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Home My WebLink About#5091 BCBS RESOLUTION NO. 5091 A RESOLUTION APPROVING A GROUP ENROLLMENT AGREEMENT BETWEEN THE CITY OF CANTON AND BLUECROSS BLUE SHIELD FOR THE GROUP MEDICAL 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 City of Canton, Illinois 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 Medical Plan as set forth in Exhibit A attached and incorporated hereto. 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 the City Clerk of Canton, Illinois, are 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, Fulton County, Illinois,and approval by the Mayor thereof. PASSED by the City Council of the City of Canton, Illinois, at a regular meeting this 18TH day of April, 2017, upon a roll call vote as follows: AYES: Aldermen Justin Nelson,Gerald Ellis,John Lovell, Angela Hale,Craig West,Tad Putrich, Ryan Mayhew NAYS: None ABSENT: None APPROVED:'/ ,oA /'J��/ Jeffrey K. Frra,.Mayor Dita'avle" ck, iyClerk BlueCros BlueShield otllBDole Account Name: CITY OF CANTON Account Number: 389388 Renewal Date: 03/01/17 Grandfathered Health Plan Form The Affordable Care Act(ACA)provides that certain group health Insurance coverage In which an Individual was enrolled on March 23,2010.(ACA's date of enactment)may be a"grandfathered health pan.'Grandfathered health plans are not subject to certain ACA provisions.Among other requirements,in order to maintain grandfathered health plan statue,an employers or employee organization's conmbut on rete toward the coat of any tier of coverage cannot decrease by more than five(5)percentage points since March 23,2010. By default,our group renewal offer(s)reflect a non-grandfathered health plan design.This OrendfafMnd Health Plan Form must be skuudjyyllissmazegresentaNke and returned to our offices at Nast 10 days prior to your renewal's)effective date in order to change your renewals)to a gnndfathsred health plan design.If a plan is modified to a non-grandfathered health plan design on Its effective date.It cannot later revert back to a grandfathered health plan design. For more Information on grandfathered health plans and what changes or events may cause a plan to lose grandfathered health plan status,go online to:bcbsII.com/affordabie_care_act.If you have questions regarding this worksheet,contact your insurance broker(if apptcesle) or your BCBSIL account representative.The rules related to grandfathered health plans are cornet's.We recommend that you seek the advice and guidance of your legal counsel regarding ACA and grandfathered heath plans. If you believe a plan or policy has lost or will lose grandfet hered status,contact your Insurance broker(if applicable)or BCBSIL representative immediately for available benefit plans options. Check the"Grandfatthend7"box for only the benefit plan(s)in effect that qualify for and that you wish to renew with a grandfathared health plan design. mium: Premium: erouP PIaWBeneM Premium: Premium: Premium: Premium: Pre Medicare Malcom Num f Agreement GrandFathredFamily 7 Employee Employee Employee Printery Primary Name/Number Only •spouse •CMM(ren) Employee Family P89388 BPP72322 ®Yea 0 No $721.95 81444.12 $1314.50 82036.65 8413.67 8827.32 P95069 MPS91605 O y0s ®No $619.84 $1239.88 $1128.58 $1748.60 $355.16 $710.32 ❑Yee No AGAMon ofHealth Cue Service Capo,m ,a Mutual Lags/Resent Company,an Independent licensee of me Blue Ona an Jaime SAeklAaRYltbn. Grand fared Health Ran Form-SUFI-2012 4111) BlueCross BlueShield of Illinois Account Name: CITY OF CANTON Account Number: 389088 Renewal Date; 06/01/17 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 plane as set forth in the Affordable Cam 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 employees 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. /rrlyntM 9 "mint Title /� [ /f /) urs tale A Division of Health Care Service Corporation,a Mutual Legal Reserve CmieanY,an Independent Licensee ofthe Blue Cres and ate ShielAmadathv. Grand/ethwed Health Plan POT)-SGFI-2012 41.111) BlueCYoss BlueShield of Illinois Account Nam*: CITY OF CANTON Account Number: 999399 Renewal Date: 05101117 Orandfathered Health Plan Form Contribution Information Complete the following information to report on employer or employee organization contribution rates only for benefit plan(s)wham YES was dwdred In the'Grendfatheredr column on page 1 of this form. Should the contributions ogler by any employee class or tier within the employer group or employee organization,each of them must be stated. Benefit Employee Class Tier Renewal Date Plan (e.g.,All, Hourly Only, (e.g.,Employee. Employer's RNRIOIRNioat Name I Salaried Only or Other(as I Employee Organization's Contribution (e.g.,PPOi defined by Employer or +Chlld(ren), Rate HMO) Employee Organization)) Employee+Spouse, 50% 75% 100% Other% Family) (indicate% amount if Omer) PPO All - All Tiers ❑ ❑ ❑ BD% ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ — ❑ ❑ ❑ ❑ ❑ ❑ - • IM ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ - ❑ ❑ 0 ❑ o ❑ - Add additional details as needed by copying this page.Make sure you return the signature and table page(*)together. A Division°Meath Cate Senate Coryeation,a Mutual'PO FaRWM Gamma,an Independent Licensee of the due Ones and afire St Aa natoon Grandfathered Health Ryan POW).SGFI-1011