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Home My WebLink About2023-160UNIMERICA INSURANCE COMPANY SUBSEQUENT POLICY PERIOD OFFER REVISED SPPO NO AGG Employer: INDIAN RIVER CNTY BOARD OF COI Effective Date: OCTOBER 01, 2023 Producer: DAVID PAVLYUK Underwriter: DONNAABERNATHY Sales Reps: BRIAN DUDZIK, SONYA LATTIMORE Date: 08/07/2023 SPECIFIC COVERAGE Option 1 Specific Deductible Amount $300,000 Aggregating Specific Deductible $100,000.00 Specific Maximum Unlimited COMPOSITE 1,685 $58.82 Total Premium 1,685 $1,189,340.40 Commission 0°% Benefits Covered MED/RX Specific Contract Basis 36/12 CONDITIONS AND ASSUMPTIONS -The Subsequent Policy Period Offer is based on data submitted, plus other information furnished relevant to underwriting the risk, including all claims or possible claims, paid, pending or denied pending additional information, or which the employer or its authorized representative should otherwise be aware of. Any inaccuracy in the data submitted or failure to disclose any such information can change the terms, conditions, rates or factors of this offer or can void the offer and coverage. -The CURRENT plan has been quoted. -The Plan will have Network: BCBS Case Manager: BCBS TPA: BCBS FL PBM: Express Scripts - Rate Cap provision is included that will guarantee your Subsequent Policy Period beginning 10/01/2024 will not contain any new lasers. In addition, the Specific Monthly Premium Rate and Aggregating Specific Deductible (if applicable) will not increase more than 50% The Rate Cap will not apply if the Company determines there is a material change to the Policyholder's Plan, the Excess Loss Policy, or the composition of the group. Continuation of the Rate Cap will be assessed annually. - Retirees ARE considered Covered Persons for benefits under the Excess Loss Policy. - All reporting should include COBRA enrollees and COBRA eligible individuals in their waiting period. - The rates and/or factors may change as of the date the Policyholder adds or deletes a subsidiary or affiliated companies or divisions, as outlined in the Policy. - Other compensation or bonuses may be indirectly reflected in this quote. Contact your broker/agent if you have any questions relatinc to their compensation for this offer. This document may contain Protected Health Information (PHI) and should only be shared with individuals designated to view such information per HIPAA regulations. In executing this form, the employer or its authorized representative, is acknowledging acceptance of the new rates, factors and terms. The employer or its authorized representative further acknowledges that all material facts, terms and conditions stated in the employers plan document and the Policy/Agreement remain unchanged and in full force and effect, unless noted above. - Claims that exceed the Specific Deductible up to the stated Aggregating Specific Deductible are not eligible claims under Specific or Aggregate coverage. - Expedited Reimbursement is available at no additional cost. This offer includes, at no additional cost, the IRO Extended Liability Endorsement which provides a 12 -month extension of coverage for any paid claim that is denied and subsequently overturned by an IRO upon appeal. - Experience Refund is not included in the above specific rates. Pursuant to the Consolidated Appropriations Act of 2020, note that Company is not, and nothing in this Policy shall be understood, construed, or interpreted to establish Company is, acting as a fiduciary for Policyholder. ��tiUntil we obtain the signed Subsequent Policy Period Offer, the rates and factors are subject to change as additional .1MlSS/p�,�•.• information is received. This Offer is valid for the stated effective date noted above provided the employer or its authorized,y ,• ' representative elects one of the above options, signs the acknowledgment and we necejue44k competed gffer by 811812W- & ODtions Elected Attest: Ryan L. Butler, Clerk of Ci • Court and Comptroller Dqxft Clark APPROVED AS TO Foii-im ANCL S FI y BY _ DEPUTY c OUNTY AT- ORINEY RIVER UNIMERICA INSURANCE COMPANY A Stock Company Administrative Offices: 11000 Optum Circle, Eden Prairie, MN 55344 Phone: 1-800-454-0233 APPLICATION FOR EXCESS LOSS INSURANCE The undersigned Applicant requests the Excess Loss Insurance Benefits shown herein and provided by Unimerica Insurance Company, and agrees to be bound by the terms and provisions of the Excess Loss Insurance Policy. Full Legal Name of Applicant: Indian River County Board of County Commissioners Address: 1800 27'" Street, Vero Beach, FL 32960 Key Contact: Suzanne M. Boyll Telephone: 772-226-1402 _ Tax ID: 59-6000674 Applicant is a: ❑ Corporation ❑ Labor Union ❑ Partnership ❑ Association ❑ Proprietorship ® Other: County Gement Nature of Business of the Group to be Insured: County Govemment _ _ Requested Effective Date: October 1, 2022 Total number of eligible persons: Employees: , 38q Retirees: ZSR Are retirees covered: ® Yes ❑ No. Affiliates or Subsidiaries: Addresses of Affiliates or Subsidiaries: Full Name of Administrator: Blue Cross and Blue Shield of Florida Pharmacy Benefit Manager: RxBenefits, Inc. / ESI Address: 4800 Deerwood Campus Parkway, Jacksonville, FL 32246 Key Contact: Jaddyn LoDuca Telephone: 727-643-2950 Agent or Broker: Lockton Companies Tax ID: ---- Address: jloduca@lockton.com SPECIFIC EXCESS LOSS INSURANCE ® Yes ❑ No Benefit Period: Covered Expenses Incurred from October 1, 2021 through September 30, 2023 and Paid from October 1, 2022 through September 30, 2023. Specific Deductible: per Covered Person: $300,000 Specific Percentage Reimbursable: 100% Maximum Specific Benefit per Covered Person: ® Unlimited ❑ Other Covered Expenses under Spec Excess Loss: ® Medical ® Stand Alone Prescription Drug Program Common Accident Provision: N Yes ❑ No I Lescnption: I Specific Premium Rates per month I 62.51 Specific Accommodation Reimbursement Endorsement ❑ Yes ® No Specific Step -Down Deductible Endorsement ❑ Yes ® No Specific Terminal Liability Endorsement ❑ Yes ® No Aggregating Specific Deductible Endorsement ® Yes ❑ No $100,000 Independent Review Organization Extended Liability Endorsement ® Yes ❑ No UMERAPP (01/12) AGGREGATE EXCESS LOSS INSURANCE: ® YES ❑ NO Benefit Period: Covered Expenses Incurred from October 1, 2021 through September 30, 2023, and Paid from October 1, 2022 through September 30, 2023. Covered Expenses under Aggregate Excess Loss Coverage: ® Medical ❑ Dental ❑ Vision ® Stand Alone Prescription Drug Program Aggregate Percentage Reimbursable: 100% ❑ Other (Please Specify) Maximum Aggregate Benefit: ❑ $500,000 ® $1,000,000 ❑ Other Minimum Annual Aggregate Deductible: $26,841,688 or 95% of the first Monthly Aggregate Deductible amount times 12, whichever is greater. Maximum Covered Expenses per Covered Person accumulating toward the Maximum Aggregate Benefit: $300,000 Aggregate Excess Loss Premium: $ 3.06 per Employee per month Aggregate Terminal Liability Endorsement: ❑ Yes ®No Aggregate Accommodation Endorsement: ❑ Yes ® No Independent Review Organization Extended Liability Endorsement ® Yes ❑ No Monthly Aggregate Factors: Covered Persons Medical Prescription Drugs Composite $1.426.99 Included It is understood and agreed by the undersigned that: 1. The statements, declarations and representations made in this Application, any request for proposal, the underwriting information provided by or on behalf of the undersigned and the Plan Document are the undersigned's representations; that any Policy is issued in reliance upon the truth of such statements, declarations, and representations; and that such statements, declarations, and representations will form a part of the Excess Loss Insurance Policy. Any inaccuracy in such information or failure to disclose any such information, including all claims or possible claims, paid or pending, or which the Employer should otherwise know about, if discovered later, can result in rejection of this Application, or can change the terms, conditions or premiums, or can void coverage. 2. As a condition precedent to the approval of this Application, the undersigned shall furnish to the Company a copy of the executed Plan Document within 90 days after the date of this application describing the benefits provided by the Plan, which shall be kept on file in the office of the Company. If the Company does not receive the Plan Document within 90 days, the Company may refund all premium and the Application shall have been null and void when signed. No Excess Loss Insurance will be effective nor reimbursement made unless a Plan Document is received and accepted by the Company. 3. The Company will evaluate the undersigned's risk, as requested by this application, the underwriting data received and represented by the Plan and may require adjustments of rates, factors, and/or special limitations. 4. Any coverage resulting from this Application shall be subject to the terms and provisions of the Policy herein applied for. Coverage shall become effective on the date specified in this Application if all requirements of the Company, including the Plan Document and the underwriting requirements have been met and the required premiums paid. 5. The receipt by the Company of the first month's premium and deposit of any check drawn in connection with this Application shall not constitute an acceptance of liability. In the event the Company does not approve this application, its sole obligation shall be to refund such sum to the undersigned. 6. The undersigned will provide or employ an Administrator to administer the Plan and to process and pay claims according to the Plan Document. The undersigned acknowledges that the Administrator is the undersigned's agent and not the agent of the Company and that statements and answers given by the Administrator are binding on the undersigned. 7. Other: Rate Cap provision is included that will guarantee your Subsequent Policy Period beginning October 1, 2023 will not contain any new Specific Deductible greater than the group's standard Specific Deductible for any covered person. In addition, the Specific Monthly Premium Rate and Aggregating Specific Deductible (if applicable) will not increase more than 50%. The Rate Cap will not apply if the Company determines there is a material change to the Policyholder's Plan, the Excess Loss Insurance Policy, or the composition of the group. Continuation of the Rate Cap will be assessed annually. UMERAPP (01/12) The undersigned has read the entire Application for Excess Loss Insurance and understag %4� jnsurance requested herein is not in effect until this Application is approved and accepted by the Company.., k0 Ssip^✓�, Full Legal Name of Signature of Authorizcd Person: Print Name: Peter D. O'Bryan Title: Chairman D. •. Date: September 13, 2022 Signature of Agent or Broker: Print Name of Agent or Broker: FRAUD WARNING NOTICES: (Please review notice that applies in your state) `R couri� For applicants in Arkansas, Louisiana, New Mexico and Rhode Island: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance, is guilty of a crime and may be subject to fines and confinement in prison. For applicants in Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, Incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds, shall be reported to the Colorado division of insurance within the Department of Regulatory Agencies. For applicants in District of Columbia: WARNING: It Is a crime to provide false or misleading information to an insurer for purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the application. For applicants in Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information Is guilty of a felony of the third degree. For applicants in Kentucky, New Mexico, Ohio, and Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits it fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. For applicants in Maine, Tennessee and Virginia: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits. For applicants in New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. For applicants in all other states: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may Include imprisonment, fines, or a denial of insurance benefits. Atteat:.tef M R. Smith, Clerk -rn FORM Cir Court and Corr>ptroller _ ,. "" l . • 0 UMERAPP (0112) ~ oevuvcanc COUNTV., i—TORNEY EXPEDITED REIMBURSEMENT AGREEMENT August 15, 2022 Indian River County Board of County Commissioners Upon receipt of your signature below, Optum agrees to expedite reimbursement of a potential Specific claim prior to adjudication by the Administrator under the following conditions: 1) Client submits a request, including claimant name and amount of reimbursement being requested, for a potential claim accompanied by a Blue Cross/Blue Shield, Aetna, Cigna report(s) and/or PBM report outlining the paid and/or pending claims included in the request. 2) Covered Expenses exceed the Specific Deductible by $10,000 or greater initially, and $5,000 or greater for subsequent expenses. 3) Administrator and/or the Client will provide complete and detailed information regarding the potential claim to Optum by the end of the following month in which the reimbursement request is made. 4) If Optum determines the claim is not eligible under the Specific Excess Loss Insurance, the Client understands and agrees that Optum will offset the amount reimbursed against future claims. In the event there are no future claims, the Client agrees to repay the expenses reimbursed within 30 days of Optum's request. 5) This agreement may be terminated at any time by Optum upon written notice.t-e4t '-b •*,, Signature of Authorized Peran ;qQ -�o�• � .•oma;' Peter D. O'Bryan •syOrwha @: Chairman C Q-lu Printed Name September 13, 2022 Date 'ro FORML Attest: Jeffrey R. Smith, Clerk of Circyil, Court and Comptroller 6`:'Dyk - -'- i COt.�[�TY;'l-TOR€ar=S' Deputy Clerk Optum EASY REPORTING AGREEMENT August 15, 2022 Indian River County Board of County Commissioners Upon receipt of your signature below, Optum will implement Easy Reporting for potential Specific claims. The following will apply: Optum will identify claims for reimbursement as a courtesy based on detailed paid claim reports submitted by the Administrator(s) and/or PBM(s). Please note that responsibility for identifying and submitting claims remains the Client's responsibility. Optum will reach out to the designated stop loss contact(s) on file, if necessary, to obtain additional information, including, but not limited to: - Eligibility documentation, work status, COBRA - Other insurance coverage - Accident details/subrogation - Any other information deemed necessary in order to fully adjudicate the stop loss claim Claim submissions whether identified by the Administrator(s), the Client, the Broker or Optum will be subject to the timely filing provision as outlined in the stop loss policy. All claim submissions/paid claim reports must be submitted within 12 months after the end of the Benefit Period in order to be eligible for reimbursement under the stop loss policy This agreement may be terminated 9OWW"01 Optum upon written notice. w J : 5Q Signature of Authorized Pers?o'.. Q: Peter D. O'Bryan ••4y9��'FR GOU�� oa •"7itle: Printed Name September 13, 2022 Chairman Date APPpokl=-t) .A'1 'TP9 FORM A:E�t L.:,: -.AL S..:FE-ICIENCY Attest: Jeffrey R. Smith, Clerk of B Circuit Court and Comptroller z 3`i i_;3.�! 1E1Ni�CJi_C� O OUN•TY Ai'T0RNEY Br.. ok Deputy Ciark