HomeMy WebLinkAbout50-92 RESOLUTION•
•
RESOLUTION NO. 50-92
A RESOLUTION AUTHORIZING THE RENEWAL OF THE
BLUE CROSS/BLUE SHIELD CONTRACT FOR GROUP
MEDICAL, DENTAL, LIFE, AD&D, AND LTD INSURANCE
PLANS FOR THE POLICY YEAR 5/1/92 THROUGH
4/30/92.
BE IT RESOLVED BY THE BOARD OF DIRECTORS OF THE CITY OF
FAYETTEVILLE, ARKANSAS:
Section 1. That the Mayor and City Clerk are hereby
authorized and directed to execute the renewal of the Blue
Cross/Blue Shield contract for Group Medical, Dental, Life, AD&D,
and LTD insurance plans for the policy year 5/1/92 through 4/30/92.
A copy of the contract authorized for execution hereby is attached
hereto marked Exhibit "A" and made a part hereof.
PASSED AND APPROVED this 7th day of April , 1992.
APPROVED:
By: eel/
Mayor
ATTEST:
By:
• 0
• /
•
City CI rk
•
•
•
USAble Life
TO: FRANCISKUEHN
FROM: JODYWIIIJAME
DATE: 3/16/92
SUBJECT: CITY OF FAYETTEVILLE
GROUP NUMBER: 2467-001
RENEWAL DATE: 6/1/92
Just a reminder that Subject Group has the following voluntary
product(s) in force:
VOLUNTARY AD&D 9 of employees enrolled
VOLUNTARY SHB 9 of employees enrolled
340
The voluntary rates will remain the same. however if the group
would like to up -grade their benefits or add employees, now is
the time to do so.
Please remember to submit these applications to the Underwriting
Department, along with a memo as to what has transpired.
Thank You(
MARKETING REPRESENTATIVE REASSIGNMENT
FROM: TO:
Regional Manager
Director of Marketing Date
USAble Life
FOR GROUP'S 1992 RENEWAL
ELECTION OR WAIVER OF PAYMENT FOR
LICENSED PROFESSIONAL COUNSELORS
A.C.A S23-85-138 requires the offering of coverage for the
payment of services rendered by licensed professional counselors.
The Plan hereby offers such coverage subject to the exclusions
and limitations of the group master contract for psychiatric care.
By accepting as indicated below, the group agrees to pay the Plan
the increased rates of $4.55 per contract for such coverage.
0 Please add this additional Valle decline this benefit
benefit at the increased rate.
K /1-•
-fa ,
Si ature 1 Administrator
ELECTION OR WAIVER OF PAYMENT FOR
PSYCHOLOGICAL EXAMINERS
A.C.A S23-79-142 requires the offering of coverage for the
payment of services rendered by psychological examiners.
The Plan hereby offers such coverage, subject to the
exclusions and limitations of the group master contract for
psychiatric care. By accepting as indicated below, the group
agrees to pay the Plan the increased rates of $4.55 per contract
for such coverage.
Please add this additional 171 We decline this benefit.
benefit at the increased rate.
)(i
44//.. N.4)/71
tura ofulAdminiStrator
c.1/121/ 14;o5:11.t"
Group Name and Number
Date
USAble Life
P0. Box 1650
Litile Rock, AR 72203
(501) 375-7200
RENEWAL NOTIFICATION FORM
Policyholder: CITY OF FAYETTEVILLE
Description of Classee
ALL EMPLOYEES
Remarks:
Current Premium itatee
Renewal Premium Rates:
LIFE AD&D
1 i X ANNUAL 14 X ANNUAL
SALARY SALARY
.28 .07
.28 .07
Renewal Date:
Marketing Represaaalive:
Group if:
Dale Typed:
STD DEP LIFE
05/01/92
KUEHN
2467
2/11/92
CERTIFICATION OF ENROLLMENT AND ELIGIBILITY
We have reviewed the enrollment in the above group plan and our employee records. We certify that:
1. The employer contribution is: Life & AD&D - /)41) °AiSID -
IMPORTANT NOTE: If Employer Contribution is 100%, all eligible employees must be enrolled. If employees are
required to pay any part of the premium, employees enrolling more than 31 days after completing their waiting period
will be required to furnish Evidence of Insurability.
2. There are 1 all/ persons digible to participate in the plan and 3l/ are enrolled.
3. All persons enrolled in the plan are:
(a) members of WI eligible dass of employees;
(b) are actively at work at least ifej hours per week, are actively working at their normal place of
employment, working in our regular business and are not in a hospital, nursing home. convalescent
facility, or are not convalescing from Hines; or injury at home; and
(c) are directly compensated by us for their serviam.
EXCEPTIONS: For any person enrolled not meeting the above requirement, the following information is provided:
NAME
DATE LAST WORKED REASON FOR EXCEPTION
/
1/
t &t41'
Marketing Representative
UND-001 (2-91)
Gr.hjtAdminist6tor Date
•
USAble Life
LONG TERM DISABILITY RENEWAL NOTIFICATION
Company Name: CITY OF EMMITEVILLE
Group Number: 2467-100
Representative: FRANCIS KUEHN
Renewal Date: 05/01/92
Date Typed= 3/16/92
Amount of Benefit: 60Z OF MOM SALARY HAMM $6,000
Benefit Period: TO AGE 65 WITH RBD
Present Rate per $100 of Covered Payroll: $.56
********************************XMAMS
Renewal Rate Per $100 of Covered Payroll: $.56
Number of LTD Employees Currently Insured: 328
Monthly Covered Payroll= $653.529
*******************************EMMM
PLEASE COMPLETE THE FOLLOWING
Percentage of Company Contribution:
- Number of Eligible Employees:
Remarks:
i'Lcaa,j,7
39/
Group Administrator: CillDate: 4'-7549
A.
USAble Life RepresentatiV 24111ta4la
***************************SZACWW*222XXXXX*************XWW*******X
MARKETING REPRESENTATIVE REASSIGNMENT
From: To=
Regional Manager
Dir. of Mkt. USAble Date
FOR GROUP'S 1992 RENEWAL
gLECTION OR WAIVER OF PAYMENT FOR
LICENSED PROFESSIONAL COUNSELORS
A.C.A S23-85-138 requires the offering of coverage for the
payment of services rendered by licensed professional counselors.
The Plan hereby offers such coverage subject to the exclusions
and limitations of the group master contract for psychiatric care.
By accepting as indicated below, the group agrees to pay the Plan
the increased rates of $4.55 per contract for such coverage.
Please add this additional
benefit at the increased rate.
X/3,2
RI We decline this benefit
11 A
Administrator
ELECTION OR WAIVER OF PAYMENT FOR
PSYCHOLOGICAL EXAMINERS
A.C.A S23-79-142 requires the offering of coverage for the
payment of services rendered by psychological examiners.
The Plan hereby offers such coverage, subject to the
exclusions and limitations of the group master contract for
psychiatric care. By accepting as indicated below, the group
agrees to pay the Plan the increased rates of $4.55 per contract
for such coverage.
•
Please add this additional M We decline this benefit.
benefit at the increased rate.
Administrator
---- ')
i
•
:7 --u
')C?/,',4/'/..
Group Name and' Number Date
-(A741'
•
ARKANSAS BLUE CROSS AND BLUE SHIELD
•
A marruAL INSURANCE COMPANY
Retention Agreement for
CITY OF FAYETTEVILLE and FAYETTEVILLE PUBLIC LIBRARY
Group Numbers 090041 and 090042
This Retention Agreement applies to the above group.
The Agreement is a retrospective refund calculation, and will be determined using earned
premiums and incurred claims of Blue Cross, Blue Shield, and Extended Benefits coverage. The
effective date of the Agreement is to be May 1, 1992. Each policy year constitutes a period
for accountability of premiums and incurred claims, and hereafter will be referred to as a
refund period. The refund will be calculated one hundred and eighty (180) days after the end
of each policy year.
The composition of the formula used to determine the refund amount and the definition of
each item contained in the formula are as follows:
EARNED PREMIUM: Blue Cross, Blue Shield, and Extended Benefits income for the
refund period.
RETENTION: The amount retained by Arkansas Blue Cross and Blue Shield for claims
administration expense, general administration expenses, general contingency, insurance risk,
and large claim pool. The retention used in establishing the refund amount is 17.6% of
earned premium.
CLAIMS COST: Claims cost is the amount of earned premium required to pay policy
benefits for claims incurred during the refund period. Provided, however, that large claim
adjustments shall be based on those amounts actually paid per covered person during the term
of the Agreement, whether those paid amounts were incurred before or during the term of the
agreement. See Paragraph LARGE CLAIM ADJUSTMENT.
LARGE CLAIM ADJUSTMENT: The Large Claim Pool base agreed to by the Carrier and
the Group is $ 50,000.00 per covered person per policy year. At the time of settlement, only
the $ 50,000.00 per covered person per policy year will be applied toward the determination
of the Retrospective Refund and Stabilization Reserve Fund.
RATE STABILIZATION RESERVE: The amount of earned premium maintained in reserve
for the Group by Arkansas Blue Gross and Blue Shield to offset unusual fluctuations in
claims. This will be 13.4% of earned premium for the policy year beginning May 1, 1992.
Once the reserve is established, it will be credited with interest earned during subsequent
periods. If an underwriting loss is incurred during the refund period, it will be charged
against the rate stabilization funds. Negative balances in the rate stabilization fund will
be carried forward to the next refund period.
•
REFUND: The retrospective•refund shall be earned premium less retention, minus
claims cost lees large claim adjustment, minus the adjustment to the stabilization fund. The
formula is illustrated as follows:
(EARNED PREMIUM - RETENTION) - (CLAIMS COST - LARGE CLAIM ADJUSTMENT) - ADJUSTMENT TO
STABILIZATION FUND = REFUND.
The refund shall be paid to the City of Fayetteville and Fayetteville Public Library.
TERMINATION: In the event the Group terminates Blue Cross and Blue Shield
coverage during the policy year, any refund or rate stabilization reserve due the Group will
be considered liquidated damages. If the termination occurs at the end of a policy year, any
refund of rate stabilization reserve due the Group will not be settled until twelve (12)
months following the group's termination.
This Agreement may be terminated by either the Policy Holder or the Plan at the end of
the policy year by thirty (30) days prior notice in writing.
ARICANSAS BLUE CROSS AND SLUE SHIELD, A MUTUAL INSURANCE COMPANY
Signed :
14 A 2.
David E. Henderson, Date:
Senior Vice President,
Group Services
CITY OF FAYETTEVILLE AND FAYETTEVILLE PUBLIC LIBRARY
J
igned:1 Date: