HomeMy WebLinkAboutContract 45285 (2)L( ' 'l f uZ Y ' 1
comp/Am-cal itct .eS
Plan Sponsor Certification of Grand fathered Status
The undersigned plan sponsor believes that each plan or coverage listed below is a
"grandfathered health plan" under the Patient Protection and Affordable Care Act. As
permitted by the act, a grandfathered health plan can preserve certain health coverage that
was in effect when that law was enacted on March 23, 2010. Being a grandfathered
health plan means that your plan may, but is not required to, include certain provisions of
the act that apply to other plans, for example, the requirement for the provision of
preventative health services without any cost sharing. However, grandfathered health
plans must comply with certain other provisions within the act, for example the
elimination of lifetime limits on benefits.
In addition, the undersignedplan sponsor certifies that it has not defeated grandfathered
status for any of the plans listed below by:
Decreasing by more than 5 percentage points* its employer contribution for
coverage or any tier of coverage for any class of similarly situated individuals
cumulatively since March 23, 2010;
Restructuring its business to avoid a loss of grandfathered status;
NI Transferring employees into the plan without a bona fide employment based
reason (changing the terms or cost of coverage is not a bona fide reason); and
Plan Sponsor is not aware of any other plan changes that would cause a loss of
grandfathered status.
Plan Sponsor Name: City of Fort Worth
•
•
• List of Grandfathered Plans:
Plan Marne Funding Arrangement Renewal Date
•
PPO Basic
PPO Basic Plus
•
•
•
•
•
Sox-tily:
Self funded 1/1/2015I
Self funded 1/2/20151
.
litAn Bate: t1t314 i I 3 I 4
Si ;natu of Authorized Representative 1 1
LA-0c4-, /4 / 6 rt t ( Title: %` SS f S`)4,v s "
Name of Authorized Representative
.,
•
•
•
•
rr /1401ct
* If your contribution rate is based on a formula, such as hours worked or tons of
produced, a decrease of 5 percent (not 5 percentage points) defeats grandfathere
For more information on grandfathered plans visit www.dol.ov/ebsa/health.refo
APPP-OVet -RRIA LaktrN e
•
b&4ts tf1 s M c o`t ASc T C CO* Atfl
•
•