HomeMy WebLinkAboutRFP - P902 BENEFITS (3)REQUEST FOR PROPOSAL
CITY OF FORT COLLINS
Proposal Number
P902
Benefits
OPENING DATE: 2:00 p.m. (our clock), August 29, 2003
City of Fort Collins, RFP 2003
8.3 Miscellaneous
The City shall not infringe upon any intellectual property right of any vendor, but specifically
reserves the right to use any concept or methods contained in this proposal. Any desired
restrictions on the use of information contained in the proposal should be clearly stated.
Responses containing your proprietary data shall be safeguarded with the same degree of
protection as The City's own proprietary data. All such proprietary data contained in your
proposal must be clearly identified. Failure to respond due to the proprietary nature of data in
your response may be construed as non -responsive and could result in disqualification. The
City shall not be under any obligation to return any materials submitted in response to this RFP.
The City's contractual selection of a vendor is final. The methodology by which the proposals
are evaluated and vendors are selected is confidential and proprietary to The City.
The City expects to enter into a written Agreement (the "Agreement") with the chosen vendor
("Chosen Vendor") that shall incorporate this RFP into your proposal. The anticipated terms
and conditions of the Agreement are set forth in this RFP; however, The City may include
additional terms and conditions in the Agreement as deemed necessary.
Section 9.0 Proposal Checklist
The following information is requested as part of the proposal process. Please indicate your
included attachments by duplicating this checklist and marking the appropriate column (Yes or
No):
City of Fort Collins, RFP 2003
10
CHECKLIST OF ITEMS INCLUDED WITH PROPOSAL
Yes No Description of Item
Proposal for Group Life Insurance, AD&D and Supplemental Life
Proposal for Group Voluntary Life
Proposal for Voluntary Group Life and AD&D
Proposal for Group Long Term Disability
Proposal for Group Dental
Proposal for Vision Care
Proposal for Transplant Coverage
Proposal for Long Term Care
Signed Proposal Compliance Letter
Signed Plan Design Confirmation
Completed and Signed Questionnaire(s)
Dental Network Access Analysis (if applicable)
Vision Network Access Analysis (if applicable)
Copy of your EOB for Dental and/or Vision Services (if applicable)
Proposed Implementation Timeline for The City.
Audited Financial Statements and/or Department of Insurance
filings for the past two years (Only if requested by The City)
Provider "Report Cards" used to provide feedback on clinical and
non -clinical performance measures
Copy of your Policy Assuring Member Satisfaction
Samples of all Standard and Optional Reports you are proposing
to provide on an account specific basis
Copy of your Banking Services Agreement
Copy of your Customer Satisfaction Survey
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
tt
Section 10.0 Questionnaires
Questionnaires for each plan appear below. Please respond to each plan for which you wish to
be considered.
10.1 Group Lona Term Disabilitv (LTD
The City's fully -insured Group LTD Plan covers classified and non -classified employees who
work 20 or more hours per week. Uniformed police and fire employees are not eligible to
participate in this plan, but rather have separate coverage. Approximately 1,100 employees
are enrolled for LTD coverage. The current volume of coverage is approximately $4,355,200 in
monthly earnings. The current carrier has served The City since January 1, 1997, and has paid
$660,021.44 in total claims. The total disabled life reserve is $1,343,162.00.
The City pays 100% of premiums, and participation is mandatory for eligible employees. For
approved LTD claims, benefits are paid at 66 2/3% of base monthly salary, to a maximum
benefit of $4,500 per month. The plan provides for a 24-month own occupation disability, after
which benefits are continued if the claimant cannot work at any job for which he/she is
reasonably qualified on the basis of education, training and experience.
A copy of the current plan booklet is available upon request. It is expected that you will use this
booklet to duplicate exactly the current plan provisions. Deviations from current plan design
must be clearly stipulated as an addendum to the questionnaire. Please answer completely the
following questions.
A recent census and a list of benefit recipients are available upon request. Contact the
Purchasing Division at (970) 221-6775.
City of Fort Collins, RFP 2003
12
QUESTIONNAIRE
Group Long Term Disability
Please refer to plan booklet for current plan provisions.
1. Will you agree to cover without limitation all employees enrolled as of December 31, 2003?
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 group LTD vendor, you may be required to make the
necessary adjustments in order to achieve replication. Otherwise, your selection may
become void.
3. What is your fully insured premium rate for this coverage? Please express your premium
rate in terms of cents per $100 of base monthly salary. Premiums must be net of any
commissions or broker fees. If you are selected for multiple plans, will you offer discounted
premiums?
4. Include samples of claim payment reports, e.g., premiums vs. claims, etc.
5. Is there a toll -free number for employees to call with questions on plan provisions or claim
status? What is the average call waiting time?
6. What is the average length of time an employee waits for an inquiry to be answered fully?
7. What performance guarantees will you provide?
8. Specify clearly any conditions and circumstances that would be excluded from coverage.
9. Please refer to the checklist on page 10 for additional items to submit (e.g., audited financial
statements, etc.).
City of Fort Collins, RFP 2003
13
10.2 Group Life Insurance. AD&D and Supplemental Life
The City's fully insured Group Life/AD&D/Supplemental Life Insurance Plan covers classified
and non -classified employees who work 20 or more hours per week. Uniformed police and fire
employees are eligible to participate in this plan. Basic coverage is mandatory for each eligible
employee, and is 100% paid by The City. No retiree life insurance is available, except through
individual conversion. Waiver of premium is required.
Eligible employees may elect basic coverage in the amounts of $10,000 or one -times annual
base salary. Basic AD&D coverage is equal to the basic life amount. Employees may also elect
additional life and AD&D coverage in amounts of one-, two- or three -times base annual salary.
Spousal coverage is available in $25,000 increments up to $100,000. Dependent child
coverage is available in amounts of $5,000 or $10,000.
The guaranteed Basic Maximum Benefit is $100,000. The guaranteed issue amount for Basic
and Optional Life is $125,000. The combined maximum benefit is $500,000. Benefits reduce
by 30% at age 65; 50% at age 70; 70% at age 75; and 80% at age 80.
A recent census and a listing showing coverage volumes are available upon request.
Contact the Purchasing Division at (970) 221-6775.
The following table indicates the coverage amounts in effect and the number of enrolled
persons:
Plan
Coverage
# Enrolled
Volume ($)
Employee Life
$10,000
149
1,490,000
1-x salary
1,305
66,777,227
Employee AD&D
$10,000
149
1,490,000
1-x salary
1,305
66,777,227
Add'I 1-x
178
9,425, 543
Add] 2-x
82
8,265,225
Add'I 3-x
107
15, 091,410
Optional Employee
1-x salary
242
12,603,726
Life
2-x salary
113
11,197,150
3-x salary
128
18,059,185
Up to $125,000
1
19,000
Up to $125,000
1
30,000
Optional Spousal
$10,000
145
1,450,000
Life
$25,000
72
1,800, 000
$50,000
64
3,200,000
$75,000
20
1,500,000
$100,000
16
1,600,000
"This level of coverage no longer available for new electors; however, this level of coverage
must be continued for those who are already enrolled.
City of Fort Collins, RPP 2003
14
QUESTIONNAIRE
Group Life Insurance, AD&D and Supplemental Life
Please refer to plan booklet for current plan provisions.
1. Do you agree to cover without limitation all employees/dependents enrolled as of December
31, 2003?
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 group life vendor, you may be required to make the
necessary adjustments in order to achieve replication. Otherwise, your selection may
become void.
3. What is your fully insured premium rate for this coverage? Please express your premium
quote in terms of cents per covered $1,000 of base annual salary. Premiums must be net of
any commissions or broker fees. If you are selected for multiple plans, will you offer
discounted premiums?
4. Include samples of claim payment reports, e.g., premiums vs. claims, etc.
5. Is there a toll -free telephone number for employees to call with questions on plan provisions
or claim status?
6. What is the average length of time required to resolve fully an employee inquiry?
7. What performance guarantees will you provide?
8. Specify any situations that would result in a claim denial.
9. Please refer to the checklist on page 10 for additional items to submit (e.g., audited financial
statements, etc.).
City of Fort Collins, RFP 2003
15
10.3 Group Voluntary Life
In addition to basic and supplemental life insurance, employees may elect additional voluntary
life insurance coverage. This coverage is fully -insured and 100% employee paid. Applications
are subject to medical evidence. Smoker and non-smoker rates are in effect. A copy of the
current plan booklet is available upon request for specific plan provisions. Coverage is available
in $10,000 increments up to $300,000. Benefits must be portable. The following coverage
amounts are in effect.
Voluntary Life — Employee:
$67,240,000
Voluntary Life — Spousal:
28,500,000
Voluntary Life — Children:
1,000,075
Voluntary AD&D (Employees and Dependents)
13,000,060
QUESTIONNAIRE
Group Voluntary Life
Please refer to plan booklet for current plan provisions.
1. Do you agree to cover without limitation all employees/dependents enrolled on December
31, 2003?
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 voluntary life vendor, you may be required to make the
necessary adjustments in order to achieve replication. Otherwise, your selection may
become void.
3. What is your fully insured premium rate for this coverage? Please express your premium
quote in terms of cents per covered $1,000 of base annual salary. Premiums must be net of
any commissions or broker fees. If you are selected for multiple plans, will you offer
discounted premiums?
4. Include samples of claim payment reports, e.g., premiums vs. claims, etc.
5. Will you provide a toll free telephone number that employees can use to ask questions
about claims or plan provisions?
6. Please refer to the checklist on page 10 for additional items to submit (e.g., audited financial
statements, etc.).
City of Fort Collins, RFP 2003
16
10.4 Group Dental — Administrative Services Onlv
The City provides to eligible employees working 20 or more hours per week a choice between
comprehensive and basic group dental benefits. Benefits are self -funded, and the cost is
shared between The City and employees.
Currently, 254 employees are enrolled for basic coverage; 1,166 are enrolled for comprehensive
coverage; 72 employees have waived coverage. Enrollment distribution between tiers of
coverage is:
Level of Coverage
Basic
Comprehensive
Individual
87
347
w/child(ren)
25
61
w/spouse
61
267
w/family
81
402
Total
254
1166
A copy of the current plan booklet, census and claims experiences are available upon
request. Contact the Purchasing Division at (970) 221-6775.
QUESTIONNAIRE
Group Dental- Administrative Services Only
Please refer to plan booklet for current plan provisions.
1. Do you agree to provide without limitation services to all employees/dependents enrolled as
of December 31, 2003?
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 dental services provider, you may be required to make
the necessary adjustments in order to achieve replication. Otherwise, your selection
may become void.
3. What is your monthly administrative fee, expressed in terms of dollars per month per
employee?
4. For each geographic area in which you have a network applicable to employee population,
provide the following information:
• Geo-Access, using 2 dental providers in 10 miles; provide a map if available
• Most recent participating provider directory and summary of the number of participating
providers in each of the applicable areas (dentists, specialists, etc.) Also provide the
website where provider information can be found.
5. For each network, describe the specific measures used by your organization to monitor
participating provider access. Provide the most recent corresponding statistics available for:
• Dentist to member ratios
• Average waiting period for an appointment
City of Fon Collins, RFP 2003
17
QUESTIONNAIRE
Group Dental- Administrative Services Only (Cont.)
6. What percentage of your providers has limited their practice to current patients?
7. What is your organization's financial rating (e.g., Best & Co., S&P)?
8. Please describe your credentialing procedures.
9. What type of reimbursement/payment method(s) is used to reimburse participating
providers? Please provide a breakdown by method of review.
10. 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.
11. If provider discounts are used, state the basis of the agreement. Are discounts based on
provider charges or actual cost of service?
12. Is there a formal committee that sets quality assurance policy and review the outcome on a
regular basis?
13. Do you capture all utilization data?
14. What claims experience and utilization reports are available? If there is additional cost,
please specify.
15. Describe patient satisfaction surveys that you perform.
16. 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?
17. Please describe your method for calculating renewal rates.
18. Do you provide a toll -free number for employees to call with questions on claims, plan
provisions or requests for dentist referrals?
19. Do you provide a care line that employees can call with questions about proper levels of
care?
20. Will you perform pre-treatment estimates? If yes, what is your average turnaround time?
21. Will you provide COBRA services?
22. Please certify that you are in compliance with HIPAA privacy regulations, and include a copy
of your privacy statement or policy.
23. Please refer to the checklist on page 10 for additional items to submit (e.g., audited financial
statements, etc.).
City of Fort Collins, RFP 2003
10.5 Vision Care —Administrative Services ON
The City makes available to eligible employees working 20 or more hours per week a Vision
Care Plan. Benefits are self -funded, and employees pay 100% of the cost.
Currently, 730 employees are enrolled for coverage. Enrollment distribution between tiers of
coverage is:
Individual: 263
w/child(ren): 70
w/spouse: 214
w/family: 183
A copy of the current plan booklet, census and claims experiences are available upon
request. Contact the Purchasing Division at (970) 221-6775.
QUESTIONNAIRE
Vision Care — Administrative Services Only
Please refer to plan booklet for current plan provisions.
1. Do you agree to provide services to all employees/dependents enrolled as of December 31,
2003?
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.
3. What is your monthly administrative fee, expressed in terms of dollars per month per
employee?
4. For each geographic area in which you have a network applicable to employee population,
provide the following information:
• Geo-Access, using 2 vision providers in 10 miles; provide a map if available
• Most recent participating provider directory and summary of the number of participating
providers in each of the applicable areas (ophthalmologists, optometrists, opticians,
etc.). Also provide the website where provider information can be found.
5. For each network, describe the specific measures used by your organization to monitor
participating provider access. Provide the most recent corresponding statistics available for:
• provider to member ratios
• Average waiting period for an appointment
6. What percentage of your providers has limited their practice to current patients?
7. Please describe your credentialing procedures.
City of Fort Collins, RFP 2003
19
REQUEST FOR PROPOSAL
CITY OF FORT COLLINS
Proposal Number P902 - Benefits
The City of Fort Collins is seeking proposals from qualified firms for certain employee benefit
plans.
Written proposals, six (6) copies, will be received at The City's Purchasing Division, 215 North
Mason Street, 2nd Floor, Fort Collins, Colorado 80524. Proposals will be received before 2:00
p.m. (our clock), August 29, 2003. Reference Proposal No. P902. If delivered, they are to be
sent to 215 North Mason Street, 2nd Floor, Fort Collins, Colorado 80504. If mailed, the address
is P.O. Box 580, Fort Collins, Colorado 80522-0580.
Questions regarding the scope of the project should be directed to Vincent Pascale, Benefits
Administrator and Project Manager for this RFP, (970) 221-6828.
Questions regarding proposal submittal or process should be directed to David Carey, C.P.M.,
Buyer, (970) 416-2191.
A copy of the Proposal may be obtained as follows:
1. Call the Purchasing Fax -line, 970-416-2033 and follow the verbal instruction to
request document #30902.
2. Download the Proposal/Bid from the Purchasing Webpage,
www.fcgov.com/purchasing.
3. Come by Purchasing at 215 North Mason St., 2nd floor, Fort Collins, and request
a copy of the Bid.
Sales prohibited/Conflict of Interest: No officer, employee, or member of City Council shall have
a financial interest in the sale to The City of any real or personal property, equipment, material,
supplies or services where such officer or employee exercises directly or indirectly any decision -
making authority concerning such sale or any supervisory authority over the services to be
rendered. This rule also applies to subcontracts with The City. Soliciting or accepting any gift,
gratuity, favor, entertainment, kickback or any items of monetary value from any person who
has or is seeking to do business with The City is prohibited.
Collusive or sham proposals: Any proposal deemed to be collusive or a sham proposal will be
rejected and reported to authorities as such. Your authorized signature of this proposal assures
that such proposal is genuine and is not a collusive or sham proposal.
The City reserves the right to reject any and all proposals and to waive any irregularities or
formalities.
Sincerely,
&J &,-L
,James B. O'Neill II, CPPO, FNIGP
Director of Purchasing & Risk Management
City of Fort Collins, RFP 2003
2
QUESTIONNAIRE
Vision Care — Administrative Services Only (Cont.)
8. What type of reimbursement/payment methods is used to reimburse participating providers?
Please provide a breakdown by method of review.
9. 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.
10. If provider discounts are used, state the basis of the agreement. Are discounts based on
provider charges or actual cost of service?
11. Is there a formal committee that sets quality assurance policy and review the outcome on a
regular basis?
12. Do you capture all utilization data?
13. What claims experience and utilization reports are available? If there is additional cost,
please specify.
14. Describe patient satisfaction surveys that you perform.
15. 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?
16. Please describe your method for calculating renewal rates.
17. Do you provide a toll -free number for employees to call with questions on claims, plan
provisions or requests for dentist referrals?
18. Do you provide a care line that employees can call with questions about proper levels of
care?
19. Will you provide COBRA services?
20. Please certify that you are in compliance with HIPAA privacy regulations, and include a copy
of your privacy statement or policy.
21. Please refer to the checklist on page 10 for additional items to submit (e.g., audited financial
statements, etc.).
22. What is your organization's financial rating (e.g., Best & Co., S&P)?
City of Fort Collins, RFP 2003
20
10.6 Transplant Coverage
Except for kidney and cornea transplants, which are covered by the City of Fort Collins Group
Health Plan, covered transplants are provided through a pooled trust. Individual group
experience is not available. The City pays 100% of premiums for this coverage. All employees
and dependents enrolled for coverage under The City of Fort Collins Group Health Plan are also
enrolled for this separate transplant coverage.
A health plan census is available upon request. Contact the Purchasing Division at (970)
221-6775.
QUESTIONNAIRE
Transplant Coverage
Please refer to plan booklet for current plan provisions.
1. Do you agree to provide services to all employees/dependents enrolled as of December 31,
2003?
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.
3. What is your monthly administrative fee, expressed in terms of dollars per month per
employee?
4. For each geographic area in which you have a network applicable to employee population,
provide the following information:
5. Geo-Access, using 2 vision providers in 10 miles; provide a map if available
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.
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:
8. Provider to member ratios
9. Average waiting period for an appointment
10. What percentage of your providers has limited their practice to current patients?
11. Please describe your credentialing procedures.
City of Fort Collins, RFP 2003
21
QUESTIONNAIRE
Transplant Coverage (Cont.)
12. What type of reimbursement/payment methods is used to reimburse participating providers?
Please provide a breakdown by method of review.
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.
14. If provider discounts are used, state the basis of the agreement. Are discounts based on
provider charges or actual cost of service?
15. Is there a formal committee that sets quality assurance policy and review the outcome on a
regular basis?
16. Do you capture all utilization data?
17. What claims experience and utilization reports are available? If there is additional cost,
please specify.
18. Describe patient satisfaction surveys that you perform.
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?
20. Please describe your method for calculating renewal rates.
21. Do you provide a toll -free number for employees to call with questions on claims, plan
provisions or requests for dentist referrals?
22. Do you provide a care line that employees can call with questions about proper levels of
care?
23. Will you provide COBRA services?
24. Please certify that you are in compliance with HIPAA privacy regulations, and include a copy
of your privacy statement or policy.
25. Please refer to the checklist on page 10 for additional items to submit (e.g., audited financial
statements, etc.).
26. What is your organization's financial rating (e.g., Best & Co., S&P)?
City of Fort Collins, RFP 2003
22
10.7 Long Term Care
The City offers employees the opportunity to enroll for long term care coverage. These plans
are individual contracts. Approximately 25 contracts are currently in force. Due to the nature of
these contracts, it is likely that they will remain in force with the current carriers.
QUESTIONNAIRE
Long Term Care
1. How long has your organization offered long term care coverage?
2. How many contracts do you have currently in force?
3. How many contracts have been cancelled in the past two years, and what has been the
primary cause of cancellations?
4. Besides employees, which family members are eligible for coverage?
5. How much in benefits has been paid by your organization during the past two years?
6. What is your organization's financial rating (e.g., Best & Co., S&P)?
7. What type(s) of contract(s) do you offer? Please provide samples of your contracts.
8. Please provide a side -by -side comparison of your various plan options.
9. How are benefits funded (e.g., with life insurance, other)?
10. Will you accommodate payroll deducted contributions? Will you permit a single annual
payment at a discounted rate?
11. Will you provide a toll free telephone number for employees to call with questions about
claims and plan provisions?
12. Please indicate the method used to calculate premiums. Do premiums remain stable
through the life of the contract?
13. Please refer to the checklist on page 10 for additional items to submit.
City of Fort Collins, RFP 2003
23
Ali -
)'AGE 1
01TV OF FORT COLLINS
G"UP PDLICY 96544
CROUP LONG TERM DISABILITY CLAIMS SUMMARY
SUN LIFE ASSURANCE COMPANY
OF CANADA
d
AS OF SIMAY2003
FOR THE PERIOD OIJAN2002 TO
3114AY2003
CERTIFICATE
DATE OF
DATE
EXPIRY
NET MONTHLY
CLAIMS PAID
TOTAL
DISABLED
NUMBER CERTIFICATE NAME
----------------
BIRTH
DISABLED
DATE
BENEFIT
THIS PERIOD
CLAIMS PAID
LIFE RESERVE
-----------
OPEN AND APPROVED
ISFE81954
IIWES2003
16FE82019
3095.60
123.12
123.a2
140492.00
29FE011844
10MY2002
28FES2009
703.31
4462.63
4062.63
26" 1.00
26MIAY19Sa
01OCT2002
26MAY2023
1399.25
7010.02
7010.82
83063.00
07JUL1953
115EP200t
07JUL2010
2350.23
41677.41
41677.41
184264.00
09JAN1939
13JAN2001
0OCT2004
993.22
16894.74
26063.23
t6335.00
IISEP1950
22JAN2000
itSEP2015
1800.42
30743.14
67514,35
187212.00
OBSEP1947
04SEP1999
OSSEP2012
6-04-64
0*55.11
43141.49
St224.00
OSOCT1952
03FEB1999
CIOCT2017
1296.75
1872a.75
50306.70
138497.00
IONOV1856
221LUGID"
10NOV2021
1290.t6
22068.71
75968.49
176004.00
14SEP1947
OTAM199T
14SEP2012
2727.89
46375.80
190167.16
247392.00
t
�eA)
16306.57
197330.07
496II.76.10
1251504.00
13AUG1841
20NOV2002
IaFE82007
2509.16
4182.44
4182.41
•00
OMMAR1950
21MOV2001
ONMAR2015
IS1D.24
23362.81
23382.61
.00
14AUG1954
24MV200D
28NOV2010
1637.79
25200.24
3T346.76
.00
2TFF61962
04JUM200D
27FE02028
1750.63
07564.65
42015.11
.00
24MAV1938
21MAY1997
24KAY2003
767.74
13234.03
56450.21
.00
8795.06
83664.tT
163395.34
.00
25102.43
280995.114
660021.44
1261504.00
27A►R/949
04APA2008
27APR2Ot4
2024.10
.00
.00
B0623.00
06JUN1929
1214AR2009
IOJUK004
129.72
.00
.00
11035.00
21lO.82
.00
.00
91659.00
TOTAL PENo1nr
2183,12
.00
.00
81658.00
TOTAL
Y
DOR
r
C
N
un
Life FisT udai'
27256.25 260985.14 6600R1.44 1343162.00
EXPIRY DALE MAY BE EARLIER THAN GATE SHOWN DEPENDING ON CONTRACTUAL LIMETATJONS
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` PAGE 1
CITY OF FORT COLLINS D
i c:
J
GROUP POLICY NO, 98544
L !
m
FOR THE PERIOD OF OI JAN 1997 TO 30 JUN 2003
N
m
GROUP LIFE CLAIMS SUMMARY m
SUN LIFE ASSURANCE COMPANY OF CANADA LAJ
BASIC OPTIONAL r
CERTIFICATE CERTIFICATE GATE DATE DATE EIASIC OPTIONAL AOND ADNO
NUMBER NAME NOTIFIED APPROVED CLOSED LIFE LIFE AMOUNT AMOUNT 07N
DEATH CLAIMS
12AU00 C1997 16SEP1997 37,000 74,00 0 C
17JAN2001 OIFES2001 34,000 34,000 34,000 34,000
04SEP2002 10SEP2002 41,000 123,000 41,000 123,000
0514AY2003 22MAY2003 46,000 $1,000 0 0
OIMAY2003 20MAY2003 35,000 138.000 0 0 m
13OCT1998 080EC1998 27,000 O 27,000 O 0
28NDV2000 27DEC2000 67,000 67,000 0 O n
26JUN200I 27JUN2001 25,000 O O 0 D
06JUN2000 270U142000 53,000 O O 0 Z
13JAM1999 28JANISS9 68,000 O 0 O DD
D
_ TOTAL EMPLOYEE
433,ODD S27,000 402,000 157.000
l' OIAPR2003 30APR2003 10,000 O 0 O
SCAUG2000 IGAUG2000 10,000 0 0 O
17MAR2000 27NKP2000 10,000 0 0 O
ISMAY1996 18MAY1998 10,000 O 0 O
TOTAL DEPENDENT
l 40,000 0 0 O f1
30
V) 1� w
H
m N
m1 'U
Q
Ulm Wellesley Hills, Massachusetts-02491
L kAtlanda1"_ Sun Life Asswagc6 Company cS Csnadv is s
CITY OF FORT COLLINS
m GROUP POLICY NO. 8e544
a
FOR THE PER[00 OF 01 JAN 1997 TO 30 JUN 2003
GROUP LIFE CLAIMS SUMMARY
SUN LIFE ASSURANCE COMPANY Of CANADA
BASIC
OPTIONAL
CERTIFICATE CERTIFICATE OA7E DATE
DATE
BASIC
LIFE
OPTIONAL
LIFE
ADND
ANDUNT
AOND
AMOUNT
NUMBER MUK NOTIFIED APPROVED
CLOSED
WAIVER OF PREMIUA{ CLAIMS (EDB)
AS OF 30JUN2003
0SSEP1997 21DCT1997
22.400
44.800
O
0
O
0
0smv l9SB 19NOOiBBB
41.000
81.000
O
27FE82003 OSJUN2003
56.000
0
0
0
D
22JAN2008 26MR2009
32.000
0
0
0
16MAR 1998 041IM1898
74,000
0
TOTAL OPEN
225,400
125,e00
O
O
09JAH2002 1414AR2002
27APR2003
35.000
138,000
O
0
O.
10JU12001 04NOV2001
27MAR2003
34.000
94.000
0
O
OBNOV2001 04DEC2001
310EC2001
17,OOD
0
0
O
0
04.IUN19Sa 11SEP1S"
22NOV2002
10,000
O
TOTAL CLOSED
86,000
172,000
O
0
N
I
u
W •4i
din
_ yFI�OG>fal
Wassley Hits.• Mssaaclwsetls 02481
Sea LI1s Asswm9 CPMPN y 01 Caoldr Is •
n
m
ZD
D
t7
D
W
01/03/02
-
THURSDAY
TIME 08:18
VISION SERVICE PLAN -
COLORADO
PEXPJ110/EXPB2331
PAGE
3
GROUP UTILIZATION REPORT
STATE:
CO
SUMMARY
2063997
FORT COLLINS COLORADO, CITY OF
2 GROUPS REPORTING
_
_____
/`\X/ _____________
_________
_______________-__K_-_________________
________V-�___
PERIOD
NUMBER
GROSS
RETENTION
RETN
NET
CLAIMS
GAIN/LOSS
PLR
AVG CLAIMS
NBR
PAID
REV/
------------------------------------------------------------------------------------------------------------------------------------
COVERED
$
$
%
$
AMT
$
%
AMT
PAID
FREQ
MBR
1998
6,953
$88,523
$14,154
16
$74,369
$67,530
$6,839
91
$100.94
669
96
$12.73
1999
0
$0
$0
0
$0
$151
$151-
0
$75.50
2
0
$.00
2000
0
$347-
$0
0
$347-
$0
$347-
0
$.00
0
0
$.00
BAL.
12,002
$153,057
$24,529
16
$128,528
$122,249
$6,279
95
$101.45
1,205
100
$12.75
JAN
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
FEB
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
MAR
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
APR
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
MAY
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
JUN
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
JUL
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
AUG
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
SEP
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
OCT
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
NOV
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
DEC
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
LTM
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
ADJ
0
$0
$0
0
$0
$0
$0
CUR CON
12,002
$153,404
$24,529
16
$128,875
$122,249
$6,626
95
$101.45
1,205
100
$12.78
YTD
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
_______________________________
*MEMBERSHIP AVERAGES* I
__-_______
**********MEMBERS*********
___
_____________
*********SPOUSE*********
__ __________-__________
*********CHILD**********
REV/
CLM
IND.
PNLI
PERIOD
CLM
#
AVG MBR
CLM
#
AVG
SP
CLM
#
AVG
CH
DPT
PERIOD MBR
___________
AMT
RATE
-_______-___
PCTJ
AMT
CLMS
CLM PCT
AMT
CLMS
CLM
PCT
AMT
CLMS
CLM
PCT
PCT
1998
$12.73
$9.71 $11.55
961
JAN
___
$0
0
_______________________
$.00 0
$0
0
_-_____
$.00
0
_--____________________
$0
0
$.00
0
0
1999
$.00
$.00
$.00
251
FEB
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
2000
$.00
$.00
$.00
01
MAR
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
QTR1
$.00
$.00
$.00
01
APR
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
QTR2
$.00
$.00
$.00
01
MAY
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
QTR3
$.00
$.00
$.00
01
JUN
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
QTR4
$.00
$.00
$.00
01
JUL
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
LTM
$.00
$.00
$.00
01
AUG
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
CUR
$12.78
$10.19 $12.11
961
SEP
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
YTD
$.00
$.00
$.00
01
OCT
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
1
NOV
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
1
1
DEC
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
------------------------------------------------------------------------------------------------------------------------------------
1
TOT
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
*ASTERISK INDICATES ESTIMATES DUE TO NON OR PARTIAL PAYMENT 21,446
O1/03/02
-
THURSDAY
TIME 08:18
VISION SERVICE PLAN - COLORADO
PEXPJ110/EXPB2331
PAGE
3
GROUP
UTILIZATION REPORT
STATE: CO
SUMMARY
2063997
FORT COLLINS COLORADO,
CITY OF
2 GROUPS REPORTING
------------------------------------------------------------------------------------------------------------------------------------
PERIOD
NUMBER
GROSS
RETENTION
RETN
NET
CLAIMS
GAIN
LOSS
PLR AVG
CLAIMS
NBR PAID
REV/
------------------------------------------------------------------------------------------------------------------------------------
COVERED
$
$
B
$
AMT
$
%
AMT
PAID FREQ
MBR
1998
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
1999
7,439
$91,611
$16,297
18
$75,314
$75,314
$0
100
$.
8
1
$2.1
2000
8,071
$94,602
$17,351
18
$77,251
$77,251
$0
100
$94 .09
621
102
$2.155
BAL.
15,510
$186,212
$33,647
18
$152,565
$152,565
$0
100
$90.44
1,687
109
$2.17
JAN
670
$10,225
$1,439
14
$8,786
$8,786
$0
100
$91.52
96
143
$2.15
FEE
689
$7,465
$1,480
20
$5,985
$5,985
$0
100
$92.08
65
94
$2.15
MAR
643
$7,733
$1,381
18
$6,352
$6,352
$0
100
$81.44
78
121
$2.15
APR
690
$6,705
$1,482
22
$5,223
$5,223
$0
100
$84.24
62
90
$2.15
MAY
688
$6,280
$1,478
24
$4,802
$4,802
$0
100
$97.84
55
80
$2.15
JUN
685
$6,363
$1,471
23
$4,892
$4,892
$0
100
$7.
50
73
$2.15
JUL
708
$8,851
$1,521
17
$7,330
$7,330
$0
100
$99.05
74
105
$2.15
AUG
695
$7,948
$1,493
19
$6,455
$6,455
$0
100
$97.80
66
95
$2.15
SEP
691
$7,873
$1,489
19
$6,384
$6,384
$0
100
$95.28
67
97
$2.15
OCT
701
$8,587
$1,508
18
$7,079
$7,079
$0
100
$93.14
76
108
$2.15
NOV
700
$7,971
$1,504
19
$6,467
$6,467
$0
100
$96.52
67
96
$2.15
DEC
702 *
$7,348 *
$1,508
* 21*
$5,840
$5,840
$0
100
$84.64
69
98
$2.15
LTM
8,262 *
$93,349 *
$17,754
* 19*
$75,595
$75,595
$0
100
$91.63
825
100
$2.15
ADJ
0
$0
$0
0
$0
$0
$0
CUR CON
8,637 *
$97,001 *
$18,579
* 19*
$78,422
$78,422
$0
100
$92.04
852
99
$2.15
YTD
8,262 *
$93,349 *
$17,754
* 19*
$75,595
$75,595
$0
100
$91.63
825
100
$2.15
_______
______________________________________
*MEMBERSHIP AVERAGES* I
**********MEMBERS*********
___
_________________________
- *********SPOUSE*********
_______________________
*********CHILD**********
REV/
CLM IND.
PNLI PERIOD
CLM
#
AVG MBR
CLM
#
AVG
SP
CLM
# AVG
CH
DPT
PERIOD MBR
__
AMT RATE
____________________
PCTJ
AMT
CLMS
CLM PCT
AMT
CLMS
CLM
PCT
AMT
CLMS CLM PCT
PCT
1998
$.00
$.00 $.00
01
JAN
$5,335
__________
56
58
$1,302
18
$76.58
__
19
$2$879
22 $87.90
_
23
__
42
1999
$2.19
$10.12 $12.30
98
FEB
$3, 804
38
100.10
$100.10 58
$1,302
17
$76.58
26
$879
10 $87.90
15
42
2000
$2.15
$9.57 $11.72
991
MAR
$3,103
37
$83.86 47
$1,938
23
$84.26
29
$1,312
18 $72.88
23
53
QTR1
$2.15
$10.55 $12.70
971
APR
$3,297
38
$86.76 61
$1,041
13
$80.07
21
$526
17 $75.14
18
39
QTR2
$2.15
$7.23 $9.38
981
MAY
$2,072
23
$90.08 42
$2,204
25
$99.35
45
$526
7
13
58
QTR3
$2.15
$9.63 $11.77
971
JUN
$2,390
25
$95.60 50
$1,391
14
$99.35
28
$1,111
11 $101.00
101.00
22
50
QTR4
$2.15
$9.22 $11.37
971
JUL
$3,940
36
$109.44 49
$1,916
19
$100.84
26
$1,474
19 $77.57
26
51
LTM
$2.15
$9.15 $11.30
971
AUG
$2,385
24
$99.37 36
$1,181
12
$98.41
18
$1,850
30
45
64
CUR
$2.15
$9.08 $11.22
971
SEP
$2,778
30
$92.60 45
$2,013
19
$92.50
28
$1,680
102$96.77
18 $$93.33
27
55
YTD
$2.15
$9.15 $11.30
971
OCT
$3,385
36
$94.02 47
$2,013
22
$91.50
29
$1,680
18 $93.33
24
53
NOV
$2,947
27
$109.14 40
$1,993
23
$86.65
34
$1,527
17 $89.82
25
60
DEC
$3,338
38
$87.84 55
$808
11
$73.45
16
$1,694
20 $84.70
29
45
_
TOT
$38,774
408
$95.03 49
$18,910
216
$87.55
26
$17,912
201 $89.11
24
51
*ASTERISK INDICATES ESTIMATES DUE TO NON OR PARTIAL PAYMENT 22,926
O1/03/02 - THURSDAY TIME 08:18
GROUP 2106603 CONTRACT NUMBER 2063997 C
CONTRACT TYPE S (12063997 0001 0001 )
INDUSTRY TYPE
VISION SERVICE PLAN - COLORADO
GROUP UTILIZATION REPORT
FORT COLLINS COLORADO, CITY OF
CITY OF FT. COLLINS, COLORADO
CITY OF FT. COLLINS
PEXPJ110/EXPB2331 PAGE 1
STATE: CO
PERIOD
___
NUMBER
________
GROSS
RETENTION
______________________________________
RETN
NET
CLAIMS
GAIN/LOSS
_______________________________________
PLR AVG
CLAIMS
NBR PAID
REV/
------------------------------------------------------------------------------------------------------------------------------------
COVERED
$
$
$
$
AMT
$
%
AMT
PAID FREQ
MBR
1998
0
$0
$0
0
$0
$0
$0
0
$.00
0 0
$.00
1999
7,260
$90,089
$15,889
18
$74,200
$74,200
$0
100
$86.78
855 118
$2.1
2000
7,875
$92,471
$16,933
18
$75,538
$75,528
$0
100
$93.84
805 102
$2.15
5
BAL.
15,135
$182,560
$32,822
18
$149,738
$149,738
$0
100
$90.20
1,660 110
$2.17
JAN
664
$9,989
$1,427
14
$8,562
$8,562
$0
100
$91.09
94 142
$2.15
FEB
679
$7,444
$1,459
20
$5,985
$5,985
$0
100
$92.08
65 96
$2.15
MAR
632
$7,710
$1,358
18
$6,352
$6,352
$0
100
$81.44
78 123
$2.15
APR
672
$6,667
$1,444
22
$5,223
$5,223
$0
100
$84.
62 92
$2.15
MAY
679
$6,079
$1,459
24
$4,620
$4,620
$0
100
$85.56
54 80
$2.15
JUN
673
$6,298
$1,446
23
$4,852
$4,852
$0
100
$99.02
49 73
$2.15
JUL
692
$8,817
$1,487
17
$7,330
$7,330
$0
100
$99.05
74 107
AUG
682
$7,830
$1,466
19
$6,364
$6,364
$0
100
$97.91
65 95
$2.15
SEP
682
$7,809
$1,470
19
$6,339
$6,339
$0
100
$9.
66 97
$2.1
OCT
689
$8,525
$1,483
17
$7,042
$7, 042
$0
100
$93.89
75 109
$2.155
NOV
691
$7,891
$1,485
19
$6,406
$6,406
$0
100
$97.06
66 96
$2.15
DEC
691 *
$7,325 *
$1,485
* 20*
$5,840
$5,840
$0
100
$84.64
69 100
$2.15
LTM
8,126 *
$92,384 *
$17,469
* 19*
$74,915
$74,915
$0
100
$91.70
817 101
$2.15
ADJ
0
$0
$0
0
$0
$0
$0
CUR CON
8,126 *
$92,384 *
$17,469
* 19*
$74,915
$74,915
$0
100
$91.70
817 101
$2.15
YTD
8,126 *
$92,384 *
$17,469
* 19*
$74,915
$74,915
$0
100
$91.70
817 101
$2.15
__
_______ _____
*MEMBERSHIP AVERAGES* I
_________ ____
**********MEMBERS*********
__________ _____________
*********SPOUSE*********
__________
________________
*********CHILD**********
REV/
CLM IND.
PNLI PERIOD
CLM
#
AVG MBR
CLM
#
AVG
SP
CLM
# AVG
CH
DPT
PERIOD MBR
_________
AMT RATE
____________
PCTJ
________
AMT
_________
CLMS
CLM PCT
AMT
CLMS
CLM
PCT
AMT
CLMS CLM
PCT
PCT
$.00
01
JAN
$5,111
54
_ ___________________________
$94.64 57
$1,367
18
$75.94
19
$2,084
22 $94.72
23
43
1999
$2.19
$10.22 $12.40
981
FEB
$3,804
38
$100.10 58
$1,302
17
$76.58
26
,,312
10 $72.88
15
42
2000
$2.15
$9.59 $11.74
991
MAR
$3,103
37
$83.86 47
$1,938
23
$80.07
29
$1885
18 $80.45
23
53
QTRI
$2.15
$10.58 $12.72
971
APR
$3,297
38
$86.76 61
$1,041
13
$80.07
21
$885
11 $80.45
16
39
QTR2
$2.15
$7.26 $9.40
981
MAY
$1,890
22
$85.90 41
$2,204
25
$88.16
46
$526
7
13
59
QTR3
$2.15
$9.74 $11.88
971
JUN
$2,349
24
$97.87 49
$1,391
14
$99.35
29
,111
$1,474
101.00
11 $$77.57
22
51
QTR4
$2.15
$9.31 $11.46
971
JUL
$3,940
36
$109.44 49
$1,916
19
$100.84
26
$1,474
19 $96.33
26
51
LTM
$2.15
$9.22 $11.37
971
AUG
$2,293
23
$99.69 35
$1,181
12
$98.41
18
$2,890
30 $96.33
46
65
CUR
$2.15
$9.22 $11.37
971
SEP
$2,733
29
$94.24 44
$1,756
19
$92.42
29
$1,850
18 $102.77
27
56
YTD
$2.15
$9.22 $11.37
971
OCT
$3,348
35
$95.65 47
$2,013
22
$91.50
29
$1,680
18 $93.33
24
53
NOV
$2,886
26
$111.00 39
$1,993
23
$86.65
35
$1,527
17 $69.62
26
61
DEC
$3,338
38
$87.84 55
$808
11
$73.45
16
$1,694
20 $84.70
29
45
------------------------------------------------------------------------------------------------------------------------------------
TOT
$38,092
400
$95.23 49
$18,910
216
$87.55
26
$17,912
201 $89.11
25
51
*ASTERISK INDICATES ESTIMATES DUE TO NON OR PARTIAL PAYMENT 22,924
Proposal Number P902 — Benefits
The City of Fort Collins is seeking proposals from qualified firms for the following employee
benefit plans:
• Basic Group Life and AD&D — fully insured and completely employer paid
• Supplemental Group Life and AD&D — fully insured and completely employee paid
• Voluntary Group Life and AD&D — fully insured, portable and completely employee paid
• Group Long Term Disability — fully insured and completely employer paid
• Dental (comprehensive and basic) TPA Services — self -funded with cost shared by employer
and employees
• Vision Care TPA Services — self -funded and completely employee paid
• Transplant Benefits — currently fully insured and completely employer paid
• Long Term Care —fully insured individual contracts and completely employee paid
Single as well as multiple plan providers are encouraged to respond. Proposals may be on one
or multiple plans.
Current plan descriptions are available upon request. Included with this RFP are: census data,
claims experience and questionnaires. For each plan in your response, please answer the
respective questionnaire in the format provided. Rates must be quoted net of broker or other
commissions, since The City does not pay commissions.
The City intends to replicate current plan provisions. Your answers must be responsive to the
current plan design and questions posed; otherwise, your organization may be deemed non-
responsive and disqualified from consideration. If you are unable to administer the plans as
written, you must specify clearly and specifically where your response deviates from current
plan design.
Section 1.0 Proposal Requirements
1.1 General Description
The City provides employee benefits to approximately 1,450 active employees and
approximately 40 retirees.
The City is requesting proposals to administer its group life, disability, dental, vision care,
transplant and long term care plans. Some plans are self -funded, while others are fully insured.
In addition, some plans are 100% employer paid, some share the cost between the employer
and the employee, and some are 100% employee paid.
Based on the proposals received, The City may select one carrier/administrator for all plans, or
separate carriers/administrators.
The City believes that an essential factor in managing the cost/service/quality balance is the
relationship with each of its business partners. The City will review the selected vendor(s) as an
active partner in assuring employee satisfaction.
City of Fat Collins, RFP 2003
3
01/03/02 - THURSDAY TIME 08:18
GROUP 2106604 CONTRACT NUMBER 2063997 C
CONTRACT TYPE S (12063997 0002 0002 )
INDUSTRY TYPE
VISION SERVICE PLAN - COLORADO
GROUP UTILIZATION REPORT
FORT COLLINS COLORADO, CITY OF
CITY OF FORT COLLINS RETIREES
CITY OF FT. COLLINS
PEXPJ110/EXPB2331 PAGE 2
STATE: CO
PERIOD
______________________________________________________________________________________
NUMBER
GROSS
RETENTION
RETN
NET
CLAIMS
GAIN/LOSS
PLR
_______________________________
AVG CLAIMS
NBR
PAID
REV/
___________________________________________________________________________________________$___&
COVERED
$
$
g
$
AMT
_
A
--
PAID
FRE
MBR
1998
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
1999
179
$1,522
$408
27
$1,114
$1,114
$0
100
$101.27
11
61
$2.28
2000
196
$2,131
$418
20
$1,713
$1,713
$0
100
$107.06
16
82
$2.13
BAL.
375
$3,652
$825
23
$2,827
$2,827
$0
100
$104.70
27
72
$2.20
JAN
6
$237
$12
5
$225
$225
$0
100
$112.50
2
333
$2.00
FEB
10
$21
$21
100
$0
$0
$0
0
$.00
0
0
$2.
MAR
11
$23
$23
100
$0
$0
$0
0
$.00
0
0
$2.0909
APR
18
$38
$38
100
$0
$0
$0
0
$.00
0
0
$2.11
MAY
9
$201
$19
9
$182
$182
$0
100
$182.00
1
Ill
$2.11
JUN
12
$66
$25
38
$41
$41
$0
100
$41.00
1
83
$2.08
JUL
16
$34
$34
100
$0
$0
$0
0
$.00
0
0
$2.13
AUG
13
$118
$27
23
$91
$91
$0
100
$.00
1
77
$2.08
SEP
9
$64
$19
30
$45
$45
$0
100
$45
.00
1
111
$2.1111
OCT
12
$62
$25
40
$37
$37
$0
100
$37.00
1
83
$2
.08
NOV
9
$80
$19
24
$61
$
$0
100
$6.00
1
11
$2.11
DEC
11
$23
$23
100
$0
$0 $0
$0
0
$$
.00
0
0
0
$2.09
LTM
136
$967
$285
29
$682
$682
$0
100
$85.25
8
59
$2.10
ADJ
0
$0
$0
0
$0
$0
$0
CUR CON
511
$4,619
$1,110
24
$3,509
$3,509
$0
100
$100.26
35
68
$2.17
YTD
136
$967
$285
29
$682
$682
$0
100
$85.25
8
59
$2.10
---
---------------------------
*MEMBERSHIP AVERAGES* I
-
-----------------------------------------------
**********MEMBERS*********
*********SPOUSE*********
--------------------------------------
- -- -
*********CHILD**********
- -
REV/
CLM
IND.
PNLI
PERIOD CLM
#
AVG MBR
CLM
#
AVG
SP
CLM
#
AVG
CH
DPT
PERIOD MBR
'------- - ------
AMT
----
RATE
PCTJ
AMT
CLMS
CLM PCT
AMT
CLMS
CLM
PCT
AMT
CLMS
CLM
PCT
PCT
1998
$.00
$.00
$.00
0
JAN
$225
2
------------------'---
$112.50 100
-----------------------------
$0
0
$.00
0
_________________
$0
0
$.00
0
0
1999
$2.28
$6.22
$8.50
1001
FEB
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
2000
$2.13
$8.74 $10.87
1001
MAR
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
QTRI
$2.07
$8.32 $10.39
1001
APR
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
QTR2
$2.10
$5.71
$7.80
1001
MAY
$182
1
$182.00 100
$0
0
$.00
0
$0
0
$.00
0
0
0
QTR3
$2.11
$3.59
$5.69
1001
JUN
$41
1
$4.00 100
$0
0
$.00
0
$0
0
$.00
0
0
QTR4
$2.09
$3.06
$5.15
100�
JUL
$0
0
$.00 0
$
$0
0
$.00
0
$0
0
$.00
0
0
0
LTM
$2.10
$5.01
$7.10
1001
AUG
$91
1
$91.00 100
$0
0
$.00
0
$0
0
$.00
0
CUR
$2.17
$6.87
$9.03
1001
SEP
$45
1
$3.00 100
$0
0
$.00
0
$0
0
$.00
0
0
YTD
$2.10
$5.01
$7.10
1001
OCT
$37
1
$37.00 100
$0
0
$.00
0
$0
0
0
NOV
$61
1
$61.00 100
$0
0
$.00
0
$0
0
$.00
$.00
0
0
0
0
DEC
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
------------------------------------------------------------------------------------------------------------------------------------
TOT$682
8
$85.25 100
$0
0
$.00
0
$0
0
$.00
0
0
*ASTERISK INDICATES
ESTIMATES
DUE TO
NON OR PARTIAL
PAYMENT
22,925
• vsP
GROUP 10: 12063997 Summary
CONTRACT TYPE: ASP
GROUP TYPE: Individually Rated
NBR
GROSS
PERIOD
COVERED
$
2000
0
$0
2001
0
$0
2002
8,651
$102,988
JUN
732
$7,796
JUL
720
$8,698
AUG
730
$8.205
SEP
718
$6,876
OCT
723
$8,511
NOV
735
$6,723
DEC
733
$9,722
JAN
754
$12,358
FEB
749
$8,421
MAR
762
$7,360
APR
714
$8,178
MAY
739
$7,978
LTM
8,799
$102,826
ADJ
0
$0
CC
3,708
$44,296
YTD
3.708
$44,296
�ii21NENfBERSifIP>RffAGES:'?<
"�'!E:
REVI
CLM
IND
PNL
PERIOD
MBR
$
RATE
%
2000
$0.00
$0.00
$0.00
0
2001
$0.00
$0.00
$0.00
0
2002
$2.15
$9.75
$11.90
98
Q1
$2.15 $10.33
$12.48
98
02
$2.15
$8.97
$11.12
97
03
$0.00
$0.00
$0.00
0
04
$0.00
$0.00
$0.00
0
LTM
$2.15
$9.53
$11.69
98
CC
$2.15
$9.79
$11.95
97
YTD
$2.15
$9.79
$11.95
97
ADJ- Adjustments
CC- Current Contract
LTM- Last Twelve Months
FM • Year To Date
CLIENT U77LI2A770NREPORT
FOR: FORTCOLLLIVSCOLORADO, C1YYOF
UTIL0001
PAGE: 1
RUN DATE: 06 / 03 / 2003
RETENTION
RETN
NET
CLAIM
GAIN/
PLR
AVG CLM
# CLMS
PAID
REV/
$
%
$
$
LOSS $
%
COST
PAID
FREQ
MBR
$0
0.0
$o
$o
$o
o
$0.00
0
0
$0$0-00
$0
0.0
$0
$o
$0
0
$0.00
0
0
$0.00
$18,625
18.1
$84,363
$84,363
$0
100
$99.46
846
98
$2.15
$1,674
20.2
$6,222
$6,222
$0
100
$103.70
60
82
$2.15
$1,548
17.8
$7.150
$7,150
$0
100
$108.33
66
92
$2.15
$1,570
19.1
$6,635
$6,635
$0
100
$103.68
64
88
$2.15
$1,563
22.7
$5,313
$5,313
$0
100
$102.18
52
72
$2.18
$1,554
18.3
$6,956
$6,956
$0
100
$103.82
67
93
$2.15
$1.580
18.1
$7,142
$7,142
$0
100
$103.61
69
94
$2.15
$1,576
16.2
$8,146
$8,146
$0
100
$100.56
81
111
$2.15
$1,621
13.1
$10,737
$10,737
$0
100
$106.30
101
134
$2.15
$1,610
19.1
$6,811
$6,811
$0
100
$100.16
68
91
$2.15
$1,617
22.0
$5,743
$5,743
$0
100
$110.44
52
69
$2.15
$1,542
18.8
$6,637
$6,637
$0
100
$93.48
71
99
$2.16
$1,589
19.9
$6,390
$6,390
$0
100
$104.75
61
83
$2.15
$18,944
18.4
$83,882
$83,882
$0
100
$103.30
812
92
$2.15
$0
0.0
$o
$o
$0
0
$0.00
0
0
$0.00
$7,979
18.0
$36,317
$36,317
$0
100
$102.88
353
95
$2A5
$7,979
18.0
$36,317
$36,317
$0
100
$102.88
353
95
$2.15
..........._......:.
aJfE A S:<:
�::::..:::.�::
°:':.:: ::::
:.:::SROi15E>:::'::':::::_:_
:: :
»: `tjp.PrNDENIS:
:>:
CLMS
#
AVG
MBR
CLMS
#
AVG
SP
CLMS
#
AVG
DPT
SP+
PERIOD
$
CLMS
COST
%
$
CLMS
COST
%
$
CLMS
COST
%
DEP %
JUN
$3,609
37
$97.64
62
$1,542
13
$116.58
22
$1,071
10
$107.14
17
38
JUL
$3,639
34
$107.03
52
$2,012
18
$111.78
27
$1,499
14
$107.06
21
48
AUG
$3,427
33
$103.86
52
$1,272
11
$115.62
17
$1,936
20
$96.82
31
48
SEP
$1,927
22
$87.58
42
$2,016
16
$126.03
31
$1,370
14
$97.87
27
58
OCT
$3,824
36
$106.23
54
$2,274
20
$113.68
30
$858
11
$78.03
16
46
NOV
$4,062
39
$104.14
57
$2,324
23
$101.03
33
$757
7
$108.14
10
43
DEC
$5,284
47
$112.42
58
$1,652
20
$82.62
25
$1,210
14
$86.40
17
42
JAN
$5,591
47
$118.97
47
$1,826
20
$91.32
20
$3,319
34
$97.61
34
53
FEB
$3,745
38
$98.56
56
$2,535
23
$110.21
34
$531
7
$75.82
10
44
MAR
$2,981
28
$114.67
50
$1,806
15
$107.09
29
$1,155
11
$105.03
21
50
APR
$3,131
36
$86.96
51
$1,163
10
$116.33
14
$2,343
25
$93.72
35
49
MAY
$2,934
26
$112.86
43
$1,424
16
$88.98
2$
$2,032
19
$106.94
31
57
TOT
$44,154
421
$104.88
52
$21,646
205
$105.59
25
$18,081
186
$97.21
23
48
Passion for people. Vision for life. SM
archive.TXT
01/03/03 - FRIDAY TIME 16:29 VISION SERVICE PLAN - COLORADO
PEXPJ110/EXPB2331 PAGE 3
GROUP UTILIZATION REPORT
STATE: CO
SUMMARY 2063997
FORT COLLINS COLORADO, CITY OF
2 GROUPS REPORTING
------------------------------------------------------------------------------------
------------------------------------------------
PERIOD
NUMBER
GROSS
RETENTION
RETN
NET
CLAIMS
GAIN/LOSS PLR AVG CLAIMS
NBR PAID REV/
COVERED
$
$
%
$
AMT
------------------------------------------------------------------------------------
------------------------------------------------
$
%
AMT
PAID
FREQ
MBR
1999
7,439
$91,611
$16,297
18
$75,314
$75,314
$0
100
$86.97
866
116
$2.19
2000
8,071
$94,602
$17,351
18
$77,251
$77,251
$0
100
$94.09
821
102
$2.15
2001
8,262
$93,350
$17,754
19
$75,596
$75,596
$0
100
$91.63
825
100
$2.15
BAL.
23,772
$279,561
$51,401
18
$228,160
$228,160
$0
100
$90.83
2,512
106
$2.16
JAN
726
$10,458
$1,560
15
$8,898
$8,898
$0
100
$102.28
87
120
$2.15
FEB
697
$7,010
$1,504
21
$5,506
$5,506
$0
100
$90.26
61
88
$2.16
MAR
710
$9,267
$1,526
16
$7,741
$7J41
$0
100
$92.15
84
118
$2.15
APR
714
$8,962
$1,535
17
$7,427
$7,427
$0
100
$101.74
73
102
$2.15
MAY
713
$8,758
$1,532
17
$7,226
$7,226
$0
100
$86.02
84
118
$2.15
JUN
732
$7,795
$1,573
20
$6,222
$6,222
$0
100
$103.70
60
82
$2.15
JUL
720
$8,697
$1,547
18
$7,150
$7,150
$0
100
$108.33
66
92
$2.15
AUG
730
$8,204
$1,569
19
$6,635
$6,635
$0
100
$103.67
64
88
$2.15
SEP
718
$6,875
$1,562
23
$5,313
$5,313
$0
100
$102.17
52
72
$2.18
OCT
723
$8,509
$1,553
18
$6,956
$6,956
$0
100
$103.82
67
93
$2.15
NOV
735
$8,721
$1,579
18
$7,142
$7,142
$0
100
$103.51
69
94
$2.15
DEC
733 *
$9,721
*
$1,575
* 16*
$8,146
$8,146
$0
100
$100.57
81
111
$2.15
LTM
8,651 *
$102,977
*
$18,615
* 18*
$84,362
$84,362
$0
100
$99.48
848
98
$2.15
ADJ
0
$0
$0
0
$0
$0
Page 1
archive.TXT "
$0
CUR CON 17,288 *
$0 100 $95.76
YTD 8,651 *
$0 100 $99.48
$199,979 * $37,194 * 19*
1,700 98 $2.15
$102,977 * $18,615 * 18*
848 98 $2.15
$162,785
$84,362
$162,785
$84,362
------------------------------------------------------------------------------------
------------------------------------------------
*MEMBERSHIP
AVERAGES* ;
**********MEMBERS*********
*********SPOUSE*********
*********CHILD**********
REV/
CLM
IND.
PNL;
PERIOD
CLM
#
AVG
MBR
CLM #
AVG SP
CLM
#
AVG CH DPT
PERIOD MBR
AMT
RATE
PCT;
AMT
CLMS
CLM
PCT
AMT
CLMS CLM
------------------------------------------------------------------------------------
PCT
AMT
CLMS
CLM PCT PCT
------------------------------------------------
1999 $2.19
$10.12
$12.30
98;
JAN
$4,576
50
$91.52
57
$2,337
18 $129.83
21
$1,985
19
$104.47 22
43
2000 $2.15
$9.57
$11.72
99:
FEB
$2,587
27
$95.81
44
$1,525
16 $95.31
26
$1,394
18
$77.44 30
56
2001 $2.15
$9.15
$11.30
97:
MAR
$3,169
40
$79.22
48
$1,891
19 $99.52
23
$2,681
25
$107.24 30
52
QTR1 $2.15
$10.38
$12.52
97:
APR
$3,918
36
$108.83
49
$1,267
12 $105.58
16
$2,242
25
$89.68 34
51
QTR2 $2.15
$9.67
$11.81
98i
MAY
$4,328
48
$90.16
57
$2,300
28 $82.14
33
$598
8
$74.75 10
43
QTR3 $2.16
$8.81
$10.96
99:
JUN
$3,609
37
$97.54
62
$1,542
13 $118.61
22
$1,071
10
$107.10 17
38
QTR4 $2.15
$10.15
$12.29
97:
JUL
$3,639
34
$107.02
52
$2,012
18 $111.77
27
$1,499
14
$107.07 21
48
LTM $2.15
$9.75
$11.89
98:
AUG
$3,427
33
$103.84
52
$1,272
11 $115.63
17
$1,936
20
$96.80 31
48
CUR $2.15
$9.42
$11.55
971
SEP
$1,927
22
$87.59
42
$2,016
16 $126.00
31
$1,370
14
$97.85 27
58
YTD $2.15
$9.75
$11.89
98:
OCT
$3,824
36
$106.22
54
$2,274
20 $113.70
30
$858
11
$78.00 16
46
NOV
$4,062
39
$104.15
57
$2,324
23 $101.04
33
$757
7 $108.14 10
43
DEC
$5,284
47
$112.42
58
$1,652
20 $82.60
25
$1,210
14
$86.42 17
42
TOT
$44,350
449
$98.78
53
$22,412
214 $104.73
------------------------------------------------------------------------------------
------------------------------------------------
25
$17,601
185
$95.14 22
47
*ASTERISK INDICATES ESTIMATES DUE TO NON OR PARTIAL PAYMENT
24,421
U
Page 2
— 0T/01/03 07:46 FAX _ Z 002
Delta Dental Plan of Colorado 07101/03
Self -Funded Group Information
Group Number. 001867
Effective,
09101W
Group Name: City
Of Fort Collins
Tenninats:
Anniversary:
Jan
Admin
Number of
Number of
Month
Eligibles
Fee
Claims
Paw Claims
Processed Claims
Jan 2001
984
2,670.50
33,568.84
345
415
Feb 2001
1,001
2,697.70
39.602.76
380
430
Mar 2001
991
2,802.55
45,592.70
418
492
Apr 2001
991
2,626.16
43,278.18
426
479
May 2001
997
2,679.15
40,814.87
385
441
Jun 2001
993
2,626.16
46,114.18
415
473
Jul 2001
1,011
2,761.30
33,090.89
364
411
Aug 2001
1,011
2,679.15
46,571.17
450
530
Sep 2001
1,008
2.636.75
40,087.20
333
374
Oct 2001
1,010
2,700.35
37,935.13
381
461
Nov 2001
1,016
2.718.90
42.698.17
411
458
Dec 2001
1,017
2.703.00
36,986.30
366
437
Totals for 12 mitts.
12,028
$32,001.86
i486,338.59
46874
51401
grouptnfosf.frx
07/01/03 07:46 FAX _ 9 003
Delta Dental Plan of Colorado 07/01/03
Self -Funded (croup Information
Group Number.
001867
Effective.
01101197
Group Nanw:
City Of Fort Collins
Termhuita
Anniversary:
Jan
Admin
Number of
Number of
Month
Eligibles
Fee
Claims
Paid Claims
Pmcessed Claims
Jan 2002
1,033
2,990.35
43,279.71
356
410
Feb 2002
1,030
2,891.62
47,780.80
425
471
Mar 2002
1,OB3
3,371.94
52,446.70
434
493
Apr 2002
1,097
3,169.18
53,440.62
445
491
May 2002
1,099
3,116.71
55,476.39
467
536
Jun 2002
1,109
3,149.90
58,200.01
464
516
Jul 2002
1,109
3,105.70
52,025.16
433
480
Aug 2002
1,125
3,123.30
55,805.67
457
505
Sep 2002
1,127
3,135.94
46,449.75
383
433
Oct 2002
1,144
3,085.18
55,472.60
476
550
Nov 2002
1,135
3,180.59
51,837.70
457
600
Dec 2002
1,185
3,200.63
59,649.41
484
646
Totals for 12 mft. 13XS $37,511.34
$636,884.62 3,Z81 $1930
yrowinfosf. frx
— 07/01/03 07:46 FAE -- _--` 9004
Delta Dental Plan of Colorado 07/01/03
Self -Funded Group lnbrmation
Group Number.
001857
EffectWe:
01/01W
Group Name:
City Of Fort Collins
Terminate:
Anniversary:
Jan
Admin
Number of
Number of
Month
Eligibles
Fee
Claims
Paid Claims
Processed Claims
Jan 2003
1.167
3,612.48
49,647.20
411
466
Feb 2003
1.175
3,711.06
62.205.90
498
547
Mar 2003
1.151
3,733.32
40,213.36
322
361
Apr 2003
1,154
3,663.38
63,514.83
502
563
May 2003
1.153
3,686.54
53,24220
421
470
Totals for 5 mthe, 6,800
$161366.76
$26%723A8
21154
2,396
groupinfosf.fxx
07/01/03 07:46 FAX
— — ----- 9003
Delta Dental Plan of Colorado 07/01103
Self -Funded Group Information
Group Number.
004856
Effectiva:
01101/97
Group Name:
City Of Fort Colftns
Terminate:
Anniversary:
Jan
Admin
Number of
Number of
Month
84Ibles
Fee
Claims
Paid Claims
Processed Claims
Jan 2001
302
70.85
3,352.00
56
67
Feb 2001
293
752.60
3,644.30
71
84
Mar 2001
268
734.05
4,232.20
73
88
Apr 2001
288
763.20
4,144.46
61
75
May 2001
286
739.35
5,329.10
84
96
Jun 2001
281
742.00
4.124.70
70
79
Jul 2001
283
760.55
3,266.30
61
71
Aug 2001
283
752-80
6,145,52
92
106
Sep 2001
281
739.35
3,817.20
65
77
Oct 2001
282
749.95
4,896.20
78
88
Nov 2001
284
723.46
4,747.00
92
107
Dee 2001
284
750.55
3,69620
69
78
Totals for 12 mths. 3,454
$9,015.30
$51,244.86
871
1,013
yzoupinfoaf.fzx
07/01/03 07:46 FAX
- — — _. __._ - — —• — — ----- — 9 006
Doha Dental Plan of Colorado 07/01/03
Self -Funded Group Information
Group Number:
0018N
Effe d":
0110t197
Group Name:
City OF Port Collins
Terminate:
Anniversary:
Jan
Admin
Number of
Number of
Month
Eligibles
Fee
Claims
Paid Claims
Processed Claims
Jan 2002
285
$05.84
6,129.42
72
85
Fab 2002
284
797.72
4,617.40
71
83
Mar 2002
263
584.26
3,867.30
58
68
Apr 2002
261
711.49
4,007,70
63
76
May 2002
260
715.11
4,407.70
65
79
Jun 2002
266
771.76
4,637.30
70
79
Jul 2002
266
748.59
3,706-40
55
66
Aug 2002
260
701.16
6,036.40
61
92
Sep 2002
260
726.03
4,137.32
68
73
Oct 2002
261
758.07
4.439.84
61
68
Nov 2002
250
729.70
3,558.90
57
65
Dec 2002
290
732.52
3,493.60
60
74
Totals for 12 mths. 3,214
$8,783.26
$51,936.88
781
908
groupinfasf.frx
07/01/03 07:47 FAX
Z 007
Delta Dental Plan of Colorado
07/01/03
Salt -Funded Group Information
Group Number. 00180
Effodm;
011MW
Group Name: City Of Fort Collins
Torminats:
Anniversary:
Jan
Admin
Number of
Number of
Month Eligibim
Fee
Claims
Paid Claims
Processed Claims
Jan 2003 263
826.80
4,809.00
69
80
Feb 2003 266
836.34
5,43&30
83
92
Mar 2003 263
855.42
3,990.40
61
89
Apr 2003 265
839.52
6,052.80
73
85
May 2003 283
842.70
2,675-10
45
55
Totals for 5 mft. 1,320
$4,200.78
$22,986.60
331
381
frx
1.2 Timetable
The following is a proposed timetable developed for this project. You will be notified of any
significant changes which might occur:
The City releases RFP to vendors
Written questions due to The City
Proposals due to The City
Finalist vendors notified
Onsite evaluations of finalists (if necessary)
Finalist negotiations (completed)
Selection of recommended vendors
Plan effective date
1.3 Proposal Submittals
August 7, 2003
August 20, 2003
August 29, 2003, 2:00 P.M. (our clock)
September 15, 2003
September 22, 2003
September 29, 2003
October 6, 2003
January 1, 2004
Your proposal must clearly indicate the name of the responding organization, as well as the
name, address and telephone number of the primary contact at your organization for this
proposal. Your proposal must include the contact name for local service and account
management whom the City can call directly.
Please submit your proposal no later than 2:00 p.m. (our clock) on August 29, 2003. Submit
six (6) copies of your proposal to:
Mr. James B. O'Neill II, CPPO, FNIGP
The City of Fort Collins
Purchasing Department
215 North Mason Street, 2nd Floor
Reference RFP P902
PO Box 580
Fort Collins, Colorado 80522-0580
Questions regarding this RFP are due to The City no later than August 20, 2003. A written
response to substantive questions will be provided to all proposers.
The City assumes no responsibility for liability for any costs you may incur in responding to this
RFP, including attending meetings, site visits or negotiations.
1.4 Deviations from RFP Specifications
All responses to this RFP must be prepared in accordance with the Proposal Requirements set
forth in Section IV of this RFP. The City reserves the right to refuse any proposal not
prepared according to the Proposal Requirements of Section 1.5.
The City retains the right to directly negotiate the finer points of your proposal that comply in
spirit with this RFP and that satisfy The City's objectives for effective, interactive and proactive
claims and (where applicable) network administration. The City shall not be bound to accept the
proposal with the lowest price. The RFP may be amended or revoked at any time prior to final
execution of an Agreement by The City.
City of Fort Collins, RFP 2003
4
ADC50 Enrollee and Dependents
List
29/JUL/2003
Page 1
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 090 Voluntary AD&D
Group 006518-0099 CITY OF FORT COLLINS
Cart No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
O1/01/1996
A
02/12/1953
M
03
S
100,000.00
O1/01/2001
A
03/19/1960
M
03
S
150,000.00
06/01/2000
A
12/06/1964
M
03
F
100,000.00
01/01/1996
A
08/08/1961
F
03
F
50,000.00
O1/01/1996
A
12/06/1952
M
03
F
150,000.00
01/01/1998
A
12/11/1941
F
03
S
100,000.00
O1/01/1996
A
12/15/1942
M
03
F
100,000.00
O1/01/1996
A
12/30/1942
F
03
S
20,000.00
02/01/2000
A
04/30/1970
M
03
S
60,000.00
01/01/1996
A
06/26/1951
M
03
F
50,000.00
O1/01/1996
A
12/06/1950
M
03
F
100,000.00
° OS/01/2002
A
05/20/1977
F
03
S
40,000.00
01/01/1996
A
03/23/1964
P
03
F
70,000.00
•
09/01/1999
A
05/27/1973
F
03
F
50,000.00
O110111996
A
12/29/1949
M
03
S
100,000.00
12/01/2000
A
06/07/1957
M
03
S
140,000.00
O1/01/1996
A
12/15/1964
F
03
S
100,000.00
O1/01/1996
A
12/27/1955
M
03
F
50,000.00
O1/01/1996
A
12/27/1956
M
03
F
120,000.00
>"
01/01/1996
A
07/29/1969
M
03
F
40,000.00
O1/01/1996
A
04/04/1957
M
03
F
20,000.00
O1/01/1997
A
12/31/1960
M
03
F
150,000.00
05/01/1999
A
04/25/1969
M
03
S
100,000.00
01/01/1996
A
09/13/1954
M
03
F
100,000.00
01/01/1996
A
O8/02/1968
F
03
S
50,000.00
05/01/1999
A
08/07/1961
M
03
F
100,000.00
08/01/2001
A
05/28/1963
F
03
F
100, 000.00
O1/01/1996
A
04/26/1947
M
03
F
100,000.00
•
01/01/1996
A
12/17/1947
F
03
F
80,000.00
03/01/1997
A
O1/31/1947
F
03
F
60,000.00
O1/01/1998
A
11/16/1955
F
03
F
70,000.00
02/01/1997
A
06/28/1963
M
03
F
150,000.00
•
01/01/1996
A
12/05/1947
F
03
F
150,000.00
O1/01/1996
A
05/27/1951
M
03
F
80,000.00
O1/01/1996
A
11/20/1953
M
03
F
100,000.00
01/01/2002
A
08/03/1946
F
03
F
10,000.00
O1/01/1996
A
12/14/1951
M
03
F
150,000.00
O1/01/1996
A
12/27/1942
F
03
S
60,000.00
05/01/1997
A
08/26/1963
M
03
S
70,000.00
O1/01/1996
A
12/17/1947
M
03
S
100,000.00
O1/01/1996
A
03/19/1951
M
03
S
50,000.00
06/01/2000
A
09/03/1944
M
03
F
50,000.00
01/01/1996
A
03/20/1958
F
03
F
100,000.00
O1/01/1996
A
10/06/1958
M
03
S
100,000.00
12/01/2002
A
11/12/1964
M
03
S
100.000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 2
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 090 Voluntary AD&D
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
03/01/2003
A
07/10/1974
M
03
F
150,000.00
O1/01/1999
A
06/04/1953
M
03
F
50,000.00
01/01/1996
A
12/04/1954
M
03
F
70,000.00
O1/01/1996
A
12/04/194G
M
03
F
40,000.00
O1/01/1996
A
05/06/1960
M
03
F
100,000.00
08/01/2002
A
09/29/1957
M
03
S
150,000.00
03/01/1997
A
07/31/1970
M
03
F
140,000.00
06/01/2000
A
02/20/1972
F
03
F
150,000.00
12/01/1997
A
03/22/1971
M
03
S
150,000.00
O1/01/1996
A
11/21/1941
F
03
F
150,000.00
O1/01/1996
A
02/19/1969
M
03
S
150,000.00
° 01/01/1996
A
12/10/1954
M
03
S
150,000.00
09/01/2002
A
12/18/1957
F
03
F
100,000.00
01/01/1996
A
12/08/1951
M
03
F
100,000.00
10/01/2001
A
10/19/1972
M
03
S
90,000.00
O1/01/1996
A
12/28/1967
F
03
F
50,000.00
01/01/1996
A
07/06/1952
M
03
F
150,000.00
01/01/2000
A
04/21/1965
M
03
F
150,000.00
01/01/1996
A
12/21/1946
M
03
F
80,000.00
08/01/1999
A
10/21/1963
F
03
S
50,000.00
O1/01/2002
A
08/22/1972
F
03
S
150,000.00
O1/01/1997
A
12/21/1966
M
03
S
50,000.00
O1/01/1996
A
12/02/1949
M
03
F
150,000.00
04/01/1997
A
06/13/1967
M
03
S
150,000.00
06/01/2002
A
10/05/1962
F
03
F
100,000.00
01/01/1996
A
09/08/1964
F
03
F
150,000.00
01/01/1997
A
06/17/1935
F
03
F
50,000.00
06/01/2003
A
09/11/1977
F
03
F
50,000.00
` 01/01/199G
A
05/09/1956
M
03
F
100,000.00
10/01/2002
A
10/27/1956
M
03
S
50,000.00
01/01/1996
A
09/17/1965
M
03
S
80,000.00
O1/01/1996
A
06/22/1952
M
03
F
120,000.00
" 01/01/1996
A
10/13/1964
M
03
S
100,000.00
O1/01/1996
A
09/23/1970
M
03
S
30,000.00
_ 01/01/1996
A
06/19/1969
M
03
F
40,000.00
O1/01/1996
A
09/11/1960
M
03
F
100,000.00
12/01/2002
A
02/15/1954
M
03
F
100,000.00
01/01/1996
A
12/07/1957
M
03
F
150,000.00
O1/01/2001
A
06/O6/1976
F
03
S
100,000.00
07/01/1996
A
04/05/1950
M
03
F
100,000.00
O1/01/1996
A
12/20/1953
M
03
F
100,000.00
03/01/1996
A
06/16/1963
M
03
F
100,000.00
08/01/2003
A
07/08/1966
F
03
S
150,000.00
02/01/2001
A
09/28/1950
M
03
S
10,000.00
O1/01/1996
A
12/02/1951
M
03
F
100.000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 3
------ ---------------------------------------- ___-------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 090 Voluntary ADSD
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
volume
12/01/2000
A
07/06/1950
M
03
F
150,000.00
O1/01/1996
A
12/10/1953
M
03
F
50,000.00
02/01/2002
A
05/09/1958
M
03
F
50,000.00
O1/01/1997
A
12/30/1948
M
03
F
100,000.00
O1/01/1996
A
02/23/1974
M
03
S
50,000.00
O1/01/1996
A
12/19/1954
M
03
F
100,000.00
O1/01/1996
A
12/09/1954
M
03
F
150,000.00
O1/01/1996
A
12/18/1966
M
03
F
100,000.00
O1/01/1996
A
12/08/1952
F
03
F
150,000.00
12/01/2002
A
10/21/1969
F
03
S
100,000.00
08/01/2002
A
09/06/1970
M
03
F
150,000.00
• 10/01/2000
A
02/01/1967
M
03
F
100,000.00
01/01/1996
A
05/16/1971
M
03
S
150,000.00
10/01/2002
A
08/17/1979
M
03
S
10,000.00
05/01/2002
A
11/24/1952
F
03
F
100,000.00
O1/01/1996
A
12/31/1964
M
03
F
100,000.00
O1/01/1996
A
09/13/1949
M
03
S
50,000.00
O1/01/1997
A
12/17/1941
F
03
F
130,000.00
O1/01/1996
A
07/14/1960
M
03
F
120,000.00
02/01/1996
A
12/27/1947
F
03
F
40,000.00
05/01/2003
A
11/02/1965
F
03
F
40,000.00
05/01/2002
A
10/29/1964
M
03
F
100,000.00
07/01/1997
A
06/25/1970
M
03
S
70,000.00
01/01/1997
A
12/03/1954
M
03
F
150,000.00
01/01/1996
A
12/23/1959
M
03
F
30,000.00
03/01/2001
A
08/09/1959
F
03
F
100,000.00
02/01/1996
A
07/25/1965
M
03
F
70,000.00
02/01/1996
A
02/20/1967
M
03
S
100,000.00
•
01/01/1996
A
11/23/1951
M
03
F
150,000.00
05/01/1999
A
05/20/1965
F
03
S
150,000.00
01/01/1997
A
12/18/1968
M
03
F
100,000.00
O1/01/1997
A
04/16/1948
M
03
S
50,000.00
.,
01/01/1996
A
12/16/1946
M
03
F
110,000.00
O1/01/1996
A
12/11/1948
F
03
S
50,000.00
12/01/1997
A
12/18/1952
M
03
F
50,000.00
O1/01/1996
A
12/25/1951
F
03
S
100,000.00
03/01/1999
A
07/22/1957
F
03
F
90,000.00
O1/01/1996
A
07/18/1942
M
03
F
20,000.00
09/01/1996
A
03/31/1962
F
03
F
50,000.00
01/01/1997
A
03/06/1957
M
03
S
100,000.00
09/01/1999
A
04/21/1970
M
03
F
150,000.00
02/01/2002
A
O1/22/1970
F
03
S
30,000.00
O1/01/1999
A
12/27/1958
M
03
F
30,000.00
O1/01/1996
A
08/02/1971
F
03
S
50,000.00
O1/01/1999
A
O8/14/1944
M
03
F
30,000.00
ADC50
Enrollee and Dependents List
-----------------------------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 090 Voluntary AD&D
r,roup 006518-0099 CITY OF FORT COLLINS
29/JUL/2003
affective Status Birthday Sex Relation
2/01/1998 A 12/29/1959 M
1/01/1996 A 12/23/1953 M
1/01/2000 A 08/13/1947 F
1/01/2001 A 04/22/1954 M
9/01/1999 A O1/14/1961 F
1/01/1996 A 12/25/1947 M
Page 4
Terminated Class
E-type
Volume
03
F
150,000.00
03
F
100,000.00
03
S
110,000.00
03
F
150,000.00
03
F
40,000.00
03
F
100,000.00
141 13,060,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 5
Company : 004 Anthem Life Insurance Company
Country : 01 United States
Coverage: 110 Voluntary Life - Employee
"9518-0099 CITY OF FORT COLLINS
ffective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
/01/1993
A
12/11/1959
F
03
N
100,000.00
/01/1992
A
12/19/1956
M
03
N
300,000.00
./01/1996
A
02/14/1959
M
03
T
70,000.00
i/01/2003
A
08/13/1972
F
03
N
100,000.00
2/01/2001
A
03/19/1960
M
03
N
150,000.00
1/01/1999
A
04/17/1947
F
03
N
10,000.00
4/01/1992
A
12/09/1943
M
03
N
30,000.00
1/01/2002
A
11/23/1955
M
03
T
30,000.00
1/01/2003
A
05/28/1973
F
03
N
200,000.00
7/01/2000
A
12/06/1964
M
03
N
300,000.00
6/01/1992
A
12/27/1964
M
03
N
300,000.00
5/01/1992
A
12/06/1952
M
03
N
130,000.00
6/01/1992
A
12/24/1949
M
03
N
170,000.00
4/01/1992
A
12/03/1957
F
03
N
100,000.00
17/01/1996
A
05/05/1965
M
03
N
250,000.00
)5/01/1992
A
12/06/1944
M
03
N
100,000.00
)7/01/2002
A
02/07/1965
M
03
N
150,000.00
)4/01/1992
A
12/11/1941
F
03
N
50,000.00
)4/01/1992
A
12/15/1946
M
03
N
30,000.00
.r 31/01/1995
A
04/11/1966
M
03
N
70,000.00
33/01/1994
A
12/15/1954
M
03
T
200,000.00
04/01/1992
A
12/15/1942
M
03
N
40,000.00
04/01/1994
A
02/24/1951
M
03
N
30,000.00
04/01/1992
A
12/28/1950
M
03
N
80,000.00
06/01/1998
A
10/03/1951
M
03
N
200,000.00
'06/01/1998
A
11/10/1958
M
03
N
300,000.00
12/01/2002
A
09/13/1972
M
03
N
300,000.00
04/01/1992
A
12/01/1947
F
03
N
120,000.00
02/01/2001
A
08/19/1949
F
03
N
50,000.00
04/01/1992
A
11/23/1959
M
03
N
160,000.00
02/01/1997
A
06/15/1964
F
03
N
40,000.00
04/01/2000
A
O1/18/1963
M
03
N
30,000.00
O1/01/1995
A
10/31/1951
M
03
N
60,000.00
06/01/1992
A
12/29/1954
M
03
N
200,000.00
02/01/1993
A
12/06/1950
M
03
T
70,000.00
02/01/1996
A
06/27/1964
M
03
N
200,000.00
O1/01/1994
A
04/20/1961
F
03
N
300,000.00
02/01/1993
A
07/15/1960
M
03
N
300,000.00
04/01/1998
A
04/08/1966
M
03
N
300,000.00
04/01/1999
A
04/06/1972
F
03
N
250,000.00
04/01/1992
A
03/23/1964
F
03
N
160,000.00
08/01/1998
A
05/27/1973
F
03
N
200,000.00
06/01/1992
A
12/31/1954
M
03
N
100,000.00
04/01/1996
A
03/01/1957
M
03
N
300,000.00
04/01/1992
A
12/04/1948
F
03
N
30,000.00
0 Enrollee and Dependents
List
29/JUL/2003
Page 6
Company 004 Anthem Life Insurance Company
Country : 01 United States
Coverage: 110 Voluntary Life - Employee
CITY OF FORT COLLINS
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
^'/01/1992
A
12/13/1959
F
03
N
40,000-00
/01/1992
A
12/29/1950
F
03
T
30,000.00
/01/1993
A
12/29/1949
M
03
T
70,000.00
/01/2001
A
06/07/1957
M
03
N
30,000.00
:/O1/1992
A
12/15/1964
F
03
N
100,000.00
;/01/1992
A
12/08/1954
F
03
N
150,000.00
1/01/1992
A
12/27/1955
M
03
N
30,000.00
)/01/2000
A
12/15/1947
M
03
N
100,000.00
4/01/1992
A
12/27/1956
M
03
N
30,000.00
9/01/1993
A
12/18/1959
F
03
N
50,000.00
4/01/1992
A
12/24/1952
F
03
N
100,000.00
4/01/1992
A
12/29/1947
M
03
N
250,000.00
4/01/1992
A
12/08/196S
M
03
N
100,000.00
•
4/01/1992
A
12/30/1951
M
03
N
150,000.00
5/01/1992
A
12/16/1961
M
03
N
200,000.00
4/01/1992
A
12/26/1958
F
03
N
140,000.00
7/01/1992
A
12/11/1947
M
03
N
30,000.00
4/01/1992
A
12/20/194S
M
03
N
30,000.00
11/01/1996
A
06/22/1958
F
03
N
100,000.00
)4/01/1992
A
12/13/1958
M
03
N
200,000.00
-1/01/1994
A
07/05/1963
M
03
N
50,000.00
)1/01/1995
A
O1/08/1966
F
03
N
30,000.00
)3/01/1999
A
04/25/1962
F
03
T
100,000.00
)8/01/1992
A
12/15/1962
F
03
N
100, 000.00
:)1/01/1994
A
12/06/1966
M
03
N
100,000.00
)4/01/1992
A
12/08/1962
M
03
N
30,000.00
04/01/1992
A
12/10/1964
F
03
N
30,000.00
04/01/1992
A
12/13/1967
F
03
N
100,000.00
'
04/01/2000
A
O1/30/1959
M
03
N
30,000.00
04/01/1992
A
12/17/1952
M
03
N
30,000-00
03/01/1994
A
12/01/1960
M
03
N
170,000.00
O1/01/1994
A
07/29/1969
M
03
N
150,000.00
^
02/01/1996
A
12/23/196S
F
03
N
30,000.00
06/01/1992
A
12/10/1966
M
03
N
300,000.00
03/01/1997
A
04/04/1957
M
03
N
110,000.00
05/01/1992
A
12/31/1960
M
03
N
100,000.00
O1/01/1994
A
07/23/1961
F
03
N
100,000.00
O1/01/2001
A
12/11/1951
M
03
N
80,000.00
05/01/1994
A
07/18/1955
M
03
N
200,000.00
04/01/1999
A
08/31/1968
M
03
N
150,000.00
05/01/1992
A
12/21/1943
F
03
N
30,000.00
03/01/2003
A
10/11/1965
M
03
N
300,000.00
04/01/1992
A
12/OS/1961
M
03
N
100,000.00
)5/01/1992
A
12/13/1950
M
03
N
30,000.00
P8/01/1998
A
09/02/1972
M
03
N
100,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 7
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
CITY OF FORT COLLINS
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
volume
^^/01/2000
A
06/21/195G
M
03
N
250,000.00
/01/1992
A
12/02/1952
M
03
N
100,000.00
/01/1992
A
12/27/1947
M
03
N
50,000.00
/01/1992
A
12/23/1962
F
03
N
100,000.00
,/01/1992
A
12/03/1948
M
03
N
150,000.00
1/01/1992
A
12/13/1952
F
03
N
120,000.00
5/01/2002
A
02/25/1978
M
03
N
100,000.00
1/01/1994
A
10/07/1960
F
03
N
100,000.00
8/01/1993
A
12/26/1955
F
03
N
100,000.00
6/01/1994
A
03/06/1952
M
03
N
100,000.00
7/01/1999
A
08/07/1961
M
03
N
230, 000.00
2/01/1993
A
12/12/1947
F
03
N
20,000.00
4/01/1992
A
12/26/1955
F
03
N
30,000.00
1/01/1995
A
07/07/1966
M
03
T
30,000.00
7/01/2000
A
04/19/1970
M
03
N
30,000.00
3/01/2002
A
04/02/1961
F
03
T
50,000.00
9/01/2001
A
05/28/1963
F
03
N
150,000.00
6/01/1992
A
12/07/1957
M
03
N
300,000.00
16/01/1992
A
12/04/1946
M
03
N
300,000.00
)9/01/1998
A
12/29/1964
F
03
N
60,000.00
)4/01/1992
A
12/17/1947
F
03
N
100,000.00
)3/01/1997
A
O1/31/1947
F
03
N
30,000.00
)4/01/1999
A
O1/26/1965
F
03
N
100,000.00
)5/01/1995
A
12/31/1957
F
03
N
250,000.00
:18/01/1998
A
11/16/1955
F
03
N
70,000.00
)4/01/1992
A
12/26/1961
M
03
N
300,000.00
33/01/2002
A
10/08/1963
F
03
N
300,000.00
05/01/2001
A
03/29/1965
M
03
N
200,000.00
04/01/1992
A
12/08/1954
M
03
N
30,000.00
04/01/1992
A
12/16/1955
M
03
N
200,000.00
08/01/1992
A
12/27/1967
F
03
N
30,000.00
02/01/1997
A
06/28/1963
M
03
T
40,000.00
06/01/1992
A
12/24/1957
M
03
N
300,000.00
12/01/1993
A
12/05/1947
F
03
N
30,000.00
04/01/1992
A
12/17/1956
M
03
T
30,000.00
04/01/1992
A
12/27/1951
M
03
N
30,000.00
O8/01/1993
A
12/08/1960
M
03
N
10,000.00
-05/01/2002
A
08/03/1946
F
03
N
20,000.00
03/01/1995
A
07/06/1951
M
03
N
10,000.00
08/01/1992
A
12/14/1951
M
03
N
300,000.00
02/01/1993
A
12/25/1952
F
03
N
100,000.00
04/01/1992
A
12/27/1942
F
03
N
30,000.00
09/01/1997
A
08/26/1963
M
03
N
100,000.00
02/01/1993
A
08/28/1952
M
03
N
50,000.00
02/01/1993
A
05/14/1949
M
03
N
100,000.00
ADC50 Enrollee and Dependents
-----------------------------
List
29/JUL/2003
Page 8
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 voluntary Life - Employee
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
volume
07/01/1992
A
12/15/1953
M
03
N
200,000.00
09/01/2001
A
09/07/1973
M
03
N
100,000.00
03/01/1997
A
06/19/1952
M
03
N
150,000.00
06/01/1992
A
12/21/1951
M
03
N
170,000.00
04/01/1992
A
12/13/1955
M
03
N
100,000.00
06/01/1992
A
12/17/1947
M
03
T
30,000.00
04/01/1992
A
12/07/1947
M
03
N
150,000.00
02/01/1994
A
03/28/1962
M
03
N
100,000.00
06/01/1992
A
12/24/1961
M
03
N
300,000.00
11/01/1999
A
03/19/1948
M
03
N
100,000.00
04/01/1992
A
12/19/195i
F
03
N
30,000.00
°
04/01/1992
A
12/29/1949
M
03
N
250,000.00
-
10/01/1999
A
08/29/1967
F
03
N
250,000.00
10/01/1999
A
O1/OS/1949
M SPOUSE
O1/01/1995
A
05/18/1953
M
03
T
40,000.00
03/01/1997
A
09/03/1944
M
03
N
100,000.00
07/01/1992
A
12/03/1954
M
03
N
30,000.00
02/01/1997
A
04/30/1970
M
03
N
240,000.00
01/01/1994
A
03/20/1958
F
03
N
100,000.00
>-�
04/01/1992
A
12/11/1965
M
03
N
150,000.00
02/01/1993
A
12/05/1951
M
03
N
200,000.00
04/01/1992
A
12/23/1952
M
03
T
50,000.00
O1/01/1994
A
09/12/1959
M
03
N
250,000.00
03/01/1998
A
06/07/1957
M
03
N
300,000.00
03/01/1997
A
08/01/1943
M
03
N
60,000.00
10/01/1999
A
07/29/1975
M
03
N
100,000.00
04/01/1992
A
12/24/1949
M
03
N
20,000.00
04/01/1992
A
12/25/1956
M
03
N
250,000.00
02/01/1993
A
10/06/1958
M
03
N
80,000.00
04/01/2002
A
11/19/1960
M
03
N
300,000.00
06/01/2002
A
05/04/1966
M
03
N
150,000.00
04/01/1997
A
O1/29/1957
M
03
'N
300,000.00
09/01/1995
A
08/20/1958
M
03
N
150,000.00
04/01/1992
A
02/25/1955
M
03
N
10,000.00
11/01/1993
A
12/13/1965
M
03
N
50,000.00
04/01/1992
A
12/16/1946
M
03
N
30,000.00
03/01/1995
A
02/25/1952
M
03
N
140,000.00
11/01/1998
A
12/12/1956
F
03
N
30,000.00
06/01/1992
A
12/10/1943
M
03
N
30,000.00
04/01/1992
A
12/06/1950
M
03
N
100,000.00
10/01/2000
A
05/10/1971
F
03
N
300,000.00
02/01/2003
A
11/12/1964
M
03
N
100,000.00
05/01/1998
A
12/30/1955
F
03
N
120,000.00
09/01/1995
A
12/08/1960
F
03
N
170,000.00
04/01/2003
A
07/10/1974
M
03
N
300,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 9
---------------------------------------------- -------__-
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
12/01/2000
A
07/06/1968
M
03
N
100,000.00
02/01/1996
A
09/05/1957
F
03
N
100,000.00
05/01/1995
A
12/01/1961
M
03
N
100,000.00
05/01/1992
A
12/25/1958
M
03
N
180,000.00
06/01/1993
A
12/04/1954
M
03
N
30, 000.00
04/01/1992
A
12/29/1954
F
03
N
60,000.00
04/01/1992
A
12/20/1960
F
03
N
30,000.00
09/01/1997
A
05/11/1954
M
03
N
100,000.00
04/01/1992
A
12/24/1959
M
03
N
300,000.00
04/01/1992
A
12/21/1952
M
03
N
100,000.00
04/01/1992
A
12/12/1959
F
03
N
190,000.00
' 05/01/1992
A
09/20/1955
F
03
N
50,000.00
02/01/1999
A
06/04/1953
M
03
N
100,000.00
01/01/1999
A
10/07/1958
F
03
N
50,000.00
04/01/1992
A
12/15/1949
F
03
N
100,000.00
04/01/1992
A
12/05/1954
F
03
N
30,000.00
04/01/1992
A
12/07/1963
M
03
N
80,000.00
06/01/1992
A
12/24/1959
F
03
N
30,000.00
04/01/1992
A
12/04/1954
M
03
N
160,000.00
04/01/1992
A
12/10/1963
M
03
N
50,000.00
05/01/1996
A
07/10/1945
M
03
N
50,000.00
O1/01/1997
A
10/10/1950
M
03
N
60,000.00
10/01/2002
A
04/30/1971
M
03
N
70,000.00
-
01/01/1996
A
05/06/1960
M
03
N
100,000.00
04/01/1992
A
12/06/1946
F
03
N
30,000.00
08/01/1993
A
12/03/1964
M
03
N
300,000.00
10/01/2002
A
09/29/1957
M
03
N
150,000.00
03/01/1993
A
12/19/1946
M
03
N
150,000.00
12/01/2002
A
02/24/1970
M
03
N
300,000.00
09/01/1995
A
03/20/1970
M
03
N
200,000.00
04/01/1997
A
07/31/1970
M
03
N
200,000.00
06/01/2000
A
02/20/1972
F
03
N
30,000.00
04/01/1992
A
09/02/1955
M
03
N
200,000.00
07/01/1994
A
10/20/1969
M
03
N
300,000.00
02/01/1998
A
03/22/1971
M
03
N
300,000.00
02/01/1997
A
11/11/1965
F
03
N
20,000.00
02/01/1996
A
O8/16/1961
M
03
N
200,000.00
04/01/1992
A
12/13/1961
M
03
N
300,000.00
02/01/1996
A
09/24/1956
F
03
N
50,000.00
04/01/1992
A
12/27/1947
M
03
N
40,000.00
01/01/1994
A
04/25/1946
M
03
N
100,000.00
04/01/1992
A
12/10/1954
M
03
N
30,000.00
10/01/2002
A
12/18/1957
F
03
N
50,000.00
03/01/2000
A
O1/24/1968
M
03
N
300,000.00
05/01/1996
A
02/08/1950
F
03
N
70,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 10
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 voluntary Life - Employee
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
--"------'-"""-
02/01/1993
A
12/30/1953
M
03
T
100,000.00
06/01/1999
A
09/28/1960
M
03
N
30,000.00
04/01/1992
A
12/08/1951
M
03
N
60,000.00
04/01/1992
A
12/05/1951
M
03
N
150,000.00
O1/01/1997
A
11/06/1961
F
03
N
250,000.00
03/01/1995
A
07/31/1950
M
03
N
100,000.00
12/01/2000
A
04/02/1961
M
03
N
30,000.00
04/01/1992
A
12/13/1963
F
03
N
100,000.00
11/01/2001
A
10/19/1972
M
03
N
300,000.00
04/01/1999
A
09/14/1968
M
03
N
250,000.00
04/01/1992
A
03/15/1954
M
03
N
100,000.00
• 04/01/1992
A
12/28/1967
F
03
N
300,000.00
02/01/1993
A
12/02/1944
M
03
N
100,000.00
O6/01/1994
A
11/12/1956
M
03
N
100,000.00
04/01/1992
A
12/05/1954
M
03
N
150,000.00
01/01/1994
A
08/10/1947
M
03
N
120,000.00
02/01/1996
A
09/18/1953
F
03
N
30,000.00
06/01/1992
A
12/02/1958
M
03
N
300,000.00
08/01/1995
A
04/21/1965
M
03
N
300,000.00
08/01/1992
A
12/21/1946
M
03
T
130, 000.00
10/01/1999
A
10/21/1963
F
03
N
120,000.00
04/01/1992
A
12/17/1963
M
03
N
200,000.00
03/01/2002
A
08/22/1972
F
03
N
200,000.00
04/01/1999
A
04/28/1970
M
03
N
300,000.00
04/01/1992
A
12/05/1949
F
03
N
30,000.00
02/01/1998
A
12/21/1966
M
03
N
200,000.00
03/01/1999
A
O6/06/1971
F
03
N
200,000.00
04/01/1992
A
12/02/1949
M
03
N
100,000.00
•
07/01/1996
A
05/13/1962
F
03
N
40,000.00
03/01/1997
A
O1/21/1953
M
03
N
150,000.00
03/01/2002
A
09/22/1966
F
03
N
30,000.00
05/01/2003
A
02/08/1962
F
03
N
250,000.00
.,
04/01/2002
A
06/19/1975
M
03
N
20,000.00
04/01/1992
A
12/13/1951
M
03
N
30,000.00
06/01/2002
A
10/05/1962
F
03
N
50,000.00
09/01/1993
A
09/08/1964
F
03
N
150,000.00
02/01/1999
A
06/07/1958
M
03
N
200,000.00
O1/01/1996
A
04/23/1974
F
03
N
50,000.00
O8/01/2000
A
07/23/1960
F
03
T
150,000.00
O1/01/1995
A
11/03/1945
M
03
N
100,000.00
06/01/2002
A
12/04/1958
M
03
N
210,000.00
08/01/1992
A
12/04/1955
M
03
N
200,000.00
05/01/1999
A
06/26/1967
M
03
N
300,000.00
04/01/1992
A
12/22/1946
M
03
N
60,000.00
06/01/1992
A
09/06/1956
M
03
N
300,000.00
Any deviations from this RFP must be clearly identified and explained in your proposal. These
deviations are to be delineated as instructed in the Proposal Requirements as set forth in
Section 1.5 of this RFP.
It is intended that you should conform to these specifications as much as possible. Do not
quote alternative plan designs unless absolutely necessary. Please quote the requested
financial arrangements only.
Your company will be bound to comply with the provisions set forth in this RFP unless any and
all deviations are explicitly stated in your proposal.
1.5 Proposal Instructions
Do not deviate from the requested formats. Provide your proposed rates and fees as specified
in this RFP.
The City is seeking an initial premium/administration cost that runs for at least 24 months
(January 1, 2004 — December 31, 2005). Please confirm the time period applicable to your
proposed rate/fee guarantees.
Quote all life, disability, long term care and transplant coverage on a fully insured non-
participating basis. Administrative services for dental and vision should be quoted for a self -
funded plan.
Define specifically what services are included in the fees your company has quoted.
Specify any charges for services that your company has not included in the fees quoted above,
including any start-up fees.
Adhere to the instructions in this section when organizing your proposal.
1.6 Proposal Requirements
Your response should be organized in the following sections:
Section I: Executive Summary
Section II: Proposal Compliance Letter (Signed by an authorized officer of your organization
signifying your proposal's complete adherence with the RFP specifications,
except as specifically noted in the appropriate sections)
Section III: Checklist of Items included with Proposal
Section IV: Plan Design Confirmation (Statement indicating your willingness to replicate
current plan provisions or indicating clearly deviations from current plan design)
Section V: Questionnaire Responses
Section VI: Performance Guarantees
Section VII: Financial Exhibits
Section VIII: Items Included with Proposal (As indicated on the Checklist included in Section
III. These items should be indexed in the order listed on the checklist, with a copy
of the index included in this section)
City of Fort Collins, RFP 2003
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 11
_____________________________ ___________ __________
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
Group : 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
03/01/2000
A
O1/09/1966
F
03
N
130,000.00
06/01/2003
A
09/11/1977
F
03
T
100,000.00
04/01/1992
A
05/09/1956
M
03
N
250,000.00
04/01/1992
A
12/05/1941
M
03
N
30,000.00
O1/01/1994
A
10/31/1957
F
03
N
50,000.00
04/01/1992
A
12/03/1957
M
03
N
30,000.00
O1/01/1994
A
O1/15/1967
M
03
T
110,000.00
O1/01/1996
A
12/10/1949
M
03
N
60,000.00
11/01/2002
A
10/27/1956
M
03
N
40,000.00
03/01/1998
A
09/17/1965
M
03
N
300,000.00
04/01/1992
A
12/12/1956
F
03
N
50,000.00
° 02/01/1993
A
12/29/1963
F
03
N
150,000.00
-
10/01/1992
A
12/25/1969
F
03
T
100,000.00
03/01/1999
A
OS/19/1959
M
03
N
100,000.00
06/01/1992
A
12/21/1952
F
03
T
200,000.00
O1/01/1994
A
06/22/1952
M
03
N
110,000.00
11/01/1999
A
08/18/1971
M
03
N
300,000.00
02/01/1997
A
03/11/1958
M
03
N
80,000.00
05/01/1992
A
12/12/19SB
M
03
N
300,000.00
,.
01/01/2001
A
10/13/1959
F
03
N
40,000.00
04/01/1992
A
12/18/1949
M
03
N
50,000.00
03/01/2000
A
09/23/1970
M
03
N
300,000.00
04/01/1992
A
12/25/1953
M
03
N
150,000.00
09/01/2000
A
06/26/1974
F
03
N
300,000.00
06/01/2000
A
O1/12/1973
M
03
N
300,000.00
11/01/1993
A
12/05/1955
M
03
N
70,000.00
04/01/1992
A
05/12/1963
F
03
N
200,000.00
04/01/1992
A
12/05/1944
M
03
T
30,000.00
_
09/01/1994
A
02/03/1950
M
03
N
200,000.00
06/01/2002
A
03/06/1970
M
03
N
100,000.00
02/01/1993
A
12/21/1957
F
03
N
10,000.00
12/01/2000
A
06/30/1973
M
03
N-
100,000.00
..
04/01/1992
A
12/25/1952
F
03
N
100,000.00
12/01/2000
A
11/22/1965
F
03
N
150,000.00
04/01/1992
A
12/20/1954
F
03
N
300,000.00
04/01/1992
A
12/24/1948
M
03
N
280,000.00
06/01/1998
A
04/22/1966
F
03
N
200,000.00
O1/01/1996
A
12/12/1957
F
03
N
30,000.00
04/01/1992
A
12/09/1961
F
03
N
30,000.00
04/01/1992
A
12/02/1957
M
03
N
250,000.00
04/01/1992
A
12/19/1959
F
03
N
120,000.00
11/01/2000
A
05/21/1977
F
03
N
200,000.00
O1/01/1996
A
02/15/1954
M
03
N
140,000.00
04/01/1992
A
12/12/1959
M
03
N
100,000.00
O1/01/1996
A
12/07/1957
M
03
1
100,000.00
ADC50 Enrollee and Dependents List 29/.7UL/2003 Page 12
___________________________________ _-___----- __________
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
01/01/2001
A
06/08/1976
F
03
T
100,000.00
04/01/1992
A
12/20/1942
M
03
N
40,000.00
02/01/1993
A
12/07/1959
M
03
N
40,000.00
04/01/1992
A
12/31/1956
M
03
N
100,000.00
04/01/1992
A
12/20/1953
M
03
N
100,000.00
08/01/1992
A
12/OS/1954
M
03
N
180,000.00
12/01/1999
A
07/25/1951
F
03
N
70,000.00
04/01/1992
A
12/14/1949
F
03
N
40,000.00
02/01/1996
A
06/16/1963
M
03
N
300,000.00
02/01/1998
A
03/09/1956
F
03
N
130, 000.00
01/01/1995
A
10/06/1964
F
03
N
300,000.00
08/01/2003
A
07/08/1966
F
03
N
200,000.00
04/01/1992
A
12/13/1955
M
03
N
100,000.00
09/01/2001
A
08/07/1968
M
03
N
30,000.00
04/01/1992
A
12/02/1951
M
03
N
150,000.00
06/01/1992
A
12/15/1952
M
03
N
250,000.00
04/01/1995
A
02/26/1961
M
03
N
300,000-00
04/01/1992
A
12/23/1946
M
03
N
30,000.00
03/01/1994
A
04/29/1963
M
03
N
50,000.00
05/01/1996
A
09/10/1968
M
03
N
220,000.00
02/01/2002
A
03/29/1955
F
03
N
80,000.00
04/01/1995
A
07/23/1947
M
03
N
50,000.00
03/01/1998
A
10/05/1953
M
03
N
200,000.00
04/01/1992
A
12/10/1953
M
03
N
250,000.00
04/01/2002
A
05/09/1958
M
03
T
100,000.00
01/01/2003
A
01/21/1971
F
03
N
150,000.00
04/01/1992
A
12/14/1961
M
03
N
120,000.00
04/01/1992
A
12/23/1965
F
03
N
110,000.00
04/01/1992
A
12/05/1948
M
03
N
60,000.00
04/01/1992
A
12/28/1965
M
03
N
170,000.00
04/01/1992
A
12/30/1948
M
03
N
20,000.00
07/01/2001
A
11/16/1958
M
03
N
150,000.00
02/01/1997
A
04/20/1959
F
03
N
30,000-00
05/01/1999
A
04/27/1951
M
03
T
30,000.00
09/01/1992
A
12/19/1959
M
03
N
180,000.00
02/01/1999
A
02/23/1974
M
03
N
300,000.00
04/01/1992
A
12/25/1953
M
03
N
100,000-00
09/01/1996
A
06/24/1945
M
03
N
300,000.00
02/01/1993
A
12/19/1954
M
03
N
200,000-00
04/01/1992
A
12/29/1958
M
03
T
140,000.00
03/01/1999
A
07/06/1965
F
03
T
20,000.00
04/01/1992
A
12/27/1956
F
03
T
30,000.00
06/01/1996
A
08/19/1971
M
03
N
120,000.00
01/01/1995
A
06/10/1955
M
03
N
50,000.00
0510112003
A
22/29/1967
F
03
M
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 13
-----------------------------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
11/01/1995
A
10/07/1970
M
03
N
30,000.00
02/01/2003
A
06/10/1967
M
03
N
300,000.00
04/01/2003
A
08/06/1971
M
03
T
200,000.00
07/01/1992
A
12/09/1954
M
03
N
200,000.00
02/01/1995
A
07/24/1964
F
03
N
50,000.00
02/01/2000
A
10/04/1949
M
03
N
50,000.00
11/01/2001
A
07/17/1953
F
03
N
100,000.00
06/01/1992
A
12/18/1966
M
03
N
100,000.00
11/01/1993
A
12/09/1958
F
03
N
150,000.00
04/01/1992
A
12/26/1951
M
03
N
100,000.00
05/01/1999
A
O1/01/1980
M
03
N
300,000.00
04/01/1992
A
12/08/1952
F
03
T
30,000.00
08/01/1992
A
12/06/1959
M
03
N
200,000.00
06/01/1992
A
12/19/1950
M
03
N
200,000.00
06/01/1995
A
09/06/1970
M
03
N
200,000.00
04/01/1992
A
12/11/1958
F
03
N
30,000.00
12/01/2000
A
02/01/1967
M
03
N
100,000.00
04/01/1992
A
12/14/1959
M
03
N
30,000.00
04/01/1992
A
08/20/1945
M
03
N
50, 000.00
O1/01/1994
A
06/11/1957
F
03
N
so, 000.00
04/01/1993
A
12/06/1959
M
03
N
300,000.00
04/01/1992
A
12/18/1952
M
03
N
30,000.00
04/01/1992
A
12/31/1964
M
03
N
100, 000.00
01/01/1997
A
09/13/1949
M
03
N
50,000.00
04/01/1992
A
12/17/1957
M
03
N
30,000.00
08/01/1992
A
12/30/1952
M
03
N
160,000.00
04/01/1992
A
12/02/1950
M
03
N
30,000.00
04/01/1992
A
12/11/1962
M
03
N
120,000.00
04/01/1992
A
12/12/1955
F
03
N
100, 000.00
04/01/1992
A
12/25/1958
M
03
N
200,000.00
05/01/1992
A
12/19/1947
M
03
N
160,000.00
02/01/1999
A
06/20/1964
F
03
N
140,000.00
.,
01/01/1997
A
11/21/1960
M
03
N
50,000.00
04/01/1992
A
12/04/1955
F
03
N
100,000.00
11/01/1994
A
03/20/1949
M
03
N
70,000.00
11/01/1993
A
12/17/1941
F
03
N
100,000.00
04/01/1992
A
12/27/1947
F
03
N
10, 000.00
05/01/2003
A
05/08/1968
M
03
N
120,000.00
03/01/1995
A
05/28/196B
M
03
N
100,000.00
04/01/1992
A
12/17/1956
F
03
N
30,000.00
07/01/2002
A
10/29/1964
M
03
N
200,000.00
02/01/1998
A
04/04/1954
M
03
N
100,000.00
04/01/1992
A
12/26/1953
M
03
N
300,000.00
02/01/1993
A
12/21/1955
F
03
N
200,000.00
04/01/1992
A
06/01/1963
F
03
N
120,000.00
ADC50 Enrollee and Dependents
-----------------------------
List
29/JNL/2003
Page 14
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
Group 006518-0099 CITY OF FORT COLLINS
Men Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
04/01/1992
A
12/21/1963
M
03
T
200,000.00
04/01/1992
A
12/03/19S4
M
03
N
150,000.00
02/01/1997
A
03/04/1948
M
03
N
100,000.00
04/01/1992
A
12/24/1940
M
03
N
100,000.00
04/01/1992
A
12/23/1959
M
03
N
30,000.00
04/01/1992
A
08/09/1959
F
03
N
60,000.00
11/01/1995
A
10/05/1968
F
03
N
200,000.00
08/01/2000
A
04/22/1951
F
03
N
30,000.00
05/01/1994
A
11/28/1966
F
03
N
100,000.00
05/01/1992
A
12/09/1954
M
03
N
100,000.00
05/01/1992
A
12/05/1957
F
03
N
30,000.00
° 10/01/1995
A
02/14/1959
M
03
N
30,000.00
04/01/1992
A
12/15/1961
M
03
N
30,000.00
04/01/1992
A
12/05/1952
M
03
N
60,000.00
04/01/1992
A
12/16/1960
M
03
N
100,000.00
02/01/1996
A
02/20/1967
M
03
N
100,000.00
10/01/1992
A
12/13/1944
M
03
N
100,000.00
01/01/1994
A
06/22/1951
M
03
N
200,000.00
10/01/1992
A
10/23/1969
M
03
N
250,000.00
;.r
10/01/2002
A
10/18/1965
F
03
N
200,000.00
02/01/2003
A
11/30/1967
F
03
N
300,000.00
04/01/2002
A
10/14/1951
F
03
N
100,000.00
04/01/1992
A
12/18/1968
M
03
N
300,000.00
04/01/1992
A
12/22/1964
M
03
N
80,000.00
03/01/2000
A
10/10/1967
F
03
N
150,000.00
02/01/1997
A
04/16/1948
M
03
N
50,000.00
04/01/1992
A
12/16/1946
M
03
N
30,000.00
OS/01/1992
A
12/11/1948
F
03
N
200,000.00
•
05/01/1999
A
11/11/1968
M
03
N
300,000.00
01/01/1994
A
10/31/1963
M
03
N
100,000.00
01/01/1995
A
12/18/1952
M
03
N
150,000.00
04/01/1992
A
12/25/1951
F
03
N
100,000.00
-•
04/01/1992
A
12/28/1949
M
03
N
150,000.00
04/01/1992
A
12/23/1953
M
03
N
120,000.00
10/01/2002
A
07/12/1970
M
03
N
100,000.00
04/01/1992
A
12/11/1954
M
03
N
80,000.00
09/01/1999
A
07/22/1957
F
03
N
120,000.00
04/01/1992
A
12/09/1954
M
03
N
100,000.00
03/01/1993
A
12/11/1955
M
03
N
300,000.00
03/01/1993
A
12/03/1961
F
03
N
300,000.00
06/01/2002
A
06/03/1957
F
03
N
40,000.00
04/01/1992
A
12/13/19S4
M
03
N
30,000.00
05/01/1999
A
08/11/1959
F
03
N
100,000.00
06/01/2000
A
06/25/1960
M
03
N
300,000.00
04/01/1992
A
12/04/1956
M
03
N
180,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 15
_____________________________
___________ __________
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
Group 006518-0099 CITY OF FORT COLLINS
ro,t No. Der Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
04/01/1992
A
12/20/1956
M
03
T
30,000.00
04/01/1992
A
12/26/1956
M
03
N
200,000.00
02/01/1993
A
12/26/1950
M
03
N
100,000.00
09/01/1996
A
03/31/1962
F
03
N
200,000.00
04/01/1992
A
12/09/1964
M
03
N
300,000.00
08/01/2001
A
06/06/1970
M
03
N
300,000.00
04/01/1992
A
12/27/1961
F
03
N
180,000.00
04/01/1997
A
03/06/1957
M
03
N
100,000.00
04/01/1992
A
12/16/1946
M
03
N
100, 000.00
05/01/1992
A
12/09/1948
M
03
N
40,000.00
03/01/1997
A
06/27/1945
M
03
N
50,000.00
° 07/01/2000
A
10/12/1973
F
03
N
300,000.00
07/01/1992
A
O1/30/1949
M
03
N
100,000.00
04/01/1992
A
05/19/1950
M
03
N
100,000.00
10/01/1998
A
08/03/1975
F
03
N
300,000.00
04/01/1992
A
12/22/1952
M
03
N
120,000.00
04/01/1992
A
09/30/1946
M
03
N
50,000.00
O1/01/1995
A
03/26/1957
F
03
N
30,000.00
O1/01/2000
A
08/21/1959
F
03
N
30,000.00
.02/01/1993
A
12/29/1955
M
03
T
200,000-00
04/01/1993
A
12/20/1948
M
03
N
100,000.00
10/01/1999
A
04/21/1970
M
03
N
300,000.00
01/01/2001
A
06/15/1962
F
03
N
100,000.00
01/01/1994
A
06/08/1964
M
03
N
100,000.00
02/01/2002
A
O1/22/1970
F
03
N
30,000.00
07/01/1997
A
03/23/1967
F
03
N
50,000.00
01/01/1999
A
05/21/1967
M
03
N
250,000-00
05/01/1992
A
12/21/1955
F
03
N
30,000.00
04/01/1992
A
12/27/1958
M
03
N
150,000.00
03/01/2000
A
08/02/1943
F
03
N
60,000.00
05/01/2000
A
04/26/1969
M
03
N
150,000.00
03/01/2002
A
02/11/1960
M
03
N
170,000.00
03/01/1996
A
12/07/1952
F
03
T
30,000.00
09/01/2001
A
05/01/1957
M
03
N
200,000.00
09/01/2002
A
02/10/1958
M
03
N
300,000.00
O1/01/1999
A
08/14/1944
M
03
N
30,000.00
04/01/1992
A
12/07/1956
M
03
N
300,000.00
O1/01/1994
A
06/23/1959
F
03
T
200,000.00
03/01/2002
A
09/03/1958
F
03
N
200,000.00
09/01/1992
A
12/23/1960
M
03
N
100,000.00
O1/01/2003
A
12/05/1950
F
03
N
140,000.00
04/01/1992
A
07/26/1950
M
03
N
300,000.00
04/01/1992
A
12/27/1949
F
03
N
30,000.00
08/01/1992
A
12/08/1954
F
03
N
100,000.00
O6/01/1992
A
12/29/1959
M
03
N
300,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
_____________________________
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
Group 006518-0099 CITY OF FORT COLLINS
Name Effective Status Birthday Sex Relation
04/01/1992 A 12/23/1953 M
04/01/1992 A 12/15/1957 F
04/01/1992 A 12/09/1949 M
07/01/2002 A 05/10/1977 F
04/01/1992 A 12/21/1951 M
04/01/1992 A 12/05/1947 M
06/01/1992 A 12/28/1951 M
09/01/2000 A 04/28/1973 M
04/01/1992 A 04/22/1954 M
O1/01/1996 A 02/17/1970 M
04/01/1992 A 12/08/1956 M
O1/01/2002 A 02/22/1976 F
10/01/1995 A 06/15/1957 M
12/01/1997 A O1/14/1961 F
O1/01/1995 A 10/12/1955 F
03/01/1995 A 07/14/1953 M
02/O1/2003 A 10/15/1980 M
04/01/1992 A 12/09/1951 F
04/01/1992 A 12/25/1947 M
04/01/1996 A 09/22/1944 M
05/01/1992 A 12/31/1951 M
04/01/1992 A 12/09/1959 M
04/01/1997 A 04/29/1970 M
04/01/1992 A 12/15/1949 M
04/01/1992 A 12/20/1962 M
Page 16
Terminated Class
E-type
Volume
03
N
100,000.00
03
N
30,000.00
03
N
80, 000.00
03
N
100,000.00
03
N
80,000.00
03
N
60,000.00
03
N
100,000.00
03
N
50,000.00
03
N
150,000.00
03
N
100,000.00
03
N
80,000.00
03
N
200,000.00
03
N
200,000.00
03
N
80,000.00
03
N
50,000.00
03
N
180,000.00
03
N
50,000.00
03
N
100,000.00
03
N
150,000.00
03
N
100,000.00
03
N
40,000.00
03
N
50,000.00
03
N
100,000.00
03
N
60,000.00
03
T
100,000.00
519 67,240,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
------ _____________________________ -_-_____-_-
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
04/01/1992 A 12/19/1956 M
04/01/1992 A O6/21/1961 F SPOUSE
O1/01/1999 A 04/17/1947 F
O1/01/1999 A 05/05/1938 M SPOUSE
02/01/2003 A 08/20/1973 F
02/01/2003 A 09/29/1971 M SPOUSE
O1/01/2003 A 05/28/1973 F
O1/01/2003 A 07/10/1974 M SPOUSE
07/01/2000 A 12/06/1964 M
07/01/2000 A OS/09/1964 F SPOUSE
04/01/1992 A 12/27/1964 M
04/01/1992 A 12/16/1965 F SPOUSE
04/01/1992 A 12/24/1949 M
04/01/1992 A 08/01/1955 F SPOUSE
07/01/1996 A 05/05/1965 M
07/01/1996 A 05/14/1967 F SPOUSE
10/01/1998 A 12/06/1944 M
10/01/1998 A 06/02/1945 F SPOUSE
04/01/1992 A 12/11/1941 F
04/01/1992 A OS/09/1936 M SPOUSE
04/01/1992 A 12/15/1946 M
04/01/1992 A 10/03/1947 F SPOUSE
04/01/1992 A 12/15/1942 M
04/01/1992 A 01/15/1942 F SPOUSE
04/01/1992 A O1/01/1980 M
04/01/1992 A 04/22/19SS F SPOUSE
04/01/1992 A 12/28/1950 M
04/01/1992 A 09/30/1949 F SPOUSE
06/01/1998 A 10/03/1951 M
06/01/1998 A 09/25/1954 F SPOUSE
06/01/1998 A 11/10/1958 M
06/01/1998 A 12/27/1965 F SPOUSE
04/01/2000 A O1/18/1963 M
04/01/2000 A 03/23/1962 F SPOUSE
02/01/1999 A 12/06/1950 M
02/01/1999 A 02/21/19SO F SPOUSE
O1/01/2002 A 03/23/1964 F
O1/01/2002 A 05/27/1959 M SPOUSE
08/01/1998 A 05/27/1973 F
08/01/1998 A 02/22/1965 M SPOUSE
08/01/2002 A 12/13/1959 F
08/01/2002 A 12/30/1957 M SPOUSE
04/01/1992 A 12/27/1955 M
04/01/1992 A 12/09/1952 F SPOUSE
04/01/1992 A 12/27/1956 M
04/01/1992 A 07/24/1556 F SPOUSE
Page 17
Terminated Class E-type
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 T
03 N
03 N
03 N
03 N
Volume
300,000.00
10,000.00
300,000.00
200,000.00
10, 000.00
200,000.00
150,000.00
190,000.00
100, 000.00
so, 000.00
30, 000.00
30, 000.00
10,000.00
10,000.00
100,000.00
130,000.00
30,000.00
30, 000.00
100,000.00
10, 000.00
200,000.00
50, 000.00
10,000.00
ADC50 Enrollee and Dependents List
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
29/JUL/2003
Cert No. Dep Name Effective Status Birthday Sex Relation
09/01/1993 A 12/18/1959 F
09/01/1993 A 02/11/1955 M SPOUSE
04/01/1992 A 12/24/1952 F
04/01/1992 A 09/30/1950 M SPOUSE
07/01/2003 A 03/16/1974 F
07/01/2003 A 10/11/1969 M SPOUSE
04/01/1992 A 12/29/1947 M
04/01/1992 A 11/20/1954 F SPOUSE
04/01/1992 A 12/08/1965 M
04/01/1992 A 05/14/1966 F SPOUSE
04/01/1997 A 12/30/1951 M
' 04/01/1997 A 08/31/1954 F SPOUSE
04/01/1992 A 12/20/1945 M
04/01/1992 A 08/15/1949 F SPOUSE
04/01/1992 A O1/01/1980 M
04/01/1992 A 05/11/1944 F SPOUSE
06/01/1998 A O1/01/1980 F
06/01/1998 A 03/27/1955 M SPOUSE
11/01/1994 A 07/05/1963 M
11/01/1994 A 07/28/1962 F SPOUSE
10/01/1992 A O1/01/1980 F
10/01/1992 A 10/31/1941 M SPOUSE
O8/01/1992 A 12/15/1962 F
08/01/1992 A 05/24/1961 M SPOUSE
02/01/1994 A 12/06/1966 M
02/01/1994 A 09/13/1969 F SPOUSE
08/01/1994 A 12/13/1967 F
08/01/1994 A 05/22/1965 M SPOUSE
09/01/1999 A 07/29/1969 M
01/01/1994 A 09/02/1971 F SPOUSE
02/01/1996 A 12/23/1965 F
02/01/1996 A 05/29/1963 M SPOUSE
04/01/1992 A 12/10/1966 M
04/01/1992 A 04/17/1967 F SPOUSE
O1/01/199S A 04/04/1957 M
O1/01/1995 A 04/06/1960 F SPOUSE
05/01/1992 A 12/31/1960 M
OS/01/1992 A 10/23/1962 F SPOUSE
O1/01/1998 A O1/01/1980 M
O1/01/1998 A 07/31/1959 F SPOUSE
11/01/1994 A O1/01/1980 F
11/01/1994 A O6/07/1952 M SPOUSE
12/01/1999 A 04/25/1969 M
12/01/1999 A 09/08/1979 F SPOUSE
O1/01/1994 A 07/23/1961 F
O1/01/1994 A 05/31/1960 M SPOUSE
Page 18
Terminated Class
E-type
03
N
03
T
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
N
Volume
50,000.00
50,000.00
100, 000.00
10,000.00
100,000.00
100, 000.00
10,000.00
10,000.00
10,000.00
30,000.00
20,000.00
100,000.00
100,000.00
50,000.00
150,000.00
10,000.00
100,000.00
110,000.00
100,000.00
50,000.00
100,000.00
100,000.00
100,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
-----------------------------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
06/01/1994 A 07/18/1955 M
06/01/1994 A 07/15/1959 F SPOUSE
06/01/2002 A 02/25/1978 M
06/01/2002 A 05/12/1978 F SPOUSE
04/01/1994 A 03/06/1952 M
04/01/1994 A O1/11/1949 F SPOUSE
07/01/1999 A 08/07/1961 M
07/01/1999 A 06/27/1962 F SPOUSE
04/01/1992 A 12/26/1955 F
04/01/1992 A 04/29/1948 M SPOUSE
09/01/2001 A 05/28/1963 F
09/01/2001 A 04/24/1963 M SPOUSE
04/01/1992 A 12/07/1957 M
04/01/1992 A 04/07/1960 F SPOUSE
04/01/1992 A 12/04/1946 M
04/01/1992 A 11/30/1941 F SPOUSE
10/01/1998 A 12/29/1964 F
10/01/1998 A 12/19/1958 M SPOUSE
01/01/1994 A O1/01/1980 M
01/01/1994 A 09/21/1959 F SPOUSE
04/01/1992 A 12/17/1947 F
04/01/1992 A 07/10/1947 M SPOUSE
03/01/1997 A O1/31/1947 F
03/01/1997 A 08/29/1946 M SPOUSE
07/01/1995 A O1/01/1980 F
07/01/1995 A 11/16/1963 M SPOUSE
03/01/1999 A O1/26/196S F
03/01/1999 A 11/23/1967 M SPOUSE
08/01/1998 A 11/16/1955 F
O8/01/1998 A 04/24/1957 M SPOUSE
05/01/2001 A 03/29/1965 M
05/01/2001 A 04/07/1965 F SPOUSE
04/01/1992 A 12/08/1954 M
04/01/1992 A 08/04/1958 F SPOUSE
03/01/2002 A 04/21/1970 F
03/01/2002 A 03/13/1969 M SPOUSE
05/01/1997 A 06/28/1963 M
05/01/1997 A 07/18/1969 F SPOUSE
04/01/1992 A 12/24/1957 M
04/01/1992 A 05/12/1958 F SPOUSE
05/01/2002 A 08/03/1946 F
05/01/2002 A 11/13/1948 M SPOUSE
03/01/1995 A 07/06/1951 M
03/01/1995 A 09/17/1959 F SPOUSE
08/01/1992 A 12/14/1951 M
08/01/1992 A 11/25/1950 F SPOUSE
Page 19
Terminated Class
E-type
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
N
03
N
03.
N
03
T
03
N
03
N
03
N
03
T
03
N
Volume
50, 000.00
100,000.00
50,000.00
100, 000.00
100,000.00
100,000.00
150, 000.00
30,000.00
100,000.00
100,000.00
100,000.00
10, 000.00
100,000.00
100, 000.00
30,000.00
100,000.00
10,000.00
100,000.00
20, 000.00
10,000.00
80, 000-00
10,000.00
300,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
------ _____________________________ -___--_----
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. ➢ep Name Effective Status Birthday Sex Relation
02/01/1993 A 12/25/1952 F
02/01/1993 A 11/19/1951 M SPOUSE
02/01/1993 A 05/14/1949 M
02/01/1993 A 05/14/1949 F SPOUSE
06/01/1992 A 12/15/1953 M
06/01/1992 A 12/19/1954 F SPOUSE
O1/01/1996 A 01/01/1980 M
O1/01/1996 A 02/16/1949 F SPOUSE
09/01/2001 A 09/07/1973 M
09/01/2001 A 03/25/1976 F SPOUSE
03/01/1997 A 06/19/1952 M
° 03/01/1997 A 08/22/19SG F SPOUSE
04/01/1992 A 12/07/1947 M
04/01/1992 A 11/20/1950 F SPOUSE
02/01/1998 A 12/24/1961 M
02/01/1998 A 05/16/1960 F SPOUSE
O1/01/1995 A 12/29/1949 M
O1/01/1995 A 10/10/1951 F SPOUSE
10/01/1999 A 08/29/1967 F
03/01/1997 A 05/18/1953 M
03/01/1997 A 03/04/1951 F SPOUSE
04/21/1993 A 03/20/1958 F
04/01/1993 A 09/01/1958 M SPOUSE
06/01/1997 A 12/11/1965 M
06/01/1997 A 12/19/1966 F SPOUSE
04/01/1992 A 12/05/1951 M
04/01/1992 A 10/29/1959 F SPOUSE
O1/01/1994 A 09/12/1959 M
O1/01/1994 A 11/04/1960 F SPOUSE
04/01/1992 A 12/25/1956 M
04/01/1992 A 05/24/1957 F SPOUSE
04/01/2002 A 11/19/1960 M
04/01/2002 A 11/11/1961 F SPOUSE
04/01/1997 A O1/29/1957 M
04/01/1997 A 04/05/1958 F SPOUSE
08/01/1995 A 08/20/1958 M
08/01/1995 A 09/07/1962 F SPOUSE
07/01/2003 A 02/25/1955 M
07/01/2003 A 08/05/1955 F SPOUSE
OS/01/2003 A OB/02/1956 F
05/01/2003 A 08/05/1954 M SPOUSE
11/01/1993 A 12/13/1965 M
11/01/1993 A 04/12/1966 F SPOUSE
04/01/1992 A 12/16/1946 M
04/01/1992 A 10/04/1949 F SPOUSE
Page 20
Terminated Class
E-type
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
volume
so, 000.00
50, 000.00
200,000.00
10,000.00
50,000.00
100,000.00
50,000.00
100,000.00
80,000.00
150,000.00
100,000.00
300,000.00
150,000.00
100,000.00
150,000.00
20, 000.00
300,000.00
300,000.00
100,000.00
50,000.00
100,000.00
30,000.00
70,000.00
Section 2.0 Services to Be Provided
In addition to the plan provisions set forth in the attachments, The City has specific vendor
requirements needed to support its day-to-day operations.
2.1 Specific Requirements
• Account Management
The account executive and service representative(s) will deal directly with The City. This
environment requires the account management team to:
➢ Be able to devote the time necessary to the account, including being available for
frequent telephone and on -site consultations with The City. Proposers who are not
committed to serious account service will not receive serious consideration;
➢ Be extremely responsive;
➢ Be comprised of individuals with specialized knowledge of the proposing company's:
- Claims and Eligibility Systems
- Provider Networks (where applicable)
- Systems Reporting Capabilities
- Claims Adjudication Policies and Procedures
- Administrative Services Contract Wording
- Standard and Non -Standard Banking Arrangements
- Relationships with Third Parties
➢ Be thoroughly familiar with virtually all of the proposing company's functions that relate
directly or indirectly to the account.
➢ Act on behalf of The City in "cutting through red tape". This facet of account
management cannot be emphasized enough — the account management team must
be able to effectively advance the interests of The City through the vendor's corporate
structure.
• Enrollment/Eligibility
The City will provide initial enrollment forms on paper, but seeks to provide eligibility
updates electronically. The initial enrollment and updates will provided directly to the
selected vendor(s) by The City.
The selected vendor(s) will perform direct eligibility certification to providers and verify
coverage as a part of the claims management and adjudication process. A quarterly
reconciliation between payroll and eligibility will be required of the selected vendor(s).
• Fee Administration
All fee/premium statements will be self -billed by The City. The City will calculate the fees/
premiums payable on a monthly basis and will submit these fees directly to the selected
vendor(s).
• COBRA Administration
City of Fort Collins, RFP 2003
6
ADC50 Enrollee and Dependents List 29/JUL/2003
Company : 004 Anthem Life Insurance Company
Country : 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
11/01/1998 A 12/12/1956 F
11/01/1998 A 12/09/1950 M SPOUSE
05/01/1998 A 12/30/1955 F
05/01/1998 A 11/19/1954 M SPOUSE
04/01/2003 A 07/10/1974 M
04/01/2003 A 11/23/1974 F SPOUSE
12/01/2000 A 07/06/1968 M
12/01/2000 A 08/24/1970 F SPOUSE
06/01/2001 A 12/01/1961 M
06/01/2001 A 02/07/1964 F SPOUSE
05/01/1992 A 12/25/1958 M
° 05/01/1992 A O1/12/1962 F SPOUSE
06/01/1993 A 12/04/1954 M
06/01/1993 A 04/02/1956 F SPOUSE
04/01/1992 A 12/29/1954 F
04/01/1992 A 08/29/1944 M SPOUSE
06/01/1992 A 12/20/1960 F
06/01/1992 A 07/25/1947 M SPOUSE
04/01/1992 A 12/24/1959 M
04/01/1992 A O1/25/1968 F SPOUSE
04/01/1992 A O1/01/1960 M
04/01/1992 A 09/29/1954 F SPOUSE
O1/01/2003 A 09/20/1955 F
04/01/1992 A 04/14/1952 M SPOUSE
02/01/1999 A 06/04/1953 M
02/01/1999 A 12/31/1953 F SPOUSE
04/01/1992 A O1/01/1980 F
04/01/1992 A 03/15/1947 M SPOUSE
06/01/1999 A 07/23/1954 F
06/01/1999 A 09/08/1948 M SPOUSE
11/01/1999 A 12/15/1949 F
04/01/1992 A 12/06/1949 M SPOUSE
- 04/01/1992 A 12/05/1954 F
04/01/1992 A 06/20/1951 M SPOUSE
O1/01/1994 A 01/01/1980 M
O1/01/1994 A 11/18/1951 F SPOUSE
04/01/1992 A 12/07/1963 M
04/01/1992 A 10/25/1965 F SPOUSE
04/01/1992 A 12/04/1954 M
04/01/1992 A 07/07/1955 F SPOUSE
04/01/1992 A 12/10/1963 M
04/01/1992 A O8/31/1963 F SPOUSE
04/01/1998 A 07/10/1945 M
04/01/1998 A 09/10/1951 F SPOUSE
04/01/1992 A O1/01/1980 M
04/01/1992 A 02/09/1959 F SPOUSE
Page 21
Terminated Class
E-type
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
N
03
T
03
N
03
N
03
T
03
N
03
T
03
N
03
N
03
N
03
N
03
N
03
N
03
T
volume
10, 000.00
130, 000.00
300,000.00
100,000.00
250,000.00
180,000.00
30,000.00
60,000.00
100,000.00
150,000.00
90,000.00
200,000.00
50,000.00
10, 000.00
100, 000.00
10,000.00
10, 000.00
70,000.00
80,000.00
50, 000.00
100,000.00
40,000.00
60, 000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
------ ----------------------------- -----------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
02/01/1996 A 05/06/1960 M
02/01/1996 A O1/17/1967 F SPOUSE
09/01/1993 A 12/03/1964 M
09/01/1993 A 04/24/1965 F SPOUSE
02/01/1993 A 12/19/1948 M
02/01/1993 A 06/19/1953 F SPOUSE
12/01/2002 A 02/24/1970 M
12/01/2002 A 07/21/1971 F SPOUSE
03/01/1997 A 07/31/1970 M
03/01/1997 A 02/20/1972 F SPOUSE
04/01/1992 A 09/02/1955 M
04/01/1992 A 04/23/1958 F SPOUSE
02/01/1998 A 10/20/1969 M
02/01/1998 A 11/11/1969 F SPOUSE
04/01/1992 A 11/11/1965 F
04/01/1992 A 11/11/1965 F SPOUSE
02/01/1996 A 08/16/1961 M
02/01/1996 A 11/30/1963 F SPOUSE
03/01/1993 A 12/13/1961 M
,.�. 03/01/1993 A 05/26/1965 F SPOUSE
04/01/1992 A 12/27/1947 M
04/01/1992 A 07/06/1948 F SPOUSE
04/01/1992 A 04/25/1946 M
04/01/1992 A 06/25/1953 F SPOUSE
10/01/2002 A 12/18/1957 F
10/01/2002 A 10/23/1957 M SPOUSE
03/01/1999 A 01/24/1968 M
03/01/1999 A 07/20/1971 F SPOUSE
04/01/1996 A 02/08/19SO F
04/01/1996 A 07/10/1945 M SPOUSE
02/01/1993 A 12/30/1953 M
02/01/1993 A 05/06/1959 F SPOUSE
.. 04/01/1992 A 12/08/1951 M
04/01/1992 A 11/21/1954 F SPOUSE
04/01/1992 A 12/05/1951 M
04/01/1992 A 12/16/1957 F SPOUSE
O1/01/1997 A 11/06/1961 F
01/01/1997 A 09/14/1961 M SPOUSE
O1/01/1995 A 07/31/1950 M
O1/01/1995 A 08/31/1953 F SPOUSE
12/01/2000 A 04/02/1961 M
12/01/2000 A 06/23/1969 F SPOUSE
11/01/2001 A 10/19/1972 M
11/01/2001 A 05/14/1974 F SPOUSE
04/01/1999 A 09/14/1968 M
04/01/1999 A 04/08/1969 F SPOUSE
Page 22
Terminated Class
E-type
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
T
03
T
03
N
03
N
03
T
03
N
03
N
03
N
Volume
100,000.00
200,000.00
150,000.00
250,000.00
10,000.00
70, 000.00
150,000-00
10,000.00
200,000.00
100,000.00
10,000.00
100,000.00
50,000.00
300,000.00
10,000.00
60,000.00
100,000-00
200,000.00
250,000.00
50,000.00
10,000.00
300,000.00
250,000-00
ADC50 Enrollee and Dependents List 29/JUL/2003
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group : 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
04/01/1992 A 03/15/1954 M
04/01/1992 A 10/26/1958 F SPOUSE
05/01/1999 A 11/17/1950 F
05/01/1999 A O1/18/1950 M SPOUSE
02/01/1999 A 12/28/1967 F
02/01/1999 A 12/03/1967 M SPOUSE
02/01/1993 A 12/02/1944 M
02/01/1993 A 12/01/1945 F SPOUSE
04/01/1992 A 12/05/1954 M
04/01/1992 A 10/31/1956 F SPOUSE
02/01/1994 A O8/10/1947 M
02/01/1994 A 02/27/1946 F SPOUSE
06/01/1992 A 12/02/1958 M
06/01/1992 A 05/08/1964 F SPOUSE
09/01/2003 A 04/21/1965 M
09/01/2003 A 02/02/1966 F SPOUSE
04/01/1992 A 12/17/1963 M
04/01/1992 A 04/26/1965 F SPOUSE
04/01/1999 A 04/28/1970 M
04/01/1999 A 07/22/1977 F SPOUSE
02/01/1999 A O1/01/1980 M
02/01/1999 A 06/25/1956 F SPOUSE
04/01/1992 A 12/02/1949 M
04/01/1992 A 05/20/1950 F SPOUSE
04/01/1992 A O1/21/1953 M
04/01/1992 A 09/24/1952 F SPOUSE
05/01/2003 A 02/08/1962 F
05/01/2003 A 06/21/1960 M SPOUSE
06/01/2002 A 10/05/1962 F
06/01/2002 A 09/28/1960 M SPOUSE
09/01/1993 A 09/08/1964 F
09/01/1993 A 04/06/1965 M SPOUSE
08/01/2000 A 07/23/1960 F
08/01/2000 A 10/20/1959 M SPOUSE
05/01/1999 A 06/26/1967 M
05/01/1999 A 04/05/1968 F SPOUSE
04/01/1992 A 12/22/1946 M
04/01/1992 A O8/15/1949 F SPOUSE
06/01/1992 A 09/06/1956 M
06/01/1992 A 03/06/1958 F SPOUSE
12/01/2002 A O1/09/1966 F
12/01/2002 A O6/26/1964 M SPOUSE
06/01/2003 A 09/11/1977 F
06/01/2003 A 04/04/1977 M SPOUSE
04/01/2000 A 05/09/1956 M
04/01/2000 A 06/04/1961 F SPOUSE
Page 23
Terminated Class E-type
03 N
03 T
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 T
03 N
03 N
03 N
03 N
03 N
03 N
03 T
03 N
Volume
50,000.00
10,000.00
300,000.00
100,000.00
100,000.00
120, 000.00
10, 000.00
300,000.00
150,000.00
100,000.00
200,000.00
80,000.00
50,000.00
250,000.00
10,000.00
150,000.00
150,000.00
100,000.00
50,000.00
200,000.00
50,000.00
50,000.00
250.000.00
ADCSO Enrollee and Dependents List 29/JUL/2003
------ ------------------------------__--__-___
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
04/01/1992 A 12/05/1941 M
04/01/1992 A O1/09/1942 F SPOUSE
04/01/1992 A 12/03/1957 M
04/01/1992 A 02/06/1957 F SPOUSE
08/01/1999 A 09/17/196S M
08/01/1999 A O1/18/1968 F SPOUSE
O1/01/1994 A 12/29/1963 F
O1/01/1994 A 06/26/1963 M SPOUSE
O1/01/1996 A 12/25/1969 F
01/01/1996 A 12/11/1969 M SPOUSE
03/01/1999 A 05/19/1959 M
03/01/1999 A 06/29/1963 F SPOUSE
06/01/1992 A 12/21/1952 F
06/01/1992 A 02/06/195G M SPOUSE
11/01/1999 A 08/18/1971 M
11/01/1999 A 07/20/1973 F SPOUSE
04/01/1997 A 03/11/1958 M
04/01/1997 A 02/12/1959 F SPOUSE
02/01/1993 A 12/12/1958 M
02/01/1993 A 08/26/1960 F SPOUSE
O1/01/2001 A 10/13/1959 F
O1/01/2001 A 07/14/1963 M SPOUSE
03/01/2000 A 09/23/1970 M
03/01/2000 A 09/09/197S F SPOUSE
04/01/1992 A 12/25/1953 M
04/01/1992 A 04/18/1956 F SPOUSE
04/01/1997 A 12/05/1955 M
04/01/1997 A 05/31/1953 F SPOUSE
04/01/1992 A O1/O1/1980 F
04/01/1992 A 11/09/1951 M SPOUSE
04/01/1992 A OS/12/1963 F
04/01/1992 A 04/20/1951 M SPOUSE
09/01/1994 A 02/03/1950 M
09/01/1994 A 02/09/1966 F SPOUSE
06/01/2002 A 03/06/1978 M
06/01/2002 A 04/12/1980 F SPOUSE
10/01/1995 A 12/12/1957 F
10/01/1995 A 05/20/1957 M SPOUSE
04/01/1992 A 12/09/1961 F
04/01/1992 A 11/01/1958 M SPOUSE
04/01/1992 A 12/19/1959 F
04/01/1992 A O8/17/1957 M SPOUSE
11/01/2000 A 05/21/1977 F
11/01/2000 A 09/14/1974 M SPOUSE
02/01/1997 A 02/15/1954 M
02/01/1997 A 04/03/1957 F SPOUSE
Page 24
Terminated Class E-type
03 N
03 N
03 N
03 N
03 T
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
Volume
10,000.00
30, 000.00
200,000.00
150,000.00
100,000.00
50,000.00
200,000.00
300,000.00
300,000.00
100,000.00
30, 000.00
100, 000.00
100, 000.00
100, 000.00
20, 000.00
100,000.00
200,000.00
100,000.00
150,000.00
20,000.00
80,000.00
200,000.00
120,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group : 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
---- 04/01/1992 A 12/20/1942 M
04/01/1992 A 01/18/1943 F SPOUSE
02/01/1993 A 12/07/1959 M
02/01/1993 A 10/25/1959 F SPOUSE
04/01/1992 A 12/31/1956 M
04/01/1992 A 04/02/1962 F SPOUSE
04/01/1992 A 12/20/1953 M
04/01/1992 A 10/06/1941 F SPOUSE
02/01/1998 A 03/09/1956 F
02/01/1998 A 02/22/1952 M SPOUSE
04/01/1992 A 12/13/1955 M
04/01/1992 A 06/15/1957 F SPOUSE
09/01/2001 A 08/07/1968 M
09/01/2001 A 09/20/1959 F SPOUSE
O1/01/1995 A 02/26/1961 M
O1/01/1995 A 04/02/1964 F SPOUSE
04/01/1992 A 12/23/1946 M
04/01/1992 A 09/25/1946 F SPOUSE
03/01/1994 A 04/29/1963 M
03/01/1994 A 04/29/1963 F SPOUSE
02/01/1996 A 09/10/1968 M
02/01/1996 A 12/09/1966 F SPOUSE
04/01/1996 A 03/29/1955 F
04/01/1996 A 09/17/1947 M SPOUSE
04/01/1995 A 07/23/1947 M
04/01/1995 A 10/04/1949 F SPOUSE
04/01/1992 A 12/10/1953 M
04/01/1992 A 11/04/1952 F SPOUSE
04/01/2002 A O5/09/1958 M
04/01/2002 A 09/16/1958 F SPOUSE
02/01/1994 A 12/28/1965 M
02/01/1994 A 02/04/1964 F SPOUSE
10/01/1996 A 04/20/1959 F
10/01/1996 A 04/20/1959 M SPOUSE
O1/01/1996 A 12/19/1959 M
01/01/1996 A 09/04/1964 F SPOUSE
04/01/1996 A 06/24/1945 M
04/01/1996 A 07/30/1944 F SPOUSE
04/01/1992 A 12/29/1958 M
04/01/1992 A O1/21/1958 F SPOUSE
04/01/1992 A 12/27/1956 F
04/01/1992 A 07/07/1956 M SPOUSE
11/01/1995 A 10/07/1970 M
11/01/1995 A 09/06/1972 F SPOUSE
02/01/2003 A 06/10/1967 M
02/01/2003 A 10/26/1966 F SPOUSE
Page 2S
Terminated Class E-type
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 T
03 N
03 N
03 N
03 N
03 N
03 N
03 T
03 N
03 N
Volume
20,000.00
30,000.00
50,000.00
50, 000.00
150,000.00
100,000.00
300,000.00
100, 000.00
10,000.00
50,000.00
100,000.00
50, 000.00
50,000.00
60,000.00
10,000.00
80,000.00
10,000.00
80,000.00
50,000.00
50,000.00
10,000.00
30,000-00
100.000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
04/01/1992 A 12/09/1954 M
04/01/1992 A 02/10/1953 F SPOUSE
04/01/1992 A 12/29/194S M
04/01/1992 A O1/22/1947 F SPOUSE
01/01/1999 A 10/04/1949 M
O1/01/1999 A 03/16/1964 F SPOUSE
11/01/2001 A 07/17/1953 F
11/01/2001 A 11/26/1954 M SPOUSE
06/01/1992 A 12/18/1966 M
06/01/1992 A 05/16/1967 F SPOUSE
09/01/1999 A 12/09/1958 F
09/01/1999 A 07/17/1949 M SPOUSE
04/01/1992 A 12/26/1951 M
04/01/1992 A 09/26/1951 F SPOUSE
O1/01/1999 A O1/01/1980 M
O1/01/1999 A 07/09/1965 F SPOUSE
04/01/1992 A 12/08/1952 F
04/01/1992 A 07/26/1955 M SPOUSE
01/01/2003 A 10/21/1969 F
01/01/2003 A 07/20/1963M SPOUSE
04/01/1992 A 12/19/19SO M
04/01/1992 A 04/13/1951 F SPOUSE
11/01/1996 A 09/06/1970 M
11/01/1996 A 02/26/1971 F SPOUSE
04/01/1992 A 12/14/1959 M
04/01/1992 A 03/02/1963 F SPOUSE
04/01/1992 A O8/20/1945 M
04/01/1992 A 03/16/19SO F SPOUSE
01/01/1994 A 06/11/1957 F
O1/01/1994 A 04/23/1949 M SPOUSE
02/01/1993 A 12/06/1959 M
02/01/1993 A 12/01/1960 F SPOUSE
., 04/01/1992 A 12/18/1952 M
04/01/1992 A 10/14/1948 F SPOUSE
04/01/1992 A 12/31/1964 M
04/01/1992 A 10/02/1964 F SPOUSE
02/01/1996 A 09/13/1949 M
02/01/1996 A 02/06/1953 F SPOUSE
08/01/1992 A 12/30/1952 M
O8/01/1992 A 11/22/1960 F SPOUSE
04/01/1992 A 12/02/1950 M
04/01/1992 A 10/04/1951 F SPOUSE
04/01/1992 A 12/11/1962 M
04/01/1992 A 12/29/1959 F SPOUSE
04/01/1992 A 12/19/1947 M
04/01/1992 A 07/19/1950 F SPOUSE
Page 26
Terminated Class
E-type
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
T
Volume
150,000.00
10,000.00
100,000.00
10, 000.00
50, 000.00
90,000.00
100,000.00
50, 000.00
10, 000.00
100,000.00
30, 000.00
250,000.00
10,000.00
50,000.00
50,000.00
150,000.00
50,000.00
100,000.00
40,000.00
100,000.00
10,000.00
100,000.00
30.000.00
ADC50
Enrollee and Dependents List 29/JUL/2003
Page 27
Group
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
00651E-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
01/01/1994 A 12/04/1955 F
O1/01/1994 A 11/22/1955 M SPOUSE
06/01/1994 A 03/20/1949 M
02/01/1994 A O1/17/1956 F SPOUSE
07/01/1992 A 12/27/1947 F
07/01/1992 A 07/12/1945 M SPOUSE
05/01/2003 A 05/08/1968 M
05/01/2003 A 04/23/1969 F SPOUSE
07/01/2002 A 10/29/1964 M
07/01/2002 A 05/03/1967 F SPOUSE
O1/01/1998 A 04/04/1954 M
O1/01/1998 A 11/16/1959 F SPOUSE
04/01/1992 A 12/26/1953 M
04/01/1992 A 09/11/1949 F SPOUSE
O1/01/1996 A 04/15/1949 F
O1/01/1996 A 07/06/1949 M SPOUSE
04/01/1992 A 12/03/1954 M
04/01/1992 A O8/08/1967 F SPOUSE
02/01/1997 A 03/04/1948 M
02/01/1997 A 04/03/1948 F SPOUSE
04/01/1992 A 12/23/1959 M
04/01/1992 A 07/13/1956 F SPOUSE
01/01/2001 A 08/09/1959 F
O1/01/2001 A 04/15/1955 M SPOUSE
O1/01/1998 A 10/05/1968 F
O1/01/1998 A 10/21/1972 M SPOUSE
04/01/1992 A 12/05/1957 F
04/01/1992 A 03/07/1954 M SPOUSE
04/01/1992 A 12/05/1952 M
04/01/1992 A 04/05/1952 F SPOUSE
04/01/1992 A 12/16/1960 M
04/01/1992 A 02/03/1959 F SPOUSE
.. 02/01/1999 A 02/20/1967 M
02/01/1999 A 08/08/1966 F SPOUSE
10/01/1993 A 06/22/1951 M
10/01/1993 A 05/16/1954 F SPOUSE
08/01/2002 A 10/23/1969 M
08/01/2002 A 06/27/1972 F SPOUSE
02/01/2003 A 11/30/1967 F
02/01/2003 A 04/06/1969 M SPOUSE
05/01/2002 A 10/14/1951 F
05/01/2002 A 11/11/1939 M SPOUSE
04/01/1992 A 12/18/1968 M
04/01/1992 A 05/20/1967 F SPOUSE
04/01/1992 A 12/22/1964 M
04/01/1992 A 02/04/1961 F SPOUSE
Terminated Class E-type
03 N
03 N
03 T
03 N
03 N
03 N
03 T
03 N
03 N
03 T
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 T
03 N
03 N
03 N
03 N
Volume
100,000.00
50,000.00
30,000.00
120,000.00
100,000.00
50,000.00
50,000.00
30, 000.00
150,000.00
10, 000.00
60, 000.00
30,000.00
200,000.00
100,000.00
10,000.00
150,000.00
100, 000.00
150, 000.00
150,000.00
300,000.00
50, 000.00
150,000.00
300,000-00
ADC50 Enrollee and Dependents List 29/JUL/2003
_____________________________
Company 004 Anthem Life Insurance Company
Country : 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
05/01/1997 A 04/16/1948 M
05/01/1997 A 10/23/1949 F SPOUSE
04/01/1992 A O1/01/1980 M
04/01/1992 A 03/07/1953 F SPOUSE
04/01/1992 A 01/01/1980 M
04/01/1992 A 06/09/1953 F SPOUSE
04/01/1992 A O1/01/1980 M
04/01/1992 A 07/20/1950 F SPOUSE
O1/01/1995 A 12/18/1952 M
O1/01/1995 A 05/29/1953 F SPOUSE
10/01/2002 A 07/12/1970 M
10/01/2002 A 06/19/1975 F SPOUSE
04/01/1992 A 12/13/1954 M
04/01/1992 A O1/12/1958 F SPOUSE
05/01/1999 A 08/11/1959 F
05/01/1999 A 11/04/1964 M SPOUSE
06/01/2000 A 06/25/1960 M
06/01/2000 A 06/07/1961 F SPOUSE
04/01/1992 A 12/20/1956 M
04/01/1992 A 03/06/1963 F SPOUSE
04/01/1992 A 12/26/1956 M
04/01/1992 A 03/11/1958 F SPOUSE
02/01/1993 A 12/26/1950 M
02/01/1993 A O1/18/1951 F SPOUSE
O1/01/1994 A O1/01/1980 F
O1/01/1994 A 08/28/1947 M SPOUSE
04/01/1992 A 12/09/1964 M
04/01/1992 A 06/14/1959 F SPOUSE
08/01/2001 A 06/06/1970 M
O8/01/2001 A O1/29/1976 F SPOUSE
04/01/1992 A 12/27/1961 F
04/01/1992 A 01/09/1960 M SPOUSE
05/01/1997 A 05/19/1950 M
05/01/1997 A 11/15/1954 F SPOUSE
O1/01/2001 A O8/03/1975 F
05/01/1997 A 03/26/1957 F
05/01/1997 A O1/22/1954 M SPOUSE
O1/01/2000 A O8/21/1959 F
O1/01/2000 A 11/17/1956 M SPOUSE
02/01/1993 A 12/29/1955 M
02/01/1993 A 10/11/1955 F SPOUSE
10/01/1999 A 04/21/1970 M
O1/01/1994 A 06/08/1964 M
O1/01/1994 A O1/08/1967 F SPOUSE
O1/01/1999 A 05/21/1967 M
O1/01/1999 A 12/26/1958 F SPOUSE
Page 28
Terminated Class E-type
03 N
03 N
03 T
03 T
03 N
03 N
03 N
03 T
03 N
03 N
03 N
03 N
03 T
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 T
03 N
03 N
Volume
30,000.00
40,000.00
50,000.00
50, 000.00
150,000.00
100,000.00
100,000.00
100,000.00
100, 000.00
10,000.00
70,000.00
50,000.00
10,000.00
100, 000.00
300,000.00
180, 000.00
100, 000.00
200,000.00
100,000.00
40,000.00
200,000.00
100,000.00
50,000.00
100, 000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
DS/01/1992 A 12/21/1955 F
05/01/1992 A 09/16/1961 M SPOUSE
O5/01/2000 A 04/26/1969 M
05/01/2000 A 05/31/1971 F SPOUSE
03/01/2002 A 02/11/1960 M
03/01/2002 A 10/25/1956 F SPOUSE
11/01/1995 A 12/07/1952 F
11/01/1995 A 10/13/1940 M SPOUSE
01/01/1999 A 08/14/1944 M
O1/01/1999 A 02/27/1950 F SPOUSE
08/01/1998 A 12/07/1956 M
08/01/1998 A 12/25/1969 F SPOUSE
05/01/1998 A 12/23/1960 M
o5/01/1998 A 06/25/1956 F SPOUSE
04/01/1993 A 12/08/1954 F
04/01/1993 A 11/14/1946 M SPOUSE
06/01/1992 A 12/29/1959 M
06/01/1992 A 10/07/1963 F SPOUSE
04/01/1992 A 12/23/1953 M
04/01/1992 A 06/18/1951 F SPOUSE
04/01/1992 A 12/28/1951 M
04/01/1992 A 07/06/1951 F SPOUSE
03/01/2001 A 04/22/1954 M
03/01/2001 A 10/22/1959 F SPOUSE
O1/01/2001 A 02/17/1970 M
O1/01/2001 A 06/14/1973 F SPOUSE
04/01/1992 A 12/08/1956 M
04/01/1992 A 02/13/1956 F SPOUSE
02/01/1998 A 10/12/1955 F
02/01/1998 A 11/20/1946 M SPOUSE
O1/01/1995 A 07/14/1953 M
01/01/1995 A 12/05/1955 F SPOUSE
04/01/1992 A 12/25/1947 M
04/01/1992 A O1/15/1956 F SPOUSE
04/01/1992 A 12/31/1951 M
04/01/1992 A 11/03/1954 F SPOUSE
04/01/1992 A 12/15/1949 M
04/01/1992 A 07/20/1951 F SPOUSE
04/01/1992 A 12/20/1962 M
04/01/1992 A 06/28/1962 F SPOUSE
Page 29
Terminated Class E-type
03 N
03 N
03 N
03 T
03 N
03 N
03 N
03 N
03 T
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 T
297
volume
80,000.00
100,000.00
100,000.00
70,000.00
10, 000.00
30, 000.00
100,000.00
100,000.00
100,000.00
10,000.00
100,000.00
150,000.00
90,000.00
50,000.00
so, 000.00
150,000.00
150,000.00
40,000.00
50,000.00
50, 000.00
28,500,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 30
------ ----------------------------- ----------- ----------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 113 Voluntary Life - Child
Group 00651E-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
10/01/1993
A
12/19/1956
M
1B
1
5,000.00
03/01/1997
A
02/14/1959
M
1B
1
5,000.00
02/01/2003
A
08/20/1973
F
1B
1
5,000.00
10/01/1993
A
12/06/1952
M
1B
1
5,000.00
10/01/1993
A
12/24/1949
M
18
1
5,000.00
10/01/1993
A
12/03/1957
F
1B
1
5,000.00
10/01/1993
A
12/11/1941
F
113
1
5,000.00
O1/01/1995
A
04/11/1966
M
1B
1
5,000.00
04/01/1994
A
02/24/1951
M
1B
1
5,000.00
10/01/1993
A
12/28/1950
M
1B
1
5,000.00
06/01/1998
A
10/03/1951
- M
1B
1
5,000.00
10/01/1993
A
11/23/1959
M
1B
1
5,000.00
10/01/1993
A
12/29/1954
M
1B
1
5,000.00
10/01/1993
A
12/06/1950
M
1B
1
5,000.00
-
01/01/1994
A
07/15/1960
M
1B
1
5,000.00
04/01/2000
A
04/08/1966
M
1B
1
5,000.00
10/01/1993
A
03/23/1964
F
1B
1
5,000.00
06/01/1998
A
05/27/1973
F
IS
1
5,000.00
10/01/1993
A
12/27/1956
M
1B
1
5,000.00
10/01/1993
A
12/24/1952
F
1B
1
5,000.00
10/01/1993
A
12/16/1961
M
1B
1
5,000.00
10/01/1993
A
12/20/1945
M
1B
1
5,000.00
10/01/1993
A
12/13/1958
M
1B
1
5,000.00
11/01/1994
A
07/05/1963
M
1B
1
5,000.00
O1/01/1994
A
12/06/1966
M
1B
1
5,000.00
10/01/1993
A
12/08/1962
M
IS
1
5,000.00
05/01/2002
A
12/13/1967
F
IS
1
5,000.00
12/01/1998
A
07/29/1969
M
1B
1
5,000.00
02/01/1996
A
04/04/1957
M
1B
1
5,000.00
02/01/1994
A
12/31/1960
M
1B
1
5,000.00
11/01/1994
A
O1/01/1980
F
1B
1
5,000.00
O1/01/1994
A
07/23/1961
F
1B
1
5,000.00
,-
05/01/1994
A
07/18/1955
M
1B
1
5,000.00
04/01/1996
A
12/03/1948
M
1B
1
5,000.00
04/01/1994
A
03/06/1952
M
1B
1
5,000.00
10/01/1993
A
12/12/1947
F
1B
1
5,000.00
03/01/2002
A
04/02/1961
F
1B
1
5,000.00
10/01/1993
A
12/07/1957
M
1B
1
5,000.00
10/01/1993
A
12/04/1946
M
1B
1
5,000.00
10/01/1993
A
12/17/1947
F
1B
1
5,000.00
07/01/1995
A
O1/01/1980
F
1B
1
5,000.00
10/01/1993
A
12/08/1954
M
1B
1
5,000.00
10/01/1993
A
12/27/1967
F
1B
1
5,000.00
02/01/1997
A
06/28/1963
M
1B
1
5,000.00
10/01/1993
A
12/17/1956
M -
1B
1
5,000.00
Where applicable, the COBRA Administration will be conducted by the chosen vendor(s)
and eligibility information will be provided by The City. Supportive services required by the
selected vendor(s) will be as follows:
➢ Accept information from The City on COBRA participants
➢ Send COBRA notifications to plan participants at termination
➢ Claims adjudication inquiries
➢ COBRA member service inquiries related to benefits and claims
• Customer Service
The selected vendor(s) must have as its primary focus on efficient and effective processing
of all inquiries. Satisfactory customer service will include prompt, courteous and accurate
responses to the City and employee inquiries regarding claim submissions, applicable
provider networks, plan design and provisions, etc. A toll free number should be available
for eligibility certification and claim submission inquiries.
• Financial Accounting
On a monthly basis, the selected vendor(s) must provide an accounting reconciliation of any
"central bank" accounts utilized.
The selected vendor(s) must provide a quarterly written report detailing all administrative
expenses charged outside the Administrative Services Agreement. The selected vendor(s)
must present a report detailing and justifying proposed fees for the coming year by
September 1st of the preceding year.
• Right to Audit
The selected vendor(s) must agree to allow The City, or its representative, the right to audit
all claims, applicable provider credentialing, financial data and other information relevant to
the City's account.
• Data and Management Information Reporting
The selected vendor(s) must provide monthly paid claim summaries and detailed claim
listings, preferably in Excel format. The vendor(s) must also provide its standard reporting
package. Ad hoc reports will periodically be requested. Enrollment, claims and
premium/fee information must be accurate and supplied in a timely manner upon request.
Please describe your online claim reporting and look -up capabilities that will be available to
The City.
• "No Loss/No Gain" for Covered Employees
It is critical that there will be no loss of coverage for any employees. Therefore it is required
that your proposal waives any "actively at work", "dependent confinement", or any other
rules that would prevent 100% continuity of coverage for any employees or dependents who
are currently covered under the plans.
City of Fort Collins, RFP 2003
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 31
___________ __________
_____________________________
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 113 Voluntary Life - Child
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
03/01/1995
A
07/06/1951
M
1B
1
5,000.00
10/01/1993
A
12/14/1951
M
1B
1
5,000.00
10/01/1993
A
12/25/1952
F
1B
1
5,000.00
02/01/1994
A
08/26/1952
M
113
1
5,000.00
10/01/1993
A
05/14/1949
M
1B
1
5,000.00
10/01/1993
A
12/15/1953
M
1B
1
5,000.00
09/01/2001
A
09/07/1973
M
1B
1
5,000.00
03/01/1997
A
06/19/1952
M
1B
1
5,000.00
10/01/1993
A
12/13/1955
M
1B
1
5,000.00
10/01/1993
A
12/07/1947
M
1B
1
5,000.00
02/01/1994
A
03/28/1962
M
1B
1
5,000.00
05/01/1997
A
05/18/1953
M
1B
1
5,000.00
01/01/1994
A
03/20/1958
F
1B
1
5,000.00
06/01/1997
A
12/11/1965
M
1B
1
5,000.00
10/01/1993
A
12/05/1951
M
is
1
5,000.00
03/01/1996
A
09/12/1959
M
1B
1
5,000.00
10/01/1993
A
12/25/1956
M
1B
1
5,000.00
04/01/2002
A
11/19/1960
M
1B
1
5,000.00
08/01/1995
A
08/20/1958
M
1B
1
5, 000.00
10/01/1993
A
02/25/1955
M
1B
1
5,000.00
10/01/1993
A
12/06/19SO
M
1B
1
5,000.00
04/01/2003
A
07/10/1974
M
1B
1
5,000.00
12/01/2000
A
07/06/1968
M
1B
1
5,000.00
03/01/1997
A
12/25/1958
M
1B
1
5,000.00
10/01/1997
A
12/24/1959
M
1B
1
5,000.00
10/01/1993
A
12/21/1952
M
1B
1
5,000.00
10/01/1993
A
01/01/1980
M
1B
1
5,000.00
02/01/1999
A
06/04/1953
M
1B
1
5,000.00
10/01/1993
A
O1/01/1980
F
1B
1
5,000.00
10/01/1993
A
12/05/1954
F
1B
1
5,000.00
10/01/1993
A
12/07/1963
M
1B
1
5,000.00
10/01/1993
A
12/04/1954
M
1B
1
5,000.00
01/01/1996
A
05/06/1960
M
1B
1
5,000.00
10/01/1993
A
12/19/1948
M
1B
1
5,000.00
06/01/2000
A
02/20/1972
F
1B
1
5,000.00
03/01/2001
A
09/02/1955
M
1B
1
5,000.00
02/01/1998
A
10/20/1969
M
1B
1
5,000.00
03/01/1996
A
11/11/1965
F
1B
1
5,000.00
10/01/1993
A
12/13/1961
M
1B
1
5,000.00
02/01/1996
A
09/24/1958
F
1B
1
5,000.00
10/01/2002
A
12/18/1957
F
1B
1
5,000.00
10/01/1993
A
12/30/1953
M
1B
1
5,000.00
O1/01/1997
A
11/06/1961
F
1B
1
5,000.00
03/01/1995
A
07/31/1950
M
1B
1
5,000.00
11/01/2001
A
10/19/1972
M
1B
1
5,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 32
-------------- `------------------------------ ----------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 113 Voluntary Life - Child
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
03/01/1999
A
12/28/1967
F
1B
1
5,000.00
10/01/1993
A
12/05/1954
M
1B
1
5,000.00
03/01/1999
A
04/21/1965
M
1B
1
5,000.00
10/01/1993
A
12/21/1946
M
1B
1
5,000.00
10/01/1993
A
12/17/1963
M
1B
1
5,000.00
12/01/2002
A
12/21/1966
M
1B
1
5,000.00
10/01/1993
A
12/02/1949
M
1B
1
5,000.00
07/01/1996
A
05/13/1962
F
1B
1
5,000.00
10/01/1993
A
12/13/1951
M
1B
1
5,000.00
06/01/2002
A
10/05/1962
F
1B
1
5,000.00
OS/01/1999
A
06/26/1967
M
1B
1
5,000.00
10/01/1993
A
12/22/1946
M
1B
1
5,000.00
10/01/1993
A
09/06/1956
M
1B
1
5,000.00
•
03/01/2000
A
01/09/1966
F
1B
1
5,000.00
06/01/2003
A
09/11/1977
F
1B
1
5,000.00
10/01/1993
A
05/09/1956
M
1B
1
5,000.00
10/01/1993
A
12/03/1957
M
1B
1
5,000.00
10/01/1993
A
12/29/1963
F
1B
1
5,000.00
02/01/1997
A
03/11/1958
M
1B
1
5,000.00
-.
10/01/1993
A
12/25/1953
M
1B
1
5,000.00
09/01/1994
A
02/03/1950
M
1B
1
5,000.00
10/01/1993
A
12/21/1957
F
1B
1
5,000.00
10/01/1993
A
12/2S/1952
F
1B
1
5,000.00
10/01/1993
A
12/24/1948
M
1B
1
5,000.00
06/01/1998
A
04/22/1966
F
1B
1
5,000.00
10/01/1993
A
12/19/1959
F
1B
1
5,000.00
11/01/2000
A
05/21/1977
F
1B
1
5,000.00
O1/01/2003
A
02/15/1954
M
1B
1
5,000.00
'
10/01/1993
A
12/07/1959
M
1B
1
5,000.00
10/01/1993
A
12/31/1956
M
1B
1
5,000.00
10/01/1993
A
12/20/1953
M
1B
1
5,000.00
10/01/1993
A
12/14/1949
F
1B
1
5,000.00
-
02/01/1996
A
06/16/1963
M
1B
1
5,000.00
02/01/1998
A
03/09/1956
F
1B
1
5,000.00
10/01/1993
A
12/13/1955
M
1B
1
5,000.00
09/01/2001
A
O8/07/1968
M
1B
1
5,000.00
10/01/1993
A
12/02/1951
M
1B
1
5,000.00
10/01/1993
A
12/23/1946
M
1B
1
5,000.00
03/01/1994
A
04/29/1963
M
1B
1
5,000.00
05/01/1996
A
09/10/1968
M
1B
1
5,000.00
04/01/1995
A
07/23/1947
M
1B
1
5,000.00
10/01/1993
A
12/10/1953
M
1B
1
5,000.00
10/01/1993
A
12/14/1961
M
1B
1
5,000.00
01/01/1994
A
12/2B/1965
M
1B
1
5,000.00
10/01/1993
A
12/30/1948
M
IS
1
5,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 33
-----------------------------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 113 Voluntary Life - Child
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
10/01/1993
A
12/25/1953
M
1B
1
5,000.00
09/01/1996
A
06/24/1945
M
1B
1
5,000.00
10/01/1993
A
12/19/1954
M
1B
1
5,000.00
10/01/1993
A
12/29/1958
M
1B
1
5,000.00
02/01/2003
A
06/10/1967
M
1B
1
5,000.00
10/01/1993
A
12/09/1954
M
1B
1
5,000.00
02/01/1995
A
07/24/1964
F
1B
1
5,000.00
11/01/2001
A
07/17/1953
F
1B
1
5,000.00
10/01/1993
A
12/26/1951
M
1B
1
5,000.00
10/01/1993
A
12/08/1952
F
1B
1
5,000.00
10/01/1993
A
12/06/1959
M
1B
1
5,000.00
10/01/1993
A
12/11/1958
F
1B
1
5,000.00
10/01/1993
A
12/14/1959
M
1B
1
5,000.00
10/01/1993
A
08/20/1945
M
1B
1
5,000.00
10/01/1993
A
12/06/1959
M
1B
1
5,000.00
10/01/1993
A
12/18/1952
M
1B
1
5,000.00
10/01/1993
A
12/31/1964
M
1B
1
5,000.00
10/01/1993
A
12/17/1957
M
1B
1
5,000.00
10/01/1993
A
12/30/1952
M
1B
1
5,000.00
10/01/1993
A
12/02/1950
M
1B
1
5,000.00
10/01/1993
A
12/19/1947
M
1B
1
5,000.00
10/01/1993
A
12/04/1955
F
1B
1
5,000.00
06/01/1994
A
03/20/1949
M
1B
1
5,000.00
07/01/2002
A
10/29/1964
M
1B
1
5,000.00
10/01/1993
A
12/26/1953
M
15
1
5,000.00
10/01/1993
A
12/21/1963
M
1B
1
5,000.00
10/01/1993
A
12/03/1954
M
1B
1
5,000.00
10/01/1993
A
12/23/1959
M
1B
1
5,000.00
10/01/1993
A
08/09/1959
F
1B
1
5,000.00
10/01/1993
A
12/05/1952
M
1B
1
5,000.00
10/01/1993
A
12/16/1960
M
1B
1
5,000.00
02/01/1996
A
02/20/1967
M
1B
1
5,000.00
10/01/1993
A
12/13/1944
M
1B
1
5,000.00
10/01/1993
A
06/22/1951
M
1B
1
5,000.00
04/01/2002
A
10/14/1951
F
1B
1
5,000.00
10/01/1993
A
12/16/1946
M
1B
1
5,000.00
10/01/1993
A
12/11/1948
F
1B
1
5,000.00
10/01/1993
A
O1/01/1980
M
1B
1
5,000.00
02/01/1995
A
10/31/1963
M
1B
1
5,000.00
O1/01/1995
A
12/18/1952
M
1B
1
5,000.00
10/01/1993
A
12/23/1953
M
1B
1
5,000.00
10/01/1993
A
12/11/1954
M
1B
1
5,000.00
04/01/1994
A
12/09/1954
M
1B
1
5,000.00
10/01/1993
A
12/03/1961
F
1B
1
5,000.00
10/01/1993
A
12/13/1954
M
1B
1
5,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
Company : 004 Anthem Life Insurance Company
Country : 01 United States
Coverage: 113 Voluntary Life - Child
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
10/01/1993 A 12/04/1956 M
10/01/1993 A 12/20/1956 M
10/01/1993 A 12/26/1956 M
10/01/1993 A 12/26/1950 M
08/01/2001 A 06/06/1970 M
04/01/1997 A 03/06/1957 M
02/01/1994 A 12/16/1946 M
10/01/1993 A 01/30/1949 M
10/01/1993 A 05/19/1950 M
10/01/1993 A 12/22/1952 M
O1/01/1995 A 03/26/1957 F
10/01/1993 A 12/29/1955 M
10/01/1993 A 12/20/1948 M
O1/01/2001 A 06/15/1962 F
O1/01/1994 A 06/08/1964 M
10/01/1993 A 12/21/1955 F
O1/01/1995 A 12/27/19SB M
OS/01/2000 A 04/26/1969 M
03/01/2002 A 02/11/1960 M
09/01/2001 A 05/01/1957 M
09/01/2002 A 02/10/1958 M
10/01/1993 A 12/07/1956 M
04/01/1996 A 06/23/1959 F
10/01/1993 A 12/08/1954 F
03/01/1996 A 12/29/1959 M
10/01/1993 A 12/15/1957 F
10/01/1993 A 12/09/1949 M
10/01/1993 A 12/28/1951 M
10/01/1993 A 04/22/1954 M
O1/01/2001 A 02/17/1970 M
10/01/1993 A 12/08/1956 M
03/01/1995 A 07/14/1953 M
10/01/1993 A 12/25/1947 M
10/01/1993 A 12/31/1951 M
10/01/1993 A 12/20/1962 M
Page 34
Terminated Class
E-type
Volume
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000,00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000-00
1B
1
5,000.00
1B
1
5, 000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5, 000.00
1B
1
5, 000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5, 000.00
1B
1
5,000.00
1B
1
5, 000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
215 1,075,0.00.00
1172109,875,000.00
COMPARISON OF PLANS FOR CITY OF FORT COLLINS
COMPREHENSIVE VS_ BASIC. - PLAN nF.c1C_N Fnu WAR IWO
COVERAGE
DELTA Preferred Option #1857
DELTA Preferred Option #1858
COMPREHENSIVE PLAN
BASIC PLAN
Provider Selection
The patient may select a DPO, Delta Participating or a Non-
The patient may select a DPO, Delta Participating or a
Participating provider. A DPO Dentist* must be used to
Non -Participating provider. A DPO Dentist* must be
receive the higher benefits. A patient who uses any other
used to receive the higher benefits. A patient who uses
provider will receive benefits at the lower percentage and may
any other provider will receive benefits at the lower
incur greater out-of-pocket expenses.
percentage and may incur greater out-of-pocket
expenses.
Annual Maximum
$1,500.00 per person
$400.00 per person
*DPO PROVIDER
NON-DPO PROVIDER
*DPO PROVIDER
NON-DPO PROVIDER
Diagnostic (X-rays, oral examinations)
(printed in red)
(printed in black)
(printed in red)
(printed in black)
100%
80%
80%
60%
Preventive (Cleanings, Fluoride)
100%
80%
80%
60%
Deductible
$25.00 per person per
$25.00 per person per
$25.00 per person per
$25.00 per person per
calendar year; $50.00 per
calendar year; $50.00 per
calendar year; $50.00 per
calendar year; $50.00 per
family per calendar year.
family per calendar year.
family per calendar year.
family per calendar year.
Deductible does not apply to
Deductible does not apply
Diagnostic & Preventive or
to Diagnostic & Preventive
Orthodontics Services.
Services.
Restorative (Fillings, Stainless steel crowns)
80%
60%
60%
50%
Endodontics (Root canal therapy)
80%
60%
60%
50%
Periodontics (Treatment of the gums)
80%
60%
60%
50%
Oral Surgery (Extractions)
80%
60%
60%
50%
Crown and Bridge
60%
50%
N/A
N/A
Prosthodontics (dentures, partials)
60%
50%
N/A
N/A
* Orthodontics: $1,500.00 Lifetime Maximum
50% (Dependents to age 19 or
50% (Dependents to age 19
N/A
N/A
per eligible dependent child(ren) to age 19 or 25
to age 25 if a full-time
or to age 25 if a full-time
if a full-time student.
student)
student)
__..__._ ._..._.. .., JO 1. IV . I'Ouu urcurrm maximum. t ne oenent for ongoing Vrthodontic treatment is 50% of the remaining Orthodontic fee balance up to $1,500.
The balance for the remaining Orthodontic fee will be determined as of January 1, 2002.
This is a brief description of your dental plan and is subject to the leans of the Contract behveen
Consultants and Actuaries:
The Segal Company
DELTA IS NOW ONLINE
You can obtain a list of dentists in your area or verify
if your dentist is a participating member with Delta.
VIstt Delta's website at:
www.deltadental.com
d DELTA DENTAL'
Delta Dental Plan of Colorado
Stanford Place III
4582 South Ulster Street
Suite 800
Denver, Colorado 80237
(303) 741-9300
Customer Service:
(303) 741-9305 or (800) 610-0201
GROUP DENTAL PLAN
for
CITY OF FORT COLLINS
(BASIC)
DPO PROGRAM
GROUP NUMBER - 1858
EFFECTIVE - JANUARY 1, 1997
d DELTA DENTAL'
Delta Dental Plan of Colorado
300 8198 1 J
No Text
Please complete an Identification Card with your
name and Social Security Number. This is presented to
you for your convenience when making dental visits.
Another card has been included for your spouse. How-
ever, this should be completed with YOUR name and
Social Security Number.
(Please cut on dotted lines)
--------------------------------------------
I I
I I
4582 South Ulster Street I
d DELTA DENTAL• Denver, Colorado 80237
I
1 I
I Delta Dental Plan of Colorado (303) 741.9300 I
Customer Service: (303)741-9305 or (800)610-0201 I
DPO IDENTIFICATION CARD
CITY OF FORT COLLINS
(BASIC)
I 1858 I
NAME GROUPNUMBER.
I I
I I
EMPLOYEE NAME EMPLOYEE SOC. SEC. NO.
I CURRENT EUGIBIUTY SUBJECT TO DETERMINATION BY DDPC I
�_ -- --' --
I I
I I
d ENTAL• 4582 South Ulster Street
DELTA D
Denver, Colorado 80237
I Delta Dental Plan of Colorado (303) 741-9300 I
Customer Scrvice: (303) 741-9305 or (800) 610-0201 I
DPO IDENTIFICATION CARD
CITY OF FORT COLLINS
(BASIC)
1858
NAME GROUP NUMBER.
I I
I I
I EMPLOYEE NAME EMPLOYEE SOC SEC. NO. I
CURRENT EUGIBIUTY SUBJECT TO DETERMINATION BY DDPC I
No Text
notify the employer in writing within thirty-one (31) days of the birth or
placement in order to add the child to the COBRA coverage. A child born,
adopted or placed for adoption and enrolled as indicated will have the same
COBRA rights as any other dependents covered by the plan before the event
that triggered COBRA coverage.
A person's continued coverage elected under the Contract will terminate
at the end of the month in which any of the following events first occurs:
1. The allowable number of months of continued coverage (i.e.18, 29 or 36
months) expires.
2. The Contract terminates.
3. Fees are not paid for the person as required.
4. The person becomes enrolled for dental benefits under another group
dental plan (as an employee or otherwise).
5. The person becomes entitled to Medicare.
Once continued coverage terminates, it cannot be reinstated.
INTRODUCTION
YOUR DENTAL PROGRAM
We are pleased to introduce you to your new dental program. If you
choose the Basic plan, you may not select the Comprehensive plan for two (2)
years. If you are waiving dental coverage altogether, you may only enroll in the
Basic plan at a later date.
ELIGIBILITY
All eligible employees and their dependents who enroll shall be covered
on the effective date. All new eligible employees will become effective on the
first day of the month following thirty (30) days of employment.
Your dependents who are covered are your lawful spouse and your
unmarried children until the end of the month towhich they attain nineteen (19)
years of age orany unmarried children, nineteen (19) years of age until the end
of the month to which they attain twenty-five (25) years who attend an
educational institution on a full-time basis and depend upon you for support.
This includes any stepchild, foster child or legally adopted child who lives with
the employee in a regular parent -child relationship.
Dependent children who are unable to gain employment because of
permanent physical or mental impairment that commenced priorto reaching
age nineteen (19) will be continued as eligible dependents for dental benefits
provided proof of such handicap or incapacity is submitted within thirty-one
(31) days after it is requested by Delta
Dependents in active military service are not covered.
"Dependent" also means any child for whom the employee or spouse is
responsible for medical or other health care benefits under a Qualified Medical
Child Support Order.
ENROLLMENT OF DEPENDENTS
a. You must select the same level of dependent coverage as chosen for
medical coverage.
b. Newly acquired dependents who are enrolled in the medical plan
provided by this employer must be enrolled within thirty-one (31) days of
acquisition. Newborn children must be enrolled within thirty-one (31)
days of birth.
c. Any eligible dependents that suffer involuntary loss of coverage through
another source will be allowed to enroll with satisfactory proof of coverage
loss. Such dependents must be enrolled within thirty-one (31) days of loss
of coverage and must also be enrolled in the medical plan provided bythis
employer.
12. 1.
Section 5.0 Evaluation
The Request for Proposal (RFP) is intended to assess which vendors have the ability to meet
The City's long-term goals and objectives as previously defined. The proposals will be evaluated
per the review and assessment criteria listed below.
5.1 Evaluation and Assessment of Proposal
An evaluation committee shall rank the interested firms based on their written proposals using
the ranking system set forth below. Firms shall be evaluated on the following criteria:
From 1 to 5, with 1 being a poor rating, 3 an average rating, and 5 an outstanding rating.
Recommended weighing factors for the criteria are listed adjacent to the qualification.
Weighting
Qualification
Standard
Factor
Does the proposal show an understanding of the City's
objectives and results desired from the plan(s)?
2.0
Scope of Proposal
Adherence to the services requested and described in
the RFP.
Do the personnel administering the plan(s) have the
needed skills and experience? Are sufficient people of
2.0
Assigned Personnel
the requisite skills assigned to the plan(s)? Quality of
care and customer service.
Can the plan(s) be completed in the time frame
required? Can targeted effective date be met? Are
other qualified personnel available if required, to
1.0
Availability
assist meeting the plan(s) schedule? Is the account
management team available to attend meetings as
required by the Project Manager?
Is the firm interested in providing the services
1.0
Motivation
requested in this RFP? Quality of responses to the
RFP's Questionnaire sections.
How competitive are the plan's costs, rate guarantees
2.0
Cost /Financial
and where applicable, provider's contracts with area
Effectiveness
providers?
Experience managing similar plans of this type and
2.0
Benefit Management
scope. Thoroughness in selecting providers and
Capability
managing benefit plans. Actively seek to provide most
appropriate level of service?
Based on results of the written evaluation, The City will select finalists for consideration. Any or
all proposals may be rejected by The City. Finalists may be asked to make formal presentations
of their proposals, as well as to demonstrate their systems and procedures for administering
The City's plans. Site visits may take place at the finalists' home offices and/or the claims and
administrative facility/facilities that would provide service to The City.
City of Fort Collins, RFP 2003
8
C
TERMINATION OF COVERAGE
Coverage of enrolled eligible employees will terminate on the earliest date
of the following:
a. The last day of the month that eligibility is terminated in accordance with
the eligibility rules of the Contract, unless the eligible employee elects
continued coverage under the COBRA provisions.
b. The last day of the month for which premium has been paid.
c. The day the Master Contract is terminated.
Coverage for enrolled eligible dependents will terminate on the earliest of
the following:
a. The day the enrolled eligible employee's coverage under which they are
covered terminates in accordance with the above.
b. The last day of the month for which premium for dependent coverage has
been paid.
c. The last day of the month during which the enrolled eligible dependent
ceases to be eligible in accordance with the eligibility rules ofthe Contract
unless continued coverage is elected by or on behalf of any dependent
under the COBRA provisions.
HOW TO USE THE DELTA DENTAL PLAN
You may visit any dentist of your choice. If your dentist is a participating
member of Delta Dental Plan, the claim form for benefits will be filed by your
dentist. The patient should complete the top or patient section of the claim
form and sign the form to indicate that he/she authorizes release of the
information to Delta.
If you are treated by a Delta Preferred Option (DPO) Network dentist
(printed in red), you will receive the highest benefits available on this plan.
Delta makes payment directly to the dentist and sends an Explanation of
Benefits to the employee indicating how much the dentist has been paid and
the amount which the employee is responsible for paying. Ifthere is an amount
not chargeable to the patient, that is shown on the Explanation of Benefits as
well. Delta Preferred Option Dentists provide services at a reduced fee which
means that your co -payment based on that fee will be less.
Both Delta Preferred Option Dentists and Delta Premier Participating
Dentists have agreed to collect only the portion of your charges for which you
are ultimately responsible (i.e., deductible and coinsurance). You will not be
charged the entire fee atthe time services are rendered unless the service you
receive is not covered by your plan.
If you are treated by a Delta Premier Participating Network dentist
(printed in black) locally or nationwide you will receive the benefits indicated
for Premier Participating dentists.
Eligible dependents losing coverage due to any of the following
Qualifying Events may elect to continue coverage for thirty-six (36)
months following the month in which the event occurs:
• An eligible employee's death;
• A divorce or legal separation from an eligible employee;
• A dependent child's ceasing to qualify as an eligible dependent under
this Program; or
• An eligible employee's entitlement to Medicare benefits.
Anyone who has elected continued coverage and becomes covered
under another plan may continue coverage if the plan contains a pre-existing
condition limitation. Coverage will be continued until the earlier of: the
expiration of the pre-existing condition limitation of the new plan or the
expiration of the original continuation period. The new plan must count the
months for which you have had prior creditable coverage for the pre-existing
condition. It is the employee's or dependent's responsibility to consult with
their new plan administrator to determine if this provision applies in their case.
If an eligible employee becomes entitled to Medicare before the expira-
tion of eighteen (18) months then any of his dependents will be entitled to
continuation of coverage for atotal of thirty-six (36) months from the date of the
original Qualifying Event.
Anyone who is entitled to elect continued coverage based on more than
one Qualifying Event shall be limited to continued coverage for a total of
thirty-six (36) months following the date of the first Qualifying Event.
You or your dependent must notify your employer within sixty (60) days
after a divorce or legal separation, or if a dependent child loses eligibility.
Otherwise, the option of continued coverage based on one of these events will
be lost.
Once aware of a Qualifying Event, the employer will notify affected
persons about their right to elect continued coverage. This notice will include
the amount of monthly fees the employer will charge them for continued
coverage as permitted by law. Persons desiring continued coverage must
advise the employerwithin sixty (60) days after receiving such notice, orwithin
sixty (60) days after losing coverage due to the Qualifying Event, whichever is
later. You or your dependent will then have forty-five (45) days to pay the initial
installment of fees which shall include fees for all months since the Qualifying
Event.
Continued coverage shall be the same as for eligible employees and their
dependents. If coverage is modified for eligible employees and their depend-
ents, it shall also be modified in the same manner for persons with continued
coverage and an appropriate adjustment in fees may be made by the
employer.
After COBRA coverage begins, the employee may add a newborn child,
an adopted child or a child who has been placed with the employee for
adoption and for whom you have financial responsibility. The employee must
2. 11.
WHEN TO USE YOUR DENTAL CARE PLAN
Routine dental care is the best way to maintain your oral health. Start at
Your earliest convenience and repeat your check-ups at least annually.
EXTENDED COVERAGE
If eligibility is lost, Delta will pay for services that were preauthorized and
started prior to the date of termination. The extended coverage will not exceed
sixty (60) days and applies only to single covered services that are fixed or
removable prosthodontic appliances, crowns, jackets, cast, fused or other
laboratory processed restorations and were installed or seated within sixty
(60) days after termination of coverage. This provision does not apply to
Orthodontic Services, if included in this program.
NOTICE OF RIGHT
TO COBRA COVERAGE
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) of
1985, as amended by Congress in 1986 and 1989and further amended by the
Health Insurance Portability and Accountability Act of 1996, eligible persons
who would lose coverage under their employer sponsored group health plan
(which includes dental plan coverage) due to certain "Qualifying Events" are
entitled to elect continued coverage at their own expense.
Eligible employees and dependents losing coverage due to either of
the following Qualifying Events may elect to continue coverage for
eighteen (18) months following the month In which the event occurs:
An eligible employee's termination of employment (other than for gross
misconduct); or
An eligible employee's reduction in work hours to less than any mini-
mum required to be eligible under the contract.
Any eligible employee or dependent who is eligible for COBRA continu-
ation coverage who is disabled and determined to be eligible for Social
Security disability benefits at the time of termination of employment or
reduction of hours may elect to extend coverage for themselves and their
dependents for up to an additional eleven 01) months following the eighteen
08) month extension allowed for the initial Qualifying Event. This right also
applies if the eligible employee or dependent is totally and permanently
disabled within sixty (60) days after termination of employment or reduction of
hours. The employee or dependent must notify the employer in writing of the
Social Security disability determination within sixty (60) days of the date it is
issued, and beforethe end of the initial eighteen (18) month COBRA coverage
period. The employee or dependent must also notify the employer within thirty
(30) days of the date of any final determination by the Social Security
Administration that the employee or dependent is no longer disabled.
10
Should you elect to receive treatment from dentist who has not enrolled
with Delta as either a DPO or a premier Participating Dentist (i.e., a non -Partici-
pating Dentist), you will be fully responsible for filing your claim and for payment
to the dentist. Delta will reimburse you for the services of a non -participating
Dentist. You may obtain a claim form from your Human Resources office orfrom
Delta by calling the number on the back cover. You will be reimbursed on the
basis of the lower level of benefits and the prevailing fees wit the country for the covered services you receive. f
By going it hin his/her a Non-Pararearea a o-
ing Dentist, you do risk additional out of pocket costs.
If you anticipate extensive dental services which would exceed $400.00,
your dentist must submit the treatment plan to Deltafor review before any work
is actually done. Predetermination ofbenefits allows both you and yourdentist
to know exactly what is covered and what your plan will pay. There is no
additional charge for having a predetermination done.
Delta will not be obligated to pay claims submitted more than fifteen (15)
months after the date the service was provided.
If the patient or employee encounters any problems relative to fee
differences, possible excessive charges, quality of care or refusal on the part
Of a DPO or Participating Dentist to cooperate with the program, the employee
should call the Customer Service Representative at Delta Dental Plan of
Colorado.
BENEFIT PAYMENT
PREFERRED OPTION DENTIST
Patients who choose a DPO dentist receive the highest level of benefits.
Preferred Option Network dentist (Printed in red), is a dentist who is licensed
to practice, has met the criteria for the Delta Preferred Option program, is a
Delta Premier Participating Dentist who has signed a special agreement with
Delta to participate in the DPO program.
PREMIER PARTICIPATING DENTIST
licensed to practice and who has signed an agreement with Delta
Premier Participating Dentist (printed in black), means a dentist who is Over 100,000 or 2 out of 3 dentists nationwide are Premier Dental Alen.
Participating
Dentists. Under the terms of a signed agreement with Delta, Premier Partici-
pating Dentists agree to render dental care to Eligible patients according to
requirements established by the Board of Trustees of Delta Dental Plan.
Premier Participating Dentists agree to:
• Submit claim forms for their patients.
• Accept direct payment from Delta; they may only charge the patient for
the portion of the treatment that is not covered by the plan, i.e., the
deductible and/or any coinsurance.
File a listing of their usual fees, on a confidential basis. Payment will be
based upon the Participating Dentist's usual, customary and reason-
able fee as filed with and accepted by Delta.
3.
NON -PARTICIPATING DENTIST (NOT IN DIRECTORY)
Non -Participating Dentists have not signed participating agreements or
filed fees. If a non -Participating Dentist is chosen, the patient may experience
additional costs out of pocket. The benefit is based on the prevailing fees of
Premier Participating Dentists.
The patient will also be fully responsible for the dentist's entire fee and for
filing the claim with Delta.
BENEFIT PERCENTAGES
DIAGNOSTIC AND PREVENTIVE SERVICES
80% of a Preferred Option Dentist's allowable fee or
60% of a Premier Participating Dentist's usual, customary and reasonable fee.
BASIC SERVICES
60% of a Preferred Option Dentist's allowable fee or
50% of a Prernier Participating Dentist's usual, customary and reasonable fee.
MAXIMUM BENEFIT
Each eligible employee and each eligible dependent may receive up to
$400.00 of covered dental benefits in each calendar year for Diagnostic,
Preventive, and Basic Services.
DEDUCTIBLE
DEDUCTIBLE APPLIES'
BASIC PLAN
(type of service)
DPO Network Dentist
Non-DPO Network Dentist
(printed in red)
(printed in black)
Diagnostic and Preventive
Basic
The patient is responsible for the first $25.00 of dental charges
each calendar ear, with a limit of $50.00 per family.
x. Any payable expense under any other group or individual plan, medical
or dental plan, whether claimed or not.
y. Charges for failure to keep a scheduled visit with your Dentist.
z. Charges for Orthodontics are not covered expenses.
aa. Charges for Special Restorative are not covered expenses.
bb. Charges for Prosthodontics are not covered expenses.
COORDINATION OF BENEFITS
a. If an eligible person is entitled to coverage undertwo or more plans, then
the benefits of the Contract shall be coordinated with other plan benefits.
"PLAN" means any plan providing dental care benefits under group,
blanket or franchise coverage; or service type plans or other group pre -paid
plans; or coverage under any governmental plan or required by law; or
"No -Fault" motor vehicle insurance.
b. Order of Benefit Determination if the other coverage is provided by a
dental insurance policy or prepaid dental care program:
1. The policy or program covering the patient as an employee shall be
primary over the policy or program covering the patient as a
dependent;
2. For dependent children's expenses the order of benefit determina-
tion shall be as follows:
a. The policy of the parent whose birthday (excluding year of
birth) occurs earlier in a year shall be primary, or;
b. If the parents are separated or divorced, the policy of the
parent who is ordered by court decree to take financial
responsibility for dental expenses shall be primary, or;
c. The policy of the parent with custody is primary and if said
parent has remarried, the step -parent's plan is secondary
and the plan of the parent without custody pays third.
3. If the above rules do not establish an order of benefit determination,
the plan that has covered the person for the longer period of time
shall be primary with the following exception:
The plan covering the person as a laid -off or retired employee or
dependent of such person, shall be determined after the benefits
of any other plan covering the person or employee.
4. Any group plan that does not contain a coordination of benefits
provision is automatically primary.
If this plan is primary as provided above, this plan shall provide benefits
without regard to benefits provided by any other plan. If this plan is secondary,
this plan will provide benefits which together with the other plan(s) will not
exceed 100% of the covered dental expense or this plan's maximum benefit,
whichever is less.
4. s
f. Habit appliances, night guards, occlusal guards, athletic mouth guards
and gnathological (jawfunction) services, bite registration or analysis, or
any related services (except as covered underthis plan).
g. Pre -medication, analgesia, hypnosis or any other patient management
services.
h. Charges for prescription drugs.
i. Experimental procedures, or any procedures other than those covered
services for which the prognosis is good. Any procedures done in
anticipation of future need (except covered preventive services).
j. Hospital costs and any additional fees charged by the dentist or hospital
for hospital services, visits, or charges for use of any facility.
k. Anesthesia other than general anesthesia, intravenous sedation or anal-
gesia administered in connection with covered oral surgery services as
provided for in the Contract.
I. Extraoral grafts (grafting of tissues or other substances from outside the
mouth to or into oral tissues), augmentations or implants and/or any
associated appliances. Removal of implants or any services associated
therewith.
m. Services forthe treatment of any disturbances of the temporomandibular
joint (jawjoint), facial pain, orany related conditions, including any related
diagnostic, preventive or interceptive services. Myofunctional therapy or
speech therapy.
n. Services not performed in accordance with the laws of the state of
Colorado, services performed by any person other than a person
authorized by license to perform such services, or services performed to
treat any condition, other than an oral or dental disease, malformation,
abnormality or condition.
o. Oral hygiene instructions or dietary instructions.
p. Completion of forms, providing diagnostic information or records, or
duplication of x-rays or other records.
q. Replacement of lost, stolen or damaged appliances.
r. Preparation for placement or replacement, removal or repair, or any other
procedure related in anyway to any procedure or service not included in
covered service. Any services not specifically included as covered.
s. Services for which payment is prohibited by any law of the jurisdiction in
which the eligible person resides at the time the expenses are incurred.
t. Services for which charges would not have been made if this coverage
had not existed, except for services as provided under Medicaid.
U. Services for which legal payment obligations have been reduced due to
a professional or courtesy discount, or for services by a relative as the
provider.
v. Services which result from an act of declared or undeclared war or armed
aggression.
w. Services which result, whether the insured person is sane or insane, from
an intentionally self-inflicted injury or sickness.
COVERED DENTAL SERVICES
*This booklet Is not a contract. The summary information In this
booklet is intended to describe in general terms the main features of the
program and does not constitute a contract. The specific terms and
conditions governing the coverage are set forth in the Contract between
Delta and your group and constitutes the basis on which claims will be
paid.
I. DIAGNOSTIC, PREVENTIVE AND ADJUNCTIVE SERVICES
Diagnostic - Provides the necessary procedures to assist the dentist in
evaluating the conditions existing and the dental care required as provided for
in the Contract. Covered Diagnostic Services include:
Oral Examination - to include initial, periodic or emergency
Dental X-Rays - to include complete (full mouth) series, single x-rays, or
bitewings
Preventive- Provides the necessary procedures ortechniques to prevent
the occurrence of dental abnormalities or disease as provided for in the
Contract. Covered Preventive Services include:
Dental Cleaning - to include removal of all deposits and/or stains, and
polishing as a single complete service
Adjunctive - Services including emergency treatment performed as a
temporary measure to relieve pain as provided for in the Contract.
LIMITATIONS ON DIAGNOSTIC, PREVENTIVE AND
ADJUNCTIVE BENEFITS
a. Complete mouth x-rays are a benefit only once in sixty (60) months,
unless special need exists.
b. Bitewing x-rays are a benefit only once in a twelve (12) month period and
are not a benefit in addition to a complete series.
c. Cleanings and oral examinations are a benefit only twice in a twelve (12)
month period.
d. Topical fluoride application is a benefit only to children through age fifteen
(15), and is a benefit only once in a twelve (12) month period.
e. Benefit for examination will not be made when performed in conjunction
with any covered Adjunctive Service.
I. Benefit for covered diagnostic services may be applied toward the cost of
special diagnostic services or techniques and the patient shall be
responsible for the portion of the dentist's fee in excess of the Delta
allowance.
5.
8.
g. Space maintainer is a benefit only for premature loss of deciduous (baby)
teeth for children through age thirteen (13).
h. Sealant Benefits include the application of sealants only to permanent
molar teeth with the occlusal surfaces intact, no caries (decay), and with
no restorations.
i. Separate benefit shall not be made for any preparation or conditioning of
the tooth or any other procedure associated with sealant application.
j. Sealant Benefits do not include any repair or replacement of a sealant on
any tooth within three (3) years of its application. Such repair or replace-
ment is considered included in the fee for the initial placement of the
sealant.
k. Sealants area benefit only for eligible dependent childrenthrough the age
of fourteen (14).
II. BASIC SERVICES
Restorative - Provides the necessary procedures to restore the teeth
other than special restorative. Covered Basic Restorative Services include
Amalgam, Silicate and Resin Restorations.
Endodontics - Includes the necessary procedures for pulpal and root
canal therapy as provided for in the Contract.
Oral Surgery - Extractions and certain other surgical services and
associated covered anesthesia as provided for in the Contract.
Perlodontics- Services fortreatment of gums and bone supporting teeth
as provided for in the Contract.
LIMITATIONS ON BASIC SERVICES
a. Benefits for the same covered basic restorative service shall not be
provided more than once in any twelve (12) month period.
b. Allowance for amalgam on posterior (back) teeth or intraorally cured
(placed and hardened completely in the mouth) resin or plastic restora-
tions (fillings) on anterior (front) teeth may be made toward the cost of
more expensive procedures or materials selected, and the patient shall
be responsible for the portion of the dentist's fee in excess of the Delta
allowance.
c. Covered surgical periodonticservices area benefitonly once in athirty-six
(36) month period and covered adjunctive periodontic services are a
benefit only once in a twenty-four (24) month period, unless evidence of
special need is provided to Delta.
d. Pulpotomy, Pulpectomy is a benefit only for deciduous (baby) teeth.
e. Benefits for non surgical periodontal procedures which include any
component of prophylaxis are limited to those provided under the
limitation of Diagnostic and Preventive Services.
f. No benefit shall be provided for any procedures performed on teeth
retained in relation to an overdenture.
GENERAL LIMITATIONS - ALL SERVICES
a. H an eligible person selects a service that is not provided for under the
terms of the Contract or specialized techniques rather than standard
services, Delta will pay the applicable percentage of the fee for the least
costly commonly performed covered service and the patient is responsi-
ble for the remainder of the dentist's fee.
b. Veneers, facings, or any other cosmetic services posterior to the first
molar are considered cosmetic and are not a benefit.
c. Pre- and post -operative procedures are considered part of any covered
service and are not benefits.
d. Local anesthesia is considered a component of any procedure in which it
is used.
e. Allowance for any covered service started but not completed shall be
limited to the amount determined by Delta.
f. A temporary dental service will be considered an integral part of a
complete dental service rather than a separate service, and separate
payment shall not be made for a temporary service unless otherwise
included as a covered service on the Contract.
g. Allowance for assistant surgeon when determined by Delta to be a
covered benefit shall not exceed 20% of the surgeon's fee for the same
covered service.
EXCLUSIONS
THE FOLLOWING SERVICES ARE NOT BENEFITS:
a. Servicesfor injuries or conditionswhich are compensable underWorker's
Compensation, employer's liability laws, no-fault auto insurance, or
services which are provided to the eligible person by any federal or state
government agency or are provided without cost to the eligible person by
any municipality, county or other political sub -division, or any services for
which the eligible person would have no obligation to pay in absence of
this coverage, except as such exclusion may be prohibited by law, such
as Medicaid.
b. Any covered service started during any period when the person was not
eligible for such service under the Contract.
c. Services for treatment of congenital (present at birth) or developmental
(following birth) malformations, except intraoral dental services for treat-
ment of a condition which is related to or developed as a result of cleft lip
and/or cleft palate, unless otherwise included as a covered service of the
Contract.
d. Services for cosmetic reasons.
e. Services for restoring tooth structure lost from wear or for any services
related to protecting, altering, correcting, stabilizing, rebuilding or main-
taining teeth due to improper alignment, occlusion or contour or for
splinting or stabilization of teeth.
s.
Visit Delta's website at:
www.deltadentalco.com
You can search for a dentist, download a claim form or
access other personal account information.
DELTA DENTAL
Delta Dental Plan of Colorado
Stanford Place III
4582 South Ulster Street
Suite 800
Denver, Colorado 80237
(303) 741-9300
Customer Service:
(303) 741-9305 or (800) 610-0201
GROUP DENTAL PLAN
for
CITY OF FORT COLLINS
(COMPREHENSIVE)
DPO PROGRAM
GROUP NUMBER - 1857
EFFECTIVE - January 1, 1997
REVISED - January 1, 2002
d DELTA DENTAL
Delta Dental Plan of Colorado
2,000
01 /02
No Text
Please complete an Identification Card with your name
and Social Security Number. This is presented to you for
your convenience when making dental visits. Anothercard
has been included for your spouse. However, this should
be completed with YOUR name and Social Security
Number.
(Please cut on dotted lines)
r-------------------------------------- I
I I
d DELTA DENTAL P.O. Box 173803
Denver, Colorado 80217-3803
Delta Dental Plan of Colorado (303) 741-9300
Customer Service: (303) 741-9305 or (800) 610-0201
DPO IDENTIFICATION CARD
CITY OF FORT COLLINS
(COMPREHENSIVE) 1857
NAME GROUP NUMBER
I I
I I
EMPLOYEE NAME EMPLOYEE SOC. SEC. NO.
CURRENT ELIGIBILITY SUBJECT TO DETERMINATION BY DDPC
I ------ I
I I
I I
d P.O. Box 1
DELTA DENTAL brad
Denver, Colorado 80217-3803
Delta Dental Plan of Colorado (303) 741-9300
Customer Service: (303) 741-9305 or (800) 610-0201
DPO IDENTIFICATION CARD
j CITY OF FORT COLLINS
(COMPREHENSIVE) 1857
NAME GROUP NUMBER
I I
EMPLOYEE NAME EMPLOYEE SOC. SEC. NO.
CURRENT ELIGIBILITY SUBJECT TO DETERMINATION BY DDPC
--------------------------------------
No Text
INTRODUCTION
YOUR DENTAL PROGRAM
We are pleased to introduce you to your new dental program. If you choose
the Basic plan, you may not select the Comprehensive plan for two (2) years. If
you are waiving dental coverage altogether, you may only enroll in the Basic plan
at a later date.
ELIGIBILITY
All eligible employees and their dependents who enroll shall be covered on the
effective date. All new eligible employees will become effective on the first day of
the month following thirty (30) days of employment.
Your dependents who are covered are your lawful spouse and your unmarried
children until the end of the month to which they attain nineteen (19) years of age
or any unmarried children, nineteen (19) years of age until the end of the month to
which they attain twenty-five (25) years who attend an educational institution on a
full-time basis and depend upon you for support. This includes any stepchild,
foster child or legally adopted child who lives with the employee in a regular
parent -child relationship.
Dependent children who are unable to gain employment because of perma-
nent physical or mental impairment that commenced prior to reaching age
nineteen (19) will be continued as eligible dependents for dental benefits provided
proof of such handicap or incapacity is submitted within thirty-one (31) days after
it is requested by Delta.
Dependents in active military service are not covered.
"Dependent" also means any child for whom the employee or spouse is
responsible for medical or other health care benefits under a Qualified Medical
Child Support Order.
ENROLLMENT OF DEPENDENTS
a. Newly acquired dependents who are enrolled in the medical plan provided
by this employer must be enrolled within thirty-one (31) days of acquisition.
Newborn children must be enrolled within thirty-one (31) days of birth.
b. Any eligible dependents that suffer involuntary loss of coverage through
another source will be allowed to enroll with satisfactory proof of coverage
loss. Such dependents must be enrolled within thirty-one (31) days of loss of
coverage and must also be enrolled in the medical plan provided by this
employer.
5.2 Reference Evaluation (Top -ranked firms)
The Project Manager will check references using the following qualification and standard
criteria. The evaluation rankings will be labeled Satisfactory / Unsatisfactory.
a. Overall Performance - Would you hire this company again?
b. Timetable — Was the plan implementation completed within the specified time?
C. Customer Service - Was the company responsive to customer needs? Did the
company provide interactive and proactive claims and network administration?
Were problems solved quickly and effectively?
C. Premium/Administration Costs — Thoroughness in selecting providers and
managing plan costs. Actively seek to provide most appropriate level of service?
d. Knowledge - Did company personnel exhibit the knowledge and skills necessary
to efficiently carry on benefit provider operations?
Section 6.0 Proposal Acceptance:
All proposals shall remain subject to initial acceptance 90 days after the day of submittal.
Section 7.0 Agreement:
Proposer to provide sample plan agreement for review by the City.
Section 8.0 Proposal Process Information and Requirements
8.1 Intent
The intent of this RFP is to confirm key information about specific proposers, receive financial
proposals and (where applicable) identify network access compatibilities with The City's
employees. The following describes the anticipated proposal process, including confidentiality,
timing, expected response format and requirements for interaction regarding questions.
Please note that The City reserves the right to accept or reject any and all proposals, to
waive any technicalities or irregularities therein, to award contracts, or to withdraw this
request for proposal without awarding a contract. Your response to this RFP and any
subsequent correspondence related to this proposal process will be considered part of the
contract, if one is awarded to you. Under no circumstances are commissions related to The
City's benefits payable to anyone in conjunction with this request.
8.2 Confidentiality
All data included in this RFP, as well as any census data and attachments, are proprietary to
The City. It is for your exclusive use in preparing a proposal and must not be shared with any
other firm or used for any other purpose. The use of the City's name in any way as a potential
customer is strictly prohibited.
City of Fort Collins, RFP 2003
9
l
TERMINATION OF COVERAGE
Coverage of enrolled eligible employees will terminate on the earliest date of
the following:
a. The last day of the month that eligibility is terminated in accordance with the
eligibility rules of the Contract, unless the eligible employee elects continued
coverage under the COBRA provisions.
b. The last day of the month for which premium has been paid.
c. The day the Master Contract is terminated.
Coverage for enrolled eligible dependents will terminate on the earliest of the
following:
a. The day the enrolled eligible employee's coverage under which they are
covered terminates in accordance with the above.
b. The last day of the month for which premium for dependent coverage has
been paid.
c. The last day of the month during which the enrolled eligible dependent
ceases to be eligible in accordance with the eligibility rules of the Contract
unless continued coverage is elected byoron behalf ofany dependent under
the COBRA provisions.
HOW TO USE THE DELTA DENTAL PLAN
You may visit any dentist of your choice. If your dentist is a participating
member of Delta Dental Plan, the claim form for benefits will be filed by your
dentist. The patient should complete the top or patient section of the claim form
and sign the form to indicate that he/she authorizes release of the information to
Delta.
If you are treated by a DeltaPreferred Option (DPO) Network dentist
(printed in red), you will receive the highest benefits available on this plan. Delta
makes payment directly to the dentist and sends an Explanation of Benefits to the
employee indicating how much the dentist has been paid and the amount which
the employee is responsible for paying. If there is an amount not chargeable to
the patient, that is shown on the Explanation of Benefits as well. DeltaPreferred
Option Dentists provide services at a reduced fee which means that your
co -payment based on that fee will be less.
Both DeltaPreferred Option Dentists and DeltaPremier Participating Dentists
have agreed to collect only the portion ofyour charges forwhich you are ultimately
responsible (i.e., deductible and coinsurance). You will not be charged the entire
fee at the timeservices are rendered unlessthe serviceyou receive is notcovered
by your plan.
If you are treated by a DeltaPremierParticipatfng Network dentist (printed
in black) locally or nationwide you will receive the benefits indicated for
Participating dentists.
prior creditable coverage for the pre-existing condition. It is the employee's or
dependent's responsibility to consult with their new plan administrator to deter-
mine if this provision applies in their case.
If an eligible employee becomes entitled to Medicare before the expiration of
eighteen (18) monthsthen any of his dependents will be entitled to continuation of
coveragefora total of thirty-six (36) months from the date of the original Qualifying
Event.
Anyone who is entitled to elect continued coverage based on more than one
Qualifying Event shall be limited to continued coverage for a total of thirty-six (36)
months following the date of the first Qualifying Event.
You oryourdependent must notify your employer within sixty (60) days after a
divorce or legal separation, or if a dependent child loses eligibility. Otherwise, the
option of continued coverage based on one of these events will be lost.
Once aware of a Qualifying Event, the employer will notify affected persons
about their right to elect continued coverage. This notice will include the amount
of monthly fees the employer will charge them for continued coverage as
permitted by law. Persons desiring continued coverage must advise the employer
within sixty (60) days after receiving such notice, or within sixty (60) days after
losing coverage due to the Qualifying Event, whichever is later. You or your
dependent will then have forty-five (45) days to pay the initial installment of fees
which shall include fees for all months since the Qualifying Event.
Continued coverage shall be the same as for eligible employees and their
dependents. If coverage is modified foreligible employees and their dependents,
it shall also be modified in the same mannerfor persons with continued coverage
and an appropriate adjustment in fees may be made by the employer.
After COBRA coverage begins, the employee may add a newborn child, an
adopted child or a child who has been placed with the employee for adoption and
for whom you have financial responsibility. The employee must notify the
employer in writing within thirty-one (31) days of the birth or placement in order to
add the child to the COBRA coverage. A child bom, adopted or placed for
adoption and enrolled as indicated will havethe same COBRA rights as any other
dependents covered by the plan before the event that triggered COBRA
coverage.
A person's continued coverage elected underthe Contractwill terminate atthe
end of the month in which any of the following events first occurs:
1. The allowable number of months of continued coverage (i.e. 18, 29 or 36
months) expires.
2. The Contract terminates.
3. Fees are not paid forthe person as required.
4. The person becomes enrolled for dental benefits under another group dental
plan (as an employee or otherwise).
5. The person becomes entitled to Medicare.
Once continued coverage terminates, it cannot be reinstated.
2. 15.
NOTICE OF RIGHT
To COBRA COVERAGE
Under the Consolidated
1985, as amended b Omnibus Budget
Health Insurance Portability Y Congress in o and 1989 Reconciliation d further act (COBRA
would lose and q mended b ) of
coverage under their employer 7996, eligible Y the
includes dental plan Plover s on Persons who
coverage) due to P soled group health plan w
elect continued coverage at their certain"Quell in (hick
Eligible em to own ex g Events" are entitled to
p Yeesandde Dense.
toll°wing Qualifying dependents losing
fY g Events may elect to 9 coverage due to eRherofthe
(18) months following the month in which the event coverage
An eligible employees ge for eighteen
P Yee's termination of occurs:
misconduct); or employment (other than for r
• An eligible employees reduction 9 gross
required to be eligible hein work hours to less than Any eligible employee under the contract. any minimum
covers e P Yee or dependent who is eligible for COB
9 who is disabled and determined to
drsability benefits at the time So continuation
of to
of a be eligible for Social
may elect to extend covers Security
additional eleven 9e for themselves and their or reduction of hours
a]/Owed for the • {11) months following the Pendants For
initial Qualifying eighteen up to an
employee or dependent istotall g Event, This light (18) month extension
after to totally and also applies if the eligible
termination of em permanently disabled dependent must notify employment or reduction within sixty (60) days
determination fy the emplo er in of hours, The employee or
Within si Y writing of the Social 5ecuri
the initial eighteen (6nt days of the date it is issued,
(18) month C and before the end 'lof
dependent must also notify the ern COBRA coverage
final determination b g Period. The employee or
employer within thirty (3p) days of the date of an
dependent is n Y the Social Security administration that the
o longer disabled-*
Y
Eligible dependents losing' amPIOYee or
mg Events 9coverageduetoan
followingmay elect to continue Yofthefollowin the month in which the event o stage For thf _ g Qualify.
• An eligible employ ccurs: rty six (36) months
• A divorcePtoyee's death.
or legal separation from an eligible emp
nloyee;
• A dependent child's ceasi
Program; or g to qualify as an eligible de
• An eligible em I Pendent under this
P oYee's entitlement to Medicare ben
Anyone who has elected continued covers
anotherplan ma benefits,
U I Ycontinuecovera coverage and becomes covered
station. Coverage will be continued the plan contains a r sled under
preiexisting condition limitation until pre-existing condition
continuation the r the
of; the expiration of the
Period. The new of the new plan or the expiration
Plan must count the monthsforwhichy theoriginal
you have had
t a.
Should you elect to receive treatment
Delta as eitherappoorapremierfromadentistwhohasnotenroiledwn
Dentist), you will be fully reremJer Participating
tiD
dentist. pelts lyil(reimby re entist(i.e., a Non_pertfciRatin
You for the serve es of claim and for payment to the
You may obtain a claim form from your Human NOn-Part1QjPatin
calling the numberon the back cover, y g Dentist
Resources office or from Delta by
lower level Of benefits a You will be reimbursed on the basis of the
the cover u r me prevailing fees within his/her area of the country for
covered services you receive. B
risk additional out of pocket costs, Igoi gtoallon-P
which would exceed YOU antici ate rticipatingDentist,youdo
for review $400.00, Yourdentist p extensive dental services
ew before any work is mustsubmitthetreatment la
both you and actually done. Predete Plan to Delta
Your dentist to know ex rmination
Pay. There is exactly what is of benefits allows
no additional char covered and what
Delta will not be obi- oe for having a predate YOUr plan will
months after the date the sate pay claims sub Rmnation done.
Iftheservice was mined more than fifteen (15)
Patient or employee en Provided.
possibleexcessivechar cOuntersany Problems relative to fee differences,
Program, the nfhepartofaDPQorParticipatin
Representative at Delta Dental Ph n of employee should g Dentist
Colorado. cell the Customer Service
3.
BENEFIT PAYMENT
PREFERRED OPTION DENTIST
Patients who choose a DPO dentist receive the highest level of benefits.
Preferred Option Network dentist (printed in red), is a dentist who is licensed to
practice, has met the criteria for the DeltaPreferred Option program, is a Delta
Participating Dentistwho has signed a special agreementwith Delta to participate
in the DPO program.
PARTICIPATING DENTIST
Participating Dentist (printed in black), means a dentist who is licensed to
practice and who has signed an agreement with Delta Dental Plan. Over 90% of
Colorado dentists, and 2 out of 3 dentists nationwide are Participating Dentists.
Underthe terms of signed agreementwith Delta, Participating Dentists agree to
render dental care to Eligible patients according to requirements established by
the Board of Trustees of Delta Dental Plan. Participating Dentists agree to:
Submit claim forms for their patients.
Accept direct payment from Delta; they may only charge the patient for the
portion of the treatment that is not covered by the plan, i.e., the deductible
and/or any coinsurance.
File a listing of their usual fees, on a confidential basis. Payment will be
based upon the Participating Dentist's usual, customary and reasonable
fee as filed with and accepted by Delta.
NON -PARTICIPATING DENTIST (NOT IN DIRECTORY)
Non -Participating dentists have not signed participating agreements or filed
fees. If a non -participating dentist is chosen, the patient may experience
additional costs out of pocket. The benefit is based on the average fees of
participating dentists.
The patient will also be fully responsible forthe dentist's entire fee and forfiling
the claim with Delta.
INTERNAL APPEAL OF CLAIMS
Questions concerning the action taken on a claim can be directed to the
Customer Service Department for clarification. If the explanation is not accept-
able, you may appeal the determination by writing to the Dental Director of Delta
Dental within one hundred and eighty (180) days after receiving a written denial.
Any written communication should include documents or records in support of
your claim. Delta may submit the matter to the Executive Committee of the Board
of Trustees for review.
EXTERNAL APPEAL OF CLAIMS (only available on qualified claims)
In addition to the Internal Appeal procedures, covered persons have certain
rights under Colorado Division of Insurance Regulation4-2-21. Youmayrequest
an Independent External Review of a claim when the above Internal Appeal
procedures result in a final denial AND that final denial is based on one of the
following reasons:
. medical necessity;
. effectiveness;
. efficiency;
. experimental; or
. investigational.
When a claim qualifies for External Review, Delta will mail you a notice that
explains your right to request an Independent External Review of the denied
claim. In addition to the notice, you will receive the required forms for submitting
your request.
EXTENDED COVERAGE
If eligibility is lost, Delta will pay forservices thatwere preauthorized and started
prior to the date of termination. The extended coverage will not exceed sixty (60)
days and applies only to single covered services that are fixed or removable
prosthodontic appliances, crowns, jackets, cast, fused or other laboratory
processed restorations and were installed or seated within sixty (60) days after
termination of coverage. This provision does not apply to Orthodontic Services, if
included in this program.
13.
COORDINATION OF BENEFITS
a. If an eligible person is entitled to coverage under two or more plans, then the
benefits of the Contract shall be coordinated with other plan benefits.
"PLAN" means any plan providing dental care benefits under group, blanket or
franchise coverage; or service type plans or other group pre -paid plans; or
coverage under any governmental plan or required by law; or "No -Fault" motor
vehicle insurance.
b. Order of Benefit Determination if the other coverage is provided by a dental
insurance policy or prepaid dental care program:
1. The policy or program covering the patient as an employee shall be
primary over the policy or program covering the patient as a depend-
ent;
2. For dependent children's expenses the order of benefit determination
shall be as follows:
a. The policy of the parent whose birthday (excluding year of birth)
occurs earlier in a year shall be primary, or;
b. If the parents are separated or divorced, the policy of the parent
who is ordered by court decree to take financial responsibility
for dental expenses shall be primary, or;
c. The policy of the parent with custody is primary and if said parent
has remarried, the step -parent's plan is secondary and the plan
of the parent without custody pays third.
3. If the above rules do not establish an order of benefit determination,
the plan that has covered the person for the longer period of time shall
be primary with the following exception:
The plan covering the person as a laid -off or retired employee or
dependent of such person, shall be determined after the benefits of
any other plan covering the person or employee.
4. Any group plan that does not contain a coordination of benefits
provision is automatically primary.
If this plan is primaryas provided above, this plan shall provide benefits without
regard to benefits provided by any other plan. If this plan is secondary, this plan
will provide benefits which togetherwith the other plan(s) will not exceed 100% of
the covered dental expense or this plan's maximum benefit, whichever is less.
WHEN TO USE YOUR DENTAL CARE PLAN
Routine dental care is the best way to maintain your oral health. Start at your
earliest convenience and repeat your check-ups at least annually.
BENEFIT PERCENTAGES
DIAGNOSTIC AND PREVENTIVE SERVICES
100% of a Preferred Option Dentist's allowable fee or
80% of a Participating or Non -Participating Dentist's usual, customary and
reasonable fee.
BASIC SERVICES
80% of a Preferred Option Dentist's allowable fee or
60% of a Participating Dentist's usual, customary and reasonable fee.
MAJOR SERVICES
60%of a Preferred Option Dentist's allowable fee or
50% of a Participating Dentist's usual, customary and reasonable fee.
ORTHODONTIC SERVICES
50% of a Preferred Option Dentist's allowable fee or
50% of a Participating Dentist's usual, customary and reasonable fee.
MAXIMUM BENEFIT
Each eligible employee and each eligible dependent may receive up to
$1,500.00 of covered dental benefits in each calendar year for Diagnostic,
Preventive, Basic and Major Services. Each eligible dependent child may receive
up to $1,500.00 per lifetime for Orthodontic Services.
DEDUCTIBLE
DEDUCTIBLE APPLIES*
COMPREHENSIVE
PLAN
(type of service)
DPO Network Dentist
anted in red(printed
Non-DPO Network Dentist
in black
Diagnostic and Preventive
+
Basic
+
+
Major
+
+
Orthodontic
The patient is responsible for the first $25.00 of dental charges
each calendar year, with a limit of $50.00 per family.
12. 5.
COVERED DENTAL SERVICES
This booklet is not a contract. The summary information in this booklet
is intended to describe in general terms the main features of the program
and does not constitute a contract. The specific terms and conditions
governing the coverage are set forth in the Contract between Delta and your
group and constitutes the basis on which claims will be paid.
I. DIAGNOSTIC, PREVENTIVE AND ADJUNCTIVE SERVICES
Diagnostic - Provides the necessary procedures to assist the dentist in
evaluating the conditions existing and the dental care required as provided for in
the Contract. Covered Diagnostic Services include:
Oral Examination - to include initial, periodic or emergency
Dental X-Rays - to include complete (full mouth) series, single x-rays, or
bitewings
Preventive - Provides the necessary procedures ortechniques to prevent the
occurrence of dental abnormalities or disease as provided for in the Contract.
Covered Preventive Services include:
Dental Cleaning - to include removal of all deposits and/or stains, and
polishing as a single complete service
Adjunctive -Services including emergency treatment performed as a tempo-
rary measure to relieve pain as provided for in the Contract.
LIMITATIONS ON DIAGNOSTIC, PREVENTIVE AND
ADJUNCTIVE BENEFITS
a. Complete mouth x-rays are a benefit only once in sixty (60) months, unless
special need exists.
b. Bitewing x-rays are a benefit only once in a twelve (12) month period and are
not a benefit in addition to a complete series.
c. Cleanings and oral examinations are a benefit only twice in a twelve (12)
month period.
d. Topical fluoride application is a benefit only to children through age fifteen
(15), and is a benefit only once in a twelve (12) month period.
e. Benefitfor examination will not be made when performed in conjunction with
any covered Adjunctive Service.
f. Benefit for covered diagnostic services may be applied toward the cost of
special diagnostic services or techniques and the patient shall be responsi-
ble for the portion of the dentist's fee in excess of the Delta allowance.
g. Space maintainer is a benefit only for premature loss of deciduous (baby)
teeth for children through age thirteen (13).
h. Sealant Benefits include the application of sealants only to permanent molar
g. Pre -medication, analgesia, hypnosis or any other patient management
services.
h. Charges for prescription drugs.
i. Experimental procedures, or any procedures other than those covered
services forwhich the prognosis is good. Any procedures done in anticipation
of future need (except covered preventive services).
j. Hospital costs and any additional fees charged by the dentist or hospital for
hospital services, visits, or charges for use of any facility.
k. Anesthesia other than general anesthesia, intravenous sedation or analge-
sia administered in connection with covered oral surgery services as
provided for in the Contract.
I. Extraoral grafts (grafting of tissues or other substances from outside the
mouth to or into oral tissues), augmentations or implants and/or any
associated appliances. Removal of implants or any services associated
therewith.
m. Services for the treatment of any disturbances of the temporomandibular
joint (jaw joint), facial pain, or any related conditions, including any related
diagnostic, preventive or interceptive services.
n. Services not performed in accordance with the laws of the state of Colorado,
services performed by any person otherthan a person authorized by license
to perform such services, or services performed to treat any condition, other
than an oral or dental disease, malformation, abnormality or condition.
o. Oral hygiene instructions or dietary instructions.
p. Completion of forms, providing diagnostic information orrecords,orduplica-
tion of x-rays or other records.
q. Replacement of lost, stolen or damaged appliances.
r. Preparation for placement or replacement, removal or repair, or any other
procedure related in any way to any procedure or service not included in
covered service. Any services not specifically included as covered.
s. Services forwhich payment is prohibited by any lawof thejurisdiction in which
the eligible person resides at the time the expenses are incurred.
I. Services for which charges would not have been made if this coverage had
not existed, except for services as provided under Medicaid.
u. Services for which legal payment obligations have been reduced due to a
professional orcourtesy discount, orforservices by a relativeasthe provider.
v. Services which result from an act of declared or undeclared war or armed
aggression.
w. Services which result, whetherthe insured person is sane or insane, from an
intentionally self-inflicted injury or sickness.
x. Charges forfailure to keep a scheduled visitwith your Dentist.
y. Any payable expense under any other group or individual plan, medical or
dental plan, whether claimed or not.
6. 11.
GENERAL LIMITATIONS - ALL SERVICES
a. If an eligible person selects a service that is not provided for under the terms
of the Contract or specialized techniques rather than standard services,
Delta will pay the applicable percentage of the fee for the least costly
commonly performed covered service and the patient is responsible forthe
remainder of the dentist's fee.
b. Veneers, facings, or any other cosmetic services posterior to the first molar
are considered cosmetic and are not a benefit.
c. Pre- and post -operative procedures are considered part of any covered
service and are not benefits.
d. Local anesthesia is considered a component of any procedure in which it is
used.
e. Allowance for any covered service started but not completed shall be limited
to the amount determined by Delta.
f. A temporary dental service will be considered an integral part of a complete
dental service rather than a separate service, and separate payment shall
not be made fora temporary service unless otherwise included as a covered
service on the Contract.
g. Allowance for assistant surgeon when determined by Delta to be a covered
benefit shall not exceed 20% of the surgeon's fee for the same covered
service.
EXCLUSIONS
THE FOLLOWING SERVICES ARE NOT BENEFITS:
a. Services for injuries or conditions which are compensable under Worker's
Compensation, employer's liability laws, no-faultauto insurance, or services
which are provided to the eligible person by any federal or state government
agencyorare provided without cost to the eligible person byany municipality,
county or other political sub -division, or any services for which the eligible
person would have no obligation to pay in absence of this coverage, except
as such exclusion may be prohibited by law, such as Medicaid.
b. Any covered service started during any period when the person was not
eligible for such service under the Contract.
c. Services for treatment of congenital (present at birth) or developmental
(following birth) malformations, except intraoral dental services for treatment
of a condition which is related to ordeveloped as a resultof cleft lip and/orcleft
palate, unless otherwise included as a covered service of the Contract.
d. Services for cosmetic reasons.
e. Services forrestoring tooth structure lostfrom wearorforany services related
to protecting, altering, correcting, stabilizing, rebuilding or maintaining teeth
due to improper alignment, occlusion or contour or for splinting or stabiliza-
tion of teeth.
f. Habit appliances, night guards, occlusal guards, athletic mouth guards and
gnathological (jaw function) services, bite registration or analysis, or any
related services (except as covered under this plan).
teeth with the occlusal surfaces intact, no caries (decay), and with no
restorations.
i. Separate benefit shall not be made for any preparation or conditioning of the
tooth or any other procedure associated with sealant application.
j. Sealant Benefits do not include any repair or replacement of a sealant on any
tooth within three (3) years of its application. Such repair or replacement is
considered included in the fee forthe initial placement of the sealant.
k. Sealants are a benefit only for eligible dependent children through the age of
fourteen (14).
II. BASIC SERVICES
Restorative - Provides the necessary procedures to restore the teeth other
than special restorative. Covered Basic Restorative Services include Amalgam,
Silicate and Resin Restorations.
Endodontics - Includes the necessary procedures for pulpal and root canal
therapy as provided for in the Contract.
Oral Surgery- Extractions and certain other surgical services and associated
covered anesthesia as provided for in the Contract.
Periodontics - Services for treatment of gums and bone supporting teeth as
provided for in the Contract.
LIMITATIONS ON BASIC SERVICES
a. Benefits forthe same covered basic restorative service shall not be provided
more than once in any twelve (12) month period.
b. Allowance for amalgam on posterior (back) teeth or intraorally cured (placed
and hardened completely in the mouth) resin or plastic restorations (fillings)
on anterior (front) teeth may be made toward the cost of more expensive
procedures or materials selected, and the patient shall be responsible forthe
portion of the dentist's fee in excess of the Delta allowance.
c. Covered surgical periodontic services are a benefit only once in a thirty-six
(36) month period and covered adjunctive periodontic services are a benefit
onlyonce in a twenty-four (24) month period, unless evidence of special need
is provided to Delta.
d. Pulpotomy, Pulpectomy is a benefit only for deciduous (baby) teeth.
e. Benefits for non surgical periodontal procedures which include any compo-
nent of prophylaxis are limited to those provided under the limitation of
Diagnostic and Preventive Services.
f. No benefit shall be provided for any procedures performed on teeth retained
in relation to an overdenture.
10. 7.
III. MAJOR SERVICES
Special Restorative - Crowns, jackets, cast, fused or other laboratory
processed restorations for teeth which cannot be restored with amalgam on
posterior teeth or resin/plastic on anterior teeth as provided for in the Contract.
LIMITATIONS ON SPECIAL RESTORATIVE BENEFITS
a. If more than one restoration is used to restore a tooth, benefit will not exceed
the covered amount for a single covered service.
b. Special restorative services are a benefit only once in sixty (60) months for
procedures involving the same teeth.
c. Special restorative services are not a benefit for children under age twelve
(12).
d. No benefit shall be provided for any procedures performed on teeth retained
in relation to an overdenture.
Prosthodontics - Services for construction or repair of fixed bridges, remov-
able partial and complete dentures to replace completely extracted or missing
natural permanent teeth as provided for in the Contract.
LIMITATIONS ON PROSTHODONTIC BENEFITS
a. Replacementof an existing prosthetic appliance is a benefitonce in sixty (60)
months and only if the appliance is unsatisfactory and cannot be made
satisfactory.
b. A covered prosthodontic appliance is a benefit only after sixty (60) months
has elapsed for any payment of covered special restorative benefit for the
same tooth.
c. Delta will pay the allowed percentage of the dentist's fee for a standard cast
base metal and/or acrylic partial denture or a standard complete denture, up
to a maximum fee allowance for a standard denture. The patient is
responsible for the portion of the dentist's fee in excess of the Delta
allowance.
d. Removable temporary partial dentures are a benefitonlywhen anteriorteeth
are missing. An allowance limited to the covered amount for a removable
appliance may be made toward the cost of the other procedures performed.
The patient is responsible for the portion of the dentist's fee in excess of the
Delta allowance.
e. Benefit based on the cost of a covered complete or partial denture may be
made toward the cost of implants and appliances constructed in association
therewith. If benefit is made for such an appliance, benefit will not be made
for any replacement within sixty (60) months thereafter.
f. Fixed bridges and/or cast metal framework partial dentures are not a benefit
for persons underage sixteen (16).
g. Fixed and removable Prosthodontic appliances are not a benefit in the same
arch except in cases of special need as determined by Delta. Any allowance
made will be limited to the cost of a removable appliance.
h. Overdenture appliance benefits will be limited to the allowance for a standard
appliance.
i. Benefit for reline or rebase of a prosthodontic appliance will be made only
once in any thirty-six (36) month period. Reline or rebase of a prosthodontic
appliance at the time of insertion and/or within six (6) months following
insertion is considered a component of the appliance and a separate
payment will not be made.
IV. ORTHODONTIC SERVICES
Provides the procedures associated with the orthodontic movement of the
teeth into proper alignment, position and occlusion. Only dependent children
underage nineteen (19) and dependent students underage twenty-five (25)
are eligible for Orthodontic benefits.
LIMITATIONS ON ORTHODONTIC BENEFITS
a. Replacementor repairof appliances is nota benefit.
b. Orthodontic care provided in the treatment of periodontal cases or cases
involving treatment or repositioning of the temporomandibularjoint or related
conditions is not a covered service.
c. The obligation of Delta to make periodic payments for an Orthodontic
treatment plan shall cease upon termination of treatment for any reason prior
to completion of the case.
d. The obligation of Delta to make periodic payments for an Orthodontic
treatmentplan begun priorto the eligibility date of the patientshall commence
with the first payment due following the patient's eligibility date. The above
mentioned maximum amount payable will apply fully to this and subsequent
payments.
e. The obligation of Delta to make periodic payments for an Orthodontic
treatment plan shall cease upon termination of the covered person's
eligibility.
f. Delta's obligation to make periodic payments for Orthodontics shall termi-
nate at the end of the month during which the eligible dependent child(ren)
reaches age nineteen (19)or age twenty-five (25) if a full-time student.
g. Extended coverage provisions do not apply to Orthodontic services.
8. 9.
0
d DELTA DENTAL 0
Delta Dental Plan of Colorado
Dentist Listing
for
DeltaPremier Plans
and
DeltaPreferred Option Plans
City of Fort Collins - bong Term Care
During open enrollment, this year only, all employees are .offered
different plan options on a MODIFIED GUARANTEED ISSUE basis.
The Plans are:
Portable,
Discounted 10% as an employee, up to 25% if you cover your spouse.
Available to family members as fully underwritten applicants.
Three Plan Options
A. 100% Nursing Facility, 75% Assisted Living, 50% Home Health Care
60 day Elimination Period, $60 Daily Benefit, 4 Year Benefit Period
B. 100% Nursing Facility, 100% Assisted Living, 100% Home Health Care
60 day Elimination Period, $120 Daily Benefit, 6 Year Benefit Period
C. 100% Nursing Facility, 100% Assisted Living, 100% Home Health Care
30 day Elimination Period, $150 Daily Benefit, Lifetime Benefit Period
There are riders available to control inflation and payment period.
Get ALL the information you may want at:
Itcworksite.com/iohnson
Choose Group Enrollment
User ID fort
Password collins
Take 10 minutes to go through LTC Education.
Then choose Benefit Info to check out your 3 plan choices and RATES.
Want a family member to look at the plan, email them from the site.
Review Definitions, Enroll, Schedule Appointments.
Everything you need or need to know is right there.
Don't wait, click that mouse.
Don't have computer access, leave me a message at X 1050.