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HomeMy WebLinkAboutRES.2492.10-19-2009BILL NO. 09-172 RESOLUTION NO.T/ A RESOLUTION AUTHORIZING THE CITY MANAGER TO EXECUTE A CONTRACT WITH ANTHEM BLUE CROSS FOR EMPLOYEE HEALTH INSURANCE SERVICES, IN THE CITY OF CAPE GIRARDEAU, MISSOURI BE IT RESOLVED BY THE COUNCIL OF THE CITY OF CAPE GIRARDEAU, MISSOURI, AS FOLLOWS: ARTICLE 1. The City Manager, for and on behalf of the City of Cape Girardeau, Missouri, is hereby authorized to execute a Contract with Anthem Blue Cross for employee health insurance services, in the City of Cape Girardeau. Said Contract shall contain the terms set out in the proposal from Anthem Blue Cross. A copy of the proposal information is attached hereto and made a part hereof. PASSED AND ADOPTED THIS ��DAY OF 20. i� Knudtson, Mayor ATTEST: Gayl 0 CBIZ Benefits & Insurance Services of Kansas City 11440 Tomahawk Creek Parkway Leawood, KS 66211.9955 www,cbfzke.com Ph: 913.234.1000 F: 913.234.1100 September 24, 2009 Ms. Lori Meyer Human Resources and Risk Manager City of Cape Girardeau, Missouri 401 Independence Street P.O. Box 617 Cape Girardeau, MO 63702 Re: Medical Plan RFP and Renewal Effective 01/01/10 Dear Lori: The health insurance plan for the employees of the City of Cape Girardeau is due to renew with .Anthem Blue Cross and Blue Shield effective January 1, 2010. As part of the renewal process, CBIZ requested proposals from the marketplace for replacement options for the current plans. The following information is the result of the RFP process, as well as the renewal from Anthem. Backtuound It is important to understand the current plan and the financial implications of terminating this arrangement if the move to a new plan is considered. The City's current plan is considered a fully insured plan. It is an "unfunded" plan -- the City holds their own reserves to pay for incurred but not recorded (IBNR) claims if the plan is cancelled. Also, the City pays for claims as they are processed by Anthem. Thus, if claims are lower than projected, the City keeps these funds. The current contract, which has been in place many years (prior to CBIZ's involvement) does have a deficit carry -forward provision. In other words, if the plan's expenses outweigh the claim liability limits in place, the City is responsible for this deficit, but does not have to pay for this immediately. It is an eventual obligation, either in lower claim years, or at cancellation. Thus, if the City terminates the plan to move to another vendor, they will be responsible for the run off claims, as well as any accumulated deficit. The contract does limit the deficit carry forward to 10% of the cumulative maximum claims liability for that year. The positive in this situation is that claims experience has improved over the last few years and the City has retained these funds to protect the fund balance moving forward, CBIZ Benefits & Insurance Services, Inc. Ms. Lori Meyer City of Cape Girardeau, Missouri September 24, 2009 Page Two The current obligation, if the City were to terminate, would be as follows: Total Termination Liability (IBNR / Run -out claims liability) as of 07/31/09: $413,421 Keep in mind that if run -out claims are lower than expected, this will lower the City's obligation. Conversely, since the final figure is calculated at year end, the current year could deteriorate, thus creating a deficit, and a higher figure. The point of this calculation is that this is an obligation that will exist if the City cancels the current contract. Thus, in our analysis, this number should be added to the cost of the other possible plans., Analysis When presenting analysis of the Request for Proposal process, CBIZ reviews several important criteria for every vendor. The most important points are: 1. Pricing: This is especially critical when reviewing self-funded plans. Many times there are several additional costs in a self-funded plan not included as standard which are included in a fully insured plan. 2. Plan of Benefits: While most of the plans have proposed a very similar plan of benefits, there are always changes when moving from one vendor to another. 3. Network Providers: The availability of providers from one option to another may be critical to the decision making process. 4. Administrative Capabilities of Administrators: How does the vendor interact with employees/policyholder/providers? 5. Health and Productivity/Wellness Capabilities: This is becoming a more important component of plans. 6. Funding Vehicle of the Plan: Self-funded, fully insured, funded or unfunded. An additional piece of information that is critical to this analysis is the current level of premium being paid by the City. Based on the current participation in the plan, the total funding/outlay by the City is $3,033,177. Keep in mind that this figure includes all premium paid by the City for employees, as well as premium paid by employees for dependents, retirees and COBRA participants. CBIZ sent the Request for. Proposal to eight possible vendors, asking for fully insured and self- funded proposals. We received three responses, as well as the renewal, for a total of four possible solutions. 11440 Tomahawk Creek Parkway • Leawood, KS 66211-9955 Co Ms. Lori Meyer City of Cape Girardeau, Missouri September 24, 2009 Page Three As a side note, two years ago when we went through this process, we had requested a proposal from Missouri Consolidated Health Care Plan. The information we received at the time was a "preliminaiy" response from Missouri Consolidated Healthcare Plan (MCHCP). It was preliminary because they said they would need to review additional claims. information prior to "guaranteeing" their proposal. While this would have been a fully insured alternative, we elected not to proceed with MCHCP due to the following: 1. The annual "non -guaranteed" premium for MCHCP would have been approximately $4,142,300 or 52% above your current funding. That did not include the additional cost of termination (run off). 2. Early retiree rates were 53% above the active employee rates on the plan. 3. MCHCP does not offer any sort of Health Savings Account or Health Reimbursement Account plans. 4. Claims experience is not available to MCHCP member plans. 5. City employees would be accessing a Coventry plan through MCHCP. The Coventry plan does not include St. Francis Hospital. These components have not changed dramatically since that time. As such, we did not contact MCHCP to ask for a proposal. The analysis of the four remaining responses follows. CIGNA: CIGNA is one of the largest health insurance providers in the United States. Their proposal actually utilizes a Great West Healthcare platform, a company they purchased two years ago. They have proposed a self-funded plan, utilizing a Great West network: 1. Pricing: CIGNA's pricing would be a total annual maximum of $2,878,318, including an individual stop loss level of $125,000, and an overall maximum of 125% of expected paid claims. As with any new stop loss coverage, the rates are not final until claims experience through the end of October is analyzed. Thus, the above numbers are subject to change. By adding the cost of termination, the total maximum cost of the first year would be $3,291,739. Also worth noting is that this is the cost for the first year plan, during which Incurred But Not Reported (IBNR) reserves should be estimated. 2. Plan of Benefits: CIGNA has proposed plan designs that would be equivalent to the current plans in place for the City. 11440 Tomahawk Creek Parkway - Leawood, KS 66211-9955 Ms. Lori Meyer City of Cape Girardeau, Missouri September 24, 2009 Page Four 3. Network Providers: CIGNA has proposed the Great West network. While this network includes both hospitals in Cape Girardeau, it is unlikely to include as many physicians as the current Anthem network. Also, because CIGNA/Great West has a much smaller market share in the area, it is unlikely that the discounts negotiated are as aggressive as those in the Anthem network. 4. Administrative Capabilities: CIGNA/Great West are very strong administrators. They have a very strong national organization and would provide a good level of service. 5. Health and Productivity/Wellness Capabilities: CIGNA is one of the stronger players in this area on a national basis. They would provide several options for these services. 6. Funding Vehicle: As a self-funded plan, the first year's policy is discounted as a result of an immature year. IBNR funding is normally expected to take place in the first year. Thus, the second year would normally include increases in claim maximums and stop loss costs to account for the maturing of the plan. While CIGNA is a strong offering, based on the fact that their pricing and network are not as strong as Anthem's, we would not recommend a change to CIGNA. UMR: UMR is a TPA located in Wausau, Wisconsin, owned by United Healthcare. CBIZ has a small amount of business with UMR, but they are a well known national player. They have proposed a plan utilizing First Health as their network. I. Pricing: UMR pricing would be approximately $3,668,922 without the administrative cost of prescription drug coverage. UMR proposed prescription drug administration based on a per transaction basis, which we are unable to estimate based on current reports. There are also the same stop loss issues mentioned previously. Finally, the additional cost of termination would put the maximum range of cost at approximately $4,082,343. 2. Plan of Benefits: UMR would assume the same plan of benefits as those currently offered, including the current HSA plan. The pricing does not vary based on these choices. 3. Network Providers: First Health is the proposed network. Frankly, First Health is not nearly as robust a network as Anthem and many providers are not included. However, a more detailed analysis would be needed to make a fair comparison. 4. Administrative Capabilities: UMR is a capable vendor, and their clients pay for it. They will do anything requested, but they charge extra to do it. UMR does not necessarily provide a package discount, or get aggressive on pricing of administrative services. 11440 Tomahawk Creek Parkway • Leawood, KS 66211-9955 M Ms. Lori Meyer City of Cape Girardeau, Missouri September 24, 2009 Page Five 5. Health and Productivity / Wellness Capabilities: UMR does provide these services, but they are all on an ad hoc, extra cost basis. 6. Funding Vehicle: The same issues exist with the UMR option as the CIGNA plan. Based on the above factors, we would not recommend UMR as an option for the City's plan. Meritain Health: Meritain Health is a third party administrator headquartered in Buffalo, NY. Claims for the City would be paid from their St. Louis claims office. While their national client list is impressive, they have relatively little business in this pant of the country. They have contracted with HealthLink to provide the network for their offering. Pricing: Mertain's pricing would be a maximum of $3,109,132. Again, as a self-funded plan, the pricing is subject to change based on final claim numbers. By adding the cost of termination, the first year, immature cost maximum would be over $3.5 million. 2. Plan of Benefits: Meritain would assume the same plan of benefits as those currently offered. Network Providers: HealthLink was the quoted network. Again, while a similar set of providers, the claim costs might suffer from lower discounts. It is estimated that the Anthem network's discounts are at least 5% better than Healthlink's. 4. Administrative Capabilities: Meritain seems capable, but we have little experience to back that up. They also will provide any services requested, it just costs more. 5. Health and Productivity / Wellness Capabilities: Meritain is actually very aggressive in this area. They have proposed several strong programs that would benefit employees and their families. 6. Funding Vehicle: The same issues that exist as with all of the self-funded options. The maximum cost is quite high, and when adding the IBNR costs, they are even more prohibitive. While Meritain provides very strong wellness programming, the possibilities do not outweigh the negatives of the other areas of comparison. We would not recommend Meritain as an option for the City. 11440 Tomahawk Creek Parkway • Leawood, KS 66211-9955 Ms. Lori Meyer City of Cape Girardeau, Missouri September 24, 2009 Page Six Anthem Blue Cross and Blue Shield: Anthem is the current provider for the City's benefit plan, and has been for many years. 1. Pricing: Anthem has provided both a current plan renewal as well as pricing for a fully insured plan option. The pricing for the current plan would have an overall increase of 7.1 % over last year's factors. As estimated total liability for 2010 would be $3,137,377. This is the lowest of any of the self-funded plan options (These components are located in Section 4). Anthem's rates for the fully insured plan (the only fully insured proposal) are attached. The annual estimated cost would be approximately $2,783,252, a decent savings from your 2010 obligation with the minimum premium plan. If the City were to change to the fully insured plan, you would be obligated to pay the run-off claims, but not the administrative cost to process those claims. Anthem has also offered an embedded deductible option. This option would be a $2,500/$5,000 family deductible, with 20% coinsurance. Anthem has projected that this would be as much as a 25% savings vs. the current HSA plan. Benefits and rates are included in Section 5. There are three points to keep in mind about the fully insured plan pricing: 1) There is no possible "surplus" from the fully insured plan. There is also no possibility of incurring a deficit. 2) The rates that Anthem provides for the fully insured plan are not suggested - - they are in fact the actual cost. The City has traditionally funded at a higher level for the individual employee cost and given employees a break on their dependent costs. The City can pay however they want, but they will be obligated for these higher costs. 3) The City would no longer be able to set their own funding levels. Currently, the City could choose to fund at any level they wish, as long as the full obligation is met at year end. With a fully insured plan, there will be a monthly obligation equal to 1/12 of the annual cost. 2. Plan of Benefits: Anthem has proposed to keep the current plan of benefits, as well as offer an additional High Deductible plan with an embedded deductible. 3. Network Providers: Anthem's plan offers two positive aspects: 1) The largest number of providers and 2) The most aggressive discounts. 4. Administrative Capabilities: While there are always issues, Anthem seems to be very capable in this area. Additionally, Anthem is the only vendor to offer a local office, which is a very solid benefit to your employees and administration. 11440 Tomahawk Creek Parkway • Leawood, KS 66211-9955 0 Ms. Lori Meyer City of Cape Girardeau, Missouri September 24, 2009 Page Seven 5. Health and Pro ductivity/Wellness Capabilities: This is an area that Anthem needs to improve. While the HSA plan is based on a wellness platform (Lumenos) they must get more aggressive in this area. Anthem is answering this call and working to provide better alternatives. 6. Funding Vehicle: The Anthem minimum premium contract is unique from others in the marketplace. While it was a disadvantage in the past with the deficit carry forward provision, it has proved beneficial in the past year in offering the surplus availability. You also have a very viable alternative in the fully insured offering. Recommendation: Based on the preceding analysis, CBIZ would recommend renewing with Anthem with all of the current plan designs. If we can provide any further data, please let us know. Thank you for your continued confidence and support.- Sincerely, upport:Sincerely, -� David J. Johnson, CEBS Senior Benefits Consultant Idlr cc: Mr. Scott Meyer, City Manager, City of Cape Girardeau, MO Ms. Heather Brooks, Assistant to the City Manager, City of Cape Girardeau, MO Mr. John Richbourg, Finance Director, City of Cape Girardeau, MO 11440 Tomahawk Creek Parkway • Leawood, KS 66211-9955 City of Cape Girardeau Blue AccessSM PPO 3.1 Summary of Benefits, Effective 01/01/2010 Anthem.0 V. Covered Benefits Deductible Sin IelFamil $2,500/$7,500 $2,500/$7,500 Out -of -Pocket Limit Sin IelFamil $5,000/$10,000 $10,000/$20,000 Physician Home and Office Services (PCP/SCP) $30/$50 50% Primary Care Physician (PCP)/Specialty Care Physician (SCP) Including Office Surgeries and allergy serum: • allergy injections (PCP and SCP) $5 50% • allergy testing 20% 50% • routine and non -routine mammograms $30 50% (regardless of outpatient setting) • diabetic self management training $30 50% (regardless of outpatient setting) $30 50% • certain medical nutritional therapy (regardless of outpatient setting) 20% 50% • MRAs; MRIs, PETS, C -Scans, Nuclear Cardiology Imaging Studies and non -maternity related Ultrasounds Preventive Care Services Services include but are not limited to: Routine Exams, Pelvic Exams, Pap testing, PSA tests, Immunizations, Annual diabetic eye exam, Routine Vision and Hearing exams • Physician Home and Office Visits (PCP/SCP) $30/$50 50% • Other Outpatient Services @ Hospital/Alternative 20% 50% Care Facility • Immunizations through age 5 No copayment/coinsurance No copayment/coinsurance Emergency and Urgent Care • Emergency Room Services @ Hospital (facility/other $150/20% $150/20% covered services) (copayment waived if admitted) • Ur ent Care Center Services $50 50% Inpatient and Outpatient Professional Services 20% 50% Include but are not limited to: • Medical Care visits (1 per day), Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams Inpatient Facility Services 20% 50% Unlimited days except for: • 60 days Network/Non-Network combined for physical medicine/rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) • 90 days Network/Non-Network combined for skilled nursing facility Outpatient Surgery Hospital/Alternative Care Facility 20% 50% • Surgery and administration of general anesthesia Other Outpatient Services (including but not limited to): 20% 50% • Non Surgical Outpatient Services For example: MRIs, C -Scans, Chemotherapy, Ultrasounds, and other diagnostic outpatient services. • Home Care Services (Network/Non-network combined) 90 visits (excludes IV Therapy) • Durable Medical Equipment and Orthotics (Network/Non-network combined) $4,000 benefit maximum (excluding Prosthetic Devices and Medical Supplies) • Prosthetic Devices $4,000 benefit maximum • Physical Medicine Therapy Day Rehabilitation programs • Hospice Care 20% 50% • Ambulance Services 20% 20% Anthem Blue Cross and Blue Shield is the trade name RightCHOICE@ Managed Care, Inc. (RIT), Healthy Alliance@ Life Insurance Company (HALIC) and HMO Missouri, Inc. use to do business in most of Missouri. RIT and certain affiliates administer non -HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT, HMO Missouri, Inc. and HALIC are independent licensees of the Blue Cross and Blue Shield Association. MO BLUE 3.1 PPO LG SOB Rev. 7106 @Registered marks Blue Cross and Blue Shield Association. CoveredBenefits Outpatient Therapy Services (Combined Network & Non -Network limits apply) • Physician Home and Office Visits (PCP/SCP) $30/$50 50% • Other Outpatient Services @ Hospital/Alternative Care 20% 50% Facility Limits apply to: • Physical/Manipulation therapy excluding Chiropractic Services: 20 visits • Occupational therapy: 20 visits • Chiropractic Services: 26 visits (Network) Non -Network Not Covered • Speech therapy: Unlimited visits Behavioral Health Services: (Network and Non -Network) • Inpatient Facility Services Copayments/Coinsurance based Copayments/Coinsurance based • Physician Home and Office Visits (SCP) on setting where covered services on setting where covered services • Other Outpatient Services @ Hospital/Alternative Care are received are received Facility 90 days Network/Non-network combined for Residential Treatment Center Human Organ and Tissue Transplants No copayment/coinsurance 30% • Acquisition and transplant procedures, harvest and storage. Prescription Drugs2 Network Tier structure equals 1/2/3 (and 4, if applicable) • Network Retail Pharmacies: $10/$35/$75"' 50% (min $75)3 (30 -day supply) 25% up to $2,500 out-of-pocket Includes diabetic test strip • Anthem Rx Direct Mail Service: $20/$90/$190` Not covered (90 -day supply) 25% up to $2,500 out-of-pocket Includes diabetic test strip Medicare Rx - Wrap Lifetime Maximum Combined Network and Non -network Unlimited Unlimited Notes: • Flat dollar copayments and Non Network Human Organ and Tissue Transplants are excluded from the out-of-pocket limits. Also Prescription Drug deductibles/copayments/ coinsurance are excluded from the out-of-pocket limits. • Deductible(s) apply only to covered medical services listed with a percentage (%) coinsurance. However, the deductible does not apply to Emergency Room Services where a copayment and a percentage (%) coinsurance applies. • Network and Non -network deductibles, copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate toward each other. • Dependent Age: to the end of the calendar year which the child attains age 26- 1 SM • Specialist copayment is applicable to all Specialists excluding General Physicians, Internist, Pediatricians, OB/GYN's and Geriatrics or any other Network Provider as allowed by the plan. • Physicians Home and office visit copayment applies if the office visit is billed with allergy injections. • No copayment/coinsurance means no deductible%opayment/coinsurance up to the maximum allowable amount. 0% means no coinsurance up to the maximum allowable amount. However, when choosing a Non -network provider, the member is responsible for any balance due after the plan payment. • PCP is a Network Provider who is a practitioner that specializes in family practice, general practice, internal medicine, pediatrics, obstetrics/gynecology, geriatrics or any other Network provider as allowed by the plan. • SCP is a Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice. • Certain diabetic and asthmatic supplies have no deductible%opayment/coinsurance up to the maximum allowable amount at network pharmacies, except diabetic test strips. • Benefit period = calendar year • Elective abortions are not covered. t Kidney and cornea are treated the same as any other illness and subject to the medical benefits. 21fapplicable, all prescription drug expenses except tier 1, (Network/Non-network, Retail/Mail-service combined) apply to the per individual RX deductible. Once the RX deductible is met, the appropriate copayment applies. Also if applicable, the Prescription Drug out ofpocket maximum applies to Network Retail and Mail -Service combined. 'Rx non -network diabetic/asthmatic supplies not covered except diabetic test strips. °Prescription Drugs do not accumulate toward the Medical Lifetime Maximum (if applicable). However, once the Medical Lifetime Maximum is met (if applicable), no additional Prescription Drug claims will be paid. Precertification: • Members are encouraged to always obtain prior approval when using non -network providers. Precertification will help avoid any unnecessary reduction in benefits for non -covered or non -medically necessary services. Anthem Blue Cross and Blue Shield is the trade name RightCHOICE0 Managed Care, Inc. (RIT), Healthy Alliance0 Life Insurance Company (HALIC) and HMO Missouri, Inc. use to do business in most of Missouri. RIT and certain affiliates administer non -HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT, HMO Missouri, Inc. and HALIC are independent licensees of the Blue Cross and Blue Shield Association. MO BLUE 3.1 PPO LG SOB Rev. 7/06 ORegistered marks Blue Cross and Blue Shield Association. Pre-existing Exclusion Period: We will not provide benefits for services, supplies or charges for any pre-existing condition for the time period specified below (subject to HIPAA portability requirements): 12 months after the member's enrollment date A pre-existing condition is a condition (mental or physical) which was present and for which medical advice, diagnosis, care or treatment was recommended or received within the 6 month period ending on the member's enrollment date. Pregnancy and domestic violence are not considered a pre-existing condition. Genetic information may not be used as a condition in the absence ofa diagnosis. This summary of benef is is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate and Schedule ofBeneftts. In the event ofa conflict between the Group Contract and this description, the terms ofthe Group Contract will prevail. Authorized group signature (if applicable) D ioz-v Underwriting signature (if applicable) Date Anthem Blue Cross and Blue Shield is the trade name RightCHOICE@ Managed Care, Inc. (RIT), Healthy Alliance@ Life Insurance Company (HALIC) and HMO Missouri, Inc. use to do business in most of Missouri. RIT and certain affiliates administer non -HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT, HMO Missouri, Inc. and HALIC are independent licensees of the Blue Cross and Blue Shield Association. MO BLUE 3.1 PPO LG SOB Rev. 7106 @Registered marks Blue Cross and Blue Shield Association. MINIMUM PREMIUM RENEWAL RATES ACCOUNT NAME: City of Cape Girardeau GROUP NUMBER: 00316734;00127864;L0127864 EFFECTIVE DATE: 1/l/10 THRU 12/31/10 LINE OF BUSINESS: MEDICAL/DRUG PPO (Actives and Under 65 Retirees) Signature: Date : EMP EE/SP EE/CH FAM COMP AGGREGATE S -L: CURRENT RATES $4.72 $9.34 $8.20 $12.81 $5.49 RENEWAL RATES 4.91 $9.71 $8.53 $13.32 5.71 % CHANGE 4.0% 4.0% 4.0% 4.0% 4.0% SPECIFIC S -L: CURRENT RATES $20.87 $41.34 $36.22 $56.70 $24.27 RENEWAL RATES 24.40 $48.33 542.34 $66.28 $28.37 % CHANGE 16.9% 16.9% 16.9% 16.9% 16.9% ADMINISTRATION: CURRENT RATES $27.97 $55.41 $48.55 $75.98 $32.52 RENEWAL RATES 28.96 $57.38 $50.28 $78.68 $33.68 % CHANGE 3.6% 3.6% 3.6% 3.6% 3.6% BLUECARD FEE: CURRENT RATES $3.26 $3.26 $3.26 $3.26 $3.26 RENEWAL RATES 0.80 $0.80 $0.80 $0.80 $0.80 % CHANGE -75.5% -75.5% -75.5% -75.5% -75.5% MAX. CLAIMS: CURRENT RATES $432.37 $856.42 $750.46 $1,078.36 $501.38 RENEWAL RATES 463.06 5917.22 $803.74 $1,154.92 $536.97 %CHANGE 7.1% 7.1% 7.1% 7.1% 7.1% TOTAL COST: CURRENT RATES $489.19 $965.77 $846.69 $1,227.11 $566.92 RENEWAL RATES $522.14 $1,033.44 $905.68 $1,314.00 $605.53 % CHANGE 6.7% 7.0% 7.0% 7.1% 6.8% TERMINAL LIABILITY: CURRENT RATES $67.80 $134.98 $118.11 $185.60 $79.70 RENEWAL RATES 54.88 $109.26 $95.61 $150.24 $64.51 %CHANGE -19.1% -19.1% -19.1% -19.1% -19.1% Signature: Date : PPO - 65+ Retirees EMP EE/SP EE/CH FAM COMP AGGREGATE S -L: CURRENT RATES $2.84 $5.66 $4.96 $7.76 $5.48 RENEWAL RATES 2.95 $5.89 $5.16 $8.07 $5.70 % CHANGE 4.0% 4.0% 4.0% 4.0% 4.07/. SPECIFIC S -L: CURRENT RATES $12.63 $25.01 $24.54 $34.31 $24.24 RENEWAL RATES 14.76 $29.24 $28.69 $40.11 $28.34 % CHANGE 16.9% 16.9% 16.9% 16.9% 16.9% ADMINISTRATION: CURRENT RATES $16.92 $33.50 $29.35 $45.95 $32.47 RENEWAL RATES 17.52 $34.69 $30.39 $47.58 $33.62 % CHANGE 3.6% 3.6% 3.6% 3.6% 3.6% BLUECARDFEE: CURRENT RATES $3.26 $3.26 $3.26 $3.26 $3.26 RENEWAL RATES $0.80 $0.80 $0.80 50.80 $0.80 % CHANGE -75.5% -75.5% -75.5% -75.5% -75.5% MAX. CLAIMS: CURRENT RATES $432.37 $856.42 $750.46 $1,078.36 $805.89 RENEWAL RATES 463.06 5917.22 $803.74 $1,154.92 $863.10 %CHANGE 7.1% 7.1% 7.1% 7.1% 7.1% TOTAL COST: CURRENT RATES $468.02 $923.85 $812.57 $1,169.64 $871.34 RENEWAL RATES $499.10 $987.83 $868.78 $1,251.48 $931.56 % CHANGE 6.6%1 6.9%1 6.9% 7.0% 6.9% TERMINAL LIABILITY: CURRENT RATES $67.80 $134.98 $118.111 $185.60 $79.70 RENEWAL RATES 54.88 109.26 95.61 1 150.24 64.51 %CHANGE -19.1% -19.1% -19.1% -19.1% -19.1% r� ..., Your Benefits City of Cape Girardeau Lumenos Health Savings Accounts Option 7 Summary of Benefits, Effective 01/01/2010 Anthem. 0 V. Covered Benefits Network on -Network Deductible Single: $2,000 Single: $2,000 Family coverage requires the family deductible to be met before coinsuranceFamily: $4,000Family: $4,000 applies. The single deductible does not apply to family coverage. Network and Non -Network deductibles are combined. This only applies to non -embedded deductible designs.) Out -of -Pocket Limit Single: $5,000 Single: $10,000 Family: $10,000Family: $20,000 Physician Home and Office Services (PCP/SCP) 00/o/20% 0% Primary Care Physician(PCP)/Specialty Care Physician (SCP) • Including Office Surgeries, allergy serum, allergy injections and allergy testing Preventive Care Services Services include but are not limited to: Routine Exams, Pelvic Exams, Pap testing, PSA tests, Immunizations, Annual diabetic eye exam, Routine Vision and Hearing exams, Routine Mammograms, Diabetic Self Management Training and Certain Medical Nutritional Therapy. Physician Home and Office Visits (PCP/SCP) No Cost Share 0% Other Outpatient Services @ Hospital/Alternative Care Facility 40% Immunizations through age 5 No Copayment/Coinsurance Emergency and Urgent Care Emergency Room Services 0% 20% (facility/other covered services) (copayment waived if admitted) Urgent Care Center Services 20% 0% Inpatient and Outpatient Professional Services 20% 0% Include but are not limited to: . Medical Care visits (I per day), Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams Inpatient Facility Services 0% 0% Unlimited days except for: • 60 days Network/Non-Network combined for physical medicine / rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) • 100 days Network/Non-Network combined for skilled nursing facility Outpatient Surgery Hospital / Alternative Care Facility 0% 0% • Surgery and administration of general anesthesia Other Outpatient Services (including but not limited to): 0% 0% Non Surgical Outpatient Services For example: MRIs, C -Scans, Chemotherapy, Ultrasounds and other diagnostic outpatient services. Home Care Services (Network/Non-network combined) 100 visits (excludes IV Therapy) Durable Medical Equipment and Orthotics (Network/Non-network combined) $4,000 benefit maximum (excluding Prosthetic Devices and Medical Supplies) Prosthetic Devices $4,000 benefit maximum Physical Medicine Therapy Day Rehabilitation programs Hospice Care 20% 0% �0% Ambulance Services 20% Anthem Blue Cross and Blue Shield is the trade name RightCHOICE® Managed Care, Inc. (RTP), Healthy Alliance® Life Insurance Company (HALIC) and HMO Missouri, Inc. use to do business in most of Missouri. Rrr and certain affiliates administer non -HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. Life and disability benefits are underwritten by Anthem Life Insurance Company (ALIC). RIT and certain affiliates only provide administrative smites for self-funded plans and do not underwrite benefits. RIT, HMO Missouri, Inc., HALIC and ALIC are independent licensees of the Blue Cross and Blue Shield Association. Anthem: 203926 -HSA Lumenos Page: 1 Your B enefits City of Cape Girardeau Lumenos Health Savings Accounts Option 7 Summary of Benefits, Effective 01/0112010 Anthem,0M, Covered Benefits Network Non -Network Outpatient Therapy Services (Combined Network & Non -Network limits apply) Physician Home and Office Visits (PCP/SCP) 00/o/20% 0% Other Outpatient Services @ Hospital/Alternative Care Facility 0% 0% Limits apply to: Physical / Manipulation therapy excludes Chiropractic Services: 20 visits Occupational therapy: 20 visits Chiropractic Services: 26 visits (Network) Non -Network Not Covered Speech therapy: Unlimited visits Behavioral Health Services: Mental Health and Substance Abuse Inpatient Facility Services 0% 0% Physician Home and Office Visits (PCP/SCP) 0%/20% 0% Other Outpatient Services @ Hospital/Altemative Care Facility 0% 0% Human Organ and Tissue Transplants 0% 0% • Acquisition and transplant procedures, harvest and storage. Prescription Drugs: Network Retail Pharmacies: 0% 0%(1) (30 -day supply) Includes diabetic test strip Anthem Mail Service: 20% Not Covered (90 -day Supply) Includes diabetic test strip ffetime Maximum (Combined Network and Non -Network) (2) nlimited -limited Notes: • All deductibles and coinsurance apply toward the out-of-pocket maximum including prescription drugs. (Excludes Non -network Human Organ and Tissue Transplants). Deductible(s) apply only to covered medical services listed with a percentage (%) coinsurance including prescription drugs. Network and Non -network deductibles are combined. Network and Non -network coinsurance and out-of-pocket maximums are separate and do not accumulate toward each other. Dependent age: to the end of the calendar year in which the child attains age 25. No copayment/coinsurance means no deductible%opayment/coinsurance up to the maximum allowable amount. However, when choosing a Non -network provider, the member is responsible for any balance due after the plan payment. No cost share means no deductible or coinsurance up to the maximum allowable amount. • Benefit period = Calendar Year (1)Rx non -network diabetic/asthmatic supplies not covered except diabetic test strips. (2)Prescription Drugs do not accumulate toward the Medical Lifetime Maximum (:f applicable). However, once the Medical Lifetime Maximum is met (if applicable), no additional Prescription Drug claims will be paid. Precertification: • Members are encouraged to always obtain prior approval when using Non -network providers. Precertification will help avoid any unnecessary reduction in benefits for non -covered or non -medically necessary services. Anthem Blue Cross and Blue Shield is the trade name RightCHOICE® Managed Care, Inc. (RM, Healthy Alliance® Life Insurance Company (HALIC) and HMO Missouri, Inc. use to do business in most of Missouri. RIT and certain affiliates administer non -HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. Life and disability benefits are underwritten by Anthem Life Insurance Company (AL:C). RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. RIT, HMO Missouri, Inc., HALIC and ALIC are independent licensees of the Blue Cross and Blue Shield Association. Anthem: 203926 -HSA Lumenos Page: 2 Anthem,, KD. V City of Cape Girardeau Lumenos Health Savings Accounts Option 7 Summary of Benefits, Effective 01/01/2010 Pre -Existing Exclusion Period: We will not provide benefits for services, supplies, or charges for any pre-existing condition for the time period specified below (subject .'o HIPAA portability requirements): 12 months after the member's enrollment date A pre-existing condition is a condition (mental or physical), which was present and for which medical advice, diagnosis, care or treatment was recommended or received within the 6 month period ending on the member's enrollment date. Pregnancy and domestic violence are not considered a pre-existing condition. Genetic information may not be used as a condition in the absence of a diagnosis. This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate, and Schedule of Benefits. In the event o own jct between the Group Contract and this description, the terms of the Group Contract will prevail. // uthorized group signature (if applicable) Date / &—/ Underwriting signature (if applicable) Lfate Anthem Blue Cross and Blue Shield is the trade name RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC) and HMO Missouri, Inc. use to do business in most of Missouri. RIT and certain affiliates administer non -HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. Lifeand disability benefits are underwritten by Anthem Life Insurance Company (ALIC). RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. RIT, HMO Missouri, Inc., HALIC and ALIC are independent licensees of the Blue Cross and Blue Shield Association. Anthem: 203926 -HSA Lumenos Page: 3 HSA - LUM 7 Signature: Date: EMP EE/SP EE/CH FAM COMP AGGREGATE S -L: CURRENT RATES $4.72 $9.34 $8.20 $12.81 $5.59 RENEWAL RATES 4.91 $9.71 $8.53 $13.32 $5.81 % CHANGE 4.0% 4.0% 4.0% 4.0% 4.0% SPECIFIC S -L: CURRENT RATES $20.87 $41.34 $36.22 $56.70 $24.73 RENEWAL RATES 24.40 $48.33 $42.34 $66.28 $28.90 % CHANGE 16.9% 16.9% 16.9% 16.9% 16.9% DMINISTRATION: CURRENT RATES $29.82 $57.26 $50.40 $77.84 $34.99 RENEWAL RATES 30.88 $59.30 $52.19 $80.61 $36.23 % CHANGE 3.6% 3.6% 3.6% 3.6% 3.6% BLUECARD FEE: CURRENT RATES $3.26 $3.26 $3.26 $3.26 $3.26 RENEWAL RATES $0.80 $0.80 $0.80 50.80 $0.80 % CHANGE -75.5% -75.5% -75.5% -75.5% -75.5% MAX. CLAIMS: CURRENT RATES $385.94 $764.44 $669.86 $962.55 $451.65 RENEWAL RATES 413.34 $818.71 $717.41 $1,030.88 $483.71 %CHANGE 7.1% 7.1% 7.1% 7.1% 7.1% TOTAL COST: CURRENT RATES $444.61 $875.64 $767.94 $1,113.16 $520.21 RENEWAL RATES $474.33 $936.85 $821.28 $1,191.90 $555.46 %CHANGE 6.7%1 7.0% 6.9% 7.1% 6.8% TERMINAL LIABILITY: CURRENT RATES $67.80 $134.98 $118.11 $185.60 $79.70 RENEWAL RATES $54.88 $109.26 $95.61 $150.24 $64.51 %CHANGE -19.1% -19.1% -19.1% -19.1% -19.1% Signature: Date: