HomeMy WebLinkAboutResolution - 2016-R0360 - Renew Transplant Insurance Coverage - AIG Benefit Solutions - 10/13/2016Resolution No. 2016-RO360
Item No. 6.18
October 13, 2016
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
renew 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 on October 13,2.01-6—
DANIEL M. POPE, MAYOR
ATTEST:
R"caGarza, City Se ret
APPROVED AS TO CONTENT:
Leisa Hutcheson
Director of Human Resources & Risk Management
RES Risk Mgmt-AIG Benefit Solutions
9.9.16
Resolution No. 2016-RO360
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:
169526
Sales:
Guy Finley
Producer:
Marsh & McLennan Agency LLC
Quote Date:
08/17/2016
Claims Admin.:
Blue Cross and Blue Shield of Texas, a division of
Quote Valid Until:
01/01/2017
Carrier:
National Union Fire Insurance
Effective Date:
01/01/2017
This proposal contemplates the utilization o/ 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:
$ 356,683.20
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 to make effective coverage, or enter Into contracts on
behalf of 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 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 08 17/2016 13.34.11 Page 1 of 2
AICA Benefit Solutions
One MacArthur Place Suite 620, South Coast Metro CA 92707 Toll Free: 800-634-7462
Organ Transplant (Specified Disease) Proposal
Nam
Employer:
CITY OF LUBBOCK
Underwriter:
Josefina Panopio
Proposal.
169526
Sales:
Guy Finley
Producer.
Marsh & McLennan Agency LLC
Quote Date:
08/17/2016
Claims Admin.
Blue Cross and Blue Shield of Texas, a division of
Quote Valid Until:
01/01/2017
Carrier.
National Union Fire Insurance
Effective Date:
01/01/2017
This proposal contemplates the uhiization of the above captioned Claims Administrator Any deviation is a material change of fact rendering this proposa' null and vo d
Contingencies
For All Producers / Groups
Explanation of any upcoming significant census changes (20%) within 30 days of effective date.
• Underwriting approval is required to increase the lifetime maximum.
• Retirees are covered.
• Contract period is for 12 months from the effective date.
• Our information indicates that the licensed broker for this quote. proposal is Travis Sartain with Marsh & McLennan Agency LLC. Only
appropriately licensed brokers 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
pooled rates in order to determine our final underwriting position.)
4I.S.,
Signature of Autho "zed Purchaser
Daniel M. Pope, Mayor _
Title Of Authorized Purchaser
October 13, 2016
Date
No coverage of 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. (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 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 08/17/2016 1334.11 Page 2 of 2
ATTEST:
.0 0,0'e, ' -,A,
Reb cca Garza
City ecretary
APPROVED AS TO CONTENT:
Leisa Hutcheson, Director of
Human Resources and Risk Mgmt.
APPR'.� LFORM:
"
Q
Mitchell Satterwhite
17
First Assistant City Attorney
AIG Benefit Solutions
Jim Colwell
Underwriting Technician
AIG Benefit Solutions
300 634-7462 Telephone
714 436-3620 Facsimile
jim.coWell@AigBenetits.com
August 17, 2016
Travis Sartain
Marsh & McLennan Agency LLC
8144 Walnut Hill Lane, 16th
Dallas, TX 75231
Re: Renewal of Organ & Tissue Transplant Policy
Policyholder: City of Lubbock
Policy Anniversary Date: January 1, 2017
Policy Number: 947-2088
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
/-uG pere..
One Mac.Aithur Place, 601 Floo,
South Coast Metro. CA 92707
NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA.
Executive Offices: 175 Water Street, 15th Floor, New York, NY 10038
(212) 458-5000
(a capital stock company, herein referred to as the Company)
Administrative Office:
AIG Benefit Solutions
7330 Woodland Drive, Suite 250
Indianapolis, Indiana 46278
(888) 449-2377
Specified Disease Renewal Endorsement
Organ & Tissue Transplant
This Endorsement is attached to and made a part of the following Specified Disease Policy:
Policyholder: City of Lubbock
Original Policy Number:
Original Policy Effective Date: January 1, 2014
It is agreed that the above referenced Specified Disease 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
S DOT -2014 -REN EW AL -TX
1 of 4
Secretary
(Policy)
NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA.
Executive Offices: 175 Water Street, 15th Floor, New York, NY 10038
(212) 458-5000
(a capital stock company, herein referred to as the Company)
INDEMNITY ENDORSEMENT
TO BE ATTACHED TO AND MADE A PART OF POLICY NO.
EFFECTIVE January 1, 2017 ISSUED TO City of Lubbock
BY NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA.
It is agreed that the above Policy is endorsed, effective January 1. 2017, as stated below.
The following provision has been added to the Policy/Certificate.
TRANSPLANT INDEMNITY PROVISION
In the event you obtain a Covered Transplant Procedure, we will pay $5,000 directly to you within 60
days after receiving required proof that the Covered Transplant Procedure has occurred. We may pay
benefits directly to any relative we deem appropriate if a benefit is payable and you are: 1) a minor; 2)
legally incapable of giving valid receipt and discharge of payment; or 3) deceased.
This Endorsement ends at the same time as the Policy, and is subject to all of the terms, limitations and conditions
of the Policy, except as stated above.
IN WITNESS WHEREOF, the Company has caused this Endorsement to be executed as of the Effective Date
shown above.
President
SDOT-2014-INDEMNITY-TX-ER
Secretary
RENEWAL SCHEDULE OF BENEFITS
POLICY YEAR: January 1, 2017 through December 31, 2017
RENEWAL POLICY NUMBER:
CURRENT ENROLLMENT: 2790
MINIMUM ENROLLMENT: 50
PREMIUMS PER MONTH:
Single Employee $6.08 Family $14.60
® Heart
® Lung/Double Lung
® Kidney (living/deceased donor)
® Pancreas
® Liver (living/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)
® Cord Blood
Including High Dose Chemo
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, if applicable;
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.
SDOT-2014-REN EWAL-TX
Page 2 of 4
(Policy)
RENEWAL SCHEDULE OF BENEFITS
(Continued)
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.
REIMBURSEMENT AMOUNTS:
A. PARTICIPATING PROVIDER: ............ 100% of Covered Charges for Covered Transplant Services
provided through a Participating Transplant Provider.
B. NONPARTICIPATING PROVIDER: ...... 80% of Covered Charges for Covered Transplant Services provided
through a Nonparticipating Transplant Provider with respect to the
type of Covered Transplant Procedure performed. Benefits for
Covered Transplant Services provided through a Nonparticipating
Transplant Provider will not exceed the Maximum Amounts stated
below:
COVERED TRANSPLANT PROCEDURE
MAXIMUM BENEFIT FOR ALL
COVERED TRANSPLANT
SERVICES PROVIDED BY A
NONPARTICIPATING
TRANSPLANT PROVIDER
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
$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.
SDOT-2014-RENEWAL-TX Page 3 of 4 (Policy)
RENEWAL SCHEDULE OF BENEFITS
(Continued)
ENDORSEMENTS: Yes ® No ❑
If yes, please specify:
Indemnity Endorsement
POLICYHOLDER'S MEDICAL PLAN ADMINISTRATOR:
Blue Cross and Blue Shield of Texas, a division of Health Care Service Corp.
SDOT-2014-RENEWAL-TX Page 4 of 4 (Policy)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.2, ,
CERTIFICATE OF INTERESTED PARTIES
FORM 2295
loll
Complete Nos. 1- 4 and 6 if there are interested parties.
Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.
OFFICE USE ONLY
CERTIFICATION OF FILING
Certificate Number:
2016-111950
Date Filed:
09/14/2016
Date Acknowledged:
09/19/2016
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
AIG
Dallas, TX United States
2 Name of governmental entity or state agency that is a party to the contract for which the form is
being filed.
City of Lubbock
3
Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a
description of the services, goods, or other property to be provided under the contract.
AIG -13063
Organ Transplant Insurance
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
I Intermediary
Sartain, Travis
Dallas, TX United States
X
5
Check only if there is NO Interested Party. ❑
6
AFFIDAVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct.
Signature of authorized agent of contracting business entity
AFFIX NOTARY STAMP / SEAL ABOVE
Sworn to and subscribed before me, by the said this the day of
20 , to certify which, witness my hand and seal of office.
Signature of officer administering oath Printed name of officer administering oath
Title of officer administering oath
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.2, ,
CERTIFICATE OF INTERESTED PARTIES
Complete Nos. 1 - 4 and 6 if there are interested parties.
Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
AIG
Dallas, TX United States
imams ur governmental entity or state agency that is as
being filed.
City of Lubbock
FORM 1295
loft
OFFICE USE ONLY
CERTIFICATION OF FILING
Certificate Number:
2016-111950
Date Filed:
09/14/2016
Date Acknowledged:
3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a
description of the services, goods, or other property to be provided under the contract.
AIG -13063
Organ Transplant Insurance
4
Name of Interested Party
Sartain, Travis
City, State, Country (place of business)
Dallas, TX United States
Nature of interest
(check applicable)
Controlling
Intermediary
X
5 Check nniu if 4h— ie nen i..•e.e�•...1 n -
6 AFFI AVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct.
LtND. AY M.' FERLAUTO
NoPublip
C0IWQNNIE+ILTH TM OF
WMY Commhelon Eq*6e Signature of authorized agent of contracting business entity
Fehr 1, 2022
AFFIX NOTARY STAMP / SEAL ABOVE
Sworn to and subscribed before me, by the said /D.4 164— t/- "A(tfXIO , this the (5 day of
20 1 k O , to certify which. witness my hand and seal of office.
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
Forms provided by Texas Ethics Commission www.ethics.state.tx.us varcinn v, 11 7