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Home My WebLink AboutResolution - 2020-R0320 - Purchase of Individual Stop-Loss CoverageResolution No. 2020-RO320 Item No. 7.15 September 22, 2020 RESOLUTION 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 and renew for and on behalf of the City of Lubbock and its health benefits program, specific stop loss insurance coverage from B1ueCross BlueShield of Texas, consistent with the terms and conditions attached hereto, and all related documents. Passed by the City Council this 22ndday of September, 2020. ATTEST: La Rebecca Garza, City Secretary APPROVED AS TO CONTENT: Bill How n, pu City Manager City Attorney ccdocs/RES.Stop Loss Renewal August 25, 2020 L'-'-11V DANIEL M. POPE, MAYOR Resolution No. 2020-RO320 •A-M.-B1ueCross BlueShield of Texas a • APPLICATION FOR STOP LOSS COVERAGE Employer Group Name: City of Lubbock Employer Group Address: 162513th Street City: Lubbock State of Situs: TX Zip Code: 79401 Account Number: 010097 Employer Group Number(s): 219476 Current Effective Date of Policy 01/01/2021 Current Policy Period: These specifications are for the Policy Period commencing on 01/01/2021 and ending on 12/31 /2021 The specifications below shall become effective on the first day of the Policy Period specified above and shall continue in full force and effect until the earliest of the following dates: (1) The last day of the Policy Period; (2) The date the Policy terminates; or (3) The date this Application is superseded in whole or in part by a later executed Application. A. Aggregate Stop Loss Coverage: ❑ Yes ® No If yes, complete items 1 through 9 below. 1. ❑ New Coverage ❑ Renewal of Existing Coverage 2. Stop Loss Coverage during the current Policy Period: ❑ New Coverage (Select one from below): ❑ Incurred and paid during the Policy Period: ❑ Incurred with Run -Out: ❑ Run-in coverage: Claims incurred and paid from Claims incurred from to and Claims paid from to Claims incurred from to and Claims paid from to to If coverage is for claims incurred prior to the effective date of the Policy and paid by Policyholder's prior claim administrator, then such claims must be reported by the Policyholder to the Company (Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company) and paid by the Policyholder's prior claim administrator by the end of the current Policy Period. ❑ Renewal of Existing Coverage: ❑ Claim Administrator's Claims: Claims incurred on or after the original Effective Date of Policy and paid during the Policy Period. ❑ Incurred with Run -Out: Claims incurred from to and Claims paid from to A Division of Health Care Service Corporation, a Mutual Legal Reserve Company an Independent Licensee of the Blue Cross and Blue Shield Association TXStopLossApp-06/17 3. Aggregate Stop Loss Coverage shall apply to: ❑ Medical Claims ❑ Outpatient Prescription Drug Claims with Company's Pharmacy Benefit Manager ❑ Outpatient Prescription Drug Claims with Policyholder's Pharmacy Benefit Manager: ❑ Dental Claims ❑ Other (please specify): 4. Average Claim Value: (per Employee per Month) Attachment Factor: % of the Average Claim Value 5. Aggregate Claim Liability and Run -Off Claim Liability Factors a. Employer's Claim Liability for each Policy Period shall be the sum of the Monthly amounts obtained by multiplying the number of Individual and Family Coverage Units for each Month by the following factors: $ for each Coverage Unit $ for each Family Coverage Unit Please use the continuous text field directly below for any other structure (leaving the fields above blank). Note: you can use the "return" key to create additional rows, if needed: b. Employer's Run -Off Claim Liability shall be calculated by multiplying the sum average of the total of all Coverage Units during each of the three calendar Months immediately preceding termination by the factors shown below. Settlement for the final accounting period will be described in the section of the Policy entitled SETTLEMENTS. $ for each Coverage Unit $ for each Family Coverage Unit Please use the continuous text field directly below for any other structure (leaving the fields above blank). Note: you can use the "return"key to create additional rows, if needed: 6. CAP Arrangement ❑ Yes ❑ No 7. Aggregate Stop Loss Claims a. The amount of Paid Claims during the current Policy Period, less: i. Individual (Specific) Stop Loss Claims ii. Any claims in excess of the Individual (Specific) Stop Loss Claims per Covered Person per Lifetime Maximum iii. Any claims in excess of the Individual (Specific) Stop Loss Claims maximum Point of Attachment that exceeds the Aggregate Point of Attachment. The Aggregate Point of Attachment shall equal the sum of the Employer's Claim Liability amounts calculated Monthly as described in item A.5.a. above for the current Policy Period. b. In the event of termination at the end of a Policy Period, the Final Settlement Aggregate Point of Attachment shall equal the sum of the Employer's Claim Liability amount for the Final Policy Period and the Employer's Run -Off Claim Liability calculated as described in item A.5.b. above. However, for the current Policy Period the minimum Aggregate Point of Attachment shall be $ TXStopLossApp-06/17 2 8. Stop Loss Premium (Select one): ❑ Annual Premium (Due on the first day of the current Policy Period): $ ❑ Monthly Premium shall be equal to the amounts obtained by multiplying the number of Individual and Family Coverage Units for a particular Month by: $ for each Coverage Unit $ for each Family Coverage Unit Please use the continuous text field directly below for any other structure (leaving the fields above blank). Note: you can use the "return"key to create additional rows, if needed: 9. The premium is based upon a current membership of Individual Coverage Units and Family Coverage Units. B. Individual (Specific) Stop Loss Coverage: ® Yes ❑ No If yes, complete items 1 through 6 below. 1. ❑ New Coverage ® Renewal of Existing Coverage 2. Stop Loss Coverage Period: ❑ New Coverage (Select one from below): ❑ Incurred and paid during the Policy Period: ❑ Incurred with Run -Out: ❑ Run-in coverage: Claims incurred and paid from to Claims incurred from to and Claims paid from to Claims incurred from to and Claims paid from to If coverage is for claims incurred prior to the effective date of the Policy and paid by Policyholder's prior claim administrator, then such claims must be reported by the Policyholder to the Company (Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company) and paid by the Policyholder's prior claim administrator by the end of the current Policy Period. ® Renewal of Existing Coverage: ❑ Claim Administrator's Claims: Claims incurred on or after the original Effective Date of Policy and paid during the Policy Period. ® Incurred with Run -Out: Claims incurred from 01/01/2021 to 12/31/2021 and Claims paid from 01 /01 /2021 to 03/31 /2021 3. Individual (Specific) Stop Loss Coverage shall apply to: ® Medical Claims ® Outpatient Prescription Drug Claims with Company's Pharmacy Benefit Manager ❑ Outpatient Prescription Drug Claims with Policyholder's Pharmacy Benefit Manager: ❑ Dental Claims ❑ Vision Claims TXStopLossApp-06/17 3 ❑ Other (please specify): 4. Individual (Specific) Stop Loss Claims a. For NA who is identified by the health identification (ID) number NA, the amount of Paid Claims during the current Policy Period in excess of the Individual Point of Attachment of $NA. Such amount shall apply for the current Policy Period. b. For each other Covered Person: The amount of Paid Claims during the current Policy Period in excess of the Individual Point of Attachment of $700,000 per Covered Person but not to exceed a maximum Point of Attachment of $ UNLIMITED per Policy Period. Paid Claims in excess of the maximum point of attachment shall not be eligible to satisfy the Aggregate Point of Attachment. Such amount shall apply for the current Policy Period. c. Covered Person per Lifetime Maximum: The Individual (Specific) Stop Loss Claims shall not exceed UNLIMITED per Covered Person per Lifetime. Paid Claims in excess of the Covered Person per Lifetime Maximum shall not be eligible to satisfy the Aggregate Point of Attachment. Point of Attachment ® Includes Claim Administrator's Provider Access Fee ❑ Excludes Claim Administrator's Provider Access Fee 5. Stop Loss Premium (select one): ❑ Annual Premium (Due on the first day of the current Policy Period): $ ® Monthly Premium shall be equal to the amounts obtained by multiplying the number of Individual and Family Coverage Units for a particular Month by: for each Coverage Unit $ for each Family Coverage Unit Please use the continuous text field directly below for anv other structure (leaving the fields above blank) Note: you can use the "return" key to create additional rows, if needed. $13.93 Composite 6. The premium is based upon a current membership of 1,233 Individual Coverage Units and 1,292 Family Coverage Units. Additional Provisions: Stop Loss Policy - Claims incurred 01 /01 /201 through 12/31 /2021 and paid 01 /01 /2021 through 03/31 /2021 Premium is based on 2,525 TXStopLossApp-06/17 4 The undersigned person represents that he/she is authorized and responsible for purchasing stop loss coverage on behalf of the Employer. It is understood that the actual terms and conditions of coverage are those contained in Application the Stop Loss Coverage Policy into which this Application shall be incorporated at the time of acceptance by Blue Cross and. Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company ("HCSC"). Upon acceptance, HCSC shall issue a Stop Loss Coverage Policy to the Employer. Upon acceptance of this Application and issuance of the Stop Loss Coverage Policy, the Employer shall be referred to as the 'Policyholder." Tave Lawhorn Sales Representative James Juroch Name of Underwriter Signature of Underwriter G - SigrAture of Authorized Purchaser City Manager Title of Authorized Purchaser September 22, 2020 INTERNAL USE ONLY I Date Application approved by Underwriting: TXStopLossApp-06/17