R08-084
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1 i RESOLUTION NO. R08- 034-
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5 A RESOLUTION OF THE CITY COMMISSION OF
6 BOYNTON BEACH, FLORIDA, AUTHORIZING THE
7 RENEWAL OF EMPLOYEE BENEFITS AND
8 PREMIUMS FOR FISCAL YEAR 2008-09 WITH BLUE
9 CROSS/BLUE SHIELD OF FLORIDA, METLIFE, AND
10 VISIONCARE INCORPORATED; AND PROVIDING AN
11 EFFECTIVE DATE.
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14 WHEREAS, the City Commission of the City of Boynton Beach, upon
15 recommendation of staff, deems it to be in the best interests of the residents and citizens of the
16 City of Boynton Beach to approve the renewal benefits and premiums for 2008-2009 health
17 insurance coverage with Blue Cross/Blue Shield of Florida medical plan, MetLife dental plan,
18 and the Vision Care Incorporated plan, for all city employees.
19 NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF
20 THE CITY OF BOYNTON BEACH, FLORIDA, THAT:
21 Section 1. The foregoing "Whereas" clauses are hereby ratified and confirmed
22 as being true and correct and are hereby made a specific part of this Resolution upon adoption
23 hereof.
24 Section 2. Upon recommendation of staff, the City Commission of the City of
25 Boynton Beach, Florida does hereby approve the renewal benefits and premiums for 2008-
26 2009 Health Insurance coverage with Blue Cross/Blue Shield of Florida medical plan,
27 MetLife dental plan, and the Vision Care Incorporated plan.
28 Section 3. That this Resolution shall become effective immediately upon passage.
S:\CA\RESO\Agreements\renewal health benefits 2008-09.doc
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1 PASSED AND ADOPTED this ~ day of August, 2008.
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3 CITY OF BOYNTON BEACH, FLORIDA
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20 ATTEST:
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28 (Corporate Seal)
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S:\CA\RESO\Agreements\renewal health benefits 2008-09.doc
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., BlueCrossmueSbiekl EMPLOYER APPLICATION
Ii I . or Florida
· · Health Optimu. (True Group Application) ~O'b-08L\
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o New Business ~ Renewal Business DOther I
1. Group Information Group # (BCBSF):170029 I (HMO):170029W
A. Name of Group: ICITY OF BOYNTON BEACH
Nature of Business: lGeneral government, nee I SIC Code: 19199
Mailing Address: Ip,o. BOX 310 BOYNTON BEACH, FL 33425
Email Address:
List below Subsidiary or
application.
Name Address
I II I
B. Applicant hereby applies for issuance of a Group Policy (herein referred to as Policy) by Blue Cross and Blue
Shield of Florida, Inc. (BCBSF) and/or Health Options, Inc. (HOI). Upon acceptance of this application by
BCBSF and/or HOI. it will become part of the Policy issued to the applicant named above.
C. Prior Health Carrier: Insurance IBCBSF I
HMO I I
D. The Policy excludes expenses for any service or supply to diagnose or treat any Condition from or in connection
with an Insured's job or employment (e.g., any service or supply which is covered by Workers' Compensation
insurance) except for medically necessary services (not otherwise excluded) for an individual who is not covered
by Workers' Compensation and that lack of coverage did not result from any intentional action or omission by
that individual. The foregoing exclusion appHes to an individual who elects exemption from Workers'
Compensation coverage and to an individual who foregoes Workers' Compensation coverage available to
employees in the Group.
E. Workers Compensation Carrier is: IPREFERRED GOVERNMENT INSURANCE TRUST (PGIT) I
II. Effective DatelEligibility Information
A. Effective Date. of this Policy shall be I: 06/09/1998 I
Effective Date of this Change to the Policy shall be 110f01l2008 I
This Policy may be terminated by the applicant or BCBSF/HOI by giving at least 45 days prior written notice to
the other party except in the case of non-payment of prem~ ~
B. Only eligible employees who regularly work a minimum of ~ ho. rs each week and their eligible dependents,
shall be eligible for coverage upon the Effective Date of this Policy.
C. Specify classification of enrollees for whom coverage is being requested, if other than eligible employees as
described in B above.
I I
D. New eligible employees may be covered effective on the I 1st of MONTH I after D!J days
of employment, so long as the eligible employee submits an application to BCBSFfHOI within 30 days of the date
the individual first meets the applicable eligibility' requirements,
E. At least [2!] % of the eligible employees must be enrolled under the Policy on the Effective Date and
throughout the term of the Policy and the Group must meet and continue to meet BCBSFIHOl's participation
requirements.
F. BCBSF/HOI shall have the right to audit the applicant's payroll records at any time to confirm eligibility for
coverage, including participation percentage criteria required by BCBSF/HOI. Applicant agrees to furnish any
such request.
G. Employer Contribution: Employee: I 100 1% Dependents:~ 010
13123-995 SR (Rev 1007) 8/812008 10:28;38AM
., mueCr08s mueShield EMPLOYER APPLICATION
it" or lllorida.
· · Health 0pt:I0ns. (True Group Application)
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III. Health Plan Summary Information (select the appropriate box[s]):
Mandated Benefit Offerings: (Optional) Applicant has been advised of the following benefit offerings mandated
by the Federal andlor State Law. Applicant's decision to accept or decline these benefits is indicated below.
Included in
product Accept Decline
~ 0 0 Mental & Nervous Disorder
~ 0 0 Alcohol & Drug Dependency
~ 0 0 Mammograms Waiver of Deductible & Coinsurance
~ 0 0 Enteral Formulas
~ Single Plan o mue Packages
Health Plan Name Rx Option (indicate copayments)
IBlueOptions Advantage 1748 - Std I ImueScript C Copay Plan 10125/40 C - Std I
Calendar Year Deductible: Coinsurance:
Per Person ISO I 5500 I In-Network I Participating 1100"Jo ~6 I
Per Family 1$0 I $1,500 I Out"of-Network 1 Non-Participating 16C1'J1l ~ I
Office Visit Copay:
Pre-Existing IPre-Existing Applies I Family Phy. ISI0 I
Rates. All Other Providers 1520 I
IV. Health Saving Account (HSA) Banking Arrangement (optional with HSA Compatible health plans)
A. Are you' choosing BCBSF's integrated HSA banking arrangement? DYes I1a No
(if left blank, the response is assumed to be No.)
V. Rate Information
A. Premium/Prepayment fee are payable monthly on or before the due date which will be; I Ist. I
B. Regular Billing- Employee applications should be submitted thirty (30) days prior to proposed Effective Date.
Employee cancellations must be submitted within 30 days of the Effective Date of the Termination.
C. The Rates established for this Policy will not be changed for the first twelve (12) months following the initial Effective
Date of Coverage unless there is a change in benefits or a 15% or more change in the composition of the group.
However, BCBSF/HOI may change the Rates that are to be effective after this initial twelve (12) month period of
covera,ge by providing notice to the employer of such changed Rates forty-fIVe (45) days prior to their Effective Date.
D. Funding Arrangements: BCBSF:IDiscount I
HMO: I Diseount I
E. Rate Comments: I I
13123-995 SR (Rev 1007) 8/812008 10:28:38AM
.'~BlueSbteld EMPLOYER APPLICATION
. oC Florida
. · · lJe8Ih OptIons. (True Group Application)
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VI. Applicant Responsibilities
A. The applicant shall: 1) Notify each enrollee to the benefits selected by the applicant. their Effective Date, and
the termination date of coverage (in this regard, applicant acts as the agent of the enrollee, and in no event
shall the applicant be deemed an agent of BCBSF/HOlfor this or any other purpose, nor shall BCBSF/HOI be
responsible for such notification to retirees). 2) Deliver to covered enrollees identification cards and certificates
of coverage furnished by BCBSF/HOI. 3) Notlfy BCBSF/HOI promptly of any changes in the eligibility of
enrollees covered under this Agreement 4) list any absentees at the time of initiaj enrollment on the
appropriate BCBSFIHOI form. Applications from absentees wil be accepted at BCBSF/HOI Corporate
Headquarters no later than thirty (30) days from the group's Effective Date. 5) Collect enrollee contribution, if
required, and remit Premium payment/prepayment fees to BCBSFIHOI as specified in this application.
B. By choosing the HSA Banking Arrangement, if applicable, I authorize BCBSF to exchange certain limited
information, for employees enrolling in a high deductible health plan designed for use with an HSA,
with BCBSF's preferred bank, for the purposes of initial enrollment in and administration of, HSAs.
I recognize that BCBSF does not provide banking services and that BCBSF is not responsible for the prOVision
of HSA services. HSA services are provided by the bank of your choice subject to the terms and conditions of
such arrangements, including fees the bank may charge.
C. Applicant hereby establishes an Employee Welfare Benefit Plan for the purpose of providing for its employees
or their beneficiaries mediCat. surgical,hospital care, or benefits in the event of sickness.
D. Any person who knowingly and with intent to injure, defraud. or deceive any insurer files a statement of claim
or an application containing any false, incomplete, or misleading information is guilty of a felony of the third
degree.
VII. Final Premiums, Benefits and Effective Dates are Subject to Approval by
BeBSF Corporate Headquarters
Issuance of the Policy by BCBSF/HOI will be deemed acceptance of this application.
D... Sjgna~ PrintJType Name & Title
11 Kllrt Brel';l';TIf'r, C,i ty M;mp.e;Jr
I 9.;l'~0611 ~
Date Blue Cross and Blue Shield of Florida, Inc. and/or Health Options, Inc. Licensed Agent (print)
I <6~~ofll r ~ hlCUA {jcuslen I
~/-c Agent License Identification Number
II 6-03~/3~ I
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13123-995 SR (Rev 1007) 81a12008 10;28;38AM