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HomeMy WebLinkAboutContract 45285-A1 (2)bOl T Z MW a3M333a Plan Sponsor Certification of Grandfathered 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 undersigned plan sponsor certifies that it has not defeated grandfathered status for any of the plans listed below by: -�� II1I Decreasing by more than 5 percentage points* its employer contributio,1 ,-lap i, ;: \11-, RECORD coverage or any tier of coverage for any class of similarly situated ind iduals cumulatively since March 23, 201 0; IIIII Restructuring its business to avoid a Joss of grandfathered status; Ill Transferring employees into the plan without a bona fide employment Min" i� r � , � -; r-7 �1�-©r'� AIRY IVIGU) tr-n9 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 Name PPO Basic PPO Basic Plus So certified: ture of Authorized Representative Susan Alanis Name of Authorized Representative Funding Arrangement Selffunded Self funded Renewal Date Date: t liS II q' Title: Assistant City Manager *If your contribution rate is based on a formula, such as hours worked or tons of c produced, a decrease of 5 percent (not 5 percentage points) defeats grandfathered s For more information on grandfathered plans visit www.dol.gov/ebsa/hcalthref(mn APPROVED AS TO F AN GALITY: ASSIS • NT C 1/1/2014 1/1/2014 • j1IORNY Human Resources Plan Sponsor Certification of Grandfathered Status (REVISED) Effective January 1, 2014 Routing and Transmittal Slip HR: Margaret Wise Law: Denis McElroy ACM: Susan Alanis City Secretary: Mary Kayser Date Received 1/15/2014 Vf c (2oi14 / Please find attached 3 copies of the Plan Sponsor Certification of Grandfathered Status (REVISED) for your signature. In the revised form the renewal date has been corrected to reflect 1/1/2014 as the effective date for the renewal of grandfather status. Initials Date Signed I / idao►'f //t)-Wki The grandfather status preserves certain health care coverage for the City of Fort Worth's PPO Basic and PPO Basic Plus Plans from the law enacted on March 23, 2010. Certain health coverages for these plans do not have to meet all standards applicable under the Patient Protection and Affordable Care Act. One example is that routine wellness exams are not required to be covered at 100% for the PPO Basic & Basic Plus. Aon Hewitt has reviewed our plans and has advised staff that the City of Fort Worth meets all requirements for grandfathering status. When completed please call Margaret Wise at extension 8058 for pick up. Thanks. McElroy, Denis C. From. Sent: To: Cc: Subject: Importance: Lenee or Mike, Wise, Margaret Wednesday January 15, 2014 12:02 PM 'Langford, Michael'; Lenee L Goyette Singleton, Stacy A; McElroy, Denis C.; Gray, Maria RE: Grandfather Form High Can you make that change and resend? I will need to re-route. Thanks, Margaret From: Langford, Michael fmailto:LanafordM@AETNA.coml Sent: Wednesday, January 15, 2014 11:54 AM To: Lenee L Goyette Cc: Wise, Margaret; Singleton, Stacy A Subject: RE: Grandfather Form Lenee, The form is actually confirming the plans are maintaining their grandfathered status in conjunction with the 1/1/14 plan year, so the renewal date should indicate 1/1/14. From. Lenee L Goyette (mailto lenee.aovette@aonhewitt.coml Sent: Tuesday, January 14, 2014 5:34 PM To: Langford, Michael Cc: Wise, Margaret (Maraaret.Wise(afortworthtexas.aov)_ Subject: FW: Grandfather Form Margaret has a question on the form — I completed the form for her signature and indicated the renewal date was 1/1/15 (as in the next renewal) but you may want the form completed with the renewal date of 1/1/14 — please advise CFW Legal is trying to keep the records straight. Lenee Goyette I Senior Consultant Fort Worth Office I Aon Hewitt 301 Commerce Street, Suite 2101, Fort Worth Texas 76102 Tel 817.339.2009 ( Fax: 847.953.4294 Email: Lenee.Govette@aonhewitt com From: Wise, Margaret (mailto:Maraaret.Wise@fortworthtexas.aovi Sent: Tuesday, January 14 2014 5:24 PM To: Lenee L Goyette Cc: Gray, Maria; McElroy, Denis C. Subject: Grandfather Form Lenee, Was attached for 2013 or 2012? i