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Home My WebLink AboutAgreement_General_09/12/2013 (3) �j Cigna Vision Solution for VILLAGE OF TEQUESTA Effective Date : 10/1/2013 Renewal quote completed by Cigna Dental & Vision Underwriting on July 10, 2013 Voluntary Fully Insured Quote (Per Employee Per Month) `20% Minimum Participation Required` Current Renewal % change Employee Only $ 5.77 $ 6.19 Employee + Spouse $ 11.53 $ 12.37 7.3% Employee + Child(ren) $ 11.64 $ 12.49 Employee + Family $ 18.35 $ 19.69 "Broker commissions of 10% are included in this quote. "Voluntary: Medical and /or dental subscribers can elect to not enroll in vision. Does not refer to contribution levels. `Quote is valid for 90 days and includes claim processing, network access, customer service, policy and certificate, and standard vision reporting. The fee also includes two vision specific ID cards, mailed directly to the member's home address (unless other arrangements are made in advance). "Our Cigna Vision proposal is contingent upon selecting Cigna for your dental and /or medical coverage. `Rates are guaranteed for one year. 'The quoted premium /rates do include the cost of the Health Insurance Assessment (PPACA), beginning on January 1, 2014. However, Cigna reserves the right to modify quoted as necessary, should there be any change in future regulation. Cigna Vision Network offers one of the largest national routine vision networks, with 54,000+ optometrists and ophthalmologists at over 23,000 locations nationwide, including private practice and national and regional retail locations. Renewal Plan Design - PPO - Scheduled Frequency is 12 months for exams, 12 months for lenses, 12 months for contact lenses, and 24 months for frames. Benefit In- Network Out -of- Network Examination Copay $20 n/a Materials Copay $30 n/a Exam Covered in Full $45 allowance Single Vision Lenses Covered in Full $32 allowance Bifocal Lenses Covered in Full $55 allowance Trifocal Lenses Covered in Full $65 allowance Lenticular Lenses Covered in Full $80 allowance Contact Lenses (retail allowance) Elective $100 allowance $87 allowance Therapeutic Covered in Full $210 allowance Frame (retail allowance) $100 allowance $55 allowance In- Network Benefits Include: • One vision and eye health evaluation including but not limited to eye health examination, dilation, refraction, and prescription for glasses • One pair of prescription plastic or glass lenses, all ranges of prescriptions (powers and prisms) • Lens Options: • Standard Polycarbonate: covered for under 18 years of age, min. 20% save, $40 out -of- pocket max. for adults • Oversize lenses: covered under plan ❑ Rose Tints: #1 and #2 - covered under plan • Solid Tints: min. 20% save, $15 out -of- pocket max. ❑ Gradient Tints: $20 out -of- pocket max. • Standard photochromics: 20% save, $78 out -of- pocket max. ❑ Standard anti - reflective coating: min. 20% save, $45 out -of- pocket max. • Standard scratch /UV coating: min. 20% save, $17 out -of- pocket max. • Progressive lenses: covered up to bifocal lens amount with 20% savings on the difference, $81 out -of- pocket max, for standard lens • One frame of choice covered up to retail plan allowance, plus a 20% savings on amount that exceeds frame allowance. • One pair or a single purchase supply of contact lenses - in lieu of lenses and frame benefit, (may not receive contact lenses and frames in same benefit year). Allowance applied towards cost of supplemental contact lense professional services (including the fitting and evaluation), and contact lens materials. • Vision Network Savings Program: o Minimum 20% savings on additional purchases of frames and /or lenses, including lens options, with a valid prescription: offered savings does not apply to contact lens materials. Check with your Cigna Vision Network Provider for details. Benefits are underwritten or administered by Cigna. This information is intended as a summary of benefits only. It does not describe all the terms, provisions and limitations of your plan. Network providers are independent contractors solely responsible for your routine vision examination and products. 18 7/10/2013 9:12 Oppty: OP- 1474457 Account Number: 3150680 ELIZABETH WILLIAMS (South Florida - 362) I Cigna. CIGNA HealthCare Group Benefits Renewal Village of Tequesta 345 Tequesta Dr Tequesta, FL 33469 SIC Code: 9111 Account Number: 3150680 Total Eligible Employees: 75 Participating Subscribers: 75 Employer Contributions: 85% Employee Contributions: 0% Dependent Contributions: 15% Waiting Period: 30 days Eligibility Definition: 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 CIGNA HealthCare may change the Quoted Rate. Proposal # 1156999 Page 1 of 20 7/23/13 Cigna. Proposed Benefits Product: Open Access Plus In- Network Situs State: FL Effective Date: 10/01/2013 Category Description In Network Out of Network Medical Benefits Copay In - Network Modular Medical Management Program PHS+ Office Visit Copay NA Primary Care Copay $20 Specialty Care Copay CCN/Non -CCN $30/45 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 Deductible /OOP Max Accumulator No Cross Accumulation OOP - Individual Maximum Amount $500 OOP - Family Maximum Amount $1,500 OOP Max Plan Deductible Includes Ded OOP Max Copays No Copays Accumulate Lifetime Maximum Amount Unlimited Lifetime Maximum - Annual Reinstatement Amount NA Outpatient Facility Copay NA Emergency Room Copay $200 Urgent Care Copay $50 Emergency Room/Urgent Care Plan Ded Applies Admin NO Option Medical Outpatient Professional Ded/Coins Other Health Care Facility IP (SNF) Maximum Days 60 Diagnostic Lab / Radiology (Independent/Outpatient/In Cover 100 %, no Office) Coverage ded Advanced Radiology Imaging (ARI), CT PET Scans $250 Copay Lab/Radiology Mid -Point Coins Option Coinsurance NA Home Health Care Maximum Days 60 Durable Medical Equipment Included Durable Medical Equipment Maximum Amount Unlimited Proposal # 1156999 Page 2 of 20 7/23/13 Cigna. Proposed Benefits Product: Open Access Plus In- Network Situs State: FL Effective Date: 10/01/2013 Category Description In Network Out of Network Medical Benefits Copay In - Network External Prosthetic Appliances Included External Prosthetic Appliances Deductible $200 External Prosthetic Appliances Maximum Amount Unlimited Short Term Rehab and Chiro Combined Maximum Days 20 Short Term Rehab Maximum Days NA Chiropractic Care Maximum Amount NA Chiropractic Care Maximum Days NA Acupuncture Maximum Days Not Covered 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 100 %, No Ded Preventive Care - Children thru Age 2 Included Preventive Care - Annual Physicals Age 3+ Included Preventive Care - Immunizations Included Preventive Care - Annual Max Maximum Amount Unlimited Breast - Feeding Equipment & Supplies 100% Supplemental Preventive Services Included Family Planning Included Family Planning - Women's Services Covered, 100% no ded Contraceptive Devices Covered, 100% no ded Allergy Treatment/Injections Standard - Same as OV Organ Transplant Included Routine Foot Care Buy -up Excluded Routine Foot Care - Cal Yr Buy -up Benefit Maximum NA Amount TM7 Included Elective Abortion Covered PCL Included Proposal # 1156999 Page 3 of 20 7/23/13 Cigna. Proposed Benefits Product: Open Access Plus In- Network Situs State: FL Effective Date: 10/01/2013 Category Description In Network Out of Network Medical Benefits Copay In - Network Medicare COB: Retirees > =65 Admin Option NA Medicare COB Type None Percent of Medicare Eligible NA Integrated Personal Health Team A (iPHT A) Clinical Excluded Program Your Health First Clinical Program 100 Health Advisor Clinical Program Excluded Incentives Programs Excluded Social Engagement Not Available 24HIL Included Healthy Rewards Included LifeSource Organ Transplant Network Transplant Included Program Language Line Included Transition of Care Included Case Management Included Provider Channeling Included Away From Home Care Included Drugstore.Com Included Pharmacy Benefits CIGNA PharmacyPlus 3 -Tier Copay Formulary Standard Plan Buy Up Option Coinsurance NA Retail - Generic Copay $15 Retail - Brand Copay $40 Retail - Non Preferred Copay $60 Home Delivery - Generic Copay $38 Home Delivery - Brand Copay $100 Home Delivery - Non - Preferred Copay $150 Retail - Individual Buy Up Option Deductible NA Retail - Family Buy Up Option Deductible NA Retail - Individual Deductible NA Retail - Family Deductible NA OOP - Individual Maximum NA NA OOP - Family Maximum NA NA Standard Preventive Drugs Excluded fr De NO Proposal # 1156999 Page 4 of 20 7/23/13 Cigna. Proposed Benefits Product: Open Access Plus In- Network Situs State: FL Effective Date: 10/01/2013 Category Description In Network Out of Network Pharmacy Benefits CIGNA PharmacyPlus 3 -Tier Copay Generic 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 Contraceptive Devices, Drugs, OTCs(Certain Products at Included 100 %) 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 Dispensing Requirement Generic Requirements No Generic Requirement 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 Unlimited MH/SA Outpatient Office Visits Copay $30 MH/SA Outpatient Office Visits Coinsurance NA MH/SA Outpatient Facility Copay NA Proposal # 1156999 Page 5 of 20 7/23/13 Cigna. Proposed Benefits Product: Open Access Plus In- Network Situs State: FL Effective Date: 10/01/2013 Category Description In Network Out of Network MH/SA Benefits OAPIN MHSA Combined MH/SA Outpatient Facility Coinsurance 100% MH/SA Outpatient Facility Plan Ded. Applied Admin YES Option MH/SA Intensive Outpatient Copay $30 MH/SA Intensive Outpatient Coinsurance 100% MH/SA OP & MH Group Therapy Combined Maximum Unlimited visits MH Grp Therapy Copay $30 MH Grp Therapy Coinsurance NA 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 MWSA 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 Benefit Exceptions: Proposal # 1156999 Page 6 of 20 7/23/13 Cigna. Group Description: FL305K (ALL ACTIVE EMPLOYEE'S) FL305L (ALL ACTIVE EMPLOYEE'S) Inforce Current Renewal Monthly Billed Tier Subscribers Members Rate Rate Amount Change EMP 19 $692.45 $737.47 $14,011.93 6.50% EMP +SPOUSE 2 $1,481.01 $1,577.30 $3,154.60 6.50% EMP+CHILD(REN) 4 $1,280.34 $1,363.59 $5,454.36 6.50% EMP + FAMILY 2 $2,076.20 $2,211.19 $4,422.38 6.50% Total 27 42 $27,043.27 Included in the proposed Monthly Billed Amount is the Benefit Advisor Fee which is not part of the monthly premium. Proposal # 1156999 Page 7 of 20 7/23/13 Cigna. Proposed Benefits Product: CIGNA HealthCare - Choice Fund HSA Open Access Plus Situs State: FL Effective Date: 10/01/2013 Category Description In Network Out of Network Medical Benefits HSA Modular Medical Management Program PHS+ Coinsurance 80% 60% Hospital IP Copay - Per Admit NA Hospital IP Deductible - Per Admit NA Hospital IP Copay Per Day NA Hospital IP Deductible - Per Day NA Maximum Reimbursable Charge Option 2 - 110% Incl NSP & Bill Negotiation Deductible /OOP Tiers Admin Option 2 2 Collective Deductible /OOP Admin Option YES YES Combined Medical/Pharmacy Deductible /OOP Admin Combined Ded Combined Ded & Option & OOP OOP Annual Individual Plan Deductible $1,500 $3,000 Annual Two Party Plan Deductible NA NA Annual Family Plan Deductible $3,000 $6,000 Deductible /OOP Max Accumulator No Cross No Cross Accumulation Accumulation OOP - Individual Maximum Amount $3,000 $6,000 OOP - Two Party Maximum Amount NA NA OOP - Family Maximum Amount $6,000 $12,000 OOP Max Plan Deductible Includes Ded Includes Ded OOP Max Copays NA NA Lifetime Maximum Amount Unlimited Lifetime Maximum - Annual Reinstatement Amount NA Outpatient Facility Copay NA Outpatient Facility Deductible NA Emergency Room Copay NA Emergency Room Deductible NA Urgent Care Copay NA Urgent Care Deductible NA Medical Outpatient Professional Ded/Coins Other Health Care Facility IP (SNF) Maximum Days 60 Diagnostic Lab/Radiology (Independent/Outpatienvin Ded/Coins or Ded/Coins or OV Office) Coverage OV applies applies Lab/Radiology Mid -Point Coins Option Coinsurance NA NA Proposal # 1156999 Page 8 of 20 7/23/13 Cigna. Proposed Benefits Product: CIGNA HealthCare - Choice Fund HSA Open Access Plus Situs State: FL Effective Date: 10/01/2013 Category Description In Network Out of Network Medical Benefits HSA Advanced Radiology Imaging (ARI), CT PET Scans $0 $0 Copay Home Health Care Maximum Days 60 Durable Medical Equipment Included Cvrd- Ded/Coins Durable Medical Equipment Maximum Amount Unlimited External Prosthetic Appliances Included Cvrd- Ded/Coins External Prosthetic Appliances Deductible $0 External Prosthetic Appliances Maximum Amount Unlimited Short Term Rehab and Chiro Combined Maximum Days 20 Short Term Rehab Maximum Days NA Chiropractic Care Maximum Amount NA Chiropractic Care Maximum Days NA Infertility Treatment Standard Coverage Not Covered Not Covered Infertility Opt 1 - Diagnoses /Corrective procedures Excluded Infertility Opt 1 - Diagnoses /Corrective procedure Not Covered Infertility Opt 2 - Opt 1 plus Invitro, GIFT, ZIFT Not Covered 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 100 %, No Ded Preventive Care - Children thru Age 2 Cvrd- Ded/Coins Preventive Care - Annual Physicals Age 3+ Cvrd- Ded/Coins; subj to max Preventive Care - Annual Max Maximum Amount Unlimited Breast - Feeding Equipment & Supplies 100% Cvrd- Ded/Coins Supplemental Preventive Services Included Cvrd- Ded/Coins Family Planning Included Included Family Planning - Women's Services Covered, 100% Cvrd- Ded/Coins no ded Contraceptive Devices Covered, 100% Cvrd- Ded/Coins no ded Allergy Treatment/Injections Standard - Same as OV Proposal # 1156999 Page 9 of 20 7/23/13 Jft Cigna. Proposed Benefits Product: CIGNA HealthCare - Choice Fund HSA Open Access Plus Situs State: FL Effective Date: 10/01/2013 Category Description In Network Out of Network Medical Benefits HSA Organ Transplant Included Cvrd - with Transplant Maximums Routine Foot Care Buy -up Excluded Not Covered Routine Foot Care Separate Buy -up Coinsurance NA Routine Foot Care - Cal Yr Buy -up Benefit Maximum NA NA Amount PCL Included Included PAC /CSR - Standard IP Admit/Case Management UR Included Program PAC /CSR IP Non Compliance Penalty Percent 50% Medicare COB: Retirees > =65 Admin Option NA TM7 Included Included Elective Abortion Covered Covered Integrated Personal Health Team A (iPHT A) Clinical Excluded Program Your Health First Clinical Program 100 Health Advisor Clinical Program Health Advisor A Incentives Programs Excluded Social Engagement Not Available Not Available 24HIL Included Healthy Rewards Included LifeSource Organ Transplant Network Transplant Included Program Language Line Included Transition of Care Included Case Management Included Provider Channeling Included Away From Home Care Included Drugstore.Com Included Pharmacy Benefits CCF CIGNA Pharmacy 3 -Tier Copay Formulary Standard Plan Coinsurance 50% Retail - Generic Copay $15 Proposal # 1156999 Page 10 of 20 7/23/13 Cigna. Proposed Benefits Product: CIGNA HealthCare - Choice Fund HSA Open Access Plus Situs State: FL Effective Date: 10/01/2013 Category Description In Network Out of Network Pharmacy Benefits CCF CIGNA Pharmacy 3 -Tier Copay Retail - Brand Copay $40 Retail - Non Preferred Copay $70 Home Delivery - Generic Copay $30 Home Delivery - Brand Copay $80 Home Delivery - Non - Preferred Copay $140 Retail - Individual Deductible Combined With NA Medical Retail - Two Party Deductible NA NA Retail - Family Deductible Combined With NA Medical Annual - Individual Maximum NA NA Annual - Two Party Maximum NA NA Annual - Family Maximum NA NA OOP - Individual Maximum Combined With NA Medical OOP - Two Party Maximum NA NA OOP - Family Maximum Combined With NA Medical Standard Preventive Drugs Excluded from Deductible NO Generic Drugs Excluded from Deductible NO Ded, Annual Max, OOP Max Apply to MOD Apply to MOD MOD Program No Mandatory Maintenance Drug List NA Oral Contraceptives/Devices Covered Contraceptive Devices, Drugs, OTCs(Certain Products at Included 100 %) Lifestyle Drugs Not Covered Oral Fertility Drugs Not Covered Smoking Cessation Not Covered Smoking Cessation Excluded from Deductible NO Prescription 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 Not Covered Proposal # 1156999 Page 11 of 20 7/23/13 Cigna. Proposed Benefits Product: CIGNA HealthCare - Choice Fund HSA Open Access Plus Situs State: FL Effective Date: 10/01/2013 Category Description In Network Out of Network Pharmacy Benefits CCF CIGNA Pharmacy 3 -Tier Copay 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 Dispensing Requirement Generic Requirements No Generic Requirement Prescriber Panel Open MH/SA Benefits CCF MHSA Combined CIGNA Behavioral Health In & Outpatient Mgmt. CAP MH/SA Hospital IP Coinsurance 80% 60% MWSA Hospital IP - Per Admit Copay NA NA MH/SA Hospital IP - Per Day Copay NA NA MH/SA Hospital IP Combined Maximum Days Unlimited MH/SA Outpatient Office Visits Coinsurance 80% 60% MH/SA Intensive Outpatient Coinsurance 80% 60% MH/SA OP & MH Group Therapy Combined Maximum Unlimited Visits MH Grp Therapy Coinsurance 80% 60% 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 # 1156999 Page 12 of 20 7/23/13 Cigna. Proposed Benefits Product: CIGNA HealthCare - Choice Fund HSA Open Access Plus Situs State: FL Effective Date: 10/01/2013 Category Description In Network Out of Network Miscellaneous Benefits HSA Fund HSA Fund Included General Medical Fund Included Medical/Rx Combined Fund YES Individual General Medical Fund Amt - Employer Contrib $0 Amount Two Party General Medical Fund Amt- Employer Contrib NA Amount Family General Medical Fund Amt- Employer Contrib $0 Amount All 213(d) Services Included Benefit Exceptions: Proposal # 1156999 Page 13 of 20 7/23/13 Cigna. Group Description: FL305I (ALL ACTIVE EMPLOYEE'S) FL305K (ALL ACTIVE EMPLOYEE'S, ALL COBRA EMPLOYEE'S, ELECTED OFFICIALS) FL305L (ALL ACTIVE EMPLOYEE'S) Inforce Current Renewal Monthly Billed Tier Subscribers Members Rate Rate Amount Change EMP 23 $534.17 $568.90 $13,084.70 6.50% EMP +SPOUSE 4 $1,143.13 $1,217.45 $4,869.80 6.50% EMP +CHU,D(REN) 3 $988.23 $1,052.48 $3,157.44 6.50% EMP +FAMILY 18 $1,602.52 $1,706.71 $30,720.78 6.50% Total 48 114 $51,832.72 Included in the proposed Monthly Billed Amount is the Benefit Advisor Fee which is not part of the monthly premium. Above rates do not reflect employer liability for fund contributions. Proposal # 1156999 Page 14 of 20 7/23/13 I Cigna. Program Administrative Fees Product Name Fee Type Enrollment PEPM Fee CIGNA HSA Admin 48 $4.84 HealthCare - Choice Fund HSA Open Access Plus Total Program Administrative Monthly Fees $232.32 For CIGNA HealthCare HRA/HSA products, the Fee above includes the CIGNA HealthCare Administrative Fee plus any Additional Options selected. Proposal # 1156999 Page 15 of 20 7/23/13 Cigna. Underwriting Contingencies For Village of Tequesta A. General Terns of this Proposal CIGNA HealthCare is pleased to present this Proposal for a Fully Insured Non - Participating 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, 07/23/2013. Any revisions or updates to this proposal will not renew this valid timeframe unless expressly communicated by CIGNA HealthCare. Proposal Caveats CIGNA HealthCare 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 HealthCare'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 75. 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 level of contribution toward the cost of the coverage. 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 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 by customer tier. 14 any of the information upon which these rates or benefits were based (including Medical History Information) changes or is inaccurate. 15 there is any reimbursement arrangement ( "gap" cards, etc.) that subsidizes or reduces the out -of- pocket obligation of covered persons under the policy. Proposal # 1156999 Page 16 of 20 7/23/13 I 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 HealthCare 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 any product with CIGNA HealthCare Behavioral Advantage and you have customers 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 Cost Containment programs designed to contain costs with respect to charges for health care services /supplies that are covered by the Plan. For administering these programs, CIGNA HealthCare retains a portion of the savings or recoveries generated. 6 includes a maximum reimbursable charge for out -of- network coverage equal to 110% of a fee schedule developed by CIGNA HealthCare 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 CIGNA HealthCare or any other affiliated 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. 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 Medicare eligible retirees are not included in this plan unless mandated by situs state legislation. 12 excludes charges for converting a qualified customer 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. 15 assumes that the group health plan or health insurance coverage to which this proposal applies will not be a "grandfathered health plan" under the Patient Protection and Affordable Care Act (the "Act ") and that it will be subject to all requirements of the Act applicable to a group health plan or health insurance coverage unless otherwise specified in writing. Proposal # 1156999 Page 17 of 20 7/23/13 tw Cigna. Underwriting Contingencies For Village of Tequesta B. Scope and Application of this Proposal Unless otherwise indicated, this Proposal: 16 includes applicable Patient Protection and Affordable Care Act fees and assessments imposed upon health insurers including the Comparative Effectiveness Research Fee, the Health Insurance Industry Fee and the Transitional Reinsurance Assessment. 17 assumes applicable requirements of the Patient Protection and Affordable Care Act will be implemented on the effective date /renewal date unless you direct otherwise. 18 Assumes a non - CIGNA HealthCare Pharmacy Benefit Manager administers oral or other self - administered anti -cancer prescription medication claims at a copayment/coinsurance level that is no less favorable than that for intravenous or injected anti-cancer medication prescribed for the same purpose and covered under employer's CIGNA HealthCare plan. This assumption is applicable only if. (a) employer has contracted with a PBM (not CIGNA HealthCare); (b) employer's plan is either insured, or, if self - funded, not subject to ERISA (i.e., is a church, government or association plan); and (c) employer's CIGNA HealthCare plan is sitused in IA, HI, NM, OR, NJ, NE, VA, MA or a state with similar chemotherapy coverage law, or covers one or more individuals residing in CO, OK, VT, WA, TX or LA or in a state with similar extraterritorial chemotherapy coverage mandate. 19 includes capitated charges for behavioral care services arranged by CIGNA Behavioral Health, Inc. However, this may not apply in certain states. 20 includes capitated charges for the provision of Hi -Tech Radiology services by MedSolutions, Inc. However, this may not apply in certain states. 21 includes charges made by third parties for care management programs to contain the cost of specific health services/items and/or improve adherence to evidence -based guidelines to promote patient safety and efficient care (e.g., charges for management of nuclear cardiology, radiation therapy and medical oncology). 22 In order to implement the requested benefit design, different funding arrangements (i.e., insured, self - insured and/or HMO) involving affiliated CIGNA HealthCare companies may be required with respect to plan participants residing in certain states. 23 Important Notice Regarding Benefit Advisor Compensation - The premium for this guaranteed cost (i.e., non -Shared Returns) policy may not include compensation payable to your benefit advisor. Check with your CIGNA HealthCare Sales representative to confirm whether this is the case. When that is the case, the proposed billed amount includes both premium and benefit advisor fees, which are not part of the monthly premium and CIGNA HealthCare will include any benefit advisor fees agreed to by the client and benefit advisor on client invoices and forward payments received to the benefit advisor if both the client and the benefit advisor authorize CIGNA HealthCare to do so by signing CIGNA HealthCare's Client and Benefit Advisor Acknowledgement Form. When required, this form must be signed before the date when the new rates take effect. If the form is not signed, the benefit advisor will be responsible for billing the client directly for any benefit advisor fees. Proposal # 1156999 Page 18 of 20 7/23/13 Cigna. Statement of Understanding Regarding "Underlying Plans" In establishing its premium rates/charges for all benefit plans insured and/or administered for you by CIGNA HealthCare companies ( "CIGNA HealthCare "), CIGNA HealthCare assumes that there are no "Underlying Plans." Underlying Plans means: • plans or arrangements that pay for or subsidize any portion of the cost - sharing responsibilities for people covered by the plan(s) including, but not limited to, co- payments, deductibles and/or member coinsurance balances • a Health Savings Account (HSA) • a Health Reimbursement Account (HRA) CIGNA HealthCare also assumes that Underlying Plans will not be put in place in the future. The existence of Underlying Plans has a material impact on CIGNA HealthCare's premiums /charges and if not previously disclosed to CIGNA HealthCare in connection with its underwriting constitutes a material modification of the plan's benefits entitling CIGNA HealthCare to increase its premiums /charges to reflect the impact of the Underlying Plans. To ensure that CIGNA HealthCare has all the material information that it needs to appropriately determine its premiums /charges, please complete and execute the following certification. Employer Certification The Village of Tequesta (Employer /Group), by its duly authorized representative, hereby represents, certifies and agrees that in connection with the plan(s) insured and/or administered by CIGNA HealthCare: 1. an Underlying Plan is not offered; OR X an Underlying Plan is offered and attached is a complete description of the Underlying Plan. With respect to a HSA or HRA that is offered, include in the description: • the level of employer fending to the HSA and/or HRA; • the order of reimbursement, and • the provisions regarding annual rollover 2. it will notify CIGNA HealthCare prior to implementing any Underlying Plan not identified above in response to No. 1; 3. the foregoing representations and the information provided above are true and complete and provided with the understanding that they are material to CIGNA HealthCare's determination of its premium rates /charges both currently and in the future, and 4. CIGNA HealthCare may rely upon the foregoing representations and information in establishing its premiums /charges both now and in the future. Proposal # 1156999 Page 19 of 20 7/23/13 _- Cigna Underwriting Contingencies For Village of Tequesta CIGNA HealthCare reserves 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 CIGNA HealthCare or any other affiliated 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, CIGNA Health and Life Insurance Company, 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 PREPAYMENTS FEES AT ANY TIME IF THE ENROLLMENT OR EMPLOYER CONTRIBUTION LEVEL IS DIFFERENT THAN ASSUMED BY CIGNA HEALTHCARE IN UNDERWRITING THE CONTRACT OR IF CIGNA HEALTHCARE IS (i) REQUIRED TO PAY ANY ASSESSMENT, OR (ii) INCUR ADDITIONAL COSTS IN ADMINISTERING THE CONTRACT AS A RESULT OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT AND THE REGULATIONS PROMULGATED THEREUNDER. Client Signature Date Mic ha ►e - 6Le4c. Valac L—", r Client Name U Title Proposal # 1156999 Page 20 of 20 7/23/13