R-1807 - 05/28/2019 - PURCHASING - Resolutions Supporting DocumentsOAK BR9蒻 場虎
ACENDA IT■MRegular Board ofTrtlstees Meeting
Of
May 28,2019
SUBJECT: Health, Third Party Administrator and Stop Loss Insurance, Dental,
Life/AD&D Insurance, Vision Insurance & Telemedicine
Agreements for 2019 - 2020 Plan Year
FROM: Kathy Vonachen, Human Resource Director/BUDGET SOURCE/BLIDGET IMPACT: Program 126-Employee Benefits
RECOMMENDED MOTION: I move to approve Resolution 2019-PL-IS-R-1807, a
Resolution Approving the Waiver of Competitive Bidding and Authorizing the Purchase of
Insurance Benefits for Employees and direct staffto execute Agreements after receiving
final attorney review with BlueCross BlueShield (BC/BS) of Illinois forGroup Health
Insurance Coverage, Third Party Administrator (TPA) Seruice, and Stop Loss
Insurance as well as Guardian for Dental, Dearborrr National for Life and EyeMed for
Vision in the Plan Year startingJuly l, 2019 through June 30,2020.
Backsround/[Iistorv:
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 affachment point or
ISL") of claims in a given plan year (July I 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%o of the annual aggregate affachment point of expected
claims. As of March, the Village health benefit program has approximately l3l
employees that include eligible dependents totaling 362 members. The Oak Brook
Park District is also on our plan paying the full premium cost for all eligible
individuals. The Village also offers a fully-insured HMO plan to all employees.
Renewal Information:
The PPO medical plan was marketed to four providers by our broker Vista National and
unfortunately two carriers declined to quote due to claims utilization. The other two carriers
ViLLAGL O「
BOARD OFttRUSttEES MEE丁lNG
SAMUELE.DEAN BOARD R00M
BUttLER GOVERNMENT CENttER
1200 0AK BR00K ROAD
OAK BR00K′ILLINOIS
630-368-5000
BOT AGENDA Page I
ITEM 12.B.1
were not competitive. Due to our enrollment on the PPO medical plan, BCIBS will not allow
us to carve out the Stop Loss because they require at least 250 enrolled employees. The HMO
medical plan was marketed to four carriers and, similar to last year, two declined to quote
due to their rates being uncompetitive. The other two carriers provided quotes, but were
uncompetitive as well.
Medical: BCBS's proposal for the PPO has a rate increase of +3.97o7o or approximately
$110,269 higher than our current plan year, although our premium equivalent contribution
rates are increasing by +5o/o. When reviewing the BCBS proposal, there are a few key areas
to highlight: (l) the estimated fixed costs were decreased by -2.36% or approximately $8,393
and (2) this year BC/BS is requesting an increase of +4.760/o or approximately $118,662 in
claim liability. We evaluated an altemative PPO plan design, an increase in the ISL as well as
a change of funding and determined the limited estimated savings did not justify a change.
For the HMO there will be an increase of +5% for the 2019 - 2020 policy year. As a reminder,
there are the Affordable Care Act (ACA) fees which were increased this year. The estimated
total cost for the PPO policies will be around $897.00 for this plan which is now only the
Patient-Centered Outcomes Research lnstitute Fee (PCORI). The last year for the Transitional
Reinsurance fee was 2016. 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 to 4%u The Village does pay that3-4o/o on the HMO within
the premiums along with the PCORI fee.
Dental: For the 2019 renewal, Delta initially proposed an increase of +5.33yu Based on
competitive marketing Delta revised the renewal to +2.83%o which equates to an estimated
annual increase of $5,507. Vista National provided a quote from Guardian Dental which offers
a decrease of 6 .06% or approxim ately a $ 1 1 ,798 savings. Guardian is offering an enhanced
dental plan which includes adult orthodontics and implant benefits.
Life/AD&D: The Village is in a rate guarantee with Dearborn National until July l,2O2O. Therefore,
there will be no additional costs associated with this benefit.
Vision: The Village is in a rate guarantee with EyeMed until July l, 2022. Therefore, there will be
no additional costs associated with this benefit plans.
Telemedicine: The Village implemented l-800MD Telemedicine in2017. The Village will
continue to promote education on this service.
The Village will continue to promote its wellness program allowing those who receive
insurance up to 2%o 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.
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.
BOT AGENDA PageZ
RESOLUTION 201 9-PL.IS-R.1 807
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, dental, and life insurance benefits
(collectively, "lnsurance Plans'); and
WHEREAS, the Village currently purchases health insurance coverage, third-party administrator
services, and stop loss insurance from Bluecross Blueshield of lllinois (collectively, ?C/8S P/ans'J; and
WHEREAS, the Village wishes to change providers and purchase dental insurance coverage
from Guardian Oenlal ("Guatdian Ptan'1: a d
WHEREAS, the Village currently purchases term life insurance coverage from Dearbom National
("Dearbom Plan\', and
WHEREAS, the lnsurance Plans are up for renewal; and
WHEREAS, instead of putting the purchase of the lnsurance Plans out to bid or request for
competitive proposals, the Village Board has once again retained Vista National lnsurance Group, lnc. to
market the lnsurance Plans to various insurance providers to obtain the most advantageous lnsurance
Plans for the Village; and
WHEREAS, because the Village retained Vista National lnsurance Group, lnc. to obtain quotes
from various insurance providers, and the Village Board believes that Vista National lnsurance Group,
lnc. has negotiated for the purchase of lnsurance Plans that are advantageous to the Village, Village staff
has recommended that the Village waive competitive bidding for the purchase of the lnsurance Plans; and
WHEREAS, Village staff has recommended the Village Board renew: (i) the BC/BS Plans so that
they continue through June 30, 2020; (ii) change providers to the Guardian Plan so that it continues
through June 30, 2020: (iii) and (iv) the Dearbom Plan so that it continues through June 30, 2020
(collectively, "Renewals'}; 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 lnsurance Plans, all subject to the appropriation of sufficient funds for the lnsurance
Plans in the future fiscal year;
NOW THEREFORE, BE IT RESOLVED BY THE PRESIDENT AND BOARO 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 Biddino Reouirements. The advertising and bidding
requirements for the purchase of the lnsurance Plans are hereby waived in accordance with Section 1-7-
4 of the Village Code.
Section 3: Authorization of lnsurance Plan. The purchase of the lnsurance Plans is hereby
authorized.
Section 4: Execution of Reouired Documentation. The President, Village Manager, and the
Village Clerk shall be, and are hereby, authorized to execute and attest, on behalf of the Village all
Resolution 20'l 9-PL-lS-R-'l 807
Approving the Purchase of
lnsurance Plans
Page 2 ol2
documents necessary to complete the purchase of the lnsurance Plans pursuant to Section 3 of this
Resolution, which documentation shall be in a final form approved by the Village Attorney.
@lionl: Effective Date. This Resolution shall be in full force and effect from and after its
passage by two{hirds of the Trustees and its approval in the manner provided by law.
APPROVEO THIS 28th day of May, 2019
Village President
PASSED THIS 28th day of May, 2019
Ayes:
Nays:
Absent:
ATTEST:
Charlotte K. Pruss
Village Clerk
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third party representatives, except
with written permission of Claim Administrator.
HCSC IL GEN ASO BPA (Rev. 06/18) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, 1
an Independent Licensee of the Blue Cross and Blue Shield Association
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
Employer Account Number (6-digits):
Group Number(s): P19545
(Non- Union) P19546 (H S A),
P56642 (Police), P56643 (Fire)
Section Number(s): 0100
(Village - Union), 0101 (Village
- Non Union), 0200 (Park
District), 0300 (Retirees), 0400
(Retirees over 65), 0500
(PSEBA), 0501 (PSEBA), 0600
(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
Is your ERISA Plan Year* a period of 12 months beginning on the Anniversary Date specified below? Yes
If not, please specify your ERISA Plan Year*: Beginning Date / / 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:
Select legal reason ; if applicable, specify other:
Is your Non-ERISA Plan Year* a period of 12 months beginning on the Anniversary Date specified below? Yes
If not, please specify your Non-ERISA Plan Year*: Beginning Date 07 /01/2019 End Date 07/01/2020 (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) / /
Anniversary Date: (Month/Day/Year) / /
Account Information NO CHANGES SEE ADDITIONAL PROVISIONS
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: Kathy Vonachen Title: Human Resource Manager
Email Address: kvonachen@oak-brook.org Phone Number: 630-368-
5036
Fax Number: 630-368-
5037
Wholly Owned Subsidiaries:
Affiliated Companies:
(If Subsidiaries or Affiliated Companies listed above are to be covered, Employer hereby confirms that Employer and the listed Subsidiaries and/or
Affiliates are treated as a single employer under Internal Revenue Code Section 414(b), (c) or (m).)
Blue Access for Employers (BAE) Contact: Kathy Vonachen
(The BAE Contact is the Employee authorized by the Employer to access and maintain the Employer’s account in BAE.)
Email Address: kvonachen@oak-brook.org Phone Number: 630-368-
5036 Fax Number: 630-368-5037
The Employer or other company listed in this BPA is a public entity or governmental agency/contractor
Schedule of Eligibility NO CHANGES SEE ADDITIONAL PROVISIONS
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third party representatives, except
with written permission of Claim Administrator.
HCSC IL GEN ASO BPA (Rev. 06/18) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, 2
an Independent Licensee of the Blue Cross and Blue Shield Association
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)
A part-time employee of the Employer.
A retiree of the Employer. Define criteria:
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:
Part-Time Employee means:
A person who is regularly scheduled to work a minimum of 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:
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third party representatives, except
with written permission of Claim Administrator.
HCSC IL GEN ASO BPA (Rev. 06/18) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, 3
an Independent Licensee of the Blue Cross and Blue Shield Association
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
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: 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. Other:
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.
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 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
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third party representatives, except
with written permission of Claim Administrator.
HCSC IL GEN ASO BPA (Rev. 06/18) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, 4
an Independent Licensee of the Blue Cross and Blue Shield Association
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.
Lines of Business (Check all applicable
services) NO CHANGES See Additional Comments
Medical Plan Services:
Participating Provider Option (PPO)
Blue Choice Select PPO
Blue Choice Options
Blue Distinction® Flexible Network
Additional Services:
Blue Care Connection®
Wellbeing Management
Wellness Incentives
Health Advocacy Solutions
Well onTarget®
Blue Directions (Private Exchange) (If selected,
the Blue Directions Addendum is attached and made
a part of the Agreement.)
Limited Fiduciary Services for Claims and Appeals
Other Select Product
Other Select Product
Other Select Product
Other Select Product
Other
Other
Consumer Driven Health Plan:
Health Care Account (HCA) Administrative
Services (if purchased, complete separate HCA BPA)
BlueEdge℠ FSA (Vendor: Select Vendor )
HSA Eligible Health Plan (Vendor: Other)
Prescription Drugs:
Covered under a pharmacy benefit (If selected, the
PBM Fee Schedule Addendum must be attached and
is part of this BPA.)
Covered under the medical benefit or Blue Script
Pharmacy Network (Select one):
Traditional Select Network
Advantage Network
Preferred Network (Not offered with Blue
Script)
Elite Network (Not offered with Blue Script)
Network on PBM Fee Schedule Addendum
PPO Drug List: Basic Drug List
Other (please specify): Enhanced
Prescription Drug Program Clinical Programs
MTM (Retrospective) (Included with HAS)
Ancillary Services:
Dental Plan Services
Vision Plan Services
Stop Loss (if selected, complete separate Exhibit
to the Stop Loss Coverage Policy)
Dearborn National Life Insurance (if selected,
complete separate Life application)
COBRA Administrative Services (if selected,
complete separate COBRA Administrative Services
Addendum to the BPA)
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third party representatives, except
with written permission of Claim Administrator.
HCSC IL GEN ASO BPA (Rev. 06/18) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, 5
an Independent Licensee of the Blue Cross and Blue Shield Association
FEE SCHEDULE
Payment Specifications NO CHANGES SEE ADDITIONALPROVISIONS
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
Claim Settlement Period: Monthly
Run-Off Period: Employer Payments are to be made for 12 months following end of Fee Schedule Period.
Standard is twelve (12) months.
Fee Schedule Period: To begin on Effective Date of Coverage and continue for 12 months. If other than 12
months, please specify: 60 Months
Administrative Per Employee Per Month
(PEPM) Charges
NO CHANGES SEE ADDITIONAL PROVISIONS
All Group
Numbers
Administrative Fee $64.96 $ $ $
Dental $ $ $ $
Limited Fiduciary Services $ $ $ $
Health Advocacy Solutions $ $ $ $
Wellbeing Management $ $ $ $
Management of the Virtual Visits Program $ $ $ $
*Rebate Credit for the Prescription Drug Program $46.65 $ $ $
MTM (Retrospective) (No cost if both HAS and
Prescription Drug Program are elected) $ $ $ $ ]
Commissions $ $ $ $
Other: Select Service Category
List Service: $ $ $ $
Other: Select Service Category
List Service: $ $ $ $
Other: Select Service Category
List Service: $ $ $ $
Other: Select Service Category
List Service: $ $ $ $
Miscellaneous: $ $ $ $
Miscellaneous: $ $ $ $
Total $18.31 $ $ $
*The Rebate Credit is a per Covered Employee per month credit applied to the monthly billing statement. The Employer and
Claim Administrator have agreed to the Rebate Credit and Employer agrees that it and its group health plan have no right
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third party representatives, except
with written permission of Claim Administrator.
HCSC IL GEN ASO BPA (Rev. 06/18) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, 6
an Independent Licensee of the Blue Cross and Blue Shield Association
to, or legal interest in, any portion of the rebates, either under the pharmacy benefit or the medical benefit, actually provided
by the Pharmacy Benefit Manager (PBM) to Claim Administrator and consents to Claim Administrator’s retention of all such
rebates. The Rebate Credit will be provided from Claim Administrator’s own assets and may or may not equal the entire
amount of rebates actually provided to Claim Administrator by the PBM or expected to be provided. Rebate Credits shall
not continue after termination of the Prescription Drug Program. Employer agrees that any provision in the governing
Administrative Services Agreement to the contrary is hereby superseded.
Administrative Line Item Charges Frequency Amount
Other: Select Service Category
List Service:
Select Billing Frequency
If applicable, describe other:
$
Other: Select Service Category
List Service:
Select Billing Frequency
If applicable, describe other:
$
Other: Select Service Category
List Service:
Select Billing Frequency
If applicable, describe other:
$
Other: Select Service Category
List Service:
Select Billing Frequency
If applicable, describe other:
$
Miscellaneous: Select Billing Frequency
If applicable, describe other:
$
Miscellaneous: Select Billing Frequency
If applicable, describe other:
$
Total: $
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 services (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.
Other Service and/or Program Fee(s) NO CHANGES SEE ADDITIONAL PROVISIONS
External Review Coordination: Yes No If yes, coordination fee: $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.
Employer elects the following process: 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.
Claim Administrator’s Third Party Recovery Vendors and Law Firms (other than Reimbursement Services):
Employer will pay no more than 25% of any recovered amount made by Claim Administrator’s Third Party Recovery
Vendor. Employer will pay no more than 35% of any recovered amount made by Claim Administrator’s third party law
firm.
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third party representatives, except
with written permission of Claim Administrator.
HCSC IL GEN ASO BPA (Rev. 06/18) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, 7
an Independent Licensee of the Blue Cross and Blue Shield Association
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.
Virtual Visits Program: Yes No If yes, Covered Persons would be able to obtain certain Covered
Services remotely via video or audio only (where available) capability from Providers participating in the Virtual Visit
program.
Termination Administrative Charge
As applies to the Run-Off Period indicated in the Payment Specifications section above:
i. For service charges (including, but not limited to, access fees) billed on a per Covered Employee basis at the
time of termination of the Agreement or partial termination of Covered Employees, 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 or date of partial termination and the Plan participation of the two (2)
months immediately preceding the termination date or date of partial termination. 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 of the Agreement or partial termination of Covered Employees, the
Termination Administrative Charge will be such service charges in effect at the time of termination of the Agreement
or partial termination of Covered Employees to be applied and billed by the Claim Administrator, and paid by the
Employer, in the same manner as prior to termination of the Agreement or partial termination of Covered Employees.
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 skip question b and refer to the Administrative Services Agreement for further information.
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. Massachusetts Health Care Reform Act:
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? Yes No
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.
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third party representatives, except
with written permission of Claim Administrator.
HCSC IL GEN ASO BPA (Rev. 06/18) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, 8
an Independent Licensee of the Blue Cross and Blue Shield Association
3. Case Management Program: Yes No The undersigned representative authorizes provision of alternative
benefits for services rendered to Covered Persons for Utilization Management, Case Management, and other health
care management programs.
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
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 BPA is binding on both parties and 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.
7. 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: The PPO UNION Police P56642 will duplicate the PPO UNION FIRE P56643 plan effective
7/1/2019 BCBSIL will provide a one-time wellness credit of $24,000 for the twelve-month period beginning on the
Contract Effective Date, to be used to cover costs and expenses associated with implementation and/or operation of a
wellness program. If Employer cancels coverage before expiration of the policy period, Employer will be required to refund
BCBSIL the full amount of the wellness credit.
Signature
Ruben Mendez
Sales Representative Signature of Authorized Purchaser
822 630-824-5197
District Phone & FAX Numbers Print Name
Producer Representative Title
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third party representatives, except
with written permission of Claim Administrator.
HCSC IL GEN ASO BPA (Rev. 06/18) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, 9
an Independent Licensee of the Blue Cross and Blue Shield Association
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 is scheduled to 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 provided 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 directors, officers, employees or agents consistent
with HCSC’s bylaws then in force and as otherwise required by applicable law.
Group Name: Village of Oak Brook
Address:
1200 Oak Brook Road
City:
Oak Brook
State:
IL
ZIP:
60523
Dated this day of
Month Year
VistaNational Insurance
Producer Firm Date
1301 West 22nd Street Suite 600
Oak Brook, IL 60523
Producer Address
Producer Phone & FAX Numbers
Producer Email Address
36-4095485
Tax I.D. No.
Group No.:
P19545
(Non- Union)
P19546 (H S
A), P56642
(Police),
P56643 (Fire)
By:
Print Signer's Name Here
Signature and Title
Proprietary and Confidential Information of Blue Cross and Blue Shield of Illinois. Not for use or disclosure outside Blue Cross and Blue Shield of Illinois,
Employer, their respective affiliated companies and third party representatives, except with written permission of Blue Cross and Blue Shield of Illinois.
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-151PLUS-H-BPA Rev. 06/18 Page 1
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):
BlueAdvantage® 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’ Legal 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.)
Physical 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 to be Covered:
Affiliated Companies to be Covered:
(Affiliated Companies must be required or permitted to be aggregated per IRS guidelines. Employer hereby confirms that
Employer, Subsidiaries and Affiliates are treated as a single employer under Internal Revenue Code Section 414(b), or
(c), or(m),or (o), or under applicable law.)
Administrative Contact: Kathy
Vonachen
Phone: 630-368-5036 Fax: 630-368-5037 Email: kvonachen@oak-
brook.org
Blue Access for Employers (“BAE”) Contact: Kathy Vonachen
(The BAE Contact is the employee of the account authorized by the Employer to access and maintain its account via
BAE.)
Title: Human Resource Manager Phone: 630-368-5036 Fax: 630-368-5037 Email: kvonachen@oak-
brook.org
Policy Effective Date: 07/01/2019 Policy Anniversary Date: 07 / 01 / 2020
Month Day Year
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
IL-LG-151PLUS-H-BPA Rev. 06.18 Page 2
If Yes, specify ERISA Plan Year*: Beginning Date: / / End Date: / / (month/day/year)
ERISA Plan Sponsor*:
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 /2019
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 Full-Time Employee who is 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.
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 Employer may elect to offer continuation coverage to Domestic Partners 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.
IL-LG-151PLUS-H-BPA Rev. 06.18 Page 3
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 unm arried 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 220 Illinois employees 220 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.
If a person is added to the Policy and it is later determined that the Policyholder reported a Coverage Date earlier than
what would apply, based on the Waiting Period and eligibility conditions the Policyholder provided to the Plan, the
Plan reserves the right to retroactively adjust the Coverage Date for such person.
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 (1st) 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.
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) If used in conjunction with a waiting period the waiting period begins on the first day after the orientation
period.
IL-LG-151PLUS-H-BPA Rev. 06.18 Page 4
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 1st 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.)
11. STANDARD PREMIUM INFORMATION:
The following elections apply to both Grandfathered and Non-Grandfathered Groups:
Premium Period:
The first (1st) 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): .
IL-LG-151PLUS-H-BPA Rev. 06.18 Page 5
(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.
Premium Rates: (Indicate “N/A” in any rate field that does not apply)
Health Coverage
1. Employee only HMO Illinois $ BlueAdvantage HMO $522.05
2. Employee plus one dependent (i.e. Employee
plus one spouse or one child) HMO Illinois $ BlueAdvantage HMO $1020.65
3. Employee plus two or more dependents HMO Illinois $ BlueAdvantage HMO $1544.84
4. Employee plus Spouse HMO Illinois $ BlueAdvantage HMO $
5. Employee plus Child(ren) (i.e. Employee plus
one or more children) HMO Illinois $ BlueAdvantage HMO $
6. Family HMO Illinois $ BlueAdvantage HMO $
Single Tier rate structure – complete item 1.
Two Tier rate structure – complete items 1. and 6.
IL-LG-151PLUS-H-BPA Rev. 06.18 Page 6
Three Tier rate structure – complete items 1., 2., and 3.
Four Tier rate structure – complete items 1., 4., 5., and 6.
Medicare Eligible Rates (When HCSC is Secondary Payer)
Single Coverage HMO Illinois $ BlueAdvantage HMO $522.05
Family Coverage HMO Illinois $ BlueAdvantage HMO $1044.10
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:
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
f) Payment Period:
Daily Weekly Bi-Weekly Monthly Other (please specify):
g) Claim Settlement Period:
Monthly Quarterly Other (please specify)
h) Excess Loss – Run Off Period: Months
Standard is twelve (12) months.
i) Final Settlement: Final Settlement is to be made within days after end of Excess Loss Run-Off Period.
Standard is sixty (60) days.
j) Employer Payments are to be made past the run-off period for all claims and adjustments.
k) Prescription Drug Program:
Yes (the Pharmacy Benefit Manager(s) (“PBM”) Fee Schedule Exhibit must be attached and is part of this
BPA.)
IL-LG-151PLUS-H-BPA Rev. 06.18 Page 7
No
Rebate Credit for Drugs covered under the Pharmacy Benefit:
$ per Covered Employee per month
HMO Pharmacy Network (Select one):
Traditional Select Network
Network shown on PBM Fee Schedule Exhibit
Other (please specify):
Prescription Drug Program Clinical Management Programs
Medication Therapy Management (MTM) (Retrospective) $ per Enrollee per month.
l) 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 of the Policy or partial termination of Covered Employees, 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 or date of partial termination and the Policy
participation of the two (2) months immediately preceding the termination date or date of partial
termination. 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 of the Policy or partial termination of Covered Employees, the
Termination Administrative Charge will be such service charges in effect at the time of termination of the
Policy or partial termination of Covered Employees to be applied and billed by the Plan, and paid by the
Policyholder, in the same manner as prior to termination of the Policy or partial termination of Covered
Employees.
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.
15. Electronic Issuance: The Employer consents to receive, via an electronic file or access to an electronic file, a
Certificate Booklet and SBC provided by BCBSIL to the Employer for delivery to each Employee. The Employer
further agrees that it is solely responsible for providing each Employee access, to the most current version of any E-
file Certificate Booklet, SBC, amendment, or other revised form provided by BCBSIL, or to provide a paper copy of the
same to an Employee upon request. The Employer is solely responsible and hold BCBSIL harmless from any misuse
of the E-file provided by BCBSIL. HMO members will continue to receive paper copies of their HMO certificates. By
providing your consent, you agree to the electronic delivery of your insurance documents. You can go back to paper
delivery at any time with no penalty. Your consent will be valid until it is withdrawn up to and including through policy
renewals. To change your preferences, contact your Account Executive. Your documents can be viewed or printed
using your computer or mobile device that supports most versions of Internet Explorer, Chrome and Firefox.
Accept – Employer consents to receive electronic versions of Certificate Booklets and SBC’s for covered
Employees. Employer may withdraw this consent at any time and request receipt of hard copy versions by contacting
their BCBSIL Account Executive.
Decline – Employer does not consent to receive electronic versions of Certificate Booklets and SBC’s for covered
Employees or the Contract and desires BCBSIL to print and distribute hard copy versions.
Authorized Company Official’s Initials: Date:
IL-LG-151PLUS-H-BPA Rev. 06.18 Page 8
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
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.
The Rebate Credit is a per Enrollee per month credit applied to the monthly billing statement. Rebate Credits shall not
continue after termination of the Prescription Drug Program, except as otherwise set forth in this BPA or the PBM Fee
Schedule Exhibit. (Further information about rebates, the Pharmacy Benefit Manager and the Rebate Credit is included in
the governing Group Administration 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”):
The SBC Addendum is attached and made a part of the Policy. BCBSIL will create SBC (only for benefits BCBSIL
insures under the Contract) and provide SBC to the Employer in electronic format. If the Employer approves of the
content, Employer will then distribute SBC to participants and beneficiaries (or hire a third party to distribute) as
required by law. If the Employer would like changes to the SBC, it will promptly notify BCBSIL. 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: Select Vendor) 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.
IL-LG-151PLUS-H-BPA Rev. 06.18 Page 9
5. Blue Directions for Large Business purchased: Yes No (if yes, The Blue Directions Addendum is attached
and made a part of the Policy.)
6. Wellbeing Management: Yes No
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.
One of those fees is: the Annual Fee on Health Insurers or “Health Insurer 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 currently 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 and/or other applicable laws may provide for the establishment of a temporary reinsurance
program(s) that may be funded by reinsurance contributions or other amounts (collectively, the “Reinsurance Fees or
Amounts”) collected from health insurance issuers and/or self-funded group health plans. Federal and/or state
governments may provide information as to how these Reinsurance Fees or Amounts are calculated. Federal regulations
establish a flat, per member, per month fee. The temporary reinsurance programs funded by these Reinsurance Fees or
Amounts may be designed help stabilize premiums in the individual or other markets.
IL-LG-151PLUS-H-BPA Rev. 06.18 Page 10
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 or Amounts, if any. These rates may be adjusted on
an annual basis for any incremental changes in Health Insurer Fees and Reinsurance Fees or Amounts, if any.
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.”
Ruben Mendez
Sales Representative Signature of Authorized Purchaser
822 630-824-5197
District Phone No. Title
Producer Representative Date
Signature of Producer Representative Witness
VistaNational Insurance
Producer Firm
1301 W. 22nd Street
Suite 600
Oak Brook, IL 60523
Producer Address
36-4095485
Producer Numer
$ Amount Submitted (not required for renewals)
IL-LG-151PLUS-H-BPA Rev. 06.18 Page 11
Producer Tax ID No.
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 is scheduled to 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 provided 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.
HCSC pays indemnification or advances expenses to directors, officers, employees or agents consistent with HCSC’s bylaws then in
force and as otherwise required by applicable law.
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: Zip Code:
Dated this: day of ,
Month Year
Cut along dotted lines
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 CARVE OUT APP Rev. 06/17
BlueCross BlueShield
of Illinois
EXHIBIT TO THE
STOP LOSS COVERAGE POLICY
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)
Current Effective Date of Policy 07/01/2019
Current Policy Period:
These specifications are for the Policy Period commencing on 07/01/2019 and ending on 07/01/2020
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 Coverage: Yes No
If yes, complete items 1. through 9. below.
1. New Coverage Renewal of Existing Coverage
2. Stop Loss Coverage during the current Policy Period:
New Coverage (Select one from below):
Incurred and paid during the
Policy Period:
Run-in coverage:
Claims incurred and paid from to
Claims incurred from to
and Claims paid from to
If coverage is for claims incurred prior to the effective date of the Policy and paid by
Policyholder’s prior claim administrator, then 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) and paid by the Policyholder’s prior claim
administrator by the end of the current Policy Period.
Renewal of Existing Coverage:
Claim Administrator’s Claims: Claims incurred on or after the original Effective Date of Policy and paid
during the Policy Period.
3. Aggregate Stop Loss Coverage shall apply to:
Medical Claims Vision Claims
Outpatient Prescription Drug Claims with Company’s Pharmacy Benefit Manager Dental Claims
GA-10-4.1 HCSC CARVE OUT APP Rev. 06/17
2
Outpatient Prescription Drug Claims with Policyholder’s Pharmacy Benefit Manager:
For Hospital Employer Groups only: Excludes % of Home Hospital Medical claims
Other (please specify):
4. Average Claim Value: $1380.44 (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:
a. 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:
$ for each Coverage Unit
$ for each Family 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 (2) 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 Claims:
a. The amount of Paid Claims during the current Policy Period, less Individual (Specific) Stop Loss Claims if
any, that exceeds the Aggregate Point of Attachment. The Aggregate Point of Attachment shall equal the
sum of the Employer’s Claim Liability amounts calculated Monthly as described in item A.5. above for the
current Policy Period. However, for the current Policy Period the minimum Aggregate Point of Attachment
shall be $2,197,172.70.
b. The following applies if the answer to item A.6. above is “Yes” (Aggregate Stop Loss Coverage includes
coverage of Run-Off Paid Claims):
In the event of termination at the end of the current Policy Period, Aggregate Stop Loss Coverage shall
equal the amount of Final Settlement Paid Claims that exceed the Final Settlement Aggregate 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 A.5. and
A.6. above. However, for the Final Settlement Period the minimum Aggregate Point of Attachment shall be
the minimum Aggregate Point of Attachment in item A.7.a. above increased by 15%.
c. The amount of “Run-in” Claims that is excluded from Individual (Specific) Stop Loss Coverage in item B.2.
is also not eligible for Aggregate Stop Loss coverage.
8. Stop Loss Premium (Select one):
Annual Premium (Due on the first day of the current Policy Period): $23,219.
The following applies if the answer to item A.6. above is “Yes” (Aggregate Stop Loss Coverage includes
coverage of Run-Off Paid Claims): In the event of termination at the end of the current Policy Period, an
additional premium amount equal to 15% of the Annual Premium will be due within ten (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
GA-10-4.1 HCSC CARVE OUT APP Rev. 06/17
3
$ for each Family Coverage Unit
The following applies if the answer to item A.6. above is “Yes” (Aggregate Stop Loss Coverage includes
coverage of Run-Off Paid Claims):
In the event of termination at the end of the current Policy Period, an additional Premium amount equal to
15% of the annualized Premium based on the participation of the two (2) months immediately preceding
termination will be due within ten (10) calendar days of receipt of the billing.
9. The premium is based upon a current membership of 30 Individual Coverage Units and 101 Family Coverage
Units.
B. Individual (Specific) Stop Loss Coverage: Yes No
If yes, complete items 1. through 6. below.
1. New Coverage Renewal of Existing Coverage
2. Stop Loss Coverage during the current Policy Period:
New Coverage (Select one from below):
Incurred and paid
during the Policy
Period:
Claims incurred and paid from to
Run-in coverage:
Claims incurred from to
and Claims paid from to
If coverage is for claims incurred prior to the effective date of the Policy and paid by Policyholder’s prior
claim administrator, then 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) paid by the Policyholder’s prior claim administrator by the end of the current Policy Period.
Renewal of Existing Coverage:
Claim Administrator’s Claims: Claims incurred on or after the original Effective Date of Policy and paid
during the Policy Period.
3. Individual (Specific) Stop Loss Coverage shall apply to:
Medical Claims Vision Claims
Outpatient Prescription Drug Claims with Company’s Pharmacy Benefit Manager Dental Claims
Outpatient Prescription Drug Claims with Policyholder’s Pharmacy Benefit Manager:
For Hospital Employer Groups only: Excludes % of Home Hospital Medical claims
Other (please specify):
4. Individual (Specific) Stop Loss Claims
For each other Covered Person:
a. Individual (Specific) Stop Loss Coverage equals the amount of Paid Claims for a Covered Person
during the current Policy Period in excess of the Individual Point of Attachment of $85,000 per Covered
Person. Such amount shall apply for the current Policy Period.
Point of Attachment Includes Claim Administrator’s Provider Access Fee
Excludes Claim Administrator’s Provider Access Fee
GA-10-4.1 HCSC CARVE OUT APP Rev. 06/17
4
b. Employer’s Claim Liability equals the sum of Paid Claims for a Covered Person during the current Policy
Period up to the Point of Attachment specified in item B.4.a. above.
5. Individual (Specific) Stop Loss Coverage includes coverage of Run-Off Paid Claims: Yes No
The following applies if the answer to item B.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 current Policy Period, Individual (Specific) Stop Loss
Coverage shall equal the amount of Final Settlement Paid Claims that exceed the Point of Attachment
specified in B.4. 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 (beginning on and ending on
.
b. In the event of termination at the end of the current 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 B.4.a. above.
Settlement for the final accounting period will be described in the section of the Policy entitled
SETTLEMENTS.
6. Stop Loss Premium (select one):
Annual Premium (Due on the first day of the current Policy Period): $ .
The following applies if the answer to item B.5. is “Yes” (Individual (Specific) Stop Loss Coverage includes
coverage of Run-Off Paid Claims): In the event of termination at the end of the current Policy Period, an
additional premium amount equal to 20% of the Annual Premium will due within ten (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:
$ 212.09 for each Coverage Unit
$ for each Family Coverage Unit
The following applies if the answer to item B.5. above is “Yes” (Individual (Specific) Stop Loss Coverage
includes coverage of Run-Off Paid Claims): In the event of termination at the end of the current Policy
Period, an additional premium amount equal to 20% of the annualized Premium based on the participation of
the two (2) months immediately preceding termination will be due within ten (10) calendar days of receipt of
the billing.
7. The premium is based upon a current membership of 35 Individual Coverage Units and 99 Family Coverage Units.
Additional Provisions:
Retirees Covered: Yes No
The undersigned person represents that he/she is authorized and responsible for purchasing stop loss coverage on behalf
of the Employer. 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. Upon acceptance of this Exhibit and
issuance of the Stop Loss Coverage Policy, the Employer shall be referred to as the "Policyholder."
Ruben Mendez
GA-10-4.1 HCSC CARVE OUT APP Rev. 06/17
5
Sales Representative Signature of Authorized Purchaser
Brian Buzecky
Name of Underwriter Title of Authorized Purchaser
Signature of Underwriter Date
INTERNAL USE ONLY Date Application approved by Underwriting:
Name of Underwriter: