Loading...
HomeMy WebLinkAboutWellmark Renewal Group Binder-5/26/2016 Wellmark® Amendment to Binder dated / / Wetlmark Blue Cross and Blue Shield is an independent RENEWAL GROUP BINDER AGREEMENT - XA GROUP licensee of the Blue Cross and Blue Shield Association. Administered by Wellmark Blue Cross and Blue Shield of South Dakota Account Legal Name Account Rep&# Effective Date City of Waterloo DeVonne Harford#44 7 / 1 / 2016 Physical Address:Address Line I: 715 Mulberry St Group/Section#'s(Include all Sections or Address Line 2: attach a matrix) City: Waterloo State: IA ZIP+4: 50703 XA025-(See Matrix) Physical Address of Billing contact: Address Line 1: Address Line 2: 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: Contact Month: Plan Year Month: Unique Alpha Prefix: 14392 March July N/A NO YES ADDITIONAL PRODUCTS CARRIER INFORMATION ❑ ❑ Dental Attached Rate Exhibit(s) ❑Blue Dental ❑Blue Dental PPO Is Wellmark the Exclusive Carrier/Administrator? ADDITIONAL SERVICES 0 Yes ❑No If No,identify carrier(s)&#of Enrolled by E ❑ COBRA Administration(Attached Addendum) carrier. ❑Standard ❑Full Service(SF only) ✓❑ ❑ Health and Care Management Services Include Rate Exhibit Is Wellmark the Stop Loss Carrier? ❑Self Funded ❑Self Funded over 5000 contracts 0 Yes ❑No ❑N/A ❑Fully Insured and Minimum Premium Buy Up If No,identify Stop Loss Carrier. E ❑ Third-Party EOBs $10/EE/Yr Stop-Loss Terms: OTHER Stop-Loss LOB: E ❑ ACA Addendum See Attached (FI and SF Grandfathered Plans Only) DENTAL COVERAGE • ❑ Is group part of an association?If yes,name and association code? If group is adding dental coverage,please answer the questions below ❑r ❑ Savings Guarantee(500+Contracts) See Attached Exhibit(s) When health and dental are both offered,are ❑ Performance Guarantee(500+Contracts) See Attached Exhibit(s) Employees required to take both products? 0 ❑ Terminal Rider(Must be signed) See Attached Rate Exhibit(s) ❑Yes ❑No E ❑ Admin Guarantee See Attached When health and dental are both offered and the Employee selects both products,are ENROLLMENT Spouse/Dependents also required to take both Date enrollment information will be received: / / products? ❑Yes ❑No Format: ❑ Paper ❑ EDI ❑✓ Blues Enroll ❑ Excel ['Yes ❑No*Employer is accountable for ❑ 0 Does the open enrollment date differ from the renewal date? communicating es OpenEnrollment date is: / / •covered benefits If yes, •noncovered benefits MSP Addendum(required regardless of group size) •practitioner and provider availability BENEFIT STRUCTURE/BILLING UNIT referral, ▪a summary of UM procedures(prior approval, referral,etc.) ✓❑ ❑ Changes(if yes,check appropriate boxes below) •potential network,service or benefit restrictions •pharmaceutical management procedures ® ❑ New group base/billing unit numbers •a summary of Wellmark's policy on collection use and disclosure of PHI 2 ❑ New benefit groupings/changes to existing benefit groupings *if no,JITKits/Enrollment Guides must be distributed N.2334 3/16 RENEWAL GROUP BINDER AGREEMENT - XA GROUP Administered by Wellmark Blue Cross and Blue Shield of South Dakota Benefit Product Selected Benefit Name Health OBS Number Rx OBS Number Benefit Name Health OBS Number Rx OBS Number Alliance Select 188067-20 188067-23 Alliance Select 188067-22 188067-23 For Internal Use Only Set Up/Description(Attach billing unit/group structure matrix or list details below.Clearly note membership,billing,funding,and group structure changes where applicable) Updated the Tier 3 drug copay to$50. Completed by Ashley Engelbart ✓❑Change CONTRACTED AGENCY SELLING AGENT NAME SELLING AGENT NUMBER CONTRACTED AGENCY ❑No Change NAME TAX ID ❑Retro ❑ Off Renewal 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 �? / 14 By Title l.�i \, L C.Svre_cicpc Printed NameS.A."—s1Sc—,\C\C rre4 Date .5 /_cQ (e► / l (co • \ @ t E ƒ ƒ § 8 fo ) ) � af� ® {/ { @a \ b ` Ra2x / 02 r 2rat \tƒ E{ � � EE & �t2/ ek � =\ { 9Q \ e ] � § E � L_. < COao { 7e2 /% / \ E� / ® t ± ±R= Q_, � § k@ � £ / = m2) © - 7G ) / § aMceos = 4 \«{ e � '— } � t afR< , E � }\ \ ) 213 ° » } \ � ƒ u § � a �/ § � § } k � k u. ) & ~ E - °] _ = u § 2 � • . \ . : I § \rKrezw = \ oN1 \ � / t33R - ~ n - z } » = ono = c ; o kw � coococ ENINwCINNNNNnmc o - lin 5 / @EG@S@ \ / \\ S \S2G@g@2E@ ??? g8G@E w § k \ ILI -i 'L > ■ ;K C E Z CC § / 1� q = 13 \ E \ a ± / � § \ U ƒ \ / § 7 ILI ƒ 0 2 to b0 \ ± _ = b \ E CI ) U § \ d / 3 k & §\ � X§ ! RJ ! \ R a2 < Eh' m 7 ; . . . I $ 22 § t § % R > > 0 Z. 0 0 \ / . , . . .rt ee Nr o ill COjNI a3NQ N1@ ) § § G § ; } \\ \ \ + 2 co\ \ VI § § e � - w re 0 0 Weitmark. e • %Vilma*Bhar Crosvon t t e$tlie,4:1 an lr.Jui * : Libart,460.te the 15hse COW.am Blue Stueld Axusocoo:P'i. Self Funded Alternate Rates Group Name: City of Waterloo Account Key: 00014392 Rating Period: 07/01/2016 to 06/30/2017 Alternate Benefit Offering Enrollment Stop Loss Terms OBS #188067-20 /#188067-23 146 Single 24/12 Contract Alliance Select 502 Family Deductible: $500/$1,000;$1,000/$2,000 No Monthly Aggregate Coinsurance: 20°/0 / 40% Weekly Draw OPM: $1,000/$2,000;$2,000/$4,000 648 Total Office Visit Copay: See OBS BlueRx Complete Deductible: $0 / $0 Copay: $15/$30/$50 FINAL RATES Estimated Annual Premium Level Fee/Contract Based on Current Enrollment Individual Stop Loss $100,000 $123.50 $960,336 Aggregate Stop Loss 125% $2.38 $18,507 Administrative Fees - Health w/weekly settlement $34.17 $265,706 Administrative Fees - PBM $1.42 $11,042 Consultant Fee $0.00 $0 Total Administrative Fees $161.47 $1,255,591 Network Access Fee $7.90 $61,430 Single Family Annual Projection Expected Claims $539.23 $1,348.08 $9,065,564 Administrative, NAF & Stop Loss Fees $78,34 $195,85 $1,317,053 Estimated Suggested Rates* $617.57 $1,543.93 $10,382,617 Attachment Points $674.04 $1,685.10 $11,331,960 Administrative, NAF & Stop Loss Fees $78.34 $195.85 $1.317.053 Estimated Maximum Liability to Fund* $752.38 $1,880.95 $12,649,013 *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 includes coverage for Health and Drug. The maximum Aggregate reimbursement is unlimited. Employer Signature: 5 Date: 5" ' ( 1P Comments: I v34882 Independent Licensee of the Blue Cross and Blue Shield Association Proposal Date: 4/11/2016 Wellmark. �a9 \Ytii?lark Btist Crtox and flue Stiled er a'.irkinpondwn l,xtmee of true Shoe Cross our Shut;.Shelia tisspciatot, Self Funded Alternate Rates Group Name: City of Waterloo Account Key: 00014392 Rating Period: 07/01/2016 to 06/30/2017 Consultant fee,if applicable,is an amount determined by the consultant and employer,and included here for the convenience of the employer to understand the total cost of services from Weltmark and the consultant. The consultant fee will be invoiced by Weltmark pursuant to agreement between Weltmark,Employer and Consultant. Weltmark 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 Wellmark'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.Weltmark 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. Weltmark will not determine whether coverage is discriminatory or otherwise in violation of Internal Revenue Code Section 105(h). Weltmark also will not provide any testing for compliance with internal Revenue Code Section 105(h). Weltmark will not be held liable for any penalties or other losses resulting from any employer offering coverage in violation of section 105(h). Weltmark will not determine whether any change in an Employer Administered Funding Arrangement affects a health plan's grandfathered health plan status under ACA or otherwise complies with ACA. Weltmark 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. v34882 Independent Licensee of the Blue Cross and Blue Shield Association Proposal Date:4/11/2016 Wei!mark. CO) M rno.Blue Crtv,.rirW Bk+e Stoe4 4111lNetondekii. L.etisee 01 the Blue CMS aad Blue 57u¢1Q ASSoc at+5r1. Self Funded Alternate Rates Group Name: City of Waterloo Account Key: 00014392 Rating Period: 07/01/2016 to 06/30/2017 Alternate Benefit Offering Enrollment Stop Loss Terms OBS#188067-22 /#188067-23 146 Single 24/12 Contract Alliance Select 502 Family Deductible: $500/$1,000;$1,000/$2,000 No Monthly Aggregate Coinsurance: 20%/40% Weekly Draw OPM: $1,000/$2,000;$2,000/$4,000 648 Total Office Visit Copay: See OBS BlueRx Complete Deductible: $0/$0 Copay:$15/$30/$50 FINAL RATES Estimated Annual Premium Level Fee/Contract Based on Current Enrollment Individual Stop Loss $100,000 $123.50 $960,336 Aggregate Stop Loss 125% $2.38 $18,507 Administrative Fees-Health w/weekly settlement $34.17 $265,706 Administrative Fees-PBM $1.42 $11,042 Consultant Fee $0.00 $0 Total Administrative Fees $161.47 $1,255,591 Network Access Fee $7.90 $61,430 Single Family Annual Projection Expected Claims $539.23 $1,348.08 $9,065,564 Administrative, NAF&Stop Loss Fees $78.34 $195.85 $1,317.053 Estimated Suggested Rates* $617.57 $1,543.93 $10,382,617 Attachment Points $674.04 $1,685.10 $11,331,960 Administrative, NAF&Stop Loss Fees $78.34 $195.85 $1.317.053 Estimated Maximum Liability to Fund* $752.38 $1,880.95 $12,649,013 *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 includes coverage for Health and Drug.The maximum Aggregate reimbursement is unlimited. Employer Signature: [ ,r���t.LJ Date: 5' ,- Comments: v34882 Independent Licensee of the Blue Cross and Blue Shield Association Proposal Date:4/11/2016 Wemark ; )6%4Im40,£iiu Crc:.x ar4 Buy$41,64 at,IncleprOwit. lceef see of IrM BtueCress rwe BIee 5ee30 Asuciatem. Self Funded Alternate Rates Group Name: City of Waterloo Account Key: 00014392 Rating Period: 07/01/2016 to 06/30/2017 Consultant fee,if applicable,is an amount determined by the consultant and employer,and included here for the convenience of the employer to understand the total cost of services from Wei/mark and the consultant The consultant fee will be invoiced by Wetlmark pursuant to agreement between Wetlmark,Employer and Consultant. We//mark 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 Wetlmark'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. Wetlmark 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. Wetlmark will not determine whether coverage is discriminatory or otherwise in violation of Internal Revenue Code Section 105(h). Wetlmark also will not provide any testing for compliance with Internal Revenue Code Section 105(h). Wetlmark will not be held liable for any penalties or other losses resulting from any employer offering coverage in violation of section 105(h). Wetlmark will not determine whether any change in an Employer Administered Funding Arrangement affects a health plan's grandfathered health plan status under ACA or otherwise complies with ACA. Wetlmark 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. v34882 Independent Licensee of the Blue Cross and Blue Shield Association Proposal Date:4/11/2016 Wellmark® 000Q2 • Wellmark Blue Cross and Blue Shield is 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 1 Des Moines,Iowa 50306-9232 I wellmark.com N-2305 5114 Page 1 of 2 Clear Form Wellmark® © � FOR ADMINISTRATIVE USE ONLY ® ® New Group:Group# Coverage Effective Date: I I Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association. 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. Employer Tax Identification Number:t• C L.0 C C 5 ( DTI 1 C Group Number(Renewing Groups Only): XA025-(See Matrix for Billing Units) Employer Name: City of Waterloo Employer Address: 715 Mulberry St City: Waterloo State: IA Zip: 50703 Contact Person: S mot- S c.)1N. -S Telephone Number: oZ3 _E-mail Address(optional): U It. .d5c-roar471. 10o'1q,. On) 1. Did your organization make contributions on behalf of any employee who was covered under a ®Yes ❑No 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, ®Yes ❑No 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, [i Yes ❑No 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 0 Yes [g No 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 0 Yes [ No 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 I certify that the information provided is accurate and truthful.All information will be used to identify the Medicare...._Second Payer status of Medicare-enrolled employees. —5 / gAr/ /(O Signatures Date Send completed MSP form based on following: IA&SD Large Groups(new or IA&SD Small Groups(new or IA Small Groups renewing with no SD Small Groups renewing with no renewal) renewing with benefit changes) benefit change-send this form to: benefit change Submit this completed MSP Submit this completed MSP form Fax:(515)376-9044 or Send this completed MSP form to: form with group's health plan with group's health plan new or Wellmark,Inc. Wellmark,Inc. new or renewal paperwork renewal paperwork PO Box 9232—Mail Station 3W396 PO Box 5023—Station 338 Des Moines,IA 50306-9232 Sioux Falls,SD 57117-5023 N-2305 5/14 Page 2 of 2 OBS - OBS ID: 188067-20 Note: This is a summary of benefits under this plan, not a statement of contract. The actual terms and conditions of coverage will be specified in the Group Insurance Policy issued by Wellmark or the Administrative Services Agreement between Wellmark and the entity below, as well as the Benefits Certificate and any amendments thereto. Benefit Summary - CITY OF WATERLOO Group Number/BU: XA025- Group Product Summary ID: 188067-20 Coverage Code: Alpha Prefix: CVVW Benefit Dates: 7/1/2016 - 6/30/2017 Summary Status: Rating Completed Account Manager: Harford, DeVonne 2016 renewal: Active $500/1000 PPO ded- Group Information Group Street Address 1 : Group Street Address 2: City/State/ZIP: , IA ProductNersion: Alliance Select (201009) Account Signature Date 5 - c7v7-1 4 General Renewing group Self-funded arrangement This plan or policy does meet minimum value Group is a government entity Union group Current union contract expiration date: 06/30/2016 Plan year begins on: 07/01 Healthcare Reform Non-Grandfathered Plan Benefit period is calendar year BlueCard PPO - In states with no PPO or PPO specialty, providers are treated as PPO as determined by Wellmark and the local Blue plan Eligibility An eligible child is married or unmarried and is under 26 years of age. An eligible child is an unmarried dependent full-time student regardless of age. An eligible child is disabled before age 26 and remains unmarried after age 26. An eligible child is unmarried and disabled while a full-time student after age 26. Dependent coverage terminates at the end of the month Two-way rate (single/family) Unmarried domestic partners are NOT covered http://wellnetapp.int.wellmark.corn/secure/obs/smryansw.asp?BUBSI.D=1062884{4/22/2016 3:18:28 PM] OBS-OBS ID:188067-20 Certificate coverage ends at the end of the month Subrogation applies Standard administration of coordination of benefits(COB) Routine maternity benefits apply to employee and spouse only Do not include ERISA Information Requirements language Coordination of benefits rules apply to members when Medicare is the primary payer Preexisting Condition Exclusion Periods New hires and special enrollees are covered when first eligible or at each group renewal. New hires and special enrollees are NOT subject to preexisting condition exclusion periods Late enrollees(a member who is not a new hire or special enrollee)may enroll at each group renewal. Late enrollees are NOT subject to preexisting condition exclusion periods Deductibles Coverage has benefit period deductibles Single deductible for PPO providers is:$500 Single deductible for non-PPO providers is:$1,000 Family deductible for PPO providers is:$1,000 Family deductible for non-PPO providers is:$2,000 Dual deductible amounts are aggregate(both ways)-PPO and non-PPO deductibles apply to each other Member has benefits after single deductible met.Entire family has benefits after family deductible has been met(or if a two-person amount is listed,then for two-person contracts, entire family has benefits after the two-person deductible has been met) Deductible from the previous 4th quarter will NOT carry over to this year's benefit period deductible Common accident deductible does NOT apply No Wellmark-to-Wellmark deductible credit.Credits will not transfer from one Wellmark employer group to another Wellmark employer group. Physician services for well-child care is NOT subject to the deductible Physician services for newborn care is NOT subject to the deductible. Facility services for well-child care is NOT subject to the deductible. Facility services for newborn's initial hospitalization are NOT subject to the deductible PPO outpatient preventive care Is NOT subject to the deductible PPO office services and PPO independent lab fees are NOT subject to the deductible PPO urgent care services are NOT subject to the deductible Most outpatient x-ray/lab services from PPO facilities are subject to the deductible One postpartum home visit if released within 48 hours after a vaginal delivery/96 hours after a cesarean delivery is NOT subject to the deductible httpJ/wellnetapp.intwellmark.com/secure/obs/smryansw.asp78UBSID=1062884[422/2016 3:18:28 PM) OBS-OBS ID:188067-20 All services with copays are NOT subject to the deductible Preventive care from PPO providers is NOT subject to the deductible Preventive care from participating providers is NOT subject to the deductible Prosthetic limbs from PPO providers are NOT subject to the deductible Other services NOT subject to the deductible are: -PPO office visit and independent labs for MHCD services Copay Primary Care Practitioner(PCP)is defined as General Practice(01), Family Practice(08), Internal Medicine(11), Obstetrics/gynecology(16), Pediatricians(37),and Nurse Practitioners(50 and 89), Physician Assistants(97). Office PCP copay-includes MHCD unless stated otherwise is:$20 Chiropractors,Speech Pathologists, Physical Therapists,and Occupational Therapists office copay amount is the same as the office PCP amount listed above Office Mental Health/Chemical Dependency copay amount is the same as the office PCP amount listed above All other providers are Non-Primary Care Practitioners(Non-PCP). Office non-PCP copay-includes MHCD unless stated otherwise is:$40 Office visit copay applies to services received from PPO practitioners Office visit copay is taken once per practitioner per date of service Office visit copay applies to any office services Preventive care is NOT subject to the office visit copay(copay is waived for preventive care) Office visit copay applies to the out-of-pocket maximum. Copay does NOT continue after the out-of-pocket maximum is met Deductible does NOT follow office visit copay Coinsurance does NOT follow office visit copay The following services have a different office visit copay:$20 copay for acupuncture. Urgent care copay is:$20 Urgent care copay applies to services received from both facility and practitioner combined Urgent care copay applies to services received from PPO providers Urgent care copay Is taken once per provider,per date of service Urgent care copay applies to all urgent care services Urgent care copay applies to the out-of-pocket maximum.Copay does NOT continue after the out-of-pocket maximum is met Deductible does NOT follow urgent care copay Coinsurance does NOT follow urgent care copay Coinsurance Coinsurance for PPO providers is the following percentage:20 http//wellnetapp.int.welimark.com/secure/obs/smryansw.asp?BUBSID 1062884[4/22(2016 3:18:28 PM] OBS-OBS ID: 188067-20 Coinsurance for non-PPO providers is the following percentage:40 One postpartum home visit if released within 48 hours after vaginal delivery/96 hours after cesarean delivery is NOT subject to coinsurance Services subject to copay are NOT subject to coinsurance Preventive care from PPO providers is NOT subject to coinsurance Preventive care from participating providers is NOT subject to the coinsurance Other services NOT subject to coinsurance are: -PPO office visit and independent labs for MHCD services. Out of Pocket Maximum Out-of-pocket maximums apply Single out-of-pocket maximum for PPO providers is:$ 1,000 Single out-of-pocket maximum for non-PPO providers is:$2,000 Family out-of-pocket maximum for PPO providers is:$2,000 Family out-of-pocket maximum for non-PPO providers is:$4,000 Participating providers are subject to the PPO OPM Dual out-of-pocket maximum amounts are aggregate(both ways)-PPO and non-PPO out-of- pocket maximum amounts apply to each other Member has benefits after single OPM met. Entire family has benefits after family OPM has been met(or if a two-person amount is listed,then for two-person contracts, entire family has benefits after the two-person OPM has been met) Deductible amounts apply to the out-of-pocket maximum Coinsurance for all services apply to the out-of-pocket maximum Deductible from the previous 4th quarter will NOT carry over to the out-of-pocket maximum for this year Coinsurance from the previous 4th quarter will NOT carry over to the out-of-pocket maximum for this year No Wellmark-to-Wellmark out-of-pocket credit.Credits will not transfer from one Wellmark employer group to another Wellmark employer group Lifetime Maximum Lifetime maximum is unlimited Lifetime maximum for hospice respite is limited to 15 days inpatient/15 days outpatient Facility Services Iowa Psychiatric Medical Institutions for Children are covered according to state mandate The cost of blood,blood components,and derivatives are covered Nonparticipating facility claims are based on maximum allowable fee You are covered for skilled nursing services received in a hospital or nursing facility with no limit.Services must be ordered and certified by your attending physician. Practitioner Services http://wellnetapp.int.weilmark.com/secure%obs/smryansw.asp?BUBSID=1062884[4/22/2016 3:18:28 PM] OBS-OBS ID:188067-20 Advanced nurse practitioners are covered Physician assistants are covered Licensed marriage family therapists are covered. Licensed mental health counselors are covered. Dental treatment for accidental injury is covered if completed within '12 months Surgical removal of impacted teeth is covered as an inpatient with a concurrent medical condition.Outpatient services are covered without a concurrent medical condition Treatment of temporomandibular joint disorder is covered,except for dental restorations/extractions,and orthodontic treatment Chiropractor services are covered as medically necessary Preventive Care/Immunizations/Mammography Preventive physical exams are covered.A separate gynecological exam is also covered One preventive physical exam per member per benefit period is covered Women's preventive care services are covered according to the ACA mandate Immunizations are covered(Travel Immunization excluded) Mammography benefits are covered according to Iowa mandate for women.Age 35-39=one base mammogram,age 40-49=one mammogram every two years,50 years of age and older=one mammogram every year. Preventive Pap smears are unlimited Routine vision exams are NOT covered Well-child and newborn care is covered according to mandate Hearing aids are covered as follows:Limited to$600 every 36 months. Routine hearing exams are covered as follows:Limited to$600 every 36 months combined with hearing aid benefit. Prescription Drugs/Contraceptives Retail drugs are covered under a Prescription Drug Program Prescription drugs/items for smoking cessation are covered under a Rx Program;related exams are covered under health Smoking cessation consultations are Included as part of preventive care Contraceptives are covered. Oral and drug delivery devices,such as insertable rings and patches,are covered under a Rx Program; injected,implanted,and medical devices,such as intrauterine devices and diaphragms,are covered under health Contraceptives covered under health are included as part of preventive care Most specialty self-administered drugs are covered under the Prescription Drug Program, NOT under Health.This drug listing can be found on www.wellmark.com under the General Pharmacy Information Other Services Supplemental accidental injury benefits are NOT covered Reminder Programs are NOT available http://wellnetapp.int.wellmark.com/secure/obs/smryansw.asp?BUBSID=1062884[4/22/2016 3:18:28 PM] OBS - OBS ID: 188067-20 Diabetic education programs are covered according to mandate Hospice services are covered Infertility benefits are NOT covered Coverage for Home Medical Equipment is unlimited. Bariatric surgery and related treatment is covered Major organ transplants are covered. Prior approval required. Transplants are NOT limited to Blue Distinction Centers for Transplant MHCD Mental health/chemical dependency treatment is unlimited Notification Requirements If you are admitted to a nursing facility, an acute rehabilitation facility, or a hospital outside the states of Iowa or South Dakota, you or someone acting on your behalf must contact us to precertify your admission. Refer to www.wellmark.com for other services subject to precertification. Related facility services may be subject to a reduction for failure to follow notification requirements - refer to your coverage manual or plan description for details. All services are subject to reduction for failure to follow notification requirements. Iowa Psychiatric Medical Institutions for Children is subject to precertification. Failure to precertify will result in a benefit reduction. All services are subject to reduction for failure to follow notification requirements Reduction for failure to precertify is 50 percent Additional Information Exclude elective abortion. Acupuncture is covered. SPD Requested. http://wellnetapp.int.wellrnark.corn/securelobs/snuyansw.asp?BUBSID=1062884[4122/2016 3:18:28 PM] OBS-OBS ID: 188067-22 Note:This is a summary of benefits under this plan, not a statement of contract.The actual terms and conditions of coverage will be specified in the Group Insurance Policy issued by Wellmark or the Administrative Services Agreement between Wellmark and the entity below,as well as the Benefits Certificate and any amendments thereto. Benefit Summary-CITY OF WATERLOO Group Number/BU: XA025- Group Product Summary ID: 188067-22 Coverage Code: Alpha Prefix: CWW Benefit Dates: 7/1/2016-6/30/2017 Summary Status: Rating Completed Account Manager: Harford, DeVonne 2016 renewal: Retiree$500/1000 PPO ded; Group Information Group Street Address 1: Group Street Address 2: City/State/ZIP: , IA ProductNersion: Alliance Select(201009) Account SignatureSiL Date 5—jaidrice.. General Renewing group Self-funded arrangement This plan or policy does meet minimum value Group is a government entity Union group Current union contract expiration date: 06/30/2016 Plan year begins on:07/01 Healthcare Reform Non-Grandfathered Plan Benefit period is calendar year BlueCard PPO- In states with no PPO or PPO specialty, providers are treated as PPO as determined by Wellmark and the local Blue plan Eligibility An eligible child is married or unmarried and is under 26 years of age. An eligible child is an unmarried dependent full-time student regardless of age. An eligible child is disabled before age 26 and remains unmarried after age 26. An eligible child is unmarried and disabled while a full-time student after age 26. Dependent coverage terminates at the end of the month Two-way rate(single/family) Unmarried domestic partners are NOT covered http://wellnetapp.int.wellmark.com/secure/obs/smryansw.asp?BUBSID=I 062888[4/22/2016 3:17:35 PM] OBS-OBS ID:188067-22 Certificate coverage ends at the end of the month Subrogation applies Standard administration of coordination of benefits(COB) Routine maternity benefits apply to employee and spouse only Do not include ERISA Information Requirements language Coordination of benefits rules apply to members when Medicare is the primary payer Additional eligibility information:For members who are eligible for Medicare Part B,but elect not to take Medicare Part B,benefits are reduced by the benefit amount to which they are entitled,or could have been entitled,with enrollment under Medicare Part B. Preexisting Condition Exclusion Periods New hires and special enrollees are covered when first eligible or at each group renewal. New hires and special enrollees are NOT subject to preexisting condition exclusion periods Late enrollees(a member who is not a new hire or special enrollee)may enroll at each group renewal. Late enrollees are NOT subject to preexisting condition exclusion periods Deductibles Coverage has benefit period deductibles Single deductible for PPO providers is:$500 Single deductible for non-PPO providers is:$1,000 Family deductible for PPO providers is:$1,000 Family deductible for non-PPO providers is:$2,000 Dual deductible amounts are aggregate(both ways)-PPO and non-PPO deductibles apply to each other Member has benefits after single deductible met.Entire family has benefits after family deductible has been met(or if a two-person amount is listed,then for two-person contracts, entire family has benefits after the two-person deductible has been met) Deductible from the previous 4th quarter will NOT carry over to this year's benefit period deductible Common accident deductible does NOT apply No Wellmark-to-Wellmark deductible credit.Credits will not transfer from one Wellmark employer group to another Wellmark employer group. Physician services for well-child care is NOT subject to the deductible Physician services for newborn care is NOT subject to the deductible. Facility services for well-child care is NOT subject to the deductible. Facility services for newborn's initial hospitalization are NOT subject to the deductible PPO outpatient preventive care is NOT subject to the deductible PPO office services and PPO independent lab fees are NOT subject to the deductible PPO urgent care services are NOT subject to the deductible http://wellnetapp.intwellmark.com/secure/obs/smryansw.asp?BUBSID=1062888[4/22/2016 3:17:35 PM] OBS-OBS ID:188067-22 Most outpatient x-ray/lab services from PPO facilities are subject to the deductible One postpartum home visit if released within 48 hours after a vaginal delivery/96 hours after a cesarean delivery is NOT subject to the deductible All services with copays are NOT subject to the deductible Preventive care from PPO providers is NOT subject to the deductible Preventive care from participating providers is NOT subject to the deductible Prosthetic limbs from PPO providers are NOT subject to the deductible Other services NOT subject to the deductible are: -PPO office visit and independent labs for MHCD services Copay Primary Care Practitioner(PCP)is defined as General Practice(01),Family Practice(08), Internal Medicine(11),Obstetrics/gynecology(16),Pediatricians(37),and Nurse Practitioners(50 and 89), Physician Assistants(97). Office PCP copay-includes MHCD unless stated otherwise is:$20 Chiropractors, Speech Pathologists,Physical Therapists,and Occupational Therapists office copay amount is the same as the office PCP amount listed above Office Mental Health/Chemical Dependency copay amount is the same as the office PCP amount listed above All other providers are Non-Primary Care Practitioners(Non-PCP). Office non-PCP copay-includes MHCD unless stated otherwise is: $40 Office visit copay applies to services received from PPO practitioners Office visit copay is taken once per practitioner per date of service Office visit copay applies to any office services Preventive care is NOT subject to the office visit copay(copay is waived for preventive care) Office visit copay applies to the out-of-pocket maximum.Copay does NOT continue after the out-of-pocket maximum is met Deductible does NOT follow office visit copay Coinsurance does NOT follow office visit copay The following services have a different office visit copay:$20 copay for acupuncture. Urgent care copay is:$20 Urgent care copay applies to services received from both facility and practitioner combined Urgent care copay applies to services received from PPO providers Urgent care copay is taken once per provider, per date of service Urgent care copay applies to all urgent care services Urgent care copay applies to the out-of-pocket maximum.Copay does NOT continue after the out-of-pocket maximum is met Deductible does NOT follow urgent care copay Coinsurance does NOT follow urgent care copay http://wellnetapp.int.wellmark.corn/secure/obs/smryansw.asp?BUBSID=1062888[4/22/2016 3:17:35 PM1 OBS-OBS ID:188067-22 Coinsurance Coinsurance for PPO providers is the following percentage:20 Coinsurance for non-PPO providers is the following percentage:40 One postpartum home visit if released within 48 hours after vaginal delivery/96 hours after cesarean delivery is NOT subject to coinsurance Services subject to copay are NOT subject to coinsurance Preventive care from PPO providers is NOT subject to coinsurance Preventive care from participating providers is NOT subject to the coinsurance Other services NOT subject to coinsurance are: -PPO office visit and independent labs for MHCD services. Out of Pocket Maximum Out-of-pocket maximums apply Single out-of-pocket maximum for PPO providers is: $1,000 Single out-of-pocket maximum for non-PPO providers is:$2,000 Family out-of-pocket maximum for PPO providers is:$2,000 Family out-of-pocket maximum for non-PPO providers is:$4,000 Participating providers are subject to the PPO OPM Dual out-of-pocket maximum amounts are aggregate(both ways)-PPO and non-PPO out-of- pocket maximum amounts apply to each other Member has benefits after single OPM met. Entire family has benefits after family OPM has been met(or if a two-person amount is listed,then for two-person contracts,entire family has benefits after the two-person OPM has been met) Deductible amounts apply to the out-of-pocket maximum Coinsurance for all services apply to the out-of-pocket maximum Deductible from the previous 4th quarter will NOT carry over to the out-of-pocket maximum for this year Coinsurance from the previous 4th quarter will NOT carry over to the out-of-pocket maximum for this year No Wellmark-to-Wellmark out-of-pocket credit.Credits will not transfer from one Wellmark employer group to another Wellmark employer group Lifetime Maximum Lifetime maximum is unlimited Lifetime maximum for hospice respite is limited to 15 days inpatient/15 days outpatient Facility Services Iowa Psychiatric Medical Institutions for Children are covered according to state mandate The cost of blood,blood components, and derivatives are covered Nonparticipating facility claims are based on maximum allowable fee http://wellnetapp.int.wellmark.com/secure/obs/smryansw.asp?BUBSID=1062888[4/22/2016 3:17:35 PM] OBS-OBS ID:188067-22 You are covered for skilled nursing services received in a hospital or nursing facility with no limit.Services must be ordered and certified by your attending physician. Practitioner Services Advanced nurse practitioners are covered Physician assistants are covered Licensed marriage family therapists are covered. Licensed mental health counselors are covered. Dental treatment for accidental injury is covered if completed within 12 months Surgical removal of impacted teeth is covered as an inpatient with a concurrent medical condition. Outpatient services are covered without a concurrent medical condition Treatment of temporomandibular joint disorder is covered,except for dental restorations/extractions,and orthodontic treatment Chiropractor services are covered as medically necessary Preventive Care/immunizations/Mammography Preventive physical exams are covered.A separate gynecological exam is also covered One preventive physical exam per member per benefit period is covered Women's preventive care services are covered according to the ACA mandate Immunizations are covered(Travel Immunization excluded) Mammography benefits are covered according to Iowa mandate for women.Age 35-39=one base mammogram,age 40-49=one mammogram every two years,50 years of age and older=one mammogram every year. Preventive Pap smears are unlimited Routine vision exams are NOT covered Well-child and newborn care is covered according to mandate Hearing aids are covered as follows: Limited to$600 every 36 months. Routine hearing exams are covered as follows:Limited to$600 every 36 months combined with hearing aid benefit. Prescription Drugs/Contraceptives Retail drugs are covered under a Prescription Drug Program Prescription drugs/items for smoking cessation are covered under a Rx Program;related exams are covered under health Smoking cessation consultations are included as part of preventive care Contraceptives are covered. Oral and drug delivery devices, such as insertable rings and patches,are covered under a Rx Program;injected, implanted,and medical devices, such as intrauterine devices and diaphragms,are covered under health Contraceptives covered under health are included as part of preventive care Most specialty self-administered drugs are covered under the Prescription Drug Program, NOT under Health.This drug listing can be found on www.wellmark.com under the General Pharmacy Information http://wellnetapp.int.wellmark.com/secure/Obs/smryansw.asp?BUBSID=1062888[4/22/2016 3:17:35 PM] OBS - OBS ID: 188067-22 Other Services Supplemental accidental injury benefits are NOT covered Reminder Programs are NOT available Diabetic education programs are covered according to mandate Hospice services are covered Infertility benefits are NOT covered Coverage for Home Medical Equipment is unlimited. Bariatric surgery and related treatment is covered Major organ transplants are covered. Prior approval required. Transplants are NOT limited to Blue Distinction Centers for Transplant MHCD Mental health/chemical dependency treatment is unlimited Notification Requirements If you are admitted to a nursing facility, an acute rehabilitation facility, or a hospital outside the states of Iowa or South Dakota, you or someone acting on your behalf must contact us to precertify your admission. Refer to www.wellmark.com for other services subject to precertification. Related facility services may be subject to a reduction for failure to follow notification requirements - refer to your coverage manual or plan description for details. All services are subject to reduction for failure to follow notification requirements. Iowa Psychiatric Medical Institutions for Children is subject to precertification. Failure to precertify will result in a benefit reduction. All services are subject to reduction for failure to follow notification requirements Reduction for failure to precertify is 50 percent Additional Information Exclude elective abortion. Acupuncture is covered. SPD Requested. http://wellnetapp.int.wellmark.com/secure/obs/smryansw.asp?BUBSID=1062888[4/22/2016 3:17:35 PM] OBS-OBS ID: 188067-23 Note:This is a summary of benefits under this plan, not a statement of contract.The actual terms and conditions of coverage will be specified in the Group Insurance Policy issued by Wellmark or the Administrative Services Agreement between Wellmark and the entity below,as well as the Benefits Certificate and any amendments thereto. Benefit Summary-CITY OF WATERLOO Group Number/BU:XA025- Group Product Summary ID: 188067-23 Coverage Code: Alpha Prefix: Benefit Dates:7/1/2016-6/30/2017 Summary Status: Rating Group Account Manager: Harford, DeVonne ALT: PPO Rx$15/30/50 copay Group Information Group Street Address 1: Group Street Address 2: City/State/ZIP: , IA Product/Version: Prescription Drug Program-Custom(201112) Account Signature t Date —earn � ,� General Wellmark Blue Cross Blue Shield of Iowa BlueRx Complete(3-tier) Renewal Self-funded arrangement Large business group(301-750) Group is a Government Entity Benefit period is defined as calendar year Healthcare Reform Non-Grandfathered Plan(ACA required drugs are covered and member cost-share is waived according to preventive care guidelines.A complete list of recommendations and guidelines related to ACA preventive services can be found at www.healthcare.gov) Plan year begins on:07/01 Eligibility When benefits have been provided by another plan,Wellmark applies benefits the lesser of 1)the amount on the claim as the member's liability or 2)what we should have paid if the claim was submitted to us first. Payment Benefit period deductibles do NOT apply Out-of-Pocket Maximum (OPM): Single out-of-pocket maximum is$5,600 Family out-of-pocket maximum is$ 11,200 http://wellnetapp.int.wellmark.com/secure/obs/smryansw.asp?BUBSID=1066318[4/22/2016 3:19:17 PM] OBS-OBS ID: 188067-23 No Wellmark to Wellmark out-of-pocket credit. Credits will not transfer from one Wellmark employer group to another Wellmark employer group. Member has benefits after single OPM met. Entire family has benefits after family OPM has been met(or if a two-person amount is listed,then for two-person contracts,entire family has benefits after the two-person OPM has been met) Days Supply(per member cost-share):30 days Payment Application(per member cost-share): Tier 1 copayment is$ 15 Tier 2 copayment is$30 Tier 3 copayment is$50 Specialty Drugs Payment Application(member cost-share per 30-day supply): The payment application for specialty drugs is the same as listed above in the Payment Application section.The specialty drug list can be found on www.wellmark.com under General Pharmacy Information. 90-Day Maintenance Supply: At retail pharmacy:90-day supply of maintenance drugs available for 3 copayments OR coinsurance per 90-day supply. Through mail order:90-day supply of maintenance drugs available for 2 copayments OR coinsurance per 90-day supply. Product Selection Penalty Rule:When a brand drug is obtained and there is an equivalent generic drug available,the member is responsible for paying their payment obligation for the equivalent generic(i.e. lowest payment application)and any remaining cost difference up to the maximum allowed fee for the brand name drug except when the provider writes "Dispense as Written"(in this case,the member pays only the appropriate payment application). Utilization Management Programs apply Benefits Contraceptives are covered Smoking Cessation: Prescription drugs only are covered Coverage of specialty drugs NOT limited to Specialty Pharmacy Program Prescription drugs covered when purchased through Participating and Non-Participating Pharmacies.Member must submit paper claim for reimbursement when purchased through a Non-Participating pharmacy. Additional Information $0 for Oral chemo medications SPD requested. $0 copay for smoking cessation prescription drugs. http://wellnetapp.int.wellmark.com/secure/obsfsmryansw.asp?BUBSID=1066318[4/22/2016 3:19:17 PM]