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HomeMy WebLinkAboutRESPONSE - RFP - P902 BENEFITSCITY OF FORT COLLINS PROPOSAL FOR TRANSPLANT COVERAGE RFP P902 THE SEGAL COMPANY AUGUST 26, 2003 SEGAL THE SEGAL COMPANY SECTION V: QUESTIONNAIRE RESPONSES Transplant Coverage Please refer to plan booklet for current plan provisions. Answer: Please refer to the attached BCS Insurance Company Certificate of Insurance and Summary Brochure. Do you agree to provide services to all employees/dependents enrolled as of December 31, 2003? Answer: Yes, subject to WCMT plan provisions and for individuals enrolled in accordance with the City's eligibility and enrollment provisions. 2. Will you agree to replicate each of the current plan's provisions? If not, please list the specific provisions you will not replicate, along with the reason you elect not to replicate the provision(s). If you do not identify those specific provisions you cannot replicate and you are selected as The City's vision services administrator, you may be required to make the necessary adjustments in order to achieve replication. Otherwise, your selection may become void. Answer: Yes, the 2004 plan benefits will be the same as 2003 benefits unless the City elects an alternative option available under the WCMT program. 3. What is your monthly administrative fee, expressed in terms of dollars per month per employee? Answer: Please see attached 2003 rate sheet. The current per capita premium rate of $8.79 which includes the drug rider will continue through 2003. The 2004 rates are expected to be available in late October, 2003. 4. For each geographic area in which you have a network applicable to employee population, provide the following information: Answer: Please see attached list in Section VIII of LifeTrac facilities located throughout the United States. There are two network facilities located in the Denver Metropolitan Area — University Hospital and Children's Hospitad/Denver. 5. Geo-Access, using 2 vision providers in 10 miles; provide a map if available. Answer: Not applicable to the Transplant program. 6. Most recent participating provider directory and summary of the number of participating providers in each of the applicable areas (physicians, specialists, institutions, etc.). Also provide the website where provider information can be found. Answer: Attached is a LifeTrac facility listing. There are no separate participating physicians or specialists under the program. LifeTrac facility information can be accessed at www.LifeTracFacility.com. Please note the website facility listing indicates kidney and cornea transplant services, which are not covered under the WCMT. 51 7. For each network, describe the specific measures used by your organization to monitor participating provider access. Provide the most recent corresponding statistics available for: Answer: LifeTrac spends extensive time and resources developing its quality and selection criteria, which are focused more on outcomes rather than geographical locations, to choose facilities for their network (see question 11). 8. Provider to member ratios Answer: Information not available. 9. Average waiting period for an appointment Answer: Information not available 10. What percentage of your providers has limited their practice to current patients? Answer: We are not aware that any providers/facilities have limited their practice or services to current patients. 11. Please describe your credentialing procedures. Answer: Following describes LifeTrac's criteria to select hospitals to participate in their network:. LifeTrac held three program selection criteria conferences in the fall of 2001. They invited panels of senior transplant physicians to advise LifeTrac on the appropriate quality and selection criteria for the network. The panel members are reviewing drafts of the recommendations at this time. Following this review LifeTrac will solicit input from the senior physicians representing all of the programs in the LifeTrac Network. All Programs: • Academic center • Current JCAHO accreditation • Current license to operate issued by the appropriate state agency • Liability insurance with $1,000,000/$3,000,000limits • Transplant trained subspecialty physicians dedicated to the transplant team • Multidisciplinary team with comprehensive coordination services including nurse coordinators pre- and post -transplant, financial coordinators, transplant pharmacist, nutritionist, dedicated social worker and others. • Post -transplant follow-up >90% at all reported intervals • Active quality improvement program 7 • Active cost containment program Solid Organ Programs: • Program has been in existence for a minimum of two years within the institution being considered for inclusion in the LifeTrac Network. • Multiple organ transplant programs • UNOS membership • Medicare certified as appropriate. • Primary surgeon must satisfy UNOS criteria and have a minimum of two years experience in that role beyond fellowship • Primary physician must satisfy LINOS criteria. • Risk -adjusted 1 month, 1 year and 3 year patient and graft survival reported by URREA as "not different" or "higher" than expected. • Post -transplant follow-up reporting is current and complete as demonstrated by 290% reporting to LINOS at all intervals. Pediatric Standalone Program: • Meets all criteria listed above • Affiliated with a major university medical center and substantially integrated with the adult counterpart at that center. • Program directors and senior faculties have full-time academic appointments at the affiliated university medical school. • Pediatric interventional radiology, cardiology, nephrology and subspecialty support. 12. What type of reimbursement/payment methods is used to reimburse participating providers? Please provide a breakdown by method of review. Answer: LifeTrac negotiates reimbursement arrangements separately with each network facility. Due to the complex nature of transplants and range of applicable costs and services, the arrangements vary and may or may not include services over and above the hospital charges such as for organ procurement, followup care and other items. LifeTrac's specific negotiated reimbursement arrangement for each network facility is not available at this time. 13. In addition to routine reimbursement and any withholding provisions, can your providers increase the total reimbursement received from your plan, e.g., by provider incentive programs? If so, please explain. Answer: Not that we are aware of- rates payable under WCMT are the LifeTrac negotiated rates. 8 14. If provider discounts are used, state the basis of the agreement. Are discounts based on provider charges or actual cost of service? Answer: No provider discounts are used; rates are generally negotiated on a global fee arrangement. 15. Is there a formal committee that sets quality assurance policy and review the outcome on a regular basis? Answer: Yes, see response in item 11., above. LifeTrac performs an annual outcome survey of each transplant program in the network. A number of performance criteria are measured through this survey, including transplant volume, survival rates, retransplant frequency, and average wait time for transplants. A variety of other transplant specific questions are also asked on the survey. The LifeTrac medical unit reviews the responses to the survey and the comparison of the data for each program to establish benchmarks. This data is updated annually for each individual program within each facility. The data is formatted into a Facility Fact Sheet and is available online at www.lifetracnetwork.com. See attached sample Facility Fact Sheets for Barnes Hospital (lung transplant) and M.D. Anderson (HCT/BMT) in Section VIII. 16. Do you capture all utilization data? Answer: BCS Insurance Company, as the underwriter of this program, captures utilization data. 17. What claims experience and utilization reports are available? If there is additional cost, please specify. Answer: The WCMT program is a fully insured pooled arrangement. Individual group claims experience and utilization information are not available. 18. Describe patient satisfaction surveys that you perform. Answer: WCMT does not conduct patient satisfaction surveys. 19. Do you have an agreement that prohibits providers from billing or collecting from patients more than the designated coinsurance or co -payment in the plan design? Answer: LifeTrac network facilities are not allowed to bill or collect from patients amounts exceeding the negotiated fees. Non -network facilities are not bound to any fee arrangements with LifeTrac and may bill patients charges not covered by the WCMT. 20. Please describe your method for calculating renewal rates. Answer: BCS reviews the overall utilization within the WCMT as well as within their organ and bone marrow transplant pool to determine the trend factors to apply to the program, as well as any additional costs that may be associated with the program (claim administration expense, risk charge etc.) to determine the renewal action that will be required for the coming contract year's exposure. 21. Do you provide a toll -free number for employees to call with questions on claims, plan provisions or requests for dentist referrals? 9 Answer: BCS Insurance Company has a toll free number available for participants and plan administrators Monday through Friday, 8:30 am to 4:30 pm Central Standard Time. BCS does not respond to requests for dentist referrals. 22. Do you provide a care line that employees can call with questions about proper levels of care? Answer: Participants can contact BCS about transplant benefits under the WCMT. There is not a care litre provided by WCMT or BCS for any other questions about proper levels of care. 23. Will you provide COBRA services? Answer: No, the cost of the WCMT should be included as part of the overall COBRA premium rate the City charges its participants. 24. Please certify that you are in compliance with HIPAA privacy regulations, and include a copy of your privacy statement or policy. Answer: BCS Insurance Company, as a Covered Entity under HIPAA, has implemented its policy and procedures to reflect its obligations to protect the privacy of individually identifiable health information that it creates, receives or maintains as a health plan. A copy of the Notice of Privacy Practices is attached in Section VIII. 25. Please refer to the checklist on page 10 for additional items to submit (e.g., audited financial statements, etc.). Answer: See Section VIII. 26. What is your organization's financial rating (e.g., Best & Co., S&P)? Answer: WCMT does not have a financial rating; however BCS Insurance Company's AM Best Rating is A- Excellent. - , 4�, ��- ��� �2 Signature Date 10 SECTION VI: PERFORMANCE GUARANTEES The Western Cost Management Trust does not offer Performance Guarantees. 11 SECTION VII: FINANCIAL EXHIBITS The Western Cost Management Trust is not required to have an audited financial statement. BCS Insurance Company, a for -profit multi -line property and casualty insurance company, has audited financial statements that are available upon request. 12 SECTION VIII: ITEMS INCLUDED WITH PROPOSAL Proposed Implementation Timeline — The City of Fort Collins currently participates in the WCMT program. Continuation of participation in the WCMT can be substantiated by written confirmation from an authorized City representative to Segal, preferably any time before the January 1, 2004 renewal effective date that the renewal rates have been accepted. Segal, in turn will notify BCS Insurance Company and Wells Fargo Bank, Trustee, of the renewal acceptance. If the City were to select an alternative plan available under the WCMT, an authorized representative of the City would, before January 1, 2004, notify Segal the alternative plan that was selected. Segal would then notify BCS Insurance Company and Wells Fargo Bank of the coverage change. Copies of all communications are submitted to the City. There is no formal administrative services agreement that needs to be signed to renew this coverage. 2. Facility Fact Sheets (i.e. Provider Report Cards) See attached samples for Barnes Hospital (lung transplant) and M.D. Anderson (HCT/BMT). 3. LifeTrac Facility Listing — see attached 4. BCS Insurance Company HIPAA Privacy Notice — see attached 5. Alternative Funding Options and 2003 Rates — see attached 6. Sample Certificate of Insurance and WCMT Brochure — see attached 13 Barnes -Jewish Hospital has participated in the UfeTrar Network since 1994. Additional information on this facility can be found at: hftp:/Awm.barnesjewish.org/ UNOS Region 8 OPO: Mid -America Transplant Services Program Program established 1988 UNOS certified 1993 Medicare certified 1995 Total transplants (inception to date 615 Volume rank 2001 2 of 66 Median LOS (days) 13 HIV+ patients accepted No Living donor Yes Good Samaritan No Primary pulmonaryhypertension program Yes Cystic fibrosis program Yes Pulmonary rehab program Yes ECMO Yes Volume reduction surgery Yes Patient/family housing on -site Yes Transplant Coordinator: 314/362-5378 Program comments* ish Hospital Barnes -Jewish Hospital Plaza Louis, MO 63110 o'AMPLE Lung - Adult Transplant Volume 1997 11998 119919 2000 2001 Adult 58 1 55 1 48 53 57 Risk Adjusted Survival 1 mo. 1 year 3ear Adult Patient Same Higher Hi her Same Hi he r HiherGraft Post-Transplant Follow-up % Median Time to Transplant ' Program comments are provided by the facility, and do not reflect the opinion of LifeTrac. Any questions about these comments should be directed to the facility's program director. Allianz Healthcare Re A division of Allianz Life Insurance Company of North America PO Box 884 Minneapolis, MN 55440.0884 800/968-8722 www.L'rfeTracNetwork.com The data provided herein are believed to be reliable, but accuracy and completeness cannot be guaranteed as transplant program changes may occur. Information should be verified prior to making patient referrals. For the most up to date statistical information on solid organ transplant programs please refer to www.ustransplant.org. This data set is updated on a regular basis and may be more current than the data we show on this fact sheet. Additional solid organ transplant information can be found at www.unos.org. LifeTrac recommends that our clients familiarize themselves with these sites. G40220 (0312003) ©2003 LifeTrac Network LIFETRAc. ................................................ N E T W O R K Median Time to Transplant ' Program comments are provided by the facility, and do not reflect the opinion of LifeTrac. Any questions about these comments should be directed to the facility's program director. Allianz Healthcare Re A division of Allianz Life Insurance Company of North America PO Box 884 Minneapolis, MN 55440.0884 800/968-8722 www.L'rfeTracNetwork.com The data provided herein are believed to be reliable, but accuracy and completeness cannot be guaranteed as transplant program changes may occur. Information should be verified prior to making patient referrals. For the most up to date statistical information on solid organ transplant programs please refer to www.ustransplant.org. This data set is updated on a regular basis and may be more current than the data we show on this fact sheet. Additional solid organ transplant information can be found at www.unos.org. LifeTrac recommends that our clients familiarize themselves with these sites. G40220 (0312003) ©2003 LifeTrac Network LIFETRAc. ................................................ N E T W O R K MD Anderson has participated in the LifeTrae Network since 1994. Additional information on this facility can be found at: hftp:/twww.mdanderson.org/ D. Anderson Cancer Center 15 Holcombe Blvd. uston, TX 77030 AMPLE Allogeneic HCT - Adult Facility Reported Data 08/08/2002 Program Program established 1975 NMDP certified 1990 FACT accredited 2000 Total transplants (inception to date 1899 Non-m eloablative transplants Yes Re -transplants Yes Patient follow-up at 1 year % Patient/family housing on -site Yes Available Transplant Services IP OP Both Mobilization therapy X Harvestin /a heresis X M eloablative therapies X Cell reinfusion X Recovery X Transplant Coordinator: 713/745-2879 Program comments' Transplant 1999 2000 2001 AML - Acute M elo enous Leukemia 66 CML - Chronic M elo enous Leukemia 24 ALL - Acute L m hoc tic Leukemia — — 21 CLL - Chronic Lymphocytic Leukemia ca cu 15 NHL - Non -Hodgkin's Lymphoma — I 'F 1 52 HD - Hodgkin's Disease 9 MDS - M elod s lastic Syndrome .r 22 AA - A lastic Anemia Z Z 5 MM - Multiple M eloma 16 Other 16 Volume . T e Median LOS.. 1999 2000 Volume%24427 Related m a� Unrelated -0 Total Allo = = Ha toCord Rel. (Cord Un.) Z Z ` Program comments are provided by the facility, and do not reflect the opinion of LifeTrac. Any questions about these comments should be directed to the facility's program director. Allianz Healthcare Re The data provided herein are believed to be reliable, but accuracy and A division of Allianz Life Insurance completeness cannot be guaranteed as transplant program changes may Company of North America occur. Program statistics may vary by facility reporting techniques and case PO Box 884 mix severity. Information should be verified prior to making patient referrals. Minneapolis, MN 55440-0884 Additional BMT transplant information can be found at: www.marrow.org, 800/96H722 www.unmc.edu/Community/fahcVHome_Page.htm and wwwibmtrorg. LifeTrac recommends that our clients familiarize themselves with these sites. LIFET1�A C- www L'rfeTracNetwak.can G40397 (0312003) ©2003 LifeTrac Network N .... E....r w 0 R It -A-SEGAL THE SEGAL COMPANY 6300 S. Syracuse Way Suite 750 Englewood, CO 80111-7302 T 303.714.9900 F 303.714.9990 www.segalco.com August 26, 2003 Mr. James B. ONeill II, CPPO, FNIGP The City of Fort Collins Purchasing Department P. O. Box 580 Fort Collins, Colorado 80522-0580 Re: RFP P902 Dear Mr. O Neill: DIRECT DIAL NUMBER 303-714-"20 WRITER'S E-MAIL ADDRESS Simming@segalco.com Enclosed are six copies of the Western Cost Management Trust's (WCMT) proposal, in response to The City of Fort Collins' (City's) RFP P902, to underwrite the City's organ and bone marrow transplant benefits effective January 1, 2004. The City has participated in this program since June 1, 1997. We look forward to continuing to work with City staff into the future. If you have any questions regarding the proposal, please let us know. Sincerely, Susan K. Imming O Enclosures cc: Theresa O'Shea, BCS Insurance Company Laurie Trujillo, The Segal Company 133080/01945.001 Benefits, Compensation and HR Consulting ATLANTA BOSTON CHICAGO CLEVELAND DENVER HARTFORD HOUSTON LOS ANGELES MINNEAPOLIS NEW ORLEANS NEW YORK PHILADELPHIA PHOENIX SAN FRANCISCO SEATTLE TORONTO WASHINGTON, DC M ,f Multinational Group of Actuaries and Consultants AMSTERDAM BARCELONA GENEVA HAMBURG JOHANNESBURG LONDON MELBOURNE MEXICO CITY OSLO PARIS WESTERN COST MANAGEMENT TRUST LIFETRAC PROVIDER NETWORK Hospital/Medical Center Location Type of Transplant Services Offered* Barnes -Jewish Hospital St. Louis, MO BMT, H, LU, H/LU, LI Baylor University Medical Center Dallas, TX BMT, H, LI Brigham & Women's Hospital Boston, MA BMT, H, LU Children's Hospital Boston Boston, MA H, BMT Children's Hospital Denver Denver, CO H, LI Cincinnati Children's Hospital Medical Center Cincinnati, OH BMT, LI Children's Medical Center of Dallas Dallas, TX LI Children's Memorial Chicago, IL BMT, H, LI Clarian Health (Indiana University/Methodist Hospital/Riley Hospital for Children) Indianapolis, IN H, LI, BMT City of Hope Duarte, CA BMT Cleveland Clinic Cleveland, OH BMT, H, LU, LI Dana Farber Cancer Institute Boston, MA BMT ike University Medical Center Durham, NC BMT, H,LU, LI, K/P Fairview -University Medical Center Minneapolis, MN BMT, H, LU, HILU, LI, KIP, P Jackson Memorial Hospital Miami, FL LI, SB Johns Hopkins Hospital Baltimore, MD BMT, H, LI, LU Loyola University Medical Center Chicago, IL BMT,H, LU Lucile Packard Children's Hospital Palo Alto, CA BMT, LI, H, LU, H/LU Massachusetts General Hospital Boston, MA BMT, H, LU Mayo Clinic Jacksonville, FL LI Mayo Clinic Rochester, MN BMT, H, LI, K/P, P Mayo Clinic Scottsdale, AR LI M.D. Anderson Cancer Center Houston, TX BMT Memorial Sloan-Kettering Cancer Center New York, NY BMT Nebraska Health System Omaha, NE BMT, LI, K/P, P, SB Ochsner Clinic Foundation New Orleans, LA H, LU, LI Ohio State University Medical Center Columbus, OH K/P, P, LI Hospital/Medical Center Location Type of Transplant Services Offered" Seattle Cancer Care Alliance (Fred Hutchinson/Children's Hospitall University of Washington) Seattle, WA BMT Shands Hospital at the University of Florida Gainesville, FL BMT, H, LU, LI, K/P, P Stanford Medical Center Palo Alto, CA BMT, H, LU, H/LU, LI University of Alabama Health System Birmingham, AL H, LI, K/P, P, LU, BMT U.C.L.A. Medical Center Los Angeles, CA BMT, H, LI, LU, KP, P U.C.S.F. Medical Center San Francisco, CA BMT, LI, KIP University of Chicago Medical Center Chicago, IL LI, K/P, P, BMT University of Colorado Hospital Denver, CO BMT, H, LI, LU, H/LU University of Michigan Medical Center Ann Arbor, MI BMT, H, LI, K/P, LU, H/LU University of Washington Medical Center Seattle, WA H, LI, K/P, LU, H/LU University of Wisconsin Hospital and Clinics Madison, WI BMT, H, LI, K/P, LU, H/LU, P University Medical Center Tucson, AZ BMT, H * BMT - Bone marrow transplant (autologous & allogenic BMT & Peripheral stem cell) H - Heart H/LU - Heart/Lung OT - Organ Transplant, not specified K/P - Kidney/Pancreas SB - Small Bowel LI - Liver LU - Lung P - Pancreas We may also disclose summary information about the enrollees in your group health plan to the plan sponsor to use to obtain premium bids for the health insurance coverage offered through your group health plan or to decide whether to modify, amend or terminate your group health plan. The summary information we may disclose summarizes claims history, claims expenses, or types of claims experienced by the enrollees in your group health plan. The summary information will be stripped of demographic information about the enrollees in the group health plan, but the plan sponsor may still be able to identify you or other enrollees in your group health plan from the summary infor- mation. Situations Other Than Those Above: In any situa- tion other than those above, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information you can later revoke that authoriza- tion to stop any future uses and disclosures. Individual Rights In most cases, you have the right to look at or get a copy of health information about you that we use to make decisions about you. If you request copies, we will charge you $.05 (5 cents) for each page. You also have the right to receive a list of instances where we have disclosed health informa- tion about you for reasons other than treatment, payment or related administrative purposes. If you believe that information in your record is in- correct or if important information is missing, you have the right to request that we correct the exist- ing information or add the missing information. All requests for access to your medical information must be made in writing by you and directed to the contact person named below. Additionally, you have the right to request that we communicate with you about your medical infor- mation by alternative means or to alternative lo- cations. We will accommodate your request if it is reasonable, specifies the alternative means or location, and continues to permit us to collect pre- miums and pay claims under your health plan. Finally, you may req in writing that we not use or disclose your .. rmation for treatment, payment and operations except when specifi- cally authorized by you, when required by law, or in emergency circumstances. We will consider your request but are not legally required to accept it. Questions and Complaints If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this notice. If you are concerned that we may have violated your privacy rights, or you disagree with a de- cision we made about access to your medical information or in response to a request you made to amend or restrict the use or disclosure of your medical information or to have us com- municate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this notice. You may also submit a written com- plaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. De- partment of Health and Human Services upon request. We support your right to the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Contact Office Harry S. Miller, Senior Vice President BCS Insurance Company 676 N. St. Clair, Suite 1600 Chicago, IL 60611 Phone: 312-951-7727 Fax:312-951-1559 Email: hmiller@bcsins.com Privacy Practices Notice F.M.W ENTITIES COVERED BY THIS NOTICE: BCS Life Insurance Company BCS Insurance Company The above are entities covered by this notice in so far as they provide or pay the cost of medical care as defined by the Health Insur- ance Portability and Accountability Act of 1996 (HIPAA) and its attendant regulations. Our Legal Duty We are required by applicable federal and state law to maintain the privacy of your medical infor- mation. We are also required to give you this notice about our privacy practices, our legal du- ties, and your rights concerning your medical in- formation. We must follow the privacy practices that are described in this notice while it is in ef- fect. This notice takes effect April 14, 2003, and will remain in effect until we replace it. We reserve the right to change our privacy prac- tices and the terms of this notice at any time, pro- vided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all medical information that we maintain, including medical information we created or received before we made the changes. Before we make a significant change in our pri- vacy practices, we will change this notice and send the new notice available to our health plan sub- scribers at the time of the change. You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please con- tact us using the information listed at the end of this notice. Uses and Disclosures of Medical Information We use and disclose medical information about you for treatment, payment, and health care operations. For example: Treatment: We may use or disclose your medi- cal information to a physician or other health care provider in order to provide treatment to you. Payment: We may use and disclose your medi- cal information to pay claims from physicians, hospitals and other providers for services deliv- ered to you that are covered by your health plan, to determine your eligibility for benefits, to coordinate benefits, to examine medical necessity, to obtain premiums, to issue explana- tions of benefits to the person who subscribes to the health plan in which you participate, and the like. We may disclose your medical infor- mation to a health care provider or entity sub- ject to the federal Privacy Rules so they can obtain payment or engage in these payment activities. Health Care Operations: We may use and disclose your medical information in connection with our health care operations. Health care operations include: • Rating our risk and determining our premi- ums for you health plan; • Quality assessment and improvement ac- tivities; • Medical review, legal services, and audit- ing, including fraud and abuse detection and compliance; • Business planning and development; and 0 Business management and general admin- istrative activities, including management activi- ties relating to privacy, customer service, resolu- tion of internal grievances, and creating de - identified medical information or a limited data set. Public Health, Auditing, Research, Emergency Pur- poses and When Required by Law: We may use or disclose identifiable health information about you without your authorization for several additional reasons. Subject to certain requirements, we may give out health information without your authorization for public health purposes, for auditing purposes, for research studies, and for emergencies. We provide information when otherwise required by law, such c for law enforcement in specific circumstances. Others Involved In Your Care or Payment of Your Care: We also may disclose your medical informa- tion to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care. We may use or disclose your name, location, and general condition or death to notify, or assist in the notification of (including identifying or locating), a person involved in your care. Before we disclose your medical information to a person involved in your health care or payment of your health care, we will provide you with an oppor- tunity to object to such uses or disclosures. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical informatir based on our professional judgment of whether the disclosure would be in your best interest. Plan Sponsors: We may disclose your medical infor- mation and the medical information of others en- rolled in your group health plan to the employer or other organization that sponsors your group health plan to permit the plan sponsor to perform plan ad- ministration functions. Please see your group health plan document for a full explanation of the limited uses and disclosures that the plan sponsor may make of your medical information in providing plan ad- ministration. .... :zxxa';L., o-„, 9i*.,5-E.>r=e'dka"rv_ f. M .A N A G 1 M F' WESTERN COST MANAGEMENT TRUST (WCMT) Organ and Bone Marrow Transplant Program 2003 Rates (January 1 through December 31, 2003) Alternative 1 Alternative II Alternative 111 Drug Rider 18 Month Benefit Period $8.27 $6.66 $3.01 $0.52 12 Month Benefit Period $7.89 $6.35 $2.88 $0.52 Rates are charged on a per employee/retiree composite basis and include coverage for eligible dependents. Alternative I: Covers 100% of covered charges. Alternative II: Covers 80% of covered charges and the participant or underlying plan covers 20% of covered charges. Alternative III: Benefits are subject to a $100,000 deductible and payable at 100% of covered charges thereafter. Drug Rider: Extended drug and support services coverage for 12 months after expiration of the 12-month or 18-month Benefit Period. Note: All Alternatives are subject to internal limitations; see WCMT brochure for details. l M A N A L \ I I R t. • �. 131912/01945.001 0300Wrap wire 7W. I-n,4lcwnod, l Aw,ido ht01 I I Phone 303714 QW0 I ay. 31137 14.0000 CERTIFICATE OF INSURANCE BCS INSURANCE COMPANY (A Stock Company Incorporated in Illinois) Executive Office: 676 N. St. Clair Street, Chicago, Illinois 60611 (herein called the Company) This is to certify that, subject to the terms of Group Contract No. OTBM-28985, the participating Employees under the Group Contract held by the Policyholder named below are insured for the benefits described in Benefits, below. Policyholder: TRUSTEES OF THE BCS FINANCIAL WESTERN COST MANAGEMENT TRUST BENEFITS This Booklet becomes your Certificate of Insurance when you become insured under the Group Contract. The benefits and the main provisions that apply to Eligible Persons are shown in this Booklet. They are subject to the terms of the Group Contract, which alone constitutes the Contract under which payments are made. This insurance takes effect only for persons who become and stay insured under the Group Contract. Benefits payable under your insurance for Covered Services may provide that all or any portion of any benefits on account of Hospital, medical and surgical or other services may be paid, at our option, directly to the Hospital or person rendering such services. ORGAN AND BONE MARROW TRANSPLANT INSURANCE WCMT CERT.A (1/00) TABLE OF CONTENTS SECTION PAGE General Provisions: Notice of Claim, 3 Proof of Claim, Payment of Claims, Examinations, Legal Actions Definitions 4 Eligibility 7 Individual Terminations 7 Schedule of Benefits 8 Pre -Existing Conditions 13 Benefits for Organ and Bone Marrow Transplants 15 Exclusions 18 Coordination of Benefits 19 CONTRACT SPECIFICATIONS Policyholder: Trustees of the BCS Financial Western Cost Management Trust Contract Number: OTBM-28985 Contract Effective Date: July 1, 1990 Governing Jurisdiction: Colorado Participating Group: Participating Group's Effective Date: WCMT CERT.A (1/00) 2 GENERAL PROVISIONS NOTICE OF CLAIM. Written notice of the event on which claim is based must be given to the Company at its Home Office in Chicago, Illinois no later than twenty days after the loss for which claim is made. Late notice will be accepted only if it is shown to have been furnished as soon as is reasonably possible. On receipt of such notice, the Company will furnish forms for filing proof of claim. If the claimant has not been given such forms within fifteen days after receipt of notice, he or she can fulfill the terms of the Contract as to proof of claim by giving written proof of: (i) the occurrence of the loss; (ii) the nature of the loss; and (III) the extent of the loss. Such proof must be given within the time stated in "Proof of Claim" below. PROOF OF CLAIM. Written proof of claim must be given to the Company at its Home Office in Chicago, Illinois, on the Company's forms as described below. Proof of claim must be given within ninety days after the date of loss for which claim is made. The Company will require itemized bills as part of the proof of claim. Late proof will be accepted only if it is shown to have been furnished as soon as is reasonably possible. PAYMENT OF CLAIMS. On receipt of due proof of claim, benefits will be paid to the Employee. If benefits are payable on a periodic basis: (i) payments will be made at least once a month; and (ii) any sum due which has not been paid at the end of a period of liability will be paid as soon as due proof is received. EXAMINATIONS. The Company at its own expense has the right to have a Physician examine any person when it deems it reasonably necessary while there is a claim pending under the Contract. LEGAL ACTIONS. No one may sue for payment of claim: (i) less than sixty days after due proof of claim is furnished; or (ii) more than three years after the date proof of claim is required by the Contract. WCMT CERT.A (1/00) 3 DEFINITIONS Note: This section defines only some of the terms used. Please refer to the Contract for more definitions. 1. CAUSE — a medical condition, disease, or physical condition which results in the need for a bone marrow transplant. 2. CHARGES/FEES/EXPENSES - The terms "charges", "fees" or "expenses," as they relate to covered transplant, will not include any amounts: a. for a service or supply which is not Medically Necessary, even if ordered by a Physician. b. for a service or supply which is provided only as a convenience, even if ordered by a Physician. C. for repeated tests which are not needed, even if ordered by a Physician. d. more than what is reasonable and customary in the locale where incurred, as determined by the Company. These amounts will be determined by the Company. 3. CONTRACT - the agreement which alone determines the benefits, terms, limitations, and conditions of the coverage provided, which is described in this Certificate. Also referred to as the "Group Contract". 4. CONTRACT RATE - The actual fees billed by a LifeTrac Transplant Network Facility to the Company for services rendered to the Company's insureds. 5. CUSTODIAL CARE - This term means room and board and other institutional or nursing services: a. which could be performed by persons without professional skills; or b. which are provided to aid the persons in doing tasks of daily living. Custodial Care includes but is not limited to: administration of medicines, dressings or therapies which can be self-administered; routine monitoring of vital signs; help in walking, getting in and out of bed, bathing, dressing and eating. 6. DURABLE MEDICAL EQUIPMENT - items which can withstand repeated use, are primarily used to serve a medical purpose, are generally not useful to a person in the absence of illness, injury or disease, and are appropriate for use in the patient's home. 7. ELIGIBLE PERSON - a person entitled to apply to be a recipient of benefits as specified in the Eligibility Section. 8. EXPERIMENTAL/INVESTIGATIVE - the use of any treatment, procedure, facility, equipment, drug, device or supply not accepted as standard medical treatment of the condition being treated or any of such items requiring Federal or other government agency approval not granted at the time services were rendered. WCMT CERT.A (1/00) 4 DEFINITIONS (Continued) 9. FREESTANDING DIALYSIS FACILITY - a Facility Other Provider which is primarily engaged in providing dialysis treatment, maintenance or training to patients on an Outpatient or home care basis. 10. HOSPITAL - a Provider that is a short-term, acute, general hospital which: a. is a duly licensed institution, b. for compensation from its patients, is primarily engaged in providing inpatient diagnostic and therapeutic services for the diagnosis, treatment, and care of injured and sick persons by or under the supervision of Physicians, C. has organized departments of medicine and major surgery, d. provides 24-hour nursing service by or under the supervision of registered nurses, e. is not, other than incidentally, a: nursing home, Custodial Care home, health resort, spa or sanitarium, place for rest, place for the aged, place for the treatment of mental illness, place for the treatment of alcoholism or drug abuse, place for the provision of hospice care, place for the treatment of pulmonary tuberculosis. 11. INCURRED - a charge shall be considered incurred on the date an Eligible Person receives the service or supply for which the charge is made. 12. LIFETRAC TRANSPLANT NETWORK FACILITY - A transplant facility which has an agreement regarding transplant network services provided to the Company's insureds. 13. MEDICALLY NECESSARY (or Medical Necessity) - services or supplies provided by a Hospital, Physician or Other Provider that the plan determines are: a. appropriate for the symptoms and diagnosis or treatment of the Eligible Person's condition, illness, disease or injury; and b. provided for the diagnosis, or the direct care and treatment of the Eligible Person's condition, illness, disease or injury; and C. in accordance with standards of good medical practice; and d. not primarily for the convenience of the Eligible Person, or the Eligible Person's Provider; and e. the most appropriate supply or level of service that can safely be provided to the Eligible Person. When applied to hospitalization, this further means that the Eligible Person requires acute care as a bed patient due to the nature of the services rendered or the Eligible Person's condition, and the Eligible Person cannot receive safe or adequate care as an Outpatient. WCMT CERT.A (1/00) 5 PROPOSAL REQUIREMENTS Section I: Executive Summary Section II: Proposal Compliance Letter Section III: Checklist of Items included with Proposal Section IV: Plan Design Confirmation Section V: Questionnaire Responses Section VI: Performance Guarantees Section VII: Financial Exhibits Section VIII: Items Included with Proposal DEFINITIONS (Continued) 14. OTHER PROVIDER - a person or entity other than a Hospital or Physician which is licensed, where required, to render Covered Services. Other Providers include: a. FACILITY OTHER PROVIDER - an institution or entity only as listed b. PROFESSIONAL OTHER PROVIDER - a person or practitioner only as listed 15. OTHER TRANSPLANT FACILITY - Any transplant facility other than a LifeTrac Transplant Network Facility. 16. PHYSICIAN - a person who is a doctor of medicine (M.D.) or a doctor of osteopathy (D.O.), licensed and legally entitled to practice medicine in all of its branches, perform surgery and dispense drugs. 17. PROVIDER - a Hospital, Physician, or Other Provider, licensed where required and performing within scope of license. 18. REGISTERED CANDIDATE - patient who is a registered heart transplant candidate. Verification of candidacy must be provided to the Company before any expenses will be reimbursed. 19. REGISTERED LIVER CANDIDATE — a patient who is a registered liver transplant candidate. Verification of candidacy must be provided to the Company before any expenses will be reimbursed. 20. USUAL, CUSTOMARY AND REASONABLE - UCR means a fee reasonably determined by BCS and that is based upon: 1) the fee that Provider usually charges for a particular service; 2) the range of usual fees charged for the same service by other Providers with similar training and experience in the same geographic area; and 3) the fee that is reasonable in light of the complexity of treatment in a particular case. Therefore, payment is based upon what many Providers charge for a service rather than what one Provider charges. 21. SKILLED NURSING FACILITY - a Facility Other Provider which is primarily engaged in providing skilled nursing and related services on an inpatient basis to patients requiring 24-hour skilled nursing services but not requiring confinement in an acute care general hospital. Such care is rendered by or under the supervision of Physicians. A Skilled Nursing Facility is not, other than incidentally, a place that provides: a. minimal care, Custodial Care, ambulatory care, or part-time care services, or b. care or treatment of mental illness, alcoholism, drug abuse or pulmonary tuberculosis. WCMT CERT.A (1/00) 6 ELIGIBILITY Information regarding eligibility requirements, insurance effective dates and termination of coverage can be found in the Contract. In the event of a discrepancy between the Contract and the Employer's eligibility and termination provisions, the Employer's plan provisions will prevail. INDIVIDUAL TERMINATIONS In the event of a discrepancy between the Contract and the Employer's individual termination provisions, the Employer's provisions will prevail. A. The insurance under the Contract of an employee ends when the first of the following events occurs or as defined in the Employer's plan booklet: 1. The Contract ceases. 2. Premium payments for the insurance of the Employee ceases. 3. The last day of the month in which the Employee's employ in the classes of the Employees eligible under the Contract ends. 4. The payment of the Maximum Lifetime Transplant Benefit. 5. The date the Employer ceases to be a participating Employer, as defined in the Contract. B. A Dependent's insurance ends when the first of the following events occurs: 1. Premium payments for the insurance of the Dependent cease. 2. The Employee's insurance under the Contract ends as described above, other than A.4. 3. The Dependent is no longer an eligible Dependent. 4. The payment of the Maximum Lifetime Benefit. WCMT CERT.A (1/00) 7 SCHEDULE OF BENEFITS FOR HUMAN ORGAN TRANSPLANTS AND BONE MARROW TRANSPLANTS COVERED PROCEDURES I. Procedures Performed at a LifeTrac Transplant Facility A. Covered Organ Transplant Procedures The following organ transplant procedures are covered: liver, heart, heart-lung, lung (single and double), pancreas, pancreas and kidney combined, and small intestine. Kidneys are only covered when a combined pancreas and kidney transplant procedure is performed. All covered medical expenses incurred during the transplant benefit period that result from or are directly related to the completion of a covered organ transplant procedure, or that are related to the condition, illness, or disease that necessitated the covered organ transplant procedure, or that are related to complications resulting from the condition, illness, or disease that necessitated the covered organ transplant procedure, or complications resulting from the covered organ transplant procedure itself, will be reimbursed, except that expenses for circulatory assist device implants will be reimbursed only as set forth in subsection C. below. B. Covered Bone Marrow Transplant Procedures The following bone marrow transplant procedures are covered if the transplant procedure is used to treat leukemia, lymphoma, blood and genetic diseases and solid tumors: allogeneic, autologous (including an autologous bone marrow transplant in breast cancer and testicular cancer), syngeneic, and peripheral stem cell. The above listed bone marrow transplant procedures are not covered if the condition, illness or disease which necessitated the transplant was caused by any human T-cell leukemia virus. All covered medical expenses incurred during the transplant benefit period that result from or are directly related to the completion of a covered bone marrow transplant procedure or that are related to the condition, illness, or disease that necessitated the covered bone marrow transplant procedure, or that are related to complications resulting from the condition, illness, or disease that necessitated the covered bone marrow transplant procedure or complications resulting from the covered bone marrow transplant procedure itself, will be reimbursed; provided, however, that reimbursement for medical expenses related to the harvest of bone marrow or acquisition of peripheral stem cells for a covered bone marrow transplant procedure will be limited to expenses incurred for the following services: Services for the harvest or acquisition of bone marrow or peripheral stem cells; WCMT CERT.A (1/00) 8 2. Hospitalization for up to two days for bone marrow puncture; 3. Processing and storage of bone marrow or peripheral stem cells, but limited to the first 30 days of expenses incurred for processing or storage services; 4. Purging or manipulation of bone marrow or blood; 5. Other services directly related to or part of harvest or acquisition services covered under 1., 2., 3., or 4. above. No harvest or acquisition expenses described under 1., 2., 3., 4., and 5. above are covered unless, and no reimbursement of such expenses will be made until after, the bone marrow transplant infusion is performed. C. Circulatory Assist Device Implants All covered medical expenses incurred by Registered Candidates during the circulatory assist device benefit period that result from or are directly related to the implant of a circulatory assist device, or that are related to the condition, illness, or disease that necessitated the circulatory assist device implant, or that are related to complications resulting from the condition, illness or disease that necessitated the circulatory assist device implant or complications resulting from the circulatory assist device itself, will be reimbursed. D. Hepatic Assist Device Implants All covered medical expenses incurred by Registered Liver Candidates during the hepatic assist device benefit period that result from or are directly related to the implant of a hepatic assist device, or that are related to the condition, illness, or disease that necessitated the hepatic assist device implant, or complications resulting from the hepatic assist device itself, will be reimbursed. It. Procedures Performed at an Other Transplant Facility Benefits will be paid for covered transplant procedures listed in I.A. and B., for circulatory assist device implants set forth in I.C., and hepatic assist device implants set forth in I.D. Benefits paid will not exceed the Contract Rate that would have been charged had the procedure been performed at the LifeTrac Transplant Network Facility nearest to the facility in which the transplant is performed. PHYSICIAN CERTIFICATION The Company will pay such benefits if the recipient receives two opinions on the need for transplant Surgery prior to the Surgery. The opinions must be given: 1. By a board certified specialist in the involved field of Surgery. 2. In writing. The specialist must certify that alternative procedures, services or sources of treatment would not be effective in the treatment of the patient's conditions. WCMT CERT.A (1/00) 9 TRANSPLANT BENEFIT PERIOD A. The transplant benefit period for a covered organ transplant procedure begins 5 days before the date of the covered organ transplant procedure and continues for 18 months beginning with the date the covered organ transplant procedure is performed. B. The transplant benefit period for a covered bone marrow transplant procedure begins 30 days prior to the date of the covered bone marrow transplant infusion and continues for 18 months beginning with the date the covered bone marrow transplant infusion is performed. Medical expenses related to the harvest of bone marrow or acquisition of peripheral stem cells for a covered bone marrow transplant procedure will be deemed to have been incurred during the transplant benefit period, if actually incurred no more than 365 days prior to the date of the covered bone marrow transplant infusion. CIRCULATORY ASSIST DEVICE BENEFIT PERIOD The circulatory assist device benefit period begins five (5) days before the circulatory assist device implant and ends on the date of a covered Heart or Heart -Lung transplant procedure. If a Registered Candidate does not receive a Heart or Heart -Lung transplant procedure, the circulatory assist device benefit period will end on the date of the Registered Candidate's death or the date of explant of the circulatory assist device, whichever occurs first. Notwithstanding the provisions of this section, the circulatory assist device benefit period will end effective on the date of termination of this Contract and no expenses incurred afterward will be insured. An expense is considered incurred on the date a service is rendered or a supply is delivered. HEPATIC ASSIST DEVICE BENEFIT PERIOD The hepatic assist device benefit period begins 5 days before the hepatic assist device implant and ends on. the date of a covered liver transplant procedure. If a Registered Liver Candidate does not receive a liver transplant, the hepatic assist device benefit period will end on the date of the Registered Liver Candidate's death or the date of explant of the hepatic assist device, whichever occurs first. Notwithstanding the provisions of this section, the hepatic assist device benefit period will end effective on the date of termination of this Contract and no expenses incurred afterward will be insured. An expense is considered incurred on the date a service is rendered or a supply is delivered. WCMT CERT.A (1/00) 10 SCHEDULE OF BENEFITS FOR ORGAN AND BONE MARROW TRANSPLANTS MAXIMUM BENEFITS FOR TRANSPLANT I. Maximum Benefit Per Lifetime'$2,000,000 II. Maximum Benefits for Procurement of Organ or Bone Marrow Per Transplant Benefit Period" A. Organ Procurement" 1. LifeTrac Transplant Network Facility a. If procurement is an included service in the Contract Rate ............................................. No Maximum Applicable b. If procurement is not an included service in the Contract Rate: I. Cadaveric organ ..................................... $35,000 Ill. Organ from living donor .......................... $65,000 2. Other Transplant Facility a. Cadaveric organ ................................................... $35,000 b. Organ from living donor ....................................... $65,000 B. Bone Marrow Procurement" 1. LifeTrac Transplant Network Facility a. If procurement is an included service in the Contract Rate ............................................. No Maximum Applicable b. If procurement is not an included service in the Contract Rate ............................................. $25,000 2. Other Transplant Facility ................................................... $25,000 III. Maximum Benefit For Transportation, Lodging, and Meals Per Transplant Benefit Period"'*$10,000 Maximum Daily Limit for Lodging and Meals"' .......................................... $200 IV. Maximum Benefits For Private Nursing Care Per Transplant Benefit Period........................................................................... $10,000 WCMT CERT.A (1/00) 11 V. Maximum Benefits for Circulatory Assist Device No Maximum Per Transplant Benefit Period Applicable VI. Maximum Benefits for Hepatic Assist Device ............................................. No Maximum Per Transplant Benefit Period Applicable 'Maximum Benefit Per Lifetime The maximum benefit per lifetime of $2,000,000 is applied per type of organ transplant and per Cause of bone marrow transplant. Benefits for subsequent retrans plantations are combined with previous benefits paid for the initial transplant and any other retransplantations in determining whether the maximum benefit per type of organ transplant or per Cause of bone marrow transplant per lifetime has been reached. Benefits for circulatory assist devices are combined with any benefits paid for a heart transplant in determining whether the maximum benefit per heart transplant per lifetime has been reached. Benefits for hepatic assist devices are combined with any benefits paid for a liver transplant in determining whether the maximum benefit per liver transplant per lifetime has been reached. "Procurement With regard to the donation of a cadaveric organ, procurement expenses include surgical, storage, and transportation costs incurred and directly related to the donation of an organ to be used in a covered organ transplant procedure that is insured under this policy, including costs resulting from complications of the donor's surgery. With regard to the donation of an organ by a living donor, procurement expenses include surgical, storage, and transportation costs which are directly related to the donation of an organ to be used in a covered organ transplant procedure that is insured under this policy, including costs resulting from complications of the donor's surgery, and which are incurred on or within 120 days from the date of the donor's surgery. With regard to the donation of bone marrow and peripheral stem cells, procurement expenses include the harvest and acquisition expenses outlined in Item I.B. of the "COVERED PROCEDURES" subsection contained in this "SCHEDULE OF BENEFITS FOR HUMAN ORGAN TRANSPLANTS AND BONE MARROW TRANSPLANTS." All procurement expenses will be reimbursed up to the maximum benefits listed above for each covered transplant procedure completed. "'Transportation, Lodging, and Meals - Recipient The following transportation, lodging, and meal expenses will be reimbursed up to the maximum benefits for each covered transplant procedure completed: If the recipient of the covered transplant procedure is an adult, costs of transportation to and from the site of the covered transplant procedure for the recipient and one other individual will be reimbursed. If the recipient of the covered transplant procedure is a minor, costs of transportation to and from the site of the covered transplant procedure for the recipient and two other individuals will be reimbursed. All reasonable and necessary lodging and meal expenses incurred, up to a daily maximum of $200.00, by said individual(s) accompanying the recipient will be reimbursed. The aggregate sum of all costs of transportation, lodging, and meals is subject to a maximum of $10,000.00. WCMT CERT.A (1/00) 12 PROCEDURE SCHEDULED BUT NOT PERFORMED If a covered transplant procedure is not done as scheduled due to the intended Eligible Insured's medical condition or death, benefits will be paid for charges incurred for procurement of a cadaveric organ and bone marrow/peripheral stem cells and transportation, lodging, and meals. Benefits for procurement of an organ from a living donor will be paid only if the covered organ transplant procedure was scheduled to occur within 24 hours of the donor's surgery. TWO OR MORE TRANSPLANT PROCEDURES These are treated as follows: If procedures are due to unrelated causes, benefit periods are treated separately. 2. If procedures are due to related causes, benefit periods are treated separately if in: (i) the case of an Employee, they are separated by his or her return to active work; or (ii) in the case of a Dependent, they are separated by at least three consecutive months. 3. If procedures are due to related causes, they are treated as one benefit period when not separated as shown in above. EXTENDED TRANSPLANT BENEFITS If at the time an Eligible Person's insurance under the Contract ends, he or she has established a transplant benefit period for which benefits are not exhausted, benefits will be paid for the remaining part of that benefit period as if such insurance had not ended. Benefits will be based on the plan in force for the person on the date the insurance ends. If the Employer ceases to be a participating Employer, the Extended Transplant Benefits provision will not apply. PRE-EXISTING CONDITIONS Except as specifically provided in the Contract, no benefits will be provided for covered services for which an Eligible Person received medical advice or treatment within three months prior to the date the Eligible Person becomes insured. This exclusion will not apply to covered expenses that are incurred after the first of these dates occur: A. The date after the Eligible Person becomes insured when no charges are incurred or advice or treatment received for said injury or sickness for three consecutive months; or B. At the end of six consecutive months in which the Eligible Person is continuously insured under this Contract. WCMT CERT.A (1/00) 13 C. In the case of a late enrollee, at the end of eighteen consecutive months in which he or she is continuously insured under this Contract; except that where the late enrollee is also subject to a waiting period for the underlying major medical policy, the length of time that the late enrollee is subject to the pre-existing condition exclusion will be reduced by the length of the waiting period. For purposes of this section, subsections (A), (B), and (C) above will be referred to as the pre-existing condition limitation periods. The duration of any pre-existing condition limitation period will be reduced by any period of time an Eligible Person was previously covered by Creditable Coverage if such Creditable Coverage was continuous to a date not more than ninety days prior to the effective date of any new Creditable Coverage. For purposes of this section, "Creditable Coverage" means benefits or coverage defined as "creditable coverage" under Colorado law, section 10-16-102 and as may be amended. WCMT CERT.A (1/00) 14 BENEFITS FOR ORGAN AND BONE MARROW TRANSPLANTS Benefits are payable for charges for the following Organ and Bone Marrow Transplant Services, subject to the terms set forth in the SCHEDULE OF BENEFITS. These charges must be incurred during a Transplant Benefit Period which begins while an Eligible Person is insured for these benefits. These charges must be due to the transplant procedure or a complication directly related to the transplant. Note: These benefits are only briefly listed below. Refer to the Contract for a more detailed description and definitions of benefits provided. A. HOSPITAL SERVICES 1. Bed, Board, and General Nursing Service Bed, board, and general nursing service when an Eligible Person is an Inpatient. 2. Ancillary Services Hospital services and supplies. 3. Surgery 4. Pre -Admission Testing B. SURGICAUMEDICAL SERVICES 1. Surgical Services a. Surgery b. Assistant At Surgery C. Anesthesia d. Second Surgical Opinion 2. Inpatient Medical Services Medical Care by a Physician or Professional Other Provider to an Eligible Person who is a Hospital Inpatient for a condition related to the transplant procedure or complication related to the transplant procedure. a. Inpatient Medical Care Visits b. Intensive Medical Care C. Concurrent Care d. Consultation WCMT CERT.A (1/00) 15 SECTION I: EXECUTIVE SUMMARY The Western Cost Management Trust (WCMT) Organ and Bone Marrow Transplant Program was conceived by The Segal Company in the mid-1980's to meet the growing needs of its self - funded health plan clients desiring to cover organ and bone marrow transplants but who could not assume the risk of these large claims within their individual plans. Over the years, as some clients have contracted with fully insured carriers and HMOs, they have maintained the stand- alone WCMT program. There are currently 22 groups covering 32,600 employees (plus their dependents) participating in the program. 2. Equitable Life Assurance Company underwrote the coverage until CIGNA, who acquired Equitable, determined in 1990 they no longer desired to offer a stand-alone organ and bone marrow transplant program. Effective July, 1990 BCS Financial Corporation became the underwriting carrier and remains in that capacity today. Wells Fargo Bank (Colorado) N.A. is Trustee and performs premium billing and collection services. 3. BCS has contracted with LifeTrac Network for preferred transplant facility arrangements throughout the U.S; two facilities are in Denver, Colorado — University Hospital and Children's Hospital. Eligible participants requiring transplants may use a LifeTrac Network or other facility. The WCMT program, a PPO plan, allows a participant to choose his/her transplant facility. Non - network coverage is based on benefits that would have been allowable in the geographically nearest LifeTrac network facility; the patient is responsible for any balances due non -network providers. 4. The WCMT program offers coverage under three alternative funding arrangements for both a 12- month and an 18-month coverage benefit period. A supplemental drug rider is also available for immunosuppressant drugs for an additional 12 months following expiration of either the 12- or 18- month benefit period. See details in Section VIII. 5. Covered transplants are listed in the attached Certificate of Insurance. Kidney and cornea transplants are not covered; however kidney/pancreas transplants are. Circulatory assist devices and hepatic assist devices are also covered for individuals awaiting their respective heart or liver transplants. 6. The program is pooled; individual group claims experience is not available. Premium rates are determined for the entire WCMT program on a calendar year basis and are available in late October for the following calendar year. 7. Segal and BCS Insurance Company are familiar with the City's account management and servicing needs having worked with the City for the past six years on the current transplant program. The same individuals, Susan Imming with The Segal Company, and Theresa O'Shea with BCS Insurance Company, will continue to provide primary account management and customer service to the City. Both Segal and BCS have designated additional staff who will be available to the City in the event the primary contacts may be unavailable. 2 3. Outpatient Medical Services Medical Care rendered by a Physician or Professional Other Provider to an Eligible Person who is an Outpatient for a condition directly related to the transplant. a. Emergency Medical Care b. Home, Office and Other Outpatient Visits C. OUTPATIENT DIAGNOSTIC SERVICES Radiology, Ultrasound and Nuclear Medicine 2. Laboratory and Pathology 3. ECG, EEG, Other Electronic Diagnostic Medical Procedures and Physiological Medical Testing. D. OUTPATIENT THERAPY SERVICES Radiation Therapy, Chemotherapy, Dialysis Treatment, Physical Therapy, Respiratory Therapy, Occupational Therapy, Speech Therapy E. PSYCHIATRIC CARE SERVICES Inpatient Medical Services The following services provided for the Inpatient treatment of mental illness by a Physician or Professional Other Provider: Medical Care visits (Inpatient Medical Care visits are limited to one visit per day.), individual psychotherapy, group psychotherapy, psychological testing, family counseling. 2. Outpatient Psychiatric Care Services Covered Inpatient Facility and Medical Services when provided for the Outpatient treatment of mental illness by a Hospital, Physician or Other Provider. F. AMBULANCE SERVICE Used only for transporting the sick and injured. G. PRIVATE DUTY NURSING SERVICES Private Duty Nursing Services of an actively practicing Registered Nurse (RN), Licensed Practical Nurse (LPN), or Licensed Vocational Nurse (LVN) when ordered by a Physician. WCMT CERT.A (1/00) 16 1. Inpatient Services If they cannot be or are not usually provided by the regular nursing staff of the Provider. 2. Home Services Nursing services that the Company determines require the skills of an RN, LPN, and LVN. H. SKILLED NURSING FACILITY SERVICES 1. Hospital Services provided to an Inpatient of a Skilled Nursing Facility. 2. No benefits are payable: a. after the maximum level of recovery possible for a particular condition has been reached. b. if solely to assist the Eligible Person with the activities of daily living or for the convenience of an Eligible Person; C. for the treatment of alcoholism, drug addiction or mental illness. I. HOME HEALTH CARE SERVICES The following services provided to an essentially homebound Eligible Person by a Hospital program for home health care or community home health care agency: Professional services of an RN, LPN, LVN, physical therapy, occupational therapy and speech therapy, medical and surgical supplies provided by the home health care provider, prescribed drugs, oxygen and its administration, medical social service consultations, health aide services, Durable Medical Equipment. Home health care benefits will be provided only when prescribed prior to discharge. The Eligible Person must be essentially confined at home. No home health care benefits will be provided for: dietitian services, homemaker services, maintenance therapy, dialysis treatment, purchase or rental of dialysis equipment, food or home delivered meals. J. DENTAL SERVICES K. PRESCRIPTION DRUGS L. DURABLE MEDICAL EQUIPMENT When prescribed by a Physician or Professional Other Provider and required for therapeutic use. WCMT CERT.A (1/00) 17 M. PROSTHETIC APPLIANCES Purchase, fitting, necessary adjustments, repairs, and replacements of prosthetic devices and supplies which replace all or part of an absent body organ (including contiguous tissue) or replace all or part of the function of a permanently inoperative or malfunctioning body organ (excluding dental appliances). N. ORTHOTIC DEVICES A rigid or semi -rigid supportive device which restricts or eliminates motion of a weak or diseased body part. EXCLUSIONS Except as specifically provided in the Contract, no benefits will be provided for services, supplies or charges: 1. For which an Eligible Person would not legally have to pay if there were no insurance; 2. Which are not prescribed by or performed by or upon the direction of a Physician or Professional Other Provider; 3. Which are not Medically Necessary as determined by the Company; 4. Rendered by other than Hospitals, Physicians, and Other Providers; 5. Which are Experimental/Investigative in nature as defined by Blue Cross and Blue Shield Association's Uniform Medical Policy; 6. For any illness or bodily injury which occurs in the course of employment if benefits or compensation are available, in whole or in part, under the provisions of any legislation of any governmental unit. This exclusion applies whether or not the Eligible Person claims the benefits or compensation and whether or not the Eligible Person recovers losses from a third parry; 7. To the extent benefits are provided by any governmental unit (i.e. Medicare); 8. For any illness or injury suffered after the Eligible Person's Effective Date which is not a direct result of transplant procedure covered under the Contract coverage; 9. Received from a medical department maintained by or on behalf of an Employer, a mutual benefit association, labor union, trust, or similar person or group; 10. For surgery and any related services intended solely to improve appearance, but not to restore bodily function or correct deformity resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes; 11. Rendered by a Provider who is a member of the Eligible Person's immediate family; WCMT CERT.A (1/00) 18 EXCLUSIONS (Continued) 12. Any transplant procedure incurred prior to the Eligible Person's Effective Date or during an Inpatient admission that commenced prior to the Eligible Person's Effective Date; 13. Any transplant procedure incurred after the date of termination of the Eligible Person's coverage; includes a transplant performed with a benefit period commencing after the termination date but performed while continuously hospitalized prior to the termination date; 14. For personal hygiene and convenience items such as, but not limited to, air conditioners, humidifiers or physical fitness equipment; 15. For telephone consultations, charges for failure to keep a scheduled visit, or charges for completion of a claim form; 16. For Custodial Care, domiciliary care or rest cures; 17. For rehabilitation treatment for alcoholism; 18. For rehabilitation treatment for drug abuse; 19. To the extent payment has been made under Medicare or would have been made if the Eligible Person had applied for Medicare and claimed Medicare benefits; i.e. multi -visceral transplants where one organ is payable by Medicare such as kidney and heart transplant. Kidney transplant is payable by Medicare; 20. For any expenses for the donor other than those provided within; 21. For any services or treatment not directly related to a complication of a transplant; 22. For recurrence of the disease for which transplant was performed; 23. For bone marrow transplant in Eligible Persons infected with any of the Human Immunodeficiency Viruses. COORDINATION OF BENEFITS If an insured person is entitled to benefits for care under this Plan and at least one other plan, the amount of benefits provided by this Plan for that care may be reduced to the extent that the total payment provided during a claim determination period by all plans by which the person is covered will not be more than the total of the Allowable Expenses that the person incurs in the same period. This will be done as set forth in Order of Payment. Plan. This term means any plan that provides coverage: a. by any group insurance, or by any other method of coverage for persons in a group. b. by any governmental plan, except Medicaid (Title XIX of the Federal Social Security Act as it now is or as it may be changed). C. required by law. d. by a "no-fault" motor vehicle plan. WCMT CERT.A (1/00) 19 This term does not mean: (a)'school accident insurance; or (b) group hospital indemnity benefits This Plan. This term means the Contract. Allowable Expenses. This term means any necessary, reasonable and customary item of expense a part of the cost of which is covered by (a) this Plan, (b) one of the other plans, except Medicare or a "no- fault" motor vehicle plan. The difference between the cost of a private Hospital room and the cost of a semi -private Hospital room will not be deemed to be an Allowable Expense; but it will be deemed to be an Allowable Expense during the period of time the patient's confinement to a private Hospital room is deemed necessary as generally accepted in health care practice. Medicare. This term means Title XVIII of the Federal Social Security Act, as it now is, or as it may be changed. A person who is eligible for Medicare will be deemed to have all the coverages for which he or she is so eligible. No-fault Motor Vehicle Plan. This term means a motor vehicle plan which is required by law and provides medical care payments which are made, in whole or in part, without regard to fault. A person subject to such law who has not complied with the law will be deemed to have received the benefits required by the law. Claim Determination Period. This term means the time during any benefit period year when a person is covered and incurs charges for one or more items of expense covered under: (i) this Plan; and (ii) at least one other plan. Order of Payment. When a person is covered under two or more plans, the rules that follow will decide the order in which the plans will pay benefits: 1. A plan which does not have a provision like this Non -Duplication of Benefits will pay before this Plan. 2. A plan which covers a person other than as a Dependent will pay before a plan which covers a person as a Dependent. 3. A plan which covers a person as a Dependent of a person whose date of birth occurs earlier in a calendar year will pay before a plan which covers the person as a Dependent of a person whose date of birth occurs later in a calendar year; provided that: (i) if said dates are the same, the plan which has covered a person for the longest time will pay first. (ii) if any other plan does not have a provision for dates of birth, as set forth above, that plan will determine the order of payment with respect to Dependents. WCMT CERT.A (1/00) 20 In this clause 3., date of birth means day and month of birth. It does not mean year of birth. However, if the person is a Dependent child of divorced or separated parents, the order will be as follows: (i) if the parent with custody has not remarried, his or her plan will pay before the plan of the parent without custody. (ii) if the parent with custody has remarried, his or her plan will pay before the plan of the stepparent or the parent without custody; and the plan of the stepparent will pay before the plan of the parent without custody. However, if there is a court decree which sets forth a financial duty for the health care expenses of the child, the plan of the parent with such financial duty will pay first. 4. If these three rules do not decide which plan will pay its benefits first, the plan which has covered the person for the longest time will pay first. Exception: a. Subject to (b) below: If a plan covers a person for whom claim is made as a laid -off or retired Employee, or as his or her Dependent, the benefits of that plan will be determined after those of a plan that covers such person as an Employee who is not laid -off or retired, or as his or her Dependent b. if any other plan does not have a provision like that in (a), this Exception will not apply to that plan. To administer claims, the Company, without the consent of any person, will have the right: a. to give or to get any data needed to determine benefits under this provision. b. to recover any sum paid above that required by this provision. C. to pay any organization the sum it is paid, but which should have been paid by the Company. Amounts so paid will be deemed benefits paid under this Plan; and to the extent so paid there will be no more liability under this Plan. Active Employees and Their Dependents Eligible for Medicare If a person insured under this Plan for medical care benefits is also eligible for Medicare benefits: a. due to end stage renal disease, this Plan will determine its benefits without taking into account Medicare benefits for which that person is eligible, during the first 30 consecutive months that person is eligible, for Medicare benefits. b. due to any other disability, or due to attainment of age 65, this Plan will determine its benefits without taking into account Medicare benefits for which that person is eligible. WCMT CERT.A (1/00) 21 10 A Plan That Points Y:.t in the Right Direction There are several directioi i organ and bone marrow i i Cost Management Trust \ directing your organizat ,i cost-effective organ and Complicated cases, repe n immunosuppression ma1v� one of the most costly me a single transplant case to $1,000,000! With ad .t i can turn when n romes to ,mt ( overage. Thr Western f) is a program ,,iilmitted to its members to hie,It quality, arrow transplant r.ire. Ispitalizationand Iilclong are �)f transplant ,aients prow dures. Its I,,,.,ible that ost anywhere from 500,000 �crits and new der, opments in the field td ri'dicine, trans- irn fen, is on the rise as shown in th, h arts at left. C Inc i i ly, i t likelihood that corr plan w.i h ive patients i i rg o ;an bone marrow u ansplint In r rent is also o rise Choosing Your Directii)n "I hiough the '( MT, you ma richer fully i i A or self --ins nsured irrai > rent, patient A [SCS Life I i trance Comp: uicl self-insu d arrangemem I:ilcrrac net\ r _ facilities. Dedicated to Excellent:e ign out -ogram to be 11 ru for a fully e ac °ss i the expertise indi bo[ a fully insured enu hav, tccess to i;( S Life Ins 1 a ice Companj a hi or, 3 a leader in the field of c ;a t and bone n i w u nsp its. BCS was he first insi .ir,:e company ter i Le (I of bone rnarrow tran-I f ins for breas -er I (ti( ; and small intestine tram - )ants. BCS atu the ndu ry in covering ,irculatory: is device imp De( cat( staff at BCS study trendy i t the field to e the vV( ` T offers leading edge organ :i i d bone marrov splu it c, =rage. When a path i t becomes a csi I ate I r ar organ or bone marrow trap 14 mt, he or she feel )ve i helmed by all the decision- h it need to be e. TI e V\ ( MT helps guide the patient i1 1o,Lgh the organ bop m,, ow transplant process. BC` tH and LifeTrr )rdii ate i l , patient's care and work w n't i he transplani ity i arr- er any questions about the pu ieit's coverage. sisti g psi' ents and coordi- nating care, I,e WCMT ease .. finis -an\ work for plans. 1"J The LifeTrac Network Choosing an organ or bone marrow transplant facility can be challenging for transplant patients, their families and physicians. The LifeTrac Network includes over 30 centers of excellence — hospitals with extensive experience in pro- viding organ and bone marrow transplants, and a proven track record of success with these treatments. LifeTrac Network facilities are evaluated on the basis of transplant volume; success rates/outcomes; surgical team experience; United Network for Organ Sharing (UNOS) participation; Medicare certification; geographic location; and fixed -fee arrangements. LifeTrac Network facilities have the volume of cases to permit confidence in treatment efficacy and cost predictability. Therefore, these facilities are better able to provide meaningful fixed -fee arrangements for inpatient care (which typically accounts for 70% of a transplant's cost). For a listing of LifeTrac Network facilities, please see the enclosed brochure. Transplant Benefit Period FOR ORGAN TRANSPLANTS — The transplant benefit period begins five days before the date of the covered organ trans- plant procedure and continues for 18 months following the date the covered organ transplant procedure is performed. FOR BONE MARROW TRANSPLANTS — The transplant benefit period begins 30 days prior to the date of the covered bone marrow transplant infusion and continues for 18 months following the date the covered bone marrow transplant infusion is performed. FOR CtRcuuuoRY ASSIST DFvtcFs — The circulatory assist device benefit period begins five days before the circulatory assist device implant and ends on the date of a covered heart or heart/lung transplant. If a patient doesn't receive a trans- plant, the circulatory assist device benefit period will end on the date the device is removed or on the date the patient dies, whichever occurs first. Immunosuppressive Drug Coverage Immunosuppressive drugs are essential to the success of organ and bone marrow transplants. Since patients take these drugs on a lifelong basis, the cost of the drugs quickly adds up. The WCMT provides immunosuppressive drug coverage for the 18-month period following the transplant. An additional 12-month immunosuppressive drug coverage rider may be purchased. No Text SECTION II: PROPOSAL COMPLIANCE LETTER See Attached Letter Benefits Payable The chart below highlights the benefits provided through the WCMT. Please note that the chart is intended to be a summary of benefits only. The listed benefits are subject to all the terms and conditions of the organ and bone marrow transplant insurance policy, including all exclusions and stated maximums set forth therein. Lifetime Maximum $2,000,000 per person per covered transplant procedure' Covered Services Covered at 100% of Heart eligible expenses Heart/Lung Lung (single and double) Liver Pancreas Kidney/Pancreas Small Intestine Autologous Bone Marrow Transplant Allogeneic Bone Marrow Transplant Organ Procurement Maximum $25,000 per transplant benefit period' Immunosuppressants Covered at 100% Transportation Maximum $10,000 per transplant benefit period (up to $200 per day for lodging and meal expenses)' Private Nursing Care $10,000 per transplant benefit period Circulatory Assist Device Covered at 100% for Implants registered heart transplant candidates Complications/Expenses Covered at 100% Related to Disease/Cause of Transplant Re -transplantation Covered up to Plan's maximums I Refer to the insurance policy for information about two or more transplants. 2 Includes surgical, storage and transportation costs incurred and directly related to the donation of an organ used in a covered transplant procedure. 3 Includes transportation to and from the site of a covered transplant procedure for the recipient and one other individual If the recipient is a minor, transportation includes the cost for two other individuals accompanying the recipient. \� \ ) \ \ \ \\\ (��\ /� . \\\�\\ § \<;� � §��\ ��2\ \\�»« «2<:\ / \\�\\ d d�«2 \©%}\\\ 5y] ^ \\\/\\\ \\/{\�� .«�\ � \ \\\ \� © ®y:<e � \\\22\ \2 \ \��� .Jz S\� �\\<«» .\ y \ � ]ƒ� \ \ Benefits Payable The chart below highlights the benefits provided through the WCMT. Please note that the chart is intended to be a summary of benefits only. The listed benefits are subject to all the terms and conditions of the organ and bone marrow transplant insurance policy, including all exclusions and stated maximums set forth therein. Lifetime Maximum $2,000,000 per person per covered transplant procedure' Covered Services Covered at 100% of Heart eligible expenses Heart/Lung Lung (single and double) Liver Pancreas Kidney/Pancreas Small Intestine Autologous Bone Marrow Transplant Allogeneic Bone Marrow Transplant Organ Procurement Maximum $25,000 per transplant benefit period' Immunosuppressants Covered at 100% Transportation Maximum $10,000 per transplant benefit period (up to $200 per day for lodging and meal expenses)3 Private Nursing Care $10,000 per transplant benefit period Circulatory Assist Device Covered at 100% for Implants registered heart transplant candidates Complications/Expenses Covered at 100% Related to Disease/Cause of Transplant Re -transplantation Covered up to Plan's maximums 1 Refer to the insurance policy for information about two or more transplarns. 2 Includes surgical, storage and transportation costs incurred and directly related to the donation of an organ used in a covered transplant procedure. 3 Includes transportation to and from the site of a covered transplant procedure for the recipient and one other individual_ If the recipient is a minor, transportation includes the cost for two other individuals accompanying the recipient. This brochure is intended to provide only a summary of the benefits offered through the Western Cost Management Trust (WCMT). The actual Plan provisions may be found in the Plan's legal document. In the event of a conflict between the wording in this brochure and the legal document, the legal document shall govern. toil { { TAW, W x'. � x u } r E it wj 1 t 5 d.{¢ {Pc5"" P y4# ? k F L .0 x•4 lvl F `i p e { 1 ri 4 d t� f I 'T-SEGAL THE SEGAL COMPANY 6300 S. Syracuse Way Suite 750 Englewood, CO 80111-7302 T 303.714.9900 F 303.714.9990 www.segalco.com August 25, 2003 Mr. James B. O'Neill II, CPPO, FNIGP The City of Fort Collins Purchasing Department P. 0. Box 580 Fort Collins, Colorado 80522-0580 DIRECT DIAL NUMBER 303-714-9936 WRITER'S E-MAIL ADDRESS Lthompson@segalco.com Re: Western Cost Management Trust (WCMT) Organ and Bone Marrow Transplant Proposal — RFP P902 Benefits Dear Mr. O'Neill: This letter is to serve as the Proposal Compliance Letter required by the referenced RFP. The Segal Company's proposal completely adheres with the RFP specifications, except as specifically noted in the appropriate sections. Sincerely, 4 Leslie L. Thompson, FSA, MAAA, EA Senior Vice President cc: Susan K. Imming Theresa M. O'Shea 133122/01945.001 Benefits, Compensation and HR Consulting ATLANTA BOSTON CHICAGO CLEVELAND DENVER HARTFORD HOUSTON LOS ANGELES MINNEAPOLIS NEW ORLEANS NEW YORK PHILADELPHIA PHOENIX SAN FRANCISCO SEATTLE TORONTO WASHINGTON, DC M (i C Multinational Group of Actuaries and Consultants AMSTERDAM BARCELONA GENEVA HAMBURG JOHANNESBURG LONDON MELBOURNE MEXICO CITY OSLO PARIS SECTION III: CHECKLIST OF ITEMS INCLUDED WITH PROPOSAL See Attached Checklist CHECKLIST OF ITEMS INCLUDED WITH PROPOSAL Yes No Description of Item _X_ Proposal for Group Life Insurance, AD&D and Supplemental Life _X_ Proposal for Group Voluntary Life _X_ Proposal for Voluntary Group Life and AD&D _X_ Proposal for Group Long Term Disability _X_ Proposal for Group Dental _X_ Proposal for Vision Care _X Proposal for Transplant Coverage _X_ Proposal for Long Term Care _X_ Signed Proposal Compliance Letter _X_ Signed Plan Design Confirmation _X_ Completed and Signed Questionnaire(s) _X_ Dental Network Access Analysis (if applicable) _X_ Vision Network Access Analysis (if applicable) _X_ Copy of your EOB for Dental and/or Vision Services (if applicable) _X_ Proposed Implementation Timeline for The City. _X_ Audited Financial Statements and/or Department of Insurance filings for the past two years (Only if requested by The City) _X_ Provider "Report Cards" used to provide feedback on clinical and non -clinical performance measures _X_ Copy of your Policy Assuring Member Satisfaction _X_ Samples of all Standard and Optional Reports you are proposing to provide on an account specific basis _X_ Copy of your Banking Services Agreement _X_ Copy of your Customer Satisfaction Survey _X_ Copy of your Administrative Services Agreement or Insurance Contract that will be in effect January 1, 2004 Signature of Authorized Representative: City of Fort Collins, RFP 2003 SECTION W: PLAN DESIGN CONFIRMATION The City of Fort Collins currently participates in the Western Cost Management Trust Organ and Bone Marrow Transplant Program. Coverage for 2004 will remain the same as in 2003, unless the City of Fort Collins elects an alternate plan design available under the WCMT. a.w k�tt, a ao o 3 Signature Date