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HomeMy WebLinkAbout2024-207An Independent Licensee of the STOP LOSS PROPOSAL FOR Blue Cross and Blue Shield Association Indian River County Board Sales Representative: George Eppl Proposed Effective Date: 10/01/2024 Broker: LOCKTON COMPANIES LLC Through Date: 09/30/2025 Claims Administrator: Blue Cross Blue Shield of South Carolina RFP Situs State: FL Provider Network(s): BCBS of SC Utilization Review Vendor(s): Blue Cross Blue Shield of South Carolina Retirees: Both Medicare Retirees and Under 65 Retirees Included Specific (Check one option) Lives 0 Opflon I r,4 Option 2 0 Option 3 0 Oplion 4 Specific Deductible (per Covered Participant) $275,000 $300,000 $325,000 $350,000 Policy Year Maximum Specific Benefit Unlimited Unlimited Unlimited Unlimited Lifetime Maximum Specific Benefit Unlimited Unlimited Unlimited Unlimited Eligible Claims Expenses Med, Rx Med, Rx Med, Rx Med, Rx Specific Premium Composite Rate 1,699 $56.95 $52.42 $46.34 $42.57 Total Lives 1,699 Estimated Policy Term Specific Premium $1,161,097 $1,068,739 $944,780 $867,917 Policy Term Aggregating Specific Loss Fund $100,000 $100,000 $100,000 $100,000 Specific Covered Claims Basis 36/12 36/12 36/12 36/12 Commission 0.00% 0.00% 0.00% 0.00% Specific Coverage Features/Options Accelerated Reimbursement Rate Cap 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: TLR (August 15, 2024) 11391839286-37516-2-2 Page 1 of 4 An Independent Licensee of the STOP LOSS PROPOSAL FOR Blue Cross and Blue Shield Association Indian River County Board PROPOSAL NOTES • The rates in this proposal are firm. Please provide a signed proposal and signed application. 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 Specific rates in this proposal are based on an Aggregating Specific arrangement. Maximum Specific Liability includes estimated Policy Term Specific premium and the Aggregating Specific fund. This proposal includes Accelerated Reimbursement. Human Organ Transplant benefits are payable in accordance with the Covered Underlying Plan and are subject to the proposed Lifetime Maximum Specific Benefit offered within this proposal. This proposal includes a 40% rate cap on the Specific Premium Rate at the renewal of your Stop Loss Policy. If applicable, this increase also will apply to the Aggregating Specific Loss Fund. The rate cap does not apply to Material Changes including, but not limited to, the following: Covered Underlying Plan, HM's Stop Loss Policy provisions, the PPO network or the Claims Administrator, and the rates may be further adjusted by such changes. The rate cap rider applies to this Policy Term only. It may be offered at subsequent Stop Loss Policy renewals at the discretion of HM Underwriting. At renewal, We will not apply any new lasers, including but not limited to, an Alternate Specific Deductible or Excluded Claim Expense, within the Special Risk Limitations section of the policy, unless requested. Lockton's standard required terms will not be automatically accepted. However, a Stop Loss Acknowledgement Form may be requested at the time of sale. PROPOSAL ACCEPTANCF To consider a group for coverage we will require submission of all underlying documentation regarding member eligibility and termination as well as the group Leave of Absence Policy. If there is no Leave of Absence Policy in place, we will require a statement from the Plan Sponsor stating there is no Leave of Absence available. Additionally, we will require an approved benefit book within 60 days of Benefit Book release by FL Blue for group approval. Please acknowledge acceptance of the terms in this proposal by signing and returning by 09/13/2024. Please also indicate which option is chosen by checking the appropriate box on the previous page. Failure to remit the signed agreement by 09/13/2024 will result in this prppo.M1 being considered expired. C0ht4��ss. Signature: title.•' Accepted on the 10th day of Sept 20 2 4 . COUNTY• APPROVED AS TO FORM AND LEG SUFFiCI'" Y BY .P O DEPUTY COUNTY ATTORNEY Attest: Ryan L. Butler, Clerk of Circuit Court and Comptroller c— By: eputy ca Coverage is underwritten by Florida Blue, Jacksonville, FL and is administered by HM Life Insurance Company, Pittsburgh, PA, HIM Life Insurance Company is an independent company providing only administrative services. Underwriter: TLR (August 15, 2024) 11391839286-37516-2-2 Page 2 of 4 Fkllftw& B&C 0 9 An Independent Licensee of the Blue Cross and Blue Shield Association BASIS OF OFFER STOP LOSS PROPOSAL FOR Indian River County Board initis ate: Q9 10 /2024 Assumptions • This proposal is subject to revision if there is a change in Proposed Effective or Renewal Dates or a change in the Covered Underlying Plan. • This proposal is based on the utilization of the Provider Network(s) and the Utilization Review Vendor(s) listed in this proposal. • This proposal assumes a minimum participation level of 50%. • This proposal assumes the Covered Underlying Plan 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 HM; employee and dependent census data; submission of any requested claim information; and any other information relevant to the underwriting risk. If any of the information was incorrect or changes the risk involved, the rates will be modified, and the Specific 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. • The terms of this proposal are subject to revision by HM if there is a change in any state law or regulation between the date of this proposal and the effective date of the proposed Stop Loss coverage if HM deems such change to have a material effect on the risk being assumed. Such a revision can be made even if the proposal has already been accepted. • 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 Maximum Specific Benefit. • The Agent is properly licensed and appointed by HM. • The initial rates are guaranteed for the proposed Policy Term unless otherwise noted. • There are no more than 15% COBRA participants. Qualifications • Any Stop Loss insurance requested and the Proposed Effective Date of that coverage must be approved by HM under Our current rules and practices. • Our approval is subject to receipt of Disclosure, Claim Information and any other information requested in connection with this proposal including, but not limited to, a 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. Such information 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 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 Covered Units change by 10% or more, either in total and/or by single/family mix. • A signed and dated Summary Plan Document is required within 60 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 may be subject to re -rating, retro -active to the Effective Date. • This quote assumes the Covered Underlying Plan will include standard industry provisions and definitions including, but not limited to, eligibility, HIPAA, termination, leave of absence or disability, FMLA, subrogation, transplants and COB and exclusions for job-related injuries, treatments that are experimental and/or investigational, cosmetic, not medically necessary, war, felonies, charges in excess of usual and customary, and foreign medical care when traveling outside of the U.S. solely for the purpose of receiving medical care. In the event that a Summary Plan Document is not available within 60 days from the Proposed Effective Date, We reserve the right to issue the policy assuming standard exclusions will apply. 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: TLR (August 15, 2024) 11391839286-37516-2-2 Page 3 of 4 F& r4& B& (e 0 C1 An Independent Licensee of the Blue Cross and Blue Shield Association STOP LOSS PROPOSAL FOR Indian River County Board 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." HM 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 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 HM 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 Policyholder and/or the Policyholder's Agent, or if the Policyholder and/or the Policyholder's Agent commits fraud. As used above: An "Agent" is the prospective Policyholder's representative including, but not limited to, the agent, producer or broker of record, or Claims Administrator. A "Claims Administrator" is a third -party administrator (TPA) designated by the Policyholder and approved by Us. Disclosure or Disclosed means to provide Claim Information and any other documentation or data requested by Us including, but not limited to, Census and Demographic Information and the estimated number of Covered Units prior to the beginning of the Policy Term. 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: TLR (August 15, 2024) 11391839286-37516-2-2 Page 4 of 4