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HomeMy WebLinkAboutContract 62447CSC No. 62447 EXCESS RISK APPLICATION ReliaStar Life Insurance Company ("ReliaStar Life") Home Office: Minneapolis, Minnesota 55440 Plan Sponsor hereby applies for the Excess Risk Policy. PLAN INFORMATION Name of Plan Sponsor (exact legal name) City of Fort Worth Address (number and street) 100 Fort Worth Trail City Fort Worth State TX Zip 76102 ❑ Corporation ❑ Partnership ❑ Sole Proprietorship 0 Other. Specify: Government Nature of Plan Sponsor's Business Government SIC Code 9111 Are subsidiaries, affiliates or other associated entities to be included? ❑ Yes 0 No If "Yes," give Names. Relationship to Plan Sponsor Please provide the number of individuals covered as noted below: Eligible Individuals Covered Persons Only Covered Persons with Dependents Enrolled Individuals 6,086 Covered Persons Only 6,086 Covered Persons with Dependents Individuals Covered Elsewhere Covered Persons Only Covered Persons with Dependents The initial Contract Period is from January 1, 2025 through December 31, 2025 CLAIM ADMINISTRATOR INFORMATION (Claim Administrator for coverages checked below for the Employee Benefit Plan) Name of Claim Administrator (exact legal name of entity) Luminare, OptumRx Claims Address (number and street) N/A City N/A State N/A Zip N/A "Claim Administrator must be approved by ReliaStar Life prior to acceptance of this Application INDIVIDUAL EXCESS RISK Individual Excess Risk: 2 Yes ❑ No Benefits To Be Covered: R1 Medical 2 Other (Please specify) Prescription Drugs Initial Coverage Period: ❑ Incurred and Paid in 12 months ❑ Incurred in 15 months and Paid in 12 months ❑ Paid in 12 months ❑ Other ❑ Incurred in 12 months and Paid in 15 months 0 Incurred in 24 months and Paid in 12 months Individual Excess Risk Deductible $ 1,000,000 per Individual Individuals subject to the Individual Adjusted Deductible as identified in the disclosure process Claimant 1 — $1,300,000 Claimant 2 — $1,600,000 Claims for Individuals subject to the Individual Adjusted Deductible that exceed the Individual Excess Risk Deductible amount are excluded under any Aggregate Excess Risk Insurance. Benefit percentage 100% OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX RL-SL-APP-2013 Page 1 of 3 — Incomplete without all pages. Order #215388 07/01 /2021 CSC No. 62447 INDIVIDUAL EXCESS RISK (Continued) Maximum Individual Benefit: Individual Excess Risk Lifetime Maximum: $ Unlimited Individual Excess Risk Annual Maximum: $ Other $ Optional Endorsements: ❑ Individual Terminal Liability ❑ 3 months ❑ 6 months Q Individual Advanced Funding ❑ Individual Step -Down Deductible ❑ Individual Gapless Renewal (Only available for 12/15 or 12/18) ❑ Aggregating Individual Deductible: $ (Individual Excess Risk must be elected) Q Plan Mirroring Coordination Q Renewal Rate Cap ❑ Other: AGGREGATE EXCESS RISK Aggregate Excess Risk: ❑ Yes Q No Benefits To Be Covered: ❑ Medical ❑ Vision ❑ Prescription Drugs ❑ Dental ❑ Other (Specify) Initial Coverage Period: ❑ Incurred and Paid in 12 months ❑ Incurred in 15 months and Paid in 12 months ❑ Paid in 12 months ❑ Other: ❑ Incurred in 12 months and Paid in 15 months ❑ Incurred in months and Paid in Aggregate Adjustment Corridor: % Minimum Annual Aggregate Deductible: See Excess Risk Schedule ReliaStar Life's Limit of Liability: $ per Coverage Period Optional Endorsements: ❑ Plan Mirroring Coordination ❑ Aggregate Terminal Liability ❑ 3 months ❑ 6 months ❑ Other Are retirees covered? Q Yes ❑ No (Individual Terminal Liability must also be elected) Unlimited Are retirees age 65 and over covered? Q Yes ❑ No months Attached to and incorporated in this Application is a copy of the Employee Benefit Plan that relates to the Excess Risk Policy being applied for. The Producer/Agent of Record (provided he/she is duly licensed as required by law) is: IMA Inc. This insurance is to be effective on January 1.2025 at 12:01 a.m. Standard Time at the Plan Sponsor's place of business, provided that the first premium is paid in full and that the Disclosure Agreement and this Application are accepted by ReliaStar Life. An advance deposit of $ N/A is attached. (The deposit is to equal the first premium.) The deposit will be applied toward payment of the premiums on the insurance requested if the application is accepted by ReliaStar Life. If not accepted, the deposit will be refunded to the Plan Sponsor Applicant. RL-SL-APP-2013 Page 2 of 3 — Incomplete without all pages. Order #215388 07/01 /2021 CSC No. 62447 ACKNOWLEDGEMENT & SIGNATURES By signing this Application below, the Plan Sponsor Applicant represents that all statements, answers and information made above in this application and in the Disclosure Agreement are complete and true to the best of its knowledge and belief. Plan Sponsor Applicant further acknowledges and agrees (i) that such statements, answers and information in this Application and in the Disclosure Agreement, together with a copy of the Employee Benefit Plan and other information attached to this application or furnished to ReliaStar Life, are submitted by the Plan Sponsor Applicant as an inducement to, and will be relied upon by, ReliaStar Life, in underwriting this risk and determining whether to accept this application and issue the Excess Risk 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 ReliaStar Life, any policy issued by ReliaStar Life may be rescinded and/or any benefits that might otherwise be payable thereunder may be denied; and (iii) the Plan Sponsor Applicant has fully read and understands this completed Application and the Disclosure Agreement. Plan Sponsor Applicant Citv of Fort Worth Name of Signer (Please print) Jesica McEachern By �� Title Assistant City Manager RL-SL-APP-2013 Page 3 of 3 — Incomplete without all pages. Order #215388 07/01 /2021 CSC No. 62447 DISCLOSURE AGREEMENT ReliaStar Life Insurance Company, Minneapolis, MN VOVA.�/ A member of the Voya° family of companies (the "Company") FINANCIAL Policy Effective Date Jan uary 01, 2025 Plan Sponsor Name Citv of Fort Worth INSTRUCTIONS FOR COMPLETION Please provide the information described in the Disclosure Reports Section below and then have an authorized representative of the Plan Sponsor submit the Disclosure Agreement. Prior to submitting this Disclosure Agreement and Disclosure Reports to the Company, please consult with your current Claim Administrator(s), Utilization Review Firm(s), Case Management, and Pharmacy Benefits Manager(s) (collectively, "Claim Vendors"), and Plan Sponsor's Broker or other insurance advisor. The Disclosure Reports must be provided to the Company no earlier than 90 calendar days prior to the Policy's Effective Date or renewal date, as applicable. Please note the required monthly claim reporting provided on behalf of the Plan Sponsor to Company will suffice for renewal purposes. Should the Company require any additional information, it will notify the Plan Sponsor and/or its designated representative in writing no later than 20 calendar days following receipt of the Disclosure Reports. Any firm quote is void unless accepted by the Plan Sponsor in writing within 30 days from the date quoted by the Company. DISCLOSURE REPORTS Plan Sponsor has provided the following reports or data (which include claimant name and primary ICD-10 diagnosis) on the following date(s): • Any individual with paid claims that has exceeded 50% of the stop loss deductible during the applicable current policy year (minimum 9 months); • Any individual with denied and/or pended claims that has exceeded $25,000 during the applicable current policy year (minimum of 9 months); • Any individual evaluated and/or listed for an organ, stem cell or bone marrow transplant; • Any individual, including claim amounts for that individual, who is or was in case management or whose condition or diagnosis would be referred to case management during the applicable current policy year (minimum 9 months) by your claims Administrator based upon the ICD-10 codes used by your Claims Administrator for referral to case management; • Any individual, including claim amounts for that individual, whose condition or diagnosis during the applicable current policy year (minimum 9 months) is represented by any of the ICD-10 codes contained in the attached list. DISCLOSURE AGREEMENT The Plan Sponsor represents to the Company, to the best of its knowledge and belief, and after making a diligent and good faith inquiry, that it has fully read and understands this Disclosure Agreement; and as of the date of submitting this Disclosure Agreement there are no known potential catastrophic claims other than those disclosed on the submitted Disclosure Reports. The Plan Sponsor understands and agrees that the Company will rely on this Disclosure Agreement and the attached Disclosure Reports to: (i) underwrite this risk, (ii) determine whether or not to issue (or renew) a Policy, and (iii) If the Company agrees to issue or renew a Policy, determine the terms, conditions, limitations and rates of or for such Policy The Plan Sponsor further understands and agrees that if there are any undisclosed claimants known to the plan sponsor that are material to the risk to be insured by the Company, any Policy issued or renewed by the Company may be rescinded, any benefits that might otherwise be payable thereunder may be denied, and/or the premium rates, deductibles, terms, conditions and limitations of the Policy may be revised by the Company; and, the requirement to submit any required Disclosure Report may not be waived by the Company without a written representation by the Plan Sponsor that there are no reports or data with respect to any individual required to be included on any of the Disclosure Reports above. To be eligible for a claim of reimbursement under the Policy, the Plan Sponsor or the Claims Administrator must request payment and provide complete and accurate Proof of Loss, in the form and content acceptable to the Company, to support a claim within 180 days after the end of the Coverage Period of the Policy. RL-SL-DISCLOSE-2020 Page 1 of 2 Order #214806 07/01/2021 CSC No. 62447 ICD-10 CODES FOR DISCLOSURE NOTIFICATION The following ICD-10 Codes for Disclosure Notification provide conditions or diagnosis which must be disclosed. Please list all Plan Participants who have been diagnosed with or treated for any of the Codes listed under the following categories during the current Benefit Period. Where a range of Codes is shown, any and all conditions or diagnosis within that range must be disclosed. A00-1399 Infectious Diseases B17.1-1317.11 Hepatitis C C00-D49 Neoplasms COO-C14 Malignancies of oral cavity and pharynx C15-C26 Malignant neoplasm of digestive organs C30-C39 Malignant neoplasm of respiratory C43-C44 Melanoma C50-050 Breast Malignancies C51-C68 Genitourinary Malignancies C69-C72 Malignancies of Nervous System C81-C96 Leukemias, Lymphomas and Myelomas D50-D89 Hematologic Disorders D57.1 Sickle Cell Anemia D61.01 Aplastic Anemia D66 Hemophilia/Hereditary Factor VIII Deficiency D81.0 Severe Combined Immune Deficiency (SCID) D82.1 DiGeorge Syndrome D83.1 Immune Deficiency T Cells (AIDS) D84.1 Alpha 1-Antitrypsin E70-E88 Metabolic Disorders E75.22 Gaucher's Disease E84.0 Cystic Fibrosis K00-K95 Disease of Digestive System K70.0-K74.69 Chronic Liver Disease K72.00-K72.91 Liver Failure M86 Diseases of Musculoskeletal System and Connective Tissue M86 Osteomyelitis N00-N99 Disease of Genitourinary System N18.1-N18.9 Chronic Renal Failure 000-09A Pregnancy, Childbirth & Puerperium 030.10--030.109 Triplet Pregnancy 030.20-030.209 Quadruplet Pregnancy 060.00--060.14 Preterm Labor P00-P96 Perinatal Conditions P07.00-P07.36 Preterm Infant P22.0 Respiratory Distress Syndrome of Newborn Q00-Q99 Congenital Malformations Q20-Q28 Congenital Heart Diseases Q39.0-Q39.4 Tracheoesophageal Fistula Q89.7 Multiple Anomalies S00-T88 Injury, Poisoning and Trauma GOO-G99 Disease of the Nervous System S06.0-S06.9 Brain Injuries G12.21 Lou Gehrig's disease (ALS) S12-S14 Spinal Cord Injuries G61 0 Guillain-Barre Syndrome S88 Amputations G82.50 Quadriplegia T07 Multiple Trauma Injuries G91.1 Obstructive Hydrocephalus T20-T32 Burns T79 Early Complications of Trauma 100-199 Disease of Circulatory System 127.0 Primary Pulmonary Hypertension T86-Z94 Complications Peculiar to Certain Specified Conditions 142.0-142.9 Cardiomyopathy T86.00-T86.02 Graft vs. Host Disease 146.9 Cardiac Arrest T86.00-T86.09 Graft vs. Host Disease 160.9 Subarachnoid Hemorrhage T86.90-T86.92 Complications of Transplants T86.90-T89.99 Complications of Transplants J00-J99 Disease of Respiratory System Z94 Transplants J96.00-J96.92 Respiratory Failure RL-SL-DISCLOSE-2020 Page 2 of 2 Order #214806 07/01/2021 RESET FORM ADMINISTRATION AGREEMENT CSC No.62447 ReliaStar Life Insurance Company, Minneapolis, MN ReliaStar Life Insurance Company of New York, Woodbury, NY Members of the Voya®family of companies FINANCIAL (the "Company") Policyholder N a me (the "Policyholder") City of Fort Worth Policy Effective Date 01/01/2025 Insurance Contracts. The Company issues insurance policies and certificates based on your application and our state approved products (the "Policies"). Our obligations are determined solely by the terms of the policies we issue. EXCESS RISK COVERAGE Claim Administration. Upon determination of a potential claim under the Policy, you will confirm employees' eligibility for coverage and provide required eligibility and claim documentation to the Company, either directly or through your health claim administrator. The Company shall be responsible for all claim reviews, determinations and payments underthe Policy. Confidentiality. Wewill keep confidential all information provided to us byyou or your health claims administrator in connection with the Policy, in compliance with applicable law. You authorize your health claims administrator, if any, to release to the Company information and data regarding claims paid to be used in connection withthePolicy. GROUP ANNUAL TERM LIFE, PERSONAL ACCIDENT INSURANCE, DISABILITY, CRITICAL ILLNESS, ACCIDENT AND/OR HOSPITAL CONFINEMENT INDEMNITY COVERAGE Policy Administration. Your group policy will be "Self -Administered". This means that you or a third party that you engage will be responsible to maintain all enrollment, beneficiary, and billing records for the Policies (as applicable). The records you keep must provide the ability for you and/or your employees to: • appropriately apply Policy limits and rules • know how much coverage the employee has at all times • provide the employee with the appropriate "Conversion" and/or "Portability" documentation (as applicable) • set up any payroll deductions correctly • pay premium to the insurance company with supporting documentation • file a claim The parties agreethat the Policies will be self-administered by Policyholder and thatthe insurance charges reflect that arrangement. Communications. All forms and other materials we provide to you must be presented to employees without alteration. Any benefit and eligibility descriptions you or your third party service provider communicates to employees must be consistent with the materials and guidelines we provide to you. We will work carefu Ily with you to make corrections in the case of any inadvertent error in communications. However, you are responsible for any costs incurred in correcting errors caused by incorrect data you provide to employees or to Company, including incorrect benefit descriptions and eligibility determinations. Evidence of Insurability. If evidence of insurability is required in connection with an application for coverage under the terms of a Policy, you will apply the evidence of insurability rules appropriately, obtain the necessaryforms from any applicantfor such coverage and provide those forms to the Company. ClaimAdministration. Upon receiptof notice of potential claim undera Policy,youwill confirm employees' eligibilityforcoverage and provide required claim documentation atthe Company's request. The Company shall be responsiblefor all claim reviews, determinations and payments. Certificates of Insurance and Summary Plan Description. If you request that we provide Summary Plan Description(s) ("SPD") for distribution to ERISA plan participants, we will provide the SPD using ourstandard language and formatunless otherwise directed byyou. If we agree to electronically post certificates of insurance and/or SPDsfor access by your employees, you are responsible for assuring that each covered employee is informed how the documents can be accessed and thateach employee has access orotherwise receives a copy(ies) of these documents. Any legal advice as to the style, format, content or distribution of the SPD or distribution of the certificate of insurance must be provided byyour legal counsel. We are unable to provide legal advice to your plan and assume no responsibility for meeting ERISA's disclosure requirements. Indemnity. Each party shall indemnify and hold the otherharmless against any and all losses, claims, damages, costs or expenses (including reasonable attorneys'fees) whichthe indemnified party may become obligated to payresultingfrom 1)the indemnifying party's error oromission in performing obligations under this Agreement, except to the extent that the indemnified party has caused or significantly contributed to such error or omission, and 2) any breach by the indemnifying party of any of its obligations underthis Agreement regardless of whether such breach is either willful or negligent. Self -Administered Page 1 of 2 - Incomplete without all pages. Order#173385 05/17/2018 CSC No. 62447 GENERAL ADMINISTRATION —ALL PRODUCTS: Record Keeping. You agree to maintain accurate books and records documenting the administration of the Policies, including employee demographics, eligibility records, dependent data, coverage amounts, enrollmenth istory, payroll deductions, benefit elections and beneficiary designations (as applicable). Such records must be maintained for a period of seven (7) years following termination of the Policies to which they relate. Upon reasonable notice, we shall have the right to review, inspect and audit, at our expense, the books, records, data files or other information maintained by you or your vendor related to the Policies. Transmission of Data. You are responsible for the accuracy and security of data transmitted to us, including data transmitted by any third party service provideryou engageto assist in administration of your benefit plans. Each partywill establish and maintain (1) administrative, technical and physical safeguards against the destruction, loss or alteration of data, and (2) appropriate security measures to protect data, which measures are consistent with all state and federal regulations relatingto personal information security, including, without limitation, the Gramm-Leach-BlileyAct. Premiumpayment.lfyou engage a third partyto submit premium to us, wewil I notconsiderthe premium paid until itis received in our HomeOffice. General terms. This Agreement will remain in effect during the duration of the Policy and will terminate automatically upon termination of all Policies. This Agreement may be amended only in writing signed by both parties. In the event of any conflict or inconsistency between the terms of this Agreement and the terms of any Policy, the terms of the Policyshall control. Governing law. This Agreement shall be governed in all respects, including validity, interpretation and effect, without regard to principles of conflict of laws, bythelawofthestatewherethe Policyisissued. Accepted and Agreed to: Policyholder Name(Pleoseprint.) Citv of Fort Worth Policyholder AuthorizedSignaturec)_ Print signer's name and title Jesica McEachern RELIASTAR LIFE INSURANCE COMPANY RELIASTAR LIFE INSURANCE COMPANY OF NEW YORK �Company Authorized Signature V� Print signer's name and title MonaZielke.Vice President Date Dec 16, 2024 Assistant City Manager Date 11/05/2024 Self -Administered Page 2 of 2 - Incomplete without all pages. Order#173385 05/17/2018 CSC No. 62447 ACCEPTED AND AGREED: CITY: City of Fort Worth By: C>--ea— Name: Jesica McEachern Title: Assistant City Manager Date: Dec 16, 2024 Approval Recommended: Name: Joanne Hinton Title: Interim HRAsst Dir Attest: �, fOgT . . Od a 008 =Se �a°ann�zas4a By: a� Name: Jannette Goodall Title: City Secretary VENDOR: By: Name: Title: Date: 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: Meagan Hailey Title: Interim Benefits Manager Approved as to Form and Legality: By: .) Name: Jessika J. Williams Title: Assistant City Attorney Contract Authorization: M&C: 24-1069 OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX 12/11/24, 10:19AM M&C Review CSC No. 62447 Official site of the City of Fort Worth, Texas CITY COUNCIL AGENDA FOR`H Create New From This M&C DATE: 12/10/2024 REFERENCE **M&C 24- LOG NAME: 1414STOPLOSS2025 NO.: 1069 CODE: C TYPE: CONSENT PUBLIC NO HEARING: SUBJECT: (ALL) Authorize Execution of Agreement with VOYA Insurance Company in an Amount Not to Exceed $1,602,000.00 for Stop Loss Insurance for the City of Fort Worth's Health Benefits Plan with an Effective Date of January 1, 2025 for a One Year Term RECOMMENDATION: It is recommended that the City Council authorize the execution of an agreement with VOYA Insurance Company in an amount not to exceed $1,602,000.00 for Stop Loss Insurance for the City of Fort Worth's Health Benefits Plan with an effective date of January 1, 2025 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 VOYA Insurance Company, for Stop Loss Insurance for the City of Fort Worth's (City) Health Benefits Plan for 2025. If approved, effective January 1, 2025, VOYA Insurance Company would provide 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 the $1 million per -participant threshold at a cost of $21.92 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. In 2023, the City's Healthcare Plan had three members exceed the $1 million in claims cost and in 2024 the City's Healthcare Plan had two members exceed the $1 million in claims cost. The City's benefits consultant, IMA, conducted a Request for Proposal and VOYA Insurance Company was selected due to cost and experience in the stop loss industry. DVIN: This solicitation was reviewed by The Business Equity Division for available business equity prospects according to the City's Business Equity Ordinance. There were limited business equity opportunities available for the services/goods requested, therefore, no business equity goal was established. Funding is budgeted in the HR Retired Employee Insurance and HR Active Employee Insurance Departments within the 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 2026 budget process. FISCAL INFORMATION/CERTIFICATION: The Director of Finance certifies that upon approval of the recommendation, funds are available in the current operating budget, as previously appropriated, in the Group Health Insurance and Retiree Healthcare Trust Funds. Prior to an expenditure being incurred, the Human Resources Department has the responsibility to validate the availability of funds. TO Fund I Department Account Project Program Activity Budget Reference # Amount ID ID Year (Chartfield 2) apps.cfwnet.org/council_packet/mc_review.asp? I D=32775&cou ncildate=12/10/2024 1 /2 12/11/24, 10:19AM M&C Review CSC No. 62447 FROM Fund Department Account Project Program Activity Budget Reference # Amount ID ID Year (Chartfield 2) Submitted for City Manaqer's Office by_ Jesica L. McEachern (5804) Originating Department Head: Dianna Giordano (7783) Additional Information Contact: ATTACHMENTS 1414STOPLOSS2025 funds availabilitv.pdf (CFW Internal) Request for Waiver of Business Equitv Goal Final-CC.pdf (CFW Internal) RLIC - Form 1295 Certificate 101287753 (sianed).pdf (CFW Internal) Stop Loss FID 2025.xlsx (CFW Internal) apps.cfwnet.org/council_packet/mc_review.asp?ID=32775&councildate=12/10/2024 2/2