Okaloosa County BOCC — August 18, 2015 — Florida Blue Employer Application — reading text

Florida Blue B EMPLOYER APP.LIC.ATION (True Group Application) An Independent Licenses of the Blue Cross and Blue Shield Association D New Business E] Renewal Business D Other I I. Group Information Group # (Florida Blue): (Florida Blue HMOY): | _ =] A. Name of Group: ngAl.OOSA CO BOARD OF CO COMMISSIONERS | Nature of Business: |GENERAL GOVERNMENT, NEC | SIC Code: |9199 ] Mailing Address: IEOIA NORTH PEARL STREET, SUITE 204 CRESTVIEW,FL 32536 —I Email Address: LLKI;ORTER@CO.OKALOOSA.FL.US | Listlli)cealggvnSubsidiary or Affiliated Companies whose employees are to be eligible and included with this iIF;Fr)ne ' Address B. 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. C. PriorInsurance Carrier: Insurance [HUMANA l HMO [NO GROUP INSURANCE | D. 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. E. Workers Compensation Carrier is: lSELl-‘ INSURED 1I. Effective Date/Eligibility Information A. Effective Date of this Policy shall be Effective Date of this Change to the Policy shall be 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, B. 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. C. 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 - 1st of the Month following DOH Eligibility - Termination is as of the end of month, the benefits are termed as of the end of month. With the exception of termination due to misconduct or mischievous conduct, then termination of benefits is as of the date of termination. D. New eligible employees may be covered effective on the Ist of the month | after [See SpecIns | days 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. E. Atleast % of the eligible employees must be enrolled under the Policy on the Effective Date and throughout the term of the Policy and the Group must meet and continue to meet Florida Blue/Florida Blue HMO participation requirements. F. 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. Applicant agrees to furnish any such request. G. Employer Contribution: Employee: % Dependents: |I|% 13123-0813R 07/31/2015 1:06:52 PM Florida Blue &Y An Independent Licensee of the Blue Cross and Blue Shield Association EMPLOYER APPLICATION (True Group Application) II1. Health Plan Summary Information (select the appropriate box[s]): Included in Product Accept Decline 0O O X O O O O O 0O 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 |z| Single Plan l:’ Blue Packages Health Plan Name Rx Option (indicate copayments) [BlueOptions Physician Copay Plan 03559 - Cust | [BieSeript Rx OOP Int $15/550/580C - NSTD [ Benefit Period : |01/01/2015 - 127312015 | Coinsurance: Deductible : In-Network / Participating ISO% 120% I Per Person |§500 /$750 | Out-of-Network/Non-Participating 60% / 40% ] Per Family |.$i500 /$2,250 ] Office Visit Copay: Pre-Existing IN/A I Family Physician |$20 l Rates All Other Providers [.'540 | Employee Employee/Spouse Employee/Child(ren) Family Spouse Child(ren) $589.23 | Spouse/Child(ren) Employee + 1 13123-0813R 07/31/2015 1:06:52 PM Florida Blue &Y An Independent Licenses of the EMPLOYER APPLICATION (True Group Application) Blue Cross and Blue Shield Association Single Plan Blue Packages [ Health Plan Name Rx Option (indicale copayments) IBlue()ptions Network Advantage Plans 03769 - Cust | [BiueSeript Rx OOP Int $15/$50/$80C - NSTD Spouse Child(ren) Benefit Period : |01/01/2015 - 12/31/2015 I Coinsurance: Deductible : In-Network / Participating Per Person [s500./ 51,500 | - out-of-Network/Non-Participating Per Family ISLI,SDO / $4,500 | Office Visit Copay: Pre-Existing IN/A I Family Physician Rates All Other Providers Employee Employee/Spouse Employee/Child(ren) Family Spouse/Child(ren) Employee + 1 ls(u%/zo% 50% /50% 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 13123-0813R Are you choosing Florida Blue's integrated HSA, HRA or FSA preferred administrator arrangement? I:IYes IE No (if left blank, the response is assumed to be No.) If Yes is selected above, which type of accounts are you choosing D HSA I:I HRA NOTE: Applicant must have elected an HSA compatible plan to be able to offer an HSA with preferred administrator. Rate Information Premium/Prepayment fee are payable monthly on or before the due date which will be: I 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. 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, Florida Blue/Florida Blue HMO 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. Funding Arrangements: Florida Blue: IANNUAL REFND NO SPEC STOP LOSS HMO: [Not Applicable Rate Comments: 07/31/2015 1:06:52 PM Florida Blue &Y EMPLOYER APP.LI(?ATION (True Group Application) An Independent Licensae of the 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 Florida Blue/Florida Blue HMO for this or any other purpose, nor shall Florida Blue/Florida Blue HMO be responsible for such notification to retirees). 2) Deliver to covered enrollees identification cards and certificates of coverage furnished by Florida Blue/Florida Blue HMO. 3) Notify Florida Blue/Florida Blue HMO 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 Florida Blue/Florida Blue HMO form. Applications from absentees will be accepted at Florida Blue/Florida Blue HMO 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 Florida Blue/Florida Blue HMO 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 Clarrier Credit under Florida law to enrolling Employees, then that plan may no longer qualify as an HSA-compatible plan. E. If applicant chose an HSA, HRA or FSA integrated arranfiement with Florida Blue’s preferred administrator, applicant agrees to obtain from each employee enrolling in a health plan issued or administered by Florida Blue and establishing an HSA, HRA or FSA in conjunction therewith, the employee's signed HIPAA compliant authorization form that authorizes Florida Blue to disclose to Florida Blue'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 Florida Blue does not provide banking or administrative services for HSA, HRA of FSAs and that Florida Blue 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 Florida Blue 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 Nathan D. Boyles, Chairman Nathan D. Boyles, Chairman Date Florida Blue and/or Florida Blue HMO Licensed Agent (Print) i il —— = 2 — Do, = 5 ,S—IU . Erprres /c- 6"“448 Signature of Agent Agent License Identification Number = Z H0/3 982 Health and vision insurance is offered by Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Bluc. HMO coverage is offered by Health Options, Inc., D/B/A Florida Blue HMO, an HMO subsidiary of Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. 13123-0813R 07/31/2015 1:07:00 PM