HomeMy WebLinkAboutWellmark-6/9/2014CITY OF WATERLOO
Council Communication
City Council Meeting: Tune 9, 2014
Prepared: May 22, 2014
Dept. Head Signature: Suzy Schares
# of Attachments:
SUBJECT: Renewal of Health Insurance
Submitted by: Suzy Schares, City Clerk
Recommended City Council Action: Resolution approving renewal of stop loss health insurance
for a premium of $915,245.00 with Wellmark Blue Cross Blue Shield and approving renewal of
contract with Wellmark Blue Cross Blue Shield to administer the employee health care benefit
plan and prescription plan, including administrative and claim services at a cost of $27.81 per
employee per month and a disease management addendum.
Summary Statement: Approval of the premium is done on a yearly basis.
Expenditure Required: $915,245.00 plus $27.81 per employee per month
Source of Funds
Policy Issue
Alternative
Background Information:
CITY OF WATERLOO, Renewal Analysis 7/1/14:
Composite Rate
7/1/2013 7/1/2014 % Inc Claims Cost Notes:
$ 1,169.77 $ 1,133.32 -3.12% Claims Cost Increase Added in the 7/1/14 plan changes.
2013 2014
$ 18.55 $ 18.96
$ 1.00 $ 1.90
$ 4.95 $ 6.95
$ 108.68 $ 114.42
$ 2.38 $ 2.38
$ - $
$ 135.56 $ 144.61 6.68%
Admin 2.21% Increase
PBM 90.00% Increase
NAF 40.40% Increase
Ind SL 5.28% Increase
Agg SL 0.00% No change
Broker Fee #DIV/01 No change
Fixed Cost Increase
$ 1,305.33 $ 1,277.93 -2.10% Total Decrease
(still billed as $.68PMPM)
We mark
Your Health. Wets Prctecteaf�
Group Name
Account Key
Rating Period:
City of Waterloo
00014392
07/01/2014 to 06/30/2015
*CO
OBS #188067-5 / #188067-4
Alliance Select
Deductible: $400/$800;$800/$1600
Coinsurance: 20% / 40%
O P M: $800/$1600;$1600/$3200
Office Visit Copay: See OBS
BlueRx Complete
Deductible: $0 / $0
Copay: $10/$20/$50
FINAL RATES
Individual Stop Loss
Aggregate Stop Loss
155 Single
498 Family
653 Total
Level
$100,000
125%
Administrative Fees - Health w/weekly settlement
Administrative Fees - PBM
Network Access Fee
Broker fee
24/12 Contract
No Monthly Aggregate
Estimated Annual Premium
Fee/Contract Based on Current Enrollment
$114.42 $896,595
$2.38 $18,650
$18.96 $148,571
$1.90 $14,888
$0.00 $0
Total Administrative Fees $137.66
Single Family
Expected Claims $518.09 $1,295.23
Administrative, NAF & Stop Loss Fees $67.45 $168.62
Estimated Suggested Rates* $585.54 $1,463.85
Attachment Points
Administrative, NAF & Stop Loss Fees
Estimated Maximum Liability to Fund*
$647.61 $1,619.03
$67.45 $168.62
$715.06 $1,787.65
$6.95
'Actual results may vary. Also, rates provided include administrative costs based on the entire group population.
Individual Stop Loss includes coverage for Health and Drug and is based on a lifetime maximum of unlimited.
Aggregate Stop Loss include7�..verage for Health and Drug. The m, imum Aggregate reimbursement is unlimited.
Above rates are net of com sion.
$1,078,704
$54,460
Annual Projection
$8,703,942
$1,133,130
$9,837,072
$10,879,878
$1,133,130
$12,013,008
Employer Signature: � `� i �� "� %' � � � ' �— Date: I9Lt
Comments:
Pharmacy Fee/Contract is an estimate based on account specific member counts at the time the renewal was completed. The account will not be
billed the estimated Pharmacy administration Fee/Contract amount. Rather, the account will be billed $0.68 PMPM on its monthly invoice.
v4.1.0 Independent Licensee of the Blue Cross and Blue Shield Association
Proposal Date: 4/25/2014
ti607,/SZ/17 :WO lesodwd
uol;eloossy platys anis pue sswo anis au;;o aesuaon;uepuedapul
O'L'tin
.saver Jo
swnrwaid aouernsu/ ygeay o; uognqu;uoo s,Jado/dwa ay; apnpw;ou saop;uawa5ueuy 6uipunn ange ;sju/wpVJadoldw3 w •alq/suodsaj dgeraueuy
aq p/nom Jagwaw ay; yo/gM Jo aauasge alp u/ (s;uawitedoo Jo 'aauewnswoa `alggonpap s ragwaw ay; se Lions) s;soo jyeuaq Jo emus s�ragwaw
a g pieMo; sa;ngpjuoo iado/dwa ay; yo/gin w JaXo/dwa ue .fq paia;siu/wpe juawafueue ue s/ juawa5ueuy 5wpund paials/u/wpV Ja fo/dwa
ue 'yder6ewed sly; jo sasodJnd Jod auawa5ueJJy 6uipunn paia;sruiwpv Jadoldw3 due woij 6ug/nsa, sassoJ Jaw Jo saq/euad due ioj algeil play aq jou
film )ew//aM "VOti LPM sa//dwoo asrrouay;o Jo yovJapun sn;e;s ue/d ygeaq patay;ejpueZ s,ue/d yyeay e spaye;uawa5ueuyfuipund palajs/u/wpy
Jado/dw3 ue w a6ueyo due JegjagM ausuua;ap jou !pm 3pew/aM '(q)SOd uogoas;o uoge/ow u! aBwanoo 6upapo Ja fo/dwa Aue wny 6ug/nsar
sasso/Jay;o Jo sa/geuaddue Jo{ a/qe// play aq jou llm )pewllaM •(y)g0/ uogoas apoo anuanab /ewa;u/ ygM aauegdwoo 101 6ugsa; due ap/nmd;ou
p/M osle XJewllaM •(q)40; uogoas apoo anuanad lewa;ul jo uogelo/n u/ asyii qjo Jo dio;eurwuos/p si a6eranoo Jayjagm auiuua;ap Jou /llnn )pewl/aM
•uogeen5ai
Jo Mel jo suoisrncud Jay;o due jo uogegrawa/dwl Jo uoge;aidJa;u; Jo sn;e;s pasay;eipuei6 saw/ e uo safueyo ue/d{o pedw! ay; ()Ise uoge;uasawdaw
ou =slew wew//a9 •sJo;e/n5ai pue sapua6e a;e;s pue /eJapaf ajeudojdde ay; dq pans; suoge/n5aj pue aouepin6 uo paseq popad 6ugei s,ue/d
e 6uunp pasrnaJ aq dew pue a6ueyo o; pafgns ale suoge/noleo pedwr Buller pue 's;uaugsnfpe a;ei;emauaw 'se;eJ `sigauaq ueld gay; a;ou asea/d
•aogouJaypnj;noygm a6ueyo o; pafgns sl pue uogewiojuw;uauno;sow aq; jo Bu/pue;sjapun ssuewpaM spayai pap/nord uogeuuo;ul ayl, •sJo;e/n6a
pue sapua6e aims pue /eiapas a;epdwdde ay; dq pap/Acid aq o; anuguoo !pm pue uaaq sey suo/s/noJd ayioads uo aouep n5 pue suogeln6ai
'Mel •aouepm6 Jo 'suogeln5aw nnel a;e;s Jo;erapaj due jo aoueildwoo o; pie6aj ygm ape /euo/ssajwdio lethal due 6u/p/noJd jou s/ 'pewits
,'pa;aa;old it
y;le'aH JCA
Wellmark®
An Independent Licensee of the Blue Cross and
Blue Shield Association
Cir Forrn
FOR ADMINISTRATIVE USE ONLY
New Group: Group dt
Coverage Effective Date: / /
CONFIRMATION OF MSP ADDENDUM
ALL NEW AND RENEWAL GROUPS ARE REQUIRED TO SUBMIT A COMPLETED FORM. FAILURE TO SUBMIT A COMPLETED
FORM WILL DELAY THE INITIAL ENROLLMENT OR RENEWAL PROCESS
UNTIL THIS FORM IS SUBMITTED.
Part A - Employer Information
Please complete a separate confirmation form for each Employer Tax Identification Number you use to report employee
earnings to the Internal Revenue Service (IRS). See the Medicare Secondary Payer Definitions page (M-1756) for more
information on terms shown in italics. n n
Employer Tax Identification Number: I II II6 I III" 1 I II I
Group Number (Renewing Groups Only): XA025
Employer Name: City of Waterloo
7
Employer Address: 715 Mulberry St
City: Waterloo
Contact Person: Suzy Schares, City Clerk
State: IA Zip: 50703
Telephone Number: 319-291-4323
E-mail Address (optional): suzy.schares@waterloo-ia.org
1. Did your organization make contributions on behalf of any employee who was covered under a
collectively bargained Health and Welfare Fund (i.e., union plan) during the previous calendar year?
2. Did you have 20 or more employees for 20 or more calendar weeks (this includes all full-time, part-time,
intermittent, leased and/or seasonal employees, not just those eligible or enrolled employees) during the
previous or current calendar year? If no, in the event you experience a change, you must notify Wellmark
when this change occurs.
3. Did you have 100 or more employees during 50 percent of your business days (this includes all full-time,
part-time, intermittent, leased and/or seasonal employees, not just those eligible or enrolled employees)
during the previous calendar year?
4. Did your organization participate in a multi or multiple employer group health plan (more than one
employer in group, i.e., Multiple Employer Welfare Association) during the previous calendar year?
If yes, what is the name and address of the multi or multiple employer plan?
Name:
Address:
City: State: Zip:
5. Was your organization part of a commonly owned or commonly controlled group of organizations during
the previous calendar year?
If yes, what is the name and address of the commonly owned/controlled entity?
Name: Name:
Address: Address:
City: State: Zip: City: State: Zip:
Part B - Employer Certification
certify that the information provided is accurate and truthful. All information will be used to identify the
Medicare Secondary Payer status of Medicare -enrolled employees.
❑✓ Yes ❑No
['Yes El No
['Yes El No
❑ Yes O No
❑Yes�✓No
Signature
Date
05 / 30 / 2014
Send completed MSP form based on following:
IA & SD Large Groups (new or
renewal)
IA & SD Small Groups (new or
renewing with benefit changes)
IA Small Groups renewing with no
benefit change - send this form to:
SD Small Groups renewing with no
benefit change
Submit this completed MSP
form with group's health plan
new or renewal paperwork
Submit this completed MSP form
with group's health plan new or
renewal paperwork
Fax: (515) 376-9044 or
Wellmark, Inc.
PO Box 9232 — Mail Station 3W396
Des Moines, IA 50306-9232
Send this completed MSP form to:
Wellmark, Inc.
PO Box 5023 — Station 338
Sioux Falls, SD 57117-5023
N-2305 12/10
Page 2 of 2
Wellmark®
An Independent Licensee of the Blue Cross and
Blue Shield Association
MEDICARE COMPLIANCE
The purpose of this communication is to notify employers of the mandatory reporting requirements of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 which were passed into law in July 2008. Your cooperation in providing
the necessary employer data and data for each employee and dependent is needed in order to comply with the
requirements.
The Section 111 mandates of the law help payers identify when the Centers for Medicare and Medicaid Services (CMS)
should pay secondary to employer group health coverage. The goal includes reducing the amount CMS may pay as
primary when they should have paid as secondary.
Under the requirements, all health plan, liability, no fault and workers compensation coverages must register with CMS
as a Responsible Reporting Entity (RRE) and must report to CMS employer and member information. In order to fulfill
the mandated requirements and report accurately to CMS, Wellmark, as a RRE, must gather and groups must provide
the following information:
• Employer Tax Identification Number (ETIN)
• Evidence of status as a Commonly Owned/Controlled Group of Organizations, Multi/Multiple Employer
Group health plan (such as an Association or Trust), Hour Bank or Union health plan
• Total number of group employees/group size
• Social Security Numbers (SSNs) or Health Insurance Claim Numbers (HICNs) of active employees,
spouses, domestic partners
• SSNs or HICNs for those dependents with end stage renal disease (ESRD) or disabled
• Status of all employees and effective date of that status (i.e. active, COBRA, retired)
• Disability information begin or end dates, if known
Please take a moment to complete the Confirmation of Medicare Secondary Payer (MSP) Addendum form. This will
allow us to capture your employer data for reporting to CMS. Member data is gathered through the use of the group's
existing enrollment and eligibility data collection channels, which may include paper applications or electronic data
exchanges and should be provided through those processes.
Failure to provide the group information requested on the attached Confirmation of MSP Addendum can result in
penalties being assessed to the group including, but not limited to, $1,000 per day per member for not accurately
reporting to CMS and/or an excise tax equivalent to 25 percent of the employer's group health plan expenses for the
relevant year.
Wellmark Blue Cross and Blue Shield of Iowa I 1331 Grand Avenue I PO Box 9232 I Des Moines, Iowa 50306-9232 I wellmark.com
N-23 05 12/10
Page 1 of 2
WeUOmark®
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 - XA GROUP
Administered by Wellmark Blue Cross and Blue Shield of South Dakota
ACCOUNT LEGAL NAME
ACCOUNT REP & #
EFFECTIVE DATE
City of Waterloo
Gregg Anne Lowe
07 / 01 / 2014
PHYSICAL ADDRESS
GROUP/SECTION #s (Include all Sections or
attach a matrix)
715 Mulberry St
Waterloo, IA 50703
XA025 - see attached matrix
NO YES ADDITIONAL PRODUCTS
❑ Blue Dental
❑ Blue
Full Service
Rate Exhibit
Exhibit(s)
Exhibit(s)
Exhibit(s)
Plans
percentage?
size
❑
/_
Dental PPO
(SF only)
code?
CARRIER INFORMATION
✓ ❑ Dental Attached
Rate Exhibit(s)
SERVICES
Is
Wellmark the Exclusive
Yes ❑ No
No, identify carrier(s)
Wellmark the Stop
Yes ❑ No ❑ N/A
No, identify Stop Loss
-Loss Terms
$100,000
COVERAGE
Carrier/Administrator?
& # of Enrolled by
Loss Carrier?
Carrier
coverage, please
below
are both offered, are
take both products?
are both offered and
both products, are
required to take both
No
ADDITIONAL
CI
If
carrier.
Is
❑ / COBRA (Attached Addendum) 17
Standard ❑
Care Management Services Include
❑ Self Funded over 5000 contracts
and Minimum Premium Buy Up
$1O/EE/Yr
14392
✓ ❑ Health and
❑ Self Funded
❑ Fully Insured
CI
If
Stop
24/12
DENTAL
✓ ❑ Third -Party EOBs
OTHER
Account Key
If group is adding dental
answer the questions
When health and dental
Employees required to
❑ Yes ❑ No
When health and dental
the Employee selects
Spouse/Dependents also
products? Yes ❑
of an association? If yes, name and association
Prefix If yes,
U ❑ Is group part
Only)
%
NA
✓ ❑ Unique Alpha
(500+ Contracts)
Guarantee (500+ Contracts)
(Must be signed) See
See Attached
See Attached (FI and
independent contractors?
See Attached
See Attached
Attached Rate
SF Grandfathered
If yes, what
of group
✓ ❑ Savings Guarantee
✓ ■ Performance
✓ ❑ Terminal Rider
✓ ❑ Admin Guarantee
✓ ❑ ACA Addendum
Plan year month
July
1 ❑ Does group cover
ENROLLMENT
WHPI
Only
is accountable for
availability
(prior approval,
or benefit restrictions
procedures
policy on collection use
Guides must be distributed
MSP Addendum regardless
• Yos • No Employer
✓ MSP Status
communicating
• covered benefits
• noncovered benefits
• practitioner and provider
• a summary of UM procedures
referral, etc.)
• potential network, service
• pharmaceutical management
• a summary of Wellmark's
and disclosure of PHI
*If no. JITKits/Enroliment
❑ Paper Applications
✓ Electronic Enrollment ❑ EDI !4
Blues Enroll
❑ Excel Spreadsheet
When will Enrollment
Information be
time true open enrollment
approval from UW)
Received?
is allowed
1 ❑ Indicate if one
(If yes, see attached
Benefit Product Selected
Benefit Name
Health OBS Number
Rx OBS Number
Benefit Name
Health OBS Number
Rx OBS Number
Alliance Select
188067-5
188067-4
Please Select
Please Select
Please Select
Please Select
Please Select
Please Select
Please Select
N-2334 2/14
RENEWAL GROUP BINDER AGREEMENT - XA GROUP
Administered by Wellmark Blue Cross and Blue Shield of South Dakota
Set Up/Description (attach additional sheet of paper if needed; include group membership changes, if applicable)
Renewal
Deductible: 400/800
OPM: 800/1600
PCP: $20/visit
Specialist: $40/visit
Completed by Linda Marovets
For Internal Use Only
rg 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 Toss 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 Iowa Law.
Group/Account
By Title
Printed Name Date / /
Weflrnark®
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 - XA GROUP
Administered by Wellmark Blue Cross and Blue Shield of South Dakota
ACCOUNT LEGAL NAME
ACCOUNT REP & #
EFFECTIVE DATE
City of Waterloo
Gregg Anne Lowe
07 / 01 / 2014
PHYSICAL ADDRESS
GROUP/SECTION
Its (Include all Sections or
attach a matrix)
715 Mulberry St
Waterloo, IA 50703
XA025 - see attached matrix
NO YES ADDITIONAL PRODUCTS
❑ Blue Dental ❑ Blue
Standard ❑ Full Service
Include Rate
5000 contracts
Buy Up
Exhibit
Exhibit(s)
Plans
❑
Dental PPO
(SF only)
code?
CARRIER INFORMATION
✓ ❑ Dental Attached
Rate Exhibit(s)
SERVICES
Is
Wellmark the Exclusive
Yes ❑ No
No, identify carrier(s)
Wellmark the Stop
Yes ❑ No ❑ N/A
No, identify Stop Loss
-Loss Terms
$100,000
COVERAGE
Carrier/Administrator?
& # of Enrolled by
Loss Carrier?
Carrier
coverage, please
below
are both offered, are
take both products?
are both offered and
both products, are
required to take both
No
ADDITIONAL
rd
If
carrier.
Is
Addendum) ❑
Care Management Services
❑ Self Funded over
and Minimum Premium
$10/EE/Yr
14392
✓ ❑ COBRA (Attached
✓ ❑ Health and
❑ Self Funded
❑ Fully Insured
Ij
If
Stop
24/12
DENTAL
,r ❑ Third -Party EOBs
OTHER
Account Key
If group is adding dental
answer the questions
When health and dental
Employees required to
❑ Yes ❑ No
When health and dental
the Employee selects
Spouse/Dependents also
products? ❑ Yes ❑
of an association? If yes, name and association
Prefix If yes,
Exhibit(s)
Exhibit(s)
percentage?
size
❑ Is group part
Only)
%
NA
✓ ❑ Unique Alpha
(500+ Contracts)
Guarantee (500+ Contracts)
(Must be signed) See
See Attached
See Attached (FI and
independent contractors?
See Attached
See Attached
Attached Rate
SF Grandfathered
If yes, what
of group
1 ❑ Savings Guarantee
✓ ❑ Performance
✓ ❑ Terminal Rider
1 ❑ Admin Guarantee
1 ❑ ACA Addendum
Plan year month
July
✓ ❑ Does group cover
ENROLLMENT
WHPI
Only
is accountable for
availability
(prior approval,
or benefit restrictions
procedures
policy on collection use
Guides must be distributed
MSP Addendum regardless
• Yes • No" Employer
✓ MSP Status
communicating
• covered benefits
• noncovered benefits
• practitioner and provider
• a summary of UM procedures
referral, etc.)
• potential network, service
• pharmaceutical management
• a summary of Wellmark's
and disclosure of PHI
*If no, JITKits/Enrollment
❑ Paper Applications
1 Electronic Enrollment ❑ EDI 1►J
Blues Enroll
❑ Excel Spreadsheet
When will Enrollment
Information be Received?—
time true open enrollment isallowed
approval from UW)
1 ❑ Indicate iifone
(If yes, see attached
Benefit Product Selected
Benefit Name
Health OBS Number
Rx OBS Number
Benefit Name
Health OBS Number
Rx OBS Number
Alliance Select
188067-5
188067-4
Please Select
Please Select
Please Select
Please Select
Please Select
Please Select
Please Select
N-2334 2/14
RENEWAL GROUP BINDER AGREEMENT - XA GROUP
Administered by Wellmark Blue Cross and Blue Shield of South Dakota
Set Up/Description (attach additional sheet of paper if needed; include group membership changes, if applicable)
Renewal
Deductible: 400/800
OPM: 800/1600
PCP: $20/visit
Specialist $40/visit
Completed by Linda Marovets
For Internal Use Only
Pi 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 Iowa Law.
Grouount
By
Printed Name brut e(- G • (ct t'l C_
Date CI 1c9 / (Lf
Werimark
Ym r t- a. rt ;t:
SELF- FUNDED OPTIONS
Rate changes will ocwr at the same time as the employer -specific health renewal period.
Personal Health Assistant 24/7
Personal Health Assistant 2417- HCM only enrollees
Disease Management Core 5 Conditions:
- Asthma
- CAD
-COPD
-Diabetes
-HF
Add IMPACT to Disease Management Core 5
Add Oncology to Disease Management Core 5
Pregnancy Gare Program
Pregnancy Care Program
PEPM
PPPM
PPPM
PPPM
PPPM
PPPM
PPPM
PPPM
Per Participant
PMPM
2013
Included
$028
$17.24
$25.25
$28.71
$20.11
$62.52
$9.19
$77.73
$202.87
$0.11
2014
Included
$029
$17.76
$26.01
$29.57
$20.71
564.40
$9.47
$80.06
$200.00
$0.11
Online Wellness Center and Wellness Assessment -Core
Online Wellness Center and Wellness Assessment- Core HCM only
enrollees
Online Wellness Cerder and Wellness Assessment -Premium
(Includes online health coaching)
Online Wellness Center and Wellness Assessmerd-Premium HCM
only enrollees
Paper Wellness Assessment
Telephonic Health Coaching -High Risk°
Telephonic Health Coaching -Moderate Rislb
Telephonic Health Coaching -Low Risk°
Tobacco Cessation Coaching with Telephonic Health Coaching- High
Risk°
Tobacco Cessation Coaching (Stand Alone)°
Tobacco Cessation Coaching with NRT and Telephonic Health
Coaching-I-0gh Risk°
Tobacco Cessation Coaching with NRT (Stand Alone)°
Wellness Challenges Set-up
Wellness Challenge - Basic Package
Wellness Challenge - Auto Upload
Debit Card Redemption°
- Implementation Fee
Onsite Wellness Screenings -Venipuncture°
Onsite Wellness Screening - Venipuncture (includes Nicotine
Melabollte)°
Onsite Wellness Screening -Venipuncture (includes Measured
Height)°
Onsite Wellness Screenings -Fingerstick (indudes exit counseling)°
Onsite Wellness Screenings -Fingerstick (includes exit counseling and
Cotinine Saliva Swab)°
Onsite Wellness Screenings -Fingerstick (includes exit counseling and
Measured Height & Weight)"
Site Fee°
Physician Fax Option°
Home let (Lipid Panel and Glucase)°
Pipe and Drape Privacy Screens
3rd Party Biometric Standard Upload (requires purchase of online
wellness tools premium)"
Workplace Wellness Assessment
Wellness Communication Strategy with Calendar
Wellness Committee Development
Vending and Cafeteria Audit
PMPM
PEPM
PMPM
PEPM
PPPP
PPPP
PPPP
PPPP
PPPP
PPPP
PPPP
PPPP
One Time Fee
PPPY
PPPY
Per Debit Card
One Time Fee
PPPP
PPPP
PPPP
PPPP
PPPP
PPPP
Per Screening Site
(per day)
PPPP
PPPP
Per Screen Per Day
Annual Fee
One -Time Fee
One -Time Fee
One -Time Fee
One -Time Fee
2013 2014
$0.08 $0.08
$0.08 50.08
$025 $0.25
$0.25 $025
$19.00 $19.00
$160.00 $160.00
$120.00 $120.00
$48.00 $48.00
$205.00 $205.00
5245.00 $245.00
$325.00
$365.00
$10,000.00
$10.00
$29.00
$4.59
$2,500.00
$325.00
5365.00
$10,000.00
$10.00
$29.00
$4.59
$2,500.00
2013 2014
$55.00 $56.65
$72.14 $74.30
$58.00 $59.74
$53.00 $54.59
$95.86 $98.74
$58.00 $59.74
$140.00 $14420
$14.00 $14.42
$51.86 $53.42
$53.00 $54.59
8500.00 $500.00
2013
$6,300.00
53,200.00
$4,800.00
$2,600.00
2014
$6,500.00
$3,300.00
54,900.00
$2,700.00
Employer Wellness Incentive Design
Employer Wellness Dashboard and Metrics
Community Based Vendor Selection
Worksite Policy and Practice Review
Wellness Certification/Accreditation
Worksite Wellness Consulting
One -Time Fee
One -Time Fee
One -Time Fee
One -Time Fee
One -lime Fee
Per Hour
$5,300.00
$5,600.00
$1,600.00
53,700.00
$3,700.00
$95.00
'Rates- such pricing will be reviewed and subject to adjustment in the event of any change in the product(s) or scope of service provided.
PMPMM= Per Member Per Month
PPPY= Per Participant Per Year
PPPP= Per Participant Per Program
PPPM= Per Participant Per Month
PEPM= Per Enrollee Per Month
- PMPM, PPPM and PEPM service rates require a 12 month purchase
- Members are based on actual member counts at the time the group purchase was completed. The account will be billed based on the pricing method and rates
above.
'These services require the purchase of Onrme Wellness Center and Wellness Assessment -Premium
Wellness Screening Notes:
Fingerstick Screenings includes: Lipid Profile [TC, HDL, TC/HDL ratio, LDL, Triglyceridesj, Glucose, Blood Pressure, Pulse Rate, BMI, Counseling (self-reported
weight/height)
Venipuncture Screenings includes: Lipid Profile ]TC, HDL, TC/HDL ratio, LDL, Triglycerides], Glucose, Blood Pressure, Pulse Rate, BMI, Counseling, Measured
Weight
Wellness screenings must be minimum of 4 hours and meet 30 participant requirement or additional fees may apply
Standard Screening hours: 7 am to 8 7 pm CST. A flat fee will be invoiced per clinic that has hours outside of standard.
Two events in one day, separated by more than 2 hours downtime, are treated as two independent everts, each with respective minimums
Participation is measured based on members scheduled for screenings 10 business days prior to screening and any increase in estimated
business days will results in additional fees participation atter 10
Travel fees may apply
All Wellness screenings must be requested at least 6 weeks in advance of the event date.
*This rating exhibit does not provide complete detail. Please refer to any communication materials addressing these services.
$5,500.00
$6,000.00
51,600.00
$3,800.00
$3,800.00
598.00
ark®
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 - XA GROUP
ACCOUNT LEGAL NAME
.._......- .-.-- •-, .•'.••.•.�.......� ....,�
ACCOUNT REP & #
ar ru orue ame&U of JOUtfl UakOta
EFFECTIVE
DATE
City of Waterloo
Gregg Anne Lowe
07 / 01 /n14
PHYSICAL ADDRESS
GROUP/SECTION #s (Include
715 Mulberry St
Waterloo, IA 50703
all Sections or attach a matrix)
XA025 - see attached matrix
NO YES ADDITIONAL PRODUCTS
CARRIER INFORMATION
i
❑ Dental Attached Rate Exhibit(s) ❑ Blue Dental ❑ Blue Dental PPO
ADDITIONAL SERVICES
Is
CI
Wellmark the Exclusive Carrier/Administrator?
Yes ❑ No
❑
i
i
/
❑
❑
COBRA (Attached Addendum) 0
Health and Care Management Services
❑ Self Funded ❑ Self Funded over
❑ Fully Insured and Minimum Premium
Third -Party EOBs $1O/EE/Yr
OTHER
Standard ❑ Full Service (SF only)
Include Rate Exhibit
5000 contracts
Buy Up
If
carrier.
Is
ra
If
Stop
24/12
No, identify carrier(s) & # of Enrolled by
Wellmark the Stop Loss Carrier?
Yes ❑ No ❑ N/A
No, identify Stop Loss Carrier
-Loss Terms
$100,000
Account Key 14392
DENTAL COVERAGE
U
❑ Is group part of an association? If yes, name and association code?
If group is adding dental coverage, please
answer the questions below
i
❑ Unique Alpha Prefix If yes,
When health and dental are both offered, are
i
i
i
i
❑ Savings Guarantee (500+ Contracts) See Attached Exhibit(s)
❑ Performance Guarantee (500+ Contracts) See Attached Exhibit(s)
❑ Terminal Rider (Must be signed) See Attached Rate Exhibit(s)
❑ Admin Guarantee See Attached
ACA
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
i
❑ Addendum See Attached (FI and SF Grandfathered Plans Only)
Plan year month
i
❑ Does group cover independent contractors? If yes, what percentage? %
July
ENROLLMENT
WHPI Only
i
❑
i
❑
MSP Status MSP Addendum regardless
Paper Applications
Electronic Enrollment ❑ EDI
Excel Spreadsheet
When will Enrollment Information
rj
be
of group size
Blues Enroll ❑ NA
Received? / /
■Yes
communicating
° covered
o noncovered
O practitioner
o a summary
referral,
9 potential
•
No* Employer is accountable for
benefits
benefits
and provider availability
of UM procedures (prior approval,
etc.)
network, service or benefit restrictions
io
❑ Indicate if one time true open enrollment is allowed
(If yes, see attached approval from UW)
pharmaceutical management procedures
0 a summary of Wellmark's policy on collection use
and disclosure of PHI
*If no. JITKlts/Enrollment Guides must be distributed
Benefit Product Selected
Benefit Name
Health OBS Number
Rx OBS Number
Benefit Name
Health OBS Number
Rx OBS Number
Alliance Select
188067-5
188067-4
Please Select
Please Select
Please Select
Please Select
Please Select
Please Select
Please Select
N-2334 2/14
RENEWAL GROUP BINDER AGREEMENT - XA GROUP
Administered by Wellmark Blue Cross and Blue Shield of South Dakota
Set Up/Description (attach additional sheet of paper if needed; include group membership changes, if applicable)
Renewal
Deductible: 400/800
OPM: 800/1600
PCP: $20/visit
Specialist $40/visit
Completed by Linda Marovets
For Internal Use Only
pg 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 Toss 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 Toss 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 Toss 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 Iowa Law.
Group/Account
By Title
Printed Name Date / /
Wellimark.
An Independent licensee of the Blue Cross and
Blue Shield Acsr-iation
FOR ADMINISTRATIVE USE ONLY
New Group: Group #
Coverage Effective Date:
CONFIRMATION OF MSP ADDENDUM
ALL NEW AND RENEWAL GROUPS ARE REQUIRED TO SUBMIT A COMPLETED FORM. FAILURE TO SUBMIT A COMPLETED
FORM WILL DELAY THE INITIAL ENROLLMENT OR RENEWAL PROCESS
UNTIL THiS FORM IS SUBMITTED.
Part A - Employer Information
Please complete a separate confirmation form for each Employer Tax Identification Number you use to report employee
eamings to the Internal Revenue Service (IRS). See the Medicare Secondary Payer Definitions page (M-1756) for more
information on terms shown in italics.
Employer Tax Identification Number:
141
2
Group Number (Renewing Groups Only): XA025
Employer Name: City of Waterloo
6
0
FIF113if
Employer Address: 715 Mulberry St
City: Waterloo
Contact Person: Suzy Schares, City Clerk
State: IA
Zip: 50703
Telephone Number: 319-2914323
E-mail Address (optional): swyshares@waterioo-ia.org
1. Did your organization make contributions on behalf of any employee who was covered under a
collectively bargained Health and Welfare Fund (i.e., union plan) during the previous calendar year?
2. Did you have 20 or more employees for 20 or more calendar weeks (this includes all full-time, part-time,
intermittent, leased and/or seasonal employees, not just those eligible or enrolled employees) during the
previous or current calendar year? If no, in the event you experience a change, you must notify Wellmark
when this change occurs.
3. Did you have 100 or more employees during 50 percent of your business days (this includes all full-time,
part-time, intermittent, leased and/or seasonal employees, not just those eligible or enrolled employees)
during the previous calendar year?
4. Did your organization participate in a multi or multiple employer group health plan (more than one
employer in group, i.e., Multiple Employer Welfare Association) during the previous calendar year?
If yes, what is the name and address of the multi or multiple employer plan?
Name:
Address:
City: State: Zip:
5. Was your organization part of a commonly owned or commonly controlled group of organizations during
the previous calendar year?
If yes, what is the name and address of the commonly owned/controlled entity?
Name:
Name:
Address:
City:
State:
Part B - Employer Certification
I certify that the information provided is accurate and truthful. All information will be used to identify the
Medicare Se ary Rayer status of Medicare -enrolled employees.
Zip:
❑✓Yes❑No
®Yes ❑ No
®Yes No
[1 Yes ❑✓ No
11 Yes 0No
Address:
City: State: Zip:
Signature
Date
05 / 30 / 2014
Page 2 of 2
Send completed MSP form based on following:
IA & SD Large Groups (new or
renewal)
IA & SD Small Groups (new or
renewing with benefit changes)
IA Small Groups renewing with no
benefit change - send this form to:
SD Small Groups renewing with no
benefit change
Submit this completed MSP
form with group's health plan
new or renewal paperwork
nf.yanc 1 Vn n
Submit this completed MSP form
with group's health plan new or
renewal paperwork
Fax: (515) 376-9044 or
Wellmark, Inc.
PO Box 9232 — Mail Station 3W396
Des Moines, IA 50306-9232
Send this completed MSP form to:
Wellmark, inc.
PO Box 5023 —Station 338
Sioux Falls, SD 57117-5023
Page 2 of 2