HomeMy WebLinkAboutContract 59113CSC No. 59113
PartnerRe
Excess Loss Insurance Application
PartnerRe America Insurance Company
Wilmington, DE
NAIC# 11835
Mailing Address:
6900 Wedgwood Road, Suite 120
Maple Grove, MN 55311
800 261 3164
The Applicant hereby applies for the Excess Loss Insurance Policy.
1. POLICYHOLDER: City of Fort Worth
Principal Address: 200 Texas Street
Fort Worth, TX 76102
2. POLICY PERIOD: Effective Date: January 1, 2023
Termination Date: January 1, 2024
3. POLICYHOLDER INFORMATION:
i. Standard Industrial Classification (SIC): 9111
ii. ❑ Corporation ❑ Partnership ❑ Sole Proprietorship
❑ Labor Union ® Other
If other, please specify:
iii. Nature of Policyholder's Business: General Government
4. CLAIM ADMINISTRATOR: Meritain
Type of Coverage: Medical
Address: Meritain Health
300 Corporate Parkway
Amherst, NY 14226
CLAIM ADMINISTRATOR: Optum Rx
Type of Coverage: Rx
Address: 2300 Main Street
Irvine, CA 92614
5. EXCESS LOSS INSURANCE:
a. Specific Excess Loss Insurance: ® Yes ❑ No
i. Specific Deductible: $1,000,000 per Covered Person
❑ MEWA
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
ESL-APP-200-US-2021 Page 1 of 3 Issue Date: 11/29/2022
Coverage Period:
Eligible Expenses Incurred from January 1, 2022, through January 1, 2024 and
Paid from January 1, 2023 through January 1, 2024
b. Aggregate Excess Loss Insurance: ❑ Yes ® No
6. The following endorsement(s) are elected:
® Yes ❑ No Specific Advanced Funding Endorsement
The coverage afforded by this Application is based upon the Excess Loss Quotation November 9,
2022 attached hereto, incorporated herein, and is conditioned upon receipt, review and
acceptance by PartnerRe America Insurance Company ("PartnerRe"), on or before November 28,
2022, of all outstanding information as detailed in Special Notations section of the quotation.
Additional underwriting adjustments, including changes to terms, premium or specific deductibles
on certain individuals, may be required.
I, the undersigned, understand and agree that:
This Application is based upon claim details, enrollment, eligibility, Benefit Plan and other
information provided by Applicant to PartnerRe. Any known material change in such information
must be reported to and agreed upon by PartnerRe prior to coverage becoming effective.
The coverage afforded by this Application is to be effective from 12:01 A.M. standard time on the
Effective Date stated above at the Policyholder's address, provided the first month's premium is
paid in full and that the Claim Disclosure Statement and this Application are accepted and
approved by PartnerRe. The coverage afforded by this Application is subject to all terms and
conditions of the Policy in current use by PartnerRe. This Application and Claim Disclosure
Statement will become a part of the Policy when issued.
This Application assumes the Producer/Agent of Record is duly licensed as required by law and
has been appointed with PartnerRe America Insurance Company in the state in which the
Policyholder is located and the Policy is to be delivered.
By signing this Application and the Claim Disclosure Statement, the Applicant represents that all
statements, answers and information provided to PartnerRe are complete and true to the best of
its knowledge. Applicant further acknowledges and agrees (i) that such statements, answers and
information provided and in the Claim Disclosure Statement, together with a copy of the Benefit
Plan and other information attached to this Application or furnished to PartnerRe, are submitted
by the Applicant as an inducement to and will be relied upon by PartnerRe in underwriting this risk
and determining whether to accept this Application and issue the policy being applied for; (ii) if
such statements, answers and information is/are incomplete or untrue and such incompleteness
or falsity is material to the risk to be insured by PartnerRe, any policy issued by PartnerRe may
be rescinded and/or any benefits that might otherwise be payable thereunder may be denied; and
(iii) the Applicant has fully read and understands this completed Application and the Claim
Disclosure Statement.
ESL-APP-200-US-2021 Page 2 of 3 Issue Date: 11/29/2022
I hereby agree to the terms as stated above and warrant that I am duly authorized to execute this
acceptance:
Applicant Signed By:
Its Corporate Officer or Authorized Representative Date
Title
Accepted by PartnerRe America Insurance Company:
Signature
Senior Group Underwriter
Title
75-6000528
FEIN#
3/15/2023
Date
INSURANCE FRAUD WARNING
Any person who with intent to defraud or knowing that he/she is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement,
or conceals information for the purpose of misleading, is guilty of insurance fraud and is
subject to criminal and/or civil penalties.
ESL-APP-200-US-2021 Page 3 of 3 Issue Date: 11/29/2022
EMPLOYER EXCESS LOSS QUOTATION
Policyholder. PartnerRe America Insurance Company ("Company")
City of Fort Worth Wilmington, DE (NAIC# 11835)
5428 Cowden Street 6900 Wedgwood Road North, Suite 120
Fort Worth, TX 76114 Maple Grove, MN 55311
Policy Period: January 01, 2023 - January 01, 2024
PartnerRe America Insurance Company
Ratings: Standard & Poor's: A+ Moody's: Al A.M. Best: A+ Fitch: A+
Claim Administrator:
Meritain
Status:
Approved
Preferred Provider Network:
Aetna PPO
Benefit Plan Basis:
Current Plan
Employees:
5,835
Total Employees:
5,835
Retirees:
Included
Option 1
Commission %:
0.0%
Specific Deductible:
Specific Annual Maximum:
Specific Lifetime Maximum:
Specific Benefit %:
Coverage Period:
Plan Benefits Included:
Monthly Specific Premium Rates
Composite:
Estimated Premium Per Policy Period:
SPECIFIC STOP LOSS
$1,0009000
Unlimited
Unlimited
100%
24/12
Medical & Rx
$7.62
$533,552
PartnerRe
City of Fort Worth (1/1/23) 11/9/2022 8:54 AM
Special Notations
PartnerRe
This Quotation is tentative and subject to receipt, review and acceptance of the following information by
the Company, which is critical to coverage structure and premium rating. Additional underwriting
adjustments, including changes in terms and higher specific deductibles on certain individuals, may be
required.
1. Final sold quotation.
2. For inclusion of prescription drug (Rx) coverage under the Specific and/or Aggregate coverage(s) when there
is a separate PBM, PartnerRe requires written documentation for underwriting purposes that all Rx
experience reports have been received. Otherwise, Rx will not be a covered expense under the stop loss
policy. PartnerRe is not responsible for aggregating medical and Rx claims data during quotation or policy
coverage periods.
3. For Plan Mirroring - Current copies of the Plan Document, all Amendments and Restatements of the Plan
Document and proposed changes are required to be submitted and approved by PartnerRe prior to binding
coverage.
4. All claim reporting submitted from the selected Administrator should be provided to PartnerRe in sortable
Microsoft Excel format throughout the Policy and Proof of Loss Periods. Failure to do so could result in a
delay of claim reimbursements.
5. Actively at Work is waived with receipt and acceptance of the PartnerRe Claim Disclosure Statement.
6. This Quotation assumes that the Agent/Broker is operating under the appropriate license in which the risk is
domiciled. The Agent/Broker license and appointment with PartnerRe will be required prior to binding
coverage.
7. This Quotation is subject to cancellation or revision prior to the binding of coverage.
8. The statements herein may vary from the final Policy wording. The final Policy wording along with the Excess
Loss Insurance Application and Claims Disclosure Statement shall govern over any inconsistency with the
wording herein.
9. This Quotation is subject to the verification and approval of the Policyholder by PartnerRe through the
economic and trade sanction watch lists enforced by the Office of Foreign Assets and Control (OFAC).
10. Coverage includes simultaneous funding.
To ensure a smooth transition and to maximize cost containment initiatives, PartnerRe offers an implementation meeting to each new
client. Our goal is to understand the specific needs of the Policyholder and to offer solutions that meet their unique requirements.
Terms presented in this Quotation expire on: November 27, 2022
Angela Szeto
Senior Underwriter
PartnerRe America Insurance Company
Direct: 1 415 609 7633
Angela.Szeto@partnerre.com
City of Fort Worth (1/1/23) 11/9/2022 8:54 AM
PartnerRe
CLAIMS DISCLOSURE STATEMENT
Excess Loss Insurance
Policyholder: City of Fort Worth
Policy Period: January 1, 2023 to January 1, 2024
Policyholder Obligations:
To complete the underwriting process, the Policyholder, or its Claim Administrator; utilization
review firm, and/or any other party who may have such information, must perform a diligent and
complete review to identify and report, to PartnerRe America Insurance Company ("PartnerRe"),
any and all claims incurred or expected to be incurred, by a covered person, during the
immediately preceding 12 months or during the Policy Period that has or may reasonably be
expected to exceed 50% of the Specific Deductible selected by the Policyholder.
Policyholder acknowledges and affirms that PartnerRe will rely upon such information in making
underwriting decisions and that PartnerRe may, based upon its sole option, exclude
reimbursement for any claim(s) and/or adjust premium, deductibles and other policy terms if
Policyholder fails to disclose claims incurred or claims expected to be incurred as required under
this form. PartnerRe's receipt and review of such information does not validate or confirm, to any
extent, the accuracy or completeness of such information or the diligence of the Policyholder's
review.
Disclosure Information (Completed by PartnerRe after receipt of the required information):
In accordance with this required disclosure, PartnerRe has received the following information:
■ 50% Claim Report
■ Trigger Diagnosis Report
■ Large Case Management Reports
■ Pended Claim Reports
■ Transplant Waiting List
■ Other (Specify)
x❑ Received ❑ Not Received
❑ Received x❑ Not Received
❑ Received ❑x Not Received
❑ Received ❑x Not Received
❑ Received ❑x Not Received
Final Sold Quotation:
In reliance upon the validity, accuracy and completeness of the information provided under this
required disclosure, PartnerRe has issued a Final Sold Quotation to the Policyholder.
This Claims Disclosure Statement is attached to and forms part of the Final Sold Quotation.
Completed by: Angela Szeto, Senior Underwriter Date: 111412022
PartnerRe America Insurance Company
6900 Wedgwood Road North, Suite 120 • Maple Grove, MN 55311 • Tel. 1 612 234 4920 • www.partnerre.com/health
CDS1022-2 Page 1 of 1
[Executed effective as of the date signed by the Assistant City Manager below.] / [ACCEPTED
AND AGREED:]
City:
By: C
Name: Jesica McEachern
Title: Assistant City Manager
Date:
Vendor:
By: 'Ma-tt
Name: Matt Janssen
Title: Senior Group Underwriter
Date: 3/15/2023
CITY OF FORT WORTH INTERNAL ROUTING PROCESS:
Approval Recommended:
lfiolly lfi Mover
By: HoIIyH Moyer (Mar lT, 202315:53 CDT)
Name: Holly H Moyer
Title: Assistant Human Resources Director
Approved as to Form and Legality:
By: a)
Name: Jessika Williams
Title: Assistant City Attorney
Contract Authorization:
M&C: 23-0151
Contract Compliance Manager:
By signing I acknowledge that I am the person
responsible for the monitoring and administration
of this contract, including ensuring all
performance and reporting requirements.
By:
Name: Joanne Hinton
Title: Benefits Manager
City Secretary:
By:
Name: Jannette S. Goodall
Title: City Secretary
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
3/17/23, 2:20 PM M&C Review
CITY COUNCIL AGENDA
Create New From This M&C
DATE: 2/28/2023 REFERENCE NO.: **M&C 23-0151 LOG NAME:
CODE: C TYPE: CONSENT PUBLIC
HEARING:
Official site of the City of Fort Worth, Texas
FoRTWORyn
14STOPLOSS2023
M
SUBJECT: (ALL) Authorize Execution of Agreement with PartnerRe America Insurance Company in
an Amount Not to Exceed $550,000.00 for Stop Loss Insurance for the City of Fort
Worth's Health Benefits Plan with an Effective Date of January 1, 2023 for a One Year
Term
RECOMMENDATION:
It is recommended that the City Council authorize the execution of an agreement with PartnerRe
America Insurance Company in an amount not to exceed $550,000.00 for Stop Loss Insurance for
the City of Fort Worth's Health Benefits Plan with an effective date of January 1, 2023 for a one year
term.
DISCUSSION:
The purpose of this Mayor and Council Communication (M&C) is to seek authorization from the City
Council to enter into an agreement with PartnerRe America Insurance Company, for Stop Loss
Insurance for the City of Fort Worth's (City) Health Benefits Plan for 2023.
Effective January 1, 2023, PartnerRe America Insurance Company began providing specific stop loss
coverage for the City's self -insured health plan. The specific stop loss coverage caps the City's
liability for annual claims on a per member basis. The City pays for all claims for each participant up
to a specified dollar amount with the Stop Loss Insurance coverage paying for any claims beyond
$1 M per -participant threshold at a cost of $7.62 per employee per month (PEPM) for each active
employee and non -Medicare retiree who is a member of the City's self -funded health plan.
The City's benefits consultant, IMA, conducted a Request for Proposal and PartnerRe America
Insurance Company was selected due to their cost and their experience in the stop loss industry.
Funding is budgeted in the Single Stop Loss Insurance account of the Human Resources
Department's Group Health Insurance and Retiree Healthcare Trust Funds, as appropriated. Funding
for the balance of terms of these contracts will be requested as part of the Fiscal Year 2024 budget
process.
FISCAL INFORMATION/CERTIFICATION:
The Director of Finance certifies that upon approval of the above recommendation funds are available
in the current operating budget, as previously appropriated, and upon adoption of the Fiscal Year
2024 Budget by the City Council, funds will be available in the Fiscal Year 2024 Operating Budget, as
appropriated, in the Group Health Insurance Fund and the Retiree Healthcare Trust Fund. Prior to an
expenditure being incurred, the Human Resources Department has the responsibility to validate the
availability of funds.
TO
Fund Department Account Project Program Activity Budget (Reference # Amount
ID ID Year Chartfield 2)
Fund Department Account Project Program Activity Budget Reference # Amount
ID ID Year (Chartfield 21
apps. cfwnet.org/counci I_packet/mc_review.asp? I D=30778&cou nciIdate=2/28/2023 1 /2
3/17/23, 2:20 PM
M&C Review
Submitted for City Manager's Office by_
Originating Department Head:
Additional Information Contact:
ATTACHMENTS
Jesica L. McEachern (5804)
Dianna Giordano (7783)
14STOPLOSS2023 funds availability_.pdf (CFW Internal)
230119 Dept Waiver signed Stop Loss.pdf (CFW Internal)
Form 1295 Certificate 101000378 - City of Fort Worth.pdf (CFW Internal)
Stop Loss PartnerRe America Insurance Company FID Table.pdf (CFW Internal)
apps. cfwnet.org/counci I_packet/mc_review.asp? I D=30778&cou nciIdate=2/28/2023 2/2