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Home My WebLink About20053729.tiff Great-West SM • HEALTHCARE Great-West Life & Annuity Insurance Company Application for Group Coverage for Weld County Government Policy Number: 358610 Full Legal Name of Firm: Is this company subject to ERISA? ❑Yes ®No Weld County Government Company Type: State of Situs: CO E ❑Corporation ❑Partnership Tax ID/EIN: 84-6000813 DS-Corp ❑Association Requested Effective Date: January 1, 2005 ®Government ❑Non-Electing Church Group (Renewal date will be the first day of the month indicated here) ❑Public/Non-Profit ❑Limited Liability Corp. (LLC) ❑Individual/Unincorporated Business/Proprietorship Industry: 9111 SIC: Executive Offic ERISA Plan Number: • ERISA Plan Year: 01/01-12/31 Company Name for ID Cards (Must be abbreviated to 30 digits): Weld County Governmen Applicant's Street Address: Subsidiaries: 915 10th Street Name Ownership% SIC Code PO Box 758 City: GreeleyState: CO Zip: 80632 BENLink Use: ❑No ®Yes (Internet Explorer 5.0 or greater required,indicate user/system info for each contact) mstmpp(Mar-01-2002)-Weld County Govemme-IGW LAMIDASOCON 11182004 1 /W. .0 „ l/ ........n:7::e!:........::... .,.,t. • ry:} r£ r r( r £ £rrn£IRNti^,;..,9 U... t4£t)!1r Applicant Information: Plan Administrator: (receives Legal/Formal Contact: Cobra Contact: routine correspondence) ❑ Same as Plan Administrator ® Same as Plan Administrator �Ian Administrator: Jewel Vaughn Name: Don Warden Name: itle: Personnel Title: Finance Director Title: Phone: 970-356-4000 x4231 Fax: Phone: 970-356-4000 x4218 Phone: Fax: 970-352-9019 Fax:970-352-9019 E-mail: E-mail:jvaughn@co.weld.co.us E-mail:dwarden@co.weld.co.us ❑BENLink Uscr SSN: 1 BENLink User ®BENLink User 1SP: Connect via: Modem SSN: 524666192 SSN: 524621138 Address:(IF DIFFERENT FROM APPLICANT ADDRESS) ISP: Connect via: Modem ISP: Connect via: Modem Address: (CHANGE IF DIFFERENT FROM Address:(IF DIFFERENT FROM APPLICANT ADDRESS) APPLICANT ADDRESS) 915 10th Street PO Box 758 Greeley,CO 80632 Additional Contact: Additional Contact: Additional Contact: Reason for Contact: Benlink Access Reason for Contact: Benlink Reason for Contact: Name: Susan Elton Access Name: Title: Assistant Director Name: Pat Persichino Title: Phone:970-356-7220 Fax:970-352- Title: Director of General Phone: Fax: 9019 Services/Personnel E-mail: E-mail:selton(a,co.weld.co.us Phone:970-356-4000 x4230 DBENLink User ®BENLink User Fax:970-352-9019 SSN: OF SN: 504560591 E-mail: ISP: Connect via:Modem P: Connect via:ModemAddress: Address:(IF DIFFERENT FROM DIFFERENT FROM APPLICANT ADDRESS) ppersichino(a�co.weld.co.us APPLICANT ADDRESS) ®BENLink User SSN: 039288886 ISP: Connect via: Modem Address:(IF DIFFERENT FROM APPLICANT ADDRESS) Employee Data: Employee Residence: Total(including those in the waiting period): 1444 _ Indicate residency outside U.S.here: 0 Indicate all states where employees reside: Ill mstrapp(Mar-01 -2002)-Weld County Govemme-IGW LAM I DASOCON1 1182004 2 ,,, - 'A Ir:8"iitit°-T:,FR ti,,rrt...;. ....ngr::::r::„:: ,r: :•:•!-,gru.n,,r,r,:,,,,!•.>..._,-,,, g4Potr,,.,! Applicant Information: ::..:' : : ::.....-=1�;: Total eligible for medical coverage: 1250 state it of State rr of State Hof ('ode Ives ('axle tics Cale Lies Total currently under medical coverage: 1050 Co 1040 WY 4 oillital number of retired employees: 37 AZ I Total employees residing outside the U.S: 0 N1: 2 H. I Percent of the employees speaking a language other than English:a) ❑ 10%or more for groups>100 lives; OR MT I 25%or more for groups< 100 lives ('A 1 b)® Less than the percents stated above. If answer is a)above,which language? Disabled Employees/ Employees not actively at HMO Option: work: Do you currently offer a Non-ONE Health Plan HMO? Do you have Disabled Employees and/or Employees not ❑No EYes actively at work? ®Yes ❑No r an ERISA plan,Great-West will have full discretion and authority to interpret the Plan and determine whether a oa im should be paid or denied on appeal and according to the provisions of the Plan as set forth in the Summary Plan escription. Wtt$ 9Y( . • i w : EPE.. .ragx.*,t:.. r,.... itail COBRA— ❑Current Ceridian COBRA Services Customer Maximum period of coverage to begin on: Applicant to administer COBRA ['date of the qualifying event ❑ Ceridian COBRA Standard Service ®date of loss of coverage ® Ceridian COBRA Enhanced Service O Another outside provider to administer Banking Options: ❑ Daily ®Weekly *Eff 5/1/03-Mid 500 cases wl Preferred Funding can not choose Weekly w/week delay ...:.: ....•.:: .:.:.:_:`.:�,!:u. • ?' �:.: f.? :.:�::I'ra?..:.::? ..:::rf'<:r:v: :..:.':i iE".1.{:!E:c":•:.: !' 'Fi?::: . 'E:: .. .,..... ,•••- re:r,:rm.,..r:e.:..:.:::::::�':.:�: r�,,. ,rweE .. .... s ::.e ,,,,...'.......,..................................... r--....o.....:'—,3'�E s.F::Fs.r.:::::.::. .i;,•. .............• ... a �!.i Annual Open Enrollment/Plan Transfers: from 12/01 to 12/31 Late Applicants: are able to enroll only during annual open enrollment period. (Automatic for HMO. Coverage becomes effective the first day of the month following the open enrollment period.) mstrapp(Mar-01 -2002)-Weld County Governme-IGWLAMIDASOCON 11182004 3 ,,,,,,,n .-5: ...'- ''an-1n,, .<c.e.r rr.,.: t rh ,. ! rp ny�n M1 t t F'�A7YRRS'STT7 ;5Atl�j I^ t h ergliC;P,llt!n�li Plan/Class/Eligibility Information: ` ..... Reinstatement after termination: Option to Waive Employee Benefits: ® 3 Months ID Waiver of benefits not allowed ®Waiver of benefits • allowed Definition of Earnings: (applies to Life Insurance(if multiple of salary),Short Term Disability,and Long Term Disability as selected by Applicant) Basic rate of pay exclusive of overtime and bonuses in effect on: Othe first day of the month Don a specific date Are annual commissions to be included in the rate of pay? ❑Yes ❑No Commissions calculated: ❑12 times average monthly commissions received during preceding calendar year Other: Definition of Retirees: Are Retirees Covered? ®Yes ❑ No Benefits: ❑ Life ®Medical O Dental O Vision Minimum Age Requirement is: 55 years of age No Minumum age employee retired,not receiving pension nemployee retired, receiving pension ®employee retired,on pension&has completed 10 years of service ITemployee retired,without pension&had completed years of service Other: The definition of Retiree is as follows: Retired from Weld County on or after December 16, 1998 with at least 10 years of service,or was an elected official of Weld County,Colorado,for at least one full four-year term. Retiree remains eligible for medical benefits with Weld County until they attain the Normal Retirement Age for SS("NRA"),or becomes eligible for health insurance coverage with another employer,or becomes eligible for Medicaid or Medicare coverage before attaining the NRA (Le becomes disabled). Maximum Retiree Medical Benefits,all conditions, Calendar Year/Lifetime Maximum: (Maximums do not apply to HMO or One+Plans) ❑$10,000/525,000 O$25,000/$50,000 O$50,000/$100,000 • mstrapp(Mar-01-2002)-Weld County Governme-IGW LAMIDASOCON 11182004 4 Plan/Class/Eligibility Information: Employer Contributions: Name of Class 1: All Employees ilife/AD&D Plan: Contributory (employee contributes a portion of costs for life lan) Employer contributes the following percentage(s): EE % Dependent % Employee contributes the following percentage(s): EE % Dependent % TOTAL must = 100% 100% ['Non-Contributory(employer contributes 100%of costs for life plan) Health Plan(s): ®Contributory(employee contributes a portion of costs for heals plan) Employer contributes the following percentage(s): EE 80% Dependent40% Employee contributes the following percentage(s): EE 20% Dependent60% TOTAL must = 100% 100% ❑Non-Contributory(employer contributes 100%of costs for health plan) Name of Class 2 (if applicable): Life/AD&D Plan: ['Contributory (employee contributes a portion of costs for life plan) Employer contributes the following percentage(s): EE_% Dependent_% Employee contributes the following percentage(s): EE_% Dependent_% TOTAL must= 100% 100% ONon-Contributory(employer contributes 100%of costs for life plan) Health Plan(s): ['Contributory(employee contributes a portion of costs for health plan) Employer contributes the following percentage(s): EE % Dependent % Employee contributes the following percentage(s): EE_% Dependent_% TOTAL must = 100% 100% • ❑Non-Contributory(employer contributes 100%of costs for health plan) Dependents: Covered Z Not Covered 0 If Dependents are Employed by the Planholder: Dependents are defined as a legal spouse, ® They are covered as Employees Only. unmarried child under age 19 O * Spouses may be covered as both an Employee and a Dependent and unmarried full-time student (benefits will be coordinated). Children are covered as Employees only. under age ®23, O25 O *Spouses and children may be covered as both and Employee and a Dependent(benefits will be coordinated). *Options not available with the HMO Plan Pre-Existing Conditions Limitation: Is the Pre-existing limitation waived for existing employees? ®Yes ❑No ®Std limit (Applies to: ALL medical plan benefits;any illness or injury up to 3 months prior to enrollment date. Limitation is waived 12 months after enrollment date.) • mstrapp(Mar-01 -2002)-Weld County Govemme-IG W LAMIDASOCON 11182004 5 nn:,: .. ,n,�, ...... ..:. ... +v rr7 m tr,rt:,:M1:.ns,e,r '11"111I"IT IMIlin Plan/Class/EIigibility Information: Definition of Benefit Classes Describe who is Eligible to Participate in Plan: All EE's Working 20 + Hours •talifying Hours: 20 per ®week ❑month !Double click for General Information and Eligibility Rules Is the eligiblility waiting period waived for existing employees? ❑Yes ❑ No Class Description Waiting Period/Termination* Benefits NOT included for this class (Include qualifying hours if different from Days from hire date OR above) A.A11 EE's Working 20 + ®Is`of month following hire date OR Hours 111 of month following Days B. Days from hire date OR n 1"of month following hire date OR n l s`of month following Days C. Days from hire date OR Fr'of month following hire date OR I I1"of month following Days *Termination of coverage is effective upon the date of the termination if the"#of days from hire date"is selected. If either "l s'of the month..."option is selected,terminations are effective the last day of the month in which the termination occurs. Change in Classes and amounts of Coverage Effective on: ❑ Date of change in status. ® First day of the month coinciding with or next following the date of change. • • mstrapp(Mar-01-2002)-Weld County Govemme-IGWLAMIDASOCON 11182004 6 .:: r t ,,,.. �,::r;•._.p,::.:�s.. .... .. ... ..::eEi; ewtaeigyr,=: ... '.. , ; , . ::. .. .............. :...•..: µ.`Es. r 11 ,"a:r.cc:ls•1.........�.e,::: :... .:nra:: 1 I . �.�s.s Plan/Class/Eligibility`Information . ::_:::: Y h=; <<• •...•.... - Class Benefit Schedule: Life AD&D Flat (If'applicable)Short (If applicable) Amount or Term Disability Long Term Disability ;ass Description Percent of Salary Flat Amount or Percent Percent rounded to next S 1,000 of Salary l ❑N'A 050% To Max Wkly Max 060% 066 2/3% 2. ❑N/A 050% 060% ❑66 2/3% To Max Wkly Max 3 ON/A 050% 060% 066 2/3% To Max Wkly Max Divisional Billing:* *A minimum of 25 employees in each division is required. Division Name Billing Address Contact Name&Phone Divisional Medical Claims: *A minimum of 25 employees in each division is required (Prescription claims are not divisionalized) Division Name Billing Address Contact Name&Phone Active etirees obra Michigan law requires insurers to provide the following mandated benefit TO RESIDENTS OF MICHIGAN. Please review the description of the benefits we are required to offer and indicate below acceptance or rejection of th benefits described. Although Great-West is required to offer you this coverage,you are under no obligation to accept it. Please contact your local Group Office for further information. • Auto Accident Exclusion-if accepted,benefits will not be payable under the Plan for nAccept nReject injuries received in an accident involving a motor vehicle if the covered person is a resident of Michigan and the accident occurs in Michigan. If rejected,benefits will be coordinated with Auto Accident coverage. I mstrapp(Mar-01-2002)-Weld County Governme-IGWLAMIDASOCON 11182004 7 Administrative Services Only (ASO) Funding: Aggregate Stop-Loss: LINo ®Yes Terminal Protection: *ecilic Stop-Loss: $100,000 Fixed: Employees S Dependents NJ =$20,000 minimum if under 50 lives Variable: 0i. ❑NY=$25.000 minimum ❑CO=$15,000 minimum(effective 1/1/03) Aggregate limitation factor: ®10% Other: Aggregate Attachment: 120% ---'.a.•,- a f ah;71 ri. Z, }.;: 5�,.! i4 [—Remove this Plan from Application for Group Coverage G Great-West Healthcare Consumer Advantage PP 0 1,i, ° ,{ . •(Standard Plan) - add PPO Dual-Option plan name s1 0,h''• ;, t ':0l'1 .r,"44"'"} it 11UI Double click for benefit information Lifetime Maximum Medical Benefits: Reimbursement Method for (all conditions) Non-network services: ❑$1,000,000 ®$2,000,000 ❑$5,000,000 ®Average Contract Rate(ACR) ['Usual&Customary Individual Break Point Per Calendar Year: Family Break Point and Calendar Year Deductible: •®$10,000 ❑ $12,500 ❑$15,000 3 times the individual amount elected. ❑$20,000 O $25,000 (Non-network services do not apply) Coinsurance Percentages: Maternity Assessment Program: ® Covered O Not Covered (Standard) Network Non- Out of Tier II Tier III Network* Area ❑ 90% 70% 50% 70% ® 80% 60% 50% 60% ❑ 70% 50% 50% 50% ❑ 70% 50% 40% 50% *Non-network services do not apply toward the breakpoint Calendar Year Deductibles: Choose Combined or Separate Deductibles ® Combined Tier II& III network deductible:(network/non-network) ❑$250/250 O $250/500 O$250/1000 O$250/2000 O$500/500 ❑ $500/1000 O$500/2000 O$750/1500 O $750/3000 ®$1000/2000 O $2000/3000 ❑ Separate Tier II & III network deductible : (pick a Tier II/Tier III Network deductible,then pick a Non- network deductible from same row) Tier 11/Tier III-Network Non-network ❑$250/250 O $500 O$750 O$1,000 O$1,500 ❑$2,000 mstrapp(Mar-01-2002)-Weld County Govemme-IGWLAMIDASOCON 11182004 8 - ❑$250/500 or ❑$300/300 ❑ $750 ❑$1,000 ❑$1,500 ❑ $2,000 ❑$300/600 or 0$400/400 ❑$1,000 0 $1,500 0$2,000 0$3,000 •❑$400/800 0$1,500 0$2,000 0 $3,000 ❑$500/250 0 $750 0 $1,000 0$1,500 0 $2,000 ❑ $500/500 ❑$1,000 0$1,500 0$2,000 ❑$3,000 ❑$500/1,000 0$1,500 0 $2,000 0 $3,000 ❑$600/300 0$1,000 0$1,500 0$2,000 0$3,000 Not available with 70/50/50 or 70/50/40 plans ❑ $750/750 ❑$1,500 0$2,000 0$3,000 Not available with 70/50/50 or 70/50/40 plans ❑$750/1,500 $3,000 Not available with 70/50/50 or 70/50/40 plans ❑$800/400 ❑$1,500 ❑$2,000 0$3,000 Not available with 70/50/50 or 70/50/40 plans IP ❑$1,000/500 ❑$1,500 0$2,000 0$3,000 Not available with 80/60/50,70/50/50 or 70/50/40 plans ❑$1,000/1,000 0 $2,000 0$3,000 Not available with 80/60/50,70/50/50 or 70/50/40 plans ❑$1,000/2,000 $3,000 Not available with 80/60/50,70/50/50 or 70/50/40 plans Hospital per confinement deductible or outpatient surgery: Network: ®$0 ❑$100 ❑$250 ❑$500 Non-network: 0$loo ❑$250 ®$500 (Non-network per confinement deductible must be equal to or greater than the network per confinement deductible.) •Note: If electing Tiered Deductibles: * If Tier II deductible is$1,000—network per confinement must be$0. * If Tier II deductible is$600,$750 or$800—network per confinement deductible must be less than$500. mstrapp(Mar-Cl-2002)-Weld County Govemme-IGWLAMIDASOCON 11182004 9 Tier I Benefits c : : Preventive Care: Network: 100%with office visit copay. Non-network: Deductible and coinsurance. •Lab/Xray: 100%for all providers. Network Office Visit Copay Amounts: (Choose one of the three options) Primary/Specialist copay: ® $20❑$25 ❑$30 El$35 ❑$40 ❑$50 ❑ Primary Care w/Specialist coinsurance: Primary Care w/higher Specialist copay: Primary: ❑$20 ❑$25 ❑$30❑$35 ❑ $40 Primary:❑$20❑$25 O$30❑ $35 ❑$40❑$50 Specialist:Tier III deductible and coinsurance ! Specialist:O$30O$35❑$40❑ $45 ❑$50❑$55 0$60 0$65 Restrictions: Minimum Differential=$10/Maximum Differential=$25 $30 or$35—only available with 50%or 60%Tier Ill coins. $40—only available with 50%Tier 111 coins. Tier II Benefits. Standard Benefits: Optional Benefits: Inpatient X-ray&Lab Inpatient Mental Health/Chemical Dependency: • j Covered ❑ Not Covered • Inpatient Hospital incl. Surgery, Anesthesia,and Rehabilitation If covered,benefit maximum calendar/lifetime days for in-hospital conditions only: • Hospice ❑ 5/10 ❑ 10/20 ®30/60 • Medical Supplies/Durable Medical Equipment (life sustaining) • Skilled Nursing— 100 days/calendar year. • Home Health Care—60 visits/calendar year. • Ambulance Tier III Benefits r • mstrapp(Mar-01 -2002)-Weld County Governme-IGWLAMIDASOCON 11182004 10 Standard Benefits: Optional Benefits: • Emergency Room Outpatient Mental Health&Chemical Dependency: ® Covered ❑ Not Covered Outpatient Services(includes surgery,anesthesia) If covered,20 visits per calendar year max. W. Outpatient X-ray and Lab: TMJ: ❑with deductible 0 Covered ® Not Covered ®without deductible If covered,$1,000 calendar year max. • Physical Therapy: Spinal Adjustment Treatment(SAT): $2,000 calendar year max. 0 Covered ® Not Covered If covered,$500 calendar year max. • Medical Supplies: (non-life sustaining) Family Planning: • Durable Medical Equipment: ® Covered 0 Not Covered $2,500 calendar year/$10,000 lifetime max. • Office Surgeries/Services Outpatient Speech Hearing&Occupational Therapy: ® Covered ❑ Not Covered If covered,$2000 per calendar year max. • • mstrapp(Mar-01-2002)-Weld County Govemme-IG WLAMIDASOCON 11182004 11 Prescription Drugs: Prescription Drug Copay Amount Drug Deductible: AClvanta a Retail ❑ ❑ O O Applies to all prescriptions. g Tier 3 -Highest Brand Name copay $60 $75 $75 $100 The family maximum is 3 Pharmacy Tier 2- Lowest Brand Name copay $30 $30 $50 $50 times the individual amount. Plan Tierl -GenericDrugcopay $10 $10 $10 $10 ❑None D$100 individual Mail Order D$150 individual Tier 3 - Highest Brand Name copay $170 $215 $215 $290 Tier 2- Lowest Brand Name copay $80 $80 $140 $140 Tier I -Generic Drug copay $20 $20 $20 $20 Maximum Allowable Cost- MAC C Contraceptives: 0 Covered (standard) 0 Not Covered- (disclosure required) Prescription Drug Copay Amount Drug Deductible: Choice Retail O O O Applies to Brand Name Tier 3-Highest Brand Name copay $40 $50 $60 prescriptions only. The Pharmacy Tier 2- Lowest Brand Name copay $20 $25 $30 family maximum is 3 times Plan Tier I -Generic Drug copay $10 $10 $10 the individual amount. alone Mail Order ❑$150 individual Tier 3- Highest Brand Name copay $80 $100 $120 ❑$250 individual Tier 2- Lowest Brand Name copay $40 $50 $60 O$500 individual Tier 1 -Generic Drug copay $20 $20 $20 Maximum Allowable Cost- MAC A Contraceptives: 0 Covered (standard) 0 Not Covered—disclosure required Prescription Drug Copay Amount Drug Deductible: Performance Retail 0 0 ® Applies to all prescriptions Tier 3- Highest Brand Name copay $20 $30 $40 only. The family Pharmacy— Tier 2-Lowest Brand Name copay $10 $15 $20 maximum is 3 times the 3-Tier Plan Tier 1-Generic Drug copay $5 $7 $10 individual amount. P Y ®None Mail Order ❑$75 individual Tier 3-Highest Brand Name copay $40 $60 $80 ❑$100 individual Tier 2-Lowest Brand Name copay $20 $30 $40 ❑$150 individual Tier 1-Generic Drug copay $10 $14 $20 Maximum Allowable Cost- MAC B Contraceptives: ®Covered (standard) 0 Not Covered—disclosure required l;t4� w�¢ 1 _ xr, .z.va.� LI! Double click for benefit information Lifetime Maximum Medical Benefits: Reimbursement Method for (all conditions) Non-network services: ❑$1,000,000 Z$2,000,000 O$5,000,000 ®Average Contract Rate(ACR) DUsual&Customary mstrapp(Mar-01 -2002)-Weld County Govemme-IG W LAMIDASOCON 11182004 12 Remove this Plan from A l>cation for rou' Cover Great-West Healthcare Consumer Advantage PPO (2) (Choice.Plan) -add Dual-Option plan name IDIndividual Break Point Per Calendar Year: Family Break Point and Calendar Year Deductible: ® $10,000 ❑$12,500 ❑ $15,000 3 times the individual amount elected. ❑ $20,000 ❑$25,000 (Non-network services do not apply) Coinsurance Percentages: Maternity Assessment Program: ® Covered ❑ Not Covered (Standard) Network Non- Out of Tier II Tier III Network* Area 90% 70% 50% 70% ❑ 80% 60% 50% 60% ❑ 70% 50% 50% 50% ❑ 70% 50% 40% 50% *Non-network services do not apply toward the breakpoint Calendar Year Deductibles: Choose Combined or Separate Deductibles ® Combined Tier II &III network deductible: (network/non-network) ❑ $250/250 ❑$250/500 ❑ $250/1000 ❑$250/2000 ❑ $500/500 ❑$500/1000 ® $500/2000 ❑ $750/1500 ❑$750/3000 D$1000/2000 ❑$2000/3000 Fl Separate Tier II& III network deductible : (pick a Tier 11/Tier III Network deductible,then pick a Non- network deductible from same row) Tier II/Tier III-Network Non-network O$250/250 ❑$500 ❑$750 O $1,000 ❑$1,500 ❑$2,000 ❑$250/500 or ❑$300/300 ❑$750 O $1,000 ❑$1,500 O $2,000 ❑$300/600 or O$400/400 O$1,000 ❑$1,500 ❑$2,000 ❑$3,000 ❑$400/800 ❑$1,500 O$2,000 ❑$3,000 ❑$500/250 ❑$750 ❑$1,000 ❑$1,500 ❑$2,000 ❑$500/500 O$1,000 ❑$1,500 ❑$2,000 ❑$3,000 O $500/1,000 ❑$1,500 ❑$2,000 ❑$3,000 ❑$600/300 O$1,000 ❑$1,500 0$2,000 ❑$3,000 Not available with 70/50/50 or 70/50/40 plans • mstrapp(Mar-01 -2002)-Weld County Governme-IGWLAMIDASOCON 11182004 13 ❑$750/750 0 $1,500 0$2,000 0 $3,000 Not available with 70/50/50 or 70/50/40 plans ❑$750/1,500 $3,000 •Not available with 70/50/50 or 70/50/40 plans ❑$800/400 0$1,500 0$2,000 0$3,000 Not available with 70/50/50 or 70/50/40 plans ❑$1,000/500 0$1,500 0$2,000 0$3,000 Not available with 80/60/50,70/50/50 or 70/50/40 plans ❑$1,000/1,000 0$2,000 0 $3,000 Not available with 80/60/50,70/50/50 or 70/50/40 plans ❑$1,000/2,000 $3,000 Not available with 80/60/50,70/50/50 or 70/50/40 plans •Hospital per confinement deductible or outpatient surgery: Network: Z$0 O5100 O5250 O5500 Non-network: O5100 ❑$250 ®$500 (Non-network per confinement deductible must be equal to or greater than the network per confinement deductible.) Note: If electing Tiered Deductibles: * If Tier II deductible is$1,000—network per confinement must be$0. * If Tier II deductible is$600,$750 or$800—network per confinement deductible must be less than$500. Preventive Care: Network: 100%with office visit copay. Non-network: Deductible and coinsurance. Lab/Xray: 100%for all providers. Network Office Visit Copay Amounts: (Choose one of the three options) El.............. Primary/Specialist copay: ® $20 0 $25 0$30 0 $35 0 $40 0$50 • mstrapp(Mar-01-2002)-Weld County Governme-IG W LAMIDASOCON 11182004 14 CPrimary Care w/Specialist coinsurance: fl Primary Care w/higher Specialist copay: Primary: ❑ $20 0 $25 0 $30❑ $35 ❑ $40 Primary: ❑$20O$25 ❑$30❑$35 0$40❑$50 Specialist:Tier III deductible and coinsurance Specialist: 0 $30O$35 0$40 0$45 0$50 0$55 ❑ $60❑ $65 Restrictions: $30 or $35-only available with 50%or 60% Tier Ill coins. Minimum Differential=$10/Maximum Differential=$25 $40—only available with 50%Tier 111 coins. Tier II Benefice: Standard Optional Benefits: Benefits: Inpatient X-ray&Lab Inpatient Mental Health/Chemical Dependency: • ® Covered ❑Not Covered • Inpatient Hospital incl. Surgery,Anesthesia,and Rehabilitation If covered,benefit maximum calendar/lifetime days for in-hospital conditions only: • Hospice ❑ 5/10 0 10/20 ®30/60 • Medical Supplies/Durable Medical Equipment (life sustaining) • Skilled Nursing— 100 days/calendar year. • Home Health Care—60 visits/calendar year. • Ambulance • Tier Ili:Benefits Standard Benefits: Optional Benefits: • Emergency Room Outpatient Mental Health&Chemical Dependency: ® Covered ❑ Not Covered • Outpatient Services(includes surgery,anesthesia) If covered,20 visits per calendar year max. • Outpatient X-ray and Lab: TMJ: 0 with deductible 0 Covered ® Not Covered without deductible If covered,$1,000 calendar year max. • Physical Therapy: Spinal Adjustment Treatment(SAT): $2,000 calendar year max. 0 Covered ® Not Covered If covered,$500 calendar year max. • Medical Supplies: (non-life sustaining) Family Planning: • Durable Medical Equipment: ® Covered 0 Not Covered $2,500 calendar year/$10,000 lifetime max. Office Surgeries/Services Outpatient Speech Hearing&Occupational Therapy: • ® Covered 0 Not Covered If covered,$2000 per calendar year max. • mstrapp(Mar-01 -2002)-Weld County Govemme-IG WLAMIDASOCON 11182004 15 Prescription Drugs: Prescription Drug Copay Amount Drug Deductible: Advantage Retail O O O O Applies to all prescriptions. Tier 3 -Highest Brand Name copay $60 $75 $75 $100 The family maximum is 3 Pharmacy Tier 2-Lowest Brand Name copay $30 $30 $50 $50 times the individual amount. Plan Tier 1 -Generic Drug copay $10 $10 $10 $10 ❑None ❑$100 individual Mail Order ❑$150 individual Tier 3-Highest Brand Name copay $170 $215 $215 $290 Tier 2-Lowest Brand Name copay $80 $80 $140 $140 Tier 1 -Generic Drug copay $20 $20 $20 $20 Maximum Allowable Cost- MAC C Contraceptives: 0 Covered (standard) 0 Not Covered- (disclosure required) Prescription Drug Copay Amount Drug Deductible: Choice Retail 0 0 0 Applies to Brand Name Tier 3 -Highest Brand Name copay $40 $50 $60 prescriptions only. The Pharmacy Tier 2-Lowest Brand Name copay $20 $25 $30 family maximum is 3 times Plan Tier 1 -Generic Drug copay $10 $10 $10 the individual amount. ❑None Mail Order ❑$150 individual Eli Tier 3 - Highest Brand Name copay $80 $100 $120 ❑$250 individual Tier 2-Lowest Brand Name copay $40 $50 $60 ❑$500 individual Tier 1 -Generic Drug copay $20 $20 $20 Maximum Allowable Cost- MAC A Contraceptives: 0 Covered (standard) 0 Not Covered-disclosure required .® Prescription Drug Copay Amount Drug Deductible: Performance Retail 0 0 ® Applies to all prescriptions Tier 3-Highest Brand Name copay $20 $30 $40 only. The family Pharmacy Tier 2-Lowest Brand Name copay $10 $15 $20 maximum is 3 times the 3-Tier Plan Tier 1-Generic Drug copay $5 $7 $10 individual amount. ZNone Mail Order ❑$75 individual Tier 3-Highest Brand Name copay $40 $60 $80 O$100 individual Tier 2-Lowest Brand Name copay $20 $30 $40 ❑$150 individual Tier 1-Generic Drug copay $10 $14 $20 Maximum Allowable Cost- MAC B Contraceptives: ®Covered (standard) 0 Not Covered—disclosure required • mstrapp(Mar-01 -2002)-Weld County Govern=-IGW LAMIDASOCON 11182004 16 Network Notification Form (Formerly Network Management/Managed Care Notification Form) Form MUST be completed for all Open Access and PPO Policies accessing a TPN or Great-West Healthcare network in OK,UT,Northeast WI,WV&WY markets in addition to all Open Access,PPO,POS&Indemnity Policies with Maternity Management • Note that there is no minimum employee participation required to submit this form. From Phone 1)3_4394710 Home Office Contact Home Office Contact Extension Effective Date: Action: Carrier: Region: a+now o,,a» waono Janus 1.2005 ❑Group Termination ®Great-West Healthcare January ® New Group O PB1 GWLA f]National Accounts O Amendment(for TPN,Pd.Name or Pd.Y change) O NEF(amendments only) O MIdto0 O Alta(amendments only) ®Mid 500 Product(s):, Amendment Type/{i.e.moving from TPN to ONE)/Notes: ®PPO ❑P0S . ❑Indemnity ❑0pen Ames! Policy No.(claim no.): Policy Name: Sales Office: ClaimS/Member Services: 358610 Weld County Government Denver Fat Scott (1.800.683.8041) Policy Street Address:(Address only need for new groups or TPN changes) City: State:. Zip: 915 10th Street PO Box 758 Greeley ca 80632 ft,* u %; Mafe ity Management Program (Forf l�r, 'Ins = 1' ' 1^...Available to National Accounts dt cases over 300 Hies.Cases under 300 lives require special app ' to , Maternity Management Covered: ❑No t8l Yes. (If yes,please check which product(s)below) ❑POS ®PPO❑Open Access O Indemnity (No Managed Care Notification Form necessary for HMO,OnePlan&Alta(Bibs)since program is automatically integrated with these products). . -.'",,r(''. .if,4 It rrh - d t 1 ... .. TPN PPO tufor it ;r The following TPN's are `"e,t '''a!'tiMon-indlcali L(: `+ ' "`"�Y„ t ; ' Please indicate OK,1ST,WV,W1 and WY Great-West Healthcare PPO netvwf nation in the Great-West Hea th care a "'`"�-.'" ra'i, - t, r tiV' ;• , eason for noftOcadon indicated in tttet fst'Niro notes at the bottom qt this tom,' .. . ':;1 0dPO%: I Network Co-Pay: I Network Deductible: Plan Type: Check One 60/50 20 1000 ElHosp-Only ®Hosp/Phys icate"A"for add or"T"for term beside any affected networks with approximate employee count. Reminder: For TPN set u ,members must reside in the TPN service area as defined on the Zi Code Ae,ort available on the Mane ed Care intranet webslie. A-add Approx. State Network Area TPN/Business code A-add Approx. State Network Area TPN/Business code T-term EE Count _ T-term EE Count _ Central MO 8 Arkansas Man.Care Org. AR AR State (AMCO)14109 MO Eastern/Midwest- Healthlink/4189 ern IL CA "Monterey,CA Coastal Health Care/4146 ..`r, — MO Western MO& Healthcare Preferred(formerlyMid 7,,>r _Topeka.KS America Health Network)/4190 CA Chico.CA "Superior of CA/4124 '," A ` 1 M7 MT State "Interwest Health/4171,4174 — r_ CO Co State except Sloans/3358 NC NC&SC State *Medcos1/4198 — Front Range — FL Winterhaven,FL —Florida First/4126 `-/''-l' A 2 NE NE& IA "Midlands Choice/3341 I GA Dalton/Northern GA 1*'Medical Network#4391 — NV Nevada State PHCN(formerly St.Mary's)4119 a-F. Upstate NY(Does IA NE&IA "Midlands Chcice/3341 NY not include "Multiplan/3392 Bultalo,NY ID Southern,ID -IPN/416D , OH Marietta.OH "Selectnet Plus/4103 Eastern/ If-,-f IL Midwestern IL& Healthlink/4189 SC SC&NC State 'MedcosV4198 Central MO ; 1 — — .i.,.,.:,, . IN Rural Indiana Sagamore/3357 t — SD SD State "America's PPO IformerlyAraz)/4389, Topeka,KS& Healthcare Preferred(tormerly )9 Eastern& KS TX ProneV3355 Western MO Mid America)/4190 5,4 — Western TX Rural WI/Mahon "WPPN/Multi Ian in rural WI only) KS Rural KS HPK14393 ',C. — WI Suburban 14159-nrral/4132Madison Suburban __ _ KY KY State "Center Care/4156,4172 `#V - WI Fox Valley WI "Network Hearth Plan/4149 1 fp— LA LAJMS State "American Lifecare/4143 WV WV Slate "Selectnet Plus/4144 :1.p MS MS/LA State "American Lifecare/4143 mstrapp(Mar-O1 -2002)-Weld County Governme-KIWI.AM I DASOCON 1 1182004 17 s ....................�, .. .:. , . t f:. °a: +tr �. Fpsa. Great West Healt care 1�PO Int`ormat an ti w,' F e . . Please indicate iiiormatwn0: thefotkiingGrest-West Healthui,enerworks.!Reasoiiiornotificationli tedamlerTPNIBG6H* u, •� -i T Please Indicate TPN network ieformation in the TEN information seedon ebosrya a,hm,:alit aft: r_.__:w PPO°/k: Network Co-Pay: Network Deductible: Plan Type. Check One / $ $ ee IS Tamil ❑Hos.-Onl ❑Hose/Ph s icate"A"for add or"T"for term beside any affected networks w/approximate employee count. A-add Approx. State Network Area Network/Business code :: A-add Approx. State Network Area Network/Business code T-term EE Count °?:".`:' 1-term EE Count Oklahoma City& **Great-West FIE OK Tulsa&Rural Healthcare(PCC)/1473 WI Northeast Great-West Healthcare/1460—"'Not Oklahoma-PPO Necessary for Id card w"�`'�,I Wisconsin available to traveling insureds production. Oklahoma City& -Great-west 8155 _ OK Tulsa&Rural Healthcare(PCC)/7900— p WY Wyoming Great-West Healthcare/1451—'"Not Oklahoma-POs Necessary for Id card - ,: available to traveling insureds production. W.01 iffi s f F' °°r",� li 3 ii ar - inl x r : t d`° { ,4 6tir$ lSr • t�.,r#fla eat°F v ,0 a. ;li'u' -y .. t dr a t� :1;', $ wAvi ee.m; anh L" 'y " vk x t, a. Tea TeN :tyar7abfe +- ° �rtx es6 Pk ass a n .. :. - , + ,. ,WI Mn #y inreat-W t HeaiNN re a peL+Ac(xss networ a}tonpp fntha4r laegF °,4s '. "k s x : ::ta, .. :;• .,. ;n; ._„'�'e;.:Rea ��fotnotlticatMitfrM�..�' . ' .fkatlWa.yt,.. �' .�,', � . �ug . :ial;..,.° ,.,-."_.2 Open Access%: Network Co-Pays: Network Deductible: Plan Type: Check One / $pcp _ $Spec _ ❑Hosp-Only ❑Hosp/Phys Indicate"A"for add or"T"for term beside any affected networks with approximate employee count. Reminder: For TPN set up,members must reside in the TPN service area as defined on the Zip Code Report available on the Managed Care intranet website. A-add Approx. State Network Area TPN/Business code _ A-add Approx. State Network Area TPN/Business code 1-term EE Count We 1-term EE Count CA Monterey,CA "Coastal Health Care/9303 cyy''`1 MT MT State "Interwest Health/9305 • -C1 CA Chico,CA "Superior of CA/9311R4 NE NE& IA "Midlands Choice/9307 '3P Upstate NY(Does IA NE&IA "Midlands Choice/9307 di NY not include "Multiplan/9308 E?: Buffalo,NY) ID Southern.ID "IPN/9306 !i0 OH Marietta,OH "Selectnet Plus/9310 ,F.* KS Rural KS "HPK/9304 SD SD State "America's PPO(IormerlyAraz)/9301 KY KY State "Center Care/9302 ;(fir+iz, WI Rural WI "WPPN/Multiplan/9312 _ LA LA/MS State "American Ldecare/9300 �'s. WI Fox Valley WI "Network Health Plan/9309 • • !S MS MS/LA State "American Lilecare/9300 xx WV WV State "Selednet Plus/9310 ai:t'.di: — a. r F :' S #",°° ss re e a z 4 d' r t 4 .z rv4�4w,fi a ""t : r 'p;. f oh' �M...4 -.,L, 4a •8' ₹'^a 343.83• s e ° 9{n- . wa .Th : y f s ez=t,x. . ... .nt, f. 'xSxz:Fn.f.l.ea e,.MnGJuJw,aA n M..il..0 s$.da` Open Access%: Network Co-Pays: Network Deductible: ��Plan Type: Check One / $.c. $S.ec $ ee/S famil O Hose-Onl ❑Hose/Ph s Indicate"A"for add or"T"for term beside any affected networks w/approximate employee count. A-add Approx. State Network Area Network/Business code Sin A-add Approx. State Network Area Network/Business code T-term EE Count 1-term EE Count Oklahoma City& "Great-West ■■■- OK Tulsa&Rural Healthcare(PCC)/9220 Oklahoma-PPO Necessary for id card ,roducoon. NOTES: -ALL PPO&Open Access members in TPNs and OK and UT Great-West Healthcare networks must be set up to obtain Id cards with the proper logo. -"'ALL PPO members residing in NE WI,WV&WY and requiring access to Great-West Healthcare markets in NE WI,WV and WY need to be set up specifically for these networks as these networks are not available to traveling insureds. Including these Great-West Healthcare networks on the form will allow Plan Services to set up these cases to access these Great-West Healthcare networks. -Members should not have access to more than one network in a given service area. "Available to traveling insureds.Members in the specified product seeking service in these TPN service areas,as indicated in the Zip Code Report,automatically have that TPN unless noted otherwise. However,members residing in this service area must have the TPN logo on their ID cards. 'Requires special notification form available from Health Care Operations x75940/rebecca.dering@gwl.com -Plan Services: Please email forms re:Network Selection to Policy Apps Please email forms re:Maternity Management to Medmgmt. iikel free to Email Policy Apes or Medmgmt with questions. (revised-7/25/04) mstrapp(Mar-01 -2002)-Weld County Govemme-IGW LAM IDASOCON 11182004 I8 Ilo , 1 t I } illimployee Benefits-Banking Authorization Letter (not applicable for HRA) pplicant's Bank Name: Bank Address: RE: Employee Benefits Plans Bank Account Authorization Please accept this as formal notification that effective January 1,2005, Great-West Life&Annuity Insurance Company(Great-West) will be responsible for the administration of some or all of Contractholder's employee benefits plans. Great-West has established a"central disbursement account"' to facilitate administration of the employee benefits plans. Contractholder hereby authorizes Great-West to initiate Automated Clearing House debits,credits and prenotification entries to Contractholder's checking or savings account(as indicated below)at the depository financial institution named below,and to debit/credit the same to such account. Contractholder acknowledges that the origination of ACH transactions to the account indicated below must comply with the provisions of U.S.law. The Contractholder has full responsibility for providing funds for these transactions. The Contractholder also shall have full responsibility for establishing and maintaining overdraft protection or a line of credit with respect to the account with Bank Name: The undersigned,as an Officer of Contractholder,with authority to make deposits and withdrawals from the account noted below,grants such authority. Bank Name: will honor demands for payment as they are received, promptly and in an expeditious manner. Contractholder's Bank: Bank Branch Office Name: Complete Address: Bank Account Name: • Bank Account Type: ❑Checking ❑Savings Account Number: Transit Number: Bank Representative: Telephone Number: The Contractholder will provide Great-West with a MICR sheet,for purposes of verifying account information. If this account is closed,the Contractholder will provide Great-West with at least 30 days advance notice. This authorization is to remain in full force and effect until Contractholder has provided written notification to Great-West of its termination. By: See Declaration of Signature Title: See Declaration of Signature cc: Great-West,with voided check enclosed • mstrapp(Mar-01-2002)-Weld County Govemme-IGWLAMIDAS0C0N 11182004 19 • ERIFICATION OF MEMBER'S PRIOR CREDITABLE COVERAGE ON PLAN'S EFFECTIVE DATE Company: Weld County Government Effective Date: January 1,2005 If an employee and/or his dependents have been covered under a plan offered by your company for a period of less than 12 months or if an employee and/or his dependents are in the process of satisfying a waiting period or if a Late or a Special Applicant is requesting coverage under your plan at the time coverage is effective with us, please provide the following information on such individuals and forward this form to the Benefit Payment Office or the Head Office as advised by your customer service representative. Name of Member Social Security No .;l Date of Hire/Eff. Number of months of pre-ex. (List names of employee anti Date* condition limitation period this his/her dependents) �` ?_-' member needs to satisfy See Census I understand that Great-West assumes no liability for any errors that may occur as a result of inaccurate information provided by the member or us. By: See Declaration of Signature Title: See Declaration of Signature • mstrapp(Mar-01 -2002)-Weld County Governme-IGWLAMIDASOCON 11182004 20 Privacy Agreement bI THIS CONTRACT is entered into on this I day of \A 4-n -,y-7t�y^J,200`1,between Great-West Life&Annuity Insurance 41mpany("Company"), 8515 E. Orchard Road,Greenwood Village,Colorado 80111 and Weld County Government ("Contractor"), 5 10th Street PO Box 758,Greeley,CO 80632. WHEREAS,COMPANY and CONTRACTOR each may make available and/or transfer or cause to be transferred to the other certain Protected Information;and WHEREAS,COMPANY and CONTRACTOR may obtain access to,through, or receive from,or at the direction of,or on behalf of, the other's customer or contractor,certain Protected Information; NOW,THEREFORE,COMPANY and CONTRACTOR agree as follows: 1. Definitions. The following terms shall have the meaning ascribed to them in this Section. A. "Applicable Law"shall mean any such item listed below in this sub-section A as it may apply to any particular Protected Information,including any amendments to any such item as such may become effective; CO the Health Insurance Portability and Accountability Act of 1996("HIPAA"), (ii) the federal regulations regarding privacy and promulgated with respect to HIPAA,found at Title 45 CFR Parts 160 and 164,and (iii) any state statute or regulation or other bulletin or document that has the force of law that has been issued by a state in furtherance of that state's protection of the privacy of an individual's health information to the extent that such statute or regulation or other bulletin or document that has the force of law is not otherwise pre-empted by any federal law;and (iv) any statute or regulation or other bulletin or document that has the force of law that has been issued in • furtherance of a governmental entity's ability to obtain health information for health oversight purposes, investigatory, administrative,judicial or law enforcement proceedings or other lawful purpose. B. "Contract"shall refer to this document. C. "Great-West Life" shall include those affiliates of Great-West that control,or are controlled by, or are under common control with Great-West,and shall also include any party for which Great-West has the authority to administer or direct the business of that entity whether through a reinsurance,administration or other agreement. D. "Individual"shall mean the person who is the subject of the Protected Information or a person who qualifies as the personal representative of the individual. E. "Protected Information"shall mean any information that relates to the past,present,or future physical or mental health or condition of an individual,the provision of health care to an individual,or the past,present or future payment for the provision of health care to an individual,including demographic information collected from an individual,that is created by a health care provider,health plan,employer or health care clearing house,or by a Party and that identifies the individual,or with respect to which there is a reasonable basis to believe that the information can be used to identify the individual,and that is related to goods or services provided by a party on behalf of the other Party,or is related to goods or services provided by a Party on behalf of or at the direction of a customer of the other Party. F. "Party"or"Parties"shall mean CONTRACTOR and COMPANY. G. "Secretary"shall mean the Secretary of the Department of Health and Human Services("HHS")and any other officer or employee of HHS to whom the authority involved has been delegated. 2.Term and Termination. The term of this Contract shall commence as of January 1,2005(the Effective Date),and shall terminate en all of the Protected Information made available and/or transferred or caused to be transferred to a Party,or obtained,accessed or received by a Party from or at the direction of or on behalf of the other Party or a customer of either Party is destroyed,rendered inaccessible,or returned to the appropriate Party. mstrapp(Mar-01 -2002)-Weld County Govemme-IG W LAMIDASOCON 11182004 21 ' 3. Limits on Use and Disclosure Established by Terms of Contract.The Parties shall be prohibited from using or disclosing the Protected Information for any purpose other than as expressly permitted or required by this Contract. 4. Permitted and Required Uses and Disclosures. Except as otherwise set forth in this Contract,the Parties shall be permitted to use and/or disclose Protected Information only for the purpose of conducting the transactions contemplated under this Contract and only r purposes within the scope of that Party's representation of,or work conducted on behalf of the other Party or a customer of the er Party. 5. Use of Protected Information for Management, Administration and Legal Responsibilities.The Parties are permitted to use Protected Information if necessary for the proper management and administration of their respective businesses and to carry out their respective legal responsibilities. 6. Disclosure of Protected Information for Management,Administration and Legal Responsibilities.The Parties are permitted to disclose Protected Information for the proper management and administration of their respective businesses and to carry out their respective legal responsibilities,provided: A. The disclosure is required by Applicable Law;or B. The disclosing Party obtains reasonable assurances from the person to whom the Protected Information is disclosed that it will be held confidentially and used or further disclosed only as required by Applicable Law or for the purposes for which it was disclosed to the person,the person will use appropriate safeguards to prevent use or disclosure of the Protected Information,and the person will immediately notify the disclosing Party of any instance of which it is aware in which the confidentiality of the Protected Information has been breached. 7. Data Aggregation Services. Each Party is permitted to use or disclose Protected Information to provide data aggregation services,as that term is defined by 45 C.F.R. 164.501,relating to the health care operations of that Party. 8. Obligations of Party Receiving Protected Information: A. Limits on Use and Further Disclosure Established by Contract and Law.The Parties hereby agree that the Protected Information shall not be further used or disclosed other than as permitted or required by this Contract or as required by Applicable Law. • B. Appropriate Safeguards. The Parties will establish and maintain appropriate safeguards to prevent any use or disclosure of the Protected Information other than as provided for by this Contract. C. Reports of Disclosures.The Parties shall maintain information related to its disclosures of Protected Information sufficient to provide each other with any necessary accounting of such disclosures and shall promptly notify the other of any such disclosures in a manner acceptable to the Parties. D. Reports of Improper Use or Disclosure.The Parties hereby agree that they shall promptly report to each other any use or disclosure of Protected Information not provided for or allowed by this Contract. E. Subcontractors and Agents.The Parties hereby agree that anytime Protected Information is provided or made available to any subcontractors or agents,the disclosing Party must enter into a subcontract with the subcontractor or agent that contains the same terms,conditions and restrictions on the use and disclosure of Protected Information as contained in this Contract. F. Right of Access to Protected Information.To the extent required by the federal regulations regarding privacy and promulgated with respect to HIPAA,found at Title 45 CFR Parts160 and 164,the Parties hereby agree to make available and provide a right of access to Protected Information by an Individual.This right of access shall conform with and meet all of the requirements of 45 C.F.R. 164.524 to the same extent as if the Party were directly subject to 45 C.F.R. 164.524. G. Amendment and Incorporation of Amendments.To the extent required by the federal regulations regarding privacy and promulgated with respect to HIPAA,found at Title 45 CFR Parts 160 and 164,the Parties agree to make Protected Information available for amendment and to incorporate any amendments to Protected Information in accordance with 45 C.F.R.164.526 to the same extent as if the Party were directly subject to 45 C.F.R. 164.526. • H. Provide Accounting.To the extent required by the federal regulations regarding privacy and promulgated with respect to HIPAA,found at Title 45 CFR Parts 160 and 164,the Parties agree to make Protected Information available as required to provide an accounting of disclosures in accordance with 45 C.F.R. 164.528 to the same extent as if the Party were directly subject to 45 C.F.R. 164.528. mstrapp(Mar-01-2002)-Weld County Govemme-IG W LAMIDASOCON 11182004 22 I. Access to Books and Records. The Parties hereby agree to make their respective internal practices,books, and records relating to the use or disclosure of Protected Information available to the Secretary or the Secretary's designee for purposes of determining compliance with the HHS Privacy Regulations.The Parties hereby agree to make their internal practices,books,and records relating to the use or disclosure of Protected Information reasonably available to each other. • J. Return or Destruction of Protected Information.At termination of this Contract each Party hereby agrees to return or destroy all Protected Information received from,or created or received by the other,and not to retain any copies of the Protected Information after termination of this Contract,if reasonably feasible. If return or destruction of the Protected Information is not feasible,the Parties agree to extend the protections of this Contract for as long as necessary to safeguard the Protected Information and to limit any further use or disclosure consistently with the intent of this Contract. If a Party elects to destroy the Protected Information,it shall certify to the other Party that the Protected Information has been destroyed. K. Mitigation Procedures. The Parties agree to have procedures in place,and to implement those procedures as necessary, for mitigating,to the extent practicable,any deleterious effect from the use or disclosure of Protected Information in a manner not consistent with this Contract. L. Minimum Necessary. When using or disclosing Protected Information under this Contract,or when requesting Protected Information from another party for purposes related to this Contract,a Party shall make reasonable efforts to limit Protected Information to the minimum necessary to accomplish the intended purpose of the use,disclosure or request. M. Notice of Restriction. The Parties agree to notify each other of requests for restriction or confidential communications, submitted in accordance with 45 C.F.R. 164.522,which may affect the performance of the other Party. Notification shall be provided in advance of any agreement to such restriction or confidential communication. 9. Termination of Contract.The Parties agree that each party has the right to terminate this Contract and seek relief under section 11 of this Contract if it determines that the other Party has violated a material term of this Contract. 10. Choice of Law.This Contract shall be governed by the law of the State of CO,except that for purposes of privacy rights of individuals,the law of the state in which the individual resided during the event(s)giving rise to the need to determine the individual's rights related to disclosures under this Contract shall apply,except to the extent that HHS Privacy Regulations may supersede such state law. �1. Injunctive Relief.Notwithstanding any rights or remedies provided for in this Contract,each Party retains all rights to seek injunctive relief to prevent or stop the unauthorized use or disclosure of Protected Information by the other Party or any agent, contractor or third party that received Protected Information. 12. Indemnification. Each party hereby agrees to hold the other Party harmless and to indemnify the other Party against any claim, assertion,or allegation brought against the indemnified Party,and related damages,awards,expense,court costs,reasonable attorney's fees,and fines or penalties,arising from the indemnifying Party's wrongful use or disclosure of Protected Information and against the indemnifying Party's failure to maintain adequate safeguards for Protected Information or other breach of this Contract. 13. Miscellaneous: A. Binding Nature and Assignment.This Contract shall be binding on the Parties hereto and their successors and assigns, but neither Party may assign this Agreement without the prior written consent of the other,which consent shall not be unreasonably withheld. B. Notices. Whenever under this Contract one Party is required to give notice to the other,such notice shall be deemed given if mailed by First Class United States mail,postage prepaid,and addressed as follows: As to Company: Great-West Life&Annuity Insurance Company ATTN: Chief Privacy Officer 8525 E. Orchard Road Greenwood Village,Colorado 80111 • As to Contractor: See address in paragraph 1 of this Contract. Either Party may at any time change its address for notification purposes by mailing a notice stating the change and setting forth the new address. mstrapp(Mar-01-2002)-Weld County Govemme-IGW LAMIDASOCON 11182004 23 C. Good Faith.The Parties agree to exercise good faith in the performance of this Contract. D. Article Headings.The article headings used are for reference and convenience only,and shall not enter into the interpretation of this Contract. • E. Force Majeure.A Party shall be excused from performance under this Contract for any period that Party is prevented from performing any services pursuant hereto,in whole or in part,as a result of an Act of God,war,civil disturbance, court order,labor dispute or other cause beyond its reasonable control,and such nonperformance shall not be grounds for termination. F. Attorney's fees.Except as otherwise specified in this Contract,if any legal action or other proceeding is brought for the enforcement of this Contract,or because of an alleged dispute,breach,default,misrepresentation,or injunctive action,in connection with any of the provisions of this Contract,each Party shall bear its own legal expenses and the other cost incurred in that action or proceeding. G. Entire Agreement.This Contract consists of this document,and constitutes the entire agreement between the Parties. There are no understandings or agreements relating to this Agreement which are not fully expressed in this Contract and no change,waiver or discharge of obligations arising under this Contract shall be valid unless in writing and executed by the Party against whom such change,waiver or discharge is sought to be enforced. IN WITNESS WHEREOF,the Parties have caused this Contract to be signed and delivered by their duly authorized representatives, as of the date set forth above. CONTRACTOR COMPANY WelfiliCountyG7e0m t F / Great-West Life&Annuity Insurance Company By: u e66----- By: Print Name: 6 I l�, ' / L &' Print Name: •t1e7-7), t i ,1t2 Title: • mstrapp(Mar-01 -2002)-Weld County Govemme-IGWLAMIDASOCON 11182004 24 MAR-21-2005 MON 01 :43 PM WELD COUNTY PERSONNEL FAX NO. 9703529019 P. 02 Privacy Agreement • THIS CONTRACT is entered into on this l 61-day of '4.3 A'n.la.,q.gtyy,200`1,between Great-West Life&Annuity Insurance Thmpany("Company"),8515 E.Orchard Road,Greenwood Village,Colorado 80111 and Weld County Government ("Contractor"), .5 10th Street PO Box 758,Greeley,CO 80632. WHEREAS,COMPANY and CONTRACTOR each may make available and/or transfer or cause to be transferred to the other certain Protected Information;and WHEREAS,COMPANY and CONTRACTOR may obtain access to,through,or receive from,or at the direction of,or on behalf of, the other's customer or contractor,certain Protected Information; NOW,THEREFORE,COMPANY and CONTRACTOR agree as follows: 1. Definitions.The following terms shall have the meaning ascribed to them in this Section. A. "Applicable Law"shall mean any such item listed below in this sub-section A as it may apply to any particular Protected Information,including any amendments to any such item as such may become effective; (1) the Health Insurance Portability and Accountability Act of 1996("HIPAA"), (ii) the federal regulations regarding privacy and promulgated with respect to HIPAA,found at Title 45 CPR Parts 160 and 164,and (iii) any state statute or regulation or other bulletin or document that has the force of law that has been issued by a state in furtherance of that state's protection of the privacy of an individual's health information to the extent that such statute or regulation or other bulletin or document that has the force of law is not otherwise pre-empted by any federal law;and (iv) any statute or regulation or other bulletin or document that has the force of law that has been issued in furtherance of a governmental entity's ability to obtain health information for health oversight purposes, • investigatory,administrative,judicial or law enforcement proceedings or other lawful purpose. B. "Contract"shall refer to this document. C. "Great-West Life"shall include those affiliates of-Great-West that control,or are controlled by,or are under common control with Great-West,and shall also include any party for which Great-West has the authority to administer or direct the business of that entity whether through a reinsurance,administration or other agreement. D. "Individual"shall mean the person who is the subject of the Protected Information or a person who qualifies as the personal representative of the individual. E. "Protected Information"shall mean any information that relates to the past,present,or future physical or mental health or condition of an individual,the provision of health care to an individual,or the past,present or future payment for the provision of health care to an individual,including demographic information collected from an individual,that is created by a health care provider,health plan,employer or health care clearing house,or by a Party and that identifies the individual,or with respect to which there is a reasonable basis to believe that the information can be used to identify the individual,and that is related to goods or services provided by a party on behalf of the other Party,or is related to goods or services provided by a Party on behalf of or at the direction of a customer of the other Party. P. "Party"or"Parties"shall mean CONTRACTOR and COMPANY. G. "Secretary"shall mean the Secretary of the Department of Health and Human Services("HHS")and any other officer or employee of HI-IS to whom the authority involved has been delegated. 2.Term and Termination. The term of this Contract shall commence as of January 1,2005(the Effective Date),and shall terminate 'hen all of the Protected Information made available and/or transferred or caused to be transferred to a Party,or obtained,accessed y,or received by a Party from or at the direction of or on behalf of the other Party or a customer of either Party is destroyed,rendered inaccessible,or returned to the appropriate Party. • Rdly‘ Ca mslrapp( lar-01-2002)-Weld County°overo i0 me- WLAMIDAS0C0NI 1182004 MAR-21-2005 MON 01 :43 PM WELD COUNTY PERSONNEL FAX NO. 9703529019 P. 03 ' 3. Limits on Use and Disclosure Established by Terms of Contract.The Parties shall be prohibited from using or disclosing the Protected Information for any purpose other than as expressly permitted or required by this Contract. 4. Permitted and Required Uses and Disclosures.Except as otherwise set forth in this Contract,the Parties shall be permitted to use and/or disclose Protected Information only for the purpose of conducting the transactions contemplated under this Contract and only `w purposes within the scope of that Party's representation of,or work conducted on behalf of the other Party or a customer of the ner Party. 5.Use of Protected Information for Management.Administration and Legal Responsibilities.The Parties are permitted to use Protected Information if necessary for the proper management and administration of their respective businesses and to carry out their respective legal responsibilities. 6. Disclosure of Protected Information for Management.Administration and Legal Responsibilities.The Parties are permitted to disclose Protected Information for the proper management and administration of their respective businesses and to carry out their respective legal responsibilities,provided: A. The disclosure is required by Applicable Law;or B. The disclosing Party obtains reasonable assurances from the person to whom the Protected Information is disclosed that it will be held confidentially and used or further disclosed only as required by Applicable Law or for the purposes for which it was disclosed to the person,the person will use appropriate safeguards to prevent use or disclosure of the Protected Information,and the person will immediately notify the disclosing Party of any instance of which it is aware in which the confidentiality of the Protected Information has been breached. 7.Data Aggreeation Services.Each Party is permitted to use or disclose Protected Information to provide data aggregation services,as that term is defined by 45 C.P.R. 164.501,relating to the health care operations of that Party. 8.Obligations of Party Rsceivina Protected Information: A. Limits on Use and Further Disclosure Established by Contract and Law.The Parties hereby agree that the Protected Information shall not be further used or disclosed other than as permitted or required by this Contract or as required by Applicable Law. • B. Appropriate Safeguards.The Parties will establish and maintain appropriate safeguards to prevent any use or disclosure of the Protected Information other than as provided for by this Contract. C. Reports of Disclosures.The Parties shall maintain information related to its disclosures of Protected Information sufficient to provide each other with any necessary accounting of such disclosures and shall promptly notify the other of any such disclosures in a manner acceptable to the Parties. D. Reports of Improper Use or Disclosure.The Parties hereby agree that they shall promptly report to each other any use or disclosure of Protected Information not provided for or allowed by this Contract. E. Subcontractors and Agents.The Parties hereby agree that anytime Protected Information is provided or made available to any subcontractors or agents,the disclosing Party must enter into a subcontract with the subcontractor or agent that contains the same terms,conditions and restrictions on the use and disclosure of Protected Information as contained in this Contract. F. Right of Access to Protected Information.To the extent required by the federal regulations regarding privacy and promulgated with respect to HIPAA,found at Title 45 CFR Parts160 and 164,the Parties hereby agree to make available and provide a right of access to Protected Information by an Individual.This right of access shall conform with and meet all of the requirements of 45 C.F.R. 164.524 to the same extent as if the Party were directly subject to 45 C.F.R. 164.524. G. Amendment and Incorporation of Amendments.To the extent required by the federal regulations regarding privacy and promulgated with respect to HIPAA,found at Title 45 CFR Parts 160 and 164,the Parties agree to make Protected Information available for amendment and to incorporate any amendments to Protected Information in accordance with 45 C.F.R.164.526 to the same extent as if the Party were directly subject to 45 C.F.R. 164.526. H. Provide Accounting.To the extent required by the federal regulations regarding privacy and promulgated with respect to IIIPAA,found at Title 45 CFR Parts 160 and 164,the Parties agree to make Protected Information available as required to provide an accounting of disclosures in accordance with 45 C.F.R. 164.528 to the same extent as if the Party were • directly subject to 45 C.F.R. 164.528. msaapp(Mar•01.2002)-Weld County Govenune-I0WLAMIPAS0C0N 11182004 22 MAR-21-2005 MON 01 :44 PM WELD COUNTY PERSONNEL FAX NO. 9703529019 P. 04 I. Access to Books and Records.The Parties hereby agree to make their respective internal practices,books,and records relating to the use or disclosure of Protected Information available to the Secretary or the Secretary's designee for purposes of determining compliance with the HHS Privacy Regulations.The Parties hereby agree to make their internal • practices,books,and records relating to the use or disclosure of Protected Information reasonably available to each other. I. Return or Destruction of Protected Information.At termination of this Contract each Party hereby agrees to return or destroy all Protected Information received from,or created or received by the other,and not to retain any copies of the Protected Information after termination of this Contract,if reasonably feasible.If return or destruction of the Protected Information is not feasible,the Parties agree to extend the protections of this Contract for as long as necessary to safeguard the Protected Information and to limit any further use or disclosure consistently with the intent of this Contract. If a Party elects to destroy the Protected Information,it shall certify to the other Party that the Protected Information has been destroyed. • K. Mitigation Procedures.The Parties agree to have procedures in place,and to implement those procedures as necessary, for mitigating,to the extent practicable,any deleterious effect from the use or disclosure of Protected Information in a manner not consistent with this Contract. L. Minimum Necessary.When using or disclosing Protected Information under this Contract,or when requesting Protected Information from another party for purposes related to this Contract,a Party shall make reasonable efforts to limit Protected Information to the minimum necessary to accomplish the intended purpose of the use,disclosure or request. M. Notice of Restriction. The Parties agree to notify each ether of requests for restriction or confidential communications, submitted in accordance with 45 C,F.R. 164.522,which may affect the performance of the other Party. Notification shall be provided in advance of any agreement to such restriction or confidential communication. 9. Termination of Contract The Parties agree that each party has the right to terminate this Contract and seek relief under section 11 of this Contract if it determines that the other Party has violated a material term of this Contract. 10. Choice of Law.This Contract shall be governed by the law of the State of CO,except that for purposes of privacy rights of individuals,the law of the state in which the individual resided during the event(s)giving rise to the need to determine the individual's rights related to disclosures under this Contract shall apply,except to the extent that HHS Privacy Regulations may supersede such state law. • -f1. Iniunctive Relief.Notwithstanding any rights or remedies provided for in this Contract,each Party retains all rights to seek injunctive relief to prevent or stop the unauthorized use or disclosure of Protected Information by the other Party or any agent, contractor or third party that received Protected Information. 12. Indemnification. Each party hereby agrees to hold the other Party harmless and to indemnify the other Party against any claim, assertion,or allegation brought against the indemnified Party,and related damages,awards,expense,court costs,reasonable attorney's fees,and fines or penalties,arising from the indemnifying Party's wrongful use or disclosure of Protected Information and against the indemnifying Party's failure to maintain adequate safeguards for Protected Information or other breach of this Contract. 13. Miscellaneous: A. Binding Nature and Assignment,This Contract shall be binding on the Parties hereto and their successors and assigns, but neither Party may assign this Agreement without the prior written consent of the other,which consent shall not be unreasonably withheld. B. Notices.Whenever under this Contract one Party is required to give notice to the other,such notice shall be deemed given if mailed by First Class United States mail,postage prepaid,and addressed as follows: As to Company: Great-West Life&Annuity Insurance Company ATTN: Chief Privacy Officer 8525 E.Orchard Road Greenwood Village,Colorado 80111 As to Contractor. See address in paragraph 1 of this Contract, • Either Party may at any time change its address for notification purposes by mailing a notice stating the change sod setting forth the new address. mmapp(Mar-0l-2002)-Weld County Govern=-)C,W LAMIPASOCON 11182004 23 MAR-21-2005 MON 01 :45 PM WELD COUNTY PERSONNEL FAX NO. 9703529019 P. 05 C. Good Faith.The Parties agree to exercise good faith in the performance of this Contract. D. Article Headings.The article headings used are for reference and convenience only,and shall not enter into the • interpretation of this Contract. , B. Force Majeure.A Party shall be excused from performance under this Contract for any period that Party is prevented from performing any services pursuant hereto,in whole or in part,as a result of an Act of God,war,civil disturbance, court order,labor dispute or other cause beyond its reasonable control,and such nonperformance shall not be grounds for termination. F. Attorney's fees.Except as otherwise specified in this Contract,if any legal action or other proceeding is brought for the enforcement of this Contract,or because of an alleged dispute,breach,default,misrepresentation,or injunctive action,in connection with any of the provisions of this Contract,each Party shall bear its own legal expenses and the other cost incurred in that action or proceeding. G. Entire Agreement.This Contract consists of this document,and constitutes the entire agreement between the Parties. There are no understandings or agreements relating to this Agreement which are not fully expressed in this Contract and no change,waiver or discharge of obligations arising under this Contract shall be valid unless in writing and executed by the Party against whom such change,waiver or discharge is sought to be enforced_ INWITNESS WHEREOF,the Parties have caused this Contract to be signed and delivered by their duly authorized representatives, as of the date set forth above. CO CTOR COMPANY Wel Co'my Go e;6tn t Great-West Life& "Annuity Insurance Company By: . '') � sy:e-ic i'M-,*e a eta Print Name:�v a L B Print Name: E 1 i io-be-H - HA vt cect— • itle71).i2 F,n , Title: Pc re Vt a%Ara e • mstrapp(Mar-01-2002)-Weld County Govemme-IGW LAMIDASOCON11182004 24 SAMPLE PRIVACY NOTICE ealth Plan Customer: This sample Privacy Notice is for your use. There are sections that require changes,or ve been written to describe the text which immediately follows the notations-these sections are noted in brackets [] and italicized. [Enter the name of your plan here such as: The Widget Factory Benefit Plan] Notice of Privacy Practices Regarding Protected Health Information Effective Date: [April 14, 2003 or April 14, 2004 or effective date w/Great-West Healthcare] THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.PLEASE REVIEW IT CAREFULLY. At[enter name of your company], we respect your privacy and will protect your health information responsibly and professionally. We're required to maintain the privacy of your health information and to provide you with this notice.Also,we're required to abide by the terms of the notice that's currently in effect. This notice applies to all members of[enter the name of the self funded benefit plan]. It describes how we may collect,use,and disclose your health information. It also describes your rights concerning your health information. As you read this notice,you'll see an important term: "protected health information"or PHI.PHI is information about you, including health and demographic information created and received by us that can reasonably be used to identify you.PHI includes information that relates to your past,present,and future physical or mental condition,the provision of health care,and payment for that care. • How We Use or Share Protected Health Information (PHI) Below are some examples of ways we may use or share information about you without your consent or authorization.These examples are considered to be treatment,payment,and health care operations.We may use or share your PHI: [This section is intended to provide illustrative examples of how you use/disclose PHI for treatment,payment or health care operations purposes. We've included the most relevant examples for your plan. These are adequate and meet the intention of the regulation;you are also able to add other examples if necessary.] [Examples,you can add others that reflect treatment,payment and health care operations purposes] • To manage our plan which includes functions such as auditing,monitoring,and managing carve-out plans. • With a third party administrator to handle claim payment and medical management functions. • With organizations that help us conduct our business operations. We only share your information with businesses that agree to keep it protected. During the course of our business,there may be additional instances in which your PHI may be used.These instances are described below.We may use or share your PHI: [The four statements below are required, if you plan on using or disclosing a member's health information for the purposes listed. As a plan administered by us, the first two will definitely apply and will need to be included in your otice. The third statement informs members that health information can be released to your plan sponsor,for the �rpose of plan administration. This statement is required if your plan sponsor receives any protected health information in the course of managing your plan. The last statement is required if you use or disclose member's information for fundraising purposes. We did not include this statement in our notice since it is not applicable; however,you will need to determine if it is applicable to your plan.] mstrapp(Mar-01-2002)-Weld County Governme-IGWLAMIDASOCON 11182004 25 • To send you a reminder for important services such as mammograms or prostate cancer screenings. • To give you information about alternative medical treatments and programs or about health-related products and services that may be of interest to you.For example,we might send you information about smoking cessation or weight-loss programs. • With our plan sponsor through which you receive health benefits for the purpose of administering our plan.We have agreed to • keep this information protected. To contact you to raise funds for our plan. There are state and federal laws that may require or allow us to release your health information to others.We may be required to provide information for the following reasons: [Each of the items below is a permissible disclosure and must be listed in the notice; it is likely that even if you do not disclose for these purposes,your business associates may.] Health Oversight Activities: We may disclose your PHI to a government agency authorized to oversee the health care system or government programs,or its contractors(e.g.,state insurance department,U.S.Department of Labor)for activities authorized by law, such as audits,examinations,investigations,inspections and licensure activities. Legal Proceedings: We may disclose your PHI in response to a court or administrative order, subpoena,discovery request,or other lawful process,under certain circumstances. Law Enforcement: We may disclose your PHI to law enforcement officials under limited circumstances.For example,in response to a warrant or subpoena,or for the purpose of identifying or locating a suspect,witness,or missing person,or to provide information concerning victims of crimes. For Public Health Activities: We may disclose your PHI to a government agency that oversees the health care system or government programs for activities such as preventing or controlling disease or activities related to the quality, safety,or effectiveness of an FDA regulated product or activity. Required by Law: We may disclose your PHI when we're required to do so by law. •orkers'Compensation: We may disclose your PHI when required by workers'compensation laws. Victims of Abuse,Neglect,or Domestic Violence: We may disclose your PHI to appropriate authorities if we reasonably believe that you're a possible victim of abuse,neglect,domestic violence or other crimes. Coroners,Funeral Directors,and Organ Donation: In certain instances,we may disclose your PHI to coroners or funeral directors, and in connection with organ donation. Research: We may disclose your PHI to researchers,if certain established steps are taken to protect your privacy. Threat to Health or Safety: We may disclose your PHI to the extent necessary to avert a serious and imminent threat to your health or safety or the health or safety of others. For Specialized Government Functions: We may disclose your PHI in certain circumstances or situations to a correctional institution if you are an inmate in a correctional facility,to an authorized federal official when it's required for lawful intelligence or other national security activities,or to an authorized authority of the Armed Forces. For Cadaveric Organ,Eye,or Tissue Donation: We may disclose your PHI for the purpose of facilitating organ,eye, or tissue donation and transplantation. Before we can use or disclose your PHI for any reason other than those listed in this section titled"How We Use or Share Protected Health Information(PHI)",we are required to obtain your written authorization.You may revoke the authorization at any time as long as you do so in writing. Information provided as a result of your authorization will no longer be provided once you revoke the authorization. • What Are Your Rights mstrapp(Mar-01 -2002)-Weld County Governme-IGWLAM1DASOCON 11182004 26 You have the following rights regarding the protected health information(PHI)we maintain about you. You have the right to ask us to restrict our use and disclosure of protected health information for the purposes of treatment, payment or health care operations.This includes uses and disclosures to family members,relatives,close personal friends,or other persons identified by you who may be involved with your care or payment for your care.We'll consider your request,but we aren't quired to agree to restrict the information. ou have the right to ask to receive confidential communications. You may request that when we send communications to you that contain PHI,we send them to you by alternative means or to an alternative location. You must request this in writing and clearly state that our disclosure of all or part of that communication could endanger you. You must also tell us the alternative location(e.g., fax number,address,etc.)to which you would like us to send the information. You have the right to inspect and obtain a copy of the protected health information(PHI)that we maintain about you in a designated record set.A designated record set contains PHI that we collect,maintain or use to administer or make decisions regarding your enrollment,payment,claims adjudication,or case/medical management.If we don't maintain the PHI,but we know who does, we'll tell you. Requests to access the information must be made in writing, and we'll respond within 30 days of receipt of your request.We may charge a reasonable,cost-based fee to provide you with the information.There are exceptions as to what information can be accessed.For example, information compiled for legal proceedings cannot be accessed.If we deny access to your information, in part or in whole,we will notify you in writing.Our denial will include the reason for the denial,your review rights(if applicable), and information on how to file a complaint. You have the right to ask us to amend protected health information about you that's contained in a designated record set(as described above).All amendment requests must be in writing and include a reason for the request.We'll respond within 60 days of receiving the request.If the request is approved,we'll amend the information in our records and notify any other individual(s)whom we know and/or whom you have told us have received the information,and we'll provide them with the amendment as well.In certain cases,your request may be denied. For example,we may deny a request if the information we have on file is accurate or if we didn't create the information. We'll notify you in writing of any denial.You may respond by filing a written statement of disagreement with us,and we have the right to rebut the disagreement statement. Should this occur,you have the right to request that your original request,our denial,and any statement of disagreement,along with our rebuttal,be included in future disclosures of the PHI. You have the right to request an accounting of certain disclosures of protected health information. An accounting will show you to whom we provided your PHI.The first accounting request in a 12-month period of time will be provided free of charge. Subsequent • uests are subject to a reasonable,cost-based fee,of which you will be made aware of in advance.All requests for disclosures must made in writing,and we'll respond within 60 days of receipt.There are some accountings we aren't required to provide. For example,we aren't required to account for disclosures made for purposes of treatment,payment,or health care operations. Also,we won't provide accountings for disclosures that you have authorized,and certain other disclosures such as for national security purposes. You have the right to a paper copy of this notice upon request.You may write us at the address provided in the complaints and inquiries section of this notice,or call us at the number on the back of your health plan identification card and we'll mail or fax a current notice to you.This privacy notice is also found on our Web site at[INSERT APPLICABLE WEBSITE NAME(S) HERE] [If your plan maintains a web site for employees to access information, it is required that you post the notice on your web site. If you do not maintain a web site, remove this reference.] For more information,or to begin the formal process connected with these rights,please contact[insert the contact point within your plan.] Complaints and Inquiries You may register a complaint to us or to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated.To file a complaint with us,please submit it in writing and address it to: [Insert your contact point information, including Title,Address and Phone Number; each of these elements is required.] To submit a complaint to the Secretary of the Department of Health and Human Services,please submit it in writing to: Secretary,Department of Health and Human Services • 200 Independence Ave SW Washington,DC 20201 877-696-6775 mstmpp(Mar-01-2002)-Weld County Governme-FGWLAMIDASOCON 11182004 27 Your complaint should include the following: • your name • the policyholder's name • contract or policy number • • name of employer or plan sponsor • the identification number on the health plan card(this may be the employee's social security number) • address or other means of communicating with you in writing • a telephone number where you can be reached • a brief description of the nature of your complaint • the names and phone numbers,if available,of any of our employees with whom you have discussed your complaint • any other information you think is important in order to resolve your complaint Please note: You won't be retaliated against or denied any health plan benefit or service because you file a complaint. Effective Date of this Notice and Revisions to the Notice This notice is effective[April 14, 2003 or April 14, 2004 or effective date w/Great-West Healthcare].We're required to abide by the terms of the notice that's currently in effect. We reserve the right to change the terms of this notice and to make the new notice effective for all PHI we maintain. If we change the notice,we will provide it to you by direct mail.Also,it is posted on our Web site at[INSERT APPLICABLE WEBSITE NAME(S) HERE]. [As mentioned before, only include this statement if you maintain a web site.] We will promptly revise and distribute this notice whenever there is a material change to the uses or disclosures,your rights, our duties,or other practices stated in this notice. Except when required by law,a material change to this notice will not be implemented before the effective date of the new notice in which the material change is reflected. • • mstrapp(Mar-01-2002)-Weld County Govemme-IGWLAMIDASOCON LAMIDASOCON 11182004 28 Plan Document Regarding HIPAA Privacy Compliance for the . Weld County Government Benefit Plan The Weld County Government Benefit Plan(hereafter,the"Plan")hereby adopts the following policies and procedures with respect to the Standards for Privacy of Individually Identifiable Health Information;Final Rules as published by the Office of the Secretary, Department of Health and Human Services in the Federal Register on Thursday,December 28,2000(hereafter,the"Privacy Regulations")and found at 45 C.F.R.Part 160 and Part 164,and any amendments thereto. 1. The Plan was established and is maintained by Weld County Government(hereafter,"Plan Sponsor"). 2. The Plan is a group plan as that term is defined in 45 C.F.R. §160.103. 3. The Plan Sponsor may use and disclose protected health information,as that term is defined in 45 C.F.R. §164.501,only as expressly provided under the Privacy Regulations and the terms and conditions of this Plan Document. 4. Disclosures by the Plan to the Plan Sponsor.The Plan Sponsor will: (A) Not use or further disclose the information other than as permitted or required by the plan documents or as required by law; (B) Ensure that any agents,including subcontractors,to whom it provides protected health information received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such information; (C) Not use or disclose the information for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor; (D) Report to the Plan any use or disclosure of the information that is inconsistent with the uses or disclosures provided for herein of which it becomes aware; (E) Make available protected health information in accordance with§I 64.524 of the Privacy Regulations that provides individuals a right of access to inspect and obtain copies of protected health information about the individual contained • in a designated record set; (F) Make available protected health information for amendment and incorporate any amendments to protected health information in accordance with§164.526 of the Privacy Regulations; (G) Make available the information required to provide an accounting of disclosures in accordance with§164.528 of the Privacy Regulations; (H) Make its internal practices,books,and records relating to the use and disclosure of protected health information received from the Plan available to the Secretary of the Department of Health and Human Services or those acting under the authority or at the direction of the Secretary for purposes of determining compliance by the Plan with the Privacy Regulations; (I) If feasible,return or destroy all protected health information received from the Plan that the Plan Sponsor still maintains in any form and retain no copies of such information when no longer needed for the purpose for which disclosure was made,except that,if such return or destruction is not feasible,the Plan Sponsor will limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible;and (J) Ensure that the adequate separation required in§164.504(f)(2)(iii)of the Privacy Regulations is established. 5. Disclosures by Others to the Plan Sponsor.The Plan Sponsor shall be entitled to receive protected health information from: (A) the Plan; (B) any business associate of the Plan; (C) any person or entity that contracts with such business associate; (D) any person or entity that contracts with the Plan Sponsor to provide services to or on behalf of the Plan; (E) any health insurer or health insurance issuer or HMO that provides health benefits coverage or services to or on behalf of the Plan; (F) any health care clearinghouse that provides services to or on behalf of the Plan or with respect to Plan participants;and (G) any other person or entity that maintains,or has the authority to direct the disclosure of,protected health information related to any Plan participant. • Adequate Separation. (A) Only those persons or classes of persons described below that are under the control of the Plan Sponsor shall be given access to protected health information that is disclosed to or otherwise obtained by the Plan Sponsor;provided that any mstrapp(Mar-01 -2002)-Weld County Govemme-IGW LAMIDASOCON 11182004 29 employee or person under the control of the Plan Sponsor who receives protected health information relating to payment under,health care operations of,or other matters pertaining to,the Plan in the ordinary course of business shall be included and treated as such a person or as within the class of persons described below: (i) an officer or employee who serves as the Plan Administrator; • (ii) an officer or employee who serves as a Plan fiduciary;and (iii) an officer or employee who performs functions related to the Plan,including but not limited to human relations,audit,legal,accounting and systems personnel. (B) The persons and classes of persons described in paragraph(A)above shall be given access to and permitted to use protected health information that is disclosed to or otherwise obtained by the Plan Sponsor solely for the purpose of Plan administration functions that the Plan Sponsor performs for the Plan. (C) Any person or class of persons described in paragraph(A)above who obtains access to or uses protected health information in a manner that is contrary to the requirements of this section shall be subject to the Plan Sponsor's disciplinary policies and procedures up to and including termination of employment. Regardless of whether a person is disciplined or terminated pursuant to this section,the Plan reserves the right to direct that the Plan Sponsor, and upon receipt of such direction the Plan Sponsor shall,modify or revoke any person's access to or use of protected health information. 7. Permitted and Required Use and Disclosure of Protected Health Information. (A) Permitted Uses and Disclosures.The Plan Sponsor is and shall be entitled to use and disclose any protected health information obtained pursuant to the authority set forth in this Plan Document, and any other information that may reasonably be deemed to be protected health information,regardless of the source of such information,that comes into the possession of the Plan Sponsor,only for the following purposes: (i) to provide and conduct administrative functions related to payment and health care operations for and on behalf of the Plan; (ii) to audit payments for claims incurred under the Plan; (iii) to request proposals for services to be provided to or on behalf of the Plan;and (iv) to investigate fraud or other unlawful act related to the Plan and committed or reasonably suspected to have . been committed by a Plan participant. (B) Required Uses and Disclosures of Protected Health Information.The Plan Sponsor shall be required to use and/or disclose protected health information: (i) to an individual,when requested under, and required by 45 C.F.R. §164.524,in order to provide an individual with access to his or her own protected health information; (ii) to an individual,when requested under,and required by 45 C.F. R. §164.528,in order to provide an individual with an accounting of disclosures of that individual's protected health information;and (iii) when required by the Secretary of the Department of Health and Human Services or those acting under the authority or at the direction of the Secretary to investigate or determine the Plan's compliance with the Privacy Regulations. 8. Prohibited Uses and Disclosures.The Plan Sponsor shall not be entitled to use or disclose protected health information for any purpose for which use and disclosure is not expressly allowed under this Plan Document,including but not limited to: (A) using or disclosing protected health information other than as permitted or required under this document or applicable law,or in a manner inconsistent with the Privacy Regulations;and (B) taking adverse employment action against any plan participant who is an employee of Plan Sponsor,except with respect to any fraud or unlawful act related to the Plan and committed or reasonably suspected to have been committed by such person. 9. Minimum Necessary.When using or disclosing protected health information or when requesting protected health information from another party,the Plan Sponsor must make reasonable efforts to limit protected health information to the minimum necessary to accomplish the intended purpose of the use or disclosure,and limit any request for protected health information to the minimum necessary to satisfy the purpose of the request. Ilite undersigned hereby certifies,represents and warrants that(i)he/she has the full authority to act on behalf of the Plan Sponsor and to execute this document,(ii)all necessary authority has been obtained from the Plan Sponsor to execute and adopt this document,and mstrapp(Mar-01-2002)-Weld County Govemme-IGWLAMIDASOCONI 1182004 30 (iii)the Plan Sponsor hereby adopts this Plan Document Regarding HIPAA Privacy Compliance effective the /,S day of By game: -1_ Wfr ad&l) Title: i) +: - 1 ytt tr oe cipi, Date: //i/o • • mstrapp(Mar-01-2002)-Weld County Govemme-IGWLAMIDASOCON 11182004 31 Verification to Great-West Life & Annuity Insurance Company of Adoption of Plan Document Regarding HIPAA Privacy Compliance for the Weld County Government Benefit Plan The Plan Sponsor of the above referenced Plan hereby verifies to Great-West Life&Annuity Insurance Company,and its affiliates, that the Plan Sponsor has adopted a plan document or amended its plan document to incorporate the provisions of 45 C.F.R. §164.504(0(2)and that the Plan Sponsor has agreed to be bound by such adopted or amended plan document and the provisions of 45 C.F.R. §164.504(0(2)and other applicable parts of the HIPAA privacy regulation. The Plan Sponsor acknowledges that by signing this verification,the Plan Sponsor is representing and warranting that the Plan Sponsor has taken action that is reasonably necessary to establish and maintain the Plan Sponsor's compliance with the adopted or amended plan document and with the applicable provisions of the HIPAA privacy regulation and that the Plan Sponsor agrees to indemnify,defend and hold harmless Great-West Life&Annuity Insurance Company and its affiliates,directors,officers,employees and contractors f and against any expense,court costs,attorneys'fees,judgment,damages or award arising from any claim, assertion or c se o action related to this v 'frcatio By /(- % Nameylc( (C� (4/,2de//� Title: � ) (�- �Inui/ ez f &Lie4/ Date: 77//65 • • mstrapp(Mar-01 -2002)-Weld County Govemme-IGWLAMIDASOCON11182004 32 r Ca Double click for additional information NEW YORK STATE DEPARTMENT OF HEALTH HEALTH CARE REFORM ACT-PUBLIC GOODS POOL ATTACHMENT 2 ELECTION FORM for PAYORS OTHER THAN THIRD PARTY ADMINISTRATORS or ADMINISTRATIVE SERVICES ORGANIZATIONS Use BLUE INK when signing Effective Date: January 1,2005 FEDERAL EMPLOYER IDENTIFICATION#(EIN) 84-6000813 PAYOR NAME: Weld County Government D/B/As(IF APPLICABLE): ADDRESS: 915 10th Street PO Box 758 Greeley, CO 80632 SNTACT PERSON: Jewel Vaughn PHONE#: 970-356-4000 x 4231 If the above referenced entity is a payor that utilizes a third party administrator or administrative services organization for claims processing,please provide the following information: TPA/ASO NAME: Great-West Life&Annuity Insurance Company TPA/ASO FEDERAL EMPLOYER IDENTIFICATION#(EIN): 84-0467907 By signature below,the above entity elects to make public goods surcharge payments directly to the Office of Pool Administration for all its lines of business and agrees to: I. remit to the Department's Office of Pool Administration required surcharge payments for all applicable services on a monthly basis on or before the 30th day following the calendar month for which monies have been paid to designated providers of service; 2. provide the Department's Office of Pool Administration monthly certified reports on or before the 30th day following the calendar month for which monies have been paid which separately report patient service expenditures for services provided by designated provider type(s)(i.e.,hospital inpatient,hospital outpatient,diagnostic&treatment center,laboratory',or ambulatory surgery center) by product line; 3. provide the Department with certification of data and access to allowance expenditure data upon request for audit verification purposes;and 3H4100(6/97)Att2-Page 1 of 2 For services provided on or after October 1,2000, freestanding clinical laboratories with Article 5 Title V permits are exempt from HCRA surcharges. mstrapp(Mar-01 -2002)-Weld County Govemme-IGWLAMIDASOCONI 1182004 33 4. the jurisdiction of the state to maintain an action in the courts of the State of New York to enforce any provision of section 2807- j of the Public Health Law. By signature below,the above entity also agrees to make public goods covered lives payments directly to the Department's Office et Pool Administration in instances where it provides inpatient coverage as a corporation organized and operating in accordance h Article 43 of the Insurance Law, an organization operating in accordance with Article 44 of the Public Health Law, a self- insured fund or third party administrator acting on behalf of such fund or a commercial insurer licensed to do business in New York State and authorized to write accident and health insurance and whose policy provides inpatient coverage on an expense incurred basis. In such instances the above entity agrees to: 1. remit to the Department's Office of Pool Administration within 30 days after the end of each month one-twelfth of both the individual and family unit annual assessment amounts for each of the individual and family unit annual assessment amounts for each of the individuals and family units residing in the state which were included on the payor's membership rolls for all or a portion of the prior month and for which the payor covered general hospital inpatient care, including retroactive additions and deletions; 2. provide the Department with data certification and access to individual and family unit data,upon request,for audit verification purposes;and 3. the jurisdiction of the state to maintain an action in the courts of the State of New York to enforce any provision of section 2807-t of the Public Health Law. By signature below, the Chief Financial Officer or other duly authorized individual of the above entity certifies that the data submitted on all applicable attachments has been carefully prepared in accordance with instructions provided, and to the best of his/her knowledge,the information presented is accurate and correct. • Signature Title: Chief Financial Officer or Duly Authorized Individual Date Note: Payors making an election are only agreeing to the jurisdiction of NYS courts for purposes of enforcing payments required under 2807-j and 2807-t. This does not, in any way, preclude a payor from litigating other issues in Federal court such as ERISA based challenges,etc. DOH4100(6/97)Att2-Page 2 of 2 • mstrapp(Mar-01 -2002)-Weld County Govemme-IGWLAMIDASOCON 11182004 34 !( O !l•,,= !§§( „„4,!, '`(\);\ ;�< "; § ( . El \ 2 j } �r(�) ` © n ) ® �( , ❑ ❑ ❑ Ow E 0 a ) § ] j \ ) \ \ } \ \ }!)\) ` / ! m ! - ° ` ❑ ❑ ❑ b ] ° VI ! V. \ § 0 _ - 0 i-IC. © 2 a \ \ \ (aqg wit � § � \ ) ` - § �` `� ` ❑ 02U 8i t h.` 3 E § § [ § § \ / | e !!||) ( ; ■ ` E § z l Z Rr: D E E } . w - - , ■ ! ; 7 § 2 ; / 0 ` ) § § W ) § § \ � § � 2 z $ z . Z ) } \ P. ( » { \ \ ao � ❑ ❑ ❑ ❑ / ' ) .iirl0 ❑ ❑ 0 a / / \ ! ; , g ! ! \ 1/4-15 } o / / // /r \ fit\ t a \ b \|\ \/\ // « //\ 0 § !2 Al Ohihuuuu1 /g! |/ )• \ ) /! R \/\ (g/ i/ q/i New York State Department of Health Health Care Reform Act(f-ICRA) NEW YORK STATE DEPARTMENT OF HEALTH • HEALTH CARE REFORM ACT- PUBLIC GOODS POOL ATTACHMENT 2.5 CHANGE OF PAYOR STATUS for PAYORS For an entity that is self-insured, the following information must be filed for any change in status from the original election submission filed except a change in Third Party Administrators (i.e., switching from one TPA to another TPA)which must be filed using Attachment#2.6. Payor Name: Weld County Government Payor Federal ID# :84-6000813 Contact Name :Jewel Vaughn Phone# :970-356-4000 x 4231 Effective Date of Change :January 1, 2005 Check any applicable box: ❑SELF-INSURED TO FULLY INSURED If as a self-insured fund you have become fully insured complete this section. If you previously used a TPA for claims processing, please list the TPA name,federal ID#, contact name, and phone#, otherwise, if you performed your own claims processing, enter N/A under TPA name. TPA Name : TPA Federal ID #: Contact Name: Frances K. Pool Phone#: 800-537-2033 Check one of the following: DTPA or fund will continue to file reports until all claims have been adjudicated, at which time a final monthly report with a copy of this form indicating same will be filed. (see note on page 2) ❑All self-insured claims have been adjudicated effective . (see note on page 2) ❑SELF-INSURED FUND WITHOUT A TPA TO SELF-INSURED FUND WITH A TPA If as a self-insured fund you did not utilize a TPA for claims processing and are now utilizing a TPA, list the TPA name, federal ID#, contact name, and phone#. A Name: TPA Federal ID#: ontact Name: Phone#: Check one of the following: DFund will continue to process claims and file reports for all dates of service prior to the change until all such claims have been adjudicated, at which time a final monthly report with a copy of this form indicating same will be filed. (see note on page 2) DFund ceased processing all claims effective and all monthly reports and pool payments will now be filed directly by the TPA. ❑All self-insured claims that fund was responsible for have been adjudicated effective . (see note below) ❑SELF-INSURED FUND WITH A TPA TO SELF-INSURED FUND WITHOUT A TPA If as a self-insured fund you previously used a TPA for claims processing and have discontinued their service and will now be performing your own claims processing, fill out the information below. Please note that if your are changing TPAs and will NOT be performing your own claims processing, you should not complete this form but complete Attachment#2.6 instead. TPA Name: TPA Federal ID#: Contact Name: Phone#: Check one of the following: DTPA will continue to process claims and file reports for all dates of service prior to the change until all such claims have been adjudicated, at which time a final monthly report with a copy of this form indicating same will be filed. (see note below) ['TPA ceased processing all claims effective and all monthly reports and pool payments will now be filed directly by the self-insured fund. ❑All self-insured claims that TPA was responsible for have been adjudicated effective .(see note below). ❑OTHER For any change of status, other than those listed above, describe below the type of status change you are filing. TE:A fund that has a status change continues to have a reporting requirement for a period of one year ollowing the end of the year in which this status change occurred or until all claims for the period during which the fund was an elector have been adjudicated. Once all run-off claims have been adjudicated (paid), a monthly report which clearly indicates that all claims for the election period have been adjudicated must be submitted, along with a copy of this form indicating same. • Signature of Payor Date Revised: March 2000 • New York State Department of Health Health Care Reform Act(HCRA) NEW YORK STATE DEPARTMENT OF HEALTH HEALTH CARE REFORM ACT -PUBLIC GOODS POOL • ATTACHMENT 2.6 CHANGE OF THIRD PARTY ADMINISTRATOR(TPA) STATUS for PAYORS If an electing payor changes their third party administrator(TPA)or administrative services only organization(ASO),the form below must be completed and submitted to the Department's pool administrator.NOTE:This form is only to be utilized by payors,not TPAs.TPAs should file Attachment#2.4-A Addendum or Attachment 2.4-B Addendum. Effective Date:January 1,2005 Fill out all applicable information. PAYOR INFORMATION: FEDERAL EMPLOYER ID#(EIN): 84-6000813 NAME: Weld County Government PREVIOUS TPA/ASO INFORMATION: FEDERAL EMPLOYER ID#(EIN): NAME: PRESENT(NEW) TPA/ASO INFORMATION: FEDERAL EMPLOYER ID#(EIN): 84-0467907 NAME: Great-West Life&Annuity Insurance Company ADDRESS: 8505 East Orchard Road Greenwood Village,CO 80111 `ONTACT PERSON: Frances K. Pool ONE#: 800-537-2033 Check one of the following(if applicable): ['Previous TPA will continue to process claims and file reports for all dates of service prior to the change for a period of one year following the end of the year in which the change in TPA occurred or until all such claims have been adjudicated,at which time a final monthly report with a copy of this form indicating same will be filed. OAR self-insured claims that previous TPA was responsible for have been adjudicated effective ['New TPA is assuming responsibility for all pending claims and HCRA reporting requirements. Signature of Payor Date Revised:March 2000 • Application For Group (Coverage-' Signature Pages: NOTE: This document is important. It affects your legal rights and obligations. This Application is for employee benefit coverage or administration provided by Great-West Life& Annuity Insurance Company(Great-West). 0 her Benefits: ❑None there are any additional benefits not previously indicated,please identify them here. In the Benefit column,list coverage affected,then in Description column describe the benefit. There will be an extra cost for each additional benefit listed. You may list up to 4 additions. Benefit Description FT Students Current Enrolled Students,age 25, FT to age 23 for new Enrollees Insulin Pumps Paid under TIER II Retiree Coverage No Maximums, Paid the same as all other employees The definition of Retiree is as follows: Retired from Weld County on or after December 16, 1998 with at least 10 years of service,or was an elected official of Weld County,Colorado,for at least one full four-year term. Retiree remains eligible for medical benefits with Weld County until they attain the Normal Retirement Age for SS("NRA") or becomes eligible for health insurance coverage with another employer,or becomes eligible for Medicaid or Medicare coverage before attaining the NRA(i.e becomes disabled). The Applicant understands that Great-West will provide Booklets electronically to the Applicant. The Applicant is responsible for distributing booklets(electronically or otherwise)to employees. The Applicant accepts and agrees that approval of the Application and the final rates, fees, and factors so determined will be based on the final enrollment information provided to Great-West by the Applicant,including the final proportion of employees electing coverage under the contract(s)for which Application is made. Approval and final rates,fees and factors will also be subject to qualification under the current underwriting rules and practices. Underwriting rules which are used by Great-West,which include but are not limited to: • Great-West is the sole provider of medical expense benefits. • No more than 10%of eligible employees will be covered under a retiree class of benefits. • • There have been no more than 2 prior carriers in the past 4 years. Carrier/Dates of Coverage 1)Pacificare 2 Years 2)Anthem BC 6 Years • The number of employed family members related to all company officers will be less than or equal to the larger of 5 or 10%of the number of eligible employees. • The Applicant will fund 50%of total plan costs or 100%of employee costs. • Employee participation minimum standards that more than 75%of eligible employees will apply for coverage under the medical plan. • Dependent participation minimum standards that more than 85%of employees with eligible dependents,excluding those who elect to waive benefits(dependents covered under another plan), will apply for dependent coverage under the medical plan. • n t ,..m'"t .., lut 747, u...... .r,t''' r . ..^^^nmpe, . .. ., .xti•>rmw + nr r. 0. a,N r i,x r q3`+`n,..,..... .r., Application for Group Coverage -- Signature Pages: Verification of Medical Information—(Applicant must answer the following questions) During the last 24 months, has any employee, dependent, COBRA continuant.or retiree been treated: or do you expect in the next ' 12 months any employee, dependent,COBRA continuant, or retiree to be treated, for any of the following 0nditions, diseases, illnesses or accidents*? a. Cancer DYes ONO b. Heart Disorder ❑Yes ❑No c. Lung Disease ❑Yes ❑No d. Organ Transplant ❑Yes ❑No e. Diabetes EYes ❑No f. Brain Disorders EYes ❑No g. AIDS,or ARC Disorders EYes ❑No h. Other adverse health conditions that cost more than$10,000 ❑Yes ❑No i. Scheduled to have surgery or an organ transplant EYes ❑No *If"Yes"was indicated on any of the above,please provide treatment/diagnosis details on the"Medical Information Detail" found following. (Information gathered will be used solely for the purpose of underwriting the group life insurance plan and self-funded medical plans. This information will also be used for underwriting purposes for fully insured medical plans where allowed by state law). State law of Colorado requires the following notice: It is unlawful to knowingly provide false,incomplete,or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment,fines,denial of insurance,and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. • • Application For Group Coverage -- Signature Pages: .. Declaration of Signature Oois Agreed that all statements, representations and answers made in this Application are considerations for and a basis of the ntract(s) between the Applicant and Great-West. Whether written, electronically received or printed, they are declared to be true, full and complete. No other statement, representation, or information will bind Great-West or affect its rights. The Applicant will promptly send to Great-West full particulars as to each employee to become covered or with a change to coverage at any time under the policy(s)/plan(s) to the satisfaction of Great-West. The Applicant agrees that all payments to be made to Great-West are the sole responsibility of the Applicant. Great-West will not be responsible for the actions or inactions of any third party that the Applicant may use to transmit information or payments to Great-West. The undersigned Signatory hereby states, affirms, represents and warrants that by affixing the Signatory's signature in the space provided below, that said signature, appearing solely on this document, shall and does constitute the Signatory's signature to each and every document, contract or agreement herein listed or described with the same force and effect as if the Signatory had separately and affirmatively affixed the Signatory's signature to such document, contract or agreement. Upon approval of this Application, documents reflecting the elections made by the Applicant in this Application will be issued. Once issued, all terms and conditions become effective as of the effective date. Signatory,by affixing the Signatory's signature in the space provided below does hereby state,affirm,represent and warrant that: i. The Signatory does hereby affix Signatory's signature to this document freely,voluntarily and without coercion of any kind or nature whatsoever. ii. that except as provided below, Signatory hereby waives and shall not assert any position,claim,defense, or counterclaim that states or implies anything contrary to the content of this document except for forgery, fraud or unlawful physical duress. iii. Signatory has had the opportunity to or has consulted with a lawyer or other counselor or advisor of Signatory's choice with respect to the effectiveness and advisability of executing this document. iv. Signatory has read or had the opportunity to read each and every document,contract or agreement herein listed. v. Signatory has reviewed and understands and agrees to be bound by any and all notices,warnings,and disclaimers • contained in the documents,contracts or agreements herein listed, including but not limited to those that appear above,below or in close proximity to the signature block contained in the documents,contracts or agreements herein listed. vi. this Signature Declaration shall be part of each and every document,contracts or agreement herein listed and vii. a copy of this document shall have the same force and effect as the original. Documents,contracts and agreements listed herein means: Application for Contract; Excess-Loss Agreement; Administrative Services Agreement; Banking letter(s);Verification of Prior Creditable Coverage; This Application must be approved by the Great-West corporate office located in Greenwood Village,Colorado. No Plan is in effect until the Application has been approved. Great-West reserves the right to reject any Application. If at any time after the effective date of this coverage there is a change in participation under this Plan,either:a) 10%in any one month when compared to the previous month;orb)20%over any period of three consecutive Policy Months;then Great-West reserves the right to adjust the rates or factors. Full Legal Name of the Firm: Weld County Government Effective Date_ January I,2005 Applicant Signature: Dated: Printed Name: Title: • Medical Information Detail: IF "YES," TO ANY OF THE PREVIOUS QUESTIONS,PLEASE COMPLETE THE INFORMATION BELOW. Name Employee or Total Medical Expenses Specific Diagnosis Dependent for last 12 Months r kt �r .m�nkt • • Hello