HomeMy Public PortalAbout2012-15 Authorizing agreement with Blue Cross Blue Shield of Florida, IncRESOLUTION NO. 2012-15
A RESOLUTION OF THE VILLAGE COUNCIL OF THE
VILLAGE OF KEY BISCAYNE, FLORIDA, AUTHORIZING
THE VILLAGE MANAGER TO ENTER INTO AN
AGREEMENT WITH BLUE CROSS BLUE SHIELD OF
FLORIDA, INC., TO PROVIDE FOR EMPLOYEE HEALTH
INSURANCE; AND PROVIDING FOR AN EFFECTIVE DATE.
WHEREAS, the Village of Key Biscayne (the "Village") selected National Marketing Group
Services, Inc. ("National") as its Health Insurance Broker of Services to, among other things, assist
the Village in obtaining estimates from health insurance providers; and
WHEREAS, National obtained various estimates for health insurance premiums from
different health insurance providers and for different insurance plans; and
WHEREAS, based upon the information provided by National, the Village Council desires
to enter into an agreement with Blue Cross Blue Shield of Florida, Inc., to provide health insurance
for its employees; and
WHEREAS, the Village Council finds that this Resolution is in the best interest and welfare
of the residents of the Village.
NOW, THEREFORE, BE IT RESOLVED BY THE VILLAGE COUNCIL OF THE
VILLAGE OF KEY BISCAYNE, FLORIDA, AS FOLLOWS:
Section 1. Recitals Adopted. Each of the above stated recitals are hereby adopted,
confirmed and incorporated herein.
Section 2. Authorization. The Village Council hereby authorizes the Village Manager
to enter into an agreement with Blue Cross Blue Shield of Florida, Inc., for Plan Number NFQ-LG
Plan 59, for employee health insurance in accordance with the terms and conditions set forth by the
Village Council, subject to the approval of the Village Attorney as to form and legal sufficiency.
Section 3. Effective Date. This Resolution shall be effective immediately upon
adoption.
ATT
PASSED AND ADOPTED this 16th day of April , 2012.
4A/ahe
TA H. ALVAREZ, MMC, VILLAGE CLERK
APPROVED AS TO FORM AND LEGAL SUFFICIENC
2
of Nokia
Hetlilit Optima.
ElNew Business Q Renewal Business
I. Group Information
B.
C. Prior Health Carver: Insurance
D
HMO
A Name of Group.
Nature of Business
Mailing Address:
Email Address:
EMPLOYER APPLICATION
(True Group Application)
0 Other
Group # (BCBSF),
(HMO):
B2203
VILLAGE OF KEY BISCAYNE
EXECUTIVE OFFICES
88 W MCINTYRE ST KEY BISCAYNE,FL 33149-1846.
SIC Code
9111
CGREAVES@KEYBISCAYNE.FL.GOV
List below Subsidiary or Affiliated Companies whose employees are to be eligible and included with this
application.
Name
Address
Applicant hereby applies for issuance of a Group Policy (herein referred to as Policy) by Blue Cross and Blue
Shield of Florida, Inc. (BCBSF) and/or Health Options, Inc. (HOI). Upon acceptance of this application by
BCBSF and/or HOI, it will become part of the Policy issued to the applicant named above.
AVMED
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 Carder is:
II. Effective Date/Eligibility Information
A. Effective Date of this Policy shall be
PREFERRED GOVERNMENT INSURANCE TRUST (PGIT)
05/01/2012
Effective Date of this Change to the Policy shall be
05/01/2012
This Policy may be terminated by the applicant or BCBSF/HOI 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
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 - DOMESTIC PARTNER COVERAGE - SAME AND OPPOSITE SEX WITFI DEPENDENTS AND 12 MONTHS PRIOR
RELATIONSHIP
30
hours each week and their eligible dependents,
D
E.
F.
G
New eligible employees may be covered effective on the 1st of the month after
of employment, so long as the eligible employee submits an application to BCBSF/HOI within 30 days of the date
the individual first meets the applicable eligibility requirements.
At least 75 % 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 BCBSF/HOI's participation
requirements.
BCBSF/HOI 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 BCBSF/HOI. Applicant agrees to furnish any
such request.
Employer Contribution- Employee: % Dependents:
30
100
0
OA
days
13123.995 SR (Rev 1007)
04/27/2012 5 21'15 PM
BlueCross BlueShield
of Florida
Health Options
51 + ENROLLMENT SUMMARY
Company Name
Sales Rep
VILLAGE OF KEY BISCAYNE
RUBEN ACOSTA
Effective Date
Group Number
5/1/2012
B2203
MEDICARE SECONDARY PAYER COMPLIANCE
Multiple Employer Plan: a plan sponsored by more than one employer Multi -employer plan: a plan jointly sponsered by employers and unions
If you are a single employer plan
Our Company employed 20 or more employees"" each working day in 20 or more calendar weeks during the current or preceding calendar
year
If you are a single employer, multiple employer or a multi -employer plan
Our Company employed 100 or more employees** on 50 percent or more of the business days during the preceding calendar year
If you are a multiple employer or a multi -employer plan:
All employers in our Group Health Plan (GHP) employed 20 or more employees' for 20 or more weeks in either the current or procedmg
calendar year
At least one of the employers in our GHP employed 20 or more employees"* for 20 or more weeks in either the current or preceding
calendar year
All employers in our GHP employed fewer than 20 employees** for 20 or more weeks in either the current or preceding calendar year
Common Ownership/Controlled Group Compliance
Our Company is part of a common ownership or Controlled Group stating that all persons treated as a single
employer under subsection (b), (c), (m) or (o) of section 414 of the Internal Revenue Code of 1986 shall be
treated as one employer
*'Employees" includes all full and/or part time employees
Yes
Yes
Yes
Participation must be collected in certain scenarios. Please use the drop down and
select the option that most fits your company.
I certify that the above information is correct to the best of my knowledge I understand t1 at this information will be used to determine my
company's compliance with Blue Cross Blue Shield of Florida, INC and/or Health Options, INC eligibility and Underwriting Guidelines, as
well as the applicability of State and Federal laws :elating to my company and plan Blue Cross Blue Shield of Florida INC and/or Health
Options, INC reserves the right to request a UCT-6 or other documentation as evidence of business activity at any tune and from time to time
in order to validate my compliance with eligibility and Underwriting Guidelines, as well as validate the applicability of State and Federal laws
I certify that the applicant is a single employer under section 414 of Internal Revenue Code ot 1986 (26 U S C 414 (b), (c), (m), or (o)), and
under any applicable state law
I understand that any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement ot claim or an
application containing any false, incomple�r misleading information is guilty of a felony of the third degree.
Officer of the Company's Signature
New Sale
Date/Time Field
14/361/?-
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E M P L O Y E R A P P L I C A T I O N
( T r u e G r o u p A p p l i c a t i o n )
M a n d a t e d B e n e f i t O f f e r i n g s : ( O p t i o n a l ) A p p l i c a n t h a s b e e n a d v i s e d o f t h e f o l l o w i n g b e n e f i t o f f e r i n g s m a n d a t e d
b y t h e F e d e r a l a n d / o r S t a t e L a w . A p p l i c a n t ' s d e c i s i o n t o a c c e p t o r d e c l i n e t h e s e b e n e f i t s i s i n d i c a t e d b e l o w
I n c l u d e d i n
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E n t e r a l F o r m u l a s
S i n g l e P l a n
E l B l u e P a c k a g e s
H e a l t h P l a n N a m e
B l u e C a r e N F Q L G G R P P l a n 5 9 - N S T D
B e n e f i t P e r i o d :
D e d u c t i b l e :
P e r P e r s o n
P e r F a m i l y
P r e - E x i s t i n g
R a t e s
E m p l o y e e
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5 4 0 4 . 2 2
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5 1 , 0 0 0 / N o t A p p l i c a b l e
A p p l i e s
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S 9 6 2 . 0 2
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B l u e C a r e R x P l a n $ 1 0 / 5 5 0 / 5 8 0 C - S T D
C o i n s u r a n c e :
I n - N e t w o r k / P a r t i c i p a t i n g
O u t - o f - N e t w o r k / N o n - P a r t i c i p a t i n g
O f f i c e V i s i t C o p a y :
F a m i l y P h y .
A l l O t h e r P r o v i d e r s
E m p l o y e e / C h i l d ( r e n )
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S e e t h e G r o u p M a s t e r P o l i c y f o r a c o m p l e t e d e s c r i p t i o n o f b e n e f i t s
I V . H e a l t h S a v i n g A c c o u n t ( H S A ) B a n k i n g A r r a n g e m e n t ( o p t i o n a l w u h 1 - I S A C o m p a t i b l e h e a l t h p l a n s )
A A r e y o u c h o o s i n g B C B S F ' s i n t e g r a t e d H S A b a n k i n g a r r a n g e m e n t ?
( i f l e f t b l a n k , t h e r e s p o n s e i s a s s u m e d t o b e N o . )
Q' Y e s E l N o
V . R a t e I n f o r m a t i o n
A . P r e m i u m / P r e p a y m e n t f e e a r e p a y a b l e m o n t h l y o n o r b e f o r e t h e d u e d a t e w h i c h w i l l b e :
B . R e g u l a r B i l l i n g - E m p l o y e e a p p l i c a t i o n s s h o u l d b e s u b m i t t e d t h i r t y ( 3 0 ) d a y s p r i o r t o p r o p o s e d E f f e c t i v e D a t e .
E m p l o y e e c a n c e l l a t i o n s m u s t b e s u b m i t t e d w i t h i n 3 0 d a y s o f t h e E f f e c t i v e D a t e o f t h e T e r m i n a t i o n .
C . T h e R a t e s e s t a b l i s h e d f o r t h i s P o l i c y w i l l n o t b e c h a n g e d f o r t h e f i r s t t w e l v e ( 1 2 ) m o n t h s f o l l o w i n g t h e i n i t i a l E f f e c t i v e
D a t e o f C o v e r a g e u n l e s s t h e r e i s a c h a n g e i n b e n e f i t s o r a 1 5 % o r m o r e c h a n g e i n t h e c o m p o s i t i o n o f t h e g r o u p .
H o w e v e r , B C B S F / H 0 1 m a y c h a n g e t h e R a t e s t h a t a r e t o b e e f f e c t i v e a f t e r t h i s i n i t i a l t w e l v e ( 1 2 ) m o n t h p e r i o d o f
c o v e r a g e b y p r o v i d i n g n o t i c e t o t h e e m p l o y e r o f s u c h c h a n g e d R a t e s f o r t y - f i v e ( 4 5 ) d a y s p r i o r t o t h e i r E f f e c t i v e D a t e .
D . F u n d i n g A r r a n g e m e n t s . B C B S F .
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H e a t h O p t i m a .
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1 3 1 2 3 - 9 9 5 S R ( R e v 1 0 0 7 )
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oBlueerosef hir�4hlaid Floritk
SieathOptima.
EMPLOYER APPLICATION
(True Group Application)
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/H01 for this or any other purpose, nor shall BCBSF/H01 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/H01 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/H01 form. Applications from absentees will be accepted at BCBSF/H01 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/H01 as specified in this application.
B. By choosing the HSA Banking Arrangement, if applicable, 1 authorize BCBSF to exchange certain limited
information, for employees enrolling in a high deductible health plan designed for use with an HSA,
with BCBSF's preferred bank, for the purposes of initial enrollment in and administration of, HSAs.
I recognize that BCBSF does not provide banking services and that BCBSF is not responsible for the provision
of HSA services. HSA services are provided by the bank of your choice subject to the terms and conditions of
such arrangements, including fees the bank may charge.
C. Applicant understands that if applying for an HSA-qualified High Deductible Health Plan and electing to grant Prior
Carrier Credit under Florida law to enrolling Employees, then that plan may no longer qualify as an HSA-compatible
plan.
D. 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.
E. 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.
VII. Final Premiums, Benefits and Effective Dates are Subject to Approval by
BCBSF Corporate Headquarters
Issuance of the Policy by BCBSF/H01 will be deemed acceptance of this application
Date
-30 la
Date
Lf-30 )
13123-995 SR (Rev 1007)
Signature of Applicant
Q Sw r
Prtnt/Type Name & Title
5hn C. ~'? HQntagec
ue Cttss and Blue Shield o on ' , Inc and/or Health Options, Inc. Licensed Agent (Print)
)• I ("1D(1?C1(e?
Signature of Agent
Agent License Identification Number
Pr \oo-503
04/27/2012 5:21 15 PM