HomeMy WebLinkAbout153-98 RESOLUTION•
•
r
RESOLUTION NO. 15 3- 9 8
A RESOLUTION APPROVING THE RENEWAL OF BLUE
CROSS/BLUE SHIELD GROUP MEDICAL CONTRACT FOR
POLICY YEAR 1-1-99 THROUGH 12-31-99.
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF FAYETTEVILLE,
ARKANSAS:
Section 1. That the City Council hereby approves renewing the Blue Cross/Blue Shield
Group Medical Contract for policy year 1-1-99 through 12-31-99; and authonzes the Mayor and City
Clerk to execute said contract. A copy of the contract is attached hereto marked Exhibit "A" and
made a part hereof.
PASSED AND APPROVED this 1Z day of November , 1998.
je,i io /
rr•
11‘
s •
By:� �L/,
Heather Woodruff, City lerk
APPROVED
By. APPROVED:
Fr&i Hanna, Mayor
11.
APPLICATION by
EXHIBIT A
Arkansas
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
Little Rock, Arkansas 72201
GROUP APPLICATION
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 no 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, Ark.
City of Fayetteville
this November 23rd , 19 98
By:
Applicant
Authorized Signature
ARKANSAS BLUE CROSS AND BLUE SHIELD
A MUTUAL INSURANCE COMPANY
Accepted By: wit."
GA -1 6/95
Authorized Signature
P. Mark White
Executive Vice President & CFO
4.
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 PM. 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'
meetings.
113 West Mountain. Fayetteville, AR
Address
79701
City of Fayetteville
MEMBER NAME
Group Number
QQ%/ 090041
By:
Signature and Title
Dated this 23rd day of November , 19 98
ADDENDUM TO LARGE EMPLOYER APPLICATION
FOR GROUP INSURANCE
The insurance laws of the State of Arkansas require the benefits outlined below be made available on an
optional basis. You must either Elect or Reject each of the following:
Psychiatric Care Benefits
This optional coverage provides increased benefits for the treatment of
psychiatric conditions limited to a maximum of eight (8) inpatient/partial
hospitalization days or forty (40) outpatient visits per Calendar Year
Substance Abuse Treatment Benefits
This optional coverage provides benefits for the treatment of drug abuse,
including alcoholism. The Company will pay the percentage set out in
your Schedule of Benefits, up to $6,000 during any twelve (12) month
period. Benefits shall not exceed two (2) admissions per lifetime.
Speech and Hearing Impairment Coverage
This optional coverage provides benefits which will parallel all other
medical conditions when you receive treatment for speech or hearing
impairment. A rejection of this coverage will limit the benefit to $500 of
your charges per Calendar Year.
Mammography Screening
This optional coverage provides one mammogram during the time when
women are between the ages of 35 and 39. One mammogram every two
years (or one mammogram per year, if recommended by a physician) for
women age 40 to 49. One mammogram annually for women age 50 or
older. Services also include mammograms, where recommended by a
physician, for women whose mothers or sisters have a history of breasts
cancer, regardless of age.
Licensed Professional Counselor Benefits
This optional coverage provides for payment of services provided by
licensed professional counselors subject to the same limitations as set forth
in the policy for mental health coverage.
Psychological Examiner Benefits
This optional coverage provides for payment of services provided by
psychological examiners subject to the same limitations as set forth in the
policy for mental health coverage.
City of Fayetteville
ELECT REJECT
El
El
1:1 El
Group Name
,,,,t,t oda/
ash_
G;. ecutive / Admmistrator/s Signature& Title
LARGE GROUP ELECTION FORM 1/98
Nov. 20, 1998
Date
REQUEST TO CONTINUE GROUP INSURANCE BENEFITS
Arkansas Blue Cross and Blue Shield
Preferred Provider Organization (PPO) and Comprehensive Major Medical (CMM)
Group Name
Group Number
Address
City
City of Fayetteville Administrator Ms. Beff Kent
090041 Anniversary Date January 1. 1999
111 'La/act Mnuntain
Fayetteville
State AR Zip 72701
To
self-addressed
It
continue your current plan
envelope.
is your desire to (check one):
please complete the following data and mail using
Maintain
xx current benefits
the enclosed
Change
benefits as follows:
Underwriting guidelines require
75% of those eligible for coverage
Employer Contribution:
the employer pay at least 50% of the individual employee rate and
(minimum 30 hours per week) participate:
Percentage Dollars
Employee
Dependent
Employee
Total
510
Statistics:
Ineligible
93 % or $
76 % or $
o Eligible 510 Enrolled 510
Alt
v. 20, 1998
Admin
for Sign ore/// Date