R12-093 RESOLUTION NO. R12 -093*
3 A RESOLUTION OF THE CITY COMMISSION OF
4 BOYNTON BEACH, FLORIDA, APPROVING A ONE
5 YEAR EXTENSION OF A PROVIDER AGREEMENT
6 FOR RFP #046- 1610- 10 /CJD "GROUP BENEFITS:
MEDICAL CLAIMS ADMINISTRATION (TPA)
SERVICES AND /OR FULLY INSURED PLANS" WITH
CIGNA CORPORATION, FOR MEDICAL INSURANCE
111 I FROM OCTOBER 1, 2012 THROUGH SEPTEMBER 30,
1 2013; AUTHORIZING THE INTERIM CITY MANAGER
1 AND CITY CLERK TO EXECUTE THE PROVIDER
1 AGREEMENT AND PROVIDING AN EFFECTIVE
1 DATE.
1 „ WHEREAS, on July 20, 2010, the City Commission of the City of Boynton Beach
1 approved the award of a Provider Agreement to CIGNA HealthCare for Group Benefits
1; Medical Claims Administration Services and /or Fully Insured Plan for the one year term from
1' October 1, 2010 to September 30, 2011; and
2 i WHEREAS, the Provider Agreement had the option to extend the Agreement for
2 three additional one -year periods; and
2. WHEREAS, this extension is the second of the three additional one -year periods to
2 extend; and
2 WHEREAS, the City Commission of the City of Boynton Beach, upon
2" recommendation of staff, deems it to be in the best interests of the residents and citizens of the
2: City of Boynton Beach to approve the one year extension of a Provider Agreement with
2 CIGNA HealthCare for the medical insurance plan for a term commencing October 1, 2012 to
2: September 30, 2013, for all city employees.
2 NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF
3 1 THE CITY OF BOYNTON BEACH, FLORIDA, THAT:
31 Section 1. The foregoing "Whereas" clauses are hereby ratified and confirmed
-t-
*Scrivener Error
1 1
I as being true and correct and are hereby made a specific part of this Resolution upon adoption
.? hereof.
3 Section 2. The City Commission of the City of Boynton Beach, Florida does
' hereby approve a one year extension of the Provider Agreement to CIGNA HealthCare for the
�; medical insurance plan for a one year term commencing October 1, 2012 to September 30,
2013 with one additional one year renewal, for all city employees, a copy of which is attached
hereto as Exhibit "A ".
Section 3. The Interim City Manager and City Clerk are authorized to execute the
Provider Agreement with CIGNA HealthCare.
11 Section 4. That this Resolution shall become effective immediately upon passage.
PASSED AND ADOPTED this 4 day of September, 2012.
1.
CITY OF BOYNTON BEACH, FLORI A
Mayor — • t
1' Vice Mayor — ! . McCray
21
2
2. COP'mi •
2
2'
2'
Commissi v r l ,( - zma
2: ommissioner — Marlene Ross
2•
3e ATTEST:
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R12 -093
PROVIDER AGREEMENT FOR
"GROUP BENEFITS: MEDICAL COVERAGE FULLY INSURED PLAN"
THIS AGREEMENT is entered into between the City of Boynton Beach, hereinafter referred to
as "the City ", and CIGNA HealthCare , hereinafter referred to as "the
Provider ", in consideration of the mutual benefits, terms, and conditions hereinafter specified.
1. PROJECT DESIGNATION. The Provider is retained by the City to perform PROVIDER
services in connection with the project designated.
2. SCOPE OF SERVICES. Provider agrees to perform the services, identified on Exhibit "A"
attached hereto and incorporated herein by reference, including the provision of all labor,
materials, equipment and supplies. Also to incorporate information outlined in Proposal
#910117 included in Exhibit "A ". No additional modifications other than those described in
the Proposal #910117 letter will be made to the original scope of work without the written
approval of the City Manager or his designee.
3. TIME FOR PERFORMANCE. Work under this agreement shall commence upon the giving
of written notice by the City to the Provider to proceed. Provider shall perform all services
and provide all work product required pursuant to this agreement.
4. TERM: October 1, 2012 through September 30, 2013 with one (1) additional one (1) year
renewals.
5. PAYMENT. The Consultant shall be paid by the Provider /City for completed work and for
services rendered under this agreement as follows:
Monthly basis per eligible employee and dependent for medical coverage invoiced by
Provider.
6. COMPLIANCE WITH LAWS. Provider shall, in performing the services contemplated by
this Agreement, faithfully observe and comply with all federal, state and local laws,
ordinances and regulations that are applicable to the services to be rendered under this
agreement.
7. INDEMNIFICATION. Provider shall indemnify, defend and hold harmless the City, its
offices, agents and employees, from and against any and all claims, losses or liability, or any
portion thereof, including attorneys fees and costs, arising from injury or death to persons,
including injuries, sickness, disease or death to Provider's own employees, or damage to
property occasioned by a negligent act, omission or failure of the Provider.
8. INSURANCE. The Provider shall secure and maintain in force throughout the duration of
this contract comprehensive general liability insurance with a minimum coverage of
$1,000,000 per occurrence and $1,000,000 aggregate for personal injury; and $1,000,000 per
PA -1
R12 -093
occurrence /aggregate for property damage, and professional liability insurance in the amount
of $1,000,000 per occurrence to 2 million aggregate with defense costs in addition to limits.
Said general liability policy shall name the City of Boynton Beach as an additional named
insured and shall include a provision prohibiting cancellation of said policy except upon
thirty (30) days prior written notice to the City. Certificates of coverage as required by this
section shall be delivered to the City within fifteen (15) days of execution of this agreement.
9. INDEPENDENT CONTRACTOR. The Provider and the City agree that the Provider is an
independent contractor with respect to the services provided pursuant to this agreement.
Nothing in this agreement shall be considered to create the relationship of employer and
employee between the parties hereto. Neither Provider nor any employee of Provider shall
be entitled to any benefits accorded City employees by virtue of the services provided under
this agreement. The City shall not be responsible for withholding or otherwise deducting
federal income tax or social security or for contributing to the state industrial insurance
program, otherwise assuming the duties of an employer with respect to Provider, or any
employee of Provider.
10. COVENANT AGAINST CONTINGENT FEES. The Provider warrants that he has not
employed or retained any company or person, other than a bonafide employee working solely
for the Provider, to solicit or secure this contract, and that he has not paid or agreed to pay
any company or person, other than a bonafide employee working solely for the Provider, any
fee, commission, percentage, brokerage fee, gifts, or any other consideration contingent upon
or resulting from the award or making of this contract.
For breach or violation of this warranty, the City shall have the right to annul this contract
without liability or, in its discretion to deduct from the contract price or consideration, or
otherwise recover, the full amount of such fee, commission, percentage, brokerage fee, gift,
or contingent fee.
11. DISCRIMINATION PROHIBITED. The Provider, with regard to the work performed by it
under this agreement, will not discriminate on the grounds of race, color, national origin,
religion, creed, age, sex or the presence of any physical or sensory handicap in the selection
and retention of employees or procurement of materials or supplies.
12 ASSIGNMENT. The Provider shall not sublet or assign any of the services covered by this
Agreement without the express consent of the City.
13. NON - WAIVER. Waiver by the City of any provision of this Agreement or any time
limitation provided for in this Agreement shall not constitute a waiver of any other provision.
PA -2
R12 -093
17. INTEGRATED AGREEMENT. This agreement, together with attachments or addenda,
represents the entire and integrated agreement between the City and the Provider and
supersedes all prior negotiations, representations, or agreements written or oral. This
agreement may be amended only by written instrument signed by both City and Provider.
DATED this 5 day of�'}1?e.°Wt,� , 20 a.
CITY OF BOYNTON BEACH
AA
Interim City anager P • vider
GAT Y p"
r uo i \o‘
Attest /Authenticated: ,, - President and General Manager 1330 I Title
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City lerk
Approved as to F • rm: Attest/Authenticated:
Office of the Ci ' Attorney Secretary
Rev 1/22/91
PA -4
R12 -093
"EXHIBIT A"
SCOPE OF SERVICES
PA -5
.00 a EXHIBIT "A"
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CIGNA
CIGNA HealthCare Group Benefits Renewal
City of Boynton Beach
100 E. Boynton Beach Boulevard
Boynton Beach, FL 33425
SIC Code: 9111
Account Number: 3333691
Total Eligible Employees: 0 Participating Subscribers: 820
Employer Contributions: Employee Contributions: 0%
Dependent Contributions: 0%
Waiting Period: 30 Days
Eligibility Definition: Active Employees working 36 hrs
Note: The Quoted rates are subject to final Underwriting approval and, as noted below, are subject to
change in the event of changes in benefits selected or changes in the risk factors upon which the
Quoted Rates are based. In addition, state law may require regulatory approval of rates.If required
regulatory approval has not been obtained on the proposed effective date, the healthplan shall use rates
that are consistent with its then currently approved rating methodology and the quoted rates shall be
effective immediately on the date for which they are approved for use. The Quoted Rates are
guaranteed while the Group Service Agreement remains in effect until the next anniversary date, unless
enrollment changes by 10% in which case CIGNA HealthCare may change the Quoted Rate.
Proposal # 910117 Page 1 of 13 5/7/12
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CIGNA
Proposed Benefits
Product: Open Access Plus
Situs State: FL Effective Date: 10/01/2012
Category Description In Network Out of Network
Medical Benefits Open Access Plus Copay
Modular Medical Management Program PHS+
Office Visit Copay NA
Primary Care Copay $20
Specialty Care Copay $30
Coinsurance 80% 60%
Hospital IP Copay - Per Admit NA
Hospital IP Deductible - Per Admit NA
Hospital IP Copay Per Day NA
Hospital IP Deductible - Per Day NA
Maximum Reimbursable Charge Option 2 - 110%
Incl NSP & Bill
Negotiation
Collective Deductible/OOP Admin Option NO NO
Combined Medical /Pharmacy Deductible/OOP Admin NO NO
Option
Annual Individual Plan Deductible $100 $400
Annual Family Plan Deductible $300 $1,200
Deduct Accumulator Standard: One Standard: One Way
Way Accumulation
Accumulation
OOP - Individual Maximum Amount $2,500 $5,000
OOP - Family Maximum Amount $5,000 $10,000
OOP Max - Accumulator Standard: One Standard: One Way
Way Accumulation
Accumulation
OOP Max Ded Includes Ded Includes Ded
OOP Max Copays Includes Copays Includes Copays
Lifetime Maximum Amount Unlimited
Lifetime Maximum - Annual Reinstatement Amount NA
Outpatient Facility Copay $100
Outpatient Facility Deductible $375
Emergency Room Copay $125
Emergency Room Deductible $125
Urgent Care Copay $75
Urgent Care Deductible $75
Proposal # 910117 Page 2 of 13 5/7/12
CIGNA.
Proposed Benefits
Product: Open Access Plus
Situs State: FL Effective Date: 10/01/2012
Category Description In Network Out of Network
Medical Benefits Open Access Plus Copay
Emergency Room/Urgent Care Plan Ded Applies Admin YES YES
Option
Other Health Care Facility IP Maximum Days 60
Diagnostic Lab /Radiology (Independent/Outpatient /In Ded/Coins or Ded/Coins or OV
Office) Coverage OV applies applies
MRI, CT PET Scans Copay $50 $100
Lab/Radiology Mid -Point Coins Option Coinsurance NA NA
Home Health Care Maximum Days 60
Durable Medical Equipment Included Cvrd - Ded/Coins
Durable Medical Equipment Maximum Amount Unlimited
External Prosthetic Appliances Included Cvrd- Ded/Coms
External Prosthetic Appliances Deductible $0
External Prosthetic Appliances Maximum Amount Unlimited
Short Term Rehab and Chiro Combined Maximum Days 60
Short Term Rehab Maximum Days NA
Chiropractic Care Maximum Amount NA
Chiropractic Care Maximum Days NA
Acupuncture Maximum Days Not Covered Not Covered
Infertility Treatment Standard Coverage Not Covered Not Covered
Infertility Opt 1 - Diagnoses/Corrective procedures Excluded
Infertility Opt 1 - Diagnoses/Corrective procedure Not Covered
Infertility Opt 2 - Opt 1 plus Invitro, GIFT, ZIFT Not Covered
Infertility Opt 2 - Opt 1 plus Invitro, GIFT, ZIFT, etc. Excluded
Infertility Opt 2 - Lifetime Maximum Amount NA
Bariatric Services Excluded
Bariatric Surgery - Lifetime Maximum Amount NA
Preventive Care - Children thru Age 2 Included Not Covered
Preventive Care Opt 2 - Annual Physicals Age 3+ Included Not Covered
Preventive Care Opt 2 - Immunizations Included
Preventive Care Opt 2 - Calendar Year Benefit Maximum Unlimited
Amount
Preventive Care at 100%, No Ded YES No
Organ Transplant Included Cvrd - Ded/Coins
Routine Foot Care Buy -up Included Cvrd - Ded/Coins
Routine Foot Care Separate Buy -up Coinsurance NA
Proposal # 910117 Page 3 of 13 5/7/12
Or
CIGA.
Proposed Benefits
Product: Open Access Plus
Situs State: FL Effective Date: 10/01/2012
Category Description In Network Out of Network
Medical Benefits Open Access Plus Copay
Routine Foot Care - Cal Yr Buy -up Benefit Maximum $1,000 NA
Amount
Non - Surgical TMJ Included Included
Elective Abortion Covered Covered
PCL Included Included
PAC /CSR - Standard IP Admit/Case Management UR Included
Program
PAC /CSR IP Non Compliance Penalty Amount $0
PAC /CSR IP Non Compliance Penalty Percent 50%
Medicare COB: Retirees >=65 Admin Option NA
Medicare COB Type None
Percent of Medicare Eligible NA
Integrated Personal Health Team A (iPHT A) Clinical Excluded
Program
Your Health First Clinical Program 200
Health Advisor Clinical Program Health Advisor
(Core &
Behavioral
Coaching)
Well Aware Program (Diabetes) Excluded
Well Aware Program (Cardiac) Excluded
Well Aware Program (Asthma) Excluded
Well Aware Program (Low Back Pain) Excluded
Well Aware Program (COPD) Excluded
Well Aware Program (Weight Complications) Excluded
Well Aware Program (Targeted Conditions) Excluded
Well Aware Program (Depression Management) Excluded
Incentive Points Program Excluded
24H1L Included
Healthy Rewards Included
LifeSource Organ Transplant Network Transplant Included
Program
Language Line Included
Transition of Care Included
Case Management Included
Provider Channeling Included
Away From Home Care Included
Proposal # 910117 Page 4 of 13 5/7/12
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r CIGNA.
CIG
Proposed Benefits
Product: Open Access Plus
Situs State: FL Effective Date: 10/01/2012
Category Description In Network Out of Network
Medical Benefits Open Access Plus Copay
Drugstore.Com Included
Pharmacy Benefits CIGNA PharmacyPlus 3 -Tier Copay
Plan Buy Up Option Coinsurance NA
Retail - Generic Copay $10
Retail - Brand Copay $25
Retail - Non Preferred Copay $50
Mail Order - Generic Copay $20
Mail Order - Brand Copay $50
Mail Order Copay - Non - preferred $100
Retail - Individual Buy Up Option Deductible NA
Retail - Family Buy Up Option Deductible NA
Retail - Individual Deductible NA
Retail - Family Deductible NA
OOP - Individual Maximum NA NA
OOP - Family Maximum NA NA
Standard Preventive Drugs Excluded from Deductible NO
Generic Drugs Excluded from Deductible NO
Ded & OOP Max Apply to MOD Do Not Apply to
MOD
MOD Program No Mandatory
Maintenance Drug List NA
Oral Contraceptives/Devices Covered
Lifestyle Drugs Not Covered
Oral Fertility Drugs Not Covered
Self- Administered Injectables Covered
Optional Injectables Buy -Up Not Covered
Insulin Covered
Insulin Needles & Syringes Covered
Glucose Test Strips Covered
Lancets Covered
Prenatal Vitamins Covered
Step Therapy Program Included
Clinical Management Program Enhanced
Enh. - Benefit Exclusion Selected
Enh. - Intensive Appropriateness of Use Selected
Proposal # 910117 Page 5 of 13 5/7/12
4 .
CIGNA
Proposed Benefits
Product: Open Access Plus
Situs State: FL Effective Date: 10/01/2012
Category Description In Network Out of Network
Pharmacy Benefits CIGNA PharmacyPlus 3 -Tier Copay
Enh. - Utilization and Unit Cost Management Selected
Generic Push Included
Formulary Incentive
Prescriber Panel Open
MB/SA Benefits OA Plus MHSA Separate
CIGNA Behavioral Health In & Outpatient
Mgmt. CAP
MH Hospital IP Coinsurance 80% 60%
MH Hospital IP - Per Admit Copay NA NA
MH Hospital IP - Per Day Copay NA NA
MH Hospital IP Maximum Days 0
SA Hospital IP Coinsurance 80% 60%
SA Hospital IP - Per Admit Copay NA NA
SA Hospital IP - Per Day Copay NA NA
SA Hospital IP Maximum Days NA
MH Outpatient Office Visits Copay $30
MH Outpatient Office Visits Coinsurance NA 60%
MH Outpatient Facility Copay NA
MH Outpatient Facility Coinsurance NA NA
MH Outpatient Facility Plan Ded. Applied Admin Option NA NA
MII OP & Group Therapy Combined Maximum Visits 0
MH Intensive Outpatient Copay $30 $30
MH Intensive Outpatient Coinsurance 50% 50%
SA Outpatient Office Visits Copay $30
SA Outpatient Office Visits Coinsurance NA 60%
SA Outpatient Facility Copay NA
SA Outpatient Facility Coinsurance NA NA
SA Outpatient Facility Plan Ded. Applied Admin Option NA NA
SA Outpatient Maximum Visits NA
SA Intensive Outpatient Copay $30 $30
SA Intensive Outpatient Coinsurance 50% 50%
MH Grp Therapy Copay $30
MH Grp Therapy Coinsurance NA 60%
Proposal # 910117 Page 6 of 13 5/7/12
' .
1.
CIGNA,.
Proposed Benefits
Product: Open Access Plus
Situs State: FL Effective Date: 10/01/2012
Category Description In Network Out of Network
MH/SA Benefits OA Plus MHSA Separate
MH OP Tiered Copay Option Excluded
MH OP Tier 1 Copay NA
MH OP Tier 1 Visits (1 to _) Maximum NA
MH OP Tier 2 Copay NA
MH OP Tier 2 Visits (Tier 1 max to ) Maximum NA
MH OP Tier 3 Copay NA
MH OP Tier 3 Visits (Tier 2 max to _) Maximum NA
SA OP Tiered Copay Option Excluded
SA OP Tier 1 Copay NA
SA OP Tier 1 Visits (I to _) Maximum NA
SA OP Tier 2 Copay NA
SA OP Tier 2 Visits (Tier 1 max to _ ) Maximum NA
SA OP Tier 3 Copay NA
SA OP Tier 3 Visits (Tier 2 max to _ ) Maximum NA
Standard IP Review /Case Mgmt UR Program Included
OP Review /Case Mgmt Buy Up 1 UR Program Excluded
OP Review /Case Mgmt Buy Up 2 UR Program Excluded
Transition of Care (90 day period) Included
Vision Benefits None
Benefit Exceptions:
CCN Benefits:
CCN Specialist Copay: 530
Non -CCN Specialist Copay: $35
Proposal # 910117 Page 7 of 13 5/7/12
44 dr
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• 04
CIGNA
Group Description: AL350C (CITY OF BOYNTON BEACH RETIREES 65 +) CO300A (CITY OF B. B.
(FIREFIGHTERS) RETIREES -65) FL305A (CITY OF BOYNTON BEACH RETIREES -65)
FL305B (CITY OF BOYNTON BEACH RETIREES -65) FL305C (CITY OF BOYNTON
BEACH RETIREES -65) FL305E (CITY OF B. B. (
Inforce Current Renewal Monthly Billed
Tier Subscribers Members Rate Rate Amount Change
EMP 607 $575.15 $660.85 $401,134.34 14.90 %
EMP+ SPOUSE 53 $1,115.80 $1,282.05 $67,948.87 14.90 %
EMP+CHILD(REN) 45 $1,035.28 $1,189.54 $53,529.15 14.90 %
EMP+ FAMILY 115 $1,282.59 $1,473 70 $169,475.03 14.90 %
Total 820 1331 5692,08739
Included in the proposed Monthly Billed Amount is the Benefit Advisor Fee which is not part of the monthly premium.
Proposal # 910117 Page 8 of 13 5/7/12
4
CIS
Underwriting Contingencies
For
City of Boynton Beach
A. General Terms of this Proposal
CIGNA HealthCare is pleased to present this Proposal for a Fully Insured Non - Participating group medical
and pharmacy benefit plan (the "Plan ") sponsored by City of Boynton Beach.This proposal is valid for 60
days from its original date of release, 05/07/2012. Any revisions or updates to this proposal will not renew
this valid timeframe unless expressly communicated by CIGNA HealthCare.
Proposal Caveats
CIGNA HealthCare may revise or withdraw this Proposal if:
1 there is a change to the effective date of the quote.
2 the policy period length is different than 12 months.
3 the policy will not be sitused in FL.
4 the Plan benefits are different than shown in the RFP or benefit modifications are requested.
5 there is a change in any law, regulation, or required assessment or tax that changes CIGNA HealthCare's costs in
offenng the plan.
6 enrollment increases or decreases by 10% or more, by product or for the total account, from the enrollment
assumptions used in establishing the rates and/or fees set forth herein.
7 participation is below 70 %. This will be based on the total eligible employees, identified as 0.
8 it is not the exclusive provider of Medical (/ Pharmacy / Vision) or like products for all of City of Boynton
Beach's employees in all worksites
9 the employer contributes less than 70% toward the total cost of the plan.
10 the employer changes its level of contribution toward the cost of the coverage.
11 either one or more of the quoted sites withdraws prior to the effective date or terminates during the contract term,
or at any time following enrollment.
12 the current waiting period is different than 30 Days.
13 the final enrollment deviates from the quoted enrollment such that t results in a needed change in premium
rates. Rates are based on final enrollment factors, including total number of enrollees, their age, sex,
demographics, location and the distribution of enrollees by product or membership tier.
14 any of the information upon which these rates or benefits were based (including Medical History Information)
changes or is inaccurate.
15 Federal, State or Local action impacting the benefit levels quoted herein or affecting our ability to meet our
obligations to you, to your employees/our members or to our contracted providers. By way of illustration, such
legislation or executive actions which impose controls or requirements that affect: our ability to determine rates;
covered medical expenses or service benefits; providers delivery of care or the fees they charge; or our contracts
with providers, may be deemed to so affect our contractual obligations. Should this happen, CIGNA HealthCare
will work to reach a new agreement that equitably reflects the circumstances as altered by government action.
16 there is any reimbursement arrangement ( "gap" cards, etc.) that subsidizes or reduces the out -of- pocket
obligation of covered persons under the policy.
Proposal # 910117 Page 9 of 13 5/7/12
CIGNA
Underwriting Contingencies
For
City of Boynton Beach
B. Scope and Application of this Proposal
Unless otherwise indicated, this Proposal:
1 supersedes and renders null and void any prior CIGNA HealthCare offer or proposal with respect to the Plan.
2 or policy may be canceled as of any Premium Due Date if the number of insured Employees fails to meet the
minimum required per group participation rules; or for failure to comply with any other material plan provision
relating to Employer contributions or group participation rules.
3 requires a separate benefit option due to state regulations, if you have purchased OAP/PPO with CIGNA HealthCare
Behavioral Advantage and you have members residing in NC or CA.
4 does not apply to part-time or seasonal employees for any plan.
5 includes the Network Savings Program (NSP) and other Cost Containment programs designed to contain costs with
respect to charges for health care services/supplies that are covered by the Plan. For administering these programs,
CIGNA Health Care retains a portion of the savings or recoveries generated.
6 includes a maximum reimbursable charge for out -of- network coverage equal to 110% of a fee schedule developed
by CIGNA HealthCare based upon a methodology similar to that used by Medicare to determine the allowable fee
for similar services in the geographic market OR 80th percentile of charges made by providers of such service or
supply in the geographic area where the service is received.
7 assumes all employees are located in the network area, and that all employees are only eligible for the CIGNA
HealthCare or any other affiliated company product offerings specified.
8 requires you notify us within 30 days if any information set forth in this form changes at any time while coverage is
provided to you by CIGNA HealthCare.
9 may require regulatory approval of rates. If, as of their proposed effective date, regulatory approval is not obtained,
the healthplan shall use rates consistent with its then currently approved rates and the foregoing rates shall be
effective automatically. If a product is new and has never had approved rates, the effective date of coverage will be
postponed until regulatory approval is received.
10 allows caveats and conditions set forth in this document to survive execution of any final contract and/or issuance
by CIGNA HealthCare of any policy and/or Group Service Agreement.
11 Medicare eligible retirees are not included in this plan unless mandated by situs state legislation.
12 excludes charges for converting a qualified member of a group plan to an individual plan.
13 is a high -level summary of the proposed coverage. It does not identify all the categones of health care expenses that
are covered or excluded.
14 may include state required continuation rates which will match the rates for the underlying plan. For Nebraska and
New York Over Age Dependents the rates will match the employee rate for the underlying plan.
15 assumes that the group health plan or health insurance coverage to which this proposal applies will not be a
"grandfathered health plan" under the Patient Protection and Affordable Care Act (the "Act ") and that it will be
subject to all requirements of the Act applicable to a group health plan or health insurance coverage unless
otherwise specified in writing.
16 assumes applicable requirements of the Patient Protection and Affordable Care Act will be implemented on the
effective date/renewal date unless you direct otherwise.
Proposal # 910117 Page 10 of 13 5/7/12
s
CIGNA
Underwriting Contingencies
For
City of Boynton Beach
B. Scope and Application of this Proposal
Unless otherwise indicated, this Proposal:
17 assumes a non -CIGNA Health Care Pharmacy Benefit Manager administers oral or other self - administered
anti -cancer prescription medication claims at a copayment/coinsurance level that is no less favorable than that for
intravenous or injected anti -cancer medication prescribed for the same purpose and covered under employer's
CIGNA HealthCare plan. This assumption is applicable only if:
(a) employer has contracted with a PBM (not CIGNA HealthCare);
(b) employer's plan is either insured, or, if self - funded, not subject to ERISA (i.e., is a church, government or
association plan); and
(c) employer's CIGNA HealthCare plan is sitused in IA, HI, NM, OR or a state with similar chemotherapy coverage
law, or covers one or more individuals residing in CO, VT or WA or in a state with similar extraterritorial
chemotherapy coverage mandate.
18 includes capitated charges for behavioral care services arranged by CIGNA Behavioral Health, Inc. However, this
may not apply in certain states.
19 includes capitated charges for the provision of Hi -Tech Radiology services by MedSolutions, Inc. However, this
may not apply in certain states.
20 In order to implement the requested benefit design, different funding arrangements (i.e., insured, self- insured and/or
HMO) involving affiliated CIGNA HealthCare companies may be required with respect to plan participants residing
in certain states.
21 For clinical /wellness/behavioral programs offered by CIGNA HealthCare that are purchased, CIGNA HealthCare
will establish a Wellness/Health Improvement Fund in the amount of $40,000. These funds will be used to defray
the cost of CIGNA HealthCare designated and arranged health and wellness improvement programs for employees
(e.g., biometric screenings, flu shots, etc.) and to reward participation in these programs. Wellness/Health
Improvement Funds are a one time credit to be used from 10/01/2012 - 09/30/2013 Unused funds cannot be rolled
over and CIGNA HealthCare must pre - approve use of the Wellness/Health Improvement Fund.
22 Important Notice Regarding Benefit Advisor Compensation - The premium for this guaranteed cost (i.e.,
non - Shared Returns) policy may not include compensation payable to your benefit advisor. Check with your Cigna
Sales representative to confirm whether this is the case. When that is the case, the proposed billed amount includes
both premium and benefit advisor fees, which are not part of the monthly premium and Cigna will include any
benefit advisor fees agreed to by the client and benefit advisor on client invoices and forward payments received to
the benefit advisor if both the client and the benefit advisor authorize Cigna to do so by signing Cigna's Client and
Benefit Advisor Acknowledgement Form. When required, this form must be signed before the date when the new
rates take effect. If the form is not signed, the benefit advisor will be responsible for billing the client directly for
any benefit advisor fees.
Proposal # 910117 Page 11 of 13 5/7/12
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CIGNA
Statement of Understanding Regarding "Underlying Plans"
In establishing its premium rates/charges for all benefit plans insured and/or administered for you by CIGNA
Health Care companies ( "CIGNA HealthCare"), CIGNA HealthCare assumes that there are no "Underlying Plans."
Underlying Plans means:
• plans or arrangements that pay for or subsidize any portion of the cost - sharing responsibilities for people
covered by the plans) including, but not limited to, co- payments, deductibles and/or member coinsurance
balances
• a Health Savings Account (HSA)
• a Health Reimbursement Account (HRA)
CIGNA Health Care also assumes that Underlying Plans will not be put in place in the future.
The existence of Underlying Plans has a material impact on CIGNA HealthCare's premiums/charges and if not
previously disclosed to CIGNA HealthCare in connection with its underwriting constitutes a material modification of
the plan's benefits entitling CIGNA HealthCare to increase its premiums/charges to reflect the impact of the
Underlying Plans. To ensure that CIGNA HealthCare has all the material information that it needs to appropriately
determine its premiums/charges, please complete and execute the following certification.
Employer Certification
0 +T• 0 F BO'f.ITO N 6Cgc Fi• (Employer /Group), by its duly authorized representative, hereby
represents, certifies and agrees that in connection with the plan(s) insured and/or administered by CIGNA HealthCare:
1. V an Underlying Plan is not offered;
OR
_ an Underlying Plan is offered and attached is a complete description of the Underlying Plan. With respect to
a HSA or HRA that is offered, include in the description:
• the level of employer funding to the HSA and/or HRA;
• the order of reimbursement, and
• the provisions regarding annual rollover
2. it will notify CIGNA HealthCare prior to implementing any Underlying Plan not identified above in response to
No. 1;
3. the foregoing representations and the information provided above are true and complete and provided with the
understanding that they are material to CIGNA HealthCare's determination of its premium rates/charges both
currently and in the future, and
4. CIGNA HealthCare may rely upon the foregoing representations and information in establishing its
premiums /charges both now and in the future.
Proposal # 910117 Page 12 of 13 5/7/12
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CIGNA
Underwriting Contingencies
For
City of Boynton Beach
CIGNA Health Care reserves the right to change the Quoted Rates and/or Quoted Benefits or to decline to offer coverage
if any of the foregoing information is inaccurate or changes prior to the proposed Effective Date indicated above, or if
the quoted rates and/or fees are not agreed to within 60 days of receipt of this summary information form. If any of the
information identified above changes either prior to the proposed Effective Date or while coverage is in effect, you agree
to notify us promptly of such change.
The "Underwriting Contingencies" set forth above shall survive execution of any insurance policy, application, etc.,
issued by CIGNA HealthCare or any other affiliated company, and shall further survive the effective date of any such
policies.
The benefits displayed in this summary are, for the most part, modular benefit packages used to develop the
rates. Please review the Benefit Summary and its attachments for information about the benefits available in your
sites.
"CIGNA HealthCare" refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided
by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance
Company, CIGNA Health and Life Insurance Company, and HMO or service company subsidiaries of CIGNA Health
Corporation and CIGNA Dental Health, Inc.
I UNDERSTAND AND AGREE ON BEHALF OF CONTRACTHOLDER THAT CIGNA HEALTHCARE MAY,
NOTWITHSTANDING THE TERMS OF THE INSURANCE POLICY OR SERVICE AGREEMENT, REVISE ANY
PREMIUM RATES OR PREPAYMENTS FEES AT ANY TIME IF THE ENROLLMENT OR EMPLOYER
CONTRIBUTION LEVEL IS DIFFERENT THAN ASSUMED BY CIGNA HEALTHCARE IN UNDERWRITING
THE CONTRACT OR IF CIGNA HEALTHCARE IS (i) REQUIRED TO PAY ANY ASSESSMENT, OR (ii) INCUR
ADDITIONAL COSTS IN ADMINISTERING THE CONTRACT AS A RESULT OF THE PATIENT PROTECTION
AND AFFORDABLE CARE ACT AND THE REGULATIONS PROMULGATED THEREUNDER.
9 2' t7. Q 14 5 .„ t .2 ) ao t a
Client Signature Date
LJ {,l Q t c (,i.f :Pi re c fb r /4144,10.,7 Resources
ack
Client Mime Title
Proposal # 910117 Page 13 of 13 5/7/12