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HomeMy WebLinkAboutPR 19144: THIRD PARTY ADMINISTRATOR ADMINISTRATIVE SERVICES ONLY, GROUP MEDICAL, DENTAL INSURNACE, BASIC LIFE, BASIC ACCIDENTAL DEATH AND DISMEMBERMENT, BLUE CROSS AND BLUE SHIELD OF TEXAS, INC. City of Port Arthur Memorandum TO: Brian McDougal, City Manager DATE: 9/3/2015 FROM: Patricia Davis, Senior Human Resources Analyst C-7 % SUBJECT: BC/BS Renewal Effective 11/1/2015 RE: P. R. No. 19144 A RESOLUTION AUTHORIZING THE CITY MANAGER TO EXECUTE CONTRACTS BETWEEN ITS THIRD PARTY ADMINISTRATOR (ADMINISTRATIVE SERVICES ONLY) FOR THE CITY OF PORT ARTHUR GROUP MEDICAL, DENTAL INSURANCE; FOR BASIC LIFE, FOR BASIC ACCIDENTAL DEATH AND DISMEMBERMENT, AND EXCESS LOSS INDEMNITY WITH BLUE CROSS AND BLUE SHIELD OF TEXAS,INC. COMMENT RECOMMENDATION: It is recommended that the City Council adopt P. R. No. 19144 which authorizes the City Manager to execute contracts between its third party administrator(administrative services only) for the City of Port Arthur group medical,dental insurance; for basic life, for basic accidental death and dismemberment, and excess loss indemnity with Blue Cross and Blue Shield of Texas, Inc., and Dearborn National Life Insurance Company for its 11/1/2015-10/31/2016 plan year. BACKGROUND: The City of Port Arthur consid4s its employees to be its most valuable asset and resource. In keeping with this p emise major medical health insurance and dental insurance, basic life insurance, basic accidental death and dismemberment are provided for its employees. Additionally, the City also provides access to its major medical health insurance coverage,including prescription drug coverage, for its retirees. The City of Port Arthur has a Preferred Provider Organization (PPO) insurance format which provides participants great latitude in selection of health care providers. This format has been deemed most beneficial for plan participants and most compatible with our organizational culture. The City also offers a lower cost Health Savings Account (HSA) option. The City is self-insured for major medical health insurance coverage. Each renewal year comes with additional elements of the Affordable Care Act impacting the City's health insurance that must be taken into account. In the upcoming renewal year there Brian McDougal/Memo 09/03/2015 Page 2 of 2 are changes to the annual deductible, maximum out-of-pocket deductible, prescription drug out-of-pocket maximum, along with an additional prescription tier level for all specialty drugs. Although, The City of Port Arthur has enjoyed surprising price stability with Blue and Cross Blue and Shield of Texas, Inc. with average rate increases of 2.3% where industry averages are significantly greater at 7%-11%. Further, the Blue and Cross and Blue and Shield network discounts and national availability provide not only significant plan cost savings, but also access for employees, retirees and dependents across the nation. This current year's renewal reflects a 5.1% increase in recommended premium funding. Also included as Attachment "A" is an analysis of this year's renewal proposal as presented by the City's insurance consultant, Mr. Mickey Moshier. The renewal as presented does not pass on any increase to employees and retirees. It provides for the City to absorb the proposed 5.1% increase. Dental, AD&D, and Life insurance rates remained constant with no increase. Additional efforts with regard to wellness and education regarding plan usage and alternatives will be a significant initiative in the upcoming renewal year. The 2015-2016 Open Enrollment period will be from October 1 to October 31, 2015. BUDGETARY/FISCAL EFFECT: Approval of P. R. No. 19144 which authorizes the City Manager to execute contracts with the following budgetary impact for which funds are available: Expected claims $7,888,643 Administration/Stoploss $1,820,672 Dental $ 332,371 Basic Life/AD&D $ 30,000 Total $10,071,686 EMPLOYEE/STAFF EFFECT: None anticipated. SUMMARY: It is recommended that the City Council adopt P. R. No. 19144 which authorizes the City Manager to execute contracts between its third party administrator (administrative services only) for the City of Port Arthur group medical, dental insurance; for basic life, for basic accidental death and dismemberment, and excess loss indemnity with Blue Cross and Blue Shield of Texas, Inc. and Dearborn National Life Insurance Company for its 11/1/2015- 10/31/2016 plan year. ATTACHMENT "A" �.5. Edwards Sherlock INSURANCE AGENCY City of Port Arthur Employee Benefits Renewal November 2015 The City solicited proposals for employee benefits in November 2013. The specifications requested a 3 year offer with options for 4th and 5th years. Fee guarantees were included in the chosen BCBS response and are part of the renewal offer received from them for November 2015. The original renewal proposal for this year suggested a 14.5% funding level adjustment as a result of overall utilization, medical trends, and ongoing large claims. There have been 9 claims over $100,000 each in the renewal calculation period. Remember that the City's health plan is a self-funded financial arrangement with stop loss protection to help avoid extremely large claims. That stop loss coverage protects the City from unexpected losses with a $100,000 deductible per covered participant. Any amount over $100,000 per individual becomes the responsibility of the stop loss carrier. Claims under $100,000 are funded by the City's health claim fund. 4155 Phelan Boulevard • Beaumont,TX 77707 • P.O. Box 22237, 77720.2237Beaumont(409)832-7736 ° Fax(409)8311721 Houston(713) 224-8723 • Review and discussion of the overall claims information with BCBS yielded some relief from the funding level to a reduced 7.8% suggested adjustment to current. That reduction was a result of updated data relating to the status of large claimants as well as a reduction in the trend/medical inflation factor that was part of the original calculation. At the direction of the City Manager and his staff, we went back to BCBS again with a goal of reaching a 5% adjustment. While claims experience would not afford that being a viable alternative at the current benefit level, we discussed and considered minor benefit adjustments that would allow the needed cost adjustment while impacting City participants in the lowest possible level. The revised renewal offer reflects a suggested funding level adjustment of 5.1%. The benefit adjustments include a deductible increase from $1000 to $1500. While the Out of Pocket maximum is moving from $4500 to $5000, it now includes prescription copays in its accumulation. Lastly, specialty prescription drugs will have a $150 copay and they are available through Prime Specialty Pharmacy. While no one wants a benefit or rate change, it is important to recognize that even after these changes, City benefits (and employee costs associated with them) are very much in line or better than most other employers in the area. The benefit adjustments will facilitate an estimated $300,000 reduction from the revised suggested funding level and an estimated $850,000 from the original renewal suggested funding level. Lastly, we were able to negotiate "no change" in costs for both dental benefits and life insurance benefits that are enjoyed by City employees. I am available for additional review or questions that City officials might have on this synopsis. Respectfully submitted, )1/(11?'"-;". Mickey M i shier, MHP P.R. No. 19144 09/03/15 — BM/pd RESOLUTION NO. A RESOLUTION AUTHORIZING THE CITY MANAGER TO EXECUTE CONTRACTS BETWEEN ITS THIRD PARTY ADMINISTRATOR (ADMINISTRATIVE SERVICES ONLY) FOR THE CITY OF PORT ARTHUR GROUP MEDICAL, DENTAL INSURANCE; FOR BASIC LIFE, FOR BASIC ACCIDENTAL DEATH AND DISMEMBERMENT, AND EXCESS LOSS INDEMNITY WITH BLUE CROSS AND BLUE SHIELD OF TEXAS, INC. FUND NO. (S) : 614-1701-583.54-00 (HEALTH INSURANCE FUND) WHEREAS, the City Council of the City of Port Arthur deems it necessary and appropriate to provide major medical health care benefits for the City's employees, City Council appointees, and its retirees; and, WHEREAS, the City Council deems it in the best interest of the citizens of Port Arthur to be self-funded and to accept the renewal I from Blue Cross and Blue Shield of Texas, Inc. as a third party administrator at an estimated cost of $554,378 per year (administrative charge based on the present number of employees and retirees) as well as at a cost of $1,266,294 per year for stop loss premium (excess indemnity) per the recommendation of the City's insurance consultant, Mickey Moshier listed hereto as Attachment "A"; and; WHEREAS, the City's group health plan coverage encompasses the enactment of the Patient Protection and Affordable Care Act (PPACA) effectuated on March 23, 2010, with continuing provisions enacted annually, and do hereby affirm to continue to make changes to its existing health plan policies or products as required to comply with the law; and, P.R. No. 19144 09/03/15 -- BM/pd Page 2 of 5 WHEREAS, such contracting with Blue Cross and Blue Shield of Texas, Inc. complies with Sections 252.021(b), Competitive Requirements for Certain Purchases, 252.024, Section of Insurance Broker, and 252.048, Change Orders, respectively of the Local Government Code; and, WHEREAS, the nature of the premiums to be charged by the City and the summary of benefits are as delineated in Exhibits "A-1", "A-2" , "B-1", and "B-2" which reflect the costs for administration by Blue Cross and Blue Shield of Texas, the stop loss premium, the expected reserve; and, WHEREAS, the Basic Life Insurance will also be continued per Dearborn National Life which includes provisions to provide basic life insurance coverage to Fire Civil Service personnel at a rate of one times his/her base annual salary in accordance with the 10/1/2011 Collective Bargaining Agreement between the City of Port Arthur, Texas and Local 397 International Association of Fire Fighters, which will cost the City $.22/per thousand dollar unit, and all other eligible employees coverage will remain a $6,000 death benefit policy, which will cost the City $.19/per thousand dollar unit/per employee/per month and attached as Exhibit "C"; and, WHEREAS, as part of the Dearborn National Life proposal, the City is also obtaining Accidental Death and Dismemberment insurance on behalf of its employees which will remain at a cost of $.04/per thousand dollar unit/ per P.R. No. 19144 09/03/15 -- BM/pd Page 3 of 5 employee (for a $5,000 accidental death and dismemberment policy for all eligible employees) per month as attached as Exhibit "C"; and, WHEREAS, the current year's renewal reflects a (5.1%) increase in recommended premium funding, the renewal as presented does not pass on any increase to employees and retirees. Further, it provides for the City to absorb the proposed 5.1% increase; now, therefore, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PORT ARTHUR: THAT, the City Council of the City of Port Arthur hereby accept the following contracts to Blue Cross and Blue Shield of Texas, Inc.; attached hereto and made a part hereof, as is fully delineated herein: INSURANCE COVERAGE ADMINISTRATIVE SERVICES EFFECTIVE DATE Administrative Services Blue Cross & Blue Shield November 1, 2015 City of Arthur's Group Medical, Stoploss Dental Blue Cross & Blue Shield November 1, 2015 Basic Life & AD&D Dearborn National Life November 1, 2015 THAT, the City Manager is hereby further authorized to execute the necessary contracts and other documents on behalf of the City of Port Arthur P.R. No. 19144 09/03/15 — BM/pd Page 4 of 5 subject to the approval of the City Attorney, and to make payment of necessary premium and administrative charges to bind coverage subject to the terms and conditions of the contract for Third Party Administrator Administrative Services and the Contracts for Insurance attached hereto as required to effectuate said services; and, THAT, the City Manager is hereby directed to take all actions necessary to ensure proper funding of the City of Port Arthur's employee health insurance Fund; and, THAT, a copy of the caption of this Resolution be spread upon the minutes of the City Council. READ, ADOPTED, AND APPROVED this day of , AD, 2015, at a Regular Meeting of the City Council of the City of Port Arthur, by the following vote: AYES: Councilmembers: P.R. No. 19144 09/03/15 — BM/pd Page 5 of 5 NOES: Deloris "Bobbie" Prince, Mayor ATTEST: Sherri Bellard, City Secretary APPROVED AS TO FORM: Valecia Tizeno, City Attorney APPROVED FOR ADMINISTRATION: Brian McDougal, City Manager APPROVED AS TO AVAILABILITY OF FUNDS: o ea4,1p //eR / /A5 Jerry Dale, Interim Director of Finance ATTACHMENT "A" J.S. Edwards Sherlock INSURANCE AGENCY City of Port Arthur Employee Benefits Renewal November 2015 The City solicited proposals for employee benefits in November 2013. The specifications requested a 3 year offer with options for 4th and 5th years. Fee guarantees were included in the chosen BCBS response and are part of the renewal offer received from them for November 2015. The original renewal proposal for this year suggested a 14.5% funding level adjustment as a result of overall utilization, medical trends, and ongoing large claims. There have been 9 claims over $100,000 each in the renewal calculation period. Remember that the City's health plan is a self-funded financial arrangement with stop loss protection to help avoid extremely large claims. That stop loss coverage protects the City from unexpected losses with a $100,000 deductible per covered participant. Any amount over $100,000 per individual becomes the responsibility of the stop loss carrier. Claims under $100,000 are funded by the City's health claim fund. 4155 Phelan Boulevard • Beaumont,TX 77707 • P.O. Box 22237, 777720-2_237 Beaumont(409)832-7736 • Fax(409)833-1721 • Houston(713)224-8723 Review and discussion of the overall claims information with BCBS yielded some relief from the funding level to a reduced 7.8% suggested adjustment to current. That reduction was a result of updated data relating to the status of large claimants as well as a reduction in the trend/medical inflation factor that was part of the original calculation. At the direction of the City Manager and his staff, we went back to BCBS again with a goal of reaching a 5% adjustment. While claims experience would not afford that being a viable alternative at the current benefit level, we discussed and considered minor benefit adjustments that would allow the needed cost adjustment while impacting City participants in the lowest possible level. The revised renewal offer reflects a suggested funding level adjustment of 5.1%. The benefit adjustments include a deductible increase from $1000 to $1500. While the Out of Pocket maximum is moving from $4500 to $5000, it now includes prescription copays in its accumulation. Lastly, specialty prescription drugs will have a $150 copay and they are available through Prime Specialty Pharmacy. While no one wants a benefit or rate change, it is important to recognize that even after these changes, City benefits (and employee costs associated with them) are very much in line or better than most other employers in the area. The benefit adjustments will facilitate an estimated $300,000 reduction from the revised suggested funding level and an estimated $850,000 from the original renewal suggested funding level. Lastly, we were able to negotiate "no change" in costs for both dental benefits and life insurance benefits that are enjoyed by City employees. I am available for additional review or questions that City officials might have on this synopsis. Respectfully submitted, N Mickey M shier, MHP EXHIBIT "A- 1 " .smelsuau • —ve,.....**Inwa..1.4*svm.awrowum - • - -.•. •ac.ednewaftrumsramaay....“cer.•1--,--.... ..**Kli.sma., ...*Potuere.m...s.mmwaymmw...,...raower.rara•aame ) j , :' '''''',..4 •cf .;'..'1:.' ..,..,::......Z.ZZ_N • ..2.5.:•••• 7 / .. tell CIP -1— ... . ( ... e...•k 1,:,..-I.r.= C i i Y Of .. ...'' '',.'- Q. k'j> '': . 71 ff., ) . !i e7)) 4, , 7 --74I-7---P5.''''7,'"- ,./' y , •,f/ ' z exas , ''-.0--., .c.,-,-4T-.v,: ,,,- ,:•. - : ii Pi '.. 1 . CITY rTytiu , 1 PORT " THLR , ! . , 1 ; P V M *LOYE0 E NE7TT REVIEW ., I . /I/1/2 01 5 : o . 6 : 1° IS. Edwards & Sherlock , Insurance Agency Mickey Moshier, MHP „. 1 as BlueCmss BlueShicld WI of Texas City of Port Arthur P. O.Box 1089 Port Arthur, Texas 77641-1089 Dear Group Administrator: Our underwriters have evaluated the November 1,2015 renewal of the group insurance coverage for the City of Port Arthur. The current and renewal information is enclosed. This renewal reflects our continued commitment to adjust to changes in the health insurance industry. Beginning in 2014,ACA provided for the establishment of temporary transitional reinsurance program(s)that runs from 2014 through 2016 and is funded by reinsurance contributions called a"Reinsurance Fee" from health insurance issuers and self-funded group health plans. Federal regulations establish a flat per member per month fee. ACA also provides that self-funded plan sponsors are responsible for the Reinsurance Fee.BCBS will not assist in the remittance of those fees to the federal government;however,upon request,we can make available to our self-funded/ASO customers,existing data and information that may be helpful in determining,reporting on, and remitting their Reinsurance Fee amounts. Please carefully review your group's Renewal Exhibit. We recommend that you speak with your Broker/Producer or Blue Cross and Blue Shield of Texas Account Representative who will be able to assist you in reviewing these materials.They can work with you to better understand how BCBSTX can support coverage changes you may be contemplating. Thank you for doing business with Blue Cross and Blue Shield of Texas. We appreciate your continued trust in our organization,and will strive to continue to exceed the service needs of you and your employees. Please contact your Broker/Producer or Account Representative if you have any questions. Sincerely, Blue Cross Blue Shield of Texas Malana.team Malana Hearn, Account Executive Phone: 409-896-0135 Fax: 409-896-0111 Email: Malana Hearn(bcbstx.com cc: Mickey Moshier A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks Blue Cross and Blue Shield Association Ls] ' BlueCross BlueShield of Texas kmdw } r G wa ® A.4g For renewals effective January 1, 2015, and thereafter ADMINISTRATIVE SERVICES ONLY (ASO) members with Blue Care Connection® Condition Management as part of their benefit plan, Care onTarget complements the wide array of health and wellness tools Product Changesalready available to all members. Members can access online condition assessments, Benefits Value Advisor(BVA) health tutorials and other health resources, by logging in This buy-up option is available to ASO groups with 250+ to Care onTarget directly or via the link in the MyHealth subscribers. BVA guides members through the health tab on Blue Access for MemberssM' care decision process, giving them the facts they need to make health care decisions. BVA offers quantifiable Care onTarget is a service mark of Health Care Service Corporation,a savings for employers and their employees. With just Mutual Legal Reserve Company. - one-call,a BVA can-provide-cost-information, explain — — —— — member benefits, let members know about available Behavioral Health Program educational tools and schedule appointments. BVAs BCBSTX's Behavioral Health program helps members document when they have provided members with access benefits for behavioral health (i.e., mental health options for lower-cost, high-quality in-network care. That and substance abuse) conditions as part of an overall information is then compared against members' claims care management program. The program helps to data to track savings. identify members who could benefit from co- management of behavioral health and medical BVA will introduce new enhancements on Jan. 1, 2015, conditions. This integrated approach to care coordination that will help ensure the greatest potential for savings for can result in improved outcomes, enhanced continuity of employers and their employees. Employers will have the care and reduced costs over time. ability to choose several options beyond the standard Some ASO accounts may select to not purchase the outpatient BVA product: component of the Behavioral Health program. Members of these • Call requirement— members must call a BVA groups will not experience the benefits of the integrated care prior to scheduling any diagnostic imaging coordination service delivery model.Additionally,outpatient care management services and any outpatient preauthorization procedure requirements will not apply. • Outbound calling —BVAs will call members based on data received from doctors that Employee Assistance Program indicates diagnostic imaging is needed BCBSTX's Employee Assistance Program offers 24/7 o Customized engagement—customized support, seminars, coaching and interactive online tools communication campaigns with targeted for employees seeking help with personal problems. messages to employees based on their claims Getting early assistance can reduce the likelihood of data (additional cost) escalated emotional and medical problems, as well as ® higher health care costs. Blue Care Connection Blue Care Connection (BCC), Blue Cross and Blue Employee Assistance Program(EAP)services are administered by Shield of Texas' (BCBSTX) integrated health care Magellan Health Services,a separate company.EAP services are available for an additional fee to groups with 151+employees enrolled management and wellness program, focuses on in a BCBSTX health plan. identifying members earlier, before their health risk factors may lead to the development of chronic 2015 HSA-compatible HDHP Requirements conditions, hospital admissions, readmissions or Each year, the U.S. Treasury Department and Internal emergency room visits. BCC programs include: CCEI® Revenue Service determine deductible minimums and Care Coordination and Early Intervention, Web-based out-of-pocket maximums for HSA-compatible (health coaching tools, expanded member outreach and lifestyle savings account) high deductible health plans (HDHPs), management programs. as well as contribution maximums to HSAs. The rules s,� apply to our BlueEdge HSAsM plans. Care onTarget This dynamic condition management tool lets members learn about and manage their health conditions. The online tool gives members an alternative way to engage in care management programs. Now available to Blue Cross and Blue Shield of Texas,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association 1 i 4010 Rol \ BlueCross BlueShield of Texas b,a72, Rj,P a e-s For renewals effective January 1, 2015, and thereafter 2015 HSA and HDHP Annual Individual Family prescriber(s) on care coordination opportunities and Requirements Coverage Coverage conducts member outreach. Mitigating the potential Minimum Deductible abuse of these medications can reduce the member's 2015 $1,300 $2,600 risk of adverse outcomes. 2014 $1,250 $2,500 Maximum Out-of-Pocket Medication Exclusions (Compound Drug Optional) (in network) Effective Jan. 1, 2015, you can elect to exclude 2015 $6,450 $12,900 coverage for certain agents or medication categories: 2014 $6,350 $12,700 HSA Contribution Maximum 2015 $3,350 $6,650 O Compound Medications —These medications 2014 $3,300 $6,550 contain two or more drugs or drug ingredients that a Minimum Embedded Deductible licensed pharmacist combines, mixesor alters_to.____.._ 2015 $2,600* $2,600 create a medication tailored to the needs of an 2014 $2,500* $2,500 individual patient. These customized drugs are not commercially available and can be high cost. They * Due to BCBSTX's system limitations, embedded deductible are also not approved by the U.S. Food and Drug requires an individual to meet the minimum family deductible of Administration (FDA) and have not been tested for $2,600 for 2015.The IRS individual minimum is $1,300 for safety, efficacy or side effects by the FDA. Members 2015. using compound drugs may be directed, through 2015 HSA Catch-up Contributions (age 55 and older): $1,000 consultation with their doctor, to FDA-approved (no change from 2014) commercially available products that have proven safety and efficacy data. Pharmacy Program* Changes Effective upon Renewal Drug List and Drug Dispensing Limits Changes to your group's prescription drug benefit plan Based on the availability of new prescription medications must be communicated to your BCBSTX representative and routine review of changes in the pharmaceuticals by the 20th of the month, two months prior to the market, revisions are regularly made to the drug list and effective date. Pharmacy benefit changes received after dispensing limits. Both the drug list and dispensing limits the 2e of the month will take effect on the first day of changes take place upon an effective date across the the third month following. For example, changes board. View the most up-to-date list and dispensing submitted Nov.20 take effect Jan.1;changes submitted limits. bcbstx.com/member/rx drugs.html Nov. 25 take effect Feb. 1. *Prime Therapeutics LLC is a pharmacy benefit management Utilization Management (UM) company. PrimeMail is a mail order pharmacy operated by Prime Therapeutics.Prime Therapeutics Specialty Pharmacy LLC is a wholly New drug categories added to the standard program owned subsidiary of Prime Therapeutics. Blue Cross and Blue Shield include: of Texas(BCBSTX)contracts with Prime Therapeutics to provide o Prior Authorization (PA) — Insulin (Jan. 1, pharmacy benefit management,prescription home delivery and 2015) specialty pharmacy services. In addition,contracting pharmacies are contracted through Prime Therapeutics.The relationship between BCBSTX and contracting pharmacies is that of independent ASO groups will need to provide approval before the contractors. BCBSTX, as well as several other independent Blue Cross new drug categories can be added to their benefits, even and Blue Shield Plans,has an ownership interest in Prime if the group currently has the standard UM program. Therapeutics. Enhanced Support for Prescribed Controlled Substance Medication Use Legislative Updates As of June 30, 2014, BCBSTX began using enhanced Please note that these summaries are for informational criteria to identify members with suspected cases of purposes only and are not intended to be legal, tax or abuse, misuse or improper utilization of prescribed compliance advice or relied upon as such. Information is controlled substance medications. The controlled subject to change as we receive new regulations and substance clinical review program is also reviewing guidance. We will communicate updates and an identified member's case through an integrated action changes as they become available-be sure to check: committee, which collectively determines the appropriate -The weekly News From the Blues employer newsletter clinical intervention, collaborates with the member's for new information Blue Cross and Blue Shield of Texas,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company.an Independent Licensee of the Blue Cross and Blue Shield Association 2 ( in] BlueCross BlueShieid of Texas For renewals effective January 1, 2015, and thereafter -Fact sheets, FAQs, other resources and the monthly immunizations and other types of care, as recommended Legislative Highlights summary in Blue Access for by the federal government. EmployerssM(see Legislative Updates tab) or consult with your account executive. BCBSTX is committed to implementing coverage changes to meet ACA requirements as well as the needs National Health Care Reform/Affordable Care Act and expectations of our members. (ACA) General Highlights of New Regulations: Preventive Action Required to Maintain Grandfathered Status services are to be covered without any cost-sharing Self-funded employer groups intending for one or more when using a network provider. Cost-sharing can still be of their benefit plans to maintain grandfathered health required when using a provider that is not in the plan status must complete and return the Grandfathered _ BCBSTX provider network. _ _ _ Health Plan Status Certification Form(s) enclosed with their renewal. New recommendations can be issued at any time. As new or updated preventive care recommendations or Uniform Summary of Benefits Coverage (SBC) guidelines are issued, employers and insurers have at The law makes it the employer's responsibility to create least one year to implement the new guidelines unless and distribute the SBC for self-insured plans. The health otherwise specified by the government. insurer has no legal obligation to do so. Plans that cover preventive services in addition to those BCBSTX will create the SBC for self-insured groups that required under ACA may apply cost-sharing request our services per the Benefit Program requirements for the additional services. Applications (BPA). The group administrator will validate and approve the information in the SBC. The AE will The regulation references preventive care services with provide the completed SBC electronically to the group an A or B rating as outlined by the United States administrator, who will distribute it to members per the Preventive Services Task Force (USPSTF). More BPA. If a self-insured client requests that BCBSTX print information about the USPSTF recommendations may and mail the SBC to subscribers, a fee will be assessed be found here. as noted on the BPA. BCBSTX may use reasonable medical management We will provide interpretive services and written techniques to apply certain limitations on the service, translations of SBCs upon request for a fee in certain including the frequency, method, treatment or setting for non-English languages (including Spanish, Chinese, the service, and the use of an out-of-network provider. Navajo, and Tagalog), in certain situations. Specifically, with respect to an address in any United States county Contraception coverage requirement*: The following to which an SBC is sent, we will provide the SBC in a contraceptive items and services are generally covered non-English language if 10 percent or more of the without cost-sharing when provided by a health care population residing in that county is literate only in that provider in the BCBSTX network. same language. Prescription–One or more products within the categories approved by the FDA for use In addition, we ensure that all English versions of the as a method of contraception SBC disclose the availability of language services in Over-the-counter–Contraceptives available these non-English languages. approved by the FDA for women (foam, Preventive Care Services Covered Without Cost- sponge, female condoms)when prescribed Sharing —Without Copay, Coinsurance or by a physician Deductible o The morning after pill ACA requires non-grandfathered health plans and o Medical devices such as IUD, diaphragm, policies to provide coverage for"preventive care cervical cap and contraceptive implants services"without cost-sharing (such as coinsurance, a Female sterilization, including tubal ligation deductible or copayment), when the member uses a network provider. Services may include screenings, 'ACA regulations provide for an exemption from the requirement to cover contraceptive services for certain Blue Cross and Blue Shield of Texas,a Division of Health Care Service Corporation,a Mutual Legat Reserve Company,an Independent Licensee of the Blue Cross aria Blue Snield association 3 c2117611 BlueCross BlueSlhield of Texas For renewals effective January 1, 2015, and thereafter group health plans established or maintained by o Custom ASO accounts can follow the EHB organizations that qualify as religious employers. Also, benchmark plan in the state in which coverage federal regulatory agencies have established an has been issued or request another state accommodation for religious affiliated eligible benchmark plan. They may also request their organizations, in which case separate payment may be own definition of EHBs through their BCBSTX available for certain contraceptive services. For more representative. information about the religious employer exemption or e Any dollar limits on EHBs that may be covered eligible organization accommodation, please contact by standard (pre-packaged) plans (51+)will be your account executive. removed or converted to visit or item limits. To identify EHBs, we will follow the EHB benchmark 2015 Approach: Essential Health Benefit plan in the state in which the coverage has been "Authorized" Definition to Address Dollar Limits and issued. ___ _-- O0t-of-Pocket Maximum (00PM) e Contact your BCBSTX account representative Large groups regardless of funding type and with additional questions about our standard grandfathered small group plans are not required by the approach to EHB and OOPM requirements. Affordable Care Act(ACA) to cover essential health benefits (EHBs) in 2015. However, for any EHBs Pharmacy Integration: For the 2015 plan year, there covered beginning with the 2014 plan year, insurers and are two options to set up the OOPM for medical and self-funded plan sponsors must use an "authorized" pharmacy benefits. Groups can keep separate OOPMs definition when designing their benefit plans to meet the for medical and pharmacy benefits. The total of the two following ACA requirements for these plan types: combined OOPMs cannot exceed $6,600/$13,200. Or groups can apply all member cost sharing for medical • No annual or lifetime dollar limits on any EHBs and pharmacy benefits to a single OOPM, not to exceed that happen to be covered; and $6,600/$13,200. Groups should consult with their • Non-grandfathered plans must set limits on account executive to discuss their preferred approach member cost-sharing for any in-network EHBs and timing. (and out-of-network emergency services) they cover. For the 2015 plan year, the out of pocket *The link provided for the state benchmark plans goes to the cros.cov maximum (OOPM) limits are $6,600/$13,200. website.The benchmark plans published on this site may not include the most current or comprehensive details for each state. Previously, insurers and self-funded plan sponsors could Employer Shared Responsibility (ESR) use a "good faith" definition to determine which benefits Generally, under ESR, applicable large employers are considered EHBs for the purpose of removing (generally, 50 or more full-time employees, including full- lifetime and annual dollar limits on EHBs. time equivalents) face a potential penalty if they don't provide minimum essential coverage (MEC)to full-time Starting with the 2014 plan year, insurers and self- employees that has both minimum value (company is funded plan sponsors must use an "authorized" definition paying at least 60 percent of covered health care to determine which benefits are EHBs. This means using expenses for a typical population) and is affordable (full- a definition authorized by the Secretary of the U.S. Dept. time employees cannot pay more than 9.5 percent of of Health and Human Services (HHS). For now, HHS their income for the lowest-cost, self-only coverage). has indicated that a state EHB benchmark plan, as supplemented (if necessary) by HHS to include Employers with fewer than 50 full-time employees are coverage of all 10 EHB categories, is considered an not subject to ACA's ESR provisions. In February 2014, "authorized" definition. Future guidance is expected from the IRS released a final rule on the ESR provisions. For the federal government on this topic. 2015, employers with between 50 and 99 full-time employees are exempt from the ESR penalty if the Our standard approach to an "authorized" definition for employer provides an appropriate certification and meets EHBs will be to follow the benchmark plan* for the state certain conditions. in which the coverage has been issued. In 2015, employers subject to the mandate must offer Important notes for large accounts: coverage to 70 percent of their full-time employees or • Only custom accounts can request an risk penalties for failure to offer coverage to all full-time alternative "authorized" definition for EHBs. employees and child dependents. Blue Cross and Blue Shield of Texas,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association 4 [vo® . '44 BlueCross BlueShield of Texas e a�t.fi.. tit -,1z-,V For renewals effective January 1, 2015, and thereafter To avoid a penalty in 2016, employers subject to ACA's 0 Discriminate against the individual on the basis ESR provisions must offer coverage to 95 percent of of the individual's participation in such trial their full-time employees and child dependents. This rule applies whether the failure to offer coverage is Mental Health Parity and Addiction Equity Act intentional or unintentional. However, this rule does not Generally, the Mental Health Parity and Addiction shield the employer from the penalty for offering Equity Act (MHPAEA) prohibits certain individual and inadequate coverage if any of the full-time employees, group health plans from applying financial requirements including those who are not offered coverage at all, (e.g., copays) or treatment limits (e.g., number of annual receive a premium tax credit or cost-sharing assistance visits) on behavioral services that are more restrictive for purchasing coverage through the Marketplace. than those applied to the health plan's medical and surgical benefits. It also prohibits certain individual and Employer Marketplace Notice group health plans from_imposing_non=quantitative________ _. Employers subject to the Fair Labor Standards Act treatment limitations (NQTLs) (e.g., medical must provide employees written notice about coverage management techniques, network reimbursement and options through the Marketplace. The U.S. Department entrance requirements, etc.) on behavioral health that of Labor(DOL) released model notices for employers are more stringently applied than those applied to the that do provide a health plan and for those that do not. health plan's medical and surgical benefits. Employers are required to provide written notice about coverage to each new employee within 14 days of an Self-funded group health plans are responsible for their employee's start date. plan's benefit design and for compliance with any applicable laws, including federal mental health parity The notice is required to be provided automatically, free rules. of charge. It can be provided in writing either by first- class mail, or electronically if the DOL's electronic Based on the requirements in the final rule and our parity disclosure safe harbor requirements are met. analysis, our standard benefit design will now typically include coverage for behavioral health services provided For more information, please visit the DOL technical in residential treatment centers (RTCs) at the inpatient release on the Marketplace notice: benefit level. http://www.dol.qov/ebsa/ne wsroom/trl3-02.h tml. Important HIPAA and Other Federal Mandates Premium Tax Credit Eligibility Notices This fact sheet details when someone might be eligible The federal Health Insurance Portability and for the federal premium tax credit on the Health Accountability Act of 1996 (HIPAA) requires Insurance Marketplace (Please log in to the secure employers to notify all eligible employees of two producer portal to see the fact sheet. Look on the important provisions in their health care plans: special Training and Administration page under Affordable Care enrollment provisions and pre-existing condition Act Education and Training). It also includes eligibility exclusion rules scenarios for employees, spouses and dependents. If you have additional questions, contact your account For your convenience, you may distribute BCBSTX's executive or call 888-775-6892. Important Notices—Initial Notice about Special . Enrollment Rights and Pre-existing Condition Exclusion Clinical Trials Coverage Rules in Your Group Health Plan to your employees. The Clinical Trials provision of ACA goes into effect for plan years beginning on or after Jan. 1, 2014 (applies Note: A notice must also be given to each new employee only to non-grandfathered plans). It requires that if a prior to his or her enrollment in, or declination of, health "qualified individual" is in an "approved clinical trial," then coverage, and must be redistributed each year at open the plan may not: enrollment. 0 Deny the individual participation in the clinical trial Deny the coverage of routine patient costs for did a isf five Updates items and services furnished in connection with the trial Blue Cross and Blue Shield of Texas,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association 5 faov BlueCross BlueShield of Texas kit c, mere ,11 xclkt.e. 1 For renewals effective January 1, 2015, and thereafter Recommended Timeline for Submitting Renewal issues. When personal or confidential issues arise, we Paperwork conduct private discussions with the member. Our To meet expectations for timely processing of renewals YouTube channel features educational videos about our and issuing ID cards: products and services, and includes brief insurance tips o Accounts that use the Automated Eligibility about using our self-service tools. Process (AEP) and add sections, cancel sections or make significant plan changes Reaching Members via Blue Access Mobiles"' should return the signed renewal paperwork at BCBSTX offers mobile features for members on-the-go. least 60 days prior to the effective date. From a mobile phone Web browser, members can: o Accounts that use any other eligibility • Locate an in-network doctor, hospital or facility process should submit the signed renewal Register for Blue Access for Members BAM paperwork at least 45-days prior to-the effective a g — -- � • Log in to BAM to view coverage details, access date. ID card information, request a new ID card, Auto Publishing for Custom Certificate Booklets check claims status and payment history, To help manage risk for BCBSTX and our group clients, contact customer service using the Message and to provide appropriate benefit booklet Center and view health and wellness information documentation to support appeals processes and other • View BCBSTX contact information legal requirements, BCBSTX has implemented an Auto- ePublishing model for custom groups. From their BAM Settings/Preferences page, members can opt-in to receive a variety of secure and helpful BCBSTX sends a draft booklet for client review. notifications for claims status and wellness updates However, if BCBSTX does not receive a response (with through emails or text alerts. any changes) or approval to the draft booklet from the broker/consultant and/or client after 60 days, BCBSTX Go to bcbstx.com/mobile for more information. To use will assume that the content has been accepted. mobile offerings, go to bcbstx.com from a mobile phone BCBSTX will then make the benefit booklet available to Web browser. To opt-in for text message offerings, the group and members electronically via Blue Access members must be registered for BAM and validate their for Employers and Blue Access for Members. mobile phone number on their BAM Settings/ Preferences page. Blue Insights"" Reporting Mobile Applications (Apps) The Blue Insight reporting package provides key BCBSTX —a free Android and iPhone app is available financial and utilization data to help you make informed, data-driven decisions for your company. Monthly reports to download on Google Play or on the Apple App Store include varied product information that allows you to (search for BCBSTX). Stay connected with BCBSTX and compare your data across time periods and against access important health benefit information wherever benchmarks. If you are not using the Blue Insight tool, you are. Use the BCBSTX app to: contact your BCBSTX representative to request access. q Find a doctor, hospital or urgent care facility or (Note: Benchmarks are not available for HMO accounts.) search for Spanish-speaking providers O Register or log in to the secure member website, You can find the ASO/Non-HMO report at Blue Access for Member?"' b/ueinsiohtreportingtx.com. New reports, which include all claim and membership data through the end of the Centered App —The Centered app, for iPhone®5s, prior month, are available around the 15th of every iPhone 6 and iPhone 6 Plus, is a free app designed to • month. Reports typically remain online for 12 months. help manage stress through activity and mindful meditation. Download the free app at the Apple App Using Social Media to Connect with Members Store (search for Centered). BCBSTX communicates with members using the media © Set a daily steps goal and a weekly meditation they prefer to facilitate two-way conversations. Our goal Facebook and Latino Facebook sites provide customer Choose from three meditation sessions - short, service support and offer wellness tips. We actively mindful or body awareness monitor Twitter to resolve members' questions or claim Blue Cross and Blue Shield of Texas,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association 6 — --- iia + i t Blue Cross BlueShield of Texas -- n `/� "cam` 'jy ..t i!%y`+.•-t K� s e'nI 1p�frets i yr + .",L S� For renewals effective January 1, 2015, and thereafter o Record activity automatically when you have and enrich your company's wellness culture. Use Well your iPhone with you. No need to open the app. onTarget to help motivate and support all employees– wherever they may find themselves along the lifelong Blue Access for Members (BAM) path to health and wellness. Encourage your employees to register for this secure website, where they can log in to: view their claims and Well onTarget is a registered mark of Health Care Service Corporation, EOBs, find doctors and hospitals, request replacement a Mutual Legal Reserve Company. ID cards, check health care account balances, and access tools to help lead a healthier lifestyle. Recently Employer Wellness Resources added features help members research options for care; Talk to your account executive about how you can use find and organize claims; search for forms and find these resources to promote health and wellness to additional help, employees. Improved Provider Finder Now Available for PPO ondemand Employer Wellness Portal and HMO Members Part of the Well onTarget program, the ondemand BCBSTX provides information and tools to help portal gives employer's tools you need to promote members make more informed health care decisions, wellness to your employees. This new online employer including selecting a network physician and determining toolkit can help you drive employee engagement. Use treatment costs. The Provider Finder tool also helps the interactive portal to review reports on employee members understand the value of their employer- participation, download employee communications, sponsored health benefits. coordinate workplace challenges, schedule workplace events and check the calendar for upcoming national With an improved design and easier search function, wellness events. Provider Finder is accessible through Blue Access for Other Employer Wellness Resources Members(BAM). When members access Provider Finder via BAM, they can identify health care O Quarterly Worksite Wellness Webinars: Our professionals based on their location, gender, languages wellness consultants discuss how to implement spoken, independent third-party quality designations, wellness programs and the potential impact on • member ratings and more. Members can also share the workplace, offer ideas and feedback about their doctor experiences, and benefit recommendations, and share best practices. from others' experiences. Online Resources: The employer toolkit at Be Additional features include: Smart. Be Well.Works® addresses health and ® Find all locations where a provider practices in wellness issues. Topics feature issues with one search quantifiable effect on workplace safety, performance, absenteeism and the bottom line. Use a global search bar to get faster results– Use the BlueResourceSM library of wellness fewer clicks! communications to create or supplement your For PPO members, this easy-to-use decision-support company's employee wellness program. Look tool lets them shop 1,600 inpatient, outpatient, for them under"Employer Resources" in Blue diagnostic and radiological procedures. Estimates of Access for Employers, or use BlueResource treatment costs are based on Blue Cross and Blue Online. Shield national claim data. Member Wellness Resources *Cost estimates are available to PPO members only. These resources can help members make healthier choices and add wellness into their daily lives. Wellness Well onTarget Part of the Blue Care Connection family,Well onTarget Well onTarget provides your company with several flexible package BCBSTX's innovative and affordable wellness solution options to fit your needs. These products can be made offers an expanded array of highly personalized tools available to your employees regardless of their health and resources to help increase employee participation plan affiliation. Well onTarget offers several new Blue Cross and Blue Shield of Texas,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association 7 �yoy� ) BlueCross BlueShield of Texas • 5. y t � Updat- .� For renewals effective January 1, 2015, and thereafter capabilities and features to serve your growing wellness program complements the Fitness Program by giving needs: members ongoing incentives for working out. Members o Integrated onmywayTM Health Assessment earn 2,500 Life Points for enrolling and up to 500 points o Life Points Reward Program a week for tracking their visits. Anyone can nominate a a Interactive Well onTarget Member Wellness fitness center for inclusion in the network by calling 888- Portal 762-BLUE (2583) or by visiting the Fitness Program site Targeted Wellness Content and Resources available through Blue Access for Members (BAM). e Self-directed Online Courses My Blue Community® O Certified Wellness Coaching —stress Available through Blue Access for Members (BAM), this management, nutrition and physical activity new health and wellness social network is a forum for e Self-Service ondeman_d Employer Wellness members to share stories, offer support and submit tips___ Portal on how to live healthier. The online community shares Workplace Competitions information and views on more than 40 health and Worksite Wellness Events such as health fairs, wellness topics. Also, My Blue Community has health ® biometric screenings, and health education and nutrition experts who answer questions and classes and workshops reputable bloggers who share their thoughts on running, parenting, food topics and more. Members may join in by • Personalized Wellness Communication creating an account via BAM. O New in 2015! Fitness Device Tracking e New in 2015! Well onTarget Mobile App BIu365®Member Discount Program Simply for being a member of BCBSTX, members are Wellness Portal able to receive exclusive health and wellness deals from The Well onTarget Member Wellness Portal offers national and local retailers to help keep them healthy. members an enhanced wellness experience through They can save money on health care products and highly personalized tools and resources. The interactive services that are not always covered by their benefit plan online tool links members to dedicated wellness health —such as gym memberships, dental and vision exams coaches, self-directed courses, wellness content, and services, hearing aids and diet-related services and trackers and health resources. many more. Members can access the program and discounts through BAM. Health Assessment The onmywayTM Health Assessment provides a better Additional Online Wellness Resources member experience, improved reporting and ® At Be Smart. Be Well. , members can access personalized questions. After completing the Health in-depth information on many wellness and Assessment, members receive a Personal Wellness prevention topics. The site features engaging Report, which shows how they are doing and offers video documentaries of real people, video areas of improvement. Members can also download a interviews with nationally recognized subject Provider Report to take to their doctor on the next visit. matter experts and extensive health and wellness resources. Visitors can sign up to Reward Program receive complimentary health News Alerts and The new Life Points program allows real-time awarding Spotlight, a bimonthly newsletter. Be Smart. Be of points, simplified point management, wider selection Well. also provides information on Facebook, of rewards and increased redemption options. Members Twitter, Pinterest and YouTube. earn Life Points for participating in healthy activities, o Life Times Member Newsletter:When such as completing their Health Assessment or tracking employees register for BAM, they receive our their workouts online. monthly health and wellness enewsletter, which also provides plan-and product-specific Convenient and Affordable Fitness Program information. (Note: Some groups may have BCBSTX's Fitness Program offers unlimited access to a chosen to exclude their employees from nationwide network of more than 8,000 fitness centers receiving this newsletter.) for a low monthly rate. The program is available to members and their covered dependents (age 18 and 0 Members can use motivational cards and screen older), with no long-term contract. The Life Points savers from eCards for HealthS'`a; find wellness Blue Cross and Blue Shield of Texas,a D{vision of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association 8 BlueCross BlueShield of Texas c nkalUpdates I • ,;•4 ..� ,._i�''>•✓t '7 r..S_.....a...kj;y For renewals effective January 1, 2015, and thereafter tips on BCBSTX's website. Facebook and Latino Facebook pages; and request a variety of secure and helpful health and wellness messages via Blue Access Mobile. Blue Crosse, Blue Shields and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. 51478.1114 ASO Blue Cross and Blue Shield of Texas,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company.an Independent Licensee of the Blue Cross and Blue Shield Association 9 EXHIBIT "A-2" PPO ASO Standard with Network BlueCro€silueShleld Deductible and Split Copayg ofTexas BENEFIT HIGHLIGHTS Prepared for City of Port Arthur BlueChoice Network Effective Date: 11 /01 /2015 Benefit Agreement #: 0002 & 0013 This is a general summary of your benefits. Please refer to your Summary of Benefits and Coverage(SBC),or you may request a copy of the policy or plan document for additional details and a description of the plan requirements and benefit design. This plan does not cover all health care expenses.Please carefully review the plan's limitations and exclusions. Overall Payment Provisions In-Network Out-of-Network Benefits Benefits Deductibles Per-admission Deductible None $200 Calendar Year Deductible $1,500 Individual/ $2,000 Individual/ Applies to all Eligible Expenses except Inpatient Hospital Expenses(unless $3,500 Family $6,000 Family otherwise indicated) Three-month Deductible carryover applies Yes Yes Out-of-Pocket Maximum $5,000 Individual/ $6,500 Individual/ $10,200 Family $15,000 Family Deductibles applies to Out-of-Pocket Yes Yes** Copayment applies to Out-of-Pocket Yes Yes*` Network Deductible&Out-of- Out-of-Network Deductible&Out-of Pocket will only apply toward Network Out-of-Pocket will also Network Deductible&Out-of- apply toward Network Deductible& Pocket Maximum Out-of-Pocket Maximum** Copayment amounts and per admission deductibles are applied but will continue to be required after the benefit percentage increases to 100%. Copayment Amounts Required Physician office visit/consultation: Primary Care Copayment Amount for office visit/consultation when $35 Primary Care Copayment services rendered by a Family Practitioner,OB/GYN,Pediatrician,Behavioral Health Practitioner,or Internist and Physician Assistant or Advanced Practice Nurse who works under the supervision of one of these listed physicians Specialty Care Copayment Amount for office visit/consultation when services $50 Specialty Care Copayment rendered by a Specialty Care Provider Refer to Medical/Surgical Expenses section for more information Urgent Care center visit $75 Copayment Amount Refer to Urgent Care Services section for more information Outpatient Hospital Emergency Room/Treatment Room visit $150 Copayment Amount $150 Copayment Amount Refer to Emergency Room/Treatment Room section for more information Maximum Lifetime Benefits Per Participant Unlimited inpatient Hospital Expenses Inpatient Hospital Expenses All services must be preauthorized All usual Hospital services and supplies,including semiprivate room,intensive 80%of Allowable Amount 60%of Allowable Amount after per- care,and coronary care units admission Deductible Penalty for failure to preauthorize services None $250 A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business PPO ASO Standard with Network Deductible,Split Copay Effective 01/01/15(Rev 11/2014 for 02/2015 Release) Page 1 of 5 PPO ASO Standard with Network -7) B1ueCrosBtuieShield Deductible and Split Copay ° of Texas Medical/Surgical Expenses In-Network Out-of-Network Benefits Benefits Medical/Surgical Expenses Services performed during the office visit/consultation when rendered by a Primary 100%of Allowable Amount after 70%of Allowable Amount after Care Provider,including lab and x-ray(does not include Certain Diagnostic Procedures $35 Primary Care Copayment** Deductible and surgical services) Services performed during the office visit/consultation when services rendered by a 100%of Allowable Amount after 70%of Allowable Amount after Specialty Care Provider,including lab&x-ray(does not include Certain Diagnostic $50 Specialty Care Copayment Deductible Procedures and surgical services) Lab&x-ray in other outpatient facilities(excluding Certain Diagnostic Procedures) 100%of Allowable Amount 70%of Allowable Amount after Deductible -Physician surgical services performed in any setting 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -Physician inpatient hospital visits 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -Certain Diagnostic Procedures;such as Bone Scan,Cardiac Stress Test,CT-Scan 80%of Allowable Amount after 60%of Allowable Amount after (with or without contrast),MRI,Myelogram,PET Scan. Deductible Deductible -Home Infusion Therapy(Services must be preauthorized) 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -All other outpatient services and supplies 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible In Vitro Fertilization Services Decline Extended Care Expenses Extended Care Expenses All services must be preauthorized 100%of Allowable Amount 70%of Allowable Amount after Deductible Skilled Nursing Facility Limited to 25 day maximum each Year* Home Health Care Limited to 60 visit maximum each Year* Hos•ice Care Unlimited Special Provisions Expenses Serious Mental Illness/Mental Health Care/ Treatment of Chemical Dependency Inpatient Services Inpatient Chemical Dependency treatment must be provided in a Chemical Dependency/Residential Treatment Center(RTC) -Hospital services(facility) 80%of Allowable Amount 60%of Allowable Amount after None Per Admission Deductible Penalty for failure to preauthorize services $250 Preauthorization required for inpatient,residential treatment centers(RTC),partial hospital program admissions,and certain outpatient professional services -Physician services 80%of Allowable Amount after 60%of Allowable Amount after Calendar Year Deductible Deductible Outpatient Services -Services performed during office visit/consultation when rendered by a Primary 100%of Allowable Amount after 70%of Allowable Amount after Care Provider(does not include psychological testing) $35 Primary Care Copayment Deductible Amount -All outpatient services and psychological testing 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible *Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated **Primary Care/Specialty Care copayments are defined in the Overall Payment Provisions section in this document. A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business PPO ASO Standard with Network Deductible,Split Copay Effective 01/01/15(Rev 11/2014 for 02/2015 Release) Page 2 of 5 PPO ASO Standard with Network BlueCross ilueShield Deductible and Split Copay t of Texas Special Provisions Expenses, cont. In-Network Out-of- e t w o r k Benefits Benee fits Emergency Room/Treatment Room Accidental Injury&Emergency Care -Facility charges 80%of Allowable Amount after$150 Copayment Amount (Copayment Amount waived if admitted,Inpatient Hospital Expenses will apply) -Physician charges 80%of Allowable Amount after Deductible Non-Emergency Care -Facility charges 80%of Allowable Amount after$150 60%of Allowable Amount after$150 Copayment Amount(Copayment Copayment Amount&Deductible Amount waived if admitted,Inpatient (Copayment Amount waived if Hospital Expenses will apply) admitted, Inpatient Hospital Expenses will apply) -Physician charges 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Urgent Care Services Urgent Care center visit,including lab&x-ray services(does not include 100%of Allowable Amount after$75 70%of Allowable Amount after Certain Diagnostic Procedures and surgical services) Copayment Amount Deductible Certain Diagnostic Procedures;such as Bone Scan,Cardiac Stress Test, CT-Scan(with or without contrast),MRI,Myelogram,PET Scan,surgical 80%of Allowable Amount after 60%of Allowable Amount after procedures and all other services and supplies. Deductible Deductible Ground and Air Ambulance Services 80%of Allowable Amount after Deductible Preventive Care Routine annual physical examinations,well-baby care exams, 100%of Allowable Amount 70%of Allowable Amount after immunizations 6 years of age&over,and any other preventive health Deductible services as determined by USPSTF Immunizations for Dependent children through the date of the child's 6th 100%of Allowable Amount 100%of Allowable Amount birthday Speech and Hearing Services Services to restore loss of or correct an impaired speech or hearing function Covered same as any other sickness Covered same as any other sickness Hearing Aid Maximum Hearing aids are subject to 1 per ear per 36 month period *Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated Physical Medicine Services Chiropractic Care-Office Services 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Maximum Limited to 35 visits each Year* All other Physical Medicine Services rendered by any other eligible Provider will be allowed on the same basis as any other sickness. "Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business PPO ASO Standard with Network Deductible,Split Copay Effective 01/01/15(Rev 11/2014 for 02/2015 Release) Page 3 of 5 PPO ASO Standard with Network BilueCs E3ttieShfeid Deductible and Split Copay of Texas Pharmacy Benefits Participating Pharmacy* Non-Participating Pharmacy (member files claim) Drug List** Preferred Drug List 1 Prescription Drug Out-of-Pocket Maximum Separate Prescription Drug Out-of-Pocket Maximum applies to Retail&Mail Service Pharmacy:Individual: $1,500/Family: $3,000 Vaccinations obtained through Pharmacies**** Yes - If yes,flu vaccinations covered as follows: Select pharmacies participating in Flu 80%of Allowable Amount minus Network—100% Copayment Amount All other in-network pharmacies— appropriate tier copay applies Retail Pharmacy (Copayment amounts are based on a 30-day supply. With appropriate prescription order,up to a 90-day supply is available. Copayment amounts apply to the Out-of-Pocket Maximum.) Generic Drug $15 Copayment Amount 80%of Allowable Amount minus Copayment Amount Preferred Brand Name Drug $35 Copayment Amount 80%of Allowable Amount minus Copayment Amount Non Preferred Brand Name Drug $60 Copayment Amount 80%of Allowable Amount minus Copayment Amount All Specialty Drugs $150 Copayment Amount 80%of Allowable Amount minus Copayment Amount Specialty Drugst Members will be required to obtain specialty medications through Prime Therapeutics Specialty Pharmacy LLC(Prime Specialty Pharmacy). Mail Order Program Yes (Copayment amounts are based on a 30-day supply. With appropriate prescription order,up to a 90-day supply is available. Copayment amounts apply to the Out-of-Pocket Maximum.) Generic Drug $15 Copayment Amount Preferred Brand Name Drug $35 Copayment Amount Non-Preferred Brand Name Drug $60 Copayment Amount Generic Incentive-Members who purchase Preferred/Non-Preferred Brand Name Drugs when a Generic equivalent exists will be required to pay the difference between the cost of the Generic and Preferred/Non-Preferred Brand Name Drug,plus the Preferred Brand Name Copayment Amount. All medications with over-the-counter(OTC)equivalents are excluded from coverage except for Omeprazole 20 mg. *To locate a participating pharmacy in your area go to myprime.com or contact customer service at the phone number on the back of your identification card. **The preferred drug list is available at: bcbstx.com/member/rx_drugs.html ****Select pharmacies participating in the Flu Network are contracted to provide vaccination services. Flu vaccinations at all other in-network and out-of- network pharmacies are payable at the non-participating Flu Network pharmacy benefit level. Each pharmacy may have age,scheduling,or other requirements that will apply. You are encouraged to contact the store in advance. Childhood immunizations subject to state regulations are not available under this pharmacy benefit. Refer to your BCBSTX medical coverage for benefits available for childhood immunizations. Diabetes Supplies are available under the Prescription Drug benefits of your plan. Diabetic Supplies include insulin and insulin analog preparations,insulin syringes necessary for self-administration,prescriptive and non-prescriptive oral agents,all required test strips and tablets which test for glucose,ketones,and protein,lancets and lancet devices,biohazard disposable containers,glucagon emergency kits,and other injection aids.All provisions of this portion of the plan will apply including Copayment Amounts and any pricing differences that may apply to the items dispensed. **Effective 11/1/2015,Specialty Lock-Out through Prime Specialty Pharmacy applies. No coverage available for specialty drugs when purchased through any other provider. One grace fill allowed. t For more information on the specialty drug program,call Prime Specialty Pharmacy at(877)627-6337. **Effective 11/1/2015,Prior Authorization is required for the drug class PCSK-9 Inhibitors(Specialty injectable drugs)for Homozygous Familial Hypercholesterolemia Agents. A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business PPO ASO Standard with Network Deductible,Split Copay Effective 01/01/15(Rev 11/2014 for 02/2015 Release) Page 4 of 5 PPO ASO Standard with Network BlueCro&s!3lrieStdefcl Deductible and Split Copay voo_ of Texas Non- Standard Covered Benefits • Radial Keratotomy covered • Lasik surgery covered • Effective 7/1/04-Medicare Assumption/Estimation • Effective 11-1-08 - Services,supplies and prescription drugs for the reduction of morbid obesity, including surgical procedures,when medically necessary,covered same as any other illness(note:prescription drugs for morbid obesity are not subject to medical necessity) • Effective 11-1-11 -Age limit increased to age 26 for the following benefit: Reconstructive surgery performed on a covered dependent child under the age of 26 due to craniofacial abnormalities to improve the function of,or attempt to create a normal appearance of an abnormal structure caused by congenital defects, developmental deformities,trauma,tumors,infections or disease. • Effective 11-1-14—Services,supplies and Prescription Drugs for Sexual Dysfunction are covered. Prescription Drugs for Sexual Dysfunction are limited to 8 pills per month. EMPLOYEE INFORMATION This is a general Summary of your benefit design. Please refer to your benefit booklet for other details and for limitations and exclusions. The following benefits apply to dependent coverage: • Dependent children are covered to age 26. • Automatic coverage for newborns for the first 31 days following birth. Infants not enrolled for coverage within the first 31 days after birth will not be eligible for coverage until the following open enrollment period or special enrollment event. Group Executive Name and Title Signature • Date (Please type or print) Agent of Record Name Signature Date (Please print or type) BCBSTX Representative Name Signature Date (Please print or type) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business PPO ASO Standard with Network Deductible,Split Copay Effective 01/01/15(Rev 11/2014 for 02/2015 Release) Page 5 of 5 BlueEdge ASO HSA with Embedded 131uecross�it�ae�5liielcf Deductible qp of Texas BENEFIT HIGHLIGHTS Prepared Blue Choice Network for City of Port Arthur Effective Date : 11 /01 /2015 **This is a general summary of your benefits. Please refer to your Summary of Benefits and Coverage(SBC),or you may request a copy of the policy or plan document for additional details and a description of the plan requirements and benefit design. This plan does not cover all health care expenses. Please carefully review the plan's limitations and exclusions. Overall Payment Provisions in-Network Out=of-Network Benefits Benefits Embedded Deductible Calendar Year Deductible $2,500 Individual/ $5,000 Individual/ Applies to all Eligible Expenses(unless otherwise indicated) $5,000 Family $10,000 Family Applies to Out-of-Pocket Maximum Family coverage:When one family member meets the individual Deductible, benefits become available under the plan for that individual. NOTE:The individual Deductible amount must be equal to or greater than the minimum family Deductible amount. This qualification is established by the U. S. Treasury for a plan to be considered a qualified HSA plan. Deductible credit from prior carrier(Applied on initial group enrollment only) Yes Yes Out-of-Pocket Maximum $5,000 Individual/ $10,000 Individual/ $10,000 Family $20,000 Family Deductibles applies to Out-of-Pocket Yes—no option Yes** Copayment applies to Out-of-Pocket Yes—no option Yes** Network Deductible&Out-of-Pocket Out-of-Network Deductible&Out- will only apply toward Network of Network Out-of-Pocket will also Deductible&Out-of-Pocket Maximum apply toward Network Deductible& Out-of-Pocket Maximum **Copayment amounts and per admission deductibles applied but will continue to be required after the benefit percentage increases to 100%. Maximum Lifetime Benefits Per Participant I Unlimited BlueEdge CDHP Health Savings Account Order of Payment(CDHP Stacking) Stack#1: HSA Inpatient Hospital. Expenses Inpatient Hospital Expenses All services must be preauthorized Inpatient Hospital Expenses 80%of Allowable Amount after 60%of Allowable Amount after Each admission must be preauthorized Deductible Deductible All usual Hospital services and supplies,including semiprivate room, intensive care, and coronary care units. Penalty for failure to preauthorize services None $250 A Division of Health Care Service Corporation,a Mutuai Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business BlueEdge ASO H S A Embedded Deductible Effective 01/01/2015(Revised 11/2014 for 02/2015 Release) Page 1 of 5 BlueEdge ASO HSA with Embedded ilitw _rocs lllueShi.eld Deductible 7,9 of Texas BENEFIT HIGHLIGHTS Prepared for City of Port Arthur Blue Choice Network Effective Date: 11 /01 /2015 Medical/Surgical Expenses Medical/Surgical Expenses -Services performed during the Physician's office visit/consultation,including 80%of Allowable Amount after 60%of Allowable Amount after lab& x-ray Deductible Deductible -Lab&x-ray in other outpatient facilities 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -Physician surgical services performed in any setting 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -Physician inpatient hospital visits 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -Certain Diagnostic Procedures;such as Bone Scan,Cardiac Stress Test,CT 80%of Allowable Amount after 60%of Allowable Amount after Scan(with or without contrast),MRI,Myelogram,PET Scan. Deductible Deductible -Home Infusion Therapy(Services must be preauthorized) 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -All other outpatient services and supplies 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible In Vitro Fertilization Services Not Covered Extended Care Expenses In-Network out-of-Network P Benefits Benefits Extended Care Expenses (must be preauthorized) 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Skilled Nursing Facility Limited to 25 day maximum each Year* Home Health Care Limited to 60 visit maximum each Year* Hospice Care Unlimited Special Provisions Expenses Serious Mental Illness/Mental Health Care/ Treatment of Chemical Dependency Inpatient Services Inpatient Chemical Dependency treatment must be provided in a Chemical Dependency/Residential Treatment Center(RTC) -Hospital services(facility) 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -Physician services 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Penalty for failure to preauthorize services None $250 Preauthorization required for inpatient,residential treatment centers(RTC), partial hospital program admissions,and certain outpatient professional services Outpatient Services -Services performed during Physician office visit/consultation (does not include psychological testing) 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -All outpatient services and psychological testing 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Emergency Room/Emergency Treatment Room Accidental Injury&Emergency Care -Facility charges 80%of Allowable Amount after Deductible -Physician charges 80%of Allowable Amount after Deductible Non-Emergency Care -Facility charges 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -Physician charges 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business BlueEdge ASO H S A Embedded Deductible Effective 01/01/2015(Revised 11/2014 for 02/2015 Release) Page 2 of 5 BlueEdge ASO HSA with Embedded iiioeCross m1,0;11441 Deductible tu, of Texas BENEFIT HIGHLIGHTS Prepared for City of Port Arthur BlueChoice Network Effective Date : 11 /01 /2015 Urgent Care Services Urgent Care center visit,including lab&x-ray services 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Certain Diagnostic Procedures;such as Bone Scan,Cardiac Stress Test,CT Scan(with or without contrast),MRI,Myelogram,PET Scan,surgical 80%of Allowable Amount after 60%of Allowable Amount after procedures and all other services and supplies. Deductible Deductible Ground and Air Ambulance Services 80%of Allowable Amount after Deductible Preventive Care Routine annual physical examinations,well-baby care exams,immunizations 6 100%of Allowable Amount 60%of Allowable Amount years of age&over,and any other preventive health services as determined by USPSTF Immunizations for Dependent children through the date of the child's 6th 100%of Allowable Amount 100%of Allowable Amount birthday *Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated. Speech and Hearing Services Services to restore loss of or correct an impaired speech or hearing Covered same as any other sickness Covered same as any other sickness function Hearing Aids 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Hearing Aid Maximum Hearing aids are subject to 1 per ear per 36 month period Physical Medicine Services Chiropractic Care-Office Services 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Maximum Limited to 35 visit maximum each Year* All other Physical Medicine Services rendered by any other Provider will be allowed on the same basis as any other sickness. *Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated. A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business BlueEdge ASO H S A Embedded Deductible Effective 01/01/2015(Revised 11/2014 for 02/2015 Release) Page 3 of 5 BlueEdge ASO HSA with Embedded lithe rosy Blue.Shield Deductible 7:9 of Texas Pharmacy Benefits Participating Non-Participating Pharmacy* Pharmacy (member files claim) Drug List** I Preferred Drug List 1 Deductible and Out of Pocket Accums-Integrated is the Standard option for HSA. Integrated RX Accum The drug deductible and Out-of-Pocket is the same as the medical Deductible and/Out-of-Pocket.All benefits,including prescription drug benefits(retail and mail order)must apply to the plan's overall Deductible and Out-of-Pocket Maximum. Vaccinations obtained through Pharmacies*** Yes - If yes, flu vaccinations covered as follows: Select pharmacies participating in Flu Network—100% All other pharmacies—apply appropriate tier copay Retail Pharmacy (Benefit payments are based on a 30-day supply. With appropriate $50 Copayment Amount after the Deductible**** prescription order,up to a 90-day supply is available.) Mail Order Program (Benefit payments are based on a 30-day supply. With appropriate $50 Copayment Amount after the Deductible**** prescription order,up to a 90-day supply is available.) Specialty Drugst Members will be required to obtain specialty medications through Prime Therapeutics Specialty Pharmacy LLC(Prime Specialty Pharmacy). No Penalty—Member pays no more than the applicable Generic,Preferred Drug,or Non-Preferred Drug Copayment. Product selection is permitted, even when generic equivalents are available. *To locate a participating pharmacy in your area,go to myprime.com or contact customer service at the phone number on the back of your identification card. **The preferred drug list is available at: bcbstx.com/member/rx_drugs.html ***Select pharmacies participating in the Flu Network are contracted to provide vaccination services. Flu vaccinations at all other in-network and out-of-network pharmacies are payable at the applicable tier copay. Each pharmacy may have age,scheduling,or other requirements that will apply. You are encouraged to contact the store in advance. Childhood immunizations subject to state regulations are not available under this pharmacy benefit. Refer to your BCBSTX medical coverage for benefits available for childhood immunizations. Diabetes Supplies are available under the Prescription Drug benefits of your plan. Diabetic Supplies include insulin and insulin analog preparations,insulin syringes necessary for self-administration,prescriptive and non-prescriptive oral agents,all required test strips and tablets which test for glucose, ketones,and protein,lancets and lancet devices,biohazard disposable containers,glucagon emergency kits,and other injection aids.All provisions of this portion of the plan will apply including Copayment Amounts and any pricing differences that may apply to the items dispensed. All medications with over-the-counter(OTC)equivalents are excluded from coverage except for Omeprazole 20 mg. **Effective 1111/2015,Specialty Lock-Out through Prime Specialty Pharmacy applies. No coverage available for specialty drugs when purchased through any other provider. One grace fill allowed. f For more information on the specialty drug program,call Prime Specialty Pharmacy at(877)627-6337. **Effective 11/112015,Prior Authorization is required for the drug class PCSK-9 Inhibitors(Specialty injectable drugs)for Homozygous Familial Hypercholesterolemia Agents. A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business BlueEdge ASO H S A Embedded Deductible Effective 01/01/2015(Revised 11/2014 for 02/2015 Release) Page 4 of 5 BlueEdge ASO HSA with EmbeddedtUtueCross flueShielct vL Deductible ' I of Texas Non-Standard Covered Benefits Effective 11-1-2011: • Radial Keratotomy covered • Lasik surgery covered • Medicare Assumption/Estimation • Services,supplies and prescription drugs for the reduction of morbid obesity,including surgical procedures,when medically necessary,covered same as any other illness(note:prescription drugs for morbid obesity are not subject to medical necessity) • Age limit increased to age 26 for the following benefit: Reconstructive surgery performed on a covered dependent child under the age of 26 due to craniofacial abnormalities to improve the function of,or attempt to create a normal appearance of an abnormal structure caused by congenital defects, developmental deformities,trauma,tumors,infections or disease. Non-Standard Covered Benefits Effective 11-1-2014: • Effective 11-1-14—Services,supplies and Prescription Drugs for Sexual Dysfunction are covered. Prescription Drugs for Sexual Dysfunction are limited to 8 pills per month. ± Please be reminded that Health Savings Accounts(HSA's)have tax and legal ramifications. Blue Cross and Blue Shield of Texas does not provide legal or tax advice,and nothing herein should be construed as legal or tax advice. These materials,and any tax-related statements in them,are not intended or written to be used,and cannot be used or relied on,for the purpose of avoiding tax penalties. Tax-related statements,if any,may have been written in connection with the promotion or marketing of the transaction(s)or matter(s)addressed by these materials. You should seek advice based on your particular circumstances from an independent tax advisor regarding the tax consequences of specific health insurance plans or products. Group Executive Name and Title Signature Date (Please type or print) Agent of Record Name Signature Date (Please print or type) BCBSTX Representative Name Signature Date (Please print or type) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business BlueEdge ASO H S A Embedded Deductible Effective 01/01/2015(Revised 11/2014 for 02/2015 Release) Page 5 of 5 Giza s�aa- " BlueCross BlueShield of Texas Dear Group Administrator, The federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires employers to notify all eligible employees of two important provisions in their health care plans: o The first is the employees' right to enroll in the plan under the "special enrollment provision." • The second is to advise employees of the plan's pre-existing condition exclusion rules that may temporarily exclude coverage for certain pre-existing conditions that they, or members of their families, may have. In addition, language has been added to the notice (in compliance with other federal mandates) to advise all eligible employees of their right (under certain plans) to designate a primary care provider. Please copy and distribute the enclosed Initial Notice about Special Enrollment Rights and Pre-existing Condition Exclusion Rules in Your Group Health Plan and additional notices directly to all of your employees as soon as possible. Please Note: you must also give this notice to each new employee prior to his or her enrollment in, or declination of, health coverage and must redistribute it each year at open enrollment. Thank you in advance for your assistance in meeting this federal requirement. 1001 East Lookout Drive, Richardson,Texas 75082•bcbstx.com t0-1-201 t Blue Cross and Blue Shield of Texas,a Division of Health Care Service Corporation a Mutual Legal Reserve Company.an Independent Licensee of the Blue Cross and Blue Shield Association • BlueCross BlueShield 44of Texas WS a a Important Notices • • I. Initial Notice About Special Enrollment Rights and Pre-existing = Condition Exclusion Rules in Your Group Health Plan A federal law called Health Insurance Portability and Accountability Act(HIPAA)requires that we notify you about two very important provisions in the plan.The first is your right to enroll in the plan under its"special enrollment provision"without being considered a late applicant if you acquire a new dependent or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons_Second,this notice-advises-you-of-the plan's pre-existing condition-exclusion-rules-that-may- temporarily exclude coverage for certain pre-existing conditions that you or a member of your family may have.Section I of this notice may not apply to certain self-insured,non-federal governmental plans.Contact your employer or plan administrator for more information. '1 A. SPECIAL ENROLLMENT PROVISIONS Loss of Other Coverage(Excluding Medicaid or a State Children's Health Insurance Program)If you are declining enrollment for yourself or your eligible dependents(including your spouse)because of other health insurance or group health plan coverage,you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage(or if you move out of an HMO service area,or the employer stops contributing toward your or your dependents'other coverage).However,you must request enrollment within 31 days after your or your dependents'other coverage ends(or move out of the prior plan's HMO service area,or after the employer stops contributing toward the other coverage). Loss of Coverage For Medicaid or a State Children's Health Insurance Program If you decline enrollment for yourself or for an eligible dependent(including your spouse)while Medicaid coverage or coverage under a state children's health insurance program is in effect,you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage.However,you must request enrollment within 60 days after your or your dependents'coverage ends under Medicaid or a state children's health insurance program. New Dependent by Marriage,Birth,Adoption,or Placement for Adoption If you have a new dependentas a result of marriage,birth,adoption,or placement for adoption,you maybe able to enroll yourself and your dependents in this plan.However,you must request enrollment within 31 days after the marriage,birth,adoption,or placement for adoption. Eligibility for State Premium Assistance for Enrollees of Medicaid or a State Children's Health Insurance Program If you or your dependents(including your spouse)become eligible for a state premium assistance subsidy from Medicaid or through a state children's health insurance program with respect to coverage under this plan,you may be able to enroll yourself and your dependents in this plan.However,you must request enrollment within 60 days 1 after your or your dependents'determination of eligibility for such assistance. You or your spouse or dependents may also have special enrollment rights in another group health plan at the time a claim is denied as a result of a lifetime limit on all benefits,if you request enrollment within 30 days after the claim has been denied. To request special enrollment or obtain more information, call Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card. B. PRE-EXISTING CONDITION EXCLUSION RULES Pre-existing condition exclusion rules do not apply to group health plans with effective dates on or after January 1,2014. Most health plans impose pre-existing condition exclusions.This means that if you have a medical condition before comin• g to our plan you might have to wait a certain period of time before the plan will provide coverage for that condition.This exclusion applies only to conditions for which medical advice,diagnosis,care or treatment was recommended or received within the six-month period before your enrollment date.Generally,this six-month t. period ends the day before your coverage becomes effective.However,if you were in a waiting period for coverage, s the six-month period ends on the day before the waiting period begins."Waiting period"generally refers to a delay between the first day of employment and the first day of coverage under the plan.The pre-existing condition i • exclusion does not apply to pregnancy or to an individual under the age of 19. i This pre-existing condition exclusion may last up to 12 months(18 months if you are a late enrollee)from your first day of coverage,or,if you were in a waiting period,from the first day of your waiting period.However,you can reduce the length of this exclusion period by the number of days you had prior"creditable coverage."Most prior health coverage is creditable coverage and can be used to reduce the pre-existing condition exclusion if you have not experienced a break in coverage of at least 63 days.To reduce the 12 month(or 18 month)exclusion period by i your creditable coverage,you should give us a copy of any certificates of creditable coverage you have.If you do not - - have a certificate, y do_ha_ve_prior_health_coverage,youu_have-a-right to-request one-from your-prior-plan of 3 i issuers.We will help you obtain one from your prior plan or issuer,if necessary. There are also other ways that you • can show you have creditable coverage.Please contact us if you need help demonstrating creditable coverage. For more information about the pre-existing condition exclusion and creditable coverage rules affecting i i your plan,call Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card. II. Additional Notices . i i Other federal laws require we notify you of additional provisions of your plan. NOTICES OF RIGHT TO DESIGNATE A PRIMARY CARE PROVIDER(FOR NON-GRANDFATHERED HEALTH PLANS ONLY) y For plans that require or allow for the designation of primary care providers by participants or beneficiaries: If the plan generally requires or allows the designation of a primary care provider,you have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members.For information on how to select a primary care provider,and for a list of the participating primary care providers,call Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card. For plans that require or allow for the designation of a primary care provider for a child:For children, • you may designate a pediatrician as the primary care provider. For plans that provide coverage for obstetric or gynecological care and require the designation by a • participant or beneficiary of a primary care provider:You do not need prior authorization from the plan or 4: from any other person(including a primary care provider)in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology.The health care , professional,however,may be required to comply with certain procedures,including obtaining prior authorization for certain services,following a pre approved treatment plan,or procedures for making referrals. _ For a list of participating health care professionals who specialize in pediatrics,obstetrics or gynecology, call Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card. f i 1 f I ` t 1 3, C J i K •1 4 Blue Cross and Blue Shield of Texas.a Division of Health Care Service Corporation a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association 53715.0913 U) a) a) o .-. 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Q3 v ° a t go a 7. = dl Ut_ 2t a Ed II Zm°c 2 32 U3 Ccr u r 7 , t7, m r E _ Q r a s 1 7 75 cr , \ \ C IC , / : . — - — - d ®« { \/ k / $ 2 ! ] _ ) - ) U \ C f! 2 i = \c n .. \ 0 U 77 2 ` § [ ) 0 16 - q / k ° ) \ - J; t © RK 2 9 co k § f§ o /§_ « e f f / =2 a. 0, 2 ) S 3 ' 2! o / �a ° ] (11 S E 2/ 2` e 2 .2 t; 0 / � # ( § \ {/ § \ y _I !) 0k BUD Z E t = ) � ) ( } �� \ • j ƒ / {\ {{ . 7 2; ` m {3 ± = A « U ) ) § ) \ / ) / = k F. { % \ \ 2 o - x2 ',.7 ET \ . 0 = / •2 § 2 0 0 ) § 2o 0 ` \ 2 2 = i U , § / ( >{ e $ , { \ @ ) ± § } ` � � \ } \ \ - ) ± , ) ) / t 2.-. k ,.-,- \ \ \ sv - = 22 � 2E. ) { k} { ) \ = ` m / - t co . } U \ » § ) m ƒ ) {{ } ) t « \ t \ .6 \ a ) § \ ) \ \ \ / } } { § • ( z ) - z \ ) .E \\ « / 2 . } a\ ` & 2 = k \ k \ \ [ ) \ E _ = k k / - J > \ { } / \ \ 6f 2 . ® _ = E ; § { [ _ t a < 0 ) ± | - } \ . = e = o w 2 2 3 2 BlueCross BlueShield LIQW of Texas City of Port Arthur Effective November 1, 2013 - October 31, 2014 Administration Fee Guarantee Contract Year Beginning: Nov 2013 Nov 2014 Nov 2015 Medical Administration Fee* $50.30 $52.82 $55.46 Commissions ** $0.00 $0.00 $0.00 Total Medical $50.30 $52.82 $55.46 RxRebate_Credit — _ ($.1.3.11-) To-Be-Determined To BeDetermined — Combined Medical and Rx Rebate Credit $37.19 To Be Determined To Be Determined * Medical Administration Fee for the contract year beginning 11/01/2013 is on a mature, 24/12 basis. **This exhibit assumes commissions will remain excluded for all contract years. NOTES: 1 See ASO Exhibit for contingencies and other information. 2 BCBSTX is agreeable to a three-year fee guarantee contingent upon BCBSTX being the administrator for all medical; coverage. Second and third year fees are contingent upon enrollment not changing by more than 10%,the benefit desi remaining in place, and no necessary mandated legislative adjustments being imposed. 3 Rx Rebate Credit is based on a three-tier copay drug card. 4 Pharmaceutical manufacturers' rebates are received from our current pharmacy benefit manager. We have applied 1 the expected rebates prospectively to the administration fee. -4 ' -44141 ,;. r - .# -7- � r. t ,.a �ti Y � 4 A -b;'... 0. 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Z H r Q CO0 LO • CO CO v Qcom Q m 00 U) d 06 4 ti Cl) a) )c) U) .- Cri v r` • . co o ao _. co co a) CO • CD CO 0 CO CO 0 v ' ,- N - CZ D 69 N N co O 69 • 3 69 69 . 69 69 69 69 = C C - C c j d co a) Q H cci Z C O v LC) ch cn r` CO CO '- //, 'a LO r) W CD CO CO 3 CO C o N CO co co co CI-• C �C) N In m,'a o �r) CT) u) N 10 c O MI 69 _ 1- 69 G _ (n 69 64 69 669 6 C0 b b n o E J � " W " c c m a, Co CD:.: N L o W C Ce �: O N da- In 0 �-. Lf).... a- a) in a- Cf) O m /I�� 0 to N 0 .� CD - Q) V: > CD U) N O „ m M CC W CD a-~ to N C 05 a) a) . e~- LO N -J� • Q = Q 0 N =. Q) (a)69 Q. O N ? m a .• M O U) �, » 69 669 US 69 69 2 m v •_ C) Ce F- m o ca • °' cu O Z c �_ c co c) O ° WL a) _' m /1 Q -j L m c m Y. a - 0 Q C) L.. 7. m ▪ " o 0 U :1'-) L O Q '2 `' N N a- N tf) M IC) N Cn N N d _ t.) `-'CL CO .- •c! m CO t- a) r- cp m CD � V w • S ' LU �'d O O a) '- ' II) 4 �t L O O a) co g r N D C) (a) Cr) = m IL) a) O O @ a) (a) co E U • E• J 0 U v6A N v_ U c CD r) CO U O 't N v_ N N r o 0 Z V 69 69 69 69 69 69 m e ZO II Z• }' 0 C) O 4- C) L N alCDa ++ + a) a) '' a) a) Z a) a) T E m m ( E m m ( E m CC a 'cn in u. a v) in u_ a v`) u) u._ 0 0 � U 0 0 2 I 2 Cr) 4 C O N '.T O N --) Co O CO Co O N N co O Q o O O I, O� Cp O O ti �i LC) o m CO N Cfl C) O N co-; co N '_t coo N co LC) co N- o) E!-} Ea CO Eft Ea a) 64 (.& 64 69 Eo ' co11 2 co 00 ti co C) c O r O co C) co of •in co °) .- (.) coco N 03 �' o N N O D- ti o) 64 ea' C7 69- 64 Eft 69. 64 C ▪C.) .L CO y :> N p O ON CO Q. 0 :J CD c N0 O (C CD N N Co O M 00 C Q CDD Nr 64 �, c ER M W LL 64 EA 69- Ef3 E C `C Ca W C) CO O O c c U) 76 CD CD o) Lo 4 m O • O O -. ca o _ O •N- N a E o r .� Q) Z `- N r N O ti CO o m C (!) 69- ER 1- E9 EA 69- o U o 4_CD mi a) L a) N v- s- .. .� a) Q ^= N d > (C CA pp 0 N N i . .Q \ r N O O L co co QC 0 C d 1.L. 69 64 64 69- Eft ? c O Otu Q' W N Cl) O O CO ca> m o O ' (n L S' C9 (N N in tC) p r• N O m m o Om d � Y d o r� � 64 n to r O U O OaER '/^ o L c C a) Na V J r-- OO 1 ° iCd E In < U) c",) CO o cd, N O o v �_ E V 2 ti O N Lo C2 c C'i 0. m D tl) - N rt (� 64 O co 1 in m t ami Ci O Q 64 64 o am lc Zc U N Q U W N O O CD o — C Q o) o o) N- 00 to m o c r .0 0 N. C`� in O ce O N '. ° m m - . Z co O N N N o ti O) > 11-) c- CO 69 • } Ef3 o b5 U) 69 64 ER Ea a L a) L .a.. 0 •0 C C Na. co -E' C' a E E ami E a) ca to 0 c U co Cl) C/) Cl) Cf) a) "_' Eiii _o E co .J J J O O co LI- O N d. D_ 0. Q Q `J 'u, o O o 0 0 0 <Qa a) m Q U . ED_ coa) a) a = O O t = a) a) 2 a) Q. 73 E 0) 0) 0) C C C a` n` 0) 0) 0) -n - 2- c C O O O O o O O O O O W O N Q LO '4. O CO O O r L- O Ln 7 I� O U d• m' . O co O co h- tt CO f` N F- 3.:2 co co r ch N- r O 1- .1- N C U CO 6 vi- r N vi CO CO CO Ln E -n- LO 69 69 EFT EF3 69 69. 69 69 0 C - N o I- r I- ,� U d ,.2 CO CO I-- N cf r N- 6) f` o d 0) a b co �i co o 4 LLU co v o U CO Lf) r CO r 69 r I- O) O) ISS o a- 69 64 69 EFT 64 69 64 69 C .._. .. >: C c In ^ cz n c °' O w Z - 7 O CD 0 v c .- L[) In O o N co co co a> °m `f6., �. cp - — O CD o CO o CO CO r Si. o c Q C E M o c*i ti C) r .. ~m d N ''I^� V ='�y M O) N CDr 69 N co co LU m V S 69 EFT 69 69- 69 r r r - L O t.30 EFT 69 69 m ma t`7 t6 C CD Q . C a) : D) co O ? m O L7 n C Q a) m COM O ti r 4 co co c O y i . M N CO `- L.0g m .}J V C V I >' r3 a) C co O N i` N Oa) 'V' in `° o L d a7 O J m O co 69 �3 69 69- EF} 69 Ln to c O O a i 69 64 m I.I. a W Z i Iii 5 o m w O O O Iv W - co Q) i„.. N r co co o` c {t.. 01- NO O E_ Q- — p r N CO O O O) N CC) O d `o O Q �' r 4e cc co cD M N ti 4 O r v ` W co CO N (D r 669- N N L!) L1") ' CLI n- Q V c LI_ 69 69 69- 6`T ER r r LO m .0 a Q. rn �•... fA 69. 69 m v EU � p � , � z o O an O Q c.),"" m p LP) f` p v LO O = v Ox-r (� .. M n c,.) 4 N o LO CO C Z N LV UQ C 0 0 •• N M •N a0 Lycci. COtri ~ = aai LL) CO EFT 69 CO 69 69 CO EfT 69- EFT 69 c c r LL .0 ° m T- r-+ O o L > 0_ a 0 a) • eL O Q W 0_ 2 W U U o Lci > 0_ fo °' o_ 69 2 E •E 0 a) 0.0 .. W J n" cn O. C Qi u) cn cr, 0 U ) �. E a) mo O -� J o U m O cts ai a L W Oc •5 .2 U 0 > o c) m o c . -o m c a •E o x ai cD •o ] v •c :TD ai Lon T_ v 0_ To To id,. 2 -0 2 a) .0 c O 2 0 O 1 2; a < 0_ Z c < F- 0_ 0_ F- City Of Port Arthur November 1,2015 - October 31,2016 Network Discount Guarantee Medical Claims Only Claims Paid 11/01/15 Through 10/31/16 Guaranteed Discount Percentage 67.0% Actual Discounts Admin Fee Penalty 65.00% or Higher 0.0% 64.20% to 64.99% 5.0% 63.40% to 64.19% 10.0% 62.60% to 63.39% 15.0% 61.80% to 62.59% 20.0% 61.79% or Lower 25.0% 1.The formula for the Overall Network Discount Percentage calculation is as follows: (Eligible/Covered Claims less Allowed Claims equals the Provider Savings.The Provider Savings divided by the Eligible/Covered Claims equals the Overall Network Discount %). 2.Both In-Network and Out-of-Network claims are included in the Overall Network Discount Percentage calculation. 3.Network Discount Guarantee applies only to eligible employees and retirees who enroll in the proposed BCBS benefit plans. 4.BOBS will exclude all claims in excess of$100,000,claims the Employer authorizes to be paid on an exception basis,Medicare claims,claims with COB,Prescription Drug claims,Specialty Rx,claims not covered/processed by BCBS,and claims for non-contracted providers paid at the in-network level of benefits. 5.BCBS reserves the right to re-evaluate and re-establish the Guaranteed Discount Percentage f participation changes by plus/minus 10.0%,and/or the distribution of enrolled employees between geographic areas,the single/family mix,or age/gender composition of the group changes significantly. 6.BCBS reserves the right to void this Network Discount Guarantee if there are less than 628 employees enrolled in the plan. 7.BCBS reserves the right to re-evaluate and re-establish the Guaranteed Discount Percentage if Medicare changes its payment systems during the term of this Network Discount Guarantee. 6.BCBS_reserves the right to re-evaluate and re-establish the Guaranteed Discount Percentage if there is a change.in the benefit plan design.._ 9.BCBS reserves the right to re-evaluate and re-establish the Guaranteed Discount Percentage if a narrow or high performance network is elected. 10.Discount Guarantee is based on In-Network Utilization of 97.7%. If In-Network Utilization is not met,Discount Guarantee does not apply. 11.Administrative Fee at Risk will be finalized upon sale of the Network Discount Guarantee. 12.Administrative Fee at Risk is the Medical Administration fee only. It does not include any additional elected services such as Fiduciary,BCC,etc. 13.Any penalty paid will be dollar for dollar up to the maximum amount at risk for each tier. 14.Guaranteed Discount Percentage will be reviewed and negotiated annually at the time of renewal. 'Amount at Risk is based on current enrollment of 698 HCSC Primary employees.Actual amount at risk is subject to change based on final enrollment of employees who select BCBS coverage. A 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 November 1,2015 - October 31,2016 In Network Utilization Guarantee Medical Claims Only Claims Paid 11/01/15 Through 10/31/16 • Guaranteed In Network Utilization 97.7% Actual In Network Utilization Admin Fee Penalty 95.70% or Higher 0.0% 94.80% to 95.69% 5.0% 93.90% to 94.79% 10.0% 93.00% to 93.89% 15.0% 92.10% to 92.99% 20.0% 92.09% or Lower 25.0% 1.The formula for the Overall In Network Utilization Percentage calculation is as follows: (The In Network Paid Claims divided by the Total Paid Claims equals the Overall In Network Utilization%). 2.In Network Utilization Guarantee applies only to eligible employees and retirees who enroll in the proposed BCBS benefit plans. 3.BCBS will exclude all claims in excess of$100,000,claims the Employer authorizes to be paid on an exception basis,Medicare claims,claims with COB,Prescription Drug claims,Specialty Rx,claims not covered/processed by BCBS,and claims for non- contracted providers paid at the in-network level of benefits. 4.BOBS reserves the right to re-evaluate and re-establish the Guaranteed In Network Utilization Percentage if participation changes by plus/minus 10.0%,and/or the distribution of enrolled employees between geographic areas,the single/family mix,or age/gender composition of the group changes significantly. 5.BOBS reserves the right to void this In Network Utilization Guarantee if there are less than 628 employees enrolled in the plan. 6.BOBS reserves the right to re-evaluate and re—establish the Guaranteed In Network Utilization Percentage if Medicare changes its payment systems during the tens of this In Network Utilization Guarantee. 7.BCBS reserves the right to re-evaluate and re-establish the Guaranteed In Network Utilization Percentage if there is a change in the benefit plan design.__________ 8.BOBS reserves the right to re-evaluate and re-establish the Guaranteed In Network Utilization Percentage if a narrow or high performance network is elected. 9.Administrative Fee at Risk will be finalized upon sale of the In Network Utilization Guarantee. 10.Administrative Fee at Risk is the Medical Administration fee only.It does not include any additional elected services such as Fiduciary,BCC,etc. 11.Any penalty paid will be dollar for dollar up to the maximum amount at risk for each tier. 12.In Network Utilization Percentage will be reviewed and negotiated annually at the time of renewal. •Amount at Risk is based on current enrollment of 698 HCSC Primary employees.Actual amount at risk is subject to change based on final enrollment of employees who select BOBS coverage. A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association (EXECUTIVE SUMMARY BlueShield orTe^<A�BlueCross .:`• NETWORK SAVINGS ANALYSIS Report Description:This report displays the covered amount, discount amount, discount percent and paid amount based on paid claims. Displayed by Medicare and non-Medicare primary indicator, and by in and out of network for the year to date. The "Discount%" is calculated as Discount/Covered. CITY OF PORT ARTHUR:AU. MEDICARE PRIMARY INDICATOR NETWORK INDICATOR SERVICE CATEGORY COVERED DISCOUNT DISCOUNT% PAID %OF PAID NO IN-NETWORK INPATIENT FACILITY :, --,; 4152 ` 9 92 � "Y28:2k OUTPATIENT FACILITY $4,745,742 $3,109,283 65.5% $1,252,540 PROFESSIONAL 58 '7.:62 3'030'•42;• , �"56fi L9G ^`$$ r3O'°d' SUMMARY $13,009,160 $8,607,350 66.2% $3,475,444 OUT-OF-NETWORK INPATIENT FACILITY 6651-399 s ,2 OUTPATIENT FACILITY $622;215. $536;361 86.2%. $47587 , .- 1.2% PROFESSIONAL T x"$359 T82=.�� 284' n 4-7-'9- 46;:q SUMMARY $1,646,796. .,$1,444,442 87.7% . $104,421 2.7%. SUMMARY y $25555. _ Qp537�93w�io 'y '�.s`+��gi�� �R2 YES IN-NETWORK INPATIENT FACILITY . $2,303,825. -_$52,455 2.3% $82,875. 2.1% OUTPATIENT FACILITY srR460•2&O �c 0,2 et ; c- ti AF'4 "` ;9 , i„; x9%a PROFESSIONAL $231,696 $81,012 ._ 35.0% $124,546 3.2% SUMMARY r X2`=54 095b78Sh : - P:3a:G80 _...3' ta`c4 -E. I OUT-OF-NETWORK INPATIENT FACILITY .515,768 ,_ $0' - . 0.0% $3,938 0.1% OUTPATIENT FACILITY _95096 sr_��_x 1, EO `��r t > t S '6 a'.z`h=iye.v 22:15ao PROFESSIONAL $28,617 . $17;095; 59.7% $3;680 ' _ 0.1% SUMMARY `-a' 639'-481 w�L/:095 .;'x �:sa� 2 e..- R� <i5ta`-fl SUMMARY $4,735,262 -$156,7.76 -3:3%. .$293,023 7.6% SUMMARYFI933g218? *�$ O20868 @ `�._ i .'iaaiT0094, Key Findings: CITY OF PORT ARTHUR: ALL's overall network savings discount (excluding Medicare) was 66.2% for the year to date. The in-network paid percent was 97.0% for the year to date. ENROLLMENT The enrollment chapter presents descriptive information on CITY OF PORT ARTHUR: ALL's subscribers and dependents enrolled in BCBSTX. Information on coverage tier, membership size, age and gender are presented for subscribers and dependents for the current reporting month and the renewal year to date. Report Description: This report shows the average subscribers, dependents and overall members for CITY OF PORT ARTHUR: ALL. CITY OF PORT ARTHUR:ALL JUN'15 YEAR TO DATE AVERAGE SUBSCRIBERS 0,4, _ _ 83 - IF.,,,' 1€ g as AVERAGE DEPENDENTS 772 775 AVERAGE MEMBERS AVERAGE CONTRACT SIZE 1.93 1.92 AVERAGE AGE(YEARS) Foar- 33a .?. ;:fu ,.�_z, M39E:3�- a;t Key Findings: CITY OF PORT ARTHUR: ALL's overall membership was 1,604 in the current reporting month and 1,619 for the year to date. The average age of members was 39.1 for the current reporting month and 39.3 for the year to date. CITY OF PORT ARTHUR: ALL i.3� E Q N r i (0 N-- N II 0 M i0 � ;1 t O 'S ti C a J 14:( CL . O co db a • 13 • N 0 wb -C UI 0 Ea , c a) Q) .9(. j1. a "J QOH i ; 0 C a 00L. Ih I Zil a. Jo l ' a) §i .o O i� Z o !t 11 tl II i! S! . I li i 1 E« ) ' -h0N - 0) - 9:* 0) ,- •- C NNOmV mo .- ,_ N m QN N N N N tn Ntm2mCobb p n r`. aZi P E 31 r e,�r n Ly 3�- �• i L^ c M G N u . )'y C.y.. a w Qao � w s �3� ':„ p . 7 Q V '3F O b n P �/Oi f` N g O n um', CO ]b' c�`.7, pNp 01i cm N top N t0 N 0 N m n 0 N tn. 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N c Q a) a) a) t➢ C o • a r- a) U -E = A W CS) V 3 C `o ao Qo II c Q E m H c • U U d' CI ,.„a3 W -E o L °'O_I Z am) co - 8 o 0 ° (1) Q Ln .6W < -93 aOaO Z _E a y E U-- 0 Q O R C y O W u `y U Z = m a)>+ a< ❑ iva •' y UZ p ° a a o ; Blue Cross and Blue Shield of Texas Dental Summary of Benefits Prepared for CITY OF PORT ARTHUR—Group #31118 Effective 11/1/2015 TYPE OF SERVICE BENEFIT GENERAL PROVISIONS FOR PREVENTIVE,BASIC AND MAJOR CARE BENEFITS Calendar Year Deductible(4th quarter carryover applies) $50 Individual/$150 Family Deductible Credit from Prior Carrier Calendar Year Maximum per Participant N/A PREVENTIVE CARE BENEFITS(deductible waived) $1,000 • Oral Examinations,X-Rays,Cleanings 100% BASIC CARE BENEFITS • Fillings, Extractions,Endodontics,Oral Surgery,Root Canal Therapy 80% MAJOR CARE BENEFITS • Prosthetics(dentures,bridgework),Crowns,Inlays and Onlays 50% ORTHODONTIC BENEFITS(no deductible) No • Orthodontic Diagnostic Procedures and Treatment Available Only to Participants Under 19 Years of Age N/A Lifetime Maximum per Participant N/A TEMPOROMANDIBULAR JOINT(TMJ)BENEFITS(no deductible) No Lifetime Maximum per Participant N/A • This is a general Summary of your benefit design. Please refer to your benefit booklet for other details and for limitations and exclusions. 11 The following eligibility provisions apply: • PP Y: Dependent children are covered until age 26. Disabled dependent children can be covered beyond age 26. IRetirees are not eligible for coverage. Employees may enroll dependent children up to age 5 on the first of the month following application with no late enrollment penalty. zl • A pre-existing condition exclusion will apply to expenses involving the replacement of teeth that were missing J prior to the effective date of the dental contract. This exclusion will not apply to: Any participant who becomes effective on the dental contract date who was covered under a previous group dental care contract by the Employer. I Any participant who has been continuously covered for 24 months under a group dental care contract with t! BCBSTX which included prosthetic benefits. • When the course of treatment will be in excess of$300, a predetermination request should be submitted to BCBSTX in advance of treatment. Please note that our dental is a "freestanding"product and can be purchased separately from the Health Care Services Corporation product, i.e., an employee can have only himself covered for health, but have dental for the family and vice versa. DENT-FRSTG-Summary of Benefits Blue Cross and Blue Shield of Texas,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Group Executive Name and Title Signature Date (Please type or print) Agent of Record Name Signature Date (Please print or type) BCBSTX Representative Name Signature Date (Please print or type) • DENT-FRS TG-Summary of Benefits Blue Cross and Blue Shield of Texas,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association EXHIBIT "B- 1 " NN N +, ++ O 0 O U V U >- >' >' 1 O 71 ,---i 4 �t N ri r\ v.) d CO t/} co r{ •� m N Is, r1 i--I m r-I r-1 Q m t/} N N th to to to N v)- th LA -n �, Ce -C) v 0 CU r-i O I— O O Q Q t= a W Z E u' w w i^ w L- Q (N Q d N N N ❑ N 0 0 Ct Q n U 0 U cC O W UTE U U U C C _ Z r1,0E— L ) v o 0 0 N 00 v Ln LD 0 r1 L mo LU v l0 °() Ln Q v- < ao a) Ill r-I 9 � � to �n 01 m i • °� r-o � � �^ al � 't� � O •N CC/ m Lu >- a) r'•••• 1-- „ ,,- � � o N oW0Nm mnQ � -LA. ` m O m mmth '= ., nth " n N Z W ce Ni '' >- - LU >- 2 W oN 0 o w 0- o Z a. = F— m H F- E g F-- —• w Li_ w w Q Q WO o 0 0 p 0 W X > I- U W U a. 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CU 0 I-- v v c Ln sz c c c c +-, +-, aJ a 0 U +� Q) a) Q) U c 0 :z a. _ c c 1? 0_ .-05- CL 0 CL) a) v v � v a) a) v -ate j. -c -a a) 0 0 ccC) a >- a a v 0 0 acs a C v N co ,--I N G a C v LLo ,-i N G O Q Q dS CZ/ 06 0 co- u oZJ oZS o2S COLU Ln 0 0 00 a) a) a) a) LU U Ln 0 O la c aJ a1 CUCU Lo ,--1 N G v v v - LD ,--I N G a a) a) a) rn -13 L • z Ca) �'a o2$ o2S cZS v a a v z Cv c'i oZ5 06 a) a a a D C C Ln Ln 111 CO CO CO CO = G C Ln Ln Lr) CL CG CL =LL to LD LD LD QJ CU O LL N D LD LD LD a a a) a) I a) a) a) a) a) (o (o (o (o I a) Q) a) a Q) (o (o CO (C U.. a) a) a) a) a) U U U_ U ll. a) a) a) a) a) UUUU J L L L L L —1 L L L L L LU CC Ir cc CU 2 2 2 2 LU cc = cc cc cc 2 2 2 2 EXHIBIT " C " Dcarb0rn National: July 27, 2015 CITY OF PORT ARTHUR ATTENTION: ELIZABETH VILLARREAL PO BOX 1089 PORT ARTHUR TX 77641-1089 Subject: Renewal Analysis Group Policy Number: G31118 Anniversary Date: November 1,2015 Dear Policyholder: Dearborn National would like to thank you for allowing us the opportunity to provide you and your employees with Group insurance products. We have reviewed the current demographics of your group insurance programs. We are pleased to inform you that there will be no change in the existing rates for the upcoming renewal period. Rates will be guaranteed until November 1, 2017. Products Current Rates Renewal Rates Life-Firefighters $0.22 per $1,000 $0.22 per $1,000 Life—All Others $0.19 per $1,000 $0.19 per $1,000 • AD&D $0.04 per$1,000 $0.04 per$1,000 If you have any questions pertaining to your renewal, or would like more information including the availability of other products as well as a quote for additional benefit programs, please contact your local Dearborn National sales office or insurance broker. We value our relationship with you and look forward to providing quality service to you in the future. Sincerely, — — — Underwriting Department- In Force Team 701 East 22nd Street, Lombard, IL 60148 A Fax: 312.540.4706 Products and services marketed under the Dearborn National®brand and the star logo are underwritten and/or provided by Dearborn National®Life Insurance Company (Downers Grove,IL)in all states(excluding New York),the District of Columbia.the United States Virgin Islands.the British Virgin Islands,Guam and Puerto Rico. A