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Home My WebLink About1999-376ORDINANCE NO 99 AN ORDINANCE ACCEPTING COMPETITIVE SEALED PROPOSALS AND AWARDING A CONTRACT FOR THE PURCHASE OF MATERIAL, SUPPLIES OR SERVICES, PROVIDING FOR THE EXPENDITURE OF FUNDS THEREFOR, AND PROVIDING FOR AN EFFECTIVE DATE (RFSP 2406 — HEALTH INSURANCE AWARDED TO AETNA U S HEALTHCARE, IN THE ESTIMATED AMOUNT OF $3,522,608 AND RFSP 2344 - VOLUNTARY EMPLOYEE PAID DENTAL INSURANCE AWARDED TO HUMANA INC, AT NO COST TO THE CITY OF DENTON AND VOLUNTARY EMPLOYEE PAID VISION INSURANCE AWARDED TO SUPERIOR VISION SERVICES AT NO COST TO THE CITY OF DENTON) WHEREAS, the City has solicited, received and evaluated competitive seal proposals for the purchase of necessary materials, equipment, supplies or services in accordance with the procedures of STATE law and City ordinances, and WHEREAS, the City Manager or a designated employee has reviewed and recommended that the herein described proposals are the lowest responsible proposals for the materials, equipment, supplies or services as shown in the `Bid Proposals" submitted therefore, and WHEREAS, the City Council has provided in the City Budget for the appropriation of funds to be used for the purchase of the materials, equipment, supplies or services approved and accepted herein, NOW, THEREFORE, THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS SECTION I, That the items in the following numbered request for proposals for materials, equipment, supplies, or services, shown in the `Bid Proposals" on file in the office of the Purchasing Agent, are hereby accepted and approved as being the lowest responsible proposal for such items RFSP ITEM NUMBER NO_ VENDOR 2406 ALL Aetna US Healthcare 2344 3 & 4 Humana, Inc 2344 5 Superior Vision Services APPROXIMATE AMOUNT $3,522,608 Employee Funded Employee Funded SECTION II That by the acceptance and approval of the above numbered items of the submitted proposals, the City accepts the offer of the persons submitting the proposals for such items and agrees to purchase the materials, equipment, supplies or services in accordance with the terms, specifications, standards, quantities and for the specified sums contained in the Proposal Invitations, Proposals, and related documents SECTION III, That should the City and person submitting approved and accepted items and of the submitted proposals wish to enter into a formal written agreement as a result of the acceptance, approval, and awarding of the proposals, the City Manager or his designated representative is hereby authorized to execute the written contract, provided that the written contract is in accordance with the terms, conditions, specifications, standards, quantities and specified sums contained in the Proposal and related documents herein approved and accepted SECTION IV That the City Manager is hereby authorized to execute the Letter Agreement, attached hereto and made a part hereof for all purposes, and contract with Aetna U S Healthcare for RFSP 2406, and contracts with Humana Inc and Superior Vision Services for RFSP 2344 SECTION V, That by the acceptance and approval of the above numbered items of the submitted proposals, the City Council hereby authorizes the expenditure of funds therefor in the amount and in accordance with the approved proposals or pursuant to a written contract made pursuant thereto as authorized herein SECTION VI That tlus ordinance shall become effective immediately upon its passage and approval PASSED AND APPROVED this the #/ — day of1999 JA M ,LER, MAYOR ATTEST JENNIFER WALTERS, CITY SECRETARY B APPROVED AS TO LEGAL FORM HERBERT L PROUTY, CITY ATTORNEY BY X-�X j- CONTRACTUAL - RFSP 2406 Aetna Health Plans 2777 Stemmons Fwy Suite 400 Dallas, TX 75207 October 11, 1999 Ms Christina Scott Health Benefits Administrator City of Denton, Texas Municipal Building 215 E McKinney Denton, TX 76201 Dear Chris Kelhe Fleming Account Executive 214-200-8956 214-200-8949 fax On behalf of Aetna U S Healthcare 1 would like to thank you for the confidence you have placed in our company by selecting us to be the recommended employee health plan vendor for the ) ear 2000 We look forward to Doming you at the City Council Meeting on October 12 1999 to present the recommendation I would like to confirm the agreed upon plan offering, rates, terms and conditions A point of enrollment program will be offered allowing employees to select between Health Maintenance Organization (HMO) or Point -of -Service (POS) plan during open enrollment annually The selected HMO plan benefits and rates are attached as Exhibit A The selected POS plan benefits and rates are attached as Exhibit B The second year rate guarantee being offered to the City of Denton is attached as Exhibit C 5 1 have received the tentative enrollment schedule (Exhibit D) and will begin to assign representatives to cover meetings as soon as an official contract award is made Please sign below if you are in agreement and the contract is awarded to Aetna U S }healthcare for the plan year beginning January I, 2000 Note that this letter does not contractually and either party but is supply a confirmation of understanding and intent on the part of bo Aetna U S Healthcare and The City of Denton I n AUSHC Authorized Representative Sincerely, Kelhe A Fleming Account Executive AUSHC Proposal For CITY OF DENTON Effective Date 01/01/2000 Service Area Texas - Dallas 240) 36d. sort (32401 45d 22 I�r�!�374 mdw) ($I32e Will. 30 day O 2 oopayst (Moo only) R{)or. Mcludad_ Page 1 Octo or 13, 1999, Renewal Date 01/01/2001 Quote 1 50491441 II i Rates '�- Parent and Chlld(r8n) $317 82 Couple $367 64 Family _ $400 83 The foregoing rates apply In the Service Area specified above Rates will vary for other service areas Service f determined by the location of the subscriber's primary care doctor 21412 o Glammiona These monthly quota and are subject to V conddions staled ab group census AUS enrollment dyers m by AUSHC of Emplo Employer CC F of the month in which he/she turns 25 Coverage will continue our dependents wno iysically handicapped prior to the end of the month they reach age 25 rates are valid as of the Effective Date and apply only to the benefit level and condthom terms and conditions set forth in the HMOs Group Master Contract Any changes in bar n; may require a change in rates Rates were developed using information which is bast C reserves the right to modify this rate should the group census be inaccurate or if actua adally from the group census This proposal i"ubject to change at any time prior to the FW For office use only r—GF0-Ty0e'0—" Quote(17-5049144-- Rall'00e CRBDTQR"RA S!qruGr # AH2HG - - _ Customer ID 1203312_ PPID _1347619 d above vet or I ,N1v1r" 2 W 14 om _ tlr27n_ IIFtIBY91AILLIrP102MlEll1 tM29. ' ' an,a Page 2. Octol Per 13. 1999. AUSHC Proonagl For CITY OF DENTON Effective Date 01/01/2000 Renewal Date 01101Y2001 Service Area Texas - Dallas Quote I 6049144 Class Rating Factor Worksheet Eligible/Enrollee Summary Single Par/Child CcuPle Family Male Male Male Male < 24 20 < 24 2 < 24 1 < 4 4 25 - 29 35 25 -29 7 25 - 29 8 2 - 29 12 30 - 34 46 30 - 34 16 30.34 4 3 - 34 35 35 - 39 38 35.39 34 35 - 39 2 3 - 39 33 40.44 27 40 - 44 22 40 - 44 7 4 - 44 36 46 - 49 32 45 - 49 26 45.49 8 4 - 49 40 50 - 54 26 60 - 54 21 50 - 54 12 5 -64 ' 21 66 - 69 14 55 - 59 1 55. 59 12 5 - 59 6 60 - 64 7 60.64 1 60 - 64 7 6 64 2 65 + 1 66 + 1 65 + 2 6 + 0 Male Subtotal 245 Male Subtotal 131 Male Subtotal 63 Male ubtotal 189 Female Female Female Femal < 24 6 < 24 0 < 24 1 < 4 1 25 - 29 26 25 - 29 3 25 - 29 3 2 - 29 2 30 - 34 19 30 - 34 14 30 - 34 2 3 - 34 4 35 - 39 27 35.39 12 35.39 0 3 - 39 6 40 - 44 21 40 - 44 14 40 - 44 1 4 - 44 8 43.49 16 45 - 49 8 45 - 49 4 4 - 49 10 60 - 54 13 50 - 54 3 50 64 4 5 -64 8 55 - 69 9 55 - 59 1 55 - 59 3 6 - 69 1 60 - 64 9 60 - 64 0 60 - 64 0 6 -64 0 65 + 1 654 0 65 + 0 6 + 0 Female Subtotal 146 Female Subtotal a5 Female Subtotal 18 Femal Subtotal 40 Single Subtotal 391 Par/Child Subtotal 186 Couple Subtotal 81 Family Su total 229 Grand Totdl 887 -�t�AETNA U S Healthcare® FLEX MEDICAL PLAN Gr CITY OF DENTON Texas - Dallas Coaavmenrs PRIMARY CARE PHYSICIAN VISITS copay Office Hours $2$20 a After Hours / Home Visits cop y SPECIALTYCARE $ 25 copay Office Visits Diagnostic Outpatient Testing S25 copay Phys,Oce,Speech Therapy copay SPU SURGERY $100 copay HOSPITALIZATION $240 copay/A EMERGENCY ROOM (copay waived if admirred) S50 copay MATERNITY First OB Visit $25 copay Hospital $240 copay/A MENTAL HEALTH MH $240 copay, 30d Inpatient SMI $240 copay, 45d Outpatient MH $25 copayN, 20v SMI $25 copayN 60v SUBSTANCEABUSE Detoxification $240 copay/A Inpatient Rehabilitation 0 copay/A $2$24copay/ Outpatient Rehabilitation PREVENTIVE CARE Routine Eye Exam (per benefit schedule) $25 Routine GYN Exam copay PRESCRIPTION LENS REIMBURSEMENT $200 every 24 months PRESCRIPTIONS $10/$20 G/B, 30 Day Covered Contraceptives 31-90 Day Supply (MOD only) $20/40 G/B copay Mandatory Generics Applies Closed Formulary DURABLE MEDICAL EQUIPMENT No copay SPEECH & HEARING Copay based on med plan 4962541 toll con all lelerlisi ohermselbeand nc0is and exservices clusions ons oenc0is ere provided ded byfrom AEITJA prima SHealihcare°ician see Certdicate of Coverage HMO-1 Plan Design & Benefits Aetna US Healthcare Texas Flexed Patriot XV Plan Plan Features Primary Care Physician Visits Office Hours After-Hours/Home Specialty Care Office Visits Diagnostic OP Lab/X Ray Testing (at facility) Diagnostic OP Lab/X Ray Testing (at spec office) Outpatient Therapy (speech, phys, occup) Outpatient Dialysis/Chemotherapy Allergy Testing/Treatment Preventive Care Routine Physicals Routine Child and Well Baby Care, Immunizations Routine GYN Care Routine Mammography Routine Eye Exam Hearing Exam Hearing Aids Emergency Care L rgent Care Out -of- Area In Network (Referred Care) $20 copay $25 copay $25 copay $25 copay with PCP referral Included in Specialist Office Visits copay for visit with PCP referral $25 copay $25 copay $25 copay for testing $20 copay for routine injections at PCP office - with or without physician encounter No serum copay $20 copay $20 copay $25 copay One routine GYN visit and pap smear/365 days Direct access to participating providers $25 copay One annual mammogram for females age 35 and over $25 copay Direct access to participating provider schedule applies $20 copay Routine hearing screenings Not covered $50 copay $50 copa Aetna U S Healthcare Plan Design & Benefits Aetna US Healthcare Teas Flexed Patriot XV Plan Plan Features Ambulance Outpatient Surgery Hospitalization Skilled Nursing Facility Care (in lieu of hospitalization for medically necessary covered benefits) Maternity OB Visits Hospital (Includes Newborn Services) Home Health Care/Hospice-Outpatient Private Duty or Special Duty Nursing Hospice - Inpatient Family Planning/Reproductive Services Sterilization Procedures Mental Health Inpatient — Serious Mental Illness Outpatient — Serious Mental Illness Inpatient — non-SMI Outpatient — non-SMI Substance Abuse Detoxification Inpatient Detoxification Outpatient Detoxification Substance Abuse Rehabilitation Inpatient Rehabilitation Outpatient Rehabilitation HMO-2 In Network (Referred Care) No copay $100 copay $240 copay $240 copay $25 copay for initial visit only $240 copay No copay Not covered unless pre -authorized by HMO, no copay when covered $240 copay Covered with applicable specialist, outpatient surgery or inpatient hospital copay if applicable, Reversal of voluntary sterilization including related follow-up care and treatment of complications of such procedures is not coN eyed $240 copay, 45 days per calendar vear $25 copay 60 visits per calendar vear $240 copay, 30 days per calendar vear $25 copay, 20 visits per calendar year $240 copay $25 copay $240 copay, 3 episodes combined IP and $25 copay, 3 episodes combined IP and Aetna U S Healthcare Plan Design & Benefits HMO-3 Aetna US Healthcare Texas Flexed Patriot XV Plan Plan Features Diabetic Supplies Prescriptions Durable Medical Equipment Lens Reimbursement In Network (Referred Care) RX copay, otherwise $20 copay $10/20 (Closed Formulary) $0 copay $200 for 24 months Emergency Care Guidelines Aetna U S Healthcare follows the "Prudent Layperson" emergency room policy set forth in the Balanced Budget Act of 1997 for all HMO members Under this Act, an emergency medical condition is "a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (i) placing the health of the individual (or with respect to a pregnant woman the health of the woman and her unborn child) in serious jeopardy, (n) serious impairment to bodily functions or (in) serious dysfunction of any bodily organ or part " Urgent Care Out -of Area Guidelines, Aetna U S Healthcare follows the Balanced Budget Act of 1997 definition of covered, immediately required out -of -service area services Specifically, Aetna U S Healthcare covers urgent services outside of the member's home service area if the services are "medically necessary and immediately required because of unforeseen illness injury, or condition, and it was not reasonable given the circumstances to obtain the services through" the member's home service area Examples of urgent care needs include • Respiratory or flu like symptoms with high fever • Earache • Severe sore throat • Severe abdominal cramps, vomiting or diarrhea Urgent care may be obtained from a private practice physician, a walk in clinic, an urgice r or n emergency facility Follow up care must be coordinated through the member's primary care physic[ Aetna U S Healthcare AUSHC Proposal For CITY OF DENTON Effective Date 01/01/2000 Service Area Texas - Dallas MH 1/P coW0 A Ci01 adss M1 3240)43d MH OIP COp y (2e) 20v1 sMl 01P (11125) Gov Roubne Eyye Exam Copay (525) Routine GVN Exam Co�a_y (823) t vlyr PresvIDU00 opay I91_ 0 am), 30 Day 1 31 90 Day'p prrply 2 copays (MOO only) Mandatory G: efics I nmr- Item rnnev istil Page 1 Octo 3er 14, 1999 Renewal Date 01/01/2001 Quote D 5052854 Rates ir5 ngle 3269 4>� Parent and Children) $361 09 Couple 5417 68 Family _ 5455 41 The foregoing rates apply In the Service Area specified above Rates will very for other service areas Service 0 determined by the location of the subscdbees primary care doctor Quote Conditions I stun its t0 tit 1119 -bnsQ` ed u$ dro 4e 81 any is 25 Coverage will continue for dependents end of the month they reach age 25 rates are valid as of the Effective Date and apply only to the benefit level and conditions s k'm3s and conditions set forth in the HMO Group Master Contract and/or the Corporate IF 'changes in benefit level or conditions stated above may require a change In rates Rates tagoo which is based on the group census AUSHC reserves the right to modify this rate i urale Or if actual plan enrollment differs jnatenal Y from the group census This proposai ii )r Idjhe acceptance by AUSHjq of En%oyees offer EmployerAulhOffeati Date-�/Q,� �//' Ivq '�'%%%% / CC FLEMING KEL STOKES, GAVIN For office uye only GipTpelEli§-001200 - —Quote ID-—5052854 ale Code CR DMIR RAW " -- Vald Cale WB _ Segp/Gro# AH21-10 "Customer 10 1263312 _ PPID 1401256 _ I i I I is ' d above h a Id the hect to Iy"+ 209101351"M 42321 LIPOMISYBILIFP103BWOI 4W2311 UF1IAMoo5"MM10194 BIG919%IN0099 Page 2 Oct or 14 1999 AUSHC Proposal For CITY OF DENTON Effective Date 01/01/2000 Renewal Date 01/01/2001 Service Area Texas - Dallas Quote D 5052854 Class Rating Factor Workshest Eligible/Enrollee Summary Single Par/Child Couple Family Male Male Male Male < 24 20 < 24 2 < 24 1 < 4 4 26 - 29 35 26.29 7 25 - 29 8 2I -29 12 30 - 34 45 30 - 34 16 30 - 34 4 3- 34 35 35.39 36 35.39 34 35 39 2 3-39 33 40 - 44 27 40 - 44 22 40 - 44 7 4- 44 36 45.49 32 45 - 49 26 45 - 49 8 4- 49 40 50 - 54 26 50 - 54 21 50 - 54 12 5- 54 21 55 - 59 14 55.59 1 55 - 59 12 5 59 6 60 - 64 7 60 - 64 1 60.64 7 6- 64 2 65 + 1 65+ 1 65+ 2 6+ 0 Male Subtotal 245 Male Subtotal 131 Male Subtotal 63 Maleblotal 189 Female Female Female Femal < 24 5 < 24 0 < 24 1 < 4 1 26 - 29 26 25 - 29 3 25.29 3 2 - 29 2 30 - 34 19 30 - 34 14 30 - 34 2 3 - 34 4 35-39 27 35-39 12 35-39 0 3 -39 6 40-44 21 40.44 14 40-44 1 4 -44 8 45 - 49 16 45 - 49 8 45 - 49 4 4 .49 10 50.54 13 50.54 3 50 - 54 4 S - 54 8 56 - 59 9 56 - 59 1 55.59 3 5 - 59 1 60-64 9 60.64 0 60-64 0 6 -64 0 66+ 1 65+ 0 65+ 0 6+ 0 Female Subtotal 146 Female Subtotal 55 Female Subtotal 18 FemaSubtotal 40 Single Subtotal 391 Par/Child Subtotal 186 Couple Subtotal 81 Family Sul,otal 229 Grand ,887 VEMB AETNA U S HEALTHCARE OF NORTH TEXAS INC.@ QUALITY ati�ASV•FLEX HMO / Liberty Flex Plan CITY OF DENTON FINANCIAL Deductible Single/Family Coinsurance Coinsurance Lmut Smgle/Famdy Lifetime Maximum Benefit PRIMARY CARE PHYSICIAN VISITS Office Hours AftenHoun / Home Visits SPECIALTY CARE Office visits Diagnostic Outpatient Testing Phys,Oec,Speach Therapy SPV SURGERY HOSPITALIZATION SKILLED NURSING FACILITY EMERGENCY ROOM (eopay waived if admixed) HOME CARE MATERNITY First OB Visit Hospital MENTAL HEALTH Inpatient Outpatient SUBSTANCE ABUSE Detoxification Inpatient Rehabilitation Outpatient Rehabilitation PREVENTIVE CARE Routine Eye Exam (per benefit schedule) Routine Physicals Iin mmixanons Routine Mammography Routine GYN Exam Pediatric Preventive Dental Exam CHIROPRACTIC CARE PRESCRIPTIONS Contraceptives 31-90 Day Supply (MOD only) Mandatory Generics Closed Formulary DURABLE MEDICAL EQUIPMENT SPEECH A HEARING N/A N/A N/A N/A $20copay $25 copay $25 copay S25 copay S25 copay $100 copay S240copay/A S240copsy/A S50copay No copay S25copsy S240 eopay/A MH $240 copay 30d SMI S240 copay, 45d MH S25 copsy/V, 20v SMI $25 copay/V 60v $240 copay/A $240 copsy/A $25 copayfV $25 copay S20 copay S20 copay $25 copay $25 copay Not Covered S I0520 G/B, 30 Day Covered $20/40 GB copay Applies fx Noxre erred' $500/S 1,500 70% S4,00038,000 SI 000,000 70% after deductible 70% after deductible 700/9 after deductible 70% after deductible 70e/s after deductible 70% after deductible 70% after deductible 70% after deductible S50 copay 70% after deductible 70% after deductible 70% after deductible Not covered (MH) 70% after deductible (SMI) 50% after deductible (MH) 70% after deductible (SMI) 70e/t after deductible 70% after deductible 70% after deductible Not covered Not covered 100% age 0-6, age 6+ not 70% after deductible 70% after deductible Not covered 70% after deductible, S 10 No copay 70% after deductible Colley based on med plan • Member preeenification required or beneflis paid will be substantially reduced To,eLetve maainwm benefits In network (released) semcss must be provided or ref ,"d bZ the participating primary care physician you In network Ircfatred) benetlts are provided by AETNA U & Healtheare at North Texas Inc Ouaof network non•rofenud) baneilts ere underwritten by Corponle Health Iniunnce' All brncNs eea�usinni and Ilmnaoons are provided In aeeordanet with the apphubis group agreement and insunnee Lertmeatt PROGRAM' max 5052854 EXHIBIT C Financial Information Aetno'Health Plans Multi -year Guarantee Multi -year Premium Rate Guarantee City of Denton Aetna Inc guarantees that at the end of the first policy period, for purposes of setting the second policy periods' monthly per employee and dependent unit rates the increase for the second policy period's rates will be no greater than 10% for HMO 13% for QPOS Aetna Inc reserves the right to review and possibly modify or terminate the guarantee arrangement described above, for any or all sites and/or coverages under consideration, if Aetna Inc determines that any of the following occur during the guarantee penod, relative to the assumptions in place at the time this guarantee was extended a a change (plus or minus) in the number of enrolled members in excess of 10%, by line of coverage, from that assumed at the time the guarantee is established, b a change in the demographic and/or geographic mix of the group from that assumed at the time the guarantee is established which changes the expected per capita claim costs by more than 4%, c a change (plus or minus) in the size of the eligible population in excess of 20% d change in the plan of benefits/services offered which is initiated by the customer or required because of legislation action, e failure of the customer to make required premium payments in accordance N"ith contract provisions, f enactment of legislation (either state or federal) which impacts the abilm of Aetna Inc to contract for efficient, cost effective medical care g all changes in the employee contribution strategy for any plan of benefits offered must be agreed to by Aetna Inc on each annual anniversary date h a change in the tier rating structure for any plan of benefits offered, i account has an incurred loss ratio of greater than 82% Incurred loss ratio will be developed by dividing paid premiums by incurred claims The definition for incurred claims is as follows "the total amount of Health Plans liability, with respect to an experience period as determined by the Health Plan for services covered by this agreement " j for POS, the preferred access of care does not equal or exceed 90% of care, as measured by claims incurred during the base year Iq A e t n a H e a l t h P I a n s 0 9/ 1 7/ 1 9 9 9 Aetna U.S. Healthcare of North Texas Inc P O Box 569440 Dallas Texas 75366-9440 214-2000-8000 or toll -free 1-800-992-7947 Texas State -Mandated Coverages Dear Employer Texas law requires employers to decide whether they want to offer their employees certain coverages Employers must decide whether they want to accept or reject each of the coverages listed below Please indicate below whether you accept or reject the following benefits for your 1- Maintenance Organization (HMO) in -network benefits and execute by signature on 2 of this document 1. In Vitro Fertilization Benefits Benefits for in vitro fertilization services If you decide to offer this benefit, additional premium will be required Accept x Reject 2 Inpatient Mental Health Benefits Benefits for mental and emotional Illness and disorders when confined in a hospital with corresponding alternative treatment facility benefits to the extent that such benefits are not mandated as serious mental illness Inpatient benefits for medical, nursing, counseling or therapeutic services in an inpatient, hospital or non -hospital residential facility Including a mental health treatment facility, crisis stabilization unit, or residential treatment center appropriate licensed by the Texas Department of Health or its equivalent Coverage is subject 1 maximum number of days Copayments will not be less favorable than for hospital coverage under your particular plan of benefits If you decide to offer this benefit, additional premium will be required. 441 Accept x Reject Page a of 2 hmo daAas tx rejection notice nb991 rev 9 3. Treatment of Speech and Hearing Impairments Diagnostic services rendered by a participating provider to find out if and to what extent the member's ability to speak or hear is lost or impaired as a result of dine injury or birth defect Habditative and rehabilitative services rendered by a participating provider to resto speech or hearing loss or to correct a speech or hearing impairment This does ni include charges made for speaking aids or training in the use of such aids The services must be directed and monitored by a participating physician and referrals be certified by health plan In advance If you reject this coverage, your plan will limit non -surgical coverage to any limitations stated in the certificate of coverage If you decide to offer this benefit, additional premium will be required Accept X Reject As indicated above, the undersigned employer hereby agrees to accept or reject th above -listed coverages for their employees and fully understands the provisions of •hese coverages Michael Jez City Manager Page hmo-dellas U re)Wian nobu nb991 rev 9 of 2 EXHIBIT D CITY OF DENTON PROPOSED 1999 INSURANCE OPEN ENROLLMENT SCHEDULE November 1 1 00 p m H R Conference Room (601 E Hickory) 2 30 p m H R Conference Room (601 E Hickory) November 2 7 00 a m H R Conference Room (601 E Hickory) 8 30 a m H R Conference Room (601 E Hickory) 10 00 a m H R Conference Room (601 E Hickory) 1 00 p m H R Conference Room (601 E Hickory) 2 30 p m H R Conference Room (601 E Hickory) 3 45 p m H R Conference Room (601 E Hickory) November 3 7 00 a m H R Conference Room (601 E Hickory) 8 30 a m H R Conference Room (601 E Hickory) 10 00 a m H R Conference Room (601 E Hickory) 1 00 p m H R Conference Room (601 E Hickory) 2 30 p m H R Conference Room (601 E Hickory) November 4 7 00 a m H R Conference Room (601 E Hickory) 8 30 a m H R Conference Room (601 E Hickory) 10 00 a m H R Conference Room (601 E Hickory) 1 00 p m H R Conference Room (601 E Hickory) 2 30 p m H R Conference Room (601 E Hickory) November 5 1 00 m H R Conference Room (601 E Hickory) COBRA 3 00 p m H R Conference Room (601 E Hickory) RETIREES p November 8 2 00 p m Central Fire Department (217 W McKinney) November 9 7 00 a m Police Training Room (601 E Hickory) 2 00 p m Central Fire Department (217 W McKinney) 3 30 p m Police Training Room (601 E Hickory) November 10 2 00 P m Central Fire Department (217 W McKinney) November 16 8 00 e m Electric Production (1701A Spencer) 9 30 a m City Hall West Conference Room (221 N Elm) 11 00 a m City Hall West Conference Room (221 N Elm) 2 00 p m City Hall West Conference Room (221 N Elm) November 17 7 00 a m Electric Subs /Dist area (1701C Spencer) 12 00 p m Electric Subs /Dist area (1701C Spencer) 2 00 p m Water Production (1701B Spencer) November 18 9 00 a m Utilities Safety Training Room (901 Texas) 01 exas) 10 30 a m Utilities Safety Training ROO 2 00 p m Laboratory (1100 S Mayhill) PLEASE POST IN YOUR AREA NTH LGUVOLASH MD\DEPTLGL\0wD ummu\Conoac kWdmW Pun mnm dm AGREEMENT FOR EMPLOYEE DENTAL BENEFIT PLAN STATE OF TEXAS § COUNTY OF DENTON § THIS AGREEMENT is made and entered into as of the 1�d day of �tvek 19 q9 , by and between the City of Denton, A Texas Municipal Corporation, with its principal office at 215 E McKinney Street, Denton, Denton County, Texas 76201, (hereinafter sometimes referred to as "CITY") and EMPLOYER HEALTH INSURANCE/HUMANA, INC and its legal subsidiaries with its corporate office at 1100 Employers Boulevard, Green Bay, WI 54344, hereinafter called the ("COMPANY") acting herein, by and through their duly authorized representative WITNESSETH, that in consideration of the covenants and agreements herein contained, the parties hereto do mutually agree as follows ARTICLE 1 EMPLOYMENT The CITY hereby contracts with COMPANY, as an independent contractor, and the COMPANY hereby agrees to perform the services herein in connection with the Project as stated in the sections to follow, with diligence and in accordance with the highest professional standards customarily obtained for such services in the State of Texas The professional services set out herein are in connection with the following described project To provide dental benefits insurance for the City of Denton employees, retirees, or those active in COBRA who wish to enroll with the COMPANY The COMPANY is to provide such insurance at rates guaranteed for a two year period and to provide employees with insurance that will help care for the needs of the employees and their families in obtaining dental care and treatment ARTICLE 2 SCOPE OF SERVICES The COMPANY shall perform the following services in a professional manner A To perform all those services set forth in COMPANY'S application which application is attached hereto and made a part hereof as Exhibit "A" as if written word for word herein \\CH LGL\VOL"HARED\DEPTLGL\Om Dmum u\Contmu\99\dmW planet mtd B If there is any conflict between the terms of this Agreement and the exhibits attached to this Agreement the terms and conditions of this Agreement will control over the terms and conditions of the attached exhibits ARTICLE 3 PERIOD OF SERVICE This Agreement shall become effective on January 1, 2000 at 12 01 a in , standard time at the address of the CITY The Agreement is effective for a period of two years, however, the Agreement is renewable each year by agreement of the parties The CITY and the COMPANY must each give written notice to the other party at least 60 days before the contract ends for the renewal to be effective ARTICLE 4 COMPENSATION The COMPANY will be compensated for its services by the paying of premiums, by wire transfer of funds made between the 15ih and 20`h of each month, by the enrolled participants in the plan at the premium rates set forth in Exhibit "B" These rates are to guaranteed for the enrollees from January 1, 2000 to December 31, 2001 The CITY will provide a reconciliation of self -bill premiums as stated in Exhibit "C" and incorporated as if set out word for word in this Agreement ARTICLE 5 INDEPENDENT CONTRACTOR The COMPANY shall provide services to CITY as an independent contractor, not as an employee of the City COMPANY shall not have or claim any right ansing from employee status ARTICLE 6. ARBITRATION AND ALTERNATE DISPUTE RESOLUTION The parties may agree to settle any dispute under this Agreement by submitting the dispute to arbitration or other means of alternate dispute resolution such as mediation No arbitration or alternate dispute resolution ansing out of or relating to, this Agreement involving one party's disagreement may include the other party to the disagreement without the other's approval ARTICLE 7 RESPONSIBILITY FOR CLAIMS AND LIABILITIES Approval by the CITY shall not constitute nor be deemed a release of the responsibility and liability of the COMPANY, its employees, associates, agents, subcontractors and subconsultants for the competency of their work, nor shall such approval be deemed to be an assumption of such Page 2 of 6 NCH LGU VOL I VhvedWeptLLGUO., O .Mu C.=w 9%dent.1 plan convazt da responsibility by the City for any work by the COMPANY, its employees, subcontractors, agents and consultants ARTICLE 8. NOTICES All notices, communications, and reports required or permitted under this Agreement shall be personally delivered or mailed to the respective parties by depositing same in the United States mail at the address shown below, certified mail, return receipt requested unless otherwise specified herein Mailed notices shall be deemed communicated as of three days mailing TO COMPANY EMPLOYERS HEALTH INSURANCE/ HUMANA, INC Attn Jerry Ganom 1100 Employers Blvd Green Bay, WI 54344 TO CITY CITY OF DENTON Atm Michael W Jez Title City Manager 215 E McKinney Denton, TX 76201 All notices shall be deemed effective upon receipt by the party to whom such notice is given or within three days mailing ARTICLE 9. ENTIRE AGREEMENT This Agreement consisting of six (5) pages and three (3) exhibits constitutes the complete and exclusive statement of the terms of their agreements and supercedes all prior contemporaneous offers, promises, representations, negotiations, discussions, communications and agreements which may have been made in connection with the subject matter hereof ARTICLE 10 SEVERABILITY If any provision of this Agreement is found or deemed by a court of competent jurisdiction to be invalid or unenforceable, it shall be considered severable from the remainder of this Agreement and shall not cause the remainder to be invalid or unenforceable In such event, the party shall reform this Agreement to replace such stricken provision with a valid and enforceable provision which comes as close as possible to expressing the intention of the stricken provision ARTICLE 11 COMPLIANCE WITH LAWS The COMPANY shall comply with all federal, state, local laws, rules, regulations, and ordinances applicable to the work covered hereunder as they may now read or hereinafter be amended Page 3 of 6 \CH LGL\p OL I�hued\depr\LGL\Our DmumenmConWxw9%denW plm cmmn doc ARTICLE 12 DISCRIMINATION PROHIBITED In performing the services required hereunder, the COMPANY shall not discriminate against any person on the basis of race, color, religion, sex, national origin or ancestry, age, or physical handicap ARTICLE 13 PERSONNEL A The COMPANY represents that it has or will secure at its own expense all personnel required to perform all the services required under this Agreement Such personnel shall not be employees or officers of, or have an contractual relations with the city COMPANY shall inform the CITY of any conflict of interest or potential conflict of interest that may anse during the term of this Agreement B All services required hereunder will be performed by the COMPANY or under its supervision All personnel engaged in work shall be qualified and shall be authorized and permitted under state and local laws to perform such services ARTICLE 14 ASSIGNABILITY The COMPANY shall not assign any interest in this Agreement and shall not transfer any interest in this Agreement (whether by assignment, novation or otherwise) without the prior written consent of the CITY except the company may assign this Agreement to an affiliate without the consent of the CITY ARTICLE 15. MODIFICATION No waiver or modification of this Agreement or of any covenant, condition, limitation herein contained shall be valid unless in writing and duly executed by the party to be charged therewith and no evidence of any waiver or modification shall be offered or received in evidence in any proceeding arising between the parties hereto out of or affecting this Agreement, or the rights or obligations of the parties hereunder, and unless such waiver or modification is in writing, duly executed, and, the parties further agree that the provisions of this section will not be waived unless as herein set forth Page 4 of 6 CH LGL\VOLINhamdWdM\LGL\Ow Oaaununu\Cono-acu�pg\d Wplanconvawdw ARTICLE 16 MISCELLANEOUS A The following exhibits are attached to and made a part of this Agreement Exhibit "A" application for dental care insurance policy Exhibit `B" list of premium rates for dental benefits plan Exhibit "C" reconciliation of self billed statement B Venue of any suit or cause of action under this Agreement shall lie exclusively in Denton County, Texas This Agreement shall be construed in accordance with the laws of the State of Texas C The captions of this Agreement are for informational purposes only and shall not in any way affect the substantive terns or conditions of this Agreement IN WITNESS HEREOF, the City of Denton, Texas has caused this Agreement to be executed by its duly authorized City Manager and COMPANY has executed this Agreement through its duly authorized undersigned officer on this the /�& day of 19W ATTEST JENNIFER WALTERS, CITY SECRETARY By APPROVED AS TO LEGAL FORM HERBERT L PROUTY, CITY ATTORNEY LA CITY OF DENTON, TEXAS 44)A4"'A�44—z ichael Je , i Manager Page 5 of 6 �\CH LGL\V0LNharc&dep0LGL\0urO ==U\Cowum 99\denul plan c=m ,do EMPLOYER HEALTH INSURANCE/ HUMANA, INC m Name Title WITNESS Page 6 of 6 G 1111011 n Employers Health Insurance/Humana Insurance Company Texas Employer Group Application RINT OR TYPE ALL SECTIONS IN BLACK INK Requested Eff Date I r I%'%F Group Number ne of Group Type of Business Phone La CaJ ( g5/0).3'V9 —'P %il4Qu,A✓ Go✓C/.1/llt/tf F9de, gtl9_D, ocation Address cling Address City State Zip ,-45- C t�1l��nev Denf%M x 74�0 ,BA and/or Divisional Names ubsidianes Affiliated Companies or Other Locations to be Induced Workers Compensation Carrier J soup No to be associated Multilocation Phone p ( ) Multilocation Fax it this coverage part of a union negotiated agreement? J YES $NO Date of Expiration )o you wish to have 24 hour coverage? (Groups of 51+ available for Owners Officers or Partners not covered by Workers Compensation) J YES J NO LIGIBILITY ull time employees working at least 30 hours per week are eligible if employed by you Part time and seasonal employees are not eligible or 51+ groups you may reduce the hourly requirement to not less than 20 hours per week idicate Hourly Requirement 070 Voluntary Lite hourly requirement is 20 hours per week otal Number Of Employees Number of Permanent Full Time Emolovees Number of Eligible Employees )n Payroll \t 010 Eligible For Coverage T4 C Enrolling ASSES OF ELIGIBLE EMPLOYEES WITH OTHER GROUP MEDICAL COVERAGE TO BE EXCLUDED )ups of 3 50 J NONE ZI UNION ] NON UNION GROUPS OF 51+ A NONE O UNION J NON UNION J HOURLY J SALARY JEW EMPLOYEE WAITING PERIOD NEW EMPLOYEE EFFECTIVE DATE PROVISION 9 0 Days ZI 1 Month O 2 Months O 3 Months' ❑ First of month following wading period ] Immediately following waiting period B Other Specify 1 o6d. c5h.trt Groups of 3 50 may not exceed 90 days he waiting period and effective date provision must be the same on all plans he employee termination date on all Humana PPO plans is as stated in the group policy On all Employers Health plans it coincides with the ffective date provision 3MPLOYER CONTRIBUTION (See Participation Requirements) ledical Non Voluntary Dental Basic Life Short Term Disability Employee_ Dependents ,SLS Employee 1 Ina% Dependents low% Qr 2s s this a replacement of your current group coverage? Medical J YES 9 NO Dental lYES J NO Prior Ortho BYES J NO STD J YES b NO f yea, furnish the following current carrier for a Medical Dental fmi..T TD Your most recent billing statement c Term date of current/prior medical coverage Effective and term date of Dental coverage "'I&t s' — i a13119 7 STD coverage Qf i Will this plan be offered in addition to another medical plan that you will continue to provide? J YES if NO Name of Carrier :OKRA Are any present or former employeestdoperidents currently on or eligible to elect COBRA/State Continuation? J YES 23 NO If yes complete Name COBRA/State Cont Expiration Date Termination of Employment J OR Other Qualifying Event (I a survivorship divorce J J J J J etc ) '-olovers Health benefit plan certificates should be sent to J Agent a Employer Ificates for Humana benefit plans are mailed to the employee s home address To provide medical and dental benefits to retired employees state attained age and years of service for retiree class eliaronity The retiree lass will be considered only If you have 51 or more employees enrolled for sucn coverage Benefits will be effective for etirees It approved 3etirees are not eligible for any life or disability benefits e! ck7F•1er �Lb NJ ear Z. ao - S glvT« .r )o you want Retirees covered for Medical 2rNO J YES Dental J NO Ill YES Ads LeO _ Years of Service10 i ti't^t y ci iiw X 77115 03 10/96 Reorder = TX 99000 HH Tit, PLAN SELECTION -To complete this Information refer to your proposal or plan brochure NOTE Submit your proposal along with this application (Multiple Choice is not available with state plans ) pR0 UCT NAME(S) ? 90/70 Freecom Plus 80% etc I DEDUCT LE (if applicable) COINSURAN (if applicable) OUT OF POCKE If applicable) NETWORK NAME (if placable) HumanaFreedom Plus (Hu na Network) Supplemental Accident Deductible Carryover Credit Copayment Drug Card S10 Generic Copay/$20 Brand Copa S5 Generic Copay/$15 Brand Copay Humana PPO (PHCS Network/Humana Netwo) and Traditional Insurance Supplemental Accident Deductible Carryovsr Credit Enhanced Preventive Care (Available with Traditional Insurance Only) Copayment Drug Card If selected, replaces Major Medical Coverage $10 Genetic Copay/$20 Brand Copay $5 Genetic Copay/$15 Brand Copley Employers Health Value Plans I Agree To Self Fund Normal Pregnancy Coverage (If group size is 15+) Supplemental Accident Copayment Drug Card Copley after deductible OR Copay (no deductible) OR ---------------------------------------0 STATE MEDICAL PLANS (Normal pregnancy in de Basic Indemnity Basic Benefit Plan PPO Catastrophic Care Benefit Plan PPO Catastrophic Indemnity Optional Alcohol d Drug Abuse Ri r Optional Mental Health Rider Optional Copayment Drug Rid Optional Preventive Care Rider avail on Basic Ransil Elective Abortion Rider SPECIAL STATE C In Vitro Fertilization Serious Mental Illne late this benefit fit Yee No Yes No 7 7 ] ] 7 7 ] 7 7 ] as No Yes No ] ] 7 ] ] 7 ] ] ] ] 7 7 ) 7 7 Yes No 1 Yes No 7 ] ] 7 ] 7 I 7 ] ] ] fes No ] 7 7 7 7 7 7 7 7 7 7 7 ] ] ] 7 7 7 Yes No 7 D ] ] , ' 7 ] ] 7 Yes No 7 7 7 ] i 7 7 ] 7 ) , 7 � , Yes No , ' 7 ] , I ] 7 ] 7 ----------=--------------------------- ] ] Il It 7 Yes ] No (Must have pregnancy coverage to select this option) Benefit 7 Yes ] No (If your group is a Municipality County School District or other Political Subdivision of the r be provided and is NOT optional ) TX 77115 03 10/96 Reorder;; TX 99000 HH 7r97 EMPLOYERS VOLUNTARY TRADITIONAL PLAN EMPLOYERS SELECT PLAN TRADITIONAL PLAN SELECT PLAN Plan J Plan A J Plan B J Plan 1 J Plan 2 {l Plan 201 J Plan 202 J Plan 101 jt Plan 1 C2 J Plan C J Plan D J Plan 3 J Plan 4 Deductible Plan A. B or C Plan D J S25 J S25 J S50 J S100 J $50 S50 In Network S50 J S50 J S75 Waive deductible Annual Maximum Plan A Plan B & C Plan D In Network Out Of Ne, o , J 51500 J 51000 J 5500 J 51000 ki 51000 )O S1000 -41-594F. J $3000 J 51500 J S 1000 J 51500 J S 1500 _ 8.400e 51000 Orthodontia J Yes J No J Yes J No -A Yes J No )a Yes J No I Waive preventive services deductible on Voluntary Traditional Plan (select box if your group chooses this option ) SEE Basic J A Salary Plan J 1 x Salary J 112 x Salary J 2 x Salary J 212 x Salary REQUIREMENTS and Accidental Death and Dismemberment Minimum requirement = S15 (rouiNod to next highest Sl 000) J 3 x Sa J 5 x Salary J 312 x Salary 512 , Salary J 4 x Salary J 6 x lary J 41h x Salary J 61h x Sa J 7 x Salary J B Level Amount Indicate Amount Class $ I_ I I III_ NOTE We suggest that amounts of Group Life Insurance be a unifoh you can select Group Life Insurance based upon other classifications times between the lowest and highest class Active full time employees age 65 or older are eligible for a reduced 1 Basic Dependent Life Benefit J YES J NO Voluntary Life/AD&D Benefit J YES J NO Minimum I or 5250 000 If chosen employee may select Voluntary See Participation Requirements Minimum J C Position = 5250 000 or 7 x saiar. $ Life/AD&D Amount or a flat amount for each employee At your request s cannot exceed 2 12 times between each class and 10 of their = $15 000/Maximum is combined Basic Life coverage $100/Maximum = $500 Life 7 x salary J A Salary Plan J B Level Amount J C Position Schedule Maximum of 662200 of Indicate Amount Class Description Short Term Disabil Amt Basic Weekly Salary/ss--- S Per WeeK I $ (rounded to next highest (in S10 Increments) II ST III S Accident SickDuration Example Short Term Dis Urty benefits begin on the first day for accident and on the eighth day for sickness and are payable for up to 26 eeks Short Term Disabilit/beneflts are available only to full time employees and terminate upon attainment of age 70 or retirement whichever I occurs first unless the employee is employed by an employer with 20 or more employees TX 77115 03 10/96 Reorder 4 TX-99000 HH 7-q- YOU the participating Employer POIICVholdef or Contractholder Intend to establish sponsor and endorse an Employee Bereft Plan which will be govemeo c the Emoloyee Retirement Income Security Act of 1974 (ERISA) YOU are the ERISA Plan Administrator THE FOLLOWING APPLIES TO BOTH EMPLOYERS HEALTH AND HUMANA S SMALL EMPLOYER MEDICAL PLANS ONLY A Small Employer is a Person firm corporation partnership association or other private legal entity acrveiv engaged in business nhidh on at east '-C working days during the preceding year employed at least 3 but not more than 50 eligible employees the masonry of whom were employed in this state Judas employees of an affiliated employer lone who is connected by commonality of ownership with a small employer I THE FOLLOWING TRUST INFORMATION APPLIES TO EMPLOYERS HEALTH LIFE/AD&D AND DEPENDENT LIFE YOU the participating Employer apply to participate in the Employers Health Insurance Benefits Trust for insurance coverage in elect or which may be —cc fled from time to time as underwritten by the insurer IWE US and OUR) Employers Health Insurance Company If YOU are accepted YOU acknowledge and agree on behalf of all persons who obtain insurance coverage through or under YOUR application to the Trust that the Trust Agreement under which AmSouth Bank Birmingham AL is named the Trustee the provisions of the Trust or any other written instrument the trustee signs on oenalf of the Trust are fully binding upon YOU The principal duties of the Trustee are to hold the insurance policyuesi through which insurarc- coverage is provided for employers in accordance with the terms of the Trust Agreement or any other written instrument which the Trustee signs on Defied c the Trust The Trust Agreement any other written instrument and the insurance policyQes) are available for inspection by YOU or cy any covered person through or under YOUR participation to the Trust during normal business hours at OUR Home Office YOU further understand and agree that the Trust and Trustee are not insurers YOU may withdraw from the Trust at any time thus terminating YOUR insurance coverage provided written nonce of termination is received by US prior to re requested termination date THE FOLLOWING INFORMATION APPLIES TO ALL PRODUCTS UNDERWRITTEN BY EMPLOYERS HEALTH OR HUMANA YOU agree to make available YOUR records which we determine are relevant to this Application and insurance coverage for Inspection by US or OUR repre sentative during YOUR normal business hours With respect to paying claims for benefits or determining eligibility for coverage under this Policy WE as administrator for claims determinations and as ERISr claims review fiduciary as described in 29 C F R 2560 503 l (g)(2) shall have full and exclusive discretionary authority to 1) interpret policy provisions 2) maKe decisions regarding eligibility for coverage and benefits and 3) resolve factual questions relating to coverage and benefits YOU understand and agree that failure to remit and pay premium when due will be considered a default in premium payment and that coverage will be term, nated by US following a grace period of 31 days from the date of non payment of premium WE may terminate YOUR insurance coverage according to me Termination of Coverage provisions stated in the Policy If coverage is terminated by US for non payment of premium YOU will still owe and WE will collec Premium for the grace period For YOU to remain eligible under the policy the eligibility Underwriting and Participation Requirements must be maintained for all coverage Failure to manta the plan eligibility Underwriting and Participation Requirements will terminate YOUR coverage under the POLICY Other termination provisions are stated in ^e Policy For Employers Health plans YOU understand that certain states may require that YOUR benefit plan cover pregnancy and related conditions the same as other medical conditions By signing this form YOU acknowledge that YOU are responsible for any difference between the pregnancy benefits provided to YOUR employees and their covered dependents by the Insurer and those required by law UNDERWRITING AND PARTICIPATION REQUIREMENTS i.iEDICAL For Employers Health and Humana products for groups of 3.50 lives 1 YOU must have 75% participation of employees eligible for medical insurance benefits 2 YOU are required to contribute at least 25% of the premium for each employee benefit 3 For groups with less than 26 employees you may not sponsor a medical plan from a carrier other than Employers Health or Humana All medical coverage may be terminated if YOU otter other medical coverage from a carrier other than Employers Health or Humana WE will deem YOU to be offering such coverage if employees have access to another carrier s metlical coverage by virtue of their employment with YOU MEDICAL For Employers Health and Humane products for groups of 2 cr 51+ lives 1 If YOU pay 1000. of the premium YOU must have 100% participation of employees eligible for medical insurance benefits 2 If YOU pay Jess than 100% of the premium YOU must have 750. participation of employees eligible for medical insurance benefits 3 YOU are required to contribute at least 25% of the premium for each employee benefit 4 All coverage may be terminated if participation falls below 2 employee lives or 50°. of the entire group 5 WE have the right to decline coverage of the entire group based upon the Employee Enrollment form 6 For groups with less than 26 employees you may not sponsor a medical plan from a carrier other than Employers Health or Humana All medical coverage. may be terminated if YOU offer other medical coverage from a carrier other than Employers Health or Humana WE will deem YOU to be offering such coverage if employees have access to another carrier s medical coverage by virtue of their employment with YOU The Following Coverages Are For Employers Health Plane Only BASIC LIFE/ADBD 1 if YOU elect this coverage YOU must have 100% Participation of all eligible employees regardless of whether they have medical coverage through their spouse for non contributory plans For contributory plans 750. participation required minimum employer contribution 25% VOLUNTARY LIFEIAD&O 1 If YOU elect this coverage YOU must have greater of 5 lives or 25% of eligible employees participating in order to offer voluntary life coverage No employer contribution required 2 Voluntary Dependent Life is available only if the employee has selected Voluntary Life/AD&D BASIC DEPENDENT LIFE 1 If YOU elect this coverage 1000. of all eligible employees electing dependent coverage must participate If YOU elect all emoloyees selecting ciepender coverage will automatically be enrolled Other employees may select as an option No employer contribution required SHORT TERM DISABILITY 1 If YOU elect this coverage 100% participation required for all eligible emplovees group size 2 9 and all non contributory size groups For contnbutory plans group size 10+ 75°a participation required Minimum employer contribution 25% DENTAL Non -Voluntary Plans 1 If YOU elect this coverage YOU must have 1000. participation of all eligible employees regardless of whether they have dental coverage through their I spouse for non contributory plans For contributory plans (minimum 25% employer contribution) YOU must have the following participation of eligible employees Eligible Employees 2 4 5 9 10 24 25+ Participation Requirements 1000. 75° 750. 750. (3 All coverage may be terminated if participation fails below 2 dental lives or 50% of the entire group VOLUNTARY DENTAL if YOU elect this coverage YOU must nave the greater of 5 lives or 25% of eligible emolovees participating No emolover contribution required TX 77115 03 10/96 Reoraer g TX 99000 HH i )7 r0U the employer (policyholder) understand and agree that the first month s estimated premium and fully completed enrollment information all eligible persons requesting insurance coverage must be submitted with this Application BEFORE action is taken on the Application For ups 3 50 with Employers Health plans you may be charged a monthly administrative fee which will not be more than $5 00 per person not o exceed $15 00 based on coverage selected YOU agree to collect any employee contribution toward premium It this application is declined ve will return the premium deposit submitted with the application YOU understand and agree that neither YOU nor the agent has the authon y to waive a complete answer to any question pass on insurability alter any contract or waive any of OUR other rights or requirements YOU iereby certify that YOU have read this document and that the information provided is accurate and complete YOU also certify that the infor nation provided here can be substantiated by business records maintained by YOU YOU agree to provide the documentation requested by JS which establishes that all eligibility underwriting and participation requirements of the policy are met YOU understand that only individuals vho meet the eligibility requirements of the Policy are entitled to maintain coverage YOU understand that providing incomplete inaccurate or intimely information may void, reduce or terminate an individuals coverage or the group s coverage This document will form part of any ontract issued Insurance coverage is not in effect unless and until YOU receive written notification from us UNDER NO CIRCUMSTANCES ;HOULD YOU CANCEL YOUR PRESENT GROUP COVERAGE WITHOUT PRIOR NOTICE OF APPROVAL BY US represent that the producer/agent has explained to me that Employers Health has made available to my firm the State Medical Plans pre ,cribed by Texas House Bill 369 providing that my firm as defined in the Act is a small employer of 3 50 eligible employees DATED ON // /810 BY (Mofith IDay Year) DATED AT k %%da'd (City and State) i AGENTIAGENCY OF RECORD (Comm uses) 2 AGENT/AGENCY OF RECORD (For Split Commissions Only) Social Secuntylfax ID No Name pity State —Zip phone No IzM :ommission Spht_°'o (Required for spit commissions only °6 should =100) WRITING AGENT (Agent who actually solicited the case) City State — Zip -Phone No ( 1 Fax No ( 1 Social Security Number bares Office Social Security fax ID Number Phone No No Commission Split_% (Required for spit oxnmissKm only °o should=100) You the agent(s) candy that you have met with the Employer submlthng this application and that you have fully explained its contents You have discussed coverage eligibility pre existing condition limitations and effect of misrepresentations and termination provisions and to employers of 3 50 eligible employees explained the state medical plans Writing Agent s Sales Office managers Agent J EHI J LNL J Other TX-77115-03 10/96 Reorder a TX 99000 HH 7/97 SEP 15 99 15 54 FROM T-559 P 04/04 F-957 fRe Employer Teo FM a0P65114W 11000 npioi NOW Orr. R y , vaa REQUEST TO MODIFY THE EMPLOYER GROUP APPLICATION (henceforth called "Request") Tv 0 F lDENToA) (exact least name) Address (svest) 7�� S9 7 3 (dty) (state) (rip) Group Number By signing this, You, the Employer, fully understand that this Request will have no effect unless and until It is approved along wtih or In addition to the Application The effective dote of any approved Request will be determined by US and may be later then the effective date requested below. The Application will be modified only to the extent expressly stated In this Request All other terms of the Application will remain In effect. In signing this Request, YOU understand and agree to comply with the Participation Requirements. The payment of premiums due for Insurance extended hereunder on and after the effective date of this Request will be deemed to conataute wrinen acceptance of this Request by the Policyholder Such payment of premiums is the only method by which this Request may be accepted by the Policyholder If this request is unacceptable to the Policyholder and the Policyholder desired to continue insurance under the Policy without this Request being placed in effect, written notice thereof must be given to Employers Heaah Insurance at the home office 1100 Employers Blvd, Green Bay WI 54344, within 31 days from the date the Policyholder receives this fora Please return this form to us at least 15 days prior to the requested effective date You the Employer, request that, effective your Employer Group Application be modified to reflect the change Indicated below Please complete the following as indicated on the alternate quote Product dVMAAM P"t— Deductible is a Tradisonei, Employers Health PPO, Dental) Coinsurance Percentage Drug Copayment (e a eofflo , aorr0) Optional Riders Other Coinsurance Limit Dental Annual Maximum Drug Deductible Please return this form to u at IRast 1s days pr r to th squested effective date. Date 9 /ti �l By �` Title f ( goaturs adma/ ge t watact) !�y David B Pieteopol, Vice President of Administration r Recyctavo W U40 Al Humana Inc yn, o,.c, Suite 1400 Dallas TY 7c2Gl 972 643 1600 '�' 9" 643 170C I lea c. e 972 643 1779 Fax HUMANA 1 TEXAS VOLUNTARY DENTAL RATES for City of Denton January 1, 2000 Voluntary Plan 101 EMPLOYEE $15.72 EMP & SPOUSE $38.18 EMP & CHILD(REN) $35.84 FAMILY $58.95 AVAILABLE OPTIONS Children Only Orthodontia (Rate 9& applies to Emp & Child and Family) *Rates are guaranteed for 2 years. *$1,000 Annual Maximum. included Humana Inc 6111 LBi rreeway >uae 14p0 Dd Ias 'X'5251 972 643 ' 600 'ei 972 643 1700 Medicare 972 641 1779 Fax HUMANA 1 ti TEXAS VOLUNTARY DENTAL RATES for City of Denton January 1, 2000 Traditional Preferred Plan 185 EMPLOYEE $20.66 EMP & sPousE $47.67 EMP & CHILD(REN) $47.12 FAMILY $74.95 AVAILABLE OPTIONS Waive Deductible on Preventive Children Only Orthodontia (Rate gWy applies to Emp & Child and Family) *Rates are guaranteed for 2 years. *$1,000 Annual Maximum included included r HUMANAO 1 Texas Plan 101 Preventive Services • Oral examinations • X rays •Ceara nq • Topical ..or ce I eatment through age 4) • Sealan,s 'h ough age 14) Basic Services • Space r, ',,ners (through age 14) • Emergency exams and palliative care for gain relief Oral sorcery • Amalgam composite fillings • Thumb sucking and harmful habit appliances (through age 14) • cxtranions trourinei Non cast pfetabncatea stainless steel • UOW-s •'an ai or co ^p e e dentu a repairs/ i ,a Majolor SeSerrvices • E^dodo -s 1,00t canals) • lie ,O,C^' CS • vorcela,n c o vns • Inlays and oniays • Removable or fixed bridgework • Partial or complete dentures I •Denture re6nes/rebascs Orthodontic option • Avauaicie for Or groups at an acgrtional Lost Covers cni,oren to age 19 Lifetime Orthodontic Maximum Calendar year Deductible Options • Ird v d,a' r cam') Is -sect one) I I lAnnual Maximum options (exnuaes orrnoaonpc serwces) 100% 80% after deductible Humana Dental Select Summary of Benefits I I 150% after deductible 1 I I I I I I i I I 50% no deductible $1,000 $50 I $ISO I � I $1,000 or 1$1,500 Questions? Call 1-800-23 3-4013 Pan avuda Espanol 1-900-922-6275 ext 4244 TDD 1-9n0-;n;-2n25 HumanaDental Select value and choice Easy to use • No claim forms Simply present your ID card at each dental visit • Fast claims processing Nearl 9094, of contpletL cl unis Ire prove ed within Ill daNi • Advanced claims payment C,,•mu are not held because of nusvnq nuor- ul,mon We Il Lail you or your denou to find answers and keep clamp movie., • Welcome calls Our represennmcc call new niembetc to mtmdutL Humana and answer questions • Hassle free customer service C ill us it 1-8nn-23¢_lfil , no a1ISUtrIi1A mtLhule, or totLe I url V]onday through Fndi} I of I oo a it to to UO p m )CS 1, and Touch to20opin CST, on Saturday Dental treatment plans You or lour dentist nul,' ,t bi It 'reicinent plan IOC ILLOII'IIILndld 10 1- L11I1-rgLtIL) sersu.n th It e%LLea j lit 1ierer to P-L-decLnnmauon of Beuetit, I y011- plan LerullLate Waiting Periods Witt III' Ptriods nip tie regL IrLd before. Lau ire eligible Fnr runib ncunen Prr%enme cerNICLS io not let ture %%aiti pLtlods Phn tern i, are Loncluls g well We'll credit deductibles Prior carntr credit is also avadablt Sunply send us a lettLr or Leplananon of benefits from vour prior carrier within 60 days of your effective date Th, eta nvpm, AhJuuu , ,, I e Tin ,, n fi u< irvn ,,n/fr wrLd,n ¢n m u , rrh, inn. SEP IB 99 15 54 FROM ttumanauental- Texas Voluntary SelectNlan Tut T-589 P 03/04 F-957 Page 1 of 1 The City of Denton WChris Scott, The City of Denton (940-340-8388) A Texas Voluntary Sailed Plan 101 HumanaDental Select Summary of Benefits Pro"llW OoMoesoml examints ns 100% MCIIr001mN1t (through ape 14M) RhraWn e0e 14) x rays ante aeMoss a0K Cher I f4/ aFood fNIAex ms (IMOg FINE" dodueObM Thum sus; gq and hhsat appliances pain ape 14) Nonceal pttdabtcam WInk= $test crowns PoNO) or wmplele donbde tepaireladjustments Am am eanpasno GN"o oral EaYa01bM IldudM) aeu0lP op deductible Inca and did ys Rou abte orved bropowoia Partal demutes or cor"M Gm rean ss"Is"es calala) P�(tow 0gla option a0% w deduairble Avalla for 10• gldups at an adMtau+el cost Coven children to age 1 Lifetime 0 MUMMM $1000 Glantiva year 90POON s301 s150 jnW, u gramay fa0eendless Mnual MUOMM OpOee $1,000 (Oxddde oromdaak a0/VMOa) mu A ner • aemproro apaweuN e/fM pain Thoplan wndkele conlams specMc quauacabona MMOMa and exclusroea Questions? Call 1.800 11-1890 TOO 14IM325-30M 01"0 HUMS@ Inc. http //www humanadental com/customtze html HumanaDental Select' value and choice Easy to use a No claim forma. Simply preeem your 10 Cord at esdl dental wait e Peet Claims preaddaine Nearly 90%at eamprou claims are processed within 10 days a Advandod clabe payments. Claims are et held beaause or mastng IhtermalM 11 Cast you or your �s Tom&" newdn and kaap a Welcome Was Our ropmeomutN" Cell newmembsn to Introduce Humana and answer question@ 0 Haalo*" customer service Cal us at 1 ON 233.4013 no answaMp machines or voice mall Monday Mtough Fridayfrom 8 00 am 166000m DdnW Treatment Pens You or your dental must submit a IrCotment plan for leccommaded non- emdr0ancy services mq ex ad $300 Rater toProodelarmonadon M eenellis In your plan CertOCote We'll" Paris& s Wallin u en doglWi roc may 00 anaurtselmer�l Osh+ra �ravant" services do no require walling periods Plan nitdlcaM contains guidelines We'll cram doduoebin Prior carrier Croft we," credit me deductible amount saddled with your poor CWW dental plan n Vow new HumanatMiul WpIaann gIl to wunin me acme Colander you 14t�y sand us a letter or eseanaton of bsn%' grim your prior confer WI In 00 days of your s"muw data TX-63330 HH 09/16/1999 SEP 16 99 IS 54 FROM ntundriduenidt - texas voluntary traattionai detect rian is3 T-569 P 02/04 F-957 Page I of I The City of Denton Chris Scott The City of Denton (940-349-8388) DORI Texas Voluntary Traditional Select Plan 166 Texas Voluntary Traditional Select Prevs tive s•mic"Oral namkNdons 100%a1a70 1 111 1 1111111, Cleo 14)-- l Ilounde kwtmam ftnmugh e0e 92 Ma (lmough ape 14) fa0� X rays ink bark le" 90% after deductible Space memnlners (through aapaes 11) Emergeney edema and palm mrs to pole reliThumb sucking end harmful heat applances (Illlaugh age 14) u ops steel �Panta�a COMPI s deemted s�tnleou Amalgam composite fillings it1rrniery rot iro6pens (rourlM) Major fervlces 00% after deductible Inlays one an e Removable or flsed bdOgavork Ps" or compNta danWds Clothes momaimbs6o Endodonhce (root Canais) Crewe P Ws ONtodOmis Option 30% no deduNole Av le for t0• groups at an aedrtlanel met covert Children all sae 1s Lifetime Orlhodonft Maalmum s10oe CalendaryyWar Deduction Option $6011130 IndnduWfamly (stages ON) Annual Moalearm Options s1 00o (ercwos o aho"ic seances) This is 4018 COMAWS dNNOawe of fM plan TIN plan Certificate contains spscdic qualaaer m6 emtsrwna and evokwAma TDDstiions? oall14M-J33-4013 Humana lontal Traditional Select: freedom to choose with an oppportunity to sous ReaOn additional savings swkpe st the arse services are racarved d you seek care from a dental who paticipsks M flum•ne'a network Contact your sacra for a provdm listing Easy to use • No claim forma Simply present yew In card of each dental visa • Past shams praeaame. Nearly 90%a Compete, "no are processed el thm to days • Adwnded claims, payment Claims am not hold because of Msemg Information Well me you or your dentist to find antw•n and keep claims moving • Welcome calls Our reprommeaws cost new members to IMMAMa Humana and answer Ou@soon& • ReaelMree OWtomen, service GO us al 1 600 233.4013 no anaw•dn0 machine$ of villa mall Monday through Friday from a 00 am lo000pat Dental Treatment Mane You of yew danger mutt submit a treatment plan for racommedod non etmrgattry, cervices that ekmeN $300 Refer to P enmunelmn of BomMs In your Dian cc to Waiting Period@ youWading di MPerWk roky be m*ted before Prit rewrdrve services do no ?"Use Will" periods Pen certificate contains oudmros We'll are& dbduatMn Prier caner GeOh. We11 credit the deductible &TMM mWned Won your Prior coda denlai pain toyr new Hu�progiwWaIlle r mwdviodo sociagWdn of Aft from yaw prior camer wi In g0 days of yi w aheCove dab 01909 Hun" Inc Insured by employers Health insurers Company http //www humanadental wnt/oustorntze html TX410B4 HH 4NO 09/16/1999 EXHIBIT C RECONCILIATION OF SELF -BILLED PREMIUMS • City will provide a summary of covered employees and the coverage type used to calculate the prenuum payment submitted by the City on a monthly basis, • City will provide a census report in alphabetical order of employee names and current coverage type and submit to the Company every calendar quarter for reconciliation, • The City will nonfv the Company within 30 days of the receipt of receiving monthly list billing from Company of any discrepancies in that billing RELIASTAR LIFE INSURANCE COMPANY ("COMPANY") 20 Washington Avenue South Minneapolis, Minnesota 55401 APPLICATION FOR VISION CARE INSURANCE POLICY ("GROUP POLICY" or "CONTRACT") Application is hereby made for the Coverage(s) specified herein to become effective on January 1, 2000, at 12 01 a m , standard time at the address of the Policyholder Applicant ("Policyholder") CITY OF DENTON Policyholder is Other, please specify [ ] Corporation [ ] Partnership [ ] Sole Proprietorship Address of Policyholder Municipal Building, 215 E McKinney, Denton, Texas 76201 Nature of Business Tax Identification Number 75-6000514-6 Are subsidiary or affiliated companies to be covered9 [ ] Yes [ ] No (if Yes, show correct legal name and address in the REMARKS section) 7 (a) Total number of Employees on payroll 114 4 Number of Employees eligible for coverage 965 in (b) A full-time Employee shall be any such employee who works regularly at least 20_ hours or more per week for the Policyholder (c) Classes of Employees to be excluded _Temoorary and Seasonal VCA900 Locations to be covered Location Number of Employees Texas 9 Mode of prennum payment [ ] Annually [ ] Semi -Annually [ ] Quarterly [ ] Tenthly [ X ] Monthly 10 List every state where employees or other covered persons reside I 1 List the current insurer or remsurer, type of coverage, limits and retention N/A 12 VISION CARE INSURANCE COVERAGE REQUESTED (Coverage Provided for each Section Completed) Per Insured Person Co -Payment Amount $10.00 (Exam Only) $10 00 (Materials Only) [ X ] Participating Provider (check all that apply) [ X ] Comprehensive Exam [ ] Intermediate Exam [ ] Preschool Wellness Exam [ X ] Lenses (Standard) per Pair [ X ] Single Vision [ X ] Bifocal [ X ] Trifocal [ X ] Lenticular [ X ] Contact Lenses (Per Pair) [ X ] Medically Necessary [ X ] Cosmetic [ X ] Frames (Standard) [ X ] Non -Participating Provider (check all that apply) [ X ] Comprehensive Exam [ ] Intermediate Exam [ ] Preschool Wellness Exam [ X ] Lenses (Standard) per Pair [ X ] Single Vision [ X ] Bifocal [ X ] Trifocal [ X ] Lenticular [ X ] Contact Lenses (Per Pair) [ X ] Medically Necessary [ X ] Cosmetic [ X ] Frames (Standard) Employee Only: $ 9.92 Employee + One: $ 19.22 Employee + Family: $ 28.26 13 Initial Premium Rate is and is guaranteed from January 1, 2000 through December 31, 2000. Premiums are not guaranteed beyond such date 14 Remarks This contract includes the SVP-8, Vision Access Plan, Discount See Attached Addendum 15 It is understood and agreed by the Policyholder that A COVERAGE UNDER THE POLICY WILL NOT BE EFFECTIVE UNTIL EACH OF THE FOLLOWING OCCURS (a) WRITTEN APPROVAL AND ACCEPTANCE IS TRANSMITTED TO APPLICANT/POLICYHOLDER, AND (b) PREMIUM IS PAID BY APPLICANT/POLICYHOLDER TO COMPANY IF NO PREMIUM IS PAID, THE COMPANY MAY REVOKE ITS APPROVAL AND ACCEPTANCE Present coverage should not be canceled until notification of acceptance in writing has been received B The information contained in this Application is true and correct to the best of the Policyholder's knowledge C The truth and veracity of the answers provided in this Application and any other written documents and information (specifically including experience data) provided to the Company by the Policyholder will form the basis of issuance of the Group Policy D Any material misstatement or failure to provide sought for information may be used as a basis for rescission of the Group Policy in the event of winch the sole liability of the Company would be a refund of all unused premiums E This Application supersedes any previous application and is otherwise subject to the terms, conditions, and definitions of the Group Policy This is not Workers' Compensation coverage nor is it a replacement for Workers' Compensation insurance ReliaStar Life Insurance Company does not sell nor is it authorized to sell Workers' Compensation insurance G By providing benefits through purchase of the Group Policy, the Applicant may have an employee benefit plan under the Employee Retirement Income Security Act of 1974 If so, tlus may require that certain information be filed with regulatory authorities and communicated to employees, and other compliance ReliaStar Life Insurance Company has informed me it is an employer's obligation to comply with this law H The agent who solicited this application and arranged to have it executed is Name N/A Address Telephone Number This Application, and any information supplied on it, shall be incorporated by reference into the Group Policy and made a part thereof Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison Signed at Date Witness Licensed Agent Approved and Accepted by Company as of , 19_ by Effective Date 19 CITY OF DENTON, TEXAS Policyholder/Applicant (Fu egal Name) %Vzz Signat re of thonze er(s) MICHAEL W JEZ Name CITY MANAGER Title APPROVED AS TO LEG HERBERT L Y, CITY BY Mailed to Policyholder on , 1� Addendum to the City of Denton Application for Vision Care Insurance 414 REMARKS a) The terms of the policv will be for one year with the right to renew The policy will automatically renew 60 days prior to the renewal date as agreed to by both parties b) There is a thirty day grace period for the premium If the premium is not received within the grace period, it will automatically terminate c) This vision coverage will match the client's current policy of offering the same coverage for all active, cobra, or retirees of the City of Denton d) The Director of Treasury, or other such representative, designated by the City Manager is hereby authorized to carry out the terms of this agreement on behalf of the City of Denton e) The City of Denton will give a 60 day written notice prior to terminating the contract f) The above remarks will override any conflicting information in the policy