HomeMy WebLinkAbout147-14 RESOLUTIONRESOLUTION NO. ] 47-14
A RESOLUTION TO APPROVE THE 2015 EMPLOYEE BENEFITS
PACKAGE
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF
FAYETTEVILLE, ARKANSAS:
Section 1: That the City Council of the City of Fayetteville, Arkansas hereby approves
the 2015 employee benefits package as recommended in the staff memorandum attached as
Exhibit "A".
PASSED and APPROVED this 5 h day of August, 2014.
ATTEST:
By: 41,61
SONDRA E. SMITH, City Clerlc(gs,,f�
wv; FAYETI EVILLE ,
CITY OF
ARKANSAS
5
1-7 r -": o?o iq G 33 6
CITY COUNCIL AGENDA MEMO
To: Mayor Lioneld Jordan and City Council members
Thru: Don Marr, Chief of Staff
From: Missy Leflar, Human Resources DirectorA/Z
Date: July 18, 2014
Subject: Employee benefits renewals
PROPOSAL:
It is proposed that the City Council renew the City's employee benefits for 2015, as more fully described
below. The proposal is made now in order for the employee benefits enrollment process to proceed on time, and
so that City employees may retain what many consider the most positive aspect of their employment with the
City: their benefits.
There are two (2) City paid benefits items coming up for renewal for 2014. One is for health insurance.
The other is for Health Savings Account administration. These are the two items requiring Council approval.
In addition, there is one employee paid benefits contract matters not requiring Council approval, since
the employees pay for these benefits rather than the City. Just for Council's information, it is for the Delta
Dental insurance renewal.
HEALTH SAVINGS ACCOUNTS
The City has for years used the services of Delta Bank & Trust for the administration of its employee
Health Savings Accounts. Its customer service has been good. Delta Bank & Trust is in the process of being
bought out by Simmons Bank. Simmons Bank has agreed to continue administration of the employee Health
Savings Accounts in 2014 and 2015 with no new charges or price increases, while providing the same level of
customer service.
The City's benefits broker, Gallagher Benefits Services, took competitive bids from other sources and
each of the two other best bidders would charge an additional $17,000+ and $18,000+ if the City were to switch
from its present provider to one of them.
Staff therefore recommends remaining with Delta Bank & Trust for the administration of employee
Health Savings Accounts. This should maintain the same level of service with no price increase.
Telecommunications Device for the Deaf TDD (479) 521-1316 113 West Mountain- Fayetteville, AR 72701
THE CITY OF FAYETTEVILLE, ARKANSAS
HEALTHINSURANCE
Last year the City had large health insurance premium increases due to high employee utilization of the
insurance (112.67 %, meaning for every dollar paid in premiums, $1.12 was spent by the insurance company on
medical claims and prescriptions). The high premium increases caused a significant shift in employee
enrollment away from the traditional PPO insurance into the High Deductible insurance. This shift has lowered
the utilization rate thus far in 2014 (49.6% through April — although that would be anticipated to rise some as
people meet their deductibles). This lower utilization rate has kept the premium increases for 2015 at a
relatively low 7.2% (the City's benefits brokers estimate that 3% of this 7.2% increase is caused by Health Care
Reform fee requirements). To put this in perspective, the national trend for health insurance premium increases
being caused by medical inflation, Health Care Reform fees, and other factors independent of utilization itself is
8 % - 9 %. Thus a 7.2% increase in health insurance premiums is, when put in perspective, a relatively low
increase.
It is proposed for the 7.2% increase to be handled in the following manner:
• Employees who have Employee Only coverage (regardless of Plan) will pick up 20% of the cost of the
increase. This would be consistent with the fact that employees with Employee Only PPO coverage
currently pay for 20% of their total premium cost, and it treats employees with Employee Only coverage
the same regardless of which Plan they selected. The City will pick up the remaining 80% of the cost of
the increase.
• Employees who have Family coverage (regardless of Plan) will pick up 35% of the cost of the increase.
This would be consistent with the fact that employees with Family PPO coverage currently pay for 35%
of their total premium cost, and it treats employees with Family coverage the same regardless of which
Plan they selected. The City will pick up the remaining 65% of the cost of the increase.
• Please refer to the attached spreadsheets for details.
One of the realities that employers face when it comes to health insurance is that if the employer
switches insurance companies too frequently then they will stop wanting to bid for that employer's business.
Insurance companies know there will be "good years" and "bad years" for them with the same employer's
claims, as far as whether and to what extent the insurance company makes a profit. They are more tolerant of
the "bad years" if they have reason to believe that future "good years" are a possibility. Otherwise one "bad
year" with an employer can be quite costly, especially if the employer switches companies the following year
with no "good year" to balance out the year with the loss. For this reason, if an employer develops a reputation
for changing insurance companies on a regular basis, the companies tend to lose interest in bidding for the
account -- or if they do, they may tend to bid extra high to cover any losses in case the employer switches again
immediately the following year. An employer thus hurts itself in the long run if it switches health insurance
companies too frequently.
The City has switched health insurance companies four times in the past eight years, including last year.
Due to concerns about how insurance companies may develop a negative perception of the City as a potential
health insurance client were it to switch again so soon, as well as the fact of the relatively low premium increase
and the inherent disruption to employees anytime their health insurance coverage changes (some have to change
doctors and/or can't get familiar prescriptions covered under a new policy), the City and its brokers deemed it
the best course of action to not take competitive bids for health insurance for 2015.
Telecommunications Device for the Deaf TDD (474)521-1316 113 West Mountain - Fayetteville, AR 727
THE CITY OF FAYETfEVILLE, ARKANSAS
Staff recommends a renewal with Arkansas Blue Cross Blue Shield for the 2015 employee health
insurance, per the above.
SUMMARY OF STAFF RECOMMENDATIONS:
Staff recommends that Council approve renewal of its Blue Cross Blue Shield health insurance at the
proposed City/Employee Contribution levels outlined in the memo and attached spreadsheets. Staff also
recommends that Council approve the City renewing with Delta Bank & Trust for the administration of
employee Health Savings Accounts, with the understanding that Delta Bank & Trust is in the process of being
bought out by Simmons Bank.
BUDGET IMPACT:
These planned insurance/benefit items are being budgeted for in the City''s 2015 budget.
City staff and staff from the City"s Benefits Broker, Gallagher Benefits Services, Inc., will be available
at the City Council Agenda Session and City Council meeting to answer any questions that Council may have.
Telecommunications Device for the Deaf TDD f479) 521-1316 113 West lblountain - Fayetteville, AR 727
Missy Leflar
Submitted By
City of Fayetteville Staff Review Form
2014-0336 °
Legistar File ID
8/5/2014
City Council Meeting Date - Agenda Item Only
N/A for Non -Agenda Item
7/18/2014 Human Resources /
Chief of Staff
Submitted Date Division / Department
Action Recommendation:
Staff: recommends that Council approve the proposed 2015 employee benefits renewals, as discussed in the memo.
xxxx.xxxx.51xx.xx
Account Number
N/A .
Project Number
Budgeted Item? Yes
Budget Impact:
Current Budget
Funds Obligated
Current Balance
Does item have a cost? Yes Item Cost
Budget Adjustment Attached? No Budget Adjustment
Remaining Budget
Citywide
Fund
N/A
Project Title
$ 4,642,000.00
$$ //gg yyyy -
"'$j42;x3d;�
$ 4,642,000.00
V20140710
Previous Ordinance or Resolution # E@lij�
Original Contract Number: ! t Approval Date:
Comments: Since the health insurance is an insurance policy application for renewal to be submitted when/if
Council approves such a submission, there is no contract to be signed. The same goes with the Health
Savings Account adminsitration, which if approved wool equire no aperwoork.
RESOLUTION NO.
A RESOLUTION TO APPROVE THE 2015 EMPLOYEE BENEFITS
PACKAGE
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF
FAYETTEVILLE, ARKANSAS:
Section 1: That the City Council of the City of Fayetteville, Arkansas hereby approves
the 2015 employee benefits package as recommended in the staff memorandum attached as
Exhibit "A".
PASSED and APPROVED this 51` day of August, 2014.
APPROVED: A ATTEST:
By:
LI NELD JftDo, Mayor SONDRA E. SMITH, City Clerk/Treasurer
r`
OEM1.
1 .
• 1
moommo
y],�' • lu'.:. _ St _
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J
2015 Health Insurance Rates (corrected by a penny)
""ii1 rA3
ti
- r
PPO Rate Tier
2014 Sin to
$355.93 $77.38
$309.55
20.00°%
2014 Yamdy
$1.025.34 $356,86
$fi6fi.48
35.00°%
2015 Single
$414,79
3
2000 %
2015 Ramify
$1,099.16 • :;
35.00%
,s:
e•?'
F�
..:: ....:.�.�'F :c'I•
- y¢,�+�.� lei-.; ..:..;.�&
' jr'. �':
1' -� rl'H�<F �•
'u�vi�. 'Y�.',^^i�:: �'"� y':-..ice-R•A..�'
r:
�':r.
HDHP Rate Tier
1e
,�J
�.:
laLa11 rb k'r::.
:'ice:; �; . _ ?.•_"�..
. ...,......
:_s,J!'sAEfs- `�i'OTd.bU 41C7.11=
::`4.'•:'
-
�,.i.>---•'�=`��.�.`.§i -YzM`= u..
_::y:a;^� ��1'�..:�;;' f1Y:i�iilJd:...:
2014 ShWe
1 $204,11 $10.20
$193,91
5,00°% $70.80 $264,71
2014 Famil
1 $540.86 1 $27.04
$513, 2
5.009°
$156.66
$670,48
2015 Sin 1e
1 $218,81
6.01%
$70.80
$276,46
2015 Family
$579.80
7.02%
$156,66
$695,76
City of Fayetteville Staff Review Form
2014-0434
Legistar File ID
N/A
City Council Meeting Date - Agenda item only
N/A for Non -Agenda item
UK N)6 2oi5
aq ee ftA�
U�$ rt CE
Missy Leflar 10/29/2014 Human Resources /
Chief of Staff
Submitted By Submitted Date Division / Department
Action Recommendation:
The Mayor's signature is needed on this health insurance paperowrk, in follow up to the City Council's approval of
the 2015 employee health insurance. Please note: This is not a contract. It is an insurance application. It is time
sensitive. Blue Cross will not move forward with necessary steps to insure our employees without it. Thank you.
Account Number
Project dumber
Budgeted Item? NA
Does item have a cost? NA
Budget Adjustment Attached? NA
Budged Impact:
Current Budget
Funds Obligated
Current Balance
Item Cost
Budget Adjustment
Fund
Project Title
S -
5
Remaining Budget -
Previous Ordinance or Resolution # 147-14 V20140710
Original Contract Number: Approval Date: 1-14
Comments:
CITY OF
Tay� I
AR.KANSAS
MEMO
To: Mayor Lioneld Jordan
Thru: Don Marr, Chief of Staff
From: Missy Leflar, Human Resources Director ,j/
Date: October 29, 2014 1"r
Subject: Blue Cross paperwork
Please sign the attached document so that I may send it to the City's Benefits Broker who will, in turn,
send it to Blue Cross. Blue Cross can then move forward with issuing employee documents and
employee insurance cards.
The Blue Cross paperwork is in follow up to the Council's prior approval of the 2015 Blue Cross
insurance.
The City's Benefits Administrator and I have carefully reviewed it and made all necessary corrections for
accuracy.
This document is not a contract. Rather it is an insurance application, much like when we fill out an
application for car insurance. When the insurance company issues the policy, at that point the issuance of
the policy means the company has accepted our offer (our application) and the policy itself is the contract.
Mailing Address:
113 W. Mountain Street vaww.fayetteville-ar.gov
Fayetteville, AR 72701
�.;.6 IVA
Arkansas
Blue Cross B1ueShield
,y,o,aprus,brrdsrC�ar ■"4iMNdR.+
ml APPLICATION bV' CITY OF W
)gMpL0yF,R APpLICAT10N
Electronic Transfer
_ (hereinafter called "Poi o e _ _
a Group Policy covering the employees of the pofthotder and the eliglble dependents of such employees. The ~
lcyholder Intends hereby to establish and maintain an ampEoyea borrefit plan (the 'Plan) for the Poltcyholdeell employees
I allolble dependents, to oonin'buts to fire cost of the Plan, and to ec vSly promote the Plan to the Poicyholdees ervby
eei
d Name of DUSiness: CITY OF FAYE7TF-Vd-LE
A: CITY OF FAYETTEVILLE
et Address:113 West Mountain
_State, Zip: Fayelw2v lre , AR , 72701 _ i County: Washington
f Address: (if different from Street) KM HR 113 W MOUNTAIN
glata, Zip: Fayeltevitie , AR , 72701 _•,
:phone #: 479-675-OM
#: 479-718-7M
-6011802
71
c. Contact: Uoneld Jordan_ _ _ i E-Mail: _ _ _
u_p_Administrotor- Missy Leflar E Ma11Ymlailar(c�ette'
rar�SiC Coda: 9199 N SIC_ Description: General Government, NEC
iness Type: Govemment Ertl - _- + _ �_•,�, ,�. .._
nl: ►, .[Agent's Lfc M — 6
nt'a r. nanv _ Aaent's Tax ld: - _
cocyhotder, as Plan Administrator, assumes responsibility for the accuracy of Information presented to Arkansas Blue
and Blue Shield ("ABCBS'), including all Intormallon an the employment status and eiptlily of Individuals W be aovere
the Plan, as well as medical information provided with respect to each such IndtMdual. The Policyholder agrees that If
presentations are made In any of the Information provided for retina or in this Group Application or any of the materials
fled with It. Including, but not Ilrnited lo, Individual applications and medical information, then ABCBS may cancel or
d this Group Policy. The Policyholder further agrees that If misrepresentalions or false or misleading Information is
rated In Sling of any claims hereunder ('Improper claims"), ABCBS may cancel or rescind the coverage of any individual
ad In presenting such a dalm. Further, ABCBS may canpel or rescnd the ehttre Group PQII y tf the Pallcyholder Of any
ientative of the Potloyholder know or should have known of the Improper claims, or it the Poilcyholder's action or Inaction
Muted to oresontatlon of impropbf claims.• -•.---
The PoEyholder hereby appoints the Board of Directors ("Board') of Arkansas Blue Cross and Blue Shield ("ABCBS'), as He
proxy to act on Its behalf al all me61ln9s of members of ABCBS. This appointment shall Include such persons as the Board
may designate by resolullon to act on its behalf. This proxy gives the Board, or Its designee, full powerto vole for the
Policyholder on all matters [het may be voted upon at any meeting. The annual meeting of Maml•►ers Is held each year at the
horns office of ABCBS localad at 80f S. Gaines SIML Little Rock, Arkansas, on the third Monday of March, at 1:DO RIM. If the
third Monday of March is a legal holiday, then the meeting wilt be at the some time and place on the next day after, which Is not
a legal holiday. A special meeting may be trilled upon notice mailed not teas than ten (Ib) or more than sixty (60) days prior to
such meeting. This proxy, unless revoked, shall remain in effect during the Policyholdees membership in ABCBS. The
Policyholder may revoke ihls proxy in writing by advising ABCBS, attention Legal Division, of such at least live (5) days prior to
env meeting. The Policyholder may also revoke ins proxy by attending and voting in person at any Mambees_meettng,
10-102i3RPAPP ROU14
PREFERRED PROVIDER ORGANIZATION PPOj-Ppoxxx -1 -- -
_ -- ---- -- r
REQUESTED EFFECTIVE DATE, PENDING APPROVAL t& 1I112014
Waiting Perlad Note; Effective Date is first of the month foUDvring the walting Period.
Date of open Enrollment Seutelobefj
Dole of Additional Open Enrollment October ,
N s month is nol apocyw,, the Groups Open Enroft t ww be the monrh onor to to Groups renewal dale. _.- ..-... ......
Chas - r Class Description Wafting Period— - contrtbutlon
1 Month Employee 80'% Dependent 65 °Jo
---------- ---J .._.____._.___.._
Nola: 7110 EmploypMust POY Il mfnlmunt of W9 orthe Employee prumilum. 7hts Potreymay be renWasfadbyMe carnpany rrthe J'Woynolder
Mffs to cortb[bule fhe perrAnla9e of EmpinYees�A r1? speed ebovR -- ----- —
Maximum
_ Dependent Aga 28—
Mandated Mental Health Parity: ----_ ........ _._ ___.___.... ._^--"--_._._.-----•._-.--
Please indlcato whether a HRA, or meosntsms vV=d to reduce 1119 employeerb portion or haallh plan ousts. Is eldhertn place ar planned to ee E
purdosed. No
Rates orfered for Ut1s plan are oontk>gent on esserUana submitted by " rnaurance eppfkant (orll3 agent) that lh9re IS no HItA or other .
hfi rov mechanism In plate, no hmnt to purchase such an alrenpemant Upon evidence toIheoontrary, thegrpup h8e1t11 plan Is sublosA to
ternrnatlon_--
'' Deductible Carryover: Yes
Deductible: _-- -- - — —~- - — _
Family Deductible _ _ - ' 2A—_ 8asls: Accumulated _ 1
Colnsuranco: 809o=% -
True out-of-pocket Max_T $3000 - .l 'rue Out-of-pocket Max Family: $6000 t
l7ltt-of-Network Calendar Year Coinsurance Max: $4� -
' Llfetirrls Maximum: _ .__+�.-•.•_... Unlimlted
Preventive Health Servfcos (PPACA requlmd)
_._.-.._.....-_._, ...........-
Presaripllon Drug Rider Plan; $101$301$60 Standard Formulary
Mall Order Drug - 2x Gopay (90 days)
Lased err actuarial review, this drug benefit option is credr7able to the standard Medicare Part D �
prescrrptFon coy_er��Ie.- _-------�._..�_ ...... .... • •--------•-----._..., .�
PPO Optional Benefits: _ - --- — --
inpatient Copay - None - - - d
y - Elect -
Co ment - Decilned '. Maternite
ter. _ .._temI -•----_._
--- — --- ; Supplemental Accidental
I Blue Card i Endorsement - Dedlned t
4 Arkansas Mandated OFtar Benefit Riders_
You must Elect or Reject Each Rider. ......
- ...- -- -
jlMamrnography - Reject Substance Abuse - I�ejett
Psyohlatric Condition - Reject ; TMJ" - Reject
�Headng Aid - Elect
'Rejection of the TMJ Benefit Ilder means Covered benefits prowm to Co+mrod Persons wal gq Indude temporornmul butar
r Jofni dlsooders (TM4 aroanlomendihuiardisordsra
` 7erm I,Ife and AD&D through LISAble Lire Is not Provided
10-107ORPAPP R01/14
- ppc)xxx - I
Two Tier Composite Total Premium
Employee0 $414-79
Family
Ifthere Is an agent or broker Involved In Ibis coverage transaction they May receive compensation from Arkansas Blue
Cross and Blue ShloW, or one of its OffiliatO8. fords or her services related to the placement of this coverage. Any such
compensation Is included In the premium paid by the &w" person. For more information on the compensation
Involved In this transaction, please direct your inqL&y to the agent or broker.__
Onandfathar Status - our reooyds Indicate that your health plan is not grandfathered.
Please confirm If you agree with the grandfathered status as Indicated above.
Yes. I agree with the status as shown
Igo, I disagree VAII) the status as shown because
I 1g_jo2ORFAPPRO1/14
3
'BENEFIT SELECTION
SLUE -BY -_DESIGN NSA-HSAXXX_-1___
REQUESTED EFFECTIVE DATE, PENDING APPROVAL IS: 1 12 1ti ~� —
Waiting Period Note: Effective Date is tirst of the month following the Waiting Period.
Date of Open Enrollment a ternber l
k Date of Additional Open Enrollment October
I I
i No month is not specM00. Iha Gnaup's Open areffarent wfN ee the mPnrh prtoric the Groapa rentwai cbfin.
Class : Glass Dascrlptian __• — Walting Period _ _;Contribution _
' C;lrroup Health__ 1 Month Employee 24 V. Dependent 93 % - -- —
Nolm The Employs rausf pay a mftmnw of tr K GIMO F-plbyee premium. TWa Pafiry maybe terrrifrrated by the comwy ffihe Paftcyhdder
I;laflsfooenGlhuflatheperc�entepeofFinp�oysas'ptafnfumspecrfiadabava. .,___._,..-_ .
Maximum Dependent Age 28
Mandated_ Mental Health
Please indicate whether a KRA. or mechan arcs utilized iP reduce the ompltWs pardon of health plan costs, is euher to place or planned lobe
purolmed. No
Ralas offered for this plan are contingent on as artIons submitted by the Insurance applicant (ar its aqw!) that there Is no HRA or other funding
Imechardsm In plea, n"Interd to pvrchaso such an arrangement Upon evidence to the eonOry, the group heats plan fa sAaci to termination,
Annual HSA Contribution by Tier:
I i ernplayQv Ony;.�^—E+nPloyeefSpouce' F�tprayeafChtld: FamltY
HS_AconUltUtionfreq_uancy: Annualll Wxnthty(j _Semi-MorOlytj_—
Deductlble� __ __
I IndMdual In -Network. $3000 - ~ —} F�nbedded Femlly In -Network: $6000 -
Individual Out -of -Network: $6000 Embedded Family Out -of -Network^ $12000 r
CoinsuranceM - -- -
In-Network;10% out ot�lelworic: 8096_
........_.. _.._....—..�.—._�----•---- ---_ ..� '_•"' rue 47ui•BFPQcket Ma...
Truo Out-Of•Pock$t lVtox: i3000 _ x Family: S80D0 —�
' Individual Oul of Nelvfor� Unllntiled -�. - Embedded ork Urdimited
• Adfustetl annoaty ibrinRallon each January 1, &r eocardanoe with Una prnvf9fPnS pf$CC[rorr 223d the Intomel Revenue code ofthd tlriReri
i States of America as amended
LlfetIme Maximum: Unlimited
Preventive Health Services (PPACA required)
� Optfortal Benefits: _ __ • __ j
(' Matem_ity -Elected ---- _-- - _ _- _ _ -- ; Biue Card
i Drug Coverage: Standard Formtrla_ry - Subject to Deductible a Colns_wance
. Tn! on actuarial review, thfs drug benefit option is credrtalxo fo the standard Afodkom P&A D preacdptio» coverage. __
�. Arkansas Mandated Offar Benefit Riders; _ _J
You Whist Etad or Reject Each Rider:- -
t Mammography -Reject j Substance Abuse - Reject
Psy6hiatrlc Condition - Reject 7MJ' -Reject
'Helection of the TMJ Senalit Rider means covered benefits provided to covered Persons will gg Include tenvotdrnarrrWar
' Jdnt dlswders (TMJ) or cranfomandlbtlar disorders.
Term Life and AD&D through USAble Lilo is not Provided _._,-•}
10-102GRPAPP R01114
-NSA XXX -1
Tier
If thero Is on agent or broker Involved In this coverage transaction They may receive compensation from Arkansas Blue
Cross and Blue Shield, or one of Its affiliates, for his or her services related to the placement of this ooverega. Any such
compensation Is included in the premium paid by the covered person. For more informallon on the conrpsnsaifOrl
Involved In this transaction, please direct your inquiry to the
Grandfather Status - Dur records Indleate that your health plan Is not grand%thered.
Please confirm if you agree With the grandfathered staters as IndIr-Oted above.
Ayes, I agree wish the status as shown
No, I disagree with the status as shown because
10-102GRPAPP R0I114
oup health plans for employers with 20 or more employees on more than 50°l0 of the business days In" previous
lender year are subject to Cobra. Employers are required to provide qualified beneficiaries an election period during
dch the beneficiary can elect to continue coverage under the guldellnes. We offer the services of a vendor, "Carldlan"
assist you In administering Cobra (no additional cost).
rlh full time and part time employees are counted to determine if a plan is subject to Cobra. Each part -tine
nployse counts as a fraction of an employee, with the fraction equal to the number of hours worked divided by the
mber of hours used to determine full time status.'
(No,J As an employer, are you currently obligated by raw to comply with COBRA?
(NoIJ Do you want to use the services of Ceridian?
'esj (No.�) If yea, are you currently contracting directly with Cerfdian?
COBRA Handbook 2009, J4.MEj[2); 26 CFR §54.4980B-2 QJA 5(b)
42 CFR §411 A 70.
adical I-ose Ratio - The determination of Large and Small Groups is based upon the average number of employees
nployed by the employer on business days during the proceeding calendar year. The Public Health Services Act
79 1(e) provides
)The term "large employer" means, In connection with a group health plan with respect to a calendar year and a ply
mr, an employer who employed an average of al least 101 employees on business days during the preceding
rlendar year and who emplays at least 2 employees on the first day of the plan year.
The term "small employer' means, In connection wilh a group health plan with raspact to a calendar year and a
an year, an employer who employed an average of at least t but not more than 100 employees on business days
rrirlg the preceding calendar year and who employs at least.l employee an the first day of the plan year.
policyholder Is a large employer _ small employer (check ono).
In the event federal or state taw roqulres the Company to rebate a portion of air annual premium payment. Company
will pay the Policyholder the total rebate applicable to the Polioy, and Policyholder shall use the amount of the rebate
that Is plopor0onate to the total amount of premium paid by all Employees undarthe policy for the benefit of
Employees In one of the following ways, at the option of the Policyholder:
1. For all Employees covered under any option offered under the policyholders group health plan at the time the rebate
Is received by the policyholder, to reduce the Employees' portlon of premium for the subsequent policy year,
2. For Employees covered, at the time the rebate Is received by the policyholder. under the group health plan option to
which Ilia Company is providing a rebate, to reduce the Employees' portion of premium for the subsequent policy year,
3. A cash refund to Employees enrolled In the group health plan option, at the time the rebate is received by the
policyholder, for tvhlch the Company is providing a rebate; and
4. The reductlon In future premium or the cash refund provided under paragraphs 1, 2 or 3 of this section may, at the
option of the policyholder, be: divided evenly among such Employees, divided based an each Employees actual
contributions to premium,. or apportioned In a manner that reasonably reflects each Employee's contributions to
premium.
5. The portion of a rebate based upon formor Employees' contributions to premium must be aggregated and used for
the benefit of current Employees In the group health plan In any manner permitted by thls section.
Policyholder wsl Indemnify the Company In the event the Company suffers any fines, penalties or expensos, lncluding
(reasonable attorney's fees, due to the Pollcyholder's faliure to carry out Its obligations under this Section L of the
10-102t3RPAPP R01114
w-j a2GRPAPP RO IA4
This Application is made and delivered In the State of Arkansas and is governed by the laws of Arkansas and the United
Slates of America. This Applicalion is Incorporated In and made a part of fhe Group Policy and Benefit Certificata,
I hereby renew tits above referenced coverage and agree the group_Insuranos. sub0c:t to the terms and conditions of the
policies renewed, will take effect as of the renewal date, provided this application is approved and the premium Is
received by the home office of Arkansas Blue Cross and Blue Shield. i also understand that my signature below
roprosents my agreement and acceptance of the premium rate schedule.
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefll or knowingly
presents false Information In connection with an application for insurance Is guilty of a crime and may be
sUblect to fines and confinement In prison.
1. Policyholder
Signed at Q,Vr (� , this day of 2a��
(�(C .stare) {
SV V t 0 Bull legal name of Pogcyholden
By,
lh rued SI lu printed Name UOMELb J-096 A
Title or 139filon AAA g 6 p_
2. Agent
I hereby aartily that all of the Infoirrral€on contained In this employer application is correct to the best of n y knowledge,
and I know nothing unfavoiabfe about this firm or any individual proposed for coverage (except as noted on the employe
applications). I have compiled with the underwriting rules and regulations and have explained in detail the coverage to
the member firm and its empioyeos Including the preexisting condition limitations and the qualilicalions of the effective
date provisions. I understand that Arkansas Blue Cross and Blue Shield will have no liability until this application has
been aWrovod and the premlum is received. -
I will provide the applicant with a signed copy of this application.
I have emailed the applicant a signed COPY of this applicalon. a
�i +
Agent Signature Insurance license #! ancy Fed. Tax 10 #
�.1,,A_ /� V 41
Agent Printed {name - — Data
1"02(3RPAPP ROII14
LETTER OF UNDERSTANDING
The purpose of this letter of understanding is to reflect the following understanding between the
City of Fayetteville and Arkansas Blue Cross Blue Shield concerning 2015 health insurance coverage for
City of Fayetteville. employees.
1. The City will offer insurance to those to whom it is Iegally required to offer insurance per
Health Cara Reform laws.
2. The City has an additional closed class consisting of one part time person, Eldon Roberts.
Eldon is the sole remaining member of a closed class of part time insureds who were
grandfathered in as insureds a few years ago when the City ceased offering insurance to
part time employees. no City has not offered and does not: offer insumnoo to any other
part time employ= since tho creation of this closed class.
k�
Arkansas
B1ueCross BlueShield
�nha�owan lw�Mc der e`,.[��nda.4ra+�neertin
Date: 9/10/2014
Group Name: CITY OF FAYETTEVILLE
113 West Mountain
Fayetteville, AR 72701
Group Number. 028723
Dear Group Administrator:
Please be advised that the current benefit you offer (PPO XXX - 1,WSA XXX - 1), meets the
minimum essential coverage requirements as defined in § 5000A of the Internal Revenue
Code (employer -sponsored plan), and provides minimum value within the meaning of § 36B(c)
(2)(C)(ii).
Effective 1/1/2015, employers are required by law to inform their employees of coverage
options under the new health care law. You will find the campliant notification document at this
link:
http:/twww.dol.gov/ebsalg&/FLa6s&ithplans.pdf,Please distribute copies of this notice to all
your employees.
If you have any questions or concerns, please contact your agent or an Arkansas Blue Cross
representative. We are happy to help you through the implementation of this new requirement.
10-102GRPAPP R01/14
Patient Protection and Affordable Care Act (PPACA) mandates a Summary of Benefits and Coverage (SBC)
iment be created for every health insurance plan. An SBC that applies to this plan(s) can be found online at
v.arkansasbluecross.conUesbc. After we receive and process your signed contract, you may access the SBC(s) for
plan by going to our SBC locator tool and entering the following unique identifier(s) into the SBC locator.
06141406144192
08141406144197
oups with more than one plan type may have more than one link. You may download and electronic copy (PDF) of
a appropriate SBC(s) to fulfill distribution requirements as mandated by the Patient Protection and Affordable Care
PACA). A printed version is available by calling your group service representative.
10-102GRPAPP RO1114