HomeMy WebLinkAbout5177 RESOLUTION NO. 5 1 7 7
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
AUBURN, WASHINGTON, AUTHORIZING THE MAYOR
TO EXECUTE AN AGREEMENT BETWEEN THE CITY OF
AUBURN AND PREMERA BLUE_ CROSS FOR HEALTH
CARE COVERAGE
WHEREAS, the City provides, among its employee benefits, health care
coverage for City employees and their families; and
WHEREAS, the costs of health care coverage has risen in recent years,
prompting the City to explore alternatives; and
WHEREAS, the City has the opportunity to provide comparable health care
coverage for those employees and their families currently covered by the Association of
Washington Cities Employee Benefit Trust (AWC) health care plans at a cost savings,
and
WHEREAS, it is therefore appropriate for the City to consider engaging in
contracts with Premera Blue Cross to provide those health care services currently
provided by AWC.
NOW, THEREFORE, THE CITY COUNCIL OF THE CITY OF AUBURN,
WASHINGTON, HEREBY RESOLVES as follows:
Section-I.. That the Mayor is hereby authorized to execute an agreement
between the City and Premera Blue Cross for health care coverage, which agreement
shall be in substantial conformity with the agreement attached hereto as Exhibit A and
incorporated herein by this reference.
Section 2. That the Mayor is authorized to implement such administrative
procedures as may be necessary to carry out the directives of this legislation.
Resolution No. 5177
October 15, 2015
Page 1 of 2
Section 3. That this Resolution shall take effect and be in full force upon
passage and signatures hereon.
Dated and Signed this day of 2015.
CITY OF AUBURN
J
ANCY KUS, MAYOR
ATTEST:
Danie le E. Daskam, City Clerk
APPROVED AS TO FORM:
IIIZIA�14A
Oo6iWIB. He itji Attorney
Resolution No. 5177
October 15, 2015
Page 2 of 2
' P.O.Box 91060 PREMEIA f
Seattle,WA 98111-9160
GROUP BLASTER APPLICATION
51 OR MORFELIGIBLE EMPLOYEES
Application Is made to Premera Blue Cross(hereafter referred to as'we,"
'us;or'our'for a new Health Care Contract,the provisions of which shall be
made available to all eligible classes of employees.
Your group cannot be enrolled prior to our receipt date of this completed and
signed applketiort,which must be accompanied by the initial subscription GROUP ID
charge paymer>i.This applcation and subscription charge payment must be -
received no less than 10 days prior to the requested effective date. (Completed by Premera Blue Cross)
1. PURPOSE
R New Group:Comply this application and submit with enrollment fors,and the first month's payment prior to the effective date of coverage.
❑Renewal:Complete this application and Benefit Selection Report in Its entirety.
❑Other _
Effective Date: From:.1/1/2016 To:.12/3V2016 Annual Contract Renewal Month January
2 GROUP INFORMATION
A. Legal Name City of Auburn - -..— -- —.. --- - -- - ---
Common Name Note:Requ6ed NLegal(tame exceeds 50 characters and spaces,othenwfse,optional.
Physical Address 25 West Main -- -
City Anbum State WA zip 98001 County King
B. Maiing Address ®Same as Physical Address ❑Separate Address,complete the following:
Street!P.O.
City _--- ----__-._ State ZIP County ---C. Billing Address R Same as Mailing Address ❑Some as Physical Address ❑Separate Address,complete the following:
Street/P.O.
- - --State ZIP
City - -- - —
Billing Contact Person p_Mr.R Mrs.❑Ms. Ronda Stella rule Payroll&AP Supervisor _
Phone No.(253)804-5018 Fax No.( ) E-mail Address rstella®auburnwa.goy
D. Group Contact Person_R Mr.❑Mrs.❑Ms. Aaron Barber Title Comp&ER Manager
Phone No.(253)8045093 Fax No.{ ) - Email Address abarberCauburnwa.gov _
E. Do you use a COBRA AdmiNstrator? ❑No ®Yes;complete the following: ❑Same as Billing Address and Contact Person
(same contact as section 2C&213)
COBRA Administrator Billing Address BCC Accounting Department Two Robinson Plaza;Suite 200
City Pittsburgh State PA ZIP 15205 County
COBRA Administrator Contact Person ❑Mr..R Mrs.❑Ms. Lauren Ganser ride Data Service.Supervisor
Phone No.(412466-4611 Fax No. } _ E-mail Address l sneer a-bezceLcom -
F: Employer Identification Number(EIN)91-6001228
Type of Business Municipality SIC#9199 NAICs it 921190
G. Is the group a subsidiary of or affiliated with another company or headquartered outside the State of Washington? R No ❑Yes,complete the following:
Legal Name _- _ _____. _. __ _ __ _-. -- -_..----.-.__...
Physical Address - - - _
city State ZIP County _
H. In the past 36 months has the group or any of filialed entity
filed for protection or operated under Federal/State Bankruptcy laws? 13 No ❑Yes
In the past 36 months has any creditor filed or threatened to file a
petition requesting the group or any affiliated entity to be put Into bankruptcy? R No ❑Yes
1. Is worker's compensation coverage provided.for all employees? R Yes ❑No,please list employees not covered and reason:
008715(01-2014)l GROUP MASTER APPLICATION 51+ PAGE 1 OF 5
An Independent licensee of the Due Goss Blue Srtield Association
3. EMPLOYEE ELIGIBILITY limalJ11REmlENTB
if all of your employees must work the same hours,meet the same probationary period and will have the same benefits options available to them,
complete section A(omit B),then continue to C,D and E.
If you are differentiating your employees by class(Le.,Managers,Hourly,etc.)complete section B(omit A),then continue to C,D and E.
A All Employees in One Class
1. Minimum Work Hours
Alt employees who normally work a minimum of 30 hours'per week and have satisfied the probationary period are eligible.
*Moto:Employees must work at feast 20 hours per week to quabfy for health coverage. The group may choose to set the minknum number of work hours
per week higher for employees to be eggtble.
2. Probationary Period Information
All eligible employees are effective on the:
❑1st of the month following Or ❑Neid day.fokwAng:
❑30 days ❑60 days ❑_Number of days from(enter date)*
*Note:Prebatlarwy period cennot be more than 60 days.
®1st of the month following date of hire fZp4A&W of hint 03 PCAj-C-,r t AM 6'P�ftPF, G
B. Employees Differentiated by Class 8AY OF T"19-PkZA1Tf't'.
Minimum Work Hours and Probationary Period Information
Only employees in a specific class or classes who normally work the specified minimum hours per week that have met the probationary period are eligible.
Complete the minimum work hours*and probationary period Information for each designated class of employee.If yyou have diff misdated your benefit
coverage selection by class of employee on your Benefit Coverage Selection Worksheet-those same classes must be represented
•Nate:Employees must work at least 20 hours per week to quab7y for health coverage.The group may choose to set the minimum number of work hours
per week higher for employees to be ellglWe.
❑Management(M) ❑Salaried(S) ❑Hourly(H) ❑Part-time(P) ❑Full-time(F) ❑Other(0)Please
specify
Minimum hours Minimum hours Minimum hours Minimum hours Minimum hours Minimum hours
❑1°of the month ❑14 of the month ❑1°of the month ❑10 of the month ❑1°of the month ❑1°of the month
following: following: following: following: following: following:
❑Date of hire ❑Date of hire ❑Date of hire ❑Date of hire ❑Date of hire ❑Date of hire
❑30 days ❑30 days ❑30 days ❑30 days ❑30 days ❑30 days
❑60 days ❑60 days ❑60 days ❑60 days ❑60 days ❑.60 days
❑Exact date of hire ❑Exact date of hire ❑Exact date of fire ❑Exact date of hire ❑Exact date of hire ❑Exact date of hire
C. Walve Probationary Period—to be completed by New Groups Only
®Waive the probationary period on all anent qualifying employees.
❑Apply the probationary perlod to all employees(current qualifying employees must satisfy the balance of the above probationary period).
D. Coverage will end:
®Last day of the month for which subscription charge is paid
❑Other - - -- -- - - --- _.
E. Domestic Partners
Domestic Partner coverage is standard for all fulty insured groups with 51 or mare employees. All domestic partners,including same sex,opposite sex;
and state-registered will be considered eligible dependents. Domestic partner eligibility will Include eligibility for COBRA continuation coverage.
If you would like to limit domestic partner coverage.to.state-registered domestic partners andlor choose not to extend COBRA coverage for domestic
partners,please contact your Premera sales representative. If your group is self-funded,please contact your sales representative for your options.
008715(01-2014)GROUP MASTER APPLICATION 51+ PAGE 2 OF 5
AL EMPLOYEE ENROLLMENT
A. Total number of employees 10. Total number of retirees eligible far benefits 56
on payroll regardless of hours worked 554
H. Total number of COBRA/Continuation of Coverage
Note:For 48 and 4C count each employee In only ONE category. subscribers 3
Be Employees not eligible to enroll 1. Do you have eligible employees employed outside the State
of Washington?
1. Employees who workless than the minimum
hours per week(as specfffed in section 34) 20 ®No ❑Yes,complete the following table:
2. Employees who are temporary or seasonal 129 Number of
State/Country Employees
3. Employees who are in a probationary period 1
4. Employees who are not In a covered class -
(employees not specified as eligible in 31t} 0
Total 40 150 - _- _.__
C. Employees not enrolling due to coverage under. _-
1. A Government plan - -
(e.g.,Medicare,CHAMPUS/Tricare,Mffftary) 0 _--
2. Other group coverage 35
3. A collective bargaining agreement(Union) 89 - ~
Total 4C 124-
D. Total number of employees eligible to enroll 280 - -�
(section 4A-46-40 -- ------
E,
Eligible arrgrloyees waning enrollment without alher coverage 0
j, Calculated Actual%of participation
F. Total numberof dlgible wVloyees enrciang(ssCW"4D-4q 280 (Completed by Premers Blue Cross) - --
S. EMPLOYEE PARTICIPATION AND EMPLOYER CONTRIBUTION
A. Minimum Employee&Dependent Participation Requirements—TO BE COMPLETED BY PREMERA
Minerium eligible employee participation requirement is % Minimum eligible dependent participation requirement is %
B. Employer Contribution Requirements-TO BE COMPLETED BY EMPLOYER
Please Note:Waivers of coverage are NOT.agowed for eligible employees of non-contributory groups.H dependent coverage is also
non-contributory,no waterers of ooverage are allowed.
1. Effective date of Contribution: (month r day r year)
2. The employer will contribute the following percentage or dollar amount toward the cost of eligible employee and dependent coverage:
Please Note: N you differentiate contributions by class of employee,those same classes must be represented here.
Medical Dental VIsion
Employee: 100 u/a n/s
Spouse/Domestic Partner. 90
Dependent Child(1 child) 90
Dependent Children(2,or more) 90
C. Employer Contribution Changes-Impact on Grandfathering
Employer Contribution towards the cost of any bar of coverage has not been decreased by more than 5 percentage points since
Mardi 23,2010
Employer Contribution towards the cost of any tier of coverage has deceased by more than 5 percentage points since
March 23,2010
Note: If the Employer contribution towards the cost of any tier of coverage has decreased by more than 5 percentage points since
March 23,2010,We plan ceases to be grandfathered.
Please Note:We reserve the right to review payroll records or comparable reports to ensure that eligibility and enrollment requirements are met.
008715(01-2014)GROUP MASTER APPLICATION 51+ PAGE 3 OF 5
6. IFEDERAL REQUIREMENTS
Helpful Hint We strongly urge you to consult legal counsel in answering the questions below. The summaries below are not Intended
to be or to replace legal advice on your particular group.it is the group's respons/bility to Inform Premera Immediately N facts change
which would cause the group's answers below to change.
A. Is the group subject to the federal Medicare Secondary Payer(MSP)laws that prohibit discrimination against individuals with group coverage
based on their(or a spouse's)current employment status who have Medicare due to age?
1. ® Yes. This plan will pay primary to Medicare as required by federal law.
❑ No. Under 20 employees.
2. Please also provide the number of employees who now meet Medicare's definition of'employee.'
Helpful Hint These laws do not apply to any employer who did not employ 20 employees or more for each working day in each of 20 or more calendar
weeks In either the currant or preceding calendar year.For these small group plans,Medicare pays primary to the group plan.
Err>p/oyees'lndude all full-tune and part-time employees as.wefi as those employees on disabft and sub)ed to FICA taxes. Also count leased
employees ff they would be counted as employees under§414(n)(2)of the Internal Revenue Code(IRC),and count employees employed by an"affigated
service group'under)RC§414(m)or by employers considered to be a'single employer under IRC§52(a)or(b).
B. Is the group subject to COBRA?
® Yes
❑ No. Give the legal reason for exemption:
Helpful Hint.Generally,these laws apply to any non-c church employer that employed 20 or more employees on at least 50%of its working days in the
preceding catendaryear.
-Employees"are h6firne and part-time common-law employees SelFemployed workers as defined m IRC§401(c)(1).corporate directors or
independent contractors shoudd not be counted unless they qualify as common-law employees Employees°may also include leased employees who
qualify as common-law employees. Please see COBRA reguldlons at 26 CFR§54.49808-2 CYA 5 for guidance on counting a part4ime employee as a
fraction of a 114"me employee.
C. Is the group subject to the federal Medicare Secondary Payer(MSP)laws that prohibit discrimination against individuals with group coverage
based on their(or a family members)current employment status who have Medicare due to disability?
1. ® Yes. This plan wail pay primary to Medicare as required by federal law.
❑ No. Under 100 employees.
2. Please also provide the number of employees who now meet Medicare's definition of'employee.* —
Helpful Hurt Generally,these laws apply to any employer that employed at least 100 employees on 50%or more of Its working days in the preceding
calendar year. Seethe helpful hint in 6A above for a defaition of employee'far this purpose.
D. Is the group subject to ERISA?
❑ Yes. Enter the month the ERISA plan year ends: Month
® No. Give the legal reason for exemption: ®Government or Public Plan ❑Church Plan
❑Other,please specify:
Helpful Hint:Generally,ERISA applies to all employer health plans except,governmental,public or church plans Non-profit status alone does not exempt
an employer from ERISA.
7. CURRENT COVERAGE INFORMATION
A. Is this Premera Blue Cross plan Intended to replace any ehdstng coverage? ❑No,go to section 78 ®Yes,complete the following:
1. Name(s)of current Medical carriers) Regence Proposed termination date 12131/2015
2. Name(s)of current Dental carrier(s) n/a Effective date of dental coverage
Proposed termination date
Does your current dental coverage include orthodontia? ❑No ❑Yes If Yes,effective date of orthodontia coverage _
3. Name(s)of current Vision carrier(s) n/a Proposed termination date —
B. Are you offering a plan from a carrier other than Premera Blue Cross? ❑No.go to section S ®Yes,more than one carriers plan is offered:
Name(s)of other Medical carrier(s) Name(s)of other Dental carrierts) Name(s)of other-
Indicate if other plan is an HSA. HSA?
®No
Group Health ❑Yes n/a n/a
❑Nc
❑Yes
No
❑Yes -
008715(01.2014)GROUP MASTER APPLICATION 51+ PAGE 4 OF 5
a. CERTIFICATE OF HEALTH COVERAGE
Requirement:The Health Insurance Portability and Accountability Act(H1PAA)requires that a Certificate of Health Coverage must be provided
to members terminating from the health plan upon their request.
A. Do you want Premiere Blue Cross to distribute Certificates of Health Coverage?
❑No,the group(or the group's designee)will produce and distribute the Certificates of Health Coverage.Go to section 9.
®Yes,go to section 88.
B. Premem will send the certificates directly to the member,unless the group requests that we send the certificates directly to the: ❑Group
9. GROUP MATERIALS
Important mote: Electronic copies of benefit booklets are available online at www.premers.com. Please Indicate if you would like printed
copies sent.
Printed copies should be sent to: Producer. ❑ Contract ❑ Benefit Booklet(s)
Group Administrator: ❑ Contract ❑ Benefit Booklet(s) Number of booklets:
10. PRODUCER AGREEMENT TO CONTRACT
A. You,the producer(s),certify that you have met with the group submitting this agreement and that you have fully explained Its contents.You
have discussed covVM,eligibility,any preexisting condition waiting periods,the effect of misrepresentations,termination provisions and
subscription charge Ilia
Producer Si nat�llt� — �(`�°-?. Date
Producer P Natalie Schiro Producer Number 855118
E-mail Address nschiro a bbtacoma.com Name of FirnlAgency Brown&Brown of WA
Effective Date Producer Is Appointed for this Group 1/1/2016
Commission: ❑ PEPM 00% ❑ Scale —�-�B. ❑Split Commission
Secondary Producer Name Secondary Producer Number
Commissions are split between the primary and secondary producer as follows(e.g.,50%150%): Primary 0 % I Secondary %
11. GROUP AGREEMENT TO CONTRACT
You,the group named In section Z of this application,understand and agree to the following.
A. This application becomes part of the contract to provide health care coverage after
•The application Is signed by you:
•The application Is received and approved by us;and
•We receive the initial month's subscription charges.
You may not assign this contract without our written consent.Any attempt to do so will not have any binding effect on us.You agree to
promptly deliver materials and notifications,including benefit booklets,received from us to all covered employees.You also agree to provide
notification regarding the plan's waiting period and special enrollment rights to all eligible employees before their enrollment.You attest to have
read this application,and certify that all statements are true and complete.You agree to the terms and obligations stated in this application.It is
understood that provisions of the Health Care Contract,Including subscription charges,may be amended or changed from time to time,upon
our notice to you.All prior applications,to the extent that you have not made changes to them in this application,remain in full force and effect.
The producer listed in section 10 will remain effective until written notice is given by either party.We are authorized to pay,on your behalf,
commission,if any,for which you are.liable to the above named producer.
B. You may elect to allow the producer listed above to act as a group benefit administrator beginning oq the group's effective date.This means
that the producer/administrator will be able to access membership and billing functions,and obtain information about group members via the
Web on behalf of the group.These functions may include,but are not limited to:
•Reinstate Terminated Members •Inquire on Invoice •Order ID Cards for an Individual or Whole Family
•Request Invoice • Inquire on Eligibility •View Group Demographic Inforrnation
•Search for a Member • Enroll a Member •Cancel a Member
•View Benefit Detail
Do you elect and authorize Premera Blue Cross to provide such information to the producer? ❑No ❑Yes
C- I affirm that this group has a physical in the S of Washington,and I am authorized to sign on behalf of the group.
Signature of Group's Re resentative I U16 Data 1 1 -2- .
Group's Representative Print Name Niney Bac Title Mayor
Please note: It is a crime to knowingly provide false, mplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment fines,and denial of insurance benefits.
TRACKING INFORMATION—TO BE COMPLETED BY PREMERA ffLUE CROSS
Date Received by Sales Information Complete ❑Yes ❑No Date Missing Information Received
Account Manager/Sales Executive Extension Rep.-Code
Sales Support Contact Extension Sales Distribution
008715(01-2014)GROUP MASTER APPLICATION 51+ PAGE 5 OF 5
IJCC
New Group Notification Form
Welcomel Thank you for choosing Benefit Coordinators Corporation as your benefit administration partner.This form is designed to help us confirm the services we are to
provide and the fees that have been agreed upon, and to provide importanl basic information that will help us prepare for a smooth implementation, In order to begin
Implementation,please complete,date and have this form signed by both the employer and broker,and return along with applicable set-up fee(s).If you have any questions or
would like assistance,please contact your sales representative.
1.General,Information
Effective Date:1/1/16 #of Healthcare Enrolled:266 #of Benefit Eligible:315
Full Legal Name:City of Auburn
Street Address:25 West Main City;Auburn _ ST:WA Zip:98001
Contact Name/Title:Aaron Barber/Benefits and Compensation Manager Phone:253-804.-5093 (ext.) j
E-mail:abarber @aubumwa.gov Fax:
EIN Number: 91.6001228 State Where Tax fD riled: WA
Broker •
Broker Contact/Title:Natalie Schlro Agency;Brown&Brown of WA
Phone; 253-396=6602 (ext.) Fax:
E-mail:nschlro @bbtacoma.com Cell; 253-820-8500
Street Address:1145 Broadway Suite 700 City:Tacoma ST:WA Zip:984D1
Administration .•
9 Consolidated Invoicing(complete attached page) ❑HRA El MRA(please attach benefit grid and employer reimbursement level)
®COBRA _ #f of people on COBRA now; ❑HSA ❑FSA or ❑FSA with Debit Card_ I Annual Maximum$
❑Retiree Billing ❑Dependent Audit ❑Self-Funded Medical ❑Parking ❑'Transit
❑Expanded Cali Center ❑Self-Funded Dental ❑Self-Funded Vision ❑Other ❑Other
❑TotalWorks Healthcare Reform Services ❑ACAWorks ❑Other ❑Other
WEB TOOL ❑BenXcel Inquiry ❑BenXcel Compare&Pay ❑BenXcel EMPLOYEE COMMUNICATIONS PORTAL: ❑Benergy ❑PlanSource
Employee Classes
CLASSES:Are there multiple classes? ®Yes El No if Yes,how many?4
DIVISIONS:Are there multiple divisions? ❑Yes ®No If Yes,how many?
Set • Fee
Prior to the implementation of any administrative service being provided,please complete,sign and date this form.
Please include the set-up fee per applicable line of coverage as listed in the proposal, $
®Paid by Employer ❑Paid by Broker
Employer Signature: �' Date:
Broker Signature: Date:
::FOR BCC USED
MILY
Group Number Assigned:
Producer:
NAE:
HINAIBCI: ❑YES ❑NO
BeneFlt Coordinators Corporatlon(BCC)I Two Robinson Plaza,Suite 200, Pittsburgh PA 15205 1 412.276.11111 www.benXcel,com I rev.20150316
Consolidated Invoicing Information(continued from Section 111)
A.COVERAGE:Please Indicate applicable carrier name(s).If there Is more than one plan design,use"Other"category.
is e
rx VWrig qtr
91
r a an 5.5
r
0 Medical:Premera ❑ 0 ❑• ❑ ❑ER Paid Dep.Life: ❑ ❑ ❑ ❑
❑Medical: ❑ 1-1 ❑ ❑ 0 ER Paid Dep.ADO: ❑ ❑ ❑ ❑
❑Medical: ❑ ❑ ❑ ❑ 0 LTD:Standard ❑ ❑
❑Dental: ❑ ❑ ❑ ❑ 0 STD:Standard
❑Dental: ❑ ❑ ❑ ❑ ❑chiro: ❑ ❑
0 Vislon:VSP ❑ ❑ ❑ ❑ ❑EE Assistance: ❑ ❑
❑Vision: ❑ ❑ ❑ ❑ ❑Other: ❑ ❑ ❑ ❑
❑Rx: ❑ ❑ ❑ ❑ ❑Other: ❑ ❑ ❑ ❑
0 Life:Standard ❑ ❑ 0 0 ❑Other: ❑ ❑ 11 ❑
0 AD&D:Standard ❑ ❑ N 0 ❑Other: 1 ❑ 1 ❑ ❑
❑
El.VOLUNTARY:Please Indicate applicable carder name(s).If there Is more than one plan design,use"Other"category.
a
Ne F
_yera
CE Vol.Life:Standard ❑ ❑ 0 0 ❑Vol.LTD: ❑ ❑ ❑
2 Vol.AD&D:Standard ❑ ❑ 0 0 ❑Vol.STD: T ❑ ❑ ❑ ❑
❑Vol.Sp.Life: ❑ ❑ ❑ ❑ 1 ❑Other: 11
❑Vol.Sp.ADW: ❑ ❑ ❑ ❑ ❑Other: ❑ C3
❑Vol.Dep.Life: ❑ ❑Other: ❑ ❑ ❑ ❑
❑Vol.Dep.AO&D: ❑ ❑ ❑ ❑ ❑Other. ❑ ❑ ❑ ❑
❑Vol.Dental: I ❑ ❑ ❑ ❑ ❑Other: ❑ ❑ 13 ❑
❑Vol.Vision: ❑ ❑ ❑ ❑ ❑Other: 11
C.Please Indicate complete carrier sales contact Information for each carrier noted above.
Prannera Stuart Croff 425-9118-8173 Exl.
Carrier Sales Contact Phone E-mall
Standard Madeline Hicks 425-263-1073Exl.
Carder Sales Contact Phone E-mall
VSP Gabe Garcia 800.852-7600 Ext.5430
Carder sales Contact Phone E-mall
Ext.
Carder Sales Contact Phone E-mail
Exi.
Carrier Safes Contact Phone E-mall
D.CONSOLIDATED INVOICING ADDITIONAL ITEMS NEEDED:Provided below is a list of additional items that BCC will need In order to continue the implementation
process. These items are needed,but are not required at the time of the submission of this Notification Form.
• Carrier Sold Proposal(s) •Any Existing Self-Funded/FSA Plan Documents
• Group Application(s) •Employee Premium Contributions
• Carrier Plan Document(s)/Contract(s) •Payroll Calendar
If any carrier required a binder check,please attach a copy of each check per carrier.
Benefit Coordinators Corporation(BCC) I Two Robinson Plaza,Suite 200,Pittsburgh PA 15205 1 412,276.1111 1 www.benXcel.com Page 2
PREMEru� I �
. .
GROUP HEALTH BENEFIT PLAN CONTRAGT �
for
City of Auburn
25 W est Main
Aubum,WA 98001
(herein refeRed to as the Group)
Premera Blue Cross, an indepenCent licensee of tFie Blue Cross Blue Shield Association, agrees to provide the
benefits described in this Contract for eligible employees of the Group and their eligible dependents who are
enrolled for coverage under this Contract, provided that the Group is a large employer, as defined on the neM
page of the Contrect, remains actively engaged in business and requirements are met that would otherwise
provide grounds for termination as stated in "Contract Termination"in the benefit booklet or booklets. All benefits
of this Contract are subject to the terms and condiGons stated herein and any endorsements or riders included or
issued thereafter.
The G�oup Health Benefit Plan delegates its autliority to Preme�a Blue Cross to administer the routine operation
of the plan. As part of this function, Premera Blue Cross must use its expertise and judgment to reasonably
construe the terms of this coverage and apply the terms of the contract for making decisions in specific eligibility,
benefits and claims situations.
This Contract is valid on the effective date indicatedbelow only when signed by an officer of Premera Blue Cross.
Payment of the subscription charges indicates that the Group accepts tFiis Contract.
Any existing group contract or agreement between the Group and Premera Blue Cross thiat is being replacetl tiy
this Contract is terminated when this one becomes effective.
_. . ..
GROUP NUMBER 4007473
__
CONTRACT EFFEGTIVE DATE January 1,2018
CONTRACT ANNIVERSARY DATE January 1, 2019
SUBSCRIPTION CHARGE DUE DATE first of each month
STATE IN WHICH GROUP IS LOCATED Washington
����i���' L.J ��_
�Si n d: Jeffrey Roe
/�r` President and Chief Executive O�cer
Title: Premera Blue Cross
3 � 1 � 18
Date; Date:January 1, 2018
40074730118EA
STANDARD PROVISIONS
LARGE EMPLOYER
A large employer is an employer that employed an average of at least 51 common law employees on business
days du�ing thepreceding calendar year and that employs at least 51 employees on the first tlay of the cuRent
Contract Term.
In the case of an employer that was not in existence throughout the preceding calendar year,the determination of
whether the employer is a large employer will be based on the average number of employees that it is reasonably
expected the employer wiil employ on business days in the current calendar year.
CONTRACT
The entire Contract between the Group and Premera Blue Cross consists of all of the following:
. The face page(page 1) and'`Standard Provisions"
• The attached benefit booklet(s)
• The Group's signed application which is kept on file with Premera Blue Cross (a copy is available upon request)
. The Funding Arrangement Agreement(Ezhibit A)tietweenlhe Group and Premera Blue Cross
• All attacFiments, endorsements and riders includeii or issued hereafter
_ _
No agent or representative of Premera Blue Cross or any other entity is authorized to make any changes,
additions or deletions to tfiis Contract or to waive any proVision of this Contract. Changes, alterations, additions
orexclusions can only be done over the signature of an officer of Premera Blue Cross.
If there is a language conflict between the standard provisions, beneft booklet or other documents,the benefit
booklet(as amended by any attachments, endorsements or riders)will govern.
NOTICE'
Anynotice Premera Blue Cross is required to submi4to the Group or subscriber will be considered to be delivered
if iYsmailed to the Group or subscriber atthe most recent address appearing on Premera Blue Cross's records.
Premera Blue Cross use the date of the postmark in determining the date of the notification. If the Group is
required to submit notice to Premera Blue Cross, it will be considered delivered 3 days after the postmark date, or
if not postmarked,the date Premera Blue Cross receives it.
CONTRACTTERM AND RENEWAL
The initial Contract Term begins on the ContracYs effective date and continues to the contract anniyersary date,
unless terminated in accordance with the terms of the Contract. If notso terminated, the Contract is kept in-force
during the ini4ial Tertn by Ehe Group's paymen4 of required subscrip4ion charges when due.
After the inifial Contract Terrn, this Contract will continue in force on a month-to-month basis by the Group's
payment of required subscription charges when due, unless it's changed or terminated in accordance with the !I
Contractchange and termination provisions stated elsewhere in this Contract.
FUNDING ARRANGEMENT AGREEMENT(EXHIBIT A) '
The subscription charges and related provisions are set forth in the Funding ArFangement Agreement(Exhibit A)
between tfie Group and Premera Blue Cross, which is attached to and made part of this Contract.
DOMESTIC PARTNERSHIP
If all requirements below are met, ail rights and tienefits afforded to a "spouse"under this plan will also be
afforded to an eligible domestic partnec In detertnining benefits for domestic partners and their child�en under
this program,the term ''establishment of 4he domestiapartnership"shall be used in place of"marnage";the term
"termination of the domestic partnership"shall be used in place of"legal.separation"and"divorce."
Domestic partners and their children are eligible if the subscriber and domestic partner have their partnership
documented in a state domestic partner registry.
CONTRACT MODIFICATIONS
In addi4ion 4o the modification provisions stated in the Funding Arrangement Agreement(Exhibit A), Premera Blue
Crossmay modify the subscription charges, benefits,or any other provisions of this Contrect by giving30 days'
advance written notice to the Group pnor to the end of the Contract:term.
z
The Group may reject the modification by written notice delivered to Premera Blue Cross at least 15 days before
the modification is to take effect. Rejection of a modification wili terminate the Contrect on tfie last date for which
subscription charges were paid. If notice is not given to Premera Blue Cross by the Group by the required time,
the ConVact will be renewed as modified, provided all required subscription charges are paid when due.
Any contrect modifications reques(ed by the Group and ag�eed to tiy Premera Blue Cross will become effectiye
on the Group's Contract effective date that coincides with or neut follows the date of 4he request. For delive,ry
timeliness, please see"Notice"earlier in this document.
OUT-OF-AREA CARE
As a member of the Blue Cross Blue Shield Association ("BCBSA"), Premera Blue Cross has artangements witfi
other Blue Cross and Blue Shield Licensees("Host Blues")for members'care outside Premera Blue Cross
service area. These arrangements are called "Inter-Plan Arrangements." Inter-Plan Arrangements follow the
rules and process set by BCBSA. A member's receiving care through these Inter-Plan Arrangements does not
change covered benefits, benefit levels, or any stated eligibility reqLirements of this plan.
The BlueCard�Program is the Inter-Plan Arrangementthat applies to most claims from Host Blues'network
providers: The Host Blue is respo�sible for such services as contracting and handling all interactions with its
network providers. Premera Blue Cross remains responsible for Premera Blue Cross other duties under the
ConVact. Other Inter-Plan Arrangements apply to providers that are not in the Host Blues'neiworks(non-
oonVacted pfoviders). This Out-Of-Area Care section explains how the plan pays both rypes of providers.
Premera Blue Cross processes claims for the Prescnption Drugs benefit directly, not through an Inter-Pian
Arrangement.
BlueCard Program
Ezcept for copays, Premera Blue Cross will base:the amount members must pay for claims from Host Blues'
network providers on the lower of the provider's billed charge for the covered services or the allowable charge that
the Host Blue made available to Premere Blue Cross.
Host Blues detertnine allowable charges for covered services, which are reflected in the tertns of their network
provider conVacts. The allowable charge can be one of the following:
• An actual price. An actual price is a negotiated amount passed to Premera Blue Cross without any other
increases or decreases.
• An estimated price. An estimated price is a negotiated price that is reduced or increased to take into account
certain payments negotiated with the provider and other claim-and non-claim-related transactions. Such
transactioris may include, 6ut are nof limited to, anti-freud and abuse recoveries, provider refunds not applied
on a claim-specific basis, retrospective settlemenfs, and perfortnanoe-related bonuses or incentiyes.
• An ayerage price.An average price is a pe�cenfage of billed charges for the covered services representing the
aggregate payments that,the Host Blue negotiated with all of its network proyiders or with its network providers
in the same or similar class. It may also include the same types of claim-and nonclaim-related transactions as
an estimated price.
Host Blues using either an estimated price or an average price may increase or reduce such prices prospectively
to reflect additional amounts or credits for claims already paid or expected to be paid to proyiders or refunds
received,or expected to b:e received from providers. However,the BlueCard Prog�am requires that the Host
Blue's allowable charge for a claim is final for that claim; no future price adjustment will change the pricing of past
claims. We take into account the various pricing methods used by Host Blues in determining subscription
charges for our plans.
Clark County Providers Services in Clark County, Washington are pcocessed through BlueCard. However,
some providers in Clark County do have conVacts with us. These pro4iders will submit claims directly to us,and
benefits wiil be based on our allowable charge for the covered service or supply.
Value-Based Progrems Members might get covered services from providers that,participate in a Host Bltie's
vaiue-based program (VBP). Value-based programs focus on meeting standards for Veatment outcomes, cost
and quality, and for coordinating care when themember is seeing more than one provider. The Host Blue may
pay VBP providers for meeting the above standards. We may include a factor in the subscription charges for this
plan to cover charges by Host Blues for thei�VBP payments.
3
Taxes,Surch:arges, and Fees
In some cases, a law or regulation may require that a surcharge, tax or other fee be applied to claims under this
plan. When this occurs,we will include that surcharge, tax or fee as a claims cost in our subscription charge
calculationa
Non-Contracted Providers
When covered services are provided outside our service area by proyiders that do not have a contract with tHe
Host Blue, the allowable charge wiil generally lie based on either our allowable charge for tFiese proViders,or the
pricing reguirements under applicable law. Members are responsible for fhe difference between 4he amount that
the non-contracted provider bills and fhis plan'spayment for the covered services. Please see fhe definition of
"Allowed Charge"in "Definitions"in the benefit boolilet for details on allowable charges.
Blue Cross Blue Shield Global Core
If inembers are outside the United States, the Commonwealth of Puerto Riw, and the U.S. Virgin Islands(the
"BlueCard service area"), they may be able to take advantage of Blue Cross BlueShield Global Core. Blue Cross
Blue Shield Global Core is unlike the BlueCard Program in the BlueCard service area in certain ways. For
instance, although Blue Cross Blue Shield Global Co�e helps membersaccess a proyider network, memberswill
typicalty haVe to pay the provider and submit.the claims themselves to get reimbursement for co4ered_services.
However, if inembers need hospital inpatient care,the Ser4ice Center can often direct them to hospitals that will
not require members to pay in full at the time of service. In such cases,these hospitals will also submifthe
member's claims to Blue Cross Blue Shield Global Core.
RECORDS MAINTENANCE
The Group shall maintain such books and records supporting the activities required by this Contract, and submit
such infortnation to Premera Blue Cross as may be required by Premera Blue Cross and as may be necessary for
compliance with the applicable provisions of.state and federal laws and regulations. Such books and records
shall be maintained in accordance with the general standards applicable to such book or rewrd keeping and shall
be riiaintained for a term of atJeast 11 years, and such obligations shall not terminate upon termination of this
Contract. Premera Blue Cross has the right to request, inspect, or audit the Group's records at any reasonable
time du�ing regular business hours.
CONFIDENTIALITY OF MEMBER INFORMATION
_ -.
Theparties acknowledge th:at Premera Blue Cross is subject or will be subject to various federal and state privacy
laws that may prohibit, limit, or otherwise restrict its ability to disclose to the Group any protected personal
information, including, but noflimited to, individually identifiable health information.
_ _ _ _ . _
MEMBERSHIP ADMINISTRATION
The Group shall provide Premera Blue Crosswith an initial list of subscribers and their dependents and notify
Premera Blue Cross of changes no lessoften than mon4hly. All eligibility updates must be provided in a file
formatShat Premera Blue Cross and the Group agree upon in advance;examples are copies of enrollment forms,
standard transaction 834 or sales spceadsheets. Any changes to the agreed file format must also be agreed upon
in.advance tiy Premera Blue Cross and th:e Group. Eligibility mformation not provided to Premera Blue Cross at
least Tbusiness days before the Group's scheduled monthly billing date may not be reflected on that bill.
The membership change detail provided must clearly and fully identify 4he applicable group, subgroup, subscriber
and member, describe the change, and show the date the change is to take effect.
PAYMENT ADMINISTRATION
During the Contract Term, Premera Blue Cross will bill the Group each month based upon the eligibility
information provided as stated in "Memtiership Administ�ation"above. The Group shall be liable for, and sFiall
pay to Preme�a Blue Cross on or before the first iiay of each,month, an amount equal to the total of the monthly
rate on behalf of th:e members name,d,on the updated eligibility list..
All payments must include all the payment detail data listed in the(3uick Reference Guide for Plan Administrators,
which standards are hereby incorporated intothisContract by reference. The payment detail data must clearly
and fuily identify fhe applicable group, subgroup; subscriber;member, and the period that the paymenf is for.
Payment information not already reflected on Premera Blue Cross's bill must include all the standard detail data in
a file format that Premera Blue Cross and the Group agree upon in advance. Any changes to the file format must
also be agreed upon by Premera Blue Cross and the Group in advance.
a
DELEGATION
The Group has the right to delega(e some or all of its administrative duties under this Contract to a third party
administrator. Notwithstandin9 such delegation, the Group shall remain responsible to give Premera Blue Cross
the required information. The Group must give Premera Blue Cross contact infortnation for the Group's third party
administrator and inform Premera Blue Cross of the scope of that administrator's duties relative ro fhisContract.
Tlie Group agrees to be responsible for the cooperation of its third party administrator with the membership and
payment adminisVation requirements of this Contrect and any other�equi�ements of this Contract that the thirtl
party administrator will be perfortning on behalf of the Group.
RETROACTIVE CHANGES TO ENROLLMENT
Requests by the Group for retroactive changes to enrollment or termination shall be limited as follows:
Enrollment: Retroactive enrollment of ofherwise eligible members shall be limited to the most recent of 3 dates:
• The date the members coverage would liave been validiy in force; or
• The first day of the second full calendar month preceding the date Premera Blue Cross receives the request for
retroactive enroilment; or
• If the plan is a high dedugtible health plan, the frst day of the current calendar year.
Termination: Retroactive tertnination of coverage for eligible members,when allowed by law, shall be limited to
the most recent of 2 dates:
• The date the member's coverage would have been terminated.
• The first day ofthe second full calentlar month preceding the date Premera Blue Cross the reguest for
retroactive terminafion.
Retroactive enrollments and terminations will be subject to appropriate subscrip4ion charge adjustments:
The Group is solely responsible for ensuring enroliment information provided to Premera Blue Cross by the Group
or its delegate's isaccurate and in compliance with all federal and state requirements, including those under the
AffoYdablg Care Act. The Group will indemnify, defend and hold Premera Blue Cross hartnless for any claims,
damages,judgments and expenses(including attorney's fees)based on or arising out of, direcUy or indirecUy, any
inaccurate or non-compliant eligibility infortnation provided to Premera Blue Cross by the Group or its delegates:
If the Group is subject to COBRA, Premera Blue Cross has the right to make exceptions for COBRA enrollments
and disenrollments as stated under the COBRA provisions of this Contract.
COMPLIANCE WITH LAW
The Group shall comply fully with all applicable state, federal and local laws and regulations, including notice and
disclosure requirements, in carrying ouf its responsibilities under the Contract. These include, but are not limited
to, corripliance with tfie Affo�da6le Care Act(including any applicable requirements for distribution of any medical
loss ratio rebates and ac;uarial value repuirements), Intemal Revenue Code, the Employee Retirement Income
Security Act of 1974(ERISA), the Consolidated Omnibus Budget Reconciliation Act of 7985(COBRA),the Family
and Medical Leave Act of 1993(FMLA), the Health Insurance Portabiliry and Accountability Act of 1996(HIPAA),
the Medica[e, Medicaid, and SCHIP Extension Act of 2007(MMSEA), and law and regulations goveming the
treatment and benefits of inembers covered by Medicare.
. The Group agrees to proyide notification required by HIPAA to all eligible employees before their enrollment:
. The Group agrees to provide Premera Blue Cross the following information required by the MMSEA:
• EmployerTax Identifcation Number(TINlEIN);
• Social Security Numbers(SSNs)of all covered individuals (employees and dependents); and
. Medicare Health Insurance Claim Numbers(HICNs)for all Medicare entitled individuals.
. The Group also agrees to notify Premera Blue Cross promptly if fhe Group experiences an increase in "total
employee count,"defined below, that would change the order of liability trom Medicare primary to Medicare
secon8ary according to the followingguidelines.
• Workina Aaed Medicare Beneficiaries'. For members that are also covered by Medicare based sblely on
their age, Medicare is the primary payer to the group health plan if the Group did not employ 20 ormore
"total ertiployees"for each working day in each of 20 or more calendar weeks in either 4he current or
preceding calendar year. For all other groups, Medicare pays secondary to the group health plan.
s
• Disabled MedicaPe.Beneficiaries*. For members that aFe also coyered by Medicare based solely on disa6ility
ottieY than End StageRenal Disease, Medicare is the primary payer to the group health plan if the Group did
not employ more 4han 100 employees on 50%0 or more of its working days in the preceding calendar year:
For all other groups, Medicare pays secondary to the group health plan.
'When determining the"total employee count," include all full-time and part-time employees, as well as those
employees on disability and sutiject to FICA,tazes, Also, count leased employees if th:ey wouldbe counted as
employeesunder§414(n)(2)of the Intemal Revenue Gode(IRC), and count employeesemployed by an
"affiliated service group"under IRC§414(m)or by employers considered to be a "single employer" under IRC
§52(a)or(b).
• The Group agrees to comply wi4h the Medicare Prescription Improvement and Modemization Act of2004
(MMA). MMA requires groups that provide prescription drug coverage to Medicare eligible individuals to
provide Medicare Part D Creditable Coverage Notices, and report creditable coverage status to the Center for
Medicare and Medicaid SerVices(CMS).
• Ifthe Group has a grandfathered plan, the Group must maintain records that will document the terms and
lirriitations of its g�andfathered plan that existed on March 23,2010. The Group must also maintain any otheP
documents needed to confirm, ezplain, or clarify the plans'grandfa;hgred status, Ttie Groupmust maintain this
documentation for as long as the Group takes the position that the plan is grandfathered. The Group must
make its documentation available to Premera Blue Cross, a member, or a state or Federal agency upon
request. If the Group no longer believes its plan to be grandfathered, or if if is found not to be grandfathered by
a State or Federal agency, tFie Group must notify Premera Blue Cross as soon as practicable. The group will
indemnify,defend, and hold Premera Blue Cross harmless for any ciaims, damages,judgments and expenses
(including attorneys fees)basetl on or arising out of, di�ectly or indirectly, the Group's determination of its
grandfathered status.
For delivery timeliness of notices to Premera Blue Cross, please see'`Notice"earlier in this document.
_ _ _ _
INACCURATE AND UNAPPROYED DESCRIPTIVE MATERIAL&
_ _
The Group will indemnify, defend and hold Premera Blue Cross harmless for any claims, damages,judgments ,
and expenses (including attomey's fees) based on or arising out of, directlyarindirectly, descriptive materials
written, created, designed or printed by the Group, or on the Group's behalf by any third party,when such
descriptive materials are used without prior approval Premera Blue Cross and/or inaccurately reflect any ofthe
tertns, conditioris, and/or provisions of this contract.
The tertn"descriptive materials" includes,without limitation, any type of circular, leaflet, tiooklet, summary,
hantlbooR, letter oY form that describes in whole or in part any of the terms, conditions and%or provisions of this
Contract.
COBRA
As directed by the Federal Consolidated Omnibus Budget Reconciliation Act of 1955, (referred to in this Contract
as"COBRA"), most employers with 20 or more employees must offer members who meet COBRA's"qualified
beneficiary'criteria an election to continue their group coverage. The Group is responsible to determine if iYs
required to comply with COBRA at the time of initial application and renewal of this Contract.
The Group;must fulfll all;he obligations andresponsibilities.regarding continued coverage that are assigned by
COBRA to the employer; plan sponsororadministrator; and to the"group health plan." Premera Blue Cross is
not the COBRA plan administrator, and Premera Blue Cross's actions pertaining to COBRA continued coverage
won't be construed as relieving the Group of responsibility under COBRA. Nothing contained herein is intended
to serJeas legal advice. The Group should consultJegal advisors as to the scope and applicability of COBRA.
The COBRA_provisio,ns outlined in the employee benefit booklet a�e.a summarization of the requirements of the
COBRA law. If there's a discrepancy between this summary and federal law, federal law will prevail.
When requested by the Group, Premera Blue Cross will provide continued coverage under this Contract,but only
to the extent that members are enfitled to continue group coverage under the COBRA law, and only to the extent
required by the COBRA law. In addition, ail the requirements listed below must be met in order for the plan to
pcovide COBRA coverage:
• The Group is subject to COBRA on the date of the qualifying event. If the Group was not subject to COBRA on
the effective date of this Contract, the Group must notify PremeraBlue Cross as soon as possible ifit will
become subject to COBRA on the next January 1. If the Group's workforoe shrinks during the calendar year,
the G�oup must also notify Premera Blue CFoss as soon as possible that it will no longer be subject to COBRA
on (he nezt January 1.
6
• The Group cornplies with all the requirements assigned by COBRA to the employer, plan sponsor; plan
atlministrator or group health plan that pertain to that qualified beneficiary. This includes all of COBRA's notice
requirements and th;e time limits set by COBRA for each. If the Group appoints a third party to perfo(m COBRA
notices orother administrative tasks,thatparty's failure to meet COBRA's standards will be deemed a failure of
the Group.
. The qualified beneficiary elects and pays for COBRA within the fime limits set by COBRA,and the application
and required subscription charges are submitted to Premera Blue Cross with the Group's next billing.
• The required subscription charges continue to be paid when due or within the 30-day COBRA grace period.
The Group must submit qualfied beneficiaries' subscription charges with its regular monthly subscription
charge payment.
• This Coritract remains in force. The Group acknowledges that even after this Contract is terminated, COBRA
mey require the Group to offer continuation unless the Group ceased to offer group health care coverage to any
employee.
The Group will terminate the coverage for any qualified beneficiary who doesn't elect COBRA continuation,
LABOR DISPUTE
Washington State law requires that 'rf a subscribers compensation is suspended or terminated,directly or
indirectly, due to a strike, lockout, or other labor dispute, that sutiscribeF must be allowed to pay the subscriptio�
charges due to keep the coverage under this plan in force for himself or herseif and his or her enrolled
dependents for up ta six months.
The Group must send written notice of this right immediately to each affected subscriber at the most recent
address the Group has for him or her. The Group is responsible for receiving the.subscription charges for this
interim coverage and remitting them to Premera Blue Cross with its payment for the same period of coverage for
active stibscribers.
The Group must notify Premera Blue Cross of tHe labor dispute as far in advance as possible, For delivery
timeliness;please see"Notice"earlier in this document.
INDEPENDENT CORPORATION
The Group hereby expressly acknowledges, on behalf of itself and all of its eligible employees and their eligible
dependents, its understanding fhat the Contract constitutes a contract solely between the Group and Premera
Blue Cross. Premera Blue Cross is an independent corporation operafing undera license with the Blue Cross
Blue Shield Association, an association of independent Blue Cross Blue Shield Licensees(the"Association").
The G�oup expressly acknowledges that Premera Blue Cross is not contracting as the agent of the Association
and th'at the Association h_as no otiligation under the Contract. The Association permits Premera Blue Cross, as a
Licensee, to use its Service Marks as follows:
_ _ _ _ _.
• The Blue Cross Service Mark in the States of Washington and Alaska
• The Blue Shield Service Mark in the State of Alaska
The Group further acknowleiJges and agrees that it has not ent@re'd into the Contract tiased upon representations
by any person other Ihan Premere Blue Cross, and that no person, entity or organization other than Premera Blue
Cross shall be held accountable or liable to the Group for any of Premera Blue Cross obligations to the Group
created under the Group Contract. This provision shall not create any additional obligations wha4soever on
Premera Blue Cross's part other than those obligations creafed under other provisions of the Contract.
RIGHTS OF ASSIGNMENT
• Notwithstanding any other provision in this Contract, and subject to any limitations of state or federal law, in the
eyent tHat Prerriera Blue Cross merges or consolidates with another corporation or enGty, or does business
under anoth_er name or jointly with another entity, or transfers this Contract to another corporation or entiry, tfiis
Contract shall remain in full force and effect in accordance with its tertns, antJ bind the Group and the
successor corporation or other entity. In such event, Premera Blue Gross guarantees 4hat all Premera Blue
Cross obligations under fhis Contract will be performed by the successor entity.
• No assignment of the Group's interesf hereunder may be made'without Premera Blue Cross prior written
consent. Any assignment made wi4hout Premera Blue Cross's written consent shall be void.
�
SEVERABILITY, CONSTRUCTION AND INTERPRETATION
This Contract and any questions conceming 4he validity, construction, interpretation, and enforcement of 4his
Contract or the benefits provided herein shall be governed by the laws of the State of Washington, except to the
extent pre-empted by federal law.
Sfiould any part, term or proVision of this Contract be field by the courts to tie illegal or in conflict with any law of
the State of Washington, the validity of the remaining portion shall not be affected.
TRADEMARK
We reserve the right to, the control of, and the use of the words"Premera Blue Cross, Premera Blue 6ross Blue
Shield of Alaska and all symbols, trademarks and service marics exis4ing or hereafter established. The Group
shall not use such words, symbols, trademarks or service marks in advertising, promotional materials, materials
supplied to members or otherwise without Premera Blue Cross's prior written consent which shall not be
unreasonably withheld.
s
EXHIBIT A
LARGE GROUP FULLYINSURED FUNDING ARRANGEMENT AGREEMENT
to the Group Health Benefit Plan Confract ("the ConfracY') between
PREMERA BLUE CROSS
AND
GITY OF AUBURN
Effective: January 1, 2018 through December 31, 2018
All participating employers and segmented employers who are members of the Group shall be treated as one
enUty for purposes of this Contract, including the establishment of ConVactual Rates, billing, and calculation of
late charges.
1. DEFINITIONS
In addition to the definitions in the"Definitions"section of tHe benefit booklet(s), the following defnitions apply:
Contractuai Rate
The tertn "Contractual Rate"means the monthly subscription charges set forth as such in Attachment A
for fhe Contract Term.
Contractuai Revenue
The term "Contractual Revenue"means the total of the Contreotual Rate for each rate classification
multiplied by the number of employees in each such classification for each month in the Contract Terin.
Contractual Revenue does not include Customization Fees, if such fees are charged for this Plan.
Contribution and Participation Requirements
The tertn "Contribution Requiremen4"means4he percentage or dollar amount contribufion the employer
will make toward the cost of employee andlor dependent coverage. The term "Participation Requirement"
means the minimum percentage or number of employees andlor dependents that must be enrolled under
the Plan. The Contribution and Participation Requirements are set forth in the Attachment A.
Customization Fee
The term "Gustomization Fee"means the fee that appliesif the Group requestseither of the following:
1. A Plan benefit configuration that Premere Blue Cross has determined to be nonstandard for 4he plan
type and was not filed as standard with the state regulators for that reason.
2. An off-anniversary benefit change, regardless of whether the desired benefit is standard for the plan
type. The Customization Fee for eacli`off-anniyersary change shall be$2,000. Any changes in
benefits made off-anniversary must be in compliance with state and federal law.
For purposes of Customization Fees, "benefits"include eligibility, termination, continuation and benefit
payment provisions, benefit terms, limita6ons, and exclusions,funding arrangement changes, and any
other standard provisions of the Plan. Fees are computed based on current administrative costs to
implement and administer the benefit.
Customization Fees assessed on this Plan as of its effective date are set forth in Attachment A. Off-
anniversary Cusromization Fees, if any, will be invoiced separately to the Group.
Due Date
The day of the month upon which subscription charge payments are due. The Due Date is shown on the
face page of this Contract.
Grace Period
The term "Grace Period"means the period of time(see Attachment A)from the Due Date during which
the Group may make the required payment and the Gontract will not be terminated for nonpayment.
II. CONTRACTUAL RATES IMONTHLY SUBSCRIPTION CHARGE$1
A. ConVactuai Rates
The monthly ConVactual Rates for the Contract Term are set forth in Attachment A.
B. Adjustments to Contractual Rates
The C.ontractual Rates set forth in II.A. above will remain in effect until ttie end of the Contract Term, anii
during any extension thereof gPanted by Premera Blue Cross, or until the Contract is terrninated, if earlier.
During the period for which this guarantee is effecti4e, Premera Blue Cross agrees to accept payment of
these subscription charges as paymenYin full for the current level of benefits provided under this
ConVacf. However, Premera Blue Cross reserves the right to revise current subscriptlon charges atany
time during the ConVact Tertn if either of the following occurs:
1. Should any federal, state or local authoriry mandate a change in benefits, eligibility or procedure or
impose or change a tax or assessment on Premera Blue Cross or the Plan during the Contraot Terrri
or any eztension of the Contract Terrn,wliether by statute, regulation, interqretation or othenvise.
PremeraBlue Cross may increase the Contractual Rates set forth in Attachment A, as of the date
specifed in Premera Blue Cross`sno4ice to the Group orits agent.
2, Premera Blue Cross may increase the Contractual Rates during the Contract Term by giving thirty
(30)days advance written notice to the Group or its agent, if Premera Blue Cross determines that the
basis upon which Premera Blue Cross assumed the risk ismaterially changed for any reason.
Ezamples of material changes;hat may require re-rating are:
a, A lienefit change requested by the Group.
b. A fluctuation of ten (10)percent or more in the number of Members as set forth on the census
informafion included in Attachment A which is herein incorporeted by reference and made a part
of this Contrect.
c. A change in the amount of the employer's contribution on behalf of each Member.
d. Fraud or intentionally false or misleading medical or other information
e. A change in procedure agreed tb by the Group and Premera Blue Cross, including any cFiange in
Premera Blue Cross's reporting requirements.
f. A change in the Group's health care plans and/or carriers from those set forth in Attachment A.
g. The addition of Members, with Premera Blue Cross's prior approval,whoiive outside Washington
and Alaska.
h. The addition of a dual,friple,or multiple choice option or a change in the plan choices offered 6y
a dual, triple or multiple choice group.
i. A change in the third-party adminishator, if any, used by the Group with respect to the benefits
provided under this Contract. The Group will provide Premera Blue Cross no less than one
hundred and riventy(120)days'advance written notice of any such change.
Any such revision to cunent subscriptiori charges will talie effect on the date specified in the notice.
For deliyery timeliness, see"Notice"in "Standard Provisio:ns."
3. Premera Blue Cross may adjust the Contractual Rates during tlie Contract Term by giving thirty(30)
days advanoe written notice ro the Group or its agent, if the Group agrees with Premera Blue Cross
that the Contrectual Rates are based in whole or in part upon a mistake 4hat materially impa,ctssuch
rates.
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III. PAYMENTS
A. Monthly Payments
No benefits are payable for expenses incurred on any date for which subscription charges are not paid.
The Group is Iiabie for all subscription charges covering any period of time that this ConVact remains in
force.
During tHe Contract Tertn, Preme�a Blue Cross will bill [he Group based upon the preyious month's
eligibility. The Group shall provide Premera Blue Cross with updated eligibility infortnation. The Group
shall be liable for,and shall pay to Premera Blue Cross on or before the first day of each month, an
amount equal to the total of the monthly Contractual Rates on behalf of the Members included on the
updated eligibility list. The Contractual Rate amounts is shown in Attachment A.
B. Late Payments
A Grace Penod (see AttacFiment A)after the Due Date shall be allowed to the Group for payment of tFie
monthly Contractual Rates. If Premera Blue Cross does not receiye payment by the end of the Grace
Period, the Contract may automatically terminate on the Due Date. No benefits will be paid for otherwise
eligible expensesincurred on any day for which payment has not been made. If a partial paymenb:has
been received, Premera Blue Cross may, at its discretion, return the payment or provide benefits for
those Members for whom payment has been made. Acceptance by Premera Blue Cross of late or partial
payment shall not be construed as a waiver of Premera Blue Cross's right to demand timely payme'nt or
to tertninate this Contract for noripayment if a subsequent payment is late.
C. Late Charges
Premera Blue Cross reserves tHe nght to invoke the provision below for all groups covered tiy this Fully
Insured funding arrangement.. Premera Blue Cross wili notify all such groups30 days in advance of the
date that Premera Blue Cross willbegin invoking this provision. Premera Blue Cross will then charge late
charges on payments that are not received within any Grace Period that falls on or after the date stated in
the notice.
If Premera Blue Cross does not receive a payment by the end of the Grace Period,the Group will pay
Premera Blue Cross a daily late charge,; This late charge is calculated from the Due Date, ratHer than
from the end of the Grace Period: The late charge is based on the average prime rate posted by
Premera Blue Cross's designated bartk during the Contract Tertn, plus two(2)percent on the amount of
the late payment for the number of days late. Late charges will not be assessed against any partial
payment that Premera Blue Cross retains. Late charges are in addition to Contractual Revenue and they
are calculated and billed at the end of the Contract Tertn or upon termination of the Contract, if earliec
D. Customization Fees
Gustomization Fees for custom benefits that take effect on the effective date shown on the Face Bage of
this Contract are due and payable prior to that effective date. Customization Fees for off-anniversary
benefit changes are due and payable prior to the effective date of the change.
IV. CONTRIBUTION AND PARTICIPATION REQUIREMENTS
A. The Group must pay at least the minimum percentage of the Contractual Rate for employees that is
sHown in Attachment A. At least theminimum percentage of eligible employees that is shown in
Attachment A must be enrolled.
B. When a percentage of 4he Contractual Rate is shown in Attachment A, the Group must pay at least the
minimum percentage of the ConVactual Rate for dependents, if any is shown in Attachment A. At least
the minimum percentage of the eligible iiependents, if any is shown in Attachment A, must be enrolled.
C. If ttie Group has Members who are continuing this plan's coverage as directed by COBRA,they do not
count toward the participation minimums.
D. For purposes of this Section IV, eligible Members are individuals who satisfy the ContracYseligibility
requirements, except for any contribution requirement.
Premera Blue Cross reserves the right to terminate this Contract if the Group fails to maintain the contribution
and participation requirements stated in the Attachment A or any eligibility requirement stated in the Group
Contract.
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V. ACCOUNTING
A. Accounting
No annual or final accountings will be performed. Except for refunds required by law, Premera Blue
Cross will absorb any gains and losses.
B. Reporting
Within one hundred twenty(120)days of the end ofthe Contract Term, Premera Blue Cross shall pYovide
infortnation to the Group for preparing Fortn 5500's when such forms are required by law. The Group
shall be solely responsible for insuring timely filing of the Fortn 5500's.
VI. .CONTRACT TERMINATION
This Contrect can be terriminated as described in "Contract Tertnination"in the"When Wiil My Coverage
End?"section of the benefit booklet.
VII. OTHER PROVISIONS
A. Credit Worthiness
Evidence of credit worthiness, which is satisfactory to Premera Blue Cross, may be required at any time
during the Contract Term as Premera Blue Cross deems necessary.
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ATTACHMENT A
ro the Fully[naured Funding Arrangement Agreement
between
PREMERA BLUE CROSS
and
CITY OF AUBORN
Effectiye: 1-Jan-2018 through 31-Dee-2018
CRACE�PERIOD
Ten Q 0)Daye
BROKERACE FEES AND COMMISS[ONS
The Contractuai Rares include brokerage£ees and mmmissions equal ro 0.00 percrnt of[he Connacmal Rate.
CONTRACTUAL RATES(MONTHLY SUBSCRIPTION CHARGES)
The monthly Contractual Rates£or the Contract Period are u follows:
Group No. 40 747
Rate Clsasificadon
E � ESC1 ESC2+ E�1 EC2+
Ac6ves $802.86 $1,61232 $1,974.91 $2,26333 $I,165.45 $1,453.87
EarlyRetirees $1,17937 $2,359.46 $3,490.54 $4,613.55 $2,310.45 $3,433.46
CONTRIBUT[ON AND PARTICIPATfON REQUIREMENTS
Employer
ConlribuNon Participation
Employees 100% I00%
Deprnden[s 90% 25%
ACCOUNTINC PROCEDURES
No annual accountings are performed under this funding acrangemrnt Premera Blue Cross absorbs all gains and losses.
NUMBER OF ENROLLEES
The Contractual Rates are based on the foilowing:
Number of Acti4e Enrollees:
Employees Spouse Chiltlren
292 190 308
Other cartiers offered: Kaiser Northwest,Delta Dental,Willamette Dental,VSP