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Home My WebLink About2012-160 q ' IU' I � 1I`t i STOP LOSS PROPOSAL FOR 8 . Indian River County Board of County Comm �� /a _ �� L ' FE ' " sup ;, " cE 001.1I'ANY PROPOSAL NOTES • The rates in this proposal are firm . Please provide a signed proposal , binder check and signed application . • The specific rates in this proposal are based on an aggregating specific arrangement. Total Specific Liability includes estimated contract specific premium and the aggregating specific fund . • Human Organ Transplant benefits are payable in accordance with the underlying plan and are subject to the proposed Lifetime Maximum Specific Benefit offered within this proposal . PROPOSAL ACCEPTANCE Please acknowledge acceptance of the terms in this proposal by signing and returning within 30 days (no signed proposal will be accepted after the effective date) . Please also indicate which option is chosen and whether Aggregate is to be included , by checking the appropriate boxes on the previous page . Failure to remit the signed agreement within the same period will result in updated large claim disclosure (and claims) being required for our review. SignatureTitle : /)�Yii44 �> 1)j'19 lc; r - Accept /onthe day of 1` '20 4 Stop Loss coverage is underwritten by HM Life Insurance Company . Pittsburgh . PA , under policy form HL 601 (905 ) or similar, in certain states the requested coverage may not be available . As included herein , " HMIG " refers to the Stop Loss carrier . Underwriter. REB (August 16 . 2012 ) 1011 52722-2012 -225125 -2-2 Page 2 of t STOP LOSS PROPOSAL FOR , I IL LIFE INSURAW E Indian River County Board of County Comm cxmT;ANY initials : date : (? � � - BASIS OF OFFER Assumptions • Aggregate coverage is only available when purchased with Specific coverage . • This proposal is subject to revision if there is a change in effective or renewal dates , or a change in the plan of benefits . • This proposal is based on the utilization of the Provider Network (s) and the Utilization Review Vendor(s) listed on this proposal . . This proposal assumes a minimum participation level of 75 % applies for all eligible enrollees under a contributory plan , and 100 % under a non - contributory plan . • This proposal assumes the plan of benefits includes a pre-certification , utilization review and large case management program . • This proposal is based on a description of the employee benefit plan (s) provided and approved by HMIG , employee and dependent census data , submission of any requested claim information , plus any other information relevant to the underwriting risk . If any of the information was incorrect or changes the risk involved , the rates and factors will be modified , and the specific and aggregate claims will be adjusted accordingly. The bad debt and charity surcharge portion of the New York Reform Act will be considered an eligible claim expense under the stop loss policy if services are rendered in New York State . Other surcharges , pool charges and/or covered lives assessments will not be covered under the stop loss . • All standard Policy provisions apply . The laws of the state where the policy is issued will apply . Certain exclusions and limitations may apply . • Retirees are included in the stop loss coverage . . This proposal will expire on the proposed effective date . • Unless otherwise limited or excluded by the stop loss policy or under the Individual Special Requirements , eligible claim expenses under the stop loss policy will follow the covered underlying plan , up to the proposed Lifetime Maximum Specific Benefit. • The Agent is properly licensed and appointed by HMIG . • The initial rates are guaranteed for the proposed policy period unless otherwise noted . There are not more than 15 % COBRA participants . Qualifications • Completed Disclosure Form , Application , first month's premium check , signed proposal , final census , and any other required information as stated under the Assumptions or Individual Special Requirements , must be received prior to the proposed effective date . Information contained on the Disclosure Form should be current up to the date of signature , and be completed in its entirety. Failure to do so will result in approval being denied or delayed until a later effective date . • The premium rates are subject to change should the number of employees change by 10 % or more , either in total and/or by single/family mix. A signed and dated Plan Document is required within 30 days of the effective date . If the descriptions of the benefits or plan provisions differ from what was initially utilized to underwrite the risk, the premium rates and aggregate factors may be subject to re-rating , retro-active to the effective date . • Quote assumes the Plan Document will include traditional industry provisions and definitions including , but not limited to the following : eligibility , HIPAA, termination provisions , extension for leave of absence or disability, FMLA, subrogation , transplants , COB , exclusions for job related injuries , experimental and cosmetic treatment, usual and customary charges , war, not medically necessary, traveling outside of the U . S. solely for the purpose of receiving medical care . In the event that a Plan Document is not available within 30 days from the proposed effective date , we reserve the right to issue the Policy assuming standard exclusions will apply. HIPAA Privacy rules permit the release of Protected Health Information ( PHI ) for the purpose of evaluating and accepting risk associated with the Plan Sponsor as part of " Health care operations" . HMIG will use this information solely for the purpose of evaluating and accepting the risk and will not disclose any PHI collected except to perform this risk evaluation . The rates and factors in this proposal are based on the disclosure of all individuals considered a special enrollee due to having previously satisfied the plan ' s lifetime maximum . Written acceptance by HM must be acknowledged before terms of coverage for such individuals are included under HM's stop loss policy. Undervvriter . REB ( August 16 . 2012 ) 10176052722 - 2012 - 225125 - 2 - 2 � � � 3 of STOP LOSS PROPOSAL FOR WIL mo , ` LIFE INSURANCE Indian River County Board of County Comm COMPANY Sales Representative : Ronald Brodeur Effective Date : 10/01 /2012 Broker: Gehring Group Inc Through Date : 09/30/2013 TPA : Blue Cross Blue Shield of Florida Provider Network(s) : Blue Cross Blue Shield of Florida Utilization Review Vendor(s) : Blue Cross Blue Shield of Florida Specifics (Check one) Lives pl, Option 1 . N Option 2 M Option Specific Deductible (per Covered Individual) $ 250 , 000 $275 , 000 $ 300 , 000 Policy Year Maximum Specific Benefit Unlimited Unlimited Unlimited Lifetime Maximum Specific Benefit Unlimited Unlimited Unlimited Covered Benefits Med , Rx Card Med , Rx Card Med , Rx Card Specific Premium Composite Rate 11565 $ 17 .45 $ 15 . 17 $ 13 . 50 Total Lives 11565 Estimated Contract Specific Premium $ 327 , 711 $284 , 893 $ 253 , 530 Contract Aggregating Specific Loss Fund $ 148 ,750 $ 148 , 750 $ 148 , 750 Contract Basis 24/12 24112 24/ 12 Commission 9 . 80 % 9 . 80 % 9 . 80 % Aggregates (include? 4 Yes 0 No) Covered Benefits Med , Rx Card Med , Rx Card Med , Rx Card Policy Year Maximum $ 1 , 000 , 000 $ 1 , 000 , 000 $ 1 , 000 , 000 Aggregate Factors Composite Proposed Factor 11565 $ 815 . 36 $ 819 .44 $ 822 . 70 Estimated Contract Attachment Point 11565 $ 15 , 312, 461 $ 15 , 389 , 083 $ 15 ,450 , 306 Contract Minimum Attachment Point ( 100 %) $ 151312 , 461 $ 15 , 389 , 083 $ 15 , 450 , 306 Aggregate Corridor 125 % 125 % 125 % Contract Basis 24112 24/12 24/ 12 Aggregate Premium Composite Rate 11565 $ 1 . 97 $ 2 . 01 $ 2. 06 Estimated Contract Aggregate Premium 11565 $ 36 , 997 $ 37 ,748 $ 38 , 687 Commission 11 . 20 % 11 . 20 % 11 . 20 % Total Combined Estimated Contract Premium $364,708 $322 , 640 $292 , 217 Note : This proposal is not complete unless accompanied by the proposal notes and the basis of offer noted on the following pages . Individual Special Requirements : Underwriter REB ( August 16 . 2012) 10176052722 -2012 -225125 - 2-2 Fagg 1 at 3