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2001-272 ORDINANCE NO ~, t')O/~.,~ 7o~_. AN ORDINANCE ACCEPTING COMPETITIVE PROPOSALS AND AWARDING A CONTRACT FOR THE PURCHASE OF HEALTH INSURANCE, PROVIDING FOR THE EXPENDITURE OF FUNDS AND PROVIDING AN EFFECTIVE DATE (RFSP 2689- EMPLOYEE HEALTH INSURANCE AWARDED TO CIGNA HEALTHCARE 1N THE ESTIMATED AMOUNT OF $5,354,000) WHEREAS, the City has solicited, received and evaluated competitive sealed proposals for the purchase of necessary materials, equipment, supplies or services in accordance with the procedure of STATE law and City ordinances, and WHEREAS, the City Manager or a designated employee has received and reviewed and recommended that the herein described proposals are the most advantageous to the City consldenng the relative importance of price and the other evaluation factors included tn the request for proposals, and WHEREAS, the City Council has provided m the City Budget for the appropriation of funds to be used for the purchase of the materials, equipment, supplies or services approved and accepted here~n, NOW, THEREFORE, THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS SECTION 1 That the items in the following numbered request for proposal for materials, equipment, supplies or services, shown in the "Request Proposals" on file in the office of the Purchasing Agent, are hereby accepted and approved as being the most advantageous to the City consldenng the relative importance ofpnce and the other evaluation factors tncluded in the request for proposals RFSP NUMBER CONTRACTOR AMOUNT 2689 CIGNA HealthCare $5,354,000 SECTION 2 That by the acceptance and approval of the above numbered items of the submitted proposals, the City accepts the offer of the persons submttt~ng the proposals for such ~tems and agrees to purchase the materials, equipment, supplies or services in accordance with the terms, spemficattons, standards quantlhes and for the specified sums contmned tn the Proposal Inwtattons, Proposals, and related documents SECTION 3 That should the C~ty and person submitting approved and accepted items and of the submitted proposals w~sh to enter into a formal written agreement as a result of the acceptance, approval, and awarding of the proposals, the C~ty Manager or h~s designated representative is hereby authorized to execute the written contract, provtded that the written contract is in accordance with the terms, conditions, spectficatlons, standards, quantities and specffied sums contmned in the Proposal and related documents herein approved and accepted SECTION 4 That the City Manager or his designated representative Is hereby authorized to execute a letter of agreement as per CIGNA HealthCare response to RFSP 2689 dated July 12, 2001, and ~ncorporated herein and made a part hereof for all purposes, and contract with CIGNA HealthCare for Employee Health Insurance RFSP 2689 SECTION 5 That by the acceptance and approval of the above numbered items of the submitted proposals, the C~ty Cotmcd hereby authorizes the expendtture of funds therefore in the amount and in accordance w~th the approved proposals or pursuant to a written contract made pursuant thereto as authorized here~n SECTION 6 That thru ordinance shall become effective ~mmedmtely upon ~ts passage and approval ASSED AND APPROVED thls the ~7~/'~ dayof 0.1./~1.~ ,2001 EULINE BROCK, MAYOR ATTEST JENNIFER WALTERS, CITY SECRETARY APPROVED AS TO LEGAL FORM HERBERT L ~:~TY, CIT~Y ATTORNEY BY ^~ CIGN Ju! 18 0;~ 03;15p T~m Bridges 940-34G-7803 A l a on for l rance ~GNA ~ ~t G~al L~e ~ ~mpany ~ ~ ~s2 CIGNA C~ty Government ALI Employees 3oo [ s00 [] [] Ute Insurance [] [] Accidental Death & Dismemban~ent Insurance [] ~ Shod Term Disability Insurance [] ~ Long Term D~sablllly Insurance [] [] Hc~p~tei Benefits [] [] Surg~cei Benefits [] [] DOCtOrs Attendance Banefrts [] [] LabOratory and X-ray Examination Benefits [] [] MajOr Medical Benefits [] [] Comprehensive Medical Benefits [] [] Dental Benefits [] l'--I Vision Care Benefits P ,n a Effective Date Requested 1/1/2002 Group Insurance et the Insorance Company's rates and under the terms of the pokcy(s) applied f~' w~i take effect on the Effective Date Requested ~f the Application is acce~ted et the t"l~me Office o! the nsurenee Company If certain persons ehglble are to C~-ltribute to the cost of the Group Insurance, such Group Insurance will take effect on the later of the date the required number have enrdled, ar on the Effective Date Requested. fi this ApPlioatlon ts nsf accepted, no insurance will become effective Any premium advanced by the Applleect will be refunded upon surrender of this Conditional Receipt · THE APPUCANT D~CLARE$; that he has reed the above statement and the answers to the above questions are complete and true to the best of his knowledge and belief The A[~pllcant agrees (1) that this Appllc~fion Is offered as an inducement for the Group Insurance applied for;, (2) that thiS. Application will form a part m any policy issuea; (3) that only the information on this Application will bind the Insurance Company~ and (4) that no waiver Or ohange will bind the Insurance Company unless signed by an Executive Oltlcer of the Insurance Company Group insurance will only be provided ler persons eligible under the policy(s) tssued SolicSing Agent If other than Witness ANY PEBSON WHO KNOWINGLY PRESENTB A FALSE O8 FRAUDULENT CLAIM FOB PAYMEN'I' OF A LOSS OR BENEFIT OR KNOWUNGLy PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE I$ GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON 00©, o .... ^gent , ~. Dollars fOr which I ho]d his receipt beagng the same number as this apphcatlon .]u! ~8 02 03:~Sp T~m BrzdGes 9~,0-3~,9-7803 CIGNA HealthCare HIPAA Certification Declaration Agreement The Health insurance Portability and Accountability Act of 1996 (HIPAA) requires that a proof of prior coverage cert~fmete be ~ssued to md~wduals, who for any reason, have lost their medical plan coverage and/or COBRA cert~hcate CIGNA HealthCare (Connectmut General Life Insurance Company) wdl automatically generate md~wdual proof of pnor coverage cert~hcates for members end their dependents ~f the employer has not deohned to have CIGNA HealthCare administer these serwces Please complete the requested ~nformat~on and return this Declaration Agreement to Miglbll/ty Services C/GNA HealthCare P 0 Box 9077 Melville. NY 11747-9077 OR Fax to $16 84E 3464 1 Emproyer Name .o,~.ty o~ Z~e~toa 2 Contact Name (~a=o! Title FeaZt;h ~ez~e~.ba ,~a-,~,,~sC=ato= Phone (940) 349-8388 3 Employer Address Crty pe~3t:o~ State 3',..~z Z~p Code ,76203, ~ ,0000 4 Account Numbers 3~,50096 Please state one of the follow[ng O We do not ele=t to use CIGNA HealthCare Certification services We will accept full respons~bd~ty to comply with the terms for issuance of certifications of prior creditable coverage required by HIPAA and apphcable state law We agree to hold CIGNA HealthCare harmless in the event that we or any party acting on our behalf fad to comply with all requirements for producing end issuing ce~flcat~ons set fo~h ~n HIPAA or State law ~We want CIGNA HealthCare to pedorm Coverage Certification services We acknowledge that CIGNA HealthCare's ab~hty to provide cort~flcation may be dependent on the quahty of mformat~on provided by us We understand that CIGNA HealthCare Is responsible only for coverage periods admimstered by CIGNA HealthCare If you have elected CiGnA HealthCare to perform the werwce=, please complete Box ~ to Box 10 5 STARTDATE For New Accounts, the start date wdl be upon effective date For exmtmg Accounts, please indicate ~ of the following ~ At renewal ~ OAs of 6 Type of Medical Coverage [Check ~ that apply) ~ommerc~af HMO ~demmw/PPO ~ Pomt-of-Serwce/Flexcare (EPP/DPP) ~ Preferred Provider Access 7 Type of Funding Arrangement (Chec~ ~ onlyJ ~ured O ASO/Self Funded O Both 8 If the ASO/Self Funded box ~s checked above, then please indicate If the account ~s ~ ERISA ~ Non-ERISA 9 is CIGNA HealthCa~BRA Admlmstrator~ 0 Yes ~ N ~ ~ ~ ore If an employer ha= chosen C/GNA He~ ~ pe~orm HIPAA ce.,f, cet, on serv/ee they w,ll standardly receive a report ~n~er e group Is mo?d or terminated within the~oount This repo~ may be used to track Individual or famdy movement between ~/un o~erl~gs or to provloe coverage mfor~atlofl to a new adm/n/strator or carrier Please return t~w page to Eligibility Se~i~e~, C/GNA ~ea~Care, P 0 ~ox 9077, Melville, NY 11747-9077 OR F~ to 516 8~ 3464 ~u! 18 02 03:lGp T~m ~r~dces 9~0-3~9-7B03 p.~ CIGNA HEALTHCARE OF TEXAS, INC. Face Sheet to the CIGNA HEALTHCARE GROUP SERVICE AGREEMENT which ~s xncorporated here~n by reference AGREEMENT NI334BER: 6327 PARTIES TO AGREEMENT: HEALTHPLAN: CIGNA HealthCare of Texas, Inc and GROUP CITY OF DENTON TERM OF AGREEMENT The mtt~al term of the Agreement shall be from .lanuary 1, 2002, (the "Effective Date"), until December 31, 2002 The Asreemant shall continue m effect for the m~ttal term and shall be automatically renewed as of the Anniversary Date of Agreement on a yearly basis thereafter unttl terrmnated The Anntversa~'y Date of Agreement shall be January 1, 2003 PREPAYMENT FEES AND GRACE PERIOD On or before the last day of each month, Group shall rermt to Healthplan on behalf of each Subscriber and Dependents the Prepayment Fee specified as follows m payment for services rendered under thts Agreement tn the following month Healthpian shall perrmt a grace period of thirty (30) days dunng which the Prepayment Fees may be pa~d Without loss of coverage under the Agreement In the event th~s Agreement termmat~ and there are Prepayment Fees due to the Healthplan, Group will be financially responsible for the Prepayment Fees This responsibility writ be m addition to any other financml obhgatlon of the Group hereunder CHC--Ps { t } 0500 (11198) ~ul 18 O2 03:lSp Ttm Brtd~es 940-3~9-7803 p.5 Group shall pay Prepayment Fees each month m the following amounts Membershio Unit Preoavment Fee Single $189 57 Two-Party $417 04 Family $644 52 Parent/Chtld $398 09 ENROLLMENT Healthplan ts only requued to consider enrollment apphcauons received by Healthplan (0 dunng the Open Enrollment Period or within fifteen (15) days thereafter, or (u) w~thm thuty--one (31) days of the event creating ebgiblhty Healthplan shall have the right, at reasonable t~mes, to exanune Group records, including the payroll records of Subscribers for the purpose of ¢onfmmng ehlBbihty and appropriate Prepayment Fees under the Agreement An inthv~dual who did not enroll for coverage under the Agreement dunng the m~ual ebglblhty period or open enrollment pened may enroll for coverage m accordance with the "Newly Ehg,bl¢ Outside of Open Enrollment Period" and "Specml Enrollment Outside of Open Enrollment" prowsions set forth m the "Enrollment" Section Newly eligible and special enrollees may enroll by submitting a completed Henlthplan enrollment application and requu-e,d Prepayment Fees within thirty-one (3 I) days of the eligibility or special enrollment event GROUP'S ENROLLMENT/ELIGIBILITY RULES Group' s enrollment an~or eligibility rules for ~ts Subscrthers and then- Dependents are as follows · New inres are eligible for ¢overnge on the first of the month following date of hire Dependent Chfldreu are covered to age 19 Dependent Students are covered to age 25 CIGNA Guest Privileges program ~s included Coverage shall terminate on the last day of employment Unless otherwise stated above, the ebgththty prowsmns set forth an the "Ehg~bdJty" SecUon of the Agreement will govern {n} CHC -- FS (11D8) O500 Jul 18 O~ 03:lGp Tim Brldces 940-348-?803 DISENROLLMENT Group shall noufy Healthplan of all employment texflunat~ons or other losses of ehgthdlty of Subscnbem and of losses of eligibility of Dependents ("NoUce of TermmaUon") Unless otherwise requuv, d by law, coverage for the Subscribers and/or Dependents shall cease at midnight on the day the loss of eligibility occurs, and Group shall remit Prepayment Fees m accordance to the roles described under the section entitled "Payment Method for Group", through the date coverage ceased, subject to the tollowmg roles and exceptions 1 Notice of Terrmmmon must be received by Healthplan w~thm mxty (60) days of the date on wluch employment ternunat~on or loss of eligibility f'LrSt occurred 2 If Not~ce of Terounatlon is not received by Healthplan wlthm sLXty (60) days of the date on which employment termmauon or loss of eligibility first occurred, then coverage shall cease at midmght on the date which is s~xty (60) days prior to the date Notice of Termination is received and Group shall be responsible for and shall submit to Hcalthplan all Prepayment Fees due through the date coverage ceased CERTIFICATION OF COVERAGE Upon request, Healthplan shall Issue Certificates of Group Coverage to Members who end coverage with Group, provided that Group repoi~s enrollment, d~senrollment and other necessary reformation to Healthplan, according to transacUons arranged between Healthplan and Group AlteraaUvely, Group may agree m wnUng to take primary responmbd~ty or to assign responsthdlty to a thtrd party for issuing Certificates of group Health Plan Coverage to Members who end coverage with Group At the request of Owup and upon payment of the applicable f~ by Group, Healthplan shall report Member enrollment date~ and dlsenwllment dates to Group after open enrollment periods and upon terrmnatlon of the Agreement CHC -- FS (11/98) O5OO Jul 18 O~ 03:l?p T~m Brld~es ~40-348-7803 p.? PAYMENT MI~TIIOD FOR GROUP I If coverage begins on or before the fifteenth (15th) day of the month, a Prepayment Fee is due for that month If coverage begins on rely other day of the month, no Prepayment Fee ~s due for that month If coverage ceases on or before the fifteenth (15th) day of the month, no Prepayment Fee ts due for that month 2 If coverage ceases on any other day of the month, a Prepayment Fee IS due for that month SCHEDULE OF COPAYMENT$ The Schedule of Copayments designating the amounts charged to Members for receipt of covered services and benefits Is attached hereto TOTAL COPAYMENTS IN A CONTRACT YEAR There Is a hmlt on the total amount of Copayments a Member and Membership Unit are required to pay for specified services dunng a contract year The hnut are as follows Ind~wdual Momber Total Copayment Maximum $2,000 Membership Unit Total Copayment Maximum $4,000 CHC --F$ { ~v } 0~00 ~ul 1~ 02 03=17p Tzm ~tdGes 9~0-3~9-7803 p 8 TERMINATION OF AGREEMENT 1 Tern~natlon on Notice The Agreement may be temunated without cause by Group upon sixty (/0) days prior wvinen notice to Healthplan The Agreement may be terrmnated by Healthplan (0 upon ninety (90) days prior written not~ce to Group of Hanlthplan's deemlon to ~hscontmue offenng this pamcular type of coverage, or (Il) upon one hundred eighty (180) days prior written notice to Group of Healthplan's decision to discontinue offenng all coverage m the applicable market 2 Tenmnatlon for Non-Payment of Fees The Agreement may be terminated by HeaJthplan for non-payment of any Prepayment Fees owed to Healthplan by Group under this Agreement Teruunat~on for Fraud or Mmmpresentation The Agreement may be tenmnated by HeaRhplan upon thirty (30) days prior wn~en notice to Group If, at any ~me, it m detenmned that Group has performed an act or practice that constitutes fraud or intentionally rmsrepresented a material fact 4 Termination for Violation of Particlpauon or Contribution Rules The Agreement may be tenmnated by Healthplan upon thirty (30) days prior written notice to Group, for the failure of Group to comply with a material plan provision relating to Group contributions or Group participation rules as established by Healthplan 5 Termination due to Association Membership ceasing Healthplan may terminate this Agreement, as to a Group member of an associaUon with which Healthplan has entered Into this Agreement, when and if the Group membership m the association ceases, in accordance with applicable State or Federal Law 6 Termination due to a change m Group's Smze The Agreement may be termmated by Healthplan upon thuty (30) days prior written notice to Group mr, at anytime, it is determined that Group's s~ze has changed, makang Group eligible for the small group reform product, as deternuned by the applicable State Law 7 Termination m accordance with State and/or Federal Law The Agreement may be terminated by Healthplan, upon prior notice to Group, m accordance with any applicable State and/or Federal Law 8 Termination Effective Date (i) When terrnmat~on ~s due to non-payment of amounts described in paragraph 2 above, coverage under the Agreement shall cease on the last day of the month for which payment is due (10 When ternunatlon is due to any other reason, coverage shall cease at nudmght on the date on which terminat~on occurs Group shall be responsible for the payment of all Prepayment Fees due through the date on which coverage ceases Subscriber will be financially responsthle for services rendered after such date If Group fmls to give wntten notice to Subscriber prior to such date, Group shall also be financially responsible for, and shall submit to Healthplan all Prepayment fees duc after such date until Group gives such notice 9 Not~ce of Termination to Members In the event the Agreement is terminated under this Section, Group shall notify Members of the termination effective date and any apphcable rights Members may have under the "Continuation of Group Coverage" Section {v} CHC -- FS (11/')8) OSO0 Jul 18 02 03'17p Tim Brid~es 940-349-?803 AMENDMENT OR MODIFICATION OF AGREEMENT 1 ~ The Agreement may be amended at any time through a subsequent written agreement between Group and Healthplan Amendments are effective Immediately unless otherwise provided 2 Mod]ficauon by Law or Reonl~non The provisions of the Agreement are subject to the approval of al/ regulatory bodies and in the event that regulatory bodies request any modfficatlon of the Agreement, such modzfication shall supersede the prow$1ons of the Agreement Furthermore, any State or Federal Laws or reguiallons enacted or promulgated which are m conflict with the provisions of the Agreement shall be deemed modlfleat]ons of the Agreement on the date such enactment or promulgut~on is applicable to this Agreement Healthplan may modify the Prepayment Fees upon any change m State or Federal Laws affecting the Agreement by giving to Group at least thtrty (30) days prior written notice 3 Unlfornl M0dlficat~oll of Coveraoe At renewal, the provisions of this Agreement may be modified to reflect product revisions which have uniformly been made to this produce 4 Modification by Nouce From l-l~.akl~_olan Healthplan may modify the provisions of the Agreement including any Prepayment Fees, Copayments and tuppl~meotal Charges ou any Anniversary Date of Agreement by giving to Group at least thirty (30) days prior written not~ee Unless Group w~thln fifteen (15) days of receipt of such notice provides wntten notice to Healthplan of Its retention to temullate this Agreement at the end of the term, the modification shall become effeetive on the date contmned m the notice and shall apply to all Members whether or not the applicable Prepayment Fee has been prod { w } CHC -- FS 0500 (11/98) ~ul lB O~ 03:17~ T~m Br~d~es 9~0-3~9-7803 p 10 NOTICE Any wntten,notlce reqmred under the Agreement shall be hand-dehvered or mailed through the Umted States Postal Service, postage prepaid, addressed as follows GROUP: Mark Carol Rucker City of Denton 215 East McKlnney Denton, TX 76201 Or, If Group elects to have notices dehvered or mailed to a designated Agent, such notmes shall be deemed as having been received by Group if hand-delivered or totaled to the fol]owmg person and address AGENT' Mark Chromster William M Mercer 3500 Chase Tower, 2200 Ross Avenue Dallas, TX '/5201 HEALTHPLAN. CIGNA HealthCare of Texas, Inc 600 East Colmas Boulevard, Suite ! 100 Irving, TX 75039 MEMBER: To the latest address furu~sbed by Group or by the Member to Healthplan AMENDMENTS, RIDERS, AND ADDITIONAL PROVISIONS · Schedule of Copeyments 15/150 · Durable Medmal Eqmpment Rtder · External Prosthetic Appliances Rider · Prescription Drugs Option 7/20/40/OC Rider CHC -- F$ (11/98) O5OO 3u! 18 02 03.~8p Tzm BrtdGes 9~0-3~9-7803 DISCRETIONARY CLAIM AUTHORITY The Plan Admmlsa'ator (Employer) named below hereby delegates to Healthplan the d~scret~onasy authority to interpret and apply plan terms and to make factual detennmatwns m connection with its review of claims under the plan Such drscretlonary authority is intended to include, but is not limited to, the determination of the ehglbdlty of persons desmng to enroll m or claim benefits under the plan, the detemunat~on of whether a person la entitled to benefits under the plan, and the computatmn of any and all benefit payments The Plan Adrmmstrator (Bmployer) also delegates to Healthplan the discretaonary authority to perform a full and fatr review, as required by ERISA, of each claim demal which has bcen appealed by the claimant or his duly authorized representative This language should be made a part of your Sununary Plan Description CHC--FS { wu } 0500 (11/98) Jul 18 02 03:18p T~m 9r~dces ~40-3~9-7803 po12 ACCEPTANCE OF AGREEMENT In W~tness whereof, the Pm:es enter rote the CIGNA HEALTHCARE GROUP SERVICE AGREEMENT through the execution of th~s Face Sheet by their duly authorized representatives In the event Group does not s;gn this Acceptance of Agreement section, Group's payment of any Prepayment Fees wdl be consIdered acceptance of the terms and conthtmns of th~s Agreement HEALTHPLAN. CIGNA HealthCare of Texas, Inc By. ~ T~fle Ken S Mul¢olmson, President and General Manager -- North Texas Date -. September 24. 200] GROUP CITy OF DI~NTON Address -- 2!5 East McKmncy -- Del~ton. TX 76201 6327/DK CHC- FS { x ) 0700 (11/98) Jul 18 O~ 03,18p Tim Brld~es 840-349-7803 p.13 DISCRETIONARY C~AIM AUTHORIZATION PLEASE RETURN THIS SIGNED FORM TO YOUR SALES REPRESENTATIVE Plan Administrator City o£ Deato~ Pohcy Number 3150096 Policyholder C~ty o£ De~,to~ The Plan Administrator named above hereby delegates to the Claim Admimstrator the d~scretlonary authority to Interpret and apply plan terms and to make a factual determmatmn m connection with its review of claims under the plan Such discretionary authority ~s intended to include, but Is not hm~ted to, [he determination of the ellgib~hty of persons demrmg to enroll in or olmm benefits under the plan and the computatmn of any end all benefl~ payments The Plan Adm~mstrator also delegates to the CImm Administrator the discretionary authority to perform a full and fair review, as required by ERISA, of each claim denial which has been appealed by the claimant or his duly authorized representative If you 8Jgn ~hi8 form, Jhl~ I~ngu~ge ahould be msde p~ of your Summ~ry Plsn ge~cnp~lon If ~he Summ~ry Plan D~8onpflon ~pp~r~ In your ce~flcs~e, 8 rider for you~ certificate will ~e 18~ued ~ddlng ~he Bbove s~8~emem ~o ~hose psges m ~he Ce~lflCS~e DISCLO1 04 18 98 ~u! ~1) 02 03: 19p Ttm 9rtd{;es 940-3~9-7803 p 14 TEXAS SPEECH AND HEARING THERAPY REJECTION FORM NOTICE OF REJECTION OF OPTIONAL AUDITORY CARE The undersigned pohcyholder rejects the benefits for treatment of audttory care described below [~1"~1 Charges made by · Phystclan or Audiologist for an Audlometrlc Examination and for a Heartng Aid Evaluation Test [~' Charges made for one Hearing A~d of an approved functional design Such coversge will be available at a ~ater date only ~f specifically requested by the Policyholder ~cyhold~r~e rxsPH 0~ 18-s~ Jul 18 02 03: 18p Tim Bp~dges 940-349-7803 p. 15 TEXAS IN VITRO FERTILIZATION REJECTION FORM NOTICE OF REJECTION OF OPTIONAL IN VITRO FERTILIZATION BENEFITS in accordance w~th the provisions of Texas Insurance requirements, the undersigned policyholder hereby rejects the benefits specified below REJECT A benefit covering charges for in wtro fertilization procedures performed on a married couple who have a h~story of infertility for at least five consecutive years or who suffer from certain spemfled heaith conditions which have caused their ~nab~llty to conceive a child The undersigned group policyholder understands that such coverage w~ll not be provided at a later date unless he or she specifically requests it Czty o~ Denton Name of Policyholder TXINV 04 1898 ~u! 18 02 03:19p Ttm ~rzdces 9~0-3~9-7803 p.16 TEXAS OPTIONAL HOME HEALTH CARE BENEFIT REJECTION FORM NOTICE OF REJECTION OF OPTIONAL HOME HEALTH CARE BENEFITS In accordance w~th the prows~ons of Texas Senate Bill 263, the understgned policyholder hereby rejects the benefits specie'md below for charges for a formal home health care plan prescribed by a physician, in favor of those described In the insurance proposal A home health oars expenses benefit hawng a maximum of 60 or more wslts m a calendar year The undersigned group policyholder understands that such coverage will not be prowded at a later date unless he or she specifically requests ~t C£t:y o~ Den~on Name of Policyholder ~/ ' I~ame' / /~/ Title TXOPT 041898