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Home My WebLink AboutWellmark-5/4/2015 (7)RENEWAL GROUP BINDER AGREEMENT - XA GROUP • Benefit Product Selected Benefit Name Health OBS Number Rx OBS Number Benefit Name Health OBS Number Rx OBS Number Alliance Select 188067-17 188067-19 Alliance Select 188067-18 188067-19 For Internal Use Only Set Up/Description (attach additional sheet of paper if needed; include group membership, billing, funding changes, if applicable) Renewal Increase ded and opm. Cover dental for accidental injury within 12 months Increase rx copays Add rx opm Completed by Linda Marovets i Change ❑ No Change ❑ Retro ❑ Off Renewal CONTRACTED AGENCY SELLING AGENT NAME SELLING AGENT NUMBER CONTRACTED AGENCY NAME TAX ID This Binder Agreement serves solely as evidence of Wellmark's agreement to provide the health coverage and administrative services and to provide services for any applicable stop loss insurance coverage indicated above. The Account agrees to the terms and payment obligations stated herein and agrees to pay Wellmark the applicable rates, administrative fees, and stop loss premium stated in the proposal(s). Execution of this Binder Agreement by the Account authorizes Wellmark to implement the administration of this coverage including the processing and settlement of claims for members of the Account's group plan incurred within the Rating Period. On or about the effective date of the coverage, Wellmark shall issue and execute a definitive agreement setting forth the rights and responsibilities of Wellmark and Account. Account's payment to Wellmark of the applicable fees as of the effective date is evidence of Account's agreement to the terms specified in the definitive agreement Account understands and agrees that Wellmark defines a National Account as any company headquartered in Iowa but which also has employees in other states whose claims are processed through the Blue Card program. Signatures on this Binder Agreement confirm that it is issued for delivery in Iowa. Only persons associated with a National Account or with Account locations in Iowa are eligible for coverage. If the entity is not headquartered in Iowa, coverage will be void for any persons associated with Account locations outside of Iowa. Account acknowledges and agrees that Wellmark will rely on the information contained in the Affordable Care Act ("ACA") Addendum. Account represents to Wellmark that the information contained in the ACA Addendum is correct. Account agrees that it will provide Wellmark at least 60 days prior written notice of any change that may affect grandfather status. This Binder Agreement shall expire upon Wellmark's issuance and execution of the definitive agreement, except the COBRA Addendum, Affordable Care Act Addendum, and/or Health and Care Management Programs/Services Rating Exhibit, if any, which will remain in effect and become a part of the definitive agreement. It is hereby agreed and understood that the terms and conditions of the definitive agreement and benefits document(s) issued by Wellmark to the Account, and the terms and conditions of the definitive stop loss policy issued by stop loss carrier, if any, shall govern and control the terms stated in this Binder. Any inconsistency between this Binder Agreement, including any attachments, and any subsequently issued executed definitive agreement(s) shall be construed in favor of the subsequently issued document. This Binder Agreement shall be governed in accordance with South Dakota Law. Group/Account By Title CL C LAC Printed Name �Z� C—/�C� Date / s Wellmark Blue Cross and Blue Shield Is an Independent Licensee of the Blue Cross and Blue Shield Association. ❑ Amendment to Binder dated / / RENEWAL GROUP BINDER AGREEMENT e XA GROUP Account Legal Name. City of Waterloo . ._.......--.-. -1 ............. Account Rep & # Devonne Harford ...-.. .....w u..0 .J.uc Vi..c.0 VI JVuul Ua1VlO Effective Date 07 / 01 / 2015 Physical Address: Address Line Address Line 2: 1: 715 Mulberry St Group/Section #'s (Include all Sections or attach a matrix) XA025 - see matrix City: Waterloo State: IA ZIP+4: 50703 Physical Address of Billing contact: Address Line 2: Address Line 1: same as above City: State: ZIP+4: If billing contact address is different than Accounts Physical Address shown above, this is: ❑ Alternate location of above Account; or ❑ 3rd Party Billing Service. (If 3rd party billing service, Account acknowledges that Wellmark Group Statement of premium invoice delivered periodically to any third party service provider can be viewed by Account by registering for electronic billing at www.wellmark.com.) Account Key: 14392 Contact Month: March Plan Year Month: July Unique Alpha Prefix: n/a NO YES ADDITIONAL PRODUCTS Dental PPO Plans Only) code? CARRIER INFORMATION ✓ ❑ Dental Attached Rate Exhibit(s) ❑ Blue Dental ❑ Blue Is Wellmark the Exclusive Carrier/Administrator? ❑ No identify carrier(s) & # of Enrolled by ADDITIONAL SERVICES ✓ Yes IfNo✓ carrriri cer. (Attached Addendum) Service (SF only) Services Include Rate Exhibit Self Funded over 5000 contracts Minimum Premium Buy Up Attached (FI and SF Grandfathered If yes, name and association ❑ COBRA Administration ❑ Standard ❑ Full ✓ ❑ Health and Care Management Is Wellmark the Stop ❑ No ❑ identify Stop Loss Carrier? N/A Loss Carrier. ❑ Self Funded ❑ ❑ Fully Insured and ✓ Yes If No, 0 ❑ Third -Party EOBs $10/EE/Yr Stop Stop -Loss Terms: -Loss LOB: OTHER 0 ❑ ACA Addendum See DENTAL COVERAGE (/J ❑ Is group part of an association? If group is adding dental coverage, please answer the questions below When health and dental are both offered, are Employees required to take both products? ❑ Yes ❑ No When health and dental are both offered and the Employee selects both products, are Spouse/Dependents also required to take both products? ❑ Yes ❑ No 0 ❑ Savings Guarantee (500+ Contracts) See Attached Exhibit(s) (500+ Contracts) See Attached Exhibit(s) be signed) See Attached Rate Exhibit(s) Attached regardless of group size / 0 ❑ Performance Guarantee 1 ❑ Terminal Rider (Must ✓ ❑ Admin Guarantee See ENROLLMENT 0 MSP Status MSP Addendum ❑ Paper Applications ❑ Excel Spreadsheet When will Enrollment WHPI Only is accountable for availability procedures (prior approval, service or benefit restrictions procedures policy on collection use PHI Guides must be distributed ❑ EDI 0 Blues Enroll ❑ NA Information be Received? / • Yes • No* Employer communicating ® covered enb ® noncovered s benefits ® practitioner and provider o a summary of UM referral, etc.) ® potential network, o pharmaceutical management ® a summary of Wellmark's and disclosure of *If no. JITKits/Enrollment ✓ ❑ Does the open enrollment date differ from the renewal date? If so, OE date is: ___/____/ N-2334 9/14