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Home My WebLink About2016-130i Flo%W4&B440 d An Independent Licensee of the STOP LOSS PROPOSAL FOR Blue Cross and Blue Shield Association Indian River County Board of County Comm Sales Representative: George Eppl Effective Date: 10/01/2016 Broker: Gehring Group Inc Through Date: 09/30/2017 TPA: Florida Blue Provider Network(s): Florida Blue Utilization Review Vendor(s): Florida Blue Specific: (Check one) Lives Current 0 Renewal 0 Option I Option Specific Deductible(per Covered Individual) i $300,000 $300,000 $325,000 $350,000 Policy Year Maximum Specific Benefit j Inforce Unlimited Unlimited Unlimited Lifetime Maximum Specific Benefit Inforce Unlimited Unlimited Unlimited Covered Benefits Med,Rx Card Med,Rx Card , Med,Rx Card Med,Rx Card Specific Premium Composite Rate 1,635 $22.02 + $24.00 $21.67 $20.02 Total Lives 1,635 Estimated Contract Specific Premium $432,032 $470,880 $425,165 $392,792 Contract Aggregating Specific Loss Fund ! $148,750 $148,750 $148,750 $148,750 Contract Basis 24/12 -36/12 36/12 f 36/12 Commission 10.00% 10.00% 10.00% f 10.00% Aggregate: (Include? 0 Yes No) Covered Benefits Med,Rx Card Med,Rx Card Med,Rx Card Med,Rx Card Policy Year Maximum $1,000,000 $1,000,000 $1,000,000 ( $19000,000 I Aggregate Factors Composite Med&Rx Card Factor 1,635 $1,010.54 $1,082.25 $1,085.50 $1,088.75 Estimated Contract Attachment Point 1,635 $19,826,795 $21,233,745 $21,297,510 $21,361,275 Contract Minimum Attachment Point(100%) $19,826,795 $21,233,745 $21,297,510 $21,361,275 Aggregate Corridor 125% I 125% 125% I 125% Contract Basis 24/12 36/12 36/12 36/.12 { Aggregate Premium Composite Rate 1,635 ! $1.47 $1.56 $1.59 $1.61 Estimated Contract Aggregate Premium 1,635 $28,841 $30,607 $31,196 $31,588 Commission 1000% 10.00% 10.00% 10 00% Total Combined Estimated Contract Premium $460,874 $501,487 $456,361 $4249380 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 8,2016) 10500541335-2016-503868-6-4 Page 1 of 4 An Independent Licensee of the STOP LOSS PROPOSAL FOR Blue Cross and Blue Shield Association Indian River County Board of County Comm PROPOSAL NOTES • The rates and factors in this proposal are firm. Please provide a signed proposal. • Large claim data must be submitted for any claims that are at or have the likelihood to exceed 50%of the group specific deductible.Large claim data must include:age,sex,diagnosis,prognosis,treatment plan,case management notes(if applicable),Pre-Cert and paid/pended claims. • The speck 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 by 08/29/2016(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 All payments after the effective date of this policy,found on the previous page,must use the rates selected. Any deviation from the rates specified could result in an underpayment leading to a possible policy cancellation. BOARD OF COUIVPY COMMIISSIIONERS OF INDIAN �CO`t�J�-C Signature: CLaw.NZY Title: Chairman Bob Solari Accepted on the 16th day of August ,20 16 •.•'tai G� SS'' • �a, • •• io' . ATTEST: Jeffrey R. Smith, Clerk of Court and Ccmptroller i*' • ',a BY: De uty Clerk :9y, f •Q��• •.9�`FR COUNTo•• Underwriter-REB(August 8,2016) 10500541335-2016-503868-6-4 Page 2 of 4 An Independent Licensee of the STOP LOSS PROPOSAL FOR Blue cross and Blue shield Association Indian River County Board of County Comm - BASIS OF OFFER initials* Q'1�date August 16, 201E 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. • Surcharges(including the bad debt and charity surcharge portion of the New York Reform Act applicable to services are rendered in New York State),pool charges,and/or covered lives assessments may be covered under the stop loss policy if such charges are considered a claim cost. HM is not responsible for the filing,and/or payment of any assessment for which HM is not directly liable including but not limited to the New Hampshire Vaccine Assessment as modified by NH HB 664. • 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 Specific Benefit Maximum. • The Agent is property 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 • Any stop loss insurance requested and requested effective date of that coverage must be approved by us under our current rules and practices. • Both the premium rates and the aggregate factors are subject to change should the number of employees change by 10%or more,either in total and/or by single/family mix. • If the descriptions of the benefits or plan provisions differ from what was initially utilized to underwrite the risk,an updated Plan Document or other acceptable plan description is required within 30 days of the proposed effective date,and 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"Healthcare 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. Coverage is underwritten by Florida Blue,Jacksonville, FL and is administered by HM Life Insurance Company,Pittsburgh, PA. HM Life Insurance Company is an independent company providing only administrative services. Underwriter REB(August 8,2016) 10500541335-2016-503868-6-4 Page 3 of 4 i An Independent Licensee of the STOP LOSS PROPOSAL FOR Blue Cross and Blue Shield Association Indian River County Board of County Comm • 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. • Any stop loss policy issued by us may be rescinded or re-underwritten if any information requested in connection with this proposal was intentionally concealed or misrepresented by or on behalf of the Applicant and/or the Applicant's Agent,or if the Applicant and/or the Applicant's Agent commits fraud. • As used above: An"Agent"is the Applicant's representative,including but not limited to,the agent,producer or broker of record,or Claims Administrator The"Applicant"is the entity,or that entity's authorized representative,that has contracted with us to provide stop loss coverage. A "Claims Administrator"is a third party administrator(TPA)designated by the Applicant and approved by us. "Claim Information"consists of Complete Details of the data requested by us in connection with this proposal following a Diligent Review;such information includes but is not limited to Know or potential catastrophic claims,large claims and/or shock losses. "Complete Details"includes the name,social security number (or unique identifier),date of birth,diagnosis,prognosis(unless prognosis cannot be obtained due to reasons beyond your or your Claims Administrator's control)of the plan's participants and the name of the provider providing treatment to any such participant covered by or eligible for coverage. A"Diligent Review"consists of a complete review by you,and/or your Claims Administrator and/or your Agent prior to the date Known or potential catastrophic claims,large claims and/or shock losses are requested by us in connection with this proposal. "Disclosure"consists of Complete Details and any other documentation requested by us in connection with this proposal following a Diligent Review including but not limited to census information and Claim Information. We consider information in connection with this proposal"Known"if,prior to the date or dates we request such information(including but not limited to Disclosure and Claim Information)a reasonable person can assume that you, and/or your Claims Administrator and/or your Agent had knowledge of any information that affects or may affect the administration or underwriting of any coverage issued following acceptance of coverage by us. Coverage is underwritten by Florida Blue,Jacksonville, FL and is administered by HM Life Insurance Company,Pittsburgh, PA. HM Life Insurance Company is an independent company providing only administrative services. Underwriter REB(August 8,2016) 10500541335-2016-503868-6-4 Page 4 of 4