HomeMy WebLinkAboutBC/BS BPA INFO �
Benefit Program Application ("ASO BPA")
Application to Administrative Services Only (ASO) 6roup Accounts
Administered by Blue Cross and Biue Shieid of Texas, a division af Heatth Care Services Corporation,
A Mutual Legal Reserve Company, hereinafter referred to as the "Claim Administrator" or "HCSC"
Group Status: RenewincLASO Account Off Cycie Change: �Yes � No
Employer AccouM Number (6-digits): 031118 Group Numbe�(s): 03111$, Section Number(s): All
031120
Legal Employer Name: City of Port Arthur
(Specify th� employw or the empFoyee trust apply+ng for coverage. AN EMPLOYEE BENEFIT PLAN MAY NOT BE NAMED)
Employer tdentification Number: 74-6001885 SIC: 9199 Public Entity? � Yes ❑ No
Primary Address: P. Q. Box 10$9
City: PoR 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 dififerent from Primary - required): 444 4th Street
City: Port Arthur State: Texas Zip: 77640
BilGng Address: P. O. Box 1089
City: Port Arthur State: Texas Zip: 77641 Billing Contact: Patricia Davis
Title: Sr. HR Analyst Phone Number: 409- Fax Number: 409-983- Email Address:
983-8214 8282 padavis@portarthur.net
Subsidiary Companies: N/A Subsidiary Address: N/A
City: N/A State: N/A Zip: N/A
Administrative CoMad: N/A Title: N/A
Phone Number: N/A Fax Number: N/A Email Address: N/A
Blue Access for Employers (BA� Corrtact: Patricia Davis
(The BAE Corrtact is the Employee of the account authorized by the Emptoyer to access and maintain its account via
BAE,)
Title: Sr. HR Analyst Phone Number: 4p9- Fax Number. 409- �mail Address: padavis�portarthur.net
983 983
Affiliated Companies: N/A Location(s): N/A
ERISA Plan: (�Yes � No If yes, specify ERISA Plan Year: N/A (mm/dd/yy)
ERISA Plan Administrator: N/A Plan Administrator's Address: N/A
Effedive Date of Coverage: 11/01/201p Anniversary Date (AD}: 11/01 Nature of Business: City Govemment
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Effective:
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 Heafth Care Service Corporation (HCSC), a Mutual Legal Reserve Company, and HCSC subsidiaries for
Emplayer's employee benefit programs. This statement rescinds any and all previous AOR ap�intments for
Employer. The AOR is authorized to perform membership transactions on behalf of Employer. This appointment will
remain in effect unt withdraw or superseded in writing by Employer.
1. *Agent(s) or Agency(ies) to whom commissions are to be paid:
Tax lD Number (TII� of ❑ Agerrt or ❑ Agency: Producer #:
Agency Address: Street: City: Zip:
Phone: Fax: Email:
Is AgenUAgency appointed with BCBSTX? ❑ Yes ❑ No General Agent? ❑ Yes ❑ No
A�liated with General Agent? ❑ Yes ❑ No
2. *Agent(s) or Agency(ies)** to whom commissions are to be paid:
Tax ID Number (TIN) of ❑ Agent or ❑ Agency: Producer #:
Agency Address: Street: City: Zip:
Phone: Fax: Email:
Is AgenUAgency appoir�ted with BCBSTX? ❑ Yes ❑ No General Agent? ❑ Yes ❑ No
Affiliated with General Agent? ❑ Yes ❑ No
If commission split, designate percerrtage for each agent/ AgenVAgency 1: °� AgentJAgency 2: °�
agency. Note: total commissions paid must equal 100°r6
3. Multiple Location Agency�es): If serviang agency is not listed above as Item 1 or 2, specify location below:
* The agent or agency name(s) above to whom commissions are to be paid must exactly match the name(s) on the appointment
application(s).
** If commissions are split, please provide the information requested above on both agents/agencies. BOTH must be appointed to do
business with BCBSTX.
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1. Eligible Person means:
❑ A full-time employee of the Employer.
❑ A fulf-time employee who is a member of:
(name of union)
❑ A part-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 dasses and describe the exdusion:
2. Full-Time Employee means:
❑ A person who is regufarly scheduled to wortc a minimum of hours per week and who is on the permanent
payroll of the Employer.
❑ Other:
3. Domestic Partners covered: ❑ Yes ❑ No
If yes: A Domestic Partner, as defined in the Plan, sha!! be considered eligibte for coverage. The Emptoyer is responsib/e for
providing notice of possib/e tax impiications to those Covered Employses with Domesfic Partners_
If yes, are Domestic Partners eligible to corrtinue coverage under COBRA? ❑ Yes ❑ No
If yes, are dependents of Domestic Partners eligible for coverage? ❑ Yes ❑ No If yes, the Limiting Age for
covered children of Domestic Partners means twenty-six (26) years, regardless of presence or absence of a child's
financial dependency, residency, student status, employmerrt, marita{ status or any combination of those fadors.
4. Are children of any age who are medically ceftified as disabted and dependent on the employee for support and
maintenance eligible for coverage? ❑ Yes ❑ No
Are children over the Limiting Age who are medically certified as disabled and dependent on the employee for support
and maintenance eligible for coverage under the plan if they were not covered under the plan prior to reaching the
Limiting Age? ❑ Yes ❑ No
5. Are unmarried grandchifdren eligible for coverage? � Yes ❑ No
If yes, must the grandchild be dependent on the employee for federal income tax purposes at the time application is
made? ❑ Yes ❑ No
6. The efFedive date for a newly eligible person who becomes effedive after the employer's initial enrollmerrt date:
❑ The date of employmer�t.
❑ The day of employment.
❑ The day of the month following month(s) or days of employment.
❑ The day of the month foliowing the date of employmerrt.
❑ Oth�r:
Is the waiting period requiremerrt to be waived on initial group enroilmerrt? (The waiting period means the waiting
period an Employee must satisfy in order for coverage to become effective. Covered family members do not have to
satisfy a waiting periad to become effective.) ❑ Yes ❑ No
Are there multiple new hire employee waiting periods? ❑ Yes ❑ No
If yes, please attach eligibility and contribution details for each section.
7. The Effec.tive Date of teRnination for a person who ceases to meet the definition of Etigible Person:
❑ The date such person ceases to meet the definition of Eligible Person.
❑ The last day of the calendar moMh in which such person ceases to meet the definition of an Eligibfe Person.
❑ Other.
8. The Limiting Age for covered children is Twenty-�six (26) years, regardless of presence or absence of a child's
finanaal dependency, residency, studer�t status, employmerrt, marital status or any combination of those factors. For
plan years beginning before January 1, 2014, an ASO grandfathered group health plan may exGude an adult child
under 26 from coverage only if the child is eligible to enroll in an eligible employer sponsored heatth plan (as defined
in Section 5000A(�(2) of the Intemal Revenue Code) other than a group health plan of a parent.
To cover children age twenty-six (26) and over, you must seEect option i. or ii. below:
i. ❑ The Limiting Age for covered children age twenty-six (26) or over,
❑ who are unmarried
❑ regardless of marital status,
is years. Twenty-seven (27) through thi�ty (30) are the available options.
ii. ❑ The Limiting Age for covered children who ar+e full-time studer�ts and age twenty-5ix (26) o� over,
❑ who are unmarried
❑ regardless of marttal status,
is years. Twenty-seven (27) through thirty (30) are the available opfio�s.
Studerrt certification: ❑ Accourrt or ❑ BCBSTX or ❑ None
Frequency of Certfication Letters: Annually (AN) ❑ Qua�teriy (QU) ❑ Semi-Annually (SA) ❑
* Certificstion Schedule: Month 1: Month 2: Month 3 Month 4:
" For Annual Notificafion, indicate one month {Jan-Dec) for notfication, for Semi-annual, select 2 months, for
quarteriy, select 4 months
Automatically cancel dependents who reach the maximum limiting age? ❑ Yes ❑ No
However, such cancellation shall be postponed in accordance with any applicable federal or state law.
9. Termination of coverage upon reaching the Limiting Age:
❑ Coverage is terminated on the birthday.
❑ Coverage is terminated on the tast day of the morrth in which the Limiting Age is reached.
❑ Coverage is terminated on the last day of the billing month.
❑ Coverage is terminated on the last day of the year (12/31) in which the Limiting Age is reached.
❑ Coverage is terrninated on the group's Anniversary Date.
Will coverage for a child who is medically certified as disabied and dependent on the parent terminate upon reachirtg
the Limiting Age even if the child continues to be both disabled and dependent on the parent? ❑ Yes ❑ No
However, such coverage shall be extended in accorcfance with any appliceble federal ar state law.
10. Enrollment:
Special Enroltmer�t: An Eligible Person may apply for coverage, Family coverage or add dependents within thirty-one
(31) days of a qualifyinq event if he/she did not apply prior to his/her Eligibility Date or when eligibte to do so. Such
person's Coverage Date, Family Coverage Date, and/or dependerrt's Coverage Date will be fhe effec�ive 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. In the case of a qualifying event due to foss of coverage under Medicaid or
a state children's heal#h insurance program, however, this enrotlmerrt opportunity is not available unless the Eligible
Person requests enrollment within si�dy (80) days after such coverage ends.
Late Enrollment. An Eligible Person may apply for coverage, Family coverage or add dependents if he/she did not
apply prior #o his/her Eligibility Date or did not apply when eligible to do so. Such person's Coverage Date, Family
Coverage Date, ar�/or depender�Ys Coverage Date will be a date mutually agreed to by the Claim Administrator and
the Empioyer.
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 Enrollmerrt Period. Such person's
Coverage Date, Family Coverage Date, and/or dependenYs Coverage Date will be a date mutually agreed to by the
Claim Administrator and the Employer. Such date shall be subsequent to the Open Enrollmerrt Period.
Late applicarrt enroilment options:
� Annual open enroltment — late applicant may apply during open enrollment and fo� applicants nineteen (19)
years of age or older, be subject to a 12-month pre-existing waiting period (credit will always be applied).
❑ No Annuat Open Enrollment — late applicants are never eligible for coverage (dental only).
❑ Annual open enrotlment — no pre-existing waiting period.
❑ Late applicarrts may apply at any time — coverage is effective first of the morrth following receipt of the
application. For applicants nineteen (19) years of age or older, an 18-month pre-ewsting waiting period
applies.
Specify Open Enrollment Period: 10/01/2010 - 10/31/2010
11. Pre-exfsting waiting period:
❑ Pre-existing waiting period waived for all pafiaparrts.
� Pre-existing waiting period waived for all participants up to age nineteen (19). A{I other partiapants age
nineteen (19) and over must serve pre-existing waiting period. Benefits for treatment incureed during the 6
morrths prior to the effective date of inembership will n� be covered for 12 months after the effedive date.
❑ Pre-existing is waived on the accounYs initial enrollment. All other partiapants age nineteen (19) and over
must serve pre-existing waiting period. Benefits for treatment incurred during the months priar to the
effective date of inembership will not be covered for months after the effective date.
12. Extension of benefts due to Temporary Layoff, Disability or Leave of Absence:
Temporary Layoff: days Disability: days Leave of Absence: days
However, benefits shall be extended for rire duration of an Eligible Person's leave in accordance with any applicable
federal or state law.
13. COBRA Auto Cancel? � Yes ❑ No
Member's COBRA/Continuation of Coverage w�ll be automatically canceNed at the end of the member's eligibility
period.
14. Eligibility reporting method (applies to ini�al enrollment):
❑ Account will self-enroll online through BlueAccess for Employers.
❑ Members will self-enroll online through BlueAccess for Members.
❑ BCBSTX will enter enrollment online through BlueAcce.ss for Employers.
❑ BCBSTX will enter enrollmerrt via paper applications.
❑ BCBSTX will enter enrollment from membership spreadsheet.
❑ BCBSTX will process enrollment via Automated Etigibitity Process (AEP).
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1. Total number of employees presently eligible for coverage: N/A - Renewing Account
2. Total number af emplayees serving new hire eligibility period: WA - Renewing Account
3. Total number of employees with other coverage (i.e., other group coverage, Medicare, Medicaid,
TRICARE/Champus): WA - Renewing Account
4. Total number of individuals currently covered under COBRA: 2
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� Managed Health Care Coverage: � PPO ❑ EPO
❑ Dual Option ❑ POS
High Plan Name: ❑ HMO
Low Plan Name: ❑ with Drug coverage
❑ without Drug coverage
❑ Consurner Driven Heafth Plan ❑ HCA
(BlueEdge) ❑ HSA
❑ Traditional coverage: ❑ Out-of-Area (Indemnity)
❑ Benefit Offering
❑ Prescription Drug Coverage: ❑ Prescription Drug Program
❑ Stand-Alone Prescription Drug Program
❑ Comprehensive Derrtai Coverage
❑ Comprehensive Vsion Coverag�
❑ In-Hospital Indemnily (IHI)
❑ PPO Provider Networfc: ❑ BtueChoice (PTXOA)
❑ BlueChoice Solutions (PSNOA)
❑ Dual Network Option (both BlueChoice and BlueChoice Solutions)
❑ Heatthcare ManagemeM Services: For BCBSTX Members: For Non-BCBSTX Members only:
❑ Blue Care Connecbion ❑ Personal Heaith Manager (Stand-alone)
❑ Special Beginnings only ❑ Heaitfi Risk Assessment (Stand-alone)
❑ BlueEdge HCA (Stand-alone)
❑ Wellness Incentives
COMMENTS: Dental is Fufly lnsured under Group Number 031120.
Effective 11-1-10, City of Port Arthur is renewing as a"Non-Grandfathered Group" with the foilowing changes
to their cuRent plan:
{1) Cafendar Year Deductible: In-Network -$1,�0 Individual/$3,000 Family; Out of Networic -$2,000
IndividuaV$6,OQ0 Family
(2) CoShare Stoploss Maximum: In-Network -$3,50Q IndividuaU$7,000 Family; Out of Network -$4,500
Individual/$9,000 Family
(3) Copayments: Primary Care Copayment -$35; Adding $50 S�pecialist Capay; Adding Urgent Care Benefits
with $75 Copay; Emergency Room Copay -$150
(4) Maximum Lifetime Max - Unlimited
(5) Extended Care Expenses: Skilled Nursing Faality - Limited to 25 day maximum each calendar year, Home
Health Care - Limited to 60 visit maximum each Calendar Year; Hospice Care - Unlimited
(6) Preventive Care - In-Network reimbursement 100% of allowable amount
('� Chiropractic Care - Calendar Year Ma�cimum - Limited to 35 visits each Calendar Year
(8) Flu Vaccinations obtained through Pharmacies - Prescription Drug Program Copayment does not apply
In addi�on to the above benefit changes, the foliawing Eligibility Changes are also being made:
•Dependerrt age limit changed to 26 regardless of student, marital or employment status. Dependent age limit
is also changing for Dental to coincide with the Health age limit change.
•Pre-existing waived for all participants up to age 19. Participants age 19 and over must serve pre-existing.
NO CHANGES TO THEIR CURRENT NON STANDARD COVERED BENEFITS THAT ARE ALREADY IN
EFFECT:
(1) Radial Keratotomy and Lasik Surgery are covered;
(2 ) EfFec�ive 11/1/U8, services, suppiies andlor p►�scrip6on dnags for reduct�n of morbid obesity, inGuding
surgical procedures, when medicaily necessary, covered same as any other illness -(NQTE — Prescription
drugs for morbid obesity are not subject to medical necessity )
FINANCIAL DOCUMENT ADMINISTRATiON
FEE SCHEDULE
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To begin on Effective Date of Coverage and confinue for:
� 12 Months ❑ Other: Months
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1. Type:
� Medical
❑ Medical / Dental
❑ Other.
2. Administrative Charge Chart:
Product ! Service Single Family
Base Administrative Charge<'� (Medicaf) $30.11 ;84.3Q S �
Prescription Drug Administrative Charge S S S �
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 Covered
Employee �r month basis. Rebate credits are paid �(7.78) ;(21.80) S 3
prospectively to the Employer and shall not continue
after termination of the Prescription Drug Program.
(Further infoRnation conceming this credit is
included in the governing Administrative Services
Agreement to which this A50 BPA is attached
under the section titled "CLAIM ADMINISTRATOR'S
SEPARATE FINANCIAL ARRANGEMENTS WITH
PHARMACY BENEFIT MANAGERS.°�
Blue Care Connection ("BCC") Program: � � � $
Select from Pull Down
BCC Program Upgrade(s): � S s S
Description:
Description: S 3 $ i
Special Beginnings $ S S S
Other: $ $ ; y�
Other: S ; S S
Other: S i S �
Total 522,33 $62,50 $ �
Additional Comments: Medical Admin Fee includes commission
Dental: $ S $ 3
3. Termination Administrative:
The Termination Administrative Charge appiicable to the Run-Off Period shall be equal to the sum of the amounts
obtained by muftiplying the total number of Covered Employees by category (per Covered Employ�ee per
individual or family composite) during the three (3) months immediately preceding the date of termination by the
appropriate fadors shown below.
Service Sin le Famil
Medical Run-off Administration Char+ge �10.64 �29.79 E 3
Other: � $ E �
Dental Run-off Administration Char�ge 3 S $ $
Additional Comments: Medical Admin Fee includes commission
Den#al: s i � s $ �
4. BlueCard Program/Network access fee: S (Available upon request)
5. Not applicable to Grandfathered Plans
External Review Coordination:
tf selected, Employer acknowledges and agrees: (i) to a fee of $700 for each extemal review requested by a
Covered Person that the Claim Administrator coordinates for the Employer in relation to the EmployePs Plan; (i�
that the Claim AdministratoPs coordination shall indude reviewing extemal review requests to ensure that they meet
eligibility requiremerrts, referring requests to accredited extemal independent review organizations, and reversing
the Plan's determinations if so indicated by extemal independerrt review onganizations; and (iii) that the extemal
reviews shalt be performed by an independent thiM party errtity or organization and not the Claim Administratof.
Amounts rsceived by Claim Administrator and external independent review organizations may be revised from time
to time and may be paid each time an extemal review is undertaken. Further, Employer elects for extemal reviews
to be performed under the Federal Afforciable Care Act external review process.
6. ReimbursemeM Provision: � Yes ❑ No
If yes: It is understood and agreed that in the event the Claim Administrator makes a recovery on a third-party liability
claim, the Claim Administrator will retain 25°� of any recovered amounts other than amounts recovered as a result of
or associated with any Workers' Compensation Law.
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1. Benefit booklets — Is BCBSTX providing benefit booklefis? ❑ Yes ❑ No
❑ Standarci benefd booklet (no additional charge)
❑ Customized benefd booklets ❑ No additional charge
❑ Supplemental Billing'"""
❑ Customized booklet covers* ❑ No additional chargE
❑ Supplemental Billing*"
❑ ERISA plan information ❑ No additional charge
❑ Supplemental Billing""`
2. Subscriber ID cards
❑ Standard subscriber ID carcis (no additional charge)
❑ Customized ID card services ❑ No additional charge
❑ Supplementat Billing""
3. Network provider diredories ❑ No additional charge
❑ Supplemerrtal Billing'"'"'
4. Subscriber claim forms, enrollmerrt 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: Additional charge: $
* Custom booklet covers are not available on electronic documents.
*"As indicated in fee table on previous page.
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Employer Payment Method: ❑ Online Bill Pay � Electronic ❑ Check
Employer Paymerrt Period: Weekly (cannot be selected if Check is selected as payment method above)
❑ Twice-Monthly
❑ Monthly
❑ Other (please specify)
Claim Settlement Period: Mor�thly
Run-Off Period: Transfer Payments are to be made for twelve (12) months following the end of the Fee Schedule Period.
Final Setttement: Final Settlemerrt 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 Rlan under the Administrative Services Agreement to which this ASO BPA is attached, the
Claim Administrator may pay the Employer's broker/consultant a+commission andlor other compensation in connection
with such services under the Agreement. If the Employer desires additional infarmation regarciing commissions and/or
other compensation paid the broker/consultant by the Claim Administrator in connection with senrices under the
Agreement, the Employer should contact its broker/consultant.
HCSC COBRA ADMINISTRATIVE SERVICES
HCSC COBRA Administrative Services Purchased: � Yes ❑ No
If yes, please complete the COBRA sections below. If no, the COBRA sections below do not apply.
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COBRA Administrative Billing Services tJniy: ❑ Yes ❑ No
COBFtA Administrative Full Services: ❑ Yes ❑ No
Notification Services induded: (Fuil Services) ❑ Yes ❑ No
Conversion Rights included: (Full Services) ❑ Yes ❑ No
Monthly Reports* included: ❑ Yes ❑ No If Yes: Email Address:
*Paper reports provided by maillelectronic reports via email
Effective date(s) of services if different from ASO Effective D�te of Coverage:
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Billing Services Fee per Participant per month: Grandfathe�ed Pricing
If NotifiCation Services inctuded(Ful! Services)
Notification Fee [per Partiapant, per notificationj: Grandfathered Pricing
Monthly Administrative Fee: Grandfathered Priang
The Employer will pay HCSC a sum af One Hundr� Dollars ($100.00) per hour for arry system programmi�g costs associated with non-standard
administration services.
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Number of Adive Members*:
Number of current COBRA partiapants/members":
Number of current COBRA retiree participantslmembers":
`Futl Service Unit (FStI) set-up of participantshnembars in 8lueStar required
FSU Location:
FSU Contad: Email Address:
Is all COBRA partiaparrt census information attached?[] Yes ❑ No
Is all COBRA participant coverage(s) and level elected information attached?� Yes ❑ No
Is all dependent census information attached?� Yes ❑ No
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Are rates (StNGLElFAMILY or TIERED) for all coverages attached? [� Yes ❑ No
Is 2°� included in attached rates? � Yes ❑ No
Does Employer have any non-HCSC coverage? � Yes ❑ No
If Yes, Other Carrier(s):
Name:
Address: Email Address:
City: State: Zip:
Administrative Contad: Phone Number: Fax Number:
Name:
Address: Email Address:
City: State: Zip:
Administrative Contact: Phone Number: Fax Number:
COBRA coverage begins: ❑ On date of Qualifying Event ❑ First of month following date of Qualifying Everrt
Should 150% of the COBRA premium be charged to pa�ticipants eligible for disability extension for the remaining 11
months of COBRA? �] Yes ❑ NO (Extension is from 18 months to 29 months when deemed t�isab/ed by Social Security)
Is contract provided and signed? ❑ Yes ❑ No
Prior COBRA administrator info:
Name:
Address: Email Address:
City: State: Zip:
Administrative Contact: Phone Plumber. Fax Number:
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1. Cert�cate of Creditable Coverage: � Yes ❑ No
If yes: The Employer direds the Gaim Administrator to issue to individua/s, whose coverag�e under fhe P/an terminates
during the term of the Administrative Services Agreement to whfch this ASO BPA is attached, a Certif'icate of
Creditable Coverage. The Certificate of Creditable Coverage shall be based �pon informafion required for issuance
of a Certificate of Creditable Coverage to be provided to the C/eim Administrator by the Employer and coverage
under the P/an during the term of the Administrative Services Agreement.
2. The Massachusetts Heaith Care Reform Ad requires employers to provide, or contract with another entity to
provide, a written statement to individuals residing in Massachusetts who had °creditabie coverage° at any time
during the prior calend�r year through the empioyer's group health pian and to file a separate electronic report to
the Massachusetts Department of Revenue verifying information in the individual written statements.
a. The Employer direds Ctaim Administrator to provide written statements of creditabie coverage to its Covered
Employees who reside, or have enrolied dependents who reside, in Massachusetts and file electronic reports to
the Massachusetts Department of Revenue in a manner consistent with the requirements under the
Massachusetts Heaith Care Reform Ad. Such written statements and electronic eeporting shali be based on
informatian provided to the Claim Administrator by the Employer and coverage under #he Plan during the term of
the Administrative Services Agreement. The Employer hereby cert�es that, to the best of its knowledge, such
coverage under the Plan is "creditable coverage" in accarclance with the Massachusetts Heanh Care Reform Act.
The Employer acknowledges that the Claim Administrator is not responsible for verifying nor ensuring
compliance with any tax and/or legat requiremeMs related to this service. The Employer or �ts Covered
Employees should seek advice from their legal or tax advisors as necessary.
� Yes ❑ No
b. {f no: The Employer acknowledges it will provide written statements and electronic reporting to the
Massachusetts Department of Revenue as required by the Massachusetts Health Gare Reform Ad.
3. Stop Loss Coverage purchased: � Yes ❑ No (If yes, complete separate Stop Loss exhibit)
4. Fort Dearbom Life Insurance purchased: � Yes ❑ No (If yes, complete separate application)
5. Health Care Account (HCA) Admi�istrative Services purchased: ❑ Yes � No pf yes, complete separate HCA
Benefit Progrem Application)
6. Employer contribution. The percentage of premium to be paid by the employer is:
� � 5fi +�e � Lk�ita — 9f� or !�
Emp:10Q% $ �P� °� $ Emp:100% $ �P: ° � 6 $
7. 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.
ADDfTIONAL PROVISIONS:
A. Grandfathered Health Plans: Employer snall provide Claim Administrator with written notice prior to renewal
(and during the plan year, at least 60 days advance written notice) of any changes that would cause any benefit
package of its group nealth plan(s� (each hereafter a"plan") to not qualify as a"grandfathered health plan" under
the Affordable Care Act and applicable regulations. Any such changes (or failure to provide timely notice thereo� can
result in retroactive and/or prospective changes by Claim Administrator to the terms and conditions of administrative
services. In no event shall Claim Administrator be responsible for any legal, tax or other ramfications related to any plan's
grandfathered heafth plan status ar any representation regarcting any plan's past, present and future grandfathered status.
The grandfathered health plan form ("Form'�, if any, shall be incorporafed by reference and part of the BPA and
Agreement, and Employer represents and warrants that such Form is true, complete and accurate.
B. Retiree Only Plans, Excepted Benefits andlor Self-Insured Nonfederal Governmental Plans: If the BPA includes
any retiree only plans, excepted benefits and/or self-insured nonfederal governmerrtal plans (with an exemption election),
then Employer represents and warrants that one or more such plans is not subject to some or all of the provisions of Part A
(Individual and Group Maricet Reforms) of Title XXVII of the Public Health Senric� Act (and/or related provisions in the
Intemal Revenue Code and Employee Retirement Income Security Act) (an "exemp� plan status'�. Any determination that
a plan does not have exempt plan status can result in retroactive and/or prospective changes by Claim Administrator to the
te�rns and conditions of administrative services. In no event shall Claim Administrator be responsible for any legal, tax or
other ramifications related to any plan's exempt plan status or any representation regarding any plan's exempt plan status.
C. Employer shall indemnify and hold harmless Claim Administrator and its directors, officers and employees against any
and all loss, liabiiity, damages, fines, penalties, taxes, expenses (including attorneys' fees and costs) or other costs or
obligations resulting from or arising out of any claims, lawsuits, demands, govemmental inquires or ackions, settlemeMs or
judgments brought or asserted against Claim Administrator in connedion with (a) any plan's grandfathered health plan
status, (b) any ptan's exempt plan status, (c) any plan's design (including but not limited to any directions, actions and
interpretations of the Employer), and/or (d) any provision of inaccurate information. Changes in state or federal law or
regulations or interpretations thereof may change the terms and cond'Rions of administrative services.
The provisions of paragraphs A-C (directly above) shall be in addition to (and do not take the place o� the other terms and
conditions of administrative services between the parties.
I UNDERSTAND AND AGREE THAT:
1. The proposed fees are effedive for 12 months, subjed to contrad provisions, and are based on the information and
conditions stated. Final fees ar9e subject to review based on actual enrol�ment results. If there is a 10% or greate�
variance in the enrollment and/or less than the minimum enrollment requiremerrt of N/A - Renewirtg Account,
BCBSTX reserves the right to review the final fees. The information provided in this application is complete and
accurate to the best of my knowledge. If this information is incomplete or inaccurate, BCBSTX may rerate the plan,
withdraw the proposal or cancel the contract.
2. No material changes have been made to the claims experience previously provided. �Yes � No If changes
have been made, please complete and attach the account experience addendum.
3. No material changes have been made to the previously provided location(s) of eligible employees? ❑ Yes �No If
changes have been made, please attach new census.
4. Receipt by BCBSTX of the advance administrative fee (where applicable), in the amount of $N/A - Renewing
ACCOUnt, and completed enrollment forms does not constitute approval and acceptance by the BCBSTX Home
Office.
5. If applicable, effedive 11l01/08, the above-named agerrt(s)or agency�es) is/are recognized as Employer's Agerrt 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 Hea1tM Care Service Corporation (HCSC), a Mutual Legal Reserve Company, and
HCSC subsidiaries for ou� employee benefit programs. This statement rescinds any and all previous Agent of Reconi
appointments for this company. The above named agent(s) 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. AgenUBroker Statement (if app�icable): I certify that I have reviewed all enrollment materials. I h�ve also advised the
Employer that f have no authqrity to bind these coverages, to alter the terms pf the CoMract(s)/Policy(ies), this Benefit
Program Application or enrollment material in any manner or to adjust any claims for benefds under the
Contract(s)/Policy(es).
7. BCBSTX will report the value of all remuneration by BCBSTX to ERISA plans with 100 or more partiapants for use in
preparation of ERISA Form 5500 schedules. Reporting will also be provided upon request to non-ERISA plans or
plans with fewer than 100 participants. Reporting will include base commissions, bonuses, incentives, or other forms
of remuneration for which your agenUconsultant is eligible for the sale or renewal of self-funded and/or insured
products.
Terry Villiva
Authorized BCBSTX Representative Sign re of Authorized Purchaser
Account F�cecutive
10/21/10 City Manager
Title Date Title
Phone: 409-896-0104 Fax: 409-896-0111 l 0/ 2 5/ 2 O l 0
BCBSTX Telephone and Fax numbers Date
Mickey Moshier - Sherfock Insurance Agency, Inc.
Agent Representative ('rf applicab/e)
10/21/10
Date
Pone:409-832-7736 Fax:409-833-1721
Agent Telephone and Fax numbers
PROXY
The undersigned hereby appoirrts the Board of Directors of Health Care Service Corporation, a Mutual Legal Reserve Company,
or any successor thereof ("HCSC'�, with full power of substitution, and such persons as the Board of Directors may designate by
resolution, as the undersigned's proxy to act on behalf of the undersigned at ail meetings of inembers of HCSC (artd at all
meetings of inembers of arry successor of HCSC) and any adjoummerrts thereof, with full power to vote on behalf of the
undersigned on all matters that may come before any such meeting and any adjoummeM thereof. The annual meeting of
members shall be held each year in the corporate headquarters on the last Tuesday of October at 12:30 p.m. Special meetings
of inembers may be calted pursuant to nofice mailed to the member not less than 30 �or 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 inembers.
Group No.: 0311181 BY�
031120 Stephen B. Fitzgibbons
Prirrt Sig Name er � � � �
� --Cit Mana er
Signature and itle
Group Name: Clty Of POft AtthUt'
Address: p. O. Box 1089
���v� Port Arthur State: Texas Zip Code: 77641
Dated this 25th day of October 2010
Month Year