i t d b th a m n s ere y ano er vendor. It is our desire that medical and serious mental illness claims paid be accumulated to apply to any deductibles, co-share amounts, and maximum lifetime benefrts of the plan.* ^ Benefits for serious mental illness are carved out of the group health plan administered by BCBSTX and are r admi i d b t th d i I ' n y ano s e e er ven or. t snatourd esirethat medical and serious mental illness claims paid be accumulated to apply to any deductibles, ca-share amounts, and maximum lifetime benefits of the plan. Benefits far Treatment of Chemical Oe enders check the box that a ties -must select one ^ We have elected to provide benefits for treatment of chemical dependency same as any other illness with no limitations on series of treatments. All benefits (paid are to be applied to the maximum lifetime benefits of the plan. We have elected to no longer provide benefits for treatment of chemipl 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. Itis ourdesirethat medical and treatment of chemical dependency claims paid be accumulated to apply to any ded!actibfe:s, 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 not 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. A Division of Health Care Service Corporation, a Mutual LegaE Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Assodation Non-HMO Renewal-MHPAEA Page 7 of 2 131ueCross B1ueShle~d t~f 'Iirxas ~senetits for F~ental Health Care check the box that a lies -must select one) _ We have elected to provide benefits 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 rare are carved out a~f the glroup health plan administered by BCBSTX and are ^ administered by another vendor. It is our desire that imedical and mental health claims paid be accumulated to `__ apply to any deductibles, co-share amounts, anti maximum lifetime benefits of the pian.* Benefits for mental health care are carved out of the group health plan administered by BCBS-I)C and are ^ administered by another vendor. ttisnotourdesirethat medical and mental health claims paid be accumulated to apply to any deductibles, co-share amounts, and maximmum lifetime benefits of the plan. *rf tie ~c:aw c _ ...._~_~ ~ _~~ .. _. __.._..._, .,,. , ,,.,,,~, , ,~~,~, ~, ~, ,,~„~, ,.,~„~, a„Hess, ana i or rrearment or Cremical Dependency are to be carved out to another vendor and the PCan Sponsor desires accumulated amounts to be applied Ito any deductibles and calendar year maximums of the plan, please provide the following: Vendor name: Address: Ciity State Phone number: Contact, if available: i3CBSTX, 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 re+tains 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 cornplianc:e with this federal law. Signature: Title: Date: A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent licensee of the Blue Cross and Blue Shield Association Non-HMO Ftene`Nal-MHPAEA Page 2 of 2