HomeMy Public PortalAboutFlorida Blue Contract-DOC-65199
Group Name:CITY OF CRESTVIEW
Group Number: 59530
Effective Date:10/01/2022
I approve the following commission to be paid to my agent(s) of record by Florida Blue and
acknowledge that the commission is included in the rates:
Contract Period:10/01/2022 - 09/30/2023
Primary Agent Name:DENNIS BARNES
Primary Agency Name:BARNES INSURANCE & FINANCIAL
SERVICES, INC - 5014
Primary Agent Commission:1.25%
Decision Maker
Name
Signature Date Signed
Jessica Leavins {{Sig_es_:signer3:signature}} {{Sig_es_:signer3:date}}Aug 23, 2022
LARGE GROUP EMPLOYER APPLICATION
Health and Vision insurance is offered by Florida Blue. HMO coverage is offered by Florida Blue HMO, CHP and/or Truli for Health, which are affiliates of Florida
Blue. Florida Combined Life Insurance Company, Inc., is the carrier for the Dental offerings in this application. These companies are Independent Licensees of
the Blue Cross and Blue Shield Association.
89424-1221R Page 1 of 5
Group Name (full and complete legal name):CITY OF CRESTVIEW Group #:59530
Doing Business As:Effective Date:10/01/2022
Contract Type: New Renewal Other___________________
I. Selection of Coverage*
Coverage Selected: Health Vision Dental
(For detailed information refer to Section IV: Benefit Information)
Blue Cross and Blue Shield of Florida, Inc., DBA Florida Blue, Health Options, Inc., DBA Florida Blue HMO, BeHealthy Florida
Inc., DBA Truli for Health, Capital Health Plan Inc. (CHP), are the carriers for Health and Vision Plan offerings in this
application. Florida Combined Life Insurance Company, Inc., is the carrier for the Dental offerings in this application.
II. Group Information
1. SIC Code: 9111 2. Nature of Business: Executive offices
3. Tax ID Number:596000295 4. Workers’ Compensation Carrier:FLORIDA LEAGUE OF CITIES
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.
Group Addresses
5. Applicant Group Physical Address: 198 N WILSON ST
County:Okaloosa City:CRESTVIEW State:FL Zip Code:32536
7. Applicant Group Billing Address (if different from above): PO BOX 1209
City
:
CRESTVIEW State:FL Zip Code:32536
Group Contact Information
8. Decision-Maker Name:Email:Phone Number:
JESSICA LEAVINS leavinsJ@cityofcrestview.org (850) 398-5458
Location(s) (if applicable):CITY OF CRESTVIEW, CRESTVIEW UNLIMITED
9. Primary Benefit Administrator Name:Email:Phone Number:
TENESHA NAPOLEON napoleonT@cityofcrestview.org (850) 682-1560
Location(s) (if applicable):CITY OF CRESTVIEW, CRESTVIEW UNLIMITED
Common Ownership, Subsidiary & Affiliate Information
10. Is your organization considered a single employer (i.e., as part of a controlled group of corporations) under
subsection (b), (c), (m) or (o) of section 414 of the Internal Revenue Code of 1986? Yes No
Billing Options
13. Bill Setup: One Bill Multiple Bill by Location Multiple Bill by Other Categories
Billing Location Name:Tax ID(If applicable):Billing Address:
CITY OF CRESTVIEW 596000295 PO BOX 1209, CRESTVIEW, FL
32536
CRESTVIEW UNLIMITED 871184737 PO BOX 1209, CRESTVIEW, FL
32536
14. Bill Itemizing: None Custom Categories
Applicant Group Name (full and complete legal name)Tax ID Group # (if applicable)
CITY OF CRESTVIEW 596000295 59530
Health and Vision insurance is offered by Florida Blue. HMO coverage is offered by Florida Blue HMO, CHP and/or Truli for Health, which are affiliates of
Florida Blue. Florida Combined Life Insurance Company, Inc., is the carrier for the Dental offerings in this application. These companies are Independent
Licensees of the Blue Cross and Blue Shield Association.
89424-1221R Page 2 of 5
15. Bill Sorting by: Alphabetical Contract Number
III. Eligibility Information
Employee Eligibility
1. Waive the waiting period for the initial group enrollment? Yes No
2. Description Product Length of Waiting
Period
Employees Become
Eligible On
Last Day of Coverage
All Employees Health 60 1st day of billing cycle Last day of billing cycle
New eligible employee must submit an application to Florida Blue/Florida Blue HMO/Truli for Health/CHP /Florida Combined
Life for Dental within 30 days of the date the individual first meets the applicable eligibility requirements.
3. Total average number of employees on payroll (full-time, part-time, and seasonal) for the prior calendar year, regardless of
insurance eligibility: 225
4. Total number of employees (including owners, partners, etc.) currently employed by your business: 230
Health
ELIGIBILITY
THE FOLLOWING
INFORMATION IS TO BE
PROVIDED ONLY FOR
COVERAGE SELECTED:
Participation
Requirements
# Eligible # Enrolled % Enrolled % Employer
Contribution
For Employee
% Employer
Contribution
For
Dependent
Health NA 230 210 100.00%100.00 50.00
1. At least 65 % of 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 and/or Florida Blue HMO/Truli for Health/CHP participation
requirements.
Only eligible employees who regularly work a minimum of 30.00 hours each week and their eligible dependents, shall be
eligible for coverage upon the Effective Date of this Policy.
2. Total # of COBRA Continuants: 0
3. Total # of Part-Time/Seasonal Employees: 0
4. Total # of New Full Time employees still in Waiting Period: 0
5. Number of Employees waiving Florida Blue and/or Florida Blue HMO/Truli for Health/CHP health benefits who are:
20 Enrolled in another group health plan
0 Without other health coverage
6. Applicant is a Single Employer Plan OR Multiple or Multi-Employer Plan
(A Multi-Employer Plan is sponsored by more than one employer and is maintained pursuant to at least one collective
bargaining agreement.)
7. Medicare Primary or Secondary Determination. Use the following information to answer questions below: Count full
and/or part-time employees each working 20 or more weeks.
One or more employers in applicant's group employed 20 or more full and/or part-time employees during the current or
preceding calendar year. Yes No
Applicant's group employed 100 or more full and/or part-time employees on 50% or more of the work days during the
preceding calendar year. Yes No
8. Florida Blue, Florida Blue HMO and/or Truli for Health is the COBRA administrator. Do you wish to waive administrative
services for COBRA? Yes No
IV. Benefit Information
Health Coverage
Administrative Options
1. Benefit Period:01/01/2022 to 12/31/2022 2. Anniversary Date:10/01
3. Funding Arrangement:Pro-Share Plus 4. Religious Exemption:None
5. Domestic Partner:Same & Opp Sex, - w/
dependents
6. Overage Dependent:Opt Out
7. Section 125:Yes 8. Initial ID Cards Sent To:SUBSCRIBER
Applicant Group Name (full and complete legal name)Tax ID Group # (if applicable)
CITY OF CRESTVIEW 596000295 59530
Health and Vision insurance is offered by Florida Blue. HMO coverage is offered by Florida Blue HMO, CHP and/or Truli for Health, which are affiliates of
Florida Blue. Florida Combined Life Insurance Company, Inc., is the carrier for the Dental offerings in this application. These companies are Independent
Licensees of the Blue Cross and Blue Shield Association.
89424-1221R Page 3 of 5
9. Subsequent ID Cards Sent
To:
SUBSCRIBER 10. Retroactive Enrollment:N/A
11. Deferred Premium
Payment:
N/A 12. Group Defines Eligibility:Not Applicable
13. Self Billing:Not Applicable 14. 15/16 Billing Rule:Does Not Apply
15. Additional Admin Options to note:
16. Florida Blue, Florida Blue HMO, CHP and/or Truli for Health shall deliver identification cards to covered enrollees. Benefit
booklet will be made available to covered enrollees by Florida Blue, Florida Blue HMO, CHP and/or Truli for Health.
Final premiums, benefits, and effective date of coverage are subject to approval by Florida Blue, Florida Blue HMO , CHP
and/or Truli for Health corporate headquarters. Issuance of the Group Policy by Florida Blue, Florida Blue HMO, CHP and/or
Truli for Health will be deemed acceptance of this application. Applicant must have an application/refusal form on file for all
eligible employees, even those who are not taking the health coverage.
Plans
Health Plan:BlueCare Predictable Cost 59 STD Rx Option:BlueCare Rx OOP Integrated ($10/$30/$50)
Premium Rates
Employee Employee/Spouse Children Family
$768.43 $1,752.01 $1,536.86 $2,458.98
Plans
Health Plan:BlueCare Lower Premium 51 STD Rx Option:BlueCare Rx OOP Integrated ($10/$50/$80)
Premium Rates
Employee Employee/Spouse Children Family
$650.23 $1,482.52 $1,300.46 $2,080.74
Plans
Health Plan:BlueOptions Predictable Cost 03559 STD Rx Option:BlueScript Rx OOP Integrated ($10/$30/$50)
Premium Rates
Employee Employee/Spouse Children Family
$838.50 $1,911.78 $1,677.00 $2,683.20
Financial Products
17. Is applicant choosing Florida Blue, Florida Blue HMO and/or Truli for Health‘s preferred administrator arrangement for their
HSA, HRA, or FSA account? Yes No
V. Applicant Responsibilities
Health, Dental, Vision: The applicant hereby applies for issuance of a Group Policy (herein referred to as a policy) by Blue
Cross and Blue Shield of Florida, Inc., DBA Florida Blue, Health Options, Inc., DBA Florida Blue HMO, BeHealthy Florida Inc.,
DBA Truli for Health, CHP and/or Florida Combined Life (FCL). Upon acceptance of the application by Florida Blue, Florida
Blue HMO, Truli for Health, CHP and/or FCL, it will become part of the Policy issued to the applicant named above. This
Policy may be terminated by the applicant or Florida Blue/Florida Blue HMO/CHP/Truli for Health/FCL by giving at least 45
days prior written notice to the other party except in the case of non-payment of Premium.
Rate Information: Premiums/Prepayment fees are payable monthly on or before the due date which will be the
1st . 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 original 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/CHP/Truli for
Health/FCL 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 at least forty-five (45) days prior to their Effective Date.
Applicant Group Name (full and complete legal name)Tax ID Group # (if applicable)
CITY OF CRESTVIEW 596000295 59530
Health and Vision insurance is offered by Florida Blue. HMO coverage is offered by Florida Blue HMO, CHP and/or Truli for Health, which are affiliates of
Florida Blue. Florida Combined Life Insurance Company, Inc., is the carrier for the Dental offerings in this application. These companies are Independent
Licensees of the Blue Cross and Blue Shield Association.
89424-1221R Page 4 of 5
A) The Applicant Shall
1)Be solely responsible for notifying each enrollee, employee, retiree, or beneficiary of the benefits selected, the
effective date, and the termination date of coverage (at no time and for no reason, will the applicant be deemed an
agent of Florida Blue/Florida Blue HMO/CHP/Truli for Health/FCL, nor shall Florida Blue/Florida Blue
HMO/CHP/Truli for Health/FCL be responsible for such notification to enrollees, employees, retirees or
beneficiaries).
2)Notify Florida Blue/Florida Blue HMO/CHP/Truli for Health/FCL promptly of any changes in the eligibility of
enrollees covered under this Agreement.
3)List any absentees at the time of initial enrollment on the appropriate Florida Blue/Florida Blue
HMO/CHP/Truli for Health/FCL form. Applications from absentees will be accepted at Florida Blue/Florida
Blue HMO/CHP/Truli for Health/FCL Corporate Headquarters no later than thirty (30) days from the group’s
original Effective Date.
4)Collect enrollee contribution, if required, and remit Premium payment/prepayment fees to Florida
Blue/Florida Blue HMO/CHP/Truli for Health/FCL as specified in this application.
5)Be solely responsible for providing an SBC to each employee and their dependents, at the following times, and under
the following circumstances: upon application for coverage; by the first day of coverage if there are changes to the
SBC after application; to special enrollees; upon renewal; or upon request for an SBC or summary information about
health coverage.
B) 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.
C) Applicant acknowledges that if applying for BlueOptions with an Exclusive Provider Provision (EPP), all eligible employees
live, reside or work in the Service Area and the applicant acknowledges receipt of a description of the following: 1) exclusive
providers; 2) the exclusive provider provisions, including coinsurance and deductible levels if providers other than exclusive
providers are used; 3) coverage for emergency and urgently needed care and other out-of-service area coverage; 4)
limitations on referrals to restricted exclusive providers and to other providers; and 5) Florida Blue's quality assurance
program and grievance procedure. Applicant further acknowledges its understanding of the restrictions of the BlueOptions
Exclusive Provider Organization.
D) If applicant chose an HSA, HRA, or FSA integrated arrangement with Florida Blue/Florida Blue HMO/Truli for Health’s
preferred administrator in Section IV under Health Coverage subsection, applicant agrees to obtain from each employee
enrolling in a health plan issued or administered by Florida Blue/Florida Blue HMO/Truli for Health and establishing an HSA,
HRA, or FSA in conjunction therewith, the employee’s signed HIPAA compliant authorization form that authorizes Florida
Blue/Florida Blue HMO/Truli for Health to disclose to Florida Blue/Florida Blue HMO/Truli for Health’s preferred administrator
such information, including protected health information, of the employee as administrator may require in order to establish
and maintain the employee’s HSA, HRA, or FSA accounts. Applicant acknowledges and agrees that Florida Blue/Florida Blue
HMO/Truli for Health does not provide banking or administrative services for HSA, HRA, or FSAs and that Florida Blue/Florida
Blue HMO/Truli for Health 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.
E) 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.
F) I understand that this information will be used to determine my group’s compliance with Florida Blue/Florida Blue
HMO/CHP/Truli for Health/FCL Underwriting Guidelines, as well as the relevant State and Federal laws relating to my group
and plan. Florida Blue/Florida Blue HMO/CHP/Truli for Health/FCL reserves the right to request documentation to support
evidence of business activity at any time, and from time to time as validation of compliance.
G) Applicant agrees to receive group invoices and other communications from Florida Blue/Florida Blue HMO/Truli for
Health/FCL electronically through your EmployerPoint account. You agree to keep your email address up-to-date in order to
access and receive required communications through your EmployerPoint account. Applicant understands that failing to
update your email address may result in delay of notification of important information including premium invoices. Applicant
may change this mailing preference at any time by calling Florida Blue/Florida Blue HMO/Truli for Health/FCL or logging into
your EmployerPoint account.
Certification:
1)The applicant hereby certifies that the information contained in this application, including any attachment to it, is true
and complete.
Fraud Notice: 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.
Applicant Group Name (full and complete legal name)Tax ID Group # (if applicable)
CITY OF CRESTVIEW 596000295 59530
Health and Vision insurance is offered by Florida Blue. HMO coverage is offered by Florida Blue HMO, CHP and/or Truli for Health, which are affiliates of
Florida Blue. Florida Combined Life Insurance Company, Inc., is the carrier for the Dental offerings in this application. These companies are Independent
Licensees of the Blue Cross and Blue Shield Association.
89424-1221R Page 5 of 5
Please print or type, except where signature is requested.
For (Name of Applicant):
CITY OF CRESTVIEW
Representative:
GWEN JOHNSON-HILLIARD
Licensed Agent (FL):
Dennis Barnes
By:
Jessica Leavins
Representative Code & License:
License #:
Signature:
{{Sig_es_:signer3:signature}}
Representative Signature:
{{Sig_es_:signer1:signature}}
Licensed Agent Signature:
{{Sig_es_:signer2:signature}}
Dated:Representative Email:
gwen.johnson-hilliard@bcbsfl.com
Licensed Agent Email:
Dbarnes@biafs.com
Date:
{{Dte_es_:signer3:date}}
Date:
{{Dte_es_:signer1:date}}
Date:
{{Dte_es_:signer2:date}}
Gwen Johnson-Hilliard (Aug 15, 2022 15:23 CDT)
Gwen Johnson-Hilliard
Aug 15, 2022
Dennis Barnes (Aug 15, 2022 16:03 CDT)
Aug 15, 2022
Aug 23, 2022