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HomeMy WebLinkAboutCAG1993-0089 - Other - Blue Cross of Washington and Alaska - Administrative Service Contract -Confirmation of Renewal and Contract Changes - 01/01/1993 TABLE OF CONTENTS SECTION I — CONFIRMATION OF RENEWAL ACTION A. Eligibility Update B. Renewal Confirmation SECTION II — CONTRACT CHANGES A. Boilerplate Changes B. Optional Benefits C. Federal Legislative Changes D. State Legislative Changes: Mandated Benefits E. State Legislative Changes: Mandated Benefit Offerings 13596,-01,-99/3 F TABLE OF CONTENTS SECTION I — CONFIRMATION OF RENEWAL ACTION A. Eligibility Update B. Renewal Confirmation SECTION II — CONTRACT CHANGES A. Boilerplate Changes B. Optional Benefits C. Federal Legislative Changes D. State Legislative Changes: Mandated Benefits E. State Legislative Changes: Mandated Benefit Offerings 13595,-01,-99/3 SECTION I CONFIRMATION OF RENEWAL ACTION Return this section to Blue Cross of Washington and Alaska. 13596,-01,-99/4 Group Name: City of Kent Group Number(s) : 13595, -01, -99 Renewal Date: January 1, 1993 ELIGIBILITY UPDATE Your current eligibility provisions are set forth in your benefit booklet(s) under the section entitled "STARTING OUT IN THE PROGRAM." Please review this section and indicate below any eligibility changes you wish implemented at the time of renewal. The following statement will be added to the "Enrollment" subsection of your booklet to comply with a directive from the Office of the Insurance Commissioner: "If the subscription charges being paid on behalf of the subscriber already include coverage for dependent children, receipt of a completed enrollment application for a natural newborn child born after the subscriber's effective date, or an adoptive child acquired after the subscriber's effective date, will not be required within the 60-day period." In addition, your COBRA provisions will be revised to address liability in the event the time frames prescribed by COBRA are not met. The following note will be added to your booklet: "IMPORTANT ROTE: The Group must notify a qualified enrollee of his or her rights under COBRA within 14 days of the date the Group received notice of the qualifying event. If the Group fails to notify you of your rights under COBRA within 14 days of the date the Group received notice of the qualifying event, you must elect continued coverage no more than 60 days after the date coverage was to end because of the qualifying event in order for continued coverage to become effective under this BCWA program. If the Group fails to notify you of your rights under COBRA within 14 days of the date the Group received notice of the qualifying event and you do not elect continued coverage within 60 days after the date coverage ends, BCWA will not be obligated to provide COBRA benefits under this program; the Group will assume full financial responsibility for payment of any COBRA benefits to which you may be entitled." BCWA will provide continued coverage under the contract to the extent that enrollees are entitled to continue group coverage under COBRA and to the extent of the other terms and limitations of the contract. In addition, we list requirements that must be met. The following will be added to that list of requirements: "The Group notifies the qualified enrollee of his or her rights under COBRA within 14 days of the date the Group received notice of the qualifying event. This requirement will be waived if the enrollee elects continued coverage no more than 60 days after the date coverage was to end because of the qualifying event." Also, we will now state that enrollees cannot purchase coverage through COBRA if they are covered by other group health plans. 13595,-01,-99/5 Group Name: City of Kent Group Number(s) : 13596 -01 -99 Renewal Date: January 1 1993 ELIGIBILITY UPDATE Your current eligibility provisions are set forth in your benefit booklet(s) under the section entitled "STARTING OUT IN THE PROGRAM." Please review this section and indicate below any eligibility changes you wish implemented at the time of renewal. The following statement will be added to the "Enrollment" subsection of your booklet to comply with a directive from the Office of the Insurance Commissioner: "If the subscription charges being paid on behalf of the subscriber already include coverage for dependent children, receipt of a completed enrollment application for a natural newborn child born after the subscriber's effective date, or an adoptive child acquired after the subscriber's effective date, will not be required within the 60-day period." In addition, your COBRA provisions will be revised to address liability in the event the time frames prescribed by COBRA are not met. The following note will be added to your booklet: "IMPORTANT NOTE: The Group must notify a qualified enrollee of his or her rights under COBRA within 14 days of the date the Group received notice of the qualifying event. If the Group fails to notify you of your rights under COBRA within 14 days of the date the Group received notice of the qualifying event, you must elect continued coverage no more than 60 days after the date coverage was to end because of the qualifying event in order for continued coverage to become effective under this BCWA program. If the Group fails to notify you of your rights under COBRA within 14 days of the date the Group received notice of the qualifying event and you do not elect continued coverage within 60 days after the date coverage ends, BCWA will not be obligated to provide COBRA benefits under this program; the Group will assume full financial responsibility for payment of any COBRA benefits to which you may be entitled." BCWA will provide continued coverage under the contract to the extent that enrollees are entitled to continue group coverage under COBRA and to the extent of the other terms and limitations of the contract. In addition, we list requirements that must be met. The following will be added to that list of requirements: "The Group notifies the qualified enrollee of his or her rights under COBRA within 14 days of the date the Group received notice of the qualifying event. This requirement will be waived if the enrollee elects continued coverage no more than 60 days after the date coverage was to end because of the qualifying event." Also, we will now state that enrollees cannot purchase coverage through COBRA if they are covered by other group health plans. 13596,-01,-99/5 I have reviewed our eligibility provisions. Other than the boilerplate changes set forth above, no changes are to be made at this time. �JI have reviewed our eligibility provisions. In addition to the boilerplate changes set forth above, please include the following changes: F oil P E N E: l TS �A-i-D P-R-O nn `i7 A-TF Nc--� Is this benefit program part of an IRC Section 125 Cafeteria Plan? Yes No If "Yes," please attach a copy of the "Changes in Family Stat s" section f your Plan document. 9a Broker Group Date Marketing Representative Date Underwriter Date INITIAL AND RETURN THIS FORM TO BLUE CROSS OF WASHINGTON AND ALASKA 13595,-01,-99/6 I have reviewed our eligibility provisions. Other than the boilerplate changes set forth above, no changes are to be made at this time. I have reviewed our eligibility provisions. In addition to the boilerplate changes set forth above, please include the following changes: %5 po(;k sE 4, Cki-O►zE r3 f g-E E I T-C� 116 L JE� Fog �N�F�Ts � ►� morn a7P�TT--- -PRE NC-, co N 1)1 1 1c)Nt), Is this benefit program part of an IRC Section 125 Cafeteria Plan? Yes No If "Yes," please attach a copy of the Changes in Family St s" section of our Plan document. Broker or G oup Date Marketing Representative Date Underwriter Date INITIAL AND RETURN THIS FORM TO BLUE CROSS OF WASHINGTON AND ALASKA 13596,-01,-99/6 Group Name: City of Kent Group Number(s) : 13596, -01, -99 Renewal Date: January 1, 1993 RENEWAL CONFIRMATION The following contract changes (described in Section II) are being presented with your renewal. Please indicate below which optional items you wish included in your contract and sign and return this form with your completed Eligibility Update form. YES SECTION II. A. BOILERPLATE CHANGES X All of the boilerplate contract changes presented in Part A of Section II will be included in your contract. Please indicate on the second page of this renewal confirmation any boilerplate changes that are unacceptable. YES . NO SECTION II. B. OPTIONAL CONTRACT CHANGES Not applicable at this time. YES NO SECTION II. C. FEDERAL LEGISLATIVE CHANGES Not applicable at this time. YES NO SECTION II. D. STATE LEGISLATIVE CHANGES: MANDATED BENEFITS Not applicable at this time. YES NO SECTION II. E. STATE LEGISLATIVE CHANGES: MANDATED BENEFIT OFFERINGS �/ E-2 Add Coverage for Chiropractic Care as any other care E-4 Add TMJ Benefit 13596,-01,-99/7 If there are any other changes you wish to make to your existing contract at renewal, please indicate below. Our records indicate the legal address for your group is: 220 Fourth Avenue South Kent Washington 98031 Is this information accurate? YES NO If "No" was marked, please indicate your correct address below. /off - oZY Broker o Group Date Marketing Representative Date Underwriter Date RETURN THIS FORM TO BLUE CROSS OF WASHINGTON AND ALASKA 13596,-01,-99/8 If there are any other changes you wish to make to your existing contract at renewal, please indicate below. Our records indicate the legal address for your group is: 220 Fourth Avenue South Kent, Washington 98031 Is this information accurate? YES NO If "No" was marked, please indicate your correct address below. Broke or Group Date Marketing Representative Date Underwriter Date RETURN THIS FORM TO BLUE CROSS OF WASHINGTON AND ALASKA 13595,-01,-99/8 SECTION II CONTRACT CHANGES 13596,-01,-99/9 A. BOILERPLATE CONTRACT WORDING • When Medicare is primary, we will no longer subtract Medicare benefits from covered expenses and use the balance to figure the benefits of your program. Instead, we will coordinate benefits with Medicare in the same way that we do with the other group health care programs. "Coordination of Benefits" and "Effect of Medicare" under "General Limitations And Exclusions" in your booklet will be revised to show this change. • Covered hospitals and state-approved chemical dependency treatment facilities outside Washington and Alaska will now be called nonpreferred providers. They will receive nonpreferred benefits for covered services and supplies. However, they will receive preferred benefits if their services are to treat a covered dependent who resides outside Washington and Alaska and the dependent has obtained a referral in advance from AdvantageCare. They will also receive preferred benefits in the case of a medical emergency or accidental injury. • The Basic Prescription Drug Benefit has been renamed the Pharmacy Drug Benefit. • Take-home drugs dispensed and billed by a medical facility will now be reimbursed as we reimburse ancillaries under the appropriate medical facility benefit. • We will be adding "utilization review" language for prescription drug overutilization, abuse and fraud to the AdvantageCare section under "Other AdvantageCare Features." This will replace the "utilization review" language currently in the Basic Prescription Drug Benefit. • The definition of Medical Emergency will be revised to include "severe pain" in our criteria for determining what qualifies as a medical emergency. The new definition will read as follows: "Medical Emergency A sudden and unexpected onset of an illness or accidental injury manifesting itself by acute symptoms of sufficient severity that, in the absence of immediate diagnosis and .treatment or alleviation of severe pain, could reasonably be expected to result in further disability or death. In making our benefit determination, we will take into consideration the specific circumstances affecting your decision to obtain medical emergency services." • We will clarify that if more than one surgical procedure is performed through the same incision during a single operative session, we will provide benefits only for the major procedure. The new language reads as follows: "When more than one surgical procedure is performed through the same incision during a single operative session, we will provide benefits only for the major procedure. When performed during a single operative session for bilateral procedures or procedures performed through different incisions, benefits will be provided based on the allowable charge for the first procedure and one half of the allowable charge for the second procedure." 13596,-01,-99/10 SECTION I CONFIRMATION OF RENEWAL ACTION Return this section to Blue Cross of Washington and Alaska. 13595,-01,-99/4 B. OPTIONAL CONTRACT CHARGES Not applicable C. FEDERAL LEGISLATIVE CHANGES: MANDATED BENEFITS Not applicable D. STATE LEGISLATIVE CHARGES: MANDATED BENEFITS Not applicable 13596,-01,-99/11 E. STATE LEGISLATIVE: MANDATED BENEFIT OFFERINGS E-2 CHIROPRACTIC CARE (SHB 336) All health carriers must offer, as an option, benefits for chiropractic care on the same basis as any other care. Your current program provides chiropractic benefits on a limited basis. The rate adjustment for this option is: E E+S E+S+C E+C $2.36 $4.27 $5.29 $3.38 Your group previously waived this optional coverage. If we do not receive written confirmation of your decision to add this optional coverage by 15 Dec 92 , we will conclude that your prior decision to waive this coverage remains unchanged. Please note that once waived, this optional coverage will not be offered until your next renewal or, if earlier, the date you change to another Blue Cross Program. 13596,-01,-99/12 E. STATE LEGISLATIVE CHARGES: MANDATED BENEFIT OFFERINGS E-4 TMJ BENEFIT In accordance with Washington State law all health carriers must offer, as an option, TMJ coverage. If you elect to add this optional coverage to your medical program, eligible services will be paid at a constant 50 percent up to a lifetime maximum of $2,500. This benefit will cover both surgical and nonsurgical services of a physician or dentist and inpatient hospital care. We would appreciate written confirmation of your decision to add or waive this optional coverage. However, if we do not receive written confirmation of your decision to add this optional coverage by 15 Dec 92 , we will conclude that you have elected to waive this coverage. Please note that once waived, this optional coverage will not be offered until your next renewal or, if earlier, the date you change to another Blue Cross Program. The additional rate to add this benefit is: $p1aaGP Gee helaw E E+S E+S+C E+C $1.40 $2.80 $3.08 $1.68 13596,-01,-99/13 Group Name: City of Kent Group Number(s) : 13595 -01 -99 Renewal Date: January 1 1993 RENEWAL CONFIRMATION The following contract changes (described in Section II) are being presented with your renewal. Please indicate below which optional items you wish included in your contract and sign and return this form with your completed Eligibility Update form. YES SECTION II. A. BOILERPLATE CHANGES E All of the boilerplate contract changes presented in Part A of Section II will be included in your contract. Please indicate on the second page of this renewal confirmation any boilerplate changes that are unacceptable. YES . NO SECTION II. B. OPTIONAL CONTRACT CHANGES Not applicable at this time. YES NO SECTION II. C. FEDERAL LEGISLATIVE CHANGES Not applicable at this time. YES NO SECTION II. D. STATE LEGISLATIVE CHANGES: MANDATED BENEFITS Not applicable at this time. YES NO SECTION II. E. STATE LEGISLATIVE CHANGES: MANDATED BENEFIT OFFERINGS Not applicable at this time. 13595,-01,-99/7 SECTION II CONTRACT CHANGES 13595,-01,-99/9 A. BOILERPLATE CONTRACT WORDING • When Medicare is primary, we will no longer subtract Medicare benefits from covered expenses and use the balance to figure the benefits of your program. Instead, we will coordinate benefits with Medicare in the same way that we do with the other group health care programs. "Coordination of Benefits" and "Effect of Medicare" under "General Limitations And Exclusions" in your booklet will be revised to show this change. • Take-home drugs dispensed and billed by a medical facility will now be reimbursed as we reimburse ancillaries under the appropriate medical facility benefit. • We will be adding "utilization review" language for prescription drug overutilization, abuse and fraud to the AdvantageCare section under "Other AdvantageCare Features." • The definition of Medical Emergency will be revised to include "severe pain" in our criteria for determining what qualifies as a medical emergency. The new definition will read as follows: "Medical Emergency A sudden and unexpected onset of an illness or accidental injury manifesting itself by acute symptoms of sufficient severity that, in the absence of immediate diagnosis and treatment or alleviation of severe pain, could reasonably be expected to result in further disability or death. In making our benefit determination, we will take into consideration the specific circumstances affecting your decision to obtain medical emergency services." • We will clarify that if more than one surgical procedure is performed through the same incision during a single operative session, we will provide benefits only for the major procedure. The new language reads as follows: "When more than one surgical procedure is performed through the same incision during a single operative session, we will provide benefits only for the major procedure. When performed during a single operative session for bilateral procedures or procedures performed through different incisions, benefits will be provided based on the allowable charge for the first procedure and one half of the allowable charge for the second procedure." 13595,-01,-99/10 B. OPTIONAL CONTRACT CHANGES Not applicable. C. FEDERAL LEGISLATIVE CHANGES: MANDATED BENEFITS Not applicable. D. STATE LEGISLATIVE CHANGES: MANDATED BENEFITS Not applicable. E. STATE LEGISLATIVE CHANGES: MANDATED BENEFIT OFFERINGS Not,. applicable. 13595,-01,-99/11 f � TABLE OF CONTENTS SECTION I - CONFIRMATION OF RENEWAL ACTION A. Eligibility Update B. Renewal Confirmation SECTION II - CONTRACT CHANGES A. Boilerplate Changes B. Optional Benefits C. Federal Legislative Changes D. State Legislative Changes: Mandated Benefits E. State Legislative Changes: Mandated Benefit Offerings 13597,-01/3 SECTION I CONFIRMATION OF RENEWAL ACTION Return this section to Blue Cross of Washington and Alaska. 13597,-01/4 Group Name: City of Kent Group Number(s): 13597 -01 Renewal Date: January 1 1993 ELIGIBILITY UPDATE Your current eligibility provisions are set forth in your benefit booklet(s) under the section entitled "STARTING OUT IN THE PROGRAM." Please review this section and indicate below any eligibility changes you wish implemented at the time of renewal. The following statement will be added to the "Enrollment" subsection of your booklet to comply with a directive from the Office of the Insurance Commissioner: "If the subscription charges being paid on behalf of the subscriber already include coverage for dependent children, receipt of a completed enrollment application for a natural newborn child born after the subscriber's effective date, or an adoptive child acquired after the subscriber's effective date, will not be required within the 60-day period." In addition, your COBRA provisions will be revised to address liability in the event the time frames prescribed by COBRA are not met. The following note will be added to your booklet: "IMPORTANT NOTE: The Group must notify a qualified enrollee of his or her rights under COBRA within 14 days of the date the Group received notice of the qualifying event. If the Group fails to notify you of your rights under COBRA within 14 days of the date the Group received notice of the qualifying event, you must elect continued coverage no more than 601days after the date coverage was to end because of the qualifyingevent order for continued coverage to become effective under this BCWA program. If the Group fails to notify you of your rights under COBRA within 14 days of the date the Group received notice of the qualifying event and you do not elect continued coverage within 60 days after the date coverage ends, BCWA will not be obligated to provide COBRA benefits under this program; the Group will assume full financial responsibility for payment of any COBRA benefits to which you may be entitled." BCWA will provide continued coverage under the contract to the extent that enrollees are entitled to continue group coverage under COBRA and to the extent of the other terms and limitations of the contract. In addition, we list requirements that must be met. The following will be added to that list of requirements: "The Group notifies the qualified enrollee of his or her rights under COBRA within 14 days of the date the Group received notice of the Conti ued covera.e nolmoregthan 60tdayslafteratheddatethcoveragelwasetocend continue g because of the qualifying event." Also, we will now state that enrollees cannot purchase coverage through COBRA if they are covered by other group health plans. 13597,-01/5 I have reviewed our eligibility provisions. Other than the boilerplate changes set forth above, no changes are to be made at —,� this time. I have reviewed our eligibility provisions. In addition to the boilerplate changes set forth above, please include the following changes: FUR, I�ftt D F R om OF MA RR I F147 OWL( II► E - EXy57lN 0-an6D I-nor�S, Is this benefit program part of an IRC Section 125 Cafeteria Plan? Yes No If "Yes," please attach a copy of the "Changes in Family Status" section f your Plan document. Broker r Group Date Marketing Representative Date Underwriter Date INITIAL AND RETURN THIS FORM TO BLUE CROSS OF WASHINGTON AND ALASKA 13597,-01/6 Group Name: City of Kent Group Number(s): 13597 -01 Renewal Date: January 1, 1993 RENEWAL CONFIRMATION The following contract changes (described in Section II) are being presented with your renewal. Please indicate below which optional items you wish included in your contract and sign and return this form with your completed Eligibility Update form. YES SECTION II. A. BOILERPLATE CHANGES X All of the boilerplate contract changes presented in Part A of Section II will be included in your contract. Please indicate on the second page of this renewal confirmation any boilerplate changes that are unacceptable. YES . NO SECTION II. B. OPTIONAL CONTRACT CHANGES Not applicable at this time. YES NO SECTION II. C. FEDERAL LEGISLATIVE CHANGES Not applicable at this time. YES NO SECTION II. D. STATE LEGISLATIVE CHANGES: MANDATED BENEFITS Not applicable at this time. YES NO SECTION II. E. STATE LEGISLATIVE CHANGES: MANDATED BENEFIT OFFERINGS Not applicable at this time. 13597,-01/7 If there are any other changes you wish to make to your existing contract at renewal, please indicate below. Our records indicate the legal address for your group is: 220 Fourth Avenue South Kent, Washington 98031 Is this information accurate? YES NO 1_1 If "No" was marked, please indicate your correct address below. Broker o Group Date Marketing Representative Date Underwriter Date RETURN THIS FORM TO BLUE CROSS OF WASHINGTON AND ALASKA 13597,-01/8 SECTION II CONTRACT CHANGES 13597,-01/9 A. BOILERPLATE CONTRACT WORDING • When Medicare is primary, we will no longer subtract Medicare benefits from covered expenses and use the balance to figure the benefits of your program. Instead, we will coordinate benefits with Medicare in the same way that we do with the other group health care programs. "Coordination of Benefits" and "Effect of Medicare" under "General Limitations And Exclusions" in your booklet will be revised to show this change. B. OPTIONAL CONTRACT CHANGES Not applicable. C. FEDERAL LEGISLATIVE CHANGES: MANDATED BENEFITS Not applicable. D. STATE LEGISLATIVE CHANGES: MANDATED BENEFITS Not applicable. E. STATE LEGISLATIVE CHANGES: MANDATED BENEFIT OFFERINGS Not applicable. 13597,-01/10 L,S. Depa;;ment of.;ustice Unites s[ltes Marsha'sSeri e Nlodiiication of - er2overnmental Aureenient i. MODIFICATION \0. EFFECT,IVE DATE OF MODIFICATION THREE (3) November 1 , 1992 :. ISSUING OFFICE 4. LOCAL GOVERNMENT 5. IGA NO. J-E86-M-247 'U.S.MARSHALS SERVICE Kent City Corrections Facility 6, FACILITY CODE(S) PROCUREMENT DIVISION 1230 South Central IGA SECTION Kent, Washington 98031 oJJ 600 ARMY NAVY DRIVE ARLINGTON,VA 22202-4210 -. ACCOUNTING CITATION 8. ESTIMATED ANNUAL PAYMENT 15X1020 $511 ,000 .00 Q. EXCEPT AS PROVIDED SPECIFICALLY HEREIN,ALL TERMS AND CONDITIONS OF THE IGA DOCUMENT REFERRED TO IN BLOCK 5. REMAIN UNCHANGED. TERMS OF THIS MODIFICATION: The purpose of this Modification is to increase the rate from $64.00 to $70.00 effective November 1, 1992, and to incorporate the availability of funds clause, as set forth below: On Page 5 of 5, add Article XI, as follows: ARTICLE XI — AVAILABILITY OF FUNDS The Federal Government's obligation under this agreement is contingent upon the availability of appropriated funds from which payment can be made and no legal liability on the part of the Government for any payment may arise until such funds are available. 10. INSTRUCTIONS TO LOCAL GOVERNMENT FOR EXECUTION OF THIS MODIFICATION: A. [] LOCAL GOVERNMENT IS NOT.REQUIRED B. [3 LOCAL GOVERNMENT IS REQUIRED TO SIGN THIS DOCUMENT TO SIGN THIS DOCUMENT AND RETURN 2 COPIES TO U.S. MARSHAL 11. APPROVALS: A. L AL G ERNMENT B. FEDERAL GOVERNMENT Arlt - Vicki Li ovIk Signature Signature ��-/�'-�j Contracting Officer 412i TITLE DATE TITLE I DATE Form USM-241a (Rev.9/91) USMS HQ USE ONLY Page t of I _Pages U.S Government Printing 01fice1992-312-327/61903