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1999-376AN 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 sohe~ted, 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 C~ty Manager or a designated employee has reviewed and recommended that the hereto described proposals are the lowest responsible proposals for the matonals, eqmpment, supplies or services as shown in the "Bid Proposals" submitted therefore, and WHEREAS, the City Cotmcfl has prowded 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 herem, NOW, THEREFORE, THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS ~ That the ~tems in the following numbered request for proposals for materials, equipment, supplies, or services, shown ~n the "B~d 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 APPROXIMATE AMOUNT 2406 ALL Aetna U S Healthcare $3,522,608 2344 3 & 4 Humana, Inc Employee Funded 2344 5 Superior V~slon Services Employee Funded ~ That by the acceptance and approval of the above numbered items of the submitted proposals, the City accepts the offer of the persons subm~tnng the proposals for such items and agrees to purchase the materials, equipment, supphes or services ~n accordance w~th the terms, speclficataons, standards, quantities and for the specified sums contained m the Proposal Inwtatlons, Proposals, and related documents ~ That should the C~ty 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, prowded that the written contract is m accordance with the terms, con&t~ons, specfficatlons, standards, quantities and spemfied sums contmned in the Proposal and related documents here~n approved and accepted ~C,!LO_]~L!_Y_ That the Ctty Manager ~s hereby authorized to execute the Letter Agreement, attached hereto and made a part hereof for all purposes, and contract wtth Aetna U S Healthcare for RFSP 2406, and contracts w~th Humana Inc and Superior V~s~on Servmes for RFSP 2344 E T~._C_TLO__~ That by the acceptance and approval of the above numbered ~tems of the submitted proposals, the C~ty Cotmcll hereby authorizes the expenditure of funds therefor ~n the mount and m accordance w~th the approved proposals or pursuant to a written contract made pursuant thereto as authorized here~n SECTION VI That tbas orchnance shall become effective lmmedmtely upon ~ts passage and approval PASSED AND APPROVED this the /q~ day of~, 1999 ATTEST JENNIFER WALTERS, CITY SECRETARY APPROVED AS TO LEGAL FORM HERBERT L PROUTY, CITY ATTORNEY CONTRACTUAL - RFSP 2406 Aetna Health Plans Kelhe Fleming 2777 Stemmons Fwy Account Executive Suite 400 214-200-8956 Dallas, TX 75207 214-200-8949 fax October I 1, 1999 Ms Christina Scott Health Benefits Administrator C~ty of Denton, Texas Mumc~pal Budding 215 E MeKmney Denton, TX 76201 Dear Chris Oa behalfofAetaa U S Healthcare I would hke to thank you for the confidence yon have placed m our company by selecting us to be the recommended employee health plan vendor for the 3 ear 2000 We look fo~ard to joining you at the C~ty Councd Meeting on October 12 1999 to preseat the recommendation I would bke to coafirm the agreed upon plan offering, rates, terms and conditions A point of earollment program wtll be offered allowing employees to select between Health Mamteaaace Orgamzat~on (HMO) or point-of-Service (POS) plan during opea earolhnent annually 2 The selected HMO plan benefits and rates are auached as Exlub~t A 3 The selected POS plan benefits and rates are aaached as Exlub~t B 4 The second year rate guarantee being offered to the C~ty of Denton ~s aUached as Exhibit C 5 I have received the tentative enrollment schedule (Exlub~t D) aud wall begin to assign representatives to cover meetings as soon as an offictal contract award Is made Please s~go below ffyou are m agreement and the contract ~s awarded to Aetna U S tlealthcare for the plan year beg~ ~n ng January I, 2000 Note that th~s letter does not contractua~y~md e~ther paay but ~s sunply a confirmatmn of uaderstandmg and intent on the pail of b~Aetna U S Healthcare and The C~ty of Denton Sincerely, Kelhe A Fleming Account Executive Page 1' er 13, 1999, ~ CITY OF DENTON Effec:tive Date 0110112000 Renewal Data 110112001 Setwce Area Texas - Dallas Quote 5049144~ ~p.e~. I_alist c,;ip_~y. (S2I .... SPU 5urgerj [;gpay Huspitall2eUbn ~;opat ~, E. meency Koom I $50) MH O/P ...COp~_y, ($tiS) ~ 8MI O/P (SSS) Routine ~va P.J~am C~ sy Routine GYN Exam ¢ ~y~{.~ti) tv~ I,ens Rel.mbUj:semen S;~ofor R4 monllm) t.'rescrlption ~-.;opsvt. 40/$20 G/B). 30 _Cp. ntracept,ve~ C;used Formum~/ .31-~ Day 8_upply. z usl~/s (MOO only) / Manoaton, uenen~ | OblE Item Copey ($0) ~ates I Parent and Child(rea) $317 82 Couple $367 64 I am.l y _ The forego~ng~rats$ apply In the Service Aras epect§ed above Rates will vary for othe~ service araa$ cieten-nlned by the Ioeatlon of Ihs subact'l~et'a primary core doctor A~eumad'gepe.asst'Elli;l'TEI1H'y'-[~nd'e'h'TEIfiCcl~o e~d'~'t-monm~n..WhiLclf'h-~.sli§.lurns ! stuclsn~ to ,~e enct of the month In which he/she flJrns 25 Cove;age will commue ;or (]epeneerits woo become meNallylphyelcally handicapped pner to the end of the month they reach age 25 These monthly quoted rates ars valid aT Of the EffsGflve Date an(] apply only to tho benefit level and coati.one s ~bove andaraaubjecttotheterrn~andoondltionasstfe/lhlntheHMOaGmupMasterContracl Any changes m pen .leveler conditions Staled above may require a change iff rates Rates we.re .developed ustng ~,nfo~m~abon ~hi~ch~ls _b.~?_e, /~ the group canaus~ AUSHC rusewes the right to modify this rate shoul(] toe group census ne maccura[e or enrollment differs materially from the gtoup census This proposal i~,~ubject to change at any brae by AUSHC of Employe/'a off~' Employar Authorteatl Date CC Ft. EMING, KELUE / // STOKES;, GAVIN / For office use ertlL V~r~Tardy~e-- OO-- ' ~'Quote lu ~'04ti144~ Rar~-co-d& CR D'T'Q'R'EA Calc WB L _Seq~/Grp~ AH2HG Cust0merlD 1263312 ~__P__PID __1347619 Page 2, Otto er 13. 1999, ~ CITY OF DENTON Elfectlve Data 01101/2000 RenewaIDate 01101~'2001 Service Area Texas - Dallas Quote 5049144 Class Rating Factor Worksheet Ehgible/Enrollee Summary $1r~gle Par/Child Couple Family Male Male Male Male < 24 20 < 24 2 < 24 I < 4 25 - 29 35 25 - 29 7 25 - 29 8 2!~ - 29 12 30 - 34 45 30 - 34 16 30 o 34 4 3~ - 34 35 35 - 39 38 35 - 39 34 35 - 39 2 31~ - 39 33 40 - 44 27 40 - 44 22 40 - 44 7 4l r. 44 36 46 - 49 32 45 - 49 26 45.49 8 41~ - 49 40 50 - 54 26 50 - 54 21 50 - 54 t2 51,- 54 ' 21 55- 12 5s 65+60 - 84 71 65+60 - 64 11 6065+- 64 2761..,~: +64 20 Male Subtotal 24~ Male Subtotal 13t Male Subtotal 63 Male ubtotat 189 Female Female Female Femal; < 24 5 < 24 0 < 24 I < :'4 1 25 - 29 26 25 - 29 3 25 - 29 3 2~ ,- 29 2 30 - 34 19 30 - 34 14 30 - 34 2 3Ir- 34 4 35 - 39 27 35 - 39 12 35 - 39 0 $~, - 39 6 40 - 44 21 40 - 44 14 40 - 44 I 4~,. 44 8 45 - 49 16 45 - 49 9 45- 49 4 4!~ - 49 10 50-54 13 50-54 3 50 54 4 51,-54 , 8 55 - 69 9 55 - 59 1 55 - 59 3 6!,- 59 1 60 - 64 9 60 - 64 0 60 - 64 0 61~ - 64 0 65 + I 65' 0 65 + 0 61i+ 0 Female Subtolal 146 Female Subtotal a5 Female Subtotal 18 Femal; Subtotal 40 Single Subtotal 391 Par/Child Subtotal 186 Couple Subtotal 91 Famdy Sul ,total 229 Grand Tot~ 887 AETNA U S Healthcare® FLEX MEDICAL PLAN CITY OF DENTON Texas - Dallas PRIMARY CARE PHYSICIAN VISITS r Office Hours $20 copay After Hours / Home V~s~ts $25 copay SPECIALTY CARE Office Vissts $25 copay D,agnosttc Outpauent Testing $25 copay Phys,Occ, Speech Therapy $25 copay SPU SURGER r $ 100 copay HOSPITALIZATION $240 copay/A EMERGENCY ROOM (copay waived If adm#ted) $50 copay MA TERNITY F~rst OB V~s~t $25 copay Hospital $240 copay/A MENTAL HEALTH Inpatient MH $240 copay, 30d SMI $240 copay, 45d Outpatient MH $25 copayN, 20v SMI $25 copay/V 60v SUBSTANCE ABUSE Detox~fi(:atson $240 copay/A Inpatient Rehabdltat~on $240 copay/A Outpatient Rehablhtatmn $25 copay/V PREVENTIVE CARE Routine Eye Exam (per benefit schedule) $2S copay Routine GYN Exam $25 copay PRESCRIPTION LENS REIMBURSEMENT $200 every 24 months $10/$20 G/B, 30 Day PRESCRIPTIONS Covered Contraceptives 31-90 Day Supply (MOD only) $20/40 G/B copay Mandatory Generics Applses Closed Formulary DURABLE MEDICAL EQUIPMENT No copay SPEECH & tlE~4RING Copay based on reed plan 4962~14 an hos 1Iai services reqmrc a written tel'trial from he prlmar/care physician See Ccmficatc orCovc~agc All non cmcrRcnc~ specialty Ld ~ , . .~fll~ ate nrovid by AEI~A U S Healthcare~ fo~completeustoflcrms, bcneu~anaexcmslons oc ....... ~_ ed _ HMO-1 Plan Design & Benefits Aetna U S Healthcare Texas Flexed Patriot XV Plan Plan Features In Network (Referred Care) Primary Care Physician Visits O/rice Hours $20 copay After-Hours/Home $25 copay Specmlty Care Office %sas :t;25 copay Dmgnosuc OP Lab/X Ray Testing (at faclhty) $25 copay w~th PCP referral Dmgnosnc OP Lab/X Ray Testing (at spec office) Included ~n Spemahst Office %sits copay for vmlt with PCP referral Outpatient Therapy (speech, phys, occup) $25 copay Outpauent D~alysm/Chemotherapy $25 copay Allergy Tesung/Treatment $25 copay for testing $20 copay for routine injections at PCP office - with or w~thout physician encounter No serum copay Preventive Care Routine Physmals $20 copay Routine Child and Well Baby Care, $20 copay lmmumzatlons Routine GYN Care $25 copay One routine GYN v~t and pap smear/365 days D~rect access to pamc~patmg prowders Routine Mammography $25 copay One annual mammogram for females age 35 and over Rouune Eve Exam $25 copay D~rect access to partm~pat~ng ' provider schedule apphes Hearing Exam $20 copay Routine hearing screemngs Heanng A~ds Not covered Emergency Care $50 copay / t rgent Care Out-of- Area $50 copa~,~ Aetna U S Healthcare HMO-2 Plan Design & Benefits Aetna U S Healthcare Texas Flexed Patriot XV Plan Plan Features In Network (Referred Care) Ambulance No copay Outpatient Surgery $100 copay Hospitalization $240 copay Skilled Nursing Facility Care {m lieu oft $240 copay hospltahzatton tot medically necessary covered benefits) Materm~ OB Vis,ts $25 copay for initial visit only Hospital (Includes Newborn Services) $240 copay Home Health Care/Hospice-Outpatient No copay Private Duty. or Special Duty Nursing Not covered unless pre-authorized by HMO, no copay when covered Hospice - Inpatient $240 copay Family Planmng/Reproductlve Services Covered with applicable specialist, outpatient Sterlhzauon Procedures surgery or inpatient hospital copay if applicable, Reversal of voluntary stenhzat~on including related follow-up care and treatment of complications of such procedures ~s not cox ered Mental Health Inpatient - Serious Mental Illness $240 copay, 45 days per calendar year Outpatient - Serious Mental Illness $25 copay 60 mslts per calendar year Inpatient - non-SMI $240 copay, 30 days per calendar year Outpatient - non-SMl $25 copay, 20 visits per calendar year Substance Abuse Detoxlficatlon Inpatient Detoxlfication $240 copay Outpatient Detoxlficatton $25 copay Substance Abuse Rehabilitation $240 copay, 3 episodes combined IP and.~ Inpatient Rehabdltatlon Outpatient Rehabditation $25 copay, 3 episodes combined IP and~ Aetna U S Healthcare Plan Design & Benefits HMO-3 Aetna U S Healthcare Texas Flexed Patriot XV Plan Plan Features In Network (Referred Care) D~abetlc Supplies ILK copay, otherwise $20 copay Prescrtpt~ons $10/20 (Closed Formulary) Durable Medical Equipment $0 copay Lens Reimbursement $200 for 24 months Emergency Care Gmdehnes 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 thts Act, an emergency medical condition ~s "a medical condition mamfest~ng ~tself by acute symptoms of sufficient seventy (mcludtng severe pain) such that a prudent layperson, who possesses an average knowledge of health and med;clne, could reasonably expect the absence ot m~medlate medical attention to result tn 0) placing the health of the ind~wdual (or w~th respect to a pregnant ~oman the health of the woman and her unborn chtld) tn serious jeopardy, (n) serious impairment to bodd'~ functions or (iii) serious dysfunction ofany bodily organ or part" Urgent Care Out-of Area Gmdehnes' Aetna U S Healthcare follows the Balanced Budget Act of 1997 defimtton of covered, ~mmediately required out-of-service area services Specifically, Aetna U S Healthcare covers urgent services outside of the member's home service area ff the services are "medically necessary and immediately reqmred because of unforeseen illness injury, or condmon, and it was not reasonable given the circumstances to obtain the services through" the member's home serwce area Examples of urgent care needs include · Respiratory, or flu like symptoms w~th high fever · Earache · Severe sore throat · Severe abdominal cramps, vomtUng or d~arrhea / Urgent care may be obtmned from a private practtce phystctan, a ,_walk tn chmc, an urgice/~ o~/an emergency facd~ty Follow up care must be coordinated through the members primary care Aetna U S Healthcare ~age 1 Oclo Der t4, lg99 AUSHC Pronesal For CI~ OF DGNTON Eff~Clwe Dale 01/01/~000 Re~owal Date 01101/~001 Se~ice ~ea Texas - Dallas Ouot~ 5052854 Benefits F=r Refaced Non. Refaced ~pe~a,st~pay (S2S~ ' ~e~u~ble ?U ~u~ge~ ~y (~?p)... coinsurance (zo~3o) ~me~ R~m.~opa~ (SS01 Ufstime Maximum Benefit (S1 MH lip ~paylA (SRo) 3~, SMI ($240) ~d Deductible Cor~over 3 Months MH O~ COp~ (S2~ 2~ SMI ~P {S~) 6~ De0ucfl~le Credit Roubne Eye bxom ~pay (S25) Roubne GYN Exam ~y (S2S) tvlyr Pm~ipUon Copay (SI~0 G~), 30 Day ~n~ceDtiv~ Qosed Fbrmula~ 31 ~ Day Su;~x 2 =o~s (MOD on~) Mnn~;to~ , DME Item Coppy (t0) ..... ~ch & Hea~g Ri~, Rates I Parent and Ch~ld(~) S361 09 Couple ~17 68 Famdy ~55 41 ~e ~r~o~ng rotes apply I~ the Semi~ ~a speared above Rates ~11 va~ for o~er se~ areas delermned by ~e logan of ~e aubs~dbeds ~a~ ~e docMr ~u~~~~'~d et monm in whiCh ne/s~e tums 19 or mlCfi~ - ~uc~ ~ts ~ ~e ~d of the mon~ in whl~ he/she lures 25 ~vemge ~11 ~nflnue for de~enden~ who ~ be~ ~llylphym~iy handtcep~d pr~r to the end of ~e mon~ they roach age 25 '&~ ;Z ~g~ roles are valid as of the Effecbve DMe and ;~ply only to the benefil level end ~nd~bons s ~ ~ aJ~ <~ ~e ~ end ~ndi~ons ~t ~ m the HMO e Group Master ConVacl end/or the ~te ~ ~IW Afl~ ~angee in benefil level or ~nd~fions s~t~ a~ve may r~u~re a change In rates Rates .ere ~ ~;~o~awhlchlsbaaedenthegmup~nsus AUSHCresewestheflghtto~d~tsrate~houldlhe ~ .~suS ~a~umle ~ ;f accel plan e~l~ent d~ffers ~aten~ imm ~e gmu~ census ~is proposal, suble~ to cc // STOKES, GAVIN [ For office u~e only ~ Va~d Calc WB Page 2 Oct(bar 14 199g ~ CITY OF DENTON Effective Date 01/01/2000 Renewal Date 01/0112001 Serwce Area Texas - Dallas Quote 5052854 Class Ralfng Factor Worksheel Ehg~blelEnrollee Summary Par/Child Couple Family Male Male Male Male < 24 20 < 24 2 < 24 1 < $ 4 25 - 29 35 25 - 29 7 25 - 29 8 ' 29 12 30 - 34 45 30 - 34 16 30 - 34 4 - 34 35 35 - 39 38 35 - 39 34 35 39 2 - 39 33 40 - 44 27 40 - 44 22 40 - 44 ? - 44 36 45 - 49 32 45 - 49 28 45 - 49 8 49 40 50 - 54 26 50 - 54 21 50 - 54 12 - 54 2~ 55 - 59 14 55 - 59 1 55 - 59 12 59 6 60 - 64 7 60 - 64 I 60 - 64 7 - 64 2 65 '* 1 65 * 1 65 + 2 + 0 Mate Subto/al 245 Male Subtotal 131 Male Subtotal 63 Male ubtotal 189 Female Female Female Fema <24 5 <24 0 <24 1 < 4 25 - 29 ' 26 25 - 29 3 25 - 29 3 - 29 2 30 - 34 19 30 - 34 14 30 - 34 2 - 34 4 35 - 39 27 35 - 39 12 35 - 39 0 - 39 6 40 - 44 21 40 - 44 14 40 - 44 1 - 44 45 - 49 16 45 - 49 8 45 - 49 4 41 49 10 s0.. 43 50. so- s4 60 - 64 9 60 - 04 0 60 - 64 0 6( - 640 65 + 1 65 + 0 65 + 0 6~ * 0 Female Subtotal t46 Female ~ubtotel 55 Female Subtotal 18 Femal~ ~ Subtotal 40 Subtotal 391 Par/Child ~ubtotal 186 Couple Subtotal 81 Family Sut total 229 Gra~d Tot; ,887 A~TNA U S ItEALTHCAI~ OF NORTR T£.v~S INC.~ QU~ITY POINT-OF-SERVICEs` PROG~I~ FLEX HMO / LJ~rty Flex Plan ~ CITY OF DENTON ................. ~ - ~ Deductible Smgl~a~ly N/A Cm~umn~ N/A 70% Co~u~nce L~t Smgle~dy N/A $4,000~8,~ P~M~R Y ~ ~HY$IC~N Offi~ Hour~ $~0 copay 70% a~er deducible A~ertHo~ / Home Vm~ S25 copay 70% afYet dedncnble ~P~CIAL TY O~ce V~uts S25 c~ny 70% after deducttble ~sagnos.c O~n.ent Testing S25 c~ny 70% after deducuble Phys,Oec~peech ~eupy S25 copay 70% a~er deductible SP~G~Y S 100 copay 70% n~er deductible HO$P~FIO~ S240 copay/A 70% afver deductible S~L~D ~1~ F~CILI~ $240 copay/A 70% ~r deducuble EM~RG~NCF~OOM (~ wm~fd i/admi~fd] $50 copay $50 copay HOM~ C~ No copay 70% aft~ dcducuble M~TERNI~ F~st OB ~lsit S25 copny 70% a~er deducuble Hospital S240 copay/A ?0% ~ d~ucuble MSNTAL HEALTH ~pattent MH S240 copny 30d Not covcr~ (MH) SMI S240 copay, 45d 70% n~er deducnble (SMI~ Ou~an~nt ME $25 c~tyN. 2~ ~0% after deducible (~) SMI 525 copay~ 6~ 70% after deduc.ble (SMI) D~oxtfica~on S240 copay/A 70% a~er deducuble ~piB~nt Rehabih~non S240 copiy/A 70% after deducible ~anent R~i~muon ~25 ~pay~ 70% a~er deductible Routine E~ Exam ~r benefit ~hedule) $25 copny ~ot covered ~ufi~e Physl~uls S20 copay Not covered ~nom S20 copay 1~% sg~ ~6, nae 64 noz c ;ered Routine ~gtaphy 525 copay 70% ~er deducuble Routine G~ ~m $25 copny 70% after deducuble Pedza~c ~vonnve D~ml Exam Not Covered Not cove~d CHIROP~IC CA~ 70% a~er deducible, S 1000 annual P~C~P~[O~ S 10~20 G~, 30 Day Con~c~nves Coveted 31-90 ~ay Supply (MOD only) $20/40 G~ copay Man~m~ Generics Apphe~ Closed Fo~ul~ DU~$LE MEDICAL EQUIPMENT No copay 70% a~et deductible ~PEECH & HE--Nfl Copay based on reed plan In ne~ (tcf~d) b~ellu are ~ovldcd by ~E~A ~ ~Nealt~st~.o~.~h Tt~ - EXHIBIT C F,nancml In£ormaUon ] ~'Health Plans Multi-year Guarantee Multt-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 ['or 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 lnc determines that any of the following occur during the guarantee period, 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 o[` 20% d change in the plan of benefits/services offered v~hmh is initiated by the customer or required because of legislation actmn, e failure of the customer to make required premium payments in accordance contract prov,sions, f enactment of legislation (either state or federal) whmh impacts the abiht', of Aetna Inc to contract for efficient, cost effective medical care g all changes in the employee contribution strateg) for any plan of benefits offered must be agreed to by Aetna Inc on each annual annlversar) date h a change in the tier rating structure for any plan of benefits offered, account has an tncurred loss ratio of greater than 82% Incurred loss ratio will be developed by dividing paid premiums by incurred clmms 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" for POS, the preferred access of care does not equa~.~x~5~ed 90% of care, as measured by clmms incurred during the base year Aetna Health Plans 09/ I 7/ I 99 9 Aetna U.s, Health=are of North Te,,as In= P O Box 569440 Dallas Texas 75366-9~i40 214-2000-8000 or toll-~ree 1-800-992-7947 Texas State.Mandated Coverages Dear Employer Texas law requ,res 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 I,sted below Please ~nd~cata below whether you accept or reject the following benefits for your Heall Maintenance Organization (HMO) in.net~ork benefits and execute by s~gnature on pa 2 of this document 1. In Vitro Fertilization Benefits Benefits for In vitro fert~hzation services If you decide to offer this benefit, addlt,onal premium w~ll be required __Accept X Reject 2 Inpatient Mental Health Benefits Benefits for mental and emotional Illness and disorders when confined ~n a hospital w,th corresponding alternative treatment faclltty banal'frs to the extent that suoh benefits are not mandated as serious mental Illness Inpatient benefits for mad,cai, nursing, counsehng or therapeutic services m an inpatient, hospital or non-hospital residential fac~l;ty Including a mental health treatment facllRy, crisis stabilization un;t, or residential treatment center appropflatel'. hcensed by the Texas Department of Health or ~ta equivalent Coverage Is subject t a maxim~Jm number of days Copaymenta will not be less favorable than for hospffal coverage under your pa~cular plan of benefits If you decide to offer this benefit, add,tlonal premium will be requ~r Accept X Reject Page of 2 hmo ~l~llS ~ ~ejecflo~ ~tlce nl~ggl ~ev g 3. Treatment of Speech and Hearing Impairments Diagnostic aewices rendered by a participating provider to find out if and to what extent the member's ability to speak or hear ;s lost or ~mpa~red as a result of disea~ ;e, injury or birth defect Hab~l,tative and rehab~l;taflve services rendered by a parhc~pat~ng prowder Io rest(= speech or hearing loss or to correct a speech or heanng impairment Th;s does m include charges made for speaking aids or training in the use of such aids The serwces must be directed and mon~ored by a parbclpaflng physician and referrals rust be certified by health plan In advance If you reject this coverage, your plan will limit non-surg;cal coverage to any hmitations stated In the certificate of coverage If you decide to offer th;s 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 ,_~, 'base coverages Michael lez City Manager Page 2 of 2 hmo-dallas tx ~eJeC~n notice nb991 my 9 2 )9 EXHIBIT D CITY OF DENTON PROPOSED 1999 INSURANCE OPEN ENROLLMENT SCHEDULE November i i 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 H~ckory) 8 30 a m H R Conference Room (601 E Hxckory) 10 00 a m H R Conference Room (601 E Hickory) i 00 p m H R Conference Room (601 E H~ckory) 2 30 p m H R Conference Room (601 E HLckory) 3 45 p m H R Conference Room (601 E HLckory) November 3 7 00 a m H R Conference Room (601 E H~ckory) 8 30 a m H R Conference Room (601 E HLckory} 10 00 a m H R Conference Room (601 E Hickory) i 00 p m H R Conference Room (601 E Hickory) 2 30 p m H R Conference Room (601 E HLckory) November 4 7 00 a m H R Conference Room {601 E HLckory) 8 30 a m H R Conference Room (601 E H~ckory) 10 00 a m H R Conference Room (601 E Hickory) i 00 p m H R Conference Room (601 E Hxokory) 2 30 p m H R Conference Room (601 E Hickory) November 5 COBRA i 00 p m H R Conference Room (601 E Hxckory) RETIREEs 3 00 p m H R Conference Room (601 E Hickory) November 8 2 00 p m Central Fare 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 Traln~ng Room (601 E H~ckory) November 10 2 00 p m Central Fire Department (217 W McKinney) November 16 8 00 a 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) Training Room (901 Texas) November la 9 00 a m utilities Safety oo~0~ 10 S0 a m Utilities Safety Training R xes) 2 00 p m Laboratory (1100 S Mayhill~ PLEASE POST IN YOUR AREA AGREEMENT FOR EMPLOYEE DENTAL BENEFIT PLAN STATE OF TEXAS § COUNTY OF DENTON § THIS AGREEMENT iS made and entered tnto as of the /~/J day of ~, 19 ~c~ , by and between the C~ty of Denton, A Texas Mumc~pal Corporation, w~th tts pnnmpal office at 215 E McYdnney Street, Denton, Denton County, Texas 76201, (hereinafter sometimes referred to as "CITY") and EMPLOYER HEALTH INSURANCE/HUMANA, INC and ~ts legal subs~dmnes with its corporate office at 1100 Employers Boulevard, Green Bay, WI 54344, hereinafter called the ("COMPANY") acting hereto, by and through thetr duly authorized representative WlTNESSETH, that m cons~deration of the covenants and agreements hereto contmned, the parties hereto do mutually agree as follows ARTICLE 1 EMPLOYMENT The CITY hereby contracts w~th COMPANY, as an independent contractor, and the COMPANY hereby agrees to perform the services herem tn connection with the ProJect as stated tn the sections to follow, with dthgence and ~n accordance wtth the highest professional standards customarily obtained for such services in the State of Texas The professional services set out herein are m connection with the following described project To provide dental benefits insurance for the City of Denton employees, retirees, or those active ~n COBRA who w~sh to enroll w~th the COMPANY The COMPANY is to provide such ~nsurance at rates guaranteed for a two year period and to provide employees w~th insurance that will help care for the needs of the employees and their famthes tn obta~mng dental care and treatment SCOPE OF SERVICES The COMPANY shall perform the followtng servmes in a professional manner A To perform all those services set forth tn COMPANY'S apphcation which apphcauon ts attached hereto and made a part hereof as Exhibit "A' as tf written word for word herein B If there is any conflict between the terms of tins 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 m, standard time at thc 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 wntten notice to the other party at least 60 days before the contract ends for the renewal to be effective COMPENSATION The COMPANY will be compensated for its services by the paying of premiums, by wire transfer of funds made between the 15th and 20th of each month, by the enrolled participants ~n the plan at the premium rates set forth m Exinblt "B" These rates are to guaranteed for the enrollees from January I, 2000 to December 31, 2001 The CITY will prowde a reconciliation of self-bill premiums as stated m Exhibn "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 mdependent contractor, not as an employee of the City COMPANY shall not have or claim any right anmng 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 arbltratton or other means of alternate dispute resolution such as medmUon No arb~traUon or alternate d~spute resolution arising out of or relaung to, tins Agreement involving one party's disagreement may mclude the other party to the disagreement wnhout the other's approval 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 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 penmtted under this Agreement shall be personally dehvered or mailed to the respective parties by depositing same in the United States mad at the address shown below, certified mai1, return receipt requested unless otherwise specified herein Marled notices shall be deemed communicated as of three days mailing TO COMPANY TO CITY EMPLOYERS HEALTH iNSURANCE/ CITY OF DENTON HUMANA, INC Attn Michael W Jez Attn Jerry Ganonl Title City Manager 1100 Employers Blvd 215 E McKlrmey Green Bay, WI 54344 Denton, TX 76201 All notices shall be deemed effective upon receipt by the party to whom such notice is given or w~thln 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, negot~ations, discussions, communications and agreements which may have been made in connection with the subject matter hereof ARTICLE 10 SEVERABILITY If any prowston ofth~s Agreement is found or deemed by a court of competent jurisdiction to be ~nvalid or unenfomeable, it shall be considered severable from the remainder of this Agreement and shall not cause the remainder to be mvahd 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 stncken provision ARTICLE 11 COMPLIANCE WITH LAWS The COMPANY shall comply w~th all federal, state, local laws, roles, regulations, and ordinances applicable to the work covered hereunder as they may now read or hereinafter be amended Page 3 of 6 ARTICLE 12 DISCRIMINATION PROHIBITED In performtng the servtces requtred hereunder, the COMPANY shall not dtscnm~nate agatnst any person on the basts of race, color, rehg~on, sex, national ongtn or ancestry, age, or phystcal handtcap ARTICLE 13 PERSONNEL A The COMPANY represents that tt has or will secure at its own expense all personnel reqmred to perform all the servtces reqmred under thts Agreement Such personnel shall not be employees or officers of, or have an contractual relattons wtth the ctty COMPANY shall inform the CITY of any conflict of interest or potenttal conflict of interest that may arise dunng the term ofthts Agreement B All servtces reqmred hereunder will be performed by the COMPANY or under its supervts~on All personnel engaged in work shall be quahfied and shall be authorized and permitted under state and local laws to perform such services ARTICLE 14 ASSIGNABILITY The COMPANY shall not assign any tnterest in thts Agreement and shall not transfer any interest m this Agreement (whether by assignment, novatton or otherwtse) wtthout the prior written consent of the CITY except the company may asstgn thts Agreement to an affihate wtthout the consent of the CITY ARTICLE 15. MODIFICATION No watver or modlficatton of thts Agreement or of any covenant, condttlon, hnntatton here~n contained shall be vahd unless tn writing and duly executed by the party to be charged therewith and no evtdenee of any waiver or modtfieatton shall be offered or recetved tn evtdence tn any proceeding arising between the parttes hereto out of or affecting flus Agreement, or the rights or obhgattons of the parttes hereunder, and unless such watver or modtfieatton ~s tn writing, duly executed, and, the parttes further agree that the provtstons of thts section will not be waived unless as hereto set forth Page 4 of 6 ARTICLE 16 MISCELLANEOUS A The following exhibits are attached to and made a part of this Agreement 1 Exhibit "A" application for dental care insurance policy 2 Exhibit "B" hst of premium rates for dental benefits plan 3 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 Thzs Agreement shall be construed m accordance with the laws of the State of Texas C The captions of this Agreement are for informational purposes only and shall not m any way affect the substantive terms or conditions of th~s Agreement IN WITNESS HEREOF, the City of Denton, Texas has caused this Agreement to be executed by its duly authorized City Manager and COMP _Ay4y has executed this Agreement thro,u~h its duly authorized undersigned officer on this the /{I~L day of t~.~(_ , CITY OF DENTON, TEXAS ~r ATTEST JENNIFER WALTERS, CITY SECRETARY APPROVED AS TO LEGAL FORM HERBERT L PROUTY CITY ATTORNEY Page 5 of 6 EMPLOYER HEALTH INSURANCE/ HUMANA, INC By Name T~tle WITNESS Page 6 of 6 Employers Health Insurance/Humana Insurance Company Texas Employer Group Apphcat,on RINT OR TYPE ALL SECTIONS IN BLACK INK Requested Eft DateI J/l/~r I Group Number [ qe of Group Type of Business Phone oca~on Address C~t C~unty State Z~ d~ng Address ~ State Z~p em~mstr~t?e Contact ~ Management C~ntact ARTN~RSH~PSPLIT~ ~Y~S ~NO SPL~T~ILLREQUEST ~Y~S ~NO MU~[LOCATION ~YES ~NC ~roup No to ~e a~soc~ate~ w~th Mulblocatlon Phone ~ ( ) Mulblocat~on Fax ~ ~ ) , t~s coverage pa~ of a umon negotiated agreement~ ~ YES ~NO Dam of Ex~rat~on )o you ~h to have 24 hour ~ve~g~ (G~u~ of ~1 + av~le for ~e~ ~ or Pa~e~ not ~er~ ~ Wo~e~ ~n~) ~ YES ~ NO 'amens} LIGIBILITY ull t~me employees working at least 30 hours per week are ehg~ble ~f emDIoyeO by you Pa~ t~me and seasonal employees are not ehg~b~e or 51+ groups you may reOuce the hourly requirement to not less than 20 hours per week ~d~cate Houdy Requirement ~ Voluntew L~fe hourly requirement ~s 20 hours per week oral Number Of Emoloyees Number of Permanent Full ~me Emolovees Number of Ehg~ble Employees >n Payroll ~[ ~ ~ Eltglble For Coverage ~ ~ Enrolhng '~ ASSES OF ELIGIBLE EMPLOYEES WITH OTHER GROUP MEDICAL COVERAGE TO BE EXCLUDED )upsof350 DNONE ~UNION ~NONUNION GROUPS OF 51+ ~NONE 2 UNION D NON UNION ~HOURLY ~SA~RY ¢EW EMPLOYEE WAITING PERIOD NEW EMPLOYEE EFFECTIVE DATE PROVISION ~ 0 Days ~ 1 M~th, ~ 2 ~ontbs ~ 3 Months' Q F~rst of month following wamng pertod ~ Immediately following wa~t~ng per~od ~ Other S~ec$~ U~ ~ Groups of 3 50 may not exceed 90 days he waiting period and effective date provlslO~ must be t~e same on all plans he employee termination date on all Humana PPO plans is as stated in t~e group pohcy On all Employers Health ~lans ~t coincides w~th the ffectlve date orovlslon ~MPLOYER CONTRIBUTION (See Pad~c~pat~on Requirements) ~ed[cal Non Volunta~ Dental Basic L~fe ~hcd Term D~saOd~tv ~mployeer~ Dependents ¢~ Employee t.o~% DePendents I~% ~ s this a replacement of your current group coverage? Medical D YES · NO Dental ~YES ~ NO Prior O~ho ~YES 2 NO STD D YES ~ NO f yes, furmsh the following current cartier fbi a Medical . Dental~TD. ) Your most recent b~lhng statement c Term date of curren~pnor medical coverage Effective and term date of Dental coverage ~x[t[fl ¢ - ~ ~1J~ q STD coverage J Wdl th~s plan De offered ~n add~bon to another medical plan that you wdl continue to prowde~ 2 YES · NO Name of Carner 20BRA Am~yp~n[or~p~~onoreh~etoel~COB~S~te~n~~ 2 YES ~ NO If yes ~m~ete Name COBR~State Cont Termination of OR Other Quah~mg Event =motovers Health benefit ~lan ce~#~cates should be sent to 2 Agent ] Em~toyer iflcates for Humana benefit ~lans are ma~led to t~e employee s ~ome address To orowOe medical and dental benefits to retired emoIoyees state a~alned age and years of se~ce for retiree class ehg~Od~W The retiree lass wilt ~e considered only if yom have 51 or more employees enrolled for such coverage Benefits will be effectwe for e[~rees ~f approved ~etlreesarenotellglbleforanyhfeordlsabd~tv~ne~ ~ ~ ~ ~ <3~ ~¢~ ~ovouw~tRe~r~s~ve~for M~I ~O JYES Den~l J NO ~YES Age~YeamofSe~ ~ ~,h~ X7711503 10/96 Reorder = TX 99000 HH PLAN SELECTION - To complete l~s ~nforrnaaon refer to your proposa~ or plan brochure NOTE Submit your proposaJ along wr~ th~s apples.on (Multiple Choice ~s not available w~th state plans ) lan 2 (s) I .E (if applicable) : (if applicable) OUT OF applicable) NE'rWORK NAME ,__ OPTIONAL BENEFITS HumenaFreedom Flue i Network) Yes No Yes No Yes No Supplemental Accident 23 ~ 23 .~ 23 23 Deductible Carryover Credit :21 -~ 23 23 23 23 Copayment Drug Card $10 Generic Copay/$20 23 23 23 23 ~1 $5 Genenc Copay/$15 Brand 23 23 ~ ~1 23 Humana PPO (PHC$ Network/Humana and Traditional Insurance No No Yes No Supplemental Accident ~ 23 23 23 -~ Deductible Carryover Credit 23 23 23 23 Enhanced Preventive Care (Available w~th Traditional Insurance Only) ;J ,~ 2~ ~ 23 Copayment Drug Card If selected, replaces Major Medical Coverage $10 Genenc Copay/$20 Brand Copay ~ :3 23 23 23 23 $5 Genenc Copay/$15 Brand Copay ~3 ~1 23 ~ 21 ~ Employers Health Value Plane Yea No Yes No Yes No I Agree To Self Fund Normal Pregnancy Coverage (If group a~ze ~s 15+) 23 23 23 23 23 Supplemental Accident 23 23 ~ 23 23 Copayment Drug Card Copay after deductible OR :3 ~ ~1 ~ -) Copay (no deductible) OR 23 .~ 23 - ~ 23 STATE MEDICAL PLANS {Normal No Basic Indemnity ~ 21 Basic Beneht Plan PPO :3 :3 Catastrophic Care Benefit Plan PPO :3 :3 Catastrophic Indemnity :3 :~ Optional Alcohol & Drug Abuse R~( ;3 ~ Optional Mental Health Rider :3 :3 Optional Copayment Drug ~1 -, Optx)naJ Prevermve Cam R~:Jer ~ aval on Bas~ Pia~) 23 23 Elective Abortion R~der 23 :3 SPECIAL STATE In V~tro Fertlhzatlon I 23 Yes 21 No {Must have pregnancy coverage to select th~s option) Senous 23 Yes 23 No (If your group ~s a Mumc~pahty County School D~stnct or other Pohtmai Subd~ws~on of the tam th~s benefit be provided and *s NOT optional ) TX 77115 03 10/96 Reorder ~ TX 99000 HH 7~97 EMPLOYERS VOLUNTARY TRADITIONAL PLAN SELECT PLAN TRADITIONAL PLAN EMPLOYERS SELECT PLAN ~)an ..iPlanA ~PlanB ~Planl _lPlan2 ~l. Plan201 _~Plan202 _~Planl01 ~[PlantC2 -[ Plan C ~ Plan D ~ Plan 3 .J Plan 4 DeOuctl01e P~an A. B or C Plan D -~ $25 ~1 $25 ~1 SE0 ~ $100 ~1 $50 $50 in Network S50 ~ $50 ~1 $75 ~ve deductible Annual Maximum Pl{tr~ A Plan B & C Plan D In Network Out Of Ne, o _1 S1500 :J $1000 -~ $500 ~1 $1000 al $1000 ~ $1000 ?-03 ~ $3000 .~ $1500 ~1S1000 251500 ~1S1500 ~3G~ S1000 Orthodontia ~ Yes ~ No ~1 Yes ~1 No '~ Yes -I No ~ Yes ~ No Waive preventive services deciuct~ble on Voluntary Traditional Plan {select box # your group cl~ooses th~s option ) Basic Em end Accidental Death and Dismemberment Minimum requirement = S15 ) or 7 x sa~ar, 2 A Salary Plan ghest $1 000) -~ B Level Amount ~1 C Position Sc 2 1 x Salary ..~ 3 2 5 x Salary Indicate Amount Class Descnpt~, L~fe/AD&D Amoum ~J l~2xSalary ,~ 3~xSalar 5~xSala~ $ I S ~ 2xSala~ ~ 4xSala~ ~ ~ 21~xSalaw ~ 4~xSala~ ~ 6~x Ill $ ~ 7 x Sala~ NOTE We suggest tflat amounts of Group L~fe Insurance fiat amount for each employee At your request you can select Group Life insurance based upon other classifications annot exceed 2 ~ tl~es be~een eac~ class an~ 10 t~mes 0e~een the lowest and highest c ass Active full time em01oyees age 65 or olOer are ehg~ble for a reOuceO a~nt ~ount / Basic Dependent Life Benefit ~ YES / ,Volunta~ Life/AD&D Benefit Q YES ~ NO Minimum = $15 000/Maximum ~s combme~ Basic ~ Life 7 x sala~ or 5250 000 If chosen employee may select Volunta~ D Life coverage See Partlc=patlon Requirements Minimum rec~u, $100/Max~mum = $500 ~1 A Salary Plan ~J B Level Amount ;~ C Position Schedule Maximum of 6623°. of Indicate Amount Class Descnpt~on y~Amt Basic Weekly Salary $ .PerWeeK I $ (rounded to next highest $10) tin $10 Increments) II S Ill $ Accident S~ck~/ss. Duration Example Short Term D~s/a~lhty benehts begin on the hrst ~ay for acc~dem an~ on the e~gntn day for s~ckness and are payable for uD to 26 ~ Sho~ Term D~sab~h~0eneflts are available only to full t~me employees and terminate upon aEamment of age 70 or retirement whichever {occurs hrst unless t~e emDIoyee ~s employed by an employer w=th 20 or more employees TX77115 03 10/96 ReorQer~ TX-99000 HH 7~ THE FOLLOWING APPLIES TO ALL PRODUCTS LISTED BELOW YOU t~p panic,Dating Employer P011cvholder or Contracthoider imeno to establls~ sponsor ano en0orse an Employee Benefit Plan winch wdl be gove.re: c the Employee Retirement Income Secun~y 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 THE FOLLOWING TRUST INFORMATION APPLIES TO EMPLOYERS HEALTH LIFE/AO&D AND DEPENDENT LIFE had from tome to time as underwnt~en by the insurer (WE US and OUR) Employers Health Insurance Company trustee s~gns on oenalf of the Trust are fully binding upon YOU The pnnclpal duties of the Trustee are to hold the insurance pohcylles] through which ~nsurar'c- THE FOLLOWING INFORMATION APPLIES TO ALL PRODUCTS UNOERWRII'I'EN BY EMPLOYERS HEALTH OR HUMANA YOU agree (o mal<e available YOUR records which we determine are relevant to th~s Apphcat~on and insurance coverage tot mspecuon Dy US or OUR repre cta~ms review fiduciary as deecnbad ~n 29 C F R 2560 503 I(g)(2) shall have full and exclusive d~scretlonary authority to 1) interpret poltcy prows~ons 2) ma~.e ~ec~s~ons regarding ehglblhty for coverage and benehts and 3) resolve factual questions relating to coverage and benefits For YOU to remain eligible uno, er the pohcy the ehg~blhty Underwnt~ng and Participation Re0u*remenls must be malnta~neo for alt coverage Fadure to ma~nta" Policy YOUR employees and their covered dependents by the Insurer and those required by law UNDERWRITING AND PARTICIPATION REQUIREMENTS ,,,EDICAL For Employers Health and Humana pro,duets for groups of 3-60 lives YOU must have 75% participation of employee~, eligible for mecltoal insurance benefits 2 YOU ere recruited to cont~lt~ute at least 25% of the premium for each employee benefit For groups w~th less than 26 employees you may not sponsor a medical plan from a carnet other than Employers Health or Humana All medical coverage may be terminated tf YOU offer other medical coverage from a carner other than Employers Health or Humana WE will Oeem YOU to be offenng such coverage if employees have access to another carners medical coverage by virtue of their employment w~th YOU MEDICAL For Employers Health and Humana products for groups of 2 or 51+ lives 2 If YOU pay tess than 100% of the premium YOU must have 75% pa~l~c~pauon of employees ehg~ble for mechcal insurance benefits 3 YOU are recurred to contnbute at least 25% of the premium for each employee benefit 4 All coverage may be terminated ~f participation fall8 below 2 embloyee ~rves or 50°o of the entire group 6 For groups w~th less than 26 employees you may not sponsor a medical ptan from a carrier other than Emptoyers Health or Humana All me(~cal coverage, may be terminated ~f YOU offer other medical coverage from a career other than Employers Health or Humana WE wdl deem YOU to be offenng SUCh The Following Coverages Are For Employers Health Plane Only BASIC LIFFJAO&D spouse for non contributor/plans For contributory plans 75% participation required mm~mum employer contribution 25% VOLUNTARY LIFFJAD&D f If YOU elect th~s coverage YOU must have greater of 5 lives or 25% of ehg~ble employees participating ~n order to offer voluntary hfs coverage No 2 Voluntary Dependent L#e ~e available only if the employee has selected Voluntary L~fe/AD&D BASIC DEPENDENT LIFE If YOU elect th~s coverage 100% of all eligible employees electing dependent coverage must participate If YOU elect ali emcioyees selecting aepen(~er' coverage w~ll automatically be enrolled Other employees may select as an option No employer contnbutlon rec~ulreci SHORT TERM DISABILITY DENTAL Non-Voluntary Plans 1 If YOU elect th~e coverage YOU must have 100% participation of all eligible employees regardless of whether they have dental coverage through their Ehg~ble Employees 2 4 5 9 10 24 25+ IVOLUNTARY DENTAL TX 77115 03 10/96 Reoraer = TX 99000 HH , D7 ,'OU the employer (pohcyholder) understand and agree that the hrst month s estimated premium and fully completed enrollment mformat~on ~ll ehg~ble persons requesting insurance coverage must be submitted w~th th~s Apphcahon BEFORE achon rs taken on the Apphcat~on For ups 3 50 w~th Employers Health ptans you may be charged a monthty administrative fee which w~ll not be more than $5 00 per person not o exceed $15 00 based on coverage selected YOU agree to collect any employee contnbut~on toward premium If {h~s apphcat~on ~s dechned ve w~ll return the premium deposit submitted w~th 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 nghts or requirements YOU ~ereby cerhfy that YOU have read th~s document and that the mformat~on prowded ~s accurate and complete YOU also certify that the mfor nat~on prowded here call be substantiated by business records maintained by YOU YOU agree to prowde the documentabon requested by JS which estabhshes that all ehg~bihty underwriting and particlpabon requirements of the pohcy are met YOU understand that only individuals vho meet the eligibility requirements of the Pohcy are entdled to maintain coverage YOU understand that prowdmg incomplete inaccurate or mt~meiy ~nformat~on may void, reduce or terminate an individual s coverage or the group s coverage Th~s document w~ll lorm part of any ontract issued Insurance coverage ~s not in effect unless and until YOU receive whiten notd~catlon 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 hrm the State Medical Plans pre .cribed by Texas House B~I1369 prowd~ng that my hrm as dehned m the Act ~s a small employer of 3 50 eligible employees (Mo~lth ~).y Year, *"' ~l~lpl°~l~*i'f~atur", ((~'ty arid-State)' ! - ~ (~tle) ~ ! AGENT/AGENCY OF RECORD (C43mmiss~ons/~uses) 2 AGENT/AGENCY OF RECORD (For Split Commissions Only) Social Security/Tax ID No Social Securdy/Tax ID Number Name Name. -3treat Street ~lty State Zip , C~ty State Z~p =hone No Fax No. Phone No ( ) Fax No ';ommlssmn Spht % (Required for spi~t commissions on¥ % should =100) Commission Spht % (Requ~redlor s~t~t comrn~ss~ons on¥ % should=100) WRITING AGENT (Agent who actually solicited the case, You the agent(s) certify that you have met w~th the Employer subm~ng th~s Name apphcat~on and that you have fully explained ~ts contents You have Street d~scussed coverage ehglb~hty pre ex~stmg cond~tmn i~mdat~ons and City. State Z~p. effect of mtsrepresentat~ons and termination prows~ons and to Phone No ( ) Fax No ( ) employers of 3 50 ehg~ble employees explained the state medical Social Security Number plans Writing Agent e Signature Date 3,~,es Office Location Sales Off~ce Manager s S~gnature Agent .J EHI J LNL _1 Other TX-77115-03 10/96 Reorder # TX 99000 HH 7/97 REQUE8T TO MODIFY THE EMPLOYER GROUP APPLICATION (henceforth celled "Request') (exist legal Addre$~ .... Group Number By signing thls~ Vou~ the Empleyer~ lul~ uadem~nd that ~ls Request will have ne erect unless and until It le approval along web er In add~n ~ ~he Applloallen The effective date ef any approved Request will be determl~d by U8 an~ may be ~ter th~n the effe~lve da~ requested below. The Application will be modred nnly to the e~ent e~mssly elated In th~ Request All other terms of the Application will remain In effe~. In signing this Requ~t, YOU understand and agree to com~ly with tho Pofllclpatlon Roqu~mento. The pa~ent of promlu~ due for Insur~ee e~fld~ hereundor on and a~r ~e eff~t~ date of th~s R~uest will ~ ~eem~ m ~onst~te w~en a~ept~ce of tn~ R~uest by Ihs Pol~older ~ugh pa~ent of premiums ms Ihs only method by whl=h ~is R~u~t m~ ~e a~ept~ by the Polm~o~er If this request ~s unacceptable to the PolmCyholder and the Po~o~er d~ir~ to contmnue insurers under the Polmcy wmthout ~ R~uest being p~ mn after, wri~en no~oe ~er~l must be g~en to Emp~yer8 H~h Insurance at the home office 1100 Emp~rs B~, Green Bay WI 5~44, w~thmn 31 d~y8 from the date the Polmcyholder receNes th~s for~ Please tatum this fo~ to us at least 18 days prior to the requested effective date You the Emp~y~, r~uest ~at, eff~e /~/~O ~ur Employer Group Appl~abon be modified to reflect the change mn~icat~ ~w Please compile the fol~wing ~ ~i=~ on the alternae quote Product ~~ D~u=t~ble Cmnsurance L~m~t (e e Tredleon~, EmOte Ho~ PPO, Co,europe Pereent~e Drag Copa~ent Drug D~t~l~ Opt~nal R~dem Dental Annual M~mum Please ~turn th~ form to u~ at I~a~t 15 d.~ p~r to t~quested effec~ve dete. / ~ ~ecycta~lo Davtd B ~c~n~l, VI~ P~stdcnt Suite 1400 972 643 1779 Fax ,~"~, H UNIANA 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 included (Rate ~ applies to Emp & Child and Family) *Rates are guaranteed for 2 years. *$1,000 Annual Maximum. 972 643 1700 Medlca[e ff.~HUMANA TEXAS VOLUNTARY DENTAL RATES for City of Denton January 1, 2000 Traditional Preferred Plan 185 EMPLOYEE $20.66 EMP & sPousE $47.67 EMP & CHILD(RI~N) $47.12 FAMILY $74.95 AVAILABLE OPTIONS Waive Deductible on Preventive included Children Only Orthodontia included (Rate oni? applies to Emp & Child and Family) *Rates are guaranteed for 2 years. *$1,000 Annual Maximum NHUMANA ® HumanaDental Select Summary of Benefits Texas Plan 101 IPreventtve Services HumanaDental Select I' Oralexam,n~nons 100% value and choice I. c ea~ % Easy to use through age ~.) your ID card at each dental w~c Serwces · Oral surge~ IlhltIOII We 11 ~all you or your del~Bsc tu I ' Tnumn sucking and harmful habit tMalor Serwces Monda~ through Fr]d~ t m ~ · Removable or fixed brmdg~ork Dental trmatm~nt plans I Wamilflg Period) Lifetime Orthodontic Maximum ~Sl,0~ Wait na ptrlods iil~x he reqtlrcd i Calendar year Deductible ~ before ;ou ~re ehg~ble q~r rclmb nCClnen IOpt~ons ~* I~dvd.a'/%m 9.1octane) $50 I S150 pct~odq Phn ~erttq~at~ ~optm~ q tt %h c W~'ll Credit d~du~tlbles I Prior carnet credit is also avadablc j benefits from vour prior carrier wtthm 60 IAnnu~l Maa~mum O~tlon~ days of your effectwe ~te ~uestions? Call 1-800-133-~013 Pan avuda Espanot 1-g00-g22-6275 e~ 4244 TDD 1-80r~-~'~-2¢23 $£P I$ 00 I$ 54 ;ROM ?-$85 P 00/04 F-SS? ttuma~auental- Jexas ¥oluntar/belect i, lan Iu! Pa6e ! of ! The Cffy of Denton Chris Scott, The C:ty of Denton (940-340-8388) Texal Volun~w ~m Plan 10t Hu~na~nml 8el~t 8ummm , of Benefits ~ ~m~ oxon. 10o% HumlflnOefltal Saint' value ~ (~) pr~eas~ ~n 10 days Iflll~ 8~ ~M Iflf~O~ ~ you or your : Ll~m OM ~ S1 ~ answ~ m~lfles ~ vo~ mall qu~lofll? Call 14~6-16~ wa~ perl~ e~anaflm M ~n~ ~ ~ur p~ ~mor 01~ ~ ~ ~3330 HH http//www h~manadentai com/customme html 09/16/1999 nU~d~lctL~nlcli - l~Xd~ voluntary ]ram~lonai beleC[ ~*]a~ la~ PaSs 1 o! I Chris Scott The City of Denton (940-349-8388) Texas Voluntmry TrmdltlonsI 8~l~t Plan 185 Texm~ Volun~ TradlUon,l 8Meat cmnmu ............ 8elKt f~om ~ ohoose with X ~y~ , R~ ~ s~ ~ t~ ~ ~um~ s~mg o~ ho~.l ~ O~ ~ Easy M uso LI~I~ ~H~ ~ MOO0 quol~l Wino ~1~ We'll ~ W PrIM ~ ~ ~ ~t t~ http//www humana, dental eom/ouatom~a hmfl 09/16/1999 EXHIBIT C RECONCILIATION OF SELF-BILLED PREMIUMS · Clt~ will provide a summary of covered employees and the coverage t~e used to calculate the prermum payment subnutted by the C~ty on a monthly basis, · C~ty will provide a census repor~ m alphabetlcai order of employee names and current coverage type and subrmt to the Company every calendar quarter for reconclllauon. · The Clt~ w~ll notify the Company within 30 days of the receipt of receiving monthly list b~llmg fi.om Company of any d~screpanctes m that btllmg RELIASTAR LIFE INSURANCE COMPANY ("COMPANY") 20 Wasbangton Avenue South Mmneapohs, M~nnesota 55401 APPLICATION FOR VISION CARE INSURANCE POLICY ("GROUP POLICY" or "CONTRACT") Apphcatmn ~s hereby made for the Coverage(s) specified hereto to become effective on January 1, 2000, at 12 01 a m, standard t~me at the address of the Pohcyholder 1 Apphcant ("Pohcyholder") CITY OF DENTON 2 Pohcyholder ~s [ ] Corporatmn [ ] Partnersbap [ ] Sole Propnetorshtp Other, please specff3' 3 Address of Pohcyholder Mumapal Building, 215 E McKmney, Denton, Texas 76201 4 Nature of Bus~ness 5 Tax Identification Number 75-6000514-6 6 Are subsM~a~ or affihated compames to be covered? [ ] Yes [ ] No 0fYes, show correct legal name and address ~n the KEMARKS secUon) 7 (a) Total number of Employees on payroll ~ q v~ Number of Employees ehg~ble for coverage cI ¢ ~ m (b) A full-t~me Employee shall be any such employee who works regularly at least 2___00_ hours or more per week for the Pohcyholder (c) Classes of Employees to be excluded __Temporary and Seasonal VCA900 8 Locations to be covered Locatmn Number of Employees Texas 9 Mode of premium payment [ ] Annually [ ] Semi-Annually [ ] Quarterly [ ] Tenthly [ X ] Monthly 10 List every state where employees or other covered persons reside ___Tex~s 11 List the current insurer or reinsurer, 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 Vtslon [ X ] Bifocal [ X ] Trifocal [ X ] Lenucular [ 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 ] LenUcular [ X ] Contact Lenses (Per Pai0 [ X ] Medically Necessary [ X ] CosmeUc [ X ] Frames (Standard) Employee Only: $ 9.92 Employee + One: $ 19.22 Employee + Family: $ 28.26 13 Imtlal Prenuum Rate is and ts guaranteed from January 1, 2000 through December 31, 2000. Prermums are not guaranteed beyond such date 14 Remarks This comract includes the SVP-8, Vision Access Plan, Discount See Attached Addendum 15 It ts understood and agreed by the Policyholder that A COVERAGE UNDER THE POLICY WILL NOT BE EFFECTIVE UNTIL EACH OF TI-I~ 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 Presem coverage should not be canceled until notification of acceptance tn writing has been received B The m_formation contained tn this Application ts tree and correct to the best of the Pohcyholder's knowledge C The truth and veracity of the answers provided tn this Apphcation and any other wnttan documents and mformatlon (specifically including experience data) provided to the Company by the Policyholder wdl form the basis of issuance of the Group Policy D Any material rmsstatement or failure to provide sought for information may be used as a basis for rescission of the Group Policy in the event of which the sole babflIty of the Company would be a refund of all unused prennums E This Application supersedes any previous apphcation and ts otherwise subject to the terms, condmons, and defimuons of the Group Policy F This is not Workers' Compensation coverage nor is n a replacement for Workers' Compensation msurance RehaStar Life Insurance Company does not sell nor is it authorized to sell Workers' Compensation msurance G By providing benefits through purchase of the Group Policy, the Applicant may have an employee benefit plan under the Employee Retirement Income Secunty Act of 1974 If so, tlus may require that certain reformation be filed with regulatory authonUes and commumcated to employees, and other ¢omphance RellaStar Life Insurance Company has informed me it is an employer's obligation to comply vath tbas law H The agent who solicited ttus apphcauon and arranged to have it executed ,s Name Address Telephone Number I Tbas Application, and any information supphed on it, shall be incorporated by reference into the Group Pohcy 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 apphcataon for insurance is guilty of a crime and may be subject to fines and confinement in prison CITY OF DENTON, TEXAS Signed at Policyholder/Applicant (Futk[fegal Name) Date S [gl~athre o f ~6thonze~t~r(s) MICHAEL W JEZ Witness L~censed Agent Name Approved and Accepted by Company CITY MANAGER as of ,19 Title by APPROVED AS TO LE~.~_~, Wt]R~ HERBERT L Y, CITY A TORNEY Effective Date ,19 ~.~-- Mmled to Policyholder on ~ Addendum to the C~ty of Denton Apphcanon for Vision Care Insurance #14 REMARKS a) The terms of the pohcv will be for one year wtth the right to renew The pohcy will automatacally renew 60 days prior to the renewal date as agreed to by both parUes b) There ~s a thirty day grace period for the prermum If the prermum ~s not received w~thm the grace period, ~t will automatically terminate c) Tlus ws~on coverage wall retch the chent's current pohcy of offering the same coverage for all acUve, cobra, or retirees of the C~ty of Denton d) The D~rector of Treasury, or other such representatave, designated by the C~ty Manager ~s hereby authorized to carry out the terms oftlus agreement on behalf of the C~ty of Denton e) The Ctty of Denton wall gtve a 60 day written noUce prior to termmaUng the contract f) The above remarks wall ovemde any conflicting mformat~on m the pohcy