2004-032 Accepts EMI Proposal for TPA•
RESOLUTION 32-2004
A RESOLUTION OF THE VILLAGE COUNCIL OF THE VILLAGE OF NORTH PALM
BEACH, FLORIDA, ACCEPTING THE PROPOSAL OF EMPLOYERS MUTUAL, INC.,
(EMI) TO PROVIDE THE VILLAGE WITH THIRD-PARTY ADMINISTRATIVE SERVICES
FOR THE VILLAGE'S SELF-FUNDED MEDICAL, DENTAL AND FSA PLANS
ESTABLISHED FOR VILLAGE EMPLOYEES, WHICH PROPOSAL IS ATTACHED TO
THIS RESOLUTION AND MADE PART HEREOF; AND, PROVIDING FOR AN
EFFECTIVE DATE.
BE IT RESOLVED BY THE VILLAGE COUNCIL OF NORTH PALM BEACH, FLORIDA:
Section 1. The Village Council of the Village of North Palm Beach, Florida, does hereby
accept the proposal of Employers Mutual, Inc., (EMI) to provide the Village with third-party
administrative services for the Village's self-funded medical, dental and FSA plans established
for Village employees, which proposal is attached to this resolution and made part hereof.
Section 2. This resolution shall take effect immediately upon its adoption.
PASSED AND ADOPTED THIS 13th DAY OF MAY, 2004.
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ATTEST:
VILLAGE CLERK
•
•
Employers Mutual, Inc.
March 23, 2004
Village of North Palm Beach
Attn: Shaukat Khan
501 US Highway One
North Palm Beach, FL 33408
RE: RFP for TPA Services
Dear Mr. Khan:
We appreciate the opportunity to propose the continuation of our administrative services for the
Village of North Palm Beach Self-Funded Health Plan as outlined in the enclosed proposal. We
have addressed each component including network access, utilization management, re-insurance,
prescription benefit services and other support services necessary for ongoing administration in
the EMI processing system.
For network access EMI proposes the continued use of Dimension Health in coordination with
EMI's proprietary network as one fully integrated preferred provider network. Out of area
coverage will be accessed through Beechstreet a national provider network. All administrative
services including utilization management and FSA administration will be provided in-house on
EMI's claims processing system from our local office based in Stuart, Florida. EMI has included
a complete market analysis for medical stop loss options as outlined in section four (4). Pacific
Life provided the most favorable overall pricing considering both premium rates and aggregate
claim factors.
With over 40 self-funded clients for both group health and workers compensation, EMI has
extensive experience providing administrative services to local government entities such as
municipalities, county governments, school districts and fire districts.
In addition to our expanded network, we welcome the opportunity to continue to provide our self-
funded administrative services to the employees of the Village of North Palm Beach. In the
meantime we look forward to discussing our proposal in more detail and responding to any
questions you may have.
Sincerely, : - ~
_.. iin Davis ~•
:/
• Vice President of Sales & Marketing
LEE COUNTY JACKSONVILLE
2055 Central Avenue 1000 Riverside Avenue, Suite 400
Ft. Myers, Florida 33901 Jacksonville, Florida 32204
239.337.8133 • Fax: 239.337.8666 800.697.2235 • Fax: 904.598.5288
Visit us at www.emi-tpa.com Visit us at www.emitpa.com
STUART
700 Central Parkway
Stuart, Florida 34994 772.287.7650
800.431.2221 Fa~~72.287.1387
Visit us at www.emi-tpa.com
• CLAIMS ADMINISTRATION
PROPOSAL FORMS
PROPOSER'S GENERAL INFORIl~ATION
Name of Administrator: Employers Mutual Inc. (EMI)
FEIN/SS#: 59-2989676
Address: 700 Central Parkway
Stuart, FL 34994
Primary
Contact: Jim Davis
Telephone Numbers
Daytime/After Hours: (800) 431-2221 ext 4450 (772) 287-7650
Email: JimD(a,EMI-TPA.com
Fax: (772)287-1387
Website Address: www.EMI-TPA.com
How many consecutive years has your organization operated as a medical
claims administrator? 20 vears
Agent/Broker Firm: N/A
(if applicable)
Agent/Broker Account
Representative: N/A
Telephone Numbers
Daytime/After Hours: N/
Email: N/A
• Fax: N/A
44
CLIENT REFERENCES
1. Indicate the number of currently contracted Florida based employers, your
organization provides TPA services to.
41 Florida Clients
2. Indicate the number of currently contracted public-sector employers in the
State of Florida your organization provides TPA services to.
21 Public Sector Clients
3. List a minimum of three (3) current clients and one (1) prior client with
similar size and/or industry as the Village, with the following information:
• Client Name
• Contact Name and Title
• Address
• Phone and Fax
• Dates of Client Relationship
• Number of Employees
• Services Provided
City of Fort Pierce
George Bergalis, Risk Manager
100 North US Highway One
Fort Pierce, FL 34954
Phone (772) 460-2200 ext. 332
Fax (772) 489-2594
October 2002 through present
365 Employees
Medical, Prescription Drugs and Dental Administration
City of Stuart
Marie Fertitta, Human Resources
121 S W 1~~lagler Avenue
Stuart, FL 34994
Phone (772) 288-531 S
Fax (772) 600-1226
October 1986 through present
247 Employees
Medical, Prescription Drugs, Dental and Flexible Spending Administration
4J
COST INFORMATION
Monthlv Administrative Service Fees for the 12 month period beginning July 1, 2004:
Cost Per Per
Elemeat - Employee Family
Claims Administration Medical $14.00 N/A
Utilization Management Included in N/A
Above
Medical Case Management Included in N/A
Above
Network Access Fee $4.25 N/A
(EMI/Dimensions Plusl
20% 20%
National Wrap Around of Saving of Saving
(Beechstreet)
Dental Administration Included in N/A
Above
Commissions N/A N/A
COBRA/ Included in N/A
HIPAA Above
Total: $18.25 N/A
Additional costs for variable expenses associated with implementation and
administration of plan
•
Variable Expense Item Cost Basis
Start-up Costs N/A
Actuarial Services Pass Through to
Client
Case Management Hourly Rate N/A
FSA Administration
(Per Account Per Month) $4.25
46
Fort Pierce Utilities Authority
Douglas Giel, Director of Human Resources
500 Boston Avenue
Fort Pierce, FL 34950
Phone (772) 466-1600 ext. 3265
Fax (772) 429-2035
January 2003 through present
270 Employees
Medical, Prescription Drugs, Dental and Flexible Spending Administration
City of Lakeland
Karen Lukhaub, Risk Manager
520 North Lake Parker Avenue
Lakeland, FL 33801
Phone (863) 834-6799
Fax (863}834-6743
October 1992 through December 2002
2,342 Employees
Medical and Flexible Spending Administration
4. How many total employees and members are you currently processing medical
claims on?
55,000 Employees
92,000 Members
•
47
SERVICES INFORMATION
1. Where is the location of the claims payment facility that will service this
account?
Village of North Palm Beach will be handled our of our Stuart Florida
location.
a. Is a toll free number available if not local?
(800 431-2221
b. Will the Village be assigned a dedicated claims processor? Yes X No
c. Indicate the name of the account representative that will service this
account. Lynne Brentnall, Account Manager
2. Do you provide Flexible Spending Accounts (FSA) Administration in-house?
Yes X No
3. Explain how your organization will coordinate with managed care network(s).
EMI proposes the continued use of the Dimension Health Network to support
both the PPO and EPO plan options. Effective July 1, 2004, EMI will
enhance the current Dimension Health Network component to include EMI's
proprietary network inclusive of all Treasure Coast counties (Martin, St.
Lucie, Indian River and Okeechobee). EMI is pleased to announce the
addition of the Dimension "Plus" product, which allows for a minimum of an
additional 15% discount off all in-network hospital charges at most
Dimension contracted facilities. Further, to expand EMI's Network, we have
contracted with all HCA facilities located throughout South Florida. It is
EMI's intent to offer these two components (EMI Network & Dimension
Health Network) as one fully integrated network proprietary to EMI members.
For coverage required outside of the local network service area, network
coverage will be accessed through Beechstreet, a national provider network.
In addition; FMI will. coordinate any potential transplant cases; when needed;
through a "Center of Excellence" network to obtain the most favorable pricing
for these services.
48
4. Describe your organization's method of data exchange and controls used to
insure accurate transfer of data from utilization review and medical case
management firm.
EMI has an in-house Utilization Review and Case Management department.
Case notes are entered into the claims system and adjusters have real time
access to medical notes, pre-certifications, authorizations and referrals.
~. Explain how your system identifies claims with medicai case management
potential?
Claims with medical case management potential are identified by the severity
of the diagnosis.
6. Do you provide in-house Utilization Management Services? Yes X No
7. A.re you currently contracted as an approved TPA with Dimension Health
Network? Yes X No
8. Do you require a specific bank? Yes_No X If yes, indicate bank
name.
9. Will you allow the Client to perform an audit of your Administration?
Yes X No
10. What is your turn around time for the last twelve months? 10 business
days/14 calendar days
11. Do you accept electronic claims? Yes X No_. If so, what percentage is
auto-adjudicated? 35%
12. Do you provide any of the following online access?
a.) Eligibility verification? Yes X No_
b.) Claims Inquiry? Yes X No Claims not yet paid? Yes X No
c.) Deductible/out of pocket accumulators? Yes X No_
d.) FSA balances and transactions? Yes X No_
e.) Qnline reports? Yes X No
**See samples located in the Website section.
49
13. Provide the name and address of the organizations providing the following
services:
a. Provider Network(s) Medical
Organization: EMI
Contact: Sandra Shull
Phone: (800) 431-2221 ext. 4441
Address: 700 Central Parkway, Stuart FL 34994
Organization: Dimension Health
Contact: Chuck Lindgren
Phone: (800) 483-4992
Address: Laurel Court, 15500 New Barn Road Ste 101
Miami Lakes FL 33104
b. ivledical Case Management
Organization: EMI
Contact: Kav Rishe
Phone: (800) 431-2221 ext. 4474
Address: 700 Central Parkway, Stuart FL 34994
c. Utilization Review
Organization: EMI
Contact: Kav Rishe
Phone: (800) 431-2221 ext. 4474
Address: 700 Central Parkway, Stuart FL 34994
d. Managed Drug and Mail Order Program
Organization: Pharmacare/United Provider Services
Contact: Keith Dunavant
Phone: (800) 618-4877
Address: 700 Central Parkway,. Stuart FL 34994
•
50
•
MANAGED CARE NETWORK
1. Explain how the Village employees will have access to network providers on
a statewide basis?
As explained in detail in the Services Information section question number 3,
EMI will offer comprehensive network coverage through the integration of the
EMI Proprietary Network and Dimension Health Network with Beechstreet as
the national wrap-around.
2. Please provide a detailed explanation concerning your specific reasons for
proposing the provider network listed.
EMI has thoroughly researched available participating provider networks
throughout South Florida, as well as the entire state of Florida. EMI has
identified the Dimension Health Network and the EMI Proprietary Network as
the most competitive network options available to self-funded employers in
South Florida. The two fully integrated network components provide the most
comprehensive coverage based on the total number of providers, as well as the
most favorable fee schedules and discounted services.
3. Will claims be re-priced in-house by the Claims Administrator, or sent to the
network for re-pricing? Repricing is handled in-house.
4. Is provider network information available on the Internet? Yes X No
If Yes, indicate website address
www.emi-tpa.com, www.dimensionhealth com www beechstreet com
5. Please indicate the participating hospitals located in Palm Beach County.
Jupiter Medical Center
Palm Beach Gardens Medical Center
(;ocri C~mantan >`~Ied:Cal Center
St. Mary's Hospital
Wellington Regional Medical Center
Columbia Hospital
JFK Medical Center
Glades General Hospital
• Bethesda Memorial Hospital
Delray Medical Center
~,
J1
Boca Raton Community Hospital
West Boca Medical Center
•
6. Does your network provide coverage in Martin and St. Lucie County?
Please explain:
Yes, the network contains coverage throughout the Treasure Coast inclusive of
Martin, St. Lucie, Indian River and Okeechobee counties. The hospitals available
through the network in these counties are, Martin Memorial South, Martin
Memorial North, St. Lucie Medical Center, Lawnwood Regional, Indian River
Memorial and Okeechobee Raulerson Hospital. In this area, the network
coverage includes all specialties with a total of 590 providers.
7. Attach a copy of your current provider directory for Palm Beach, Martin and
St. Lucie Counties.
See Participating Provider Network Section.
•
52
•
SAMPLING OF NEGOTIATED HOSPITAL PAYMENTS BY LOCAL
uncprT e r .c
Complete using the most current data available. Indicate if coverage is based on
_ per diems and confirm the per diem amount and any outliers that may apply.
Indicate if your allowance is based on DRGs. If based on a percentage of
Medicare, indicate the percentage or percentile utilized. If based on a percentage
of billed charges, please indicate and show the percentage allowed.
SURGICAL SCENERIO: Cholecystectomy
ICD-9-CM Diagnosis: 574.5
CPT-4 Code for Surgery: 47611 -
Authorized Stay: 3 days
EMI Participating Provider Network
Hos ital Negotiated Fee
EPO O tion Negotiated Fee
PPO O tion
Palm Beach Gardens Refer to Dimension
Below Refer to Dimension
Below
St. Mary's Refer to Dimension
Below Refer to Dimension
Below
Columbia Medical Center $5,600.00 $5,600.00
Martin Memorial Hos ital 50% Discount $35% Discount
St. Lucie Medical Center $4,540.00 $5,075.00
Jupiter Medical Center Refer to Dimension
Below Refer to Dimension
Below
Other (identif )
SAMPLING OF PPO PHYSICAN ALLOWABLES
CPT Description Negotiated Fee
EPO O tion Negotiated Fee
PPO O tion
88305 Surgical Pathology
Level IV $97.12 $97.12
70553 MRI -Brain $1126.92 $1126.92
71020 Chest X-Ray, 2 Views $36.66 $36.66
95004 Aller y Tests -Scratch $4.44 $4.44
53
•
78465 Myocardial Perfusion
Ima in $552.02 $552.02
27447 Total Knee
Re lacement $1549.11 $1549.11
17000 Descruction Skin
Lesion $63.00 $63.00
29881 Knee
Arthoscopy/Meniscus $623.21 $623.21
95117
Allergy Injections 2+ $20.10 $20.10
66984 Remove Cataract $687.35 $687.35
43239 ~ Upper GI Endoscopy,
Bio s $345.87 $345.87
45378 Diagnostic
Colonosco $40.08 $450.08
11100 Biopsy of Skin Lesion $78.87 $78.87
93000 Routine ECG $27.40 $27.40
80050 General Health Panel $14.77 $14.77
Dimension Health Network
Hos ital Negotiated Fee
EPO O tion Negotiated Fee
PPO O tion
Palm Beach Gardens $2,550.00 $2,550.00
St. Ma 's $2,850.00 $2,850.00
Columbia Medical Center Refer to EMI Above Refer to EMI Above
Martin Memorial Hos ital Refer to EMI Above Refer to EMI Above
St. Lucie Medical Center Refer to EMI Above Refer to EMI Above
Jupiter Medical Center $3,051.00 $3,051.00
Other (identif
SAMPLING OF PPO PHYSICAN ALLOWABLES
CPT Description Negotiated Fee Negotiated Fee
EPO O tion PPO O tion
88305 Surgical Pathology $80.00 $80.00
Level IV
70553 MRI -Brain $1351.36 $1351.36
54
l
71020 ~ Chest X-Ray, 2 Views $44.01 $44.01
95004 Allergy Tests -Scratch $5.28 $5.28
78465 Myocardial Perfusion
Ima in $662.42 $662.42
27447 Total Knee
Replacement $1,991.06 $1,991.06
~
17000 Descruction Skin
Lesion $59.47 $59.47
29881 Knee
Arthosco /Meniscus $753.83 $753.83
95117 ~
Ailergy injections 2+ $24.45 $24.45
66984 Remove Cataract $882.12 $882.12
43239 ~ Upper GI Endoscopy,
Bio s $291.32 $291.32
45378 Diagnostic
Colonosco $403.15 $403.15
11100 Biopsy of Skin Lesion $82.01 $82.01
93000 Routine ECG $35.38 $35.38
80050
I General Health Panel
I $21.00
~ $21.00
9. Indicate the costs/fees associated with your proposed prescription
drug program:
a. Discount percentage off the AWP for retail card Brand minus 14%
Generic MAC Pricing
b. Discount percentage off the AWP for mail order Brand minus 18%
Generic minus 48% or MAC
c. Dispensing fee per prescription Retail_Brand=$2.25, Retail
Generic=$2.50, Mail Brand=$1.00, Mail Generic $1.00
d. Transaction/service fee per prescription $.59
e. Please describe pharmacy rebates, drug utilization reporting and other
pharmacy services provided.
Rebates are available to the plan. Numerous types of reporting are
• available online or upon request. The available reports include but are
not limited to drug utilization, top drugs dispensed, mail vs. retail
utilization and claims summary.
55
r~
U
•
DEVIATIONS FROM MODEL PROGRAM
EMI is recommending the following changes to the current PPO plan design. EMI feels
that these changes would maximize steerage into the network and overall reduce claims
experience. The stop loss terms are based upon the current plan design. If the Village is
interested in pursing these changes, data will be sent to the stop loss carver for review. A
reduction in claims will reduce the terms (factors and/or- rates) under the stop loss
contract. In addition, in order to maximize the discounts under the Dimension "Plus"
program, a 20% coinsurance differential must be in place between in and out of network
services.
PPO Current
Coinsurance:
In-Network 80%
Out of Network 70%
PPO Proposed
Coinsurance:
In-Network 80%
Out of Network 60%
Deductible:
In-Network Single $200
In-Network Family $600
Out of Network Single $200
Out of Network Family $600
Deductible:
In-Network Single $200
In-Network Family $600
Out of Network Single $400 °----
Out of Network Family $1200
56
STOP-LOSS INSURANCE
PROPOSAL FORMS
PROPOSER'S GENERAL INFORMATION
Name of Insurer: Pacific Life Insurance Com~any
FEIN/SS#: 95-1079000 (TINS
Address: P O Box 2890 ~
Newport Beach, CA 92658-9010
Primary
Contact: Rick Dawson ~Re~ional Sales Director) or Marianne
Koenig (Stop Loss Sales Coordinator)
Telephone Numbers
Daytime/After Hours: Rick~800) 578-5666, Marianne (800L800-7661 x2124
Email: rdawson(~pacificlife.com
Agent/Broker Firm:
(if other than TPA)
AgentBroker Account
Representative: N/A
Telephone Numbers
Daytime/After Hours:N/A
Email: N/A
Fax: N/A
•
58
•
~~
~_~
MINIMUM QUALIFICATIONS
Provide your current financial rating from each of the following firms. If not
applicable, please indicate by "N/A."
Rating Firm
A.M. Best
Moody's
Standard & Poor's
Weiss Ratings, Inc.
Ratin
A++ (Superior)
Aa3 (Excellent.)
Very Stron~l
N/A
GENERAL INFORMATION
1. When a specific cap is reached, indicate (check) when the Village will receive
reimbursement:
Monthly
End of Calendar Year
End of Contract/Plan Year
Other (explain) Within 5 davs of receipt of a complete
reimbursement request.
2. Does the specific stop-loss insurance cover all organ transplants included in
their current coverage? Yes_ No~_
If No, please explain: Our Quote covers transplants as defined in the Plan
Document.
3. Does the aggregate stop-loss insurance cover all organ transplants included in
their current coverage? Yes_ No__
If No, please explain: Our Ouote covers transplants as defined in the Plan
Document.
4. Does the aggregate stop-loss insurance have a maximum reimbursement
limitation (cap)? Yes_ No_
If Yes, indicate that dollar limit: $1,000.000
5. Is an intermediary or MGU utilized in connection with this proposal? If so,
please provide details including contact name, telephone numbers and
address. N/A
59
PLAN COST INFORMATION
1. Are rates sub~ect to Chan eat final underwriting? Yes No_
J g
If Yes, specify conditions: quoted Rates and Factors are subject to final
Pacific Life Disclosure.
2. Please provide a complete copy of the underwriting contingencies.
Refer to the Quotation Conti~encies page of the attached Quotation Proposal.
SPE IFIC 4ND AGGREGATE STOP DOSS PRICING
$50,000 Specific with $1,000,000 Aggregate:
Benefits to be covered: Medical Only (no RX or Dental)
Current Dual Option Plan Design (EPO/PPO)
$50,000 Specific 24/12
Specific Stop-Loss Aggregate Stop-Loss
Limit of Liability Per Covered Unit $1,950,000 $1,000,000
Reimbursement Factor 100% 100%
Monthly Premium Per Covered Unit
Covered Units
Employee/Dependent Basis Employee
178
$64.52 Dependent
84
$68.72 Composite
~ $5.54
Monthly Aggregate Factor
Covered Units
Employee/Dependent Basis
N/A
N/A Composite
$592.27
Monthly Transplant Rider Rate N/A
Aggregate Advance Factor N/A
Maximum Claims Liability N/A
Expected Claims N/A.
Are agent broker commissions included in your fees or rates? Yes ___No
Please state the amount of commissions as a percentage of premiums. _10_%
of Both (i.e., aggregate, specific or both).
NOTE: Individual Lifetime Maximum is $2,000,000
60
iS ~ Uc, i'irii.: 1 r , ~E'L
•OP LOSS QUOTATION
PLAN SPONSOR: Village of North Palm Beach
TPA: Employers Mutual, Inc.
NATURE OF BUSINESS: Municipality
PROPOSED EFFECTIVE DATE: July 1, 2004
PLAN LIFETIME MAXIMUM: $2,000,000.00
COMMISSIONS: 10.0%
SPECIFIC STOP LOSS COVERAGES INCLUDE:
- Medical
ASSUMED LIVES EE: 176
DEP: 84
OPTION ~ - DEDUCTIBLE: $50,000
SPECIFIC STOP LOSS
ACCUMULATION PERIOD: Incurred in 24/Paid in 12
MONTHLY RATES: EE
$64.52
AGGREGATE STOP LOSS
ACCUMULATION PERIOD: Incurred in 24/Paid in 12
AGGREGATE DED: 25%
TEL t•.li_t : G49-c::l ~- =„P;.4 #~~ FJG~I S F'HGE : ~ -~
~~ I~A~I FIB LII= ~
B.ANNll(TYCOMPANY
Stop Loss Products Underwritten by Pacific Life Insurance Company
STATE: FL SIC CODE: 9111
AGREEMENT PERIOD: July 1, 2004 through June 30, 2005
MONTHLY ACCOMMODATION: No
AGGREGATE REIMBURSEMENT MAXIMUM: $1,000,000.00
AGGREGATE STOP LOSS COVERAGES INCLUDE:
Medical
ASSUMED LIVES EE: 176
DEP: 84
MONTHLY ANNUAL
DEP :COST-.. COST
$68.72 ,~" $17,128.00 $205,536.00 ~._-
MONTHLY ATTACHMENT AGGREGATE ~ ~ '
f,~.
C
~
FACTORS ANNUAL RATE MONTHLY ANNUAL
'
~
COMPOSITE DEDUCTIBLE COMPOSITE COST COST
$592.27 $1,250.874.24 $5.54 $975.04 $11,700.4&
OPTION Z - DEDUCTIBLE: $65,000
SPECIFIC STOP LOSS ,
ACCUMULATION PERIOD: Incurred in 24/Paid in 12
MONTHLY ANNUAL
MONTHLY RATES: EE DEP COST COST
$48.07 $53.52 $12.956.00 $155,472.00
AGGREGATE STOP LOSS
ACCUMULATION PERIOD: Incured in 24/Paid in 12
AGGREGATE DED: 25%
MONTHLY ATTACHMENT AGGREGATE
FACTORS ANNUAL RATE MONTHLY ANNUAL
COMPOSITE DEDUCTIBLE COMPOSITE COST COST
$622.20 $1,314,276.48 $5.54 $975.04 $11,700.48
PLEASE SEE NEXT PAGE FOR MORE OPTIONS
•
51
~',: flr=, LIAR 1?, 2E1Er4
STOP LOSS QUOTAT{®N CONTINUE®
TEL N0~ y49-E1~-_;8E4 #,~E1Erb4:~ F'AGE~ ~~~
PACIFIC LIFE 8~ ANNUITY COMPANY
Stop Loss Products Underwritten by Pacific Life Insurance Company
~PTION 3 - DEDUCTIBLE: $75,000
SPECIFIC STOP LOSS
ACCUMULATION PERIOD: Incurred in 24/Paid in 12
MONTHLY ANNUAL
MONTHLY RATES: EE DEP COST COST
$41.83 $46.59 $11,275.64 $135,307.68
AGGREGATE STOP LOSS
ACCUMULATION PERIOD: Incurred in 24/Paid in 12
AGGREGATE DED: 25°rb
MONTHLY ATTACHMENT AGGREGATE
FACTORS ANNUAL RATE MONTHLY ANNUAL
COMPOSITE DEDUCTIBLE COMPOSITE COST COST
$633.16 $1.337,276.16 $5.54 $975.04 $11,700.48
PLEASE SEE NEST PAGE FOR ALL QUOTATION CONTINGENCIES
•
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~~
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QUOTATION CONTINGENCIES PACIFIC LIFE 8~ ANNUITY COMPANY
Stop Loss Products Underwritten by Pacific Life Insurance Company
• The rates, factors, and terms in this proposal are conditional upon receipt of the following:
1.
a. Complete proposal will be presented to Plan Sponsor.
b. The Pacific Life Disclosure Statement completed in full, signed by the Plan Sponsor, and submitted within the time frame noted on fhe form.
c. Receipt of updated medical status, case management notes (if available), date of onset, treatment received, and current course of treatment, at the
time of disclosure, for shock claimants #1, #3, #5, and #ti.
d. Report of any claims in house (pended/held/preprocessed/etc.) but not yet paid as of the disclosure date.
e. Receipt of updated aggregate experience through the end of May 2004 on carrier/TPA letterhead. Please provide the prior plan year aggregate on
letterhead also.
f. An explanation for the fluctuation in monthly paid claims. Why are the reported, gross paid claims for August 2003 so low and March 2003 a
negative number'?
g. Receipt of current and/or renewal Specific and Aggregate rates or premium.
h. Verification of the current number of Fire/Police/Sheriff department enrollees.
i. Receipt of prior plan year Schedule of Benefits.
j. Receipt of current eligibility provisions as defined in the Plar. Document.
2. Managed Care Vendor(s):
a. Dimensions Network
b. Beechstreet
3. Utilization Review Vendor(s):
a. EMI
4. TPA will advise Pacific Life Insurance Company of any material changes in the information used to develop the proposal that could
impact quoted rates and/or attachment factors.
5. Coverage will not become effective until acceptance is confirmed in writing by Pacific Life.
6. Com~~ersion option available at a cost of $1.t7C per employee per month. Due to state requirements, the com~ersior, option is not
available in Oregon.
7. This Stop Loss Quotation covers entity named above. No affiliates/subsidiaries or other related entities are covered.
8. Quote Assumes:
a. The number of Fire/Police/Sheriff Department employees is less than 50% of the total enrollees.
b. The current Plan of Benefits which includes retiree coverage.
c. There is no coverage under the Plan for part-time, seasonal, temporary, contracted employees or independent agents. The quote also assumes
there is no coverage for the Board of Directors, unless they meet the definition of a full-time employee.
d. Lives on the effective date will not differ by more than 10% from the quoted lives, or we reserve the right to re-evaluate our offer.
The minimum annual aggregate deductible will be calculated using the greater of lives quoted or the lives on the effective date.
f. Overall group participation in the Employee Benefit Plan is at least 50%.
g. HMO penetration does not exceed 50%.
h. COBRA content does not exceed 5%.
i. Employer is contributing at least 50% of the employee cost.
j. A minimum of 75% of the covered lives are enrolled in a PPO.
k. Aggregate Reimbursement Maximum: $1,000,000.00
If this prospec± does not meet these minimum assumptions, please contact us immediately.
• ,. - ' lie
CONFIDENTIALITY CLAUSE: The parties acknov/ledge that in preparing this proposal, either party may have access to and receive from the other party non puo
personally identifiable financial and/or health information (NPI), as defined in federal and state taw. The parties agree to maintain fhe confidentiality of such NPi and
shall not use, disclose, furnish or make accessible such NPI to anyone ether than authorized employees and agents of tha( party.
63
~ = : i_~" I~tAF.' 17 . 2k~U4 TEL NCt ~ 94y-X15-~8E4 #~t7t~64~ PAGE ~ ~ -'
• STOP LOSS PROPOSAL
PLAN DOCUMENT STANDARDS
All Pacific Life quotations assume that similar or more restrictive provisions will be in the PLAN
DOCUMENT.
Claim Submission: Provision stating written proof of claim must be submitted within 12 months
of date of service or less.
COBRA: Should be consistent with Federal notification requirements.
Coordination of Benefits: Should identify any Plan with which the Plan Sponsor's Plan will
coordinate and state the order of benefit determination.
Definition of an Eligible Employee: Must be working in a full-time capacity for not less than 20
hours per week.
Definition of ar. Eligible Dependent: Includes only legal spouse and unmarried children under
age 19, extension for full-time students up to age 25.
Definitions: Plan Document should at least clearly define: Medical Necessity, Total Disability,
Usual & Customary, Physician, Nurse, Hospital, Open Enrollment, Actively-at-Work and Leave
of Absence.
Exclusions: Plan Document should, at a minimum, exclude charges related to the following:
Work related Injuries/Illness; Act of War, Cosmetic Surgery, Government Provided Services,
Experimental/Investigative Procedures, Excess of Usual & Customary, not Medically Necessary
and not Legally Obligated to Pay.
Extension of Eligibility Provision: Should state the maximum period of extended coverage for
each cause, as an approved Leave of Absence or Medical Disability Leave.
Late Enrollment: Should be consistent with Federal requirements.
Mental Heaith Benefits: Should be consistent vvith Federal requirements.
Third Party Recovery: Provision stating the Plan's right to recover monies payable when a third
party liability is established.
An acceptable Plan Document, with signature page and ERISA requirements where applicable,
forms a part of the Stop Loss Agreement (SL-1 ). The exact wording for these minimum
standards should be made by the Plan Sponsor; but the substance of the provisions must
comply with the general description above.
NOTE: As a matter of company policy, Pacific Life will not accept Plan
Documents with AIDS limitations or restrictions.
•
64
Carrier.
Enrollment
# Single
# Family
Specific Deductible
Contract Basis 24/12
Specific Rates
Single
Family
Annual Premium
Aggregate Coverage
Contract Basis 24/12
Aggregate Factors
Single
Family
Aggregate Maximum Claims
Annual Expected Claims
Aggregate Rate (Composite)
Annual Aggregate Premium
Total Reinsurance Premium
Total Premium & Claims Liability
Conversion
Annual Cost
EMI Administration Fee
Etvll/Dimensions Network Mana
Total Annual Admin Fees
Total Annual Fixed Costs
Total Annual Maxiumum Costs
Total Annual Expected Costs
•
Current
Safeco
Medical Only
92
64
$50,000.00
VILLAGE OF NORTH PALM
JULY 1, 2004 RENEWAL
Renewal Excess Risk RE Sun Life NBR Pacific Life RMTS
Safeco OBE Moulton
Medical Only Medical Only Medical Only Medical Only Medical Only Medical Only Medical Only
92 92 92 92 92 92 92
84 84 84 84 84 84 84
$50,000.00 $50,000.00 $50,000.00 $50,000.00 $50,000.00 $50,000.00 $50,000.00
PPO $66.88/EPO $56.85 PPO $87; 96/EPO $74.77 $69. 82 $114. 30 $138.17 $121.76 $64.52 80.47
PPO $151.43/EPO $128.72 PPO $199.17/EPO $169.30 $164. 42 $239. 19 $313.10 $307.90 $133.24 214.49
,.
' '.w::tq,.^,
' _::x.._ ~
.. _
.~
$219,798.00 $289 086.96` $242,816. 64 $367,290. 72 $468,144.48 $444,786.24 % $205 536.00 ; $305,044.80
PPO $494.96/EPO $569.21 PPO $663.12/EPO $677.66 $536. 64 $414. 64 $658.70 $406.31 $592.27 $629.81
PPO $494.96/EPO $569.21 PPO $663.12/EPO $677.66 $536. 64 $867. 69 $658.70 $938.27 $592.27 $629.81
$1,075,649.52 $1,406,441.76 $1,133,383. 68 $1,332,394. 08 $1,391,174.40 $1,394,342.40 $1,250,874.24 $1,330,158.72
$860,519.62 $1,125,153.41 $906,706. 94 $1,065,915. 26 $1,112,939.52 $1,115,473.92 $1,000,699.39 $1,064,126.98
$13.53 $5. 97 $7. 15 $8.52 $7.58 y»~$s:5~1 2,000 Lump
$28,575.36 28,575.36 $12,608 .64 $15,100. 80 $17,994.24 $16,008.96 $.11,700.48 ,! $12,000.00
$248,373.36 $317,662.32 $255,425 .28 $382,391. 52 $486,138.72 $460,795.20 $217,236.48 $317,044.80
$1,324,022.88 $1,724,104.08 $1,388,808 .96 $1,714,785. 60 $1,877,313.12 $1,855,137.60 $1,468,110.72 $1,647,203.52
$0.55 $0.50 $0 .75 $0. 75 $0.75 $0.75
,_-$0:75-a<
$0.75
$1,161.60 $1`,056.00 `: $1,584 .00 $1,584 .00 $1,584.00 $1,584.00 ~1,,584.Q0;°"" $1,584.00
$13.50 $14.00 $14 .00 $14 .00 $14.00 $14.00 $14.00 $14.00
$2.T5 $4.25 $4 .25 $4 .25 $4.25 $4.25 $4.25 $4.25
$34,320.C10 $38,544.00 $38,544 .00 $38,544 .00 .$38,544.00 $38,544.00 $38,544.00 $38,544.00
$283,854.96 $357,262.32 $295,553 .28 $422,519 .52 $526,266.72 $500,923.20 $257,364.48 $357,172.80
$1,359,504.48 $1,763,704_08 c ~$1,428,936 .96 $1,754,913 .60 $1,917,441.12 $1,895,265.60 $1,5 8.72"
~'~ $1,687,331.52
$1,144,374.58
$1,482,415.73
$1,202,260
.22
$1,488,434
.78
$1,639,206.24
$1,616,397.12 _-.
;~$1,258,063.87~
$1,421,299.78
.. _. ~.,
,.~,
VILLAGE OF NORTH PALM
JULY 1, 2004 RENEWAL
Carrier Safeco Excess Risk RE Sun Life NBR Pacific Life RMTS
DBE Moulton
Medical Only Medical Only Medical Only Medical Only Medical Only Medic:310n1y Medical Only
Enrollment
# Single 92 92 92 92 92 92 92
# Family 84 84 84 84 84 84 84
Specific Deductible $65,000.00 $65,000.00 $65,000.00 $65,000.00 $65,000.00 $65,000.00 $65,000.00
Contract Basis 24/12
Specific Rates
Single PPO $68.86/EPO $58.53 $56.13 $89.17 $118.64 $103.70 $48.07 65.16
Family PPO $155.92/EPO $132.53 $135.19 $191.90 $273.86 $262.25 $101.59 173.56
Annual Premium $226,309.92 $198,239.04 $291,878.88 $407,029.44 $378,832.80 $15,472.00 $246,885.12
Aggregate Coverage
Contract Basis 24/12
Aggregate Factors
Single PPO $686.66/EPO $701.73 $557.75 $427.08 $685.38 $419.01 $622.29 645.56
Family PPO $686.66/EPO $701.73 $557.75 $893.72 $685.38 $967.59 $622.29 645.56
Aggregate Maximum Claims $1,456,374.48. $1,177,968.00 $1,372,366.08 $1,447,522.56 $1,437,917.76. $1,314,276.48 $1,363,422.72
Annual Expected Claims $1,165,099.58 $942,374.40 $1,097,892.86 $1,158,018.05 $1,150,334.21 $1,051,421.18 $1,090,738.18
Aggregate Rate (Composite) $15.83 $5.97 $7.15 $8.52 $7.58 $5.54 $13,500 Lump Sum
Annual Aggregate Premium $33,432.96 $12,608.64 $15,100.80 $17,994.24 $16,008.96 $11,700.48 $13,500.00
Total Reinsurance Premium $259,742.88 $210,847.68 $306,979.68 $425,023.68 $394,841.76 $167,172.48 $260,385.12
Total Premium 8 Claims Liability $1,716,117.36 $1,388,815.68 $1,679,345.76 $1,872,546.24 $1,832,759.52 $1,481,448.96 $1,623,807.84
Conversion $0.50 $0.75 $0.75 $0.75 $0.75 $0.75 $0.75
Annual Cost $1,056.00 $1,584.00 $1,584.00 $1,584.00 $1,584.00 81,584.00 $1,584.00
EMI Administration Fee $14.00 $14.00 $14.00 $14.00 $14.00 $14.00 $14.00
EMI/Dimensions Network Management Fee $4.75 $4.75 $4.75 $4.75 . $4.75 $4.75 $4.75
Total Annual Admin Fees $39,600.00 $39,600.00 $39,600.00 $39,600.00 $39,600.00 $39,600.00 $39,600.00
Total Annual Fixed Costs $300,398.88 $252,031.68 $348,163.68 $466,207.68 $436,025.76 $208,356.48 $301,569.12
Total Annual Maxiumum Costs $1,756,773.36 $1,429,999.68 $'1,720,529.76 $1,913,730.24 $1,873,943.52 $1,522,632.96 $1,664,991.84
Total Annual Expected Costs $1,465,498.46 $1,194,406.08 $'1,446,05Ei.54 $1,624,225.73 $1,58E'i,359.97 $1,2.°i9,777.66 $1,392,307.30
• •
Carrier
Enrollment
# Single
# Family
Specific Deductible
Contract Basis 24112
Specific Rates
Single
Family
Annual Premium
Aggregate Coverage
Contract Basis 24/12
Aggregate Factors
Single
Family
Aggregate Maximum Claims
Annual Expected Claims
Aggregate Rate (Composite)
Annual Aggregate Premium
Total Reinsurance Premium
Total Premium & Claims Liability
Conversion
Annual Cost
.EMI Administration Fee
EMI/Dimensions Network Management Fee
Total Annual Admin Fees
Total Annual Fixed Costs
Total Annual Maxiumum Costs
Total Annual Expected Costs
1
Safeco
Medical Only
92
84
$75,000.00
PPO $59.06/EPO $50.20
PPO $133.72lEPO $113.66
$194,092.32
PPO $698.757EP0 $714.09
PPO $698.75lEPO $714.09
$1,482,018.72
$1,185,614.98
$17.18
$36,284.16
$230,376.48
$1,712, 395.20
$0.50
$1,056.00
$14.00
$4.25
$38,544.00
$269,976.48
$1,751,995.20
$1,455,591.46
VILLAGE OF NORTH PALM
JULY 1, 2004 RENEWAL
Excess Risk RE Sun Lite NBR Pacific Life
OBE Moulton
Medical Only Medical Only Medical Only Medical Only Medical Only
92 92 92 92 92
84 84 84 84 84
$75,000.00 $75,000.00 $75,000.00 $75,000.00 $75,000.00
$46.76 $77.75 $97.53 $78.95 $41.83
$114.41 $169.73 $237:73 $199.66 $88.42
$166,948.32 $256,923.84 $347,304.96 $288,418.08 $135,307.68
RMTS
Medical Only
92
84
$75,000.00
$54.17
$144.16
$205,116.96
$572.57 $439.89 $711.42 $435.94 :5633.18 $658.47
$572.57 $920.53 $711.42 $1,006.68 $633.18 $658.47
$1,209,267.84 $1,413,532.80 $1,502,519.04 $1,496,011.20 $1,337,276.16 $1,390,688.64
$967,414.27 $1,130,826.24 $1,202,015.23 $1,196,808.96 $1,069,820.93 $1,112,550.91
$5.97 $7.15 $8.52 $7.58 $5.54 $15,000 Lump Sum
$12,608.64 $15,100.80 $17,994.24 $16,008.96 $1'1,700.48 $15,000.00
$179,556.96 $272,024.64 $365,299.20 $304,427.04 $14',008.16 $220,116.96
$1,388,824.80 $1,685,557.44 $1,867,818.24 $1,800,438.24 $1,48~t,284.32 $1,610,805.60
$0.75 $0.75 $0.75 $0.75 $0.75 $0.75
$1,584.00 $1,584.00 $1,584.00 $1.584.00 $1,584.00 $1,584.00
$14.00 $14.00 $14.00 $14.00 $14.00 $14.00
$4.25 $4.25 $4.25 $4.25 $4.25 $4.25
$38,544.00 $38,544.00 $38,544.00 $38,544.00 $38,544.00 $38,544.00
$219,684.96 $312,152.64 $405,427.20 $344,555.04 $187,136.16 $260,244.96
$1,428,952.80 $1,725,685.44 $1,907,946.24 $1,840,566.24 $1,524,412.32 $1,650,933.60
$1,187,099.23 $1,442,978.88 $1,607,442.43 $1,541,364.00 $1,2`6,957.09 $1,372,795.87
t'~