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HomeMy WebLinkAboutES10-045 - Amendment - #12 - LifeWise Assurance Company - Stop Loss Insurance Policy - 01/01/2021ApprovalOriginator:Department: Date Sent:Date Required: Authorized to Sign: Director or Designee Mayor Date of Council Approval: Grant? Yes No Type:Review/Signatures/RoutingDate Received by City Attorney: Comments: Date Routed to the Mayor’s Office: Date Routed to the City Clerk’s Office:Agreement InformationVendor Name:Category: Vendor Number:Sub-Category: Project Name: Project Details: Agreement Amount: Start Date: Basis for Selection of Contractor: Termination Date: Local Business? Yes No* Business License Verification: Yes In-Process Exempt (KCC 5.01.045) If meets requirements per KCC 3.70.100, please complete “Vendor Purchase-Local Exceptions” form on Cityspace. Notice required prior to disclosure? Yes No Contract Number: Agreement Routing Form For Approvals, Signatures and Records Management This form combines & replaces the Request for Mayor’s Signature and Contract Cover Sheet forms. (Print on pink or cherry colored paper) Visit Documents.KentWA.gov to obtain copies of all agreementsadccW22373_1_20 Budget Account Number: Budget? Yes No Dir Asst: Sup/Mgr: Dir/Dep: rev. 200821 FOR CITY OF KENT OFFICIAL USE ONLY (Optional) * Memo to Mayor must be attached OK to sign 3/19/2021, TW. AMENDMENT NO. 12 To be attached to and made part of Policy WA 518212 issued to City of Kent as Policyholder It is hereby agreed the Policy shall be amended as follows Effective January 1, 2021. The following Section has been replaced Section 1, Declarations. The following Rider renews for the 2021 Policy Year: o Specific Advance Funding Rider. All other terms and conditions of the contract remain unchanged LifeWise Assurance Company Name and Title of Officer Signature of Officer ffO*n";- )- q{^Iil.= Michael L. Krutt President LifeWise Assurance CompanyDate of Signature 1 . Sign and return copy to LifeWise Assurance Company2. Retain copy with Your Policy. PSL-soo wAAM (9-18)Amendment Dana Ralph, Mayor 03/22/2021 This Declarations for Policy Number WA 518212 apply to the Policy Term January 1,2021throughDecember 31, 2021 in its entirety. SECTION 1 - DECLARATIONS A. POLICY INFORMATION 1. Policy Number WA518212 2. Policyhotder City of Kent 3. Policy Term January 1,2}21through December 31,2021 4. Covered Underlying plan City of Kent,s Health plan 5. Claim Administrator premera Blue Cross B. SPECIFIC BENEFIT SCHEDULE For all Eligible Losses except those to which a Special Risk Limitation applies: 1. Covered Loss Basis Covered Services lncurred from January 1 , 2o1o through December 91 , zo2j and paid fromJanuary 1,2021 through December 31,2021 lf an Eligible Claim Expense is denied by the Covered Underlying plan and that denial issub.sequently reversed by an lndependent Review Organizatibn tf nO), the date such EligibleClaim Expense was originally denied by the Covered -Underlying'plan will be considered the"Paid" date under the above referenced policy. 2. Covered Services include Medical Prescription Drug 3. Number of Covered Units Composite 721 4. Specific Deductibte per participant $200,000 (Please note: Specific deductible per Participant sha// not exceed the .esser of S%o ofexpected ctaims or $100,000). 5. specific Payable percentage (in excess of specific Deductible) 100% 6. Maximum specific Benefit in excess of the specific Deductible Per Policy Term Per Lifetime Unlimited Unlimited 1PSL-500 wA (e-18) G. AGGREGATE BENEFIT SCHEDULE For all Eligible Losses except those to which a Special Risk Limitation applies: 1. Covered Loss Basis Covered Services lncurred from January 1,2010 through December 31 ,2021and paid from January 1, 2021 through December 31, 2021. lf an Eligible Claim Expense is denied by the Covered Underlying Plan and that denial is subsequently reversed by an lndependent Review Organization (lRO), the date such Eligible Claim Expense was originally denied by the Covered Underlying Plan will be considered the "Paid" date under the above referenced policy. 2. Covered Services include Medical Prescription Drug 3. Number of Covered Units Composite 72j 4. Aggregate Payable Percentage in excess of Deductible lOOo/o 5. Aggregate Corridor 2e0o/o (Please note: Aggregate Conidor wilt never be /ess than 120o/o of expected claims). 6. Minimum Aggregate Deductible The greater of: A. 927,916,630;or B. The sum of Aggregate Monthly Factors, multiplied by the corresponding number of Covered Units used to calculate premium in the first month of the Policy Term, multiplied by the number of months in the policy Term, multiplied by g5%. 7. Annual Aggregate Deductible ls equal to the greater of A or B, where: A = The sum of the Monthly Aggregate Deductible Amounts applicable to each Policy Month in the Policy Term B = The Minimum Aggregate Deductible Please Note: Annual Aggregate Deductible cannot be finatized untit the Monthty Aggregate Deductibb Amounts are calculated for each Policy Month of the Poticy Term. 8. Aggregate Monthly Factor per Covered Unit Composite 9. Maximum Aggregate Eligible Loss per participant 10. Maximum Aggregate Benefit per policy Term $3,226.61 $200,000 $1,000,000 2PSL-s00 WA (9-18) D. PREMIUM Specific Monthly Premium Rate Composite $128.79 Specific Rate Guarantee Period 12 Months Aggregate Monthly Premium Rate Per Covered Unit Composite $0.02 Aggregate Rate Guarantee Period 12 Months The Specific Monthly Premium Rate and the Aggregate Monthly Premium Rate apply only to this Policy Term. E. SPECIAL RISK LIMITATIONS Disabled / hospital confined, actively at work, activity of daily living, cognitively impaired, or similar requirements waived Retirees lncluded Other: Lasered lndividual Member lD: 60015680802 Specific Deductible: $300,000 F. AFFILIATE Name None Covered rlvino Plan Yes Yes Yes 3PSL-500 WA (9-18) 7 LifeWise Assurance Company Elfect¡ve Oâb: Group Nahe: Gbup Number: Agsncy Neme: 1t'I2021 City of Kent 1014212 Cùrrcnt Enrcltmêht Employees 721 1933 Proposed rates ¡n this opl¡on are conl¡ngenl upon the lasering ofthg follow¡ng memberal levels shown abovê forcontract pa¡d dales. Diagnosis code on largè claims report is âs shown bdil: . $300,000 Laser on MemberA - COMMON VARIABLE IMMUNODEFICIENCY /uþ z/.r"t¿ Deduct¡ble Deductible Producls Coveaed Covered Conlrâcl Bâsis Spec¡fic Mâxiñuh Prcmium (PEPM) Laabilily Protection Basis Plan I Expected Claim (PEP¡r) Rètunding 12 Month Paid Contracl (Renewal Year) $200,000 N/A Unlimited Annual/Lifelìñe lncluded N/AÍ r 5.70 N/A 12 Month Paid Contract (Renewal Year) 2000/o $1,000,000 ¡0.02 ¡23,817,918 Medical/Rx $1376.44 lu 7t2 Aa 12 Monlh Pa¡d Conlract (Renewâl Year) $200,000 N/A lncluded l.l/A ¡128.79 N/A MedicaVRx 12 Monlh Paid Contact (Renewal Year) 2000/. $1,000,000 ¡0.02 127,9'16,630 $1,613.30 fVedicaUfu 0.00/, o oo/" 0.0% o oo/.