HomeMy WebLinkAboutWellmark-11/12/2013Wellmark.
Wellmark Blue Cross and Blue Shield is an Independent
Licensee of the Blue Cross and Blue Shield Association.
New Group Binder Agreement - Iowa
Administered by Wellmark Blue Cross and Blue Shield of South Dakota
ACCOUNT LEGAL NAME
BUSINESS DEVELOPER
REP ID#
EFFECTIVE DATE
City of Waterloo
Jeff Kramer
123
01 / 01 /2014
PHYSICAL ADDRESS*
GROUP/SECTION #s (Include
all Sections or attach a matrix)
715 Mulberry St
Waterloo IA 50703
XA025-see attached matrix
GROUP CONTACTS
Contact
Phone Number
Fax Number
Email Address
Administrative Contact
(Executive Contact)
Suzy Schares
(319) 291-4522 (3008)
suzy.schares@waterloo-i
Billing Contact
(Who bills are to be sent to)
Suzy Schares
(319) 291-4522 (3008)
suzy.schares@waterloo-i
Correspondence Contact
(Who makes benefit decisions)
Suzy Schares
(319) 291-4522 (3008)
suzy.schares@waterloo-i
*If Billing, Correspondence, or Administrative address differ from the Group's Physical Address, please attach.
NO YES ADDITIONAL PRODUCTS
CARRIER INFORMATION
121 ❑ Dental Attached rate Exhibit(s) ❑ Blue Dental ❑ Blue Dental PPO
ADDITIONAL SERVICES
Is Wellmark the
Administrator?
Exclusive
Carrier/
Yes
❑
in
Pj
I7
❑
❑
COBRA (Attached Addendum) 0
Health and Care Management Services
❑ Self Funded ❑ Self Funded over
❑ Fully Insured and Minimum Premium
Third -Party EOBs $10/EE/Yr
OTHER
Standard ❑ Full Service (SF only)
See Attached Rate Exhibit
5000 contracts
Buy Up
If
by
Is
(•J
If
Stop
No, identify carrier(s)
carrier.
Wellmark the
Yes ❑ No
No, identify Stop
-Loss Terms
P
Stop
❑
❑ No
& # of Enrolled
Loss Carrier?
N/A
Loss Carrier
Account Key 14392
24/12 $100,000 spec/125% agg
I►j
❑ Is group part of an association? If yes, name and association code
Renewal delivery month
N
❑ Unique Alpha Prefix If yes,
April
Savings Guarantee (500+ Contracts) See Attached Exhibit(s)
Plan year month
!A
❑
0
❑ Performance Guarantee (500+ Contracts)
Fiscal July
a
n❑
n
❑ Terminal Rider (Must be signed) See Attached Rate Exhibit(s)
Admin Guarantee See Attache,.-,
ACA Addendum See Attached (FI and SF Grandfathered Plans Only)
❑ Reconciled Job Service Report (FI only) See Attached
❑ Does group cover independent contractors? If yes, what percentage? %
ENROLLMENT
•
•
•
•
•
Yes
communicating
covered
noncovered
practitioner
a summary
WHPI Only
■ No* Employer is accountable for
benefits s
benefits
and provider availability
of UM procedures (prior
pi
❑
❑
pi
MSP Status MSP Addendum required regardless of group size
Paper Applications
Electronic Enrollment ❑ EDI ❑ Blues Enroll ❑ NA
Excel Spreadsheet
When will enrollment information be received? / /
approval, referral, etc.)
• potential network, service or benefit
restrictions
• pharmaceutical management procedures
• a summary of Wellmark's policy on
collection use and disclosure of PHI
*If no. JITKits/Enrollment Guides be
❑ ❑ Indicate if one time true open enrollment is allowed (lf yes, see attached approval from UW)
must
distributed
Benefit Product Selected
Benefit Name
Health OBS Number
Rx OBS Number
Benefit Name
Health OBS Number
Rx OBS Number
$300 Deductible Plan
188067-1
188067-2
N-53294 7/13
New Group Binder Agreement - Iowa
Administered by Wellmark Blue Cross and Blue Shield of South Dakota
NEW HIRE WAITING PERIOD
The period of time newly hired members and family dependents must wait before becoming eligible
for coverage:
❑ No Waiting Period (Eligibility begins on date of hire)
If group allows "odd dates" of hire, premiums will be prorated. (Fully Insured only)
OR
on -bra -
0
n -ba❑ One -Month Period; ❑ Two -Month Period; ❑ Three -Month Period; OR
Other 90 day waiting period eXc q I ckt
(If other, define entire rule i.e., give example including Effective Date & Waiting Periods)
. . -
ID Cards Delivered
ID cards will be delivered to the
member unless indicated below
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
Set Up/Description (attach additional sheet of paper if needed; include membership changes, if applicable)
FAI Migration
Completed by Shelly Bryan
For Internal Use Only
SIC CODE
9111
WELLMARK RETENTION
REP. NAME/#
Gregg Ann Lowe #614
CONTRACTED AGENCY
NAME
SELLING AGENT NAME
SEWNG AGENT NUMBER
CONTRACTED AGENCY 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.
GrouApeount
By
Printed Name .�f1r"ST
Title
Date / / 2 / ��