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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
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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
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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