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Home My WebLink AboutAgreement_General_09/09/2010 (2) C� CIGNA CIGNA HealthCare Group Benefits Renewal Village of Tequesta 345 Tequesta Dr Tequesta, FL 33469 SIC Code: 9111 Account Number: 3150680 Total Eligible Employees: 87 Participating Subscribers: 87 Employer Contributions: Employee Contributions: 100% Dependent Contributions: 75% Waiting Period: 30 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, 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. Proposal # 550905 8/12/10 Page 1 of 10 CIGNA Proposed Benefits Product: Open Access Plus In- Network Situs State: FL Effective Date: 10/01/2010 Category Description In Network Out of Network Medical Benefits Open Access Plus Copay In - Network Modular Medical Management Program PHS+ Office Visit Copay NA Primary Care Copay $20 Specialty Care Copay/ Non CCN Copay $30345 Coinsurance 100 Hospital IP Copay - Per Admit NA Hospital IP 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 $1,500 Deduct Accumulator No Cross Accumulation OOP - Individual Maximum Amount $500 OOP - Family Maximum Amount $1,500 OOP Max - Accumulator No Cross Accumulation OOP Max Ded Includes Ded OOP Max Copays Excl Copays Lifetime Maximum Amount Unlimited Lifetime Maximum - Annual Reinstatement Amount NA Outpatient Facility Copay NA Emergency Room Copay $200 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 Days 20 Proposal # 550905 8/12/10 Page 2 of 10 MA 0 CIGNA Proposed Benefits Product: Open Access Plus In- Network Situs State: FL Effective Date: 10/01/2010 Category Description In Network Out of Network Medical Benefits Open Access Plus Copay In - Network Short Term Rehab Maximum Days NA Chiropractic Care Maximum Amount NA Chiropractic Care Maximum Days NA Infertility Treatment Standard Coverage Not Covered Infertility Opt 1 - Diagnoses/Corrective procedures Excluded Infertility Opt 2 - Opt 1 plus Invitro, GIFT, ZIFT, etc. Excluded Infertility Opt 2 - Lifetime Maximum Amount NA Bariatric Services Excluded Bariatric Surgery - Lifetime Maximum Amount NA Preventive Care - Children duu Age 2 Included Preventive Care Opt 2 - Annual Physicals Age 3+ Included Preventive Care Opt 2 - Immunizations Included Preventive Care Opt 2 - Calendar Year Benefit Maximum Unlimited Amount Organ Transplant Included Health Advisor 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 Medicare Eligible NA Well Aware Program (Diabetes) Included Well Aware Program (Cardiac) 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 24HIL Included Healthy Rewards Included LifeSource Organ Transplant Network Transplant Included Program Proposal # 550905 8/12/10 Page 3 of 10 up 0 CIGNA Proposed Benefits Product: Open Access Plus In- Network Situs State: FL Effective Date: 10/01/2010 Category Description In Network Out of Network Medical Benefits Open Access Plus Copay In - Network Language Line Included Transition of Care Included Case Management Included Provider Channeling Included Away From Home Care Included Drugstore.Com Included Pharmacy Benefits CIGNA Advantage Pharmacy 4 -Tier Plan Coinsurance NA Retail - Generic Coinsurance 0% Retail - Generic Minimum Copay $15 Retail - Generic Maximum Copay NA Retail - Brand Coinsurance 0% Retail - Brand Minimum Copay $40 Retail - Brand Maximum Copay NA Retail - Non Preferred Coinsurance 0% Retail - Non Preferred Minimum Copay $60 Retail - Non Preferred Maximum Copay NA Retail - 4th Tier Coinsurance 20% Retail - 4th Tier Minimum Copay NA Retail - 4th Tier Maximum Copay $100 Mail Order - Generic Coinsurance NA Mail Order - Generic Copay NA Mail Order - Generic Minimum Copay $38 Mail Order - Generic Maximum Copay NA Mail Order - Brand Coinsurance NA Mail Order - Brand Copay NA Mail Order - Brand Minimum Copay $100 Mail Order - Brand Maximum Copay NA Mail Order - Non - Preferred Coinsurance NA Mail Order Copay - Non - preferred NA Mail Order - Non Preferred Minimum Copay $150 Mail Order - Non Preferred Maximum Copay NA Mail Order - 4th Tier Coinsurance 20% Mail Order - 4th Tier Copay NA Mail Order - 4th Tier Minimum Copay NA Proposal # 550905 8/12/10 Page 4 of 10 CIGNA Proposed Benefits Product: Open Access Plus In- Network Situs State: FL Effective Date: 10/01/2010 Category Description In Network Out of Network Pharmacy Benefits CIGNA Advantage Pharmacy 4 -Tier Mail Order - 4th Tier Maximum Copay $250 4th Tier - Self Administered Injectables Included 4th Tier - Oral Contraceptives Excluded 4th Tier - Erectile Dysfunction Excluded 4th Tier - Cold & Cough Excluded 4th Tier - Antihistamines Excluded Retail - Individual Deductible NA NA Retail - Family Deductible NA NA Annual - Individual Maximum NA NA Annual - Family Maximum NA NA OOP - Individual Maximum NA NA OOP - Family Maximum NA NA Standard Preventive Drugs Excluded from Deductible NO Ded, Annual Max, 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 Smoking Cessation Not Covered Smoking Cessation Excluded from Deductible NO Non - Prenatal Vitamins Not Covered Non- Prenatal Vitamins Excluded from Deductible NO Anti- Obesity & Anorexiants Not Covered Anti- Obesity & Anorexiants Excl. from Deductible NO Self- Administered Injectables Covered Optional Injectables Buy -Up 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 Proposal # 550905 8/12/10 Page 5 of 10 CIGNA Proposed Benefits Product: Open Access Plus In- Network Situs State: FL Effective Date: 10/01/2010 Category Description In Network Out of Network Pharmacy Benefits CIGNA Advantage Pharmacy 4-Tier Enh. - Utilization and Unit Cost Management Selected No Mandatory Generic Included Formulary Advantage Prescriber Panel Open MH/SA Benefits OAPIN MHSA Combined CIGNA Behavioral Health In & Outpatient Mgmt. CAP MH/SA Hospital IP Coinsurance 100% MH/SA Hospital IP - Per Admit Copay NA MH/SA Hospital IP - Per Day Copay NA MH/SA Hospital IP Combined Maximum Days 365 MH/SA Outpatient Copay NA MH/SA Outpatient Coinsurance 100% MH/SA Intensive Outpatient Copay s0 MH/SA Intensive Outpatient Coinsurance 100% MH/SA OP & MH Group Therapy Combined Maximum 365 Visits MH Grp Therapy Copay NA MH Grp Therapy Coinsurance 100% MH/SA OP Tiered Copay Option Excluded MH/SA OP Tier 1 Copay NA MH/SA OP Tier 1 Visits (1 to _) Maximum NA MH/SA OP Tier 2 Copay NA MH/SA OP Tier 2 Visits (Tier 1 Max to _) Maximum NA MH/SA OP Tier 3 Copay NA MH/SA OP Tier 3 Visits (Tier 2 Max to _) Maximum NA 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 Care (90 day period) Included Vision Benefits None Proposal # 550905 8/12/10 Page 6 of 10 CIGNA Group Description: FL305I (B1) FL305K (B1) FL305L (B1) ME300F (B1) Inforce Current Renewal Monthly Tier Subscribers Members Rate Rate Premium Change Single 42 $481.40 $20,218.80 Two -Party 10 $1,029.61 $10,296.10 Parent -Child 8 $890.10 $7,120.80 Family 27 $1,443.39 $38971.53 Total 87 192 $76,607.23 Proposal # 550905 8/12/10 Page 7 of 10 0 CIGNA 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, 08/12/2010. 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 0. 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). 11 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. 13 14 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. 15 any of the information upon which these rates or benefits were based (including Medical History Information) changes or is inaccurate. 16 there is any reimbursement arrangement ( "gap" cards, etc.) that subsidizes or reduces the out -of- pocket obligation of insured persons under the policy. Proposal # 550905 8/12/10 Page 8 of 10 CIGNA Underwriting Contingencies For Village of Tequesta 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 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. 8 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. 9 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. 10 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. 11 does not apply to Medicare eligible retirees for any plan. 12 excludes charges for converting a qualified member of a group plan to an individual plan. 13 is a high -level summary of the proposed coverage. It does not identify all the categories of health care expenses that are covered or excluded. 14 may include state required continuation rates which will match the rates for the underlying plan. For Nebraska and New York Over Age Dependents the rates will match the employee rate for the underlying plan. Proposal # 550905 8/12/10 Page 9 of 10 CIGNA Underwriting Contingencies For Village of Tequesta 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., Intracorp, 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. O, Client Signature ate Client Name Title Proposal # 550905 8/12/10 Page 10 of 10