HomeMy WebLinkAbout114-97 RESOLUTION •
t '
SC ANI " r•T
RESOLUTION NO. 11 4-9 7
A RESOLUTION APPROVING A GROUP MEDICAL
CONTRACT WITH BLUE CROSS/BLUE SHIELD FOR THE
POLICY YEAR OF JANUARY 1, 1998 THROUGH DECEMBER
31, 1998; AND APPROVAL OF THE ADDITIONAL PREMIUM
COST PAID BY THE CITY.
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF FAYETTEVILLE,
ARKANSAS:
Section 1. That the City Council hereby approves a group medical contract with Blue
Cross/Blue Shield for the policy year of January 1, 1998 through December 31, 1998; and approval
of the additional premium cost paid by the city. A copy of the contract is attached hereto marked
Exhibit "A" and made a part hereof.
F`.40vD AND APPROVED this 2nd day of December , 1997.
•
'` fir . � � ; ,..
APPROVED:
��
4 i4'
��. .�`� Fre
t� d Hanna Mayor
ATTEST: �Q
By: 7G /
Traci Paul, City Clerk
,J
Y.
•
•
EXHIBIT A
ct Arkansas
V:69 BlueCross BlueSh'geld
a An Independent Licensee of the Blue Cross and Blue Shield Assocration'
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A MUTUAL INSURANCE COMPANY
601 Gaines Street
Little Rock, Arkansas 72201
GROUP APPLICATION
APPLICATION by
City of Fayetteville
(herein called "Applicant")
for a Group Policy covering the employees of Applicant and the eligible dependents of
such employees.
In making this application, Applicant agrees to the terms of the Group Policy, including
but not limited to the Covenants of the Policyholder, and to pay the required premium.
This Application is made and delivered in the State of Arkansas and is governed by the
laws of Arkansas. This Application is incorporated in and made a part of the Group
Policy.
Signed at Fayetteville, Arkansas , this December 3rd • , 1997
City of Fayetteville
Applicant
By: 040etAt0.--
Authorized Signature
ARKANSAS BLUE CROSS AND BLUE SHIELD
A MUTUAL INSURANCE COMPANY ir
IL)
Accepted By: — DEC — X97
Authorized gnature
ICTTTEVILLEOFFI DIFSTRAYECE
GA-1 6/95
• PROXY
I hereby appoint the Board of Directors ("Board") of Arkansas Blue Cross and Blue Shield, A Mutual
Insurance Company ("Company"), as my proxy to act on my behalf at all meetings of members of the
Company. This appointment shall include such persons as the Board may designate by resolution to act
on its behalf.This proxy gives the Board,or its designee,full power to vote for me on all matters that may
Be voted upon at any meeting.The annual meeting of Members is held each year at the home office of the
Company located at 601 Gaines Street,Little Rock,Arkansas,on the third Monday of March,at 1:00 p.m.
If the third Monday of March is a legal holiday, then the meeting will be at the same time and place on
the next day after, which is not a legal holiday. Special meetings may be called upon notice mailed not
less than ten (10) nor more than sixty (60) days prior to such meeting. This proxy, unless revoked, shall
remain in effect during my membership in the Company.I may revoke this proxy in writing by advising
the Company of such at least five(5) days prior to any meeting.I may also revoke my proxy by attending
and voting in person at any Members' meeting.
Fayetteville, AR 72701
Address
City of Fayetteville
MEMBER NAIVE
GroupNumber 090041
BY /e� W
�
Signature and Title
Dated this 3rd day of December 19 97
iuiij -1
LiI
FAY f t._Vil Lc
p,'1RIcI fi-'
„/O,
REQUEST TO CONTINUE GROUP INSURANCE BENEFITS
Arkansas Blue Cross and Blue Shield
Preferred Provider Orginization(PPO)and Comprehensive Major Medical(CMM)
Group Name City of Fayetteville Administrator ms. Beff Kent
Group Number 090041 Anniversary DateJanuary 1, 1998
Address 113 W. Mountain Street
City Fayattevi11e State AR Zip 77701
To continue your current plan please complete the following data and mail using the enclosed
self-addressed enevelope.
Maintain Change
It is your desire to (check one): xx current benefits benefits as follows:
Underwriting guidelines require the employer pay at least 50% of the individual employee rate
and 75% of those eligible for coverage (minimum 3hours per week)participate:
40
Employer Contribution: (Including Dental) Percentage Dollars
Employee 85 % or $
inepetidax Family 65 % or $
Employee Statistics: • •
Total 490 Ineligible 0 Eligible 100% • Enrolled 100%
Dec. 3, 1997
Adminis r Signature Date
DEG
DISTRICI OFFICE
zrb. Arkansas
(-76) -TT
BlueCross BlueShield
An Independent Licensee of the Blue Cross and Blue Shield Association
ARKANSAS BLUE CROSS AND BLUE SHIELD
A Mutual Insurance Company
601 Gaines Street
P.O. Box 2181
Little Rock, Arkansas 72203
GROUP POLICY
We agree to provide to the eligible Employees of the Policyholder, and their covered
Dependents, the benefits set forth in the Benefit Certificate(s), attached to and
incorporated as part of this Policy in accordance with the terms, provisions and
limitations of this Policy.
This Policy is issued in consideration of the Policyholder's application, a copy of
which is attached, the Policyholder's covenants and the Policyholder's payment of
the premium.
This Policy becomes effective at 12:01 a.m. on the effective date shown on the
Schedule page. The Policy is renewable month to month, by payment of the
monthly premium. The premium for the Policy may be adjusted upon thirty (30)
days' notice. The Policy is subject to termination according to its terms.
The following pages, including the Benefit Certificate(s), the application and any
riders, endorsements or amendments are part of this Policy.
It is signed at our Home Office on the effective date.
President
GROUP INSURANCE POLICY
GMC-3 7/97
TABLE OF CONTENTS
PAGE
CLAIMS 15
COVENANTS OF THE POLICYHOLDER 7
DEFINITIONS 4
GENERAL PROVISIONS 17
POLICY PROVISIONS RELATIVE TO MEMBERSHIP,
MEETINGS AND VOTING 20
PROVISIONS RELATING TO PERSONAL
AND DEPENDENT INSURANCE 9
SCHEDULE 3
GMC-3 (7/97) 2
PLACE SCHEDULE HERE
e
E
■
I
I
■
I
e!
l
f
GMC-3 (7/97) 3
csa y
Arkansas 237 Millsap Road—Suite#1
v Q k' BlueCross BlueSineld Fayetteville,one:( 01 Ar7 72703
O Phone:(501)527-2310
FAX: (501)527-2323
CITY OF FAYETTEVILLE #090041
FAYETTEVILLE PUBLIC LIBRARY #90042
Summary of Comprehensive Major Medical(CMM) Benefits
DEDUCTIBLE: $100 per person,per year. Maximum of two per
family,per year.
THREE-MONTH CARRY-OVER: Services provided & applied toward the
deductible during the last three months of the
calendar year will be applied toward the
deductible for the next calendar year.
PAYMENT: After the deductible is met, except for some
items with special limitations, this program will
pay 80% of eligible charges until the $5,000
stop loss is met per person, per year. Remaining
eligible charges are paid in full for the calendar
year.
MAXIMUM BENEFIT: $1,000,000 maximum,per covered person.
SUPPLEMENTAL ACCIDENT: Pays first $500 of eligible expenses in full.
Deductible and co-insurance apply to eligible
charges above$500.
SPECIAL MATERNITY BENEFITS: 100% of routine outpatient pre-natal care.
"Special Delivery" 1-800-742-6457
PRESCRIPTION DRUG CARD: Per 34 day supply, $3 generic co-pay and $10
brand name co-pay. The $10 brand name co-
pay will apply when a generic drug is not
available or Policyholder's doctor prescribes
dispense as written. Co-pays do not apply
toward deductible or out-of-pocket.
CUSTOMER SERVICE TELEPHONE: Fayetteville Regional Office:
501-527-2310 or 1-800-817-7726
Little Rock Central Office: 1-800-421-1112
Together. For A State Of Better Health.
Arkansas Blue Cross and Blue Shield, A Mutual Insurance Company
An Independent Licensee of the Blue Cross and Blue Shield Association
•
1 1
CITY OF FAYETTEVILLE
FAYE F1'LVILLE PUBLIC LIBRARY
CMM Benefits Summary
Page 2
HOSPITAL ADMISSION: Pre-Admission certification: 1-800-451-7302
$200 penalty for non-compliance.
WELLNESS BENEFITS: See attached.
SPECIAL BENEFIT LIMITATIONS:
Psychiatric, Drug&
Alcoholism Conditions 50% -Maximum $4,000 per year
Ambulance 80%-Maximum $ 300 per year
Private-Duty Nursing 80% -Maximum $4,000 per year
Speech Therapy 80%-Maximum $ 500 per year
MANAGED DRUG PROGRAM
CO-PAY FEATURE
1. If the Policyholder accepts the generic drug:
Policyholder pays $3.00 (Generic Drug)
2. If there is no generic or prescription id"Dispense as Written"(DAW):
Policyholder pays $10.00 (Brand Name Drug)
3. If the Policyholder insists on brand name(not DAW):
Policyholder pays $3.00 plus the difference between the generic and brand name drug.
Minimum of$10.00
THE ABOVE LITERATURE IS FOR INFORMATION PURPOSES ONLY AND REFERS TO THE POLICYHOLDER'S
CONTRACT. THE INFORMATION PRESENTS A GENERAL OVERVIEW OF BENEFITS AND DOES NOT INCLUDE
ALL LIMITATION AND EXCLUSION PROVISIONS OF THE CONTRACT. ALL STATEMENTS ARE SUBJECT TO
THE TERMS OF THE CONTRACT. THE ABOVE INFORMATION IS NOT YOUR POLICY.
Arkansas'
OURCE
A Managed Health Care Partnership
WELLNESS BENEFIT CLARIFICATION
Arkansas Blue Cross and Blue Shield is now offering a Wellness Benefit to its Arkansas'
FirstSource PPO groups. Charges related to services provided under the Wellness Benefit can be
allowed up to the benefit maximum. A summary of the Wellness Benefit follows.
Provider Services Benefits In-Network Out-of-Network
WELLNESS BENEFIT
Routine Physical Exam Per Schedule
- For adult males and females 18 and older 100% 0%
-Per schedule, 1 exam 18-30, 1 exam 31-39 No Deductible
and one every 5 years after age 40 No Co-pay
- Up to $150 benefit
Annual Routine Gynecological Examinations and
Mammography Per Schedule
- Annual Routine Pelvic Exam 100% 0%
-Annual Routine Pap Smear No Deductible
-Mammography per schedule: 1 Mamm 35-40; No Co-pay
1 Mamm every 2 years 40-50; 1 Mamm per year
50+
-Up to $200 benefit
Preventive Child Care
- Covers children from birth to age 16 100% 0%
- Routine scheduled physical exams, assessments No Deductible
-Normal immunizations No Co-pay
- Covered visits are listed below
A covered visit is one occurring during one of the following intervals:
* within two weeks after birth;
* within two weeks preceding or following the eligible dependent reaches two, four, six, nine, 12
15 and 18 months of age;
* within one month preceding or following the eligible dependent reaches two, three, four, five,
six, eight, 10, 12, 14 and 16 years of age.
•
at. Arkansas 237 Millsap Road—Suite#1
VA BlueCross BlueShield Fayetteville,Arkansas 72703
Phone:(501)527-2310
FAX: (501)527-2323
CITY OF FAYETTEVILLE #090041 ,
•
FAYETTEVILLE PUBLIC LIBRARY #90042
Summary of Benefits & Rates
Anniversary Effective January 1, 1998
Current Benefits and Rates:
Benefits:
$100 Deductible; Two (2) deductibles maximum per family,per calendar year
80%/20% co-insurance split of the next$5,000
Remaining eligible charges paid in full for calendar year.
$1,000,000 Lifetime maximum
Wellness Benefits
$500 Supplemental Accident Endorsement
$3 generic co-pay/$10 name brand co-pay Drug Program
Maternity
Rates:
Employee $154.65
Family $374.29
•
Together. For A_State Of Better Health.
—Arkansas Blue Cross and.Blue Shield, A Mutual Insurance Company
An Independent Licensee of the Blue Cross and Blue Shield Association
as Arkansas 237 Millsap Road—Suite#1
929 BlueCross B1ueSliie�d Fayetteville, Arkansas 72703
Phone:(501) 527-2310
° FAX: (501) 527-2323
CITY OF FAYETTEVILLE #090041
FAYETTEVILLE PUBLIC LIBRARY #90042
Summary of Dental Benefits
Preventive Care Only
Services Include:
* Oral examination * Palliative (dental pain) emergency treatment
* X-Rays * Fillings
* Topical fluoride application for * Simple extractions
subscribers under age 19 * Endodontics, including pulpotomy, pulp
* Prophylaxis, including cleaning, capping and root canal treatment
scaling, and polishing * Space maintainers
* Repair of dentures
Payment will be based on 100%of the Dental Fee Schedule
Restorative Care
- Services Include:
* Crowns
* Bridges
* Oral surgery
* Periodontics ( diseases of the tissue and bones)
* Dentures (full and partial)
Payment will be based on 50%of the Dental Fee Schedule
Orthodontic Care
For members under age 19, this plan will cover the initial and subsequent installation of
orthodontic appliances and treatments for the reduction or elimination of an existing
malocclusion.
Payment will be based on 50%of the Dental Fee Schedule
Annual Deductible and Maximum Payments, Per Person:
Deductible for Preventive Care Only or Full Package $ 50.00
Maximum payment for Preventive Care Only or Full Package $1,500.00
Maximum lifetime payment for Orthodontic $1,000.00
The Preferred Payment Plan(PPP)Directory lists participating dentists who agree to accept the Dental Fee
Schedule and also agree to file claims for you. Dental Benefits and Rates
Together. For A State Of Better Health.
Arkansas Blue Cross and Blue Shield, A Mutual Insurance Company
An Independent Licensee of the Blue Cross and Blue Shield Association
Arkansas 237 Millsap Road—Suite#1
Qa 04.
Fayetteville,Arkansas 72703
vQQ `P BlueCross BlueShield Phone:(501)527-2310
° FAX: (501) 527-2323
CITY OF FAYETTEVILLE #090041
FAYETTEVILLE PUBLIC LIBRARY #90042
Dental Benefits Rates
Rates for Preventive,Restorative Employee $14.26
and Orthodontic Care: Family $49.97
Rates are guaranteed for twelve months from the policy's anniversary date.
All employees and dependents enrolled in the group health plan must be enrolled in the dental
plan.
Dependent coverage to age 19, dependent students coverage to age 23.
This plan does not provide benefits for cases covered by worker's compensation laws,
employer's liability, occupational disease, vehicle no-fault laws, rest cures, or services received
as a matter of legal right at federal or local expense.
THE ABOVE LITERATURE IS FOR INFORMATION ONLY AND REFERS TO THE POLICYHOLDER'S CONTRACT.
ALL STATEMENTS ARE SUBJECT TO THE TERMS OF THE CONTRACT.
Together. For A State Of Better Health.
Arkansas Blue Cross and Blue Shield, A Mutual Insurance Company
An Independent Licensee of the Blue Cross and Blue Shield Association
•
DEFINITIONS
Child means an Employee's natural Child, legally adopted Child, stepchild or Foster
Child. "Child" also means a Child that has been placed with the Employee for
adoption. "Child" also means a Child for whom the Employer must provide medical
support under a qualified medical Child support order.
Company means Arkansas Blue Cross and Blue Shield, A Mutual Insurance
Company.
Contributory Insurance means insurance for which the Employee must apply and
agree to make the required premium contributions.
Covered Person means an Employee or Dependent who is insured under this
Policy.
Dependent means only the following persons who are not otherwise eligible as
Employees:
a. an Employee's spouse;
b. an Employee's unmarried Child less than 19 years of age;
c. an Employee's unmarried Child age 19 but less than age 23, who is:
(1) not working on a full-time basis; and
(2) is a full-time student in an accredited school; or
d. an Employee's unmarried Child who is incapable of self support
because of mental retardation or severe physical handicap, provided
such Child is or was under the limiting age of dependency stated in
subsections b. and c. above at the time of application for coverage.
Dependent Insurance means insurance on the Dependent of an Employee.
Eligibility Date means:
For an Employee, the latest of the following dates:
1) the Policy effective date for an Employee working for the Employer on that
date;
2) the date the required Eligibility Period is completed for any Employee hired
after the Policy effective date.
For a Dependent, the latest of the following dates:
1) the date the Employee becomes eligible for Dependent Insurance;
2) the date a person becomes a Dependent; or
3) the date this Policy is amended to include the Employee's class as being
eligible for Dependent Insurance.
Eligibility Period means the time beginning with the Employee's most recent date of
continuous employment with the Employer and ending on the date he is eligible for
insurance. The Employer establishes the Eligibility Period.
GMC-3 (7/97) 4
Employed on a part-time basis means that the employment of a person results in
his active expenditure of less than thirty hours per week or less than 48 weeks per
year. Such person employed on a part-time basis is not eligible for insurance.
Employee means a person who is directly employed by the Employer for 30 hours
or more each week and 48 weeks or more each year. This person must reside in
the United States and be paid for full-time work in the conduct of the Employer's
regular business. No director or officer of the Employer shall be considered an
Employee unless he meets the above conditions.
Employer means a sole proprietorship, partnership, or corporation which is the
Policyholder.
Foster Child or Stepchild means a child who is related to an Employee by blood or
marriage or a Child for whom an Employee has assumed a legal duty, provided:
a. such Child lives with the Employee in a parent-child relationship; and
b. the Employee has a legal right to claim such Child as a Dependent on
his federal income tax form.
Grace Period means the period of 31 consecutive days beginning with any premium
due date after the first which shall be allowed for payment of premium.
Non-Contributory Insurance means insurance for which the employee must apply
but does not have to make any premium contributions.
Personal Insurance means insurance on the employee.
Placement, or being placed, for adoption means the assumption and retention of
a legal obligtion for total or partial support of a Child by a person with whom the
Child has been placed in anticipation of the Child's adoption. The Child's placement
for adoption with such person terminates upon the termination of such legal
obligation.
Plan means the Employee Health Benefit Plan established by the Employer. The
terms of the Plan are set forth in this Policy.
Plan Administrator means the Employer.
Plan Year means the Plan Year stated in the Employee Health Benefit Plan
Summary Plan Description, or if not stated in that document, or if that document
does not exist, the twelve month period ending on the day before the anniversary
date of the effective date of this Policy.
Policy means this policy.
3
Policyholder means the Employer as shown in the Schedule.
Policy Month means a month commencing on the first day of the calendar month
and expiring on the last day of the calendar month or commencing on the fifteenth
GMC-3 (7/97) 5
•
day of the month and expiring on the fourteenth day of the following month,
depending upon the billing cycle applied by the Company. The Policy Month is set
out in the Schedule.
Stepchild see definition of Foster Child.
GMC-3 (7/97) 6
COVENANTS OF THE POLICYHOLDER
As part of the consideration for this Policy, Policyholder understands, acknowledges
and agrees:
Plan Administrator
The Policyholder is the Plan Administrator of the Employee Health Benefit Plan, the
terms of which are set forth in this Policy. The Policyholder gives the Company
authority and full discretion to audit Policyholder's records relating to this Policy and
to determine all questions arising in connection with insurance benefits, including but
not limited to eligibility, interpretation of Plan language, and findings of fact with
regard to any such questions. The actions, determinations and interpretations of the
Company acting on behalf of the Plan within the scope of this authority shall be
conclusive and binding on the Policyholder and the Covered Person.
Employee and Dependent Eligibility
The Policyholder shall accurately report Employee and Dependent eligibility
information to the Company. Failure of the Policyholder to provide timely notice
to the Company of a change in the eligibility status of an Employee or
Dependent shall result in the Policyholder being liable to the Company for any
claims paid in error to such Employee or Dependent by the Company.
Employee Participation
This Policy may be terminated by the Company if the percentage of eligible
Employees of the Policyholder covered by the Policy becomes less than the
percentage of Employee participation specified in the Schedule, or if the number of
insured Employees falls below the minimum number of insured Employees specified
in the Schedule.
Dependent Participation
This Policy may be terminated by the Company if the percentage of eligible
Dependents of eligible Employees of the Policyholder covered by the Policy
becomes less than the percentage of Dependent participation specified in the
Schedule.
Contribution
This Policy may be terminated by the Company if the Policyholder fails to contribute
the percentage of Employees' premium specified in the Schedule.
Payment of Premium
The Policyholder shall pay the Company the premiums for covered Employees and
Dependents every month, in advance.
COBRA
If COBRA applies to the Plan, the Policyholder, as Plan Administrator, must provide
its Employees and their Dependents notice of COBRA rights at the time their
coverage commences under this Policy and must notify the Employee or Dependent
of his right to elect continuation of coverage under COBRA within fourteen (14) days
of the happening of a "qualifying event" under COBRA. The Company shall not
GMC-3 (7/97) 7
assume the Policyholder's obligation to provide benefits under COBRA if the
Policyholder fails to provide these notices at the times specified in this Policy,
nor shall the Company be responsible for providing any COBRA notices to
Employees or Dependents.
HIPAA
The Policyholder, as Plan Administrator, is legally obligated, along with the
Company, to comply with the provisons of the Health Insurance Portability and
Accountability Act of 1996, ("HIPAA"). The Policyholder shall cooperate with the
Company to assure information concerning prior health insurance coverage of
individuals, both Employees and Dependents, is communicated to the Company
when such individuals are enrolled. The Policyholder shall assist the Company in
providing Certificates of Creditable Coverage to individuals, both Employees and
Dependents, who terminate their coverage under this group Policy, in accordance
with the provisions of HIPAA. Policyholder agrees to indemnify and hold the
Company harmless if any action or inaction of the Policyholder results in the
Company being charged with violating HIPAA.
Agent for Employees
The Policyholder is the agent for its Employees and their Dependents in all dealings
between Employees or Dependents and the Company, including:
1. payment of premiums to the Company;
2. notifying the Company of changes in Employee or Dependent status;
3. securing and forwarding to the Company applications for coverage of new
Employees or new Dependents; and
4. providing Employees and Dependents all communications and notices from
the Company.
Contract with Arkansas Blue Cross and Blue Shield
On behalf of Policyholder and its Employees, the Policyholder acknowledges its
understanding that this Policy constitutes a contract solely between the Policyholder
and Arkansas Blue Cross and Blue Shield, that Arkansas Blue Cross and Blue
Shield is an inDependent corporation operating under a license with the Blue Cross
and Blue Shield Association, an association of independent Blue Cross and Blue
Shield Plans, (the "Association") permitting Arkansas Blue Cross and Blue Shield to
use the Blue Cross and Blue Shield Service Marks in the State of Arkansas, and that
Arkansas Blue Cross and Blue Shield is not contracting as the agent of the
Association. The Policyholder further acknowledges and agrees that it has not
entered into this Policy based upon representations by any person other than
Arkansas Blue Cross and Blue Shield and that no person, entity, or organization
other than Arkansas Blue Cross and Blue Shield shall be held accountable or liable
to Policyholder for any of the obligations created under this Policy.
GMC-3 (7/97) 8
PROVISIONS RELATING TO PERSONAL AND DEPENDENT INSURANCE
Individual Eligibility Date
Employees who work on a full-time basis for the Employer are eligible for insurance
after completion of the required Eligibility Period, provided they are in a class of
Employees who are included in the Plan and set out in the Schedule. Employees
shall be considered to work on a full-time basis if they customarily work at least 30
hours per week and 48 weeks per year..
An Employee shall become eligible for insurance on the latest of the following dates:
1) the effective date of this Policy;
2) the end of the specified Eligibility Period;
3) the date this Policy is changed to include the Employee's class; or
4) the date the Employee becomes a member of a class eligible for insurance.
Effective Date of Personal Insurance
An Employee must use forms provided by the Company when applying for
insurance.
The Employee's insurance shall be effective 12:01 a.m.:
1) if it is non-contributory, on the first day of the Policy Month following the date
the Employee becomes eligible for coverage regardless of when application
was made; or
2) if it is contributory and the Employee makes application within 30 days after
the date he first became eligible, on the first day of the Policy Month following
his Eligibility Date.
3) if it is contributory and the Employee does not apply for insurance within 30
days after the date he first became eligible, the first day of the Policy Month
following the date the Employee's application is accepted by the Company.
Termination of Personal Insurance
Personal Insurance shall terminate at 12:00 midnight on the earliest of the following
dates:
1) the last day of the period for which a premium payment is made, if the next
payment is not made;
2) the date the Employee becomes a member of the armed forces;
3) the date this Policy terminates or is amended to terminate insurance provided
by a particular provision;
4) the date the Employee ceases to be a member of a class eligible for
insurance; or
5) the last day of the period for which a premium payment is made in which the
Employee ceases to be a full time Employee.
During any leave taken under the Family and Medical Leave Act, the Employee shall
continue to have coverage under this Policy provided premiums for continuation of
coverage are paid by or through the Employer. Coverage shall terminate on the
date determined by 1 through 5 above, even if the Employee has rights against his
Employer under the Family and Medical Leave Act.
GMC-3 (7/97) 9
Eligibility Date for Dependent Insurance
Dependents are eligible for insurance on the latest of the following dates:
1) the date the Employee becomes eligible for Dependent Insurance;
2) the date a person becomes a Dependent; or
3) the date this Policy is amended to include the Employee's class as being
eligible for Dependent Insurance.
The Employee's spouse or Child shall not be eligible for Dependent Insurance if
they:
1) have Personal Insurance under this Policy; or
2) are in active military service.
If both the Employee and spouse are insured as Employees, their eligible children
may be insured as Dependents of only one of them.
Effective Date of Dependent Insurance
An Employee must use forms provided by the Company when applying for
Dependent Insurance.
Dependents shall not be insured until the Employee is insured.
The Dependent Insurance shall be effective at 12:01 a.m.:
1) if it is non-contributory, on the date the Dependent becomes eligible for
coverage regardless of when application was made; or
2) if it is contributory and the Employee makes application within thirty (30) days
after the date the Dependent first became eligible, on the first day of the
Policy Month following the Dependent's Eligibility Date. If the Dependent is a
newborn Child, coverage will be effective as of the date of the Child's birth,
Dependent Insurance premium shall be payable from the first day of the
billing cycle in which the Child is born.
3) if it is contributory and the Employee fails to make application within thirty (30)
days after the date the Dependent becomes eligible, the first day of the Policy
Month following the date the Employee's application is accepted by the
Company. If the Dependent is an adopted Child and the application is
submitted within 60 days of the date of the petition for adoption or within 60
days of the Child being placed with the Employee for adoption, coverage will
be effective as of the date of the petition or placement for adoption. Coverage
will begin on the adopted Child's date of birth if the petition for adoption or
placement for adoption and the application for coverage occurred within sixty
days of the Child's birth. Dependent Insurance premium shall be payable
from the first day of the billing cycle in which the adopted Child is covered
under this Policy.
Medical Support Orders
Dependent Insurance shall be extended, on the same basis as to other children, to
a Child for whom the Employee must provide medical support under a qualified
medical support order regardless of whether the Child resides with the Employee or
is claimed by the Employee as an exemption for federal income tax purposes.
GMC-3 (7/97) 10
Termination of Dependent Insurance
Insurance on a Dependent shall terminate at 12:00 midnight on the earliest of the
following dates:
1) the-last day of the period for which a premium payment is made in which he
ceases to be a Dependent as defined in the Definition section;
2) the date the Employee ceases to be a member of a class eligible for
Dependents insurance;
3) the date the Employee's insurance under this Policy terminates;
4) the last day of the period for which a required Dependent's premium payment
is made, if the next payment is not made; or
5) the date this Policy terminates.
Continuation of Insurance for a Handicapped Dependent Child
If a Dependent is not capable of self-sustaining employment due to mental
retardation or physical handicap, his insurance shall not terminate when the Child
reaches the limiting age for dependency. The insurance shall continue as long as
the Child remains handicapped, unless coverage terminates as described in the
Termination of Dependent Insurance provision above, if the Employee gives the
Company proof that the Child is:
1) incapable of self-sustaining employment; and
2) chiefly Dependent on the Employee for support and maintenance.
The Employee must give the Company written proof after the Child reaches the
limiting age for dependency and at any time after as the Company may require. The
Company shall not require proof more than once a year after the two year period
following the date the Child reaches the limiting age for dependency.
Continuation Privileges
A Covered Person whose employment terminates or dependency status changes
shall have the right to elect continuation of coverage under the Policy as outlined
below. In order to be eligible for this option, the Covered Person must:
1. have been continuously covered under the Policy for at least three (3)
consecutive months prior to employment termination or change in
dependency status; and
2, make the election by notifying the Policyholder [Employer] or the
Company in writing no later than ten (10) days after the employment
termination or change in dependency status.
Continuation shall terminate on the earliest of:
1. One hundred twenty (120) days after the date the election is made;
2. the date the Covered Person fails to make any premium payments or
the Policyholder fails to pay the premium to the Company;
3. the date on which the Covered Person is or could be covered by
Medicare;
4. the date on which the Covered Person is covered for similar benefits
under another group or individual Policy;
GMC-3 (7/97) 11
5. the date on which the Covered Person is eligible for similar benefits
under another group Plan;
6. the date on which similar benefits are provided for or available to the
Covered Person under any state or federal law; or
7. the date on which the Policy terminates.
Any Covered Person qualifying for continuation of coverage may elect a converted
Policy instead of such continuation of group insurance. If the Covered Person has
elected continuation under this provision, he shall have the option of conversion
coverage at the end of the maximum continuation period.
FEDERAL RIGHTS
Continuation of Benefits
If Section 10001 of the Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA) applies to the Employer, the coverage of an Employee or Dependent
whose insurance ends due to a Qualifying Event may be continued while the Policy
remains in force subject to the terms of this section and all terms and provisions of
the Group Policy not inconsistent with this section.
This provision shall not be interpreted to grant to any Covered Person any
continuation rights under this Policy in excess of those required by COBRA. If the
Policyholder fails to comply with the provisions of this Policy concerning COBRA or
the notice requirements or other standards under COBRA, the Company shall not
assume the Policyholder's obligation to provide COBRA continued coverage under
the Plan.
Qualifying Events
The following is a list of events which could result in termination of a Covered
Person's insurance under the Group Policy. If such should occur, for purposes of
this section, the event shall be called a Qualifying Event.
1) An Employee's death.
2) Termination of employment (other than by reason of an Employee's gross
misconduct), or of an Employee's eligibility due to reduction in the Employee's
hours.
3) An Employee divorcing or becoming legally separated from his spouse.
4) An Employee becoming eligible for Medicare.
5) A Dependent Child ceasing to be a Dependent Child as defined in the Group
Policy.
Requirements for COBRA Continuation
Continuation under this section is subject to a Covered Person requesting it and
paying any required premium contributions to the Policyholder within his election
period.
The Policyholder, as Plan Administrator, must have provided the Covered Person an
initial notice of COBRA rights at the time coverage commenced under the Plan (this
Policy); and the Plan Administrator must notify the person qualified to elect
continuation of coverage under COBRA ("Qualified Insured") of his right to elect
coverage within fourteen (14) days of the happening of any of the qualifying events
GMC-3 (7/97) 12
listed above. The Covered Person must notify the Plan Administrator within 60 days
of the happening of qualifying event (3) or (5) above.
The Qualified Insured must elect to continue the group insurance within sixty (60)
days of the later of:
(a) the date the notification of election rights is sent; or
(b) the date benefits under the Plan terminate.
Otherwise it shall end on the date sixty (60) days following the date his insurance
terminated.
If an Employee with Dependent Insurance requests continuation of coverage under
this section, such request shall include the Dependent Insurance, unless the
Employee asks that it be dropped. In like manner, such a request on the part of the
insured spouse of an Employee shall include coverage for all Dependents of the
Employee who were insured.
Insurance Continued
The benefit continued for a Covered Person in accordance with this section shall be
the same as otherwise provided under the Group Policy for other Covered Persons
in the same benefit class in which such Covered Person would have been insured
had his insurance not, except for this section, terminated. As such, the coverage
shall be subject to the Group Policy affecting the benefits of such class following the
Qualifying Event.
In no case shall the coverage continued under this section include insurance to
which this section does not apply.
Termination
Coverage being continued for a Covered Person under this section shall terminate
on the earliest of the following applicable dates:
1) The date the Group Policy terminates or is amended to terminate the
insurance of the particular section of the Group Policy under which the
coverage is provided;
2) At the end of the last period for which premium contributions for such
coverage have been made, if the Employee or other responsible person does
not make, when due, the required premium contribution to the policyholder;
3) The date ending the maximum period. In the case of Qualifying Event 2
above (relating to termination of employment or reduction in hours), this date
shall be the date eighteen (18) months after the date of that Qualifying Event;
unless the Covered Person is disabled at the time of, or within sixty (60) days
after his termination or reduction in hours, in which case this date shall be
twenty-nine (29) months after the Qualifying Event. In all other cases, such
date shall be the date thirty-six (36) months after the date of that Qualifying
Event which applies;
4) The date the Covered Person becomes a covered Employee under any other
group health Plan;
5) The date the Covered Person becomes eligible for Medicare; or
GMC-3 (7/97) 13
6) In the case of the Employee's spouse or former spouse, the date such
Covered Person remarries and becomes covered under any other group
health Plan.
Conversion Privileges
A Covered Person whose coverage terminates shall have the right to a conversion
Policy issued by the Company.
There is no right of conversion if:
1. the termination of coverage occurred because of the Covered Person's
failure to make a required premium contribution or the discontinued or
terminated group coverage was replaced by similar group coverage
within thirty-one (31) days of the discontinuance;
2. the Covered Person is or could be covered by Medicare;
3. the Covered Person has similar benefits under another group or
individual Plan;
4. the Covered Person is eligible for similar coverage under another
group Plan whether insured or uninsured; or
5. similar benefits are provided for or are available to the Covered Person
under any state or federal law.
Written application and payment of the first premium must be made to the Company
within thirty-one (31) days after the date coverage terminates.
No evidence of insurability is required.
GMC-3 (7/97) 14
CLAIMS
Proof of Loss
Written proof of a claim must be given not later than December 31 of the calendar
year following the one in which the services, supplies or treatment causing the claim
were received.
Subject to all applicable statutory provisions and rules and regulations state or
federal regulatory authority, all benefits payable under this policy shall be payable
immediately upon receipt of written proof of loss.
Facility of Payment
The Company may, at its option, pay all or any benefits to the hospital, other
institutions or the person giving medical services or supplies to the Covered Person.
Any payment made according to the above paragraph shall discharge the Company
to the extent of any such payment. The Company shall not be bound to see to the
use of the money so paid.
Legal Actions
The Covered Person may not bring suit to recover until 60 days after written proof of
loss is furnished. No suit may be brought more than three years from the time
written proof of loss is required to be given.
Not Worker's Compensation Insurance
The insurance provided by the policy shall not take the place of and shall not affect
any requirement for coverage by Worker's Compensation Insurance.
Assignment
No assignment of benefits under this policy shall be valid until approved and
accepted by the Company. The Company reserves the right to make payment of
benefits, in its sole discretion, directly to the provider of service or to the Covered
Person.
Claim Review
If a claim for benefits is denied either in whole or in part, the Employee shall receive
a notice explaining the reason or reasons for the denial. The Employee may request
a review of a denial of benefits for any claim or portion of a claim by sending a
written request to the Appeals Coordinator, Arkansas Blue Cross and Blue Shield, A
Mutual Insurance Company, Post Office Box 2181, Little Rock, AR 72203. The
Employee's request must be made within 60 days after he has been notified of the
denial of benefits.
In preparing his request for review, the Employee or his duly authorized
representative shall have the right to examine documents pertinent to the
Employee's claim. However, medical information may be released to the Employee
only upon the written authorization of his physician. The Employee or his
representative may submit, with his request for review, any additional information
GMC-3 (7/97) 15
•
relevant to his claim and may also submit issues and comments in writing. A
complete review shall then be made of all information relating to the claim. The
Employee shall receive a final decision in writing within sixty (60) days after the
receipt of his review request, except where special circumstances require extensive
review. A final decision shall be sent to the Employee after no longer than 120 days.
The Company acting on behalf of the Plan shall have authority and full discretion to
determine all questions arising in connection with the Employee's insurance benefits,
including but not limited to eligibility, interpretation of Plan language, and findings of
fact with regard to any such questions. The actions, determinations and
interpretations of the Company acting on behalf of the Plan with respect to all such
matters, and with respect to any other matters within the scope of its authority, shall
be conclusive and binding on the Employee and the policyholder.
GMC-3 (7/97) 16
•
•
•
GENERAL PROVISIONS
Entire Contract
The entire contract of insurance is made up of this policy, the benefit certificate
issued to Employees, amendments to the Policy, amendments to the benefit
certificate and the application of the Policyholder attached. The individual
applications also become a part of this contract. Benefit Summary Cards issued to
Covered Persons are for convenient summary only and do not constitute part of this
contract of insurance. In the absence of fraud, all statements made by the
Policyholder or by persons insured are representations and not warranties. No such
statement shall be used in any contest under this Policy unless it is contained in a
written instrument and a copy of such instrument is or has been furnished to such
person.
Time Limit on Certain Defenses
Except for failure to comply with the participation and contribution requirements or
nonpayment of premium, this Policy shall not be contested after it has been in force
for two years. Statements a Covered Person makes about his insurability shall not
be used to void insurance or deny a claim unless:
1. the statements are contained in a written document signed by the Covered
Person; and
2. the loss on which claim is based occurs within two (2) years following the date
of the signed written document.
Changes to Policy
The company reserves the right to amend this policy, in which case the amendment
shall be deemed an amendment to the policyholder's employee health benefit plan.
The procedure for amendment to this policy and the Plan shall be that the company
shall give 30 days' written notice to the policyholder, prior to the next renewal date of
the policy. The chang3 shall go into effect on the date fixed in the notice.
No agent or employee of the company may change or modify any benefit, term,
condition, limitation or exclusion of this policy. Any change or amendment must be
in writing and signed by an officer of the company.
Premium Payments
All premiums are payable at the Company's Home Office. The Policyholder must
make the first premium payment on or before the date the insurance is scheduled to
take effect. Future premiums are due and payable in advance.
Premium Rates
The premiums charged for insurance under this Policy may be changed with 30 days
written notice:
1. on any premium due date; or
2. if the Policy's terms have been changed.
Misstatement of Age
If the age of a Covered Person has been misstated and such misstatement requires
a correction in the premium rate, premiums shall be adjusted to the premium rate for
GMC-3 (7/97) 17
the correct age, and the difference in past premium paid shall shall be paid to or
refunded by the Company.
Right of Rescission
Material representation, misstatements, or omissions of information may be used by
the Company as the basis for rescission of coverage of the Policyholder, any
Employee or any Dependent.
Grace Period
Any premium for this insurance which is not paid on or before the date it becomes
due is in default. After the first premium payment, the Policyholder shall be allowed
a 31 days Grace Period. During the Grace Period, there is no interest charge and
the insurance shall remain in force.
Termination of This Policy
The Policyholder may terminate this Policy on any premium due date by giving the
Company written notice of termination in advance of the premium due date. Any
premiums paid beyond the requested termination date shall be refunded.
The Company may terminate this Policy on any premium due date if:
1. the percentage of eligible Employees of Policyholder covered by the Policy
becomes less than the percentage of Employee participation specified in the
Schedule, or if the number of insured Employees falls below the minimum
number of insured Employees specified in the Schedule;
2. the percentage of eligible Dependents of eligible Employees of Policyholder
covered by the Policy becomes less than the percentage of Dependent
participation specified in the Schedule;
3. the Employer fails to contribute the agreed upon share of the
premiumsspecified in the Schedule; or
4. the Employer performs an act or practice that constitutes fraud or makes an
intentional misrepresentation of a material fact under the terms of the coverage.
The Company may terminate this Policy upon giving the Employer 90 days notice, in
the event the Company discontinues issuing this Policy form in the State of
Arkansas. In such event the Company shall offer the Employer the option to
purchase any other group health insurance coverage currently being offered by the
Company in Arkansas.
This Policy shall terminate at the end of the Grace Period, if the premium due is not
paid within the Grace Period.
When the Policy terminates, the Policyholder is liable to the Company for payment of
all premiums which are due but unpaid at the time of termination or for
reimbursement to the Company for all claims incurred during the Grace Period,
which ever is the greater amount.
It is the duty of the Policyholder, and not the Company, to notify all affected Covered
Persons that the Policy and their coverage is terminated. The Company shall not be
responsible under any circumstances to provide notices to any Employee or other
GMC-3 (7/97) 18
Covered Person of the status of premium payments, coverage or the lack of
coverage under this Policy or the Plan.
If this Policy terminates because the Policyholder has failed to pay the premium, the
Policyholder shall not be eligilbe to reapply for another Policy with the Company for a -
period of six months from the date this Policy terminated.
Records and Reports
The Policyholder shall keep records and furnish information to the company upon -
request regarding:
1. Covered Persons and their insured Dependents; -
2. changes in the amounts of insurance; and =
3. termination of insurance.
Clerical Errors
A clerical error shall not affect the amount of insurance to which the Covered Person
is entitled. Delay or failure to report termination of any insurance shall not continue the insurance in force beyond the date it terminates. A retroactive adjustment of
premium, for up to 12 months, shall be made if clerical error is found.
Certificate of Insurance _
The Company shall provide the Policyholder with benefit certificates or booklets like
the one which is incorporated into and made a part of this Policy. It is the obligation
of the Policyholder to distribute these benefit certificates to each Covered Person.
ERISA Notices and Plan Documents -
The Policyholder, and not the Company, shall be responsible, as Plan Administrator,
for providing all ERISA notices and summary plan descriptions to Covered Persons.
Sex and Number
When used in this Policy, the masculine includes the feminine, the singular the
plural, and the plural the singular.
Conformity With Statutes
If any provision does not comply with any law of the State of Arkansas, this Policy is
deemed amended to meet the minimum requirements of the law, unless such law is
pre-empted by federal law or found to be void by a court of competent jurisdiction, in
which case any amendment to the Policy required by the pre-empted or voided law
shall be deemed rescinded.
GMC-3 (7/97) 19
POLICY PROVISIONS RELATIVE TO MEMBERSHIP, MEETINGS AND VOTING
Membership
The Policyholder is a member of Arkansas Blue Cross and Blue Shield, a Mutual
Insurance Company.
Annual Meeting
An annual meeting of the members shall be held each and every calendar year in
the State of Arkansas for the purpose of electing directors, receiving and considering
reports as to the business and affairs of the Corporation and transacting such other
business as may properly come before the meeting. The meeting shall be held
between January 1 and April 1 of each year at such place, date and time as shall be
fixed by the Board of Directors or the Chief Executive Officer. The Board of
Directors may, from time to time, provide that the place, date and time of the annual
meeting shall be set forth in the Policy of members as provided in Article III, Section
3 of these Bylaws.
"THE ANNUAL MEETING OF THE MEMBERS SHALL BE HELD
EACH YEAR AT THE HOME OFFICE, LOCATED AT 601 GAINES
STREET, LITTLE ROCK, ARKANSAS, ON THE THIRD MONDAY IN
MARCH AT 1 :00 P.M. (PROVIDED, IF SUCH DAY SHALL BE A
LEGAL HOLIDAY, THEN AT THE SAME TIME AND PLACE ON THE
NEXT SUCCEEDING DATE WHICH IS NOT A LEGAL HOLIDAY)."
Special Meetings
A special meeting of members for any purpose may be called by the Board of
Directors or Chief Executive Officer, and shall be called by the Chief Executive
Officer of the Secretary at the request of members holding one-third (1/3) of the
voting power entitled to vote thereat. Such request shall state the purpose or
purposes of the meeting, and no other business outside the scope of the state
purpose or purposes shall be transacted. Unless ordered by the Board of Directors,
the time and place of each special meeting of members shall be determined by the
Chief Executive Officer.
Notice of Meetings
So long as each insurance Policy issued by the Corporation sets forth the place,
date and hour of the annual meeting of members, no notice of any annual meeting
shall be required to be given to any member, regardless of the number or nature of
proposals to be considered and voted upon at the annual meeting. If notice of the
annual meeting is not set forth in each insurance Policy, written or printed notice of
the annual meeting and every special meeting of the members, stating the place,
date, time and the purpose or purposes of such meeting shall be given to the
members entitled to vote at such meeting not less than ten (10), nor more than sixty
(60), days before the date of the meeting. All such notices shall be given, either
personally or by the mail, by or at the direction of the Chief Executive Officer or
Secretary unless ordered by the Board of Directors. Notices which shall be mailed
shall be deemed to be "given" when deposited in the United States Mail addressed
to the member at the member's address as it appears on the records of the
Corporation, with postage prepaid [first class mail], if the notice is mailed thirty (30)
GMC-3 (7/97) 20
•
days or less before the date of the meeting], and any notice transmitted other than
by mail shall be deemed to have been "given" when delivered to the member.
Quorum
Except as otherwise provided by applicable law, a majority of the members of the
Corporation (present in person or by proxy) shall be necessary to constitute a
quorum for the transaction of business at any annual or special meeting of the
members of the Corporation.
Voting Rights
Each member shall be entitled to one vote for each Policy held by him upon each
matter coming to a vote at meetings of members. Provided, a group Policyholder
shall be entitled to a number of votes equal to the number of certificate holders
insured under the group Policy. Such vote may be exercised in person or by written
proxy.
Vote Required
A majority of the voting power represented at any meeting of members shall be
necessary and sufficient to approve any given matter. There shall be no cumulative
voting.
Proxy
At all meetings of members a member may vote by proxy executed in writing by the
member or by the member's duly authorized attorney in fact. Such proxy shall be
filed with the Secretary before commencement of the meeting or at such late time as
shall be expressly permitted by the Corporate officer presiding at such meeting.
Each application for an insurance Policy issued by the Corporation shall contain a
provision pursuant to which the Policyholder thereof grants a revocable proxy to the
Board of Directors with respect to all matters to be considered and voted upon by
members at any meeting occuring while such insurance Policy is in force.
GMC-3 (7/97) 21