R95-166RESOLUTION NO. R95~/~
A RESOLUTION OF THE CITY COMMISSION OF THE
CITY OF BOYNTON BEACH, FLORIDA, AUTHORIZING
THE MAYOR AND CITY CLERK TO EXECUTE RENEWAL
OF THE CONTRACT WITH BLUE CROSS/BLUE SHIELD
AND HEALTH OPTIONS FOR THE PROVISION OF
HEALTH INSURANCE COVERAGE FOR CITY
EMPLOYEES; AND PROVIDING AN EFFECTIVE DATE.
W~EREAS, the City of Boynton Beach has a long-standing
relationship with Blue Cross/Blue Shield for the provision of
employee health insurance; and
WHEREAS, City staff has been able to negotiate certain
enhancements to the employee health insurance plan under the
HMO, as well as a minimal decrease in premiums for both the HMO
and PPC Plan; and
WHEREAS, it has been determined by the City Commission to
be in the best interests of the City to execute a renewal with
Blue Cross/Blue Shield of Florida and Health Options, Inc., for
employee health insurance coverage;
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF
THE CITY OF BOYNTON BEACh, FLORIDA, THAT:
~ The Mayor and City Clerk are hereby
authorized to execute a renewal of the contract with Blue
Cross/Blue Shield of Florida and Health Options, Inc., for
employee health insurance coverage, a copy of said renewal being
attached hereto as Exhibit "A"
~ That this Resolution shall become effective
immediately upon passage.
PASSED AND ADOPTED this ~ day of October, 1995.
CITY OF BOYNTON BEACH, FLORIDA
Mayo r
ATTEST:
Vice Mayor
~Ma~ Pro~ Tem ~
C±~ Clerk
(Corporate Seal)
Authsig.doc
10/2/95
B/C-B/S/~O
AN INDEPENDE.~T LICENSEE OF THE BLUE CROSS AND BLUE SHIELD A$SOSIATION.
[~].New [] Renewal [] Other: CHANGE BENEFITS
GROUP CONTRACT 1
(True Group App.)
Group #: 70029
A. Name of Group CITY OF BOYNTON BEACH
Address P.O. B_OX 310 I BOYNTON BEACH FL 33425
Div.#: 001. W01 C01 R03 .
Nature of Business General government, nec
List below Subsidiary or Affiliated Companies whose employees are to be eligible and included with this application.
NAME ADDRESS
Applicant hereby applies for a Blue Cm== and Blue Shield of Florida, Inc. (herein referred to as BCBSF) Group Contract (herein referred to as the Contract).
Upon acceptance of this application by BCBSF, it will become part of the contract issued to the applicant named above.
C. The Contract benefits do not cover any service or supply to diagnose or treat any Condition resulting from or in connection with an Insured's job or employment
[~e.=. any service or supply which is covered by Worker's Compensation Insurance). Benefits will not be provided under the Contract to an individual who elects
nption form Worker's Compensation coverage or who waives entitlement to Worker's Compensation benefits for which he/she is eligible.
D. ~ ~er's Compensation Carrier is SELF-INS/PROFESSIOAL ADMINIORLANDO
A. Effective Date of this contract shall be 10101/95 . This Contract may be terminated by the
the applicant or BCBSF by giving at least 45 days prior written notice to the other party.
B. Only active employees who regularly work a minimum of 30 hours each week and their eligible dependents, shall be eligible for coverage upon
the Effective Date of this Contract.
C. Specify classification of enrollees for whom coverage is being requested, if other than employees as described in B above.
D. Eligible new employees may be covered after of employment,
so long as the employee submits an application to BCBSF within 30 days of the date the individual first meets the applicable eligibility requirements.
E. At least 76 % of the eligible employees and 60 % of the eligible dependents must be enrolled under the contract on the effective date and throughout the
term of the contract. Number Enrolled Total Eligible Percent Enrolled D Multi Option Split
F. Enrollment data: PPO HMO
Emp!oyees
Employees with Dependents
G. BCBSF shall have the right to audit the applicant's payroll records at any time to confirm eligibility for coverage; applicant agrees to furnish any such records
upon request.
A. Traditional [] Basic [] Comprehensive Option # [] Standard [] Non-Standard
B. Preferred Patient Care Classic Option # [] Standard [] Non-Standard
C. Preferred Patient Card Point of Service Option # POS 19 [] Standard [] Non-Standard
D.~,sential Hospital and Surgical Option # [] Standard [] Non-Standard
E. kP Dental: [] Standard [] Non-Standard [] With Orthodontics [] Without Orthodontics
F.~ . pe Contract (including Summary of Benefits)
POINT OF SERVICE/PLAN 10:
$1(30 Deductible (3 / Family - Aggregate).
90/10% Coinsurance When Usin~l PPC Providera/PPC Schedule.
70/30% Coinsurance When Usin~l Non-PPC Providers/MAP Schedule.
Optional Mandated Benefits Offerings - Applicant has
been advised of the following benefit offerings as
mandated by State Law. Applicant's decision to accept
or decline these beneffis is indicated below.
A~pt Decline
[] Mental & Nervous Disorder *
[] [] Alcohol & Drug Dependency *
[] [] Other
· If declined, indicate other Mental & Nervous Disorder or Alcoho
s requested by Group.
~1000 Out-Of-POcket Maximum. ~100 Per Admission Deductible/For All Non-PPC Hospital t I ~ Waived nitial Enroll 0 '
Admissions. Second Sur,qical opinion/Mandatory Usin,q Non-PISC'Providers Only. I I-1 Dfl3 Daughler Malemilv I ~ . npj
100°,6 Supplemental Accident (Up to `$500 within 90 days). I [] Dru; Card Program - I L..J Wa!ved After Initial Enroll.
! ""' Other See III G I [] Waived For All Enrollment
HMO OPT;~ RXB10C I I I ( - ) I [] Other (See Ill-F)
A. Premiums are payable on or before the due date which will be C. Premiums/Contributions/Funding Arrangements for Composite Rating.
determined: (options may be subject of Home Office approval) Do special funding arrangements apply? [] YES [] NO
If a Special Funding Arrangement applies to this contract, the Group's
Accounting and Retention Agreement is made a part of this contract.
1. Select One: [] Monthly [] Quarterly
[] Regular Billing - Employee applications should be
submitted thirty (30) days prior to proposed effective date.
Employee $202.16
Employees I Spouse
Employee / Child(ran)
Employee / Family $202.16
Other
Comments:
Employer Employee Total
Contribution Contribution Premium
$0.00 $202.16
· ,$266.90
$469.06
The rates established for this contract will not be changed for the first twelve (12) months following the initial effective date of coverage. However, Blue Cross may
chan~e(45~=~sthepriorrateSto whichtheir effectiveare to bedate.effective after this initial twelve (12) month period of coverage by providing notice to the employer of such changed rates forty-five
A.~ ,, ~e Applicant Shall:
1) Notify each enrolles to the benefits selected by the applicant, their effective date, and the termination date of coverage (in this regard, applicant acts as the
agent of the enrollees, and in no event shall the applicant be deemed an agent of BCBSF for this or any other purpose, nor shall BCBSF be responsible for
such notification to enrollees). 2) Deliver to covered enrollees identification cards and certificates of coverage furnished by BCBSF. 3) Notify BCBSF promptly
of any changes in the eligibility of enrollees covered under this agreement. 4) List any absentees at the time of initial enrollment on the appropriate BCBSF
form. Applications from absentees will be accepted at BCBSF Corporate Headquarters no later than 30 days from the group's effective date.
5) Collect. enrollee contribution if required, and remit premium payment to BCBSF as specified above in section VII Rates.
B. Applicant hereby establishes an Employee Welfare Benefit Plan for the purpose of providing for its employees or their beneficiaries medical, sUrgical,
hospital care, or benefits in the event of sickness.
Issuance of the c.i,[.~c~ by BCBSF will be deer,~eG acceptance of this application,
Date Signature of Applicant
Print I Type Name Title
Agenl License Identification Number
Date
10263-1194R S
Blue Cross and Blue Shield of Florida Licensed Agenl
· i-IEALTH O~ONS ®-.
HEALTH OPTIONS, Inc.
P.O. Box 2210
Jacksonville, Florida 32203-2210
GROUP APPLICATION 1
For Office Use Only:
Group Number: 70029W
HMO Plan: OPT. I RXGSB10C
1. GROUP'S LEGAL NAME: CITY OF BOYNTON BEACH
2. STREET ADDRESS:
(if different)
3. MAILING ADDRESS: P.O. BOX
(show exact corf~ratu name to be used on contract)
C~
BOYNTON BEACH
State Zip Code
FL 33425
State Zip C~le
4. SSOCIATED COMPANIES TO BE INCLUDED (if any):
Name of Company
N/A
Number of
Location Employees
GROUP'S ELIGIBILITY REQUIREMENTS: In order to be eligible for Coverage, an employee must work a minimum of
30 hours each week or be a bona fide Group retiree otherwise eligible for Coverage under the terms of the
Group Health Services Agreement (the Agreement), and meet any other applicable eligibility requirement set forth in
Section Iil of the Agreement. In addition to the eligibility requirements set forth in Section III of the Agreement,
employees must meet the following requirements (e.g., waiting periods following employment, etc.) established by the
Group in order to be eligible for Coverage under any health benefits program offered through such Group.
ENROLLMENT INFORMATION: The Group has approximately, eligible Subscribers. HOI requires that at
least 75 % of such Subscribers enroll under this Agreement, and that the Group contribute at least 75 % of
the payment required for single Subscriber Coverage. Such requirements may be changed from time to time by HOI
With proper notice to the Group. Acceptance of this Group Application by HOI and Coverage under the Agreement is
conditioned upon such enrollment and contribution requirements being met and maintained by the Group.
7. EFFECTIVE DATE OF COVERAGE: 10101195 ANNUAL ANNIVERSARY DATE: 10/01
8. SELECT SUPPLEMENTAL BENEFITS DESIRED BY GROup: Su oDlemental Char.qea
Subscriber and One or Subscriber, Spouse
Endorsement Subscriber Subscriber and Spouse More Dependent(s) and Dependent(s)
~ Vision $ $ $ $
~] Prescription Drug RXG5B10C $ $ $ $
~ Dental $ $ $ $
[] Extended Benefits $ $ $ $
Mental/nervous '
Alcohol/drug
[] Other ELECTIVE STERILIZATION $ $. $ $
$,, $, $ $
9. GROUP DECLINES OPTION OF: [] Mental health benefits (Chapter 627.668 of Florida State Law)
[] Drug abuse benefits (Chapter 627.669 of Florida State Law)
10. COMPOSITE RATING PREPAYMENT FEES: The following fees shall be effective for each Subscriber and Dependent
Basic Fee
Supplemental Charges
Total Prepayment Fee Per Month
Member as of the Effective date of this Agreement:
'Subscriber Subscriber and Spouse
Subscriber and One or
More Dependent(s)
Subscriber, Spouse
and Dependent(s)
$202.16
$459.06
1. REPRESENTATIONS: The Group hereby representsthatthe information contained in this Application is accurate and
complete. The Group understands that HOI relies upon such information in considering or accepting this Application
'~Nhich shall become part of the Group Health Services Agreement. The Group further acknowledges and represents that
it has received and understands the Agreement and that, if this Application is accepted by HOi, the Group accepts all of
the terms and conditions set forth in such Agreement. The Group also understands the HOI Provider Network is subject
to change without pdor notice to, or approval by, the Group or any Member.
The representative signing this Application has been duly authorized by the Group to submit this Application and to bind
the Group to the terms of the Agreement.
For the Group:
S"'~
ignature: ~)
Typed:
Title:
Date Signed:
Accepted by HOI:
Signature:
Typed: EDWARD MORANZ, III
Title: Marketing Represerltetive
Date Signed:
Licensed Agent (if applicable)
85000-1186
(REV. 11/94)
An HMO Subsiclfarg of Blue Cross and Blue Shie~ of Floriclo~ Inc
* AN INDEPENDENT LICENSEE OF THE BLUE CROSS AND BLUE SHIELD ASSOCIATION.
®' REGISTERED MARK OF BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC.
~ OFIIONS ®'*
IN WITNESS WHEREOF, each of the parties to this Agreement, through their duly authorized representative,
hereby acknowledges Ihat they have read and understand this Agreement, and the below listed endorsement/
amendments, and agree to be bound by their terms.
Group Health Services Agreement
Attachment A - Zip Codes
Attachment B -Grievance Procedure
Attachment C - Schedule of Benefits
Attachment D - Schedule of Copayments
Notice of HOI Grievance Procedure
85001 1188 (Rev. 9t91)
86002 1188 (Rev. 2/?.4189)
85366 291 (Rev. 7191)
85305 589 (Rev. 7119191)
85386 591 (Rev. 10115191)
55409 1291
85225 488
(Rev. 2/92)
Prescription Drug: $5.00 Generic I $10.00 Brand
Endorsement/Amendment Title
Oral Contraceptives - Rx Co-pay applies
Ertdorsemenl/Amendment Title
Gynecological services: specialist co-pay
Endorsemenl/Amendment Title
Surgical Sterilization $?0.00/$220 Co-pay
Endorsement/Amendment Title
Endorsement/Amendment~
Endorsement/Amendmenl Title
Endorsemertt/A~ent Title
Endorsement/Amendment Title
_GrolJ D:,
By:,,.
Name: (typed)
Title:
CITY OF BOYNTON BEACH
85330 490 (Rev. ?190)
Form Number
85270 289 (Rev.11190)
Form Number
85552 694
Form Number
85196 288 (Rev. 8/89)
Form Number
Form Number
Form Number
Form Number
Form Nu rriDer
Date:
HEALTH OPTIONS, INC.
By:
Name: (typed) NICK STAM
Title: _ REGIONAL VICE-PRESIDENT
Date:
4 III'~IM'~RED MAI#$ OF THE I~.UE CBQla AND BLUE aHIELE &la*CClA?I~N e' REGIS'TIRID M&RK O# I~&L,'H C~p .q'~)HS, INC.