HomeMy WebLinkAboutDocumentation_Regular_Tab 9A_9/13/2001 I ` 1
H 1670
X4.1'14
Memo This document contains time-sensitive information. Please read
immediately and'respond as specified.
To Michael R. Couzzo,Jr.,Village Manager�(),,
From Kim Bodinizzo, Personnel Specialist l J ,/
Date/Time September 6,2001
Subject Consideration of Approval of Group Service Agreement with
CIGNA HealthCare of Florida, Inc.
C.)� Prior to the renewal of the Village's group health insurance policy on
October I st of each year, Acordia reviews the market to possibly
obtain equivalent coverage at a competitive rate. This year, the
Village has been presented a quote from CIGNA HealthCare of
Florida, Inc. for a policy which provides comparable benefits, as well
as some improvements to the current Florida Municipal Insurance
Trust (FMIT) Point-of-Service (POS) Policy. The CIGNA policy,
which is a dual-option HMO/POS open access policy, will provide a
considerable savings-to Village, as well as to our employees electing
dependent coverage. For these reasons, we believe it is in the best
interest of Village -and -our-employees to change health insurance
providers from FMIT to CIGNA effective October I, 2001,
contingent upc i Village-C-ountil approval.
Attached please find the following documents:
Village of Tequesta Group Benefit Plan August 2001 Prepared by Steven
J. Olsen,Vice-President,Acordia I
CIGNA HealthCare of Florida, Inc. Group Service Agreement`
(Sample Document) M
If approved by the Village Council, the Group Service Agreement u.,_ ....
between CIGNA #HeaithCare.-of Florida, Inc. and the Village of
Tequesta would remain in force for a period of 12 months, during
which time thq-rates are guaranteed.
Thank you for your-consideration-of-this important matter.
/krb 250 Tequesta Drive
Attachments Suite 300
Tequesta,Florida 33469
561-575-6209
561-575-6203 Fax
CIGNA HEALTHCARE OF FLORIDA, INC.
Face Sheet
•
to the
CIGNA HEALTHCARE GROUP SERVICE AGREEMENT
which is incorporated herein by reference.
AGREEMENT NUMBER: insert agreement number
PARTIES TO AGREEMENT:
HEALTHPLAN: CIGNA HealthCare of Florida,Inc.
and
GROUP: insert group name
TERM OF AGREEMENT
The initial term of the Agreement shall be from insert effective date (the "Effective Date")until
insert termination date . The Agreement shall continue in effect for the initial term and shall be
automatically renewed as of the Anniversary Date of Agreement on a yearly basis thereafter until
terminated. The Anniversary Date of Agreement shall be insert anniversary date.
PREPAYMENT FEES AND GRACE PERIOD
On or before the last day of each month, Group shall remit to the Healthplan on behalf of each
Subscriber and his Dependents the Prepayment Fee specified as follows in payment for services
rendered under this Agreement in the following month. The Healthplan shall permit a grace
period of thirty-one(31)days during which the Prepayment Fees may be paid without loss of
coverage under the Agreement. In the event this Agreement terminates and there are Prepayment
Fees due to the Healthplan,the Group will be financially responsible for the Prepayment Fees.
This responsibility will be in addition to any other financial obligation of the Group hereunder.
Group shall pay Prepayment Fees each month in the following amounts:
Membership Unit
Prepayment Fee
insert prepayment fee
GSA-FS(01)FL 1 9/99
ENROLLMENT
The Healthplan is only required to consider enrollment applications received by the Healthplan (i)
during the Open Enrollment Period or within sixty(60)days thereafter, or(ii)within sixty(60)
days of the event creating eligibility. The Healthplan shall have the right, at reasonable times,to
examine Group records, including the payroll records of Subscribers for the purpose of confirming
eligibility and appropriate Prepayment Fees under the Agreement.
An individual who did not enroll for coverage under the Agreement during the initial eligibility
period or Open Enrollment Period may enroll for coverage in accordance with the "Enrollment
after the Open Enrollment Period"provision in"Section II. Enrollment and Effective Date of
Coverage"section.
GROUP'S ENROLLMENT/ELIGIBILITY RULES
Group's enrollment and/or eligibility rules for its Subscribers and their Dependents are as follows:
insert group specific enrollment info
Unless otherwise stated above, the eligibility provisions set forth in"Section II. "Enrollment and
Effective Date of Coverage"section of the Agreement will govern.
DISENROLLMENT
Group shall notify Healthplan of all employment terminations or other losses of eligibility of
Subscribers and of losses of eligibility of Dependents ("Notice of Termination"). Unless otherwise
required by law, coverage for the Subscribers and/or Dependents shall cease at midnight on the
day the loss of eligibility occurs, and Group shall remit Prepayment Fees in accordance to the rules
described under the section entitled "Payment Method for Group",through the date coverage
ceased, subject to the following rules and exceptions:
1. Notice of Termination must be received by Healthplan within sixty(60)days of the date
on which employment termination or loss of eligibility first occurred.
2. If Notice of Termination is not received by Healthplan within sixty(60) days of the date
on which employment termination or loss of eligibility first occurred, then coverage shall
cease at midnight on the date which is sixty(60)days prior to the date Notice of
Termination is received and Group shall be responsible for and shall submit to Healthplan
all Prepayment Fees due through the date coverage ceased.
GSA-FS(01)FL 2 9/99
CERTIFICATION OF COVERAGE
Healthplan shall issue Certificates of Group Health Plan Coverage to Members who end coverage
with Group,provided that Group reports enrollment, disenrollment and other necessary
information to Healthplan, according to transactions arranged between Healthplan and Group.
Alternatively, Group may agree in writing to take primary responsibility or to assign responsibility
to a third party for issuing Certificates of group Health Plan Coverage to Members who end
coverage with Group.
At the request of Group and upon payment of the applicable fee by Group, Healthplan shall report
Member enrollment dates and disenrollment dates to Group after open enrollment periods and
upon termination of the Agreement.
PAYMENT METHOD FOR GROUP
A. New Enrollment
1. If coverage begins on or before the fifteenth (15th)day of the month, a
Prepayment Fee is due for that month.
2. If coverage begins on any other day of the month,no Prepayment Fee is due for
that month.
B. Termination
1. If coverage ceases on or before the fifteenth (15th)day of the month,no
Prepayment Fee is due for that month.
2. If coverage ceases on any other day of the month, a Prepayment Fee is due for that
month.
SCHEDULE OF COPAYMENTS
The Schedule of Copayments designating the amounts charged to Members for receipt of covered
services and benefits is attached hereto.
TERMINATION OF AGREEMENT
1. Termination for Non-Payment of Fees. We may terminate this Agreement for the Group's
non-payment of any Prepayment Fees owed to us.
2. Termination on Notice. The Group,without cause, may terminate this Agreement upon
sixty(60) days prior written notice to us. We,without cause,may terminate this
Agreement upon either: (i)ninety(90) days prior written notice to the Group of our
decision to non-renew this particular type of coverage; or(ii) one hundred eighty(180)
days prior written notice to the Group of our decision to non-renew all coverage in the
applicable market. If coverage is terminated in accordance with (i) above, the Group may
purchase a type of coverage currently being offered in that market.
3. Termination for Fraud or Misrepresentation. We may terminate this Agreement upon
forty-five (45) days prior written notice to the Group if, at any time,we determine that the
Group has performed an act or practice that constitutes fraud or has intentionally
misrepresented a material fact.
4. Termination for Violation of Contribution or Participation Rules. We may terminate this
Agreement upon forty-five (45)days prior written notice to the Group if, after the initial
GSA-FS(01)FL 3 9/99
twelve (12)month or other specified time period, it is determined that the Group is not in
compliance with the participation and/or contribution requirements as established by us.
5. Termination Due to Association Membership Ceasing. If this Agreement covers an
association,we may terminate this Agreement in accordance with applicable state or
federal law as to a member of a bona fide association if the member is no longer a member
of the bona fide association.
6. Termination in Accordance with State and/or Federal law. We may terminate this
Agreement upon prior notice to the Group in accordance with any applicable state and/or
federal law.
Termination Effective Date. Coverage under this Agreement shall terminate at midnight of the
date of termination provided in the written notice, except in the case of termination for non-
payment of fees, in which case this Agreement shall terminate immediately upon our notice to the
Group. However, we will not retroactively cancel the Agreement for non-payment of fees,to a
date prior to the date HEALTHPLAN sends notice of the termination to the Group, unless we
send notice to the Group prior to(forty-five)45 days following the Prepayment Fee due date.
Notice of Termination to Members. If this Agreement is terminated for any reason in this section,
the Group shall notify you of the termination effective date and any applicable rights you may
have.
Responsibility for Payment. The Group shall be responsible for the payment of all Prepayment
Fees due through the date on which coverage ceases. You shall be financially responsible for all
services rendered after that date. The Group shall be responsible for providing appropriate notice
of cancellation to all Members in accordance with applicable state law. If the Group fails to give
written notice to you prior to such date,the Group shall also be financially responsible for, and
shall submit to us, all Prepayment Fees due until such date as the Group gives proper notice.
AMENDMENT OR MODIFICATION OF AGREEMENT
1. Consent of Parties. The Agreement may be amended at any time through a subsequent
written agreement between Group and Healthplan. Amendments are effective
immediately unless otherwise provided.
2. Modification by Law or Regulation. The provisions of the Agreement are subject to the
approval of all regulatory bodies and in the event that regulatory bodies request any
modification of the Agreement, such modification shall supersede the provisions of the
Agreement. Furthermore, any state or federal laws or regulations enacted or promulgated
which are in conflict with the provisions of the Agreement shall be deemed modifications
of the Agreement on the date such enactment or promulgation is applicable to this
Agreement.
Healthplan may modify the Prepayment Fees upon any change in state or federal laws
affecting the Agreement by giving to Group at least thirty(30)days prior written notice.
3. Uniform Modification of Coverage. At renewal,the provisions of this Agreement may be
modified to reflect product revisions which have uniformly been made to this product.
4. Modification by Notice From Healthplan. Healthplan may modify the provisions of the
Agreement including any Prepayment Fees, Copayments and Supplemental Charges on
any Anniversary Date of Agreement by giving to Group at least thirty(30)days prior
written notice. Unless Group within fifteen (15) days of receipt of such notice provides
GSA-FS(01)FL 4 9/99
written notice to Healthplan of its intention to terminate this Agreement at the end of the
term,the modification shall become effective on the date contained in the notice and shall
apply to all Members whether or not the applicable Prepayment Fee has been paid.
NOTICE
Any written notice required under the Agreement shall be hand-delivered or mailed through the
United States Postal Service,postage prepaid, addressed as follows:
To GROUP: insert group name
insert group street address
insert group city, state, zip
Or,if Group elects to have notices delivered or mailed to a designated agent, such notices shall be
deemed as having been received by Group if hand-delivered or mailed to the following person and
address: insert agent address
To Healthplan: CIGNA HealthCare of Florida, Inc.
5404 Cypress Center Drive, Suite 150
Tampa,Florida 33609
Other Offices
1101 N. Lake Destiny Road, Suite 300
Maitland, Florida 32751
6700 N. Andrews Avenue, Suite 300
Ft. Lauderdale,Florida 33309
To Member: To the latest address furnished by Group or by the Member to Healthplan.
AMENDMENTS,RIDERS AND ADDITIONAL PROVISIONS
insert riders, etc.
DISCRETIONARY CLAIM AUTHORITY
The Plan Administrator(Employer)hereby delegates to Healthplan the discretionary authority to
interpret and apply plan terms and to make factual determinations in connection with its review of
claims under the plan. Such discretionary authority is intended to include,but is not limited to,the
determination of the eligibility of persons desiring to enroll in or claim benefits under the plan, the
determination of whether a person is entitled to benefits under the plan, and the computation of
any and all benefit payments. The Plan Administrator(Employer) also delegates to Healthplan the
GSA-FS(01)FL 5 9/99
discretionary authority to perform a full and fair review, as required by ERISA, of each claim
denial which has been appealed by the claimant or his duly authorized representative.
This language should be made a part of your Summary Plan Description.
GSA-FS(01)FL 6 9/99
NOTE: Include this page only when Performance Guarantees have been_agreed upon. Performance
Guarantees are NOT allowed for groups with,under 500 lives.
PERFORMANCE GUARANTEES
Healthplan shall pay to Group the following amounts if it does not provide the services specified:
insert performance guarantees
GSA-FS(02) 7 9/99
ACCEPTANCE OF AGREEMENT
In witness whereof, the Parties enter into the CIGNA HEALTHCARE GROUP SERVICE AGREEMENT
through the execution of this Face Sheet by their duly authorized representatives. In the event Group does
not sign this Acceptance of Agreement section, Group's payment of any Prepayment Fees will be
considered acceptance of the terms and conditions of this Agreement.
Healthplan: CIGNA HealthCare of Florida, Inc.
By: a `' ) � c..4
Title: Andrew D. Crooks,President and General Manager
Date: insert date
Group: insert group name
Address: insert group address
By:
Title: insert title of signatory
Date: insert date
GSA-FS(03) 8 9/99
CIGNA HEALTHCARE OF FLORIDA,INC.
ACCEPTANCE/REJECTION OF CERTAIN STATE "MANDATORY OFFER"BENEFITS
The Group has accepted/rejected the following benefits:
Substance Abuse Benefit
The Group n ACCEPTS REJECTS the Substance Abuse Benefit of thirty(30) days per contract
year for inpatient services and forty-four(44)sessions per contract year for outpatient services, as provided
in Florida Statute Title XXXVII, Chapter 627,Part VII.627.669. If Accepted,the benefit will be reflected
in the Schedule of Copayments.
Mental Health Benefit
The Group ACCEPTS REJECTS the Mental Health Illness Benefit of(30) days per contract
year for inpatient services and up to $1,000 maximum per contract year for inpatient services as provided
in Florida Statute Title XXXVII, Chapter 627,Part VII.627.668. If Accepted,the benefit will be reflected
in the Schedule of Copayments.
VILLAGE OF TEQUESTA
GROUP BENEFIT PLAN
AUGUST 2001
r � •
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Prepared For:
VILLAGE OF TEQUESTA
August 2001
Presented by:
Steven J. Olsen
Vice President
CS4ordia.
501 South Flagler Drive, Suite 600
West Palm Beach, FL 33401
(561) 655-5500
q 6 41 mi,.f&g
West Palm Beach
Insurance•Bonding•Employee Benefits
TABLE OF CONTENTS
1. INTRODUCTION
2. OBJECTIVES
3. MEETING THE OBJECTIVES
4. SERVICES
5. MEDICAL BENEFIT COMPARATIVE ANALYSIS
FLORIDA MUNICIPAL
6. MEDICAL BENEFIT COMPARATIVE ANALYSIS
FLORIDA MUNICIPAL/CIGNA
7. MEDICAL BENEFIT COMPARATIVE ANALYSIS
FLORIDA MUNICIPAL/CIGNA
8. MEDICAL BENEFIT COMPARATIVE ANALYSIS
FLORIDA MUNICIPAL/BLUE CROSS
9. DENTAL BENEFIT COMPARATIVE ANALYSIS
GUARDIAN
4.:
tr-o!;Wil
tff;
ragei-r,
riFbuc;gtst
West Palm Beach
Insurance Bonding Employee Benefits
INTRODUCTION
Thank you for allowing us the opportunity to quote your group benefits plan. Our objective is to design a program that is affordable
and offers the comprehensive care your employees have come to value. We are sure you will agree that such a plan is found in this
proposal.
Acordia Southeast is an insurance brokerage organization specializing in a full range of high quality insurance, employee benefits,
financial products, and services. Acordia Southeast is also part of the Acordia Group of Companies --the sixth largest insurance
broker in the United States. Each of our clients benefit from the national contracts this affiliation brings us.
The types of services we provide our clients include: Group
Medical
401K Pension & Deferred Compensation,
Profit Sharing Plans Universal Life,
Keyman Insurance
Short and Long C^ �cordia. Group
Term Disability Life
Section 125,
Cancer Insurance, Commercial
Long Term Care Insurance Property & Casualty
Dental
Our mission is to explore your needs and offer customized solutions to fulfill your company's objectives. We are certain that both
Village of Tequesta and Acordia Southeast will benefit from a long lasting and mutually profitable business relationship. W'e�r. m `� -git }
forward to being of continuing service. , , ,
.ter
1 West Palm Beach
Insurance o Bonding o Employee Benefits
s
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OBJECTIVES
The objectives established for this proposal are as follows:
* Evaluate the present program based on employer's specifications;
* Improve on administration and service of present program coverage; and
* Where possible, improve the cash outlay of your present benefit program.
tom '
ile
2 West Palm Beach
Insurance o Bonding o Employee Benefits
•
•
MEETING THE OBJECTIVES
To meet the objectives established for this proposal, we have reviewed the current benefit package of Village of Tequesta and compared it
with several insurance companies that have experience with groups of your size:
BLUE CROSS GUARDIAN
CIGNA JEFFERSON PILOT(Declined to quote)
AETNA UNITED HEALTHCARE
On the following pages we are presenting a summary of benefits from those carriers who were competitive, along with rates that were
quoted based on your current employee census.
The proposed rates are based on census data originally submitted. Final rates will be based on actual enrollment to be effective 10/1/01.
Rates quoted herein are subject to adjustment if there is a change in the proposed effective date,the package of benefits illustrated, or the
census information used to determine final rates.
a p t 7rA
7` �qq S
3 West Palm Beach
Insurance 0 Bonding a Em ployee Benefits
SERVICES
If Village of Tequesta elects to change from their current carrier, Acordia Southeast will implement the conversion from your present
program to the plan selected. We will implement the delivery of a master policy, employee benefits booklets, and represent the
employer as agent.
In addition to the standard services coordinated by Acordia employee benefits, we will conduct employee meetings for program
review.
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4 West Palm Beach
Insurance•Bonding•Employee Benefits
•
•
•
CIGNA
Underwriting Contingencies
For
Village of Tequesta (cont.)
*Medical History Information is accurate to the best of your knowledge
*Out of Network benefit maximums are reduced by In-Network utilization.
*Urgent Care is subject to plan deductible and coinsurance if member is out of area.
*Emergencies are always covered In-Network provided that the situation meets CIGNA HealthCare's
standard definition of an Emergency.
*All covered Out-of-Network services are subject to plan deductible and coinsurance.
*Out-of-Network Chiropractic,Durable Medical Equipment,External Prosthetic Appliances,Infertility,
Prescription Drug, Vision,Mental Health/Substance Abuse and Organ Transplants are not covered.
*Short-term rehabilitation: If a 90-visit option is selected,participants will be permitted a maximum of 60
Out-of-Network visits reduced by In-Network utilization.
*At CIGNA's option,this Proposal,and any rate,fee,trend,or other guarantee included in this Proposal,
or agreements arising from this proposal,shall be void in the event of Federal, State or Local action
impacting the benefit levels quoted herein or affecting our ability to meet our obligations to you,to your
employees/our members or to our contracted providers. By way of illustration,such legislation or
executive actions which impose controls or requirements that affect: our ability to determine rates;covered
medical expenses or service benefits;providers'delivery of care or the fees they charge;or our contracts
with providers,may be deemed to so affect our contractual obligations. Should this happen,CIGNA will
make a good faith effort to work with Village of Tequesta to reach a new agreement that equitably reflects
the circumstances as altered by government action.
The CIGNA HealthCare Companies reserve the right to change the Quoted Rates and/or Quoted Benefits or to
decline to offer coverage if any of the foregoing information is inaccurate or changes prior to the proposed
Effective Date indicated above, or if the quoted rates and/or fees are not agreed to within 60 days of receipt of
this summary information form. If any of the information identified above changes either prior to the proposed
Effective Date or while coverage is in effect,you agree to notify us promptly of such change.
The"Underwriting Contingencies"set forth above shall survive execution of any insurance policy,application,
etc., issued by Connecticut General Life Insurance Company or any other CIGNA HealthCare company,and
shall further survive the effective date of any such policies.
Client Signature Date
Client Name Title
1-X5QH211-SIF-1 Revisionl 14 of 14 08/01/01
Village of Tequesta
VILLAGE OF TEQUESTA
COMPANY I FLORIDA MUNICIPAL
Gold Plan
PLANS POS
Benefits In Network Out of Network
PHYSICIAN SERVICES 100%after 70%after
Office Visits CO-PAY-PRIMARY $20 co-pay annual deductible
Office Visits CO-PAY-SPECIALIST $20 co-pay
90%after 70%after
INPATIENT HOSPITAL SERVICES $100 co-pay $500 PAD
100%after 100%after
EMERGENCY ROOM SERVICES $50 co pay $50 co pay
MATERNITY SERVICES same as any same as any
illness illness
PRESCRIPTION DRUG BENEFITS 100%after
Generic $10 co-pay N/A
Brand-Formulary $20 co-pay
Brand-Non-Formulary $35 co-pay
CASH DEDUCTIBLE none $300/$900
(Individual/Family)
OUT-OF-POCKET $1,000/$2,000 $2,300/$4,900
(Individual/Family)
LIFETIME MAXIMUM unlimited $1,000,000
MONTHLY PREMIUM RATES ' CURRENT
Employee (34) $333.18
Employee and Spouse(8) $713.02
Employee and Child(ren)(12) $616.40
Employee and Family (15) $996.24
MONTHLY TOTAL $39,372.68
ANNUAL TOTAL $472,472.16
This summary is not intended to be a complete explanation of benefits of the proposed insurance policies.Actual premiums and benefits will be determined by the final enrollment and are subject to underwriting approval.
5
VILLAGE OF TEQUESTA
COMPANY I FLORIDA MUNICIPAL I CIGNA
I Gold Plan I I I Retirees
PLANS POS HMO* POS** PPp
Benefits In Network Out of Network Authorized In Network Out of Network In Network Out of Network
PHYSICIAN SERVICES 100%after 70%after 100°/uafter ,'100%after ° .. 100%after
70/o alter 70%after Office Visits CO-PAY-PRIMARY $20 co-pay $10 co-pay $10 co-pay'' .$1Sco-pay
annual deductible annual deductible annual deductible Office Visits CO-PAY-SPECIALIST $20 co-pay $20 Co-pay P Y - $ZO co pay - - $�15 w-pay, % ... .
0 0, o .. u -, 70%after annual "�` u' • :' 70%°after annual :_
90%after 70,o after 100%after 100!after: ,90!after
INPATIENT HOSPITAL SERVICES deductible deductible
$100 co-pay $500 PAD $100 co pay $100 co pay ? +$100-i?AD - annual deductible. - +$300 PAD
EMERGENCY ROOM SERVICES 100%after 100%after 100%after 100%after: 70°fo after - 90%after,' : 70%o after
$50 co-pay $50 co-pay $50 Co-Pay _,$50 co pay; annual dedutible annual deductible annual deductble,,;.
same as any same as any same as any.. same as any E same as an same as an r 3 same as MATERNITY SERVICES Y Y azly
illness illness : :illness :oiliness ,'_" .illness .{ ;illness ,,a, . . .._- illn?ss
PRESCRIPTION DRUG BENEFITS 100%after 100019 after 100%alter 4100%after$ 7
fg▪ e
$$ c l
: ai "Generic $10 co-pay N/A $5 co-pay 5 o a N/A $7c--pay
N/AY r , o
4 `Brand-Formulary $20 co-pay $15 co-pay 15 o-pay:` $I5 -pji . . 3
it
h� t "
5 iBrand-Non-Formulary $35 co-pay $35 co-Pay , $3c P4: ...} rUA ' _ t .
CASH DEDUCTIBLE -
(Individual/Family) none $300/$900 done ,;none $300/$600 a 4$3004,$900 - 1$500/$1,500 ,
OUT-OF-POCKET
(Individual/Family) $1,000/$2,000 $2,300/$4,900 $1,000/.$2,000 $1000($2 000 $2 300/$4 600 $1 800`I$5 400 a $3x 500/::tl0 S00
LIFETIME MAXIMUM unlimited $1,000,000 - unlimited unlimited T ;,$1000;000, ` ,$1,004000,tL; «; N/A,. ;e
MONTHLY PREMIUM RATES r CURRENT I PROPOSED I PROPOSED I PROPOSED
Employee (34)2 are Retirees $333.18 $234.55 $295.23 $295.40
Employee and Spouse(8) $713.02 $501.93 $631.80
Employee and Child(ren)(12) $616.40 $433.91 $546.18
Employee and Family (15) $996.24 $703.64 $885.70
MONTHLY TOTAL $39,372.68 $27,282.56 $34,341.31 $590.80
ANNUAL TOTAL $472,472.16 $327,390.72 $412,095.73 $7,089.60
COMBINED MONTHLY TOTAL $27,873.36 $34,932.11
COMBINED ANNUAL TOTAL $334,480.32 $419,185.33
*For Authorized Benefits all services and supplies must be furnished or approved through your Primary Care Physician.
**Cigna POS option is Open Access.You do not need to go through your Primary Care Physician to see a specialist.
This summary is not intended to be a complete explanation of benefits ofthe proposed insurance policies.Actual premiums and benefits will be determined by the fmal enrollment and are subject to underwriting approval.
6
VILLAGE OF TEQUESTA
COMPANY I FLORIDA MUNICIPAL I CIGNA
I Gold Plan I I I Retirees
PLANS POS HMO* PPO PpO
Benefits In Network Out of Network Authorized In Network Out of Network In Network Out of Network
PHYSICIAN SERVICES 100%after 70%after 100%after 100%after ° 100%after ...
Office Visits CO-PAY-PRIMARY $20 co-pay 70/o after ; 70%after
$10 co-pay $15 co-pay $15 w pay: annual deductible':
Office Visits CO-PAY-SPECIALIST $20 co-pay annual deductible annual deductible
P Y $20 co-pay $15 co-Pair $15 co pay!
70%after annual. 70%after annual
INPATIENT HOSPITAL SERVICES _ 90%after 70%after 100%after 90%after deductible 90%after
$100 co-pay $500 PAD $250 co-pay annual deductible. annual deductible deducible
5300 PAD ;1+$300 PAD
EMERGENCY ROOM SERVICES 100%after 100%after 100%after .90%after : 70%after 90%after> 70%after --
$50 co-pay $50 co-pay $50 co-pay annual deductible annual dedutible annual'deductible 'annual;dedutibis
MATERNITY SERVICES same as any same as any same as any same as any same as any am se as any: ' same as any
illness illness illness illness.. illness 'illness illness
PRESCRIPTION DRUG BENEFITS 100%after 100%after 100%after 100%after_
Generic $10 co-pay N/A $5 co-pay $7 co-pay N/A $7 co-pay NA-.
Brand-Formulary $20 co-pay $15 co-pay $15 co-PaY $15 co-pay
Brand-Non-Formulary $35 co-pay $35 co-pay N/A N/A..,
CASH DEDUCTIBLE none $300/$900 none $300/$900 $500/$1,500 $300/$900 $500/,$1;500
(Individual/Family)
OUT-OF-POCKET $1,000/$2,000 $2,300/$4,900 $2,000/$4,000 $1,800/$5,400 $3,500/$10,500 ' $1,800/$5,400 ',$3,500/$10 500
(Individual/Family)
LIFETIME MAXIMUM unlimited $1,000,000 unlimited $1,000,000. N/A $1000 000!: N/A:'.
MONTHLY PREMIUM RATES I CURRENT I PROPOSED I PROPOSED I PROPOSED
Employee (34)2 are Retirees $333.18 $241.95 $402.30 $295.40
Employee and Spouse(8) $713.02 $517.77 $860.93
Employee and Child(ren)(12) $616.40 $447.60 $744.26
Employee and Family (15) $996.24 $725.85 $1,206.91
MONTHLY TOTAL $39,372.68 $28,143.51 $46,795.81 $590.80
ANNUAL TOTAL $472,472.16 $337,722.12 $561,549.72 $7,089.60
COMBINED MONTHLY TOTAL $28,734.31 $47,386.61
COMBINED ANNUAL TOTAL $344,811.72 $568,639.32
*For Authorized Benefits all services and supplies must be furnished or approved through your Primary Care Physician.
This summary is not intended to be a complete explanation of benefits of the proposed insurance policies.Actual premiums and benefits will be determined by the final enrollment and are subject to underwriting approval.
7
COMPANY I FLORIDA MUNICIPAL I BLUE CROSS
I Gold Plan I Plan 10 I 706 Plan
PLANS POS HMO* PPO
Benefits In Network Out of Network Authorized Only In Network Out of Network
PHYSICIAN SERVICES 100%after 100%after 100%after
70%after 70%of allowance after`
Office Visits CO-PAY-PRIMARY $20 co-pay $15 co-pay $15 copay
annual deductible annual deductible
Office Visits CO-PAY-SPECIALIST $20 co pay $25 co-pay $15 co-pay
90%after 70%after 100%after 90%after 70%of allowance•after::
INPATIENT HOSPITAL SERVICES ' annual deductible
$100 co-pay $500 PAD $250 co-pay "'annual deductible = +$300.PAD
•
EMERGENCY ROOM SERVICES 100%after 100%after 100%after 90%'after 70%of allowance after'
$50 co-pay $50 co-pay $50 co-pay annual deductible annual deductible
MATERNITY SERVICES same as any same as any same as any same as any 'same as any
illness illness illness ,,illness tllness-
PRESCRIPTION DRUG BENEFITS 100%after 100%after 100%after 4.'
Generic $10 co-pay N/A $5 co-pay $5 co-pay N/A
Brand-Formulary $20 co-pay $15 co-pay '` $15 co-pay
Brand-Non-Formulary $35 co-pay $30 co-pay $30 co-pay
CASH DEDUCTIBLE none $300/$900 none , $300 f$900 $300/$900
(Individual/Family)
OUT-OF-POCKET $1,000/$2,000 $2,300/$4,900 $1,500/$3,000 $1 800/`$5 400 ` $1800/$5400
(Individual/Family)
LIFETIME MAXIMUM unlimited $1,000,000 unlimited $5 000,000 •, `;$5,000,000
MONTHLY PREMIUM RATES I CURRENT I PROPOSED I PROPOSED
Employee (34) $333.18 $242.54 $349.80
Employee and Spouse(8) $713.02 $524.45 $749.60
Employee and Child(ren)(12) $616.40 $463.37 $702.60
Employee and Family (15) $996.24 $745.28 $1,102.40
MONTHLY TOTAL $39,372.68 $29,181.60 $42,857.20
ANNUAL TOTAL $472,472.16 $350,179.20 $514,286.40
*For Authorized Benefits all services and supplies must be furnished or approved through your Primary Care Physician.
This summary is not intended to be a complete explanation of benefits of the proposed insurance policies.Actual premiums and benefits will be determined by the final enrollment and are subject to underwriting approval.
8
VILLAGE OF TEQUESTA "` ,;'
. DENTAL
COMPANY I GUARDIAN
Benefits I Silent PPO I PPO I PPO
Yearly Maximum $1,000 i1 ` 4 '' A
j�. } 'adJ 4 sf L k dey. Y..�.'1cW}; f A�'Y 1��d T!Y
Deductible (individuaUfamily) $50/$150 `"$50 .$t15Q r$100.(. $ 0b $50/$1S0 5$50/$150
Preventive - 100%* _ai'1 d %b*4 s s3�10d°/o�''. ' ..100%* �j 00%0
Basic 80% f 104°�4 f., $O9/6 °'�N o/ o '
ref �z at� >✓ �Sy�, i00 � 80% A
Major50% f; , 60V4t4 rrF 60°�">�`c f 60% �'50%
-
MONTHLY RATES I PROPOSED I PROPOSED I PROPOSED
Employee (34) $26.06 $22.97 $26.58
Employee and Spouse(8) $61.53 $54.25 $62.77
Employee and Child(ren) (12) $55.86 $49.25 $56.98
Family (15) $91.33 $80.52 . $93.16
Monthly Total $3,418.55 $3,013.78 $3,486.94
Annual Total $41,022.60 $36,165.36 $41,843.32
*Deductible does not apply
This summary is not intended to be a complete explanation of benefits of the proposed insurance policies.Actual premiums and benefits will be determined by the final enrollment and are subject to underwriting approval.
9
F'!..
Wendy Geyer
From: Calvert, Donald T 362 [Donald.Calvert@CIGNA.com]
Sent: Thursday, July 26, 2001 7:59 AM
To: 'wendy_geyer@acordia.com'
Subject: Village of Tequesta
1,
Village,of T eque.ata'doc Village.of reque4t2'2.dor.
Here are two proposals for your review.
The first is an HMO/POS plan with a PPO plan for retirees. } ilia
1D Q P6b4
The 2nd is a HMO/PPO option. plCCAS v
Let me know if you need any additional information.
<<Village of Tequesta.doc>> <<Village of Tequesta 2.doc>>
CONFIDENTIALITY NOTICE: If you have received this e-mail in error, please immediately
notify the sender by e-mail at the address shown. This e-mail transmission may contain
confidential information. This information is intended only for the use of the individual
(s) or entity to whom it is intended even if addressed incorrectly. Please delete it from
your files if you are not the intended recipient. Thank you for your compliance.
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
1
It ,
1 'y_
Tx
CIGNAi4
�A CIGNA HealthCare Group Benefits Proposal
� fi#h Village of Tequesta
357 Tequesta Drive
Tequesta,FL 33469
SIC Code : 9111
> x t Group Contact : Benefit Manager
Total Eligible Employees: 69 Participating Subscribers : 69
Air
Employer Contributions : Employee Contribution : 100%
Dependent Contribution: 75%
heyp .
Waiting Period : 90 days
Eligibility Definition : Active Employees working 30 hrs
T
tt
Note: The Quoted rates are subject to final Underwriting approval and,as noted below, are subject to
change in the event of changes in benefits selected or changes in the risk factors upon which the Quoted
Rates are based. In addition,the Quoted Rates are subject to regulatory approval. If required regulatory
approval has not been obtained on the proposed effective date,the healthplan shall use rates that are
consistent with its then currently approved rating methodology and the quoted rates shall be effective
immediately on the
date for which they are approved for use. The Quoted Rates are guaranteed while the Group Service
Agreement remains in effect until the next anniversary date,unless enrollment changes by 15%in which
case the CIGNA Companies may change the Quoted Rate.
1-X5QH211-SIF-1 Revisionl 1 of 14 08/01/01
`r ` Village of Tequesta
0
CIGNA
h Proposed Benefits
:, Product: CIGNA HealthCare HMO (HMO/POS)
Effective Date: 10/01/2001
Benefits Summary
Category Description In Network
Medical Benefits
PCP Office Visit Copay $10
Specialist Office Visit Copay $20
Hospital IP Copay-Per Admit $100
Hospital IP Coinsurance NA
' Outpatient Facility Copay $50
Outpatient Coinsurance NA
Emergency Room Copay $50
Urgent Care Copay $25
';:;' Skilled Nursing Facility Copay $0
Skilled Nursing Facility Maximum Days 60
Home Health Care Copay $0
Home Health Care Maximum Visits Unlimited
DME Included
Y:
Durable Medical Equipment Maximum $3,500
f EPA Included
External Prosthetic Appliances Deductible $200
External Prosthetic Equipment Maximum $1,000
Chiro Included
Short Term Rehab Copay $20
Chiro Copay $20
Short Term Rehab and Chiro Combined Maximum 60
Visits
"``' Short Term Rehab Maximum Visits NA
Self-Referred Chiro Maximum Visits NA
- , MRI,CT PET Scans Copay $50
``" Out of Pocket Maximum-Individual $1,000
Out of Pocket Maximum-Family $2,000
Lifetime Maximum Unlimited
`�' PCL Excluded
Infertility Excluded
Robust Reporting Package Excluded
Working Wonders Included
4;` 24 Hour Health Info Line Included
Well Aware Program Included
Well Being Newsletter Included
Healthy Babies Included
Healthy Rewards Included
_- Life Source Organ Transplant Network Included
Guest Privileges Included
Language Line Included
Drugstore.Com Included
1-X5QH211-SIF-1 Revisionl 2 of 14 08/01/01
Village of Tequesta
Ti • .0 •••
dr
I. ilk
R
t� CIGNA
r
Proposed Benefits
r x >' Product: CIGNA HealthCare HMO (HMO/POS)
_ Effective Date: 10/01/2001
4; Benefits Summary(Cont.)
' v,:; ', Category Description In Network
��,f Pharmacy Benefits $5/$15/$35
Generic Copay $5
Brand Copay $15
'�' t Copay-Non-Preferred $35
u _I. _ Mail Order-Generic Copay $10
_.. Mail Order-Brand Copay $30
y Mail Order-Non-Preferred Copay $70
4� Oral Contraceptives ._ Covered
T Contraceptive Devices Covered
,%.d Insulin Needles&Syringes Covered
«fir;%,',. Glucose Test Strips/Lancets Covered
' `' Prenatal Vitamins Covered
>.,, Oral Fertility Drugs Not Covered
,viz,-; Covered
'a�;•.;:�-. Insulin
b^ Generic Push Included
S f, ::. Formulary Incentive
"`: Prescriber Panel Open
M F
W.?",`::.`. MH/SA Benefits Option 4-High
` ' Inpatient Per Day Copay $50
:g ' Inpatient Max Number of Days MH/SA Combined 25
R1.,,, : MH Outpatient Copay 1 to 20 Visits $30
f. :. MH Outpatient Max Number of Visits 20
a-a; Outpatient SA visits 1-2 Copay $15
Outpatient SA visits 3-20 Copay $30
SA Outpatient Max Number of Visits 20
;t,�,,;<, Group Therapy Outpatient Copay $15
s: ; .
1,.. Group Therapy MH/SA Combined Maximum Visits 40
:k'':'.: Vision Benefits Low Plus
#w Eye Exam Copay $10
tik",z Eye Exam Frequency(months) 12
,,, ,: Hardware
Not Covered rfa
4Y
r,z;
;
thbln'''
$Y'y',
Yt
5SJ
Vim;=..:,
Ik- 1-X5QH211-SIF-1 Revisionl 3 of 14 08/01/01
;y;l- . Village of Tequesta
h},'
•
i
CIGNA
PALM BEACH,FL
Medical rates
Tier Subscribers Premium Rate Monthly Premium
Employee 32 $234.55 $7,505.60
Emp+Spouse 8 $501.93 $4,015.44
Emp+Child(ren) 12 $433.91 $5,206.92
Emp+Family 15 $703.64 $10,554.60
Total 67 $27,282.56
1-X5QH211-SIF-1 Revisionl 4 of 14 08/01/01
Village of Tequesta
k
..
2ti 7.; •
4..
V''!', CIGNA
Y'.•;
x `- Proposed Benefits
6''1-` Product: CIGNA HealthCare POS (HMO/POS)
' .; Effective Date: 10/01/2001
fi-j''` Benefits Summary
0,"ry . Category Description In Network Out of Network
ir: Medical Benefits
Coinsurance 70%
a.., PCP Office Visit Copay $10
`i`1,,', Specialist Office Visit Copay $20
Hospital IP-Per Admit Copay $100 $100
Hospital IP Coinsurance NA
Outpatient FacilityCopay $50
,``''- Outpatient Coinsurance - NA
Emergency Room Copay $50
Urgent Care Copay $25
,J,,: ` Skilled Nursing Facility Copay $0
• Skilled Nursing Facility Maximum Days 60 60
r.._; Home Health Care Copay $0
..1..)' Home Health Care Maximum Visits Unlimited 40
}: DME Included
g ' Durable Medical Equipment Deductible NA
i':' `; Durable Medical Equipment Maximum $3,500 NA
EPA Included
" c,. External Prosthetic Appliances Deductible $200
c..
`--`` External Prosthetic Equipment Maximum $1,000 NA
Chiro Included
Short Term Rehab Copay $20
k r:• Chiro Copay $20 NA
,k,, ;: Short Term Rehab and Chiro Combined Maximum 60 NA
Visits
Short Term Rehab Maximum Visits NA 60
Self-Referred Chiro Maximum Visits NA NA
MRI,CT PET Scans Copay $50
Plan Deductible-Individual $300
Plan Deductible-Family $600
,;,A Out of Pocket Maximum-Individual $1,000 $2,000
Out of Pocket Maximum-Family $2,000 $4,000
Lifetime Maximum Unlimited $1,000,000
T," PCL Excluded
Infertility Excluded
Robust Reporting Package Excluded
Working Wonders Included
��y`' 24 Hour Health Info Line Included
i` Well Aware Program Included
Well Being Newsletter Included
f Healthy Babies Included
Healthy Rewards Included •
1-X5QH211-SIF-1 Revisionl 5 of 14 08/01/01
: Village of Tequesta
•
0
CIGNA
Proposed Benefits
Product: CIGNA HealthCare POS (HMO/POS)
Effective Date: 1 0/01/2001
Benefits Summary(Cont.)
Category Description In Network Out of Network
Medical Benefits(Cont.) Life Source Organ Transplant Network Included
Guest Privileges Included
Language Line Included
Drugstore.Com Included
Description In Network
Pharmacy Benefits $5/$15/$35
Copay-Generic $5
Copay-Brand $15
Non-Preferred Copay $35
Mail Order-Generic Copay $10
Mail Order-Brand Copay $30
Mail Order Copay-Non-preferred $70
Oral Contraceptives Covered
Contraceptive Devices Covered
Insulin Needles&Syringes Covered
Glucose Test Strips/Lancets Covered
Prenatal Vitamins Covered
Oral Fertility Drugs Not Covered
Insulin Covered
Generic Push Included
Formulary Incentive
Prescriber Panel Open
MH/SA Benefits Option 4-High
Inpatient Per Day Copay $50
Inpatient Max Number of Days MH/SA Combined 25
MH Outpatient Copay 1 to 20 Visits $30
MH Outpatient Max Number of Visits 20
Outpatient SA visits 1-2 Copay $15
Outpatient SA visits 3-20 Copay $30
SA Outpatient Max Number of Visits 20
Group Therapy Outpatient Copay $15
Group Therapy MH/SA Combined Maximum Visits 40
1-X5QH211-SIF-1 Revisionl 6 of 14 08/01/01
Village of Tequesta
•
•
•
CIGNA
Proposed Benefits
Product: CIGNA HealthCare POS (HMO/POS)
Effective Date: 10/01/2001
Benefits Summary(Cont.)
Category Description In Network
Vision Benefits Low Plus
Eye Exam Copay $10
Eye Exam Frequency(months) 12
Hardware Not Covered
1-X5QH211-SIF-1 Revisionl 7 of 14 08/01/01
Village of Tequesta
0
CIGNA
PALM BEACH, FL
Medical rates
•
Tier Subscribers Premium Rate Monthly Premium
Premium
`3tk,. Employee 32 $273.36
$8,747.52
Emp+Spouse 8 $585.00 $4,680.00
•
Emp+Child(ren) 12 $505.72 $6,068.64
Emp+Family
15 $820.09 $12 301.35
3`" ; Total 67
$31,797.51
�1q5 �3
5qu. IDS
q/5
4.'"f
4 74-
•
1-X5QH211-SIF-1 Revisionl 8 of 14 08/01/01
- Village of Tequesta
▪ F
a, V
t▪� .L
"a�:; CIGNA
Proposed Benefits
` Product: CIGNA PPO
▪ Effective Date: 10/01/2001
'` ` Benefits Summary
Category Description In Network Out Network
-
:.-; fit,:., ' Medical Benefits
die Medical Cost Sharing Inpatient Coinsurance 90% 70%
Outpatient Coinsurance 90% 70%
?;'' PCP Copay $15.00 N/A
Hospital IP Deductible-Per Day N/A N/A
• '" Hospital IP Deductible-Per Admit N/A $300.00
z ER Deductible N/A N/A
Plan Deductible-Individual $300.00 $500.00
Plan Deductible-Family $900.00 $1,500.00
' Out of Pocket Maximum-Individual $1,500.00 $3,000.00
' ..:-• Out of Pocket Maximum-Family $9,000.00
; ^r Lifetime Maximum $1,000 000.00 N/A
.`may>6
Pharmacy Benefits
RxPRIME Two-Tier Copay
▪ Pharmacy Cost Sharing Pharmacy Coinsurance N/A N/A
;.,' Copay-Generic $7.00 N/A
; ' '•'` Copay-Brand $15.00 N/A
..�'e Mail Order Copay-Generic $14.00 N/A
ec: Mail Order Copay-Brand $30.00 N/A
;t= Drug Deductible N/A N/A
r Formulary Open Open
?r` Network Match% 95% N/A
31•`` Insulin Covered
at Oral Fertility Drugs Covered
Prenatal Vitamins Covered
r'�'' '''`' Glucose Test Strips/Lancets Covered
r
` , Insulin Needles&Syringes Covered
Contraceptive Devices Covered
I'' Oral Contraceptives Covered
rir ;-;. MD Dispense as Written Covered
a
* c J
T .:
t ':
�t
z A▪ ,. 1-X5QH211-SIF-1 Revisionl 9 of 14 08/01/01
51� ,
h
ry
Village of Tequesta
{
•
• 1
•
CIGNA
Proposed Benefits
Product: CIGNA PPO
Effective Date: 10/01/2001
Benefits Summary(Cont.)
Category Description In Network Out Network
MH/SA Benefits
(Mental Health-Alcohol&
Drug Abuse}
MH/SA Cost Sharing Inpatient Coinsurance 90% 70%
Outpatient Coinsurance N/A 50%
Outpatient Copay $25.00 N/A
Inpatient Deductible-Per Admit N/A N/A
Inpatient Deductible-Per Day N/A N/A
Inpatient Cal Year Max Days 30 30
Inpatient Lifetime Max Days 180 180
Outpatient Cal Year Max Days 20 20
Outpatient Lifetime Max Days 180 180
Vision Benefits None
1-X5QH211-SIF-1 Revisionl 10 of 14 08/01/01
Village of Tequesta
•
i
CIGNA
PPO (Retirees)
Medical rates
Tier Subscribers Premium Rate Monthly Premium
Employee 2 $295.40 $590.80
Emp+Spouse 0 $590.79 $0.00
Emp+Family 0 $886.19 $0.00
Total 2 $590.80
1-X5QH211-SIF-1 Revisionl 11 of 14 08/01/01
Village of Tequesta
•
i
CIGNA
Medical History Information
For
Village of Tequesta
1. Have there been any claims over$10,000 in the last 12 N
months?
2. Has any employee missed more than 10 consecutive days in N
the last 12 months due to illness or injury?
3. Are there any employees with ongoing disabilities? N
4. Have any individuals been diagnosed,received treatment, or .N
are currently receiving treatment for any of the following
conditions in the past three years?
No known medical conditions exist.
1-X5QH2 1 1-SIF-1 Revision1 12 of 14 08/01/01
Village of Tequesta
3
A
' .
ki x
CIGNA
Underwriting Contingencies
For
Fiii4- Village of Tequesta
it
€#,, *The rates are guaranteed for a period of 12 months while the contract remains in force.
Kar *The employer contributes at least 50%toward the total cost of the plan.
r,,-I, *No seasonal employees are covered under this plan.
3 *The current waiting period is 90 days.
7
KEI *This quote assumes all employees are located in the network area,and that all employees are only eligible
for the product offerings specified.
r1 *The CIGNA HealthCare Companies retain the right to modify the rates and benefits set forth in this
quotation,or to decline to offer coverage if any of the information upon which these rates or benefits was
Y`: . based changes or is not accurate.
f •
*If any information set forth in this form changes at any time while coverage is provided to you by CIGNA
;? ; HealthCare Companies,you must notify us within 30 days of these changes.
4
*There is a minimum participation of 50%required. This will be based on the total eligible employees,
4, identified as employees.
:f, *If a decision is not reached within 60 days.from the date the rates and/or fees set forth herein are received,
then Connecticut General Life Insurance Company and its affiliated companies and entities(collectively,
"CIGNA")reserves the right to revise said rates and/or fees.
*If enrollment increases or decreases by 15%or more from the enrollment assumptions used in establishing
' the rates and/or fees set forth herein,CIGNA reserves the right to revise said rates and/or fees.
x *The rates identified are subject to regulatory approval. If,as of their proposed effective date,regulatory ry
approval is not obtained,the healthplan shall use rates consistent with its then currently approved rates and
the foregoing rates shall be effective automatically upon approval.
*Quoted benefits may not include site specific state mandates and may,therefore,be amended/revised
accordingly.
?:. *CIGNA HealthCare is the exclusive provider of healthcare coverage to your employees.J.
*No Medicare eligible retirees are covered under this plan.
1-X5QH211-SIF-1 Revisionl 13 of 14 08/01/01
Village of Tequesta
CIGNA
CIGNA HealthCare Group Benefits Proposal
Village of Tequesta
357 Tequesta Drive
Tequesta,FL 33469
SIC Code : 9111
Group Contact : Benefit Manager
Total Eligible Employees: 69 Participating Subscribers : 69
Employer Contributions : Employee Contribution : 100%
Dependent Contribution: 75%
Waiting Period : 90 days
Eligibility Definition : Active Employees working 30 hrs
Note: The Quoted rates are subject to final Underwriting approval and, as noted below, are subject to
change in the event of changes in benefits selected or changes in the risk factors upon which the Quoted
Rates are based. In addition,the Quoted Rates are subject to regulatory approval. If required regulatory
approval has not been obtained on the proposed effective date,the healthplan shall use rates that are
consistent with its then currently approved rating methodology and the quoted rates shall be effective
immediately on the
date for which they are approved for use. The Quoted Rates are guaranteed while the Group Service
Agreement remains in effect until the next anniversary date, unless enrollment changes by 15% in which
case the CIGNA Companies may change the Quoted Rate.
1-X5QH221-SIF-1 Revisionl 1 of 12 08/01/01
Village of Tequesta
1
�t
IP
CIGNA
E
Proposed Benefits
; ` Product: HMO/PPO CIGNA CHMO
Effective Date: 10/01/2001
N - Benefits Summary
na=:.
a::
Category Description In Network Out Network
',:''' Medical Benefits
Medical Cost Sharing PCP Copay $10.00 N/A
ti�:;'`; Hospital IP Copay-Per Admit $250.00 N/A
Outpatient Surgical Facility $75.00 N/A
ER Copay $50.00 N/A
Out of Pocket Maximum-Individual $2,000.00 N/A
Out of Pocket Maximum-Family $4,000.00 N/A
'- Lifetime Maximum Unlimited N/A
'.-y Pharmacy Benefits
98 Plan-5/15/35,3X-5,Push
Pharmacy Cost Sharing Copay-Generic $5.00 N/A
Copay-Brand $15.00 N/A
Copay-Non-Preferred $35.00 N/A
`'''` Mail Order Copay-Generic $10.00 N/A
zY Mail Order Copay-Brand $40.00 N/A
Mail Order Copay-Non-Preferred $100.00 N/A
Insulin Covered
Oral Fertility Drugs Covered
Prenatal Vitamins Covered
Glucose Test Strips/Lancets Covered
Insulin Needles&Syringes Covered
Contraceptive Devices Covered
Oral Contraceptives Covered
Generic Push Covered
MH/SA Benefits
Core
MH/SA Cost Sharing Inpatient Per Day Copay $50.00 N/A
Group Therapy Outpatient Copay $15.00 N/A
Individual Outpatient Copay $30.00 N/A
Inpatient Max Number of Days MH/SA Combined 30 N/A
MH Outpatient Max Number of Visits 20 N/A
SA Outpatient Max Number of Visits 20 N/A
Vision Benefits Low-$10 Copay-Exam only every 24 months
Miscellaneous Benefits EPA Included
DME Included
1-X5QH221-SIF-1 Revision! 2 of 12 08/01/01
Village of Tequesta
•
•
CIGNA
PALM BEACH, FL
Medical rates
Tier Subscribers Premium Rate Monthly Premium
•=;:,..1 Employee 32 $241.95 $7,742.40
Emp+Spouse 8 $517.77 $4,142.16
Emp+Child(ren) 12 $447.60 $5,371.20
Emp+Family 15 $725.85 $10,887.75
Total 67 $28,143.51
z 5,
•
1-X5QH221-SIF-1 Revisionl 3 of 12 08/01/01
Village of Tequesta
.11::'::
r.:1-. 0
CIGNA
ref.,
Proposed Benefits
Product: HMO/PPO CIGNA PPO
Effective Date: 10/01/2001
:r Benefits Summary
r'
Cate or
,;.;, .. g y Description In Network Out Network
V. Medical Benefits
'xi Medical Cost Sharing Inpatient Coinsurance 90% 70%
'' Outpatient Coinsurance
u o
P.:;-. ' P 90/0 70/o
'='.._-' PCP Copay $15.00 N/A
[,',-:-.- Hospital IP Deductible-Per Day N/A N/A
Hospital IP Deductible-Per Admit N/A $300.00
Z;'.% ER Deductible N/A N/A
"`` Plan Deductible-Individual $300.00
$500.00
Plan Deductible-Family $900.00 $1,500.00
Out of Pocket Maximum-Individual $1,500.00 $3,000.00
V',`;;:• Out of Pocket Maximum-Family
y $4,500.00 $9,000.00
Lifetime Maximum $1,000,000.00 N/A
t
k Pharmacy Benefits
^ 'r RxPRIME Two-Tier Copay
'. Pharmacy Cost Sharing Pharmacy Coinsurance N/A N/A
Copay-Generic
$7.00 N/A
y Copay-Brand $15.00 N/A
F-.1-;. Mail Order Copay-Generic $14.00 N/A
¢i-,•-z Mail Order Copay-Brand $30.00 N/A
Drug Deductible N/A N/A
'$'`' Formulary Open Open
Network Match% 95% N/A
y Insulin Covered
Oral Fertility Drugs Covered
Prenatal Vitamins Covered
e..7 Glucose Test Strips/Lancets Covered
ik',.-..' Insulin Needles&Syringes Covered
V' Contraceptive Devices Covered
Oral Contraceptives Covered
' MD Dispense as Written Covered
r,-
1-X5QH221-SIF-1 Revisionl 4 of 12 08/01/01
-= Village of Tequesta
i
lik
CIGNA
Proposed Benefits
Product: HMO/PPO CIGNA PPO
Effective Date: 10/01/2001
Benefits Summary(Cont.)
Category Description In Network Out Network
MH/SA Benefits
{Mental Health-Alcohol&
Drug Abuse}
MH/SA Cost Sharing Inpatient Coinsurance 90% 70%
Outpatient Coinsurance N/A 50%
Outpatient Copay $25.00 N/A
Inpatient Deductible-Per Admit N/A N/A
Inpatient Deductible-Per Day _ N/A N/A
Inpatient Cal Year Max Days 30 30
Inpatient Lifetime Max Days 180 180
Outpatient Cal Year Max Days 20 20
Outpatient Lifetime Max Days 180 180
Vision Benefits None
1-X5QH221-SIF-1 Revisionl 5 of 12 08/01/01
Village of Tequesta
1
CIGNA
PPO
zzt:, Medical and RX rates
RX Prime
Tier Subscribers Premium Rate MonthlyPremium
Premium Rate
Employee 32 $326.69 $75.61 $12,873.60
t,SKr Emp+Spouse 8 $699.12 $161.81 $6,887.44
` Emp+Child(ren) 12 $604.38 $139.88 $8,931.12
- Emp+Family 15 - $980.07 $226.84 $18,103.65
Total 67 $46,795.81
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1-X5QH221-SIF-1 Revisionl 6 of 12 08/01/01
Village of Tequesta
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•
•
CIGNA
Proposed Benefits
Product: CIGNA PPO
Effective Date: 10/01/2001
Benefits Summary
Category Description In Network Out Network
Medical Benefits
Medical Cost Sharing Inpatient Coinsurance 90% 70%
Outpatient Coinsurance 90% 70%
PCP Copay $15.00 N/A
Hospital IP Deductible-Per Day N/A N/A
Hospital IP Deductible-Per Admit N/A $300.00
ER Deductible N/A N/A
Plan Deductible-Individual $300.00 $500.00
Plan Deductible-Family $900.00 $1,500.00
Out of Pocket Maximum-Individual - $1,500.00 $3,000.00
Out of Pocket Maximum-Family $4,500.00 $9,000.00
Lifetime Maximum $1,000,000.00 N/A
Pharmacy Benefits
RxPRIME Two-Tier Copay
Pharmacy Cost Sharing Pharmacy Coinsurance N/A N/A
Copay-Generic $7.00 N/A
Copay-Brand $15.00 N/A
Mail Order Copay-Generic $14.00 N/A
Mail Order Copay-Brand $30.00 N/A
Drug Deductible N/A N/A
Formulary Open Open
Network.Match% 95% N/A
Insulin Covered
Oral Fertility Drugs Covered
Prenatal Vitamins Covered
Glucose Test Strips/Lancets Covered
Insulin Needles&Syringes Covered
Contraceptive Devices Covered
Oral Contraceptives Covered
MD Dispense as Written Covered
1-X5QH221-SIF-1 Revisionl 7 of 12 08/01/01
Village of Tequesta
'
t CIGNA
Proposed Benefits
' r' ' Product: CIGNA PPO
' ` Effective Date: 10/01/2001
s
Benefits Summary(Cont.)
r}' Category Description In Network Out Network
s
MH/SA Benefits
{Mental Health-Alcohol&
' Drug Abuse}
:, MH/SA Cost Sharing Inpatient Coinsurance 90% 70%
'_,°�= Outpatient Coinsurance N/A 50%
` Outpatient Copay $25.00 N/A
Inpatient Deductible-Per Admit N/A N/A
;� Inpatient Deductible-Per Day _ N/A N/A
A ', Inpatient Cal Year Max Days 30 30
Inpatient Lifetime Max Days 180 180
'
•�-"��_ Outpatient Cal Year Max Days 20 20
f -r:
:ram Outpatient Lifetime Max Days 180 180
Vision Benefits None
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.' 1-X5QH221-SIF-1 Revisionl 8 of 12 08/01/01
3 :°:. . Village of Tequesta
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tT CIGNA
PPO (Retirees)
Medical rates
: 1 Tier Subscribers Premium Rate Monthly Premium
Employee 2 $295.40 $590.80
r , Emp+Spouse 0
Emp+Family 0 $ 86.19
8 $0.00
Total 2 $590.80
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`> 1-X5 H221-SIF-1 Revisionl 9 of 12 08/01/01
;;;;' Village of Tequesta
•
i
CIGNA
Medical History Information
For
Village of Tequesta
1. Have there been any claims over$10,000 in the last 12 N
months?
2. Has any employee missed more than 10 consecutive days in N
the last 12 months due to illness or injury?
3. Are there any employees with ongoing disabilities? N
4. Have any individuals been diagnosed,received treatment,or N
are currently receiving treatment for any of the following
conditions in the past three years?
No known medical conditions exist.
1-X5QH221-SIF-1 Revisionl 10 of 12 08/01/01
Village of Tequesta
•
•
•
CIGNA
Underwriting Contingencies
For
Village of Tequesta
*The rates are guaranteed for a period of 12 months while the contract remains in force.
*The employer contributes at least 50%toward the total cost of the plan.
*No seasonal employees are covered under this plan.
*The current waiting period is 90 days.
*This quote assumes all employees are located in the network area,and that all employees are only eligible
for the product offerings specified.
*The CIGNA HealthCare Companies retain the right to modify the rates and benefits set forth in this
quotation,or to decline to offer coverage if any of the information upon which these rates or benefits was
based changes or is not accurate.
*If any information set forth in this form changes at any time while coverage is provided to you by CIGNA
HealthCare Companies,you must notify us within 30 days of these changes.
*There is a minimum participation of 50%required. This will be based on the total eligible employees,
identified as employees.
*If a decision is not reached within 60 days from the date the rates and/or fees set forth herein are received,
then Connecticut General Life Insurance Company and its affiliated companies and entities(collectively,
"CIGNA")reserves the right to revise said rates and/or fees.
*If enrollment increases or decreases by 15%or more from the enrollment assumptions used in establishing
the rates and/or fees set forth herein,CIGNA reserves the right to revise said rates and/or fees.
*The rates identified are subject to regulatory approval. If,as of their proposed effective date,regulatory
approval is not obtained,the healthplan shall use rates consistent with its then currently approved rates and
the foregoing rates shall be effective automatically upon approval.
*Quoted benefits may not include site specific state mandates and may,therefore,be amended/revised
accordingly.
*CIGNA HealthCare is the exclusive provider of healthcare coverage to your employees.
*No Medicare eligible retirees are covered under this plan.
1-X5QH22 1-SIF-1 Revision1 11 of 12 08/01/01
Village of Tequesta
•
•
CIGNA
Underwriting Contingencies
For
Village of Tequesta (cont.)
*Quote is based on all employees within the PPO network covered by either the HMO or PPO plan.
Specified employees would be covered by an outlier plan.
nt :.
*If total enrollment in the PPO is more than 15%of the group,we reserve the right to re-rate the group.
*If one or more of the quoted sites withdraws prior to the effective date of the account, CIGNA HealthCare
reserves the right to re-rate.
*Medical History Information is accurate to the best of your knowledge
*The employer must contribute the same flat dollar amount to each plan.
* At CIGNA's option,this Proposal,and any rate,fee,trend,or other guarantee included in this Proposal,
or agreements arising from this proposal,shall be void in the event of Federal, State or Local action
impacting the benefit levels quoted herein or affecting our ability to meet our obligations to you,to your
employees/our members or to our contractedproviders. Bywayof illustration, such legislation or
g�
{ executive actions which impose controls or requirements that affect: our ability to determine rates;covered
.: medical expenses or service benefits;providers'delivery of care or the fees they charge; or our contracts
with providers, may be deemed to so affect our contractual obligations. Should this happen,CIGNA will
=: a make a good faith effort to work with Village of Tequesta to reach a new agreement that equitably reflects
the circumstances as altered by government action.
The CIGNA HealthCare Companies reserve the right to change the Quoted Rates and/or Quoted Benefits or to
decline to offer coverage if any of the foregoing information is inaccurate or changes prior to the proposed
Effective Date indicated above,or if the quoted rates and/or fees are not agreed to within 60 days of receipt of
this summary information form. If any of the information identified above changes either prior to the proposed
Effective Date or while coverage is in effect,you agree to notify us promptly of such change.
The"Underwriting Contingencies"set forth above shall survive execution of any insurance policy, application,
etc,, issued by Connecticut General Life Insurance Company or any other CIGNA HealthCare company, and
shall further survive the effective date of any such policies
Client Signature Date
Client Name Title
1-X5QH221-SIF-1 Revisionl 12 of 12 08/01/01
za Village of Tequesta
VILLAGE OF TEQUESTA
,7
RATE ANALYSIS
•
r x Health Options Plan FHLGNQ10 + $5/$15/$30 Drug Rider.
Single Employee: $242.54 x 34.00 = $8,246.36
Employee & Spouse: $524,45 x 8.00 - = $4,195.60
Employee & Children: $463.37 x 12.00 = $5,560.44
Employee & Famil.. .r, y: $745.28 x 15,00 = $11,179.20
Monthly Cost: $29,181.60
PLGLP706 with $5/$15//30 RXRider (Oral Contraceptives Included)
Single Employee: $349.80 x 34.00 = $11,893.20
Employee & Spouse: $749.60 x 8.00 = $5,996.80
�3a
Employee & Children: $702.60 x 12.00 = $8,431.20
Employee & Family: $1102.40 x 15.00 ; $16,536,00
Monthly Cost: $42,857.20
This Proposal Expires: September 20, 2001
See accompanying Proposal Assumptions page
All gates arc subject to Florida Department of Insurance approval.Poliayholders will not he billed with the
proposed rates until the rates are approved by the Florida Department a(In9uriuco.A check equal to the first
month's premium based an tho proposed rites must accompany the application.
A S
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* ,-. BLUECARE FOR LARGE GROUPS
BENEFIT HIGHLIGHTS PLAN 10
z
4
Care must be received from or arranged by your HOI-Primary Care Physician.
-3
.v.
.._ BENEFITS COST To You
Physician Office Services
Ftl� • Primary Care Physician office services $15 copay per visit
wt
Participating Specialist office services
. $25 copay per visit
• One annual self-referral to participating GYN $25 copay per visit
•- for well-woman exam
7
These office services may include:
■ Pediatric and well-baby care
• Periodic health evaluation and immunizations
• Other diagnostic services
• Health education
irce4, • Professional counseling (family planning,
=G t; nutritional, and medical social services)
• Vision and hearing screening
"!' • Familyplanning services
^1i • In-office surgery
;1
Additional Services(Office or Outpatient Facility)
W.i • Allergy testing .
',-"lc. No$5
• Allergy injection, including serum copay
$5 copay per visit
;;1 • Outpatient physical, speech, cardiac and $5 copay per visit
< occupational therapies
pies
a Diagnostic lab and X-ray No copay
Hospital Services (Inpatient Facility)
4
- • Room and board $250 per admission
These inpatient hospital services may include:
• Anesthesia, use of operating and recovery rooms,
,. ' oxygen, drugs, and medications
} • Intensive Care Unit and other special units
,i.c- • Laboratory and X-ray services
k ' • Inpatient physical, speech, cardiac and
:, occupational therapies
Hospital or Ambulatory Surgical Center(Outpatient Facility)
0 • Outpatient surgical services may include: $100 copay
Anesthesia, use of operating and recovery
rooms, oxygen, drugs and medication, including:
Ar1° • Hospital or surgical center
-.' • Surgeon's fees
„r': • Outpatient laboratory, X-ray, and other tests
BlueCare is offered by Health Options,the HMO from Blue Cross and Blue Shield of Florida
j�.f..
'..,-> . ' Plan 10 Rev.5/99
BLUECARE FOR LARGE GROUPS
BENEFIT HIGHLIGHTS PLAN 10
BENEFITS COST To You
Emergency Services(Hospital)
• Use of emergency rooms and emergency $50 coy
services at participating hospitals P Y per visit
• Use of emergency rooms and emergency
services outside of service area or at non-
participating $50 copay per visit
hospitals
Maternity Services
• Primary Care Physician office services
• Participating Specialist office services-initial OB visit only $15copay
• Certified Nurse Midwife or Midwife N$25 copay
• Inpatient hospital services copay
• Birthing center services $22 50 per admission
No copay
Behavioral Health Services
Mental Health Care
• Outpatient visits=20 per calendar year $25 copay
• Inpatient facility-30 days per calendar year e Y per visit
• Partial hospitalization (2 partial days for inpatient day) No copay
payer admission
Substance Dependency
• Outpatient visits-20 per calendar year $15 copay per visit
• Inpatient hospitalization (detoxification only) $250 per admission
Infertility Services
• Primary Care Physician $15 copay
• Participating Specialist $25 copay
per visit
y per visit
Special Services
• Hospice care No copay
• Skilled nursing facility-90 days per calendar year No copay
• Home health care P y
• Ambulance(medically necessary) No copay
No copay
• Durable medical equipment
No copay
• Prosthetics and orthotics
No copay
BlueCare Rx: Pharmacy Program
• When prescribed by a participating physician $7.00 generic
and filled at a participating pharmacy $20.00 brand
Mail Order Pharmacy (Incl. Oral Contraceptives)
• For your convenience, a 90-day supply of $14.00 generic
maintenance medication is available through $40.00 brand
the mail (Incl. Oral Contraceptives)
Additional information related to access to providers can be found in the Provider Directory.
Plan 10 Rev.5/99
BLUECARE FOR LARGE GROUPS
BENEFIT HIGHLIGHTS
PLAN 10
Maximum Out-Of-Pocket •
$1,500 per Member
$3,000 per family
SELECT EXCLUSIONS AND LIMITATIONS
The following is a partial listing of services that are excluded from coverage under this agreement,
only if, and to the extent that, such exclusion is permitted under law. For a complete listing please refer
to the Master Policy.
• All services not specifically listed in the schedule of benefits or in any rider or endorsement,
unless such services are specifically required by state or federal law;• Elective cosmetic surgery;
• Hearing aids or eyeglasses, dental care, or oral appliances;
• Physical for insurance, licensing, school, or recreational purposes;
• Elective abortions;
• Workers'compensation;
• Prescription drugs(unless included through BlueCare Rx); and
• Complementary and Alternative Healing Methods(CAM).
The copayments are the responsibility of the Member and must be paid to the provider at the time
•
service is rendered.
Should it become necessary, a grievance procedure is available to all Members as detailed in the
Master Policy.
A pre-existing condition limitation applies for those who do not have previous creditable coverage at
enrollment. Please refer to the Master Policy for details.
All health care services must be provided or authorized by your Primary Care Physician. This summary is only a partial description of the
many benefits and services covered by Health Options,the HMO subsidiary of Blue Cross and Blue Shield of Florida,Inc. These benefits
apply only to groups of 51 or more employees. Health Options,Inc.and Blue Cross and Blue Shield of Florida,Inc.are independent licensees
of the Blue Cross and Blue Shield Association. This does not constitute a contract. For a complete description of benefits and exclusions,
please see Master Policy 86002 R0399 SR;its terms prevail.
Plan 10 Rev.5/99
Summary of BlueChoice PPO Physician Copayment Plan Benefits
Group Name
BlueChoice PPO Physician Copay Plan 706
Deductibles:
• Individual Calendar Year Deductible $300
• Family Calendar Year Deductible $900
• Hospital Per Admission Deductible
— PPO Hospitals $0
— Non-PPO Hospitals $300
• Emergency Room Per Visit Deductible $0
(All Hospitals)
NOTE: The calendar year deductible is waived for Independent Clinical Laboratory services.
The Hospital Per Admission Deductible and the Emergency Room Per Visit Deductible are in
addition to the Calendar Year Deductible.
Coinsurance Percentage Payable by BCBSF:
• PPO Providers 90%
• Non-PPO Providers 70%
— Ambulance Services 90%
Maximum Out of Pocket Coinsurance
Responsibility Per Calendar Year:
• Individual Coinsurance Limit $1,500
• Family Coinsurance Limit $4,500
NOTE: Maximum Out of Pocket Coinsurance Responsibility Limits do not include any
deductibles, copayments, any benefit penalty reduction, non-covered charges or any charges
in excess of the Allowed Amount.
Office Services
• PPO Family Physicians $15 Copay
(Family Practice,General Practice,
Internal Medicine,or Pediatrics)
• Other.PPO Providers $15 Copay
— Allergy Injections(All PPO Providers) $5 Copay
• Non-PPO Providers Calendar Year Deductible and
Coinsurance
NOTE:Durable Medical Equipment, Prosthetics, and Orthotics are not subject to the
Copayment requirement, but are subject to the Individual Calendar Year Deductible and
Coinsurance responsibility.
Calendar Year Maximums Per Insured
• Mental Health Services:
— Inpatient days/visits or 30
combination of inpatient and
Partial Hospitalization days
— Outpatient visits 20
• Home Health Care $2,500
• Skilled Nursing Facility Days 60
• Low Protein Food Products $2,500
• Outpatient Cardiac, Occupational, Physical, $2,500
Speech, and Massage Therapies and Spinal
Manipulations
Lifetime Maximums Per Insured
• Total $5,000,000
• Substance Dependency Care and Treatment $2,500
(inpatient,outpatient,or any combination) •
• Hospice Benefit $7,500
Wellness Benefit(Adults) Covered services for an adult(age 17 and
over)include an annual exam and related
wellness services up to a calendar year
maximum of$150.These services are not
subject to the Calendar Year Deductible,
but are subject to the applicable copayment
or coinsurance responsibility.Routine
vision and hearing examinations are not
covered.
BlueScript Retail Pharmacy Program
• Preferred Generic Drugs $copay
• Preferred Brand Drugs $copay
• Non-Preferred Drugs $copay
• Maximum Supply One month
• Oral Contraceptives and Devices Covered
Mail Order Pharmacy Program
• Preferred Generic Drugs $ copay `
• Preferred Brand Drugs $copay
• Non-Preferred Drugs $copay
• Maximum Supply 90 days
• Oral Contraceptives and Devices Covered
•
OR
Mediscript Subject to the calendar year deductible
and reimbursed at the lower coinsurance.
Member files claim.
This is a summary of benefits and not a contract. All benefits are subject to the provisions, exclusions
and limitations set forth In the master contract. This plan provides coverage for certain physician office
services, without having to satisfy a calendar year deductible requirement, when obtained from a PPO
physician. To verify a provider's specialty or participation status, the insured may contact the local
BCBSF office, contact the provider's office, or review the most recent Provider Directory. It is the
insured's sole responsibility to select and verb a provider's network participation status at the time
services are rendered
BlueChoice PPO Physician Copay Plan 706
. 0 '
DENTAL BENEFITS FOR:
GUARDIAN'
Village of Tequesta
Calendar Year Maximimum per Person 51,000
Network Access ppo X1' PPO X7 PPO XQ ' PPO XA
Plan _
Deductible
• In-Network $50 $50 $50 $50 _ $50
Out-of-Network $50 $100 _ S100 $100 $100
Waived for Waived for Waived for Waived for Waived for
preventive services preventive services preventive services preventive services preventive services
in-nework only In-nework only in-nework only • in-nework only
Network 13onofits IN OUT IN OUT _ IN OUT IN OUT IN OUT
Preventive Services 100% 100% 100% 100% 100% 80% 100% 90% 100% 100%
Basic Services 80% B0% 100% 80% 80% 70% 100% 70% 60% 50%
Major Services _ 50% 50% 60% 50% 50% 40% 60% 40% 50% 25%
'TO LOWER'OUT OF NETWORK'DEDUCTIBLE TO 550,AND WAIVE FOR PREVENTIVE SERVICES,MULTIPLY PPO X1 RATES EY: 1.157
Network Access PP0 X1' PPO X7 - PPO XQ PPO XA
MONTHLY RATES Plan
Employee Only ' $28.08 $22.97 $19.58 $21.36 • $17.14
Employee&Spouse $61.53 $54.25 $46.25 $50.45 $40.48
Employee&Chlld(ren) $55.86 $49.25 $41.98 $45.79 $38.74
Employee& Family $91.33 $80.52 $88.85 $74.80 $60.08
Orthodontia Benefit
Drthodontic benefit covers dependent children up to age 19. Lifetime orthodontia maximum is $1,000
Orthodontic benefits are optional by groups, not individuals. To include orthodontia in the dental benefits, add the rates shown below to
'he Employee & Chlld(ron)rate and the Employee &Family rate.
4 minimum of 35 lives or 4 dependent units Is required for the orthodontia benefit.
Network Access PPO X1" PPO X7 PPO XQ PPO XA
Plan _
'child Orthodontia '
50% Payment rate: $ 11.10 $ 11.10 Not available Not available Not available
40% Payment rate: $ 10.88 $ • 10.88 $ 10.88 5 10.8B Not available
25°r6 Payment rate: $ 10.55 $ 10.55 $ 10.55 $ 10.55 $ 10.55
STANDARD DGIV RATES AND PLAN DESIGNS,ASSUMED PARTICIPATION; 75%
75% Vail eligible employees or 90% of all employees that are not covered elsewhom must by enrolled.
57E of all eligible dependents not covered elsewhere must bo enrolled.
Rates Valid through: October 14, 2001
The Guardian's STANDARD plan designs classify covered procedures as follows:
PREVENTIVE SERVICES BASIC SERVICES MAJOR_SERVICES
'Initial and periodic oral examinations (once
wary six months) 'Laboratory Tests ' Gold& Porcelain fillings &crowns
'X-Rays (bite-wings: 4 x-rays per visit, once ' Installations, repair and maintenance of
•eve 12 months) Fillings (amalgam, silicate and acrylic)
ry bridgework&dentures
'Teeth Cleaning(once every six months) " Dlagnosltc consultations •Acrylic Crowns
'Full mouth series or panoramic film (once in
30 consecutive months) ' Endodontic Services
'Fluoride Treatment for Chlldren(once every
3 months under 14 years of age) ' Periodontic Services and Surgery
' Space Maintainers for Children •Anesthia far surgical purposes
'Sealants For Children(limited to children
_.._ . .. " EYtrartinna and nlhnr nrnl ei}rnory
Yetwork Access Plan GUARDIAN
the Network Access Plan is a way of utilizing the PPO discounts of our DentalGuard Preferred Notwork on Indemnity Dental
3usinoss. This plan allow members to take advantage of the Notwork foo schedules when a covered person goes to a notwork
ientist.
JentalGuard PPO: Paint of Service i lans(X1, X7, X13 and XAI
at the time of treatment, the employee can choose any dentist, in or out of network. Treatment by in-network dentists is
etmbursed at a higher percentage with no deductible for preventive services and based on a negotiated foo shodulo. An
imployoo is froe to go to a non-network provider and still receive a high level of benefits. Out-of-network is reimbursed based on
,sual, customary and reasonable charges.
Jsual, Customary & Reasonable
JCR chargas aro limited to the 90th percentile.
iuy-Up Options:
f the employer elects to make two plan options available to employees, the rates for the higher option must be
ncreased by 10%.
)oductible:
:hinges used to satisfy the in-notwork deductible are also credited toward the out-of-network deductible, and charges
!sod to satisfy the out-of-network deductible aro also credited toward the in-network deductible.
)pen Enrollment:
In annual open enrollment may be added to the plan for an additional 2%.
Innual Maximum:
! rates shown ere based on a calender year maximum benefit of $1,000 per person, you may increase the annual maximum to
,500 by multiplying the.rates shown by 1.12. For en annual maximum of 92,000, multiply the rates shown by 1.22.
'articlpatlon Adjustments:
Ratos.shown are based on a participation level of 75% or more of eligible employees. If less than 75% of the eligible
employees enroll, the planholdor may choose one of the following options:
1. Load the rates with no change to plan design (OptIon 1)
2. Change the annual maximum benefit with no change to the rates (Option 2)
Option 1 Option 2
participation Level Rate Adjustment Maximum Arijustrmrut
75% None S1,000
65%-74% +7% 6750
50%-04% +15% 9500
35%-49% +22% Not Available
Minimum participation is 10 employees or 35% of eligible employees, whichever is groator.
lease Note:
Covoragos limited to chargas that are necessary to prevent, diagnose or treat dental disease, defect or injury. Tho plan
does not cover oral hygiene services (except as covorod under preventive care), orthodontic services, cosmetic services,
experimental treatments, any treatment to the extent benefits are payable by any other payor or for which no charge Is
made, prosthetic devices unless certain conditions aro mot, and services ancillary to surgical treatment. The plan limits
benefits for ancillary to surgical treatments. The plan limits benefits for diagnostic consultations and for preventive,
restorative, ondodontic, poriodontic and prasthodontic services. The services, exclusions and limitations previously
listed to not constitute a contract and aro a summary only. Tho Guardian plan documents are the final arbiter of
coverage.
claw is a list of options to further reduce the accompanying plan designs and rates:
omovo limit of 3 deductibles per family
imit oral exams and flourida treatments to once every 12 months
'over x-rays as a basic service
,over endodontic services as major service
over periodontic services (non-surgical) as major service
over periodontic surgery as major service
over oral surgery lexcept simple extractions) as major service
xclude covcraaa of aonnral a nnath, rn
•o%20.1)1 L; .-_. ?[bihl: Fax r).i c 9..,_?ir. Group TO: (.561) 8.38 )663 PAGE: ;)ill OF iP`.•1
ROGERS BF. NF. FIT GROUP
FACSIMILE TRANSMITTAL SHEET
TO. FROM:
Wendy Geyer Barbara I Ioughtaling
COMPANY: DATE:
Acordia 07/09/2001
FAX NUMBER: TOTAL NO.OF PAGES INCLUDING COVER:
838-9683 1
cc:
Marti Kula.
RE. YOUR REFERENCE NUMBER:
Village of Tequesta
❑URGENT ❑FOR REVIEW 0 PLEASE COMMENT ❑PLEASE REPLY ❑PLEASE RECYCLE
NOTES/COMMENTS.
Thank you for your request for proposal for Village of Tequesta. Unfortunately,Aetna will not
be able to provide a proposal for this group. They do not have a network in Martin and St.Lucie
Counties. For this reason, I must respectfully decline In release a proposal.
Please call me if you have any questions.
(CLICK IIERE AND TYPE RETURN ADDRESS)
1/1112
JEFFERSON PILOT
FINANCIAL
July 12, 2001
Wendy Geyer
Acordia of South Florida
501 S Flagler Dr Ste 600
West Palm Beach, FL 33401
RE: Village of Tequesta
Dear Wendy:
Thank you for giving Jefferson Pilot Financial Insurance Company the opportunity to review the
specifications for the above referenced prospect.
We are declining to quote Dental coverage as we are not competitive with the inforce plan. In
addition, we are unable to offer an open class for the retirees.
I am sorry my response cannot be more favorable. Please call me if you have any questions
regarding this decision.
Sincerely,
Jeff Eilers
RGO Marketing Rep - Miami
UnitedHealthcare
cA UnitadHoalt Group Company
13621 NW 121h Street,3'4 Floor
Sunrise,Florida 33323
(800)762-6662
07/16/2001
Steve Olsen
Acordia of South Florida
501 South Flagler Drive, Suite 600
West Palm Beach,Florida 33401
Via Fax: (561) 838-9683
RE: Village of Tequesta
Dear Steve:
Thank you for the opportunity to offer health care benefit plan(s) to your client, Village
of Tequesta. At present United HealthCare of Florida, Inc. is unable to offer this group
health care benefit coverage. Our inability to offer health care coverage at this time is
due to the following reason(s):
* Overall risk considerations.
Should the company's profile change in the future, and you would like to reconsider
United Healthcare, please don't hesitate to contact us.
Thank you for the opportunity to work with you. We look forward to serving you and
your clients in the future.
Sincerely,
er(ry Specter
Sales Representative
(954) 858-4053