HomeMy WebLinkAbout12. 20-401 SEPTEMBER 22, 2020 20-401 RESOLUTION
(CARRIED 7-0 LOST LAID OVER WITHDRAWN )
PURPOSE: RENEW EMPLOYEE HEALTH INSURANCE AGREEMENT WITH
ROBIN HEALTH PARTNERS
INITIATED BY: ADMINISTRATIVE SERVICES
WHEREAS, the City of Oshkosh requested proposals for Employee Health
Insurance for 2021; and
WHEREAS, the proposal submitted by Robin Health Partners meets the
requirements of the request for proposals, will result in the City of Oshkosh incurring a
seven (7%) increase in costs over the current City plan, and will provide minimal
disruption to employee-provider relationships; and
NOW, THEREFORE, BE IT RESOLVED by the Common Council of the City of
Oshkosh that the proper City officials are hereby authorized to enter into and take those
steps necessary to implement an appropriate agreement with Robin Health Partners for
participation in the Robin Health Partners health benefit plan with costs and coverage as
generally outlined in the attachment to this resolution.
BE IT FURTHER RESOLVED that money for this purpose is hereby appropriated
from:
Acct. No. XXX-XXXX-6306-XXXXX Health Insurance
Oshkosh
TO: Honorable Mayor and Members of the Common Council
FROM: John Fitzpatrick, Assistant City Manager/Director of Administrative Services
DATE: September 22, 2020
RE: Employee Health Insurance Agreement
BACKGROUND
As Council is aware, through your direction and as a matter of good practice, the City
regularly reviews our contract agreements and benefit structures in order to provide the
best benefits possible for our staff at the most cost effective level possible for our
taxpayers. With these thoughts in mind, and in consideration of the expiration of our
agreement with Robin Health Partners at the end of 2020, city staff and USI Insurance
Services (formerly known as Associated Benefits Risk and Consulting) have been taking
the appropriate steps to establish a relationship with a provider for health benefits for
2021.
ANALYSIS
After evaluating current medical plan costs, the decision was made to conduct a
comprehensive request for proposals (RFP). Although there was one proposal which
allowed for cost savings in 2021, such a change would entail substantial coverage and
provider changes associated with that option. Changing individual health providers at
this time would prove to be disruptive to employees and the city, particularly during the
COVID pandemic. As a result, city staff and USI Insurance services' consultants concluded
the best option was to remain with Robin Health Partners as illustrated by the RFP and
corresponding analysis. This renewal will result in a seven (7.0%) increase as we discussed
with Council at Budget Workshop #2, but will also provide minimal disruption to our
employees when considering the providers they currently have established relationships
with. The Robin agreement/application is for 2021 only.
FISCAL IMPACT
Staff is estimating an overall seven percent (7.0%) increase for the health program in 2021.
Although the city employee focus group on health insurance, staff and City Manager
Rohloff are satisfied with the outcome of this year's process, all parties understand that
it will be necessary to evaluate our plan for 2022 due to the one year agreement in order
to consider what changes may be necessary in order to preserve the best benefits possible
for our staff at the most cost effective level possible for our taxpayers moving forward.
RECOMMENDATION
Based on the analysis conducted, staff recommends approval of the renewal with the
aforementioned employee health insurance agreement with Robin Health Partners.
Please let me know if you have any questions regarding this matter and thank you as
always for your assistance and support.
Respectfully Submitted, Approved:
Jo n M. Fitzpatric Mark A. Rohloff
Assistant City Manager / City Manager
Director of Administrative Services
Attachments: Health Insurance RFP Summary
Health Partners Master Group Policy
cc: Michelle Behnke, HR Manager
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HEALTHPARTNERS INSURANCE COMPANY
an affiliated company of HealthPartners, Inc.
(called the "Company")
has issued this
MASTER GROUP POLICY
(called the "Policy")
for
MAJOR MEDICAL EXPENSE INSURANCE
Policy Number: 36478
Policyholder: City of Oshkosh, dba City of Oshkosh, W1 (called the "Organization"),
contracts with the Company, for the provision of the Benefits described in the Group Certificate(s), to its eligible
persons (called "Employees") and their eligible dependents (called "Dependents") who enroll hereunder in accordance
with the terms and conditions of this Policy. Consideration for coverage under this Policy are the approved
applications of the Organization and the Employees and timely payment of premiums. Payment of premiums in
accordance with the "Premiums" section constitutes the Organization's acceptance of the terms and conditions of this
Policy.
This Policy is delivered in the state of Wisconsin and governed by its laws.
Policy Effective Date: .January 1, 2020
Policy Anniversary Date: January 1, 2021 (called "Anniversary Date") and annually thereafter.
Policy Renewal Dates: the Anniversary Date, following this Policy Effective Date, and annually renewable thereafter
(called "Renewal Date"), subject to the terms and conditions of this Policy.
NOTE: We are not required to offer guaranteed issue or renew coverage under this Master Group Policy if the
Organization has any outstanding premium payments due for any prior coverage offered by HealthPartners or a
related company for the twelve-month period preceding the effective date or renewal date of this Master Group
Policy or any new Master Group Policy.
Signed for the Company on the date of issue.
Brian O'Shields, President
ot°�ur�f-
Nancy L. Evert, Secretary
HealthPartners Insurance Company
8170 33rd Avenue South
Minneapolis, MN 55440-1309
Prepared by: MMK January 30, 2020
GP-900.13 LE WI
(LE ONE) 36478-MAS-CON-1-2020
TABLE OF CONTENTS
Section Page
1. Benefits...............................................................................................................................................................I
2. Term................................................................................................................................................................... I
3. Premiums............................................................................................................................................................ I
4. Grace Period and Termination............................................................................................................................2
5. Participation and Contribution Requirements..................................................................................................... 3
6. Eligibility and Effective Date of Employees...................................................................................................... 3
7. Eligibility and Effective Date of an Employee's Dependents............................................................................ 5
8. Open Enrollment................................................................................................................................................. 6
9. Changes in Benefits............................................................................................................................................ 6
10. Termination of Individual Benefits..................................................................................................................... 6
11. Termination of this Policy.................................................................................................................................. 7
12. Continuation Rights............................................................................................................................................ 7
13. Replacement....................................................................................................................................................... 7
14. Standard Provisions............................................................................................................................................ 8
15. Sole Carrier.........................................................................................................................................................9
16. Rights Shall Not Vest......................................................................................................................................... 9
17. Request for PDF File.......................................................................................................................................... 9
18. Protected Health Information...........................................................................................................................10
GP-900.13 LE WI
(LE ONE) 36478-MAS-CON-1-2020
1. Benefits: The Company provides and underwrites coverage of benefits described in the Group Certificate(s).
The benefits are set forth in the Group Certificate(s), Benefits Chart(s), and any Amendments attached thereto,
or subsequent Group Certificate(s), Benefits Chart(s), and any Amendments issued periodically. The Group
Certificate(s), Benefits Chart(s) and any Amendments issued by the Company are hereby incorporated and made
fully a part of this Policy.
2. Term: Benefits and premiums shall become effective on this Policy's Effective Date. They will continue until
the Organization's next Anniversary Date and shall be renewed thereafter on each Renewal Date of the
Organization. A sixty (60) day advance written notice shall be given by the Company or the Organization to
change said benefits and/or premiums. The Company reserves the right to terminate benefits, as provided in
sections 4. and 11.
3. Premiums: The amount of each premium due, at the time such premium falls due, is the aggregate of the
amounts applicable to each enrolled Employee and Dependent of the Organization. The amount so payable is
determined according to the notice of rates sent to the Organization prior to the issuance of this Policy. The
amount so payable is determined according to the benefits for which each Employee and Dependent is enrolled.
Such premiums are due and payable to the Company by the Organization, or its authorized representative, on or
before the first day of the month (called "premium due date"), for each month benefits are in force (called
"premium period"), for all persons enrolled, at the time such premium falls due. Interest of 1.5% per month
(18% per annum), compounded daily, will be charged on any unpaid balances, beginning at the end of your
grace period, retroactive to the premium due date, regardless of termination of this Policy.
The Company reserves the right to change the premiums on any premium due date on or after the first
Anniversary Date. The Company shall give the Organization at least sixty (60) days' advance written notice of
any such change. The Organization shall notify each Employee of such change, as necessary.
The Company may change premium due, if the total number of eligible Employees changes by more than 10%.
The Company shall give the Organization at least (60) days' advance written notice of any such change.
In addition, the Company may change premium due if the Organization adds or deletes a plan or carrier. Any
resulting change in premium will be effective on the date that the plan or carrier was added or deleted.
The Organization's collection of an Employee's premium contribution is solely for the convenience of the
Organization and does not create an agency relationship between the Organization and the Company.
The Organization shall give the Company written notice, should the Organization change existing benefits which
it provides to any or all of its Employees, no less than thirty-one (31) days before the effective date of such
change. Upon receipt of such notice, the Company reserves the right to modify the above premiums, thirty-one
(31) days after the date of said receipt.
The Company will not extend retroactive coverage to Employees or Dependents due to clerical errors by the
Organization, for a time period greater than ninety (90) days. In compliance with state or federal law, the
Company will extend retroactive enrollment to Employees or Dependents who are eligible for continuation
coverage to 115 days after the date coverage under this Policy terminated due to a qualifying event and to 160
days if coverage was terminated because of the death of the Employee.
GP-900.13 LE W1
(LE ONE) 1 36478-MAS-CON-1-2020
The Company will only allow retroactive termination of Employees or Dependents due to clerical errors by the
Organization if the Employee or Dependent has not paid premium or contribution to the Organization, but in no
event for a time period greater than ninety (90) days. It is the responsibility of the Organization to ensure that
only those retroactive enrollment changes allowed under this paragraph will be sent to the Company. The
Organization is responsible for making payments for any Employee or Dependent coverage that cannot be
retroactively terminated under applicable law until the date that termination is permitted.
Benefits for a newly enrolled Employee or Dependent (or additional or increased benefits for an already enrolled
Employee or Dependent), who is hired or otherwise becomes eligible for benefits hereunder on or before the
fifteenth day of any month, shall be provided on the basis of premium for the full month; benefits for a newly
enrolled Employee or Dependent (or additional or increased benefits for an already enrolled Employee or
Dependent) who becomes eligible for benefits hereunder after the fifteenth day of any month, shall be provided
for the balance of such month without additional premium, unless the new enrollment is: 1) due to the addition
of a new class of Employees, or 2) substantially all Employees in an existing class. Under these circumstances,
the premium will be pro -rated to reflect the addition of those Employees.
4. Grace Period and Termination: A grace period of thirty-one (31) days after the premium due date shall be
granted for any premium due after the initial premium payment, provided the Organization has not previously
given written notice to the Company that the benefits for all enrolled Employees and Dependents are to be
terminated as of the end of the grace period. If the Organization fails to make premium payment within the
grace period, benefits for all enrolled Employees and Dependents shall be terminated, subject to written notice
of termination by the Company to the Organization. The Company shall provide the Organization a notice form
in sufficient number to be distributed to Employees and Dependents indicating the termination date and any
rights that are available to them upon termination. The termination shall be processed at the end of such grace
period. The Organization shall be liable to the Company for all premiums due and unpaid, including premiums
for the grace period. If, however, written notice is given by the Organization to the Company during the grace
period that the benefits for all enrolled Employees and Dependents are to be terminated before the expiration of
the grace period, such benefits shall be terminated as of the date specified by the Organization or the date of
receipt of such written notice by the Company, whichever is later, and the Organization shall be liable to the
Company for pro-rata premium payment for the period commencing with the last premium due date and ending
with the date of such termination. The acceptance by the Company of any late payments by the Organization
shall not be construed as a waiver of any provisions in this section.
Termination of benefits shall not prejudice any claim incurred prior to the date of such termination.
GP-900.13 LE W1
(LE ONE) 2 36478-MAS-CON-1-2020
5. Participation and Contribution Requirements: The Organization shall contribute at least 50% of each
Employees' payments.
In addition, the following provisions apply:
A. At least 50% of all eligible Employees must participate under this Policy, regardless of waivers. If this
minimum participation requirement is not met, the Company may add a risk adjustment to rates.
AMD-2020 Group Policy Chg
B. Employees who waive coverage may receive no more than 50% of the pre-tax single premium in cash or
cash equivalent in lieu of medical coverage. Employees who exercise this option must have other group
medical coverage.
The Company will periodically review the Organization's participation and contribution levels to determine if
the specified participation requirement and contribution levels were met during the preceding calendar year. The
Organization agrees to cooperate with the Company to provide all necessary information relating to participation
and contribution levels in accordance with section 14.(e) hereof. In the event the Organization does not meet
the participation requirement and contribution levels for any reason, the Company will notify the Organization
in writing. The Organization shall then have thirty-one (31) days from the date of notice in which to fulfill the
participation requirement. If the participation requirement is not fulfilled within such time period, this Policy
will be terminated in accordance with section 11. hereof.
6. Eligibility and Effective Date of Employees: The Organization's Employees in the following categories are
eligible for benefits:
All Employees who work on a permanent basis and have a normal work week of 24 or more hours. The term
includes sole proprietor, a business owner, including the owner of a farm business, a partner of a partnership and
a member of a limited liability company if the sole proprietor, business owner, partner or member is included as
an employee under a health benefit plan of an employer, but the term does not include an employee who works
on a temporary or substitute basis.
Employees of the Organization who belong to the following classification(s):
(a) All permanent full-time Employees who work at least 1200 hours per year, or 975 hours per year for
grandfathered Employees hired before 7/1/2011.
(b) Retirees, Early Retirees, and Retiree Spouses until they reach Medicare eligibility.
Employees in those categories shall become eligible on: the first ofthe month following 30 days ofemployment;
Employees hired between the 1st and the 5th ofthe month will be eligible the first ofthe following month; rehired
employees with a break in service of13 weeks or less will be eligible the date ofrehire (called "Eligibility Date")
subject to section 3.
An "Employee" is the person who enrolls with the Organization for coverage under this Group Policy.
GP-900.13 LE W1
(LE ONE) 3 36478-MAS-CON-1-2020
If the Employee enrolls with the Organization within the thirty (30) day period after the Eligibility Date, benefits
shall become effective on the Eligibility Date.
An Employee eligible, but not covered on the Eligibility Date, may also apply for Employee and Dependent
benefits on a date later than the Eligibility Date, if one of the following life events occur, provided the event
causes discontinuation of another employer's or other group contractholder's contribution toward the cost, or
termination of, another group contract actually covering the Employee for medical benefits.
Life events are limited to an Employee's (1) divorce; (2) spouse's layoff from, or loss of, employment; (3)
spouse's death; (4) voluntary or involuntary loss of other medical coverage.
The Employee must enroll with the Organization for Employee or Dependent benefits within thirty (30) days
after the date the life event occurs. The effective date of benefits shall be the application date.
No other application made more than thirty (30) days after the Eligibility Date shall be accepted, unless made
during an annual open enrollment period, as described in the section titled "Effective Date and Eligibility" of
the Group Certificate.
The Organization must submit any enrollment information to the Company as soon as possible following receipt
of the information. In any case, the Company will not extend retroactive coverage to Employees or Dependents
due to clerical errors by the Organization, for a time period greater than ninety (90) days. In compliance with
state or federal law, the Company will extend retroactive enrollment to Employees or Dependents who are
eligible for continuation coverage to 115 days after the date coverage under this Policy terminated due to a
qualifying event and to 160 days if coverage was terminated because of the death of the Employee.
The Company will only allow retroactive termination of Employees or Dependents due to clerical errors by the
Organization if the Employee or Dependent has not paid premium or contribution to the Organization, but in no
event for a time period greater than ninety (90) days. It is the responsibility of the Organization to ensure that
only those retroactive enrollment changes allowed under this paragraph will be sent to the Company. The
Organization is responsible for making payments for any Employee or Dependent coverage that cannot be
retroactively terminated under applicable law until the date that termination is permitted.
If an enrolled Employee is not actively -at -work on the date on which benefits would otherwise become effective,
benefits shall not become effective until the date of return to active work. The effective date of coverage shall
not be delayed if the Employee is not actively at work on the effective date of coverage due to the Employee's
health status, medical condition, or disability. "Actively -at -world' means that an Employee is performing in his
customary manner all the regular duties of his occupation on a full-time basis, according to the definition of
Employee in the first paragraph of this section, at the customary place of employment or business, or at some
location to which that employment requires travel. An Employee will be considered actively -at -work for the
time period absent from work solely by reason of vacation or holiday, if the Employee was actively -at -work on
the last preceding regular work day.
GP-900.13 LE W1
(LE ONE) 4 36478-MAS-CON-1-2020
7. Eligibility and Effective Date of an Employee's Dependents: An enrolled Employee with Dependents may
enroll a Dependent who is eligible according to the definition of "Eligible Dependents" in the Group Certificate
and the provisions of this section, provided the Employee enrolls the Dependent with the Organization within
thirty (30) days of the date the Dependent is eligible for benefits hereunder, and the required premium payment
for that Dependent is made. Benefits for the Dependent shall become effective on the eligibility date.
In addition, the following provisions apply when an Employee seeks Dependent benefits:
(a) A Dependent can be added during an open enrollment period. The effective date of benefits shall be the
Anniversary Date.
(b) A Dependent can be added during a special enrollment period, as described in the section of the Group
Certificate titled, "Effective Date and Eligibility".
(c) A Dependent can be added when he or she is first eligible if the Company receives written notification
within thirty (30) days from the date of eligibility of that Dependent (within sixty (60) days from the date
of eligibility for newborn infants and the date of adoption or placement for adoption for newly adopted
children). The effective date of benefits shall be the date of eligibility for that Dependent. Newborn
infants, including a newborn child of a covered child and a newly adopted child, may be covered if notice
is received by the Company within one year following the date of birth. However, premium payments are
required from the date of eligibility, before benefits will be paid. Premium payments which are past due
may be subject to interest.
(d) A Dependent can be added at the time of a life event if the Company receives written application reasonably
acceptable to the Company within thirty (30) days from the date of the life event. The effective date for
benefits shall be the date of application.
(e) A Disabled Dependent can be added at any time. The effective date of benefits shall be the date the
Company receives and accepts written application and the appropriate premium payment.
The Organization must submit any enrollment information to the Company as soon as possible following receipt
of the information. In any case, the Company will not extend retroactive coverage to Dependents due to clerical
errors by the Organization, for a time period greater than ninety (90) days. In compliance with state or federal
law, the Company will extend retroactive enrollment to Employees or Dependents who are eligible for
continuation coverage to 115 days after the date coverage under this Policy terminated due to a qualifying event
and to 160 days if coverage was terminated because of the death of the Employee.
The Company will only allow retroactive termination of Employees or Dependents due to clerical errors by the
Organization if the Employee or Dependent has not paid premium or contribution to the Organization, but in no
event for a time period greater than ninety (90) days. It is the responsibility of the Organization to ensure that
only those retroactive enrollment changes allowed under this paragraph will be sent to the Company. The
Organization is responsible for making payments for any Employee or Dependent coverage that cannot be
retroactively terminated under applicable law until the date that termination is permitted.
GP-900.13 LE WI
(LE ONE) 5 36478-MAS-CON-1-2020
8. Open Enrollment: After the Effective Date of this Policy, an open enrollment period of at least fourteen (14)
calendar days will be held once each calendar year. During an open enrollment period, any eligible person of
the Organization not covered hereunder, may enroll regardless of health status. An Employee may also enroll
eligible Dependents, not covered hereunder, during the open enrollment period. The effective date of benefits
for newly covered Employees and Dependents will be the Anniversary Date.
9. Changes in Benefits: The effective date of any change in benefits requested by the Company or the
Organization, shall be the Anniversary Date, subject to the Company's approval of that change, unless the
provision pertaining to that change specifically provides otherwise. Any change in benefits required by state or
federal law, shall become effective according to law. The effective date of a change in benefits requested by the
Company or the Organization, will be delayed for an Employee or Dependent who is confined to a hospital or
skilled nursing facility on that date. The delay will end on the date the Employee or Dependent is not so confined.
10. Termination of Individual Benefits:
Coverage for benefits of an Employee and Dependent(s) shall terminate on the earliest of the dates shown below:
A. For Employees:
(c) the date this Policy terminates; or
(d) the last day of the premium period for which premium payment has been made, should the
Organization, or the Employee (or former Employee exercising group continuation privileges) fail to
pay premium when due, subject to section 4.; or
(e) the last day of the month, subject to section 4., on which an Employee ceases to be eligible for benefits
under this Policy, if the Employee does not, within the time limits established by law, elect group
continuation privileges as provided under state or federal law; or
(f) the last day of the eligibility period for group continuation privileges provided under state or federal
law; or
(g) the open enrollment date, if the Employee elects to terminate benefits under this Policy, provided the
Employee gives written notice to the Company, at least thirty (30) days prior to such date.
(h) if the Employee knowingly gives false information on his/her application or otherwise misrepresents
or omits a fact, and if that false information or omission is material to our acceptance, coverage for
the Employee will automatically terminate upon thirty (30) days' notice, provided discovery of the
false information is made within two (2) years of the date of enrollment.
To the extent that a termination would be considered a rescission (a cancellation or discontinuance of
coverage under a health Plan that has a retroactive effect) under federal law under item (c), the group health
plan sponsor is required to give the Employee 30 days advance notice of termination.
B. For Dependents:
(a) the date this Policy terminates; or
(b) the last day of the month, subject to section 4. on which a person ceases to be eligible to be enrolled
as a Dependent, if said Dependent does not, within the time limits established by law, elect group
continuation privileges available to the Dependent under state or federal law; or
(c) the date on which the Employee's benefits terminate, as provided under paragraph A. above, if neither
the Employee nor the eligible Dependent elects, within the time limits established by law, group
continuation privileges available to the Dependent under state or federal law; or
(d) the last day of the eligibility period, for group continuation privileges provided under state or federal
law; or
(e) the last day of the premium period for which premium payment has been made, should the
Organization, or the Dependent (or the Employee on the Dependent's behalf) fail to pay premium,
when due, subject to section 4.; or
(f) the last day of the premium period if an Employee elects to terminate Dependent coverage.
To the extent that a termination would be considered a rescission (a cancellation or discontinuance of
coverage under a health Plan that has a retroactive effect) under federal law under item (b), the group health
plan sponsor is required to give the Employee 30 days advance notice of termination.
GP-900.13 LE WI
(LE ONE) 6 36478-MAS-CON-1-2020
11. Termination of this Policy: Coverage for benefits of all the Organization's and their Employees and
Dependents shall terminate on the earliest of the dates described below:
(a) the last day of the premium period for which premium payment has been made, if the Organization is in
breach of any of the terms and conditions for coverage of this Policy. The Company shall give the
Organization written notice of its intent to terminate due to the Organization's breach of any said provisions
sixty (60) days in advance of the termination date. In the event the Organization makes the changes
required by the Company to come into compliance with the specified provisions within the sixty (60)-day
period following notification of termination, this Policy may be continued only upon joint agreement of
the Organization and the Company; or
(b) the end of the grace period, as provided in section 4.; or
(c) any premium due date after the first Anniversary Date, as specified by the Organization, if the Organization
gives the Company written notice at least sixty (60) days prior to the date of termination; or
(d) the first renewal date following 180 days notice by the Company to the Organization of the Company's
intention to cease doing business in the group market.
Termination of this Policy shall not prejudice any claims incurred prior to the effective date of termination.
12. Continuation Rights: The Company agrees to provide continuation coverage, as specified in the Group
Certificate referenced herein, for an Employee or Dependent who is no longer eligible under the terms of this
Policy.
13. Replacement: This section applies to Employees and Dependents who were covered by a prior carrier on the
day prior to this Policy's Effective Date. "Prior carrier" means any group medical benefits obtained through the
Organization, for which this Policy is a replacement.
Liability of prior carrier.
The prior carrier remains liable to the extent of its accrued liability and any contractual liability for extension of
benefits at the time of replacement. "Accrued liability" includes, but is not limited to, responsibility for covered
inpatient expenses, subject to applicable deductibles, copayments, and limitations, incurred by a covered
individual who is confined in a hospital on the date of replacement. Coverage will be extended only for services
related to the confinement and incurred prior to the date that coverage ends or services billed with the facility
charges. The responsibility on the part of the prior carrier continues until the covered individual is discharged
from the hospital or contract maximums have been reached, whichever occurs first.
Liability of the Company as replacement carrier.
1. Each individual who is eligible under this Policy, with respect to provisions regarding eligibility, or
nonconfinement in a hospital or skilled nursing facility, is covered by this Policy as of the Effective Date
of this Policy.
2. Each individual who is not eligible for coverage in accordance with paragraph 1., is nevertheless covered
by this Policy in accordance with the following rules, provided that such individual (including an individual
who has exercised the option for continuation of coverage pursuant to Wisconsin Law) was validly covered
under the prior carrier on the date it was discontinued and the individual is otherwise eligible for coverage
under this Policy.
a. The minimum level of benefits that shall be provided by this Policy, is the lesser of the benefits
available under the prior carrier's plan reduced by any benefits payable by the prior carrier, or the
benefits available under this Policy.
b. Coverage shall be provided by this Policy at least until the earlier of the following dates: the date the
individual becomes eligible under the terms of this Policy, or the date the individual's coverage would
otherwise terminate, for each type of coverage, in accordance with the individual termination of
coverage provisions of this Policy.
GP-900.13 LE WI
(LE ONE) 7 36478-MAS-CON-1-2020
3. Deductible or waiting period. In applying any deductible or waiting period, this Policy shall give credit
for the full or partial satisfaction of the same or similar provisions under the prior carrier. In the case of
deductible provisions, the credit shall apply for the same or overlapping benefit periods, to the extent the
same expenses are recognized under the terms of this Policy and are subject to a similar deductible
provision.
4. Statement of benefits available. In any situation where a determination of the prior carrier's benefits is
required by the Company, at the Company's request, the prior carrier shall furnish a statement of the
benefits available and other pertinent information sufficient to permit the Company to verify or determine
benefits.
5. Controlling terms. Benefits of the prior carrier shall be determined in accordance with the definitions,
conditions and covered expense provisions of the prior carrier rather than those of this Policy.
14. Standard Provisions:
(a) Entire Policy; Changes:
This Policy, including attached Amendments (if any), the Group Certificates including attached
Amendments (if any), the application of the Organization, and the individual applications of the Employees
constitute the entire contract between the parties. This Policy, or any change to this Policy, shall be valid
only when approved by the Company and the Organization, and such approval is attached hereto or
endorsed hereon, or is otherwise acknowledged by the Organization, by making the required premium
payments. No individual who is not an authorized employee of the Company and as such designated by
the Company, has authority to change this Policy or the Group Certificate or to waive any of their
provisions.
(b) Effective Time:
The effective time for any dates shall be 12:01 A.M., Central Time. For provisions which are based on a
calendar year, calendar year means the period commencing at 12:01 A.M., Central Time, on January 1, to
12:00 midnight of the following December 31.
(c) Masculine Pronouns:
Masculine pronouns in this Policy apply to both sexes.
(d) Group Certificates:
A Group Certificate will be issued to each Employee, or to the Organization (for delivery to each
Employee). The benefits and coverage terms described in the Group Certificates are controlled by the
provisions of this Policy and are subject to any changes in this Policy. The Organization must have this
Policy available for inspection by Employees at all reasonable times. The terms of the Group Certificate
may be altered by (1) requirements of state or federal law; or (2) the methods outlined in sections 2, 3. and
9. hereof.
(e) Required Information:
The Organization shall furnish all information required by the Company to compute premiums due from
the Organization, review the Employee participation, and maintain necessary administrative records. The
Organization's records which have a bearing on this agreement shall be available for inspection by the
Company at any reasonable time.
(f) Misstatement of Age:
If the age of any person enrolled under this Policy has been misstated, then: (1) the Organization or the
Company (whichever is applicable) agree to adjust premiums to correspond to the person's true age; and
(2) applicable benefits shall be corrected accordingly (in which case the premium adjustment shall take
such a correction into account).
(g) Conformity with State Laws:
Any provision of this Policy which, on its Effective Date, is in conflict with the laws of the State of
Wisconsin, shall be amended to conform to the minimum requirements of such laws.
GP-900.13 LE W1
(LE ONE) 8 36478-MAS-CON-1-2020
(h) The Organization agrees to include the following information in the employer's plan documents and make
such information available to Employees and Dependents as may be required by law: name of employer
plan, address of employer plan, plan year, plan fiscal year ending date, eligible classes, waiting periods (if
any), employer name and Internal Revenue Service identification number, plan identification number,
employer contribution levels and the name and address of the person or entity that should receive notices
from enrolled Employees and Dependents under subsection "Election of Continuation Coverage" of the
"Continuation of Group Coverage" section of the Group Certificate.
(i) Final discretionary authority to construe the terms of the Plan and coverage of a claim under the Group
Certificate is with the Company. This is not intended to abrogate any common law principles on contract
construction.
(j) Notice of Change to Self -Insured Coverage:
If the Organization is terminating the coverage under this Group Policy and replacing it with a self -insured
plan, the Organization must notify the Company of such change by the tenth of the month prior to the
effective date of the change. If the Organization fails to give the Company such notice, the Company may
bill the Organization for any claims incorrectly processed due to late notice.
(k) Medicare Secondary Payer Mandatory Reporting Requirements issued by the Centers for Medicare and
Medicaid Services: The Organization shall furnish all information required by the Centers for Medicare
and Medicaid Services.
(1) Summaries of Benefits and Coverage (SBC):
The Organization shall furnish to participants or employees the SBC for each benefit plan provided by
the Company for which such participants or employees are eligible no later than the first date on which
the participant or employee is eligible to enroll in coverage for participant or any beneficiaries. The
Organization must notify the Company at least 30 days prior to the effective date of coverage of any
change to the plan benefits currently reflected in the distributed SBC. No change in benefits may occur
after the effective date of coverage without 60 days prior notification to participants and beneficiaries.
15. Sole Carrier: The benefits provided under this Policy by the Company to the Employees of the Organization
shall be the sole benefits offered to such Employees by the Organization.
16. Rights Shall Not Vest: No provision or benefits provided hereunder, shall vest in any Employee rights which
would prevent modification or change of such provision or benefits, mutually agreed to by the parties to this
Policy.
17. Request for PDF File: In response to a specific request, the Company will furnish to the Organization, or an
agent of the Organization, an electronic version of the Group Certificate or other document in a PDF or
comparable format solely for the convenience of the Organization or its agent. The Organization agrees that the
sole permissive use is a display of the PDF file on an internal intranet site or individual computer for the exclusive
use of Organization or its agent, in a complete and unaltered format. The Organization must display the file in
the manner designated by The Company (including any and all disclaimers and introductory text accompanying
the Group Certificate or other document) and cease using the PDF file immediately upon request by the
Company. The Organization agrees to indemnify and hold harmless the Company and its related organizations
for any negligent or intentional acts by Organization or its employees, officer or agents which result in damage
to the Company or its related organizations in regards to the provision and use of the electronic version of the
Group Certificate or other document, to include, but not limited to: improper distribution of the PDF file,
alteration of the PDF file after delivery by the Company or inaccurate or incomplete information resulting from
improper posting and/or maintenance of the PDF file after delivery by the Company. This provision shall be in
effect indefinitely throughout the use and possession of the PDF file by Organization or its agent.
GP-900.13 LE W1
(LE ONE) 9 36478-MAS-CON-1-2020
18. Protected Health Information: In the event that protected health information is requested by the
Organization, the Company may only disclose such information as permitted by the Health Insurance
Portability and Accountability Act of 1996 ("HIPAA") and regulations promulgated thereunder and as
amended for purposes including certain plan administrative functions, such as: claims review, subrogation,
quality assurance, auditing, monitoring and management of carve out plans. Information may be disclosed to
the Organization only upon receipt of a certification from the Organization that this plan document has been
amended to include the following provisions and that the Organization agrees to:
a. Not use or further disclose information except as listed above or as required or permitted by law;
b. Ensure that any agents or subcontractors agree to the same restrictions and conditions that apply to the
Organization and that such agents and subcontractors agree to implement reasonable and appropriate
security measures to protect electronic protected health information;
C. Not use or disclose any information for employment —related actions or decisions;
d. Not use or disclose any information in connection with any other employee benefit plan of the
Organization;
e. Report to the Company any security incident related to electronic protected health information it becomes
aware of and any use or disclosure of the information that is inconsistent with the uses or disclosures
described above;
f. Make information available to fulfill employee rights to access protected health information;
g. Make information available for amendment or to incorporate applicable amendments;
h. Make information available in order to provide an accounting of disclosures;
i. Make internal practices, books and records relating to the use and disclosure of information received from
the Company available to Department of Health and Human Services to determine compliance with
HIPAA;
j. Return or destroy all protected health information received from the Company, if feasible, when use or
disclosure is no longer required. If return or destruction is not possible, limit further uses and disclosures
to those purposes that make the return or destruction of the information infeasible;
k. Ensure only certain classes of employees designated by the Organization are permitted access to
protected health information for plan administration functions;
1. Implement an effective mechanism for handling noncompliance by the employees designated access to
protected health information;
in. Implement administrative, physical and technical safeguards that reasonably and appropriately protect the
confidentiality, integrity and availability of the electronic protected health information that is created,
received, maintained or transmitted on behalf of the group health plan; and
n. Ensure adequate separation between the group health plan and the Organization is supported by reasonable
and appropriate security measures.
GP-900.13 LE WI
(LE ONE) 10 36478-MAS-CON-1-2020
OUT OF AREA NETWORK SERVICE AGREEMENT
This Network Services Agreement (the "NSA") is between Connecticut General Life Insurance Company
("CIGNA") and City of Oshkosh, dba City of Oshkosh, WI ("Employer").
WHEREAS, CIGNA has established a national panel of physicians, hospitals and other health care practitioners and
entities ("Participating Providers") to provide or arrange for the provision of "Covered Services" (defined herein) at
rates of reimbursement specified in agreements with the Participating Providers (the "Provider Agreements"); and
WHEREAS, Employer sponsors a health benefit Plan (herein defined) that provides for the reimbursement of certain
expenses incurred for health care services and supplies in accordance with the terms and conditions of the Plan
("Covered Services"); and
WHEREAS, Employer desires to make available CIGNA's panel of Participating Providers to those of its employees
and their dependents who are covered under the Plan ("Participants") for the provision of Covered Services;
NOW, THEREFORE, in consideration of the foregoing premises and the mutual promises and covenants contained
herein, CIGNA and Employer hereby agree as follows:
L CIGNA's DUTIES
CIGNA shall, consistent with the terms of its Provider Agreements, make its panel of Participating Providers available
for the provision of Covered Services to Participants in Employer's "Plan". "Plan' means a health care benefit plan
established by Employer and funded by a Master Group Contract issued by HealthPartners or a related organization
with respect to which CIGNA has entered into an agreement for the shared administration of Participating Provider
claims (a "Shared Administration Agreement"). CIGNA shall not be responsible for making Participating Providers
and Participating Provider Rates (defined hereafter) available to Participants if the terms of the Plan do not encourage
Participants to utilize the services of Participating Providers or where CIGNA's agreement with the Participating
Provider does not otherwise apply.
CIGNA shall be responsible for the credentialing and re-credentialing, if any, of Participating Providers in accordance
with its credentialing standards. CIGNA may remove any Participating Provider from its panel of Participating
Providers. CIGNA or its designee shall make available to Participants its list of Participating Providers.
Participating Providers will be required by CIGNA to accept as payment in full for all Covered Services rendered to
all Participants the charges reflected in the applicable Provider Agreements.
CIGNA's standard Provider Agreements shall require that Participating Providers look solely to HealthPartners or its
related organization for reimbursement of charges for Covered Services provided to Participants except for
coinsurance, co -payments and deductibles identified in the Plan which are the responsibility of Participants.
II. EMPLOYER'S DUTIES
CIGNA's charges for the services provided by it pursuant to this NSA shall be incorporated in the premiums charged
to Employer by HealthPartners or its related organization. Payment in full of such premiums when due shall discharge
Employer's obligation to reimburse CIGNA for the performance of the services described herein.
III. EFFECTIVE DATE &TERMINATION
Unless rejected by signing below and returning to HealthPartners at the address indicated below, this NSA shall be
effective on the later of (i) the date of receipt of this NSA by Plan Sponsor or (ii) January 1, 2007 (the "Effective
Date " ) provided there is then in effect an insurance policy or Master Group Contract with HealthPartners or its
related organization with respect to the Plan.
This NSA shall automatically terminate upon:
(i) termination of Employer's insurance policy or Master Group Contract with HealthPartners or its related
organization, or
(i) termination of the Shared Administration Agreement.
In addition, this NSA may be terminated by CIGNA immediately if CIGNA in its sole discretion determines that
HealthPartners or its related organization is not paying Participating Providers on a timely basis and in accordance
with the terms of this NSA and/or the Shared Administration Agreement, however, CIGNA may not so terminate this
NSA unless HealthPartners or its related organization has been notified of the failure and HealthPartners or its related
organization has not cured the failure to CIGNA's satisfaction within thirty (30) days of said notice.
IV. RESPONSIBILITY FOR PLAN BENEFITS
CIGNA and its affiliates shall under no circumstance be financially responsible to Employer, the Plan, a Participant,
a Participating Provider or any other party for the payment of any benefits under the Plan it being understood and
agreed that the payment of all Plan benefits is the responsibility of the Plan or HealthPartners or its related
organization. This provision shall survive the termination of this NSA.
V.GENERAL
Any use of CIGNA's Corporation name, logo, trademark, or service mark or the name, logo, trademark, or service
mark of any CIGNA Affiliate by Employer without CIGNA's prior written approval is prohibited.
The relationship of the parties under this NSA is that of independent contractors.
This NSA and any subsequent amendments represent the entire agreement between the parties hereto and supersede
any and all previous written or oral agreements or understandings regarding the subject matter. Neither party may
assign its interest in this NSA, except with the written consent of the other party. This NSA may be amended upon the
mutual written consent of the parties.
CONNECTICUT GENERAL LIFE INSURANCE COMPANY
Chris Hocevar
Officer of Connecticut General Life Insurance Company ("CIGNA")
EMPLOYER: SIGN HERE AND RETURN ONLY IF YOU REJECT THIS AGREEMENT.
If rejected by Employer, sign below and return to HealthPartners.
Aaron Forbort, Product & Market Solutions
HealthPartners
PO BOX 1309
Bloomington, MN 55440-1309
CC: CIGNA
EMPLOYER:
L-12
Date: