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Home My WebLink AboutContract 46149 CITY SECRETARY 41 DELTACAR E* CONTRACT No. ® New Group ❑ Sublocation DeltaCare OFFICIAL RECORD Managed Care CITY SECRETARY Dental Program GROUP FT. � WORTH TX APPLICATION DeltaCare GROUP INFORMATION Name of contracting entity City of Fort Worth Phone no. 817-392-7750 Address 1000 Throckmorton Street City,State,Zip Fort Worth,Texas 76102 Subsidiary or parent companies Billing address (same as above) City,State,Zip Fort Worth,Texas 76102 Agent or representative to receive notice(consultant/broker) Gallagher Benefit Services,Inc, Address 221 W.6"h Street,Suite 1980 City,State,Zip Austin,Texas 78701 RATES Proposed effective date January 1,2015 Term of agreement January 1,2015 to December 31,2017 Enrollee only $ 2rapg Enrollee/spouse $ 2nd pg Enrollee/child(ren) $ 2nd pg (one party) (two party) Enrollee/spouse/child(ren)$ 2nd pp Composite$N/A (three party+) Monthly® ❑Tenthly ❑Quarterly ❑Biweekly ❑Semi-annually ❑Annually Employer contributions to the plan*: Employee 0% Dependents 0% Account executive Norma V.Cardenas/Kirk Lavallee Broker of record Gallagher Benefit Services,Inc. Location PMI assigned# TX-76983 Broker's tax I.D.number Janet Forbes Justin Sylvester Address 221 W.6th Street Suite 1980 Austin Texas 78701 Phone 512 499-8005 Service Rep. Nola Ray Commission 0 % CENSUS DATA Total number of employees 8,916 Total number of eligible employees 8,916 Employee locations(major) Tarrant County,Texas (county,region or state) Type industry Municipality/City Government SIC code 9190 PROGRAM DESCRIPTION Complete if: Dual choice -name of other program Delta Dental Insurance Company Takeover -name of other carrier Cigna Healthcare Option selected from proposal no. 15A&M74-see 2nd pg Plan no. See'other information'on 2"d page Orthodontic copayments: Children-Amount See Sched Start-up fee See Sched ❑ Adults- See Sched Additional benefits Orthodontic Takeover Group contact for eligibility Dagoberto Garza Title IT Sr Programmer Phone no. Mail contracts to: Doris Brent-Contract Compliance Spec CC: Maria L.Gray-Benefits Manager;Mona Bran iff-SrAn alyst. Renewals to: Same as contracts above CC: PRINTING INFORMATION(ALL printed material must be approved by PMI) Solicitation brochure: Standard X Other Amount Date required Enrollment card: Standard X Other Amount Date required Panel listing: Standard Other Amount Send DeltaCare ID cards to❑Group ®Enrollee Distribution instructions: Home mailing to EE's home address-ID cards and Evidence of Coverage booklet Delta 1735(5/00) r-f F RECEIVED NOV 19 2014 ELIGIBILITY RULES ❑ Same as Health and Welfare Plan.(Attach copy) ❑Present employees, 1st of the month following completion of months of continuous employment at hours per week. ❑Future employees, 19r of the month following completion of months of continuous employment at hours per week. ® Other 20 hours or more per week; Employee Eff date—1 month from Date of Hire Dependent coverage: Format of eligibility to be furnished by PMI: ®Spouse ®Children to age 26 ®Students to age 26 ❑Combined billing with Delta Classes of employees: Eligible Ineli jble ❑Direct bill to group Hourly employees ® ❑Direct bill to enrollee Salaried employees ® ❑ ❑Hard copy submitted Supervisory employees ® ❑ billings needed ❑Yes ❑No Non-supervisory employees ® ❑ ❑Magnetic tape match Employees covered by collective bargaining ® ❑ billings needed ❑Yes ❑No Retirees ® ❑ ®Other Self Bill by COFW and backup will be provided in Excel Other(specify) ❑ ❑ IT IS AGREED THAT A CURRENT ELIGIBILITY LIST WILL BE SUBMITTED TO PMI PRIOR TO THE FIRST OF EACH MONTH OTHER INFORMATION 15A Rates-EO-$13.54, E+SP-$23.31, E+Child(ren) $27,10, E+Sp+Child(ren)-$41.33 and available in the following states-AK,AL, AR, AZ, FL, GA, HI, LA, MO, NC, NM, NY, OH, OK, OR, TN, TX, UT,VA&WA; LOFFICIAL M74 Rates-EO -$9.13, E+Sp-$15.66, E+Child(ren)-$16.30, E+Sp+Child(ren)-$24.38 RECORD and available in the following state-TX only; Y SECRETARY Term Agreement-Rates are guaranteed January 1, 2015 to December 31, 2017(3 WORM TX years)with two one-year renewals that include a not to exceed rate cap of 7.5%. Name of administrator* None Address City,State,ZIP Agent for legal process* Phone no. Address City,State,ZIP Plan identification number* Employer identification number Department of Labor Welfare Plan file number(if any)* Ending date of plan's fiscal year* Month Day Schedule A(Form 5500)required ❑Yes ❑No If yes,send to at Plan category(check one)* ®Single employer ❑Multi-employer ❑Trade or association maintained by a group of employers financially unrelated ❑Other Is this a plan established or maintained pursuant to one or more collective bargaining agrebments,or have plan benefits bden the subject of negotiation with Tabor organization?* ❑Yes ® No List any documents other than the PMI contract establishing or affecting the plan* Name,title,and address of plan fiduciary or trustees* The program shall become effective only upon issuance of a written agreement executed by a duly authorized officer of PMI. It is understood and agreed that this application be made a part of such agreement. Authorized ignature: Title: i *This information, if applicable, is requ o°� A ROVED AS TO ° AN LEGALITY: by' 1-9.3$ a %Nt; l•AAW 0 1 °0600000°�'° Ronald P. Gonzales, Asst,City - SI AN ITY ATTORNEY TEMPOROMANDIBULAR JOINT DYSFUNCTION OFFER FORM FOR WASHINGTON ENROLLEES The undersigned applicant has been offered temporomandibular joint dysfunction coverage of $1,000 per calendar year and $5,000 lifetime or $500 per calendar year and $1,000 lifetime, per Enrollee, and applicant j rejects the offer of temporomandibular joint dysfunction coverage, per enrollee. ❑ accepts coverage of$1,000 per calendar year and $5,000 lifetime per enrollee. ❑ accepts coverage of$500 per calendar year and $1,000 lifetime per enrollee. OFFICIAL RECORD h 11 1-1 CITY SECRETARY (Date) FT.WORTH,TX 76983 (Group Number) City of Ft. Worth (Applicant) I By:— (Authorized Signature) APPROVED AS TO FORM AND LEGALITY: ASSISTAW CITY ATTORNEY -�8°°'' �Z v$ A by: 4'°O°°°°°O° �XA� Ronald P. Gonzwes,Asst~ City WA TMJ OFFER FORM Rev. 02/2008 DENTAL POINT-OF-SERVICE OPTION OFFER FORM FOR ARKANSAS ENROLLEES A dental point-of-service option allows an Enrollee to obtain dental care services from Dentists and other providers outside the dental provider network of this plan. Arkansas law requires that the dental benefits offered under the point-of-service option shall be the same as those offered through the network. Please be advised that although the out-of-network dental benefits offered are required to be equal to those provided through your in network health plan, the co-payment, co-insurance and other cost sharing features may be higher should the Enrollee use an Out-of- Network dentist, on a non-emergency basis. No Copayment or co-insurance, however, may exceed 25% of the Copayment required to be paid to in network Dentists. The out-of-network Dentist may also bill the Enrollee for the balance of any charges which are not otherwise reimbursed by Dentegra. Applicant has been offered a Point of Service Plan in compliance with the Arkansas Dental Point of Service Act, A.C.A. § 23-99-601, and ❑ Accepts the offer of point of service coverage (Delta Premier or Delta PPO) provided by Delta Dental of Arkansas, or Rejects the offer of point of service coverage. OFFICIAL RECORD CITY SECRETARY < < � FT. WORTH,TX (Date) 76983 (Group Number) City of Ft.Worth (Applicant) By: (Authorized Signature) APPROVE LEGALITY: R A SIS T T CITY ATTORNEY y oo� O o � ►' A A. Al� City of Ft Worth Arkansas POS.doc Ronald P. Gonzales,Asst.City SSe