HomeMy WebLinkAboutWellmark-6/24/2013Wellrnark.
BlueCross
® v ® BlueShield
M Independent Licensee oft the Bh,e Goss and Blue Shield Assor tion
1. General lnformation
City of Waterloo
Application For Group Insurance
Please type or print. Must be completed in full.
Indicate "NA" if item does not apply.
Full Legal Name of Group
42-6005327
Tax I.D. Number
715 Mulberry Street
Address
Waterloo IA
City, State
http:www.wplwlooiib.ia.us/waterloo
Internet Address
Municipality
Nature of Business
2. Requested Effective Date: 7/1/2013
( 319 )2914522 ext 3008
Business Telephone Number
( 319 )291-4571
Fax Number
50703
Zip Code
suzy schares@waterloo-ia.org
E -Mail Address
9111
SIC Code
3: Number of Eligible Employees: Number of Participating Employees: 643
4. Stop Loss Benefits / Premiums:
Aggregate Coverage
Aggregate Stop Loss: Yes (Yes / No)
Aggregate Contract: 24/12 (15/12, 12/18, other)
Employee Benefit Plan expenses will be Incurred from 7/1/2012
❑ New Group
7/1/2013 through 6/30/2014
Aggregate Stop Loss Eligible Expenses Include:
Aggregate Stop Loss Deductible:
Aggregate Stop Loss Premium (per contract per month):
Aggregate Attachment Points:
Benefit Description/Plan Single
Amount Enrollment
New Alt 1 $668.44 140
Annual Minimum Aggregate Deductible:
Maximum Aggregate Reimbursement:
Aggregate Run-in, if applicable:
125%
$238
$0.00
Renewal
through 6/30/2014 , and Paid from
$2.38
Health 0
Prescription 0
Premium Amount
Broker Fee / Commission
Total Aggregate Premium
Family
Amount Enrollment
$1,671.10 503
Calculated upon execution of agreement
Unlimited
NA
EE/Sp
Amount Enrollment
Dental
Other
EE/Ch
Amount Enrollment
Individual Coverage
Individual Stop Loss: Yes (Yes / No)
Individual Contract: 24/12 (15/12, 12/18, other)
Employee Benefit Plan expenses will be Incurred from 7/1/2012 through 6/30/2014 , and Paid from
7/1/2013 through 6/30/2014
Individual Stop Loss Eligible Expenses Include:
Individual Stop Loss Deductible (per person):
Aggregating Individual Deductible (if applicable):
Individual Stop Loss Premium (per contract per month):
Individual Stop Loss Lifetime Maximum (per person):
5. Policy Limitations:
Individuals requiring separate Individual Stop Loss Deductible (please list by Social Security number and relationship to employee)
Social Security Number Relationship Individual Stop Loss Deductible Excluded? Diagnosis
NA
$100000.00
$0.00
$108.68
$0.00
$108.68
$t.00
►'1
Health
Prescription
Premium Amount
Broker Fee / Commission
Total Individual Premium
❑ Dental
❑ Other
10/2009 Page 1
Other Policy Limitations:
Advanced Funding:
6: Administration
Case Management:
Ship to:
Claims in excess of the group's Individual Stop Loss deductible level will not be covered under the
Aggregate Stop Loss coverage.
Reimbursement of Third Party Fees, related to negotiation of out of network bills, is limited to 30% of the
amount saved.
Retirees over age 65 are not eligible for stop loss coverage under the group plan. Active employees and
their spouses who are age 65 and older and exercising their rights under TEFRA/DEFRA are eligible only
if they elect the account's group coverage as primary to Medicare. If Medicare is chosen as primary,
employees and spouses are not eligible for group benefits.
Yes (Yes / No)
Wellmark Blue Cross Blue Shield of Iowa
Stop Loss Policy
Special Instructions:
FAI
I represent the statements contained in this application are true and complete to the best of my knowledge and belief, and I
understand they form the basis for Wellmark Blue Cross Blue Shield of Iowa's approval of the coverage requested.
Name of Applicar t'
orized Representative
41111111►
Signature of A
Title
cgnt's Ay orized Representative
Date
Signature of Witness and/or Agent
Location, City/State
Gregg -Anne Lowe
Name of Resident Agent
Signature of Resident Agent
0009427007
Resident Agent License Number
10/2009
Page 2
` elimark
- Your Health. Well Protected.
Group Name City of Waterloo
Rating Period: 07/01/2013 to 06/30/2014
FINAL RATES
FAI ALT
Deductible: $300/$600
Coinsurance: 20%/40%
OPM: $600/$1,200
Office Visit Copay: $15/$30
Rx
Deductible: $0 / $0
Copay: $10/$20/$50
Aggregate Stop Loss Level
Individual Stop Loss
FAI Health
Deductible: $250/$500
Coinsurance: 20%/40%
OPM: $500/$1,000
Office Visit Copay: $15/$30
Rx
Deductible: $0 / $0
Copay: $5/$10/$25
Aggregate Stop Loss Level
Individual Stop Loss
far
140 Single
503 Family
643 Total
Fee/Contract
24/12 Contract
$2.38 125% Attachment Points
Single Family
$108.68 $100,000 $668.44 $1,671.10
$92.97 $110,000 $680.80 $1,702.00
$91.97 $120,000 $691.16 $1,727.90
Fee/Contract
$2.38 125% Attachment Points
Single Family,
$108.68 $100,000 $691.52 $1,728.80
$92.97 $110,000 $704.31 $1,760.78
$91.97 $120,000 $715.03 $1,787.58
The above self-funded rates are based on the current benefit plans and Select First network.
Above rates are net of broker commission.
Pursuant to the Affordable Care Act, health plans and carriers will be imposed an estimated Reinsurance Fee of $5.25 per member per month. The
actual fees will be included on your billing statements beginning January 1, 2014.
v4.1.0 Independent Licensee of the Blue Cross and Blue Shield Association Proposal Date: 4/5/2013
Wilmark
Your Health. Well Protected"
First Administrators, inc. (FAi) is not providing any legal or professional advice with regard to compliance of any federal or state law, regulations, or
guidance. Law, regulations and guidance on specific provisions has been and will continue to be provided by the appropriate federal and state
agencies and regulators. The information provided reflects FAI's understanding of the most current information and is subject to change without further
notice. Please note that plan benefits, rates, renewal rate adjustments, and rating impact calculations are subject to change and may be revised during
a plan's rating period based on guidance and regulations issued by the appropriate federal and state agencies and regulators. FAI makes no
representation as to the impact of plan changes on a plan's grandfathered status or interpretation or implementation of any other provisions of law or
regulation.
FAI will not determine whether coverage is discriminatory or otherwise in violation of Internal Revenue Code Section 105(h). FAI also will not provide
any testing for compliance with Internal Revenue Code Section 105(h). FAI will not be held liable for any penalties or other losses resulting from any
employer offering coverage in violation of section 105(h). FAI will not determine whether any change in an Employer Administered Funding
Arrangement affects a health plans grandfathered health plan status under ACA or otherwise complies with ACA. FAI will not be held liable for any
penalties or other losses resulting from any Employer Administered Funding Arrangement. For purposes of this paragraph, an Employer Administered
Funding Arrangement" is an arrangement administered by an employer in which the employer contributes toward the member's share of benefit costs
(such as the member's deductible, coinsurance, or copayments) in the absence of which the member would be financially responsible. An Employer
Administrative Funding Arrangement does not include the employer's contribution to health insurance premiums or rates.
v4.1.0 Independent Licensee of the Blue Cross and Blue Shield Association Proposal Date: 4/5/2013
City of Waterloo
Stop Loss Period: 7/1/2013 to 6/30/2014
Conditions and Limitations
The self-funded rates and factors are FINAL.
Following are further conditions/limitations of the terms to the contract proposed:
The minimum aggregate will be based on 90% of 140 single and 503 family contracts.
Individual Stop Loss Insurance is based on an unlimited plan lifetime maximum.
The maximum Aggregate Reimbursement is unlimited.
Individual Stop Loss Insurance includes coverage for both health and drug.
Aggregate Stop Loss Insurance includes coverage for both health and drug.
Wellmark will handle case management.
Should the number of employees, either in total or by single/family mix, change by 10% or more,
Wellmark reserves the right to recalculate both the reinsurance premiums and aggregate
attachment points.
Policy Limitations
Reimbursement of Third Party Fees, related to negotiation of out of network bills, is limited to
30% of the amount saved.
Claims in excess of the group's Individual Stop Loss deductible level will not be covered under
the Aggregate Stop Loss coverage.
Retirees over age 65 are not eligible for stop loss coverage under the group plan. Active
employees and their spouses who are age 65 and older and exercising their rights under
TEFRA/DEFRA are eligible only if they elect the account's group coverage as primary to
Medicare. If Medicare is chosen as primary, employees and spouses are not eligible for group
benefits.
April 05, 2013