Okaloosa County BOCC — June 17, 2014 — MedicareCarveOut — reading text

CONTRACT & LEASE INTERNAL COORDINATION SHEET Contract/Lease Number:_(_ O& - ) G%I - en Tracking Number: G2 [7 Grant Funded: YES NOX Contractor/Lessee Name: Bhs Onan) Purpose PV )p hee a xp Garnre- ond puke Date/Term: jo] 1/4 = val 30] 15 1, [Xt Greater THAN $50,000 Amount: 2. L] GREATER THAN $25,000 Department: Rain 3. L] $25,000 or Less 4 7) Dept. Monitor nome Slee ussen [Kel Document has been reviewed and includes any attachments or exhibits. Purchasing Review :) Procurement ecole ‘ pane//; wer Burchasitlg Director or Designee Pp ane kKbh L Risk Management Review Approved as writte I ee . f Yd Date: SY aot Sf anager or designee SET 7 Ah County Attorney Review Appfoved as writt&n: ,~ aw . Date: ( ~Y-( = Cunt Aor "Gores AT New U2 Following Okaloosa County approval: Contracts & Grants Document has been received: Date: Contracts & Grants Manager Florida Blue An Independent Licensee of the (True Group Application) Blue Cross and Blue Shield Association EMPLOYER APPLICATION [| New Business Renewal Business [_] Other | . Florida I. Group Information Bluse # (Florida |y1954 lue : HMO): A. Name of Group: [OKALOOSA CO BOARD OF CO COMMISSIONERS Nature of Business: |GENERAL GOVERNMENT, NEC | SIC Code: [9199 Mailing Address: [601A NORTH PEARL STREET, SUITE 204 CRESTVIEW,FL 32536. Email Address: | jtundy@co.okaloosa.fl.us | List below Subsidiary or Affiliated Companies whose employees are to be eligible and included with this application. Name Address E. Applicant hereby applies for issuance of a Group Policy (herein referred to as a Policy) by Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue and/or Health Options, Inc., D/B/A Florida Blue HMO. Upon acceptance of this application by Florida Blue and/or Florida Blue HMO, it will become part of the Policy issued to the applicant named above. Prior Insurance Carrier: Insurance |HUMANA HMO |No GROUP INSURANCE The Policy excludes expenses for any service or supply to diagnose or treat any Condition from or in connection with an Insured's job or employment (e.g., any service or supply which is covered by Workers’ Compensation insurance) except for medically necessary services (not otherwise excluded) for an individual who is not covered by Workers’ Compensation and that lack of coverage did not result from any intentional action or omission by that individual. The foregoing exclusion applies to an individual who elects exemption from Workers’ Compensation coverage and to an individual who foregoes Workers' Compensation coverage available to employees in the Group. Workers Compensation Carrier is: [SELF INSURED II. Effective Date/Eligibility Information A. B. C. Effective Date of this Policy shall be 10/01/2000 Effective Date of this Change to the Policy shall be 10/01/2014 This Policy may be terminated by the applicant or Florida Blue/Florida Blue HMO by giving at least 45 days prior written notice to the other party except in the case of non-payment of Premium. Only eligible employees who regularly work a minimum of hours each week and their eligible dependents, shall be eligible for coverage upon the Effective Date of this Policy. Specify classification of enrollees for whom coverage is being requested, if other than eligible employees as described in B above. Eligibility - Full Time Employees - Ist of the Month 30 Days / Dept Heads - Ist of the Month following DOH D. New eligible employees may be covered effective on the 1st of the month __| after |See Spec Ins of employment, so long as the eligible employee submits an application to Florida Blue/Florida Blue HMO within 30 days of the date the individual first meets the applicable eligibility requirements. At least % of the eligible employees must be enrolled under the Policy on the Effective Date and throughout fhe ferm of the Policy and the Group must meet and continue to meet Florida Blue/Florida Blue HMO participation requirements. Florida Blue/Florida Blue HMO shall have the right to audit the applicant's payroll records at any time to confirm eligibility for coverage, including participation percentage criteria required by Florida Blue/Florida Blue HMO. 13123-0813R 05/27/2014 days 3:31:32 PM Florida Blue GV An Independent Licensee of the Blue Cross and Blue Shield Assaciation EMPLOYER APPLICATION (True Group Application) Applicant agrees to furnish any such request. G. Employer Contribution: Employee: % Dependents: [90 ] % III. Health Plan Summary Information (select the appropriate box[s]): Included in Product Accept Decline Bx) Bx) Bx) Bx) OOOO 0 O 0) O Mandated Benefit Offerings:(Optional) Applicant has been advised of the following benefit offerings mandated by the Federal and/or State Law. Applicant's decision to accept or decline these benefits is indicated below. Mental & Nervous Disorder Alcohol and drug dependency Mammograms Waiver of Deductible & Coinsurance Enteral Formulas [x] Single Plan C] Blue Packages Health Plan Name Rx Option (indicate copayments) STD | | BlueSeript I $15/SS0/S80C - NSTD Benefit Period : {01/01/2014 - 12/31/2014 Coinsurance: In-Network / Participating Out-of-Network/Non-Participating Office Visit Copay: | Family Physician Employee|s457.60 Employee/Spouse Spouse [N/A | Child(ren) |[BlueOptions Physician Copay Plan 03559 - Deductible : Per Person {$500 / $750 Per Family [$1,500 / $2250 Pre-Existing [N/A Rates All Other Providers Employee/Child(ren) [ s0.00 | Family [80% 120% {60% / 40% |s20 [s40 | $1,029.64 $915.24 | N/A Spouse/Child(ren) N/A | Employee + 1 [$915.24 13123-0813R 05/27/2014 3:31:56 PM Florida Blue BV An Independent Licensee of the Blue Cross and Blue Shield Association fx] Single Plan EMPLOYER APPLICATION (True Group Application) C] Blue Packages Health Plan Name Rx Option (indicate copayments) [BlueOptions Network Advantage Plans 03769 - Cust [BlueScript 1 $15/$50/$80C - NSTD Benefit Period : |o1/01/2014 - 12/31/2014 Coinsurance: Deductible : In-Network / Participating [80% / 20% Per Person {s500 / $1,500 Qut-of-Network/Non-Participating {50% 150% Per Family {$1,500 / $4,500 | Office Visit Copay: Pre-Existing [N/A Family Physician [525 Rates All Other Providers Family [so Employee| $428.33 | Employee/Spouse Employee/Child(ren) | $0.00 Spouse [N/A Child(ren) N/A Spouse/Child(ren) [N/A | Employee + 1 [3856.70 | [x] Single Plan CT] Blue Packages Health Plan Name Rx Option (indicate copayments) |[BlueOptions Family Physician Plan 3361 - NSTD | |BlueScript I $15/S50/$80C - NSTD | Benefit Period : [01/01/2014 - 12/31/2014 Coinsurance: Deductible : In-Network / Participating 75% 125% Per Person {$2,000 / Combined w/ In-Network | _Out-of-Network/Non-Participating [50% / 50% Per Family {$6,000 / Combined w/ In-Network | Office Visit Copay: Pre-Existing [N/A | Family Physician 530 Rates All Other Providers DED + Coinsurance Employee| $390.87 | _Employee/Spouse [s0.00 | Employee/Child(ren) [ $0.00 | Family $879.52 Spouse | N/A Child(ren) N/A Spouse/Child(ren) | N/A Employee + 1 | $781.78 See the Group Master Policy for a complete description of benefits. IV. Health Savings Account (HSA), Health Reimbursement Arrangement (HRA) or Flexible Spending Account (FSA) A. Are you choosing BCBSF'’s integrated HSA, HRA or FSA preferred administrator arrangement? [yes [x] No [rsa [HRA [Jrs4 NOTE: Applicant must have elected an HSA compatible plan to be able to offer an HSA with preferred administrator. (if left blank, the response is assumed to be No.) B. If Yes is selected above, which type of accounts are you choosing V. Rate Information A. Premium/Prepayment fee are payable monthly on or before the due date which will be: | Ist B. Regular Billing - Employee applications should be submitted thirty (30) days prior to proposed Effective Date. Employee cancellations must be submitted within 30 days of the Effective Date of the Termination. 3:31:56 PM 13123-0813R 05/27/2014 tlovida Blue Gd EMPLOYER APPLICATION An independent Licensee of the (True Group Application) Blue Cross and Blue Shield Association C. The Rates established for this Policy will not be changed for the first twelve (12) months following the initial Effective Date of Coverage unless there is a change in benefits or a 15% or more change in the composition of the group. However, BCBSF/HOI may change the Rates that are to be effective after this initial twelve (12) month period of coverage by providing notice to the employer of such changed Rates forty-five (45) days prior to their Effective Date. D. Funding Arrangements: BCBSF: |ANNUAL REFND NO SPEC STOP LOSS HMO: [Not Applicable E. Rate Comments: This TGA is specifically for retirees. The rate descriptions are as follows: Retiree Only (Over age 65 w/Medicare), Retiree + 1 (Over age 65, Both w/Medicare), Retiree/Family (1 Over age 65 w/Medicare) 13123-0813R 05/28/2014 1:39:10 PM Klevida Blue ay EMPLOYER APPLICATION An Independent Licensee of the (True Group Application) Blue Cross and Blue Shield Association VI. Applicant Responsibilities A. The applicant shall: 1) Notify each enrollee to the benefits selected by the applicant, their Effective Date, and the termination date of coverage (in this regard, applicant acts as the agent of the enrollee, and in no event shall the applicant be deemed an agent of BCBSF/HO] for this or any other purpose, nor shall BCBSF/HOI be responsible for such notification to retirees). 2) Deliver to covered enrollees identification cards and certificates of coverage furnished by BCBSF/HOI. 3) Notify BCBSF/HOI promptly of any changes in the eligibility of enrollees covered under this Agreement. 4) List any absentees at the time of initial enrollment on the appropriate BCBSF/HOI form. Applications from absentees will be accepted at BCBSF/HOI Corporate Headquarters no later than thirty (30) days from the group's Effective Date. 5) Collect enrollee contribution, if required, and remit Premium payment/prepayment fees to BCBSF/HOI as specified in this application. B. 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. C. Applicant hereby establishes an Employee Welfare Benefit Plan for the purpose of providing for its employees or their beneficiaries medical, surgical, hospital care, or benefits in the event of sickness. D. Applicant understands that if applying for an HSA-qualified High Deductible Health Plan and electing to grant Prior pauiet Credit under Florida law to enrolling Employees, then that plan may no longer qualify as an HSA-compatible plan. E. {f applicant chose an HSA, HRA or FSA integrated Aree with BCBSF’s preferred administrator, applicant agrees to obtain from each employee enrolling in a health plan issued or administered by BCBSF and establishing an HSA, HRA or FSA in conjunction therewith, the employee’s signed HIPAA compliant authorization form that authorizes BCBSF to disclose to BCBSF’s preferred administrator such information, including information, of the employee as the administrator may require in order to establish and protected health maintain the employee's HSA, HRA or FSA accounts. Applicant acknowledges and agrees that BCBSF does not provide banking or administrative services for HSA, HRA of FSAs and that BCBSF is not responsible for the provision of HSA,HRA or FSA services. HSA, HRA or FSA services are provided by the administrator of applicant's choice subject to the terms and conditions of such agreements, including any fees that the administrator may require. VII. Final Premiums, Benefits and Effective Dates are Subject to Approval by BCBSF Corporate Headquarters Issuance of the Policy by Florida Blue/Florida Blue HMO will be deemed acceptance of this application. Date Signature of Applicant Print/Type Name & Title Date Florida Blue