HomeMy Public PortalAboutBlue Cross & Blue ShieldAn Independent Licensee of the
Blue Cross and Blue Shield Association
EMPLOYER APPLICATION
(True Group Application)
❑p New Business ❑ Renewal Business ❑ Other
I. Group Information
Group # (Florida Blue): [59530 (Florida Blue HMO): [59530
J
A. Name of Group: ICITY OF CRESTVIEw - — - -1
Nature of Business: LExECUTIVE OFFICES j SIC Code: 1_911 t 1
Mailing Address: I798 N WILSON STREET CRESTVIEW FL 32536
---------- - _ _ _
Email Address: [elizabethroy@ciryafcrestview.org - - J
List below Subsidiary or Affiliated Companies whose employees are to be eligible and included with this application.
Name 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., DB/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. Prior Insurance Carrier:
Insurance 'UNITED HEALTHCARE CORP
HMO [UNITED HEALTHCARE CORP
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: [FLORIDA LEAGUE OF CITIES
II. Effective Date/Eligibility Information
A. Effective Date of this Policy shall be (minors
Effective Date of this Change to the Policy shall be 110i01/2016
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 130 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.
D. New eligible employees may be covered effective on [1st Day Of Billing Cycle s of employment,
s— after60 - I--.- .= ment, days P Y
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. At least I65 ] % 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's 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 fumish
any such request.
G. Employer Contribution: Employee:11m % Dependents: [50 %
III. Health Plan Summary Information (select the appropriate box[s]):
13123-0515R
An Independent Licensee of the
Blue Cross and Blue Shield Association
EMPLOYER APPLICATION
(True Group Application)
Mandated Benefit Offerings:(Optional) Applicant
Federal and/or State Law. Applicants decision to a
Included in
Product
O
O
O
0
Accept
Decline
has been advised of the following benefit offerings mandated by the
crept or decline these benefits is indicated below.
Mental 8 Nervous Disorder
Alcohol and drug dependency
Mammograms Waiver of Deductible 8 Coinsurance
Enteral Formulas
❑ Single Plan
p Blue Package
Health Plan Name
l BlueOptions - BlueOptions Physician Gooey Plan 03559 - GUST
Benefit Period: 01/01/2016 - 12/31/2016
Deductible:
Per Person
Per Family
Pre -Existing:
Rates:
Employee
$500 / $750
$1,500 / $2,250
N/A
$573.13
Employee/Spouse $1364.05
Rx Option (indicate copayments)
3 ueScripl Rx OOP Int - $10/$30/$50 - STD
Coinsurance:
In -Network / Participating *)%/20%
Out-of-Network/Non-
Participating
160% / 40%
Office Visit Copay:
Family Physician 1$20 l
All Other Providers $ao J
Employee/Child(ren) l$1054.56 Family $1788.17
Health Plan Name
l BlueOptions - Predictable Cost Plan 05770 - CUST
Benefit Period:
Deductible:
Per Person
Per Family
Pre -Existing:
Rates:
Employee
01/01/2016- 12/31/2016
f $1,060 / $3,000
*3,000 / 56,000 l
IN/A
$563.50
Employee/Spouse I$1341.14
Rx Option (indicate copayments)
IBIueScript Rx OOP Int - $10/$30/$50 - STD
Coinsurance:
In -Network / Participating
Out-of-Network/Non-
Participating
Office Visit Copay:
Family Physician
All Other Providers
180% / 20%_ _ J
150% / 50% - 1
2-5
$45
Employee/Child(ren) l$1036.65 Family
I$175a.14
Health Plan Name
Rx Option (indicate copayments)
lBlueCare - BlueCare NFQ LG GRP Plan 59 - CUST
Benefit Period: 01/01/2016 - 12/31/2016
Deductible:
Per Person
Per Family
$500 / Not l
Applicable
151,000 / Not Applicable
Pre -Existing: l N/A
Rates:
Employee1$452.68 l Employee/Spouse l$1077.39
BlueCare Rx OOP INT - $10/$30/$50 - STD
Coinsurance:
In -Network / Participating *o% / 10%
Out-of-Network/Non- - -
Participating [Not Applicable / Not Appl
1515
l$35
Employee/Child(ren) l$s32.94 Family
Office Visit Copay:
Family Physician
All Other Providers
151412.37
See the Group Master Policy for a complete description of benefits.
13123-0515R
An Independent Licensee of the
Blue Cross and Blue Shield Association
EMPLOYER APPLICATION
(True Group Application)
IV. Health Savings Account (HSA), Health Reimbursement Arrangement (HRA) or Flexible Spending Account (FSA)
A. Are you choosing Florida Blue's integrated HSA, HRA or FSA preferred administrator arrangement?
(if left blank, the response is assumed to be No.)
B. If Yes is selected above, which type of accounts are you choosing ❑ HSA ❑ HRA ❑ FSA
NOTE: Applicant must have elected an HSA compatible plan to be able to offer an HSA with preferred administrator.
V. Rate Information
❑ Yes p No
A. Premium/Prepayment fee are payable monthly on or before the due date which will be: I1st
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.
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, 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.
D. Funding Arrangements: Florida Blue: 'Fully Insured__
Florida Blue HMO: IFuny insured
E. Rate Comments
1
13123-0515R
An Independent Licensee of the
Blue Cross and Blue Shield Association
VI Applicant Responsibilities
EMPLOYER APPLICATION
(True Group Application)
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 ads 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 fumished 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. If applicant chose an HSA, HRA or FSA integrated arrangement 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 protected health information, of the employee as the
administrator may require in order to establish and 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.
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. Applicant agrees to receive group invoices and other communications from Florida Blue/Florida Blue HMO electronically through
your BlueBiz account. You agree to keep your email address up-to-date in order to access and receive required communications
through your BlueBiz account. Applicant understand 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 or logging into your BlueBiz account.]
G. If applicant is applying for BlueOptions which includes a pharmacy plan with an Exclusive Provider Provision (EPP), applicant
acknowledges that all eligible employees live, reside or work in the Service Area. Applicant acknowledges receipt of 1) a
description of the exclusive providers; 2) a description of the exclusive provider provisions including coinsurance and deductible
levels if providers other than exclusive providers are used; 3) a description of coverage for emergency and urgently needed care
and other out -of -service area coverage; 4) a description of limitations on referrals to restricted exclusive providers and to other
providers; and 5) a description of Florida Blue's quality assurance program and grievance procedure. Applicant further
acknowledges that applicant understands the restrictions of the BlueOptions Exclusive Provider Organization for pharmacy plans
that include this provision.
13123-0515R
An Independent Licensee of the
Blue Cross and Blue Shield Association
EMPLOYER APPLICATION
(True Group Application)
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
I -Sep 19, 2016
Date
I--
Signature of Applicant
Print/Type Name 8 Title
1 I Elizabeth M Roy, City Cle
Florida Blue and/or Florida Blue HMO Licensed Agent (Print)
Signature of Agent
_J
Agent License Identification Number
I I
Health and vision insurance is offered by Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue. 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.
13123-0515R
FlVI-a& Magi 92 V
An Independent Licensee of the
Blue Cross and Blue Shield Association
s
Medicare Secondary Payor Compliance
ENROLLMENT SUMMARY
For Groups with 51 + Eligible Employees
Multiple Employer Plan: a plan sponsored by more than one employer. Multi -employer plan: a plan jointly sponsored by employers and unions.
If you are a single employer plan:
Yes ❑ No 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 multi -employer plan:
Yes ❑ No 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:
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑No
All employers in our Group Health Plan (GHP) employed 20 or more employees ** for 20 or more weeks in
either the current or proceeding 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.
**"Employees" includes all full and/or part time employees.
Common Ownership/Controlled Group Compliance 11110.1111111.11111111111111111.10.111.
❑ Yes 0 No
Our Company is part of a common ownership or Controlled Group as defined by the Health Insurance
Portablility and Accountability Act of 1996. ("HIPAA") states 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.
General Information IMMIONNOW MM.
Group Name CITY OF CRESTVIEW
Group Number 59530
Tax ID # 596000295
Group Sales Rep/Agent BARNES, DENNIS Effective Date 10/01/2016
Employer Contribution Toward Employees Premium (50% recommended for groups with 51+ employees) 100%
What was the average total number of all employees (full-time, part-time, and seasonal) In the previous calendar year? 225
II. ReCap of Employee Participation���,,
New Sale
Provide information regarding the questions listed below in the right hand column. Some cells are auto -calculated and cannot be typed within.
1. How many TOTAL EMPLOYEES ON PAYROLL, do you have?
2. How many TOTAL, COBRA CONTINUANTS are currently enrolled in your Group Health Plan (GHP)?
3. The form will calculate the TOTAL INELIGIBLE EMPLOYEES according to answers in 3A through 3C below.
A. How many Total Part Time and Seasonal Employeels) do you currently have?
B. How many Total New Emp oyees (in Waiting Period) do you currently have?
C. How many Total Other Employee(s) are not eligible or accounted for in 3A & 3B?
4. The form will calculate the TOTAL ELIGIBLE EMPLOYEES according to above answers to determine Group size.
A. How many Total Employees with Other Coverage are not enrolling in this GHP?
B. Indicate Other employee(s) totals not accounted for above that are eligible.
C. How many employees are Not Covered by BCBSFIH01 ? (Provide Total from Common Ownership Groups.)
5. The form will calculate the TOTAL ELIGIBLE FOR PARTICIPATION according to the above answers.
A. Enter the number of Total Refusals. This represents employees refusing coverage without other coverage.
225
0
12
11
1
0
213
21
0
0
192
0
Page 1 of 2
Enrollment Summary Form 7823SR (Rev 0613) Last Revised 09/16/2013
rorid Blue t2) d
An Independent Licensee of the
Blue Cross and Blue Shield Association
ENROLLMENT SUMMARY
For Groups with 51 + Eligible Employees
6. The form will calculate the TOTAL ENROLLED according to the answers provided above.
7. The form will calculate the total EMPLOYEE PARTICIPATION using the answers provided. (65% Recommended)
S. The form will calculate the ENROLLED PERCENT OF TOTAL (614) (50% RULE) using the answers provided.
192
100%
90%
Please read the information below and provide electronic signatures when the document is completed,
I certifiy that the above information is correct to the best of my knowledge. I understand that 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 relating 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 time 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 understand that 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.
ge;ua der/ /1( /Qoy Sep 19, 2016
ElvabeN M Roy (Sep 19, 20161
Officer of the Company's Signature Date/Time Field
Page 2 of 2
Enrollment Summary Form 7823SR (Rev 0613) Last Revised 09/16/2013
Florida
Blue � d
1ST MONTH PREMIUM FOR
CITY OF CRESTVIEW
BlueOptlons
Plan Name BlueOptions Physician Copay Plan 03559
RATE # EMPS. Amount
Employee 573.13 129 $73,933.77
Emp. /Spouse 1364.05 12 $16,368.60
Emp. /Child(ren) 1054.56 24 $25,309.44
Emp. /Family 1788.17 17 $30,398.89
Premium Due: $146,010.70
Plan Name Predictable Cost Plan 05770
RATE # EMPS. Amount
Employee 563.50 1 $563.50
Emp. /Spouse 1341.14 0 $0.00
Emp. /Child(ren) 1036.85 1 $1,036.85
Emp. /Family 1758.14 0 $0.00
Premium Due: $1,600.35
Plan Name BlueCare NFQ LG GRP Plan 59
RATE # EMPS. Amount
Employee 452.68 2 $905.36
Emp. /Spouse 1077.39 4 $4,309.56
Emp. /Child(ren) 832.94 0 $0.00
Emp. /Family 1412.37 2 $2,824.74
Premium Due: $8,039.66
Total Health Premium: $155,650.71
Checks should be made payable to: FloridaBlue
Checks should be sent to:
4800 Deerwood Campus Parkway
Corporate Cash Receipts 1-3
Jacksonville, FL 32246
An Independent Licensee of the
Blue Cross and Blue Shield Association
E New Business ❑ Renewal Business ❑ Other
I. Group Information
EMPLOYER APPLICATION
(True Group Application)
Group # (Florida Blue): '59530 j (Florida Blue HMO): *530
A. Name of Group: 'CITY OF CRESTVIEW
Nature of Business: IExECUTIVE OFFICES
Mailing Address: 1198 N WILSON STREET CRESTVIEW FL 32536
Email Address: 'elizabethro bccityofcrestview.org
SIC Code: 19111
List below Subsidiary or Affiliated Companies whose employees are to be eligible and included with this application.
Name 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., DB/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. Prior Insurance Carrier: Insurance
HMO
UNITED HEALTHCARE CORP
'UNITED HEALTHCARE CORP
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: IFLORIDA LEAGUE OF CITIES
II. Effective Date/Eliglbillty Information
A. Effective Date of this Policy shall be Lioi01i2o16 1
Effective Date of this Change to the Policy shall be 110/01/201-6
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 130 ' 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.
D. New eligible employees may be covered effective on '1st Day Of Billing Cycle after 60 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. At least 65 % 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's 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 fumish
any such request.
G. Employer Contribution: Employee:1100 l % Dependents: [50 %
III. Health Plan Summary Information (select the appropriate box[s]):
13123-0515R
An Independent Licensee of the
Blue Cross and Blue Shield Association
EMPLOYER APPLICATION
(True Group Application)
Mandated Benefit Offerings:(Optional) Applicant has been advised of the following benefit offerings mandated by the
Federal and/or State Law. Applicants decision to accept or decline these benefits is indicated below.
Included in
Product
O
O
0
0
Accept
Decline
Mental 8 Nervous Disorder
Alcohol and drug dependency
Mammograms Waiver of Deductible & Coinsurance
Enteral Formulas
❑ Single Plan
p Blue Package
Health Plan Name Rx Option (indicate copayments)
kBlueOptions - BlueOptions Physician Copay Plan 03559 - CUST I BlueScript Rx OOP int - $10/$30/$50 - STD J
Benefit Period:
Deductible:
Per Person $500 / $750 1
Per Family L$1,500 / $2,250 1
01/01/2016- 12/31/2016
Pre -Existing: risr/A 1
Rates:
Employee
$573.13
Employee/Spouse
$1364.05
Coinsurance:
In -Network / Participating 180% / 20%
Out-of-Network/Non- Aso°i° / 40°i°
Participating
Office Visit Copay:
Family Physician 11$20 1
All Other Providers 1640 11
Employee/Child(ren) I$1054.56 —1 Family
l$1788.17
Health Plan Name
Rx Option (indicate copayments)
BlueOptions - Predictable Cost Plan 05770 - CUST
Benefit Period: 01/01/2016- 12/31/2016
Deductible:
Per Person *i sm / $3,000
Per Family 163,000 / $6,000
Pre -Existing: 1N/A
Rates:
Employee 1$563.50 Employee/Spouse
BlueScript Rx OOP Int - $10/$30/$50 - STD
Coinsurance:
In-Network/Participating In%/20%
Out-of-Network/Non-
Participating
150% / 50%
Office Visit Copay:
Family Physician Is25
All Other Providers I$45
1$1341.14 Employee/Child(ren) 1$1o3s.65 I Family
IS1758.14
Health Plan Name Rx Option (indicate copayments)
IBIueCare - BlueCare NFQ LG GRP Plan 59 - CUST [BlueCare Rx OOP INT - $10/$30/$50 - STD
Benefit Period: 01/01/2016 - 12/31/2016
Deductible:
Per Person
Per Family
Pre -Existing:
Rates:
$500 / Not Applicable
$1,000 / Not Applicable
N/A
Employee L$452.68 Employee/Spouse
Coinsurance:
In -Network / Participating 190i° / la%
Out-of-Network/Non- —
Participating INot Applicable / Not Appl
Office Visit Copay:
Family Physician
All Other Providers
I$15
$35 ------
*077.39 1 Employee/Child(ren)0332.94 l Family 1$1412.37
See the Group Master Policy for a complete description of benefits.
13123-0515R
An Independent Licensee of the
Blue Cross and Blue Shield Association
EMPLOYER APPLICATION
(True Group Application)
IV. Health Savings Account (HSA), Health Reimbursement Arrangement (HRA) or Flexible Spending Account (FSA)
A. Are you choosing Florida Blue's integrated HSA, HRA or FSA preferred administrator arrangement?
(if left blank, the response is assumed to be No.)
B. If Yes is selected above, which type of accounts are you choosing ❑ HSA ❑ HRA ❑ FSA
NOTE: Applicant must have elected an HSA compatible plan to be able to offer an HSA with preferred administrator.
V. Rate Information
❑ Yes ❑p No
A. Premium/Prepayment fee are payable monthly on or before the due date which will be: list
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.
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, 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.
D. Funding Arrangements: Florida Blue:
Florida Blue HMO:
E. Rate Comments
Fully Insured
(Fully Insured
13123-0515R
An Independent Licensee of the
Blue Cross and Blue Shield Association
VI Applicant Responsibilities
EMPLOYER APPLICATION
(True Group Application)
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. If applicant chose an HSA, HRA or FSA integrated arrangement 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 protected health information, of the employee as the
administrator may require in order to establish and 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.
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. Applicant agrees to receive group invoices and other communications from Florida Blue/Florida Blue HMO electronically through
your BlueBiz account. You agree to keep your email address up-to-date in order to access and receive required communications
through your BlueBiz account. Applicant understand 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 or logging into your BlueBiz account.]
G. If applicant is applying for BlueOptions which includes a pharmacy plan with an Exclusive Provider Provision (EPP), applicant
acknowledges that all eligible employees live, reside or work in the Service Area. Applicant acknowledges receipt of 1) a
description of the exclusive providers; 2) a description of the exclusive provider provisions including coinsurance and deductible
levels if providers other than exclusive providers are used; 3) a description of coverage for emergency and urgently needed care
and other out -of -service area coverage; 4) a description of limitations on referrals to restricted exclusive providers and to other
providers; and 5) a description of Florida Blue's quality assurance program and grievance procedure. Applicant further
acknowledges that applicant understands the restrictions of the BlueOptions Exclusive Provider Organization for pharmacy plans
that include this provision.
13123-0515R
An Independent Licensee of the
Blue Cross and Blue Shield Association
EMPLOYER APPLICATION
(True Group Application)
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 Printaype Name & Title
Sep 19, 2016 .. N.ey
J �..�,�..�,,, , I I Elizabeth M Roy, City Cle
Date Florida Blue and/or Florida Blue HMO Licensed Agent (Print)
Sep 19, 2016 I James Glenn Little
Signature of Agent
—
Agent License Identification Number
Health and vision insurance is offered by Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue. 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.
13123-0515R
Pion dBlue Ve
An Independent Licensee of the
Blue Cross and Blue Shield Association
Medicare Secondary Payor Compliance
ENROLLMENT SUMMARY
For Groups with 51 + Eligible Employees
Multiple Employer Plan: a plan sponsored by more than one employer. Multi -employer plan: a plan jointly sponsored by employers and unions.
If you are a single employer plan:
Yes ❑ No 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 multi -employer plan:
0 Yes El No 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:
El Yes ❑ No All employers in our Group Health Plan (GHP) employed 20 or more employees ** for 20 or more weeks In
either the current or proceeding calendar year.
El Yes ❑ No 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.
El Yes ❑ No All employers In our GHP employed fewer than 20 employees** for 20 or more weeks in either the current
or preceding calendar year.
""Employees" includes all full and/or part time employees.
Common Ownership/Controlled Group Compliance
❑ Yes 2 No
Our Company is part of a common ownership or Controlled Group as defined by the Health Insurance
Portablility and Accountability Act of 1996. ("HIPAA") states 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.
Group Name CITY OF CRESTVIEW
Group Number 59530
Group Sales ReplAgent BARNES, DENNIS
Tax ID # 596000295
Effective Date 10/01/2016
Employer Contribution Toward Employees Premium (50% recommended for groups with 51+ employees) 100%
What was the average total number of all employees (full-time, part-time, and seasonal) in the previous calendar year? 225
II. ReCap of Employee Participation
New Sale
Provide information regarding the questions listed below in the right hand column. Some cells are auto -calculated and cannot be typed within.
1. How many TO AL EMPLOYEES ON PAYROLL, do you have?
2. How many TOTAL COBRA CONTINUANTS are currently enrolled in your Group Health Plan (GHP)?
3. The form will calculate the TOTAL INELIGIBLE EMPLOYEES according to answers in 3A through 3C below.
A. How many Total art Time and Seasonal Employeelal do you currently have?
B. How many Total New Employees (in Waiting Period) do you currently have?
C. How many Total Other Employee(s) are not eligible or accounted for in 3A 8 3B7
4. The form will calculate the TOTAL ELIGIBLE EMPLOYEE according to above answers to determine Group size.
A. How many Total Employees with Other Coverage are not enrolling in this GHP?
B. Indicate Other employee(s) totals not accounted for above that are eligible.
C. How many employees are Not Covered by BCBSFIH01 ? (Provide Total from Common Ownership Groups.)
5. The form will calculate the TOTAL ELIGIBLE FOR PARTICIPATION according to the above answers.
A. Enter the number of Total Refusals. This represents employees refusing coverage without other coverage.
Page 1 of 2
225
0
12
11
1
0
213
21
0
0
192
0
Enrollment Summary Form 7823SR (Rev 0613) Last Revised 09/16/2013
Florida Blue
An Independent Licensee of the
Blue Cross and Blue Shield Association
vov
.d
ENROLLMENT SUMMARY
For Groups with 51+ Eligible Employees
6. The form will calculate the TOTAL ENROLLED according to the answers provided above.
7. The form will calculate the total EMPLOYEE PARTICIPATION using the answers provided. (65% Recommended)
8. The form will calculate the ENROLLED PERCENT OF TOTAL (614) (50% RULE) using the answers provided.
192
100%
90%
,Please read the information below and provide electronic signatures when the document is completed,
I certifiy that the above information is correct to the best of my knowledge. I understand that 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 relating 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 time 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 understand that 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.
�bia.�er� /1( key Sep 19, 2016
Elizabeth M Roy (Sep 19, 20161
Officer of the Company's Signature Daterrime Field
Page 2 of 2
Enrollment Summary Form 7823SR (Rev 0613) Last Revised 09/16/2013
no' &
Blue O C)
1ST MONTH PREMIUM FOR
CITY OF CRESTVIEW
BlueOptions
Plan Name BlueOptions Physician Copay Plan 03559
RATE # EMPS. Amount
Employee 573.13 129 $73,933.77
Emp. /Spouse 1364.05 12 $16,368.60
Emp. /Child(ren) 1054.56 24 $25,309.44
Emp. /Family 1788.17 17 $30,398.89
Premium Due: $146,010.70
Plan Name Predictable Cost Plan 05770
RATE # EMPS. Amount
Employee 563.50 1 $563.50
Emp. /Spouse 1341.14 0 $0.00
Emp. /Child(ren) 1036.85 1 $1,036.85
Emp. /Family 1758.14 0 $0.00
Premium Due: $1,600.35
Plan Name BlueCare NFQ LG GRP Plan 59
RATE # EMPS. Amount
Employee 452.68 2 $905.36
Emp. /Spouse 1077.39 4 $4,309.56
Emp. /Child(ren) 832.94 0 $0.00
Emp. /Family 1412.37 2 $2,824.74
Premium Due: $8,039.66
Total Health Premium: $155,650.71
Checks should be made payable to: FloridaBlue
Checks should be sent to:
4800 Deerwood Campus Parkway
Corporate Cash Receipts 1-3
Jacksonville, FL 32246
Contract-DOC-1993
Adobe Sign Document History
09/19/2016
Created: 09/19/2016
By: Florida Blue SeIlPoint (LGAgentCommission@bcbsfl.com)
Status: Signed
Transaction ID: CBJCHBCAABAAcAgKCPCViywrf8AixRPz3UtWO4WELctX
"Contract-DOC-1993" History
n Document created by Florida Blue SeIlPoint (LGAgentCommission@bcbsfl.com)
09/19/2016-12:53:23 PM EDT- IP address: 157.174.221.254
El Document emailed to Elizabeth M Roy (elizabethroy@cityofcrestview.org) for signature
09/19/2016 - 12:53:44 PM EDT
t Document viewed by Elizabeth M Roy (elizabethroy@cityofcrestview.org)
09/19/2016 - 2:05:34 PM EDT- IP address: 98.191.223.210
43 Document e-signed by Elizabeth M Roy (elizabethroy@cityofcrestview.org)
Signature Date: 09/19/2016 - 2:08:27 PM EDT - Time Source: server- IP address: 98.191.223.210
El Document emailed to Glenn Little (glittle@biafs.com) for signature
09/19/2016 - 2:08:28 PM EDT
'5 Document viewed by Glenn Little (glittle@biafs.com)
09/19/2016 - 2:17:43 PM EDT- IP address: 70.184.44.196
co Document e-signed by Glenn Little (glittle@biafs.com)
Signature Date: 09/19/2016 - 2:19:41 PM EDT - Time Source: server- IP address: 70.184.44.196
O Signed document emailed to Glenn Little (glittle@biafs.com), Elizabeth M Roy
(elizabethroy@cityofcrestview.org) and Florida Blue SeIlPoint (LGAgentCommission@bcbsfl.com)
09/19/2016 - 2:19:41 PM EDT
Florida Blue a r,
In the pursuit of health Adabe Sign