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Home My WebLink AboutResolution - 2011-R0500 - Purchase Transplant Insurance Coverage - Medical Excess - 11_16_2011Resolution No. 2011-RO500 November 16, 2011 Item No. 5.5 RESOLUTION BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THAT the City Manager of the City of Lubbock is hereby authorized and directed to purchase for and on behalf of the City of Lubbock, transplant insurance coverage, by and between the City of Lubbock and Medical Excess, with first dollar coverage pursuant to the terms and conditions attached hereto as Exhibit "A," offering the same benefits as set forth in Exhibit "A" hereto, and in a final form and substance acceptable to the City Manager and City Attorney; and THAT the City Manager or designee may execute any routine documents and Forms associated with said insurance coverage. Passed by the City Council this November 16, 2011 TOM UARTIN, MAYOR ATTEST: PROVED AS TO CONTENT: uma Hutcheson, Director of Human Resources & isk Management PPROVE AS T C/ had Weaver, Ass]; FORM: City Attorney -s/RES.Medical Excess 2011 17, 2011 EXHIBIT A Resolution No. 2011-R0500 Josefina Panopio Sr. Under.vriter Medical Excess 800 634-7462 'T" Ir-phcne 714 436-3620 Facsunle iosefina cony CHARTIS August 12, 2011 Travis Sartain McQueary Henry Bowles Troy, LLP 8144 Walnut Hill Lane, 16th Dallas, TX 75231 Re: Renewal of Organ & Tissue Transplant Policy Policyholder: City Of Lubbock Policy Anniversary Date: January 1, 2012 Policy Number: 280-8776 Dear Travis, The Organ & Tissue Transplant Policy issued to the above captioned group is approaching its anniversary date, and we are looking forward to renewing it with you. Attached is the renewal proposal for the group. If there has been a change in the group's administrator, please report it to Medical Excess immediately, as this may alter or negate the terms of this renewal proposal. Otherwise, please respond to this letter within 15 days of the renewal date to allow us to prepare the renewal Policy in a timely manner. Your response should include an update regarding those individuals that were originally excluded from coverage under this Policy. In addition, please identify: 1. Any new potential transplant exposures and related medical information (clinical or case management notes - including type of transplant, date of evaluation, hospital listing and current diagnosis). 2. Any significant census changes (current and/or future). 3. Any change in the group's third party administrator. Please forward the information requested in Items 1&2 (above) to my attention within 45 days prior to the renewal date. Thank you very much for this opportunity to continue our relationship. Should you have any questions, please do not hesitate to call. Sincerely, Josefina Panopio cc: Russ Jehs, Vice President, Organ Transplant Production Manger Medical Excess Diie kIncArthur Pln--e. Suite it ? SOr;llfl C(,73s+ ), C-r^, Zit/ 1i Accident & Health Corporate Benefits CHARTIS Onp MarArthur Place Suites 82n Snuth Cnast Metrn_ CA 92707 Toll Fri- 800-634-7462 Employer: CITY OF LUBBOCK Underwriter: Josefina Panopio Proposal: 90232 Sales: Stanley Self Producer: McQueary Henry Bowles Troy, LLP Quote Date: M12/2011 Claims Admin.: Blue Cross and Blue Shield of Texas, a division of Quote Valid Until: 01/01/2012 Carrier: National Union Fire Insurance Effective Date: 01/01/2012 This proposal contemplates the utilization of the above captioned Claims Administrator. Any deviation is a material change of fact rendering this proposal null and void. Summary of Coverage Lifetime Maximum: $1,000,000 Policy Deductible : $0 Notification ! Coordination : See requirements in attached policy specimen Transplant Benefit Period : Evaluation through 365 days post transplant Reimbursement : • 100% of covered transplant -related costs, including organ procurement, when performed in -network. ' 80% of covered transplant -related costs up to scheduled maximum amount per transplant when performed out -of -network (see policy) Transportation : $200 per day, $10,000 maximum for patient and companion Experimental : Coverage of NCI Clinical Trials Phase III and IV for adults, all phases for pediatric Pre -Existing Requirements : Pre -Ex is waived for current Participants (unless they are completing an established Pre -Ex Waiting Period). However, Participants added from the acquisition of a new group, affiliate, division, and/or subsidiary, are subject to a 12 month Pre -Ex Wafting Period that begins on the date the acquisition is covered under the Policy. A Pre -Existing Condition is any condition for which the Participant has within the past 24 months: been advised that a transplant may be necessary; had a transplant consultation, workup, or evaluation; been scheduled for a transplant consultation, workup, or evaluation; received or has been listed to receive a transplant; received dialysis treatments; or been diagnosed with Chronic Kidney Disease or End Stage Renal Disease. Other Coverage I Services : Please refer to policy specimen Rate : $ 6.33 Single $ 14.56 Family " Premium : $ 329,793.72 Commission : Rates include 0% commission Rates and benefits are subject to state approval, and the 24 month Pre -Ex 'look -back" period may vary by state. Russ Jehs Vice President, Organ Transplant Product Management No coverage of any kind is made effective by this quote transmitted. Sales Representatives, and brokers or agents, have no authority fe make efreethe coverage, or moor into cw,&vCta on behalf of the company. Coverage wgl bo a feedve only titer. (I) a quotation Is issued by the company,• (Y) a completed and signed application and disclosure Is mcetved by the company; 13) the Application is approved by the conwany; ({) Wrftten notice conAnnMg elrecfive coverage is Issued by the company. This proposal supersedes all others previously Issued to you, and all other Propmwla and Rate Quot+tfons pmWously Issued to you are void JCOLWELL 06/12/2011 09:19:46 Page 1 of 2 Accident & Health Corporate Benefits One MacArthur Place Suite 620, South Coast Metro, CA 92707 Toll Free: 1300-634-7462 Employer: CiTY OF LUBBOCK Underwriter: Josefina Panopio Proposal: 90232 Sales: Stanley Self Producer: McQueary Henry Bowles Troy, LLP Quote Date: 08/12/2011 Claims Admin.: Blue Cross and Blue Shield of Texas, a division of Quote Valid Until: 01101/2012 Carrier: National Union Fire Insurance Effective Date: 01/01/2012 CHARTIS This proposal contemplates the utilization of the above capfionad Claims Administrator. Any deviation is a material change of fact rendering this proposal nufl and void. Contingencies For All Producers / Groups • Explanation of any upcoming significant census changes (20%) within 30 days of effective date. • Proposal assumes no less than 80% of the participants reside in Texas. • Contract period is for 12 months from effective date. • in the event that Plan participants are covered under a High Deductible Health Plan (as defined under Title 26, Subtitle A, Chapter 1, Subchapter B. Part VII, § 223 of the Internal Revenue Code), the Plan's Deductible Amount must be met prior to benefits being paid under the Organ and Tissue Transplant Policy. For Non -Select Groups: In addition to the Information requested above, please provide the following: (Attached Proposal is 'indication only based on our Pooled Producer rates. The information requested below is to determine any variance from pooled rates in order to determine our final underwriting position.) No coverage ofany klnd Is made efiective by this quote transmitted. Sales Representatives, and brokers or spent:, have no authorrry to make elrectrve coverage, orMtarAWV oontraets on behab'of the company, Coverage wdll be effective only &Her. (I) a quotation Is Issued by the company; (2) a completed and signed eppltcallon and disclosure Is received by the company; (J) me application is approved by the company; (4) Written notice confirming effective coverage is Issued by the company. This proposal supersedes all others previously Issued to you, and aft outer proposals and Rate Quotation previousty Issued to you are void. JCOLWELL 08/12/2011 09:19:46 Page 2 of 2 NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. Executive Offices: 175 Water Street, New York, NY 10038 (212) 770-7000 (a capital stock company, herein referred to as the Company) Administrative Office: Medical Excess LLC 8777 Purdue Road, #330 Indianapolis, Indiana 46268 (888)449-2377 Organ & Tissue Transplant Renewal Endorsement This Endorsement is attached to and made a park of the following Organ & Tissue Transplant Policy: Policyholder: City of Lubbock Policy Number: 280-8776 Original Policy Effective Date: January 1, 2005 It is agreed that the above referenced Organ & Tissue Transplant Policy is renewed for the Policy Year stated in the attached Renewal Schedule of Benefits. The Policy Number and all terms and conditions set forth in the attached Renewal Schedule of Benefits replace and supersede all previously issued Schedules of Benefits. This Endorsement is subject to all the provisions of the Policy. Payment of the premium for the insurance provided by the Policy as endorsed constitutes acceptance by the Policyholder of the terms of this Endorsement. This Policy is signed for the Company by its President and Secretary. President OT-2009-RENEWAL-TX Secretary (Rev. 312009) RENEWAL SCHEDULE OF BENEFITS POLICY YEAR: January 1, 2011 through December 31, 2011 CURRENT ENROLLMENT: 2585 MINIMUM ENROLLMENT: 250 PREMIUMS PER MONTH: Single Employee $6.33 Family $14.56 COVERRED 'TRANSPLANTS: ® Heart ® Lung/Double Lung ® Kidney (living or deceased donor) ® Pancreas ® Liver (living or deceased donor) ® Intestine TRANSPLANT BENEFIT PERIOD: ® Heart/ Lung ® Kidney/ Pancreas ® Kidney/Liver ® Liver/Intestine ® Pancreas/Intestine ® Liver/Pancreas/Intestine ❑ Other (specify): ® Autologous Bone Marrow Peripheral Stem Cell Including High Dose Chemo ® Allogeneic Bone Marrow Peripheral Stem Cell Including High Dose Chemo (related) ® Allogeneic Bone Marrow Peripheral Stem Cell Including High Dose Chemo (unrelated) The Transplant Benefit Period begins on the date of Transplant Evaluation for a Covered Transplant Procedure. The Transplant Benefit Period ends on the earliest of the following dates: 1. The end of the 365th day following the Covered Transplant Procedure; 2. The date the Participant's Lifetime Limit has been reached under the Policy or under the Medical Plan; 3. The date the Policy terminates, but only if: a. The Policyholder cancels the Policy prior to the last day of the current Policy Year; or b. The Participant's Transplant Benefit Period has begun, but such Participant has not received a Covered Transplant Procedure as of the date of termination of the Policy; or 4. The date the Participant's COBRA benefits terminate, if applicable. 5. The date established by the Non -Performance of Covered Transplant Procedures provision. If there is no Transplant Evaluation, the Transplant Benefit Period begins on the date of a Covered Transplant Procedure. For a Bone MarrowlPeripheral Stem Cell Tissue Transplant, the date the tissue is re -infused is deemed to be the date of the Covered Transplant Procedure, All benefits provided during a Transplant Benefit Period that extend beyond the Policy Year will be based on the Policy terms in effect at the start of the Transplant Benefit Period. A Transplant Benefit Period cannot begin prior to the date the Participant first becomes covered under the Policy. LIFETIME LIMIT: $1,000,000 for each Participant The following charges are included within and reduce each Participant's Lifetime Limit: 1. All benefits paid on behalf of the Participant (including covered donor charges) under the Policy and any preceding or succeeding Organ & Tissue Transplant Policy between us and the Policyholder; and 2. All benefits paid by us under the "Travel, Lodging, and Meals Benefit" provision. OT-2009-RENEWAL-TX Page 2 of 4 (Rev. 3/2009) RENEWAL SCHEDULE OF BENEFITS (Continued) DEDUCTIBLE AMOUNT (APPLICABLE TO HIGH DEDUCTIBLE HEALTH PLANS ONLY): Although the Policy does not impose a Deductible Amount, if a Participant selects a high deductible health plan sponsored by the Policyholder, then the Deductible Amount set forth in such Policyholder's high deductible health plan must be paid by the Participant before benefits are payable under the Policy. This requirement is necessary in order for the Participant to remain eligible for the tax benefits afforded by the health savings account associated with the Policyholder's high deductible health plan. REIMBURSEMENT AMOUNTS: A. PARTICIPATING PROVIDER: ........ _.. 100% of Covered Charges for Covered Transplant Services provided through a Participating Transplant Facility. (All Participants subject to a Deductible Amount must meet the Deductible Amount before Covered Charges are eligible for reimbursement.) B. NONPARTICIPATING PROVIDER: ...... 80% of Covered Charges for Covered Transplant Services provided through a Nonparticipating Transplant Facility with respect to the type of Covered Transplant Procedure performed. (All Participants subject to a Deductible Amount must meet the Deductible Amount before Covered Charges are eligible for reimbursement,) Benefits for Covered Transplant Services provided through a Nonparticipating Transplant Facility will not exceed the Maximum Amounts stated below: COVERED TRANSPLANT PROCEDURE MAXIMUM BENEFIT FOR ALL COVERED TRANSPLANT SERVICES PROVIDED BY A NONPARTICIPATING TRANSPLANT FACILITY Heart $437,000 Lung (Single) $261,000 Double $363,000 -Lung Kidney (living or deceased donor $156,000 Pancreas $163,000 Liver (living or deceased donor) $196,000 Intestine $626,000 Heart/Lung $495,000 Kidne ?Pancreas $200,000 Kidney/Liver $419,000 Liver/Intestine $700,000 Pancreas/Intestine $668,000 Liver/Pancreas/intestine $716,000 Autologous Bone Marrow/Peripheral Stem Cell Including High Dose Chemothera $175,000 Allogeneic Bone Marrow/Peripheral Stem Cell Including High Dose Chemotherapy - related $297,000 Allogeneic Bone Marrow/Peripheral Stem Cell Including High Dose Chemotherapy- unrelated $380,000 C. SECONDARY PAYOR:..................... When benefits under the Policy are considered secondary, as determined by the Coordination of Benefits provisions, benefit payments will be based on the lesser of: a) Covered Charges; or b) the negotiated amount established between the primary payor and the Provider. OT-2009-RENEWAL-TX Page 3 of 4 (Rev. 3/2009) RENEWAL SCHEDULE OF BENEFITS (Continued) ENDORSEMENTS: Yes ❑ No If yes; please specify: POLICYHOLDER'S MEDICAL PLAN ADMINISTRATOR: BCBS of TX OT-2009-RENEWAL-TX Page 4 of 4 (Rev. 3/2009)