HomeMy WebLinkAboutResolution #5050 (BCBS Group Dental) RESOLUTION NO. 5050
A RESOLUTION APPROVING A GROUP ENROLLMENT AGREEMENT BETWEEN THE CITY
OF CANTON AND BLUECROSS BLUESHIELD FOR THE GROUP DENTAL PLAN AND
DIRECTING THE MAYOR AND THE CITY CLERK TO EXECUTE AND DELIVER SAID
AGREEMENT ON BEHALF OF THE CITY OF CANTON, ILLINOIS.
WHEREAS, the Insurance Committee of the City of Canton has determined that it is necessary and in
the best interest to enter into an agreement with BlueCross BlueShield to administer the City's Group
Dental Plan as set forth in Exhibit A attached hereto and incorporated herein; and
WHEREAS, the City Council of the City of Canton has made similar determination.
NOW, THEREFORE, BE IT RESOLVED BY THE MAYOR AND THE CITY COUNCIL OF THE
CITY OF CANTON, FULTON COUNTY, ILLINOIS, as follows:
1. That the agreement attached hereto and incorporated herein as Exhibit A is hereby approved by the
Canton City Council.
2. That the Mayor and City Clerk of the City of Canton, Illinois is hereby authorized and directed to
execute and deliver said agreement on behalf of the City of Canton.
3. That this resolution shall be in full force and effective immediately upon its passage by the City
Council of the City of Canton, Illinois and approval by the Mayor thereof.
PASSED by the City Council of the City of Canton this 19th day of April, 2016.
AYES: Aldermen Craig West, Tad Putrich, Jim Nelson, Ryan Mayhew, Justin Nelson, John
Lovell, Angela Hale
NAYS: Alderman Gerald Ellis
ABSENT: None
APPROVED:
Jeffrey A. Fritz, Mayor
S
Diana Pavley-Rock, rty Clerk
09
BlueCross BlueShield
of Illinois
Account Name: CITY OF CANTON Account Number: 389388 Renewal Date: 05/01/16
TO BE SIGNED BY THE GROUP REPRESENTATIVE:
I,the undersigned, a duly authorized representative of the policyholder named above("Policyholder"), hereby: (i)
represent that I am knowledgeable as to standards associated with a"grandfathered health plan"as set forth in the
Affordable Care Act and applicable regulations, and that the information contained in this Grandfathered Health Plan
Form,and any subsequent updates to such Form, are true, complete and accurate; (ii) agree that the Policyholder will
immediately provide BCBSIL with written notice prior to renewal(and during the plan year,with at least 60 days advance
written notice)of any changes to the employer's or employee organization's contribution rate toward the cost of any tier
of coverage;and (iii)agree that BCBSIL retains the authority to determine, at its sole discretion,whether any health
insurance coverage constitutes a grandfathered health plan under the Affordable Care Act, applicable regulations and
interpretations thereof.
r aV 1CQ 14 C l,erj�z l-
Pri me Prifit Title
Signa Date
A Division of Health Care Service Corporation,a Mutual Lepal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association.
Grandfathered Health Plan Form-SGFI-1011
1`
MHHB196 _N/A N/A $1,500 $30 $150 $10/$40/$60
MHHB100 N/A N/A $1,500 $20 $150 $10/$40/$60
❑MHH8166 N/A N/A $1,500 $30 $150 $10/$40/$60
MHHB19C N/A N/A $1,500 $30 $150 $8/$35/$75!$150
MHH1133F $0 100% $5,600 $30 $400' $0!$10/$35/$75/$150
H. g. HMO Value Choice
MHVBV0C N/A N/A $3,000 $40 $250 $8/$35/$75!$150
MHVBV03C N/A $300 $8/$35/$75!$150
..O
..� r, 'rda' P ,,r, v :.. ,- .. + Far-sP:r .a'a� .R..'».. .;•kfS" 3 `.,.,, . ...
MPP11T3F $0/$6,600 100%/800/. $5,60(0)/$13,200 $30 $400' $0/$10/$35/$75!$150
MPP12J2G $0/$0 90%/70% $250/$1,000 $20 $150 $0/$10/$50/$100/$150
MPPH3T6G $5,000/$10,000 80%/60% $5,600/$12 200 $40 $250 $0/$10/$50/$100/$150
MPP43M4F $250/$500 80%/60% $1,250/$2,500 $25 $0/$10/$35!$75/$150MPP8353G $ , , 80%/60%
$3,000/$6,000 $30 $400` $0/$10/$50/ 100/$150
MPP73863 1 $500/$1,000 80%/60% $5,000/$10,000 1 $40 $400* $15!$30/$50
MPP9391F _.$1,5001$3,000 80%/60% $3,500!$7,000 $10 $400' $0/$10/$35/$75/$150
❑MPP83436 $1,000/$2,000 80%/60%--- $3,000/
M $6,000 $30 $150 $101$40/$60
PP82326 $1,000/$2,000 90°0/70°l0 $2,000/$4,000 $20 $150 $10/$40/$80
MPP83D36 $1 0001$2 000 80%/60% $4,0001$8,000 $30 $150 $10/$40/$60
MPP8343C $1,000!$2,000 80°J 160% $3,000/$6,000 $30 $150 $8/$35/$75/150
❑MPP93C36 $1,500/$3,000 80%/60% $3,500/$7,000 $30 $150 $101$40/$60
MPP9383C $1,500/$3,000 80%/60% $4,500/$9,000 1 $30 $150 $8/$35/$75/150
MPPC3836 $2,500/$5,000 80%/60% $4,500/$9,000 $30 $150 $10/$40/$60
MPPC3038 $2,5001$5,000 80%/60% $5,500/$11,000 $30 $150 $10/$40/$60
❑MPPC3826 $2,500/$5,000 80%/60% $4,5001$9,000 $20 $150 $10/$40/$60
LJ MPPC2C26 $2,500/$5,000
90%/70% $3,500/$7,000 $20 $150 $10/$40/$60
MPP43323 $250/$500 80%/60% $1,2501$2,500 $20 $150 $15/$301$50
MPPE3Q26 $3,500 I$7,000 80%/60% $5,500/$11,000 $20 $150 $10/$40/$60
MPP73426 $500/$1,000 8040!60% $2,500/$5,000 $20 $150 __ $10/$40/$60
MPP72326 $500/$1,000 90%/70% $1,500/$3,000 $20 $150 $10/$40/$60
MPP72226 $500/$1,000 80%/60°l0 $2,5001$5,000 $30 $150 $10/S40/$60
MPP72226 $500!$1,000 90%/7Q% $1,000/$2,000 $20 $150 $10/$40($60
MPP73C3C $500!$1,000 80%160% $3,500/$7,000 $30 $150 $$10/$ 0/$600
Li MPP93C26 $1,500/$3,000 $0_21
160% $3,500/$7,000 $20 $150 $10/$40/$60
MPP93C3C $1,500/$3,000 80%%60% $3,500/$7,000 $30 $150 $8/$35/$75/150
❑MPPA3C3F $2,000/$4,000 80%/60% $4,0001$8,000 $30 $150 $01$101$35/$751$150
MPPA303F $2,000/$4,000 80%/60% $5,5001$11,000 $30 $150 $0/ 10/$35!$75/$150
MPPF303F $4,000/$II,000 100%/100% $4.0001$8,000 $30 $150 $0/$10/$35/$75/$150
MPPF303F $4,000/$8,000 80°%!60°/ $5,500/$11,000 $30 $150 $0!$10/$35/$75/$150
`ER Copay is Per Occurrence
*Products and services marketed umicr the Dearborn National*hrtnd and the sear lino are underwritten and or pro,ided bN Ikarborn National`I ire Insurance(-untpany 1[),ja n
,tales(excluding New York),rod cemun or ns tttiliatw. 1)arbunt National'Lite Insurance Company is a separate Company that d °r;Grove.I l l in all
(Joen. provtdc Blue Oros,and Blue Shield of///mots products of
t
services Dearborn National Y t de In uranCC('ompany i. oiely responstble tier the life and dtsahilitr product de.enbed m thn,illus(. not
R A Division of Health('arc Sen wv I otpomoon.a Mutual I:gal Resme Company.an lndependem Licensee nl'the Btu,Un-and Blue Shield also,tan.,r,
GA-10-9-SMGRP BPSF HCSC MM Rev.02/18!16
3
Section 4-New Business:
Please select plan designs (Up to a maximum of 6 plans) GROUP NUMBER:
sm
A. Blue Choice Options
Tiered Network(Blue Choice OPT PPO-BC/PPO-PPO Out of Network-OON)
ffi• ,
d d
MTP72C2F $500/$1,500/$3,000 900/o/70%150% $4,000/$5,600/$12,000 $20/$50 $400*/$400' $0/$10/$35/$751$150
MTP3274F $1,000/$2,5001$5,000 90%!70%/50% $2.500/$5,500/$11,000 $25/$50 $400*/$400* $0/$10/$35/$75/$150
MTETIV07 $2,600/$4,5001$9,000 100%(80%/60% $2,600/$6,450!$12,900 N/A/N/A NIA/N/A 100%
MTPF305F $4,000/$5,000/$10,000 1 80%!60%/50% $5,600/$5,600 I$13,200 $35/$60 $500*/ $500' $01$10/$351$75/$150
❑MTP7122F $500/$1,500/$3,000 100%/70%/50% $500/$3,0001$6,000 $20/$50 $400'/$400 $01$10/$351$75/$150
MTP7272F $500/$1,500/$3,000 90%/70%150% $2,5001$5,500/$11,000 $20/$50 $400*/$400* $01$10/$35/$75/$150
Ll MTP9253F $1,500/$3,500 I$7,000 90%!70%/50% $3,000/$5,5001$11,000 $30/$50 $400'/$400- $0/$10/$35/$75/$150
MTPC173F $2,500/$4,5001$9,000 100%/80%/60% 1 $2,500/$5,550/$11,000 $30/$50 $400-/$40n- $0/$10/$35/$75/$150
sm
B.Blue Choice Select
MBP0353G $1,000/$2,000 80%/60% $3,000/$6,000 $30 $400* $0/$10/$50/$100/$150
MBPC3836 $2,500/$5,000 80%/50% $4,500/$9,000 $30 $150 $10/$40/$60
MBP72326 $500/$1,000 90%/60% $1,500/$3,000 $20 $150 $10/$40/$60
Lj MSP92326 $1,500 t$3,000 90%/60% $2,500/$5,000 $20 $150 $10/$40/$60
Lj MSP93C3C $1,500/$3,000 80%/50% $3,500/$7,000 $30 $150 $8/$35/$75/$150
MBP8343C $1.000/$2,000 80%/50% $3.000/$6,000 $30 $150 $8/$35/$75/$150
171 MBP82326 $1,0001$2,000 90%/60% $2,000/$4,000 $20 $150 $10/$40/$60
MBP42326 $250/$500 90%/60% $1,2501$2,500 $20 $150 $10/$40/$60
MBP73436 $5001$1,000 80%/50% $2,500/$5,000 $30 $150 $10/$40/$60
El MBPA3C3F $2,000/$4,000 80%160% $4,000/$8,000 $30 $150 $0/$10/$35/$751$150
MBPA303F $2,000/$4,000 80%/60% $5,500/$11,000 $30 $150 1 $0/$10/$35/$75/$150
MBPF1C3F 1 $4,000/$8,000 100%1100% ! $4,000/$8,000 $30 $150 $0/$10/$35/$75/$150
MBPF3Q3F 1 $4.000/$8,000 1 80%/60% $5,500/$11,000 $30 $150 $0/$10/$35/$75/$150
C.BlueEdge Select HSA-Asterisk Indicates Aggregate
n
MBSC1807* 1 $2,500/$5,000 100%/70% $2,500/$5,000 100% 100% 100%
MBSC3805* 1 $2,500/$5,000 80%/50% $5,000/$10,000 80% 80% 80%
CPO-ThisD. •• •
MCP7202C 1 $500 90% $2,500 $20 $150 $8/$35/$75/$150
$1,000 80% $5,000 $20 $150 $8/$35/$751$150
$2,000 60% $14,000 60% $150 $8/$35/$75/$150
CO #of Ees
CO #of Ees
Initial Employee Enrollment by CPO Network I CO #of Ees
Total#of Em to ees Enrolled:
E. ..• Aggregate
s
❑MPET290H $2,600/$5,200 90%170% $3,5001$7,000 N/A N/A 90%
❑ MPSC1807 $2,500 100%l 80% $5,000 100% 100% 100%
❑MPETIV07 $2,600/$5,200 100%/80% $2,600 I$10,400 100% 100% 100%
❑MPET3Y05 $2,6001$5,200 80%/60% $5.200/$10,400 80% 90% 80%
0 MPS91605 $1,500 100%180% $3,000 100% 90% 80%
❑MPS93505 $1,500/$3,000 80%160% $3,000/$6,000 80% 90% 80%
❑MPSC3805* $2,500/$5,000 80%/60% $5,000/$10,000 80% 90% 80%
❑MPSE3X05* $3,500/$7,000 80%/600,16 $5,8001$11,600 80% 90% 80%
MPPO1007 $6,000/$12,000 100%/100% $6,000/$12,000 N/A N/A 100%
F.CPO Value Choice-This Product Is not available in all geographic areas(Network:CPO/PPO OUT)
X0'1$NRi1 biz w, ro,y� r # ' d ' „f
.PIIlh.tl Now
Ll MCV82305 $1,000 1 90% 1 $2,000 1 90% $150 80%
$2,000 80% $4,000 90% $150 80%
$4,000 50% $8,000 90% $150 80%
CO #of Ees _
CO #of Ees
Initial Employee Enrollment by CPO Network CO #of Ees
Total#of Employees Enrolled:
"Products adc�rvices marketed a tTihc ea un National-ions rant an to star ogo are un envn ten an or provicietlFiye'Tf r-UumaR'Tonal" t e Insurance(bmpanyIllowners. Lirove,11.1irtall
states(excluding New York)and ccrtmo of it,affiliates. Dearborn National'Life Insurance Company is it separate company that does not provide Blue C'roo and Blue Shield of Illinois products or
services Dearhom National K Life lusurans Company i;solely responsible for the life and disability products described in this illustration
it A ni%ision of Health Care Scr%:cc(-n p,nratwn.a'Stutual Legal Reser-ir Company.au Independent I the Blue Cross and Blue Shield Association,
GA-10-9-SMGRP BPSF HCSC MM Rev.02/18/16 2
B1ueCross BlueShield
Dearborn i`tat>onal'
�•� of Illinois
s •
BENEFIT PLAN SELECTION (BPS)
(To Be Used for Mid-Market Group Accounts)
Please complete&return this form in its entirety, including the required signatures
Section 1 -Account Information:
Employer Name: H / ;)
� ir, ri r` r
BIueSTAR Account#: „ ,t 9 Effective Date: j ; 5i` iAnniversar Date:
Health Products/Mid-Market Benefit Plan Selection:
• The OPX in all non-HSA plans listed below will not exceed$1,000 for RX or$5,600 for Medical for Individual;and$3,000 for RX or
$10,200 for Medical for Family. For HSA plans,the OPX will not exceed$6,450.The OPX is inclusive of all deductibles,copays and
coinsurance costs incurred on in-network benefits.
• There are four health product categories which include multiple products(i.e.Blue Choice PPO)and their applicable benefit plans.
• A group may select up to six health plan options.
• The Prescription Drug Card may vary between products.
Section 2a-Renewing Groups Only: *If New Business, skip to Section 3
Current Plan: Retaining Plan: Replacing Plan:
Please list current plan(s)below Please list replacement plan in space below.
1. ❑Yes ❑ No
2. ❑Yes ❑ No
3. ❑Yes ❑ No
4. ❑Yes ❑ No
5. ❑Yes ❑ No
6. ❑Yes ❑ No
Section 2b-Renewing Groups Only: (*If New Business skip to Section 3)
Adding Plan(Medical andlor Dental): ---
Please list new plan(s)below
2.
3.
4.
5.
6.
Section 3—HSA/ FSA Plans:
HSA Vendor: FSA Vendor:
•If HSA is selected,a vendor will need to be selected. *If FSA is selected,a vendor will need to be selected.
(If no selection is made,HSA Vendor will default to Other!None.) (If no selection is made FSA Vendor will default to Other 1 None.)
I
I
❑ Option A: BenefitWallet ❑ Option D: FSA ConnectYourCare
i
❑ Option B: FIexHSA Plan ( ❑ Option E: FSA Other/None
l
❑ Option C: HSA Bank ❑ Option F: HSA Other/None
I
•Products and scn,ces marketed under the Dearborn National'brand and fhe star lcipn arc underwritten and ar pr,,cicled h%Dearborn National*Life Insurance Cnntpau�(Downers Grovr.Il.)in all
states(excluding No,York)and cenam of its affiliates Dcarbont N itim:ai"t ile lu,unnce(ompom 1,i"prate cumpany that dues not provide Blue Crus,and Bhte Shield ut llliuuis products ur
sen lees. Lkarbom ,,atiotai a ute ln,urnwe Company is vilely rc,pon,cble for the lite and di,ama"Imatucta de,crihed in this illustntion.
I,A Di%sion of Health(arc Scn ice Corvontion.a Mutual Legal Resene Cnmpam.an Independent I iceuxcc(11 lite Blue(rnss and Blue Shield Acsociauon
GA-10-9-SMGRP BPSF HCSC MM Rev.02/18/16 1
in Network Out
. Network"
s �•
Iralurgery Services
Surgical tooth extractions
Alveoloplasty and vestibuloplasty
Excision of benign odontogenic tumor/cyst 80% 80%
Excision of bone tissue
Incision and drainage of an intraoral abscess
Surgical Periodontal Services
Gingivectomy or gingivoplasty and gingival flap procedures
Clinical crown lengthening
Osseous surgery
Osseous grafts 80% 80%
Soft tissue grafts/allografts
Distal or proximal wedge procedure
Anatomical crown exposures
Major Restorative Services
Single crown restorations
Gold foil and inlay/onlay restorations 50% 50%
Labial veneer restorations
Crowns placed over Implants
Prosthodontic Services
Complete and removable partial dentures
Denture reline/rebase procedures 50% 50%
Fixed bridgework
Prosthetics placed over implants
Miscellaneous Restorative and Prosthodontic Services
Prefabricated crowns
Recementations 50% 50%
Post and core,pin retention and crown/bridge repairs
Adjustments
l� • • g •
Ort o optic Services
Orthodontic Diagnostic Procedures and Treatment 50%
Lifetime Maximum per Participant $1,000
(Deductible waived)
Dental implants are not covered.
The above is a listing of common services available through your network of Participating Dentists.
The Member's share of the cost is determined by whether care is received from a Participating or Non-Participating Dentist.
"For services rendered by a Non-Participating Dentist(out of network,the Allowable Charge is the Provider's usual charge,not to exceed the amount
that the Plan would reimburse a Participating Dentist rendering the same services. The Member will be responsible for the full amount by which the
Non-Participating Dentist's actual charges exceed the Allowable Charge.
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
228615.0815
Of oss BlueShield BlueCare Dental PPOsm
of Illin
Plan ID:DINHM08
This information only provides a summary of the benefirs for this Dental Plan.Please refer to your Dental Benefit Booklet for additional benefit
information. The Deductibles,Coinsurance and Benefit Period Maximum shown below are subject to change as permitted by applicable low.
------
Summary of 4 N i i
Program
B.sics
�' •il �I a i
Benefit Period Maximum
$1,000 $1,000
Deductible
$50 Individual/$150 Family $50 Individual/$150 Family
B ' a
Diagnostic Evaluations
Periodic oral evaluations 100% 100%
Problem focused oral evaluations (Deductible waived) (Deductible waived)
Comprehensive oral evaluations
Preventive Services
Prophylaxis(cleanings) 100% 100%
Topical fluoride applications (Deductible waived) (Deductible waived)
Diagnostic Radiographs
Full-mouth and panoramic films 100% 100%
Bitewing films (Deductible waived) (Deductible waived)
Periapical films
Miscellaneous Preventive Services
Sealants 100% 100%
Space maintainers (Deductible waived
(Deductible waived)
Basic Restorative Dental Services
Amalgams
Resin-based composite restorations 80% 80%
Non-Surgical Extractions
Removal of retained coronal remnants
Removal of erupted tooth or exposed root 80% 80%
Non-Surgical Periodontal Services
Periodontal scaling and root planing
Full-mouth debridement 80% 80%
Periodontal maintenance procedures
Adjunctive Services
Palliative treatment(emergency)
Deep sedation/general anesthesia 80% 80%
Endodontic Services
Therapeutic pulpotomy and pulpal debridement
Root canal therapy 80% 80%
Apexification/recalcification
B1ueCross BlueShield
�•� � of Illinois
CITY OF CANTON
SIC Code:9111 Coverage Effective Date:05/01/16
Rated ZIP Code:61520 Proposal Expires:05/31/16
Date Prepared:03/29/2016
Illinois Dental Plans
Coinsurance
Deductible Annual Total
Plan In/Out Benefit Out of- Outof Orthodontia Employee Employee Employee Monthly
Plan Type Fam:3 x Network In Network Lifetime + + Family
Max Reimb. Network Max Only Spouse Children Dental
Ind)z In/Out Cost-
True
High Allocation
DINHMI2 Passive $25/$75 $750 MAC 100/80 100180 NA $9.43 $20.27 $29.64 $44.22 $0.00
DINHMIO Active $50/$50 $1500/1000 MAC 100/80150 80/60/40 NA $19.98 $42.89 $51.25 $79.97 $0.00
DINHM08 Passr.e $50,'$50 $1000 100;8W50;50 100/80%50/50 $1000 $22.57 $48.49 $62.51 $95.82 $0.00 1
DINHRO3 Passne !00180;50!50 $1500 533.79 $72.58 $87-63 $136.40 $0.00
} RLC
DINHRO2 Passive $50/$50 $2000 90th 100/80/50/50 300/80150/50 $2000 $34.94 $75.06 $91.25 $141.78 $0.00
R&C
DINHR01 Passive $25/$25 $3000 90th 300/80,1S0/50 100/80/50/50 52000 $36.92 $79.31 $93.97 $146.91 $0.00
R&C
DINHRO4 Active $50/$75 $1500/1000 90th 100/80/50/50 80/60/50(50 $1000 $26.69 $57.33 $69.51 $108.08 $0.00
R&C
Low Allocation
DINLRO6 Passive $501$50 $1000 90th 100/80;50 IOJi30/50 NA $27.35 $58.74 $68.73 $107.78 $0.00
R&C
DINLM09 Passive $501$50 51000 MAC 100/80/50 100/80/50 NA $19.92 $42.78 $51.70 $80.45 $0.00
DINLRO5 Passive $50/$50 $1000 90th 100/80;50/50 100/80/50/50 $1000 $27.96 $60.04 $74.56 $115.27 $0.00
R&C
DINLM11 Active 575/$75 $1000 MAC 90/70/50 70/50/30 NA $15.16 $32.56 $39.78 $61.73 $0.00
DINL1107 Passive $751$75 $1000 90th 90170/50 90/70.!50 NA $23.40 $50.27 $58.21 $91.52 $0.00
R&C
Voluntary
High Allocation
DINHMI6 Passive $251$75 $750 MAC 100,180 100!80 NA $10.34 $22.21 $32.56 $48.55 $0.00
DINHMI4. Active $50/550 $1500/1000 MAC 100/80/50 80/60 40 NA $21.95 $47.14 $56.41 $87.98 $0.00
DINHR13 Passive 550/$50 $1500 90th 100/80/50/50 100/80/50/50 $1500 $35.36 $75.95 $94.39 $145.91 $0.00
R&C
Low Allocation
DINLMI5,. Active $75/$75 $1000 MAC 9Oi70/50 70/50/30 NA $16.69 $35.84 $43.74 $67.91 $0.00
Coinsurance Type-I :Exams/Cleanings/X•Rays(both High&Low Coverage)
Coinsurance Type-!I:Basic Restorative,Simple Extractions,Non-surg Perio(both High&Low Coverage),Endodontics,Oral Surgery,Surgical Perio(High)
Coinsurance Type-III:Major Restorative,Prothotlontics,Prothsodontics(both High&Low Coverage),Endodontics,Oral Surgery,Surgical Peru(Low)
Coinsurance Type-IV:Ortho(both High&Low Coverage)
R&C: Reasonable and Customary,MAC:Max-Allowed Charge
'Waived Deductible applies to all Class I services and 3x family deauctible limit.
"Waiting Period 12 month applicable for Surgical Perio/Ma)or Restorative/Prothodonbcs/Misc Rest&Prosth Services
True Group=(>70%Participation AND>50%Employer Contribution),Voluntary Group=(:-259%o Participation AND<50%Employer Contnbuuon)
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association
?age 17 of 13 03/29/2016 11:32 AM
CIS OF CA( T{ 1
051 11201 b-Rev�s0d2
Q
Ra*
- � :.. - -.,.. � -
-Ra Summary
CURRENT BPP72322 RENEWAL BPP72322
Livts Rates lips Rates
HCSC Primary
Single 30 $679.76 30 $733.95
Single + Spouse 30 $1,360.17 30 $1,462.74
Single + Child(ren) 19 $1,264.85 19 $1,326.47
Family 38 $1,945.26 38 $2,055.25
Medicare Primary
Single 0 $396.09 0 $420.54
Family 0 $792.17 0 $841.08
Monthly Total 117 $159,149.93 117 $169,203.13
Annual Total $1,909,799.16 $2,030,437.56
_ CURRENT NPS91605 RENEWAL.MPS91605
Lim Rates Lias Rates
HCSC Primary
Single 5 $580.55 5 $626.55
Single + Spouse 3 $1,161.66 3 $1,248.68
Single + Child(ren) 4 $1,080.25 4 $1,132.36
Family 0 $1,661.36 0 $1,754.49
Medicare Primary
Single 0 $338.28 0 $359.00
Family 0 $676.56 0 $718.00
Monthly Total 12 $10,708.73 12 $11,408.23
Annual Total $128,504.76 $136,898.76
Total $2,038,303.92 $2,167,336.32
Rates include Taxes and Fees Renewal Increase 106.33%
Excess Amounts of Life Insurance:
Evidence of Insurability will be required for individual life insurance amounts in excess of$ . Such excess insurance amounts shall become effective on
the date Evidence of Insurability is approved by Dearborn National•Life Insurance Company.Waiver of Premium,in the event of total disability,will terminate at
age 65 or when no longer disabled,whichever is earlier.Being Actively at Work is a requirement for coverage.If an employee is not Actively at Work on the day
coverage would otherwise be effective,the effective date of coverage will be the date of return to Active Work.If an employee does not return to Active Work,
he/she will not be covered.
2. Dependent Life
❑Yes 5NO Spouse Children—age birth to 14 Children—age 14 days to 6 Children—age 6 months to
days months 26 years/student 26
❑Option 1 $10,000 ( $100
$100 $5,000
Choose a
Plan: ❑Option 2 $5,000
$100 $100 $5,000
❑Option 3 $5,000 A '100
$100 $2,000
Short13.
❑Yes [+f No Complete Item 4 below if Short Term Disability benefits vary by class
Benefit will not exceed 66 2/3%of Basic Weekly Salary and is payable for non-occupational disabilities only
Choose a Benefit:
❑Flat$ weekly(not to exceed$250)
❑Salary Based(select one)- ❑50% ❑60% ❑66 2/3%of Basic Weekly Salary up to a maximum of$
Choose a Plan:Accident/Sickness/Duration
❑ 1 !8/13 weeks ❑8/8/13 weeks ❑ 15/15 113 weeks 1 *❑31 /31/13 weeks 'Only available to groups with 10 or more lives enrolled
❑ 1!8/26 weeks ❑8/8126 weeks ❑ 15/15 126 weeks *❑31 /31/26 weeks
'4. Classes
Please complete this chart if Term Life or Short Term Disability benefits vary by class(3 Max 2—9 lives) (6 Max 10+lives)
Class Description Term Life 1 ADBD Short Term Disability
Electronic Issuance:
(Non-HMO Health and Dental Pians only) The Policyholder consents to receive,via an electronic file or access to an electronic file,a Certificate Booklet
provided by HCSC to the Policyholder for delivery to each Insured. The Policyholder further agrees that it is solely responsible for providing each Insured access,
via the internet,intranet or otherwise,to the most current version of any electronic file provided by HCSC to the Policyholder and,upon the Insured's request,a
paper copy of the Certificate Booklet.
Additional Provisions:
Use this section to indicate if the account is retaining any plan(s)not shown above,or need to indicate any other instruction or important information.
Section 6—Signatures:
Signatures
Employer/Authorized Purchaser ---- TI eL{+t t C Date
Underwriter Title Date
'Products and sen ices marketed under the Dearborn National"brand and the star logo are undetwnnen and or pan idea by Dearborn Naltonalf'Life Insurance Company(Downers Grose.It.)in all
-rates lescludinc New 1'orkl and certain outs adiliatc- Dearborn National"Lill In-unenec t'ornpany is a separ:ne contpam'hat dues not provide Blue Cross and Blue Shield of Illinois products or
,cn ices Dcarhuro NatioiudK Lite lusura of c Comp on is solctt responsible for the lite and dwbihith products dcxribed in this illuslrahou.
KA Dic isron of I Icalih('arc Scrncc Corporation.a,%lutual I cgal Rescnr Contpauy,au Independent Licensee rt t1w Bloc Cross and Blue Shield \s-iociarion
GA-10-9-SMGRP BPSF HCSC MM Rev,02/18/16 5