R-1569 - 05/24/2016 - PERSONNEL - Resolutions Supporting Documents ITEM i O.A. 1)
BOARD OF TRUSTEES MEETING
VILLAGE OF SAMUEL E. DEAN BOARD ROOM
OAK B R K BUTLER GOVERNMENT CENTER
1200 OAK BROOK ROAD
OAK BROOK, ILLINOIS
630-368-5000
AGENDA ITEM
Regular Board of Trustees Meeting
of
May 24, 2016
SUBJECT: Health, Third Party Administrator and Stop Loss Insurance, Dental,
Life/AD&D Insurance and Vision Insurance Agreements for 2016-
2017 Plan Year
FROM: Riccardo F. Ginex, Village Manager
BUDGET SOURCE/BUDGET IMPACT: Program 133-Employee Benefits
RECOMMENDED MOTION: I move to approve Resolution 2016-PL-IS-R-1569 a
Resolution Approving the Waiver of Competitive Bidding and Authorizing the Purchase
of Insurance Benefits for Employees and direct staff to execute Agreements after
receiving final attorney review with BlueCross BlueShield (BC/BS) of Illinois for
Group Health Insurance Coverage,Third Party Administrator (TPA) Service, and
Stop Loss Insurance for the Plan Year starting July 1, 2016 through June 30, 2017.
Further, I move to approve the staff recommendation and direct staff to execute an
Agreement after receiving final attorney review with Lincoln Financial for the Plan
Year starting July 1,2016 through June 30, 2017.
Backy-round/History:
The Village operates a self-insured health insurance program for all PPO claims on a
per individual basis for the first $85,000 ("individual specific attachment point") of
claims in a given plan year (July 1 to June 30). This program has been in place in
this format since 1993, but with different • specific attachment points and TPAs.
The Village secures Stop Loss Coverage for claims that exceed $85,000 per
individual or over 125% of the annual aggregate specific attachment point of
expected claims. The Village health benefit program has approximately 174
employees, which includes approximately 30 retirees (retirees/COBRA employees
on the traditional insurance plan who pay 100% of the equivalent premium for
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their coverage) in the program, plus eligible dependents for a total of
approximately 399 participants. The Oak Brook Park District is also on our plan
paying the full premium cost for all eligible individuals.
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Renewal Information:
Our medical, dental & life plans were up for renewal. The medical plan was marketed by
our broker Vista National, to four providers, all who declined to quote. The HMO medical
plan was marketed to four carriers (UHC, Aetna, Humana and Cigna). All markets
declined to quote. The primary reason for declination was due to their rates being
uncompetitive. The PPO medical plan was marketed to twelve carriers. Most declined due to
being uncompetitive and the carriers that did provide a quote were not competitive enough
compared to BCBS. The medical rates are proposed for 1 year.
Medical: A fter negotiations, BC/BS's final proposal has a rate increase of 3.94%
(approximately $113,386) higher than our current plan year. When reviewing the BC/BS
proposal, there are a few key areas to highlight. The first is the estimated fixed costs.
This was increased by 1.81% or approximately $6,640. Next, was claim liability, which
was increased 4.25% or approximately $106,745.
The HMO portion of the medical is increasing about 7% or approximately $26,382.
Lastly, there are the Affordable Care Act (ACA) fees, which are decreasing with this
plan year. The estimated total cost for the PPO policies will be around $12,277 for this
plan year and include the Transitional Reinsurance fee & Patient-Centered Outcomes
Research Institute Fee. The Village avoids paying the Insurance Industry Fee by
continuing to be self-funded on the PPO policies. If we were subject to the fee, it would
increase costs by approximately 3%.
Dental: This year, the Village's dental insurance was also up for renewal. This year, the
Village will be transitioning from ASO Delta Dental to Fully Insured Lincoln Financial,
which will save the Village 16.11% and approximately $28,251. The dental rate is being
proposed for 1 year with a 2nd year rate cap of 8%. Lincoln Financial is also offering their
Max Rewards Program that allows members the opportunity to rollover part of their un-used
annual maximum benefit into the next year.
Life/AD&D: This year, the Village's Life/AD&D insurance was also up for renewal.
Dearborn presents no increase to the rates and also provide a two year rate guarantee.
Vision: The village is currently in the middle of a four year agreement with EyeMed for
vision insurance which will expire on July 1, 2018. Therefore, there will be no additional
costs associated with this benefit plans.
Finally, the Village will begin a "Telemedicine" concept for our employees and their
families. This will give them 24/7 access to a physician network that they can connect to by
phone, e-mail or video conferencing. We will also be looking into the possibility of adding a
separate plan, for our Medicare eligible post 65 retirees, which will mirror our current BCBS
plans. The premium equivalent rates will be going up 8.2% to build up reserves and also
include the cost of Telemedicine, ACA Fee's and Broker Commission.
The Village will continue to promote its wellness program allowing those who receive
insurance up to 2% off their premium and for those without insurance the opportunity to
receive gift cards for achieving pre-determined wellness goals. Overall, the program
continues to provide many opportunities for employees to continue their healthy efforts.
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These programs include annual wellness evaluation, lunch and learn programming and
group fitness activities such as the pink 5k event at the Oak Brook Park District.
Recommendation:
The Board approves the Resolution as presented.
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RESOLUTION 2016-PL-IS-R-1569
A RESOLUTION APPROVING THE WAIVER OF COMPETITIVE BIDDING AND AUTHORIZING
THE PURCHASE OF INSURANCE BENEFITS FOR EMPLOYEES
WHEREAS, the Village provides its employees with health and dental insurance benefits
(collectively, "Insurance Plans"); and
WHEREAS, the Village currently purchases health insurance coverage, third-party administrator
services, and stop loss insurance from BlueCross BlueShield of Illinois (collectively, "BC/BS Plans'; and
WHEREAS, the Village currently purchases dental insurance coverage from Lincoln Financial
("Lincoln Plan'; and
WHEREAS, the Insurance Plans are up for renewal; and
WHEREAS, instead of putting the purchase of the Insurance Plans out to bid or request for
competitive proposals, the Village Board retained Vista National Insurance Group, Inc. to market the
Insurance Plans to various insurance providers to obtain the most advantageous Insurance Plans for the
Village; and
WHEREAS, because the Village retained Vista National Insurance Group, Inc. to obtain quotes
from various insurance providers, and the Village Board believes that Vista National Insurance Group,
Inc. has negotiated for the purchase of Insurance Plans that are advantageous to the Village, Village staff
has recommended that the Village waive competitive bidding for the purchase of the Insurance Plans;
and
WHEREAS, Village staff has recommended the Village Board renew the BC/BS Plans and the
Lincoln Plan through June 30, 2016 (collectively, "Renewa/s'D; and
WHEREAS, the President and Board of Trustees, being fully advised in the premises, have
determined that it is in the best interests of the Village and its residents to so waive competitive bidding
and to approve the Renewals, all subject to the appropriation of sufficient funds for the Renewals in the
future fiscal year;
NOW THEREFORE, BE IT RESOLVED BY THE PRESIDENT AND BOARD OF TRUSTEES OF
THE VILLAGE OF OAK BROOK, DU PAGE AND COOK COUNTIES, ILLINOIS as follows:
Section 1: Recitals. The foregoing recitals are hereby incorporated into, and made a part
of, this Resolution as the findings of the President and Board of Trustees of the Village of Oak Brook.
Section 2: Waiver of Competitive Bidding Requirements. The advertising and bidding
requirements for the purchase of the Insurance Plans are hereby waived in accordance with Section 1-7-
4 of the Village Code.
Section 3: Authorization of Renewals. The purchase of the Renewals is hereby authorized.
Section 4: Execution of Required Documentation. The President, the Village Manager, and
the Village Clerk shall be, and are hereby, authorized to execute and attest, on behalf of the Village all
documents necessary to complete the purchase of the Renewals pursuant to Section 3 of this Resolution,
which documentation shall be in a final form approved by the Village Attorney.
Section 5: Effective Date. This Resolution shall be in full force and effect from and after its
passage by two-thirds of the Trustees and its approval in the manner provided by law.
Resolution 2016-PP-IS-R-1569
Approving the Purchase of
Insurance Plans
Page 2 of 2
[SIGNATURE PAGE FOLLOWS]
APPROVED THIS 241h day of May, 2016
Gopal G. Lalmalani
Village President
PASSED THIS 24th day of May, 2016
Ayes:
Nays:
Absent:
ATTEST:
Charlotte K. Pruss
Village Clerk
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ASO
Benefit Program Application ("ASO BPA")
Applicable to Administrative Services Only(ASO) Group Accounts
administered by Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, hereinafter referred to as"Claim Administrator'or"HCSC"
Group Status: Renewing ASO Account
Section Number(s): 0100
(Village- Union), 0101 (Village
- Non Union), 0200 (Park
District), 0300 (Retirees), 0400
Group Number(s): P19545 (Retirees over 65), 0500
Employer Account Number(6-digits): 019545 (Non- Union) P19546 (H S A), (PSEBA), 0501 (PSEBA), 0600
P56642 (Police), P56643 (Fire) (Police Union), 0800 (Union-
Fire), 1000 (PSEBA- Union),
1100 (Police- Union), 8887
(COBRA) 8888 (COBRA),
8889 (COBRA), 8900
(COBRA)
Legal Employer Name: Village of Oak Brook
(Specify the Employer or the employee trust applying for coverage. Names of subsidiary or affiliated companies to be
covered must also be named below. AN EMPLOYEE BENEFIT PLAN MAY NOT BE NAMED.)
ERISA Regulated Group Health Plan*: ❑ Yes ® No
If Yes, is your ERISA Plan Year*a period of 12 months beginning on the Anniversary Date specified below? ❑Yes ❑ No
If No, please specify your ERISA Plan Year*: Beginning Date_/—IF_ End Date_/ / (month/day/year)
ERISA Plan Administrator*: Plan Administrator's Address:
If you maintain that ERISA is not applicable to your group health plan, give legal reason for exemption:
Non-Federal Governmental Plan (Public Entity) ; if applicable, specify other:
Is your Non-ERISA Plan Year*a period of 12 months beginning on the Anniversary Date specified below? ®Yes ❑No
If no, please specify your Non-ERISA Plan Year*: Beginning Date_/ / End Date If If (month/day/year)
For more information regarding ERISA, contact your Legal Advisor.
*All as defined by ERISA and/or other applicable law/regulations
Effective Date of Coverage: (Month/Day/Year) 07/01 /2016
Anniversary Date: (Month/Day/Year) 07/01 /2017
Account Information NO CHANGES SEE ADDITIONAL PROVI •
Standard Industry Code (SIC): 8990 Employer Identification Number(EIN): 36-6009534
Address: 1200 Oak Brook Road
City: Oak Brook State: IL ZIP: 60523
Administrative Contact: Diana Maciejewski Title: HR Generalist
Email Address: dmaciejewski@oak-brook.org Phone Number: 630
@ g 368-5024 Fax Number:
Wholly Owned Subsidiaries:
Affiliated Companies:
(If Affiliated Companies listed above are to be covered,a separate"Addendum to the Benefit Program Application Regarding Affiliated Companies"must
be completed,signed by the Employer's authorized representative,and attached to this Benefit Program Application.)
Blue Access for Employers (BAE) Contact: Diana Maciejewsk
(The BAE Contact is the Employee authorized by the Employer to access and maintain the Employer's account in BAE.)
Email Address: dmaciejewski@oak-brook.org Phone Number: 630-368-
@ g 5024 Fax Number:
® The Employer or other company listed in this BPA is a public entity or governmental agency/contractor
HCSC IL GEN ASO BPA(Rev. 11/15) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, page 1
an Independent Licensee of the Blue Cross and Blue Shield Association
SCHEDULE OF ELIGIBILITY
® NO CHANGES ❑ SEE ADDITIONAL PROVISIONS
Employer has made the following eligibility decisions:
1. Eligible Person means:
® A full-time employee of the Employer.
❑ A full-time employee of the Employer who is a member of: (name of union)
® Other: Part-time employees that work at least 20 hours per week are enrolled in the Group Health Plan as of
06/30/2006 are eligible for Group Health Coverage under this plan. Part-time employees that are not enrolled as
of 06/30/2006 and future part-time will not be eligible for coverage.
Are any classes of employees to be excluded from coverage? ❑ Yes ❑ No
If yes, please identify the classes and describe the exclusion:
2. Employee Definitions
Full-Time Employee means:
® A person who is regularly scheduled to work a minimum of 30 hours per week and who is on the permanent
payroll of the Employer.
❑ Other:
3. The Effective Date of termination for a person who ceases to meet the definition of Eligible Person:
® The date such person ceases to meet the definition of Eligible Person.
❑ The last day of the calendar month in which such person ceases to meet the definition of an Eligible Person.
❑ Other:
4. Select an effective date rule for a person who becomes an Eligible Person after the Effective Date of the Employer's
health care plan (The effective date must not be later than the 91st calendar day after the date that a newly eligible
person becomes eligible for coverage, unless otherwise permitted by applicable law).
❑ The date of employment.
The 31st day of employment.
❑ The day of the month following month(s) of employment.
❑ The day of the month following days of employment.
❑ The day of the month following the date of employment.
❑ Other:
Is the waiting period requirement to be waived on initial group enrollment? ❑ Yes ® No
Are there multiple new hire waiting periods? ❑Yes ® No
If yes, please attach eligibility and contribution details for each section.
5. Domestic Partners covered: ❑ Yes ® No
If yes: a Domestic Partner is eligible to enroll for coverage.
If yes, are Domestic Partners eligible for continuation of coverage? ❑ Yes ❑ No
If yes, are dependents of Domestic Partners eligible to enroll for coverage? ❑ Yes ❑ No
If yes, are dependents of Domestic Partners eligible for continuation of coverage? ❑ Yes ❑ No
The Employer is responsible for providing notice of possible tax implications to those Covered Employees with
coverage for Domestic Partners.
6. Civil Union Partners covered:
i. ®The Employer is an Illinois county, municipality, the State of Illinois, subject to the Illinois School Code, a
church plan or other non-ERISA plan. For such Employers, a Civil Union Partner and his or her dependents are
automatically eligible to enroll for coverage and, once enrolled, eligible for continuation of coverage as
described in the Employer's Plan.
ii. For all other Employers, ❑Yes ❑ No
If yes: A Civil Union Partner and his or her dependents are eligible to enroll for coverage.
If yes, are Civil Union Partners and his or her dependents eligible for continuation of coverage? ❑ Yes ❑ No
HCSC IL GEN ASO BPA(Rev. 11/15) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, page 2
an Independent Licensee of the Blue Cross and Blue Shield Association
The Employer is responsible for providing notice of possible tax implications to those Covered Employees with
coverage for Civil Union Partners.
7. Limiting Age for covered Children
i. ® Twenty-six (26) years, regardless of presence or absence of a child's financial dependency, residency,
student status, employment status, marital status, eligibility for other coverage, or any combination of those
factors. (Standard)
ii. ❑ The Limiting Age for covered children age twenty-six(26) or over,
❑ who are unmarried
❑ regardless of marital status,
is years. (Twenty-seven (27)through thirty(30) are the available options.)
iii. ❑ The Limiting Age for covered children who are full-time students and age twenty-six(26) or over,
❑ who are unmarried
❑ regardless of marital status,
is years (Twenty-seven (27) through thirty(30) are the available options.)
Student status certification: ❑ Employer or ❑ HCSC or ❑ None
Frequency of Certification Letters: Annually (AN) ❑ Quarterly(QU) ❑ Semi-Annually(SA) ❑
•Certification Schedule: Month 1: Month 2: Month 3: Month 4:
• For Annual certification letters, indicate one month (Jan-Dec), for Semi-annual, select 2 months, for quarterly,
select 4 months
If Employer is an Illinois county, municipality, the State of Illinois, or subject to the Illinois School Code, this Limiting
Age is extended to thirty(30) years, for unmarried eligible military personnel as described in the Employer's Plan.
8. Termination of coverage upon reaching the Limiting Age:
❑ The last day of coverage is the day prior to the birthday.
® The last day of coverage is the last day of the month in which the limiting age is reached.
❑ The last day of coverage is the last day of the billing month.
❑ The last day of coverage is the last day of the year(12/31) in which the limiting age is reached.
❑ The last day of coverage is the day prior to the Employer's Anniversary Date.
Will coverage for a child who is medically certified as disabled and dependent on the employee terminate upon
reaching the limiting age even if the child continues to be both disabled and dependent on the employee?
❑ Yes ❑ No
However, such coverage shall be extended in accordance with any applicable federal or state law. The Employer will
notify HCSC of such requirements.
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HCSC I L GEN ASO BPA(Rev. 11/15) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, page 3
an Independent Licensee of the Blue Cross and Blue Shield Association
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9. Will extension of benefits due to temporary layoff, disability or leave of absence apply?
® Yes (specify number of days below) ❑ No
Temporary Layoff: 0 days Disability:Police& Fire by IL Statute; Other 90 days Leave of Absence: 0 days
However, benefits shall be extended for the duration of an Eligible Person's leave in accordance with an applicable
federal or state law. The Employer will notify HCSC of such requirements.
10. Enrollment:
Special Enrollment: An Eligible Person may apply for coverage, Family coverage or add dependents within thirty-one
(31) days of a Special Enrollment qualifying event if he/she did not previously apply prior to his/her Eligibility Date or
when otherwise eligible to do so. Such person's Coverage Date, Family Coverage Date, and/or dependent's
Coverage Date will be the effective date of the qualifying event or, in the event of Special Enrollment due to marriage
or termination of previous coverage, then no later than the first day of the Plan Month following the date of receipt of
the person's application of coverage.
An Eligible Person may apply for coverage within sixty (60) days of a Special Enrollment qualifying event in the case
either of a loss of coverage under Medicaid or a state Children's Health Insurance program, or eligibility for group
coverage where the Eligible Person is deemed qualified for assistance under a state Medicaid or CHIP premium
assistance program.
Late Enrollment: An Eligible Person may apply for coverage, family coverage or add dependents if he/she did not
apply prior to his/her Eligibility Date or did not apply when eligible to do so. Such person's Coverage Date, family
Coverage Date, and/or dependent's Coverage Date will be a date mutually agreed to by the Claim Administrator and
the Employer.
Open Enrollment: An Eligible Person may apply for coverage, family coverage or add dependents if he/she did not
apply prior to his/her Eligibility Date or did not apply when eligible to do so, during the Employer's Open Enrollment
Period. Such person's Coverage Date, family Coverage Date, and/or dependent's Coverage Date will be a date
mutually agreed to by the Claim Administrator and the Employer. Such date shall be subsequent to the Open
Enrollment Period.
Specify Open Enrollment Period: The month of June for a July 1St effective date
11. * Does COBRA Auto Cancel apply? ® Yes ❑ No
Member's COBRA/Continuation of Coverage will be automatically cancelled at the end of the member's eligibility
period.
*Not recommended for accounts with automated eligibility.
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HCSC IL GEN ASO BPA(Rev. 11/15) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, Page 4
an Independent Licensee of the Blue Cross and Blue Shield Association
Lines of Business (Check all applicable products) NO CHANGES See Additional Comments
Managed Care Coverage:
® Participating Provider Option (PPO)
❑ Blue Choice Select
❑ Blue Choice Options
❑ Comprehensive Major Medical
❑ Base Plus
Consumer Driven Health Plan:
❑ Health Care Account(HCA)Administrative Services
(if purchased, complete separate HCA BPA)
❑ BlueEdge FSA(Vendor: ConnectYourCare)
❑ HSA Eligible Health Plan
Outpatient Prescription Drugs:
® Outpatient Prescription Drug Program
❑ Covered under the medical benefit(e.g. Blue Script)
❑ Dental Coverage
® Blue Care Connection®
® Stop Loss (if selected, complete separate Exhibit to the Stop Loss Coverage Policy)
❑ Dearborn National Life Insurance (if selected, complete separate Life application)
❑ Well On Target
❑ Wellness Incentives
❑ HCSC COBRA Administrative Services (if selected, complete separate COBRA Administrative Services
Addendum to the BPA)
❑ Blue Directions (Private Exchange) (If selected, the Blue Directions Addendum is attached and made a part of
the Agreement.)
Additional Comments:
HCSC IL GEN ASO BPA(Rev. 11/15) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, page 5
an Independent Licensee of the Blue Cross and Blue Shield Association
FEE SCHEDULE
Employer Payment Method: ❑ Online Bill Pay ® Electronic ❑ Auto Debit ❑ Check
Employer Payment Period: ❑ Weekly (cannot be selected if Check is selected as payment method above)
❑ Semi Monthly
® Monthly
❑ Other(please specify)
Claim Settlement Period: ® Monthly ❑ Other(please specify)
Run-Off Period: Employer Payments are to be made for 12 months following end of Fee Schedule Period.
Standard is twelve (12) months.
Final Settlement: Final Settlement is to be made within 60 days after end of Run-Off Period.
Standard is sixty(60) days.
Schedule Fee . . Em
To begin on Effective Date of Coverage and continue for:
® 12 Months ❑ Other(please specify): Months
Administrative Charge(s)
❑ NO CHANGES ® SEE ADDITIONAL PROVISIONS
®Applies to all coverages
❑ Different percentage(s) or amount(s)for the following types of coverages. Please specify:
Subscriber Share Methodology for Illinois Network Provider Claims Applies: ❑ Yes ❑ No
(if no,a letter declining Subscriber Share Methodology for Claims processing must be attached to this Benefit Program Application.)
Administrative Charge Chart:
Each column can be used to differentiate fees between product types or employee tiers. All columns do not need to be
used. All fees listed are per employee per month.
Administrative Per Employee per Month (PEPIVI) Charges
All group
Product 1 Service numbers
Medical Administrative Fee $69.77 $ $ $
Commissions $ $ $ $
Dental $ $ $ $
Claims Fiduciary $ $ $ $
Prescription Drug Administrative Fee
*Prescription Drug Rebate Credit $ 23.71 $ $ $
t
[Other: Select Service Category $Service:
HCSC IL GEN ASO BPA(Rev. 11/15) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,
page 6
an Independent Licensee of the Blue Cross and Blue Shield Association
Other: Select Service Category $ $ $ $
List Service:
Other: Select Service Category $ $ $ $
List Service:
Other: Select Service Category $ $ $ $
List Service:
Miscellaneous: $ $ $ $
Miscellaneous: $ $ $ $
Total $46.06 $ $ $
*Prescription Drug Rebate Credit per Covered Employee per month is the guaranteed Prescription Drug Rebate savings
reflected as a Prescription Drug Rebate credit. Expected rebate amounts to be received by the Claim Administrator are
passed back to the Employer with one hundred percent(100%) of the expected amount applied as a credit on the monthly
billing statement on a per Covered Employee per month basis. Rebate credits are paid prospectively to the Employer and
shall not continue after termination of the Prescription Drug Program. (Further information concerning this credit is
included in the governing Administrative Services Agreement ("Agreement") to which this ASO BPA is attached under the
section titled "CLAIM ADMINISTRATOR'S SEPARATE FINANCIAL ARRANGEMENTS WITH PHARMACY BENEFIT
MANAGERS.") Rebates for some drugs covered under the medical benefit are retained by the Claim Administrator as
compensation for its administrative services.
Administrative Line Item Charges Frequency Amount
Other: Select Service Category Select Billing Frequency $
List Service: If applicable, describe other:
Other: Select Service Category Select Billing Frequency $
List Service: If applicable, describe other:
Other: Select Service Category Select Billing Frequency $
List Service: If applicable, describe other:
Other: Select Service Category Select Billing Frequency $
List Service: If applicable, describe other:
Miscellaneous: Select Billing Frequency $
If applicable, describe other:
Miscellaneous: Select Billing Frequency $
If applicable, describe other:
Total:
Note: Additional services and/or fees may be itemized in the "Miscellaneous" fields above or in the Additional Comments
section below.
Additional Comments (Provide any additional details regarding the fee structure):
Claim Administrator Provider Access Fee(s) NO CHANGES SEE ADDITIONAL PROVISIONS
Group Number(s): P19545(Non-Union) P19546 (H S A), P56642 (Police), P56643 (Fire)
® % of ADP Savings: 2.51%
❑ $ per Covered Employee per month: $
❑ Group with multiple Provider Access Fees by products(e.g., CMM, and/or PPO plans):
Group Number(s):
❑ % of ADP Savings: %
❑ $ per Covered Employee per month: $
BlueCard Program/Network access fees: Available upon request.
HCSC IL GEN ASO BPA(Rev. 11/15) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, page ]
an Independent licensee of the Blue Cross and Blue Shield Association
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Other Service and/or Program Fee(s) NO CHANGES SEE ADDITIONAL PROVISIONSm
Not applicable to Grandfathered Plans
External Review Coordination: ❑ Yes (Claim Administrator coordinates external reviews) ❑ No
If selected, Employer acknowledges and agrees: (i) to a fee of $700 for each external review requested by a Covered
Person that the Claim Administrator coordinates for the Employer in relation to the Employer's Plan; (ii) that the Claim
Administrator's coordination shall include reviewing external review requests to ensure that they meet eligibility
requirements, referring requests to accredited external independent review organizations, and reversing the Plan's
determinations if so indicated by external independent review organizations; and (iii) that the external reviews shall be
performed by an independent third party entity or organization and not the Claim Administrator. Amounts received by
Claim Administrator and external independent review organizations may be revised from time to time and may be paid
each time an external review is undertaken. Further, Employer elects for external reviews to be performed under the
process selected below(select one):
❑ State of Illinois External Review Process
® Federal Affordable Care Act Process
Reimbursement Service: ® Yes ❑ No
If yes:The Employer has elected to utilize the reimbursement service offered by the Claim Administrator, the Corporate
Reimbursement Subrogation department. It is understood and agreed that in the event the Claim Administrator makes a
recovery on a third-party liability claim, the Claim Administrator will retain 25% of any recovered amounts other than
recovered amounts received as a result of or associated with any Workers' Compensation Law.
Conversion Privilege: ❑ Yes ® No If yes, conversion fee: $6,000 per conversion.
Claim Administrator's Third Party Recovery Vendor:
Recoveries from healthcare providers can arise in several ways, including, but not limited to, anti-fraud and abuse
recoveries, healthcare provider/hospital audits, credit balance audits, data mining, utilization review refunds, and
unsolicited refunds. The Claim Administrator may engage a third party to assist in identification or collection of recovery
amounts related to Claim Payments. It is understood and agreed that in the event the Claim Administrator's Third Party
Recovery Vendor makes a recovery on a claim, the Employer will pay no more than 25% of any recovered amount.
Alternative Compensation Arrangements:
Employer acknowledges and agrees that Claim Administrator has Alternative Compensation Arrangements with
contracted Providers, including but not limited to Accountable Care Organizations and other Value Based Programs.
Further information concerning Employer's payment for covered services under such Arrangements is described in the
Administrative Services Agreement.
Termination Administrative Charge
As applies to the Run-Off Period indicated in the Payment Specifications section below:
i. For service charges (including, but not limited to, access fees) billed on a per Covered Employee basis at the
time of termination, the Termination Administrative Charge will be the amount equal to ten percent (10%) of the
annualized charges based on the service charges in effect as of the termination date and the Plan participation of the
two (2) months immediately preceding the termination date. Such aggregate amount will be due the Claim
Administrator within ten (10) days of the Claim Administrator's notification to the Employer of the Termination
Administrative Charge described herein.
ii. For service charges (including, but not limited to, access fees) billed on a basis other than per Covered
Employee at the time of termination, the Termination Administrative Charge will be such service charges in effect at
the time of termination to be applied and billed by the Claim Administrator, and paid by the Employer, in the same
manner as prior to termination.
Termination Administrative Charges assume the continuation of the Plan benefit pr ogram(s) and the administrative
services in effect prior to termination. Should such Plan benefit program(s) and/or administrative services change, or in
the event the average Plan enrollment during the three (3) months immediately preceding termination varies by ten
percent (10%) or more from the enrollment used to determine the service charges in effect at the time of termination, the
Claim Administrator reserves the right to adjust the fees for service charges (including, but not limited to, access fees) to
be used to compute the Termination Administrative Charge.
HCSC IL GEN ASO BPA(Rev. 11/15) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, page 8
an Independent Licensee of the Blue Cross and Blue Shield Association
OTHER PROVISIONS
® NO CHANGES ❑ SEE ADDITIONAL PROVISIONS
1. Summary of Benefits & Coverage:
a. Will Claim Administrator create Summary of Benefits&Coverage(SBC)?
® Yes. Please answer question b. The SBC Addendum is attached.
❑ No. If No, then the Employer acknowledges and agrees that the Employer is responsible for the creation
and distribution of the SBC as required by Section 2715 of the Public Health Service Act(42 USC 300gg-15)
and SBC regulations (45 CFR 147.200), as supplemented and amended from time to time, and that in no
event will the Claim Administrator have any responsibility or obligation with respect to the SBC. The Claim
Administrator is not obligated to respond to or forward misrouted calls, but may, at its option, provide
participants and beneficiaries with Employer's contact information. (Skip question b.)
b. Will Claim Administrator distribute the Summary of Benefits&Coverage (SBC) to participants and beneficiaries?
® No. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the
Agreement) and provide SBC to Employer in electronic format. Employer will then distribute SBC to
participants and beneficiaries (or hire a third party to distribute) as required by law.
❑ Yes. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the
Agreement) and provide SBC to Employer in electronic format. Employer will then distribute to participants
and beneficiaries as required by law, except that Claim Administrator will send the SBC in response to the
occasional request received directly from individuals.
❑ Yes. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the
Agreement) and distribute SBC to participants and beneficiaries via regular hardcopy mail or electronically.
Distribution Fee for hardcopy mail is $1.50 per package. The distribution fee will not apply to SBCs that
Claim Administrator sends in response to the occasional request received directly from individuals.
2. Does Employer have any Employees that reside in Massachusetts? ® Yes ® No
The Massachusetts Health Care Reform Act requires Employers to provide, or contract with another entity to provide,
a written statement to individuals residing in Massachusetts who had "creditable coverage" at any time during the
prior calendar year through the Employer's group health plan and to file a separate electronic report to the
Massachusetts Department of Revenue verifying information in the individual written statements.
a. Does the Employer direct Claim Administrator to provide written statements of creditable coverage to its Covered
Employees who reside, or have enrolled dependents who reside, in Massachusetts and file electronic reports to
the Massachusetts Department of Revenue in a manner consistent with the requirements under the
Massachusetts Health Care Reform Act? Such written statements and electronic reporting shall be based on
information provided to the Claim Administrator by the Employer and coverage under the Plan during the term
of the Administrative Services Agreement. The Employer hereby certifies that, to the best of its knowledge, such
coverage under the Plan is "creditable coverage" in accordance with the Massachusetts Health Care Reform
Act. The Employer acknowledges that the Claim Administrator is not responsible for verifying nor ensuring
compliance with any tax and/or legal requirements related to this service. The Employer or its Covered
Employees should seek advice from their legal or tax advisors as necessary.
® Yes ❑ No
b. If no: The Employer acknowledges it will provide written statements and electronic reporting to the
Massachusetts Department of Revenue as required by the Massachusetts Health Care Reform Act.
3. Case/Utilization Management Program: ® Yes ❑ No
If yes: The undersigned representative authorizes provision of alternative benefits for services rendered to Covered
Persons in accordance with the provisions of the Administrative Services Agreement to which this ASO BPA
is attached and the Employer's plan document.
4. Employer acknowledges and agrees to utilize Claim Administrator's standard list of services and supplies for which
pre-notification or preauthorization is required: ® Yes ❑ No If no, Employer authorizes Claim Administrator to post
Employer's pre-notification or preauthorization requirements on Claim Administrator's Website: ❑ Yes ❑ No
HCSC IL GEN ASO BPA(Rev. 11/15) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, Page 9
an Independent Licensee of the Blue Cross and Blue Shield Association
i
5. Essential Health Benefits ("EHB") Election:
Employer elects EHBs based on the following:
®1. EHBs based on a HCSC state benchmark:
® Illinois ❑ Oklahoma
❑ Montana ❑ Texas
❑ New Mexico
❑ 2. EHBs based on benchmark of a state other than IL, MT, NM, OK and TX
If so, indicate the state's benchmark that Employer elects:
❑3. Other EHB, as determined by Employer
In the absence of an affirmative selection by Employer of its EHBs, then Employer is deemed to have elected the
EHBs based on the Illinois benchmark plan.
6. This ASO Benefit Program Application (ASO BPA) is incorporated into and made a part of the Administrative
Services Agreement with both such documents to be referred to collectively as the"Agreement" unless specified
otherwise.
Producer/Consultant Compensation
The Employer acknowledges that if any producer/consultant acts on its behalf for purposes of purchasing services in
connection with the Employer's Plan under the Administrative Services Agreement to which this ASO BPA is
attached, the Claim Administrator may pay the Employer's producer/consultant a commission and/or other
compensation in connection with such services under the Agreement. If the Employer desires additional information
regarding commissions and/or other compensation paid the producer/consultant by the Claim Administrator in
connection with services under the Agreement, the Employer should contact its producer/consultant.
ADDITIONAL PROVISIONS:
A. Grandfathered Health Plans: Employer shall provide Claim Administrator with written notice prior to renewal (and
during the plan year, at least 60 days advance written notice) of any changes that would cause any benefit package of
its group health plan(s) (each hereafter a"plan")to lose its status as a"grandfathered health plan" under the
Affordable Care Act and applicable regulations. Any such changes (or failure to provide timely notice thereof) can
result in retroactive and/or prospective changes by Claim Administrator to the terms and conditions of administrative
services. In no event shall Claim Administrator be responsible for any legal, tax or other ramifications related to any
plan's grandfathered health plan status or any representation regarding any plan's past, present and future
grandfathered status. The grandfathered health plan form ("Form"), if any, shall be incorporated by reference into and
become part of the BPA and Agreement, and Employer represents and warrants that such Form is true, complete and
accurate.
B. Retiree Only Plans, Excepted Benefits and/or Self-Insured Nonfederal Governmental Plans: If the BPA includes
any retiree only plans, excepted benefits and/or self-insured nonfederal governmental plans(with an exemption
election), then Employer represents and warrants that one or more such plans is not subject to some or all of the
provisions of Part A(Individual and Group Market Reforms) of Title XXVII of the Public Health Service Act(and/or
related provisions in the Internal Revenue Code and Employee Retirement Income Security Act) (an "exempt plan
status"). Any determination that a plan does not have exempt plan status can result in retroactive and/or prospective
changes by Claim Administrator to the terms and conditions of administrative services. In no event shall Claim
Administrator be responsible for any legal, tax or other ramifications related to any plan's exempt plan status or any
representation regarding any plan's exempt plan status.
I
HCSC IL GEN ASO BPA(Rev. 11/15) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, page 10
an Independent Licensee of the Blue Cross and Blue Shield Association
C. Employer shall indemnify and hold harmless Claim Administrator and its directors, officers and employees against any
and all loss, liability, damages, fines, penalties, taxes, expenses(including attorneys' fees and costs) or other costs or
obligations resulting from or arising out of any claims, lawsuits, demands, governmental inquires or actions,
settlements or judgments brought or asserted against Claim Administrator in connection with (a) any plan's
grandfathered health plan status, (b) any plan's exempt plan status, (c) any plan's design (including but not limited to
any directions, actions and interpretations of the Employer), (d) any provision of inaccurate information, (e) the SBC,
and/or(f) selection of Employer's EHB benchmark for the purpose of ACA. Changes in state or federal law or
regulations or interpretations thereof may change the terms and conditions of administrative services.
The provisions of paragraphs A-C (directly above) shall be in addition to(and do not take the place of) the other terms and
conditions of administrative services between the parties.
Effective 07/01/2016. this account will be renewing with no changes.
Ruben Mendez
Sales Representative Signature of Authorized Purchaser
822 630 824 5197
District Phone&FAX Numbers Title
Producer Representative Date
Vista National Insurance
Producer Firm Signature of HCSC Vice President
1301 West 22nd Street
Suite 600
Oak Brook, IL 60523
Producer Address Signature Underwriting
Producer Phone&FAX Numbers
Producer Email Address
36-4095485
Tax I.D. No.
HCSC I L GEN ASO BPA(Rev. 11/15) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, page
j an Independent Licensee of the Blue Cross and Blue Shield Association
I
PROXY
The undersigned hereby appoints the Board of Directors of Health Care Service Corporation, a Mutual Legal Reserve Company,
or any successor thereof("HCSC"),with full power of substitution, and such persons as the Board of Directors may designate by
resolution, as the undersigned's proxy to act on behalf of the undersigned at all meetings of members of HCSC (and at all
meetings of members of any successor of HCSC) and any adjournments thereof, with full power to vote on behalf of the
undersigned on all matters that may come before any such meeting and any adjournment thereof. The annual meeting of
members shall be held each year in the corporate headquarters on the last Tuesday of October at 12:30 p.m. Special meetings
of members may be called pursuant to notice mailed to the member not less than thirty (30) nor more than sixty (60) days prior
to such meetings. This proxy shall remain in effect until revoked in writing by the undersigned at least twenty (20) days prior to
any meeting of members or by attending and voting in person at any annual or special meeting of members.
From time to time, HCSC pays indemnification or advances expenses to a director, officer, employee or agent consistent with
HCSC's bylaws then in force and as otherwise required by applicable law.
P19545 By:
(Non- Union)
Group No.: P19546 (H S y
A), P56642
(Police),
P56643 (Fire)
Print Signer's Name Here
Signature and Title
Group Name: Village of Oak Brook
Address: 1200 Oak Brook Road
City: Oak Brook State: IL ZIP : 60523
Dated this day of
Month Year
i
HCSC IL GEN ASO BPA(Rev. 11/15) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,
page 12
an Independent Licensee of the Blue Cross and Blue Shield Association
B1ueCross B1ueShield The HMOs of Blue Cross
G of Illinois and Blue Shield of Illinois
O •
Benefit Program Application ("BPA")
(All items are applicable to 151-Plus Grandfathered and Non-Grandfathered Insured Group Accounts unless
otherwise specified.)
Employer Account Number: 019545
HMO Illinois Employer Group Number(s):
HMO Illinois Section Number(s):
BlueAdvantageu HMO Employer Group Number(s): B19545
BlueAdvantage HMO Section Number(s): 0101 (Village/Non-Union), 0200 (Park District), 0300 (Retirees)
0400 (Retirees 65+), 0500 (PSEBA), 0501 (PSEBA) 0600 (Police
Union), 8888 (COBRA)
Employer Name: Village of Oak Brook
(Specify the Employer, the employee trust, or the association applying for coverage. Names of subsidiary or affiliated
companies to be covered must also be included below. An employee benefit plan may not be named.)
Address: 1200 Oak Brook Road
City: Oak Brook State: IL Zip Code: 60523
Billing Address (if different from above):
Employer Identification Number("EIN"): 36-6009534
City: State: Zip Code:
Wholly Owned Subsidiaries:
Affiliated Companies:
(If Affiliated Companies to be covered are listed above, a separate "Addendum to the Benefit Program Application
Regarding Affiliated Companies" must be completed, signed by the Employer's authorized representative, attached to this
BPA, and is made a part of the Policy.)
Administrative Contact: Diana Phone: 630 368 5024 Fax : Email: dmaciejewski(�oak-
Maciejewsk brook.org
Blue Access for Employers ("BAE") Contact: Diana Maciejewsk
(The BAE Contact is the employee of the account authorized by the Employer to access and maintain its account via
BAE.)
Title: HR Generalist Phone: 630-368-5024 Fax : Email: dmaciejewski(a_oak-
brook.org
Policy Effective Date: 07/01/2016 Policy Anniversary Date: 07/01 /2017
Month Day Year
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
IL-LG-151 PLUS-H-BPA Rev. 05/15 Page 1
The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for
employee benefit plans in the private industry. In general, all employer groups, insured or ASO, are subject to ERISA
provisions except for governmental entities, such as municipalities and public school districts, and "church plans" as
defined by the Internal Revenue Code.
ERISA Regulated Group Health Plan*: Yes ❑ No
If Yes, specify ERISA Plan Year*: Beginning Date:_/ / End Date: _/ / (month/day/year)
ERISA Plan Sponsor*:
(If the Employer is required to file Form 5500 Schedule A with the IRS, the following ERISA items must be completed):
ERISA Plan Administrator*:
ERISA Plan Administrator's Address:
City: State: Zip Code:
ERISA Plan Administrator's Email:
Please provide your Non-ERISA Plan Month/Year: 07/2016
If you contend ERISA is inapplicable to your group health plan, please give legal reason for exemption*:
❑ Federal Governmental Plan (e.g., the government of the United States or agency of the United States)
® Non-Federal Governmental Plan (e.g., the government of the State, an agency of the state, or the
government of a political subdivision, such as a county or agency of the State)
❑ Church Plan (complete and attach a Medical Loss Ratio Assurance form)
❑ Other, please specify:
For more information regarding ERISA, contact your Legal Advisor.
*All as defined by ERISA and/or other applicable law/regulations.
1. Eligible Person:
Employer has decided that Eligible Person means a person who resides in the Service Area of a Participating IPA and
is:
❑ A Full-Time Employee of the Employer.
❑ A member of(name of union or association):
® Other(please specify): A full-time non-union or union employee of the employer
Full-Time Employee means:
®An Employee of the Employer who is regularly scheduled to work a minimum of 30 hours per week.
❑ Other(please specify):
The term "Employee" shall have the meaning set forth under ERISA and applicable law. HCSC reserve the right to
audit Employer's initial and ongoing eligibility determinations.
2. Civil Union Partner Coverage:
A Civil Union partner, as defined in the Policy, and his or her dependents are automatically eligible to enroll for
coverage and, once enrolled, eligible for continuation of coverage as described in the Certificate Booklet. The
Employer as Policyholder is responsible for providing notice of possible tax implications to those Insureds with
coverage for Civil Union partners.
3. Domestic Partner Coverage: ❑ Yes ® No
If Employer elects "Yes", a Domestic Partner, as defined in the Policy, shall be considered eligible for coverage. The
Employer is responsible for providing notice of possible tax implications to those Insureds with Domestic Partner
Coverage.
IL-LG-151 PLUS-H-BPA Rev. 05/15 Page 2
Continuation coverage for Domestic Partners: If Employer elects coverage for Domestic Partners, Domestic Partners
are not eligible for continuation coverage under Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA),
but are eligible for continuation coverage similar to that available to spouses under COBRA continuation.
Domestic Partner Coverage Continuation (only available if Domestic Partners are covered): ❑ Yes ❑ No
4. The Limiting Age for covered children:
Hereafter, covered children means a natural child, a stepchild, an eligible foster child, an adopted child (including a
child involved in a suit for adoption,) a child for whom the Insured is the legal guardian, under twenty-six(26) years of
age, regardless of presence or absence of a child's financial dependency, residency, student status, employment
status (if applicable under the Policy), marital status, or any combination of those factors. If the covered child is
eligible military personnel, the Limiting Age is thirty (30) years as described in the Certificate Booklet.
To cover children age twenty-six(26) or over, you may select option (a) or(b) below:
(a) ❑ Limiting Age for covered children age twenty-six (26) or over, ❑ who are married ❑ who are unmarried ❑
regardless of marital status, is years (twenty-seven (27) —thirty (30) are the available options). If the covered
child is eligible military personnel, the Limiting Age is thirty(30) years as described in the Certificate Booklet.
(b) ❑ Limiting Age for covered children who are full-time students and age twenty-six (26 or over, ❑ who are
married ❑ who unmarried ❑ regardless of marital status, is years (twenty-seven (27) — thirty (30) are the
available options). If the covered child is eligible military personnel, the Limiting Age is thirty (30) years as described
in the Certificate Booklet.
Coverage will terminate:
❑ At the end of the period for which premium has been accepted.
®At the end of the month in which the Limiting Age is reached.
❑ At the end of the calendar year in which the Limiting Age is reached.
❑ On the Limiting Age Birthday.
❑ Other(please specify):
However, coverage shall be extended due to a leave of absence in accordance with any applicable federal or state
law.
5. Total number of employees: (indicate the total number of actual employees, not enrollees)
Of the Employer 174 Illinois employees 174 National employees 0
6. Eligibility Date: All current and new employees must satisfy the substantive eligibility criteria and required waiting
period indicated below before coverage will become effective. No waiting period may result in an effective date that
exceeds ninety-one (91) calendar days from the date that an employee becomes eligible for coverage, unless
otherwise permitted by applicable law.
❑ The date of employment.
® The 31st day of employment. Note: This may not exceed ninety-one (91) calendar days.
❑ The day (select 1St or 15th) of the month following month(s) (option of 1 or 2 months)of
employment.
❑ The day (select 1St or 15th) of the month following days (option of up to 60 days)of employment.
❑ The day of the month following the date of employment.
❑ Other(please specify): Note: This may not exceed ninety-one (91)calendar days.
A full month's premium will be charged for the first month of coverage for those employees whose Coverage Dates
fall between the first (1S) and fifteenth (15th) day of the Premium Period. No premium will be charged for the first
month of coverage for those employees whose Coverage Dates fall between the sixteenth (16th) day and the end of
the Premium Period.
I
IL-LG-151PLUS-H-BPA Rev.05/15 Page 3
Substantive eligibility criteria.
Provide a representation below regarding the terms of any eligibility conditions (other than any applicable
waiting period already reflected above) imposed before an individual is eligible to become covered under the
terms of the plan. If any of these eligibility conditions change, Employer is required to submit a new BPA to
reflect that new information.
Check all that apply:
❑ An Orientation Period that:
1)Does not exceed one month (calculated by adding one calendar month and subtracting one calendar day
from an employee's start date); and
2)lf used in conjunction with a waiting period the waiting period begins on the first day after the orientation
period.
❑ A Cumulative hours of service requirement that does not exceed 1200 hours
® An hours of service per period (or full-time status) requirement for which a Measurement period is used to
determine the status of variable-hour employees, where the measurement period:
1)Starts between the employee's date of hire and the first day of the following month;
2)Does not exceed 12 months; and
3)Taken together with other eligibility conditions does not result in coverage becoming effective later than
13 months from the employee's start date plus the number of days between a start date and the first day of
the next calendar month (if start day is not the first day of the month).
❑ Other substantive eligibility criteria not described above; please describe:
7. Special Enrollment: An Eligible Person may apply for coverage, Family coverage or add dependents within thirty
one (31) days of a Special Enrollment event if he/she did not apply prior to his/her Eligibility Date or when eligible to
do so. Such person's Coverage Date, Family Coverage Date, and/or dependent's Coverage Date will be the effective
date of the Special Enrollment event or, in the event of Special Enrollment due to termination of previous coverage,
the date of application for coverage. In the case of a Special Enrollment event due to loss of coverage under
Medicaid or a state children's health insurance program, however, this enrollment opportunity is not available unless
the Eligible Person requests enrollment within sixty(60) days after such coverage ends.
Open Enrollment: Specify Open Enrollment Period:The month of June for a July 1" effective date. An Eligible
Person may apply for coverage, Family coverage or add dependents if he/she did not apply prior to his/her Eligibility
Date or did not apply when eligible to do so, during the Employer's Open Enrollment Period. Such person's Coverage
Date, Family Coverage Date, and/or dependent's Coverage Date will be a date mutually agreed to by Blue Cross and
Blue Shield of Illinois, A Division of Health Care Service Corporation, A Mutual Legal Reserve Company ("HCSC")
and the Employer. Such date shall be subsequent to the open enrollment period.
8. Effective Date of Termination for a person who ceases to meet the definition of an Eligible Person:
® The date such person ceases to meet the definition of Eligible Person.
❑ The last day of the calendar month in which such person ceases to meet the definition of an Eligible Person.
❑ Other(please specify):
9. Extension of Benefits due to Temporary Layoff, Disability or Leave of Absence:
Temporary Layoff: 0 days; Disability: Police and Fire by IL Statute; Other 90 days; Leave of Absence: 0 days
❑ Other(please specify):
However, benefits shall be extended for the duration of an Eligible Person's leave in accordance with any applicable
federal or state law.
10. Funding Arrangement: ® Premium Prospective (complete section 12.) ❑ Cost Plus (complete section 15.)
IL-LG-151 PLUS-H-BPA Rev.05/15 Page 4
11. STANDARD PREMIUM INFORMATION:
The following elections apply to both Grandfathered and Non-Grandfathered Groups:
Premium Period:
® The first (1s) day of each calendar month through the last day of each calendar month. (This option applies to all
coverages if the Employer has BlueCare®Dental HMO Coverage.)
❑ The day of each calendar month through the day of the next calendar month. (This option is not
available for any coverage if the Employer has BlueCare Dental HMO Coverage.)
12. MINIMUM EMPLOYER CONTRIBUTION INFORMATION:
(a) The following elections apply to Grandfathered and Non-Grandfathered Groups:
Employer Contribution:
❑ One hundred percent(100%)of the Individual Coverage Premium and an amount equal to one hundred
percent(100%) of the Individual Coverage Premium will be contributed toward the Family Coverage Premium.
® 87.5% of the Individual Coverage Premium, and 87.5% of the Family Coverage Premium.
❑ Other(please specify):
(b) The following applies to Grandfathered and Non-Grandfathered Groups:
HCSC reserves the right to change premium rates when a substantial change occurs in the number or composition
of subscribers covered. A substantial change will be deemed to have occurred when the number of subscribers
covered changes by ten percent (10%) or more over a thirty (30) day period or twenty five percent (25%) or more
over a ninety(90)day period.
(c) The following applies to Non-Grandfathered Groups:
HCSC reserves the right to take any or all of the following actions: 1) initial rates will be finalized for the effective date
of the policy based on the employer contribution levels; 2) after the policy effective date the group will be required to
maintain a minimum Employer contribution of 25%. In the event the group is unable to maintain the contribution
requirements, then the rates will be adjusted accordingly; and/or 3) non-renew or discontinue coverage unless the
25% minimum employer contribution is met. Employer will promptly notify HCSC of any change in Employer
contribution.
(d) The following applies to Grandfathered Groups:
It is understood that no Policy will be issued or renewed on a contributory basis unless at least 25% of the Eligible
Persons, and for Family Coverage 75% of the Eligible Persons with eligible dependents, have enrolled for coverage.
13. Essential Health Benefits ("EHB") Definition Election:
Employer elects EHBs based on the following:
® a. EHBs based on a HCSC state benchmark:
® Illinois ("IL") ❑ Oklahoma ("OK")
❑ Montana ("MT) ❑ Texas ("TX")
❑ New Mexico ("NM")
❑ b. EHBs based on benchmark of a state other than IL, MT, NM, OK and TX
In the absence of an affirmative selection by Employer of its EHBs, then Employer is deemed to have elected the
EHBs based on the IL benchmark plan.
i IL-LG-151 PLUS-H-BPA Rev. 05/15 Page 5
does not apply)
P rem i u m Rates: (indicate "NIA in any rate field that 1. Employee only HMO Illinois$ BlueAdvantage HMO $538.67
2. Employee plus one dependent(i.e. Employee HMO Illinois$ BlueAdvantage HMO$1053.14
plus one spouse or one child)
3. Employee plus two or more dependents HMO Illinois$ BlueAdvantage HMO$1594.02
4. Employee plus Spouse HMO Illinois$ BlueAdvantage HMO $
5. Employee plus Child(ren) (i.e. Employee plus HMO Illinois$ BlueAdvantage HMO$
one or more children)
6. Family HMO Illinois$ BlueAdvantage HMO$
Single Tier rate structure—complete item 1.
Two Tier rate structure—complete items 1. and 6.
Three Tier rate structure—complete items 1., 2., and 3.
Four Tier rate structure—complete items 1., 4., 5., and 6.
- - - a
r
t =
'_�� r - '� , m _ -
Single Coverage HMO Illinois$ BlueAdvantage HMO $538.67
Family Coverage HMO Illinois$ BlueAdvantage HMO $1077.33
14. Cost Plus Program:
a) Service Charges for Claim Payments:
❑ HMO Illinois: %of Claim Payments; $ per Enrollee per month for health Claim
Payments.
❑ BlueAdvantage HMO: % of Claim Payments; $ per Enrollee per month for health Claim
Payments.
b) Physician's Services Fees:
❑ HMO Illinois: $ per month per single Enrollee; $ per month per Enrollee with one or more
Dependents.
❑ BlueAdvantage HMO: $ per month per single Enrollee; $ per month per Enrollee with one or
more Dependents.
c) ❑ HMO Managed Care Fee: $ per HMO enrollee per month.
d) ❑ Transfer Payment Method: i
❑Wire Transfer ❑ Draft ❑ Electronic Fund Transfer ❑ Other(please specify):
Tentative Final Settlement Period -Transfer payments required after termination for:
❑ 3 months ❑ 6 months ❑ 9 months ❑ 12 months ❑ Other(please specify):
e) ❑ Post Payment Method
IL-LG-151 PLUS-H-BPA Rev.05/15 Page 6
f) Payment Period:
❑ Daily ❑ Weekly ❑ Bi-Weekly ❑ Monthly ❑ Other(please specify):
g) Claim Settlement Period:
❑ Monthly ❑ Quarterly ❑ Other(please specify)
h) Prescription Drug Rebate:
$ per Enrollee per month is the guaranteed Prescription Drug Rebate savings reflected as a
Prescription Drug Rebate credit.
i) Termination Administrative Charge
As applies to the Run-Off Period indicated in the Payment Specifications section below:
i. For service charges(including, but not limited to, access fees) billed on a per Covered Employee basis at
the time of termination, the Termination Administrative Charge will be the amount equal to ten percent
(10%)of the annualized charges based on the service charges in effect as of the termination date and the
Policy participation of the two (2) months immediately preceding the termination date. Such aggregate
amount will be due the Plan within ten (10) days of the Plan's notification to the Policyholder of the
Termination Administrative Charge described herein.
ii. For service charges (including, but not limited to, access fees) billed on a basis other than per Covered
Employee at the time of termination, the Termination Administrative Charge will be such service charges
in effect at the time of termination to be applied and billed by the Plan, and paid by the Policyholder, in the
same manner as prior to termination.
Termination Administrative Charges assume the continuation of the Policy benefit program(s) and the
administrative services in effect prior to termination. Should such Policy benefit program(s) and/or administrative
services change, or in the event the average Policy enrollment during the three (3) months immediately preceding
termination varies by ten percent(10%) or more from the enrollment used to determine the service charges in
effect at the time of termination, the Plan reserves the right to adjust the rates for service charges (including, but
not limited to, access fees)to be used to compute the Termination Administrative Charge.
Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage.
The undersigned representative is authorized and responsible for purchasing insurance on behalf of the Employer, has
provided the information requested in this BPA and on behalf of the Employer offers to purchase the benefit program as
outlined in the proposal document submitted to the Employer by the Sales Representative. It is understood and agreed
that the actual terms and conditions of the benefit program are those contained in the Policy. This BPA is subject to
acceptance by HCSC. Upon acceptance, HCSC shall issue a Policy to the Employer and this BPA shall be incorporated
and made a part of the Policy. Upon acceptance of this BPA and issuance of the Policy, the Employer shall be referred to
as the Policyholder. In the event of any conflict between the proposal document and the Policy, the provisions of the
Policy shall prevail. No coverage will begin until receipt of the first premium by HCSC.
The undersigned representative acknowledges that any broker/producer is acting on behalf of the Employer for purposes
of purchasing the Employer's insurance, and that if HCSC accepts this BPA and issues a Policy to the Employer, HCSC
may pay the Employer's broker/producer a commission and/or other compensation in connection with the issuance of
such Policy. The undersigned representative further acknowledges that if the Employer desires additional information
regarding any commissions or other compensation paid to the broker/producer by HCSC in connection with the issuance
of a Policy, the Employer should contact its broker/producer.
The undersigned representative hereby acknowledges that the Employee Retirement Income Security Act of 1974, as
amended, ("ERISA"), establishes certain requirements for employee welfare benefit plans. As defined in Section 3 of
ERISA, the term "employee welfare benefit plan" includes any plan, fund or program which is established or maintained by
an employer or by an employee organization, or by both, to the extent that such plan, fund or program was established or
is maintained for the purpose of providing for its participants or their beneficiaries, through the purchase of insurance or
otherwise, medical, surgical or hospital benefits, or benefits in the event of sickness, accident or disability. The
undersigned representative further acknowledges that: (i) an employee welfare benefit plan must be established and
maintained through a separate plan document which may include the terms hereof or incorporate the terms hereof by
reference, and that (ii) an employee welfare benefit plan document may provide for the allocation and delegation of
responsibilities thereunder. However, notwithstanding anything contained in the employee welfare benefit plan document
of the Employer (or any group member if the group is an association), the Employer agrees that no allocation or
IL-LG-151 PLUS-H-BPA Rev. 05/15 Page 7
delegation of any fiduciary or non-fiduciary responsibilities under the employee welfare benefit plan of the Employer (or
any group member if the group is an-association) is effective with respect to or accepted by HCSC except to the extent
specifically provided and accepted in this BPA or the Policy or otherwise accepted in writing by HCSC.
Prescription Drug Rebate Credit per Covered Employee per month is the guaranteed Prescription Drug Rebate savings
reflected as a Prescription Drug Rebate credit. Expected rebate amounts to be received by HCSC are passed back to the
Employer with one hundred percent (100%) of the expected amount applied as a credit on the monthly billing statement
on a per Covered Employee per month basis. Rebate credits are paid prospectively to the Employer and shall not
continue after termination of the Prescription Drug Program. (Further information concerning this credit is included in the
governing Group Administrative Document to which this BPA is attached under the section titled "The Plan's Separate
Financial Arrangements Regarding Prescription Drugs.").
OTHER PROVISIONS:
1. Summary of Benefits and Coverage ("SBC"):
a) HCSC will create SBC?
® Yes. If Yes, please answer question (b). The SBC Addendum is attached and made a part of the Policy.
❑ No. If No, then the Policyholder acknowledges and agrees that the Policyholder is responsible for the creation
and distribution of the SBC as required by Section 2715 of the Public Health Service Act (42 USC 300gg-15) and
SBC regulations (45 CFR 147.200), as supplemented and amended from time to time, and that in no event will
HCSC have any responsibility or obligation with respect to the SBC. HCSC may, but is not required to, monitor
Policyholder's performance of its SBC obligations, audit the Policyholder with respect to the SBC, request and
receive information, documents and assurances from Policyholder with respect to the SBC, provide its own SBC
(or SBC corrections) to participants and beneficiaries, communicate with participants and beneficiaries regarding
the SBC, respond to SBC-related inquiries from participants and beneficiaries, and/or take steps to avoid or
correct potential violations of applicable laws or regulations. The Plan is not obligated to respond to or forward
misrouted calls, but may, at its option, provide participants and beneficiaries with Policyholder's contact
information. A new clause (e) is added to Subsection C. in the Additional Provisions as follows: "(e) the SBC".
(Skip question (b).)
b) HCSC will distribute SBC to participants and beneficiaries?
® No. The Plan will create SBC (only for benefits the Plan insures under the Policy) and provide SBC to the
Policyholder in electronic format. Policyholder will then distribute SBC to participants and beneficiaries (or hire a
third party to distribute) as required by law.
❑ Yes. The Plan will create SBC (only for benefits the Plan insures under the Policy) and distribute SBC to
participants and beneficiaries via regular hardcopy mail or electronically in response to occasional requests
received directly from individuals. All other distribution is the responsibility of the Policyholder.
2. BlueEdge FSA(Vendor: ConnectYourCare) purchased: ❑ Yes ® No
3. It is understood and agreed that in the event HCSC makes a recovery on a third-party liability claim, HCSC will retain
twenty five percent(25%) of any recovered amounts (under cost-plus funding) or deduct twenty five percent (25%) of
any recovered amounts from the amount credited to the group's experience (under premium funding), other than
recovery amounts received as a result of, or associated with, any Workers' Compensation Law.
4. Excess Loss Coverage purchased: ❑ Yes ® No
If yes: Complete separate Application for Excess Loss Coverage.
5. Blue Directions (Private Exchange) purchased: ❑ Yes ® No (if yes, The Blue Directions Addendum is attached
and made a part of the Policy.)
I
IL-LG-151PLUS-H-BPA Rev. 05/15 Page 8
ADDITIONAL PROVISIONS:
A. Grandfathered Health Plans: Policyholder shall provide HCSC with written notice prior to renewal (and during the
plan year, at least sixty (60) days advance written notice) of any changes in its Contribution Rate Based on Cost of
Coverage or Contribution Rate Based on a Formula towards the cost of any tier of coverage for any class of Similarly
Situated Individuals as such terms are described in applicable regulations. Any such changes (or failure to provide
timely notice thereof) can result in retroactive and/or prospective changes by HCSC to the terms and conditions of
coverage. In no event shall HCSC be responsible for any legal, tax or other ramifications related to any benefit
package of any group health insurance coverage (each hereafter a "plan") qualifying as a "grandfathered health plan"
under the Affordable Care Act and applicable regulations or any representation regarding any plan's past, present and
future grandfathered status. The grandfathered health plan form ("Form"), if any, shall be incorporated by reference
and part of the BPA and Group Policy, and Policyholder represents and warrants that such Form is true, complete and
accurate. If Policyholder fails to timely provide HCSC with any requested grandfathered health plan information,
HCSC may make retroactive and/or prospective changes to the terms and conditions of coverage, including changes
for compliance with state or federal laws or regulations or interpretations thereof.
B. Retiree Only Plans and/or Excepted Benefits: If the BPA includes any retiree only plans and/or excepted benefits,
then Policyholder represents and warrants that one or more such plans is not subject to some or all of the provisions
of Part A (Individual and Group Market Reforms) of Title XXVII of the Public Health Service Act (and/or related
provisions in the Internal Revenue Code and Employee Retirement Income Security Act) (an "exempt plan status").
Any determination that a plan does not have exempt plan status can result in retroactive and/or prospective changes
by HCSC to the terms and conditions of coverage. In no event shall HCSC be responsible for any legal, tax or other
ramifications related to any plan's exempt plan status or any representation regarding any plan's past, present and
future exempt plan status.
C. Policyholder shall indemnify and hold harmless HCSC and its directors, officers and employees against any and all
loss, liability, damages, fines, penalties, taxes, expenses (including attorneys' fees and costs) or other costs or
obligations resulting from or arising out of any claims, lawsuits, demands, governmental inquiries or actions,
settlements or judgments brought or asserted against HCSC in connection with (a) any plan's grandfathered health
plan status, (b) any plan's exempt plan status, (c) any directions, actions and interpretations of the Policyholder, (d)
any provision of inaccurate information, (e) the SBC, (f) any plan's design (including but not limited to any directions,
actions and interpretations of the Policyholder, and/or(g) Employer's selection of EHB definition for the purpose of the
Patient Protection and Affordable Care Act ("ACA"). Changes in state or federal law or regulations or interpretations
thereof may change the terms and conditions of coverage.
The provisions of paragraphs A-C (directly above) shall be in addition to(and do not take the place of)the other terms and
conditions of coverage and/or administrative services between the parties.
ACA FEE NOTICE: ACA established a number of taxes and fees that will affect our customers and their benefit plans.
Two of those fees are: (1) the Annual Fee on Health Insurers or "Health Insurer Fee"; and (2) the Transitional
Reinsurance Program Contribution Fee or"Reinsurance Fee".
Section 9010(a) of ACA requires that"covered entities" providing health insurance ("health insurers") pay an annual fee to
the federal government, commonly referred to as the Health Insurer Fee. The amount of this fee for a given calendar year
will be determined by the federal government and involves a formula based in part on a health insurer's net premiums
written with respect to health insurance on certain health risk during the preceding calendar year. This fee will go to help
fund premium tax credits and cost-sharing subsidies offered to certain individuals who purchase coverage on health
insurance exchanges.
In addition, ACA Section 1341 provides for the establishment of a temporary reinsurance program(s) (for a three (3) year
period (2014-2016)) which will be funded by Reinsurance Fees collected from health insurance issuers and self-funded
group health plans. Federal and state governments will provide information as to how these fees are calculated. Federal
regulations establish a flat, per member, per month fee. The temporary reinsurance programs funded by these
Reinsurance Fees will help stabilize premiums in the individual market.
Except for the Cost Plus Program, your premium, which already accounts for current applicable federal and state taxes,
includes the effects of the Health Insurer Fees and Reinsurance Fees. The Cost Plus HMO premium includes the Health
Insurer Fee. These rates may be adjusted on an annual basis for any incremental changes in Health Insurer Fees and
Reinsurance Fees.
IL-LG-151 PLUS-H-BPA Rev.05/15 Page 9
i
Notwithstanding anything in the Policy or Renewal(s) to the contrary, HCSC reserves the right to revise our charge for the
cost of coverage (premium or other amounts) at any time if any local, state or federal legislation, regulation, rule or
guidance (or amendment or clarification thereto) is enacted or becomes effective/implemented, which would require
HCSC to pay, submit or forward, on its own behalf or on the Policyholder's behalf, any additional tax, surcharge, fee, or
other amount(all of which may be estimated, allocated or pro-rated amounts).
Renewals Only: If this BPA is blank, it is intentional and this BPA is an addendum to the existing BPA. In such case, all
terms of the existing BPA as amended from time to time shall remain in force and effect. However, beginning with the
Policyholder's first renewal date on or after September 23, 2010, the provisions of paragraphs A-C (above) shall be part of
(and be in addition to)the terms of the existing BPA as amended from time to time.
Any reference in this BPA to eligible dependents may include Domestic Partners or Civil Union partners, but will include
dependent covered children under the Limiting Age of twenty-six(26), or election made above.
Any reference in this BPA to the Limiting Age for covered children means twenty-six (26) years, or election made above,
regardless of presence or absence of a child's financial dependency, residency, student status, employment, marital
status or any combination of those factors. If the covered child is eligible military personnel, the Limiting Age is thirty (30)
years as described in the certificate booklet.
Any reference in this BPA to the "Employee plus one dependent" rate structure means "Employee plus one spouse
(includes Civil Union partner and/or, if elected, Domestic Partner) or one child."
Any reference in this BPA to the"Employee plus Child(ren)" rate structure means"Employee plus one or more children."
Effective 07/01/2016 this account will be renewing with Generics Plus Drug List.
IL-LG-151PLUS-H-BPA Rev. 05/15 Page 10
Ruben Mendez
Sales Representative Signature of Authorized Purchaser
822 630 824 5197
District Phone No. Title
Producer Representative Date
Signature of Producer Representative Witness
Vista National Insurance
Producer Firm
1301 W. 22nd Street
Suite 600
Oak Brook, IL 60523
Producer Address $ Amount Submitted (not required for renewals)
36-4095485
Producer Tax ID No.
UNDERWRITING AUTHORIZATION
Date BPA approved by Underwriting:
INTERNAL
USE Printed Name and Signature of Underwriter
ONLY
IL-LG-151 PLUS-H-BPA Rev. 05/15 Page 11
PROXY
The undersigned hereby appoints the Board of Directors of Health Care Service Corporation, a Mutual Legal Reserve
Company, or any successor thereof("HCSC"), with full power of substitution, and such persons as the Board of Directors
may designate by resolution as the undersigned's proxy to act on behalf of the undersigned at all meetings of members of
HCSC (and at all meetings of members of any successor of HCSC) and any adjournments thereof, with full power to vote
on behalf of the undersigned on all matters that may come before any such meeting and any adjournment thereof. The
annual meeting of members shall be held each year in the corporate headquarters on the last Tuesday of October at
12:30 p.m. Special meetings of members may be called pursuant to notice mailed to the member not less than 30 nor
more than 60 days prior to such meetings. This proxy shall remain in effect until revoked in writing by the undersigned at
least 20 days prior to any meeting of members or by attending and voting in person at any annual or special meeting of
members.
Group No(s).: B19545 By:
Print Signer's Name Here
Group Name: Village of Oak Brook
Address: 1200 Oak Brook Road Signature and Title
City: Oak Brook State: IL Zip Code: 60523
Dated this: day of
Month Year
Cut along dotted lines
IL-LG-151 PLUS-H-BPA Rev.05/15 Page 12
BlueCross BlueShield
of Illinois
EXHIBIT TO THE
STOP LOSS COVERAGE POLICY
(ASO Accounts Only)
Employer Group Name: Village of Oak Brook
Employer Group Address: 1200 Oak Brook Road
City: Oak Brook State of Situs: IL Zip Code: 60523
Account Number: 019545
Employer Group Number(s): P19545 (Non-Union), P56642 (Police), P56643 (Fire), P19546 (H S
A)
Effective Date of Policy 07/01/2016
Policy Period: These specifications are for the Policy Period commencing on 07/01/2016 and ending on 06/30/2017
The specifications below shall become effective on the first day of the Policy Period specified above and shall continue in
full force and effect until the earliest of the following dates: (1)The last day of the Policy Period; (2) The date the Policy
terminates; or(3) The date this Exhibit is superseded in whole or in part by a later executed Exhibit.
A. Aggregate Stop Loss Insurance: ® Yes ❑ No
If yes, complete items 1. through 9. below.
1. ❑ New Coverage ® Renewal of Existing Coverage
2. Stop Loss Coverage Period:
❑ New Coverage (Select one from below):
❑ Standard: Claims incurred and paid during the Policy Period.
❑ Standard with "Run-in" included: Claims incurred on or after and paid during the Policy
Period.
"Run-in" includes claims paid by Policyholder's prior claim administrator: Yes ❑ No ❑
If yes, such claims must be reported by the Policyholder to the Company (Blue Cross and Blue
Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve
Company)within 12 months of the Effective Date of Policy and paid by the Policyholder's prior
claim administrator within 6 months after the Effective Date of Policy.
® Renewal of Existing Coverage:
Claims incurred on or after the original Effective Date of Policy and paid during the Policy Period.
3. Aggregate Stop Loss Insurance shall apply to:
® Medical Claims ❑ Vision Claims
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company
an Independent Licensee of the Blue Cross and Blue Shield Association
GA-10-4.1 HCSC Rev.4/07
Z Outpatient Prescription Drug Claims ❑ Dental Claims
❑ For Hospital Employer Groups only: Excludes %of Home Hospital Medical claims
❑ Other(please specify):
4. Average Claim Value: 1.127.30 (per employee per month)
® Includes Claim Administrator's Provider Access Fee
❑ Excludes Claim Administrator's Provider Access Fee
Attachment Factor: 125% of the Average Claim Value
5. Aggregate Attachment Claim Liability:
Employer's Claim Liability for each Policy Period shall be the sum of the Monthly amounts obtained by
multiplying the number of Individual and Family Coverage Units for each Month by the following factor:
$1,409.13for each Coverage Unit
6. Aggregate Stop Loss Coverage includes coverage of Run-Off Paid Claims: ® Yes ❑ No
Run-Off Attachment Claim Liability Factors:
Employer's Run-Off Claim Liability shall be an amount equal to 15% of the annualized Employer Claim Liability
based on the participation of the two calendar months immediately preceding termination. Settlement for the
final accounting period will be described in the section of the Policy entitled SETTLEMENTS.
7. Aggregate Stop Loss Coverage:
a. The amount of Paid Claims during the current Policy Period, less Individual (Specific) Stop Loss Claims, if
any, that exceed the Point of Attachment. The Point of Attachment shall equal the sum of the Employer's
Claim Liability amounts calculated Monthly as described in Item 5. above for the indicated Policy Period.
However, for the indicated Policy Period the minimum Point of Attachment shall be$2,343.664.90.
b. The following applies if the answer to item 6. above is"Yes-" (Aggregate Stop Loss Coverage includes
coverage of Run-Off Paid Claims):
In the event of termination at the end of a Policy Period, Aggregate Stop Loss Coverage shall equal the
amount of Final Settlement Paid Claims that exceed the Final Settlement Point of Attachment. Final
Settlement Paid Claims shall equal the sum of the Paid Claims during the Final Policy Period and the Paid
Claims during the Run-Off Period, less Individual (Specific) Stop Loss Claims, if any. The Final Settlement
Point of Attachment shall equal the sum of the Employer's Claim Liability amount for the Final Policy Period
and the Employer's Run-Off Claim Liability calculated as described in items 5. and 6. above. However, for
the Final Settlement Period the minimum Point of Attachment shall be the minimum Point of Attachment in
item 7.a. above increased by 15%.
8. Premium (Select one):
® Annual Premium (Due on the first day of the Policy Period): $20.416.
The following applies if the answer to item 6. above is Yes-' (Aggregate Stop Loss Coverage includes
coverage of Run-Off Paid Claims): In the event of termination at the end of a Policy Period, an additional
premium amount equal to 15% of the Annual Premium will be due within 10 calendar days of receipt of the
billing.
❑ Monthly Premium shall be equal to the amounts obtained by multiplying the number of Individual and Family
Coverage Units for a particular Month by:
$ for each Coverage Unit
The following applies if the answer to item 6. above is"Yes.." (Aggregate Stop Loss Coverage includes
coverage of Run-Off Paid Claims):
In the event of termination at the end of a Policy Period, an additional premium amount equal to 15% of the
annualized Premium based on the participation of the two months immediately preceding termination will be
due within 10 calendar days of receipt of the billing.
GA-10-4.1 HCSC Rev.4/07
9. The premium is based upon a current membership of 46 Individual Coverage Units and 108 Family Coverage
Units.
B. Individual (Specific) Stop Loss Insurance: ® Yes ❑ No
If yes, complete items 1. through 6. below.
1. ❑ New Coverage ® Renewal of Existing Coverage
2. Stop Loss Coverage Period:
❑ New Coverage (Select one from below):
❑ Standard: Claims incurred and paid during the Policy Period.
❑ Standard with "Run-in" included: Claims incurred on or after and paid during the Policy Period.
"Run-in" includes claims paid by Policyholder's prior claim administrator: Yes ❑ No ❑
If yes, such claims must be reported by the Policyholder to the Company(Blue Cross and Blue Shield of
Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company)within 12
months of the Effective Date of Policy and paid by the Policyholder's prior claim administrator within 6
months after the Effective Date of Policy.
® Renewal of Existing Coverage:
Claims incurred on or after the original Effective Date of Policy and paid during the Policy Period.
3. Individual (Specific) Stop Loss Insurance shall apply to:
® Medical Claims ❑Vision Claims
® Outpatient Prescription Drug Claims ❑ Dental Claims
❑ For Hospital Employer Groups only: Excludes % of Home Hospital Medical claims
❑ Other(please specify):
4. Individual (Specific) Stop Loss Coverage
a. Individual Stop Loss Coverage equals the amount of Paid Claims for a Covered Person during the
current Policy Period in excess of the Point of Attachment of$85.000 per Covered Person. Such
amount shall apply for the Policy Period.
Point of Attachment ® Includes Claim Administrator's Provider Access Fee
❑ Excludes Claim Administrator's Provider Access Fee
b. Employer's Claim Liability equals the sum of Paid Claims for a Covered Person during the Policy Period
up to the Point of Attachment specified in 4.a. above.
5. Individual Stop Loss Coverage includes coverage of Run-Off Paid Claims: ® Yes ❑ No
The following applies if the answer to item 5. above is"Yes" (Individual Stop Loss Coverage includes coverage of
Run-Off Paid Claims):
a. In the event of termination at the end of the Policy Period, Individual Stop Loss Coverage shall equal
the amount of Final Settlement Paid Claims that exceed the Point of Attachment specified in 4.a.
above. Final Settlement Paid Claims shall equal the sum of Paid Claims for a Covered Person during
the Final Policy Period and the Run-Off Period.
b. In the event of termination at the end of the Policy Period, Employer's Final Settlement Claim Liability
equals the sum of Paid Claims for a Covered Person during the Final Policy Period and Run-Off Period
up to the Point of Attachment specified in Item 4.a. above.
Settlement for the final accounting period will be described in the section of the Policy entitled
SETTLEMENTS.
GA-10-4.1 HCSC Rev.4/07
6. Premium (select one):
❑ Annual Premium (Due on the first day of the Policy Period): $
The following applies if the answer to item B.S. is"Yes" (Individual Stop Loss Coverage includes coverage of
Run-Off Paid Claims): In the event of termination at the end of a Policy Period, an additional premium
amount equal to 20%of the Annual Premium will due within 10 calendar days of receipt of the billing.
® Monthly Premium shall be equal to the amounts obtained by multiplying the number of Individual and Family
Coverage Units for a particular Month by:
$143.71 for each Coverage Unit
The following applies if the answer to item B.S. above is"Yes" (Individual Stop Loss Coverage includes
coverage of Run-Off Paid Claims): In the event of termination at the end of a Policy Period, an additional
premium amount equal to 20% of the annualized Premium based on the participation of the two months
immediately preceding termination will be due within 10 calendar days of receipt of the billing.
7. The premium is based upon a current membership of 46 Individual Coverage Units and 108 Family
Coverage Units.
Additional Provisions:
The undersigned person represents that he/she is authorized and responsible for purchasing stop loss coverage on behalf
of the Employer Group. It is understood that the actual terms and conditions of coverage are those contained in this
Exhibit and the Stop Loss Coverage Policy into which this Exhibit shall be incorporated at the time of acceptance by Blue
Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company
("HCSC"). Upon acceptance, HCSC shall issue a Stop Loss Coverage Policy to the Employer Group. Upon acceptance of
this Exhibit and issuance of the Stop Loss Coverage Policy, the Employer Group shall be referred to as the"Policyholder."
Robert Ebbole
Sales Representative Signature of Authorized Purchaser
Annette Norkus
Name of Underwriter Title of Authorized Purchaser
Date
INTERNAL USE ONLY Date Application approved by Underwriting:
Name of Underwriter:
f
f
GA-10-4.1 HCSC Rev.4/07
Chy)Group Enrollment Agreement
SUBMISSION TYPE: New Group ,Group Renewal , Change in Group Info
Group Name Effective Date #Members
Village of Oak Brook . M._. 7i1i2016 _,,.. iApproximately 154
Mailing Address _ City State Zip Code
W._ .�_ ,..�.._ _.. ., _.,.... .� ,
1200 Oak Brook Road Oak Brook IL 160523
GROUP ADMINS: You can perform administrative functions for your group online with up to 2 people designated as administrators.Administrators
have full access to add/change/terminate employees,view or modify non-medical member data and view invoice statuses.
First Name of Primary Administrator Last Name of Primary Administrator
Diana
.. R e ... .��.. i,M. ..... wski
Administrator E-mail Address Administrator Phone Number
dmacietewski @oak brook org X1630-368-5024
m�
First Name of Second Administrator Last Name of Second Administrator
KathyP Vonachen
Second Administrator's E-mail Address Second Administrator's Phone Number
.. .�w ,..
kvonachen @oak-brook.org '..630-368-5039�..
AUTHORIZED AGENT/TPA: t�By checking here you allow the Authorized Agent/TPA to perform Employee Administrative Functions including
adding/changing/terminating employees,updating/changing employee information,and/or requesting policy change/cancellations.
First Name of Authorized Agent/TPA Last Name of Authorized Agent/TPA
VistaNatlonal Insurance Group- Amber iMarusarz
Authorized Agent/TPA E-mail Address Authorized Agent/TPA Phone Number
marusarza @vistanational com 1 1630 468-6514
060 VIP
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Signature Date