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Home My WebLink About20242436.tiffRESOLUTION RE: APPROVE APPLICATION FOR GROUP DENTAL AND/OR EYE CARE INSURANCE, AND AUTHORIZE CHAIR PRO-TEM TO SIGN - AMERITAS LIFE INSURANCE CORP. 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 an Application for Group Dental and/or Eye Care Insurance from the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Resources, to Ameritas Life Insurance Corp., with further terms and conditions being as stated in said application, and WHEREAS, after review, the Board deems it advisable to approve said application, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Application for Group Dental and/or Eye Care Insurance from the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Resources, and Ameritas Life Insurance Corp., be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair Pro -Tern be, and hereby is, authorized to sign said application. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 16th day of September, A.D., 2024. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST: �.•�-�+4 J C�� Weld County Clerk to the Board BY: , l4 . 1,(JaA Deputy Clerk to the Board APPD AS County Att• ney Date of signature: arl �1Z� EXCUSED Keviri J . Ross, Chair erry L. B k, Pro -Tern ike F , eman on Saine cc:pE(SS/A?ASP) 0/24 /.y 2024-2436 PE0036 Cofl+rotC+ t0 #1O1 BOARD OF COUNTY COMMISSIONERS PASS -AROUND REVIEW PASS -AROUND TITLE: Ameritas Group Dental and Eye Care Insurance Application DEPARTMENT: Human Resources DATE: 9/5/2024 PERSON REQUESTING: Jill Scott & Allison Palmer Brief description of the problem/issue: Weld County HR -Benefits team is requesting to switch Dental and Vision provider for the 2025 plan year. By signing this form we are allowing Ameritas to process and manage our dental and eye care claims starting 1/1/2025. What options exist for the Board? Approve the application process, and leave un-checked "If you do not want your company name used by Ameritas Life Insurance Corp. in our effort to recruit Network providers, check this box." Recommendation: The County will transition the dental and vision plan to Ameritas. Three dental plan options will be available: Low, Middle, and High. A $0 employee -paid dental option will continue to be offered. The Weld County Dental Reimbursement Plan will be discontinued. In response to employee feedback, the High dental plan will now include orthodontic care for children. Vision Frame allowance will increase, and while the network will remain unchanged, the premium discount will be passed on to employees as it is an employee -paid benefit. Allowing Ameritas to use the Weld County name on their recruiting materials could be advantageous. Dentists in the area might be more inclined to join the network if they see a connection between Weld County and Ameritas. Support Recommendation Schedule Place on BOCC Agenda Work Session Other/Comments: Perry L. Buck, Pro -Tern Mike Freeman Scott K. James Kevin D. Ross , Chair Lori Seine 2024-2436 °9/ 1 Co PZoo3c, application Group Dental and/or Eye Care Insurance Ameritas Life Insurance Corp. P.O. Box 81889, Lincoln, NE 68501-1889 Ameritas See reverse side for additional information 1. Applicant's Legal Name Weld County Government 2. Doing business as Weld County 3' PO Box 758 P.O. Box / ZIP Code 1150 O Street Street Address Greeley, CO 80632 City /State / ZIP (970) 400-4265 Phone No. Fax No. apalmer@weld.gov 84-0857486 E-mail Address Tax I.D. No. 4. What Is the nature of your business or Industry? Government 5. Eligibility Total Number of Eligible Employees 1887 Employees in Wafting Period 30 6. Are any classes or locations excluded? ❑ Yes ® No Are domestic partners included? ❑ Yes ® No Are retirees included? ❑ Yes ® No (If yes, please use reverse side for explanation.) 7. Are any subsidiary and/or affiliated companies to be insured? ❑ Yes NI No (If yes, please use reverse side to list name and location.) 8. How many hours per week equals full time employment, 30 9. Employee Participation Employer contributes 99 % of employee premium. ❑Tied -to -Medical (All employees covered on employer's medical plan must be insured, except those listed under excluded classes or locations.) ❑ Non -Contributory (Policyholder contributes 100% of premiums. All employees must be insured, except those listed under excluded classes or locations.) ❑ Non -Contributory, except covered elsewhere (If policyholder contributes 100% of premiums, all employees must be insured, except those listed under excluded classes or locations and those covered elsewhere.) ® Contributory (Policyholder is required to contribute to the employee premium and must contribute at least 25% of the total employee and dependent premium.) ❑ Voluntary (Policyholder does not contribute towards premium, 100% contribution by employee.) 10. Dependent Participation: Employer contributes 99 % of dependent premium. ❑ Tied -to -Medical (All eligible dependents covered on employer's medical plan must be insured, except those listed under excluded classes or locations.) ❑ Non -Contributory (Policyholder contributes 100% of premiums. All eligible dependents must be insured, except those listed under excluded classes or locations.) ❑ Non -Contributory, except covered elsewhere (If policyholder contributes 100% of premiums, all eligible dependents must be insured, except those listed under excluded classes or locations and those covered elsewhere.) ►�� Contributory (Policyholder is required to contribute to the employee premium and must contribute at least 25% of the total employee and dependent premium.) ❑ Voluntary (Policyholder does not contribute towards premium, 100% contribution by employee.) 11. Section 125 Plan Election Period 10/28/24-11/14/24 Plan Year 1/1/2025-12/31/2025 12. Employee welfare benefit plans that are subject to ERISA must satisfy various reporting, disclosure and related obligations. These requirements include the provisioning of a Summary Plan Description or SPD. The certificate of coverage can serve as an SPD if certain information is additionally disclosed. Please check one of the following (failure to respond shall be considered a positive response for A. and a negative response for B). A. ❑ Plan is subject to ERISA (complete question 12.B.) ® Plan is NOT subject to ERISA — Church or Govt. employer or other safe -harbor exception (see DOL Reg. §2510.3-1(j)) THIS POLICY DOES NOT INCLUDE COVERAGE OF PEDIATRIC DENTAL SERVICES AS REQUIRED UNDER THE AFFORDABLE CARE ACT. COVERAGE OF PEDIATRIC DENTAL SERVICES IS AVAILABLE FOR PURCHASE IN THE STATE OF COLORADO AND CAN BE PURCHASED AS A STAND-ALONE PLAN. PLEASE CONTACT YOUR INSURANCE CARRIER, AGENT, OR CONNECT FOR HEALTH COLORADO TO PURCHASE EITHER A PLAN THAT INCLUDES PEDIATRIC DENTAL COVERAGE OR AN EXCHANGE -QUALIFIED STAND-ALONE DENTAL PLAN THAT INCLUDES PEDIATRIC DENTAL COVERAGE. THIS IS A LIMITED BENEFIT HEALTH COVERAGE POLICY AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. GR 902 CO Ed. 05-18 Page 1 of 3 05-11-18 B. ❑ Applicant requests that Ameritas Life les. Corp. prepare a SPD for its dental and/or vision plan ❑ Yes ❑ No If yes, the company is to prepare a SPD. The following information is required under ERISA and MUST be included in the SPD. Plan No. Plan Fiscal Year End Date Plan Administrator: Name: Address: City, State, ZIP Phone No. Plan Fiscal Year Please Note: Applicant remains responsible for ensuring that SPD form provided by Ameritas Life Insurance Corp. is complete and accurate and satisfies applicable laws and regulations. Moreover, applicant remains responsible for providing its plan participants with SPD updates as required by applicable law and regulations. 13. Waiting Period 0 for those employed on or before the policy effective date 30 for those employed after the new policy effective data ❑ month(s) ® calendar days ❑ working days 14. Effective Date and Termination Date ❑ Immediate ® First of Month Effective date / End of Month Termination date ❑ Other not coinciding 15. Premium Payment Mode (In advance) ® Monthly ❑ Quarterly ❑ Semi -Annual ❑ Annual ❑ Payroll Deduction (To choose this option, employee must pay employee and dependent premium.) If policy effective date is other than first of the month, is a first of the month premium due date desired? ... ❑ Yes ❑ No Billing Options �1 Home Office ❑ Third -Party Administration Allison Palmer Contact Name Benefits Manager Title 1150 O Street Street Address Greeley/CO/80631 City / State / ZIP (970) 400-4265 Phone No. Fax No. apalmer@wetd.gov E-mail Address 16. The following coverages are applied for: Employee 8 Dependents Benefits ® Dental ® Orthodontia X Eye Care ❑ Other Employee Only Benefits ® Dental ® Orthodontia ® Eye Care ❑ Other This Insurance shall be effective on: 1/1/25 (Premiums due prior to the coverage period.) 17. Policy and Certificate Delivery (select one) A. eCert*ePolicy (*generic cert, non -personalized) ® via PDF format sent via a -mall to: courtney.seward@hubinternational.com ❑ via eService and member portal B. Paper policy/personalized certificates ❑ Initial employees only ❑ Subsequently added employees Note: eCert will be available on member portal for ail members. 18. Insurance requested on this application will replace the coverage(s) checked. Coverages: ® Dental ® Orthodontia ® Eye Care ❑ Other Name of Current Carrier SunLife Policy No. ❑ Coverage applied for is replacing comparable coverage now or previously in force with another carrier. Termination Date Original Effective Date GR 902 CO Ed. 05-18 Page 2 of 3 05-11-18 Item 6: Exclusions a. Classes, include reason for exclusion. b. Locations, if location is different from applicant's, list city and state. Item 7: Subsidiary and/or affiliated companies to be insured. List names and locations. Plan Design and Proposed Rates:_ Additional Remarks: Agreements This application will be subject to review and approval by the Home Office of Ameritas Life Insurance Corp. If this application is accepted, the final rates and benefits will be based on verification of this information and final enrollment numbers. This applicant represents that he/she has read the statements and answers to the above questions and that they are complete and true to the best of his/her knowledge and belief. Any policy including riders issued as a result of this application will, with this application, be the entire insurance contract. If this application is accepted at the Home Office of Ameritas Life Insurance Corp., group insurance at the Company's rates and under the terms applied for shall take effect as of the date set forth in the policy. If this application is not accepted, any premium advanced shall be refunded. Statements Note for Colorado Residents: 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. ❑ If you do not want your company name used by Ameritas Life insurance Corp. in our effort to recruit Network providers, check this box. Signed at: City Greeley/Weld County State Colorado Date SEP 1 6 2024 Signed by: (Policyholder Representative) Printed name and title Perry L. Buck, Pro—Tem, Board of County Commissioners Signature 0/44,44 Soliciting Agent: I under and and agree that if I'm not already appointed with Ameritas Life Insurance Corp., I must apply to and be appointed with Ameritas before I present this product to any client. Printed Name Am Hecklinger provides GR 902 CO Ed. 05-18 Page 3 of 3 05-11-18 aq.n Contract Form Entity Information Entity Name* Entity ID. AMERITAS LIFE INSURANCE CORP @00049030 ❑ New Entity? Contract Name * Contract ID AMERITAS GROUP DENTAL AND EYE CARE INSURANCE 8707 APPLICATION Contract Status CTB REVIEW Contract Lead BPETERSON Contract Lead Email bpeterson@weld.gov Parent Contract ID Requires Board Approval YES Department Project # Contract Description REQUESTING TO SWITCH OUR DENTAL AND VISION PROVIDER TO AMERITAS FOR THE 2025 PLAN YEAR. Contract Description 2 Contract Type * APPLICATION Amount* $0.00 Renewable YES Automatic Renewal Grant IGA Department HUMAN RESOURCES Department Email CM- HumanResources@weldgo v.com Department Head Email CM-HumanResources- DeptHead@weldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEY@WEL D.GOV If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Requested BOCC Agenda Due Date Date* 09/12/2024 09/16/2024 Will a work session with BOCC be required?* HAD Does Contract require Purchasing Dept. to be included? Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Termination Notice Period Contact Information Contact Info Review Date * 11/03/2025 Renewal Date* 12/01/2025 Committed Delivery Date Expiration Date Contact Name Contact Type Contact Email Contact Phone 1 Contact Phone 2 Purchasing Purchasing Approver Purchasing Approved Date Approval Process Department Head JILL SCOTT DH Approved Date 09/10/2024 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 09/16/2024 Finance Approver CHERYL PATTELLI Legal Counsel BYRON HOWELL Finance Approved Date Legal Counsel Approved Date 09/11/2024 09/11/2024 Tyler Ref* AG 091624 Originator BPETERSON Hello