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BCBS 2002• 0 New Business El Renewal Business I.-APPLICANT INFORMATION A. Name of Group: CITY OFOKEECHOBEE Nature of Business Executive Offices Marling Address $5 SE 3RD AVE OKEECHOBEE, FL 34974 -2903 Ust below Subsidiary or Affiliated Companies whose employees are lo be efigib:e and included with this application. Name: Address Other EMPLOYEH HNIyr_ILN r !UN (True Group App.) Group a (SCBSF): (HMO) 90206 SIC Code: 911 IMP Div a IBCBSF): oo1,c01,Ro1 Dive (HMOj: B. Applicant hereby applies for coverage /membership through Blue Cross and Blue Srtied or Florida, Inc. (BCBSF) and/or Healer Options, In :. (Het) Grcu; Contract (herein referred to as the Contract). Upon acceptance ot this application by BCBSF and/or HOI, it will' become pan of the Contract Issued to list applicant named above. C. The Contract benefits do not cover any service or supply to diagnose or treat any Condition resulting from or ir+ connection with a Mewed's job or employment (e.g., any service or supply which is covered by Worker's Compensation Insurance) Benefits will not be provided under the Contract to an individual one elects and Is statutorily authorized for exemption from Workers Compensation coverage. D. Workers Compensation carrier is KLAIST & COMPANY Prior Carrier is: PRINCIPAL. FINANCIAL GROUP (HMO) 1I. EFFECTIVE DATE / ELIGIBILITY INFORMATION A. Effective Date ot this Contract shall be 09/01,2002 prior written notice to the other party. B. Only active eligible employees who regularly work a minimum of upon the Effective Date of thls Contract. C. Specify classification Of enrollees for whom coverage is being requested, it other than eligible employees as described in B above. . This Contract may be terminated by the applicant or BCBSFIHOI by giving at least 45 d 30 hours each week and their eligible dependents. shalt be el,g:b!e 1a coverage D. New eligible employees maybe covered attar FIRST OF MONTH AFTER DATE OF HIRE of employment, so long at eligible employee submits an application to BCBSF/H01 within 30 days of the date the individual first meets the applicable eligibility requirements. E. Al least 75 % 01 the eligible employees and 60 % of the eligible dependents most be enroried under the Contract or the Effective Dale and throughout the term of the Contract. Muni - Option Spf•I F. Enrollment data Employees Employer Contribution. EMP: Total inellarble Total Number Employees Employees* Eligible Enrolled Percent Enrolled PPO HMO 65 1 tit 64 1 tY) j 0 1 64 I-5— 100 °io DEP: 25 'Please provide a Ilst of name(s) and reason(*) for ineligible employees and depend G. BCBSF.41Ot shalt nave the right to audit the applicant's payroll records at any lime to confirm eligibility for coverage; appticartt agrees to lurrnsh any suer records upon request. Ill. HEALTH PLAN SUMMARY INFORMAT1ONJseleet th* roprlat* boxis BLUE CROSS AND BLUE SHIELD OF FLORID INC. n Standard Non Standard Custom A Health Care Benefits MANDATED BENEFrT OFFERINGS 8. Benefits: Co Ins.: ! PPC % Non PPC /Optional) Applicant has been eovtsed of the Deductible Per Person Per Calendar Year fol7owmy benefit offers-up us mar. atedby Deductible Family Aggregate Pe' Calendar Year r e Federal ardor State Lew, Apptican "e Copay: Per Office Visit decision to accept or Pectin. Those benefits Per Adm. Deductible For All Non -PPC Hospitals rs rndicateo below: Maximum Out of Pocket Accept beeline e•.r..rr C. Pe Program: Copay: GenerIc Brame NonPreferred Contraceptives: D. Dental: 0 Standard ❑ Non - Standard With Orthodontics E. Other: © Manta! 6 Nervous Qlsordar [] [� Alcohol b Ong D.oenderury O ❑ mammograms waives of Dereeetl. 8 Conturence ❑ ® Enteral Formulas Q Yes el No DentalEnrotlment: MEAL.TH OPTIONS Standard Non -Star ❑ Cuatom Health Options Plan e eBlwCare N1=Q LO Grp Plan a B. Ax BtueCere Fix 5/15/3, 5 Generic 15 Braid 30 Nonerel Coeseceel All C. Vision ❑ Yes El No PRE - EXISTING: IV. RATE INFORMATION A. Premiums/Prepayment tee are payable mouthy at or before the due data welch will be determined: Regular Billing - Employee applications should be submitted thirty 00) days prior to proposed effective date. B. Funding Arrangements: HMO: Discount Dental Erap ogee Employee/Spouse Employee r Cnlld(ren) Employee / Family Other Comments: to 5297.09 maw RCM A536.45 The rates estabilshed 1or this Contract wll not be changed tot the first twelve !12) months fctiowmg the !unlit effective date of Coverage. However ECBSFRIOI may change the rates which are lo be effective after this Initial twelve (12) month period of coverage by providing notice to the employe. such chanced rates tong- -five 451 days net to their effective date. wrr�i,rrrr i u wr.�rrea.� V. APPLICANT RESPONSIBILITIES A. The applicant shell: 1) Notify each enrollee to the benefits selected by the applicant, their effective ante, and The eirmination date or coverage (.1 this applicant acts as the agent of die enrollee, and in no event shall the applicant be deemed an agent of BCEsSFrHOI for this or any other purpose. not sr BCBSFiHOI be responsible for such notification to retirees). 21 Deliver to covered enrollees identification cards and certificates o' coverage furnist'od t BCBSF /HOJ_ 3) Notify BCBSF/HOI promptly of any changes in the eliglb Iffy el enrollees covered under this Agreement 4) List any absentees at the ter Initial enrollment on the appropriate BCBSFMOI torm. Applications Irrnn absentees will be accepted at BCBSFMOI Corporate Headquarters no !store telly (30) days from the group's effective Date 5) Collect enrollee contribution, !f required, and remit premium payment/prepayment tees to BCBSF.'H( specified above in Section IV. Rates. Applicant hereby establishes an Employee Welfare Benefit Plan tor tee purpose of providh^g for Its employees or their t'eneficJanea medical, surgtcat. hospital care, or benefits in the event of sickness. Any person who knowingly and with intent to injure. defraud, or deceive any insurer tees a statement of claim or an application containing any false. incom . ete or mil . •' • information is • uil of a felon of the third d • tee B. C. issuance of the Contract by tication ) iv' 14- y0 Pont i Tyyu Name a Title Sent By: Group In,s.trance Solutions, Inc.; 561 747 3524; du1 -30 -02 8:38; ENROLLMENT SUMMARY COB COMPLIANCE (CHECK APPROPRIATE BOXI Our company employed 20 or more full andior part -time employees* during the previous calendar year and is subject to federal COBRA. All full and part -time common law employees of an employer are considered in determining COBRA compliance. All full time employees are counted u, one employee and each part-time employee is counted as a fraction of an employee. 0 Our conlpaliy employed fewer than 20 full and /or part-time employees' during the previous calendar year and is subject to the Florida Health Insurance Coverage Continuation Act ( "FHICCA "). Ail full and pan -time common law employees of an employer are considered in determining COBRA compliance. All full time employees arc counted as one employee and each part -time employee is counted as a fraction of an employee, For COBRA and FHICCA purposes, self - employed individuals, independent contractors and non- employee directors are not counted. MEDI' ARE SECONDARY PAYER COMPLIANCE (CHECK APPROPRIATE BOX) if yo are a .single employer plan: es ❑ No Our company employed 20 or more employees ** each working day in 20 or more calendar weeks (does not have to he consecutive weeks) during the current or preceding calendar year. If you are a single employer, multiple employer or a multi - employer plan: [] Yes 0 No Our company employed 100 or more employees ** on 50 percent or more of the business days during the preceding calendar year. If you are a multiple employer or a multi - employer plan: Ycs ❑ No All employers in our Group Health Plan (GHP) employed 20 or more employees ** for 20 or more consecutwe weeks in either the current or preceding calendar year. 0 Yes D No At least one of the employers in our GHP employed 20 or more employees* "fur 20 or more consecutive weeks in either the current or preceding calendar year. ❑ es ❑ No All employers in our GIIP employed fewer than 20 employees ** for 20 or more consecutive weeks in either the current or preceding calendar year. " "Employees" includes all full and /or part time employees Page 4/4 1. Group Name CITY OF OKEECHOBEE 2. Group Nurnber 90206 i, Group Sales Rep /Agent MARIBETH CROKHOWSKY (T06) 1 4. Effective Date 8/1/2002 5. Employer Contribution Toward Employees Premium (must be at least 50% for 1.50, 75% for 51 +) I. 'TOTAL EMPLOYEES ON PAYROLL A.' Total Pats i ime I:mploycc(s) B. Total New Employee(s) (In Waiting Period) C. 'Total Employee(s) Not Actively At Work ?. TOTAL INELIGIBLE EMPLOYEES (A THROUGH C) t. T'OT'AL ELIGIBLE EMPLOYEES (I Minus 2) (DETERMINES GROUP SIZE & PRODUCT) D. Total Employees with Other Coverage 1. TOTAL ELIGIBLE FOR PARTICIPATION (3 Minus D) E. Total Refusals F. Total Absentee i . TOTAL ENROLLED - i. EMPLOYEE PARTICIPATION (5 divided by 4) (75% IS REQUIRE(} C(NLf .e c, A. r2+e g &e( i1 is important for the employer to have each employee who chooses not to participate, complete the refusal port on of the application and retains the refusal form as part of the employee's record. (Use separate piece of paper if necitgsary) 823 SR (Rev 0601) fieer's Signature te) / Title Blue Cross and Blue Shield of Florida. and Health Opt•ns, Inc are Independent Licensees 01 tiw Blue Cross and Blue Shied Association Date NAME ( REASON CODE l l REASON CODE Pig,`YEE N /Y:x►- f114- W /4- / t'7" 1 y E , / 823 SR (Rev 0601) fieer's Signature te) / Title Blue Cross and Blue Shield of Florida. and Health Opt•ns, Inc are Independent Licensees 01 tiw Blue Cross and Blue Shied Association Date Sent By: Group Insurance Solutions, Inc.; 561 747 3524; ►�� ,g/ 01 Florida a Health Options. Jul -30 -02 8:37; H,,an Opnon• nrd fn P,•eN. Bleu Cana mna Olu ,`dr¢b M FF1011p ni•inuxcwrrnn' t •ceMefa ulna Crcaa onr foJs Srrsb Afa��aeffc BlueCare Non - Federally Qualified Page 3/4 IN WITNESS WHEREOF, each of the parties to this Agreement, through their duly authorized representative hereby acknowledges that they have read and understand this Agreement, and the below listed endorsement/amendments, and agree to be bound by their terms. Master Policy: BlueCare for Large Groups (Non - Federally Qualified) Grievance Form (pink Told out) Grievance Appeal Form (green fold out) BlueCare Rx HM() Pharmacy Program S5/;15/$30 11 - Contraceptives (with RA Only) 16297 R0399 SR 16298 R0399 SR 86034 R0599 SR 86027 R0401 SR Optional Endorsement/Amendment Title Form Number Group: Cl OKEECHOBEE By: �s?iiGl•-•- Name: 111 e S L Date 7_3c -n Title: �1 l� y 4 r HEALTH OPTIONS, INC. By: Name: Ken Sellers Date Title: Regional VP 366 AGENDA CLOSE PUBLIC HEARING - Mayor. VIII. UNFINISHED BUSINESS. A. 1. a) Motion to remove from the table, a motion to adopt proposed Resolution No. 02 -8 authorizing the execution of a State Highway Lighting, Maintenance and Compensation Agreement with the Department of Transportation - City Administrator (Exhibit 2). b) Vote on motion to remove from the table. 2. a) Discussion regarding motion to adopt proposed Resolution No. 02 -8 (Motion made by Council Member Watford, second by Council Member Oliver). b) Vote on motion. IX. NEW BUSINESS. A. Motion to award a Health Insurance Bid - City Administrator (Exhibit 3). JULY 16, 2002 - REGULAR MEETING - PAGE 4 OF 9 COUNCIL ACTION - DISCUSSION -VOTE MAYOR KIRK CLOSED THE PUBLIC HEARING AT 6:15 P.M. Council Member Oliver moved to remove from the table, a motion to adopt proposed Resolution No. 02 -8 authorizing the execution of a State Highway Lighting, Maintenance and Compensation Agreement with the Department of Transportation; seconded by Council Member Chandler. VOTE KIRK - YEA CHANDLER - YEA OLIVER - YEA WATFORD • YEA WILLIAMS • YEA MOTION CARRIED. There was a brief discussion between the Council and the Staff, regarding the liability of entering into this agreement. City Attorney Cook stated that the letter in Exhibit Two was enough to bind Public Risk Management to cover the City (this is the City's Property and Casualty Insurance Company). VOTE KIRK • YEA CHANDLER • YEA OLIVER - YEA WATFORD - YEA WILLIAMS - YEA MOTION CARRIED. Mayor Kirk asked if there were any representatives from insurance companies that bid on the health insurance. There were no representatives from Arthur J. Gallagher & Company. Mary Beth Grokhowsky was present, a representative from Blue Cross Blue Shield. AGENDA IX. NEW BUSINESS CONTINUED A. Motion to award a Health Insurance Bid continued. JULY 16, 2002 - REGULAR MEETING - PAGE 5 OF 9 367 COUNCIL ACTION - DISCUSSION • VOTE Council Member Watford inquired if the proposal from Arthur J. Gallagher and Company was a pool. Staff answered by stating that in fact it was a pool, and there were additional risks because of this. Mayor Kirk stated that the City was looking at hefty increases. There was a lengthy discussion between the Council and Ms. Grokhowsky regarding the prices of prescriptions, and the options that were available when purchasing prescriptions. The difference in the current plan and what is being proposed. Employees will also be able to switch from the HMO Plan and PPO Plan once a year during open enrollment. Another major concern was the fact that the current insurance plan ends July 31, 2002. This does not give sufficient time to have all the City employee's complete the necessary paperwork, send it to Blue Cross Blue Shield and send the appropriate cards to the employee's. Therefore the City's insurance representative, Scott Harris was able to get an extension of the existing contract, at the same rates until August 31, 2002. Council Member Oliver moved to award a Health Insurance Bid to Blue Cross Blue Shield option five plan, up to the HMO amount; seconded by Council Member Chandler. Motion and second was withdrawn. Council Member Oliver moved to award a Health Insurance Bid to Blue Cross Blue Shield, HMO Plan 5 /Blue Choice PPO Plan 317, that the City will pay up to the HMO amount, and the seventy dollars ($70.00)toward the employees family and or spouse; seconded by Council Member Chandler. Employee's will have the option of choosing the HMO Plan or the PPO Plan. However, the City will only pay up to the HMO Plan. If an employee chooses the PPO Plan they will have to pay the difference between the two plans. VOTE KIRK - YEA CHANDLER • YEA OLIVER - YEA WATFORD - YEA WILLIAMS - YEA MOTION CARRIED. City Administrator Veach asked Ms. Grokhowsky if elected officials and the City Attorney would be covered under the plan. She answered that current elected officials would be covered. If the City Attorney is an employee he would be covered. Elected Officials that are not re- elected would not be eligible.