HomeMy WebLinkAboutResolution #5304 - insurance renewal with blue cross blue shield for May 1, 2021 to April 30, 2023 RESOLUTION NO. 5304
A RESOLUTION APPROVING AN INSURANCE RENEWAL BETWEEN THE
CITY OF CANTON AND BLUE CROSS BLUE SHIELD OF ILLINOIS FOR THE
POLICY TERM PERIOD MAY 1,2021 TO APRIL 30,2023
WHEREAS, the City of Canton, Illinois(the"City")provides health insurance to not only
its various Union employees, but also its non-Union employees and elected officials;
WHEREAS, the City and the Insurance Committee investigated and determined what
options would be available for health insurance purposes to continue said coverage for City
employees;
WHEREAS, the City has determined that it is necessary and in the best interest to renew
the health insurance policy and coverage through Blue Cross Blue Shield of Illinois for the policy
term period May 1, 2021 through April 30, 2023.
NOW, THEREFORE, BE IT RESOLVED BY THE MAYOR AND THE CITY
COUNCIL OF THE CITY OF CANTON, FULTON COUNTY, ILLINOIS AS FOLLOWS:
1. The City of Canton hereby finds as fact the recitals set forth above and are incorporated
herein as though fully set forth;
2. The Mayor and the City Clerk are hereby authorized and directed to execute and deliver
any renewal documents necessary to accomplish a two-year renewal, at a total increase of
4.46%, on behalf of the City with BCBS.
3. This Resolution shall be in full force and effective immediately upon its passage by the
City Council of the City of Canton and approval by the Mayor thereof.
PASSED AND APPROVED THIS 30th day of March, 2021.
AYES Aldermen Andra Chamberlin, Quin Mayhew, John Lovell, Craig West, Angela
Hale, Jeff Fritz, Angela Lingenfelter
NAYS: None
ABSENT: Alderman Justin Nelson
APPRO ED: A �J�
By: • //A/I [
Kent McDowell ayor
ATTEST: 0-4
Diana Pavley-Rock, City Clerk
EXHIBIT A
zra BlueCross BlueShield
Cj of Illinois
BENEFIT PROGRAM APPLICATION ("BPA")
(All items are applicable to 51-150 Grandfathered and Non-Grandfathered Insured Group Accounts unless otherwise specified.)
(All items are applicable to the HMO plan and the Non-HMO plan unless otherwise specified.)
Employer Group No.(s): Section No.(s):
Account No. (Blue Stars""): 389388 Customer No. (if different, for existing business only):
Employer's Legal Name: City of Canton
(Specify the employer applying for coverage and list the names of any subsidiary or affiliated companies to be covered below.)
Physical Address: City: State: Zip Code:
2 N Main St Canton Illinois 61520-2618
Billing Address(if different from above): City: State: Zip Code:
see B*for affiliated company addresses
Employer Identification Number("EIN"): 376000876 Standard Industry Code (SIC): 9111
Wholly Owned Subsidiaries to be Covered:
Affiliated Companies to be Covered: Canton Park District, Greenwood Cemetery, Parlin Ingersoll Library
(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: Phone: Fax: Email:
Diana Pavley-Rock 309-647-0020 309-647- dpavleyacantoncityhall.org
1310
Blue Access for Employers`" ("BAESM') Contact:
(The BAE Contact is the employee of the account authorized by the Employer to access and maintain its account via BAE)
Title: Phone: Fax: Email:
City Clerk
Policy Effective Date: 05/01/2021 Policy Anniversary Date: 05/01 /2022
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 ❑
If Yes, specify ERISA Plan Year*: Beginning Date: 05 /01/2021 End Date: 04/30/2022 (month/day/year)
ERISA Plan Sponsor*: City of Canton
ERISA Plan Administrator*: Diana Pavley-Rock
ERISA Plan Administrator's Address: City: State: Zip Code:
2 N Main St Canton Illinois 61520-2618
ERISA Plan Administrator's Email: dpavley(cr�.cantoncityhall.orq
Life and Disability insurance is underwritten by Dearborn Life Insurance Company,701 E.22'd St.Suite 300,Lombard,IL 60148.Dearborn Life Insurance
Company is an independent Blue Cross and Blue Shield licensee.BLUE CROSS®,BLUE SHIELD®and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association,an association of independent Blue Cross and Blue Shield Plans.
Medical and Dental benefits are offered by 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.
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.
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-51-150-HP-BPA Rev. 06/20 -1 -
Please provide your Non-ERISA Plan Month/Year:_/_
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)
0 Church Plan (complete and attach a Medical Loss Ratio Assurance form)
El Other, please specify:
For more information regarding ERISA,contact your Legal Advisor.
*AII as defined by ERISA and/or other applicable law/regulations.
1. Eligible Person. Employer has decided that Eligible Person means:
El a Full-Time Employee of the Employer. Full-time Employee means an Employee of the Employer who is regularly
scheduled to work a minimum of hours per week.
The term "Employee" shall have the meaning set forth under ERISA and applicable law. Blue Cross and Blue Shield
of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company ("BCBSIL") reserves 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 El 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 and Civil Union partners under COBRA continuation.
Domestic Partner Coverage Continuation (only available if Domestic Partners are covered) 0 Yes ❑ No
4. Retiree Coverage: Yes El No 0 If yes, complete the following, as applicable:
A. Retiree means those persons covered as retirees under the Employer's health care plan prior to the date the
Employer initially purchased coverage from BCBSIL. Yes 0 No ❑
If yes, complete item 14. below.
B. Retiree means those persons who retire on or after the effective date of this BPA: Yes ❑ No El
If yes: Such retirees must be at least years of age on the date of retirement with years of
continuous full-time employment with the Employer. Note: Minimum years of age is fifty-five(55); minimum years
of continuous full-time employment is ten (10).
For existing groups, former Employees who retired after the date the Employer initially purchased coverage from
BCBSIL and prior to the initial effective date of the retiree coverage specified in item 4.B. above are not eligible. An
Employer may only elect or change retiree coverage on the Policy Effective Date or Policy Anniversary Date. For Life
Plans, retiree coverage is not available.
5. 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 Employer reported a Coverage Date earlier than
what would apply to the Employee or Dependent, based on the Waiting Period and eligibility conditions the Employer
provided to BCBSIL, BCBSIL reserves the right to retroactively adjust the Coverage Date for such person.
IL-LG-51-150-HP-BPA Rev. 06/20 -2-
A. For Health, Dental PPO and Life Coverage (If purchasing life or short-term disability coverage, the account
must have a first (1St) of the month effective date):
❑ The date of ❑ The day of employment. El The first day of the month
following the date of
employment. Note: This may not exceed 91 calendar days employment.
❑ The day (select 1St or 15th)of the month following month(s) of employment (option of 1 or 2
months)
El The day (select 1St or 15th)of the month following days of employment(option of up to 60
days)
Note: For multiple classes with different eligibility dates, use the Additional Provisions section below to specify
each class and eligibility date.
B. For Dental HMO Coverage:
El The first(1St)day of the month following the date of employment.
❑ The first(1St)day of the month following month(s) of employment(option of 1 or 2 months)
El The first (1St) day of the month following day(s)of employment(option of up to 60 days)
Note: For multiple classes with different eligibility dates, use the Additional Provisions section below to specify
each class and eligibility date.
C. Waive the Waiting Period on initial group enrollment? ❑Yes El No
D. Number of Employees serving Waiting Period:
E. 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.
El A Cumulative hours of service requirement that does not exceed 1200 hours
El 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).
El Other substantive eligibility criteria not described above; please describe:
6. 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. For health and
dental Plans, coverage will terminate at the end of the period for which premium has been accepted. For Life Plans,
coverage will terminate on the birthday. However, coverage shall be extended due to a leave of absence in
accordance with any applicable federal or state law.
IL-LG-51-150-HP-BPA Rev. 06/20 -3-
7. Disabled Dependent: A Disabled Dependent means a dependent child who is medically certified as disabled and
dependent upon the Employee or his/her spouse.
To administer medical certification of disabled Dependents, you may select option (a) Standard Rules or (b) Custom
Rules. If (b) is selected there are additional selections regarding age, proof of prior coverage, certification review,
forms, and previous medical certification approvals.
(a) ❑ Disabled Dependent Administration will follow Standard Rules.
A disabled Dependent may continue coverage beyond the limiting age, provided the disability began
before the child attained the age of 26. A disabled Dependent may add coverage beyond the limiting age,
provided the disability began before the child attained the age of 26, and proof of coverage as a disabled
Dependent is provided.
Administration of Certification Review is handled by BCBSIL; a BCBSIL Disabled Dependent Certification
Form must be submitted to BCBSIL.
(b) ❑ Disabled Dependent Administration will follow Custom Rules. Please make the following sections:
Age: Please select one option regarding age of when the disability began.
O The disability must have begun before the child attained the age of 26 or other age permitted by law.
❑ All disabled Dependents are covered regardless of when the disability began.
Proof of Prior Coverage: Please select required or not required below:
When adding coverage, proof of prior coverage as a disabled Dependent is ❑ required ❑ not required.
Certification Review: Please select one option regarding handling of Certification Review.
❑ Certification Review is handled by BCBSIL; a Disabled Dependent Certification Form must be
submitted to BCBSIL.
❑ Certification Review is handled by the Employer; there are no Disabled Dependent Certification Form
requirements.
If Certification Review is selected as handled by BCBSIL, please select one option regarding forms:
❑ The BCBSIL Disabled Dependent Certification Form will be utilized.
❑ A ❑ Custom or❑ Other Disabled Dependent Certification Form will be utilized
If Certification Review is selected as handled by BCBSIL, please select allowed or not allowed below:
A disabled Dependent approved medical certification from a prior carrier is ❑ allowed ❑ not allowed.
A disabled Dependent approved medical certification from a prior BCBS policy is ❑ allowed
❑ not allowed.
8. Enrollment:
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 effective on
the 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.
Annual Open Enrollment: For Health and Dental Plans only, an Eligible Person, who did not enroll under Timely
Enrollment, may apply for Individual coverage, Family coverage or add Dependents during the Employer's Annual
Open Enrollment Period. The Open Enrollment Period is to be held thirty (30) days prior to the Policy Anniversary
Date of the program. Such person's Individual Coverage Date, Family Coverage Date and/or Dependent's Coverage
Date will be the Policy Anniversary Date following the Open Enrollment Period, provided the application is dated and
signed prior to that date.
Late Enrollment: For Non-Voluntary Life, Accidental Death and Dismemberment (AD&D) and Short-Term Disability
Plans only, an Eligible Person who did not apply under Timely Enrollment may apply for Individual coverage, Family
coverage or add Dependents. Late enrollees must furnish acceptable evidence of insurability if the Employer
contributes less than one hundred percent (100%). If the Employer contributes one hundred percent (100%), such
person's effective date will be a date mutually agreed to by the insurance company and the Employer. For Voluntary
Life Plans only, Employees applying for or increasing coverage after their initial eligibility period can only enroll during
the Employer's annual enrollment period. Satisfactory evidence of insurability will be required for Voluntary Life
coverages in these circumstances.
IL-LG-51-150-HP-BPA Rev. 06/20 -4-
9. Extension of Benefits: An Extension of Benefits will be provided for a period of thirty (30) days in the event of
Temporary Layoff, Disability or Leave of Absence. However, benefits shall be extended for the duration of an Eligible
Person's leave in accordance with any applicable federal or state law. In the event of Total Disability at the time the
group policy is terminated, an Extension of Benefits will be provided for a period of no more than twelve (12) months
from the date of termination, to the extent required, and in accordance, with any applicable federal or state law.
For Life Plans, an extension of benefits will be provided as follows: Due to Disability - until the end of the twelfth
month following the month in which the disability began; Due to Layoff and Leave of Absence - until the end of the
month following the month during which the layoff or leave of absence began. The extension will apply, provided all
premiums are paid when due.
10. Premium Period: The Premium Period must be consistent with the Policy Effective Date and/or Policy Anniversary
Date.
❑ 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 HMOs" coverage.)
❑ Fifteenth (15th) day of each calendar month through the fourteenth (14th) day of the following calendar month.
(This option is not available for any coverage if the Employer has BlueCare Dental HMO coverage.)
Note: Groups with life and/or disability coverage and having less than one hundred dollars ($100.00) monthly
combined life and disability premium will be billed on a quarterly basis.
11. Employer Contribution:
(a)The following elections apply to both Grandfathered and Non-Grandfathered Groups:
Health and Dental Plans
❑ %for Employee Coverage ❑ %for Employee plus Spouse Coverage
❑ %for Employee plus Child(ren) Coverage ❑ %for Family Coverage
❑ 100% of the Employee Coverage Premium will be applied toward the Family ❑ Other(specify):
Coverage Premium.
(b) The following elections apply to both 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.
❑ % of the Individual Coverage Premium and %of the Family Coverage Premium.
❑ Other(please specify): .
(c) The following applies to both Grandfathered and Non-Grandfathered Groups:
BCBSIL 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.
(d) The following applies to Grandfathered Groups:
The required minimum Employer contribution is twenty five percent (25%). No policy will be issued or renewed
unless at least seventy percent (70%) of Eligible Employees have enrolled for coverage. This applies to health
and dental business separately. This does not include those Eligible Employees waiving coverage under BCBSIL
due to other group coverage. In no event, however, shall the policy be issued or renewed unless at least two (2)
Eligible Employees have enrolled for coverage.
(e) The following applies to Non-Grandfathered Groups:
BCBSIL 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 enrolled participation and Employer contribution levels; 2) after the policy effective
date the group will be required to maintain a minimum Employer contribution of 25%, and at least a 70%
participation of Eligible Employees (less valid waivers). In the event the group is unable to maintain the
contribution and participation requirements, then the rates will be adjusted accordingly; and/or 3) non-renew or
discontinue coverage unless the 25% minimum Employer contribution is met and at least 70% of Eligible
Employees (less valid waivers) have enrolled for coverage. Employer will promptly notify BCBSIL of any change
in participation and Employer contribution.
IL-LG-51-150-HP-BPA Rev. 06/20 -5-
(f) The following elections apply to both Grandfathered and Non-Grandfathered Groups:
Life,Accidental Death&Dismemberment(AD&D) and Short-Term Disability Plans
❑ %for Group Life, AD&D ❑ %for Dependent Life ❑ %for Short Term Disability '
If the Employer contributes one hundred percent (100%) toward the cost of coverage, no policy will be issued or
renewed unless at least one hundred percent (100%) of Eligible Employees have enrolled for that coverage. If
both the employer and employee contribute toward the cost of coverage, no policy will be issued or renewed
unless at least seventy five percent (75%) of Eligible Employees have enrolled for that coverage. Eligible
Employees are those who meet the definition of an Eligible Person, regardless of if an Eligible Employee waives
coverage under BCBSIL medical due to having coverage elsewhere.
12. Reimbursement: It is understood and agreed that in the event BCBSIL makes a recovery on a third-party liability
claim, BCBSIL will retain twenty five percent(25%) of any recovered amounts, other than recovery amounts received
as a result of, or associated with, any Workers' Compensation Law.
13. Third Party Recovery Vendors and Law Firms Provisions (other than Reimbursement Services): BCBSIL
engages with third party recovery vendors and law firms on a post-pay basis to identify and/or recover any potential
overpayments that may have been made to Providers.
14. Wellbeing Management(included): The undersigned representative authorizes the provision of alternative benefits
rendered to Covered Persons in accordance with the provisions of the Policy.
15. BlueEdge FSASM (Vendor: Select Vendor) purchased: El Yes 0 No
16. Blue Directions for Large BusinesssM purchased: ❑Yes ❑ No(if yes, The Blue DirectionssM Addendum is
attached and made a part of the Policy.)
17. Eligible Persons: If applicable, list the names of persons of the group who are eligible retirees as described in Item
4.A. above.
Name of Retiree Name of Retiree
18. Massachusetts Health Care Reform Act: Notwithstanding anything to the contrary in this BPA, with respect to the
Employer's Employees who live in Massachusetts (if any) the Employer represents that it offers the health insurance
benefits provided for herein to all full-time Employees, and the Employer will not make a smaller premium contribution
percentage to a full-time Employee living in Massachusetts than to any other full-time Employee living in
Massachusetts who receives an equal or greater total hourly or annual salary. For purposes of this representation, a
"full-time Employee" is defined by Massachusetts law, generally an Employee who is scheduled or expected to work
at least the equivalent of an average of thirty-five(35) hours per week.
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 are those contained in the Policy. It is further understood and agreed that the terms of
the BPA may be subject to change. The final terms may be specified in a benefit program and premium notification letter
or the applicable rate summary (ies) for the plan number(s) selected which may be attached hereto and made a part of
the BPA. Payment of the first premium due under the Policy constitutes acceptance of such terms. No coverage will begin
until receipt of the first premium by BCBSIL.
This BPA is subject to acceptance by BCBSIL as to coverage it underwrites. We certify that all the information and all
attestations provided to BCBSIL is correct and complete. Upon acceptance of this BPA, Dearborn Life shall issue this
BPA to the Employer. Upon acceptance of this BPA, BCBSIL shall issue a Policy to the Employer and this BPA and the
benefit program and premium notification letter or the applicable rate summary (ies)for the plan number(s) selected shall
be incorporated and made a part of the Policy. Upon acceptance of this BPA by BCBSIL 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.
IL-LG-51-150-HP-BPA Rev. 06/20 -6-
The undersigned representative acknowledges that any producer is acting on behalf of the Employer for purposes of
purchasing the Employer's insurance, and that if BCBSIL accepts this BPA and issues a Policy to the Employer, BCBSIL
may pay the Employer's 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 producer by BCBSIL in connection with the issuance of a Policy, the
Employer should contact its producer.
The undersigned representative 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 or delegation of
responsibilities there under. However, notwithstanding anything contained in the employee welfare benefit plan document
of the Employer, the Employer agrees that no allocation or delegation of any fiduciary or non-fiduciary responsibilities
under the employee welfare benefit plan of the Employer is effective with respect to or accepted by BCBSIL except to the
extent specifically provided and accepted in this BPA or the Policy or otherwise accepted in writing by BCBSIL.
With respect to Life and/or Short-Term Disability coverage applied for:
We agree to comply with and participate in all provisions of the Group Policy providing the coverage applied for. We
understand that BCBSIL intends to rely on this information in determining whether the enrolling Employees may become
insured.
ADDITIONAL PROVISIONS:
2 year rate guarantee: Premium Rates will be guaranteed for 24 months from the effective date of this policy. Please note
that an annual open enrollment shall be held 12 months from the effective date of this policy and any applicable benefit
changes will be implemented.
IL-LG-51-150-HP-BPA Rev. 06/20 -7_
Producer Agency Representative Sign ure of Employer/Authorized Purchaser
Signature of Producer Agency Representative Title
--
Producer Agency Name Date
Producer Address Witness
Producer Phone No.
Producer Number
$ Amount Submitted (not required for
renewals)
Contracted Producer Tax ID No. Other Information:
BCBSIL Sales Representative District/Cluster
UNDERWRITING AUTHORIZATION
INTERNAL USE Benefit program and premium notification letter included:0 Yes 0 No Date of Letter:
ONLY
IL-LG-51-150-HP-BPA Rev. 06/20 -8-
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 HCSC 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 either 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 its directors, officers, employees or agents consistent with HCSC's
bylaws then in force and as otherwise required by applicable law.
Group No(s).: By:
Print Signer's Name Here
Signature and Title
Group Name:
Address:
City: State: Zip Code:
Dated this day of
Month Year
IL-LG-51-150-HP-BPA Rev. 06/20 -9-
Blue Cross BlueShield
g of Illinois
Renewal Exhibits for CITY OF CANTON
Group number(s): P89388, P95069
Renewal Effective: 05/01/2021
Rate Effective:05/01/2021
Current Health Monthly Rates
Medicare Medicare
Empl.+ Empl.+ Primary Primary Total Monthly
Current Health Plan(sl Fowl Spouse Child(ren) Family Single Single+1 Health Cost
BPP72322 $827.01 $1,722.08 $1,663.88 $2,558.96 $472.50 $945.00 $172,080.21
Contracts 33 23 14 32 0 0 102
MPS91605 $737.26 $1,535.20 $1,483.31 $2,281.26 $421.22 $842.44 $21,736.71
Contracts 10 2 3 3 0 0 18
Total Monthly Health Cost $193,816.92
Total Health Contracts 120
Renewal Health Monthly Rates
Medicare Medicare
Empl.+ Empl.+ Primary Primary Total Monthly
Renewal Health Planlsl Emo1, Spouse Childlren) Family Single Single+1 }lealth Cost
BPP72322 $869.56 $1,794.56 $1,738.81 $2,663.80 $494.61 $989.23 $179,555.30
Contracts 33 23 14 32 0 0 102
MPS91605 $784.20 $1,618.40 $1,568.10 $2,402.30 $446.06 $892.13 $22,990.00
Contracts 10 2 3 3 0 0 18
Total Monthly Health Cost $202,545.30
Total Health Contracts 120
Health Renewal Premium Change Components
a.Account/Benefit Program Adjustment(incl.Trend): 1.98%
b.Demographic Adjustment: 1.54%
c.Change in Risk: 0.92%
Total*: 4.50%
*The total health renewal premium change percentage is calculated by multiplying each of the components in the above table.This change percentage is based
upon total monthly premium.Each tier's rate change may vary from the total change percentage.
Change Component Definitions
a) Account/Benefit Program Adjustment(incl.Trend)includes group and benefit plan specific pricing changes due to factors such as medical cost trends,
pool adjustments,plan,industry and geographical pricing,etc.
b) Demographic Adjustment is the pricing change for age,gender,group size and dependent composition differences.
c) Change in Risk is the pricing change resulting from BCBSIL's analysis of medical conditions and experience.
BlueCross BlueShield
(7 of Illinois
Account Name: (CITY OF CANTON 'Account Number: 1389388 (Renewal Date: 105/01/21
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, (ACAs date of enactment)may be a"grandfathered health plan."Grandfathered health plans are not subject to certain ACA
provisions.Among other requirements, in order to maintain grandfathered health plan status,an employer's contribution rate toward the
cost of any tier of coverage cannot decrease by more than five(5)percentage points since March 23,2010.
This Grandfathered Health Plan Form must be signed by the group representative and returned to our offices by the standard
renewal paperwork deadline in order to certify your grandfathered 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: bcbsil.com/PDF/aca_grandfathered_plans_il.pdf. If you have questions regarding this worksheet, contact your
insurance broker(if applicable)or your BCBSIL account representative.The rules related to grandfathered health plans are complex.We
recommend that you seek the advice and guidance of your legal counsel regarding ACA and grandfathered health plans. If you believe a
plan or policy has lost or will lose grandfathered status,contact your insurance broker(if applicable)or BCBSIL representative
immediately for available benefit plan options.
Check the"Grandfathered?"box for only the benefit plan(s)in effect that qualify for and that you wish to renew with a grandfathered
health plan design.
Plan/Benefit Premium: Premium: Premium: Premium: Premium:
Group Premium: Medicare Medicare
Number Agreement Grandfathered? Employee Employee Employee Family Primary Primary
Name/Number Only +Spouse +Child(ren) Employee Family
P89388 BPP72322 ® Yes 0 No $869.56 $1794.56 $1738.81 $2663.80 $494.61 $989.23
P95069 MPS91605 17 Yes 1M No $784.20 $1618.40 $1568.10 $2402.30 $446.06 $892.13
❑ Yes ❑ No
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 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.
Di.. a Pavley City Clerk
Pr n . '• Print Title
4/5/2021
G, Erre Date
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association.
Grandfathered Health Plan Form-SGFI Page 1 of 2
Blue{Cross BlueShield
7 of Illinois
Account Name: (CITY OF CANTON 'Account Number: 1389388 (Renewal Date: 105/01/21
Grandfathered Health Plan Form
Contribution Information
Complete the following information to report on employer contribution rates only for benefit plan(s)where YES was checked in the
"Grandfathered?"column on page 1 of this form.
Should the contributions differ by any employee class or tier within the employer group,each of them must be stated.
Benefit Plan Name Employee Class Tier Renewal Date
(e.g., PPO, HMO) (e.g., All, Hourly (e.g., Employee, Employer's Contribution
Only, Salaried Only Employee Rate
or Other(as defined +Spouse, 50% 75% 100% Other%
by Employer)) Employee
+Child(ren), (Indicate% amount if Other)
Family)
PPO All All Tiers ❑ ❑ ❑ 80%
❑ ❑ ❑
❑ ❑ ❑
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❑ ❑ ❑
❑ ❑ ❑
Add additional details as needed by copying this page.Make sure you return the signature and table page(s)together.
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association.
Grandfathered Health Plan Form-SGFI Page 2 of 2
B1ueCross B1ueShield
of Minlois
Account Nam CITY OF CANTON JAccount Number: 1389388 lRenewal Date: 10510112022
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 plan:'Grandfathered health plans are not
subject to certain ACA provisions.Among other requirements,in order to maintain grandfathered health plan status,an.
employer's or employee organization's contribution rate toward the cost of any tier of coverage cannot decrease by more
than five(5)percentage points since March 23,2010.
This Grandfathered Health Plan Form must be signed by the group representative and returned to our offices by the standard
renewal paperwork deadline in order to certify your grandfathered 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:bcbsil.com/PDF/aca_grandfathered_plans_ii.pdf.If you have questions regarding this worksheet,contact your
insurance broker(if applicable)or your BCBSIL account representative.The rules related to grandfathered health plans are complex.We
recommend that you seek the advice and guidance of your legal counsel regarding ACA and grandfathered health plans.If you believe a
plan or policy has lost or will lose grandfathered status,contact your insurance broker(if applicable_)or BCBSIL representative
immediately for available benefit plan options.
Check the"Grandfathered?"box for only the benefit plan(s)in effect that qualify for and that you wish to renew with a
grandfathered health plan design.
Employee Employee Family Medicare Medicare
Group Number Plan/Benefit Agreement Name/Number Grandfathered? Premium: Premium: Premium: Premium: Premium: Premium:
P89388 BPP72322. IK Yes r No $869.66 $1,794.56 $1,73.8.81 $2,663.80 $494.61 $989.23
P95069 MPS91605 r Yes K No
$784.20 $1618.40 $1568.10 $2402.30 $446.06 $892.13
r,Yes M No
r Yes r No
r Yes C No
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
insuran coverage co tes a grandfa red health plan under the Affordable Care Act,applic ble regulations and-
interprei thereof.
(21*y
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Tame P1
za22
I
1g re Dite
BlueCross B1ueShield
of Minols
Account Name: ICITY OF CANTON jAccount Number: 1389388 lRenewal Date: 05/01/2022
Grandfathered Health Plan Form
Contribution Information
Complete the following information to report on employer or employee organization contribution rates only for benefit
plan(s)where YES was checked in the"Grandfathered?"column on page 1 of this form.
Should the contributions differ by any employee class or tier within the employer group or employee organization,each of
them must be stated.
Benefit Plan Name(e.g.,PPO,HMO) Employee Class Tier Renewal Date
(e.g.,Al,Hourly Only,Salaried Only or (e.g., Employee, Employers or Employee
Other(as defined by Employer or Employee Employee+Child(ren), Organization's Contribution
Organization)) Employee+Spouse, Rate
Employee+Family)
50% 75% 100% Other%
(Please indicate%amount if Other)
PPO All All Tiers ❑ ❑ El °
❑ E ❑ —�
❑ ❑ ❑ —�
❑ ❑ ❑ —�
❑ ❑ ❑ -�.
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❑ a ❑ —�
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Add additional details as,needed by copying this page.Make sure you return the signature and table page(s)together.
B1ueCross B1ueShield
o of Illinois
Renewal Exhibits for City Of Canton
Group number(s):P89388,P95069
Renewal Effective:5/1/2022
Rate Effective:5/1/2022
Current Health Monthly Rates
Medicare Medicare
Empl+ Empl.+ Primary Primary Total Monthly
Current Health Plan(s) Empl. Spouse Child(ren) Family Single Sinale+1 Health Cost
BPP72322 $869.56 $1,794.56 $1,738.81 $2,663.80 $494:61 $989.23 $173,301.76
Contracts 29 21 16. 31 0 0 97
MPS91605 $784.20 $1,618.40 $1,568.10 $2,402.30 $446.06 $892.13 $24,558..10
Contracts 11 1 3 4 0 0 19
Total Monthly Health Cost $197,859.86
Total Health Contracts 116
Renewal Health Monthly Rates
Medicare Medicare
Empl+ Empl.+. Primary Primary_ Total Monthly
Renewal Health Plan(s) Empl. Spouse Child ren Family Sinale Single+1 Health Cost
BPP72322 $869.56 $1,794.56 $1,738.81 $2,663.80 $494.61 $989.23 $173,301.76
Contracts 29 21 : 16 31 0 0 97
MPS9.1605 $784.20 $1,618.40 $1,568.10 $2,402.30 $446.06 $892.13 $24,558.10
Contracts 11 1 3 4 0 0 19
Total Monthly Health Cost $197,859.86
Total Health Contracts 116
"HCSC establishes rates that are actuarially sound;provide long-term stability in the market and properly match premiums
with expected incurred health care costs for the upcoming pricing period."
Health Renewal Premium Change Components
a.Account/Benefit Program Adjustment(incl.Trend): 5.43%
b.Demographic Adjustment: -0.97%
c.Change in Risk: -3.75%
Total*: 0.00%
*The total health renewal premium change percentage is calculated by multiplying each of the components in the above table. .
This change percentage is based upon total monthly premium.Each tiers rate change may vary from the total change percentage.
Change Component Definitions
.a) Account/Benefit Program Adjustment(incl.Trend)includes group and benefit plan specific pricing changes due to factors
such as medical cost trends,pool adjustments,plan,industry and geographical pricing,etc.
b) Demographic Adjustment is the pricing change for age;gender,group size and dependent composition differences. .
c) Change in Risk is the pricing change resulting.from BCBSIL's.analysis of medical conditions and experience.
Following is the large claim detail identified during the renewal evaluation:
$52,457.82-Active
$68,924.47-Active
$72,783.71 -Active
$83,139.37-Cancelled
$112,797.51 =Active
$137,123.18-Active
$146,816.46-Active
$162,560.70-Active
$221,679.16-Active