HomeMy WebLinkAboutResolution - 2013-R0428 - Purchase - Transplant Insurance - AIG Benefit Solutions - 12_12_2013RESOLUTION
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 AIG Benefit Solutions, 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 December 12, 2013
GLENI-V. WBERTSON, MAYOR
ATTEST:
Reb6cca Garza, City Secreta
APPROVED AS T CONTENT:
Leisa Hutcheson, Director of Human Resources &
Risk Management
APPROVE AS TO FORM:
Chad Weaver, Assistant City Attorney
vw/cedoes/RES.Risk Mgmt-AIG Benefit Solutions
November 6, 2013
E: nefit Solutions
Exhibit "A"
Jim Colwell
Underwriting Technician
AIG Benefit Solutions
800 634-7462 Telephone
714 436-3620 Facsimile
jim.colwetl@AigBenefits.com
October 29, 2013
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, 2014
Policy Number: 949-5683
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 AIG Benefit Solutions 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,
Jim Colwell
cc: Russ Jehs, Vice President, Organ Transplant Production Manger
AIG Benefit Solutions
One MacArthur Place. 6th Floor
South Coast Metro, CA 92707
0
One MacArthur Place Suite 620, South Coast Metro, CA 92707 Toll Free: 800-634-7462
Organ Transplant (Specified Disease) Proposal
Employer:
CITY OF LUBBOCK
Underwriter:
Josefina Panopio
Proposal:
119754
Sales:
Guy Finley
Producer:
McQueary Henry Bowles Troy, LLP
Quote Date:
10/29/2013
Claims Admin.:
Blue Cross and Blue Shield of Texas, a division of
Quote Valid Until:
01/01/2014
Carrier:
National Union Fire Insurance
Effective Date:
01/01/2014
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 :
$300 per day, $15,000 maximum for patient and companion. Coverage includes a
separate ambulance benefit.
Experimental :
Coverage for all phases of NCI Clinical Trials
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 Waiting
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 / Services : Please refer to policy specimen
Rate : $ 6.08 Single
$ 14.60 Family
Premium: $ 333,086.40
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 or any kind is made effective by this quote transmitted. Sales Representatives, and brokers or agents, have no authority to make effective coverage, or enter into contracts on
behalf or the company. Coverage will be effective only after: (1) a quotation is issued by the company; (2) a completed and signed application and disclosure is received by the company; (3) the
application is approved by the company; (4) Written notice confining effective coverage is issued by the company. This proposal supersedes all others previously issued to you, and all other
Proposals and Rate Quotations previously issued to you are void.
JCOLWELL 10/29/201319:43:41
Page 1 of 2
One MacArthur Place Suite 620, South Coast Metro, CA 92707 Toll Free: 800-634-7462
Organ Transplant (Specified Disease) Proposal
Employer:
CITY OF LUBBOCK
Underwriter:
Josefina Panopio
Proposal:
119754
Sales:
Guy Finley
Producer:
McQueary Henry Bowles Troy, LLP
Quote Date:
10/29/2013
Claims Admin.:
Blue Cross and Blue Shield of Texas, a division of
Quote Valid Until:
01/01/2014
Carrier:
National Union Fire Insurance
Effective Date:
01101/2014
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.
Contingencies
For All Producers / Groups
• Application must be received by AIG Benefit Solutions within 15 days of the effective date. Applications received later may be
subject to request for additional information and underwriting review of the proposed rates.
• All Value Propositions, Proposals and Quotes are not final until the Application is received, reviewed and approved.
• Explanation of any upcoming significant census changes (20%) within 30 days of effective date.
Underwriting approval is required to increase the lifetime maximum.
• Proposal assumes at least 80% of the participants reside in Texas.
• Contract period is for 12 months from effective date.
Our information indicates the Licensed Agent for this quote/proposal is Travis Sartain with McQueary Henry Bowles Troy, LLP. Only
appropriately licensed Agents can sell, solicit and negotiate insurance products with prospective AIG Benefit Solutions' customers'.
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
pooleu r tes in ordi,..., determine our final underwriting posltion.)
No coverage or any kind is made effective by this quote transmitted. Sales Representatives, and brokers or agents, have no authority to make effective coverage, or enter into contracts on
behalf of the company. Coverage will be effective only after: (I) a quotation is issued by the company; (2) a completed and signed application and disclosure is received by the company; (3) the
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 all other
Proposals and Rate Quotations previously issued to you are void.
JCOLWELL 10129/201319:43:41
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 part of your Certificate issued in relation to the following
Organ & Tissue Transplant Policy:
Policyholder: City of Lubbock
Policy Number: 949-6683
Original Policy Effective Date: JanuarV1. 2006
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.
y JY/�(JJ
4
President
OT-2009-RENEWAL-TX
9 rr+
abut
Secretary
(Rev. 5/2010 - Cert)
POLICY YEAR:
COVERED TRANSPLANTS:
RENEWAL SCHEDULE OF BENEFITS
January 1, 2013 through December 31, 2013
® 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 Marrow/Peripheral 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. 5/2010 - Cert)
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:
MAXIMUM BENEF11. FOR.ALL`:
COVERED TRANSPLANT
COVERED TRANSPLANT' PFiQGEt]IJRE �S�Ii�VIOF F'RC�VIDED BY A
NONfP,ARTiG:1PdTIN
1`�tAN$15LANT'FACILITY
Heart
1 $437,000
Lung (Single)
$261,000
Lung Double
$363,000
Kidney (living or deceased donor)
$156,000
Pancreas
$163 000
Liver (living or deceased donor) _
--In
Intestine
$196,000
$626,000
Heart/LungHeart/Lung
$495,000
Kidney/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 Chemotherapy
$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. 5/2010 - Cert)
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. 5/2010 - Cert)
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 part of the following Organ & Tissue Transplant Policy:
Policyholder: City of Lubbock
Policy Number: 949-5683
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. 3/2009)
RENEWAL SCHEDULE OF BENEFITS
POLICY YEAR: January 1, 2013 through December 31, 2013
CURRENT ENROLLMENT: 2757
MINIMUM ENROLLMENT: 250
PREMIUMS PER MONTH:
Single Employee $6.84 Family $15.72
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 Marrow/Peripheral 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.
0"r-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 PROLE SURE
MAXIMUM BENEFIT FOR.
COVERED TRANSPLANT :
SERVICES PROVIDED BY A
.' NQNPAf2T'ICIPATING
TRAt�LSpLANT. FACILITY
Heart
$437,000
Lung (Single)
$261,000
Lung Double
$363,000
Kidney (living or deceased donor) _
$156,000
Pancreas
$163,000
Liver (living or deceased donor)
$196,000
Intestine
$626,000
Heart/Lung
$4951000
Kidney/Pancreas
_ _
$200,000
Kidney/Liver
$419,000
Liver/Intestine �- 4 J __
$700,000
-_ _
-Pancreas/Intestine`
_ $668,000
$716,000
_Liver/Pancreas/Intestine
Autologous Bone Marrow/Peripheral Stem Cell
Including High Dose Chemotherapy_
$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)