HomeMy WebLinkAboutR26-143 RESOLUTION NO. R26-143
A RESOLUTION OF THE CITY COMMISSION OF THE CITY OF BOYNTON
2 BEACH, FLORIDA, AWARDING THE REQUEST FOR PROPOSAL FOR
3 EMPLOYEE MEDICAL AND PHARMACY ADMINISTRATION SERVICES
4 AND STOP LOSS INSURANCE TO AETNA LIFE INSURANCE COMPANY
5 FOR CONTINUED MEDICAL, VISION, AND DENTAL SERVICES; AND
6 FOR ALL OTHER PURPOSES.
7
8 WHEREAS, the City and Aetna Life Insurance Company ("Aetna") entered into a Master
9 Services Agreement, MSA-0192692, effective October 1, 2023, approved by Resolution No. R23-
10 117; and
11 WHEREAS, the City's benefits Consultant, Michael Gelin, solicited these services on the
12 City's behalf pursuant to his existing contract with the City; and
13 WHEREAS, acting under that authority, the Consultant issued a Request for Proposal
14 ("RFP")for Employee Medical and Pharmacy Administration Services and Stop Loss Insurance. Five
15 carriers submitted proposals, of which two were determined to be responsive and responsible:
16 Aetna, the incumbent carrier, and United Healthcare; and
17 WHEREAS, the City and the Consultant used the lower-cost options available through
18 United Healthcare/Neighborhood Health as leverage to reduce Aetna's proposed renewal costs.
19 As a result, the increase to Aetna's fixed administrative fees was reduced from an initial 37% to a
20 final 16%; and
21 WHEREAS, the City desires to renew and extend the Master Services Agreement, MSA-
22 0192692, with Aetna, with the rates negotiated from the RFP; and
23 WHEREAS, the City Commission, upon the recommendation of staff, has deemed it in the
24 best interests of the City's citizens and residents to award the RFP for Employee Medical and
25 Pharmacy Administration Services and Stop Loss Insurance to Aetna Life Insurance Company for
26 continued Medical, Vision, and Dental services.
27
28 NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF THE CITY OF BOYNTON
29 BEACH, FLORIDA, THAT:
30 SECTION 1. The foregoing "Whereas" clauses are hereby ratified and confirmed as
31 being true and correct and are hereby made a specific part of this Resolution upon adoption.
RESOLUTION NO. R26-143
32 SECTION 2. The City Commission of the City of Boynton Beach, Florida, does hereby
33 award the RFP for Employee Medical and Pharmacy Administration Services and Stop Loss
34 Insurance to Aetna Life Insurance Company for continued Medical, Vision, and Dental services, as
35 further detailed in the Aetna proposal, attached hereto as Exhibit A.
36 SECTION 3. The City Commission of the City of Boynton Beach, Florida, hereby extends
37 and renews the Master Services Agreement, MSA-0192692, with Aetna at the rates negotiated in
38 the RFP.
39 SECTION 4. The City Commission of the City of Boynton Beach, Florida, hereby
40 authorizes the Mayor and/or the City Manager to execute any ancillary documents as may be
41 necessary to accomplish the purpose of this Resolution.
42 SECTION 5. This Resolution shall take effect in accordance with the law.
43 [SIGNATURES ON THE FOLLOWING PAGE]
44
RESOLUTION NO. R26-143
45 PASSED AND ADOPTED this �iday of C`c.�Q\(A...4N k. 2026.
46 CITY OF BOYNTON BEACH, FLORIDA
47 YES NO
48 Mayor- Rebecca Shelton ✓
49
50 Vice-Mayor-Thomas Turkin Ci-V3 s Q"-L 1 -
51
52 Commissioner-Angela Cruz ✓
53
54 Commissioner- Mack McCray ✓
55
56 Commissioner-Aimee Kelley
57
58 VOTE d '
59 ATTEST:
60 /".
61 �Cs�Q�
62 Tammy Stanzio e, CMC Rebecca Shelton
63 City Clerk r-- Mayor
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64 .••• TO��%
65 ;ma ;•'GORPpR/ <p i. APPROVED AS TO FORM:
66 (Corporate Seal) s •INcS�A T , �,
67 i ORPo L• I_
68 '.$ •.•••1 gz p rF° % ll.�46 Q/nh
69 %I�� �'�•''•••"' Shawna G. Lamb
70 ‘‘�°RlDA - City Attorney
vaetnar.
261 N. University Drive
Plantation, FL 33324
August 12, 2026
City of Boynton Beach
Mayor Rebecca Shelton
100 E. Ocean Avenue
Boynton Beach, FL 33435
Re: Confirmation of Renewal of Employee Benefits Programs Effective
October 1, 2026
Dear Mayor:
We are pleased to be re-awarded the City of Boynton Beach's employee benefits program business,
effective October 1, 2026. This renewal is subject to the terms, conditions, rates, guarantees, and
provisions outlined in the applicable Request for Proposal (RFP), renewal exhibits, service
agreements, fee schedules, policies, certificates, and related governing documents, including the
Master Service Agreement currently in place.
The City's renewal includes the following programs:
Self-Funded Medical Administration Services
Prescription Drug Benefits Administration
Stop Loss Insurance
Dental Benefits
Vision Benefits
Renewal Financial Summary
Medical Administration Services
Aetna will continue to administer the City's self-funded medical plans at a guaranteed administrative
fee of$38.20 per employee per month (PEPM).This fee is guaranteed through September 30,
2029, subject to the terms and conditions contained in the renewal agreement.
Prescription Drug Benefits
Prescription drug benefits will continue to be administered by Aetna pursuant to the Pharmacy
Services Agreement and applicable fee schedules incorporated into the renewal package.
Stop Loss Insurance
The City has elected to renew Aetna Stop Loss with the following coverages:
Individual Stop Loss Deductible: $250,000
Aggregate Stop Loss Coverage: 125%
Combined Stop Loss Premium: $131.17 PEPM
Estimated Annual Stop Loss Premium: $1,429,228
Dental Benefits
The City has elected to renew Aetna Dental coverage with an estimated monthly premium of
$63,988, subject to final enrollment and policy provisions.
Vision Benefits
The City has elected to renew Aetna Vision coverage at the following monthly rates:
Employee Only: $4.45
Employee + Spouse: $8.56
Employee + Child(ren): $8.22
Employee + Family: $11.81 These Vision rates are guaranteed for a thirty-six (36) month period,
subject to the terms and conditions contained in the renewal documentation.
Acknowledgement
This letter serves as formal confirmation of the City of Boynton Beach's intent to renew the employee
benefits identified herein effective October 1, 2026. The summary above is provided for convenience
and does not supersede the governing terms and conditions contained in the applicable contracts,
renewal agreements, schedules, certificates, policies, and related documents.
The parties acknowledge that the final governing provisions shall be contained within the executed
contractual documents and associated exhibits.
We appreciate the opportunity to continue serving the City of Boynton Beach and its employees and
look forward to another successful year of partnership.
Sincerely,
Kimberly McMenamy
Manager, Acco nt Executive
Aetna I CVS Health
Acceptedn Agreed:
Mayor / 1
City of BKnton Beach
Date: 08 -a 5-a C.
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valetna®
An Aetna Proposal
Presented to
City Of Boynton Beach
Effective: October 1, 2026
Plan Sponsor Number: 192692
aetnaG
Shannon Blakeslee
151 Farmington Avenue
Hartford,CT 06156
Phone:860-273-3600
Email:BlakesleeS@aetna.com
7/1/2026
City Of Boynton Beach
Danielle Whitefiled,HR
100 E.Ocean Avenue
Boynton Beach,FL 33435
Re:City Of Boynton Beach-Confirmation of Sold Products,Programs,Services and Fees
Dear Danielle:
Thank you for selecting Aetna.We look forward to beginning our business relationship with you.Based on our original
proposal and subsequent discussions,we have outlined the products and services City Of Boynton Beach has purchased for
the plan,effective October 1,2026.Please review and confirm this information accurately reflects your understanding.If you
have any questions or concerns regarding the information outlined in this letter
and the attachments,you may contact Kimberly Mcmenamy to discuss any necessary changes.
The contract period begins on October 1,2026 and provides for automatic renewal upon the completion of each Guarantee
Period unless either party invokes the termination provision.The termination provision requires 90 days advance
written notice of termination to the other party.This provision may be invoked at any time and is not limited to termination
occurring on the renewal date,subject to the terms of the contract(s).
Refer to the attached documents for complete details of our offer.Our final offer includes:
• Medical Administrative Services-Attached ASC Fees,Programs and Services and Caveats
If we do not receive a response from you by September 15,2026,we will consider our proposal of products,programs,services,
and fees to be approved.We appreciate your business and look forward to a successful plan implementation.
Both parties(City Of Boynton Beach and Aetna)agree to abide by the terms and conditions of this letter and the Master
Services Agreement(MSA)until such time as the MSA is executed.The parties agree to work in
good faith and finalize the MSA for the services outlined in this letter by December 1,2026.Upon execution of the MSA,
this letter and its attachments shall be of no further force and effect.
Sincerely,
dJ raf-ta.u¢—
Shannon Blakeslee
Ld Dir,Underwriting
Aetna
cc: Kimberly Mcmenamy
David Gimler
Gelin Benefits Group
�►aetnaT.
Paget
July 2026 CONFIDENTIAL LOU
City Of Boynton Beach
Contact Information/Assumptions
Account Executive: Kimberly Mcmenamy
Email: McmenamyKL@aetna.com
Telephone: 904-322-2623
Mem/EE Ratio: 1.57
Administrative Service Fees Effective Date:October 1,2026 End Date:September 30,2027
Year 1 Year 2 Year 3
Guarantee Period Effective Date October 1,2026 October 01,2027 October 01,2028
Fee Contract Basis Mature Mature Mature
Runoff Claim Processing Included Included Included
Estimated
Guaranteed Medical Administrative Fee(PEPM)* Year 1 Year 2 Year 3
Enrollment
Choice POS II 758 $38.20 $38.20 $38.20
OA Aetna Select 122 $38.20 $38.20 $38.20
Administrative Fee Guarantee%Change* 0.0% 0.0%
Administrative Fee Summary(Plan Year) Year 1 Year 2 Year 3
Guaranteed Medical Administrative Fees $403,392 $403,392 $403,392
Total Fees $403,392 $403,392 $403,392
*Clarifications
•PEPM is defined as Per Employee,Per Month for subscribers covered under your Aetna medical plan.
•Please see Programs and Services for additional information.Some services may come at additional cost to the fees shown above.
•Broker Compensation,if applicable,is subject to customer approval.
•Any Plan Year costs are based on the Estimated Enrollment and subject to change based on actual enrollment.
Administrative Fee Guarantee
Our offer includes an administrative fee guarantee for the Guarantee Period October 1,2026 to September 30,2029.
The guaranteed administrative fees excludes broker compensation,fee adjustments and other charges listed above.
The guarantee is subject to the terms and conditions as stated in the caveats and is contingent upon the customer
maintaining all lines of business with Aetna.Programs and Services billed via the Claim Wire and Additional Buy-up services
outlined on the Programs and Services exhibit may be subject to annual increases provided at time of renewal.
Prescription Drug Benefits
Our quotation assumes that prescription drug benefits will be provided by Aetna.
Additional pharmacy administrative fees may apply.Refer to our Pharmacy Service and Fee Schedule and Program
Summary for additional information.
If you terminate prescription drug benefits with us,we will increase the ASC Medical Service Fees and the medical trend
assumption used for any applicable claim projections or guarantees.You may also be subject to additional charges to
integrate data with external Pharmacy vendors.Refer to the reporting charges outlined in the Programs and Services
exhibit for more information.
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies.
The information contained in this proposal is confidential and should not be shared with anyone other than your broker or benefit plan
consultant.
�►aetna Page
July 2026 CONFIDENTIAL ASC Fees
City Of Boynton Beach
Programs and Services—Self-Funded Effective Date: October 01, 2026
Program Summary Choice POS II OA Aetna Select
Programs&Services Included in the Service Fee
General Administration
Experienced Account Management Team Included Included
Designated billing,eligibility,plan set up,underwriting Included Included
Onsite Open Enrollment Meeting Preparation Included Included
Open Enrollment Marketing Material(non-customized) Included Included
ID Cards* Included Included
Review or draft plan documents Included Included
Summary of Benefits and Coverage(SBC) Included Included
Claim Fiduciary Option 1 Included Included
External Review Included Included
Non-ERISA Included Included
Claim Administration Included Included
Plan Sponsor Liaison Included Included
Special Investigations/Zero Tolerance Fraud Unit Included Included
Network Services
Full National Reciprocity* Included Included
Institutes of Excellence"* I Included I Included
Institutes of Quality®(IOQ)Network I Included I Included
Gene-Based,Cellular and other Innovative Therapies(GCIT®)network I Included I Included
National Medical Excellence Program® I Included I Included
Network access I Included I Included
Aetna Compassionate Care`' Included Included
Aetna Advice I Included I Included
Aetna Healthy Chapters" I Included I Included
Preventive Care Considerations(Electronic) I Included I Included
Utilization Management(Inpatient Precertification,Concurrent Review,Discharge
Planning, Retrospective Review) Included Included
ember Resources
Designated Service Center Included Included
Aetna Concierge(includes First Impression Treatment) I Included I Included
Provider search(online provider directory) I Included I Included
Dedicated Toll Free Number I Included I Included
Member Website and Mobile Experience I Included I Included
Online Programs I Included I Included
24-Hour Nurse Line: 1-800#Only Included Included
Aetna Health Your Way'Health Assessment and Digital Support I Included I Included
Aetna Health Your Way"Plus(includes MedQuery and Personal Health Record) I Included I Included
vaetnaM Page
July 2026 CONFIDENTIAL Programs and Services ASC
Allowances
Health Plan Allowance Included Included
Reporting and Integration
Analytic Consultation from Plan Sponsor Insights(10 Hours) Included Included
ART Reports- New analytic reporting platform I Included I Included
Aetna Health Information AdvantageTM (AHIA) I Included I Included
Monthly Financial Claim Detail Reports I Included I Included
'Monthly Banking Reports I Included I Included
Behavioral Health
Managed Behavioral Health Included Included
Behavioral Health Condition Management Program-Standard I Included I Included
Applied Behavior Analysis(ABA) I Included I Included
Aetna Discount Program
at home products,fitness, hearing, LifeMart°shopping website, natural products and Included Included
services,oral health care,vision,weight management
Programs & Services Included in the Claim Wire*
No Surprises Act-Fees*
No Surprises Act(NSA)claim administration fee(per NSA eligible claim) $94 $94
Applicable fees Applicable fees
No Surprises Act(NSA)Independent Dispute Resolution(IDR) initial fee(per are as set by law are as set by law
arbitration case) and passed and passed
through to the through to the
plan plan
Applicable fees Applicable fees
No Surprises Act(NSA) Independent Dispute Resolution (IDR)arbitration expenses are as set by law are as set by law
(per arbitration case) and passed and passed
through to the through to the
plan plan
vaetna Pages
July 2026 CONFIDENTIAL Programs and Services ASC
Network Services
CVS Health Virtual Care'"(PEPM)* $0.40 $0.40
Subrogation* 37.5%of savings 37.5%of savings
Contracted Services*(Coordination of Benefits,Retro Terminations,Medical Bill and
Hospital Bill Audits,Workers Compensation,DRG and Implant Audits) 37.5%of savings 37.5%of savings
Claim and Code Review Program* 37.5%of savings 37.5%of savings
We will retain We will retain
National AdvantageTM Program(NAP)* 50%of savings 50%of savings
(includes FCR, (includes FCR,
IBR, PCRS) IBR,PCRS)
National AdvantageTM Program Cap(includes Facility Charge Review,Itemized Bill Cap of$100,000 Cap of$100,000
per individual per individual
Review,and PCRS when applicable) claim claim
Aetna One® Flex(per engaged member,per month)* $735 $735
Enhanced Clinical Review Program(PMPM)* $0.70 $0.70
High Tech Imaging Included Included
Diagnostic Cardiac Included Included
Sleep Management Included Included
Cardiac Implantable Devices Included Included
Interventional Pain Included Included
Hip and Knee Arthroplasties Included Included
Additional Available Programs&Services(per employee, per month unless otherwise noted)
Member Resources
Aetna Smart Compare® Intelligent Matching $0.50 $0.50
Aetna Informed Choice1M® I $0.50 I $0.50
Aetna Custom ConnectionsTM Standard I $0.50 I $0.50
vaetna M Page
July 2026 CONFIDENTIAL Programs and Services ASC
City Of Boynton Beach
Programs and Services—Self-Funded Effective Date:October 01,2026
*Additional Program Details
Claim Wire Billing,ID Cards,Subrogation,Contracted Services,Claim and Code Review
Details can be found in our UW Disclosure document located at the following URL:
httos://www.aetna.com/co ntent/da m/aetna/odfs/aetnacom/le¢a I-notices/documents/la r¢e-erouo-and-public-labor-self-funded-medical-
underwriti ne-disclosures-as-of-01-01-2026.odf
No Surprises Act-Fees
The NSA claim administration fee will increase at each annual proposal and apply to NSA eligible claims paid on or after that
proposal date.Refer to the NSA Payment Practices in our Caveats for information on our payment practices for NSA eligible claims.
No Surprises Act-IDR Fees
IDR fees are required by the NSA rules and are payable to the IDR entity.There is an initial fee to begin an arbitration,which applies
to each case.There is also an additional fee for the arbitration expenses;the losing party within the dispute is liable for this fee.
For batch cases,the NSA permits IDR entities to charge a different arbitration fee based on a set fee range and/or percentage of the
batch fee.The fees are passed through(with no mark up by Aetna)to a customer based on the number of line items for their plan
that were included in the batch case.The current NSA fees are set by federal agencies.Both the initial fee and the arbitration
expense fee are subject to future adjustments by the agencies(and any such adjustments shall be applied to your plan).
Aetna Informed Choice"'
Aetna Informed Choice"'requires Aetna Smart Compare•Intelligent Matching.Enhanced Clinical Review Program-Hip and Knee
Arthroplasties is required if purchasing Procedure Bundles.
Aetna One Flex
Engagement begins upon a two-way interaction(i.e.telephonic,email,secured messaging,etc.)with a member of the multi-disciplinary
care team(i.e.nurse,registered social worker,pharmacist,health coach,or behavioral health specialist).After one month without
a two-way interaction a member is no longer considered engaged.
CVS Health Virtual Care"'
In addition to the administrative fees as outlined above,there is a per consultation charge which will be shared by the member and
plan sponsor based on type of service provided and member's benefit plan.Specific charges are available upon request.
Enhanced Clinical Review
This fee will only be charged based upon those members who fall into service areas where the program is available.
Full National Reciprocity
Excludes some standalone Aetna Whole Health networks.Details are available upon request.
Institutes of Excellence"'(IOE)
This program includes a steerage component by educating members on the benefits of using an IOE designated facility.However,
benefit differential steerage is not supported for IOE Infertility network.
National Advantage"'Program(including the Contracted Rates,Facility Charge Review and Itemized Bill Review Components)
NAP includes a Contracted Rates component and two optional components:Facility Charge Review(FCR)and Itemized Bill Review(IBR).
In addition,some plans also elect Professional Claims Repricing Service(PCRS)as their out-of-network plan rate for professional
services.NAP's Contracted Rates component offers access to contracted rates for many medical claims from non-network providers
(including claims for emergency services and claims by hospital-based specialists such as anesthesiologists and radiologists who do not
contract with insurers)and ad hoc negotiations(when a contracted rate is not available).We retain a percentage of savings achieved
through NAP,including savings achieved through FCR,IBR,and PCRS,if elected.This NAP Fee is in addition to the per employee,
per month administrative service fees.
vaetna Pagel
July 2026 CONFIDENTIAL ASC Program Details
City Of Boynton Beach
Allowances-Self-Funded Effective Date:October 01,2026
We are including allowance(s)for your Aetna plans applicable to each year of the Guarantee Period as outlined in the chart below.
Allowance dollars must be used for your commercial Aetna medical plans and Aetna medical members.
nnual Allowance Type Year 1 Year 2 Year 3
an Year Effective Date 10/01/2026 10/01/2027 10/01/2028
Health Plan $142,000 $142,000 $142,000
Total I $142,000 I $142,000 I $142,000
Annual allowance amounts may be adjusted if actual enrollment changes by 15 percent or more from our enrollment assumptions.
Health Plan Allowance
• The Health Plan allowance can be used to offset reasonable documented expenses applicable to the Guarantee Period(s)for
which it is offered.Your allowance can be used for implementation,communication,reporting,and audit associated with
your Aetna Medical plan.Examples of reimbursable expenses include:
—implementing your contract with us
—promoting our products,programs or services,such as,educational content and materials for enrollees or prospective enrollees
—Aetna required technology platforms or our system front-end charges to support our plans
—communicating with our members
—auditing our readiness
—recurring or ad hoc reporting with us
—reporting costs to integrate our data with third-party vendors.
• Your allowance can also be used to offset reasonable documented wellness-related programs or activities incurred during the
Guarantee Period for which the allowance is offered.Wellness allowance expenses must be for wellness-related programs or
activities that are reasonably designed to promote the health and well-being of Aetna members,or to educate Aetna members
about healthy lifestyles and/or prevent disease.This means that there must be a connection to the health and well-being of the
members,with a focus on preventative measures or healthy living(i.e.,diet,exercise),not on acute care.Wellness programs
and activities funded by allowance funds are not covered benefits under your Aetna plan.
• Claims audit expenses must be incurred during the Guarantee Period for which the allowance is offered.
• Should you terminate your contract with us,the allowance cannot be used to fund implementation/communication expenses
related to the new carrier's contract.
• Any expenses associated with the implementation,administration or communication of another carrier's plans,programs
or services are also ineligible.
The above referenced fund(s)will be available after the effective date of each plan year.Only those expenses performed and billed by a
third party are payable.Reimbursement for time and materials incurred directly by the plan sponsor(e.g.,hours worked by the plan
sponsor's own employees)are not eligible.Your normal business operation expenses,including employee salaries and overtime,
are not eligible under the allowance.Our preferred method of payment is directly to the third-party vendor.We require submission
of appropriate documentation detailing charges for the services provided by the vendor.Acceptable documentation includes,but
is not limited to,detailed vendor invoices itemizing services provided,specific cost-elements and associated line-item charges.
On an exception basis,we can reimburse you directly provided you submit both the detailed invoice and receipt showing payment to
the third-party vendor.
You should submit documentation within 60 days of the invoice date.We must receive all documentation no later than 60 days
following the close of the plan year to be considered for reimbursement.
The allowance amounts indicated above for the following Allowance Type(s)are available for the years indicated in the chart.These
allowances are forfeited at the end of each plan year if not fully utilized.There is no roll over of unused funds to the next policy year.
Any unredeemed wellness incentives that may be offered through a"reward program"are forfeited at the end of each plan year.
• Health Plan
�►aetna Page
July 2026 CONFIDENTIAL Allowance ASC
We assume the funding of any allowance dollars is either at the request of your Plan Administrator acting in its fiduciary capacity or
for the exclusive benefit of your Plan.You are responsible for determining that your use of allowance dollars is appropriate and legally
compliant.With respect to allowance dollars that are used in connection with a wellness program,you are responsible for ensuring
that the program and any incentives/rewards comply with applicable laws,including limitations on maximum allowable
incentives/rewards.We will pay any allowances in accordance with applicable law.We suggest you seek appropriate accounting
and legal counsel for all payments to ensure they comply with applicable accounting principles and laws.
If you terminate your medical plan with us in whole or in part prior to the end of the multi-year Guarantee Period,you'll be
responsible for remitting payment for any allowance amounts used during the multi-year Guarantee Period.Payment is due to us
within 31 days of the invoice.Termination is defined as a 50 percent or greater membership reduction from the membership we
assumed in this proposal.
I,aetnaM Page
July 2026 CONFIDENTIAL Allowance ASC
City Of Boynton Beach
Caveats-Self-Funded Effective Date:October 01,2026
For the purposes of this document,Aetna may be referred to using"we","our"or"us"and City Of Boynton Beach may be referred to
using"you"or"your".
If fees are adjusted,the caveats below will apply and be based on the new assumptions.
Underwriting Caveats
Your pricing considers all the products,programs and services you have with us and will be in effect for the full 12 months of
the plan year.Pricing for some programs and services are amortized over a 12-month period.Therefore,fees will not be
reduced if termination occurs prior to the end of the plan year.We also assume the proposal assumptions below remain
consistent throughout the plan year.We require notice to properly terminate before the plan year ends in accordance with
the Termination provision in your Agreement.Otherwise,you may be charged for the cost until that notice is met.
If any of the changes outlined below occur,we may adjust your Guaranteed Fees.If this happens,you'll have to pay any
difference between the fees collected and the new fees calculated back to the start of the Guarantee Period.If you are not
notified of the change in advance,such difference will be reconciled in the year-end accounting for the Guarantee Period.
If fees are adjusted,the caveats below will be based on the new assumptions.
During the Guarantee Period we may adjust your Guaranteed Fees if:
Enrollment
There is a 15 percent change in total or by product from the assumed enrollment shown on the Fee exhibit.
Our proposal assumes coverage will not be extended to additional employee groups without review of supplemental
census information and other underwriting information for appropriate financial review.
Member-to-Employee Ratio
The member-to-employee ratio changes by more than 15 percent from the 1.57 ratio assumed in this quote.
Projected Processed Claim Transactions(PCT)Per Employee
The actual PCT ratio changes by more than 15 percent from the 26.60 ratio assumed in this quote.
Age 65 and Over Enrollment
The number of enrolled employees age 65 and over(excluding those enrolled on Medicare Direct plans)exceeds 3.8 percent
of the total enrolled group or changes by more than 15 percent from the 33 enrollees assumed in this quote.Patient
Management programs are excluded for Medicare primary members.
Quoted Benefits and Administration
A material change is initiated by you or by legislative or regulatory action which materially affects the cost of the plan.
This includes,but is not limited to,changes impacting standard contract provisions,claim settlement practices,plan
administration,plan benefits or changes to the programs and services we offer you.
National Advantage1M Program
You change or terminate the National AdvantageTM Program(NAP),Facility Charge Review(FCR),Itemized Bill Review(IBR),
or Professional Claims Repricing Service(PCRS)programs.
Multi-Year Provision
You place the products,programs and services included in this multi-year fee guarantee out to bid with an effective date prior
to September 30,2029,then this guarantee is no longer valid.
Total Replacement
Any of the quoted lines of coverage are offered with an additional carrier.
Performance Guarantees
If any of the conditions outlined above occur,then any performance guarantees may be changed or terminated based on the
caveats outlined in those guarantee documents.
Multiple Employer Welfare Arrangements(MEWAs)and Employer Association Health Plans(AHPs)
This quote was prepared based on the demographic information for eligible enrollees,including their home zip codes,in
accordance with all applicable mandates.We must be notified immediately of any changes that affect plan locations due to
new or changing enrollment statuses.We will evaluate regulatory requirements and may not be able to extend coverage in states
which prohibit large group coverage through MEWAs and AHPs.
vaetnaPage 10
July 2026 CONFIDENTIAL Caveats ASC
Assumptions
Underwriting
Agreement Provisions
Our quotation assumes our standard Agreement provisions and claim settlement practices apply unless otherwise stated.
Participation
A minimum of 150 enrolled employees is required to administer the proposed products on a self-funded basis.
Plan Design
This proposal is based on the current benefit plan designs,plus any noted deviations,subject to the terms of our Benefit
Review document.
Retiree-Only Plans and No Surprises Act(NSA)
Retiree-only plans,as defined by the Department of Labor,are exempt from the NSA.It is your responsibility to notify Aetna if
you have a plan that qualifies as a retiree-only plan or if there are any changes to your plan's retiree-only status.Please
contact your Account Team if you have a retiree-only plan,or if the retiree-only status changes,to ensure that the NSA and
other Consolidated Appropriations Act(CAA)provisions are applied appropriately to your plan.Failure to do so may result in
your plan's non-compliance with the NSA.
Claim Fiduciary-Option 1
Our proposal assumes we've been delegated claim fiduciary responsibilities.As claim fiduciary,we'll be responsible for final
claim determination and the legal defense of disputed benefit payments.Our appeal administrative services are automatically
included when we've been delegated claim fiduciary responsibilities.
External Review
We've included external review in our proposal.External review uses outside vendors who coordinate medical review through
their network of outside physician reviewers.
Non-ERISA
For non-ERISA plan,the risk and responsibilities are different from those under ERISA plans,since the ERISA preemption and
ERISA standard of performance do not apply.Our charge for non-ERISA plans must account for the additional liability risk as
compared to known risks under an ERISA plan.
Member Communications
Pricing assumptions include direct communications access to Aetna membership through both ongoing Aetna Health
communications and relevant ongoing included product/program specific communications.These communications can reduce
member and plan costs by guiding in care navigation,managing chronic conditions,promoting preventive services,and more.
Wellness Incentives and Rewards
We offer several different wellness incentives and rewards programs that you may choose from to offer to your members.We,
or our third-party vendors,will administer and distribute to your members any wellness incentives or rewards earned based on
the programs selected under the direction and control of your plan.The wellness incentives and rewards earned through these
programs may be taxable for your members.We will provide you with reporting which will identify members who have earned
such wellness incentives or rewards.These reports will provide the data needed for any tax information reporting
requirements that you determine are necessary.
With regard to these wellness incentives and rewards,you,as the Plan Sponsor have the following responsibilities:
•Ensure any incentives or rewards offered to your members comply with applicable law and any limitations imposed
thereunder.This includes but is not limited to,the Health Insurance Portability Act(HIPAA),the Americans With Disabilities
Act(ADA)and the Genetic Information Nondiscrimination Act(GINA).
•Distribute notices and/or obtain any authorizations required by law.
•Comply with all tax information reporting requirements regarding any wellness incentives or rewards earned through
these programs(cash,cash equivalent,or other tangible property)and provided by us or our third-party vendor to your
members.
•Assume any and all liability for your noncompliance with any tax withholding or information reporting requirements.
You may wish to consult with your legal counsel or other advisors as to the proper tax treatment of such wellness incentives
or rewards and to ensure that the incentives or rewards offered under your program comply with applicable law.
Mental Health/Substance Abuse Benefits
Our quotation assumes that mental health/substance abuse benefits are included.
vaetnaN Page ii
July 2026 CONFIDENTIAL Caveats ASC
Prescription Drug Benefits
Our quotation assumes that prescription drug benefits will be provided by Aetna.
Additional pharmacy administrative fees may apply.Refer to our Pharmacy Service and Fee Schedule and Program Summary for
additional information.
If you terminate prescription drug benefits with us,we will increase your ASC Medical Service Fees and the medical trend
assumption used for any applicable claim projections or guarantees.You may also be subject to additional charges to integrate
data with external Pharmacy vendors.Refer to the reporting charges outlined in the Programs and Services exhibit for more
information.
Stop Loss Reporting
Our quotation assumes stop loss coverage is provided by Aetna and therefore reporting to an external vendor is not required.
If we are no longer the stop loss carrier,external reporting charges will apply.
Medical Pharmacy Rebates
Rebates for pharmacy products administered and paid through the medical benefit rather than the pharmacy benefit will be retained
by Aetna as compensation for our efforts in administering this program.
Additional Products,Programs and Services
Costs for special services rendered that are not included or assumed in the pricing guarantee will be billed through the claim
wire,on a single claim account,when applicable,to separately identify charges.Additional charges that are not collected
through the claim wire during the year will either be direct-billed or reconciled in conjunction with the year-end accounting
and may result in an adjustment to the final administration charge.For example,you will be subject to additional charges for
customized communication materials,as well as costs associated with custom reporting,booklet and SPD printing,etc.The
costs for these types of services will depend upon the actual services performed and will be determined at the time the service
is requested.
Billing Information
Advanced Notification of Fee Change
We'll notify you of any off-anniversary fee change within 31 days of the fee change.
Late Payment
We reserve the right to assess a late payment charge at a 12 percent annual interest rate as follows:
•if you fail to pay plan benefit payments in accordance with the terms as outlined in your Master Service Agreement.
•if you fail to pay administrative service fees within the agreed upon extended grace period of 45 days.
We'll notify you of any changes in late payment interest rates.The late payment charges described in this section are without
limitation to any other rights or remedies available to us under the Agreement or at law or in equity for failure to pay.
Incurred late wire interest charges will be added to a future wire request and collected through your claim wire billing account.
Incurred late fee payment interest charges will be added to a future service fee bill.
We reserve the right to change the extended period for paying Service Fees at any time.We'll provide you with 30 days written prior
notice in the event we decide to change the arrangement.Any Service Fees due after the end of the 30-day notice period will be
subject to the new arrangement.We reserve all rights to enforce Agreement remedies as to any Service Fees overdue.
Producer Compensation
The quoted fees don't include producer compensation.
Claim and Member Services
Runoff Claims Processing
Your administrative service fees are mature.The expenses associated with processing runoff claims following termination are
covered for one year.
vaetna, Page 12
July 2026 CONFIDENTIAL Caveats ASC
Reporting and Data Transfer
Aetna Intellectual Property
Under the Agreement,you may have access to certain of Aetna's Plan Sponsor reporting systems.Aetna represents that it has
either the ownership rights or the right to use all of the intellectual property used by Aetna in providing the Services under the
Agreement("Aetna IP").Aetna will grant you,as the Plan Sponsor,a nonexclusive,non-assignable,royalty free,limited right to
use certain of the Aetna IP for the purposes described in the Agreement.You agree not to modify,create derivative product
from,copy,duplicate,decompile,dissemble,reverse engineer or otherwise attempt to perceive the source code from which
any software component of the Aetna IP is compiled or interpreted.Nothing in the Agreement shall be deemed to grant any
additional ownership rights in,or any right to assign,sublicense,sell,resell,lease,rent,or otherwise transfer or convey,the
Aetna IP to you.
Data Integration(Historical)
Our proposal assumes one historical medical and one historical pharmacy data integration feed.Additional fees will
apply if feeds from more than one historical vendor are required.
Data Integration(Ongoing)
Options and pricing for integrating claims data from an external vendor into one or more of our systems will vary depending
on the scale of your integration needs.
Data Transfer at Termination
Upon Agreement termination,we agree to cooperate with succeeding administrators in producing and transferring required
claim and enrollment data.Data will be transferred within 30 days after determination of specific format and content
requirements,subject to a charge that is based on direct labor cost and data processing time.
Banking
We've assumed that you provide funds through a bank initiated ACH wire transfer for drafts issued under the self-funded
arrangement assumed in this proposal.
When claims have accumulated to more than$20,000,a request will be sent to you and/or your bank requesting funds for the
total claims from the previous day(s).For most customers,this will mean daily claim wire transfers.In addition,there will be a
month end close out request on the first banking day of each subsequent month.
The proposed banking arrangement is subject to change based on results of a credit risk evaluation.We may complete an
evaluation upon notification of sale.
We've assumed you'll use no more than three primary banking lines which are shared across all self-funded products,
excluding Flexible Spending Account(FSAS).Additional wire lines and customized banking arrangements will result in an
adjustment to the proposed pricing.
Additional
Please review the additional important information found at the following URL.This information is incorporated by reference
into this package and considered part of your Agreement.This quote is subject to all the terms and conditions set
forth in this URL.In the event that any information contained herein conflicts or is inconsistent with the information in the
Underwriting Disclosure Document,the information in your package prevails.
httas://www.aetna.com/content/dam/aetna/odfs/aetnacom/legal-notices/documents/large-crow o-a nd-ou bl ic-labor-self-fu nded-
medica l-u nderwriti ng-d isclosures-as-of-O1-01-2026.odf
�►aetna. Page 13
July 2026 CONFIDENTIAL Caveats ASC
Legislative and Regulatory Requirements
Affordable Care Act(ACA)Taxes and Fees-Notice to Self-Funded Group Health Plan's Financial Liability
The Affordable Care Act(ACA)imposed Patient-Centered Outcome Research Trust Fund fee(PCORI)on the issuers of specified
health insurance policies and plan sponsors of applicable self-insured health plans.The fee was set to end in 2019,but it was
extended for 10 years through 2029.The fee applies to policy or plan years ending on or after October 1,2012,and before
October 1,2029.
Any taxes or fees(assessments)related to the Affordable Care Act that apply to the self-insured health plans are your
obligation.The Administrative Service Fee does not include any such liability or the remittance of the fees on your behalf.
NSA Payment Practices
The No Surprises Act(NSA)applies to certain out of network claims at participating facilities when the member doesn't have
a choice or is unaware the provider is out of network.The law protects plan participants by limiting cost sharing to the
preferred benefit level and prohibits balance billing by out of network providers.For NSA eligible claims,we will pay the
out of network provider an initial payment amount.In most cases,the initial payment will be an amount equal to the
qualifying payment amount as defined in NSA regulations(generally,the median contracted rate for a specific service in a
geographic area).A provider may choose to go to independent dispute resolution(IDR)if the provider does not accept our
payment as payment in full.During the IDR process,you authorize us to pay more than the qualified payment amount in
order to reasonably settle the matter when it appears expedient to do so.
Recovery of Overpayments
Our process of recovering overpayments attempts to recoup money in the most accurate,effective,and cost-efficient manner.
When seeking recovery of overpayments from a provider,we have established the following process:If unable to recover the
overpayment through other means,we may offset one or more future payments to that provider for services rendered to
Plan Participants by an amount equal to the prior overpayment.We may reduce future payments to the provider(including
payments made to that provider involving your or other health and welfare plans that are administered by us)by the amount
of the overpayment,and we will credit the recovered amount to the plan that overpaid the provider.By entering into an
agreement with us,you are agreeing that its right to recover overpayments shall be governed by this process and that it has
no right to recover any specific overpayment unless otherwise provided for in the Agreement.
�►aetna, Page 14
July 2026 CONFIDENTIAL Caveats ASC
City Of Boynton Beach
Guarantee Summary Effective Date:October 01,2026
We believe that measuring the activities described below is an important indicator of how well we service your account,as such,
we have included the following performance guarantee(s)as part of our proposed offering.
This information pertains to any performance guarantee(s)shown below,or for any additional guarantees which may be offered
for the same Guarantee Period.Refer to the guarantee documents for additional conditions and details.
The performance guarantee(s)described herein will not apply if the Agreement is terminated prior to the end of the Guarantee
Period.In addition,all included performance guarantee(s)are subject to enrollment requirements as outlined in the financial
conditions of each included guarantee.
Aggregate Maximum
The maximum payout for all guarantees combined is 45 percent of the fees at risk based on the calculation as noted in the
provisions below.
General Guarantee Provisions
1. Fees at risk are calculated at the year-end reconciliation,using the paid medical administrative service fees for employees covered
under each guarantee for the Guarantee Period and excludes:
•Allowance(s)
•Any charges for services performed which are not included on the monthly administrative service fee bill
2. Results are estimated to be available at the end of the quarter noted below,following the close of the Guarantee Period:
Second Quarter
•Service Performance Guarantee
Third Quarter
•Discount Guarantee
3. If the guarantee(s)have not been met,we will either:
•Provide reimbursement to you for the amount due,or
•Reduce future administrative fee payment(s)by the amount due to you.
4. These guarantee(s)are considered an amendment to your existing services Agreement.Continuance of your benefit plan and
payment of fees constitutes an acceptance of these guarantee(s).
5. We reserve the right to revise or remove these guarantee(s)if a material change to the plan is initiated by you or legislative or
regulatory action which:
•Impacts our standard claim adjudication process,member services functions,medical management or network
management
•Changes the products,programs and services we offer you
6. The guarantee(s)are considered met if:
•You terminate participation in products,programs and services tied directly to guarantee(s),prior to the end of the Guarantee
Period.
•You terminate your Aetna medical plan in whole or in part(defined as 50 percent or greater membership reduction from the
membership we assumed in this proposal)prior to the end of the multi-year Fee Guarantee Period,September 30,2029.
•You fail to meet your obligations under the Agreement(for example,a submission of incomplete eligibility or failure to fund
claim payments)
7. If you do not purchase a product,program or service tied directly to a guarantee,the guarantee will be removed.
�►aetna Page 15
July 2026 CONFIDENTIAL Guarantee Summary
Medical Service Performance Guarantee
We guarantee the administration of your medical and behavioral health product(s)in the following areas:
Performance Category Minimum Standard Maximum Fees at Risk
ntMa "-
Overall Account Management Average score of 3.0 2.00%
Turnaround Time(TAT) I 14 days for 90.0% 2.00%
Turnaround Time(TAT Tier-2) I 30 days for 95.0% I 2.00%
Financial Accuracy 99.0% 2.00%
Total Claim Accuracy 95.0% 2.00%
Customer Effort Score(CES) 95.0% 3.00%
Customer Satisfaction Score(CSAT) 95.0% 3.00%
Telephone Service Factor(TSF) I 60.0%in 30 seconds I 2.00%
First Call Resolution(FCR) 90.0% 2.00%
Total 20.00%
Discount Guarantee
We guarantee that your in-network discount for the Guarantee Period will be 75.3 percent or better,assuming current enrollment
and book-of-business service mix.The illustrative composite discounts are below.
Illustrative Inpatient Hospital Illustrative Outpatient Illustrative Physician/Other Illustrative Composite %of Fees at
Discount Hospital Discount Discount Target Discount Risk
79.29% 79.35% 65.93% 75.31% 25.00%
rae t n a Page 16
July2026 CONFIDENTIAL Guarantee Summary
City Of Boynton Beach
Medical Service Guarantees Effective Date:October 01,2026
Guarantee Period: October 1, 2026 through September 30,2027
Medical Fees at Risk: 20.0%
We guarantee the administration of your self-funded medical and behavioral health product(s)in the following areas:
Category Guarantee Fees at Risk Criteria
Account Management
An average score of 3.0 on the semi-annual
surveys for on-going account management,
financial,eligibility,drafting and benefit
administration.The average is based on 24
questions with a rating scale of 1 to 5(1=
Mutually agreed upon Measurement basis
lowest,5=highest).
adjustment if the final Customer specific
evaluation score falls
Overall Account below a 3.0,(meaning Measurement period
Management The results of the surveys are used to facilitate that service levels have Annually
a discussion between you and your Account not improved),up to a
Team regarding the results achieved and maximum of 2.0%of Reporting period
opportunities for improvement. medical fees. Annually
If the online surveys are not completed within
15 business days of receipt,it is assumed that
the service provided to you is satisfactory and
the guarantee is deemed met.
Claim Administration
14 calendar days for 90.0%of the processed Measurement basis
claims on a cumulative basis. Customer specific:
z 3,000 enrolled members
0.40%for each full day Site Level:
We measure TAT from the claimant's that the TAT exceeds 14 3,000 enrolled members
Turnaround Time(TAT) viewpoint;that is,from the date the claim is calendar days for 90.0%
received in the service center to the date that of the processed claims, Measurement period
it is processed(paid,denied or pended).TAT up to a maximum of Annually
excludes those claims identified as rework. 2.0%of medical fees.
Weekends and holidays are included in
turnaround time. Reporting period
Quarterly
�►ae t n a M Page 17
July 2026 CONFIDENTIAL Service Guarantee ASC
30 calendar days for 95.0%of the processed
claims on a cumulative basis. Measurement basis
Customer specific:
0.40%for each full day
>3,000 enrolled members
that the TAT exceeds 30 Site Level:
We measure TAT from the claimant's <3,000 enrolled members
Turnaround Time(TAT viewpoint;that is,from the date the claim is calendar days for 95.0%
Tier-2) received in the service center to the date that of the processed claims,
Measurement period
it is processed(paid,denied or pended).TAT up to a maximum of Annually
excludes those claims identified as rework. 2.0%of medical fees.
Weekends and holidays are included in Reporting period
turnaround time. Quarterly
99.0%
Financial accuracy is measured using industry
accepted stratified audit methodology.The Measurement basis
results are determined by calculating the Unit(s)processing your
financial accuracy for a subset of claims(a claims(all customers'claims
stratum).We extrapolate the results based on 0.40%for each full 1.0% handled in that unit,not just
the size of the population and combine them that financial accuracy your plan's claims)
Financial Accuracy with the extrapolated results of the other drops below 99.0%,up
strata.Each overpayment and underpayment is to a maximum of 2.0%of Measurement period
considered an error;they do not offset each medical fees. Annually
other.Financial accuracy includes both manual
Reporting period
and auto adjudicated claims.
Quarterly
Dollars Paid Correctly
Total Dollars Paid
95.0%
Measurement basis
Total claim accuracy is measured using industry Unit(s)processing your
accepted stratified audit methodology.We claims(all customers'claims
extrapolate the results based on the size of the 0.40%for each full 1.0% handled in that unit,not just
population and combine them with the that total claim accuracy your plan's claims)
Total Claim Accuracy extrapolated results of the other strata. drops below 95.0%,up
Accuracy in each stratum(a subset of the claim to a maximum of 2.0%of Measurement period
population)is calculated by: medical fees. Annually
Number of claims processed correctly Reporting period
Quarterly
Total number of claims audited
raetna Page 18
July 2026 CONFIDENTIAL Service Guarantee ASC
Member Services
Positive response rate of 95.0%or better on Measurement basis
the following statement"On a scale of 1 to 5, Accountable unit or the
with 1 being the least likely and 5 being the business segment level that
most likely,please indicate if you agree with services your plan in effect
the following:"The representative was easy to 0.60%for each full 1.0%
that our positive
at the time of the member's
Customer Effort Score work with". p call
response rate falls below
(CES) 95.0%,up to a maximum
The survey assumes a 5-point scale with the Measurement period
top 2 responses viewed as positive.The result of 3.0%of medical fees. Annually
is based on a member completing an
interactive survey that is offered at the end of Reporting period
the call. Annually
Positive response rate of 95.0%or better on
the following statement On a scale of 1 to 5, Measurement basis
Accountable unit or the
with 1 being the least likely and 5 being the
most likely,please indicate if the following is business segment level that
true:"I was satisfied with the service I received 0.60%for each full 1.0% services yourplaniffect
at the time off theemee mmber's
Customer Satisfaction today". that our positive call
(CSAT) response rate falls below
The survey assumes a 5-point scale with the 95.0%,up to a maximum Measurement period
top 2 responses viewed as positive.The result of 3.0%of medical fees. Annually
is based on a member completing an
interactive survey that is offered at the end of Reporting period
the call.
Annually
60.0%of all calls responded to within a 30
second service level.
Measurement basis
TSF measures the speed in which calls are o 0
answered by a Customer Service Professional 0.40/for each full 1.0% Phone skill(s)providing your
that the cumulative TSF customer service
(CSP)after being placed in queue by the auto falls below 60.0%for
Telephone Service Factor attendant.This does not include the time the
calls to be answered Measurement period
(TSF) caller spent navigating through any auto within the service level, Annually
attendant menus.TSF includes total calls up to a maximum of
(answered and abandoned)that are offered to
2.0%of medical fees. Reporting period
CSPs. Interactive Voice Response(IVR)system
Quarterly
calls are not included in the measurement of
TSF.
i►ae t n a Page 19
July 2026 CONFIDENTIAL Service Guarantee ASC
90.0%
Measurement basis
Accountable unit or the
business segment level that
0.40%for each full 1.0% services your plan in effect
that the first call at the time of the member's
First Call Resolution(FCR) We define the first call resolution rate as resolution rate falls call
percentage of member calls resolved on the below 90.0%,up to a
first call. maximum of 2.00%of Measurement period
medical fees. Annually
Reporting period
Quarterly
General Guarantee Provisions
• For purposes of the performance guarantees,the term"Business Day"is defined as Aetna's normal business hours on any day
other than a Saturday or Sunday or a day on which Aetna is closed for general business purposes.
• These guarantees do not apply to third party benefit administrators contracted by Aetna.
• This offer does not contemplate significant changes in volume of claims and calls that may occur with novel conditions or
circumstances affecting broad populations that place a significant strain on the health care system and/or your plan(s).These
conditions include but are not limited to COVID-19.We reserve the right to adjust the terms and factors of this guarantee in
response to these conditions and/or circumstances if necessary.
• In the event there is an outage or when experiencing peak volumes,calls may be transferred to other Aetna call centers.This
guarantee may not apply,and a payment may not be made if results are not achieved due to severe weather events which
directly or indirectly impact performance during the Guarantee Period.
• If we process runoff claims from a prior carrier or administrator,the performance guarantees described in this document(other
than Account Management Guarantees)will begin 3 months after the Guarantee Period effective date.
• If we process runoff claims upon termination of the Agreement,the Turnaround Time,Financial Accuracy,and/or Total Claim
Accuracy performance guarantee(s)will not apply to runoff claims.
aetnaPage 20
July 2026 CONFIDENTIAL Service Guarantee ASC
City Of Boynton Beach
Medical Discount Guarantee Effective Date:October 01,2026
Guarantee Period: October 01,2026 through September 30,2027
Your in-network discount will be 75.3 percent or better*
*Assuming current enrollment and book-of-business service mix.
Products: Aetna Choice*Point of Service II(CPII)and Open Access Aetna Select" (OA AS)
What we guarantee
Attachment A of the Discount Guarantee Attachment shows:
• Our guaranteed network contracted discounts by market,for each of the following three service types:
— Inpatient hospital
— Outpatient hospital
— Physician/other
• Illustrative aggregate guaranteed network contracted discount based on a weighting of:
— Projected,customer-specific employees by market
— Book-of-business weighting by service type
We finalize the discount target during the reconciliation process.The final aggregate guaranteed discount will be determined by weighting
the discounts by the actual aggregate billed eligible charges by product and service type.The reconciliation will be completed once the
actual enrolled employees by market and product,and the actual billed eligible charges are known.
How discounts are calculated
The achieved discount percentage is calculated using the following calculation:
In-network provider discounts in dollars
Total in-network billed eligible charges*
We calculate the discount using data from our Aetna Informatics°data warehouse.Three months of runout data will be included in the
calculation.The guarantee reconciliation excludes each medical case where the claims in that medical case exceed$100,000.
A medical case summarizes clinical events by linking or associating all of the claims submitted for a member during the same treatment
For example,all claims associated with an Inpatient Acute hospital stay or an Outpatient Facility based procedure.
The guarantee results combine the CPII and SEL product(s)and we report in aggregate for purposes of this guarantee reconciliation.
*Billed eligible charges are charges prior to application of plan design,discounts and member cost sharing(copays and deductibles).Billed
eligible charges exclude the following:
• Duplicate or other ineligible/not covered/denied claims
• Claims paid by coordination of benefits where we are not primary(e.g.Medicare)
• Claims on members age 65 and over
• Claims incurred in passive or custom networks
• Behavioral health claims
• Non-medical claims(e.g.dental and vision hardware claims,pharmacy and specialty pharmacy claims,including some of those
specialty pharmacy claims paid under the medical plan)
• Charges where the provider billed at or below the allowed amount
• All pay for performance payments,including but not limited to,accountable care payments(ACP)and coordination of care(COC)
payments.
vaetna Page 21
July 2026 CONFIDENTIAL Discount Guarantee
Guarantee reconciliation
We compare the guaranteed discount against the total achieved discount.The guaranteed discount is based on the actual enrollment by
product and market,and billed eligible charges by product and service type.Based on the outcome of the comparison,we will make any
applicable fee adjustments as shown in the table below.
Fee Adjustment Max Guarantee Period Adjustment
2.0%fee reduction for each full 1.0%the achieved discount falls below the risk-free corridor 25.0%
There is a risk-free corridor of 2.0 percentage points.
Any fee adjustment is calculated as follows:
• A fee reduction occurs when the achieved discount falls below the difference of the guaranteed discount minus the risk-free corridor
by a full percentage point or greater.
Conditions for the guarantee
We rely on information from you and your representatives in creating and reconciling the terms of this guarantee.If any of this information
is inaccurate,it may have an impact on the guaranteed network discounts.We reserve the right to revise the guarantee if any of the
following conditions are not met.
• Group Composition
You do not close any acquisitions or divestitures during the Guarantee Period.
• Minimum Enrollment
You must enroll a minimum of 300 subscribers in the quoted Aetna self-funded medical products.
• Pharmacy claims
Pharmacy and specialty pharmacy claims,including those paid under the medical plan,are excluded.
• In-Network Claim Utilization
Our discount guarantee requires at least 80 percent of claims paid are in-network.
• Provider Practice
Guarantee Year provider billing and reimbursement practices remain consistent with current practices.
vaetna Page 22
July 2026 CONFIDENTIAL Discount Guarantee
City Of Boynton Beach
Medical Discount Savings Illustration Effective Date:October 01,2026
Attachment A
Illustrative Inpatient Hospital Illustrative Outpatient Hospital Illustrative Physician/Other Illustrative Composite Target
Discount(1) Discount"" Discount 111131 Discount(2)
79.29% 79.35% 65.93% 75.31%
(1) These discounts are illustrative only as they have been weighted by the distribution of employees by network from the
current census file.
(2) This composite target is illustrative only.The final guaranteed target will depend on the actual enrolled members by network
and claim service mix known at the end of the Guarantee Period.For purposes of this illustration,the service mix of network billed
eligible charges prior to discount is based on network level assumed utilization of hospital inpatient,hospital outpatient,and
physician/other.
(3) Charges where the provider billed at or below the allowed amount.
Discounts by Location
We consider information concerning fees negotiated with providers to be proprietary,commercially valuable information,which is not in
public domain.Consequently,the information contained herein is to be maintained in a confidential manner,and used solely for the
purposes of reviewing this proposal.
Product Market Name Rating Area
Employees Hospital Hospital Physician/
Within Inpatient Outpatient Other
CPII Atlanta(MC) GA-Atlanta 3 61.93% 67.63% 52.00%
CPII FL Martin St.Lucie Preferred FL-Palm Beach 706 79.84% 79.91% 66.14%
CPII Miami-Dade/Broward,FL MC FL-Miami/Broward County 65 76.36% 75.26% 65.27%
CPII Miami-Dade/Broward,FL MC FL-Palm Beach 6 80.00% 79.90% 66.20%
ICPII Jacksonville,FL(MC) FL-Volusia County 1 58.90% 60.70% 60.30%
CPII Orlando,FL(MC) FL-Orlando 1 70.50% 70.60% 62.50%
CPII Brevard County,FL(MC) FL-Brevard County 1 62.60% 66.90% 58.80%
CPII Raleigh/Durham NC MC NC-Raleigh/Durham 1 55.20% 56.00% 46.40%
CPII Birmingham/Central AL(MC AL-Birmingham 1 76.60% 78.30% 59.30%
CPII Oregon Direct MC OR-Rural 1 47.10% 42.00% 44.50%
CPII Cent West MI Aetna MC MI-Central 1 51.60% 56.80% 58.10%
ISEL TampaBay/St.Petersburg EC FL-Tampa 1 67.80% 70.00% 64.60%
ISEL Daytona Beach,FL FL-Volusia County 1 58.90% 60.70% 60.30%
SEL Orlando,FL FL-Orlando 1 68.70% 69.30% 62.10%
SEL Miami-Dade/Broward,FL EC FL-Miami/Broward County 10 76.68% 75.85% 65.34%
SEL Miami-Dade/Broward,FL EC FL-Palm Beach 1 80.00% 80.40% 66.20%
SEL FL Martin St.Lucie Preferred FL-Brevard County 1 62.60% 67.20% 58.80%
ISEL FL Martin St.Lucie Preferred FL-Palm Beach 104 79.97% 80.43% 66.18%
Total Subscribers 906
raetna. Page 23
July 2026 CONFIDENTIAL Attachment A
City Of Boynton Beach
Stop Loss Financials Effective Date: October 01, 2026
Control#192692
Policy Period: October 01,2026 through September 30, 2027
Status: Final/Firm
Valid until: 6/1/2026
• Please refer to the Stop Loss Assumptions and Caveats for additional information.
• Stop Loss rates and factors will be billed on a Composite PEPM basis.
Quote Specifications Current $250,000 ISL
Contract Situs Florida Florida
Policy Period Length (months) 12 12
Total Enrollment 889 908
Producer Commission None None
Terminal Liability Option TLO-3 TLO-3
Individual Stop Loss(ISI)Coverage Current $250,000 ISL
Covered Benefits Medical/Rx Medical/Rx
Individual Stop Loss Amount $200,000 $250,000
Lasered High Risk Claimants No No
Aggregating Specific Amount None None
Contract Type Paid Paid
ISL Coinsurance% 100% 100%
Maximum Annual ISL Payment Amount Unlimited Unlimited
ISL Composite PEPM Rate $108.49 $124.58
Estimated ISL Policy Period Premium $1,157,371 $1,357,424
%Change in Individual Stop Loss Premium 14.8%
Aggregate Stop Loss(ASL)Coverage Current $250,000 ISL
Covered Benefits Medical/Rx Medical/Rx
Aggregate Stop Loss Percentage 125% 125%
Contract Type Paid Paid
Maximum Annual ASL Payment Amount $1,000,000 $1,000,000
ASL Composite PEPM Rate $5.67 $6.59
Estimated ASL Policy Period Premium $60,488 $71,805
Projected Policy Period Total Claims $10,838,379 $11,520,557
Projected Policy Period Liability Limit $13,547,930 $14,400,698
Aggregate Stop Loss Factor PEPM $1,269.96 $1,321.65
Minimum ASL Liability Limit $13,547,933 $14,400,698
Financial Summary Current $250,000 151
5/21/202.
Proprietary vaetna SL Financials
City Of Boynton Beach
Stop Loss Financials Effective Date: October 01, 2026
Total ISL&ASL Composite PEPM Rate $114.16 $131.17
Estimated Monthly Premium $101,488 $119,102
Estimated Policy Period Stop Loss Premium $1,217,859 $1,429,228
Change in Total Stop Loss Premium 14.9%
If Terminal Liability Option is Elected at Termination Current $250,000 ISL
TLO Total PEPM Rate $114.16 $131.17
TLO Premium Due at Termination 2 Months 2 Months
Projected TLO Claim Liability $14,451,128 $15,360,743
This quotation is issued or underwritten by Aetna Life Insurance Company.
5/21/2026
Proprietary vaetna SL Financials
City Of Boynton Beach
Stop Loss Assumptions&Caveats Effective Date: October 01,2026
For the purposes of this document,Aetna may be referred to using"we", "our",or"us" and City Of Boynton Beach may be referred
to using"you"or"your".
We are pleased to provide you with our renewal for Stop Loss insurance.These Assumptions and Caveats,
in conjunction with the Stop Loss Financials exhibit,combine to form the entirety of this renewal. Please
review them carefully and notify us immediately if any of the features do not meet your expectations or if any of
our assumptions are incorrect.Changes in the features or assumptions may affect premium rates or claim factors.
Additional state-specific notices should be reviewed at this link:
https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/legal-notices/documents/stop-loss-u nderwriti nQ-d isclosu res-06-06-
2023.pdf
If you renew Aetna's Stop Loss coverage,you will receive your application for insurance electronically.You will access
it via a link delivered by email and endorse it using electronic signature capabilities.You will also receive your policy
electronically.This process requires a web browser which supports the HTTPS protocol,HTML,and cookies.You will also
need to view PDF documents using software such as Adobe Reader or similar.
You have the right to request that these transactions occur by regular mail using paper copies,which would require you to
physically sign your application and mail it back to us. Please contact your broker and/or your Aetna Account Manager
to make this request.
Stop Loss policies and applications/schedules of insurance are updated annually upon renewal. Please contact your broker
and/or your Aetna Account Manager for a copy of the Stop Loss policy.
This proposal assumes you have notified us of any known applicants for gene replacement therapy.
Renewal Status
This is a final,firm offer.You must accept the rates by 6/1/2026.
If you fail to accept the rates by 6/1/2026,we reserve the right to request updated underwriting data,
which may alter the rates and terms of the offer.
Assumptions
• The policy period is indicated on the Stop Loss Financials.The Stop Loss policy period must agree with the
self-funded plan's contract period,both of which must end on the next renewal date.
• When Aetna is the claims administrator and Stop Loss insurer, it is assumed Aetna is also the claim fiduciary of the
self-funded plan(s). Claims approved by fiduciary override/exception are not covered by Stop Loss.
• Eligibility for Stop Loss coverage will apply as described in the self-funded benefit plan(s)and in accordance
with the Stop Loss policy provisions.
• In at least one quoted option,Post-65 retirees and their dependents have been included in Stop Loss coverage. Pre-65 retirees
and their dependents have been excluded from Stop Loss coverage and will need separate account structure.
• There must be common ownership among all participating divisions or subsidiaries for this quote to remain valid.
• Your business and/or Standard Industrial Code is 8211.
What Is Covered
• Self-funded benefit plans covered by Stop Loss are identified on the Stop Loss Financials.All other benefit plans are
excluded.
• Gene Replacement Therapy Drug coverage:
— High Risk Individual Stop Loss Amounts(lasers)are not applied to an FDA-approved or pipeline gene replacement
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Proprietary vaetna SL Caveats
City Of Boynton Beach
Stop Loss Assumptions&Caveats Effective Date: October 01,2026
therapy drug dispensed as approved and directed.
— Gene replacement therapy drug claims will not be included in the ISL claim experience used for rating purposes at the
Stop Loss renewal.
— This feature specifically applies only to the gene replacement therapy drugs approved to treat specific disease,age,
and gene expressions via one-time infusion therapies—or curative treatments—for previously untreatable,often fatal,
conditions.
• High Risk Individual Stop Loss Amounts may apply for all other diseases or drugs, including medical costs associated
with the underlying condition or medical services associated with the gene replacement therapy treatment.
• Coverage of gene replacement therapy drugs will apply as follows:
— When a gene replacement therapy drug is administered for the indicated disease,age,and gene expression by one of
Aetna's"Gene-based,Cellular,and other Innovative Therapies" (GCIT)network providers,we will consider the eligible
claim expense for the gene replacement therapy drug less the ISL amount shown on the Stop Loss Financials exhibit.
• The Stop Loss Financials displays the projected policy period liability limit. It will be updated to reflect actual monthly enrollmen
during the policy period.The projected Aggregate liability limit is also subject to the minimum Aggregate Stop Loss Amount.
• Contract Type-As indicated on the Stop Loss Financials,eligible claim expenses will be covered for incurred
and paid dates based on:
— A Paid contract type-Claims paid during the policy period,regardless of the incurral date,are included under Stop
Loss. However,if the prior policy period was covered by any Stop Loss policy with a run-out contract type or provision,
claims paid during the prior policy's run-out period are not covered by this Stop Loss proposal.
• Terminal Liability Option(TLO)-This renewal includes TLO coverage for run-out protection upon termination of the
Stop Loss policy in at least one quotation.The terms of the coverage are identified in the Stop Loss Financials.The TLO
may be exercised by giving 31 days written notice prior to the termination of the Stop Loss Policy.
The total TLO premium due by the termination date,using rates and factors on the Stop Loss Financials,is calculated as:
TLO PEPM rate x enrollment covered on the first day of the last policy month x the number of months indicated
Upon termination,the final policy period's Individual Stop Loss amount will continue through the TLO run-out period.
The Aggregate liability limit for the final policy period will be increased to include the TLO period based on the
enrollment covered on the first day of the last policy month,a certain number of months based on the TLO period,and subject t
Minimum ASL liability limit.
The TLO run-out period will be reconciled and any reimbursement made after the end of the run-out period.
• A Maximum Annual Aggregate Stop Loss Payment amount is included in the coverage options on the Stop Loss Financials.
It reflects the maximum reimbursement we will pay for Aggregate Stop Loss coverage during the policy period.
If you elect this coverage feature,it will create a gap in coverage between your benefit plan(s)and your Stop Loss policy.
If the total eligible claim expenses funded by Aggregate Stop Loss reach the Maximum Annual Aggregate Stop Loss
Payment amount during a policy period,all subsequent eligible claim expenses will be funded by you until the renewal
date.
What Is Not Covered
Coverage exclusions include but are not limited to the following:
• Expenses that are not payable under the plan or in accordance with Aetna's clinical policy and established claim practices.
This includes expenses that are experimental or investigational, not medically necessary, in excess of the reasonable
and customary charge,or any claim exception;
• Eligible claim expenses covered by another valid Stop Loss policy,including another Aetna policy,during the same time period,
or run-in claims also covered by a prior policy carrier's run-out provision;
• Plan administration expenses including, but not limited to cost containment administrative fees,care management fees,
and network access fees,with the exception of shared savings fees associated with our National Advantage Program(NAP);
• Assessments or surcharges applied to claims by any government body,with the exception of the MA Uncompensated
Care Pool,Minnesota Care Provider Tax,or New York Health Care Reform Act surcharges;
• Incentive or risk share payments,care coordination payments,and other non-fee-for-service payments associated
with any agreement with an accountable care or similar provider organization;
• Expenses for non-emergency services,treatment,or related complications provided outside the United States.This includes
5/21/2026
Proprietary vaetna SL Caveats
City Of Boynton Beach
Stop Loss Assumptions&Caveats Effective Date: October 01,2026
prescription drugs or medical supplies provided by non-U.S. based companies;
• Capitation payments excluded from Individual Stop Loss but included under Aggregate Stop Loss.
Stop Loss Reimbursement
• When Aetna is also the plan's administrator and the Stop Loss policy is in-force,eligible claims are funded by Stop Loss
immediately,as they are approved for payment under the plan.This"Immediate Reimbursement" means that your cash
flow is not impacted by waiting for reimbursement of claims exceeding the Stop Loss amount and claim reports are
not required.Additional reconciliation is necessary when run-in or run-out is covered,or when other than a 12/12 or
Paid contract type is utilized.
When Aetna is not the claims administrator, reconciliation for reimbursable amounts is performed at the end of
the policy period once you provide appropriate claim details and other necessary information.
• The Monthly Budget Feature standardly applies to Aggregate Stop Loss claims as long as we are the claims administrator
and the Stop Loss policy remains in-force.This feature provides cash flow protection by capping your monthly claim
liability. However,when you choose to fund claims:
— through multiple primary wire lines,or
— through one primary wire line and report through one or more internal wire lines,
additional,final reconciliation is necessary after the close of the policy period.
When Aetna is not the claims administrator, reconciliation for reimbursable amounts is performed at the end of
the policy period once you provide appropriate claim details and other necessary information.
Underwriting Requirements
• We reserve the right to amend or withdraw our offer to reflect the underwriting impact of any additional information
we obtain or in the event you are unable to provide us any of the information we need to fully underwrite the risk.
• If you fail to meet the our underwriting requirements,including but not limited to a minimum of 51 eligible subscribers,
our Stop Loss offer will be withdrawn.
• We reserve the right to adjust the premium rate or any aggregate Stop Loss factor as of the date of any change to the
underlying assumptions that impacts the risk assumed.Changes include, but are not limited to:
— Any change of+/-10 percent in enrollment
— Any change to the plan document(s)that will change the risk assumed under the Stop Loss policy
— Any change to this policy
— Any addition or deletion of a unit,division,subsidiary,affiliated or associated company exceeding 10 percent
of existing enrollment
— Any change in federal or state law or regulation that impacts the policy or the coverage provided
— Any change impacting the risk we have assumed, including but not limited to:age,gender,geography,occupation,
incorrect or incomplete information provided in Disclosure statements,etc.,that impacts the nature of the risk
by more than 10 percent
— Any change in claims administrator, provider network or cost containment vendor, provided we have consented
to the change in writing
— Any change in the claims administrator's claim payment system or payment practices that causes a variation of
+/-5 percent versus the most recent 12 month average claim processing time.
New units,subsidiaries,etc.,will be underwritten. Claim reports may be requested. If this information is not provided,
we reserve the right to require a completed and signed Disclosure and may apply AAW/DNC rules on the acquired group.
5/21/2026
Proprietary vaetna SL Caveats
‘409-
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aetna®
An Aetna Renewal MIND
Presented To
City Of Boynton Beach
By Gelin Benefits Group
Effective: October 1, 2026
Plan Sponsor Number: 192692
Vaetna
City Of Boynton Beach
Aetna's Dental Value Story Effective Date:October 1,2026
At Aetna,we dedicate ourselves to help members reach their best health.As a trusted carrier for millions of dental members,
Aetna is the largest integrated carrier in the business.We're also one of the first to study the benefits of dental-medical
integration,which leads to better health outcomes for our members.
Improving overall health through better dental health
Dental health has a significant impact on emotional health.One's overall happiness and confidence is often impacted by the
health of their teeth. Our dental program meets members where they are on their dental health journey.Aetna's member
outreach and education has helped change member behaviors, allowing them to reach dental health goals.
Aetna Dental focuses on driving value through three key areas:
Tailored benefits
Targeted, local networks make it easier for members to access care and keep costs low.A variety of plan options allow you to
better manage cost,coverage and access. We are driving down the cost of care with several network initiatives that include
getting members better discounts, partnering with key dental providers and dental offices, mobile and teledentistry,and
alternative orthodontics.
Integrated care
Our care programs use dental health and primary care information to drive improved overall health outcomes. Our Dental-
Medical Integration (DMI) program is the only automated program that identifies at-risk members who haven't had recent
dental care and provides proactive educational outreach and enhanced benefits to those with pregnancy,diabetes,or
cardiovascular conditions.
Member empowerment
Affordable plan options provide the coverage and protection members want.Tools and information drive engagement and
help members make the most of their benefits.
Large provider networks offer greater access to care,choice and flexibility.
Our National Dental Preferred Provider Organization (DPPO)and Dental Maintenance Organization (DMO)are large networks
that offer greater access to care,choice and flexibility.As we meet members on their journey,we'll focus on what's
important—their needs and the needs of their families.We'll personalize their experience and guide them to their best dental
health.
You can learn more about Aetna here: httas://www.aetna.com/about-us.html
vaetna°
Kimberly Mcmenamy
Field
Tallahassee,FL 32301
Phone:(904)322-2623
Email: McmenamyKL@aetna.com
June 24,2026
City Of Boynton Beach
Danielle Whitefiled
100 E.OCEAN AVENUE
Boynton Beach, FL 33435
Dear Danielle Whitefiled:
Thank you for trusting us to continue to provide your dental benefit during the past year. Enclosed is your dental renewal for the
October 1,2026 policy period.
As your partner,we will continue to help you deliver cost savings and offer the right experiences for every member,on every
journey—one that's seamless,easy to access and where you want us to be.
This renewal includes the following exhibits and changes:
Outlined below are highlights of the changes to your plan(s)and the information presented in the renewal package.
• Proposed Rates
—Additional Bundle up Discounts may be available if you purchase additional coverages with us.
• Proposed Plan Design
This is a high level summary of our proposed plan design.Talk to your Account Team for additional
details.
• Dental Programs and Services
• Caveats
Please review the additional important information found at the following URL.This information is incorporated by reference into
this package and considered part of your policy.This quote is subject to all the terms and conditions set forth in this URL. In the
event that any information contained herein conflicts or is inconsistent with the information in the Underwriting Disclosure
Document,the information in your Renewal Package prevails.
httos://www.aetna.com/content/dam/aetna/odfs/aetnacom/legal-notices/documents/large-grove-dental-underwriting-fully-
i nsured-disclosures-as-of-01-01-2026.odf
For the best implementation experience,please notify your Account Team of changes to your plan design,programs and services no
later than August 1,2026.Some programs and services require additional notification prior to effective date for successful
implementation. Please discuss with your Account Team for program specific implementation lead times.We will strive to
implement these changes on a timely basis.
Your insured renewal package remains in effect until September 30,2027.
If there are no changes impacting this renewal as outlined in your Caveats,the rates will remain in effect through September 30,
2027.This renewal package beginning with the Proposed Rates is considered an amendment to your existing policy.Continuance of
your benefit plan and payment of rates constitutes acceptance of this renewal. Please contact your Account Manager by July 1,
2026 to ensure they are able to address your questions prior to implementing your renewal.
Sincerely,
Kimberly Mcmenamy
Mgr,Account Executive
Illustrative
City Of Boynton Beach
Contact Information
Account Manager: Kimberly Mcmenamy Email: McmenamyKL@aetna.com
Telephone Number: (904)322-2623
Assumptions
Contract State: FL Lives: 1,051
Commissions: 0.00% SIC Code: 8211
Mem/EE Ratio: 1.73
Proposed Rates Effective Date: October 1, 2026 End Date: September 30, 2027
DPPO plans include a 6.50%Rate Cap for the period of 10/1/2027 to 9/30/2028*
DPPO plans include a 6.50%Rate Cap for the period of 10/1/2028 to 9/30/2029*
Coverage Lives Current Rates Proposed Rates
PPO
Non Al,,LA,MS,TX
EE 675 $36.97 $35.76
EE+SP I 121 I $83.06 I $71.53
EE+Children I 106 I $79.74 I $95.41 I
Family I 144 I $114.52 I $143.41 I
Total I 1,046 I $59,948 I $63,558 I
Coverage Lives Current Rates Proposed Rates
PPO
AL,LA,MS,TX Only
EE 2 $36.97 $35.76
EE+SP I 1 I $83.06 I $71.53 I
EE+Children I 0 I $79.74 I $95.41 I
Family I 2 I $114.52 I $143.41 I
Total I 5 I $386 I $430 I
Total Dental Lives: 1,051
Current Monthly Premium: $60,334
Proposed Monthly Premium: $63,988
Proposed Total Contract Period Premium: $767,850
*Clarifications:
Rate Cap
Refer to the Rate Cap document for terms and conditions.
6/24/2026
Proprietary vaetna Quote ID:975279
City Of Boynton Beach
Proposed Plan Designs Effective Date: October 1, 2026
4
PPO PPO
j Non AL,LA,MS,TX AL,LA,MS,TX Only
Plan Features
In Out In Out
Deductible Applies To Basic and Major Basic and Major Basic and Major Basic and Major
Deductible Ind/Fam I $25/$75 I $25/$75 I $25/$75 I $25/$75
1st exam using 1st exam using
virtual vendors virtual vendors
Virtual Dental Visit fully covered;no N/A fully covered; no N/A
limits apply limits apply
Preventive/Diagnostic I 100% 90% I 100% 90%
Services
Basic Services 90% 70% 90% 70%
Major Services 60% 50% 60% 50%
Annual Benefit Maximum $2,000 $1,250 $2,000 $1,250
Office Visit Copay N/A N/A N/A N/A
Ortho Applies To Adult/Child Adult/Child Adult/Child Adult/Child
Orthodontic Services 50% 50% 50% 50%
OrthodonticMaxmumetime I $1,500 $1,500 $1,500 $1,500
Work In Progress 'Exclusion ApplieslExclusion AppliesI€xclusion ApplieslExclusion Applies.
Exclusion
Implants I 90% I 70% I 90% I 70%
R&C N/A 90%-Billed N/A 90%-Billed
Root Canal Therapy 90% 70% 90% 70%
Osseous Surgery I 90% I 70% I 90% I 70%
RemovalTooth Impacted I 90% 70% 90% 70%
General Anesthesia 60% 50% 60% 50%
Posterior Composite Not Covered Not Covered Not Covered Not Covered
Prosthetic Replacement 5 Years 5 Years 5 Years 5 Years
Fluoride Age Limit To Age 16 To Age 16 To Age 16 To Age 16
Sealant Age Limit To Age 16 To Age 16 To Age 16 To Age 16
Non-surgical TMJ Service Not Covered Not Covered Not Covered Not Covered
Missing Tooth Exclusion 'Exclusion ApplieslExclusion ApplieslExclusion ApplieslExclusion Applies,
This material is for informational purposes only and is neither an offer of coverage nor dental advice.It contains only a partial,general description of plan
benefits or programs and does not constitute a contract.
Benefits may vary due to state specific mandates and/or filing limitations.
Consult the plan documents:Schedule of Benefits,Certificate of Coverage,Evidence of Coverage,Group Agreement,and Group Insurance Certificate,to
determine governing contractual provisions,including procedures,exclusions and limitations relating to Benefits described in this document are specific to
your plan and otherwise our standards will apply.While this material is believed to be accurate as of the print date,it is subject to change.
6/24/2026v a et n a
Proprietary Quote ID:975279
City Of Boynton Beach
Rate Cap Effective Date: October 1, 2026
We guarantee the per employee,per month (PEPM)premium for the Guarantee Period will not increase by more than the
percentage(s)stated in the chart below from the Prior Period premium PEPM.
Any applicable change in Federal(ACA or otherwise)or State Tax,Fees,or Assessments for the subsequent 12-month period will be
added to the premium rate increase.Any additional taxes or fees resulting from new Federal or State legislation will be added to the
premium before the premium rate increase is applied.
Each plan is renewed separately then reviewed in aggregate against the maximum overall rate increase.
Product Year 2 Year 3
DPPO 6.5% 6.5%
Guarantee Assumptions
Guarantee Period 10/1/2027-9/30/2028 10/1/2028-9/30/2029
Prior Period 10/1/2026-9/30/2027 10/1/2027-9/30/2028
Conditions for the Guarantee:
We reserve the right to revise or remove the guarantee if any of the following occur during or prior to the guarantee period:
• Novel Conditions and Circumstances
This offer does not contemplate the changes in costs, utilization, risk or any form or type of testing associated with novel
conditions or circumstances affecting broad populations that place a significant strain on the health care system and/or your
plan(s).These conditions include but are not limited to COVID-19.We reserve the right to adjust the terms and factors of this
guarantee in response to these conditions and/or circumstances if necessary.
• Base Year Claims
We reserve the right to adjust base year/gap claims used in the development of our experience and rate projection to
account for the anticipated impact of novel conditions, as stated above.These adjustments would be applied to normalize
the experience for the projected impact of these conditions. (Only applies to cases that are partially or fully experience rated
at the time of proposal.)
• Group Size Variation
• A total of 1,051 employees are expected to be enrolled in the quoted dental products.
• Of this assumed enrollment, the combined enrolled COBRA, pre-65 retirees, and disabled employees does not vary
by more than two percent of the total Aetna covered group from the originally assumed enrollment. In addition,we
assume that the combined enrolled COBRA, pre-65 retirees, and disabled employees will not comprise more than
five percent of total Aetna covered group.
• Prior Carrier Claims Experience
We do not receive complete mature claims experience for all current plans including enrollment by month and by plan
incurred to October 1,2026 and paid through January 31,2027.
• The premium rate increase is subject to the terms and conditions as stated in the caveats.
• A change of greater than 10 percent from the assumed enrollment in total or by plan.
• A change in the quoted plan designs.
• A change of greater than 10 percent from the current employee contributions.
• We are no longer the sole dental carrier including any self-funded plans we offer you.
• Failure to make your required premium payments in accordance with contract provisions.
• The dental plan is put out to bid for the first renewal period.
• Material changes required by legislative or regulatory action or initiated by you to the plan of benefits offered, claim
payment requirements or procedures, changes in state premium taxes or assessments, or any other changes affecting the
manner or cost of providing coverage.
• Filing changes that affect our ability to offer this guarantee or exercise underwriting judgment.
6/24/2026
Proprietary A►aetna Quote ID:975279
City Of Boynton Beach
Programs &Services-Conventional Prospective Effective Date: October 1, 2026
Non AL, LA, AL, LA, MS,
Program Summary MS,TX TX Onl
General Admin
Communication Materials Yes Yes
Customer Team Services Yes Yes
Eligibility(Standard) Yes Yes
Experienced Account Management Team Yes Yes
Claim and Member Services
Aetna Dental/Medical Integrations"" (DMI) Yes Yes
Aetna Voice Advantage®Level 2 Yes I Yes
Claim Administration Yes I Yes
Digital ID Cards Yes I Yes
Member Services Yes Yes
Network Information
Network Access Yes Yes
Provider Relations Yes Yes
Web Tools
Claim Research/forms/Contact us(English&Spanish Version) Yes Yes
Member Website and Mobile Experience Yes Yes
Aetna Discount Program
Aetna Discount Program-at home products,fitness,hearing,
LifeMart®shopping website,natural products and services, Yes Yes
oral health care,vision,wei:ht mana:ement
Reporting
Utilization Management Reporting Yes Yes
6/24/2026
Proprietary vaetna Quote ID:975279
City Of Boynton Beach
Caveats-Conventional Prospective Effective Date: October 1, 2026
For the purposes of this document,Aetna may be referred to using"we","our"or"us"and City Of Boynton Beach may be referred
to using"you"or"your".
Our renewal is illustrative and subject to change based upon underwriting review of the information listed and requested below.
Any of the information listed below,which has not been provided, may be required prior to final approval of a sale.
Underwriting Caveats
We reserve the right to revise the premium, modify the terms of the offer or terminate if:
Contract Provisions
The final benefit provisions,account structure,claim payment requirements or services change from those proposed.
Enrollment
The actual enrollment in total or by plan changes by more than 10 percent compared with what was proposed.Our renewal
assumes coverage will not be extended to additional employee groups without review of supplemental census information and
other underwriting information for appropriate financial review.
Member-to-Employee Ratio
The member-to-employee ratio changes by more than 10 percent from the 1.73 ratio assumed in this quote.
Retiree Enrollment
If the number of Retirees enrolled exceeds 20 percent of the total enrolled group or the total number of Retirees enrolled increases
by more than 10 percent from the 0 enrollees assumed in this quote.
Quoted Benefits and Administration
A material change is initiated by you or by legislative or regulatory action which materially affects the cost of the plan.This includes,
but is not limited to,changes impacting standard contract provisions,claim settlement practices, plan administration,plan benefits
or changes to the programs and services we offer you.
Industry
The nature of business and/or Standard Industrial Code(SIC)8211 changes compared with what was assumed in setting the rates.
Information Accuracy/Demographics
The information provided is inaccurate and/or the demographics of the quoted group change resulting in+/-5 percent premium
difference.
Multiple Employer Welfare Arrangements(MEWAs)and Employer Association Health Plans(AHPs)
This quote was prepared based on the situs state and demographic information for eligible enrollees, including their home zip
codes,in accordance with all federal and state mandates.We must be notified immediately of any changes that affect plan locations
due to new or changing enrollment statuses.We will evaluate regulatory requirements and may not be able to extend coverage in
states which prohibit large group coverage through MEWAs and AHPs.
6/24/2026 vaetna Quote ID:975279
Proprietary
City Of Boynton Beach
Caveats-Conventional Prospective Effective Date: October 1, 2026
Assumptions
nderwriting
•
Prospective Quoting
The quoted insured dental rates are offered on a prospectively rated basis. No policy year accounting balance will be calculated for
these coverages.
Aetna Medical/Dental Coverage
The proposed medical and dental rates are contingent upon you purchasing both medical and dental lines of coverage.
Contribution and Participation
Our rates assume compliance with our standard guidelines on employer contribution strategy. We standardly require that the
employer contribute 75 percent of the employee cost,or 50 percent of the total employee and dependent cost. Minimum
participation requirements for this contribution structure is 30 percent of total eligible lives.
Plan Design
This renewal is based on the current benefit plan designs, plus any noted deviations.
Waiting Period
New employees must complete the waiting period designated by their employer prior to enrolling in one of our plans.The waiting
period must be consistently applied within a class of employees.
Additional Products and Services
Costs for special services,that are not included or assumed in the rate guarantee will be direct billed after such services have been
rendered. For example, additional charges will apply for customized communication materials.The costs for these types of services
will depend upon the actual services performed and will be determined at the time the service is requested.
Billin: Information
Billing and Payment of Premium
Amount due is payable on the first day of the month covered by the invoice. If the amount due is not paid in full within 30 days,we
reserve the right to terminate the contract and/or assess late premium payment charges.
Producer Compensation
We are not serving as billing and collection agent for producer compensation. Our quoted rates do not include Producer Service
Fees or commissions.
Dental Service Center
Claim administration and member services for the quoted plans will be centrally managed. Members will be able to reach the
Member Service representatives Monday through Friday,from 8 a.m.to 6 p.m.,local time(based on where the member resides).
6/24/2026 vaetna Quote ID:975279
Proprietary
City Of Boynton Beach
Caveats-Conventional Prospective Effective Date: October 1, 2026
Reporting and Data Transfer
Aetna Intellectual Property
Under the Group Policy,you may have access to certain of Aetna's Customer reporting systems.Aetna represents that it has either
the ownership rights or the right to use all of the intellectual property used by Aetna in providing the Services under the Group
Policy("Aetna IP").Aetna will grant you,as the Customer,a nonexclusive, non-assignable,royalty free, limited right to use certain of
the Aetna IP for the purposes described in the Group Policy.You agree not to modify,create derivative product from,copy,
duplicate,decompile,dissemble, reverse engineer or otherwise attempt to perceive the source code from which any software
component of the Aetna IP is compiled or interpreted.Nothing in the Group Policy shall be deemed to grant any additional
ownership rights in,or any right to assign,sublicense,sell, resell, lease,rent,or otherwise transfer or convey,the Aetna IP to you.
Additional
Please review the additional important information found at the following URL.This information is incorporated by reference into
this package and considered part of your policy.This quote is subject to all the terms and conditions set forth in this URL. In the
event that any information contained herein conflicts or is inconsistent with the information in the Underwriting Disclosure
Document,the information in your Renewal Package prevails.
httas://www.aetna.com/content/dam/aetna/adfs/aetnacom/legal-notices/documents/large-group-dental-underwriting-fully-
insured-disclosu res-as-of-01-01-2026.odf
Legislative and Regulatory Requirements
Regulatory Reporting
We are entitled to rely on information supplied by you in connection with any regulatory filings we provide on your behalf or any
other services we provide.We are not responsible for any penalities or fees associated with reporting delays/errors caused by your
failure to provide us with accurate or timely information.
6/24/2026 vaetna Quote ID:975279
Proprietary
City Of Boynton Beach
Aetna's Dental/Medical Integrations M Program Effective Date: October 1, 2026
Put the bite on medical costs with an integrated dental/medical program.
Help reduce the risks of heart disease, diabetes and the complications of pregnancy. Better dental care can mean healthier
employees.
Early dental care may help lower risk for certain illnesses' Visit the Dentist Regularly'
Recent medical studies suggest a connection between Regular checkups,cleanings, and maintenance are important,
periodontal disease and complications of cardiovascular certainly. But a study from Aetna and Columbia University
disease. Also, periodontal disease may increase the likelihood College of Dental Medicine indicates that proactive periodontal
for expectant mothers to deliver their babies early. And it may care appears to have a positive effect on the cost of medical
even make it more difficult for diabetics to control their blood care,with earlier treatment resulting in lower medical expenses
sugar levels. But that's not all: Periodontal disease has been for members with diabetes,coronary artery disease and stroke.
linked to respiratory infections in people with lung problems.
Smart Aetna programs bring together dental and medical care
Educate at-risk members who may not be aware of how oral health can affect their specific medical conditions. Members of dental
and medical insurance plans from Aetna may get these added benefits,when you select the DMI program.
jeffit
Our Dental/Medical Integration competitive advantage lies in successfully affecting member behavior.Since we have medical and
dental claims data,we can put our knowledge to work for your members because we have a complete picture of their claims
history.We differentiate ourselves from the market because of how we identify those members who should be concerned with their
dental health and its impact to their overall medical condition.At this time,Aetna defines at-risk members as those who are
pregnant or have cardiovascular disease or diabetes.
• Focusing on members who have not had a recent dental visit,the DMI member outreach program uses multiple outreach
methods proven to be successful in motivating at-risk members to seek care.
• Claim data is monitored to determine if the member sought care after initial contact. Follow-up outreach is provided if the
member does not seek care.
Enhanced Benefit* Programs Fully Cover Additional Services with NO deductible
For pregnant women,members with diabetes and coronary artery disease/cerebrovascular disease
• One additional prophylaxis(cleaning visit)
• Scaling and root planning
• Full mouth debridement to enable comprehensive evaluations and diagnosis
• Periodontal maintenance
Members will receive educational material and will be encouraged to call our Dental Service Center to:
• Enroll in the enhanced benefit •Select a dentist •Get help with making a dentist appointment
*Exclusions and limitations may apply.Refer to your plan documents,available after enrollment,for details.
1Periodontal Disease and Systemic Health https://www.perio.org/consumer/other-diseases.Accessed October 2018
z"An examination of periodontal treatment and per member per month(PMPM)medical costs in an insured population"BMC Health Services
Research 2006:103
6/24/2026
Proprietary vaetna Quote ID:975279
etna Visions' Preferred
Summary of Benefits for City Of Boynton Beach
Effective Date: 10/01/2026
External Plan ID: 1032263105
Line Value:489
Frequency(Exam/Frame/Lens): 12/24/12 In Network Member Cost ,P! Out of Network Member
Aetna Vision Network Reimbursement*
Enhanced Plan-191(a)E NV-24
Current Vision Plan,with 4 Tier Rates
978059-Package A
Exam
Eye Exam with Dilation as Necessary $10 Copay $38 Reimbursement
Retinal Imaging I Member pays discounted fee of$39 I Not Covered
Standard Contact Lens Fit/Follow Up' I Member pays discounted fee of$40 I Not Covered
Premium Contact Lens Fit/Follow Up' 10%off retail price Not Covered
Frames
Any Frame available, including frames for prescription $0 Copay; $150 Allowance**, 20%off
sunglasses balance over allowance $75 Reimbursement
Standard Plastic Lenses
Single Vision $10 Copay $28 Reimbursement
Bifocal $10 Copay $44 Reimbursement
Trifocal $10 Copay $72 Reimbursement
Lenticular $10 Copay $72 Reimbursement
Standard Progressive Lens(copay includes bifocal cost) $75 Copay $44 Reimbursement
Premium Progressive Lens Tier 1 (copay includes bifocal cost)2 $95 Copay $44 Reimbursement
Premium Progressive Lens Tier 2 (copay includes bifocal cost)2 $105 Copay $44 Reimbursement
Premium Progressive Lens Tier 3 (copay includes bifocal cost)2 $120 Copay $44 Reimbursement
Premium Progressive Lens Tier 4(copay includes bifocal cost)2 $75 Copay;80%of Charge less$120 $44 Reimbursement
allowance
Lens Options
UV Treatment Member pays discounted fee of$15 Not Covered
Tint(Solid And Gradient) Member pays discounted fee of$15 Not Covered
Standard Plastic Scratch Coating $0 Copay $12 Reimbursement
Polycarbonate Lenses-Adult Member pays discounted fee of$40 Not Covered
Polycarbonate Lenses-Children to age 19 $0 Copay $32 Reimbursement
Standard Anti-Reflective Coating Member pays discounted fee of$45 Not Covered
Premium Anti-Reflective Coating Tier 12 Member pays discounted fee of$57 Not Covered
Premium Anti-Reflective Coating Tier 22 Member pays discounted fee of$68 Not Covered
Premium Anti-Reflective Coating Tier 32 20%off retail price Not Covered
Photochromic/Transitions Plastic-Adult Member pays discounted fee of$75 Not Covered
Photochromic/Transitions Plastic-Children to age 19 Member pays discounted fee of$75 Not Covered
Other Add-Ons 20%off retail price Not Covered
7/1/2026 vaetna Quote ID:978059
Proprietary
Contact Lenses
Conventional $0 Copay; $150 Allowance**, 15%off
balance over allowance $120 Reimbursement
Disposable I $0 Copay;$150 Allowance I $120 Reimbursement
Medically Necessary Covered in Full $200 Reimbursement
Frequency Children to age 19 Adults age 19 and over
Exam once every rolling 12 months once every rolling 12 months
Frame once every rolling 24 months once every rolling 24 months
Lenses once every rolling 12 months once every rolling 12 months
Contact Lenses once every rolling 12 months once every rolling 12 months
Lens Coverage can be used for eyeglass lenses OR 1 order of contact lenses
In Network Discounts
Discounts cannot be combined with any other discounts or promotional offers and may not be available on all brands
Additional pairs of eyeglasses or prescription Up to 40%off prescription eyeglasses/sunglasses and 15%off conventional contact
sunglasses3 lenses once the funded benefit has been used
Non-covered Items4 I 20%off retail price
Lasik Laser vision correction or PRK from U.S. Laser
15%discount off retail price or 5%discount off promotional price
Networks. Call 1-800-422-6600
Hearing Discounts6 -two ways to save:
Save on hearing aids,exams,batteries, repairs and more
Hearing Care Solutions 1-866-344-7756
Amplifon Hearing Health Care 1-877-301-0840
Rates (assumes all plans within a package must be purchased together)
Tiers Lives Monthly Rate&Premium
Employee Only I 652 I $4.45
Employee&Spouse I 104 I $8.56
Employee&child(ren) I 88 I $8.22
Employee& Family I 136 I $11.81
Totals I 980 I $6,121
7/1/2026 vaetna Quote ID:978059
Proprietary
Rate Information and Assumptions
Funding Arrangement
We have quoted a fully insured vision plan(s)for your employees.
Affordable Care Act—Fees and Assessments
Any additional mandated fees or taxes required by Federal laws or regulations(such as,the Patient Protection and Affordable Care Act
("PPACA"), Health Insurance Provider Fee ("HIF")tax)will be built into the rate development for the applicable contract year.
Commissions
Commissions have been excluded from our quoted rates.
Rate Guarantee
Our quoted rates are guaranteed for the first 36 months of the policy period and are valid as of the plan effective date.The quoted rates
apply only to the benefit levels and conditions specified and any variations in benefit level or assumed conditions may require a rate change.
We reserve the right to review and modify or terminate the guarantee arrangement if any of the following occur during the guarantee
period:
Participation
A minimum participation level of 10 enrolled subscribers is required.
Customer/Employee Contributions&Participation
There is no minimum participation requirement for the first year. Beginning with the first renewal we will require a minimum participation
level of 15.0%of eligibles.
We have made every effort to respond to your request in a manner that reflects existing and expected business practices for the effective
date that you have chosen.
Pricing and Underwriting Assumption Our proposal assumes that coverage will be extended to all eligible employees.This quotation is on a
pretax basis and will be void for post-tax offerings.
Policies and Claim Settlement Practices Our proposal assumes that our standard contract provisions and claim settlement practices will
apply. If a material change is initiated by Summary of Benefits for City Of Boynton Beach or due to legislative or regulatory action in the claim
payment requirements or procedures,account structure,or any changes materially affecting the manner or cost of paying benefits,we
reserve the right to adjust our proposal accordingly.
Plan Offering We have assumed that Aetna will be the sole Vision vendor offered to Summary of Benefits for City Of Boynton Beach's
employees.
Terms of Offer The Vision Plan is offered on a prospectively insured, no deficit carry-forward basis.
The quoted rates are valid until the earliest of 90 days from the date of this quotation or 30 days prior to the assumed effective date.We
reserve the right to update this quotation if the quote is not accepted within this time frame.
• Failure to make required premium payments in accordance with policy provisions.
• A material change in the plan of benefits offered that is initiated by Summary of Benefits for City Of Boynton Beach or required
because of legislative or regulatory action.
Plan Eligibility Our quoted rates assume that permanent full-time employees work a minimum of 25 hours per week on a regularly
scheduled basis and that eligible dependents include an employee's spouse and unmarried children up to age 26. Retirees are not eligible for
coverage.
Run-Off Claim Processing Our quoted rates reflect an incurred (mature) claim base and take into account the expenses associated with the
processing of run-off claims following cancellation, subject to the conditions of our financial guarantee.
Claim Fiduciary Our proposal assumes that Aetna will assume claim fiduciary responsibilities. As claim fiduciary,we will be responsible for
final claim determination and the legal defense of disputed benefit payments.
ID Cards Our quoted rates include the cost for ID cards. Each vision subscriber will receive two ID cards.The ID card includes a toll-free
number for accessing member services.
7/1/2026 vaetna Quote ID:978059
Proprietary
Partial list of exclusions and limitations
Enrolled members can access our secure member website once their plan becomes effective. Enrolled subscribers will receive a welcome
packet with ID card mailed to their home within 15 business days after enrollment is processed.
*Out of network coverage is available.To receive reimbursement up to the amounts listed above,a claim form with itemized receipt is
required. Reimbursement will not exceed the providers actual charge. Claims forms can be found at aetnavision.com or by calling customer
service Monday through Sunday at 1-877-973-3238.Completed claim forms can be submitted electronically or mailed to Aetna,PO Box 8504
Mason,OH 45040-7111.You also have access to Allied Providers,such as Costco Vision,who will apply your out-of-network benefits at the
point of service and handle the claim submission process for you.
**Allowances are one-time use benefits. No remaining balances may be used.The plan does not provide a declining balance benefit.
1Contact lens fit and two follow-up visits are allowed once an eye exam has been completed.
2Premium progressives and premium anti-reflective Brand designations are subject to annual review and change based on market
conditions.Ask your eye care provider for more information. Premium Progressive Lens cost includes bifocal cost.
3Additional pair discount applies to purchases made after the plan allowances have been exhausted. Discounts are not insurance.
4Non covered discounts may not be available in all states.
5Lasik or PRK from the US Laser Network,owned and operated by LCA Vision.
6Aetna does not endorse any vendor,product or service associated with these discount offers.Vendors are independent of Aetna,not agents
or employees. Programs, products and services may not be available at all times.Certain offers may not be available in some states. Products
and services are provided by Hearing Care Solutions and Amplifon Hearing Health Care(formerly HearPO).
Policies and plans are insured and/or administered by Aetna Life Insurance Company(Aetna).Certain claims administration services are
provided by First American Administrators,Inc.and certain network administration services are provided through EyeMed Vision Care
("EyeMed"),LLC.
Not all services are covered.See plan documents for a complete description of benefits,exclusions and limitations of coverage. Plan features
and availability may vary by location and are subject to change.These are the plan's main exclusions and limitations.See the booklet-
certificate for a complete description.The plan does not cover:special vision procedures,such as orthoptics,vision therapy or vision training;
vision services or supplies that do not meet professionally accepted standards;piano(nonprescription) lenses; nonprescription sunglasses;
two pair of glasses in lieu of bifocals; medical and/or surgical treatment of the eyes;cosmetic services;lost or broken lenses,frames,glasses
or contact lenses.
Providers in the Aetna Vision network are contracted and credentialed through EyeMed Vision Care, LLC according to EyeMed's
requirements. EyeMed and Aetna are independent contractors and not agents of each other. Provider participation may change without
notice.
Refer to Aetna.com for more information about Aetna®plans.
7/1/2026 vaetna Quote ID:978059
Proprietary
Aetna Inc.complies with applicable Federal civil rights laws and does not discriminate on the basis of race,color, national origin,age,
disability,or sex(consistent with 45 CFR§92.101(a)(2)).Aetna Inc.does not exclude people or treat them less favorably because of race,
color,national origin,age,disability,or sex.
Aetna Inc.:
• Provides people with disabilities reasonable modifications and free appropriate auxiliary aids and services to communicate
effectively with us,such as:
o Qualified sign language interpreters
o Written information in other formats(large print,audio,accessible electronic formats,other formats).
• Provides free language assistance services to people whose primary language is not English,which may include:
o Qualified interpreters
o Information written in other languages.
If you need reasonable modifications,appropriate auxiliary aids and services,or language assistance services,call 1-800-872-3862 (TTY: 711)
or the number on the back of your ID card.
If you believe that Aetna Inc. has failed to provide these services or discriminated in another way on the basis of race,color, national origin,
age,disability,or sex,you can file a grievance with:
Civil Rights Coordinator
Attn: 1557 Coordinator
CVS Pharmacy,Inc.
1 CVS Drive,MC 2332,
Woonsocket, RI 02895
Phone: 1-800-648-7817.TTY:711
Email: CRCoordinator@aetna.com
You can file a grievance in person, by mail,or email. If you need help filing a grievance,the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,Office for Civil Rights,electronically through
the Office for Civil Rights Complaint Portal,available at httas://ocraortal.hhs.rov/ocr/aortal/lobbv.isf,or by mail or phone at:
U.S.Department of Health and Human Services
200 Independence Avenue,SW
Room 509F,HHH Building
Washington, D.C.20201
1-800-368-1019. 1-800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
This notice is available at Aetna Inc.'s website: httos://www.aetna.com/
7/1/2026 vaetna Quote ID:978059
Proprietary
Compensation to Producers(Brokers,Agents and Consultants):
Licensed and appointed producers may earn compensation in the form of a commission on the sale of this product.The amount of
compensation varies depending on a number of factors, including customer segment and the product selected.Aetna offers additional bonus
programs to its producers,which may also apply. Please consult your broker for additional information concerning their compensation for
this sale, including commissions and any applicable bonus programs.The producer is prohibited by law from altering the amount of
compensation received from Aetna based in whole or in part on the sale.
Compensation to Salaried Aetna Employees:
Salaried employees may earn compensation on the sale of Aetna products.The compensation varied depending on a number of factors,
including customer segment and product selected. Combining all factors, compensation for each product quoted averages less than 8%of
the total first year annual premium.Aetna offers additional bonus programs,which may also apply. Neither Aetna nor the employee has
material ownership interest in the other.The employee may not alter the amount of compensation received from Aetna.You may obtain
additional information about the compensation expected to be received by eligible employees, based in whole or in part on the sale of an
Aetna product,or alternative options presented, by contacting Aetna at
www.aetna.com/about-us/forms/emolovee-compensation-disclosure.html.
Customer Signature: Date:
TTY:711
English To access language services at no cost to you,call the number on your ID card,
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Arabic t t ii;o J)c 'ys y.il ti�l1 k� Yl.4)1.%aLi 3i J�„y 1:llt�d_,:x ufe�J�all I
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Carolinian
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Chamorro Para un hago'i setbision lengguahi ni dibatde para hagu, gang i numiru gi iyo-mu kard aidentifikasion.
Chinese Traditional > M11445. 1[o$1 A6'tR. o M#TIV1 -#±P7rt$99hitint4
Cushitic Oromo Tajaajnloota afaann gatii bilisaa at argaachuuf,lakkoofsa fuula waraaqaa eenyummaa(ID)kee irraa
jiruun bilbili
French Pour acceder gratuitement aux services linguistiques,veuillez composer le numero indique sur votre carte
d'assurance sante.
French Creole(Haitian) Pou ou jwenn sevis gratis nan lang ou,rele nimewo telefon ki sou kat idantifikasyon asirans sante ou.
German
Urn auf den fur Sie kostenlosen Sprachservice auf Deutsch zuzugreifen,rufen Sie die Nummer auf Ihrer ID-
Karte an.
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Pennsylvanian-Dutch Urn Schprooch Services zu griege mitaus Koscht,ruff die Nummer uff dei ID Kaart.
7/1/2026 vaetna Quote ID:978059
Proprietary
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Polish Aby uzyskac dostep do bezptatnych ustug jczykowych,naleiy zadzwonic pod numer podany na karcie
identyfikacyjnej.
Portuguese Para aceder aos servicos linguisticos gratuitamente,ligue para o ntimero indicado no seu cartao
de identificacao.
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Serbo-Croatian Za besplatne prevodilai:ke usluge pozovite broj naveden na Vasoj identifikacionoj kartici-
Spanish Para acceder a los servicios linguisticos sin costo alguno,(lame al numero que figura en su tarjeta
de identification.
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Tagalog Upang ma-access ang mga serbisyo sa wika nang walang bayad,tawagan ang numero sa iyong ID card.
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Proprietary-Updated 2025
7/1/2026 v ae`n a Quote ID:978059
Proprietary
Aetna Life Insurance Company 151 Farmington Avenue
Hartford, CT 06156
Stop Loss Application and Schedule of Insurance
Policyholder Information
Policyholder name(full legal name of entity): CITY OF BOYNTON BEACH
Street: 100 E. OCEAN AVENUE
City: BOYNTON BEACH State: FL Zip Code: 33435
Email: antillonh@bbfl.us Phone: (561)742-6273
Policy period start: 10/01/2026 Policy period end:09/30/2027
Total number of employees/covered units covered under the policy: 908
Pre-65 Retirees: El Included IZI Excluded I Retirees 65+: 2 Included ❑ Excluded
Medical paid claims basis: 0 Issued ❑ Cleared ❑ N/A
Business Type: El Corporation El Government ❑ Association El Union ❑ Other I I
Affiliates or subsidiaries included? 2 No ❑ Yes If yes, list name(s) and address state of the primary location(s) below.
Affiliate full legal name(s): Address state of Primary location(s):
Affiliate full legal name(s): Address state of Primary location(s):
Affiliate full legal name(s): Address state of Primary location(s):
Affiliate full legal name(s): Address state of Primary location(s):
Affiliate full legal name(s): Address state of Primary location(s):
Affiliate full legal name(s): Address state of Primary location(s):
Affiliate full legal name(s): Address state of Primary location(s):
Affiliate full legal name(s): Address state of Primary location(s):
Affiliate full legal name(s): Address state of Primary location(s):
Affiliate full legal name(s): Address state of Primary location(s):
Third Party Administrator? 0 No ❑ Yes If yes, complete for each administrator or vendor.
Medical:
Prescription drug:
Other:
Individual Stop Loss Coverage (ISL)
Individual Stop Loss coverage? ❑ No 0 Yes I Individual Stop Loss amount: $250,000
Does individual Stop Loss amount differ by plan or class? EI No ❑Yes
If yes, please include the plan(s)/class(es)and amounts below.
Plan/class: Individual Stop Loss amount: $
Plan/class: Individual Stop Loss amount: $
Plan/class: Individual Stop Loss amount: $
AL HPoI-App-SOI-SL 02 1 FL
Plan/class: Individual Stop Loss amount: $
Plan/class: Individual Stop Loss amount: $
High risk individual Stop Loss amount(s)* included? ❑ N/A 0 No ❑ Yes *See Coverage Limitations identified below.
Covered benefits: 2 Medical 0 Prescription drug ❑ Other I I
Contract type: Claims incurred from through or 0 paid basis
Claims paid from 10/01/2026 through 09/30/2027
Maximum run-in claims: 0 N/A or $ ❑ per covered person ❑ in total
Individual coinsurance percentage reimbursable: 100%
IOE transplant Stop Loss amount: ❑ N/A 2 No or $
Family individual Stop Loss amount: ❑ N/A 2 No or $
Aggregating Specific Stop loss amount: ❑ N/A E No or $
Maximum lifetime individual Stop Loss payment amount: 2 Unlimited or $
Experience Refund Option included? ❑ N/A 0 No ❑ Yes
Experience refund period: Start date through
Loss ratio threshold: % Refund share: %
Maximum refund: % Large claim adjustment: 0 No or Adjustment is:
Large claim identifier: Date of birth:
Large claim identifier: Date of birth:
Large claim identifier: Date of birth:
Large claim identifier: Date of birth:
Large claim identifier: Date of birth:
Premier product included? ❑ N/A 2 No ❑Yes
Renewal risk cap included? ❑ N/A 2 No ❑ Yes Cap: %
Other rate cap included? 0 N/A ❑ No ❑ Yes Cap: %
Terminal run-out coverage for claims incurred prior to policy termination and paid after termination? ❑ No 0 Yes
Terminal reserve or liability period:g months
Reimbursement types:
Immediate reimbursement(Aetna as claims administrator): ❑ N/A ❑ No 0 Yes
Individual accelerated claim reimbursement (TPA as claims administrator): ❑ N/A 0 No ❑ Yes
Other conditions or provisions:
Aggregate Stop Loss Coverage (ASL)
Aggregate Stop Loss coverage? ❑ No ❑ Yes I Aggregate Stop Loss percentage: 125%
Covered benefits: 0 Medical 0 Prescription Drug ❑ Dental ❑ Vision ❑ Other I
Contract type: Claims incurred from through or 0 paid basis
Claims paid from 10/01/2026 through 09/30/2027
Maximum run-in claims: 0 N/A or $ ❑ per covered person ❑ in total
Individual Stop Loss insurer: ❑ Aetna or I 1
AL HPoI-App-SOI-SL 02 2 FL
Minimum aggregate Stop Loss amount: ❑ N/A $ 14,400,698
Individual internal limit: 0 N/A E No 0 Yes If yes,amount: $
Maximum annual aggregate Stop Loss payment amount? 0 N/A 0 No Z Yes If yes, amount: $1,000,000
Deficit recoup provision? 0 N/A 0 No 0 Yes If yes, deficit cap:
Termination provision? 0 N/A Z No 0 Yes
Terminal run-out coverage for claims incurred prior to policy termination and paid after termination? 0 No 0 Yes
Terminal reserve or liability period:0 months
Reimbursement types:
Monthly budget feature (Aetna as claims administrator): 0 N/A 0 No 0 Yes
Aggregate accelerated claim reimbursement(TPA as claims administrator): 0 N/A 2 No 0 Yes
Other conditions or provisions:
Coverage Limitations
Mental Health claim expenses are El Included 0 Excluded
Transplant coverage is 0 Included 0 Excluded
Is the policyholder a hospital or hospital group? 0 No 0 Yes
If yes, are drafts suppressed for domestic claims? N/A 0 No 0 Yes
If yes, domestic claims are reimbursed at?1 N/A 0 100% 0 0% 0 Other %
Are any of these limitations included under this Stop Loss policy?
Pre-existing conditions exclusion? Z No ❑ Yes
Dependent non-confinement? 0 No 0 Yes
Actively at Work? 0 No 0 Yes
High Risk Individual Stop Loss amounts:
Member Identifier Date of Birth Amount Description
Premium Rates and Factors
Premium rate:
*Composite: $131.17 per employee per month (PEPM)
*If individual and aggregate Stop Loss coverage is included, the premium rate is combined.
Terminal liability premium rate:
*Composite: $131.17 per employee per month (PEPM) or ❑ N/A
*If individual and aggregate Stop Loss coverage is included, the premium rate is combined.
AL HPoI-App-SOI-SL 02 3 FL
Aggregate Stop Loss factor:
Composite: $1,321.65 per employee per month (PEPM) or ❑ N/A
Terminal Liability Stop Loss factor:
Composite: $1,321.65 per employee per month (PEPM) or ❑ N/A
Certification and Signature
You hereby represent that the information contained in this Stop Loss Application and Schedule of Insurance, any
Disclosure statement, and all other information and documents provided by you to us, is true and complete to the best
of your knowledge and belief.
Printed name of authorized representative: . • �.„„ Signatur authorized representative:
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Official Title: 1.^a,�� •
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Fraud Notice
WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,which
is a crime and subjects such person to criminal and civil penalties.
State-specific notices:
AL: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or
confinement in prison, or any combination thereof.
AR: Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information, or conceals for the purpose of
misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.
CA: For your protection, California law requires the following to appear on this form: Any person who knowingly
presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of
a loss is guilty of a crime and may be subject to fines and confinement in state prison.
CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company
for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment,fines,
denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly
provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of
defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from
insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
DC: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
FL: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or
an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
KY: Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information or conceals, for the purpose of
misleading, information concerning any material fact thereto, commits a fraudulent insurance act,which is a crime.
LA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
ME: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment,fines and denial of insurance benefits.
MD: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject
to fines and confinement in prison.
NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NM: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and
criminal penalties.
NY: Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information, or conceals for the purpose of
misleading, information concerning any material fact thereto, commits a fraudulent insurance act, which is a crime, and
shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each
such violation.
AL HPoI-App-SOI-SL 02 5 FL
OH: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
OK: WARNING -Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
OR: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance may be guilty of a crime and may be subject to civil fines and
criminal penalties.
RI: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
TN: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
VA: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer,submits an
application or files a claim containing a false or deceptive statement may have violated state law.
WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
WV: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
AL HPoI-App-SOI-SL 02 6 FL