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Home My WebLink AboutES10-045 - Amendment - #14 - LifeWise Assurance Company - Stop Loss Insurance Policy - 01/01/2023 FOR CITY OF KENT OFFICIAL USE ONLY Sup/Mgr: Agreement Routing Form DirAsst: • For Approvals,Signatures and Records Management Dir/Dep: ICE N T This form combines&replaces the Request for Mayor's Signature and Contract Cover (Optional) WASHINGTON Sheet forms. (Print on pink or cherry colored paper) Originator: Department: Laura Horea Human Resources Date Sent: Date Required: 0 05/04/2023 5/8/2023 a Authorized to Sign: Date of Council Approval: aOMayor or Designee 4 4 2023 Budget Account Number: Grant? Yes❑ No21 Budget? Yes[—]No Type: N/A Vendor Name: Category: LifeWise Contract Vendor Number: Sub-Category: = Amendment 0 4w Project Name: LifeWise OProject Details: w C C Basis for Selection of Contractor: £ Agreement Amount: 1,189,290 Other *Memo to Mayor must be attached Start Date: 1/1/2023 Termination Date: 12/31/2023 Q Local Business?Des❑No` lfmeets requirements per KCC3.70.700,please complete"Vendor Purchase-Local Exceptions"form on Cityspace. Business License Verification: ❑Yes❑In-Process E]Exempt(KCC 5.01.045) ❑Authorized Signer Verified Notice required prior to disclosure? Contract Number: ❑Yes❑No ES 10-045 Comments: 1 LifeWise Contract Amendment L Im 3 0 a, a, oc Date Received:City Attorney: 5/5/23 Date Routed:Mayor's Office 5/6/23 City Clerk's Office 5/9/23 adccW22373_1_20 Visit Documents.KentWA.gov to obtain copies of all agreements rev.20221201 AMENDMENT NO. 14 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, 2023: The following Section has been replaced- Section 1, Declarations. The following Rider renews for the 2023 Policy Year: • Specific Advance Funding Rider. All other terms and conditions of the contract remain unchanged. Dana Ralph,Mayor LifeWise Assurance Company harne and Title of ir r Signature of Officer Rick Grover 05/09/2023 President and Chief Executive Officer Date of Signature LifeWise Assurance Company 1. Sign and return copy to LifeWise Assurance Company- 2. Retain copy with Your Policy. PSL-500 WA AM (9-18) Amendment This Declarations for Policy Number WA 518212 apply to the Policy Term January 1, 2023 through December 31, 2023 in its entirety. SECTION 1 — DECLARATIONS A. POLICY INFORMATION 1. Policy Number WA 518212 2. Policyholder City of Kent 3. Policy Term January 1, 2023 through December 31, 2023 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 Incurred from January 1, 2010 through December 31, 2023 and Paid from January 1, 2023 through December 31, 2023. If an Eligible Claim Expense is denied by the Covered Underlying Plan and that denial is subsequently reversed by an Independent Review Organization (IRO), 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 I Composite 701 4. Specific Deductible per Participant $200,000 (Please note: Specific deductible per Participant shall not exceed the lesserof 5%of expected claims 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 Unlimited Per Lifetime Unlimited PSL-500 WA(9-18) 1 C. AGGREGATE BENEFIT SCHEDULE For all Eligible Losses except those to which a Special Risk Limitation applies: 1. Covered Loss Basis Covered Services Incurred from January 1, 2010 through December 31, 2023 and Paid from January 1, 2023 through December 31, 2023. If an Eligible Claim Expense is denied by the Covered Underlying Plan and that denial is subsequently reversed by an Independent Review Organization (IRO), 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 701 4. Aggregate Payable Percentage in excess of Deductible 100% 5. Aggregate Corridor 200% (Please note: Aggregate Corridor will never be less than 120%of expected claims). 6. Minimum Aggregate Deductible The greater of: A. $29,344,420.80; 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 95%. 7. Annual Aggregate Deductible Is 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 finalized until the Monthly Aggregate Deductible Amounts are calculated for each Policy Month of the Policy Term. 8. Aggregate Monthly Factor per Covered Unit Composite $3,488.40 9. Maximum Aggregate Eligible Loss per Participant $200,000 10. Maximum Aggregate Benefit per Policy Term $1,000,000 PSL-500 WA(9-18) 2 D. PREMIUM Specific Monthly Premium Rate Composite $155.28 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 Retirees Included Yes Other: Yes Lasered Individual Member ID: 600156808-02 Specific Deductible: $300,000 Paid Claims between $200,000 and$300,000 are not eligible under the Aggregate Benefit. F. AFFILIATE Name Covered Underlying Plan None PSL-500 WA(9-18) 3