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HomeMy WebLinkAboutAgreement_General_08/13/2009 (2)CIGNA Healthcare CIGNA Healthcare Group Benefits Proposal Village of Tequesta 345 Tequesta Dr Tequesta, FL 33469 SIC Code :9111 Group Contact Account Number :3150680 Total Eligible Employees: 90 Employer Contributions Waiting Period Eligibility Definition Participating Subscribers : 0 Employee Contribution : 100% Dependent Contribution: 75% 30 days Active Employees working 40 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, state law may require regulatory approval of rates. 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 10% in which case the CIGNA Companies may change the Quoted Rate. S2-GRAHL91-S[F-1 Revisionl 1 of l3 08/13/09 Village of Tequesta CIGNA HealthCaxe Proposed Benefits Product: Open Access Plus In- Network Situs State: FL Effective Date: 10/01/2009 Benefits Summary Category Description In Network Medical Benefits Modular Medical Management Program Benefit PHS+ Option Office Visit Copay NA Primary Care Copay $15 Specialty Care Copay (Tier 1/Tier 2) $25/40 Coinsurance 100% Hospital IP -Per Admit Copay NA Hospital [P Copay Per Day NA Collective Deductible/OOP Admin Option NO Combined Medical/Pharmacy Deductible/OOP Admin NO Option Annual Individual Plan Deductible $500 Annual Family Plan Deductible $1,000 Deduct Accumulator Standard: One Way Accumulation OOP -Individual Maximum Amount $500 OOP -Family Maximum Amount $1,000 OOP Max -Accumulator Standard: One Way Accumulation OOP Max Ded Includes Ded OOP Max Copays Excl Copays Lifetime Maximum Amount $5,000,000 Lifetime Maximum -Annual Reinstatement Amount NA Outpatient Facility Copay NA Emergency Room Copay $150 Urgent Care Copay $50 Other Health Care Facility IP Maximum Days 60 Lab/Radiology Standard Coverage Plan Ded/Coins MRI, CT PET Scans Copay $250 Lab/Radiology Mid-Point Coins Option Coinsurance NA Home Health Care Maximum Days 60 Durable Medical Equipment Included Durable Medical Equipment Maximum Amount $1,000 External Prosthetic Appliances Included External Prosthetic Appliances Deductible $200 External Prosthetic Appliances Maximum Amount $1,000 Short Term Rehab and Chiro Combined Maximum 20 Days Short Term Rehab Maximum Days NA S2-GRAHL91-SIF-1 Revisionl 2 of 13 08/13/09 Village of Tequesta cIGNA Healthcare Proposed Benefits Product: Open Access Plus In- Network Situs State: FL Effective Date: 10/01/2009 Benefits Summary (Cont.) Category Description In Network Medical Benefits (Cont.) Chiropractic Care Maximum Amount NA Chiropractic Care Maximum Days NA Infertility Treatment Standard Coverage Not Covered Infertility Opt 1 -Diagnoses/Corrective procedure Excluded Infertility Opt 2 -Opt 1 plus Invitro, GIFT, Z1FT Excluded Infertility Opt 2 -Lifetime Maximum Amount NA Bariatric Services Excluded Bariatric Surgery -Lifetime Maximum Amount NA Preventive Care -Children thru Age 2 Included Preventive Care Opt 2 -Annual Physicals Age 3+ Included Preventive Care Opt 2 -Immunizations Included Preventive Caze Opt 2 -Calendar Year Benefit Unlimited Maximum Amount Organ Transplant Included Health Advisor Benefit Option Excluded Routine Foot Care Buy-up Excluded Routine Foot Care -Cal Yr Buy-up Benefit Maximum NA Amount Non-Surgical TMJ Included PCL Included Medicare COB: Retirees >=65 Admin Option NA Medicare COB Type None Percent of Medicaze Eligible NA Well Aware Program (Diabetes) Included Well Aware Program (Cazdiac) Included Well Aware Program (Asthma) Included Well Aware Program (Low Back Pain) Included Well Aware Program (COPD) Included Well Aware Program (Weight Complications) Included Well Aware Program (Targeted Conditions) Included Well Aware Program (Depression Management) Included Incentive Points Program Excluded 24H1 L Included Healthy Rewards Included LifeSource Organ Transplant Network Transplant Included Program Language Line Included Transition of Care Included S2-GRAHL91-SIF-1 Revisionl 3 of 13 08/13/09 Village of Tequesta cIGNA Healthcare Proposed Benefits Product: Open Access Plus In- Network Situs State: FL Effective Date: 10/01/2009 Benefits Summar~Cont.) Category Description In Network Medical Benefits (Cont.) Case Management Included Provider Channeling Included Away From Home Care Included Drugstore.Com Included S2-GRAHL91-SIF-1 Revisionl 4 of 13 08/13/09 Village of Tequesta cIGNA Healthcare Proposed Benefits Product: Open Access Plus In- Network Situs State: FL Effective Date: 10/01/2009 Benefits Summary (Cont.) Category Description In Network Pharmacy Benefits CIGNA PharmacyPlus 3-Tier Copay Plan Buy Up Option Coinsurance Retail -Generic Copay $10 Retail -Brand Copay $35 Retail -Non Preferred Copay $50 Mail Order -Generic Copay $25 Mail Order -Brand Copay $88 Mail Order Copay -Non-preferred $125 Retail -Individual Buy Up Option Deductible Retail -Family Buy Up Option Deductible Retail -Individual Deductible NA Retail -Family Deductible NA OOP -Individual Maximum NA OOP -Family Maximum NA Standard Preventive Drugs Excluded from Deductible NO Ded & OOP Max Apply to MOD Do Not Apply to MOD MOD Program No Mandatory Maintenance Drug List NA Oral Contraceptives/Devices Covered Lifestyle Drugs Not Covered Oral Fertility Drugs Not Covered Self-Administered Injectables Covered Optional Injectables Buy-Up Not Covered Insulin Covered Insulin Needles & Syringes Covered Glucose Test Strips Covered Lancets Covered Prenatal Vitamins Covered Step Therapy Program Included Clinical Management Program Enhanced Enh. -Benefit Exclusion Selected Enh. -Intensive Appropriateness of Use Selected Enh. -Utilization and Unit Cost Management Selected Generic Push Included Formulary Incentive Prescriber Panel Open Out of Network NA NA NA NA NA S2-GRAHL91-SIF-1 Revisionl 5 of 13 08/13/09 Village of Tequesta CIGNA Health axe Proposed Benefits Product: Open Access Plus In- Network Situs State: FL Effective Date: 10/01/2009 Benefits Summary (Cont. Category Description In Network MH/SA Benefits OAPIN MHSA Separate CIGNA Behavioral Health Benefit Option In & Outpatient Mgmt. CAP MH Hospital IP Coinsurance 100% MH Hospital IP -Per Admit Copay NA MH Hospital [P -Per Day Copay $50 MH Hospital lP Maximum Days 30 SA Hospital IP Coinsurance 100% SA Hospital IP -Per Admit Copay NA SA Hospital IP -Per Day Copay $50 SA Hospital IP Maximum Days 30 MH Outpatient Copay $25 MH Outpatient Coinsurance NA MH OP & Group Therapy Combined Maximum Visits 20 MH Intensive Outpatient Copay $50 MH Intensive Outpatient Coinsurance 100% SA Outpatient Copay $25 SA Outpatient Coinsurance NA SA Outpatient Maximum Visits 44 SA Intensive Outpatient Copay $50 SA Intensive Outpatient Coinsurance 100% MH Grp Therapy Copay $15 MH Grp Therapy Coinsurance NA MH OP Tiered Copay Option Excluded MH OP Tier 1 Copay NA MH OP Tier 1 Visits (1 to _) Maximum NA MH OP Tier 2 Copay NA MH OP Tier 2 Visits (Tier 1 max to _) Maximum NA MH OP Tier 3 Copay NA MH OP Tier 3 Visits (Tier 2 max to _) Maximum NA SA OP Tiered Copay Option Excluded SA OP Tier 1 Copay NA SA OP Tier 1 Visits (1 to _) Maximum NA SA OP Tier 2 Copay NA SA OP Tier 2 V isits (Tier 1 max to _) Maximum NA SA OP Tier 3 Copay NA SA OP Tier 3 Visits (Tier 2 max to _) Maximum NA S2-GRAHL91-SIF-1 Revisionl 6 of 13 08/13/09 Village of Tequesta CIGNA Healthcare Proposed Benefits Product: Open Access Plus In- Network Situs State: FL Effective Date: 10/01/2009 Benefits Summary (Cont. Category Description In Network MH/SA Benefits (Cont.) Standard IP Review/Case Mgmt UR Program Included OP Review/Case Mgmt Buy Up 1 UR Program Excluded OP Review/Case Mgmt Buy Up 2 UR Program Excluded Transition of Caze (90 day period) Included Vision Benefits None Benefits Summary Comment: OAPIN WITH CCN Plan A S2-GRAHL91-S1F-1 Revision] 7 of 13 08/13/09 Village of Tequesta CIGNA Healthcare Tier Subscribers Members Renewal Rate Monthly Premium Single 50 $472.31 $23,615.50 Two-Party 1 1 $1,010.76 $11,118.36 Parent-Child 8 $873.77 $6,990.16 Familv 94 $1 416 95 $133 193 30 Total $153,917.32 S2-GRAHL91-SIF-1 Revision) 8 of 13 08/13/09 Village of Tequesta cIGNA Healthcare Medical History Information For Village of Tequesta 1. Have there been any claims over $10,000 in the last 12 months? 2. Has any employee missed more than 10 consecutive days in the last 12 months due to illness or in'u ? 3. Are there an em to ees with on oin disabilities? 4. Have any individuals been diagnosed, received treatment, or are currently receiving treatment for any of the following conditions in the past three years: Alcohol/Drug abuse, Cancer, Diabetes, Heart Conditions, Immune System Disorders, Kidney Ailments, Liver Diseases, Lung Conditions, Obesity, Organ Trans lants? No known medical conditions exist S2-GRAHL91-SIF-1 Revisionl 9 of 13 08/13/09 Village of Tequesta CIGNA He~.1t11Care Underwriting Contingencies For Village of Tequesta A. General Terms of this Proposal The CIGNA Healthcare Company identified herein ("CIGNA") is pleased to present this Proposal for a Guaranteed Cost group medical and pharmacy benefit plan (the "Plan") sponsored by Village of Tequesta. This proposal is valid for 60 days from its original date of release, 08/13/2009. Any revisions or updates to this proposal will not renew this valid timeframe unless expressly communicated by CIGNA. Proposal Caveats CIGNA may revise or withdraw this Proposal if: 1 there is a change to the effective date of the quote. 2 the policy period length is different than 12 months. 3 the policy will not be sitused in FL. 4 the Plan benefits are different than shown in the RFP or benefit modifications are requested. 5 there is a change in any law, regulation, or required assessment or tax that changes CIGNA's costs in offering the plan. 6 enrollment increases or decreases by 10% or more, by product or for the total account, from the enrollment assumptions used in establishing the rates and/or fees set forth herein. 7 participation is below 50%. This will be based on the total eligible employees, identified as 90 employees. 8 it is not the exclusive provider of Medical (/ Pharmacy /Vision) or like products for all of Village of Tequesta's employees in all worksites. 9 the employer contributes less than 50% toward the total cost of the plan. 10 the employer changes its contribution to the plan rates (either the percentage or amount). 1 I either one or more of the quoted sites withdraws prior to the effective date or terminates during the contract term, or at any time following enrollment. 12 the current waiting period is different than 30 days. S2-GRAHL91-S[F-1 Revisionl ]0 of 13 08/13/09 Village of Tequesta CIGNA Healthcare Underwriting Contingencies For i~illage of Tequesta (cont.) 13 the final enrollment deviates from the quoted enrollment such that it results in a needed change in premium rates. Rates are based on final enrollment factors, including total number of enrollees, their age, sex, demographics, location and the distribution of enrollees by product or membership tier. 14 any of the information upon which these rates or benefits were based (including Medical History Information) changes or is inaccurate. B. Scope and Application of this Proposal Unless otherwise indicated, this Proposal: 1 supersedes and renders null and void any prior CIGNA offer or proposal with respect to the Plan. 2 or policy may be canceled as of any Premium Due Date if the number of insured Employees fails to meet the minimum required per group participation rules; or for failure to comply with any other material plan provision relating to Employer contributions or group participation rules. 3 requires a separate benefit option due to state regulations, if you have purchased OAP/PPO with CIGNA Behavioral Advantage and you have members residing in NC or CA. 4 does not apply to part-time or seasonal employees for any plan. 5 includes the Network Savings Program (NSP) and other bill negotiation. 6 includes a maximum reimbursable charge for out-of-network coverage equal to 110% of a fee schedule developed by CIGNA based upon a methodology similar to that used by Medicare to determine the allowable fee for similar services in the geographic market. OR 80th percentile of charges made by providers of such service or supply in the geographic area where the service is received. 7 includes a maximum reimbursable charge for out-of-network coverage equal to 80th percentile of charges made by providers of such service or supply in the geographic area where the service is received. 8 assumes all employees are located in the network area, and that all employees are only eligible for the Connecticut General or other CIGNA company product offerings specified. 9 requires you notify us within 30 days if any information set forth in this form changes at any time while coverage is provided to you by CIGNA Healthcare Companies. S2-GRAHL91-SIF-1 Revisionl 11 of 13 08/13/09 Village of Tequesta CIGNA Healthcare Underwriting Contingencies For Village of Tequesta (conlf) 10 may require regulatory approval of rates. 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. If a product is new and has never had approved rates, the effective date of coverage will be postponed until regulatory approval is received. 11 allows caveats and conditions set forth in this document to survive execution of any final contract and/or issuance by CIGNA Healthcare of any policy and/or Group Service Agreement. 12 does not apply to Medicare eligible retirees for any plan. 13 excludes charges for converting a qualified member of a group plan to an individual plan. S2-GRAHL91-SIF-1 Revision] 12 of 13 08/13/09 Village of Tequesta CIGNA Healthcare Underwriting Contingencies For Village of Tequesta (cont.) 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. The benefits displayed in this summary are, for the most part, modular benefit packages used to develop the rates. Please review the Benefit Summary and its attachments for information about the benefits available in your sites. "CIGNA Healthcare" refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company, Tel-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., lntracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. I UNDERSTAND AND AGREE ON BEHALF OF CONTRACTHOLDER THAT CIGNA HEALTHCARE MAY, NOTWITHSTANDING THE TERMS OF THE INSURANCE POLICY OR SERVICE AGREEMENT REVISE ANY PREMIUM RATES OR PREPAYMENT FEES AT ANY TIME IF THE ENROLLMENT OR EMPLOYER CONTRIBUTION LEVEL IS DIFFERENT THAN ASSUMED BY CIGNA HEALTHCARE IN UNDERWRITING THE CONTRACT. Client Client Name ~,~~• ~/Q Dae 4~'C''"~f Title S2-GRAHL91-SIF-1 Revisionl 13 of 13 08/13/09 Village of Tequesta