HomeMy WebLinkAboutResolution - 2007-R0539 - Specific And Aggregate Stop Loss Insurance - High Mark Life Insurance Co. - 11/20/2007Resolution No. 2007-RO539
November 20, 2007
Item No. 5.4
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, specific and aggregate stop
loss insurance coverage, by and between the City of Lubbock and High Mark Life
Insurance Company pursuant to the terms and conditions attached hereto as Exhibit "A"
within the amount budgeted for said coverage, 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, for the City's health benefits program; 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 20th day of November , 2007.
Leisa Hutcheson, Director of Risk Manager
19101TA 91 off." k*N 03W13 IN UV
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gs/ccdocshiigh Mark Life Ins Cores
11/08107
DAVID A. MILLER, MAYOR
Stop Loss Proposal for
Resolution No. 2007—RO539
mil City of Lubbock
E t! I f V,t R rvc r EXHIBIT "A"
C(}rI1"%tip Carrier: HM Life Insurance Company
Effective Date: 11112008
Sales Representative: Albert Lucio, Dallas Sales Office
TPA: HCSC - BCBS of Texas
Broker: Wachovia Insurance Services, Inc.
Lives
ICURRENT
RENEWALI
OPTION 1I
OPTION 2
SPECIFIC
Specific Deductible (per Covered Person)
$175,000
$175,000
$200,000
$225,000
Lifetime Maximum Specific Benefit
$825,000
$1,825,000
$1,800,000
$1,775,000
Covered Benefits
Medical, Rx
Medical, Rx
Medical, Rx
Medical, Rx
Specific Premium
Single Rate
1327
$8.33
$9.10
$7.60
$6.36
Family Rate
1120
$19.48
$21.34
$18.22
$15.52
2447
Estimated Contract Specific Premium
$394,458
$431,718
$365,899
$309,865
Contract Basis
12115
12/15
12115
12115
Commission
0.0%
0.0%
0.0%
0.0%
AGGREGATE
Covered Benefits
Medical, Rx
Medical, Rx
Medical, Rx
Medical, Rx
Policy Year Maximum
$1,000,000
$1,000,000
$1,000,000
$1,000,000
Aggregate Factors
Composite Medical Factor
2,447
$499.36
$499.36
$502.86
$505.35
Composite Rx Factor
2,447
$142.93
$144.36
$145.37
$146.10
Estimated Contract Attachment Point
4,894
$18,860,204
$18,902,194
$19,034,626
$19,129,178
Contract Minimum Attachment Point (100%)
$18,860,204
$18,902,194
$19,034,626
$19,129,178
Aggregate Corridor
120%
120%
120%
120%
Contract Basis
12115
12115
12115
12115
Aggregate Premium
Composite Rate
2,447
$2.05
$2.17
$2.18
$2.19
Estimated Contract Aggregate Premium
2,447
$46,519
$63,720
$64,014
$64,307
Commission
0.0%
6.0%a
0.0%
0.0%
TOTAL COMBINED CONTRACT PREMIUM
$440,977
$495,438
$429,913
$374,173
` This proposal is not complete unless accompanied by the Basis of Offer noted in the next page.
Please acknowledge acceptance of the above terms by signing and returning the proposal no later November 21, 2007.
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
Accepted the day of 20
Coverage provided under policy form HL6901 (905); in certain states the requested coverage may not be available, or may be
underwritten by Highmark Life Insurance Company.
Underwriter: DEW 1110812007 03:25 PM
HM Life Insurance Company Stop Loss Insurance
Basis of Offer
Group Name: City of Lubbock 1118/2007
Assumptions
Initials: Date:
* This proposal is based on duplication of the current plan of benefits with the amendments as requested by the city via e-mail 10/2312007,
including utilization of the BCBS TX network and the HCSC - BCBS of Texas Utilization Review vendor.
* 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 benefits provided, 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 B.18% bad debt and charity surcharge portion of the New York Reform Act will be applicable under the stop loss.
* All standard Policy provisions apply. Certain exclusions, limitations and laws of the state where the Policy is issued, may apply. Please contact
your HMIG Sales Representative for details.
* Retirees are included in the stop loss coverage.
* This proposal will expire November 21, 2007.
* Eligible claim expenses arising out of any treatment for human organ transplants will not exceed $0 per lifetime.
* Minimum aggregate deductible percentage will be 100%.
* Expenses arising out of any treatment for mental or nervous disorders will follow the underlying plan.
* Expenses arising out of any treatment for drug or substance abuse or alcoholism will follow the underlying plan.
* The Agent is properly licensed and appointed by HMIG.
* The initial rate guarantee is 12 months from the approved effective date.
* There are not more than 5% COBRA participants.
Qualifications
* Actively -at -work, disabled, hospital confined, or similar provisions will apply unless a completed and signed Disclosure Form, or other information
acceptable to HMIG, is received and approved by underwriting. Other information acceptable by HMIG must be approved prior to final
underwriting acceptance.
* Should the number of employees, either in total and/or by single/family mix, change by 10% or more, both the premium rates and the aggregate
retention factors are subject to change.
* A signed and dated Plan Document is required within 60 days of the proposed effective date. If the description of the benefits or plan provisions
differ from what was initially utilized to underwrite the risk, the premium rates and aggregate retention factors may be subject to re -rating, retro-
active to the effective date.
* HIPAA Privacy rules permit the release of Protected Health Information (PHI) for the purpose of evaluating and accepting risk associated with the
Plan Sponsor as part of "Health care operations". HMIG will use this information solely for the purpose of evaluating and accepting the risk and
will not disclose any PHI collected except to perform this risk evaluation.
* Individual Special Requirements:
Specific
Individual Deductible Required Information
Current Policy Individual Limitations to be continued
Underwriter: DEW 11!0812007 03:25 PM
HM Life Insurance Company Stop Loss Insurance
Exclusions
Group Name: City of Lubbock 111$!2007
EXCLUSIONS Initials: Date:
* Any amount incurred 1 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.
* 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 1 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.
* 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: DEW 11/08/2007 03:25 PM