HomeMy WebLinkAboutPremera Blue Cross PREMEIZA I �
. .
GROUP HEALTH BENEFIT PLAN CONTRACT �
for
City of Auburn
25 West Main
Aubum, WA 98001
(herein refened to as the Group)
Premera Blue Cross, an independent licensee of the Blue Cross Blue Shield Association, agrees to proyide the
benefits described in this ConVact for eligible employees of the Group and their eligible dependents who are
enrolled for coverege under 4his Contract, provided that the Group is a large employer, as defined on thene�ct
page of the Contrect, remains actively engaged in business and requirements are met that would othervvise
provide grounds for tertnination as stated in "Contrect Termination" in the benefit booklet or booklets. All benefits
of this ConVact are subject to the terms and conditions stated herein and any endorsements or riders included or
issued thereafter.
The Group Health Benefit Plan delegates its authority to Premera Blue Cross to administer the routine operation
of tFie plan. As part of this function, Premera Blue Cross must use its expertise and judgment to reasonably
construe the tertns of this coverage and apply the terms of the conVact for making decisions in specific eligibility,
benefits and claims situations.
This Contract is valid on the effective date indicated below only when signed by an officer of Premera Blue Cross.
Payment of the subscrip[ion charges indicates that the Group accepts this Contract.
Any ezisting group contract or agreement between the Group and Premera Blue Cross that is being replaced by
this Eontract is terminated when this one becomes effective.
GROUP NUMBER 4007473
CONTRACT EFFECTIVE DATE January 1, 2018
CONTRACT ANNIVERSARY DATE January 1, 2019
SUBSCRIPTION CHARGE DUE DATE first of each month
STATE W WHICH GROUP IS LOCATED Washington
����i�!I" V �.L
Sign�d: Jeffrey Roe
M
1 1 r President and Chief Ezecutive Officer
Title: Premera Blue Cross
3 � t � Ig
Date: Date: January 1, 2018
40074730118EA
STANDARD PROVISIONS
LARGE EMPLOYER
A large employer is an employer that employed an ayerage of at least 51 common law employees on business
days during fhe preceding calendar year and that employs at least 51 employees on the first day of the current
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 wiii be based on the average number of employees that it is reasonably
ezpected;he employer will 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"Standarii 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(Exhibit A) between the Group and Premera Blue Cross
• All attachments, endorsements and riders included or issued hereafter
No agent or representative of Premera Blue Cross or any other entity is authorized to make any changes,
additions o�deletions to this Contract or to waive any proyision of this Contract. Changes, alterations, additions
or exclusiqns can only be done over the signatu�e of an officer of Preme(a Blue Cross.
If there is a language wnflict tietween the standard provisions, benefit booklet or other documents, the benefit
booklet(as amended by any attachments, endorsements or riders)will govern.
NOTICE
Any notice Premera Blue Cross is required to submit to the Group or subscriber wiil be considered to be delivered
if iYs mailed to the Group or subscriber at the 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.
CONTRACT TERM AND RENEWAL
The initial Contract Term begins on the ContracYs effective date and continues to the contract anniversary date,
unless terminated in accordance with the terms of the Contract. If not so terminated, the ConVact is kept in force
during the initial Term by fhe Group's payment of required subscription cha�ges when due.
After the initial Contract Term, this Contract will continue in force on a month-to-month basis by the Group's
payment of required subscription charges when due, unless iYs changed or terminated in accordance with the
Contract change and termination provisions stated elsewhere in this Contract.
FUNDING ARRANGEMENT AGREEMENT(EXHIBIT A)
TFie sutiscription charges and related provisions are set forth in the Funding Arrangement Agreement(Exhibit A)
belween the Group and Premera Blue Cross,which is attacFied to and made part of this Contract.
DOMESTIC PARTNERSHIP
If all requirements below are met, all rights and benefts afforded to a "spouse"under this plan will also be
afforded to an elig'ible domestic partner. In determining benefits for domes;ic partners and tHeir children under
this program,the 4erm "establishment of the domestic partnership"shall be used in place of"marriage"; the term
"termination of the domestic partnership"shall be used in place of"legal separation"and "divorce."
D.omestic 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 addition to ihe modification provisions stated in the Funding Arrangement Agreement(Exhibit A), Premera Blue
Crossmay modify the subscription charges, benefits, or any other provisions of this Contract by giving 30 days'
advance written notice to the Group prior to the end of the Contract term.
z
The Group may reject the modification by written notice deiivered to Premera Blue Cross at least 15 days before
the modification is to take effect. Rejection of a modifcation will terminate the Contract on the 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 Contract will be renewed as modified, provided all required subscription charges are paid when due.
Any contract modifications reques[ed tiy the Group and agreed to.by Premera Blue Cross will become effective
on the Group's Contract effective date that coincides with or next follows the date of the request. For deliyery
timeliness, please see"Notice"earlier in this document.
OUT-OF-AREA CARE
As a member of 4he Blue Cross Blue Shield Association ("BCBSA"), Premera Blue Cross has artangements w,ith
other Blue Cross and Blue Shield licensees("Host Blues")for members'care outside Premera Blue Cross
service area. These arrangements are calied "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, o�any stated eligibility requirements of this plan.
The BlueCard�Program is the Inter-Plan Arrangement that applies to most claims from Host Blues'network
providers. The Host Blue is responsible 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
Contract. Other Inter-Plan Arrangements apply to providers that are not in the Host Blues'networks(non-
cont�acted providers). This Out-Of-Area Care section explains how the plan pays twth rypes of providers.
Premera Blue Cross processes claims for the Presc�iption Drugs benefit directly, not through an Inter-Plan
Arrahgement.
BlueCard Program
Ezcept for copays, Premera Blue Cross will base the amount members must pay for claims from Host Blues'
network providers on the lowerof the provider's billed charge for the coVered services or the allowable charge that
the Host Blue made available to Premera Blue Cross.
Host Blues determine allowable charges for covered services, which are reflected in the terms of their network
provider contracts. 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 nego6ated price that is reduced or increased to take into account
certain paymenfs negotiated with the provider and other claim-and non-claim-related transactions. Such
Vansactions may indude, but are not limited to, anti-fraud and atiuse recoveries, provider refunds not applied
on a claim-specific basis, retrospective settlements, and performance-related bonuses or incentives.
• An average price. An average price is a percentage of billed ch"arges for the covered seryices representing tlie
aggregate payments that the Host Blue negotiated with all of its neMrork providers or with its network providers
in the same or simiiar class. It may also include the same types of claim-and non-claim-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 ezpected to be paid to providers or refu�ds
received orexpected to be received from providers, However, tlie BlueCard Program requires th:at the Host
Blue's allowable charge for a claim is final for that claim; no future price adjustrnent will change the pricing of past
claims. We take into accountthe various pricing methods used by Host Blues in determining subscnption
cliarges for our plans.
Clark 6ounty Providers Services in Clark County,Washington are processed tfirough BlueCard. HoweJer,
some providers in Clark County do have contracts with us. These providers will submit claims directly to us, and
benefits will 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 Blue's
value-based program (VBP). Value-based programs focus on meeting standards for treatment outcomes,cost
and quality, and for coordinating care when the memberis seeing more than one providec ?he Host Blue may
pay VBP providers for meeting the abo4e standarils. We may include a factor in the subscription charges for this
plan to cover charges by Host Blues for their VBP payments.
3
Taxes,Surcharges, 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
calculations.
Non-Contrected Providers
When covered services are provided outside our service area by providers that do not have a contract with the
Host Blue, the allowable charge will generally be based on either our allowable charge for these providers or the
pricing requirements under applicable law. Members are responsible for the difference between the amount that
the non-contracted provider tiills and this plan's payment for the covered services. Please see the definition of
"Allowed Charge" in"Definitions"in the benefit booklet for details on allowable charges.
Blue Cross Blue Shield Global 6ore
If inembers are outside the United States, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands(th:e
"BlueCard service area"), they may be able to take advantage of Blue Cross Blue Shield Global Core. Blue Gross
Blue Shield Global Core is unGke the BlueCard Program in the BlueCard service area in certain ways. For
instance, although Blue Cross Blue Shield Global Core helps members access a provider network, members will
typically fiave to pay the proyider and submit the claims themselves to get reimbursement for covered services.
However, if inembers need hospital inpatient care, the Service 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 sutimit the
memtier'sclaims 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 4he 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 record keeping and shall
be maintained for a term of atJeast 11 years, and such obligations shall not terminate upon terrimination of this
Contract. Premera Blue Cross has the right to reguest, inspect, orauiiit the Group's records at any reasonable
time tluring regular business hours.
_ _ . _ . . _
60NFIDENTIALITY OF MEMBER INFORMATION
_ . . . _.. .
The paRies acknowledge that Premera Blue Cross is,subject or will be subject to Various federal and state priyacy
laws thatmay prohibit; Iimit, or otherwise restrict its ability to discbse to the Group any protected personal
information, including, but not limited to, individually identifiable health information.
MEMBERSHIP ADMINISTRATION
The Group shall provide Premera Blue Cross with an initial list of subscribers and their dependents and nofify
Premera BIue.Cross of changes no less often than monthly. All eligibility updates must be provided in a file
format that Premera Blue Cross and tFie Group agree upon in advance; examples are copies of enrollment foriiis,
standard;ransaction 834 or sales spreadsheets: Any changes to the agreed file format must also b_e ag�eed upon
in advance by Premera Blue Cross and the Group. Eligibility information not provided to Premera Blue£ross at
Ieast 7 business days before the Group'sscheduled monthly billing date may not be reflected on 4hat biil.
The membership change detail provided must clearly and fully identify tfie applicable group, subgroup, subscriber
and rimembe�, describe the change, and show ttie date the change is to take effect.
PAYMENT,4DMINISTRATION
During the Con;ract Term, Premera Blue Cross will bill the Group each month based upon the eligibility
information provided as stated in "Membership Administration"atiove. The Group shall be liable for, and sFiall
pay to Premera Blue Cross on or before the first day of each month, an amount equal to the total of the monthly
rate on behalf of the members named on the updated eligibility list.
All payments must include all the payment detail data listed in the Quick Reference Guide for Plan Administrators,
whichstandards are hereby incorporated into this Contract by reference. The payment detail data must clearly
and fullyidentify the applicable group, su6group, subscriber, member, and the period that the payment is for.
Payment information not already reflecteii on Premera Blue Cross's bill must include all the standarii detail data in
a file format that Premera Blue Cross and.the Group agree upon in advance. Any changes to th'e file fortnat must
also be agreed upon by Premera Blue Cross and tfie Group in advance.
a
DELEGATION
The Group has;he right ro delegate some or all of its administrative duties under this ConVact[o a third party
administrator. Notwithstanding such delegation, tFie Group shall remain responsibie to give Premera Blue Cross
the required infortnation. The Group must give Premera Blue Cross contact information for the Group's third party
administrator and infortn Premera Blue Cross of the scope of that administrator's duties relative to this Contract.
The Group agrees to be responsible for the cooperation of its third party administrator with the membership and
payment administration requirements of this Contract and any other requirements of this Contract that the thi�iJ
party administrator will be perfortning on betialf of the Group.
RETROACTIVE 6HANGES TO ENROLLMENT
Requests by the Group for retroactive changes to enrollment or termination shall be limited as follows:
Enrollment: Retroactive enrollment of otherwise eligible members shall be limited to the most recent of 3 dates:
. The date the member's coverage would have been validly in force; or
• The first day of the second full calenda�month preceding the date Premera Blue Cross receives the request for
retroactive enrollment; or
• If the plan is a high deductible health plan, the first day of the current calendar year.
Termination: Retroactive termination 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 of the second full calendar month preceding the date Premera Blue Cross the request for
retroactive terrnination.
Retroactive enrollments and terminations will be subject to appropriate subscription charge adjustments.
The Group is solely responsible for ensuring enroliment information provided to Premera Blue Cross by the Group
or ifs delegates is accurate and in compliance with all federal and state�equirements, including those under the
Affordable Care Act. The Group will indemnify, defenil and liold Premera Blue Cross harmless for any claims,
damages,judgmentsand expenses (including attorney's fees) based on or arising out of,directly or indirectly, any
inaccurate or non-compliant eligibility information 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
disclosuFe requirements, in carrying out its responsibilities under the Contract. These include,buYare not limited
to, compliance with the Affordable Care Act(induding any applicable requirements for distribution of any medical
loss ratio rebates and actuarial value requirements), Intemal ReVenue Code, the Employee Retirement Income
_
Security Ad of 1974(ERISA), the Consolidated Omnibus Budget Reconciliation Act of 1985(COBRA),the Family
and Medical Leave Act of 1993 (FMLA),the Health Insurance Portabiiity and Accountability Act of 1996(HIPAA),
tlie Medicare, 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 provide notification required 6y HIPAA to all eligible employees before their enro�lment.
. The Group agrees to provide Premera Blue Cross the following information required 6y the MMSEA:
• Employer Tax Identification Number(TINlEIN);
• Social Security Numbers(SSNs)of all covered individuals(employees and dependents); and
• Medicare Health Insurance Claim Numbers (HICNs)for all Medicare entitled indi4iduals.
• The Group also agrees to notify Preme�a Blue Cross promptly if the Group experiences an increase in "total
employee count,"de�ned below, tfiat would change the order ofiiability from Medicare primary to Medicare
secondary according to the following guidelines.
• Workina Aaed Medicare Beneficiaries'. For members that are also covered by Medicare based solely on
their age, Medicare is the prima:ry payet to the group health plan if the Group did not employ 20 or more
"total employees"for each working day in each of 20 or more calendar weeks in either the cunent or
preceding calendar year. Forall other groups, Medicare pays secondary to the group health ptan.
s
• Disabled-Medicare Beneficiaries". For members that are also covered by Medicare based solely on disability
other than Entl Stage Renal Disease, Medicare is the primary payer to the group health plan if tFie Group ditl
not empioy more than 100 employees on 50%0 or more of its working days in the preceding calendar year:
For all other groups, Medicare pays secondary fo the group health plan.
'When determining the"total employee wunt," include all full-time and part-time employees, as well as those
employees on:disability and subject to FICA taxes. Also, count,leased employees if they would be counted as
emptoyees under§414(n)(2)ofthe Intemal Revenue Gode(IRC), and count employees employed by an
"affiliated service group" under IRC §414(m)or by employersconsidered to be a "single employer" under IRC
§52(a)or(b).
• The Group agrees to comply with the Medicare Prescription Improvement and Modemization Act of 2004
(MMA). MMA requires groups that provide prescription drug coverage to Medicare eligible individuals to
provide Medicare PaR D Creditable Coverage Notices, and report creditable coyerage status to the Center for
Medicaie and Medicaid Services(CMS).
• If the Group fias a grandfathered plan, the Group must maintain records that wifl document ihe terms and
limitations of its grandfathered plan that ezisted on March 23, 201.0. The Group must also maintain.any other
documents needed to confrtn,explain, or clarify the plans'grandfathered status. The Group must maintain this
documentation for as long as the Group takes the position that fhe plan is grandfathered. The Group must
make its documentation available to Premera Blue Cross, a member, or a state or Federal agency upon
reijuest. If the Group no longer believes its plan to be grandfathered, or if it is found not to be grandfathered by
a State or Federal agency, the Group must notify Premera Blue Cross as soon as pPacticable. The group will
indemnify, defend, and hold Premera Blue Crossharmless for any claims, damages,judgments and ezpenses
(including attomey's fees)based on or arising out of, directly 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 UNAPPROVED DESCRIPTIVE MATERIALS
The Group will indemnify, defend and hold Premera Blue Cross harmless for any claims, damages,.judgments ,
and expenses(including attorney's fees) based on or arising out of, directly or indirectly, descriptive materials
written, created, designed or prinfed by the Group, or on the Group's behalf by any third party, when such
descriptiye materials are used without prior approval Premera Blue Cross and/or inaccurately reflect any of the
terms, conditions, and/orprovisions of this contract.
The term "descriptive materials" includes, without limitation, any type of circular, leaflet, booklet, summary,
handbook, le4ter or 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 1985, (referred to in this ConUact
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 coyerage. The Group is respbnsible to determine if it's
required to comply with COBRA at the time of initial application and renewal of this Contract.
The Group must fulfill all the obligations and responsibilities regarding continued coverage that are assigned by
COBRA to the employer, plan sponsor or administrator, and to the"group health plan." Premera Blue Cross is
not;he COBRA plan'administrator, and Premera Blue Cross's actions pertaining to COBRA continued coyerage
won't be construed as relieving the Group of responsibility under COBRA. Nothing contained herein is intended
to serve as legal advice. The Group should consult legal advisors as to the scope and applicabiliry of COBRA.
The COBRA provisions outlined in the employeebenefitbooklet are asummarization of the requirements of the
COBRA law. If there's a discrepancy between this summary and federel law, federal law will prevail.
When requested by tHe Group, Premera Blue Cross will provide continued coverage under this Contract, but only I
to the extent that members are entitled to continue group coverage under tHe COBRA law, and only to the eztent
required by the COBR.41aw. In addition, all the requirements listed below must tie met in order for th:e plan.to
provide COBRA coverage:
• The Group is subject to COBRA on the date of the qualifying event, If the Group was notsubject to,COBRA on
the effective date of this Contract, the Group must notify Premera Blue Gross as soon as possible if it will
become subject to COBRA on the next January 1. If the Group's workforce shrinks during the calendar year,
the Group must also notify Premera Blue Cross as soon as possible that it will no longer be subject to COBRA
on the next January 1.
6
. The Group cornplies with all the reguirements assigned by COBRA to the employer, plan sponsor, plan
administrator or group health Plan that perJain to that qualified tieneficiary. This includes all of COBRA's notice
requirements and the time limits set by COBRA for each. If the Group appoints a third party to perfortn COBRA
notices or other administrative tasks, that party'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 time limits set tiy COBRA, and the application
anii requiredsubscription cliarges are submitted to Premera Blue Gross with the Group's next billing.
• There:quired subscription charges continue to be paid wHen due or within the 30-day COBRA grace period.
The Group must submit qualified beneficiaries' subscription charges with its regular mon4hly subscription
charge payment.
• This Contract remains in force. The Group acknowledges that even after this ConVact is tertninated, COBRA
may require the Group to offer continuation unless the Group ceased to offer group health care coverage to any
employee.
The Group wiil terminate the coverage forany qualified beneficiary who doesn't elect COBRA continuation.
LABOR DISPUTE
Washington State law requires that if a subscriber's compensation is suspended or terminated, directly or
indirectly, due to a strike, lookout, or othe�labor dispute, that subscriber must be allowed to pay the subscription
charges due to keep the coverage under this plan in force for himself or herself and his or her enrolled
dependents forup to six months.
The Group musf 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 P�emera Blue Cross with its payment for the same period of coverage for
active subscritiers.
The Group must notify Premera Blue Cros"s of th:e labor dispute as far in advance as possible, For deliyery
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
dependenfs;its understanding fhat the Contract constitutes a contract solely between the Group and Premera
Blue Cross. Premera Blue Cross is an independent corporation operating under a license with the Blue Cross
Blue Shield Association, an association of independent Blue Cross Blue Shield Licensees (the"Association").
The Group expressly acknowledges that Premera Blue Cross is not contracting as the agent of the Association
and that the Association has no obligation under the Contract. The Association pertnits Premera Blue Cross, as a
Licensee, to use its SerVice Marks as follows:
• The Blue Cross$ervice Mark in the$tates of Washington and Alaska
• The Blue Shield Service Mark in the State of Alaska
__ . . . ._. _ _ __. _.
The Group further acknowledges and agrees that it has not entered into 4he Gontract based upon representatio�s
by any person other than Premera 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 Cont�act. This provision shall not create any additional obligations whatsoeyer on
Premera Blue Cross's part other than those obligations created under other provisions of the Contract.
RIGHTS OF ASSIGNMENT
• Notwithstanding any other provision in tFiis Contract, and subject to any limitations of state or federal law, in the
e4ent that Premere Blue Cross merges orconsolidates with another corporation or entity, or does business
under ano4hername or jointly wi4h another entity, or transfers 4his Confract to another corporetion orentity, this
Contract shall remain in full force and effect in accordance with i4s terms, and bind the Group and the
successor corporation or other entity. In such event, Premera Blue Cross guarantees that all Premera Blue
Crossobligations under this Contreot will be performed by the successor entiry.
• No assignment of the Group's interest hereunder may be made without Premera Blue Cross prior written
consent. Any assignment made without P�emera Blue Cross's written consent shall be void.
�
SEVE_RABILITY, CONSTRUCTION AND INTERPRETATION
This Contrect and any questions conceming tFie valitlity, construction, interpretation, and enforcement of this
Contract or the benefits provided herein shall be govemed by the laws of the State of N/ashington, except to the
extent pre�mpted by federal law.
Should any part, tertn or provision of this Contract be held by the courts to be illegal or in conflict with any law of
the State of Washington, the validity of the remaining poRion shall not be affected.
TRADEMARK
We reserve th:e right to, the control of, and the use of the words"Premera Blue Cross, Premera Blue Cross Blue
Shield of Alaska and all symbols, trademarks and service marks existing or hereafter establisFied. 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
unreasonabiy withheid.
8
EXHIBIT A
LARGE GROUP FULLY INSURED FUNDING ARRANGEMENT AGREEMENT
to the Group Heal4h Beneft Plan Contract (`'the ContracY`) between
PREMERA BLUE CROSS
AND
CITY OF AUBURN
Effective: January 1, 2018 through December 31, 2018
All participating employers and segmented employers who are members of the Group shall be Veated as one
entiry for purposes of this Contract, including tFie establisFiment of Contractual Rates, billing, and calculation of
late charges.
I. DEFINITIONS
In addition to the definitions in the"Definitions"section of the benefit booklet(s), the following definitions apply:
Contractual Rate
The tertn "ConVactual Rate"means the monthly subscription charges set forth as such in Attachment A
for the Contrect Term.
Gontractual Revenue
The term "ConVactual Revenue"means the total of the Contractual Rate for each rate classification
multiplied by the number of employees in each such classification for each month in the Contract Term.
Contrectual Revenue does not include Customization Fees, if such fees are charged for this Plan.
Contribution and Participation Requirements
The term "Contritiution RequiremenY' m'eans the percentage o�dollar amount contribution the employer
will make toward the cost of employee a,nd/or dependent coveiage. The term "Rarticipation RequiremenY'
means the minimum percentage or number of employees and%or dependents that must be enrolled under
the Plan. The Contribution and Participation Requirements are set forth in the Attachment A.
Customization Fee
Tfie term "Gustomization Fee"meansthe fee that applies if the Group requests either of the following:
1. A Plan benefit configuration tFiatPremera Blue Cross has determined to be nonstandard for the plan
_ ._. . _
type and was not filed as standard with the state regulators for thatreason.
2. An off-anniversary benefit change, regardless of whether the desired benefit isstandard for the plan
type. The Customization Fee for each off-anniversary change shall be$2,000. Any changes in
tienefits made off-anniversary must be in compliance with state and federal law.
For purposes of Customization Fees, "behefits"include eligibility, termination, continuation anC beneft
payment provisions, benefit terms, limitations, and exclusions,funding arrangement changes, and any
other standard provisions of the Plan. Fees are computed based on current administra4ive 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 Customization Fees, if any,will be invoiced separately to the Group.
DOe 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 ttie period of time(see Attachment A)from the Due Date during wFtich
the Group may make the required payment and the Contract will not be tertninated for nonpayment.
II. CONTRACTUAL RATES(MONTHLY SUBSCRIPTION CHARGESI
A. ConVactualRates
The monthly Contrectual Rates for tFie Contract Term are set forth in Attachment A.
B. Adjustrnents to Contractual Rates
The Gontractual Rates set forth in II.A above will remain in effect until the end of the ConVact Tertn,and
during any eutension thereof granted by Premera Blue Cross,or until the ContracYistemiinated, if earlier.
During the period for which this guarentee is effective, Premera Blue Cross agrees to accept payment of
these subscnption charges as payment in full for the current level of benefits provided under this
ConVact. However, Premera Blue Cross reseryes the right to revise cuRent subscription charges at any
time during the ConVact Tertn if either of the following occurs:
1. Should any federal, state or local authority mandate a change in benefits, eligibility or procedure or
impose or change a tax or assessment on Premera Blue Cross or the Plan during 4he Gontract Tertn
or any extension of the Contract Term,whether by.statute, regulation, interpretation or othervvise.
Premera Blue Cross may increase the Contractual Rates set forth in Attachment A, as of the date
specified in Premera Blue Cross's notice to the Group or its agent.
2, Premera Blue Cross may increase the Contractu8l Rates during the Contract Term tiy giving thirty
(30)days advance written notice to the Group or its agent, if Premera Blue Cross detertnines that the
basis upon which Premera Blue Cross assumed the risk ismaterially changed for any reason.
Examples of material changes thatmay require re-rating are:
a. A benefit 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
information included in Attachment A which is herein,incorporated by reference and made a part
of this Gontrect.
c. A change in the amount of the employer's contribution on behalf of each Member:
d. FPaud or intentionally false or misleading medical or other information
e. A cfiange in procedure agreed to by the Group and Premera Blue Cross, including any change 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,w'ith Premera Blue Cross'spnor approval,who live outside Washington
and Alaska.
h. The addition of a dual, triple,.or multiple choice option or a change in tfie plan choices offered by
a dual, triple or multiple choice group.
i. A change in the third-party administrator, if any, used by the Group with respect to the benefits
provided under 4his Contract. The Group will provide Premera Blue Crossno less fhan one
hundred and twenty(120)days'advance written notice of any such change.
Any such revision to current subscription charges will take effect on the date specified in the notice.
For delivery timeliness, see "Notice"in"Standard P�ovisions."
3. Premere B�ue Cross may adjust the Contractual Rates during the Contract Term by giving tliirty(30)
days advance written notice to the Group or its agent, if the Group agrees with Premera Blue Cross
that the Contractual Rates are based in whole or in part upon a mistake that materially impactssuch
rates.
-2-
III.-.PAYMENTS
A. Monthly Payments
No benefits are payable for expensesincurred on any date for which subscription chargesare not paid:
The Group is liable for all subscripdon charges covering any period of time that this Contract remains in
force.
During the Contract Term, Premera Blue Cross will bill the Group based upon the previous month's
eligibility. The Group shall provide Premera Blue Cross with updated eligibility infortnaGon. 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 ConVactual 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 Period (see Attachment A)after the Due Date shall be allowed to the Group for payment of tRe
monthly Contractual Rates. If Premera Blue Cross does not receive paymenYby the end ofthe Grace
Period, the Contract may automatically tertninate on the Due Date. No benefits will be paid for othenvise
eligible expenses incurred on any day for which payment has not been made. If a partial payment has
been received, Premera Blue Cross may, at its discretion, retum the payment or provide benefits for
those Members for whom payment tias been made. Acceptance by Premera Blue Cross of late or partial
payment sHall not be construed as a waiyer of Premera Blue Cross'sright to demand timely payment or
to terminate this Contract for nonpayment if a subsequent payment ig late.
G. Late Charges
Premera Blue Cross reserves the right to invoke the provision below forall groups covered by this Fully
Insured funding arrangement. Premera Blue Cross will notify all.such groups 30 days in advance of the
date that Premera Blue Cross will begin 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 Rremera Blue Gross 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 4he 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 bank during the Contract Term, plus two (2)percent on the amount of
the late payment for the number of days late. Late charges will not be assessed against anypaitial
payment tFiat Premera Blue Cross retains. Late charges are in addition to Contractual ReVenue and they
are calculated and billed at the end of the Contract Term orupon termination of the Contract, if earlier:
D. Customization Fees
Customization Fees for custom benefits that take effect on the effective dateshown on the Face Page of
this ConVact are due and payable prior to that effective date. Customization Fees for off-anniversary
benefit changes are due and payalile 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 Ieast the minimum percentage of eligible employees that is shown in
Attachment A must be enrolled.
B. When a percentage of the Contractual Rate is shown in Attachment A, th;e Groupmust pay at least the
minimum percentage of the Contractual Rate fordependents, if any is shown in Attachment A. At least
the minimum percentage of the eligible dependents, if any is shown in Attachment A, must be enrolled.
C. If the 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 a�e individuals who satisfy tlie Contract's eligibility
requirements, ezcept for any contribution requirement.
Premera Blue Cross resenies 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 tlie Group
Gontract.
-3-
Y. .ACCOUNTING
A. Accounting
No annual or Flnal accountings will be performed. Except for refunds required by law, Premera Blue
Cross will absorb any gains and losses.
B. Reporting
Within one hundred rivenry(120)days of the end of fhe Contract Term, Premera Blue Cross shall provide
infortnation to the Group for preparing Form 5500's when such forms are required by law. The Group
shall be solely responsible for insuring timely filing of the Form 5500's.
VI. CONTRACT TERMINATION
This Contract can be terrninated as descritied in "Contract Tertnination"in tFie"WHen Will 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 ConVact Term as Premera Blue Cross deems necessary.
-4-
ATTACHMENT A
to the Fully Insured Funding Arrangement Agreement
between
PREMERA BLUE CROSS
and
CITY OF AUBURN
Effective:. 1-Jan-2018 through,31-Dec-2018
GRACEPERIOD
Ten p0)Days
BROKERACE FEES AND COMMISSIONS
The Contractual Rates include brokerage fees and commissions equal ro 0.00 percent o£the Conrcactual Rare.
.. . ... . _ . . . ... ..._ .__ . . ..
CONTRACiUAL RATES(MONTHLY SUBSCRIP"CION CHARGES)
The monthly Connactual Rates for the Contract Period are as follows:
�Group�No. 4007473
Rate Classificatlon
E ES ESC1 ESC2+ F�C� EC2+
Actives $802.86 $1,61232 $1,974.91 $2,26333 $I,I65.45 $1,453.87
Early Retirees $1,179.37 $2,359.46 $3,490.54 $4,613.55 $2,310.45 $3,433.46
CONTRIBOTION AND PARTICIPATION REQUIREMENTS
. . .. . . . .. .. .. . . ..._ _.. ..
Employer
Contribution Participation
Employees 100% 100%
Dependen[s 90% 25%
ACCOUNTINGPROCEDURES
No annual accountings are perfortned under[his£unding artangemrnt Premera Blue Cross absorbs a0 gains and losses.
NUMBER OF ENROLLEES
Ttie Con[rac[ual Ra1es are based on Ihe following:
Number of Active Enrollees:
Employees Spouse ChHdren
292 190 308
Othercartiersoffered: KaiserNorthwest;DelfaDental,WillametieDentaI;VSP