HomeMy WebLinkAbout950345.tiffFHP OF COLORADO, INC.
EVIDENCE OF COVERAGE AND OWNER'S MANUAL
SIGNATURE SHEET
The attached Evidence of Coverage and Owner's Manual (Group Agreement), this Signature Sheet, and
Group Application (if any) collectively constitute a contract (Agreement) between FHP of Colorado, Inc.
(FHP), and the Subscribing Group named below for the provision of specified healthcare benefits to
eligible persons electing to enroll hereunder as Subscribers and Dependents.
1. SUBSCRIBING GROUP:
A. The name, address, and group number(s) of the Subscribing Group are as follows:
Weld County Colorado Mr. Donald Warden
P.O. Box 758 (303) 457-100To X y2/17Greeley, CO 80632 3361Y�
Group Number: OUROO
B. The following entities affiliated with the Subscribing Group shall be deemed to be
included within it for purposes of this Agreement.
N/A
C. The number of employees of the Subscribing Group who are eligible to enroll as
Subscribers is 950 and the SIC Code of the Subscribing Group is 9000.
2. EFFECTIVE DATE:
This Agreement takes effect 12:01 A.M. on January 1, 1995, and will remain in effect through
11:59 P.M. on December 31, 1995, subject to the terms and conditions of the Agreement.
3. COVERAGE:
EOC Edition: 1995 FHP of Colorado Evidence of Coverage and Owner's Manual (HMO)
Medical Plan Copayment Schedule: 10045
Optional benefits: Rx10045
4. MONTHLY RATE SCHEDULE:
Subscriber Only $148.62
Subscriber, Spouse and Child(ren) (Family) $410.19
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950345
5. PAYMENT ARRANGEMENTS / ELIGIBILITY:
The following specifies payment arrangements as well as conditions of eligibility for
enrollment as a Subscriber that are in addition to the conditions enumerated in Chapter 4 of the
Group Agreement (and, to the extent that any of the following conditions contradict the terms
of Chapter 4, the following shall prevail):
New employees are eligible on the first of the month occuring on or following one full pay
period. Employees will be covered through the end of the month in which their
employment terminates. Full monthly premium is due for any employee enrolled foran
entire month.
6. UNDERWRITING CONDITIONS:
The Subscribing Group (A) represents that the underwriting conditions listed below exist as of
the effective date noted in number 2 above, and (B) covenants that all such underwriting
conditions shall continue to be met at all times while this Agreement is in force.
Subscribing Group must contribute for all Subscribers at least 75% of "Employee" monthly rate
or 50% of each monthly rate.
If FHP (HMO) is part of a multi -option plan offering a FHP's Preferred / Indemnity plan
the Subscribing Group must have at least 75% participation of all eligible employees.
Military employees or employees covered by a spouse's plan will not be counted as an
eligible employee for the purpose of this minimum participation requirement. The
minimum number of enrolled employees between the HMO and PPO / Indemnity plans
cannot be less than 51 lives.
Additionally, FHP reserves the right to re-evaluate the risk at any premium due date based upon
substantial changes to other assumptions including, but not limited to, a change in demographics;
divisions added or deleted; or the offering of an additional employer sponsored health plan.
Notwithstanding any other provision of this Agreement, FHP may terminate this Agreement on
any premium due date if any underwriting condition listed above is not then being met and notice
of intention to terminate has been given to the Subscribing Group at least 31 days in advance.
7. OPEN ENROLLMENT PROVISIONS:
The group enrollment period shall be November, 1995.
8. OTHER PROVISIONS:
Eligible dependents will be covered as outlined in Chapter 4 of the Agreement. Payment
arrangements for newly acquired dependents shall be the same as for newly hired employees as
described in number 5 above, PAYMENT ARRANGEMENTS / ELIGIBILITY.
9. GOVERNING LAW:
This Agreement shall be governed by and construed in accordance with the internal laws of the
State of Colorado.
10. COUNTERPARTS:
This Agreement may be executed in two or more counterparts, each of which shall construe an
original but all of which shall constitute one and the same instrument.
IN WITNESS WHEREOF, FHP and the Subscribing Group have caused this Agreement to be
executed by their respective duly authorized representatives.
SUBSCRIBING GROUP FHP
AUTHORIZED REPRESENTATIVE AUTHORIZED REPRESENTATIVE
By:
/L'' J t 144s. 7Thi
By:
Pamela A. Butler
Title: C)*tR yrtto Wct [ o alma /SsiuneRS Title: Director of Employer Services
Date: /3—I — r/ Date: December 1, 1994
BAW/no
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