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HomeMy WebLinkAboutResolution - 2021-R0498 - Employee Group Health Plan 2022-2023 with BlueCross BlueShield 12.14.21Resolution No. 2021-R0498 Item No. 6.21 December 14, 2021 RESOLUTION BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute for and on behalf of the City of Lubbock, the B1ueCross BlueShield of Texas Administrative Services Only Benefit Program Application (ASO BPA) for the Employee Group Health Plan for plan year January 1, 2022 to January 1, 2023. Said ASO BPA is attached hereto and incorporated in this resolution as if fully set forth herein and shall be included in the minutes of the City Council. Passed by the City Council on ATTEST: Reb cca Garza, City Sec eta APPROV S TO CONTENT: December 14, 2021 -f -'� VN YORPROTEM STEVE Clifton Beck, Director of Human Resources APPROVED first Assistant City Attorney Aocs/RES.ASO BPA-BlueCross BlueShield ovember 8, 2021 Resolution No. 2021-R0498 Benefit Program Application ("ASO BPA") Application to Administrative Services Only (ASO) Group Accounts administered by Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, hereinafter referred to as the "Claim Administrator" or "BCBSTX" Group Status: Renewing ASO Account Employer Account Number (6-digits): 010097 Group Number(s): 106837, 219476 Section Number(s): All Legal Employer Name: City of Lubbock (Specify the Employer or the employee trust applying for coverage. Names of subsidiary or affiliated companies to be covered must also be named below. AN EMPLOYEE BENEFIT PLAN MAY NOT BE NAMED) ERISA Regulated Group Health Plan*: ❑ Yes ® No Is your ERISA Plan Year* a period of 12 months beginning on the Effective Date of Coverage specified below? ❑Yes If not, please specify your ERISA Plan Year*: Beginning Date _/ /_ End Date /_/_ (month/day/year) ERISA Plan Administrator*: Plan Administrator's Address: If you maintain that ERISA is not applicable to your group health plan, give legal reason for exemption: Non -Federal Governmental Plan (Public Entity) ; if applicable, specify other: Is your Non-ERISA Plan Year* a period of 12 months beginning on the Anniversary Date specified below? ®Yes If not, please specify your Non-ERISA Plan Year*: Beginning Date _/_/_ End Date _/ /_ (month/day/year) For more information regarding ERISA, contact your Legal Advisor. *All as defined by ERISA and/or other applicable law/regulations Effective Date of Coverage: (Month/day/Year) 01 / 01 / 2022 Anniversary Date: (Month/Day/Year) 01 / 01 / 2023 Standard Industry Code (SIC): 9111 Address: 1314 Avenue K City: Lubbock Administrative Contact: Lou Moore Email Address: Imoore(a),mylubbock.us ❑ Mailing address is different from primary address Mailing Address: City: Mailing Contact: Email Address: ® Billing address is different from primary address Billing Address: PO Box 2000 City: Lubbock Billing Contact: Lou Moore Email Address: ImoorePmylubbock.us Wholly Owned Subsidiaries to be covered: Employer Identification Number (EIN): 75-6000590 State: TX ZIP: 79401-3830 Title: Benefits and Wellness Manaaer Phone Number: 806-775-2317 Fax Number: 806-775- 3965 State: ZIP: Title: Phone Number: Fax Number: State: TX ZIP: 79457 Title: Benefits and Wellness Manager Phone Number: 806-775-2317 Fax Number: 806-775- 3965 Affiliated Companies to be covered: Employer Identification Number (EIN): (Affiliated Companies must be required or permitted to be aggregated per IRS Guidelines., Employer hereby confirms that Employer, Subsidiaries and Affiliates are treated as a single employer under Internal Revenue Code Section 414(b), or (c), or (m) or (o), or under Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except with written permission of Claim Administrator. TX GEN ASO BPA (Rev. 06/21) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, page 1 an Independent Licensee of the Blue Cross and Blue Shield Association applicable law.) Subsidiary / Affiliate Address: City: State: ZIP: Subsidiary / Affiliate Contact: Title: Email Address: Phone Number: Fax Number: Blue Access for Employerss" ("BAEs^"") Contact: Lou Moore Title: Benefits and Wellness Manager (The BAE Contact is the Employee authorized by the Employer to access and maintain the Employer's account in BAE.) Email Address: Imoore(abmylubbock.us Phone Number: 806-775-2317 Fax Number: 806-775- 3965 ® The Employer or other company listed in this BPA is a is a public Entity or governmental agency/contractor Effective: 01 /01 /2016 If applicable, the below -named producer(s) or agency(ies) is/are recognized as the Employer's Producer of Record (POR) to act as representative in negotiations with and to receive commissions from BCBSTX, or Claim Administrator's corporate subsidiaries, as applicable, for procuring Claim Administrator's claims administration services for Employer's employee benefit program(s). This statement rescinds any and all previous POR appointments for the Employer. The POR is authorized to perform membership transactions on behalf of the Employer. This appointment will remain in effect until withdrawn or superseded in writing by Employer. Producer or Agency to whom commissions are to be paid``: Marsh & McLennan Agency Texas Producer#:010000731 Address: City: Phone: NPN: 263237576 State: ZIP: Fax: Email: Is Producer/Agency appointed with BCBSTX in Texas? ® Yes ❑ No General Agent? ❑ Yes ❑ No Affiliated with General Agent? ❑ Yes ❑ No Is there a secondary Producer or Agency to whom commissions are to be paid? ❑ Yes ® No If Yes**, Producer or Agency to whom commissions are to be paid*: Texas Producer #: NPN: Address: City: State: ZIP: Phone: Fax: Email: Is Producer/Agency appointed with BCBSTX in Texas? ❑ Yes ❑ No General Agent? ❑ Yes ❑ No Commissions: ❑ PCPM $ Does a Monthly Cap Apply ❑ Yes ❑ No $ (If cap is annual, divide by twelve) ❑ Flat $ Does a Monthly Cap Apply ❑ Yes ❑ No $ (If cap is annual, divide by twelve) ❑ Percentage of Stop Loss: % ADDITIONAL COMMISSIONS: Affiliated with General Agent? ❑ Yes ❑ No If commission split**, designate percentage for each producer/agency (total commissions paid must equal 100%): Producer /Agency 1: % Producer /Agency 2: % Multiple Location Agency(ies): If servicing agency is not listed above as primary or secondary Producer or Agency above, specify location below: * The Producer or agency name(s) above to whom commissions are to be paid must exactly match the name(s) on the appointment application(s). Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except with written permission of Claim Administrator. TX GEN ASO BPA (Rev. 06/21) A Division o/Health Care Service Corporation, a Mutual Legal Reserve Company, page 2 an Independent Licensee of the Blue Cross and Blue Shield Association `" If commissions are split, please provide the information requested above on both producers/agencies. Both must be appointed to do business with BCBSTX in Texas. Employer has made the following eligibility decisions: 1. Eligible Person means: ® A full-time employee of the Employer. ❑ A full-time employee of the Employer who is a member of: (name of union) ❑ A part-time employee of the Employer. ® A retiree of the Employer. Define criteria: Pre 65 ❑ Other: Are any classes of employees to be excluded from coverage? ❑ Yes ❑ No if yes, please identify the classes and describe the exclusion: 2. Employee definition: Full -Time Employee means: ® A person who is regularly scheduled to work a minimum of 30 hours per week and who is on the permanent payroll of the Employer. ❑ Other: Part -Time Employee means: ❑ A person who is regularly scheduled to work a minimum of hours per week and who is on the permanent payroll of the Employer. ❑ Other: 3. The Effective Date of termination for a person who ceases to meet the definition of Eligible Person: ® The date such person ceases to meet the definition of Eligible Person. ❑ The last day of the calendar month in which such person ceases to meet the definition of an Eligible Person. ❑ Other: 4. Select an effective date rule for a person who becomes an Eligible Person after the Effective Date of the Employer's health care plan (The effective date must not be later than the 91st calendar day after the date that a newly eligible person becomes eligible for coverage, unless otherwise permitted by applicable law). ❑ The date of employment. ❑ The day of employment. ❑ The day of the month following month(s) of employment. ® The 1 st day of the month following 30 days of employment. ❑ The day of the month following the date of employment. ❑ Other: Is the waiting period requirement to be waived on initial group enrollment? ❑ Yes ❑ No Are there multiple new hire waiting periods? ❑ Yes ❑ No if yes, please attach eligibility and contribution details for each section. 5. Domestic partners covered: ❑ Yes ® No if yes, a domestic partner is eligible to enroll for coverage. if yes, are domestic partners eligible for continuation of coverage? ❑ Yes ❑ No if yes, are dependents of domestic partners eligible to enroll for coverage? ❑ Yes ❑ No if yes, are dependents of domestic partners eligible for continuation of coverage? ❑ Yes ❑ No The Employer is responsible for providing notice of possible tax implications to those Covered Employees with coverage for domestic partners. 6. Are unmarried grandchildren eligible for coverage? ® No ❑ Yes (answer the question below) Must the grandchild be dependent on the employee for federal income tax purposes at the time application is made? ❑ Yes ❑ No Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except with written permission of Claim Administrator. TX GEN ASO BPA (Rev. 06/21) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, page 3 an Independent Licensee of the Blue Cross and Blue Shield Association 7. Limiting Age for covered children: Twenty-six (26) years, regardless of presence or absence of a child's financial dependency, residency, student status, employment status, marital status, eligibility for other coverage, or any combination of those factors. Other: 8. Termination of coverage upon reaching the Limiting Age: ❑ The last day of coverage is the day prior to the birthday. ❑ The last day of coverage is the last day of the month in which the limiting age is reached. ® The last day of coverage is the last day of the billing month. ❑ The last day of coverage is the last day of the year (12/31) in which the limiting age is reached. ❑ The last day of coverage is the day prior to the Employer's Anniversary Date. Automatically cancel dependents when they reach the day their coverage terminates? ® Yes ❑ No Will coverage for a child who is medically certified as disabled and dependent on the employee terminate upon reaching the Limiting Age even if the child continues to be both disabled and dependent on the employee? ❑ Yes ® No However, such coverage shall be extended in accordance with any applicable federal or state law. The Employer will notify BCBSTX of such requirements. 9. Disabled dependent: A disabled dependent means a dependent child who is medically certified as disabled and dependent upon the Employee or his/hgr spouse. To administer medical certification of disabled dependents, you may select option (a) Standard Rules or (b) Custom Rules. BCBSTX will administer its standard process for administration of disabled dependent coverage if (a) below is selected by Employer, or at the Employer's direction memorialized below, BCBSTX will follow a customized process if Employer selects (b). If (b) is selected there are additional selections regarding age, proof of prior coverage, certification review, forms, and previous medical certification approvals. (a) ® Disabled dependent administration will follow Standard Rules. A disabled dependent is eligible to continue coverage beyond the limiting age, provided the disability began before the child attained the age of 26. A disabled dependent is eligible to add coverage beyond the limiting age, provided the disability began before the child attained the age of 26, and proof of coverage as a disabled dependent is provided. Administration of certification review is administered by BCBSTX; a disabled dependent certification form must be submitted to BCBSTX. (b) ❑ Disabled dependent Administration will follow Custom Rules. Please make the following sections: Age: Please select one option regarding age of when the disability began. ❑ The disability must have begun before the child attained the age of 26. ❑ All disabled dependents are covered regardless of when the disability began. Proof of prior coverage: Please select required or not required below. When adding coverage, proof of prior coverage as a disabled dependent is ❑ required ❑ not required. Certification review: Please select one option regarding the administration of certification review. ❑ Certification review is administered by BCBSTX; a disabled dependent certification form must be submitted to BCBSTX. ❑ Certification review is administered by the Employer; there are no disabled dependent certification form requirements. If certification review is administered by BCBSTX, please select one option regarding forms: ❑ Utilize BCBSTX's disabled dependent certification forms. ❑ Utilize custom/other disabled dependent certification forms. If Certification Review is administered by BCBSTX, please select allowed or not allowed below: A disabled dependent approved certification from a prior insurance carrier is ❑ allowed ❑ not allowed. A disabled dependent approved certification from a prior BCBS policy is ❑ allowed ❑ not allowed. Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except with written permission of Claim Administrator. TX GEN ASO BPA (Rev. 06/21) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, page 4 an Independent Licensee of the Blue Cross and Rlue Shield Association 10. Will extension of benefits due to temporary layoff, disability or leave of absence apply? ❑ Yes (specify number of days below) ® No Temporary Layoff: days Disability: days Leave of Absence: days However, benefits shall be extended for the duration of an Eligible Person's leave in accordance with any applicable federal or state law. The Employer will notify BCBSTX of such requirements. 11. Enrollment: Special Enrollment. An Eligible Person may apply for coverage, family coverage or add dependents within thirty-one (31) days of a Special Enrollment qualifying event if he/she did not previously apply prior to his/her Eligibility Date or when otherwise eligible to do so. Such person's Coverage Date, family Coverage Date, and/or dependent's Coverage Date will be the effective date of the qualifying event or, in the event of Special Enrollment due to marriage or termination of previous coverage, then no later than the first day of the Plan Month following the date of receipt of the person's application of coverage. An Eligible Person may apply for coverage within sixty (60) days of a Special Enrollment qualifying event in the case either of a loss of coverage under Medicaid or a state Children's Health Insurance program, or eligibility for group coverage where the Eligible Person is deemed qualified for group coverage assistance under a state Medicaid or CHIP premium assistance program. Open Enrollment: An Eligible Person may apply for coverage, family coverage or add dependents if he/she did not apply prior to his/her Eligibility Date or did not apply when otherwise eligible to do so, during the Employer's annual Open Enrollment Period. Such person's Coverage Date, family Coverage Date, and/or dependent's Coverage Date will be a date mutually agreed to by the Claim Administrator and the Employer. Such date shall be subsequent to the Open Enrollment Period. Specify Open Enrollment Period: 2 week period in October / November 2021 Late Enrollment: An Eligible Person may apply for coverage, family coverage or add dependents if he/she did not apply prior to his/her Eligibility Date or did not apply when otherwise eligible to do so. Such person's Coverage Date, family Coverage Date, and/or dependent's Coverage Date will be a date mutually agreed to by the Claim Administrator and the Employer. Select one of the provisions below: ® Open Enrollment — Late applicants may only apply during Open Enrollment. ❑ Late Entrant — Late applicants may apply at any time — coverage effective date is determined by the receipt date and allowed rules governing off -cycle enrollments. 12. * Does COBRA Auto Cancel apply? ® Yes ❑No Member's COBRA/Continuation of coverage will be automatically cancelled at the end of the member's eligibility period. *Not recommended for accounts with automated eligibility ® NO CHANGES ® Current number of Employees enrolled 2491 ❑ SEE ADDITIONAL PROVISIONS Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except with written permission of Claim Administrator. TX GEN ASO BPA (Rev. 06121) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, page 5 an Independent Licensee of the Blue Cross and Blue Shield Associaoon Current Employee Eligibility Information only applies to new accounts. If your account is renewing, please just indicate the current number of enrolled employees (above). Total number of Employees/Subscribers: 1. on payroll 2. total number of employees presently eligible for coverage 3. on COBRA continuation coverage 4. with retiree coverage (if applicable) 5. who work part-time 6. serving the new hire probationary period 7. declining because of other group coverage (e.g., other commercial group coverage, Medicare, Medicaid, TRICARE/Champus) 8. declining coverage (not covered elsewhere) Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except with written permission of Claim Administrator. TX GEN ASO BPA (Rev. 06121) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, page 6 an Independent Licensee of the Blue Cross and Blue Shield Association Medical Plan Services: ❑ PPO: Plan Name: Plan Name: Plan Name: Plan Name: Plan Name: ❑ HMO: Plan Name: ❑ Prescription Drug Option: Select From List ❑ No Prescription Drug Option ❑ Blue High Performance NetworksM (Blue HPNsM) without Tiers ❑ Blue High Performance Network with Tiers (Blue HPNT) ® EPO: Plan Name: EPO EPO ❑ POS: Plan Name: Additional Services: ❑ Wellbeing Management ❑ Wellness Incentives ❑ Health Advocacy Solutions ❑ Mercer Health Advantage ❑ Custom Care Management Unit ❑ Blue DirectionssM (Private Exchange) (/f selected, the Blue Directions Addendum must be attached and made a part of the parties' Administrative Services Agreement.) ❑ In -Hospital Indemnity (IHI) ❑ Limited Fiduciary Services for Claims and Appeals Consumer Driven Health Plan ❑ BlueEdgesM HCA, (if selected, complete separate HCA Benefit Program Application) ❑ BlueEdgesM HSA, (if selected, provide HSA Administrator or trustee name: Select Vendor) ❑ FSA (vendor: Select Vendor) ❑ HRA (vendor: Select Vendor) Traditional Coverage: ❑ Out -of -Area (Indemnity) ❑ Benefit Offering Prescription Drugs: ❑ (If selected, the PBM Fee Schedule Addendum must be attached and is part of this BPA.) Pharmacy Network (Select one): ❑ Traditional Select Network ® Advantage Network ❑ Preferred Network ❑ Elite Network ❑ Network on PBM Fee Schedule Addendum ❑ Other (please specify): Drug List: Select Drug List Other (please specify): PPO/HSA Preventive Drug List: Please specify: Select Option Other Rx programs: Please specify: Select Program ❑ Other Select Product Ancillary Services: ❑ Vision Insurance (if selected, complete a separate application) ❑ Other Select Product ® Stop Loss Coverage (If selected, complete separate Stop Loss ❑ Other Select Product exhibit) ❑ Other Select Product ❑ Life or Disability Insurance (If selected, complete a separate application for those coverages) ❑ Other ® COBRA Administrative Services (If selected, complete separate ❑ Other COBRA Administrative Services ® Dental Plan Services Plan Name: PPO P Dental Employer -paid Plan Name: Select From List Plan Name: Select From List Plan Name: Select From List Mercer Health Advantage is offered by Mercer, an independent company, and is administered by Blue Cross and Blue Shield of Texas. Custom Care Management Unit is offered by Willis Towers Watson, an independent company, and is administered by Blue Cross and Blue Shield of Texas. Medical and Dental benefits and services are administered by 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. Life Insurance Company, 701 E. 22nd St. Suite 300. Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS°, BLUE SHIELD* 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. Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except with written permission of Claim Administrator. TX GEN ASO BPA (Rev. 06/21) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, page 7 an Independent Licensee of the Blue Cross and Blue Shield Association FEE SCHEDULE Employer shall pay amounts Claim Administrator bills Employer for benefit claims Claim Administrator processes on Employer's behalf as well as administrative fees as set forth in this Fee Schedule. Payment Specifications NO CHANGES SEE ADDITIONAL PROVISIONS Employer Payment Method: ❑ Online Bill Pay ❑ Electronic ❑ Auto Debit ❑ Check Employer Payment Period: ❑ Weekly (cannot be selected if Check is selected as payment method above) ❑ Semi Monthly (cannot be selected if Check is selected as payment method above) ❑ Monthly Claim Settlement Period: ❑ Monthly Run -Off Period: Employer Payments are to be made for months following the end of the Fee Schedule Period. Standard is twelve (12) months. Fee Schedule Period: To begin on Effective Date of Coverage and continue for 12 months. If other than 12 months, please specify: months. Per Employee per Month NO CHANGES 0 SEE ADDITIONAL PROVISIONS ChargesAdministrative 2022 2022 dental Administrative Fee $43.91 $ $ $ Dental $ $3.20 $ $ Limited Fiduciary Services $ $ $ $ Advanced Payment Review $4.20 $ $ $ 'Medical Drug Rebate Credit $-2.50 $ $ $ 'Rebate Credit for the Prescription Drug Program $-71.13 $ $ $ Outpatient Imaging Management Services $ $ $ $ Management of the Virtual Visits Program $ $ $ $ Wellbeing Management $4.95 $ $ $ Health Advocacy Solutions $ $ $ $ Commissions: $ $ $ $ Commissions: $ $ $ $ Commissions: $ $ $ $ Other: Prescription Drug Administrative Fee $5.60 $ $ $ List Service: Other: Other Services $0.19 $ $ $ List Service: Retiree Drug Subsidy Support Other: Other Services $3.97 $ $ $ List Service: MMA Rx Solutions Consulting Fee Miscellaneous: Livongo $1.59 $ $ $ Miscellaneous: $ $ $ $ Total $44.62 $3.20 $ $ Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except with written permission of Claim Administrator. TX GEN ASO BPA (Rev. 06121) A Division ofHea/th Care Service Corporation, a Mutual Legal Reserve Company, page 8 an Independent Licensee of the Blue Cross and Blue Shie/d Association *The Rebate Credit is a per Covered Employee per month credit applied to the monthly billing statement. The Employer and Claim Administrator have agreed to the Rebate Credit and Employer agrees that it and its group health plan have no right to, or legal interest in, any portion of the rebates, either under the pharmacy benefit or the medical benefit, actually provided by the Pharmacy Benefit Manager ("PBM") or a pharmaceutical manufacturer to Claim Administrator and consents to Claim Administrator's retention of all such rebates. The Rebate Credit will be provided from Claim Administrator's own assets and may or may not equal the entire amount of rebates actually provided to Claim Administrator by the PBM or expected to be provided. Rebate Credits shall not continue after termination of the Prescription Drug Program. Employer agrees that any Rebate Credit provision in the governing Administrative Services Agreement to the contrary is hereby superseded. kcd •- -• • Other: Select Service Category Select Billing Frequency $ List Service: If applicable, describe other: Other: Select Service Category Select Billing Frequency $ List Service: If applicable, describe other: Other: Select Service Category Select Billing Frequency $ List Service: If applicable, describe other: Other: Select Service Category Select Billing Frequency $ List Service: If applicable, describe other: Miscellaneous: Select Billing Frequency $ If applicable, describe other: Miscellaneous: Select Billing Frequency $ If applicable, describe other: Total: $ Not applicable to Grandfathered Plans External Review Coordination: ® Yes ❑ No /f yes, coordination fee: $700 for each external review requested by a Covered Person that the Claim Administrator coordinates for the Employer in relation to the Employer's Plan. Employer elects for external reviews to be performed under the Affordable Care Act external review process. Advanced Payment Review (APR): N Yes U No APR is a suite of payment integrity offerings. Refer to the Matrix. If Employer elects APR, indicate APR Savings Program or PEPM below: ® APR Savings Program ❑ PEPM For APR capabilities other than Reimbursement Services: If Employer elects APR Savings Program, Claim Administrator will invoice the percentage indicated in the Fee Schedule of any recovered amounts identified by Claim Administrator or third -party vendor other than recovery amounts received as a result of or associated with any Workers' Compensation Law. Reimbursement Services: ® Yes ❑ No If yes, Claim Administrator will retain twenty-five percent (25%) of any recovered amounts made on third -party liability claims other than recovery amounts received as a result of or associated with anv Workers' Compensation Law. Third -Party Law Firms Provisions (other than Reimbursement Services): ❑ Yes ® No Employer will pay no more than 35% of any recovered amount made by Claim Administrator's third -party law firm or up to 35% of any recovered amount will be deducted from the amount distributed according to established allocation processes. Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except with written permission of Claim Administrator. TX GEN ASO BPA (Rev. 06/21) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, page 9 an Independent Licensee of the Blue Cross and Blue Shield Association Alternative Compensation Arrangements: Employer acknowledges and agrees that Claim Administrator has Alternative Compensation Arrangements with contracted providers, including but not limited to Accountable Care Organizations and other Value Based Programs. Further information concerning Employer's payment for covered services under such Arrangements is described in the Administrative Services Agreement between the Claim Administrator and the Employer. Virtual Visits Program: ❑ Yes ® No If yes, Covered Persons would be able to obtain certain Covered Services remotely via interactive video and/or interactive audio/video (where available) capability from Virtual Visits powered by MDLIVE. is a separate company that operates and administers Virtual Visits for persons with coverage through Blue Cross and Blue Shield of Texas. MDLIVE is solely responsible for its operations and for those of its contracted providers. MDLIVE° and the MDLIVE logo are registered trademarks of MDLIVE, Inc., and may not be used without permission. Termination Administrative Charges As applies to the Run -Off Period indicated in the Payment Specifications section above: The Termination Administrative Charge applicable to the Run -Off Period shall be equal to the sum of the amounts obtained by multiplying the total number of Covered Employees by category (per Covered Employee per individual or family composite) during the three (3) months immediately preceding the date of termination by the appropriate factors shown below. In the event of a partial termination, the Termination Administrative Charge shall be the sum of the amount obtained by multiplying three (3) times the total number of terminated Covered Employees by the appropriate factors shown below. Service 2022 Medical Run-off Administration Charge $15.16 $ $ $ Dental Run-off Administration Charge $0.00 $ $ $ Miscellaneous $ $ $ $ Miscellaneous $ $ $ $ Total: $15.16 $ $ $ 1. Summary of Benefits & Coverage: a. Will Claim Administrator create Summary of Benefits and Coverage (SBC)? ® Yes. (Please answer question b. The SBC Addendum is attached.) ❑ No. (If No, then skip question band refer to the Administrative Services Agreement for further information.) b. Will Claim Administrator distribute the (SBC) to Covered Persons? ❑ No. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the Agreement) and provide SBC to Employer in electronic format. Employer will then distribute SBC to Covered Persons (or hire a third party to distribute) as required by law. ® Yes. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the Agreement) and provide SBC to Employer in electronic format. Employer will then distribute to Covered Persons as required by law. ❑ Yes. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the Agreement) and distribute SBC to plan participants and beneficiaries via regular hardcopy mail or electronically. Distribution Fee for hardcopy mail is $1.50 per package.. 2. Massachusetts Health Care Reform Act: Does the Employer direct Claim Administrator to provide written statements of creditable coverage to its Covered Employees who reside, or have enrolled dependents who reside, in Massachusetts and file electronic reports to the Massachusetts Department of Revenue in a manner consistent with the requirements under the Massachusetts Health Care Reform Act? ® Yes ❑ No If no: The Employer acknowledges it will provide written statements and electronic reporting to the Massachusetts Department of Revenue if required by the Massachusetts Health Care Reform Act. Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except with written permission of Claim Administrator. TX GEN ASO BPA (Rev. 06/21) A Division of Health Care Serv: ce Corporation, a Mutual Legal Reserve Company, page 10 an Independent Licensee of the Blue Cross and Blue Shie/d Association 3. Alternative Care Management Program (applicable to the purchased medical management program): ❑ Yes ® No The undersigned representative authorizes provision of alternative benefits for services rendered to Covered Persons for Utilization Management, Case Management, including but not limited to Behavioral Health, and other health care management programs. 4. Prior Authorization (applicable to the purchased medical management program): Employer acknowledges and agrees to utilize Claim Administrator's standard list of services and supplies for which Prior Authorization (also called pre -notification or preauthorization) is required. 5. Essential Health Benefits ("EHB") Election: Employer elects EHBs based on the following: 1. ® EHBs based on a Claim Administrator state benchmark: ❑ Illinois ❑ Montana ❑ New Mexico ❑ Oklahoma ® Texas 2. ❑ EHBs based on benchmark of a state other than IL, MT, NM, OK and TX If so, indicate the state's benchmark that Employer elects: _ 3. ❑ Other EHB, as determined by Employer In the absence of an affirmative selection by Employer of its EHBs, then Employer is deemed to have elected the EHBs based on the Texas benchmark plan. 6. Employer contribution: Employer Contribution — Medical Employer Contribution — Dental • of Employee's premium, or $ % of Employee's premium, or $ % of Dependent's premium, or $ % of Dependent's premium, or $ Comments: 7. This ASO BPA is binding on both parties and is incorporated into and made a part of the Administrative Services Agreement between the parties with both such documents to be referred to collectively as the "Agreement" unless specified otherwise. 8. Producer/Consultant Compensation: The Employer acknowledges that if any its POR acts on its behalf for purposes of purchasing services in connection with the Employer's Plan under the Administrative Services Agreement to which this ASO BPA is attached, the Claim Administrator may pay the Employer's POR a commission and/or other compensation in connection with such services under the Agreement. If the Employer desires additional information regarding commissions and/or other compensation paid to the POR by the Claim Administrator in connection with services under the Administrative Services Agreement, the Employer should contact its POR. Additional Provisions: Client is renewing stop loss, therefore a $26,000 credit would apply for 2022. Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except with written permission of Claim Administrator. TX GEN ASO BPA (Rev. 06/21) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, page 11 an Independent Licensee of the Blue Cross and Blue Shield Association Signature HollyHerin Wallace Digitally signed by Holly Herin Wallace Y Date: 2021.11.22 13:38:54 -06'00' Sales Representative District Phone & FAX Numbers Producer Representative Producer Firm Producer Address Producer Phone & FAX Numbers Producer Email Address Tax I.D. No. Signature of Authorized Purchaser Title December 14, 2021 Date ATTEST: City ecretary / Rebecca t a Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except with written permission of Claim Administrator. TX GEN ASO BPA (Rev. 06/21) A Division o%Health Care Service Corporation, a Mutual Legal Reserve Company, page 1: nn InilononAonr I iron coo of rhs Rtn rr nnct wh Chiow Ac inrinn PROXY The undersigned hereby appoints the Board of Directors of Health Care Service Corporation, a Mutual Legal Reserve Company, or any successor thereof ("HCSC"), with full power of substitution, and such persons as the Board of Directors may designate by resolution, as the undersigned's proxy to act on behalf of the undersigned at all meetings of members of HCSC (and at all meetings of members of any successor of HCSC) and any adjournments thereof, with full power to vote on behalf of the undersigned on all matters that may come before any such meeting and any adjournment thereof. The annual meeting of members is scheduled to be held each year in the HCSC corporate headquarters on the last Tuesday of October at 12:30 p.m. Special meetings of members may be called pursuant to notice provided to the member not less than thirty (30) nor more than sixty (60) days prior to such meetings. This proxy shall remain in effect until either revoked in writing by the undersigned at least twenty (20) days prior to any meeting of members or by attending and voting in person at any annual or special meeting of members. From time to time, HCSC pays indemnification or advances expenses to its directors, officers, employees or agents consistent with HCSC's bylaws then in force and as otherwise required by applicable law. Group No.: 010097 By: Group Name: City of Lubbock Address: 1314 Avenue K City: Lubbock Dated this 14th day of STEVE MAS GAL MM PRO TEM - tvIayvi Signature and Title ATTEST: City Secretary Rebecca Garz 11-1 State: TX ZIP: 79401 December 2021 Month Year Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except with written permission of Claim Administrator. TX GEN ASO BPA (Rev. 06121) A Division o(Health Care Service Corporation, a Mutual Legal Reserve Company, page 13 nn i.d....A~ I iron of rh< Rluo rr i 4 Rluo ChinlA d ccn�inrinn