HomeMy WebLinkAboutResolution - 2010-R0565 - Contract 9861 HM Life Insurance Company For City's Health Program - 11/15/2010Resolution No. 2010-RO565
November 15, 2010
Item No. 5.2
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK
THAT the Mayor of the City of Lubbock BE and is hereby authorized and
directed to purchase for and on behalf of the City of Lubbock and its health benefits
program, specific and aggregate stop loss insurance coverage, by and between the City of
Lubbock and HM Life Insurance Company pursuant to the terms and conditions attached
hereto as Exhibit "A"; offering the same benefits as set forth in Exhibit "A" hereto; for
which the individual -specific per -member, per -month premium amount shall not exceed
$6.72 for a single employee and $18.90 for a family; for which the per -member, per -
month aggregate premium amount shall not exceed $2.31; and in a final form and
substance acceptable to the City Manager and City Attorney, as well as execute any
related documents required in connection therewith; 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 15_ 2010.
APPROV AS TO CONTENT:
L
Leisa Hutcheson, Director of Risk Management
APPROVED TO FORM:
r
i c City Attorney
gs ccdocs l Iigh Mark Ole Insurance Resolution. 10
1029 10
TOM MARTIN, MAYOR
STOP LOSS PROPOSAL FOR
City of Lubbock
Sales Representative: J. Albert Lucio
Broker: No Writing Agent
TPA: HCSC - BCBS of Texas (Austin)
Provider Network(s): HCSC - BCBS of Texas (Austin)
Utilization Review Vendor(s): Blue Cross Blue Shield of Texas
Specific Deductible (per Covered Individual)
Lifetime Maximum Specific Benefit
Covered Benefits
Resolution No. 2010—RO565
Effective Date: 01/01/2011
Through Date: 12/31/2011
$350,000 $350,000 $350,000
$1,650,000 $1,650,000 Unlimited
Med, Rx Card Med, Rx Card Med, Rx Card
Specific Premium
Med, Rx Card
Med, Rx Card
Single Rate
1,343 $4.85
$5.44
$6.72
Family Rate
1,263 $13.15
$15.45
$18.90
Total Lives
2,606
_
Composite Medical Factor
Estimated Contract Specific Premium
$277,464
$321,831
_
$394,748
Contract Basis
12/15
12/15
12/15
Commission
0.00%
0.00%
0.00%
Covered Benefits
Med, Rx Card
Med, Rx Card
Med, Rx Card
Policy Year Maximum
$1,000,000_
$_1,000,000
$1,000,000
Aggregate Factors
_
Composite Medical Factor
2,518
$661.37
$646.50
$646.50
Composite Rx Card Factor
2,518
$164.21
$182.53
$182.53
Estimated Contract Attachment Point
$24,945,725
$25,049,970
$25,049,970
Contract Minimum Attachment Point (100%)
$24,945,725
$25,04.9,970
$25,049,970
Aggregate Corridor
125%
125%
125%
Contract Basis
12/15
12/15
12/15
Aggregate Premium
Composite Rate
2,606
$2.40
$2.31
$2.31
Estimated Contract Aggregate Premium
2,606
$75,053
$72,238
$72,238
Commission
0.00%
0.00%
0.00%
Total Combined Estimated Contract Premium
$352,517
$394,070
$466,986
rk,
LIFE INSURANCE
COMPANY
Note: This proposal is not complete unless accompanied by the proposal notes, the basis of offer and the exclusions noted on the following
pages.
Individual Special Requirements:
Underwriter. BKS (October 28, 20 10) 10077873163-2010.96999-5-7 Page 1 of 4
STOP LOSS PROPOSAL FOR A mn
City of Lubbock LIFE INCOMPANY
PROPOSAL NOTES
• The rates and factors in this proposal are firm. You have 30 days to provide a signed proposal.
PROPOSAL ACCEPTANCE
Please acknowledge acceptance of the terms in this proposal by returning this proposal no later than 15 days from the proposal effective date.
Please also indicate which option is chosen and whether Aggregate is to be included, by checking the appropriate boxes on the previous page.
Failure to remit the signed agreement within the same period will result in updated large claim disclosure (and claims) being required for our review.
Signature: Title: Mayor
Tom Martin
Accepted on the 15th day of November, 20 10
ATTEST:
Rebekca Garza, City Secre tn
APPROVED A TO CONTENT:
k
Leisa Hutcheson, Director Human Resources
APPROVED AS T
Iww
-dify Attorney
Stop Loss coverage is underwritten by HM Life Insurance Company, Pittsburgh, PA, under policy form HL 601 (905) or similar, in
certain states the requested coverage may not be available. As included herein, "HMIG" refers to the Stop Loss carrier
Underwriter: BKS (October 28, 2010) 10077873163-2010-96999-5-7 Page 2 of 4
STOP LOSS PROPOSAL FOR (Rk
NSURANCE
City of Lubbock LIFE I COMPANY
initials-4140"— date: 11/15/10
BASIS OF OFFER
Assumptions
b Aggregate coverage is only available when purchased with Specific coverage.
This proposal is subject to revision if there is a change in effective or renewal dates, or a change in the plan of benefits.
This proposal is based on the utilization of the Provider Network(s) and the Utilization Review Vendor(s) listed on this proposal.
This proposal assumes a minimum participation level of 75% applies for all eligible enrollees under a contributory plan, and 100% under a non-
contributory plan.
This proposal assumes the plan of benefits includes a pre-certification, utilization review and large case management program with a benefit
penalty for non-compliance.
This proposal is based on a description of the employee benefit plan(s) provided and approved by HMIG, employee and dependent census data,
plus any other information relevant to the underwriting risk. If any of the information was incorrect or changes the risk involved, the rates and
factors will be modified, and the specific and aggregate claims will be adjusted accordingly.
The bad debt and charity surcharge portion of the New York Reform Act will be applicable under the stop loss if services are rendered in New
York State. Other surcharges, pool charges and/or covered lives assessments will not be covered under the stop loss.
a All standard Policy provisions apply. Certain exclusions, limitations and laws of the state where the Policy is issued, may apply. See "Exclusions"
for details.
n Retirees are included in the stop loss coverage.
z This proposal will expire 15 days after the proposed effective date.
Human Organ Transplant benefits are payable in accordance with the underlying plan and subject to the individual lifetime maximum.
ry Lifetime Maximum Specific Benefit will follow underlying plan, up to the proposed maximums offered within this proposal.
Expenses arising out of any treatment for mental or nervous disorders will follow the underlying plan.
Expenses arising out of any treatment for drug or substance abuse or alcoholism will follow the underlying plan.
The Agent is properly licensed and appointed by HMIG.
. The initial rates are guaranteed for the proposed policy period, unless otherwise noted.
There are not more than 5% COBRA participants.
Qualifications
Should the number of employees, either in total and/or by single/family mix, change by 10% or more, the premium rates are subject to change,
y If the descriptions of the benefits or plan provisions differ from what was initially utilized to underwrite the risk, an updated Plan Document or other
acceptable plan description is required within 60 days of the proposed effective date, and the premium rates and aggregate retention factors may
be subject to re -rating, retro -active to the effective date.
F HIPAA Privacy rules permit the release of Protected Health Information (PHI) for the purpose of evaluating and accepting risk associated with the
Plan Sponsor as part of "Health care operations". HMIG will use this information solely for the purpose of evaluating and accepting the risk and
will not disclose any PHI collected except to perform this risk evaluation.
Underwriter: BKS (October 28, 2010) 10077873163-2010-96999-5-7 Page 3 of 4
STOP LOSS PROPOSAL FOR
City of Lubbock
EXCLUSIONS
LIFE INSURANCE
COMPANY
initials:A&/ date: 11/15/1
• Any amount incurred I paid: (1) when the underlying medical plan is not in effect; by a person who is not a plan participant; (2) not specifically
covered by the underlying medical plan; or (3) by any plan that has not been identified as included; or (4) that the policyholder is not required to
pay in accordance with the terms of the underlying medical plan.
Caused or contributed to by war or an act of war unless a person is required to be in a location where a war or act of war has or may occur as a
condition of employment.
For any injury or illness which is eligible for coverage under a workers' compensation or occupational disease policy or agreement, whether or not
such policy or agreement is actually in force and whether or not such benefits are received (subject to applicable laws).
Caused or contributed to by a person committing or attempting to commit an assault or felony, participating in an illegal occupation, or actively
participating in a violent disorder or riot (does not include being at the scene of a violent disorder or riot while performing his or her official duties).
Treatment received in person, by mail or otherwise outside the U.S. if the purpose of such travel or communication is to obtain treatment.
Expense incurred prior to the initial incurred date, or the date another affiliate I class of employees is acquired or established.
Any known medical conditions not accurately Disclosed prior to the effective date, the date another affiliate is acquired, another class of
employees established, the date of renewal, or upon request the date a person becomes eligible for benefits through the underlying medical plan.
For drugs, procedures, services, supplies or treatments which are considered experimental or investigational, or which are not medically
necessary and appropriate.
For any expenses for benefits payable by another medical plan, which when combined with the benefits payable through the underlying medical
plan would cause the total benefits payable to exceed 100% of the person's actual expenses.
fi Amounts paid for administrative costs, including but not limited to, administrative costs for claim payments, networks, case management fees, in
excess of the usual and customary charge, PPO access fees and Prescription Drug administration fees.
For a person's out-of-pocket expense(s), or any amount incurred by a person for the cost of drugs, procedures, services, supplies or treatment in
excess of any reimbursement negotiated with, scheduled to be paid or due a provider or facility.
• Amounts over fee, reimbursement percentage or other form of payment negotiated with a provider or facility as total reimbursement to the provider
or facility.
• Excluded claim expenses.
• Capitation fees.
• For the expense of litigation, extra contractual damages, compensatory damages, or punitive damages.
Lost provider discounts due to untimely payment of claims.
Underwriter. BKS (October 28, 2010) 10077873163-2010-96999-5-7 Page 4 of 4