HomeMy WebLinkAboutContract 45285-A1 CONTRACT NO, V I
Plan S onsior Certification Grandfathered Status
The undersigned pla sponsor sur elieve at each plan or coverage listed e low is
grandfathered health plan" under the Patient Protection and Affordable (,.are Apt. As
perr witted y the act, a,grandfiathered hey tt h plan area preserve certain health coverage that
way in effect when that law was enacted on March 23 20101. Being a gr uu d athered
health plea rr cabs,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 provisi r of
preventative health services without auk. cost sharing. Howe er, rid ,atli red he It
plans must comply with rtain ether prow siurus within the act, for example 'the
el ir a n .tion of % u fl to m t can benefits.
In addition, the Undersigned plain sponsor certifies, that it his not defeated grand fathered
status for any of the plans listed
below y:
��� �e�r����r � more than 5 percen tage u � points* employer contHbUti
IC'IAL RECORD
� i a� y
coverage � r r tier�f"u�� ���r�uu for "lug of similarly situated frid r Is
ORD
cur a ul t v ly since arch 2 , 1 1
RY
Restructuring its business to,avoid a Joss of mind f t ere status,,
FT* WORTH, 'TX
111 Transferring employees into the plan without a bona,fide eniployment seid
r cost of coverage rs not bona fide reason
(changing,th.� t �
reason � ; are
Pl,an,Sponsor is not aware of any other plan changes that Would cause a, lines
grand fathered status.
Plan Sponsor Nar e,. City of Fort Worth,
List ol" rar dfather d Plans-.
i
Plan Name Funding,ng,, Arrangement Renewal Date
x"01 Basic Setffunded 4
.... _..�._..
PP01 Basic 'PIUS Self funded 1/ . 2 0
Sol cup Ord.
U)
Date: t
S of Authorized Representative
Susan la rd Assistant City
Ma a Ier
... ------------ .........
Name of author zd
e
e p re entat ve
Cn
rn elf your contribution rate is, based on a f01-11,111,11a, such as hours worked r tons of c �
".
produced, a decrease of 5 percent(riot ' percentage ntage p int )defeats grand fiathered s ta
For more information on, grandfathered prune visit www.dol.gov/ebsa/hca,ltl-tref(,tnil,
We
APPROVED, AS TO,
F AN TM
r
L'V.�GALITY:
Mor
ly
L VC1
ASSISTANT
NE,Y
k
I I F RT ORTHO
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Human Resources,
Plan Sponsor Certification of Grandfathered Status (REVISED)
Effective January 1, 2014
Routing and Transmittal Slip Date Received Initials Date Signed
HR: Margaret Wise 1/151/2,014
(2-c f
Law- Denis McElroy (2
..........
ACM: Susan Alanis
City Secretary.- Mary Kayser
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.
The grandfather status preserves certain health care coverage for the City of Fort Worth's P Basic
and PPO Basic Plus Plans from the law enacted on March 23, 2010. Certain health coverages foir these
plans, do, not have to meet all standard's applicable under the Patient Protection and Affordable Care Act.
One example is that routine wellness exams are not required to be covered at 1001% foir 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 lease call MpLgaret Wise, at extension 8058 for is up. Thanks.
McEllrow Denis C.
Y
From: Wise, Margaret
Sent.- Wednesday, January 5, 2014 12-02, PM
To 'Langford, Michael'; Lenee L Goyette
Cc: Singleton, Stacy A; McElroy, Denis C.; Gray, Maria
S bjecto, RE. Grandfather Form,
Importance: High
Len ee or Mike,
Can you malke, that cha�nge and riesend? I will need to, re-rolute.
Thanks,
Margaret
From: Langford, Michael [mai Ito:LanofordM@AE-rNA.com]
Sent,: Wednesday, January 15, 2014 .54 AM
To: Lenee L Goyettle
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 [mliailtoide,nee.1, py
I -Qtte@gonhewitt.com]
Sent: Tuesday,, January 14, 2014 5X1-34 PM
To: Langford, Michael
Cc: Wise, Margaret (M,arg,aret.,Wise@fortworthtexasi.q,ov)
Subject,.@, FW., Grandfather Form
Margaret has a question on the form—I completed the form foir her sig,nature and indicated the renewal date was
1/1/15 (as in the next renewal) but YOU may want the form colmplleted with the renewal date of 1/1/14— please advise—
CF' 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 7610!2
Tek 817.339.2009 1 Fax 847.953.4294
Ernail.- Lenee.G,oyette@,ao hewitt.com
From: Wise, Ma�rga�re,t [mai Ito,,M.arg,a,re,t.Wise fortworthtexa ig, y]
Sent: Tuesday, January 14, 2014 5:24 PM
To: Lenee L Goyette
Cc: Gray, Maria, McElroy, Denis C.
Subject-, Grandfather Form
Lenee,
Was atta�ched for 2 013, or 2 012?