HomeMy WebLinkAbout4.q. Request for Proposals - Employee Benefit Programs i
CITY OF ROSEMOUNT
�BECUTIVE SUMMARY FOR ACTION
CITY COUNCIL MEETING DA�'E: OCTOBER 5, 1993
AGENDA ITEM: RFP'S FOR HEALTH, DENTAL AND AGENDA SECTION: CONSENT
LONG TERM DISABILITY/AUTHORIZE AD FOR NOTICE
pREpARED BY: SUSAN WALSH AGENDA NO. /f
ADMINISTRATIVE ASSISTANT 'Lt• �/ -
ATTACHMENTS: REQUEST FOR 1994 EMPLOYEE AP Y' �
BENEFITS PROPOSAL
Since the appointment of Mr. Jeff Azen of James Bissonet as the city's
agent of record for various city benefit programs, he has met twice with -
the EmpZoyee Insurance Committee. The results of discussions from these -
committee meetings is the attached Request for Proposal.
The insurance committee is comprised of two members from each of the city's
unions and from the non-union group. Members of the committee are Doug
Aldrich, Jim Koslowski, Maryann Stoffel, Diana Korpela, Bryan Burkhalter,
Mark Robideau, Jeff May and Dwayne Kuhns.
The attached proposal includes specifications for health, dental and long
term disability. The City is required by law to solicit bids for health,
and the committee agreed it would be appropriate to also solicit for dental
insurance since our dental contract is almost four years old.
The long term disability proposal is strictly voluntary, and the cost would
be paid entireiy by the employee. The Insurance Committee members
expressed an interest in receiving costs and proposals on this benefit.
Mr. Azen felt doin so would not im ede the health and dental proposals and
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that this was an appropriate time to do this. Of course the Council will
be kept well informed of the LTD proposals. '
Sealed proposals for these benefits will be accepted until October 22,
1993 . The committee and Mr. Azen will review the proposals and make
recommendation at the November 16 Council Meeting.
Although this is a consent agenda items, Mr. Azen will be at the meeting to
answer any questions.
Thank you for your consideration in this matter.
RECOMMENDED ACTION: MOTION TO APPROVE THE REQUEST FOR 1994 EMPLOYEE
BENEFIT PROPOSALS AND TO AUTHORIZE ADVERTISEMENT OF THE RFP IN THE
OFFICIAL NEWSPAPER.
COIINCIL ACTION:
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' REQUEST FQR 1994
' EMPLOYEE BENEFIT PROPOSALS
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Issued By:
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� The Cit of Rosemount
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2875 - 145th Street West
� Rosemount Minnesota 55068-0510
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October 7, 1993
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JAMES BISSONETT & ASSOCIATES
EMPLOYEE BENEFIT CONSULTING
' 7901 FLYING CLOUD DRIVE,SUITE 154
EDEN PRAIRIE,MINNESOTA 55344-5384
OFFICE:(612)944-7117 FAX:(612)944-7056
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� CONTENTS
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' L GENERAI.REQUEST FOR PROPOSAL(RFP)INFORMATION 1 -3
� II. MEDICAL BENEFITS SPECIFICATIONS 4 - 17
' III. DENTAL INSURANCE SPECIFICATIONS 18 -25
' IV. GROUP LONG-TERM DISABII,ITY SPECIFICATIONS 26 -33
' V. EMPLOYEE CENSUS 34- 36
` VI. ADDENDUMS
A. MEDICAL ACCOIJNTING/FINANCIAL SUNIlVIARiES A1 -A6
� B. DENTAL ACCOUNTING/FINANCIAL SLT�vIlVI1�l�S B 1 -B3
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� GENERAL RE UEST FOR PROPOSAL
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(RFP) INFORMATION
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'' GENERAL TNSTRUCTIONS '
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Ciry of Rosemount
28�5-145th Street West
� R�semnunt,MN 55068-OSIO
' 1) The City must receive sealed proposals no later than 3:00 p.m., Friday, October 29, 1993. Please
address envelopes containing proposals to the attention of: Ms. Susan Walsh, Administrative
� Assistant, City of Rosemount, 2875 - 145th Street West, Rosemount, Minnesota 55068-0510.
Mark in the lower left comer: "SEALED PROPOSAL--GROUP BENEFITS".
2) Please provide two(2)copies of your proposal. All proposals must be signed by an officer(or other
' person) of the company authorized to enter into a contract. Proposal must be submitted on the
Proposal Forms included with the specifications (proposal forms may be photocopied if additional
forms are needed).
' 3) All deviations from the �ecifications should be clearlY noted. Any deviation deemed to be
significant by the CitylCity Council will disqualify the proposal.
� 4) The proposals submitted in response to this Request for Proposal wiil be considered the only
respon$e,unless revised proposals are requested by the City/City Councii.
� 5) The City/City Council reserves the right to accept or reject any or all proposals, or any part thereof,
and to waive any formalities or irregularities. The City/City Council also reserves the right to
negotiate plan amendments and/or modifications to financial or administrative arrangements.
, 6) Proposals received within the required period will be opened, recorded, and reviewed by Ms. Susan
Walsh and the City's consultantlagent-of-record, James Bissonett&Associates, Inc. NO FORMAL
OPENING OF THE PROPOSALS WILL OCCUR. Questions should not be directed to the City of
' Rosemount. Any questions regarding the Request for Proposal should be in writing(faaLes accepted)
and directed to: Jeffrey A. Azen of James Bissonett& Associates, Inc., 7901 Flying Cloud Drive,
Suite 154, Eden Prairie,MN 55344--(612)944-7117, Fax: (612)944-7056.
, 7) All Insurers , and Health Maintenance Organiza.tions, submitting proposals must be licensed to do
business in the State of Minnesota. The CitylCity Council reserves the right to request additional
financial information and documentation of any portion of the proposal as deemed necessary.
� 8) Base the proposals on a 12:01 a.m.,January O1, 1994 effective date. Changes in rates or benefits by
the Insurer/HMO, for exarnple; during renewals, may not be made without written notice 120 days
' prior to the anniversary date. The City Council reserves the right to terminate the contract with no
less than 30 days written notice.
9) Proposals can be for one or more of the specified Group Benefits. However,the rate for ea.ch benefit
t must be independently determined. You ean provide an alternative proposal if by combining benefits
there would be a reduction in costs/premiums.
' 10) All medical and dental proposals must answer all applicable questions on the enclosed
questionnaires.
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' 11) The Ciry does not currently offer Long Term Disability(LTD}Benefits to its employees. Due to the
tax advantages of employee paid LTD coverage and budget objectives,the City would like to offer a
100%contributory(employee paid)LTD Plan.
� 12) If you decline to quote,please provide a deciination notice.
' 13) The proposal and any subsequent modifications submitted will become part of the contractual
obligation and incorporated by reference into the ensuing contract. All information submitted to the
City/City Council, will be considered public mformation in accordance with Minnesota Statutes
governing data practices.
1 14) The City/City Council's objective is to select Insurers and/or a Health Maintenance Organization
who will provide the best possible service at the best possible cost while meeting the Request for
� Proposal specifications. Please keep in mind that the City is not obligated to award the contract
based on cost alone.
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! EVALUATION CRITERIA <
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Medical/Dental/Group Long Term Disability Benefits}'roposals:
t1) Compliance with specifications.
' 2) Ability to provide services to the City and its covered employees and dependents.
3) Compliance with applicable State and Federal statutes and regulations.
' 4) Premium rates, retention costs,administration fees,and renewal undervvriting procedures.
5) Size and locations of Medical and Dental{if applicable)Provider Network.
� 6) Nature of inedical and dental (if applicable) provider contracts, including provider discounts
and other cost containment methods.
7) Answers to the Medical and Dental Benefits Questionnaire.
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' IMPORTANT NOTE: The City will choose the proposal which best fits its needs and ihe needs
of its employees and dependents. The City is not obligated to award the
contract based on cost alone.
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:GENERAL>�NFORMATION ;
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' Under conditions set forth in Minnesota Statute 471.6161, the City of Rosemount currently offers its
employees a very comprehensive benefits program. As required under Statute 471.6161, subdivision
4,the City is required to "Request proposals for coverage at least once every 60 months". In order to
' comply with subdivision 4,the City is requesting proposals for: Dental Insurance; Group Long Term
Disability Insurance; and Medical Benefits.
Full-Time employees are defined as permanent (non-seasonal) employees working 40 hours or more
1 per week. Full-Time employees are eligible for benefits the first of the month following date of lure.
The City currently contributes S 119.54 per month for Medical Benefits and S 19.96 per month for
Dental Benefits.
-� The City has insured its Medical Benefits through Blue Cross Blue Shield of Minnesota since July O1,
1976. Due to the City's empioyer contribution structure, half the single enrollees elect the Base Plus
Major Medical Plan and most family enrollees elect the Aware Gold Limited Plan. The Base Plus
� Major Medical Plan provides 100% coverage for inpatient and outpatient hospital and surgical
expenses. Under the Base Plus Major Medical Plan, non-hospital services are subject to a $100
calendar year deductible and 80-20%coinsurance of the first$10,Q00. The Aware Gold Limited with
� Copay Plan, has a $15 office visit copay and inpatient services are subject to a $200 deductible and
80-20%coinsurance of the first$5,000.
Delta Dental of Minnesota,has insured the City's Dental Benefits since March Ol, 1990. Employee's
, of the City's Police Department became eligible for Dental Benefits effective July O 1, 1993.
The City does not currently offer Long Term Disability (LTD) benefits to its employees. Due to the
' tax advantages of employee paid LTD coverage and budget objectives, the City woald like to offer a
104%contributory(employee paid)LTD Plan.
' The Request for Proposal (RFP) is intended to meet all statutory proposal solicitation obligations
required of the City. Serious consideration will be given to RFP Responses. However, the City
reserves the nght to renew with its current Insurers based on their renewal and/or responses to the
Request for Proposal. The City is interested in maintaining a long-term relationship with the
� Insurance and/or HMO companies awarded contracts.
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MEDICAL BENEFIT SPECIFICATIONS
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MEDICAL BENEFIT SPECIFICATI4NS
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1) Only fully-insured plans will be considered. Ali life insurance companies submitting proposals for
medical benefits must have no less than an "A" rating from A.M. Best and/or an "A.A" rating from
� Standard & Poor's for the last five years. Please provide rating verifications on the Group
MedicallI-�VIO Plan(s} "Proposal Forms A1,A2 and B".
' 2) The City will consider "Total Carrier Replacement (Dual or Triple Option Point of Service)°
proposals. Please provide proposals based on the cunent Aware Gold Limited with Copay benefit
levels, (see Rate Proposal Forms A 1,A2, B and Benefit Proposal Forms C 1,C2).
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3) The City prefers to continue to provide benefits through a large provider network such as exist
' through its current plans(BCBSM Aware Gold) However,proposals with smaller provider networks
will be considered if it can be shown that significant premium savings can be accomplished an both a
short-term as well as a long term basis.
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4) Non-Network indemnity benefits must be included in any proposal. These benefits should include a
deductible and coinsurance provisions at appropriate but fair levels to protect the financial integrity
' of the plan by discouraging non-network utilization. Benefits under any Non-Network coverage must
not limit eligibility to loca.tion of residence. However, if necessary, Retirees age 65 or older who are
eligible for Medical Benefits may be required to choose a Medicare supplement plax� through an
, HMO and eligibility,#herefore,may be limited to residency.
5) The City does not intend to exclude or further reduce any benefits. For example,the City's two plans
' currentty cover as an eligible expense non-durable/disposable medical supplies such as syringes,
needles,glucose test strips,ostomy supplies,etc. The City requires that the new plan(s) include non-
durable/disposable medical supplies, and that durable medical supplies, include repairs and
, replacements. The City also requires that there be In Network, as well as, Out-of-Network,
Chiropractic Benefits.
' 6j The City currently uses a Two-Tier premium rate structure (single and family). In addition to Two-
Tier rates (see Rates Proposals Forms Al & A2), please provide proposals based on the foilowing
Three-Tier premium rate structure; single, single+l dependent, and family (see Rate Proposal Form
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7) Initial and renewal premium rates must be guaranteed for no less than a 12 month period. In addition
' to the initial 12 month rate guarantee, the City would like to see, if possible, guaranteed second and
third year renewal rates. If you are unwilling to provide guaranteed rene���al rates, ma�cimum
percentage (%) rate guarantees would be appreciated. Initial and renewal premium rates must be
identified for active and early retirees on Rate Proposal Forms Al & B"and for retirees age 65 or
' older on Rate Proposal Forms A2".
8) All eligible employees and dependents, including retirees and their dependents (see Chapter 488 of the
� 1992 Minnesota Session Laws - copy available upon request from James Bissoneit and Associates,
Inc.), rnust be able to participate, and if applicable, change plans during annual open enrollment
periods.
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9) Unless approved by the City/City Council, Employee only rates and/or (if applicable) Employee+l
Dependent rates, must not be disproportionately high in order to keep Family rates disproportionately
' low.
� 10) A breakdown of retention costs is required (See Proposal Forms A1, A2 and B). Retention
calculations should include a 5%servicing agent fee.
' 11) Provide the City and its consultant/agent-of-record with detailed paid claims and utilization reports on
a quarterly basis. Separate paid claims and Utilizaxion Reports must be maintained for the following
three classes of employees: Active,Retirees under age 65,and Retirees age 65 or older. Even though
' separate reports are being requested, the Insurer/IIlVIO and the City must comply with Minnesota
Chapter 488.
, 12) The Insurance Company or HMO(s) awarded the bid, must assist the City in the enrollment process.
This is especially important in terms of Retirees age 65 or older who are on Medicare(HCFA) °Risk
Contracts", if any,and will ha.ve to change plans.
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13) Fu11-Time students should be eligible and covered as dependents until age 25.
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14) Dependents(spouse and children,as applicable) should be able to waive coverage if they are covered
under the employee's spouse's employer's medical plan. Dependents who waive coverage because
' they are covered under the employee's spouse's employer's plan, but subsequently lose coverage due
to the spause's voluntary or involuntary loss of job, or the spouse's employer's termination of the
plan, should be immediately eligible,upon proper verification,to be covered under the City's plan(s).
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15) Insurers/�IMO's responding to this RFP who employ more than 20 full time employees,must be able
' to provide verification that they have adopted a written Af�rmative Action Policy.
16) Answer the Medical Benefit Questionnaire, which includes a request for a summary of the key
, benefit provisions for your medical plan(s) on Proposal Form Cl, C2. Please refer to the Medical
Benefit Summary, which follows the Medical Benefit Questionnaire, for the key benefit provisions
of the Aware Gold LTD w/Copay plan. Copies of the Certificate of Coverage for the medical plan is
' available upon request from James Bissonett and Associates,Inc.
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3NEDICAL BENEFIT QLTESTIONNAIRE '
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Please provide answers to the following questions on a separate form. You do not need to restate the questions as long as the
' number of your answer directly corresponds with the number of the appropriate question. Your response to this questionnaire is
xequired and will be considered part of your proposal to the City. If you feel the question does not apply to you, please explain
why.
' 1. Please summarize the key benefit provisions for your plans on Proposal Form C (Proposal Forms may be photocopied if
additional forms are neecled for your different plans). Also, Please carefully identify and explain on Proposal Form C all
' deviations from the specifications.
2. Clearly identify any restrictions and/or limitations on coverage or eligibility for cunent or future insureds(for example;pre-
existing condition limitations under "non-network"benefits or any actively-at-work requirements, etc.).
' 3. To what extent are your proposed rates based on the historical claims experience andJor utilization reports? If not fully
based on claims experience and/or utilization reports,what other factors were considered?
' 4. Do you develop renewal rates in any fashion different from your answer to Question #3? What percentage rate are you
currently using as an medical inflation trend factor for 1994 renewals? What medical inflation trend factor are you
projecting\targeting for 1995?
, 5. At what level will a specific claim be pooled? Please indicate the percentage of premium for specific stop-loss/pooling risk
charges on the Proposal Form under Retenzrai Breakdown.
' 6. Once non-network claims are received,what is the claim tum-around time and how often is the claims payment made?
7. What criteria do you use to set non-network usual and customary (U & C) limits? Is the criteria different for locations
' within Minnesota or for other states?
8. Provide three public sector references (name, address, and phone number of the contact person who is familiar with the
� administration of the program and the level of service provided).
9. Explain in detail your method(s) for managed health care and cost containment. What procedures do you have in place to
' assure quality of care?
10. When do your provider natwork contracts expire? Do you anticipate any significant loses or additions of any major clinics?
' i L Do you agree to indemnify and hold harmless the City/City Council from any and all damages, costs and eapenses, and
lawsuits for injury or death to any insured person resulting from or alleged to result from malpractice, wrongful act,etc. in
connection with the provision of health services by the medical plan or any of its participating providers?
' �12. If there is a change in medical carriers, how will you coordinate care that is on going; for example, pregnancy, surgery,
therapy, etc.?
, 13. Frovide examples of your paid claims and utilization reports.
14. How much time after receipt of all information will you require to issue administrative materials, benefit booklets, master
' contract, and I.D. cards?
15. Has your provider Network received an independent, external review and accreditation from the National Committee for
Quality Assurance (NCQA), the Joint Commission Accreditation of Healthcare Organizations (JCAHO), the American
' Accreditation Program, Inc. (AAPI),or a comparable organization? If yes, please provide a copy of the review.
16. Does your proposal include a medical conversion privilege? If yes, please provide a sample contract and give examples of
, ihe cunent rate schedule based on the following demographics:
(a) Male Ages 35, 45, and 55.
(b) Female Ages 35, 45, and 55.
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GROUP MEDICAL/HIVIO PLAN(S) - RATE �'ROPOSAL FORM A1
' FOR ACTIVE EMPLOYEES AND EARLY RETIREES
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A.M. BEST RATING STANDARD & POOR S RATING
I # OF PARTICIPANTS RATES MONTHLY
MEDTCAL PLANS,SI: l ST YEAR RATES SINGLE FAMILY SINGLE FAMTLY PREMIUM
' A.Current Plan {Aware Gold LTD w/copays)
B. Alternative Plan*:
C Alternative Plan*:
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' MAXiMUM RENEWAL GUARANTEES:
1995 Rates or % (See Speci�cations)
A.Current Plan (Aware Gold LTD w/copays)
' B, Alternative Plan*:
C. Alternative Plan*:
' 1996 Rates or % (See Speci�cations)
A.Current Plan (Aware Gold LTD w/copays)
' B. Alternative Plan*:
C.Alternative Plan*:
, PERCENTAGE OF PREMIUM
RETENT�ON FACTORS 1ST YEAR 2ND YEAR 3RD YEAR 4TH YEAR STH YEAR
' Premium Taxes % % % % 9�
Servicing Agent Fees 5%a 5% 5% 5% 5%
Risk Charge % % % % �'o
Claims Administration % % � 9b 9'0
' Contract Administration % % , % % 9b
, Pooling Level Charges* % % % � �
Miscellaneous Charges* % � % � �
' Retention Totals % % % 9'0 �
' *Please identify and explain
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' Please summarize the key bene�t provisions for your plan(s) as requested on Benefit Proposal Form Cl.
Signature of O�cer or Authorized Person: Date:
' Name of Office or Authorized Person: Title:
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GROUP 1VIEDICAL/HMO PLAN(S) - RATE PROPOSAL FORM A2
' FOR RETIREES AGE 65'OR OLDER)
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' A M B T RATIN TANDARD &POOR'S RATING
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, �i OF PARTICIPANTS RATES MONTHLY
MEDiCAL PLAN(Sl: lST YEAR RATES IN LE SSI+SPOUSE SiNGLE (S`�+SPOUSE PRE1bIIUM
' A.Basic Medicare Supplement Plan (MSP)
B. MSP w/Outpatient Prescription*:
C Other Medicare Supplement Plans*:
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MAXIMUM RENEWAL GUARANTEES:
' 1995 Rates or % (See Specifications)
A.Basic Medicare Supplement Plan (MSP)
B. MSP w/Outpatient Prescription*:
' C Other Medicare Supplement Plans*:
1996 Rates or % (See Speci�cations)
' A.Basic Medicare Supplement Plan (MSP)
B. MSP w/Outpatient Prescription*:
C Other Medicare Supplement Plans*:
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PERCENTAGE OF PREMIUM
, RETENTION FACTORS 1ST YEAR 2ND YEAR 3RD YEAR 4TH YEAR �TH YEAR
Premium Taxes % �a % �o %
' Servicing Agent Fees 5% 5% 5% 5% 5%
Risk Charge % % % % %
Claims Administration % 9'o Ro � %
Contract Administration % % % % %
' Pooling Level Charges* % 9'0 � % �
Miscellaneous Charges* % % % �0 9b
' Retention Totals % % % % %
*Please identify and explain
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Piease summarize the key benefit provisions for your plan(s)as requested on Bene�t Proposal Form C2.
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Signature of Officer or Authorized Person: Date:
, Name of Office or Authorized Person: Title:
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' GROUP MEDI�AL/HMO;PLAN(S) - RATE PROPOSAL FORM B <
� FOR A�'TIVE EMPLOYEES A1VD EARLY RETIREES
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A.M. BEST RATING STANDARD & POOR S RATING
I �/OF PARTICIPANTS RATES MONTHLY
MEDICAL PLAN(Sl: 1ST YEAR RATES � S+1 Q � �S+1) Q PREMIUM
' A.Cunent Plan (Aware Gold LTD wlcopays)
B. Alternative Plan*:
C Alternative Plan*:
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� MAXIMUM RENEWAL GUARANTEES:
1995 Rates or % (See Speci�cations)
A.Current Plan (Aware Gold LTD w/copays)
, B. Alternative Plan*:
C. Alternative Plan*:
� 1996 Rates or % (See Speci�cations)
A.Current Plan (Aware Gold LTD w/copays)
, B. Alternative Plan*:
C.Alternative Plan*:
' PERCENTAGE OF PREMIUM
RETENTION FACTORS 1ST YEAR 2ND YEAR 3RD YEAR 4TH YEAR 5TH YEAR
' Premium Taxes % % % % �O
Servicing Agent Fees 5% 5l 5% 5% 5°l0
Risk Charge % % % % 90
' Claims Administration % � % % %
Contract Administration % % % lo �o
Pooling Level Charges* % % % % %
Miscellaneous Charges* % % � % �o
� Retention Totats % % % % %
*Please identify and explain
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Please summarize the key bene�t provisions far your plan(s) as requested on Benefit Proposal Form CL
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' Signature of Officer or Authorized Person: Date:
Name of Office or Authorized Person: Title:
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CURRENT BENEFITS SUMMARY
AWARE GOLD
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Aw�re Gold Network ' Nonparticipating Providers"
No Deduc#ible �200 Ann�tal deductibie*'
SCou pay 20°10 in eligible expenses up to the'
out-of-pocket ma7c�mum per catentlar year;
for most se�vices.; Then payment:is 100%I<
oftttie attowed amonrtt.*'" <'
COY@1'e(� S81'VICeS
Preventive Care l00% so*
Hearing, vision, and routine exams,
vaccinations, weil-child -care, prenatal
services.
Office visits $15 Copay 80*
Other physician services �ap% gp`
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Physical therapy, occupational,and go% 80*
s eech thera
Diagnostic faboratory and X-ray i�% so*
tests
Home heaith care l00% so*
$5,000 maximum (prior authorization must
be obtained
Inpatient hospita! 80%to$5,000, 100%thereafter. 80%'* (includes facilities for emotionally
Semiprivate room for unlimited days of handicapped children) Subject to a
medicatly necessary care in an acute or reduction of an additional 25%of allawed
skilled nursing facility. amount if the admission is not
reauthorized.
Outpatient hospital 100% ($40 copay may appiy to certain 80"/0'*
outpatient hospital services)
Medical emergencies l00% loo��o**
Any services that do not meet medical
emergency criteria will be paid as outpatient
hos ital benefits.
Chiropractic Care ��°/a 80% '* Limited to 15 services per person
per calendar year.
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CURRENT BENEFITS SUMMARY
AWARE GOLD
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Primary Network Nonparti�ipating Providers !
No Deductibte i $200 Annual deductible� '
` Services must be provided or autharized bp You p�y 20°/u in eligible expenses up tb the
; your,primar��care clinic, aut-of pocket maximum per calendar year;
far most services..::Then payment is i(70°l0
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of'the alTowed�rr►tiunt.** '
Ambulance g�% 80%**
Coverage for emergencies and for other
ambulance use authorized by the primary
care clinic or plan. If air ambulance is not
medically necessary,benefits are paid up to
the cost of und trans rt.
Medical su lies 80% g0°�o*•
Prescription drugs 100%after$8/$12 copay 100%after S8J$12 copay
34-day or 100-unit supply per copay (3 You pay the bill and file your own claim
cycles for contraceptives). Dif�'erent copays
a 1 for formula and nonformul dru s.
Inpatient mental health 100% for up to 73 days per calendar year Refer to your certificate of coverage or
� Coverage is limited to a total of 73 days per (includes facilities for emotionally contract.
calendar ear, handicapped children) For most members,there is no coverage.t
Inpatient chernical dependency 100% for up to 73 days per calendar year Refer to yow certificate of coverage or
Coverage is limited to a total of 73 days per for chemical dependency. contract. '
calendar ear. For most members,there is no coverage.t
Outpatient mental health 80%for the first 10 hours Refer to your certificate of coverage or
Coverage is limited to a total of 40 hours �5%for ttte next 30 hours contract.
per calendar year. For hours 11-40, you For most members,there is no coverage.t
must obtain reauthorization.
Outpatient chemical dependency 100%for up to 130 hours per calendar year Refer to your certificate of coverage or
Coverage is limited to a total of 130 hours contract.
per calendar year for ali networks _ For most members,there is no coverage.t
combined.
Annual out-of-packet maximum$
• per person $500 $800 for columns$and C combined
• r famil $1,000 $2,400 for cotumnsB and C combined
Lifetime m�ximum er erson $1,000,000 for columns A and B combined S1 million for columns A and B combined
* Prescription drugs copays and emergrncy charges do not apply toward your deductible.
*"Fayments for nonparticipating providers'services(column B)are based on allowed amounts. You are responsible for the diPference between billed charges and
allowed amounts,so you may have substantisl outof-pocket expense in addition to your deductible,coinsurance,and copay.
t If you have no coverage,your certificate of rnverage or contract will explain special exception.c. If you have coverage,your benefits are outlined in the
certificate of coverage or contract.
$Annuai out-o£-pocket maximum indud�your dedudible,copays,and rninsurance charges.
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POINT-OF-SERVICE PLAN (DUAL OR TRIPLE OPTION) - BENEFIT PROPOSAL FORM C1
(FOR ACTIVE EMPLOYEES AND EARLY RETIREES)
- lst of 3 a es-
__ _ __ ____ ____ ____ ___ _ _ _ __ __ _ __ __ __ _ _ _ _ __
{A) (B) :(C)
Primary Network; Extended Network(if any) : Nonparticipating Providers
NO DeduCtible. You pay 20%o in eiigible expenses up ta the $300 AnnuAl deduCtible*
Sertrices;must be provided ot anfhori�ed by �ut-of pocket maximum per calendar year, you pay�0%in eligible expenses u�to the
your primary care clinic. Th�n payment is 1�0% out-of-pocket maximum;per calendar year
for most'services. Then'payment is 100"/0'
>.of the allowed amount,**
Covered Services
Preventive Care
Hearing, vision, and routine exams,
vaccinations, well-child care, prenatal
services.
Oftice visits
�., Other physician services
N
Physical therapy, occupational, and .
speechtherapy
Diagnostic laboratory and X-ray
tests
Home health care
$S,OUO maximum in eligible expenses far
columns B and C combined. No maximum
for column A.
Inpatient hospital
Semiprivate room for unlimited days of
medically necessary caze in an acute or
skiiled nursing facility. �
Outpatient hospital
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POINT-OF-SERVICE PLAN (DUAL OR TRIPLE OPTION) - BENEFIT PROPOSAL FORM C1
(FOR ACTIVE EMPLOYEES AND EARLY RETIREES)
- 2ndof3 a es -
(A) > ' �B)' (C)
PrimAry Network : Extendedl Network(if any) ;; Nonparticipafing Providers
No Deductible Youpay 20%in eligible expenses up�o the $300 Annual deductible�
Setwices;mr�st be!'prdvided or�uthorized by °ix�-0f-pocket,maximum per calendar year. you pay',30%in eligible expenses vp ta the
your primary eare:ctinic. ��n payment is 1�0% out-of-pocket maximum per oalendar year
for most':services. Then!,payment is I00%o``
of th��llowed amount.'•'<
Medical emergencies
Any services that do not meet medical
emergency criteria will be paid as oatpatient
hospital benefits.
Chiropractic Care
Ambulance
Coverage for emergencies and for other
ambulance use authorized by the primary
W care clinic or plan. If air ambulance is not
medically necessary,benefits are paid up to
the cost of ground transport.
Medical supplies
• Non-Durable(syringes,needles,
glucose test strips,ostomy
supplies,etc)
• Durabte(including repairs&
replacements)
Prescription drugs
34-day or t00-unit suPP�Y P�' �nPaY (3
cycles for contraceptives). Dif'1'erent copays
apply for formulary and nonformulary drugs.
Inpatient mental health
Coverage is limited to a total of 73 days per
calendar year for all networks combined.
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POINT-OF-SERVICE PLAN (DUAL OR TRIPLE OPTION) - BENEFIT PROPOSAL FORM C1
(FOR ACTIVE EMPLOYEES AND EARLY RETIREES)
- 3rd of 3 a es -
�A) (B)> (G) !
Primary Nefwork Extended Network�if any) ' Nonparticipating Providers
Na Deductible You;pay 20%o in etigible expenses up to the $300 Annual deductible'�
Services must be provided tir autliorizal by p1tt-0f-pncket maximum per calendar year. you pay 30%in eligible expenses up to the
your primary care clinic. .< T�►eri payment is 1�0"/0 out-of-pocket maximum :per calendar year
for most!services. Then>payment is 100"!0''
of the allowed amount.*"!.
Inpatient chemical dependency
Coverage is limited to a total of 73 days per
calendar year for all networks combined.
Outpatient mental health
Coverage is limited to a total of 40 hours
per calendar year for all networks
combined. For hours 11-40, you must
obtain preauthorization.
,,,, Outpatient chemicat dependency
;' Coverage is limited to a totaI of 130 hours
per calendar year for all networks
combined.
Annual out-of-pocket maximum
� per person
• per family
Lifetime maximum per person
Please Identify Medical Plan
Deviations from Bid Specifications
(if�ny):
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MEDICARE SUPPLEMENT PLAN (MSP) - BENEFIT FROPOSAL FORM C2
(FOR RETIREES AGE 65 OR OLDER)
- lst of 3 Pages-
(A) ' �B); �C� ,
Network Benefits < >� Nan-Network Benefifs if an Medicare Benetits >
Covered Services
Preventive Care
Hearing, vision, and routine exams,
vaccinations, well-child care, prenatal
services.
O�ce visits
Qther physician services
....
Physical therapy,occupationat, and
�^ speech therapy
Diagnostic taboratory and X-ray .
tests
Home heaith care
$S,Ot?0 maximum in eligible expenses for
columns B and C combined. No maximum
for column A.
Inpatient hospital
Semiprivate room for uniimited days of
medically necessary care in an acute or
skilled nursing facility.
Outpatient hospital
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MEDICARE SUPPLEMENT PLAN (MSP)- BENEFIT PROPOSAL FORM C2
(FOR RETIREES AGE 65 OR OLDER)
- 2nd of 3 Pages -
(�� ' (B)! (C)
Network Benefits Non-Network Benefifs (if any) Medicare Benefits ;
Medicat emergencies
Any services that do not meet rnedical
emergency criteria will be paid as outpatient
hospital benefits.
Chiropractic Care
Ambulance
Covetage for emergencies and for other
ambulance use authorized by the primary
care clinic or plan. If air ambulance is not
medicalty necessary,benefits are paid up to
the cost of ground transport.
�
°` Medical supplies
• Non-Durable(syringes,needles,
glucose test strips,ostomy
supplies,etc)
• Durable(including repairs&
replacements)
Prescription drugs
34-day or 100-unit supply per copay (3
cycles for contraceptives). Difl'erent copays
apply for fonnulary and nonformulary drugs.
Inpatient mental health
Coverage is limited to a total of 73 days per
calendar year for all networks combined.
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MEDICARE SUPPLEMENT PLAN (MSP) - BENEFTT PROPOSAL FORM C2
(FOR RETIREES AGE 65 OR OLDER)
-3rd of 3 Pages-
�A) > ' �B�i �C) '
Network Benefits ' Non-Network Benetits (if�ny) Medicare Benefits
Inpatient chemical dependency
Coverage is limited to a total of 73 days per
catendar year for all networks combined.
Outpatient mental health
Coverage is timited to a total of 40 hours
per calendar year for aIl networks
combined. Far hours 11-40, you must
obtain preauthorization.
Outpatient chemical dependency
Coverage is limited to a total of 130 hows
per calendar year for all networks
combined.
��
�
Annual oat-of-pocket maximum
• Per Person .
� per family
Lifetime maximum per person
Please Identify Medical Plan
Deviations from Bid Specifications
(if any):
RosemouM�rfp94
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DENTAL BENEFIT SPECIFICATIONS
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DENTAI, BENEFITS SPECIFICATIONS
�
� 1 1 i n will nsidered.
) On y Fully Insured Proposals based on the cunent plan des g be co
' 2) Provide the cunent plan design under an open access fee-for-service plan and/or through a provider
network of dentists; Preferred Provider Organiza6on (PPO) and/or Dental Maintenance Organiza6on
� (DMO), who have agreed to provide quality managed dental care which includes but is not limited to
negotiated(discount)fees.
1 3) The insurance company or service plan provider shall process all Dental PPO and/or DMO Network claims
directly with the dentist.
� 4) All claims with non-network dentists will be paid on the usual, customary and reasonable fee basis (80th
percentile in-state and 90th percentile out-of-state).
� r
5) Covered persons who use Dental Network Prov�ders are not io be respons�ble for excess charges ove the
negotiated fee maximums allowed(e�+cluding deductibles and copayments).
�
6) The City currently uses a Two-Tier premium rate structure (single and family). In addition to Two•Tier
' rates (see Rate Proposal Forms D1), please provide proposals based on the following Three-Tier premium
rate structure; Single, Single+l Dependent,and Family(see Rate Proposal Form D2).
� 7) Retention calculadons should include a 10%level Servicing Agent Fee..
� 8) Submit proposals on the Group Dental Plan(s) Rate Proposal Form D1,D2 and the Dental Benefit Proposal
Form E.
� 9) P'rovide on a quarterly basis,detailed paid claims and utilization data.
' 10) All deviations from the specifications should be clearly ident�ed. Any deviations deemed to be sign�cant
by the City/City Council will disqualify the proposal.
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` rosemount\rfp94 18
�
DENTAL BENEFITS QUESTIONNA�RE
i
tPlease provide answers to the following questions on a separate form. You do not need to restate the
questions as long as the number of your answer dire�tly corresponds with the number of the appropriate
question.
� 1) Are there any start-up costs or other charges not included in your Fully-Insured proposal rates?
� 2) Please identify any areas where your proposal deviates from the specifications (see Dental Benefit
Proposal Form E).
3) Do you utilize a pre-approval system? If yes, at what level of expense must a treamient plan be
� submitted? If a pre-treatment plan is not submitted, will you deny the claim or pay the claim as if
the pre treatment plan was submitted?
' 4) Please describe your professional claim review department's procedures to determine necessity and
appropriateness of services(care). Can you document savings to the purchaser by your professional
review department? If yes,please supply a sample report.
, 5) How do you propose to handle work in progress?
6) Please supply your methodology for deterinining UCR fee levels?
� 7) Does your contract with your dental network guarantee that charges in excess of the negotiated fees
can not be charged to the covered person?
' 8) Please outline your procedures for detecting and correcting the following :
a). Procedure splitting.
b). The legitimacy of minor procedures performed.
� 9) Please supply an illustration of fee maximums for#he following procedures:
� Non-Network Non-Network
Twin Cities Phcenix Arizona
Procedure In Network �80th Percentile) (90th Percentile)
� a). Amalgam- 1 surface
b). Amalgam-2 surface
' c). Composite- 1 surface
d). Single ea�traction
e). Crown-porcelain to metal
1 fl. Pulp cap, direct
g). Full gold crown
� 10) What im act would there be on our rates if the followin benefit changes were made:
P Y g
a) Add a$1250 orthodontic benefit(children only).
� b) Increase the calendar year deductible from$25/person to$50/person and add the$1250
orthodontic benefit(children only).
11) If the above noted benefit changes were made what impact (% increase) an the total claims would �
, you project for(a)?,for(b)? .
, rosemount�rfp94 19
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� THE BENEFITS AVAILABLE UNDER YOUR DENTAL PLAN WITH DELTA DENTAL ARE AS
FOLLOa'S;
ipeduciibles and Maximums:
Your dentai program has a$25.00 annual deductible per person and 575.00 maximum per family. Ttiis
� means that each coverage year, you must pay a deductible on Coverages B1 through C2 before the
appropriate copayment level is applied. To encourage you to seek regular dental care,this does not apply
to Coverage A. There is an annual maximum of SI,250.40 per person per year for Coverages A through
� C. .
COVER.AGE A• (DiaQnostic and Preventive Servicesl - 1009b Conavment
� A. Ora] examinations at six (6) month intervals, including bitewing x zays at twelve (12) month
intervals.
B. Full mouth x-rays once in any five(5)year interval, unless special nced is shown.
� C. Six (6) intraoral periapical x-rays in any twelve {12)month period.
D. Dental prophylaxis or periodontal maintenance, as prescribed by the dentist, but not more than
once every six (6) months.
� E. Topical fluoride applications as prescribed by the dentist, but not more than once in any taelve
(12)month interval and then only for covered person under the age of nineteen(19)years,unless
special need is shown.
� COVER.AGE B 1 a• tBasic Services)-809b Copayment
A. Emergency veatment for relief of pain.
B. Space maintainers for missing posterior primary teeth.
� C. Restoration of lost tooth swcture as � result of tooth decay or fracture, when restored with
amalgams or synthetic porcelain restorations,or preformed crowns for degendent children only
up to age nineteen (19)years.
1 D. Restorations of lost tooth structure as a result af to�th decay or fracture, when restored with
plastic or composite restorations for anterior t�eeth otily. When such reswrations are place� in
posterior teeth, or if inlays or onlays are placed, benefits shall be limited to the same surfaces
� and allowances for amalgam.
LIAiITA'TION: Benefit for the replacement of restorations shall be provided only after a two(2)
- year period has elapsed measured from the date on ��hich the procedure was last benefitterl by
� Delta. �
CO\'ERAGE B l b� (Endodontics)- 80 k Conavment
� A. Includes pulpal therapy and root canal filling. No coverage is provided for retreatment.
�Q�'ERAGE Btc- (Periodontics)- 80% Conavment
A. Non-surgical periodontics: procedures necessary for the treatment of the diseases of the gingiva
t (gum�).
LII�IITATION: Benefit for the repeat of any non-surgical periodontal treatment will be provided
onl�� after a two (2)year period has elapsed.
t B. Surgical periodontics: the surgical procedures necessary for the treatment of diseases of the
gingiva {gums) and bone supporting the teeth.
LIAiTTATION: Benefit for ihe repeat of any surgical periodontal treatment will be pravided anly
� after a three{3) year period has elapsed.
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� �OVERAGE Bld• (Oral Surge 1 - 80% Conavment
A. Surgica] and non-surgical excractions for tooth removal, including pre- and post-operative care.
, $. Surgical and non-surgical treatment of temporomandibular joint disorder and craniomandibular
disorder pursuant to Minnesota Statutes Section 62A.043 Subd.3, subject to the provisions of
Section II (Coordination of Benefits).
� VERA E B2: S ecial restorative rocedures to restore lost t th tructure as a re uit tooth eca
Qr fracturel - 50� G.pavment
' A. Crow�ns, when the te�th cannot be restored with a filling material.
LIMITATION: Benefit for the replacement of a crown will be provided only after a five(5)year
period measured from the date on which the procedure was last benefitted by Delta.
� �OVERAGE C1• (Prosthetics -Repairs and Adjustments)- 809b Conavment
A. Prosthetics: Provides for repairs and adjustrnents to prosthetic appliances.
' LIhsITATION: No adjustments, relining or rebasing will be benefitted if performed during the
first six (6} months following denture placement. Tissue conditioning,relining or rebasing will
be allowed no more often than once in a two (2)year period.
` �nvFu er;F t��• �rr,�rheticc - Removable and Fixedl -50°k Covavment
A. Prosthetics: Provides bridges, partial dentures or full dentures for the replacement of fully
extracted or missing permanent teeth. Benefits are limited to the cammonly performed method
' of tooth replacement.
EXCLUSION: Coverage is NOT provided for the replacement of misplaced,lost or stolen denta;
prosthetic appliances.
' LIMIT'AT10N: Coverage is NOT provided for initial instaltation of a bridge or denwre to
replace teeth missing prior to coverage by Delta.
B. Replacement Benefits: a given prosthetic appliance for the purpose of replacing any eacisting
� apptiance will be provided only afier five (5) years have elapsed from when iast benefitte� by
Delta, and then only in the event that the existing appliance is not, and cannot be made
satisfactory. Services which are necessary to make an appliance satisfacwry will be provided.
� EXCLUSION: Coverage will not be provided for the replacement of an existing partial denture
with a bridge.
� C. Alvealectom��, alveoplasty and vestibuloplasry when required to prepaze for dentures.
,
lf you ha�•e specific questions about your dental program, you a�ill find the answers in the dental benefiu
' brochure you ��ill be receiving in the near fut►ire. You may atso call Delta Dental's Benefit Depar�ment
at 6l2/944-5252.
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� GROUP b�NT1�1L PLAN(5) 1tATE PROP4�AL �'dRM D1
(FOR ACTIVE EMPLOYEES, �ARLY I�ETIREES AND RETIREES)
,
A.M. BEST RATING STANDARD & POOR'S RATING
� !{OF PARTICIPANTS RATES MONTHLY
DENTAL PLAN(Sl: IST YEAR RATES SINGLE FAMTLY IS NGLE FAMILY PREMIUM
` A.Current Plan Design
B. Alternative Plan*:
C Alternative Plan*:
'
' MAXIMUM RENEWAL GUARANTEES:
1995 Rates or % (See Speci�cations)
' A.Current Plan Design
B. Alternative Plan*:
C.Alternative Plan*:
' 1996 Rates ar % (See Specifications)
A.Current Plan Design
, B. Alternative Plan*:
C.Alternative Plan*:
' PERCENTAGE OF PREMIUM
RETENTION FACTORS 1ST YEAR 2ND YEAR 3RD YEAR 4TH YEAR STH YEAR
, Premium Taxes % % % Rb %
Servicing Agent Fees 10% 10% 10% 10% 10%
Risk Charge � % % `� �
� Claims Administration '% % % � %
Contract Administration % % % % %
Pooling Level Charges* 30 9'0 % % Ro
Miscellaneous Charges* % % % � %
� Retention Totals 9'0 % % % �
' *Please identify and explain
'
� Please summarize the key benefit provisions for your plan(s) as requested on Bene�t Proposal Form E.
: � Signature of O�cer or Authorized Person: Date:
Name of Office or Authorized Person: Title:
' msemount�rfp94 22
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' GROUP DENTAL PLAN{S) -ItATE PROPOSAL FORM D2
(FOR AC?'lVE EMPLOYEES, EARLY ItETIREES AND RETIREES)
,
A.M. BEST RATING STANDARD & POOR'S RATING
� �OF PARTICIPANTS RATES MONTHLY
DENTAL PLAN(S): 1ST YEAR RATES �S' (5+11 Q S�` �S+1) LF� PREMIUM
, A.Current Plan Design
B. Alternative Plan*:
� C Alternative Plan*:
' MAXTMUM RENEWAL GUARANTEES:
1995 Rates or % (See Speci�ications)
, A.Current Plan Design
B. Alternative Plan*:
C. Alternative Plan*:
� 1996 Rates or % (See Speci�cations)
A.Current Plan Design
' B.Alternative Plan*:
C. Alternative Plan*:
' PERCENTAGE OF PREMIUM
RETENTION FACTORS 1ST YEAR 2ND YEAR 3RD YEAR 4TH YEAR STH YEAR
� Premium Taxes % � �o � �
Servicing Agent Fees 109'0 10% 10% 10% 109b
' Risk Chatge % % °lo % 96
Clairns Administration % % % �o �
Contract Administration % % l % °16
Pooling Level Charges* % � % % �
, Miscellanepus Charges* % % % % �
Retention Totals % % % � �o
' *Please identify and explain
,
, Please summarize the key benefit pravisions for your plan(s) as requested on Benefit Proposal Form E.
' Signature of Q�cer or Authorized Person: Date:
Name of Office or Authorized Person: Title:
� rosemount�rfp94 23
�
GR4UP DENTA�,PLAI�T�S) - BENEFIT PROPOSAL FORM� '
'
(FOR AC�'IVE EMPLQYEES, EARLY ItETIREES AND RETIREES)
' -lstof2 a es-
�
Deductibles and Maximums:
1
1 � .
' COVERAGE A: Dia nostic and Preventive Services - 100% Co a ment
'
'
, COVERAGE Bla: (Basic Services)-80% Conavment
�
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' COVERAGE Blb: (Endodontics)-SO% Conavment
'
'
COVERAGE B1 c: (Endodonticsl-80% Copavment
�
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'
' Rosemo�nt�rfp94 24
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�ROUP DENTATf PLAN�S) - BENEFiT PROPOSAT� F4RM E ; .;
'
(FOR ACTIVE EMPLUYEES, EARLY IiETIREES}iND RETIREES)
' •2nd of� a es-
' o
COVERAGE Bld: (Oral Surgerv)-80/o Copavment
'
'
' COVERGAE B2: (Special restorative nrocedures to restore lost tooth structure as a result of
tooth decav or fracture)-50%Copavment
,
'
, COVERAGE CL• (Prosthetics-Repairs and Adiustments)-80% Copayment
�
'
COVERAGE C2: (Prosthetics-Removable and Fixedl-50% Copavment
'
,
� PLEASE IDENTIFY DENTAL PLAN DEVIATIONS FROM BID SPECIFICATION(IF ANY):
'
'
,
' Rosemountlrfp94 25
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'
1 � GROUP LONG-TERM DISABILITY
1
SPECIFICATIONS
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' GROUP LONG TERM DISABILITY�LTD�
INSURANCE SPECIFICATIONS
,
' 1) Only fully-insured proposals will be considered.
2) All life insurance companies submitting proposals for group LTD insurance must have no less than an "A" rating
, from A.M. Best and/or a "AA" rating from Standard & Poor's for the last five years. Please provide ratings
verification.
, 3) Proposals can be based on either a participating(dividend paying),and/or non participating premium structure. If you
can offer both please do sa If proposals are based on a participating premium structure, please provide an
explanation of the dividend formula.
'
4) Submit proposals on the °LTD Rate Proposal Form F and LTD Benefit Proposal Form G". Proposal forms may be
' photocopied if additional forms are needed.
' S) Initial rates should be guaranteed for no less than a 24 month period. Retention caiculations should include a 10%
Servicing Agent Fee. See LTD Rate Proposal Form F.
' 6) Provide a sample group contract. Please note that the LTD Ra.te Proposal Form F requires a proposal without (w/o)
cost of living (COLA) benefits under Total Disability Benefit Provisions and a proposal with (wn COLA Benefits
based on CPI (not to exceed 5%) unlimited duration. Also please note the LTD Benefit Proposal Form G requires
� page references for verification of key defuutions and provisions from the requested sample group cantract.
7) The City intends to offer Long Term Disability Benefits on a voluntary basis (100%employee paid). Please provide
' proposals based on one or more of the following minimum participation requirements; (1) 75% minimum
participation, (2) 90+%minimum participation, (3) 100%participation. See LTD Rate Proposal Form F.
' 8) The City intends to make a major effort to get satisfactory participation in the LTD Plan. The City requests that
there be a one time"open enrollment period"prior to the January O1, 1994 effective date.
' 9) All deviations from the specifications should be clearly identified when completing the LTD Benefit Proposal Form
G. Any deviations deemed to be significant by the City/City Council will disqualify the proposal.
0
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' rosemount�rt'p94 26
e
GROi1P LONG'I`ERM DI�ABILITY �ATE'PROPOSA�.,FORIVI E
�
, INSURANCE COMPANY'S NAME
' A.M. Best Rating Standard&Poor's Rating
Type of Contract: Participating Non-Participating
'
RateJ$100 Rate Monthlv
' 90 Day Elimination Period wlo COLA Covered Payroll Guarantee Volume Premium
w/75%minimum participation
, w/90+%minimum participation
' w/100%participation
� 90 Dav Elimination Period w/COLA
w/75%minimum participation
' w/90+%minimum participation
' w/100%participation
, Please summarize the key definitions and provisions noted on the LTD Benefit Proposal Form G.
Remember to also include where indicated the page references from the sample group contra.ct.
'
'
'
,
'
' Signature of Officer or Authorized Person: Date:
Name of Office or Authorized Person: Title:
' Rosemount�rfp94 27
'
' LONG-TERM DISABILITY BENEFIT PROPOSAL FORM G '
' FORTIS BENEFITS (Current Plan� RFP Response
BASIC BENEFITS: Sample Group Contract
' Reference Page(s)
Elimination Period 90 Day
' Benefit Percenta.ge 60%of monthly pay
Maximum Benefit $4,500 per month.
� Minimum Benefit $100 minimum regardless
Amount of income from other
sources.
'
Maximum Benefit Disability Benefit
� Period Commencin� Period
Prior to The day before
age 60 retirement age(65)
as defined by the
' Social Security Normal
Retirement Age as
stated in the 1983
' Revision af the
United Staxes Social
Security Act.
1 60 but The day before
before retirement age(65)
65 or 36 months of
' disability,whichever
is longer.
� 65 but 24 months of disability.*
before
68
' 68 but 18 months of disabiliry.*
before
70
� 70 but 15 months of disability.*
before
' 72.
Age 72 12 months Of disability.*
or more
,
' *Following the end of the qualifying period.
' Rosemount�rfp94
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� ' LONG-TERM DISABILITY BENEFIT PROPOSAL FORM G
� �
FORTIS BENEFITS (Current Plan) RFP Response
' DISABILIT'Y DEPINITIONS: Sample Group Contract
Reference Page(s)
Total Disability
' (Due to illness or
injury during"Own
Occupation Period")
�
During the first 36 months
of disability benefit payments,
' an injury,sickness,
or pregnancy requires that
you be under the regular
' care and attendance of a
doctor,and prevents you
from performing the material
' duties of your regular
occup�tion.
, Total Disability After 36 months of disability benefit
Thereafter payments,an injury, sickness,or
pregnancy prevents you from
' perfornung the material
duties of any occupation
for which your education,
' qualifies you.
' Residual Definition If you meet the occupational
(Does not require a test, limited employment
penod of total will not interrupt the
disability during qualifying period or the
' elimination period) period of disability. An
insured person is working,
partially/residually disabled,
' and not able to earn more
than 80%of pre-disability
monthly earnings due to
' iliness, injury,or pregnancy.
The monthly earnings figure
used to determine total disability
is increased by 7.5%on each
� anniversary�of the date of
disability.
�
, Rosemount�rfp94
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�
� LONG-TERM DISABILTTY BENEFIT PROPOSAL FORM G
�
FORTIS BENEFITS(Current Plan� RFP Res�onse
' INTEGRATION(BENEFIT OFFSETS): Sample Group Contract
Reference Page(s)
, Social Security -Disability benefits from
United States Social Security
Act,as a Primarv Benefit.
� Other Integration -Any other group(Employer Paid)
Disability Plans.
Worker's Compensation.
� -Other Governmental Disability
Benefit Plans.
-Retirement Benefits from a
� Government Plan.
� Other Sources If you are eligible to receive
any salary wages . . . from the
� Policy Holderor which you earn
from any work you do, (The
Insurer)will not consider such
, income for the 12 consecutive
months starting on the day you
become entitled to it,as long as
the sum of:
' -The Income Described Above,
-The Schedule Amount and
� -Benefits from any source
described under"Monthly
Payment Limit" is not more
� than 100% . . . (The Insurer)
will subtract the amount
over 100%from the
schedule amount . . .
' After this 12 month period,
50%of the amount determined
� a$er reducing any salary.
.
'
�
� Rosemountlrfp94
30
'
I ' LONG-TERM DtSABILTTY BENEFIT PROPOSAL FORM G
�
FORTIS BENEFITS (Current Plan� RFP Response
, INTEGRATION(BENEFIT OFFSETS) CONTINUED: Sample Group Contract
Reference Page(s)
� Monthly Payment After 12 months,if the
Limit Scheduled Benefit plus
the payments from the
' following sources is more
than 70%of the Claimant's
Monthly Earnings,the
excess is subtracted from
� the Benefits othenvise
Payable.
-By any Child Care Expense
� (Not more than$250 per
child, per month)
-Disability Benefits
Received under any Group
' Insurance Plan for which
The Employer pays no
portion of the cost
� directly or indirectly.
-No Fault Auto Insurance
Disability Benefits.
' -50%of Any Disability
Benefits from the
United States Sacial
Security Act for your
' dependents. '
-Retirement Benefits from
a Retirement Plan Sponsored
' by your Employer.
' ,
Non-Integrated Items -Plan}ou pay for
entirely(i.e. Individual
' Disability Plan)
-Qualified Profit-Sharing Plan
-Thrift Plan
' -Individual Retirement Account(IRA)
-Tax Sheltered Annuity(TSA)
-Stock O���nership Plan
-Deferred Compensation Plan
� -401(k)Plan
'
� Rosemountkfp94
31
'
I ' LONG-TERM DISABILITY BENEFIT PROPOSAL FORM G
'
FORTIS BENEFITS (Current Plan� RFP Response
' LIMITATIONS: Sample Group Contract
Reference Page(s)
' Mental and Nervous If you are not hospital
Diseases or Disorders confined,the Maximum
Benefit Period for all
' Periods of Disability is
24 months. This is not
a separate m�imum for
each condition,or for
' each period of disability,
but a combined maximum
for all periods of disability
' and for all of the conditions.
If you are Hospital Confined,
' the Maximum Benefit Period
is the same as for any Injury
or sickness covered under the
policy. However, if you have
e received 24 months of benefits
as an Outpatient, (The Insurer)
only pays benefits if:
, -Your Hospital Confinement
starts within 3 months after
the end of a previous Hospital
� Confinement in which you
Qualified for benefits;or
' -You can return to active
work and then start a new
Period Of Disability,and your
' , Hospital Confinement starts
during the Qualifying Period
or within 3 months after you
satisfy it.
'
' Pre-Existing 3-3-12
Conditions
'
�
� Rosemourrt�rfp94
32
'
ILONG-TERM DISABILIT'Y BENEFIT PROPOSAT;,FORM G
'
FORTIS BENEFITS (Current Planl RFP Response
' GENERAL PROVISIONS: Sample Group Contract
Interruption of A return to full-time Reference Page(s)
Elimination Period work of up to the
' Provision following number of
working days will not
require a new Elimination-
' Period: 90 day
Etimination Period-15
Working Days.
' Recunent Disability Successive periods of
Provision disability due to the
' same or related causes
shall be treated as one
Period of Disability and
' will not require a new
Elimination Period if
separated by less than
6 Months.
� EXCLUSIONS: Sample Group Contract
-War or any Act of War, Reference Page(s)
' whether declared or not.
-Intentionally self-inflicted
Injury,while sane or insane
-Taking part in or the result
' of taking part in committing
a felony.
, MISCELLANEOUS: Sample Group Cantract
Conversion Provision If your LTD Insurance ends . . . Reference Page(s)
(and)you have been insured under
' the Policy for at least a year.
-The Proof af Good Health is not
required.
, -The Benefits . . .will be those
be offered for conversion at
that time. . .
' -The Premium will be based on
Rates in effect for conversion
at that time.
� Cost of Living Rider CPI not to exceed 5%for an Sample Group Contract
. unlimited duration Reference Page(s)
'
' Rosemountlrfp94 .
33
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�0��
Single (S}, Famil9 C�!
Aware (A), Ist D�ol�ar ($}
�i�RE # AiVN'[IAL
DOB S�X NIEDIC�LL DENTAG DATE DEF OLCUFAT�f�N SALARY
4-3{1-60 l�t � A F 5-18-92 5 1V�eeha�c I 22,216
1(k4-�60 M F A F 1-4-89 3 Bng"sn�eer�n.g�'echnician 24,529
$-19-50 M F A F 5-$-89 1 IVlaurbenance III 32,919
5-15-11 1VI S $ S 4-5-93 Polive �€f'icer 28,6�52
12-1-44 A�t S $ 5 9-5-$3 Pazks 8r Rec Dirn.,cbar 53,454
3-1-6� M F A S 5-21-87 3 Ffllive C}ff'i�c�er 40,4Z8
3-27-51 Nt F A F 7-24-?2 2 . Pazks Ma,incEenauve Superv. 4�,875
W
6-22-68 � F S A S 9-2-92 PrQgrarn Direcs�or 19,}89
� 9-Zl-St} F P A F � 7-b-92 3 R�ec�ptiflnist �0,5$8 .
2-14-45 M P A F 10-4-$fi 3 Mai�tbenance I 23,86b
8-Y-67 M S $ 5 4-5-94 Maintenanee II 30,4g4
I1-2-5d F S $ S 1-1(}-?7 Public l�arks Secretary 28,34'l
4-14-62 M S A S 1(}-7-85 Folice Serg�ant 4�,368
4-10-60 F S A� S G-I3-91 P�annin�Directtor 51,41Z
b-1-50 M F A F 10-9-�0 -2 Maintenance I 23,630
1U-3-52 M S $ S 2-1-93 Suilding Inspectcsr 27,490
6-9-53 F F A F 5-13-91 3 Acca�ntant 36,228
9-12-63 1Vi F A F i�Z.i8--87 1 Building In�gecEor 32,b{k�
3-8 SI F S � S 1�-t4-8T Ad�mirriistrati�r�Secret2try 25,808
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Single (S), Family (P�
A�srare �A), 1 st Dollar ($)
HIRE # ANNUAL
D4B SEX NfEDICAL Q�tTAL t}ATE DEP C3�CUPATION SA�ARY
4-21-47 M F A F 5-24-$$ 1 Mainbenanc�e [ 23,866
10�-23-'72 F S A► �tJ►BRA
it�-15-4'7 lM F A F I1-I-$6 1 Cit� 1�.c�ninistr�tor 67,'Tlfl
2 2 54 A+I S $ F '7-�9-$9 Maintenance II �1,b95
6-24-62 F S A � 3-Lq-85 .+�ssL Parks &Rec. DFirector 36,840
11-2�-38 M F A F 12-13-72 1 Police CY�i�f 54,496
5-5-61 14� S A� S 11-15-86 DVlaintenance II 32,Ot}? �
W
�9-11-fi4 F S A S 8-23-83 Acoouncant 2�,347 .
`� 3-24-54 M S � S ' 6-I8-94 A�ain�+enance II � 3�,3d8
Z-2b-56 Nt P A F 1-1(�-$1 3 Poliee Lieutenant . 47,394
3-t$-54 M F A F 3-1-93 3 Bngineering 'Fechaician 2$,U52
7-5-52 P S A S fr12?3 Poiice Se�retary 3a,710
1�-15-56 M S $ S 5-� Fir�ance I�ir�c�or 52,973
14-2Q-42 M S $ S 6 22 92 Bcvnotnic I)evelcspcnent Coo�+d. 47,38fl
�-22-6] M F A F 1-27-92 3 Palice Offricer 33,431
9-fU-64 M P A S 9-4-88 1 Fvlice Officer 40,�2$
12-18-58 M S � S 2-i{}-80 �olice �ergeant 4S,$13
8-31-54 M S $ 5 2-17-9Z Cit� Engine�r 46,990
9-28-55 Ivi S A 5 1-2Z-92 Assistant Plac�ner 30,S�J4
� � � � � � � � � � � � � � � r � � �
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_ �'
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5ingle (S), Famiiy (F}
A�var+� (A), 1 st 1?ollar�}
HJR� # .��NN�TAL
DOB SEX MEDICAL DEN'�AL DA1'� DEF €?�CUPATION SALARY
6-4-49 F F A F 2-23-$1 I Piz�ntir�g Secre�ary 28,34�
11-9-52 M P A F ?-1-'78 2 Folic� Officer �1,221
i2-13-28 F S A C4B12A
�8 � � �S ��
3-15-57 M S A S 4-4-88 A,+techani+�III 32,433
12-31-64 M F A F 2-4-86 3 Ffllice 4ffic�r 40,428
8�2-69 M P A S 1�3 9U 3 Mai�mertance I 23,?34
� , 5-2'7-54 F S � S 4-17-84 Building Dept. S�ect�tary �5,8�8
8-15-58 M F A F � 5-1-�0 3 l�aintena�ce � 34,041 � �
i-25-6fi M S A S �-24-9t} Pblic:� 4ffcer 39,53�
5-31-56 14�E F A F 6-2A3 3 �acnmuiuty Centet D�az�ager 43,548
�-22-48 F F � S 3-13-$5 2 Adminis�rative Assistant 44,U79
1-2$-51 I4i F A F 4-1-$� 2 Public Warks Dirc�ctor 54,4�2
8-2-�0 lM F � F 10 2-85 3 Po�ice Offiaer 40,4�8
6-27-54 F S A S 2-fr-89 Deputy Registrar 24,3�ib
12 Z�-57 F S � F 4-G-88 Fcon. De�v./Persannel Scc. 2fi,718
S-9 3S M F A S I1-i-84 3 Public Works Sup�rvisor 44,943
'
,
'
'
�
� ADDENDUM A
I MEDICAL ACCOUNTING/FINANCIAL
�
SUMMARIE S
�
�
�
1
�
�
�
�
�
� :
�
�
i
1
BLUE CROSS BLUE SHIELD MEDTCAL PLAN RATE HISTORY
'
�
,
_ Base Plus Major Medical Aware Gold LTD w/Copays
'
>:::::>::>:.;:�::;:�;";::::::<:::::::>>;::<:':::::::;::::;`:: :;:;:::::>::::>:::::::<>::::':::::>>::::>;:::::::>:«:::>::;;:''::>::
am� ..<:
:<:»::>�» ;:: .<:>:::::;:<::<::: <
::;<:>:::
::>:<::.<.:::>:::: : �� ... ..... . l':<:::�::::::'<:;:: :..........S�n le : F .
:::::::>:::�ecounfin <:Per�ad:::>::>::>:::>::;' .......Sin le:::::>:::::::::.:::. :.:.::.:.::Farru
::,;: »
... ::
::::<::�:�:;.::�:::......t....._..:_�._:....�.......:::::�..::. .:.:....,,—�.—.:.:::.:�::::
....,.`395.27::::<::';::
�� 13 L'76 �..�`
�:;�:s::>: 36317,::>::``��>: :`'>�: $ ��:: $
:;;<�::;;�1/94 thru�:<12/94� �� � � �121�.06�� . $ .
, $
' i2192 thru 12/93* $119.54 $420.69 $129.87 $399.68
12/91 thru 11/92 $113.54 $399.60 $126.39 $388.97
� 12/90 thru 11/91 $114.Q9 $401.54 $127.07 390.80
12/89 thru 11/90 $105.47 $370.43 $131.74 $398.32
'
12/88 thru 1ll89 $105.35 $363.98 $131.b2 $398.05
' 12/87 thru 11/88 $ 80.44 $277.75 5100.99 $305.13
'
' " 12/92- 12/93 Contract and rates extended for one month(total of 13 months).
'
�
'
'
' Rosemount�rfp94 1�1
� � � � � � � � O � � � � � � � � � �
ANNUAL RENEWAL
MARKETING REPRESENTATIVE: JANA EDGREN NUMBER: 0024
T0: MARKETING
DATE: OS/19/93
5U8JECTt THE DECEMBER, 1993 RENEWAL OF:
GROUP NAME: CITY OF ROSEMOUNT
GROUP NUMBER: GM047 CITY: ROSEMOUNT ZIP: 55068
GROUP SIZE: . BC: 55 BS: 55
ELIGIBIIiTY INFORMATION
NUMBER OF SUBS CONTRIBUTION PROB HRS EFFECTIVE OATE
CLA55 DEFtNITION SINGLE FAMILY DESCRIPTION DESCRIPT REQ COVERAGE
OGM047'000 ALL FULL TIMECdas�rw.�s �+.t�� 14 0 100� EMPLOYEE-PARTIAL/NO DEPENOENT NONE 30.00 15T DAY CONT MO-FOL ELIG
OGM047010 FULLTIME-IIMITED GOLD 14 27 100� EMRLOYEE-PARTIAL/NO DEPENDENT NONE 30.00 iST DAY CONT MO-FOL ELIG
RATES ARE CONTINGENT UPON THE ENROLLMENT CHANGING NOT MORE THAN 10$.
�C�i�C�t�c�C�C�C�c�tx�C�C�4�'csc�C4c�C�C�i�Y�c�Ci<�C�t�h�t�C�t�C�44c�c�t�C�t��C�h�&�t�F�k�Ir�k�e�Ci��Ci�c�F�C�C�C�C91t��t�kit�t�t�c�C�C�t�t�t�ti�C�Cic�h�Y�C�icfc�C�C�t�c�C�C�k�k�F�t�C�C�Ci�C�C�C�r�Fic�2�C�hiir�Y9F�C�r�i�C�C�k�c4c��e�'c�C�t�t�C�C�F�C�r�F�k91r�ClF�k
*�� NOTE ��� MARKETING - PLEASE VERIFY ALL OF THE ABOVE INFORMATION AND INDICATE ANY NECESSARY CHANGES.
S 1 GNATUF2E (MARRET I NG REPRESENtAT I VE) : DA7E:___,_
;- --- -
. __ _ _---. _. _ ___�.___._ _._ .._.._.__..__ .._._.
N
BLUE CROSS 6LUE SHIELD CURREN7 8 RENEWAL RATES
RENEWAL DATE 12/O1/93 PAGE 1
RAID THROUGH DATE O6/30/93
TRADfTIONAL HOSPITAL/MfD SURG/MAJ MED
LfMiT�D GOLD WITH CQPAYS GROUP NUMBEttM�OGM047
OVERALL � RATE CHG DECREASED 1 .0 �
CURRENT RATE5 EFFECTiVE 12/O1/92 RENEWRI RATES EFFEC7IVE 12/O1193
COMMENT5 CT CURRENT RENEWAL
FIRST DOtLAR S: 14 SINGIE 119.54 121 .06
F: 0 FAMILY 420.69 363.i7
A.G. LTD W/CPY S: 13 SINGLE 129.$7 131 .76
F: 26 FAMILY 399.68 395.27
� � � � � � � � � � � � � � � � � � �
BLUE CROSS BLUE SHIELD RENEWAL DEVELOPMENT SUMMARY
RENfWAL DATf 12/Ol/93 PAGE 1
PAID THROUGH DATE 06/30j93
TRADITIONAL HOSPtTAL/MED SURG/MAJ MED
CITY OF RQSEMOUNT
LIMITED GOLD WITH COPAYS GROUP NUMBER OGM047
GROUP SIZE 03
EXCESS CLAIM POOLING LIMIT $ 25,000
fACILITY PROFESSIONAL DRUGS TOTAL
1 . 12.0 MONTH RENEWAL RATE BA5E PERIOD
SERVICE DATES FROM 05/92 THRU 04/93
CLAIMS PAYMEN7 $ 28,796 $ 42,967 $ 12,430 $ 84,193
2� MINNESOTACAREEHOSPRTAL PROVIOER CHARGE (1992 ONLY) $ 313 $ 0 $ 0 $ 313
3. RENEWAL RATE BASE PERtOD IBNR $ 1,992 $ 2,947 $ 491 $ 5,430
4. TOTAL COMPLETED CLAIMS $ 31, 101 $ 45,914 $ 12,921 $ $9,936
5. EXCESS POOLED CLAIMS $ 0 $ 0 $ 0 $ 0
6. EXCESS CLAIM POOLING CHARGE $ 8,748 $ 4,116 $ 4,288 $ 17,152
Y
" 7. TOTAL RENEWAL RATE-BASE-CLAIMS $ 39,849 $ 50,030 $ t7,209 $ 107,088
8. CURRENT CONTRACT YR COST TREND ( 7.0 MONTHS} 106.79� 106.79X T06.79� 106.79�
9. PROJECTED CURRENT CONTRACT YEAR CLAIMS (12.0 MONTHS) $ 42,555 $ 53,427 $ 18,377 $ 114,359
10. RENEWAL YEAR CQST TREND ( 12.0 MONTHS) 111 .64� t11 .64� 111 .64� 111 .64�
11 . PROJECTED RENEWAL YEAR CLAIMS (12.0 MONTHS) $ 47,508 $ 59,646 $ 20,516 $ 127,670
12. 7ARGET LOSS RATIO 78.9�
13. NEEDEO INCOME $ 161,812
14. RATE BASE INCOME $ 157,357
15. INCREASE CALCULATEb 2.$�
1'6. 1NCREA5E BASED ON CREDIBiLITY BAND 2.8�
DECREpSE EFFECTIVE 12/O1/93 - DUE TO BENEFIT CHANGES, THIS MAY NOT BE THE FiNAL RECOMMENDATION. 1 .0�
REFER T0 THE ATTACHED FOR FINAL RENEWAL RATES.
00004816k 0000666-100/009.001 E680 08/19/93
� � � � � � � � � � � � � � � � � � �
BLUE CRO55 BLUE SHIELD MONTHLY UTILIZATION - INCURRED
RENEWAI �ATE 12/Ol/93 PAGE 2
PAID THROUGH DATE 06/30/93
TRADITIONAL NOSPITAL/MED SURG/MAJ MED
CITY OF ROSEMOUNT BENEFIT PAYMENI'
LIMITED GOLD W(TH COPAYS GROUP NUMBER OGM047
- CONTRACTS - CLAtMS COMPLETED LOSS
MONTH SINGLE 2-PARTY fAMILY TOTAL INCOME PAYMENT CLAIMS RATIO
12191 25 20 45 10,784.95 2�432.01 2,432.01
01/92 26 20 46 10,898.49 6�813.36 6�813.36 ,
02/92 25 22 47 11,550.04 17, 145.59 17, 146.90
03/92 26 22 48 11,b63.58 11,323.8Q 11,324.25
04/92 26 22 48 11,663.58 3,634.39 3.634.72
05/92 26 22 48 11,663.58 3,350.98 3,469.67
06/92 26 23 49 12,052.55 4,260.19 4,414.40
07/92 26 23 49 12,052.55 4.523.18 4.692.50
08/92 25 25 50 12,716.95 5,519.2} 5.73T.49
09/92 25 25 50 12,716.95 5,752.07 5,978.78
10/92 25 25 50 12�716.95 6�311 .44 6,579.08
11/92 25 25 50 12,716.95 16, 109.91 16,831.32
TOTAL 306 274 580 $ 143,197.12 $ $7. 176.13 $ 89�048.48 62.2 $
� 12/92 25 25 50 13,104.46 3.939.77 4,134.81
�, Ot/93 26 24 50 12,83#.65 13,376.11 14, 139.7T
02/93 27 24 51 12,954.19 2,837.19 3,026.07
03/93 25 25 50 13,114.79 6,599.44 7,215.29
04/93 26 26 52 13,634,01 11,613.58 13,407.97
5 MON7H
TOTAL 129 124 253 S 65,642.10 $ 38,366.09 $ 41,923.91 63.9 �
05/93 27 26 53 $ 13,753.55 � 7,628.81
06/93 27 2b 53 $ 13,753.55 1,694.54
7 MON7H 47 6$9.44
TOTAL 183 176 359 $ 93,149.20 ______S +
RENEWAL RATE BASE 05/92 THRU 04/93
TOTAL 307 292 599 $ 152,278.58 $ 84,193.07 $ 89,621 .i5 5$.9 $
CLAIMS ARE BY SERVICE OA7E
000048164 OOOd666-100/009.000 E61T 07/17/93
� � � � � � � � � � � � � � � r � � �
BLUE CRO55 BLUE SHIELD MONTHIY UTILIZATION - INCURRED
RENEWAI DATE 12/Ol/93 PAGE 1
PAID THROUGH DATE 06/30/93
TRADITIONAL HOSPITAL/MED SURG/MAJ MED
CITY OF ROSEMOUNT BENEFIT PAYMENT
LIMITED GOLD WITH COPAYS GROUP NUMBER OGM047
- CONTRACTS - CLAIMS COMPLETED LOSS
MON7H SINGIE 2-PARTY FAMILY TOTAL INCOME PAYMENT CLAIMS RAT10
12/90 27 20 47 11 ,075.91 7,024.74 7,026.03
O1/91 27 20 47 11 ,075.91 85,074.55 $5,074.91
02/91 27 19 46 10,685.11 $,345.34 8,345.34
03/91 28 17 45 10,006.86 3,832.92 3,832,92
04/91 28 16 44 9,616.06 4,150.29 4,150.29
05/91 28 16 44 9,616.06 2,459.24 2,459.24
06I9} 29 i7 46 10,146.91 4,862.5T 4,862.51
07191 29 l8 k7 10,537.71 2,777.59 2,777.59
08/91 28 18 46 10,423.62 6,090. 14 6,090.14
09/91 28 18 46 10,423.62 2,659.58 2,659.58
10/91 26 20 46 10,951 .08 3,527.54 3,527.54
il/91 26 20 46 10,951 .0$ 2,747.00 2,747.00
TOTAL 331 219 550 $ 125,509.93 $ 133,551 .44 $ 133,553.09 106.4 $
a
�„
0000481b4 0040b66-100/009.000 E61T 07I17/93
� � � � � � � � � � � � � � � • � � � �
BLUE CROSS BLUE SHIELD TOTAL HISTORICAL U7ILIZATION - INCURRED
RENEWAL DATE 12/O1/93 PAGE 1
PAID THROUGH DATE 06/30/93
TRADITIONAL HOSPITAL/MED SURG/MAJ MED
CITY OF ROSEMOUNT BENEFIT PAYMENT
LIMITED GOLD WITH CflPAYS GROUP NUMBER OGM047
------------------------------------- ( B Y C O N T R A C T Y E A R ) -----------
--------------------------- -----------
YfAR CONT AT ANNUAL CLAIMS COMPLETED LOSS
E N D I N G Y R E N D I N C O M E PAYM€NT CLAIMS RAT10
11/30/91 46 $ 125,510 $ 133,551 $ 133,553 106.4 �
11/30/92 50 $ 143,197 $ 87, 176 $ 89,048 62.2 �
TOTAL $ 268,707 $ 220,727 $ 222,601 82.$ �
------------------------------------- ( B Y C A L f N D A R Y E A R ) --------------------------------------------------
YEAR CONT AT ANNUAL CLAIMS COMPLETED LOSS
ENDING YR END INCOME PAYMENT CLAIMS RATIO
------------------------------------------------------------------------------------------------------------------------------
PRIOR YR5 28 $ 258,295 $ 178,210 $ 178,210 69.0 �
�86 29 $ 39,614 $ 73,387 $ 73,387 185.3 �
87 32 $ 61 ,070 $ 61,417 $ 61,417 100.6 �
88 39 $ 88,028 $ 64,423 $ : 64,423 73.2 �
$9 44 $ 130,060 $ 74,711 $ 74,711 57.4 �
90 47 $ 132,621 $ 72,440 $ 72,442 54.6 X
91 45 $ 125,219 $ 128,959 $ 128,959 103.0 �
92 50 $ 145,517 $ 88,684 $ 90,751 62.4 �
70TAL YRS 18 $ 980,424 $ 742,231 $ 744,300 75.9 �
CLAlMS ARE BY SERVICE DAtE
000048164 0000666-100/009.000 E60T 07/17/93
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ADDENDUM B
I DENTAL ACCOUNTING/FINANCIAL
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SUMMARIE S
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' DECTA QENTAL P�AlV OF MWNESOTA
1807 CREEKRID6F CIACt�
MtNNEAPOLIS, MflYNESOTA 65440
'
RATE NIST�RY �OR CtTY 0� ROSEMpNT
� GROUP NUMBER: 40i3�Q000
AATES FAOM MAHGH 1A9p-DECEi�RBEk 1883
'
' SIN61� �AMILY
MARCN 188�-I�BRUARY 1981 f 16.60 t42.85
' MARCH 1991-OECEMBER i981 t17.00 f�13.90
.IANUARY 1882•DECEMBEH 199Z =tg,qp �qb,g�
, JANUARY 1893-DECENB�R 19� =19-95 t61.40
'
'
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'
PREPAREO BY AcTupRu� �tMC)
, P�EPAR�O ON SEPtEN�ER 22.1989
' B1
'
' PREHItqI ANb CI,AIH NIS�ORY I�oR WtOUp ND,: 352T-0039 24 SEp 1993
' PERlOD Prm Date Pren� Amt,._,,, Nbr Cteioa Ctaim Amt..,,., C(a1m AdJ. GROUP NO,,,,
90Q3 03-12-90 776.65 2 92.06 3527-�Q39
' 9004 04-30-90 -T16.65 7 '583.20 3527-p039
W.-30-90 776.65
04-09-90 T16.65
9005 05-07-90 716.b5 2Z 1�612,40 3527•0039
' D0�6 06-{p4-90 716.l45 14 'T�1.00 3527-0034
9007 OT-D2-90 71d.65 6 #5H.80 352T-OQ39
9008 0�-�0-90 640.50 3 119.20 3527-003q
09-t0-90 42.d3
' 12-03-9Q �6.15
9004 09-10-90 647.85 4 368.60 3527'-q034
9010 10-OS•9Q 690.50 3 2p3.00 3527-0034
90l1 11-05-90 69G.50 15 679.�40 352T•Q039
' 9012 12-03-90 7D7.�0 9 671.OQ 3527-Od34
9�01 12-,28-90 b24.45 7 464.�0 35zT-0039
47Q2 01-25-91 �r.70 4 349.30 3527-003q
' 910� 02-25-91 562.30 8 447.90 3527-00�9
91(N► 04-08-91 616,1� 6 2�1.90 35�7-0039
4105 45-06-91 1,158.60 14 T67.00 35P7-0039
9106 06-03-91 a30.00 15 7,499.40 3527-0039
' 07-61-Ot 43.9D
910T 07-Ot-91 924.90 6 324.Z0 3527-p039
4108 07-Z9-91 9D7.90 b ly8p.70 �5a7-0039
49bSi 09-09-91 9b1.70 6 3T9,60 3527-00'S9
' 9110 1Q-07-97 9b1.70 T T13.30 352Y-0034
9i11 10-'�i•91 9b1.70 8 442.00 '�527-0034
9112 17-29-91 961.T0 95 1,119.b0 3527-0034
9Z01 72-27-91 1i0�'8.95 6 52'I.30 35�7-0039
' 9202 02-70-92 1�?37.85 1T Q64.80 3527-0039
4203 03-09•92 1,133.1,b 3 22�.00 35ET-OQ39
9204 Q4-86,9z 1.133.40 10 1,1�.80 3527-OQ39
4205 Q5-04•92 1,133.40 t 440.8Q �527•0039
, 9206 06-01-92 1,133.i0 d 4C4.00 3527-0039
9207 t16-29•92 1�227,30 14 741.2U 3S2T•0039
920h OB•10-92 1,148.55 13 912.80 3527-6439
' 9�09 Oq-08•92 1,245.50 4 343,a0 35Z7•0034
9210 10-05-92 1�265.50 71 581.20 3527-0b39
9Z11 11-02•92 1�245.50 11 869.Y0 SS2)•0039
9212 1i•27-92 1,245.5U 22 1�64i.20 35Z7•U�39
' 9301 Ot-iq-q3 1,3b4.10 14 933.40 3527-0039 �
9302 02-12-93 t,3d4.10 11 1,268.80 3527-OD39
9303 �3•10-93 1,384.05 14 734.00 3527-0039
D4-OS-93 19.95
' 9304 04-08-93 1,444.15 18 1,48G.90 3527-OQ�4
9305 05•06-93 1�486.85 11 912.40 3527-0039
05-10-93 19.95
, 9306 Ob-04-9'� 7��15.25 70 1,223.40 3527-0039
9307 p6•29-93 1�526.75 1�1 864.rrD �3527-�039
430B 07-34-4� 2�097.55 21 1,627.p0 3527-OU39
Ob-31•93 39.90
' 43�631.30 42� 30.239.10 .aQ TOTAi.
' w"�" 43.631.30 423 30,23l.10 . .00
' BZ
,
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' pdTA DEN1'AL PLAN OF MINNES�TA
T80T CREEKRIDG�CWCLE
�tINNEAPOI.lS, �IINNESOTA 55444
'
EUGIBILITY 8Y MONTN
' 6fl0UP NAME: CITY OF ROSEMOUNT
BRbUp NUMBER:a6�7-0038
� ELIOiBUTIf FOR OCtOB�R 1.1882•SFPTEaI[BER 31,19ea
, �Nl6L� FAMILY TOTA1
CDYERA(� COVEHAGE CUVERII�E
' OCTOBER 2Z 18 " {p �
NOUEMBEp Z2 18 �p
' OECEMBER 22 tg {p
JANUARY � ig �
' FEBRUARY Z2 18 {p
NIARCH 23 18 41
� APRIi. ?'1 19 �0
' AdAY � �g 4Z
JUNE Zb 19 48
' JULY 25 2Q �;
QUCUST � 2e �
' a�r�u�sFa �
24 51
............. .........5�
�9D 23g ,
'
'
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�iEPAF�O !Y A6TUARIAL (LMG�
' PREP�D l�J SEPTEMBER 22,1993 '
' B3