HomeMy WebLinkAboutRES 21-309RESOLUTION NO. 21-309
BE IT RESOLVED BY THE CITY COUNCIL
OF THE CITY OF BEAUMONT
THAT the City Manager be and he is hereby authorized to execute an annual contract
for the purchase of Stop Loss Insurance with Blue Cross and Blue Shield of Texas
(BCBSTX), of Richardson, Texas, in the amount of $1,377,248.00 for use in the
Employee Benefits Fund.
The meeting at which this resolution was approved was in all things conducted in
strict compliance with the Texas Open Meetings Act, Texas Government Code, Chapter
551.
PASSED BY THE CITY COUNCIL of the City of Beaumont this the 16th day of
November, 2021.
gJ4C4,L le' j
- Mayor Robin Mouton -
0-
Employer Group Name: Beaumont
Employer Group, Address: 801 Main Street, Suite 3201,
City:: Beaumo, State of Sites: Tx Zip Code-.77701.
rat.
Account Number: 067099
Employer Group Number(s): 067099
Current, Effective Date of'Polilcy 01101/2022
Current Policy Period.- These, specifications are for the Policy Period commencing on 01/01/2022 and ending on
1r)
The specifications below shall become effective on the first day of the Policy Period specified above and shall continue in,
(�2) The date the Policy (1) The last day ofthe Policy Period,
full force, and effect until the eliarliest of the following dates
terminates; or (3) The date this Application is su perseded 'I ni whole or In part by a later executed Application.
A., Aggregate Stop Loss, Coverage: Yes No
If yes, complete iterns 1 through 9 below.
1. F-1 New Coverage El Renewal of Existing Coera
Coverage (Sellect one from below):
El incurred and paid dur,ing the, Claims incurred and paid from to
Policy Periiod,:�
Incurred with Run -Out- Claims incurred from to
and Claims paid from to
El Run-in coverage: Claims incurred from to
and Claims paid from to
If coverage is for claims incurred prior to the effective date of the Policy and paid by Policyholder's
prilor claim admi nistrator, then such claims must be reported by the Policyholder to the Company
(Blue Cross and Blue Shield of Texas, a Division of Health Care Service, Corporation, a M 'utual
Legal Reserve Company) and pa,id by the Policyholder's prior cliai,m administrator by 'the end of
the current Policy Period.
Ell Claim Administrator's, Claimsi* Claims incurred on or after the original Effective Datef of Policy and paid
during the Policy Period.
Eff Incurred with Run -Out- Claims incurred from ttf,
and, iClaims id from _pa,l I to
ilippiplip
El Medical Claims
"_1 L Outpatient Prescription Drug Claims with Company's Pharmacy Benefit Manager
El Outpatient Prescription Drug Claims with, Policyholders Pharmacy Benefit Manager:
El Dental Claims
F-1 Other (please specify)*
14. Average Claim Value:�, (per Employee per Month)
Attachment, Factor: % of the Average Claim Value
a. Employer's Claim Liability for each Policy Period' shall be the surn of the Monthly amounts obtained by
multiplying the number of Individual and Family Coverage U�ni'ts for each Month by the following factor&
$1 for each Coverage Unit
$_ for each Family Coverage Unit
Please use the continuous text fi6ld directly below for any other structure (leaving the fields, above blank).
Note.- you can use the "return" key to create additional rows i needed:
I If
b. Employers Run -Off Claim Liability shall be calculated by multiplying the sum, average of the total of all
Coverage Units during each of the three calendar Months immediately precedin,g termination by the factors
shown below. Settlement for the final accounting period will be described in the sectioin of the Policy entitled
SETTLEMENTS.
for each Coverage Unit
for each Familly Cloverage, Unit
Please use the continuous text -field direct/k bielow for any other structure (leaving the fields above blank)
Note: you can use the, "retum'" key, to create additional rows, if needied.,
6., CAP, Arrangement [:1 Yes
11 i
a. The amount. of Paid' Claims du ri n 4111001URMN =1 1=0 111,51wimm
� =03mrsurirri
ii. Any cl I aims in, excess of the Individual (Specific,) Stop Loss Claims, per Covered Person pier
Lif6tillef VPRyij1u4j1
11I Any claims, in, excess of' the Individual (Specific) Stop Loss Claims maximum Point of Attachment
that exceedsthe Aggregate Point of'Attachment. 'The Aggregate �Point of'Attaclhment shall equal the suriri 0
the Employer's Claim Liability amounts, calculated Monthly as described in item A.5,.a., above for the curren
Polilicy Ptriod.
4. In the event ofterminafion at the end of a Policy Period, the Final Settlement Aggregate Point of Attachment
shall equal the sum of the Employer's Claim Liabill'ity amount for the Final Policy Period and the Employer S
Run -Off Claim Liability calculated as described in item A.5.,b., above. However, for, the current Policy Period
the minimum Aggregate Point of Attachment shall be $
TXStopLossApp-061/20
8. Stop Loss, Premium (Select oine):
F-1 Annual Premium (Due on the first day of the current Policy Periold)-
E:1 Monthly Premium shall be equal to the amounts obtained by multi plying the number of Individua,l and Family
Coverage Units for a, particular Month by:
fir each, Coverage Unit
for each Family Coverage Unit
The rates shown in this, Application reflect a volume -based discount in an amount up to 4% of the Sitop-Loss
Pirlemium for the, Policy Period., If the, ancillary coverage lapses, during the Policy Period, Company reserves thli
right to remove the discount on the Stop-Lioss, Premium. In such event, upon sj�xty (60) days prior written notice
to Policyholderthe premium payment will revert to the non -discounted arniount.,
Please use the continuous text field directly, below for any other striticture (leaving the fields above blaink). Note -
key to create additional rows if neieded.-
you can use the "retUrn
9. The premium is based upon a current mernbership of Individual Coverage Units and Family
Coverage Units.,
B. Ind"41vidual (Specific) Stop Loss, Coverage,,: Yes No
If yes, complete items 1 through 6 below.
1. M New Coverage Renewal of Existing Coverage
2. Stop, Loss, Coverage Period,
Z New Coverage (Select one from bielow)-
El Incurred and paid during the Claims incurred and paid from to
Policy Period:
El Incurred' with Run -Out:, Claims incurred from to,
and Claims paid from to
Runi-in coverage: Claims incurred from 01/01/2,020 to 12�/31/2032,2
and Claims paid from 01/01/,21022 to 12/311/2022
If coverage is for claims incurred prior to the effective date of the! Policy and paid by Policyholder's,
'then such claims must be by the to the Company prior claim, admreported Policyholder
inistrator,
(Blue Cross and Bilue Sh ield ofTexas, a Division of Health Care Service Corploration, a Mutual
Legal Reserve Company) and paid' by the Pol icy holder's prior claim administrator by the end of the
current Policy Period.
El Renewal of Existing Coverage:
E] Claim Administratior's, Clairns-0 Claims incurred on or after the original Effective Date of Policy and pail
during the Policy Period., I
E]
ed a -Out, till Incurrwilth RunClims incurred from
and Claims paid from to
M 1.1
TXStopLossApp-06/20
Outpatient Prescription Drug Claims, with Company's Pharmacy Benefit Manager
Outpatient Prescription Drug, Claims, with Policyholder's Pharmacy Benefit Manager -
El Dental Claims
El Vision Claims
[:1 Other (please, specify)*
4. Individual (Specific) Stop Loss, Claims
For n/a who is identified by the health identification ('ID) number.n/a, the amofunt of Paid Claims dur'n,ig the 4
current Policy Period in excess of the Individual Point of Attachment of $n/a. Such amount shall apply for
the current, Policy Period.
b. For each other Covered Person,
'The amoun't of Plaid Claims during the current Policy Periold in excess, of the Individual Point of Attachment
of $275 00 per Covered Person but not to exceed a maximum Poin't of Attachment of $1 unlimited 10 ,O per Po icy
Period., Paid Claims in excess of the maximum point of aftachment shall not, be eligible to satisfy the
Aggre ate? Point of Attachment. Such amount shall apply for the current Policy Period.
9 i '
The Individual (Specific) Stop Loss Claims shall not exceed n/al per Covered Person per Lifetime. Paid,
Clairris in excess of the Covered Person per Lifetime Maximum shall not be efigilble to satisfy the AgIgregatt
Point of Attachment.
Point of'Attac,hm,ent Includes Claim Administrator's Provider Access Fee
El Excludes Claim Administrator's Provider Access, Fee
5. Stop Loss Premium, (select one):
El Annual, Premium (Due on the first day of the! current Policy Period)* $_.,
Month�ly Premium shall be equal to the amounts obtained by multiplying the number of Individual and Family
Coverage Units for a particular Month by:
$81.11 for each Coverage Unit
$ for, each Family Coverage Unit
Please use the continuous text field directly below for any other sn,ictutthe fields above blan'�).., N I ote.*
,yotj can use the, "rettyp"key, to, create, adffition,al rows, if needed.,
6. The premium is based upon a curren't membership of
Coverage Units,.
L"Im, vein. I
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TXSto1PLossApp-0,6/20
Sales Riepres6A—f—ive
Signature of Underwriter
112
lifflIFT'' 11111 1 1 wmam wo ffminearm
POP"
Signature df-Authorized Purchaser
Title of Authorized Purchaser
Date
IN�TERNAL USE ONLY Date �pp�icafion approved by Underwriti
TXStopLossApp-06120 5