HomeMy WebLinkAbout20002667.tiff RESOLUTION
RE:: APPROVE 2001 GROUP MASTER CONTRACT FOR HEALTH CARE PROGRAM
AND AUTHORIZE CHAIR TO SIGN -ANTHEM BLUE CROSS AND BLUE SHIELD
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Group Master Contract for the Health
Care Program between the County of Weld, State of Colorado, by and through the Board of
County Commissioners of Weld County, and Anthem Blue Cross and Blue Shield, commencing
January 1, 2001, with further terms and conditions being as stated in said contract, and
WHEREAS, after review, the Board deems it advisable to approve said contract, a copy
of which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners o'
Weld County, Colorado, that the Group Master Contract for the Health Care Program between
the County of Weld, State of Colorado, by and through the Board of County Commissioners of
Weld County, and Anthem Blue Cross and Blue Shield be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said contract.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 30th day of October, A.D., 2000.
BOARD OF COUNTY COMMISSIONERS
W LD COUNTY, COLORADO
`1.1 i • � hG, _ K/ � y----
ATTEST: LU i � � l /
Iarbara J. r}(meyer, Chair u
Weld County Clerk to the ' .. p..bp( '�"/ G6l. i
J. ile, ro-Tem ---
BY %_. to I_�_. �. /' -
Deputy Clerk to the Bo? ( ' \ '\ _ ` ---
'Georg . Baxter
APPROVED AS,TD M: __--
Dale K. Hall
!� —
County Attorney- 4 ',,,, 1,/ft.e. --_
Glenn Vaad
2000-2667
C t PE0018
A Group Health
Care Program
Group Master Contract
HM
9p9
Co or 2000-2667
® ® An ludeyendeut Licensee of the
Bide Cnc ss and Blue Shield l,ssi'clarion
HMO COLORADO
GROUP MASTER CONTRACT
TABLE OF CONTENTS
Page No.
SECTION L APPLICATION-ACCEPTANCE 1
SECTION 11. GENERAL AGREEMENTS 1
Contract effective date 1
Anniversary date ' ' 1
Employee .
Employer 1
Remittance - 1
Benefit booklet 1
Group administrator 2
Assignment . 2
Contract provision changes .
Notices . . 2
Governing Laws 2
Attorneys' fees and expenses . 2
Enforcement of the contract . . 3
Interpretation of the contract 3
Termination of the contract
Reinstatement of contract . . 3
SECTION III. PREMIUM: CHANGES,PAYMENT, TERMINATION FOR NON-PAYMENT,
REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE . 4
Changes . 4
Payment . . 4
Termination for non-payment - . 4
Refund of membership premium 4
Cashing of check not acceptance
c
SECTION IV. MEMBERSHIP/APPLICATION
Eligibility
Notification of cessation of membership
Acceptance of contract 5
S
Group eligibility requirements
ELUHII'JG'lk:
HMG Colorado ,•® "ro Anthem.. 09
Addendum to Application
GROUP'lUMBER A VNIVERSARV MONTH 'ADDENDUM EFF E Jl I JE DA"I
COF)'),E)O /-t 1f %
PLEASE PRINT FIRMLY TO ENSURE THAT ALL COPIES ARE LEGIBLE. DO NOT TYPE—DO NOT TEAR FORM APART
Complete all information on this Addendum to Application (Addendum)if you are completing the Application.Il you have pi-viously submitted an Aii lend 'i-comple
only information':hat is relevant to the change.If a change is not indicated,the previous Ash endum will remai in effect.
CHANd —Indicate one or snore
U ClassifiCation of Employees Eligible O Dependent Age -C Probationary Period Coverage Applied For
❑optional:Group Benefit_sd CQERA willing Notification O New ownership _
This Addendum is issued to:Weld County Government
("THE EMPLOYER" -CORRECE LEGAL NAME OF ACC OUNT)
This Addendum amends provisions of the Application.II we approve this Addendum,we will return the approved Addendum with the ellectii it date eirn.detcd. l
Addendum will become a part of the Contract If we do not approve this Addendum,it will be returned.Other thin specifically amended herein,the toms a provis'u. s
of the Application and Contract shall remain in full force and effect.
CLASSIFICATION OF EMPLOYEES ELIGIBLE he Employerrequires that all eligible Employees ha e a regular work week of at least _ _ 20 __hip.
per w Lick(minimum of 24 hours per week). Eligible I mploycc do not include those on a teinpomry or substit Pc basis. If other Eligibility,please c:,plot _ _
She Employer hereby certifies the following number of Employees in each category below
Total Employees employed by the employer working at least 24 hours per week(include hose not yet eligible) -_Enrolling for coverage.
Total Eligible Employees who have met probationary period __Encode.I eke d.ore
COBRA or Colorado State law continuation of coverage enrollees __No nihn COW r;le
Other,please explain:
DEPENDENTS--Unmarried dependent children are covered until the end of the month in which they become age 19,or 25 if financially depende it up m the pan. t.
PROBATIONARY PERIOD
I^'of the month following firs)full pay period wane(1,employer assigns effective date.
GROUP HEALTH COVERAGE APPLIED FOR(select only one):
BlueAdvantage HMO Plan Plan No. 15-1-15/25:40 4 of Employees enrolling
BlueAdvantage Point of Service Plan No. 15-I-15/25/40$250 deductible#of Employees enrolling
BluerAdvantage C'us'tom Plus Deductible $200 single$4110 family Coinsurance SS%to S5,000/510,000 #of Employees enrolling
Eighteen months pre-existing clause for late entrants with no prior coverage for the Custon.Plus.
OPTIONAL GFIOUP BENEFIT INFORMATION
Optional Chemical Dependency Rehabilitation Program
ry Others e Health Network eve exam once eve:v 24 months ---
REMARKS Retirees age 55 through 64 will have an option to continue health insurance coverage until the date their age changes to 65,provided they nice tl is Iullo i, s
criteria and stipulations:
a) Eligible employees must retire from county service with at least ten years of service,of be a county elected official for at least one full fmu-year tic n
b) Eligible employees must be enrolled in the county's health insurance plan at the time r retirement or leave of county office.
of Dependent coverage will be provided for eligible employees dependents who are enrolled at the time of retirement or leaving of county of tics
d) Coverage fur the eligible employee and dependents will only be provided until the emp oyee reaches ageit5,or becomes eligible for health mMu r nice 4 vcrage 7. di
another emp loyer,or becomes eligible for Medicaid ro Medicare coverage before attaining the age of 65.Dependent coverage if still applicanle sill hiitfered u,, ei
the same terms of COBRA offered employee's de'penden ts-
e) The county will offer to the retirees the suite coverage at the same rates as regular comity employees at the same time.The county will be l es punubiC-0' payns le
40%surclta-ge of the premium,and the county contribution for the employee and dept ndents in the same;manner as provided regular emp oy ees
f) Alter COBRA,dependents will have the same conversion rights as regular employees and dependents.
The Employer II derstands that if we approve this Addendum,the employer agrees to be bi and by the terms,if the Contract and this Addendum.
Dated at _ Greet v, /Co orado this 30th dayot October 220OO_
( `
B •fX,L.. L Chair, Barbara S. Kirkmeyer
--' �,i%� .
) ¢/ A �SIGNATL�FF,1OF AU' 1O IZED PERSON TIl'LE
Approved and e ted by M&Colorado9n, nth 31ne Cross and//// It Shield
c Pl / } 11-4tV\tDate [ 2-I-�By
? j4l
� CHI O Nv HMO COI OKP.DO
Date ,-��( S.T�'
By
CHIEF OPA7V�r�s '�%Nr7s c'R�UE SHIELD
Weld County uovi
BlueAdvantage Application For BlueAdvantage
Qa INTERNAL USE ONLY
Vacs ti From HMO Colorado' ---
d An Independent Licensee of the Blue Cross GROUP NUMISEft ANNIVERSARY MONTH COMPACT❑'v I :Th;r:1.TE
1' m and Blue Shield Association "r _ / _/ y - ( -
PLEASE PRINT FIRMLY TO ENSURE THAT ALL COPIES ARE LEGIBLE. DO NOT TYPE—DO NOT TEAR FORM APART
Application for BlueAdvantage (Application)group coverage is hereby made for eligible Employees of the Employer. If this Applic won is
approved by HMO Colorado and Anthem Blue Cross and Blue Shield(if applicable),this coverage will be issued to:
Weld County Government ---
("THE EMPLOYER"—CORRECT LEGAL.NAME OF ACCOUNT)
915 10'"Street Greeley Co 806631 ----
(PHYSICAL ADDRESS—STREET,CITY,STATE,ZIP CODE)
(MAILING ADDRESS—IF DIFFERENT)
NOTE: Nye,'"Us,"and'Our"refer to HMO Colorado.For group sizes of 51 or n lore Employees,BlueAdvantage is federally qualifie d iu \dam s,
Arapahoe,Boulder,Clear Creek,Crowley,Denver,Douglas,El Paso, Fremont,Gilpin,Huerfano,Jefferson,Larimer,O'ero,Pueblo,Teller and
Weld counties.For groups with 51 or more employees,counties not listed are not federally qualified.For group sizes of 50 or fewer En y loaves.
BlueAdvantage is a not a federally qualified HMO product.When the product is not federally qualified,BlueAdvantage coverage cats diffcr from
those required by ose re BlueAdvantage ral tOu n regulatio laws and regulations. "We; "Us,"and"Our"also refers to Anthem Blue Cross and Blue Shield if con rage is
provided for C
IN CONSIDERATION of the submission of this Application by the Employer. approval thereof by us, and of the payment of prernauns in
accordance with the Group Master Contract(Contract),we agree to provide group coverage as described in the Contract,the Benefit l;onklet,
and this Application and the Addendum to the Application for BlueAdvantage(Addendum), for any eligible enrolled Employees and eligible
enrolled dependents,and the Employer agrees to abide by the terms,conditions,and limitations contained in such docurnents.
GENERAL AGREEMENT
I. NATURE OF BUSINESS(please be specific):County Goverinment -- ----- .
Type of organization: ❑ Proprietorship CI Corporation O Partnership
2. Do you have current coverage in force? O Yes No.if"Yes"do you intend to cancel that coverage? El Yes ❑ No. If you are app yii Ig for
or retaining other group health coverage in addition to this coverage on some or all Employees specify coverage(s).Carrier,a,nos ah-and
give details:
3. Do you intend to enroll retirees under this group health Plan?(Retirees may(1 enroll for coverage if there are 51 or m ore E&nl)Icy.ees •o)oiled
under this coverage.) F Yes E No If Yes,"give details: T1 0,-j 'r r� f 'i 11 — -
d. CONTRIBUTION—The Employer will be required to contribute a minimum of 50,Y0 toward the Employee's single or 30% f the F.Iopinyees
portion of the family-cost of membership premiums.
5. PREMIUMS—It is understoodthat the premiums quoted may change based on the actual enrollment of the group.Premiums,ails he billed
by us monthly,and will be reviewed in accordance with the Contract and State or Federal requirements.
6. CLASSIFICATION OF EMPLOYEES ELIGIBLE—MI eligible Employees of the Employer who have a regular work week as state I on the
Addeadum,shall be eligible to enroll.If the Employerreduces the working hours of such Employees to less hours per week than staled on
the Addendum,coverage will be continued for such Employees and their dependents under the same conditions and for the sar he pr el Ilium,
if the following conditions are met and the Employer so certifies:
(a) The covered Employee has been continuously employed as an Employee of the Employer and has been insured under tt e group
Contract,or under any group Contract providing similarbenefitswhich said group Contract replaces,for at least six mouths tm[aei'lately
prior to such reduction in working hours;
(b) The Employer has imposed such reduction in working hours due to economic conditions;and
(c) The Employer intends to restore the Employee to a full work week schedule as soon os economic conditions improve
7. ENROLLMENT PERCENTAGE REQUIREMENTS— For all size groups to apply for and retain group coverage and rates if wE are the sole
carrier,the Employer agrees to maintain the following enrollment percentage requirements,based on TOTAL ELIGIBLE EM:'LOS'F ES:
• Group size 50 or fewer Employees must have 75%enrollment based on NET ELIGIBLE EMPLOYEES
• Group size 51 or more Employees must have 759(0 enrollment based an NET ELIGIBLE EMPLOYEES,with no less than 50%of l OTAL
ELIGIBLE EMPLOYEES.
To arrive at NET ELIGIBLE EMPLOYEES,Employees covered elsewhere with the following tt pes of groupinsurance n Lay be ex 1 ude I,unless
such coverage is offered through THE EMPLOYER:
• A Blue Cross and Blue Shield Plan;
• A Health Maintenance Organization.;
• The Federal Employees Program;
• ladian Health Services;
• Federal Peace Corps;
• Colorado Uninsurable Health Insurance Plan.or
• Through a commercial carrier.
FORM NO.56)64(I':E 11tsr�
Weld Cry At V!wpb
NOTE: In the event the group does not meet the minimum enrollment requirements,we reserve the right to accept this Apit curie with
prior underwriting approval.
In all cases the Employer must meet the minimum enrollment and eligibility requirements according to HMO Iolorado ,edee lvriting
regula:ions and policies and Colorado State law.
If we are a dual carrier,to apply for and retain group coverage and rates,a minimum of three Employees must be enrolled at all ti met \\then
we are a dual carrier,the enrollment percentage requirements do not apply
If the number of eligible Employees enrolled does not comply with the required percentage,we reserve the right to cancel the Contra I ipon
thirty clay advance written notice.
Employers with 50 or fewer Employees may also be,sole proprietor's,a single full time Employee of a subchapter S or C corpora•is n,
limited liabilitycompany,or a partnership that has carried on significant business activity fora period of at least one year prior is app lir uiion
for coverage.
The Employer agrees and warrants that no person who is not an eligible member under this provision will be liste:l,named,c r otherwise
represented by it in any way to be an eligible member,and that the Employer will not remit membership premiums for any inch p •rson
or participant or assist in obtaining or maintaining a Benefit Booklet for suet,ineligible person. The Employer agrees to mainta n cc Ilittlere
recorc.s and to furnish to us,upon request,such information as may be requested by us for our underwriting review The Employee further
agrees to permit a payroll audit by us or by a representative appointed by us.This may include a request for business tax records
8. DEPENDENT—Dependent children are covered until they attain the age is stated on the Addendum.
9- PROBATIONARY PERIOD—Probationary period selection is as stated on the Addendum.There will be one open enrollment or the group's
Anniversary Date for the BlueAdvantage HMO Plan and/or BlueAdvantage Point-of-Service Plan. For BlueAdvantage Custom Plus, late
entrants with prior coverage can be added at the group's anniversary date.In addition,if BlueAdvantage Triple Option coverage is selected
by the Employer,members will be allowed to choose between the HMO Plan,Point-of-Service,and Custom Plus coverage(for Employers
with 50 or fewer employees only out-of-state employees can enroll in the Custom Plus).
10. GROUP HEALTH COVERAGE APPLIED FOR—Coverage selection is as stated on the Addendum.
COLORADO INSURANCE LAW REQUIRES ALL CARRIERS IN THE SMALL GROUP MARKET TO ISSUE ANY
HEALTH BENEFIT PLAN IT MARKETS IN COLORADO TO SMALL EMPLOYERS OF 2-50 EMPLOYEES,
INCLUDING A BASIC OR STANDARD HEALTH BENEFIT PLAN,UPON THE REQUEST OF A SMALL EMPLOYER
TO THE ENTIRE SMALL GROUP,REGARDLESS OF THE HEALTH STATUS OF ANY OF THE INDIVIDUALS IN
THE GROUP.BUSINESS GROUPS OF ONE CANNOT BE REJECTED UNDERA BASIC OR STANDARD HEALTH
BENEFIT PLAN.
I I. Employer represents,agrees,and warrants that the Employer is in compliance with all applicable local,state,and federal laves,rules and
regulations,including but not limited to COBRA,the Family Medical Leave Act, TEFRA, DEFRA, and OBRA.To the extent an✓pal t r if this
application is inconsistent with such laws,rules,and regulations,such provision shall not be deemed a part of this application-H.Iwever,
the application shall be otherwise enforceable.If the Employer has agreed to have us perform specific billing and not ificationdutie_'related
to COBRA,such information will be stated on the Addendum.
Masoud Shirazi-Shirazi&Assoc (970)356-5151 --- - -
BROKER TELEPHONE NUMBER
1770 251"Avenue#302 Greeley Co 80631 _
STREET,CITY,STATE,ZIP CODE
The Employer represents,agrees,and warrants that the information contained in this Application is true and correct and f onus an ei sent ial basis
for our issuance of the Contract.EVEN THOUGH THIS APPLICATION IS SUBMITTED WITH PROPOSED PREMIUMSOR OTHER FUNDS.THERE
WILL BE NO COVERAGE UNTIL THIS APPLICATION IS APPROVED BY US. If we approve this Application,we will send you a Contract of
which this Application will become a part.Your prior coverage should not he cancelled until you have been notified that your Application has
been accepted.No agent can bind coverage,set an effective date,or waive or alter any provision of this Application.The Contract will specify
the effective date of group coverage. If we do not approve this Application,the submitted funds will be returned to the Employer.
The Employer understands that if we approve this Application,the Employer agrees to be bound by the terms of the Contras L.
Dated {_ Greele , olorado this 30th _day of October A8_ 2OOO
/ C.
By, ; zl r Lk ' Chair, Barbara J. Kirkmayer__
SIGNAT RE OF AU 0RIZED PERSON 'FITI.E
Approved and d e.ted b HMO Coloradb,$ni r r Blue Cross .rd Blue Shield
d f i.
By _ • . u.�..l.. _ L*.st Date_ e!
CHIEF OP RATI' { tFFI —HMO COLORADO
By r�, Vijl.L� ! f s,4 . ♦f Date (lC i r LT4'- Pt'
LL _
CHIEF OPERA' G OFFICER—A TH B f1E 'OSS LUE IELD
FORM NCI.5(164(1:6: 11197
Weld Cly ArF wpa
HMO COLORADO
GROUP MASTER CONTRACT
NO. 01-00772001
For
Weld County Government
Employer
C07720
Group Number
SECTION I. APPLICATION-ACCEPTANCE
The application and addendum for group health coverage("application/addendum") executed by the cm r1o' Cr has
been accepted by HMO Colorado(sometimes referred to as "we," "us," and"our"). Such application/addendum and
their contents are incorporated in this group master contract("contract"). In the event of any inconsistency bctwecn
the terms of the application/addendum and the terms of the contract, the terms of the contract will contra]
SECTION II. GENERAL AGREEMENTS
The purpose of this contract is to provide under the circumstances specified herein health and hospitalizat.on benefits
to certain of the employer's employees and their dependents. Such persons,w hen covered hereunder. are -eten ed to
as "members."
I. Contract effective date.The effective date of the contract shall be 12:01 A.M. on the first day rf,lanuam,
2001. at Denver, Colorado; the contract shall continue to nmain in effect on an annual basis from :a/2ar '.o year
thereafter unless terminated in accordance with the provit,ions of the contract.
2. Anniversary date.The anniversary date is the effective date for(i)coverage; (ii)changes to group enrollment
and benefit eligibility implemented by the employer; and (iii) the date a group is due for appropriate r nnewal
rating.
3. Employee.An employee as defined in the application/addendum as eligible for enrollment the employe is the
individual who is employed by the employer.
4. Employer. The employer or organization with whom HMO Colorado has contracted, and by rer sor of the
contract the employees and their dependents become eligible for the coverage and benefits described m the
contract.
5. Remittance. The employer shall pay to us monthly and prior to the first day in each month. tl-e required
premium on behalf of all enrolled employees and dependents who meet the eligibility requirements specified
in the group application/addendum and benefit booklet that are incorporated in this contract.
6. Benefit booklet. The definitions and other terms of the benefit booklet are incorporated herein by reference.
7. Group administrator.The employer will designate a person as the principal contact for all matters pet taming
to HMO Colorado group coverage. That person will assist employees in the administration and payment of
claims. It is understood that HMO Colorado is not the "administrator" within the meaning of the Employee
Retirement Income Security Act(ERISA).
1
IiLCHI19C.QJC
8. Assignment. None of the rights., benefits, duties, or obligations of the employer shall be assigned v,i tho,tt the
prior written consent of a duly authorized officer of HMO Colorado. Any attempted assignment will be void.
9. Contract provision changes.
a. This contract, the benefit booklet and any amendments thereto, and the group application,aalde idum
constitute the entire agreement between the parties hereto and supersede all other contracts, either oral or
in writing, between the parties with respect to the subject matter hereof. No course of action, usage or
custom or internal policy of HMO Colorado may amend or become a part of this contract Incept as
provided in paragraphs b. and c. immediately below, no change or modification to this contract sh al l be
valid unless the same is in writing and signed by the parties hereto.
b. During the initial annual term or any renewal annual term of the contract, the provisions of thins contract
may be amended at any time by an endorsement signed only b) a duly authorized officer of HMO
Colorado. When the endorsement has been so signed, the endorsement shall be deemed a part of the
contract, effective as of the date specified by the endorsement.
c. Any amendment resulting from state or federal law, or regulation, or ruling or apprrytI by the
Commissioner of Insurance of the State of Colorado may be made at any time by endorsement '.o the
contract signed only by a duly authorized officer of HMO Colorado and shall become effective as o' the
effective date of such law, regulation, ruling, or approval.
10. Notices. All notices to HMO Colorado shall be sent by United States mail or personal delivery to HOMO
Colorado, 700 Broadway, Denver, CO 80203-3441. All notices to employees or the employer shall be sent by
United States mail to the last address appearing in the records of HMO Colorado or by personal delivery to the
office of the employer. The employer shall notify member; in the event that this contract is temmated within
ten (10) days of the date that the employer has notice that this contract is to be or has been terminated,
whichever occurs first. If the employer has engaged the services of a broker/consultant. then delivery of all
notces to the named broker/consultant meets the requirements of this contract.Notice shall be effccticc upon
mail ing.
Notice mailed to the employer or broker/consultant shall be deemed effective notice -o each employee.
However, the employer agrees to post each notice promptly in a place reasonably calculated to facilitate the
employees'reading of the notice. The employer agrees to hold us harmless for its failure to provide notice to
the employees of any contract provision changes or termiration.
11. Governing Laws. This contract is made and delivered in the State of Colorado, and will be interfretrd and
enforced so as to remain in compliance with Colorado statutes and regulations.Nothing contained herein ,hall
be interpretedto mean that HMO Colorado is doing business in any other state of jurisdiction.Any legal action
against us must be brought in the City and County of Denver, Colorado
12. Attorneys' fees and expenses.
a. Should it become necessary for either party to this contract to seek the assistance of an attorney or the
purpose of litigating or arbitrating any action against the other party arising from any part of the contract.
the prevailing party shall be entitled to recover from the losing party its reasonable attorneys' fees. In
addition,the prevailing partyshallbe entitled to recover from the losing party all other reasonably incurred
costs and expenses.
b. The Employer shall indemnify and hold harmless HMO Colorado from its costs including losses, claims,
settlements,judgments, or fees, including attorneys' fees and other litigation costs, and our internal costs
if such costs were incurred by us by our participation in lawsuits or arbitration proceedings related to the
obligations undertaken or acts performed by us under this contract. However,except for costs incurred by
us in participating in lawsuits or arbitrationproceedings brought by persons who are ineligible for coverage
hereunder, the employer's obligation to indemnify us shall apply only to costs incurred after th s contract
has been cancelled or terminated.
HMI I PJGCOC
13. Enforcement of the contract. Failure of HMO Colorado or the employer to enforce any of the provision, of
this contract shall not constitute a waiver of rights for that or subsequent breaches.
14. Interpretation of the contract.This contract shall not be interpreted against any party for the reason of hav in
prepared its language and provisions. Rather, it shall be construed so as to effect the purposes of the aarties in
a manner consistent with the terms of this contract and sound principles of contract interpretation.
15. Termination of the contract.
The employermay terminate the contract at any time during its term upon giving 30 days advance written mince
rice
of termination to HMO Colorado. A group which voluntarily cancels coverage will not be consider_d to re-
enrollment until a two-month period has elapsed from the date of cancellation. Such re-enrollmen: shal I be
subject to then current operating procedures and underwriting regulations of HMO Colorado.
HMO Colorado may terminate the contract at any time during its term for(i)employer's failure to make timely
payment of amounts due hereunder, (ii) failure of the group to meet eligibility requirements,(iii) failure o! the
group to maintain enrollment percentage requirements, as provided in the application/addendum, er (iv)
misrepresentation of material facts or any other breach of the contract:. any such termination shall be ;ub ec t to
the terms of the contract and any endorsements.
16. Reinstatement of contract. HMO Colorado, at its sole option, may reinstate this contract after it has been
terminated.We may impose such conditions on the contract's reinstatement as we deem appropriate, inch[ding,
without limitation, acceptable health statements. It is understood, however, that there is no right to
reinstatement, and any reinstatement will be in the sole discretion of HMO Colorado.
3
caul'Kea(
SECTION III. PREMIUM: CHANGES, PAYMENT,
TERMINATION FOR NON-PAYMENT,
REFUND OF MEMBERSHIP PREMIUM,
CASHING OF CHECK NOT ACCEPTANCE
1. Changes. HMO Colorado may change monthly premium as outlined in any endorsements to this contract.
HMO Colorado reserves the right to review monthly premium whenever a group, section, or classu teat a in of
employees is added to or deleted from enrollment under the contract.The employer shall notify HMO Colorado
no later than 30 days prior to the effective date of such addition or deletion, and any change in monthly
premium which may be required as the result of an increased or decreased total group enrollment w ill become
effective on the same date as such addition to or deletion from tota'. enrollment under the contrac . This
prevision shall apply regardless of the employer's normal rate review date or any other advance rate noti f c it i on
agreement which may be in effect between HMO Colorado and the employer.
2. Payment. Initial premium shall become payable on or before the effective date of the contract. Subsequent
premium shall be payable on or before the first o f each month thereafter.Eli gibi l ityof members,claims processing,
and payment will be suspended if premium is not timely paid. In no event shall coverage under the contract
become effective until we accept the application/addendum and payment of the initial premium is received
by HMO Colorado.
3. Termination for non-payment. The contract shall terminate by its own terms if premium is not Nair (in or
before 30 days after the first day of the month,and no notice of cancellation other than this prevision shall be
required. However, we may by sending notice thereof terminate this contract before 30 days after the first day
of the month if premium is not paid on or before the first day of the morth. When the contract is leruun-rted or
cancelled,the effective date of such cancellation or termination shall be t`ie date to which members h tit pr_r i i u m
was last paid. Members shall no longer he eligible to receive covered health services and all claims stall be
refused when dates of service are beyond the last day of the month for wh eh payment has been recei vsed.( Maims
that we deny because the employer fails to submit premium payments it a timely manner should be submitted
for payment to, and may be the responsibility of, the emp oyer.
4. Refund of membership premium.
a. If the employer terminates the coverage of a member or terminates this contract for any reason, a refund
of membership premium paid beyond the first of the month following the termination date will le g ranted
only if written notification of termination is received by HMO Colorado at least 30 days het c: the
termination date,covered health services have not been provided and benefit payments have not newt !made
for services rendered subsequent to the termination date. If notification of termination is received less than
31) days before the termination date, no refund of membership premium will be made and coverage shall
cease on the first of the month following the termination date.
b. If HMO Colorado terminates coverage of a member or terminates this contract for any reason, a re i and of
membership premium paid beyond the termination dale will only be granted if covered health services have
not been provided and benefit payments have not been made for services rendered subsegt ent to the
termination date.
5. Cashing of check not acceptance. It is understood that negotiation and deposit of checks sent to us shall not
be deemed to be acceptance by us of such payment,nor shall such negotiation and deposit of the cheek prevent
us from later returning such payment by issuance of a check for the amount of the check to us.
4 BLLI I 196.(700
SECTION IV. MEMBERSHIP/APPLICATION
1. Eligibility.All employees,who have a regular work week as indicated on the application and/or aide:idu:r paid
for such employment by the employer, and listed as an employee on the employer's State unemployment
insurance tax returns, and the dependents of the employees, are eligible to enroll for membership under the
contract. We may inspect such records, public and private, as are necessary to verify employment
Applications of employees and dependents at open enrollment must be received prior to the anniverst rr date
to be effective on the anniversary date. If applications are not received prior to the anniversary date, then•will
not be effective until the next anniversary date.
2. Notification of cessation of membership.The employer shall advise us when the employer has notice that a
member is no longer employed by the employer or otherwise does not satisfy membership requirements.The
employer shall so notify us, at the latest. by the first day of the month after a member ceases to be employed
by employer or otherwise ceases to meet membership requirements. Such coverage shall terminate at the end
of the month in which the member is no longer employed or does not satisfy membership requirements. The
employer agrees that no person will be kept on the employer's payroll or otherwise be represented as an
employee of the employer for the purpose of obtaining or maintaining coverage when no longer el Ion.such
coverage hereunder. The employer agrees to observe the terms thereof, and hold us harmless fu all costs
incurred, including attorneys' fees, in the defense of any claim or suit brought at any time by a pc son v.ho is
ineligible for coverage.
3. Acceptance of contract. The employer's signature on the group application/addendum and tl-is ' .,'itract
constitutes acceptance of this contract
4. Group eligibility requirements. If the employer does not comply with the group eligibility requirerr cot, we
reserve the right to cancel the contract upon 30 days advr-nce written notice.
Weld County Government LIMO LORADO
(Group Name) tat �' I
ol
i:•••tf�.r °G/ •
;t; `' By
Barbara J. Kirkmeyer (10/"40/)ono)_ Caroline Matthews
Printed or Typed Name Printed or Typed Nair
(Title) ._ Chair, Board of Commissioners (Title) Chief Operating Officer
(Date) October 30, 2000 (Date) October 19, 2000 _
•
ATTEST: NJ
WELD C0U TY CLERK T�; :,a I'wc►F`�
BY: le'P I�A�i._ , "�►•�
DEPUTY CLERK TO THE'
ltflljNNn—!SV �`�
5
B6W❑19C.COC
rj LIMO
Colorado
ifal, isilmk
HMO Colorado
700 Broadvc ay
Denver, Colorado 80203
ENDORSEMENT NO.: 1
TO GROUP MASTER CONTRACT NO.: 01-00772000
The Contract identified above is hereby amended by this endorsement which is issued to form di
of the Contract between HMO Colorado(HMOC) and Weld County Government(the Employer),
effective as of the Contract Effective Date as follows:
For the period beginning on the Contract Effective Date(January 1. 2000)and ending on December
31, 2001, paragraph 1. Changes of Section of Section III. Premiums Changes, Payment, Service
Date, Termination For Non-Payment, Retroactive Refund of Membership Premium, Cashing
for Check Not Acceptance of the Contract, shall be replaced in its entirety with the following
provision:
1. (a) Subject to the provisions of subparagraph (c), below, the premiums specified in Exhibit
A to this endorsement shall remain in effect for a period of 12 months from January 1 ,2001.
(b) Notwithstanding the provisions of subparagraphs (a) and (b), above, HMOC may change
the monthly premiums due hereunder, effective immediately, whenever (i) benefits are
changed by endorsement or by federal or state law; or (ii) the number of Employees
covered under the Contract in any given month differs from the number of Employees
covered under the Contract as of the Contract Effective Date by 20% of enrollment.
(c) For the period beginning on January 1, 2001, the Employer shall remit an advanced che<-K
for premiums of$230,000 to Anthem BCBS/HMOC upon signature of this Endorsement or
no later than January 31, 2001. This payment will be used to offset the required rate
increase of 14.84% to decrease the billed premium rates for the period of January 1, 2001
through December 31, 2001.
2. For the period beginning on the Contract Effective Date (January 1, 2000) and ending on
December 31, 2001, paragraph 20. Termination of Contract of Section H. General
Agreements, of the Contract shall be amended by adding the following sentence to the end
of subparagraph (b) of paragraph 20:
"Notwithstanding the foregoing,HMOC agrees not to terminate this Contract solely
because of poor claims experience of Employees and Dependents covered under
this Contract."
3. Effective on the earlier of(i) any date on whichHMOC changes the premiums due hereunder
in accordance with the provisions of subparagraph 1(c)(ii) of Section III of the Contract, as
amended above, or (ii) two years from the Contract Effective Date, the provisions of this
endorsement shall be of no further effect and the original provisions of paragraph 1 of Section
III and paragraph 20. of Section II of the Contract shall be reinstated as if they had never been
amended.
4. Except as otherwise specifically amended hereby.all terms and conditions of the Contractsn.ill
remain in full force and effect.
Weld County 2"'yr Rate Guaewpd
Weld County Government HMO 3lorado
(Group Name)
By Y ,-t ( t: * i c; tc<� ' By --0 —
Barbara J. Kirkmeyer (10/30/2000) Caroline Matthews
Printed or Typed Name Printed or Typed Name
(Title) Chair, Board of Commissioners (Title) Chief Operating Officer
Date October 30, 2000 _ Date October 19, 2000 _
1@AII F
IE�It'�t1 Y /0/6() �r��
�
T f letle u, '� -
Qp ' '.1 y. $
Weld County 2'''yr Rate Guar wpd
EFFECTIVE JANUARY 1, 2001
EXHIBIT A
Group Name: Weld County Government
Coverage: Triple Option Modified
Employee Employee Plus
Only Dependents
1. BlueAdvantage HMO 15/1/15-25-40 RX: $199 08 $527 72
COBRA (Direct bill) $203 06 $538.27
2. BlueAdvantage Point-of-Service 15//15-25-40 RX: $209 45 $555.02
COBRA (Direct bill) $213.64 $566.12
3. Custom Plus $200/$00 deductible 80% coinsurance: $263.78 $699.03
COBRA (Direct bill) $269.06 $713.01
In addition a $200,000 payment to BCBSC/HMOC is required.
Weld County 2'tt yr Rate Guar.wpd
Anthem,0 V)
A Group Health
Care Program
Group Master
Contract
THE ANTHEM BLUE CROSS AND BLUE SHIELD
GROUP MASTER CONTRACT
TABLE OF CONTENTS
Page No.
SECTION I. APPLICATION-ACCEPTANCE 1
SECTION II. GENERAL AGREEMENTS 1
Contract Effective Date 1
Anniversary Date 1
Annual Renewal Date 1
Employee 1
Employer 1
Remitting Agent 1
Remittance 1
Membership Certificate Terms 2
Group Administrator 2
Assignment 2
Contract Provision Changes 2
Reserve Funds 2
Notices 2
Governing Laws 2
Attorneys' Fees and Expenses 3
Warranties and Representations 3
Enforcement of the Contract 3
Interpretation of the Contract 3
BlueCard Program. 3
Termination of Contract 4
SECTION III. PREMIUMS CHANGES, PAYMENT, SERVICE DATE, TERMINATION FOR NON-
PAYMENT, RETROACTIVE REFUND OF MEMBERSHIP PREMIUM,
CASHING OF CHECK NOT ACCEPTANCE 4
Changes 4
Payment 4
Service Date 4
Termination for Non-Payment 4
Retroactive Refund of Membership Premium 5
Cashing of Check Not Acceptance 5
SECTION IV. MEMBERSHIP/APPLICATION
5
Eligibility 5
Receipt of Applications 5
Notification of Cessation of Membership 5
BCB5)2G 00C
HMO Colorado e0 Anthem '1/41
Addendum to Application
GRCUP NUMBER ANNIVERSARY MONTH ADDEJOJhlE-=`CTIVE'_.
CG rl / -1 - - / - -
PLEASE PRINT FIRMLY TO ENSURE THAT ALL COPIES ARE LEGIBLE. DO NOT TYPE—DO NOT TEAR FORM APART
Complete all information on this Addendum to Application (Addendum)if you are completingthe Application.If you have previously submitted at Add).-worn,201 ien:
only information that is relevant to the change.If a change is not indicated,the previous Addendum will remain in effect.
CHANGE— Indicate one or more
D Classification of Employees'Eligible O Dependent Age .O Probationary Period O Coverage Applied For
❑Optional Group Benefit '-❑COBRA.Billing Notification 0 New ownership
'his Addendum is issued to:Weld County Government
("THE EMPLOYER"--CORRECT LEE AL NAME OF A.:COUNT') _--�-- -
This Addendum amends provisions of the Application. If we approve this Addendum,wt will return the approved Addendum with:he effectiv-date ctmnpleit the
Addendum will become a part of the Contract.If we do not approve this Addendum,it will be returned Other than specifically amended herein the term aed pro ono
of the Application and Contract shall remain in full force and effect.
CLASSIFICATION OF EMPLOYEES ELIGIBLE—The Employer requ ices that all eligible Employees lave a regular work week ofat least
per week(minimum of 24 hours per week).Eligible Employees do not include those on a temporary or substitute basis. If other Eligibility,ukase exp sin
The Employer hereby certifies the following number of Employees in each category below:
Total Employees employed by the employer working at least 24 hours per week(include those not yet eligible) _Enrolling for coverage
Total Eligible Employees who have met probationary period __ Enrolled el e,.here
COBRA or Colorado State law continuation of coverage enrollee: No other a crrage
Other,please explain:
__
DEPENDENTS --Unmarried dependent children are covered until the end of the month n which they become age 19,or 25 if(nan dependent-:p m the c.
PROBATIONARY PERIOD
I'of the month following first full pay period worked,employer assigns effective date.
GROUP HEALTH COVERAGE APPLIED FOR(select only one):
BlueAdvantage HMO Plan Plan No. 15-I-I 5/25/40 x of Employees enrolling
BlueAd vantage Point of Service Plan No. 15-1-15/25/405250 deductible#of Employees enrolling _
BlueAdvantage Custom Plus Deductible $200 single$400 family Coinsurance 10%to$5,000/$I0.000 #or Employees enrolling
Eighteen months pre-existing clause for late entrants with no prior coverage for the Custom Plus.
OPTIONAL y GROUP BENEFIT INFORMATION
W Optional Chemical Dependency Rehabilitation Program
c
yo Other five Health Network eve exam once every 24 months _ _ -_-
REMARKS Retirees age 55 through 64 will have an option to continue health insurance coverage until the dace their age changes to 65,provided the r me-c'he foil elg
criteria and stir ulations:
a) Eligible employees must retire from county service with at least ten years of service,or be a county elected official for at least one full tout—tar to-m
b) Eligible employees must be enrolled in the county's health Insurance plan at the time of retirement or leave of county otTice.
el Dependent coverage will be provided for eligible employees dependents who are enrolled at the time of retirement or leaving of county office.
di Coverage for the eligible employee and dependents will only be provided until the employee reaches age 65,or becomes eligib le for health nsuranc, coverage ith
another employer,or becomes eligible for Medicaid ro Medicare coverage before attaining the age of 65.Dependent coverage ifstill applicable will he offered t.t Icr
the same terms of COBRA offered employee's de pendents.
e) The county will offer to the retirees the same coverage at the same rates as regular county employees at the same time.The county will he re sponsibl' f.tr paying -he
40%surcharge of the premium,and the county contribution for the employee and dependents in the same manner as provided regular employ des
t) After COBRA,dependents will have the same conversion rights as regular employees and dependents.
The Employer understands that if we approve this Addendum,the employer agrees to he bcund by the terms of the Contract and this Addendum.
Dated Greeley, Co1lorado this 30th _day of October 20 00____
0 ) 1- _ Chair, Barbara J. Kirkrne er
SIGNATUIt OF A H 11ZED PERSON TITLE
Approved Teeple by HMG Cola e Blue Cross Ad Blue Shield ,
By IIJ�L('�\ - Date CCY°:�i,i c I —!h-J)
r O \TING OFFICRZ—HMO COLORADO
ac )
By a � Date �Cb PO,�� IS)CX1 �,
CHIEF���Wpp . IN a O FI R— N HEM BLUE OSS AND BLUE SHIELD
WeIJ County Hoyt
Ara. BlueAdvantage Application For BlueAdvantage
INTERNAL USE ONLY
'I From HMO Colorado*
a� � An Independent Licensee of the Blue Cross GROUP NUMBER ANNIVERSARY MONTH CONTRACT Ef°EEC-TINE Ol LE
® and Blue Shield Association CO /._ .•
PLEASE PRINT FIRMLY TO ENSURE THAT ALL COPIES ARE LEGIBLE. DO NOT TYPE—DO NOT TEAR FORM APART
Application for BlueAdvantage (Application) group coverage is hereby made for eligible Employees of the Employer If this Applic(ton :s
approved by HMO Colorado and Anthem Blue Cross and Blue Shield(if applicable),this coverage will be issued to:
Weld County Government ----—
('THE EMPLOYER"—CORRECT LEGAL NAME OF ACCOUNT)
915 10'Street Greeley Co 8066:31(PHYSICAL ADDRESS—STREET,CITY,STATE.ZIP CODE)
(MAILING ADDRESS—IF DIFFERENT)
NOTE: "'We,'"Us,"and'"Our"refer to HMO Colorado.For group sizes of 51 or more Employees,BlueAdvantage is federallyquatified in auams,
Arapahoe,Boulder,Clear Creek,Crowley,Denver,Douglas,El Paso, Fremont, Gilpin,Huerfano,Jefferson,Larimer,Otero.Pueblc,Teller and
Weld counties.For groups with 51 or more employees,counties not listed are not federally qualified.For group sizes of 50 or fewer Employees,
BlueAdvantage is a not a federally qualified HMO product.When the product is not federally qualified,BlueAdvantage coverage call differ front
those required by federal HMO laws and regulations.'We,""Us,"and"Our"also refers to Anthem Blue Cross and Blue Shield if coverage is
provided for BlueAdvantage Custom Plus coverage.
IN CONSIDERATION of the submission of this Application by the Employer, approval thereof by us, and of the payment of p'emiurns in
accordance with the Group Master Contract(Contract),we agree to provide group coverage as described in the Contract,the Benefit Elo(/klet,
and this Application and the Addendum to the Application for BlueAdvantage(Addendum),for any eligible enrolled Employees and eligible
enrolled dependents.and the Employer agrees to abide by the terms.conditions,and limitations contained in such documents.
GENERAL AGREEMENT
I. NATURE OF BUSINESS(please be specific):County Goverrnment ------
Type of organization: ❑ Proprietorship C Corporation 0 Partnership
2. Do you have current coverage in force? C Yes Oftlo,if"Yes"do you intend to cancel that coverage? O Yes L No. If you are applying for
or retaining other group health coverage in addition to this coverage on some or all Employees specify coverage(s I,Carrier,amounts,and
give details: _
3. Do you intend to enroll�{retirees under this group health Plan?(Retirees may enro�I for coverage if there are 51 or more Employees e m ailed
7
under this coverage.) Yes O No If"Yes,"give details: `iOO CI ci .lOTI(7(t'i'Yl ----
4. CONTRIBUTION—The Employer will be required to contribute a minimum of 50%toward.'ne Employee's single or 50%of flit Em yeas
portion of the family-cost of membership premiums.
5. PREM IUMS—It is understoodthat the premiums quoted may change based on the actual enrollment of the group.Premiums will be billed
by us monthly,and will be reviewed in accordance with the Contract and State or Federal requirements.
6. CLASSIFICATION OF EMPLOYEES ELIGIBLE—All eligible Employees of the Employer who have a regular work week as stated on the
Addendum,shall be eligible to enroll.If the Employerreduces the working hours of such Employees to less hours per week th.m stated on
the Addendum,coverage will be continued for such Employees and their dependents under the same conditions and for the same pren
if the following conditions are met and the Employer so certifies:
(a) The covered Employee has been continuously employed as an Employee of the Employer and has been insured under th t group
Contract,or under any group Contract providing similarbenefits which said group Contract replaces,for at least six months imm.'diately
prior to such reduction in working hours;
(h) The Employer has imposed such reduction in working hours due to economic conditions;and
(c) The Employer intends to restore the Employee to a full work week schedule as soon as economic conditions improve.
7. ENROLLMENT PERCENTAGE REQUIREMENTS— For all size groups to apply for and retain group coverage and rates if we are :he sole
carrier,the Employer agrees to maintain the following enrollment percentage requirements,based on TOTAL,ELIGIBLE EM PLO YEi-:5:
• Croup size 50 or fewer Employees must have 75%enrollment based on NET ELIGIBLE EMPLOYEES
• Croup size 51 or more Employees must have 75%enrollment based on NET ELIGIBLE EMPLOYEES,with no less than 5C%0l TOTAL
ELIGIBLE EMPLOYEES.
To anive at NET ELIGIBLE EMPLOYEES,Employees covered elsewhere with the following types of groupinsurancernay be exc hider,unless
uch coverage is offered through THE EMPLOYER:
P.Blue Cross and Blue Shield Plan;
P.Health Maintenance Organization;
The Federal Employees Program:
Indian Health Services;
Federal Peace Corps;
Colorado Uninsurable Health Insurance Plan,or
Through a commercial carrier.
FORM NO.99(6/1 IRE‘ 11/97)
Weld EN App.wptl
NOTE In the event the group does not meet the minimum enrollment requirements,we reserve the right to accept this Appl cation with
prior underwriting approval.
In all cases the Employer must meet the minimum enrollment and eligibility requirements according to HMO Colorado underwriting
regulations and policies and Colorado State law.
If we are a dual carrier,to apply for and retain group coverage and rates,a minimum of three Employees must be enrolled at all t.men When
we are a dual carrier,the enrollment percentage requirements do not apply
If the number of eligible Employees enrolled does not comply with the requ!red percentage,we reserve the right to cancel the Cc ntra 5 [pon
thirty day advance written notice.
Employers with 50 or fewer Employees may also be,sole proprietor's,a single full time Employee of a subchapter S or C corpora len,
limitedliabilitycompany.liabilitycompany,or a partnership that has carried on significant business activity for a period of at least one year prior to ap f kiration
for coverage.
The Employer agrees and warrants that no person who is not an eligible member under this provision will be listed.named.c•r otllcwise
represented by it in any way to be an eligible member,and that the Employer will not remit membership premiums for any such u•arson
or participant or assist in obtaining or maintaining a Benefit Booklet for such ineligible person. The Employer agrees to maintain cc n.plere
records and to furnish to us,upon request,such information as may be requested by us for our underwriting review. the Employe! further
agrees to permit a payroll audit by us or by a representative appointed by us.This may include a request for business tax records
8. DEPENDENT—Dependent children are covered until they attain the age as stated on the Addendum.
9. PROE'ATIONARY PERIOD—Probationary period selection is as stated on the Addendum.There will be one open enrollment on the group's
Anniversary Date for the BlueAdvantage HMO Plan and/or BlueAdvantage Point-of-Service Plan. For BlueAdvantage Custo n P us, late
entrants with prior coverage can be added at the group's anniversary date.In addition,if BlueAdvantage Triple Option coverage is selected
by the Employer.members will be allowed to choose between the HMO Plan,Point-of-Service,and Custom Plus coverage(for En players
with 50 or fewer employees only out-of-state employees can enroll in the Custom Plus).
10. GROUP HEALTH COVERAGE APPLIED FOR—Coverage selection is as stated on the Addendum.
COLORADO INSURANCE LAW REQUIRES ALL CARRIERS IN THE SMALL GROUP MARKET TO ISSUE.ANY
HEALTH BENEFIT PLAN IT MARKETS IN COLORADO TO SMALL EMPLOYERS OF 2-50 EMPLOYEES,
INCLUDING A BASIC OR STANDARD HEALTH BENEFIT PLAN,UPON THE REQUEST OFA SMALL EMPLOYER
TO THE ENTIRE SMALL GROUP, REGARDLESS OF THE HEALTH STATUS OF ANY OF THE INDIVIDUALS IN
THE.GROUP.BUSINESS GROUPS OF ONE CANNOT BE REJECTED UNDERA BASIC OR STANDARD HEALTH
BENEFIT PLAN.
II. Employer represents,agrees,and warrants that the Employer is in compliance with all applicable local,state,and federal laws,n Iles and
regulations,including but not limited to COBRA,the Family Medical Leave Act,TEFRA. DEFRA. and OBRA.To the extent am pact of this
application is inconsistent with such laws,rules,and regulations,such provision shall not be deemed a part of this application. H.pv:ever,
the application shall be otherwise enforceable.If the Employer has agreed to have us perform specific billing and notification duties rioted
to COBRA,such information will be stated on the Addendum.
Mason('Shirazi-Shirazi&Assoc (970)356-5151 TELEPHONE NUMBER
1770 25"'Avenue#302 Greeley Co 80631
STREET.CITY,STATE,ZIP CODE
The Employer represents,agrees,and warrants that the information contained:n this Application is true and correct and forms an essential basis
for our issuance of the Contract.EVEN THOUGH THIS APPLICATION IS SUBMITTED WITH PROPOSED PREMIUMSOR OTHER FUNDS.THERE
WILL BE NO COVERAGE UNTIL THIS APPLICATION IS APPROVED BY US. If we approve this Application,we will send you a Contract of
which this Application will become a part.Your prior coverage should not be cancelled until you have been notified that yourApplication has
been accepted.No agent can bind coverage,set an effective date,or waive or alter any provision of this Application.The Contract will specify
the effective date of group coverage. If we do not approve this Application.the submitted funds will be returned to the Employer.
The Employer understands that if we approve this Application.the Employer agrees to be bound by the terms of the _ontmc:.
Dated Greeley, Colorado this_ 30th day of October x2OOO ___
j Chair, Barbara J. Kirkme,Le.]_
SIGNATURF/OF UTH/ ID PERSON TITLE
Approved an. ccepted +y I-1100 Colora0 d •.•t em Blue Cross and Blue Shield
1 i � I V.` Date L—C '—C x -{` �21 <?Ii��
HI O RA
By - ' ' r - � 1 + MO COLORADO
° s I�
By_ 1 _ a ♦.L) - Date /‘--7 n 'JO,-
CHIEF OPE°.• ''' -•FFICER— • TH M BLUE CROSS AND BLUE SHIELD
FORM NO.96064(I'S 1 11:97':
Weld Uy APu wpd
ANTHEM BLUE CROSS AND BLUE SHIELD
GROUP MASTER CONTRACT
NO. 01-00772000
For
Weld County Government
Employer
C07720
Group Number
SECTION L APPLICATION-ACCEPTANCE
The Application for Group Health Coverage("Application)executed by the Employer has beer accepted
by Anthem Blue Cross and Blue Shield(sometimes referred to as"we ""us,"and "our") Such Application
and its contents are incorporated in this Group Master Contract ("Contract"). In the event )f any
inconsistency between the terms of the Application and the terms of the Contract, the terms of the
Contract will control.
SECTION II. GENERAL AGREEMENTS
The pArpose of this Contract is to provide under the circumstances specified herein health and
hospitalization benefits to certain of the Employer's Employees and their Dependents. Suet persons
when covered hereunder, are referred to as "Members.'
1. Contract Effective Date. The effective date of the Contract shall be 12:01 A.M. on the first day of
January, 2001, at Denver, Colorado; the Contract shall continue to remain in effect on an annual
basis from year to year thereafter unless terminated in accordance with the provisions of the
Contract..
2. Anniversary Date.The Anniversary Date is the effective date for CO enrollment or coverage changes
to the Employee's Membership or(ii)to group enrollment and benefit eligibility implemented by the
Employer.
3. Annual Renewal Date. The date a group is due for rate modification through applicat.on of the
appropriate renewal rating fomiulas.
4. Employee.An Employee as defined in the Application as eligible for enrollment; the Employe is the
Subscriber, and Identification Cards for the Employee and his or her covered Dependents are issued
in the name of the Employee as the Subscriber.
5. Employer. The Employer or organization with whom Anthem Blue Cross and Blue Shield has
contracted, and by reason of the Contract the Employees and their Dependents become dig able for
the coverage and benefits described in the Contract.
6. Remitting Agent. The Employer agrees to (i) act as remitting agent for the enrolled Members, (ii)
make payroll deductions for that part of premium not otherwise provided for, and (iii) remit all
premiums to us not later than the due date for each remitting period.
7. Remittance. The Employer shall pay to us monthly, in advance, required premiums on, behalf of all
enrolled Employees and Dependents who meet the eligibility requirements specified in the
Application.
1
8. Membership Certificate Terms.The definitions and other terms of the Membership Certif cal e are
incorporated herein by reference.
9. Group Administrator.The Employer will designate a person as the principal contact for all matters
pertaining to Anthem Blue Cross and Blue Shield group coverage. That person will assist Employees
in the administration and payment of claims.It is understood that Anthem Blue Cross and Blue Shield
is not the "administrator" within the meaning of the Employee Retirement Income Security Act
(ERISA).
10. Assignment. None of the rights, benefits, duties, or obligations of the Employer may be assigned
without the prior written consent of a duly authorized officer of Anthem Blue Cross and Blue Siield.
Any attempted assignment will be void.
11. Contract Provision Changes.
a. This Contract constitutes the entire agreement between the parties hereto and supersedes all
other contracts, either oral or in writing, between the parties with respect to the subject matter
hereof. No course of action, usage or custom or intemal policy of Anthem Blue Cross and Blue
Shield may amend or become a part of this Contract. Except as provided in paragraphs b. and
c. immediately below, no change or modification to this Contract shall be valid unless the same
is in writing and signed by the parties hereto.
b. During the initial annual term or any renewal annual term of the Contract, the provisio is of this
Contract may be amended at any time by an endorsement signed only by a duly at dhorized
officer of Anthem Blue Cross and Blue Shield. When the endorsement has been so signe.l, the
endorsement shall be deemed a part of the Contract, effective as of the date specified by the
endorsement.
c. Any amendment resulting from state or federal law, or regulation, or ruling or approval by the
Commissioner of Insurance of the State of Colorado may be made at any time by endorsement
to the Contract signed only by a duly authorized officer of Anthem Blue Cross and Blue Shield
and shall become effective as of the effective date of such law, regulation, ruling, or approval.
12. Reserve Funds. Neither any Member nor the Employer shall be entitled to share in any reserve or
other funds that may be accumulated or otherwise owned by Anthem Blue Cross and Blue Shield,
unless and until a right to share in such funds is granted in writing by the Board of Dir_ctors of
Anthem Blue Cross and Blue Shield.
13. Notices. All notices to Anthem Blue Cross and Blue Shield shall be sent by United States nail or
personal delivery to Anthem Blue Cross and Blue Shield, 700 Broadway, Denver, CO £02Y3 All
notices to Employees or the Employer shall be sent by United States mail to the last address
appearing in the records of Anthem Blue Cross and Blue Shield or by personal delivery to the office
of the Employer. The Employer shall notify Members in the event that this Contract is terminated
within ten (10) days of the date that the Employer has notice that this Contract is to be or las been
terminated,whichever occurs first. If the Employer has engaged the services of a broker cons dlant,
then delivery of all notices to the named broker/consultant meets the requirements of this :'ontract.
Notice shall be effective upon mailing.
Notice mailed to the Employer or broker/consultant shall be deemed effective nonce to each
Employee. However, the Employer agrees to post each notice promptly in a place reasonably
calculated to facilitate the Employees'reading of the notice.
14. Governing Laws. This Contract is made and delivered in the State of Colorado, and will be
interpreted and enforced so as to remain in compliance with Colorado statutes and regulations.
Nothing contained herein shall be interpreted to mean that Anthem Blue Cross and Blue Shield is
doing business in any other state or jurisdiction. Any legal action against us must be brotr„ht in the
City and County of Denver, Colorado.
2
Should any provision of this Contract in any way contravene the laws of Colorado or the United Slates
of America, such provision shall not be deemed a part of the Contract. However, the Contract shall
be otherwise enforceable.
15. Attorneys' Fees and Expenses.
a. Should it become necessary for either party to this Contract to seek the assistance of ar attorney
for the purpose of litigating or arbitrating any action against the other party arising from any part
of the Contract, the prevailing party shall be entitled to recover from the losing party its
reasonable attorneys' fees. In addition, the prevailing party shall be entitled to recover from the
losing party all other reasonably incurred costs and expenses.
b. The Employer shall indemnify and hold harmless Anthem Blue Cross and Blue Shield from its
costs including losses, claims, settlements, judgments, or fees, including attorneys' fees and
other litigation costs,and our internal costs if such costs were incurred by us by our paricipation
in lawsuits or arbitration proceedings related to the obligations undertaken or acts performed by
us under this Contract. However, except for costs incurred by us in participating in laws mils or
arbitration proceedings brought by persons who are ineligible for coverage hereunder the
Employer's obligation to indemnify us shall apply only to costs incurred after this Contrast has
been canceled or terminated.
16. Warranties and Representations. The Employer acknowledges that no warrz.nti,rs or
representations other than those contained in this Contract have been made or given by Anther i Blue
Cross and Blue Shield or its representatives or, if so given, have not been relied upcn by the
Employer.
17. Enforcement of the Contract. Failure of Anthem Blue Cross and Blue Shield or the Emplcver to
enforce any of the provisions of this Contract shall not constitute a waiver of rights for that or
subsequent breaches.
18. Interpretation of the Contract.This Contract shall not be interpreted against any party for the reason
of having prepared its language and provisions. Rather, it shall be construed so as to effect the
purposes of the parties in a manner consistent with the terms of this Contract and sound principles
of contract interpretation.
19. BlueCard Program. The calculation of subscriber liability for covered services for claims incurred
outside the geographic area Anthem Blue Cross and Blue Shield serves and processed throu;l m the
BlueCard Program typically will be at the lower of the provider's billed charges or the negotiated rate
Anthem Blue Cross and Blue Shield pays the on-site Blue Cross and/or Blue Shield Plan
The negotiated rate paid by Anthem Blue Cross and Blue Shield to the on-site Blue Cross and/or Blue
Shield Plan for health care services provided through the BlueCard Program may represent either(i)
the actual price paid on the claim, or (ii) an estimated price that reflects adjusted aggregate
payments expected to result from settlements or other non-claims transactions with all of the or -site
Plan's health care providers or one or more particular providers,or(iii)a discount from billed charges
representing the on-site Plan's expected average savings for all of its providers or for a specified group
of providers.
Plans using either the estimated price or average savings factor methods may prospectively adjust
the estimated or average price to correct for over-or underestimation of past prices.
In addition, statutes require Blue Cross and/or Blue Shield Plans in a small number of states to use
a basis for calculating member/subscriber liability for covered services that does not reflect the entire
savings realized or expected to be realized on a particular claim. Thus, when your covered
employees/subscribers receive covered services in these states,their subscriber liability for covered
services will be calculated using these states' statutory methods
3
BCB5931GC(K
20. Termination of Contract.
a. The employer may terminate the contract at any time during its term upon giving 30 days
advance written notice of termination to Anthem Blue Cross and Blue Shield. A group who
voluntarily cancels coverage will not be considered for re-enrollment until a two-month period
has elapsed from the date of cancellation. Such re-enrollment shall be subject to then current
operating procedures and underwriting regulations of Anthem Blue Cross and Blue Shield.
b. Anthem Blue Cross and Blue Shield may terminate the Contract at any time during its term for
(i)Employer's failure to make timely payment of amounts due hereunder, (ii) failure of the group
to meet eligibility requirements, (Hi) failure of the group to maintain enrollment percentage
requirements, as provided in the Application, or (iv) misrepresentation of material facts or any
other breach of the Contract.
c. Anthem Blue Cross and Blue Shield, at its sole option, may reinstate this Contract after it has
been terminated.We may impose such conditions on the Contract's reinstatement as we deem
appropriate, including, without limitation, acceptable health statements. It is understood,
however, that there is no right to reinstatement, and any reinstaterent will be in the sole
discretion of Anthem Blue Cross and Blue Shield.
SECTION III. PREMIUMS CHANGES, PAYMENT,
SERVICE DATE, TERMINATION FOR NON-PAYMENT,
RETROACTIVE REFUND OF MEMBERSHIP PREMIUM,
CASHING OF CHECK NOT ACCEPTANCE
1. Changes. Anthem Blue Cross and Blue Shield may change monthly premium as outlined in am
endorsements to this Contract.
Anthem Blue Cross and Blue Shield reserves the right to review monthly premium whenever a group.
section, or classification of Employees is added to or deleted from enrollment under the Contract.
The Employer shall notify Anthem Blue Cross and Blue Shield no later than 30 days p-ior to the
effective date of such addition or deletion, and any change in monthly premium which may be
required as the result of an increased or decreased total group enrollment will become effective on
the same date as such addition to or deletion from total enrollment under the Contract. This
provision shall apply regardless of the Employer's normal rate review date or any other advance rate
notification agreement which may be in effect between Anthem Blue Cross and Blue Shield and the
Employer.
2. Payment. Initial premium shall become payable on or before the effective dale of the Contract.
Subsequent premiums shall be payable on or before the established Service Date of each month
thereafter. Claims processing and payment will be suspended if premium is not timely paid. In no
event shall coverage under the Contract become effective until we accept the Application and
payment of the initial premium is received by Anthem Blue Cross and Blue Shield.
3. Service Date. The Service Date is the 1st or 16th day of the month as established for the group for
billing purposes (the "due date").
4. Termination for Non-Payment.The Contract shall terminate by its own terms if premium is not paid
on or before 30 days after the Service Date, and no notice of cancellation other than this provision
shall be required.However,we may by sending notice thereof terminate this Contract before:30 days
after the Service Date if premium is not paid on or before the Service Date. When the Contract is
terminated or canceled, the effective date of such cancellation or termination shall be the date to
which membership premium was last paid. All claims shall be refused when dates of service are
4
BLev`[2t.FOt
beyond the last"paid-to-date" of coverage according to the records of Anthem Blue Cross and Blue
Shield.
5. Retroactive Refund of Membership Premium.
a. A retroactive refund of membership premium paid beyond the date of terminations will be
granted if written notification is received by Anthem Blue Cross and Blue Shield at least one
month before the termination date and benefit payments have not been made on behalf of a
Member's claim for services rendered subsequent to the termination date.
b. If notification is received less than one month before the termination date, no refund of
membership premium will be made.
Failure to comply with this provision shall negate any claim by, or on behalf of, the Employer or the
Member for a retroactive refund of membership premium.
6. Cashing of Check Not Acceptance. It is understood that negotiation and deposit of checks 5 cut to
us shall not be deemed to be acceptance by us of such payment, nor shall such negotiation and
deposit of the check prevent us from later returning such payment by issuance of a check lor- the
amount of the check to us. —_
SECTION IV. MEMBERSHIP/APPLICATION
1. Eligibility. All Employees, who have a regular work week as indicted on the application and
addendum,paid for such employment by the employer,and listed as an Employee on the Employer's
State unemployment insurance tax returns, and the Dependents of the Employees, are eligible to
enroll for membership under the Contract. We may inspect such records, public and private, as are
necessary to verify employment.
2. Receipt of Applications.Applications for Employees coverage must be received by us within 30 days
of the Contract Effective Date or within 30 days of eligibility for coverage, whichever is later li the
application is not received within this time period, the Employee is subject to current underwriting,
state or federal law for provisions for late enrolles.
3. Notification of Cessation of Membership.Employer shall advise us when Employer has notii ie that
a Member is no longer employed by Employer or otherwise does not satisfy membership
requirements. Employer shall so notify us, at the latest, by the first Service Date after a Member
ceases to be employed by Employer or otherwise ceases to meet membership requirements.
Employer agrees that no person will be kept on Employer's payroll or otherwise be represer ted as
an Employee of the Employer for the purpose of obtaining or maintaining coverage hereunder The
Employer agrees to observe the terms thereof, and hold us harmless for all costs incurred. including
attorneys' fees, in the defense of any claim or suit brought at any time by a person ineliginle for
coverage.
Weld County Government ANTHEM BLUE CROSS AND BLUE SHIEl D
(Group Name)
fi I
BJ-21itS /iA4iCki 4 By IALA_Q
Barbara J. Kirkmeyer (10/30/2000) Caroline Matthews
Printed or Typed Name Printed or Typed Name
(Title) _ Chair, Board of Comm;GGi onarc (Title) Chief Operating Officer
(Date) October 30, 2000 (Date) October 19, 2000
5
OCOn2?G a¢
PROGRAM ARRANGED
BY
Anthem Blue Cross and Blue Shield
700 Broadway
Denver, Colorado 80273
Phone: 831-2131
A Registered Milks Blur Cross and!Slue Shield Association
Rca 22u2l
ENDORSEMENT NO.: 1
TO GROUP MASTER CONTRACT NO.: 01-00772000
The Contract identified above is hereby amended by this endorsement which is issued to form part
of the Contract between Anthem Blue Cross and Blue Shield (Anthem BCBSC) and Weld County
Government (the Employer), effective as of the Contract Effective Date as follows:
For the period beginning on the Contract Effective Date(January 1, 2000)and ending on December
31, 2001, paragraph 1. Changes of Section of Section III. Premiums Changes, Payment, Service
Date, Termination For Non-Payment, Retroactive Refund of Membership Premium, Cashing
for Check Not Acceptance of the Contract, shall be replaced in its entirety with the following
provision:
1. (a) Subject to the provisions of subparagraph (c), below, the premiums specified in Exhibit
A to this endorsement shall remain in effect for a period of 12 months from January 1, 2001.
(b) Notwithstanding the provisions of subparagraphs (a) and (b),above, BCBSC.may change
the monthly premiums due hereunder, effective immediately, whenever (i) bene its are
changed by endorsement or by federal or state law; or (ii) the number of Ernployec s
covered under the Contract in any given month differs from the number of Errrployees
covered under the Contract as of the Contract Effective Date by 20% of enrollment.
(c) For the period beginning on January 1, 2001, the Employer shall remit an advanced chi x k
for premiums of$230,000 to Anthem BCBS/HMOC upon signature of this Endorsement or
no later than January 31, 2001. This payment will be used to offset the required rate
increase of 14.84% to decrease the billed premium rates for the period of January 1, 2001
through December 31, 2001.
2. For the period beginning on the Contract Effective Date (January 1, 2000) and ending on
December 31, 2001, paragraph 20. Termination of Contract of Section II. General
Agreements, of the Contract shall be amended by adding the following sentence to the end
of subparagraph (b) of paragraph 20:
"Notwithstanding the foregoing,BCBSC agrees not to terrninatethis Contract solely
because of poor claims experience of Employees and Dependents covered under
this Contract."
3. Effective on the earlier of(i) any date on which BCBSC changes the premiums due hereunder
in accordance with the provisions of subparagraph 1(c)(ii) of Section III of the Contract. as
amended above, or (ii) two years from the Contract Effective Date, the provisions of this
endorsement shall be of no further effect and the original provisions of paragraph 1 of ect ion
ill and paragraph 20. of Section II of the Contract shall be reinstated as if they had neve r bt tr n
amended.
4. Except as otherwise specifically amended hereby,all terms and conditions of the Contra:t shall
remain in full force and effect.
Weld County 2"d yr Rate Guar.wpd
Weld County Government Anthe Blue Cross and Blue Shield
(Group Name) . ,
�,(�.,tu� Q
s.
By_ „IT,Ze GC6�'. a i;r ()LAI t g By /�� � 41��.t'
Barbara J. Kirkmeyer (10/30/2000) Caroline Matthews
Printed or Typed Name Printed or Typed Name
(Title) Chair, Board of Commissioners (Title) Chief Operating Officer
Date October 30, 2000 Date October 19, 2000
t/0/11/ATTEST' Ida
WELD COUNTY CLERK TO * B''
/ / / •I 1861�' .�0 4* --,
BY:
DEPUTY CLERK TO TH'`
®uric
Weld County r'yr Rate Guar.wpd
EFFECTIVE JANUARY 1, 2001
EXHIBIT A
Group Name: Weld County Government
Coverage: Triple Option Modified
Employee Employee Plus
Only Dependents
I. BlueAdvantage HMO 15/1/15-25-40 RX: $199 08 $527.72
COBRA (Direct bill) $203 06 $538.27
2. BlueAdvantage Point-of-Service 15/115-25-40 RX: $209 45 $555.02
COBRA (Direct bill) $213 64 $566 12
3. Custom Plus $200/$00 deductible 80% coinsurance: $263 78 $699.03
COBRA (Direct bill) $269 06 5713.01
In addition a $200,000 payment to BCBSC/HMOC is required.
Weld County 21°yr Rate Guar.wpd
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